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POST-TRAUMATIC STRESS DISORDER, METACOGNITIONS, 
COGNITIVE AND GLOBAL FUNCTIONING


EMIR TUPKOVIC1, RUSMIR SOFTIC 2,

1 Department of Neuropsychiatry of Primary Health Centre Tuzla
75000Tuzla, Bosnia and Herzegovina
2 University Clinical Center, Psychiatry Clinic, Solina bb,
75000 Tuzla, Bosnia and Herzegovina


Corresponding author:
Rusmir Softic, University Clinical Center, Psychiatry Clinic,Trnovac bb,
75000 Tuzla, Bosnia and Herzegovina
E mail: dr.softic@gmail.com
Phone: +387 61 135 241




Abstract
Background: Individuals with posttraumatic stress disorder, show cognitive impairment in higher degree than individuals exposed to trauma without posttraumatic stress disorder. The presence of dysfunctional metacognitions in variety of anxiety disorders can represent not only factor of generic vulnerability for anxiety disorders, but also elements that contribute to maintaining the disorder. There is little empirical information about the metacognition in war veterans with posttraumatic stress disorder, especially lacking information that metacognitions put in relations with cognitive and/or social, occupational and psychological functioning. Aim of this paper is to determine the values and reciprocal correlations of different aspects of  metacognition, with cognitive and global functioning in outpatient war veterans with posttraumatic stress disorder. Methods: The study was conducted on 25 war veterans (24 male), with confirmed diagnosis of posttraumatic stress disorder by a trained psychiatrist, with average age 48,5�6,2 (38-63) years, and average duration of symptoms of 9,9�4,7 (0,5-16) years. We used the Metacognitions questionnaire, Mini Mental Status Examination, and Global Assessment of Functioning Scale to assess metacognition, cognitive impairment, and global functioning. Median values of Metacognitions questionnaire subcomponents, Global Assessment of Functioning Scale and Mini Mental Status Examination (in last one distribution of cognitive function) were determined, and also reciprocal correlations of all parameters expressed with Spearman Rank Correlation. Results: Even 12 patients (48%) had impaired cognitive function. Significant negative correlation of score on Mini Mental Status Examination, and negative beliefs about worry is observed (r=-0,4278, p=0,034), as well as non significant correlations between rest of metacognition subscales and score on Mini Mental Status Examination. Cognitive self-consciousness showed high positive correlation with Global Assessment of Functioning Scale (r =0,7436, p<0,0001). Conclusion: Follow up of metacognitions, cognitive and global functioning, and its relations, may have an important role in assessment of war veterans with posttraumatic stress disorder.
Key words: Metacognition, war veterans, posttraumatic stress disorder, cognitive impairment, global functioning. 






INTRODUCTION
Post-traumatic stress disorder (PTSD) is the postponed or extended response to the provocative event or the situation of threatening or catastrophic nature (1). Chronic post-traumatic stress disorder (PTSD) has been associated with cognitive impairments involving memory and attention (2). Individuals with PTSD, particularly veterans, show signs of cognitive impairment when tested with neuropsychological instruments, more so than individuals exposed to trauma who do not have PTSD (3). There is a suggestion that some cognitive decrements occur in PTSD patients only when they have co morbid psychiatric diagnoses (4). Striking disturbances in cognition, especially memory, have prompted research on the cognitive mechanisms of PTSD (5). 
The metacognitions questionnaire (MCQ) is an instrument for assessing beliefs that are involved in the way a person appraises his/her own thoughts. It consists of five subscales including positive beliefs about worry (19 questions), negative beliefs about worry (16 questions), cognitive confidence (10 questions), general negative belief (13 questions) and cognitive self-consciousness (7 questions). It is designed in purpose of assessment of individual�s differences in positive and negative beliefs about worry and intrusive thoughts, metacognitive monitoring and assessment if cognitive function is satisfying (6). 
The presence of dysfunctional metacognitions in both patients with obsessive-compulsive disorder (OCD), and those with panic disorder (PD), suggests that such beliefs can represent not only generic vulnerability factors for anxiety disorders but also elements that contribute to maintaining the disorder, as evidenced by their associations with aspects of OCD and PD symptoms (7).
The study of participants with OCD, schizophrenia, and nonclinical controls assessed with the Metacognitions Questionnaire (MCQ-30), showed that, except for positive beliefs about worry, both patient samples exceeded nonclinical controls on all MCQ subscales. Notwithstanding large pathogenetic differences between OCD and schizophrenia, findings suggest that obsessions and hallucinations may share a common metacognitive pathway (8). In Turkish study significant positive correlations between subscales of MCQ-C and measures of anxiety and obsessive-compulsive symptoms, with standardization of Turkish form of metacognition questionnaire for children and adolescents (9).
Global Assessment of Functioning Scale (GAF) is the standard method in the approach in the clinical assessment of the entire level of functioning of a patient and it contains information about the axis V DSM IV (10). As such, it is widely used as the scale for the estimate of the level of disorders among patients with psychological, that is psychiatric disorders (11). It allows the hospital staff to examine the patient�s immediate functioning as well as the highest level of psychological, social and professional functioning during several months of the past year, which has great importance in the foreseeing of the result of the treatment (12, 13). 
However, the fact that there is relatively little empirical information about the adequateness of MCQ in patients with PTSD is surprising, especially those that metacognitions put in relations with cognitive functioning and GAF. 
The research goal is to determine the values and reciprocal correlations of subcomponent of MCQ, with values of GAF and MMS in ambulatory treated PTSD patients. 

PARTICIPANTS AND METHODS 
The examined group consisted 25 war veterans, 24 male, with confirmed diagnosis of PTSD by a trained psychiatrist, with average age 48,5�6,2 (38-63) years, and average duration of symptoms of 9,9�4,7 (0,5-16) years. In all of them in the time of study in therapeutic scheme was ordained antidepressants, hypnotics and sedatives, antipsychotics in 18, while in 3 cases was ordained additional therapy. All of them respondents had a diagnosis of depressive or anxiety-depressive disorder. In Three patients was verified stroke, in one cortical brain atrophy, and additional diagnoses had 4 patients (epilepsy in 2, and cardiac arrhythmia in one of patients). 
The metacognitions questionnaire (MCQ), Global Assessment of Functioning Scale (GAF), and cognitive function were determined. Level of cognitive function is assessed by Mini-Mental State examination (MMSE). This test has a maximal score of 30; subjects with scores 27-30 have normal cognition; subject with scores 20-26 are considered mildly impaired, subjects with level 10-19 have moderate, and the ones less than 9 serious cognitive impairment. 
Median values of MCQ subcomponents, GAF and MMSE (in last one distribution of cognitive function) were determined, and also reciprocal correlations of all parameters expressed with Spearman Rank Correlation.









RESULTS
Values of MCQ subcomponents are exposed in table 1. Even 12 patients had decreased values of cognitive function measured with MMSE (fig. 1).
Level of cognitive functions measured with MMSE, and level of global functioning measured with GAF are exposed in table 2. 
Significant negative correlation of MMSE and negative beliefs about worry is observed (tab. 3, fig. 2). Non significant correlations between rest of MCQ subcomponents and MMSE are determined (tab. 4, fig. 3).





















DISCUSSION
Even 48% of PTSD patients had decreased cognitive function. But, just one from five MCQ subscales, negative beliefs about worry, showed significant negative correlation with MMSE, and also cognitive self-consciousness showed high positive correlation with Global Assessment of Functioning Scale (GAF).
These parameters, also their reciprocal correlations, might have some importance in following of disease process, and effect of therapy. Since cognitive behavioural therapy combined with medication significantly improves all metacognition subcomponents in anxiously depressive patients. These subcomponents are after therapy even lower compared with control group of healthy participants, that confirms not only sensitivity of the MCQ subscales, but also values of cognitive behavioural therapy (14).
Considering follow up of patients functioning, some studies confirmed correlation between symptoms severity citied by patients and Global Assessment of Functioning Scale of clinician (15). Due to fact that patients usually return to previous level of functioning after one episode of acute illness, assessment of patient�s highest level of functioning during previous year might have some prognostic importance.
Neuropsychological approaches may provide an important insight into susceptibility and resiliency factors by identifying pretrauma cognitive functions that relate to subsequent development of PTSD as well as posttraumatic cognitive processes that may influence development or maintenance of the disorder. Finally, understanding these cognitive processes may provide new approaches for treatment to improve long-term outcomes of individuals with PTSD (16).
On the other hand, follow up of metacognitions, cognitive and global functioning, and its relations, have an important place in evaluation of PTSP patients, from which prominent number have decreased cognition. That might determine further therapeutic strategy with appropriate pharmacological and psychotherapeutic treatments. For all that, like especially important appeared effect of cognitive self-consciousness on level of global functioning. All of that might have importance in assessment of disease process or healing results of PTSD patients.
CONCLUSION
Follow up of metacognitions, cognitive and global functioning, and its relations, MAY have an important role in assessment of disease process or healing results of war veterans with PTSD.




REFERENCES
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