The Autism Rating Scale for Schizophrenia - Revised English Version: An Instrument to Characterize Schizophrenia Spectrum Disorders Phenotype.

Dis-sociality (DS) reflects the impairment of social experience in people with schizophrenia; it encompasses both negative features (disorder of attunement, inability to grasp the meaning of social contexts, the vanishing of social shared knowledge) and positive features (a peculiar set of values, ruminations not oriented to reality), reflecting the existential arrangement of people with schizophrenia. DS is grounded on the notion of schizophrenic autism as depicted by continental psychopathology. A rating scale has been developed, providing an experiential phenotype. Here we present the Autism Rating Scale for Schizophrenia - Revised English version (ARSS-Rev), developed on the Italian version of the scale. The scale is provided by a structured interview to facilitate the assessment of the phenomena investigated here. ARSS-Rev is composed of 16 distinctive items grouped into 6 categories: hypo-attunement, invasiveness, emotional flooding, algorithmic conception of sociality, antithetical attitude toward sociality, and idionomia. For each item and category, an accurate description is provided. Different intensities of phenomena are assessed through a Likert scale by rating each item according to its quantitative features (frequency, intensity, impairment, and need for coping). The ARSS-Rev has been able to discriminate patients with remitted schizophrenia from euthymic patients with psychotic bipolar disorder. This instrument may be useful in clinical/research settings to demarcate the boundaries of schizophrenia spectrum disorders from affective psychoses.

Promoting Reflection on the Process of Recovery: Unique Contributions from Literature and the Humanities for Practitioner.

Recovery from serious mental illness requires persons to make their own meaning and deal with evolving challenges and possibilities. Psychiatric rehabilitation thus must offer more than manualized curricula that address symptoms and skills. We suggest that exposure to the humanities and in particular literature may offer practitioners unique avenues for developing interventions that are sensitive to the processes that enable meaning to be made. We suggest that through what the poet Keats called negative capability, reading novels may enhance practitioners? abilities to see and accept uncertainty, tolerate ambiguity without need for complete resolution, and accept the complex and ambiguous nature of persons. As an illustration we described how reading two novels, The Trial and Slaughterhouse-Five enhanced the process of meaning making while supporting the recovery of one prototypical person with serious mental illness during his efforts to make sense of his experience of returning to work.

Homework assignments in relational psychoanalytic treatment of personality disorders: A case study of a patient with narcissistic personality disorder.

Homework assignments, or specific tasks patients are asked to engage in or complete between sessions, are a controversial topic among psychoanalysts. While many argue these interventions contradict psychoanalytic principles, others believe they can help address problems and promote coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient's experience and that homework may be an important component of treating personality disorders (PD). We present the case of a man diagnosed with narcissistic PD. He often felt superior to and reported that he despised others, though the core self-image was of fragile. He embraced the role of the omnipotent caregiver, which came with boredom and anger and lack of satisfaction in his social life. The patient tried to control therapy, asserting that he could psychoanalyze himself. As a result, therapy was stalled and progress was limited. At this point, the therapist asked him to complete homework assignments that encouraged him to refrain from his compulsive caregiving to better understand what motivated this behavior. Through this process, the patient came to realize he acted out of avoidance, as he did not want to disclose his own vulnerabilities and flaws. At that point he was able to experience relationships while adopting different stances and finding new meanings. We argue that homework can be fully integrated into the relational psychoanalytic repertoire to improve self-reflection and foster change in patients with PD.

A pilot randomized controlled trial comparing a novel compassion and metacognition approach for schizotypal personality disorder with a combination of cognitive therapy and psychopharmacological treatment.

BACKGROUND: Schizotypal personality disorder is characterized by a pervasive pattern of maladaptive behavior that has been associated with the liability for schizophrenia. Little is known about effective psychosocial interventions. This pilot non-inferiority randomized controlled trial aimed to compare a novel form of psychotherapy tailored for this disorder and a combination of cognitive therapy and psychopharmacological treatment. The former treatment - namely, Evolutionary Systems Therapy for Schizotypy-integrated evolutionary, metacognitively oriented, and compassion focused approaches. METHODS: Thirty-three participants were assessed for eligibility, twenty-four randomized on a 1:1 ratio, nineteen included in the final analysis. The treatments lasted 6 months (24 sessions). The primary outcome was change across nine measurements in personality pathology, the secondary outcomes were remission from diagnosis and pre-post changes in general symptomatology and metacognition. RESULTS: Primary outcome suggested a non-inferiority of the experimental treatment in respect to control condition. Secondary outcomes reported mixed results. There was no significant difference in terms of remission, but experimental treatment showed a larger reduction of general symptomatology (η2 = 0.558) and a larger increase in metacognition (η2 = 0.734). CONCLUSIONS: This pilot study reported promising results about the effectiveness of the proposed novel approach. A confirmatory trial on large sample size is needed to provide evidence about relative effectiveness of the two treatment conditions. TRIAL REGISTRATION: ClinicalTrials.gov; NCT04764708; Registration day 21/02/2021.

Negative Schizotypy Mediates the Relationship Between Metacognition and Social Functioning in a Nonclinical Sample.

ABSTRACT: Reduced metacognitive abilities-difficulty making sense of and understanding oneself and others-have been found to be key predictors of social functioning across a range of clinical and nonclinical groups. However, the exact processes through which metacognition impacts social functioning are unclear. This study examined whether subclinical negative symptoms mediated the relationship between metacognition and social functioning in a nonclinical sample of young adults (n = 98). Results demonstrated that lower metacognitive mastery was found to be uniquely associated with greater subclinical negative symptoms, whereas higher subclinical negative symptoms were associated with reduced social functioning. Further, the effects of lower metacognition on reduced social function were mediated by subclinical negative symptoms and not positive or disorganized subclinical symptoms. Results suggest that subclinical negative symptoms may link reductions in metacognition with social functioning in nonclinical samples. Training aimed at enhancing metacognition may support normative social functioning in the general population.

Metacognitive Beliefs and Metacognitive Capacity: Do They Assess Related Phenomena?

ABSTRACT: Metacognition has been defined several ways across different fields. In schizophrenia, two primary approaches to assessing metacognition focus on measuring metacognitive beliefs and metacognitive capacity. The degree of association between these two approaches is unclear. In this pilot study, schizophrenia (n = 39) and control (n = 46) groups were assessed using metacognitive beliefs (Metacognition Questionnaire-30) and metacognitive capacity (Metacognition Assessment Scale-Abbreviated) scales. We also examined how these two approaches predicted quality of life. Results showed anticipated differences for metacognitive beliefs, metacognitive capacity, and quality of life when comparing schizophrenia and healthy control groups. However, metacognitive beliefs and metacognitive capacity were not significantly related and only predicted quality of life in the healthy control group. Although preliminary, these findings suggest that these two approaches have a limited relationship with one another. Future studies should test these findings in larger samples and focus on examining associations at different levels of metacognitive functioning in those with schizophrenia.

Contrasting Metacognitive, Emotion Recognition and Alexithymia Profiles in Bulimia, Anorexia, and Schizophrenia.

ABSTRACT: Alexithymia, or deficits in emotion recognition, and metacognitive capacity have been noted both in psychosis and eating disorders and potentially linked to psychopathology. This study sought to compare levels of impairments in these phenomena and their associations with psychopathology in groups with eating disorders and psychosis. Participants with diagnoses of a schizophrenia spectrum disorder (SSD; n = 53), anorexia (n = 40), or bulimia (n = 40) were recruited from outpatient clinics. Alexithymia was measured with the Toronto Alexithymia Scale; emotion recognition, with the Ekman Faces Test; and metacognition, with the Metacognitive Assessment Scale-Abbreviated. Psychopathology was measured with the Eating Attitudes Test, Body Image Questionnaire, and Positive and Negative Syndrome Scale. Results indicated that the SSD group had significantly poorer metacognitive function than either eating disorder group. Metacognition was related to body image in the anorexia group and a range of different forms of general psychopathology in the bulimia group. Alexithymia was related to eating disorder behaviors in the bulimia group.

Clinical insight in first episode psychosis: the role of metacognition.

BACKGROUND: Poor clinical insight has been commonly reported in those with First Episode Psychosis (FEP) and thought to be influenced by a range of factors, including neurocognition and symptoms. Clinical insight may be compromised as a result of alterations in higher-level reflective processes, such as metacognitive ability and cognitive insight. AIMS: To explore whether metacognitive ability and cognitive insight are associated with clinical insight while controlling for IQ, depression, and symptoms in FEP. METHODS: 60 individuals with FEP completed measures for clinical insight, metacognitive ability, cognitive insight, positive and negative symptoms, depression, and IQ. RESULTS: Higher levels of metacognitive ability were associated with better clinical insight, even when controlling for IQ, depression, positive and negative symptoms, and medication. Integration subscale of metacognitive ability was most strongly associated with clinical insight. Cognitive insight was associated with clinical insight when controlling for covariates. However, when including metacognitive ability and cognitive insight in the predictive model, only metacognitive ability was significantly related to clinical insight. DISCUSSION: Metacognitive ability, specifically the ability to describe one's evolving mental state to provide a coherent narrative, was significantly related to clinical insight, independent of covariates, and may be a potentially important target for intervention in FEP.

Metacognitive mastery moderates the relationship between positive symptoms and distress in adults with serious mental illness.

BACKGROUND: Research supports the possibility that a person's metacognitive ability may influence the impact of positive symptoms. This connection is important because understanding how metacognitive capacity relates to positive symptoms and distress can guide treatment and bolster recovery. AIMS: To explore this, we assessed the moderating role of Metacognitive Mastery on the relationship of positive symptoms to affective symptoms, or markers of distress, measured both concurrently and at a later time point (to assess durability of metacognition) with persons with serious mental illness. To rule out the possibility that any findings were the result of cognitive impairments or general psychopathology we included measures of neurocognition and symptoms as potential covariates. METHODS: Participants were 67 individuals with the majority diagnosed with either schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were measured using the Brief Psychiatric Rating Scale and verbal memory was measured using the California Verbal Learning Test. RESULTS: Metacognitive Mastery moderated the relationship between positive symptoms and affective symptoms at both time points with differential patterns at each point. CONCLUSIONS: Metacognitive Mastery may exert a complex influence upon the effects of positive symptoms on distress.

Impaired insight in schizophrenia: impact on patient-reported and physician-reported outcome measures in a randomized controlled trial.

BACKGROUND: Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizophrenia. METHODS: In a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NCT00014001), insight was measured using the Positive and Negative Syndrome Scale (PANSS) Item G12 (lack of insight). Additional assessments for this analysis included the 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS), physician- and patient-reported Clinical Global Impression-Severity (CGI-S), MATRICS Consensus Cognitive Battery, and Calgary Depression Scale for Schizophrenia. Relationships between patient-reported outcomes and PANSS total and Item G12 ratings were evaluated. RESULTS: Among 1431 CATIE study participants in this analysis, increasingly impaired insight at baseline was significantly associated with better patient-reported quality of life (QoL), lower baseline depression, and greater divergence between physician- and patient-reported illness severity. Patients with more severely impaired insight reported milder illness compared with physician reports, particularly those with moderate-severe to extreme impairment (PANSS Item G12 rating ≥ 5), approximately 10% (138/1431) of CATIE participants. For the 90% of patients with PANSS Item G12 ratings < 5, patient-reported QoL decreased with increasing symptoms. SF-12 MCS scores were linearly related to baseline PANSS total score only in patients with PANSS total score < 90 (moderately ill or better), and better symptom scores were associated with higher QoL. No significant relationship between insight and neurocognition was observed. CONCLUSIONS: In the small subgroup (10%) of CATIE study patients with schizophrenia and PANSS Item G12 ratings ≥5, moderate-severe-severe/extreme insight impairment was associated with significantly more positive perception of QoL and illness severity by the patient versus the treating physician. This was not observed in the remaining 90% of patients with normal to moderately impaired insight, suggesting that poor insight as a threat to the validity of self-report is uncommon.

Centrality and Decentration: A Model for Understanding Disturbances in the Relationship of the Self to the World in Psychosis.

ABSTRACT: A considerable body of phenomenological research has described different ways in which the relationship of the person to the world in psychosis is affected. This literature, however, has lacked an accepted unifying theoretical model and means of quantitatively measuring these disturbances. To address this, the current article seeks to integrate a novel phenomenological model of psychosis offered by Henri Grivois, which is explicitly concerned with centrality or a person's sense of being the center of all things, with empirical research on the integrative model of metacognition, which allows for measurements of decentration or the degree to which persons can form integrated ideas about their place in their larger community. It is proposed that this literature may allow for a model of how psychotherapy can address centrality through the building of intersubjectivity and enhancing metacognition.

Total Metacognitive Capacity Predicts Competitive Employment Acquisition Across 6 Months in Adults With Serious Mental Illness Receiving Psychiatric Rehabilitation Services.

ABSTRACT: Deficits in metacognitive capacity are common among people with serious mental illness (SMI), although there is a gap in knowledge regarding how these impairments predict later functioning, especially employment. This study aimed to prospectively examine the relationship between metacognitive capacity and 6-month competitive employment attainment in adults with SMI who were participating in a study testing a cognitive behavioral therapy intervention added to supported employment services. Sixty-seven participants with complete data at baseline and the 6-month follow-up comprised the sample. Data were analyzed using stepwise logistic regression covarying for work history and study assignment. Results indicate that total metacognitive capacity at baseline significantly predicted employment acquisition at 6 months; the final model correctly classified 83.3% of participants who obtained work. In conclusion, these findings suggest that better overall metacognitive capacity may be key for future work functioning. Thus, interventions that target metacognitive capacity may lead to enhancements in community outcomes.

Psychopathology and Poor Clinical Insight in Psychotic Patients: Does the Diagnosis Matter?

ABSTRACT: Poor clinical insight is one of the most common features of schizophrenia spectrum disorders and plays a critical role in prognosis and treatment. Considering the biological and phenomenological overlap between schizophrenia and bipolar I disorder with psychotic features (BID) and increasing incidents of methamphetamine-induced psychotic disorder (MIPD) patients in Iran, it is necessary to have a clear picture of insight among these three groups. The aim of the present study was to compare clinical insight and other aspects of illness among three different disorders: schizophrenia, BID, and MIPD. In addition, we sought to examine the relationship of the severity of psychotic symptoms with clinical insight in each group. A total of 115 male inpatients, including 48 persons diagnosed with schizophrenia, 35 persons diagnosed with BID, and 32 persons diagnosed with MIPD, were selected. All participants completed the Scale to Assess Unawareness of Mental Disorder and the Positive and Negative Syndrome Scale. The results of analysis of variance indicated that schizophrenia patients reported higher rates of illness duration and number of hospital admissions in comparison to the MIPD and BID groups. In addition, persons diagnosed with BID reported more of these outcomes than MIPD groups. However, the three groups showed similar patterns in terms of age of onset and educational, marital, and occupational statuses. The results also revealed that awareness of the disorder was more impaired in schizophrenia patients compared with BID and MIPD patients and in MIPD compared with BID groups. However, the level of awareness of the effect of medication, the awareness of social consequences, and the total score of clinical insight were similar across the three diagnostic groups. As expected, poor clinical insight was correlated with high levels of positive, negative, and cognitive symptoms in the schizophrenia group; with high levels of positive, cognitive, and depressive symptoms in the BID group; and with high levels of positive and excitement symptoms in MIPD. In addition, hierarchical linear regression analyses revealed that only cognitive symptoms in the schizophrenia group and excitement symptoms in the MIPD group significantly predicted the overall score of clinical insight. In the BID group, both cognitive and depressive symptoms significantly predicted clinical insight. These findings suggest that there are differing levels of poor clinical insight in schizophrenia, MIPD, and BID and that poor clinical insight found within each group may have different antecedents.

Contrasting the Social Cognitive and Metacognitive Capacities Among Patients With Schizophrenia and Autism Spectrum Disorders Enrolled in Psychiatric Rehabilitation.

ABSTRACT: Unique deficits in synthetic metacognition have been found in schizophrenia when compared with other psychiatric conditions and community controls. Although persons with autism spectrum disorders (ASD) display similar deficits in social cognition relative to those with schizophrenia, to date no study has compared metacognitive function between these groups. We aimed to compare the metacognitive capacities of persons with schizophrenia and ASD and their associations with other outcomes (neurocognition, social cognition, depression, and quality of life). Fifty-six outpatients with schizophrenia or ASD (mean age, 32.50 [9.05]; 67.9% male) were recruited from two French Centers of Reference for Psychiatric Rehabilitation of the REHABase cohort. Evaluation included the Indiana Psychiatric Illness Interview, Metacognition Assessment Scale-Abbreviated, Movie for the Assessment of Social Cognition, and a large cognitive battery. Compared with those with schizophrenia, participants with ASD had higher self-reflectivity ( p = 0.025; odds ratio, 1.38 [1.05-1.86]) in univariable analyses. Metacognitive deficits may be found in ASD with a profile that varies from what is found in schizophrenia. It is possible that methods for enhancing metacognitive abilities during psychiatric rehabilitation may be refined to assist adults with ASD to better manage their own recovery.

Long-term effect of aripiprazole lauroxil on health-related quality of life in patients with schizophrenia.

BACKGROUND: This post hoc analysis of clinical trial data evaluated long-term, self-reported mental and physical health-related quality of life (HRQoL) scores in schizophrenia patients receiving aripiprazole lauroxil (AL), an atypical long-acting injectable (LAI) antipsychotic approved for the treatment of schizophrenia in adults. METHODS: The study population included 291 stable schizophrenia outpatients enrolled in 2 consecutive long-term safety studies of AL given every 4 weeks for up to 124 weeks. HRQoL was measured using the SF-36v2® Health Survey (SF-36v2) over the course of the follow-up. The primary outcome was change in SF-36v2 mental component summary (MCS) and physical component summary (PCS) scores from baseline to 124 weeks. To contextualize these scores, descriptive analyses were conducted to compare the scores with available scores for the general population as well as for other populations with chronic medical (ie, hypertension and type 2 diabetes) or psychiatric (ie, depression) conditions. RESULTS: Results from this post hoc analysis indicated that the mean MCS score for patients continuing AL improved significantly from baseline over 124 weeks (P < .05, all timepoints), while mean PCS score showed little change over 124 weeks. At baseline, patients had lower (worse) MCS scores than the normed general population, but by week 124, patients had MCS scores comparable to those in the general population. This pattern of change was not observed with PCS scores. Comparison of study MCS scores with those associated with other diseases showed that this schizophrenia cohort had lower scores than those with chronic medical conditions but higher scores than those with depression. PCS scores were higher in the study population than published scores for all reference populations at baseline and week 124. CONCLUSIONS: In this post hoc analysis, outpatients with schizophrenia who continued the LAI antipsychotic AL showed gradual and sustained improvement in self-reported mental HRQoL over several years of follow-up, whereas self-reported physical HRQoL did not change. By the end of follow-up, mental health scores of study patients with schizophrenia were comparable to those of the general population and better than those of patients with depression. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01626456 [trial registration date: June 15, 2012] and NCT01895452 [trial registration date: July 5, 2013]).

Autobiographical memory in schizophrenia: The role of metacognition.

BACKGROUND: Autobiographical memory is an important component of declarative memory, which refers to the ability to recall personal events that happened in the past. This requires that the person senses or experiences himself/herself in the past (i.e., conscious recollection). For people with schizophrenia, conscious recollection can be particularly difficult, resulting in difficulty accessing detailed, specific autobiographical information. Our hypothesis is that the ability to monitor and think about one's cognitive processes (metacognition) is a requisite for conscious recollection, and that it mediates the association between having schizophrenia and recalling fewer specific, personal memories. METHODS: Participants were 30 adults with schizophrenia and 30 matched healthy controls. The main assessment instruments were the Metacognition Assessment Scale-Abbreviated (MAS-A) and the Autobiographical Memory Test (AMT). Severity of symptoms was assessed using the Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Cognitive performance was measured with the Screen for Cognitive Impairment in Psychiatry (SCIP). Mediation analysis was conducted following Baron and Kenny's procedure. RESULTS: People with schizophrenia had more semantic associations and fewer specific memories than controls in the AMT. Metacognition (MAS-A total score) partially mediated the association between having schizophrenia and recalling fewer specific past events, even after controlling for cognitive impairment as a potential confounding source. CONCLUSIONS: Metacognitive ability, which can be improved with available programs, intervenes in the process of accessing autobiographical memories in people with schizophrenia. Practical implications of this finding are discussed.

Schizophrenia, the self and psychotherapy: Is there really anything new under the sun?

INTRODUCTION: This issue of In Session in The Journal of Clinical Psychology offers in depth case studies of psychotherapy for persons with differing types of schizophrenia spectrum disorders across international settings. METHOD: To understand the context and import of this work, this commentary explores commonalities of this work with past work including respect for patients' autonomy, compassion, and attention to the therapeutic relationship. The commentary then discusses themes which harken to the past including framing psychosis as something than can be understood jointly by therapist and patient rather than being unilaterally imposed. RESULTS: It is suggested that this work is emblematic of new movements in the literature which focus on the person who is experiencing schizophrenia. CONCLUSIONS: This focus extends to understanding the purposes, place of the person in the world and their possibilities, which enables them to make sense of what they need and how want to manage their own recovery.

Emerging psychotherapeutic approaches to addressing self-experience in schizophrenia spectrum disorders.

Growing awareness that many who are diagnosed with schizophrenia recover has spurred the development of new psychosocial approaches to treatment. These new approaches include forms of individual and group psychotherapy whose focus extends beyond reducing symptoms and improving skills to subjective outcomes related to sense of self. This paper introduces an issue of In Session which presents six case reports which illustrating these approaches in differing international contexts. First, we explore the larger issues of subjective outcomes from schizophrenia. We then discuss each of the papers separately along with implications of these papers as a group for how treatment might promote the recapturing of a sense of self or place in the world.

Metacognitive reflection and insight therapy in an inpatient setting: Transforming messianism to a coherent mission.

Metacognitive reflection and insight therapy (MERIT) is an integrative form of psychotherapy which seeks to help adults with serious mental illness make sense of the psychosocial challenges and possibilities they face and decide how to respond to them and direct their own recovery. In this article, we present an adaptation of MERIT to the context of an inpatient ward with an accompanied case illustration. Specifically, we describe how this approach is supported by a broad intersubjective framework, followed by a presentation of processes and contents of the treatment. Special attention is given to the concurrent improvements in reflective abilities and overall well-being of the patient. The unique role that psychotherapy in general, and approaches that emphasize reflective processes in particular, play during acute crises in an inpatient setting is discussed.

Utilizing MERIT to promote recovery in schizotypal personality disorder: An illustrative case study.

INTRODUCTION: Difficulties forming an integrated sense of oneself, others, and one's place in the community have been observed to pose a barrier to recovery from schizophrenia spectrum disorders (SSD). This has promoted the development of metacognitive approaches to psychotherapy that seek to assist persons in making sense of and managing their psychosocial challenges. One of these approaches, Metacognitive Reflection Insight Therapy (MERIT), has begun to be more broadly explored among adults with schizophrenia. Persons with other forms of SSD, including schizotypal personality disorder (SPD), also experience difficulties forming an integrated sense of themselves and others and could potentially be amenable to MERIT. METHODS: To explore this possibility, this study reports the application of MERIT to an adult with SPD in a unique cultural context. RESULTS: Evidence of acceptability and meaningful resultant clinical gains are described. CONCLUSIONS: Taken as a whole, this study provides a rich illustration of how metacognition can be successfully targeted by MERIT in forms of SSD potentially less severe than schizophrenia, including SPD in a unique cultural setting.