Investigating the relationship between specific negative symptoms and metacognitive functioning in psychosis: A systematic review.

BACKGROUND: Disrupted metacognition is implicated in development and maintenance of negative symptoms, but more fine-grained analyses would inform precise treatment targeting for individual negative symptoms. AIMS: This systematic review identifies and examines datasets that test whether specific metacognitive capacities distinctly influence negative symptoms. MATERIALS & METHODS: PsycINFO, EMBASE, Medline and Cochrane Library databases plus hand searching of relevant articles, journals and grey literature identified quantitative research investigating negative symptoms and metacognition in adults aged 16+ with psychosis. Authors of included articles were contacted to identify unique datasets and missing information. Data were extracted for a risk of bias assessment using the Quality in Prognostic Studies tool. RESULTS: 85 published reports met criteria and are estimated to reflect 32 distinct datasets and 1623 unique participants. The data indicated uncertainty about the relationship between summed scores of negative symptoms and domains of metacognition, with significant findings indicating correlation coefficients from 0.88 to -0.23. Only eight studies investigated the relationship between metacognition and individual negative symptoms, with mixed findings. Studies were mostly moderate-to-low risk of bias. DISCUSSION: The relationship between negative symptoms and metacognition is rarely the focus of studies reviewed here, and negative symptom scores are often summed. This approach may obscure relationships between metacognitive domains and individual negative symptoms which may be important for understanding how negative symptoms are developed and maintained. CONLCLUSION: Methodological challenges around overlapping participants, variation in aggregation of negative symptom items and types of analyses used, make a strong case for use of Individual Participant Data Meta-Analysis to further elucidate these relationships.

Investigating the relationship between negative symptoms and metacognitive functioning in psychosis: An individual participant data meta-analysis.

PURPOSE: Negative symptoms are a persistent, yet under-explored problem in psychosis. Disturbances in metacognition are a potential causal factor in negative symptom development and maintenance. This meta-analysis uses individual participant data (IPD) from existing research to assess the relationship between negative symptoms and metacognition treated as summed scores and domains. METHODS: Data sets containing individuals with negative symptoms and metacognition data, aged 16+ with psychosis, were identified according to pre-specific parameters. IPD integrity and completeness were checked and data were synthesized in two-stage meta-analyses of each negative symptoms cluster compared with metacognition in seemingly unrelated regression using restricted maximum likelihood estimation. Planned and exploratory sensitivity analyses were also conducted. RESULTS: Thirty-three eligible data sets were identified with 21 with sufficient similarity and availability to be included in meta-analyses, corresponding to 1301 participants. The strongest relationships observed were between summed scores of negative symptoms and metacognition. Metacognitive domains of self-reflectivity and understanding others' minds, and expressive negative symptoms emerged as significant in some meta-analyses. The uncertainty of several effect estimates increased significantly when controlling for covariates. CONCLUSIONS: This robust meta-analysis highlights the impact of using summed versus domain-specific scores of metacognition and negative symptoms, and relationships are not as clear-cut as once believed. Findings support arguments for further differentiation of negative symptom profiles and continued granular exploration of the relationship between metacognition and negative symptoms.

Multi-family group and single-family intervention in first-episode psychosis: A prospective, quasi-experimental cohort study.

BACKGROUND: The evidence for manualized psycho-educative family intervention (FI) in first-episode psychosis (FEP) is well-established to reduce relapse and caregiver distress. Less is known, however, about type and duration of FI. AIM: To compare two different types of manualized family interventions for FEP: Multi-Family Groups (MFG) and Single-Family Intervention (SFI). METHODS: This was a prospective, quasi-experimental cohort study of all participants of an early psychosis service (OPUS) with an ICD-10 diagnosis of F20 to F29 (excl. F21), aged 18 to 35 years, in Psychiatry Region Zealand, Denmark, during a 2-year period. All service users and their relatives are offered FI, either MFG or SFI. Assessment of level of participation, psychopathology measured by The Positive and Negative Syndrome Scale (PANSS), remission status and relapses was carried out at 3-year follow up. RESULTS: We found no differences between the service users participating in SFI (N = 25) or MFG (N = 18) on number of readmissions or relapses after baseline or psychopathology. A binary logistic regression analysis on remission status at follow up showed a trend in favour of MFG. A surprisingly high proportion of the families did not receive an FI. CONCLUSIONS: SFI and MFG seem equally effective in an FEP programme. The low attendance of FI may be due to several issues-among others, the probability that the FI did not sufficiently match the needs of the service users. Further studies involving larger samples are needed, included randomized controlled trials and implementation studies.

Mobile App Integration Into Dialectical Behavior Therapy for Persons With Borderline Personality Disorder: Qualitative and Quantitative Study.

BACKGROUND: The advancement of and access to technology such as smartphones has implications for psychotherapeutic health care and how interventions for a range of mental health disorders are provided. OBJECTIVE: The objective of this study was to describe the experiences of participants while using a mobile phone app that was designed to enhance and support dialectical behavior therapy for personality disorders. METHODS: A combination of in-depth interviews and questionnaires were used to capture the experiences of participants who used the app while undergoing dialectical behavior therapy treatment. A mixed methods approach was used; qualitative data from the interviews were analyzed using thematic analysis and were combined with quantitative data from the questionnaires. RESULTS: Participants (N=24) who were receiving dialectical behavior therapy used the trial app. Participants (n=20) completed an evaluation questionnaire and a subset of this group (n=8) participated in semistructured interviews. Major themes that were identified from the interviews were (1) an overall positive experience of using the app-participants perceived that the app facilitated access and implementation of dialectical behavior therapy strategies (to regulate mood and behavior in challenging situations)-and (2) that the app provided a common source of information for patient and therapist interactions-app-based interactions were perceived to facilitate therapeutic alliance. Qualitative themes from the interviews were largely congruent with the quantitative responses from the questionnaires. CONCLUSIONS: Participants welcomed the integration of technology as a supplement to clinical treatment. The app was perceived to facilitate and support many of the therapeutic techniques associated with dialectical behavior therapy treatment. The incorporation of technology into psychotherapeutic interventions may facilitate the transfer of knowledge and strategies that are learned in therapy to use in real-world settings thereby promoting recovery from mental health problems.

Acceptance- and mindfulness-based interventions for persons with psychosis: A systematic review and meta-analysis.

BACKGROUND: Acceptance- and mindfulness-based approaches have gained popularity in recent years. OBJECTIVE: A systematic review and meta-analysis of the efficacy and safety of acceptance- and mindfulness-based therapies for persons with a psychotic or schizophrenia spectrum disorder. METHODS: Following PRISMA guidelines, relevant databases were searched for published randomized controlled trials (RCTs) up to October 2018. Outcomes were severity of overall symptomatology, hospitalization, positive and negative symptoms, depression, anxiety, social functioning, quality of life, acceptance, mindfulness skills and safety of the interventions. RESULTS: Sixteen studies comprising 1268 people with a schizophrenia spectrum disorder were included in the meta-analyses. Moderate to large effect sizes were found for overall symptomatology and hospitalization at endpoint (SMD .80, 95% CI -1.31, -0.29 and MD 4.38, -5.58, -3.17 respectively) and follow-up (SMD 1.10, -2.09, -0.10 and MD 7.18, -8.67, - 5.68 respectively). There were significant small effects on negative symptoms (SMD .24; -0.44, -0.03), small to moderate effects for depression (SMD .47; -0.80, -0.14), social functioning (SMD .43; -0.75, - 0.12) and mindfulness (SMD .51; -0.97, -0.05), moderate to large effects for acceptance (SMD .78; -1.44, -0.12), while no significant effects for positive symptoms (SMD .27; -0.65, 0.00), anxiety (SMD 2.11; -4.64, 0.42) or quality of life (SMD .43; -0.88, 0.02). Majority of studies (75%) had low risk of bias and sensitivity analyses supported the findings. CONCLUSION: Acceptance- and mindfulness-based approaches appear to be effective and safe interventions for individuals with schizophrenia spectrum disorders and could be a useful extension of standard casemanagement and psychofarmacology.

Does childhood trauma predict poorer metacognitive abilities in people with first-episode psychosis?

Research suggests that people with first-episode psychosis (FEP) report more childhood traumas and have lower metacognitive abilities than non-clinical controls. Childhood trauma negatively affects metacognitive development in population studies, while the association remains largely unexplored in FEP populations. Metacognition refers to the identification of thoughts and feelings and the formation of complex ideas about oneself and others. This study hypothesized that childhood trauma would be associated with lower metacognitive abilities in people with FEP. In a representative sample of 92 persons with non-affective FEP, we assessed childhood trauma, metacognitive abilities and symptoms of psychosis. We used the Childhood Trauma Questionnaire (CTQ) and the Metacognitive Assessment Scale--Abbreviated which includes Self-reflectivity, Awareness of the Mind of the Other, Decentration and Mastery. Hierarchical regression analyses were performed with metacognitive domains as outcome variables and childhood traumas as independent variables, while controlling for age, gender, first-degree psychiatric illness and negative symptoms. We found few significant associations between the different types of childhood trauma and metacognitive domains, and they suggested childhood trauma are associated with better metacognitive abilities. Study limitations included the cross-sectional design and use of self-report measures. Future studies could preferably be prospective and include different measures of psychopathology and neuropsychology.

Important first encounter: Service user experience of pathways to care and early detection in first-episode psychosis.

BACKGROUND: Long duration of untreated psychosis is associated with poor clinical and functional outcomes. However, few systematic attempts have been made to reduce this delay and little is known of service users' experience of early detection efforts. AIM: We explored service users' experience of an early detection service and transition to specialized treatment service, including pathway to care, understanding of illness and barriers to adequate assessment and treatment. METHODS: In-depth interviews were conducted with 10 service users (median age 21, range 18-27, five males and five females) who were diagnosed with a first-episode non-affective psychosis and who were seen by an early detection team (TOP) and currently enrolled in a specialized early intervention service for this disorder (OPUS). RESULTS: Stigma and fear of the 'psychiatric system' were reported as significant barriers to help seeking, while family members were seen as a crucial support. Moreover, the impact of traumatic events on the experience and development of psychosis was highlighted. Finally, participants were relieved by the prospect of receiving help and the early detection team seemed to create a trusting relationship by offering a friendly, 'anti-stigmatized' space, where long-term symptomatology could be disclosed through accurate and validating questioning. CONCLUSIONS: Early detection services have two important functions. One is to make accurate assessments and referrals. The other is to instil hope and trust, and to facilitate further treatment by forming an early therapeutic alliance. The findings in this study provide important insights into the way in which early detection efforts and pathways to care are experienced by service users, with direct implications for improving psychiatric services.

Determinants of duration of untreated psychosis among first-episode psychosis patients in Denmark: A nationwide register-based study.

BACKGROUND: Information on determinants of duration of untreated psychosis (DUP) is still needed to inform campaigns targeting people with first episode psychosis (FEP). This nation-wide study analysed the association between demographic factors (age, sex, ethnicity, marital status, and geographic area), premorbid and illness-related factors (global functional level, substance misuse, and contact to police), healthcare factors (referral source and first FEP contact) and DUP. METHOD: The study population of 1266 patients aged 15-25years diagnosed with FEP (ICD10 F20.0-F20.99) was drawn from the Danish National Indicator Project during 2009-2011. The study population was combined with data from national administrative registers. A multinomial regression model was estimated to analyse the impact of demographic, premorbid and illness-related, and healthcare factors on DUP. RESULTS: One third of the population had a DUP below 6months. DUP longer than 12months was associated with older age at onset, being female, having cannabis misuse, and living in peripheral municipalities. Being charged by the criminal authorities during one year before FEP was associated with a DUP over 6months. CONCLUSION: DUP is related to a number of demographic, premorbid and healthcare factors. These findings suggest that future information campaigns should focus on increasing the awareness of early signs of psychosis not only among mental health professionals but also other professionals in contact with adolescents such as the police. It may also be useful to consider how to target information campaigns towards persons living in peripheral areas.

Moderated online social therapy for depression relapse prevention in young people: pilot study of a 'next generation' online intervention.

AIM: Implementation of targeted e-mental health interventions offers a promising solution to reducing the burden of disease associated with youth depression. A single-group pilot study was conducted to evaluate the acceptability, feasibility, usability and safety of a novel, moderated online social therapy intervention (entitled Rebound) for depression relapse prevention in young people. METHODS: Participants were 42 young people (15-25 years) (50% men; mean age = 18.5 years) in partial or full remission. Participants had access to the Rebound platform for at least 12 weeks, including the social networking, peer and clinical moderator and therapy components. RESULTS: Follow-up data were available for 39 (92.9%) participants. There was high system usage, with 3034 user logins (mean = 72.2 per user) and 2146 posts (mean = 51.1). Almost 70% of users had ≥10 logins over the 12 weeks, with 78.5% logging in over at least 2 months of the pilot. A total of 32 (84%) participants rated the intervention as helpful. There was significant improvement between the number of participants in full remission at baseline (n = 5; none of whom relapsed) relative to n = 19 at 12-week follow-up (P < 0.001). Six (14.3%) participants relapsed to full threshold symptoms at 12 weeks. There was a significant improvement to interviewer-rated depression scores (Montgomery-Asberg Depression Rating Scale (MADRS); P = 0.014, d = 0.45) and a trend for improved strength use (P = 0.088, d = 0.29). The single-group design and 12-week treatment phase preclude a full understanding of the clinical benefits of the Rebound intervention. CONCLUSIONS: The Rebound intervention was shown to be acceptable, feasible, highly usable and safe in young people with major depression.

Metacognitive mastery in persons with first-episode psychosis and their caregivers: Implications for timely help-seeking and caregiver experiences. Brief report.

While metacognitive mastery seems to be closely linked to general functioning in persons with psychosis, little is known of metacognitive capacity of family members, who often play an important role in recovery and often report high levels of distress. We gathered assessments of metacognitive mastery from persons with first-episode psychosis and their mothers. We found that relatively higher overall mean mastery levels among the dyads, was related to less negative caregiver experiences, and less caregiver criticism. Greater levels of mastery were related to decreased duration of untreated psychosis. Clinical implications in terms of family intervention programmes repertoire are discussed.

Metacognition in first-episode psychosis and its association with positive and negative symptom profiles.

There is growing evidence that metacognitive abilities which include the ability to synthesize knowledge regarding mental states in self and others and use this ability to solve problems are impaired in non-affective psychosis and associated with positive and negative symptom severity. We sought to (a) investigate the severity of metacognitive impairments in first-episode psychosis (FEP) compared to non-clinical controls and (b) explore associations with positive and negative symptom profiles. Ninety-seven people with FEP were compared to 101 control persons. Metacognition was assessed with interviews and the Metacognitive assessment scale-abbreviated. Four groups based on positive and negative symptoms were identified by cluster analysis and compared on metacognition, childhood adversities, duration of untreated psychosis and premorbid social and academic adjustment. Those with high levels of negative symptoms had poorer metacognitive abilities. Those with high positive and low negative symptoms did not have poorer metacognitive abilities than those with low positive and negative symptoms. None of the other predictors differed between the groups. The FEP group had poorer metacognitive abilities than the control group. Inclusion of metacognition in psychosis models may improve our understanding of negative symptoms, while previous findings of a relation with positive symptoms may have been confounded. Implications for current interventions are discussed.

The Experience of Childhood Trauma and Its Influence on the Course of Illness in First-Episode Psychosis: A Qualitative Study.

Persons with schizophrenia spectrum disorders often report high levels of childhood trauma, which often exacerbates symptoms and impede the process of recovery. However, little is known about how these traumas are experienced by service users and how they are integrated in their life stories. To examine this, we conducted in-depth interviews with 15 service users with a diagnosis of a first-episode nonaffective psychosis who had reported 1 or more childhood traumas in self-report measures. There was an unexpected discrepancy between the number of traumas reported in self-report measures and in semistructured interviews, and many of the traumas did not seem integrated in their personal narratives. The analyses further revealed that although participants often described complicated and traumatic childhood environments, they still felt supported by their families; they reported a range of ways in which they tried to cope with and gain control of their psychotic disorder, and they described a general optimistic view of the future.

Childhood adversity specificity and dose-response effect in non-affective first-episode psychosis.

BACKGROUND: Reviews conclude that childhood and adolescence sexual, physical, emotional abuse and emotional and physical neglect are all risk factors for psychosis. However, studies suggest only some adversities are associated with psychosis. Dose-response effects of several adversities on risk of psychosis have not been consistently found. The current study aimed to explore adversity specificity and dose-response effects of adversities on risk of psychosis. METHOD: Participants were 101 persons with first-episode psychosis (FEP) diagnosed with ICD-10 F20 - F29 (except F21) and 101 non-clinical control persons matched by gender, age and parents' socio-economic status. Assessment included the Childhood Trauma Questionnaire and parts of the Childhood Experience of Care and Abuse Questionnaire. RESULTS: Eighty-nine percent of the FEP group reported one or more adversities compared to 37% of the control group. Childhood and adolescent sexual, physical, emotional abuse, and physical and emotional neglect, separation and institutionalization were about four to 17 times higher for the FEP group (all p<0.01). The risk of psychosis increased two and a half times for each additional adversity. All associations between specific adversities and psychosis decreased when they were adjusted for other adversities. CONCLUSION: Our findings suggest that there is a large shared effect of adversities on the risk of psychosis. Contrary to the call for further research into specific adversities, we suggest a search for mechanisms in the shared effects of traumatization. Clinical implications are thorough assessment of adversities and their possible effects.

The Role of Metacognitions in Expressed Emotion and Distress: A Study on Caregivers of Persons with First-Episode Psychosis.

BACKGROUND: In first-episode psychosis, the family is considered an important part in the recovery process. This is often accompanied by significant distress, which is acknowledged in numerous studies. However, little is known about the psychological factors involved. METHOD: One hundred and twenty-seven caregivers of persons with first-episode psychosis completed a series of questionnaires aimed at investigating the contribution of expressed emotion and metacognitions to caregiver distress. RESULTS: Linear mixed model analysis found that emotional over-involvement and metacognitions independently predicted caregiver distress. Mediation analysis using bootstrapping showed that emotional over-involvement could be seen as mediating the effect of metacognitions on distress. CONCLUSION: The current study is a first step towards understanding the role of metacognitions in caregiver distress, thus opening up for the possibility of using interventions from 'contextual behaviour therapies'. Implications and future studies are discussed. KEY PRACTITIONER MESSAGE: This study is the first attempt to address caregiver concerns from the perspective of contextual cognitive behavioural therapy. The metacognitive framework for caregiver distress in first-episode psychosis may help develop new therapeutic interventions to better support families. The study proposes a psychological understanding of emotional over-involvement and caregiver distress.

Caregiver distress in first-episode psychosis: the role of subjective appraisal, over-involvement and symptomatology.

BACKGROUND: Caregivers of persons with first-episode psychosis (FEP) often report high levels of distress. Preventing long-term or chronic distress within the whole family is an important focus of early intervention for psychosis. However, a more comprehensive understanding of the psychological factors involved is needed. AIMS: To examine the impact of subjective appraisals and expressed emotion on caregiver distress in FEP. METHOD: Within a cross-sectional design, 154 caregivers of 99 persons with FEP in a clinical epidemiological sample completed a series of questionnaires to examine potential predictors of caregiver distress. RESULTS: Thirty-seven percent of caregivers were suffering from clinically significant distress. A linear mixed model analysis found that, after controlling for caregiver socio-demographic factors, service-user symptoms and global functioning, emotional over-involvement and subjective appraisal of caregiving were significant predictors of caregiver distress. CONCLUSION: Caregiver distress is significant in the early phase of illness, and this seems to be more related to their subjective appraisal and over-involvement, than to variations in symptoms and global functioning of the person diagnosed with FEP. This lends further support to the stress-appraisal coping model and the cognitive model of caregiving in FEP, and highlights supportive interventions aimed at handling unhelpful cognitions and behaviors.

Service user perspectives on the experience of illness and pathway to care in first-episode psychosis: a qualitative study within the TOP project.

Delays in initiating treatment are associated with poor clinical and functional outcomes, yet there remains unclarity as to what facilitates and what acts as barriers to accessing appropriate support for first-episode psychosis. To explore this we examined service users' views of their illness trajectory and help-seeking behavior. To describe service-users' experiences with and understanding of their illness and pathway to care, including their need for treatment, the role of their relatives and experience with the treatment service. In-depth interviews were conducted with eleven randomly selected service users (median age 20, range 15-24, 6 males, 5 females) diagnosed with a first-episode psychosis and currently enrolled in treatment for this disorder. Fear of stigma, lack of knowledge about mental illness and normalisation of symptoms were barriers to accessing appropriate treatment, while support from significant others and information accessed by internet were reported as important elements in seeking appropriate treatment. The findings regarding barriers to treatment are in accordance with themes found in earlier studies and serve to validate these. Our study highlights the need to include psychological factors such as normalisation of symptoms and fear of stigma when attempting to reduce DUP in early psychosis, in addition to initiatives to reduce service delays. Also, a greater use of the potentials inherent in Internet and social media platforms seems important in this regard.

Towards a better understanding of caregiver distress in early psychosis: a systematic review of the psychological factors involved.

OBJECTIVES: We sought to review empirical studies of psychological factors accounting for distress in caregivers of young people with early psychosis. METHOD: Following the PRISMA guidelines, we included studies that empirically tested psychological models of caregiver distress in early psychosis by searching the following databases up until March 2014: PsycINFO, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL). This was followed by additional manual searches of reference lists and relevant journals. RESULTS: The search identified 15 papers describing 13 studies together comprising 1056 caregivers of persons with early psychosis. The mean age of caregivers was 47.2years (SD=9.8), of whom 71.5% were female and 74.4% were parents. Nine different psychological variables were examined in the included studies, which were categorised in the following non-mutually exclusive groups: coping, appraisal/attribution and interpersonal response. There was considerable data to support the link between distress and psychological factors such as avoidant coping, appraisal and emotional over-involvement. However, the possibilities of drawing conclusions were limited by a number of methodological issues, including cross-sectional data, small sample sizes, confounding variables not being accounted for, and a wide variation in outcome measures. DISCUSSION: The strengths of the review were the systematic approach, the exclusion of non-empirical papers and the rating of methodological quality by two independent raters. Limitations were that we excluded studies published in languages other than English, that data extraction forms were developed for this study and hence not tested for validity, and that there was a potential publication bias in favour of significant findings. CONCLUSION AND IMPLICATIONS: A better grasp of the psychological factors accounting for caregiver distress early in the course of illness may help us understand the trajectory of distress. This is an important step in preventing long-term distress in caregivers and supporting recovery in the whole family.