Clinicians' concepts of the cognitive deficits of schizophrenia

Evidence supporting the use of a brief cognitive assessment in routine clinical assessment for psychosis

Cognitive impairment is a core feature of psychosis. Full cognitive assessments are not often conducted in routine clinical practice as administration is time-consuming. Here, we investigated whether brief tests of cognition could be used to predict broader neurocognitive performance in a manner practical for screening use in mental health services. We carried out a principal component analysis (PCA) to obtain an estimate of general cognitive function (N = 415). We investigated whether brief tests of memory accounted for a significant percentage of variation in the PCA scores. We used discriminant function analysis to determine if measures could predict classification as lower, intermediate or higher level of cognitive function and to what extent these groups overlapped with groups based on normative data. Memory tests correctly classified 65% of cases in the highest scoring group, 35% of cases in the intermediate group, and 77% of cases in the lowest scoring group. These PCA-derived groups and groups based on normative scores for the two tests were significantly associated (χ2 = 164.00, p < 0.001). These measures accurately identified three quarters of the low performing group, the group of greatest interest from the perspective of identifying those likely to need greater supports as part of clinical care. In so doing they suggest a potentially useful approach to screening for cognitive impairment in clinical services, upon which further assessment can be built if required.

The Fracture of Relational Space in Depression: Predicaments in Primary Care Help Seeking

Primary care clinicians treat the majority of cases of depression in the United States. The primary care clinic is also a site for enactment of a disease-oriented concept of depression that locates disorder within an individual body. Drawing on theories of the self and stigma, this article highlights problematics of primary care depression treatment by examining the lived experience of depression. The data come from individuals who screened positive for depressive symptoms in primary care settings and were followed over ten years. After iterative mixed-methodological exploration of a large dataset, we analyzed interviews from a purposive sample of 46 individuals using grounded and phenomenological approaches. We describe two major results. First, we note that depression is experienced as located within and inextricable from relational space and that the self is experienced as relational, rather than autonomous, in depression. Second, we describe the ways in which the experience of depression contradicts a disease-oriented concept such that help-seeking intensifies rather than alleviates the relational problem of depression. We conclude by highlighting that an understanding of illness experience may be essential to improving primary care depression treatment and by questioning the bracketing of relational concerns in depression within the construct of stigma.

[Variants of cognitive development in children and adolescents with different forms of schizophrenia]

OBJECTIVE

To explore cognitive disorders in children and adolescents with schizophrenia from the perspective of cognitive dysontogenesis concept, assess severity and specificity of cognitive deficits and identify variants of the dynamics and types of cognitive development.

MATERIAL AND METHODS

Three diagnostic groups of patients were studied: 1) childhood onset schizophrenia, 2) schizotypal disorder, and 3) other types of schizophrenia. RESULTS AND СONCLUSION: There was a predomination of cognitive development types, named cognitive dysontogenesis, which structure was determined by a combination of the dynamics of cognitive development and severity of cognitive deficits. Severity and type of the dynamics of cognitive deficits were associated with the diagnosis and cognitive process.

The Experience of Cognitive Impairment in People with Psychosis

Cognitive impairment has been widely studied in people with psychosis. However, research is lacking into the subjective experience of cognitive impairment, its impact and ways in which individuals cope. This study aimed to provide an account of the experience of cognitive impairment in people with a diagnosis of schizophrenia, including what difficulties people experience, how these difficulties are understood, how people respond to these difficulties and how they perceive others' views of these difficulties. A semi-structured interview was carried out with eight participants with a diagnosis of schizophrenia focusing on participants' experiences of difficulties with cognitive functioning. Interpretative phenomenological analysis was used to analyse interview transcripts. Experience of cognitive impairment was understood in terms of six master themes: impaired controlled thinking, physical sensations and impaired movement, explanations for the impairment and comparisons to the past, managing the impairment, how others see the impairment and anticipating the future. This study is the first rigorous qualitative study of the subjective experience of cognitive impairment in people with psychosis, and it provides greater context for empirical findings. The results have significant implications for clinical psychology, including education about cognitive difficulties and the importance of cognitive functioning to formulation. New areas for research include coping strategies in relation to functioning and future perspectives, ascertaining staff understanding of cognitive impairment, and reflective conversation style as an intervention for metacognitive difficulties. Key Practitioner Message Difficulties with cognitive functioning should be considered in clinical practitioners' formulations of clients' difficulties in the context of psychosis. Services should consider providing service user and carer education about cognitive impairment in psychosis. Staff may need further training in order to support people with psychosis who have difficulties with cognitive functioning.

Identifying attentional deficits in people with first-episode psychosis with the Scale for the Assessment of Negative Symptoms attention subscale: is it possible?

OBJECTIVE

The aim of this study was to examine the correspondence between clinical ratings of inattention problems in the early course of a psychotic disorder and concurrent neuropsychological data for sustained attention and speed of processing/executive functioning (SP/EF) derived from a comprehensive neuropsychological test battery.

METHOD

A sample of 131 patients with first-episode psychosis (FEP) was clinically rated after clinical stabilization with the attention subscale of the Scale for the Assessment of Negative Symptoms (SANS) and a completed neuropsychological test battery, which included measurements of sustained attention and SP/EF. To test the associations of the clinical ratings and objective data, correlations and regression analyses were conducted.

RESULTS

Clinical ratings of inattention showed only weak correlations with the global score of SP/EF and with the clinical ratings of negative symptoms (ρ < 0.25). None of the independent variables entered in the logistic regression model were significant (all P values > .05). Percentages of agreement between clinical judgment and neuropsychological measures were unacceptably low (ranged from 53% to 68%). κ values indicate only slight agreement (κ < 0.2).

CONCLUSIONS

Clinical ratings based on the SANS attention subscale do not reliably match neuropsychological test measures of attention or other related cognitive processes in FEP. Even for those cognitive domains more pronouncedly impaired, mental health professionals will likely need to rely on psychometric testing or, alternatively, specific guidelines and also, probably, to collect data from different sources to adequately identify cognitive impairments.

Assessing function and functional outcome in schizophrenia

The diagnosis of schizophrenia can only be made in the presence of a loss of functioning in domains such as employment, independent living, and social functioning. Accurately measuring functioning is central to research on the course of the disorder, treatment and rehabilitation outcomes, and biosocial factors in schizophrenia. Assessments of functional disability have described three dimensions of functioning: functional capacity, functional performance, and functional outcome. The "competence/performance" distinction refers to the observation that an individual may demonstrate an ability to perform a functional task (capacity) but may not do so in her own community environment (performance). Functional outcomes are the result of both capacity and performance. Several recent reviews have compared the characteristics, reliability, and validity of various functional assessment instruments. Two major initiatives are underway to gather additional comparative data about functional assessment strategies. Recently, both the recovery movement and the recognition of the role of environmental factors in functioning have raised questions about the conceptual content of the functioning construct (construct validity). For instance, several studies have demonstrated that features of functioning need not track together over the course of the illness. In addition, the notion of recovery emphasizes processes like community integration and subjective well-being that are not static outcomes but are continually evolving features of the life course in chronic illness. Findings on the dynamic role of environmental moderators such as support and opportunity also present challenges to scientific constructs. For these reasons and others, the ecological validity of functional assessments has become a central concern. Both the verisimilitude and veridicality of functional assessments can be empirically assessed, but to date very few studies have measured the extent to which functional measures accurately predict individuals' behavior in their usual environments. Observational studies in naturalistic environments are one important area for future research.

A digit symbol coding task as a screening instrument for cognitive impairment in first-episode psychosis

Cognitive impairment may be detected largely by examining the performance on a single neuropsychological measure. The purpose of the present study was to evaluate the validity and diagnostic accuracy of a coding task in comparison with other related tasks. One hundred thirty-one first-episode psychosis patients were administered five cognitive tasks related to a "speed of processing and executive functioning" dimension (Digit Symbol, Trail Making Test [TMT] parts A and B, Cancellation Test, and Digit Span-backward) and an additional measure of functional outcome. Digit Symbol provided good indices of accuracy and correlations with the global composite score of a comprehensive neuropsychological assessment represented large effect sizes. Correlations with a functional outcome were modest. Similar results were observed with the TMT. The processing speed, as measured by Digit Symbol, may be particularly good in capturing the generalized dysfunction which may be causing the widespread cognitive failures in schizophrenia spectrum disorders.

Psychometric comparison of computerized and standard administration of the neurocognitive assessment instruments selected by the CATIE and MATRICS consortia among patients with schizophrenia

Neurocognitive assessment is an essential component for clinical trials of candidate "cognitive-enhancing" treatments for schizophrenia. However, manual administration of large, paper-based, neurocognitive batteries is often inefficient, error-prone, and inconsistent across multiple sites. Existing computerized testing systems are also limited both in the assessment instruments available and in the range of impairments that can be accommodated with the subject sitting alone at a single display. Therefore, a dual-display computerized testing system was developed, with funding from the National Institute of Mental Health (NIMH), that integrates (rather than replaces) the examiner for computerized administration of standard neurocognitive assessment batteries.

PURPOSE

To compare standard administration versions (SAVs) of tests selected by the NIMH-sponsored CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) and MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) consortia, with structurally- and functionally-equivalent, computerized administration versions (CAVs).

METHOD

116 outpatients with schizophrenia received both the SAVs and CAVs within one week and again, approximately 30 days later.

RESULTS

Intraclass Correlation Coefficient (ICC) comparisons between SAVs and CAVs yielded highly significant measures of absolute agreement for all tests, ranging 0.61-0.95. ICCs for test-retest reliability, ranging 0.56-0.94 for SAVs and 0.59-0.98 for CAVs, were also highly significant for both batteries, though significantly higher for CAVs overall.

CONCLUSIONS

The CAVs of the neurocognitive assessment instruments selected by the CATIE and MATRICS consortia are substantially equivalent to antecedent SAVs. Importantly, the increased reliability afforded by computerization highlight the potential for increasing power, thereby decreasing sample size requirements, for clinical evaluations of putative "cognitive-enhancing" treatments.