Metacognition and social function in schizophrenia: associations over a period of five months

The paradoxical moderating effects of metacognition in the relationships between self-esteem, depressive symptoms, and quality of life in anorexia and bulimia

BACKGROUND

Self-esteem and depressive symptoms contribute to a lower quality of life in people suffering from eating disorders. However, limited research has examined whether other factors may affect how these variables influence one another over time. Metacognition is a previously unexplored determinant that may impact the relationships between self-esteem, depressive symptoms, and quality of life in instances of eating disorders.

AIM

This study sought to examine metacognitive self-reflectivity and mastery as moderators of the relationships between self-esteem, depressive symptoms, and quality of life and to determine if these relationships are different in people with anorexia compared with people with bulimia.

METHODS

Participants with anorexia (n=40) and bulimia (n=40) were recruited from outpatient clinics. The participants were assessed on their metacognitive ability and self-reported on measures to assess their depressive symptoms, self-esteem, and quality of life.

RESULTS

The results indicate that metacognitive self-reflectivity moderates the relationship between self-esteem, depressive symptoms, and quality of life in people with anorexia such that when self-reflectivity is high, lower self-esteem and higher depressive symptoms are associated with a lower quality of life. These relationships did not appear to be significant when self-reflectivity was low. In contrast, in the anorexia and bulimia groups, metacognitive mastery appeared to moderate the relationships between self-esteem, depressive symptoms, and quality of life such that when mastery was low, lower self-esteem and higher depressive symptoms were associated with a lower quality of life. These relationships did not appear significant when mastery was high.

CONCLUSION

Metacognitive self-reflectivity and mastery seem to play paradoxical moderating roles in the relationships between self-esteem, depressive symptoms, and quality of life in people with anorexia and bulimia. These findings pave the way toward further research and have important clinical implications.

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

ABSTRACT

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

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

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

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

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

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.

Metacognition over time is related to neurocognition, social cognition, and intrapsychic foundations in psychosis

Core impairments underlying schizophrenia encompass several domains, including disruptions in metacognition, neurocognition, social cognition, and intrapsychic foundations. Little is known about how these phenomena change over time and whether changes co-occur. The current study sought to address these gaps and examine the relationships between these cognitive domains across a 12 month period in adults with schizophrenia. Seventy-five adult outpatients with schizophrenia spectrum disorders were enrolled in a randomized trial comparing two cognitive interventions designed to improve work performance. Cognitive outcomes were measured at baseline, a 6-month follow-up and a 12-month follow-up. Multilevel linear modeling was used to understand the longitudinal relationships between metacognition and social cognition, neurocognition, and intrapsychic foundations across the 12-month follow-up. Metacognition significantly improved across 12 months. Improvements in overall neurocognition were significantly associated with increases in the metacognition domains of self-reflectivity and mastery across time. Improvements in social cognition over time were associated with improvements in total metacognition and the metacognitive domain of mastery. Improvements in intrapsychic foundations scores over 12 months were significantly associated with improvements in overall metacognition, self-reflectivity, and mastery. In conclusion, over time, improvements in metacognition across domains co-occur with other core cognitive and social capacities in persons with schizophrenia. As persons became better able to form integrated senses of themselves and adaptively use this knowledge, improvements in neurocognition, social cognition, and intrapsychic foundations were also present.

Metacognitive Capacity Is Related to Self-Reported Social Functioning and May Moderate the Effects of Symptoms on Interpersonal Behavior

Impairments in metacognition or the ability to form integrated senses of self and others have been linked to deficits in laboratory-based measures of social functioning in schizophrenia. This study examined whether self-reported social functioning was related to metacognition in 88 adults in a nonacute phase of schizophrenia. Concurrent assessments were made of metacognition with the Metacognition Assessment Scale-Abbreviated, social functioning with the Social Functioning Scale, symptoms with the Positive and Negative Syndrome Scale, and neurocognition with the Wisconsin Card Sorting Task. Univariate correlations revealed that self-reported social functioning was related to metacognition. Symptom severity was linked to interpersonal relationships, and overall metacognition was found to significantly moderate that relationship such that the effects of symptoms on function grew less as metacognitive capacity was stronger, independent of the effects of neurocognition. This may suggest the potential of metacognitive interventions to titrate the negative effects of symptoms on social function.

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

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

Three-Year Follow-Up Study Exploring Metacognition and Function in Individuals With First Episode Psychosis

Introduction: Research has demonstrated that functional outcome in psychosis is predicted by factors such as neurocognition, functional capacity, symptoms and, more recently, metacognition. Metacognitive ability has been demonstrated to mediate between neurocognition and functional outcome in First Episode Psychosis (FEP). Whether metacognition also predicts longer-term recovery in first episode psychosis is unknown. This study assessed whether neurocognition, functional capacity and metacognitive ability in FEP predicted functional outcome three years later. Methods: Eighty individuals with First Episode Psychosis were re-contacted after an average 3 years (range: 26-45 month follow-up) from baseline. Twenty-six participants (33%) completed completed measures of neurocognition, metacognition, functional capacity, functional outcome (hours spent in structured activity per week) and psychopathology at baseline and at follow-up. Results: Individual regression analyses demonstrated neurocognition, functional capacity, and metacognitive ability at baseline significantly predicted functional outcome at three years. However, when baseline functional outcome was controlled, only metacognitive ability was a significant predictor of change in functional outcome from baseline to follow-up, p < 0.001. This model explained 72% (adjusted r ² = 0.69) of the variance in functional outcome at follow-up. Negative symptoms did not change the model. Discussion: This study demonstrated that better metacognitive ability significantly predicted improvement in functioning in FEP across a 3-year period. This highlights the potential value of clinical interventions that focus on improving metacognitive ability at first point of illness to maximize recovery.

Metacognition, Personal Distress, and Performance-Based Empathy in Schizophrenia

BACKGROUND

People with schizophrenia experience significant deficits in the kinds of empathic skills that are the foundation for interpersonal relationships. Researchers have speculated that deficits in empathic skills in schizophrenia may be related to disturbances in metacognition and heightened levels of personal distress. To explore this issue, this study examined whether better metacognition and reduced personal distress would be associated with improved performance on cognitive and affective empathy tasks. Further, we tested whether metacognition moderated the relationship between personal distress and empathy.

METHOD

Fifty-eight participants with schizophrenia-spectrum disorders receiving community-based treatment completed a self-report questionnaire of personal distress, a performance-based measure of empathy, and an observer-rated interview to assess metacognitive capacity.

RESULTS

Correlation analyses revealed that metacognitive capacity, but not personal distress, was significantly associated with cognitive and affective empathy performance. Moderation results suggest the relationship between personal distress and affective empathy performance was significant for those with low metacognition, but that the relationship was the opposite of hypotheses-increased personal distress predicted better performance. This relationship changed at higher levels of metacognition, when increased personal distress became associated with reduced performance.

CONCLUSIONS

This study is the first of its kind to examine performance-based empathy with metacognition and personal distress. Results suggest interventions targeted to improve metacognition may be useful in enhancing empathic skills.

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

BACKGROUND

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

METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSION

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

TRIAL REGISTRATION

ISRCTN10917911 . Retrospectively registered 30 November 2016.

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

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

Trauma, Dissociation and Synthetic Metacognition in Schizophrenia

Both childhood trauma and dissociation are associated with schizophrenia. More rudimentary form of dissociation known already from Eugen Bleuler as splitting of association is theoretically close to the modern concept of synthetic metacognition in schizophrenia. The synthetic metacognition as a psychological process is described as a capability to synthesize intentions, thoughts, feelings, and connections between events, and to integrate them into larger complex representations of self and others. Disturbed synthetic metacognition was found in early as well as in late forms of schizophrenia and has its typical formula. Deficit of synthetic metacognition is related to symptoms of schizophrenia and psychosocial functions. Synthetic metacognition is measurable by analyzing discourse using standardized procedures. The level of metacognition is assessed from the sample of narrative on the basis of the Metacognitive Assessment Scale — Abbreviated (MAS-A). Psychotherapies focused on strengthening of metacognitive functions concentrate on integration of fragmented mental content or on promoting of formation of stable mental representations in this disorder.

Relation of formal thought disorder to symptomatic remission and social functioning in schizophrenia

OBJECTIVE

The aim of this cross-sectional study is to examine the relation of formal thought disorder (FTD) with symptomatic remission (SR) and social functioning in patients with schizophrenia.

METHOD

The study was carried out with a sample consisting of 117 patients diagnosed with schizophrenia according to DSM-IV. The patients were assessed with the Positive and Negative Syndrome Scale (PANSS), the Thought and Language Index (TLI), and the Personal and Social Performance Scale (PSP). We used logistic regression in order to determine the relation between FTD and SR and linear regression to identify the strength of association between FTD and social functioning.

RESULTS

Logistic regression analysis revealed that poverty of speech (odds ratio: 1.47, p<0.01) and peculiar logic (odds ratio: 1.66, p=0.01) differentiated the remitted patients from the non-remitted ones. Linear regression analysis showed that the PSP total score was associated with poverty of speech and peculiar logic items of the TLI (B=-0.23, p<0.01, B=-0.24, p=0.01, respectively).

CONCLUSION

Our findings suggest that poverty of speech and peculiar logic are the specific domains of FTD which are related to both SR status and social functioning in patients with schizophrenia.

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

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTITIONER POINTS

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

LIMITATIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Meta-cognition is associated with cortical thickness in youth at clinical high risk of psychosis

Meta-cognition is compromised in people with schizophrenia and people at clinical high risk (CHR) of psychosis. In the current work in a CHR sample, we hypothesized that meta-cognitive functions would correlate with cortical thickness in five brain regions implicated in the pathogenesis of psychosis: inferior and middle frontal cortices, anterior cingulate cortex, superior temporal cortex and insula. Secondly, we hypothesized that similar neural systems would underlie different meta-cognitive functions. Narratives were gathered for 29 youth at CHR of psychosis using a semi-structured interview. Four meta-cognitive functions within the narratives were measured with the Meta-cognition Assessment Scale and regressed on cortical thickness from our a priori regions of interest using FreeSurfer. Mapping statistics from our a priori regions of interest revealed that meta-cognition functions were associated with cortical thickness in inferior and middle frontal gyri, superior temporal cortex and insula. The distribution of cortical thickness was partially similar across the four MAS items. Results confirm our hypothesis that cortical thickness is significantly associated with meta-cognition in brain regions that consistently show gray matter reductions across the schizophrenia spectrum. Evidence for thickness covariation in a variety of regions suggests partial dependence in the neural architecture underlying various meta-cognitive functions in CHR.

Metacognitive profiles in individuals with a first episode of psychosis and their relation to social functioning and perceived social support

Poorer metacognitive abilities are recognized as strong predictors of social functioning deficits in individuals with schizophrenia, but have not been studied in relation to perceived social support. Furthermore, traditional measures of metacognition fail to consider ecological aspects such as the interaction between thinking of one's own or other's mind, and mastery. As a constellation, these abilities may influence domains of social functioning and perceived social support differently. Therefore, this study aimed to establish whether distinct metacognitive profiles exist within a population of individuals with a first psychotic episode, and to determine how such profiles influence individual domains of social functioning and perceived social support. Participants (n=50) were recruited from two early psychosis outpatient clinics in Montreal, Canada. Demographic information, social functioning and perceived social support were measured using self-reported questionnaires, and metacognition was scored from the transcripts of a semi-structured interview designed to avoid leading responses. Cluster analysis revealed three distinct metacognitive profiles: (1) overall better abilities; (2) poor abilities on thinking of one's own and other's mind, but better mastery; and (3) overall poorer abilities. Analyses showed significant differences between profiles only for self-reported intimacy and independent living abilities, with the second profile showing better abilities than the third. Profiles did not simply represent consistently higher or lower functioning across subscales. Although mastery was predictive of social functioning, the ability to think in an increasingly complex manner of one's self and others did not seem to improve functioning in individuals with a first episode of psychosis.

Metacognitive Deficits in Schizophrenia: Presence and Associations With Psychosocial Outcomes

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

Metacognition in Early Phase Psychosis: Toward Understanding Neural Substrates

Individuals in the early phases of psychotic illness have disturbed metacognitive capacity, which has been linked to a number of poor outcomes. Little is known, however, about the neural systems associated with metacognition in this population. The purpose of this study was to elucidate the neuroanatomical correlates of metacognition. We anticipated that higher levels of metacognition may be dependent upon gray matter density (GMD) of regions within the prefrontal cortex. Examining whole-brain structure in 25 individuals with early phase psychosis, we found positive correlations between increased medial prefrontal cortex and ventral striatum GMD and higher metacognition. These findings represent an important step in understanding the path through which the biological correlates of psychotic illness may culminate into poor metacognition and, ultimately, disrupted functioning. Such a path will serve to validate and promote metacognition as a viable treatment target in early phase psychosis.

Metacognitive capacity as a predictor of insight in first-episode psychosis

Impaired insight is common in the first episode of psychosis (FEP). Although considerable research has examined the factors that are associated with impaired insight in chronic psychosis, less is known about the factors that underlie and sustain poor insight in FEP. Impaired metacognition, or the ability to form integrated representations of self and others, is a promising potential contributor to poor insight in FEP. To explore this possibility, the authors assessed insight and metacognition in 40 individuals with FEP and then examined the relationship between these areas and social cognition domains, neurocognitive domains, and psychotic symptoms. Correlation analyses revealed that improved insight was associated with higher metacognition, better vocabulary and Theory of Mind scores, and fewer symptoms. The domain of metacognitive mastery also predicted clinical insight. Results support the need to develop an integrative therapeutic approach focused on improving metacognition, hence addressing poor insight in FEP.

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

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

A mentalization-based approach to the development of the therapeutic alliance in the treatment of schizophrenia

This article presents a clinical illustration of a mentalization-based approach to the development of a therapeutic alliance in the treatment of schizophrenia. A clinically focused overview of the attachment-based understanding of mentalization central to the mentalization-based treatment model is first provided. This is followed by a brief summary of the theory and evidence supporting the possible link between attachment disturbances and deficits of mental state understanding in schizophrenia. A case presentation then illustrates the application of core mentalization-based principles and interventions to enhance the therapeutic alliance by addressing disruptions of mentalization and reducing paranoia in the treatment of a patient with early course schizophrenia.

Attentional control mediates the relationship between social anhedonia and social impairment

Social anhedonia (SA), a trait-like disinterest in social contact and diminished capacity to experience pleasure from social interactions, is consistently associated with social impairments in both healthy and clinical populations. However, the mechanisms underlying the relationship between SA and social impairment are poorly understood. Attentional control, selecting and focusing on relevant information and inhibiting irrelevant, may be one such mechanism. We examined individual differences in SA, attentional control, and social impairment in 108 healthy adults. High SA related to low attentional control and high social impairment. Moreover, attentional control mediated the relationship between SA and social impairment, establishing attentional control as one mechanism underlying aberrations in the fundamental human need for social contact. Although both attentional deficits and social impairment have been separately noted in SA, the relationship between SA, attentional control and social impairment in this non-clinical sample reflects a novel contribution.

Literature as an exploration of the phenomenology of schizophrenia: disorder and recovery in Denis Johnson's Jesus' Son

When read as a fictional psychosis narrative, Jesus' Son, a collection of short stories by Denis Johnson, reveals important elements of the phenomenology of schizophrenia and recovery. It is possible that Jesus' Son, as a work of fiction, may be able to uniquely add depth and nuance to an understanding of the phenomenology of schizophrenia involving a state of psychological fragmentation, an ever-changing interpersonal field and a loss of personal agency. In addition, by following the protagonist in Jesus' Son as he begins to resolve some of his difficulties, the book also offers an individualised account of recovery. The authors detail how the book reveals these insights about schizophrenia and recovery and suggest that these elements are intertwined in such a manner that leads to a profound disruption of self-experience, characterised by a collapse of metacognitive processes. Jesus' Son may add depth to our understanding of the subjective experience of schizophrenia and recovery, and also may serve as one example in which the study of humanities offers an opportunity to explore the human elements in the most profound forms of suffering.

Exploring the Response Shift Effect on the Quality of Life of Patients with Schizophrenia

Background. Interpretation of quality of life (QoL) scores over time can be difficult because of possible changes in internal standards, values, and conceptualization of QoL by individuals. This effect is called a response shift (RS). The purpose of this study was to examine whether an RS effect occurred over a 24-mo period in patients who were suffering from schizophrenia. Methods. The random forest method was applied to detect any RS reprioritization in a multicenter cohort study. QoL was recorded using a generic questionnaire (SF36) at baseline (T0), 12 mo (T12), and 24 mo (T24). Patients were categorized into 3 groups based on psychotic symptoms and relapse (stable, improved, and worsened groups) from their clinical profiles. The random forest method was performed to predict the General Health score of the SF36 from the other QoL domain scores of the SF36. We estimated the average variable importance of the QoL domain for each of the 3 groups. Results. A total of 124 (53.2%) patients were defined as stable, 59 (25.3%) as improved, and 50 (21.5%) as worsened. Among the stable group, the Social Functioning domain became more important over time. Of those classified as improved, the Mental Health domain became more important over time, while the Vitality domain became less important. Among those in the group who worsened, the Mental Health domain became less important while the Vitality and Bodily Pain domains became more important. Conclusions. Our study identified differential RS reprioritization among patients with different clinical profiles. Further work is needed to determine whether RS should be interpreted as a measurement bias or as an effect integrated in a true change.

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

Research has suggested that many with schizophrenia experience decrements in synthetic metacognition, or the abilities to form integrated representations of oneself and others and then utilize that knowledge to respond to problems. Although such deficits have been linked with functional impairments even after controlling for symptoms and neurocognition, it is unclear to what extent these deficits can distinguish persons with schizophrenia from others experiencing significant life adversity but without psychosis. To explore this issue we conducted logistic regression analysis to determine whether assessment of metacognition could distinguish between 166 participants with schizophrenia and 51 adults with HIV after controlling for social cognition and education. Metacognition was assessed with the Metacognitive Assessment Scale Abbreviated (MAS-A), and social cognition with the Bell Lysaker Emotion Recognition Test. We observed that the MAS-A total score was able to correctly classify 93.4% of the schizophrenia group, with higher levels of metacognition resulting in increased likelihood of accurate categorization. Additional exploratory analyses showed specific domains of metacognition measured by the MAS-A were equally able to predict membership in the schizophrenia group. Results support the assertion that deficits in the abilities to synthesize thoughts about oneself and others into larger representations are a unique feature of schizophrenia.

Mechanisms of Change in Psychotherapy for People Diagnosed with Schizophrenia: The Role of Narrative Reflexivity in Promoting Recovery

Narrative reflexivity was investigated as a potential mechanism of therapeutic change during a 12–18 month trial of Metacognitive Narrative Psychotherapy for people diagnosed with schizophrenia. Participants were nine adult clients (8 male, 1 female) aged between 25–65 years (M = 44, SD = 12.76) with a diagnosis of schizophrenia consistent with DSM-IV criteria and seven female provisional psychologists aged between 25–29 years (M = 26.8 years, SD = 1.47 years). Recovery and narrative reflexivity were measured at three time points using the Recovery Assessment Scale (RAS) and the Narrative Processes Coding System (NPCS). Results were reported descriptively due to limited sample size (n = 9). The majority of clients (n = 7) reported an increase in recovery over the course of treatment. For six clients, an overall increase in recovery was associated with an increase in narrative reflexivity. This study provides preliminary support for narrative reflexivity as a potential mechanism of therapeutic change in the psychotherapy of people diagnosed with schizophrenia.

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.

Differential associations of cognitive insight components with pretreatment characteristics in first-episode psychosis

An increasing number of studies have focused on cognitive insight (i.e. awareness of one's own thinking) in psychotic disorders. However, little is known about the premorbid and pretreatment correlates of cognitive insight in the early course of psychosis. One hundred and three patients experiencing first-episode psychosis (FEP) were assessed shortly after treatment initiation for cognitive insight. Pretreatment and baseline clinical, functional and neurocognitive characteristics were examined. The self-reflectiveness dimension of cognitive insight was independently associated with clinical insight and executive functioning, whereas self-certainty was associated with premorbid IQ, premorbid academic adjustment and clinical insight. The amount of variance explained by the independent variables was small to moderate. Self-reflectiveness and self-certainty have differential pretreatment correlates in FEP and may reflect separate cognitive processes which require targeted interventions.

Intersubjectivity in schizophrenia: life story analysis of three cases

The processes involved in schizophrenia are approached from a viewpoint of understanding, revealing those social elements susceptible to integration for psychotherapeutic purposes, as a complement to the predominant medical-psychiatric focus. Firstly, the paper describes the patients’ disturbances of self-experience and body alienations manifested in acute phases of schizophrenia. Secondly, the paper examines the patients’ personal biographical milestones and consequently the acute episode is contextualized within the intersubjective scenario in which it manifested itself in each case. Thirdly, the patients’ life stories are analyzed from a clinical psychological perspective, meaningfully connecting symptoms and life-world. Finally, it will be argued that the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia but also upon the psychotherapeutic treatment best suited to each individual case.

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

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

Metacognitive mastery and intrinsic motivation in schizophrenia

Deficits in intrinsic motivation (IM) have been linked to poorer outcome in schizophrenia, but its proximal mechanisms remain poorly understood. This study examined whether metacognitive mastery, or the capacity to use knowledge of self, others, and context to identify and cope with psychological difficulties, predicted levels of IM for 6 months among 75 participants with prolonged schizophrenia. Repeated-measures analysis of variance revealed that high metacognitive mastery predicted consistently higher levels of IM; however, intermediate and low mastery did not produce unique IM profiles. The findings suggest that metacognitive mastery may have an important role in IM over time and could be a meaningful treatment target.

The neural basis of theory of mind and its relationship to social functioning and social anhedonia in individuals with schizophrenia

Theory of mind (ToM), the ability to attribute and reason about the mental states of others, is a strong determinant of social functioning among individuals with schizophrenia. Identifying the neural bases of ToM and their relationship to social functioning may elucidate functionally relevant neurobiological targets for intervention. ToM ability may additionally account for other social phenomena that affect social functioning, such as social anhedonia (SocAnh). Given recent research in schizophrenia demonstrating improved neural functioning in response to increased use of cognitive skills, it is possible that SocAnh, which decreases one's opportunity to engage in ToM, could compromise social functioning through its deleterious effect on ToM-related neural circuitry. Here, twenty individuals with schizophrenia and 18 healthy controls underwent fMRI while performing the False-Belief Task. Aspects of social functioning were assessed using multiple methods including self-report (Interpersonal Reactivity Index, Social Adjustment Scale), clinician-ratings (Global Functioning Social Scale), and performance-based tasks (MSCEIT—Managing Emotions). SocAnh was measured with the Revised Social Anhedonia Scale. Region-of-interest and whole-brain analyses revealed reduced recruitment of medial prefrontal cortex (MPFC) for ToM in individuals with schizophrenia. Across all participants, activity in this region correlated with most social variables. Mediation analysis revealed that neural activity for ToM in MPFC accounted for the relationship between SocAnh and social functioning. These findings demonstrate that reduced recruitment of MPFC for ToM is an important neurobiological determinant of social functioning. Furthermore, SocAhn may affect social functioning through its impact on ToM-related neural circuitry. Together, these findings suggest ToM ability as an important locus for intervention.

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Individuals with schizophrenia exhibited reduced recruitment of MPFC for ToM.

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MPFC and RTPJ activities correlate with measures of social functioning and ability.

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MPFC activity mediates the relationship between social anhedonia and functioning.

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Neural circuitry supporting ToM may represent an important area for remediation.

Do persons with schizophrenia who have better metacognitive capacity also have a stronger subjective experience of recovery?

Research suggests that persons with schizophrenia experience deficits in the ability to synthesize complex and integrated representations of themselves and others. While impairments in these metacognitive capacities are hypothetically related to the ability to make sense of the challenges of schizophrenia, little is known about their relationship with the subjective experience of recovery from mental illness. To examine this question, this study investigated whether persons with stronger self-reported recovery had better metacognitive capacity, after controlling for severity of psychiatric symptoms. Forty-six outpatients with schizophrenia spectrum disorders who were taking part in a study of the Illness Management and Recovery program were concurrently administered the Recovery Assessment Scale, the Positive and Negative Syndrome Scale, and the Indiana Psychiatric Illness Interview which was scored using the Abbreviated Metacognitive Assessment Scale. Analysis of covariance revealed that metacognitive capabilities reflecting self-reflectivity and decentration were differentially related to several components of recovery beyond the effects of psychiatric symptoms. The metacognitive abilities to think about oneself in a sophisticated way and form integrated ideas about oneself and others within the larger world, understanding that none are the metaphorical center are present in individuals holding strong perceptions of recovery.

The phenomenon of social isolation in the severely mentally ill

PURPOSE

The phenomenon of social isolation is closely linked with the experience of having a severe mental illness (SMI). This paper offers scholarly perspectives and analyses of the phenomenon of social isolation as it applies to people with SMI by highlighting relevant definitional, historical, theoretical, and conceptual understanding surrounding this phenomenon.

CONCLUSIONS

Stigma, alienation, and existential loneliness when taken together provide an understanding of the multidimensional problem of social isolation for people with SMI.

PRACTICE IMPLICATIONS

Mental health services should be provided which take into account the importance of human contact and social connection for people who live with SMI. Services can be offered which are designed to develop social skills, as well as to create opportunities for social connection and community involvement.

Quality of life is predictive of relapse in schizophrenia

BACKGROUND

The objective of this study was to evaluate whether quality of life (QoL), as measured by the SF36 and the Quality of Life Interview (QoLI), is predictive of relapse for patients with schizophrenia.

METHODS

Using data from a multicenter cohort study conducted in France, Germany, and the United-Kingdom (EuroSC), we performed Cox proportional-hazards models to estimate the associations between QoL at baseline and the occurrence of relapse over a 24-month period, with adjustment for age; gender; positive, negative and general psychopathology PANSS factors; functioning (GAF); medication; side-effects; and compliance measures.

RESULTS

Our sample consisted of 1,024 patients; 540 (53%) had at least one period of relapse, and 484 (47%) had no relapse. QoL levels were the most important features predicting relapse. We found that a higher level of QoL predicts a lower rate of relapse at 24 months: HR = 0.82 (0.74; 0.91), p < 0.001 for the SF36-Physical Composite Score; and HR = 0.88 (0.81; 0.96), p = 0.002 for the SF36-Mental Composite Score. These results were not confirmed using the QoLI: HR = 0.91 (0.81; 1.01), p = 0.083. To a lesser extent, older age, better functioning, and a higher compliance score also predict a lower rate of relapse at 24 months (HRs from 0.97 to 0.98; p < 0.05).

CONCLUSIONS

QoL, as assessed by the SF36, is an independent predictor of relapse at a 24-month follow-up in schizophrenia. This finding may have implications for future use of the QoL in psychiatry. Moreover, our findings may support the development and monitoring of complementary therapeutic approaches, such as 'recovery-oriented' combined with traditional mental health cares to prevent relapse.

From social experience to illness experience: reviewing the psychological mechanisms linking psychosis with social context

This review was undertaken to describe the psychological processes that are associated with the social experiences and behaviours of people with psychosis. A systematic search was conducted using MEDLINE and PsycINFO search engines. In each of the major topic domains, the search was comprised of review articles published from 2004 to present, and individual article searches for papers published from 2010 to present. The key psychological mechanisms in this context are social cognition, self-concept, emotion, and communication. While diverse in content, there were several cross-cutting themes in these literatures. These include evidence of the presence of social processing difficulties in high-risk and psychosis populations that have both state and trait characteristics, are related to, but not fully accounted for by, neurocognition and symptomatology, and have significant implications for social functioning. There are numerous established and promising treatments linked to our understanding of social cognition. Limitations cutting across these literatures include a substantial reliance on cross-sectional studies that use control groups comprised of people who have not experienced significant psychological or social adversity. There is also limited inquiry into how psychological mechanisms may differ owing to sex, ethnicity, and race. Despite these issues, this line of inquiry is very promising as part of the larger movement toward an integrative model of psychosis that is able to account for the complex interactions of social, biological, and psychological risks.

Synthetic metacognition as a link between brain and behavior in schizophrenia

Deficits in metacognitive capacity in schizophrenia can be conceptualized as existing along a spectrum from more discrete to more synthetic activities. These capacities may be of great importance in schizophrenia research given their potential to mediate and moderate the impact of illness-related factors on outcome. To explore this possibility this review summarizes research on synthetic metacognition using a paradigm in which metacognitive capacity is rated on the basis of spontaneously produced personal narratives. Evidence from a review of the literature shows that these deficits are detectable in patients with schizophrenia and are related to, but not reducible to, symptom severity and poorer neurocognitive function. Independent of symptoms and neurocognition, deficits in synthetic metacognition, which are likely linked to the brain’s ability to integrate information, are related to a range of outcomes including functional competence, learning potential, and insight. These deficits may also play a role in long term psychosocial functioning via their impact on the ability to sustain social functions.

The development of the Metacognition Assessment interview: instrument description, factor structure and reliability in a non-clinical sample

BACKGROUND

Metacognition is a multi-facet psychological construct; deficits in metacognitive abilities are associated to low social functioning, low quality of life, psychopathology, and symptoms. The aim of this study was to describe and develop a valid and reliable interview for assessing metacognition.

METHODS

The semi-structured interview, based on the author's theory model of the metacognition construct, is described. The Metacognition Assessment Interview (MAI) is an adaptation of the Metacognition Assessment Scale (MAS) and evaluates how the subject is interviewed used metacognition during his own real life experiences elicited by the interviewer. A user manual was developed to assist the interview and scoring procedure.

RESULTS

Exploratory factor analysis and confirmatory factor analysis revealed preliminary evidence of a two factor-hierarchical structure, with two lower-order scales, representing the two main theoretical domains of the metacognitive function, "the Self" and "the Other", and one single higher-order scale that we labelled metacognition. Contrary to the authors' prediction the existence of the four distinct dimensions under the two domains was not confirmed. The MAI and its two domains demonstrated acceptable levels of inter-rater reliability and internal consistency.

CONCLUSIONS

The MAI appears to be a promising instrument for assessing metacognition. Future psychometric validation steps and clinical directions are discussed.

Cognitive insight in schizophrenia: the missing link between insight and neurocognitive complaint?

The aim of this study was to explore the associations between cognitive insight, clinical insight, and neurocognitive complaint in a sample of 54 outpatients with schizophrenia spectrum disorders. Cognitive insight assessed using the Beck Cognitive Insight Scale (BCIS) was not associated with clinical insight assessed using the Scale to Assess Unawareness of Mental Disorder. Associations were found between the BCIS scores and the neurocognitive complaints assessed using the Subjective Scale to Investigate Cognition in Schizophrenia. A high level of neurocognitive complaints was positively associated with self-reflectiveness and negatively associated with self-certainty about beliefs and judgments. These results provide further support for the construct validity of the BCIS. The data also suggest that cognitive insight and neurocognitive complaint are close constructs that should be differentiated from awareness of having a mental illness.