فراشناخت و عملکرد اجتماعی در اسکیزوفرنی: ارتباط تسلط با شایستگی مهارت کاربردی

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.

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 and Dimaggio and Lysaker, 2010). These difficulties are often referred to as impairments in “Social cognition,” “Metacognition,” “Theory of Mind,” and “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 and 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 (Abdel-Hamid et al., 2009, Bell et al., 2009, Lysaker et al., 2010a and Lysaker et al., 2010b). Of note, these difficulties include problems carrying out relatively discrete processes such as mental state attribution and mental state reasoning (Brüne, 2005 and 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, Bora et al., 2009, Brüne et al., 2007, Stratta et al., 2007 and Salvatore et al., in press). Deficits involved in thinking about thinking, however, also include difficulties with more synthetic processes including those required to construct 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 and 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 and Dimaggio et al., 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 and 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 and Lysaker et al., 2010b).