Metacognition and reflexivity in patients with schizophrenia

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

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

Insights into the molecular genetic basis of individual differences in metacognition

There is a striking lack of studies on the molecular genetic basis of metacognition, i.e., the higher-order ability to monitor mental processes. Here, an initial step toward resolving this issue was undertaken by investigating functional polymorphisms from three genes of the dopaminergic or serotonergic systems (DRD4, COMT, and 5-HTTLPR) in relation to behaviorally assessed metacognition in six paradigms across three cognitive domains. We report evidence for a task-dependent higher average confidence level (metacognitive bias) in carriers of at least one S or L_G-allele in the 5-HTTLPR genotype and integrate these findings within a differential susceptibility framework.

Metacognitive sensitivity and symptoms of mental disorder: A systematic review and meta-analysis

Introduction

Metacognition is a term used to refer to cognition about cognitive processes. In this systematic review and meta-analysis, we reviewed studies that investigated the relationship between experimentally measured objective metacognitive sensitivity and diverse symptoms of mental disorder. In these studies, metacognitive sensitivity is operationalized as the correspondence between the accuracy of task performance and reported confidence therein.

Methods

A literature search was conducted across four databases and studies were selected for review based on predefined eligibility criteria. Twenty studies were included in the review and separate meta-analyses were conducted for psychotic and non-psychotic categories of psychiatric symptoms.

Results

A significant reduction (medium effect size) in metacognitive sensitivity was found in individuals with psychosis-related symptoms of mental disorder compared to healthy control groups, but no significant difference was found for individuals with non-psychotic symptoms. It should be noted though, that fewer studies were available for the latter group. Sub-group analysis found no evidence that the effect of metacognitive impairment depended on whether perceptual or non-perceptual experimental tasks were employed.

Discussion

These findings are discussed in relation to other conceptualizations of metacognition and the role reduced metacognitive sensitivity may play in forms of mental disorder.

Relationships between neuropsychological performance, insight, medication adherence, and social metacognition in schizophrenia

BACKGROUND

Social metacognition is still poorly understood in schizophrenia, particularly its neuropsychological basis and its impact on insight and medication adherence. We therefore quantified social metacognition as the agreement between objective and subjective mentalization and assessed its correlates in a sample of individuals with schizophrenia spectrum disorders.

METHODS

Participants consisted of 143 patients with schizophrenia or schizoaffective disorders who underwent a metacognitive version of a mentalization task, an extensive neuropsychological battery, and a clinical evaluation to assess their insight into illness and medication adherence. We studied potential interactions between confidence judgments and several neuropsychological and clinical variables on mentalization accuracy with mixed-effects multiple logistic regressions.

RESULTS

Confidence judgments were closely associated with mentalization accuracy, indicative of good social metacognition in this task. Working memory, visual memory, and reasoning and problem-solving were the three neuropsychological dimensions positively associated with metacognition. By contrast, the two measures of medication adherence were associated with poorer metacognition, whereas no association was found between metacognition and clinical insight. The multiple regression model showed a significant positive impact of better working memory, older age at onset, longer duration of hospitalization, and worse medication adherence on social metacognition.

CONCLUSIONS

We discuss possible mechanisms underlying the apparent association between social metacognition and working memory. Adherence should be monitored when remediating social metacognition, and psychoeducation should be given to patients with a high level of awareness of their capacity to mentalize.

Subjective cognitive functioning, depressive symptoms, and objective cognitive functioning in people with treatment-resistant psychosis

Introduction: Relationships between subjective cognitive functioning (SCF), objective cognitive functioning (OCF), and depressive symptoms are poorly understood in treatment-resistant psychosis (TRP). This study (a) compares SCF in TRP using positively and negatively worded scales, (b) assess these scales' accuracy, and (c) explores the association between these scales and depressive symptoms. We hypothesised that both SCF scales would be highly correlated, minimally associated with OCF, and similarly associated with depressive symptoms. Methods: Archival clinical data from 52 TRP inpatients was utilised. OCF composite scores were derived from a broad neuropsychological battery. SCF was assessed using the norm-referenced PROMIS 2.0 Cognitive Abilities (positively worded) and Concerns (negatively worded) subscales. A depressive symptom score was derived from the Positive and Negative Syndrome Scale. Results: SCF ratings were higher in patients than OCF. There was a small but significant correlation between PROMIS subscales (r = .30). Neither PROMIS subscale was associated with OCF (r = -.11, r = .01). Depressive symptoms were correlated with the positively (r = -.29) but not negatively worded scale (r = -.13). Conclusion: Individuals with TRP inaccurately rate their cognitive functioning and tend to overestimate their ability. Positively and negatively worded SCF scales associate variably with depressive symptoms, indicating they may not be used interchangeably in TRP.

How Local and Global Metacognition Shape Mental Health

Metacognition is the ability to reflect on our own cognition and mental states. It is a critical aspect of human subjective experience and operates across many hierarchical levels of abstraction-encompassing local confidence in isolated decisions and global self-beliefs about our abilities and skills. Alterations in metacognition are considered foundational to neurologic and psychiatric disorders, but research has mostly focused on local metacognitive computations, missing out on the role of global aspects of metacognition. Here, we first review current behavioral and neural metrics of local metacognition that lay the foundation for this research. We then address the neurocognitive underpinnings of global metacognition uncovered by recent studies. Finally, we outline a theoretical framework in which higher hierarchical levels of metacognition may help identify the role of maladaptive metacognitive evaluation in mental health conditions, particularly when combined with transdiagnostic methods.

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

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

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

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

Abnormalities of confidence in psychiatry: an overview and future perspectives

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

The Importance of Metamemory Functioning to the Pathogenesis of Psychosis

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

Metamemory in patients with schizophrenia measured by the feeling of knowing

Cognitive awareness in patients with schizophrenia is crucial for clinical management of cognitive deficits. Traditional approaches using self-report inventories have questionable validity and reliability. Using the Feeling-of-Knowing (FOK) procedure to measure metamemory might overcome such weakness. A cross-sectional study comparing 40 patients and 40 demographically matched normal controls, using a recall-judgment-recognition (RJR) procedure and the Hamann coefficient was conducted to examine whether patients with schizophrenia have FOK deficits and what neurocognitive mechanism might account for these deficits. General IQ, executive function, and memory tests were also assessed. The results show that as a group, patients with schizophrenia had impaired FOK ability and evidenced a disposition to underestimate their memory performance. However, patient's FOK ability was variable, with 42.5% of patients exhibited a below chance level performance. There were marked relationships between FOK and set formation and visual recognition abilities in healthy controls, while such feature was not evident in patient group. These findings are in line with the prefrontal cortex dysfunction, reduced intrapsychic monitoring ability, and impaired utilization of mental resources noticed in patients with schizophrenia. A routine evaluation of metamemory function by FOK might be helpful for designing customized cognitive rehabilitation programs considering their missed estimation of memory capacity.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Subjective competence breeds overconfidence in errors in psychosis. A hubris account of paranoia

BACKGROUND AND OBJECTIVES

Overconfidence in errors is a well-replicated cognitive bias in psychosis. However, prior studies have sometimes failed to find differences between patients and controls for more difficult tasks. We pursued the hypothesis that overconfidence in errors is exaggerated in participants with a liability to psychosis relative to controls only when they feel competent in the respective topic and/or deem the question easy. Whereas subjective competence likely enhances confidence in those with low psychosis liability as well, we still expected to find more 'residual' caution in the latter group.

METHODS

We adopted a psychometric high-risk approach to circumvent the confounding influence of treatment. A total of 2321 individuals from the general population were administered a task modeled after the "Who wants to be a millionaire" quiz. Participants were requested to endorse one out of four response options, graded for confidence, and were asked to provide ratings regarding subjective competence for the knowledge domain as well as the subjective difficulty of each item.

RESULTS

In line with our assumption, overconfidence in errors was increased overall in participants scoring high on the Paranoia Checklist core paranoia subscale (2 SD above the mean). This pattern of results was particularly prominent for items for which participants considered themselves competent and which they rated as easy.

LIMITATIONS

Results need to be replicated in a clinical sample.

DISCUSSION

In support of our hypothesis, subjective competence and task difficulty moderate overconfidence in errors in psychosis. Trainings that teach patients the fallibility of human cognition may help reduce delusional ideation.

Metacognitive training for delusions (MCTd): effectiveness on data-gathering and belief flexibility in a Chinese sample

Metacognitive training (MCT) was developed to promote awareness of reasoning biases among patients with schizophrenia. While MCT has been translated into 31 languages, most MCT studies were conducted in Europe, including newer evidence recommending an individualized approach of delivery. As reasoning biases covered in MCT are separable processes and are associated with different symptoms, testing the effect of selected MCT modules would help to develop a targeted and cost-effective intervention for specific symptoms and associated mechanisms. This study tested the efficacy of a four-session metacognitive training for delusions, MCTd (in Traditional Chinese with cultural adaptations, provided individually), as an adjunct to antipsychotics in reducing severity and conviction of delusions, jumping to conclusions (JTC) bias and belief inflexibility. Forty-four patients with delusions were randomized into the MCTd or the wait-list control condition. Patients on wait-list received the same MCTd after 4 weeks of treatment as usual (TAU). Assessment interviews took place before and after the treatment, and at 4-week follow-up. There was an additional baseline assessment for the controls. JTC and belief flexibility were measured by the beads tasks and the Maudsley Assessment of Delusions Scale. Attendance rate of the MCTd was satisfactory (84.5%). Compared to TAU, there was a greater reduction in psychotic symptoms, delusional severity and conviction following MCTd. There was a large treatment effect size in improvement in belief flexibility. Improvement in reaction to hypothetical contradiction predicted treatment effect in positive symptoms and delusions. JTC bias was reduced following MCTd, although the treatment effect was not significantly larger than TAU. Our results support the use of process-based interventions that target psychological mechanisms underlying specific psychotic symptoms as adjuncts to more conventional approaches.

Metamemory in schizophrenia: retrospective confidence ratings interact with neurocognitive deficits

Prior studies with schizophrenia patients described a reduced ability to discriminate between correct and false memories in terms of confidence compared to control groups. This metamemory bias has been associated with the emergence and maintenance of delusions. The relation to neuropsychological performance and other clinical dimensions is incompletely understood. In a cross-sectional study, metamemory functioning was explored in 32 schizophrenia patients and 25 healthy controls. Metamemory was assessed using a verbal recognition task combined with retrospective confidence level ratings. Associations of metamemory performance with six neuropsychological domains (executive functioning/problem solving, speed of processing, working memory, verbal and visual learning, and attention/vigilance) and psychopathological measures were analyzed. Results revealed a significantly smaller discrepancy between confidence ratings for correct and incorrect recognitions in the patient group. Furthermore, patients showed significantly lower recognition accuracy in the metamemory task and marked deficits in all neuropsychological domains. Across all participants, metamemory performance significantly correlated with executive functioning and working memory. No associations with delusions were found. This data confirms prior findings of metamemory biases in schizophrenia. Selective neuropsychological abilities seem to be modulating factors of metamemory functioning. Longitudinal studies in at risk mental state and first-episode patients are needed to reveal causal interrelations.

An event-related potential investigation of error monitoring in adults with a history of psychosis

OBJECTIVE

Previous research suggests that deficits in error monitoring contribute to psychosis and poor functioning. Consistent with the NIMH Research Domain Criteria initiative, this study examined electrophysiological brain activity, appraisal of self-performance, and personality traits related to psychosis during error monitoring in individuals with and without a history of psychosis across disorders.

METHODS

Error-related negativity (ERN), correct response negativity (CRN), error positivity (Pe), and correct response positivity (Pc) were recorded in 14 individuals with a history of psychosis (PSY) and 12 individuals with no history of psychosis (CTR) during a flanker task. Participants continuously rated their performance and completed the Schizotypal Personality Questionnaire-Brief Revised (SPQ-BR).

RESULTS

Compared with CTR, PSY exhibited reduced ERN and Pe amplitudes and was also less accurate at evaluating their performance. Group differences were specific to error trials. Across all participants, smaller Pe amplitudes were associated with greater scores on the SPQ-BR Cognitive-Perceptual factor and less accuracy in subjective identification of errors.

CONCLUSIONS

Individuals with a history of psychosis, regardless of diagnosis, demonstrated abnormal neural activity and imprecise confidence in response during error monitoring.

SIGNIFICANCE

Results suggest that disruptions in neural circuitry may underlie specific clinical symptoms across diagnostic categories.

Metacognitive training for schizophrenia: a multicentre randomised controlled trial

A psychotherapeutic approach for schizophrenia is now recommended as an adjuvant for psychopharmacology, since antipsychotic medications only have a partial impact especially as regards positive symptoms and insight. In addition, cognitive distortions and the lack of metacognitive skills might increase positive symptoms leading to poor social functioning. This underlines the need for specific approaches which target cognitive processes relevant for insight, and abilities in metacognition. Metacognitive training (MCT) is a structured group intervention, which enhances a patient's reflection on cognitive biases and improves problem-solving. The aim of our study was to assess MCTs' short term impact on insight, symptoms and quality of life. Fifty patients with schizophrenia or schizoaffective disorders and persistent positive symptoms (delusions or hallucinations) were enrolled in the study. After baseline assessment participants were randomised either to supportive therapy or MCT. Both groups used the same design (1h-session twice a week during 8weeks) although the basic knowledge given to participants was different between interventions. Participants were assessed at eight weeks based on the Scale to Assess Unawareness of Mental Disorder, Positive and Negative Syndrome Scale (PANSS), Psychotic Symptom Rating Scales, the Calgary Depression Scale for Schizophrenia and the Quality of Life Scale. Between-group differences were significant in favour of MCT on the PANSS positive scale. Between-group differences in post- and pre-test values showed a trend in favour of MCT for insight on hallucinations. Results of our study indicate that the MCT has an effect on reducing positive symptomatology, and a trend impact on insight and social functioning.

Self perception of empathy in schizophrenia: emotion recognition, insight, and symptoms predict degree of self and interviewer agreement

Many with schizophrenia have been found to experience difficulties recognizing a range of their own mental states including memories and emotions. While there is some evidence that the self perception of empathy in schizophrenia is often at odds with objective observations, little is known about the correlates of rates of concordance between self and rater assessments of empathy for this group. To explore this issue we gathered self and rater assessments of empathy in addition to assessments of emotion recognition using the Bell Lysaker Emotion Recognition Task, insight using the Scale to Assess Unawareness of Mental Disorder, and symptoms using the Positive and Negative Syndrome Scale from 91 adults diagnosed with schizophrenia spectrum disorders. Results revealed that participants with better emotion recognition, better insight, fewer positive symptoms and fewer depressive symptoms produced self ratings of empathy which were more strongly correlated with assessments of empathy performed by raters than participants with greater deficits in these domains. Results suggest that deficits in emotion recognition along with poor insight and higher levels of positive and depressive symptoms may affect the degree of agreement between self and rater assessments of empathy in schizophrenia.

Repetition is good? An Internet trial on the illusory truth effect in schizophrenia and nonclinical participants

BACKGROUND AND OBJECTIVES

The investigation of cognitive biases has considerably broadened our understanding of the cognitive underpinnings of schizophrenia. This is the first study to investigate the illusory truth or validity effect in schizophrenia, which denotes the phenomenon that the renewed exposure to difficult knowledge questions shifts responses toward affirmation. We hypothesized an excess of the truth effect in schizophrenia, which may play a role in the maintenance of the disorder, particularly relating to positive symptoms.

METHODS

The study was set up over the Internet. The final analyses considered 36 patients with a probable diagnosis of schizophrenia, and a sample of 40 healthy subjects. Both groups took part on two occasions. In the baseline survey, difficult knowledge questions on neutral (e.g., "On each continent there is a town called Rome." (true)) or emotional (delusion-relevant; e.g., "The German federal police uses approximately 3000 cameras for the purpose of video-based face-detection." (not true)) topics were presented as statements, which were either correct or incorrect. After one week, subjects were requested to take part in the second and final survey. Here, previously presented as well as novel statements had to be appraised according to their truth.

RESULTS

As expected, an overall truth effect was found: statements that were repeated achieved higher subjective truth ratings than novel statements. Patients high on positive symptoms showed an excessive truth effect for emotional (delusion-relevant) items. The positive syndrome was correlated with the emotional truth effect in both healthy and schizophrenia participants.

LIMITATIONS

The sample was recruited via online forums and had probable but not externally validated diagnoses of schizophrenia. No psychiatric control group was tested.

DISCUSSION

The truth effect for emotional items appears to be exaggerated in patients high on positive symptoms, which may play a role in delusion formation and maintenance. Several limitations of the study however render our conclusions preliminary. As patients with schizophrenia often dwell on and ruminate over selective and distorted pieces of information (e.g., conspiracy theories), the subjective authenticity of this information may be further elevated by means of the truth effect.

Failures of metacognition and lack of insight in neuropsychiatric disorders

Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.

Cognitive factors associated with subclinical delusional ideation in the general population

Cognitive biases have been found to be associated with delusions in schizophrenia and schizotypy. In the current study, we examined the relationship between subclinical delusional ideation, measured using the Peters Delusions Inventory, and cognitive biases including the bias against disconfirmatory evidence (BADE), 'jumping to conclusions', and need for closure, evaluated using the computerized BADE program, in a sample of 117 healthy, non-psychiatric controls. Our results suggest that subclinical delusional ideation is associated with BADE, greater need for closure, a 'jumping to conclusions' response style, and a tendency to rate absurd and unlikely interpretations of an event as more plausible, which might be indicative of insufficient evidence integration or 'liberal acceptance'. These cognitive biases, which occur in a much milder fashion than seen in typical deluded patient samples, may nonetheless additively play a role in the development of delusional ideation, and suggest common pathways seen in healthy and psychiatric samples.

Influence of self-efficacy on the interpersonal behavior of schizophrenia patients undergoing rehabilitation in psychiatric day-care services

AIM

The present study examined whether the self-efficacy of interpersonal behavior influenced the interpersonal behavior of schizophrenia patients using psychiatric day-care services.

METHODS

Thirty-nine patients with schizophrenia were examined with the Interpersonal Relations subscale of the Life Assessment Scale for Mentally Ill, the Self-efficacy Scale of Interpersonal Behavior, the Brief Assessment of Cognition in Schizophrenia-Japanese version, and the Positive and Negative Syndrome Scale.

RESULTS

The Life Assessment Scale for Mentally Ill score was significantly correlated with the self-efficacy of interpersonal behavior, and was also significantly correlated with neurocognitive functions and negative symptoms. However, the Self-efficacy Scale of Interpersonal Behavior score was not correlated with neurocognitive functions and negative symptoms. To examine the causal correlations between the above social, psychological and clinical factors, multiple regression analysis was performed with the self-efficacy of interpersonal behavior, neurocognitive functions, and negative symptoms as the independent variables and interpersonal behavior as the dependent variable. The self-efficacy of interpersonal behavior was found to contribute to interpersonal behavior as well as neurocognitive functions.

CONCLUSION

The self-efficacy of interpersonal behavior contributed to the interpersonal behavior as well as the neurocognitive functions in the case of schizophrenia patients in the community. This suggested that interventions targeting the self-efficacy of interpersonal behavior, as well as those targeting neurocognitive functions, were important to improve the interpersonal behavior of schizophrenia patients undergoing psychiatric rehabilitation in the community.

The influence of social cognition on ego disturbances in patients with schizophrenia

BACKGROUND

Subjects experiencing ego disturbances can be classified as a distinct subgroup of schizophrenia patients. These symptoms imply a disturbance in the ego-world boundary, which in turn implies aberrations in the perception, processing and understanding of social information. This paper provides a comparison of a group of schizophrenia patients and a group of healthy controls on a range of social-cognitive tasks. Furthermore, it analyzes the relationship between ego disturbances and social-cognitive as well as clinical variables in the schizophrenia subsample.

METHODS

Two groups - 40 schizophrenia patients and 39 healthy subjects - were compared. In the source monitoring task, subjects performed simple computer mouse movements and evaluated the partially manipulated visual feedback as either self- or other-generated. In a second step, participants indicated the confidence of their decision on a 4-point rating scale. In an emotion-recognition task, subjects had to identify 6 basic emotions in the prosody of spoken sentences. In the 'reading-the-mind-in-the-eyes' test, subjects had to infer mental states from pictures that depicted others' eyes. In an attribution task, subjects were presented with descriptions of social events and asked to attribute the cause of the event either to a person, an object or a situation. Additionally, all subjects were tested for cognitive functioning levels.

RESULTS

The schizophrenia patient group performed significantly worse on all social-cognitive tasks than the healthy control group. Correlation analysis showed that ego disturbances were related to deficits in person attribution and lower levels of confidence in the source monitoring task. Also, ego disturbances were related to higher PANSS positive scores and a higher number of hospitalizations. Stepwise regression analysis revealed that social-cognitive variables explained 48.0% of the variance in the ego-disturbance score and represented the best predictors for ego disturbances. One particular clinical variable, namely the number of hospitalizations, additionally explained 13.8% of the variance.

CONCLUSION

Our findings suggest that ego disturbances are related to deficits in the social-cognitive domain, and, to a lesser extent, to clinical variables such as the number of hospitalizations.

Know thyself: real-world behavioral correlates of self-appraisal accuracy

Accurate appraisal of one's own abilities is one metacognitive skill considered to be an important factor affecting learning and behavior in childhood. The present study measured self-appraisal accuracy in children using tasks of executive function, and investigated relations between self-appraisal and informant ratings of real-world behaviors measured by the BRIEF. We examined self-appraisal accuracy on fluency tasks in 91 children ages 10-17. More accurate self-appraisal was correlated with fewer informant ratings of real-world behavior problems in inhibition and shifting, independent of actual performance. Findings suggest that self-appraisal represents cognitive processes that are at least partially independent of other functions putatively dependent on the frontal lobes, and these self-appraisal-specific processes have unique implications for optimal daily function.

Detecting and defusing cognitive traps: metacognitive intervention in schizophrenia

PURPOSE OF REVIEW

Until recently, psychological therapy for schizophrenia was considered harmful or inefficient by many clinicians. The reservation against psychotherapy is partly rooted in the assumption that delusions in particular and schizophrenia in general are not amenable to psychological understanding and represent 'utter madness'. However, meta-analyses suggest that cognitive intervention is effective in ameliorating schizophrenia symptoms. In addition, evidence has accumulated that cognitive biases, such as jumping to conclusions, are involved in the pathogenesis of schizophrenia positive symptoms, particularly delusions. A recently developed group program, called metacognitive training (MCT), is presented targeting these biases. MCT is a hybrid of psychoeducation, cognitive remediation and cognitive-behavioural therapy.

RECENT FINDINGS

This review introduces new evidence on cognitive biases involved in the pathogenesis of schizophrenia and demonstrates how the MCT raises the patients' (metacognitive) awareness to detect and defuse such 'cognitive traps'. At the end, a new individualized variant entitled MCT+ is presented targeting individual delusional ideas. Finally, empirical results are summarized that speak in favour of the feasibility and efficacy of MCT.

SUMMARY

Recent studies assert marked cognitive biases in schizophrenia. MCT has evolved as a feasible and effective complement of standard psychiatric treatment.

Different sides of the same coin? Intercorrelations of cognitive biases in schizophrenia

INTRODUCTION

A number of cognitive biases have been associated with delusions in schizophrenia. It is yet unresolved whether these biases are independent or represent different sides of the same coin.

METHODS

A total of 56 patients with schizophrenia underwent a comprehensive cognitive battery encompassing paradigms tapping cognitive biases with special relevance to schizophrenia (e.g., jumping to conclusions, bias against disconfirmatory evidence), motivational factors (self-esteem and need for closure), and neuropsychological parameters. Psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

Core parameters of the cognitive bias instruments were submitted to a principal component analysis which yielded four independent components: jumping to conclusions, personalising attributional style, inflexibility, and low self-esteem.

CONCLUSIONS

The study lends tentative support for the claim that candidate cognitive mechanisms for delusions only partially overlap, and thus encourage current approaches to target these biases independently via (meta)cognitive training.

A fine-grained analysis of the jumping-to-conclusions bias in schizophrenia: Data-gathering, response confidence, and information integration

Impaired decision behavior has been repeatedly observed in schizophrenia patients. We investigated several cognitive mechanisms that might contribute to the jumping-to-conclusions bias (JTC) seen in schizophrenia patients: biases in information-gathering, information weighting and integration, and overconfidence, using the process tracing paradigm Mouselab. Mouselab allows for an in-depth exploration of various decision-making processes in a structured information environment. A total of 37 schizophrenia patients and 30 healthy controls participated in the experiment. Although showing less focused and systematic information search, schizophrenia patients practically considered all pieces of information and showed no JTC in the sense of collecting less pieces of evidence. Choices of patients and controls both approximated a rational solution quite well, but patients showed more extreme confidence ratings. Both groups mainly used weighted additive decision strategies for information integration and only a small proportion relied on simple heuristics. Under high stress induced by affective valence plus time pressure, however, schizophrenia patients switched to equal weighting strategies: less valid cues and more valid ones were weighted equally.

Aberrant frontoparietal function during recognition memory in schizophrenia: a multimodal neuroimaging investigation

Prefrontal-parietal networks are essential to many cognitive processes, including the ability to differentiate new from previously presented items. As patients with schizophrenia exhibit structural abnormalities in these areas along with well documented decrements in recognition memory, we hypothesized that these patients would demonstrate memory-related abnormalities in prefrontal and parietal physiology as measured by both functional magnetic resonance imaging and magnetoencephalography (MEG). Medicated outpatients with schizophrenia (n = 18) and age-matched healthy control subjects (n = 18) performed an old-new recognition memory task while physiological data were obtained. Whereas controls exhibited strong, bilateral activation of prefrontal and posterior parietal regions during successful identification of old versus new items, patients exhibited greatly attenuated activation of the right prefrontal and parietal cortices. However, within the patient group, there was strong correlation between memory performance and activation of these right-sided regions as well as a tight correlation between old-new effect-related activations in frontal and parietal regions, a pattern not seen in control subjects. Using MEG, control subjects-but not patients-exhibited a sequential pattern of old > new activity in the left posterior parietal cortex and then right prefrontal cortex; however, patients uniquely exhibited old > new activity in right temporal cortex. Collectively, these findings point to markedly different distributions of regional specialization necessary to complete the old-new item recognition task in patients versus controls. Inefficient utilization of prefrontal-parietal networks, with compensatory activation in temporal regions, may thus contribute to deficient old-new item recognition in schizophrenia.

Memory and metamemory in schizophrenia: a liberal acceptance account of psychosis

BACKGROUND

In previous studies we suggested that liberal acceptance (LA) represents a fundamental cognitive bias in schizophrenia and may explain why patients are more willing to accept weak response alternatives and display overconfidence in incorrect responses. The aim of the present study was to test a central assumption of the LA account: false alarms in schizophrenia should be particularly increased when the distractor-target resemblance is weak relative to a control group.

METHOD

Sixty-eight schizophrenia patients were compared to 25 healthy controls on a visual memory task. At encoding, participants studied eight complex displays, each consisting of a unique pairing of four stimulus attributes: symbol, shape, position and colour. At recognition, studied items were presented along with distractors that resembled the targets to varying degrees (i.e. the match between distractors and targets ranged from one to three attributes). Participants were required to make old/new judgements graded for confidence.

RESULTS

The hypotheses were confirmed: false recognition was increased for patients compared to controls for weakly and moderately related distractors only, whereas strong lure items induced similar levels of false recognition for both groups. In accordance with prior research, patients displayed a significantly reduced confidence gap and enhanced knowledge corruption compared to controls. Finally, higher neuroleptic dosage was related to a decreased number of high-confident ratings.

CONCLUSIONS

These data assert that LA is a core mechanism contributing to both enhanced acceptance of weakly supported response alternatives and metamemory deficits, and this may be linked to the emergence of positive symptomatology.

Flexibility and variability in lexicon usage among Yoruba-speaking Nigerian outpatients with schizophrenia: a controlled study

BACKGROUND

The studies on language dysfunction in schizophrenia are few, inconclusive and have all been done in the western culture. There may be cross-cultural and cross-lingual differences in problems with speeches of patients with schizophrenia. This study aims to examine the flexibility or variability in the use of words among a group of Nigerian patients with schizophrenia compared with healthy controls.

SAMPLING AND METHODS

The spoken samples of 48 outpatients with schizophrenia and 48 matched controls were assessed using the mean segmental type-token ratio (MSTTR). The sociodemographic and clinical variables of the patients with schizophrenia were also compared with their MSTTR scores.

RESULTS

The MSTTR score for the patients with schizophrenia was significantly lower compared with that of healthy controls (p < 0.001). The factors independently associated with a lower MSTTR in patients with schizophrenia include younger age at onset of illness, presence of negative formal thought disorder and simple or hebephrenic subtype of schizophrenia.

CONCLUSIONS

The problem with flexibility and variability in lexicon usage among patients with schizophrenia is a cross-cultural phenomenon. The MSTTR may have value in predicting clinical judgements of thought disorder or in identifying deviant language. These may have broad potentials for application in longitudinal and pathogenetic studies of schizophrenia.

Metacognitive training in schizophrenia: from basic research to knowledge translation and intervention

PURPOSE OF REVIEW

There has been a marked increase in the study of cognitive biases in schizophrenia, which has in part been stimulated by encouraging results with cognitive-behavioral interventions in the disorder. We summarize new evidence on cognitive biases thought to trigger or maintain positive symptoms in schizophrenia and present a new therapeutic intervention.

RECENT FINDINGS

Recent studies indicate that patients with paranoid schizophrenia jump to conclusions, show attributional biases, share a bias against disconfirmatory evidence, are overconfident in errors, and display problems with theory of mind. Many of these biases precede the psychotic episode and may represent cognitive traits. Building upon this literature, we developed a metacognitive training program that aims to convey scientific knowledge on cognitive biases to patients and provides corrective experiences in an engaging and supportive manner. Two new studies provide preliminary evidence for the feasibility and efficacy of this approach.

SUMMARY

The gap between our advanced understanding of cognitive processes in schizophrenia and its application in clinical treatment is increasingly being narrowed. Despite emerging evidence for the feasibility and efficacy of metacognitive training as a stand-alone program, its most powerful application may be in combination with individual cognitive-behavioral therapy.