Self-assessed cognitive dysfunction and objective performance in outpatients with schizophrenia participating in a rehabilitation program

OBJECTIVE: To explore the pattern of associations between self-assessed and objective neuropsychological performance in a sample of outpatients with schizophrenia participating in a rehabilitation program. METHOD: The Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS) [Compr. Psychiatry 44 (2003) 331] was used to assess cognitive complaints in 73 subjects with schizophrenia. Visuo-spatial tests of the Cambridge Neuropsychological Test Automated Battery (CANTAB) [Cogn. Neuropsychiatry 3 (1998) 45] were administered as objective measures. RESULTS: Cognitive complaints in several cognitive domains were mainly correlated with a true difficulty in memory. Higher SSTICS attention scores, i.e. increased complaints, were associated with poorer CANTAB explicit visual memory and planning performances. Higher SSTICS executive functioning scores were associated with poorer CANTAB explicit visual memory scores. CONCLUSION: These findings suggest that outpatients with schizophrenia express some cognitive difficulties. However, the cognitive nature of these subjective complaints does not strictly correspond with objective performances. These results also suggest that theoretical constructs of cognitive functions do not always have ecological validity. Thus, subjective cognitive complaints should be taken into account in assessment of patient well-being, but cannot be used as a substitute to objective cognitive measures. The simultaneous use of subjective and objective measures of cognitive dysfunction may provide a more complete picture of individual rehabilitation targets in patients with schizophrenia.     

Cognitive predictors of psychosocial functioning outcome in schizophrenia: a follow-up study of subjects participating in a rehabilitation program

The aims of this prospective study were to explore in subjects with psychosis participating in a rehabilitation program whether cognitive performances at baseline predicted (i) psychosocial functioning over a 15-16 month follow-up; (ii) improvement in psychosocial functioning over the rehabilitation program. Visuo-spatial tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were administered to assess cognitive performance in 55 subjects with schizophrenia spectrum disorders who completed a rehabilitation program. The Multnomah Community Ability Scale (MCAS) was used to measure dimensions of community functioning. One subscale of the Client's Assessment of Strengths, Interests, and Goals (CASIG) provided a measure of subjective quality of life (QoL). Improvement was defined as a 15% or more increase in psychosocial scores between baseline and follow-up. Worse baseline sustained attention predicted better self-rated quality of life, and better baseline visual memory predicted better community functioning over the rehabilitation follow-up period, in particular, higher autonomy in activities of daily living, and less physical and psychiatric symptoms that could interfere with rehabilitation. Baseline cognitive performances predicted community functioning improvement during the follow-up period: visual memory predicted improvement in daily living autonomy and in social competence; sustained attention predicted improvement in behavioral problems (such as medication compliance, collaboration with treatment providers or impulse control) and social competence; planning performances predicted improvement in social competence. These cognitive functions could be specifically targeted in a rehabilitation program aimed at enhancing functioning in those particular dimensions.     

Computer-assisted cognitive rehabilitation reduces negative symptoms in the severely mentally ill

Thirty-four-day treatment program clients diagnosed with schizophrenia or schizoaffective disorder were randomly assigned to a computer-assisted cognitive rehabilitation (CACR) group or a wait-list Control group. CACR clients received 16 CACR sessions over an 8-week period. Measures of cognitive functioning, negative symptoms and self-esteem were administered at the beginning and end of this period. CACR clients showed greater improvement in cognitive functioning (verbal memory and attention) and negative symptoms. Symptom reduction was not mediated by raised self-esteem. CACR's effects may go beyond cognitive remediation to include some of the most disabling and refractory clinical features of schizophrenia.     

Rehabilitation of the central executive component of working memory: a re-organisation approach applied to a single case

This paper describes and evaluates a programme of neuropsychological rehabilitation which aims to improve three sub-components of the working memory central executive: processing load, updating and dual-task monitoring, by the acquisition of three re-organisation strategies (double coding, serial processing and speed reduction). Our programme has two stages: cognitive rehabilitation (graduated exercises subdivided into three sub-programmes each corresponding to a sub-component) which enables the patient to acquire the three specific strategies; and an ecological rehabilitation, including analyses of scenarios and simulations of real-life situations, which aims to transfer the strategies learned to everyday life. The programme also includes information meetings. It was applied to a single case who had working memory deficits after a surgical operation for a cerebral tumour on his left internal temporal ganglioglioma. Multiple baseline tests were used to measure the effectiveness of the rehabilitation. The programme proved to be effective for all three working memory components; a generalisation of its effects to everyday life was observed, and the effects were undiminished three months later.     

Rehabilitation of the central executive component of working memory: A re-organisation approach applied to a single case

This paper describes and evaluates a programme of neuropsychological rehabilitation which aims to improve three sub-components of the working memory central executive: processing load, updating and dual-task monitoring, by the acquisition of three re-organisation strategies (double coding, serial processing and speed reduction). Our programme has two stages: cognitive rehabilitation (graduated exercises subdivided into three sub-programmes each corresponding to a sub-component) which enables the patient to acquire the three specific strategies; and an ecological rehabilitation, including analyses of scenarios and simulations of real-life situations, which aims to transfer the strategies learned to everyday life. The programme also includes information meetings. It was applied to a single case who had working memory deficits after a surgical operation for a cerebral tumour on his left internal temporal ganglioglioma. Multiple baseline tests were used to measure the effectiveness of the rehabilitation. The programme proved to be effective for all three working memory components; a generalisation of its effects to everyday life was observed, and the effects were undiminished three months later.     

Quality of life of schizophrenic patients living in the community: the relationships with personal characteristics, objective indicators and self-esteem

The relationship of personal characteristics, objective indicators, and self-esteem to quality of life (QOL) was investigated cross-sectionally in 73 Japanese schizophrenic patients, and the question of how objective conditions affect subjective evaluation was evaluated. Depressive mood and uncooperativeness were negatively correlated with self-esteem, and self-esteem was positively correlated with QOL. Self-esteem was considered to directly affect QOL, and depressive mood and uncooperativeness to affect QOL via self-esteem. Findings suggest that, in order to improve the QOL of schizophrenia patients, interventions to help alleviate psychiatric symptoms (e.g. depressive mood, uncooperativeness) must be utilized. A change in Japanese society itself must occur so that the consequences of stigma may be reduced and patient coping skills improved.     

The link between depressive symptoms, negative cognitive bias and memory complaints in older adults

OBJECTIVES: We sought to examine the relationship between depressive symptoms and subjective memory problems. We hypothesized that the relationship between depressive symptoms and poor subjective memory functioning is mediated by negative cognitive bias that is associated with hopelessness, a wish to die and low self-esteem. METHODS: Complete data were available for 299 older adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate, completed a baseline in-home assessment. Subjective memory functioning and psychological status was assessed with commonly used, validated standard questionnaires. RESULTS: In regression models that included terms for age, gender and cognitive measures, depressive symptoms were significantly inversely associated with the global self-assessment of memory (beta=-0.019; p=0.006). When components of negative cognitive bias were included in the model (hopelessness, low self-esteem, a wish to die), the relationship of depressive symptoms with subjective memory problems was attenuated, consistent with mediation. CONCLUSIONS: Our results suggest that assessment and successful interventions for memory complaints in non-demented older adults need to account for negative cognitive bias as well as depressive symptoms. Longitudinal research is needed to confirm our findings before a mediator relationship can be presumed.     

The role of subjective cognitive complaints and depressive symptoms in social re-integration following stroke: a mediation explanation in a cross-sectional sample

Background: For long-term stroke survivors, objective neuropsychological impairments and subjective cognitive difficulties are common, and may contribute to ongoing difficulties in community reintegration. However, subjective cognitive complaints have been as much associated with low mood as with actual cognitive performance.

Objective: The objective of our study was to investigate the extent to which subjective cognitive complaints predicted community reintegration following a stroke, and whether this relationship would be mediated by emotional status.

Methods: Using a cross-sectional design, patients with a primary diagnosis of stroke (n = 102; age range 25–89 years) were recruited from the register of a neurological rehabilitation service if they were at least 6 months post-stroke and had been discharged home following the stroke. Exclusions included history of dementia, co-morbid psychiatric or neurological disorder, or significant aphasia. Assessments included the Subjective Cognitive Complaints Questionnaire, the Community Integration Questionnaire, and the Depression Anxiety and Stress Scale.

Results: Subjective cognitive complaints were common, with moderate to high levels of complaint most frequent for working memory (58.9%), and information processing speed (53%). Subjective cognitive complaints were significantly associated with social integration (r = ?.23, p < .05). However, examination of relationships using statistical mediation revealed that depressive symptoms fully mediated the relationship between subjective cognitive complaints and social integration.

Conclusions: Subjective cognitive complaints are common in long-term outcome following stroke and predict difficulty in community reintegration. However, this relationship is mediated by variation in emotional status. Therefore, addressing cognitive complaints through cognitive rehabilitation programs that include components to improve mood (for example, building self-efficacy or confidence) may also improve community reintegration post-stroke.     

Subjective memory complaints in an elderly sample: a cross-sectional study

BACKGROUND: Community based studies show that neurological or psychiatric symptoms are very frequent among the elderly population, with poor memory complaints being the most common. However, the relationship between poor memory complaints and objective memory performance is unclear. We designed this study to evaluate whether subjective memory complaints (SMC) are associated with objective cognitive performance or depression amongst the elderly Brazilian generation. METHODS: A cross-sectional study was carried out in 114 patients who were 50+, with or without SMC having no obvious cognitive impairment at its baseline (this was screened by the Mini-Mental State Examination with cut-off values adapted according to the subjects' educational background). Subjects were assessed regarding memory difficulty complaints, demographic data and underwent a neuropsychological assessment made up of nine cognitive tests (Rey Auditory Verbal Learning Test, Visual Reproduction Test, Logic Memory--History A, Free and Cued Selective Reminding Test, Stroop Test, Digit Span, Digit Symbol, Trail Making Test, fluency tests: naming animals and fruits) and the Geriatric Depression Scale. RESULTS: Twenty-one percent of the subjects had subjective memory complaints. The scores in the cognitive assessment of subjects with SMC did not differ from the scores of subjects without SMC. However, patients with subjective memory complaints had lower scores in the fluency test--category animals and the Geriatric Depression Scale. CONCLUSIONS: These results support the finding from other cross-sectional studies showing that subjective memory complaints are associated with depressive symptoms rather than objective cognitive performance.     

Enhancement of executive functioning skills: an additional tier in the treatment of schizophrenia

Schizophrenia is viewed by most as having a neuropsychological component, with deficits primarily occurring in the areas of attention/concentration, memory, and executive functioning. These deficits often contribute to difficulties in everyday living and social functioning. The purpose of this study is to examine the efficacy of cognitive rehabilitation methods, typically utilized by brain-injured patients, to improve the executive functioning skills of patients with schizophrenia spectrum disorders. While this pilot study is limited in terms of sample size, results suggest that the addition of cognitive rehabilitation to the comprehensive treatment of schizophrenia could be beneficial in enhancing daily living skills.     

慢性精神分裂症综合康复治疗前后认知功能的比较研究

目的 探讨综合康复训练对于慢性精神分裂症患者认知功能的改善情况.方法 64例慢性精神分裂症患者劳动技能训练,生活技能训练、健康教育以及心理治疗等综合康复措施,与治疗前后分别采取简明精神症状量表(BPRS),住院精神病人康复疗效评定量表(IPROS)和威斯康星卡片分类测验(WCST)进行评定.结果 治疗6个月后,64例患者的BPRS、IPROS和WCST较治疗前有显著性改变(P＜0.01).WCST的分类数、正确数明显提高(P＜0.01);总错误数、持续错误数和随机错误数明显降低(P＜0.01).结论 综合康复训练能有效改善慢性精神分裂症患者的精神症状,提高患者的康复疗效,改善患者的认知功能.     

Is it possible to improve social functioning of schizophrenia with cognitive rehabilitation?]

Social dysfunction of schizophrenia is observed in many domains including social skills, ability to conduct tasks, attention/durability, volition/motivation, stability of social life, and insight of dysfunction. These dysfunctions have been found to relate to non-social cognitive functioning to some extent. Social skills may have a strong relationship with social cognition. The intervention technique of cognitive functioning of schizophrenia, known as cognitive rehabilitation or cognitive remediation, has its main target as non-social cognition. Cognitive behavior therapy focuses on the contents of the cognitive process, while cognitive rehabilitation focuses on the cognitive process (information process) or thinking skills. Which cognitive functioning should be targeted was revealed as were theoretical models of cognitive rehabilitation, and various intervention techniques and their usefulness. It has been found that some elements of cognitive functioning, such as executive functioning, could be improved in experimental settings in efficacy studies. However, comprehensive rehabilitation including cognitive rehabilitation should be used in order to relieve social dysfunctioning or psychiatric symptoms. Some experts insisted that an individualized program with several steps, along with cognitive abilities, is required to enhance usefulness and effectiveness. Other experts said more complex cognitive functioning profoundly associated with social life should be targeted, rather than elementary cognitive functioning. The conclusions of meta-analyses of randomized controlled trails were not consistent until now, because inclusion criteria of meta-analysis was different. Finally, it was discussed how the theory and techniques of cognitive rehabilitation should be implemented in traditional rehabilitation.     

Effects of tapering of long-term benzodiazepines on cognitive function in patients with schizophrenia receiving a second-generation antipsychotic

Background

The high use of long-term benzodiazepines (BZDs) with second-generation antipsychotics (SGAs) has been identified as an important issue in the treatment of schizophrenia in Japan. The aim of this study was to evaluate the effects of gradual reduction or discontinuation of daytime BZD use on cognitive function and quality of life (QOL) in patients with chronic schizophrenia receiving an SGA.

Methods

Thirty schizophrenic patients who had received an SGA with concomitant BZDs for at least 3 months were enrolled. Before and 4 weeks after tapering of daytime BZDs, the Brief Assessment of Cognition in Schizophrenia Japanese-language version (BACS-J) and the Schizophrenia Quality of Life Scale Japanese-language version (SQLS-J) were administered. Clinical evaluation also included the Positive and Negative Syndrome Scale (PANSS). To compare for practice effects on the BACS-J, 10 patients with chronic schizophrenia were assessed without tapering BZDs.

Results

BZDs were reduced or discontinued safely in most patients, and no emergent withdrawal symptoms were observed. Significant improvements were shown in verbal memory, working memory, and composite score, as measured by the BACS-J without practice effects. In addition, the motivation/energy score on the SQLS-J, the negative symptoms and total scores on the PANSS significantly improved after tapering BZDs.

Conclusion

Reduction or discontinuation of long-term daytime use of BZDs may be warranted in patients with schizophrenia treated with SGAs, as it may improve cognitive function, subjective QOL, and psychiatric symptoms with no significant adverse effects.     

Cognitive functioning and psychiatric symptomatology in patients with chronic hepatitis C.

Hepatitis C virus (HCV) infection is a major public-health-care problem, with over 170 million infected worldwide. Patients with chronic HCV infection often complain of various cognitive problems as well as symptoms of depression, anxiety, and fatigue. Relatively little is known, however, about the specific cognitive deficits that are common among HCV patients, and the influence of psychiatric symptomatology on cognitive functioning. In the current study of 21 chronically infected HCV patients, we assessed subjective cognitive dysfunction, depression, anxiety, and fatigue and compared these symptom areas to cognitive tests assessing visuoconstruction, learning, memory, visual attention, psychomotor speed, and mental flexibility. Results revealed that cognitive impairment ranged from 9% of patients on a visuoconstruction task to 38% of patients on a measure of complex attention, visual scanning and tracking, and psychomotor speed, and greater HCV disease severity as indicated by liver fibrosis was associated with greater cognitive dysfunction. Objective cognitive impairment was not related to subjective cognitive complaints or psychiatric symptomatology. These findings suggest that a significant portion of patients with chronic HCV experience cognitive difficulties that may interfere with activities of daily living and quality of life. Future research using cognitive measures with HCV-infected patients may assist researchers in identifying if there is a direct effect of HCV infection on the brain and which patients may be more likely to progress to cirrhosis and hepatic encephalopathy.     

Association of estrogen levels with neuropsychological performance in women with schizophrenia.

OBJECTIVE: This study sought to determine the relationship of estrogen levels with psychiatric symptoms and neuropsychological function in female patients with schizophrenia. METHOD: Psychiatric symptoms were assessed and average estrogen and progesterone levels from four consecutive weekly blood samples were measured in 22 female inpatients with schizophrenia who were also administered a neuropsychological battery. RESULTS: There were strong positive correlations between average estrogen level and cognitive function, especially measures of global cognitive function, verbal and spatial declarative memory, and perceptual-motor speed. Correlations of hormone levels with psychiatric symptoms were nonsignificant. CONCLUSIONS: Higher estrogen levels in female patients with schizophrenia are associated with better cognitive ability. These results may have implications for potential treatment of cognitive dysfunction with adjunctive estrogen in female patients with schizophrenia.     

Cognitive function in schizophrenia. Deficits, functional consequences, and future treatment.

This article has discussed the relationship between cognitive deficits and functional outcome in schizophrenia. This relationship was noted first by Kraepelin and Bleuler at the beginning of the twentieth century. With the introduction of conventional neuroleptics, the focus shifted toward the treatment of positive symptoms. In the past few decades, cognitive dysfunction has been recognized as a fundamental feature of schizophrenia and has been shown repeatedly to have a negative association with functional outcome [6]. Improvement in cognitive functioning became one of the most important clinical targets in the treatment of schizophrenia in the 1990s [82]. Main domains of cognition that are disrupted significantly in schizophrenia include attention, executive function, verbal and visuospatial working memory, and learning and memory. Although conventional antipsychotics are effective in treating positive symptoms, they lack the ability to improve cognitive impairment and produce poor functional outcome. Previous research has shown superior efficacy of atypical antipsychotics on cognitive impairments in schizophrenia compared with conventional antipsychotics. Because the heterogeneity of atypical antipsychotics in their pharmacologic properties, they have differential profiles of cognitive efficacy in patients with schizophrenia. Establishing the cognitive profile of each atypical antipsychotic is an important task. This knowledge can be used to address individual cognitive problems and needs. Because cognitive deficits have been shown to have associations with different aspects of clinical symptoms, limited learning in rehabilitation programs, and functional outcome in schizophrenia, targeting individual cognitive deficits would lead to greater treatment success in terms of clinical and functional outcome. Although atypical antipsychotics have some benefit on cognitive function, further efforts to improve cognitive function are required. Attempts at improving cognition in schizophrenia with specific cognitive enhancers pharmacologically and psychological therapies such as cognitive remediation might lead to better functional outcome in patients with schizophrenia.     

Effects of cognitive remediation on cognitive and social functions in individuals with schizophrenia

ABSTRACT

Individuals with schizophrenia exhibit cognitive impairments, which are related to impairments in social functions. This study investigated the effects of cognitive remediation on cognitive, social, and daily living impairment. Participants were individuals with schizophrenia between 20 and 60 years old (N?=?44). Participants were randomly assigned to two groups: a cognitive remediation intervention group and a non-intervention control group. The control group was provided with conventional drug therapy and either day care or occupational therapy. The intervention group was provided with the “neuropsychological educational approach to cognitive remediation” developed by Medalia and co-workers. We assessed cognitive functions using the brief assessment of cognition in schizophrenia (BACS), and evaluated social and daily living functions using the global assessment of functioning (GAF) scale. Significant group by time interaction effects indicated that verbal memory, working memory, attention, and executive function showed significantly greater improvement at post-intervention for the intervention group than the control group. Social and daily living function also improved in the intervention group and improvements were maintained one year after intervention. These preliminary findings indicate that the combination of cognitive remediation and psychiatric rehabilitation is effective for facilitating improvements in cognitive function and social and daily living functions in individuals with schizophrenia.     

Affective symptoms and cognitive functions in the acute phase of Graves' thyrotoxicosis

In the acute phase of Graves' thyrotoxicosis patients often have subjective cognitive complaints. Continuing controversy exists about the nature of these symptoms and whether they persist after treatment. This prospective study included 31 consecutively referred, newly diagnosed, and untreated patients with Graves' thyrotoxicosis. A control group of 34 individuals matched for age, education and premorbid intelligence was also included. At baseline all patients and control subjects were examined with psychiatric rating scales and a comprehensive neuropsychological battery. The effect of treatment on affective symptomatology was examined in the patient group after reaching euthyroidism and 1 year after treatment initiation. At initial examination patients had significantly higher scores on psychiatric rating scales as compared with controls, and the majority reported memory and concentration problems. No significant differences between the patient and the control group on neuropsychological test performances were found. Thyroid levels did not correlate with the neuropsychological test performances or psychiatric ratings. After reaching euthyroidism the level of affective symptoms (including reports of cognitive deficits) had decreased significantly, with further normalisation 1-year after treatment initiation. In conclusion, patients had subjective reports of cognitive deficits in the toxic phase of Graves' thyrotoxicosis but comprehensive neuropsychological testing revealed no cognitive impairment. Reports of cognitive dysfunction may reflect affective and somatic manifestations of thyrotoxicosis and in most patients these symptoms disappear after treatment of Graves' thyrotoxicosis.     

Differences in quality of life domains and psychopathologic and psychosocial factors in psychiatric patients

BACKGROUND: Although treatment of severe mental disorders should strive to optimize quality of life (QOL) for the individual patient, little is known about variations in QOL domains and related psychopathologic and psychosocial factors in patients suffering from schizophrenia, schizoaffective disorder, and/or mood disorders. We hypothesized that QOL in severe mental disorder patients would have a more substantial relationship with psychosocial factors than with illness-associated factors. METHOD: A case-control, cross-sectional design was used to examine QOL of 210 inpatients who met DSM-IV criteria for a severe mental disorder and who were consecutively admitted to closed, open, and rehabilitation wards. Following psychiatric examination, 210 inpatients were assessed using standardized self-report measures of QOL, insight, medication side effects, psychological distress, self-esteem, self-efficacy, coping, expressed emotion, and social support. QOL ratings for patients and a matched control group (175 nonpatients) were compared. Regression and factor analyses were used to compare multidimensional variables between patients with schizophrenia and schizoaffective and mood disorders. RESULTS: In all QOL domains, patients were less satisfied than nonpatient controls. Patients with schizophrenia reported less satisfaction with social relationships and medication when compared with patients with schizoaffective and/or mood disorders. Regression analysis established differential clusters of predictors for each group of patients and for various domains of QOL. On the basis of the results of factor analysis, we propose a distress protection model to enhance life satisfaction for severe mental disorder patients. CONCLUSION: Psychosocial factors rather than psychopathologic symptoms affect subjective QOL of hospitalized patients with severe mental disorders. The findings enable better understanding of the combining effects of psychopathology and psychosocial factors on subjective life satisfaction and highlight targets for more effective intervention and rehabilitation.     

Subjective memory complaints, mood, and memory deficits among HIV/AIDS patients in Hong Kong

Diagnosis of HIV-associated neurobehavioral disorders often heavily relies upon patient complaints of cognitive difficulties. Yet, research in North America suggests that such complaints may be heavily influenced by affective factors. However, no work in this area has been done in China. The present study examined the relationships among depressed mood, anxiety, memory performance and subjective memory complaints among HIV/AIDS patients in Hong Kong. A total of 90 individuals with HIV were administered the Beck Depression Inventory (BDI), State-Trait Anxiety Inventory, Patient's Assessment of Own Functioning Inventory (PAOF), and Hong Kong List Learning Test. Forward regression analysis indicated that the BDI Cognitive-Affective score was the most significant predictor of subjective memory complaints on the PAOF. Furthermore, present results also supported previous findings that some individuals with HIV infection are more "accurate" than others in the self-appraisal of their memory ability. Given inaccuracies that exist in subjective memory complaints, these findings highlight the importance of comprehensive cognitive assessment when evaluating the neuropsychological status of individuals of HIV.