Reasoning in psychosis: risky but not necessarily hasty.

INTRODUCTION: A liberal acceptance (LA) threshold for hypotheses has been put forward to explain the well-replicated "jumping to conclusions" (JTC) bias in psychosis, particularly in patients with paranoid symptoms. According to this account, schizophrenia patients rest their decisions on lower subjective probability estimates. The initial formulation of the LA account also predicts an absence of the JTC bias under high task ambiguity (i.e., if more than one response option surpasses the subjective acceptance threshold). METHODS: Schizophrenia patients (n = 62) with current or former delusions and healthy controls (n = 30) were compared on six scenarios of a variant of the beads task paradigm. Decision-making was assessed under low and high task ambiguity. Along with decision judgments (optional), participants were required to provide probability estimates for each option in order to determine decision thresholds (i.e., the probability the individual deems sufficient for a decision). RESULTS: In line with the LA account, schizophrenia patients showed a lowered decision threshold compared to controls (82% vs. 93%) which predicted both more errors and less draws to decisions. Group differences on thresholds were comparable across conditions. At the same time, patients did not show hasty decision-making, reflecting overall lowered probability estimates in patients. CONCLUSIONS: Results confirm core predictions derived from the LA account. Our results may (partly) explain why hasty decision-making is sometimes aggravated and sometimes abolished in psychosis. The proneness to make risky decisions may contribute to the pathogenesis of psychosis. A revised LA account is put forward.

Sustained and "sleeper" effects of group metacognitive training for schizophrenia: a randomized clinical trial.

IMPORTANCE: Cognitive interventions increasingly complement psychopharmacological treatment to enhance symptomatic and functional outcome in schizophrenia. Metacognitive training (MCT) is targeted at cognitive biases involved in the pathogenesis of delusions. OBJECTIVE: To examine the long-term efficacy of group MCT for schizophrenia in order to explore whether previously established effects were sustained. DESIGN, SETTING, AND PARTICIPANTS: A 2-center, randomized, controlled, assessor-blind, parallel group trial was conducted. A total of 150 inpatients or outpatients with DSM-IV diagnoses of schizophrenia spectrum disorders were enrolled. All patients were prescribed antipsychotic medication. The second follow-up assessment took place 3 years later after the intervention phase was terminated. INTERVENTIONS: Group MCT targeting cognitive biases vs neuropsychological training (COGPACK). Patients received a maximum of 16 sessions. MAIN OUTCOMES AND MEASURES: The primary outcome measure was a delusion score derived from the Positive and Negative Syndrome Scale (PANSS). The PANSS positive syndrome and total scores, the Psychotic Symptom Rating Scales, the jumping to conclusions bias, self-esteem, and quality of life served as secondary outcome measures. RESULTS: The intention-to-treat analyses demonstrated that patients in the MCT group had significantly greater reductions in the core PANSS delusion score, after 3 years compared with the control group (η2partial = .037; P = .05). Among the secondary outcomes, the intention-to-treat analyses also demonstrated that patients in the MCT group had significantly greater reductions in the PANSS positive syndrome score (η2partial = .055; P = .02) and the Psychotic Symptom Rating Scales delusion score (η2partial = .109; P = .001). Significant group differences at the 3-year follow-up were also found on measures of self-esteem and quality of life, which did not distinguish groups at earlier assessment points. Attention was improved in the neuropsychological training group relative to the MCT group. The completion rate was 61.3% after 3 years. CONCLUSIONS AND RELEVANCE: Metacognitive training demonstrated sustained effects in the reduction of delusions, which were over and above the effects of antipsychotic medication. Moreover, there were some unanticipated ("sleeper") effects as both self-esteem and quality of life were improved after 3 years. Effects on self-esteem and well-being were found even in the absence of an improvement on the jumping to conclusions bias. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN95205723.

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.

Predictors of early stable symptomatic remission after an exacerbation of schizophrenia: the significance of symptoms, neuropsychological performance and cognitive biases.

Neuropsychological deficits and severity of initial psychopathology have been repeatedly associated with poor symptomatic outcomes in schizophrenia. The role of higher-order cognitive biases on symptomatic outcomes of the disorder has not yet been investigated. The present study aimed to assess the contribution of cognitive biases, psychopathology and neuropsychological deficits on the probability of achieving early symptomatic remission after a psychotic episode in patients with schizophrenia. Participants were 79 patients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder undergoing an acute psychotic episode, and 25 healthy controls. According to psychopathology assessments, patients were split into those who had achieved remission after an average follow-up interval of 7 months, and those who had not (NR). Patients who achieved remission exhibited higher premorbid IQ and better performance on the TMT-B, as well as lower baseline positive, disorganized and distress symptoms than NR patients. TMT-B performance and positive symptoms at baseline were the best predictors of remission. Cognitive biases and negative symptoms were not associated with later remission. The findings highlight the significance of initial symptom severity for at least short-term symptomatic outcomes and, thus, the importance of adequate symptomatic treatment and prevention of psychotic outbreaks in patients.

Predictors of performance improvements within a cognitive remediation program for schizophrenia.

Cognitive impairment is regarded a core feature of schizophrenia and is associated with low psychosocial functioning. There is rich evidence that cognitive remediation can improve cognitive functions in patients with schizophrenia. However, little is known about what predicts individual remediation success. Some studies suggest that baseline cognitive impairment might be a limiting factor for training response. Aim of the current study was to further examine the role of cognitive and symptom variables as predictors of remediation success. We studied a total sample of 32 patients with schizophrenia and schizoaffective disorder who were engaged in a computer-based cognitive training program (CogPack). A pre-training test battery provided cognitive measures of selective attention, executive functioning, processing speed, verbal memory, and verbal intelligence along with measures for positive and negative symptoms. Training response was defined as improvement on training tasks. Correlation analyses revealed no significant relationship between any of the baseline cognitive or symptom measures and improvement rates. However, better baseline cognition was associated with a higher percentage of tasks with initial ceiling effects. We conclude that not carefully tailoring task difficulty to patients' cognitive abilities constitutes a much more severe threat to cognitive remediation success than cognitive impairment itself.

"Don't give me that look" - overconfidence in false mental state perception in schizophrenia.

Dysfunctions in social cognition are implicated in the pathogenesis of schizophrenia and have been extensively replicated over the years. For memory research, the administration of cognitive tasks with metacognitive aspects like confidence ratings has deepened our insight into how impairments contribute to symptoms of the disorder. A total of 76 patients with schizophrenia or schizoaffective disorder and a sample of 30 healthy participants were tested with the Reading the Mind in the Eyes test (Eyes-test). The Eyes-test was complemented with a rating scale requesting response confidence and was administered along with paradigms tapping neuropsychological parameters and cognitive insight. Schizophrenia patients showed impaired abilities on mental state perception. In addition, they committed more high-confidence errors and at the same time made fewer high-confidence correct responses. Impairments were most pronounced in patients with formal thought disorder. The patients displayed a decreased metacognitive awareness for their deficits. The results suggest that adding confidence ratings to the investigation of social cognition promises to advance our understanding of social cognition in schizophrenia. Patients not only show severe impairments in social cognition, but are overconfident in their judgments and lack cognitive insight into their deficits. The results highlight the need for metacognitive therapeutic approaches for the treatment of this population.

Maturation of P300 amplitude and short-term learning as reflected by P300 habituation between trial blocks in children.

Although numerous studies concerning P300 have been reported in adults, few have focused on the normal development of children, particularly in relation to habituation. The aim of this study was to investigate maturation of the P300 component and its habituation (short-term automatic learning) in a sample of healthy children and adolescents. Four models of maturation of the P300 (linear, quadratic or two different linear regressions for the pre-pubertal and pubertal age groups as well as age-inverse) were applied and compared, in order to find the most adequate model according to the Bayesian Information Criterion. A visual oddball paradigm was presented to 81 healthy children and adolescents aged 6-18 years. Three blocks, each with 200 trials were recorded to assess between-block habituation. The data was best fitted to (a) an age-inverse relation between P300 latency and age, and (b) a linear relationship between P300 amplitude and age. An age-dependent effect of habituation was detected in the P300 amplitude, where a considerable amplitude decline was found in the younger children and no significant change for adolescents. Our results support the hypothesis that younger children show stronger habituation effects because they activate a larger neuronal pool from which unnecessary neurons can be excluded during short-term learning. In contrast, in adolescents, these neurons may have already been eliminated as a consequence of pruning, thus reducing habituation effects. Future studies are required to test this hypothesis because our data do not permit alternative explanations to be discarded.

Context representation and thought disorder in schizophrenia.

BACKGROUND: Formal thought disorder (FTD) in schizophrenia is related to a disturbance in the representation of contextual information. This study aimed to assess the extent to which the 'context module' is disturbed in patients with schizophrenia. The context module is needed to mediate an appropriate behavioral response. It comprises 2 cognitive functions, namely working memory and behavioral inhibition, and is linked to networks in the prefrontal cortex. We compared patients with enhanced FTD (n = 15) to ones with low levels and a control group (n = 21, respectively). We hypothesized that FTD patients would have greater degradation of the context module by presenting both working memory and inhibition deficits, while in low FTD patients mild degradation of the context module would be present with working memory deficits only. METHODS: Using a within-subjects design, subjects underwent a battery of neuropsychological tests with different demands on the context module. We also divided patients according to first-episode versus chronic course. RESULTS: Our results confirmed our predictions on FTD. However, first-episode patients showed working memory deficits more than those with several episodes. CONCLUSION: We conclude that the context module is more degraded in FTD patients, although our results have to be interpreted with caution because of the small sample size.

Metacognitive training for patients with schizophrenia (MCT): feasibility and preliminary evidence for its efficacy.

BACKGROUND: The treatment program "Metacognitive training for patients with schizophrenia" (MCT) addresses cognitive deficits and biases assumed to play a crucial role in the pathogenesis of delusions (e.g. jumping to conclusions, theory of mind deficits, bias against disconfirmatory evidence). The feasibility of this approach and its effects on positive symptoms and cognitive biases were investigated in this pilot study. METHODS: Thirty inpatients of the Department of Psychiatry of the University Hospital Heidelberg with a schizophrenia spectrum diagnosis were randomly assigned to either MCT or an active control intervention. Both training programs were carried out over a time period of four weeks. Psychopathological, cognitive and metacognitive measures were collected at baseline and after completion of the training. Schizophrenia symptoms were determined blind to group allocation with the Positive and Negative Syndrome Scale (PANSS). RESULTS: No adverse reactions were noted in the MCT group and patients expressed a greater subjective training success relative to the control condition (d = .57). A stronger improvement on all PANSS subscales was found at a descriptive level; positive symptoms attenuated under MCT with a medium effect size of d = .43. In addition, results showed a reduced jumping to conclusions bias for MCT patients (d = .31). However, none of the effects reached statistical significance. Optimal sample size was calculated for future studies. CONCLUSION: The present study confirms the feasibility of MCT and provides preliminary evidence for its efficacy ameliorating positive symptoms and the jumping to conclusions bias.