Download Embodied and narrative understandings of the self in schizophrenia

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
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Giancarlo Dimaggio
John Lysaker
Debbie Warman
David Roe
Marina Kukla
Kelly Buck
Jay Hamm
Benjamin Buck
Susanne Harder
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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
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The added role of social
environmental processes
Genetics
Brain
Function
Neurocognition
And symptoms
Social environmental processes
e.g. Trauma, Stigma, Urbanicity,
Lack of attachments, Poverty
Psychosocial
Function
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
No home
Provide
access
to work
Provide
access
to
housing
No
Selfesteem
No
friends
Provide
access
to self
esteem
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
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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
Noticing specific behaviors.
Making accurate vs.
inaccurate attributions.
Declarative and working
memory
Noticing having made an
error.
Noticing one is performing
poorly on a task
Realizing one is the source of
an action or thought.
Moderately discrete
processes
Thinking specific things about
a relatively circumspect
aspects of one’s experiences.
Endorsing vs. rejecting
specific beliefs or label for a
specific belief or emotion.
Declarative memory
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
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Stimuli which are
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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
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Assessment of metacognition within
self narratives: The Indiana
Psychiatric Illness Interview1
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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, 197206.
The Indiana Psychiatric Illness
Interview
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Interview consists of 6 sets of prompts which
are offered as the interview progresses
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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
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The goal is a spontaneous speech sample
that
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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
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1
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
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
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The MAS-A consider metacognition as a
series of semi-independent capacities.
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Some capacities may be more impaired or
more functional than others
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These capacities involve increasingly complex
tasks which are largely hierarchical in nature
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The MAS-A Scales are in likert format and
higher ratings are suggestive of greater
metacognitive function
MAS subscales
 Self reflectivity – representations of
oneself
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Understanding the mind of the
other – representations of other people
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Decentration – situating oneself and
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Mastery – Using knowledge of mental
others in the world
states to solve psychological problems
9 Anchor points for self reflectivity
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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
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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
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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 transcripts1.
Internal consistency: coefficient alpha = .80, p < .05 (for
all four subscales)2.
Good test-retest reliability (intraclass r for 3 points: .70.84)
1Lysaker,
Warman, Dimaggio, et al. (2008). Metacognition in prolonged
schizophrenia: Associations with multiple assessments of executive function. J
Nerv Ment Dis
2Lysaker, 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
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Validity
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Correlations with assessments of
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1Lysaker,
cognitive insight1
traditional measures of awareness of illness2
assessments of complexity of social schema using the
TAT3
coping style using the Ways of Coping Questionaire4
Warman, Dimaggio, et al. (2008). Metacognition in prolonged schizophrenia: Associations with multiple
assessments of executive function. J Nerv Ment Dis 196: 384-389.
2Lysaker, 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.
3Lysaker, 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
4Lysaker 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
Social environmental processes
e.g. Trauma, Stigma, Urbanicity,
Lack of attachments, Poverty
Function
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
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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
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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
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Neurocognitive assessments:
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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
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Procedudres
Neurocognitive assessments reduced to a factor
using a principal components analysis:one
(Eigenvalue = 2.40) which accounted for 48% of
the variance.
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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).
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QOLS
Interpersonal
relations
Neurocognition
Factor score
for 5 variables
Metacognition
MAS
Mastery
Score
QOLS
Intrapsychic
Foundations
Path Model of Mastery as a mediator of the impact of
neurocognition on social function controlling for
negative and cognitive symptoms
r =.27
Neurocognition
Factor score
for 5 variables
r =.37
Metacognition
MAS
Mastery
Score
r =. 23
r =.30
r =.16
QOLS
Interpersonal
relations
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. Cognitive Neuropsychiatry 16(3),
241-55
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<
(n= 45)
(n=25)
______________________________________________________________
MAS Self reflectivity
4.16 (1.57)
6.22 (1.77)
12.62
0.001
MAS Mind of the Other
2.85 (1.07)
4.60 (1.32)
20.42
0.001
MAS Decentration
0.89 (0.95)
1.86 (0.82)
8.19
0.006
MAS Mastery
3.35 (1.49)
5.64 (1.87)
16.54
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
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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
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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. Comprehensive
Psychiatry.52(3) 253-260.
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)
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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
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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
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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
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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
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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
All identifying information in this report has been systematically
disguised
1
Sketch of Greig’s progress over 2.5
years
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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
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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
18
Months
24
30
0
5
10
15
MAS Total Score
20
25
30
Case 2: Scarlatti1
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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
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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
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Conclusions
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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
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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