Integrated Metacognitive Therapy in First Episode Psychosis
Condition: Schizophrenia; Schizophreniform Disorder; Schizoaffective Disorder
MeSH terms: Schizophrenia; Psychotic Disorders; Mental Disorders
Study type: Interventional

Summary: 
      Insight, or lack of illness awareness, is a prominent and pressing clinical concern in the
      treatment and recovery of patients with psychotic disorders. Impaired insight results in poor
      treatment engagement and adherence, more frequent hospitalizations, greater positive and
      negative symptoms, and poor psychosocial functioning. Addressing these complications early in
      the disease process may lead to altered illness course with better outcomes. To date, only a
      small number of nonpharmacological interventions have been developed, none of which
      adequately address poor insight during the first few years of psychotic illness. Further,
      presently available therapeutic interventions do not attend to difficulties associated with
      improved insight, such as depression. The purpose of this investigation is to implement a
      novel intervention designed to improve insight, metacognition, neurocognition, symptoms, and
      ultimately overall functioning in persons with early psychosis. The novel intervention will
      integrate a number of previously established therapeutic approaches, such as metacognitive,
      narrative, cognitive behavioral and motivational interviewing, and hence be labeled
      Integrated Metacognitive Therapy (IMT). In order to measure the efficacy of IMT, all subjects
      will undergo a battery of assessments in each of these domains prior to and following either
      a novel intervention (N = 10) or treatment as usual (N = 10) for a period of approximately
      six months. Throughout the study, each IMT session (N = 10, 24 sessions each) will be audio
      recorded, transcribed, and de-identified to allow for careful ongoing qualitative analyses of
      potential active and inert ingredients of the approach and ultimately the development of an
      IMT manual which can then be tested in a larger, more rigorous randomized control trial. This
      investigation will play an important role in advancing current knowledge about treating
      insight in early psychosis. Further, it will serve to expand upon the intervention tools
      available by producing a much needed treatment manual designed specifically to target insight
      during an illness phase crucial for positive long term outcomes in psychosis.
    

Detailed description: 
      The National Advisory Mental Health Council recently called for the development of
      non-pharmacological treatments that identify and target specific disease processes for
      clinical improvement in schizophrenia and other psychotic illnesses. One such illness
      process, vital for positive outcomes, is impaired awareness of illness or insight. Insight is
      often thought of as factual knowledge and acknowledgement of one's illness. More
      specifically, insight in psychosis has been conceptualized as a multi-dimensional construct,
      with several independent but overlapping dimensions, such as the ability to appropriately
      label aberrant mental events (e.g. hallucinations and delusions), recognition of illness, and
      willingness to engage in treatment. Relative to individuals with other mental illnesses,
      those with psychotic illness have the most impaired insight, presenting a number of
      challenges, including: poor treatment engagement and adherence, more frequent
      hospitalizations, greater positive and negative symptoms, and poor psychosocial functioning.
      This problem is particularly relevant in early phases of psychotic illness, where there
      remains a paucity of data. Data that is available has shown decreased insight is associated
      with increased symptoms and poorer cognitive functioning, both of which have the potential to
      impact illness course.

      Two reasons account for a lack of attention to the development of treatments for insight: i)
      the lack of an adequate model of the forces which cause and sustain poor insight and ii) a
      failure to consider an integrated treatment. Without an idea of the processes which sustain
      poor insight, interventions have been able to offer education about the nature of illness but
      have not been equipped to respond to the underlying processes that block the emergence of
      insight in treatment. While earlier literature framed insight as a failure to grasp a
      specific fact, more recent efforts suggest poor insight is primarily the result of a failure
      to create a coherent account of the complex events and personal experiences related to a
      psychiatric illness. These difficulties becoming aware of one's illness may be
      multi-determined and result from factors including deficits in metacognition, neurocognition,
      and symptoms.

      The development of insight is complex and highly dependent upon metacognitive processes,
      which have a unique, potentially moderating role. Metacognition involves a range of faculties
      that allow an individual to form representations of mental states of self and others, which
      then leads to the formation and revision of thoughts, beliefs, feelings, behaviors, and even
      individual aspirations. Therapies targeting metacognitive or mentalizing deficits have been
      successfully implemented for personality disorders, depression and anxiety. In psychotic
      disorders, decreased metacognitive capacity is thought to result in difficulties identifying
      the source of one's experiences, such as illness and its consequences. This leads to an
      inability to perceive the self as an active agent in the world and problems in understanding
      and acting upon the social cues (emotions and intentions) of others. A recently proposed
      Integrated Metacognitive therapeutic approach argues that insight will improve as an
      individual utilizes a constructed narrative to make sense of his or her experiences. In other
      words, illness and its consequences are understood in an individualized, personally relevant
      and acceptable way. Importantly, this approach addresses many obstacles to gaining insight
      not addressed by other approaches, including learning to deal with related emotional pain and
      depression, loss, and internalized stigma. This view is also consistent with intervention
      research showing that establishment of personal meaning is important for recovery, and
      promotes improved function and reduced symptoms. Case studies from our group and others have
      provided evidence that therapy targeting metacognitive processes is feasible in psychotic
      disorders and can indeed improve insight and function in persons with chronic schizophrenia.
      However, this approach has not been tailored to target insight, evaluated or tested in
      patients in the early phase of psychosis.

      In addition to metacognitive deficits, neurocognitive deficits have also been commonly
      observed in schizophrenia and involve decrements in capacities for attention/vigilance,
      verbal memory and executive function. Deficits in executive function have been found to
      predict concurrent and prospective assessments of poorer insight, spurring hypotheses that
      impairments in executive function leave persons unable to synthesize illness related
      experiences into a coherent and adequate story about how and why they are ill. Deficits in
      attention and memory may additionally obscure how historical events are connected to each
      other. As a whole, neurocognitive deficits may cause difficulties piecing together the
      individual's experience of illness into a coherent whole resulting in poor insight.
      Therefore, development of personal narratives using an integrated therapy would allow
      subjects the opportunity to better understand their illness experience, hence improving
      insight.

      The research presented above suggests that improving insight early in the psychotic disease
      process would likely result in improved treatment participation, ultimately leading to better
      outcomes. Motivated by a clear and pressing need to better address illness insight in early
      psychotic illness and recent positive findings related to doing so, the present investigation
      serves to test a novel Integrated Metacognitive Therapy (IMT) which targets insight and other
      important domains in early psychosis. Assuming IMT is successful, ongoing qualitative
      analysis of IMT sessions will allow for manual development, future randomized control trials,
      and ultimately treatment dissemination.
    

Intervention name(s): Integrated Metacognitive Therapy; Treatment as Usual
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Integrated Metacognitive Therapy; Treatment as Usual
Other intervention name(s): No intervention/Treatment as Usual
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: schizophrenia; schizophreniform disorder; schizoaffective disorder; cognition; metacognition; insight; first episode psychosis; psychosis