Advertisement

Cognitive Therapy and Research

, Volume 42, Issue 1, pp 80–91 | Cite as

Moderators of Symptomatic Outcome in Metacognitive Training for Psychosis (MCT). Who Benefits and Who Does Not?

  • Steffen MoritzEmail author
  • Mahesh Menon
  • Devon Andersen
  • Todd S. Woodward
  • Jürgen Gallinat
Original Article

Abstract

Metacognitive training (MCT) for psychosis is a group intervention targeted at reducing positive symptoms in schizophrenia through an improvement of cognitive biases in these patients. Despite evidence for its feasibility and efficacy, the recommendations for including or excluding patients from MCT have so far been largely based on anecdotal clinical wisdom rather than empirical evidence. Predictors and moderators of outcome are presently unknown. We reanalyzed data from a large randomized controlled trial, for which 150 patients were randomly assigned to either MCT or CogPack® (neurocognitive training) and followed up for up to 3 years. We explored which demographic variables, baseline symptoms, and cognitive biases would predict overall outcome and specific treatment benefits in MCT. Low self-esteem and social anxiety at baseline as well as positive appraisal of the intervention were consistently associated with improved outcome in MCT relative to CogPack®. Among other variables, improvement of cognitive biases and selective attention during the intervention period as well as number of sessions attended were general predictors of positive outcome, irrespective of the type of intervention. Patients with cognitive biases and psychological strain (e.g., low self-esteem and quality of life) paired with social problems may represent an ideal target group for MCT. The present findings await replication in independent samples and may not generalise to other forms of metacognitive training (e.g., MCT for depression) or individualized metacognitive intervention for psychosis (MCT+).

Keywords

Metacognitive training Cognitive biases Randomized controlled trial Moderation Outcome 

Notes

Funding

The study was funded by the German Research Foundation (DFG; Mo 969/6-1 and 6-2).

Compliance with Ethical Standards

Conflict of Interest

The study was funded by the German Research Foundation (DFG), awarded to SM (DFG Mo 969/6-1 and 6-2). SM and TSW are developers of metacognitive training for psychosis (MCT). SM has received a honorarium from Janssen and Lilly for speaking about MCT. Steffen Moritz, Mahesh Menon, Devon Andersen, Todd S. Woodward and Jürgen Gallinat declares that they no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional as well as national research committee and with the 1964 Helsinki declaration and its later amendments. We received ethical approval by the Medical Board Hamburg.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Animal Rights

This article does not contain any studies with animals performed by any of the authors.

References

  1. Beck, A. T., Baruch, E., Balter, J. M., Steer, R. A., & Warman, D. M. (2004). A new instrument for measuring insight: The Beck Cognitive Insight Scale. Schizophrenia Research, 68(2–3), 319–329. doi: 10.1016/S0920-9964(03)00189-0.CrossRefPubMedGoogle Scholar
  2. Boswell, J. F., Sauer-Zavala, S. E., Gallagher, M. W., Delgado, N. K., & Barlow, D. H. (2012). Readiness to change as a moderator of outcome in transdiagnostic treatment. Psychotherapy Research, 22(5), 570–578. doi: 10.1080/10503307.2012.688884.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Brickenkamp, R. (1978). Test d2. Göttingen: Hogrefe.Google Scholar
  4. Byrne, R., Davies, L., & Morrison, A. P. (2010). Priorities and preferences for the outcomes of treatment of psychosis: A service user perspective. Psychosis, 2(3), 210–217. doi: 10.1080/17522430903456913.CrossRefGoogle Scholar
  5. Drake, R., Haddock, G., Tarrier, N., Bentall, R., & Lewis, S. (2007). The Psychotic Symptom Rating Scales (PSYRATS): Their usefulness and properties in first episode psychosis. Schizophrenia Research, 89(1–3), 119–122. doi: 10.1016/j.schres.2006.04.024.CrossRefPubMedGoogle Scholar
  6. Dudley, R., Taylor, P., Wickham, S., & Hutton, P. (2015). Psychosis, delusions and the “jumping to conclusions” reasoning bias: A systematic review and meta-analysis. Schizophrenia Bulletin. doi: 10.1093/schbul/sbv150.PubMedPubMedCentralGoogle Scholar
  7. Eichner, C., & Berna, F. (2016). Acceptance and efficacy of metacognitive training (MCT) on positive symptoms and delusions in patients with schizophrenia: A meta-analysis taking into account important moderators. Schizophrenia Bulletin, 42(4), 952–962. doi: 10.1093/schbul/sbv225.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Field, A. (2013). Discovering statistics using IBM statistics (4th ed.). Los Angeles, CA: Sage. doi: 10.1111/j.1365-2648.2007.04270_1.x.Google Scholar
  9. Garety, P. A., & Freeman, D. (2013). The past and future of delusions research: From the inexplicable to the treatable. British Journal of Psychiatry, 203(5), 327–333. doi: 10.1192/bjp.bp.113.126953.CrossRefPubMedGoogle Scholar
  10. Greenstein, D. K., Franklin, M. E., & McGuffin, P. (1999). Measuring motivation to change: An examination of the University of Rhode Island Change Assessment Questionnaire (URICA) in an adolescent sample. Psychotherapy: Theory, Research, Practice, Training, 36(1), 47–55. doi: 10.1037/h0087813.CrossRefGoogle Scholar
  11. Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS). Psychological Medicine, 29(4), 879–889. doi: 10.1017/S0033291799008661.CrossRefPubMedGoogle Scholar
  12. Hauschildt, M., & Moritz, S. (2015). Randomized-controlled trial of a newly-ceveloped self-help approach “myMCT” for obsessive compulsive disorder. In Annual Conference of the European Association for Behavioural Cognitive Therapies (EACBT). Israel: Jerusalem.Google Scholar
  13. Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Publications.Google Scholar
  14. Hezel, D. M., & McNally, R. J. (2015). A theoretical review of cognitive biases and deficits in obsessive–compulsive disorder. Biological Psychology. doi: 10.1016/j.biopsycho.2015.10.012.PubMedGoogle Scholar
  15. Jelinek, L., Hauschildt, M., Wittekind, C. E., Schneider, B. C., Kriston, L., & Moritz, S. (2016). Efficacy of metacognitive training for depression: A randomized controlled trial. Psychotherapy and Psychosomatics. doi: 10.1159/000443699.PubMedGoogle Scholar
  16. Kay, S. R., Opler, L. A., & Lindenmayer, J. P. (1989). The Positive and Negative Syndrome Scale (PANSS): Rationale and standardisation. British Journal of Psychiatry. doi: 10.1093/schbul/13.2.261.Google Scholar
  17. Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21–37. doi: 10.1177/1745691610393527.CrossRefPubMedGoogle Scholar
  18. Kinderman, P., & Bentall, R. P. (1996). A new measure of causal locus: The internal, personal and situational attributions questionnaire. Personality and Individual Differences, 20(2), 261–264. doi: 10.1016/0191-8869(95)00186-7.CrossRefGoogle Scholar
  19. Kinderman, P., & Bentall, R. P. (1997). Causal attributions in paranoia and depression: Internal, personal, and situational attributions for negative events. Journal of Abnormal Psychology, 106(2), 341–345. doi: 10.1037/0021-843X.106.2.341.CrossRefPubMedGoogle Scholar
  20. Knopp, J., Knowles, S., Bee, P., Lovell, K., & Bower, P. (2013). A systematic review of predictors and moderators of response to psychological therapies in OCD: Do we have enough empirical evidence to target treatment? Clinical Psychology Review. doi: 10.1016/j.cpr.2013.08.008.PubMedGoogle Scholar
  21. Kuhnigk, O., Slawik, L., Meyer, J., Naber, D., & Reimer, J. (2012). Valuation and attainment of treatment goals in schizophrenia: Perspectives of patients, relatives, physicians, and payers. Journal of Psychiatric Practice, 18(5), 321–328. doi: 10.1097/01.pra.0000419816.75752.65.CrossRefPubMedGoogle Scholar
  22. Marker, K. (2003). COGPACK manual. Ladenburg: Marker Software.Google Scholar
  23. Mehl, S., Landsberg, M. W., Schmidt, A.-C., Cabanis, M., Bechdolf, A., Herrlich, J., … Wagner, M. (2014). Why do bad things happen to me? Attributional style, depressed mood, and persecutory delusions in patients with schizophrenia. Schizophrenia Bulletin, 40, 1338–1346. doi: 10.1093/schbul/sbu040.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Menon, M., Andersen, D. R., Quilty, L. C., & Woodward, T. S. (2015). Individual factors predicted to influence outcome in group CBT for psychosis (CBTp) and related therapies. Frontiers in Psychology, 6, 1563. doi: 10.3389/fpsyg.2015.01563.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Menon, M., Pomarol-Clotet, E., McKenna, P. J., & McCarthy, R. A. (2006). Probabilistic reasoning in schizophrenia: A comparison of the performance of deluded and nondeluded schizophrenic patients and exploration of possible cognitive underpinnings. Cognitive Neuropsychiatry, 11(6), 521–536. doi: 10.1080/13546800544000046.CrossRefPubMedGoogle Scholar
  26. Moritz, S., & Woodward, T. S. (2007). Metacognitive training for schizophrenia patients (MTC): A pilot study on feasibility, treatment adherence, and subjective efficacy. German Journal of Psychiatry, 10, 69–78.Google Scholar
  27. Moritz, S., Andreou, C., Schneider, B. C., Wittekind, C. E., Menon, M., Balzan, R. P., & Woodward, T. S. (2014a). Sowing the seeds of doubt: A narrative review on metacognitive training in schizophrenia. Clinical Psychology Review, 34(4), 358–366. doi: 10.1016/j.cpr.2014.04.004.CrossRefPubMedGoogle Scholar
  28. Moritz, S., Veckenstedt, R., Andreou, C., Bohn, F., Hottenrott, B., Leighton, L., … Roesch-Ely, D. (2014b). Sustained and “sleeper” effects of group metacognitive training for schizophrenia. JAMA Psychiatry, 71(10), 1103–1111. doi: 10.1001/jamapsychiatry.2014.1038.CrossRefPubMedGoogle Scholar
  29. Moritz, S., Berna, F., Jaeger, S., Westermann, S., & Nagel, M. (2015a). The customer is always right? Subjective target symptoms and treatment preferences in patients with psychosis. European Archives of Psychiatry and Clinical Neuroscience, 267, 335–339.CrossRefGoogle Scholar
  30. Moritz, S., Woodward, T. S., Hauschildt, M., & Group, M. S. (2015b). Metacognitive Training for Psychosis (MCT). Sixth volume, version 6.2. Hamburg: VanHam Campus Press.Google Scholar
  31. Moritz, S., Jelinek, L., Hauschildt, M., & Naber, D. (2010a). How to treat the untreated: Effectiveness of a self-help metacognitive training program (myMCT) for obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 12(2), 209–220.PubMedPubMedCentralGoogle Scholar
  32. Moritz, S., Schilling, L., Wingenfeld, K., Köther, U., Wittekind, C., Terfehr, K., & Spitzer, C. (2011). Psychotic-like cognitive biases in borderline personality disorder. Journal of Behavior Therapy and Experimental Psychiatry, 42(3), 349–354. doi: 10.1016/j.jbtep.2011.02.003.CrossRefPubMedGoogle Scholar
  33. Moritz, S., Stepulovs, O., Schröder, J., Hottenrott, B., Meyer, B., & Hauschildt, M. (2016a). Is the whole less than the sum of its parts? Full versus individually adapted metacognitive self-help for obsessive-compulsive disorder: A randomized controlled trial. Journal of Obsessive-Compulsive and Related Disorders, 9, 107–115. doi: 10.1016/j.jocrd.2016.04.001.CrossRefGoogle Scholar
  34. Moritz, S., Woodward, T. S., & Balzan, R. (2016b). Is metacognitive training for psychosis effective? Expert Review of Neurotherapeutics, 16(2), 105–107. doi: 10.1586/14737175.2016.1135737.CrossRefPubMedGoogle Scholar
  35. Moritz, S., Van Quaquebeke, N., & Lincoln, T. M. (2012). Jumping to conclusions is associated with paranoia but not general suspiciousness: A comparison of two versions of the probabilistic reasoning paradigm. Schizophrenia Research and Treatment. doi: 10.1155/2012/384039.PubMedPubMedCentralGoogle Scholar
  36. Moritz, S., Veckenstedt, R., Bohn, F., Hottenrott, B., Scheu, F., Randjbar, S., … Roesch-Ely, D. (2013). Complementary group Metacognitive Training (MCT) reduces delusional ideation in schizophrenia. Schizophrenia Research, 151(1–3), 61–69. doi: 10.1016/j.schres.2013.10.007.CrossRefPubMedGoogle Scholar
  37. Moritz, S., Veckenstedt, R., Hottenrott, B., Woodward, T. S., Randjbar, S., & Lincoln, T. M. (2010c). Different sides of the same coin? Intercorrelations of cognitive biases in schizophrenia. Cognitive Neuropsychiatry, 15(4), 406–421. doi: 10.1080/13546800903399993.CrossRefPubMedGoogle Scholar
  38. Moritz, S., Vitzthum, F., Randjbar, S., Veckenstedt, R., & Woodward, T. S. (2010b). Detecting and defusing cognitive traps: Metacognitive intervention in schizophrenia. Current Opinion in Psychiatry, 23(6), 561–569. doi: 10.1097/YCO.0b013e32833d16a8.CrossRefPubMedGoogle Scholar
  39. Moritz, S., & Woodward, T. S. (2005). Jumping to conclusions in delusional and non-delusional schizophrenic patients. The British Journal of Clinical Psychology/the British Psychological Society, 44(Pt 2), 193–207. doi: 10.1348/014466505X35678.CrossRefGoogle Scholar
  40. Moritz, S., & Woodward, T. S. (2007). Metacognitive training in schizophrenia: From basic research to knowledge translation and intervention. Current Opinion in Psychiatry, 20(6), 619–625. doi: 10.1097/YCO.0b013e3282f0b8ed.CrossRefPubMedGoogle Scholar
  41. Moritz, S., Woodward, T. S., & Burton, M. (2005). Metacognitive skill training for patients with schizophrenia (2nd ed.). Hamburg: VanHam Campus Verlag. doi: 10.1093/schbul/sbt011.Google Scholar
  42. Pankowski, D., Kowalski, J., & Gawęda, Ł. (2016). The effectiveness of metacognitive training for patients with schizophrenia: A narrative systematic review of studies published between 2009 and 2015. Psychiatria Polska, 50(4), 787–803. doi: 10.12740/PP/59113.CrossRefPubMedGoogle Scholar
  43. Peralta, V., & Cuesta, M. J. J. (1994). Psychometric properties of the Positive and Negative Syndrome Scale (PANSS) in schizophrenia. Psychiatry Research, 53(1), 31–40. doi: 10.1016/0165-1781(94)90093-0.CrossRefPubMedGoogle Scholar
  44. Peters, E. R., Moritz, S., Schwannauer, M., Wiseman, Z., Greenwood, K. E., Scott, J., … Garety, P. A. (2014). Cognitive biases questionnaire for psychosis. Schizophrenia Bulletin, 40(2), 300–313. doi: 10.1093/schbul/sbs199.CrossRefPubMedGoogle Scholar
  45. Reitan, R. M. (1992). Trail Making Test. Manual of administration and scoring. Tucson, AZ: Reitan Neuropsychology Laboratory.Google Scholar
  46. Riggs, S. E., Grant, P. M., Perivoliotis, D., & Beck, A. T. (2012). Assessment of cognitive insight: A qualitative review. Schizophrenia Bulletin, 38(2), 338–350. doi: 10.1093/schbul/sbq085.CrossRefPubMedGoogle Scholar
  47. Rosenberg, M. (1965). Society and the adolescent self image. Princeton, NJ: Princeton University Press.CrossRefGoogle Scholar
  48. Ross, K., Freeman, D., Dunn, G., & Garety, P. (2011). A randomized experimental investigation of reasoning training for people with delusions. Schizophrenia Bulletin, 37(2), 324–333. doi: 10.1093/schbul/sbn165.CrossRefPubMedGoogle Scholar
  49. Ross, R. M., McKay, R., Coltheart, M., & Langdon, R. (2015). Jumping to conclusions about the beads task? A meta-analysis of delusional ideation and data-gathering. Schizophrenia Bulletin, 41(5), 1183–1191. doi: 10.1093/schbul/sbu187.CrossRefPubMedPubMedCentralGoogle Scholar
  50. Roth, A., & Fonagy, P. (2005). What works for whom? A critical review of psychotherapy research. New York: Guilford Press.Google Scholar
  51. Roth, M., Decker, O., Herzberg, P. Y., & Brähler, E. (2008). Dimensionality and norms of the Rosenberg self-esteem scale in a German general population sample. European Journal of Psychological Assessment, 24(3), 190–197. doi: 10.1027/1015-5759.24.3.190.CrossRefGoogle Scholar
  52. Salkovskis, P. M., & Forrester, E. (2002). Responsibility. In R. O. Frost & G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions—theory, assessment, and treatment (pp. 45–51). Amsterdam: Pergamon.CrossRefGoogle Scholar
  53. Santor, D. A., Ascher-Svanum, H., Lindenmayer, J.-P., & Obenchain, R. L. (2007). Item response analysis of the Positive and Negative Syndrome Scale. BMC Psychiatry, 7, 66. doi: 10.1186/1471-244X-7-66.CrossRefPubMedPubMedCentralGoogle Scholar
  54. Schilling, L., Moritz, S., Köther, U., & Nagel, M. (2015). Preliminary results on acceptance, feasibility, and subjective efficacy of the add-on group intervention metacognitive training for borderline patients. Journal of Cognitive Psychotherapy, 29(2), 153–164. doi: 10.1891/0889-8391.29.2.153.CrossRefGoogle Scholar
  55. Schneider, S. D., Jelinek, L., Lincoln, T. M., & Moritz, S. (2011). What happened to the voices? A fine-grained analysis of how hallucinations and delusions change under psychiatric treatment. Psychiatry Research, 188(1), 13–17. doi: 10.1016/j.psychres.2010.12.013.CrossRefPubMedGoogle Scholar
  56. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl. 20), 22–33. doi: 10.1016/S0924-9338(99)80239-9.PubMedGoogle Scholar
  57. Speechley, W. J., Whitman, J. C., & Woodward, T. S. (2010). The contribution of hypersalience to the “jumping to conclusions” bias associated with delusions in schizophrenia. Journal of Psychiatry and Neuroscience, 35(1), 7–17. doi: 10.1503/jpn.090025.CrossRefPubMedPubMedCentralGoogle Scholar
  58. Suzuki, T. (2011). Which rating scales are regarded as “the standard” in clinical trials for schizophrenia? A critical review. Psychopharmacology Bulletin, 44(1), 18–31.PubMedPubMedCentralGoogle Scholar
  59. van der Gaag, M., Cuijpers, A., Hoffman, T., Remijsen, M., Hijman, R., de Haan, L., … Wiersma, D. (2006). The five-factor model of the Positive and Negative Syndrome Scale I: Confirmatory factor analysis fails to confirm 25 published five-factor solutions. Schizophrenia Research, 85(1–3), 273–279. doi: 10.1016/j.schres.2006.04.001.PubMedGoogle Scholar
  60. van Oosterhout, B., Krabbendam, L., de Boer, K., Ferwerda, J., van der Helm, M., Stant, A. D., & van der Gaag, M. (2014). Metacognitive group training for schizophrenia spectrum patients with delusions: A randomized controlled trial. Psychological Medicine, 44(14), 3025–3035. doi: 10.1017/S0033291714000555.CrossRefPubMedGoogle Scholar
  61. van Oosterhout, B., Smit, F., Krabbendam, L., Castelein, S., Staring, A. B. P., & van der Gaag, M. (2015). Metacognitive training for schizophrenia spectrum patients: A meta-analysis on outcome studies. Psychological Medicine. doi: 10.1017/S0033291715001105.PubMedGoogle Scholar
  62. Voruganti, L. P., Baker, L. K., & Awad, A. G. (2008). New generation antipsychotic drugs and compliance behaviour. Current Opinion in Psychiatry, 21(2), 133–139. doi: 10.1097/YCO.0b013e3282f52851.CrossRefPubMedGoogle Scholar
  63. Waller, H., Emsley, R., Freeman, D., Bebbington, P., Dunn, G., Fowler, D., … Garety, P. (2015). Thinking Well: A randomised controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs. Journal of Behavior Therapy and Experimental Psychiatry, 48, 82–89. doi: 10.1016/j.jbtep.2015.02.007.CrossRefPubMedPubMedCentralGoogle Scholar
  64. Wilson, B., Cockburn, J., & Baddeley, A. (1985). The Rivermead behavioural memory test. Reading: Thames Valley Test.Google Scholar
  65. Wilson, B., Cockburn, J., & Baddeley, A. (1992). Rivermead behavioural memory test. German translation. Bury St. Edmunds: Thames Valley Test Company.Google Scholar
  66. Wilson, B., Cockburn, J., Baddeley, A., & Hiorns, R. (1989). The development and validation of a test battery for detecting and monitoring everyday memory problems. Journal of Clinical and Experimental Neuropsychology, 11(6), 855–870. doi: 10.1080/01688638908400940.CrossRefPubMedGoogle Scholar
  67. Wittekind, C. E., Terfehr, K., Otte, C., Jelinek, L., Hinkelmann, K., & Moritz, S. (2014). Mood-congruent memory in depression—The influence of personal relevance and emotional context. Psychiatry Research, 215(3), 606–613. doi: 10.1016/j.psychres.2013.11.027.CrossRefPubMedGoogle Scholar
  68. World Health Organization. (2004). The World Health Organization quality of life (WHOQOL)-BREF. World Health Organization. Geneva: World Health Organization.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Steffen Moritz
    • 1
    Email author
  • Mahesh Menon
    • 2
  • Devon Andersen
    • 2
  • Todd S. Woodward
    • 2
  • Jürgen Gallinat
    • 1
  1. 1.Department of Psychiatry and PsychotherapyUniversity Medical Center Hamburg-EppendorfHamburgGermany
  2. 2.Department of PsychiatryUniversity of British ColumbiaVancouverCanada

Personalised recommendations