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THE INFLUENCE OF MALADAPTIVE METACOGNITIONS IN EDUCATION: RETHINKING PRONESS TOWARD ADDICTION

December 2022

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Emporia State University

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Metacognition plays a role in motivation, executive function, declarative and procedural knowledge, and has been found to develop as early as three years of age (Marulis & Nelson, 2021). Metacognition is “thinking about thinking” (Flavell, 1992), operates across ordered levels of concepts (Seow et al., 2021), and is the knowledge and cognitive process that involves the appraisal, control, and monitoring of thinking (Flavell, 1979). Dysregulation of metacognition has the potential to develop into maladaptive coping rather than healthy self-regulation skills (Wells & Matthews, 1996), which in turn, can develop into mental illness or addiction (Chen, et al., 2021). Maladaptive metacognitions have been implicated in the learning of associations between stimuli, modification of behavior through motivation, and performance of an action to obtain a reward (Liljeholm & O’Doherty, 2012). To what extent pornography exposure and use that began in adolescence interfere with metacognitions in the adult population is lacking in research, therefore, this study aimed to identify associations between pornography use and maladaptive metacognitions in a sample of adults who actively used, or were attempting to quit, using pornography. A survey was created and posted in several Facebook groups, on twitter, and sent through messages. It was also posted on sites dedicated to those who are attempting to quit using pornography. A total of 3301 responses were recorded, however, only 877 were used for the purpose of this study, the rest were omitted due to being incomplete. Results confirmed that pornography use was a predictor of maladaptive metacognitions.

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THE INFLUENCE OF MALADAPTIVE METACOGNITIONS IN EDUCATION:

RETHINKING PRONESS TOWARD ADDICTION

A Dissertation by

Treva Etsitty

Master of Education, Wichita State University, 2019

Bachelor of General Studies, Wichita State University, 2017

Submitted to the Department of Intervention Services & Leadership in Education

and the faculty of the Graduate School of

Wichita State University

in partial fulfillment of

the requirements for the degree of

Doctor of Education

December 2022

THE INFLUENCE OF MALADAPTIVE METACOGNITIONS IN EDUCATION:

RETHINKING PRONESS TOWARD ADDICTION

The following faculty members have examined the final copy of this dissertation for form and

content and recommend that it be accepted in partial fulfillment of the requirement for the

Doctor of Education with a major in Educational Psychology and Leadership.

Jason Herron, Committee Chair

Jody Fiorini, Committee Member

Marlene Schommer-Aikins, Committee Member

Phillip Mullins, Committee Member

Jaehwan Byun, Committee Member

Accepted for the College of Applied Studies

Clay Stoldt, Interim Dean

Accepted for the Graduate School

Coleen Pugh, Dean

ABSTRACT

Metacognition plays a role in motivation, executive function, declarative and procedural

knowledge, and has been found to develop as early as three years of age (Marulis & Nelson,

2021). Metacognition is “thinking about thinking” (Flavell, 1992), operates across ordered levels

of concepts (Seow et al., 2021), and is the knowledge and cognitive process that involves the

appraisal, control, and monitoring of thinking (Flavell, 1979). Dysregulation of metacognition

has the potential to develop into maladaptive coping rather than healthy self-regulation skills

(Wells & Matthews, 1996), which in turn, can develop into mental illness or addiction (Chen, et

al., 2021). Maladaptive metacognitions have been implicated in the learning of associations

between stimuli, modification of behavior through motivation, and performance of an action to

obtain a reward (Liljeholm & O’Doherty, 2012). To what extent pornography exposure and use

that began in adolescence interfere with metacognitions in the adult population is lacking in

research, therefore, this study aimed to identify associations between pornography use and

maladaptive metacognitions in a sample of adults who actively used, or were attempting to quit,

using pornography. A survey was created and posted in several Facebook groups, on twitter, and

sent through messages. It was also posted on sites dedicated to those who are attempting to quit

using pornography. A total of 3301 responses were recorded, however, only 877 were used for

the purpose of this study, the rest were omitted due to being incomplete. Results confirmed that

pornography use was a predictor of maladaptive metacognitions.

iii

TABLE OF CONTENTS

Chapter Page

1. INTRODUCTION.................................................................................................2

1.1.1 The Self-Regulatory Executive Function Model…………………….3

1.1.2 Mental Health and Addiction in Adolescence……………………….7

2. LITERATURE REVIEW............................................................................................12

2.1 Dysfunctional Metacognitions, Addiction, and Executive Function...............14

2.2 Brain Model of Addiction ...............................................................................17

2.3 The Neurobiology of Addiction.......................................................................19

2.3.1 Cognitive Processing in Long-Term Addiction....................................23

2.4 Triphasic Metacognitive Formulation of Addictive Behaviors……................24

2.4.1 Metacognition in Problematic Internet Use…………………………..26

2.4.2. Metacognition and Online Gambling Addiction…………..…………27

2.4.3. Metacognition and Alcohol Use Disorder (AUD)……………………27

2.5 Recovery Tools Used in Treatment Programs..................................................28

2.5.1. Exercise, Recovery, and Metacognitions……………………………..29

3. METHODOLOGY .......................................................................................................29

3.1 Participants…………………………….............................................................31

3.2 Demographics…………………………............................................................32

3.2.1. Table 1 Participant Gender……………………………………………..32

3.2.2. Table 2 Participant Age Groups……………………………………….32

3.2.3. Table 3 Relationship Status……………………………………………..33

3.2.4. Table 4 Highest Educational Degree Obtained………………..………33

3.2.5. Table 5 Participants Seeing a Professional…………………………….34

3.2.6. Table 6 Participants Who Feel They Need to See a Professional…...…34

3.2.7. Table 7 Religious/Spiritual Views……………………………………..35

3.3 Research Tools…………………………............................................................36

TABLE OF CONTENTS (continued)

Chapter Page

3.3.1. The Short Form of the Metacognition Questionnaire (MCQ-30)………37

3.3.2. The Metacognitions About Desire Thinking Questionnaire (MDTQ)….37

3.3.3. The Brief Pornography Screener (BPS)…………………………………38

3.3.4. Recovery Elements…………………………………………………..…..38

3.4 Procedures ............................................................................................................40

3.5 Data Analysis ........................................................................................................41

4. RESULTS .................................................................................................................................41

4.1 Question 1..............................................................................................................43

4.1.1 Question 2..............................................................................................................45

4.1.2 Question 3..............................................................................................................45

5. DISCUSSION...................................................................................................................46

5.1 Rethinking Addiction ...........................................................................................52

5.2 Implications...........................................................................................................54

5.3 Limitations……………………………………………………………..………...55

5.4 Future Research………………………………………………………………….56

REFERENCES…………………….. ...........................................................................................56

APPENDIX....................................................................................................................................72

CHAPTER 1

INTRODUCTION

Metacognition plays a role in motivation, executive function, declarative and procedural

knowledge, and has been found to develop as early as three years of age (Marulis & Nelson,

2021). Metacognition, in essence, is “thinking about thinking” (Flavell, 1992) and operates

across ordered levels of concepts which include the ability to make decisions based on isolated

events (local confidence) and how one perceives their abilities and skills (global beliefs) (Seow

et al., 2021). Metacognition refers to knowledge and cognitive processes involving the appraisal,

control, or monitoring of thinking (Flavell, 1979), and it is through the cognitive process of

metacognition that an individual develops concepts such as knowledge of others, of different

tasks that require cognitive thought, and of possible strategies to navigate and/or cope through

different tasks (Flavell, 2000). Metacognition can also play an important role in student

academic success through practice self-regulation learning strategies and environmental

nurturing of the integration of new knowledge with existing knowledge (Ohtani & Hisasaka,

2018). Healthy development of the ability to reason with one's own judgments of knowledge is a

crucial component for effective navigation through life. Dysregulation of the development of

metacognitive beliefs has the potential to develop into maladaptive strategies that further develop

into maladaptive coping mechanisms (Wells & Matthews, 1996), which can later develop into

mental illness or dysfunction (Chen, et al., 2021).

Development of self-regulation is generally a normal process that occurs during early

childhood and extends through the lifespan. The maturity of the brain, social factors, and coping

mechanisms play a role in how self-regulation skills are practiced in the adolescent brain

(Andrews, et al., 2018). The ability to plan, monitor, comprehend, reflect, and perform tasks in

educational settings require aspects of self-regulation, a form of metacognition (Cromley &

Kunze, 2020), therefore it is suggested that teaching strategies that enhance this ability are of

importance given how metacognitive skills appear to predict academic performance (Ohtani &

Hisasaka, 2018). Moreover, expression of creativity and experimenting with knowledge has been

proven beneficial for developing information about creative metacognitive strengths and

limitations (Kaufman & Beghetto, 2013). Students who were taught cognitive strategies through

instructional learning were shown to have higher cognitive skills than their peers (Apaydin &

Hossary, 2017). Therefore, enhancing a student’s awareness of their metacognitive abilities

through the learning process allows the students to not only be conscious of self, but it also

allows them to be involved in the learning situation, which in turn activates memories, previous

knowledge, and abilities that are directly related to their metacognitive processes (Wagener,

2013).

The Self-Regulatory Executive Function Model

The Self-Regulatory Executive Function model (S-REF) is a model that explains self-

regulation processing that is driven by self-beliefs (Wells & Matthews, 1994). It proposes that

metacognitive beliefs that become dysfunctional activate pathways associated with maladaptive

coping mechanisms that can perpetuate the cycle of psychological distress. This distress becomes

persistent and strengthens when dysfunctional thinking patterns and coping mechanisms of

emotional responses are activated. The features of this model are:

1. Unconscious or automatic thought processes that produce

conscious intrusive thoughts that garner attention.

2. Capacity limited conscious processing meant to regulate and

appraise the importance of the intrusive thoughts and subsequent

actions.

3. Processing and response to the intrusive thoughts that is guided

by stored knowledge from long-term memory and metacognitive

beliefs.

Maladaptive coping such as rumination, thought suppression, avoidance, and substance

use, are linked to dysfunctional metacognitive beliefs such as the worry about the need to control

thoughts, worrying about planning for potential threats, the inability to control rumination of

negative thoughts, and more (Spada & Roarty, 2015). Executive function plays an important role

in self-regulation because working memory, flexible shifting of attention, inhibition, and

purposeful regulation of behavior contribute to reasoning abilities (Blair, 2016) otherwise known

as cognitive processes. Dysfunctional metacognitions disrupt the ability to self-regulate cognitive

processes through metacognitive biases and beliefs, and the S-REF model serves as a distinction

between those cognitive and metacognitive processes (Bright et al., 2018). The distinction being

that unconscious metacognitive processes activate cognitive thoughts and emotional responses to

the thoughts.

Metacognitive processing of external events relies on declarative beliefs and procedural

beliefs. Declarative beliefs are what allow for thoughts regarding the appraisal of external events

and procedural beliefs are actions towards the event, the extent of which are dependent upon the

significance of the event (Wells & Matthews, 1996). Through these beliefs, The S-REF model

operates at three levels, the first of which consists of an operating process that is intrusive,

stimulus-driven, and occurs outside of conscious awareness. Intrusions include feelings of

anxiousness, pain, and other affective responses. The second level is the conscious, voluntary

system of processing aimed at the maintenance of self-regulation which is in response to the

intrusions that occur within the first level (Spada & Roarty, 2015). It is within this second level

that implementation of self-regulated processing strategies are meant to help reduce the

discrepancies between desired and current states of self-regulation with effective coping

mechanisms. The third level refers to metacognitive knowledge, which is beliefs and information

about the conscious system of processing that holds either positive or negative content such as

worrying about thoughts, rumination, and worry about danger (Wells & Matthew, 1994).

For emotional disorders, the S-REF model proposes that metacognition plays a role in

maladaptive self-regulation strategies that account for a deficit in processing external and

internal events and is referred to as the Cognitive-Attentional Syndrome (CAS). “This syndrome

consists of heightened self-focused attention, reduced efficiency of cognitive functioning,

activation of self-beliefs and self-appraisal, attentional bias and capacity limitations” (Wells &

Matthews, 1996, p. 883). The Cognitive Attentional Syndrome (CAS) is defined as a

combination of unhelpful coping strategies activated by underlying maladaptive metacognitions,

along with a combination of negative thinking processes. Unhelpful coping strategies include the

inability to move away from self-focused thinking, continued worry and rumination, and

thoughts of a perceived threat in the environment (Fisher & Wells, 2009). CAS asserts the

inability to effectively self-regulate with healthy coping strategies in response to a trigger can

prolong emotional distress. In other words, the importance of the event significantly impacts the

duration of negative emotions experienced leading up to and following the event, effectively

activating pathways for maladaptive coping mechanisms, leading to rumination, worry, reduced

cognitive functioning, and inability to regulate emotions. In those with impulse control disorders,

a causal link was observed between reduced cognitive functioning and impulsiveness (Soutschek

& Tobler, 2020) which could indicate the possibility for problematic responses to situations that

cause distress due to the reduction of an individual's ability to monitor and control declarative

and procedural beliefs.

The S-REF model also describes a set of metacognitive beliefs that include dysfunctional

beliefs about the ability to control thoughts and beliefs about cognitive self-consciousness. Since

metacognitive beliefs can influence knowledge and cognitive processes, they have been shown to

also play a role in addictive behaviors, as seen in a systematic review of 38 studies that assessed

the role of metacognitive beliefs and tendency towards alcohol use, gambling, problematic

internet use, nicotine use, and gambling (Hamonnier & Varescon, 2018).

The evidence tends to show that people who engage in

addictive behaviors hold dysfunctional generic

metacognitive beliefs, metacognitive beliefs about

addiction-related thoughts, and metacognitive beliefs about

craving. These metacognitive beliefs are more prevalent in

clinical than control populations and predict addictive

behaviour category membership, the severity of addictive

behaviour and craving, as well as relapse (Hamonnier &

Varescon, 2018, p. 60).

Dysfunctional metacognitive beliefs are those that can continue to reinforce addictive behavior

by way of holding onto maladaptive beliefs through internal self-talk, rumination, and emotional

responses regarding the addiction. These beliefs can vary in duration and intensity, which is

generally how prediction of the severity of the addiction and possibility of relapse is possible

(Hamonnier & Varescon, 2018).

Mental Health and Addiction in Adolescence

Disruption in healthy development of metacognitive strategies and self-regulation that

occurs in adolescence could potentially cause problems long-term. “Adolescence being defined

as a transition phase towards autonomy and independence, is a natural time of learning and

adjustment particularly in the setting of long-term goals and personal aspirations” (Jadhav &

Boutrel, 2019). It could be argued that an adverse experience prior to full prefrontal development

could interfere with adult trajectory and prefrontal cortex development, potentially exposing a

vulnerability in thinking, subsequently creating a tendency towards an addiction (Jadhav &

Boutrel, 2019). Disruption in healthy development of self-regulation skills can be seen among

8480 students in Taiwan, where the combination of internet addiction tendencies and poorer

mental and physical health significantly impacted mental well-being (Yu & Chao, 2016).

Working memory disfunction was found in a study of 30 juvenile participants who were

considered addicted to pornography, also demonstrating diminished memory capabilities

(Prawiroharjo, et al., 2019). Of 648 students, a relationship existed between internet pornography

preference and internet addiction with classroom introversion exacerbating the risk towards both

(Alexandraki, et al., 2018). Efrati, et al., (2021) found a relationship between impulsiveness,

thought suppression, and dysregulated metacognitions in three behavioral disorders (internet

gaming disorder, compulsive sexual behavior disorder, and problematic social network use)

among 474 teenagers in Israel. The severity of internet gaming disorder and dysregulated

metacognitive beliefs was associated with higher levels of impulsiveness and maladaptive

metacognitions, while lower monitoring of thinking processes were associated with the severity

of compulsive sexual behavior disorder and impulsiveness (Efrati, et al., 2021). Uncontrolled

metacognitive beliefs were also associated with the severity of problematic social networking

usage and higher impulsiveness (Efrati, et al., 2021), and a relationship between maladaptive

metacognitions and compulsive sexual behavior among 718 adolescent participants was also

found (Efrati, et al., 2020). A relationship between internet pornography and alcohol

consumption was found in a study with 610 adolescents, asserting that the inhibition effects of

alcohol could lead to a tendency towards reenacting pornographic scenes (Morelli, et al., 2017).

Parental bonding and care appeared to serve as a buffer for internet addiction as shown in 2,017

Greek high school student participants that were screened for internet addiction over a two-year

period whereas parental overprotection appeared to be counterproductive to internet addiction

prevention (Siomos, et al., 2012).

Dysfunctional Metacognitions

Metacognition is the ability to process thoughts and feelings and having this ability is

important for developing self-awareness and critical thinking skills. When it comes to learning

environments, metacognition helps individuals gain valuable insight into how their thought

processes work and allows for improved ability to adapt to changes and integration of new

information. The ability to monitor and reflect on one’s thought processes have been linked to

success in education (Cromley & Kunze, 2020; Wagener, 2013; Ohtani & Hisasaka, 2018;

Apaydin & Hossary, 2017; Kaufman & Beghetto, 2013) and has also been shown to reduce

impulsive decisions (Soutschek & Tobler, 2020). Recent research reflects how metacognition

begins in children as young as age three and is directly related to motivation and executive

functioning (Marulis & Nelson, 2021). As we have shifted toward more technology over the

years in educational classrooms, how screen time impacts the cognitive or metacognitive

processing has raised concerns over long-term implications. “Overall increased screen time is

associated with negative outcomes such as lowered self-esteem, increased incidence and severity

of mental health issues and addictions, slowed learning and acquisition, and an increased risk of

premature cognitive decline (Neophytou, et al., 2021, 724). This concern is further evidenced in

another study that found excessive screen time was associated with lower communication

abilities and lower problem-solving abilities in children (Rocha, et al., 2021).

Maladaptive metacognitions have been associated with depression (Chen et al., 2021)

and anxiety (Knapp et al., 2021), and have been implicated as contributing factors in addictive

behaviors (Bahramnejad et al., 2012, Hamonniere & Varescon, 2018; Spada & Roarty, 2015).

Behavioral addictions are generally present with comorbid symptomatology as underlying

conditions that work against recovery, such as anxiety and depression (Mansueto et al., 2016;

Jauregui et al., 2016). Successful recovery from an addiction has been shown to have direct

associations with metacognitive strategies since recovery relies on reflection of thoughts and

implementation of tools needed to navigate effectively through withdrawals and triggers, (Spada

& Roarty, 2015; Hamonnier & Varescon, 2018; Zhou et al., 2021) and to serve as a buffer

against the cycle often associated with addiction. Teaching metacognitive strategies may even be

useful in prevention of addiction (Bahramnejad et al., 2012; Ünal-Aydın et al., 2021).

Research Background

The aim of this study is to examine the relationship between pornography use and

maladaptive metacognitions in a population of adults. Although previous studies have discussed

aspects of pornography exposure and use in adolescence and components of executive function

such as working memory were shown to be affected (Prawiroharjo, et al., 2019), little is known

about how maladaptive metacognitions are affected long term if pornography exposure or use

begins in adolescence. It is therefore hypothesized that the absence of healthy self-regulation

strategies created coping mechanisms that turned dysfunctional, which furthers maladaptive

metacognitions, and these maladaptive metacognitions created a cycle of prolonged emotional

distress.

Research Problem

The average age of exposure to pornography is 13, with introduction occurring in some

as young as five years of age (American Psychological Association, 2017). A review of

pornography related research by Owens, et al (2012) regarding exposure to internet pornography

and adolescents, noted six relationships:

1. Exposure to sexually explicit material increased

sexual thoughts and decreased cognitive attention

towards other important things,

2. Exposure to violent genres of pornography made

viewers 6 times more likely to be sexually

aggressive than those who were not exposed,

3. Exposure to pornography increased the view that

women were sexual objects,

4. There was a statistically significant relationship

between pornography addiction recovery and

aggressive behavior and/or delinquent behavior in

school,

5. Exposure to aggressive genres of pornography

also increased aggressive behaviors such as theft,

manipulation of others, and rape, and

6. Exposure to internet pornography increased the

likelihood of clinical depression and lowered the

chance of bonding with a caregiver (Owens, et al.,

2012).

A review by Kang, et al., (2020) states that it is possible to identify children who are

addicted to pornography using EEG signals. “Our study shows that the porn addiction in children

will make them more impulsive and may affect their learning ability, poor decision making,

memory problem, and emotion regulation” (Kang, et al., 2020, 11). Another study has shown

that frequent usage of pornography can facilitate erroneous sexual beliefs, as well as preference

to the screen over a partner in adolescence (Wright et al., 2019), which could be exacerbated due

to hindrance of brain maturity and understanding of healthy coping mechanisms (Jadhav &

Boutrel, 2019).

The purpose of this study was explore aspects of self-regulation and maladaptive

metacognitions that may develop from long-term pornography use in the adult population. Since

little is known about the long-term impacts of pornography exposure, this research aims to fill a

gap while also providing insight as to why it may be difficult to abstain after exposure, especially

if exposure occurs in adolescence.

Research Questions

For the present study, this research aims to explore if the variables associated with substance

and behavioral addiction recovery techniques work in a similar way to those who use

pornography excessively and those attempting to abstain from pornography use to further

understand the role of maladaptive metacognitions. These variables include items such as

exercise, meditation, and therapy. If exposure occurs in adolescence, it could be possible that in

response to triggers, activation of the CAS occurred, and pornography use became a maladaptive

coping mechanism due to inefficient self-regulation strategies. The research proposes the

following questions:

1. Is there a relationship between excessive pornography use and maladaptive

metacognitions?

2. Is there a relationship between excessive pornography use and variables associated with

addiction recovery, such as exercise, meditation, and therapy?

3. Is there a relationship between variables associated with addiction recovery and

maladaptive metacognitions?

CHAPTER 2

LITERATURE REVIEW

Craving is a critical component of addiction (Caselli & Spada, 2010). A maladaptive

coping mechanism that continues the addiction cycle involved with craving is desire thinking.

Desire thinking involves a voluntarily process in the engagement of mental elaboration of the

desired substance and serves as a maladaptive way to manage cravings. This can be an effective

strategy short-term, however, over time it paradoxically escalates craving due to the desired

object that is craved and mentally elaborated on is not actually obtained (Caselli & Spada, 2010).

The Self-Regulatory Executive Function Model (S-REF) model that explains self-

regulation processing that is driven by self-beliefs, describes desire thinking as a form of

extended thinking and is a key component in the maintenance of CAS when it is in the context of

addictive behaviors (Spada & Roarty, 2015). Caselli & Spada (2011) describes two types of

desire thinking, the first of which is verbal perseveration, and the second being imaginal

prefiguration. Verbal perseveration is an elaborate self-talk strategy that focuses on the need to

obtain the desired object whereas imaginal prefiguration is the mental construction of the desired

object (Caselli & Spada, 2011). The desired object becomes more compelling over time as the

addict perceives the substance as the only possible relief from cravings, as evidenced in one

study where craving was found to impair memory, metacognitive processing, and performance in

participants who were craving caffeine (Palmer, et al., 2017).

Dysfunctions in metacognitive beliefs that are associated with stress, depression, and

anxiety disrupt metacognitive processing (Chen, et al., 2021), which is often the case in

behavioral and substance addiction and withdrawal. Since addictive behavior often presents with

a comorbid diagnosis such as stress, anxiety, or depression, this can further pave the way for the

manifestation of maladaptive metacognitions that keep the addict in the loop of addiction (Knapp

et al., 2021; Amendola et al., 2020; Alexandraki et al., 2018; Efrati et al., 2020; Efrati et al.,

2021). Although tendencies towards addiction are often thought to begin in adulthood, it can start

as early as 12 to 13 years of age with some children being exposed even younger (National

Institute on Drug Abuse, 2020). The adolescent brain could potentially be more susceptible to

problems associated with addiction given how risk taking and sensation seeking are primary

factors in typical adolescent development (Jadhav & Boutrel, 2019).

Two areas of the brain that are suspected to contribute to metacognitive processing are

the lateral frontopolar cortex (Qiu et al., 2018), and anterior lateral prefrontal cortex (Miyamoto

et al., 2021), both of which make up parts of the prefrontal cortex. In one study that induced

disruption in metacognitive processing in the anterior lateral prefrontal cortex, it was shown that

this disruption interfered with appropriate decision-making (Miyamoto et al., 2021). Another

factor that can influence and disrupt metacognitive thought are maladaptive metacognitive

beliefs associated with depression and anxiety (Chen et al., 2021), both of which can also be seen

alongside addiction. Developing self-regulation skills and appropriate coping mechanisms in

response to emotions plays a critical role in prefrontal cortex development.

The areas of the brain most suspected to contribute to addiction are the basal ganglia, the

extended amygdala, and the prefrontal cortex (U.S. Office of the Surgeon General & United

States Substance Abuse and Mental Health Services Administration, 2016). The basal ganglia is

responsible for the formation of addictions due to its role in controlling the rewarding experience

associated with substance use. The extended amygdala is the part of the brain associated with the

“fight or flight” response system which includes feelings such as stress and anxiety, both of

which are also associated with substance use withdrawal. The prefrontal cortex is primarily

associated with executive function, which also plays a role in exerting control over substance use

(U.S. Office of the Surgeon General & United States Substance Abuse and Mental Health

Services Administration, 2016).

Dysfunctional Metacognitions, Addiction, and Executive Function

Metacognition and executive function play a role in cognitive development, memory, and

motivation (Marulis & Nelson, 2021). They have been linked to self-regulated learning strategies

and integration of current knowledge (Ohtani & Hisasaka, 2018) and operate across ordered

levels of concepts such as local confidence and global beliefs (Seow et al., 2021). Maladaptive

metacognitions have been implicated in psychological disorders (Wells & Matthews, 1994), and

are associated with depression (Chen et al., 2021) and anxiety (Knapp et al., 2021), as well as

contributing factors in addictive behaviors (Bahramnejad et al., 2012, Hamonniere & Varescon,

2018; Spada & Roarty, 2015).

Processing information in the environment involves the use of the striatum, the area of

the brain associated with cognition, mainly action planning, decision-making, motivation,

reinforcement, and reward perception (Liljeholm & O’Doherty, 2012) and has been implicated in

the learning of associations between stimuli, modifying behavior through motivation, and

performance of an action to obtain a reward. The striatum is connected to the prefrontal cortex

and this connection influences decision making through processes of executive function, which

includes the ability to distinguish the difference between stimuli that is of importance and stimuli

that is not through midbrain signals to the prefrontal cortex, both of which produce dopamine.

(Blair, 2016). Overstimulation of the prefrontal cortex with too many dopamine

neurotransmitters causes a decrease in activity, which can in turn, inhibits reasoning ability

(Blair, 2016). It is through this process of reasoning inhibition that can lead to compulsive or

addictive behaviors, such as when people find themselves unable to control the use of a formerly

harmless activity such as sex (or pornography), gambling, work, internet and chatroom usage,

shopping, or exercising (Tao et al., 2010).

The nucleus accumbens is the main component of the striatum and plays a critical role in

behavior modification through its activation of dopamine neurons evidenced in Pavlovian

reward-circuit learning(Day & Carelli, 2007). This style of learning can work against an

individual who lacks the ability to self-regulate, which can lead to behavioral addictions. “Thus,

understanding reward-related Pavlovian learning could shed light on a variety of human

activities, including drug taking, food seeking, social attachment, and sexual behavior” (Day &

Carelli, 2007, p. 1). The facilitation of Pavlovian learning along with the inhibition of working

memory was evidenced by participants addicted to pornography, who indicated cue-reactive

responses when watching preferred sexual images while also showing increased activity in the

ventral striatum, the area of the brain that places value on a rewarding stimulus (Brand et al,

2016). In other words, this type of cue-reactive learning could imply impairments of executive

function including inhibition of reasoning and decreased working memory capabilities. These

impairments were further evidenced during a test of working memory capabilities in participants

with problematic sexual behavior who had better recall of pornographic pictures presented rather

than task-relevant pictures when compared to healthy controls (Sinke et al., 2020). Moreover,

similar inhibition in working memory occurred in another study when participants were

presented pictures that contained explicit imagery among those with problematic sexual behavior

(Laier et al., 2013).

A significant postulate of this commentary is that all addictions create, in

addition to chemical changes in the brain, anatomical and pathological

changes which result in various manifestations of cerebral dysfunction

collectively labeled hypofrontal syndromes. In these syndromes, the

underlying defect, reduced to its simplest description, is damage to the

“braking system” of the brain (Hilton & Watts, 2011).

Addictive behaviors have been shown to be associated with the need to control thoughts

as well as lack of cognitive confidence: “From the perspective of the metacognitive model of

addictive behaviour, metacognitive beliefs contribute to the initiation and preservation of

addictive behavior because they promote harmful thinking styles and dysfunctional coping

strategies, which in turn increase the likelihood of engaging in addictive behaviour” (Hamonnier

& Varescon, 2018, 60). Tendency towards addiction and maladaptive metacognitive beliefs was

found in a study that administered the Short Version of the Metacognitive Questionnaire (MCQ-

30) to 200 first year male university students: “The results of the study indicated that

metacognition is perhaps the most important mediator of psychoactive drug use in those looking

for treatment” (Bahramnejad, et al., 2012, 69). Negative cognitive experiences, otherwise known

as metacognitive consequences (stress, anxiety, depression), were shown to be highly associated

with substance use (Toneatto, 1999), while maladaptive metacognitions have also been

associated with distressing and out of control sexual thoughts, feelings, and behaviors (Thomas,

et al., 2020). Maladaptive metacognitions about desire thinking have also been shown in relation

to cravings for pornography in participants with problematic pornography usage (Allen, et al.,

2017). To further substantiate the relationship between metacognitive beliefs and addiction,

evidence for metacognitive therapy as a therapeutic intervention for maladaptive metacognitions

has shown success in treating addictions (Spada & Roarty, 2015).

Brain model of addiction

The brain disease model of addiction (BDMA) is the current model used to explain how

addiction impacts the individual's brain (Basu, 2020). However, this model may have

inadvertently added more stigma to those in recovery, as Sussman (2021) stated: “..terms

ascribed to persons in recovery now include being weak-willed, immoral (willful misconduct),

and sick” (Sussman, 2021, 186). Lang and Rosenberg (2017) in a survey of 612 participants

found that when it comes to addiction, the public seems unwilling to affiliate themselves with

someone they know that suffers from alcohol, heroin, gambling, marijuana, or pornography

addiction.. “A large nationwide sample of the lay public was less willing to affiliate with those

described as having an alcohol, heroin, or gambling addiction than those with a marijuana or

pornography addiction. Furthermore, women were less willing to affiliate with someone addicted

to pornography than were men” (Lang & Rosenberg, 2017, 83). Similar results were found in

the study by Lindsay, et al., (2020) with sexual addiction being one of the less understood

addictions (Lindsay, et al., (2020).

The BDMA does not put much emphasis on how social factors can shape how addiction

and recovery occurs, as evidenced by the work of Basu (2020) who traveled to five countries to

see how social responses to addiction played a role in individual recovery. These social factors

included narratives for isolation, pain, frustration, recovery, and hope, all of which play a role in

addiction and successful recovery, and all of which should be considered as essential social

aspects of not just recovery, but also prevention (Basu, 2020). As discussed in a

phenomenological study with 18 participants who had successfully achieved long-term recovery:

“These findings suggest that the relationships most helpful for initiating abstinence involved

recognition by a peer or a caring relationship with a service provider or sibling” (Pettersen, et al.,

2019, 5). With excessive pornography use not being recognized as an addiction, resources for

those who struggle with it may find it difficult to receive the adequate support needed to

successfully abstain from use. Furthermore, a crucial element in maintaining long-term success

in recovery is through positive relationships with others with whom the addict can connect to

without fear of shame, guilt, or being stigmatized over their past (Pettersen, et al., 2019).

Addressing addiction and recovery to integrate levels of understanding, experience, and control

over their recovery could produce successful results (Wiers & Verschure, 2021) and help the

individual learn metacognitive strategies that would be helpful for long-term success.

People in recovery were once viewed as weak-willed if they struggled with an addiction

(Sussman, 2021). However, successfully quitting an addiction can be challenging if help is not

available or difficult to access. Considering new evidence, it takes more than willpower alone to

be successful in recovery (Snoek et al., 2016) as employment of various strategies in recovery is

contingent on the knowledge one possesses regarding the effectiveness of those strategies or

tools, one of which is abstaining from the triggers and effective navigation through withdrawals

that are associated with the addiction. “Supporting this view, participants in recovery cite more

strategies and are more enthusiastic about them than those who have not succeeded in controlling

substance use” (Snoek et al., 2016, p. 106). Stigma being attached to people in recovery can

make it difficult to abstain from triggers associated with the addiction (Sussman, 2021). Several

aspects of the stigma include blaming the individual for their shortcomings and inability to

prevent the addiction from occurring in the first place, considering them dangerous, criminal,

sinners, dirty, worthless, no job potential, hopeless, and living in denial (Sussman, 2021).

Alleviation of the stigma would be helpful for individuals who suffer from addiction and/or

struggle with recovery and part of this is through public education, activism efforts, peer

recovery support services, and health communications literacy (Sussman, 2021).

The Neurobiology of Addiction

The average age of exposure to pornography is 13, with exposure occurring as young as

five years of age (American Psychological Association, 2017). Exposure that occurs during

adolescence could be a cause for concern (Wright et al., 2019). Understanding the neurological

aspect of addiction in how it relates to interference with the striatum and NAc provides insight to

the aspects of maladaptive metacognitions, especially if exposure occurs during a time when the

brain is not fully developed because the human brain mechanisms are designed to provide

reinforcements to make experiences related to survival rewarding (Hyman, 2006). However,

these same mechanisms can become hijacked by certain drugs such as those with

psychostimulant properties like cocaine and amphetamines (Hyman, 2006, Koob, 2010). Once

hijacked, the brain mechanisms create reinforcements that further the behavior associated with

consumption of a drug such as seeking, intake, and tolerance. Substance addiction is

characterized by the individual's need to take the drugs, tolerance of the drug, loss of control over

intake of the drug, followed by negative emotional states after the drug has worn off (Koob,

2010). Since humans learn cues in their environment, a form of Pavlovian learning (Day &

Carelli, 2007), these cues can also motivate substance seeking behaviors (Hyman, 2006) and

become driving forces that motivate the addict toward the substance, which eventually causes

structural changes in the brain. Structural changes such as motivation associated with drug

administration, tolerance, and withdrawal are due to alterations in the natural reward system of

the brain, otherwise known as the dopaminergic system (Koob, 2010). The dopaminergic system

plays a role in cognitive flexibility and regulation of executive function and the alterations of the

dopaminergic system are what influences the continuation of addictive behaviors by labeling

cues associated with the addictive substance, along with consumption of the substance, as

rewarding and reinforcing (Brewer, 2007).

The neurobiology of addiction that influences the dopaminergic systems has been shown

to have the same structural changes in behavioral addictions as we would see in someone who

suffers with substance addiction (Brewer & Potenza, 2007). Conditioned responses to cues that

are drug-related can include stimuli that are external or interoceptive (Hyman, et al, 2006)

meaning the cues don’t have to be external to have an influence on behaviors and actions. These

conditioned responses in the dopaminergic system that occur in behavioral addictions also cause

a release of dopamine to produce feelings of pleasure when primed with cues in the environment

or internal cues that are related to the behavioral addiction (Brewer, 2007). Dopamine is known

for its role in motivation and absence of dopamine removes the motivation of obtaining a

substance or behavior, therefore dopamine plays a powerful role in motivation to obtain the

reward (Hyman, et al, 2006).

Molecular underpinnings in new research has shown that addiction pathways are induced

due to several proteins in the brain, one of which is DeltaFosB (Nestler, 2008). DeltaFosB is part

of the Fos family and is encoded by the fosB gene, which heterodimerizes with other family

proteins known as Jun, to activate and bind to other sites in the brain (Nestler, 2008). The Fos

family proteins that activate during certain behavioral or cellular situations show that after acute

consumption or administration of several drugs of abuse, they induce rapidly and transiently in

specific brain regions (Nestler, 2008) one of which being the nucleus accumbens (NAc), which is

critical for the reinforcement of rewarding behavior, including sexual rewards (Pitchers, et al.,

2010). This leads to structural changes and alterations in the NAc, such as the formation of

dendritic spines that persist long after the removal of the drug or behavior ceases (Hedges, et al.,

2009). Although the Fos family proteins are unstable and return to basal levels within hours after

drug administration, chronic administration of drugs creates biochemically modified isoforms of

DeltaFosB after repeated exposure which persist some 6-8 weeks after the last intake (Nestler,

2008; Hedges, et al, 2009).

Molecular research has also asserted that the NAc also plays a role in mediating natural

rewards, thus developing a relationship between natural rewards and the accumulation of

DeltaFosB (Wallace, et al, 2008). In a study with experimental rats, it was indeed shown that

DeltaFosB accumulates in the NAc for two types of natural rewards: sucrose and sex (Wallace,

et al, 2008). “These increases were observed by Western blotting and immunohistochemistry;

using both methods ensures that the observed protein product is indeed DeltaFosB and not full-

length FosB, another product of the fosB gene” (Wallace, et al, 2008, 10276). Another study of

experimental rats by Pitchers, et al., 2010 shows similar results, in that, accumulation of

DeltaFosB is also caused by sexual experience and the accumulation occurs in several of the

limbic-associated brain regions. “Specifically, reducing DeltaFosB-mediated transcription

attenuated experience-induced facilitation of sexual motivation and performance, while

overexpression of DeltaFosB in the NAc caused an enhanced facilitation of sexual behavior, in

terms of increased sexual performance with less experience” (Pitchers, et al., 2010, 836).

Hedges, et al., 2009 found similar results with female Syrian hamsters, adding that the

conditioned place of sexual activity causes dopamine to release in the NAc after repeated

copulatory interactions with males (Hedges, et al, 2009). If the place of interaction with sexual

experience becomes associated with dopamine release (Wallace, et al., 2008) this would imply

that the setting also plays an important role in the rewarding behavior and motivation to perform

the behavior associated with the reward. “It is reasonable to consider DeltaFosB as acting as a

transcriptional nexus that is mediating both long-term modifications in behavior and the

underlying neuronal plasticity consequent to the activation of the downstream targets of

DeltaFosB” (Hedges, et al., 2009, 446). This has considerable impact on how an individual

functions within their environment, and how motivation, seeking, thinking, urges, and desire

thinking of natural rewards can impact and alter behavior. During the process of imaginal

prefiguration in desire thinking, dopamine can be produced, which can then initiate verbal

perseveration of the desired target, thus causing emotional distress until the desired target is

obtained.

Tolerance to the drug or behavior of the addicted individual is also due to changes in the

molecular structure of the brain (Love, 2015). As dopamine floods the reward system, molecular

signals occur which lead to tolerance, such as activation of the CREB protein. CREB activates in

the NAc in response to stimuli and regulates neural plasticity (Barrot, et al., 2002). Increased

CREB activity in the brain’s reward pathway decreases the response to stimuli which in turn,

creates tolerance. When an addict abstains from a substance or behavior CREB reduces quickly

whereas DeltaFosB levels drop slowly over time, making DeltaFosB the primary component of

addiction (Love, 2015, Nestler, 2001).

Cognitive Processing in Long-Term Addiction. The human brain contains more neurons

than other species, and it is thought through the evolutionary process of human brain

development, that this growth of additional neurons were responsible for new neural circuits and

cognitive functioning that greatly contributed to cultural evolution (Muchnik, et al., 2019). This

additional growth of neuronal functioning eventually gave rise to cognition in the way we know

and understand it today. Cognitive processing of information relies heavily on executive function

capabilities as well as metacognitive abilities, as mentioned above. Rapid shifting of attention

from one task to another, or from one stimulus to another requires a substantial amount of effort

and increases cognitive load. When cognitive load occurs, it decreases the ability to process

information efficiently in the environment, thus, negatively impacting executive function. In

those with psychological disorders, cognitive capacity is already compromised, as evidenced in a

review of 200 peer-reviewed studies in patients with psychological disorders, where it was found

that the majority reported reduced grey matter in crucial areas of the brain responsible for

cognitive processes, which in turn, created disruptions in cognition (McTeague, et al., 2016).

Cognitive processing deficits in individuals with long-term addictions was evidenced in a

study that assessed 23 patients who were admitted to a hospital for recovery treatment from

substance addiction (Lopera, et al. 2019). These deficits include impairments in attention, focus,

executive function, memory, and ability to learn and retain information (Rajeswaran & Bennett,

2018). Another process associated with the cycle of addiction that plays a role in maladaptive

metacognitions, is that of affective processes. “Affective processes include physiological and

subjective responses to addiction-related stimuli, reward sensitivity and reward anticipation,

experiences of gratification, emotion (dys-) regulation, mood management, and stress sensitivity

(Wegmann & Brand, 2021, 1-2). The role of affective processes shows that dysfunctional generic

metacognitive beliefs have an influence over metacognitive beliefs about thoughts related to

addiction, and metacognitive beliefs about craving, and can also predict not only the severity of

the addiction, but also cravings related to the addiction (Hamonniere & Varescon, 2018).

Triphasic Metacognitive Formulation of Addictive Behaviors

Understanding of the neurobiological underpinnings of addiction shows how addiction

related cues can have considerable impact on how an individual is able to function within their

environment. The cues that activate neural pathways impact how motivation, seeking, thinking,

urges, and desire thinking of natural rewards can alter behavior by putting a strain on cognitive

resources. This process can eventually create a system of coping mechanisms that work against

the individual who is experiencing distress from the cycle of addiction.

Cognitive Attentional Syndrome (CAS) is a range of coping mechanisms that are argued

to extend negative thinking and negative emotions in response to an external event, according to

the S-REF model (Wells & Matthews, 1994). The external event in terms of addiction is

associated with stimuli-related cues in the environment as well as internal cues based on triggers

that occur during unconscious processing. As a result, these negative emotions and thoughts

consist of the need to control worry, need to control thoughts, desire thinking, and rumination.

During periods of psychological distress, metacognitive techniques serve to reduce worry

through the introduction of healthier coping mechanisms in response to stimulus-driven

intrusions (Spada & Roarty, 2015). For addictive behaviors, CAS and metacognitive beliefs are

broken down into three phases, which are pre-engagement, engagement, and post-engagement

(Spada, et al., 2014). The pre-engagement phase is associated with triggers, urges, memories,

thoughts, and images which in turn, guide judgment toward coping mechanisms which then

activate metacognitive beliefs associated with the appraisal of the addictive substance. This

activation of CAS leads to preservation of the intrusive thoughts which increase urges and

cravings. During the engagement phase, positive metacognitive beliefs and thoughts associated

with those beliefs are activated and changes how metacognitive processing is monitored, which

in turn, reduces the ability to self-regulate behavior. In the post-engagement stage, withdrawal

symptoms and self-blame activate positive metacognitive beliefs, which activates rumination,

which in turn increases the likelihood of relapse or re-engagement in the substance (Spada &

Roarty, 2015).

The triphasic metacognitive formulation of addictive behaviors proposes that aspects of

the CAS such as attentional bias, extended thinking (e.g., desire thinking, rumination and worry),

disruption in metacognitive monitoring and thought suppression should be associated with

addictive behaviors and lead to maladaptive consequences including increased levels of craving

and engagement. The formulation also proposes that metacognitive beliefs should be associated

with aspects of the CAS and addictive behaviors. (Spada & Roarty, 2015, 12).

Attentional bias consists of automatic processing and implementation of strategies that

can lead to dysfunctional coping styles. These coping styles are what appraises and determines

the relevance of the stimuli, thus, allowing the implementation of metacognitive beliefs as a

strategy for determining whether to engage in or disengage from thoughts associated with the

stimuli. Extended processing of the stimuli such as rumination and worry, can lead to the

continuation of desire thinking of the stimuli. Thought suppression, which is the attempt to

suppress thoughts and urges associated with the stimuli, paradoxically causes further thinking of

thoughts and urges. Disruptions in metacognitive monitoring create problems with attentional

processing, thus, reducing cognitive processing. Metacognitive beliefs are both positive and

negative in nature and are both related to maladaptive thinking patterns. Positive beliefs are

thoughts that allow for engagement in the substance whereas negative beliefs are related to the

lack of executive control over the regulation of engaging in the addictive substance (Spada &

Roarty, 2015)

Metacognition in Problematic Internet Usage. Problematic internet usage, internet addiction,

and social media addiction are not currently recognized by the DSM-V as disorders. Regardless,

there have been several studies that have found dysfunctional metacognitive beliefs after

administering the MCQ-30 to participants who fell into one of the three categories, with one

study noting a significant relationship between internet addiction and metacognition, as well as a

relationship between general health and metacognition (Bidi, et al., 2012). Feeling unable to

control thoughts when faced with a stressful event could incapacitate metacognitive processing,

leading to an overestimation of environmental threat and underestimation of coping abilities.

“The experience of emotional tension in persons with high scores of uncontrollability and risk

involves them in using maladaptive coping strategies which would in turn cause the concepts of

threatening in process more accessible and stress and negative excitement more intensified”

(Bidi, et al., 2012, 54). In another study it is suggested that maladaptive metacognitive beliefs are

associated with problematic social networking usage, asserting the possibility that problematic

social networking usage exhibits similar symptoms of other addictions (tolerance, mood

modification, relapse, withdrawal, etc.), further stating that individuals with problematic social

networking usage scored higher on all subunits of the MCQ-30, with the exception of cognitive

self-confidence, than that of the control participants (Balıkçı, et al., 2020). A relationship

between depression and dysfunctional metacognitions in those with smartphone addiction in

Chinese adolescents was found (Zhou, et al., 2021) as well as a relationship between

dysfunctional metacognitions and social networking addiction among adolescence (Ünal-Aydın,

et al., 2021). Activation of the dopaminergic reward system and deactivation of executive

functioning was found among participants addicted to Instagram (Nasser, et al., 2020) and

maladaptive personality functioning was found in a sample of adolescent participants addicted to

the internet, video games, and mobile phones (smartphones) (Amendola, et al., 2020).

Metacognition and Online Gambling Addiction. Gambling disorder is listed in the DSM-V as

a behavioral disorder and is characterized as a persistent and recurrent problem related to

gambling behavior that causes impairment or distress that reaches clinical significance

(American Psychiatric Association, 2013). After administration of the MCQ-30, such

impairments were found in the case of 69 pathological gamblers, where MM were present in

participants with comorbid mental disorders (Mansueto, et al., 2016). Another study of 124

pathological gamblers found similar results (Jauregui, et al., 2016), with another suggesting that

metacognitive biases played a role in pathological gambling while at the same time providing

empirical support for metacognitive training to dispel these false beliefs (Moritz, et al., 2021).

Metacognition and Alcohol Use Disorder (AUD). AUD is listed in the DSM-V and is

characterized as a brain disorder that involves chronic relapses, increased consumption over

time, and inability to reduce or eliminate consumption regardless of negative consequences that

occur with continued usage (American Psychiatric Association, 2013). According to S-REF

theory, metacognitive beliefs serve as strategies for self-regulation that become

counterproductive in psychological disorders, such as anxiety and depression (Wells &

Matthews, 1996): In a study of 10 problem drinkers, it was found that if the participants had the

initial goal of drinking to reduce or eliminate unwanted thoughts or emotions, they were unaware

of whether their goal had been reached or not and continued to drink until they felt ill, which

could indicate dysfunctional metacognitive beliefs in response to emotional changes (Spada &

Wells, 2006). Another study found a relationship between alcohol use and dysfunctional

metacognitions in four of the five units of the MCQ-30 when administered to 97 participants as

well as positive metacognitions in two of the five units for proneness to problem drinking (Spada

& Wells, 2005) suggesting the presence of maladaptive metacognitive processing in relation to

alcohol consumption.

Recovery tools used in treatment programs

Meditation as a tool in recovery does appear to offer some promising results in

decreasing maladaptive metacognitions. One finding that emerged from a meta-analysis was that

spiritual meditation significantly reduced addiction related consequences and appeared to have

an impact on the discontinuation of drug intake among participants (Kadri, et al., 2020).

Mindfulness meditation appeared to contribute to the reduction of stress and other factors that

stem from maladaptive coping skills that, if left unmanaged in recovery, would allow the

individual who is recovering unable to deter themselves from a relapse (Witkiewitz & Bowen,

2010). One of the factors of mindfulness meditation is its use of metacognitive techniques. “In

vipassana meditation, mindfulness regulates attention in such a way that attention is directed to

monitor the ever-changing experiences from moment to moment so that the practitioner attains

the ‘metacognitive insight’ into the nature of things” (Kuan, 2012, 35). It is suggested that if a

client in recovery is open to meditation, that meditation techniques should be taught in

counseling, so the individual has another tool for recovery to utilize outside of therapy (Pruett, et

al., 2007). This method of teaching client’s meditation was performed in a study of 72 cocaine-

dependent participants, and the integration of meditation and acupuncture suggests that

meditation may help improve attention, prevent relapse, and reduce tension because participants

were able to utilize these tools at home (Chen, et al., 2013). This was also demonstrated in

another study where participants were given tools to take home to practice meditation: “The

mindfulness practices employed in the course were designed to help clients increase awareness

of and change the relation to challenging situations, including negative emotional states, without

“automatically” or habitually reacting” (Witkiewitz & Bowen, 2010, 369). This demonstrates an

increase in metacognitive functioning as individuals in recovery can redirect thoughts away from

compulsive habits, thus remaining abstinent from substances.

Exercise, Recovery, and Metacognition. We all understand the benefits that exercise can

provide for overall physical health and well-being. Regardless, some people have trouble finding

the time or motivation for it despite evidence that supports the benefits of exercise on cognition

and metacognition (Stern, et al., 2019; Raichlen & Alexander, 2017).

Participants who were recovering from methamphetamine addiction that participated in

an exercise and cognition program for a duration of 3 months found that negative mood states

associated with withdrawal and cravings were reduced (Lu, et al., 2021) and in a completed 8-

week trial of an exercise program there was a reduction in depression symptoms among

methamphetamine users in recovery (Haglund, et al., 2014). A study with Sprague-Dawley rats

who were introduced to chronic exercise on a treadmill over an 8-week period suggests that

exercise may serve as a prevention from addiction (Fontes-Ribeiro, et al., 2001).

CHAPTER 3

METHODOLOGY

The purpose of this study is to examine the relationship between maladaptive

metacognitions and excessive pornography use in the adult population. It is hypothesized that

results will be comparable to previous studies examining maladaptive metacognitions in

problematic internet use (Balıkçı, et al., 2020, Bidi, et al., 2012, Nasser, et al., 2020, Ünal-Aydın,

et al., 2021, Zhou, et al., 2021), alcohol use disorder (Spada & Wells, 2006), and online

gambling disorder (Mansueto, et al., 2016, Moritz, et al., 2021, Jauregui, et al., 2016). Therefore,

this research proposes the following questions:

1. The first question states that there will be a relationship between excessive

pornography use and maladaptive metacognitions. The relationship will show that as

pornography use increases, maladaptive metacognitions will also increase.

2. The second question states that there will be a significant relationship between

pornography use and activities associated with substance abuse recovery programs. It

is also assumed that pornography use contains an emotional component, which will

be evidenced by the responses in the Triggers section in Recovery Elements. More

specifically, as pornography use increases, emotional struggles will also increase

while items such as meditation and exercise, which serve to increase metacognitive

abilities, will decrease

3. The third question states that there will be a relationship between emotional struggles,

and tools used in substance addiction recovery groups, with dysfunctional

metacognitions. It is assumed that as emotional struggles increase, maladaptive

metacognitions will also increase which continues the cycle of addiction. It is also

assumed that tools used in substance addiction recovery programs will serve to

decrease maladaptive metacognitions.

Participants

The Internal Review Board (IRB) at Wichita State University reviewed and approved the

survey to be administered on January 7th, 2020. Participants had to be at least 18 years of age or

older to participate in the survey. The assessments, along with demographic information

questions, were compiled onto one survey on Qualtrics and distributed via anonymous link. No

personal information was collected, and respondents were able to remain anonymous. The survey

was posted on various social media pages such as Twitter, Facebook, and Reddit, as well as sent

via Facebook Messenger to help initiate the snowball sampling effect. It was also posted in

several Facebook groups for the same reason.

A research proposal was sent to the NoFap (2011) website for permission to post the

survey link to members of that community on January 9th, 2022, to sample the very population

we were seeking. Permission was granted to sample from both the NoFap (2011) website, as well

as the subreddit of NoFap on January 19th, 2022. An anonymous account was made in both

places, and the survey was posted in various forums on the NoFap (2011) website as well as the

subreddit forum of NoFap. Considering the participation rates greatly increased after posting the

surveys on NoFap (2011) and the subreddit of NoFap, it has led the researchers to believe most

participants came from one of these sites.

Over 3000 participants responded to the questionnaire. However, 2423 participants had to

be excluded from the analysis due to incomplete data leaving a sample of 877 participants.

Participants (n=877) provided consent to participate and were 18 years of age or older.

Participants self-reported on the assessment that contained demographics, pornography use

history, the BPS, MCQ-30, MDTQ, and Recovery Elements.

Demographics

Data collected included gender (table 1), age (table 2), relationship status (table 3),

education level (table 4), whether they were seeing a mental health professional (table 5), or if

they felt they needed to see a mental health professional (table 6), and religious affiliation (see

table 7).

As shown in Table 1, the primary gender of participants were male.

TABLE 1

PARTICIPANT GENDER

GENDER

NUMBER

Male

849

Female

Nonbinary

Transgender

Prefer not to say

Total

877

As shown in Table 2, the most common age group of participants was 20-24.

TABLE 2

PARTICIPANT AGE GROUPS

AGE

NUMBER

18-19

200

20-24

357

25-29

185

30-39

106

40-49

50-59

60+

Total

877

As shown in Table 3, the most common relationship status selected was single.

TABLE 3

RELATIONSHIP STATUS

NUMBER

Valid

Single

617

Dating but not committed

Committed relationship

162

Married

Other

Total

875

Missing

System

Total

877

As shown in Table 4, there is some variation in education.

TABLE 4

HIGHEST EDUCATIONAL DEGREE OBTAINED

EDUCATION

NUMBER

Some high school

High school graduate

178

Some college

237

Associate degree

Bachelor’s degree

261

Master’s degree

Doctorate degree

College certificate

Medical professional

Total

877

As shown in Table 5, most participants are not currently seeing a professional.

TABLE 5

PARTICIPANTS SEEING A PROFESSIONAL

CONDITION

NUMBER

Anxiety

Depression

ADHD

Autism

Bi-Polar Disorder

Addiction/Compulsion

Something not Listed

I am not seeing a professional

682

Total

748

Missing

System

129

Total

877

As shown in Table 6, most participants did not feel as though they needed to see a

professional.

TABLE 6

PARTICIPANTS WHO FEEL THEY NEED TO SEE A PROFESSIONAL

CONDITION

NUMBER

Anxiety

Depression

ADHD

Autism

Bi-Polar Disorder

TABLE 6 (continued)

Addiction/Compulsion

Something not Listed

I am not seeing a professional

337

Total

546

Missing

System

331

Total

877

As shown in Table 7, there is much variation within the participants’ religious and/or spiritual

views.

TABLE 7

RELIGIOUS/SPIRITUAL VIEWS

VIEWS

NUMBER

I don’t have a religion/I am not spiritual

211

I believe in something, but I don’t follow a particular religion or spiritual practice

208

I practice a religion, but I am not heavily involved (Christianity, Catholicism, etc.)

216

I am heavily involved in religion

101

I include spiritual practices in my life, but I am not heavily involved in them

I am heavily involved in spiritual practices

I practice something, but don't feel as though any of these apply to me

Prefer not to say

Total

877

The history of individual pornography use questions were also included in the survey and

participants had the option to skip the section if they felt uncomfortable with the questions. We

asked how many years participants viewed pornography, the duration in which they had last

viewed pornography, the age they were first exposed to pornography, the most frequent means of

accessing pornography, if they are actively trying to quit using pornography, if their significant

other is aware of the pornography use, if their significant other was supportive in their efforts to

quit using pornography, and if they were actively trying to quit using pornography. Most

participants reported they had first been exposed to pornography under age 15 (n= 830), they last

viewed pornography within 0-3 months from the time they responded to the survey (n=803), and

they were trying to quit using pornography (n= 741). The most frequent means of viewing was

through a smartphone (n=447) and high-speed internet on a computer (n=344).

Research Tools

The assessments that will be used for the purpose of this study include, The Brief

Pornography Screener (BPS), The Short Form of the Metacognitions Questionnaire (MCQ-30),

Metacognitions about Desire Thinking Questionnaire (MDTQ), and Recovery Elements. The

BPS consists of five questions and will help determine problematic use of pornography, with

those scoring four points or higher indicating problematic pornography usage (Kraus, et al.,

2020). The MCQ-30 consists of 30 questions with five subscales that measure maladaptive

metacognitions (Wells & Cartwright-Hatton, 2004). These scales include the following: Negative

beliefs about uncontrollability of danger, cognitive confidence, positive beliefs, cognitive self-

consciousness, and negative beliefs about the need to control thoughts. The MDTQ consists of

three subscales that measure metacognitions about desire thinking (Caselli & Spada, 2013),

which for the purpose of this study the desired item is pornography. These subscales include the

following: Negative metacognitions about desire thinking and need to control desire-related

thoughts. Recovery Elements consist of various tools used in recovery as well as frequency of

triggers related to the addiction, and media use (For full review of Recovery Elements, see

Appendix).

The Short Form of the Metacognition Questionnaire (MCQ-30). The adult version of the

Metacognitions Questionnaire-30 (MCQ-30) (Wells & Cartwright-Hatton, 2004), which is a

shortened version of the Metacognitions Questionnaire, and measures metacognitive beliefs

through self-report. The MCQ-30 is considered more economical, with good internal consistency

(Wells & Cartwright-Hatten, 2004). It is a 30-item scale that will assess five different scales of

metacognitive beliefs which are: Negative beliefs about uncontrollability of danger, cognitive

confidence, positive beliefs, cognitive self-consciousness, and negative beliefs about the need to

control thoughts. Participants rate each item on a 4-point Likert scale with higher scores

indicating more maladaptive metacognitions. It has been validated as an assessment of

metacognitive beliefs in at risk mental state for psychosis and has demonstrated good fit and very

good internal consistency (Bright, et al., 2018), and has demonstrated a positive association

between internet gaming disorder and maladaptive metacognitions in the Chinese adapted

version (Zhang, et al., 2020).

The Metacognitions About Desire Thinking Questionnaire (MDTQ). The MDTQ contains 18

questions measured along three scales which are as follows; Positive metacognitions about desire

thinking (8 questions), Negative metacognitions about desire thinking (6 questions), and need to

control desire-related thoughts (4 questions). Participants rate each item on a 4-point Likert scale

with higher scores indicating more maladaptive metacognitions related to desire. For this study,

desire thinking is related to feelings towards pornography. The MDTQ has shown good

psychometric properties as well as divergent and predictive validity (Caselli & Spada, 2013).

The Brief Pornography Screener (BPS). The BPS is a 5-question assessment where

questions are answered as never (0 points), sometimes (1 point), and frequently (3 points), with

participants scoring 4 or under as not likely having a problem with pornography usage (Kraus, et

al., 2018). The BPS, which was developed by Kraus et al., (2018) has been used as a way to

detect problematic pornography use (score range: 0–10) with higher scores indicative of more

problematic pornography use. It has been demonstrated to have high internal consistency,

elements of construct, convergent criterion, and discriminant validity (Cronbach’s alpha 0.84), to

determine if participants have a problem with pornography usage (Kraus, et al., 2020).

Recovery Elements. The NoFap (2011) website was founded in June of 2011 by

Alexander Rhodes for the purpose of providing a community-based website for users seeking

support from excessive pornography use and compulsive sexual behavior (NoFap, 2011).

Multiple strategies have been reported by the users on the NoFap (2011) website as beneficial

tools used to abstain from pornography use and include, but are not limited to, meditation,

exercise, playing sports, reading, puzzle games, learning new things, involvement in religious or

spiritual practices, adjusting sleep schedules, attending individual or group therapy, and speaking

with an accountability partner. An accountability partner is akin to that of a sponsor and is an

individual who also struggles with excessive pornography use, who shares insights and strategies

they found helpful to other persons who feel stuck in their own process.

Maintaining a positive view in recovery is an important component of recovery (Snoek et

al., 2016) and it has been reported on the NoFap (2011) website by users that how an addict

views their own recovery can either benefit or hinder the process. However, having a positive

attitude can be difficult due to stigma, and being stigmatized as a person in recovery can serve as

a hindrance in seeking help for any addiction. This stigma could be due to how people in

recovery were once viewed as weak-willed if they struggled with an addiction (Sussman, 2021),

despite evidence that shows to successfully quit an addiction it takes more than willpower alone

(Snoek et al., 2016). It takes a positive attitude towards recovery, motivation to quit, along with

the employment of various strategies to maintain a successful recovery (Snoek et al., 2016). How

someone views recovery, uses various strategies for recovery, and motivation towards a

successful recovery from pornography use may play a role in comorbid conditions which in turn,

could play a role in metacognitive functioning.

Mindfulness meditation has been shown as a possible resource for increasing

metacognitive processes by reducing anxiety (Knapp et al., 2021) and depression, both of which

are implicated in persons with substance addictions (Kadri et al., 2020; Witkiewitz & Bowen,

2010; Kuan, 2012; Chen et al., 2013). Exercise has also been shown to provide overall physical

and mental well-being, which is beneficial for recovery due to the increase in cognition and

metacognition and reduction of stress, anxiety, and depression (Stern et al., 2019; Raichlen &

Alexander, 2017). How either of these play a role in abstaining from excessive pornography use

in adults is not understood, however, they could potentially prove to be as beneficial as they do

in other treatment programs.

How an individual views their personal journey in recovery may influence recovery

success and could be a part of the maladaptive metacognitions. For example, stigma, acceptance

of personal responsibility and the ability to maintain positive views towards one's own recovery

are important components of a successful recovery (Pettersen, et al., 2019; Snoek et al., 2016). If

persons who are in recovery are unable to reflect on their decisions, it could lead them back into

the addiction. Information in this section will be collected to better understand if a person

recovering from pornography addiction feels as though they are in control of their own recovery

and will be based on self-reported tools from users on the NoFap (2011) website. Recovery

Elements, for the purpose of this study, is a broad term to describe categories that will assess

items such as, recovery tools, activities, trigger response, and engagement in media. Recovery

tools include, but are not limited to meditation, exercise, individual therapy, group therapy,

engaging in sports, practicing yoga, reading literature pertaining to pornography addiction,

getting involved with religious or spiritual practices, and response/intensity to triggers. The

effectiveness of these elements in general have not been studied in relation to pornography

addiction, however, a few tools have been studied in relation to other addictions, such as exercise

and meditation as described previously. The survey will include use of recovery tools, activities

participants engage in, how much media participants consume, and how participants respond to

triggers (for full review, see Appendix).

Procedures

Assessments were compiled in Qualtrics with a total of nine blocks. Participants had to

be 18 years of age or older and had to consent to participate to proceed through the survey. They

were provided the option to skip questions or sections deemed uncomfortable and were able to

end the survey at any time. Participants who consented completed the survey via computer or

mobile device at their convenience with the average time to complete the survey being 30

minutes. Survey administered contained the MCQ-30, MDTQ, BPS, Recovery Elements, history

of pornography use, as well as demographic information. Once participants opened the survey,

they had seven days to complete it. Survey remained opened from January 7th, 2022, to February

16th, 2022, with the last response being recorded February 23rd, 2022.

Data Analysis

A principal component factor analysis was used to better understand which of the

recovery elements were most used. The primary purpose of a principal component analysis is to

identify and compute which recovery elements for factors are the source of underlying changes

being made, or not made, to abstain from pornography use, and to decrease maladaptive

metacognitions. This procedure was appropriate for the purpose of this study as it enabled the

investigation of which concepts were most used and allowed for the reduction of recovery

elements to better understand which ones were most effective in decreasing maladaptive

metacognitions and pornography use. After the principal component factor analysis was

performed, a multiple regression analysis was performed to test if the recovery elements

significantly predicted participants pornography use and maladaptive metacognition. Another

multiple regression analysis was performed to see if the subscales of the MDTQ and MCQ-30

significantly predicted participants pornography use and maladaptive metacognition. Multiple

regression analysis was appropriate for the purpose of this study because it assesses the strength

of the relationship between the dependent variable and predicter variables, as well as establishes

the importance of the predictors on the relationship.

CHAPTER 4

RESULTS

The purpose of this study was to examine the relationship between maladaptive

metacognitions and excessive pornography use in the adult population. It was hypothesized that

results will be comparable to previous studies that examined the relationship between

maladaptive metacognitions in problematic internet use (Balıkçı, et al., 2020, Bidi, et al., 2012,

Nasser, et al., 2020, Ünal-Aydın, et al., 2021, Zhou, et al., 2021), alcohol use disorder (Spada &

Wells, 2006), and online gambling disorder (Mansueto, et al., 2016, Moritz, et al., 2021,

Jauregui, et al., 2016). The research questions of this study are as follows:

4. The first question states that there will be a relationship between excessive

pornography use and maladaptive metacognitions. The relationship will show that as

pornography use increases, maladaptive metacognitions will also increase.

5. The second question states that there will be a significant relationship between

pornography use and activities associated with substance abuse recovery programs. It

is also assumed that pornography use contains an emotional component, which will

be evidenced by the responses in the Triggers section in Recovery Elements. More

specifically, as pornography use increases, emotional struggles will also increase

while items such as meditation and exercise, which serve to increase metacognitive

abilities, will decrease

6. The third question states that there will be a relationship between emotional struggles,

and tools used in substance addiction recovery groups, with dysfunctional

metacognitions. It is assumed that as emotional struggles increase, maladaptive

metacognitions will also increase which continues the cycle of addiction. It is also

assumed that tools used in substance addiction recovery programs will serve to

decrease maladaptive metacognitions.

The average score of the BPS was over four points (M=7.6) indicating problematic use

among the sample collected (Kraus, et al., 2018). To better understand which of the recovery

elements were most used, a principal component analysis was performed. Principal components

analysis was used because the primary purpose was to identify and compute which recovery

elements for factors are underlying the changes being made or not made to abstain from porn use

and decrease maladaptive metacognitions. Items used for analysis contained Eigenvalues over 1.

The Kaiser Meyer Olkin (KMO) measure of sampling adequacy was conducted to examine the

strength of a correlation between the variables. It is ideal for scores on the KMO to be closer to

1, with scores falling below 0.5 considered unacceptable. Five items were retained from tools for

a cumulative percentage of 54.86% (see table 8). The KMO for tools is .769 (p = .000). Four

items were retained for activities for a cumulative percentage of 61.96% (see table 9). The KMO

measure for activities is .721 (p = .000). Three items were retained for engagement with media

for a cumulative percentage of 46.16% (see table 10). The KMO measure for engagement in

media is .695 (p < .001). Five items were retained for activities for a cumulative percentage of

63.31% (see table 11). The KMO measure for triggers is .920 (p = .000). All regression analyses

were performed in IBM SPSS statistics version 27.

Question 1

The first question states that there will be a relationship between the Brief Pornography

Screener and MCQ-30/MDTQ. The relationship will show that as pornography use increases,

maladaptive metacognitions will also increase. To test this question, a multiple regression

analysis was performed to see if dysfunctional metacognitions significantly predicted

participants’ pornography use. The results indicate the MDTQ explained 24% of the variance

(R2 = .238, F(1, 875) =273.41, p<.001) and MCQ-30 explained 11% of the variance (R2 = .108,

F(1, 875) =140.58, p<.001). It was found that the MDTQ significantly predicted pornography

use (β =.123, p < .001) as did the MCQ-30 (β =.025, p < .001).

To further understand the extent to which maladaptive metacognitions influence

pornography use and to test the linear relationship of each subscale, the BPS was analyzed with

each subscale of the MCQ-30 and MDTQ separately.

A multiple regression analysis was performed to test if the subscales of the MDTQ

significantly predicted participants’ pornography use. The results indicate the MDTQ subscale

PMDT explained 5% of the variance (R2 = .053, F(1, 875) = 49.39, p<.001). It was found that

the PMDT significantly predicted pornography use (β = .110, p < .001). The subscale NMDT

explained 30% of the variance (R2 = .303, F(1, 875) = 381.21, p<.001). It was found that the

NMDT significantly predicted pornography use (β = .305, p < .001). The subscale NCDT 12% of

the variance (R2 = .119, F(1, 875) = 118.25, p<.001). It was found that the NCDT significantly

predicted pornography use (β = .266, p < .001).

A multiple regression analysis was performed to test if the subscales of the MCQ-30

significantly predicted participants’ pornography use. Negative beliefs about thoughts

concerning uncontrollability and danger explained 10% of the variance (R2 = .102, F(1, 875)

=99.03, p<.001). It was found that the negative belief subscale significantly predicted

pornography use (β =.159, p < .001). Negative beliefs about the need to control thoughts

explained 8% of the variance (R2 = .080, F(1, 875) =76.13, p<.001). It was found that the

negative belief subscale significantly predicted pornography use (β =.115, p < .001). Positive

beliefs about worry explained 2% of the variance (R2 = .016, F(1, 875) =14.40, p<.001). It was

found that the positive belief subscale significantly predicted pornography use (β =.076, p <

.001). Cognitive confidence explained 4% of the variance (R2 = .044, F(1, 875) =40.70, p<.001).

It was found that the cognitive confidence subscale significantly predicted pornography use (β

=.108, p < .001). Cognitive self-consciousness explained 1% of the variance (R2 = .012, F(1,

875) =10.33, p = .001). It was found that the cognitive self-consciousness subscale significantly

predicted pornography use (β =.066, p = .001)

Question 2

The second question states that there will be a significant relationship between

pornography use and recovery elements used. More specifically, it is assumed that as

pornography use increases, triggers and media will also increase while tools and activities

decrease. A multiple regression analysis was performed to test if Recovery Elements

significantly predicted participants’ pornography use. To further understand how Recovery

Elements are utilized, Tools and Triggers were ran separate from Media and Activities in the

analysis. The results indicate that Tools and Triggers explained 1% of the variance (R2 = .011,

F(2, 872) = 6.01, p =.003), and Activities and Media explained 1% of the variance (R2 = .013,

F(2, 873) = 6.01, p =.001). It was found that tools (β =-.-.069, p=.001 ), triggers (β =.206,

p=.000 ), activities (β =-.071, p=.018 ), and media(β =.119, p=.002 ) significantly predicted

pornography use.

Question 3

The third question states that there will be a relationship between dysfunctional

metacognitions and recovery elements used. It is predicted that tools and activities will decrease

dysfunctional metacognitions whereas media and triggers will increase dysfunctional

metacognitions. A multiple regression analysis was performed to test if Recovery Elements

significantly predicted participants’ dysfunctional metacognitions. For consistency, both the

MCQ-30 and MDTQ were run with tools and triggers, then activities and media as it was when

analysis was with the BPS. The results indicate that for the MCQ-30 Tools and Triggers

explained 12% of the variance (R2 = .124, F(2, 870) = 61.56, p <.001) and Activities and Media

explained .7% of the variance (R2 = .007, F(2, 873) = 6.01, p =.049). It was found that tools (β

=-.532, p=.000 ), triggers (β =.805, p=.000 ), activities (β =--.355, p=.046 ), but not media,

significantly predicted dysfunctional metacognitions on the MCQ-30.

For the MDTQ, it was found that Tools and Triggers explained 16% of the variance (R2

= .158, F(2, 870) = 81.53, p <.001) and Activities and Media explained 2% of the variance (R2 =

.016, F(2, 873) = 6.89, p =.001). Tools (β =-.211, p=.014 ), Triggers (β =.633, p=.000 ),

Activities (β =--.343, p=.004 ), and Media(β =.393, p=.010 ) significantly predicted

dysfunctional metacognitions on the MDTQ.

CHAPTER 5

DISCUSSION

The Self-Regulatory Executive Function model (S-REF) is a model that explains self-

regulation processing that is driven by self-beliefs (Wells & Matthews, 1994). It proposes that

metacognitive beliefs that become dysfunctional activate pathways associated with maladaptive

coping mechanisms that can perpetuate the cycle of psychological distress. This distress becomes

persistent and strengthens when dysfunctional thinking patterns and coping mechanisms of

emotional responses are activated. Maladaptive coping such as rumination, thought suppression,

avoidance, and substance use, are linked to dysfunctional metacognitive beliefs such as the

worry about the need to control thoughts, worrying about planning for potential threats, the

inability to control rumination of negative thoughts, and more (Spada & Roarty, 2015). For

emotional disorders, the S-REF model proposes that metacognition plays a role in maladaptive

self-regulation strategies that account for a deficit in processing external and internal events and

is referred to as the Cognitive-Attentional Syndrome (CAS) (Wells & Matthews, 1996). The

Cognitive Attentional Syndrome (CAS) includes a combination of unhealthy coping strategies

that are activated by underlying maladaptive metacognitions and negative thinking processes.

These unhelpful coping strategies include the inability to move away from self-focused thinking,

continued worry and rumination, and thoughts of perceived threats in the environment (Fisher &

Wells, 2009). CAS asserts the inability to effectively self-regulate with healthy coping strategies

in response to a trigger can prolong emotional distress

The S-REF model also describes a set of metacognitive beliefs that include dysfunctional

beliefs about the ability to control thoughts and beliefs about cognitive self-consciousness. Since

metacognitive beliefs can influence knowledge and cognitive processes, they can also play a role

in addictive behaviors. These dysfunctional metacognitive beliefs are those that can continue to

reinforce addictive behavior by way of holding onto maladaptive beliefs through internal self-

talk, rumination, and emotional responses regarding the addiction. These beliefs can vary in

duration and intensity, which is generally how prediction of the severity of the addiction and

possibility of relapse is possible (Hamonnier & Varescon, 2018). The triphasic metacognitive

formulation of addictive behaviors proposes that aspects of the CAS such as attentional bias,

extended thinking (e.g., desire thinking, rumination and worry), disruption in metacognitive

monitoring and thought suppression should be associated with addictive behaviors and lead to

maladaptive consequences including increased levels of craving and engagement. The

formulation also proposes that metacognitive beliefs should be associated with aspects of the

CAS and addictive behaviors. (Spada & Roarty, 2015). The S-REF model describes desire

thinking as a form of extended thinking and is a key component in the maintenance of CAS

when it is in the context of addictive behaviors (Spada & Roarty, 2015). Caselli & Spada (2011)

describes two types of desire thinking, the first of which is verbal perseveration, and the second

being imaginal prefiguration. The desired object becomes more compelling over time as the