COGNITION IN

SCHIZOPHRENIA

Presenter: Dr. Parvaiz Ahmad Khan NIMS Hospital Jaipur

INTRODUCTION

• Cognitive deficits in schizophrenia are evident across virtually every measured aspect of cognition

• Are present by the first episode of the illness

• Persist over time

• Largely unaffected by contemporary pharmacologicapproaches to symptom management

Irani et al., 2011; Gold et al., 2009; 2

Cognitive deficits in schizophrenia are : P5 • Pervasive

• Persistent

• Present early

• Progress early

• Predict functional disability

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COGNITION IN SCHIZOPHRENIA

Neurocognition

Social Cognition

Metacognition4

Neurocognition In Schizophrenia

Attention/Vigilance

Verbal Learning

Visual Learning

Reasoning and Problem Solving

Speed of Processing

Verbal Fluency

Immediate/Working Memory5

ATTENTION / VIGILANCEAttention: Ability to respond to targets, not respond to non- targets, over a period of time

Vigilance: Ability to maintain attention over time

Continuous Performance Test – Identical Pairs :

A series of two- to four-digit numbers is presented on a computer screen at a rate of one per second

Press on the button each time a number is identical to the previous number

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Continuous Performance TestPress when you see the same number twice in a row

100 ms

HOLD PRESSHOLDHOLD

254 743364 743STIMULI

RESPONSE

1 sec

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Impairments in attention/vigilance can result in :

Difficulty in social conversations

Inability to follow important instructions : Treatment, Therapy, Or Work.

Simple activities like reading or watching television can become labored or impossible

Related to various aspects of outcome, including social deficits, community functioning, and skills acquisition

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VERBAL LEARNING

Ability to learn & retain newly learned information over time, and also recognize previously presented material

o Hopkins Verbal Learning testo California Verbal Learning Test

Patient is required to listen to 12 to 16 words

Recall as many of the words as possible

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California Verbal Learning Test:

• First Trial - Normal controls - recall 8 of 16

Schizophrenics - recall about 5

• After Five Consecutive Trials Controls recall - up to 13 Schizophrenia - only 9

Patients show larger deficits in learning than in retention10

VISUAL LEARNING

Visual information is not as easily expressed as verbal information

Visual learning tests :

Require subjects to draw figures from memory or

To indicate which among an array of figures was previously presented

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Visual memory impairment is correlated with :

Employment Status

Job Tenure

Psychosocial Rehabilitation Success

Social Functioning

Quality Of Life Ratings

Functional Capacity

Not as impaired as verbal memory12

Reasoning & Problem Solving

• Numerous tests of reasoning and problem solving

• Frequently utilized in schizophrenia research is

• Wisconsin Card Sorting Test (WCST)

• Patients are given a deck of cards with various colors, numbers & shapes

• Principle of test is to learn to sort the cards on the basis of color, number & shape

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COLOR SHAPENUMBER

• Can also measure vigilance & visual memory

Wisconsin Card Sorting Test

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Repeated sorting attempts by the previously correct principle are referred to as perseverations

Poor performance on the WCST and the reduced activity of the dorsolateral prefrontal cortex during performance

Led to hypothesis of Frontal Hypoactivation in schizophrenia

Impairment on measures of reasoning and problem-solving lead to difficulty adapting to the rapidly changing world around them

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SPEED OF PROCESSING

• Latency of response to environmental demands and the time required to execute tasks that require the processing of information

• Important domain of neurocognition

Wechsler Adult Intelligence Scale Digit Symbol Test

• A simple symbol is associated with each numeral (1 - 9)

• Subjects are required to copy as many as possible in 90 seconds

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Impairment in processing speed causes disturbance in

• Daily life activities

• Job tenure

• Independent living status

Increased response latency in social settings also hampers social relationships

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VERBAL FLUENCY

• Most neurocognitive assessments have included verbal fluency as a separate domain of functioning

Phonological Fluency & Semantic Fluency

• Phonological fluency :- ability to produce as many words as possible beginning with a particular letter within 60 seconds

• Semantic fluency :- ability to produce words within a particular meaning based category, such as – animals

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Schizophrenia patients produce fewer words than normal controls

Often produce inappropriate words

Impaired verbal fluency :

• Damage functioning in social and vocational settings

• Making communication difficult and awkward

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Immediate / Working Memory• Immediate memory : refers to the ability to hold a limited

amount of information “online” for a brief period of time

Eg., Repeating a string of digits (digits forward)

• Working memory : refers to the ability of manipulation of the information being held online

Eg., Repeating a series of digits in the reverse order than they are presented (digits backward)

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SOCIAL COGNITION

“ We mortals cannot read other people’s minds directly. But we make good guesses from what they say, what we read between the lines, what they show in their faces and eyes, and what best explains their behavior”

It is our species’s most remarkable talent

Steven Pinker21

SOCIAL COGNITION

Ability to perceive and understand relevant

social cues:

–Facial expression & voice tone

–Hints and indirect suggestions

–Social norms

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Social cognition impairments appear to make a unique contribution to the functioning in people with schizophrenia

Fett et al. 2011; Green et al., 2012

Individuals with schizophrenia exhibit marked deficits in social cognition across a range of domains

Salva et al., 2013

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Emotion Processing

Theory Of Mind (Tom)

Social Perception

Attributional Style

SOCIAL COGNITION DOMAINS :

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EMOTION PROCESSING

Emotion processing refers to emotion perception and utilization of emotion information

Model proposed by Salovey and Sluyter (1997) :

a. Identifying emotions

b. Facilitating emotions

c. Understanding emotions

d. Managing emotions25

Identifying emotions : Via facial affect or vocal prosody

Facilitating emotions : Understanding how certain emotions can assist

performance on different tasks

Understanding emotions : Understanding emotional blends and transitions

Managing emotions : Regulation of emotional states of self and others

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SCHIZOPHRENIC PATIENTS :

• Vast majority of studies in emotion processing have focused on emotion identification

• Exhibited significant impairment in facial and vocal emotion identification

Comparelli et al., 2013; Thompson et al., 2012

• Some studies found greater difficulty in identifying negative than positive emotions

Amminger et al., 2012

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HIGH-RISK PEOPLE :

• Presence of transient psychotic symptoms that resolve spontaneously

• Subthreshold positive symptoms of psychosis ‘attenuated psychotic symptoms’

• Genetic high-risk accompanied by recent deterioration in functioning

Tandon et al., 2012 28

Two studies report no significant differences between clinical high-risk and control groups on facial emotion identification tests

Pinkham et al., 2007; Thompson et al., 2012

Six studies report impaired performance on tasks of facial emotion identification

Amminger et al., 2012; Comparelli et al., 2013

High-risk participants differed from controls on facial affect and vocal prosody identification tasks

Amminger et al., 2012

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UNAFFECTED RELATIVES :

One meta-analysis of 20 studies suggested :

• Presence of moderate impairment in emotion processing in relatives of schizophrenics

• Larger effect sizes observed for tasks of affect identification than for affect discrimination

Lavoie et al., 2013

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Theory Of Mind (ToM)

• ToM refers to the ability to make inferences about the thoughts, beliefs, and intentions of others

• Also referred to as Mentalizing, Mind reading

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Eyes task:

• Making mental state attributions via decoding complex emotional states from pictures of the eye region of faces

Hinting task:

• Consists of ten short passages presenting an interaction between two characters

• One of the characters drops an obvious hint

• Subjects were asked what the character really meant

• Appropriate response – 2 score• Response after a hint – 1 score• Inappropriate response hint – 0

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SCHIZOPHRENIC PATIENTS :

• One meta-analysis of eight studies demonstrated significant differences between patients and controls on ToM tasks

• Impairment was observed across visual and verbal ToM tasks

Bora and Pantelis, 2013

• To date, no clear pattern clinical correlates of significant association between positive symptoms and performance on a ToM task

Koekelbeck et al., 2010

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HIGH-RISK PEOPLE :

One meta-analysis of seven studies reported an impaired performance on ToM tasks compared with controls

Bora and Pantelis, 2013

UNAFFECTED RELATIVES :

Two meta-analyses (evaluating 10 and 11 studies) reported a moderate impairment in unaffected relatives

Larger effect for mental state reasoning (e.g., Hinting Task) than for mental state decoding (e.g., Eyes Task)

Bora and Pantelis, 2013 34

SOCIAL PERCEPTION

• Identifying and utilizing social cues to make judgments about social roles, rules, relationships, context, or the characteristics (e.g., trustworthiness) of others

• Profile of Nonverbal Sensitivity (PONS)

• Social Cue Recognition Test (SCRT)

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Tests of social perception include :

• videotaped scenes that require the viewer to make inferences and judgments

• about ambiguous social situations

• based on limited verbal and nonverbal social cues

Relationships Across Domains task (RAD):

• Requires participants to make inferences about the nature of relationships between people based on short written vignettes

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SCHIZOPHRENIC PATIENTS :

Five studies of social perception exhibit impaired performance on social perception tasks compared with controls

Bertrand et al., 2008; Green et al., 2012

HIGH-RISK PEOPLE :

Two studies have examined social perception in clinical high-risk samples and both reported impairments

Green et al., 2012

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UNAFFECTED RELATIVES :

• A meta-analysis two studies of social perception suggested presence of moderate social perception impairment in unaffected relatives

Lavoie et al., 2013

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ATTRIBUTIONAL STYLE

Attributional style refers to the causal explanations one makes for outcomes of life events

Internal (i.e., due to oneself) or External (i.e., not due to oneself)

External attributions are either

personal (i.e., due to a specific person) or situational (i.e., due to chance or situational factors)

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Individuals prone to persecutory delusions tend to show a personalizing bias, i.e. attribute negative outcomes to others rather than situations

Attributional style is assessed via :

• Internal, Personal, and Situational Attributions Questionnaire (IPSAQ)

• Ambiguous Intentions Hostility Questionnaire (AIHQ)

• Questionnaires ask subjects to make causal attributions about hypothetical events

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• SCHIZOPHRENIC PATIENTS :

Two studies examined attributional bias and showed :

• preference for personal-external attributions for negative events

• an ‘other person bias’ (i.e., preference for blaming others for negative events rather than oneself)

Fornells-Ambrojo and Garety, 2009

On the AIHQ, patients were more likely to attribute hostile intentions to others in ambiguous situations (i.e., ‘hostility bias’) than controls

An et al., 2010 41

HIGH-RISK PEOPLE :

Two studies found that high-risk subjects exhibited greater ‘externalizing bias’ (blame others rather than circumstances)

An et al., 2010; Thompson et al., 2013

Two studies found no significant group differences Devylder et al., 2013; Janssen et al., 2006

UNAFFECTED RELATIVES :

One study found no evidence for an externalizing bias on the among unaffected relatives

Janssen et al. (2006)

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Across Phases of Illness

• Emotion processing, social perception and ToM have a comparable impairments across recent-onset and chronically ill patients

• Impairments in these domains remains relatively stable during postonset period rather than showing improvement or progressive decline

• Impairments tend to be smaller and less consistent in clinical high-risk subjects

• Small and contradictory evidence about the course of attributional biases

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METACOGNITION

Mental activities forming coherent and complex ideas about oneself and others and thinking about them

• Eg., noticing that one is making an error or forming a belief about a specific thing

• One of the key aspects promoting deeper understanding and transfer of ideas and skills

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Metacognitive Activities:

Forming and reflecting about complex representations of oneself - Self reflectivity

Forming and reflecting about complex representations of other people - Understanding the mind of other s

Situating representations of self and others in the larger world - Decentration

The use of complex representations of self and others to solve emergent psychological challenges - Mastery

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INTERVENTIONS

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Antipsychotic Treatment • No U.S. Food and Drug Administration (FDA) approved

treatments for cognitive impairment

• Antipsychotics are unable to improve cognition in schizophrenia

• 1st gen. AP’S side effects & anticolinergics used in treatment of side effects worsen cognition in schizophrenia

• 2nd gen. AP’S have higher efficacy and fewer side effects, less anticholinergic effects

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Cognitive Behavioural Therapy

• Establish, maintain therapeutic relationship

• Coping strategies to reduce distress of psychotic symptoms

• Help to understand illness and deal better with negative self evaluations

• Marked improvement in overall adjustment, decreased symptoms, moderate gains sustained at 9 months f/u

Thara & Anuradha 2007 ; Sriharsh, Sippy et al 200348

Cognitive Enhancement Therapy

• Small-group approach

• Combines approximately 75 hours of progressive software training

• Exercises in attention, memory, and problem solving

• 1.5 hours per week of social cognitive group exercises

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• A 2-year, RCT with neuropsychological and behavioral assessments at baseline and at 12 and 24 months (121patients)

• Robust CET has effect on neurocognition and processing speed composites

Hogarty et al., 2004

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Cognitive Remediation• Cognitive remediation is an intervention

• Targeting cognitive deficit

• Using scientific principles of learning

• Ultimate goal of improving  functional outcomes.• • Effectiveness is enhanced when provided in a context (formal

or informal) that provides support and opportunity for extending everyday functioning

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Principles Of Cognitive Remediation :

• Progressive, “Bottom-up”

• Repetition, and Practice.

• Individualized to patient’s cognitive style, ability and progress

• Stress Free, Success oriented and Strategic, Top-Down

• Motivation, Focus on Intrinsic motivation

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Methods:

Involve a variety of methods

• Computer based or• Paper or Pencil rote practice• Strategy coaching• Group-based practice approaches

• Focus on restoration of cognitive functions, & teaching strategies for compensating for cognitive impairments

• Combination of computer-based training exercises, strategy coaching, group work

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• Most programs last 3-6 months

• Range of intensity and duration of programs: –3 to 75 hours–1 to 5 hours per week

• The “average” program provides about 20 hours of practice delivered over about 16 weeks.

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Requirements For Participation :

• Reading level of at least 4th grade

– Lower reading levels necessitate more help from staff

• Competency with computer mouse

– Less competency can increase frustration levels, and eliminate the ability to use certain exercises

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Role of Cognitive Specialist :

The following attributes of the cognitive specialist are instrumental to participant success in program:

1-Interpersonal warmth and empathy

2- High energy and enthusiasm

3- Optimistic and hopeful

4- Ability to notice and reinforce small improvements (i.e., Take a “Shaping” approach to rehabilitation)

5- Task and goal oriented56

• Learning-based behavioural skills designed to enhance neuro and/ or social cognitive skills,

• Based on drills & strategies

• Ultimate goal: generalization to improve psychosocial outcomes

• Innovations:– Incorporate new generation of computerized cognitive training, – Integrate CR with skills training,– Apply techniques to enhance motivation and learning during

CR (Saperstein & Kurtz 2013)

Cognitive Remediation:

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• Associated with medium effect sizes for cognitive and functional outcomes

• Better if – Integrated with psychosocial rehabilitation programs– Incorporate strategy teaching, methods to address beliefs

and motivation (Medalia & Saperstein 2013)

• Positive treatment response: attention, motivation and clinician expertise, along with 'brain reserve’

• CR is accompanied by structural and functional neural changes in key frontal and temporal brain regions.

Kurtz 201258

Computer-assisted cognitive remediation

• Virtual Reality environment

• Developed via the NeuroVr2.0 software

• For shifting, sustained attention and action planningfunctions

(La Paglia, 2013)

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Social Cognition TrainingFocus on domains of :

• Facial affect• Emotion recognition • Theory of mind (ToM)• Attributional bias

• ToM is amenable to change but not emotion recognition and attributional bias.

(Henderson 2013)60

Physical Exercise/Activity

• Improvements in 

– Physical– Subjective– Disorder-specific clinical outcomes

(Zschuke, Gaudlitz, Strohle 2013)

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Cognitive Impairment & Yoga

Adjunctive cognitive remediation for schizophreniausing yoga

An open, non-randomized trial:

• significant improvement in cognitive function after 3 weeks of training

(Bhatia, Agarwal, et al 2012)

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Psychosocial Rehabilitation Programmes

• Cognitive adaptation training (Velligan and Bow-Thomas, 2000)

• Errorless learning, workbook for memory Skills (Kennedy, 1996)

• Goal management training (Robertson et al., 2005)

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People with compromised cognitive functioning

• Learn more slowly and benefit less from psychiatric rehabilitation

Improved cognitive functioning produced by cognitive remediation

• may benefit the capacity to learn new skills• result in increased benefit from psychiatric

rehabilitation programs64

SUMMARY

Cognitive deficits in schizophrenia are

Pervasive, Persistent, Present early, Progress early, Predict functional disability

Mainly three domains:

Neurocognition; Social cognition; Metacognition

Maximal impairment in memory, attention, and executive function

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Relative preservation of old learning and visual perceptual skills

No U.S. Food and Drug Administration (FDA) approved treatments

CBT; CET; CR have shown to improve cognition to some extent

Better outcome if CBT; CET; CR are integrated with psychosocial rehabilitation programs

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Thank You

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