Skip to content
BY-NC-ND 3.0 license Open Access Published by De Gruyter Open Access September 13, 2013

Synthetic metacognition as a link between brain and behavior in schizophrenia

  • Paul Lysaker EMAIL logo , Petr Bob , Ondrej Pec , Jay Hamm , Marina Kukula , Jen Vohs , Raffaele Popolo , Giampaolo Salvatore and Giancarlo Dimaggio


Deficits in metacognitive capacity in schizophrenia can be conceptualized as existing along a spectrum from more discrete to more synthetic activities. These capacities may be of great importance in schizophrenia research given their potential to mediate and moderate the impact of illness-related factors on outcome. To explore this possibility this review summarizes research on synthetic metacognition using a paradigm in which metacognitive capacity is rated on the basis of spontaneously produced personal narratives. Evidence from a review of the literature shows that these deficits are detectable in patients with schizophrenia and are related to, but not reducible to, symptom severity and poorer neurocognitive function. Independent of symptoms and neurocognition, deficits in synthetic metacognition, which are likely linked to the brain’s ability to integrate information, are related to a range of outcomes including functional competence, learning potential, and insight. These deficits may also play a role in long term psychosocial functioning via their impact on the ability to sustain social functions.

[1] Bleuler E. (Ed.), Dementia praecox or the group of schizophrenias, International Universities Press, New York, 1950 Search in Google Scholar

[2] Braff D.L., Freedman R., Schork N.J., Gottesman I.I., Deconstructing schizophrenia: an overview of the use of endophenotypes in order to understand a complex disorder, Schizophr. Bull., 2007, 33, 21–32 in Google Scholar PubMed PubMed Central

[3] Green M.J., Cairns M.J., Wu J., Dragovic M., Jablensky A., Tooney P.A., et al., Genome-wide supported variant MIR137 and severe negative symptoms predict membership of an impaired cognitive subtype of schizophrenia, Mol. Psychiatry, 2012, 18, 774–780 in Google Scholar PubMed

[4] Hori H., Yamamoto N., Fujii T., Teraishi T., Sasayama D., Matsuo J., et al., Effects of the CACNA1C risk allele on neurocognition in patients with schizophrenia and health individuals, Sci. Rep., 2012, 2, 634 in Google Scholar PubMed PubMed Central

[5] LeBlanc M., Kulle B., Sundet K., Agartz I., Melle I., Djurovic S., et al., Genomewide study identifies PTPRO and WDR72 and FOXQ1-SUMO1P1 interaction associated with neurocognitive function, J. Psychiatr. Res., 2012, 46, 271–278 in Google Scholar PubMed

[6] Light G.A., Braff D.L., Mismatch negativity deficits are associated with poor functioning in schizophrenia patients, Arch. Gen. Psychiatry, 2005, 62, 127–136 in Google Scholar PubMed

[7] Toulopoulou T., Picchioni M., Rijsdijk F., Hua-Hall M., Ettinger U., Sham P., et al., Substantial genetic overlap between neurocognition and schizophrenia: genetic modeling in twin samples, Arch. Gen. Psychiatry, 2007, 64, 1348–1355 in Google Scholar PubMed

[8] Lee S.H., Kim D.W., Kim E.Y., Kim S., Im C.H., Dysfunctional gammaband activity during face structural processing in schizophrenia patients, Schizophr. Res., 2010, 119, 191–197 in Google Scholar PubMed

[9] Uhlhaas P.J., Singer W., Abnormal neural oscillations and synchrony in schizophrenia, Nat. Rev. Neurosci., 2010, 11, 100–113 in Google Scholar PubMed

[10] Bob P., Palus M., Susta M., Glaslova K., EEG phase synchronization in patients with paranoid schizophrenia, Neurosci. Lett., 2008, 447, 73–77 in Google Scholar PubMed

[11] Bob P., Susta M., Glaslova K., Boutros N.N., Dissociative symptoms and interregional EEG cross-correlations in paranoid schizophrenia, Psychiatry Res., 2010, 177, 37–40 in Google Scholar PubMed

[12] Bowie C.R., Leung W.W., Reichenberg A., McClure M.M., Patterson T.L., Heaton R.K., et al., Predicting schizophrenia patients’ real-world behavior with specific neuropsychological and functional capacity measures, Biol. Psychiatry, 2008, 63, 505–511 in Google Scholar PubMed PubMed Central

[13] Carrión R.E., Goldberg T.E., McLaughlin D., Auther A.M., Correll C.U., Cornblatt B.A., Impact of neurocognition on social and role functioning in individuals at clinical high risk for psychosis, Am. J. Psychiatry, 2011, 168, 806–813 in Google Scholar PubMed PubMed Central

[14] Lin A., Wood S.J., Nelson B., Brewer W.J., Spiliotacopoulos D., Bruxner A., et al., Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis, Schizophr. Res., 2011, 132, 1–7 in Google Scholar PubMed

[15] Lipkovich I.A., Deberdt W., Csernansky J.G., Sabbe B., Keefe R.S., Kollack-Walker S., Relationships among neurocognition, symptoms and functioning in patients with schizophrenia: a path-analytic approach for associations at baseline and following 24 weeks of antipsychotic drug therapy, BMC Psychiatry, 2009, 9, 44 in Google Scholar PubMed PubMed Central

[16] Kurtz M.M., Neurocognition as a predictor of response to evidencebased psychosocial interventions in schizophrenia: what is the state of the evidence?, Clin. Psychol. Rev., 2011, 31, 663–672 in Google Scholar PubMed PubMed Central

[17] van Os J., Kenis G., Rutten B.P., The environment and schizophrenia, Nature, 2010, 468, 203–212 in Google Scholar PubMed

[18] Lysaker P.H., Roe D., Yanos P.T., Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders, Schizophr. Bull., 2007, 33, 192–199 in Google Scholar PubMed PubMed Central

[19] Walker E.F., Diforio D., Schizophrenia: a neural diathesis-stress model, Psychol. Rev., 1997, 104, 667–685 in Google Scholar PubMed

[20] Read J., Perry B.D., Moskowitz A., Connolly J., The contribution of early traumatic events to schizophrenia in some patients: a traumagenic neurodevelopmental model, Psychiatry, 2001, 64, 319–345 10.1521/psyc.64.4.319.18602Search in Google Scholar PubMed

[21] Green M.F., What are the functional consequences of neurocognitive deficits in schizophrenia?, Am. J. Psychiatry, 1996, 153, 321–330 10.1176/ajp.153.3.321Search in Google Scholar PubMed

[22] Green M.F., Hellemann G., Horan W.P., Lee J., Wynn J.K., From perception to functional outcome in schizophrenia: modeling the role of ability and motivation, Arch. Gen. Psychiatry, 2012, 69, 1216–1224 in Google Scholar PubMed PubMed Central

[23] Frankl V., Man’s search for meaning, Beacon Press, Boston, MA, USA, 1959/2006 Search in Google Scholar

[24] May R., Angel E., Ellenberger H.F. (Eds.), Existence: a new dimension in psychiatry and psychology, Basic Books, New York, NY, USA, 1958 10.1037/11321-000Search in Google Scholar

[25] Dinsmore D.L., Alexander P.A., Louglin S.M., Focusing the conceptual lens on metacognition, self-regulation, and self-regulated learning, Educ. Psychol. Rev., 2008, 20, 391–409 in Google Scholar

[26] Flavell J.H., Metacognition and cognitive monitoring: a new area of cognitive-developmental inquiry, Am. Psychol., 1979, 34, 906–911 in Google Scholar

[27] Tarricone P., The taxonomy of metacognition, Psychology Press, Taylor and Francis, East Sussex, UK, 2011 10.4324/9780203830529Search in Google Scholar

[28] Lysaker P.H., Vohs J.L., Ballard R., Fogley R., Salvatore G., Popolo R., et al., Metacognition, self reflection and recovery in schizophrenia: review of the literature, Fut. Neurol., 2013, 8, 103–115 in Google Scholar

[29] Wells A., Emotional disorders and metacognition: innovative cognitive therapy, John Wiley and Sons, New York, NY, USA, 2000 Search in Google Scholar

[30] Main M., Metacognitive knowledge, metacognitive monitoring, and singular (coherent) vs. multiple (incoherent) models of attachment: findings and directions for future research, In: Harris P., Stevenson-Hinde J., Parkes C. (Eds.), Attachment across the life cycle, Routledge, New York, NY, USA, 1991, 127–159 Search in Google Scholar

[31] Semerari A., Carcione A., Dimaggio G., Falcone M., Nicolò G, Procaci M., et al., How to evaluate metacognitive function in psychotherapy? The metacognition assessment scale and its applications, Clin. Psychol. Psychother., 2003, 10, 238–261 in Google Scholar

[32] Dewey J., The middle works, 1899–1924, Volume 14, Human nature and conduct, 1922, Southern Illinois University Press, Carbondale, IL, USA, 2008 Search in Google Scholar

[33] Dimaggio G., Vanheule V., Lysaker P.H., Carcione A., Nicolò G., Impaired self-reflection in psychiatric disorders among adults: s proposal for the existence of a network of semi independent functions, Conscious Cogn., 2009, 18, 653–664 in Google Scholar PubMed

[34] Bacon E., Huet N., Danion J.M., Metamemory knowledge and beliefs in patients with schizophrenia and how these relate to objective cognitive abilities, Conscious Cogn., 2011, 20, 1315–1326 in Google Scholar PubMed

[35] Fourneret P., de Vignemont F., Franck N., Slachevsky A., Dubois B., Jeannerod M., Perception of self-generated action in schizophrenia, Cogn. Neuropsychiatry, 2002, 7, 139–156 in Google Scholar PubMed

[36] van’ t Wout M., Aleman A., Bermond B., Kahn R.S., No words for feelings: alexithymia in schizophrenia patients and first-degree relatives, Compr. Psychiatry, 2007, 48, 27–33 in Google Scholar PubMed

[37] Moritz S., Woodward T.S., Burlon M., Braus D., Andresen B., Attributional style in schizophrenia: evidence for a decreased sense of self-causation in currently paranoid patients, Cogn. Ther. Res., 2007, 31, 371–383 in Google Scholar

[38] Bennouna-Greene M., Berna F., Conway M.A., Rathbone C.J., Vidailhet P., Danion J.M., Self-images and related autobiographical memories in schizophrenia, Conscious Cogn., 2012, 21, 247–257 in Google Scholar PubMed

[39] Berna F., Bennouna-Greene M., Potheegadoo J., Verry P., Conway M.A., Danion J.M., Impaired ability to give a meaning to personally significant events in patients with schizophrenia, Conscious Cogn., 2011, 20, 703–711 in Google Scholar PubMed

[40] Raffard S., D’Argembeau A., Lardi C., Bayard S., Boulenger J.P., Van der Linden M., Narrative identity in schizophrenia, Conscious Cogn., 2010, 19, 328–340 in Google Scholar PubMed

[41] Moskowitz A., Association and dissociation in the historical concept of schizophrenia, In: Moskowitz A., Schafer I., Dorahy M.J. (Eds.) Psychosis trauma and dissociation, John Wiley and Sons, West Sussex, UK, 2008, 35–50 in Google Scholar

[42] Bacon E., Danion J.M., Kauffmann-Muller F., Bruant A., Consciousness in schizophrenia: a metacognitive approach to semantic memory, Conscious Cogn., 2001, 10, 473–484 in Google Scholar PubMed

[43] Bacon E., Izaute M., Metacognition in schizophrenia: processes underlying patients’ reflections on their own episodic memory, Biol. Psychiatry, 2009, 66, 1031–1037 in Google Scholar PubMed

[44] Fourneret P., de Vignemont F., Franck N., Slachevsky A., Dubois B., Jeannerod M., Perception of self-generated action in schizophrenia, Cogn. Neuropsychiatry, 2002, 7, 139–156 in Google Scholar PubMed

[45] Koren D., Seidman L.J., Poyurovsky M., Goldsmith M., Viksman P., Zichel S., et al., The neuropsychological basis of insight in firstepisode schizophrenia: a pilot metacognitive study, Schizophr. Res., 2004, 70, 195–202 in Google Scholar PubMed

[46] Koren D., Seidman L.J., Goldsmith M., Harvey P.D., Real-world cognitive — and metacognitive — dysfunction in schizophrenia: a new approach for measuring (and remediating) more “right stuff”, Schizophr. Bull., 2006, 32, 310–326 in Google Scholar PubMed PubMed Central

[47] Lysaker P.H., Carcione A., Dimaggio G., Johannesen J.K., Nicolò G., Procacci M., et al., Metacognition amidst narratives of self and illness in schizophrenia: associations with insight, neurocognition, symptom and function, Acta Psychiatr. Scand., 2005, 112, 64–71 in Google Scholar PubMed

[48] Lysaker P.H., Dimaggio G., Buck K.D., Carcione A., Nicolò G., Metacognition within narratives of schizophrenia: associations with multiple domains of neurocognition, Schizophr. Res., 2007, 93, 278–287 in Google Scholar PubMed

[49] Hamm J.A., Renard S.B., Fogley R.L., Leonhardt B.L., Dimaggio G., Buck K.D., et al., Metacognition and social cognition in schizophrenia: stability and relationship to concurrent and prospective symptom assessments, J. Clin. Psychol., 2012, 68, 1303–1312 in Google Scholar PubMed

[50] Lysaker P.H., Ringer J.M., Buck K.D., Grant M., Olesek K., Luedtke B., et al., Metacognitive and social cognition deficits in patients with significant psychiatric and medical adversity: a comparison between participants with schizophrenia and a sample of participants who are HIV-positive, J. Nerv. Ment. Dis., 2012, 200, 130–134 in Google Scholar PubMed

[51] Lysaker P.H., Warman D.M., Dimaggio G., Procacci M., LaRocco V., Clark L.K., et al., Metacognition in prolonged schizophrenia: associations with multiple assessments of executive function, J. Nerv. Ment. Dis., 2008, 19, 384–389 in Google Scholar PubMed

[52] Delis D.C., Kaplan E., Kramer J.H., Delis-Kaplan Executive Function System (D-KEFS): examiner’s and technical manual, The Psychological Corporation, San Antonio, TX, USA, 2001 10.1037/t15082-000Search in Google Scholar

[53] Kay S.R., Fizszbein A., Opler L.A., The positive and negative syndrome sale for schizophrenia, Schizophr. Bull., 1987, 13, 261–276 in Google Scholar PubMed

[54] Nicolò G., Dimaggio G., Popolo R., Carcione A., Procacci M., Hamm J., et al., Associations of metacognition with symptoms, insight, and neurocognition in clinically stable outpatients with schizophrenia, J. Nerv. Ment. Dis., 2012, 200, 644–647 in Google Scholar PubMed

[55] Rabin S. J., Hasson-Ohayon I., Avidan M., Rozencwaig S., Shalev H., Kravetz S., Metacognition in schizophrenia and schizotypy: relations to symptoms and social quality of life, Isr. J. Psychiatry, in press Search in Google Scholar

[56] McLeod H., Gumley A, Lysaker P.H., Schwannauer M., The contribution of metacognition to understanding the development and maintenance of negative symptoms, Schizophr. Bull., 2013,39supplement 1, 300 Search in Google Scholar

[57] Lysaker P.H., Dimaggio G., Carcione A., Procacci M., Buck K.D., Davis L.W., et al., Metacognition and schizophrenia: the capacity for self-reflectivity as a predictor for prospective assessments of work performance over six months, Schizophr. Res., 2010, 122, 124–130 in Google Scholar PubMed

[58] Luedtke B.L., Kukla M., Renard S., Dimaggio G., Buck K.D., Lysaker P.H., Metacognitive functioning and social cognition as predictors of accuracy of self-appraisals of vocational function in schizophrenia, Schizophr. Res., 2012, 137, 260–261 in Google Scholar PubMed

[59] Tas C., Brown E.C., Esen-Danaci A., Lysaker P.H., Brüne M., Intrinsic motivation and metacognition as predictors of learning potential in patients with remitted schizophrenia, J. Psychiatr. Res., 2012, 46, 1086–1092 in Google Scholar PubMed

[60] Lysaker P.H., Shea A.M., Buck K.D., Dimaggio G., Nicolò G., Procacci M., et al., Metacognition as a mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders, Acta Psychiatr. Scand., 2010, 122, 405–413 in Google Scholar PubMed

[61] Lysaker P.H., Erickson M.A., Buck B., Buck K.D., Olesek K., Grant M.L., et al., Metacognition and social function in schizophrenia: associations over a period of five months, Cogn. Neuropsychiatry, 2011, 16, 241–255 in Google Scholar PubMed

[62] Lysaker P.H., Dimaggio G., Daroyanni P., Buck K.D., LaRocco V.A., Carcione A., et al., Assessing metacognition in schizophrenia with the Metacognition Assessment Scale: associations with the Social Cognition and Object Relations Scale, Psychol. Psychother., 2010, 83, 303–315 in Google Scholar PubMed

[63] Westen D., Lohr N., Silk K., Gold L., Kerber K., Object relations and social cognition in borderlines, major depressives, and normals: a Thematic Apperception Test analysis, Psychol. Assess., 1990, 2, 355–364 in Google Scholar

[64] Davis L.W., Eicher A.C., Lysaker P.H., Metacognition as a predictor of therapeutic alliance over 26 weeks of psychotherapy in schizophrenia, Schizophr. Res., 2011, 129, 85–90 in Google Scholar PubMed

[65] Lysaker P.H., Dimaggio G., Buck K.D., Callaway S.S., Salvatore G., Carcione A., et al., Poor insight in schizophrenia: links between different forms of metacognition with awareness of symptoms, treatment need and consequences of illness, Compr. Psychiatry, 2011, 52, 253–260 in Google Scholar PubMed

[66] Kukla M., Lysaker P.H., Salyers M. Do persons with schizophrenia who have better metacognitive capacity also have a stronger subjective experience of recovery?, Psychiatry Res., 2013, pii: S0165-1781(13)00224-2 Search in Google Scholar

[67] Lysaker P.H., McCormick B.P., Snethen G., Buck K., Hamm J., Grant M., et al., Metacognition and social function in schizophrenia: associations of mastery with functional skills competence, Schizophr. Res., 2011, 131, 214–218 in Google Scholar PubMed

[68] Patterson T.L., Goldman S., McKibbin C.L., Hughs T., Jeste D.V., UCSD performance based skills assessment: development of a new measure of everyday functioning for severely mentally ill adults, Schizophr. Bull., 2001, 27, 235–245 in Google Scholar PubMed

[69] Bob P., Brain, mind and consciousness: advances in neuroscience research, Springer Verlag, New York, NY, USA, 2011 in Google Scholar

[70] Crick F., The astonishing hypothesis. The scientific search for the soul, Simon and Schuster, London, UK, 1994 Search in Google Scholar

[71] Gabbard G.O., A neurobiologically informed perspective on psychotherapy, Brit. J. Psychiatry, 2000, 177, 117–122 in Google Scholar PubMed

[72] Kandel E. R., Biology and the future of psychoanalysis: a new intellectual framework for psychiatry revisited, Am. J. Psychiatry, 1999, 156, 505–524 10.1176/ajp.156.4.505Search in Google Scholar

[73] Rogers C., The therapeutic relationship with schizophrenics, The University of Wisconsin Press, Madison, WI, USA, 1967 Search in Google Scholar

[74] Hasson-Ohayon I., Integrating cognitive behavioral-based therapy with an inter-subjective approach: addressing metacognitive deficits among people with schizophrenia, J. Psychother. Integr., 2012, 22, 356–374 in Google Scholar

[75] Lysaker P.H., Buck K.D., Caricione A., Procacci M., Salvatore G., Nicolò G., et al., Addressing metacognitive capacity for self reflection in the psychotherapy for schizophrenia: a conceptual model of the key tasks and processes, Psychol. Psychother., 2011, 84, 58–69 in Google Scholar PubMed

[76] Lysaker P.H., Buck K.D., Fogley R., Ringer J., Harder S., Hasson-Ohayon I., et al., The mutual development of intersubjectivity and metacognitive capacity in the psychotherapy for persons with schizophrenia with severe paranoid delusions, J. Contemp. Psychother., 2013, 43, 63–72 in Google Scholar

[77] Rosenbaum B., Harder S., Knudsen P., Køster A., Lindhardt A., Lajer M., et al., Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: two-year outcome, Psychiatry, 2012, 75, 331–341 10.1521/psyc.2012.75.4.331Search in Google Scholar PubMed

[78] Salvatore G., Russo B., Russo M., Popolo R., Dimaggio G., Metacognition-oriented therapy for psychosis: the case of a woman with delusional disorder and paranoid personality disorder, J. Psychother. Integr., 2012, 22, 314–329 in Google Scholar

Published Online: 2013-9-13
Published in Print: 2013-9-1

© 2013 Versita Warsaw

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Downloaded on 7.6.2023 from
Scroll to top button