Giuseppe Nicolò

Metacognition and schizophrenia: The capacity for self-reflectivity as a predictor for prospective assessments of work performance over six months

Research has indicated that many with schizophrenia experience deficits in metacognitive capacity, defined as impairments in the ability to think about thinking. These difficulties are related to, but not reducible to symptoms and have been hypothesized to function as an independent impediment to psychosocial function. To explore the possibility that deficits in one domain of metacognition, self-reflectivity, are a barrier to effective work function, 56 participants with schizophrenia were categorized into three groups according to their capacity for self reflection based on an interview conducted prior to accepting a job placement. Blind ratings of work performance of these three groups over the next six months were then compared. Results of repeated measures ANOVA revealed that the group rated as having the highest level of metacognition, that is, able to see that their conclusions are subjective and fallible, had higher ratings of work performance over time than groups with medium and low levels of self reflectivity. These findings were found to persist even when impairment on a test of executive function was controlled for statistically. Results are interpreted as consistent with emerging models that deficits in metacognition may be key features of severe mental illness which affect function. Clinical and theoretic implications are discussed.

Metacognition within narratives of schizophrenia: Associations with multiple domains of neurocognition

Research has suggested many with schizophrenia experience impairments in metacognition, or difficulties apprehending their own thoughts and the thoughts of others, and that those deficits are not reducible to a single symptom or cognitive impairment. While links between metacognition and more severe levels of symptoms have emerged, less clear is whether there are consistent associations between metacognition and other neurocognitive capacities. Accordingly the current study sought to examine whether different patterns of metacognition deficits have different neurocognitive correlates. Narratives were gathered from 69 adults with schizophrenia spectrum disorder using the Indiana Psychiatric Illness Interview along with a symptom interview and neurocognitive battery including subtests of the Wechsler Adult Intelligence Scale III, Wechsler Memory Scale III and the Wisconsin Card Sorting Test. Metacognitive capacity within the narrative interview was assessed using the Metacognition Assessment Scale and participants were divided based on those scores into three groups: minimal self-reflectivity/not decentered (n=25); basic self-reflectivity/not decentered (n=33); and basic self-reflectivity/decentered (n=11). Basic self-reflectivity refers to the ability to distinguish ones own thoughts and feelings while decentered refers to the ability to see others as having independent perspectives and relationships with one another. MANOVA and ANOVA comparing groups revealed that the participants lacking basic self-reflectivity had significantly poorer working memory and more symptoms of disorganization, while participants able to see others as having independent perspectives and relationships demonstrated better visual memory. Results suggest different deficits in metacognition may be linked to different neurocognitive capacities.

Metacognition in schizophrenia: associations with multiple assessments of executive function.

Deficits in metacognitive capacity, or the abilities to think about thinking, are thought to be a key barrier to functioning in schizophrenia. Although metacognitive function may be linked to executive function, it is unclear how the different domains of each phenomenon are related to one another. Accordingly, we assessed 4 domains of metacognition on the basis of a self-generated narrative using the Metacognition Assessment Scale. These were correlated with subtests of the Delis Kaplan Executive Function System which assessed 2 domains of executive function: mental flexibility and inhibition. Participants were 49 men with schizophrenia spectrum disorders in a postacute phase of illness. Spearman Rho correlations revealed awareness of ones thoughts and feelings were more closely linked to performance on tests which required mental flexibility while recognizing others’ needs, and independent relationships were more closely linked to performance on tasks which required inhibitory control. Results suggest different domains of metacognition may be influenced by and influence different neurocognitive processes.

Poor insight in schizophrenia: links between different forms of metacognition with awareness of symptoms, treatment need, and consequences of illness

OBJECTIVE Many persons with schizophrenia experience poor insight or reflexive unawareness of the symptoms and consequences of their illness and, as a result, are at risk for treatment nonadherence and a range of negative outcomes. One recent theory regarding the origins of poor insight in schizophrenia has suggested that it may result, in part, from deficits in metacognitive capacity, or the ability to think about thinking, both ones own and the thinking of others. METHODS Participants were 65 adults with a schizophrenia spectrum disorder in a postacute phase of illness living in the community. For all participants, we obtained measures of three domains of metacognition, including self-reflectivity, mastery, and perspective taking, using the Metacognitive Assessment Scale and the hinting test and three domains of insight, which were awareness of symptoms, treatment need, and consequences of illness, using the Scale to Assess Unawareness of Mental Disorder. Measures of neurocognition were also collected for potential use as covariates. RESULTS Univariate correlations followed by stepwise multiple regressions, which controlled for neurocognition, indicated that self-reflectivity was significantly linked with awareness of symptoms, mastery with treatment need, and mastery and perspective taking were linked with awareness of consequences of illness. CONCLUSIONS Results suggest that metacognition may be linked to insight in persons with schizophrenia independent of concurrent impairments in neurocognition.

Impaired self-reflection in psychiatric disorders among adults: A proposal for the existence of a network of semi independent functions

Self-reflection plays a key role in healthy human adaptation. Self-reflection might involve different capacities which may be impaired to different degrees relatively independently of one another. Variation in abilities for different forms of self-reflection are commonly seen as key aspects of many adult mental disorders. Yet little has been written about whether there are different kinds of deficits in self-reflection found in mental illness, how those deficits should be distinguished from one another and how to characterize the extent to which they are interrelated. We review clinical and experimental literature and suggest four different forms of deficits in self-reflection: (a) sense of ownership of ones own thoughts and actions, (b) emotional awareness, (c) distinction between fantasy and reality and (d) the integration of a range of different views of oneself and others. We propose how these different impairments in self-reflection are linked with one another.

Understanding minds: Different functions and different disorders? The contribution of psychotherapy research

Abstract Disorders in the ability to understand mental states (metacognition) have an important role in psychopathology. Some clinicians talk of a generalised impairment of metacognition and others of malfunctioning of specific aspects. We compare two contrasting hypotheses. We call the first one ‘fast running’ hypothesis according to which metacognition is a single function, like speed in running. The second one is the ‘tennis playing’ hypothesis according to which metacognition is composed, like the ability to play tennis, of various, relatively independent skills, which can get impaired selectively. We reviewed the main theories and researches on metacognition and, therefore, we outlined a research programme based on them, describing the contribution made by the research on the psychotherapeutic process to this programme.

Metacognition in schizophrenia: Correlates and stability of deficits in theory of mind and self-reflectivity

Research suggests that many with schizophrenia experience a range of deficits in metacognition including difficulties recognizing the emotions and intentions of others as well as reflecting upon and questioning their own thinking. Unclear, however, is the extent to which these deficits are stable over time, how closely related they are to one another and whether their associations with core aspects of the disorder such as disorganization symptoms are stable over time. To explore this issue, we administered three assessments of Theory of Mind (ToM), the Beck Cognitive Insight Scale (BCIS), and the Positive and Negative Syndrome Scale at baseline and 6 months to 36 participants with schizophrenia. Correlations revealed the ToM and BCIS scores were stable across the two test administrations and that the ToM tests were closely linked to each other but not to the BCIS. Poorer baseline performance on the ToM tests and the Self-Certainty scale of the BCIS were linked to greater cognitive symptoms at baseline and follow-up, while greater Self-Reflectivity on the BCIS was linked to greater levels of emotional distress at both baseline and 6-month follow-up. Results are consistent with assertions that deficits in metacognition are a stable feature of schizophrenia.

Alexithymia in personality disorders: Correlations with symptoms and interpersonal functioning

Impairment in the ability to recognize and make sense of emotions has been hypothesized to be present in a sub-sample of people suffering from personality disorder (PD). In particular it is possible that difficulty recognizing and expressing feelings, or alexithymia, is related to many of the symptoms and problems in making sense of social interactions which are hallmarks of PD. In this study we measured levels of alexithymia with the Toronto Alexithymia Scale-20 and explored its correlations with the overall presence of PD and different PD diagnoses, symptoms, and interpersonal difficulties. Results were largely consistent with the hypothesis. Higher levels of alexithymia were related to high levels of global psychopathology and with dysfunctional representation of interpersonal relations. A sub-sample of patients, mostly suffering from avoidant, dependent, passive-aggressive and depressive PD, had alexithymic features and, in particular reported difficulties describing their feelings to others. A patient with cluster B PD featured no alexithymia. Implications of this study for future research and treatment are discussed.

Assessing metacognition in schizophrenia with the Metacognition Assessment Scale: Associations with the Social Cognition and Object Relations Scale

OBJECTIVES Impairments in metacognition are believed to be closely linked with functional impairments among persons with schizophrenia. Recently, we proposed a method for assessing multiple domains of metacognition by rating a narrative generated by a semi-structured interview with an abbreviated form of the Metacognition Assessment Scale (MAS). Less is known about how this measure is linked to social cognition. DESIGN The current study sought to compare, in a cross-sectional design, assessments of metacognition using the MAS and social cognition measured using the Social Cognition and Object Relations Scale (SCORS). METHODS Participants were 37 adults with schizophrenia spectrum disorders who completed an assessment battery that included the Hopkins Verbal Learning Test, Wisconsin Card Sorting Test, the Positive and Negative Syndrome Scale, and the procedures needed to derive the MAS and SCORS indices. RESULTS Univariate correlations and multiple regressions revealed that mastery, a domain of metacognition measuring thinking about oneself and coping with psychological challenges, was linked to SCORS indices which assess awareness of interpersonal relationships as the result of complex psychological forces and the recognition that relationships involve people with independent needs. This relationship persisted when the effects of symptoms and neurocognitive deficits were statistically controlled. CONCLUSIONS Mastery, one domain of metacognition, is linked to social cognition independent of neurocognitive function and symptoms.

Associations of metacognition with symptoms, insight, and neurocognition in clinically stable outpatients with schizophrenia.

Abstract Research indicates that many with schizophrenia experience deficits in metacognitive capacity or the ability to form complex representations of themselves and others. Previous work has found that metacognitive capacity in schizophrenia is correlated with symptoms, insight, and neurocognitive deficits. We sought to replicate these results in a sample of Italian participants treated in a community setting. Metacognition was assessed with the abbreviated Metacognition Assessment Scale and correlated with concurrent assessment of symptoms, insight, and neurocognitive abilities, including verbal and visual memory, premorbid intelligence, processing speed, and executive function. Correlations revealed that, consistent with previous work, lesser capacity for self-reflectivity was related to greater levels of negative symptoms, poorer insight, neurocognitive impairment (particularly impairments in verbal and visual memory) premorbid intelligence, and processing speed. Other metacognitive domains were also linked to poorer neurocognition. Results support contentions that deficits in metacognition are linked with negative symptoms, insight, and neurocognitive deficits.