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.

Impaired integration of disambiguating evidence in delusional schizophrenia patients.

BACKGROUND: It has been previously demonstrated that a cognitive bias against disconfirmatory evidence (BADE) is associated with delusions. However, small samples of delusional patients, reliance on difference scores and choice of comparison groups may have hampered the reliability of these results. In the present study we aimed to improve on this methodology with a recent version of the BADE task, and compare larger groups of schizophrenia patients with/without delusions to obsessive-compulsive disorder (OCD) patients, a population with persistent and possibly bizarre beliefs without psychosis. METHOD: A component analysis was used to identify cognitive operations underlying the BADE task, and how they differ across four groups of participants: (1) high-delusional schizophrenia, (2) low-delusional schizophrenia, (3) OCD patients and (4) non-psychiatric controls. RESULTS: As in past studies, two components emerged and were labelled 'evidence integration' (the degree to which disambiguating information has been integrated) and 'conservatism' (reduced willingness to provide high plausibility ratings when justified), and only evidence integration differed between severely delusional patients and the other groups, reflecting delusional subjects giving higher ratings for disconfirmed interpretations and lower ratings for confirmed interpretations. CONCLUSIONS: These data support the finding that a reduced willingness to adjust beliefs when confronted with disconfirming evidence may be a cognitive underpinning of delusions specifically, rather than obsessive beliefs or other aspects of psychosis such as hallucinations, and illustrates a cognitive process that may underlie maintenance of delusions in the face of counter-evidence. This supports the possibility of the BADE operation being a useful target in cognitive-based therapies for delusions.

Antipsychotic treatment beyond antipsychotics: metacognitive intervention for schizophrenia patients improves delusional symptoms.

BACKGROUND: Although antipsychotic medication still represents the treatment of choice for schizophrenia, its objective impact on symptoms is only in the medium-effect size range and at least 50% of patients discontinue medication in the course of treatment. Hence, clinical researchers are intensively looking for complementary therapeutic options. Metacognitive training for schizophrenia patients (MCT) is a group intervention that seeks to sharpen the awareness of schizophrenia patients on cognitive biases (e.g. jumping to conclusions) that seem to underlie delusion formation and maintenance. The present trial combined group MCT with an individualized cognitive-behavioural therapy-oriented approach entitled individualized metacognitive therapy for psychosis (MCT+) and compared it against an active control. METHOD: A total of 48 patients fulfilling criteria of schizophrenia were randomly allocated to either MCT+ or cognitive remediation (clinical trial NCT01029067). Blind to intervention, both groups were assessed at baseline and 4 weeks later. Psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS) and the Psychotic Symptom Rating Scales (PSYRATS). Jumping to conclusions was measured using a variant of the beads task. RESULTS: PANSS delusion severity declined significantly in the combined MCT treatment compared with the control condition. PSYRATS delusion conviction as well as jumping to conclusions showed significantly greater improvement in the MCT group. In line with prior studies, treatment adherence and subjective efficacy was excellent for the MCT. CONCLUSIONS: The results suggest that the combination of a cognition-oriented and a symptom-oriented approach ameliorate psychotic symptoms and cognitive biases and represents a promising complementary treatment for schizophrenia.

Decision making under uncertainty and mood induction: further evidence for liberal acceptance in schizophrenia.

BACKGROUND: Cognitive biases, especially jumping to conclusions (JTC), are ascribed a vital role in the pathogenesis of schizophrenia. This study set out to explore motivational factors for JTC using a newly developed paradigm. METHOD: Twenty-seven schizophrenia patients and 32 healthy controls were shown 15 classical paintings, divided into three blocks. Four alternative titles (one correct and three lure titles) had to be appraised according to plausibility (0-10). Optionally, participants could decide for one option and reject one or more alternatives. In random order across blocks, anxiety-evoking music, happy music or no music was played in the background. RESULTS: Patients with schizophrenia, particularly those with delusions, made more decisions than healthy subjects. In line with the liberal acceptance (LA) account of schizophrenia, the decision threshold was significantly lowered in patients relative to controls. Patients were also more prone than healthy controls to making a decision when the distance between the first and second best alternative was close. Furthermore, implausible alternatives were judged as significantly more plausible by patients. Anxiety-evoking music resulted in more decisions in currently deluded patients relative to non-deluded patients and healthy controls. CONCLUSIONS: The results confirm predictions derived from the LA account and assert that schizophrenia patients decide hastily under conditions of continued uncertainty. The fact that mood induction did not exert an overall effect could be due to the explicit nature of the manipulation, which might have evoked strategies to counteract their influence.

Further evidence for the efficacy of a metacognitive group training in schizophrenia.

Metacognitive training (MCT) for patients with schizophrenia is a novel psychological group treatment targeting cognitive biases putatively involved in the pathogenesis of schizophrenia (e.g. jumping to conclusions, overconfidence in errors). Its eight modules are available cost-free online in many languages. In the present study, 36 subacute or remitted patients were randomly allocated to either the MCT or a wait-list group who received treatment-as-usual (TAU). Baseline and post assessments were 8 weeks apart and were performed blind to group status. MCT showed significantly greater improvement on the following parameters relative to the TAU group: delusion distress (PSYRATS), memory and social quality of life. In the MCT group, the rate of jumping to conclusions bias was reduced after training. No differences occurred on the PANSS. The present study confirms prior reports that MCT exerts beneficial effects on some cognitive and symptomatic parameters.