Abstract
Metacognitive training (MCT) was developed to promote awareness of reasoning biases among patients with schizophrenia. While MCT has been translated into 31 languages, most MCT studies were conducted in Europe, including newer evidence recommending an individualized approach of delivery. As reasoning biases covered in MCT are separable processes and are associated with different symptoms, testing the effect of selected MCT modules would help to develop a targeted and cost-effective intervention for specific symptoms and associated mechanisms. This study tested the efficacy of a four-session metacognitive training for delusions, MCTd (in Traditional Chinese with cultural adaptations, provided individually), as an adjunct to antipsychotics in reducing severity and conviction of delusions, jumping to conclusions (JTC) bias and belief inflexibility. Forty-four patients with delusions were randomized into the MCTd or the wait-list control condition. Patients on wait-list received the same MCTd after 4 weeks of treatment as usual (TAU). Assessment interviews took place before and after the treatment, and at 4-week follow-up. There was an additional baseline assessment for the controls. JTC and belief flexibility were measured by the beads tasks and the Maudsley Assessment of Delusions Scale. Attendance rate of the MCTd was satisfactory (84.5%). Compared to TAU, there was a greater reduction in psychotic symptoms, delusional severity and conviction following MCTd. There was a large treatment effect size in improvement in belief flexibility. Improvement in reaction to hypothetical contradiction predicted treatment effect in positive symptoms and delusions. JTC bias was reduced following MCTd, although the treatment effect was not significantly larger than TAU. Our results support the use of process-based interventions that target psychological mechanisms underlying specific psychotic symptoms as adjuncts to more conventional approaches.
Highlights
Psychosis is a complex condition encompassing a range of symptoms (van Os et al, 1999; Bürgy, 2008; Demjaha et al, 2009)
This study evaluated the effect of a four-session MCT for delusions (MCTd) on reducing delusions and improving data-gathering and belief flexibility
MCTd focused on reasoning biases that have been shown to be closely associated with the pathogenesis of delusions
Summary
Psychosis is a complex condition encompassing a range of symptoms (van Os et al, 1999; Bürgy, 2008; Demjaha et al, 2009). Rather than focusing directly on the content of patients’ delusional beliefs and their associated emotions, MCT takes the ‘back door approach,’ identifying and discussing at length the underlying cognitive processes that contribute to the delusional interpretations of experiences (Moritz et al, 2011a; Kumar et al, 2014) This non-directive approach in addressing delusional beliefs and underlying reasoning biases is considered to be less threatening to participants and potentially helpful in minimizing treatment resistance (Moritz et al, 2014a). As the study aimed to examine treatment outcome in delusions, only the modules related to data-gathering and belief flexibility were included in MCTd. Based on findings from Waller et al (2011) and Garety et al (2014), MCTd was delivered individually. (1) The four-session package of MCTd will be considered feasible, acceptable and useful by patients with delusions (2) There will be a greater reduction in severity and conviction of delusions after MCTd than wait-list (3) There will be a greater improvement in data-gathering and belief flexibility after MCTd than wait-list (4) Treatment effect on delusions will be mediated by improvement in cognitive biases (JTC and belief flexibility)
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