Metacognition, Personal Distress, and Performance-Based Empathy in Schizophrenia

Abstract

Background

People with schizophrenia experience significant deficits in the kinds of empathic skills that are the foundation for interpersonal relationships. Researchers have speculated that deficits in empathic skills in schizophrenia may be related to disturbances in metacognition and heightened levels of personal distress. To explore this issue, this study examined whether better metacognition and reduced personal distress would be associated with improved performance on cognitive and affective empathy tasks. Further, we tested whether metacognition moderated the relationship between personal distress and empathy.

Method

Fifty-eight participants with schizophrenia-spectrum disorders receiving community-based treatment completed a self-report questionnaire of personal distress, a performance-based measure of empathy, and an observer-rated interview to assess metacognitive capacity.

Results

Correlation analyses revealed that metacognitive capacity, but not personal distress, was significantly associated with cognitive and affective empathy performance. Moderation results suggest the relationship between personal distress and affective empathy performance was significant for those with low metacognition, but that the relationship was the opposite of hypotheses–increased personal distress predicted better performance. This relationship changed at higher levels of metacognition, when increased personal distress became associated with reduced performance.

Conclusions

This study is the first of its kind to examine performance-based empathy with metacognition and personal distress. Results suggest interventions targeted to improve metacognition may be useful in enhancing empathic skills.

Introduction

People with schizophrenia show significant deficits in empathy,^1,2 or, broadly speaking, the ability to understand and share the feelings of others.³ These impairments were noted in the original work of Bleuler⁴ and Kraepelin,⁵ offered as a potential root of the difficulties that many with schizophrenia experience forming emotional connections with others. The importance of empathy for social connections is well established. In the general population, those who demonstrate empathy appear warm and genuine to others, leading to larger and more supportive social networks.⁶ Studies also suggest those high in empathy are more sensitive to emotional and socially relevant information,^7,8 and those with a greater tendency to experience analogous emotion when faced with the emotions of others are more able to forgive and repair conflicts in relationships.^9,10 Of note, one’s empathic abilities are also often judged by others within just a few seconds of interpersonal exposure,¹¹ emphasizing the importance of empathy even before a relationship has begun.

Although numerous studies have established the presence of deficits in empathy in schizophrenia, less is known about their potential roots. One potentially important factor that may reflect the potential for an empathic response is metacognition. Metacognition refers to the activities involved in thinking about and forming integrated ideas about oneself and others. The term metacognition was originally used in the education literature,¹² but has evolved to now encompass a spectrum of psychological functions that range from discrete awareness of specific mental experiences to a more synthetic level of awareness where intentions, thoughts, and feelings are brought together into integrated representations of self and others.^13,14 Metacognition has been proposed by Semerari et al¹⁴ to have 4 domains: self-reflectivity, the ability to understand one’s own thoughts and feelings; understanding of others’ minds, the ability to understand others’ thoughts and feelings; decentration, the ability to interpret the world and others’ actions as independent from oneself; and mastery, the ability to use skills in the first 3 domains to respond to psychological and social problems.^15,16

There are several reasons to believe metacognitive capacity could affect the potential for empathic responses. First, for one to emphasize with another who is in the middle of a certain set of circumstances, one may need to have access to a sense of one’s own thoughts and feelings when one previously had a similar experience. For example, to empathize with someone who is grieving, it would certainly help to be able to recall a time when one felt similar grief. Second, in order to see how another person may have a unique reaction to the circumstances they are facing, it may be necessary to have a complex sense of the other including their thoughts, emotions, and feelings as well as the ability to see how events can be viewed from different perspectives. Third, the ability to manage emotional distress, or mastery, may allow persons to respond to their own distress when facing the distress of others, and thus be more able to reflect deeply on others’ experiences. To date, empirical support for these possibilities is lacking outside of a single study that found positive correlations between metacognition and empathy on a self-report inventory.¹⁷ This study was conducted with 77 Chinese participants; results indicated positive relationships between the Metacognition Assessment Scale–Abbreviated (MAS-A) and the Perspective Taking and Empathic Concern subscales of the Interpersonal Reactivity Index–Chinese version (IRI-C). Further research is needed to clarify these links and extend our understanding beyond self-report instruments.

A second related construct that could potentially affect empathy is personal distress. Personal distress, sometimes called emotional contagion,¹⁸ refers to the experience of self-oriented distress resulting from emotions such as anxiety or fear when faced with negative experiences of others.¹⁹ Personal distress has potential to negatively influence the tendency to empathize with others. In an empathic context, heightened levels of personal distress might discourage one from empathizing when one perceives that others’ distress has potential to heighten one’s own distress.^20,21 For example, when a person who has relatively higher levels of personal distress is confronted with a person who is grieving, that person may choose not to empathize (or even engage) with the grieving person to avoid heightening their own distress. Evidence supporting this possibility includes findings that people with schizophrenia typically exhibit heightened personal distress compared to healthy controls when confronted with others’ situations or emotions.²² Of note, although we have separately presented how metacognition and emotional distress could affect empathy, it is possible that these 2 variables also impact one another; indeed, those with better metacognitive capacity may be more able to appropriately interpret experiences of personal distress, reducing the likelihood that personal distress will interfere with empathic interaction. This would be consistent with recent research indicating metacognitive self-reflectivity moderates the relationship between distress tolerance, a construct closely linked to personal distress, and empathy.²³

To explore these issues, we gathered assessments of empathy, metacognitive capacity, and personal distress in a sample of people with schizophrenia or schizoaffective disorder. Because research has shown that people with schizophrenia tend to overestimate their empathic abilities on self-report measures compared to reports from informants²⁰ or clinical observers,²¹ we assessed empathy using a computerized, performance-based task including both cognitive and affective empathy domains, consistent with much research on empathy in schizophrenia and encompassing the idea that empathy consists of more than a singular ability. Cognitive empathy refers to the ability to take the perspective of the other person (allowing you to understand their thoughts and feelings), whereas affective empathy refers to an emotional reaction felt in response to the emotional experiences of another (frequently matching the emotional state of the other).³ Meta-analyses have summarized these findings, indicating deficits in cognitive aspects of empathy^1,24,25 as well as affective empathy.²

We made the following hypotheses:

1. Greater metacognitive capacity and lower personal distress would be associated with better empathic performance (cognitive and affective). We expected that this pattern would hold for all 4 subdomains of the metacognition construct.

2. Metacognitive capacity would moderate the relationships between personal distress and cognitive and affective empathy, such that with lower levels of metacognitive skill, personal distress would significantly predict poorer cognitive and affective empathic performance, while for those with relatively higher metacognitive skill, personal distress would no longer impact empathic performance.

Method

Participants

Participants included 58 clients receiving mental health services with diagnoses of schizophrenia or schizoaffective disorder (confirmed with a modified version of the Structured Clinical Interview for the Diagnostic and Statistical Manual-5 (SCID-5)).²⁶ Participants were required to be at least 18 years of age, fluent in English, able to provide informed consent, and receiving services at one of two participating community mental health centers (CMHCs).

Measures

Empathy

The computerized, performance-based Derntl paradigm²⁷ adapted for the English language²⁸ was administered using the program Presentation.²⁹ The Derntl paradigm is a forced-choice, timed, computer-based assessment of empathy producing 3 subscale scores that reflect different empathic components (the emotion perception score is not discussed here). To assess cognitive empathy (referred to in this paradigm as emotional perspective-taking), respondents are shown 58 contextual images of 2 actors engaged in social interaction. One actor’s face is masked, and respondents are required to select the appropriate facial emotion image that would portray the actor’s emotion in the scene. To assess affective empathy (referred to in this paradigm as affective responsiveness), respondents are asked to judge how they would feel in various emotional scenarios, presented as 150 brief sentences describing emotional and neutral situations. Correct choices for this task reflect the emotion most people would feel for the given scenario (ie, the normative response).²⁸

Metacognition

Metacognition was assessed using the MAS-A.¹⁵ The MAS-A produces scores on 4 subscales or domains: self-reflectivity, awareness of others’ minds, decentration, and mastery,³⁰ with higher scores reflecting greater metacognitive capacity. All are rated based on a speech sample with emphasis on opportunities for self-reflection. In this study, we elicited this kind of sample using the Indiana Psychiatric Illness Interview (IPII),³¹ a semi-structured interview designed to elicit illness narratives of psychiatric challenges. The MAS-A conceptualizes metacognitive processes for each domain as holistic in nature and as involving a series of hierarchical steps. In each step, a new kind of information is introduced and integrated into a more nuanced sense of oneself or others. In other words, the ability to successfully carry out the operation described by a given step requires the ability to adequately perform the step beneath it.³² Past evidence indicates the MAS-A has good internal consistency,³³ inter-rater reliability,³⁰ and validity,¹⁶ in individuals with schizophrenia-spectrum disorders. Internal consistency was acceptable in this sample (α = .70).

Personal Distress

The Interpersonal Reactivity Index (IRI)¹⁹ was used to assess personal distress. The IRI contains 28 Likert-style self-report items rated from 0 (does not describe me well) to 4 (describes me very well). The IRI is designed to produce 4 subscale scores (each based on 7 items): personal distress, empathic concern, perspective-taking, and fantasy.¹⁹ Only personal distress is discussed here. The IRI personal distress subscale was developed for use in the general population and displayed adequate convergent and divergent validity and good internal consistency in the original development study.¹⁹ The IRI has since been used extensively in schizophrenia samples.^34–37 Internal consistency was somewhat low in the current sample (α = .56).

Symptoms

Symptoms were assessed using the observer-rated Positive and Negative Syndrome Scale (PANSS).³⁸ Five-factor scoring of the 30-item PANSS produces a total score plus 5 subscale scores: positive symptoms, negative symptoms, cognitive symptoms, hostility, and emotional discomfort.³⁹ The PANSS has been used extensively in schizophrenia research in the past,^40–42 and shows evidence of acceptable validity, inter-rater reliability, and internal consistency.^38,39 Internal consistency of the total and 5 subscale scores were adequate in this sample (alphas ranging from .68 to .85).

Procedure

Participants were recruited from 2 local CMHCs via clinician referrals and informational fliers. Research assessments began with the informed consent process. Diagnostic confirmation was then obtained via the modified SCID-5. If not eligible, the participant was given $5 and the interview concluded. If the participant met inclusion criteria, a demographic survey was administered, followed by the battery of assessments. Participants were compensated $35. All interviews were conducted by the first author or a trained research assistant.

Analyses

Bivariate correlations, t tests, and ANOVAs were conducted to assess for associations between scores on empathy tasks, symptoms, and demographic variables. Results of these analyses were used to select appropriate control variables. To test the first hypothesis, bivariate correlations examined associations between scores on the empathy tasks, metacognition, and personal distress.

Proposed moderating relationships were tested using Hayes’ PROCESS macro,⁴³ which conducts ordinary least squares (OLS) regression analyses. To assess whether metacognition (M) moderated the relationship between personal distress (X) and cognitive empathy (Y), the interaction term (XM) was added to the OLS regression model predicting cognitive empathy. If the interaction term was significant (P < .05) and significantly improved the regression model, metacognition was considered to moderate the relationship between personal distress and cognitive empathy. If significant moderation was detected, 2 techniques were used to probe the interaction. First, the pick-a-point approach⁴⁴ was used to visualize any moderation detected. In this analysis, values of the moderator (metacognition) are chosen at which to graphically represent the relationship between X (personal distress) and Y (cognitive empathy); typically these values are plus and minus 1 standard deviation from the mean. Second, the Johnson–Neyman technique⁴⁵ was used to identify the actual value of the moderator (metacognition) where the relationship between X and Y changed significance.⁴³ This procedure was repeated for affective empathy. All analyses were conducted in SPSS, version 24.

Results

See table 1 for detailed descriptive statistics. Cognitive empathy was associated with age (r = −.34, P = .01). Affective empathy showed mean differences for both race [t(53) = −2.67, P = .01] and marital status [t(55) = −2.30, P = .025], such that white participants scored significantly higher than black participants, and those who were ever married scored higher than those who were never married. For both tasks, results suggested those with schizoaffective disorder performed significantly better than those with schizophrenia [cognitive empathy: t(55) = −2.29, P = .026; affective empathy: t(55) = −2.65, P = .011].

Table 1.

Demographic Characteristics (n = 58)

Variable	n	Percentage
Diagnosis
Schizophrenia	36	62.1
Schizoaffective disorder	22	37.9
Gender
Male	23	39.7
Female	35	60.3
Race
Black	40	69.0
White	16	27.6
Mixed race	1	1.7
Not reported	1	1.7
Hispanic	2	3.4
Marital status
Single, never married	34	58.6
Ever married	24	41.4
Education
Less than HS	20	34.5
HS diploma or GED	13	22.4
Some college	22	37.9
Bachelor’s level degree	3	5.2
	M	SD
Age (years)	46.60	9.75

Note: HS, High School; GED, General Education Development; M, mean; SD, standard deviation.

See table 2 for correlations between empathy tasks and symptoms. Both empathy tasks displayed moderate, negative correlations with cognitive symptoms, suggesting increased cognitive deficits are associated with decreased performance. Performance on cognitive empathy was further negatively associated with negative symptoms, and performance on affective empathy was negatively associated with hostility.

Table 2.

Correlations

	1	2	3	4	5	6	7	8	9	10	11	12	13
1. Cognitive empathy performance	1
2. Affective empathy performance	.60**	1
3. MAS-A total	.43**	.42**	1
4. MAS-A self-reflectivity	.47**	.42**	.87**	1
5. MAS-A awareness of the other	.34*	.31*	.71**	.51**	1
6. MAS-A decentration	.39**	.25	.71**	.64**	.54**	1
7. MAS-A mastery	.25	.33*	.86**	.57**	.45**	.44**	1
8. Personal distress	−.07	.09	.00	−.02	.01	.05	.02	1
9. PANSS positive symptoms	.11	−.05	.11	.11	.12	.08	.07	.21	1
10. PANSS negative symptoms	−.28*	−-.18	−.29*	−.28*	−.19	−.17	−.23	.15	.20	1
11. PANSS cognitive symptoms	−.40**	−.45**	−.22	−.25	−.08	.03	−.23	.03	.21	.41**	1
12. PANSS emotional discomfort	.11	.16	.08	.12	.00	−.02	.07	.32*	.65**	.35**	.04	1
13. PANSS hostility	−.11	−.30*	−.02	.07	−.10	−.14	−.03	.20	.59**	.13	.18	.52**	1

** Correlation is significant at the .01 level (2-tailed). * Correlation is significant at the .05 level (2-tailed). MAS-A, Metacognitive Assessment Scale-Abbreviated; PANSS, Positive and Negative Syndrome Scale. Higher scores for the empathy tasks and MAS-A total score indicate better performance or higher metacognitive capacity, respectively. Higher scores on the Personal Distress scale indicates greater experience of personal distress.

As can be seen in table 2, both empathy performance tasks displayed moderate, positive correlations with metacognition, suggesting increased empathic performance is associated with greater metacognitive capacity. This relationship held for all metacognitive subdomains except mastery with cognitive empathy and decentration with affective empathy, though, notably, both of those correlations were trending toward significance (P = .06). Neither empathy task was significantly correlated with personal distress.

Moderation Models

See table 3 for moderation results. In the model for cognitive empathy performance, metacognition, age, and cognitive symptoms reached significance as predictors, but the interaction term remained nonsignificant, suggesting that metacognition did not moderate the relationship between personal distress and cognitive empathy performance. In the model for affective empathy performance, metacognition, personal distress, race, marital status, cognitive symptoms, and hostility were all significant predictors. Importantly, the interaction term also reached significance (P = .002), suggesting the relationship between personal distress and affective empathy performance was moderated by metacognition. The pick-a-point approach provides a useful graphic with which to understand this relationship (figure 1). Results of the Johnson–Neyman procedure revealed that the model had 2 critical values of metacognition: 11.10 and 16.02. For those with scores of 11.10 or lower (30% of the sample), increased personal distress was associated with better affective empathy performance. For those with metacognition scores greater than 16.02 (15% of the sample), increased personal distress was associated with reduced affective empathy performance. For those with metacognition scores between 11.10 and 16.02, personal distress was not significantly related to affective empathy performance.

Table 3.

Moderation Results

Variable	Coefficient	SE	t	P
Cognitive empathy: R2 = .39, F = 4.43, P < .001
Constant	38.16	12.10	3.15	.003
Metacognition	1.84	0.90	2.05	.046
Personal distress	5.89	5.06	1.16	.250
Diagnosis (schizoaffective)	1.36	1.81	0.75	.455
Age	−0.25	0.08	−2.89	.006
Cognitive symptoms	−0.64	0.24	−2.67	.010
Negative symptoms	0.02	0.18	0.11	.917
Interaction term	−0.53	0.38	−1.39	.172
Affective empathy: R2 = .60, F = 8.52, P < .001
Constant	67.35	19.63	3.43	.001
Metacognition	5.05	1.51	3.34	.002
Personal distress	27.63	8.56	3.22	.002
Diagnosis (schizoaffective)	3.49	3.06	1.14	.260
Race (white)	8.09	3.25	2.49	.017
Marital (ever married)	8.49	2.99	2.84	.007
Cognitive symptoms	−1.16	0.39	−2.95	.005
Hostility	−2.01	0.58	−3.48	.001
Interaction term	−2.07	0.64	−3.23	.002

Note: Higher scores for the empathy tasks and metacognition indicate better performance or higher metacognitive capacity, respectively. Higher scores on personal distress indicate greater experience of personal distress.

Fig. 1.

Visualization of relationship between personal distress and affective empathy, moderated by MAS-A total scores. M = Metacognitive Assessment Scale–Abbreviated (MAS-A) total score.

Discussion

This study is the first to our knowledge to investigate the roles of 2 potential determinants of performance-based empathy—metacognition and personal distress. Results indicate that, at the bivariate level, metacognition is significantly, positively associated with performance on both cognitive and affective empathy tasks. This relationship largely held for all 4 MAS-A subscales. Against expectations, personal distress was not associated with empathic performance. Finally, we found that metacognition moderated the relationship between personal distress and affective empathy performance, but not cognitive empathy performance. Contrary to hypotheses, this moderating relationship suggests that increased personal distress improved affective empathy performance for those with lower metacognition, whereas increased personal distress reduced affective empathy performance for those with higher metacognition.

Though the literature suggests both metacognition and personal distress may be important to empathic performance, these data indicate metacognition may be more important in determining empathic performance. Metacognition was positively associated with both cognitive and affective empathy performance in correlational analyses, to the order of a medium effect size, suggesting that those with higher metacognition may be better able to accurately respond during an empathy task. Only one study had thus far examined the link between these 2 constructs.¹⁷ The current study extends those findings by linking metacognition with performance-based cognitive and affective empathy, suggesting that observer-rated metacognitive abilities may have an impact on real-world empathic interactions.

Although the lack of an association between personal distress and empathic performance was unexpected, it is consistent with recent research suggesting that empathy and distress tolerance, a related construct,²³ are not related. There are several possible explanations for our finding. The measure of personal distress was a self-report scale, implying participants’ perception of their experience with personal distress was being measured, rather than their observer- or performance-based ability or experience. Participants’ perceptions may vary from their real-world abilities, as has been shown with empathy.^2,20,21 Alternatively, it is possible that the Derntl paradigm tasks did not actually activate an experience of personal distress, thus negating any effect personal distress might have on performance in this context. In the real world, empathic interactions would naturally be more complex than those presented in the Derntl paradigm. It may be that complexities not simulated in the Derntl paradigm are what triggers an experience of personal distress, which can then interfere with empathy.

Regarding the moderation models, the model for affective empathy performance suggests that metacognition moderated the relationship between personal distress and affective empathy performance such that for those with low metacognition (less than a score of 11.10), increased experience of personal distress predicted better performance on the affective empathy task, and for those with higher metacognition (above a score of 16.02), increased experience of personal distress predicted poorer performance on the affective empathy task. Although the presence of moderation is consistent with hypotheses, the direction and dual nature of the effect is not. It was expected that increased personal distress would hamper performance on empathy tasks, and that those with better metacognition would be able to overcome this effect. However, analyses in these data suggest the opposite–that those with lower metacognition who report experiencing greater personal distress were more able to accurately identify the normative response in the affective empathy task.

Although surprising, these findings may provide support for emerging models of metacognition that highlight how the ability to form an integrated sense of self and others within the flow of life is a key element of human adaptation. It follows from theoretical observations that a person must have a sense of themselves in order to grasp the experience of others.⁴⁶ Furthermore, our results are consistent with other more global findings linking metacognition with qualities of social function, both concurrently and prospectively.⁴⁷

Our moderation results may be best interpreted within the context of MAS-A scores suggesting specific levels of metacognitive capacity. Scores on the MAS-A range from 0 to 28 and comprise the scores from 4 subscales (self-reflectivity, awareness of the other, decentration, and mastery). A score of 11 could result from a variety of possible subscale scores but would generally suggest the participant is able to identify their own basic cognitive operations as well as those of others but has little or no ability to integrate that knowledge into a cohesive sense of self or understanding of how one interacts with the world and other people in it.^15,16 Applying this understanding of metacognitive capacity can help elucidate how personal distress could possibly have a positive effect on empathic performance. One possible explanation could be that more intense internal experiences of emotion may foster greater empathic emotion felt for the other. Experiencing more frequent or intense negative, self-oriented emotion may allow a person to develop greater understanding of what others might feel in emotionally provocative situations, and thus, allow that person to share the other’s emotion in an empathic manner more easily. This may be especially true for those with low metacognition who are otherwise less able to use cognitive resources to enhance their experience of empathic emotion. As one obtains relatively higher metacognitive capacity (above a score of 16.02 in this sample), it may be that perception of personal distress changes, with the person becoming aware that internal, self-oriented distress is unpleasant and perhaps inappropriate in empathic interactions. In this way, personal distress may interfere more with affective empathy for those with better metacognitive capacity than for those with moderate capacity, and those with lower capacity may actually receive some sort of enhancement to their affective empathy performance from experiencing personal distress.

Across findings, one factor that may influence interpretation of results is the nature of the affective empathy task. As mentioned earlier, this task requires participants to respond to a sentence describing an emotional situation with how they would feel. Thus, the task may more accurately assess a construct such as emotional responsiveness or emotionality. Those who experience more personal distress may naturally also experience more emotion, generally. This may convey some benefit in identifying normative emotional responses in the Derntl paradigm’s affective task. This explanation would imply that those with moderate or higher levels of metacognition are able to rely more on their metacognitive abilities to accurately identify normative emotional responses, whereas those with lower metacognition may need to rely on their own emotional experiences to do well on the task. Though such an explanation could make sense in the context of these results, it also indicates that the Derntl paradigm may not assess true affective empathy, despite its historical use to assess this construct.^28,48,49 If this is the case, future research is needed to develop robust empathy measures, especially for affective empathy performance.

Our findings have clinical implications. Chief among them is that people with schizophrenia who have low metacognition may benefit from interventions designed to help them access and understand their own emotional experiences; such an intervention could have a trickle-down effect to help clients better identify and understand the emotions of others.

This type of treatment could help people regain metacognitive capacity and become better able to integrate internal experiences and develop a stronger sense of self. He or she may then rely less on internal experiences of distress, thus reducing any relationship between personal distress and affective empathy. One intervention of particular promise, Metacognitive Reflection and Insight Therapy (MERIT),⁵⁰ was developed to align with the metacognitive components measured by the MAS-A, allowing the intervention to be tailored to the metacognitive level of the client. Indeed, MERIT was designed specifically for people with schizophrenia, suggesting MERIT may be particularly appropriate to address the empathic deficits seen in this group while also enhancing metacognition.

Some limitations should be acknowledged. The personal distress scale had lower internal consistency (α =.56). Low internal consistency can result in conservative statistical analyses and increased risk of type II error.⁵¹ Further limitations of this study include the cross-sectional nature of the data, precluding the ability to make causal or truly directional statements, and the relatively small sample size. The sample may also not be representative of all with schizophrenia-spectrum disorders. One notable example of this is that the majority of the sample were female, an unusual distribution in schizophrenia studies. Further, nearly all participants came from the same urban CMHC. Results may differ for those in other service settings.

Taken together, this study, the first of its kind to examine performance-based empathy with metacognition and personal distress, may begin to answer some long-standing questions about empathy by suggesting a close association with metacognitive capacity. With replication, our results suggest interventions designed to enhance metacognitive capacities⁵⁰ may benefit empathic performance in patients when they also enable patients to become more in touch with the pain they have experienced in their lives, and subsequently tolerate and make sense of that pain. Improving empathic performance through such an intervention has potential to positively influence social functioning and the quality of interpersonal relationships, both of which are related to empathy.^7,8,52 Future work should continue to explore the relationships between metacognition and both cognitive and affective empathy and how they may be impacted by particular interventions.

Conflict of interest

The authors have declared that there are no conflicts of interest in relation to the subject of this study.