Enhancement program of social information processing based on metacognitive training for Schizophrenia patients

Abstract

The purpose of this study was to examine the effects of applying a program to enhance social information processing ability in schizophrenic patients. We confirmed the positive effects of the program on the theories of mind and attribution style, which are the social information elements of patients, and confirmed the effect of decreasing paranoid ideation. We used the theory of mind(hinting task, the false belief task), the attributional style questionnaire(external bias, personal bias), and the paranoia scale to test the effectiveness of the program. Specifically, in theory of mind, hinting task performance was improved(t=4.14, p=.000),. The scores of personal bias(t=-7.9, p=.000) and paranoid ideation(t=-2.98, p=.004) decreased. Further research is needed to verify the effectiveness of meta - cognitive training to enhance social information processing.

1. Introduction

Recently, a non - pharmacologic supplementary approach has been of interest to treat delusional symptoms or cognitive impairment in patients with schizophrenia. However, the results of the meta-analysis of cognitive-behavioral therapy for psychosis have shown only a small to moderate effect size[3]. The metacognitive training (MCT) developed by Moritz and Woodward is a psychological intervention that based on Cognitive behavioral therapy for psychosis (CBTp), but has a different approach in the treatment of cognitive biases for schizophrenia, such as delusions (for an overview, see[4]). MCT is focused on thinking patterns and processing, whereas the CBTp aims to cope with individual dysfunctional thoughts, emotions, and behavior. MCT takes more of targeting the delusional belief and social cognition. According to results of a meta-analyses[5], CBTp is less effective for chronic patients as compared to acute patients. Many studies have shown that that psychosis involves deficits in social cognition processing including theory of mind and attributional biases[6]. MCT reduces paranoid ideation as well as delusional belief. This cognitive distortion is due to biases on uncertain evidence and is associated with symptoms[7].

The Theory of mind (ToM) is an important component of social cognition[8] and the ability to deduce the intent, thoughts, and beliefs of others. The process of theory of mind implies the ability to look at the world from the perspective of others. Frith and Corcoran[9] is concerned with the impairment of the theory of mind or mentalizing. He explained that the patient's impairment of theory of mind is related to thinking of others and intentional supervision disorder (including relational delusions, damaged consciousness, and hallucination that occur when the patient makes inexplicable inferences about the mind state of others). Theory of mind deficits of schizophrenia are associated with psychotic symptoms[10] and related to delusions[11]. The subject of delusions is generally based on inferences about the harmful intentions or actions of others[12]. When patients with chronic illnesses fail to distinguish their subjective experience from objective reality. Cognitive biases can lead to the formation of a delusional picture, if they can infer the intention of others or ignore social cues without evidence[13]. The patients with schizophrenia tend to externalize their personal experience in negative events, which may increase the sense of powerlessness or being controlled[14]. Patients with schizophrenia tend to have excessive single causal reasoning[15]. First of all, paranoid people tend to criticize others for negative events rather than for the environment. Lack of ability to understand situational factors of others' behavior creates delusions of blaming others in combination with defensive avoidance of self-denunciation of negative events[16].

Kinderman and Bentall[17] proposed external attribution errors and personalization errors as two separate attribution errors explaining vulnerabilities to paranoid delusion. They explained that paranoid people tend to blame others for negative events rather than the environment. An external attribution error (EB) is a criticism of the environment or someone else rather than self when a negative event occurs, and personalization error means denouncing others rather than (PB) environment. Although the MCT has been applied in various countries and languages, its effectiveness has not yet been verified in various cultures including Korea. Therefore, this study was accomplished to identify whether MCT could improve social information processing in a Korean schizophrenic patients. It is therefore important to identify the feasibility and efficacy of MCT in a Korean patients.

Specifically, the influences of enhancement program of social information processing(EPSIP) were evaluated on: 1) theory of mind; 2) paranoid ideation; and 3) attributional biases. The research hypotheses were that EPSIP would reduce paranoid ideation and attributional biases, and improve theory of mind.

2. Methods

2.1 Study Design

This quasi-experimental study was conducted using a pretest-posttest design with a non-equivalent control group.

2.2 Participants

Thirty six experimental schizophrenic patients and thirty one controls participated in the study. These patients were recruited from two community psychiatric centers in Korea and assessed according to DSM-V criteria. All patients were clinically stable. Data collection was conducted using the structured questionnaires from Februaryto August 2018. We have followed the Declaration of Helsinki and ethical Principles. Substance abuse, comorbid medical disorders, and history of neurological disease were excluded. All participants received explanations of the study and signed an informed consent before participating. We explained that participants could be dropped at any time during the study. All participants were given stationery after the test, and snacks were provided each time they participated in the program.

2.3. Measures

2.3.1 Theory-of-mind assessments

a) Hinting task

The hinting task[18]was used to test inference ability, consists of 10 short passages. 10 stories included dialogues between two characters. The English version of tasks was translated into Korean. At the end of each passage, participants were asked what the meanings of the words that the characters are vaguely expressed mean. Exact answer is scored two points. If the participant responses incorrectly, additional information was given; a subsequent correct answer is given one point. At this stage, if the participants response incorrectly, the score will be zero. Cronbach’s α was .71 in this study.

b) False belief task

The false belief task consisted of six stories was used. It was developed by Frith and Corcoran[9]. We revised the original task to cartoons. The task requires the participants to infer from the story what one character considers about the intention of another character. The task includes two first-order stories and two second-order stories. The first-order story tests was used to find whether the participant can infer a character’s false belief. For example, a man leaves the room after putting things in the drawer. After a while a woman comes in and leaves the room with the things in the drawer. When the man returns and believes that there will still be it in the drawer. Through this story, participants should answer what is the man false beliefs.

The second-order stories require participants to infer also. There are three characters in this story. The participant should deduce the content that one of the characters infer thought of another character from the relationship of the two. At the end of each passage, there is a question about the thought of the character (0 = incorrect answer 1 = correct answer). Cronbach’s α was .72 in this study.

2.3.2 Attribution style

The Internal Personal and Situational Attributions Questionnaire(IPSAQ) was used to investigate attributional style[16]. The questionnaire comprises 32 statements which describe 16 positive and 16 negative social event. For each item the participants are required to imagine a most likely, cause and then to classify it as being either internal (something to do with the respondent), personal (something to do with another person or persons) or situational (something to do with circumstances or chance). The questionnaire is scored by summing the number of positive or negative items for which each type of attribution has been chosen. Externalizing bias (EB) is calculated by subtracting the number of internal attributions for negative events from the number of internal attributions for positive events. A positive EB score indicates strong self-serving biases (blaming oneself less for negative events than for positive events). Personalizing bias for negative events (PB), calculated by dividing the number of personal attributions by the sum of both personal and situational attributions for negative events, represents the proportion of attributions for negative events which are personal as opposed to situational. A PB score of greater than 0.5 represents a tendency to use personal rather than situational external attributions for negative events. Cronbach’s α was .70 in this study.

2.3.3 Paranoia

The Paranoia Scale (PS)[19] was used to assess paranoid ideation. The PS is a self-report inventory using 20–item. PS scores range from 20 to 100. Whereas the PS was designed originally for use with non-clinical samples, this scale has been used many times since to assess general paranoid ideation (not necessarily of delusional intensity) in schizophrenia[20]. In the present study, the PS showed good internal consistency within patients (Cronbach’s alpha .86) and within controls (Cronbach’s alpha .87).

2.4. Data analysis

Statistical analysis was performed by using the SPSS program v22. Descriptive statistics, t-test and Chi square were used for group comparison, etc.

3. Procedure of Metacognitive program 

The topics and contents of each session of the EPSIP are described in Table 1. All sessions were conducted once or twice a week for a total of 10 weeks. It took about 40 minutes for each session, and pictures and educational materials using PowerPoint were used. Each session started with a warming up and was given a challenge each time, but did not give the pressure to do. All sessions were conducted with training, explanations, examples, telling own situation, feedback, and answering questions. Controls were provided only educational materials when all sessions and tests were completed.

Table 1. Procedure of enhancement program of social information processing

4. Results

The results of this study are shown in the table 2 and 3. As a result of the homogeneity test between the experimental group and the control group, there was no difference between the two groups(p=.054~.618) (Table 2). As a result of comparing before and after treatment of experimental group and control group, there were two group differences in hinting task(t=4.14, p=.000), PB(t=-7.9, p=.000),, and Paranoia scores(t=-2.98, p=.004),. The hinting task score of the experimental group was significantly higher than that of the control group, and the PB and paranoia scores were significantly decreased (Table 3).

Table 2. Homogeneity for general characteristics and main variables between the two groups

Exp.=Experimental group; Cont.=Control group; IPSAQ=The Internal Personal and Situational Attributions Questionnaire

Table 3. Comparison of dependent variables between two groups after treatment

Exp.=Experimental group; Cont.=Control group; IPSAQ=The Internal Personal and Situational Attributions Questionnaire

5. Discussion and Conclusion

We attempted to investigate the effect of the program to enhance the social information processing on schizophrenic patients. In general, schizophrenic patients are reported to be vulnerable to social information processing, and it is known that they tend not to sympathize with others[21].

Herold, et al.[22] suggested that patients showed impairment on ToM task. Also, they have deficits interpreting social situations, and tend to blame others or circumstances in negative events. As a result of applying EPSIP, the score was improved in hinting task, but score was not improved in false belief task. The false belief task is known to require complex theory-of-mind abilities than the hinting task. The false belief task poses higher information processing demands, performance partly determined by general cognitive abilities[24].

The reason for not improving on the false belief task is that the enhancement program focuses on the social cognition based on the social situation and does not include the cognitive domain such as memory or attention. This training did not affect the external bias of patients with schizophrenia, but it was found to improve personal bias. External bias need more cognitive effort to function unconsciously and contextualize to defend weak self-concepts by avoiding negative self-attributions. On the other hand, PB is a liability avoidance method that makes it easy to blame others[28]. When inferring the state of minds of others in complex social contexts, those who lack these skills are more likely to blame others for negative events. There is a possibility that the complex social situation and PB are in some way connected.

This program has the effect of reducing the paranoid ideation. Schizophrenia tend to pay selective attention to threatening and have difficulty understanding the minds of other people. Cognitive imbalances can cause delusions[13]. Previous research has suggested that delusions are associated with disruptions in inductive reasoning[25] and that paranoid patients show ToM deficits[9].

The lack of ability to understand the behavior of others in a situation will cause delusions to blame others in combination with defensive avoidance of self - denunciation of negative events. Therefore, as the social cognitive properties of the enhancement program improves the paranoid ideation and the theory of mind ability at the same time, it is necessary to examine closely the relationship between the mechanism of the paranoid delusion and the theory of mind.

6. Acknowledgement

This work was supported by 2018 Hannam University Research Fund.