Assessing metacognitive and help-seeking strategies in schizophrenia: design and psychometric validation of the Versailles Metacognitive Strategies Evaluation Questionnaire.

OBJECTIVES: The aim of this study is to design a questionnaire, the Versailles Metacognitive Strategies Evaluation Questionnaire, for assessing the use of metacognitive and help-seeking strategies in three key-domains of impaired daily functioning in schizophrenia. To evaluate its psychometric properties (internal consistency, factor structure, convergent and divergent validity, and stability). DESIGN: Development of a questionnaire and psychometric validation procedure in patients with schizophrenia compared with healthy controls. Stability over one year was assessed in the patient group. SETTING: Schizophrenia Centers of Expertise (French FondaMental Network). SUBJECTS: A total of 141 patients with schizophrenia, among whom 77 participated in the second evaluation; 97 healthy subjects. MAIN MEASURES: The Versailles Metacognitive Strategies Evaluation Questionnaire, Positive and Negative Symptoms Scale, Personal and Social Performance Scale, Evaluation of Cognitive Processes involved in Disability in Schizophrenia Scale, Schizophrenia Quality of Life Questionnaire, and Stages of Recovery Instrument. RESULTS: From the 36-items version, stepwise exploratory factor analysis (oblimin) produced a 25-items scale which had a 3-factors structure (hygiene concern, social relationships, and hygiene help-seeking). Cronbach's were respectively equal to 0.91, 0.82, and 0.78. One-year stability was good (intra-class correlation coefficient = 0.7). The three factors showed good convergent validity with measures of quality of life (rho = 0.34, P ⩽ 0.001). The first two factors correlated with recovery (N = 34, rho = 0.53, P ⩽ 0.001). On the contrary, the factors exhibited divergent validity, with no significant correlation, with symptoms and cognitive and psychosocial functioning (P > 0.05). Factor structure in healthy controls did not match with that of patients, all items but one were found significantly different among groups. CONCLUSION: The Versailles Metacognitive Strategies Evaluation Questionnaire provides a simple and valid means to assess metacognitive strategies in individuals with schizophrenia.

Outcome prediction with a social cognitive battery: a multicenter longitudinal study.

The interest in social cognition in schizophrenia is justified by the relationship between deficits in these skills and negative functional outcomes. Although assessment batteries have already been described, there is no consensus about which measures are useful in predicting patient functioning or quality of life (QoL). We investigated a set of five measures of recognition of facial emotions, theory of mind (ToM), and empathy in a cohort of 143 patients with schizophrenia or schizoaffective disorder at inclusion and, amongst whom 79 were reassessed 1 year later. The distribution was satisfactory for the TREF (Facial Emotion Recognition Task), V-SIR (Versailles-Situational Intention Reading), and QCAE (Questionnaire of Cognitive and Affective Empathy). Internal consistency was satisfactory for the TREF, V-SIR, V-Comics (Versailles Intention Attribution Task), and QCAE. Sensitivity to change was acceptable for the TREF. The TREF and V-SIR showed a cross-sectional relationship with functioning beyond the clinical symptoms of schizophrenia but not beyond neurocognition. Moreover, the TREF and V-SIR at inclusion could not predict functioning one year later, whereas most neurocognitive and clinical dimensions at inclusion could. Finally, only affective QCAE showed a significant cross-sectional, but not longitudinal, association with QoL. In conclusion, the TREF had satisfactory psychometric properties and showed a cross-sectional, but not longitudinal, association with objective outcome measures, thus appearing to be reliable in clinical practice and research. The V-SIR also showed promising psychometric properties, despite a possible weakness to detect change. However, these measures should be interpreted within the context of the good predictive power of the neurocognitive and clinical status on the outcome.

Quantitative assessment of attribution of intentions to others in schizophrenia using an ecological video-based task: a comparison with manic and depressed patients.

Schizophrenia is characterized by the impairment of several facets of social cognition. This has been demonstrated in numerous studies that focused on specific aspects of social cognition such as the attribution of intentions, emotions, or false beliefs to others. However, most of these studies relied on complex verbal descriptions or impoverished social stimuli. In the present study, we evaluated a new task (Versailles-Situational Intention Reading, V-SIR) that is based on video excerpts depicting complex real-life scenes of social interactions. Subjects were required to rate the probabilities of several affirmations of the intentions of one of the characters. The V-SIR task was administered to schizophrenic patients (N=15), depressed patients (N=12), manic patients (N=15), and healthy controls (N=15). The performance of schizophrenic patients was significantly impaired in comparison to healthy and depressed subjects. There was a trend toward a significant difference between schizophrenic and manic patients. Manic patients also demonstrated impaired performance relative to healthy subjects. Schizophrenic patients' V-SIR scores were significantly correlated with their scores on another attribution of intentions task that used comic strips. These results show that tasks based on more ecological stimuli are powerful enough to detect theory-of-mind abnormalities in pathological populations such as schizophrenic patients.

Confirmation of a Two-Factor Solution to the Questionnaire of Cognitive and Affective Empathy in a French Population of Patients With Schizophrenia Spectrum Disorders.

The Questionnaire of Cognitive and Affective Empathy (QCAE) is a tool for self-assessing the cognitive and emotional components of empathy. A study showed that a two-factor model fits the data of patients with schizophrenia, whereas other reports on healthy subjects have suggested a five-factor decomposition. We aimed to replicate the model of Horan et al. in a French population with schizophrenia spectrum disorders (i.e., schizophrenia and schizoaffective disorders) participating in the EVACO Study (NCT02901015). In total, 133 patients were assessed with the QCAE, the Positive and Negative Symptom Scale (PANSS), the Personal and Social Performance Scale (PSP), and the Self rating Quality of Life Scale (S-QoL). The two-factor model demonstrated an adequate fit with the data, comparable to that reported by Horan et al. Males scored higher on the Affective subscore than females. After correction for multiple tests, psychopathology (PANSS) and functioning (PSP) did not correlate significantly with the QCAE subscores. However, quality of life (S-QoL) correlated positively with the Emotional Contagion subscore. Thus, the variability of empathetic disposition in schizophrenia may be considered through the cognitive versus affective dichotomy and properly investigated with the QCAE. The results support further investigation of the relationship between QCAE scores and subjective outcome measurements, such as quality of life, and emphasize the importance of cross-cultural comparisons.

Two-year study of relapse prevention by a new education program in schizophrenic patients treated with the same antipsychotic drug.

It is not clear whether patient's psycho-education enhances compliance to antipsychotic treatments and reduces the number of relapses. Here we investigated the impact of a new psycho-educational program (SOLEDUC) on the one- and two-years rate of relapse (primary outcome measure) and a number of clinical assessments (secondary outcome measures). This was a multicentric French clinical trial (51 centers) of Phase IV, open, controlled, randomized, consisting in two parallel groups: the Soleduc group (N=111) and the control group (N=109). All subjects received a variable dose over the 2-year period of the same antipsychotic drug (amisulpride). Soleduc consisted of a 7-session program (1h per session), presented three times (at baseline, 6-months and 12-months). Patients in the control group received a non-specific psychosocial training for an equivalent period of time. The models of Andersen-Gill (AG) and Prentice, Williams and Peterson (PWP) were used to analyze relapses. Patients in the Soleduc group attended 14.8+/-6.1 sessions (mean+/-SD), including 17 patients who never attended a session. Intent to treat analysis showed less patients relapsing in the Soleduc group as compared to the control group (21.6% versus 28.4% after 1 year and 84.4% versus 90.8% after 2years), but the differences were not statistically significant. Relapse risk was significantly reduced for patients who followed at least 7 modules (p=0.015 AG-test; p<0.001 PWP-test). In conclusion, no significant differences in relapse rates were found between patients attending the Soleduc program and the control group. Attendance of at least 7 out of 21 program sessions was required to see a modest, but significant two-year relapse prevention in schizophrenia. Other well designed studies are required to evaluate the medical impact of patient's education programs.

Outcome revealed by preference in schizophrenia (OPS): development of a new class of outcome measurements.

The objective of this paper is to describe the development of a new type of outcome measurement, based on revealed preference, which can be used in serious chronic illnesses. Fifteen texts of about 200 words each were written by one of the authors on the day-to-day life of 15 schizophrenic patients. These 15 'slices of life' thus described were then ranked in terms of acceptability by a second group of 10 schizophrenic patients and by a group of 12 relatives of schizophrenic patients. From these rankings, six situations were selected so as to obtain evenly distributed positioning on an axis of acceptability. These six situations comprised the final instrument. In administration, the patients were first asked if the 'slices of life' that were described were acceptable or not, then if the 'slices of life' described were more or less acceptable than their own lives. Two scores were derived, one for an absolute level and the other for a relative level of the patient's satisfaction with his or her existence. Validation results were presented to a new sample of 229 schizophrenic patients. Internal consistency appeared good and the initial ranking of the six situations in terms of acceptability was confirmed. This study encourages the development of global outcome measures based on revealed preference in chronic serious illnesses.

Patients with schizophrenia are less prone to interpret virtual others' empathetic questioning as helpful.

Individuals with schizophrenia are impaired in their neurocognition and present cognitive biases. These impairments may lead to a deficit in recognizing helping intentions of others. To investigate recognition of help, we designed a card-guessing game (Virtual Help Recognition Paradigm) involving two successive virtual agents asking questions to the participant at different moments of the game. These questions were either empathetic (i.e. on the subject's feelings) or non-empathetic (i.e. on technical aspects of the game). We assessed how much the participant felt that the virtual agent had helped him and, her attitude and personality traits. We measured how much the participant trusted the virtual agent with a monetary allocation procedure. Twenty individuals with schizophrenia and twenty healthy controls were recruited. The controls' ratings demonstrated that they interpreted empathetic questioning as helping and rewarded it positively with an increased monetary allocation. Participants with schizophrenia had a reduced perception of the differences between the two agents. Only the rating concerning the "interest/attention" of the agent toward these participants yielded significant differences among conditions. Hypothetically, individuals with schizophrenia take into account the fact they are the object of another's attention, but may fail to infer a helping intention and to behave accordingly.

Scale for the evaluation of communication disorders in patients with schizophrenia: a validation study.

OBJECTIVE: A scale for the evaluation of communication disorders in patients with schizophrenia (Schizophrenia Communication Disorder Scale-SCD) is proposed based on studies showing that cognitive disorders specific to the disorganization seen in schizophrenia consist of context processing deficits and problems in the attribution of mental states. Thus the focus of this scale is on the cognitive difficulties revealed in conversation during a structured interview. METHOD: Fifty-six patients with schizophrenia, depression or mania were evaluated. RESULTS AND CONCLUSION: Significantly elevated scores on the SCD were present in patients with schizophrenia compared to all other groups. Thus, this scale adds to the tools available for evaluating the language of patients with schizophrenia and helps focus on characteristics that are specific to this psychotic diagnosis.

How and why affective and reactive virtual agents will bring new insights on social cognitive disorders in schizophrenia? An illustration with a virtual card game paradigm.

In recent decades, many studies have shown that schizophrenia is associated with severe social cognitive impairments affecting key components, such as the recognition of emotions, theory of mind, attributional style, and metacognition. Most studies investigated each construct separately, precluding analysis of the interactive and immersive nature of real-life situation. Specialized batteries of tests are under investigation to assess social cognition, which is thought now as a link between neurocognitive disorders and impaired functioning. However, this link accounts for a limited part of the variance of real-life functioning. To fill this gap, advances in virtual reality and affective computing have made it possible to carry out experimental investigations of naturalistic social cognition, in controlled conditions, with good reproducibility. This approach is illustrated with the description of a new paradigm based on an original virtual card game in which subjects interpret emotional displays from a female virtual agent, and decipher her helping intentions. Independent variables concerning emotional expression in terms of valence and intensity were manipulated. We show how several useful dependant variables, ranging from classic experimental psychology data to metacognition or subjective experiences records, may be extracted from a single experiment. Methodological issues about the immersion into a simulated intersubjective situation are considered. The example of this new flexible experimental setting, with regards to the many constructs recognized in social neurosciences, constitutes a rationale for focusing on this potential intermediate link between standardized tests and real-life functioning, and also for using it as an innovative media for cognitive remediation.

[The construct of late schizophrenia: a misleading concept]. / Le diagnostic de schizophrénie tardive: les questions qu'il pose.

In the DSM-IV, late schizophrenia is defined by an onset over 40 or even 60 of age, delusional ideas, hallucinations, favorable response to treatment and a good outcome. The relevance of this construct is discussed with regard to the French psychiatric tradition in which the dissociative syndrome is central to the diagnosis of schizophrenia. The occurrence of psychotic symptoms in patients over 60 raises difficult diagnostic questions and is considered according to the potential consequences of the diagnosis of late schizophrenia.

[Suicide and depression in the elderly]. / Conduites suicidaires et dépression du sujet âgé.

Twenty per cent of the annual 12,000 deaths by suicide in France occur in subjects aged over 65. The rate of suicide by age in the population increases with aging. Aged people usually commit suicide by more violent means than younger people. Overall, the risk of suicide is multiplied by 20 in depressed subjects and by 40 in case of previous suicide attempt. This risk is probably higher in the aged. Suicide attempts are always to be sternly considered in aged people on account of the risk of a second successful attempt but also of a diminished life expectancy due to somatic as well as psychiatric reasons. Suicidal ideas are frequent in aged subjects but they strongly suggest depression which should be actively investigated. The so-called existential suicide, expression of the free will of subjects devoid of any psychiatric disorder who want, willingly and consciously, make an end to their life, probably exists. However, the high frequency of depression associated with suicide induces to be especially watchful in case of suicide ideas or previous suicide attempt in aged subjects.

[Depression in the elderly: prodroma or risk factor for dementia? A critical review of the literature]. / Dépression du sujet âgé : prodrome ou facteur de risque de démence ? Revue critique de la littérature.

A strong link between depression and dementia is now well documented in the literature. However, the nature of this relationship is much discussed. Are depression and dementia linked by comorbidity due to the frequency of both disorders in the aged? Can depression be a prodrome of dementia? Are recurrent depressive episodes a risk factor for dementia? Despite many methodological difficulties, strong arguments are developed in the litterature to support these various assumptions. It seems well established that depression can be the first symptoms of dementia, but the time between a depressive episode and the occurrence of dementia is very variable depending of authors. The highest risks to develop dementia after a depressive episode are high cultural level, depression severity, major dysexecutive syndrome and poor efficacy of antidepressant drugs. Most often, dementia following a depressive episode is dementia of the Alzheimer type. In addition, depressive episodes in adulthood seem to increase the risk of dementia occurence, but this hypothesis remains questionable. The influence of other risk factors, such as stress, depression severity and/or treatment with psychotropic drugs is just beginning to be reported in the literature. These topics are of concern for the clinician practice to develop preventive strategies in this population particularly vulnerable.

Correlations of theory of mind deficits with clinical patterns and quality of life in schizophrenia.

BACKGROUND: Numerous studies have demonstrated the existence of theory of mind (ToM) impairments in patients with schizophrenia. The clinical consequences of these impairments are currently under debate. Accumulated evidence suggests that ToM deficits are linked to negative and disorganization symptoms, but direct correlations are lacking. Moreover, it is unclear whether ToM deficits are related to reduced quality of life (QoL). METHODS: To extend the understanding of objective (i.e., clinical symptoms) and subjective (QoL) correlates of impaired ToM, we assessed 206 patients with schizophrenia based on performance of an ecological task (Versailles-Situational Intention Reading, V-SIR), a Communication Disorders Scale (SCD), the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression rating, and a QoL questionnaire (S-QoL). Statistical inferences were drawn from correlations analyses considering both factors/subscales aggregates and single items. RESULTS: ToM performance was negatively correlated to disorganization and negative PANSS factors. Poor V-SIR performance was correlated with "conceptual disorganization," "difficulties in abstract thinking," and "apathy/social withdrawal." The SCD was correlated with "negative," "disorganization," and "anxiety/depression" PANSS factors. The S-QoL total score was not significantly correlated with ToM performance. Only the item "difficulties in expressing feelings" was significantly correlated with poorer V-SIR performance. CONCLUSION: We discuss the intriguing paucity of the results and what they reveal about the difficulties faced by psychiatrists with patients not expressing complaints about lack of social skills.

[Cognitive aging in schizophrenia]. / Le vieillissement cognitif des patients atteints de schizophrénie.

The development of studies of aging patients with schizophrenia results from their increasing life expectancy in accordance with that of the general population, but remains far below that one. Studies devoted to cognitive deficits in these patients globally show various complex cognitive deficits, which usually remain stable in their evolution. However, some patients develop a severe cognitive decline after 65 years, following a long institutionalization. Complex cognitive functions particularly deserve to be systematically explored in patients presenting with cognitive complaints and/or communication difficulties. As an example, we present the case report of a patient showing a theory of mind deficit.