Metacognition in schizophrenia: correlates and stability of deficits in theory of mind and self-reflectivity

Is self-awareness necessary to have a theory of mind?

Forty years ago, Gallup proposed that theory of mind presupposes self-awareness. Following Humphrey, his hypothesis was that individuals can infer the mental states of others thanks to the ability to monitor their own mental states in similar circumstances. Since then, advances in several disciplines, such as comparative and developmental psychology, have provided empirical evidence to test Gallup's hypothesis. Herein, we review and discuss this evidence.

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

BACKGROUND

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

AIMS

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

MATERIALS & METHODS

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

RESULTS

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

DISCUSSION

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

CONLCLUSION

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

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

BACKGROUND

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

STUDY DESIGN

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

STUDY RESULTS

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

CONCLUSIONS

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

Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach

Background

Treatment guidelines for psychosis recommend offering psychotherapy already in the acute illness phase. However, there is a lack of available interventions adapted to the specific needs and key change mechanisms of inpatients experiencing severe symptoms and crisis. In this article we outline the scientific development process of a needs-oriented and mechanism-based group intervention for acute psychiatric inpatients with psychosis (MEBASp).

Methods

To guide our intervention design, we used Intervention Mapping (IM), a six-step framework for developing evidence-based health interventions that consisted of an extensive literature review, an in-depth problem definition and needs analysis, the modeling of change mechanisms and outcomes and the production of an intervention prototype.

Results

Our low-threshold modularized group intervention consists of nine stand-alone sessions (two per week) within three modules and targets different aspects of metacognitive and social change mechanisms. Module I and II aim to reduce acute symptoms by fostering cognitive insight, Module III focuses on reducing distress via cognitive defusion. Therapy contents are adapted from existing metacognitive treatments such as the Metacognitive Training and presented in a destigmatizing, simply understandable and experience-oriented way.

Conclusion

MEBASp is currently evaluated in a single-arm feasibility trial. Using a systematic and rigorous development methodology and providing a detailed description of the development steps demonstrated to be invaluable in improving the intervention's scientific foundation, validity, and replicability for similar research.

Relationship between cognition and suicidal behavior in recent-onset psychosis

Suicidal behavior (SB) is common in first-episode psychosis (FEP), and cognitive impairment has also been described in psychosis. Despite well-established risk factors for SB in psychosis, the role of cognition and insight remains unclear. This study aimed to explore the relationship between history of SB and cognition in recent-onset FEP, distinguishing between neurocognition, social cognition, and metacognition, and including cognitive insight (CI) as a metacognitive variable. The sample consisted of 190 participants with recent-onset FEP recruited from two multicentric studies. Two groups were formed based on presence/absence of a history of SB. Demographic, clinical, and cognitive data were compared by group, including significance level adjustments and size effect calculation. No differences were found regarding demographic, clinical, neurocognitive, social cognition, and metacognitive variables except for CI (18.18 ± 4.87; t = -3.16; p = 0.0020; d = -0.635), which showed a medium effect size. Small to medium effect size were found for attributional style (externalizing bias) (1.15 ± 3.94; t = 2.07; d = 0.482), theory of mind (ToM) (1.73 ± 0.22; t = 2.04; d = -0.403), jumping to conclusions bias (JTC) (23.3 %; X² = 0.94; V = 0.178). In recent-onset psychosis, neurocognitive functioning was not related to the history of SB. As novelty, individuals with previous SB showed higher CI. Also, regarding social cognition and metacognition, individuals with prior SB tended to present extremely low externalizing bias, better ToM, and presence of JTC.

An evolutionary account of impairment of self in cognitive disorders

Recent research has proposed that certain aspects of psychosis, as experienced in, e.g., schizophrenia (SCZ), but also aspects of other cognitive conditions, such as autism spectrum disorders (ASD) and synesthesia, can be related to a shattered sense of the notion of self. In this paper, our goal is to show that altered processing of self can be attributed to an abnormal functioning of cortico-striatal brain networks supporting, among other, one key human distinctive cognitive ability, namely cross-modality, which plays multiple roles in human cognition and language. Specifically, our hypothesis is that this cognitive mechanism sheds light both on some basic aspects of the minimal self and on some aspects related to higher forms of self, such as the narrative self. We further link the atypical functioning in these conditions to some recent evolutionary changes in our species, specifically, an atypical presentation of human self-domestication (HSD) features. In doing so, we also lean on previous work concerning the link between cognitive disorders and language evolution under the effects of HSD. We further show that this approach can unify both linguistic and non-linguistic symptoms of these conditions through deficits in the notion of self. Our considerations provide further support for the hypothesis that SCZ and ASD are diametrically opposed cognitive conditions, as well for the hypothesis that their etiology is associated with recent human evolution, leading to a deeper understanding of the causes and symptoms of these disorders, and providing new cues, which can be used for an earlier and more accurate diagnostics.

Impaired sense of agency and associated confidence in psychosis

The Sense of Agency (SoA), our sensation of control over our actions, is a fundamental mechanism for delineating the Self from the environment and others. SoA arises from implicit processing of sensorimotor signals as well as explicit higher-level judgments. Psychosis patients suffer from difficulties in the sense of control over their actions and accurate demarcation of the Self. Moreover, it is unclear if they have metacognitive insight into their aberrant abilities. In this pre-registered study, we examined SoA and its associated confidence judgments using an embodied virtual reality paradigm in psychosis patients and controls. Our results show that psychosis patients not only have a severely reduced ability for discriminating their actions but they also do not show proper metacognitive insight into this deficit. Furthermore, an exploratory analysis revealed that the SoA capacities allow for high levels of accuracy in clinical classification of psychosis. These results indicate that SoA and its metacognition are core aspects of the psychotic state and provide possible venues for understanding the underlying mechanisms of psychosis, that may be leveraged for novel clinical purposes.

Mediating role for metacognitive processes in the relationship between schizotypy and anxiety and depression symptoms

Introduction: Depression and anxiety symptoms are highly prevalent in schizophrenia-spectrum disorders and are commonly associated with schizotypy in non-clinical samples. However, it remains unclear what factors could be contributing to the relationships between schizotypy and anxiety and depression symptoms. Using path analysis, we explored the complex interplay between schizotypy, metacognitive beliefs, cognitive insight, and symptoms of emotional distress.Methods: Self-report data of schizotypy, metacognitive beliefs, cognitive insight, depression, and anxiety symptoms were collected from 344 participants from a predominantly student sample.Results: Path analysis confirmed unique associations between schizotypy dimensions, metacognitive beliefs, and cognitive insight. Furthermore, negative beliefs about worry mediated the link between the schizotypy dimensions, unusual experiences, cognitive disorganisation, and introvertive anhedonia and both depression and anxiety symptoms. Lack of cognitive confidence also mediated the relationship between cognitive disorganisation and depression symptoms. Finally, the cognitive insight subcomponent self-reflectiveness mediated the relationship between unusual experiences and cognitive disorganisation and anxiety.Conclusions: This study significantly furthers our understanding of the complex relationship between schizotypy, metacognitive processes, and emotional distress. Our findings also provide support for interventions which modify metacognitive beliefs and self-reflectiveness, which may prove beneficial for treatment in clinical settings.

Patients and physician’s self-assessment regarding clinical stability in severe mental disorders: a cross-sectional study

ABSTRACT Objective This study explores the relationship between patients’ self-assessment and physicians’ evaluation regarding clinical stability. Methods This cross-sectional study was carried out at the general outpatient clinic of the Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB-UFRJ) in a large sample (1,447) of outpatients, of which 67.9% were patients with severe mental disorders (SMD). We collected information using a structured questionnaire developed for this purpose, filled in by the patient’s physician. Clinical stability was assessed by means of five psychiatric instability criteria and by the physician’s global clinical impression over the six previous months. The patients’ self-assessment was based on a question about how they evaluated their health status: stable/better, worse, does not know. For the analyses, patients’ self-evaluation was considered as our standard. Results The sample was composed of 824 (57%) women with an average age of 49 years. The most prevalent diagnoses within the SMD category corresponded to 937 patients, of whom 846 (90.3%) assessed themselves as stable/better. The physicians’ evaluations agreed more with patients with bipolar disorders and less with schizophrenics regarding stability. As for patients with depressive disorder, physicians agreed more with them regarding instability. Conclusion The data analysis confirms our hypothesis that the self-assessment made by patients with SMD was accurate regarding their health condition, and that the self-assessment made by patients who considered themselves stable agree with the physicians’ evaluation.

Measuring Emotional Awareness in Patients With Schizophrenia and Schizoaffective Disorders

The ability to mentalize (i.e., to form representations of mental states and processes of oneself and others) is often impaired in people with schizophrenia spectrum disorders. Emotional awareness (EA) represents one aspect of affective mentalizing and can be assessed with the Levels of Emotional Awareness Scale (LEAS), but findings regarding individuals with schizophrenia spectrum disorders are inconsistent. The present study aimed at examining the usability and convergent validity of the LEAS in a sample of N = 130 stabilized outpatients with schizophrenia or schizoaffective disorders. An adequacy rating was added to the conventional LEAS rating to account for distortions of content due to, for example, delusional thinking. Scores of the patient group were compared with those of a matched healthy control sample. Correlation with symptom clusters, a self-report measure of EA, a measure of synthetic metacognition (MAS-A-G), and an expert rating capturing EA from the psychodynamic perspective of psychic structure (OPD-LSIA) were examined. Regarding self-related emotional awareness, patients did not score lower than controls neither in terms of conventional LEAS nor in terms of adequacy. Regarding other-related emotional awareness, however, patients showed a reduced level of adequacy compared to controls whereas no such difference was found for conventional LEAS scores. Higher conventional LEAS scores were associated with fewer negative symptoms, and higher structural integration of self-perceptions measured by the OPD-LSIA. Higher adequacy of responses correlated with fewer symptoms of disorganization as well as excitement, higher scores of self-reflection on the MAS-A-G as well as self- and object-perception and internal and external communication as measured by the subscales of the OPD-LSIA. Findings suggest that the LEAS might not be sensitive enough to detect differences between mildly symptomatic patients with schizophrenia or schizoaffective disorders and healthy controls. However, LEAS ratings are still suitable to track intraindividual changes in EA over time. Observing the adequacy of patients’ responses when using the LEAS may be a promising way to increase diagnostical utility and to identify patterns of formal and content-related alterations of mentalizing in this patient group. Methodological indications for future studies are discussed.

[Metacognitive deficit in schizophrenia: Characteristics and links]

OBJECTIVES

Research indicates that many patients with schizophrenia experience deficits in metacognitive capacity defined as the ability to form complex representations of themselves and others. The aim of the current study was to assess metacognitive deficit in patients with schizophrenia. These variables were collected together with many other sociodemographic, clinical and therapeutic data.

METHODS

We conducted a descriptive and analytical cross-sectional study in the psychiatry department at the Hedi Chaker University Hospital in Sfax (Tunisia). Patients were in a non-acute phase, defined by the absence of any psychiatric symptoms during the last four weeks, also, no changes in medication during the previous month had been required. An informed written consent was obtained, following which patients completed questionnaires assessing sociodemographic and clinical data during structured interviews. Symptoms and severity of the illness were assessed using the Positive and Negative Symptoms Scale (PANSS). Insight was assessed using the Insight Scale (Q8). In addition, the Metacognition Assessment Scale-Abbreviated (MAS-A) was used to assess metacognitive capacities. The MAS-A contains four dimensions: self-reflectivity, awareness of the mind of others, decentration, and mastery. Higher scores reflect an ability to effectively respond to psychological challenges on the basis of psychological knowledge.

RESULTS

We recruited 74 adults with schizophrenia disorder. The diagnosis was with DSM5. Their average age was 45 years (SD=9.84 years) with a sex ratio (M/F) of 1.552. Nineteen patients (25.5%) were married, and low educational level was present in 43% of cases. Forty patients (54%) were unemployed. Metacognitive deficit was detected in all the patients. They had low levels in all four dimensions of metacognition. The most affected dimension in our series was "Mastery". All patients had an overall insight score less than six (the average score was 2.73) with poor awareness in 62% of patients. The main factors correlated with metacognitive deficit were: occupational inactivity (P-0.015), Primary education level (P=0.045), tobacco consumption (P=0.002), low insight (P-0.001), negative symptomatology (P<10-3) and the use of first generation of antipsychotics (P=0.003). The multivariate analysis showed that three factors (occupational inactivity, low insight and the presence of negative symptomatology) were predictors of metacognitive deficits.

CONCLUSION

Based on our results, occupational inactivity, negative symptomatology and low insight are predictors of metacognitive deficit in schizophrenia. Specific therapeutics should be proposed to act on these factors. A metacognitive training program, tailored to this vulnerable population, is a priority to improve their quality of life.

Overestimation of volatility in schizophrenia and autism? A comparative study using a probabilistic reasoning task

BACKGROUND AND OBJECTIVES

A plethora of studies has investigated and compared social cognition in autism and schizophrenia ever since both conditions were first described in conjunction more than a century ago. Recent computational theories have proposed similar mechanistic explanations for various symptoms beyond social cognition. They are grounded in the idea of a general misestimation of uncertainty but so far, almost no studies have directly compared both conditions regarding uncertainty processing. The current study aimed to do so with a particular focus on estimation of volatility, i.e. the probability for the environment to change.

METHODS

A probabilistic decision-making task and a visual working (meta-)memory task were administered to a sample of 86 participants (19 with a diagnosis of high-functioning autism, 21 with a diagnosis of schizophrenia, and 46 neurotypically developing individuals).

RESULTS

While persons with schizophrenia showed lower visual working memory accuracy than neurotypical individuals, no significant group differences were found for metamemory or any of the probabilistic decision-making task variables. Nevertheless, exploratory analyses suggest that there may be an overestimation of volatility in subgroups of participants with autism and schizophrenia. Correlations revealed relationships between different variables reflecting (mis)estimation of uncertainty, visual working memory accuracy and metamemory.

LIMITATIONS

Limitations include the comparably small sample sizes of the autism and the schizophrenia group as well as the lack of cognitive ability and clinical symptom measures.

CONCLUSIONS

The results of the current study provide partial support for the notion of a general uncertainty misestimation account of autism and schizophrenia.

Sustained antipsychotic effect of metacognitive training in psychosis: A randomized-controlled study

Persistent psychotic symptoms represent a major challenge for psychiatric care. Basic research has shown that psychotic symptoms are associated with cognitive biases. Metacognitive training (MCT) aims at helping patients to become aware of these biases and to improve problem-solving. Fifty-two participants fulfilling diagnostic criteria of schizophrenia or schizoaffective disorders and persistent delusions and stabilized antipsychotic medication were enrolled in this study. Following baseline assessment patients were randomized either to treatment as usual (TAU) conditions or TAU + MCT. The intervention consisted of eight weekly 1-hour sessions (maximum: 8 hours). Participants were assessed at 8 weeks and 6-months later by blind assessors. Participants were assessed with the Psychotic Symptoms Rating Scales (PSYRATS) and the positive subscale of the PANSS. Between-group differences in post- and pre-test values were significant at a medium effect size in favor of the MCT for the PSYRATS delusion scale and the positive scale of the PANSS both at post and follow-up. The results of this study indicate that MCT training has a surplus antipsychotic effect for patients suffering from schizophrenia-related disorders who demonstrate only a partial response to antipsychotic treatment and that the effect of the intervention persists for at least 6 months after the intervention.

Aggressive behavior and metacognitive functions: a longitudinal study on patients with mental disorders

BACKGROUND

Metacognitive functions play a key role in understanding which psychological variables underlying the personality might lead a person with a severe mental disorder to commit violent acts against others. The aims of this study were to: (a) investigate the differences between patients with poor metacognitive functioning (PM group) and patients with good metacognitive functioning (GM group) in relation to a history of violence; (b) investigate the differences between the two groups in relation to aggressive behavior during a 1-year follow-up; and (c) analyze the predictors of aggressive behavior.

METHODS

In a prospective cohort study, patients with severe mental disorders with and without a lifetime history of serious violence were assessed with a large set of standardized instruments and were evaluated bi-monthly with MOAS in order to monitor any aggressive behavior. The total sample included 180 patients: 56% outpatients and 44% inpatients, and the majority were male (75%) with a mean age of 44 (± 9.8) years, and half of them had a history of violence. The sample was split into two groups: poor metacognition (PM) group and good metacognition (GM) group, according to MAI evaluation scores.

RESULTS

The PM patients reported a history of violence more frequently than GM patients, during the 1-year follow-up, but no differences between groups in aggressive and violent behavior were found. The strongest predictors of aggressive behavior were: borderline and passive-aggressive personality traits and a history of violence, anger, and hostility. The metacognitive functions alone did not predict aggressive behavior, but metacognitive functions interacted with hostility and angry reactions in predicting aggressive behavior.

CONCLUSIONS

This study led to some important conclusions: (a) some aspects closely related to violence are predictive of aggressive behavior only in patients with poor metacognition, thus good metacognition is a protective factor; (b) poor metacognition is associated with a history of violence, which in turn increases the risk of committing aggressive behavior.

Metacognition strengthens the association between neurocognition and attenuated psychosis syndrome: Preliminary evidence from a pilot study among treatment-seeking versus healthy adolescents

BACKGROUND

In a pilot study, we assessed the potential value of deficits at the metacognitive versus the neurocognitive level of functioning for identifying adolescents with attenuated psychotic syndrome (APS).

METHOD

Twenty-two treatment-seeking adolescents with APS, 42 treatment-seeking comparisons, and 34 age-matched healthy comparisons were evaluated using the Prodromal Questionnaire, the Structured Interview for Prodromal Syndromes, and the Mood and Anxiety Symptom Questionnaire. Neurocognitive and metacognitive functioning were assessed in two non-social (verbal memory and executive functioning) and two social (facial emotion perception and theory of mind) cognitive domains. In addition to the standard neurocognitive administration of the tasks, subjects were asked to rate their confidence level on each answer and to choose whether they wanted it "counted" toward their overall task performance score on the task. Choices were rewarded.

RESULTS

As hypothesized, APS among treatment-seeking adolescents was more strongly associated with impaired neurocognition than with impaired metacognition. Likewise, as hypothesized, impaired metacognition was shown to significantly improve the APS prediction beyond the contribution of impaired neurocognition alone, even after controlling for general intellectual ability, negative symptoms, social functioning, and depression.

CONCLUSIONS

These results suggest that metacognitive monitoring and control play a strengthening role in the association between neurocognition and APS. One possible explanation is that metacognition serves as an indicator of insight into the condition, accounting for differences in insight not explained by neurocognition alone. However, further research with larger samples that include non-treatment seeking individuals, established measures of insight, and follow-up data is required to assess this possibility.

Basic self-disturbance, neurocognition and metacognition: A pilot study among help-seeking adolescents with and without attenuated psychosis syndrome

AIM

The goal of this pilot study was to assess the association between basic self-disturbance (SD) and deficits in neurocognitive and metacognitive functioning among help-seeking adolescents with and without attenuated psychosis syndrome (APS).

METHODS

Sixty-one non-psychotic, help-seeking adolescents (age 13-18) were assessed with the examination of anomalous self-experience, the structured interview for prodromal syndromes and a new metacognitive approach to neurocognitive assessment applied to two non-social (executive functions and verbal memory) and two social (theory of mind and emotion recognition) domains. After each answer, subjects were also requested to indicate their level of confidence in the answer and to decide whether they desired it to be "counted" toward their total score on the task. Each volunteered answer earned a 5-cent gain if correct, but an equal fine if wrong.

RESULTS

As hypothesized, metacognitive monitoring and control had a significant contribution to the prediction of SD over and above neurocognitive functioning and attenuated psychotic symptoms. However, the direction of this association was positive rather than negative. Also, inconsistent with or hypothesis, it was not moderated by the presence of APS.

CONCLUSIONS

These pilot results provide preliminary support a modest association between SD and metacognition, which is not reducible to neurocognition and APS. In addition, they raise an intriguing possibility regarding metacognitive monitoring and control being indicators of hyper-reflectivity that characterizes individuals with SD. However, further research with larger samples and high-stress assessment conditions are needed to assess this possibility.

The Dream and the Image: Creative Transformations in Psychoanalytic Space

Psychoanalysis is a transformational process through which meanings become visible and foreclosed identity may be further constituted. Winnicott (1971) marks the crucial developmental function of the relationship that is good enough to tolerate the separateness of the other. The analyst's ability to "take the transference" enables the patient to locate himself in relation to another mind and being in ways that did not happen sufficiently in childhood. This process requires the signification of personal meanings that can become consensual without subverting one's own becoming in the process. The dream provides idiosyncratic images that can demarcate conceptual space in ways that can enable the individual to move from the sign to the symbol; from what Kleinians term the symbolic equation, to the symbol proper, the domain of language and consensual meanings. I describe a case in which one young man used his dreams as a way of moving from a universe in which meanings could not be made into one in which he could build meanings in relation to his own experience and ideas.

Exploring the use of the Hinting Task in first-episode psychosis

INTRODUCTION

The aim of the study was to elucidate the association between performance-related neurocognitive abilities and Theory of Mind (ToM) as measured by the Hinting Task (HT) performance and investigate the psychometric properties of the HT for use in First-Episode Psychosis (FEP).

METHODS

Cross-sectional data of 132 participants with FEP, aged 15-25 years, enrolled in a randomised controlled trial of vocational intervention, were analysed. A comprehensive cognitive battery including social cognitive and neurocognitive measures, a social and occupational functioning measure and psychopathological measures, were used. Psychometric properties were measured through bivariate correlations and associations with neurocognitive domains were assessed through hierarchical regression.

RESULTS

Low convergent validity of the HT with other ToM measures, moderate discriminant validity with an emotion recognition task, low predictive validity with social and occupational functioning, and high internal consistency were revealed. HT performance was significantly associated with verbal reasoning and verbal memory.

CONCLUSION

Results provide preliminary evidence of low convergent validity and moderate discriminant validity of the HT in FEP, and the influence of verbal reasoning and verbal memory on HT performance, indicating that caution is warranted when employing the HT as a screening tool in isolation for detection of ToM deficits in FEP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The self-concept of person with chronic schizophrenia in Japan

AIMS

People with schizophrenia have some problems in terms of function of consciousness of the self. Therefore, what they are conscious of themselves remains unclear. The aim of this study was to elucidate the self-concept of Japanese with schizophrenia.

METHODS

We interviewed Japanese with a diagnosis of schizophrenia and analyzed the interview transcription by means of qualitative content analysis.

RESULTS

Qualitative content analysis yielded 2001 meaning units and 53 codes from the transcription. The codes were classified into 6 categories: Present Cognition and Definition of the Self, Feeling Towards and Evaluation of the Self, The Self That Is Seen by Others, The Past Self-Image, The Self-Image About Possibility and the Future, and How I Should Be and the Ideal Self.

CONCLUSION

One of the categories, Feeling Towards and Evaluation of the Self, means self-confidence, pride, and self-acceptance. In this category, some participants could not accept themselves because they felt "this is not the true self." Considering our finding and the background in Japan, psychiatric hospitalization is long, while hospitalized people with schizophrenia might be aware of the negative stereotypes about them. Therefore, staff should more focus on what people with schizophrenia want to be in their new life and develop new approaches to enhance rebuilding new goal in life and reduce the self-stigma.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A longitudinal study of cognitive insight and cortical thickness in first-episode psychosis

Among individuals with psychosis, those with poor cognitive insight (lower Self-Reflectiveness, higher Self-Certainty) show volumetric reductions in cortical structure. We evaluated whether changes in cognitive insight are associated with progressive changes in cortical structure in first-episode psychosis (FEP) and control subjects. Beck Cognitive Insight Scale ratings and magnetic resonance imaging scans were acquired at baseline for 130 FEP and 52 controls, 59 FEP and 28 controls at 1-year, and 53 FEP and 20 controls at 2-years. Cortical thickness was computed across scans and analyzed with linear mixed models. At baseline, groups did not differ on Self-Reflectiveness or Self-Certainty. At baseline, higher Self-Reflectiveness significantly correlated with thinner right occipital cortex in FEP, and higher Self-Certainty was significantly negatively correlated with cortical thickness in left posterior cingulate in controls. Longitudinal analysis showed that Self-Reflectiveness and Self-Certainty did not change over time in either group. Interestingly, the lack of change in cognitive insight aligned with longitudinal cortical thickness results, where no interaction effects were seen with cortical thickness between time and either Self-Reflectiveness or Self-Certainty. Exploratory analyses with a reduced threshold found that in FEP, across all time-points, higher Self-Certainty associated with thinner cortex in left posterior cingulate/precuneus. Results suggest that the posterior cingulate may be a common neural correlate for Self-Certainty in FEP and non-clinical subjects.

Relationship between insight and theory of mind in schizophrenia: A meta-analysis

Poor insight in schizophrenia has been associated with executive dysfunction and deficits in general cognitive ability. The overall outcome of available neurocognitive studies suggests that there is a significant but modest relationship between cognitive deficits and poor insight in schizophrenia. However, social cognitive abilities, particularly, theory of mind (ToM), might also play a role in poor insight in schizophrenia. A novel meta-analysis of the relationship between ToM and insight in schizophrenia was conducted. Current meta-analysis included 16 studies including 1085 patients with schizophrenia-spectrum disorders. There was a significant association between ToM and clinical insight (r=0.28, CI=0.20-0.36). By contrast, there was no significant relationship between ToM and cognitive insight. Current findings suggest that there is a small but significant relationship between ToM and clinical insight in schizophrenia. ToM impairment is one of the factors contributing to poor insight in schizophrenia.

Aspects of Theory of Mind that attenuate the relationship between persecutory delusions and social functioning in schizophrenia spectrum disorders

BACKGROUND AND OBJECTIVES

Despite the apparent relevance of persecutory delusions to social relationships, evidence linking these beliefs to social functioning has been inconsistent. In this study, we examined the hypothesis that theory of mind moderates the relationship between persecutory delusions and social functioning.

METHODS

88 adults with schizophrenia or schizoaffective disorder were assessed concurrently for social functioning, severity of persecutory delusions, and two components of theory of mind: mental state decoding and mental state reasoning. Mental state decoding was assessed using the Eyes Test, mental state reasoning using the Hinting Task, and social functioning assessed with the Social Functioning Scale. Moderation effects were evaluated using linear models and the Johnson-Neyman procedure.

RESULTS

Mental state reasoning was found to moderate the relationship between persecutory delusions and social functioning, controlling for overall psychopathology. For participants with reasoning scores in the bottom 78th percentile, persecutory delusions showed a significant negative relationship with social functioning. However, for those participants with mental state reasoning scores in the top 22nd percentile, more severe persecutory delusions were not significantly associated with worse social functioning. Mental state decoding was not a statistically significant moderator.

LIMITATIONS

Generalizability is limited as participants were generally men in later phases of illness.

CONCLUSIONS

Mental state reasoning abilities may buffer the impact of persecutory delusions on social functioning, possibly by helping individuals avoid applying global beliefs of persecution to specific individuals or by allowing for the correction of paranoid inferences.

Cognitive Correlates of Different Mentalizing Abilities in Individuals with High and Low Trait Schizotypy: Findings from an Extreme-Group Design

Mentalizing or Theory of Mind (ToM) deficits in schizophrenia have been studied to great extent, but studies involving samples of trait schizotypy yield ambiguous results. Executive functions like cognitive inhibition, cognitive flexibility, and agency are all prerequisites of mentalizing, and it is assumed that the impairment of these functions contributes to ToM deficits in schizophrenia. Whether these impairments influence the ToM performance of people with high trait schizotypy remains unclear. Although impaired self-agency has repeatedly been identified in people with schizotypy, its role in mentalizing is yet to be investigated. The main aim of this study was to explore whether deficits in cognitive and affective ToM can be found in high trait schizotypy, and to identify in what way these deficits are related to the positive and negative dimensions of schizotypy. The secondary aim was to examine whether these deficits correlate with executive functions. Based on the dimensional view of the schizophrenia spectrum, an extreme-group design was applied to non-clinical volunteers demonstrating high (N = 39) and low (N = 47) trait schizotypy. Affective and cognitive ToM were investigated using the Movie for Assessment of Social Cognition, a sensitive and video-based measurement. Cognitive inhibition was assessed using the Stroop Test, and cognitive flexibility was analyzed using the Trail-Making Test. Agency was measured using a computerized self-agency paradigm. Participants in the high-schizotypy group performed significantly worse in the affective ToM task (d = 0.79), and their overall ToM performance was significantly impaired (d = 0.60). No between-group differences were found with regards to cognitive ToM, executive functions, and self-agency. Cognitive flexibility correlated negatively with positive schizotypy, and contributed to a worse overall and affective ToM. Impaired cognitive inhibition contributed to undermentalizing-type errors. It was found that non-clinical participants with high trait (positive) schizotypy - especially those with slight executive-function deficits - may have difficulties in understanding the emotional state of others and consequently in functioning in social situations.

Can cognitive insight predict symptom remission in a first episode psychosis cohort?

BACKGROUND

The outcome of first episode psychosis (FEP) is highly variable and difficult to predict. Cognitive insight measured at illness onset has previously been found to predict psychopathology 12-months later. The aims of this study were to examine whether the prospective relationship between cognitive insight and symptom severity is evident at four-years following FEP and to examine some psychological correlates of cognitive insight.

METHODS

FEP participants (n = 90) completed the Beck Cognitive Insight Scale (BCIS) at illness onset, and associations between BCIS scores with symptom severity outcomes (4-years after FEP) were assessed. The BCIS scales (self-reflectiveness and self-certainty) were examined as a composite score, and individually compared to other cognitive measures (IQ and jumping to conclusions (JTC) bias).

RESULTS

Regression analyses revealed that the cognitive insight composite did not predict 4-year symptom remission in this study while the self-reflection subscale of the BCIS predicted severity of symptoms at 4-years. Self-certainty items of the BCIS were not associated with symptom severity. Significant correlations between the JTC bias, self-certainty and IQ were found, but self-reflection did not correlate with these other cognitive measures.

CONCLUSIONS

Self-reflective capacity is a more relevant and independent cognitive construct than self-certainty for predicting prospective symptom severity in psychosis. Improving self-reflection may be a useful target for early intervention research.

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

OBJECTIVE

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

DESIGN

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

METHOD

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

RESULTS

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

CONCLUSION

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

PRACTITIONER POINTS

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

Evidence for Trait Related Theory of Mind Impairment in First Episode Psychosis Patients and Its Relationship with Processing Speed: A 3 Year Follow-up Study

This study aimed to confirm whether first-episode psychosis patients present a stable trait impairment in theory of mind (ToM) and to examine the potential relationship between ToM and clinical symptomatology and neurocognition. Patients with a first episode of psychosis (N = 160) and healthy controls (N = 159) were assessed with an extensive neuropsychological test battery, which included a mental state decoding task known as “The Reading the Mind in the Eyes” (Eyes test), at baseline and reassessed after 1 and 3 years. The clinical group performed below healthy controls on the Eyes test while not showing test-retest differences between baseline and follow-up administrations. Analyses revealed age, education and premorbid IQ as potential moderators. Poorer performance on the Eyes test was not linked to clinical symptomatology but was associated with greater neurocognitive deficit, particularly related to processing speed. The persistence of ToM deficits in patients suggests that there are trait related metalizing impairments in first episode psychosis. This study shows the influence of processing speed and moderator variables on efficient ToM.

Theory of mind correlates with clinical insight but not cognitive insight in patients with schizophrenia

Research on the relationship between insight and social cognition, in particular Theory of Mind (ToM), in schizophrenia has yielded mixed findings to date. Very few studies, however, have assessed both clinical insight and cognitive insight when examining their relationships with ToM in schizophrenia. The current study thus investigated the relationship between clinical insight, cognitive insight, and ToM in a sample of 56 patients with schizophrenia and 30 healthy controls. Twenty-seven patients were classified as low in clinical insight according to their scores on the 'insight' item (G12) of the Positive and Negative Syndrome Scale (PANSS). Moreover, cognitive insight and ToM were assessed with the Beck Cognitive Insight Scale (BCIS) and the Yoni task, respectively. The results indicated that patients with poor clinical insight performed worse on tasks of second-order cognitive and affective ToM, while the ToM performance of patients with high clinical insight was equivalent to that of healthy controls. Furthermore, while clinical insight was correlated with ToM and clinical symptoms, cognitive insight did not correlate with clinical insight, ToM, or clinical symptoms. Clinical insight thus appears to be an important factor related to ToM in schizophrenia.

Metacognitive training for young subjects (MCT young version) in the early stages of psychosis: Is the duration of untreated psychosis a limiting factor?

OBJECTIVES

The treatment program 'Metacognitive training for patients with schizophrenia' (MCT) addresses cognitive biases assumed to play a crucial role in the pathogenesis of delusions (e.g., jumping to conclusions, theory of mind deficits). The aim of our study was to examine the effectiveness and the feasibility of this intervention targeted to early phases of psychosis (MCT young version).

DESIGN

An experimental design included two groups of subjects on the basis of their duration of untreated psychosis (DUP) 'short' (less or equal than 12 months) and 'long' DUP (longer than 12 months), assessed at baseline and after the 4-month intervention.

METHODS

Fifty-six young subjects affected by early psychosis were assessed on psychopathology, social functioning, neurocognitive, and metacognitive measures. The primary outcome was the reduction of psychopathology. Secondary outcomes included reduction of cognitive and emotional dysfunction and improvement of social functioning.

RESULTS

At the end of the 4-month MCT, both groups showed significant improvements in many variables: positive symptoms, cognitive functions, as verbal memory, attention and mental flexibility, and metacognitive functions, as cognitive insight. Significant and positive changes were found in theory of mind abilities and social perception.

CONCLUSIONS

The difference in DUP between the two groups of young subjects of our sample did not seem to influence the intervention outcomes, still taking into account that the average difference between the two groups in terms of DUP is 12.6 months.

PRACTITIONER POINTS

Metacognition refers to the general ability 'to think about thinking,' that is, the ability to think about one's mental state and the mental states of others. Persons with schizophrenia experience different metacognitive impairments. The metacognitive training for patients with schizophrenia - young version can be applied to young people affected by psychosis and seems to improve symptomatology, social functioning, cognitive, and metacognitive abilities, independently by their Duration of Untreated Psychosis over a 2-year period.

A novel 3q29 deletion associated with autism, intellectual disability, psychiatric disorders, and obesity

Copy number variation (CNV) has been associated with a variety of neuropsychiatric disorders, including intellectual disability/developmental delay (ID/DD), autism spectrum disorder (ASD), and schizophrenia (SCZ). Often, individuals carrying the same pathogenic CNV display high clinical variability. By array-CGH analysis, we identified a novel familial 3q29 deletion (1.36 Mb), centromeric to the 3q29 deletion region, which manifests with variable expressivity. The deletion was identified in a 3-year-old girl diagnosed with ID/DD and autism and segregated in six family members, all affected by severe psychiatric disorders including schizophrenia, major depression, anxiety disorder, and personality disorder. All individuals carrying the deletion were overweight or obese, and anomalies compatible with optic atrophy were observed in three out of four cases examined. Amongst the 10 genes encompassed by the deletion, the haploinsufficiency of Optic Atrophy 1 (OPA1), associated with autosomal dominant optic atrophy, is likely responsible for the ophthalmological anomalies. We hypothesize that the haploinsufficiency of ATPase type 13A4 (ATP13A4) and/or Hairy/Enhancer of Split Drosophila homolog 1 (HES1) contribute to the neuropsychiatric phenotype, while HES1 deletion might underlie the overweight/obesity. In conclusion, we propose a novel contiguous gene syndrome due to a proximal 3q29 deletion variably associated with autism, ID/DD, psychiatric traits and overweight/obesity.

Theory of Mind in Schizophrenia: Associations With Clinical and Cognitive Insight Controlling for Levels of Psychopathology

Poor insight in schizophrenia is a risk factor for both poor outcomes and treatment adherence. Accordingly, interest in identifying causes of poor insight has increased. This study explored whether theory of mind (ToM) impairments are linked to poor clinical and cognitive insight independent of psychopathology. Participants with schizophrenia (n = 37) and control subjects (n = 40) completed assessments of ToM with the Hinting Task and the Brüne Picture Sequencing Task, clinical insight and psychopathology with the Positive and Negative Syndrome Scale, and cognitive insight with the Beck Cognitive Insight Scale. Results indicated that the schizophrenia group had greater impairments in ToM relative to control subjects. In the schizophrenia group, the Hinting Task performance was related to both cognitive and clinical insight, with only the relationship with cognitive insight persisting after controlling for psychopathology. Picture Sequencing Task performance was related to cognitive insight only. Future research directions and clinical implications are discussed.

Implicit and explicit self-related processing in relation to insight in patients with schizophrenia

INTRODUCTION

Self-related processing (SRP) has been associated with clinical and cognitive insight. We investigated the relationship between implicit SRP (ISRP) and explicit SRP (ESRP) and insight. We first hypothesised that impaired insight is associated with the extent to which implicit feedback is incorporated in the self-image and subsequently influences behaviour. Second, we hypothesised that impaired insight is related to the way patients handle explicit feedback and use it to guide subsequent behaviour, therefore we expected to find a positive relationship between level of insight and the explicit self-related processing task.

METHODS

Thirty-four schizophrenia patients and 23 healthy controls participated in the study. Patients were assessed with the Schedule for the Assessment of Insight-Expanded and the Beck Cognitive Insight Scale. ISRP was measured using a working memory two-back priming task. ESRP was measured with an adapted version of the Wisconsin Card Sorting Task where patients received explicit feedback on their performance.

RESULTS

Cognitive insight, but not clinical insight, was positively associated with ISRP after implicit positive cues. Both clinical and cognitive insight were positively associated with the ability to adjust performance upon receiving explicit feedback, though cognitive insight was more strongly associated with overall task performance.

CONCLUSIONS

Priming with positive cues improved performance on a working memory task in patients with good cognitive insight, but worsened performance in patients with impaired cognitive insight. Furthermore, our findings suggest that the ability to adequately use feedback may be a specific capacity that is related to insight.

Theory of Mind Impairments in Youth at Clinical High Risk of Psychosis

OBJECTIVE

The normal maturational processes of theory of mind (ToM) capacity are ongoing during adolescence and even early adulthood. However, research has shown that ToM ability also declines among adults suffering from prodromal psychotic experiences. The goal of this study was to investigate the characteristics of ToM performance in youth with clinical high risk (CHR) of psychosis.

METHODS

The Reading Mind in Eyes Task (RMET), including own-race and other-race eyes, was administered to 40 CHR youth; 42 age-, gender-, and education-matched healthy controls (HCs); and 62 adult patients with schizophrenia (SZ). Nine-month follow-up data were collected from 31 CHR subjects, of whom 7 (22.6%) had made the transition to psychosis.

RESULTS

CHR youth showed significant impairment in RMET performance compared to HC youth but performed better than did SZ patients. Moreover, they were significantly slower than were HC youth in responding to the RMET, with a response time similar to that of SZ patients. In particular, they had significantly poorer accuracy in interpreting positive and neutral eye expressions compared to the HC group, but not in interpreting negative eye expressions. Preliminary follow-up data showed a trend toward significance (p = 0.079) for RMET performance between those who transitioned to psychosis and those who did not.

CONCLUSIONS

Our findings illustrate that deficits in ToM capacity, specifically the ability to interpret people's mental state from eye expressions, occur early on in prodromal psychosis in youth. Early interventions for CHR youth focusing on ToM enhancement may halt progress toward psychosis.

Differential lexical correlates of social cognition and metacognition in schizophrenia; a study of spontaneously-generated life narratives

OBJECTIVES

Social cognition and metacognition have been identified as important cognitive domains in schizophrenia, which are separable from general neurocognition and predictive of functional and treatment outcomes. However, one challenge to improved models of schizophrenia has been the conceptual overlap between the two. One tool used in previous research to develop cognitive models of psychopathology is language analysis. In this article we aimed to clarify distinctions between social cognition and metacognition in schizophrenia using computerized language software.

METHODS

Fifty-eight (n=58) individuals with schizophrenia completed the Metacognitive Assessment Scale Abbreviated and measures of social cognition using the Hinting, Eyes, BLERT and Picture Arrangement test. A lexical analysis of participants' speech using Language Inquiry and Word Count software was conducted to examine relative frequencies of word types. Lexical characteristics were examined for their relationships to social cognition and metacognition.

RESULTS

We found that lexical characteristics indicative of cognitive complexity were significantly related to level of metacognitive capacity while social cognition was related to second-person pronoun use, articles, and prepositions, and pronoun use overall. The relationships between lexical variables and metacognition persisted after controlling for demographics, verbal intelligence, and overall word count, but the same was not true for social cognition.

CONCLUSIONS

Our findings provided support for the view that metacognition requires more synthetic and complex verbal and linguistic operations, while social cognition is associated with the representation and clear identification of others.

Relationship between cognitive insight and subjective quality of life in outpatients with schizophrenia

BACKGROUND

The concept of cognitive insight refers to the cognitive processes involved in patients' re-evaluation of their anomalous experiences and of their misinterpretations. The purpose of the present study was to examine the relationship between cognitive insight and subjective quality of life in patients with schizophrenia to further shed light on the nature of cognitive insight and its functional correlates in schizophrenia.

METHODS

Seventy-one stable outpatients with schizophrenia were evaluated for cognitive insight and subjective quality of life using the Beck Cognitive Insight Scale (BCIS) and the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4). The symptoms of schizophrenia were also assessed. Pearson's correlation analysis and partial correlation analysis that controlled for the severity of symptoms were performed to adjust for the possible effects of symptoms.

RESULTS

The self-reflectiveness subscale score of the BCIS had significant positive correlations with the SQLS-R4 psychosocial domain and total SQLS-R4 scores, indicating that the higher the level of cognitive insight, the lower the subjective quality of life. In partial correlation analysis controlling for symptoms, the BCIS self-reflectiveness subscale score still had a significant correlation with the SQLS-R4 psychosocial domain score. The correlation coefficient between the BCIS self-reflectiveness and total SQLS-R4 scores was reduced to a nonsignificant statistical tendency.

CONCLUSION

The results of our study suggest that cognitive insight, particularly the level of self-reflectiveness, is negatively associated with the level of subjective quality of life in outpatients with schizophrenia and that this relationship is not wholly due to the confounding effect of symptoms. Future studies are necessary to explore possible mediating and moderating factors and to evaluate the effects of therapeutic interventions on the relationship.

Metacognitive training (MCT) for schizophrenia improves cognitive insight: a randomized controlled trial in a Chinese sample with schizophrenia spectrum disorders

Metacognitive training (MCT) is a group-based treatment program for people with schizophrenia that targets the cognitive biases thought to contribute to the pathogenesis and maintenance of delusions. Although effective in reducing the severity of delusions, the influence of MCT on cognitive insight, and its feasibility in Chinese culture, has yet to be investigated. The present randomized-controlled trial attempted to address these inconsistencies. A Chinese sample of 80 participants with schizophrenia spectrum disorders was randomized to the eight-module MCT program or continued treatment as usual (TAU). All participants were assessed using the Beck Cognitive Insight Scale, which assesses two components of cognitive insight (self-reflectiveness and self-certainty). Participants in the MCT condition subjectively rated their satisfaction with the training. Retention rates were high after four-weeks of MCT (n = 38) or TAU (n = 39). Clients randomized into the MCT condition rated the program favourably and showed significant improvements in cognitive insight (i.e., increased self-reflectiveness), relative to TAU controls, who exhibited decreases in cognitive insight at follow-up. These findings suggest that the MCT program is not only subjectively efficacious in Chinese samples, but also improves metacognitive awareness of the processes underlying delusional symptoms.

Investigating the state-like and trait-like characters of social cognition in schizophrenia: a short term follow-up study

BACKGROUND AND OBJECTIVES

Controversial findings exist in the literature regarding the state- and trait-like characters of social cognition in schizophrenia. In order to explore the relationship of social cognition with symptom severity in the present study, Theory of mind (ToM) and emotion recognition were tested in an acute phase and later in a clinically stable phase in patients.

METHODS

ToM and emotion recognition abilities were examined by using the Reading the Mind in the Eyes Test (RMET) and the Ekman 60 Faces Test (FEEST) in 43 patients with schizophrenia and 41 healthy controls. Research diagnoses were based on SCID interviews. Symptom severity in patients was assessed by the Positive and Negative Syndrome Scale (PANSS).

RESULTS

ToM and emotion recognition deficits improved in the clinically stable phase compared to relapse, but were still found to be impaired compared to healthy controls. Negative symptom severity showed strong correlation with emotion recognition and ToM at both visits.

CONCLUSIONS

Both ToM and emotion recognition fluctuated together with symptom severity, which confirmed the "state-like" component of these abilities. Our results, taken together with the findings of previous investigations show that social cognition deficits in schizophrenia have both state-like and trait-like components.

The longitudinal association between social functioning and theory of mind in first-episode psychosis

INTRODUCTION

There is some cross-sectional evidence that theory of mind ability is associated with social functioning in those with psychosis but the direction of this relationship is unknown. This study investigates the longitudinal association between both theory of mind and psychotic symptoms and social functioning outcome in first-episode psychosis.

METHODS

Fifty-four people with first-episode psychosis were followed up at 6 and 12 months. Random effects regression models were used to estimate the stability of theory of mind over time and the association between baseline theory of mind and psychotic symptoms and social functioning outcome.

RESULTS

Neither baseline theory of mind ability (regression coefficients: Hinting test 1.07 95% CI -0.74, 2.88; Visual Cartoon test -2.91 95% CI -7.32, 1.51) nor baseline symptoms (regression coefficients: positive symptoms -0.04 95% CI -1.24, 1.16; selected negative symptoms -0.15 95% CI -2.63, 2.32) were associated with social functioning outcome. There was evidence that theory of mind ability was stable over time, (regression coefficients: Hinting test 5.92 95% CI -6.66, 8.92; Visual Cartoon test score 0.13 95% CI -0.17, 0.44).

CONCLUSIONS

Neither baseline theory of mind ability nor psychotic symptoms are associated with social functioning outcome. Further longitudinal work is needed to understand the origin of social functioning deficits in psychosis.

Creativity measured by divergent thinking is associated with two axes of autistic characteristics

Creativity generally involves the conception of original and valuable ideas, and it plays a key role in scientific achievement. Moreover, individuals with autistic spectrum conditions (ASCs) tend to achieve in scientific fields. Recently, it has been proposed that low empathizing and high systemizing characterize individuals with ASCs. Empathizing is the drive to identify the mental status of other individuals and respond to it with an appropriate emotion; systemizing is the drive to analyze a system. It has been proposed that this higher systemizing underlies the scientific achievement of individuals with ASCs, suggesting the possible positive association between creativity and systemizing. However, previous findings on the association between ASCs and creativity were conflicting. Conversely, previous studies have suggested an association between prosocial traits and creativity, indicating the possible association between empathizing and creativity. Here we investigated the association between creativity measured by divergent thinking (CDT) and empathizing, systemizing, and the discrepancy between systemizing and empathizing, which is called D score. CDT was measured using the S-A creativity test. The individual degree of empathizing (empathizing quotient, EQ) and that of systemizing (systemizing quotient, SQ), and D score was measured via a validated questionnaire (SQ and EQ questionnaires). The results showed that higher CDT was significantly and positively correlated with both the score of EQ and the score of SQ but not with D score. These results suggest that CDT is positively associated with one of the characteristics of ASCs (analytical aspects), while exhibiting a negative association with another (lower social aspects). Therefore, the discrepancy between systemizing and empathizing, which is strongly associated with autistic tendency, was not associated with CDT.

Klein and Lacan meet 21st century schizoid man: fairy stories for the modern era

Melanie Klein invited us into the phenomenology of the schizoid dilemma through her depictions of the paranoid-schizoid position. By inserting his recursive arrows, Bion extended this conceptualization, showing us the folly of believing that we can ever entirely move beyond the frightening fantasies and realities of social exclusion and isolation. The 21st century has brought, along with the explosion of technology, an expulsion from the social order of many children who have found refuge from isolation and humiliation in the more accessible and less terrifying world of media and technological invention. What may look like narcissism can mask a terrible underlying schizoid failure to enter into the human race. This is the realm of fantasy run amok, where desire becomes alien and alienated such that one is haunted and hunted down by its very possibility. In this universe, conceptualizations from Klein, Bion, and Lacan help us to locate the individual who has become caught in a massive psychic retreat such that there is no subject because there are no objects. To illustrate, I describe my work with a young man who is living in a terrible "zombie zone" where people are not real and therefore are incomprehensible and terribly dangerous. The poignancy of his dilemma is heartbreaking. Perhaps that is one lesson we can still take from our old fairy tales: when one's heart can be broken by another's plight, then comes the possibility of a healing, an entry through that piercing of what had been impenetrable.

Der Beitrag subjektiver Krankheitsrepräsentationen zur Erklärung beeinträchtigter Krankheitseinsicht bei Schizophrenie

Theoretischer Hintergrund: Die Genese von Defiziten der Krankheitseinsicht bei Schizophrenie wird bisher unzureichend und teilweise widersprüchlich erklärt. Mehrfaktorielle Einsichtsmodelle, die inkonsistente Befunde integrieren, existieren kaum. Fragestellung: Kann ein typologischer Ansatz und die Erweiterung um die gesundheitspsychologische Perspektive subjektiver Krankheitskonzepte bisherige klinisch-psychiatrische Einsichtsmodelle verbessern? Methode: Für 95 Personen mit Diagnosen aus dem Schizophrenie-Spektrum wurden Krankheitseinsicht, subjektive Krankheitskonzepte, Symptomatik und Neurokognition querschnittlich erhoben. Ergebnisse: Eine einsichtige, kognitiv intakte sowie zwei uneinsichtige Subgruppen (kognitiv beeinträchtigt vs. unbeeinträchtigt) wurden clusteranalytisch identifiziert. Letztere ließ sich anhand von mehr Positivsymptomen, Bewertungen von verringerter Kontrollierbarkeit und emotionaler Bedeutung ihrer Problematik multinomial vorhersagen (R2N = .56). Schlussfolgerungen: Der Einschluss subjektiver Krankheitskonzepte in klinisch-psychiatrische Einsichtsmodelle erscheint fruchtbar. Neben einer defizitbasierten Uneinsichtigkeit lassen sich angesichts spezifischer Krankheitsbewertungen motivationale Einsichtsbarrieren vermuten.

Metacognition, social cognition, and symptoms in patients with first episode and prolonged psychoses

While it has been documented that persons with prolonged schizophrenia have deficits in metacognition and social cognition, it is less clear whether these difficulties are already present during a first episode. To explore this issue we assessed and compared metacognition using the Metacognition Assessment Scale-Abbreviated (MAS-A) and social cognition using the Eyes, Hinting and Bell-Lysaker Emotional Recognition Tests (BLERT) in participants with first episode psychosis (FEP; n=26), participants with a prolonged psychosis (n=72), and a psychiatric control group consisting of persons with a substance use disorder and no history of psychosis (n=14). Analyses revealed that both psychosis cohorts scored lower than controls on the MAS-A total and all subscales except metacognitive mastery. Compared to the FEP group, the persons with prolonged psychosis demonstrated greater metacognitive capacities only in those MAS-A domains reflective of the ability to understand the mental state of others and to see that others may have motivations and desires separate from their own. Other domains of metacognition did not differ between psychosis groups. The Eyes, Hinting and BLERT scores of the two psychosis groups did not differ but were poorer than those produced by the control group. Exploratory correlations in the FEP group showed a pattern similar to that previously observed in prolonged psychosis. Taken together, these findings suggest that while certain domains of metacognition could improve with prolonged psychosis, difficulties with global metacognition and social cognition may be stable features of the disorder and perhaps unique to psychosis.

The nature and evolution of insight in schizophrenia: a multi-informant longitudinal study of first-episode versus chronic patients

BACKGROUND AND AIMS

This study investigated a novel distinction between two possible sources of poor insight in schizophrenia: primary unawareness, in which the ill person is not aware that other people think one has a problem, and secondary unawareness (or disagreement), in which a person does appreciate that other people think one has a problem. A secondary goal was to compare the evolution of insight in first-episode and chronic schizophrenia.

METHODS

Sixty-eight first-episode and 51 chronic patients were administered two versions of the Scale of Unawareness of Mental Disorder (SUMD) at three time points: hospital admission, discharge, and 6-month post-discharge. In the first standard SUMD version, they were asked about their own opinions, whereas in the second modified version, they were asked about their best guess of their doctor's opinion.

RESULTS

While overall level of unawareness remained stable within each single episode, there were significant Type of Unawareness (primary versus secondary) by Clinical Status (admission versus discharge versus 6-month post-discharge) and Type of Unawareness by Phase of Illness (first-episode versus chronic) interaction effects. More specifically, in the first-episode group, primary unawareness steadily decreased over time. In contrast, in the chronic group, primary unawareness decreased markedly during hospitalization and returned to baseline after discharge.

CONCLUSIONS

These results provide preliminary support for the notion that impaired insight is an additive outcome of primary unawareness and disagreement, and that change in insight over time occurs mostly at the level of their relative proportion as opposed to their overall sum. Implications for studying and treating poor insight in schizophrenia are discussed.