title: Investigating ways of improving psychosocial recovery from negative symptoms: the role of metacognition
Creators: name: McGuire, Nicola
Publisher: name: University of Glasgow
Year: 2022

description: Introduction: Negative symptoms represent deficits of experience: reduced experiences of pleasure, social engagement and motivation, and expressive deficits: reduced affective expression through voice, facial expressions and gestures. These difficulties are common and often persistent in people who experience psychosis. They impact substantially on quality of life and functional outcomes, meaning more precise treatment targets are required. Neurocognitive deficits and cognitive biases have been associated with negative symptoms, but treatments targeting these mechanisms show limited success. Metacognition, the ability to make sense of self-referential experience and the minds of others, which has been shown to explain a large amount of the variance in negative symptoms, may be a more effective treatment target. This thesis aimed to examine the degree of association between negative symptoms, metacognition and related constructs, and methodological factors which impacting on these associations. The level of specificity required to identify meaningful associations when exploring these multi-factorial constructs was assessed to be able to identify avenues for clinical change. Methods: Four studies were conducted. A systematic review (Chapter 3) summarised existing literature reporting relationships between metacognition and negative symptoms, and the risk of bias. Chapter 4 used data derived from the systematic search in an Individual Participant Data Meta-Analysis (IPDMA) of the relationship between metacognition and negative symptoms at their summed and subcategory level. Secondary data analysis (Chapter 5) compared levels of negative symptoms in individuals with psychosis dependant on levels of metacognition and attachment classification and reflective function (the ability to understand self and others in affect-laden interpersonal contexts). Path models were also used to explore how metacognition, reflective function and attachment classification were related to each other. Chapter 6 used two novel samples to explore the relationship between negative symptoms and constructs which emerged as significant in the previous analyses (metacognition and attachment classification) and emotion regulation. Sensitivity analyses were conducted throughout to explore the reliability of these findings. Results: Few previous studies have focused on examining the relationship between metacognition and negative symptoms; these associations are often reported as an incidental finding. Existing data are at risk of bias as unique participants often contribute to several reported analyses which is not transparently reported. IPDMA reveals that, similar to published reports, there is an inverse association between negative symptoms and metacognition, but contrary to expectations, the association between total negative symptoms and metacognition is stronger than any one relationship between negative symptom subtypes and metacognitive subdomains. Contrastingly, in Chapters 5 and 6, similar-strength associations are seen between domains of metacognition and experiential and expressive deficits as well as total negative symptoms. Avoidant attachment (reflecting a working model which downplays relationships), and emotion regulation strategies associated with reduced affective expression, support seeking, and cognitive reappraisal were also associated with increased levels of negative symptoms. Reflective functioning was not strongly associated with negative symptoms despite being correlated with metacognition and avoidant attachment. Discussion: Across all chapters, negative symptoms were inversely associated with metacognition. However, persons with severe negative symptoms and greater metacognitive dysfunction were not as well represented in these samples compared to those with lower levels of metacognitive dysfunction and negative symptoms. These sampling issues potentially obscure cut-off effects or nonlinear relationships, whereby individuals with severe negative symptoms experience disproportionately greater metacognitive deficits than individuals with less severe negative symptoms. Negative symptoms were also associated with several deactivation strategies (avoidant attachment, and expressive suppression) and decreased use of strategies requiring social engagement or cognitive reappraisal. Associations between attachment, metacognition and emotion regulation suggest some possibility that these constructs exert top-down influence on the others respectively. Overall, there is moderate evidence supporting the proposition that metacognition is one of several important treatment targets for negative symptoms. This justifies the need for further research in samples with severe negative symptoms and evaluation of treatment strategies to enhance metacognition for persons with negative symptoms.