Levels of Structural Integration Mediate the Impact of Metacognition on Functioning in Non-affective Psychosis: Adding a Psychodynamic Perspective to the Metacognitive Approach

Synthetic metacognition is defined by integrative and contextualizing processes of discrete reflexive moments. These processes are supposed to be needed to meet intrapsychic as well as interpersonal challenges and to meaningfully include psychotic experience in a personal life narrative. A substantial body of evidence has linked this phenomenon to psychosocial functioning and treatment options were developed. The concept of synthetic metacognition, measured with the Metacognition Assessment Scale-Abbreviated (MAS-A), rises hope to bridge gaps between therapeutic orientations and shares valuable parallels to modern psychodynamic constructs, especially the 'levels of structural integration' of the Operationalized Psychodynamic Diagnosis (OPD-2). As theoretical distinctions remain, aim of this study was to compare the predictive value of both constructs with regard to psychosocial functioning of patients with non-affective psychoses, measured with the International Classification of Functioning, Disability and Health (MINI-ICF-APP). It was further explored if levels of structural integration (OPD-LSIA) would mediate the impact of metacognition (MAS-A) on function (MINI-ICF-APP). Expert ratings of synthetic metacognition (MAS-A), the OPD-2 'levels of structural integration' axis (OPD-LSIA), psychosocial functioning (MINI-ICF-APP) and assessments of general cognition and symptoms were applied to 100 individuals with non-affective psychoses. Whereas both, MAS-A and OPD-LSIA, significantly predicted MINI-ICF-APP beyond cognition and symptoms, OPD-LSIA explained a higher share of variance and mediated the impact of MAS-A on MINI-ICF-APP. Levels of structural integration, including the quality of internalized object representations and unconscious interpersonal schemas, might therefore be considered as valuable predictors of social functioning and as one therapeutic focus in patients with non-affective psychoses. Structural integration might go beyond and form the base of a person's actual reflexive and metacognitive capabilities. Psychotherapeutic procedures specific for psychoses may promote and challenge a patient's metacognitive capacities, but should equally take the need for maturing structural skills into account. Modern psychodynamic approaches to psychosis are shortly presented, providing concepts and techniques for the implicit regulation of interpersonal experience and aiming at structural integration in this patient group

Modeling Incoherent Discourse in Non-Affective Psychosis

Background: Computational linguistic methodology allows quantification of speech abnormalities in non-affective psychosis. For this patient group, incoherent speech has long been described as a symptom of formal thought disorder. Our study is an interdisciplinary attempt at developing a model of incoherence in non-affective psychosis, informed by computational linguistic methodology as well as psychiatric research, which both conceptualize incoherence as associative loosening. The primary aim of this pilot study was methodological: to validate the model against clinical data and reduce bias in automated coherence analysis. Methods: Speech samples were obtained from patients with a diagnosis of schizophrenia or schizoaffective disorder, who were divided into two groups of n = 20 subjects each, based on different clinical ratings of positive formal thought disorder, and n = 20 healthy control subjects. Results: Coherence metrics that were automatically derived from interview transcripts significantly predicted clinical ratings of thought disorder. Significant results from multinomial regression analysis revealed that group membership (controls vs. patients with vs. without formal thought disorder) could be predicted based on automated coherence analysis when bias was considered. Further improvement of the regression model was reached by including variables that psychiatric research has shown to inform clinical diagnostics of positive formal thought disorder. Conclusions: Automated coherence analysis may capture different features of incoherent speech than clinical ratings of formal thought disorder. Models of incoherence in non-affective psychosis should include automatically derived coherence metrics as well as lexical and syntactic features that influence the comprehensibility of speech

Measuring Emotional Awareness in Patients With Schizophrenia and Schizoaffective Disorders

The ability to mentalize (i.e., to form representations of mental states and processes of oneself and others) is often impaired in people with schizophrenia spectrum disorders. Emotional awareness (EA) represents one aspect of affective mentalizing and can be assessed with the Levels of Emotional Awareness Scale (LEAS), but findings regarding individuals with schizophrenia spectrum disorders are inconsistent. The present study aimed at examining the usability and convergent validity of the LEAS in a sample of N = 130 stabilized outpatients with schizophrenia or schizoaffective disorders. An adequacy rating was added to the conventional LEAS rating to account for distortions of content due to, for example, delusional thinking. Scores of the patient group were compared with those of a matched healthy control sample. Correlation with symptom clusters, a self-report measure of EA, a measure of synthetic metacognition (MAS-A-G), and an expert rating capturing EA from the psychodynamic perspective of psychic structure (OPD-LSIA) were examined. Regarding self-related emotional awareness, patients did not score lower than controls neither in terms of conventional LEAS nor in terms of adequacy. Regarding other-related emotional awareness, however, patients showed a reduced level of adequacy compared to controls whereas no such difference was found for conventional LEAS scores. Higher conventional LEAS scores were associated with fewer negative symptoms, and higher structural integration of self-perceptions measured by the OPD-LSIA. Higher adequacy of responses correlated with fewer symptoms of disorganization as well as excitement, higher scores of self-reflection on the MAS-A-G as well as self- and object-perception and internal and external communication as measured by the subscales of the OPD-LSIA. Findings suggest that the LEAS might not be sensitive enough to detect differences between mildly symptomatic patients with schizophrenia or schizoaffective disorders and healthy controls. However, LEAS ratings are still suitable to track intraindividual changes in EA over time. Observing the adequacy of patients' responses when using the LEAS may be a promising way to increase diagnostical utility and to identify patterns of formal and content-related alterations of mentalizing in this patient group. Methodological indications for future studies are discussed

Between a rock and a hard place: Associations between Mentzos' “dilemma”, self‐reported interpersonal problems, and psychosocial functioning in individuals with non‐affective psychoses

Primary aim of this study was to determine the extent and type of self-reported interpersonal problems in patients with non-affective psychoses and their impact on psychosocial functioning. Furthermore, we aimed to explore potential links with the psychodynamic construct of Stavros Mentzos' "psychotic dilemma", which describes an insufferable inner tension caused by an individual's struggle of being torn between "self-oriented" and "object-oriented" tendencies. In a cross-sectional study among 129 patients with non-affective psychoses, measures of cognition, symptom load and social functioning as well as a tentative, psychodynamic assessment of Mentzos' "dilemma" were obtained during a clinical research visit. Self-report data on interpersonal problems were gathered using the Inventory of Interpersonal Problems (IIP-64D) and compared with a German representative standard sample. Second, IIP-64D scores were compared between groups with or without Mentzos' "dilemma". Hierarchical regression analyses were performed to test for the impact of interpersonal problems on psychosocial functioning, while controlling for cognitive deficits and psychopathology. Results showed that IIP-64D scores differed significantly from healthy controls, except for "self-centred" and "intrusive" interpersonal styles. Participants with a potential "psychotic dilemma" scored significantly higher on the subscales: "domineering", "self-centred", "cold", and "socially avoidant" than the group without a "psychotic dilemma". The total amount of interpersonal problems, and particularly high scores on the IIP-64D "socially avoidant" subscale, predicted psychosocial dysfunction, whereas a "cold" interpersonal style had an opposite effect. In conclusion, specific interpersonal problems may predict psychotherapeutic outcome measures like psychosocial functioning and are partly compatible with the psychodynamic construct of Stavros Mentzos' "psychotic dilemma"

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 and 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. Conclusion: 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

Indicators of change to assess efficacy of modified psychodynamic psychotherapy in patients with non-affective psychosis – the role of synthetic metacognition, psychic structure and linguistic characteristics

Spätestens seit einer Änderung der Psychotherapierichtlinien im Jahr 2014 gelten psychotherapeutische Interventionen bei schizophrenen und schizoaffektiven Psychosen in jeder Phase der Erkrankung als indiziert. Aktuell imponiert ein Ungleichgewicht wissenschaftlicher Evidenz bezogen auf die psychotherapeutischen Richtlinienverfahren, zu Ungunsten der psychodynamischen Therapie. Gegenstand der vorliegenden Forschungsarbeit war eine Querschnittsauswertung der Baseline-Stichprobe einer der ersten randomisiert-kontrollierten Studien zu einem manualbasierten psychodynamischen Verfahren in dieser Patient:innengruppe. Hierbei wurden solche Fähigkeiten näher untersucht, die eine Veränderung durch modifizierte psychodynamische Interventionen im Längsschnitt anzeigen könnten, nämlich: Metakognitive, strukturelle und interpersonelle Fähigkeiten. Besondere Bedeutung wurde hierbei der Qualität der ausgewählten Fähigkeiten dahingehend beigemessen, als Veränderungsmaße über eine Symptomremission hinaus zu fungieren. Dies geschah vor dem Hintergrund, dass psychodynamische Verfahren einen regulativen Aspekt von Symptomen für darunter liegende Spannungsfelder betonen und diese eher sekundär adressieren. Metakognitive, strukturelle und interpersonelle Fähigkeiten erklärten je einen signifikanten Anteil im psychosozialen Funktionsniveau, der über kognitive Fähigkeiten und die Psychopathologie hinausreichte. Hier zeigte sich ein erster empirischer Indikator für die Operationalisierbarkeit relevanter psychologischer Fähigkeiten/Mechanismen. Ferner wurde in einem methodenorientierten Design die Möglichkeit einer automatisierten Vorhersage sprachlicher Merkmale erprobt. In Synergie klinischer Einschätzungen und computerlinguistischer Methoden könnten klinisch relevante Veränderungsmaße durch solche objektiveren Verfahren ergänzt werden. Erste explorative Ergebnisse gaben Hinweise auf eine Übereinstimmung der computerlinguistischen und klinischen Einschätzung semantischer Kohärenz, zeigten aber auch, dass ein Anteil an Varianz im klinischen Eindruck durch die automatische Modellierung nicht bedeutsam vorhergesagt werden konnte. Zuletzt wurden psychodynamische Kernkonzepte detaillierter eingeführt und eine Adressierbarkeit durch Psychotherapie sowie der Zusammenhang zu den ausgewählten Veränderungsmaßen dis-kutiert.Since the German practice guidelines for psychotherapy were revised in 2014, psychotherapeutic interventions have been indicated for patients with non-affective psychosis at every stage of the disease. Nevertheless, an imbalance remains regarding the evidence base of psychotherapeutic treatments, to the disadvantage of psychodynamic therapy. This thesis reports on a cross-sectional evaluation of the baseline sample of one of the first randomized-controlled trials using a manual-based psychodynamic method in this patient group. The aim was to investigate certain abilities that might improve through modified psychodynamic interventions in a longitudinal design, namely: metacognitive, structural and interpersonal capacities. Psychodynamic therapy emphasizes a regulatory or compensatory quality of symptoms with regard to underlying tensions and therefore addresses symptoms more implicitly. As a consequence, the extent to which the above-mentioned abilities might indicate changes beyond symptom remission was of particular interest. Metacognitive, structural and interpersonal abilities each predicted a significant share of variance in psychosocial functioning beyond general cognitive capacities and psychopathology. This finding was a first empirical indicator for the operationalization of relevant psychological abilities/mechanisms. Furthermore, in a primarily methodological design, automatized prediction of linguistic characteristics via computerlinguistic methods was explored. Joining together clinical assessments and computerlinguistic methods might offer a more objective perspective on changes brought on by psychodynamic therapies. Exploratory results indicated a certain overlap of computerlinguistic and clinical assessments of semantic coherence, but also showed that a share of variance in the clinical impression was not significantly predicted through automatized modeling. Lastly, psychodynamic key concepts were introduced in greater detail, leading to a discussion as to how psychodynamic psychotherapy might address those concepts and how they might relate to the investigated indicators of change

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

No abstract available