Metacognitive knowledge and experience in recently diagnosed patients with bipolar disorder

Cognitive Remediation in Bipolar (CRiB2): study protocol for a randomised controlled trial assessing efficacy and mechanisms of cognitive remediation therapy compared to treatment as usual

BACKGROUND

A substantial proportion of people with bipolar disorder (BD) experience persistent cognitive difficulties associated with impairments in psychosocial functioning and a poorer disorder course. Emerging evidence suggests that cognitive remediation (CR), a psychological intervention with established efficacy in people with schizophrenia, can also benefit people with BD. Following a proof-of-concept trial showing that CR is feasible and potentially beneficial for people with BD, we are conducting an adequately powered trial in euthymic people with BD to 1) determine whether an individual, therapist-supported, computerised CR can reduce cognitive difficulties and improve functional outcomes; and 2) explore how CR exerts its effects.

METHODS

CRiB2 is a two-arm, assessor-blind, multi-site, randomised controlled trial (RCT) comparing CR to treatment-as-usual (TAU). Participants are people with a diagnosis of BD, aged between 18 and 65, with no neurological or current substance use disorder, and currently euthymic. 250 participants will be recruited through primary, secondary, tertiary care, and the community. Participants will be block-randomised (1:1 ratio, stratified by site) to continue with their usual care (TAU) or receive a 12-week course of therapy and usual care (CR + TAU). The intervention comprises one-on-one CR sessions with a therapist supplemented with independent cognitive training for 30-40 h in total. Outcomes will be assessed at 13- and 25-weeks post-randomisation. Efficacy will be examined by intention-to-treat analyses estimating between-group differences in primary (i.e., psychosocial functioning at week 25 measured with the Functional Assessment Short Test) and secondary outcomes (i.e., measures of cognition, mood, patient-defined goals, and quality of life). Global cognition, metacognitive skills, affect fluctuation, and salivary cortisol levels will be evaluated as putative mechanisms of CR through mediation models.

DISCUSSION

This study will provide a robust evaluation of efficacy of CR in people with BD and examine the putative mechanisms by which this therapy works. The findings will contribute to determining the clinical utility of CR and potential mechanisms of action.

TRIAL REGISTRATION

Cognitive Remediation in Bipolar 2 (CRiB2): ISRCTN registry: https://www.isrctn.com/ISRCTN10362331 . Registered 04 May 2022. Overall trial status: Ongoing; Recruitment status: Recruiting.

Do depressed patients really over-report cognitive impairment?

BACKGROUND

Depressed patients report more severe cognitive impairment than is detectable by neuropsychological tests because they may underestimate their cognitive performance. Alternatively, it is possible that cognitive impairment primarily occurs under everyday life conditions as referred to in most questionnaires. The aim of the present study is to investigate the validity of self-reports in patients with major depression in order to better understand the pronounced impairment in self-reports.

METHODS

We investigated 58 patients with major depression and 28 heathy control participants. We administered the "Screen for Cognitive Impairment in Psychiatry" (SCIP) to assess cognitive performance, the "Questionnaire for Cognitive Complaints" (FLei), and the newly developed scale for "Self-Perception of Cognitive Performance in everyday life and test settings" to ask for the self-assessed cognitive performance in everyday life and in a test situation more specifically.

RESULTS

Depressed patients showed an inferior test performance and reported much more general everyday life related cognitive problems compared to healthy participants. When asked more specifically for their cognitive performance in the test-situation compared to others and compared to everyday life, they did not report more test-related and everyday life related impairment than healthy participants did.

LIMITATIONS

Results might be influenced by comorbidity.

CONCLUSIONS

These results have implications for the assessment of subjective cognitive performance of depressed patients and shed light on the negative effects of general versus more specific recall of autobiographical information.

Does cognitive improvement translate into functional changes? Exploring the transfer mechanisms of cognitive remediation therapy for euthymic people with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with cognitive and functional difficulties, persistent beyond mood episodes. Cognitive remediation (CR) is a psychological therapy targeting cognitive and functioning difficulties. Recent evidence suggests that CR may enhance long-term functioning but transfer mechanisms on functional outcomes have not been explored. We aim to investigate whether and how cognitive gains after CR transfer to functional improvement.

METHODS

We considered data from a randomized controlled trial comparing CR (n = 40) to treatment-as-usual (TAU; n = 40) in euthymic people with BD. Treatment outcomes included individual cognitive domains and global cognition, psychosocial functioning, and goal attainment. Regression-based mediation and moderation modelling were used to assess whether and how post-treatment cognitive changes translate into functional improvement at follow-up, three months after treatment end.

RESULTS

Cognitive gains after CR transferred to functional changes three months later: improvement in post-treatment global cognition partially mediated the effect of CR on psychosocial functioning (standardized indirect effect: -0.23, 95% CI -0.51 to -0.04). Goal attainment was not significantly mediated by changes in cognition, but post-treatment cognitive performance moderated the effect of CR on the GAS at follow-up (interaction effect: 0.78, 95% CI 0.08-1.55).

CONCLUSIONS

Our findings suggest that cognitive improvements contribute to functional improvement but transfer mechanisms differ between psychosocial functioning and idiosyncratic recovery goals. Cognition accounted for only a proportion of the total CR effect on functional outcomes. Future studies should consider other variables, such as metacognition, that may drive the transfer of CR effects to functional outcomes.

Revisiting the dynamic comprehensive model of self-awareness: a scoping review and thematic analysis of its impact 20 years later

This study aimed to (1) describe the scope of research related to the Dynamic Comprehensive Model of Awareness (DCMA) (Toglia & Kirk, 2000); (2) identify themes and support for key model postulates; and (3) suggest future research directions related to this model. Using PRISMA scoping guidelines, 366 articles were reviewed, and 54 articles met our inclusion criteria. Selected studies were clustered into three themes: (1) the relationship between general and online self-awareness (50%); (2) interventions based on the model (41%); and (3) factors contributing to self-awareness (9%). Most studies were conducted with participants with acquired brain injury (BI) and traumatic BI (68%), most used a cross-sectional design (50%), and most intervention studies utilized a single-subject design (18%), followed by an experimental design (9%). This review provides evidence for the wide application of the DCMA across varying ages and populations. The need for a multidimensional assessment approach is recognized; however, stronger evidence that supports a uniform assessment of online self-awareness is needed. The intervention studies frequently described the importance of direct experience in developing self-awareness; however, few studies compared how intervention methods to influence general versus online self-awareness, or how cognitive capacity, self-efficacy, psychological factors, and context, influence the development of self-awareness.

Association between discrepancy in objective and subjective cognitive abilities and treatment response in patients with major depressive disorder: A CAN-BIND-1 study report

BACKGROUND

Major Depressive Disorder (MDD) is characterized by objective and subjective cognitive deficits. Discrepancies between objective and subjective cognitive performance can reflect under- to over-estimations of cognitive abilities, and these discrepancies are referred to as cognitive self-appraisals. Despite evidence that low self-appraisals are associated with depression, the modifiability of self-appraisals and their association with treatment outcome remains unclear. The current study examined whether self-appraisals change following antidepressant treatment. Furthermore, we investigated the association of self-appraisals with treatment outcome.

METHODS

As part of the CAN-BIND-1 clinical trial, 154 patients with MDD completed measures of objective and subjective cognitive abilities, depressive symptoms, and functional outcomes (work productivity, psychosocial functioning, and quality of life) at baseline and post-escitalopram treatment. Self-appraisals were calculated based on discrepancies between objective and subjective cognitive abilities, with higher scores indicating overestimation of cognitive abilities.

RESULTS

Baseline self-appraisals were not predictive of treatment outcomes. However, self-appraisals increased from pre- to post-treatment. Moreover, pre-post treatment increases in self-appraisals were associated with positive treatment response and remission, decreases in depressive symptoms, and improvements in work productivity, psychosocial functioning, and quality of life.

LIMITATIONS

The pre-post intervention design precluded examining the temporal precedence of change in self-appraisals versus depressive symptoms and functional outcomes.

CONCLUSIONS

Findings are the first to demonstrate that self-appraisals are treatment-sensitive and are associated with treatment outcomes and recovery from MDD. Cognitive self-appraisals may represent a key marker of treatment response and a valuable target for assessment and intervention, as well as a potential mechanism underlying risk and recovery.

Exploring Clinical Correlates of Metacognition in Bipolar Disorders Using Moderation Analyses: The Role of Antipsychotics

The determinants of metacognition are still poorly understood in bipolar disorders (BD). We aimed to examine the clinical determinants of metacognition, defined as the agreement between objective and subjective cognition in individuals with BD. The participants consisted of 281 patients with BD who underwent an extensive neuropsychological battery and clinical evaluation. To assess subjective cognition, participants provided a general rating of their estimated cognitive difficulties. Clinical characteristics of BD were also recorded, along with medication. We studied the potential moderation of the association between cognitive complaints and global objective cognitive performance by several clinical variables with ordinal logistic regressions. Depression and impulsivity were associated with greater cognitive complaints. The only variable that moderated the relationship between objective and subjective cognition in the global model was the prescription of antipsychotics. Patients taking antipsychotics had a poorer association between cognitive complaints and objective neuropsychological performance. This result suggests a role for dopamine in the modulation of metacognitive performance, and calls for the systematic control of antipsychotic medication in future studies documenting metacognitive deficits in severe and persistent mental disorders. Depression and impulsivity should be investigated as potential therapeutic targets for individuals with BD and cognitive complaints, before proposing an extensive neuropsychological evaluation.

Metacognitive knowledge and experience across multiple cognitive domains in euthymic bipolar disorder

Background

Metacognitive knowledge (MK; general awareness of cognitive functioning) and metacognitive experience (ME; awareness of cognitive performance on a specific cognitive task) represent two facets of metacognition that are critical for daily functioning, but are understudied in bipolar disorder. This study was conducted to evaluate MK and ME across multiple cognitive domains in individuals diagnosed with bipolar disorder and unaffected volunteers, and to investigate the association between metacognition and quality of life (QoL).

Methods

Fifty-seven euthymic participants with bipolar disorder and 55 demographically similar unaffected volunteers provided prediction and postdiction ratings of cognitive task performance across multiple cognitive domains. Self-ratings were compared to objective task performance, and indices of MK and ME accuracy were generated and compared between groups. Participants rated QoL on the Quality of Life in Bipolar Disorder Scale (QoL.BD).

Results

Metacognitive inaccuracies in both MK and ME were observed in participants with bipolar disorder, but only in select cognitive domains. Furthermore, most metacognitive inaccuracies involved underestimation of cognitive ability. Metacognitive indices were minimally associated with medication variables and mood symptoms, but several indices were related to QoL.

Conclusions

Individuals with bipolar disorder demonstrate inaccuracies in rating their cognitive functioning and in rating their online cognitive task performance, but only on select cognitive functions. The tendency to underestimate performance may reflect a negative information processing bias characteristic of mood disorders. Metacognitive variables were also predictive of QoL, indicating that further understanding of cognitive self-appraisals in persons with bipolar disorder has significant clinical relevance.

Metacognition in adult ADHD: subjective and objective perspectives on self-awareness of cognitive functioning

Although attention deficit hyperactivity disorder (ADHD) in adulthood is associated with marked cognitive impairment, research on metacognition in adult ADHD is scarce. Deficits in metacognition may have a negative impact on treatment adherence, functional outcomes, and everyday life. This study explores metacognition, specifically self-awareness of cognitive performance, in adults with ADHD by combining objective and subjective assessments. Forty-seven patients with ADHD and 47 control individuals completed a neuropsychological assessment battery including tests for attention, executive functions and memory (objective assessment), as well as questionnaires for cognitive functioning and symptom severity (subjective assessment; self- and informant-report). Participants evaluated their test performance of the objective assessment after test completion by selecting a percentile rank which was subtracted from their normed test result, yielding a discrepancy score. Compared to controls, adults with ADHD showed impairments in attention (medium effects) and memory (small and medium effects), but not in executive functions. The discrepancy scores between self-evaluation and cognitive performance revealed deficits in self-awareness of attentional functions (small effects), but not in executive functions and memory in patients with ADHD compared to controls. Discrepancy scores between self- and informant-reports of cognitive functioning revealed no significant differences. Adults with ADHD show impairments in metacognition in attentional functions, but may have intact metacognitive abilities in other domains. Patients with ADHD tend to overestimate their abilities, especially in attentional functions. Subjective and objective measures of metacognition may not correspond, highlighting the need for clinicians to not solely rely on patients' self-report in their assessment.

Cognitive remediation for the treatment of neuropsychological disturbances in subjects with euthymic bipolar disorder: findings from a controlled study

INTRODUCTION

Individuals with euthymic Bipolar Disorder (BD) can experience deteriorated cognitive functioning, with such deterioration being associated with functional impairment. Cognitive remediation (CR) is considered an effective add-on intervention for neuropsychological impairments, but relatively few CR controlled studies have been performed on BD. In the present study the efficacy of a CR intervention designed for the improvement of cognition and functioning in patients with euthymic BD was tested.

METHODS

Patients (n = 54) with euthymic BD were assigned to receive active (n = 27) or control (n = 27) intervention. The active intervention (i.e. the Cognitive Remediation in Integrated Treatment - CRIIT - protocol) was made of 20 individual sessions focused on the treatment of attention, memory and executive functioning through the COGPACK software; each session was integrated with psychoeducation and rehabilitation interventions implemented through a metacognitive approach aimed at ameliorating personal agency.

RESULTS

A significant (p ≤ 0.015) time x group interaction at repeated measures MANOVA was observed on Rey Auditory Verbal Learning Test, Rey Complex Figure Test, Wisconsin Card Sorting Test, Trail Making Test, Visual Search, Life Skills Profile, and Barratt Impulsiveness Scale.

LIMITATIONS

A single-blind approach was used.

DISCUSSION

The results showed that patients undergoing active intervention improved in domains related to executive functions, attention, memory, functioning and impulsivity more significantly than patients undergoing control interventions. This study adds to the evidence that CR improves neurocognition in BD, and suggests that CRIIT protocol represents an add-on intervention of potential relevance to increase cognition and functioning in BD euthymic patients.

Metacognitive functioning in bipolar disorder versus controls and its correlations with neurocognitive functioning in a cross-sectional design

INTRODUCTION

Metacognition is an important factor in the development and persistence of bipolar disorder. One of the most striking examples of impairment in metacognitive functioning in bipolar disorder is the lack of insight these patients have in their disorder. Despite its importance, research regarding metacognition in bipolar disorder is scarce. Furthermore, the neurocognitive basis of metacognitive functioning is unknown.

METHODS

The current study included 29 patients with bipolar disorder and 29 age, educational level and gender matched healthy controls. All the participants filled in a metacognition questionnaire that examined their metacognitive beliefs. In addition, it was tested how well they estimated their performance on a neurocognitive test-battery beforehand (metacognitive knowledge) and afterwards (metacognitive experience).

RESULTS

Bipolar disorder patients showed maladaptive metacognitive beliefs in comparison with the healthy controls. They also showed impaired metacognitive knowledge and experience. That is, they overestimated their own cognitive performance. However, the latter result was also true for the healthy controls. In addition, metacognition had neurocognitive correlates. However, for the bipolar patients, depressive symptomatology had an important effect on this relationship and on metacognition in general.

CONCLUSION

Maladaptive metacognitive skills are related to depression in bipolar disorder. A more healthy metacognitive thinking should be promoted. An effective training for this could be a therapy that includes various elements, from basic cognitive- to higher order metacognitive training.

Discrepancy between objective and subjective cognition in major depressive disorder

Objective and subjective cognitive measures are altered in major depressive disorder (MDD), but there is a poor correlation between them. This study aims to explore such discrepancy and the characteristics explaining this phenomenon. 229 patients with MDD subdivided into remitted (n = 57), partially remitted (n = 90) and acute (n = 82) underwent a clinical interview, completed self-report questionnaires and a neuropsychological assessment. The association between objective and subjective cognition was evaluated in the areas of attention and memory. Also, dependent measures of concordance and self-appraisal were calculated for each patient. Potential predictors of these outcomes were evaluated through regression analysis. Depressive symptoms correlated negatively with objective but especially with subjective cognition. Patients in an acute episode showed a significant correlation between objective and subjective attention/memory measures, but also the greatest underestimation of their cognitive performance. In those with fewer depressive symptoms, objective and subjective cognition showed poor correspondence between them. In the regression analyses with the full MDD sample, higher scores on depressive symptoms, intelligence quotient and executive functions predicted lower self-appraisal. Objective and subjective cognition show poor concordance in MDD patients, especially in those with residual mood symptoms. Higher executive functions also explain this discrepancy. Assessments of both subjective cognitive complaints and objective performance seem necessary as they may be measuring different aspects of cognitive functioning.

Mood and Personality Characteristics are Associated with Metamemory Knowledge Accuracy in a Community-Based Cohort of Older Adults

OBJECTIVES

Emerging work reveals the neuroanatomic changes that compromise metacognition; however, little is known about the impact of premorbid factors. Research suggests that psychological variables influence the perception of cognition, but whether they influence the accuracy of those perceptions (i.e., metacognition) has not been directly examined.

PARTICIPANTS AND METHODS

Using Latent Class Analysis (LCA), we tested for discrete personality (NEOFFI) and mood (STAI, BDI-II, and GDS) classes among a community-based cohort of 151 older adults, enrolled in the NKI-Rockland study. Metamemory was calculated by comparing subjective memory ratings (modified Cognitive Failures Questionnaire) to objective memory (Rey Auditory Verbal Learning Test) to determine the degree to which individuals were overconfident, underconfident, or accurate in their self-assessment. A generalized linear model was used to examine whether metamemory differed across the emergent classes. A one sample t test was used to determine whether the metamemory scores of the emergent classes were statistically significantly different from zero, that is, over or under confident.

RESULTS

Two discrete classes emerged in the LCA: Class 1 was characterized predominantly by high extraversion and conscientiousness and low neuroticism and anxiety; Class 2 was characterized predominantly by low extraversion and conscientiousness and high neuroticism and anxiety. Metamemory differed significantly as a function of Class Membership (F(4,151)=5.42; p<.001), with Class 1 demonstrating accurate metamemory (M=0.21; SD=1.31) and Class 2 demonstrating under-confidence (M=-0.59; SD=1.39) in their memory.

CONCLUSIONS

The significant association between psychological factors and metamemory knowledge accuracy suggests that such characteristics may be important to consider in the conceptualization, assessment, and treatment of metacognitive disturbances. (JINS, 2018, 24, 498-510).

Awareness of cognitive impairment in individuals with essential tremor

OBJECTIVE

The extent to which individuals with ET who have clinically significant cognitive impairment are aware of their cognitive changes is unclear. Reduced awareness has important implications for everyday function and decision-making.

METHODS

150 individuals with ET (109 Normal Cognition (ET-NC group), and 30 with MCI and 11 dementia (ET-CI group)) completed self-ratings and objective assessments of memory, language, and executive functioning. Discrepancy scores were calculated to assess awareness of cognitive functioning. One sample t-tests evaluated whether mean discrepancy scores in each group were comparable to zero (i.e., accurate). Analyses of covariance (ANCOVA) compared discrepancy scores across two groups controlling for age and education.

RESULTS

In the ET-NC group, discrepancy scores for language (M=-0.08, SD=1.10) and executive functioning (M=-0.01, SD=0.99) were comparable to zero. Memory discrepancy scores (M=0.32, SD=1.22) were greater than zero. In the ET-CI group, memory, (M=0.78, SD=1.01), language, (M=0.46, SD=0.95), and executive (M=0.39, SD=1.14) discrepancy scores were all greater than zero. Discrepancy scores were larger in ET-CI group than in ET-NC group for memory: F(1,148)=4.02, p=0.047, language: F(1,148)=6.16, p=0.014, and executive: F(1,148)=4.51, p=0.035.

CONCLUSIONS

Individuals with ET and normal cognition accurately assessed their language and executive abilities, demonstrating mild overconfidence in memory function. Individuals with ET and cognitive impairment overestimated their performance in all domains of functioning. Since ET is linked to increased risk for cognitive impairment, and such impairment may not be accurately perceived, cognitive functioning should be proactively and regularly screened in ET.

Predictors of the discrepancy between objective and subjective cognition in bipolar disorder: a novel methodology

OBJECTIVE

The poor relationship between subjective and objective cognitive impairment in bipolar disorder (BD) is well-established. However, beyond simple correlation, this has not been explored further using a methodology that quantifies the degree and direction of the discrepancy. This study aimed to develop such a methodology to explore clinical characteristics predictive of subjective-objective discrepancy in a large BD patient cohort.

METHODS

Data from 109 remitted BD patients and 110 healthy controls were pooled from previous studies, including neuropsychological test scores, self-reported cognitive difficulties, and ratings of mood, stress, socio-occupational capacity, and quality of life. Cognitive symptom 'sensitivity' scores were calculated using a novel methodology, with positive scores reflecting disproportionately more subjective complaints than objective impairment and negative values reflecting disproportionately more objective than subjective impairment ('stoicism').

RESULTS

More subsyndromal depressive and manic symptoms, hospitalizations, BD type II, and being male positively predicted 'sensitivity', while higher verbal IQ predicted more 'stoicism'. 'Sensitive' patients were characterized by greater socio-occupational difficulties, more perceived stress, and lower quality of life.

CONCLUSION

Objective neuropsychological assessment seems especially warranted in patients with (residual) mood symptoms, BD type II, chronic illness, and/or high IQ for correct identification of cognitive deficits before commencement of treatments targeting cognition.