Gender,premorbid characteristics and negative symptoms in schizophrenia

The interrelationships among gender, premorbid functioning, and negative symptoms were examined in a first-admission inpatient sample with DSM-III-R schizophrenia. Fifty-two subjects were assessed with the Schedule for the Assessment of Negative Symptoms (SANS) at baseline and 6-month follow-up. Three indicators of premorbid functioning were examined: the Premorbid Adjustment Scale, the Quick Test, and the GAF for the best month in the year prior to the baseline interview. Men and women had relatively similar ratings on each of the 5 SANS global subscales at both times; they were also relatively similar on most of the indicators of premorbid functioning. The men and women were categorized into low vs moderate-high negative symptom groups at baseline, and no differences in premorbid functioning were detected. When the sample was classified into those with and without consistent negative symptoms at baseline and 6-month follow-up, the enduring negative men and women had significantly poorer premorbid functioning in several areas than the consistently non-negative patients. Our findings support the importance of assessing negative symptoms longitudinally and suggest that gender is not strongly associated with negative symptoms and premorbid functioning in patients ascertained at early stages of schizophrenia.     

Accuracy of self-reported premorbid functioning in schizophrenia

BACKGROUND: Information on premorbid functioning is often based on patients recalling their past. Premorbid functioning is relevant as it is associated with treatment response and other outcomes. The extent to which memory impairments of persons with schizophrenia may bias such reporting has not been investigated. The purpose of the current study was to assess the extent to which persons with schizophrenia might exhibit biased reporting relative to controls. METHODS: Seventy males with schizophrenia or schizoaffective disorder and 51 males with no psychiatric symptoms participated in the study. Contemporaneous and retrospective reports from a behavioral functioning assessment conducted as part of the Israeli Draft Board were compared. This assessment routinely administered to all 17 years old males in the country assesses social functioning, individual autonomy, organizational ability, physical activity and functioning in structured environments. We compared the groups on the Draft Board behavioral measures at age 17 and at re-assessment. We also examined the relationship between symptom severity, neuropsychological performance and differences between age 17 and current behavioral assessment scores. RESULTS: In a repeated measures MANCOVA of the five measures there was no overall significant difference in accuracy of reporting between persons with schizophrenia and those without. Both groups showed a slight tendency to glorify their past. Consistency of reporting was not significantly correlated with neuropsychological performance or levels of psychotic symptoms. CONCLUSIONS: We found that when reporting on personal and social functioning during teen age years persons with schizophrenia report with the same level of consistency as persons without schizophrenia. This suggests that self-report of premorbid functioning of persons with schizophrenia can be trusted as being reasonably accurate.     

Cognitive functioning and positive and negative symptoms in schizophrenia

The present study examined schizophrenics' performance on a variety of cognitive measures in order to explore the relationship between schizophrenic symptoms and cognitive performance. The Wechsler Adult Intelligence Scale and a battery of neuropsychological tests, developed at the Montreal Neurological Institute, were administered to 38 acutely ill, hospitalized schizophrenics. Patients were diagnosed using DSM III criteria. Negative symptoms were assessed with the SANS and positive symptoms with the SAPS. Both the cognitive tests and the symptom rating scales were re-administered to this sample at a 6 month follow-up period. Analyses revealed that, at both time periods cognitive deficits were more likely to be associated with high negative symptom ratings than with positive symptoms. Only certain tests showed significant improvement at the follow-up period. Furthermore, improved cognitive functioning was related to an improvement in positive, but not negative, symptoms.     

Insight and negative symptoms as predictors of functioning in a work setting in patients with schizophrenia

The present study was conducted to explore correlates of vocational outcome for individuals with schizophrenia. Seventy-eight individuals with schizophrenia were recruited to take part in a supported employment program in which they were provided with approximately 6 months of part-time work through a VA hospital. Positive symptoms, negative symptoms, and level of insight into mental illness were assessed once every 4 weeks, in addition to a work performance evaluation with participants' supervisors. Hierarchical longitudinal regression analysis revealed that negative symptom severity and impaired insight were significantly associated with poor work performance, and this relationship persisted over time. By contrast, positive symptom severity was not significantly associated with work performance. These results indicate that insight and negative symptoms, which can fluctuate over time, may be driving fluctuations in work performance and may therefore be a valuable target for future interventions.     

Cognitive functioning and negative symptoms in first episode schizophrenia: Different patterns of correlates

Negative symptoms of schizophrenia have been related to disturbances of executive functions, memory, attention and motor functioning. The executive functions dimension comprises a variety of cognitive subprocesses, including speed of processing, flexibility and working memory. We independently analysed the relationship between different cognitive tasks and clinical symptoms (negative, positive and disorganized) in a sample of 126 first-episode patients with schizophrenia spectrum disorders. Negative symptoms were significantly associated with performance on executive-functions and motor coordination tasks. Within the executive functions domain only those tests that required speeded performance showed a significant association with the negative dimension. The widely described relationship between negative symptoms and executive impairments in schizophrenia appears to be mediated by likely dysfunctions in the speed of processing instead of by working memory impairment.     

The negative symptoms of schizophrenia: a cognitive perspective.

Recent reports of improvement in the negative symptoms of schizophrenia following targeted cognitive interventions have prompted interest in the cognitive underpinnings of these symptoms. This review integrates current experimental research with the phenomenological accounts of patients participating in cognitive therapy for these specific symptoms. We propose that, in addition to the well-established role of neurobiological factors in their development and maintenance, specific cognitive appraisals and beliefs play a role in the expression and persistence of negative symptoms. This cognitive model of negative symptoms is based on a diathesis-stress formulation: a continuum of predispositional traits from the premorbid personality to the full-blown negative symptomatology, the incorporation of negative social and performance attitudes within these traits, and low expectancies for pleasure or success in goal-oriented activities. We suggest that negative symptoms represent, in part, a compensatory pattern of disengagement in response to threatening delusional beliefs, perceived social threat, and anticipated failure in tasks and social activities. A psychological aspect of this motivational and behavioural inertia appears to be the patient's perception of limited psychological resources--a perception that motivates patients to conserve energy by minimizing investment in activities requiring effort.     

Metacognition,symptoms and premorbid functioning in a First Episode Psychosis sample

Significant metacognitive impairments are observed in chronic psychosis samples but metacognition is less understood in first episode psychosis (FEP). The current study explored correlations between metacognition, symptoms and premorbid functioning in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology, premorbid adjustment, and clinician rated service engagement were also measured. Lower scores for metacognitive understanding of other's minds were significantly correlated with greater negative symptoms, poorer early adolescent social adjustment and poorer clinician rated help-seeking. Our findings suggest that FEP individuals with difficulties in understanding other's minds have more social deficits and may be less able to make effective use of treatment.     

Nonresponse to clozapine and premorbid functioning in treatment refractory schizophrenia

Introduction

It is recognized that early treatment can improve outcomes and generally improve recovery potential for those with schizophrenia. Data suggest that poor premorbid functioning has been found to be related to more severe symptoms and poor antipsychotic response; however, little is known about premorbid functioning in patients who have no response to clozapine treatment.

Methods

This study compares the premorbid functioning among patients who responded to clozapine treatment (20% decrease in total Brief Psychiatric Rating Scale [BPRS] score; n = 35) and those who did not respond (n = 50) to 8 weeks of clozapine treatment. Premorbid functioning was assessed using the Cannon-Spoor Premorbid Adjustment Scale.

Results

Patients who did not respond to clozapine had significantly lower total BPRS scores (P = .01) at baseline, driven primarily by lower ratings in hostility (P = .007) and activation (P = .02), compared with those who responded to clozapine. Responders and nonresponders did not differ in their age, race, level of education, marital status, age of onset, characterization of the deficit syndrome, and positive or negative symptoms. Nonresponders to clozapine did not improve in any area of symptoms or global functioning, whereas there were significant improvements in BPRS total scores (analysis of covariance) and all symptom domains in the responder groups (P < .0001). Level of functioning scores in those who responded to clozapine was significantly higher at end point (P = .02). As for premorbid functioning, there were no differences in scores between responders and nonresponders at the time of early and late adolescence; however, there was a trend toward lower premorbid functioning in the clozapine nonresponders on most childhood measures (before the age of 11 years). Clozapine nonresponders tended to be less social and more withdrawn as compared with those who responded to clozapine (P = .08), as well as tended to have poorer adaptation to school (P = .06) and fewer peer relationships (P = .08). These results did not reach significance. Work and/or school performance changed more insidiously in the nonresponders group before illness onset (P = .045).

Discussion

Clozapine is beneficial to many patients with treatment-resistant symptoms; however, nonresponse to this medication may represent a subtype of patients who may present differently with symptoms. These findings should encourage further examination of early childhood indicators and opportunities for appropriate and effective intervention.     

Low birth weight and a family history of schizophrenia predict poor premorbid functioning in psychosis.

Risk factors thought to predispose to schizophrenia, and premorbid functioning, were assessed blind to diagnosis by interviewing the mothers of 73 patients with DSM-III schizophrenia or affective psychosis. Higher risk of schizophrenia in relatives, lower mean birth weight, a more frequent history of obstetric complications, and poorer educational achievement distinguished the patients with schizophrenia from those with affective psychosis. Low birth weight and obstetric complications each predicted childhood schizoid and schizotypal traits. Poor social adjustment between ages 5 and 11 was predicted by low birthweight and by a family history of schizophrenia.     

Validity and stability of performance-based estimates of premorbid educational functioning in older patients with schizophrenia

This paper presents the results of two studies of the validity of word-recognition reading as an indicator of premorbid functioning in schizophrenia. The first examined the stability over a 6-year follow-up period of word recognition reading compared to other aspects of cognitive functioning, including verbal learning and delayed recall, verbal fluency, constructional skills, and naming ability. The second study examined the relative predictive power of indicators of premorbid functioning as compared to current cognitive functioning for the prediction of current social and self-care skills. In the first study 218 patients with chronic schizophrenia participated. For the second study, 231 male veterans with schizophrenia were assessed for cognitive functioning, indicators of premorbid adjustment, and current functional status. Analyses of the differences between correlations indicated that word recognition reading ability was significantly more stable than other aspects of cognitive functioning over a six-year period during which decline in some other aspects of performance was found. In the second study, premorbid educational and social attainment, word recognition reading skill, and current cognitive functioning were all significantly related to current functional status, defined by correlations with ratings of current functional status. Path analyses indicated, however, that current cognitive functioning was the only significant predictor of current functional status when the intercorrelations of the variables were considered. In sum, Premorbid functioning estimated with word-recognition reading was stable over time (study 1) and correlated with both current cognitive and functional status (study 2). The results of these two studies suggest that word-recognition reading skills are useful screening instruments to estimate premorbid functioning even in deteriorated patients with schizophrenia.     

Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia

Poor social and vocational outcomes have long been observed in schizophrenia. Two of the most consistent predictors are negative symptoms and cognitive impairment. We investigate the hypothesis that cognitive content--defeatist beliefs regarding performance--provides a link between cognitive impairment, negative symptoms, and poor functioning in schizophrenia. A total of 77 individuals (55 patients diagnosed with schizophrenia or schizoaffective disorder and 22 healthy controls) participated in a cross-sectional study of psychopathology. Tests of memory, abstraction, attention, and processing speed, as well as current psychopathology, functioning, and endorsement of defeatist beliefs, were employed. Greater neurocognitive impairment was associated with elevated defeatist belief endorsement, higher negative symptom levels, and worse social and vocational functioning. Notably, statistical modeling indicated that defeatist belief endorsements were mediators in the relationship between cognitive impairment and both negative symptoms and functioning. These effects were independent of depression and positive symptom levels. The results add to the emerging biopsychosocial understanding of negative symptoms and introduce defeatist beliefs as a new psychotherapeutic target.     

Increased developmental deviance and premorbid dysfunction in early onset schizophrenia

Abnormal neurodevelopment and poor premorbid function have been described in schizophrenia. It is unclear whether abnormalities in these domains are increased in patients with early onset schizophrenia (EOS; onset before the 18th birthday) and whether they act to precipitate the earlier onset of the disorder. To address these questions, we collected information based on maternal interviews about the premorbid function of 40 adolescents with recent onset schizophrenia and an equal number of healthy controls using the Developmental Scale Score, the Premorbid Schizoid and Schizotypal Trait Scale (PSST) and Premorbid Adjustment Scale (PAS). Data on the PSST and PAS were also available in 54 patients with adult onset schizophrenia (AOS; onset after the 20th birthday). Compared to healthy controls, EOS patients had (a). delayed speech milestones, difficulties in reading and spelling and greater overall developmental deviance; (b). poor premorbid adjustment in childhood, which became even more deviant in adolescence particularly in boys and (c). more schizophrenia spectrum traits. Both premorbid adjustment and personality traits were more abnormal in patients with increased developmental deviance suggesting the possibility that they represent different manifestations of ongoing abnormalities in developmental processes. EOS patients had more impaired premorbid adjustment in adolescence and schizophrenia spectrum traits compared to AOS cases. Age of onset was related to developmental deviance, premorbid schizophrenia spectrum traits and childhood adjustment in EOS patients only.     

Clinical evaluation of negative symptoms in schizophrenia.

The florid positive symptoms of schizophrenia (hallucinations, delusions, grossly disordered thinking) are often obvious. By comparison, negative symptoms (flattened affect, impoverished speech, apathy, avolition, anhedonia) are subtler and more difficult to recognize and diagnose. However, there is increasing recognition of the importance of negative symptoms in patients with schizophrenia. Secondary negative symptoms attributable to such factors as unrelieved positive symptoms, the adverse effects of antipsychotic pharmacotherapy, or social isolation may subside with resolution of such factors. In contrast, primary negative symptoms are an intrinsic aspect of schizophrenia; they are persistent and have been associated with poorer clinical outcomes. Although the lack of a reliably effective treatment for negative symptoms is a serious unmet need in this patient population, accurate diagnosis is still important. Assessment of suspected negative symptoms, using validated rating scales, can help to rule out comorbid affective or cognitive disorders that may mimic negative symptoms and to distinguish primary negative symptoms from potentially reversible secondary negative symptoms. This article reviews the definitions and classification of negative symptoms, compares the tools available for their assessment, and offers practical clinical algorithms for sorting through the differential diagnosis.     

Lower corneal temperature in neuroleptic-treated vs. drug-free schizophrenia patients

Antipsychotic drugs (APDs) can decrease core body temperature in schizophrenia patients. Core temperature may correlate with corneal temperature and thus, we hypothesized that neuroleptic-treated schizophrenia patients would display lower corneal temperature compared with drug-free patients. Corneal temperature of 12 typical APD-treated and 9 drug-free male schizophrenia patients was assessed using a FLIR thermal imaging camera. The APD-treated patients exhibited substantially and significantly lower corneal temperature compared with the drug-free patients (31.57 +/- 0.98 degrees C vs. 34.55 +/- 1.65 degrees C; p < 0.0001). Our results suggest that APDs may decrease corneal/core temperature in schizophrenia patients. The relevance of this finding to the pathophysiology of schizophrenia or to the antipsychotic effect of neuroleptics merit further investigation.     

Premorbid functioning, cognitive functioning, symptoms and outcome in schizophrenia.

In this study we examined the relationship between premorbid functioning, outcome, cognitive functioning and positive and negative symptoms of schizophrenia. Cognitive functioning and symptoms were examined longitudinally in a sample of 39 subjects with schizophrenia (according to the DSM-III criteria). Subjects were assessed at admission to hospital and six months later during a period of relative remission. Premorbid functioning was significantly associated with negative symptoms but not with positive symptoms at both the acute phase and the remitted phase of the illness. Outcome was also associated with negative symptoms at admission and with both positive and negative symptoms at follow-up. Deficits on cognitive tests of verbal reasoning and concept formation were significantly associated with poor premorbid functioning and outcome.     

Early treatment-induced improvement of negative symptoms predicts cognitive functioning in treatment-naive first episode schizophrenia: a 2-year followup

Studying neuroleptic-naive first episode schizophrenia is a strategy for investigating clinical and neuropsychological abnormalities at a very early phase of the disease without confounding influences of illness duration and medication effects. We examined the clinical and neuropsychological time course over 2 years in 32 neuroleptic-naive first episode patients (20 males, 12 females) and 21 healthy individuals with similar sociodemographic characteristics. Early treatment-induced reduction of negative symptoms predicted superior cognitive performance throughout followup in the domains of verbal fluency, attention, and non-verbal learning and memory. There were no associations between psychotic or disorganized symptoms and cognitive variables. These findings suggest an important relationship between treatment efficacy of antipsychotic medication and the longer term course of cognitive deficits in schizophrenia.