Complementary group Metacognitive Training (MCT) reduces delusional ideation in schizophrenia.

BACKGROUND: Symptom reduction under antipsychotic agents is incomplete for most schizophrenia patients. In order to enhance outcome, cognitive approaches are increasingly adopted as add-on interventions. The present study aimed to determine the efficacy of group Metacognitive Training (MCT), which targets cognitive biases putatively involved in the pathogenesis of delusions. METHODS: A two-center, randomized, assessor-blind, controlled trial between MCT group training and cognitive training was carried out (ISRCTN95205723). A total of 150 in- and outpatients with DSM diagnoses of schizophrenia spectrum disorders were enrolled. All patients were concurrently prescribed antipsychotic medication. Assessments were made at baseline, four weeks and six months later. The primary outcome was a delusion score derived from the Positive and Negative Syndrome Scale (PANSS). The Psychotic Symptom Rating Scales (PSYRATS) as well as cognitive measures served as secondary outcomes. RESULTS: Completion at follow-up was 86%. According to intention-to-treat (ITT) analyses, patients in the MCT group showed significantly greater symptom reduction on the PANSS delusion subscore (follow-up), PANSS positive score (post-treatment) and PSYRATS delusion score (post-treatment and follow-up). Improvement on the PANSS positive scale at post-treatment and follow-up was positively correlated with the number of attended MCT sessions. No changes were seen for other psychopathological syndromes. DISCUSSION: MCT, a low-intensity training aimed at enhancing patients' awareness of cognitive biases subserving paranoia, led to improvement in delusion symptoms relative to the control condition and over and above the effects of antipsychotic medication. This improvement was sustained at follow-up.

Risk recognition and sensation seeking in revictimization and posttraumatic stress disorder.

Impaired risk recognition has been suggested to be associated with the risk for revictimization and the development of posttraumatic stress disorder (PTSD). Moreover, risk behavior has been linked to high sensation seeking, which may also increase the probability of revictimization. A newly designed behavioral experiment with five audiotaped risk scenarios was used to investigate risk recognition in revictimized, single-victimized, and nontraumatized individuals with and without PTSD. Moreover, the potential role of sensation seeking in revictimization, and PTSD as well as its relation to risk recognition was explored. Revictimized, single-victimized, and nontraumatized individuals did not differ with regard to general risk recognition. However, delayed risk recognition was found for the revictimized group when arousal ratings were considered. No differences in sensation seeking were found between the three groups; only the nontraumatized group showed lower boredom susceptibility relative to the revictimized group. Delayed risk recognition was associated with high sensation seeking. Furthermore, PTSD symptoms significantly predicted exit levels of risk scenarios. Findings are discussed against the background of previous research.

Incorrigibility, jumping to conclusions, and decision threshold in schizophrenia.

INTRODUCTION: Previous studies confirmed a bias against disconfirmatory evidence (BADE) for both delusional and delusion-neutral events in paranoid schizophrenia. In the present study, we examined a potential relationship between the BADE and delusional ideation. METHODS: Fifty-five patients with schizophrenia (32 with current delusions), 20 patients with obsessive-compulsive disorder and 30 healthy participants were presented written scenarios composed of three successive sentences which increasingly disambiguated the situation. Participants were asked to rate interpretations presented along with the sentences. After each new sentence, participants could adjust their judgements in view of the new information. One interpretation ("true") did not seem to fit the first statement but became increasingly plausible, whereas "lure" interpretations appeared very likely initially but were eventually incorrect. Patients were given the option to decide for one of the statements. RESULTS: Patients with schizophrenia, irrespective of delusion severity, attenuated their ratings significantly less for lure interpretations in face of disconfirmatory evidence (BADE) compared to both control groups. We found no impairment regarding the integration of confirmatory evidence. Patients with schizophrenia made more incorrect decisions after the first sentence indicating jumping to conclusions relative to healthy controls. Participants with schizophrenia showed a lowered decision threshold compared to the controls. CONCLUSIONS: The findings lend further evidence to the claim that patients with schizophrenia are hastier and rather inflexible in their decision making. This response pattern may represent a trait-like vulnerability factor for the emergence of delusional incorrigibility, a hallmark symptom of schizophrenia.

Was Freud partly right on obsessive-compulsive disorder (OCD)? Investigation of latent aggression in OCD.

Inflated responsibility is increasingly regarded a pathogenetic mechanism in obsessive-compulsive disorder (OCD). In seeming contrast, there is mounting evidence that latent aggression is also elevated in OCD. Building upon psychodynamic theories that an altruistic façade including exaggerated concerns for others is partly a defense against latent aggression, evidence was recently obtained for high interpersonal ambivalence in OCD patients relative to psychiatric and healthy controls using a newly developed instrument entitled the Responsibility and Interpersonal Behaviors and Attitudes Questionnaire (RIBAQ). A total of 46 OCD patients and 23 healthy participants took part in the present study. OCD patients displayed a higher social responsibility than controls. At the same time, patients also disclosed more latent aggression/calculating behavior and interpersonal distrust. While the pathogenic role of latent aggression is still not fully uncovered, it may deserve more consideration in treatment in view of frequent tensions in the families of OCD patients. Longitudinal studies with at-risk sample are needed to assess the relationship between problems with anger expression as well as (exaggerated) moral standards in OCD.

Detecting and defusing cognitive traps: metacognitive intervention in schizophrenia.

PURPOSE OF REVIEW: Until recently, psychological therapy for schizophrenia was considered harmful or inefficient by many clinicians. The reservation against psychotherapy is partly rooted in the assumption that delusions in particular and schizophrenia in general are not amenable to psychological understanding and represent 'utter madness'. However, meta-analyses suggest that cognitive intervention is effective in ameliorating schizophrenia symptoms. In addition, evidence has accumulated that cognitive biases, such as jumping to conclusions, are involved in the pathogenesis of schizophrenia positive symptoms, particularly delusions. A recently developed group program, called metacognitive training (MCT), is presented targeting these biases. MCT is a hybrid of psychoeducation, cognitive remediation and cognitive-behavioural therapy. RECENT FINDINGS: This review introduces new evidence on cognitive biases involved in the pathogenesis of schizophrenia and demonstrates how the MCT raises the patients' (metacognitive) awareness to detect and defuse such 'cognitive traps'. At the end, a new individualized variant entitled MCT+ is presented targeting individual delusional ideas. Finally, empirical results are summarized that speak in favour of the feasibility and efficacy of MCT. SUMMARY: Recent studies assert marked cognitive biases in schizophrenia. MCT has evolved as a feasible and effective complement of standard psychiatric treatment.

Generic and illness-specific quality of life in obsessive-compulsive disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) is a chronic and disabling disorder. It profoundly compromises various aspects of patients' everyday life, thus affecting their quality of life (QoL). Using generic instruments, several studies have confirmed severely impaired health-related QoL in patients diagnosed with OCD. However, there has been a dearth of research on illness-specific QoL. AIMS: The present study aimed to further investigate subjective QoL in individuals with OCD with a focus on illness-specific aspects. METHOD: To assess subjective QoL in a broad OCD sample, an internet survey was conducted with 123 participants with obsessive-compulsive symptoms. The survey comprised both a generic (WHOQOL-BREF) and a novel self-developed OCD-specific QoL measure (QoLOC). Psychopathology was determined with diagnostic standard instruments (self-report forms of: Y-BOCS, OCI-R, BDI-SF). RESULTS: Regression analyses confirmed depression as the best predictor for decreased QoL. In addition, participants reported high despair resulting from OCD-related problems that differed across symptom subtypes. An exploratory factor analysis suggested four domains of OCD-specific problems tapped by the QoLOC: (1) depressiveness in association with OCD; (2) constraints in activities due to OCD symptoms or avoidance; (3) problems with partner and/or family due to OCD symptoms or avoidance; (4) self-concept/coping of own illness. CONCLUSIONS: Results produced a comprehensive picture of QoL impairments and their relation to psychopathology in a representative OCD sample. Illness-specific concerns should be further addressed in QoL research in OCD because such problems are not sufficiently mirrored in generic QoL measures.

Characteristics and organization of the worst moment of trauma memories in posttraumatic stress disorder.

It has been proposed that the organization of the worst moment in traumatic memories ("hotspots") is of particular importance for the development of PTSD. However, current knowledge regarding the organization and content of worst moments is incomplete. In the present study, trauma survivors with (n=25) and without PTSD (n=54) were asked to indicate the worst moment of their trauma and to give a detailed narrative of the traumatic event. The worst moment and the remaining narrative were analyzed separately with regard to organization and emotional content. Results indicated that worst moments of trauma survivors with PTSD differed from the remaining narrative and from worst moments described by trauma survivors without PTSD in that they were characterized by more unfinished thoughts, more use of the present tense and lower levels of cognitive processing. However, hypotheses regarding differentiating emotional content were not supported. Implications for our theoretical understanding of PTSD and potential therapeutic interventions are discussed.

Different sides of the same coin? Intercorrelations of cognitive biases in schizophrenia.

INTRODUCTION: A number of cognitive biases have been associated with delusions in schizophrenia. It is yet unresolved whether these biases are independent or represent different sides of the same coin. METHODS: A total of 56 patients with schizophrenia underwent a comprehensive cognitive battery encompassing paradigms tapping cognitive biases with special relevance to schizophrenia (e.g., jumping to conclusions, bias against disconfirmatory evidence), motivational factors (self-esteem and need for closure), and neuropsychological parameters. Psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS). RESULTS: Core parameters of the cognitive bias instruments were submitted to a principal component analysis which yielded four independent components: jumping to conclusions, personalising attributional style, inflexibility, and low self-esteem. CONCLUSIONS: The study lends tentative support for the claim that candidate cognitive mechanisms for delusions only partially overlap, and thus encourage current approaches to target these biases independently via (meta)cognitive training.

Perseveration and not strategic deficits underlie delayed alternation impairment in obsessive-compulsive disorder (OCD).

The claim that the prefrontal cortex, particularly its orbito-frontal part, is involved in obsessive-compulsive disorder (OCD) is based upon evidence from neuroimaging as well as behavioral studies. Studies have repeatedly suggested problems with delayed alternation learning in OCD, an executive dysfunction that presumably involves the orbito-frontal cortex. However, it is unclear whether such impairment stems from perseveration or strategic deficits as these aspects are intertwined in the original task. In the present study, 36 OCD and 16 healthy controls underwent a variant of the delayed alternation task involving three response options instead of two as in the original task. This modification enabled us to separate perseveration errors (i.e., the participant incorrectly chooses the same response option as before) from shift errors (i.e., the decision is switched to an incorrect response alternative). We found that patients with OCD committed significantly more perseveration errors following previously valid response options, whereas perseveration for previously invalid responses and shift errors did not distinguish groups. Group differences were not accounted for by comorbid depression and may be linked to the pathogenesis of OCD.

Evidence for an attentional bias for washing- and checking-relevant stimuli in obsessive-compulsive disorder.

There is equivocal evidence whether or not patients with obsessive-compulsive disorder (OCD) share an attentional bias for concern-related material and if so, whether this reflects hypervigilance towards or problems to disengage from disorder-related material. In a recent study, we failed to detect an attentional bias in OCD patients using an emotional variant of the inhibition of return (IOR) paradigm containing OCD-relevant and neutral words. We reinvestigated the research question with a more stringent design that addressed potential moderators. A new IOR paradigm was set up using visual stimuli. Forty-two OCD patients and 31 healthy controls were presented with neutral (e.g., cup), anxiety-relevant (e.g., shark), checking-relevant (e.g., broken door), and washing-relevant (e.g., dirty toilet) cue pictures at one of two possible locations. Following a short or long interval sensitive to automatic versus controlled processes, a simple target stimulus appeared at either the cued or the uncued location. OCD patients responded significantly slower to targets that were preceded by an OCD-relevant cue. Results lend support to the claim that OCD patients share a processing abnormality for concern-related visual material.

The organization of autobiographical and nonautobiographical memory in posttraumatic stress disorder (PTSD).

Disorganized trauma memory seems to play an important role in the pathogenesis of posttraumatic stress disorder (PTSD). However, it is unclear whether memory organization of nonautobiographical material (i.e., sequence memory) is also impaired in PTSD. A novel task designed to assess nonautobiographical memory for content and order information was administered to trauma survivors with (n = 26) and without PTSD (n = 55) as well as to nontraumatized healthy adults (n = 30). In addition, traumatized participants were asked to give a detailed narrative of the traumatic event and an unpleasant autobiographical event. Transcripts of both types of narratives were analyzed with regard to disorganization. Results indicated that trauma memories were more disorganized than memories of an unpleasant event in the PTSD group in comparison with the non-PTSD group. However, no differences were found for memory organization of nonautobiographical material among trauma survivors with and without PTSD and nontraumatized controls. With regard to memory accuracy of nonautobiographical material, group differences were more strongly associated with trauma exposure than with PTSD.

Visual false memories in post-traumatic stress disorder (PTSD).

There is an ongoing debate whether or not patients with post-traumatic stress disorder (PTSD) are more prone to produce false memories. The present study investigated this question using a visual variant of the Deese-Roediger-McDermott (DRM) paradigm, additionally addressing underlying mechanisms of false memory production (e.g., depression, dissociation, emotional valence, arousal). The visual paradigm was administered to 48 traumatized individuals with (n=20) and without PTSD (n=28) and 28 non-traumatized controls. Groups did not differ with regard to memory performance and memory confidence. False memories were correlated with depression. We recommend that future studies employ trauma-related material to further explore memory aberrations in PTSD.

No evidence for object alternation impairment in obsessive-compulsive disorder (OCD).

Recent neuroimaging studies have consistently ascribed the orbito-frontal cortex (OFC) a pivotal role in the pathogenesis of obsessive-compulsive disorder (OCD). Cognitive tests presumed sensitive to this region, such as the Object Alternation Task (OAT), are considered important tools to verify this assumption and to investigate the impact of cortical dysfunction on behavior. The aim of the present study was to assess if patients with OCD show enhanced perseveration errors on the OAT relative to healthy controls taking into account several potential moderators, especially comorbid depression and OCD subtype. Thirty-five OCD patients and 18 healthy controls underwent the OAT as well as the Trail-Making Tests (TMT) A and B. In line with prior studies, OCD patients were slowed on both TMT tasks. In contrast, samples performed similarly on the OAT. While the latter finding does not invalidate the assumption that the OFC is affected in OCD, dysfunctions involving this region may be more subtle than often claimed and likely encompass only a small subset of functional domains hosted in the OFC.

Words may not be enough! No increased emotional Stroop effect in obsessive-compulsive disorder.

Conflicting evidence has been obtained whether or not patients diagnosed with obsessive-compulsive disorder (OCD) share an attentional bias towards disorder-related stimuli. Some of these inconsistencies can be accounted for by suboptimal stimuli selection. In consideration of the heterogeneity of OCD, we investigated Stroop interference effects for two classes of OCD items (i.e., washing and checking) in 23 OCD patients and 23 healthy controls. In order to cover prevalent OCD concerns, item compilation was based on experts' appraisals. Patients neither displayed greater immediate as well as delayed Stroop interference nor any bias for OCD and subtype-congruent stimuli. On the contrary, for washing-related items, OCD patients, and here especially washers, displayed facilitation relative to healthy controls. Although the present study at first sight refutes the notion of an attentional bias in OCD in contrast to other anxiety disorders, several potential moderators need to be considered before this account is ultimately dismissed. In particular, an attentional bias may only be elicited using visual material that is more attention-grabbing than verbal stimuli. Finally, blockwise instead of random item administration and greater consideration of individual relevance may be crucial prerequisites for the effect to emerge.

Does the evocation of traumatic memories confound subsequent working memory performance in posttraumatic stress disorder (PTSD)?

The role of heightened arousal has been previously discussed as a contributor to neurocognitive impairment in posttraumatic stress disorder (PTSD). To investigate whether psychological effects (distraction, re-location of resources) elicited by the evocation of traumatic memories impact on subsequent cognitive performance in PTSD, two parallel versions of a working memory task were administered to 33 trauma-exposed participants (15 with and 18 without PTSD). Between first and second working memory assessment a trauma-related interview was conducted including the narration of the trauma. Levels of working memory impairment in PTSD patients remained unchanged. This study provides preliminary evidence that neurocognitive impairment is not secondary to psychological effects induced by the evocation of traumatic memories. Nevertheless, it is recommended that future PTSD research should devote more care to the order in which trauma-related and other dependent variables such as cognitive tests are presented to participants.