Metacognitive deficits predict future levels of negative symptoms in schizophrenia controlling for neurocognition, affect recognition, and self-expectation of goal attainment

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).

Investigating the relationship between specific negative symptoms and metacognitive functioning in psychosis: A systematic review

BACKGROUND

Disrupted metacognition is implicated in development and maintenance of negative symptoms, but more fine-grained analyses would inform precise treatment targeting for individual negative symptoms.

AIMS

This systematic review identifies and examines datasets that test whether specific metacognitive capacities distinctly influence negative symptoms.

MATERIALS & METHODS

PsycINFO, EMBASE, Medline and Cochrane Library databases plus hand searching of relevant articles, journals and grey literature identified quantitative research investigating negative symptoms and metacognition in adults aged 16+ with psychosis. Authors of included articles were contacted to identify unique datasets and missing information. Data were extracted for a risk of bias assessment using the Quality in Prognostic Studies tool.

RESULTS

85 published reports met criteria and are estimated to reflect 32 distinct datasets and 1623 unique participants. The data indicated uncertainty about the relationship between summed scores of negative symptoms and domains of metacognition, with significant findings indicating correlation coefficients from 0.88 to -0.23. Only eight studies investigated the relationship between metacognition and individual negative symptoms, with mixed findings. Studies were mostly moderate-to-low risk of bias.

DISCUSSION

The relationship between negative symptoms and metacognition is rarely the focus of studies reviewed here, and negative symptom scores are often summed. This approach may obscure relationships between metacognitive domains and individual negative symptoms which may be important for understanding how negative symptoms are developed and maintained.

CONLCLUSION

Methodological challenges around overlapping participants, variation in aggregation of negative symptom items and types of analyses used, make a strong case for use of Individual Participant Data Meta-Analysis to further elucidate these relationships.

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.

Metacognition in schizophrenia: A practical overview of psychometric metacognition assessment tools for researchers and clinicians

Metacognition refers to the cognitive ability to control, monitor and modulate cognitive processes thus guiding and orienting behavior: a continuum of mental activities that ranges from more discrete ones, such as the awareness of the accuracy of others' judgment, to more integrated activities, such as the knowledge of cognitive processes. Metacognition impairment in schizophrenia, which is considered a core feature of the illness, has become a growing research field focusing on a wide range of processes including reasoning, autobiographical memory, memory biases, cognitive beliefs and clinical insight. There is a well-established relationship between metacognition and schizophrenia symptoms severity, as well as between impaired metacognitive functioning and specific symptomatic sub-domains, such as positive symptoms, negative symptoms, or disorganization. The development of specific cognitive-derived psychotherapies for metacognitive deficits in schizophrenia has been ongoing in the last years. Although sharing a metacognitive feature, these treatments focus on different aspects: false or unhelpful beliefs for metacognitive therapy; cognitive biases for metacognitive training; schematic dysfunctional beliefs for cognitive behavioral therapy (CBT) for psychoses; metacognitive knowledge and sense of identity for MERIT; interpersonal ideas or events triggering delusional thinking for MIT-P. This article reviews the instruments designed to assess metacognitive domains and functions in individuals with schizophrenia, providing mental health professionals with an overview of the heterogeneous current scenario ranging from self-administered scales to semi-structured interviews, which are supported by a variety of theoretical frameworks. Future directions may address the need for more specific and refined tools, also able to follow-up psychotherapeutic-induced improvements.

Meaning-making processes across the lifespan: An investigation of the developmental course of metacognitive capacity

Deficits in metacognitive capacity (i.e., the ability to integrate knowledge of oneself and others into a cohesive whole) have been shown to lead to poor functional outcome in psychosis. However, there is a gap in the literature concerning the role of metacognition in typically developing populations, which makes it difficult to define what level of metacognition is normative and at what point deficits in metacognition suggest pathology. To explore this issue, we utilized cross-sectional design to assess metacognitive capacities among 69 neurotypical adults whose ages varied from 18 to 65 using the Metacognitive Assessment Scale - Abbreviated (MAS-A) and then compared those with MAS-A scores from a second previously gathered sample of 360 adults diagnosed with psychosis across four key developmental windows: emerging adulthood, early adulthood, middle adulthood, and late adulthood. Our findings suggest that in our overall sample, individuals with psychosis had significantly lower levels of metacognitive capacity across all domains assessed by the MAS-A in comparison to neurotypical individuals. Additionally, our data suggest a deleterious effect of psychosis such that individuals with psychosis showed significantly lower metacognition in each developmental stage. Additionally, these differences were largest in emerging and late adulthood and for both groups awareness of others stood out as the single metacognitive domain which was significantly less impaired among older groups. Our results suggest a developmental course for metacognitive capacity such that awareness of others is the sole domain that grows over the lifespan.

Efficacy of metacognitive training on symptom severity, neurocognition and social cognition in patients with schizophrenia: A single-blind randomized controlled trial

Over the past decades, a number of complementary treatments for schizophrenia have emerged. One of these is metacognitive training (MCT), which combines the principles of cognitive‐behavioral therapies, cognitive remediation, and psychoeducation into a hybrid approach placing emphasis on increasing metacognitive awareness. The aim of our study was to investigate the efficacy of MCT on symptom severity, and neurocognitive and social cognitive functioning in schizophrenia; also, attention was paid to the assessment of subjective acceptability. Forty‐six patients diagnosed with schizophrenia were included in our single‐blind randomized controlled trial, who were assigned to the intervention or control group. The intervention group was provided standard MCT, while the control group received treatment as usual. We assessed symptom severity and cognitive functions before and after the training, as well as after a 6‐month follow‐up period. Compared to the control group, the intervention group showed improvement in overall symptom severity, and positive and disorganized symptoms. Training participans showed further improvement at the follow‐up assessment. Regarding neurocognitive functions, improvement in visuospatial functions was observed between pre‐ and post‐intervention assessments compared to the control group. Patients showed excellent adherence, and evaluated the training as useful and interesting. In line with the results of previous studies, our results demonstrate the efficacy of MCT on symptom severity in schizophrenia. Improvements in cognitive functions that are closely related to the onset and prevalence of symptoms of schizophrenia were also found.

Verbal manifestations of metacognitive and social cognitive operations in patients with schizophrenia who received metacognitive training

The study investigates with inductive content analysis the verbal manifestations of schizophrenia patients, their utterances within the theory of mind modules of Metacognitive Training. Participants were recruited via psychiatrists’ verbal referrals. Four small groups were formed, two of which consented to the audio recording of their sessions. Only the sessions of these two groups of five and four patients respectively were investigated. As two participants dropped out, the verbalisations of seven participants were eventually analysed. All patients had schizophrenia diagnosis (mean age: 43 years, male: two, female: five). The verbal contents were transcribed, then two independent coders did the categorisation of the content; investigator triangulation ensured the reliability and validity of the study. As a result, a five-level hierarchy of cognitive operations was revealed in a bottom-up way. Patients attempted to interpret not only facial expressions but expressive movements, too, during emotion recognition. When deducing the state of others, patients sought contextual information; moreover, the burden of the illness and stigmatisation became easy to share. No signs of awareness of the consequences of the inferred states were found regarding future adjustment. Our hierarchical structure was consistent with related literature, and the specificities of cognitive operations of participants were also revealed.

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.

Manipulating feedback on schizophrenia: Evidence from a Posner task

Individuals with schizophrenia show difficulties in achieving vital objectives. Abnormal behavioral and emotional responses to environmental feedback may be some of the psychological mechanisms underlying this lack of goal attainment in schizophrenia. The present study aims to assess how different types of feedback may affect performance in a computerized affective Posner task (non-monetary vs. monetary rewards; contingent vs. non-contingent feedback). The sample was composed of 32 patients with schizophrenia and 35 controls. Reaction times and error rates were the behavioral measurements. The emotional experience was assessed through self-reported affective scales. The results indicated that: ii) the performance with monetary rewards was better than with non-monetary ones in all participants, especially in patients with schizophrenia when higher attentional resources are required (invalid trials). Second, all participants demonstrated faster reaction times, but higher error rates, with non-contingent feedback (frustration condition). Significantly, the schizophrenia group only equaled the controls performance in the non-contingent condition with monetary rewards. Additionally, the higher the negative symptoms were in patients, the worse performance they had under frustration. Third, discrepancies between performance and self-report affect were found in patients. Specifically, after the induction of frustration, the patients reported feeling better and having no arousal changes. Therefore, the findings suggest that, in schizophrenia: i) non-monetary rewards are relatively less important; ii) monetary rewards lessen the negative effects of frustration, iii) discrepancies in self-reported affective scales suggest an unrealistic self-evaluation made under frustration. These findings shed light on the underlying mechanisms of the lack of goal attainment in schizophrenia.

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

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

Metacognition Is Uniquely Related to Concurrent and Prospective Assessments of Negative Symptoms Independent of Verbal Memory in Serious Mental Illness

The inability to synthesize information into experience of self and others could be one significant cause of negative symptoms. To explore this possibility, we examined the relationships between baseline metacognition and concurrent and prospective negative symptoms controlling for verbal memory. The participants were 62 adults diagnosed with serious mental illness enrolled in outpatient treatment. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were assessed using the Brief Psychiatric Rating Scale, and verbal memory was assessed using the California Verbal Learning Test. Significant correlations were found, indicating that poorer overall metacognition was associated with greater levels of negative symptoms assessed concurrently (r = 0.39) and 1 month later (r = 0.36). A significant relationship persisted after controlling for verbal memory and education. These findings support the idea that metacognitive deficits are related to negative symptoms and point to the potential of metacognitive interventions to positively influence negative symptoms.

Contrasting metacognitive profiles and their association with negative symptoms in groups with schizophrenia, early psychosis and depression in a Russian sample

Research has suggested that negative symptoms in psychotic disorders may be in part fueled by deficits in metacognition or the ability to form integrated ideas about oneself and others. One limitation of this work is that it has largely come from North America and Western Europe. To further the literature, we assessed symptoms using the Positive and Negative Syndrome Scale and Metacognition using the Metacognitive Assessment Scale - Abbreviated in a sample of outpatients with prolonged schizophrenia (n = 41), early episode psychosis (n = 37) and major depression (n = 30) gathered in Moscow, Russia. Verbal memory was assessed for use as a potential covariate. ANOVA revealed the two groups with psychosis had significantly poorer metacognitive function in terms of self-reflectivity and awareness of the other, than the group with depression. In both psychosis groups negative symptoms were more robustly related to metacognition than other forms of symptoms after controlling for neurocognition. Results support the possibility that metacognitive deficits are a psychological factor which cross culturally contributes to negative symptoms and point to metacognition as a potentially important target for intervention.

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

Background.

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

Methods.

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

Results.

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

Conclusions.

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The association between metacognitive abilities and outcome measures among people with schizophrenia: A meta-analysis

Background:

Deficits in metacognition are one of the major causes of the difficulties experienced by individuals with schizophrenia. Studies have linked these deficits to symptom exacerbation and deterioration in psychosocial functioning. The aim of the present meta-analysis was to examine the extensive existing literature regarding metacognitive deficits among persons with schizophrenia; a further aim was to assess the extent to which metacognitive abilities are linked to outcome measures of symptoms and psychosocial functioning.

Method:

We conducted a systematic literature search of studies examining the relationship between metacognitive abilities and outcome measures among people with schizophrenia. We then analyzed the data using a random-effects meta-analytic model with Cohen's d standardized mean effect size.

Results:

Heterogeneity analyses (k = 32, Cohen's d = −.12, 95% CI.−1.92 to 1.7) produced a significant Q-statistic (Q = 456.89) and a high amount of heterogeneity, as indicated by the I2 statistic (93.04%), suggesting that moderator analyses were appropriate. As hypothesized, measure type moderated the metacognitive deficit with homogenous effect for psychosocial functioning measures (Q = 9.81, I2 = 19.47%, d = .94. 95% CI .58 to 1.2) and symptoms (Q = 19.87, I2 = 0%, d = −1.07, 95% CI −1.18 to −.75). Further analysis found homogenous effects for MAS-A subscales as well as PANSS factors of symptoms.

Conclusion:

Our meta-analysis results illustrated a significant association between metacognitive deficits and both symptomatic and psychosocial functioning measures. These links suggest that the associations between metacognitive abilities and symptomatic outcomes are different from those between metacognitive abilities and psychosocial functioning measures. Intriguing hypotheses are raised regarding the role that metacognitive abilities play in both symptoms and psychosocial functioning measures of people diagnosed with schizophrenia spectrum disorders.

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.

Impaired introspective accuracy in schizophrenia: an independent predictor of functional outcomes

INTRODUCTION

Individuals with schizophrenia present across a spectrum of symptomatology. Disability remains a debilitating reality across varying disease presentations and remains pervasive despite psychiatric medications. Cognition (neuro/social cognition) and negative symptoms have emerged as the strongest predictors of real-world disability, but account for <50% of the variance in outcomes.

METHODS

Our attempts to determine what accounts for the remaining 50% of variance has shown that poor introspective accuracy (IA) may be the most potent predictor of functional outcomes 25% of individuals with schizophrenia. We define IA as the adequacy of self-assessments of ability, skills, performance, or decisions. We suggest that IA is a progression of metacognition and can extend beyond cognition to include misestimation of prior and likely future performance in social or other adaptively relevant situations.

RESULTS

Additionally, IA is bidirectional and self-orientated. Emerging research has found that IA of neurocognitive ability better predicts everyday functional deficits than scores on performance-based measures or neurocognitive skills and has found that IA of social cognition accounts unique variance in real-world disability above social cognitive performance.

DISCUSSION

We argue that impaired IA, affecting 25-50% of patients with schizophrenia, in the absence or minimal presence of other impairments might be the most powerful predictor of functional outcomes.

The centrality of cognitive symptoms and metacognition within the interacting network of symptoms, neurocognition, social cognition and metacognition in schizophrenia

Schizophrenia involves a range of interrelated impairments in functioning due to symptoms and deficits in varying domains of cognition including neurocognition, social cognition and metacognition. Yet little is known whether certain symptoms or cognitive impairments play a more central role than others. To explore, we conducted a network analysis of five types of symptoms, six domains of neurocognition and multiple aspects of both social cognition and metacognition. Participants were 81 adults with a schizophrenia spectrum disorder in a non-acute phase of the disorder. Results of the network analysis suggest that the cognitive symptoms node is most central in the network, metacognition abilities have high strength centrality measures followed by visual learning and emotion identification. In addition, distinction between the four groups of variables was supported. This suggests the need for both cognitive remediation and metacognitively oriented therapies in order to promote recovery from schizophrenia.

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

A pilot study of the effects of metacognition-oriented social skills training (MOSST) on social functioning in patients with schizophrenia spectrum disorders (SSDs) reported promising results. The main purpose of the current trial was to compare the effectiveness and potential benefits of MOSST vs conventional social skills training (SST). Single-blind randomized controlled trial with 2 groups of patients aged 18-65 with SSDs on partial hospitalization. Participants were randomly assigned (1:1) to receive 16 group sessions with MOSST or conventional SST, both in addition to standard care, over 4 months, with a 6-month follow-up. Psychosocial functioning, metacognition, and symptom outcomes were measured by blind assessors. Statistical analyses used mixed models to estimate treatment effects in each postrandomization time point. Thirty-six patients were randomly assigned to the MOSST group and 33 patients to the conventional SST group. Between-group differences were significant in favor of MOSST on Social and Occupational Functioning Assessment Scale (SOFAS) and Personal and Social Performance Scale (PSP) total scores at post-treatment and follow-up. Concerning PSP subscales, there were significant between-group differences in favor of MOSST at follow-up on socially useful activities, personal and social relationships, and disturbing and aggressive behaviors. Metacognition only improved following MOSST group. For people with SDDs, MOSST appears to have short- and long-term beneficial effects on social functioning and symptoms. Further studies are required to replicate the current results in other samples.

A Disorder by Any Other Name: Metacognition, Schizophrenia, and Diagnostic Practice

Humanistic psychology has made us aware that any understanding of schizophrenia must see persons diagnosed with this condition as whole persons who are making sense of what wellness and recovery mean to them. This has raised questions about what the diagnosis of schizophrenia means and whether the diagnostic label of schizophrenia is helpful when we try to conceptualize the actions and aims of treatment. To examine this issue we propose it is essential to consider what is systematically occuring psychologicaly in recovery when persons experience, interpret and agentically respond to emerging challenges. We then review how the integrated model of metacognition provides a systematic, person-centered, evidence-based approach to understanding psychological processes which impact recovery, and discuss how this guides a form of psychotherapy, metacognitive reflection and insight therapy, which promotes metacognitive abilities and support recovery. We suggest this work indicates that metacognitive capacity is something that can be diagnosed without stigmatizing persons. It can be used to meaningfully inform clinical practice across various theoretical models and offers concrete implications for rehabilitation.

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

Research indicates that individuals with schizophrenia recover. Recovery, however means different things to different individuals and regardless of what kind of experiences define recovery, the individual diagnosed with the serious mental illness must feel ownership of their recovery. This raises the issue of how mental health services should systematically promote recovery. This paper explores the practical implications for research on metacognition in schizophrenia for this issue. First, we present the integrated model of metacognition, which defines metacognition as the spectrum of activities which allow individual to have available to themselves an integrated sense of self and others as they appraise and respond to the unique challenges they face. Second, we present research suggesting that many with schizophrenia experience deficits in metacognition and that those deficits compromise individuals’ abilities to manage their lives and mental health challenges. Third, we discuss a form of psychotherapy inspired by this research, Metacognitive Reflection and Insight Therapy which assists individuals to recapture the ability to form integrated ideas about themselves and others and so direct their own recovery. The need for recovery oriented interventions to focus on process and on patient’s purposes, assess metacognition and consider the intersubjective contexts in which this occurres is discussed.

Metacognitive profiles in schizophrenia and bipolar disorder: Comparisons with healthy controls and correlations with negative symptoms

While deficits in metacognition, or the ability to notice and reflect upon mental states has been observed in schizophrenia and linked with poorer concurrent and future function, it is unknown whether these deficits are unique to schizophrenia. Accordingly, this study assessed metacognition using the Metacognitive Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire- 30 (MCQ-30) among 26 adults with schizophrenia, 23 with bipolar disorder and 23 healthy controls. Symptom levels of the psychiatric groups were assessed with the Brief Psychiatric Rating Scale. ANCOVA controlling for age and education revealed that the schizophrenia group had lower scores on the MAS-A total and its subscales compared to the bipolar group and healthy controls. The bipolar disorder group also had lower MAS-A scores than the healthy control group. No group differences were found for the MCQ-30. Examination of symptom correlates revealed MAS-A scores were most commonly related to negative symptoms in both clinical groups. The total score and need for control subscale of MCQ-30 was related to total symptomatology and positive symptoms in patients with bipolar disorder. Correlations between the two measures of metacognition revealed that higher MAS-A scores were significantly related to lower scores on the Need to Control Thoughts MCQ-30 subscale.

A decline in self-defining memories following a diagnosis of schizophrenia

PURPOSE

Receiving a diagnosis of schizophrenia can be a profound life transition that often has a negative influence on the patient's sense of self. The present study is the first to examine how self-defining memories are temporally distributed around age at diagnosis of schizophrenia.

METHOD

25 patients and 25 matched control participants identified 3 self-defining memories from their lives. In addition, participants were assessed with standardized interviews and questionnaires on negative and positive symptoms as well as tests of cognitive function.

RESULTS

Patients' self-defining memories increased in the years leading up to diagnosis and declined abruptly in the years immediately following diagnosis. The pre-diagnosis increase in self-defining memories was not attributable primarily to a rise in disease-related recollections.

CONCLUSION

The sharp post-diagnosis memory decline suggests that patients find it difficult to establish new or evolve existing definitions of self. Implications for models of schizophrenia and for clinical practice are discussed.

Randomized control trial to assess the efficacy of metacognitive training compared with a psycho-educational group in people with a recent-onset psychosis

BACKGROUND

Aims were to assess the efficacy of metacognitive training (MCT) in people with a recent onset of psychosis in terms of symptoms as a primary outcome and metacognitive variables as a secondary outcome.

METHOD

A multicenter, randomized, controlled clinical trial was performed. A total of 126 patients were randomized to an MCT or a psycho-educational intervention with cognitive-behavioral elements. The sample was composed of people with a recent onset of psychosis, recruited from nine public centers in Spain. The treatment consisted of eight weekly sessions for both groups. Patients were assessed at three time-points: baseline, post-treatment, and at 6 months follow-up. The evaluator was blinded to the condition of the patient. Symptoms were assessed with the PANSS and metacognition was assessed with a battery of questionnaires of cognitive biases and social cognition.

RESULTS

Both MCT and psycho-educational groups had improved symptoms post-treatment and at follow-up, with greater improvements in the MCT group. The MCT group was superior to the psycho-educational group on the Beck Cognitive Insight Scale (BCIS) total (p = 0.026) and self-certainty (p = 0.035) and dependence self-subscale of irrational beliefs, comparing baseline and post-treatment. Moreover, comparing baseline and follow-up, the MCT group was better than the psycho-educational group in self-reflectiveness on the BCIS (p = 0.047), total BCIS (p = 0.045), and intolerance to frustration (p = 0.014). Jumping to Conclusions (JTC) improved more in the MCT group than the psycho-educational group (p = 0.021). Regarding the comparison within each group, Theory of Mind (ToM), Personalizing Bias, and other subscales of irrational beliefs improved in the MCT group but not the psycho-educational group (p < 0.001-0.032).

CONCLUSIONS

MCT could be an effective psychological intervention for people with recent onset of psychosis in order to improve cognitive insight, JTC, and tolerance to frustration. It seems that MCT could be useful to improve symptoms, ToM, and personalizing bias.

Metacognition deficits as a risk factor for prospective motivation deficits in schizophrenia spectrum disorders

Although motivation deficits are key determinants of functional outcomes, little is known about factors that contribute to prospective motivation in people with schizophrenia. One candidate factor is metacognition, or the ability to form complex representations about oneself, others, and the world. This study aimed to assess whether metacognition deficits were a significant predictor of reduced prospective motivation, after controlling for the effects of baseline motivation, anticipatory pleasure, and antipsychotic medication dose. Fifty-one participants with a schizophrenia spectrum disorder completed measures of metacognition and anticipatory pleasure at baseline; participants also completed a measure of motivation at baseline and six months after the initial assessment. Baseline antipsychotic dose was obtained from medical charts. Hierarchical regression analysis revealed that lower levels of baseline metacognition significantly predicted reduced levels of motivation assessed six months later, after controlling for baseline levels of motivation, anticipatory pleasure, and antipsychotic dose. Higher baseline antipsychotic dose was also a significant predictor of reduced six month motivation. Results suggest that metacognition deficits and higher antipsychotic dose may be risk factors for the development of motivation deficits in schizophrenia. Implications include utilizing interventions to improve metacognition in conjunction with evaluating and possibly lowering antipsychotic dose for people struggling with motivation deficits.

Metacognitive Reflection and Insight Therapy (MERIT) with a Patient with Persistent Negative Symptoms

Metacognition comprises a spectrum of mental activities involving thinking about thinking. Metacognitive impairments may sustain and trigger negative symptoms in people with schizophrenia. Without complex ideas of the self and others, there may be less reason to pursue goal-directed activities and less ability to construct meaning in daily activities, leading to the experience of negative symptoms. As these symptoms tend to be nonresponsive to pharmacotherapy and other kinds of treatment metacognition might be a novel treatment target; improvement of metacognition might lead to improvements in negative symptoms. One therapy that seeks to promote metacognition is the Metacognitive Reflection and Insight Therapy (MERIT). In this study, a case is presented in which a first episode patient with severe negative symptoms is treated with MERIT. A case illustration and the eight core principles of MERIT are presented. Independent assessments of metacognition and negative symptoms before and after therapy show a significant increase of metacognition and decrease of negative symptoms over the course of 40 weeks.

Intrinsic motivation as a mediator between metacognition deficits and impaired functioning in psychosis

OBJECTIVE

Poor functioning has long been observed in individuals with psychosis. Recent studies have identified metacognition - one's ability to form complex ideas about oneself and others and to use that information to respond to psychological and social challenges-as being an important determinant of functioning. However, the exact process by which deficits in metacognition lead to impaired functioning remains unclear. This study first examined whether low intrinsic motivation, or the tendency to pursue novel experiences and to engage in self-improvement, mediates the relationship between deficits in metacognition and impaired functioning. We then examined whether intrinsic motivation significantly mediated the relationship when controlling for age, education, symptoms, executive functioning, and social cognition.

DESIGN

Mediation models were examined in a cross-sectional data set.

METHODS

One hundred and seventy-five individuals with a psychotic disorder completed interview-based measures of metacognition, intrinsic motivation, symptoms, and functioning and performance-based measures of executive functioning and social cognition.

RESULTS

Analyses revealed that intrinsic motivation mediated the relationship between metacognition deficits and impaired functioning (95% CI of indirect effect [0.12-0.43]), even after controlling for the aforesaid variables (95% CI of indirect effect [0.04-0.29]).

CONCLUSIONS

Results suggest that intrinsic motivation may be a mechanism that underlies the link between deficits in metacognition and impaired functioning and indicate that metacognition and intrinsic motivation may be important treatment targets to improve functioning in individuals with psychosis.

PRACTITIONER POINTS

The findings of this study suggest that deficits in metacognition may indirectly lead to impaired functioning through their effect on intrinsic motivation in individuals with psychosis. Psychological treatments that target deficits in both metacognition and intrinsic motivation may help to alleviate impaired functioning in individuals with psychosis.

LIMITATIONS

The cross-sectional design of this study is a limitation, and additional longitudinal studies are needed to confirm the direction of the findings and rule out rival hypotheses. Generalization of the findings may be limited by the sample composition. It may be that different relationships exist between metacognition, intrinsic motivation, and functioning in those with early psychosis or among those in an acute phase or who decline treatment.