Embodied and narrative understandings of the self in schizophrenia: Advances from the study of metacognition and implications for psychotherapy

Paul H Lysaker Roudebush VA Medical Center And the Indiana University School of Medicine

Colleagues and collaborators

         Giancarlo Dimaggio John Lysaker Debbie Warman David Roe Marina Kukla Kelly Buck Jay Hamm Benjamin Buck Susanne Harder          Morris Bell Giovanni Stanghellini Phil Yanos Louanne Davis Giampaolo Salvatore Ilanit Hasson-Ohayon Andrew Gumley Jamie Ringer Jarod Outcalt

Outline

 A space for the intersubjective in biological and social models of mental illness  Metacognition and intersubjectivity  Quantitative methods for more assessing synthetic forms metacognition within personal narratives  Example of empirical findings to date  Application to psychotherapy  Conclusions

The added role of social environmental processes

Genetics Brain Function Neurocognition And symptoms Psychosocial Function Social environmental processes e.g. Trauma, Stigma, Urbanicity, Lack of attachments, Poverty

A missing piece or neglected space

Genetics Brain Function Neurocogniton symptoms Function Social environmental processes (e.g. Trauma, Stigma, Urbanicity, Lack of attachments, Poverty)

The same problem framed in service provision

No job Provide access to work No Self esteem Provide access to self esteem No home Provide access to housing No friends Provide access to friends

The same problem framed in service provision

No job access to work No friends access to friends

Outline

 A space for the intersubjective in biological and social models of mental illness 

Metacognition and intersubjectivity

 Quantitative methods for more assessing synthetic forms metacognition within personal narratives  Example of empirical findings to date  Application to psychotherapy  Conclusions

Aspects of self experience relevant to intersubjectivity

Without a valuation of life and experience of persons with any condition, we hazard undermining the study of that disorder as a meaningful element of the human condition, amputating the person from the disorder Lysaker & Lysaker (2008). Schizophrenia and the Fate of the Self. Oxford University Press

Aspects of self experience relevant to intersubjectivity

Successful intersubjective activity carried out by embodied selves should have predictable traces, residues or metaphorical metabolites: A complex personal narrative in which self and others are portrayed in integrated and agentic manner That is: Synthetic metacognitive activity

Related Terms

 Metacognition  Mentalization  Theory of Mind (ToM)  Mindreading  Social Cognition  Emotional Intelligence  Psychological Mindedness  Mindfulness  Observing Ego

Metacognitive activities

 Discrete activities including noticing one is making an error or forming a belief about a specific belief – Roots in the educational literature  Synthetic activities including forming a coherent and complex ideas about oneself and others and thinking about that – Roots in attachment and related clinical literatures

Level of metacognitive complexity Metacognitive activities Core processes assessed Memory processes employed Examples Highly discrete processes Moderately discrete processes

Noticing specific behaviors. Thinking specific things about a relatively circumspect aspects of one’s experiences.

Making accurate vs. inaccurate attributions.

Endorsing vs. rejecting specific beliefs or label for a specific belief or emotion.

Declarative and working memory Declarative memory Noticing having made an error.

Noticing one is performing poorly on a task Realizing one is the source of an action or thought.

Having a specific belief about a symptom or forming a belief about something one feels.

Moderately synthetic processes

Forming coherent and integrated ideas about of oneself and others.

Representation of oneself and others which are more vs. less complex.

Autobiographical and declarative memory Understanding how different thoughts and feelings affect each for oneself or another person.

Highly synthetic processes

Utilizing integrated ideas about oneself and others to solve psychological problems.

Utilizing more vs. less complex representations of the self and others to respond to psychological problems.

Autobiographical and declarative memory Using an awareness of how one differs from another person in terms of thoughts and emotions to repair an interpersonal conflict.

Synthetic metacognitive activities

 Forming and reflecting about complex representations of oneself  Forming and reflecting about complex representations of other people  Situating representations of self and others in the larger world with no singular center  The use of complex representations of self and others to solve emergent psychological challenges

Neurocognition And symptoms Social environmental processes Synthetic And Discrete Metacognitive Activities Psychosocial Function

Processes called for when assessing synthetic metacognitive activities

 Stimuli which are     Affect laden Personally relevant Tied to episodic and implicit memory Activities can occur spontaneously without repeated cues signaling the participant to form ideas of themselves and others

Outline

 A space for the intersubjective in biological and social models of mental illness  Metacognition and intersubjectivity 

Quantitative methods for more assessing synthetic forms metacognition within personal narratives

 Example of empirical findings to date  Application to psychotherapy  Conclusions

Assessment of metacognition within self narratives: The Indiana Psychiatric Illness Interview

1 1      Interview typically lasts 30-60 min Interview seeks to offer an opportunity to tell about life and challenges Unlike symptoms interviews specific aspects of illness/problems are not asked about Only non-directive comments are suggested Conversational tone Lysaker PH, Clements CA, Placak Hallberg C, Knipschure SJ & Wright DE (2002): Insight and personal narratives of illness in schizophrenia. Psychiatry, 65, 197 206.

The Indiana Psychiatric Illness Interview

 Interview consists of 6 sets of prompts which are offered as the interview progresses  Tell me the story of your life.

     Do you think you have a mental illness? Because of this what has and has not changed?

What do you control/what controls you?

How does it affect others/how do others affect it?

What do you see in the future?

The Indiana Psychiatric Illness Interview

 The goal is a spontaneous speech sample that    Provides a glimpse about how life and the experience of illness are narratized.

Provides an opportunity for synthetic metacognitive activity which can be rated.

Is not largely scaffolded by the interviewer.

Assessing metacognition with IPII narratives

 IPII narratives are transcribed with identifying information removed  Blind raters then rate the transcript for metacognitive capacity using the an adapted version of the Metacognition Assessment Scale (MAS-A) 1 1 SEMERARI A, CARCIONE A, DIMAGGIO G, FALCONE M, NICOLO G, PROCACI M, ALLEVA G. How to evaluate metacognitive function in psychotherapy? The Metacognition assessment scale its applications. Clinical Psychology and Psychotherapy 2003; 10: 238-261

Assessing metacognition with IPII narratives

 The MAS-A consider metacognition as a series of semi-independent capacities.

 Some capacities may be more impaired or more functional than others  These capacities involve increasingly complex tasks which are largely hierarchical in nature  The MAS-A Scales are in likert format and higher ratings are suggestive of greater metacognitive function



MAS subscales Self reflectivity –

oneself representations of 

Understanding the mind of the

other –

representations of other people 

Decentration –

others in the world situating oneself and 

Mastery –

Using knowledge of mental states to solve psychological problems

9 Anchor points for self reflectivity

         1. I know there are thoughts in my head 2. I know the thoughts are my own 3. I can distinguish different cognitive operations 4. I can distinguish feelings 5. My conclusions are subjective 6. My wishes are not the same as reality 7. My thoughts and feelings are connected in the moment 8. My thoughts and feelings are connected in consistent ways across many moments 9. My thoughts and feelings are connected in across the larger story of my life.

9 Anchor points for mastery

         1. No plausible problems.

2. Psychological problems but they are not plausible 3. Plausible psychological problem which is responded to passively by altering an internal state (e.g. eating or sleeping) 4. Plausible psychological problem responded to by avoiding the issue or seeking support 5. Plausible psychological problem responded to behaviorally.

6. Plausible psychological problem responded to cognitively.

7. Plausible psychological problem responded to by modifying beliefs on the basis of understanding the relationship between cognitions, emotions, behaviors, and relationships. 8. Plausible psychological problem responded to as per level 7 but also an understanding of the relationship between cognitions, emotions, and behaviors in other people. 9. Plausible psychological problem responded to as per above but understanding that not all cannot be completely controlled.

Reliability    Interrater reliability: significant intraclass correlations for all four MAS scales ranging from r = 0.61 (Decentration) to r = 0.93 (total score) - 2 raters rating 25 transcripts 1 . Internal consistency: coefficient alpha = .80, p < .05 (for all four subscales) 2 .

Good test-retest reliability (intraclass r for 3 points: .70 .84) 1 Lysaker, Warman, Dimaggio, et al. (2008). Metacognition in prolonged schizophrenia: Associations with multiple assessments of executive function. J Nerv Ment Dis 2 Lysaker, Dimaggio, Buck et al. (2007). Metacognition within narratives of schizophrenia: Associations with multiple domains of neurocognition. Schizophr Res 93: 278-287.

Outline

 A space for the intersubjective in biological and social models of mental illness  Metacognition and intersubjectivity  Quantitative methods for more assessing synthetic forms metacognition within personal narratives 

Example of empirical findings to date

 Application to psychotherapy  Conclusions

Validity

 Correlations with assessments of  cognitive insight 1  traditional measures of awareness of illness 2   assessments of complexity of social schema using the TAT 3 coping style using the Ways of Coping Questionaire 4 1 Lysaker, Warman, Dimaggio, et al. (2008). Metacognition in prolonged schizophrenia: Associations with multiple assessments of executive function. J Nerv Ment Dis 196: 384-389. 2 Lysaker, Carcione, Dimaggio et al (2005). Metacognition amidst narratives of self and illness in schizophrenia: Associations with insight, neurocognition, symptom and function.

Acta Psychiatric Scandinavica

. 112, 64-71. 3 Lysaker, Dimaggio, Daroyanni et al., (2010) Assessing metacognition in schizophrenia with the Metacognition Assessment Scale: Associations with the Social Cognition and Object Relations Scale. Psychology and Psychotherapy 4 Lysaker PH, Erickson MA, Ringer J, et al. (In press). Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety and various facets of neurocognition.

British Journal of Clinical Psychology.

A missing piece or neglected space

Genetics Brain Function Neurocogniton symptoms Function Social environmental processes e.g. Trauma, Stigma, Urbanicity, Lack of attachments, Poverty

Self reflectivity predicting work function over the next 6 months

  56 males with schizophrenia or schizoaffective disorder Modal age: Late 40s; Modal education: 12 years  In outpatient treatment at a VA Medical Center or community mental health center    Often with a history of multiple hospitalizations Prescribed anti-psychotic medication Completed 4 of a 6 month vocational placements Lysaker PH, Dimaggio G, Carcione A, et al., (2010). Metacognition and Schizophrenia: The capacity for self- reflectivity as a predictor for prospective assessments of work performance over six months. Schizophrenia Research . 122(1-3), 124-130

(n = 21, 22, 13)

Effects of neurocognition upon social function are mediated by metacognition: Path analysis

  N = 102 with schizophrenia or schizoaffective disorder Male and female; Age: Late 40s ; Modal education: 12 yrs  In outpatient treatment at a VA Medical Center or community mental health center  Often with a history of multiple hospitalizations   Prescribed anti-psychotic medication No hospitalizations within the last month Lysaker PH, Shea AM, Buck KD, et al., (2010) Metacognition as a mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders. Acta Psychiatrica Scandinavica 122(5), 405-413.

Methods

 Neurocognitive assessments:      Wisconsin Card sorting test Hopkins Verbal Learning Test WAIS III Vocabulary WAIS III Digit Symbol WMS III Visual Reproduction  Metacognition rated from typed transcribed narratives by a blind rater using the MAS  Assessment of social connections and capacity for relatedness obtained using the Heinrichs Quality of Life scale (QOLS) interview  Symptoms assessed using the PANSS

Procedudres

 Neurocognitive assessments reduced to a factor using a principal components analysis:one (Eigenvalue = 2.40) which accounted for 48% of the variance.

 Path Analysis using LISREL 8.8

 Model fit evaluated with chi-square statistic (χ2), root mean square error of approximation (RMSEA), Comparative Fit Index (CFI), Goodness of Fit Index (GFI), and the standardized root mean square residuals (SRMR).

Neurocognition

Factor score for 5 variables

Metacognition

MAS Mastery Score QOLS Interpersonal relations QOLS Intrapsychic Foundations

Path Model of Mastery as a mediator of the impact of neurocognition on social function controlling for negative and cognitive symptoms QOLS Interpersonal relations r =.27

Neurocognition

Factor score for 5 variables r =.37

Metacognition

MAS Mastery Score r =. 23 r =.30

r =.16

QOLS Intrapsychic Foundations

Path analysis Mastery and social function with assessments 5 months apart

Lysaker PH, Erickson MA, Buck KD, et al. (2011). Metacognition and social function in schizophrenia: Associations over a period of five months. 241-55 Cognitive Neuropsychiatry 16(3),

Mastery and working alliance in cognitive therapy

Davis LW, Eicher AC, & Lysaker PH. (2011). Metacognition as a predictor of therapeutic alliance over 26 weeks of psychotherapy in schizophrenia. Schizophrenia Research, 129(1): 85-90.

Persons with HIV+ exhibit greater metacognitive capacity when engaging in our narrative task compared with patients with schizophrenia _____________________________________________________________ Schizophrenia HIV+ F P < MAS Self reflectivity MAS Mind of the Other (n= 45) (n=25) ______________________________________________________________ 4.16 (1.57) 6.22 (1.77) 4.60 (1.32) 1.86 (0.82) 5.64 (1.87) 12.62

0.001

MAS Decentration MAS Mastery 2.85 (1.07) 0.89 (0.95) 3.35 (1.49) 20.42

8.19

16.54

0.001

0.006

0.001

______________________________________________________________ Lysaker PH, Ringer JM, Buck KD, Grant MLA, Olesek K, Leudtke B & Dimaggio D. (In press) Metacognitive and social cognition deficits in patients with significant psychiatric and medical adversity: a comparison of participants with schizophrenia and a sample of participants who are HIV+. Journal of Nervous and Mental Disease

Other Findings

 After controlling for neurocognition and symptoms Mastery is linked to  A biases to jump to conclusions in probabilistic reasoning task  Performance on the planning comprehension subscale of the UPSA Buck KD, Warman DM, Huddy V & Lysaker PH (In press). The relationship of metacognition with jumping to conclusions among persons with schizophrenia spectrum disorders. Psychopathology Lysaker PH , McCormick BP, Snethen G, Buck KD, Hamm JA, Grant MLA, Nicolò G & Dimaggio G. (In press). Metacognition and social function in schizophrenia: Associations of mastery with functional skills competence. Schizophr Res

Other Findings

 MAS-A and ToM capacities have a unique links with different domains of insight  Self-reflectivity is most closely linked to awareness of symptoms  Awareness of the other was correlated to awareness of treatment needs  Mastery and the Hinting Test were correlated to awareness of consequence of illness Lysaker PH, Dimaggio G, Buck KD, Callaway SS, Salvatore G, Carcione A, Nicolò G & Stanghellini G. (2011). Poor insight in schizophrenia. Psychiatry.52(3) 253-260.

Comprehensive

Ongoing studies  MAS-A predicts function in a Turkish sample with symptoms remission (poster presented)  MAS-A and PANSS ratings in an Italian schizophrenia sample (submitted)  MAS-A and attachment in a Scottish first episode sample (data collected)  MAS-A and depression in a Danish sample (data collected)  MAS-A and first episode psychosis sample in a French Canadian sample (data collected)  MAS-A and first episode psychosis sample in an Israeli sample (data collected)  MAS-A in combat PTSD and their partners (data collection)  MAS-A in homeless sample (data collection)

Outline

 A space for the intersubjective in biological and social models of mental illness  Metacognition and intersubjectivity  Quantitative methods for more assessing synthetic forms metacognition within personal narratives  Example of empirical findings to date 

Application to psychotherapy

 Conclusions

   Psychotherapy could be a place to develop various capacities for metacognition: *Self reflectivity *Mastery *Decentration Interventions could be keyed to help persons to practice metacognitive acts consonant with their current abilities MAS could assess change over time

   Targeting a capacity – not content or solving an issue or problem Helping people practice and learn to perform a particular cognitive act Seeing improvements as occurring along on a continuum – not as categorical

Two cases

   Lysaker PH, Davis LD, Eckert GJ, Strasburger A, Hunter N & Buck, KD (2005). Changes in narrative structure and content in schizophrenia in long term individual psychotherapy: A single case study. Clinical Psychology and Psychotherapy . 12, 406-416.

Lysaker PH & Hermans HJM. (2007). The dialogical self in psychotherapy for persons with schizophrenia: A case study. Journal of Clinical Psychology , 63, 129-139 Lysaker PH, Buck KD & Ringer J (2007). The recovery of metacognitive capacity in schizophrenia across thirty two months of individual psychotherapy: A case study. Psychotherapy Research. 17, 713 - 720

          

Case 1: Greig

1 Divorced man in his 50s High school education Lived in his community Outpatient psychiatric care for undifferentiated schizophrenia. Hallucinations, delusions thought disorder since his early 20s No periods of symptom remission.

Blunted affect and lack of volition Disorganized speech and significant levels of anxiety. Multiple hospitalizations, lost jobs, social alienation, No substance abuse or legal problems. Grave impairments in memory and executive function 1 All identifying information in this report has been systematically disguised

Sketch of Greig’s progress over 2.5 years

      Exploration/confrontation of delusions Discussion of conflicting feelings about adult children Processing losses inherent in divorces Focus on inability to love Discussion of sense of “self-as-loser” Detailing his symptoms of mental illness

Case 1: Greig

    Two transcripts per month selected MAS blindly rated for MAS for the first 32 weeks MAS rated for exploratory purposes for the following 2 years Correlation of MAS with time is 0.70; p < .0001

0 6 12 Months 18 24 30

         

Case 2: Scarlatti

1 Divorced man in his 40s College education Lived in his community Received outpatient psychiatric care for paranoid schizophrenia. Hallucinations and delusions since his early 20s No periods of symptom remission.

Denial of illness Pressured speech and significant levels of anxiety. Multiple hospitalizations, lost jobs, social alienation, substance abuse and legal problems. Grave impairments in memory 1 All identifying information is systematically disguised

Case 2: Scarlatti

 De-idenitifed psychotherapy transcript selected one per month for 32 months  MAS and Delusions from the Positive and Negative Syndrome Scale rated by 2 raters  Raters blind

Metacognition and Delusions

Metacognition by domain

Outline

 A space for the person in biological and social models of mental illness  Metacognition and its relevancy for recovery  Quantitative methods for metacognition within personal narratives  Example of empirical findings to date  Application to psychotherapy 

Conclusions

Conclusions

    The study of schizophrenia is not complete without the consideration of the person How persons thinking about their thinking mediates the impact of schizophrenia. Synthetic metacognitive activities may be assessed quantitatively.

Metacognition may be a foci of psychotherapy.

Limitations

     One form of assessment of metacognition Studies were conducted in one lab Participants were generally in their 40s in a later stage of illness Replication is needed with more diverse samples Longitudinal studies are warranted