Metacognition and social cognition in schizophrenia: stability and relationship to concurrent and prospective symptom assessments

Investigating the relationship between specific negative symptoms and metacognitive functioning in psychosis: A systematic review

BACKGROUND

Disrupted metacognition is implicated in development and maintenance of negative symptoms, but more fine-grained analyses would inform precise treatment targeting for individual negative symptoms.

AIMS

This systematic review identifies and examines datasets that test whether specific metacognitive capacities distinctly influence negative symptoms.

MATERIALS & METHODS

PsycINFO, EMBASE, Medline and Cochrane Library databases plus hand searching of relevant articles, journals and grey literature identified quantitative research investigating negative symptoms and metacognition in adults aged 16+ with psychosis. Authors of included articles were contacted to identify unique datasets and missing information. Data were extracted for a risk of bias assessment using the Quality in Prognostic Studies tool.

RESULTS

85 published reports met criteria and are estimated to reflect 32 distinct datasets and 1623 unique participants. The data indicated uncertainty about the relationship between summed scores of negative symptoms and domains of metacognition, with significant findings indicating correlation coefficients from 0.88 to -0.23. Only eight studies investigated the relationship between metacognition and individual negative symptoms, with mixed findings. Studies were mostly moderate-to-low risk of bias.

DISCUSSION

The relationship between negative symptoms and metacognition is rarely the focus of studies reviewed here, and negative symptom scores are often summed. This approach may obscure relationships between metacognitive domains and individual negative symptoms which may be important for understanding how negative symptoms are developed and maintained.

CONLCLUSION

Methodological challenges around overlapping participants, variation in aggregation of negative symptom items and types of analyses used, make a strong case for use of Individual Participant Data Meta-Analysis to further elucidate these relationships.

Conceptual disorganization as a mediating variable between visual learning and metacognition in schizophrenia

Objectives

The aim of this study was to evaluate the relative contributions of visual learning and conceptual disorganization to specific metacognitive domains in a sample of outpatients with stable schizophrenia.

Methods

A total of 92 consecutive outpatients with stable schizophrenia were recruited in a cross-sectional study. We analyzed the data with five path analyses based on multiple regressions to analyze the specific effect of visual learning on metacognitive capacity and metacognitive domains and the possible mediating role of conceptual disorganization.

Results

We found that (i) visual learning was negatively correlated to metacognitive capacity and its domains on the one hand and conceptual disorganization on the other hand; (ii) conceptual disorganization was negatively associated with metacognition and its domains; and (iii) when the mediation effect was considered, conceptual disorganization fully mediated the relationship between visual learning and mastery, whereas it served as a partial mediator of the effect of visual learning on the other metacognition domains, i.e., self-reflectivity, understanding others' mind, and decentration.

Conclusion

These results delineate an articulated panorama of relations between different dimensions of metacognition, visual learning, and conceptual disorganization. Therefore, studies unable to distinguish between different components of metacognition fail to bring out the possibly varying links between neurocognition, disorganization, and metacognition.

Age-Related Social Cognitive Performance in Individuals With Psychotic Disorders and Their First-Degree Relatives

BACKGROUND

Social cognitive impairment is a recognized feature of psychotic disorders. However, potential age-related differences in social cognitive impairment have rarely been studied.

STUDY DESIGN

Data came from 905 individuals with a psychotic disorder, 966 unaffected siblings, and 544 never-psychotic controls aged 18-55 who participated in the Genetic Risk and Outcome of Psychosis (GROUP) study. Multilevel linear models were fitted to study group main effects and the interaction between group and age on emotion perception and processing (EPP; degraded facial affect recognition) and theory of mind (ToM; hinting task) performance. Age-related differences in the association between socio-demographic and clinical factors, and EPP and ToM were also explored.

STUDY RESULTS

Across groups, EPP performance was associated with age (β = -0.02, z = -7.60, 95% CI: -0.02, -0.01, P < .001), with older participants performing worse than younger ones. A significant group-by-age interaction on ToM (X2(2) = 13.15, P = .001) indicated that older patients performed better than younger ones, while no age-related difference in performance was apparent among siblings and controls. In patients, the association between negative symptoms and ToM was stronger for younger than older patients (z = 2.16, P = .03).

CONCLUSIONS

The findings point to different age-related performance patterns on tests of 2 key social cognitive domains. ToM performance was better in older individuals, although this effect was only observed for patients. EPP was less accurate in older compared with younger individuals. These findings have implications with respect to when social cognitive training should be offered to patients.

Metacognition in Schizophrenia Spectrum Disorders-Current Methods and Approaches

Metacognition essentially represents "thinking about thinking", or the individual's capacity to control and monitor their own cognitive processes. Metacognition impairment in schizophrenia represents a core feature of the disease, and, in the last fifteen years, the subject has evolved into a growing study area concentrating on a wide variety of processes, such as clinical insight, autobiographical memory, cognitive beliefs, reasoning, and memory biases. Since metacognition is a complex subject, we wanted to focus on the different nuances of metacognition transposed into the lives of patients diagnosed with either schizophrenia or a schizoaffective disorder. Therefore, this narrative review aims to analyze the literature in order to provide an insight regarding the current methods and approaches in the study of metacognition in schizophrenia or schizoaffective disorders, as well as the results provided. Results from the reviewed studies showed that patients with schizophrenia have a lower metacognitive ability, which is strongly reflected in their lives. Studies to date have highlighted the interaction between schizophrenia symptoms and metacognition, which shows how metacognition impacts work performance, autobiographical memory, motivation, the severity of symptoms, and social cognition.

Does social cognition change? Evidence after 4 years from the Italian Network for Research on Psychoses

BACKGROUND

Deficits in social cognition (SC) are significantly related to community functioning in schizophrenia (SZ). Few studies investigated longitudinal changes in SC and its impact on recovery. In the present study, we aimed: (a) to estimate the magnitude and clinical significance of SC change in outpatients with stable SZ who were assessed at baseline and after 4 years, (b) to identify predictors of reliable and clinically significant change (RCSC), and (c) to determine whether changes in SC over 4 years predicted patient recovery at follow-up.

METHODS

The reliable change index was used to estimate the proportion of true change in SC, not attributable to measurement error. Stepwise multiple logistic regression models were used to identify the predictors of RCSC in a SC domain (The Awareness of Social Inference Test [TASIT]) and the effect of change in TASIT on recovery at follow-up.

RESULTS

In 548 participants, statistically significant improvements were found for the simple and paradoxical sarcasm of TASIT scale, and for the total score of section 2. The reliable change index was 9.8. A cut-off of 45 identified patients showing clinically significant change. Reliable change was achieved by 12.6% and RCSC by 8% of participants. Lower baseline TASIT sect. 2 score predicted reliable improvement on TASIT sect. 2. Improvement in TASIT sect. 2 scores predicted functional recovery, with a 10-point change predicting 40% increase in the probability of recovery.

CONCLUSIONS

The RCSC index provides a conservative way to assess the improvement in the ability to grasp sarcasm in SZ, and is associated with recovery.

Exploring the Latent Structure and Convergent and Incremental Validity of the Metacognition Assessment Scale - Abbreviated in a Sample of Patients with Non-Affective Psychosis

Synthetic metacognition is a heterogeneous construct related to psychotic disorders. One important tool to assess this construct is the Metacognition Assessment Scale - Abbreviated (MAS-A). In this study, we investigated the latent structure as well as the interrater reliability and convergent and incremental validity of the MAS-A in a sample of patients with non-affective psychosis. Analyses indicated that the scale might be one-dimensional. Interrater reliability of the MAS-A total score was good. In terms of convergent validity, correlational analyses showed significant associations of MAS-A metacognition with the Operationalized Psychodynamic Diagnosis Level of Structural Integration Axis (OPD-LSIA) and the Levels of Emotional Awareness Scale (LEAS). In terms of construct validity, a significant association was observed between MAS-A metacognition and a short version of the International Classification of Functioning, Disability and Health (MINI-ICF), which persisted after self-report measures of impairments in structural capacities (Structure Questionnaire of Operationalized Psychodynamic Diagnosis [OPD-SQS]) and mentalizing abilities (Mentalization Questionnaire [MZQ]) were included as covariates, but not after symptom dimensions were included. There was a significant correlation with the current living situation, but not with other external criteria like diagnosis or duration of illness. Future studies should explore alternative outcomes and replicate results in longitudinal designs.

Metacognition in schizophrenia: A practical overview of psychometric metacognition assessment tools for researchers and clinicians

Metacognition refers to the cognitive ability to control, monitor and modulate cognitive processes thus guiding and orienting behavior: a continuum of mental activities that ranges from more discrete ones, such as the awareness of the accuracy of others' judgment, to more integrated activities, such as the knowledge of cognitive processes. Metacognition impairment in schizophrenia, which is considered a core feature of the illness, has become a growing research field focusing on a wide range of processes including reasoning, autobiographical memory, memory biases, cognitive beliefs and clinical insight. There is a well-established relationship between metacognition and schizophrenia symptoms severity, as well as between impaired metacognitive functioning and specific symptomatic sub-domains, such as positive symptoms, negative symptoms, or disorganization. The development of specific cognitive-derived psychotherapies for metacognitive deficits in schizophrenia has been ongoing in the last years. Although sharing a metacognitive feature, these treatments focus on different aspects: false or unhelpful beliefs for metacognitive therapy; cognitive biases for metacognitive training; schematic dysfunctional beliefs for cognitive behavioral therapy (CBT) for psychoses; metacognitive knowledge and sense of identity for MERIT; interpersonal ideas or events triggering delusional thinking for MIT-P. This article reviews the instruments designed to assess metacognitive domains and functions in individuals with schizophrenia, providing mental health professionals with an overview of the heterogeneous current scenario ranging from self-administered scales to semi-structured interviews, which are supported by a variety of theoretical frameworks. Future directions may address the need for more specific and refined tools, also able to follow-up psychotherapeutic-induced improvements.

Mentalizing in first-episode psychosis: Correlates with symptomatology and traits of borderline personality disorder

AIM

To explore the associations between mentalizing, positive and negative symptoms of psychosis, and traits of borderline personality disorder, in a sample of patients with first-episode psychosis, and in a non-clinical sample.

METHODS

A quantitative cross-sectional design was employed. Thirty-two adults with first-episode psychosis and 148 non-clinical participants were assessed using the reflective functioning questionnaire. The questionnaire measures two dimensions of mentalizing, certainty and uncertainty about mental states. Traits of borderline personality disorder and symptoms of psychosis were measured using the self-report version of the Zanarini rating scale, the Community Assessment of Psychotic Experiences, and the Green et al., paranoid thought scale.

RESULTS

Patients with first-episode psychosis reported increased mentalizing impairments, characterized as hypomentalizing tendencies, compared to the non-clinical group. Regression analysis showed significant associations between higher scores on the uncertainty about mental states scale and negative symptoms of psychosis in both groups. No associations were found between mentalizing impairments and traits of borderline personality disorder in the clinical sample, although associations were found in the non-clinical sample.

CONCLUSIONS

The present findings suggests that impairments in mentalizing may be associated with negative symptoms of psychosis across both clinical and non-clinical samples. Mentalizing impairments was found to be associated with traits of borderline personality disorder, but this finding was only confirmed in the non-clinical sample. Mentalizing should therefore be considered in the early assessment and treatment of patients experiencing difficulties with negative symptoms of psychosis.

Efficacy of metacognitive training on symptom severity, neurocognition and social cognition in patients with schizophrenia: A single-blind randomized controlled trial

Over the past decades, a number of complementary treatments for schizophrenia have emerged. One of these is metacognitive training (MCT), which combines the principles of cognitive-behavioral therapies, cognitive remediation, and psychoeducation into a hybrid approach placing emphasis on increasing metacognitive awareness. The aim of our study was to investigate the efficacy of MCT on symptom severity, and neurocognitive and social cognitive functioning in schizophrenia; also, attention was paid to the assessment of subjective acceptability. Forty-six patients diagnosed with schizophrenia were included in our single-blind randomized controlled trial, who were assigned to the intervention or control group. The intervention group was provided standard MCT, while the control group received treatment as usual. We assessed symptom severity and cognitive functions before and after the training, as well as after a 6-month follow-up period. Compared to the control group, the intervention group showed improvement in overall symptom severity, and positive and disorganized symptoms. Training participans showed further improvement at the follow-up assessment. Regarding neurocognitive functions, improvement in visuospatial functions was observed between pre- and post-intervention assessments compared to the control group. Patients showed excellent adherence, and evaluated the training as useful and interesting. In line with the results of previous studies, our results demonstrate the efficacy of MCT on symptom severity in schizophrenia. Improvements in cognitive functions that are closely related to the onset and prevalence of symptoms of schizophrenia were also found.

Computational mechanisms underlying illusion of control in delusional individuals

Humans navigate complex situations that require the accurate estimation of the controllability of the environment. Aberrant controllability computation might lead to maladaptive behaviors and poor mental health outcomes. Illusion of control, which refers to a heightened sense of control while the environment is uncontrollable, is one such manifestation and has been conceptually associated with delusional ideation. Nevertheless, this association has not yet been formally characterized in a computational framework. To address this, we used a computational psychiatry approach to quantify illusion of control in human participants with high (n = 125) or low (n = 126) trait delusion. Participants played a two-party exchange game in which their choices either did ("Controllable condition") or did not ("Uncontrollable condition") influence the future monetary offers made by simulated partners. We found that the two groups behaved similarly in model-agnostic measures (i.e., offer size, rejection rate). However, computational modeling revealed that compared to the low trait delusion group, the high delusion group overestimated their influence ("expected influence" parameter) over the offers made by their partners under the Uncontrollable condition. Highly delusional individuals also reported a stronger sense of control than those with low trait delusion in the Uncontrollable condition. Furthermore, the expected influence parameter and self-reported beliefs about controllability were significantly correlated in the Controllable condition in individuals with low trait delusion, whereas this relationship was diminished in those with high trait delusion. Collectively, these findings demonstrate that delusional ideation is associated with aberrant computation of and belief about environmental controllability, as well as a belief-behavior disconnect.

"I'd Be A Completely Different Person if I Hadn't Gone to Therapy": A Qualitative Study of Metacognitive Therapy and Recovery Outcomes in Adults with Schizophrenia

OBJECTIVE

Metacognitive oriented treatments are novel therapies designed to address metacognition deficits in schizophrenia, defined as the set of mental activities that allows reflection on oneself and others, and the integration of this knowledge into sophisticated mental representations that guide adaptive responses to life's demands and to the challenges imposed by psychiatric illness. However, little is known about the first-person experiences of engaging in this treatment. Hence, the purpose of this qualitative study was to characterize first-person experiences of recovery outcomes among people with schizophrenia spectrum disorders who take part in metacognitively oriented psychotherapy.

METHOD

A sample of 13 adult veterans with schizophrenia or schizoaffective disorder in an outpatient setting who were receiving one form of individual metacognitively oriented therapy, Metacognitive Reflection and Insight Therapy, for a minimum of 12 months participated in an open-ended interview; 27 questions probed their experiences with therapy and the outcomes and changes they have observed within themselves as a result. Interviews were analyzed using an inductive consensus based approach.

RESULTS

Findings indicate that participants observed changes in their lives in five recovery domains: improvements in real world functioning, increased formation of life pursuits, enhanced interpersonal connections, emergence of self compassion, and improved quality of life and wellness.

CONCLUSIONS

This study sheds further light on first person experiences of people with schizophrenia and adds to the growing body of evidence supporting the use of this form of metacognitively oriented psychotherapy to promote recovery in important life domains.

Metacognition Is Uniquely Related to Concurrent and Prospective Assessments of Negative Symptoms Independent of Verbal Memory in Serious Mental Illness

The inability to synthesize information into experience of self and others could be one significant cause of negative symptoms. To explore this possibility, we examined the relationships between baseline metacognition and concurrent and prospective negative symptoms controlling for verbal memory. The participants were 62 adults diagnosed with serious mental illness enrolled in outpatient treatment. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were assessed using the Brief Psychiatric Rating Scale, and verbal memory was assessed using the California Verbal Learning Test. Significant correlations were found, indicating that poorer overall metacognition was associated with greater levels of negative symptoms assessed concurrently (r = 0.39) and 1 month later (r = 0.36). A significant relationship persisted after controlling for verbal memory and education. These findings support the idea that metacognitive deficits are related to negative symptoms and point to the potential of metacognitive interventions to positively influence negative symptoms.

Contrasting metacognitive profiles and their association with negative symptoms in groups with schizophrenia, early psychosis and depression in a Russian sample

Research has suggested that negative symptoms in psychotic disorders may be in part fueled by deficits in metacognition or the ability to form integrated ideas about oneself and others. One limitation of this work is that it has largely come from North America and Western Europe. To further the literature, we assessed symptoms using the Positive and Negative Syndrome Scale and Metacognition using the Metacognitive Assessment Scale - Abbreviated in a sample of outpatients with prolonged schizophrenia (n = 41), early episode psychosis (n = 37) and major depression (n = 30) gathered in Moscow, Russia. Verbal memory was assessed for use as a potential covariate. ANOVA revealed the two groups with psychosis had significantly poorer metacognitive function in terms of self-reflectivity and awareness of the other, than the group with depression. In both psychosis groups negative symptoms were more robustly related to metacognition than other forms of symptoms after controlling for neurocognition. Results support the possibility that metacognitive deficits are a psychological factor which cross culturally contributes to negative symptoms and point to metacognition as a potentially important target for intervention.

Relationship of Metacognition and Insight to Neural Synchronization and Cognitive Function in Early Phase Psychosis

Metacognition is the process of thinking about one's own mental states. It involves a range of faculties that allow an individual to integrate information and form understanding of self and others, and use this understanding to respond to life challenges. Clinical insight is the awareness of one's mental illness, its consequences, and the need for treatment. Persons with psychotic disorders show impaired metacognition and insight, but the neurobiological bases for these impairments are not well characterized. We hypothesized that metacognition and insight may depend on capacity of neural circuits to synchronize at gamma frequencies, as well as the integrity of underlying cognitive processes. In order to test these hypotheses, 17 adults with early phase psychosis were evaluated. Metacognition was assessed with the Metacognition Assessment Scale-Abbreviated, and insight was assessed with the Scale of Unawareness of Illness-Abbreviated. The auditory steady state response (ASSR) to gamma range stimulation (40 Hz) was used as an index of neural synchronization. Cognitive function was assessed using the Brief Assessment of Cognition in Schizophrenia. Increases in ASSR power were associated with poorer metacognition and insight. Higher cognitive performance was associated with higher levels of metacognitive function and insight. These findings suggest that altered neural synchronization and constituent cognitive processes affect both metacognition and insight in early phase psychosis and may offer targets for both pharmacological and psychotherapeutic interventions.

The association between metacognitive abilities and outcome measures among people with schizophrenia: A meta-analysis

Background:

Deficits in metacognition are one of the major causes of the difficulties experienced by individuals with schizophrenia. Studies have linked these deficits to symptom exacerbation and deterioration in psychosocial functioning. The aim of the present meta-analysis was to examine the extensive existing literature regarding metacognitive deficits among persons with schizophrenia; a further aim was to assess the extent to which metacognitive abilities are linked to outcome measures of symptoms and psychosocial functioning.

Method:

We conducted a systematic literature search of studies examining the relationship between metacognitive abilities and outcome measures among people with schizophrenia. We then analyzed the data using a random-effects meta-analytic model with Cohen's d standardized mean effect size.

Results:

Heterogeneity analyses (k = 32, Cohen's d = −.12, 95% CI.−1.92 to 1.7) produced a significant Q-statistic (Q = 456.89) and a high amount of heterogeneity, as indicated by the I2 statistic (93.04%), suggesting that moderator analyses were appropriate. As hypothesized, measure type moderated the metacognitive deficit with homogenous effect for psychosocial functioning measures (Q = 9.81, I2 = 19.47%, d = .94. 95% CI .58 to 1.2) and symptoms (Q = 19.87, I2 = 0%, d = −1.07, 95% CI −1.18 to −.75). Further analysis found homogenous effects for MAS-A subscales as well as PANSS factors of symptoms.

Conclusion:

Our meta-analysis results illustrated a significant association between metacognitive deficits and both symptomatic and psychosocial functioning measures. These links suggest that the associations between metacognitive abilities and symptomatic outcomes are different from those between metacognitive abilities and psychosocial functioning measures. Intriguing hypotheses are raised regarding the role that metacognitive abilities play in both symptoms and psychosocial functioning measures of people diagnosed with schizophrenia spectrum disorders.

Metacognition over time is related to neurocognition, social cognition, and intrapsychic foundations in psychosis

Core impairments underlying schizophrenia encompass several domains, including disruptions in metacognition, neurocognition, social cognition, and intrapsychic foundations. Little is known about how these phenomena change over time and whether changes co-occur. The current study sought to address these gaps and examine the relationships between these cognitive domains across a 12 month period in adults with schizophrenia. Seventy-five adult outpatients with schizophrenia spectrum disorders were enrolled in a randomized trial comparing two cognitive interventions designed to improve work performance. Cognitive outcomes were measured at baseline, a 6-month follow-up and a 12-month follow-up. Multilevel linear modeling was used to understand the longitudinal relationships between metacognition and social cognition, neurocognition, and intrapsychic foundations across the 12-month follow-up. Metacognition significantly improved across 12 months. Improvements in overall neurocognition were significantly associated with increases in the metacognition domains of self-reflectivity and mastery across time. Improvements in social cognition over time were associated with improvements in total metacognition and the metacognitive domain of mastery. Improvements in intrapsychic foundations scores over 12 months were significantly associated with improvements in overall metacognition, self-reflectivity, and mastery. In conclusion, over time, improvements in metacognition across domains co-occur with other core cognitive and social capacities in persons with schizophrenia. As persons became better able to form integrated senses of themselves and adaptively use this knowledge, improvements in neurocognition, social cognition, and intrapsychic foundations were also present.

Influences on functional outcome and subjective recovery in individuals with and without First Episode Psychosis: A metacognitive model

Models of functional and subjective recovery in psychosis suggest that the path between neurocognition and functioning is mediated by cognitive processes, which may include metacognition, considered 'thinking about thinking'. Metacognition has several components: metacognitive ability, experience and efficiency, connected by metacognitive monitoring and metacognitive control processes; akin to executive control processes. This study aimed to explore whether metacognitive components are fragmented, how individuals with FEP perform on the metacognitive scores compared to healthy control participants, and whether metacognitive components are associated with functioning and, for FEP only, subjective recovery. 62 individuals with FEP and 73 matched healthy controls completed measures of metacognition, functional capacity, functional outcome, and subjective recovery; covariates: IQ and symptoms. Factor analysis, to assess loading of metacognitive items onto separate factors, demonstrated that metacognitive ability, experience, efficiency and monitoring were separate components, with limited association. Metacognitive ability and metacognitive control process were reduced in FEP sample, but metacognitive experience and monitoring process were higher in FEP. Metacognitive ability predicted functional capacity, functional outcome and subjective recovery. Metacognitive experience predicted functional capacity. This is the first study to assess key metacognitive components within a large model and consider the distinct contributions to both functional and subjective recovery.

Piecing together fragments: Linguistic cohesion mediates the relationship between executive function and metacognition in schizophrenia

Speech disturbances are prevalent in psychosis. These may arise in part from executive function impairment, as research suggests that inhibition and monitoring are associated with production of cohesive discourse. However, it is not yet understood how linguistic and executive function impairments in psychosis interact with disrupted metacognition, or deficits in the ability to integrate information to form a complex sense of oneself and others and use that synthesis to respond to psychosocial challenges. Whereas discourse studies have historically employed manual hand-coding techniques, automated computational tools can characterize deep semantic structures that may be closely linked with metacognition. In the present study, we examined whether higher executive functioning promotes metacognition by way of altering linguistic cohesion. Ninety-four individuals with schizophrenia-spectrum disorders provided illness narratives and completed an executive function task battery (Delis-Kaplan Executive Function System). We assessed the narratives for linguistic cohesion (Coh-Metrix 3.0) and metacognitive capacity (Metacognition Assessment Scale - Abbreviated). Selected linguistic indices measured the frequency of connections between causal and intentional content (deep cohesion), word and theme overlap (referential cohesion), and unique word usage (lexical diversity). In path analyses using bootstrapped confidence intervals, we found that deep cohesion and lexical diversity independently mediated the relationship between executive functioning and metacognitive capacity. Findings suggest that executive control abilities support integration of mental experiences by way of increasing causal, goal-driven speech and word expression in individuals with schizophrenia. Metacognitive-based therapeutic interventions for psychosis may promote insight and recovery in part by scaffolding use of language that links ideas together.

Tracing Metacognition in Psychotherapy: Associations With Symptoms of General Distress and Depression

Deficits in metacognition have often been identified as a central feature in various forms of psychopathology. The current study explores changes in metacognition and symptoms during the process of psychodynamic-oriented psychotherapy conducted in a community setting among people with diverse psychological challenges. We examined the associations between metacognition and symptoms at both the within-client and the between-clients level. Nine good-outcome and nine poor-outcome cases of psychodynamic treatment were analyzed. In terms of metacognitive abilities, results showed that clients who were part of the good-outcome group had higher levels of decentration than did clients who were part of the poor-outcome group. In addition, clients' ability to understand the other's mind improved significantly only for clients in the good-outcome group. Furthermore, sessions in which clients' self-reflectivity was higher were followed by increased symptom levels (in the next session) beyond group (poor or good outcome group). Clinical implications regarding the improvement of metacognitive abilities and their associations with outcome measures are discussed.

Effects of a Korean version of the metacognitive training program for outpatients with schizophrenia on theory of mind, positive symptoms, and interpersonal relationships

BACKGROUND

Since the significance of metacognition as the theoretical basis of a psychological intervention for schizophrenia first emerged, there have been ongoing attempts to restore or strengthen patients' metacognitive abilities.

AIM

A Korean version of the metacognitive training (MCT) program was developed, and its effects on theory of mind, positive and negative symptoms, and interpersonal relationships were examined in stable outpatients with schizophrenia.

METHOD

A pre-test-post-test design with a control group was used. The participants were 59 outpatients (30 in experimental group, 29 in control group) registered at five mental health facilities in a city in South Korea. The developed MCT program was applied for a total of 18 sessions, 60 min per session, over a period of 14 weeks. The hinting task, false belief task, Scale for the Assessment of Positive and Negative Symptoms, and Relationship Change Scale were used to verify the effects of this program. Data were analysed by the chi-square test, t-test, and Mann-Whitney U-test using the SPSS/PASW 18.0 statistics program.

RESULTS

The general characteristics, intelligence, and outcome variables of the two groups were homogeneous. After the intervention, the experimental group showed significant improvements in theory of mind, positive and negative symptoms and interpersonal relationships compared with the control group.

CONCLUSION

These results suggest that the MCT program can be a complementary psychotherapy that contributes to symptom relief and interpersonal functioning in patients with schizophrenia, and is effective in the Korean culture, beyond the Western context.

Metacognitive functioning in bipolar disorder versus controls and its correlations with neurocognitive functioning in a cross-sectional design

INTRODUCTION

Metacognition is an important factor in the development and persistence of bipolar disorder. One of the most striking examples of impairment in metacognitive functioning in bipolar disorder is the lack of insight these patients have in their disorder. Despite its importance, research regarding metacognition in bipolar disorder is scarce. Furthermore, the neurocognitive basis of metacognitive functioning is unknown.

METHODS

The current study included 29 patients with bipolar disorder and 29 age, educational level and gender matched healthy controls. All the participants filled in a metacognition questionnaire that examined their metacognitive beliefs. In addition, it was tested how well they estimated their performance on a neurocognitive test-battery beforehand (metacognitive knowledge) and afterwards (metacognitive experience).

RESULTS

Bipolar disorder patients showed maladaptive metacognitive beliefs in comparison with the healthy controls. They also showed impaired metacognitive knowledge and experience. That is, they overestimated their own cognitive performance. However, the latter result was also true for the healthy controls. In addition, metacognition had neurocognitive correlates. However, for the bipolar patients, depressive symptomatology had an important effect on this relationship and on metacognition in general.

CONCLUSION

Maladaptive metacognitive skills are related to depression in bipolar disorder. A more healthy metacognitive thinking should be promoted. An effective training for this could be a therapy that includes various elements, from basic cognitive- to higher order metacognitive training.

Metacognitive function and fragmentation in schizophrenia: Relationship to cognition, self-experience and developing treatments

Bleuler suggested that fragmentation of thought, emotion and volition were the unifying feature of the disorders he termed schizophrenia. In this paper we review research seeking to measure some of the aspects of fragmentation related to the experience of the self and others described by Bleuler. We focus on work which uses the concept of metacognition to characterize and quantify alterations or decrements in the processes by which fragments or pieces of information are integrated into a coherent sense of self and others. We describe the rationale and support for one method for quantifying metacognition and its potential to study the fragmentation of a person's sense of themselves, others and the relative place of themselves and others in the larger human community. We summarize research using that method which suggests that deficits in metacognition commonly occur in schizophrenia and are related to basic neurobiological indices of brain functioning. We also present findings indicating that the capacity for metacognition in schizophrenia is positively related to a broad range of aspects of psychological and social functioning when measured concurrently and prospectively. Finally, we discuss the evolution and study of one therapy that targets metacognitive capacity, Metacognitive Reflection and Insight Therapy (MERIT) and its potential to treat fragmentation and promote recovery.

Metacognition moderates the relationship between self-reported and clinician-rated motivation in schizophrenia

Introduction

Prior work has found varied relationships between self-reported and clinician-rated motivation measures in schizophrenia, suggesting that moderators might impact the strength of this relationship. This current study sought to identify whether metacognition – the ability to form complex representations about oneself, others, and the world – moderates the relationship between self-reported and clinician-rated motivation measures. We also explored whether clinical insight and neurocognition moderated this relationship.

Methods

Fifty-six participants with a schizophrenia-spectrum disorder completed the Motivation and Pleasure Self-Report Scale and the clinician-rated motivation index from the Heinrichs-Carpenter Quality of Life Scale.

Results

Metacognition significantly moderated the relationship; self-reported and clinician-rated motivation were positively and significantly correlated only when metacognition was relatively high. Neither clinical insight nor neurocognition moderated the relationship.

Discussion

Metacognition appears to be a key variable impacting the strength of the relationship between self-reported and clinician-rated motivation measures and may help to partly explain the varied relationships observed in prior work. Using a metacognitive framework to guide assessment interviews and targeting metacognition in psychosocial treatments may help to improve the synchrony between self-perceptions and clinician ratings of motivation.

Does childhood trauma predict poorer metacognitive abilities in people with first-episode psychosis?

Research suggests that people with first-episode psychosis (FEP) report more childhood traumas and have lower metacognitive abilities than non-clinical controls. Childhood trauma negatively affects metacognitive development in population studies, while the association remains largely unexplored in FEP populations. Metacognition refers to the identification of thoughts and feelings and the formation of complex ideas about oneself and others. This study hypothesized that childhood trauma would be associated with lower metacognitive abilities in people with FEP. In a representative sample of 92 persons with non-affective FEP, we assessed childhood trauma, metacognitive abilities and symptoms of psychosis. We used the Childhood Trauma Questionnaire (CTQ) and the Metacognitive Assessment Scale--Abbreviated which includes Self-reflectivity, Awareness of the Mind of the Other, Decentration and Mastery. Hierarchical regression analyses were performed with metacognitive domains as outcome variables and childhood traumas as independent variables, while controlling for age, gender, first-degree psychiatric illness and negative symptoms. We found few significant associations between the different types of childhood trauma and metacognitive domains, and they suggested childhood trauma are associated with better metacognitive abilities. Study limitations included the cross-sectional design and use of self-report measures. Future studies could preferably be prospective and include different measures of psychopathology and neuropsychology.

Measuring disorganized speech in schizophrenia: automated analysis explains variance in cognitive deficits beyond clinician-rated scales

BACKGROUND

Conveying information cohesively is an essential element of communication that is disrupted in schizophrenia. These disruptions are typically expressed through disorganized symptoms, which have been linked to neurocognitive, social cognitive, and metacognitive deficits. Automated analysis can objectively assess disorganization within sentences, between sentences, and across paragraphs by comparing explicit communication to a large text corpus.

METHOD

Little work in schizophrenia has tested: (1) links between disorganized symptoms measured via automated analysis and neurocognition, social cognition, or metacognition; and (2) if automated analysis explains incremental variance in cognitive processes beyond clinician-rated scales. Disorganization was measured in schizophrenia (n = 81) with Coh-Metrix 3.0, an automated program that calculates basic and complex language indices. Trained staff also assessed neurocognition, social cognition, metacognition, and clinician-rated disorganization.

RESULTS

Findings showed that all three cognitive processes were significantly associated with at least one automated index of disorganization. When automated analysis was compared with a clinician-rated scale, it accounted for significant variance in neurocognition and metacognition beyond the clinician-rated measure. When combined, these two methods explained 28-31% of the variance in neurocognition, social cognition, and metacognition.

CONCLUSIONS

This study illustrated how automated analysis can highlight the specific role of disorganization in neurocognition, social cognition, and metacognition. Generally, those with poor cognition also displayed more disorganization in their speech-making it difficult for listeners to process essential information needed to tie the speaker's ideas together. Our findings showcase how implementing a mixed-methods approach in schizophrenia can explain substantial variance in cognitive processes.

Metacognitive Deficits Predict Impaired Insight in Schizophrenia Across Symptom Profiles: A Latent Class Analysis

The integrated model of insight in schizophrenia suggests that poor insight is the result of multiple factors which compromise persons' abilities to integrate streams of information into a personal awareness of psychiatric challenges, and make adaptive responses. This model hypothesizes that metacognitive deficits, or difficulties forming a complex and integrated understanding of the self and others, influence insight, regardless of other proximal causes including clinical profile. To explore this possibility, we performed a latent class analysis on 324 adults with schizophrenia or schizoaffective disorder. This analysis produced 4 groups on the basis of assessment of insight and Positive and Negative Syndrome Scale (PANSS) positive, negative, cognitive, and hostility symptoms. The resultant groups were characterized as: Good Insight/Low Symptoms (n = 71), Impaired Insight/High Negative Symptoms, (n = 43), Impaired Insight/High Positive Symptoms (n = 50) and Impaired Insight/Diffuse Symptoms (n = 160). When we compared metacognitive function as assessed with the Metacognition Assessment Scale - Abbreviated (MAS-A) across groups, we found that the good insight group had better overall metacognition as well as higher levels of self-reflectivity, awareness of the other and mastery as compared to all 3 groups with impaired insight. When controlling for total symptoms, all differences in metacognitive function between the good insight and the impaired insight groups remained significant. These results are consistent with the view that, independent of symptoms, impaired metacognition contributes to difficulties integrating information and hence impedes insight, or awareness of psychiatric challenges. Consistent with extant literature, results suggest that interventions focusing on metacognition as the target may lead to improved insight.

Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia

BACKGROUND

Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition.

METHODS

This study is a randomized controlled trial. Patients in the active condition (n = 35) received forty MERIT sessions, the control group (n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness).

RESULTS

Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition (N = 5) or before the first session (N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes.

CONCLUSIONS

On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.

The centrality of cognitive symptoms and metacognition within the interacting network of symptoms, neurocognition, social cognition and metacognition in schizophrenia

Schizophrenia involves a range of interrelated impairments in functioning due to symptoms and deficits in varying domains of cognition including neurocognition, social cognition and metacognition. Yet little is known whether certain symptoms or cognitive impairments play a more central role than others. To explore, we conducted a network analysis of five types of symptoms, six domains of neurocognition and multiple aspects of both social cognition and metacognition. Participants were 81 adults with a schizophrenia spectrum disorder in a non-acute phase of the disorder. Results of the network analysis suggest that the cognitive symptoms node is most central in the network, metacognition abilities have high strength centrality measures followed by visual learning and emotion identification. In addition, distinction between the four groups of variables was supported. This suggests the need for both cognitive remediation and metacognitively oriented therapies in order to promote recovery from schizophrenia.

Disorganization and real-world functioning in schizophrenia: Results from the multicenter study of the Italian Network for Research on Psychoses

BACKGROUND

A general consensus has not yet been reached regarding the role of disorganization symptoms in real-world functioning in schizophrenia.

METHODS

We used structural equations modeling (SEM) to analyze the direct and indirect associations between disorganization and real-world functioning assessed through the Specific Levels of Functioning Scale (SLOF) in 880 subjects with schizophrenia.

RESULTS

We found that: 1) conceptual disorganization was directly and strongly connected with SLOF daily activities; difficulty in abstract thinking was associated with moderate strength to all SLOF domains, and poor attention was connected with SLOF work skills; 2) grandiosity was only related with poor work skills, and delusions were associated with poor functioning in all SLOF domains; interpersonal relationships were weakly indirectly influenced by hallucinatory behavior, delusions and unusual thought contents through the mediation of social cognition (SC); 3) among the negative symptoms, avolition had only direct links with SLOF work skills and SLOF activities; anhedonia had direct links with SLOF work skills and SLOF interpersonal and indirect link with SLOF work skills through functional capacity (FC); asociality with SLOF interpersonal; blunted affect had direct links with SLOF activities and indirect links with SLOF interpersonal relationships mediated by SC. Lastly, alogia had only indirect links mediated by SC, FC, and neurocognition (NC).

CONCLUSIONS

Overall conceptual disorganization is the symptom that contributed more (both directly and indirectly) to the activities of community living in real-world. Thus, it should be considered as a treatment target in intervention programs for patients with schizophrenia.

Themes of unfulfilled agency and communion in life stories of patients with schizophrenia

We examined themes of agency and communion in life stories of individuals with schizophrenia. Twenty-four individuals diagnosed with schizophrenia and 24 control participants matched on age, gender, and education described their life stories in a free format. The life stories were coded for the presence of agency and communion themes and whether or not the themes captured fulfillment of agency and communion needs. In addition, the temporal macrostructure was coded. Individuals with schizophrenia described their life stories with similar levels of temporal macrostructure as controls, but they expressed more themes focusing on unfulfilled agency and communion needs. We suggest possible avenues for using these insights to improve recovery in schizophrenia.

The Effects of Metacognition-Oriented Social Skills Training on Psychosocial Outcome in Schizophrenia-Spectrum Disorders: A Randomized Controlled Trial

A pilot study of the effects of metacognition-oriented social skills training (MOSST) on social functioning in patients with schizophrenia spectrum disorders (SSDs) reported promising results. The main purpose of the current trial was to compare the effectiveness and potential benefits of MOSST vs conventional social skills training (SST). Single-blind randomized controlled trial with 2 groups of patients aged 18-65 with SSDs on partial hospitalization. Participants were randomly assigned (1:1) to receive 16 group sessions with MOSST or conventional SST, both in addition to standard care, over 4 months, with a 6-month follow-up. Psychosocial functioning, metacognition, and symptom outcomes were measured by blind assessors. Statistical analyses used mixed models to estimate treatment effects in each postrandomization time point. Thirty-six patients were randomly assigned to the MOSST group and 33 patients to the conventional SST group. Between-group differences were significant in favor of MOSST on Social and Occupational Functioning Assessment Scale (SOFAS) and Personal and Social Performance Scale (PSP) total scores at post-treatment and follow-up. Concerning PSP subscales, there were significant between-group differences in favor of MOSST at follow-up on socially useful activities, personal and social relationships, and disturbing and aggressive behaviors. Metacognition only improved following MOSST group. For people with SDDs, MOSST appears to have short- and long-term beneficial effects on social functioning and symptoms. Further studies are required to replicate the current results in other samples.

Metacognition in schizophrenia disorders: Comparisons with community controls and bipolar disorder: Replication with a Spanish language Chilean sample

Metacognition refers to the activities which allow for the availability of a sense of oneself and others in the moment. Research mostly in North America with English-speaking samples has suggested that metacognitive deficits are present in schizophrenia and are closely tied to negative symptoms. Thus, replication is needed in other cultures and groups. The present study accordingly sought to replicate these findings in a Spanish speaking sample from Chile. Metacognition and symptoms were assessed among 26 patients with schizophrenia, 26 with bipolar disorder and 36 community members without serious mental illness. ANCOVA controlling for age and education revealed that the schizophrenia group had greater levels of metacognitive deficits than the bipolar disorder and community control groups. Differences in metacognition between the clinical groups persisted after controlling for symptom levels. Spearman correlations revealed a unique pattern of associations of metacognition with negative and cognitive symptoms. Results largely support previous findings and provide added evidence of the metacognitive deficits present in schizophrenia and the link to outcome cross culturally. Implications for developing metacognitively oriented interventions are discussed.

Emotion perception, non-social cognition and symptoms as predictors of theory of mind in schizophrenia

BACKGROUND

Theory of mind (ToM) can be divided into cognitive and affective ToM, and a distinction can be made between overmentalizing and undermentalizing errors. Research has shown that ToM in schizophrenia is associated with non-social and social cognition, and with clinical symptoms. In this study, we investigate cognitive and clinical predictors of different ToM processes.

METHODS

Ninety-one individuals with schizophrenia participated. ToM was measured with the Movie for the Assessment of Social Cognition (MASC) yielding six scores (total ToM, cognitive ToM, affective ToM, overmentalizing errors, undermentalizing errors and no mentalizing errors). Neurocognition was indexed by a composite score based on the non-social cognitive tests in the MATRICS Consensus Cognitive Battery (MCCB). Emotion perception was measured with Emotion in Biological Motion (EmoBio), a point-light walker task. Clinical symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Seventy-one healthy control (HC) participants completed the MASC.

RESULTS

Individuals with schizophrenia showed large impairments compared to HC for all MASC scores, except overmentalizing errors. Hierarchical regression analyses with the six different MASC scores as dependent variables revealed that MCCB was a significant predictor of all MASC scores, explaining 8-18% of the variance. EmoBio increased the explained variance significantly, to 17-28%, except for overmentalizing errors. PANSS excited symptoms increased explained variance for total ToM, affective ToM and no mentalizing errors.

DISCUSSION

Both social and non-social cognition were significant predictors of ToM. Overmentalizing was only predicted by non-social cognition. Excited symptoms contributed to overall and affective ToM, and to no mentalizing errors.

A Disorder by Any Other Name: Metacognition, Schizophrenia, and Diagnostic Practice

Humanistic psychology has made us aware that any understanding of schizophrenia must see persons diagnosed with this condition as whole persons who are making sense of what wellness and recovery mean to them. This has raised questions about what the diagnosis of schizophrenia means and whether the diagnostic label of schizophrenia is helpful when we try to conceptualize the actions and aims of treatment. To examine this issue we propose it is essential to consider what is systematically occuring psychologicaly in recovery when persons experience, interpret and agentically respond to emerging challenges. We then review how the integrated model of metacognition provides a systematic, person-centered, evidence-based approach to understanding psychological processes which impact recovery, and discuss how this guides a form of psychotherapy, metacognitive reflection and insight therapy, which promotes metacognitive abilities and support recovery. We suggest this work indicates that metacognitive capacity is something that can be diagnosed without stigmatizing persons. It can be used to meaningfully inform clinical practice across various theoretical models and offers concrete implications for rehabilitation.

Social-cognitive risk factors for violence in psychosis: A discriminant function analysis

It has been proposed that mixed findings in studies investigating social cognition as a risk factor for violence in psychosis may be explained by utilizing a framework distinguishing between social-cognitive tests which measure relatively more basic operations (e.g. facial affect recognition) and measures of more complex operations (mentalizing, metacognition). The current study investigated which social cognitive and metacognitive processes are related to a violent history over and above illness-related deficits. Data from control participants (n = 33), patients with a psychotic disorder and no violent history (n = 27), and patients with a psychotic disorder in a forensic clinic (n = 23) were analyzed utilizing discriminant analysis. Metacognition and associative learning emerged as significant factors in predicting group membership between the three groups. In a follow-up analysis between only the patient groups, metacognitive Self-Reflectivity and Empathic Accuracy emerged as statistically significant predictors of group membership. The control group presented with higher levels of social cognitive and metacognitive capacity than patient groups, and the forensic patient group had lower levels than the non-forensic patient group. Our findings support previous research findings implying impaired metacognitive Self-Reflectivity in particular as a risk factor for violence.

An uncontrolled trial of multi-component care for first-episode psychosis: Effects on social cognition

Growing evidence suggests that specialized, multi-component treatment programmes produce improvements in numerous outcomes among individuals with first-episode psychosis. However, these programmes often lack interventions specifically designed to address deficits in social cognition. This raises questions about the effectiveness of such programmes in addressing deficits in social cognition that accompany psychotic disorders. We investigated the effect of participation in a multi-component treatment programme on social cognition among 71 individuals with first-episode psychosis. Participants experienced gains in emotion processing, social knowledge, social perception and theory of mind. However, after controlling for multiple comparisons, these improvements were limited to theory of mind and recognition of social cues in low emotion interactions. Although our findings should be interpreted cautiously, they raise the possibility that individuals participating in multi-component treatment programmes for first-episode psychosis without interventions specifically targeting social cognition may still experience gains in social cognition.

The experience and expression of anger in posttraumatic stress disorder: the relationship with metacognition

BACKGROUND

Anger experience and expression are a common issue in those experiencing PTSD. However, it remains unclear what variables affect anger and its expression in PTSD.

AIMS

To explore the relationships of synthetic forms of metacognition and metacognitive beliefs with anger experience and expression in PTSD, independent of the effects hyperarousal and depression symptoms.

METHOD

Participants were 51 veterans with diagnosed with PTSD. Metacognition was assessed using the Metacognition Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire (MCQ). Depression, PTSD symptom severity, and seven domains of anger expression were also assessed.

RESULTS

Correlations showed after controlling for overall levels of hyperarousal, higher MAS-A total scores were related to lower levels of State Anger, Feeling Angry, Expressing Anger Physically, and Anger Expression in. Lower MCQ scores were related to lower State anger, Expressing anger verbally, and Expressing anger physically. Higher levels of depression were related to higher levels of Trait anger, Expressing anger physically, Anger expression out, and Anger expression in. Multiple regressions suggested that the MAS-A and MCQ predicted unique portions of the variance in anger experience and expression.

CONCLUSIONS

Metacognitive deficits may affect anger experience and expression in those with PTSD and may be an important treatment target.

Promoting recovery from severe mental illness: Implications from research on metacognition and metacognitive reflection and insight therapy

Research indicates that individuals with schizophrenia recover. Recovery, however means different things to different individuals and regardless of what kind of experiences define recovery, the individual diagnosed with the serious mental illness must feel ownership of their recovery. This raises the issue of how mental health services should systematically promote recovery. This paper explores the practical implications for research on metacognition in schizophrenia for this issue. First, we present the integrated model of metacognition, which defines metacognition as the spectrum of activities which allow individual to have available to themselves an integrated sense of self and others as they appraise and respond to the unique challenges they face. Second, we present research suggesting that many with schizophrenia experience deficits in metacognition and that those deficits compromise individuals’ abilities to manage their lives and mental health challenges. Third, we discuss a form of psychotherapy inspired by this research, Metacognitive Reflection and Insight Therapy which assists individuals to recapture the ability to form integrated ideas about themselves and others and so direct their own recovery. The need for recovery oriented interventions to focus on process and on patient’s purposes, assess metacognition and consider the intersubjective contexts in which this occurres is discussed.

Social cognition in the course of psychosis and its correlation with biomarkers in a male cohort

INTRODUCTION

Patients diagnosed with schizophrenia display deficits in Theory of Mind (ToM) and Emotion Perception (EP) even before the appearance of full-blown symptomatology.

METHODS

We evaluated ToM and EP in a male cohort consisting of 25 First Episode Psychosis (FEP) and 16 relapsed schizophrenic patients (CHRON) compared to 12 subjects in Ultra-high Risk (UHR) and 23 healthy controls (CTR). Furthermore, we measured the levels of Cortisol, Insulin like Growth Factor (IGF-1), TNF-a, TNF-b and several interleukins as potential biomarkers.

RESULTS

Deficits in EP and ToM were found in FEP, CHRON patients and UHR subjects compared to CTR. The impairments in these two domains seem to follow different patterns in the course of psychosis. EP was more impaired in subjects with a longer history of symptomatology whereas there was no statistically significant difference regarding ToM. On the other hand IL-4 was the only biomarker correlated to ToM and EP scores in two different samples of our study.

CONCLUSION

Social Cognition (SC) domains are impaired in patients with psychosis as well as in UHR subjects compared to healthy controls. There are differences in the progress of ToM and EP deficits in the course of psychosis. Interleukins as IL-4 could correlate to SC.

A decline in self-defining memories following a diagnosis of schizophrenia

PURPOSE

Receiving a diagnosis of schizophrenia can be a profound life transition that often has a negative influence on the patient's sense of self. The present study is the first to examine how self-defining memories are temporally distributed around age at diagnosis of schizophrenia.

METHOD

25 patients and 25 matched control participants identified 3 self-defining memories from their lives. In addition, participants were assessed with standardized interviews and questionnaires on negative and positive symptoms as well as tests of cognitive function.

RESULTS

Patients' self-defining memories increased in the years leading up to diagnosis and declined abruptly in the years immediately following diagnosis. The pre-diagnosis increase in self-defining memories was not attributable primarily to a rise in disease-related recollections.

CONCLUSION

The sharp post-diagnosis memory decline suggests that patients find it difficult to establish new or evolve existing definitions of self. Implications for models of schizophrenia and for clinical practice are discussed.

Metacognition as a Mediating Variable Between Neurocognition and Functional Outcome in First Episode Psychosis

BACKGROUND

Neurocognitive and functional outcome deficits have long been acknowledged in schizophrenia and neurocognition has been found to account for functional disability to a greater extent than psychopathology. Much of the variance in functional outcome however still remains unexplained and metacognition may mediate the relationship between neurocognition, functional capacity, and self-reported social and occupational function.

METHOD

Eighty first episode psychosis participants were recruited and completed measures of neurocognition (memory, executive function, and intelligence quotient), metacognition (Beck Cognitive Insight Scale, Metacognitive Awareness Interview), psychopathology (PANSS), and both functional capacity (UPSA) and real-life social and occupational function (The Time Use Survey). Path analyses investigated the relationships between variables through structural equation modeling.

RESULTS

A series of path models demonstrated that metacognition partially mediates the relationship between neurocognition and functional capacity, and fully mediates the relationship between functional capacity and social and occupational function.

CONCLUSION

The present study findings identify that metacognition may be critical to translating cognitive and functional skills into real-world contexts, and this relationship is found at early stages of illness. Understanding how individuals translate cognitive and functional skills into the real-world (the competence-performance gap) may offer valuable guidance to intervention programs. This finding is important to models of recovery as it suggests that intervention programs that focus on enhancing metacognition abilities may have a greater impact than traditional rehabilitation programs focusing on cognitive abilities, on social and occupational outcomes.

Association of medial prefrontal resting state functional connectivity and metacognitive capacity in early phase psychosis

Metacognition refers to a range of cognitive processes that allow one to form complex ideas of self and others and to use this information to navigate psychosocial challenges. Several studies in both early-phase and prolonged schizophrenia have demonstrated not only that significant deficits in metacognitive ability are present, but importantly that they are associated with significant functional impairment and decreased quality of life. In spite of the importance of metacognitive impairment in schizophrenia, relatively little is known about the biological substrates that may contribute to this dysfunction. In this study, we examined the relationship between resting state functional connectivity of the medial prefrontal cortex (mPFC), a structure shown in prior voxel-based morphometry studies to be associated with metacognition, with metacognitive function in an early-phase psychosis cohort (n=18). Analyses revealed a positive association of resting state functional connectivity between the mPFC and precuneus and posterior cingulate structures and metacognitive ability. These results provide evidence of disrupted resting state connectivity in structures relevant to metacognitive dysfunction in early-phase psychosis, which may have implications for pathophysiological models of complex cognitive deficits in this illness.

Emotion processing deficits in the different dimensions of psychometric schizotypy

Schizotypy refers to a personality structure indicating "proneness" to schizophrenia. Around 10% of the general population has increased schizotypal traits, they also share other core features with schizophrenia and are thus at heightened risk for developing schizophrenia and spectrum disorders. A key aspect in schizophrenia-spectrum pathology is the impairment observed in emotion-related processes. This review summarizes findings on impairments related to central aspects of emotional processes, such as emotional disposition, alexithymia, facial affect recognition and speech prosody, in high schizotypal individuals in the general population. Although the studies in the field are not numerous, the current findings indicate that all these aspects of emotional processing are deficient in psychometric schizotypy, in accordance to the schizophrenia-spectrum literature. A disturbed frontotemporal neural network seems to be the critical link between these impairments, schizotypy and schizophrenia. The limitations of the current studies and suggestions for future research are discussed.

Differential patterns in mind perception in subclinical paranoia: relationships to self-reported empathy

INTRODUCTION

Although social cognition skills and biases are well-studied in paranoia, "mind perception" - perceiving the extent to which someone even possesses a thinking, feeling mind - is not. We sought to better characterise the profile of mind perception for individuals with paranoia.

METHODS

We examined links between mind perception and paranoia in a large (n = 890) subclinical sample. Participants completed measures of paranoia, schizotypy, mind perception, and dispositional empathy. These assessments were examined for their relationships to one another, as well as the possibility that mind perception partially mediates the relationship between paranoia and empathy.

RESULTS

Analyses revealed that increased paranoia was linked to less mind perception towards people. This distorted mind perception partially explained the link between paranoia and both perspective taking and empathic concern.

CONCLUSIONS

In paranoia - and psychopathology more broadly - understanding and addressing distorted mind perception may be one component of restoring social functioning.

Metacognition deficits as a risk factor for prospective motivation deficits in schizophrenia spectrum disorders

Although motivation deficits are key determinants of functional outcomes, little is known about factors that contribute to prospective motivation in people with schizophrenia. One candidate factor is metacognition, or the ability to form complex representations about oneself, others, and the world. This study aimed to assess whether metacognition deficits were a significant predictor of reduced prospective motivation, after controlling for the effects of baseline motivation, anticipatory pleasure, and antipsychotic medication dose. Fifty-one participants with a schizophrenia spectrum disorder completed measures of metacognition and anticipatory pleasure at baseline; participants also completed a measure of motivation at baseline and six months after the initial assessment. Baseline antipsychotic dose was obtained from medical charts. Hierarchical regression analysis revealed that lower levels of baseline metacognition significantly predicted reduced levels of motivation assessed six months later, after controlling for baseline levels of motivation, anticipatory pleasure, and antipsychotic dose. Higher baseline antipsychotic dose was also a significant predictor of reduced six month motivation. Results suggest that metacognition deficits and higher antipsychotic dose may be risk factors for the development of motivation deficits in schizophrenia. Implications include utilizing interventions to improve metacognition in conjunction with evaluating and possibly lowering antipsychotic dose for people struggling with motivation deficits.

Compared to high and low cannabis use, moderate use is associated with fewer cognitive deficits in psychosis

Literature on the relationship of cannabis use and cognition in schizophrenia provides the paradoxical view that cannabis use is sometimes linked with less severe impairment in neurocognition. This paper explored the possibility that this is a reflection of a dose related response between lifetime cannabis use and two forms of cognition, neurocognition and metacognition, in schizophrenia. It was hypothesized that three groups of patients could be differentiated, those with (1) little to no cannabis use with poor levels of cognition, (2) moderate cannabis use and relatively better levels of cognition and (3) high cannabis use with relatively poorer levels of cognition. Sixty-six adults with schizophrenia completed assessments of neurocognition, metacognition and months of lifetime cannabis use. A k-means cluster analysis yielded three distinct groups based on these assessments. The clusters included: (1) low cannabis/poor cognition (n = 34); (2) heavy cannabis/moderately impaired cognition (n = 10); and (3) moderate cannabis/higher cognition (n = 22). Consistent with our hypothesis, participants with high and moderate lifetime cannabis use had lesser impairment of neurocognition and metacognition compared to low lifetime cannabis use. Participants with moderate lifetime cannabis use also had lesser impairment of metacognition compared to low and heavy use. These findings suggest that a dose related relationship exists between cannabis use and cognition. Results could be due to an influence of pre-existing cognitive level on likelihood of lifetime cannabis use, or to an interaction between use and cognitive function.

Longitudinal stability of social cognition in schizophrenia: A 5-year follow-up of social perception and emotion processing

BACKGROUND

Individuals with schizophrenia exhibit marked and disproportional impairment in social cognition, which is associated with their level of community functioning. However, it is unclear whether social cognitive impairment is stable over time, or if impairment worsens as a function of illness chronicity. Moreover, little is known about the longitudinal associations between social cognition and community functioning.

METHOD

Forty-one outpatients with schizophrenia completed tests of emotion processing (Mayer-Salovey-Caruso Emotional Intelligence Test, MSCEIT) and social perception (Relationships Across Domains, RAD) at baseline and approximately five years later. Stability of performance was assessed using paired t-tests and correlations. Longitudinal associations between social cognition and community functioning (Role Functioning Scale, RFS) were assessed using cross-lagged panel correlation analysis.

RESULTS

Performance on the two social cognition tasks were stable over follow-up. There were no significant mean differences between assessment points [p's≥0.20, Cohen'sd's≤|0.20|], and baseline performance was highly correlated with performance at follow-up [ρ's≥0.70, ICC≥0.83, p's<0.001]. The contemporaneous association between social cognition and community functioning was moderately large at follow-up [ρ=0.49, p=0.002]. However, baseline social cognition did not show a significant longitudinal influence on follow-up community functioning [z=0.31, p=0.76].

CONCLUSIONS

These data support trait-like stability of selected areas of social cognition in schizophrenia. Cross-lagged correlations did not reveal a significant unidirectional influence of baseline social cognition on community functioning five years later. However, consistent with the larger literature, a moderately large cross-sectional association between social cognition and community functioning was observed. Based on stability and cross-sectional associations, these results suggest that social cognition might have short-term implications for functional outcome rather than long-term consequences.