Metacognition and general functioning in patients with schizophrenia and a history of criminal behavior

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.

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study

PURPOSE

Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia.

METHOD AND MATERIALS

In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending.

RESULTS

Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles.

CONCLUSIONS

Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

Associations Between Clinical Insight and History of Severe Violence in Patients With Psychosis

Background and Hypothesis

Violence is more prevalent in patients with psychotic disorders compared to the general population. Hence, adequate violence risk assessment is of high clinical importance. Impaired insight is suggested as a risk factor for violence in psychosis, but studies have yielded conflicting results. We hypothesized that impaired insight was associated with a history of severe violence in patients with psychotic disorders.

Study Design

Clinical insight was assessed both using the Birchwood Insight Scale (BIS) and the Positive and Negative Symptom Scale (PANSS) item G12 (lack of judgment and insight). The degree of impaired clinical insight was compared between psychosis patients with (N = 51) and without (N = 178) a history of severe violence. Multiple linear regression analyses were performed to investigate the effects of putative confounders.

Study Results

We found that a history of severe violence was significantly associated with lower insight in one of the three BIS components (the relabeling of symptoms) (P = .03, R2 = 0.02) and the PANSS item G12 (P = .03, R2 = 0.02) also after controlling for putative confounders.

Conclusions

The results suggest there is an association between impaired insight and severe violence in psychosis patients. We propose that examination of insight by validated instruments comprising different components may add useful information to clinical violence risk assessment in psychosis patients.

Path analysis from COVID-19 perceptions to psychological health: The roles of critical distance and mastery

OBJECTIVE

The Coronavirus disease 2019 (COVID-19) pandemic was previously associated with psychopathological symptoms. However, the psychological mechanisms underlying these associations are largely unexplored. Previous studies suggested associations between metacognitive abilities (e.g., mastery) and symptomatology, which may have impacts on COVID-19 perceptions. This study aims to explore, using path analysis, the mediational role of Critical Distance (differentiation and decentration abilities) and Mastery on the relationships between COVID-19 perceptions and psychological well-being and distress.

METHODS

In a cross-sectional design, 227 participants (M = 34.21, SD = 10.9) filled self-report questionnaires.

RESULTS

Metacognitive abilities were negatively correlated with psychopathological symptoms. Both Critical Distance and Mastery mediated the path from COVID-19 perceived severity and anxiety to psychological distress and well-being. Critical Distance seems to augment Mastery which tends to increase psychological well-being and limited psychological distress.

CONCLUSIONS

Metacognition seems to play a mediational role on the relationship between COVID-19 perceptions and mental health. Clinical psychologists and psychotherapists may enhance psychological interventions regarding COVID-19 psychopathological symptomatology by working on metacognitive Critical Distance and Mastery abilities.

Metacognition Mediates the Relationship Between Maladaptive Personality Traits and Levels of Personality Functioning: A General Investigation on a Nonclinical Sample

ABSTRACT

The impaired ability to reflect on one's own state of mind and that of others (called metacognition or mentalization) is a central feature of personality disorders (PDs). Metacognition involves different specific abilities, which can be selectively impaired with different PDs and personality maladaptive traits. Moreover, research in the field of PDs has indicated that personality features and metacognitive abilities are associated with the severity of personality pathologies. In this study, we tested a mediation model of the interactions between these variables on predicting levels of personality functioning in a sample of adults taken from the general population (N = 775). Results showed that the relationship between personality traits and personality functioning is partially mediated by metacognitive abilities. These findings support the hypothesis that metacognition plays a significant role in predicting the levels of impairment in personality functioning. These findings have several clinical implications.

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

Background:

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

Method:

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

Results:

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

Conclusion:

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

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.

Dynamic relationships between emotional distress, persecutory ideation, and metacognition in schizophrenia

OBJECTIVE

Determine whether metacognitive capacity (i.e., a range of abilities that involve recognition, reflection, and integration of mental states) influences the relationships between emotional distress and persecutory ideation (PI).

METHODS

The present study examined emotional distress, metacognition and PI in a sample (n = 337) of individuals with schizophrenia or schizoaffective disorder and clinician-rated PI. Pearson and partial correlations were used to examine relationships between variables, as well as between-subjects analysis of variances to compare groups characterized based on emotional distress and persecutory ideation scores.

RESULTS

While emotional distress and PI are associated with one another, metacognition is negatively associated with PI and positively associated with emotional distress. Subgroup comparisons demonstrated that individuals with high emotional distress and low PI had significantly higher metacognitive capacity than those elevated in PI or reduced in both emotional distress and PI.

CONCLUSIONS

Findings suggest metacognitive capacity may relate to improved awareness of distress and reduced PI.

Metacognitive self-assessment scale: psychometric properties and clinical implications

Metacognition is a higher-order psychological construct that has been conceptualized as the ability to identify and describe mental states, beliefs, and intentions of self and others. The Metacognition Self-Assessment Scale (MSAS), was developed to assess different functions of metacognition, being a potential asset in fields such as psychotherapy and clinical neuropsychology. However, a reliability and validity study is still lacking, as well, the study with other related metacognitive constructs. This research describes the psychometric analysis of the MSAS in a cross-sectional design and the study of the relationship between metacognitive functions, meta-beliefs and cognitive fusion. The sample comprised 194 participants from the general population (76% women), with an average age of 32 years old. Exploratory factor analysis, Cronbach alpha, test-retest, and validity procedures through bivariate correlations with convergent/divergent measures were conducted. The scale showed satisfactory psychometric properties with good internal consistency along with appropriate convergent/divergent validity. Metacognition and cognitive fusion were negatively correlated, while negative meta-beliefs and mastery predicted the variance of cognitive fusion. Decentering-differentiation factor correlated negatively with cognitive fusion and personal discomfort. These results suggest that MSAS may be a reliable tool to assess metacognition in the Portuguese population. Clinical implications are discussed.

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.

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.

Judgment of moral and social transgression in schizophrenia

INTRODUCTION

Despite evidence of pervasive social-cognitive deficits in schizophrenia, little is known of moral cognition in this population. While recent research indicates that impairment of explicit moral reasoning is explained by these individuals' other cognitive deficits, their capacities for basic moral judgment are unknown.

METHODS

45 people with schizophrenia and 27 healthy controls completed the Moral-Conventional Distinction Task: a classic task that assesses judgment of violations of moral or social convention on permissibility, severity, and authority-contingence. Justifications of judgments were also probed. Basic cognition was indexed by measures of IQ, verbal memory, and information processing speed. Self-report inventories were used to assess different facets of 'empathy' (e.g., perspective-taking, or theory of mind, and empathic concern), and aggressive tendencies.

RESULTS

Groups did not differ significantly in judgments of permissibility or authority-contingency, or justifications of judgments. Patients did, however, rate violations of social (but not moral) convention more harshly. They also took longer to judge impermissibility of moral (but nor social) transgressions. Slower moral judgment in patients was associated with lower levels of self-reported empathic concern, while harsher condemnation of social transgression was associated with poorer (self-reported) perspective-taking.

CONCLUSIONS

Findings provide no evidence that moral judgment is fundamentally compromised in schizophrenia. Evidence of slower moral judgment in schizophrenia does suggest, however, that patients were less influenced by automatic aversive responses to amoral conduct. The association found between poorer (self-reported) perspective-taking and greater condemnation of social transgressions also suggests that an insensitivity to others' extenuating motives may exacerbate social misunderstandings in schizophrenia.

Autistic and schizotypal traits and global functioning in bipolar I disorder

OBJECTIVE

To determine the expression of autistic and positive schizotypal traits in a large sample of adults with bipolar I disorder (BD I), and the effect of co-occurring autistic and positive schizotypal traits on global functioning in BD I.

METHOD

Autistic and positive schizotypal traits were self-assessed in 797 individuals with BD-I recruited by the Bipolar Disorder Research Network. Differences in global functioning (rated using the Global Assessment Scale) during lifetime worst depressive and manic episodes (GASD and GASM respectively) were calculated in groups with high/low autistic and positive schizotypal traits. Regression analyses assessed the interactive effect of autistic and positive schizotypal traits on global functioning.

RESULTS

47.2% (CI=43.7-50.7%) showed clinically significant levels of autistic traits, and 23.22% (95% CI=20.29-26.14) showed clinically significant levels of positive schizotypal traits. In the worst episode of mania, the high autistic, high positive schizotypal group had better global functioning compared to the other groups. Individual differences analyses showed that high levels of both traits were associated with better global functioning in both mood states.

LIMITATIONS

Autistic and schizotypal traits were assessed using self-rated questionnaires.

CONCLUSIONS

Expression of autistic and schizotypal traits in adults with BD I is prevalent, and may be important to predict illness aetiology, prognosis, and diagnostic practices in this population. Future work should focus on replicating these findings in independent samples, and on the biological and/or psychosocial mechanisms underlying better global functioning in those who have high levels of both autistic and positive schizotypal traits.

Positive symptoms, substance use, and psychopathic traits as predictors of aggression in persons with a schizophrenia disorder

It is still not clear what the unique contribution of particular psychopathological factors is in explaining aggression in schizophrenia. The current study examined whether persecutory ideations, psychopathy and substance use are associated with different measures of aggressive behavior. We expected that persecutory ideations are associated with reactive aggression, and psychopathic traits are more associated with proactive aggression of inpatients. 59 inpatients with schizophrenia were included. Persecutory ideations we assessed using the Persecutory Ideation Questionnaire (PIQ), psychopathic traits with the revised version of Psychopathic Personality Inventory (PPI-R) and substance use was assessed using the Comprehensive Assessment of Symptoms and History (CASH). In addition, aggression was measured with the Reactive and Proactive Aggression Questionnaire (RPQ), in an experimental task using the Point Subtraction Aggression Paradigm (PSAP) and on the ward using the Social Dysfunction and Aggression Scale (SDAS). Results showed that psychopathy explains most of the variance in self-reported proactive and reactive aggression. In contrast, persecutory ideations explain most of the variance in observed aggression on the ward. Results implicate that it is important to acknowledge comorbid factors in patients with schizophrenia for more precise risk assessment and appropriate treatment for aggressive patients with schizophrenia.

Mindfulness moderates the relationship between aggression and Antisocial Personality Disorder traits: Preliminary investigation with an offender sample

INTRODUCTION

Poor mentalizing has been described as a characteristic of Antisocial Personality Disorder (ASPD), along with the well-established role of aggressiveness. In the current study, we tested this hypothesis focusing on a specific aspect of mentalization (i.e., mindfulness).

METHOD

We explored the unique and joint contribution of aggression dimensions and mindfulness facets to ASPD traits in an offender sample (N=83).

RESULTS

Mindfulness deficits were associated with ASPD traits, and a significant unique association emerged between difficulties in acting with awareness and ASPD traits. Likewise, physical aggression confirmed its association with ASPD traits. Moderation analyses revealed that mindfulness interacted with aggression in predicting ASPD. Specifically, at low levels of mindfulness, the association between aggression and ASPD dropped to nonsignificance.

CONCLUSIONS

Results suggest that fostering self-mentalizing is a relevant treatment target when treating offenders with ASPD.

Conceptual disorganization weakens links in cognitive pathways: Disentangling neurocognition, social cognition, and metacognition in schizophrenia

Disentangling links between neurocognition, social cognition, and metacognition offers the potential to improve interventions for these cognitive processes. Disorganized symptoms have shown promise for explaining the limiting relationship that neurocognition holds with both social cognition and metacognition. In this study, primary aims included: 1) testing whether conceptual disorganization, a specific disorganized symptom, moderated relationships between cognitive processes, and 2) examining the level of conceptual disorganization necessary for links between cognitive processes to break down. To accomplish these aims, comprehensive assessments of conceptual disorganization, neurocognition, social cognition, and metacognition were administered to 67 people with schizophrenia-spectrum disorders. We found that conceptual disorganization significantly moderated the relationship between neurocognition and metacognition, with links between cognitive processes weakening when conceptual disorganization is present even at minimal levels of severity. There was no evidence that conceptual disorganization-or any other specific disorganized symptom-drove the limiting relationship of neurocognition on social cognition. Based on our findings, conceptual disorganization appears to be a critical piece of the puzzle when disentangling the relationship between neurocognition and metacognition. Roles of specific disorganized symptoms in the neurocognition - social cognition relationship were less clear. Findings from this study suggest that disorganized symptoms are an important treatment consideration when aiming to improve cognitive impairments.

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.