Significant metacognitive impairments are observed in chronic psychosis samples but metacognition is less understood in first episode psychosis (FEP). The current study explored correlations between metacognition, symptoms and premorbid functioning in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology, premorbid adjustment, and clinician rated service engagement were also measured. Lower scores for metacognitive understanding of other's minds were significantly correlated with greater negative symptoms, poorer early adolescent social adjustment and poorer clinician rated help-seeking. Our findings suggest that FEP individuals with difficulties in understanding other's minds have more social deficits and may be less able to make effective use of treatment.
Individuals with psychotic disorders experience significant difficulties in reflecting upon their own mental states, mental states of others, and in using mental state information to solve problems [1]. These difficulties can be understood as semi-independent capacities, associated with, but not reducible to functional or neurocognitive deficits [2]. Difficulties in mental state capacities have been variously referred to as theory of mind (ToM), social cognition or metacognition. There is evidence of significant metacognitive impairments in chronic psychosis samples [e.g. 1], related to social function, negative symptoms, cognitive disorganization and work performance. The most consistent finding is the association between poor metacognition and greater negative symptoms [3]. Indeed deficits in metacognition are risk factors for suboptimal vocational and functional outcomes, linked to social cognitions and communication difficulties [4], [5], [6] and [7].
However, there is accumulating evidence to suggest that there are differences between discrete forms of social cognition such as ToM that refer to an individual's capacity to make judgements regarding one aspect of a given social situation (e.g. presence or absence of sadness), as opposed to synthetic metacognitive processes that refer to the ability to organise complex social information in such a way as to enable the individual to understand and reflect upon the other's mental state and use this information to cope with distressing experiences and guide the individual's own actions in a given situation [8], [9] and [10]. Similarly, there are nuanced differences between ToM's focus on using mental state information to inform understanding of the physical world, or to develop cognitive understanding of other's beliefs; as compared to the greater emphasis in synthetic metacognition on the interplay of cognition, affect and meaning [11]. As evidence suggests that social cognition influences outcome in psychotic disorders [4], [5], [6] and [7], thus delineation of the boundaries and areas of overlap between discrete and synthetic aspects of metacognition, as they relate to specific outcome domains in psychotic disorders, can enable better matching of specific interventions to specific metacognitive profiles.
Impairments in social cognition and function precede the onset of a first episode of psychosis (FEP), and are associated with poorer outcome in the early stages of the disorder [12] and [13] however the profile of metacognitive impairment is poorly understood in FEP. Evidence has accumulated suggesting deficits in discrete metacognitive processes, such as Theory of Mind, are present in FEP [e.g. [14] and [15]. Evidence also suggests that greater degrees of mentalization (a psychological construct related to metacognition and similarly predicated on individuals' capacity for understanding of self and others' behaviour in terms of mental states) are not associated with symptoms [16]. In this sample higher levels of metacognition were associated with better engagement with treatment. Furthermore, associations between premorbid factors and synthetic metacognition have not been examined in this population. Therefore, the current study sought to establish the magnitude of associations between synthetic metacogntion and other variables, specifically symptoms and premorbid functioning in a FEP sample. Specifically, we hypothesized that lower metacognition scores would be associated with greater negative symptoms, poorer premorbid adjustment and poorer engagement with treatment.
