Efficacy of psychological interventions targeting cognitive biases in schizophrenia: A systematic review and meta-analysis

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Transdiagnostic cognitive biases in psychiatric disorders: A systematic review and network meta-analysis

Psychiatric disorders are characterized by cognitive deficits, which have been proposed as a transdiagnostic feature of psychopathology ("C" factor). Similarly, cognitive biases (e.g., in attention, memory, and interpretation) represent common tendencies in information processing that are often associated with psychiatric symptoms. However, the question remains whether cognitive biases are also transdiagnostic or are specific to certain psychiatric disorders/symptoms. The current systematic review sought to address whether the proposed "C" factor of transdiagnostic cognitive dysfunction in psychopathology can be extended to cognitive biases. Overall, 31 studies comprising 4401 participants (2536 patients, 1865 non-clinical controls) met inclusion criteria, assessing 19 cognitive biases across 20 diagnostic categories, with most studies focusing on interpretation (k = 22) and attention (k = 11) biases and only 2 assessing memory biases. Traditional meta-analyses found a moderate effect size (g = 0.32) for more severe cognitive biases in all patients relative to non-clinical controls, as well as small but significant associations between interpretation biases and transdiagnostic symptom categories (general psychopathology: r = 0.20, emotion dysfunction: r = 0.17, psychotic symptoms: r = 0.25). Network meta-analyses revealed significant patient versus non-clinical control differences on attention and interpretation biases across diagnoses, as well as significant differences between diagnoses, with highest severity in panic disorder for attention biases and obsessive-compulsive disorder for interpretation biases. The current findings extend the big "C" interpretation of transdiagnostic cognitive dysfunction in psychiatric disorders to cognitive biases and transdiagnostic symptom dimensions. Results also suggest that while the presence of cognitive biases is transdiagnostic, bias severity differs across diagnoses, as in traditional neurocognitive deficits.

Reliability and validity of the Nepean Beliefs Scale for delusions and overvalued ideas in chronic schizophrenia: analysis of a preliminary pilot study

Introduction

The Nepean Beliefs Scale by Brakoulias et al. is an interview-based multidimensional instrument that measures pathological beliefs in various psychiatric disorders. This study examined the reliability and validity of Nepean Beliefs Scale (NBS) for delusions and overvalued ideas in patients with chronic-phase schizophrenia. Methods: Multiple raters at two healthcare settings examined the beliefs of 28 individuals with schizophrenia using the NBS. Concurrently, PANSS, PDI-21, BCIS, PHQ-9 and GAD-7 were administered.

Results

The NBS had high reliability and correlation with relevant scales.

Discussion

The NBS was found to have sufficient reliability and validity for assessing the pathological beliefs of patients with chronic schizophrenia. Although NBS is an easy-to-instruct instrument, it should be noted that appropriate explanations and examples should be added to instructions to obtain reliable responses from patients with chronic schizophrenia.

Rumination as a Transdiagnostic Phenomenon in the 21st Century: The Flow Model of Rumination

Rumination and its related mental phenomena share associated impairments in cognition, such as executive functions and attentional processes across different clinical conditions (e.g., in psychotic disorders). In recent decades, however, the notion of rumination has been increasingly narrowed to the "self-focused" type in depressive disorders. A closer review of the literature shows that rumination may be construed as a broader process characterized by repetitive thoughts about certain mental contents that interfere with one's daily activities, not only limited to those related to "self". A further examination of the construct of rumination beyond the narrowly focused depressive rumination would help expand intervention opportunities for mental disorders in today's context. We first review the development of the clinical construct of rumination with regard to its historical roots and its roles in psychopathology. This builds the foundation for the introduction of the "Flow Model of Rumination (FMR)", which conceptualizes rumination as a disruption of a smooth flow of mental contents in conscious experience that depends on the coordinated interactions between intention, memory, affect, and external events. The conceptual review concludes with a discussion of the impact of rapid technological advances (such as smartphones) on rumination. Particularly in contemporary societies today, a broader consideration of rumination not only from a cognition viewpoint, but also incorporating a human-device interaction perspective, is necessitated. The implications of the FMR in contemporary mental health practice are discussed.

Social cognitive bias increases loneliness both directly and by decreasing social connection in patients with schizophrenia

While considerable emphasis has been put on investigating the mechanisms that drive reduced social connection in patients with schizophrenia (SCZ), recent studies have increasingly focused on the issue of loneliness in SCZ. As both social cognitive bias and self-reported empathy predict loneliness in non-clinical populations, the current study aims to examine the relationship between loneliness, reduced social connection and social cognitive biases, and self-reported empathy in SCZ. Ninety-three adult SCZ and sixty-six matched healthy individuals completed a battery of questionnaires measuring loneliness and social connection (Revised-UCLA Loneliness Scale, Lubben-Social Network Scale, Social Disconnectedness Scale), cognitive biases (Ambiguous Intentions Hostility Questionnaire, Davos Assessment of Cognitive Biases Scale, Cognitive Biases Questionnaire for psychosis) and self-reported empathy (Interpersonal Reactivity Index). Significant predictors of loneliness in SCZ were entered into two latent variables ("Social Threat Bias", "Social Connection"), and structural equation modeling was used to explore the direct and indirect relationships between Social Threat Bias, symptoms. and loneliness in SCZ. Patients reported higher levels of loneliness, cognitive biases and personal distress compared to controls. Furthermore, SCZ reported less social connection and perspective taking compared to controls. Structural equation modeling revealed that Social Threat Bias was linked to increased loneliness in SCZ both directly and indirectly via decreased social connection. Negative symptoms were directly linked with loneliness, while the association between affective symptoms and loneliness was mediated via Social Threat Bias. The results of the current study suggest that social threat bias should be considered while planning the interventions aimed to reduce loneliness in schizophrenia.

The Emotion Regulation Mechanism in Neurotic Individuals: The Potential Role of Mindfulness and Cognitive Bias

Neuroticism is a personality trait that impacts daily life and raises the risk of mental problems and physical illnesses. To understand the emotion regulation mechanism of neurotic individuals, we developed two complementary studies to examine the effects of mindfulness and negative cognitive bias. In Study 1, four scales (EPQ-RSC, FFMQ, CERQ, NCPBQ) were used for assessment. Correlation analysis and structural comparison showed that: (1) the level of neuroticism was positively correlated with negative emotion regulation; (2) negative cognitive bias mediated the relationship between neuroticism and emotion regulation; (3) mindfulness and negative cognitive bias mediated the relationship in a chain. Study 1 showed that cognitive bias may play a key role in the emotion regulation mechanism. Study 2 further explored the cognitive bias of neurotic individuals using three behavioral experiments. A mixed-design ANOVA indicated that individuals with high neuroticism levels exhibited negative attention, memory, and interpretation biases. Our findings extend previous research on emotion regulation problems of neurotic individuals and broaden the field to personality-based emotion disorders. In particular, a theoretical rationale is provided for the application of cognitive behavioral therapy, such as mindfulness-based cognitive therapy (MBCT), to the emotion regulation of neurotic individuals.

Thinking biases and their role in persecutory delusions: A systematic review

AIM

Thinking biases are posited to be involved in the genesis and maintenance of delusions. Persecutory delusions are one of the most commonly occurring delusional subtypes and cause substantial distress and disability to the individuals experiencing them. Their clinical relevance confers a rationale for investigating them. Particularly, this review aims to elucidate which cognitive biases are involved in their development and persistence.

METHODS

MEDLINE, Embase, PsycINFO and Global Health were searched from the year 2000 to June 2020. A formal narrative synthesis was employed to report the findings and a quality assessment of included studies was conducted.

RESULTS

Twenty five studies were included. Overall, 18 thinking biases were identified. Hostility and trustworthiness judgement biases appeared to be specific to persecutory delusions while jumping to conclusions, self-serving attributional biases and belief inflexibility were proposed to be more closely related to other delusional subtypes. While the majority of the biases identified were suggested to be involved in delusion maintenance, hostility biases, need for closure and personalizing attributional biases were believed to also have aetiological influences.

CONCLUSIONS

These findings show that some cognitive biases are specific to paranoid psychosis and appear to be involved in the formation and/or persistence of persecutory delusions.

Remote cognitive assessment in severe mental illness: a scoping review

Many individuals living with severe mental illness, such as schizophrenia, present cognitive deficits and reasoning biases negatively impacting clinical and functional trajectories. Remote cognitive assessment presents many opportunities for advancing research and treatment but has yet to be widely used in psychiatric populations. We conducted a scoping review of remote cognitive assessment in severe mental illness to provide an overview of available measures and guide best practices. Overall, 34 studies (n = 20,813 clinical participants) were reviewed and remote measures, psychometrics, facilitators, barriers, and future directions were synthesized using a logic model. We identified 82 measures assessing cognition in severe mental illness across 11 cognitive domains and four device platforms. Remote measures were generally comparable to traditional versions, though psychometric properties were infrequently reported. Facilitators included standardized procedures and wider recruitment, whereas barriers included imprecise measure adaptations, technology inaccessibility, low patient engagement, and poor digital literacy. Our review identified several remote cognitive measures in psychiatry across all cognitive domains. However, there is a need for more rigorous validation of these measures and consideration of potentially influential factors, such as sex and gender. We provide recommendations for conducting remote cognitive assessment in psychiatry and fostering high-quality research using digital technologies.

Self-reported cognitive biases in psychosis: Validation of the Davos Assessment of Cognitive Biases Scale (DACOBS) in a Spanish sample of psychotic patients and healthy controls

Cognitive biases have been demonstrated to be important in developing and maintaining psychosis. However, self-report measures for everyday clinical practice have been developed only recently. We aimed to study one of these instruments for assessing cognitive biases: the Davos Assessment of Cognitive Biases Scale (DACOBS). In a Spanish sample of 84 patients diagnosed with schizophrenia-spectrum disorders and 152 healthy controls, we examined a) the factor structure using Confirmatory Factor Analysis (CFA) to test the original one-, three- and seven-factor solutions, b) the reliability (Cronbach's alpha), c) the discriminative power (Multivariate Analysis of Covariance - MANCOVA) and d) the relationships of cognitive biases with positive psychotic-like experiences (PPLEs) in healthy individuals and with psychotic symptoms in schizophrenia-spectrum patients. The CFA revealed that the seven-factor solution achieved the best fit. The DACOBS overall scale (Cronbach's alpha = .92) and subscales obtained good internal consistencies. MANCOVA, controlling for age and education, demonstrated that all subscales differentiated between healthy controls and psychotic patients (Wilks' Lambda = 0.87; F_{7, 226} = 4.70; p < .000; partial eta squared = 0.13). In addition, the DACOBS showed high correlations with PPLEs (controls) and moderate correlations with positive and general symptoms (patients), demonstrating its predictive validity. Concluding, the DACOBS proved to be a psychometrically suitable instrument for assessing cognitive biases in psychosis and adequately differentiated between patients and healthy individuals within the Spanish population. Norm scores are provided.

Heterogeneity in Response to MCT and Psychoeducation: A Feasibility Study Using Latent Class Mixed Models in First-Episode Psychosis

Metacognitive training (MCT) is an effective treatment for psychosis. Longitudinal trajectories of treatment response are unknown but could point to strategies to maximize treatment efficacy during the first episodes. This work aims to explore the possible benefit of using latent class mixed models (LCMMs) to understand how treatment response differs between metacognitive training and psychoeducation. We conducted LCMMs in 28 patients that received MCT and 34 patients that received psychoeducation. We found that MCT is effective in improving cognitive insight in all patients but that these effects wane at follow-up. In contrast, psychoeducation does not improve cognitive insight, and may increase self-certainty in a group of patients. These results suggest that LCMMs are valuable tools that can aid in treatment prescription and in predicting response to specific treatments.

Clinical insight in first-episode psychosis: Clinical, neurocognitive and metacognitive predictors

OBJECTIVE

Poor insight is a major problem in psychosis, being detrimental for treatment compliance and recovery. Previous studies have identified various correlates of insight impairment, mostly in chronic samples. The current study aimed to determine clinical, neurocognitive, metacognitive, and socio-cognitive predictors of insight in first-episode psychosis.

METHODS

Regression analyses of different insight dimensions were conducted in 190 patients with first-episode psychosis. Measures of clinical symptoms, neurocognition, metacognition, social cognition, and 'jumping to conclusions' bias were entered as predictors.

RESULTS

Delusions, disorganisation, and certain negative symptoms were associated with unawareness in various domains, while depression was associated with greater awareness of illness. Deficit in theory of mind and self-reflective processes, as well as a 'jumping to conclusions' bias, contributed to poor insight. Several neuropsychological scores also contributed to this but their contribution was no longer observed in regression analyses that included all the previously identified clinical and cognitive predictors. A measure of perseverative errors was still associated with unawareness and misattribution of symptoms.

CONCLUSION

In models that account for 28 % to 50 % of the variance, poor insight in first-episode psychosis is mainly associated with delusions and certain negative symptoms. At the cognitive level it does not appear to result from neuropsychological impairment but rather from altered reasoning bias and dysfunction in metacognitive processes. Therapeutic strategies specifically directed at these mechanisms could help improve the evolution of insight in first episode psychosis.

Automated Detection of Cognitive Distortions in Text Exchanges Between Clinicians and People With Serious Mental Illness

OBJECTIVE

The authors tested whether natural language processing (NLP) methods can detect and classify cognitive distortions in text messages between clinicians and people with serious mental illness as effectively as clinically trained human raters.

METHODS

Text messages (N=7,354) were collected from 39 clients in a randomized controlled trial of a 12-week texting intervention. Clinical annotators labeled messages for common cognitive distortions: mental filtering, jumping to conclusions, catastrophizing, "should" statements, and overgeneralizing. Multiple NLP classification methods were applied to the same messages, and performance was compared.

RESULTS

A tuned model that used bidirectional encoder representations from transformers (F1=0.62) achieved performance comparable to that of clinical raters in classifying texts with any distortion (F1=0.63) and superior to that of other models.

CONCLUSIONS

NLP methods can be used to effectively detect and classify cognitive distortions in text exchanges, and they have the potential to inform scalable automated tools for clinical support during message-based care for people with serious mental illness.

Impaired insight in schizophrenia: impact on patient-reported and physician-reported outcome measures in a randomized controlled trial

BACKGROUND

Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizophrenia.

METHODS

In a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NCT00014001), insight was measured using the Positive and Negative Syndrome Scale (PANSS) Item G12 (lack of insight). Additional assessments for this analysis included the 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS), physician- and patient-reported Clinical Global Impression-Severity (CGI-S), MATRICS Consensus Cognitive Battery, and Calgary Depression Scale for Schizophrenia. Relationships between patient-reported outcomes and PANSS total and Item G12 ratings were evaluated.

RESULTS

Among 1431 CATIE study participants in this analysis, increasingly impaired insight at baseline was significantly associated with better patient-reported quality of life (QoL), lower baseline depression, and greater divergence between physician- and patient-reported illness severity. Patients with more severely impaired insight reported milder illness compared with physician reports, particularly those with moderate-severe to extreme impairment (PANSS Item G12 rating ≥ 5), approximately 10% (138/1431) of CATIE participants. For the 90% of patients with PANSS Item G12 ratings < 5, patient-reported QoL decreased with increasing symptoms. SF-12 MCS scores were linearly related to baseline PANSS total score only in patients with PANSS total score < 90 (moderately ill or better), and better symptom scores were associated with higher QoL. No significant relationship between insight and neurocognition was observed.

CONCLUSIONS

In the small subgroup (10%) of CATIE study patients with schizophrenia and PANSS Item G12 ratings ≥5, moderate-severe-severe/extreme insight impairment was associated with significantly more positive perception of QoL and illness severity by the patient versus the treating physician. This was not observed in the remaining 90% of patients with normal to moderately impaired insight, suggesting that poor insight as a threat to the validity of self-report is uncommon.

Further validation of the Cognitive Biases Questionnaire for psychosis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

'You are trying to teach us to think more slowly!': Adapting Metacognitive Training for the acute care setting-A case report

Psychological group interventions for the acute inpatient care setting are scarce. Whereas Metacognitive Training for patients with Psychosis (MCT) provides a widely accessible, easy-to-implement intervention for patients with mild to moderate symptoms, it is less adequate for the acute care setting with respect to length and density of information. We present the adaptation process and the resulting adaptation of MCT, MCT-Acute, for the acute inpatient care setting. We report the case of a first patient, NK, who participated in MCT-Acute during her mandated stay on the locked acute ward due to an exacerbation of schizophrenia. NK participated in MCT-Acute 12 times, evaluated the training overall as positive and reported that she used exercises she had learned during training to improve her mood. She also described changing her behaviour in everyday life to think more slowly and make less hasty decisions, which is a central topic discussed in MCT and MCT-Acute. Conducting an adapted version of MCT in the acute care setting is feasible, and the present case report suggests that MCT-Acute may be a useful complement to a multidisciplinary treatment plan to stabilize patients with severe mental illness in acute inpatient care.

Jumping to conclusions correlates with negative symptoms, poor response inhibition, and impaired functioning in individuals diagnosed with schizophrenia

BACKGROUND

The jumping to conclusions (JTC) bias is the tendency to make immediate decisions based on little information. There are few studies that have investigated the relationship between JTC and frontal lobe function. We examined the association between JTC and the Brief Psychiatric Rating Scale (BPRS), Frontal Assessment Battery (FAB), and Global Assessment of Functioning (GAF) scale in individuals with schizophrenia.

METHODS

In total, 50 individuals diagnosed with schizophrenia and 50 healthy control individuals were administered the beads task. Individuals diagnosed with schizophrenia were assessed using the FAB, BPRS, and GAF.

RESULTS

There was a significant negative correlation between JTC and the negative symptoms of the BPRS (rs=-.368, p = .008). There was a significant positive correlation between JTC and the Go/No-Go task of the FAB (rs=.319, p = .026), and the GAF (rs=.433, p = .002).

CONCLUSION

JTC in individuals with schizophrenia may be categorized according to several causes, including negative symptoms and poor response inhibition.

Immediate and Sustained Outcomes and Moderators Associated With Metacognitive Training for Psychosis: A Systematic Review and Meta-analysis

IMPORTANCE

A substantial increase in the number of trials examining metacognitive training (MCT) for psychosis necessitates an updated examination of the outcomes associated with MCT.

OBJECTIVES

To review the immediate and sustained associations of MCT with proximal (directly targeted) and distal (indirectly influenced) outcomes and assess treatment- and participant-related moderators to identify the potential factors associated with the expected heterogeneity of effect sizes.

DATA SOURCES

Eleven electronic databases were searched from 2007 to June 3, 2021 (alert until September 10, 2021). Reference lists of earlier meta-analyses and included reports were screened.

STUDY SELECTION

Reports examined MCT and included participants with schizophrenia spectrum and related psychotic disorders (1045 reports identified; 281 assessed). There were no age, sex, gender, race and ethnicity, language, or study design restrictions. Two reviewers performed the selection of studies to be analyzed.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed. Data were extracted by 3 reviewers and pooled using random effects models. Hedges g effect sizes were computed. The Mixed-Methods Appraisal tool was used to assess study quality.

MAIN OUTCOMES AND MEASURES

Proximal outcomes were global positive symptoms, delusions, hallucinations, and cognitive biases. Distal outcomes were self-esteem, negative symptoms, quality of life, well-being, and functioning. Immediate and sustained outcomes were examined. Meta-regressions, subgroup, and sensitivity analyses assessed moderators.

RESULTS

This systematic review and meta-analysis included 43 studies (46 reports). Forty reports were synthesized in meta-analysis (N=1816 participants) and 6 reports were included in narrative review. In the studies examined, MCT was associated with positive symptoms (g = 0.50; 95% CI, 0.34-0.67), delusions (g = 0.69; 95% CI, 0.45-0.93), hallucinations (g = 0.26; 95% CI, 0.11-0.40), cognitive biases (g = 0.16; 95% CI, 0.03-0.29), self-esteem (g = 0.17; 95% CI, 0.03-0.31), negative symptoms (g = 0.23; 95% CI, 0.10-0.37), and functioning (g = 0.41; 95% CI, 0.12-0.69). These associations were maintained up to 1 year. The quality of life effect size was nonsignificant (g = 0.20; 95% CI, -0.07 to 0.47); only 1 study assessed well-being. Publication year was associated with moderated hallucinations (β = 0.04; 95% CI, 0.00-0.07). Overall, narrative review results corroborated meta-analytic findings.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, MCT for psychosis was associated with benefits up to 1 year postintervention in several treatment contexts. These findings suggest that MCT may merit integration in treatment guidelines for schizophrenia.

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

BACKGROUND

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

The relationship between jumping to conclusions and social cognition in first-episode psychosis

Jumping to conclusions (JTC) and impaired social cognition (SC) affect the decoding, processing, and use of social information by people with psychosis. However, the relationship between them had not been deeply explored within psychosis in general, and in first-episode psychosis (FEP) in particular. Our aim was to study the relationship between JTC and SC in a sample with FEP. We conducted a cross-sectional study with 121 patients with FEP, with measures to assess JTC (easy, hard, and salient probability tasks) and SC (emotional recognition, attributional style, and theory of mind). We performed Student's t-test and logistic regression in order to analyse these associations.We found a statistically significant and consistent relationship of small-moderate effect size between JTC (all three tasks) and impaired emotional recognition. Also, our results suggest a relationship between JTC and internal attributions for negative events. Relationships between JTC and theory of mind were not found. These results highlight the importance of psychological treatments oriented to work on a hasty reasoning style and on improving processing of social information linked to emotional recognition and single-cause attributions.

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

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Cognitive Behavioral Therapy in Treatment of Schizophrenia

Schizophrenia is a heterogeneous disorder that affects behavioral, affective, and cognitive domains and consists of positive and negative psychotic symptoms. Antipsychotic therapy is the first-line treatment for schizophrenia. However, treatment adherence levels are low. Even if there is good treatment compliance, residual symptoms and treatment resistance can be seen. As a result, recent schizophrenia treatment guidelines suggest Cognitive Behavioral Therapy (CBT) as adjunctive to antipsychotic therapy. CBT is known effective, especially on positive symptoms. This paper aims to review CBT practices and their effectiveness in schizophrenia.

Neural Correlates of Aberrant Salience and Source Monitoring in Schizophrenia and At-Risk Mental States-A Systematic Review of fMRI Studies

Cognitive biases are an important factor contributing to the development and symptom severity of psychosis. Despite the fact that various cognitive biases are contributing to psychosis, they are rarely investigated together. In the current systematic review, we aimed at investigating specific and shared functional neural correlates of two important cognitive biases: aberrant salience and source monitoring. We conducted a systematic search of fMRI studies of said cognitive biases. Eight studies on aberrant salience and eleven studies on source monitoring were included in the review. We critically discussed behavioural and neuroimaging findings concerning cognitive biases. Various brain regions are associated with aberrant salience and source monitoring in individuals with schizophrenia and the risk of psychosis. The ventral striatum and insula contribute to aberrant salience. The medial prefrontal cortex, superior and middle temporal gyrus contribute to source monitoring. The anterior cingulate cortex and hippocampus contribute to both cognitive biases, constituting a neural overlap. Our review indicates that aberrant salience and source monitoring may share neural mechanisms, suggesting their joint role in producing disrupted external attributions of perceptual and cognitive experiences, thus elucidating their role in positive symptoms of psychosis. Account bridging mechanisms of these two biases is discussed. Further studies are warranted.

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

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