Dysexecutive syndrome and social adjustment in schizophrenia

OBJECTIVE: This paper reports on a study designed to (i) assess levels of executive functions among patients suffering from schizophrenia; (ii) investigate associations between measures of executive functions and psychosocial adjustment; and (iii) examine the influence of psychopathology on the relationship between executive functions and psychosocial adjustment. Clear knowledge of executive functions and of their impact on social adjustment in patients with schizophrenia may play a decisive role in preparing and structuring appropriate outpatient care. METHOD: An extensive battery constituted of several tests developed for the assessment of executive functions was used in 38 inpatients with a DSM-IV diagnosis of schizophrenia. Psychosocial adjustment was assessed with a set of commonly used scales. RESULTS: Performance on measures of executive functions was heterogeneous among the patient population, with a subgroup performing within normal scores. A similar pattern was found on measures of psychosocial adjustment. Most of the executive measures were not dependent on demographic or clinical variables. A factorial analysis on measures of psychosocial adjustment yielded a one-factor model which showed inconsistent, and at most, weak to moderate correlations with executive functions. Regression analysis revealed that symptom levels accounted for two-thirds of the variance of psychosocial adjustment, and together with measures of executive functions for 91% of the variance. General and negative symptoms showed strong correlations with psychosocial adjustment. CONCLUSIONS: Our study supports the view that executive function is a heterogeneous construct with several subdimensions. Additionally, it suggests that symptom level has an important role as "rate limiting factor" on psychosocial adjustment and is partially mediated by executive dysfunction. Our results call for careful and detailed assessment in this patient population in order to establish appropriate treatment programmes such as cognitive remediation.     

Premorbid adjustment and neuropsychological performance in schizophrenia

To examine the relationship between premorbid adjustment and neuropsychological deficit in schizophrenia, this report examined retrospective ratings of social and school adjustment during three age epochs (childhood, early adolescence, and late adolescence) as predictors of neurocognitive performance in 61 clinically and pharmacologically stabilized schizophrenia outpatients. Results indicated greater cognitive deficits when premorbid adjustment was unfavorable, particularly for measures of attention and executive functions. Premorbid number and quality of peer relationships and psychosocial adaptation to the school environment were more closely related to neuropsychological performance during adulthood than were premorbid withdrawal and premorbid academic performance. Early onset of poor premorbid adjustment rather than deterioration from childhood to adolescence was associated with greater neuropsychological disturbance in adulthood. It is suggested that childhood onset of premorbid deficits in selective areas of social and academic adjustment appears to influence the cognitive performance seen in adult schizophrenia. This study is consistent with findings from other related reports; it extends these findings to a larger and clinically stabilized sample.     

Parenting and adolescent adjustment: the role of parental reflective function

Reflective function (RF) is the capacity to reflect on one's own mental experiences and those of others. This study examined the relationship between parental RF and adolescent adjustment. One hundred and five adolescents, aged 14-18, and their mothers and fathers were interviewed and completed questionnaires during home visits. We measured parental RF, aspects of parenting behavior, and adolescent outcomes. We found that parental RF correlated with adolescent RF and social competence. Unexpectedly, it also correlated with internalizing problems and less positive self-perception. In addition, parental RF, particularly paternal RF, interacted with aspects of parenting behavior. In the presence of higher levels of parental RF, these behavioral aspects were associated with more positive adolescent outcomes. We conclude that (a) parental RF is associated with both desirable outcomes and possible costs and (b) parental RF, particularly paternal RF, is a significant moderator of the associations between parenting behaviors and adolescent outcomes.     

Insight in relation to psychosocial adjustment in schizophrenia

Insight impairment occurs commonly in patients with schizophrenia, and it can be expected that patients with impaired insight may subsequently have poorer psychosocial adjustment. The aim of the present study was to measure the relationship between insight and psychosocial adjustment in 38 inpatients with a diagnosis of DSM-IV schizophrenia. Insight was assessed using the Scale to Assess Unawareness of Mental Disorder. A comprehensive set of measures was used to assess psychosocial adjustment. No relationship was found between measures of psychosocial adjustment and insight. However, a self-rated measure of psychosocial adjustment was partially related to insight. Our results suggest that patients' insight levels may not be reliable predictors of the patients' level of psychosocial adjustment, and that these findings may need to be considered in continuous care of psychotic patients, in particular when outpatient care needs to be planned.     

Parenting and schizophrenia: an Australian study of expressed emotion

Parents of 66 schizophrenic Sydney patients were interviewed using the abbreviated Camberwell Family Interview (CFI). Using pre-established criteria, 71% of the mothers, 58% of the fathers and 74% of the households were categorised as being of high expressed emotion (EE) status. Comparison is made with published data on the CFI and on EE categorisation for similar groups studied in England, the United States and India. The Sydney families were described as 'vocal, ambitious and aggressive', and EE scale scores more resembled the Los Angeles families than the British families originally studied. A number of factors influencing high EE categorisation (e.g., family intactness, socio-demographic variables) are noted.     

Premorbid adjustment in bipolar disorder: comparison with schizophrenia

Knowledge that poor premorbid adjustment (PMA) precedes illness onset in many schizophrenia cases can facilitate early detection. Increasing consideration is being given to a similar early detection strategy for bipolar disorder (BPD). Results of this preliminary investigation comparing PMA in BPD (N = 53) and schizophrenia (N = 39) outpatients revealed a significant difference at the late adolescent (F[1,58] = 4.499, p = 0.038) stage only, with specific differences in two areas of PMA: adaptation to school (t [58] = 1.83, p = 0.036) and social sexual functioning (t [58] = 2.441, p = 0.009). However, mood state may affect some PMA ratings in BPD. Depression ratings were not correlated with reported late adolescent PMA, but a significant, positive correlation was found for the childhood stage (r = 0.32, p = 0.02). Findings fail to support a trend similar to schizophrenia of deteriorating PMA in BPD; however, the approach to investigations of PMA in BPD may need to be reconsidered.     

Social adjustment in schizophrenia: factors predictive of short-term social adjustment in a sample of schizophrenic patients

A sample of 60 Spanish schizophrenic patients was studied in order to ascertain the relationship between their relatives' expressed emotion (EE) and social adjustment after 2 years of follow-up. The average extent of the disability did not increase over time, and differences in dysfunction rates between the various specific social roles were identified. No differences in social outcome were detected between patients with high EE and low EE families. Three factors which predict social adjustment outcome were obtained using logistic regression analysis, namely clinical conditions, baseline social adjustment and the occurrence of a psychotic relapse during the follow-up period.     

A deficit in the adjustment of grip force responses in schizophrenia

Delusions of control in schizophrenia may be due to a deficit in the generation of an efference copy, used to distinguish between self generated and externally imposed changes in the environment. This hypothesis was tested using a framework that differentiated automatic and controlled levels of motor behavior. Subjects resisted collisions that were either self or externally imposed. The grip to load force correlation (response accuracy) and the overall grip force level used (response efficiency) were measured. Controls improved both accuracy and efficiency of their grip force responses in self compared to externally imposed collisions. Patients improved accuracy but not efficiency of motor response. There was no difference between patients with and without delusions of control. These results refute the hypothesis of a perturbed efference copy in patients with delusions of control. We rather propose that schizophrenia globally preserves the automatic level but affects the controlled, more voluntary level of motor behavior.     

Confirmation of a two-factor model of premorbid adjustment in males with schizophrenia

Because schizophrenia is considered to be a neurodevelopmental disorder, premorbid adjustment is of particular interest. Premorbid adjustment is probably not a unitary construct but rather is expressed across a number of developmental domains. The current investigation examined the validity of a two-factor model that differentiated premorbid adjustment across social and academic domains and evaluated relationships between these premorbid adjustment domains and other variables of interest. Participants with schizophrenia (n = 141) underwent evaluation of premorbid adjustment (using the Premorbid Adjustment Scale), intellectual functioning, and psychiatric symptoms. Using confirmatory factor analysis, a two-factor model of premorbid adjustment was identified that included an academic domain and a social domain. The social domain was associated with symptom variables, while the academic domain was associated with measures of intelligence. Results provide evidence for at least two domains of premorbid adjustment in schizophrenia. Distinguishing between these two premorbid domains may be theoretically important because of potential differences in incidence rates and deterioration courses; some individuals with schizophrenia may exhibit adequate academic adjustment but poor social adjustment, while others may exhibit the opposite pattern.     

The role of premorbid adjustment in schizophrenia: Focus on cognitive remediation outcome

ABSTRACT

Premorbid adjustment has been associated with several outcomes in schizophrenia and has been proposed as an index of cognitive reserve. This study aims to comprehensively analyse the relation between premorbid adjustment and clinical, neurocognitive, socio-cognitive and functional assessments, as well as to investigate the effect of premorbid adjustment on cognitive improvements after a cognitive remediation therapy protocol. Seventy-nine clinically stabilised outpatients with schizophrenia underwent a combined intervention consisting of cognitive remediation therapy added to standard rehabilitation therapy. All patients were assessed at baseline for psychopathology, premorbid adjustment, intellectual level, cognition and functioning. Cognitive evaluations were also repeated after the intervention. At baseline, significant correlations were observed between premorbid adjustment and working memory. The global cognitive improvement after treatment was significantly predicted by age and premorbid adjustment. This study confirms the association between premorbid adjustment and cognitive impairment and is the first to highlight the possible role of premorbid adjustment on the capacity to recover from cognitive deficits through a cognitive remediation therapy protocol. The data suggest that cognitive remediation may be particularly effective for people in the early course and that the assessment of premorbid adjustment could be of value to design individualised interventions.     

Social competence in schizophrenia: premorbid adjustment, social skill, and domains of functioning

The relations between premorbid adjustment, social skill, and domains of functioning (symptoms, social adjustment) were examined in a group of 107 schizophrenic, schizoaffective, and affective disorder patients. Premorbid sexual adjustment was moderately correlated with social skill in the schizophrenic and schizoaffective patients. Schizophrenic patients had the lowest premorbid adjustment and social skill, followed by schizoaffectives, and then affective patients. Within the schizophrenic group, social skill was significantly related to both current social adjustment and negative symptoms, but not positive symptoms. Similar but weaker effects were found for premorbid adjustment. The results suggest that deficits in social skill are correlated with poor premorbid and morbid social adjustment of schizophrenics.     

Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study

Bailer J, Bräuer W, Rey E-R. Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study. Acta Psychiatr Scand 1996: 93: 368–377. © Munksgaard 1996. The present prospective follow-up study of 163 schizophrenic patients admitted to hospital for the first time examined the relationship between premorbid adjustment and different measures of the 3-year course and outcome. The same instruments had been used in all phases of the study. The Premorbid Adjustment Scale was used to assess premorbid social functioning. Outcome measures were positive symptoms, negative symptoms, social disability and number of rehospitalizations. The results of the multiple regression analyses showed that premorbid adjustment was the strongest overall predictor of outcome. Premorbid adjustment was significantly associated with negative symptoms and social disability over the 3-year course of illness. In a further step, we examined the relationship between good, moderate and poor premorbid adjustment and the course of positive symptoms, negative symptoms and social disability within the first 3 years after index admission. The most important finding was that premorbid functioning showed a stronger correlation with the course of negative symptoms and social disability than with the course of positive symptoms. Poor premorbid social functioning implies a poor social course of the illness. Female subjects showed better premorbid functioning than male subjects. Good premorbid adjustment was strongly associated with an acute onset of the illness, and poor premorbid adjustment with an insidious onset.     

Premorbid adjustment in first episode schizophrenia and schizoaffective disorders: a comparison of social and academic domains

OBJECTIVE: Recent evidence suggests that premorbid adjustment in schizophrenia and related disorders can be separated into social and academic domains. In this paper, we examine the correlates of and prognostic significance of social and academic premorbid adjustment in a sample of 113 patients. METHOD: Premorbid adjustment, symptoms and cognitive functioning were assessed at presentation for treatment and symptoms were re-assessed after a year of treatment. RESULTS: Females and those with a diagnosis of schizoaffective disorder were found to have better premorbid adjustment in the academic domain, but not in the social domain. Neurocognitive functioning was more consistently related to academic than social adjustment. Better social and academic premorbid adjustment was correlated with lower negative symptoms after 1 year of treatment, but neither was a significant predictor of positive symptoms. CONCLUSION: Social and academic premorbid adjustments show different relations to gender, specific diagnosis and neurocognitive functioning in schizophrenia and related disorders.