Participation, a term used within the international classification of functioning, disability, and health,1 is active engagement in everyday life, family, work, and community. It results from interactions among factors related to the person (e.g., metacognitive functions) and the person’s environment and chosen activity or occupation.2–4
Research has examined the relationships between participation, metacognitive functions, and symptoms among people with schizophrenia.5–7 Metacognitive functions represent goal-oriented behaviors, including decision-making, flexibility of thought, insight, and judgment.8 Metacognitive function is a higher-level cognitive function that includes accurately judging task demands, anticipating the likelihood of problems, and monitoring, regulating, and evaluating performance within the activity’s context.9,10 Metacognition is also viewed as an umbrella concept that includes awareness and executive functions (EF).11,12
Metacognitive functions are considered specific predictors of functional limitations that manifest in reduced participation.5,13 Limitations in metacognitive functions have been found to be negatively associated with symptoms14 and significantly higher among people with schizophrenia than nonclinical populations.15 Therefore, the impact of metacognitive limitations on participation is of essential clinical and theoretical interest.
Schizophrenia symptoms are typically measured by the Positive and Negative Syndrome Scale (PANSS).16 The appearance of symptoms also might partly explain reduced participation. However, the literature revealed mixed results regarding the association of symptoms with EF limitations and their impact on participation. For example, alongside MacBeth et al.’s study identifying associations between metacognitive limitations and symptomatic distress,17 researchers have reported that both positive18 and negative19 symptoms specifically predicted participation.
Some studies found positive correlations between negative symptoms, cognitive limitations (e.g., attention and memory), and metacognitive limitations (e.g., EF); other studies reported negative correlations.20 Further, associations have been found between positive symptoms and EF limitations,21 alongside studies that found no association with cognitive limitations in general or EF limitations in particular.22 Moreover, researchers claimed that people with schizophrenia and the greatest metacognitive limitations also manifested the most pronounced negative symptoms. Thus, at least on a cross-sectional basis, metacognitive limitations are linked to psychiatric symptoms.23
To explain the relationships among symptoms, EF, and participation, researchers explored whether those relationships are direct or due to associations with other factors.24 For example, the person’s functional capacity,24 insight,25 and social cognition26 have predicted the severity of everyday functioning limitations. A study on the ability to perform skills postulated that whereas negative symptoms affect the likelihood of functioning, EF affect the ability to function.26
Various models in the literature address the association among symptoms, metacognitive limitations, and participation in people with schizophrenia. Lysaker et al. proposed an integrated metacognition model in which metacognitive limitations and negative symptoms mutually influence one another and contribute to reduced participation.27 However, another meta-analytic review produced contradictory evidence: Negative symptoms were found to predict short-term functioning, whereas metacognition affected long-term functioning.5
Other studies found that negative symptoms partially modulated the relationship between metacognitive function and participation23,28 – such as how motivation and anhedonia evolve during the illness progression and how each might contribute at different times.23 Moreover, education predicted functional capacity, which supported claims that metacognitive limitations have both direct and indirect effects on participation.28
Considering the range of inconsistent findings, it is necessary to explore the impact of symptoms on participation to gain a better understanding of the relationship between metacognitive limitations and symptoms and the mechanisms that affect participation.19,29 As such, we used measures with high ecological validity in our study.
Identifying moderators may help explain how or why symptoms influence participation. Thus, the aim of this study was to examine whether symptoms moderate the association between EF components and participation among people with schizophrenia following a metacognitive group intervention (MCG).6 We hypothesized that symptoms constitute a moderator between EF as a component of metacognition and participation among people with schizophrenia.