Integrated Metacognitive Therapy in First Episode Psychosis

The National Advisory Mental Health Council recently called for the development of
non-pharmacological treatments that identify and target specific disease processes for
clinical improvement in schizophrenia and other psychotic illnesses. One such illness
process, vital for positive outcomes, is impaired awareness of illness or insight. Insight is
often thought of as factual knowledge and acknowledgement of one's illness. More
specifically, insight in psychosis has been conceptualized as a multi-dimensional construct,
with several independent but overlapping dimensions, such as the ability to appropriately
label aberrant mental events (e.g. hallucinations and delusions), recognition of illness, and
willingness to engage in treatment. Relative to individuals with other mental illnesses,
those with psychotic illness have the most impaired insight, presenting a number of
challenges, including: poor treatment engagement and adherence, more frequent
hospitalizations, greater positive and negative symptoms, and poor psychosocial functioning.
This problem is particularly relevant in early phases of psychotic illness, where there
remains a paucity of data. Data that is available has shown decreased insight is associated
with increased symptoms and poorer cognitive functioning, both of which have the potential to
impact illness course.

Two reasons account for a lack of attention to the development of treatments for insight: i)
the lack of an adequate model of the forces which cause and sustain poor insight and ii) a
failure to consider an integrated treatment. Without an idea of the processes which sustain
poor insight, interventions have been able to offer education about the nature of illness but
have not been equipped to respond to the underlying processes that block the emergence of
insight in treatment. While earlier literature framed insight as a failure to grasp a
specific fact, more recent efforts suggest poor insight is primarily the result of a failure
to create a coherent account of the complex events and personal experiences related to a
psychiatric illness. These difficulties becoming aware of one's illness may be
multi-determined and result from factors including deficits in metacognition, neurocognition,
and symptoms.

The development of insight is complex and highly dependent upon metacognitive processes,
which have a unique, potentially moderating role. Metacognition involves a range of faculties
that allow an individual to form representations of mental states of self and others, which
then leads to the formation and revision of thoughts, beliefs, feelings, behaviors, and even
individual aspirations. Therapies targeting metacognitive or mentalizing deficits have been
successfully implemented for personality disorders, depression and anxiety. In psychotic
disorders, decreased metacognitive capacity is thought to result in difficulties identifying
the source of one's experiences, such as illness and its consequences. This leads to an
inability to perceive the self as an active agent in the world and problems in understanding
and acting upon the social cues (emotions and intentions) of others. A recently proposed
Integrated Metacognitive therapeutic approach argues that insight will improve as an
individual utilizes a constructed narrative to make sense of his or her experiences. In other
words, illness and its consequences are understood in an individualized, personally relevant
and acceptable way. Importantly, this approach addresses many obstacles to gaining insight
not addressed by other approaches, including learning to deal with related emotional pain and
depression, loss, and internalized stigma. This view is also consistent with intervention
research showing that establishment of personal meaning is important for recovery, and
promotes improved function and reduced symptoms. Case studies from our group and others have
provided evidence that therapy targeting metacognitive processes is feasible in psychotic
disorders and can indeed improve insight and function in persons with chronic schizophrenia.
However, this approach has not been tailored to target insight, evaluated or tested in
patients in the early phase of psychosis.

In addition to metacognitive deficits, neurocognitive deficits have also been commonly
observed in schizophrenia and involve decrements in capacities for attention/vigilance,
verbal memory and executive function. Deficits in executive function have been found to
predict concurrent and prospective assessments of poorer insight, spurring hypotheses that
impairments in executive function leave persons unable to synthesize illness related
experiences into a coherent and adequate story about how and why they are ill. Deficits in
attention and memory may additionally obscure how historical events are connected to each
other. As a whole, neurocognitive deficits may cause difficulties piecing together the
individual's experience of illness into a coherent whole resulting in poor insight.
Therefore, development of personal narratives using an integrated therapy would allow
subjects the opportunity to better understand their illness experience, hence improving
insight.

The research presented above suggests that improving insight early in the psychotic disease
process would likely result in improved treatment participation, ultimately leading to better
outcomes. Motivated by a clear and pressing need to better address illness insight in early
psychotic illness and recent positive findings related to doing so, the present investigation
serves to test a novel Integrated Metacognitive Therapy (IMT) which targets insight and other
important domains in early psychosis. Assuming IMT is successful, ongoing qualitative
analysis of IMT sessions will allow for manual development, future randomized control trials,
and ultimately treatment dissemination.

Inclusion Criteria:

- 18-35 years of age at study entry

- Male or female

- DSM IV-TR Diagnosis of schizophrenia, schizophreniform disorder, schizoaffective
disorder as confirmed by Structured Clinical Interview for DSM-IV-TR (SCID)

- Onset of schizophreniform disorder, schizophrenia, or schizoaffective disorder within
the past five years as defined by first medical records documentation of these
conditions

- Score of 4 or higher (moderate impairment) on the Positive and Negative Syndrome Scale
(PANSS) insight item

Exclusion Criteria:

- History of significant neurological illness or head trauma

- Known IQ < 70 based on medical history

- Current alcohol or drug dependence (excluding nicotine or caffeine) based on the SCID
interview.

- Subjects considered a high risk for suicidal acts - active suicidal ideation as
determined by clinical interview OR any suicide attempt in 90 days prior to screening