Metamemory in schizophrenia: retrospective confidence ratings interact with neurocognitive deficits

Hot metacognition: poorer metacognitive efficiency following acute but not traumatic stress

Aberrations to metacognition-the ability to reflect on and evaluate self-performance-are a feature of poor mental health. Theoretical models of post-traumatic stress disorder propose that following severe stress or trauma, maladaptive metacognitive evaluations and appraisals of the event drive the development of symptoms. Empirical research is required in order to reveal whether disruptions to metacognition cause or contribute to symptom development in line with theoretical accounts, or are simply a consequence of ongoing psychopathology. In two experiments, using hierarchical Bayesian modelling of metacognition measured in a memory recognition task, we assessed whether distortions to metacognition occur at a state-level after an acute stress induction, and/or at a trait-level in a sample of individuals experiencing intrusive memories following traumatic stress. Results from experiment 1, an in-person laboratory-based experiment, demonstrated that heightened psychological responses to the stress induction were associated with poorer metacognitive efficiency, despite there being no overall change in metacognitive efficiency from pre- to post-stress (N = 27). Conversely, in experiment 2, an online experiment using the same metamemory task, we did not find evidence of metacognitive alterations in a transdiagnostic sample of patients with intrusive memory symptomatology following traumatic stress (N = 36, compared to 44 matched controls). Our results indicate a relationship between state-level psychological responses to stress and metacognitive alterations. The lack of evidence for pre- to post-stress differences in metamemory illustrates the importance for future studies to reveal the direction of this relationship, and consequently the duration of stress-associated metacognitive impairments and their impact on mental health.

False Memories in Individuals With Stabilized Schizophrenia

This study aimed to examine the false memories in individuals with stabilized schizophrenia. Using the Deese, Roediger, and McDermott (DRM) task, schizophrenia patients and matched healthy controls had to recall words from each DRM list. Following the presentation of the DRM lists, the participants performed a recognition task. Neuropsychological tests were also administered. Results demonstrated that patients with schizophrenia recalled and recognized significantly fewer studied words than the healthy participants. This failure in retrieval is likely to result from a lack of encoding strategies. Results also showed that a stabilized schizophrenic pathology neither increased nor reduced false memories. Patients and controls showed high levels of false memories. Signal detection analyses revealed that patients discarded the critical word as not having been studied, relying on a lax decision criterion (based on familiarity, best guess or chance). Although false memories fell within the normal range for both groups, in individuals with schizophrenia they probably result from deficient encoding processes. Nevertheless, correlational analyses did not show which cognitive deficits contribute to false memories in schizophrenia.

Confidence in visual detection, familiarity and recollection judgments is preserved in schizophrenia spectrum disorder

An effective way to quantify metacognitive performance is to ask participants to estimate their confidence in the accuracy of their response during a cognitive task. A recent meta-analysis1 raised the issue that most assessments of metacognitive performance in schizophrenia spectrum disorders may be confounded with cognitive deficits, which are known to be present in this population. Therefore, it remains unclear whether the reported metacognitive deficits are metacognitive in nature or rather inherited from cognitive deficits. Arbitrating between these two possibilities requires equating task performance between experimental groups. Here, we aimed to characterize metacognitive performance among individuals with schizophrenia across three tasks (visual detection, familiarity, recollection) using a within-subject design while controlling experimentally for intra-individual task performance and statistically for between-subject task performance. In line with our hypotheses, we found no metacognitive deficit for visual detection and familiarity judgments. While we expected metacognition for recollection to be specifically impaired among individuals with schizophrenia, we found evidence in favor of an absence of a deficit in that domain also. We found no specific metacognitive deficit in schizophrenia spectrum disorder in the visual or memory domain. The clinical relevance of our findings is discussed in light of a hierarchical framework of metacognition.

Investigating False Memory and Illusory Pattern Perception Bias in Schizophrenia Patients with and without Delusions

Background

Whether the false memory dysfunction in schizophrenia is at the early (encoding, perceptual) or later (retrieval) stages and how delusions affect it remains unclear.

Method

In this study, we examined the perception and memory biases in schizophrenia patients with (Sch/D; n = 31) and without delusions (Sch/Nd; n = 32) and compared them with healthy controls (HCs; n = 35). We used the Deese Roediger McDermott (DRM) Paradigm and the Noise Task to measure the false memory and illusory pattern perception (IPP) biases, respectively.

Results

We found that the patient groups performed lower in both the recall and recognition phases for the DRM and the Noise tasks and made more errors compared to the HC group. Additionally, the performance of the Sch/D group was remarkably lower than the Sch/Nd and HC groups.

Conclusions

Our results indicated that the information-processing problem in schizophrenia exists in both the encoding and retrieval stages. Also found significant relationship between the presence of delusions and the increase in cognitive deficits.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10393-6.

Influence of emotional stimuli on metacognition: A study in arithmetic

We investigate the role of negative emotional stimuli on direct and indirect metacognition, and document age-related differences in this role during adulthood. Participants were presented with negative or neutral pictures while asked to select which of two available strategies was the better strategy to find approximate estimates of two-digit multiplication problems. Following each strategy selection, participants provided either a direct (confidence judgment; Expt. 1) or an indirect (opt-out judgment; Expt. 2) evaluation of their strategy choice. Negative emotional stimuli decreased metacognitive accuracy for arithmetic strategy selection, but only when indirect metacognitive measures were collected. No differences were found when direct metacognitive judgments were requested. The effects of emotional stimuli on indirect metacognition and lack of effects on direct metacognition were found in both young and older adults. These findings have important implications for our understanding of the mechanisms underlying the effects of emotion on metacognition in young and older adults.

Psychiatrically relevant signatures of domain-general decision-making and metacognition in the general population

Human behaviours are guided by how confident we feel in our abilities. When confidence does not reflect objective performance, this can impact critical adaptive functions and impair life quality. Distorted decision-making and confidence have been associated with mental health problems. Here, utilising advances in computational and transdiagnostic psychiatry, we sought to map relationships between psychopathology and both decision-making and confidence in the general population across two online studies (N's = 344 and 473, respectively). The results revealed dissociable decision-making and confidence signatures related to distinct symptom dimensions. A dimension characterised by compulsivity and intrusive thoughts was found to be associated with reduced objective accuracy but, paradoxically, increased absolute confidence, whereas a dimension characterized by anxiety and depression was associated with systematically low confidence in the absence of impairments in objective accuracy. These relationships replicated across both studies and distinct cognitive domains (perception and general knowledge), suggesting that they are reliable and domain general. Additionally, whereas Big-5 personality traits also predicted objective task performance, only symptom dimensions related to subjective confidence. Domain-general signatures of decision-making and metacognition characterise distinct psychological dispositions and psychopathology in the general population and implicate confidence as a central component of mental health.

Systematic review and meta-analysis of metacognitive abilities in individuals with schizophrenia spectrum disorders

Metacognitive deficits are well documented in schizophrenia spectrum disorders as a decreased capacity to adjust confidence to performance in a cognitive task. Because metacognitive ability directly depends on task performance, metacognitive deficits might be driven by lower task performance among patients. To test this hypothesis, we conducted a Bayesian meta-analysis of 42 studies comparing metacognitive abilities in 1425 individuals with schizophrenia compared to 1256 matched controls. We found a global metacognitive deficit in schizophrenia (g = -0.57, 95 % CrI [-0.72, -0.43]), which was driven by studies which did not control task performance (g = -0.63, 95 % CrI [-0.78, -0.49]), and inconclusive among controlled-studies (g = -0.23, 95 % CrI [-0.60, 0.16], BF₀₁ = 2.2). No correlation was found between metacognitive deficit and clinical features. We provide evidence that the metacognitive deficit in schizophrenia is inflated due to non-equated task performance. Thus, efforts should be made to develop experimental protocols accounting for lower task performance in schizophrenia.

Confidence in visual motion discrimination is preserved in individuals with schizophrenia

BACKGROUND

Metacognition is the set of reflexive processes that allows humans to evaluate the accuracy of their mental operations. Metacognitive deficits have been described in people with schizophrenia using mostly narrative assessment, and they have been linked to several key symptoms.

METHODS

We assessed metacognitive performance objectively by asking people with schizophrenia or schizoaffective disorder (n = 20) and matched healthy participants (n = 21) to perform a visual discrimination task and report their confidence in their performance. Metacognitive performance was defined as the adequacy between visual discrimination performance and confidence.

RESULTS

Bayesian analyses revealed equivalent metacognitive performance in the 2 groups, despite a weaker association between confidence and trajectory tracking during task execution among people with schizophrenia. We reproduced these results using an evidence accumulation model, which showed similar decisional processes in the 2 groups.

LIMITATIONS

These results from a relatively small study sample cannot be generalized to other perceptual and nonperceptual tasks. To meet this purpose, ecological tasks are needed. As well, the role of antipsychotic medication and design deserves greater attention in the future.

CONCLUSION

We found similar decisional and metacognitive capabilities between people with schizophrenia and healthy controls in a visual discrimination task.

Using virtual reality to explore differences in memory biases and cognitive insight in people with psychosis and healthy controls

Memory biases (e.g. overconfidence in false memories) are implicated in the pathogenesis of delusions. Virtual reality (VR) may provide an opportunity to observe such biases and improve cognitive insight in patients with psychosis via corrective feedback. Thirty-nine patients with psychosis and 20 healthy controls explored VR environments designed to elicit false memories and subsequently had to recollect items and faces. We used a randomised-controlled design where half of the sample received performance feedback on the recollection task in order to correct overconfidence. Changes in cognitive insight were measured using the Beck Cognitive Insight Scale. Regarding accuracy, patients performed worse on the social task (recollection of faces) only. Patients displayed overconfidence in false memories for emotions and gave more high-confident responses compared to healthy controls on the social task. Feedback did not improve cognitive insight. Patients rated their cognitive insight higher than healthy controls. Future research should address problems with subjective measurements for cognitive insight. To conclude, patients with psychosis showed impaired social cognition and there was evidence for impaired metacognition, as patients reported higher cognitive insight despite comparable or worse performance as well as overconfidence relative to controls.

Abnormalities of confidence in psychiatry: an overview and future perspectives

Our behavior is constantly accompanied by a sense of confidence and its' precision is critical for adequate adaptation and survival. Importantly, abnormal confidence judgments that do not reflect reality may play a crucial role in pathological decision-making typically seen in psychiatric disorders. In this review, we propose abnormalities of confidence as a new model of interpreting psychiatric symptoms. We hypothesize a dysfunction of confidence at the root of psychiatric symptoms either expressed subclinically in the general population or clinically in the patient population. Our review reveals a robust association between confidence abnormalities and psychiatric symptomatology. Confidence abnormalities are present in subclinical/prodromal phases of psychiatric disorders, show a positive relationship with symptom severity, and appear to normalize after recovery. In the reviewed literature, the strongest evidence was found for a decline in confidence in (sub)clinical OCD, and for a decrease in confidence discrimination in (sub)clinical schizophrenia. We found suggestive evidence for increased/decreased confidence in addiction and depression/anxiety, respectively. Confidence abnormalities may help to understand underlying psychopathological substrates across disorders, and should thus be considered transdiagnostically. This review provides clear evidence for confidence abnormalities in different psychiatric disorders, identifies current knowledge gaps and supplies suggestions for future avenues. As such, it may guide future translational research into the underlying processes governing these abnormalities, as well as future interventions to restore them.

Holding on to false beliefs: The bias against disconfirmatory evidence over the course of psychosis

BACKGROUND AND OBJECTIVES

The ability to integrate evidence into a reasoning process is crucial in order to react to changing information, e.g. to adapt one's beliefs according to new evidence or to generate new beliefs when facing better alternatives. Evidence integration ability is thus associated with belief flexibility. A specific bias of evidence integration, a bias against disconfirmatory evidence (BADE), can be found in patients with schizophrenia and has been linked to delusion development and maintenance. Knowledge about whether the BADE occurs already in risk constellations of psychosis can clarify its role in the pathogenesis of psychosis.

METHODS

This article reviews the current literature on BADE. Many studies demonstrate BADE over the course of illness, ranging from healthy controls with subclinical properties of schizotypy, over patients with at-risk mental states (ARMS) and patients with a first episode of psychosis to patients with chronic schizophrenia. These data allow a comparison of competences and deficits over the course of illness. Underlying mechanisms of BADE are discussed, including interrelations with neurocognitive performance and dopaminergic processes.

RESULTS

The BADE could be found in different phases of psychosis development and can be regarded as a cognitive marker of the beginning psychotic state.

LIMITATIONS

The presented findings are derived from independent cross-sectional studies. So far, no comprehensive longitudinal assessment has been published.

CONCLUSIONS

Treatments of metacognitive deficits in general and as early as in the ARMS might interfere with the cognitive pathogenesis of psychosis, and thereby ameliorate, postpone or even prevent the transition to psychosis.

The Importance of Metamemory Functioning to the Pathogenesis of Psychosis

Many studies up to date have implied that biases in the metacognition of memory, so called metamemory, contribute to the development and maintenance of positive symptoms in schizophrenia. However, no study exists which has longitudinally followed patients experiencing positive symptoms. The present article therefore reviews cross-sectional studies on retrospective metamemory abilities in participants within different stages of a schizophrenia spectrum disorder, with heterogeneous symptom severities, creating a pseudo-longitudinal overview. Summarized, a deterioration of these abilities correlating with psychosis development can be inferred. The reviewed publications indicate that metamemory biases can already be found in patients with an at-risk mental state for psychosis (ARMS). Patients in their first episode of psychosis (FEP) seem to be more severely impaired than ARMS-patients but similarly affected compared to chronic patients. The contribution of these biases to the pathogenesis of psychosis is discussed, giving consideration to relations with other cognitive- and metacognitive functions, neurochemical processes and neural correlates. It is hypothesized that the biases represent early cognitive markers of the beginning and persisting psychotic state. An early treatment program could help patients to ameliorate the general course of illness or even to prevent the risk of a transition to psychosis.

Overconfidence across the psychosis continuum: a calibration approach

INTRODUCTION

An 'overconfidence in errors' bias has been consistently observed in people with schizophrenia relative to healthy controls, however, the bias is seldom found to be associated with delusional ideation. Using a more precise confidence-accuracy calibration measure of overconfidence, the present study aimed to explore whether the overconfidence bias is greater in people with higher delusional ideation.

METHODS

A sample of 25 participants with schizophrenia and 50 non-clinical controls (25 high- and 25 low-delusion-prone) completed 30 difficult trivia questions (accuracy <75%); 15 'half-scale' items required participants to indicate their level of confidence for accuracy, and the remaining 'confidence-range' items asked participants to provide lower/upper bounds in which they were 80% confident the true answer lay within.

RESULTS

There was a trend towards higher overconfidence for half-scale items in the schizophrenia and high-delusion-prone groups, which reached statistical significance for confidence-range items. However, accuracy was particularly low in the two delusional groups and a significant negative correlation between clinical delusional scores and overconfidence was observed for half-scale items within the schizophrenia group. Evidence in support of an association between overconfidence and delusional ideation was therefore mixed.

CONCLUSIONS

Inflated confidence-accuracy miscalibration for the two delusional groups may be better explained by their greater unawareness of their underperformance, rather than representing genuinely inflated overconfidence in errors.

Bias against disconfirmatory evidence in the 'at-risk mental state' and during psychosis

Prior studies have confirmed a bias against disconfirmatory evidence (BADE) in schizophrenia which has been associated with delusions. However, its role in the pathogenesis of psychosis is yet unclear. The objective was to investigate BADE for the first time in subjects with an at-risk-mental-state for psychosis (ARMS), patients with a first episode of psychosis without antipsychotic treatment (FEP) and healthy controls (HC). A standard BADE test presenting written scenarios was employed. In addition, psychometric rating scales and a neuropsychological test battery were applied. A three-staged image was revealed. FEP-patients showed a significant BADE compared to the other groups. The performance of ARMS-patients lay in between HC and FEP-patients. A trend towards significance became evident for a bias against confirmatory evidence (BACE) in FEP-patients. Results were not attributable to antipsychotic or other medication or depressive symptoms. Correlations with delusions reached medium effect sizes but failed significance after Bonferroni-corrections. These results provide evidence for aberrations in evidence integration in the pathogenesis of psychosis and contribute to our knowledge of metacognitive functioning which can be used for (meta-)cognitive intervention in psychosis.

Investigation of metamemory functioning in the at-risk mental state for psychosis

BACKGROUND

Metamemory describes the monitoring and knowledge about one's memory capabilities. Patients with schizophrenia have been found to be less able in differentiating between correct and false answers (smaller confidence gap) when asked to provide retrospective confidence ratings in previous studies. Furthermore, higher proportions of very-high-confident but false responses have been found in this patient group (high knowledge corruption). Whether and how these biases contribute to the early pathogenesis of psychosis is yet unclear. This study thus aimed at investigating metamemory function in the early course of psychosis.

METHOD

Patients in an at-risk mental state for psychosis (ARMS, n = 34), patients with a first episode of psychosis (FEP, n = 21) and healthy controls (HCs, n = 38) were compared on a verbal recognition task combined with retrospective confidence-level ratings.

RESULTS

FEP patients showed the smallest confidence gap, followed by ARMS patients, followed by HCs. All groups differed significantly from each other. Regarding knowledge corruption, FEP patients differed significantly from HCs, whereas a statistical trend was revealed in comparison of ARMS and FEP groups. Correlations were revealed between metamemory, measures of positive symptoms and working memory performance.

CONCLUSIONS

These data underline the presence of a metamemory bias in ARMS patients which is even more pronounced in FEP patients. The bias might represent an early cognitive marker of the beginning psychotic state. Longitudinal studies are needed to unravel whether metacognitive deficits predict the transition to psychosis and to evaluate therapeutic interventions.