Metacognitive function and fragmentation in schizophrenia: Relationship to cognition, self-experience and developing treatments

Abstract

Bleuler suggested that fragmentation of thought, emotion and volition were the unifying feature of the disorders he termed schizophrenia. In this paper we review research seeking to measure some of the aspects of fragmentation related to the experience of the self and others described by Bleuler. We focus on work which uses the concept of metacognition to characterize and quantify alterations or decrements in the processes by which fragments or pieces of information are integrated into a coherent sense of self and others. We describe the rationale and support for one method for quantifying metacognition and its potential to study the fragmentation of a person's sense of themselves, others and the relative place of themselves and others in the larger human community. We summarize research using that method which suggests that deficits in metacognition commonly occur in schizophrenia and are related to basic neurobiological indices of brain functioning. We also present findings indicating that the capacity for metacognition in schizophrenia is positively related to a broad range of aspects of psychological and social functioning when measured concurrently and prospectively. Finally, we discuss the evolution and study of one therapy that targets metacognitive capacity, Metacognitive Reflection and Insight Therapy (MERIT) and its potential to treat fragmentation and promote recovery.

<p>Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis</p>

“…The potential importance of metacognitive deficits as a treatment target in psychosis comes from multiple sources. As summarized in recent reviews, 19,20 cross cultural studies using the MAS-A have found that persons with psychosis experience deficits in metacognition relative to healthy controls 32 and individuals who experience significant medical but not psychiatric adversity. Differing profiles of metacognitive function have also been observed in persons diagnosed with various conditions including schizophrenia, 32,33 borderline personality disorder, 34 bipolar disorder, 35 depression, 36 PTSD, 37 and substance use disorders.…”

“…In this vein, MERIT explicitly proposes that metacognitive processes may represent just such a set of quantifiable phenomena which underlie self-experience. 19,20 Since its introduction as a psychological construct over 40 years ago, metacognition has been described as a set of multilevel processes involved in thinking about one's own mental or internal experiences. 21,22 MERIT relies on the integrative model of metacognition, which proposes that metacognition can be characterized as a spectrum of mental activities.…”

“…40 Deficits in metacognition have also been linked to prospective assessments of behavior including measures of work function, negative symptoms and motivation. 20 More recent work has linked metacognition to selfcompassion, 41 self and rater assessments of social connections 42,43 and the link between emotional distress and paranoia. 44 Consistent with earlier clinical reports, 45 more recent research has also documented how changes in metacognitive capacity are linked with changes over time in social function, neurocognition and social cognition among persons diagnosed with schizophrenia enrolled in rehabilitation.…”

Levels of Structural Integration Mediate the Impact of Metacognition on Functioning in Non-affective Psychosis: Adding a Psychodynamic Perspective to the Metacognitive Approach

“…It is based on the Metacognition Assessment Scale (MAS; Semerari et al, 2003Semerari et al, , 2007, a tool to assess frequency of metacognitive acts within psychotherapy transcripts. MAS-A follows its main construction of sub-dimensions, but was adapted to interview situations and particularly emphasizes increasing complexity of single metacognitive acts (Lysaker et al, 2020). Four implied sub-dimensions represent semi-independent metacognitive capacities, namely self-and other reflection (S-Scale: "Understanding of One's Mind, " O-Scale: "Understanding of Other's Mind), perspective-taking (D-Scale: "Decentration") and the overall capacity to integrate and use metacognitive knowledge to master intrapsychic and interpersonal challenges adopting a psychologically minded stance (M-Scale: "Mastery").…”

Introspective and Neurophysiological Measures of Mind Wandering in Schizophrenia

“…This later component has been named meta-awareness, and research has demonstrated that individuals are only intermittently aware of the fact that their minds have disengaged from the external world. Research exploring the meta-awareness of MW in schizophrenia should have in mind that deficits in metacognition are common in schizophrenia 30 . Metacognition implies self-conscious awareness and reflection about one's own cognitive events.…”