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

Investigating the relationship between negative symptoms and metacognitive functioning in psychosis: An individual participant data meta-analysis

PURPOSE

Negative symptoms are a persistent, yet under-explored problem in psychosis. Disturbances in metacognition are a potential causal factor in negative symptom development and maintenance. This meta-analysis uses individual participant data (IPD) from existing research to assess the relationship between negative symptoms and metacognition treated as summed scores and domains.

METHODS

Data sets containing individuals with negative symptoms and metacognition data, aged 16+ with psychosis, were identified according to pre-specific parameters. IPD integrity and completeness were checked and data were synthesized in two-stage meta-analyses of each negative symptoms cluster compared with metacognition in seemingly unrelated regression using restricted maximum likelihood estimation. Planned and exploratory sensitivity analyses were also conducted.

RESULTS

Thirty-three eligible data sets were identified with 21 with sufficient similarity and availability to be included in meta-analyses, corresponding to 1301 participants. The strongest relationships observed were between summed scores of negative symptoms and metacognition. Metacognitive domains of self-reflectivity and understanding others' minds, and expressive negative symptoms emerged as significant in some meta-analyses. The uncertainty of several effect estimates increased significantly when controlling for covariates.

CONCLUSIONS

This robust meta-analysis highlights the impact of using summed versus domain-specific scores of metacognition and negative symptoms, and relationships are not as clear-cut as once believed. Findings support arguments for further differentiation of negative symptom profiles and continued granular exploration of the relationship between metacognition and negative symptoms.

Metacognitive interpersonal therapy-eating disorders versus cognitive behavioral therapy for eating disorders for non-underweight adults with eating disorders: study protocol for a pilot pre-registered randomized controlled trial

Eating disorders (ED) are serious disorders characterized by an alteration of eating habits and excessive concern about weight and body shapes (Fairburn, 2002), accompanied by significant impairment inequality of life, high mortality rates and serious organic consequences (Jenkins et al., 2011; Treasure et al., 2015; 2020). Although evidence-based psychological therapies for nonunderweight ED presentations such as cognitive behavioral therapy for eating disorders (CBT-ED) are widely available, there is substantial scope for improvements, particularly in terms of efficacy and adherence. One option is to develop interventions to address elements of pathology not fully addressed by existing empirical supported treatments, such as incorporating techniques aimed at addressing interpersonal problems and personality disorder features into existing treatment delivery. We adapted Metacognitive Interpersonal Therapy, a psychological intervention supported by evidence for treating personality disorders and integrated it with existing CBT techniques for eating disorders (MIT-ED). MIT-ED targets aspects of ED that are not included in the transdiagnostic CBT-E model such as poor metacognition, or maladaptive interpersonal schemas. This is a pre-registered (Protocol number: 0000781) pilot randomized clinical trial aimed at assessing acceptability and feasibility of MIT-ED and establishing preliminary evidence of effectiveness for future larger studies. Twenty patients (10 in each arm) will be randomized to 20 sessions of individual psychotherapy, either MIT-ED or CBTE. Repeated follow-ups will be collected up to 24 months. Participants are recruited at a private outpatient clinic for ED treatment. Acceptability will be assessed via session attendance, completion rates and preliminary outcomes. The primary outcome is ED pathology assessed with the Eating Disorder Examination Questionnaire-6. Other ED outcomes assessed will be eating disorder attitudes, clinical impairment and binge eating pathology. Secondary treatment outcomes are anxiety, depression, and global symptomatology. We will also assess emotional awareness, emotion regulation and therapeutic alliance. Based on previous studies of MIT for personality disorders we hypothesize that MIT-ED will be acceptable to patients, evidenced by high treatment adherence and retention. We hypothesize that MIT-ED will be associated with reductions in eating disorder pathology, at least equivalent to CBT-E. Results will be used to inform the study design, sampling, likely effect sizes and choice of outcome measures for future larger trials of MIT-ED in ED samples.

Do People With Schizophrenia Enjoy Social Activities as Much as Everyone Else? A Meta-analysis of Consummatory Social Pleasure

BACKGROUND

The "emotion paradox" of schizophrenia suggests people with schizophrenia demonstrate deficits when reporting anticipated and retrospective pleasure; yet, in-the-moment, consummatory pleasure is largely intact. It is uncertain how these findings extend to social situations. This meta-analysis aimed to (1) determine the mean difference in consummatory social pleasure between people with schizophrenia and healthy controls, and (2) examine moderators of this effect, including study design and clinical characteristics of participants.

DESIGN

A literature search using PsycINFO, Web of Science, Pubmed, and EMBASE databases was conducted. Studies measuring consummatory social pleasure using experience sampling methods and laboratory social simulations were included. Random effects meta-analyses were conducted using Hedge's g.

RESULTS

Meta-analysis of 26 studies suggests people with schizophrenia exhibited a small, significant deficit in consummatory social pleasure (g = -0.38, 90% CI [-0.53, -0.22]). There was significant heterogeneity in effect sizes; magnitude was moderated by study design and type of measure used to assess social pleasure.

CONCLUSIONS

Overall, people with schizophrenia seem to exhibit less consummatory social pleasure than controls. However, this deficit is smaller than in studies of anticipated and retrospective pleasure. Thus, consummatory social pleasure may not be quite as impaired in people with schizophrenia as traditional anhedonia research suggests. Moreover, pleasure deficits observed in people with schizophrenia may result from differences in the quality of their daily social experiences rather than differences in their capacity for social pleasure. Results have important implications for clinical interventions that address barriers to social engagement, low-pleasure beliefs, and cognitive remediation to treat schizophrenia.

Contrasting the Social Cognitive and Metacognitive Capacities Among Patients With Schizophrenia and Autism Spectrum Disorders Enrolled in Psychiatric Rehabilitation

ABSTRACT

Unique deficits in synthetic metacognition have been found in schizophrenia when compared with other psychiatric conditions and community controls. Although persons with autism spectrum disorders (ASD) display similar deficits in social cognition relative to those with schizophrenia, to date no study has compared metacognitive function between these groups. We aimed to compare the metacognitive capacities of persons with schizophrenia and ASD and their associations with other outcomes (neurocognition, social cognition, depression, and quality of life). Fifty-six outpatients with schizophrenia or ASD (mean age, 32.50 [9.05]; 67.9% male) were recruited from two French Centers of Reference for Psychiatric Rehabilitation of the REHABase cohort. Evaluation included the Indiana Psychiatric Illness Interview, Metacognition Assessment Scale-Abbreviated, Movie for the Assessment of Social Cognition, and a large cognitive battery. Compared with those with schizophrenia, participants with ASD had higher self-reflectivity ( p = 0.025; odds ratio, 1.38 [1.05-1.86]) in univariable analyses. Metacognitive deficits may be found in ASD with a profile that varies from what is found in schizophrenia. It is possible that methods for enhancing metacognitive abilities during psychiatric rehabilitation may be refined to assist adults with ASD to better manage their own recovery.

Oxytocin administration versus emotion training in healthy males: considerations for future research

Identifying emotions correctly is essential for successful social interaction. There is therefore a keen interest in designing therapeutic interventions to improve emotion recognition in individuals who struggle with social interaction. The neuropeptide oxytocin has been proposed as a potential physiological intervention due to its important role in emotion recognition and other aspects of social cognition. However, there are a number of caveats to consider with the current form of intranasal oxytocin commonly used in the literature. Psychological interventions, on the other hand, do not carry the same caveats, and there is, therefore, a need to understand how intranasal oxytocin administration compares to psychological interventions designed to target the same psychological phenomena; and whether a combined intervention approach may provide additive benefits. Here we present a pilot, proof-of-concept study in healthy volunteers comparing the effect of intranasal oxytocin against a validated emotion training programme, finding that the psychological intervention, and not intranasal oxytocin, improved emotion recognition specifically for angry expressions. We discuss the theoretical implications of the research for future clinical trials. This article is part of the theme issue 'Interplays between oxytocin and other neuromodulators in shaping complex social behaviours'.

Metacognitive mastery moderates the relationship between positive symptoms and distress in adults with serious mental illness

BACKGROUND

Research supports the possibility that a person's metacognitive ability may influence the impact of positive symptoms. This connection is important because understanding how metacognitive capacity relates to positive symptoms and distress can guide treatment and bolster recovery.

AIMS

To explore this, we assessed the moderating role of Metacognitive Mastery on the relationship of positive symptoms to affective symptoms, or markers of distress, measured both concurrently and at a later time point (to assess durability of metacognition) with persons with serious mental illness. To rule out the possibility that any findings were the result of cognitive impairments or general psychopathology we included measures of neurocognition and symptoms as potential covariates.

METHODS

Participants were 67 individuals with the majority diagnosed with either schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were measured using the Brief Psychiatric Rating Scale and verbal memory was measured using the California Verbal Learning Test.

RESULTS

Metacognitive Mastery moderated the relationship between positive symptoms and affective symptoms at both time points with differential patterns at each point.

CONCLUSIONS

Metacognitive Mastery may exert a complex influence upon the effects of positive symptoms on distress.

Metacognitive interpersonal group therapy for adolescents with avoidant personality disorder: The case of Sofia

INTRODUCTION

Early intervention studies for adolescents and early adults are required to explore the acceptability and effectiveness of psychological therapies across the full range of personality disorders (PDs) beyond just borderline PD. The main aim of the current paper was to describe a Metacognitive Interpersonal Therapy group adaptation for adolescents (MIT-GA) presenting with PDs featuring overcontrol and social inhibition, and in particular Avoidant PD characteristics.

METHODS

We report findings from a single case of a female adolescent diagnosed with Avoidant PD providing preliminary data on feasibility and the possible effectiveness of MIT-GA.

RESULTS

Evidence of acceptability and meaningful clinical gains are described.

CONCLUSIONS

Results suggest that MIT-GA could be a powerful treatment option in patients with generalized social avoidance who do not currently receive gold-standard psychotherapeutic treatments. This intervention also appears to be effective and cost-effective in initiating significant clinical changes in profiles of young patients with non-borderline PD symptoms.

Gender Differences in Psychiatric Symptoms and the Social Functioning of 610 Patients with Schizophrenia in Urban China: A 10-Year Follow-Up Study

PURPOSE

To explore the different outcomes between male and female patients with schizophrenia after long-term follow-up.

PATIENTS AND METHODS

Schizophrenia patients were participants in our study. First, two senior psychiatrists collected data on the demographic characteristics and clinical symptoms of patients from the Hospital Information System between February 2009 and January 2010. Second, two other senior psychiatrists called the patients and their guardians between February 2019 and January 2020 to get general information on the patients and assess their psychiatric symptoms and social functioning using the Positive and Negative Syndrome Scale (PANSS) and the Personal and Social Performance (PSP) scale.

RESULTS

Of the 610 participants, the 306 female participants were younger (48.32 ± 12.99 vs 49.84 ± 12.60) and had received more education (8.08 ± 3.76 vs 7.94 ±3 0.73). After 10 years, women were found to have more outpatient visits than men (20.86 ± 22.21 vs 16.11 ± 16.87, P < 0.05). However, there was no significant gender difference in number of hospitalizations (3.12 ± 5.34 vs 2.77 ± 5.84, P > 0.05). The PANSS scores were lower for both groups at the 10-year follow-up. Women had significantly lower scores than men after the 10-year period (P < 0.05). With regard to social functioning, there was a significant difference in social functioning between baseline scores and 10-year follow-up scores indicating an improvement in social functioning. PSP scores had significantly increased in women (P < 0.01) but not in men (P > 0.05).

CONCLUSION

Female patients had significantly lower levels of psychiatric symptoms and higher levels of social functioning at 10-year follow-up than male patients. They also reported more outpatient visits, which may have contributed to the gender differences in outcomes. Family members and doctors of patients should urge patients to make regular outpatient visits for better outcomes after hospitalization.

Psychoeducation, motivational interviewing, cognitive remediation training, and/or social skills training in combination for psychosocial functioning of patients with schizophrenia spectrum disorders: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Psychoeducation, motivational interviewing, cognitive remediation training, and social skills training have been found to be effective interventions for patients with schizophrenia spectrum disorders. However, their efficacy on psychosocial functioning when provided in combination remains unclear, compared with all types of control conditions. It would also be meaningful to explore the differences of efficacy in patients with first-episode psychosis (FEP) and those with longer term of illness.

METHODOLOGY

The present review followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Full-text English journal articles of randomized controlled trials published in the past decade in the databases of PubMed, CINAHL Complete, Embase, and PsycINFO were searched. Included studies were all randomized controlled trials (RCTs) with participants diagnosed with schizophrenia spectrum disorders. The included studies should test combined interventions with at least two components from: psychoeducation, motivational interviewing, cognitive remediation training, and social skills training and incorporate assessment of psychosocial functioning at least at baseline and post-intervention.

RESULTS

Seven studies were included for systematic review, and six of them were eligible for meta-analysis. Five out of the seven studies reported effects on psychosocial functioning that favored combined interventions over any type of control condition. A significant pooled effect was derived from the six studies, SMD = 1.03, 95% CI [0.06, 2.00], Z = 2.09, p = 0.04, I ² = 96%. However, the pool effect became insignificant when synthesizing five of the studies with non-FEP patients as participants and four of the studies testing relative effects of combined interventions compared with stand-alone interventions/interventions with one less component. None of the included studies adopted motivational interviewing and only one of the studies worked with FEP patients.

CONCLUSION

Psychoeducation, cognitive remediation training, and social skills training in combination can effectively enhance psychosocial functioning of patients with schizophrenia spectrum disorders. It is warranted to conduct more RCTs to test the effects of different specific combinations of the above interventions on psychosocial functioning, especially in FEP patients.

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

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

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

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

The Effect of Mindfulness-Based Psychosocial Skills Training on Functioning and Insight Level in Patients with Schizophrenia

This study aims to determine the effect of mindfulness-based psychosocial skills training (MBPST) on the functional recovery and insight level in patients with schizophrenia. In this study, 40 patients with schizophrenia registered in the Aksaray Community Mental Health Centre were divided into two groups: the intervention group (n = 20) and the non-intervention group (n = 20). The Functional Recovery Scale in Schizophrenia (FRSS) and the Beck Cognitive Insight Scale (BCIS) were measured at preintervention and postintervention. The posttest mean scores of FRSS and BCIS of the intervention group were statistically higher than the non-intervention group (p < 0.05). The MBPST program improved functional recovery and cognitive insight in schizophrenia. In line with these results, it has been recommended that MBPST program should be provided along with medical treatment in Community Mental Health Centres.

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

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

Scoping review protocol on non-pharmacological interventions for interpersonal and self-directed violence in adults with severe mental illness

INTRODUCTION

Violence committed by people with mental illness has implications for mental health policy and clinical practice. Several strategies to reduce the risk of aggressive and violent behaviour have been proposed, and these include non-pharmacological interventions. There is, however, a need to identify which of these interventions are effective, and as a first step, we will conduct a scoping review to identify non-pharmacological interventions for self-directed or interpersonal violence in adults with severe mental illness across different conditions and settings.

METHODS AND ANALYSIS

This is a scoping review protocol. The review will include any randomised controlled trials (RCTs) and cluster RCTs that assess the efficacy of interventions on self-directed or interpersonal violence with no restrictions on the control treatment in people with severe mental illness in any setting. No restrictions will be applied in terms of language or date of publication. To identify studies, a search will be performed in the following databases: Embase, MEDLINE (via PubMed), PsycINFO, CINAHL, LILACS, SciELO, Cochrane Library, Web of Science, Scopus, ProQuest, Epistemonikos and databases of clinical trials. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement will be followed for reporting the findings, including the use of a PRISMA flow diagram. A standardised form will be used to extract data from studies. The findings will be classified using conceptual categories that will be specified in detail and a descriptive summary of the main results will be created. Moreover, it will be assessed whether the studies identified have been included in systematic reviews or meta-analyses and the results will be used to generate a conceptual map.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. We will prepare a manuscript for publication in a peer-reviewed journal and the results will be presented at mental health conferences.

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

PRACTITIONER POINTS

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

Improving social function with real-world social-cognitive remediation in schizophrenia: Results from the RemedRugby quasi-experimental trial

Background.

Functional capacity (FC) has been identified as a key outcome to improve real-world functioning in schizophrenia. FC is influenced by cognitive impairments, negative symptoms, self-stigma and reduced physical activity (PA). Psychosocial interventions targeting FC are still under-developed.

Methods.

we conducted a quasi-experimental study evaluating the effects of an exercise-enriched integrated social cognitive remediation (SCR) intervention (RemedRugby [RR]) compared with an active control group practicing Touch Rugby (TR). To our knowledge, this is the first trial to date evaluating the effectiveness of such a program provided in a real-life environment.

Results.

Eighty-seven people with schizophrenia were included and allocated to either the RR group (n = 57) or the TR group (n = 30) according to the routine clinical practice of the recruiting center. Outcomes were evaluated at baseline and post-treatment in both groups and after 6 months of follow-up in the RR group using standardized scales for symptom severity, social functioning, self-stigma, and a large cognitive battery. After treatment we observed moderate to large improvements in social function (Personal and Social Performance Scale [PSP], p < 0.001, d = 1.255), symptom severity (Positive and Negative Syndrome Scale [PANSS] negative, p < 0.001, d = 0.827; PANSS GP, p < 0.001, d = 0.991; PANSS positive, p = 0.009, d = 0.594), verbal abstraction (p = 0.008, d = 0.554), aggression bias (p = 0.008, d = 0.627), and self-stigma (stereotype endorsement, p = 0.019, d = 0.495; discrimination experiences, p = 0.047; d = 0.389) that were specific to the RR group and were not observed in participants playing only TR. Effects were persistent over time and even larger between post-treatment and follow-up.

Conclusions.

Exercise-enriched integrated SCR appears promising to improve real-life functioning in schizophrenia. Future research should investigate the potential effects of this intervention on neuroplasticity and physical fitness.

The Role of Personal Identity on Positive and Negative Symptoms in Psychosis: A Study Using the Repertory Grid Technique

BACKGROUND

People with psychosis experience disruptions in personal identity that affect positive and negative symptoms, but the complexity of these phenomena needs to be addressed in an in-depth manner. Using the Personal Construct Theory, we examined whether distinct dimensions of personal identity, as measured with the Repertory Grid Technique along with other cognitive factors, might influence psychotic symptomatology.

METHOD

Eighty-five outpatients with schizophrenia-spectrum disorders completed a repertory grid, an observed-rated interview of psychotic symptoms, and measures of cognitive insight, depressive symptoms, neurocognition, and theory of mind.

RESULTS

Structural equation models revealed that interpersonal dichotomous thinking directly affected positive symptoms. Self-discrepancies influenced positive symptoms by mediation of depressive symptoms. Interpersonal cognitive differentiation and interpersonal cognitive richness mediated the impact of self-reflectivity and neurocognitive deficits in negative symptomatology.

CONCLUSIONS

This study is the first of its kind to examine the structure of personal identity in relation to positive and negative symptoms of psychosis. Results suggest interventions targeted to improving interpersonal dichotomous thinking, self-discrepancies, interpersonal cognitive differentiation, and interpersonal cognitive richness may be useful in improving psychotic symptoms.

Brain Structural Correlates of Metacognition in First-Episode Psychosis

Metacognition is impaired in schizophrenia and is an important predictor of functional outcome, but the underlying neuropathology is not clear. Studies have implicated frontal regions and there is also some evidence that the hippocampus might play a pivotal role, but findings are inconsistent. We set out to more comprehensively investigate the neural underpinnings of insight in first-episode psychosis (FEP) using 2 metacognitive measures (the Beck Cognitive Insight Scale [BCIS]) and a perceptual metacognitive accuracy task alongside structural magnetic resonance imaging (MRI). We measured cortical thickness in insula and frontal regions, hippocampal (including subfield) volumes, hippocampal microstructure (using neurite orientation dispersion and density imaging [NODDI]), and fractional anisotropy in fornix. Relative to controls, FEP showed poorer metacognitive accuracy, thinner cortex in frontal regions and lower fornix integrity. In healthy controls (but not FEP), metacognitive accuracy correlated with cortical thickness in frontal cortex and insula. Conversely, in FEP (but not controls), metacognitive accuracy correlated with hippocampal volume and microstructural indices. Subicular hippocampal subregions were particularly implicated. No structural correlates of BCIS were found. These findings suggest that the neural bases of metacognition might differ in FEP: hippocampal (rather than frontal) integrity seems to be critical. Further, the use of objectively measured metacognitive indices seems to be a more powerful method for understanding the neurocircuitry of metacognition in FEP, which has the potential to inform therapeutic strategies and improve outcome in these patients.

The effect of assertiveness training in schizophrenic patients on functional remission and assertiveness level

PURPOSE

This research is conducted to evaluate the effect of assertiveness training in schizophrenic patients on functional remission and assertiveness level.

DESIGN AND METHODS

The research is designed as a randomized controlled trial with a pretest and posttest control group and repeated measures. Assertiveness training was carried out for a total of 8 weeks with the experimental group.

FINDINGS

Assertiveness training in schizophrenic patients was found to be effective in increasing the functional remission and assertiveness levels of patients.

PRACTICE IMPLICATIONS

Assertiveness training in schizophrenia should be implemented by psychiatric nurses within the scope of rehabilitation services.

Levels of Structural Integration Mediate the Impact of Metacognition on Functioning in Non-affective Psychosis: Adding a Psychodynamic Perspective to the Metacognitive Approach

Synthetic metacognition is defined by integrative and contextualizing processes of discrete reflexive moments. These processes are supposed to be needed to meet intrapsychic as well as interpersonal challenges and to meaningfully include psychotic experience in a personal life narrative. A substantial body of evidence has linked this phenomenon to psychosocial functioning and treatment options were developed. The concept of synthetic metacognition, measured with the Metacognition Assessment Scale-Abbreviated (MAS-A), rises hope to bridge gaps between therapeutic orientations and shares valuable parallels to modern psychodynamic constructs, especially the 'levels of structural integration' of the Operationalized Psychodynamic Diagnosis (OPD-2). As theoretical distinctions remain, aim of this study was to compare the predictive value of both constructs with regard to psychosocial functioning of patients with non-affective psychoses, measured with the International Classification of Functioning, Disability and Health (MINI-ICF-APP). It was further explored if levels of structural integration (OPD-LSIA) would mediate the impact of metacognition (MAS-A) on function (MINI-ICF-APP). Expert ratings of synthetic metacognition (MAS-A), the OPD-2 'levels of structural integration' axis (OPD-LSIA), psychosocial functioning (MINI-ICF-APP) and assessments of general cognition and symptoms were applied to 100 individuals with non-affective psychoses. Whereas both, MAS-A and OPD-LSIA, significantly predicted MINI-ICF-APP beyond cognition and symptoms, OPD-LSIA explained a higher share of variance and mediated the impact of MAS-A on MINI-ICF-APP. Levels of structural integration, including the quality of internalized object representations and unconscious interpersonal schemas, might therefore be considered as valuable predictors of social functioning and as one therapeutic focus in patients with non-affective psychoses. Structural integration might go beyond and form the base of a person's actual reflexive and metacognitive capabilities. Psychotherapeutic procedures specific for psychoses may promote and challenge a patient's metacognitive capacities, but should equally take the need for maturing structural skills into account. Modern psychodynamic approaches to psychosis are shortly presented, providing concepts and techniques for the implicit regulation of interpersonal experience and aiming at structural integration in this patient group.

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.

Effects of Metacognitive Training on Cognitive Insight in a Sample of Patients with Schizophrenia

Metacognitive training (MCT) is a group intervention that addresses cognitive biases and distortions that could help maintain delusions and hallucinations in people with schizophrenia. This program has proven its effectiveness in reducing the symptoms, but its impact on cognitive insight has scarcely been investigated. Therefore, the aim of the study was to assess the program’s impact on cognitive insight in patients with long-term schizophrenia. A sample of 22 patients with schizophrenia was divided into two groups: one received 16 sessions of MCT (n = 11), while the other received the usual treatment (n = 11). They were assessed using the Beck Cognitive Insight Scale which measures two components, self-reflection and self-certainty, and the Positive and Negative Syndrome Scale (PANSS). The experimental group showed high levels of adherence, an increase in self-reflection, and a decrease in self-assurance levels as hypothesized. We found statistically significant differences between the control and experimental groups in excitation, hostility, positive symptomatology total score, hallucinatory behavior, and suspicion. In the usual treatment group, a non-significant decrease in positive symptoms was also observed. The findings showed that the implementation of the MCT program in real clinical settings can contribute to an improvement in the metacognitive ability and symptomatology of people with schizophrenia.

Metacognitive Interpersonal Mindfulness-Based Training for Worry About Interpersonal Events: A Pilot Feasibility and Acceptability Study

Individuals with personality disorders experience worry and repetitive thoughts regarding interpersonal scenarios. Mainstream mindfulness-based approaches may be insufficient to soothe these individual's distress due to difficulties in letting thoughts go and refocusing attention to the present moment. For this reason, we devised an adapted form of mindfulness-based program called Metacognitive Interpersonal Mindfulness-Based Training (MIMBT) for personality disorders. In this pilot study, 28 individuals attended nine weekly sessions to evaluate the feasibility and acceptability, and to establish preliminary outcomes. All individuals completed the program. Attendance was very high (96%). Significant changes were observed on the primary outcome of reduction in repetitive thinking, measured using the Metacognition Questionnaire-30. We also observed a decrease in depression severity. Despite important limitations, this pilot study suggests that MIMBT has the potential to be a viable and well-accepted option for increasing positive outcomes in the treatment of personality disorders. Clinical considerations and directions for future research are discussed.

Metacognitive Interpersonal Therapy in group (MIT-G) for young adults with personality disorders: A pilot randomized controlled trial

Young adults with personality disorders (PD) other than borderline are in urgent need of validated treatments to help them in managing important life transitions. Therapeutic interventions focused upon social and interpersonal difficulties may facilitate these individuals in maximizing opportunities for employment, forming stable romantic relationships, and belong to social groups. It is also important that they are offered evidence-based, first-line time-limited treatments in order to maximize effectiveness and reduce costs. We developed a 16-session programme of group-based Metacognitive Interpersonal Therapy (MIT-G) including psychoeducation on the main interpersonal motives, an experiential component enabling practice of awareness of mental states; and use of mentalistic knowledge for purposeful problem-solving. We report a feasibility, acceptability, and clinical significance randomized clinical trial. Participants meeting inclusion criteria were randomized to receive MIT-G (n = 10) or waiting list+TAU (n = 10). Dropout rate was low and session attendance high (92.19%). Participants in the MIT-G arm had symptomatic and functional improvements consistent with large effect sizes. In the MIT-G arm similarly large effects were noted for increased capacity to understand mental states and regulate social interactions using mentalistic knowledge. Results were sustained at follow-up. Our findings suggest potential for applying MIT-G in larger samples to further test its effectiveness in reducing PD-related symptoms and problematic social functioning.

Exploring identity and personal meanings in psychosis using the repertory grid technique: A systematic review

Current research and clinical practice in person-centred approaches highlight the importance of self, identity, and personal meanings in psychosis. Previous research has focused on dimensions of self, but less attention has been paid to the personal meanings involved in identity. The personal construct theory framework and the repertory grid technique (RGT) allow the study of identity and personal meanings within person-centred approaches of psychopathology and treatment in psychosis, as suggested by studies that began more than 40 years ago. However, their contributions have not yet been reviewed. We aimed to systematically review the evidence for the role of identity and personal meanings in psychotic disorders. We performed a systematic search using personal construct and RGT terms in PsycINFO, Web of Science, PubMed, EBSCO, Scopus, and Google Scholar. After identifying 2,574 articles, 15 were included. Nine studies followed an idiographic assessment, and six were nomothetic. Patients reported their subjective experience of isolation in terms of high self-ideal discrepancy and high perceived discrepancy with their significant others, which some studies associated with a lower degree of recovery or with the way in which positive symptoms were construed. Self-fragmentation either decreased with interventions or was associated with recovery. Evidence regarding interpersonal construing was less consistent, but there was a tendency for patients to show a more rigid cognitive structure than controls. To conclude, we found some evidence that self-discrepancies, fragmentation of self, and interpersonal construing are affected in psychosis and potentially modifiable through psychotherapy.

Metacognitively oriented psychotherapy for schizotypal personality disorder: A two-case series

Schizotypal personality disorder represents a broad range of maladaptive behaviour, which has been linked to both personality disorder and schizophrenia spectrum disorders; however, to date, little effort has been devoted to developing psychosocial treatment approaches to address it. In response, we conducted two case studies exploring the effects of two metacognitively oriented forms of psychotherapy: metacognitive interpersonal therapy and metacognitive reflection and insight therapy for patients with schizotypal personality disorder. We chose these two forms of therapy as they have been successfully delivered, respectively, to persons with other personality disorders and schizophrenia spectrum disorders. Both treatments consisted of weekly individual psychotherapy sessions over a period of 6 months. General symptoms were assessed during the first week of treatment, at treatment end and at 1 month following treatment using the Symptom Check List-90-Revised, while schizotypal traits were assessed with the Structured Clinical Interview for DSM-5. Both patients completed all sessions, and there were no reports of any adverse outcomes. Both patients achieved reliable change in symptoms (ranging from 4.98 to 9.81) and a significant reduction in schizotypal features. Results provide preliminary evidence of the feasibility of metacognitively oriented interventions for schizotypal personality disorder. © 2019 John Wiley & Sons, Ltd.

Nonsocial and social cognition in schizophrenia: current evidence and future directions

Cognitive impairment in schizophrenia involves a broad array of nonsocial and social cognitive domains. It is a core feature of the illness, and one with substantial implications for treatment and prognosis. Our understanding of the causes, consequences and interventions for cognitive impairment in schizophrenia has grown substantially in recent years. Here we review a range of topics, including: a) the types of nonsocial cognitive, social cognitive, and perceptual deficits in schizophrenia; b) how deficits in schizophrenia are similar or different from those in other disorders; c) cognitive impairments in the prodromal period and over the lifespan in schizophrenia; d) neuroimaging of the neural substrates of nonsocial and social cognition, and e) relationships of nonsocial and social cognition to functional outcome. The paper also reviews the considerable efforts that have been directed to improve cognitive impairments in schizophrenia through novel psychopharmacology, cognitive remediation, social cognitive training, and alternative approaches. In the final section, we consider areas that are emerging and have the potential to provide future insights, including the interface of motivation and cognition, the influence of childhood adversity, metacognition, the role of neuroinflammation, computational modelling, the application of remote digital technology, and novel methods to evaluate brain network organization. The study of cognitive impairment has provided a way to approach, examine and comprehend a wide range of features of schizophrenia, and it may ultimately affect how we define and diagnose this complex disorder.