A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight.

Poor insight in schizophrenia spectrum disorders (SSD) is linked with negative outcomes. This single-centre, assessor-blind, parallel-group 1-year follow-up randomised controlled trial (RCT) tested whether metacognitive training (MCT) (compared to psychoeducation) may improve insight and outcomes in outpatients with SSD assessed: at baseline (T0); after treatment (T1) and at 1-year follow-up (T2). Insight (primary outcome) was measured with (i) the Schedule for Assessment of Insight-Expanded version- (SAI-E), including illness recognition (IR), symptom relabelling (SR), treatment compliance (TC) and total insight scores (TIS); and (ii) the Beck Cognitive Insight Scale (BCIS). Between-group comparisons were nonsignificant, while within the MCT group (but not within controls) there was a significant medium effect size for improved TIS at T2 (d = 0.67, P = 0.02). Secondary outcomes included cognitive measures: Jumping to Conclusions (JTC), Theory of Mind (ToM), plus symptom severity and functioning. Compared to psychoeducation, MCT improved the PANSS excitement (d = 1.21, P = 0.01) and depressed (d = 0.76, P = 0.05) factors at T2; and a JTC task both at T1 (P = 0.016) and at T2 (P = 0.031). Participants in this RCT receiving MCT showed improved insight at 1-year follow-up, which was associated with better mood and reduced JTC cognitive bias. In this pilot study, no significant benefits on insight of MCT over psychoeducation were detected, which may have been due to insufficient power.

Investigating the Contribution of Decision-Making, Cognitive Insight, and Theory of Mind in Insight in Schizophrenia: A Cross-Sectional Study.

INTRODUCTION: Insight in schizophrenia spectrum disorders (SSD) is associated with outcomes. Although the neurocognitive basis of insight is widely accepted, the specific contribution of decision-making (Jumping to Conclusions [JTC]), Cognitive Insight (CI), and Theory of Mind (ToM) to insight remains unclear. METHODS: The sample included N = 77 SSD outpatients aged 18-64 years from a randomized controlled trial of metacognitive training. Assessments included JTC-Beads Task, CI-Beck Cognitive Insight Scale, ToM-Hinting Task, and the Emotions Recognition Test Faces. STATISTICS: hierarchical multivariable linear regression models tested their contribution to total insight (TI) and three insight dimensions - illness recognition (IR), symptom relabelling (SR), and treatment compliance (TC) - measured with the Schedule for the Assessment of Insight - Expanded version, whilst adjusting for potential confounders. RESULTS: Bivariate analyses showed that CI was associated with TI (R2 change = 0.214; p < 0.001), IR (R2 change = 0.154; p = 0.003), and SR (R2 change = 0.168; p = 0.003), while JTC predicted IR (R2 change = 0.790; p = 0.020). Multivariable regression models showed that CI predicted TI (R2 change = 0.116; p = 0.036) and SR (R2 change = 0.166, p = 0.011), whereas JTC was linked with IR (R2 change = 0.710; p = 0.026). ToM was not linked with any insight score. No cognitive variable was associated with treatment compliance. DISCUSSION: Results supported the (meta)cognitive model of insight in SSD. JTC and CI emerged as the main (meta)cognitive processes underlying insight. Metacognitive interventions may therefore improve insight in SSD, although these therapies alone may fail to address treatment compliance.

Investigating the Role of Insight, Decision-Making and Mentalizing in Functional Outcome in Schizophrenia: A Cross-Sectional Study.

BACKGROUND: Recovery has become a priority in schizophrenia spectrum disorders (SSDs). This study aimed to investigate predictors of objective-general functioning and disability-and subjective-quality of life (QoL)-measures of functional outcomes in SSD. METHODS: Sample: n = 77 SSD outpatients (age 18-64, IQ > 70) participating in a randomised controlled trial. Baseline data were used to build three multivariable linear regression models on: (i) general functioning-General Assessment of Functioning (GAF); (ii) disability-the World Health Organization Disability Assessment Schedule (WHODAS-2.0); and (iii) QoL-Satisfaction Life Domains Scale (SLDS). RESULTS: Young age and being employed (R2 change = 0.211; p = 0.001), late adolescence premorbid adjustment (R2 change = 0.049; p = 0.0050), negative symptoms and disorganization (R2 change = 0.087; p = 0.025) and Theory of Mind (R2 change = 0.066, p = 0.053) predicted general functioning. Previous suicidal behaviour (R2 change = 0.068; p = 0.023) and negative and depressive symptoms (R2 change = 0.167; p = 0.001) were linked with disability. Previous suicidal behaviour (R2 change = 0.070, p = 0.026), depressive symptoms (R2 change = 0.157; p < 0.001) and illness recognition (R2 change = 0.046, p = 0.044) predicted QoL. CONCLUSIONS: Negative, disorganization and depressive symptoms, older age, unemployment, poor premorbid adjustment, previous suicide attempts and illness awareness appear to underlie a poor global functional outcome in SSD. Achieving recovery in SSD appears to require both symptomatic remission (e.g., through antipsychotics) and measures to improve mastery and relieve low mood.

Use of Ecological Momentary Assessment Through a Passive Smartphone-Based App (eB2) by Patients With Schizophrenia: Acceptability Study.

BACKGROUND: Ecological momentary assessment (EMA) tools appear to be useful interventions for collecting real-time data on patients' behavior and functioning. However, concerns have been voiced regarding the acceptability of EMA among patients with schizophrenia and the factors influencing EMA acceptability. OBJECTIVE: The aim of this study was to investigate the acceptability of a passive smartphone-based EMA app, evidence-based behavior (eB2), among patients with schizophrenia spectrum disorders and the putative variables underlying their acceptance. METHODS: The participants in this study were from an ongoing randomized controlled trial (RCT) of metacognitive training, consisting of outpatients with schizophrenia spectrum disorders (F20-29 of 10th revision of the International Statistical Classification of Diseases and Related Health Problems), aged 18-64 years, none of whom received any financial compensation. Those who consented to installation of the eB2 app (users) were compared with those who did not (nonusers) in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight, and metacognitive variables. A multivariable binary logistic regression tested the influence of the above (independent) variables on "being user versus nonuser" (acceptability), which was the main outcome measure. RESULTS: Out of the 77 RCT participants, 24 (31%) consented to installing eB2, which remained installed till the end of the study (median follow-up 14.50 weeks) in 14 participants (70%). Users were younger and had a higher education level, better premorbid adjustment, better executive function (according to the Trail Making Test), and higher cognitive insight levels (measured with the Beck Cognitive Insight Scale) than nonusers (univariate analyses) although only age (OR 0.93, 95% CI 0.86-0.99; P=.048) and early adolescence premorbid adjustment (OR 0.75, 95% CI 0.61-0.93; P=.01) survived the multivariable regression model, thus predicting eB2 acceptability. CONCLUSIONS: Acceptability of a passive smartphone-based EMA app among participants with schizophrenia spectrum disorders in this RCT where no participant received financial compensation was, as expected, relatively low, and linked with being young and good premorbid adjustment. Further research should examine how to increase EMA acceptability in patients with schizophrenia spectrum disorders, in particular, older participants and those with poor premorbid adjustment. TRIAL REGISTRATION: ClinicalTrials.gov NCT04104347; https://clinicaltrials.gov/ct2/show/NCT04104347.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis.

BACKGROUND: Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved. METHODS: We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up. RESULTS: Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = -0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results. CONCLUSIONS: Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.

[Severe hyponatremia secondary to Phyllomedusa bicolor (Kambó frog) poisoning. Report of one case]. / Hiponatremia grave secundaria a la exposición a veneno de Phyllomedusa Bicolor (Rana Kambó). Caso clínico.

Phyllomedusa bicolor or Kambo is a frog that lives in the Amazon rainforest. It can release through its skin a substance used in healing rituals that are common among South-American tribes, as well as in urban people of America and Europe. We report a 41-year-old female patient who, during a healing ritual consumed ayahuasca (a drink obtained from the mixture of Banisteriopsis caapi, Psychotria viridis and Mimosa hostilis) and 12 hours later received the poison of Kambo Frog (Phyllomedusa bicolor) on superficial right shoulder skin burns. The ritual included a minimum of six-liter water intake over a few hours period. She evolved with clouding of sensorium, motor agitation, frequent vomiting, and generalized tonic-clonic seizures. She presented lethargic to the emergency room, with a weak pupillary light reflex, generalized stiffness, moving all four limbs. Laboratory showed severe hyponatremia (120 mEq/L) and a creatine kinase level of 8,479 UI/L, that increased 107,216 IU/L within few days. An admission CT Brain scan was normal. The toxicological screening did not identify the presence of other substances. During hospitalization the patient developed severe psychomotor agitation controlled by a dexmedetomidine infusion, hyponatremia, low plasma osmolality (248 mOsm/kg), and disproportionately high urinary osmolality (448 mOsm/kg), suggestive of inappropriate antidiuretic hormone secretion syndrome (SIADH). With correction of hyponatremia, the patient gradually recovered consciousness. Rhabdomyolysis was assumed to be secondary to seizure and managed by volume and bicarbonate infusions with a positive response.

Hiponatremia grave secundaria a la exposición a veneno de Phyllomedusa Bicolor (Rana Kambó): caso clínico / Severe hyponatremia secondary to Phyllomedusa bicolor (Kambó frog) poisoning: report of one case

Phyllomedusa bicolor or Kambo is a frog that lives in the Amazon rainforest. It can release through its skin a substance used in healing rituals that are common among South-American tribes, as well as in urban people of America and Europe. We report a 41-year-old female patient who, during a healing ritual consumed ayahuasca (a drink obtained from the mixture of Banisteriopsis caapi, Psychotria viridis and Mimosa hostilis) and 12 hours later received the poison of Kambo Frog (Phyllomedusa bicolor) on superficial right shoulder skin burns. The ritual included a minimum of six-liter water intake over a few hours period. She evolved with clouding of sensorium, motor agitation, frequent vomiting, and generalized tonic-clonic seizures. She presented lethargic to the emergency room, with a weak pupillary light reflex, generalized stiffness, moving all four limbs. Laboratory showed severe hyponatremia (120 mEq/L) and a creatine kinase level of 8,479 UI/L, that increased 107,216 IU/L within few days. An admission CT Brain scan was normal. The toxicological screening did not identify the presence of other substances. During hospitalization the patient developed severe psychomotor agitation controlled by a dexmedetomidine infusion, hyponatremia, low plasma osmolality (248 mOsm/kg), and disproportionately high urinary osmolality (448 mOsm/kg), suggestive of inappropriate antidiuretic hormone secretion syndrome (SIADH). With correction of hyponatremia, the patient gradually recovered consciousness. Rhabdomyolysis was assumed to be secondary to seizure and managed by volume and bicarbonate infusions with a positive response.