Effects of metacognitive training (MCT) on social cognition for schizophrenia spectrum and related psychotic disorders: a systematic review and meta-analysis.

BACKGROUND: Individuals with schizophrenia spectrum and related psychotic disorders (SSD) experience significant impairments in social cognition that impede functioning. Social cognition is a multidimensional construct consisting of four domains: 1. theory of mind, 2. emotion processing, 3. attributional style and 4. social perception. Metacognitive training (MCT) is an intervention designed to target cognitive biases in psychosis containing two modules addressing social cognition. METHODS: A systematic review and meta-analysis was conducted to investigate the effects of MCT on social cognition and two of its domains: theory of mind and emotion processing. Ten electronic databases were scoured from 2007 to 1 February 2022 for MCT studies reporting social cognition outcomes for people with SSD (1050 identified, 282 assessed). Effect sizes were calculated using Cohen's d in R. RESULTS: Nine studies were included in the meta-analysis (nMCT = 212, ncontrol = 194). MCT had a small but positive effect on global social cognition (d = 0.28 [95% CI 0.07-0.49]) and theory of mind (d = 0.27 [95% CI 0.01-0.52]). MCT showed no evidence of an effect on emotion processing (d = 0.03 [95% CI -0.26 to 0.32]). CONCLUSION: MCT has a small but significant effect on social cognition for people with SSD. Our results add to other recent meta-analyses showing significant effects of MCT on clinically relevant outcomes such as positive symptoms, cognitive biases and cognitive insight. We recommend that future studies on MCT report outcomes on all four domains of social cognition. TRIAL REGISTRATION: PROSPERO (in the process of registration) available at https://www.crd.york.ac.uk/prospero/#recordDetails.

Prevalence of body-focused repetitive behaviors in a diverse population sample - rates across age, gender, race and education.

BACKGROUND: Prevalence estimates for body-focused repetitive behaviors (BFRBs) such as trichotillomania differ greatly across studies owing to several confounding factors (e.g. different criteria). For the present study, we recruited a diverse online sample to provide estimates for nine subtypes of BFRBs and body-focused repetitive disorders (BFRDs). METHODS: The final sample comprised 1481 individuals from the general population. Several precautions were taken to recruit a diverse sample and to exclude participants with low reliability. We matched participants on gender, race, education and age range to allow unbiased interpretation. RESULTS: While almost all participants acknowledged at least one BFRB in their lifetime (97.1%), the rate for BFRDs was 24%. Nail biting (11.4%), dermatophagia (8.7%), skin picking (8.2%), and lip-cheek biting (7.9%) were the most frequent BFRDs. Whereas men showed more lifetime BFRBs, the rate of BFRDs was higher in women than in men. Rates of BFRDs were low in older participants, especially after the age of 40. Overall, BFRBs and BFRDs were more prevalent in White than in non-White individuals. Education did not show a strong association with BFRB/BFRDs. DISCUSSION: BFRBs are ubiquitous. More severe forms, BFRDs, manifest in approximately one out of four people. In view of the often-irreversible somatic sequelae (e.g. scars) BFRBs/BFRDs deserve greater diagnostic and therapeutic attention by clinicians working in both psychology/psychiatry and somatic medicine (especially dermatology and dentistry).

Same but different? Phenomenological differences among various types of body-focused repetitive behaviors.

BACKGROUND: Body-focused repetitive behaviors (BFRBs) are highly prevalent conditions at the border of psychiatry and dermatology. Using a newly developed scale, the Generic BFRB scale (GBS-36), we aimed to compare 4 prominent BFRBs in terms of phenomenology, age at onset, and other illness-related aspects. METHODS: A sample of 391 individuals with different forms of BFRBs completed the GBS-36, the Patient Health Questionnaire-9 (depression), and the World Health Organization Quality of Life-BREF global item (quality of life). RESULTS: Most individuals showed multiple BFRBs (73.9%). Skin picking and nail biting were reported most frequently (nail biting: 68.3%; skin picking: 60.9%; trichotillomania: 52.4%; lip-cheek biting: 31.7%). Nail biting was most common in childhood; the other BFRBs began mainly in adolescence. Both trichotillomania and skin picking were associated with the greatest impairment and urge to perform the behavior. The 2 conditions also showed a higher association with obsessive-compulsive disorder. Overall symptom severity was correlated with earlier age of onset, number of concurrent BFRBs, and severity of depression as well as suicidality. CONCLUSIONS: BFRBs are a heterogeneous group of conditions, with trichotillomania and skin picking showing the largest similarities. Whether the observed differences reflect specific etiological factors awaits further testing.

The relationship between negative symptoms and MATRICS neurocognitive domains: A meta-analysis and systematic review.

BACKGROUND: Negative symptoms (NS) are a core symptom domain in schizophrenia spectrum disorders and are associated with poorer social and vocational functioning, and with increased likelihood and durations of hospital admission. NS are not well understood, limiting available interventions. However, numerous studies have reported associations between neurocognitive domains and NS severity. Thus, one promising area in understanding NS is in relation to neurocognition. Currently, the specificity of the relationship between NS and neurocognition is unknown, meaning that there is no consensus regarding which neurocognitive domain is most strongly associated with NS. There is a need to systematically examine the relationship between NS and various neurocognitive domains within study samples. METHODS: A systematic search of Ovid PsycINFO, Ovid MEDLINE and Web of Science was performed for articles published since 2004 (year of MATRICS Consensus publication). Inclusion criteria were: 1) individuals with schizophrenia spectrum disorders, first episode psychosis or clinical high risk 2) assessed all six MATRICS neurocognitive domains (processing speed, attention, working memory, verbal learning & memory, visual learning & memory, reasoning & problem solving), 3) reported correlations between all six MATRICS neurocognitive domains and global NS. A three-level random effects hierarchical meta-analysis was performed to assess the relationship between NS (global, expressive, and experiential dimensions) and the six MATRICS neurocognitive domains. RESULTS: 21 studies were included in the review (n = 3619). All MATRICS neurocognitive domains had small significant correlations with global NS (r = -0.16 to -0.20, p < 0.0001). This relationship was significantly moderated by diagnosis and the moderating effect of sex/ gender trended on significance. Analysis of a subset of the studies revealed that MATRICS neurocognitive domains also had small significant correlations with the two NS dimensions, expressive and experiential. Correlations were stronger with the expressive NS dimension. CONCLUSIONS: This review is novel in assessing the relationship between multiple neurocognitive domains and NS within the same sample, by synthesizing close to two decades of research. Our results suggest that there is a non-specific relationship between neurocognition and NS, and that expressive NS may have a stronger relationship with neurocognitive functioning-based on the MATRICS classification of neurocognition and the neurocognitive assessments used in the included studies. This has implications on our understanding of NS and neurocognition, as well as their treatments. As we gain better understanding of the directionality of the NS-cognition relationship, it could suggest that NS, particularly in the expressive domain, could be improved by targeting cognition globally or that neurocognitive treatments could be more effective if NS are addressed first. Further implications of these results are discussed.

Self-Help Habit Replacement in Individuals With Body-Focused Repetitive Behaviors: A Proof-of-Concept Randomized Clinical Trial.

Importance: Body-focused repetitive behaviors (BFRBs; eg, skin picking) encompass a set of conditions at the interface of dermatology and psychiatry/psychology. The disorder is prevalent but currently underdiagnosed and undertreated. Objective: To compare a new self-help intervention, habit replacement, against a wait-list control condition for the treatment of BFRBs. Design, Setting, and Participants: This randomized clinical trial was conducted online in 2022. Participants were a population-based nonclinical sample with BFRBs and were recruited via social media. Initially, 481 individuals entered the assessment; 213 were excluded blind to results. A final sample of 268 participants were randomized. The intervention period was 6 weeks. Interventions: Participants were randomized to a self-help intervention, habit replacement, or a wait-list control condition (each n = 134). Main Outcomes and Measures: The Generic BFRB Scale-45 (GBS-45, self-report) represented the primary outcome. Results: Individuals in the 2 conditions (n = 268; 241 [89.9%] women; mean [SD] age, 36.8 [11.1] years; skin picking, 68.3%; trichotillomania, 28.4%; nail biting, 36.6%; lip-cheek biting, 26.1%; other, 20.1%) did not differ on any baseline characteristics. The experimental group significantly improved on the primary outcome (GBS-45) for both the per-protocol (technique was used at least once weekly, ηp2 = 0.068, P = .001) and the intention-to-treat analyses relative to the wait-list control group (expectation-maximization algorithm; ηp2 = 0.019, P = .02). The interaction of group and time yielded statistical trends in favor of the experimental condition only on the Patient Health Questionnaire-9 and quality of life. For the Clinical Global Impressions scale, more individuals in the habit replacement group reported improvement (52.8% vs 19.6%; P < .001). User satisfaction in the habit replacement group was high. Moderation analyses that included all baseline variables showed that those who exhibited nail biting particularly benefited from the new technique. Conclusions and Relevance: The present proof-of-concept randomized clinical trial tentatively demonstrates that habit replacement is a feasible and effective self-help strategy against BFRBs, especially for nail biting. Study limitations include the lack of external assessment and verified diagnoses. In addition, the study is missing follow-up data. Self-help habit replacement shows promise in reducing BFRBs but not concomitant symptoms. Trial Registration: German Clinical Trials Register Identifier: DRKS00030511.

Decoupling: adaptation of a treatment for body-focused repetitive behaviour to Tourette syndrome. A case report.

AIMS: Tourette syndrome (TS) is a neurological condition; its etiology is not yet fully understood. Cognitive behavioural therapy with habit reversal training is the recommended first-line treatment, but is not effective in all patients. This is the first report examining the usefulness of decoupling, a behavioural self-help treatment originally developed for patients with body-focused repetitive behaviours, in a patient with TS. METHOD: Patient P.Z. showed 10 motor and three vocal tics on the Adult Tic Questionnaire (ATQ) before treatment. He was taught decoupling by the first author. RESULTS: The application of decoupling led to a reduction of P.Z.'s eye tics, which was one of his first and most enduring and severe tics. It was not effective for other areas. Quality of life and depression improved, which P.Z. attributed to the improvement of his tics. CONCLUSION: Decoupling may be adopted as an alternative, when habit reversal training is not feasible. Future research, preferably using a controlled design with a large sample, may elucidate whether decoupling is only effective for tics relating to the eyes, the most common symptom in tic disorder/TS, or whether its effects extend to other symptoms.

The magnitude of neurocognitive impairment is overestimated in depression: the role of motivation, debilitating momentary influences, and the overreliance on mean differences.

BACKGROUND: Meta-analyses agree that depression is characterized by neurocognitive dysfunctions relative to nonclinical controls. These deficits allegedly stem from impairments in functionally corresponding brain areas. Increasingly, studies suggest that some performance deficits are in part caused by negative task-taking attitudes such as poor motivation or the presence of distracting symptoms. A pilot study confirmed that these factors mediate neurocognitive deficits in depression. The validity of these results is however questionable given they were based solely on self-report measures. The present study addresses this caveat by having examiners assess influences during a neurocognitive examination, which were concurrently tested for their predictive value on performance. METHODS: Thirty-three patients with depression and 36 healthy controls were assessed on a battery of neurocognitive tests. The examiner completed the Impact on Performance Scale, a questionnaire evaluating mediating influences that may impact performance. RESULTS: On average, patients performed worse than controls at a large effect size. When the total score of the Impact on Performance Scale was accounted for by mediation analysis and analyses of covariance, group differences were reduced to a medium effect size. A total of 30% of patients showed impairments of at least one standard deviation below the mean. CONCLUSIONS: This study confirms that neurocognitive impairment in depression is likely overestimated; future studies should consider fair test-taking conditions. We advise researchers to report percentages of patients showing performance deficits rather than relying solely on overall group differences. This prevents fostering the impression that the majority of patients exert deficits, when in fact deficits are only true for a subgroup.

Exploring the factor structure of the PTSD checklist for DSM-5 in psychotic disorders.

OBJECTIVE: The PTSD Checklist for DSM (PCL) is the most widely used screener to assess posttraumatic stress disorder (PTSD) in those with psychotic disorders (psychosis), though previous research has questioned its validity in psychosis. Considerable symptom overlap between the 2 disorders (e.g., concentration difficulties, avoidance, etc.) along with the general underdiagnosing of PTSD in psychosis speaks to the need for consensus regarding brief screeners. This hypothesis-generating study is the first to explore the PCL-5 (its most recent iteration) factor structure in psychosis to assess if a more valid underlying structure may exist. METHOD: Sixty-5 individuals who met the DSM-5 PTSD criterion A traumatic event following an interview subsequently completed the PCL-5. Exploratory factor analysis was conducted to explore the latent structure of the PCL-5 in psychotic disorders. RESULTS: A 4-factor solution differing from the DSM-5 4-factor model emerged as the best fitting model. Resulting PCL-5 dimensions in psychosis were identified as (1) Reexperiencing/Negative Affect; (2) Depressive; (3) Externalizing Anxious Behaviors; and (4) Avoidance/Physiological Reactivity. CONCLUSIONS: Results guide the hypothesis that the latent structure of the PCL-5 may be unique in psychosis, which will have important clinical implications. Research is now needed to confirm the proposed model in larger samples of individuals with psychosis. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Severe childhood trauma and emotion recognition in males and females with first-episode psychosis.

AIM: Childhood trauma increases social functioning deficits in first-episode psychosis (FEP) and is negatively associated with higher-order social cognitive processes such as emotion recognition (ER). We investigated the relationship between childhood trauma severity and ER capacity, and explored sex as a potential factor given sex differences in childhood trauma exposure. METHODS: Eighty-three FEP participants (52 males, 31 females) and 69 nonclinical controls (49 males, 20 females) completed the CogState Research Battery. FEP participants completed the Childhood Trauma Questionnaire. A sex × group (FEP, controls) ANOVA examined ER differences and was followed by two-way ANCOVAs investigating sex and childhood trauma severity (none, low, moderate, and severe) on ER and global cognition in FEP. RESULTS: FEP participants had significantly lower ER scores than controls (p = .035). No significant sex × group interaction emerged for ER F(3, 147) = .496, p = .438 [95% CI = -1.20-0.57], partial η2  = .003. When controlling for age at psychosis onset, a significant interaction emerged in FEP between sex and childhood trauma severity F(3, 71) = 3.173, p = .029, partial η2  = .118. Males (n = 9) with severe trauma showed ER deficits compared to females (n = 8) (p = .011 [95% CI = -2.90 to -0.39]). No significant interaction was observed for global cognition F(3, 69) = 2.410, p = .074, partial η2  = .095. CONCLUSIONS: These preliminary findings provide support for longitudinal investigations examining whether trauma severity differentially impacts ER in males and females with FEP.

Habit Reversal Training and Variants of Decoupling for Use in Body-Focused Repetitive Behaviors. A Randomized Controlled Trial.

Background: Behavioral interventions hold promise in improving body-focused repetitive behaviors (BFRBs), such as hair pulling and skin picking. The effect of combining different treatment techniques is currently unknown. Methods: In the framework of a randomized controlled crossover trial, 334 individuals with at least one BFRB were allocated either to a waitlist control or to three experimental conditions (1:1:1:1). Participants in the experimental condition received self-help manuals teaching habit reversal training (HRT), decoupling (DC) and decoupling in sensu (DC-is) during a six-week period. Treatment conditions differed only in the order of manual presentation. We examined whether applying more than one technique would lead either to add-on or interference effects. Results: The three treatment conditions were significantly superior to the waitlist control group in the improvement of BFRBs according to intention-to-treat analyses at a medium effect size (all p ≤ 0.002, d = 0.52 - 0.54). The condition displaying DC first significantly reduced depressive symptoms (p = 0.003, d = 0.47) and improved quality of life (p = 0.011, d = 0.39) compared to the waitlist control. Those using more techniques concurrently showed the strongest decline in BFRB symptoms, even after controlling for days practiced. Participants rated all manuals favorably, with standard DC and HRT yielding greatest acceptability. Discussion: Results tentatively suggest the concurrent application of different behavioral treatments for BFRBs leads to add-on effects. Results were superior when DC was practiced first, with positive effects extending to depressive symptoms and quality of life. Integrating the three techniques into one self-help manual or video along with other treatment procedures (e.g., stimulus control techniques) is recommended.

Adaptation of movement decoupling for compulsive joint cracking: A case report.

Compulsive joint cracking is a body-focused repetitive behavior (BFRB), which often results in negative social feedback due to its characteristic sound. While behavioral techniques are recommended in BFRBs, no published studies or case reports exist specifically for compulsive joint cracking. The authors report the case of DZ, who engaged in severe joint cracking of his knuckles and, at times, his back. The individual was assessed with an adapted version of the Generic BFRB Scale (GBS). DZ was instructed on how to perform decoupling, a technique that has shown efficacy in other BFRBs. He was also advised to use "fidget devices" that mimic aspects of the dysfunctional behavior in a less conspicuous way. Scores on the GBS were reduced by almost 50%, which corresponded with DZ's subjective appraisal of feeling more in control. Randomized controlled trials are needed to assess the (differential) efficacy these techniques to ameliorate compulsive joint cracking.

The Generic BFRB Scale-8 (GBS-8): a transdiagnostic scale to measure the severity of body-focused repetitive behaviours.

BACKGROUND: Body-focused repetitive behaviours (BFRBs) such as skin picking and hair pulling are frequent but under-diagnosed and under-treated psychological conditions. As of now, most studies use symptom-specific BFRB scales. However, a transdiagnostic scale is needed in view of the high co-morbidity of different BFRBs. AIMS: We aimed to assess the reliability as well as concurrent and divergent validity of a newly developed transdiagnostic BFRB scale. METHOD: For the first time, we administered the 8-item Generic BFRB Scale (GBS-8) as well as the Repetitive Body Focused Behavior Scale (RBFBS), modified for adults, in 279 individuals with BFRBs. The GBS-8 builds upon the Skin Picking Scale-Revised (SPS-R), but has been adapted to capture different BFRBs concurrently. A total of 170 participants (61%) were re-assessed after 6 weeks to determine the test-retest reliability of the scale. RESULTS: Similar to the SPS-R, factor analysis yielded two dimensions termed symptom severity and impairment. The test-retest reliability of the scale was satisfactory (r = .72, p<.001). Concurrent validity (r = .74) with the RBFBS was good (correlational indexes for concurrent validity were significantly higher than that for discriminant validity). DISCUSSION: The GBS-8 appears to be a reliable and valid global measure of BFRBs. We recommend usage of the scale in combination with specific BFRB scales to facilitate comparability across studies on obsessive-compulsive spectrum disorders.

Group therapy for schizophrenia: Why Burlingame et al. (2020) should redo their meta-analysis.

Comments on the meta-analysis by G. M. Burlingame et al. (see record 2020-37337-001) on group therapy in schizophrenia. The commenting authors explain why they think that the meta-analysis is seriously flawed and should be recalculated and updated. First, however, they briefly reflect on the role of meta-analyses in contemporary research to emphasize that this discussion is not merely an academic debate but may have significant implications for the psychotherapeutic landscape as a whole. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Immediate and Sustained Outcomes and Moderators Associated With Metacognitive Training for Psychosis: A Systematic Review and Meta-analysis.

Importance: A substantial increase in the number of trials examining metacognitive training (MCT) for psychosis necessitates an updated examination of the outcomes associated with MCT. Objectives: To review the immediate and sustained associations of MCT with proximal (directly targeted) and distal (indirectly influenced) outcomes and assess treatment- and participant-related moderators to identify the potential factors associated with the expected heterogeneity of effect sizes. Data Sources: Eleven electronic databases were searched from 2007 to June 3, 2021 (alert until September 10, 2021). Reference lists of earlier meta-analyses and included reports were screened. Study Selection: Reports examined MCT and included participants with schizophrenia spectrum and related psychotic disorders (1045 reports identified; 281 assessed). There were no age, sex, gender, race and ethnicity, language, or study design restrictions. Two reviewers performed the selection of studies to be analyzed. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed. Data were extracted by 3 reviewers and pooled using random effects models. Hedges g effect sizes were computed. The Mixed-Methods Appraisal tool was used to assess study quality. Main Outcomes and Measures: Proximal outcomes were global positive symptoms, delusions, hallucinations, and cognitive biases. Distal outcomes were self-esteem, negative symptoms, quality of life, well-being, and functioning. Immediate and sustained outcomes were examined. Meta-regressions, subgroup, and sensitivity analyses assessed moderators. Results: This systematic review and meta-analysis included 43 studies (46 reports). Forty reports were synthesized in meta-analysis (N=1816 participants) and 6 reports were included in narrative review. In the studies examined, MCT was associated with positive symptoms (g = 0.50; 95% CI, 0.34-0.67), delusions (g = 0.69; 95% CI, 0.45-0.93), hallucinations (g = 0.26; 95% CI, 0.11-0.40), cognitive biases (g = 0.16; 95% CI, 0.03-0.29), self-esteem (g = 0.17; 95% CI, 0.03-0.31), negative symptoms (g = 0.23; 95% CI, 0.10-0.37), and functioning (g = 0.41; 95% CI, 0.12-0.69). These associations were maintained up to 1 year. The quality of life effect size was nonsignificant (g = 0.20; 95% CI, -0.07 to 0.47); only 1 study assessed well-being. Publication year was associated with moderated hallucinations (ß = 0.04; 95% CI, 0.00-0.07). Overall, narrative review results corroborated meta-analytic findings. Conclusions and Relevance: In this meta-analysis, MCT for psychosis was associated with benefits up to 1 year postintervention in several treatment contexts. These findings suggest that MCT may merit integration in treatment guidelines for schizophrenia.

A Head-to-Head Comparison of Three Self-Help Techniques to Reduce Body-Focused Repetitive Behaviors.

Body-focused repetitive behaviors (BFRBs) include skin picking, trichotillomania, nail biting and cavitadaxia/lip-cheek biting, among other behaviors. For the first time, we compared three different self-help techniques aimed at reducing BFRBs. We explored the acceptance and preliminary efficacy of the approaches and whether the techniques exerted differential effects depending on BFRB-type.A total of 113 participants with at least one BFRB were randomly allocated to either habit reversal training (HRT; active elements: awareness and competing response training), decoupling (DC) or decoupling in sensu (DC-is). Reassessment was conducted 4 weeks later. The Generic Body-Focused Repetitive Behavior Scale (GBS) served as the primary outcome. The completion rate was best for DC-is (68.6%) as compared to HRT (57.1%) and DC (53.5%). A total of 34.8% of completers in the DC group showed an improvement of at least 35% on the GBS compared to 10.0% in the HRT and 23.3% in the DC-is group. In accordance with previous work, moderator analyses showed that improvement under DC is best for non-skin-pickers. A dose-effect relationship emerged, particularly for HRT. Subjective appraisal ratings were more favorable for DC-is and HRT than for DC. With respect to completion rate, subjective appraisal and symptom improvement, DC-is yielded consistently satisfactory results, whereas HRT showed good subjective but rather poor objective improvement. Those who performed DC, especially non-skin-pickers, showed good improvement but overall completion and subjective efficacy were low. Future studies should investigate whether the three techniques exert add-on effects when combined and whether demonstration via new media (e.g., video) will augment comprehensibility and thus efficacy of the techniques.

Impaired test performance yet spared neurocognitive functioning in individuals with obsessive-compulsive disorder: the role of performance mediators.

INTRODUCTION: Although most studies report neurocognitive deficits in patients with obsessive-compulsive disorder (OCD), important exceptions exist, highlighting the possible role of mediators (e.g., poor motivation). This study investigated neurocognitive functioning and potential influences affecting performance in OCD. METHODS: Forty-three participants (13 OCD patients, 30 healthy controls) were assessed using a battery of neurocognitive tests. During the assessment, the examiner completed the Impact on Performance Scale (IPS) which measures variables that may impact neurocognitive performance. RESULTS: Pooled neurocognitive performance was lower in OCD patients versus healthy controls at a moderate effect size. Patients performed more poorly on the IPS, particularly the Well-Being During Assessment subscale. Performance differences across the two groups were attenuated to a non-significant small-to-medium effect when the IPS was entered as a covariate. A total of 34% of patients showed scores greater than one standard deviation below the mean compared to 9.63% in healthy individuals. Yet, when a conservative impairment criterion (≥2 standard deviations below the mean) was applied, less than 10% of patients displayed deficits. CONCLUSIONS: Neurocognitive impairment in OCD is likely exaggerated. In addition to considering important mediators researchers should report the percentage of participants displaying performance deficits rather than mean group differences alone; the latter obscures the high percentage of patients without impairment and thus may unduly foster stigma in this population.

A student-led curriculum framework for homeless and vulnerably housed populations.

BACKGROUND: Medical student demands for competency based homeless health education is increasing. Indeed, humans living homeless is a treatable health and social emergency. This innovation report outlines the initial development of an education framework for homeless health. METHODS: A medical student task force and educators conducted a mixed method study, including a scoping review of homeless health curriculum and competencies, a cross-country survey of medical students, and unique clinical guidelines. The task force collaborated with persons with lived experience and clinical guideline developers from the Homeless Health Research Network. The students presented at the Toronto Homeless Health Summit and refined the framework with feedback from homeless health experts. RESULTS: The main outcome was an evidence-based Homeless Health Curriculum Framework. It uses seven core competencies; with communication, advocacy, leadership, and upstream approaches playing the strongest roles. The framework integrated the new clinical guideline (housing, income assistance, case management and addiction). In addition, it identified approaches to support mental health care with trauma informed and patient centered care. It identified public health values, clinical objectives, and case studies. The framework aims to inform the design, delivery, service learning and evaluation for medical school curriculum. CONCLUSIONS: This student-led curriculum framework can support the design, implementation, delivery and evaluation of homeless health within the undergraduate medical curriculum. The framework can lay the foundation for new doctors, research and development; support consistency across programs; and support the creation of national learning and evaluation tools.

Understanding sex differences in cognitive insight across first-and-multiple episode psychosis.

OBJECTIVE: Cognitive insight represents the capacity to self-reflect and consider external feedback when re-evaluating faulty beliefs. It is associated with specific cognitive capacities such as verbal memory, of which there is substantial evidence for sex differences in psychotic disorders. Like more general cognitive capacities, cognitive insight might too be modulated by sex differences. METHOD: One hundred and seventy-one first episode psychosis (FEP; 123 males, 48 females), and 203 multiple episode psychosis (MEP; 147 males, 56 females) participants completed the Beck Cognitive Insight Scale (BCIS). A two-way MANOVA was conducted on the three BCIS measures (self-reflectiveness, self-certainty, composite index) with sex (male, female) and illness stage (FEP, MEP) as factors, followed by two-way ANOVAs and a post hoc test of simple effects. RESULTS: The only significant interaction to emerge was between sex and illness stage in self-certainty (F(1, 373) = 5.88, p = .016). A test of simple effects revealed that self-certainty group means were significantly different for males and females in FEP, where females had lower self-certainty than males (p = .053) but not during MEP (p = .119). CONCLUSION: Sex differences do not modulate cognitive insight in MEP, which may be attributable to females having greater positive symptom severity than males. In FEP however, results revealed that females were significantly less self-certain than males. Lower self-certainty relative to self-reflectiveness predicts treatment response in psychological interventions, and as such future FEP studies should explore sex differences in psychological interventions.