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Ethics code: IR.IAU.YAZD.REC.1402.046
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Received: 2025/01/31 | Accepted: 2025/03/10 | Published: 2025/03/17
Received: 2025/01/31 | Accepted: 2025/03/10 | Published: 2025/03/17
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Mirbagheri A, Hamoun A, Hazareh Z, Hazareh M, Bidaki R. The Relationship between Metacognitive Beliefs and Perfectionism with Rumination in Multiple Sclerosis Patients. J Clinic Care Skill 2025; 6 (1) :33-38
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URL: http://jccs.yums.ac.ir/article-1-380-en.html
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1- Department of Clinical Psychology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Department of Clinical Psychology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
2- Department of Clinical Psychology, Islamic Azad University, Yazd Branch, Yazd, Iran
3- Department of Psychiatry, School of Medicine, Shahid Sadougi University of Medical Sciences, Yazd, Iran
4- Department of Psychiatry, Fellowship of Neuropsychiatry, Research Center of Addiction and Behavioral Sciences, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2- Department of Clinical Psychology, Islamic Azad University, Yazd Branch, Yazd, Iran
3- Department of Psychiatry, School of Medicine, Shahid Sadougi University of Medical Sciences, Yazd, Iran
4- Department of Psychiatry, Fellowship of Neuropsychiatry, Research Center of Addiction and Behavioral Sciences, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Introduction
Multiple sclerosis (MS) is acknowledged as the most prevalent non-traumatic disabling condition among young adults, despite its underlying etiology remaining incompletely elucidated [1]. As of 2020, it is estimated that approximately 2.8 million people worldwide are living with MS. This figure represents a 30% increase from the 2013 estimates, which utilized the same methodology. The global prevalence of MS in 2020 was reported to be approximately 35.9 cases per 100,000 people, reflecting a substantial increase in the disease’s prevalence across all regions since 2013 [2]. A significant incidence and prevalence of psychological and psychiatric symptoms have been documented in the literature for patients with MS, exceeding those observed in individuals experiencing comparable levels of disability [3]. One of the primary psychological symptoms associated with this disease is rumination, which can exacerbate the development of other psychological issues, such as depression and anxiety disorders, in affected individuals [4].
Ruminations are characterized by passive and repetitive thought patterns that focus on the causes and consequences of distressing symptoms. This process not only impedes effective problem-solving but also precipitates an escalation of negative thoughts [5]. Research findings suggest that individuals who engage in rumination frequently perceive their problems as insurmountable and unbearable, which can exacerbate feelings of hopelessness and distress. This perception discourages individuals from pursuing more effective solutions, thereby compromising their problem-solving strategies and overall resilience. Consequently, rumination can impede the capacity to formulate and implement more effective solutions to challenges [6]. Research indicates that rumination significantly contributes to the exacerbation of psychological symptoms in individuals with MS. Specifically, rumination involves persistent thoughts of despair about the future and negative reflections, which can precipitate the development of depression and anxiety disorders in individuals with MS [7, 8].
One of the key components influencing the intensity of rumination is metacognitive beliefs [9]. Metacognition encompasses the knowledge and cognitive processes involved in evaluating, monitoring, and regulating cognitive functions [9]. Metacognitive beliefs can be categorized into three distinct sub-types, including generic metacognitive beliefs, which pertain to internal cognitive-affective experiences and their perceived significance, positive metacognitive beliefs, which concern the perceived utility of cognitive-attentional strategies and are linked to their activation, and negative metacognitive beliefs, which relate to the perceived controllability and potential detrimental effects of mental events [10]. Metacognitive beliefs and rumination are intricately linked, with research indicating that these beliefs play a pivotal role in initiating and maintaining rumination. Positive metacognitive beliefs can lead individuals to perceive rumination as a beneficial strategy for problem-solving, whereas negative metacognitive beliefs can intensify worry and anxiety by reinforcing the perceived uncontrollability and potential harm of mental events. These beliefs can perpetuate rumination and exacerbate negative emotions. Consequently, understanding and modifying these beliefs can facilitate a reduction in rumination and enhance mental well-being [9]. Research has indicated a relationship between metacognitive beliefs and rumination. For example, Schneider et al.'s study found that metacognitive beliefs predict rumination in depression [11]. Cherry et al. also demonstrate that metacognitive beliefs can predict rumination in diabetic patients [12].
Perfectionism is another important component related to rumination in patients with MS [13]. Perfectionism is a personality trait characterized by an intense striving for exceptionally high, often unattainable standards. Individuals exhibiting this trait typically maintain elevated expectations for themselves and others, regarding anything less than perfection as unacceptable [14]. Research suggests that perfectionism can significantly contribute to increased stress and anxiety, potentially exacerbating symptoms of MS. Furthermore, perfectionism may also lead to depressive symptoms and difficulties in accepting the disease, which is a common challenge faced by individuals with MS [15]. Research also indicates a connection between perfectionism and rumination. For example, Xie et al. highlight the relationship between perfectionism and rumination in psychological disorders, such as anxiety [16]. Other studies, such as those by Egan et al. [17] and De Rosa et al. [18], have also emphasized the predictive role of perfectionism in rumination in post-traumatic stress disorder and depression.
Although research suggests that metacognitive beliefs and perfectionism can contribute to rumination and stress in diverse contexts, there remains a notable gap in research exploring their specific impact on patients with MS. There is a particular need to investigate how metacognitive beliefs and perfectionism contribute to rumination in MS patients. Furthermore, exploring therapeutic strategies to target these factors could help reduce rumination and improve the quality of life for individuals with MS. We aimed to check whether there is a significant correlation between negative metacognitive beliefs and rumination in individuals with MS. Additionally, it was hypothesized that a significant relationship exists between maladaptive perfectionism and rumination among these patients. Ultimately, the study suggests that rumination in individuals with MS can be predicted based on both metacognitive beliefs and perfectionism. Therefore, the present study aimed to explore the relationship between metacognitive beliefs, perfectionism, and rumination in patients with MS, focusing on understanding how these factors interrelate and impact psychological well-being.
Instrument and Methods
This correlational study involved patients with MS who were members of the MS Association of Yazd in 2024. A sample of 160 participants was selected using convenience sampling from this population. The sample size was using parameters, such as effect size (e.g., 0.5), significance level (0.05), and power (0.80) specified in GPower. Participants completed several questionnaires designed to assess various aspects of their condition. Regarding the inclusion criteria, each participant had to have a confirmed diagnosis of MS documented in their medical records and must be willing to complete the questionnaires. Conversely, the exclusion criteria were established to ensure the sample’s homogeneity and relevance to the study’s objectives. Participants were excluded if they had another chronic medical condition, such as diabetes, a history of mental health hospitalization, or if they refused to complete the questionnaires. In this study, a sample size was calculated using GPower software. To determine this sample size, parameters such as effect size (e.g., 0.5), significance level (0.05), and power (0.80) were specified in GPower
Research tools
Frost Multidimensional Perfectionism Scale (FMPS): This questionnaire is a psychological assessment tool developed by Robert O. Frost et al. in 1990. It is designed to measure perfectionism as a multidimensional construct, comprising 35 items. The FMPS assesses various dimensions of perfectionism, providing a comprehensive framework for understanding this complex psychological trait. The FMPS consists of six distinct subscales, including worry about mistakes, doubts about actions, parental expectations, parental criticism, personal standards, and organizational habits. The FMPS utilizes a five-point Likert scale for scoring, with each subscale’s score calculated independently. This assessment tool is appropriate for evaluating perfectionism in individuals aged 15 and older. The FMPS is particularly useful in the diagnosis and treatment of various mental health disorders, including obsessive-compulsive disorder, body image disorders, and anxiety disorders. During the standardization of the original version, the internal consistency coefficient of the questionnaire was reported to range between 0.80 and 0.88 [19]. This questionnaire was standardized in Iran by Aminizadeh et al. in 2013, with a reported Cronbach’s alpha coefficient of 0.80 [20]. In the current study, the Cronbach’s alpha coefficient for this tool was 0.72.
Metacognition Questionnaire (MCQ-30): The MCQ-30, developed by Wells and Cartwright-Hatton, is a psychological assessment tool designed to measure metacognitive beliefs. This 30-item questionnaire comprises five subscales: Positive beliefs about worry, Negative beliefs about the uncontrollability and danger of worry, cognitive confidence, need for thought control, and cognitive self-consciousness. Responses are recorded on a four-point Likert scale, ranging from “do not agree” to “agree very much,” with higher scores indicating more pronounced metacognitive issues. In the standardization of the original version, the Cronbach’s alpha coefficient of this questionnaire was reported to be 0.91 [21]. The standardization of this questionnaire in Iran among the youth population was conducted by Khoramdel et al. in 2012, with a reported Cronbach’s alpha coefficient of 0.86 [22]. In the present study, the Cronbach’s alpha coefficient was 0.83.
Ruminative Response Scale (RRS): This questionnaire, developed by Nolen-Hoeksema and Morrow in 1991, serves as a psychological assessment tool designed to measure negative repetitive thoughts or ruminative thinking. It comprises 22 items, each scored using a four-point Likert scale. In the standardization of the original version, the Cronbach’s alpha coefficient was reported to be 0.92 [23]. This questionnaire was standardized in Iran by Khosravani et al., who reported a Cronbach’s alpha coefficient of 0.89 [24]. Here, the Cronbach’s alpha coefficient for this instrument was 0.79.
Data analysis
Data analysis was performed using both descriptive and inferential statistical methods. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were employed to summarize and characterize the data. Inferential statistics, specifically regression analysis, were utilized to examine relationships between parameters and to make predictions. All analyses were conducted using SPSS version 29.
Findings
This study comprised 160 patients with MS with an average age of 31.17±3.12 years (Table 1).
Table 1. Frequency of demographic information of the subjects
Upon examining the normality of the parameters using the Kolmogorov-Smirnov test and assessing the degree of skewness and kurtosis, it was determined that all three parameters exhibited a normal distribution (Table 2).
Table 2. Checking the normality status of parameters
To examine the correlation between metacognitive beliefs and perfectionism with rumination, given the normal distribution of the data, the Pearson correlation was utilized. All components of metacognitive beliefs exhibited a significant positive relationship with rumination. Furthermore, all components of perfectionism, except for worry and organization, demonstrated a significant positive relationship with rumination (Table 3).
Table 3. Correlation of metacognitive beliefs and perfectionism with rumination
Multiple regression analysis was employed to assess the predictability of the criterion parameter. Both metacognitive beliefs and perfectionism were significantly related to rumination, and the correlation between the two predictor parameters was less than 0.7. Consequently, all parameters were included in the regression analysis (Table 4).
Table 4. Correlation between predictor and criterion parameters
For the multicollinearity assumption, a multiple regression model was implemented. Approximately 74% of the variance in the criterion parameter was explained by the parameters included in the model. Furthermore, the adjusted coefficient of determination was equivalent to 70%. Consequently, 70% of the variance in rumination was accounted for by the predictor parameters (Table 5).
Table 5. Summary of the regression model for predicting rumination
The regression was significant, indicating that rumination could be predicted by metacognitive beliefs and perfectionism. To determine which of the predictor parameters included in the model were effective in predicting criterion, a t-test was employed (Table 6).
Table 6. The results of the t-test and the coefficients related to the predictor parameters of rumination
Based on standardized beta coefficients, metacognitive beliefs played a more significant role than perfectionism in predicting intellectual development in MS patients.
Discussion
This study aimed to explore the relationship between metacognitive beliefs, perfectionism, and rumination in patients with MS. There was a significant positive correlation between metacognitive beliefs and rumination in individuals with MS. This correlation suggests that as metacognitive beliefs intensify, the level of rumination also increases. In essence, higher scores on metacognitive beliefs are associated with more pronounced rumination in these patients. Our findings align with the results of earlier investigations [9, 25, 26]. Metacognitive factors contribute to the persistence of negative emotions by fostering maladaptive thinking patterns. The foundation of the metacognitive approach is rooted in the “self-regulatory executive function” theory. This model posits that metacognitive knowledge predisposes individuals to develop specific response patterns to internal thoughts and events, characterized by excessive self-focus, thought retrieval, and avoidance or suppression of thoughts [27]. When discussing the relationship between metacognitive beliefs and rumination in MS patients, several key points can be noted. Metacognitive beliefs influence individuals’ perceptions of their thought processes and their control over them [28]. MS patients who believe they lack control over their thoughts are more susceptible to developing rumination. Furthermore, these beliefs can lead MS patients to view their negative thoughts as threatening, prompting them to engage in rumination about these thoughts. This process often exacerbates emotional distress and can be linked to broader psychological challenges faced by individuals with MS [29].
There was a significant positive correlation between perfectionism and rumination in MS patients. This correlation suggests that an increase in perfectionism scores is accompanied by an escalation in rumination levels. Consequently, higher perfectionism scores are associated with more pronounced rumination in these patients. Our findings align with those of previous research [17, 18, 30]. Several points can be noted in explaining this result. Research indicates that increased perfectionism leads to a more negative evaluation of oneself, thoughts, and behaviors, which can manifest as rumination. Perfectionism frequently results in heightened fear and anxiety, prompting MS patients to ruminate about their symptoms and the progression of their disease [31]. Additionally, perfectionism can contribute to increased rumination in these patients, compounded by factors, such as reduced distress tolerance and the establishment of unattainable standards, which are often unrealistic for individuals with MS due to the nature of the disease [32].
Rumination could be predicted by both metacognitive beliefs and perfectionism. Several factors contribute to this finding. Metacognitive beliefs influence how thoughts and emotions are processed. Specifically, holding the metacognitive belief that rumination aids in resolving issues more effectively is an unproductive belief that can increase anxiety and worry in individuals [9]. Metacognitive beliefs trigger specific coping mechanisms in response to perceived threats. These strategies include thought suppression, neutralization, checking, and ruminative reasoning, ultimately resulting in increased repetitive thinking, or rumination [33]. Perfectionism contributes to heightened anxiety and worry by establishing unattainable standards, which can lead to rumination. Additionally, research indicates that perfectionism can be intertwined with negative metacognitive beliefs, fostering the belief that achieving goals is paramount, even if it results in stress and rumination. Metacognitive beliefs and perfectionism can serve as predictors of rumination in MS patients because they influence cognitive and psychological processes, potentially leading to increased worry and rumination [30].
Metacognitive beliefs appeared to foster increased rumination by potentially instigating a perception of reduced control over one’s thoughts and an amplified sense of threat from negative cognitions. Perfectionism, similarly, contributed to rumination by promoting adverse self-evaluations and counterproductive behaviors, thereby exacerbating anxiety and fear. These outcomes suggest that metacognitive beliefs and perfectionism may function as predictors of rumination in individuals with MS, consequently intensifying psychological distress and overall challenges. Therefore, therapeutic strategies aimed at addressing metacognitive beliefs and perfectionistic tendencies, such as cognitive behavioral therapy (CBT) and metacognitive therapy (MCT), may prove effective in alleviating rumination and enhancing psychological well-being within this demographic. Future investigations should prioritize assessing the effectiveness of these interventions through rigorous clinical trials involving MS patients.
This study has several limitations that should be considered. The reliance on convenience sampling and the geographical confinement to Yazd may compromise the generalizability of the findings. Additionally, the exclusion criteria may have inadvertently excluded certain patients from participation. To address these limitations, future studies should consider utilizing probability sampling methods and conducting research across diverse geographical locations. Furthermore, it would be advantageous to investigate other psychological factors, such as social support and resilience, concerning repetitive thinking, as well as to conduct a longitudinal study to evaluate temporal changes in metacognitive beliefs and perfectionism.
Conclusion
There was a significant association between metacognitive beliefs and perfectionism with rumination in MS patients.
Acknowledgments: We express our gratitude to all the MS patients who participated in this research, as well as to the esteemed Research Department of the Islamic Azad University, Yazd Branch.
Ethical Permissions: The study received ethical approval from the Ethics Committee of Islamic Azad University, Yazd Branch, under the ethics code IR.IAU.YAZD.REC.1402.046. It was conducted in full accordance with ethical principles, encompassing informed consent acquisition, questionnaire anonymization, and the maintenance of participant demographic data confidentiality.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors' Contribution: Mirbagheri AM (First Author), Introduction Writer/Main Researcher/Methodologist/Discussion Writer (40%); Hamoun A (Second Author), Assistant Researcher (15%); Hazareh Z (Third Author), Assistant Researcher (15%); Hzareh M (Fourth Author), Assistant Researcher (15%); Bidaki R (Fifth Author), Statistical Analyst (15%)
Funding/Support: This research received no funding.
Multiple sclerosis (MS) is acknowledged as the most prevalent non-traumatic disabling condition among young adults, despite its underlying etiology remaining incompletely elucidated [1]. As of 2020, it is estimated that approximately 2.8 million people worldwide are living with MS. This figure represents a 30% increase from the 2013 estimates, which utilized the same methodology. The global prevalence of MS in 2020 was reported to be approximately 35.9 cases per 100,000 people, reflecting a substantial increase in the disease’s prevalence across all regions since 2013 [2]. A significant incidence and prevalence of psychological and psychiatric symptoms have been documented in the literature for patients with MS, exceeding those observed in individuals experiencing comparable levels of disability [3]. One of the primary psychological symptoms associated with this disease is rumination, which can exacerbate the development of other psychological issues, such as depression and anxiety disorders, in affected individuals [4].
Ruminations are characterized by passive and repetitive thought patterns that focus on the causes and consequences of distressing symptoms. This process not only impedes effective problem-solving but also precipitates an escalation of negative thoughts [5]. Research findings suggest that individuals who engage in rumination frequently perceive their problems as insurmountable and unbearable, which can exacerbate feelings of hopelessness and distress. This perception discourages individuals from pursuing more effective solutions, thereby compromising their problem-solving strategies and overall resilience. Consequently, rumination can impede the capacity to formulate and implement more effective solutions to challenges [6]. Research indicates that rumination significantly contributes to the exacerbation of psychological symptoms in individuals with MS. Specifically, rumination involves persistent thoughts of despair about the future and negative reflections, which can precipitate the development of depression and anxiety disorders in individuals with MS [7, 8].
One of the key components influencing the intensity of rumination is metacognitive beliefs [9]. Metacognition encompasses the knowledge and cognitive processes involved in evaluating, monitoring, and regulating cognitive functions [9]. Metacognitive beliefs can be categorized into three distinct sub-types, including generic metacognitive beliefs, which pertain to internal cognitive-affective experiences and their perceived significance, positive metacognitive beliefs, which concern the perceived utility of cognitive-attentional strategies and are linked to their activation, and negative metacognitive beliefs, which relate to the perceived controllability and potential detrimental effects of mental events [10]. Metacognitive beliefs and rumination are intricately linked, with research indicating that these beliefs play a pivotal role in initiating and maintaining rumination. Positive metacognitive beliefs can lead individuals to perceive rumination as a beneficial strategy for problem-solving, whereas negative metacognitive beliefs can intensify worry and anxiety by reinforcing the perceived uncontrollability and potential harm of mental events. These beliefs can perpetuate rumination and exacerbate negative emotions. Consequently, understanding and modifying these beliefs can facilitate a reduction in rumination and enhance mental well-being [9]. Research has indicated a relationship between metacognitive beliefs and rumination. For example, Schneider et al.'s study found that metacognitive beliefs predict rumination in depression [11]. Cherry et al. also demonstrate that metacognitive beliefs can predict rumination in diabetic patients [12].
Perfectionism is another important component related to rumination in patients with MS [13]. Perfectionism is a personality trait characterized by an intense striving for exceptionally high, often unattainable standards. Individuals exhibiting this trait typically maintain elevated expectations for themselves and others, regarding anything less than perfection as unacceptable [14]. Research suggests that perfectionism can significantly contribute to increased stress and anxiety, potentially exacerbating symptoms of MS. Furthermore, perfectionism may also lead to depressive symptoms and difficulties in accepting the disease, which is a common challenge faced by individuals with MS [15]. Research also indicates a connection between perfectionism and rumination. For example, Xie et al. highlight the relationship between perfectionism and rumination in psychological disorders, such as anxiety [16]. Other studies, such as those by Egan et al. [17] and De Rosa et al. [18], have also emphasized the predictive role of perfectionism in rumination in post-traumatic stress disorder and depression.
Although research suggests that metacognitive beliefs and perfectionism can contribute to rumination and stress in diverse contexts, there remains a notable gap in research exploring their specific impact on patients with MS. There is a particular need to investigate how metacognitive beliefs and perfectionism contribute to rumination in MS patients. Furthermore, exploring therapeutic strategies to target these factors could help reduce rumination and improve the quality of life for individuals with MS. We aimed to check whether there is a significant correlation between negative metacognitive beliefs and rumination in individuals with MS. Additionally, it was hypothesized that a significant relationship exists between maladaptive perfectionism and rumination among these patients. Ultimately, the study suggests that rumination in individuals with MS can be predicted based on both metacognitive beliefs and perfectionism. Therefore, the present study aimed to explore the relationship between metacognitive beliefs, perfectionism, and rumination in patients with MS, focusing on understanding how these factors interrelate and impact psychological well-being.
Instrument and Methods
This correlational study involved patients with MS who were members of the MS Association of Yazd in 2024. A sample of 160 participants was selected using convenience sampling from this population. The sample size was using parameters, such as effect size (e.g., 0.5), significance level (0.05), and power (0.80) specified in GPower. Participants completed several questionnaires designed to assess various aspects of their condition. Regarding the inclusion criteria, each participant had to have a confirmed diagnosis of MS documented in their medical records and must be willing to complete the questionnaires. Conversely, the exclusion criteria were established to ensure the sample’s homogeneity and relevance to the study’s objectives. Participants were excluded if they had another chronic medical condition, such as diabetes, a history of mental health hospitalization, or if they refused to complete the questionnaires. In this study, a sample size was calculated using GPower software. To determine this sample size, parameters such as effect size (e.g., 0.5), significance level (0.05), and power (0.80) were specified in GPower
Research tools
Frost Multidimensional Perfectionism Scale (FMPS): This questionnaire is a psychological assessment tool developed by Robert O. Frost et al. in 1990. It is designed to measure perfectionism as a multidimensional construct, comprising 35 items. The FMPS assesses various dimensions of perfectionism, providing a comprehensive framework for understanding this complex psychological trait. The FMPS consists of six distinct subscales, including worry about mistakes, doubts about actions, parental expectations, parental criticism, personal standards, and organizational habits. The FMPS utilizes a five-point Likert scale for scoring, with each subscale’s score calculated independently. This assessment tool is appropriate for evaluating perfectionism in individuals aged 15 and older. The FMPS is particularly useful in the diagnosis and treatment of various mental health disorders, including obsessive-compulsive disorder, body image disorders, and anxiety disorders. During the standardization of the original version, the internal consistency coefficient of the questionnaire was reported to range between 0.80 and 0.88 [19]. This questionnaire was standardized in Iran by Aminizadeh et al. in 2013, with a reported Cronbach’s alpha coefficient of 0.80 [20]. In the current study, the Cronbach’s alpha coefficient for this tool was 0.72.
Metacognition Questionnaire (MCQ-30): The MCQ-30, developed by Wells and Cartwright-Hatton, is a psychological assessment tool designed to measure metacognitive beliefs. This 30-item questionnaire comprises five subscales: Positive beliefs about worry, Negative beliefs about the uncontrollability and danger of worry, cognitive confidence, need for thought control, and cognitive self-consciousness. Responses are recorded on a four-point Likert scale, ranging from “do not agree” to “agree very much,” with higher scores indicating more pronounced metacognitive issues. In the standardization of the original version, the Cronbach’s alpha coefficient of this questionnaire was reported to be 0.91 [21]. The standardization of this questionnaire in Iran among the youth population was conducted by Khoramdel et al. in 2012, with a reported Cronbach’s alpha coefficient of 0.86 [22]. In the present study, the Cronbach’s alpha coefficient was 0.83.
Ruminative Response Scale (RRS): This questionnaire, developed by Nolen-Hoeksema and Morrow in 1991, serves as a psychological assessment tool designed to measure negative repetitive thoughts or ruminative thinking. It comprises 22 items, each scored using a four-point Likert scale. In the standardization of the original version, the Cronbach’s alpha coefficient was reported to be 0.92 [23]. This questionnaire was standardized in Iran by Khosravani et al., who reported a Cronbach’s alpha coefficient of 0.89 [24]. Here, the Cronbach’s alpha coefficient for this instrument was 0.79.
Data analysis
Data analysis was performed using both descriptive and inferential statistical methods. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were employed to summarize and characterize the data. Inferential statistics, specifically regression analysis, were utilized to examine relationships between parameters and to make predictions. All analyses were conducted using SPSS version 29.
Findings
This study comprised 160 patients with MS with an average age of 31.17±3.12 years (Table 1).
Table 1. Frequency of demographic information of the subjects
Upon examining the normality of the parameters using the Kolmogorov-Smirnov test and assessing the degree of skewness and kurtosis, it was determined that all three parameters exhibited a normal distribution (Table 2).
Table 2. Checking the normality status of parameters
To examine the correlation between metacognitive beliefs and perfectionism with rumination, given the normal distribution of the data, the Pearson correlation was utilized. All components of metacognitive beliefs exhibited a significant positive relationship with rumination. Furthermore, all components of perfectionism, except for worry and organization, demonstrated a significant positive relationship with rumination (Table 3).
Table 3. Correlation of metacognitive beliefs and perfectionism with rumination
Multiple regression analysis was employed to assess the predictability of the criterion parameter. Both metacognitive beliefs and perfectionism were significantly related to rumination, and the correlation between the two predictor parameters was less than 0.7. Consequently, all parameters were included in the regression analysis (Table 4).
Table 4. Correlation between predictor and criterion parameters
For the multicollinearity assumption, a multiple regression model was implemented. Approximately 74% of the variance in the criterion parameter was explained by the parameters included in the model. Furthermore, the adjusted coefficient of determination was equivalent to 70%. Consequently, 70% of the variance in rumination was accounted for by the predictor parameters (Table 5).
Table 5. Summary of the regression model for predicting rumination
The regression was significant, indicating that rumination could be predicted by metacognitive beliefs and perfectionism. To determine which of the predictor parameters included in the model were effective in predicting criterion, a t-test was employed (Table 6).
Table 6. The results of the t-test and the coefficients related to the predictor parameters of rumination
Based on standardized beta coefficients, metacognitive beliefs played a more significant role than perfectionism in predicting intellectual development in MS patients.
Discussion
This study aimed to explore the relationship between metacognitive beliefs, perfectionism, and rumination in patients with MS. There was a significant positive correlation between metacognitive beliefs and rumination in individuals with MS. This correlation suggests that as metacognitive beliefs intensify, the level of rumination also increases. In essence, higher scores on metacognitive beliefs are associated with more pronounced rumination in these patients. Our findings align with the results of earlier investigations [9, 25, 26]. Metacognitive factors contribute to the persistence of negative emotions by fostering maladaptive thinking patterns. The foundation of the metacognitive approach is rooted in the “self-regulatory executive function” theory. This model posits that metacognitive knowledge predisposes individuals to develop specific response patterns to internal thoughts and events, characterized by excessive self-focus, thought retrieval, and avoidance or suppression of thoughts [27]. When discussing the relationship between metacognitive beliefs and rumination in MS patients, several key points can be noted. Metacognitive beliefs influence individuals’ perceptions of their thought processes and their control over them [28]. MS patients who believe they lack control over their thoughts are more susceptible to developing rumination. Furthermore, these beliefs can lead MS patients to view their negative thoughts as threatening, prompting them to engage in rumination about these thoughts. This process often exacerbates emotional distress and can be linked to broader psychological challenges faced by individuals with MS [29].
There was a significant positive correlation between perfectionism and rumination in MS patients. This correlation suggests that an increase in perfectionism scores is accompanied by an escalation in rumination levels. Consequently, higher perfectionism scores are associated with more pronounced rumination in these patients. Our findings align with those of previous research [17, 18, 30]. Several points can be noted in explaining this result. Research indicates that increased perfectionism leads to a more negative evaluation of oneself, thoughts, and behaviors, which can manifest as rumination. Perfectionism frequently results in heightened fear and anxiety, prompting MS patients to ruminate about their symptoms and the progression of their disease [31]. Additionally, perfectionism can contribute to increased rumination in these patients, compounded by factors, such as reduced distress tolerance and the establishment of unattainable standards, which are often unrealistic for individuals with MS due to the nature of the disease [32].
Rumination could be predicted by both metacognitive beliefs and perfectionism. Several factors contribute to this finding. Metacognitive beliefs influence how thoughts and emotions are processed. Specifically, holding the metacognitive belief that rumination aids in resolving issues more effectively is an unproductive belief that can increase anxiety and worry in individuals [9]. Metacognitive beliefs trigger specific coping mechanisms in response to perceived threats. These strategies include thought suppression, neutralization, checking, and ruminative reasoning, ultimately resulting in increased repetitive thinking, or rumination [33]. Perfectionism contributes to heightened anxiety and worry by establishing unattainable standards, which can lead to rumination. Additionally, research indicates that perfectionism can be intertwined with negative metacognitive beliefs, fostering the belief that achieving goals is paramount, even if it results in stress and rumination. Metacognitive beliefs and perfectionism can serve as predictors of rumination in MS patients because they influence cognitive and psychological processes, potentially leading to increased worry and rumination [30].
Metacognitive beliefs appeared to foster increased rumination by potentially instigating a perception of reduced control over one’s thoughts and an amplified sense of threat from negative cognitions. Perfectionism, similarly, contributed to rumination by promoting adverse self-evaluations and counterproductive behaviors, thereby exacerbating anxiety and fear. These outcomes suggest that metacognitive beliefs and perfectionism may function as predictors of rumination in individuals with MS, consequently intensifying psychological distress and overall challenges. Therefore, therapeutic strategies aimed at addressing metacognitive beliefs and perfectionistic tendencies, such as cognitive behavioral therapy (CBT) and metacognitive therapy (MCT), may prove effective in alleviating rumination and enhancing psychological well-being within this demographic. Future investigations should prioritize assessing the effectiveness of these interventions through rigorous clinical trials involving MS patients.
This study has several limitations that should be considered. The reliance on convenience sampling and the geographical confinement to Yazd may compromise the generalizability of the findings. Additionally, the exclusion criteria may have inadvertently excluded certain patients from participation. To address these limitations, future studies should consider utilizing probability sampling methods and conducting research across diverse geographical locations. Furthermore, it would be advantageous to investigate other psychological factors, such as social support and resilience, concerning repetitive thinking, as well as to conduct a longitudinal study to evaluate temporal changes in metacognitive beliefs and perfectionism.
Conclusion
There was a significant association between metacognitive beliefs and perfectionism with rumination in MS patients.
Acknowledgments: We express our gratitude to all the MS patients who participated in this research, as well as to the esteemed Research Department of the Islamic Azad University, Yazd Branch.
Ethical Permissions: The study received ethical approval from the Ethics Committee of Islamic Azad University, Yazd Branch, under the ethics code IR.IAU.YAZD.REC.1402.046. It was conducted in full accordance with ethical principles, encompassing informed consent acquisition, questionnaire anonymization, and the maintenance of participant demographic data confidentiality.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors' Contribution: Mirbagheri AM (First Author), Introduction Writer/Main Researcher/Methodologist/Discussion Writer (40%); Hamoun A (Second Author), Assistant Researcher (15%); Hazareh Z (Third Author), Assistant Researcher (15%); Hzareh M (Fourth Author), Assistant Researcher (15%); Bidaki R (Fifth Author), Statistical Analyst (15%)
Funding/Support: This research received no funding.
Keywords:
References
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