Relationship between neurocognition and theory of mind as a function of symptomatic profile in schizophrenia: results from the national FACE-SZ cohort.

INTRODUCTION: Deficits in theory of mind (ToM) can vary depending on the predominant schizophrenia symptoms, and though most neurocognitive functions are involved in ToM, all may not be associated with the same symptoms. With consideration to the relationships between symptoms, neurocognition and ToM, the aim of the present study is to identify the neurocognitive functions influencing ToM capacities according to symptomatic profile. METHODS: The study is based on a sample of 124 adults with schizophrenia from a French national cohort. Patients were divided into two groups according to their scores on the five Wallwork factors of the Positive and Negative Syndrome Scale using hierarchical clustering before carrying out multivariable analyses. RESULTS: The "disorganised group" (n = 89) showed high scores on the disorganised factor, and had a ToM associated with reasoning, visual recognition and speed of processing. The "positive group" (n = 35) showed high scores on the positive and depressive factors, and had a ToM associated with working memory. CONCLUSIONS: These results suggest that neurocognitive predictors of ToM in schizophrenia are different according to the predominant clinical dimension, thus refining our knowledge of the relationship between symptoms, neurocognition and ToM, and acknowledging their status as important predictors of patients' functional status.

Assessing metacognitive and help-seeking strategies in schizophrenia: design and psychometric validation of the Versailles Metacognitive Strategies Evaluation Questionnaire.

OBJECTIVES: The aim of this study is to design a questionnaire, the Versailles Metacognitive Strategies Evaluation Questionnaire, for assessing the use of metacognitive and help-seeking strategies in three key-domains of impaired daily functioning in schizophrenia. To evaluate its psychometric properties (internal consistency, factor structure, convergent and divergent validity, and stability). DESIGN: Development of a questionnaire and psychometric validation procedure in patients with schizophrenia compared with healthy controls. Stability over one year was assessed in the patient group. SETTING: Schizophrenia Centers of Expertise (French FondaMental Network). SUBJECTS: A total of 141 patients with schizophrenia, among whom 77 participated in the second evaluation; 97 healthy subjects. MAIN MEASURES: The Versailles Metacognitive Strategies Evaluation Questionnaire, Positive and Negative Symptoms Scale, Personal and Social Performance Scale, Evaluation of Cognitive Processes involved in Disability in Schizophrenia Scale, Schizophrenia Quality of Life Questionnaire, and Stages of Recovery Instrument. RESULTS: From the 36-items version, stepwise exploratory factor analysis (oblimin) produced a 25-items scale which had a 3-factors structure (hygiene concern, social relationships, and hygiene help-seeking). Cronbach's were respectively equal to 0.91, 0.82, and 0.78. One-year stability was good (intra-class correlation coefficient = 0.7). The three factors showed good convergent validity with measures of quality of life (rho = 0.34, P ⩽ 0.001). The first two factors correlated with recovery (N = 34, rho = 0.53, P ⩽ 0.001). On the contrary, the factors exhibited divergent validity, with no significant correlation, with symptoms and cognitive and psychosocial functioning (P > 0.05). Factor structure in healthy controls did not match with that of patients, all items but one were found significantly different among groups. CONCLUSION: The Versailles Metacognitive Strategies Evaluation Questionnaire provides a simple and valid means to assess metacognitive strategies in individuals with schizophrenia.

Screening for cognitive deficits with the Evaluation of Cognitive Processes involved in Disability in Schizophrenia scale.

OBJECTIVE:: This study aimed to evaluate the validity of the Evaluation of Cognitive Processes involved in Disability in Schizophrenia scale (ECPDS) to discriminate for cognitive impairment in schizophrenia. DESIGN:: This multicentre cross-sectional study used a validation design with receiver operating characteristic (ROC) curve analysis. SETTINGS:: The study was undertaken in a French network of seven outward referral centres. SUBJECTS:: We recruited individuals with clinically stable schizophrenia diagnosed based on the Structured Clinical Interview for assessing Diagnostic and Statistical Manual of Mental Disorders (4th ed., rev.; DSM-IV-R) criteria. MAIN MEASURES:: The index test for cognitive impairment was ECPDS (independent variable), a 13-item scale completed by a relative of the participant. The reference standard was a standardized test battery that evaluated seven cognitive domains. Cognitive impairment was the dependent variable and was defined as an average z-score more than 1 SD below the normative mean in two or more cognitive domains. RESULTS:: Overall, 97 patients were included (67 with schizophrenia, 28 with schizoaffective disorder, and 2 with schizophreniform disorder). The mean age was 30.2 (SD 7.7) years, and there were 75 men (77.3%). There were 59 (60.8%) patients with cognitive impairment on the neuropsychological battery, and the mean ECPDS score was 27.3 (SD 7.3). The ROC curve analysis showed that the optimal ECPDS cut-off was 29.5. The area under the curve was 0.77, with 76.3% specificity and 71.1% sensitivity to discriminate against cognitive impairment. CONCLUSION:: The ECPDS is a valid triage tool for detecting cognitive impairment in schizophrenia, before using an extensive neuropsychological battery, and holds promise for use in everyday clinical practice.

Efficacy of the my health too online cognitive behavioral therapy program for healthcare workers during the COVID-19 pandemic: A randomized controlled trial.

Background: Healthcare workers' mental health has been impacted by the COVID-19 pandemic, emphasizing the need for mental health interventions in this population. Online cognitive behavioral therapy (CBT) is efficient to reduce stress and may reach numerous professionals. We developed "MyHealthToo", an online CBT program to help reduce stress among healthcare workers during the COVID-19 pandemic. Objective: The aim of our study is to investigate the efficacy of an online CBT program on stress and mental health conditions among healthcare workers during a health crisis. Methods: We performed a multicentric randomized controlled trial among 155 participants allocated either to the experimental or active control group (bibliotherapy). The primary outcome was the decrease of perceived stress scores (PSS-10) post-treatment. Secondary outcomes included depression, insomnia and PTSD symptoms along with self-reported resilience and ruminations. Assessments were scheduled pretreatment, mid-treatment (4 weeks), post-treatment (8 weeks), and at 1-month and 4-months follow-up. Results: For both interventions, mean changes on the PSS-10 were significant post-therapy (W8), as at 1-month (W12) and 4-months (W24) follow-ups. The between-group comparison showed no difference at any time point (ps > 0.88). Work-related ruminations significantly decreased in the experimental group with a significant between-group difference at W8 (Δ = -1.83 [-3.57; -0.09], p = 0.04). Posttraumatic stress symptoms significantly decreased in the experimental group with a significant between-group difference at W12 (Δ = -1.41 [-2.68; -0.14], p = 0.03). The decrease in work-related ruminations at W8 mediated the decrease in posttraumatic stress symptoms at W12 (p = 0.048). Conclusion: The "MyHealthToo" online CBT intervention may help reduce ruminations about work and posttraumatic stress symptoms among healthcare workers during a major health crisis. Work-related ruminations may represent a relevant target of online interventions to improve mental health among healthcare workers.

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.

Subtyping chronic catatonia: Clinical and neuropsychological characteristics of progressive periodic catatonia and chronic system catatonias vs. non-catatonic schizophrenia.

Catatonia has been defined by ICD-11 as a nosologically unspecific syndrome. Previous neuropsychiatric conceptions of catatonia such as Wernicke-Kleist-Leonhard's (WKL) one, have isolated chronic catatonic entities, such as progressive periodic catatonia (PPC) and chronic system catatonias (CSC). This study aimed at comparing the clinical and neuropsychological features of PPC, CSC and non-catatonic patients, all diagnosed with a schizophrenia spectrum disorder (SSD). The clinical and cognitive measures were compared among 53 SSD patients, first by separating catatonic (C-SSD, n = 27) and non-catatonic patients (NC-SSD, n = 26), and second, by separating PPC (n = 20), CSC (n = 6) and NC-SSD patients. Bayes factors were used to compare the model with 1 or 2 catatonic groups. We found that PPC had a more frequent schizo-affective presentation, higher levels of depression and less positive psychotic symptoms than both CSC and NC-SSD. CSC patients had an earlier illness onset, a poorer cognitive functioning, and higher antipsychotics doses than both PPC and NC-SSD. Most differences between C- and NC-SSD were accounted by characteristics of either PPC or CSC. The model with 2 catatonic groups clearly outperformed that with 1 catatonic group. Our results point to a substantial clinical heterogeneity of 'catatonia' within the SSD population and suggest that distinguishing (at least) 2 chronic catatonic phenotypes (PPC and CSC) may represent a relevant step to apprehend this heterogeneity. It is also a more parsimonious attempt than considering the around 32.000 distinct catatonic presentations resulting from the combinations of 3 out of 15 polythetic criteria for ICD-11 catatonia.

Outcome prediction with a social cognitive battery: a multicenter longitudinal study.

The interest in social cognition in schizophrenia is justified by the relationship between deficits in these skills and negative functional outcomes. Although assessment batteries have already been described, there is no consensus about which measures are useful in predicting patient functioning or quality of life (QoL). We investigated a set of five measures of recognition of facial emotions, theory of mind (ToM), and empathy in a cohort of 143 patients with schizophrenia or schizoaffective disorder at inclusion and, amongst whom 79 were reassessed 1 year later. The distribution was satisfactory for the TREF (Facial Emotion Recognition Task), V-SIR (Versailles-Situational Intention Reading), and QCAE (Questionnaire of Cognitive and Affective Empathy). Internal consistency was satisfactory for the TREF, V-SIR, V-Comics (Versailles Intention Attribution Task), and QCAE. Sensitivity to change was acceptable for the TREF. The TREF and V-SIR showed a cross-sectional relationship with functioning beyond the clinical symptoms of schizophrenia but not beyond neurocognition. Moreover, the TREF and V-SIR at inclusion could not predict functioning one year later, whereas most neurocognitive and clinical dimensions at inclusion could. Finally, only affective QCAE showed a significant cross-sectional, but not longitudinal, association with QoL. In conclusion, the TREF had satisfactory psychometric properties and showed a cross-sectional, but not longitudinal, association with objective outcome measures, thus appearing to be reliable in clinical practice and research. The V-SIR also showed promising psychometric properties, despite a possible weakness to detect change. However, these measures should be interpreted within the context of the good predictive power of the neurocognitive and clinical status on the outcome.

My Health Too: Investigating the Feasibility and the Acceptability of an Internet-Based Cognitive-Behavioral Therapy Program Developed for Healthcare Workers.

Background: The COVID-19 crisis has had a considerable mental health impact on healthcare workers. High levels of psychological distress are expected to have a significant impact on healthcare systems, warranting the need for evidence-based psychological interventions targeting stress and fostering resilience in this population. Online cognitive behavioral therapy (CBT) has proved to be effective in targeting stress and promoting resilience. However, online CBT programs targeting stress in healthcare workers are lacking. Objective: The aim of our study is to evaluate the feasibility and acceptability of an internet-based CBT intervention, the My Health Too program we developed during the first COVID-19 epidemic peak in France. Methods: We recruited 10 participants among Alsace region hospital staff during the first peak of the pandemic in France. They were given 1 week to test the website and were then asked to answer an internet survey and a semi-structured phone interview. Results: We conducted a thematic analysis of the content from the phone interviews. Major themes were identified, discussed and coded: the technical aspects, the content of the website and its impact on participants' emotions and everyday life. Overall, the participants reported finding the website easy to use and interactive. They described the resources as easy to understand, readily usable, and useful in inducing calm and in helping them practice self-compassion. Conclusion: Our results suggest that the My Health Too online CBT program is highly feasible and acceptable to healthcare workers during the highly stressful times of the pandemic peak. The feedback provided helped to improve the program whose efficacy is to be tested.

Reproduction Function in Male Patients With Bardet Biedl Syndrome.

PURPOSE: Bardet-Biedl syndrome (BBS) is a ciliopathy with a wide spectrum of symptoms due to primary cilia dysfunction, including genitourinary developmental anomalies as well as impaired reproduction, particularly in males. Primary cilia are known to be required at the following steps of reproduction function: (i) genitourinary organogenesis, (ii) in fetal firing of hypothalamo-pituitary axe, (iii) sperm flagellum structure, and (iv) first zygotic mitosis conducted by proximal sperm centriole. BBS phenotype is not fully understood. METHODS: This study explored all steps of reproduction in 11 French male patients with identified BBS mutations. RESULTS: BBS patients frequently presented with genitourinary malformations, such as cryptorchidism (5/11), short scrotum (5/8), and micropenis (5/8), but unexpectedly, with normal testis size (7/8). Ultrasonography highlighted epididymal cysts or agenesis of one seminal vesicle in some cases. Sexual hormones levels were normal in all patients except one. Sperm numeration was normal in 8 out of the 10 obtained samples. Five to 45% of sperm presented a progressive motility. Electron microscopy analysis of spermatozoa did not reveal any homogeneous abnormality. Moreover, a psychological approach pointed to a decreased self-confidence linked to blindness and obesity explaining why so few BBS patients express a child wish. CONCLUSIONS: Primary cilia dysfunction in BBS impacts the embryology of the male genital tract, especially epididymis, penis, and scrotum through an insufficient fetal androgen production. However, in adults, sperm structure does not seem to be impacted. These results should be confirmed in a greater BBS patient cohort, focusing on fertility.

Confirmation of a Two-Factor Solution to the Questionnaire of Cognitive and Affective Empathy in a French Population of Patients With Schizophrenia Spectrum Disorders.

The Questionnaire of Cognitive and Affective Empathy (QCAE) is a tool for self-assessing the cognitive and emotional components of empathy. A study showed that a two-factor model fits the data of patients with schizophrenia, whereas other reports on healthy subjects have suggested a five-factor decomposition. We aimed to replicate the model of Horan et al. in a French population with schizophrenia spectrum disorders (i.e., schizophrenia and schizoaffective disorders) participating in the EVACO Study (NCT02901015). In total, 133 patients were assessed with the QCAE, the Positive and Negative Symptom Scale (PANSS), the Personal and Social Performance Scale (PSP), and the Self rating Quality of Life Scale (S-QoL). The two-factor model demonstrated an adequate fit with the data, comparable to that reported by Horan et al. Males scored higher on the Affective subscore than females. After correction for multiple tests, psychopathology (PANSS) and functioning (PSP) did not correlate significantly with the QCAE subscores. However, quality of life (S-QoL) correlated positively with the Emotional Contagion subscore. Thus, the variability of empathetic disposition in schizophrenia may be considered through the cognitive versus affective dichotomy and properly investigated with the QCAE. The results support further investigation of the relationship between QCAE scores and subjective outcome measurements, such as quality of life, and emphasize the importance of cross-cultural comparisons.

Psychiatric disability as mediator of the neurocognition-functioning link in schizophrenia spectrum disorders: SEM analysis using the Evaluation of Cognitive Processes involved in Disability in Schizophrenia (ECPDS) scale.

The functional outcome in schizophrenia spectrum disorders is affected by multiple factors such as cognitive performance and clinical symptoms. Psychiatric disability may be another important determinant of functional outcome. The purpose of this study was to test whether schizophrenia symptoms and psychiatric disability mediated the association between cognition and functioning. Between April 2013 and July 2017, we included 108 community-dwelling adults with stable schizophrenia spectrum disorder in a multicenter study. Psychiatric disability was assessed with the Evaluation of Cognitive Processes involved in Disability in Schizophrenia (ECPDS) scale by relatives of patients. ECPDS focused on the broad array of motivational, neurocognitive, sociocognitive, and metacognitive impairments that result in activity restrictions. We used a battery of tests to assess seven cognition domains (processing speed, attention/vigilance, working, verbal and visual memory, reasoning and problem solving, and executive functioning) and cross-sectional structural equation modeling (SEM) for the mediation analyses. We estimated the one-year temporal stability of ECPDS scores in 45 participants. The model provided showed good fit and explained 43.9% of the variance in functioning. The effect of neurocognition on functioning was fully mediated by symptoms (proportion mediated: 36.5%) and psychiatric disability (proportion mediated: 31.3%). The ECPDS score had acceptable one-year temporal stability. The ECPDS scale has satisfactory psychometric properties, and shows significant convergence with neurocognition and functioning, suggesting a role for this tool in the routine evaluation of cognitive remediation needs. Our model validates psychiatric disability as a crucial step from cognitive impairment to restricted participation in life situations.