Stress is a bad advisor. Stress primes poor decision making in deluded psychotic patients.

Stress is implicated in the onset of psychosis but the complex links between stress and psychotic breakdown are yet poorly understood. For the present study, we examined whether two prominent cognitive biases in psychosis, jumping to conclusions and distorted attribution, in conjunction with neuropsychological deficits play a role in this process. Thirty participants with schizophrenia and acute delusional symptoms were compared with 29 healthy controls across three conditions involving a noise stressor, a social stressor or no stressor. Under each condition participants had to perform parallel versions of cognitive bias tasks and neuropsychological tests including a probabilistic reasoning task (jumping to conclusions), the revised Internal, Personal and Situational Attributions Questionnaire (IPSAQ-R; attributional style), and the Corsi block-tapping task (nonverbal memory). Stress, particularly noise, aggravated performance differences of patients relative to controls on memory. Participants with psychosis demonstrated an escalated jumping to conclusion bias under stress. At a medium effect size, patients made more monocausal attributions, which increased under social stress. The present study is partially in line with prior studies. It suggests that stress negatively affects cognition in psychosis more than in controls, which is presumably insufficiently realized by patients and thus not held in check by greater response hesitance. Raising patients' awareness about these response tendencies and encouraging them to be more cautious in their judgments under conditions of increased stress may prove beneficial for improving positive symptoms.

Do People With Psychosis Have Specific Difficulties Regulating Emotions?

UNLABELLED: Difficulties in emotion regulation (ER) are present in psychotic disorders, but their precise nature is not yet fully understood and it is unclear which difficulties are unique to psychosis compared with other disorders. This study investigated whether ER difficulties in psychosis are more prominent for the ability to modify emotions or for the ability to tolerate and accept them. Furthermore, it investigated whether ER difficulties occur for sadness, anxiety, anger and shame likewise. ER skills were assessed in participants with psychotic disorders (n = 37), participants with depression (n = 30) and healthy controls (n = 28) using the Emotion Regulation Skill Questionnaire that asks participants to rate the intensity of different emotions over the past week and the skills employed to handle each of them. Compared with healthy controls, participants with psychosis showed reduced skills related to awareness, understanding and acceptance of potentially distressing emotions, but not in the ability to modify them. These differences remained significant after controlling for depression. Participants with psychosis showed reduced ER skills in regard to all of the assessed emotions compared with the healthy controls, despite the fact that they only reported sadness as being significantly more intense. The participants with depression showed a similar pattern of ER skills to the psychosis sample, although with a tendency towards even more pronounced difficulties. It is concluded that psychosis is characterized by difficulties in using specific ER skills related to awareness, understanding and acceptance to regulate anger, shame, anxiety and sadness. These difficulties are not unique to psychosis but nevertheless present a promising treatment target. KEY PRACTITIONER MESSAGE: The participants with psychosis found it more difficult to be aware of their emotions, to understand them and to accept them than the healthy control group. However, they reported equal skills when it came to actively modifying emotions. The difficulties in emotion regulation reported by the participants with psychosis were comparable with those reported by the participants with depression, and they occurred for all types of negative emotions likewise. The difficulties in using specific ER skills related to awareness, understanding and acceptance are a promising target for psychological treatment of psychosis. Interventions that are aimed specifically at increasing these skills need to be further developed.

Efficacy of a psychological online intervention for depression in people with epilepsy: a randomized controlled trial.

OBJECTIVE: Depression is the most prevalent psychiatric disorder in persons with epilepsy (PWEs). Despite its major impact on quality of life and risk of suicide, most PWEs are not treated for depression. A current challenge in mental health care is how to close this treatment gap and increase access to psychological services. Psychological online interventions (POIs) have shown efficacy in improving depression among individuals without neurologic disorders. This pilot study aimed to assess the feasibility and efficacy of a psychological online intervention for depression (Deprexis) in PWEs who have symptoms of depression. METHODS: Participants with self-reported epilepsy and subjective complaints of depressive symptoms were randomized to an intervention condition (Deprexis) or to a waiting list control (WLC) condition. After 9 weeks, participants were invited to complete an online reassessment. RESULTS: Relative to the waiting list group, program users experienced a significant symptom decline on the Beck Depression Inventory - I (BDI-I, primary outcome) with a moderate effect size in the complete observations analysis and a small effect size in the intention-to-treat analysis. Furthermore, there was a significant improvement with a moderate effect size on the "energy/fatigue" subscale of the Quality of Life In Epilepsy Inventory - 31 (QOLIE-31). SIGNIFICANCE: The results of this trial suggest that POIs may be a feasible and beneficial tool for PWEs who have comorbid depressive symptoms.

"Don't give me that look" - overconfidence in false mental state perception in schizophrenia.

Dysfunctions in social cognition are implicated in the pathogenesis of schizophrenia and have been extensively replicated over the years. For memory research, the administration of cognitive tasks with metacognitive aspects like confidence ratings has deepened our insight into how impairments contribute to symptoms of the disorder. A total of 76 patients with schizophrenia or schizoaffective disorder and a sample of 30 healthy participants were tested with the Reading the Mind in the Eyes test (Eyes-test). The Eyes-test was complemented with a rating scale requesting response confidence and was administered along with paradigms tapping neuropsychological parameters and cognitive insight. Schizophrenia patients showed impaired abilities on mental state perception. In addition, they committed more high-confidence errors and at the same time made fewer high-confidence correct responses. Impairments were most pronounced in patients with formal thought disorder. The patients displayed a decreased metacognitive awareness for their deficits. The results suggest that adding confidence ratings to the investigation of social cognition promises to advance our understanding of social cognition in schizophrenia. Patients not only show severe impairments in social cognition, but are overconfident in their judgments and lack cognitive insight into their deficits. The results highlight the need for metacognitive therapeutic approaches for the treatment of this population.

Normal mind-reading capacity but higher response confidence in borderline personality disorder patients.

AIM: Borderline personality disorder (BPD) is characterized by a pattern of instability in interpersonal relationships. Therefore, the investigation of social cognition is of compelling interest for the understanding of BPD. One important aspect of social cognition is theory of mind (ToM), which describes the ability to understand others' mental states, such as beliefs, desires and intentions. The aim of the present study was to further investigate ToM in BPD patients. METHODS: The Reading the Mind in the Eyes Test was assessed in 31 BPD patients and 27 healthy controls. In addition, the test was complemented by a response confidence rating. RESULTS: BPD patients and healthy controls did not differ in their mind-reading ability with respect to accuracy, but patients were significantly more often highly confident in their decisions than controls. CONCLUSIONS: Overconfidence might contribute to the severe difficulties in interpersonal relationships often observed in BPD patients.

Emotion perception and overconfidence in errors under stress in psychosis.

Vulnerability stress models are well-accepted in psychosis research, but the mechanisms that link stress to psychotic symptoms remain vague. Little is known about how social cognition and overconfidence in errors, two putative mechanisms for the pathogenesis of delusions, relate to stress. Using a repeated measures design, we tested four groups (N=120) with different liability to psychosis (schizophrenia patients [n=35], first-degree relatives [n=24], participants with attenuated positive symptoms [n=19] and healthy controls [n=28]) and depression patients (n=14) as a clinical control group under three randomized experimental conditions (no stress, noise and social stress). Parallel versions of the Emotion Perception and Confidence Task, which taps both emotion perception and confidence, were used in each condition. We recorded subjective stress, heart rate, skin conductance level and salivary cortisol to assess the stress response across different dimensions. Independent of the stress condition, patients with schizophrenia showed poorer emotion perception performance and higher confidence in emotion perception errors than participants with attenuated positive symptoms and healthy controls. However, they did not differ from patients with depression or first-degree relatives. Stress did not influence emotion perception or the extent of high-confident errors, but patients with schizophrenia showed an increase in high-confident emotion perception errors conditional on higher arousal. A possible clinical implication of our findings is the necessity to provide stress management programs that aim to reduce arousal. Moreover, patients with schizophrenia might benefit from interventions that help them to reduce overconfidence in their social cognition judgements in times in which they feel being under pressure.

Emotion recognition in depression: An investigation of performance and response confidence in adult female patients with depression.

Abnormalities in emotion recognition are frequently reported in depression. However, emotion recognition is not compromised in some studies, and confidence judgments, which are essential for social interaction, have not been considered to date. Due to the high prevalence rate of depression in women, and sex differences in emotion recognition, the aim of the present study was to investigate emotion recognition and confidence judgments in women with depression. A sample of female patients with depressive disorders (n=45) was compared with female healthy controls (n=30) in their ability to correctly identify facial emotion expressions along with confidence judgments. Groups performed similarly on emotional face recognition and showed no difference regarding confidence ratings. A negative correlation between self-assessed depression and response confidence was found. While some limitations of the study must be taken in consideration (e.g., small number of items per emotion category, low severity of depression), abnormalities in emotion recognition do not seem to be a major feature of depression. As self-assessed depression is accompanied by low response confidence for emotional faces, it is crucial to further examine the role of confidence judgments in emotion recognition, as underconfidence may foster interpersonal insecurity in depression.

Preliminary Results on Acceptance, Feasibility, and Subjective Efficacy of the Add-On Group Intervention Metacognitive Training for Borderline Patients.

OBJECTIVE: The add-on intervention "metacognitive training for borderline patients (B-MCT)" targets cognitive biases in patients with borderline personality disorder (BPD). We aimed to evaluate acceptance, feasibility, and subjective use of this group intervention. METHODS: Forty-eight inpatients with BPD were randomly assigned to 8 sessions of B-MCT versus an active control intervention (progressive muscle relaxation). Subjective use was assessed after 4 weeks. RESULTS: B-MCT yielded significantly superior scores relative to the control group on several parameters, for example, use, fun, recommendation, and subjective improvements in symptomatology and cognitive abilities (e.g., perspective taking). CONCLUSIONS: The trial provides preliminary evidence for the acceptance and feasibility of metacognitive training in BPD. However, randomized controlled trials with larger samples and symptomatic outcomes are needed to investigate the specific impact of B-MCT on psychopathology and cognition.

Dealing with feeling: Specific emotion regulation skills predict responses to stress in psychosis.

Elevated negative affect is an established link between minor stressors and psychotic symptoms. Less clear is why people with psychosis fail to regulate distressing emotions effectively. This study tests whether subjective, psychophysiological and symptomatic responses to stress can be predicted by specific emotion regulation (ER) difficulties. Participants with psychotic disorders (n=35) and healthy controls (n=28) were assessed for ER-skills at baseline. They were then exposed to a noise versus no stressor on different days, during which self-reported stress responses, state paranoia and skin conductance levels (SCL) were assessed. Participants with psychosis showed a stronger increase in self-reported stress and SCL in response to the stressor than healthy controls. Stronger increases in self-reported stress were predicted by a reduced ability to be aware of and tolerate distressing emotions, whereas increases in SCL were predicted by a reduced ability to be aware of, tolerate, accept and modify them. Although paranoid symptoms were not significantly affected by the stressors, individual variation in paranoid responses was also predicted by a reduced ability to be aware of and tolerate emotions. Differences in stress responses in the samples were no longer significant after controlling for ER skills. Thus, interventions that improve ER-skills could reduce stress-sensitivity in psychosis.

Responses to stress in patients with psychotic disorders compared to persons with varying levels of vulnerability to psychosis, persons with depression and healthy controls.

BACKGROUND AND OBJECTIVES: An experimental design was used to test whether self-reported, psychophysiological and symptomatic stress-responses increase as a function of the underlying vulnerability to psychosis as proposed by vulnerability-stress-models. METHODS: Stress-responses of participants with psychotic disorders (PSY, n = 35) were compared to those of participants with attenuated positive symptoms (AS, n = 29), first-degree relatives of persons with psychotic disorders (REL, n = 26), healthy controls (HC, n = 28) and controls with depression (DEP, n = 30). Using a repeated measures design, participants were assigned to a noise stressor, a social stressor and a no stress condition in random order. Stress-responses were assessed via self-report, salivary cortisol levels, heart rate and skin conductance levels. State-paranoia and depression were assessed with clinical scales. RESULTS: PSY reported to be significantly more stressed than HC, AS and REL across all conditions which went along with increased heart rate and decreased overall cortisol release. In contrast, AS showed elevated levels of cortisol. PSY showed a stronger response of self-reported stress to the noise condition compared to the no stress condition than HC, but no stronger response than the other samples. Furthermore, the stressors did not trigger stronger psychophysiological responses or symptom-increases in PSY. LIMITATIONS: The social stressor was brief and not individualized and did not have an effect on cortisol. CONCLUSIONS: The findings support the notion that subjective stress-responsiveness increases with vulnerability, but not the assumption that symptoms arise directly as a function of stress and vulnerability. Also, the generally high levels of arousal seem to be more relevant to psychosis than the responsiveness to specific stressors.

Bridging psychophysiological and phenomenological characteristics of psychosis--Preliminary evidence for the relevance of emotion regulation.

In psychosis, the alleged increased subjective stress-sensitivity is reflected in abnormal physiological arousal such as higher heart rate, elevated skin conductance levels, decreased vagal activity, and unusual cortisol levels. Despite ongoing research, possible mechanisms that explain the interplay between the phenomenological (i.e., subjective stress and symptoms) and psychophysiological processes are not thoroughly understood. Building on the model of neurovisceral integration by Thayer and Lane (2000) that focuses on regulative mechanisms, we postulate that emotion regulation will be associated with vagal activity, and with both subjective and physiological stress. In the present analysis, we used data from a baseline relaxation period including a 5-minute assessment of heart rate variability (HRV), salivary cortisol, and momentary subjective stress ratings from a sample of 19 participants with psychosis (mean age=40.9, SD=11.1; 36.8% female). Emotion regulation modification skills were assessed for specific emotions (i.e., stress and arousal, anxiety, anger, sadness, shame) if these were present during the previous week. Vagal HRV was significantly and moderately associated with emotion regulation. Both stress parameters (i.e., cortisol, subjective stress) were significantly associated with emotion regulation, but not with HRV. We provide preliminary support for the notion that emotion regulatory processes represent a crucial link between phenomenological and psychophysiological phenomena in psychosis. A potential model that ascribes emotion regulation a central role in the restoration of homeostasis is discussed. Future studies are needed to verify its generalizability and predictive value.

Development of a questionnaire measuring Attitudes towards Psychological Online Interventions-the APOI.

BACKGROUND: Only a minority of people suffering from depression receive adequate treatment. Psychological Online Interventions (POIs) could help bridge existing treatment gaps and augment the effectiveness of current treatments. Apart from effectiveness, user acceptance of POIs must be achieved if such interventions are to be broadly implemented in existing health-care. Valid measurement tools examining attitudes towards POIs are lacking. Therefore, we examined the dimensionality of attitudes towards POIs, developed a novel questionnaire, the Attitudes towards Psychological Online Interventions Questionnaire (APOI), and gathered data to examine its reliability. METHODS: We recruited a sample of 1004 adults with mild to moderate depressive symptoms from a range of sources. We constructed a set of 35 items based on literature review as well as expert and patient queries. The initial items were subjected to an exploratory factor analysis (EFA) in a randomly selected subsample. A final set of 16 items was subjected to a confirmatory factor analysis (CFA) to cross-validate the factor structure in a separate subsample. RESULTS: The EFA revealed four dimensions: "Scepticism and Perception of Risks", "Confidence in Effectiveness", "Technologization Threat" and "Anonymity Benefits". The model fit in the CFA was excellent relating to all applied indices (χ(2)=105.816, p=.651; SRMR=.042; RMSEA=.013; CFI=.994) and the APOI total scale showed acceptable to good internal consistency. CONCLUSIONS: Further research with the APOI might facilitate the development and dissemination of POIs and, ultimately, help improve the quality of care for people experiencing depressive symptoms.

Altered autonomic arousal in psychosis: an analysis of vulnerability and specificity.

Vulnerability-stress models implicate that alterations of the autonomous nervous system contribute to the development of psychosis. Previous research has found autonomic arousal alterations in psychotic disorders and at-risk individuals that are not explained by medication alone. To test whether these alterations are associated with the extent of an individual's vulnerability and whether they are specific to psychosis, we compared participants with psychosis (n=23), first-degree relatives of individuals with psychosis (n=21), and healthy participants with attenuated positive symptoms (n=23) to participants with depression (n=24) and healthy controls (n=24). At rest, skin conductance level was assessed and photoplethysmography was applied to measure time- and frequency-domain heart rate variability (HRV). Univariate and multivariate analyses of covariance with perceived stress and psychophysiological values as dependent variables showed significant between-group differences for perceived stress (p=.010), heart rate (p=.022), time-domain HRV indices (all ps≤.027), and vagal activity (p=.017). Group differences in sympathetic activity were nonsignificant (p=.069). In an additional analysis with medication as a second between-group factor, the physiological between-group differences remained significant or trend significant (all ps≤.060). With the exception of sympathetic activity, participants with psychosis exhibited more extreme arousal than the control groups. First-degree relatives and participants with attenuated symptoms showed comparable autonomic activity to healthy controls. Thus, the hypothesized association of an alteration of arousal and vulnerability to psychosis was not confirmed. However, particularly low time-domain HRV was found for psychosis, with significant differences to healthy controls (all ps≤.007) and to depression (all ps≤.004), with the latter indicating a specificity to psychosis.

Investigation of the role of the jumping-to-conclusions bias for short-term functional outcome in schizophrenia.

Symptom severity and neuropsychological deficits negatively influence functional outcomes in patients with schizophrenia. Recent research implicates specific types of biased thinking styles (e.g. jumping-to-conclusions) in the pathogenesis of schizophrenia. This is the first study to test the impact of jumping-to-conclusions on functional outcome in schizophrenia. The aim of the study was to investigate the association of psychopathology, neuropsychology and JTC with subjective quality of life, vocational outcome and housing status in schizophrenia. Analyses were carried out both cross-sectionally at baseline, and longitudinally over the course of symptomatic improvement in the immediate aftermath of a psychotic exacerbation. Seventy-nine patients with schizophrenia were included in the study. Data concerning the variables of interest were collected at baseline, after one month, and after six months. Positive symptomatology was the most significant predictor of subjective and vocational outcome and changes across time. Verbal memory deficits were associated with functional status cross-sectionally, whereas general cognitive capacity significantly predicted functional changes over time. Improvement of the jumping-to-conclusions bias positively affected vocational outcome. Though limited, the observed effect of this bias on real-world functioning highlights the possible usefulness of interventions aimed at improving (meta)cognitive deficits in schizophrenia.

Can virtual reality reduce reality distortion? Impact of performance feedback on symptom change in schizophrenia patients.

BACKGROUND AND OBJECTIVES: There is emerging evidence that the induction of doubt can reduce positive symptoms in patients with schizophrenia. Based on prior investigations indicating that brief psychological interventions may attenuate core aspects of delusions, we set up a proof of concept study using a virtual reality experiment. We explored whether feedback for false judgments positively influences delusion severity. METHODS: A total of 33 patients with schizophrenia participated in the experiment. Following a short practice trial, patients were instructed to navigate through a virtual street on two occasions (noise versus no noise), where they met six different pedestrians in each condition. Subsequently, patients were asked to recollect the pedestrians and their corresponding facial affect in a recognition task graded for confidence. Before and after the experiment, the Paranoia Checklist (frequency subscale) was administered. RESULTS: The Paranoia Checklist score declined significantly from pre to post at a medium effect size. We split the sample into those with some improvement versus those that either showed no improvement, or worsened. Improvement was associated with lower confidence ratings (both during the experiment, particularly for incorrect responses, and according to retrospect assessment). LIMITATIONS: No control condition, unclear if improvement is sustained. DISCUSSION: The study tentatively suggests that a brief virtual reality experiment involving error feedback may ameliorate delusional ideas. Randomized controlled trials and dismantling studies are now needed to substantiate the findings and to pinpoint the underlying therapeutic mechanisms, for example error feedback or fostering attenuation of confidence judgments in the face of incomplete evidence.

Sustained and "sleeper" effects of group metacognitive training for schizophrenia: a randomized clinical trial.

IMPORTANCE: Cognitive interventions increasingly complement psychopharmacological treatment to enhance symptomatic and functional outcome in schizophrenia. Metacognitive training (MCT) is targeted at cognitive biases involved in the pathogenesis of delusions. OBJECTIVE: To examine the long-term efficacy of group MCT for schizophrenia in order to explore whether previously established effects were sustained. DESIGN, SETTING, AND PARTICIPANTS: A 2-center, randomized, controlled, assessor-blind, parallel group trial was conducted. A total of 150 inpatients or outpatients with DSM-IV diagnoses of schizophrenia spectrum disorders were enrolled. All patients were prescribed antipsychotic medication. The second follow-up assessment took place 3 years later after the intervention phase was terminated. INTERVENTIONS: Group MCT targeting cognitive biases vs neuropsychological training (COGPACK). Patients received a maximum of 16 sessions. MAIN OUTCOMES AND MEASURES: The primary outcome measure was a delusion score derived from the Positive and Negative Syndrome Scale (PANSS). The PANSS positive syndrome and total scores, the Psychotic Symptom Rating Scales, the jumping to conclusions bias, self-esteem, and quality of life served as secondary outcome measures. RESULTS: The intention-to-treat analyses demonstrated that patients in the MCT group had significantly greater reductions in the core PANSS delusion score, after 3 years compared with the control group (η2partial = .037; P = .05). Among the secondary outcomes, the intention-to-treat analyses also demonstrated that patients in the MCT group had significantly greater reductions in the PANSS positive syndrome score (η2partial = .055; P = .02) and the Psychotic Symptom Rating Scales delusion score (η2partial = .109; P = .001). Significant group differences at the 3-year follow-up were also found on measures of self-esteem and quality of life, which did not distinguish groups at earlier assessment points. Attention was improved in the neuropsychological training group relative to the MCT group. The completion rate was 61.3% after 3 years. CONCLUSIONS AND RELEVANCE: Metacognitive training demonstrated sustained effects in the reduction of delusions, which were over and above the effects of antipsychotic medication. Moreover, there were some unanticipated ("sleeper") effects as both self-esteem and quality of life were improved after 3 years. Effects on self-esteem and well-being were found even in the absence of an improvement on the jumping to conclusions bias. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN95205723.

Can we trust the internet to measure psychotic symptoms?

Online studies are increasingly utilized in applied research. However, lack of external diagnostic verification in many of these investigations is seen as a threat to the reliability of the data. The present study examined the robustness of internet studies on psychosis against simulation. We compared the psychometric properties of the Community Assessment of Psychic Experiences scale (CAPE), a self-report instrument measuring psychotic symptoms, across three independent samples: (1) participants with a confirmed diagnosis of schizophrenia, (2) participants with self-reported schizophrenia who were recruited over the internet, and (3) clinical experts on schizophrenia as well as students who were asked to simulate a person with schizophrenia when completing the CAPE. The CAPE was complemented by a newly developed 4-item psychosis lie scale. Results demonstrate that experts asked to simulate schizophrenia symptoms could be distinguished from real patients: simulators overreported positive symptoms and showed elevated scores on the psychosis lie scale. The present study suggests that simulated answers in online studies on psychosis can be distinguished from authentic responses. Researchers conducting clinical online studies are advised to adopt a number of methodological precautions and to compare the psychometric properties of online studies to established clinical indices to assert the validity of their results.

Predictors of early stable symptomatic remission after an exacerbation of schizophrenia: the significance of symptoms, neuropsychological performance and cognitive biases.

Neuropsychological deficits and severity of initial psychopathology have been repeatedly associated with poor symptomatic outcomes in schizophrenia. The role of higher-order cognitive biases on symptomatic outcomes of the disorder has not yet been investigated. The present study aimed to assess the contribution of cognitive biases, psychopathology and neuropsychological deficits on the probability of achieving early symptomatic remission after a psychotic episode in patients with schizophrenia. Participants were 79 patients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder undergoing an acute psychotic episode, and 25 healthy controls. According to psychopathology assessments, patients were split into those who had achieved remission after an average follow-up interval of 7 months, and those who had not (NR). Patients who achieved remission exhibited higher premorbid IQ and better performance on the TMT-B, as well as lower baseline positive, disorganized and distress symptoms than NR patients. TMT-B performance and positive symptoms at baseline were the best predictors of remission. Cognitive biases and negative symptoms were not associated with later remission. The findings highlight the significance of initial symptom severity for at least short-term symptomatic outcomes and, thus, the importance of adequate symptomatic treatment and prevention of psychotic outbreaks in patients.

Complementary group Metacognitive Training (MCT) reduces delusional ideation in schizophrenia.

BACKGROUND: Symptom reduction under antipsychotic agents is incomplete for most schizophrenia patients. In order to enhance outcome, cognitive approaches are increasingly adopted as add-on interventions. The present study aimed to determine the efficacy of group Metacognitive Training (MCT), which targets cognitive biases putatively involved in the pathogenesis of delusions. METHODS: A two-center, randomized, assessor-blind, controlled trial between MCT group training and cognitive training was carried out (ISRCTN95205723). A total of 150 in- and outpatients with DSM diagnoses of schizophrenia spectrum disorders were enrolled. All patients were concurrently prescribed antipsychotic medication. Assessments were made at baseline, four weeks and six months later. The primary outcome was a delusion score derived from the Positive and Negative Syndrome Scale (PANSS). The Psychotic Symptom Rating Scales (PSYRATS) as well as cognitive measures served as secondary outcomes. RESULTS: Completion at follow-up was 86%. According to intention-to-treat (ITT) analyses, patients in the MCT group showed significantly greater symptom reduction on the PANSS delusion subscore (follow-up), PANSS positive score (post-treatment) and PSYRATS delusion score (post-treatment and follow-up). Improvement on the PANSS positive scale at post-treatment and follow-up was positively correlated with the number of attended MCT sessions. No changes were seen for other psychopathological syndromes. DISCUSSION: MCT, a low-intensity training aimed at enhancing patients' awareness of cognitive biases subserving paranoia, led to improvement in delusion symptoms relative to the control condition and over and above the effects of antipsychotic medication. This improvement was sustained at follow-up.

Response confidence for emotion perception in schizophrenia using a Continuous Facial Sequence Task.

Deficits in emotion perception and overconfidence in errors are well-documented in schizophrenia but have not been examined concurrently. The present study aimed to fill this gap. Twenty-three schizophrenia patients and twenty-nine healthy subjects underwent a Continuous Facial Sequence Task (CFST). The CFST comprised two blocks: a female (1st block) and a male protagonist (2nd block) displayed the six basic emotions postulated by Ekman as well as two more complex mental states and a neutral expression. Participants were first asked to identify the affect displayed by the performer and then to judge their response confidence. No group differences emerged regarding overall emotion perception. Follow-up analyses showed that patients were less correct in detecting some negative emotions but performed better for neutral or positive emotions. Regarding confidence, incorrect decisions in patients were associated with higher confidence than in controls (statistical trend level, moderate effect size). Patients displayed significant overconfidence in errors for negative emotions. In addition, patients were more prone to high-confident errors for emotions that were displayed in weak emotional intensity. While the study supports the view that the examination of confidence adds unique information to our understanding of social cognition, several methodological limitations render its findings preliminary.