Neuropsychological function in subjects with psychotic and affective disorders. Relationship to diagnostic category and duration of illness

Speech Understanding in Manic and Depressive Episodes of Mood Disorders

OBJECTIVE

The aim of this study was to assess the perception of speech in adverse acoustic conditions during manic and depressive episodes of mood disorders.

METHODS

Forty-three patients with bipolar disorder (mania, N=20; depression, N=23) and 32 patients with unipolar depression were included for analyses. Thirty-five participants served as the control group. The study of speech understanding was carried out using the Polish Sentence Matrix Test, allowing for the determination of the speech reception threshold (SRT). The test was performed in the clinical groups both during an acute episode and remission; during remission, patients underwent audiometric evaluation.

RESULTS

Compared with control subjects, patients with mood disorders had worse speech understanding (higher SRT), regardless of the episode or remission. A manic episode in the course of bipolar disorder was not associated with worse speech understanding compared with remission of mania. However, an episode of depression in the course of both bipolar disorder and unipolar depression was associated with worse speech understanding compared with remission of depression. In bipolar depression, this correlated with age, duration of the disorder, number of episodes, and number of hospitalizations, as well as in remission with age and duration of illness. In unipolar depression, poor speech understanding was more severe in individuals with hearing impairment.

CONCLUSIONS

These findings revealed that patients with mood disorders had impaired speech understanding, even while in remission, and manic episodes in the course of bipolar disorder were not associated with impaired speech understanding compared with mania remission.

Guidelines for Discontinuation of Antipsychotics in Patients Who Recover From First-Episode Schizophrenia Spectrum Disorders: Derived From the Aggregated Opinions of Asian Network of Early Psychosis Experts and Literature Review

OBJECTIVE

Antipsychotic discontinuation has been a long-standing clinical and medicolegal issue. The Asian Network of Early Psychosis developed guidelines for antipsychotic discontinuation in patients who recover from first-episode non-affective psychosis. We reviewed the existing studies and guidelines on antipsychotic discontinuation to develop guidelines for antipsychotic discontinuation in such patients.

METHODS

We reviewed the relevant studies, reviews, guidelines, and ongoing trials related to antipsychotic discontinuation in patients with first-episode psychosis or schizophrenia. The quality of randomized controlled trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Most studies had low to very low quality, and 2 had moderate quality. All studies, except 1, advised against antipsychotic discontinuation because of higher relapse rates in the antipsychotic discontinuation group (19%-82% at 1-year follow-up) than the treatment maintenance group compared with the maintenance group. Based on expert opinion and Grading of Recommendations Assessment, Development, and Evaluation evidence of trials, guidelines have been recommended for future discontinuation studies on patients with first-episode schizophrenia spectrum disorders.

CONCLUSIONS

Currently, there are no recommendations for antipsychotic discontinuation in patients with first-episode schizophrenia spectrum disorders. However, there is a pressing need to conduct more rigorous research in remitted patients using more stringent criteria of full recovery, which can form the basis of guidelines on when and how antipsychotics should be tapered and discontinued. Studies that evaluate the patient characteristics and biomarkers that predict successful antipsychotic discontinuation are also needed.

ReMind, a smartphone application for psychotic relapse prediction: A longitudinal study protocol

BACKGROUND

Psychotic disorders are associated with a high rate of relapse. In addition to medication non-adherence, some psychosocial factors have been found to be predictive of relapse (e.g., poor premorbid adjustment, high expressed emotion and substance misuse). Impairments in cognitive functions including general memory functioning, set shifting, attention, processing speed and working memory have also been indicative of a subsequent psychotic episode. As clinical appointments do not always allow for timely or accurate detection of these early warning signs, the ReMind app is developed to explore potential relapse predictors and enhance the process of relapse monitoring.

AIM

The ReMind app aims (1) to assess whether verbal or visual working memory predicts psychotic relapse in 1 year and (2) to determine whether social factors such as stressful life events, level of expressed emotion and medication adherence also predict relapse in 1 year.

METHODS

This is a one-year prospective follow-up study involving 176 remitted patients diagnosed with schizophrenia or non-affective psychoses. Monthly relapse predictor assessments will be conducted via ReMind throughout the one-year study duration. These assessments include neurocognitive tasks and psychosocial questionnaires.

RESULTS

Recruitment began in August 2017 and is still ongoing. Preliminary user feedback suggested an overall positive experience with the app.

CONCLUSION

The ReMind app presents a step forward to the identification and sensitive detection of reliable psychosis relapse predictors. With its anticipated success, it may offer an alternative means of monitoring relapse for the Chinese-speaking population in the future.

Impact of subjective vs. objective remission status on subjective cognitive impairments in depression

OBJECTIVE

The impact of subjective vs. objective illness severity on subjective cognitive impairment in patients with depression has not been addressed.

METHODS

This study is a post-hoc analysis of our cross-sectional study in Japanese outpatients with depressive disorder (ICD-10) (Ozawa et al., 2017). The participants received assessments with the Japanese version of the Perceived Deficits Questionnaire (J-PDQ), Quick Inventory of Depressive Symptomatology (QIDS), and Montgomery-Asberg Depression Rating Scale (MADRS). First, multiple regression analysis was conducted to examine the effects of demographic and clinical characteristics, including illness severity and medications (e.g., antidepressants and benzodiazepines), on the PDQ total score. Next, we categorized the participants into 4 groups based on the presence/absence of subjective and objective symptom remission (i.e., QIDS total score of ≤5 and MADRS total score of ≤9, respectively), and compared the differences in PDQ total scores between the QIDS- and MADRS-remitted group and the QIDS-non-remitted but MADRS-remitted group.

RESULTS

102 participants were included (45 men; mean ± SD age, 50.5 ± 14.7 years). Higher QIDS and MADRS total scores were significantly associated with a greater PDQ total score (both p's < 0.001), while other factors did not exhibit any associations. The QIDS-non-remitted but MADRS-remitted group showed a significantly higher PDQ total score than that of the QIDS- and MADRS-remitted group (median 10.0 [8.0-12.0] vs. 3.0 [range: 2.0-4.0], p < 0.001).

CONCLUSIONS

These findings suggest that objective remission in the absence of subjective remission may not be adequate to improve subjective cognitive functioning.

Social cognition and interaction training for major depression: A preliminary study

The present work investigated the efficacy of social cognition and interaction training (SCIT) for patients with major depression. Thirty first-episode patients with major depression who received the SCIT plus the treatment-as-usual (i.e., SCIT + TAU group) were compared with twenty-nine patients who only received treatment-as-usual (i.e., TAU group). Patients received SCIT showed a significantly greater improvement on emotion perception, theory of mind, and attributional styles from baseline to follow-up assessments, with a significant reduction of severity of depressive symptoms, compared to those in TAU group. The preliminary findings indicate that SCIT is a feasible and promising method to improve social cognition for patients with major depression.

Cognitive impairment in schizophrenia and depression: A comparison of stability and course

Cognitive deficits are clinically relevant features in schizophrenia and depression, yet little comparative data on changes in both disorders is available. This study compares cognitive performance of inpatients with schizophrenia (N = 52) and unipolar major depression (N = 67) during psychiatric treatment, assessing performance twice: after admission to hospital (acute) and prior to discharge (postacute) on average seven weeks later. A group of healthy controls was tested at comparable intervals. Data was analyzed using a multivariate linear model. Patients with schizophrenia and depression showed significantly impaired performance compared to healthy controls. On follow-up both patient groups showed improved performance. Contrary to expectation, patients with schizophrenia showed greater improvement in verbal memory, visual memory, and psychomotor speed than depressive patients. Verbal fluency presented as a possible candidate to differentiate between both disorders. Similar profiles of generalized cognitive deficits were observed in both patient-groups on acute and postacute assessment, which might indicate trait-like deficits with persistent functional implications in both disorders. Findings do not support assumptions of greater cognitive impairment in schizophrenia compared to depression. A distinction of the disorders on the grounds of cognitive functioning seems to be less specific than presumed.

Cognitive Dysfunction in Major Depressive Disorder: Assessment, Impact, and Management

Cognitive dysfunction is increasingly being recognized as an important clinical dimension in major depressive disorder. This review summarizes the existing data on the epidemiology, assessment, and treatment of cognitive dysfunction among nonelderly adults with the disorder. Overall, cognitive dysfunction is prevalent, persists through periods of symptom remission, and may be independently associated with functional outcomes. However, although the evidence increasingly suggests that clinicians should be heedful of their patients' cognitive functioning, there is as yet no consensus on how best to monitor cognition clinically. In addition, although most studies have reported improved cognition with antidepressant medications, psychotherapy, and neuromodulation, the clinical significance of these improvements is unclear, and high-level evidence to guide decision making is limited. Nonetheless, given the important functional implications, clinicians should assess and monitor cognition and optimize both medication and psychological treatments to mitigate cognitive dysfunction among patients with major depressive disorder.

Is duration of illness really influencing outcome in major psychoses?

BACKGROUND

An increasing number of studies identifies the duration of illness (DI) as an important predictor of outcome in patients affected by major psychoses (MP). The aim of the present paper was to revise medical literature about DI and its effects on MP, focusing in particular on the relationship between DI and outcome with particular reference to treatment response, suicidal risk, cognitive impairment and social functioning.

METHODS

A search in the main database sources has been performed to obtain a comprehensive overview. Studies with different methodologies (open and double-blinded) have been included, while papers considering other variables such as duration of untreated episode/illness were excluded. MP included the diagnoses of schizophrenia, bipolar disorder and major depressive disorder.

RESULTS

Available data show that DI influences treatment response, suicidal risk and loss of social functioning in schizophrenic patients, while results are more controversial with regard to cognitive impairment. In bipolar disorder, a long DI has been associated with less treatment response, more suicidal risk and cognitive impairment, but more data are needed to draw definitive conclusions. Finally, studies, regarding DI of illness and its predictive value of outcome in major depressive disorder show contradictory results.

CONCLUSIONS

DI appears a negative outcome factor particularly for schizophrenia, while with regard to mood disorders, more data are needed to draw definitive sound conclusions.

Verbal memory impairment in new onset bipolar disorder: Relationship with frontal and medial temporal morphology

OBJECTIVES

Verbal memory (VM) impairment is a trait feature of bipolar I disorder (BDI) that is present at illness onset and associated with functional outcome. However, little is known about the morphological abnormalities underlying this deficit early in the disease course. This study examined the neurobiological correlates of VM impairment in euthymic newly diagnosed patients, with attention to frontal and medial temporal (MT) structures known to contribute to VM.

METHODS

Euthymic patients with BDI recently recovered from their first episode of mania (n = 42) were compared with healthy subjects (n = 37) using measures of the California Verbal Learning Test (CVLT-II) associated with frontal and MT functioning. A subset of participants had 3T MRI scan (n = 31 patient group, n = 30 healthy subject group). Hippocampal and prefrontal volumes were analyzed using FreeSurfer 5.1 and correlated with their corresponding CVLT-II subscores.

RESULTS

Patients showed decreased performance in total learning as well as short and long delay verbal recall. Consistent with MT dysfunction, they also showed deficits in recognition discriminability and learning slope. In the patient group only, left hippocampal volumes were negatively correlated with these measures.

CONCLUSIONS

These results suggest that anomalous MT functioning is involved with VM impairment early in the course of BDI.

The neurocognitive functioning in bipolar disorder: a systematic review of data

BACKGROUND

During the last decades, there have been many different opinions concerning the neurocognitive function in Bipolar disorder (BD). The aim of the current study was to perform a systematic review of the literature and to synthesize the data in a comprehensive picture of the neurocognitive dysfunction in BD.

METHODS

Papers were located with searches in PubMed/MEDLINE, through June 1st 2015. The review followed a modified version of the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses statement.

RESULTS

The initial search returned 110,403 papers. After the deletion of duplicates, 11,771 papers remained for further evaluation. Eventually, 250 were included in the analysis.

CONCLUSION

The current review supports the presence of a neurocognitive deficit in BD, in almost all neurocognitive domains. This deficit is qualitative similar to that observed in schizophrenia but it is less severe. There are no differences between BD subtypes. Its origin is unclear. It seems it is an enduring component and represents a core primary characteristic of the illness, rather than being secondary to the mood state or medication. This core deficit is confounded (either increased or attenuated) by the disease phase, specific personal characteristics of the patients (age, gender, education, etc.), current symptomatology and its treatment (especially psychotic features) and long-term course and long-term exposure to medication, psychiatric and somatic comorbidity and alcohol and/or substance abuse.

Executive deficits: a continuum schizophrenia-bipolar disorder or specific to schizophrenia?

Executive dysfunction is a core deficit in schizophrenia (SCH). However, some controversy exists when examining such deficits in studies of bipolar disorder (BD). The aim of the present research was to investigate whether executive deficits were similar or distinct in both illnesses. 148 patients with BD, 262 patients with stable SCH and 108 healthy controls (CT) were recruited for the study. The BD patients were also differentiated according to the clinical subtype (BD subtype I, BDI, or subtype II, BDII) they exhibited and according to whether there was a previous history of psychosis. All subjects completed a broad neuropsychological battery. The influences of other clinical data were also evaluated. Both the BD and SCH patients showed widespread deficits in all executive tasks, with no differences between these two groups of patients. BDII patients only showed some selective deficits, and their scores on planning and inhibitory tasks fell on the continuum between the CT, the BDI and the SCH patients. Psychotic phenotypes did not influence the BD patients' performance on the battery. Other clinical variables related to illness severity did influence deficits in any subgroup of patients. Our results point to the existence of common executive disturbances in both diagnostic categories. Moreover, the inclusion of subclinical phenotypes in research may be helpful in cognitive assessment studies.

The relevance of cognitive, clinical and premorbid variables in predicting functional outcome for individuals with first-episode psychosis: a 3 year longitudinal study

Real-world functional deficits are common and persistent in individuals with psychosis. Cognitive deficits have been shown to compromise functioning. We aimed to study the predictive values of premorbid, sociodemographic, and baseline clinical and neurocognitive factors on long-term functional outcome for individuals with first episode non-affective psychosis. We failed to demonstrate a significant relationship between cognitive deficits at baseline and functional disability at 3 year follow-up. Diagnosis of schizophrenia (OR=2.457, p=0.011), shorter education (OR=1.177, p=0.005) and poor premorbid social adjustment (OR=1.628, p=0.013) emerged as the strongest predictors for the 114 subjects (56%) that exhibited functional disability at 3-year follow-up. A considerable proportion of the variance in functioning (74% at 1 year and 77% at 3 year) remained unexplained by baseline variables. The set of variables that predicted functional outcome at medium- (1 year) and long-term (3 years) differed. In conclusion, the length of follow-up influenced the relationship between baseline variables and functional outcome. A substantial proportion of the variance in function was not explained by these variables and therefore the influence of other factors warrants further investigation. The data support the notion that premorbid social adjustment is an important aspect in functional outcome over the course of the illness.

Neuropsychological functioning in inpatients with major depression or schizophrenia

BACKGROUND

Studies that compare neuropsychological functioning in inpatients with mood disorder or schizophrenia come to heterogeneous results. This study aims at investigating the question whether there are different neuropsychological test profiles in stabilised post-acute inpatients with affective disorders or schizophrenia.

METHOD

We were interested in evaluating impairment in specific areas of cognitive functioning in patients with schizophrenia or depression. In clinical reality, patients with depression and schizophrenia are often treated together with little attention to their specific needs. 74 patients with major depression and 38 patients with schizophrenia were assessed in a comprehensive neuropsychological battery. All patients were in a post-acute stage of their illness, i.e. remission of acute symptoms.

RESULTS

In spite of a comparable mean score of psychopathological symptoms in the Brief Psychiatric Rating Scale-Expanded (BPRS-E) as well as in the Global Assessment Functioning Scale (GAF), patients with depressive disorder showed significantly better results in verbal and visual short-term memory, verbal fluency, visual-motor coordination, information processing in visual-verbal functioning and selective attention compared to patients with schizophrenia. No significant differences between both samples were found in practical reasoning, general verbal abstraction, spatial-figural functioning, speed of cognitive processing.

CONCLUSIONS

These results show that there are differences in scores in psychopathology (BPRS-E, GAF) in patients with affective disorders or schizophrenia and different neuropsychological test profiles in the post-acute stage of their illness.

Executive dysfunction and memory impairment in schizoaffective disorder: a comparison with bipolar disorder, schizophrenia and healthy controls

BACKGROUND

Deficits in memory and executive performance are well-established features of bipolar disorder and schizophrenia. By contrast, data on cognitive impairment in schizoaffective disorder are scarce and the findings are conflicting.

METHOD

We used the Wechsler Memory Scale (WMS-III) and the Behavioural Assessment of the Dysexecutive Syndrome (BADS) to test memory and executive function in 45 schizophrenic patients, 26 schizomanic patients and 51 manic bipolar patients in comparison to 65 healthy controls. The patients were tested when acutely ill.

RESULTS

All three patient groups performed significantly more poorly than the controls on global measures of memory and executive functioning, but there were no differences among the patient groups. There were few differences in memory and executive function subtest scores within the patient groups. There were no differences in any test scores between manic patients with and without psychotic symptoms.

CONCLUSIONS

Schizophrenic, schizomanic and manic patients show a broadly similar degree of executive and memory deficits in the acute phase of illness. Our results do not support a categorical differentiation across different psychotic categories with regard to neuropsychological deficits.

Clinical factors that predict cognitive function in patients with major depression

OBJECTIVES

To compare the performance of depressed patients to healthy control subjects on discrete cognitive domains derived from factor analysis and to examine the factors that may influence the performance of depressed patients on cognitive domains in a large sample.

METHODS

We compared the cognitive performance of 149 patients with major depression to 104 healthy control subjects using multivariate ANCOVA. We used principal component factor analysis to group the cognitive variables into cognitive domains. Finally, we conducted regression analysis to examine the contribution of predictor factors to the cognitive domains that were impaired in the depressed group.

RESULTS

Verbal memory and speed of processing were impaired in depressed patients, compared with healthy control subjects. Patient IQ, duration of depressive illness, and number of hospitalizations significantly contributed to the performance of patients on verbal memory and speed of processing. The severity of mood symptoms did not correlate with performance on any cognitive domain.

CONCLUSIONS

Understanding the factors that predict cognitive performance of patients with depression may provide an insight into the processes by which depression leads to cognitive dysfunction. Our study showed that premorbid IQ and factors related to burden of illness are strong independent predictors of cognitive dysfunction in patients with major depression.

Neurocognition in early-onset schizophrenia and schizoaffective disorders

OBJECTIVE

We examined the neuropsychological functioning of youth enrolled in the NIMH funded trial, Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS). We compared the baseline neuropsychological functioning of youth with schizophrenia (SZ, n = 79) to those with schizoaffective disorder (SA, n = 40), and examined the relationship of different variables of illness severity and adaptive behavior to neuropsychological functioning.

METHOD

Participants ranged in age from 8 to 19 years. Diagnostic status was confirmed via structured interview over multiple time points. Domains of neuropsychological functioning included fine-motor, attention, working memory, problem-solving efficiency, inhibitory control, and social cognition. Other variables included intelligence (IQ), academic achievement skills, adaptive behavior, and different measures of illness severity.

RESULTS

The two groups did not differ on IQ or on any of the neuropsychological domains. The SZ group performed significantly lower in spelling. A high proportion of individuals in both groups reflected significant intellectual and academic achievement skill deficits. Significant correlations were found between the neurocognitive domains and both illness severity and adaptive behavior variables.

CONCLUSIONS

There were few differences between the SZ and SA groups on IQ, achievement, or neuropsychological functioning; however, both groups showed significantly high rates of deficits in IQ and basic academic skills. Correlations of the neurocognitive functions with illness severity and adaptive behavior were small to moderate in magnitude. These findings continue to implicate the importance of neurocognitive functioning as a key area of vulnerability in the study of youth with schizophrenia spectrum disorders.

Cognitive functioning in schizophrenia, schizoaffective disorder and affective psychoses: meta-analytic study

BACKGROUND

Cognitive functioning in affective psychosis and schizoaffective disorder is much less studied compared with schizophrenia.

AIMS

To quantitatively undertake a meta-analysis of the available data that directly compares cognitive functioning across schizophrenia, schizoaffective disorder and affective psychosis.

METHOD

Following a thorough literature review, 31 studies that compared the performances of people with schizophrenia (1979 participants) with that of those with affective psychosis or schizoaffective disorder (1314 participants) were included. To determine the effect of demographic and clinical confounders, meta-regression and subgroup analyses were conducted.

RESULTS

In 6 of 12 cognitive domains, people with schizophrenia performed worse than people with schizoaffective disorder or affective psychosis. However, the between-group differences were small and the distribution of effect sizes showed substantial heterogeneity. The between-group differences were driven by a higher percentage of males, more severe negative symptoms and younger age at onset of illness in the schizophrenia samples.

CONCLUSIONS

Neuropsychological data do not provide evidence for categorical differences between schizophrenia and other groups. However, a subgroup of individuals with schizophrenia who have more severe negative symptoms may be cognitively more impaired than those with affective psychosis/schizoaffective disorder.

Memory functioning in familial bipolar I disorder patients and their relatives

OBJECTIVE

The aim of this study was to compare the memory function of patients with familial bipolar I disorder (BD I) who had shown psychotic features, their non-psychotic, non-bipolar first-degree relatives, and normal controls.

METHOD

We assessed 38 patients with a lifetime diagnosis of BD I who had experienced psychotic symptoms, 49 of their non-psychotic, non-bipolar first-degree relatives, and 44 controls. Patients and relatives were from families multiply affected with functional psychotic illness. A five-subtest short form of the Wechsler Adult Intelligence Scale-Revised and three Wechsler Memory Scale subtests were administered to all participants.

RESULTS

BD I patients showed deficits in verbal memory and verbal learning but not in visual memory. Compared to controls, relatives showed worse verbal learning at a statistically significant or suggestive level and performed significantly worse in both immediate and delayed verbal memory. Similar to patients, there were no differences between the relatives and control group for visual memory.

CONCLUSION

Impaired verbal memory and learning were found in patients and their relatives. These deficits may represent candidate endophenotypic markers for bipolar disorder.

Premorbid intelligence of inpatients with different psychiatric diagnoses does not differ

The diagnostic specificity of poor premorbid intelligence is controversial. We explored premorbid intelligence level in psychiatric patients with personality disorders, depressive disorders, bipolar disorders and schizophrenic disorders. 273 consecutively admitted patients and 81 controls were included in the study and tested with the 'Test di Intelligenza Breve', an Italian adaptation of the National Adult Reading Test. Significant differences between the clinical samples and the control subjects were found but not among the 4 clinical groups. The observation of premorbid IQ deficits in subjects with diagnoses other than schizophrenia suggests a common vulnerability diathesis, which is most likely to have a neurodevelopmental basis.

Major psychoses with mixed psychotic and mood symptoms: are mixed psychoses associated with different neurobiological markers?

OBJECTIVE

Evidence related to overlapping clinical and genetic risk factors in schizophrenia and bipolar disorder (BD) have raised concerns about the validity of 'Kraepelinian dichotomy'. As controversies mainly arise in mixed psychoses that occupy the intermediate zone between schizophrenia and BD, investigating neurobiological markers of mixed psychoses may be relevant to understanding the nature of psychotic disorders.

METHOD

In this article, we review studies comparing magnetic resonance imaging, neuropsychological and electrophysiological findings in mixed psychoses with each other, as well as with more prototypical cases of schizophrenia and BD.

RESULTS

The evidence reviewed suggests that mixed psychoses may be associated with different genetic and neurobiological markers compared with prototypical forms of schizophrenia and BD.

CONCLUSION

These findings may be compatible with more sophisticated versions of dimensional and continuum models or, alternatively, they may suggest that there is an intermediate third category between prototypical schizophrenia and BD.

The cognitive and neurophysiological basis of emotion dysregulation in bipolar disorder

BACKGROUND

Bipolar disorder is characterized by fluctuating affect and mood, and is associated with specific neurocognitive deficits consistent with neuropathology in cerebello-striatal-prefrontal neural networks. This network is critical for emotion regulation.

METHODS

Relevant literature was located via PsychINFO and Medline to provide a comprehensive review of cognitive and neural mechanisms of social information processing and affect generation in bipolar disorder (BD) in the context of recent research examining the neural mechanisms of emotion regulation via conscious cognitive strategies.

RESULTS

Emotion regulation relies on synergy within brainstem, limbic and cortical processes that promote the adaptive generation and regulation of affect, with prefrontal and cingulate regions inhibiting sub-cortical and cortical emotion processing systems in the cognitive control of emotional experience. Current evidence of structural and functional brain abnormalities in BD alongside aberrant social cognition, affect generation, and neuropsychological function are consistent with a model of emotion dysregulation to account for the symptoms of BD.

LIMITATIONS

A precise understanding of emotion dysregulation in BD is currently limited by a paucity of longitudinal research directly examining these issues.

CONCLUSION

Aberrant emotion perception alongside increased limbic activity during emotion perception and affect generation in BD, alongside impaired executive control associated with aberrant neurophysiological abnormalities in sub-regions of the prefrontal cortex, is consistent with impaired emotion regulation. We propose a cognitive and neurophysiological framework within which the variations of mood that are characteristic of BD can be understood as specific impairments of the cognitive control of emotion.

Neuropsychological functioning in bipolar disorder and schizophrenia

BACKGROUND

Some patients with bipolar disorder (BD) demonstrate neuropsychological deficits even when stable. However, it remains unclear whether these differ qualitatively from those seen in schizophrenia (SZ).

METHODS

We compared the nature and severity of cognitive deficits shown by 106 patients with SZ and 66 patients with BD to 316 healthy adults (NC). All participants completed a cognitive battery with 19 individual measures. After adjusting their test performance for age, sex, race, education, and estimated premorbid IQ, we derived regression-based T-scores for each measure and the six cognitive domains.

RESULTS

Both patient groups performed significantly worse than NCs on most (BD) or all (SZ) cognitive tests and domains. The resulting effect sizes ranged from .37 to 1.32 (mean=.97) across tests for SZ patients and from .23 to .87 (mean=.59) for BD patients. The Pearson correlation of these effect sizes was .71 (p<.001).

CONCLUSIONS

Patients with bipolar disorder suffer from cognitive deficits that are milder but qualitatively similar to those of patients with schizophrenia. These findings support the notion that schizophrenia and bipolar disorder show greater phenotypic similarity in terms of the nature than severity of their neuropsychological deficits.

A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context

Why is adolescence an "age of risk" for onset of bipolar spectrum disorders? We discuss three clinical phenomena of bipolar disorder associated with adolescence (adolescent age of onset, gender differences, and specific symptom presentation) that provide the point of departure for this article. We present the cognitive vulnerability-transactional stress model of unipolar depression, evidence for this model, and its extension to bipolar spectrum disorders. Next, we review evidence that life events, cognitive vulnerability, the cognitive vulnerability-stress combination, and certain developmental experiences (poor parenting and maltreatment) featured in the cognitive vulnerability-stress model play a role in the onset and course of bipolar disorders. We then discuss how an application of the cognitive vulnerability-stress model can explain the adolescent age of onset, gender differences, and adolescent phenomenology of bipolar disorder. Finally, we further elaborate the cognitive vulnerability-stress model by embedding it in the contexts of normative adolescent cognitive (executive functioning) and brain development, normative adolescent development of the stress-emotion system, and genetic vulnerability. We suggest that increased brain maturation and accompanying increases in executive functioning along with augmented neural and behavioral stress-sensitivity during adolescence combine with the cognitive vulnerability-stress model to explain the high-risk period for onset of bipolar disorder, gender differences, and unique features of symptom presentation during adolescence.

A longitudinal analysis of neurocognitive function in unipolar depression

Neurocognitive function is reduced in major depression, but uncertainties remain about if and to what extent improvement in neurocognitive function follows remission of depressive symptoms. A total of 30 patients with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) diagnosis of unipolar major depressive disorder (MDD) at baseline were tested neuropsychologically again, after a mean test-retest interval of 2 years. At retest, patients were partly or completely recovered from depression. Remission of depression was followed by improvement in verbal memory function up to the level of healthy controls, but no associations between improvement in depression and improvement in other dimensions of neurocognitive function were found. Neurocognitive function at baseline was not predictive of improvement in depressive symptoms over time. The present study provided some support for the state hypothesis as to the association between neurocognitive impairment and depression.

Disability and its treatment in bipolar disorder patients

Bipolar disorders (BPD) are major, life-long psychiatric illnesses found in 2-5% of the population. Prognosis for BPD was once considered relatively favorable, but contemporary findings suggest that disability and poor outcomes are prevalent, despite major therapeutic advances. Syndromal recovery from acute episodes of mania or bipolar major depression is achieved in as many as 90% of patients given modern treatments, but full symptomatic recovery is achieved slowly, and residual symptoms of fluctuating severity and functional impact are the rule. Depressive-dysthymic-dysphoric morbidity continues in more than 30% of weeks in follow-up from initial episodes as well as later in the illness-course. As few as 1/3 of BPD patients achieve full social and occupational functional recovery to their own premorbid levels. Pharmacotherapy, though the accepted first-line treatment for BPD patients, is insufficient by itself, encouraging development of adjunctive psychological treatments and rehabilitative efforts to further limit morbidity and disability. Interpersonal, cognitive-behavioral, and psychoeducational therapies all show promise for improving symptomatic and functional outcomes. Much less is known about how these and more specific rehabilitative interventions might improve vocational functioning in BPD patients.

Shared cognitive processes underlying performance on the Wisconsin Card Sorting Test and the Stroop Test in patients with schizophrenia: a measurement artifact?

We explored the hypothesis that, while sensitive to different aspects of executive functioning in patients with schizophrenia, the Wisconsin Card Sorting Test (WCST) and the Stroop Test also measure the same construct, namely, inhibitory control. Specifically, our goal was to confirm and extend previous findings [A. Rossi, E. Daneluzzo, P. Mattei, M. Bustini, M. Cassachia, P. Stratta, Wisconsin Card Sorting Test and Stroop performance in schizophrenia: a shared construct, Neurosci. Lett. 226 (1997) 87-90] by demonstrating the independence of this construct from other abilities necessary to successfully perform the tasks. More importantly, we sought to improve on this previous study by eliminating the influence of the variance of speed of responding. We examined 55 patients with schizophrenia and initially found that performance on the Stroop Color-Word condition could, indeed, be predicted only by the percentage of perseverative errors on the WCST, and not variables reflective of other cognitive skills, thus replicating and extending previous findings. Once we removed the influence of speed of responding from our measure, however, thus isolating the inhibitory process, this finding disappeared. Therefore, our findings highlight the importance of isolating the individual components of interest from complex measures before drawing conclusions regarding the cognitive processes underlying particular test performance.

Specificity of cognitive deficits in bipolar disorder versus schizophrenia. A systematic review

BACKGROUND

More and more epidemiological, genetic and neuroimaging studies show similarities between bipolar disorder (BD) and schizophrenia (SZ). Cognitive functions are known to be highly impaired in SZ and are increasingly studied in BD. When both populations are compared, the conclusions appear to be contradictory. The purpose of this review is to help define the profile of cognitive deficits in BD and in SZ.

METHODS

A systematic review of the literature of neuropsychological studies comparing BD and SZ was made, beginning in January 1990 and ending in January 2005. Thirty-eight studies met the required quality criteria and were included in this review.

RESULTS

Bipolar patients exhibit extensive cognitive abnormalities with a pattern of deficits that is not unique to this disease. However, when compared to schizophrenic patients, bipolar patients demonstrate a lesser degree of deficits, particularly concerning premorbid and current intelligence quotient and perhaps attention, verbal memory and executive functions. When looking into effect sizes, there seem to be different profiles even in studies finding no significant differences.

CONCLUSIONS

The neuropsychological differences reported between both groups could be due to the presence of psychotic features, to environmental factors (stressful events, duration of the disease and number of hospitalisations) and could also be related to differences during the neurodevelopmental phase. Further studies should confirm whether these results are truly related to different neurobiological backgrounds.

Fronto-temporal function may distinguish bipolar disorder from schizophrenia

OBJECTIVES

There is evidence for differential neural alterations within the prefrontal cortex (PFC) in bipolar disorder I (BDI) and schizophrenia that may translate into different cognitive deficits. Our objective was to compare the cognitive profile of stable BDI and schizophrenic patients using neuropsychological tasks which utilize frontal systems but differ in terms of the exact neural circuits and cognitive processes involved.

METHODS

We studied 43 patients with BDI, 54 with schizophrenia and 46 matched healthy participants. All participants completed (i) the Wisconsin Card Sorting Test (WCST) which is known to recruit the dorsal and ventral PFC, (ii) the verbal fluency task (VFT), which engages frontal-temporal regions, and (iii) the Stroop Colour Word Test (SWCT) which depends on the integrity of the cingulo-frontal network. A series of multivariate analyses examined differences between the cognitive profiles of BD and schizophrenic patients relative to that of healthy participants controlling for general intellectual ability and gender.

RESULTS

Bipolar disorder I patients showed minimal verbal fluency impairment while schizophrenic patients demonstrated marked deficits on this task relative to the control and BDI groups. The two patient groups had comparable performance on the WCST. In the SWCT, schizophrenic patients showed impairment in both congruent and incongruent conditions while BD patients had deficits only in the latter.

CONCLUSIONS

Absence of significant verbal fluency abnormalities and by inference dysfunction in the associated fronto-temporal circuitry may distinguish BDI from schizophrenia. Both disorders may show impairment in tasks involving cingulo-frontal networks with evidence of greater cingulate dysfunction in schizophrenia.

Sources of declarative memory impairment in bipolar disorder: mnemonic processes and clinical features

BACKGROUND

There is mounting evidence that declarative memory processes are impaired in patients with bipolar disorder. However, predictors of the observed impairment are not well understood. This study seeks to: (i) better characterize the nature of declarative memory impairment in bipolar disorder, and (ii) determine the relationship between clinical variables and memory function in bipolar disorder.

METHODS

49 adult patients with bipolar disorder in varying mood states and 38 demographically matched healthy participants completed a comprehensive neurocognitive battery assessing general cognitive functioning, processing speed, and declarative memory. The California verbal learning test was used to characterize learning and memory functions.

RESULTS

Although patients with bipolar disorder utilized a similar semantic clustering strategy to healthy controls, they recalled and recognized significantly fewer words than controls, suggesting impaired encoding of verbal information. In contrast, lack of rapid forgetting suggests relative absence of a storage deficit in bipolar patients. While severity of mood symptomatology and illness duration were not associated with task performance, gender and family history significantly affected memory function.

CONCLUSIONS

Results suggest that declarative memory impairments in bipolar patients: (1) are consistent with deficits in learning, but do not appear to be related to different organizational strategies during learning, and (2) do not appear to be secondary to clinical state, but rather may be associated with the underlying pathophysiology of the illness.

[Wiscosin card sorting task in patients with schizophrenia and thier siblings]

OBJECTIVE

This study's first objective was to confirm that patients with schizophrenia and their nonmentally ill siblings share the same impaired executive function when compared to healthy control subjects. The second objective was to study the relation between Wisconsin card sorting task (WCST) performance and the persistence and severity of clinical symptoms, as well as different clinical dimensions.

METHOD

Ninety subjects were involved in this study, divided in 3 groups of 30 each: one group of patients with schizophrenia, one group of their siblings, and a control group. Symptom severity was assessed with the Positive and Negative Syndrome Scale (PANSS), and social functioning was measured by the Global functioning scale (GFS). The WCST was administered to all 3 groups.

RESULTS

Patients with schizophrenia and their siblings had a significantly lower WCST performance than control subjects. Statistical analysis showed that the patient group had a significantly greater impaired WCST performance than the 2 other groups. Siblings also had a significantly lower performance than the control subjects. Furthermore, no significant relation was found between WCST performance and other variables, including age, gender, education, illness duration, treatment, and different PANSS and GFS scores.

CONCLUSION

Patients with schizophrenia and their nonmentally ill siblings share the same impaired executive function. These findings suggest that WCST performance can be considered a schizophrenia vulnerability marker in siblings of patients with schizophrenia.

Cognitive functioning in patients with schizophrenia and bipolar disorder: a quantitative review

OBJECTIVE

Evidence suggests that cognitive functioning in bipolar disorder may be impaired even in euthymic states, but it is unclear if the pattern of deficits is similar to the deficits found in schizophrenia. The aim of this study was to review quantitatively the studies on cognitive performance in schizophrenia and bipolar disorder.

METHODS

Articles for consideration were identified through a literature search in MEDLINE and PsycLIT in the period between 1985 and October 2004, using the keywords "schizophrenia" combined with "bipolar disorder", or "manic-depress*" or "manic" combined with "cogniti*" or "neuropsycholog*". Thirty-one studies were included that: i) evaluated cognitive performance using standardized and reliable neuropsychological testing procedures; ii) compared adult patients with schizophrenia and with bipolar disorder; iii) reported test scores of both patient groups, or exact p-values, t-values, or F-values; and iv) were published as an original article in a peer-reviewed English language journal.

RESULTS

Meta-analyses of all studies indicated that patients with bipolar disorder generally perform better than patients with schizophrenia, but the distribution of effect sizes showed substantial heterogeneity. Results based on a more homogeneous subset of studies that matched patient groups on clinical and demographic characteristics pointed in the same direction, with effect sizes in the moderate range.

CONCLUSIONS

Patients with bipolar disorder show better cognitive performance than patients with schizophrenia, even when matched for clinical and demographic characteristics.

The Maudsley Bipolar Disorder Project: executive dysfunction in bipolar disorder I and its clinical correlates

BACKGROUND

Cognitive abnormalities are increasingly recognized as a feature of bipolar I disorder (BDI,) but there is limited information regarding the pattern and severity of cognitive impairment during remission and its relationship with clinical variables.

METHODS

Forty-four remitted BDI patients recruited from a representative treatment sample and an equal number of matched healthy volunteers underwent comprehensive clinical and cognitive assessments. Cognitive evaluation covered the domains of IQ, memory, and executive function. The profile of cognitive deficits in patients was examined, and the correlation of executive function with clinical features and treatment variables was explored.

RESULTS

Remitted BDI patients were impaired in tests of executive function compared with healthy participants. Within the patient group, current antipsychotic treatment predicted worse performance across all executive function tests, whereas duration of illness predicted loss of inhibitory control. Residual mood symptoms, regardless of polarity, had a negative impact primarily on measures of attentional interference.

CONCLUSIONS

These results suggest that impaired executive function might be an important feature of BDI. Antipsychotic treatment, duration of illness, and level of symptoms are the most significant contributors to the observed impairment.

Face emotion perception and executive functioning deficits in depression

Frontal, limbic and temporal regions of the brain important in emotion perception and executive functioning also have been implicated in the etiology and maintenance of depression; yet, the relationships among these topics remain poorly understood. The present study evaluated emotion perception and executive functioning among 21 depressed women and 20 nondepressed women controls. Depressed women performed significantly worse than controls in emotion perception accuracy and in inhibitory control, an aspect of executive functioning, whereas the groups did not differ in other cognitive tests assessing memory, visual-spatial, motor, and attention skills. The findings suggest that emotion perception and executive functioning are disproportionately negatively affected relative to other cognitive functions, even in a high-functioning group of mildly depressed women. Measures of emotion perception and executive functioning may be of assistance in objectively measuring functional capability of the ventral and dorsal neural systems, respectively, as well as in the diagnosis of depression.

Neuropsychological dysfunction in bipolar affective disorder: a critical opinion

Data from the imaging literature have led to suggestions that permanent structural brain changes may be associated with bipolar disorder. Individuals diagnosed with bipolar disorder display deficits on a range of neuropsychological tasks in both the acute and euthymic phases of illness, and correlations between experienced number of affective episodes and task performance are commonly reported. These findings have renewed interest in the neuropsychological profile of individuals with bipolar disorder, with deficits of attention, learning and memory, and executive function, asserted to be present. This paper critically reviews five different potential causes of neurocognitive dysfunction in bipolar disorder: (i) iatrogenic, (ii) acute functional changes associated with depression or mania, (iii) permanent structural lesions of a neurodegenerative origin, (iv) permanent structural lesions that are neurodevelopmental in origin, and (v) permanent functional changes that are most likely genetic in origin. Although the potential cognitive effects of residual symptomatology and long-term medication use cannot be entirely excluded, we conclude that functional changes associated with genetically driven population variation in critical neural networks underpin both the neurocognitive and affective symptoms of bipolar disorder. The philosophical implications of this conclusion for neuropsychology are briefly discussed.

Association of symptoms and executive function in schizophrenia and bipolar disorder

The extent to which cognitive impairment in psychosis is related to the particular disorder or the pattern of symptoms is unclear. We examined executive function in two groups of schizophrenia patients with predominant symptoms of disorganisation (n=15) and psychomotor poverty (n=15), respectively, two groups of bipolar I disorder patients with predominant symptoms of mania (n=15) and depression (n=15), respectively, and 30 healthy controls. We predicted that the pattern of symptoms ('excess' [disorganisation/mania] or 'deficiency' [negative symptoms/depression]) would be more related to executive ability than the underlying disorder. The patient groups showed partially overlapping executive dysfunctions relative to the control group. There were no significant differences between groups with 'excess' symptoms (schizophrenia patients with thought disorder and bipolar patients with mania), or between groups with 'deficiency' symptoms (schizophrenia patients with negative symptoms and bipolar patients with depression). In contrast, differences were noted between groups with the same diagnosis: Schizophrenia patients with disorganisation were less accurate in semantic verbal fluency than those with negative symptoms; and bipolar patients with mania tended to be faster, but less accurate, in sentence completion than those with depression. A statistical comparison of the associations of 'diagnosis' and the 'excess-deficiency' dimension with executive function revealed a trend for a greater association of the latter with two measures of performance accuracy. Executive dysfunction in patients with psychotic disorders may be more related to their symptom profile than their diagnosis.

Cognitive functioning in young people with first episode psychosis: relationship to diagnosis and clinical characteristics

OBJECTIVE

To examine the extent and nature of neuropsychological deficits in adolescents and young people with first episode psychosis (FEP), and to determine whether the pattern and extent of neuropsychological deficits varied according to diagnosis.

METHOD

A total of 83 FEP subjects aged 13-25 years, and 31 healthy controls completed a comprehensive battery of neuropsychological tests, grouped into 10 cognitive domains. First episode psychosis subjects were stratified into three diagnostic groups (schizophrenia, affective disorders, substance-induced psychosis) and differences in cognitive profiles were examined. The contribution of demographic and clinical characteristics to cognitive performance was also explored.

RESULTS

The schizophrenia group demonstrated significantly worse performance on tasks of verbal learning and memory than the affective disorders group. Compared to healthy controls, the schizophrenia group also demonstrated global impairment across the majority of cognitive domains. The substance-induced group's performance lay between that of the schizophrenia and affective disorders groups. Analyses of differential deficits revealed that verbal learning, verbal memory and current intellectual functioning were selectively impaired in the schizophrenia group, whereas the affective disorders group demonstrated a selective deficit in speeded processing. Premorbid intellectual functioning, negative symptomatology and medication levels were the strongest predictors of cognitive performance in FEP subjects.

CONCLUSIONS

Verbal memory deficits differentiate individuals with schizophrenia from those with psychotic affective disorders. Although significant cognitive deficits are evident across all diagnostic FEP groups, individuals with schizophrenia appear to have more generalized impairment across a broad array of cognitive functions than other psychotic diagnoses. Lower premorbid intellectual functioning does not appear to contribute to greater cognitive deterioration following onset of psychosis, but severity of illness may be a more important factor than levels of mood disturbance.

A prospective study of the association among impaired executive functioning, childhood attentional problems, and the development of bipolar disorder

Studies of adults who have been diagnosed with, and treated for, bipolar disorder have shown that these patients exhibit impairment on measures of executive functioning. However, it is unclear whether executive dysfunction precedes the diagnosis of bipolar illness, or develops subsequent to its onset. Moreover, investigators have failed to control for the effects of premorbid attentional problems on cognitive performance in these patients. The present authors explored these questions using data from a longitudinal prospective study of individuals at risk for major mood disorder. Results revealed that 67% of participants who met criteria for bipolar disorder in young adulthood showed impairment on the Wisconsin Card Sorting Test (WCST) when they were assessed during adolescence, as compared with 17% of individuals with no major mood diagnosis, and 19% with unipolar depression. This association between performance on the WCST and bipolar illness was not accounted for by high rates of premorbid attentional disturbance. In fact, among participants with early attentional problems, only those who ultimately developed bipolar disorder exhibited impairment on the WCST. Early attentional problems that preceded unipolar depression or no mood disorder were not associated with executive dysfunction.

Boundaries of schizophrenia

The frontiers of schizophrenia are being increasingly challenged from several directions. In addition to ongoing debate as to divisions between schizophrenia and disorders of the schizophrenic spectrum, including schizotypal personality disorder and schizophreniform disorder, it has been suggested that obsessive-compulsive disorder might overlap phenomenologically with schizophrenia. There has been a long debate around the relationship of schizophrenia to affective disorders, particularly bipolar and schizoaffective disorder. The evidence suggests that although schizotypal personality and schizophreniform disorders are not homogeneous syndromes, they are related to or represent milder forms of schizophrenia. Obsessive-compulsive disorder seems to involve pathology in many of the same regions as observed in some patients with schizophrenia, which may account for the significant incidence of obsessive-compulsive symptoms in a subset of patients with schizophrenia. Despite similarities between schizophrenia and bipolar disorder, significant differences extend across suggested causes, phenomenology, and pathophysiology. These findings support the current conceptualization that the two disorders represent distinct disorders, probably with heterogeneous causes, rather than the ends of a spectrum of symptoms comprising a single syndrome. Schizoaffective disorder likely is made up of patients from the schizophrenic and bipolar cluster of illnesses. The long-standing debate as to the boundaries of schizophrenia is ultimately must await the eventual further elaboration of the underlying causes of schizophrenia and other psychotic disorders.

Neuropsychology of bipolar disorder: a review

BACKGROUND

Bipolar disorder (BD) may be associated with significant and persistent cognitive impairment. The aim of this study was to describe the profile of cognitive deficits in BD at different phases of the illness and determine whether it is different from that of schizophrenia and unipolar (UP) depression.

METHODS

A systematic review of the computerised literature of neuropsychological studies of BD published between 1980 and 2000.

RESULTS

General intellectual function: this was largely preserved in BD. Impairments when present were limited to acute episodes and to performance scores. Attention: attentional abnormalities were seen in symptomatic BD patients and persisted in remission in measures of sustained attention and inhibitory control. Memory: verbal memory was impaired even in euthymic patients while visuo-spatial memory deficits were variable depending on the tasks used. Executive function: all aspects of executive function (planning, abstract concept formation, set shifting) were impaired in symptomatic BD patients. Performance on executive function tests was sensitive to the presence of even residual symptoms but it may be normal in fully recovered patients with uncomplicated BD. Comparison to other patient groups: no major differences in cognitive profile between BD and UP depression were found. Remitted BD patients out-performed stable schizophrenics on most cognitive measures but this advantage disappeared when they were acutely symptomatic.

CONCLUSIONS

Symptomatic BD patients have widespread cognitive abnormalities. Trait related deficits appear to be present in verbal memory and sustained attention. Executive function and visual memory may be also affected at least in some recovered BD patients.

Social and clinical consequences of cognitive deficits in early psychosis: a two-year follow-up study of first-admitted patients

OBJECTIVE

To explore whether baseline memory and executive deficits predicted poor social and clinical outcome over the 2 years following a first admission for psychosis, regardless of categorical diagnosis.

METHOD

Cognitive functioning was assessed in first-admitted subjects with psychosis (n=35) with a neuropsychological battery of tests measuring executive, language and memory functions. Social and clinical outcome were assessed at 6-monthly intervals over a two-year follow-up using multiple sources of information.

RESULTS

A dose-response relationship was found between visual and verbal memory performance at first admission and clinical outcome over the 2-year follow-up: the poorer the memory performance, the more likely the risk of presenting with psychotic symptoms and rehospitalization. Poor baseline performance on the WCST executive function predicted better medication adherence. No association was found between cognitive performance and occupational or residential outcome.

CONCLUSION

Cognitive performance was a better predictor of clinical than social outcome in this sample of first-episode patients. The association between cognitive deficits and poor social outcome may be more marked in subjects with chronic psychosis than in first-episode subjects. The finding that cognitive deficits predict better medication adherence is in need of further exploration.

Executive control function in psychiatric and medical illness

Executive Control Function (ECF) is the ability to plan, sequence, and monitor one's behavior in order to accomplish a given goal while simultaneously exercising cognitive flexibility to adapt to changing task requirements. Multiple studies demonstrate that ECF predicts functional outcome, level of care required, and work potential for both well and ill populations. However, clinicians often do not routinely assess ECF during mental status evaluations because of the perceived lack of practical bedside tests. This review article discusses the major neuropsychological measures used to probe for impairment, with special emphasis on those that are easily administered at the patient's bedside. The current literature on executive dysfunction in psychiatric and medical illness is reviewed. The neuroanatomy and neurochemistry of ECF is also reviewed, with emphasis on structural dysfunction in specific illnesses. Finally, various treatment options, both pharmacological and psychotherapeutic, are discussed.

Spatial working memory performance in patients with schizoaffective psychosis versus schizophrenia: a tale of two disorders?

We explored the relationship between schizophrenia and schizoaffective disorder by comparing the two patient groups in terms of their performance on measures of executive functioning (spatial working memory and Wisconsin Card Sorting Test). Patients with schizophrenia (N=34) and those with schizoaffective disorder (N=23) performed significantly poorer than community controls (N=30). However, the schizoaffective and schizophrenia groups did not differ from each other in terms of working memory accuracy or mean response latencies. Similarly, the two patient groups did not differ in terms of the number of categories achieved or number of perseverative errors on the Wisconsin Card Sorting Test. Among the patients, working memory accuracy was associated with number of WCST perseverative errors and number of categories achieved, though working memory performance was not associated with number of WCST nonperseverative errors. These findings indicate that both schizophrenia and schizoaffective disorder are associated with executive functioning deficits. The findings are discussed in the context of the ongoing debate regarding the conceptualization of schizoaffective disorder.

Is it time to develop a new cognitive therapy for psychosis--cognitive remediation therapy (CRT)?

The cognitive difficulties associated with the disorder of schizophrenia seem to be predictive of future dependence on psychiatric services and predict social functioning. Cognitive remediation therapy (CRT) was designed to rehabilitate these cognitive functions, and the interest in it has grown dramatically over the past ten years. However, the programmes are rarely based on clear theoretical principles and sometimes rely heavily on practice rather than guided learning. The evidence for their efficacy is variable and seems to be dependent on the use of specific components of training. The current review tries to put this evidence into context and sets out a programme of research, which is essential in this area if future progress is to be made.