Deficits in metacognitive capacity distinguish patients with schizophrenia from those with prolonged medical adversity

[Promoting mental health recovery through metacognitive reflection and insight therapy (MERIT): A systematic literature review]

OBJECTIVES

To demonstrate the effects of a metacognitive reflection and insight therapy (MERIT) in people suffering from psychiatric disorders.

METHOD

A systematic review was carried out on PubMed, PsychInfo, Psycharticles and Psychological and Behavioral Science Collection from 1980 to 2024.

RESULTS

The review included five randomized controlled studies, four observational group studies and 22 case studies with quantitative measures. Analyses indicated that MERIT significantly increases metacognitive abilities to reflect on oneself and others, as well as mastery of one's strategies. In addition, some studies found an improvement in insight and symptomatology. Most studies included participants with psychotic disorders.

CONCLUSION

MERIT is an effective therapy for promoting subjective recovery by improving metacognitive abilities in people with psychotic disorders. However, further studies are needed to generalize this result to other psychiatric disorders.

A Systematic Review and Meta-Analysis of Social Cognition Among People Living with HIV: Implications for Non-Social Cognition and Social Everyday Functioning

Social cognition-the complex mental ability to perceive social stimuli and negotiate the social environment-has emerged as an important cognitive ability needed for social functioning, everyday functioning, and quality of life. Deficits in social cognition have been well documented in those with severe mental illness including schizophrenia and depression, those along the autism spectrum, and those with other brain disorders where such deficits profoundly impact everyday life. Moreover, subtle deficits in social cognition have been observed in other clinical populations, especially those that may have compromised non-social cognition (i.e., fluid intelligence such as memory). Among people living with HIV (PLHIV), 44% experience cognitive impairment; likewise, social cognitive deficits in theory of mind, prosody, empathy, and emotional face recognition/perception are gradually being recognized. This systematic review and meta-analysis aim to summarize the current knowledge of social cognitive ability among PLHIV, identified by 14 studies focused on social cognition among PLHIV, and provides an objective consensus of the findings. In general, the literature suggests that PLHIV may be at-risk of developing subtle social cognitive deficits that may impact their everyday social functioning and quality of life. The causes of such social cognitive deficits remain unclear, but perhaps develop due to (1) HIV-related sequelae that are damaging the same neurological systems in which social cognition and non-social cognition are processed; (2) stress related to coping with HIV disease itself that overwhelms one's social cognitive resources; or (3) may have been present pre-morbidly, possibly contributing to an HIV infection. From this, a theoretical framework is proposed highlighting the relationships between social cognition, non-social cognition, and social everyday functioning.

Metacognition as a Transdiagnostic Determinant of Recovery in Schizotypy and Schizophrenia Spectrum Disorders

The term schizotypy refers to the latent personality organization that is thought to underpin the liability to develop schizophrenia and associated disorders. Metacognition, or the ability to understand and form increasingly complex and integrated ideas of oneself, others, and one's community, has been proposed to be an important transdiagnostic construct across schizophrenia spectrum disorders and a range of both clinical and non-clinical manifestations of schizotypy. In this paper, we review evidence that deficits in metacognition are present in individuals with relatively high levels of schizotypy and that these deficits are related to symptomology, function, and quality of life. We address the idea that decrements in metacognition may also contribute to the progression from schizotypy to more severe manifestations, while the amelioration of these deficits may enhance aspects of recovery, including the ability to form an integrated sense of self, others, and the wider world. We also review the following two recovery-oriented psychotherapies that target metacognition to promote recovery in individuals with clinical manifestations of schizotypy: Evolutionary Systems Therapy for Schizotypy (ESTS) and Metacognitive Reflection and Insight Therapy (MERIT).

Mild vs. moderate: How behavioral speech measures predict metacognitive capacity across different levels of formal thought disorder

Disorganized speech is a key component of formal thought disorder (FTD) in schizophrenia. Recent work has tied disorganized speech to deficits in metacognition, or one's ability to integrate experiences to form complex mental representations. The level of FTD at which differences in metacognitive capacity emerge remains unclear. Across two studies, using different cut scores to form FTD groups, we aimed to 1) explore the relationship between disorganized speech and metacognition and 2) compare trained rater and automated analysis methods. Clinical interviews were coded for disorganized speech and metacognition using the Communication Disturbances Index (CDI), Coh-Metrix multidimensional indices, and Metacognition Assessment Scale. In Study 1, we examined CDI and Coh-Metrix's ability to predict metacognition in FTD (n = 16) and non-FTD (n = 29) groups. We hypothesized the FTD group would have lower metacognition and that both CDI and Coh-Metrix would account for significant variance in metacognition. In Study 2, we conducted the same analyses with an independent sample using more stringent FTD cut scores (FTD: n = 23; non-FTD: n = 23). Analyses indicated that at a moderate but not mild cutoff: 1) automated methods differentiated FTD and non-FTD groups, 2) differences in metacognition emerged, and 3) behavioral measures accounted for significant variance (34%) in metacognition. Results emphasize the importance of setting the FTD cutoff at a moderate level and using samples that contain high levels of FTD. Findings extend research linking FTD and metacognition and demonstrate the benefit of pairing trained rater and automated speech measures.

Negative Schizotypy Mediates the Relationship Between Metacognition and Social Functioning in a Nonclinical Sample

ABSTRACT

Reduced metacognitive abilities-difficulty making sense of and understanding oneself and others-have been found to be key predictors of social functioning across a range of clinical and nonclinical groups. However, the exact processes through which metacognition impacts social functioning are unclear. This study examined whether subclinical negative symptoms mediated the relationship between metacognition and social functioning in a nonclinical sample of young adults (n = 98). Results demonstrated that lower metacognitive mastery was found to be uniquely associated with greater subclinical negative symptoms, whereas higher subclinical negative symptoms were associated with reduced social functioning. Further, the effects of lower metacognition on reduced social function were mediated by subclinical negative symptoms and not positive or disorganized subclinical symptoms. Results suggest that subclinical negative symptoms may link reductions in metacognition with social functioning in nonclinical samples. Training aimed at enhancing metacognition may support normative social functioning in the general population.

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

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

Atypical meta-memory evaluation strategy in schizophrenia patients

BACKGROUND

Previous research has reported that patients with schizophrenia would regard false memories with higher confidence, and this meta-memory deficit was suggested as a neurocognitive marker of schizophrenia. However, how schizophrenia patients determine their memory decision confidence has received scant consideration. This study, therefore, aimed to characterize the extent to which meta-memory evaluation strategy differs between schizophrenia patients and healthy individuals, and how such difference contributes to the patients' meta-memory performance.

METHODS

27 schizophrenia patients and 28 matched healthy controls performed a temporal-order judgement (TOJ) task, in which they judged which movie frame occurred earlier in an encoded video, and then made retrospective confidence rating. Mixed effect regression models were performed to assess the between-group metacognitive evaluation strategy difference and its relationship to clinical symptoms.

RESULTS

Compared to the control group, the patients' confidence ratings were correlated more with the recent confidence history and less with the TOJ-related evidence. The degree of dependence on recent history of confidence was negatively correlated with the severity of positive symptoms. Furthermore, by controlling for the first-order TOJ performance, we observed that the patients discriminated correct memory decisions from the incorrect ones as accurately as the controls.

CONCLUSION

The present investigation revealed that schizophrenia patients tend to use more heuristics in making meta-memory evaluations, and such atypical strategy is related to their clinical symptoms. This study provides new insights into how schizophrenia patients perform meta-memory processes. Future research could consider examining such metacognitive deficits in light of other cognitive domains in psychosis.

Centrality and Decentration: A Model for Understanding Disturbances in the Relationship of the Self to the World in Psychosis

ABSTRACT

A considerable body of phenomenological research has described different ways in which the relationship of the person to the world in psychosis is affected. This literature, however, has lacked an accepted unifying theoretical model and means of quantitatively measuring these disturbances. To address this, the current article seeks to integrate a novel phenomenological model of psychosis offered by Henri Grivois, which is explicitly concerned with centrality or a person's sense of being the center of all things, with empirical research on the integrative model of metacognition, which allows for measurements of decentration or the degree to which persons can form integrated ideas about their place in their larger community. It is proposed that this literature may allow for a model of how psychotherapy can address centrality through the building of intersubjectivity and enhancing metacognition.

Telemedicine solutions for patients with mental disorders: a Delphi study and review of mobile applications in virtual stores

Mental disorders are a critical public health challenge since they profoundly affected people lifestyle. Mental healthcare treatments aim to promote a higher quality of life of the patients. These procedures include interventions for prolonged mental illness which can be supported by telemedicine technologies. This paper presents a comprehensive analysis of mobile applications selected to address the most critical needs of people with mental problems. Needs include areas of the patient's life, such as basic activities, behavioral changes, and daily life tasks. This work has two main objectives; (1) identify critical needs for patients with mental disorders and (2) identify and analyze apps that can meet the identified critical needs. A Delphi methodology survey was carried with a group of thirteen volunteers, including nurses, assistants, and psychiatrists who are working in Zamora and Valladolid, Spain. This survey has recommended different needs for patients with mental disorders and address objective 1. Google Play and Apple Store have been assessed to select the most relevant mobile applications that were recommended in the Delphi study to address the essential needs of these patients according to objective 2. The results of the Delphi survey show 24 different needs for patients with mental disorders. This study has analyzed 62 mobile applications which address the essential needs recommended in the Delphi study. The selected mobile applications represent 31 applications with feedback (50%); 15 informative applications (24%), and 16 independent applications (26%). On the one hand, applications with feedback request can address 13 recommended needs (54%). On the other hand, informative applications can address 7 needs (29%). Finally, the independent applications are only able to respond to 4 of the 24 recommend needs (17%). Mobile health applications present effective technologies to support the needs of patients with mental disorders. However, this study suggests a critical limitation of mobile applications for mental health since the majority of the applications require user activity. Therefore, future research initiatives on the design and development of mobile apps for people who have mental disorders should focus on independent applications.

Social Dysfunction in Psychosis Is More Than a Matter of Misperception: Advances From the Study of Metacognition

Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of disturbances in social function remain poorly understood. One recent model has proposed that deficits in social cognition may be a root cause of social dysfunction. In this model social relationships become untenable among persons diagnosed with psychosis when deficits in social cognition result in inaccurate ideas of what others feel, think or desire. While there is evidence to support the influence of social cognition upon social function, there are substantial limitations to this point of view. Many with psychosis have social impairments but not significant deficits in social cognition. First person and clinical accounts of the phenomenology of psychosis also do not suggest that persons with psychosis commonly experience making mistakes when trying to understand others. They report instead that intersubjectivity, or the formation of an intimate shared understanding of thoughts and emotions with others, has become extraordinarily difficult. In this paper we explore how research in metacognition in psychosis can transcend these limitations and address some of the ways in which intersubjectivity and more broadly social function is compromised in psychosis. Specifically, research will be reviewed on the relationship between social cognitive abilities and social function in psychosis, including measurement strategies and limits to its explanatory power, in particular with regard to challenges to intersubjectivity. Next, we present research on the integrated model of metacognition in psychosis and its relation to social function. We then discuss how this model might go beyond social cognitive models of social dysfunction in psychosis by describing how compromises in intersubjectivity occur as metacognitive deficits leave persons without an integrated sense of others' purposes, relative positions in the world, possibilities and personal complexities. We suggest that while social cognitive deficits may leave persons with inaccurate ideas about others, metacognitive deficits leave persons ill equipped to make broader sense of the situations in which people interact and this is what leaves them without a holistic sense of the other and what makes it difficult to know others, share experiences, and sustain relationships. The potential of developing clinical interventions focused on metacognition for promoting social recovery will finally be explored.

Metacognition, social cognition, and mentalizing in psychosis: are these distinct constructs when it comes to subjective experience or are we just splitting hairs?

Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised - as often occurs in psychosis - results in the loss of persons' sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.

[Metacognition as a pathway to the study and treatment of fragmentation in schizophrenia]

This paper explores the potential of recent research on metacognition to offer new avenues to assess and address the phenomenon of fragmentation in schizophrenia, which was described by E.Bleuler as «splitting». The concepts of metacognition characterize and quantify alterations or decrements in the processes by which fragments or pieces of information are integrated into a coherent sense of self and others. A method for assessing metacognition is presented along with research examining the presence and importance of metacognitive deficits in schizophrenia. Greater levels of metacognitive deficits have been detected in different phases of schizophrenia and linked to poorer psychosocial outcomes. These data were obtained both in foreign and preliminary Russian studies. The authors suggest that treatments, which successfully target metacognitive capacity, may uniquely promote wellness and recovery in schizophrenia.

Narrative Identity, Metacognition, and Well-Being in Patients With Schizophrenia or HIV

It has been proposed that schizophrenia reflects disturbances in personal identity, which include sense of personal agency, sense of belonging within a social group, and metacognition. Less is known about how these different processes are related to one another and to well-being outcomes. To study this, we measured themes of agency and communion in narrative identity in 29 individuals with schizophrenia and 29 individuals with HIV. All participants had previously been assessed on metacognitive abilities using the Indiana Psychiatric Illness Interview (IPII) and completed scales measuring hopelessness and self-esteem. For the present study, themes of agency and communion were coded from the IPII transcripts. Results indicated that participants with schizophrenia had lower levels of agency and communion compared with participants with HIV. More presence of agency and communion themes were related to better metacognitive abilities as well as less hopelessness and higher self-esteem across groups. Agency predicted variance in hopelessness after controlling for metacognitive abilities. The results suggest that although the construction of narrative identity may depend on metacognitive abilities, agency themes predict outcomes beyond metacognition.

A cognitive model of diminished expression in schizophrenia: The interface of metacognition, cognitive symptoms and language disturbances

The resistance of negative symptoms to pharmacologic treatment has spurred interest in understanding the psychological factors that contribute to their formation and persistence. However, little is understood about the psychological processes that reinforce and sustain the negative symptoms domain of diminished expression. Prior research has shown that higher levels of diminished expression relate to deficits in metacognitive capacity. We propose a more complex model in which diminished expression occurs when impairments in metacognitive self-reflectivity, alterations in higher-order language structure, and cognitive symptoms interact and thus interfere with persons' ability to understand and express emotions in ways others can recognize. Individuals with schizophrenia-spectrum disorders (N = 201) provided personal narratives detailing their life story and reflections about their mental illness. Self-reflectivity was measured with the Metacognition Assessment Scale-Abbreviated, and situation models were extracted from participants' personal narratives via Coh-Metrix 3.0, an automated program that calculates language indices. Diminished expression and cognitive symptoms were measured with the Positive and Negative Syndrome Scale. Structural equation models (SEM) examined whether self-reflectivity mediated the impact of cognitive symptoms and situation models on diminished expression. Results of the SEM revealed that self-reflectivity partially mediated the impact of situation models on diminished expression (β = -.073, p = .008, ±95% CI [-0.126, -0.019]). and fully mediated the influence of cognitive symptoms in diminished expression (β = 0.099, p = .001, ±95% CI [0.038, 0.160]). In conclusion, results suggest that self-reflectivity, linguistic cohesion, and cognitive symptoms may be useful targets for intervention in efforts to treat diminished expression in psychosis.

A qualitative evaluation of the effects of Metacognitive Reflection and Insight Therapy: 'Living more consciously'

OBJECTIVES

Extensive research showed that one of the major difficulties that people with schizophrenia spectrum disorders are struggling with involves their ability to reflect on their own and others' mental activities, also defined as metacognition. Several new psychotherapies have been developed to assist patients (re)gain metacognitive capacity, including Metacognitive Reflection and Insight Therapy (MERIT). The current study investigated the client's subjective experience of psychotherapy, to determine whether service users found MERIT effective and whether these gains align with quantitative findings, which processes they considered responsible for these benefits, in which ways participants found MERIT similar or different from other interventions, and whether they experienced non-desirable factors and outcomes.

DESIGN

All participants who had participated in a randomized controlled trial investigating the efficacy of MERIT were offered a structured post-therapy interview by an independent assessor. Fourteen out of 18 (77%) participants, all of whom had completed therapy, responded.

RESULTS

Most participants (10/14) indicated that they had experienced the therapy as beneficial to their recovery, and in general contributed to their understanding of their own thinking, which maps closely onto the quantitative findings reported elsewhere. They mainly attributed these changes to their own active role in therapy, the intervention letting them vent and self-express, and forming an alliance with the therapist.

CONCLUSIONS

Participants reports of change map closely onto the quantitative findings from the randomized controlled trial. Findings are discussed in the frameworks of the metacognitive model of psychosis and the integrative intersubjective model of psychotherapy for psychosis emphasizing the role of the clients as active agent of change.

PRACTITIONER POINTS

The use of a systematic, qualitative interview at the conclusion of therapy may yield important information regarding process and outcome. Analysis of the interview revealed that clients' perceptions regarding change within themselves closely maps onto quantitative findings. MERIT may not be the appropriate intervention for all clients; some may prefer a more solution-oriented approach such as CBTp or Metacognition-Oriented Social Skills training. Self-expressing with a trained clinician may be therapeutic in itself.

Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis

Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.

Predicting therapy success from the outset: The moderating effect of insight into the illness on metacognitive psychotherapy outcome among persons with schizophrenia

The degree to which a person recognizes their mental disorder, attributes symptoms to the disorder, and recognizes that treatment may be necessary is frequently referred to as clinical insight. The current study investigates whether clinical insight at baseline moderates the effects on metacognitive capacity of 40 sessions of metacognitive reflection and insight therapy among 35 participants with psychosis. Findings showed that clinical insight did not predict drop-out from therapy. Multilevel analyses provided support for our hypotheses that insight at baseline significantly moderates metacognitive gains at both postmeasurement and follow-up. Our findings demonstrate that lacking clinical insight substantially hampers the effect of this psychosocial intervention. We posit that research efforts should shift from developing interventions, which enhance clinical insight, to interventions, which are effective in absence of clinical insight.

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

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

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

Introduction

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

Methods

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

Results

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

Discussion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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

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

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

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

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

An evaluation of functional mental capacity in forensic mental health practice: the Dundrum capacity ladders validation study

BACKGROUND

Because of the potential gravity of finding a person incompetent, assessment of mental capacity is challenging for clinicians. We aimed to test validity of a new structured professional judgement tool designed to assess functional mental capacity in three domains - finances, welfare and healthcare.

METHODS

Fifty-five male forensic psychiatric patients with Schizophrenia were interviewed using the Dundrum Capacity Ladders - a new semi-structured interview, and scores were assigned on a stratified scoring system, measuring ability to understand, reason, appreciate the personal importance of the decision at hand and communicate a decision. Data were also gathered pertaining to level of therapeutic security at the time of interview, diagnosis, neurocognitive function and a validated measure of real world function.

RESULTS

The results show that internal consistency and inter-rater reliability were high for all items. There were correlations between higher scores of functional mental capacity, neurocognitive function and measures of real world function in this population. Correlations were in the range 0.358 to 0.693, effect sizes that were moderate to high.

CONCLUSIONS

The DUNDRUM Capacity Ladders appear to be a valid measure of functional mental capacity in this population. Further prospective studies of functional mental capacity as a measure of recovery are now required.

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

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

Clinical and therapeutic role of mentalization in schizophrenia-a review

Recent empirical findings from clinical and genetic studies suggest that mentalization, a key area of social cognition, is a distinct construct, although it is closely related to the neurocognitive deficits and symptoms of schizophrenia. Mentalization contributes a great deal to impaired social functioning. Current measures often display methodological problems, and many aspects should be taken into account when assessing mentalization. Moreover, advances in cognitive and affective neurosciences have led to the development of more advanced behavioral methods to assess the relationship between cognitive functions, symptoms, and social cognition based on their underlying neural mechanisms. The development of assessment tools that better examine the neural circuitry of such relationships may lead to the development of new psychosocial and pharmacological treatments.

Metacognitive profiles in schizophrenia and bipolar disorder: Comparisons with healthy controls and correlations with negative symptoms

While deficits in metacognition, or the ability to notice and reflect upon mental states has been observed in schizophrenia and linked with poorer concurrent and future function, it is unknown whether these deficits are unique to schizophrenia. Accordingly, this study assessed metacognition using the Metacognitive Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire- 30 (MCQ-30) among 26 adults with schizophrenia, 23 with bipolar disorder and 23 healthy controls. Symptom levels of the psychiatric groups were assessed with the Brief Psychiatric Rating Scale. ANCOVA controlling for age and education revealed that the schizophrenia group had lower scores on the MAS-A total and its subscales compared to the bipolar group and healthy controls. The bipolar disorder group also had lower MAS-A scores than the healthy control group. No group differences were found for the MCQ-30. Examination of symptom correlates revealed MAS-A scores were most commonly related to negative symptoms in both clinical groups. The total score and need for control subscale of MCQ-30 was related to total symptomatology and positive symptoms in patients with bipolar disorder. Correlations between the two measures of metacognition revealed that higher MAS-A scores were significantly related to lower scores on the Need to Control Thoughts MCQ-30 subscale.

A pilot study on feasibility, acceptance and effectiveness of metacognitive-oriented social skills training in schizophrenia

BACKGROUND

In preparation for a randomized controlled trial, a pilot study was conducted to investigate the feasibility, acceptability and effectiveness of a psychotherapy group based on metacognitive-oriented social skills training (MOSST).

METHODS

Twelve outpatients with schizophrenia were offered 16 group-sessions of MOSST. Effect sizes were calculated for changes from baseline to treatment end for both psychosocial functioning and metacognitive abilities measured by the Personal and Social Performance Scale (PSP) and the Metacognition Assessment Scale-Abbreviated (MAS-A) respectively.

RESULTS AND DISCUSSION

Ten patients finished the full treatment protocol and nonsignificant moderate effect sizes were obtained on PSP and MAS-A scores. To date, this is the first study in Spain to suggest that outpatients with schizophrenia will accept metacognitive therapy for social skills training and evidence improvements in psychosocial functioning and metacognition.

CONCLUSION

Despite limitations inherent in a pilot study, including a small sample size and the absence of a control group, sufficient evidence of effectiveness was found to warrant further investigation.

TRIAL REGISTRATION

ISRCTN10917911 . Retrospectively registered 30 November 2016.

Insight in psychosis: Standards, science, ethics and value judgment

BACKGROUND

The clinical assessment of insight solely employs biomedical perspectives and criteria to the complete exclusion of context and culture and to the disregard of values and value judgments.

AIM

The aim of this discussion article is to examine recent research from India on insight and explanatory models in psychosis and re-examine the framework of assessment, diagnosis and management of insight and explanatory models.

METHODS

Recent research from India on insight in psychosis and explanatory models is reviewed.

RESULTS

Recent research, which has used longitudinal data and adjusted for pretreatment variables, suggests that insight and explanatory models of illness at baseline do not predict course, outcome and treatment response in schizophrenia, which seem to be dependent on the severity and quality of the psychosis. It supports the view that people with psychosis simultaneously hold multiple and contradictory explanatory models of illness, which change over time and with the trajectory of the illness. It suggests that insight, like all explanatory models, is a narrative of the person's reality and a coping strategy to handle with the varied impact of the illness.

CONCLUSION

This article argues that the assessment of insight necessarily involves value entailments, commitments and consequences. It supports a need for a broad-based approach to assess awareness, attribution and action related to mental illness and to acknowledge the role of values and value judgment in the evaluation of insight in psychosis.

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

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

Unique and Overlapping Symptoms in Schizophrenia Spectrum and Dissociative Disorders in Relation to Models of Psychopathology: A Systematic Review

Schizophrenia spectrum disorders (SSDs) and dissociative disorders (DDs) are described in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) and tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) as 2 categorically distinct diagnostic categories. However, several studies indicate high levels of co-occurrence between these diagnostic groups, which might be explained by overlapping symptoms. The aim of this systematic review is to provide a comprehensive overview of the research concerning overlap and differences in symptoms between schizophrenia spectrum and DDs. For this purpose the PubMed, PsycINFO, and Web of Science databases were searched for relevant literature. The literature contained a large body of evidence showing the presence of symptoms of dissociation in SSDs. Although there are quantitative differences between diagnoses, overlapping symptoms are not limited to certain domains of dissociation, nor to nonpathological forms of dissociation. In addition, dissociation seems to be related to a history of trauma in SSDs, as is also seen in DDs. There is also evidence showing that positive and negative symptoms typically associated with schizophrenia may be present in DD. Implications of these results are discussed with regard to different models of psychopathology and clinical practice.

Insight in Psychosis: An Indicator of Severity of Psychosis, an Explanatory Model of Illness, and a Coping Strategy

Recent studies related to insight, explanatory models (EMs) of illness and their relationship to outcome of psychosis are reviewed. The traditional argument that insight predicts outcome in psychosis is not supported by recent longitudinal data, which has been analyzed using multivariable statistics that adjust for severity and quality of illness. While all cognition will have a neurobiological representation, if "insight" is related to the primary psychotic process, then insight cannot be seen as an independent predictor of outcome but a part of the progression of illness. The evidence suggests insight, like all EMs, is belief which interacts with the trajectory of the person's illness and the local culture to produce a unique understanding of the illness for the particular individual and his/her family.

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.

The Relationship Between Interoception and Metacognition

Abstract. Recently, Garfinkel and Critchley (2013) proposed to distinguish between three facets of interoception: interoceptive sensibility, interoceptive accuracy, and interoceptive awareness. This pilot study investigated how these facets interrelate to each other and whether interoceptive awareness is related to the metacognitive awareness of memory performance. A sample of 24 healthy students completed a heartbeat perception task (HPT) and a memory task. Judgments of confidence were requested for each task. Participants filled in questionnaires assessing interoceptive sensibility, depression, anxiety, and socio-demographic characteristics. The three facets of interoception were found to be uncorrelated and interoceptive awareness was not related to metacognitive awareness of memory performance. Whereas memory performance was significantly related to metamemory awareness, interoceptive accuracy (HPT) and interoceptive awareness were not correlated. Results suggest that future research on interoception should assess all facets of interoception in order to capture the multifaceted quality of the construct.

Intrinsic motivation as a mediator between metacognition deficits and impaired functioning in psychosis

OBJECTIVE

Poor functioning has long been observed in individuals with psychosis. Recent studies have identified metacognition - one's ability to form complex ideas about oneself and others and to use that information to respond to psychological and social challenges-as being an important determinant of functioning. However, the exact process by which deficits in metacognition lead to impaired functioning remains unclear. This study first examined whether low intrinsic motivation, or the tendency to pursue novel experiences and to engage in self-improvement, mediates the relationship between deficits in metacognition and impaired functioning. We then examined whether intrinsic motivation significantly mediated the relationship when controlling for age, education, symptoms, executive functioning, and social cognition.

DESIGN

Mediation models were examined in a cross-sectional data set.

METHODS

One hundred and seventy-five individuals with a psychotic disorder completed interview-based measures of metacognition, intrinsic motivation, symptoms, and functioning and performance-based measures of executive functioning and social cognition.

RESULTS

Analyses revealed that intrinsic motivation mediated the relationship between metacognition deficits and impaired functioning (95% CI of indirect effect [0.12-0.43]), even after controlling for the aforesaid variables (95% CI of indirect effect [0.04-0.29]).

CONCLUSIONS

Results suggest that intrinsic motivation may be a mechanism that underlies the link between deficits in metacognition and impaired functioning and indicate that metacognition and intrinsic motivation may be important treatment targets to improve functioning in individuals with psychosis.

PRACTITIONER POINTS

The findings of this study suggest that deficits in metacognition may indirectly lead to impaired functioning through their effect on intrinsic motivation in individuals with psychosis. Psychological treatments that target deficits in both metacognition and intrinsic motivation may help to alleviate impaired functioning in individuals with psychosis.

LIMITATIONS

The cross-sectional design of this study is a limitation, and additional longitudinal studies are needed to confirm the direction of the findings and rule out rival hypotheses. Generalization of the findings may be limited by the sample composition. It may be that different relationships exist between metacognition, intrinsic motivation, and functioning in those with early psychosis or among those in an acute phase or who decline treatment.

Metacognitive deficits predict future levels of negative symptoms in schizophrenia controlling for neurocognition, affect recognition, and self-expectation of goal attainment

The recalcitrance of negative symptoms in the face of pharmacologic treatment has spurred interest in understanding the psychological factors that contribute to their formation and persistence. Accordingly, this study investigated whether deficits in metacognition, or the ability to form integrated ideas about oneself, others, and the world, prospectively predicted levels of negative symptoms independent of deficits in neurocognition, affect recognition and defeatist beliefs. Participants were 53 adults with a schizophrenia spectrum disorder. Prior to entry into a rehabilitation program, all participants completed concurrent assessments of metacognition with the Metacognitive Assessment Scale-Abbreviated, negative symptoms with the Positive and Negative Syndrome Scale, neurocognition with the MATRICS battery, affect recognition with the Bell Lysaker Emotion Recognition Task, and one form of defeatist beliefs with the Recovery Assessment Scale. Negative symptoms were then reassessed one week, 9weeks, and 17weeks after entry into the program. A mixed effects regression model revealed that after controlling for baseline negative symptoms, a general index of neurocognition, defeatist beliefs and capacity for affect recognition, lower levels of metacognition predicted higher levels of negative symptoms across all subsequent time points. Poorer metacognition was able to predict later levels of elevated negative symptoms even after controlling for initial levels of negative symptoms. Results may suggest that metacognitive deficits are a risk factor for elevated levels of negative symptoms in the future. Clinical implications are also discussed.

Prospective cohort study of the relationship between neuro-cognition, social cognition and violence in forensic patients with schizophrenia and schizoaffective disorder

BACKGROUND

There is a broad literature suggesting that cognitive difficulties are associated with violence across a variety of groups. Although neurocognitive and social cognitive deficits are core features of schizophrenia, evidence of a relationship between cognitive impairments and violence within this patient population has been mixed.

METHODS

We prospectively examined whether neurocognition and social cognition predicted inpatient violence amongst patients with schizophrenia and schizoaffective disorder (n = 89; 10 violent) over a 12 month period. Neurocognition and social cognition were assessed using the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

Using multivariate analysis neurocognition and social cognition variables could account for 34 % of the variance in violent incidents after controlling for age and gender. Scores on a social cognitive reasoning task (MSCEIT) were significantly lower for the violent compared to nonviolent group and produced the largest effect size. Mediation analysis showed that the relationship between neurocognition and violence was completely mediated by each of the following variables independently: social cognition (MSCEIT), symptoms (PANSS Total Score), social functioning (SOFAS) and violence proneness (HCR-20 Total Score). There was no evidence of a serial pathway between neurocognition and multiple mediators and violence, and only social cognition and violence proneness operated in parallel as significant mediators accounting for 46 % of the variance in violent incidents. There was also no evidence that neurocogniton mediated the relationship between any of these variables and violence.

CONCLUSIONS

Of all the predictors examined, neurocognition was the only variable whose effects on violence consistently showed evidence of mediation. Neurocognition operates as a distal risk factor mediated through more proximal factors. Social cognition in contrast has a direct effect on violence independent of neurocognition, violence proneness and symptom severity. The neurocognitive impairment experienced by patients with schizophrenia spectrum disorders may create the foundation for the emergence of a range of risk factors for violence including deficits in social reasoning, symptoms, social functioning, and HCR-20 risk items, which in turn are causally related to violence.

Metacognitive Deficits in Schizophrenia: Presence and Associations With Psychosocial Outcomes

Early formulations of schizophrenia suggested that the disorder involves a loss of ability to form integrated ideas about oneself, others, and the world, resulting in reductions in complex goal-directed behaviors. Exploring this position, the current review describes evidence that persons with schizophrenia experience decrements in their ability to form complex ideas about themselves and to ultimately use that knowledge to respond to psychological and social challenges. Studies are detailed that find greater levels of these impairments, defined as metacognitive deficits, in persons with schizophrenia in both early and later phases of illness as compared with other clinical and community groups. Furthermore, studies linking metacognitive deficits with poorer psychosocial functioning and other variables closely linked to outcomes are summarized. Clinical implications are also discussed.

Engagement as an Element of Safe Inpatient Psychiatric Environments

BACKGROUND

The American Psychiatric Nurses Association (APNA) Institute for Safe Environments (ISE) has focused on key elements that affect safety in psychiatric treatment environments; one of these key elements is patient engagement. An ISE workgroup discussed and reviewed the literature on engagement and safety in inpatient psychiatric settings. This article presents what we have learned about the role that engagement plays in inpatient treatment of severely mentally ill individuals and evidence that links nurse-patient engagement to safety.

OBJECTIVES

To describe, using supporting literature, the role that nurse-patient engagement plays in creating safe, therapeutic environments for individuals with severe mental illness.

DESIGN

(1) Define engagement and describe why it is an important element of safe treatment environments; (2) identify what helps and what hinders patients in their engagement with nurses, and nurses in their engagement with patients; (3) describe how engagement may improve unit safety; and (4) propose recommendations and set future directions for practice, research, and education.

CONCLUSION

Engagement may provide the foundation for safe, therapeutic, and recovery-oriented treatment. In the future, APNA's ISE plans to build upon this foundation by developing a clinical model of nurse-patient engagement and safety by drawing together emerging research and practice models.

Metacognitive and social cognition approaches to understanding the impact of schizophrenia on social quality of life

While some studies view metacognition and social cognition as representing the same phenomenon, others suggest that they represent distinctive sets of abilities that are related to different outcomes. The current study used a cross-sectional design that includes samples of persons with schizophrenia (N=39) and healthy individuals (N=60) to further explore the distinction between social cognition and metacognition and their associations with social quality of life. The Face Emotion Identification Task (FEIT), Faux-Pas Task, Indiana Psychiatric Illness Interview (IPII), Metacognition Assessment Scale - Abbreviated (MAS-A), and Social Quality of Life Scale were administrated to all participants. Correlations, t-tests and regressions were conducted. Results showed that persons with schizophrenia performed more poorly on all measures than healthy controls. Social cognition and metacognition measures were related for the combined total sample, but only a few associations were found among both sub-samples. A diagnosis of schizophrenia and metacognitive capacity, but not social cognition, predicted social quality of life. Self-reflectivity had a negative relationship to social quality of life while understanding of others' minds had a positive relation to social quality of life. The current study provides evidence that many with schizophrenia experience deficits in both social cognition and metacognition and that those deficits may be distinct and have different kinds of relationships with social quality of life. Clinical implications include the need to emphasize narrative aspects of psychotherapy in order to promote metacognition.

Individual Psychotherapy and Changes in Self-Experience in Schizophrenia: A Qualitative Comparison of Patients in Metacognitively Focused and Supportive Psychotherapy

OBJECTIVE

Deficits in metacognition, or the ability to form complex ideas about self and others, may be a root cause of dysfunction in schizophrenia. Accordingly, forms of psychotherapy have been proposed to address metacognitive deficits. This study explored whether metacognitively focused individual psychotherapy can affect self-experience by conducting narrative interviews of patients with a schizophrenia spectrum disorder enrolled in either metacognitively oriented psychotherapy (n = 12) or supportive psychotherapy (n = 13) in a naturalistic setting.

METHOD

Participants in both groups completed a narrative interview consisting of questions that focused on perceptions and process of psychotherapy and its impact on outcomes. Interviews were audiotaped, transcribed, and coded using an inductive process informed by grounded theory.

RESULTS

Qualitative analyses revealed all participants reported psychotherapy led to improvements in self-esteem and the ability to think more clearly and set meaningful goals. The group receiving metacognitively oriented therapy, in contrast to those receiving supportive therapy, reported being able to integrate their current experiences into the larger narratives of their lives and an increased experience of sense of agency and the ability to understand and manage pain.

CONCLUSIONS

Results provide evidence that metacognitively oriented psychotherapy may promote subjective forms of recovery.

Necessary, but not sufficient: links between neurocognition, social cognition, and metacognition in schizophrenia are moderated by disorganized symptoms

Intact neurocognition has been posited as a necessary, but not sufficient prerequisite for efficient social cognition and metacognition in schizophrenia. Disorganized symptoms likely play a prominent role in these cognitive processes, given the detrimental effects of disorganization on one's ability to synthesize discrete information into an organized whole. However, the relationship between disorganized symptoms and cognitive processes remains unclear. In this study, we examined whether disorganized symptoms: 1) exhibited stronger inverse relationships with cognitive processes than other symptoms, and 2) moderated links between neurocognition and a) social cognition, and b) metacognition. Trained raters assessed psychotic symptoms, neurocognition, social cognition, and metacognition in patients with schizophrenia from a Midwestern VA Medical Center (n=68) using validated, clinician-rated instruments. We observed significantly greater inverse associations with cognitive processes for disorganized compared to reality distortion symptoms; inverse associations with neurocognition and social cognition were significantly greater for disorganized than negative symptoms. Our hypotheses that disorganized symptoms would moderate relationships between neurocognition and a) social cognition, and b) metacognition were also supported. These findings highlight the importance of disorganized symptoms in elucidating links between neurocognition and social cognitive and metacognitive abilities. Future work should assess whether similar findings occur across the schizophrenia-spectrum, and investigate if targeting disorganization can ameliorate social cognitive and metacognitive impairments in schizophrenia.

Insight in psychosis: an independent predictor of outcome or an explanatory model of illness?

While the traditional view within psychiatry is that insight is independent of psychopathology and predicts the course and outcome of psychosis, recent data from India argues that insight is secondary to interaction between progression of illness on one hand and local culture and social environment on the other. The findings suggest that "insight" is an explanatory model (EM) and may reflect attempts at coping with the devastating effects of mental disorders. Most societies are pluralistic and offer multiple, divergent and contradictory explanations for illnesses. These belief systems interact with the trajectory of the person's illness to produce a unique personal understanding, often based on a set of complex and contradictory EMs. Like all EMs, insight provides meaning to explain and overcome challenges including disabling symptoms, persistent deficits, impaired social relations and difficult livelihood issues. The persistence of distress, impairment, disability and handicap, despite regular and optimal treatment, call for explanations, which go beyond the simplistic concept of disease. People tend to choose EMs, which are non-stigmatizing and which seem to help explain and rationalize their individual concerns. The frequent presence of multiple and often contradictory EMs, held simultaneously, suggest that they are pragmatic responses at coping. The results advocate a non-judgmental approach and broad based assessment of EMs of illness and their comparison with culturally appropriate beliefs, attributions and actions. The biomedical model of illness should be presented without dismissing patient beliefs or belittling local cultural explanations for illness. Clinical practice demands a negotiation of shared model of care and treatment plan between patient and physician perspectives. The diversity of patients, problems, beliefs and cultures mandates the need to educate, match, negotiate and integrate psychiatric and psychological frameworks and interventions. It calls for multifaceted and nuanced understanding of "insight" and explanatory models of illness.

Anhedonia in prolonged schizophrenia spectrum patients with relatively lower vs. higher levels of depression disorders: associations with deficits in social cognition and metacognition

This study has sought to explore whether there are at least two subtypes of anhedonia in schizophrenia: one closely linked with depression and another that occurs in the absence of depression which is related to a general paucity of internal experience. Participants were 163 adults with schizophrenia who completed assessments of depression, anhedonia, executive functioning, positive and negative symptoms, social cognition and metacognition. A cluster analysis based on participants' depression and anhedonia symptom scores produced three groups: High Depression/High Anhedonia (n=52), Low Depression/Low Anhedonia (n=52), and Low Depression/High Anhedonia (n=59). An ANCOVA and post hoc comparisons controlling for positive and negative symptoms found that the Low Depression/High Anhedonia group had poorer metacognition and social cognition than other groups. These findings point to the possibility of a subtype of anhedonia in schizophrenia, one occurring in the relative lesser levels of depression, and tied to deficits in the ability to think about oneself and others.