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Antipsychotic treatment beyond antipsychotics: metacognitive intervention for schizophrenia patients improves delusional symptoms

  • S. Moritz (a1), R. Veckenstedt (a1), S. Randjbar (a1), F. Vitzthum (a1) and T. S. Woodward (a2) (a3)...

Although antipsychotic medication still represents the treatment of choice for schizophrenia, its objective impact on symptoms is only in the medium-effect size range and at least 50% of patients discontinue medication in the course of treatment. Hence, clinical researchers are intensively looking for complementary therapeutic options. Metacognitive training for schizophrenia patients (MCT) is a group intervention that seeks to sharpen the awareness of schizophrenia patients on cognitive biases (e.g. jumping to conclusions) that seem to underlie delusion formation and maintenance. The present trial combined group MCT with an individualized cognitive-behavioural therapy-oriented approach entitled individualized metacognitive therapy for psychosis (MCT+) and compared it against an active control.


A total of 48 patients fulfilling criteria of schizophrenia were randomly allocated to either MCT+ or cognitive remediation (clinical trial NCT01029067). Blind to intervention, both groups were assessed at baseline and 4 weeks later. Psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS) and the Psychotic Symptom Rating Scales (PSYRATS). Jumping to conclusions was measured using a variant of the beads task.


PANSS delusion severity declined significantly in the combined MCT treatment compared with the control condition. PSYRATS delusion conviction as well as jumping to conclusions showed significantly greater improvement in the MCT group. In line with prior studies, treatment adherence and subjective efficacy was excellent for the MCT.


The results suggest that the combination of a cognition-oriented and a symptom-oriented approach ameliorate psychotic symptoms and cognitive biases and represents a promising complementary treatment for schizophrenia.

Corresponding author
*Address for correspondence: Prof. Dr. S. Moritz, University Hospital Hamburg-Eppendorf, Hospital for Psychiatry and Psychotherapy, Martinistraße 52, Hamburg, Germany. (Email:
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Aghotor, J, Pfueller, U, Moritz, S, Weisbrod, M, Roesch-Ely, D (2010). Metacognitive training for patients with schizophrenia (MCT): feasibility and preliminary evidence for its efficacy. Journal of Behavior Therapy and Experimental Psychiatry 41, 207211.
Andreasen, NC, Carpenter, Jr. WT, Kane, JM, Lasser, RA, Marder, SR, Weinberger, DR (2005). Remission in schizophrenia: proposed criteria and rationale for consensus. American Journal of Psychiatry 162, 441449.
Bell, V, Halligan, PW, Ellis, HD (2006). Explaining delusions: a cognitive perspective. Trends in Cognitive Sciences 10, 219226.
Borm, GF, Fransen, J, Lemmens, WA (2007). A simple sample size formula for analysis of covariance in randomized clinical trials. Journal of Clinical Epidemiology 60, 12341238.
Brakoulias, V, Langdon, R, Sloss, G, Coltheart, M, Meares, R, Harris, A (2008). Delusions and reasoning: a study involving cognitive behavioural therapy. Cognitive Neuropsychiatry 13, 148165.
Byerly, MJ, Nakonezny, PA, Lescouflair, E (2007). Antipsychotic medication adherence in schizophrenia. Psychiatric Clinics of North America 30, 437452.
Couture, SM, Penn, DL, Roberts, DL (2006). The functional significance of social cognition in schizophrenia: a review. Schizophrenia Bulletin 32 (Suppl. 1), S44S63.
de Haan, L, Lavalaye, J, van Bruggen, M, van Nimwegen, L, Booij, J, van Amelsvoort, T, Linszen, D (2004). Subjective experience and dopamine D2 receptor occupancy in patients treated with antipsychotics: clinical implications. Canadian Journal of Psychiatry 49, 290296.
Drake, R, Haddock, G, Tarrier, N, Bentall, R, Lewis, S (2007). The Psychotic Symptom Rating Scales (PSYRATS): their usefulness and properties in first episode psychosis. Schizophrenia Research 89, 119122.
Elkis, H (2007). Treatment-resistant schizophrenia. Psychiatric Clinics of North America 30, 511533.
Fowler, D, Garety, P, Kuipers, E (1995). Cognitive Behaviour Therapy for Psychosis. Theory and Practice. Wiley: Chichester.
Freeman, D, Garety, P, Kuipers, E, Colbert, S, Jolley, S, Fowler, D, Dunn, G, Bebbington, P (2006). Delusions and decision-making style: use of the Need for Closure Scale. Behaviour Research and Therapy 44, 11471158.
Freeman, D, Garety, PA, Fowler, D, Kuipers, E, Bebbington, PE, Dunn, G (2004). Why do people with delusions fail to choose more realistic explanations for their experiences? An empirical investigation. Journal of Consulting and Clinical Psychology 72, 671680.
Freeman, D, Garety, PA, Kuipers, E, Fowler, D, Bebbington, PE, Dunn, G (2007). Acting on persecutory delusions: the importance of safety seeking. Behaviour Research and Therapy 45, 8999.
Frith, CD (1994). Theory of mind in schizophrenia. In The Neuropsychology of Schizophrenia(ed. David, A. S. and Cutting, H. J.), pp. 147161. Lawrence Erlbaum Associates: Hillsdale, NJ.
Frith, CD, Corcoran, R (1996). Exploring ‘theory of mind’ in people with schizophrenia. Psychological Medicine 26, 521530.
Garety, PA, Freeman, D (1999). Cognitive approaches to delusions: a critical review of theories and evidence. British Journal of Clinical Psychology 38, 113154.
Haddock, G, McCarron, J, Tarrier, N, Faragher, EB (1999). Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychological Medicine 29, 879889.
Kay, SR, Opler, LA, Lindenmayer, JP (1989). The Positive and Negative Syndrome Scale (PANSS): rationale and standardisation. British Journal of Psychiatry 155 (Suppl. 7), 5967.
Kinnear, PR, Gray, CD (2009). SPSS 16 – Made Simple. Taylor & Francis: London.
Kumar, D, Zia, Ul, Haq, M, Dubey, I, Dotiwala, K, Siddiqui, SV, Abhishek, P (2010). Effect of meta-cognitive training in the reduction of positive symptoms in schizophrenia. European Journal of Psychotherapy & Counselling 12, 149158.
Kupper, Z, Tschacher, W (2008). Lack of concordance between subjective improvement and symptom change in psychotic episodes. British Journal of Clinical Psychology 47, 7593.
Landa, Y, Silverstein, SM, Schwartz, F, Savitz, A (2006). Group cognitive behavioral therapy for delusions: helping patients improve reality testing. Journal of Contemporary Psychotherapy 36, 9–17.
Lehrl, S (1995). Mehrfachwahl-Wortschatz-Intelligenztest: MWT-B [Multiple Choice Vocabulary Test]. PERIMED-spitta: Balingen.
Leucht, S, Arbter, D, Engel, RR, Kissling, W, Davis, JM (2009). How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials. Molecular Psychiatry 14, 429447.
Leucht, S, Barnes, TR, Kissling, W, Engel, RR, Correll, C, Kane, JM (2003). Relapse prevention in schizophrenia with new-generation antipsychotics: a systematic review and exploratory meta-analysis of randomized, controlled trials. American Journal of Psychiatry 160, 12091222.
Lincoln, TM, Ziegler, M, Mehl, S, Rief, W (2010). The jumping to conclusions bias in delusions: specificity and changeability. Journal of Abnormal Psychology 119, 4049.
McGurk, SR, Twamley, EW, Sitzer, DI, McHugo, GJ, Mueser, KT (2007). A meta-analysis of cognitive remediation in schizophrenia. American Journal of Psychiatry 164, 17911802.
Manschreck, TC, Boshes, RA (2007). The CATIE schizophrenia trial: results, impact, controversy. Harvard Review of Psychiatry 15, 245258.
Marker, K (2003). COGPACK Manual Version 5.9. Marker Software: Ladenburg.
Mass, R, Schoemig, T, Hitschfeld, K, Wall, E, Haasen, C (2000). Psychopathological syndromes of schizophrenia: evaluation of the dimensional structure of the positive and negative syndrome scale. Schizophrenia Bulletin 26, 167177.
Medalia, A, Thysen, J, Freilich, B (2008). Do people with schizophrenia who have objective cognitive impairment identify cognitive deficits on a self-report measure? Schizophrenia Research 105, 156164.
Menon, M, Mizrahi, R, Kapur, S (2008). ‘Jumping to conclusions’ and delusions in psychosis: relationship and response to treatment. Schizophrenia Research 98, 225231.
Menon, M, Pomarol-Clotet, E, McKenna, PJ, McCarthy, RA (2006). Probabilistic reasoning in schizophrenia: a comparison of the performance of deluded and nondeluded schizophrenic patients and exploration of possible cognitive underpinnings. Cognitive Neuropsychiatry 11, 521536.
Mizrahi, R, Rusjan, P, Agid, O, Graff, A, Mamo, DC, Zipursky, RB, Kapur, S (2007). Adverse subjective experience with antipsychotics and its relationship to striatal and extrastriatal D2 receptors: a PET study in schizophrenia. American Journal of Psychiatry 164, 630637.
Moritz, S, Kerstan, A, Veckenstedt, R, Randjbar, S, Vitzthum, F, Schmidt, C, Heise, M, Woodward, TS (in press). Further evidence for the effectiveness of metacognitive training in schizophrenia. Behaviour Research and Therapy.
Moritz, S, Peters, MJV, Karow, A, Deljkovic, A, Tonn, P, Naber, D (2009). Cure or curse? Ambivalent attitudes towards neuroleptic medication in schizophrenia and non-schizophrenia patients. Mental Illness 1, 49.
Moritz, S, Veckenstedt, R, Hottenrott, B, Woodward, TS, Randjbar, S, Lincoln, TM (2010 a). Different sides of the same coin? Intercorrelations of cognitive biases in schizophrenia. Cognitive Neuropsychiatry 15, 406421.
Moritz, S, Veckenstedt, R, Randjbar, S, Vitzthum, F (2010). Individualisiertes Metakognitives Therapieprogram für Menschen mit schizophrener Psychose (MKT+) [Individualized Metacognitive Therapy for Patients with Psychosis (MCT+)]. Springer: Heidelberg.
Moritz, S, Veckenstedt, R, Randjbar, S, Vitzthum, F, Karow, A, Lincoln, TM (2010 b). Course and determinants of self-esteem in people diagnosed with schizophrenia during psychiatric treatment. Psychosis 2, 17522439.
Moritz, S, Woodward, TS (2005). Jumping to conclusions in delusional and non-delusional schizophrenic patients. British Journal of Clinical Psychology 44, 193207.
Moritz, S, Woodward, TS (2007 a). Metacognitive training for schizophrenia patients (MCT): a pilot study on feasibility, treatment adherence, and subjective efficacy. German Journal of Psychiatry 10, 6978.
Moritz, S, Woodward, TS (2007 b). Metacognitive training in schizophrenia: from basic research to knowledge translation and intervention. Current Opinion in Psychiatry 20, 619625.
Moritz, S, Woodward, TS, Burlon, M (2005). Metacognitive Skills Training for Patients with Schizophrenia (MCT). Manual. VanHam Campus: Hamburg.
Moritz, S, Woodward, TS, Metacognition Study Group (2007). Metacognitive Training for Patients with Schizophrenia (MCT). VanHam Campus Verlag: Hamburg.
Moritz, S, Woodward, TS, Rodriguez-Raecke, R (2006). Patients with schizophrenia do not produce more false memories than controls but are more confident in them. Psychological Medicine 36, 659667.
Müller, DR, Roder, V (2010). Integrated psychological therapy and integrated neurocognitive therapy. In Neurocognition and Social Cognition in Schizophrenia Patients. Basic Concepts and Treatment(ed. Roder, V. and Medalia, A.), pp. 118144. Karger: Basel.
Penn, DL, Roberts, DL, Combs, D, Sterne, A (2007). Best practices: the development of the Social Cognition and Interaction Training program for schizophrenia spectrum disorders. Psychiatric Services 58, 449451.
Peralta, V, Cuesta, MJ (1994). Psychometric properties of the positive and negative syndrome scale (PANSS) in schizophrenia. Psychiatry Research 53, 3140.
Perivoliotis, D, Grant, PM, Peters, ER, Ison, R, Kuipers, E, Beck, AT (2010). Cognitive insight predicts favorable outcome in cognitive behavioral therapy for psychosis. Psychosis 2, 2333.
Peters, E, Garety, P (2006). Cognitive functioning in delusions: a longitudinal analysis. Behaviour Research and Therapy 44, 481514.
Pilling, S, Bebbington, P, Kuipers, E, Garety, P, Geddes, J, Orbach, G, Morgan, C (2002). Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine 32, 763782.
Rathod, S, Kingdon, D, Weiden, P, Turkington, D (2008). Cognitive-behavioral therapy for medication-resistant schizophrenia: a review. Journal of Psychiatric Practice 14, 2233.
Ross, K, Freeman, D, Dunn, G, Garety, P (in press). A randomized experimental investigation of reasoning training for people with delusions. Schizophrenia Bulletin First published online: 11 June 2009. doi:10.1093/schbul/sbn165.
Santor, DA, Ascher-Svanum, H, Lindenmayer, JP, Obenchain, RL (2007). Item response analysis of the Positive and Negative Syndrome Scale. BMC Psychiatry 7, 66.
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R, Dunbar, GC (1998). The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59 (Suppl. 20), 2233.
Speechley, WJ, Whitman, JC, Woodward, TS (2010). The contribution of hypersalience to the ‘jumping to conclusions’ bias associated with delusions in schizophrenia. Journal of Psychiatry and Neuroscience 35, 7–17.
Tai, S, Turkington, D (2009). The evolution of cognitive behavior therapy for schizophrenia: current practice and recent developments. Schizophrenia Bulletin 35, 865873.
van der Gaag, M (2006). A neuropsychiatric model of biological and psychological processes in the remission of delusions and auditory hallucinations. Schizophrenia Bulletin 32 (Suppl. 1), 113122.
van der Gaag, M, Hoffman, T, Remijsen, M, Hijman, R, de Haan, L, van Meijel, B, van Harten, PN, Valmaggia, L, de Hert, M, Cuijpers, A, Wiersma, D (2006). The five-factor model of the Positive and Negative Syndrome Scale II: a ten-fold cross-validation of a revised model. Schizophrenia Research 85, 280287.
van Os, J, Kapur, S (2009). Schizophrenia. Lancet 374, 635645.
Vickers, AJ, Altman, DG (2001). Statistics notes: analysing controlled trials with baseline and follow up measurements. British Medical Journal 323, 11231124.
von Knorring, L, Lindstrom, E (1995). Principal components and further possibilities with the PANSS. Acta Psychiatrica Scandinavica Suppl. 388, 5–10.
Voruganti, LP, Baker, LK, Awad, AG (2008). New generation antipsychotic drugs and compliance behaviour. Current Opinion in Psychiatry 21, 133139.
Woodward, TS, Munz, M, Leclerc, C, Lecomte, T (2009). Change in delusions is associated with change in ‘jumping to conclusions’. Psychiatry Research 170, 124127.
Wykes, T, Steel, C, Everitt, B, Tarrier, N (2008). Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin 34, 523537.
Zimmermann, G, Favrod, J, Trieu, VH, Pomini, V (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research 77, 19.
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