Promoting recovery from severe mental illness: Implications from research on metacognition and metacognitive reflection and insight therapy

Targeting metacognitive change mechanisms in acute inpatients with psychotic symptoms: feasibility and acceptability of a modularized group intervention

Emerging evidence suggests the usefulness of psychological interventions targeting metacognitive change mechanisms in patients experiencing psychosis. Although many of these patients are treated in acute psychiatric contexts, only few studies have adapted such interventions for acute inpatient settings. The present study aimed to assess the feasibility, acceptability, and preliminary clinical outcomes of a novel modularized group intervention focusing on different aspects of metacognitive change mechanisms. In particular, the intervention aims to reduce patients' acute symptoms by enhancing cognitive insight and to relieve distress via cognitive defusion (i.e. coping). A sample of 37 participants with acute psychosis received up to nine sessions of the intervention. Baseline and post-intervention assessments were conducted for general psychopathology, psychotic symptoms, global functioning, and symptom distress. Measures of change mechanisms were assessed before and after the respective treatment module. Participants' experiences were explored in feedback questionnaires and interviews. Recruitment, retention, and attendance rate met the pre-set feasibility benchmark of 80%. The intervention was well received by participants, who emphasised the group's clear structure, positive atmosphere, and helpful contents. Response rates were high and linear mixed models revealed significant medium-to-large time effects on all clinical outcomes. As expected, increase in hypothesised change mechanisms cognitive insight and decrease in cognitive fusion was found. However, the uncontrolled design limits interpreting clinical effects. The study provides evidence that an intervention based on a metacognitive model is feasible and acceptable for acute inpatients with psychosis. Positive results on clinical outcomes and change mechanisms warrant further exploration in a randomized controlled trial.

Psychotherapy on an Acute Psychiatric Ward: Preliminary Findings From a Controlled Study

This study investigated the efficacy of psychotherapy during hospitalization on an acute psychiatric ward. A controlled trial was conducted to assess the effects of Metacognitive Reflection and Insight Therapy (MERIT) upon metacognition and psychiatric symptoms. Data from 40 inpatient women were analysed. Findings included significant interaction effects between group (intervention or control group) and time (preintervention and postintervention) in regard to the metacognitive abilities and general psychiatric symptoms. Participating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve symptomatology level.

Metacognition as a Transdiagnostic Determinant of Recovery in Schizotypy and Schizophrenia Spectrum Disorders

The term schizotypy refers to the latent personality organization that is thought to underpin the liability to develop schizophrenia and associated disorders. Metacognition, or the ability to understand and form increasingly complex and integrated ideas of oneself, others, and one's community, has been proposed to be an important transdiagnostic construct across schizophrenia spectrum disorders and a range of both clinical and non-clinical manifestations of schizotypy. In this paper, we review evidence that deficits in metacognition are present in individuals with relatively high levels of schizotypy and that these deficits are related to symptomology, function, and quality of life. We address the idea that decrements in metacognition may also contribute to the progression from schizotypy to more severe manifestations, while the amelioration of these deficits may enhance aspects of recovery, including the ability to form an integrated sense of self, others, and the wider world. We also review the following two recovery-oriented psychotherapies that target metacognition to promote recovery in individuals with clinical manifestations of schizotypy: Evolutionary Systems Therapy for Schizotypy (ESTS) and Metacognitive Reflection and Insight Therapy (MERIT).

Impact of Delusions and Hallucinations on Clinical Insight Dimensions in Schizophrenia Spectrum Disorders

INTRODUCTION

Insight in psychosis has been conceptualized as a continuous, dynamic, and multidimensional phenomenon. This study aims to determine the impact of delusions and hallucinations in different dimensions of clinical insight in schizophrenia spectrum disorders.

METHODS

Cross-sectional multicenter study including 516 patients (336 men) diagnosed with schizophrenia spectrum disorders. Based on dichotomized scores of Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations), patients were assigned to four groups according to current clear presence of delusions (scores 4 or above 4 in PANSS item P1) and/or hallucinations (scores 4 or above 4 in PANNS item P3). Insight was assessed using the three main dimensions of the Scale of Unawareness of Mental Disorder (SUMD).

RESULTS

Around 40% of patients showed unawareness of illness; 30% unawareness of the need for treatment; and 45% unawareness of the social consequences of the disorder. Patients with current clear presence of delusions had higher overall lack of awareness, regardless of current clear presence of hallucinations. Similarly, the clear presence of delusions showed a greater predictive value on insight than the presence of hallucinations, although the implication of both in the prediction was modest.

CONCLUSIONS

Our results confirm that lack of insight is highly prevalent in schizophrenia spectrum disorders, particularly when patients experience delusions. This study adds insight-related data to the growing symptom-based research, where specific types of psychotic experiences such as hallucinations and delusions could form different psychopathological patterns, linking the phenomenology of delusions to a lack of clinical insight.

Aberrant function of the salience network related to maltreatment experiences during thought-action fusion

Childhood maltreatment (CM) causes early deviations in cognitive and affective processes, leading to future adaptation failures and psychopathology. Specifically, CM has been linked to cognitive distortions, and recent studies have focused on the impact of CM on the higher level of metacognitive beliefs. However, only a few studies have revealed the neural mechanisms underlying the association between altered metacognition and CM. Therefore, this functional magnetic resonance imaging (fMRI) study investigated the neural correlates of thought-action fusion (TAF) tendency and CM experiences. Overall, 40 young and healthy adults (21 men) participated in this study and underwent fMRI during the TAF task as well as psychological evaluation for CM, TAF tendency, anxiety, and depressive symptoms. During the TAF task, they were asked to read negative (Neg) or neutral (Neu) statements about neutral or close people (CP). Notably, significant activations were found in regions such as the bilateral anterior insula, dorsal anterior cingulate cortex (dACC), caudate, thalamus, medial prefrontal cortex, precuneus, and right amygdala in the NegCp > NeuCP contrast. Furthermore, anterior insula and dACC activities were significantly correlated with total scores of CM experiences and TAF. Exaggerated TAF tendency in persons with CM experiences was associated with increased response of the anterior insula and dACC, which are two core hubs of the salience network. Our results therefore seem to suggest insights for a better understanding of the neural mechanisms underlying metacognitive beliefs related to CM experiences.

Psychometric properties of an Arabic translation of the short form of the metacognition questionnaire (MCQ-30) in a non-clinical adult sample

BACKGROUND

Previous linguistic validations of the 30-item Metacognition Questionnaire (MCQ-30) have been performed in Western/Eastern populations, and no Arabic validated version exists to date for the wide Arabic-speaking populations in the Middle East-North African region and abroad. In this regard, we sought through the present study to test the psychometric properties of an Arabic translation of the MCQ-30 in a sample of Arabic-speaking community adults from Lebanon.

METHODS

The sample of this cross-sectional study consisted of 423 participants (mean age: 38.13 ± 11.03 years; 61.2% females). The Metacognition Questionnaire-short form, Teruel Orthorexia Scale and Emotion regulation questionnaire were used to assess metacognition, orthorexia nervosa and emotion regulation (cognitive reappraisal and expressive suppression) respectively.

RESULTS

Findings of Confirmatory Factor Analyses revealed that the five-factor model provided a good fit to the data. McDonald's ω coefficients ranged from 0.78 to 0.94 for the five MCQ-30 subscales, and was of 0.93 for the total score, hence supporting the adequacy of scale reliability. Results also supported configural, metric, and scalar equivalence of the five-factor model across gender groups. The MCQ-30 subscales showed patterns of correlations with the emotion regulation and disordered eating constructs in the expected directions, providing evidence of the criterion-related validity of the measure. In particular, positive emotion regulation strategies (i.e., cognitive reappraisal) were negatively correlated with cognitive self-consciousness and need to control thoughts; whereas maladaptive emotion regulation strategies (i.e., expressive suppression) showed positive correlations with lack of cognitive confidence, negative beliefs and need to control thoughts. Additionally, all metacognition dimensions (except for cognitive self-consciousness) were significantly and positively correlated with higher levels of orthorexia nervosa behaviors.

CONCLUSIONS

Our findings preliminarily suggest that the scale is valid, reliable, and can be recommended for use among the broad Arabic-speaking community worldwide.

Patterns and correlates of insight among patients with schizophrenia in China：A network perspective

OBJECTIVE

To explore the patterns and correlates of insight among patients with schizophrenia in a large Chinese population.

METHOD

A multi-center cross-sectional study was conducted in Guangdong province, China. Patients with schizophrenia were included. Basic socio-demographic and clinical characteristics were collected in this study. Univariate analyses, multivariate logistic regression, and network analysis were conducted.

RESULTS

A total of 6090 participants (58.8% were male, and 41.2% were female) met the study criteria and completed all the assessments. 63.5% (n = 3869) patients with schizophrenia had impaired insight. Fewer drug sides effect, higher psychological and environment domains scores in quality of life have a positive significant impact on insight in patients with schizophrenia. Younger age, higher BPRS scores have a negative significant impact on insight in patients with schizophrenia. The node ITAQ 8 (strength=1.17) was the most central node within the ITAQ network, while node ITAQ 3 was the least central node (strength=0.69). The edge ITAQ 1-ITAQ 2 was the thickest and most saturated edge in network model.

CONCLUSIONS

Considering patterns and correlation of insight, it is necessary to ensure adherence to medications and engagement with mental health services for patients with schizophrenia, which could also improve their quality of life. Taking medication actively is more central to identify ITAQ and might be the potential targets for future interventions.

Creative writing as a means to recover from early psychosis- Experiences from a group intervention

BACKGROUND

In this paper, we explore the subjective experiences of a group intervention in creative writing (CW) for young adults being treated for psychosis.

METHOD

A qualitative and exploratory design was applied. Five out of eight patients who were offered a course in CW with two-hour weekly sessions for 12 weeks took part in this study. The five participants who followed through were interviewed after project termination. Systematic text condensation was applied to the transcribed interviews.

RESULTS

The analysis revealed three overarching themes: a) the group was valued as a creative community, b) there was safety in the structured yet flexible framing of the course, c) the participants experienced creative freedom that enabled a feeling of mastery.

CONCLUSION

CW was well conceived. The feelings of connectedness and mastery were prominent. The participants experienced growth on several levels. Our findings support previous work on arts therapy as a means to recovery.

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.

Inter-relationships among psychopathology, cognition, and real-life functioning in early and late phase schizophrenia: A network analysis approach

Many illness-related factors contribute to the reduction of the real-life functioning observed in people with schizophrenia (SZ). These include the psychopathological dimensions of the disorder such as positive, negative, disorganization, and depressive symptoms as well as impairment in neurocognition, social cognition, and metacognition. The associations between some of these variables change with the duration of illness (DOI), but this aspect was not explored with a network approach. This study aimed at describing and comparing the inter-relationships between psychopathological, cognitive, and functioning variables in early (DOI ≤ 5 years) and late (DOI > 5 years) phase SZ with network analyses and at assessing which variables were more strictly and directly associated with the real-life functioning. A network representation of the relationships between variables and the calculation of centrality indices were performed within each group. The two groups were compared with a network comparison test. Seventy-five patients with early and ninety-two with late phase SZ were included. No differences in the global network structure and strength were found between the two groups. In both groups, visual learning and disorganization exhibited high centrality indices and disorganization, negative symptoms, and metacognition were directly and strongly associated with real-life functioning. In conclusion, regardless of the DOI, a rehabilitation aimed at improving visual learning and disorganization (i.e., the most central variables) might reduce the strength of the associations that compose the network and therefore indirectly facilitate functional recovery. Simultaneously, therapeutic interventions targeting disorganization and metacognition might directly improve real-life functioning.

Decreased insight, but not self-stigma or belief about medicine, is associated with greater severity of delusions in a sample of long-stay patients with schizophrenia: a cross-sectional study

BACKGROUND

There are, to date, limited and inconsistent findings concerning the relationship between insight and psychotic symptoms, despite some evidence in favor of the clinical and therapeutic relevance of the insight construct. We aimed to add to the pool of the available data in this area, by examining the correlations between the severity of insight and positive psychotic symptoms (delusions and auditory hallucinations), while accounting for self-stigma and attitudes towards medication, in a sample of long-stay inpatients with schizophrenia.

METHODS

A cross-sectional study was conducted at the Psychiatric Hospital of the Cross, between July and October 2021. A total of 82 patients diagnosed with schizophrenia (aged 55.55 ± 10.21 years, 54.9% males) were enrolled. The semi-structured psychotic symptom rating scales, the Birchwood Insight Scale, the Belief About Medicine Questionnaire, and the Internalized Stigma of Mental Illness were used.

RESULTS

The mean duration of illness in years was 30.15 ± 11.73, and the mean duration of hospitalization in years was 17.56 ± 9.24. Sixteen out of the 82 patients (19.5%) were considered as having poor insight. Bivariate analyses showed that higher chlorpromazine equivalent dose was significantly associated with more delusions, whereas higher insight was significantly associated with lower delusions. Multivariable analyses revealed that Higher chlorpromazine equivalent dose (Beta = 0.004) was significantly associated with more delusions, whereas higher insight (Beta = - 0.89) was significantly associated with less delusions. No significant associations were found between insight, self-stigma and hallucinations.

CONCLUSION

Our results imply that more impaired insight is associated with greater severity of delusions, above and beyond the effects of self-stigma and medication doses. These findings are valuable to aid clinicians and researchers improve their understanding of the relationship insight-psychotic symptoms, and could help personalize prevention and early intervention strategies in schizophrenia.

Finding the Person in the Disorder: Adapting Metacognitive Reflection and Insight Therapy for Bipolar Mood Disorder (MERIT-BD)

Metacognitive Reflection and Insight Therapy (MERIT) was originally developed as an integrative recovery-oriented therapeutic approach to address the needs of people with a diagnosis of schizophrenia and other forms of severe mental illness. The approach, conceptualized as transtheoretical, aims to promote a more coherent and synthetic sense of self, through stimulating insight, sense of coherence, and metacognitive capacity. We argue that MERIT therapy, designed to facilitate peoples’ ability to form complex ideas about themselves and others and to use this knowledge to respond to psychological problems, has application in addressing deficits associated with bipolar disorder (BD), where there may be a significant injury to the person’s sense of self. That is, the therapy addresses the nascent sense of self in a context where disturbance of mood is dominant, and in relation to the experience of episodic manic episodes which may be understood as dissociative events, often associated with shame. The application of the therapeutic approach, which we term MERIT-BD draws upon MERIT’s primary principle of facilitating complexity and integration of the self, and additionally addresses shame, allowing for the facilitation of metacognitive capacity and insight in the context of finding the person. This approach will be illustrated with case vignettes illustrating the application of key components of MERIT-BD. Early findings drawn from a series of case studies are encouraging.

A qualitative study exploring personal recovery meaning and the potential influence of clinical recovery status on this meaning 20 years after a first-episode psychosis

PURPOSE

Long-term data on recovery conceptualisation in psychotic illness are needed to support mental health services to organise themselves according to recovery-oriented frameworks. To our knowledge, no previous research has investigated how first-episode psychosis (FEP) service users (sampled across psychotic illness type) perceive recovery beyond 5 years after diagnosis. We aimed to explore personal recovery meaning with individuals 20 years after their FEP and examine the potential influence of clinical recovery status on how they defined recovery (i.e. personal recovery).

METHODS

Twenty participants were purposefully sampled from an epidemiologically representative FEP incidence cohort. At 20-year follow-up, semi-structured interviews were conducted with 10 cohort members who met full 'functional recovery criteria' (Clinically Recovered Group) and 10 who did not (Not Clinically Recovered Group). A thematic analysis was performed to develop shared themes and group-specific sub-themes to capture agreement and divergence between groups.

RESULTS

Five shared themes were produced: pursuing balance in conflict, generating meaning in life, experiencing a dynamic personal relationship with time, redressing inequality while managing added challenges/vulnerability, and directing life from resilience to flourishing. The five group-specific sub-themes developed illuminate differences in the meaning ascribed to personal recovery by each group.

CONCLUSION

Findings emphasise the role of time in how personal recovery is conceptualised by service users and identify ways clinical recovery may influence personal recovery meaning in FEP at mid-later life. Mental health services failing to consider temporal changes in meaning-making and discounting clinical recovery risk ignoring key factors affecting personal recovery.

Persons with first episode psychosis have distinct profiles of social cognition and metacognition

Subjects with first-episode psychosis experience substantial deficits in social cognition and metacognition. Although previous studies have investigated the role of profiles of individuals in social cognition and metacognition in chronic schizophrenia, profiling subjects with first-episode psychosis in both domains remains to be investigated. We used latent profile analysis to derive profiles of the abilities in 174 persons with first-episode psychosis using the Beck's Cognitive Insight Scale, the Faces Test, the Hinting Task, the Internal, Personal and Situational Attributions Questionnaire, and the Beads Task. Participants received a clinical assessment and a neuropsychological assessment. The best-fitting model was selected according to the Bayesian information criterion (BIC). We assessed the importance of the variables via a classification tree (CART). We derived three clusters with distinct profiles. The first profile (33.3%) comprised individuals with low social cognition. The second profile (60.9%) comprised individuals that had more proneness to present jumping to conclusions. The third profile (5.7%) presented a heterogeneous profile of metacognitive deficits. Persons with lower social cognition presented worse clinical and neuropsychological features than cluster 2 and cluster 3. Cluster 3 presented significantly worst functioning. Our results suggest that individuals with FEP present distinct profiles that concur with specific clinical, neuropsychological, and functional challenges. Each subgroup may benefit from different interventions.

Impact of anticholinergic load on functioning and cognitive performances of persons with psychosis referred to psychosocial rehabilitation centers

BACKGROUND

Few studies have explored whether high-anticholinergic load may hamper rehabilitation in persons with schizophrenia. We aim to explore the associations between anticholinergic load of psychotropic treatment and functioning or cognitive performances of persons with psychosis engaged in psychosocial rehabilitation.

METHODS

The study was performed using data collected at baseline assessment in the REHABase cohort including persons referred to a French network of psychosocial rehabilitation centers. The composite-rating scale developed by Salahudeen et al. was used to rate the anticholinergic load of psychotropic drugs prescribed at baseline assessment. The associations between total anticholinergic load score (categorized as 'low' <3 v. 'high' ⩾3) and functioning or cognitive characteristics were explored using multivariate analyses.

RESULTS

Of the 1012 participants with schizophrenia spectrum disorders identified in the REHABase, half used at least two psychotropic drugs with anticholinergic activity and one out of three was prescribed at least one psychotropic drug with high-anticholinergic activity. High-anticholinergic load was significantly associated with lower stage of recovery [odds ratio (OR) = 1.70, 95% confidence interval (CI) 1.05-2.76, p = 0.03], poor mental well-being (OR = 1.55, 95% CI 1.02-2.33, p = 0.04) and poor self-rated medication adherence (OR = 2.14, 95% CI 1.29-3.53, p = 0.003). Regarding cognition, a high-anticholinergic score was associated with poorer delayed-episodic memory (OR = 1.69, 95% CI 1.01-2.85, p = 0.05) and at the trend level with faster completion time on the test exploring executive performance (OR = 0.67, 95% CI 0.43-1.04, p = 0.07).

CONCLUSIONS

The psychosocial rehabilitation plan of persons with psychosis should integrate optimization of psychotropic treatment in order to lessen the functional and cognitive impact of high-anticholinergic load.

The poetics of vulnerability: creative writing among young adults in treatment for psychosis in light of Ricoeur's and Kristeva's philosophy of language and subjectivity

There is a growing interest in the application of creative writing in the treatment of mental illness. Nonpharmacological approaches have shown that access to poetic, creative language can allow for the verbalisation of illness experiences, as well as for self-expressions that can include other facets of the subject outside of the disease. In particular, creative writing in a safe group context has proven to be of particular importance. In this article, we present a pilot on a creative writing group for young adults in treatment for psychosis. We set the texts and experiences from the writing group in dialogue with Paul Ricoeur's and Julia Kristeva's philosophies on poetic language as meaning making and part of subject formation. The focus is on language as materiality and potentiality and on the patient's inherent linguistic resources as founded in a group dynamic. As a whole, the project seeks to give an increased theoretical and empirical understanding of the potentiality of language and creativity for healing experiences, participation and meaning-making processes among vulnerable people. Furthermore, a practice founded in poetic language might critically address both the general and biomedical understanding of the subject and disease.

Introspective accuracy for substance use across a year of treatment for first episode psychosis

Substance use exacerbates psychosis, mania, depression, and poor functioning in people with first episodes of psychosis (FEP) and is associated with poor treatment outcomes, even when it does not reach the level of a formal disorder. Impaired insight and substance use are common issues that may interfere with treatment outcomes among people experiencing FEP, yet both are treatable. Improvements in these domains are associated with better outcomes. Low insight could increase risk for substance use by impairing the ability to self-appraise and assess consequences. Introspective accuracy (IA) is understudied in this area and is one way of considering self-appraisal. This study is an archival review using data collected from NAVIGATE, a coordinated specialty care program treating people with FEP. IA was operationalized as the difference between clinician and client ratings of substance use. We tested whether IA changed over one year of treatment and whether those changes occurred alongside changes in symptoms and illness self-management. No changes in IA were detected in relation to illness self-management. Changes in IA for substance use occurred midway through treatment—individuals with greater symptom remission had more overconfident IA. Prior research on insight has shown a paradox where greater insight accompanies more symptoms. However, past research has also shown a relationship between IA and functional outcomes, like illness self-management, and that overconfidence in one domain can positively bias clinician ratings in another. Our findings suggest either a positive bias for ratings associated with overconfident IA or an insight paradox type effect.

•

Introspective accuracy is a form of insight that can be applied to early psychosis.

•

Introspective accuracy for substance use paradoxically interacted with symptoms

•

Introspective accuracy for substance use was unrelated to illness self-management.

The alliance-outcome relationship in individual psychosocial treatment for schizophrenia and early psychosis: A meta-analysis

The therapeutic alliance, or client-provider relationship, has been associated with better treatment engagement and outcomes for persons with schizophrenia-spectrum disorders (SSDs) and early psychosis in some studies, but not others. We conducted a meta-analysis of the research on alliance in SSDs and early psychosis across a range of interventions and outcomes. Parallel literature searches were conducted in PubMed and PsycINFO databases for articles between inception and 6/11/2020. English-language studies were included if they evaluated the relationship between alliance and a prospective outcome (treatment engagement, medication adherence, functioning, or total, positive, negative, or depressive symptoms) in an individual clinical treatment for SSDs/early psychosis and contained analyzable data. Correlations and partial correlations were meta-analyzed with random effects models to calculate mean across-study correlations and to carry out subsequent homogeneity and moderator variable analyses. Fourteen studies consisting of 2968 participants that assessed six outcomes across six psychosocial treatments were included. Results indicated that better client-rated (r = 0.20) and other-rated (i.e., provider- or observer-rated; r = 0.25) alliance were associated with better treatment engagement. Treatment type and sample race/ethnicity, but not age, gender, or timing of alliance rating moderated the association between other-rated alliance and engagement. Further, better other-rated alliance was related to improvements in positive (r = -0.14) and negative (r = -0.22) symptoms. A strong therapeutic alliance is important for both engaging clients with SSDs and early psychosis in treatment and facilitating improvements in positive and negative symptoms. Delivery and monitoring of treatments for this population should include assessment of the therapeutic alliance from multiple perspectives.

The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation

Abstract. This systematic review aimed to evaluate the efficacy of Cognitive Behavioral Therapy (CBT), META Cognitive Therapy (MCT), Metacognitive Training (MCTR), Metacognitive Reflection and Insight Therapy (MERIT), of various rehabilitation programs and of recovery programs in schizophrenia. Medline/Pubmed was searched for studies published in English from January 2010 to August 2018, which were screened against inclusion criteria by two reviewers. The methodological quality of the included studies was evaluated by two independent raters, which are the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies and the fidelity criteria. The study included 41 RCTs and 12 case studies with n = 3,059 persons with schizophrenia. Cognitive Behavioral Therapy (CBT) proved to be superior in terms of the improvement of primary and secondary outcomes. MCT decreased positive symptoms and improved metacognitive capacity and insight. MCTR reduced positive symptoms and socially disruptive behavior. MERIT improved metacognitive capacity and insight. Rehabilitation programs were efficacious in the improvement of cognition, symptoms, and functional outcome. The recovery programs enhanced illness-management knowledge, attitudes toward medication and insights related to negative symptoms. It is recommended to combine the above evidence based psychotherapeutic interventions. Limitations of this systematic review are discussed toward the end of the essay. Some important factors have to be considered in the future have been mentioned.

Exploration of recovery of people living with severe mental illness (SMI) in low/middle-income countries (LMICs): a scoping review

OBJECTIVE

To examine the literature on how recovery of people with severe mental illness (SMI) is conceptualised in low/middle-income countries (LMICs), and in particular what factors are thought to facilitate recovery.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We searched 14 electronic databases, hand searched citations and consulted with experts during the period May-December 2019. Eligible studies were independently screened for inclusion and exclusion by two reviewers. Unresolved discrepancies were referred to a third reviewer.

DATA EXTRACTION AND SYNTHESIS

All bibliographical data and study characteristics were extracted using a data charting form. Selected studies were analysed through a thematic analysis emerging from extracted data.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram offers a summary of the results: 4201 titles, 1530 abstracts and 109 full-text articles were screened. Ten articles were selected for inclusion: two from Turkey, two from India, and one each from China, Swaziland, Indonesia, Egypt, South Africa and Vietnam. Although most studies used qualitative methods, data collection and sampling methods were heterogeneous. One study reported on service provider perspectives while the rest provided perspectives from a combination of service users and caregivers. Three themes emerged from the data analysis. First, studies frame recovery as a personal journey occurring along a continuum. Second, there was an emphasis on social relationships as a facilitator of recovery. Third, spirituality emerged as both a facilitator and an indicator of recovery. These themes were not mutually exclusive and some overlap exists.

CONCLUSION

Although there were commonalities with how high-income countries describe recovery, we also found differences in conceptualisation. These differences in how recovery was understood reflect the importance of framing the personal recovery concept in relation to local needs and contextual issues found in LMICs. This review highlighted the current sparse evidence base and the need to better understand recovery from SMI in LMICs.

Narrative Identity, Metacognition, and Well-Being in Patients With Schizophrenia or HIV

It has been proposed that schizophrenia reflects disturbances in personal identity, which include sense of personal agency, sense of belonging within a social group, and metacognition. Less is known about how these different processes are related to one another and to well-being outcomes. To study this, we measured themes of agency and communion in narrative identity in 29 individuals with schizophrenia and 29 individuals with HIV. All participants had previously been assessed on metacognitive abilities using the Indiana Psychiatric Illness Interview (IPII) and completed scales measuring hopelessness and self-esteem. For the present study, themes of agency and communion were coded from the IPII transcripts. Results indicated that participants with schizophrenia had lower levels of agency and communion compared with participants with HIV. More presence of agency and communion themes were related to better metacognitive abilities as well as less hopelessness and higher self-esteem across groups. Agency predicted variance in hopelessness after controlling for metacognitive abilities. The results suggest that although the construction of narrative identity may depend on metacognitive abilities, agency themes predict outcomes beyond metacognition.

Beyond the cognitive insight paradox: Self-reflectivity moderates the relationship between depressive symptoms and general psychological distress in psychosis

BACKGROUND

People with psychosis experience significant emotional burden and distress associated with the symptomatic consequences of their mental disorder, thus difficulting their recovery. Several studies have found self-reflectivity, a dimension of cognitive insight, to be associated with effects which taken together may seem paradoxical, by predicting less psychotic symptom severity but more depression. To elucidate this issue, we examined the influence of psychotic symptoms, depressive symptoms, and self-reflectivity, on psychological distress. Further, we tested whether self-reflectivity moderated the relationship between depressive symptoms and psychological distress.

METHODS

Seventy-six outpatients with psychotic-spectrum disorders were assessed using measures of psychotic symptoms, depressive symptoms, cognitive insight (i.e., self-reflectivity, self-certainty) and psychological distress.

RESULTS

A regression model revealed that depressive, positive symptoms and the interaction between depressive symptoms and self-reflectivity had a significant effect on psychological distress. The moderation analysis showed that higher levels of self-reflectivity were related to less psychological distress associated with depressive mood.

CONCLUSIONS

The role of self-reflectivity on depression and distress may be more complex than a direct effect. Interventions targeted to improve metacognition by enhancing self-reflectivity might be important for lowering the psychological distress associated with depressive symptoms in people with psychosis.

Subjective Recovery in Patients with Schizophrenia and Related Factors

Subjective recovery is a personally perceived recovery involving other factors beyond clinical recovery. This study aims at investigating the factors related to subjective recovery in patients with schizophrenia living in Turkey. This study assessed 120 clinically stable outpatients with schizophrenia or schizoaffective disorder using the clinical and psychosocial scales. Gender, type of the diagnosis of disease, and age of the illness onset were found to be correlated with the subjective recovery. Subjective recovery was significantly correlated with CGI-S (r = - 0.25), total PANSS score (r = - 0.29), global assessment of functioning (r = 0.27), social functioning (r = 0.43), internalized stigma (r = - 0.38), self-esteem (r = 0.56), depression (r = - 0.59), and hopelessness (r = - 0.55). Hopelessness and self-esteem were found to be predictive of the subjective recovery explaining 52% of the variance. It can be argued that efforts to promote hope and self-esteem contribute to the subjective recovery.

Metacognitive and cognitive-behavioral interventions for psychosis: new developments

This review describes four cognitive approaches for the treatment of schizophrenia: cognitive-behavioral therapy for psychosis (CBTp), metacognitive therapy, metacognitive training, and metacognitive reflection insight therapy (MERIT). A central reference point of our review is a seminal paper by James Flavell, who introduced the term metacognition (“cognition about cognition”). In a way, every psychotherapeutic approach adopts a metacognitive perspective when therapists reflect with clients about their thoughts. Yet, the four approaches map onto different components of metacognition. CBTp conveys some “metacognitive knowledge” (eg, thoughts are not facts) but is mainly concerned with individual beliefs. Metacognitive therapy focuses on unhelpful metacognitive beliefs about thinking styles (eg, thought suppression). Metacognitive training brings distorted cognitive biases to the awareness of patients; a central goal is the reduction of overconfidence. MERIT focuses on larger senses of identity and highlights metacognitive knowledge about oneself and other persons. For CBTp and metacognitive training, meta-analytic evidence supports their efficacy; single studies speak for the effectiveness of MERIT and metacognitive therapy.


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.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Schizophrenia, recovery and the self: An introduction to the special issue on metacognition

In this special issue, work is presented linking metacognition among persons with schizophrenia with a range of psychosocial outcomes including vocational functioning, empathy, motivation, self-evaluation, and other cognitive functions. This overview will highlight how these works allow for the quantitative study of processes which underpin alterations in self-experience in schizophrenia, which in turn allows self-experience to be studied as part of a larger set of brain-based and social phenomena whose interaction influences the trajectory of one's life and illness. We explore the hypothesis that metacognitive capacity, as a node in a larger biopsychosocial network, may be accessible by psychosocial treatment and, if successfully targeted, may disrupt the processes which perpetuate disability. Limitations and directions for future research are also discussed.

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

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

Exploration of recovery of people living with severe mental illness (SMI) in low-income and middle-income countries (LMIC): a scoping review protocol

INTRODUCTION

The construct of recovery was conceptualised in high-income countries and its applicability in low-income and middle- income countries is underexplored. A scoping review is proposed to synthesise knowledge, review conceptual overlap and map key elements of recovery from severe mental illness in low-income and middle-income countries. We aim to appraise the literature so as to inform future recovery-oriented services that consider the cultural and contextual influences on recovery from severe mental illness.

METHODS AND ANALYSIS

The following electronic databases: MEDLINE via PubMed, SCOPUS (which included contents of Embase), PsycINFO, CINAHL, Africa-Wide Information, PsycARTICLES, Health source: Nursing/Academic Edition, Academic Search Premier and SocINDEX all via the EBSCOHOST platform, the Latin American and Caribbean Health Sciences Literature, the Cochrane Centre Register of Controlled Trials) and grey literature sources will be searched between May and December 2019. Eligible studies will be independently screened for inclusion and exclusion by two reviewers using a checklist developed for this purpose. Studies published between January 1993 and November 2019 that focus on recovery from severe mental illness in a low-income and middle-income country will be included. Findings will be compared and discrepancies will be discussed. Unresolved discrepancies will be referred to a third reviewer. All bibliographic data and study characteristics will be extracted and thematically analysed using a tool developed through an iterative process by the research team. Indicators will be classified according to a predefined conceptual framework and categorised and described using qualitative content analysis.

ETHICS AND DISSEMINATION

The review aims to synthesise information from available publications, hence it does not require ethical approval. The results will be disseminated through publications, conference presentations and future workshops with stakeholders involved within the recovery paradigm of mental health policy and practice. The scoping review title is registered with the Joanna Briggs Institute.

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

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

The Independent Relationships of Metacognition, Mindfulness, and Cognitive Insight to Self-Compassion in Schizophrenia

The debilitating nature of psychosis may be exacerbated by societal stigma and feelings of social isolation over and above positive (e.g., hallucinations) and negative (e.g., flat affect) symptoms. Thus, recovery may be facilitated by increasing self-compassion, the ability to respond with a nonjudgmental attitude of kindness toward oneself as a result of connecting with one's own inadequacies and suffering. We conducted a stepwise regression in individuals with schizophrenia-spectrum disorders (n = 92) to determine the unique contributions of cognitive variables in predicting self-compassion, such as metacognition (the ability to form complex and integrated ideas about oneself and others), mindfulness, and cognitive insight. Results indicated that increased metacognitive awareness of others and mindfulness uniquely predicted greater self-compassion (i.e., self-kindness), whereas increased cognitive insight predicted greater lack of self-compassion (i.e., self-judgment). These findings suggest the potential for mindfulness and metacognitive interventions to increase positive self-compassion and promote recovery in psychosis.

The French Integrative Psychosocial Rehabilitation Assessment for Complex Situations (FIPRACS): Modelization of an Adapted Assessment Method Toward Long-Term Psychiatric Inpatients With Disabling, Severe and Persistent Mental Illness

For the past forty years, the generalization of community-based approaches has prompted psychiatry into promoting a deinstitutionalization movement and a psychosocial rehabilitation approach (PSR) for individuals with schizophrenia and related difficulties. Unfortunately, this approach generally does not involve the most severe cognitive and psycho-affective clinical situations among this population despite an increasing number of publications advocating that all individuals should be included in PSR and deinstitutionalization programs. In this context, considering the absence of an assessment battery designed for French individuals with particularly disabling, severe, and persistent mental illness (IDSPMI), we constructed an integrative assessment model adapted to this specific population. To select the most suitable tools for this population, a literature review (inspired by the PRISMA protocol) and a systematic review were combined with a clinical assessment study. The literature review first identified the cognitive and psycho-affective functions which mainly influence the day-to-day life adaptation of individuals engaged in a PSR/deinstitutionalization program. The systematic review then gathered all of the useable French validated tools to assess the initially selected dimensions (n = 87). To finish, for each dimension, the selected 87 tools were included in a clinical assessment study performed within a French psychiatric hospital. The authors collected and verified the characteristics of each tool (validity, French norms, French version, the average speed of the test, ease of use, ability to assess other dimensions). Their suitability was also assessed when applied to IDSPMI. Based on this final clinical evaluation, the authors selected one tool per function to create the French Integrative Psychosocial Rehabilitation Assessment for Complex Situations (FIPRACS). This battery is an assessment tailored to the neurocognitive and psycho-affective potentials of IDSPMI. While further validation studies of this battery are ultimately required, the practical/clinical implications of this battery are presented and discussed.

Functioning and cognitive characteristics of clozapine users referred to psychosocial rehabilitation centers: A REHABase cohort study

OBJECTIVES

To explore whether clozapine users have specific rehabilitation needs compared to users of other antipsychotics.

METHODS

The study was performed using the REHABase collecting data on persons referred to a French network of psychosocial rehabilitation centers. It was restricted to persons with schizophrenia spectrum disorder using antipsychotics. Multivariate analyses were used to compare baseline functioning and cognitive characteristics in clozapine users vs. users of other antipsychotics.

RESULTS

Of the 675 patients identified in the REHABase, one out of ten (n = 70) used clozapine. Compared to users of other antipsychotics, clozapine users had been more frequently hospitalized in psychiatry and presented less frequently with psychoactive substance use. Functional measures did not significantly differ between the two groups. Clozapine users had poorer short-term verbal memory performance than users of other antipsychotics and did not differ on executive performance.

CONCLUSION

Clozapine users may reach a recovery level comparable to that obtained in persons without treatment-resistant schizophrenia. In order to reduce the negative impact of memory deficits on the recovery process of clozapine users, it is necessary to optimize their psychotropic treatment and to promote their access to cognitive remediation programs addressing their specific needs.

Effects of a Korean version of the metacognitive training program for outpatients with schizophrenia on theory of mind, positive symptoms, and interpersonal relationships

BACKGROUND

Since the significance of metacognition as the theoretical basis of a psychological intervention for schizophrenia first emerged, there have been ongoing attempts to restore or strengthen patients' metacognitive abilities.

AIM

A Korean version of the metacognitive training (MCT) program was developed, and its effects on theory of mind, positive and negative symptoms, and interpersonal relationships were examined in stable outpatients with schizophrenia.

METHOD

A pre-test-post-test design with a control group was used. The participants were 59 outpatients (30 in experimental group, 29 in control group) registered at five mental health facilities in a city in South Korea. The developed MCT program was applied for a total of 18 sessions, 60 min per session, over a period of 14 weeks. The hinting task, false belief task, Scale for the Assessment of Positive and Negative Symptoms, and Relationship Change Scale were used to verify the effects of this program. Data were analysed by the chi-square test, t-test, and Mann-Whitney U-test using the SPSS/PASW 18.0 statistics program.

RESULTS

The general characteristics, intelligence, and outcome variables of the two groups were homogeneous. After the intervention, the experimental group showed significant improvements in theory of mind, positive and negative symptoms and interpersonal relationships compared with the control group.

CONCLUSION

These results suggest that the MCT program can be a complementary psychotherapy that contributes to symptom relief and interpersonal functioning in patients with schizophrenia, and is effective in the Korean culture, beyond the Western context.

Impulsivity issues in borderline personality disorder and it's links with insight: the role of urgency

Objective

Impulsivity plays a major role in a wide range of disorders including Borderline Personality Disorder. Another crucial clinical dimension is insight. This clinical dimension is linked with symptomatology and treatment issue. The present study aims to investigate the impact of positive and negative urgency on insight in Borderline Personality Disorder.

Methods

We recruited eighty-one women with Borderline Personality Disorder and assessed insight level and impulsivity scores using the Beck Cognitive insight scale and the UPPS-short form scale.

Results

Our results showed interesting links between positive urgency and insight quality.

Conclusion

Negative emotions play a fundamental role for the insight quality, but positive emotions are surprisingly related to clinical insight. We discuss the possible therapeutical impact of this results on treatment adaptation.

Supervision in the Psychotherapy of Schizophrenia: Awareness of and Mutual Reflection upon Fragmentation

Historical and newly emerging models of schizophrenia suggest it is a disorder characterized by the fragmentation of the experience of the self and the world, leading to the interruption of how a unique life is unfolding in the world. It has been proposed that psychotherapy might therefore promote recovery by facilitating the development of a greater ability to integrate information about the self and others. In this paper we explore how the supervision of a metacognitively-oriented psychotherapy can assist therapists to experience and conceptualize fragmentation within sessions, join patients in the gradual process of making sense of their psychiatric problems and life challenges, and ultimately envision and achieve recovery. Common challenges and responses within supervision are described and discussed.

Cortisol stress response in psychosis from the high-risk to the chronic stage: a systematic review

OBJECTIVES

We review studies of whether cortisol levels following psychosocial stress exposure differ between patients with psychosis and healthy control subjects.

METHODS

Original research published between 1993 and February 2019 was included in the literature search. Studies that used experimentally induced psychosocial stress and reported stress response measures of plasma or saliva cortisol levels in patients at any stage of illness (i.e. high risk, first episode and chronic phase) were included.

RESULTS

A total of 17 studies were included. Although there was evidence of inconsistencies in measures, we observed moderate evidence of an association with stress-induced cortisol blunting response across studies.

CONCLUSIONS

This review highlights recent evidence of blunting of cortisol response following experimentally induced psychosocial stress. While there was some evidence of this blunted response across illness types and stages, the strongest evidence was observed for those with chronic schizophrenia. Due to the low number of studies, in particular in bipolar disorder, much work is still needed to accurately characterise the biological effects of stress in psychosis.

Autism and psychosis as diametrical disorders of embodiment

Humans have evolved an elaborate system of self-consciousness, self-identity, self-agency, and self-embodiment that is grounded in specific neurological structures including an expanded insula. Instantiation of the bodily self has been most-extensively studied via the 'rubber hand illusion', whereby parallel stimulation of a hidden true hand, and a viewed false hand, leads to the felt belief that the false hand is one's own. Autism and schizophrenia have both long been regarded as conditions centrally involving altered development of the self, but they have yet to be compared directly with regard to the self and embodiment. Here, we synthesize the embodied cognition literature for these and related conditions, and describe evidence that these two sets of disorders exhibit opposite susceptibilities from typical individuals to the rubber hand illusion: reduced on the autism spectrum and increased in schizophrenia and other psychotic-affective conditions. Moreover, the opposite illusion effects are mediated by a consilient set of associated phenomena, including empathy, interoception, anorexia risk and phenotypes, and patterns of genetic correlation. Taken together, these findings: (i) support the diametric model of autism and psychotic-affective disorders, (ii) implicate the adaptive human system of self-embodiment, and its neural bases, in neurodevelopmental disorders, and suggest new therapies and (iii) experimentally ground Bayesian predictive coding models with regard to autism compared with psychosis. Lay summary: Humans have evolved a highly developed sense of self and perception of one's own body. The 'rubber hand illusion' can be used to test individual variation in sense of self, relative to connection with others. We show that this illusion is reduced in autism spectrum disorders, and increased in psychotic and mood disorders. These findings have important implications for understanding and treatment of mental disorders.

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

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

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

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

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

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

The Multiple Dimensions of Insight in Schizophrenia-Spectrum Disorders

The concept of insight is used to indicate the propensity of patients with schizophrenia and other severe mental disorders to recognize their illness and engage in treatment. Thus, insight may have notable consequences for the ill individual: Those who lack insight are at higher risk of nonadherence to treatments, negative clinical outcomes, and worse community functioning. Although insight is an intuitive concept, its essence remains difficult to capture. However, many rating scales are available to aid assessment, both for clinical and research purposes. Insight cannot be reduced to a symptom, a psychological mechanism, or a neuropsychological function. It is likely to have dynamic relationships with all these dimensions and with responses to personal events and contextual factors. In particular, social consequences of mental illness and explanatory models that are alternative to the medical model may fundamentally shape insight and treatment choice. Moreover, the cultural or individual stigmatization of mental illness may turn the acquisition of insight into a painful event and increase the risk of depression. Clinicians need to carefully evaluate and promote insight through a personalized approach to aid patient process of care and personal growth.

Does childhood trauma predict poorer metacognitive abilities in people with first-episode psychosis?

Research suggests that people with first-episode psychosis (FEP) report more childhood traumas and have lower metacognitive abilities than non-clinical controls. Childhood trauma negatively affects metacognitive development in population studies, while the association remains largely unexplored in FEP populations. Metacognition refers to the identification of thoughts and feelings and the formation of complex ideas about oneself and others. This study hypothesized that childhood trauma would be associated with lower metacognitive abilities in people with FEP. In a representative sample of 92 persons with non-affective FEP, we assessed childhood trauma, metacognitive abilities and symptoms of psychosis. We used the Childhood Trauma Questionnaire (CTQ) and the Metacognitive Assessment Scale--Abbreviated which includes Self-reflectivity, Awareness of the Mind of the Other, Decentration and Mastery. Hierarchical regression analyses were performed with metacognitive domains as outcome variables and childhood traumas as independent variables, while controlling for age, gender, first-degree psychiatric illness and negative symptoms. We found few significant associations between the different types of childhood trauma and metacognitive domains, and they suggested childhood trauma are associated with better metacognitive abilities. Study limitations included the cross-sectional design and use of self-report measures. Future studies could preferably be prospective and include different measures of psychopathology and neuropsychology.

Measuring disorganized speech in schizophrenia: automated analysis explains variance in cognitive deficits beyond clinician-rated scales

BACKGROUND

Conveying information cohesively is an essential element of communication that is disrupted in schizophrenia. These disruptions are typically expressed through disorganized symptoms, which have been linked to neurocognitive, social cognitive, and metacognitive deficits. Automated analysis can objectively assess disorganization within sentences, between sentences, and across paragraphs by comparing explicit communication to a large text corpus.

METHOD

Little work in schizophrenia has tested: (1) links between disorganized symptoms measured via automated analysis and neurocognition, social cognition, or metacognition; and (2) if automated analysis explains incremental variance in cognitive processes beyond clinician-rated scales. Disorganization was measured in schizophrenia (n = 81) with Coh-Metrix 3.0, an automated program that calculates basic and complex language indices. Trained staff also assessed neurocognition, social cognition, metacognition, and clinician-rated disorganization.

RESULTS

Findings showed that all three cognitive processes were significantly associated with at least one automated index of disorganization. When automated analysis was compared with a clinician-rated scale, it accounted for significant variance in neurocognition and metacognition beyond the clinician-rated measure. When combined, these two methods explained 28-31% of the variance in neurocognition, social cognition, and metacognition.

CONCLUSIONS

This study illustrated how automated analysis can highlight the specific role of disorganization in neurocognition, social cognition, and metacognition. Generally, those with poor cognition also displayed more disorganization in their speech-making it difficult for listeners to process essential information needed to tie the speaker's ideas together. Our findings showcase how implementing a mixed-methods approach in schizophrenia can explain substantial variance in cognitive processes.

Disturbances in Self-Experience in Schizophrenia: Metacognition and the Development of an Integrative Recovery-Oriented Individual Psychotherapy

BACKGROUND/AIMS

Disturbances in first person experience is a broadly noted feature of schizophrenia, which cannot be reduced to the expression of psychopathology. Yet, though categorically linked with profound suffering, these disturbances are often ignored by most contemporary treatment models.

METHODS

In this paper, we present a model, which suggests that deficits in metacognition and their later resolution parsimoniously explain the development of self-disturbance and clarify how persons can later recover. We define "metacognition" as processes integral to the availability of a sense of self and others within the flow of life and report research suggesting its contribution to schizophrenia and link to self-disturbance.

RESULTS

We describe a newly emerging integrative form of psychotherapy, Metacognitive Reflection and Insight Therapy (MERIT), designed to target metacognition and enhance the recovery of healthy self-experience. We describe eight measurable core elements that allow MERIT to be operationalized and discuss about how to address disturbances in self-experience.

CONCLUSIONS

We detail research that provides evidence of the feasibility, acceptability, and effectiveness of MERIT across a broad range of patients, including those who might not otherwise be offered psychotherapy. MERIT represents one form of psychotherapy that may address self-disorders among adults with schizophrenia.

Metacognitive Deficits Predict Impaired Insight in Schizophrenia Across Symptom Profiles: A Latent Class Analysis

The integrated model of insight in schizophrenia suggests that poor insight is the result of multiple factors which compromise persons' abilities to integrate streams of information into a personal awareness of psychiatric challenges, and make adaptive responses. This model hypothesizes that metacognitive deficits, or difficulties forming a complex and integrated understanding of the self and others, influence insight, regardless of other proximal causes including clinical profile. To explore this possibility, we performed a latent class analysis on 324 adults with schizophrenia or schizoaffective disorder. This analysis produced 4 groups on the basis of assessment of insight and Positive and Negative Syndrome Scale (PANSS) positive, negative, cognitive, and hostility symptoms. The resultant groups were characterized as: Good Insight/Low Symptoms (n = 71), Impaired Insight/High Negative Symptoms, (n = 43), Impaired Insight/High Positive Symptoms (n = 50) and Impaired Insight/Diffuse Symptoms (n = 160). When we compared metacognitive function as assessed with the Metacognition Assessment Scale - Abbreviated (MAS-A) across groups, we found that the good insight group had better overall metacognition as well as higher levels of self-reflectivity, awareness of the other and mastery as compared to all 3 groups with impaired insight. When controlling for total symptoms, all differences in metacognitive function between the good insight and the impaired insight groups remained significant. These results are consistent with the view that, independent of symptoms, impaired metacognition contributes to difficulties integrating information and hence impedes insight, or awareness of psychiatric challenges. Consistent with extant literature, results suggest that interventions focusing on metacognition as the target may lead to improved insight.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The role of childhood trauma in cognitive performance in schizophrenia and bipolar disorder - A systematic review

Childhood trauma (CT) has repeatedly been associated with cognitive deficits in patients with psychosis but many inconsistencies have been reported so that the nature of the relationship remains unclear. The purpose of this review was to better characterize the contribution of CT to cognitive deficits by considering the type, severity and frequency of childhood traumatic events and their relationships with psychosis at all stages.

Relevant studies were identified via electronic and manual literature searches and included original studies that investigated the relationship between CT and higher cognitive performance or social cognitive performance in patients with schizophrenia, bipolar disorder and psychosis at all stages of the illness stages (i.e. ultra-high risk, first episode or chronic phase).

Overall, a majority of studies reported that patients who experienced CT displayed deficits in general cognitive ability compared to patients with psychosis without such a history. Associations between CT and other cognitive function were more mixed. When comparing patient groups, the association between CT and cognitive function was more inconsistent in patients with chronic schizophrenia than in healthy participants, ultra-high risk individuals, first-episode patients and patients with chronic bipolar disorder.

In understanding the variability in the reported relationships between CT and cognition across study populations, we highlight the variety of questionnaires used and discuss the likelihood of there being differences in cognitive function based on specific stressors, severity and frequency. Finally, we consider future research steps that may shed light on psychobiological mechanisms underlying CT and cognitive performance in patients with psychosis.

Associations of oxytocin and vasopressin plasma levels with neurocognitive, social cognitive and meta cognitive function in schizophrenia

Many with schizophrenia experiences deficits in social cognition, neurocognition and metacognition. Yet the biological mechanisms which may underpin these cognitive deficits are poorly understood. Two candidate causes of these deficits are disturbances in oxytocin (OT) and vasopressin (VP). To explore this we assessed plasma OT and VP in 34 schizophrenia patients and 31 healthy controls. We also concurrently assessed social cognition using the Reading the Mind from the Eyes test, neurocognition using the Wisconsin Card Sorting Test and metacognition using the Metacognitive Assessment Scale-Abbreviated. Group comparisons revealed lower plasma OT levels in the schizophrenia group. Plasma VP levels did not differ between groups. Correlations revealed that lower levels of OT were associated with poorer levels of metacognitive functioning in the schizophrenia group but not poorer social cognition or neurocognition. In a stepwise multiple regression, plasma OT level, neurocognition and social cognition contributed uniquely to the prediction of metacognition in the schizophrenia group. Results may suggest that disturbance in OT is linked with deficits in metacognition and may interact with other forms of cognitive deficits, interfering with the person's abilities to form a complex and integrated sense of self and others.