Social Dysfunction in Psychosis Is More Than a Matter of Misperception: Advances From the Study of Metacognition

Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of disturbances in social function remain poorly understood. One recent model has proposed that deficits in social cognition may be a root cause of social dysfunction. In this model social relationships become untenable among persons diagnosed with psychosis when deficits in social cognition result in inaccurate ideas of what others feel, think or desire. While there is evidence to support the influence of social cognition upon social function, there are substantial limitations to this point of view. Many with psychosis have social impairments but not significant deficits in social cognition. First person and clinical accounts of the phenomenology of psychosis also do not suggest that persons with psychosis commonly experience making mistakes when trying to understand others. They report instead that intersubjectivity, or the formation of an intimate shared understanding of thoughts and emotions with others, has become extraordinarily difficult. In this paper we explore how research in metacognition in psychosis can transcend these limitations and address some of the ways in which intersubjectivity and more broadly social function is compromised in psychosis. Specifically, research will be reviewed on the relationship between social cognitive abilities and social function in psychosis, including measurement strategies and limits to its explanatory power, in particular with regard to challenges to intersubjectivity. Next, we present research on the integrated model of metacognition in psychosis and its relation to social function. We then discuss how this model might go beyond social cognitive models of social dysfunction in psychosis by describing how compromises in intersubjectivity occur as metacognitive deficits leave persons without an integrated sense of others' purposes, relative positions in the world, possibilities and personal complexities. We suggest that while social cognitive deficits may leave persons with inaccurate ideas about others, metacognitive deficits leave persons ill equipped to make broader sense of the situations in which people interact and this is what leaves them without a holistic sense of the other and what makes it difficult to know others, share experiences, and sustain relationships. The potential of developing clinical interventions focused on metacognition for promoting social recovery will finally be explored

Autobiographical memory in schizophrenia: The role of metacognition.

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

Promoting Affect Regulation Among Individuals Experiencing Psychosis In Metacognitive Reflection and Insight Therapy (MERIT)

Theorists have suggested that individuals experiencing psychosis have significant affective dysregulation, and that expressions of psychosis may in fact serve as one form of expression of painful affect. As such, therapeutic approaches to work with individuals experiencing psychosis may incorporate therapist actions targeted to promote affect regulation in clients. Metacognitive Reflection and Insight Therapy (MERIT) is an integrative approach to psychotherapy that incorporates eight elements to target metacognition among individuals experiencing psychosis. MERIT has been shown to promote improvement in metacognition for persons with psychosis, but little has been done within this framework to explore the therapists’ role in promoting affect regulation among individuals experiencing psychosis. This paper discusses how therapist actions related to each of the eight components of MERIT may promote affect regulation in the therapeutic context. Case examples are given to illustrate the application of this approach. Common challenges faced among therapists, limitations, and future directions are also discussed

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

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