Metacognitive and cognitive-behavioral interventions for psychosis: new developments

"Talk and Chalk": An emotion regulation intervention for anger after acquired brain injury

Uncontrollable anger is a debilitating consequence of acquired brain injury (ABI). This proof-of-concept study investigated the preliminary efficacy of an emotion regulation intervention for managing post-ABI anger. A secondary objective was to determine which participant characteristics were related to intervention gains. With a pre-post intervention design and three-month follow-up, there were five individually administered meetings on Zoom, over a four-month period. 24 adults who had sustained an ABI were enrolled. Participants were mostly males, from 24 to 85 years old. A series of one-way repeated-measures ANOVAs were conducted to determine the intervention's efficacy, and Spearman's rho bivariate correlations for the association between participant characteristics and intervention gains. Significant differences were observed in external anger from baseline to post-treatment; there were no further changes from post-treatment to follow-up. Of the participant characteristics, only readiness to change and anxiety were correlated. The proposed intervention presents a brief, feasible, and preliminary efficacious alternative for regulating post-ABI anger. Intervention gains are associated with readiness to change and anxiety, which has important implications for clinical delivery.

Two decades of metacognitive training for psychosis: successes, setbacks, and innovations

INTRODUCTION

Schizophrenia is among the most debilitating mental health conditions. While antipsychotic medication represents the primary pillar of treatment, guidelines now also recommend psychotherapy. Metacognitive Training (MCT) has emerged over the past 20 years as a novel approach that addresses the cognitive biases involved in the pathogenesis of schizophrenia. MCT seeks to enhance patients' awareness of their cognitive distortions and reduce overconfidence. MCT is available in individual and group formats.

AREAS COVERED

This review provides a comprehensive overview of MCT, detailing its theoretical foundations, development, and implementation. The authors present meta-analyses demonstrating its efficacy in improving positive symptoms as well as negative symptoms and self-esteem. Lastly, the review covers the integration of the COGITO app to support MCT. For our narrative review we searched data bases including PubMed, Web of Science, EMBASE, PsycINFO, and MEDLINE.

EXPERT OPINION

MCT represents a significant advance in the treatment of schizophrenia, offering a flexible, low-threshold intervention that can be easily implemented in various clinical settings. The training's focus on metacognitive processes provides patients with tools to understand and manage their symptoms. Future research should seek to develop shortened as well as more personalized versions and investigate the long-term sustainability of the effects.

Metacognitive training for psychosis (MCT): a systematic meta-review of its effectiveness

OBJECTIVE

Metacognitive training for psychosis (MCT) targets cognitive biases implicated in the pathogenesis of psychosis, e.g., jumping to conclusions, overconfidence in errors, and inflexibility. This systematic meta-review investigated the current meta-analytic evidence for the effectiveness of MCT with respect to core symptom features in schizophrenia (i.e., positive symptoms, delusions and hallucinations, negative symptoms, and overall psychotic symptoms).

DATA SOURCES

This meta-review was registered with PROSPERO (CRD42023447442) on July 28, 2023. Articles were searched across five electronic databases from January 1, 2007 to September 1, 2023.

STUDY SELECTION

Meta-analyses addressing metacognitive interventions targeting psychotic symptoms were eligible for meta-review.

DATA EXTRACTION AND SYNTHESIS

PRISMA guidelines were followed when applicable. Data extraction was done independently by two authors (AM, AS). A random-effects model was used to pool data within meta-analyses.

MAIN OUTCOMES AND MEASURES

Main outcomes were levels/severity of positive symptoms, delusions and hallucinations, negative symptoms, and overall psychotic symptoms after intervention.

RESULTS

Eight meta-analyses and two re-analyses were included for meta-review. A total of eight analyses provided sufficient data for analysis. Significant evidence was found in favor of MCT for positive symptoms (85.71%; N = 35, g = 0.473 [0.295, 0.651], I2 = 74.64), delusions (60%; N = 24, g = 0.639 [0.389, 0.889], I2 = 80.01), hallucinations (100%; N = 9, g = 0.265 [0.098, 0.432], I2 = 6.1), negative symptoms (100%; N = 17, g = 0.233 [0.1, 0.366], I2 = 34.78), and overall symptoms (50%; N = 37, g = 0.392 [0.245, 0.538], I2 = 65.73). None of the meta-analyses included a large enough sample size to meet the criteria for 'suggestive', 'convincing', or 'highly convincing' evidence according to metaumbrella.org guidelines (required sample size > 1000 cases). None of the meta-analyses scored 'moderate' or 'high' on methodological quality. Meta-analyses with significant results were more recent and/or considered more primary studies.

CONCLUSIONS AND RELEVANCE

There is consistent evidence that MCT ameliorates positive symptoms and delusions in schizophrenia.

The role of metacognition and social cognition in childhood trauma effecting on prognosis: 1-year follow-up study in patients with first-episode schizophrenia

BACKGROUND

Childhood trauma (CT) is common in first episode schizophrenia (FES), affecting prognosis and functionality. However, the mechanisms by which CT effects prognosis are not clear. This study aimed to investigate how metacognition (MC) and social cognition (SC) mediate effects of CT on symptoms in FEP.

METHODS

52 first episode schizophrenia patients who were diagnosed for first time and had been symptomatic for at most 2 years were included. Patients were administered Metacognition Assessment Scale-Abbreviated to assess MC; Reading the Mind in the Eyes Test, Facial Emotion Recognition and Discrimination Tests to assess SC; Positive and Negative Syndrome Scale to assess psychopathology and Global Assessment of Functioning Scale to assess functionality at first interview. Patients were followed up for 1 year. At second interview the above scales and Childhood Trauma Questionnaire-33 were applied to 38 patients who met remission criteria.

RESULTS

MC and SC modulated effects of CT on negative symptoms, but not on positive symptoms. CT had different effects on symptoms, MC and SC skills in episode and remission. Pharmacological treatment was not sufficient to improve these skills.

CONCLUSIONS

MC and SC skills are important in modulating CT effecting on prognosis and non-pharmacological interventions should be developed to improve these skills.

CLINICAL TRIAL NUMBER

Not applicable.

Brief imagery based metacognitive intervention for flashforwards in psychosis: a fixed baseline case series

BACKGROUND

Distressing mental images are common in people with psychosis. The central role of metacognitive difficulties in psychosis suggests that metacognitive interventions with imagery properties could play a central role in managing distressing mental imagery. A brief imagery-based metacognitive intervention was developed to target the control mechanism of distressing mental images in psychosis.

AIMS

A fixed baseline case series was designed to investigate whether the intervention was acceptable, feasible and effective.

METHOD

Eight participants who met criteria for a schizophrenia spectrum diagnosis and experienced distressing future-oriented mental images took part in the case series, which consisted of three phases; baseline, intervention, and follow-up. Symptoms of anxiety, depression, persecutory delusions and schemas were assessed pre- and post-intervention, and qualitative feedback was collected at follow-up.

RESULTS

The metacognitive intervention was feasible, acceptable, and rated as highly satisfactory. One participant dropped out at the baseline phase. No adverse events were reported. Positive change scores with a decrease in symptoms were reported for anxiety, depression, persecutory delusions, and schemas. Tau-U analysis showed positive trends and high effect sizes on mental imagery characteristics at follow-up.

CONCLUSION

Our findings suggest that it is acceptable and feasible to engage people with psychosis in a brief imagery-based metacognitive intervention and that positive change can be achieved. Further studies are needed to replicate and clarify the findings of our study and develop the evidence base for this intervention.

Effects of Interpersonal Stress and Maladaptive Metacognitive Beliefs on Paranoid Ideation Among Japanese University Students

INTRODUCTION

Paranoid ideation, a crucial component of psychotic-like experiences, tends to increase between early and late adolescence, even in the general population, and it negatively affects overall mental health and social adjustment. Japanese adolescents experience high levels of interpersonal stress. However, few studies have examined the relationship between paranoid ideation and interpersonal stress. This study investigated the effects of maladaptive metacognitive beliefs and interpersonal stress on paranoid ideation to provide suggestions for preventive education and early intervention for paranoid ideations among Japanese university students.

METHODS

An online questionnaire survey involving 400 Japanese university students, aged between 18 and 22 years, was conducted. The questionnaires used were the Paranoia Checklist, the Metacognitive Questionnaire-30, and the Interpersonal Stressor Scale. The Interpersonal Stressor Scale was developed specifically for Japanese adolescents.

RESULTS

A multiple regression analysis was performed, which showed that the regression coefficients of the interaction between maladaptive metacognitive beliefs and interpersonal stress were significant for paranoid ideation. The results of the simple slope analysis regarding the scales on which interactions were found also indicated that the influence of maladaptive metacognitive beliefs on paranoid ideation was greater when interpersonal stress levels were higher.

CONCLUSION

The combination of interpersonal stress and maladaptive metacognitive beliefs exacerbates paranoid ideation among Japanese university students. It is important to modify metacognitive and cognitive biases in preventive education and early intervention strategies.

Does metacognitive training for psychosis (MCT) improve neurocognitive performance? A systematic review and meta-analysis

BACKGROUND

Metacognitive training for psychosis (MCT) offers benefits for addressing hallmark deficits/symptoms in schizophrenia spectrum disorders including reductions in cognitive biases and positive/negative symptoms as well as improvements in social cognition and functioning. However, differing results exist regarding the relationship between MCT and neurocognition. A comprehensive understanding of the nature of this relationship would significantly contribute to the existing literature and our understanding of the potential added value of MCT as a cognitive intervention for psychosis.

METHODS

Across eleven electronic databases, 1312 sources were identified, and 14 studies examining MCT and neurocognition in psychosis were included in this review. Measures of estimated effect sizes were calculated with Hedge's g, moderator analyses used Cochrane's Q statistic and significance tests to measure group differences according to control conditions.

RESULTS

Twelve studies, 11 randomized controlled trials (RCTs) and 1 non-RCT, were included in the main meta-analyses, consisting of 673 participants (nMCT = 345, ncontrol = 328). When comparing MCT against control interventions, non-significant differences in estimated effect sizes were observed across all neurocognitive domains when evaluating pre-post changes (g ≤ 0.1, p > .05). Two additional studies corroborated these results in a narrative review.

CONCLUSION

These findings suggest that when compared against control conditions, MCT does not pose a statistically meaningful benefit to neurocognitive performance. General practice/learning effects are likely the main contributor that explains improvement in neurocognitive performance, and not a difference of intervention allocation when considering MCT against the included control comparators. These findings help establish the specificity of the effects of MCT.

Effectiveness of a social cognition remediation intervention for patients with schizophrenia: a randomized-controlled study

This randomized-controlled study evaluates the effectiveness of a newly developed social cognition rehabilitation intervention, the modified Social Cognition Individualized Activity Lab (mSoCIAL), in improving social cognition and clinical and functional outcomes of persons with schizophrenia recruited in two Italian sites: University of Campania "Luigi Vanvitelli" in Naples and ASST Fatebenefratelli-Sacco in Milan. mSoCIAL consists of a social cognitive training module focusing on different domains of social cognition and of a narrative enhancement module. We assessed changes in social cognition, clinical characteristics and functional variables in patients with schizophrenia who participated in 10 weekly sessions of mSoCIAL or received treatment as usual (TAU). A paired-sample t test and a repeated-measures MANOVA were used to investigate respectively within and between-group differences. Twenty people with schizophrenia were blindly assigned to mSoCIAL and 20 to TAU. After 10 weeks, mSoCIAL significantly improved disorganization, emotion recognition, functional capacity and real-life functioning. As compared to TAU, the mSoCIAL group showed a significant improvement in minimal and enriched social inference domain of theory of mind, and in key domains of real-life functioning (interpersonal relationships, everyday life skills, and work skills). mSoCIAL improved social cognition and real-life functioning of people with schizophrenia. These results highlight the importance of social cognition deficit treatment in schizophrenia and the necessity for these interventions to be multifaced and personalized. Such an approach ensures that improvements in social cognition translate into enhanced functional outcomes.Trial registration NCT05130853, registered on 24 November 2021.

Ruminative thinking mediates the effects of exposure to adverse life events on psychotic-like experiences

Introduction

A growing literature has shown that exposure to adverse life events during childhood or adolescence is associated with the presence of psychotic-like experiences (PLEs), which is in turn associated with the risk of psychotic outcomes. Ruminative thinking, i.e., the tendency to dwell on particular issues or ideas, may affect the perceived aversiveness and ability to cope with adverse life events. However, the role that rumination plays in the relationship between adverse life events and the presence of PLEs remains unclear. The purpose of this study is to assess the association between adverse life events and PLEs in a longitudinal sample of young adults and adolescents, and to investigate whether this relationship is mediated by ruminative thinking.

Methods

We used a longitudinal naturalistic sample of 706 volunteers assessed at ages 18 and 22 years, within the Imagen consortium. Lifetime occurrence of adverse life events (i.e., events perceived as strongly negative by participants) was investigated using the Life Events Questionnaire. The Community Assessment of Psychic Experience (CAPE-42) served to assess the presence of PLEs, while ruminative thinking was investigated through the Ruminative Response Scale.

Results

Results showed that both frequency of PLEs and their persistence over time were associated with greater adverse life events exposure (r = 0.32, p < 0.001 and F 1 = 9.8; p < 0.001, respectively) and greater ruminative response (r = 0.66, p < 0.001 and F 1 = 94.9; p < 0.001, respectively). Mediation analyses showed that relationship between adverse life events and PLEs frequency was partially mediated by rumination (direct effect Z: 5.4, p < 0.001; indirect effect Z: 6.9, p < 0.001; total effect Z: 5.9, p < 0.001). Considering changes between the two assessment timepoints, relationship between PLEs variation between 18 and 22 years and adverse life events occurred during the same period was partially mediated by changes in rumination (direct effect Z: 2.8, p < 0.005; indirect effect Z: 4.3, p < 0.001; total effect Z: 4.3; p < 0.001).

Discussion

Overall, our findings confirm that the presence of adverse life events may increase the risk of experiencing PLEs in healthy individuals and suggest that dysfunctional coping strategies, such as ruminative thinking, may be related to psychosis proneness. Results do not disentangle whether individuals with greater risk for psychosis tend to ruminate more or whether rumination exacerbates psychosis risk.

The architecture of paranoia in the general population: A self-report and ecological momentary assessment study

Paranoia is a common delusion type found in clinical and non-clinical populations. A hierarchical, dimensional model of paranoia in the general population has been proposed, with four categories representing increasing levels of paranoia: interpersonal sensitivity (IP), mistrust (M), ideas of reference (IR), persecutory ideas (PI). What is currently lacking and could provide insights into etiology is a comprehensive clinical characterization of the lower end of the paranoia spectrum, psychological domains that are associated with symptom severity, and how paranoia and its structure fluctuate over time. This study conducted both cross-sectional and longitudinal surveys with 802 participants from the German population assessing paranoia and general psychopathology. Data was collected through Ecological Momentary Assessment (EMA). Several statistical approaches were used including confirmatory factor analysis (CFA), latent class analysis (LCA) and mixed modelling analyses (ME). Paranoid experiences appear to be a common phenomenon that occur in people with and without mental illness. Subjects clustered into four paranoia severity subgroups (IP, M, IR, PI) and showed significant associations in various psychological domains like increased psychiatric symptoms and maladaptive coping. Paranoia fluctuates over time in all four severity subgroups, but the hierarchical subgrouping was stable. Both persecutory ideations and interpersonal sensitivity were significant predictors of paranoia. Findings provide important insights into the architecture of paranoia in the German population by characterizing their hierarchical, dimensional, and dynamic structure and its link to psychopathology.

A chain mediation model reveals the association between metacognition and quality of life in hematologic tumor patients

The study aims to explore the relationship among metacognition (MC), fear of disease of progression (FoP), psychological distress (PD), and quality of life (QoL), and verify whether FoP and PD have a chain mediating effect between MC and QoL. 231 hematologic tumor patients in a large tertiary hospital were investigated by using Meta-Cognitions Questionnaire-30, Fear of Progression Questionnaire-Short Form, Hospital Anxiety and Depression Scale, and Functional Assessment of Cancer Therapy scale. Data analyses were performed using IBM SPSS (version 25.0) and the PROCESS macro (version 4.1). The results showed that the direct impact of MC on QoL was not statistically significant. However, the indirect influence of MC on QoL manifest through the independent influences of PD and FoP, as well as the chain mediating effect of "PD → FoP." In addition, all four dimensions of QoL (physical, social and family, emotional, and functional) satisfy the chain mediation model, except for the social and family domain. These insights advance our comprehension of the intricate interplay between MC and QoL, underscoring the importance of improving MC to alleviate patients' PD, mitigate FoP, and ultimately improve the QoL of hematologic tumor patients.

Overview on cognitive impairment in psychotic disorders: From impaired microcircuits to dysconnectivity

Schizophrenia's cognitive deficits, often overshadowed by positive symptoms, significantly contribute to the disorder's morbidity. Increasing attention highlights these deficits as reflections of neural circuit dysfunction across various cortical regions. Numerous connectivity alterations linked to cognitive symptoms in psychotic disorders have been reported, both at the macroscopic and microscopic level, emphasizing the potential role of plasticity and microcircuits impairment during development and later stages. However, the heterogeneous clinical presentation of cognitive impairment and diverse connectivity findings pose challenges in summarizing them into a cohesive picture. This review aims to synthesize major cognitive alterations, recent insights into network structural and functional connectivity changes and proposed mechanisms and microcircuit alterations underpinning these symptoms, particularly focusing on neurodevelopmental impairment, E/I balance, and sleep disturbances. Finally, we will also comment on some of the most recent and promising therapeutic approaches that aim to target these mechanisms to address cognitive symptoms. Through this comprehensive exploration, we strive to provide an updated and nuanced overview of the multiscale connectivity impairment underlying cognitive impairment in psychotic disorders.

Effects of cognitive training and behavior modification on aggressive behavior and sleep quality in schizophrenia

Background

Schizophrenia (SCZ) is linked to a heightened risk of impulsive aggression and disturbances in sleep patterns. Cognitive and social cognitive impairments have been connected to aggression, with social cognitive deficits appearing to play a more immediate role. In this investigation, we conducted a retrospective analysis of the impact of cognitive training and sleep interventions on aggressive behavior and the quality of sleep among individuals with SCZ who were hospitalized.

Methods

This study divided 80 hospitalized patients into two groups according to medical advice, namely the normal group and the study group. The control group received routine drug treatment and education; The research group implemented cognitive training and sleep intervention based on the normal group. Collect basic clinical data, aggressive behavior indicators, and sleep quality indicators.

Results

There is no difference in the basic information statistics between the two groups. Both groups can reduce aggressive behavior and improve sleep quality. In the study group, there was a notable decrease in aggressive behavior compared to the control group. Furthermore, the sleep quality in the study group exhibited significant improvement when compared to the control group.

Conclusion

Cognitive training and sleep intervention have been proven to be effective nonpharmacological treatments, effectively reducing aggressive behavior and improving sleep quality.

A Pilot Study of Metacognitive Training in U.S. Republican Leaners: Reducing Polarization Toward LGBTIQ+ Persons

Negative attitudes and stigmatization toward sexual minorities is a cause of minority stress of non-heterosexual persons on an individual level and has a negative impact on democratic coexistence in postmodern, plural society on a societal level. Derived from clinical research, we developed a short metacognitive training (MCT) intended to induce doubt toward inaccurate beliefs about LGBTIQ+ persons. We expected this MCT to reduce homonegativity, threat perceptions of LGBTIQ+ persons, and to foster extended outgroup tolerance compared to an education and a no-treatment control condition. We tested this hypothesis in U.S. Republican leaners who represent a social group that is likely to hold homonegative attitudes. We randomly assigned 490 U.S. Republican leaners to an MCT condition comprising 16 questions and respective answers (n = 166) vs. an education control condition (n = 164) vs. a no-treatment control condition (n = 160). We found that Republican leaners after receiving MCT (1) had a significant reduction of homonegativity (ds ≥ 0.28), (2) significantly perceived LGBTIQ+ persons as less threatening (ds ≥ 0.30), and (3) were significantly more tolerant of various outgroups such as LGBTIQ+ persons, feminists, liberals, and climate activists (ds ≥ 0.23) relative to both control conditions. The small effects of this short intervention and the possibility of systematically applying MCT in social discourse to reduce homonegativity with its potential significance for LGBTIQ+ individuals' mental health are discussed. Furthermore, we highlight this pilot study's significance toward intervention possibilities regarding political division and polarization in postmodern, democratic societies.

Unveiling Assessment Gaps in Parkinson's Disease Psychosis: A Scoping Review

BACKGROUND

Parkinson's disease psychosis (PDP) is a multidimensional construct that is challenging to measure. Accurate assessment of PDP requires comprehensive and reliable clinical outcome assessment (COA) measures.

OBJECTIVE

To identify PDP measurement gaps in available COAs currently used in clinical and research settings.

METHODS

We conducted a scoping review using Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. We implemented a three-step search strategy in international databases with keywords related to Parkinson's disease (PD), psychosis, and COA. We analyzed studies using COA to assess PDP, classifying their items according to domains and subdomains.

RESULTS

From 5673 identified studies, we included 628 containing 432 PDP core items from 32 COAs. Among the 32 COAs, 19 were PD-specific, containing 266 items, constructed as clinician-reported outcomes (ClinRO) (148 items), patient-reported outcomes (PRO) (112 items), and observer-reported outcomes (ObsRO) (six items). Across all PD-specific COAs, regardless of structure, 89.4% of the items from 27 COAs focused primarily on assessing PDP symptoms' severity, and only 9.7% of items probed the impact of PDP on a person's daily functioning.

CONCLUSIONS

Symptom-based domains are currently prioritized for measuring the severity of PDP, with limited coverage of the functional impact of PDP on patients' lives. Whereas the International Parkinson and Movement Disorder Society has traditionally developed a "Unified" COA that culls items from prior COAs to form a new one, a new COA will largely need newly developed items if the functional impact of PDP is prioritized. © 2024 International Parkinson and Movement Disorder Society.

Acceptance and commitment therapy for psychosis: Current status, lingering questions and future directions

PURPOSE

Acceptance and Commitment Therapy for psychosis (ACTp) is a contextual behavioural intervention that promotes psychological flexibility by fostering active acceptance, cognitive defusion, values construction and committed action to enhance well-being and recovery. Multiple studies have shown that ACTp is acceptable and efficacious, but questions remain as to its distinction from similar approaches and the conditions under which it would be implemented most effectively.

METHODS

We present the current evidence for processes and outcomes of ACTp and summarise the qualitative findings of experiences of service users in ACT programmes. We compare ACTp with other cognitive behavioural therapies and mindfulness-informed interventions for psychosis.

RESULTS

Acceptance and commitment therapy for psychosis is promising as a pragmatic, process-driven intervention model. Further efforts are needed to investigate psychological flexibility in the context of psychosis with observational, experimental and intervention studies that will inform model scope and treatment refinement. Additionally, implementation research is the necessary next step, including how support persons can be trained in ACTp. Lower intensity and technology-assisted approaches have the potential to reduce barriers to accessing ACTp and extend impact.

CONCLUSIONS

Over the last 20 years, ACTp has demonstrated meaningful effects in individual and group formats in a range of settings, targeting outcomes such as rehospitalisation, depression, psychotic symptom distress and impact. Future work should focus on how best to integrate ACTp with other current evidence-based interventions for psychosis.

Development of the Delusional Interpretation Scale and examination of related variables

Aim

Delusions are a common symptom in schizophrenia. Some scales have been developed to measure delusional tendencies in healthy people, and nonpathological delusional thinking can occur even among these individuals. The existing scales measure the presence and frequency of delusional thoughts, distress levels, and confidence levels. However, these scales are limited because they do not consider the context of the delusions (i.e., where, with whom, and when). In this study, we developed a new scale that presents detailed scenes using illustrations and sentences and measures the tendency toward delusional interpretations.

Methods

Factor analysis was conducted to confirm the factor structure of the new scale. To examine the validity of the scale, we analyzed the correlations between delusional tendencies and related variables and verified the consistency between the current scale and previously developed tools.

Results

Factor analysis confirmed that the new scale has a two-factor structure, including "internal attribution and paranoid tendency" and "external attribution tendency." The new scale was found to have acceptable reliability and validity. The internal attribution and paranoid tendency factor was negatively correlated with self-esteem and decentering. Furthermore, the internal attribution and paranoid tendency factor showed a moderate positive correlation with depressive state and anxiety tendency and a very weak positive correlation with experiences of bullying or harassment.

Conclusion

The correlations between the new scale and related variables confirmed the construct validity and replicated the results reported in previous studies. This new scale enables the measurement of delusional tendencies in healthy subjects based on the social context.

Mental Pain Correlates with Mind Wandering, Self-Reflection, and Insight in Individuals with Psychotic Disorders: A Cross-Sectional Study

Understanding the cognitive processes that contribute to mental pain in individuals with psychotic disorders is important for refining therapeutic strategies and improving patient outcomes. This study investigated the potential relationship between mental pain, mind wandering, and self-reflection and insight in individuals diagnosed with psychotic disorders. We included individuals diagnosed with a 'schizophrenia spectrum disorder' according to DSM-5 criteria. Patients in the study were between 18 and 65 years old, clinically stable, and able to provide informed consent. A total of 34 participants, comprising 25 males and 9 females with an average age of 41.5 years (SD 11.5) were evaluated. The Psychache Scale (PAS), the Mind Wandering Deliberate and Spontaneous Scale (MWDS), and the Self-Reflection and Insight Scale (SRIS) were administered. Statistical analyses involved Spearman's rho correlations, controlled for potential confounders with partial correlations, and mediation and moderation analyses to understand the indirect effects of MWDS and SRIS on PAS and their potential interplay. Key findings revealed direct correlations between PAS and MWDS and inverse correlations between PAS and SRIS. The mediation effects on the relationship between the predictors and PAS ranged from 9.22% to 49.8%. The largest statistically significant mediation effect was observed with the SRIS-I subscale, suggesting that the self-reflection and insight component may play a role in the impact of mind wandering on mental pain. No evidence was found to suggest that any of the variables could function as relationship moderators for PAS. The results underscore the likely benefits of interventions aimed at reducing mind wandering and enhancing self-reflection in psychotic patients (e.g., metacognitive therapy, mindfulness). Further research will be essential to elucidate the underlying mechanisms.

Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach

Background

Treatment guidelines for psychosis recommend offering psychotherapy already in the acute illness phase. However, there is a lack of available interventions adapted to the specific needs and key change mechanisms of inpatients experiencing severe symptoms and crisis. In this article we outline the scientific development process of a needs-oriented and mechanism-based group intervention for acute psychiatric inpatients with psychosis (MEBASp).

Methods

To guide our intervention design, we used Intervention Mapping (IM), a six-step framework for developing evidence-based health interventions that consisted of an extensive literature review, an in-depth problem definition and needs analysis, the modeling of change mechanisms and outcomes and the production of an intervention prototype.

Results

Our low-threshold modularized group intervention consists of nine stand-alone sessions (two per week) within three modules and targets different aspects of metacognitive and social change mechanisms. Module I and II aim to reduce acute symptoms by fostering cognitive insight, Module III focuses on reducing distress via cognitive defusion. Therapy contents are adapted from existing metacognitive treatments such as the Metacognitive Training and presented in a destigmatizing, simply understandable and experience-oriented way.

Conclusion

MEBASp is currently evaluated in a single-arm feasibility trial. Using a systematic and rigorous development methodology and providing a detailed description of the development steps demonstrated to be invaluable in improving the intervention's scientific foundation, validity, and replicability for similar research.

The Comorbidity of Depression and Anxiety Symptoms in Tinnitus Sufferers: A Network Analysis

OBJECTIVE

Sufferers of tinnitus, especially of the prolonged type, frequently suffer from comorbid depression and anxiety. From the perspective of the network model, this comorbidity is thought to be an interacting system of these two symptoms. In our study, we conducted a network analysis of depression and anxiety comorbidity in tinnitus sufferers, aiming to identify the central and bridge symptoms and make informed suggestions for clinical interventions and psychotherapy.

METHOD

A total of 566 tinnitus sufferers were enrolled in our study. The Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder 7-Item Questionnaire (GAD-7) were selected to evaluate depression and anxiety symptoms, respectively, followed by network analysis to construct the interacting networks.

RESULTS

The findings identified six edges of strongest regularized partial correlations in this network. Of these, three were depression symptoms and three were anxiety symptoms. The anxiety symptoms "Unable to control worry" and "Relaxation difficulty" and the depression symptom "Feeling depressed or hopeless" had the highest expected influence centrality. The analysis results also revealed three bridge symptoms: "Afraid something awful might happen", "Feeling of worthlessness", and "Trouble concentrating". As for "Suicidal ideation", the direct relations between this symptom and "Afraid something awful might happen" and "Feeling depressed or hopeless" were the strongest.

CONCLUSIONS

The central and bridge symptoms of the interacting network of depression and anxiety symptoms in tinnitus sufferers can be considered a significant transdiagnostic intervention target for the management of this comorbidity. In particular, clinical prevention and psychotherapy should be implemented, targeting the symptoms that have the strongest associations with suicidal ideation.

In the eyes of the beholders: Subjective experiences of positive symptoms among patients with symptoms of psychosis seeking psychotherapy

BACKGROUND

Reduction of positive symptoms is often the focus of psychiatric treatment for patients with psychosis; however, it is becoming increasingly clear that some patients experience ambivalence towards positive symptoms or may even experience them as pleasant. The present study extends upon work from online studies of patients without verified diagnoses. The first aim was to examine the frequency with which patients report negative, neutral or even positive appraisals of positive symptoms. A second aim was to identify whether these appraisals were associated with medication adherence.

METHODS

One-hundred twelve treatment-seeking patients with current symptoms of psychosis completed the Subjective Perception of Positive Symptoms-Revised (SUPPOSY-R), a scale assessing appraisals of positive symptoms (e.g., gain from illness, impact on daily life), as well as questions regarding medication adherence.

RESULTS

Although most patients reported experiencing positive symptoms as predominantly unpleasant, appraisals differed between symptom clusters and up to 54.4 % reported that they would miss at least some aspects of positive symptoms should they disappear. Patients particularly welcomed the disappearance of auditory hallucinations (71.2 %). Symptom appraisal was not significantly associated with medication compliance (p > .17); however, more patients with low medication adherence reported they would feel at least some regret if their symptoms were to completely disappear (48.9 %, n = 23) versus patients with high adherence (41.7 %, n = 20).

DISCUSSION

Ambivalent or positive appraisals of positive symptoms are lower among treatment-seeking patients compared to patients recruited for online studies, who may not be actively seeking treatment. Auditory hallucinations may cause most distress among treatment-seeking patients. A collaborative approach including assessment of possible positive appraisals of symptoms is important when identifying treatment goals.

Exploring the Latent Structure and Convergent and Incremental Validity of the Metacognition Assessment Scale - Abbreviated in a Sample of Patients with Non-Affective Psychosis

Synthetic metacognition is a heterogeneous construct related to psychotic disorders. One important tool to assess this construct is the Metacognition Assessment Scale - Abbreviated (MAS-A). In this study, we investigated the latent structure as well as the interrater reliability and convergent and incremental validity of the MAS-A in a sample of patients with non-affective psychosis. Analyses indicated that the scale might be one-dimensional. Interrater reliability of the MAS-A total score was good. In terms of convergent validity, correlational analyses showed significant associations of MAS-A metacognition with the Operationalized Psychodynamic Diagnosis Level of Structural Integration Axis (OPD-LSIA) and the Levels of Emotional Awareness Scale (LEAS). In terms of construct validity, a significant association was observed between MAS-A metacognition and a short version of the International Classification of Functioning, Disability and Health (MINI-ICF), which persisted after self-report measures of impairments in structural capacities (Structure Questionnaire of Operationalized Psychodynamic Diagnosis [OPD-SQS]) and mentalizing abilities (Mentalization Questionnaire [MZQ]) were included as covariates, but not after symptom dimensions were included. There was a significant correlation with the current living situation, but not with other external criteria like diagnosis or duration of illness. Future studies should explore alternative outcomes and replicate results in longitudinal designs.

Psychosis spectrum illnesses as disorders of prefrontal critical period plasticity

Emerging research on neuroplasticity processes in psychosis spectrum illnesses-from the synaptic to the macrocircuit levels-fill key gaps in our models of pathophysiology and open up important treatment considerations. In this selective narrative review, we focus on three themes, emphasizing alterations in spike-timing dependent and Hebbian plasticity that occur during adolescence, the critical period for prefrontal system development: (1) Experience-dependent dysplasticity in psychosis emerges from activity decorrelation within neuronal ensembles. (2) Plasticity processes operate bidirectionally: deleterious environmental and experiential inputs shape microcircuits. (3) Dysregulated plasticity processes interact across levels of scale and time and include compensatory mechanisms that have pathogenic importance. We present evidence that-given the centrality of progressive dysplastic changes, especially in prefrontal cortex-pharmacologic or neuromodulatory interventions will need to be supplemented by corrective learning experiences for the brain if we are to help people living with these illnesses to fully thrive.

Mechanisms of action and processes of yoga-based group intervention for inpatients with schizophrenia spectrum disorders-A longitudinal qualitative study

BACKGROUND

Research exploring the effects of yoga therapy (YT) on individuals with schizophrenia spectrum disorders (SSD) is scarce. Therefore, the current study aimed to explore possible mechanisms of actions and processes, as well as adverse effects of a novel yoga-based group intervention (YoGI) for in-patients with SSD in a German university hospital setting.

MATERIAL AND METHODS

A longitudinal qualitative study was integrated into a rater-blinded randomized controlled trial, exploring the impact of a 4-week YoGI as add-on treatment. In-depth interviews were conducted with participants receiving YoGI (n = 19) in addition to treatment as usual (TAU) and a control group (n = 14) which only received TAU. Interviews were conducted at baseline (n = 33) and 4 weeks post-intervention (N = 28) to assess the participant's experiences and how they changed over time. The interviews (N = 61) were audio-taped, translated, coded, and analyzed by means of inductive thematic analysis. Separate case summaries were prepared for each participant to analyze longitudinal changes within subjects. The research team members collaboratively discussed the final list of themes and subcodes. Rater-based questionnaires, such as the Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), and Personal and Social Performance Scale (PSP) were administered at baseline to assess clinical outcomes.

RESULTS

At baseline, participants reported a desire to improve their stress- and symptom management. A minority of participants expressed reservations toward yoga, and several psychosocial barriers were named, including worries about symptom exacerbation. At post-intervention, four mechanisms of change became evident from the interviews: (1) acquiring competence in relaxation, (2) increased interoceptive awareness, (3) feeling connected, and (4) a sense of spiritual wellbeing. A small number of participants reported difficulties with YoGI.

CONCLUSION

Generally, YoGI positively influenced participants' experiences of their inpatient stay, regarding distress, self- and body awareness, social connectedness, and spiritual wellbeing. However, participants also illuminated necessary adjustments to improve the intervention. YoGI will therefore be adapted and further developed in an iterative process based on a participant involvement approach. The efficacy regarding outcomes and processes needs to be investigated in a future larger-scaled randomized controlled trial.

Metacognition vulnerabilities in time of crisis: Who to protect from suicidal risk?

INTRODUCTION

During stressful events, we are all trying to cope. We may not be equal depending on our emotional, psychological, and mental states. During the COVID-19 pandemic, we could try to avoid negative information processing and anxiogenics content to prevent unhealthy thinking processes. One of the processes we can observe regarding our way of thinking and its impact on our psychological well-being is Metacognition.

METHODS

We recruited 104 outpatients in 2018. In 2020, during the pandemic, we recruited 216 outpatients and 176 healthy controls. We assessed their level of metacognition with the MCQ30 scale together with Suicidal risk and Hopelessness.

RESULTS

All three groups showed significant differences, with the nonclinical sample having higher scores in MCQ30. Regression revealed the different profiles where Hopelessness was the only predictor for the clinical sample, whereas metacognition was an adjunctive predictor of suicidal risk for the nonclinical sample.

CONCLUSION

Our results showed that the COVID-19 crisis influenced metacognitive levels for the nonclinical sample but not for the clinical population. Moreover, Hopelessness predicted suicide risk for both populations, but Metacognition was also a predictive factor for the nonclinical sample. We conclude with the possible impact of preventive measures based on Metacognitive work that can be created out of these results.

Total Metacognitive Capacity Predicts Competitive Employment Acquisition Across 6 Months in Adults With Serious Mental Illness Receiving Psychiatric Rehabilitation Services

Deficits in metacognitive capacity are common among people with serious mental illness (SMI), although there is a gap in knowledge regarding how these impairments predict later functioning, especially employment. This study aimed to prospectively examine the relationship between metacognitive capacity and 6-month competitive employment attainment in adults with SMI who were participating in a study testing a cognitive behavioral therapy intervention added to supported employment services. Sixty-seven participants with complete data at baseline and the 6-month follow-up comprised the sample. Data were analyzed using stepwise logistic regression covarying for work history and study assignment. Results indicate that total metacognitive capacity at baseline significantly predicted employment acquisition at 6 months; the final model correctly classified 83.3% of participants who obtained work. In conclusion, these findings suggest that better overall metacognitive capacity may be key for future work functioning. Thus, interventions that target metacognitive capacity may lead to enhancements in community outcomes.

Heterogeneity in Response to MCT and Psychoeducation: A Feasibility Study Using Latent Class Mixed Models in First-Episode Psychosis

Metacognitive training (MCT) is an effective treatment for psychosis. Longitudinal trajectories of treatment response are unknown but could point to strategies to maximize treatment efficacy during the first episodes. This work aims to explore the possible benefit of using latent class mixed models (LCMMs) to understand how treatment response differs between metacognitive training and psychoeducation. We conducted LCMMs in 28 patients that received MCT and 34 patients that received psychoeducation. We found that MCT is effective in improving cognitive insight in all patients but that these effects wane at follow-up. In contrast, psychoeducation does not improve cognitive insight, and may increase self-certainty in a group of patients. These results suggest that LCMMs are valuable tools that can aid in treatment prescription and in predicting response to specific treatments.

Efficacy of Metacognitive Training in a Chilean Sample of People with Schizophrenia

INTRODUCTION

Moritz et al.'s metacognitive training (MCT), a new development of cognitive therapy, is a manualised group training programme, designed to correct cognitive biases involved in the formation and maintenance of psychotic symptoms, especially delusions. We report on the efficacy of MCT in a Chilean sample of people with schizophrenia.

METHODS

50 outpatients from the Hospital Del Salvador in Valparaíso, Chile, were randomly assigned to the intervention group that received MCT or the control group that only received treatment as usual (TAU). Subjects were assessed at the beginning and end of the study with the Positive and Negative Syndrome Scale (PANSS), Cognitive Biases Questionnaire for Psychosis (CBQ-P) and Beck Cognitive Insight Scale (BCIS).

RESULTS

Greater statistically significant improvements were recorded in the MCT group, both in symptoms and cognitive biases and in cognitive insight, than in the control group. When comparing both groups, significant results in favor of MCT were only observed in positive symptoms.

CONCLUSIONS

The results of this study suggest MCT is superior to TAU in treating positive symptoms. It was not possible to demonstrate its superiority in improving cognitive biases and cognitive insight.

Stressor reflections, sleep, and psychological well-being: A pre-registered experimental test of self-distanced versus self-immersed reflections

Evidence supports the effectiveness of cuing people to analyse negative autobiographical experiences from self-distanced rather than self-immersed perspectives. However, the evidence on which this expectation resides is limited largely to static snapshots of mean levels of cognitive and emotional factors. Via a pre-registered, randomised controlled trial (N = 257), we examined the differential effectiveness of self-distanced relative to self-immersed reflections on mean levels and within-person variability of sleep duration and quality as well as psychological well-being over a 5-day working week. Except for sleep quality, we found that reflecting from a psychologically distanced perspective, overall, was no more effective for mean levels and within-person variability of sleep duration, well-being, and stress-related factors than when the current self is fully immersed in the experiential reality of the event. We consider several substantive and methodological considerations (e.g., dosage, salience of stressor event) that require interrogation in future research via experimental and longitudinal observational methods.

Etiopathogenic Models of Psychosis Spectrum Illnesses Must Resolve Four Key Features

Etiopathogenic models for psychosis spectrum illnesses are converging on a number of key processes, such as the influence of specific genes on the synthesis of proteins important in synaptic functioning, alterations in how neurons respond to synaptic inputs and engage in synaptic pruning, and microcircuit dysfunction that leads to more global cortical information processing vulnerabilities. Disruptions in prefrontal operations then accumulate and propagate over time, interacting with environmental factors, developmental processes, and homeostatic mechanisms, eventually resulting in symptoms of psychosis and disability. However, there are 4 key features of psychosis spectrum illnesses that are of primary clinical relevance but have been difficult to assimilate into a single model and have thus far received little direct attention: 1) the bidirectionality of the causal influences for the emergence of psychosis, 2) the catastrophic clinical threshold seen in first episodes of psychosis and why it is irreversible in some individuals, 3) observed biotypes that are neurophysiologically distinct but clinically both convergent and divergent, and 4) a reconciliation of the role of striatal dopaminergic dysfunction with models of prefrontal cortical state instability. In this selective review, we briefly describe these 4 hallmark features and we argue that theoretically driven computational perspectives making use of both algorithmic and neurophysiologic models are needed to reduce this complexity and variability of psychosis spectrum illnesses in a principled manner.

Mobile facial affect recognition and real-time social experiences in serious mental illness

Background

Emotion recognition deficits are linked with social dysfunction in psychosis, as is inaccurate self-assessment of emotion recognition abilities. However, little is known about the link between ER and real-time social appraisals and behavior.

Methods

In 136 people with psychotic disorders or affective disorder with psychosis we administered a novel ecological momentary cognitive test of emotion recognition which both assesses emotion recognition ability and self-assessed performance in conjunction with ecological momentary assessment of social appraisals, motivation, and time spent alone. Hybrid mixed effects models evaluated emotion recognition's associations with social experiences.

Results

Better recognition ability was associated with greater pleasure and more positive appraisals of others during interactions, whereas accuracy of self-assessment of emotion recognition ability was associated with more positive appraisals of interactions and social motivation. Overestimation of emotion recognition was linked with concurrent higher social motivation yet greater desire to avoid others. Time alone was unrelated to emotion recognition ability or self-assessment of ability.

Discussion

Mobile emotion recognition performance was associated with appraisals of recent interactions but not behavior. Self-assessment of social cognitive performance was associated with more positive appraisals and social motivation, and may be a novel target for interventions aimed at social dysfunction.

Visual worry in patients with schizophrenia

OBJECTIVE

Worrying is a pervasive transdiagnostic symptom in schizophrenia. It is most often associated in the literature with verbal modality due to many studies of its presence in generalised anxiety disorder. The current study aimed to elucidate worry in different sensory modalities, visual and verbal, in individuals with schizophrenia.

METHOD

We tested persons with schizophrenia (n = 92) and healthy controls (n = 138) in a cross-sectional design. We used questionnaires of visual and verbal worry (original Worry Modality Questionnaire), trait worry (Penn State Worry Questionnaire) and general psychopathology symptoms (General Functioning Questionnaire-58 and Brief Psychiatric Rating Scale).

RESULTS

Both visual and verbal worry were associated with psychotic, anxiety and general symptoms of psychopathology in both groups with medium to large effect sizes. Regression analyses indicated that visual worry was a single significant predictor of positive psychotic symptoms in a model with verbal and trait worry, both in clinical and control groups (β's of 0.49 and 0.38, respectively). Visual worry was also a superior predictor of anxiety and general psychopathology severity (β's of 0.34 and 0.37, respectively) than verbal worry (β's of 0.03 and -0.02, respectively), under control of trait worry, in the schizophrenia group. We also proposed two indices of worry modality dominance and analysed profiles of dominating worry modality in both groups.

CONCLUSIONS

Our study is the first to demonstrate that visual worry might be of specific importance for understanding psychotic and general psychopathology symptoms in persons with schizophrenia.

Impaired insight in schizophrenia: impact on patient-reported and physician-reported outcome measures in a randomized controlled trial

BACKGROUND

Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizophrenia.

METHODS

In a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NCT00014001), insight was measured using the Positive and Negative Syndrome Scale (PANSS) Item G12 (lack of insight). Additional assessments for this analysis included the 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS), physician- and patient-reported Clinical Global Impression-Severity (CGI-S), MATRICS Consensus Cognitive Battery, and Calgary Depression Scale for Schizophrenia. Relationships between patient-reported outcomes and PANSS total and Item G12 ratings were evaluated.

RESULTS

Among 1431 CATIE study participants in this analysis, increasingly impaired insight at baseline was significantly associated with better patient-reported quality of life (QoL), lower baseline depression, and greater divergence between physician- and patient-reported illness severity. Patients with more severely impaired insight reported milder illness compared with physician reports, particularly those with moderate-severe to extreme impairment (PANSS Item G12 rating ≥ 5), approximately 10% (138/1431) of CATIE participants. For the 90% of patients with PANSS Item G12 ratings < 5, patient-reported QoL decreased with increasing symptoms. SF-12 MCS scores were linearly related to baseline PANSS total score only in patients with PANSS total score < 90 (moderately ill or better), and better symptom scores were associated with higher QoL. No significant relationship between insight and neurocognition was observed.

CONCLUSIONS

In the small subgroup (10%) of CATIE study patients with schizophrenia and PANSS Item G12 ratings ≥5, moderate-severe-severe/extreme insight impairment was associated with significantly more positive perception of QoL and illness severity by the patient versus the treating physician. This was not observed in the remaining 90% of patients with normal to moderately impaired insight, suggesting that poor insight as a threat to the validity of self-report is uncommon.

Online versus face-to-face metacognitive educational counseling program on anxiety and meta-worry in women with a history of miscarriage: A randomized clinical trial

BACKGROUND

In the COVID-19 outbreak, women with a history of miscarriage need more mental health. Anxiety and meta-worry as consequences of miscarriage, besides concerns due to pregnancy during coronavirus, show the necessity of appropriate online and face-to-face educational counseling. This study aimed to evaluate the effectiveness of online metacognitive educational counseling versus face-to-face method on anxiety and meta-worry in these women.

MATERIALS AND METHODS

In this randomized clinical trial, 80 women with a history of miscarriage, anxiety, and meta-worry referred to Imam Jafar Sadegh hospital (labor, women ward and women clinic), Meybod, Iran, were selected conveniently and randomly assigned into two groups (n = 20/each). The participants received 8-session metacognitive educational counseling package online or face-to-face. Data were collected by Beck Anxiety Inventory, Wellz meta-worry questionnaire at baseline, week eight, and follow up as primary outcomes and analyzed via SPSS software (Anova and Repeated measure statistic tests).

RESULTS

Anxiety in the 12^th week (online group 13.75 ± 3.59 vs. face to face 18.25 ± 5.91, P = 0.04) was statistical significantly less than baseline (respectively 22.15 ± 5.67 vs. 22.35 ± 4.93, P = 0.56); with fewer anxiety scores in the online group. Meta-worry in the 12^th week (online group 11.90 ± 2.59 vs. face to face 15.70 ± 4.06, P = 0.03) was statistically significant compared to baseline (respectively 17.15 ± 2.70 vs. 18.50 ± 3.47, P = 0.36); with fewer meta-worry scores in the online group. Belief about worry in 12^th week (online group 66.50 ± 14.60 vs. face to face 78.45 ± 9.27, P = 0.01) was statistical significantly less than baseline (respectively 85.50 ± 8.87 vs. 86.05 ± 8.85, P = 0.96); with less score of belief about worry in the online group.

CONCLUSION

Online and face-to-face metacognitive educational counseling methods decreased anxiety, meta-worry, and belief about worry in women with miscarriage. But online educational counseling was more effective. Distance online counseling in COVID-19 can help the mental health of women with miscarriage.

Metacognitive training for psychosis (MCT): past, present, and future

This article provides an overview and retrospective on metacognitive training for psychosis (MCT), which first appeared approximately 2 decades ago. We recount how our empirical understanding of psychosis at that time led to the first preliminary version of the program. We describe setbacks and challenges that led to major changes, including revisions to existing modules (e.g., more focus on metacognitive variables, particularly on decision confidence as one of the primary targets of treatment) and the creation of new modules addressing mood, as well as attempts to improve sustainability of effects via homework exercises and a smartphone app ( www.uke.de/mct_app ). We have also enhanced dissemination efforts by creating new culturally sensitive language versions and facilitating low-threshold training through e-learning courses ( www.uke.de/e-mct ). Finally, we discuss several meta-analyses on the efficacy of MCT that have been published over the last decade. While reviews were initially inconsistent, possibly reflecting the insufficient statistical power and lower design quality of the first MCT studies, more recent meta-analyses have confirmed the efficacy of MCT on positive symptoms, insight, and cognitive biases, which has led to the inclusion of MCT in some national treatment guidelines for schizophrenia.

Remote cognitive assessment in severe mental illness: a scoping review

Many individuals living with severe mental illness, such as schizophrenia, present cognitive deficits and reasoning biases negatively impacting clinical and functional trajectories. Remote cognitive assessment presents many opportunities for advancing research and treatment but has yet to be widely used in psychiatric populations. We conducted a scoping review of remote cognitive assessment in severe mental illness to provide an overview of available measures and guide best practices. Overall, 34 studies (n = 20,813 clinical participants) were reviewed and remote measures, psychometrics, facilitators, barriers, and future directions were synthesized using a logic model. We identified 82 measures assessing cognition in severe mental illness across 11 cognitive domains and four device platforms. Remote measures were generally comparable to traditional versions, though psychometric properties were infrequently reported. Facilitators included standardized procedures and wider recruitment, whereas barriers included imprecise measure adaptations, technology inaccessibility, low patient engagement, and poor digital literacy. Our review identified several remote cognitive measures in psychiatry across all cognitive domains. However, there is a need for more rigorous validation of these measures and consideration of potentially influential factors, such as sex and gender. We provide recommendations for conducting remote cognitive assessment in psychiatry and fostering high-quality research using digital technologies.

The Relation between Negative Automatic Thoughts and Psychological Inflexibility in Schizophrenia

Background: Schizophrenia is one of the most severe disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) spectrum. Negative automatic thoughts (NAT), cognitive fusion (CF), and experiential avoidance (EA), as part of psychological inflexibility (PI), can be considered important dysfunctional cognitive processes in schizophrenia. Methods: In the present study, two samples were included: a target group consisting of 41 people with schizophrenia (23 females; aged 44.98 ± 11.74), and a control group consisting of 40 individuals with end-stage chronic kidney disease (CKD) (27 males; aged 60.38 ± 9.14). Results: Differences were found between the two groups, with patients with schizophrenia showing an increased frequency of NAT, as well as higher levels of CF and EA (psychological inflexibility), compared to the control group. NAT were the mediator in the relation between the schizophrenia diagnosis and CF, as well as EA. Conclusion: Individuals with schizophrenia present a specific dysfunctional pattern of cognitive functioning, in which negative automatic thoughts represent a distinctive pathway to cognitive fusion and experiential avoidance.

Social Cognition Individualized Activities Lab for Social Cognition Training and Narrative Enhancement in Patients With Schizophrenia: A Randomized Controlled Study to Assess Efficacy and Generalization to Real-Life Functioning (Prot. n°: NCT05130853)

Subjects affected by schizophrenia present significant deficits in various aspects of social cognition, such as emotion processing, social perception and theory of mind (ToM). These deficits have a greater impact than symptoms on occupational and social functioning. Therefore, social cognition represents an important therapeutic target in people with schizophrenia. Recent meta-analyses showed that social cognition training (SCT) is effective in improving social cognition in subjects with schizophrenia; however, real-life functioning is not always ameliorated. Integration of SCT with an intervention targeting metacognitive abilities might improve the integration of social cognitive skills to daily life functioning. Our research group has implemented a new individualized rehabilitation program: the Social Cognition Individualized Activities Lab, SoCIAL, which integrates SCT with a module for narrative enhancement, an intervention targeting metacognitive abilities. The present multi-center randomized controlled study will compare the efficacy of SoCIAL and treatment as usual (TAU) in subjects diagnosed with a schizophrenia-spectrum disorder. The primary outcome will be the improvement of social cognition and real-life functioning; while the secondary outcome will be the improvement of symptoms, functional capacity and neurocognition. The results of this study will add empirical evidence to the benefits and feasibility of SCT and narrative enhancement in people with schizophrenia-spectrum disorders.

Brain Stimulation and Group Therapy to Improve Gesture and Social Skills in Schizophrenia-The Study Protocol of a Randomized, Sham-Controlled, Three-Arm, Double-Blind Trial

An important component of nonverbal communication is gesture performance, which is strongly impaired in 2/3 of patients with schizophrenia. Gesture deficits in schizophrenia are linked to poor social functioning and reduced quality of life. Therefore, interventions that can help alleviate these deficits in schizophrenia are crucial. Here, we describe an ongoing randomized, double-blind 3-arm, sham-controlled trial that combines two interventions to reduce gesture deficits in schizophrenia patients. The combined interventions are continuous theta burst stimulation (cTBS) and social cognitive remediation therapy (SCRT). We will randomize 72 patients with schizophrenia spectrum disorders in three different groups of 24 patients. The first group will receive real cTBS and real SCRT, the second group will receive sham cTBS and real SCRT, and finally the third group will receive sham SCRT. Here, the sham treatments are, as per definition, inactive interventions that mimic as closely as possible the real treatments (similar to placebo). In addition, 24 age- and gender-matched controls with no interventions will be added for comparison. Measures of nonverbal communication, social cognition, and multimodal brain imaging will be applied at baseline and after intervention. The main research aim of this project will be to test whether the combination of cTBS and SCRT improves gesture performance and social functioning in schizophrenia patients more than standalone cTBS, SCRT or sham psychotherapy. We hypothesize that the patient group receiving the combined interventions will be superior in improving gesture performance.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NCT04106427].

Acceptance and Commitment Therapy for Patients with a First Psychotic Episode

The search for the most effective methods of therapy for mental disorders is a priority for modern psychiatry. An approach to the early diagnostics and rehabilitation of patients experiencing psychotic episodes for the first time is proposed in the present article. The proposed approach is based on the combination of drug therapy and acceptance and commitment therapy (ACT) characterized by the development of the patient's psychological flexibility, rather than controlling the disease symptoms. The article describes the main processes of the ACT model: acceptance, cognitive defusion, contact with the present moment, understanding of the inner world, awareness of significant values, and the regulation of purposeful behaviour for the implementation of these values. Recommendations for different stages of treatment were also developed by specialists of the First Psychotic Episode Clinic at the Mental Health Clinic No.1 named after N.A. Alexeev. The psychological rehabilitation of patients with the use of ACT in the case of psychotic disorders with both negative and positive symptoms was elaborated. The application of acceptance and commitment therapy in the early diagnostics and treatment of patients experiencing a first psychotic episode results in fewer readmissions and improved psychosocial functioning in both inpatient and outpatient care.

Effectiveness of Metacognitive Regulation Intervention on Attention-Deficit-Hyperactivity Disorder Students' Scientific Ability and Motivation

This study investigated the effect of metacognitive regulation (McR) intervention on attention-deficit-hyperactivity disorder (ADHD) students' astronomy knowledge acquisition and learning motivation. Through a cognitive-behavioural treatment design, this study selected 97 ADHD learners who had poor academic performance. This study divided ADHD students randomly into one experimental group and one control group. After 15 weeks of intervention, results showed that the experimental group students performed significantly better than the control group in scientific abilities, learning motivation, and metacognition. Results suggested that the McR intervention is an effective approach for improving the ADHD students' science knowledge learning abilities.

Improvement of Insight with Non-Invasive Brain Stimulation in Patients with Schizophrenia: A Systematic Review

Patients with schizophrenia are often unaware of their condition and the consequences of their illness. This lack of insight results in impaired functioning, treatment non-adherence and poor prognosis. Here, we aimed to investigate the effects of non-invasive brain stimulation (NIBS) on two forms of insight, clinical and cognitive, in patients with schizophrenia. We conducted a systematic review of the literature registered in the PROSPERO database (CRD42020220323) according to PRISMA guidelines. The literature search was conducted in Medline and Web of Science databases based on studies published up until October 2020 that included pre-NIBS and post-NIBS measurements of clinical and/or cognitive insight in adults with schizophrenia. A total of 14 studies were finally included, and their methodological quality was assessed by using the QualSyst tool. Despite the lack of well-conducted large randomized-controlled studies using insight as the primary outcome, the available findings provide preliminary evidence that NIBS can improve clinical insight in patients with schizophrenia, with a majority of studies using transcranial direct current stimulation with a left frontotemporal montage. Further studies should investigate the effect of NIBS on insight as a primary outcome and how these effects on insight could translate into clinical and functional benefits in patients with schizophrenia.

Metacognitive Training Modified for Negative Symptoms (MCT-N): A Feasibility study

OBJECTIVE

Although patients often prioritise the treatment of negative symptoms, few psychological interventions targeting negative symptoms exist. This study attempts to fill this gap by piloting a modified Metacognitive training programme, specifically targeted at negative symptoms (MCT-N), with a group of patients with prominent negative symptoms.

METHOD

We adopted a mixed methods case series design, providing detailed quantitative data on changes over time, to focus on potential mechanisms underlying the intervention, in combination with qualitative interviews.

RESULTS

The intervention showed good feasibility as demonstrated by the attendance rate, the positive feedback from participants and the multidisciplinary team, and the improvements on negative symptoms observed following the intervention. Multilevel modelling showed that depression, internalised stigma, and reflective functioning explained the variance in negative symptoms.

DISCUSSION

The pilot study indicated that the intervention has high feasibility and that improvements in negative symptoms can be partially explained by improvements on depression, stigma, and reflective functioning.

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.

Efficacy of Metacognitive Training in a Chilean Sample of People with Schizophrenia

INTRODUCTION

Moritz et al.'s metacognitive training (MCT), a new development of cognitive therapy, is a manualized group training program, designed to correct cognitive biases involved in the formation and maintenance of psychotic symptoms, especially delusions. We report on the efficacy of MCT in a Chilean sample of people with schizophrenia.

METHODS

50 outpatients from the Hospital Del Salvador at Valparaíso, Chile, were randomly assigned to the intervention group (MCT), or the control group, that only received treatment as usual (TAU). Subjects were assessed at the beginning and end of the study with the Positive and Negative Syndrome Scale (PANSS), Cognitive Biases Questionnaire for Psychosis (CBQ-P) and Beck Cognitive Insight Scale (BCIS).

RESULTS

In the MCT group, we found larger, statistically significant improvements, in symptoms, cognitive biases and cognitive insight, than in the control group. However, after a direct comparison of both groups, only the improvement in psychotic symptoms for the MCT group, remained significantly different.

CONCLUSIONS

The results of this study suggest superiority of MCT over TAU in the amelioration of positive symptoms. We could not, however demonstrate its superiority in the improvement of the cognitive biases and cognitive insight.

Thought Suppression in Primary Psychotic Disorders and Substance/Medication Induced Psychotic Disorder

Introduction: First episode-psychosis (FEP) represents a stressful/traumatic event for patients. To our knowledge, no study to date has investigated thought suppression involved in FEP in a Romanian population. Our objective was to investigate thought suppression occurring during FEP within primary psychotic disorders (PPD) and substance/medication induced psychotic disorders (SMIPD). Further, we examined the relationship between thought suppression and negative automatic thoughts within PPD and SMIPD. Methods: The study included 30 participants (17 females) with PPD and 25 participants (10 females) with SMIPD. Psychological scales were administered to assess psychotic symptoms and negative automatic thoughts, along a psychiatric clinical interview and a biochemical drug test. Results: Participants in the PPD group reported higher thought suppression compared to SMIPD group. For the PPD group, results showed a positive correlation between thought suppression and automatic thoughts. For the SMIPD group, results also showed a positive correlation between thought suppression and automatic thoughts. Conclusions: Patients with PPD rely more on thought suppression, as opposed to SMIPD patients. Thought suppression may be viewed as an unhealthy reaction to FEP, which is associated with the experience of negative automatic thoughts and might be especially problematic in patients with PPD. Cognitive behavioral therapy is recommended to decrease thought suppression and improve patients’ functioning.

Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis

Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.