فراشناخت در اسکیزوفرنی: ارتباط و ثبات اختلالات در تئوری ذهن و خود بازتاب پذیری

Research suggests that many with schizophrenia experience a range of deficits in metacognition including difficulties recognizing the emotions and intentions of others as well as reflecting upon and questioning their own thinking. Unclear, however, is the extent to which these deficits are stable over time, how closely related they are to one another and whether their associations with core aspects of the disorder such as disorganization symptoms are stable over time. To explore this issue, we administered three assessments of Theory of Mind (ToM), the Beck Cognitive Insight Scale (BCIS), and the Positive and Negative Syndrome Scale at baseline and 6 months to 36 participants with schizophrenia. Correlations revealed the ToM and BCIS scores were stable across the two test administrations and that the ToM tests were closely linked to each other but not to the BCIS. Poorer baseline performance on the ToM tests and the Self-Certainty scale of the BCIS were linked to greater cognitive symptoms at baseline and follow-up, while greater Self-Reflectivity on the BCIS was linked to greater levels of emotional distress at both baseline and 6-month follow-up. Results are consistent with assertions that deficits in metacognition are a stable feature of schizophrenia.

Metacognition refers to the general capacity to think about thinking (Semerari et al., 2003). It is thought to reflect a general aptitude that involves a wide range of semi-independent faculties, which include awareness of one's own mental processes, the fallibility of one's own thought, the ability to infer emotions from others faces and prosody, and Theory of Mind (ToM) (Baron-Cohen et al., 1985) or the cognitive understanding of ideas, beliefs and intentions of other people. As such, metacognition refers to a number of discrete tasks such as forming and revising representations of one's own mental states and the mental states of others in any of a number of rapidly evolving contexts. It is through metacognitive processes that persons are able to discern their own cognitive abilities and knowledgeably apply them in appropriate situations. While metacognition may be associated with neurocognition, which refers to more general cognitive capacities (e.g. memory, attention and flexibility in abstract thought), it differs from that construct in that it refers both to implicit and explicit understanding of, or recognition of, knowledge about one's own and other's thought processes and internal states. Over the last 15 years, research has increasingly suggested that many with schizophrenia experience a range of different kinds of impairments in metacognitive capacity. Persons with schizophrenia, for instance, have been found to have a range of ToM difficulties including problems with forming ideas about the things other people are thinking, decoding irony in speech, and grasping the meaning of words and gestures (Franck et al., 2001, Brüne, 2005 and Brüne & Brüne-Corrs, 2006). They may also experience difficulties with self-reflection, struggling to recognize themselves as the source of one's own thoughts and actions as well as evolving a coherent account of their personal narrative over time (Lysaker et al., 2005, Stratta et al., 2007 and Lysaker and Lysaker, 2008; Dimaggio et al., 2009 and Saavedra et al., 2009). Deficits in metacognition are of interest for persons with schizophrenia given that they may represent unique barriers to the recovery of function. Impairments in ToM and self reflectivity have been found to be a significant predictor of social and work function, for instance, independent of concurrent assessments of neurocognition (Roncone et al., 2002, Bora et al., 2006, Brüne et al., 2007, Bell et al., 2009, Lysaker et al., 2010 and Lysaker et al., 2009). One limitation of the literature to date, however, is that it has tended to involve assessments at one point in time, leaving unclear the role that these deficits play over time for persons in a stable phase of illness (Bell et al., 2010). Further, as noted by Sprong and colleagues (2007), only five studies were available which involved remitted patients, and the number of remitted patients in these studies was very small. Thus, unresolved at present is whether metacognitive deficits, for instance, resemble positive symptoms in that they appear and disappear over time? Do their associations with other outcomes vary over time? In particular, we would suggest that research is needed that examines: i) the extent to which these deficits are stable over time, ii) how closely or not closely are these deficits related to one another and iii) whether their associations with core aspects of the disorder such as negative and disorganization symptoms are stable over time. To address these issues, the current study is among the first to examine whether scores on three separate assessments of ToM which are specific to the intentions and feeling of others, and two measures of selected aspects of self reflectivity, the self-reflectiveness and self-certainty subscales of the Beck Cognitive Insight Scale (BCIS; Beck et al., 2004), gathered at baseline would be significantly correlated with scores obtained on the same measures six months later. Previous studies supporting this possibility includes work by Shur and colleagues (2008) that suggest that level of symptom severity explained the majority of the variance in performance on ToM tasks requiring the recognition of affect and intention. In addition, Inoue et al., 2006 and Bora et al., 2009 have reported ToM deficits could be found in all phases of illness, further suggesting it may be a stable feature of illness. In contradiction to this, Pousa and colleagues (2008) have reported evidence suggesting that these deficits are state dependent and may fluctuate with the presence and absence of positive symptoms. We secondly sought to test the predictions that different measures of ToM focused on the intentions and feelings of others would be more closely related to one another than to measures of two orthogonal aspects of self-awareness measured using the Beck Cognitive Insight Scale: Self Certainty and Self-Reflectiveness (BCIS; Beck et al., 2004). Evidence suggests that knowing the thoughts of others may involve a slightly different set of brain functions than knowing oneself, though overlapping areas serving both mechanisms have been found, in particular under conditions in which the target is perceived as similar by the subject (Heberlein et al., 2005, Mitchell et al., 2006 and Saxe, 2006). Thus, it is at least theoretically possible that either the capacity for knowing oneself or knowing the other may be impaired while the other may be at least partially intact. Importantly, research and theory suggest that ToM includes a range of semi independent verbal and non-verbal functions including inferring emotions in the others and inferring intentions and beliefs and reasoning about them (Baron-Cohen, 2005, Dimaggio et al., 2009 and Bell et al., 2010). Accordingly, we included a measure of the verbal-reasoning aspect of ToM, the Hinting Task (Corcoran et al., 1995), a measure of the non-verbal aspect, the Eyes Test (Baron-Cohen et al., 2001) and another test involving both verbal and non-verbal elements, the Bell Lysaker Emotion Recognition Task (BLERT, Bryson et al., 1997), which offers cues in terms of spoken content, prosody and facial expression. Finally, this study is among the first to test the prediction that poorer performance on baseline assessment of ToM tests of awareness of the thoughts and feelings of other people would be significantly correlated with concurrent and future levels of negative and disorganization symptoms, and that greater Self reflectivity on the BCIS would be linked to depression while greater Self-Certainty would be correlated with higher disorganization and positive symptoms. Research supporting these predictions includes findings that deficits in the ability to understand the thoughts and feelings of others is more closely linked with disorganized or cognitive symptoms than other symptom domains (Bryson et al., 1997 and Greig et al., 2004). This finding has been replicated by Abdel-Hamid and colleagues (2009), who also found a weaker, though significant, link between ToM and negative symptoms. At least one other group has also found links between ToM tests and negative symptoms (Shamay-Tsoory et al., 2007), while in general links have not been consistently found between ToM and positive symptoms. Pertaining to self awareness, previous research has linked the Self-Certainty but not the Self-reflectivity subscale of the Beck Cognitive Insight Scale with higher levels of positive symptoms (Pedrelli et al., 2004). Other studies which have analyzed personal narratives in terms of self-reflectivity have found poorer self reflectivity was linked to disorganization symptoms and also to relatively lower levels of depression (Lysaker et al., 2007). Regarding a possible link between negative symptoms with self-reflectivity, findings have been inconsistent (Pedrelli et al., 2004). In this study we have chosen to examine persons with schizophrenia spectrum disorders and included participants with both schizophrenia and schizoaffective disorder. This decision was based on previous findings suggesting that the metacognitive as well as neurocognitive performance of these groups tends to be equivalent (Evans et al., 1999 and Lysaker et al., 2005).