Closing the Gap Between Cognitive Performance and Real-World Functional Outcome in Schizophrenia: The Importance of Metacognition

Functional outcome in schizophrenia has received increased attention in recent years, as the knowledge that cognitive functioning is a major determinant of outcome has become widely accepted. While impaired cognitive functioning is the most consistent predictor of functional deficits in schizophrenia, the overlap is far from complete and cognition accounts for at most 50% of the variance in functional outcome. In this paper, we review the research on factors other than cognition that relate to functional skills deficits in schizophrenia and focus on several potential moderators between cognition and functional outcome. These factors include various affective and societal variables, as well as metacognition. Metacognitive processes include the ability to appraise the accuracy of one's knowledge and competence and to use these appraisals to adjust real-world behaviors accordingly. Metacognition is related to, but separate from social cognition as well as from formal, base-level cognitive test performance. An example of metacognitive process is the ability to monitor the limits of personal knowledge base, and seek assistance in situations where requisite information or skills are lacking. Being able to perform these monitoring and control operations can allow for suitable functional performance despite cognitive limitations. Conversely, failing to perform these operations can account for poor functional outcome despite intact cognitive abilities. We argue that metacognition is an important moderator between cognition and real-world function and that this factor, in contrast to societal variables, may be modifiable in individual patients with schizophrenia.