Cognitive rehabilitation of the updating sub-component of working memory in schizophrenia: A case study

Longitudinal course of core cognitive domains in first-episode acute and transient psychotic disorders compared with schizophrenia

Acute and transient psychotic disorder (ATPD) is characterized by acute onset of psychotic symptoms and early recovery. Contrastingly, schizophrenia (SZ) is a chronic mental disorder characterized by impaired functioning including a deficit in cognition. In SZ, the cognitive deficit is among the core symptoms, but in ATPDs, the existing evidence brings mixed results. Our primary aim was to compare three core cognitive domains (executive functioning/abstraction, speed of processing and working memory) of patients diagnosed with ATPD and SZ over a 12-month period. Moreover, we explored how these diagnostic subgroups differed in their clinical characteristics. We recruited 39 patients with a diagnosis of SZ and 31 with ATPD with schizophrenic symptoms. All patients completed clinical and neuropsychological assessments. At baseline, we used a one-way ANCOVA model with a group as the between-subjects factor. Mixed-model repeated-measures ANOVAs with time as the within-subjects factor and group as the between-subjects factor were run to test the overtime differences. At baseline, we did not find any differences in cognition - with sex, education and age as covariates - between ATPDs and SZ. After one year, all patients showed an improvement in all three domains, however, there were no significant overtime changes between ATPDs and SZ. Regarding clinical profiles, ATPDs demonstrated less severe psychopathology and better functioning compared to SZ both at baseline and after 12 months. The medication dosage differed at retest, but not at baseline between the groups. Our findings suggest clinical differences and a similar trajectory of cognitive performance between these diagnostic subgroups.

Retrieval practice improves memory in patients with schizophrenia: new perspectives for cognitive remediation

BACKGROUND

Schizophrenia is associated with severe cognitive deficits, particularly episodic memory deficits, that interfere with patients' socio-professional functioning. Retrieval practice (also known as testing effect) is a well-established episodic memory strategy that involves taking an initial memory test on a previously learned material. Testing later produces robust long-term memory improvements in comparison to the restudy of the same material both in healthy subjects and in some clinical populations with memory deficits. While retrieval practice might represent a relevant cognitive remediation strategy in patients with schizophrenia, studies using optimal procedures to explore the benefits of retrieval practice in this population are still lacking. Therefore, the purpose of our study was to investigate the benefits of retrieval practice in patients with schizophrenia.

METHODS

Nineteen stabilised outpatients with schizophrenia (DSM-5 criteria) and 20 healthy controls first studied a list of 60 word-pairs (30 pairs with weak semantic association and 30 non associated pairs). Half the pairs were studied again (restudy condition), while only the first word of the pair was presented and the subject had to recall the second word for the other half (retrieval practice condition). The final memory test consisted in a cued-recall which took place 2 days later. Statistical analyses were performed using Bayesian methods.

RESULTS

Cognitive performances were globally altered in patients. However, in both groups, memory performances for word-pairs were significantly better after retrieval practice than after restudy (56.1% vs 35.7%, respectively, Pr(RP > RS) > 0.999), and when a weak semantic association was present (64.7% vs 27.1%, respectively; Pr(weak > no) > 0.999). Moreover, the positive effect of RP was observed in all patients but one.

CONCLUSIONS

Our study is the first to demonstrate that retrieval practice efficiently improves episodic memory in comparison to restudy in patients with schizophrenia. This learning strategy should therefore be considered as a useful tool for cognitive remediation programs. In this perspective, future studies might explore retrieval practice using more ecological material.

A systematic review of moderators of cognitive remediation response for people with schizophrenia

Background

There is evidence that cognitive remediation (CR) is moderately effective in improving cognitive and functional difficulties in people with schizophrenia. However, there is still a limited understanding of what influence different treatment responses.

Aim

To identify moderators influencing CR response in people with schizophrenia.

Methods

This systematic review follows PRISMA guidelines. Searches were conducted up to January 2019 on PubMed and PsychInfo to identify randomized controlled trials of CR reporting analyses of moderators of treatment response. All papers were assessed for methodological quality and information on sample size, intervention and control condition, moderators, outcomes, effect of moderator on outcomes and demographic characteristics from each study was extracted and critically summarised.

Results

Thirty-six studies were included, considering 2737 participants. Study participants consisted on average of people in their late-thirties, mostly men, with over 10 years of illness. The review identified moderators that could be grouped into five categories: demographics, biological, cognitive and functional, psychological, and illness-related characteristics. The assessment of methodological quality showed that many studies had a high risk of bias.

Conclusions

There was no high-quality replicated evidence which identifies reliable moderators of CR response. Many moderators were not replicated or presented in single, underpowered studies. Studies also investigated moderators independently despite their potential to overlap (e.g. age and education). Future research should concentrate on evaluating, with sound studies, the role moderators may play in affecting CR treatment response. This information can inform who will benefit most from the therapy and help to improve the benefits of CR.

High Schizotypal Individuals Are More Creative? The Mediation Roles of Overinclusive Thinking and Cognitive Inhibition

Although a theoretical link between positive schizotypy and heightened creativity has been established in the literature, little empirical research has been conducted to examine the underlying cognitive processes that contribute to this association. In addition, previous studies found a negative relationship between positive schizotypy and cognitive inhibition; however, they often used the paradigm of latent inhibition. This study used the paradigm of prepotent response inhibition indicated by Stroop interference effect and examined the mediation effects of overinclusive thinking (OT) and cognitive inhibition on the creativity of schizotypal individuals. Two groups of low and high schizotypal individuals (N = 78) participated in the study. Each participant completed one OT task, one color-word Stroop task, three other executive functioning (EF) control tasks, and two creativity tasks. The results indicated that the high schizotypal group outperformed the low schizotypal group in the creativity tasks. They also exhibited higher OT as indicated by faster reaction time and higher cognitive inhibition as indicated by lower Stroop interference effect. Further, participant's levels of OT and cognitive inhibition partially mediated the relationship between schizotypy and creativity. The results were discussed under the context of schizotypy and creativity research and implications for rehabitation were further provided.

Specific vs general cognitive remediation for executive functioning in schizophrenia: a multicenter randomized trial

BACKGROUND

This study assesses the benefits of an individualized therapy (RECOS program) compared with the more general cognitive remediation therapy (CRT).

METHODS

138 participants took part with 65 randomized to CRT and 73 to RECOS. In the RECOS group, participants were directed towards one of five training modules (verbal memory, visuo-spatial memory and attention, working memory, selective attention or reasoning) corresponding to their key cognitive concern whereas the CRT group received a standard program. The main outcome was the total score on BADS (Behavioural Assessment of Dysexecutive Syndrome) and the secondary outcomes were: cognition (executive functions; selective attention; visuospatial memory and attention; verbal memory; working memory) and clinical measures (symptoms; insight; neurocognitive complaints; self-esteem). All outcomes were assessed at baseline (T1), week 12 (posttherapy, T2), and follow-up (week 36, i.e., 6months posttherapy, T3).

RESULTS

No difference was shown for the main outcome. A significant improvement was found for BADS' profile score for RECOS at T2 and T3, and for CRT at T3. Change in BADS in the RECOS and CRT arms were not significantly different between T1 and T2 (+0.86, p=0.108), or between T1 and T3 (+0.36, p=0.540). Significant improvements were found in several secondary outcomes including cognition (executive functions, selective attention, verbal memory, and visuospatial abilities) and clinician measures (symptoms and awareness to be hampered by cognitive deficits in everyday) in both treatment arms following treatment. Self-esteem improved only in RECOS arm at T3, and working memory improved only in CRT arm at T2 and T3, but there were no differences in changes between arms.

CONCLUSIONS

RECOS (specific remediation) and CRT (general remediation) globally showed similar efficacy in the present trial.

Rehabilitation of executive functions in a real-life setting: goal management training applied to a person with schizophrenia

The aim was to assess the efficacy of a modified version of Goal Management Training (GMT) in a person with schizophrenia who had difficulties in attaining the final goal for new and multitasking daily-life situations. GMT is designed to improve abilities in establishing goal-directed plans and carrying them out effectively. Beneficial effects of GMT were measured for several clinical questionnaires, laboratory tasks, and three real-life situations: meal preparation (trained, familiar); washing (nontrained, familiar); meeting preparation (nontrained, unfamiliar). The results revealed improvement in planning and on trained laboratory and meal preparation tasks and a generalization of GMT effects on nontrained laboratory and everyday tasks. Self-esteem also improved. Finally, a two-year followup indicated the durability of the beneficial effects.

An individualized and everyday life approach to cognitive rehabilitation in schizophrenia: a case illustration

Objective. The effectiveness of an individualized and everyday approach to cognitive rehabilitation for schizophrenia was examined in a case study. Method. After cognitive and functional assessment, concrete objectives were targeted for the person's everyday complaints. Strategies were constructed based on an analysis of the cognitive profile, daily life functioning, and processes involved in activities. They included a memory strategy for reading, a diary to compensate memory difficulties, and working memory exercises to improve immediate processing of information when reading and following conversations. Efficacy was assessed with outcome measures. Results. The program had beneficial effects on the person's cognitive and everyday functioning, which persisted at a 3-year follow-up. Conclusion. Findings provide suggestive evidence that an individualized and everyday approach may be a useful alternative in order to obtain a meaningfully lasting transfer of training to daily life, compared to the nomothetic ones which dominate the field.

The Effectiveness of the Attention Training Technique in Reducing Intrusive Thoughts in Schizophrenia

The aim of this study was to investigate the effectiveness of the attention training technique (ATT) on the frequency of intrusive thoughts experienced by a person with schizophrenia in her daily life. The attentional procedure was designed to attenuate self-focused attention and to reinforce attentional control and consisted of auditory external exercises. Homework practice was included to promote transfer to everyday life. The efficacy and specificity of the ATT were assessed with cognitive, functional, and control measures. The impact of ATT on symptomatology, work functioning, and self-esteem was also measured. Postrehabilitation results showed that, after nine training sessions, there was a reduction in intrusive thoughts for the cognitive and ecological outcome measures. Selective attention, attention switching, and resistance to distractive interference specifically improved. The person reported a reduction in intrusive thoughts in her daily life. In addition, positive symptoms decreased. Finally, a 6-month follow-up assessment revealed the maintenance of most of the beneficial effects in daily life.

Processing speed and working memory span: their differential role in superficial and deep memory processes in schizophrenia

Previous work has suggested that decrement in both processing speed and working memory span plays a role in the memory impairment observed in patients with schizophrenia. We undertook a study to examine simultaneously the effect of these two factors. A sample of 49 patients with schizophrenia and 43 healthy controls underwent a battery of verbal and visual memory tasks. Superficial and deep encoding memory measures were tallied. We conducted regression analyses on the various memory measures, using processing speed and working memory span as independent variables. In the patient group, processing speed was a significant predictor of superficial and deep memory measures in verbal and visual memory. Working memory span was an additional significant predictor of the deep memory measures only. Regression analyses involving all participants revealed that the effect of diagnosis on all the deep encoding memory measures was reduced to non-significance when processing speed was entered in the regression. Decreased processing speed is involved in verbal and visual memory deficit in patients, whether the task require superficial or deep encoding. Working memory is involved only insofar as the task requires a certain amount of effort.

Notes from Underground: Are Cognitive-Enhancing Drugs Respecting their Promises?

Cognitive deficits are increasingly acknowledged as a highly relevant clinical feature of schizophrenia, susceptible of therapeutic intervention. Considerable efforts have been devoted to identify and develop pharmacological agents that provide cognitive-enhancing benefits to patients with schizophrenia. However, results from studies are not univocal and the "real world" cognitive functioning gain provided by these agents seems disappointingly modest. Three issues are crucial in this respect. First, there is no convincing evidence that atypical agents are any better than typical agents in improving cognitive functioning. Second, even though studies observe statistically significant treatment effects on cognition, these gains are poor or imperceptible on a clinical and functional level. Third, studies do not report differences in treatment effect compared to placebo effect in terms of their cognitive enhancing effects. Finally, examples of interventions that do provide important and meaningful improvements in cognitive functioning in schizophrenia patients will be briefly presented.