Francesca Bohn

Sustained and “Sleeper” Effects of Group Metacognitive Training for Schizophrenia: A Randomized Clinical Trial

IMPORTANCEnCognitive interventions increasingly complement psychopharmacological treatment to enhance symptomatic and functional outcome in schizophrenia. Metacognitive training (MCT) is targeted at cognitive biases involved in the pathogenesis of delusions.nnnOBJECTIVEnTo examine the long-term efficacy of group MCT for schizophrenia in order to explore whether previously established effects were sustained.nnnDESIGN, SETTING, AND PARTICIPANTSnA 2-center, randomized, controlled, assessor-blind, parallel group trial was conducted. A total of 150 inpatients or outpatients with DSM-IV diagnoses of schizophrenia spectrum disorders were enrolled. All patients were prescribed antipsychotic medication. The second follow-up assessment took place 3 years later after the intervention phase was terminated.nnnINTERVENTIONSnGroup MCT targeting cognitive biases vs neuropsychological training (COGPACK). Patients received a maximum of 16 sessions.nnnMAIN OUTCOMES AND MEASURESnThe primary outcome measure was a delusion score derived from the Positive and Negative Syndrome Scale (PANSS). The PANSS positive syndrome and total scores, the Psychotic Symptom Rating Scales, the jumping to conclusions bias, self-esteem, and quality of life served as secondary outcome measures.nnnRESULTSnThe intention-to-treat analyses demonstrated that patients in the MCT group had significantly greater reductions in the core PANSS delusion score, after 3 years compared with the control group (η2partialu2009=u2009.037; Pu2009=u2009.05). Among the secondary outcomes, the intention-to-treat analyses also demonstrated that patients in the MCT group had significantly greater reductions in the PANSS positive syndrome score (η2partialu2009=u2009.055; Pu2009=u2009.02) and the Psychotic Symptom Rating Scales delusion score (η2partialu2009=u2009.109; Pu2009=u2009.001). Significant group differences at the 3-year follow-up were also found on measures of self-esteem and quality of life, which did not distinguish groups at earlier assessment points. Attention was improved in the neuropsychological training group relative to the MCT group. The completion rate was 61.3% after 3 years.nnnCONCLUSIONS AND RELEVANCEnMetacognitive training demonstrated sustained effects in the reduction of delusions, which were over and above the effects of antipsychotic medication. Moreover, there were some unanticipated (sleeper) effects as both self-esteem and quality of life were improved after 3 years. Effects on self-esteem and well-being were found even in the absence of an improvement on the jumping to conclusions bias.nnnTRIAL REGISTRATIONnisrctn.org Identifier: ISRCTN95205723.

Complementary group Metacognitive Training (MCT) reduces delusional ideation in schizophrenia

BACKGROUNDnSymptom reduction under antipsychotic agents is incomplete for most schizophrenia patients. In order to enhance outcome, cognitive approaches are increasingly adopted as add-on interventions. The present study aimed to determine the efficacy of group Metacognitive Training (MCT), which targets cognitive biases putatively involved in the pathogenesis of delusions.nnnMETHODSnA two-center, randomized, assessor-blind, controlled trial between MCT group training and cognitive training was carried out (ISRCTN95205723). A total of 150 in- and outpatients with DSM diagnoses of schizophrenia spectrum disorders were enrolled. All patients were concurrently prescribed antipsychotic medication. Assessments were made at baseline, four weeks and six months later. The primary outcome was a delusion score derived from the Positive and Negative Syndrome Scale (PANSS). The Psychotic Symptom Rating Scales (PSYRATS) as well as cognitive measures served as secondary outcomes.nnnRESULTSnCompletion at follow-up was 86%. According to intention-to-treat (ITT) analyses, patients in the MCT group showed significantly greater symptom reduction on the PANSS delusion subscore (follow-up), PANSS positive score (post-treatment) and PSYRATS delusion score (post-treatment and follow-up). Improvement on the PANSS positive scale at post-treatment and follow-up was positively correlated with the number of attended MCT sessions. No changes were seen for other psychopathological syndromes.nnnDISCUSSIONnMCT, a low-intensity training aimed at enhancing patients awareness of cognitive biases subserving paranoia, led to improvement in delusion symptoms relative to the control condition and over and above the effects of antipsychotic medication. This improvement was sustained at follow-up.

Beyond the Usual Suspects: Positive Attitudes Towards Positive Symptoms Is Associated With Medication Noncompliance in Psychosis

Antipsychotic medication represents the treatment of choice in psychosis according to clinical guidelines. Nevertheless, studies show that half to almost three-quarter of all patients discontinue medication with antipsychotics after some time, a fact which is traditionally ascribed to side-effects, mistrust against the clinician and poor illness insight. The present study investigated whether positive attitudes toward psychotic symptoms (ie, gain from illness) represent a further factor for medication noncompliance. An anonymous online survey was set up in order to prevent conservative response biases that likely emerge in a clinical setting. Following an iterative selection process, data from a total of 113 patients with a likely diagnosis of schizophrenia and a history of antipsychotic treatment were retained for the final analyses (80%). While side-effect profile and mistrust emerged as the most frequent reasons for drug discontinuation, 28% of the sample reported gain from illness (eg, missing voices, feeling of power) as a motive for noncompliance. At least every fourth patient reported the following reasons: stigma (31%), mistrust against the physician/therapist (31%), and rejection of medication in general (28%). Approximately every fifth patient had discontinued antipsychotic treatment because of forgetfulness. On average, patients provided 4 different explanations for noncompliance. Ambivalence toward symptoms and treatment should thoroughly be considered when planning treatment in psychosis. While antipsychotic medication represents the evidence-based cornerstone of the current treatment in schizophrenia, further research is needed on nonpharmacological interventions for noncompliant patients who are willing to undergo intervention but refuse pharmacotherapy.

Predictors of performance improvements within a cognitive remediation program for schizophrenia

Cognitive impairment is regarded a core feature of schizophrenia and is associated with low psychosocial functioning. There is rich evidence that cognitive remediation can improve cognitive functions in patients with schizophrenia. However, little is known about what predicts individual remediation success. Some studies suggest that baseline cognitive impairment might be a limiting factor for training response. Aim of the current study was to further examine the role of cognitive and symptom variables as predictors of remediation success. We studied a total sample of 32 patients with schizophrenia and schizoaffective disorder who were engaged in a computer-based cognitive training program (CogPack). A pre-training test battery provided cognitive measures of selective attention, executive functioning, processing speed, verbal memory, and verbal intelligence along with measures for positive and negative symptoms. Training response was defined as improvement on training tasks. Correlation analyses revealed no significant relationship between any of the baseline cognitive or symptom measures and improvement rates. However, better baseline cognition was associated with a higher percentage of tasks with initial ceiling effects. We conclude that not carefully tailoring task difficulty to patients cognitive abilities constitutes a much more severe threat to cognitive remediation success than cognitive impairment itself.

Individualized metacognitive therapy for delusions: A randomized controlled rater-blind study

BACKGROUNDnTheory-driven interventions targeting specific factors that contribute to delusions are receiving increased interest. The present study aimed to assess the efficacy of individualized metacognitive therapy (MCT+), a short manualized intervention that addresses delusion-associated cognitive biases.nnnMETHODSn92 patients with current or past delusions were randomized to receive 12 twice-weekly sessions of either MCT+xa0or a control intervention within a randomized controlled rater-blind design. Psychopathology and cognitive biases were assessed at baseline, 6 weeks and 6 months. ANCOVAs adjusted for baseline scores were used to assess differences between groups regarding outcome variables. Both per-protocol and intention-to-treat analyses were conducted.nnnRESULTSnAt 6 weeks, there was a significant difference in favor of MCT+xa0regarding decrease in delusion severity and improvement of self-reflectiveness (medium effect size), and a trend-wise difference regarding probability thresholds to decision. These effects increased, when only patients attending a minimum of 4 therapy sessions were considered. Control group patients subsequently showed further improvement while patients in the MCT+xa0group remained stable, such that there were no differences between groups at the 6-month follow-up.nnnLIMITATIONSnLower attendance rates in the control group possibly leading to unequal therapeutic effort; lower baseline delusion severity in the MCT+xa0group.nnnCONCLUSIONSnThe result pattern suggests that MCT+xa0led to earlier improvement in delusions and cognitive biases compared to the control intervention. The absence of a long-term effect might reflect floor effects in the MCT+xa0group, but may also indicate the need for further measures to promote sustainability of MCT+xa0effects.

The other side of “madness”: frequencies of positive and ambivalent attitudes towards prominent positive symptoms in psychosis

Background: Phenomenological descriptions of psychosis traditionally emphasize the subjective burden that psychosis inflicts on patients. However, a growing body of work suggests that in a subgroup of patients, psychotic symptoms are appraised as positive. The present study set out to explore the frequency of positive, negative and ambivalent attitudes towards positive symptoms. We were also interested in characterizing the phenomenological structure of positive symptoms. Method: Participants were recruited over the Internet via specialized psychosis forums. Among other questionnaires, participants completed the Community Assessment of Psychic Experiences (CAPE) scale. In addition, we administered a novel scale called Subjective Perception of Positive Symptoms (SUPPOSY) that assesses core positive symptoms along various dimensions (e.g. emotional appraisal, impact on daily life). Results: For all symptom clusters, the majority of participants expressed ambivalence. Psychotic symptoms were associated with both self-reported positive and negative emotions. Experiencing regret should positive symptoms disappear was associated with prior medication noncompliance. Discussion: The present study indicates that symptoms are neither regarded as an “emotional hell” nor as a “preferred reality”. Thus, for a symptom to become a target of treatment, various aspects of the symptom have to be carefully weighed.

Subjective versus objective cognition: Evidence for poor metacognitive monitoring in schizophrenia

BACKGROUNDnPatients with schizophrenia display a number of cognitive biases, particularly a tendency to jump to conclusions, which are implicated in the pathogenesis of the disorder. The present study contrasted the degree of objective reasoning biases with subjective cognitive insight. We expected that patients with schizophrenia would display greater objective than subjective impairment suggestive of poor metacognitive awareness.nnnMETHODSnPatients with schizophrenia (n=140) and healthy controls (n=60) underwent a test battery encompassing a cognitive bias paradigm (beads task) as well as neurocognitive tests (story recall, trail-making tests). In addition, they were administered the Beck Cognitive Insight Scale (BCIS), a subjective measure of (meta)cognitive awareness.nnnRESULTSnCorroborating prior research on decision making, draws to decisions were significantly delayed in controls relative to patients, whereas the core jumping to conclusion parameter (i.e., decision after one or two pieces of information) bordered significance. Patients with schizophrenia showed a lowered decision threshold and impaired neurocognition relative to nonclinical controls. Despite poor cognitive performance and prior psychotic episodes, patients with schizophrenia showed similar scores on the self-confidence subscale of the BCIS and reported even higher levels of self-reflectiveness relative to healthy controls.nnnDISCUSSIONnThe study demonstrates that patients with schizophrenia show severe cognitive biases and neurocognitive deficits but display only partial awareness herein. Raising cognitive insight in a non-insulting fashion and elevating patients corrigibility as well as willingness to consider others feedback and advice may help to narrow this gap and improve psychiatric symptomatology.

Predictors of early stable symptomatic remission after an exacerbation of schizophrenia: The significance of symptoms, neuropsychological performance and cognitive biases

Neuropsychological deficits and severity of initial psychopathology have been repeatedly associated with poor symptomatic outcomes in schizophrenia. The role of higher-order cognitive biases on symptomatic outcomes of the disorder has not yet been investigated. The present study aimed to assess the contribution of cognitive biases, psychopathology and neuropsychological deficits on the probability of achieving early symptomatic remission after a psychotic episode in patients with schizophrenia. Participants were 79 patients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder undergoing an acute psychotic episode, and 25 healthy controls. According to psychopathology assessments, patients were split into those who had achieved remission after an average follow-up interval of 7 months, and those who had not (NR). Patients who achieved remission exhibited higher premorbid IQ and better performance on the TMT-B, as well as lower baseline positive, disorganized and distress symptoms than NR patients. TMT-B performance and positive symptoms at baseline were the best predictors of remission. Cognitive biases and negative symptoms were not associated with later remission. The findings highlight the significance of initial symptom severity for at least short-term symptomatic outcomes and, thus, the importance of adequate symptomatic treatment and prevention of psychotic outbreaks in patients.

Probleme und Lösungsmöglichkeiten

Im Folgenden werden mogliche Probleme und Fragen, die sich bei der Durchfuhrung des MKT+ ergeben konnen, angesprochen (siehe auch ▸ Abschn. 4.1 zu therapeutischen Fallen)

Bayesian analyses of the effect of metacognitive training on social cognition deficits and overconfidence in errors

Social cognition (SC) impairments in schizophrenia predict interpersonal problems and low functional outcome, which might be aggravated by low (meta-) cognitive awareness of individual symptoms and cognitive biases. Metacognitive Training (MCT) aims to raise patients awareness of cognitive biases, for example overconfidence in errors. We examined whether MCT reduces high-confident false mental state perceptions and tried to identify possible underlying mechanisms of SC impairments. A total of 150 patients were enrolled in a randomized clinical trial comparing the MCT with cognitive remediation (CogPack®) as the active control. Participants were assessed at baseline and at four weeks (post) and further six months (follow-up) later with the Reading the Eyes in the Mind-test also measuring the patients response confidence. We found that compared to CogPack® MCT reliably reduced the amount of overconfident SC errors by approximately 40% at follow-up. Additionally, we were able to link several symptomatic features and neuropsychological parameters to SC impairments and overconfidence herein.