Deficits in the ability to recognize one's own affects and those of others: associations with neurocognition, symptoms and sexual trauma among persons with schizophrenia spectrum disorders

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.

A machine-learning approach to investigating the complexity of theory of mind in individuals with schizophrenia

Individuals with schizophrenia have difficulty attributing mental states to themselves and to others - Theory of Mind (ToM). ToM is a complex, multifaceted theoretical construct comprising first and second order, first and third person, egocentric and allocentric perspective, and cognitive and affective ToM. Most studies addressing ToM deficit in people with schizophrenia consider it an "all-or-nothing" ability and use a classical statistical methodology to test a null hypothesis. With the present study, we investigated ToM in individuals with schizophrenia, considering its complex nature and degrees of impairment. To do this, we used a machine-learning approach to detect patterns in heterogeneous and multivariate data. Our findings highlight the complex nature of ToM deficit in individuals with schizophrenia and reveal the relationship between various different aspects of ToM.

Alexithymia in chronic schizophrenia and its mediating effect between cognitive deficits and negative symptoms

BACKGROUND

Although cognition is known to impact clinical symptoms of schizophrenia, few studies investigate the potential mediators of this relationship. This study aimed to examine the relationship between cognitive deficits and negative symptoms in schizophrenia, considering the mediating role of alexithymia as an important psychological variable. Moreover, the prevalence of alexithymia in patients with schizophrenia was investigated.

METHODS

A total of 689 patients with schizophrenia were recruited from two psychiatric hospitals. All patients completed the Positive and Negative Syndrome Scale (PANSS), 20-item Toronto Alexithymia Scale (TAS-20), and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We used structural equation modeling to examine the hypothesized mediated model.

RESULTS

In total, 31.5 % of patients with schizophrenia were classified as alexithymia. The path analyses showed that two factors of alexithymia (i.e., the difficulty in identifying feelings and difficulty in describing feelings), played a mediating role in the pathway from cognitive deficits to negative symptoms (all p < .001).

LIMITATIONS

Self-reported measurement for alexithymia may not be sufficiently reliable due to response bias.

CONCLUSION

Our findings demonstrated a high occurrence of alexithymia in patients with schizophrenia. Moreover, the mediating role of alexithymia suggests that targeting emotion processing and cognition may be a feasible way to mitigate negative symptoms.

Pathways from threat exposure to psychotic symptoms in youth: The role of emotion recognition bias and brain structure

BACKGROUND

Research supports an association between threatening experiences in childhood and psychosis. It is possible that early threat exposure disrupts the development of emotion recognition (specifically, producing a bias for facial expressions relating to threat) and the brain structures subserving it, contributing to psychosis development.

METHODS

Using data from the Philadelphia Neurodevelopmental Cohort, we examined associations between threat exposure and both the misattribution of facial expressions to fear/anger in an emotion recognition task, and gray matter volumes in key emotion processing regions. Our sample comprised youth with psychosis spectrum symptoms (N = 304), control youth (N = 787), and to evaluate specificity, youth with internalizing symptoms (N = 92). The moderating effects of group and sex were examined.

RESULTS

Both the psychosis spectrum and internalizing groups had higher levels of threat exposure than controls. In the total sample, threat exposure was associated with lower left medial prefrontal cortex (mPFC) volume but not misattributions to fear/anger. The effects of threat exposure did not significantly differ by group or sex.

CONCLUSIONS

The findings of this study provide evidence for an effect of threat exposure on mPFC morphology, but do not support an association between threat exposure and a recognition bias for threat-related expressions, that is particularly pronounced in psychosis. Future research should investigate factors linking transdiagnostic alterations related to threat exposure with psychotic symptoms, and attempt to clarify the mechanisms underpinning emotion recognition misattributions in threat-exposed youth.

Examining associations, moderators and mediators between childhood maltreatment, social functioning, and social cognition in psychotic disorders: a systematic review and meta-analysis

Childhood maltreatment (CM) has been related to social functioning and social cognition impairment in people with psychotic disorders (PD); however, evidence across different CM subtypes and social domains remains less clear. We conducted a systematic review and meta-analysis to quantify associations between CM, overall and its different subtypes (physical/emotional/sexual abuse, physical/emotional neglect), and domains of social functioning and social cognition in adults with PD. We also examined moderators and mediators of these associations. A PRISMA-compliant systematic search was performed on 24 November 2022 (PROSPERO CRD42020175244). Fifty-three studies (N = 13 635 individuals with PD) were included in qualitative synthesis, of which 51 studies (N = 13 260) with 125 effects sizes were pooled in meta-analyses. We found that CM was negatively associated with global social functioning and interpersonal relations, and positively associated with aggressive behaviour, but unrelated to independent living or occupational functioning. There was no meta-analytic evidence of associations between CM and social cognition. Meta-regression analyses did not identify any consistent moderation pattern. Narrative synthesis identified sex and timing of CM as potential moderators, and depressive symptoms and maladaptive personality traits as possible mediators between CM and social outcomes. Associations were of small magnitude and limited number of studies assessing CM subtypes and social cognition are available. Nevertheless, adults with PD are at risk of social functioning problems after CM exposure, an effect observed across multiple CM subtypes, social domains, diagnoses and illness stages. Maltreated adults with PD may thus benefit from trauma-related and psychosocial interventions targeting social relationships and functioning.

Comparison of cognition and alexithymia in patients of schizophrenia with and without comorbid alcohol use: A cross-sectional exploratory study

BACKGROUND

Cognitive impairment and alexithymia are commonly associated with schizophrenia and alcohol use disorder independently. Both can lead to poor prognosis and recovery. In patients with dual diagnosis, this association can be more prevalent and severe.

MATERIALS AND METHODS

A total of 75 participants were grouped into two (35 each): Group A, a Schizophrenia group and Group B with comorbid alcohol use. Sociodemographic factors, clinical profile, cognitive functions, and alexithymia were compared between the two groups using semi-structured pro forma, Positive and Negative Syndrome Scale, Alcohol Use Disorders Identification Test (AUDIT), Montreal Cognitive Assessment (MoCA) Scale, Toronto Alexithymia Scale (TAS-20) (subcategorized into three subscales (1) "Difficulty describing feelings" (DDF), (2) "Difficulty identifying feeling" (DIF), and (3) "Externally-Oriented Thinking" and Brief Psychiatric Rating Scale. Statistical analysis was performed using the Chi-square tests and t-tests as applicable. P < 0.05 was considered statistically significant.

RESULTS

The mean age of the participants was 33.61 (standard deviation [SD]-8.11), mean duration of schizophrenia was 70.8 months (SD-47.5) and mean duration of alcohol consumption was 9.10 years (SD-7.7). MoCA score was significantly lower (mean-21.80, SD-2.98) and TAS total score was significantly higher in Group B (Mean-67.31, SD-8.10). DDF (Mean-19.28, SD-4.02) and DIF scores (Mean-22.86, SD-4.66) were significantly higher in alcohol group compared to nonalcohol group. Furthermore, MoCA score was significantly impaired and TAS total, DDF and DIF scores were significantly higher in participants with AUDIT score >8 (P < 0.05). Lower score on MoCA correlated with the higher score of alexithymia.

CONCLUSION

Cognitive dysfunction and alexithymia were significantly more in patients of schizophrenia with comorbid alcohol use and positively correlated with the severity of alcohol use disorder.

Effects of childhood trauma on facial recognition of fear in psychosis

INTRODUCTION

Childhood trauma has been reported as a risk factor for psychosis. Different types of traumatic experiences in childhood could lead to different clinical manifestations in psychotic disorders.

METHODS

We studied differences in social cognition (emotion recognition and theory of mind) and clinical symptoms in a sample of 62 patients with psychosis (less than five years of illness) and childhood trauma, analysing performance by trauma type.

RESULTS

Psychotic patients with a history of childhood trauma other than sexual abuse were more capable of recognizing fear as a facial emotion (especially when facial stimuli were non-degraded) than participants with a history of sexual abuse or with no history of childhood trauma (P = .008). We also found that the group that had suffered sexual abuse did not show improvement in fear recognition when exposed to clearer stimuli, although this intergroup difference did not reach statistical significance (P = .064). We have not found other differences between abuse groups, neither in clinical symptoms (PANSS factors) nor in Hinting Task scores.

CONCLUSION

We have found differences in fear recognition among patients with psychotic disorders who have experienced different types of childhood trauma.

Exploring the Interplay Between Adversity, Neurocognition, Social Cognition, and Functional Outcome in People With Psychosis: A Narrative Review

History of adversity is associated with subsequent psychosis, and with a spectrum of cognitive alterations in individuals with psychosis. These cognitive features go from neurocognitive aspects as working memory and attention, to complex social cognitive processes as theory of mind and emotional perception. Difficulties in these domains impact patients' social and occupational functioning, which has been shown to be more impaired in those previously exposed to childhood trauma. However, the interplay between adversity, neurocognition, and functioning is yet poorly understood. This narrative review aims to explore the evidence on whether deficits in neurocognitive and social cognitive domains may act as possible putative mechanism linking adversity with functioning in people with psychosis. We show available evidence supporting the link between adversity and poorer functioning in psychosis, especially in chronic stages; and replicated evidence suggesting associations of social cognition and, to a lesser extent, neurocognition with impairment in functioning in patients; although there is still an important gap in the literature testing particularly deficits in social cognition as mediator of the link between adversity and functional decline in psychosis. Targeting interventions focusing on neurocognition and social cognition in individuals with adversity and psychosis seems important, given the severe deterioration of these patients in these domains, although more research is needed to test whether such treatments can specifically improve functioning in individuals with psychosis and adversity. Literature aiming to understand the determinants of functional outcome should consider the pervasive impact of childhood adversity, and its related effects on cognition.

Relationship between childhood trauma and social adaptation in a sample of young people attending an early intervention service for psychosis

INTRODUCTION

Childhood trauma has been associated with an increased risk of psychosis, a greater severity of psychopathological symptoms, and a worse functional prognosis in patients with psychotic disorders. The current study aims to explore the relationship between childhood trauma, psychopathology and social adaptation in a sample of young people with first episode psychosis (FEP) or at-risk mental states (ARMS).

MATERIAL AND METHODS

The sample included 114 young people (18-35 years old, 81 FEP and 33 ARMS) who were attending an Early Intervention Service for Psychosis. Positive, negative and depressive symptoms were assessed with the PANSS and the Calgary Depression Scale; history of childhood trauma was assessed with the Childhood Trauma Questionnaire; social adaptation was assessed with the Social Adaptation Self-evaluation Scale (SASS). Structural equation modeling (SEM) was used to explore the relationship between childhood trauma, psychopathology and SASS dimensions in the global sample (including FEP and ARMS). An exploratory SEM analysis was repeated in the subsample of FEP patients.

RESULTS

ARMS individuals reported more emotional neglect and worse social adaptation compared to FEP. SEM analysis showed that childhood trauma is associated with a worse social adaptation, in a direct way with domains involving interpersonal relationships, and mediated by depressive symptoms with those domains involving leisure, work and socio-cultural interests.

CONCLUSIONS

Childhood trauma has a negative effect on social adaptation in young people with early psychosis. Depressive symptoms play a mediation role in this association, especially in domains of leisure and work.

Victimization, violence and facial affect recognition in a community sample of first-episode psychosis patients

AIMS

This exploratory study is the first to examine previously identified variables of increased vulnerability to victimization, the prevalence of aggression in a cohort of patients with first-episode psychosis and the potential impact of impairments in facial affect recognition (FAR) on victimization.

METHODS

Sixty-nine male participants completed assessments of IQ, substance use, psychopathy, childhood trauma, aggressive behaviour and psychopathology. Participants were asked about violent victimization in the past year and charges for violent offences. FAR was assessed using the Animated Full Facial Comprehension Test.

RESULTS

The victimized group (n = 25) had significantly higher psychopathy traits (P = .042) and lower recognition of sadness (P < .01) compared to the non-victimized group (n = 44). Participants who reported charges for violent offences (n = 15) had significantly higher scores on measures of physical abuse in childhood (P < .01), substance use (P < .05 for cannabis, P < .001 for cocaine and amphetamine use), psychopathy traits (P < .01), psychopathology (P = .031) and lifetime aggressive behaviour (P < .01). The logistic regression models using FAR sadness and Psychopathic Personality Inventory-Revised (PPI-R) total score as predictors for victimization (χ ² [2] = 13.81, P = .001; Nagelkerke R ² = .30) and using physical abuse in childhood, PPI-R total score, and psychopathology as predictors for violent offences (χ ² [3] = 14.89, P = .002; Nagelkerke R ² = .36) were significant.

CONCLUSIONS

These findings highlight the value of considering victimization in psychotic illness from a social information processing perspective in addition to known clinical and lifestyle factors. Based on these results, future studies could explore the use of affect recognition training early in the course of the illness as a possible intervention to reduce victimization.

Childhood trauma and cognitive functioning in individuals at clinical high risk (CHR) for psychosis

Evidence suggests that early trauma may have a negative effect on cognitive functioning in individuals with psychosis, yet the relationship between childhood trauma and cognition among those at clinical high risk (CHR) for psychosis remains unexplored. Our sample consisted of 626 CHR children and 279 healthy controls who were recruited as part of the North American Prodrome Longitudinal Study 2. Childhood trauma up to the age of 16 (psychological, physical, and sexual abuse, emotional neglect, and bullying) was assessed by using the Childhood Trauma and Abuse Scale. Multiple domains of cognition were measured at baseline and at the time of psychosis conversion, using standardized assessments. In the CHR group, there was a trend for better performance in individuals who reported a history of multiple types of childhood trauma compared with those with no/one type of trauma (Cohen d = 0.16). A history of multiple trauma types was not associated with greater cognitive change in CHR converters over time. Our findings tentatively suggest there may be different mechanisms that lead to CHR states. Individuals who are at clinical high risk who have experienced multiple types of childhood trauma may have more typically developing premorbid cognitive functioning than those who reported minimal trauma do. Further research is needed to unravel the complexity of factors underlying the development of at-risk states.

Neuro-cognitive correlates of alexithymia in patients with circumscribed prefrontal cortex damage

Alexithymia has been extensively reported in studies of psychiatric patients. However, little attention has been paid regarding its occurrence in the context of patients with circumscribed prefrontal cortex lesions. Moreover, the neuro-cognitive impairments that lead to alexithymia remain unclear and limited numbers of studies have addressed these issues. The authors investigated the impact of prefrontal cortex lesions on alexithymia and its neuro-cognitive correlates in a population of 20 patients with focal frontal lesions, 10 patients with parietal lesions and 34 matched control participants. Alexithymia was screened using the Toronto Alexithymia Scale (TAS-20) and executive functions were assessed using a large battery of executive tasks that address inhibition, flexibility and the planning process. Results showed that patients with prefrontal cortex damage showed significantly increased difficulty in facets of identifying feelings (DIF) and externally oriented thinking (EOT) on TAS-20, compared to parietal patients and control participants. Moreover, both correlation and regression analysis revealed that higher alexithymia levels on the three facets of TAS-20 were consistently but differentially associated with impairment in inhibition, flexibility and planning tasks for frontal patients and both control groups. These findings provide clinical evidence of the implication of prefrontal cortex damage and executive control in alexithymia. Our results were also discussed in the light of the cognitive appraisal concept as a mechanism involved in emotion episode processing. This study suggests that increased neuropsychological attention should be directed to the relation between the neuro-cognitive model of executive functions and cognitive appraisal theory in processing emotion.

Effects of childhood trauma on facial recognition of fear in psychosis

INTRODUCTION

Childhood trauma has been reported as a risk factor for psychosis. Different types of traumatic experiences in childhood could lead to different clinical manifestations in psychotic disorders.

MATERIAL AND METHODS

We studied differences in social cognition (emotion recognition and theory of mind) and clinical symptoms in a sample of 62 patients with psychosis (less than 5 years of illness) and childhood trauma, analysing performance by trauma type.

RESULTS

Psychotic patients with a history of childhood trauma other than sexual abuse were more capable of recognizing fear as a facial emotion (especially when facial stimuli were non-degraded) than participants with a history of sexual abuse or with no history of childhood trauma (P=.008). We also found that the group that had suffered sexual abuse did not show improvement in fear recognition when exposed to clearer stimuli, although this intergroup difference did not reach statistical significance (P=.064). We have not found other differences between abuse groups, neither in clinical symptoms (PANSS factors) nor in Hinting Task scores.

CONCLUSION

We have found differences in fear recognition among patients with psychotic disorders who have experienced different types of childhood trauma.

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.

Disorganisation, thought disorder and socio-cognitive functioning in schizophrenia spectrum disorders

BACKGROUND

Poor social cognition is prevalent in schizophrenia spectrum disorders. Some authors argue that these effects are symptom-specific and that socio-cognitive difficulties (e.g. theory of mind) are strongly associated with thought disorder and symptoms of disorganisation.AimsThe current review tests the strength of this association.

METHOD

We meta-analysed studies published between 1980 and 2016 that tested the association between social cognition and these symptoms in schizophrenia spectrum disorders.

RESULTS

Our search (PsycINFO, MEDLINE and Web of Science) identified 123 studies (N = 9107). Overall effect size as r = -0.313, indicating a moderate association between symptoms and social cognition. Subanalyses yielded a moderate association between symptoms and theory of mind (r = -0.349) and emotion recognition (r = -0.334), but smaller effect sizes for social perception (r = -0.188), emotion regulation (r = -0.169) and attributional biases (r = -0.143).

CONCLUSIONS

The association is interpreted within models of communication that highlight the importance of mentalisation and processing of partner-specific cues in conversational alignment and grounding.Declaration of interestsNone.

Metacognitive interpersonal therapy in group: a feasibility study

Patients with personality disorders (PDs) other than borderline, with prominent features of social inhibition and over-regulation of emotions, are in need of specialized treatments. Individuals present with poor metacognition, that is the capacity to understand mental states and use psychological knowledge for the sake of purposeful problem solving; and are guided by maladaptive interpersonal schemas. We developed a short-term group intervention, Metacognitive Interpersonal Therapy in Groups (MIT-G), incorporating psychoeducational and experiential elements, to help these individuals become more aware of their drives when interacting with others; and to help them adopt more flexible behaviors via improvements in metacognition. We present results of an effectiveness study, evaluating whether we could replicate the initial positive results of our first pilot randomized controlled trial. Seventeen young adults outpatients with personality disorders were included in the 16 session program. Effect sizes were calculated for change from baseline to treatment end for the primary outcome, symptoms and functioning (Clinical Outcomes in Routine Evaluation Outcome Measure) and then for one putative mechanism of change - metacognition. Emotional dysregulation and alexithymia were also assessed. Qualitative evaluations of the acceptability and subjective impact of the treatment were also performed. MIT-G was acceptable to participants. There were medium to large magnitude changes from pre- to post- treatment on wellbeing, emotion dysregulation, alexithymia and metacognition. These gains were maintained at follow-up. There was evidence of clinically significant change on key variables. MITG appears acceptable to patients, as evidenced by the absence of drop-out from treatment. In light of the positive outcomes of this study and the expanding evidence base, MIT-G is a candidate for dissemination and investigations in larger trials as a possible effective intervention for PDs characterized by tendencies to overcontrol.

Can childhood trauma influence facial emotion recognition independently from a diagnosis of severe mental disorder?

INTRODUCTION

Facial emotion recognition (FER) is a fundamental component in social interaction. We know that FER is disturbed in patients with severe mental disorder (SMD), as well as those with a history of childhood trauma.

MATERIAL AND METHODS

We intend to analyze the possible relationship between the existence of trauma in childhood irrespective of a SMD, measured by the CTQ scale and facial expression recognition, in a sample of three types of subjects (n=321): healthy controls (n=179), patients with BPD (n=69) and patients with a first psychotic episode (n=73). Likewise, clinical and socio-demographic data were collected. The relationship was analyzed by a technique of multivariate regression adjusting for sex, age, IQ, current consumption of drugs and group to which the subject belonged.

RESULTS

Sexual and/or physical trauma in childhood related independently to the existence of SMD with a worse total FER ratio, as well as to a worse rate of recognition in expressions of happiness. Furthermore, the subjects with a history of childhood trauma attributed expressions of anger and fear more frequently to neutral and happy faces, irrespective of other variables.

CONCLUSIONS

The existence of trauma in childhood seems to influence the ability of subjects to recognize facial expressions, irrespective of SMD. Trauma is a preventable factor with specific treatment; therefore, attention should be paid to the existence of this background in clinical populations.

Early life experiences and social cognition in major psychiatric disorders: A systematic review

Objective:

To present a systematic review of the literature on the associations between early social environment, early life adversity, and social cognition in major psychiatric disorders, including schizophrenia, bipolar disorder, borderline personality disorder, major depressive disorder and posttraumatic stress disorder.

Method:

Relevant studies were identified via electronic and manual searches of the literature and included articles written in English and published in peer-reviewed journals up to May 2018. Quality assessment was performed using the quality evaluation scale employed in previous systematic reviews.

Results:

A total of 25 studies were included in the systematic review with the quality assessment scores ranging from 3 to 6 (out of 6). The vast majority of the studies reviewed showed a significant association between early childhood social experience, including both insecure attachment and adversity relating to neglect or abuse, and poorer social cognitive performance.

Conclusion:

We discuss these findings in the context of an attachment model, suggesting that childhood social adversity may result in poor internal working models, selective attention toward emotional stimuli and greater difficulties with emotional self-regulation. We outline some of the steps required to translate this understanding of social cognitive dysfunction in major psychiatric disorders into a target for interventions that mitigate the adverse effects of childhood maltreatment and poor parental attachment on social cognition.

Achieving recovery in patients with schizophrenia through psychosocial interventions: A retrospective study

AIM

Recovery, or functional remission, represents the ultimate treatment goal in schizophrenia. Despite its importance, a standardized definition of remission is still lacking, thus reported rates significantly vary across studies. Moreover, the effects of rehabilitative interventions on recovery have not been thoroughly investigated. This study aimed to evaluate recovery in a sample of patients with chronic schizophrenia engaged in rehabilitation programs and to explore contributing factors, with a focus on sociocognitive rehabilitative interventions.

METHODS

Data from 104 patients with schizophrenia treated either with a standard rehabilitation program, including cognitive remediation (n = 46), or the latter plus a specific sociocognitive intervention (n = 58), and assessed for psychopathology, cognition, social cognition, and Quality of Life Scale, were retrospectively analyzed for this study.

RESULTS

Recovery, evaluated with the Quality of Life Scale, was achieved by 56.76% of patients in our sample. While no effects were observed for clinical, cognitive, or sociocognitive variables, participation in the sociocognitive rehabilitative interventions was positively associated with recovery.

CONCLUSION

Our results indicate that high rates of recovery can be achieved in patients treated with psychosocial interventions and suggest that rehabilitative programs targeting social cognition may further facilitate the process of recovery. If confirmed, these results may have relevant implications for daily clinical practice and service provision, allowing clinicians to develop and optimize specific rehabilitation programs in order to promote recovery.

Attachment and thought problems in an adolescent inpatient sample: The mediational role of theory of mind

BACKGROUND

Previous research has documented increased incidence of insecure attachment and theory of mind (ToM) deficits in individuals experiencing psychotic disorders. ToM has been theorized as a possible mediator of the relation between attachment and psychosis (Korver-Nieberg et al., 2014). The current study sought to extend this area of research to adolescents for the first time by examining adolescent-parent attachment and ToM in inpatient adolescents.

METHODS

Participants were 362 inpatient adolescents and their parents; participants completed the Child Attachment Interview, Movie for the Assessment of Social Cognition, Youth Self Report, and Child Behavior Checklist.

RESULTS

Bivariate correlations indicated that attachment coherence (a marker of security) was significantly and positively correlated with ToM abilities, and that low attachment coherence and poor ToM performance were each associated with increased youth- and parent-reported thought problems. Mediational models indicated that ToM mediated the relation between insecure attachment and thought problems according to both parent- and self-report.

CONCLUSIONS

The results of the current study provide support for a model in which impairments in ToM contribute to the frequently documented association between insecure attachment and emerging psychotic symptoms. Theoretical and clinical implications of these results are discussed, including the potential support for ToM-based interventions for early psychotic symptoms.

Integrated Trauma-Focused Cognitive-Behavioural Therapy for Post-traumatic Stress and Psychotic Symptoms: A Case-Series Study Using Imaginal Reprocessing Strategies

Despite high rates of trauma in individuals with psychotic symptoms, post-traumatic stress symptoms are frequently overlooked in clinical practice. There is also reluctance to treat post-traumatic symptoms in case the therapeutic procedure of reprocessing the trauma exacerbates psychotic symptoms. Recent evidence demonstrates that it is safe to use reprocessing strategies in this population. However, most published studies have been based on treating post-traumatic symptoms in isolation from psychotic symptoms. The aims of the current case series were to assess the acceptability, feasibility, and preliminary effectiveness of integrating cognitive-behavioural approaches for post-traumatic stress and psychotic symptoms into a single protocol. Nine participants reporting distressing psychotic and post-traumatic symptoms were recruited from a specialist psychological therapies service for psychosis. Clients were assessed at five time points (baseline, pre, mid, end of therapy, and at 6+ months of follow-up) by an independent assessor on measures of current symptoms of psychosis, post-traumatic stress, emotional problems, and well-being. Therapy was formulation based and individualised, depending on presenting symptoms and trauma type. It consisted of five broad, flexible phases, and included imaginal reprocessing strategies (reliving and/or rescripting). The intervention was well received, with positive post-therapy feedback and satisfaction ratings. Unusually for this population, no-one dropped out of therapy. Post therapy, all but one (88% of participants) achieved a reliable improvement compared to pre-therapy on at least one outcome measure: post-traumatic symptoms (63%), voices (25%), delusions (50%), depression (50%), anxiety (36%), and well-being (40%). Follow-up assessments were completed by 78% (n = 7) of whom 86% (n = 6) maintained at least one reliable improvement. Rates of improvements following therapy (average of 44% across measures post therapy; 32% at follow-up) were over twice those found during the waiting list period (19%). No participant indicated a reliable worsening of any symptoms during or after therapy. The study shows that an integrative therapy incorporating reprocessing strategies was an acceptable and feasible intervention for this small sample, with promising effectiveness. A randomised controlled trial is warranted to test the efficacy of the intervention for this population.

The relationship between childhood trauma, emotion recognition, and irritability in schizophrenia patients

This study investigated the relationship between childhood trauma, irritability, and emotion recognition, in schizophrenia patients during a psychotic break. Thirty-six schizophrenia inpatients and 36 healthy controls were assessed with the Irritability Questionnaire (IRQ) and two facial emotion recognition tasks, the Emotion Discrimination Test (EDT) and Emotion Identification Test (EIT). Patients were further assessed with the Structured Clinical Interview for DSM III-R Axis II Disorders (SCID-II), the Positive and Negative Symptom Scale (PANSS), and the Childhood Trauma Questionnaire-28 (CTQ-28). EDT and EIT performance was significantly impaired in patients compared to healthy controls. Furthermore, patients tended to misidentify sad, surprised, or angry faces as showing fear, and this misidentification correlated with the patients' irritability. Childhood adversity increased irritability both directly and indirectly through emotion misidentification.

The neural correlates of childhood maltreatment and the ability to understand mental states of others

Background: Emotional abuse and emotional neglect are related to impaired interpersonal functioning. One underlying mechanism could be a developmental delay in mentalizing, the ability to understand other people's thoughts and emotions. Objective: This study investigates the neural correlates of mentalizing and the specific relationship with emotional abuse and neglect whilst taking into account the level of sexual abuse, physical abuse and physical neglect. Method: The RMET was performed in an fMRI scanner by 46 adolescents (Age: M = 18.70, SD = 1.46) who reported a large range of emotional abuse and/or emotional neglect. CM was measured using a self-report questionnaire (CTQ). Results: Neither severity of emotional abuse nor neglect related to RMET accuracy or reaction time. The severity of sexual abuse was related to an increased activation of the left IFG during mentalization even when controlled for psychopathology and other important covariates. This increased activation was only found in a group reporting both sexual abuse and emotional maltreatment and not when reporting isolated emotional abuse or neglect or no maltreatment. Functional connectivity analysis showed that activation in the left IFG was associated with increased activation in the right insula and right STG, indicating that the IFG activation occurs in a network relevant for mentalizing. Conclusions: Being sexually abused in the context of emotional abuse and neglect is related to an increase in activation of the left IFG, which may indicate a delayed development of mirroring other people's thoughts and emotions. Even though thoughts and emotions were correctly decoded from faces, the heightened activity of the left IFG could be an underlying mechanism for impaired interpersonal functioning when social situations are more complex or more related to maltreatment experiences.

Determining the effectiveness of the third person interview in the level of insight psychotic patients

The goal of this study was to determine the effectiveness of the third person interview in increasing the level of insight and cooperation in psychotic patients. We used a quasi-experimental posttest design with an alternative method group. A number of 40 individuals with a definite diagnosis of psychosis were selected using a simple random sampling, and were put randomly in an experimental group (third person interview) and an alternative control group (clinical interview). The results indicated that using the third person interview, the insight level of the psychotic patients increased in all dimensions of insight, except awareness of flat or blunted affect and awareness of unsociability. The results of the independent t-test samples showed no significant difference in cooperation between the two groups of psychotic patients. It seems that the ability to consider one's mental viewpoint from other's, is dependent on the relative ability of psychotic patients to represent other's mental states (theory of mind). But, psychotic patients have severe impairment in the ability to represent their own mental states, resulting in an impairment in the recognition of their mental disorder, psychotic symptoms, the need for therapy, and social consequences of their mental disorder.

Process analysis of trauma-focused cognitive behavioural therapy for individuals with schizophrenia

OBJECTIVE

Therapeutic alliance, modality, and ability to engage with the process of therapy have been the main focus of research into what makes psychotherapy successful. Individuals with complex trauma histories or schizophrenia are suggested to be more difficult to engage and may be less likely to benefit from therapy. This study aimed to track the in-session 'process' of working alliance and emotional processing of trauma memories for individuals with schizophrenia.

DESIGN

The study utilized session recordings from the treatment arm of an open randomized clinical trial investigating trauma-focused cognitive behavioural therapy (TF-CBT) for individuals with schizophrenia (N = 26).

METHOD

Observer measures of working alliance, emotional processing, and affect arousal were rated at early and late phases of therapy. Correlation analysis was undertaken for process measures. Temporal analysis of expressed emotions was also reported.

RESULTS

Working alliance was established and maintained throughout the therapy; however, agreement on goals reduced at the late phase. The participants appeared to be able to engage in emotional processing, but not to the required level for successful cognitive restructuring.

CONCLUSION

This study undertook novel exploration of process variables not usually explored in CBT. It is also the first study of process for TF-CBT with individuals with schizophrenia. This complex clinical sample showed no difficulty in engagement; however, they may not be able to fully undertake the cognitive-emotional demands of this type of therapy. Clinical and research implications and potential limitations of these methods are considered.

PRACTITIONER POINTS

This sample showed no difficulties engaging with TF-CBT and forming a working alliance. However, the participants may not have achieved a level of active involvement required for successful cognitive restructuring of trauma memories. This discrepancy may relate to the mediating role of both working alliance and cognitive-emotional processing. The results underscore the importance of therapists understanding the relationship between alliance and other process factors which may be implicit in facilitating change.

Metacognition in first-episode psychosis and its association with positive and negative symptom profiles

There is growing evidence that metacognitive abilities which include the ability to synthesize knowledge regarding mental states in self and others and use this ability to solve problems are impaired in non-affective psychosis and associated with positive and negative symptom severity. We sought to (a) investigate the severity of metacognitive impairments in first-episode psychosis (FEP) compared to non-clinical controls and (b) explore associations with positive and negative symptom profiles. Ninety-seven people with FEP were compared to 101 control persons. Metacognition was assessed with interviews and the Metacognitive assessment scale-abbreviated. Four groups based on positive and negative symptoms were identified by cluster analysis and compared on metacognition, childhood adversities, duration of untreated psychosis and premorbid social and academic adjustment. Those with high levels of negative symptoms had poorer metacognitive abilities. Those with high positive and low negative symptoms did not have poorer metacognitive abilities than those with low positive and negative symptoms. None of the other predictors differed between the groups. The FEP group had poorer metacognitive abilities than the control group. Inclusion of metacognition in psychosis models may improve our understanding of negative symptoms, while previous findings of a relation with positive symptoms may have been confounded. Implications for current interventions are discussed.

Childhood adversity and social functioning in psychosis: Exploring clinical and cognitive mediators

Childhood adversity may increase risk of impaired social functioning across the continuum of psychosis. However, the pathways by which adversity dictates functional outcome remain underexplored. This study investigated the association between childhood adversity and social functioning, and the clinical and cognitive mediators of this relationship. Fifty-four clinical (20 chronic, 20 first episode, 14 at ultra-high risk) and 120 non-clinical participants completed standardised questionnaires, semi-structured interviews and tests of theory of mind ability. The authors used multiple group structural equation modelling to fit mediation models allowing for differential relationships between the clinical and non-clinical samples. When examining each pathway separately, depression, paranoia and anxious attachment mediated the effect of childhood adversity on social functioning. In a combined model, depression was the only significant mediating variable with greater adversity predicting lower mood across groups. Childhood adversity did not significantly predict theory of mind ability in any of the models. This is the first study to indicate that childhood adversity acts on social functioning by increasing levels of depression, suggesting a common mechanism across the spectrum of psychosis. Clinical interventions should target low mood in order to improve social functioning at all stages of psychotic disorder.

Childhood sexual and physical abuse: age at exposure modulates impact on functional outcome in early psychosis patients

BACKGROUND

Evidence suggests a relationship between exposure to trauma during childhood and functional impairments in psychotic patients. However, the impact of age at the time of exposure has been understudied in early psychosis (EP) patients.

METHOD

Two hundred and twenty-five patients aged 18-35 years were assessed at baseline and after 2, 6, 18, 24, 30 and 36 months of treatment. Patients exposed to sexual and/or physical abuse (SPA) were classified according to age at the time of first exposure (Early SPA: before age 11 years; Late SPA: between ages 12 and 15 years) and then compared to patients who were not exposed to such trauma (Non-SPA). The functional level in the premorbid phase was measured with the Premorbid Adjustment Scale (PAS) and with the Global Assessment of Functioning (GAF) scale and the Social and Occupational Functioning Assessment Scale (SOFAS) during follow-up.

RESULTS

There were 24.8% of patients with a documented history of SPA. Late SPA patients were more likely to be female (p = 0.010). Comparison with non-SPA patients revealed that: (1) both Early and Late SPA groups showed poorer premorbid social functioning during early adolescence, and (2) while patients with Early SPA had poorer functional level at follow-up with lower GAF (p = 0.025) and lower SOFAS (p = 0.048) scores, Late SPA patients did not.

CONCLUSION

Our results suggest a link between exposure to SPA and the later impairment of social functioning before the onset of the disease. EP patients exposed to SPA before age 12 may present long-lasting functional impairment, while patients exposed at a later age may improve in this regard and have a better functional outcome.

Impact of childhood adversities on the short-term course of illness in psychotic spectrum disorders

Accumulating evidence indicates an impact of childhood adversities on the severity and course of mental disorders, whereas this impact on psychotic disorders remains to be specified. Effects of childhood adversities on comorbidity, on symptom severity of the Positive and Negative Syndrome Scale and global functioning across four months (upon admission, 1 and 4 months after initial assessment), as well as the course of illness (measured by the remission rate, number of re-hospitalizations and dropout rate) were evaluated in 62 inpatients with psychotic spectrum disorders. Adverse experiences (of at least 1 type) were reported by 73% of patients. Patients with higher overall level of childhood adversities (n=33) exhibited more co-morbid disorders, especially alcohol/substance abuse and dependency, and higher dropout rates than patients with a lower levels of adverse experiences (n=29), together with higher levels of positive symptoms and symptoms of excitement and disorganization. Emotional and physical neglect were particularly related to symptom severity. Results suggest that psychological stress in childhood affects the symptom severity and, additionally, a more unfavorable course of disorder in patients diagnosed with psychoses. This impact calls for its consideration in diagnostic assessment and psychiatric care.

Lexical analysis in schizophrenia: how emotion and social word use informs our understanding of clinical presentation

BACKGROUND

The words people use convey important information about internal states, feelings, and views of the world around them. Lexical analysis is a fast, reliable method of assessing word use that has shown promise for linking speech content, particularly in emotion and social categories, with psychopathological symptoms. However, few studies have utilized lexical analysis instruments to assess speech in schizophrenia. In this exploratory study, we investigated whether positive emotion, negative emotion, and social word use was associated with schizophrenia symptoms, metacognition, and general functioning in a schizophrenia cohort.

METHODS

Forty-six participants generated speech during a semi-structured interview, and word use categories were assessed using a validated lexical analysis measure. Trained research staff completed symptom, metacognition, and functioning ratings using semi-structured interviews.

RESULTS

Word use categories significantly predicted all variables of interest, accounting for 28% of the variance in symptoms and 16% of the variance in metacognition and general functioning. Anger words, a subcategory of negative emotion, significantly predicted greater symptoms and lower functioning. Social words significantly predicted greater metacognition.

CONCLUSIONS

These findings indicate that lexical analysis instruments have the potential to play a vital role in psychosocial assessments of schizophrenia. Future research should replicate these findings and examine the relationship between word use and additional clinical variables across the schizophrenia-spectrum.

Complexities of emotional responses to social and non-social affective stimuli in schizophrenia

BACKGROUND

Adaptive emotional responses are important in interpersonal relationships. We investigated self-reported emotional experience, physiological reactivity, and micro-facial expressivity in relation to the social nature of stimuli in individuals with schizophrenia (SZ).

METHOD

Galvanic skin response (GSR) and facial electromyography (fEMG) were recorded in medicated outpatients with SZ and demographically matched healthy controls (CO) while they viewed social and non-social images from the International Affective Pictures System. Participants rated the valence and arousal, and selected a label for experienced emotions. Symptom severity in the SZ and psychometric schizotypy in CO were assessed.

RESULTS

The two groups did not differ in their labeling of the emotions evoked by the stimuli, but individuals with SZ were more positive in their valence ratings. Although self-reported arousal was similar in both groups, mean GSR was greater in SZ, suggesting differential awareness, or calibration of internal states. Both groups reported social images to be more arousing than non-social images but their physiological responses to non-social vs. social images were different. Self-reported arousal to neutral social images was correlated with positive symptoms in SZ. Negative symptoms in SZ and disorganized schizotypy in CO were associated with reduced mean fEMG. Greater corrugator mean fEMG activity for positive images in SZ indicates valence-incongruent facial expressions.

CONCLUSION

The patterns of emotional responses differed between the two groups. While both groups were in broad agreement in self-reported arousal and emotion labels, their mean GSR, and fEMG correlates of emotion diverged in relation to the social nature of the stimuli and clinical measures. Importantly, these results suggest disrupted self awareness of internal states in SZ and underscore the complexities of emotion processing in health and disease.

Theory of Mind and attachment styles in people with psychotic disorders, their siblings, and controls

OBJECTIVE

Impaired Theory of Mind (ToM) and insecure (adult) attachment styles have been found in persons with schizophrenia as well as in their healthy siblings. ToM refers to the ability to infer mental states of self and others including beliefs and emotions. Insecure attachment is proposed to underlie impaired ToM, and comprises avoidant (discomfort with close relationships, high value of autonomy) and anxious (separation anxiety, dependency on others) attachment. Insight into the association between attachment style and ToM is clinically relevant, as it enhances our understanding and clinical approach to social dysfunction in schizophrenia. Therefore, we studied the association between insecure attachment styles and ToM in patients with schizophrenia, their siblings, and healthy controls.

METHODS

A total of 111 patients with a diagnosis in the schizophrenia spectrum, 106 non-affected siblings and 63 controls completed the Psychosis Attachment Measure, the Conflicting Beliefs and Emotions, a subsection of the Wechsler Adult Intelligence Scale, and the Childhood Trauma Questionnaire-Short Form. Severity of symptoms was assessed with the Community Assessment of Psychic Experiences and the Positive and Negative Syndrome Scale.

RESULTS

After controlling for sex, intelligence, history of trauma and symptom severity, avoidant attachment was significantly associated with cognitive as well as with affective ToM, showing U-shaped associations, indicating better ToM performance for patients with lower or higher levels of avoidant attachment compared to medium levels. Anxious attachment in patients was associated with more problems in cognitive ToM.

CONCLUSION

The results from this study support the idea that an anxious attachment style is associated with worse ToM performance in patients. Results also suggested a potential protective role of higher levels of avoidant attachment on ToM. These findings bear clinical relevance, as activation of (insecure) attachment mechanisms may affect interpersonal relations, as well as therapeutic working alliance. Further clarification is needed, especially on associations between ToM and avoidant attachment.

The quest for tailored treatments: a meta-discussion of six social cognitive therapies

In this commentary on the 6 articles comprising this In Session issue on metacognition and mentalizing in the psychotherapeutic treatment of severe mental disorders, we strive to contextualize and bring together salient issues reflected in these articles. In the foreground of our discussion is the point that the commonalities of these and related social cognitive treatments far outweigh their differences. We attempt to pinpoint some of the more specific tailored treatment elements described by the authors and relate these to empirical findings and theoretical and practical problems. Among the key issues addressed in this commentary are conceptual fallacies, therapist transparency, personality disorder and self-harm in adolescence, therapeutic alliance, and a metacognitive-informed group psychotherapy practice for patients with avoidant personality disorder or alexithymia.

Alexithymia in schizophrenia: associations with neurocognition and emotional distress

While alexithymia, or difficulties identifying and describing affect, has been commonly observed in schizophrenia, little is known about its causes and correlates. To test the hypothesis that deficits in emotion identification and expression result from, or are at least related to, deficits in neurocognition and affective symptoms, we assessed alexithymia using the Toronto Alexithymia Scale (TAS-20), symptoms using the Positive and Negative Syndrome Scale (PANSS), and neurocognition using the MATRICS battery among 65 adults with schizophrenia spectrum disorders in a non-acute phase of illness. Partial correlations controlling for the effects of social desirability revealed that difficulty identifying feelings and externally oriented thinking were linked with greater levels of neurocognitive deficits, while difficulty describing feelings was related to heightened levels of emotional distress. To explore whether neurocognition and affective symptoms were uniquely related to alexithymia, a multiple regression was conducted in which neurocognitive scores and affective symptoms were allowed to enter to predict overall levels of alexithymia after controlling for social desirability. Results revealed both processing speed and anxiety uniquely contributed to the prediction of the total score on the TAS-20. Results suggest that dysfunctions in both cognitive and affective processes may be related to alexithymia in schizophrenia independently of one another.

Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up

BACKGROUND

Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses.

AIMS

To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months.

METHOD

The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis.

RESULTS

Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months.

CONCLUSIONS

Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.

Metacognitive capacities for reflection in schizophrenia: implications for developing treatments

Models of schizophrenia, which focus exclusively on discrete symptoms and neurocognitive deficits, risk missing the possibility that a core feature of the disorder involves a reduced capacity to construct complex and integrated representations of self and others. This column details a new methodology that has been used to assess deficits in the metacognitive abilities that allow persons to form complex ideas about themselves and others and to use that knowledge to respond to psychosocial challenges in schizophrenia. Evidence is summarized supporting the reliability and validity of this method, as well as links this work has revealed between metacognition and psychosocial outcomes. It is suggested that this work points to the need to develop interventions which move beyond addressing symptoms and specific skills, and assist persons to recapture lost or atrophied metacognitive capacity and so form the kind of ideas about themselves and others needed, to move meaningfully toward recovery.

Sexual trauma increases the risk of developing psychosis in an ultra high-risk "prodromal" population

Studies indicate a high prevalence of childhood trauma in patient cohorts with established psychotic disorder and in those at risk of developing psychosis. A causal link between childhood trauma and development of psychosis has been proposed. We aimed to examine the association between experience of childhood trauma and the development of a psychotic disorder in a large "Ultra High Risk" (UHR) for psychosis cohort. The data were collected as part of a longitudinal cohort study of all UHR patients recruited to research studies at the Personal Assessment and Clinical Evaluation clinic between 1993 and 2006. Baseline data were collected at recruitment to these studies. The participants completed a comprehensive follow-up assessment battery (mean time to follow-up 7.5 years, range 2.4-14.9 years), which included the Childhood Trauma Questionnaire (CTQ), a self-report questionnaire that assesses experience of childhood trauma. The outcome of interest was transition to a psychotic disorder during the follow-up period. Data were available on 233 individuals. Total CTQ trauma score was not associated with transition to psychosis. Of the individual trauma types, only sexual abuse was associated with transition to psychosis (P = .02). The association remained when adjusting for potential confounding factors. Those with high sexual abuse scores were estimated to have a transition risk 2-4 times that of those with low scores. The findings suggest that sexual trauma may be an important contributing factor in development of psychosis for some individuals.

Metacognition, symptoms and premorbid functioning in a first episode psychosis sample

Significant metacognitive impairments are observed in chronic psychosis samples but metacognition is less understood in first episode psychosis (FEP). The current study explored correlations between metacognition, symptoms and premorbid functioning in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology, premorbid adjustment, and clinician rated service engagement were also measured. Lower scores for metacognitive understanding of other's minds were significantly correlated with greater negative symptoms, poorer early adolescent social adjustment and poorer clinician rated help-seeking. Our findings suggest that FEP individuals with difficulties in understanding other's minds have more social deficits and may be less able to make effective use of treatment.

Empathic accuracy and cognition in schizotypal personality disorder

Interpersonal dysfunction contributes to significant disability in the schizophrenia spectrum. Schizotypal Personality Disorder (SPD) is a schizophrenia-related personality demonstrating social cognitive impairment in the absence of frank psychosis. Past research indicates that cognitive dysfunction or schizotypy may account for social cognitive dysfunction in this population. We tested SPD subjects and healthy controls on the Empathic Accuracy (EA) paradigm and the Reading of the Mind in the Eyes Test (RMET), assessing the impact of EA on social support. We also explored whether EA differences could be explained by intelligence, working memory, trait empathy, or attachment avoidance. SPD subjects did not differ from controls in RMET, but demonstrated lower EA during negative valence videos, associated with lower social support. Dynamic, multimodal EA paradigms may be more effective at capturing interpersonal dysfunction than static image tasks such as RMET. Schizotypal severity, trait empathy, and cognitive dysfunction did not account for empathic dysfunction in SPD, although attachment avoidance is related to empathic differences. Empathic dysfunction for negative affect contributes to decreased social support in the schizophrenia spectrum. Future research may shed further light on potential links between attachment avoidance, empathic dysfunction, and social support.

Alteration of pain recognition in schizophrenia

BACKGROUND

Schizophrenia patients display impaired recognition of their own emotions and those of others and deficits in several domains of empathy. The first-person experience of pain and observing others in pain normally trigger strong emotional mechanisms. We therefore hypothesized that schizophrenia patients would display impaired recognition and categorization of both their own pain and the pain of others.

METHODS

We studied 29 patients (18 men/11 women; 36 ± 13 years old) with paranoid schizophrenia-spectrum disorder and 27 healthy volunteers (20 men/7 women; 31 ± 9 years old) matched for age, gender, IQ and socio-cultural level. We assessed symptom severity and theory of mind. The participants' ability to detect and categorize pain in others was assessed with the sensitivity to expressions of pain (STEP) test, which is based on facial expressions, and another dynamic test involving a series of video sequences showing various pain-inducing events. The ability of patients to evaluate their own pain was assessed with the situational pain questionnaire (SPQ), which includes a series of questions assessing how one would expect to feel in different imaginary situations. Empathic tendencies were assessed with the interpersonal reactivity index.

RESULTS

Patients and controls differed significantly in STEP, pain video and SPQ scores. By contrast with control subjects, the patients' pain judgements were not correlated with their affective or cognitive empathic capacities.

CONCLUSIONS

Schizophrenic patients have a deficit of the identification and categorization of pain both in themselves and in others.

Social cognition and metacognition in schizophrenia: evidence of their independence and linkage with outcomes

OBJECTIVE

Research suggests that many with schizophrenia experience deficits in the ability to make discrete judgments about the thoughts and feelings of others as well as to form larger integrated representations of themselves and others. Little is known about whether these difficulties may be distinguished from one another and whether they are linked with different outcomes.

METHOD

We administered three assessments of social cognition which tapped the ability to identify emotions and intentions and two metacognitive tasks which called for the formation of more integrated and flexible representations of the self and others. We additionally assessed symptoms, social functioning and neurocognition. Participants were 95 individuals with a schizophrenia spectrum disorder.

RESULTS

A principle components analysis followed by a varimax rotation revealed two factors which accounted for 62% of the variance. The first factor was comprised of the three social cognition tests and the second of two tasks that tapped the ability to create representations of oneself and others which integrate more discreet information. The first factor was uniquely correlated with negative symptoms, and the second was uniquely correlated with social function.

CONCLUSION

Results suggest that deficits in social cognition and metacognition represent different forms of dysfunction in schizophrenia.

Dissociation and social cognition in schizophrenia spectrum disorder

While there is emerging evidence that dissociation is linked with trauma history and possibly symptoms in schizophrenia, it remains unclear whether dissociation represents a symptom dimensions in its own right in schizophrenia and as such is uniquely related to other features of illness. To explore this issue the current study sought to find out whether dissociation was uniquely related to an index of social cognition closely linked to social functioning, namely affect recognition. We hypothesized that dissociation would be linked with affect recognition because symptoms of dissociation may uniquely disrupt processes which are expected to be needed for correctly recognizing emotions. The sample contained 49 participants diagnosed with a schizophrenia spectrum disorder who were in a non-acute phase of disorder. Participants were concurrently administered the Bell-Lysaker Emotion Recognition Task, the Dissociative Experiences Scale, the Post Traumatic Stress Disorder Checklist and the Positive and Negative Symptoms Scale. Stepwise linear regression analyses were performed in which dissociative symptoms were forced to enter after the other symptoms in order to predict deficits in affect recognition. These analyses revealed that greater levels of dissociative symptoms predicted poorer recognition of negative emotions over and above that of positive, negative, cognitive and PTSD symptoms. Results are consistent with the possibility that dissociation represents a unique dimension o f psychopathology in schizophrenia which may be linked to function.

Metacognition, affect regulation and symptom expression: a transdiagnostic perspective

The editors of this special section commissioned this commentary to bring together some of the conceptual, empirical and measurement issues arising from this series of articles. This commentary explores metacognition in relation to its neurobiology, and diverse syndromes and clinical phenotypes, including schizophrenia, alexithymia, and personality disorders, as well as its relation to assessment and prospects for the further delineation of mechanisms of change in psychological therapy.