Metacognitive Reflection and Insight Therapy (MERIT): Application to a Long-Term Therapy Case of Borderline Personality Disorder.

Impairments in metacognitive capacity-or the processes that enable individuals to access, understand, and integrate their ideas about their own and others' mental states-are a core barrier to recovery for many people with borderline personality disorder. Although therapeutic approaches that focus on metacognitive capacity are emerging, few deal with the concept of recovery at a foundational level. This article describes how a form of metacognitively oriented psychotherapy focused on recovery, metacognitive reflection and insight therapy (MERIT), assisted a patient with borderline personality disorder and initial metacognitive deficits to develop a complex understanding of himself and others and then to use that knowledge to act as an agent in the world and effectively respond to life challenges. The eight elements of MERIT that stimulate and promote metacognitive capacity are presented with an emphasis on how they were implemented to assist the patient in achieving recovery.

Negative symptoms in bipolar disorder and schizophrenia: A psychometric evaluation of the brief negative symptom scale across diagnostic categories.

Past studies have demonstrated that the Brief Negative Symptom Scale (BNSS) has excellent psychometric properties in patients with schizophrenia. In the current study, we extended this literature by examining psychometric properties of the BNSS in outpatients diagnosed with bipolar disorder (n=46), outpatients with schizophrenia (n=50), and healthy controls (n=27). Participants completed neuropsychological testing and a clinical interview designed to assess negative, positive, disorganized, mood, and general psychiatric symptoms. Results indicated differences among the 3 groups in the severity of all BNSS items, with SZ and BD scoring higher than CN; however, SZ and BD only differed on blunted affect and alogia items, not anhedonia, avolition, or asociality. BD patients with a history of psychosis did not differ from those without a history of psychosis on negative symptom severity. The BNSS had excellent internal consistency in SZ, BD, and CN groups. Good convergent and discriminant validity was apparent in SZ and BD groups, as indicated by relationships between the BNSS and other clinical rating scales. These findings support the validity of the BNSS in broadly defined serious mental illness populations.

Concurrent sound segregation impairments in schizophrenia: The contribution of auditory-specific and general cognitive factors.

The present study sought to test whether perceptual segregation of concurrently played sounds is impaired in schizophrenia (SZ), whether impairment in sound segregation predicts difficulties with a real-world speech-in-noise task, and whether auditory-specific or general cognitive processing accounts for sound segregation problems. Participants with SZ and healthy controls (HCs) performed a mistuned harmonic segregation task during recording of event-related potentials (ERPs). Participants also performed a brief speech-in-noise task. Participants with SZ showed deficits in the mistuned harmonic task and the speech-in-noise task, compared to HCs. No deficit in SZ was found in the ERP component related to mistuned harmonic segregation at around 150ms (the object-related negativity or ORN), but instead showed a deficit in processing at around 400ms (the P4 response). However, regression analyses showed that indexes of education level and general cognitive function were the best predictors of sound segregation difficulties, suggesting non-auditory specific causes of concurrent sound segregation problems in SZ.

Differential impairment of social cognition factors in bipolar disorder with and without psychotic features and schizophrenia.

While it is well-established that patients with schizophrenia and bipolar disorder exhibit deficits in social cognition, few studies have separately examined bipolar disorder with and without psychotic features. The current study addressed this gap by comparing patients with bipolar disorder with (BD+) and without (BD-) psychotic features, patients with schizophrenia (SZ), and healthy controls (NC) across social cognitive measures. Principal factor analysis on five social cognition tasks extracted a two-factor structure comprised of social/emotional processing and theory of mind. Factor scores were compared among the four groups. Results identified differential patterns of impairment between the BD+ and BD- group on the social/emotional processing factor while all clinical groups performed poorer than controls on the theory of mind factor. This provides evidence that a history of psychosis should be taken into account while evaluating social cognition in patients with bipolar disorder and also raises hypotheses about the relationship between social cognition and psychosis.

Emotion perception abnormalities across sensory modalities in bipolar disorder with psychotic features and schizophrenia.

Emotion perception deficits are a well-established feature of schizophrenia (SZ). Individuals with SZ have difficulty labeling emotional stimuli across auditory, visual, and audio-visual modalities and also misattribute threat towards neutral stimuli. The relationship between a history of psychosis and similar abnormalities in bipolar disorder (BD) is less clear. The current study set out to examine emotion perception across sensory modalities in a sample of 24 stabilized individuals meeting criteria for SZ, 24 remitted individuals meeting criteria for BD with psychotic features, 24 remitted individuals meeting criteria for BD without psychotic features, and 24 healthy controls. Results indicated that the bipolar with psychotic features group had intermediary performance between the SZ group and the other two groups for auditory, visual, and audio-visual items, with particularly poor performance in identifying angry stimuli. The SZ group misattributed neutral stimuli as negative when they were in visual format, but as positive when they were in auditory or audio-visual formats. The bipolar with psychotic features group had a trend towards misattributing more neutral visual stimuli as negative. These findings indicate that emotion perception deficits are present in BD with psychotic features and comparatively spared in BD without psychotic features, and that a similar bias of misattributing negative emotions to neutral visual stimuli may be present across diagnostic boundaries.

Differences in developmental changes in academic and social premorbid adjustment between males and females with schizophrenia.

The assessment of premorbid adjustment in schizophrenia has received considerable attention because of models suggesting that schizophrenia is a neurodevelopmental disorder characterized by abnormalities in functioning prior to onset of the disorder. Some studies suggest that premorbid adjustment is best viewed as a multidimensional construct where different areas of functioning might be differentially impacted by the illness and sex. The current study examined these matters using of Premorbid Adjustment Scale (PAS) in a sample of 421 individuals with schizophrenia. Confirmatory factory analyses conducted for three developmental periods (childhood, early adolescence, late adolescence) and for males and females separately, indicated that the PAS consists of academic and social factors that are invariant across developmental period and sex. However, differences in severity of academic and social premorbid impairment were present between males and females across developmental periods. Findings suggest important differences between males and females in the course of premorbid deterioration prior to onset of schizophrenia.

Factor structure of the Comprehensive Trail Making Test in children and adolescents with brain dysfunction.

The Comprehensive Trail Making Test (CTMT) is a relatively new version of the Trail Making Test that has a number of appealing features, including a large normative sample that allows raw scores to be converted to standard T scores adjusted for age. Preliminary validity information suggests that CTMT scores are sensitive to brain injury and demonstrate expected correlations with other neuropsychological tests, although the evidence also suggests that the factor structure of the CTMT may differ in children with brain dysfunction in comparison to the standardization sample. The present study addresses this matter by conducting a confirmatory factor analysis (CFA) of the CTMT in 382 children and adolescents. Of the 382, 191 were diagnosed with various forms of brain dysfunction, including 140 who had sustained a traumatic brain injury. The other 191 participants were healthy controls who were individually matched on age and gender to the clinical group with brain dysfunction. Results of the CFA indicated that for the clinical group, a 2-factor model composed of Simple Sequencing and Complex Sequencing/Shifting factors provided the best fit for the data. Although these 2 factors were also identified in the controls, differences in pattern of loadings were present. Results suggest that the presence of brain dysfunction may alter the factor structure of the CTMT in children and adolescents.

Measures of learning, memory and processing speed accurately predict smoking status in short-term abstinent treatment-seeking alcohol-dependent individuals.

AIM: Chronic cigarette smoking appears to adversely affect several domains of neurocognition in those with alcohol use disorders (AUDs). The primary goal of this study was to identify which measures commonly used to assess neurocognition in AUDs accurately predict smoking status of individuals seeking treatment of alcohol dependence. METHODS: Treatment-seeking alcohol-dependent participants (ALC; n = 92) completed a comprehensive neuropsychological battery after 33 ± 9 days of abstinence. Measures significantly different between smoking and non-smoking ALC were entered as predictors in binary logistic regression and discriminant analysis models, with smoking status as the dependent variable. RESULTS: Smoking ALC performed significantly worse than non-smoking ALC on measures assessing processing speed, auditory-verbal and visuospatial learning and memory. Using these measures as predictors, a logistic regression model accurately classified 91% of smokers and non-smokers into their respective groups overall and accounted for 68% of the variance in smoking status. The discriminant analysis confirmed the findings from the logistic regression. In smoking ALC, smoking chronicity was inversely related to performance on multiple measures after controlling for lifetime alcohol consumption. CONCLUSIONS: Measures of processing speed, learning and memory robustly predicted the smoking status of ALC with high sensitivity and specificity during early abstinence. The results identified specific measures within a comprehensive neurocognitive battery that discriminated smoking and non-smoking alcohol-dependent individuals with a high sensitivity and specificity. The association of greater smoking chronicity and poorer performance on multiple measures after control for alcohol consumption suggests that chronic smoking adds an additional burden to neurocognitive function in those with alcohol dependence.

Timing is everything: neural response dynamics during syllable processing and its relation to higher-order cognition in schizophrenia and healthy comparison subjects.

Successful linguistic processing requires efficient encoding of successively-occurring auditory input in a time-constrained manner, especially under noisy conditions. In this study we examined the early neural response dynamics to rapidly-presented successive syllables in schizophrenia participants and healthy comparison subjects, and investigated the effects of noise on these responses. We used magnetoencephalography (MEG) to reveal the time-course of stimulus-locked activity over bilateral auditory cortices during discrimination of syllable pairs that differed either in voice onset time (VOT) or place of articulation (POA), in the presence or absence of noise. We also examined the association of these early neural response patterns to higher-order cognitive functions. The M100 response, arising from auditory cortex and its immediate environs, showed less attenuation to the second syllable in patients with schizophrenia than healthy comparison subjects during VOT-based discrimination in noise. M100 response amplitudes were similar between groups for the first syllable during all three discrimination conditions, and for the second syllable during VOT-based discrimination in quiet and POA-based discrimination in noise. Across subjects, the lack of M100 attenuation to the second syllable during VOT-based discrimination in noise was associated with poorer task accuracy, lower education and IQ, and lower scores on measures of Verbal Learning and Memory and Global Cognition. Because the neural response to the first syllable was not significantly different between groups, nor was a schizophrenia-related difference obtained in all discrimination tasks, early linguistic processing dysfunction in schizophrenia does not appear to be due to general sensory input problems. Rather, data suggest that faulty temporal integration occurs during successive syllable processing when the signal-to-noise ratio is low. Further, the neural mechanism by which the second syllable is suppressed during noise-challenged VOT discrimination appears to be important for higher-order cognition and provides a promising target for neuroscience-guided cognitive training approaches to schizophrenia.

Neuropsychological substrates and everyday functioning implications of prospective memory impairment in schizophrenia.

Individuals with schizophrenia demonstrate impairment in prospective memory (ProM), which describes the multifaceted ability to execute a future intention. Despite its clear implications for everyday functioning, the neuropsychological substrates and functional correlates of ProM impairment in schizophrenia remain poorly understood. In this study, the Memory for Intentions Screening Test (MIST), a standardized measure of ProM, was administered to 72 outpatients with schizophrenia or schizoaffective disorder as part of a comprehensive neuropsychological and psychiatric research evaluation. Results showed that ProM was positively correlated with standard clinical tests of attention, working memory, processing speed, learning, and executive functioning, but not delayed recall. In the context of multiple neuropsychological predictors, learning ability was the only domain that independently contributed to ProM. Importantly, better ProM was predictive of higher functional capacity (as measured by the UCSD Performance-Based Skills Assessment-Brief Version), above and beyond the variability explained by demographic and disease factors. Analysis of component processes revealed that event-based ProM, as well as no response (i.e., omission) and task substitution errors were the strongest predictors of everyday functioning. Overall, these findings suggest that ProM impairment in schizophrenia is associated with multiple cognitive substrates, particularly episodic learning deficits, and plays an important role in everyday living skills. Studies regarding the potential effectiveness of ProM-based remediation strategies to improve functional outcomes in schizophrenia are indicated.