2026 ECNP Congress
PS03-3242Towards clinically relevant therapeutic targets: associations of metacognitive mastery and theory of mind performance with negative symptoms in schizophrenia
Background: Negative symptoms are strongly associated with functional and clinical outcomes in schizophrenia. While social-cognitive and metacognitive impairments are clinically relevant features and relevant treatment targets of this illness, the relationship between these two is still not fully understood. Theory of mind (ToM) usually relies on higher-order metacognitive abilities, especially the capacity to use knowledge about mental states to manage psychosocial challenges. This study examined metacognition, ToM and negative symptoms in schizophrenia.
Aim: Examine whether global metacognitive capacity and the ‘mastery’ domain are associated with ToM performance and negative symptoms.
Methods: Forty-four adults with ICD-10 diagnosis of schizophrenia were recruited from four Hungarian clinical and community sites. Participants were in remission and received stable antipsychotic treatment (19 men, 25 women; mean age=45.05, SD=10.25; illness duration=20.11 years, SD=7.86, n=41). ToM was assessed with the Theory of Mind Picture Stories Task (Cartoon Test). Symptom severity, with a focus on negative symptoms, was rated with the Positive and Negative Syndrome Scale (PANSS). Metacognition was assessed with the Metacognition Assessment Scale (MAS-A), scored from narratives elicited by the Indiana Psychiatric Illness Interview (IPII). Reliability and normality were checked. Associations were tested using Spearman correlations, partial correlations and linear regression models, controlling for sex, age, educational level, marital status and illness duration.
Results: Global metacognitive capacity showed a moderate significant positive association with ToM performance (ρ=0.352, p=0.019). This remained significant after controlling for demographic and illness-related variables (partial ρ=0.470, p=0.004). In multiple regression, global metacognition significantly predicted ToM performance (B=1.058, β=0.469, p=0.004), with the model explaining 37.0% of the variance (R2=0.370, p=0.011). The mastery domain showed the strongest association with ToM (ρ=0.412, p=0.006), which remained significant in partial correlation analysis (ρ=0.441, p=0.007). In hierarchical regression, adding the four metacognitive domains increased explained variance from 19.2% to 42.1% (R2=0.421, p=0.028), mastery (β=0.321, p=0.032) and self-reflectivity (β=0.379, p=0.049) were significant predictors. In a stepwise model including mastery and self-reflectivity, only mastery remained significant (β=0.444, p=0.042; R2=0.174). Global metacognition was negatively associated with negative symptoms (ρ=-0.373, p=0.014), but this relationship was no longer significant after adjustment (partial ρ=-0.267, p=0.121; ΔR²=0.042, p=0.121). Associations between metacognitive domains and negative symptoms showed a similar pattern, with initial or near-significant relationships that did not remain significant after controlling for covariates. ToM was not significantly associated with negative symptoms.
Conclusions: Metacognitive capacity, particularly mastery, was associated with ToM performance in people with schizophrenia, even after controlling for demographic and illness-related variables. This suggests that the ability to apply mental-state understanding in dealing with psychosocial challenges may be important for social-cognitive functioning in this patient group. Associations with negative symptoms were weaker and not robust after adjustment, indicating that additional factors may contribute to this relationship. Given that the Cartoon Test primarily captures cognitive aspects of ToM, the observed associations may specifically reflect this component of social cognition. Metacognitive mastery may therefore represent a relevant target for interventions designed to improve social cognition, particularly its cognitive aspects, in schizophrenia.