**7. Clinical implications of dual-process framework of social cognition and consciousness**

Given the proposed framework of dual-process social cognition [6] and access in the global workspace [33, 34, 38], we attempt to explain abnormal social cognition in clinical disorders. We demonstrate how our framework can bring new light into understanding selected examples of clinical disorders in which there are deficits in mindreading and metacognition. Here, we show examples of clinical disorders such as borderline personality and schizophrenia.

A vivid of example showing abnormality in conscious access may be presented by patients with borderline personality disorder. Individuals diagnosed with BDP characterize instability of emotional and behavioral reactions as well as unstable relationships with others [49]. It has been argued that BDP symptoms arise from deficits in perceiving and interpreting social signals [50–52]. Several researchers believe that patients with BPD have difficulties in their ability to correctly ascribing mental states to oneself and recognizing others' mental states; therefore, BPD is considered to be a metarepresentation disorder [53]. It is believed that a lack of longterm bonds with others may be due to the difficulty in maintaining a stable representation of others' mind and one's own mind [54]. Moreover, Semerari and colleagues [53] point out that impairments in BPD in reflecting one's own thoughts and emotions are of selective nature, since they are mainly associated with integrating representations of self and others in consciousness. In particular, these researchers have video-taped four patients suffering from BDP and then evaluated clinical outcomes of therapeutic intervention over the first year of their therapy with the Metacognition Assessment Scale [55]. The MAS focuses on measuring basic metacognitive functions such as monitoring, integration, and differentiation [55]. Here, we focus on monitoring dimension associated with the ability to identify one's inner states, and other functions of metacognition linked with integration defined as the "ability reflect in different mental states and or contents giving them an order and hierarchical relevance" [55]. The study clearly has demonstrated that four patients had the ability to identify their own internal states, although their integration functions aimed at organizing metacognitive representations of self and others were impaired. Following our theoretical framework of dual-process cognition and consciousness, this abnormal pattern of the metarepresentative functions in patients with BPD may indicate that the low-level structures of control and evaluation are preserved; however, there may be difficulties in consciously accessing higher-level structures containing available psychological knowledge. Since conscious access should endorse integrating nature of the metacognition-mindreading relation, its disturbances can lead to abnormal information flow between both subsystems [3]. Here, one can interpret this situation as results of abnormal regulation in accessing the information content that goes in the "from-low-to-highlevel" direction. Therefore, low-level processes of evaluation and monitoring work properly, but the further attribution of psychological contents fails. Thus, our theoretical proposal is that patients with BPD may have disturbances in conscious access that affects activation of interpretative data from metacognition and mindreading to establish proper social behavior.

mindreading module [46]. Interestingly, functional neuroimaging studies of clinical population have demonstrated that mindreading deficits are associated with decreasing activation within the medial prefrontal cortex [47]. Some other fMRI study on mindreading deficits in patients with schizophrenia also shows abnormal activation within the left medial prefrontal cortex [48]. Obviously, the actual organization of brain circuity resulting from the proposed framework of linking the dual-process social cognition and the global workspace is considerably more complicated. However, such simplified cognitive architecture of conscious social cognition can allow us to understand how normal and abnormal behavioral and neuronal

Given the proposed framework of dual-process social cognition [6] and access in the global workspace [33, 34, 38], we attempt to explain abnormal social cognition in clinical disorders. We demonstrate how our framework can bring new light into understanding selected examples of clinical disorders in which there are deficits in mindreading and metacognition. Here, we show examples of clinical disorders such as borderline personality and schizophrenia.

A vivid of example showing abnormality in conscious access may be presented by patients with borderline personality disorder. Individuals diagnosed with BDP characterize instability of emotional and behavioral reactions as well as unstable relationships with others [49]. It has been argued that BDP symptoms arise from deficits in perceiving and interpreting social signals [50–52]. Several researchers believe that patients with BPD have difficulties in their ability to correctly ascribing mental states to oneself and recognizing others' mental states; therefore, BPD is considered to be a metarepresentation disorder [53]. It is believed that a lack of longterm bonds with others may be due to the difficulty in maintaining a stable representation of others' mind and one's own mind [54]. Moreover, Semerari and colleagues [53] point out that impairments in BPD in reflecting one's own thoughts and emotions are of selective nature, since they are mainly associated with integrating representations of self and others in consciousness. In particular, these researchers have video-taped four patients suffering from BDP and then evaluated clinical outcomes of therapeutic intervention over the first year of their therapy with the Metacognition Assessment Scale [55]. The MAS focuses on measuring basic metacognitive functions such as monitoring, integration, and differentiation [55]. Here, we focus on monitoring dimension associated with the ability to identify one's inner states, and other functions of metacognition linked with integration defined as the "ability reflect in different mental states and or contents giving them an order and hierarchical relevance" [55]. The study clearly has demonstrated that four patients had the ability to identify their own internal states, although their integration functions aimed at organizing metacognitive representations of self and others were impaired. Following our theoretical framework of dual-process cognition and consciousness, this abnormal pattern of the metarepresentative functions in patients with BPD may indicate that the low-level structures of control and evaluation are preserved; however, there may be difficulties in consciously accessing higher-level structures containing

patterns that accompany conscious processes in social cognition can be developed.

**7. Clinical implications of dual-process framework of social** 

**cognition and consciousness**

112 Prefrontal Cortex

Now, turning to the domain of schizophrenia, we attempt to present how development of clinical symptoms in schizophrenic patients suffering from persecutory delusions can be understood within our proposed framework. With reference to delusional beliefs in schizophrenia, cognitive theories suggest that persecutory delusions often emerge as misinterpretation of social interactions [56]. Therefore, individuals with persecutory delusions are preoccupied with intensions to others [57]. Thus, psychotic patients fail to make accurate judgments in relation to their experiences attributed to others. It has been also suggested that delusional impairments in inferences on the social data may arise from the mindreading deficits. Apparently, deficits in mindreading are demonstrable in schizophrenia as indicated by the meta-analysis by Sprong et al. [21]. Frith [58] hypothesizes that mindreading skills in people with persecutory delusions develop normally; however, those theories of mind capacities are "lost" during psychotic episodes. There is also substantial evidence for mentalizing deficits in patients with first-order episode schizophrenia in the early course of schizophrenia [59]. In fact, mentalizing skills have been shown empirically to be impaired in psychotic patients with persecutory delusions. Patients that follow a paranoid subtype of schizophrenia perform poorly on a wide range of the "theory of mind" tasks including those exercising the attribution of intentions [60]. Moore et al. [61] have explored cognitive etiology of persecutory delusions in patients with late onset of schizophrenia and found that patients performed poorly in a deception task by making more mentalizing errors as compared to healthy participants.

Interestingly, theoretical developments in the conceptualization of relation between metacognition and mindreading skills underlie an interesting casual formation of persecutory delusions. As we mentioned above, the Carruthers' account [4] views metacognition as beliefs of our own attitudes that arise from turning mindreading capacities on ourselves. This implicates that mindreading deficits are prior leading in consequences to dysfunctional metacognition capacities. On the other hand, another explanation is possible as at least deficits in both capacities are paired and may be explained by the interactionist view on social cognition [6]. Indeed, an empirical study by Köther and collaborators [62] on schizophrenic patients could support such interactionist view on persecutory delusions as results of mindreading deficits accompanied with relevant dysfunctional metacognition capacity. In particular, the researchers by employing Reading the Mind in the Eyes test (Eyes Test; [63]) with an additional confidence measure showed in schizophrenic patients not only impaired social cognition in terms of perceiving emotional and social cues but had also commitments to make more high-confidence errors and at the same time made fewer high-confidence correct responses. Obviously, this raises questions about specificity of delusions that may be due to the failures of mentalizing skills and subsequently failures in lower-level metacognition that mirrors mindreading deficits in delusional-prone individuals. Following our framework on social cognition and consciousness, it is likely that unconscious interpretative contents from the higher-level structures are not properly broadcasted to other systems via global workspace in order to get proper monitoring and evaluations from the low-level structures. Moreover, because the information contents remain unconscious, correction of faulty beliefs and interpretations is not possible.

and propositional nature are broadcasted globally within a cognitive system. According to Baars' theory [33, 38], we predict that consciousness mobilizes two levels of processing in "from-low-to-high" or "from-high-to-low" directions depending on a psychological contexts (related to self or other people) and integrates metacognitive and mindreading functions in such a way that interpretative contents are globally available for other specialized areas of the brain. Thus, the combined framework of dual-process social cognition and global workspace explains the basic processes that may potentially underlie normal and abnormal regulation of social behavior. This account suggests that global broadcasting enables corrective interpretation in case of detecting erroneous information about themselves and false assessments of others' behaviors, intentions, etc. We believe that this framework offers a useful cognitive perspective for better understanding of clinical disorders characterized by abnormal relations between mindreading and metacognition and elaborating their therapeutic interventions.

Consciousness and Social Cognition from an Interactionist Perspective: A New Approach…

http://dx.doi.org/10.5772/intechopen.79584

115

In fact, psychological and psychiatric research clearly shows (see [12]) that people in terms of social interactions need in a continuous way to adjust their behavior and regulate distress, implicating in this fashion a great need for establishing psychological interventions aimed at improving their metacognitive and mentalizing capabilities. Our paper clearly addresses this need by providing more comprehensive cognitive explanations of complex mental health problem as well as offering a new path toward understanding symptom expression of metacognitive and mindreading disturbances. The vital point in this paper is to demonstrate that phenomenology of social interactions as well as symptom expression in severe psychological and mental disorders can be described by adapting an interactionist approach that combines access consciousness mechanisms with mental capacities of mindreading and metacognition in a complex unit. According to this view, social cognition can be driven by a set of independent mental functions in the brain that interact with each other [12, 24, 25], and as a matter of fact each element underlying this interaction may be a subject of selective impairment. On the other hand, the interactionist model undoubtedly maximizes a role of individual within the process of psychotherapeutic intervention by emphasizing his/her conscious efforts. For instance, given the interactionist view on global access and both forms of mentalization, we can also efficiently explain the way the therapy based on metacognitive training provides promising results in treating severe psychiatric disorders [27]. Indeed, the interactionist approach suggests that the individual can consciously correct his/her theories and interpretations about oneself and others, since access consciousness mediates the effective interaction between the sets of independent mental capacities. Moreover, interactionist perspective assumes that consciousness mechanisms by its mediating and integrating functions improve social cognition including metacognitive and mentalizing skills. Therefore, future studies should seek for effects of consciousness on improving both metacognition and mindreading

This research has been supported by the National Science Centre (Poland) and funded under

skills either in clinical or in nonclinical population samples.

the award number 2014/15/B/HS6/03834 to RS.

**Acknowledgements**

Interestingly, disturbances in conscious access presented in schizophrenia seem to be confirmed by studies on metacognitive and mindreading malfunctioning by Lysaker and colleagues [64]. Researchers have investigated the impairments within self-generated personal narratives in terms of perceiving one's own state and mental states of others in adults with schizophrenia spectrum disorders. The researchers by using the MAS measure (MAS measure; [55]) have identified three groups of patients: the first one with impaired metacognition ("minimal reflectivity") and poor mindreading, the second group with intact basic self-reflectivity and poor mindreading, and the third group characterized with intact self-reflection and mindreading ability in terms of attributing thoughts and emotions to other people. It turned out that individuals with impaired metacognition and mindreading facilities performed worst in recognizing negative affective cues in others' faces and voices in the video-typed material. According to Dimaggio and colleagues [8], these findings could fit into the concept of the simulation theory (see above) proposed by Gallese and Goldman [65]. Thus, these findings can support the idea of priority of having direct access to one's own internal states to further involve simulation and inferences to interpret and understand others' mental states. Since the study by Lysaker and colleagues [64] was of the correlation nature, alternative interpretations cannot be ruled out. In particular, the study showed that performance results in emotion recognition task were positively correlated with general metacognitive functions (*r* = 0.44) assessed with the "Understanding one's own mind" subscale and to some extent with mindreading capacity (*r* = 0.26) as indicated by scores on the "Decentration" dimension (the ability to perceive others as having their own emotions, thoughts, and perspectives) [64]. These results may have also implication to the idea of dual-process model of social cognition and global workspace. Clearly, better performance in recognizing affective cues in other's faces and voices was linked with activation of both higher- and lower-level structures. Subsequently, the MAS measure "Understanding one's own mind" subscale including also metacognitive function of integration could indicate that low-level metacognitive functions in emotion recognition were supported by conscious access to some extent.

### **8. Conclusions**

In our opinion, it becomes clear that efficient interactions between metacognition and mindreading capacities should be supported by access consciousness. The GWT framework by Baars [33, 38] indicates that consciousness can mediate the interaction between metacognition and mindreading subsystems by managing the access to interpretative contents from both mental faculties. Since the GWT assumes the interaction of unconscious and conscious processes, it becomes crucial how and under what conditions interpretative data of a mentalizing and propositional nature are broadcasted globally within a cognitive system. According to Baars' theory [33, 38], we predict that consciousness mobilizes two levels of processing in "from-low-to-high" or "from-high-to-low" directions depending on a psychological contexts (related to self or other people) and integrates metacognitive and mindreading functions in such a way that interpretative contents are globally available for other specialized areas of the brain. Thus, the combined framework of dual-process social cognition and global workspace explains the basic processes that may potentially underlie normal and abnormal regulation of social behavior. This account suggests that global broadcasting enables corrective interpretation in case of detecting erroneous information about themselves and false assessments of others' behaviors, intentions, etc. We believe that this framework offers a useful cognitive perspective for better understanding of clinical disorders characterized by abnormal relations between mindreading and metacognition and elaborating their therapeutic interventions.

In fact, psychological and psychiatric research clearly shows (see [12]) that people in terms of social interactions need in a continuous way to adjust their behavior and regulate distress, implicating in this fashion a great need for establishing psychological interventions aimed at improving their metacognitive and mentalizing capabilities. Our paper clearly addresses this need by providing more comprehensive cognitive explanations of complex mental health problem as well as offering a new path toward understanding symptom expression of metacognitive and mindreading disturbances. The vital point in this paper is to demonstrate that phenomenology of social interactions as well as symptom expression in severe psychological and mental disorders can be described by adapting an interactionist approach that combines access consciousness mechanisms with mental capacities of mindreading and metacognition in a complex unit. According to this view, social cognition can be driven by a set of independent mental functions in the brain that interact with each other [12, 24, 25], and as a matter of fact each element underlying this interaction may be a subject of selective impairment. On the other hand, the interactionist model undoubtedly maximizes a role of individual within the process of psychotherapeutic intervention by emphasizing his/her conscious efforts. For instance, given the interactionist view on global access and both forms of mentalization, we can also efficiently explain the way the therapy based on metacognitive training provides promising results in treating severe psychiatric disorders [27]. Indeed, the interactionist approach suggests that the individual can consciously correct his/her theories and interpretations about oneself and others, since access consciousness mediates the effective interaction between the sets of independent mental capacities. Moreover, interactionist perspective assumes that consciousness mechanisms by its mediating and integrating functions improve social cognition including metacognitive and mentalizing skills. Therefore, future studies should seek for effects of consciousness on improving both metacognition and mindreading skills either in clinical or in nonclinical population samples.
