European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 https://doi.org/10.1007/s00406-022-01438-0 ORIGINAL PAPER Males and females with first episode psychosis present distinct profiles of social cognition and metacognition M. Ferrer‑Quintero1,2,3 · D. Fernández1,3,4,18,20 · R. López‑Carrilero1,3,4 · I. Birulés1,2 · A. Barajas5,6 · E. Lorente‑Rovira3,7 · A. Luengo7 · L. Díaz‑Cutraro1,22 · M. Verdaguer1,5,21 · H. García‑Mieres1,3 · A. Gutiérrez‑Zotes3,8 · E. Grasa3,9 · E. Pousa3,9,10,11 · E. Huerta‑Ramos1,3 · T. Pélaez1,3 · M. L. Barrigón12,13 · J. Gómez‑Benito2,23 · F. González‑Higueras14 · I. Ruiz‑Delgado15 · J. Cid16 · S. Moritz17 · J. Sevilla‑Llewellyn‑Jones19 · Spanish Metacognition Group · S. Ochoa1,3 Received: 20 October 2021 / Accepted: 23 May 2022 / Published online: 8 July 2022 © The Author(s) 2022 Abstract Deficits in social cognition and metacognition impact the course of psychosis. Sex differences in social cognition and metacognition could explain heterogeneity in psychosis. 174 (58 females) patients with first-episode psychosis completed a clinical, neuropsychological, social cognitive, and metacognitive assessment. Subsequent latent profile analysis split by sex yielded two clusters common to both sexes (a Homogeneous group, 53% and 79.3%, and an Indecisive group, 18.3% and 8.6% of males and females, respectively), a specific male profile characterized by presenting jumping to conclusions (28.7%) and a specific female profile characterized by cognitive biases (12.1%). Males and females in the homogeneous profile seem to have a more benign course of illness. Males with jumping to conclusions had more clinical symptoms and more neuropsychological deficits. Females with cognitive biases were younger and had lower self-esteem. These results suggest that males and females may benefit from specific targeted treatment and highlights the need to consider sex when planning interventions. Keywords Sex differences · Profiles · Psychosis · Schizophrenia · Social cognition · Metacognition Background levels. Especially concerning the latter, a corpus of studies has shown the protective role of estrogens in psychosis [10] Sex differences in the onset and expression of psychosis and its promise as a pharmacological treatment [11]. are apparent since the first episode of psychosis (FEP) [1, As well as biological variables, there are psychological 2]. Sex is one of the most predictive variables of clinical constructs that deserve attention in their potential role for sex features in FEP [3] although this predictive power may be differences in psychosis, such as social cognition and meta- related to the large disparities that exist in other risk factors cognition. Patients with FEP experience significant deficits between the two sexes [4]. Men with psychosis have poorer in social cognition [12] and metacognition [13]. Social cog- premorbid adjustment, higher levels of substance abuse and nition encompasses perception, interpretation, and informa- dependence, and more negative symptoms [2, 4]. Further- tion processing for adaptive social interactions [14], while more, men usually exhibit worse social functioning [5] and metacognition refers to the spectrum of mental activities that male sex is a predictor of relapse after FEP [6]. Although involve reflection upon one's own, and others', thinking, and the reasons behind better prognosis in females remain to be the synthesis of these phenomena into an integrated sense of fully understood, there is cumulative evidence suggesting self and others [15, 16]. Both social cognition and metacog- that disparities between both sexes start at a biological level, nition are important predictors of functional outcome when for instance at the genetic [7], neural [8] and hormonal [9] assessed globally [14, 17–19], but even specific subdomains of both constructs have distinct impacts on the disorder. The Jumping to Conclusions bias (JTC) has specific associations * M. Ferrer‑Quintero marta.ferrerq@sjd.es with neurocognition [20–23], inaccurate processing of social information [24], worse outcome [25], delusion forming and Extended author information available on the last page of the article 13 Vol.:(0123456789) 1170 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 severity [21, 26, 27], and suicidal behavior [28]. Clinical Methods insight has been related to treatment compliance, quality of life, depression, and symptoms among others [17, 29–31] The design of the study and data collection stems from but seems to be independent of neurocognition [32]. Attribu- two research sources that had addressed the effectiveness tional style has a clear influence in paranoia and persecutory of metacognitive training in people with FEP, under the delusions [33–35], and cognitive insight is related to depres- register numbers NCT04429412 (conducted between 2015 sive symptoms [36], and treatment compliance, symptoms, and 2017) and NCT02340559 (conducted between 2012 and quality of life [17]. and 2014). Data on the efficacy of metacognitive training Research exploring sex differences in social cognition and of the clinical trial NCT02340559 have been published metacognition is inconclusive, probably due to the tendency elsewhere [47]. Data of the clinical trial NCT04429412 to present averaged results [37]. A majority of studies have have not been published yet. For the purposes of this work, failed to find significant differences between sexes in social only the baseline data of both clinical trials have been cognition [38–40] or metacognition [41, 42]. However, included in this study. exploring differences in social cognition and metacognition Participants from the two sources did not differ in beyond mean differences has often led to the discovery of age (t(170) = 0.91, p = 0.369, CI [ – 1.336, 3.578]), sex important results. For instance, [18], looking for the effects (χ 2(1) = 0.749, p = 0.387) or diagnosis (χ 2(5) = 3.671, of insight on symptoms found across symptom profiles, p = 0.598). found a group characterized by positive symptoms and impaired insight that contained a majority of females [43]. Cobo et al. found that clinical insight correlated with differ- Participants ent variables in each sex [42]. Similarly, García-Mieres et al. [43] found that females with psychosis present more extreme Participants were 174 (58 females) individuals with FEP. dichotomous thinking but a richer personal identity system Patients were referred by clinicians at one of the commu- than men [44]. Likewise, Salas-Sender et al. found that men nity mental-health services of the following participant and females with FEP responded differently to metacogni- groups: Fundación Jiménez Díaz (Madrid), Servicio Anda- tive training [45]. luz de Jaén, Servicio Andaluz de Málaga, Centro de Salud Differences in social cognition and metacognition in psy- Mental de Corporació Sanitària i Universitària Parc Taulí chosis may not be apparent when comparing performance, (Sabadell), Consultas externas del Hospital de Sant Pau but may be rooted in discrepancies in information process- (Barcelona), Centro de Higiene Mental Les Corts (Bar- ing. Data-driven methods permit capturing the heterogene- celona), Institut Pere Mata (Reus), Institut d´Assistència ity in data in an exploratory manner. For example, Latent Sanitària Girona, Hospital Clínic de València and Parc Profile Analysis (LPA) represents a promising technique to Sanitari Sant Joan de Déu (PSSJD). understand the possible configurations of social cognition Inclusion criteria were as follows: (1) a diagnosis of and metacognition in males and females. LPA was designed schizophrenia, psychotic disorder not otherwise specified, to identify construct-based profiles [46], meaning that each delusional disorder, schizoaffective disorder, brief psy- profile captures latent attributes of a similar population. Fur- chotic disorder, or schizophreniform disorder (according thermore, LPA is a person-based approach, which permits to DSM-IV-TR); (2) < 5 years from the onset of symptoms; focusing on the characteristics of the individuals in predict- (3) a score ≥ 4 in item delusions, grandiosity, or suspi- ing outcomes of interest [46]. ciousness of PANSS in the last year; (4) age between 18 In this work, we explored whether males and females and 45 years. with FEP present different profiles of social cognition and Exclusion criteria were as follows: (1) traumatic brain metacognition using LPA. As a second objective, we tested injury, dementia, or intellectual disability (premorbid differences in demographic, clinical, and neuropsychological IQ ≤ 70); (2) substance dependence (3) Scores higher than variables among the derived profiles. Given the exploratory 6 in the PANSS items “Hostility” or “Suspiciousness”. nature of this study and the use of data-driven methods, we did not have a priori assumptions on the number of profiles and their characteristics or on the clinical differences among Measures the profiles. We did, however, hypothesize that LPA is an adequate technique to detect configurations of social cogni- Sociodemographic questionnaire: Data on socio-demo- tion and metacognition for each sex, and that profiles would graphic variables were collected on-site. Diagnosis and have distinct clinical features. treatment were collected from the clinical history of the participants. We transformed the antipsychotic treatment to olanzapine defined daily dose (DDD) [48]. 13 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 1171 Clinical measures: The Positive and Negative Syndrome (CPT-II for Windows) [68, 69] was used to assess sus- Scale (PANSS) [49, 50] was used to measure clinical and tained attention and impulsivity. MATRICS CPT [70, 71] general symptoms. We used the 7-factor solution proposed was used as a measure of attention in a subsample of the by Emsley [51]. The Spanish version of the Scale Unaware- participants. We created the composite variable “Atten- ness of Mental Disorders (SUMD) [52, 53] was used to tion” by adding the D-prime scores of both measures measure unawareness of the mental disorder. Higher scores standardized into T scores. All the neuropsychological represent more unawareness of the mental disorder. We used variables are presented in T scores. The Weschler Adults the Rosenberg Self-Esteem Scale [54], where higher scores Intelligence Scale (WAIS) [72] subtests Vocabulary and indicate better self-esteem. Digits were used to measure premorbid intelligence and Metacognition: The Beck Cognitive Insight Scale (BCIS) verbal fluency, and working memory respectively. The [55, 56] was used to measure cognitive insight. The BCIS scores are presented in their conversion to IQ. is composed of the following two subscales: self-certainty and self-reflectivity, which are analyzed separately. Higher scores in self-reflectivity represent a higher ability to ques- Statistical analysis tion one's beliefs. Higher scores in self-certainty represent more certainty in one's interpretations and misinterpreta- All descriptive analyses to explore the dataset were con- tions. The Beads Task [57] was used to measure the JTC ducted using SPSS Version 22. We explored differences bias. Participants were shown a picture of two containers between sexes in all measures prior to conducting the filled with 100 colored beads in reciprocal proportions. We Latent Profile Analysis using U-Mann Whitney tests. used the following three trials with different conditions: a Effect size is reported using Cohen’s d. probabilistic trial with a 85/15 ratio, a second probabilistic Latent Profile Analysis (LPA) broken down by sex was trial with a 60/40 ratio, and a final trial with an affective carried out using R Version 3.5.3 [73], and in particular condition in a 60/40 ratio. Participants were told that the the R package mclust [74]. This method identifies profiles computer had selected a container and that the goal of the of individuals, called latent profiles, based on responses task was to determine which container. To this end, partici- to a series of continuous variables. The number of latent pants were shown one bead at a time, and instructed to see profiles was determined by analyzing 2–6 group models as many beads as needed to guess which container the beads in which the variables included were: Faces Test (total came from. Our outcome variable was the number of draws score), the Hinting Task (total score), the IPSAQ (person- to decision in the three probabilistic conditions. Less than alizing bias and externalizing bias scores), the BCIS (self- three draws to decision is considered indicative of present- reflectivity and self-certainty scores), and the three condi- ing the JTC bias. tions of the Beads Task (trials to decision). Participants Social Cognition: The Internal, Personal, and Situational that lacked data in any of the aforementioned variables Attributions Questionnaire (IPSAQ) [58] was used to assess were excluded from the study. Of the initial 192 people attributional style. We used the folloing two indexes: person- that participated in the clinical trials, 174 were included alizing bias and externalizing bias. Personalizing bias refers in the LPA.Model selection to determine the optimal num- to a tendency to blame others rather than circumstances for ber of latent trajectories was performed according to the negative events. Externalizing bias refers to a tendency to Bayesian Information Criterion (BIC) [75]. Additionally, attribute the causes of negative events to others or circum- we assessed variable importance by applying a classifica- stances rather than to oneself [59] tion tree via the R package rpart [76]. Model selection has The Faces Test [60, 61] was used to measure emotion been performed via Bayesian Information Criterion (BIC) recognition. A reduced version of The Hinting Task [62, 63] for the specified LPA model numbers of clusters, which was used to measure theory of mind. is fitted by EM algorithm [77] initialized by model-based Functional outcome: The Global Assessment of Func- hierarchical clustering [74, 78]. Additionally, the assess- tioning (GAF) [64] was used to measure clinical and social ment of the variable importance was achieved building a functioning on a scale of 0–100. Higher scores represent CART model via recursive partitioning trees [79]. This better functioning. ranking of variables is computed based on the correspond- Neuropsychology: The Wisconsin Sorting Card Test ing reduction of predictive accuracy when the predictor of (WSCT) [65, 66] was used to assess flexibility and inhi- interest is removed using a measure of decrease of node bition [67]. The Stroop Test (Stroop, 1935) was used to impurity [80]. measure flexibility and inhibition. The Trail Making Tests We used Kruskal–Wallis and Dwass-Steel-Critchlow- (TMT-A and TMT-B) [68, 69] were used as a measure Fligner pairwise comparisons to calculate mean differences of visuomotor attention, sustained attention, speed, and among the clusters. Effect size is reported using epsilon cognitive flexibility. The Continuous Performance Test squared. 13 1172 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 Results orientation aligned to the coordinate axes) according to BIC (BIC =  – 2854.815). Additionally, the CART classifi- Characteristics of the sample cation tree assessed that the affective condition of the beads task (40%) and the 60–40 condition of the beads task (36%) A total of 174 patients with FEP were included in the analy- were the most important variables in determining the profile sis. Females were significantly older than males (p = 0.013) structure. and had received significantly more education (p = 0.028). The JTC profile (28.7%) included males that had one SD The samples differed in diagnosis (p = 0.004), depression below the mean draws to decision in the three conditions as measured by the PANSS (p = 0.0016), theory of mind of the Beads Task than the other two groups, suggesting a (p = 0.031), immediate recall (p = 0.009), short (p = 0.011) bigger tendency to present the jumping to conclusions bias. and long-term memory (p = 0.026), and the interference con- The Indecisive profile (18.3%) presented a number of dition of the Stroop Test (0.05). We did not find any other draws to decision of one SD above the mean in the three significant differences between sexes. Full characteristics of conditions of the Beads Task. The Homogeneous profile the sample and comparisons by sex can be found in Sup- (53%) comprised participants who scored around the mean plementary Table 1. in all the variables examined. Figure 1 shows the graphic representation of each profile Profile analysis in the male group. Kruskal–Wallis tests yielded significant differences in positive (p = 0.03) and disorganized (p = 0.03) Males symptoms. Significant differences in positive symptoms did not survive subsequent pairwise comparisons. However, we We identified three diagonal, variable volume, variable found that males in the JTC profile had worse disorganized shape, coordinate axes orientation (VVI) profile profiles symptoms than males in the Homogeneous profile. Further, (i.e., diagonal profiles with variable shape, volume, and males in the JTC profile presented worse clinical insight Fig. 1  Profiles of each group in the male sample with standardized means in each of the variables included in the LPA. Group 1 refers to the JTC profile. Group 2 refers to the Indecisive profile. Group 3 refers to the Homogeneous profile 13 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 1173 than the other two profiles. We did not find other clinical Consistent with our hypothesis, males and females with FEP differences. present different profiles of social cognition and metacog- As for neuropsychological variables, we found that males nition that are identifiable using LPA and that are associ- in the JTC profile scored worse than their counterparts in ated with specific presentations of the disorder. Males in the profiles Indecisive and Homogeneous in TMT-A and TMT- Homogeneous profile seemed to have a more benign course B, and worse than males in the Homogeneous profile in total of illness than males in the other profiles, particularly the errors of WSCT. JTC profile. Females in the homogeneous profile were older, Males in the JTC profile scored better in our sustained had fewer depressive symptoms, and higher self-esteem than attention measure than males in the Homogeneous profile. females in the Cognitive Bias profile. The mean scores of each variable included in the LPA and These findings may have relevant clinical consequences, mean differences among profiles are presented in Table 1. as our results suggest that having similar performance in Differences among the profiles in clinical and neuropsycho- all levels of social cognition and metacognition could be logical variables are displayed in Table 2. indicative of a more benign course of illness, although this explanation should be clarified in future research. Females We found a second profile common to both sexes (Inde- cisive), characterized by average scores in most variables We identified three diagonal, variable volume, equal shape, except for draws to decision, which were a standard devia- coordinate axes orientation (VEI) profiles for females (i.e., tion higher than the mean. Females in this profile only pre- diagonal profiles with variable volume, equal shape, and ori- sented significantly better self-esteem than the other pro- entation aligned to the coordinate axes) according to BIC files. Males in this profile had more positive symptoms than (BIC =  – 1443.49). The CART classification tree indicated males in the homogeneous profile but scored significantly that the most important variables in defining the profile better in attention than males in the JTC profile. This profile structure were the Personalizing Bias (32%) and External- grouped the least proportion of participants both in males izing Bias (23%) subscales of the IPSAQ. (18.3%) and females (8.6%). Participants in these groups The Homogeneous profile (79.3%) was the dominant seemed to have a clinical state similar to participants in the group. Participants in this group scored around the mean in homogeneous profile. However, the importance of its traits all the variables examined. cannot be neglected. Although to our knowledge the role of The Indecisive profile (8.6%) of the sample included par- an excessive number of DTDs in the beads task has not been ticipants with an excessive number of trials to decision in studied, one interpretation could be excessive metacogni- the Beads Task. tive monitoring. Participants could be constantly evaluating The Cognitive Biases profile (12.1%) was defined by high whether they have enough information to make a decision, self-reflectivity, very low externalizing bias, and very high which could inhibit decision making [29]. The particularities personalizing bias. of this profile indicate that subjects with this profile could Figure 2 shows the graphic representation of each profile benefit from a different therapeutic approach. in the female group. Kruskal–Wallis tests yielded significant Males in the JTC profile had worse neuropsychological age differences (p = 0.04) and self-esteem (p = 0.04). Sub- performance, more positive and disorganized symptoms, sequent pairwise comparisons indicated that females in the and worse clinical insight. These results are consistent with Homogeneous profile were significantly older than females previous studies reporting the association between a higher in the Cognitive Bias profile. tendency to present JTC and more positive symptoms [21] The mean scores of each variable included in the LPA and and worse neuropsychological deficits [20–22]. Some stud- mean differences among profiles are presented in Table 1. ies have suggested that JTC could likely be a consequence Differences among the profiles in clinical and neuropsycho- of pre-existing neuropsychological deficits [21, 23]. On the logical variables are summarized in Table 2. contrary, the association between clinical insight seems to be independent of neurocognitive abilities [32]. Neverthe- less, the three constructs have been associated with poorer Discussion outcomes [17, 19, 25], indicating that males in this profile could have a more troubled course of the disease and worse In this study, we conducted a latent profile analysis to functioning. obtain profiles of social cognition and metacognition in FEP Females in the Cognitive Bias profile had more personal- according to sex. We identified three profiles in each sex. We izing bias and self-reflectivity, but lower self-esteem than found two profiles (Homogeneous and Indecisive) that were females in the other profiles. Further, we found a trend for present in males and females, while we found two profiles significance in depression measured with BDI. Females in (JTC and Cognitive Biases) that were specific to each sex. the Cognitive Bias profile scored higher in depression than 13 1174 13 Table 1  Mean scores of the social cognition and metacognition variables in each profile according to gender Males Females Profile 1 Profile 2 Profile 3 Profile 1 Profile 2 Profile 3 JTC Indecisive Homogeneous p Pairwise comparisons ε2 Homogeneous Indecisive Cognitive bias p Pairwise comparisons ε2a N = 33 N = 21 N = 61 N = 46 N=5 N=7 Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Beads Task 85–15 2.33 (1.16) 9.90 (6.14) 3.98 (1.70) 0.001 1 < 3, 1 < 2, 2 > 3 0.406 4.15 (2.53) 19.40 (0.89) 4.1 (3.18) 0.001 1 > 3, 2 > 3 0.241 60–40 3.12 (2.17) 15.14 (4.70) 8.18 (2.48) 0.001 1 < 2, 1 < 3, 2 > 3 0.647 6.72 (4.09) 18.00 (2.00) 6.71 (3.68) 0.002 1 > 3, 2 > 3 0.225 Salient task 2.88 (1.74) 13.52 (4.13) 7.72 (2.18) 0.001 1 < 2, 1 < 3, 2 > 3 0.685 6.96 (3.88) 18.20 (1.64) 6.71 (3.68) 0.002 1 > 3, 2 > 3 0.226 BCIS Self-certainty 9.12 (3.090) 9.12 (4.22) 7.78 (2.74) 0.083 8.07 (3.97) 8.40 (3.64) 8.00 (3.10) 0.964 Self-reflectivity 14.33 (5.06) 16.0 (5.35) 16.48 (4.07) 0.101 14.26 (5.42) 15.20 (2.84) 20.29 (1.89) 0.009 1<3 0.165 Faces test 16.52 (2.81) 17.19 (1.91) 17.90 (1.50) 0.059 17.28 (1.73) 18.40 (0.54) 16.57 (1.39) 0.072 Hinting task 1.33 (0.55) 1.61 (0.28) 1.62 (0.32) 0.053 1.70 (0.33) 1.60 (0.15) 1.52 (0.24) 0.104 IPSAQ Personalising bias 1.25 (0.70) 1.04 (0.71) 1.30 (0.53) 0.205 0.092 (0.46) 1.30 (0.20) 2.75 (0.62) 0.0001 1 < 3 0.366 Externalising bias 0.45 (3.88) 2.52 (4.86) 0.23 (3.21) 0.099 2.54 (3.35) 1.00 (3.33) – 4.86 (1.95) 0.0001 1 > 3, 2 > 3 0.3 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 Table 2  Mean scores and mean differences among the profiles in demographic, clinical and neuropsychological variables Males Females Profile 1 Profile 2 Profile 3 Profile 1 Profile 2 Profile 3 2 JTC Indecisive Homogeneous p Pairwise comparisons ε Homogeneous Indecisive Cognitive bias p Pairwise comparisons ε2 N = 33 N = 21 N = 61 N = 46 N=5 N=7 Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Age (years) 26.45 (6.70) 26.05 (8.06) 27.7 (6.87) 0.474 31.24 (7.86) 29.00 (5.97) 23.43 (7.85) 0.046 1 > 3 0.108 Education (years) 0.001 0.001 (%) Incomplete primary 18.2 14.3 5 6.5 school Complete primary 24.2 28.6 11.7 10.9 20 28.6 school Incomplete second- 27.3 9.5 28.3 13.0 20 28.6 ary school Complete secondary 18.2 23.8 33.3 23.9 20 28.6 school Incomplete superior 6.1 14.3 8.3 17.4 40 14.3 studies Complete superior 6.1 9.5 13.3 28.3 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 studies Antipsychotic dose 14.17 (13.86) 9.03 (4.19) 18.73 (58.54) 0.372 22.38 (62.61) 9.58 (6.98) 12.51 (8.75) 0.703 (DDD) Diagnosis (%) 0.001 0.001 Schizophrenia 48.48% 33.33% 52.46% 26.09% 60 28.57% Psychotic disorder 12.12% 28.57% 36.07% 30.43% 20 14.29% NOS Schizoaffective 15.15% 4.76% 1.64% 10.87% 20 42.86% disorder Delusional disorder 3.03% 14.29% 4.92% 13.04% 14.29% Brief psychotic 12.12% 19.05% 3.28% 13.04% disorder Schizophreniform 6.03% 1.64% 6.52% disorder Emsley factors Positive symptoms 17.97 (7.21) 17.71 (5.60) 14.97 (6.31) 0.021 1 > 3, 2 > 3 0.069 16.18 (6.42) 13.60 (3.91) 13.29 (4.72) 0.465 Negative symptoms 16.18 (7.90) 16.76 (6.46) 15.46 (7.06) 0.680 14.36 (6.77) 15.80 (6.76) 15.29 (5.22) 0.986 Disorganised symp- 9.82 (4.28) 8.85 (3.62) 7.80 (3.32) 0.039 1 > 3 0.058 8.05 (3.85) 7.20 (3.27) 7.71 (2.36) 0.875 toms Excited symptoms 6.15 (3.12) 5.52 (2.50) 5.41 (2.49) 0.408 5.43 (3.14) 4.20 (0.45) 4.43 (0.79) 0.472 13 1175 Table 2  (continued) 1176 Males Females 13 Profile 1 Profile 2 Profile 3 Profile 1 Profile 2 Profile 3 2 JTC Indecisive Homogeneous p Pairwise comparisons ε Homogeneous Indecisive Cognitive bias p Pairwise comparisons ε2 N = 33 N = 21 N = 61 N = 46 N=5 N=7 Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Motor symptoms 2.91 (1.87) 2.67 (1.28) 2.98 (1.44) 0.268 2.61 (1.11) 3.40 (2.19) 3.43 (1.27) 0.121 Depression 4.52 (2.58) 4.76 (1.95) 4.08 (1.92) 0.333 5.09 (2.51) 6.40 (3.36) 5.29 (2.21) 0.603 Anxiety 5.94 (2.38) 6.05 (2.27) 5.74 (2.28) 0.772 5.83 (2.42) 5.00 (1.22) 6.00 (3.42) 0.837 GAF 60 (12.71) 57.10 (11.34) 60.11 (12.97) 0.538 60.00 (12.22) 54.2 (9.12) 60.43 (14.88) 0.467 Rosenberg (total) 28.1 (6.83) 27.0 (5.20) 27.1 (6.12) 0.668 27.3 (5.42) 31.6 (8.02) 22.7 (6.52) 0.043 1 > 2, 2 > 3 0.110 BDI (total) 14.79 (9.35) 15.86 (7.61) 14.20 (9.43) 0.501 14.46 (9.12) 15.60 (12.12) 22.86 (7.49) 0.085 0.086 SUMD (global) 8.18 (3.86) 5.81 (3.63) 5.59 (3.02) 0.040 1 > 3 0.096 5.80 (3.97) 6.20 (5.07) 4.57 (2.15) 0.770 WSCT (T) Total errors 39.71 (9.34) 46.90 (16.85) 47.46 (12.62) 0.024 0.072 44.98 (14.35) 43.60 (5.81) 41.29 (11.15) 0.968 Perseverative errors 42.15 (8.10) 47.33 (17.21) 48.98 (12.58) 0.063 44.95 (15.13) 44.00 (8.43) 44.43 (7.44) 0.855 Non-perseverative 40.25 (7.93) 45.33 (17.55) 46.61 (12.68) 0.063 45.45 (14.14) 43.40 (5.37) 39.71 (13.00) 0.704 errors Stroop test (T)— 85.58 (19.11) 55.62 (11.76) 55.22 (12.21) 0.772 53.69 (10.71) 50.75(5.06) 51.29(14.77) 0.551 interference WAIS-III (T) Digits 40.96 (7.96) 41.42 (9.67) 45.49 (9.93) 0.044 1 < 3 0.05 44.22 (9.26) 48.66 (6.41) 42.14 (10.11) 0.534 Vocabulary 85.58 (19.11) 92.29 (24.92) 95.57 (18.32) 0,045 1 < 3 0.057 94.21 (21.07) 97.00 (7.58) 89.90 (27.45) 0.593 Attention (T) 51.40 (12.11) 42.73 (14.20) 46.00 (6.12) 0.022 1 > 2 0.079 49.84 (13.19) 36.65 (15.60) 51.92 (11.76) TMT (seconds) TMT-A 73.19 (23.38) 64.24 (17.26) 62.31 (15.41) 0.049 1 > 3 0.055 65.94 (24.34) 66.25 (13.59) 64.58 (11.72) 0.664 TMT-B 107.38 71.51 (18.91) 70.06 (23.28) 0.001 1 > 3 0.123 68.42 (20.13) 59.82 (14.00) 73.47 (17.11) 0.434 (81.88) Tavec Immediate recall 39.6 (9.20) 38.7 (9.22) 39.5 (9.92) 0.970 45.2 (12.4) 43.9 (15.1) 36.2 (7.20) 0.109 Short-term memory 32.6 (12.3) 38.0 (16.8) 35.3 (17.7) 0.291 40.5 (13.3) 39.1 (9.58) 35.0 (13.2) 0.633 Long-term memory 30.7 (14.2) 35.33 (17.68) 33.94 (16.26) 0.413 39.6 (14.2) 40.3 (10.5) 33.6 (18.0) 0.735 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 1177 Fig. 2  Profiles of each group in the female sample with standardized means in each of the variables included in the LPA. Group 1 refers to the Homogeneous profile. Group 2 refers to the Indecisive profile. Group 3 refers to the Cognitive Biases profile the other two profiles. This presentation seems consistent size of each profile varied greatly. Therefore, although we with the insight paradox [30], a phenomenon in which more used non-parametric tests to determine mean differences, self-reflectivity is positively associated with more depres- some significant differences may not have been detected. sion and lower self-esteem [36]. Similarly, we did not conduct post-hoc analysis, as the com- Depression, self-esteem, and personalizing bias have been parisons presented in this work are qualitative comparisons found not only to be closely associated with persecutory based on the graphical representation of the clusters. We did ideation and paranoia [33, 34, 58], but also with the severity not have a control group. Therefore, whether these profiles of paranoia in subjects with FEP [35]. Females in this profile appear in the general population, the extent of the impair- have more self-reflectivity, indicating that they have a bet- ment, and cut-off scores could not be calculated. We used ter ability to reflect upon their processes. This ability may a cross-sectional design that did not allow testing profile lead to a better awareness of their symptoms and difficulties, stability. There are other possible predictors of profile mem- which could decrease self-esteem and increase depression. bership that were not collected in the present work, such as Ultimately, to preserve their self-esteem, females in this pro- differences in personality[81], that should be considered in file could blame other persons for negative events, which future studies. These limitations notwithstanding, this is the may, in turn, increase paranoid symptoms and perpetuate first work yielding evidence of sex profiles in social cog- symptoms. This explanation, however, remains speculative nition and metacognition. Future research confirming our as this study did not explore causality. profile solution, profile membership predictors, and illness We note that females in the Homogeneous profile were course according to profile and sex are recommended, as older than those in the Cognitive Bias profile. Although well as understanding therapeutic components of interven- examining hormonal differences between the profiles is tions that are more adequate to specific sexes and profile beyond the aim of this work, it is possible that differences in presentations. estrogen levels are partially responsible for the clinical pres- There are relevant clinical implications to our work. A entation of each profile. This hypothesis should be examined first implication is that males that present JTC and females in future research. that present higher self-reflectivity in conjunction with Our work has several limitations. personalizing bias may have a worse presentation of the First, our sample was not balanced in sex, which could disorder. Importantly, the JTC and other cognitive biases have hampered our statistical power. Likewise, the sample are modifiable [82]. Therefore, the early identification of 13 1178 European Archives of Psychiatry and Clinical Neuroscience (2022) 272:1169–1181 cognitive and metacognitive profiles may help clinicians – Review & Editing. EG: Investigation. EP: Writing- Review & Edit- deliver early targeted treatment, what could have a benefi- ing. EH-R: Writing- Review & Editing, Supervision. TP: Resources. MLB: Resources. JG-B: Writing – Review & Editing, Supervision. cial effect in prognosis. FG-H: Resources. IR-D: Resources. JC: Resources. SM: Writing – Patients with different profiles of social cognition and Review & Editing. Resources. SO: Conceptualization, Methodology, metacognition may respond differently to therapeutic Supervision, Project administration, Funding acquisition, Writing – approaches. A study assessing sex differences in response to Review & Editing. metacognitive treatment in a sample with FEP [45] reported Funding Open Access funding provided thanks to the CRUE- that females improved more in cognitive insight, personal- CSIC agreement with Springer Nature. This study was funded by izing bias, and general symptoms than males. Conversely, the Instituto de Salud Carlos III, Spanish Government, (PI11/01347, males improved more in the salient condition of the Beads PI14/00044 and PI18/00212), by the Fondo Europeo de Desarrollo Task, but not females. Our results are consistent with them Regional (FEDER), Health Department of Catalonia, PERIS call (SLT006/17/00231), Progress and Health Foundation of the Andalu- in that our profiles follow the same direction as their findings sian Regional Ministry of Health, (PI-0634/2011 and PI-0193/2014), and further support them in that future studies should study Obra Social La Caixa (RecerCaixa call 2013), Obra Social Sant Joan which contents of metacognitive interventions could be de Déu, BML (RTI2018-100927-J-I00) administrated by Ministerio de more beneficial according to sex and profile of impairment. Ciencia e Innovación (MCI, Spain), by the Agencia Estatal de Inves- tigación (AEI, Spain), and by the European Regional Development While all the profiles could benefit from therapies that Fund (FEDER, UE). DF has been supported by Marsden (E2987-3648) target metacognition, males could benefit from boosting administered by the Royal Society of New Zealand, by grant 2017 sessions aimed at correcting the JTC, while females could SGR 622 (GRBIO) administrated by the Departament d'Economia benefit from boosting sessions directed to modify cogni- i Coneixement de la Generalitat de Catalunya (Spain) and by Min- isterio de Ciencia e Innovación (Spain) [PID2019-104830RB-I00/ tive insight and attributional biases. Moreover, males that DOI (AEI): 10.13039/501100011033], MFQ has received funding present JTC may find optimal treatment in combining neu- from CIBER -Consorcio Centro de Investigación Biomédica en Red- rocognitive training with metacognitive therapy. Predic- (CB/07/09/0028), Instituto de Salud Carlos III, Ministerio de Ciencia tors of profile membership and possible illness trajectories e Innovación. emerge in our work as promising topics for future research. Longitudinal studies assessing the prognosis of each profile Declarations and profile stability are encouraged to help confirm these Conflict of interest The authors declare that they have no conflict of exploratory findings. interest. Supplementary Information The online version contains supplemen- Ethical standards All individuals were given an informative sheet, and tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00406-0​ 22-0​ 1438-0. all of them signed an informed consent file for participation in this study. The Ethics Committee of each participating center approved this Acknowledgements We thank all the participants that volunteered to project. The authors assert that all procedures contributing to this work take part in their study for their altruism and their time. We thank all comply with the ethical standards of the relevant national and institu- the members of the Spanish Metacognition Study Group for their valu- tional committees on human experimentation and with the Helsinki able advice in this work. Acevedo A, Anglès J, Argany MA, Barajas A, Declaration of 1975, as revised in 2008. Barrigón ML, Beltrán M, Birulés I, Bogas JL, Cabezas A, Camprubí N, Carbonero M, Carrasco E, Casañas R, Cid J, Conesa E, Corri- pio I, Cortes P, Crosas JM, de Apraiz A, Delgado M, Domínguez L, Open Access This article is licensed under a Creative Commons Attri- Escartí MJ, Escudero A, Esteban Pinos I, , Franco C, García C, Gil V, bution 4.0 International License, which permits use, sharing, adapta- , Gonzalez-Casares R, González Higueras F, González-Montoro MªL, tion, distribution and reproduction in any medium or format, as long González E, Grasa E, Guasp A, Gutierrez-Zotes A, Huerta-Ramos Mª as you give appropriate credit to the original author(s) and the source, E, Huertas P, Jiménez-Díaz A, Lalucat LL, LLacer B, , López-Carrilero provide a link to the Creative Commons licence, and indicate if changes R, Lorente E, Luengo A, Mantecón N, Mas-Expósito L, Montes M, were made. The images or other third party material in this article are Moritz S, Murgui E, Nuñez M, Ochoa S, Palomer E, Paniego E, Peláez included in the article's Creative Commons licence, unless indicated T, Pérez V, Planell K, Planellas C, Pleguezuelo-Garrote P, Pousa E, otherwise in a credit line to the material. If material is not included in Rabella M, Renovell M, Rubio R, Ruiz-Delgado I, San Emeterio M, the article's Creative Commons licence and your intended use is not Sánchez E, Sanjuán J, Sans B, Schilling L, Sió H, Teixidó M, Torres permitted by statutory regulation or exceeds the permitted use, you will P, Vila MA, Vila-Badia R, Villegas F, Villellas R need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. Author contributions MF-Q: Conceptualization, Methodology, Writ- ing-original draft. DF: Formal analysis, Data Curation, Visualization, Writing- Review&Editing. 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Ochoa1,3 1 12 Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregats, Dr. Departament of Psychiatry, University Hospital Virgen del Pujades 42. Sant Boi de Llobregat 08830, Barcelona, Spain Rocio, Seville, Spain 2 13 Departament de Psicologia Social I Psicologia Quantitativa, Psychiatry Service, Area de Gestión Sanitaria Sur Granada, Facultat de Psicologia, Universitat de Barcelona, Barcelona, Motril, Granada, Spain Spain 14 Comunidad Terapéutica Jaén Servicio Andaluz de Salud, 3 Centro de Investigación Biomédica en Red de Salud Mental, Jaén, Spain Instituto de Salud Carlos III, Madrid, Spain 15 Unidad de Salud Mental Comunitaria Malaga Norte, Malaga, 4 Fundació Sant Joan de Déu, Spain Esplugues de Llobregat Barcelona, Spain 16 Mental Health and Addiction Research 5 Departament de Psicologia, Facultat de Psicologia Clínica Group. IdiBGi. Institut d’Assistencia Sanitària, Girona, Spain I de La Salut. Serra Hunter Fellow, Universitat Autònoma 17 Department of Psychiatry and Psychotherapy, University de Barcelona, Cerdanyola del Vallès, Bellaterra, Barcelona, Medical Center Hamburg, Hamburg, Germany Spain 18 6 Serra Húnter Fellow. Department of Statistics and Operations Department of Research, Centre d’Higiene Mental Les Corts, Research (DEIO), Universitat Politècnica de Catalunya Barcelona, Spain BarcelonaTech (UPC), Barcelona 08028, Spain 7 Psychiatry Service, Hospital Clínico Universitario de 19 Institute of Psychiatry and Mental Health, Health Research Valencia, Valencia, Spain Institute (IdISSC), Clinico San Carlos Hospital, Madrid, 8 Hospital Universitari Institut Pere Mata, Institut Spain d’Investigació Sanitària Pere Virgili-CERCA, Universitat 20 Institute of Mathematics of UPC ‑ BarcelonaTech (IMTech), Rovira i Virgili, Reus, Spain Universitat Politècnica de Catalunya, Barcelona 08028, 9 Department of Psychiatry, Hospital de la Santa Creu i Sant Spain Pau, Institut d’Investigació Biomèdica-Sant Pau (IIB-Sant 21 Departament de Psicologia Clínica i de la Salut, Pau), Barcelona, Spain Facultat de Psicologia, Universitat Autònoma de 10 Salut Mental Parc Taulí. Sabadell (Barcelona), Hospital Barcelona, Bellaterra, Cerdanyola del Vallès, Spain Universitari–UAB Universitat Autònoma de Barcelona, 22 COMSAL research group, FPCEE, Blanquerna Ramon Llull Barcelona, Spain University, Barcelona, Spain 11 Neuropsiquiatria I Addicions, Hospital del Mar. IMIM 23 GEIMAC, Institut de Neurociències, Universitat de (Hospital del Mar Medical Research Institute), Barcelona, Barcelona, Barcelona, Spain Spain 13