Validation of the Shortened Version of the Metacognition Questionnaire for Insomnia-6 (MCQI-6) Among Clinical Sample of Insomnia

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Abstract

INTRODUCTION

Metacognition, often referred to as “thinking about thinking,” is defined as a cognitive process aimed to monitor and modify one’s own way of thinking or thoughts themselves [1]. It focuses on the thinking process, rather than the specific contents of thoughts [2]. Metacognition has been associated with various psychological disorders including anxiety disorders, obsessive compulsive disorder, depression, and psychosis [3]. This relationship can be explained through Wells’ Self-Regulatory Executive Function (S-REF) model, an information-processing framework that entails self-regulation [4]. The model is metacognitive in nature, as it suggests that cognitive activity itself becomes the object of monitoring and control. It provides a clear explanation for the mechanism of emergence and maintenance of psychological disorders.

When an individual perceives a discrepancy between their ideal state (e.g., asleep) and their current state (e.g., awake), intrusive thoughts may arise [5]. These thoughts are spontaneous, involuntary, and associated with negative affection, leading to difficulties in attentional control. Once intrusions occur, the individual’s appraisal and coping strategy is determined by their preexisting metacognitive beliefs [6]. However, maladaptive metacognitive belief—such as declarative beliefs about the meaning of thoughts (e.g., trying hard to fall asleep will improve my sleep) and subsequent strategies aimed at modifying cognitive activity (e.g., I should try different strategies to fall asleep)—can lead to counterproductive coping strategies [7]. Reactions such as rumination, threat monitoring, and worrying not only fail to resolve the issue but also reinforce negative emotions, which in turn become internal metacognitive data that maintains this vicious cycle. Notably, intrusive thinking at bedtime is widely recognized as a major characteristic of primary insomnia [5,8,9]. Additionally, maladaptive metacognitive beliefs and associated coping strategies—including rumination, worrying, thought control and hyperarousal— are considered distinctive features of primary insomnia, and a prolonging factor of sleep onset latency (SOL). Considering these factors, metacognition appears to be a critical factor in understanding and addressing primary insomnia.

Based on the consensus that metacognition can influence the development and maintenance of psychological disorders, the metacognitive questionnaire (MCQ) was developed to evaluate metacognitive thoughts [10]. However, the relationship between metacognition and primary insomnia was not a primary focus of MCQ. To address this, MCQ-I, a 60-item scale specific for metacognition in primary insomnia, was developed [11]. Although it has been a useful tool validated in clinical samples, its length has limited its broader application in clinical and research setting. Therefore, a shortened version, MCQI-6 consisting of 6 items was developed using random forest method, a machine learning algorithm for feature selection [12]. This study aimed to assess the validity and reliability of the MCQI-6 in patients presenting with insomnia.

METHODS

A retrospective medical record review study was conducted. This study was conducted on patients aged 18 to 80 years old who visited the Sleep Clinic in Asan Medical Center, Seoul, Korea between May 1st, 2023 and January 31st, 2024. Patients who complained of sleep disturbance were included. Exclusion criteria were 1) those who were unable to move on their own, 2) those with impaired cognitive function, 3) those with delirium or psychosis, 4) those who were unable to complete self-rating scales, or 5) those who had communication difficulties. We collected participants’ information on age, sex, or sleep indices, and psychiatric diagnosis, and responses to rating scales. The Institutional Review Board (IRB) of Asan Medical Center approved the protocol (IRB approval number: 2024-0784). The requirement for informed consent was waived by the IRB due to the retrospective nature of this study.

We collected sleep indices such as time variables and duration variables by averaging usual times reported. Based on patient’s report, we calculated time variables including bedtime, sleep onset time, and wake-up time. In addition, we determined the duration variable using the time variables, including SOL, time in bed (TIB), duration from wake-up time to bedtime (WTB), and duration from wakeup time to sleep onset time (WTS). In addition, we asked patients the time in bed during 24 hours (TIB/d).

The MCQI-6 is a brief self-report rating scale designed to measure metacognitive thoughts of insomnia patients. It is a shortened version of the original 60-item MCQ-I scale [11]. We developed shortened versions, MCQI-6 and MCQI-14 using a machine learning approach [12]. We used the MCQI-6 in this study to explore its reliability and validity using clinical samples of insomnia patients. The Insomnia Severity Index (ISI) is a self-report rating scale composed of 7 items for assessing the severity of insomnia [13]. It is accepted as a useful diagnostic and assessment tool. A score of 15 is cut-off value for insomnia. In this study, we applied the Korean version of the scale, which was validated in a previous study [14]. The scale demonstrated a good internal consistency in this study with a Cronbach’s alpha of 0.881. Dysfunctional Beliefs and Attitudes about Sleep-16 items (DBAS-16) is a brief self-report rating scale to measure sleep-related cognition. It is driven from DBAS with 30 items, and clinically used for identifying maladaptive beliefs and perception toward sleep [15]. Each item is rated from 0 (strongly disagree) to 10 (strongly agree) and in this study, the Korean version of the scale was used [16]. The final score was calculated by averaging all 16 items. The scale demonstrated a good internal consistency in this study, with a Cronbach’s alpha of 0.852. The Patient Health Questionnaire-9 items (PHQ-9) [17] is a self-report rating scale to measure experienced depressive symptoms in the past 2 weeks. It is a reliable tool to diagnose and evaluate depression. Its nine items are rated from 0 (not at all) to 9 (nearly every day). The cut-off value for depressive symptoms has a score of 10. In this study, a Korean version of PHQ-9 was used, as it has shown good reliability and validity. The scale demonstrated a good internal consistency in this study, with a Cronbach’s alpha of 0.910.

RESULTS

Demographic characteristics and rating scales score of the sample are presented in Supplementary Table 1 (in the online-only Data Supplement). For the 135 patients diagnosed with insomnia, the mean age was 60.0±12.1 years. Of them, 39.7% were males. Regarding sleep patterns, the average bedtime was 10:36 PM, with a SOL of 60.7±67.1 minutes. Insomnia was the primary diagnosis in 61.5% of patients. The remaining cases had insomnia associated with other conditions. In the questionnaire assessments, dysfunctional beliefs about sleep were measured using DBAS-16 with mean scores of 5.4±2.4. The MCQI-6 had a mean score of 16.1±4.9. Normality assumption was confirmed with skewness ranging from −0.63 to −0.07 and kurtosis ranging from −1.21 to −0.75 (Table 1). Sampling adequacy and data suitability were checked based on 0.858 of KMO measure and Bartlett’s’ sphericity (p<0.001).

Table 1

CITCs and factor loadings of the MCQI-6 among insomnia patients (n=135)

The MCQI-6 showed a good model fit for single factor structure, with a CFI of 0.941, a TLI of 0.901, an SRMR of 0.043, and an RMSEA of 0.135. Factor loading of each item ranged from 0.615 to 0.833, indicating that they were tied to the same factor (Table 1 and Fig. 1). Total score of MCQI-6 was significantly correlated with the ISI (r=0.59, p<0.01), DBAS-16 (r=0.53, p<0.01), and PHQ-9 (r=0.54, p<0.01) score, suggesting sufficient convergent validity. The scale also demonstrated good internal consistency, with a Cronbach’s alpha of 0.87.

Fig. 1

Factor structure of the Metacognition Questionnaire for Insomnia-6 (MCQI-6) among insomnia patients.

DISCUSSION

In this study, we observed that MCQI-6 was a valid and reliable scale in clinical samples of primary insomnia. CFA showed a good model fit for a single structure model correlation analysis supported convergent validity. These results suggest that the MCQI-6 can be used as a reliable and practical instrument for assessing metacognitive beliefs in patients with insomnia in clinical practice.

These findings extend the applicability of the scale to patients actively seeking clinical treatment. Cognitive behavioral therapy is currently considered a first-line treatment for primary insomnia. The MCQI-6 may serve as a tool for identifying patient groups who are likely to benefit more from such treatments. For example, individuals with higher MCQI-6 scores might be particularly suitable for a line of cognitive therapy. Moreover, briefer scale would allow repeated assessments throughout the course of treatment for monitoring changes of metacognitive thoughts. Such data can provide clinical decisions regarding treatment efficacy and continuation. In the long term, we expect that the MCQI-6 scale will contribute to the development of a metacognitive model of primary insomnia, which is established in other psychological disorders including generalized anxiety and obsessive-compulsive disorder.

However, several limitations of this study should be noted. First, it was designed as a cross-sectional study. Predictive validity of MCQI-6 was not fully evaluated. Whether high MCQI-6 scores predict future symptom severity or treatment outcomes should be verified using clinical samples. This setting could not determine causal relationships between variables either. The association can be unidirectional, reciprocal, or influenced by unmeasured underlying factors. Future longitudinal studies are needed to determine the predictive validity of the scale and establish the relations between the variables. Repeated responses to the questionnaire with time gap could also help validate test-retest reliability of the scale and significance of metacognition in different clinical groups. Second, although the MCQI-6 showed good construct validity in a clinical setting, its sensitivity to actual changes in metacognitive beliefs has not been tested yet. The current design could not determine whether changes in scores reflected true cognitive change. Future studies including experimental manipulation of metacognitive beliefs (e.g., including or reducing specific metacognitive thought patterns) could provide stronger evidence for the scale’s validity.

In conclusion, the MCQI-6 scale demonstrated reliability and validity in clinical settings. MCQI-6 is a brief and specialized tool for measuring metacognition in primary insomnia, which offers practical advantages for both research and clinical purposes. If utilized in future longitudinal or experimental research, it would enable repeated measurement. We expect this convenient and focused scale to draw more academic attention and achievements to this previously under-recognized field and, hopefully, provide guidance for clinical decisions.

Supplementary Materials

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