Metacognition and social function in schizophrenia: Associations of mastery with functional skills competence

Schizophrenia Research 131 (2011) 214–218

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Schizophrenia Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s

Metacognition and social function in schizophrenia: Associations of mastery with functional skills competence Paul H. Lysaker a, b,⁎, Bryan P. McCormick c, Gretchen Snethen d, Kelly D. Buck a, Jay A. Hamm e, Megan Grant e, Giuseppe Nicolò f, g, Giancarlo Dimaggio h a

Roudebush VA Medical Center, Indianapolis, IN, United States Indiana University School of Medicine, Indianapolis, IN, United States Indiana University, Department of Recreation, Park & Tourism Studies, Bloomington, IN, United States d Temple University, Department of Rehabilitation Sciences, United States e University of Indianapolis, School of Psychological Science, Indianapolis, IN, United States f Terzo Centro di Psicoterapia Cognitiva, Italy g Associazione di Psicologia Cognitiva, Rome Italy h Clinical Psychology Specialization Program, University La Sapienza Rome, Italy b c

a r t i c l e

i n f o

Article history: Received 17 May 2011 Received in revised form 10 June 2011 Accepted 15 June 2011 Available online 13 July 2011 Keywords: Schizophrenia Recovery Metacognition Theory of mind Social function Neurocognition

a b s t r a c t Research has suggested that many with schizophrenia experience deficits in the ability to form complex ideas about their own mental states and those of others and to use that in the service of responding to the challenges of both everyday life and the illness itself. Preliminary evidence suggests that deficits in such metacognitive and social cognitive functions are a predictor of function independent of other aspects of schizophrenia. In this study, we explored whether the domain of metacognition that reflects the ability to form knowledge about one's own mental states and those of others and to use that knowledge to respond to psychological challenges, known as Mastery, was related to performance on a test of functional skills competence. Participants were 40 adults with schizophrenia spectrum disorders in a non-acute phase of illness. Metacognitive Mastery was assessed using the Metacognitive Assessment Scale (MAS) and skills competence was assessed using the UCSD Performance-Based Skills Assessment Battery (UPSA). Symptoms were also assessed using the Positive and Negative Syndrome Scale and executive function was assessed with the Wisconsin Card Sorting Test. Correlations revealed a significant relationship between Mastery and the UPSA comprehension/planning subscale. This relationship persisted even after controlling for symptoms and executive function in a regression analysis. Results are consistent with the possibility that the ability to use metacognitive knowledge to respond to daily life is uniquely linked with certain forms of functional competence among persons with schizophrenia, independent of the effects of illness severity. Published by Elsevier B.V.

1. Introduction Persons with schizophrenia have been observed to experience deficits in a range of tasks that call for thinking about one's own thoughts and those of others. They may experience difficulties understanding the intentions and emotions inherent in the speech, gestures, and actions of others. They may struggle to put their own emotions into words, to recognize that they are the source of their own actions, to question their own beliefs, or to form complex representations of themselves and others (Frith, 1992; Dimaggio and Lysaker, 2010). These difficulties are often referred to as impairments in “Social cognition,” “Metacognition,” “Theory of Mind,” and

⁎ Corresponding author at: Roudebush VA Med Center (116H), 1481 West 10th St, Indianapolis, IN 46202, United States. Tel.: +1 317 988 2546. E-mail address: [email protected] (P.H. Lysaker). 0920-9964/$ – see front matter. Published by Elsevier B.V. doi:10.1016/j.schres.2011.06.011

“Mentalizing.” They describe limitations in the capacity to think about thinking and emotion and are not reducible to symptoms or other general deficits in neurocognition (Penn et al., 1997; Langdon et al., 2001; Hasson-Ohayon et al., 2009). These deficits are of growing interest given evidence that their relationship to outcome is independent of other global indicators or wellness or illness (AbdelHamid et al., 2009; Bell et al., 2009; Lysaker et al., 2010a; 2010b). Of note, these difficulties include problems carrying out relatively discrete processes such as mental state attribution and mental state reasoning (Brüne, 2005; McGlade et al., 2008). At the more elemental level these kinds of deficits have been suggested to result in dysfunction because they interfere with recognizing important information occurring within social interactions, for example the meaning of a joke or casual comment (Bora et al., 2006; 2009; Brüne et al., 2007; Stratta, et al., 2007; Salvatore et al., in press). Deficits involved in thinking about thinking, however, also include difficulties with more synthetic processes including those required to construct

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complex ideas or representations of oneself and others and the use of that knowledge to solve difficulties that arise in daily life (Roe and Davidson, 2005; Silverstein and Bellack, 2008; Kean, 2009; Saavedra et al., 2009). Here we are referring to deficits that leave persons without a sense of the larger picture of what is happening that is needed to make sense of dilemmas, find meaning in life, and adapt to a changing environment (Dimaggio et al., 2008; 2009). In this paper we are concerned explicitly with these more synthetic aspects of the capacity for thinking about thinking and their use to respond to challenges. For simplicity sake we will refer overall to these cognitive processes as “metacognition.” By metacognition we refer to this general set of semi-independent faculties which involve primarily reflexive qualities needed to form ideas about oneself and others (e.g. Semerari et al., 2003). We will further refer to the use of metacognitive knowledge in response to difficulties as Mastery. We underscore that deficits in Mastery may affect function not merely in that they reflect difficulties in making sense out of discrete mental states, but in that they reflect difficulties synthesizing knowledge of one's own thoughts and feelings and the knowledge of the thoughts and feelings of others in order to form adaptive ways to respond pragmatically to life challenges (Semerari et al., 2003). Thus, these deficits may theoretically be an additional impediment to function beyond deficits in discrete neurocognitive or social cognitive abilities in that they may leave persons without a larger synthesized account of what is transpiring between themselves and others which, if intact, might allow for persons to find ways to make accommodations for more discrete deficits. To date, we have reported, in several studies, links between the capacity for metacognitive mastery and social function among adults with prolonged forms of schizophrenia. Specifically, we have found that Mastery mediates the impact of neurocognitive deficits on concurrent levels of the frequency and quality of daily social contacts (Lysaker et al., 2010b). We have also found that the links between Mastery and social function persist when assessed longitudinally (Lysaker et al., 2011), that Mastery is related to more impoverished social schemas (Lysaker et al., 2010c) and that lower levels of Mastery are related to both low self-esteem and social anxiety (Lysaker et al., in press). One limitation of this work is that it has largely relied on assessments of social functioning which are derived from interview and not observation. It is thus possible that our findings have been a reflection of persons who perform poorly on interview measures since we have also assessed Mastery on the basis of an interview. To respond to this limitation, the current study seeks to examine whether assessments of Mastery, using the modified Metacognition Assessment Scale (MAS; Semerari et al., 2003; Lysaker et al., 2005), would be related to a comprehensive behavioral assessment of functional competency using the UCSD Performance-Based Skills Assessment Battery (UPSA; Patterson et al., 2001). The UPSA has been found to be a valid and reliable assessment of real life function (Green et al., 2011) and contains at least two subscales that we hypothesize should be related to metacognition: Comprehension/Planning and Communication. We reasoned that with lower levels of Mastery in particular, persons might be less able to imagine, plan and carry out more organized actions and as a result display poorer comprehension and planning skills. Similarly, with deficits in Mastery, we expected that communication skills might also be lower. Specifically, we made two predictions. We first predicted that greater levels of Mastery would be related to better performance on both the Comprehension/ Planning and Communication UPSA subscales. We found no reason to believe that the other three UPSA subscales Finance, Transportation and Household Chores would be linked to metacognition, as none seems to require any kind of reflective quality. Second, we predicted that the links between Mastery and functional competence would persist after controlling for symptoms and executive function, variables potentially linked to Mastery in previous studies (e.g. Lysaker et al., 2005; 2010b).

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2. Methods 2.1. Participants A total of 45 adults were recruited as part of a study of the correlates of daily activity among persons with schizophrenia. Of these, one participant subsequently withdrew following initial data collection while four others failed to provide data on at least one of the study instruments leaving a total of 40 with viable data. All met the criteria for schizophrenia (n = 19, 48%) or schizoaffective disorder (n = 21, 52%). Participants were recruited from a VA medical center (n = 32, 80%) or a community mental health center (n = 8, 20%). The sample was predominantly male (90%) and reported being of either African American, non-Hispanic origin (n = 22, 55%) or Caucasian (n = 18; 45%). The mean age was 48.50 (sd = 8.62; range = 21–65). The mean educational level was 12.55 (sd = 1.46). All participants had previously participated in a study of the effects of cognitive therapy on outcome in schizophrenia. 2.2. Instruments 2.2.1. Indiana Psychiatric Illness Interview Indiana Psychiatric Illness Interview (IPII; Lysaker, et al., 2002) is a semi-structured interview developed to assess how individuals understand their experience with mental illness. Trained research assistants conducted the interview that typically lasted between 30 and 60 min. Responses were audio-taped and later transcribed. The interview is conceptually divided into five sections. First, rapport is established and participants are asked to tell the story of their lives, beginning with their earliest memory. Second, participants are asked if they think they have a mental illness and, if so, whether or not this condition has affected different facets of their life. Third, participants are asked if and how their condition controls their life and, alternately, how they control their condition. Fourth, they are asked how their condition affects and is affected by others. Finally, participants are asked about their expectations of the future. The IPII differs from other psychiatric interviews in that only minimal content is introduced for the participant to comment on and thus results in a self-report that can be analyzed in terms of the metacognitive capacities that appear spontaneously. 2.2.2. The Metacognition Assessment Scale The Metacognition Assessment Scale (MAS; Semerari et al., 2003) is a rating scale that assesses metacognitive abilities. It was originally designed to detect growth within psychotherapy transcripts and, in consultation with the authors, has been abbreviated and adapted for the study of IPII transcripts (Lysaker et al., 2005). The MAS differs from other more structured assessments of metacognition in that it focuses on metacognitive functions that arise spontaneously, rather than cued as in a task or referenced in a questionnaire. For the purposes of this study, we were interested in the Mastery subscale. Mastery refers to the ability to respond to and cope with psychological problems using metacognitive knowledge. Mastery scores on the MAS range from 0 to 9. Higher ratings suggest the capacity to utilize knowledge about mental states to adaptively manage conflicts and subjective distress while lower ratings suggest difficulties identifying or describing psychological problems in plausible terms or at best responding to them with avoidance. Assessments of inter-rater reliability revealed significant levels of agreement between blind raters in this study (r = 0.91; p b .0001). The other MAS subscales (i.e., self-reflectivity, awareness of the other's mind, and decentration) were not included to limit the number of analyses and risk of false positives. Evidence of validity of the Mastery subscale includes findings linking it with other assessments of social cognition and coping independent of indicators of psychopathology and cognitive function (Lysaker et al., 2010c; in press).

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2.2.3. The Positive and Negative Syndrome Scale The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) is a 30-item rating scale completed by clinically trained research staff at the conclusion of chart review and a semi-structured interview. For the purposes of this study, two of the five PANSS factor analytically derived components (Bell et al., 1994) were used: Positive Symptoms, which include hallucinations and delusions, and Negative Symptoms, which includes symptoms such as lack of affect and lack of volition. Assessment of inter-rater reliability for this study was found to be high to excellent with intra-class correlations for blind raters observing the same interview ranging from .84 to .93. 2.2.4. Wisconsin Card Sorting Test Wisconsin Card Sorting Test (WCST; Heaton, 1981) is a neuropsychological test sensitive to impairments in executive function. Participants sort cards that vary according to an unarticulated matching principle that changes periodically. The current study utilized the percentage of responses in which the participant continued to perseverate after being cued that that response type was in error. 2.2.5. UCSD Performance-Based Skills Assessment Battery UCSD Performance-Based Skills Assessment Battery (UPSA; Patterson et al., 2001) is a battery of assessments that directly assesses functional skills competence among persons with severe mental illness who face the demands of regular life in their communities. This test measures everyday functioning skills using standardized role-playing situations to evaluate skills in five different functional domains: Comprehension/ Planning (e.g., organizing outings to the beach or the zoo), Finance (e.g., counting change, and paying bills), Transportation (e.g., using public transportation), Household Chores (e.g., planning menus and shopping) and Communication (e.g., using the telephone, rescheduling medication appointments). It is among the most recommended forms of assessment of functional competence for persons with schizophrenia (Green et al., 2011). 2.3. Procedure All procedures were approved by research review committees of Indiana University and the Roudebush VA Medical Center. Following informed consent, diagnoses were determined using the Psychosis and Affective modules of the Structured Clinical Interview (SCID; Spitzer et al., 1994), and the IPII and WCST were administered as part of an intake for a study of the effects of cognitive therapy on rehabilitation outcome. Next, in a second study of predictors of daily functioning, participants were administered the PANSS and UPSA by trained research assistants with a minimum of a Bachelor's degree in psychology. The participants in this report are those who had data collected at both points. The time interval between the two data collection points was generally between 2 and 5 months. IPII narratives were rated blind to all other testing. 2.4. Analyses Analyses were planned in four stages. First, we planned to examine whether demographic variables were related to the MAS Mastery subscale in order to determine whether they needed to be employed as covariates. Second we planned to examine the correlation of the Mastery Subscale, WCST percent perseverative errors, and PANSS Positive and Negative components with each of the UPSA subscales. Third, if Mastery was found to be linked to the UPSA Comprehension/ Planning and Communication subscales we planned to conduct a logistic regression controlling for executive function using the WCST and the positive and negative symptoms using the PANSS to determine whether the relationship of Mastery was independent of these factors.

3. Results Study variables were found to be generally univariate normal; however, WCST percent perseverative error demonstrated a positive skew while the UPSA total demonstrated a negative skew (see Table 1). Examining demographics, we found that age, gender and years of formal education were not found to be significantly associated with either the Mastery score or the UPSA scores, and were excluded from subsequent analyses. Next we correlated Mastery, WCST and PANSS Positive and Negative component scores with the UPSA total and subscales. As revealed in Table 2, Mastery was significantly correlated with the Comprehensive planning subscale. The relationship between Mastery and the Communication subscale did not reach significance and was found only at the trend level. Next to examine whether Mastery was uniquely related to the Comprehensive planning subscale, a blocked multiple regression was performed in which WCST and PANSS variables were entered in the first block and Mastery in the second. In this analysis a significant predictor equation was produced (F(4,35 = 6.93, p b .001). The first block explained 30.0% of the variance with Mastery accounting for an additional 14.2% of the variance (R 2 change p b .01). The only significant beta weights produced were for the WCST (beta = −.38 p b .01) and Mastery score (beta = .39; p b .01). 4. Discussion In previous studies we have reported that Mastery was associated with interview-based assessments of psychosocial function in adults with schizophrenia, independent of symptoms and neurocognition. In the current study, we sought to expand this work by looking at the association of Mastery with one of the most widely used assessments of functional competence which employs standardized role-playing situations. As predicted, greater levels of Mastery were linked to greater levels of Comprehension and planning, even after controlling for symptoms and neurocognition. Contrary to our predictions, Mastery was not significantly related to the Communication subscale, though a trend was observed here (p b .06). Importantly, no other correlations were noted between the other UPSA subscales and Mastery suggesting that the link between Mastery and the Comprehension was not merely a matter of globally poor performance. While the correlational nature of these results precludes drawing any causal conclusions, the results may still provide speculation for future research. For instance, decrements in Mastery may make persons withdraw from more complex daily tasks such as organizing complex plans for activity, resulting in the atrophy of functional abilities. Perhaps with limited capacities to use metacognitive knowledge to respond to challenges, persons are left with only the basic evolutionary defenses (cf. Gilbert, 2001) and respond habitually to difficulties with anxious arousal and heightened vigilance, all leading to the increasing loss of functional competence. Such a

Table 1 Mean symptom, neurocognition, metacognition and functional capacity scores. Means and standard deviations Instrument

Score

Mean

Standard deviation

PANSS PANSS WCST MAS UPSA UPSA UPSA UPSA UPSA UPSA

Positive symptoms Negative symptoms % Perseverative error Mastery Total Comprehensive planning Financial skills Communication Transportation Household management

16.80 18.23 33.68 3.26 73.65 13.98 14.86 13.39 16.92 14.50

(5.54) (4.21) (22.00) (1.55) (17.77) (3.73) (3.68) (4.57) (4.16) (6.77)

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Table 2 Bivariate correlations of mastery, symptoms and WCST with the UPSA total and scale scores (n = 40). UPSA scores

Metacognitive mastery WCST% perseverative errors PANSS positive symptoms PANSS negative symptoms

Total

Comprehensive planning

.20 .59⁎ −.18 .36⁎

.47⁎⁎ −.50⁎⁎ −.04 −.35⁎

Financial skills −.10 −.35⁎ −.33⁎ −.18

Communication ^

.31 −.37⁎ −.02 −.37⁎

Transportation

Household management

.12 −.44⁎⁎ −.16 −.32⁎

.03 −.55⁎⁎ −.16 −.21

^ p b .06. ⁎ p b .05. ⁎⁎ p b .01.

possibility is consistent with evolving models suggesting that adaption to daily life involves not only the processing of specific information and performance of discrete tasks but also the complex and recursive process in which persons' consideration of their own mental states and those of others allows for meaning to be made and applied to daily life (Damasio, 2000; Dimaggio et al., 2008). The links between mastery and function are additionally consistent with emerging theoretical (Lysaker and Lysaker, 2008) and first-person accounts of schizophrenia (Chadwick, 2007; Kean, 2009) which stress that recovery from schizophrenia involves the active interpretation and synthesis of the larger picture which forms the context for dealing with daily challenges. Of note, alternative hypotheses cannot be ruled out. It is possible that decrements in functional capacity erode metacognitive function or that the observed relationships were the result of factors not measured here including alogia or a fundamental compromise in verbal ability. The lack of a significant link between Mastery and communication was unexpected and may suggest that Mastery is not so closely related to interpersonal communication about life events. It is also possible other aspects of the metacognitive symptoms or more elemental aspects of Theory of Mind are related here. Finally, the lack of a significant association may also be indicative of the nature of the UPSA Communication subscale. A majority of the items on this subscale are related to communication skills (e.g., dialing a correct phone number) with considerably fewer related to forming effective communication content. As such this subscale may be more akin to subscales such as finance, transportation, and household chores. More research is needed in this area. Importantly, there are other limitations to this study. Participants were mostly male, middle aged and generally many years had passed since the onset of their illness. Additionally, all were in some form of active treatment and were offered rehabilitation services in between baseline and follow-up assessments. Replication is therefore needed with more diverse groups of participants including women, persons in an earlier phase of illness, and those refusing treatment. We would be interested to know, for instance, whether deficits in mastery among persons who are just becoming ill or are on the cusp of becoming ill are also linked in the same manner to functional competence. We additionally examined only one element of neurocognition and used simulated assessments of function. More work is needed with other aspects of neurocognition including attention and memory as well as direct observation of social function in a person's natural life settings. Participants were also in a range of different clinical treatments including cognitive therapies which might have affected function and metacognition in ways that we could not control. Finally, the UPSA and MAS were not necessarily assessed at the same time point, however it should be noted that this would be expected to weigh against finding an association rather than creating a spurious one. In summary, results are largely consistent with emerging models that deficits in the ability to use knowledge of mental states to respond to life challenges (i.e., Mastery) play a role in the persistence of psychosocial dysfunction in schizophrenia. With replication, there

may be implications for treatment. Paralleling the field of the study of treating personality disorders (Bateman and Fonagy, 2001; Dimaggio et al., 2007), it may be that treatment may be of assistance if it can encourage persons to exercise and develop the capacity to plausibly represent psychological and interpersonal problems and to cope with them through the use of metacognitive knowledge. As suggested in a number of preliminary case studies and theoretical analyses, psychotherapy (Lysaker, et al., 2007; Buck and Lysaker, 2009) or rehabilitation (Hasson-Ohayon et al., 2009) could potentially be tailored or modified to help persons with schizophrenia to develop metacognitive capacity with an end goal of enhancing outcomes related to daily function. Role of funding source Portions of this study were funded by the VA Rehabilitation Research and Development Service. This body played no role in study design; the collection, analysis and interpretation of data, in the writing of the report; and in the decision to submit the paper for publication.

Contributors Lysaker, Buck, Nicolo, Dimaggio, Hamm and Grant were involved in literature searches. McCormick undertook the statistical analyses. Lysaker wrote the complete first draft and all authors subsequently made meaningful contributions to the writing. All authors contributed to and have approved the final manuscript. Conflict of interest There are no conflicts of interest.

Acknowledgments Research was funded in part by the Veterans Administration Rehabilitation Research and Development Service.

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