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Psychology and Psychotherapy: Theory, Research and Practice (2016), 89, 50–65 © 2015 The British Psychological Society www.wileyonlinelibrary.com

Metacognitive training for young subjects (MCT young version) in the early stages of psychosis: Is the duration of untreated psychosis a limiting factor? Donatella Ussorio1, Laura Giusti1, Charlotte E. Wittekind2, Valeria Bianchini1, Maurizio Malavolta1, Rocco Pollice1†, Massimo Casacchia1 and Rita Roncone1* 1

Unit of Psychiatry, Department of Life, Health and Environmental Sciences, University of L’Aquila, Italy 2 Department of Psychiatry and Psychotherapy, University Medical Center Hamburg – Eppendorf, Germany Objectives. The treatment program ‘Metacognitive training for patients with schizophrenia’ (MCT) addresses cognitive biases assumed to play a crucial role in the pathogenesis of delusions (e.g., jumping to conclusions, theory of mind deficits). The aim of our study was to examine the effectiveness and the feasibility of this intervention targeted to early phases of psychosis (MCT young version). Design. An experimental design included two groups of subjects on the basis of their duration of untreated psychosis (DUP) ‘short’ (less or equal than 12 months) and ‘long’ DUP (longer than 12 months), assessed at baseline and after the 4-month intervention. Methods. Fifty-six young subjects affected by early psychosis were assessed on psychopathology, social functioning, neurocognitive, and metacognitive measures. The primary outcome was the reduction of psychopathology. Secondary outcomes included reduction of cognitive and emotional dysfunction and improvement of social functioning. Results. At the end of the 4-month MCT, both groups showed significant improvements in many variables: positive symptoms, cognitive functions, as verbal memory, attention and mental flexibility, and metacognitive functions, as cognitive insight. Significant and positive changes were found in theory of mind abilities and social perception. Conclusions. The difference in DUP between the two groups of young subjects of our sample did not seem to influence the intervention outcomes, still taking into account that the average difference between the two groups in terms of DUP is 12.6 months.

*Correspondence should be addressed to Rita Roncone, Unit of Psychiatry, Department of Health, Life and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi, Coppito, 67100 L’Aquila, Italy (email: [email protected]). †

In the loving memory of Prof. Rocco Pollice, Professor of Psychiatry.

DOI:10.1111/papt.12059

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Practitioner points  Metacognition refers to the general ability ‘to think about thinking,’ that is, the ability to think about one’s mental state and the mental states of others. Persons with schizophrenia experience different metacognitive impairments.  The metacognitive training for patients with schizophrenia – young version can be applied to young people affected by psychosis and seems to improve symptomatology, social functioning, cognitive, and metacognitive abilities, independently by their Duration of Untreated Psychosis over a 2-year period.

Schizophrenia is one of most disabling disorders worldwide that is associated with severe and persistent functional impairment. Identifying factors contributing to functional outcome becomes an important issue not only for drug treatments but also for psychiatric rehabilitation interventions. Functional outcome is related to social cognition which is impaired in subjects affected by schizophrenia (Fett et al., 2011; Green, Kern, Braff, & Mintz, 2000; Horan et al., 2012; Roncone et al., 2002). Social cognition (SC) refers to the mental operations underlying social behaviour, such as the interpretation of another person’s intentions or emotions. SC is a multidimensional construct that comprises functions such as (1) emotional processing (EP); (2) social perception and knowledge (SP); (3) Theory of Mind (ToM); and (4) attributional bias (AS) (Bellack et al., 2007; Green et al., 2008; Penn, Sanna, & Roberts, 2008). Social cognition includes the broader concept of metacognition and, over the last 15 years, research has increasingly suggested that persons with schizophrenia experience different metacognitive impairments (Brune, 2005; Lysaker et al., 2005). Metacognition refers to the general ability ‘to think about thinking’ which generally includes awareness of one’s own mental processes, the fallibility of one’s own thought, the ability to infer emotions from others faces and prosody, and the cognitive understanding of ideas, beliefs, and intentions of other people (Lysaker et al., 2011; Semerari et al., 2003). Metacognition refers to a spectrum of activities ranging from more discrete to more synthetic activities (Lysaker et al., 2013). Examples of discrete processes include metacognitive activities concerned with immediate awareness or accuracy of judgments about one’s own experiences, such as error detection (Koren, Seidman, Goldsmith, & Harvey, 2006). Examples of synthetic metacognitive operations include the activities by which incoming information is organized and integrated into a complex and coherent representations of self and others (Lysaker et al., 2005). In metacognition Beck, Baruch, Balter, Steer and Warman (2004) and Pedrelli et al. (2004) proposed the concept defined as ‘cognitive insight’, distinguishing between ‘cognitive’ and clinical insight. The latter defines a person’s awareness and acceptance of illness, while cognitive insight identifies the cognitive style or attributive metacognitive ability – specifically flexibility towards their beliefs, judgments, and experiences (David, Bedford, Wiffen, & Gilleen, 2012). Persons with schizophrenia, particularly deluded persons, were proposed to have limited ‘cognitive insight,’ that is a limited capacity for evaluation of their erroneous inferences and seem relatively resistant to corrective feedback (Beck et al., 2004; Pedrelli et al., 2004). The advantages of early intervention are well known, with additional benefits to be gained in severe and long-standing psychiatric conditions, such as schizophrenia (Birchwood et al., 2013; Ruhrmann, Schultze-Lutter, Maier, & Klosterkotter, 2005). Meanwhile, research has shown that the duration of untreated psychosis (DUP) influences aspects of treatment outcome (Norman, Lewis, & Marshall, 2005). Two meta-analyses (Marshall et al., 2005; Perkins, Gu, Boteva, & Lieberman, 2005) found that prolonged DUP had a negative impact on recovery.

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Cognitive-behavioural therapy (CBT) showed important benefits for people with nonaffective psychosis who have social recovery problems, showing persistent signs of poor social functioning and unemployment (Fowler et al., 2009). Also, it seems to be mainly effective in preventing the worsening of emerging psychotic symptoms (Morrison et al., 2012). Moritz, Vitzthum, Randjbar, Veckenstedt, and Woodward (2010) and Moritz and Woodward (2007) developed a new group treatment program entitled metacognitive training for patients with schizophrenia, MCT, available in different languages (Gaweda, Moritz, & Kokoszka, 2009; Hasson-Ohayon, Kravetz, Levy, & Roe, 2009). While CBT typically focuses directly on symptoms and delusional content, MCT indirectly addresses such symptoms by focusing on the underlying cognitive biases, such as jumping to conclusions, JTC, a response pattern based on gathering very little information before arriving at strong conclusions. The primary aim of MCT is to raise the patients’ awareness for boththe presence and dysfunctionalityofcognitivedistortions bymeans ofexerciseswhich frequently evoke cognitive biases often resulting in erroneous decisions (Moritz & Woodward, 2007; Moritz et al., 2010). Like CBT for psychosis (CBTp), MCT shares the goal of targeting psychotic symptoms, but adopts a ‘back door approach’ by dealing with cognitive processes first. MCT exerts beneficial differences effects (Aghotor, Pfueller, Moritz,Weisbrod,&Roesch-Ely,2010;Moritz,Kerstan,et al.,2011),providingevidencefor its efficacy in ameliorating positive symptoms, such as delusions (Favrod, Maire, Bardy, Pernier, & Bonsack, 2011; Gaweda et al., 2009; Kumar et al., 2010; Moritz, Veckenstedt, Randjbar,Vitzthum,&Woodward,2011;Ross,Freeman, Dunn,&Garety,2009),andmental capacity and global functioning (Naughton et al., 2012). The long-term efficacy of group MCT for schizophrenia showed some unanticipated (‘sleeper’) effects both for self-esteem and quality of life after 3 years (Moritz et al., 2014). The samples examined in these studies included an adult population of subjects affected by schizophrenic spectrum disorder. The aim of this study was to examine the efficacy and the feasibility of the intervention of our MCT – young version which we adapted to the needs of young people with psychotic disorders. Two groups of subjects were formed on the basis of their DUP. We expected that: (1). In analogy with the application in older populations, the application of MCT could produce significant metacognitive modifications, leading to improved symptoms, cognitive and emphatic abilities, self-esteem, and social functioning. (2). The changes achieved by MCT could be influenced by DUP: the shorter the DUP, the more effective could be the training.

Methods Participants Participants were recruited from a service for early interventions in young people. The subjects, consecutively referred in a 12-month period (February 2012–February 2013) admitted as outpatients to the service, were diagnosed as affected by psychosis. The criteria for inclusion in the study were as follows: (1). a diagnosis of schizophrenia or related syndromes (F20–25 in ICD-10) according to both ICD-10 and DSM-IV criteria (American Psychiatric Association, 2000); (2). a diagnosis of affective psychosis (bipolar disorder or unipolar disorder with psychotic features) (F30–33 in ICD-10) according to both ICD-10 and DSM-IV criteria (American Psychiatric Association, 2000); (3). age 18–35 years.

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At entry in the study, patients were taking new generation antipsychotics without differences in terms of type and dosage. 34% was treated with quetiapine, 9% were treated with aripiprazole, 27% were treated with risperidone, and 30% were treated with amisulpride. Given the lack of standardized criteria available for use in distinguishing between ‘short’ and ‘long’ DUP, we decided to use a conservative approach dividing patients in two groups according to a median split (12 months) (Perkins et al., 2005), as adopted in other studies (Szymanski et al., 1995). All subjects were asked to participate in the group intervention of MCT – young version which we adapted from the MCT adult version (Moritz & Woodward, 2007). The MCT sessions included subjects independently by their DUP. All subjects provided written informed consent to participate in the study.

Metacognitive training (MCT) Each MCT group comprised between six and nine patients and was delivered by a Psychiatric Rehabilitation Technician and a Clinical Psychologist for the duration of 4 months. The training was administered once weekly. All MCT group members received a maximum of 16 sessions (in each session a different MCT module was delivered). Each session lasted 45–60 min according to the study protocol and the instructions provided in the official manual (Moritz & Woodward, 2007). To address the needs of young people, we made the following changes compared to the Italian version of the manuscript: (1). the materials (images in pdf) included in the files used for the intervention were modified by incorporating slides more animated and colourful, enriched by funny comics and cartoons, like snoopy and friends (Peanuts, created by Schulz in the 1950), and Simpson characters to intersperse the sections of exercises. The use of Peanuts strips was not aimed to ‘infantilize’ the participants, as their characters are children ‘outside,’ but ‘inside’ they face and cope with adult and complex problems in every moment of their ‘life in the comic’ (Schultz, 2002); (2). some examples relating to specific modules and target domains were replaced by other examples relating to youth difficulties contextualized in daily and social scenery (i.e., school and university exams, fighting with siblings or friends) and including current idols (i.e., from sports, music, and cinema); (3). the term ‘psychosis’ frequently used in the adult version MCT, especially in the section about ‘learning goals,’ was replaced with softer terms, as ‘distress,’ ‘discomfort,’ ‘difficulty’ and ‘problem,’ more suited to young subjects in a vulnerable condition like the early and less defined stage of psychosis. The young version of MCT does not alter the original version of the treatment and the conceptual paradigm of the training, as checked by one of the Author (CW). Moreover, the presentation via slides show during the sessions guarantees a good reproducibility of the intervention. The following battery of instruments was administered at baseline and after the MCT, at the 4 month.

Psychopathology assessment Positive and negative syndrome scale (PANSS). The PANSS (Kay, Fiszbein, & Opler, 1987), in its Italian version (Pancheri et al., 1995), is a 30-item rating scale used for

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measuring positive and negative symptoms of patients with schizophrenia. Higher scores reflect greater psychopathology. For the purposes of this study, four PANSS scores were used: Total score, general psychopathology cluster, negative cluster, and positive cluster. The PANSS has good psychometric properties (Peralta & Cuesta, 1994).

Brief psychiatric rating scale-24 items (BPRS). The BPRS (Ventura, Green, Shaner, & Liberman, 1993; Ventura, Lukoff, et al., 1993) was used in its Italian version (Morosini & Casacchia, 1995; Roncone et al., 1999, 2003) to assess the global severity of psychopathology. Each symptom on the 24-item scale was rated from 1 to 7 (1 = absence of symptoms; 7 = very severe symptoms). The key score was composed of the total item score. The scale demonstrates high validity and reliability (Roncone et al., 1999).

Social functioning and social network assessment Personal and social performance scale (PSP). The PSP (Morosini, Magliano, Brambilla, Ugolini, & Pioli, 2000) was used to assess subjects’ social functioning. Patients’ functioning is assessed in four core areas: Socially useful activities; personal and social relationships; self-care; and disturbing and aggressive behaviours. A global item is rated by the interviewer, ranging from 1 to 100 at 10-point intervals with lower scores indicating poorer functioning (Morosini et al., 2000). The PSP shows good psychometric properties (Nasrallah, Morosini, & Gagnon, 2008).

Questionnaire on social network (QSN). The QSN in its Italian version (Magliano et al., 1998) is a self-administered questionnaire that assesses both structural and qualitative aspects of the social network. It includes 15 items, grouped into four factors: (1) quality and frequency of social contacts; (2) social support; (3) practical emotional support; and (4) quality of an intimate significant relationship. Each item is rated on a scale from 1 ‘never’ to 4 ‘always’ (higher scores are indicative of better social network).

Metacognitive assessment Beck cognitive insight scale (BCIS). The BCIS (Beck et al., 2004) was used to assess cognitive insight. It is a 15-item self-report measure that asks individuals to what extent they agree with statements pertaining to how certain they are of the accuracy of their judgments. It is composed of two subscales: Nine Self-Reflectiveness items (range: 0–27) that assess objectivity, reflection, and openness to feedback (e.g., ‘Some of my experience that have seemed very real may have been due to my imagination’) and six Self-Certainty items (range: 0–18) that tap certainty about being right and resistance to correction (e.g., ‘My interpretation of my experiences are definitely right’). Higher scores on SelfReflectiveness are indicative of higher levels of cognitive insight, while higher levels on Self-Certainty are reflective of lower levels of cognitive insight.

Measures of ToM. We included two advanced measures of ToM. The first measure was the Strange Stories Test that assesses the verbal-reasoning aspect of ToM (Happ
e, 1994) and consists of a short version of 12 short vignettes, including Pretend, Joke, Lie, White lie,

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Misunderstanding, Double Bluff, and Contrary Emotion (score range: 0–12; high scores are indicative of a good ToM ability). The second measure was the Eyes Task (Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001) to tap the non-verbal aspect of ToM. The Eyes Task (Baron-Cohen et al., 2001) shows participants 36 photographs of one set of eyes surrounded by four words that could be used to describe the feeling or thought expressed by the eyes (score range: 0–36; higher scores mean a better ToM social perception).

Neurocognitive assessment Rey auditory verbal learning test (RAVLT). The RAVLT (Carlesimo, Caltagirone, & Gainotti, 1996; Rey, 1958) was used to assess short- and long-term verbal memory. The test consists of a list of 15 semantically unrelated words that the subject must memorize and repeat immediately and 15 min later. In both trials, higher scores are indicative of good memory.

Trail making test (TMT). The Trail Making Test (TMT) Part A and B (Mondini, Mapelli, Vestri, Arcara, & Bisiacchi, 2011; Reitan, 1992) was used to assess sustained attention, visual–spatial search, and psychomotor speed. The A-form requires the subject to combine numbers as fast as possible in ascending order. In the B-part, the subject has to combine numbers and letters as quickly as possible in both alternating and ascending fashion (1-A-2-B-3-C.). The rating is based on the number of seconds needed to complete the test. Three scores are obtained: Part A, Part B, and the difference between B and A. Lower scores are indicative of good attentive abilities.

Self-esteem assessment Self-esteem rating scale (SERS). The SERS (Nugent & Thomas, 1993) is a 40-item instrument that provides a clinical measure of self-esteem. The respondents are required to rate themselves on a 7-point scale (1 = Never; 7 = Always). Positive scores are indicative of higher self-esteem. The instrument shows a high level of internal consistency (a of .97), and good content and factorial validity (Nugent, 1995).

Post-assessment questionnaire At the end of the MCT intervention, the young participants were administered an evaluation questionnaire which took approximately 5 min to complete (Moritz & Woodward, 2007). Participants were reminded to provide an open and critical feedback. The questionnaire includes 10 questions rated on a 5-point Likert scale (1 = fully disagree, 5 = fully agree) that cover distinct aspects of training satisfaction: Effectiveness, usefulness, applicability to daily life, transparency of the aims and fun. Higher scores designated greater satisfaction.

Statistical analysis One-way analyses of variance (ANOVA) were conducted to examine baseline differences between the short (DUP 12 months, LDUP) on demographic, clinical, social functioning, cognitive, and metacognitive variables. ANOVA repeated measures were also run for group (SDUP group vs. LDUP group) and time factors (Pre-training–T0 vs. Post-training–T1) on results, whereas psychopharmacological (mg/Equivalents chlorpromazine) dosage was included as covariate to control for confounding effects. To evaluate the effectiveness of MCT treatment (Pre-training–T0 vs. Post-training–T1), effect sizes were calculated for all subjects using Cohen’s d (Moritz, Woodward, & Di Michele, 2010). Statistical analyses were performed using SPSS 16.0 (SPSS Inc., Chicago, IL, USA).

Results The total sample included 56 young subjects affected by psychosis, 28 subjects belonging to the SDUP group (21 men, 7 women; mean age, years, 21.1 SD 4) and 28 subjects belonging to the LDUP group (20 men, 8 women; mean age, years, 23.4 SD 5.2). We found no statistical differences between the two groups in the distribution of age and educational level (SDUP mean educational years 13.5 SD 2.2; LDUP mean educational years 14 SD 2.4) and in antipsychotic dose mg/Equivalents chlorpromazine (SDUP mean mg/Eq 109.9 SD 65.1; LDUP mean mg/Eq 114.4 SD 79.7). For the 2 groups clinical, social functioning, neurocognitive, and metacognitive variables are reported in Table 1. The mean DUP differed significantly between groups, F (1.54) = 56.6, p < .001, according to our criteria in group identification. At baseline, all the other variables did not show any statistical significant differences on neurocognition, social cognition, and metacognition measures between the two groups. At the end of the MCT, we found no statistical differences between the two groups in antipsychotic dose mg/Equivalents chlorpromazine (SDUP mean mg/Eq 95.8 SD 57.1; LDUP mean mg/Eq 101.2 SD 63.6). The mean values of measures post-MCT for both experimental groups are reported in Table 1. At the end of the MCT, we found no statistical significant Group 9 Time interaction on examined variables, including psychopathology, social functioning, cognition, and metacognition, showing that the different level of DUP did not have any interaction effect in our sample, after controlling for dosage drug treatment, as covariate.

Psychopathology Statistical significant differences in the PANSS subscale scores, PANSS total: F (1.54) = 26.9, p < .001, d = 1.33; PANSS positive: F(1.54) = 28.9, p < .001; d = 1.52, and in the BPRS score, BPRS total: F(1.54) = 27.87, p < .001; d = 1.23 were found at the end of the MCT compared to baseline, showing an improvement in general psychopathology and in positive symptoms for both groups. The effect size of MCT treatment was very large for general psychopathology and positive symptoms. Very small effect sizes for between-group difference were found for PANSS total: F (1.54) = 0.111, p = .740; d = .09), for PANSS general: F(1.54) = 0.007, p = .934; d = .12, for PANSS positive: F(1.54) = 0.014, p = .905; d = .007, for PANSS negative: F (1.54) = 0.332, p = .567; d = .06, and for BPRS total score: F(1.54) = 0.381; p = .54; d = .06, suggesting that the DUP did not influence the effect of MCT treatment on symptoms.

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Table 1. Means and SD of clinical, social functioning, neurocognitive, metacognitive measures of both groups short DUP and long DUP pre (T0) and post-training (T1) LDUP group (n = 28) (DUP >12 months) Mean (SD)

SDUP group (n = 28) (DUP ≤ 12 months) Mean (SD) Variables DUP (months) Clinical measures PANSS total PANSS general symptoms PANSS negative symptoms PANSS positive symptoms BPRS total score Social Functioning measures PSP total score SNQ total score Neurocognitive measures RAVLT-A: Short term verbal memory RAVLT-B: Long term verbal memory TMT-A: Visual spatial research/ sustained attention TMT-B: Cognitive flexibility and shifting Metacognitive measures BCIS, SR BCIS, SC EYES TASK Advanced ToM task (Strange stories) Self-esteem rating scale

T0

T1

9.4 (2.1)

T0

T1

22 (8.6)**

70.4 (13.4) 34.7 (6) 17.7 (7.4) 17 (4.3) 60.4 (7.1)

69.1 (12.8)** 36.6 (5.8) 17.7 (7.4) 17.09 (4.2)** 56.7 (6.6)**

69.5 (12.5) 34.6 (5.2) 16.5 (7.3) 18.2 (3.8) 58.4 (6.5)

67.9 (11.7)** 34.5 (5.2) 16.6 (7.3) 16.9 (3.5)** 56.7 (5.1)**

61.3 (7.3) 31.5 (5.1)

63. (6.7)** 43.1 (4.2)**

61.4 (7.1) 33.7 (6.7)

63.6 (7.8)** 43.9 (4.9)**

29.1 (6.1)

41.7 (9.4)**

29.9 (6.7)

37.2 (6.7)**

7.5 (0.9)

8.4 (1)**

7.4 (1.03)

8.8 (1.1)**

39 (20.2)**

63.6 (37.7)

37.7 (18.1)**

113 (48.8)

84.3 (37.7)**

121 (52.7)

96.2 (51.6)**

13.2 (3.6) 8 (3.3) 19.3 (2.7) 6.8 (1.1)

11.7 (2.3)** 6.9 (2.1)** 20.2 (2.4)** 9.7 (1)**

64.8 (37.04)

6.4 (25.1)

9.6 (24)

13.04 (3.9) 9.7 (3.7) 18.1 (3.1) 6.5 (0.9) 1.5 (20.9)

11 (2.08)** 6.2 (1.9) 18.6 (3.1)** 9.6 (1)** 7.4 (15)

Note. *p < .05; **p < .01. DUP, Duration of untreated psychosis; PANSS, Positive and Negative Syndrome Scale; BPRS, Brief Psychiatric Rating Scale; PSP, Personal and Social Performance; SNQ, Social Network Questionnaire; RAVLT, Rey’s Auditory Verbal Learning Test; TMT A, B, Trail Making Test A, B; BCIS, Beck Cognitive Insight Scale; SR, Self-Reflectiveness; SC, Self-Certainty; ToM, Theory of Mind; SERS, Self-Esteem Rating Scale.

Social functioning and social network At the end of the group intervention, statistical significant differences were found in the social functioning measures: PSP total, F(1.54) = 48, p < .001; SNQ: F(1.54) = 100.8, p < .001, compared to baseline, showing a good social improvement for both groups. At the end of the MCT intervention, statistical significant differences were also found for social functioning (PSP total score d = 1.81), and in the social network measure (SNQ total score d = 2) compared to the entry in the study, showing a good social improvement for both groups with very large effect size of MCT treatment on these dimensions for all subjects.

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Small effect sizes for between-group difference were found, F(1.54) = 0.010; p = .919; d = .10 for social and personal functioning measure and F(1.54) = 2.597, p = .113; d = .12 for social network and social support measure, suggesting that the DUP does not impact MCT effectiveness on functioning and social network measures.

Neurocognition Compared to baseline, at the end of the MCT, statistical significant differences were found in neurocognitive measures, as in verbal memory and executive functions, as assessed by the RAVLT and TMT: RAVLT A: F(1.54) = 70, p < .001, d = 2; RAVLT B: F(1.54) = 51.6, p < .001, d = 1.88; TMT A: F(1.54) = 37.6, p < .001, d = 1.59; TMT B: F(1.54) = 27.3, p < .001, d = 1.38, showing marked improvement in attentive, executive, and memory functions for all subjects with large effect sizes of MCT treatment on cognitive functions. Regarding effect sizes for between-group difference results favored SDUP group for shortterm verbal memory as measured by RAVLT A at medium effect size: F(1.54) = 1.314, p = .257; d = .61, and LDUP group for long-term verbal memory as measured by RAVLT B at a small effect size, F(1.54) = 0.555, p = .459; d = 0.28, and executive function as measured by TMT B at a small effect size, F(1.54) = 0.695, p = .408; d = .24, showing that DUP influences mildly cognitive functions improved by MCT intervention.

Metacognition At the end of the group intervention, statistical significant differences were found in most of the metacognitive measures, BCIS Self-Reflectiveness: F(1.54) = 7.46, p = .008, d = .91; BCIS Self-Certainty: F(1.54) = 13.4, p = .001, d = .84; Eyes task: F (1.54) = 26.4, p < .001, d = 1.41; ToM task: F(1.54) = 189, p < .001, d = 2, in both our groups compared to baseline with a very large effect size of MCT treatment on metacognitive functions. Regarding effect sizes for between-group difference results favored SDUP group for the ability to evaluate their erroneous inferences (SelfReflectiveness of BCIS) at a predominantly small to medium effect size, F (1.54) = 0.795, p = .377; d = .35, and LDUP group for improvement in their overconfidence (Self-Certainty of BCIS) at a medium effect size, F(1.54) = 1.204, p = .277; d = .52, and in their non-verbal social reasoning as measured by Eyes task at a medium effect size, F(1.54) = 6.548, p = .063; d = .52.

Self-esteem Compared to baseline, at the end of MCT intervention, in both groups, no difference was found regarding self-esteem, as assessed by SERS, which values showed a stability, F (1.54) = 4.087, p = .068.

Subjective appraisal of MCT There were no dropouts from either treatment group and every participant completed pre- and post-test assessments. The result of the post-assessment training appraisal is listed in Table 2, showing that the young participants were satisfied with the training.

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Table 2. Subjective appraisala of MCT training – young version Items 1. The training was useful and sensible 2. I had to force myself to go to the training regularly 3. In every-day life, I do not apply the lessons learned 4. The training was an important part of my treatment program 5. I would have liked to spend the time doing something else 6. The training was fun 7. A lot of what I learned during training is useful to my daily routine 8. The goals and rationale of the training were clear to me 9. I would recommend the training to others 10. I found it beneficial that the training was administered in a group

Yes (%) 93 16.3 11.6 65.1 16.3 65.1 69.8 81.4 81.4 76.7

Note. aYes responses = either 4 (agree) or 5 (fully agree) were endorsed.

Discussion Our study shows the feasibility of the metacognitive training for young outpatients in the early stages of psychosis (Moritz & Woodward, 2007) which was adapted to meet the needs of young people with psychotic disorders (MCT young version). Controlled for dosage of prescribed drug treatment, the present ‘real world’ study provides encouraging clinical, social functioning, neuropsychological, and metacognitive evidence of the efficacy of a metacognitive rehabilitation strategy addressed to young people affected by psychosis. Disconfirming our initial hypothesis, in which we supposed that the shorter was the DUP, the more effective would be the training, the difference in DUP between the two groups of young subjects of our sample did not seem to influence the intervention outcomes. In fact, we observed that a DUP longer than 12 months did not imply a reduction of the effects of the MCT compared to the intervention conducted in subjects with a DUP shorter than 12 months. All participants expressed a great satisfaction with the MCT young version highlighting the pleasant atmosphere of the group intervention. In our sample, the average difference between the two groups of young participants in terms of DUP was of 12.6 months and an important issue could be whether 1 year difference is enough to predict a different response to a given treatment. The clinical emphasis put on addressing early interventions in psychotic young people can justify our interest in verifying if the MCT can be successfully administered in a 2-year period after the onset of psychosis, to improve and optimize the time planning and the choice of treatments. At the end of the MCT intervention, we found a total and general symptomatology reduction in both groups, as measured by PANSS and BPRS total score, and a reduction of positive symptoms. However, we did not find a statistical significant Group 9 Time interaction on examined variables, including psychopathology, social functioning, cognition, and metacognition, showing that the different level of DUP did not have any interaction effect in our sample. The reduction of the positive symptomatology confirms the results of recent studies (Aghotor et al., 2010; Kumar et al., 2010; Moritz, Kerstan, et al., 2011; Moritz, Veckenstedt, et al., 2011; Ross et al., 2009), underlining the specific therapeutic effects of ameliorating positive symptoms, as the MCT modules are addressed to restructure the cognitive biases that are thought to trigger, aggravate, or maintain positive symptoms in

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schizophrenia, particularly delusions (Moritz & Woodward, 2007). In the studies of Aghotor et al. (2010) and Moritz, Kerstan, et al., 2011, analysis of metacognitive data was restricted to the most well studied cognitive bias, jumping to conclusion, JTC, and in both studies, the MCT training showed a high efficacy to reduce them. In our study, the MCT young version seems to ameliorate both components of cognitive insight (i.e., SelfReflectiveness, Self-Certainty) in both groups. The strong improvement of cognitive insight, in terms of cognitive mental flexibility, can be presumably tied to the young age of our subjects and this result seems very relevant to us. Recently Giusti, Mazza, Pollice, Casacchia, and Roncone (2013) found that the Self-Reflectiveness deficit was the best predictor of low global functioning in schizophrenia. Our MCT training intervention seems to improve an another metacognitive ability, that is, the ability to understand and interpret the mental state of themselves and others and thus predict and explain their behaviour, measured in this study by the ToM task (Frith & Corcoran, 1996; Mazza, De Risio, Surian, Roncone, & Casacchia, 2001). Kettle, O’BrienSimpson, and Allen (2008) showed ToM impairment in first episode patients and a recent meta-analysis found that such an impairment is comparable to that of chronic patients (Bora, Yucel, & Pantelis, 2009). The ToM ability represented a target of two MCT modules (module 4 and module 6) and, at the end of the intervention, we found an improvement in both verbal and non-verbal ToM measures. Another relevant and interesting finding of the present study concerns the improvement of the social functioning, as measured by PSP and social network, as measured by SNQ, showing benefits in interpersonal relationships, as found by Naughton et al. (2012), presumably undermined by frequent misunderstandings and cognitive distortions in previous interpersonal relationships. According to Moritz, Kerstan, et al., 2011, our study found that the MCT training intervention improved some neurocognitive abilities of our young subjects. We observed a statistical significant improvement for both groups in attention, executive, and memory functions, while Moritz, Kerstan, et al., 2011 found only an improvement in memory capacity (the MCT training includes a specific module on meta-memory). We suppose that the good level of attention and concentration of our young participants helped them to improve the measures of attention, while the executive functions could be increased by improved cognitive flexibility, as shown in the BCIS. Moreover, our neurocognitive results corroborate the results of Moritz, Kerstan, et al., 2011 that the MCT intervention does not exert direct effect on cognitive functions. However, the attenuation of distress may have released those cognitive resources previously occupied by, for example, ruminative and paranoid thoughts. The MCT intervention did not show any improvement in self-esteem in our sample at the end of the training. Many patients with schizophrenia experience alterations in their self-experience, assessed as a matter of self-esteem (Bentall et al., 2008; Ritsner & Blumenkrantz, 2007; Vauth, Kleim, Wirtz, & Corrigan, 2007) and personal narrative (Lysaker, Buck, Taylor, & Roe, 2008; Raffard et al., 2009; Skodlar, Tomori, & Parnas, 2008). Therefore, many patients with this condition come to have a possible difficulty and unique struggle with issues of self-concepts. Greater insight has been associated with lowered self-esteem and hope (Warner, Taylor, Powers, & Hyman, 1989). Our finding is in line with the hypothesis of Roberts (Roberts, 1991) suggesting that the experience of the self might be particularly destabilized in the transition phase, between acute and remission points of the illness. Roberts suggested that deluded patients may subjectively fulfill many of their needs through a ‘reconstruction of reality,’ in which they are protected from depression. On the basis of the recent study of Moritz et al. (2014), we could foresee

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that self-esteem will improve in the course of time, since in their 3-year follow MCT study, Moritz et al. showed that previously non-significant between-group differences in quality of life and self-esteem reached significance after 3 years. Our study presents two main limitations. First, our study is not a randomized trial, and it was conducted on antipsychotic-treated subjects; surely, drug treatment could have contributed to improvements in our sample through good drug compliance, allowing the participation to the treatment sessions, and a better allocation of neurocognitive resources (Moritz, Kerstan, et al., 2011). However, as we controlled for psychopharmacological treatment dosage, our data seem to show specific advantages of the MCT. Second, generalization of our findings is limited by sample size and by sample gender (predominantly males). Based on the encouraging initial findings of some recent studies (Aghotor et al., 2010; Kumar et al., 2010; Moritz, Kerstan, et al., 2011), our study, which focused primarily on early psychosocial interventions, suggests that a metacognitive approach may be essential to achieve good improvements in functional outcome of young people affected by psychosis by improving their symptomatology, neurocognitive, and metacognitive abilities, independently by their DUP, at these very early stages of psychosis. Our results can encourage mental health professionals to apply the MCT intervention with subjects presenting a DUP longer than 12 months (till to 2 years), as the achieved benefits will be the same as they will have promptly conducted the intervention. Further studies are needed to confirm to verify the period of time within the effectiveness of the MCT intervention is maintained, albeit confirming the need of an early intervention for young psychotic people.

Acknowledgements The authors thank Steffen Moritz and Todd Woodward for permission to use and adapt their group training modules. Steffen Moritz gave many suggestions and an important contribution in the drafting of our study also. The authors wish to acknowledge Vittorio di Michele from the Department of Mental Health, National Health Trust, Pescara, Italy, as coordinator and trainer of MCT Italian version for his valuable support and training. The authors thank Luigia Marcocci for her technical support.

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