فراشناخت و عملکرد کلی در بیماران مبتلا به اسکیزوفرنیا و سابقه رفتار مجرمانه

Metacognitive difficulties have been linked to social dysfunction in schizophrenia. However, research examining the role of metacognition in the social functioning of patients with a history of violence and criminality is very limited. This research is especially important for this group given their relatively poor prognosis and their risk to reoffend, as well as the promising benefits of integrating metacognitive approaches in psychosocial treatments. In this study, the association between metacognition and global social functioning was examined in 79 patients with schizophrenia with a criminal background. We also examined the association of positive, negative and disorganized symptoms with social functioning and the extent to which metacognition mediates this association. The results indicate that poor social functioning is associated with metacognitive difficulties and higher levels of delusions and Conceptual Disorganization. In addition, meditation analyses showed that metacognition accounted for about 11% of the total effect size of the association between delusions and social dysfunction, suggesting that the relationship between delusions and social dysfunction is partially driven by impaired metacognition. These findings underscore the importance of interventions designed to enhance the patients׳ metacognitive capacities, that is, the more proximal capacities linked to poorer social functioning.

Impairments in psychosocial functioning are characteristic features of schizophrenia spectrum disorders (Bellack et al., 1990). These include reduced levels of self-care (Brüne et al., 2011), vocational functioning (Lysaker et al., 1994) and social relationships (Penn et al., 1997 and Roberts and Penn, 2013) all of which not only reduce the patients׳ quality of life but also negatively influence the prognosis of the disorder and serve as a risk factor for relapse and the development of comorbid psychopathology (Perlick et al., 1992, Sullivan et al., 1990 and Tien and Eaton, 1992). In light of findings showing that only a small proportion of the variance in psychosocial functioning in schizophrenia is explained by the conventional symptomatology described within the diagnostic systems (Ertuğrul and Uluğ, 2002, McGurk and Meltzer, 2000 and Rabinowitz et al., 2012), efforts have been underway to understand the more subtle causes of psychosocial deficits in this population. These efforts point to possible mediating variables that could explain the association between symptom severity and psychosocial functioning in schizophrenia. One such possible mediating variable that could explain the link between psychotic symptoms and psychosocial functioning is the capacity to recognize and reason about self and other mental states. Difficulties in this capacity are often associated with failures to understand mental states and are apparent when engaged in both emotionally and unemotionally arousing interactions during the pursuit of personal goals (Liotti and Gilbert, 2011). In this paper, we will refer to the reflections people form about themselves and others as metacognition. Specifically, metacognition refers to a spectrum of mental activities that involves thinking about thinking, ranging from more discrete acts in which people recognize specific thoughts and feelings to more synthetic acts in which an array of intentions, thoughts, feelings, and connections between events are integrated into larger complex representations (Lysaker et al., 2013a, Lysaker et al., 2013b, Semerari et al., 2007 and Semerari et al., 2003). Although metacognition has been considered a part of social cognition (Pinkham et al., 2013), one operational difference is that metacognition includes many different aspects, ranging from the ability to recognize specific aspects of subjective experience such as an emotion or a belief, to more synthetic aspects such as the ability to reason about the cause–effect links between different mental states or the ability to maintain a sense of unity and thus an understanding of different aspects of internal experience. At issue with respect to synthetic forms of metacognition is not specifically what one thinks or correctly notices, but is instead whether basic elements of experience are recognized and then synthesized into meaningful wholes. Synthetic metacognitive acts also affect life in a different manner than do specific beliefs or singular judgments, in that they lend meaning to events, and thus, supply reasons as to why one carries out a certain act, as well as premises for deciding what is the best course of action to resolve dilemmas encountered in daily interactions ( Lysaker et al., 2013a and Lysaker et al., 2013b). As such, metacognitive capacities are essential for the understanding of cognitive and affective mental states ( Abu-Akel and Shamay-Tsoory, 2011 and Semerari et al., 2003), the management of distress ( Weiss et al., 2006) and empathy ( Blair, 2005 and Shamay-Tsoory et al., 2010). Deficits in metacognition have been found in many schizophrenia samples, both in earlier and later phases of the illness (Vohs et al., 2014, Lysaker et al., 2005 and Abu-Akel and Abushua׳leh, 2004’; Ang and Pridmore, 2009, Bora et al., 2009, Brune, 2005, Chung et al., 2013, Frith, 2004, Hamm et al., 2012, Harrington et al., 2005, Lysaker et al., 2011a, Lysaker et al., 2011b and Lysaker et al., 2014). For example, it has been shown that patients with schizophrenia have lesser capacities for metacognition compared with participants with chronic non-psychiatric conditions and at least two other prolonged psychiatric conditions (PTSD and substance abuse) (Lysaker et al., 2014). In addition, studies consistently report a link between schizophrenia and social dysfunction, which has been attributed by some to the presence of metacognitive difficulties. However, studies linking metacognition and poor social functioning in schizophrenia have drawn on small sample sizes and did not systematically control for essential confounding factors such as the presence of co-morbid clinical syndromes (i.e. depression, anxiety, bi-polar disorders, drug and alcohol dependence etc.), socio-demographic factors (i.e. gender, age, educational level, socioeconomic status, ethnicity), and the influence of present state emotional arousal at the time of assessing metacognitive abilities, which has been shown to affect metacognitive performance (Bateman and Fonagy, 2011). Moreover, there are a limited number of studies that examined the role of metacognition in understanding criminal behavior in patients with schizophrenia (Bo et al., 2013), and to the authors׳ knowledge, there is only one study to date that explored the relationship of metacognition with past history of violence in patients with schizophrenia (Mitchell et al., 2012). Determining the role of metacognition in functional outcome is thus especially important for this group given their relatively poor prognosis and their potential to reoffend (Witt et al., 2013). Research has also suggested that metacognition may be addressed in a range of psychosocial treatments (Lysaker et al., 2010a, Lysaker et al., 2010b, Salvatore et al., 2012a and Salvatore et al., 2012b) and so confirmation of the role of metacognitive deficits in social dysfunction in this group could offer important possibilities for treatment and recovery. In the current study, we extended this work by accounting for these limitations and examined the nature of the association of metacognition with global social functioning in a relatively large sample of primarily criminal and violent patients with schizophrenia. Specifically, we tested the following four hypotheses. First, we predicted that lower levels of social functioning were associated with decreased metacognition. Second, we predicted that poor metacognition was associated with symptom severity. Based on previous work, we predicted that deficits in metacognition would be specifically associated with the negative symptoms Blunted Affect and emotional withdrawal (Nicolò et al., 2012, Mitchell et al., 2012 and Hamm et al., 2012; Rabin et al., 2014; McLeod et al., 2013), the positive symptoms hallucinations and delusions (Bjørkly, 2002a and Bjørkly, 2002b), and disorganization symptoms (Lysaker et al., 2005, Lysaker et al., 2012a and Lysaker et al., 2012b). Finally, we predicted that metacognition would mediate the relationship between symptom severity and social functioning. It is important to note that our intention is not to examine what causes criminal behavior, but rather to gain insight into how metacognition, symptom severity and social functioning are related in schizophrenia patients with a history of criminal behavior.