Metacognition and Social Functioning in Schizophrenia

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Metacognition and Social Functioning in Schizophrenia: Evidence, Mechanisms of Influence and Treatment Implications Martin Brüne*,a, Giancarlo Dimaggiob and Paul H. Lysakerc a

Research Department of Cognitive Neuropsychiatry and Psychiatric Preventive Medicine, LWL University Hospital Bochum, Germany; bThird Centre of Cognitive Psychotherapy – Via Ravenna 9/c 00161, Rome, Italy; cRoudebush VA Medical Center and the Indiana University School of Medicine, Indianapolis Indiana USA Abstract: Objective: The term “schizophrenia” concerns heterogeneous psychopathological syndromes that are often associated with neurocognitive impairment and poor functional outcome. Research over the past 20 years or so has revealed that many symptoms associated with schizophrenia can be interpreted as a result of poor “metacognition”, first defined as the ability to think about one’s mental operations, which in our understanding more specifically refers to the ability to reflect upon mental states of oneself and others, and to flexibly entertain this knowledge in social interaction and problemsolving (termed “mastery”). The latter aspect implies that metacognitive dysfunction is putatively critical to explain social impairment. Method: The present article reviews the evidence for a link between metacognitive deficits in schizophrenia and poor social functioning. Results: Metacognition including its subcomponents such as self-reflectivity, empathetic perspective-taking and mastery are profoundly linked with awareness of illness and social functioning in schizophrenia. The impact of metacognition on awareness of illness and social functioning seems to be partially independent of neurocognitive functioning. Conclusion: Research into metacognitive abilities in schizophrenia have revealed new insights into the understanding of individual symptoms and outcome measures, with potentially important implications for psychotherapy and (meta)cognitive remediation in schizophrenia.

Keywords: Metacognition; social functioning; insight; theory of mind; social cognitive remediation; schizophrenia. INTRODUCTION Bleuler and the Concept of Schizophrenic Autism When Eugen Bleuler [1] suggested the term “schizophrenia” in a scientific meeting in 1908, he introduced a novel perspective on psychosis: Instead of focusing on cognitive deterioration, as reflected in the expression “dementia praecox” [2], Bleuler proposed that many cognitive abilities remained intact, yet hidden behind the basic symptoms (“Grundsymptome”) of schizophrenia, namely “loosening of associations”, “disintegrated affect”, “ambivalence” and “autism” [1]. Bleuler probably chose the term “schizophrenia” (literally “split mind”), because he sought to emphasize that patients’ subjective experience of the self as a person was distorted. In contemporary accounts, what Bleuler called “schizophrenic autism” has been reformulated as disorder of intersubjectivity, which includes [1] a unique disturbance of intentionality as shown in the loss of meaning and perplexity, [2] a disturbance in self-reflectivity including anomalous *Address correspondence to this author at the Research Department of Cognitive Neuropsychiatry and Psychiatric Preventive Medicine, LWL University Hospital Bochum, Ruhr-University Bochum, Alexandrinenstr. 1, 44791 Bochum, Germany; Tel: +49-234-5077-1130; Fax: +49-234-5077-1329; E-mail: [email protected] All authors contributed equally to the paper. 1573-4005/11 $58.00+.00

self-experiences, and [3] an impairment in intersubjectivity, which entails disorders of social and personal functioning [4]. Metacognition: Operational Definition and Related Concepts W suggest, in line with Parnas et al. [4] and Stanghellini and Ballerini [5], that this general capacity, which Bleuler regarded as central to the schizophrenia phenotype(s), embraces several facets of detecting, reasoning upon and using mental state information for problem solving purposes and has been named metacognition [6, 7]. The term “metacognition”, as it is used henceforth, clearly overlaps with the concepts of social cognition [8], theory of mind (ToM) [9], metarepresentation [3], mentalizing [10, 11], mental state attribution [12], and cognitive and affective empathy [13], which are often used in largely interchangeable ways [see 14]. Here, we chose the term metacognition, in keeping with a long-standing clinical tradition starting with Main [15] who emphasized that metacognition is the cognitive capacity that enables an individual to understand that others’ behavior is guided by intentional mental states. The use of the term of metacognition in the context of clinical psychology was endorsed by Fonagy et al. [16] and Liotti [17], and by Semerari © 2011 Bentham Science Publishers

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and colleagues [7, 18, 19] to frame problems of patients with personality disorders in understanding human interaction on the basis of mental operations such as thoughts, intentions and feelings of the interacting characters. In this tradition, metacognition refers to a set of skills necessary for identifying mental states and ascribing them to oneself and others, which includes the deciphering of expressions of emotion, the reasoning about mental states and the use of mentalistic information in order to decide, solve problems and interpersonal conflicts, and to master subjective suffering [20]. Currently, the clinical use of the term is even more widespread in investigations of mentalistic problems in patients with personality disorders, mood disorders, post-traumatic stress disorder [6, 17, 21, 23, 24, 25, 26, 27, 28] and schizophrenia [29]. A useful distinction between “attributive” and “strategic” metacognition has been put forth by Saxe and Offen [30], according to which attributive metacognition concerns the ability to attribute beliefs and desires to oneself and others, whereas strategic metacognition pertains to the ability to monitor and control ongoing mental operations [30, p.14]. In contrast to our relatively broad definitional criteria, the term metacognition has also been used in a narrower sense as describing cognitions about one’s own cognitions [31]. Our definition also overlaps considerably with mentalizing [11], whereby the latter mainly concerns reflecting about mental states in different states of activation of the attachment system, while metacognition refers to a wider array of mechanisms that enable an individual to make sense of mental states in the context of any kind of human interactions, including matters of social rank or social exclusion [32]. Moreover, metacognition shares features with the concept of social cognition, which has often been used in research on schizophrenia, including subprocesses such as theory of mind or mentalising. Social cognition, narrowly defined, involves the ability to imagine oneself in situations that are different from the here-and-now, and to take a less subjective stance while evaluating one’s current thoughts and emotions, as adopting the perspective of an external observer about the self [33]. Other researchers see social cognition as a multidimensional construct that includes a broader set of mental operations underlying social action, including emotion recognition; social perception and knowledge; ToM, and attributional style [34, 35, 36, 37]. In contrast to social cognition, metacognition includes in its definition the ability to form integrated narratives built around complex and coherent accounts of how the mental states of both oneself and others change over time. Metacognition also pertains to skills involved in figuring out that mental states of self and others are distinct processes, yet may influence one another during social interaction. Finally, metacognition enables one to use mentalistic information for purposeful problem solving, and, in the case of mental illness, to effectively deal with symptoms, something which is absent in the definition of social cognition [38, 39]. The mastery aspect of metacognition clearly overlaps with aspects of emotional regulation processes described by Ochsner and colleagues [40, 41], emphasizing that emotional regulation is mostly based on understanding the mental states of self and others and use those mental states to modulate one’s affective response, i.e. the other person’s putative intentions. For example, reappraising another’s remark expressed with a negative emotional ex-

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pression as a sign of weakness and not anger may help down-regulating one’s fear of being attacked [41]. Notably, Ochsner [40] suggested that disturbed processes of mentalistic emotion regulation may be prominent in schizophrenia and lead to poor functional outcomes. For example poor regulation of emotion in social context may be due to deficits in correctly understanding the emotions of others. Accordingly, metacognition involves several semiindependent faculties [7, 29, 42] that allow an individual to perform discrete tasks such as forming representations of his or her own mental states and the mental states of others; labeling variations in arousal with appropriate emotional names; inferring emotions in others from non verbal cues such as face and prosody; form, question, accept, reject or revise ideas of what is believed, felt, dreamt of, feared, feigned or pretended in a broad variety of rapidly changing contexts, and to experience agency. These capacities make it possible to assume that others view the world differently than oneself, and to bring existing ambiguity to one’s awareness. Deficits in Metacognition in Schizophrenia and the Theoretical Basis and Preliminary Evidence for their Link with Social Dysfunction In recognition of the complexity of psychosocial dysfunction found in schizophrenia, Chris Frith [3] offered a starting point to systematically address the question of the association of poor metacognition and symptomatology in schizophrenia. He [3, 43] suggested that abilities to form representations of other’s minds and one’s own mind are frequently disrupted in schizophrenia and these disruptions may be one cause of the “core” symptoms and social problems found in schizophrenia. For example, misinterpreting other persons’ intentions due to an inability to discriminate between reality and subjective representation may cause delusional ideation. Difficulties in understanding one’s own behavior as the result of self-generated intentions may lead to the conviction of being under alien control or other socalled passivity symptoms. The inability to initiate an action on the basis of one’s own intentions may manifest in the form of disorganized behavior. Since conscious selfrepresentation including the ability to reflect upon one’s mental and physical integrity includes the concept of insight, impaired metacognition could also be the “missing link” which explains the elusive problem of unawareness of illness in schizophrenia [44, 45]. With regard to social functioning, there are a range of reasons to assume that the hypothesized deficits in metacognition might impact social and vocational function as well. Both evolutionary and developmental perspectives support the view that the ability to form metacognitive representations emerged primarily to flexibly guide an individual’s social behavior [46, 47, 48]. Without such abilities intact, it has been suggested that relationships with others become confusing for persons with schizophrenia and withdrawal the best solution [49]. A plausible representation of one’s own mental states is a prerequisite for the ability to experience the self as an agent such that behavior can be initiated on the basis of one’s perceived intentions [42]. A distortion of this

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ability, as described by Bleuler, would in turn lead to ambivalence, autism and abulia (disorders of “willed action”). Consistent with Bleuler’s insights and Chris Frith’s neuropsychological account, people with schizophrenia have been found to be affected from a wide array of deficits in several of the semi-independent domains of metacognitive functioning. Beginning with self reflectivity, patients with schizophrenia have difficulties in performing tasks which involve the ability to monitor basic cognitive operations [50, 51], to name emotional states [29] and to scrutinize their own beliefs or reflect on their reasoning strategy [52]. They may additionally experience themselves as possessing a limited sense of personal agency and struggle to create complex narratives which capture the story of their lives [53]. Concerning knowledge about thoughts, feeling and intentions of others, a wealth of studies have revealed impaired mental state decoding on the basis of observable cues such as facial expressions of emotions, poor mental state reasoning based on inference, problems in deciphering the hidden meaning behind indirect speech, in understanding metaphors, irony and sarcasm, and in applying the pragmatic rules of language [summarized in 54]. Thus there is evidence of metacognitive deficits that might be expected to limit psychosocial function. Unclear, though, is which kinds of metacognitive deficits are related to which aspects of function and exactly in what manner. More importantly, the question whether metacognitive functioning is linked to psychosocial function independently of other aspects of the disorder, including neurocognitive impairment and individual symptoms is to some extent obscure. Studies of both symptoms and neurocognition suggest that each is somehow linked to psychosocial function [36, 55, 56], however, metacognitive capacity seems to be an important mediating or moderating variable in the complex calculus that determines level of function in schizophrenia [57]. This article aims to explore these questions by reviewing recent studies that examined which aspects of metacognitive dysfunction in schizophrenia are linked to aspects of functioning in the presence or absence of other clinical features of the disorder (or group of disorders). Specifically, we highlight studies into the association of self-reflectivity, metacognitive mastery, and mentalizing skills, including mental state decoding and mental state reasoning, with work function, quality of interpersonal relationships and awareness of illness. We will examine studies of metacognitive capacities using both laboratory “offline” tasks which call for judgments about imaginary situations as portrayed in stories and cartoons, and clinical interviews which solicit a sample of persons’ personal narratives. Following our review, we will discuss treatment implications for the treatment of schizophrenia, specifically the potential of non-pharmacological treatment strategies as well as the areas needing more research. SOCIAL FUNCTIONING AND METACOGNITION Correlations Between Deficits in Self-Reflectivity and Functioning Self-reflectivity refers to the extent to which persons can think in complex ways about themselves, that is, about their

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thoughts and feelings, the interconnections between their thoughts and feelings and about the role of these over the larger course of their lives. Lysaker and colleagues have sought to explore the correlates of self-reflectivity in a range of studies in an outpatient setting with participants with schizophrenia spectrum disorders generally in a later and non-acute phase of illness. In the first of several studies an adaptation of the Metacognitive Assessment Scale (MAS) [7] was used to assess the capacity for self reflectivity on the basis of an interview designed to elicit participants’ personal narrative [29]. Participants were adult men receiving outpatient psychiatric treatment and enrolled in a vocational program. Correlations with concurrent assessment of neurocognition and symptoms revealed that greater levels of self reflectivity were linked to greater levels of awareness of illness, lesser negative symptoms and better performance on tests of verbal and visual memory and processing speed. In a second study with a new sample with a schizophrenia spectrum disorder in a non-acute phase of illness, participants were divided into two groups again using an adaption of the MAS: those who were able as opposed to those who were unable to distinguish different emotional states from one another [58]. Comparisons between groups on symptoms and metacognition assessments revealed that the group able to distinguish their own emotional states was better able to recognize negative affective states in others in an experimental task and had lesser levels of negative and disorganization symptoms. Following up on these finding using a slightly expanded version of this same sample, the authors next explored whether differing levels in the capacity for selfreflectivity were related to prospective performance over the next six months in a work placement for participants who worked the majority of that time [59]. In this study, participants were divided into those not able to distinguish their own emotions, those able to distinguish their own emotions and to see the possible fallibility of their thinking and those able to both distinguish their own emotions but not able to see the possible fallibility of their thinking. A repeatedmeasures ANOVA was then conducted comparing 13 biweekly blind assessments of work performance. This analysis revealed that the group able to distinguish their own emotions and able to see the possible fallibility of their thinking had higher levels of work performance across the 6 months period and also improved at a faster rate. Of note this finding persisted even when an assessment of executive functioning was employed as a covariate. Correlations between Deficits in Metacognitive Mastery and Functioning A second form of metacognition related to but distinct from self-reflectivity is metacognitive mastery. Metacognitive mastery refers to the use of knowledge of mental states to be able to solve psychological problems1. Persons with reduced capacities for metacognitive mastery would struggle to be able to plausibly represent psychological problems. 1

We emphasize that metacognitive mastery is different from coping, as the former involves only ways of dealing with distress and social problems that are fed by mentalistic information.


Persons with mid level capacities of mastery would be able to plausibly represent psychological problems, but mostly have only generally avoidant responses to those stressors. By contrast persons with superior capacities of mastery would be able to plausibly represent psychological problems and respond to them by changing how they think about the problem using metacognitive knowledge about themselves and others [60]. Using the MAS, Lysaker and colleagues [29] reported that while metacognitive mastery was correlated with self reflectivity, it had a unique relationship with quality of life. In particular, participants with superior mastery were judged by independent raters to experience higher levels of social functioning compared to those patients with poor mastery. Focusing more carefully on social functioning, Lysaker and colleagues [61] conducted a study using an independent sample receiving outpatient treatment for a schizophrenia spectrum disorder. In this project, a path analyses was conducted exploring whether the effects of deficits in neurocognition upon quality and quantity of social relationships were mediated by metacognitive mastery. Neurocognitive functioning was estimated on the basis of assessment of executive function, verbal and visual memory, processing speed and verbal intelligence. Using statistical path analysis, an acceptable fit was found for the proposed model. The model remained significant even after controlling for a range of covariates including levels of negative and disorganization symptoms. Results thus were taken as consistent with the hypothesis that mastery not only is linked to function as was originally found but also mediates the impact of other features of illness upon the depth and breadth of social lives of persons with schizophrenia in a non-acute phase of illness. In further analyses of this data, the effects of mastery on social function were found to persist over an interval of five month [62]. A recent study has investigated the correlation between use of emotion regulation strategies based on mentalistic understanding of problems and functional outcome in schizophrenia. Persons with schizophrenia were less likely to use acceptance of their own emotions as a strategy to cope when compared to healthy controls, a pattern of coping related to poorer psychosocial outcome. The difficulty in accepting one’s own emotions as a possible coping strategy might have been due to a relatively poorer ability to describe one’s own emotions, and therefore to activate emotionsensitive regulatory strategies. Contrary to expectations, the authors found no differences between patients and controls for the use of reappraisal strategies [63]. Association of Mental State Decoding Deficits and Mental State Reasoning Deficits with Social Functioning Turning to the issue of the relationship of mental state decoding and mental state reasoning with social functioning, the majority of studies have approached this issue using cartoon picture stories or short stories to examine patients’ ability to comprehend the mental states of story characters [54]. Roncone and colleagues [64] were among the first to report that patients’ compromised metacognitive abilities were the second-best predictor (after duration of illness) of poor social functioning in the community, and statistically predicted a greater share of the variance in deficits in social competence,

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compared with verbal fluency, executive functioning and negative or positive symptoms. This finding was replicated in a study, which called for the comprehension of cartoon story characters, with the differences that impaired metacognition statistically accounted for more than a quarter of the variance of social competence [65]. More recently, another study in an independent sample of patients with schizophrenia spectrum disorders (which included a small number of patients with schizoaffective disorders and “pure” delusional disorder) demonstrated that impaired metacognition accounted for 50% of the variance of social functioning independent of general intelligence, executive functioning and medication [66], with positive symptoms and duration of illness contributing only small percentages of additional variance. Since the relationships between syndromal dimensions, metacognition and social functioning have been inconsistent across studies, Brüne and colleagues [67] performed a reanalysis of a pooled dataset with specific emphasis on the relationships between metacognition, neurocognition, symptomatology and social skills in schizophrenia. In addition, they aimed to minimize confounding effects, that is, data were adjusted for age, premorbid intelligence and passing of the reality questions of the metacognition questionnaire. Also, two separate metacognitive tasks were chosen to test for their interrelationship and their associations with neurocognition, symptomatology and social functioning. These analyses revealed that metacognitive deficits were present in the sample in both tasks, and that these impairments could not be completely accounted for by deficits in other cognitive domains (including general sequencing ability). A regression analysis revealed that metacognition and executive functioning contributed to explain variance in the odds of being a patient. However, metacognition was the best predictor of social competence in patients with schizophrenia, explaining 20% of the variance. In a similar vein, Mehl and colleagues [68] reported that metacognitive skills, as well as autobiographical memory predicted the performance of patients with schizophrenia spectrum disorders in a social roleplay. When differentiating schizophrenia patients with largely preserved metacognitive performance and patients with impaired metacognition, Brüne and Schaub [67] were able to show that the former had fewer social behavioral abnormalities than patients with poor metacognitive skills, even when general intelligence was controlled for, in which the groups also differed. No differences emerged between “fair” and “poor” performers regarding two executive functioning tasks tapping into the domains of cognitive flexibility and planning skills, nor did the groups differ with regard to medication. However, patients with largely preserved metacognitive skills had fewer disorganized symptoms and presented with less excitement (particularly hostility) than poor performers. In fact, the severity of disorganized symptomatology (comprising stereotyped thinking, poor attention, disorientation, conceptual disorganization, difficulty in abstraction, mannerism, lack of judgment and insight, disturbance of volition, and preoccupation) had a mediating effect on the prediction of social behavioral skills by metacognitive abilities [69].


The aforementioned studies did, however, not distinguish between mental state decoding and mental state reasoning abilities, two processes related to metacognition that can be examined separately. Bora and colleagues [70] hypothesized that mental state decoding from facial expressions of emotions or from more complex and ambiguous cues as, for example, required in the detection of sarcasm from prosody, involves the ability to use contextual information perhaps with greater immediacy than mental state reasoning. By contrast, the latter more specifically relies on the ability to decipher verbally transmitted information, which does not even require the presence of the person to which mental states are to be ascribed. Accordingly, Bora et al. [70] used a task showing the facial region surrounding the eyes from which the mental state has to be “decoded” [71], and a task designed to recognize the hidden meaning behind indirect speech (as an example for a mental state reasoning task; [10]). Only the former predicted poor social functioning when neurocognition was statistically controlled. Consistent with Bora and colleagues [70], affect recognition deficits have been found to correspond to the severity of negative and affective symptoms as well as to poor work and global functioning [72]. McGlade and colleagues [73] have also replicated the findings of Bora et al [70], while Pijnenborg and colleagues [74] found that the understanding of faux-pas situations – a more sophisticated “offline” task tapping into metacognition – predicted levels of community functioning in schizophrenia and accounted for about one third of the variance alone. Interestingly, one study has suggested that impairment in metacognition in schizophrenia can be predicted by childhood social dysfunction, as well as, by visual and language context processing deficits [75]. A slightly different aspect of metacognitive dysfunction that may lead to poor social functioning is the impaired ability to recognize the emotions in others as evident from nonverbal markers such as facial expressions [76]. If the face of the other is opaque to oneself, one may rely on more primitive defense strategies that make one either flee or attack [77, 78]. A restricted capacity for empathy might reduce a sense of sharing and reciprocity and further impair the ability to sustaining social contact. Sparks and colleagues [79] investigated whether the association between affect recognition and social functioning in schizophrenia was mediated by selfreported empathy. Thirty patients with schizophrenia or schizoaffective disorder, and twenty-five healthy controls completed two tasks investigating affect recognition a wellvalidated facial affect processing task (Ekman 60-faces facial task from the Facial Expressions of Emotion - Stimuli and Tests; FEEST) and The Awareness of Social Inference Test (TASIT), and measures of self-reported empathy and social functioning. Patients with schizophrenia had poorer performance in emotional identification on both tasks, and their skill in understanding counterfactual information in social exchanges, for example, comprehending if the other was sarcastic or lying, was associated with higher personal distress, and lower recreational functioning. However, empathy could not be explored as a mediator of associations between affect recognition and functional outcome, due to lack of common associations with functional outcome measures.


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Taken together, these studies strongly support an important link between capacities for mental state decoding deficits and mental state reasoning and social functioning in schizophrenia. A recent path analysis underscores this interpretation by confirming that metacognitive abilities mediate the relationship between neurocognition and social functioning [57]. Since insight into illness constitutes a crucial factor in social functioning and outcome measures, we will explore in the next section as to what extent poor metacognition could mediate the association between insight and functioning in schizophrenia. Social Functioning, Insight, and Metacognition As widely recognized, the ability to recognize symptoms and treatment need is a prerequisite for consent to and participation in treatment [80]. Poor insight has been linked with poorer social functioning [81] and is believed to interfere with interpersonal relationships in that a consensually valid account of one’s struggles is often a necessary basis for intimacy [44]. Evolving ways of understanding insight or awareness of illness have stressed that to know one is ill is more than the acceptance of a singular fact. To be meaningful, awareness of illness and insight are core elements of a larger personal understanding of one’s life [82, 83]. From this perspective, insight is comprised of two qualities. First, it reflects a personally constructed narrative and not just the endorsement or rejection of a label. Second, it is an account of events that can be understood by others [53]. As so reframed, knowing one is ill should require a certain degree of metacognitive capabilities above and beyond any decrements in neurocognition. Since causal attribution of symptoms is distorted in schizophrenia and often part of delusional thinking [84], it is well conceivable that impaired metacognition contributes to poor insight and may also mediate the association of poor insight with compromised social functioning. Lysaker et al. [62] reported that poorer levels of insight were linked with decrements in the ability to create complex representations of social interactions independent of neurocognition. Langdon and colleagues [85] found that a strong self-serving bias as expressed by a high number of externalizing and personalizing attributions of negative events seem to exacerbate poor insight. The term “self-serving bias” refers to one’s tendency to ascribe positive events to the self, while negative events are attributed externally and preferably blamed on other persons with hostile intentions [86]. Although metacognition deficits did not increase the personalization bias, it was associated with impaired insight [85]. Similarly, Bora and colleagues [87], as well as Langdon and Ward [88], found that impaired metacognition predicted poor insight and symptom misattribution best. On the other hand, it needs to be emphasized that there is no straightforward association of poor metacognition with poor insight in schizophrenia. Pousa and colleagues [89] found that the two are largely independent of one another. In fact, in their study involving 61 patients with schizophrenia, metacognition did not correlate with insight. It even turned out that patients who misattributed their symptoms (i.e. had poor insight) had better metacognitive skills, indicating that somewhat pre-


served metacognitive abilities may even be necessary to misattribute causality or intentions [90]. More recently Lysaker and colleagues [91] reported that different aspects of metacognition were uniquely linked with specific aspects of insight. Controlling for neurocognition, self reflectivity was significantly linked with awareness of symptoms, while mastery was linked with awareness of treatment need. Interestingly both mastery and perspective taking as assessed with the Hinting Test [10] were each uniquely associated with awareness of consequences of illness. In support of this finding, a longitudinal study using functional brain imaging found that patients after recovery from acute episodes of schizophrenia showed increased activity in the medial prefrontal cortex – a key area of the brain involved in metacognition. Moreover, restoration of medial prefrontal activity correlated with insight scores and social functioning [92], thus underscoring the link between metacognition, insight and social functioning. In summary, some of these findings are strongly suggestive of the possibility that poor metacognitive functioning may contribute to at least certain aspects of insight such as awareness of symptoms and attribution of causation, but not necessarily in the expected way. However, even though this suggests that impaired metacognition in schizophrenia may mediate the association of poor insight and poor social functioning, this issue needs to be carved out in detail in future studies that take direct measures of social functioning into account. Such an approach should ideally include various measures of metacognition, including attributional style, mentalizing, and metacognitive mastery, as well as measures of different aspects of social functioning such as the quality of interpersonal relationships, occupational performance and self-care. TREATMENT IMPLICATIONS Psychotherapy If deficits in self-reflectivity and metacognitive mastery were linked to impairments in social and vocational functioning, one implication would be that a form of psychotherapy be developed or refined to specifically address diminished metacognition in schizophrenia. One reason to think that this is possible is that a range of psychotherapies exist which focus on promoting metacognitive capacity in persons with mental disorders generally less severe than schizophrenia [93]. Most prominently, Fonagy and colleagues [11] developed a psychotherapy that seeks to enhance the ability to think about mental states. While these procedures were rooted in the psychoanalytic tradition, others have similarly linked improvements in metacognition with increases in health and wellness in psychotherapy in a range of Axis I and II disorders [22, 94, 95, 96]. One particularly interesting possibility is that if metacognition is thought of as a capability that varies along a continuum from good to limited, psychotherapy could be conceptualized as aiding in the recovery of metacognitive capacity by providing a place in which such capacities can be practiced and exercised at increasing degrees of complexity [97]. Psychotherapy could offer clients a chance, in the manner of physical therapy, to develop over time the capacity to re-

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engage in acts they were once better able to perform. With such practice, metacognitive capacities may be improved such that more complex metacognitive acts can be performed with greater ease in regular life, leading to a genuinely greater sense of empowerment and self-confidence. Following the metaphor of physical therapy, practicing these capacities may be difficult and painful, but incremental progress is to be expected given the plasticity of the human brain. Consistent with this assertion, Chadwick [98] has described a psychotherapy which aims to promote metacognitive insight with regard to the meaning of symptoms, relationship to internal experiences, negative self-schemata, and the self as a complex, contradictory, and changing process. Metacognitive Training The previous sections have shown that social functioning is linked with patients’ ability to entertain metacognitive abilities such as perspective-taking, thinking about thinking and intact self-reflection and self-reflection can predict better social functioning in a clinical trial. This, in turn, emphasizes the necessity to search for new intervention strategies to achieve improvements in this domain, particularly in light of ambiguous findings regarding the potential for improvement of metacognition of psychopharmacological treatment [37]. Previous intervention studies have typically focused on one aspect of social cognition, but have not examined whether or not findings of improved social cognition after training can be generalized to improvements in social functioning [99]. According to this therapeutic gap, Roberts & Penn [33] developed a Social Cognitive Interaction and Treatment program (SCIT) that targets several key components of social cognition including various aspects of metacognition. A pilot study revealed improvements in mentalizing, and a reduced externalizing and personalizing bias in patients with schizophrenia [99]. The same group could demonstrate in a subsequent study that social cognitive training leads to improved social relationships and a decrease in aggressive incidents in forensic inpatients. These changes were independent of changes in clinical symptoms [100]. A similar program (The Metacognitive Training for Schizophrenia Patients; MCT) devised by Moritz & Woodward [101], yielded comparable results including a strengthening of metacognitive competences and relapse prevention [102]. This program comprises training modules designed to help patients modify their attributional styles and to develop more flexibility in evaluating ambiguous social information in order to reduce patients’ tendency to accept conclusions based on insufficient information. Unlike Combs et al. [99], the study by Aghotor et al. [102] showed that metacognitive training might also be helpful in reducing the amount of positive symptoms. Consistent with this finding, Moritz and colleagues [103] found that metacognitive training improved social functioning and memory, and reduced distress caused by delusional ideation compared to treatment as usual, yet no difference in measures of psychopathology emerged. Although at this stage preliminary, these findings tentatively suggest that metacognitive training can serve as a useful tool to induce changes in real-world behavior beyond the effects of psychopharmacological treatment.


SUMMARY AND DIRECTIONS FOR FUTURE RESEARCH In the past, poor social functioning has been one of the most critical aspects of schizophrenia that has proven difficult to improve effectively by means of psychopharmacological treatment or cognitive remediation therapy. The evidence reviewed here brings further support to the idea impaired social functioning – regardless whether social communication, performance at work or functioning in the community is the prime target of measurement – can at least in part be attributed to impaired metacognitive or social cognitive abilities in patients with schizophrenia above and beyond neurocognitive impairments [59, 60, 104, 105]. As we have tried to explore in this paper, several sub-processes may be involved in explaining such a link between poor understanding of mental states and impaired social or community functioning. First, deficits in emotion recognition from nonverbal markers may cause difficulties in identifying relevant social cues and responding accordingly so that an ongoing social exchange can be sustained with no harmful tendency to disengage as the mind of the others become impossible to understand. Second, cognitive biases foster certain attributional styles and, if combined with impaired metacognition, may influence an individual’s interpretation of incoming communications in a misleading way. Third, deficits in social or communication skills can bring about ineffective interpersonal performance, which reflects a part of poor social functioning [34]. Another avenue is that the inability to question one’s own belief can make negotiation in the social arena, such as work placement, impossible, therefore as stressful interaction starts the person suddenly resign in order to avoid pain [59]. Finally, poor awareness of illness, and in particular of the way others see the distorted mental processes the person with schizophrenia endorses may lead to a communication breakdown, opening the way to a steep decline toward social alienation and losing a chance to receive appropriate cares which could stop relational withdrawal [49, 106]. We contend that all such mechanisms may be the topic of future investigation of the now established link between poor metacognition and reduced social functioning, improving our understanding of the mechanisms and processes underlying such a correlation. This view is consistent with recent research that has suggested that metacognitive abilities can be distinguished according to their levels of complexity, and their relationship to functional capacity [107]. However, a question that is open for future research is whether these processes are similar across groups of patients with schizophrenia who have different symptom profiles. Metacognitive deficits seem to be most severe in patients with prominent disorganization symptoms [67, 108]. Accordingly, it is equally unknown whether patients with different subtypes respond differentially to social cognitive remediation therapy. Future studies should include standardized functional outcome measures and multiple measures of metacognition and insight to elucidate the relationships between these constructs. It would also be desirable to devise longitudinal studies of the association of social functioning, metacognition and insight in individuals at risk of developing schizophrenia


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to evaluate the potentially predictive value of these domains for transition into full-blown psychosis and to examine whether early social cognitive, including metacognitive interventions can even contribute to prevent the transition into manifest schizophrenia. REFERENCES [1] [2] [3] [4] [5]

[6] [7]

[8] [9] [10] [11] [12]

[13] [14] [15]

[16]

[17]

[18]

[19]

Bleuler E. Dementia praecox oder Gruppe der Schizophrenien. Leipzig, Wien: F. Deuticke 1911. Kraepelin E. Psychiatrie. Ein Lehrbuch für Studirende und Aerzte. Sechste, vollständig umgearbeitete Auflage. 2 Bde. Leipzig: J. A. Barth 1899; p. 137. Frith CD. The cognitive neuropsychology of schizophrenia. Hove: Lawrence Erlbaum Associates Ltd. 1992. Parnas J, Bovet P. Autism in schizophrenia revisited. Compr Psychiatry 1991; 32: 1-15. Stanghellini G, Ballerini M. What is it like to be a person with schizophrenia in the social world? A first-person perspective study on schizophrenic dissociality – Part 1: state of the art. Psychopathology 2008; 44: 172-82. Dimaggio G, Lysaker PH, eds. Metacognition and severe adult mental disorders: from basic research to treatment. London: Routledge 2010. Semerari A, Carcione A, Dimaggio G, et al. How to evaluate metacognitive functioning in psychotherapy? The Metacognition Assessment Scale and its applications. Clin Psychol Psychotherapy 2003; 10: 238-61. Brothers L. The social brain: a project for integrating primate behavior and neurophysiology in a new domain. Concepts Neurosci 1990; 1: 27-51. Premack D, Woodruff G. Does the chimpanzee have a ‘theory of mind’? Behav Brain Sci 1978; 4: 515-26. Corcoran R, Mercer G, Frith CD. Schizophrenia, symptomatology and social inference: investigating ‘theory of mind’ in people with schizophrenia. Schizophr Res 1995; 17: 5-13. Fonagy P, Gergely G, Jurist EL, Target M. Affect regulation, mentalization, and the development of the self. New York: Other Press 2002. Sarfati Y, Hardy-Baylé MC, Brunet E, Widlöcher D. Investigating theory of mind in schizophrenia: influence of verbalization in disorganized and non-disorganized patients. Schizophr Res 1997; 37: 183-90. Shamay-Tsoory SG, Shur S, Barcai-Goodman L, et al. Dissociation of cognitive from affective components of theory of mind in schizophrenia. Psychiatry Res 2007; 149: 11-23. Allen JG, Fonagy P, Bateman AW. Mentalizing in clinical practice. Washington DC: American Psychiatric Publishing 2008. Main M. Metacognitive knowledge, metacognive monitoring, and singular (coherent) vs. multiple (incoherent) models of attachment: Findings and directions for future research, in: P. Harris, J. Stevenson-Hinde & C. Parkes, editors, Attachment across the life cycle. New York: Routledge 1991; pp. 127-59. Fonagy P, Steele M, Steele H, Leigh T, Kennedy R, Mattoon G, et al. Attachment, the reflective self, and borderline states: The predictive specificity of the Adult Attachment Interview and pathological emotional development. In S. Goldberg, R. Muir & J. Kerr (Eds.), Attachment theory: Social, developmental and clinical perspectives. New York: Analytic Press 1995; pp. 233-78. Liotti G, Prunetti E. Metacognitive deficits in trauma-related disorders: contingent on interpersonal motivational contexts?. In Dimaggio G, Lysaker PH, eds. Metacognition and severe adult mental disorders: from basic research to treatment. London: Routledge 2010; pp. 196-214. Semerari A, Dimaggio G, Nicolò G, Procacci M, Carcione A. Understanding minds: different functions and different disorders? The contribution of psychotherapeutic research. Psychotherapy Res 2007; 17: 106-19. Carcione A, Semerari A, Nicolò G, Pedone R, Popolo R, Conti L, Fiore D, Procacci M, Dimaggio G. Metacognitive mastery dysfunctions in personality disorder psychotherapy. Psychiatry Res (in press).

8 Current Psychiatry Reviews, 2011, Vol. 7, No. 3 [20] [21] [22] [23] [24]

[25] [26]

[27] [28] [29]

[30]

[31] [32] [33] [34] [35]

[36] [37] [38] [39] [40] [41] [42]

[43] [44]

Carcione A, Dimaggio G, Conti L, et al. Metacognition Assessment Scale (MAS) Manual V.4.0. Rome, 2010 (unpublished manuscript). Clarkin JF. An integrated approach to psychotherapy techniques for patients with personality disorder. J Pers Disord (in press). Dimaggio G, Semerari A, Carcione A, et al. Psychotherapy of personality disorders: metacognition, states of mind and interpersonal cycles. London: Routledge 2007. Given-Wilson Z, McIlwain D, Warburton W. Meta-cognitive and interpersonal difficulties in overt and covert narcissism. Pers and Indiv Diff 2011; 50: 1000-5. Levy KN, Beeney JE, Wasserman RH, Clarkin J. Conflict begets conflict: Executive control, mental state vacillations, and the therapeutic alliance in treatment of borderline personality disorder. Psychother Res 2010; 20: 413-22. Livesley WJ. Integrated treatment: A conceptual framework for an evidence-based approach to the treatment of personality disorder. J Pers Disord (in press). Prunetti E, Framba R, Barone L, Fiore D, Sera F, Liotti G. Attachment disorganization and borderline patients' metacognitive responses to therapists' expressed understanding of their states of mind: A pilot study. Psychother Res 2008; 18: 28-36. Osatuke K, Stiles WB. Relationship between mental states in depression: The assimilation model perspective. Psychiatry Res (in press). Vanheule S. Challenges for alexithymia research: A commentary to ‘the construct of alexithymia: Associations with defence mechanisms’. J Clin Psychol 2008; 64: 332-7. Lysaker PH, Carcione A, Dimaggio G, et al. Metacognition amidst narratives of self and illness in schizophrenia: associations with neurocognition, symptoms, insight and quality of life. Acta Psychiatr Scand 2005; 112: 64-71. Saxe R, Offen S. Seeing ourselves. What vision can teach us about metacognition. In Dimaggio G, Lysaker PH, eds. Metacognition and severe adult mental disorders: from basic research to treatment. London: Routledge 2010; pp. 13-29. Wells A. A metacognitive model and therapy for generalised anxiety disorder. Clin Psychol Psychother 1999; 6: 86-95. Liotti G, Gilbert P. Mentalizing, motivation, and social mentalities: Theoretical considerations and implications for psychotherapy. Psychol Psychother: Theor Res Pract 2011; 84: 9-25. Roberts DL, Penn DL. Social Cognition and Interaction Training (SCIT), Training Manual. Unpublished manuscript 2006. Dickinson D, Bellack AS, Gold JM. Social comm unication skills, cognition, and vocational functioning in schizophrenia. Schizophr Bull 2007; 33: 1213-20. Green MF, Olivier B, Crawley JN, Penn DL, Silverstein S. Social cognition in schizophrenia: recommendations from the measurement and treatment research to improve cognition in schizophrenia new approaches conference. Schizophr Bull 2005; 31: 882-7. Penn DL, Corrigan PW, Bentall RP, et al. Social cognition in schizophrenia. Psychol Bull 1997; 121: 114-32. Penn DL, Sanna LJ, Roberts DL. Social cognition in schizophrenia: an overview. Schizophr Bull 2008; 34: 408-11. Carcione A, Semerari A, Nicolò G, et al. Metacognitive mastery dysfunctions in personality disorder psychotherapy. Psychiatry Res (in press). Semerari A, Carcione A, Dimaggio G, et al. Understanding minds, different functions and different disorders? The contribution of psychotherapeutic research. Psychother Res 2007; 17: 106-19. Ochsner KN. The social-emotional processing stream: five core constructs and their translational potential for schizophrenia and beyond. Biol Psychiatry 2008; 64: 48-61. Olsson A, Ochsner KN. The role of social cognition in emotion. Trends Cogn Sci 2005; 12: 65-71. Dimaggio G, Lysaker PH, Carcione A, et al. Know yourself and you shall know the other... to a certain extent. Multiple paths of influence of self-reflection on mindreading. Consc Cogn 2008; 17: 778-9. Frith CD. Schizophrenia and theory of mind. Psychol Med 2004; 34: 385-9. Lysaker PH, Yanos PT, Roe D. The role of insight in the process of recovery from schizophrenia: a review of three views. Psychosis 2009; 1: 103-12.

Brüne et al. [45]

[46] [47] [48] [49]

[50] [51] [52]

[53] [54] [55] [56] [57]

[58] [59]

[60]

[61]

[62]

[63] [64]

[65] [66]

[67]

Morgan KD, David AS. Awareness is not the same as acceptance: exploring the thinking behind insight and compliance. In: Dimaggio G, Lysaker PH, Eds. Metacognition and severe adult mental disorders: from basic research to treatment, London: Routledge 2010; pp. 95-114. Suddendorf T, Whiten A. Mental evolution and development: evidence for secondary representation in children, great apes, and other animals. Psychol Bull 2001; 127: 629-50. Brüne M. Theory of mind and social competence in schizophrenia. Clin Neuropsychiatry 2006; 3: 132-8. Brüne M, Brüne-Cohrs U. Theory of Mind-evolution, ontogeny, brain mechanisms and psychopathology. Neurosci Biobehav Rev 2006; 30: 437-55. Salvatore G, Dimaggio G, Popolo R, Lysaker PH. Deficits in mindreading in stressful contexts and their relationships to social withdrawal symptoms in schizophrenia. Bull Menninger Clin 2008; 72: 189-207. Lafargue G, Franck N, Sirigu A. Sense of motor effort in patients with schizophrenia. Cortex 2006; 42: 711-9. Synofzik M, Thier P, Leube DT, et al. Misattributions of agency in schizophrenia are based on imprecise predictions about the sensory consequences of one's actions. Brain 2010; 133: 262-71. Freeman D, Garety PA, Fowler D, et al. Why do people with delusions fail to choose more realistic explanations for their experiences? An empirical investigation. J Consult Clin Psychol 2004; 72: 671-80. Lysaker PH, Buck KD, Salvatore G, et al. Lack of awareness of illness in schizophrenia: conceptualizations, correlates and treatment approaches. Expert Rev Neurotherapeut 2009; 9: 1035-43. Brüne M. “Theory of mind” in schizophrenia: a review of the literature. Schizophr Bull 2005; 31: 21-42. Ertugrul A, Ulug B. The influence of neurocognitive deficits and symptoms on disability in schizophrenia. Acta Psychiatr Scand 2002; 105: 196-201. McGurk SR, Meltzer HY. The role of cognition in vocational functioning in schizophrenia. Schizophr Res 2000; 45: 75-184. Couture SM, Granholm EL, Fish SC. A path model investigation of neurocognition, theory of mind, social competence, negative symptoms and real-world functioning in schizophrenia. Schizophr Res 2011; 125: 152-60. Lysaker PH, Dimaggio G, Buck KD, et al. Metacognition within narratives of schizophrenia: associations with multiple domains of neurocognition. Schizophr Res 2007; 93: 278-87. Lysaker PH, Dimaggio G, Carcione A, et al. Metacognition and schizophrenia: the capacity for self-reflectivity as a predictor for prospective assessments of work performance over six months. Schizophr Res 2010; 122: 124-30. Lysaker PH, Erickson MA, Ringer J, et al. Metacognition in schizophrenia: the relationship of mastery to coping, insight, selfesteem, social anxiety and various facets of neurocognition. Br J Clin Psychol (in press). Lysaker PH, Shea AM, Buck KD, et al. Metacognition as a mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders. Acta Psychiatr Scand 2010; 122: 405-13. Lysaker PH, Daroyanni P, Ringer JM, et al. Associations of awareness of illness in schizophrenia spectrum disorder with social cognition and cognitive perceptual organization. J Nerv Ment Dis 2007; 195: 618-21. Perry Y, Henry JD, Grisham JR. The habitual use of emotion regulation strategies in schizophrenia. Br J Clin Psychol 2011; 50: 21722. Roncone R, Falloon IRH, Mazza M, et al. Is theory of mind in schizophrenia more strongly associated with clinical and social functioning than with neurocognitive deficits? Psychopathology 2002; 35: 280-8. Brüne M. Emotion recognition, ‘theory of mind’, and social behavior in schizophrenia. Psychiatry Res 2005; 133: 135-47. Brüne M, Abdel-Hamid M, Lehmkämper C, Sonntag C. Mental state attribution, neurocognitive functioning, and psychopathology: what predicts poor social competence in schizophrenia best? Schizophr Res 2007; 92: 151-9. Brüne M, Schaub D, Juckel G, Langdon R. Social skills and behavioral problems in schizophrenia: the role of mental state attribution,


[68]

[69] [70]

[71]

[72]

[73] [74]

[75] [76] [77]

[78] [79] [80] [81] [82] [83] [84] [85] [86] [87] [88]


neurocognition and clinical symptomatology. Psychiatry Res (in press). Mehl S, Rief W, Mink K, Lüllmann E, Lincoln TM. Social performance is more closely associated with theory of mind and autobiographical memory than with psychopathological symptoms in clinically stable patients with schizophrenia-spectrum disorders. Psychiatry Res 2010; 178:276-83. Brüne M, Schaub D. Mental state attribution in schizophrenia: what distinguishes patients with “poor” from patients with “fair” mentalising skills? Eur Psychiatry (in press). Bora E, Eryavuz A, Kayahan B, et al. Social functioning, theory of mind and neurocognition in outpatients with schizophrenia; mental state decoding may be a better predictor of social functioning than mental state reasoning. Psychiatry Res 2006; 145: 95-103. Baron-Cohen S, Wheelwright S, Hill J, et al. The “Reading the Mind in the Eyes” test revised version: a study with normal adults, and adults with Asperger Syndrome or high-functioning autism. J Child Psychol Psychiatry 2001; 42: 241-51. Hofer A, Benecke C, Edlinger M, et al. Facial emotion recognition and its relationship to symptomatic, subjective, and functional outcomes in outpatients with chronic schizophrenia. Eur Psychiatry 2009; 24: 27-32. McGlade N, Behan C, Hayden J, et al. Mental state decoding v. mental state reasoning as a mediator between cognitive and social function in psychosis. Br J Psychiatry 2008; 193: 77-8. Pijnenborg GHM, Withaar FK, Evans JJ, et al. The predictive value of measures of social cognition for community functioning in schizophrenia: Implications for neuropsychological assessment. J Int Neuropsychol Soc 2009; 15: 239-47. Schenkel LS, Spaulding WD, Silverstein SM. Poor premorbid functioning and theory of mind deficit in schizophrenia: evidence of reduced context processing? Psychiatry Res 2005; 39: 499-508. Derntl B, Finkelmeyer A, Toygar T, et al. Generalized deficit in all core components of empathy in schizophrenia. Schizophr Res 2009; 108: 197-206. Gilbert P, Birchwood M, Gilbert J, et al. An exploration of evolved mental mechanisms for dominant and subordinate behaviour in relation to auditory hallucinations in schizophrenia and critical thoughts in depression. Psychol Med 2001; 31: 1117-27. Flannelly KJ, Koenig HG, Galek K, Ellison CG. Beliefs, mental health, and evolutionary threat assessment systems in the brain. J Nerv Mental Dis 2007; 195: 996-1003. Sparks A, McDonald S, Lino B, et al. Social cognition, empathy and functional outcome in schizophrenia. Schizophr Res (in press). Osatuke K, Ciesla J, Kasckow JW, et al. Insight in schizophrenia: a review of etiological models and supporting research. Compr Psychiatry 2008; 49: 70-7. Francis JL, Penn DL. The relationship between insight and social skill in persons with severe mental illness. J Nerv Mental Dis 2001; 189: 822-9. Roe D, Yanos PT. Psychoeducation for people with psychotic symptoms: moving beyond information and towards inspiration. Behav Ther 2006; 29: 53-5. Williams C. Insight, stigma and post diagnosis identities in schizophrenia. Psychiatry Interpers Biol Proc 2008; 71: 246-56. Warman D, Lysaker PH, Martin JM. Cognitive insight and psychotic disorder: the impact of active delusions. Schizophr Res 2007; 90: 325-33. Langdon R, Corner T, McLaren J, et al. Externalizing and personalizing biases in persecutory delusions: the relationship with poor insight and theory-of-mind. Behav Res Ther 2006; 44: 699-713. Kinderman P, Bentall RP. Self-discrepancies and causal attributions: Studies of hypothesized relationships. Br J Clin Psychol 2000; 39: 255-73. Bora E, Sehitoglu G, Aslier M, et al. Theory of mind and unawareness of illness in schizophrenia: is poor insight a mentalizing deficit? Eur Arch Psychiatry Clin Neurosci 2007; 257: 104-11. Langdon R, Ward P. Taking the perspective of the other contributes to awareness of illness in schizophrenia. Schizophr Bull 2009; 35: 1003-11.

Received: 00 00, 2011

[89]

9

Pousa E, Duñó R, Blas Navarro J, et al. Exploratory study of the association between insight and Theory of Mind (ToM) in stable schizophrenia patients. Cogn Neuropsychiatry 2008; 13: 210-32. [90] Abu-Akel A, Bailey AL. The possibility of different forms of theory of mind. Psychol Med 2000; 30: 735-8. [91] Lysaker PH, Dimaggio G, Buck KD, et al. Poor insight in schizophrenia: links between different forms of metacognition with awareness of symptoms, treatment need and consequences of illness. Compr Psychiatry 2011; 52(3):253-60. [92] Lee KH, Brown WH, Egleston PN, et al. A functional magnetic resonance imaging study of social cognition in schizophrenia during an acute episode and after recovery. Am J Psychiatry 2006; 163: 1926-33. [93] Choi-Kain LW, Gunderson JG. Mentalization: ontogeny, assessment and application in the treatment of borderline personality disorder. Am J Psychiatry 2008; 165: 1127-35. [94] Dimaggio G, Carcione A, Salvatore G, et al. Progressively increasing metacognition through a step-by-step procedure in a case of obsessive-compulsive personality disorder treated with Metacognitive Interpersonal Therapy. Psychol Psychother: Theor Res Pract 2001; 84: 70-83. [95] Karlsson R, Kermott A. Reflective functioning during the process in brief psychotherapies. Psychol Psychother: Theor Res Pract 2006; 43: 65-84. [96] Scarderude F. Eating one’s words: Part 3. Mentalizing based psychotherapy for anorexia nervosia: an outline for treatment and a training manual. Eur Eat Dis Rev 2007; 15: 323-39. [97] Lysaker PH, Buck KD, Carcione A, et al. Addressing metacognitive capacity for self reflection in the psychotherapy for schizophrenia: a conceptual model of the key tasks and processes. Psychol Psychother: Theor Res Pract 2011; 84: 58-69. [98] Chadwick P. Person-based cognitive therapy for distressing psychosis. New York: Wiley 2006. [99] Combs DR, Adams SD, Penn DL, et al. Social Cognition and Interaction Training (SCIT) for inpatients with schizophrenia spectrum disorders: preliminary findings. Schizophr Res 2007; 91: 1126. [100] Penn DL, Roberts DL, Combs D, Sterne A. Best practices: the development of the Social Cognition and Interaction Training Program for schizophrenia spectrum disorders. Psychiatr Serv 2007; 58: 449-51. [101] Moritz S, Woodward TS. Metacognitive Training for schizophrenia patients (MCT). Manual. Hamburg: VanHam Campus 2008. [102] Aghotor J, Moritz S, Pfüller U, et al. Evaluation eines Metakognitiven Trainingsprogramms für schizophrene Patienten: Effekte auf die Positivsymptomatik. 2007; Poster at DGPPN-Congress 2007, Berlin. [103] Moritz S, Kerstan A, Veckenstedt R, Randjbar S, Vitzthum F, Schmidt C, Heise M, Woodward TS. Further evidence for the efficacy of a metacognitive group training in schizophrenia. Behav Res Ther 2011; 49:151-7. [104] Abdel-Hamid M, Lehmkämper C, Sonntag C, Juckel G, Daum I, Brüne M. Theory of mind in schizophrenia: The role of clinical symptomatology and neurocognition in understanding other people’s thoughts and intentions. Psychiatry Res 2009; 165: 19-26. [105] Fett AK, Viechtbauer W, Dominguez MD, et al. The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis. Neurosci Biobehav Rev (in press). [106] Salvatore G, Dimaggio G, Lysaker PH. An inter-subjective perspective on negative symptoms of schizophrenia: implications of simulation theory. Cogn Neuropsychiatry 2007; 12: 144-64. [107] Mancuso F, Horan WP, Kern RS, Green MF. Social cognition in psychosis: multidimensional structure, clinical correlates, and relationship with functional outcome. Schizophr Res 2011; 125:14351. [108] Sprong M, Schothorst P, Vos E, et al. Theory of mind in schizophrenia. Br J Psychiatry 2007; 191: 5-13.

Revised: 00 00, 2011

Accepted: 00 00, 2011