Effectiveness of metacognitive interventions for mental disorders in adults-A systematic review and meta-analysis (METACOG)

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults: Réseau canadien pour les traitements de l'humeur et de l'anxiété (CANMAT) 2023 : Mise à jour des lignes directrices cliniques pour la prise en charge du trouble dépressif majeur chez les adultes

BACKGROUND

The Canadian Network for Mood and Anxiety Treatments (CANMAT) last published clinical guidelines for the management of major depressive disorder (MDD) in 2016. Owing to advances in the field, an update was needed to incorporate new evidence and provide new and revised recommendations for the assessment and management of MDD in adults.

METHODS

CANMAT convened a guidelines editorial group comprised of academic clinicians and patient partners. A systematic literature review was conducted, focusing on systematic reviews and meta-analyses published since the 2016 guidelines. Recommendations were organized by lines of treatment, which were informed by CANMAT-defined levels of evidence and supplemented by clinical support (consisting of expert consensus on safety, tolerability, and feasibility). Drafts were revised based on review by patient partners, expert peer review, and a defined expert consensus process.

RESULTS

The updated guidelines comprise eight primary topics, in a question-and-answer format, that map a patient care journey from assessment to selection of evidence-based treatments, prevention of recurrence, and strategies for inadequate response. The guidelines adopt a personalized care approach that emphasizes shared decision-making that reflects the values, preferences, and treatment history of the patient with MDD. Tables provide new and updated recommendations for psychological, pharmacological, lifestyle, complementary and alternative medicine, digital health, and neuromodulation treatments. Caveats and limitations of the evidence are highlighted.

CONCLUSIONS

The CANMAT 2023 updated guidelines provide evidence-informed recommendations for the management of MDD, in a clinician-friendly format. These updated guidelines emphasize a collaborative, personalized, and systematic management approach that will help optimize outcomes for adults with MDD.

Group based metacognitive therapy for alcohol use disorder: a pilot study

Introduction

Alcohol use disorder (AUD) is a severe clinical disorder, which has been associated with 5.3% of death worldwide. Although several treatments have been developed to improve AUD symptomatology, treatment effects were moderate, with a certain amount of patients displaying symptom deterioration after treatment termination. Moreover, outpatient treatment placements become increasingly scarce, thus necessitating more efficient treatment options. Therefore, the aim of the present study was to investigate the efficacy, feasibility, and acceptability of a newly invented, short, group based metacognitive therapy (MCT) for patients diagnosed with AUD.

Method

Seven patients were treated with eight sessions of group based MCT using a single case series design with an A-B replication across patients. Patients were assessed one month and one week before treatment, as well as one week and three months after treatment termination.

Results

Patients improved significantly and with large effect sizes regarding dysfunctional metacognitive beliefs, desire thinking/craving and depressive symptoms up to three months after treatment termination. AUD symptomatology as well as positive and negative metacognitive beliefs improved at post-treatment, but improvements could not be maintained at follow-up. All included patients completed the treatment and were highly satisfied.

Conclusion

The presented findings show preliminary evidence for the efficacy, feasibility, and acceptability of the implemented group based MCT treatment. Large scale randomized controlled trials (RCTs) are needed to confirm the effectiveness of the developed program for patients diagnosed with AUD.

Do metacognitive therapies for schizophrenia-spectrum disorders work? A meta-analytic investigation

Recent reviews and meta-analyses of metacognitive therapy for schizophrenia-spectrum disorder (SSD) have included uncontrolled studies, single-session interventions, and/or analyses limited to a single form of metacognitive therapy. We sought to evaluate the efficacy of metacognitive therapies more broadly based on controlled trials (CT) of sustained treatments. We conducted a pre-registered meta-analysis of controlled trials that investigated the effects of meta-cognitive therapies on primary positive symptom outcomes, and secondary symptom, function and/or insight measures. Electronic databases were searched up to March 2022 using variants of the keywords, 'metacognitive therapy', 'schizophrenia', and 'controlled trial'. Studies were identified and screened according to PRISMA guidelines. Outcomes were assessed with random effects models and sample, intervention, and study quality indices were investigated as potential moderators. Our search identified 44 unique CTs with usable data from 2423 participants. Data were extracted by four investigators with reliability >98%. Results revealed that metacognitive therapies produced significant small-to-moderate effects on delusions (g = 0.32), positive symptoms (g = 0.30) and psychosocial function (g = 0.31), and significant, small effects on cognitive bias (g = 0.25), negative symptoms (g = 0.24), clinical insight (g = 0.29), and social cognition (g = 0.27). Findings were robust in the face of sample differences in age, education, gender, antipsychotic dosage, and duration of illness. Except for social cognition and negative symptoms, effects were evident even in the most rigorous study designs. Thus, results suggest that metacognitive therapies for SSD benefit people, and these benefits transfer to function and illness insight. Future research should modify existing treatments to increase the magnitude of treatment benefits.

Psychosis superspectrum II: neurobiology, treatment, and implications

Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.

Effects of metacognitive training (MCT) on social cognition for schizophrenia spectrum and related psychotic disorders: a systematic review and meta-analysis

BACKGROUND

Individuals with schizophrenia spectrum and related psychotic disorders (SSD) experience significant impairments in social cognition that impede functioning. Social cognition is a multidimensional construct consisting of four domains: 1. theory of mind, 2. emotion processing, 3. attributional style and 4. social perception. Metacognitive training (MCT) is an intervention designed to target cognitive biases in psychosis containing two modules addressing social cognition.

METHODS

A systematic review and meta-analysis was conducted to investigate the effects of MCT on social cognition and two of its domains: theory of mind and emotion processing. Ten electronic databases were scoured from 2007 to 1 February 2022 for MCT studies reporting social cognition outcomes for people with SSD (1050 identified, 282 assessed). Effect sizes were calculated using Cohen's d in R.

RESULTS

Nine studies were included in the meta-analysis (nMCT = 212, ncontrol = 194). MCT had a small but positive effect on global social cognition (d = 0.28 [95% CI 0.07-0.49]) and theory of mind (d = 0.27 [95% CI 0.01-0.52]). MCT showed no evidence of an effect on emotion processing (d = 0.03 [95% CI -0.26 to 0.32]).

CONCLUSION

MCT has a small but significant effect on social cognition for people with SSD. Our results add to other recent meta-analyses showing significant effects of MCT on clinically relevant outcomes such as positive symptoms, cognitive biases and cognitive insight. We recommend that future studies on MCT report outcomes on all four domains of social cognition.

TRIAL REGISTRATION

PROSPERO (in the process of registration) available at https://www.crd.york.ac.uk/prospero/#recordDetails.

A systematic review and meta-analysis of transdiagnostic cognitive behavioural therapies for emotional disorders

Transdiagnostic cognitive behavioural psychotherapy (TD-CBT) may facilitate the treatment of emotional disorders. Here we investigate short- and long-term efficacy of TD-CBT for emotional disorders in individual, group and internet-based settings in randomized controlled trials (PROSPERO CRD42019141512). Two independent reviewers screened results from PubMed, MEDLINE, PsycINFO, Google Scholar, medRxiv and OSF Preprints published between January 2000 and June 2023, selected studies for inclusion, extracted data and evaluated risk of bias (Cochrane risk-of-bias tool 2.0). Absolute efficacy from pre- to posttreatment and relative efficacy between TD-CBT and control treatments were investigated with random-effects models. Of 56 identified studies, 53 (6,705 participants) were included in the meta-analysis. TD-CBT had larger effects on depression (g = 0.74, 95% CI = 0.57-0.92, P < 0.001) and anxiety (g = 0.77, 95% CI = 0.56-0.97, P < 0.001) than did controls. Across treatment formats, TD-CBT was superior to waitlist and treatment-as-usual. TD-CBT showed comparable effects to disorder-specific CBT and was superior to other active treatments for depression but not for anxiety. Different treatment formats showed comparable effects. TD-CBT was superior to controls at 3, 6 and 12 months but not at 24 months follow-up. Studies were heterogeneous in design and methodological quality. This review and meta-analysis strengthens the evidence for TD-CBT as an efficacious treatment for emotional disorders in different settings.

Affective and cognitive Theory of Mind in patients with alcohol use disorder: Associations with symptoms of depression, anxiety, and somatization

INTRODUCTION

Theory of Mind (ToM) is the ability to ascribe thoughts (cognitive ToM) and feelings (affective ToM) to others. Ample evidence exists for impairments of affective and cognitive ToM in individuals with alcohol use disorder (AUD); however, evidence regarding changes of these impairments during AUD treatment and their possible relationship to comorbid symptoms is ambiguous. The current study analyzed changes in ToM during treatment and tested associations with comorbid symptoms of depression, anxiety, somatization, and social functioning.

METHODS

We analyzed data from 175 individuals with AUD. The study assessed ToM and comorbid symptoms of depression, anxiety, somatization, and social functioning at the time of admission and at the time of discharge from an approximately 60 days long abstinence-oriented inpatient treatment. We assessed affective and cognitive ToM using the Movie for the Assessment of Social Cognition, a measure with high ecological validity.

RESULTS

All symptoms, total and cognitive ToM improved following treatment; however, affective ToM did not improve. Moreover, cognitive ToM at the beginning of treatment was associated with improved symptoms of depression and somatization, while affective ToM was not.

CONCLUSIONS

Our study shows improvements in total and cognitive ToM as well as symptoms of depression, anxiety, somatization, and social functioning following long-term treatment. Furthermore, cognitive ToM was related to improvements in comorbid symptoms. This finding suggests that ToM may be an important treatment target in patients with AUD.

Predictors of paranoia in the daily lives of people with non-affective psychosis and non-clinical controls: A systematic review of intensive longitudinal studies

BACKGROUND AND OBJECTIVES

Worrying, self-esteem, sleep problems, anomalous internal experiences, reasoning biases, and interpersonal sensitivity are associated with paranoia. However, no review has examined whether these variables function as predictors of paranoia in everyday life. The present systematic review of intensive longitudinal studies (e.g., experience sampling) examined contemporaneous and time-lagged associations between paranoia and each candidate mechanism in individuals with non-affective psychosis and controls (pre-registration: https://osf.io/uwr9d).

METHODS

We searched electronic databases, PsyArXiv, and reference lists for studies published since 1994.

RESULTS

Of n = 5,918 results, n = 54 fulfilled inclusion criteria (n = 43 datasets). Most studies examined individuals with non-affective psychosis (n = 34). Strong evidence emerged for negative affect (subsumed under 'anomalous internal experiences') and sleep problems. For self-esteem, results suggest contemporaneous and lagged effects on paranoia but associations are likely driven by between-person variance. The low number of studies (n = 2 studies each) allowed no conclusions regarding worrying and reasoning biases. Findings on interpersonal sensitivity, which should be interpreted with caution because of the predictor's conceptual overlap with paranoia, indicate contemporaneous effects whereas time-lagged and within-person associations could not be judged due to insufficient data.

LIMITATIONS

The present review used a narrative data-synthetization and it did not cover outcomes such as hallucinations.

CONCLUSIONS

Despite convincing evidence for affect and sleep problems, it remains unclear whether affective states are precursors or also consequences of paranoia (vicious circle), and which of the actigraphy measures (sleep time, -efficiency, -fragmentation, etc.) best predicts paranoia.

Metacognitions in patients with chronic obstructive pulmonary disease: a psychometric study of the metacognitions questionnaire-30

The metacognitions questionnaire-30 (MCQ-30) was developed for the assessment of metacognitive beliefs and processes that are central components of the metacognitive model of emotional disorders. Anxiety and depression commonly occur in patients with chronic obstructive pulmonary disease (COPD). Testing such a model for anxiety and depression in patients with COPD is warranted. However, the psychometric properties of the MCQ-30 in COPD patients are unknown. Therefore, in this study we aimed to examine these properties in COPD patients. The MCQ-30 was administered to 203 COPD patients referred to a rehabilitation unit in respiratory medicine. Confirmatory factor analysis (CFA) was used to test the five-factor as well as the bi-factor models of MCQ-30. Exploratory factor analyses were also performed. Both models did not meet the criteria for an acceptable fit on Comparative Fit Index (CFI) of 0.810 and 0.858 vs. criterion of ≥0.9, but the Root Mean Square Error of Approximation (RMSEA) criterion ≤0.08 was acceptable for both models with RMSEA = 0.074 and 0.066, respectively. The factors were mostly moderately correlated (0.41-0.58) with acceptable reliability coefficients (0.73-0.87). The exploratory factor analysis identified three of the five factors originally described in the five-factor model of the MCQ-30. These data show that the factor structure of the MCQ-30 appears to differ from that of the original instrument in COPD patients and further studies are needed to confirm its validity and reliability in this patient group.

The relationship between childhood trauma, eating behaviours, and the mediating role of metacognitive beliefs

Disordered eating poses a significant risk to psychological and physical health. The experience of childhood trauma has been linked to the development of disordered eating behaviours, but the causal psychological mechanisms remain unclear. The metacognitive model holds promise as a potential framework for understanding the mediating psychological processes that explain how childhood trauma may lead to disordered eating. The purpose of this study was to examine the role of metacognitive beliefs mediating the relationship between childhood trauma and disordered eating behaviours. Adults from the Australian community (N = 461) completed an online self-report survey measuring childhood maltreatment (Childhood Trauma Questionnaire - Short Form), disordered eating behaviour (Three Factor Eating Questionnaire - Revised 21), and metacognitive beliefs (Metacognitive Questionnaire 30). Hierarchical multiple regression analyses revealed no independent associations between any forms of childhood maltreatment and cognitive restraint, while childhood emotional abuse was uniquely associated with uncontrolled eating and emotional eating. Through bootstrapping tests, the mediating effect between childhood trauma and uncontrolled and emotional eating consistently involved the metacognitive beliefs that thoughts are uncontrollable and dangerous. Future longitudinal research is required to confirm causal relationships.

Cognitive bias modification for paranoia (CBM-pa): a randomised controlled feasibility study in patients with distressing paranoid beliefs

BACKGROUND

Cognitive Bias Modification for paranoia (CBM-pa) is a novel, theory-driven psychological intervention targeting the biased interpretation of emotional ambiguity associated with paranoia. Study objectives were (i) test the intervention's feasibility, (ii) provide effect size estimates, (iii) assess dose-response and (iv) select primary outcomes for future trials.

METHODS

In a double-blind randomised controlled trial, sixty-three outpatients with clinically significant paranoia were randomised to either CBM-pa or an active control (text reading) between April 2016 and September 2017. Patients received one 40 min session per week for 6 weeks. Assessments were given at baseline, after each interim session, post-treatment, and at 1- and 3-months post-treatment.

RESULTS

A total of 122 patients were screened and 63 were randomised. The recruitment rate was 51.2%, with few dropouts (four out of 63) and follow-up rates were 90.5% (1-month) and 93.7% (3-months). Each session took 30-40 min to complete. There was no statistical evidence of harmful effects of the intervention. Preliminary data were consistent with efficacy of CBM-pa over text-reading control: patients randomised to the intervention, compared to control patients, reported reduced interpretation bias (d = -0.48 to -0.76), improved symptoms of paranoia (d = -0.19 to -0.38), and lower depressed and anxious mood (d = -0.03 to -0.29). The intervention effect was evident after the third session.

CONCLUSIONS

CBM-pa is feasible for patients with paranoia. A fully powered randomised control trial is warranted.

A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight

Poor insight in schizophrenia spectrum disorders (SSD) is linked with negative outcomes. This single-centre, assessor-blind, parallel-group 1-year follow-up randomised controlled trial (RCT) tested whether metacognitive training (MCT) (compared to psychoeducation) may improve insight and outcomes in outpatients with SSD assessed: at baseline (T0); after treatment (T1) and at 1-year follow-up (T2). Insight (primary outcome) was measured with (i) the Schedule for Assessment of Insight-Expanded version- (SAI-E), including illness recognition (IR), symptom relabelling (SR), treatment compliance (TC) and total insight scores (TIS); and (ii) the Beck Cognitive Insight Scale (BCIS). Between-group comparisons were nonsignificant, while within the MCT group (but not within controls) there was a significant medium effect size for improved TIS at T2 (d = 0.67, P = 0.02). Secondary outcomes included cognitive measures: Jumping to Conclusions (JTC), Theory of Mind (ToM), plus symptom severity and functioning. Compared to psychoeducation, MCT improved the PANSS excitement (d = 1.21, P = 0.01) and depressed (d = 0.76, P = 0.05) factors at T2; and a JTC task both at T1 (P = 0.016) and at T2 (P = 0.031). Participants in this RCT receiving MCT showed improved insight at 1-year follow-up, which was associated with better mood and reduced JTC cognitive bias. In this pilot study, no significant benefits on insight of MCT over psychoeducation were detected, which may have been due to insufficient power.

Is Metacognitive Training effective for improving neurocognitive function in patients with a recent onset of psychosis?

The aims are to assess improvements in memory, attention and executive function in first-episode psychosis after Metacognitive Training (MCT). A multicenter randomized clinical trial was performed with two arms: MCT and psychoeducational intervention. A total of 126 patients with a diagnosis of psychosis, less than 5 years from the onset of the disease, were included. Patients were assessed two or three moments (baseline, post-treatment, 6 months follow-up) depending on the test, with a battery of neurocognitive tests (TAVEC, TMTA-B, CPT, WCST, Stroop and premorbid IQ). General linear models for repeated measures were performed.  A better improvement in the MCT was found by an interaction between group and time in CPT Hit index, TMTB, Stroop, recent memory and number of perseverations of the TAVEC. Considering three assessments, a better improvement was found in non-perseverative, perseverative and total errors of the WCST and TMTB. The MCT is an effective psychological intervention to improve several cognitive functions.

Effectiveness of a Metacognitive Intervention for Schizophrenia (MCI-S) Program for Symptom Relief and Improvement in Social Cognitive Functioning in Patients with Schizophrenia

This study investigated the effectiveness of a metacognitive intervention program for symptom relief and improvement in social cognitive functioning among adults with schizophrenia. The program focused on enhancing metacognition to encourage self-awareness and step-by-step perspective expansion. There were 24 participants in the experimental group and 19 participants in the control group. Delusions decreased, and social cognition and social functioning improved in the experimental group compared to the control group. The program demonstrated utility as a treatment modality, which can be part of an overall program of a mental health promotion institution to improve functioning in patients with schizophrenia.

Metacognitive Training to Improve Insight and Work Outcome in Schizophrenia

ABSTRACT

Individuals with psychotic disorders have deficits in metacognition. Thirty-four adults with schizophrenia were randomized to 2 months of metacognitive training (MCT) or a healthy living skills control group. All participants were enrolled in a work therapy program, followed by a supported employment program. Assessments were conducted at baseline, at the end of the 2-month active intervention, and at 4- and 12-month follow-ups. At the end of active intervention, the MCT group demonstrated greater improvement and better work behavior relative to controls. At follow-up, the MCT group demonstrated significantly greater insight and fewer positive symptoms and a greater percentage were employed in the community. We speculate that being better able to think about one's thoughts, recognize biases in thinking, and correct those thoughts may aid in responding to workplace challenges and hence improve work outcomes.

Further validation of the Cognitive Biases Questionnaire for psychosis

BACKGROUND

Cognitive biases are recognized as important treatment targets for reducing symptoms associated with severe mental disorders. Although cognitive biases have been linked to symptoms in most studies, few studies have looked at such biases transdiagnostically. The Cognitive Bias Questionnaire for psychosis (CBQp) is a self-reported questionnaire that assesses cognitive biases amongst individuals with a psychotic disorder, as well as individuals with other severe mental disorders. The current study aims to validate a French version of the CBQp and to explore transdiagnostic cognitive biases in individuals with psychotic disorders, individuals with depression, and in healthy controls.

METHODS

The CBQp was translated into French following a protocol based on international standards. Discriminant validity and internal consistency were determined for total score and each subscale score. Confirmatory factor analyses were performed to test construct validity. Finally, cluster analyses were conducted to investigate cognitive biases across diagnostic groups.

RESULTS

Our results were similar to those of the original authors, with the one-factor solution (assessment of a general thinking bias) being the strongest, but the two-factor solution (assessing biases within two themes relating to psychosis) and the five-factor solution (assessment of multiple distinct biases) being clinically more interesting. A six-cluster solution emerged, suggesting that individuals with similar diagnoses score differently on all cognitive biases, and that individuals with different diagnoses might have similar cognitive biases.

CONCLUSIONS

The current findings support the validity of the French translation of the CBQp. Our cluster analyses overall support the transdiagnostic presence of cognitive biases.

Remote group therapies for cognitive health in schizophrenia-spectrum disorders: Feasible, acceptable, engaging

Severe cognitive impairments and cognitive distortions are core to schizophrenia-spectrum disorders (SSDs) and are associated with deteriorated social functioning. Despite well-established efficacy of group psychosocial therapies targeting cognitive health in SSDs, dissemination of these programs remains limited. Remote delivery offers a promising strategy for increasing the programs' accessibility. Yet, little research has evaluated group therapies for cognitive health delivered in this way. Thus, we aimed to assess, from participants' and therapists' perspectives, the feasibility, acceptability, as well as levels and process of engagement in a videoconference delivery of group psychosocial therapies for SSD patients' cognitive health. Participants, outpatients, attended Action Based Cognitive Remediation or Metacognitive Training, both adapted for videoconference. Then, participants and therapists completed post-therapy questionnaires. Of the 28 participants attending at least one session, 75% completed more than half of sessions and seven dropped out. Technology did not appear to significantly hinder participation in the programs. All completing participants reported a positive experience with therapy, 67% were not bothered by the distance from the therapist, and 77% trusted that the information shared was kept confidential. Therapist-rated levels of attention M = 7.5/9 (SD = 1.04), participation M = 6.91/9 (SD = 1.32), and social interactions M = 5.31/9 (SD = 1.96) were satisfactory. Nonetheless, participants indicated that they would have appreciated more social interactions with group members. These positive results validate the earliest stage in the implementation process for remote group therapies targeting cognitive health in SSDs. Remote delivery promises to improve access to therapies targeting cognitive health and, ultimately, facilitate functional recovery for SSD patients.

The effectiveness of metacognitive training on impairments in social cognition in patients with schizophrenia: mental health nursing practice in a community mental health center

BACKGROUND

Social cognition is an independent structure from the positive symptoms of schizophrenia and contributes to negative symptoms, neurocognitive impairment, and social functioning.

AIM

To examine the effectiveness of the metacognitive training intervention on social cognition in people with schizophrenia.

DESIGN

This study was conducted as a randomized quasi-experimental (pre-test/post-test and follow-up) design with a control group.

METHODS

Thirty-nine patients with schizophrenia were enrolled and randomly assigned to either the control group (n = 19) or the metacognitive training group (n = 20). A 10-week metacognitive training program was offered to the intervention group. The study involved a pre-test/post-test design with a 3-month follow-up assessment. The primary outcome was social cognition, as measured by the Facial Emotion Discrimination/Identification Tests, Reading the Mind in the Eyes Test, and Attributional Style Questionnaire. The secondary outcome was measured by the metacognitive training subjective efficacy form.

RESULTS

Completion at follow-up was high (92.3%). The results show that the changes over time in the False Belief Task 1st level, Attributional Style Questionnaire negative events global-specific dimension, and positive events stable-unstable dimension mean scores, time interaction, were statistically significant. Metacognitive Training was efficacious on the theory of mind and in performing more functional attributions. Patients in the intervention group showed high-level positive feedback.

CONCLUSION

Metacognitive Training applied by psychiatric and mental health nurses demonstrated a user and practitioner-friendly, safe and effective program on social cognition. Also, the social and cultural feasibility and effectiveness of the Metacognitive Training program were shown for the first time in a Turkish population.

Verschwörungstheorien und paranoider Wahn: Lassen sich Aspekte kognitionspsychologischer Modelle zu Entstehung und Aufrechterhaltung von paranoiden Wahnüberzeugungen auf Verschwörungstheorien übertragen?

Der vorliegende narrative Übersichtsartikel stellt zunächst verschiedene Definitionen von Verschwörungstheorien und Verschwörungsmentalität vor und präsentiert Studien zu Zusammenhängen zwischen Persönlichkeitseigenschaften, Symptomen psychischer Störungen und Verschwörungstheorien. Anschließend werden die Kontinuumshypothese des Wahns sowie neuere Konzeptualisierungen von allgemeinem und paranoiden Wahn diskutiert, des Weiteren werden typische kognitionspsychologische Modelle präsentiert, die die Entstehung und Aufrechterhaltung von Wahnüberzeugungen durch eine Interaktion von biologischen Vulnerabilitätsfaktoren, psychologischen Faktoren und sozialen Faktoren erklären. In diesen Modellen mediieren sowohl kognitive Verarbeitungsstile („cognitive biases“) als auch emotionale Prozesse die Entstehung und Aufrechterhaltung von Wahn, beispielsweise die Tendenz, voreilige Schlussfolgerungen zu treffen („jumping to conclusions bias“), sowie externale Kontrollüberzeugungen und ein externalisierender personalisierender Kausalattributionsstil. Anschließend wird diskutiert, ob Menschen, die Verschwörungstheorien zugeneigt sind, ebenfalls ähnliche kognitive Verarbeitungsstile aufweisen, die auch bei Personen zu finden sind, die paranoiden Wahnüberzeugungen zustimmen und unter psychotischen Störungen leiden. Parallelen bestehen zwischen beiden Personengruppen beispielsweise im Hinblick auf eine Neigung zu externalen Kontrollüberzeugungen und einen external personalisierenden Kausalattributionsstil. Auch bestehen Ähnlichkeiten in der Neigung, voreilige Schlussfolgerungen zu treffen. Fragen nach Gemeinsamkeiten und Unterschieden zwischen beiden Phänomenen sollten in weiteren präregistrierten experimentellen Studien quer- sowie längsschnittlich untersucht werden. Möglicherweise könnten moderne niedrigschwellige Interventionsmethoden der kognitiven Verhaltenstherapie von Psychosen (CBTp) in die Beratung oder Prävention von Verschwörungstheorien implementiert werden.

Metacognitive training for psychosis (MCT): past, present, and future

This article provides an overview and retrospective on metacognitive training for psychosis (MCT), which first appeared approximately 2 decades ago. We recount how our empirical understanding of psychosis at that time led to the first preliminary version of the program. We describe setbacks and challenges that led to major changes, including revisions to existing modules (e.g., more focus on metacognitive variables, particularly on decision confidence as one of the primary targets of treatment) and the creation of new modules addressing mood, as well as attempts to improve sustainability of effects via homework exercises and a smartphone app ( www.uke.de/mct_app ). We have also enhanced dissemination efforts by creating new culturally sensitive language versions and facilitating low-threshold training through e-learning courses ( www.uke.de/e-mct ). Finally, we discuss several meta-analyses on the efficacy of MCT that have been published over the last decade. While reviews were initially inconsistent, possibly reflecting the insufficient statistical power and lower design quality of the first MCT studies, more recent meta-analyses have confirmed the efficacy of MCT on positive symptoms, insight, and cognitive biases, which has led to the inclusion of MCT in some national treatment guidelines for schizophrenia.

Investigating the Role of Insight, Decision-Making and Mentalizing in Functional Outcome in Schizophrenia: A Cross-Sectional Study

BACKGROUND

Recovery has become a priority in schizophrenia spectrum disorders (SSDs). This study aimed to investigate predictors of objective-general functioning and disability-and subjective-quality of life (QoL)-measures of functional outcomes in SSD.

METHODS

Sample: n = 77 SSD outpatients (age 18-64, IQ > 70) participating in a randomised controlled trial. Baseline data were used to build three multivariable linear regression models on: (i) general functioning-General Assessment of Functioning (GAF); (ii) disability-the World Health Organization Disability Assessment Schedule (WHODAS-2.0); and (iii) QoL-Satisfaction Life Domains Scale (SLDS).

RESULTS

Young age and being employed (R2 change = 0.211; p = 0.001), late adolescence premorbid adjustment (R2 change = 0.049; p = 0.0050), negative symptoms and disorganization (R2 change = 0.087; p = 0.025) and Theory of Mind (R2 change = 0.066, p = 0.053) predicted general functioning. Previous suicidal behaviour (R2 change = 0.068; p = 0.023) and negative and depressive symptoms (R2 change = 0.167; p = 0.001) were linked with disability. Previous suicidal behaviour (R2 change = 0.070, p = 0.026), depressive symptoms (R2 change = 0.157; p < 0.001) and illness recognition (R2 change = 0.046, p = 0.044) predicted QoL.

CONCLUSIONS

Negative, disorganization and depressive symptoms, older age, unemployment, poor premorbid adjustment, previous suicide attempts and illness awareness appear to underlie a poor global functional outcome in SSD. Achieving recovery in SSD appears to require both symptomatic remission (e.g., through antipsychotics) and measures to improve mastery and relieve low mood.

Persons with first episode psychosis have distinct profiles of social cognition and metacognition

Subjects with first-episode psychosis experience substantial deficits in social cognition and metacognition. Although previous studies have investigated the role of profiles of individuals in social cognition and metacognition in chronic schizophrenia, profiling subjects with first-episode psychosis in both domains remains to be investigated. We used latent profile analysis to derive profiles of the abilities in 174 persons with first-episode psychosis using the Beck's Cognitive Insight Scale, the Faces Test, the Hinting Task, the Internal, Personal and Situational Attributions Questionnaire, and the Beads Task. Participants received a clinical assessment and a neuropsychological assessment. The best-fitting model was selected according to the Bayesian information criterion (BIC). We assessed the importance of the variables via a classification tree (CART). We derived three clusters with distinct profiles. The first profile (33.3%) comprised individuals with low social cognition. The second profile (60.9%) comprised individuals that had more proneness to present jumping to conclusions. The third profile (5.7%) presented a heterogeneous profile of metacognitive deficits. Persons with lower social cognition presented worse clinical and neuropsychological features than cluster 2 and cluster 3. Cluster 3 presented significantly worst functioning. Our results suggest that individuals with FEP present distinct profiles that concur with specific clinical, neuropsychological, and functional challenges. Each subgroup may benefit from different interventions.

[Ketamine Augmented Psychotherapy (KAP) in mood disorder: User guide]

Ketamine, a non-competitive NMDA receptor antagonist, is used as a fast-acting antidepressant therapy in depressive disorders. This treatment provokes dissociative effects associating derealization and depersonalization, and a synaptogenic signaling cascade promoting brain plasticity. Despite several preliminary studies suggesting the usefulness of its combination with psychotherapy, administration of ketamine isn't generally combined with per- and post-infusion psychotherapy protocols in its clinical antidepressant use. However, the phenomenology of psychodysleptic experiences and the synaptogenic effect could potentiate cognitive and behavioral therapies (CBT). In this article, we purpose a practical protocol to Ketamine Augmented Psychotherapy (KAP) synthesizing contemporary data from the literature and our clinical experience. We detail proposals for clinical practice, and propose four important steps for the use of a psychodysleptic molecule for antidepressant purposes: preparation, administration, integration, and prolongation. Finally, we discuss the limits and prospects of this combination in the management of mood disorders.

Metacognitive Training Modified for Negative Symptoms (MCT-N): A Feasibility study

OBJECTIVE

Although patients often prioritise the treatment of negative symptoms, few psychological interventions targeting negative symptoms exist. This study attempts to fill this gap by piloting a modified Metacognitive training programme, specifically targeted at negative symptoms (MCT-N), with a group of patients with prominent negative symptoms.

METHOD

We adopted a mixed methods case series design, providing detailed quantitative data on changes over time, to focus on potential mechanisms underlying the intervention, in combination with qualitative interviews.

RESULTS

The intervention showed good feasibility as demonstrated by the attendance rate, the positive feedback from participants and the multidisciplinary team, and the improvements on negative symptoms observed following the intervention. Multilevel modelling showed that depression, internalised stigma, and reflective functioning explained the variance in negative symptoms.

DISCUSSION

The pilot study indicated that the intervention has high feasibility and that improvements in negative symptoms can be partially explained by improvements on depression, stigma, and reflective functioning.

Modelling the contribution of metacognitions and expectancies to problematic smartphone use

BACKGROUND AND AIMS

In the current study we have sought to clarify the contribution of metacognitions concerning smartphone use relative to smartphone use expectancies in the relationship between well-established predisposing psychological factors and problematic smartphone use (PSU). We tested a model where psychological distress, impulsivity, and proneness to boredom predict metacognitions about smartphone use and smartphone use expectancies, which in turn predict PSU.

METHODS

A sample of 535 participants (F = 71.2%; mean age = 27.38 ± 9.05 years) was recruited.

RESULTS

The model accounted for 64% of the PSU variance and showed good fit indices (χ 2 = 16.01, df = 13, P = 0.24; RMSEA [90%CI] = 0.02 [0-0.05], CFI = 0.99; SRMR = 0.03). We found that: (i) when it comes to psychological distress and boredom proneness, negative metacognitions, and both positive and negative expectancies play a mediating role in the association with PSU, with negative metacognitions showing a dominant role; (ii) there is no overlap between positive expectancies and positive metacognitions, especially when it comes to smartphone use as a means for socializing; (iii) impulsivity did not show a significant effect on PSU Direct effects of the predictors on PSU were not found.

DISCUSSION AND CONCLUSIONS

The current study found additional support for applying metacognitive theory to the understanding of PSU and highlight the dominant role of negative metacognitions about smartphone in predicting PSU.

Moderators of cognitive insight outcome in metacognitive training for first-episode psychosis

Metacognitive training (MCT) is a promising treatment for improving cognitive insight associated with delusional beliefs in individuals with psychotic disorders. The aim of this study was to examine potential moderators of cognitive insight in individuals with first-episode psychosis (FEP) who received either MCT or psychoeducation. The present study was based on data from a randomized control trial comparing MCT to psychoeducation. Baseline sociodemographic and clinical characteristics in a sample of 122 patients with FEP were examined as potential moderators of the self-reflectiveness and self-certainty dimensions of cognitive insight using the SPSS PROCESS macro. The only variable that moderated self-reflectiveness at the post-treatment evaluation was age of onset (b = -0.27, p = .025). The effect of MCT in reducing self-certainty was stronger in women (b = -3.26, p = .018) and in individuals with average or above average baseline self-esteem (b = -0.30, p = .007). Overall, our findings support the generalization of MCT to a variety of sociodemographic and clinical profiles. While some patient profiles may require targeted interventions such as MCT to improve cognitive insight, others may do equally as well with less demanding interventions such as a psychoeducational group.

Personality traits predict regression of pelvic girdle pain after pregnancy: a longitudinal follow-up study

Background

Pelvic girdle pain (PGP) is a multifactorial condition with a partly unknown etiology. This condition can be mentally and physically compromising both during and after pregnancy. To provide all-around preventive measures to improve the recovery from PGP, it is a necessity for obstetricians and orthopaedists to develop predictive studies about the worse prognosis for this condition. Therefore, this study aims to determine whether personality traits can predict the consequences of long-term pregnancy-related PGP.

Methods

This was a prospective study conducted from January 2015 to August 2018. A total of 387 pregnant women were enrolled in this study. According to whether they had experienced PGP during the past 4 weeks, the subjects were classified into no PGP and PGP groups. Persistent PGP after the pregnancy was defined as a recurrent or continuous visual analog score (VAS) pain rating of ≥3 for more than 1 week. The Quick Big Five Personality Test (QBFPT) was used to assess personality traits. Data were obtained by mail or in the clinic. The authors collected data including age, BMI, educational level, annual household income, cesarean delivery, breastfeeding, unexpected sex of the baby, parity, sick leave, no or rare ability to take rest breaks at work, and PGP in the previous pregnancy.

Results

Of 387 included women, 264 subjects experienced PGP during the pregnancy with a mean age of 26.3 ± 4.5 years. A total of 80 of 264 (30.3%) women experienced persistent PGP after the pregnancy. Persistent PGP after the pregnancy was associated with higher levels of neuroticism (OR = 2.12, P = 0.001). Comparing women with persistent PGP, those who reported higher levels of extraversion and conscientiousness were more likely to recover from this condition (OR = 0.65, P = 0.001; OR = 0.78, P = 0.010, respectively). Besides, neuroticism was positively associated with higher pain scores (r = 0.52, P = 0.005). However, extraversion and conscientiousness domains showed negative correlations with pain score (r = − 0.48, P = 0.003; r = − 0.36, P = 0.001).

Conclusions

Personality traits were significantly associated with the outcomes of PGP.

Delusions beyond beliefs: a critical overview of diagnostic, aetiological, and therapeutic schizophrenia research from a clinical-phenomenological perspective

Delusions are commonly conceived as false beliefs that are held with certainty and which cannot be corrected. This conception of delusion has been influential throughout the history of psychiatry and continues to inform how delusions are approached in clinical practice and in contemporary schizophrenia research. It is reflected in the full psychosis continuum model, guides psychological and neurocognitive accounts of the formation and maintenance of delusions, and it substantially determines how delusions are approached in cognitive-behavioural treatment. In this Review, we draw on a clinical-phenomenological framework to offer an alternative account of delusion that incorporates the experiential dimension of delusion, emphasising how specific alterations to self-consciousness and reality experience underlie delusions that are considered characteristic of schizophrenia. Against that backdrop, we critically reconsider the current research areas, highlighting empirical and conceptual issues in contemporary delusion research, which appear to largely derive from an insufficient consideration of the experiential dimension of delusions. Finally, we suggest how the alternative phenomenological approach towards delusion could offer new ways to advance current research and clinical practice.

Mindreading and metacognition patterns in patients with borderline personality disorder: experimental study

Current psychopathology attempts to understand personality disorders in relation to deficits in higher cognition such as mindreading and metacognition. Deficits in mindreading are usually related to limitations in or a complete lack of the capacity to understand and attribute mental states to others, while impairments in metacognition concern dysfunctional control and monitoring of one's own processes. The present study investigated dysfunctional higher cognition in the population of patients with borderline personality disorder (BPD) by analyzing the accuracy of metacognitive judgments in a mindreading task [reading the mind in the eyes Test (RMET)] and a subsequent metacognitive task based on self-report scales: a confidence rating scale (CR) versus a post-decision wagering scale (PDW). It turned out that people from the BPD group scored lower in the RMET. However, both groups had the same levels of confidence on the PDW scale when giving incorrect answers in the RMET test. As initially hypothesized, individuals with BPD overestimated their confidence in incorrect answers, regardless of the type of metacognitive scales used. The present findings indicate that BPD individuals show dysfunctional patterns between instances of mindreading and metacognition.

Die Rolle von Verhaltensexperimenten in der Behandlung von Zwangsstörungen: Ein Update zur effektiven Gestaltung und Durchführung in der Praxis

Das Ziel des Artikels ist es, den neuesten Stand zum effektiven Einsatz von Verhaltensexperimenten im Rahmen der Psychotherapie für Zwangsstörungen darzulegen. Dazu werden im ersten Teil die evidenzbasierten Psychotherapien zur Behandlung von Zwangsstörungen vorgestellt sowie die Probleme bei der Implementierung dieser Verfahren aufgezeigt. Dabei zeigt sich, dass trotz der guten Evidenzlage die Verfahren zu selten eingesetzt werden und so die Forschungs-Praxis-Lücke fördern. Im Anschluss werden die zugrundeliegenden Rationale zur Durchführung von Verhaltensexperimenten erläutert, in Bezug zu aktuellen Forschungsarbeiten gestellt und damit die Bedeutung von Verhaltensexperimenten in der Therapie von Zwangsstörungen unterstrichen. Daraus werden Empfehlungen für die effektive Umsetzung von Verhaltensexperimenten in der Praxis abgeleitet. Die Funktionsanalyse der zwangsspezifischen Symptomatik stellt das zentrale Element im Rahmen der Behandlung von Zwangsstörungen dar. Dabei müssen die Verhaltensexperimente an die individuell befürchtete Konsequenz bei Unterlassen von Ritualen und Sicherheitsverhalten (d.h. die furchtbasierte Überzeugung) ausgerichtet sein, um eine maximale Erwartungsverletzung zu ermöglichen. Klinische Fallbeispiele werden skizziert, anhand deren effektive Verhaltensexperimente anschaulich und praxisnah dargestellt werden. Abschließend werden noch Hinweise, Tipps und Fallstricke für Praktiker zur Durchführung von effektiven Verhaltensexperimenten beleuchtet und die Grenzen von Verhaltensexperimenten benannt.

Sleep problems and worrying precede psychotic symptoms during an online intervention for psychosis

OBJECTIVE

Experience sampling assessments (multiple assessments per day for approximately one week) indicate that positive symptoms fluctuate over time in psychosis. Precursors, such as sleep problems or worrying, predict these fluctuations. To date, it remains unclear whether the same precursors predict symptom variability also during treatment in an online intervention for psychosis, using assessments lying temporally further apart.

METHODS

Participants completed brief intermediate online self-report assessments on their computers (up to every 7 days during a 2-month waiting period and up to twice every 6 days during a 2-month intervention period) within a randomized controlled trial. We monitored the course of paranoia, auditory verbal hallucinations, and their theory-driven precursors worrying, negative affect, self-esteem, self-reported cognitive biases, and quality of sleep in n = 124 participants (M = 10.32 assessments per participant; SD = 6.07). We tested group differences regarding the course of the composite of precursors, group differences regarding the effect of the composite on subsequent momentary psychotic symptoms, and the effect of each individual precursor on subsequent psychotic symptoms, using (lagged) linear mixed models.

RESULTS

The course composite precursors over time and their lagged effect on subsequent momentary psychotic symptoms did not differ between groups. During the intervention, increased worrying and decreased quality of sleep preceded heightened momentary psychotic symptoms.

CONCLUSION

The regression-based design does not allow drawing causal conclusions. However, worrying and sleep problems likely represent underlying mechanisms of psychotic symptom variability during online psychosis treatment, indicating that experience sampling findings from everyday life generalize to interventions with assessments lying several days apart.

PRACTITIONER POINTS

Worrying and sleep problems represent important mechanisms of symptom fluctuations during an online intervention for people with psychosis. Our findings further support the notion that worrying and sleep problems are important treatment targets in psychological interventions for people with psychosis. Momentary levels of worrying and quality of sleep can signal subsequent fluctuations of psychotic symptom severity so practitioners should monitor these variables during treatment. Worrying seems to predict subsequent paranoia specifically during treatment whereas quality of sleep predicts both paranoia and auditory verbal hallucinations.

Effects and side effects of a transdiagnostic bias modification intervention in a mixed sample with obsessive-compulsive and/or depressive symptoms-a randomized controlled trial

Obsessive-compulsive disorder (OCD) and major depression disorder (MDD) are underdiagnosed and undertreated mental disorders. Prior studies have verified the efficacy of the self-help manual My Metacognitive Training (myMCT) for patients with primary OCD. As depression and OCD share a number of (meta)cognitive biases and dysfunctional coping strategies, we examined the efficacy of myMCT in a mixed patient sample with OCD and/or depression. A total of 80 Italian-speaking individuals with symptoms of OCD and/or depression were randomized to either myMCT or to a waitlist control group (both groups had access to care as usual during the intervention). Post-assessment was carried out 6 weeks after inclusion. Scores on the Beck Depression Inventory-II scale (BDI-II) served as the primary outcome. Adverse effects were assessed with a newly devised self-report scale. Participants in the myMCT condition showed significant symptom improvement on the BDI-II scale at a medium to large effect size compared to the control group (using intention-to-treat and per protocol analyses). The intention-to-treat analyses yielded significant positive effects on the PHQ-9 scores and psychological as well as environmental well-being in favor of myMCT; for the OCI-R total score, group differences bordered significance in favor of the myMCT. The most prevalent adverse effects were feeling pressured by the suggested exercises or feeling bad due to not performing the exercises correctly. Our results indicate that the myMCT manual represents an effective program for patients with OCD as well as those with depressive symptoms in an Italian-speaking population. Adverse events due to unguided self-help deserve more attention in the future.

The Metacognitive Training for obsessive-compulsive disorder: A pilot study

More than 50% of patients with obsessive-compulsive disorder (OCD) do not receive first-line psychological treatment such as cognitive-behavioral therapy with exposure and response prevention. To narrow this treatment gap, there is an urgent need for therapies that are easy to disseminate and highly accepted by patients. The aim of the present pilot study was to evaluate the effectiveness of the Metacognitive Group Training for OCD (MCT-OCD). Fifty patients with OCD participated in the MCT-OCD for 4 weeks during their inpatient stay in a single-arm pilot trial. Patients were assessed before and after the intervention and filled out an online survey 6 months after post assessment. Results showed a decrease in obsessive compulsive symptoms according to the Yale-Brown Obsessive Compulsive Scale (primary outcome) from baseline to post assessment with a large effect size. Symptom reduction remained stable over 6 months and was positively correlated with appraisal ratings of the training. The reduction in frequency of obsessive compulsive symptoms, distress due to obsessive compulsive symptoms, cognitive biases, and depressive symptoms remained stable over 6 months after the intervention. Our findings tentatively imply that the MCT-OCD is a promising treatment for OCD patients. A randomized controlled trial is thus warranted to further clarify the efficacy of the MCT-OCD. Trial Registration: German Clinical Trials Register (DRKS-ID: DRKS00012531), date of registration: 16.06.2017.

Assessing the efficacy and feasibility of providing metacognitive training for patients with schizophrenia by mental health nurses: A randomized controlled trial

AIM

To evaluate the efficacy of metacognitive group training in reducing psychotic symptoms and improving cognitive insight and functions in people with schizophrenia.

DESIGN

Randomized controlled trial. It was carried out between July 2019 -February 2020.

METHODS

Fifty-six patients with schizophrenia were enrolled and randomly assigned to either a control group (N = 29) or a metacognitive training group (N = 27). Blinded assessments were made at baseline, 1-week post-treatment and at follow-up 3 months after treatment. The primary outcome measure was psychotic symptoms based on the Psychotic Symptom Rating Scales (PSYRATS). Secondary outcomes were assessed by the Beck Cognitive Insight Scale (BCIS), the Personal and Social Performance (PSP) scale and the World Health Organization Disability Assessment Schedule (WHODAS).

RESULTS

Completion at follow-up was high (92.86%). The intention-to-treat analyses demonstrated that patients in the metacognitive training group had significantly greater improvements of the Psychotic Symptom Rating Scales delusion score and total score and the Personal and Social Performance Scale, after 3 months, compared with the control group. The effect size was medium to large. The intention-to-treat analyses also demonstrated that patients in the metacognitive training group had significantly greater reductions of the Psychotic Symptom Rating Scales hallucination score and Beck Cognitive Insight Scale self-certainty score post-treatment, compared with the control group. The effect size was medium to large.

CONCLUSION

The metacognitive training administered by psychiatric and mental health nurses was effective in ameliorating delusions and social functioning over time and it immediately reduced hallucinations post-treatment.

IMPACT

Metacognitive training for treating psychosis in patients with schizophrenia is efficacious and administration is clinically feasible in the Portuguese context.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID NCT03891186.

CBT at the Crossroads: The Rise of Transdiagnostic Treatments

Transdiagnostic treatments span a heterogeneous group of interventions that target a wider range of disorders and can be applied to treat several disorders simultaneously. Several meta-analyses have highlighted the evidence base of these novel therapies. However, these meta-analyses adopt different definitions of transdiagnostic treatments, and the growing field of transdiagnostic therapies has become increasingly difficult to grasp. The current narrative review proposes a distinction of “one size fits all” unified and “my size fits me” individualized approaches within transdiagnostic therapies. Unified treatments are applied as “broadband” interventions to a range of disorders without tailoring to the individual, while individualized treatments are tailored to the specific problem presentation of the individual, e.g., by selecting modules within modular treatments. The underlying theoretical foundation and relevant empirical evidence for these different transdiagnostic approaches are examined. Advantages and limitations of the transdiagnostic treatments as well as future developments are discussed.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis

BACKGROUND

Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved.

METHODS

We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up.

RESULTS

Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = -0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results.

CONCLUSIONS

Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.

Moderators of treatment efficacy in individualized metacognitive training for psychosis (MCT+)

BACKGROUND AND OBJECTIVES

Individualized Metacognitive Training (MCT+) is a manualized intervention designed to improve delusional severity by reducing delusion-associated cognitive biases such as jumping-to-conclusions. Increased interest in personalized medicine stipulates the identification of patients who are more likely to benefit from specialized interventions. The present study aimed to explore baseline moderators of MCT+ efficacy on delusions and overall positive symptoms in psychosis.

METHODS

We analyzed data from a randomized rater-blind controlled trial, in which 92 patients with psychotic disorders and current or past delusions were randomly assigned to either MCT+ or CogPack®, a cognitive remediation software. Baseline moderator variables consisted of jumping-to-conclusions, cognitive insight, quality of life, self-esteem, selective attention, and patients' attitudes towards their symptoms. Linear mixed-effects models were applied to investigate specific moderators of MCT+ efficacy.

RESULTS

In MCT+ relative to CogPack, presence of a jumping-to-conclusions bias, a lowered decision threshold, and low self-esteem were associated with larger improvements in delusional severity and/or overall positive symptoms over time. Subjective reasoning style and insight, as well as subjective attitudes towards psychosis, did not moderate the treatment efficacy of MCT+ relative to CogPack.

LIMITATIONS

Participation of both treatment groups in group MCT as a part of standard care, possibly leading to additional effects on delusional severity.

CONCLUSIONS

Patients with low self-esteem and those who are prone to jumping-to-conclusions seem to particularly benefit from MCT+. Our results can help inform clinical practice as they provide specific criteria for selecting patients for whom MCT+ is most appropriate.

Insight and psychosis: the next 30 years

Academic interest in the concept of insight in psychosis has increased markedly over the past 30 years, prompting this selective appraisal of the current state of the art. Considerable progress has been made in terms of measurement and confirming a number of clinical associations. More recently, the relationship between insight and involuntary treatment has been scrutinised more closely alongside the link between decision-making capacity and insight. Advances in the clinical and cognitive neurosciences have influenced conceptual development, particularly the field of 'metacognition'. New therapies, including those that are psychologically and neurophysiologically based, are being tested as ways to enhance insight.

Cognitive biases in individuals with psychotic-like experiences: A systematic review and a meta-analysis

A prior meta-analyze using behavioral tasks demonstrated that individuals with subclinical delusional ideations jump to conclusion (JTC). The major aim of our systematic review and meta-analyses was to highlight the relationship between cognitive biases and psychotic-like experiences (PLEs) when both are assessed by self-reports measures. In accordance with PRISMA guidelines, four electronic databases were searched. A total of 669 studies were identified, 39 articles met inclusion criteria for the systematic review and 27 for the random effects meta-analysis on healthy and UHR samples investigating cognitive biases (JTC, aberrant salience (ASB), attention to threat (ATB), externalizing bias (ETB), belief inflexibility (BIB), personalizing bias, aggression bias and need for closure). Effect size estimates were calculated using Pearson's correlation coefficients (r). In samples including both healthy and Ultra High Risk (UHR) individuals, positive psychotic-like experiences (PPLEs) were positively associated with ATB (r_s = 0.38), ETB (r_s = 0.35), BIB (r_s = 0.19), JTC (r_s = 0.10), and personalizing (r_s = 0.24). In community samples, PPLEs were positively associated with ASB (r_s = 0.62), ATB (r_s = 0.34), ETB (r_s = 0.36), BIB (r_s = 0.18), JTC (r_s = 0.11). In addition, negative PLEs were positively associated with ATB (r_s = 0.28), ETB (r_s = 0.37), BIB (r_s = 0.19) and ASB (r_s = 0.18). In UHR samples, positive associations were established between PPLEs and ATB (rs = 0.47), ETB (rs = 0.34), personalizing (r_s = 0.36) and the aggression bias (r_s = 0.35). Our results support cognitive models of psychosis considering the role of cognitive biases in the onset and the maintenance of psychotic symptoms. Cognitive interventions targeting cognitive biases could potentially prevent transition to psychosis in youth reporting PLEs and in UHR.

Metacognitive Training for Obsessive-Compulsive Disorder: a study protocol for a randomized controlled trial

BACKGROUND

A high number of patients with obsessive-compulsive disorder (OCD) do not receive cognitive-behavioral therapy with exposure and response prevention, which is the most effective treatment for OCD. Therefore, Metacognitive Training for OCD (MCT-OCD) was developed, which is a structured group therapy aiming at the modification of dysfunctional (meta-)cognitive biases, beliefs and coping styles. It can be administered by less trained personnel, thus may reach a higher number of patients. An uncontrolled pilot study (MCT-OCD pilot version) provided first evidence that the training is highly accepted by patients; OC symptoms decreased with a high effect size (η2partial = 0.50). The aim of the present study is to address the shortcomings of the pilot study (e.g., no control group) and to assess the efficacy of the revised version of the MCT-OCD in the framework of a randomized controlled trial.

METHODS

Eighty patients with OCD will be recruited. After a blinded assessment at baseline (-t1), patients will be randomly assigned either to the intervention group (MCT-OCD; n = 40) or to a care as usual control group (n = 40). The MCT-OCD aims to enhance patients' metacognitive competence in eight modules by addressing dysfunctional (meta-)cognitive biases and beliefs associated with OCD (e.g., intolerance of uncertainty). After 8 weeks, patients will be invited to a post assessment (t1), and then they will receive a follow-up online questionnaire 3 months following t1 (t2). The primary outcome is the Y-BOCS total score, and the secondary outcomes include the HDRS, OCI-R, OBQ-44, MCQ-30, WHOQOL-BREF, BDI-II, and subjective appraisal ratings of the MCT-OCD. We expect that OC symptoms will decrease more in the intervention group compared with the care as usual control group from -t1 to t1 and that treatment gains will be maintained until t2.

DISCUSSION

The planned study is the first to investigate the MCT-OCD, a promising new treatment, in a randomized controlled trial. The MCT-OCD may help to overcome existing treatment barriers for patients with OCD.

TRIAL REGISTRATION

German Registry for Clinical Studies ( DRKS00013539 ), 22.02.2018.

Metacognitive and cognitive-behavioral interventions for psychosis: new developments

This review describes four cognitive approaches for the treatment of schizophrenia: cognitive-behavioral therapy for psychosis (CBTp), metacognitive therapy, metacognitive training, and metacognitive reflection insight therapy (MERIT). A central reference point of our review is a seminal paper by James Flavell, who introduced the term metacognition (“cognition about cognition”). In a way, every psychotherapeutic approach adopts a metacognitive perspective when therapists reflect with clients about their thoughts. Yet, the four approaches map onto different components of metacognition. CBTp conveys some “metacognitive knowledge” (eg, thoughts are not facts) but is mainly concerned with individual beliefs. Metacognitive therapy focuses on unhelpful metacognitive beliefs about thinking styles (eg, thought suppression). Metacognitive training brings distorted cognitive biases to the awareness of patients; a central goal is the reduction of overconfidence. MERIT focuses on larger senses of identity and highlights metacognitive knowledge about oneself and other persons. For CBTp and metacognitive training, meta-analytic evidence supports their efficacy; single studies speak for the effectiveness of MERIT and metacognitive therapy.


Study protocol of a randomised clinical trial testing whether metacognitive training can improve insight and clinical outcomes in schizophrenia

BACKGROUND

Although insight in schizophrenia spectrum disorders (SSD) has been associated with positive outcomes, the effect size of previous treatments on insight has been relatively small to date. The metacognitive basis of insight suggests that metacognitive training (MCT) may improve insight and clinical outcomes in SSD, although this remains to be established.

METHODS

This single-center, assessor-blind, parallel-group, randomised clinical trial (RCT) aims to investigate the efficacy of MCT for improving insight (primary outcome), including clinical and cognitive insight, which will be measured by the Schedule for Assessment of Insight (Expanded version) (SAI-E) and the Beck Cognitive Scale (BCIS), respectively, in (at least) n = 126 outpatients with SSD at three points in time: i) at baseline (T0); ii) after treatment (T1) and iii) at 1-year follow-up (T2). SSD patients receiving MCT and controls attending a non-intervention support group will be compared on insight level changes and several clinical and cognitive secondary outcomes at T1 and T2, whilst adjusting for baseline data. Ecological momentary assessment (EMA) will be piloted to assess functioning in a subsample of participants.

DISCUSSION

To the best of our knowledge, this will be the first RCT testing the effect of group MCT on multiple insight dimensions (as primary outcome) in a sample of unselected patients with SSD, including several secondary outcomes of clinical relevance, namely symptom severity, functioning, which will also be evaluated with EMA, hospitalizations and suicidal behaviour.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04104347. Date of registration: 26/09/2019 (Retrospectively registered).

The efficacy of extended metacognitive training for psychosis: A randomized controlled trial

This study investigated the efficacy of 10-module metacognitive training (MCT) among Japanese patients with schizophrenia by conducting a multicenter randomized controlled trial to test the influence of the most recent and extended version of MCT on positive symptoms. A six-center, randomized, assessor-blind, controlled trial between "treatment as usual" (TAU) and TAU + MCT was conducted. Fifty inpatients and outpatients with schizophrenia, schizotypal, and delusional disorders (ICD 10) were enrolled, then randomly assigned to TAU (n = 26) or TAU + MCT (n = 24). Assessments were made at baseline, after six weeks, immediately posttreatment, and 1-month post-treatment. The primary outcome was positive symptom score, as measured by the Positive and Negative Syndrome Scale (PANSS). General assessment of functioning (GAF) and measures of cognitive biases were secondary outcomes. Completion at post-treatment (10 weeks later) and 1-month follow-up was high-TAU + MCT, n = 22 (91.67%) and TAU, n = 23 (88.46%). The severity of PANSS positive symptoms declined significantly in the TAU + MCT treatment group compared with the TAU group. GAF also showed significantly greater improvement in the TAU + MCT group compared with the TAU group. There was also a trend for greater efficacy of MCT on cognitive biases. In conclusion, this study provides support for the efficacy of 10 module MCT concerning positive symptomatology (especially, delusion) and general functioning.

Abnormalities of confidence in psychiatry: an overview and future perspectives

Our behavior is constantly accompanied by a sense of confidence and its' precision is critical for adequate adaptation and survival. Importantly, abnormal confidence judgments that do not reflect reality may play a crucial role in pathological decision-making typically seen in psychiatric disorders. In this review, we propose abnormalities of confidence as a new model of interpreting psychiatric symptoms. We hypothesize a dysfunction of confidence at the root of psychiatric symptoms either expressed subclinically in the general population or clinically in the patient population. Our review reveals a robust association between confidence abnormalities and psychiatric symptomatology. Confidence abnormalities are present in subclinical/prodromal phases of psychiatric disorders, show a positive relationship with symptom severity, and appear to normalize after recovery. In the reviewed literature, the strongest evidence was found for a decline in confidence in (sub)clinical OCD, and for a decrease in confidence discrimination in (sub)clinical schizophrenia. We found suggestive evidence for increased/decreased confidence in addiction and depression/anxiety, respectively. Confidence abnormalities may help to understand underlying psychopathological substrates across disorders, and should thus be considered transdiagnostically. This review provides clear evidence for confidence abnormalities in different psychiatric disorders, identifies current knowledge gaps and supplies suggestions for future avenues. As such, it may guide future translational research into the underlying processes governing these abnormalities, as well as future interventions to restore them.

Does uncertainty breed conviction? On the possible role of compensatory conviction in jumping to conclusions and overconfidence in psychosis

Background: Jumping to conclusions (JTC) and overconfidence in errors are well established in individuals with a liability to psychosis. Experimental research suggests that subjecting individuals to dilemmas and doubt prompts a subsequent hardening of attitudes and may foster delusion-like convictions. For the present study, we examined whether this compensatory conviction process is exaggerated in individuals with a liability to psychosis and might in part explain JTC and overconfidence. Methods: A large sample of participants from the general population were screened for psychotic experiences with the Community Assessment of Psychic Experiences scale (CAPE) and then randomly allocated to either a condition in which they should experience doubt or a control condition. Participants (final sample, n = 650) were then tested on JTC and overconfidence. Results: Participants who scored high on the positive subscale of the CAPE made fewer draws to decision, showed greater confidence, and made more errors relative to low scorers. Yet, none of the parameters was modulated by experimental condition. Conclusions: Our results at present do not support the idea that JTC is elevated by a prior experience of a dilemma or doubt. Yet, this possibility should not be entirely dismissed as the presumed process may take time to evolve and perhaps needs to be more pervasive.