Cognitive training in schizophrenia: a neuroscience-based approach

Working memory and sensory memory in subclinical high schizotypy: An avenue for understanding schizophrenia?

The search for robust, reliable biomarkers of schizophrenia remains a high priority in psychiatry. Biomarkers are valuable because they can reveal the underlying mechanisms of symptoms and monitor treatment progress and may predict future risk of developing schizophrenia. Despite the existence of various promising biomarkers that relate to symptoms across the schizophrenia spectrum, and despite published recommendations encouraging multivariate metrics, they are rarely investigated simultaneously within the same individuals. In those with schizophrenia, the magnitude of purported biomarkers is complicated by comorbid diagnoses, medications and other treatments. Here, we argue three points. First, we reiterate the importance of assessing multiple biomarkers simultaneously. Second, we argue that investigating biomarkers in those with schizophrenia-related traits (schizotypy) in the general population can accelerate progress in understanding the mechanisms of schizophrenia. We focus on biomarkers of sensory and working memory in schizophrenia and their smaller effects in individuals with nonclinical schizotypy. Third, we note irregularities across research domains leading to the current situation in which there is a preponderance of data on auditory sensory memory and visual working memory, but markedly less in visual (iconic) memory and auditory working memory, particularly when focusing on schizotypy where data are either scarce or inconsistent. Together, this review highlights opportunities for researchers without access to clinical populations to address gaps in knowledge. We conclude by highlighting the theory that early sensory memory deficits contribute negatively to working memory and vice versa. This presents a mechanistic perspective where biomarkers may interact with one another and impact schizophrenia-related symptoms.

Effectiveness of a Computerized Home-Based Cognitive Stimulation Program for Treating Cancer-Related Cognitive Impairment

Cancer patients assert that after chemotherapy their cognitive abilities have deteriorated. Cognitive stimulation is the clinical treatment of choice for reversing cognitive decline. The current study describes a computerized home-based cognitive stimulation program in patients who survived breast cancer. It aims to assess safety and effectiveness of cognitive stimulation in the oncology population. A series of 45-min training sessions was completed by the participants. A thorough assessment was performed both before and after the intervention. The mini-Mental Adjustment to Cancer Scale, the Cognitive Assessment for Chemo Fog Research, and the Functionality Assessment Instrument in Cancer Treatment-Cognitive Function served as the main assessment tools. The State-Trait Anxiety Inventory, Beck Depression Inventory, Brief Fatigue Inventory, and Measuring Quality of Life-The World Health Organization data were gathered as secondary outcomes. Home-based cognitive stimulation demonstrated beneficial effects in the oncology population, with no side effects being reported. Cognitive, physical, and emotional improvements were observed, along with decreased interference in daily life activities and a better overall quality of life.

A combined exercise and cognitive training intervention induces fronto-cingulate cortical plasticity in first-episode psychosis patients

OBJECTIVE

Schizophrenia (SZ) is characterized by neurobiological and associated cognitive and functional deficits, including pronounced cortical thinning, that lead to acute and long-term functional impairment. Research with older adults supports the role of non-pharmacological interventions, such as exercise (E) and cognitive training (CT), for cognitive impairments. This literature influenced the development of combined CT&E treatments for individuals with SZ. However, the impact of longer combined treatment duration (6 months) on neuroanatomy has yet to be explored in patients in the early course of the illness. The impact of adding exercise to cognitive training for key brain regions associated with higher-order cognition was examined here using magnetic resonance imaging (MRI) in first-episode psychosis (FEP) patients.

METHODS

UCLA Aftercare Research Program patients with a recent first episode of schizophrenia were randomly assigned to either combined cognitive and exercise training (CT&E) (N = 20) or cognitive training alone (CT) (N = 17) intervention. Cortical thickness was measured longitudinally and analyzed for two regions of interest using FreeSurfer.

RESULTS

Compared to patients in the CT group, those in the CT&E group demonstrated an increase in cortical thickness within the left anterior cingulate cortex over the six-month treatment period (ACC: F(1, 35) = 4.666, P < .04). Directional tendencies were similar in the left dorsolateral prefrontal cortex (DLPFC: F(1,35) = 4.132, P < .05).

CONCLUSIONS

These findings suggest that exercise and cognitive training may synergistically increase fronto-cingulate cortical thickness to mitigate progressive neural atrophy in the early course of SZ. This combined intervention appears to be a valuable adjunct to standard pharmacologic treatment in FEP patients.

Expectation effects in working memory training

There is a growing body of research focused on developing and evaluating behavioral training paradigms meant to induce enhancements in cognitive function. It has recently been proposed that one mechanism through which such performance gains could be induced involves participants' expectations of improvement. However, no work to date has evaluated whether it is possible to cause changes in cognitive function in a long-term behavioral training study by manipulating expectations. In this study, positive or negative expectations about cognitive training were both explicitly and associatively induced before either a working memory training intervention or a control intervention. Consistent with previous work, a main effect of the training condition was found, with individuals trained on the working memory task showing larger gains in cognitive function than those trained on the control task. Interestingly, a main effect of expectation was also found, with individuals given positive expectations showing larger cognitive gains than those who were given negative expectations (regardless of training condition). No interaction effect between training and expectations was found. Exploratory analyses suggest that certain individual characteristics (e.g., personality, motivation) moderate the size of the expectation effect. These results highlight aspects of methodology that can inform future behavioral interventions and suggest that participant expectations could be capitalized on to maximize training outcomes.

A Case for Thalamic Mechanisms of Schizophrenia: Perspective From Modeling 22q11.2 Deletion Syndrome

Schizophrenia is a severe, chronic psychiatric disorder that devastates the lives of millions of people worldwide. The disease is characterized by a constellation of symptoms, ranging from cognitive deficits, to social withdrawal, to hallucinations. Despite decades of research, our understanding of the neurobiology of the disease, specifically the neural circuits underlying schizophrenia symptoms, is still in the early stages. Consequently, the development of therapies continues to be stagnant, and overall prognosis is poor. The main obstacle to improving the treatment of schizophrenia is its multicausal, polygenic etiology, which is difficult to model. Clinical observations and the emergence of preclinical models of rare but well-defined genomic lesions that confer substantial risk of schizophrenia (e.g., 22q11.2 microdeletion) have highlighted the role of the thalamus in the disease. Here we review the literature on the molecular, cellular, and circuitry findings in schizophrenia and discuss the leading theories in the field, which point to abnormalities within the thalamus as potential pathogenic mechanisms of schizophrenia. We posit that synaptic dysfunction and oscillatory abnormalities in neural circuits involving projections from and within the thalamus, with a focus on the thalamocortical circuits, may underlie the psychotic (and possibly other) symptoms of schizophrenia.

Cognitive Flexibility and Reaction Time Improvements After Cognitive Training Designed for Men Perpetrators of Intimate Partner Violence: Results of a Pilot Randomized Controlled Trial

Purpose Current interventions for intimate partner violence (IPV) perpetrators are designed to reduce IPV recidivism by treating risk factors and increasing protective factors. However, these interventions pay less attention to cognitive functioning in IPV perpetrators and how these variables interfere with the future risk of recidivism. Therefore, the main objective of this research was to compare the effectiveness of Standard Intervention Programs for men who perpetrate IPV [SIP] + cognitive training vs SIP + placebo training in promoting cognitive improvements and reducing recidivism. Furthermore, we also aimed to assess whether changes in the risk of recidivism would be related to cognitive changes after the intervention. Method IPV perpetrators who agreed to participate were randomly allocated to receive SIP + cognitive training or SIP + placebo training. Several cognitive variables were assessed before and after the interventions with a complete battery of neuropsychological tests assessing processing speed, memory, attention, executive functions, and emotion decoding abilities. Moreover, we also assessed the risk of recidivism. Results Our data pointed out that only the IPV perpetrators who received the SIP + cognitive training improved their processing speed and cognitive flexibility after this intervention. Furthermore, these participants presented the lowest risk of recidivism after the intervention. Nonetheless, cognitive improvements and reductions in the risk of recidivism after the intervention were unrelated. Conclusions Our study reinforces the importance of implementing cognitive training to reduce risk of recidivism after SIP. Hence, these results might encourage professionals to incorporate neuropsychological variables in IPV intervention programs.

Targeting executive function for weight loss in adults with overweight or obesity

Obesity is associated with a multitude of negative health sequalae. Behavioral weight loss (BWL) is currently the recommended behavioral treatment for obesity; however, it is not effective for approximately half of the individuals who participate. BWL requires individuals to carry out many tasks requiring executive function (EF; i.e., higher order cognitive functions such as planning and problem solving) in order to be successful. Growing research supports that lower EF may be associated with attenuated weight loss following BWL, and targeting EF in treatment could improve outcomes. This paper aims to describe the rationale for the development of Novel Executive Function Training for Obesity (NEXT), which adapts Compensatory Cognitive Training to be delivered in conjunction with BWL. We summarize evidence relating EF to obesity and reduced weight loss following BWL, as well as the past success of cognitive training on EF. Then we describe the treatment model for NEXT followed by initial data suggesting that NEXT is feasible and acceptable and may impact EF and weight. Obesity treatments incorporating cognitive training, especially those that train compensatory strategies, may improve weight-loss outcomes and provide a more durable treatment than traditional interventions, but larger randomized control trials are necessary.

Video games for people with schizophrenia

BACKGROUND

Commercial video games are a vastly popular form of recreational activity. Whilst concerns persist regarding possible negative effects of video games, they have been suggested to provide cognitive benefits to users. They are also frequently employed as control interventions in comparisons of more complex cognitive or psychological interventions. If independently effective, video games - being both engaging and relatively inexpensive - could provide a much more cost-effective add-on intervention to standard treatment when compared to costly, cognitive interventions.

OBJECTIVES

To review the effects of video games (alone or as an additional intervention) compared to standard care alone or other interventions including, but not limited to, cognitive remediation or cognitive behavioural therapy for people with schizophrenia or schizophrenia-like illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (March 2017, August 2018, August 2019).

SELECTION CRITERIA

Randomised controlled trials focusing on video games for people with schizophrenia or schizophrenia-like illnesses.

DATA COLLECTION AND ANALYSIS

Review authors extracted data independently. For binary outcomes we calculated risk ratio (RR) with its 95% confidence interval (CI) on an intention-to-treat basis. For continuous data we calculated the mean difference (MD) between groups and its CI. We employed a fixed-effect model for analyses. We assessed risk of bias for the included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

This review includes seven trials conducted between 2009 and 2018 (total = 468 participants, range 32 to 121). Study duration varied from six weeks to twelve weeks. All interventions in the included trials were given in addition to standard care, including prescribed medication. In trials video games tend to be the control for testing efficacy of complex, cognitive therapies; only two small trials evaluated commercial video games as the intervention. We categorised video game interventions into 'non-exergame' (played statically) and 'exergame' (the players use bodily movements to control the game). Our main outcomes of interest were clinically important changes in: general functioning, cognitive functioning, social functioning, mental state, quality of life, and physical fitness as well as clinically important adverse effects. We found no clear difference between non-exergames and cognitive remediation in general functioning scores (Strauss Carpenter Outcome Scale) (MD 0.42, 95% CI -0.62 to 1.46; participants = 86; studies = 1, very low-quality evidence) or social functioning scores (Specific Levels of Functioning Scale) (MD -3.13, 95% CI -40.17 to 33.91; participants = 53; studies = 1, very low-quality evidence). There was a clear difference favouring cognitive remediation for cognitive functioning (improved on at least one domain of MATRICS Consensus Cognitive Battery Test) (RR 0.58, 95% CI 0.34 to 0.99; participants = 42; studies = 1, low-quality evidence). For mental state, Positive and Negative Syndrome Scale (PANSS) overall scores showed no clear difference between treatment groups (MD 0.20, 95% CI -3.89 to 4.28; participants = 269; studies = 4, low-quality evidence). Quality of life ratings (Quality of Life Scale) similarly showed no clear intergroup difference (MD 0.01, 95% CI -0.40 to 0.42; participants = 87; studies = 1, very low-quality evidence). Adverse effects were not reported; we chose leaving the study early as a proxy measure. The attrition rate by end of treatment was similar between treatment groups (RR 0.96, 95% CI 0.87 to 1.06; participants = 395; studies = 5, low-quality evidence). One small trial compared exergames with standard care, but few outcomes were reported. No clear difference between interventions was seen for cognitive functioning (measured by MATRICS Consensus Cognitive Battery Test) (MD 2.90, 95% CI -1.27 to 7.07; participants = 33; studies = 1, low-quality evidence), however a benefit in favour of exergames was found for average change in physical fitness (aerobic fitness) (MD 3.82, 95% CI 1.75 to 5.89; participants = 33; studies = 1, low-quality evidence). Adverse effects were not reported; we chose leaving the study early as a proxy measure. The attrition rate by end of treatment was similar between treatment groups (RR 1.06, 95% CI 0.75 to 1.51; participants = 33; studies = 1). Another small trial compared exergames with non-exergames. Only one of our main outcomes was reported - physical fitness, which was measured by average time taken to walk 3 metres. No clear intergroup difference was identified at six-week follow-up (MD -0.50, 95% CI -1.17 to 0.17; participants = 28; studies = 1, very low-quality evidence). No trials reported adverse effects. We chose leaving the study early as a proxy outcome.

AUTHORS' CONCLUSIONS

Our results suggest that non-exergames may have a less beneficial effect on cognitive functioning than cognitive remediation, but have comparable effects for all other outcomes. These data are from a small number of trials, and the evidence is graded as of low or very low quality and is very likely to change with more data. It is difficult to currently establish if the more sophisticated cognitive approaches do any more good - or harm - than 'static' video games for people with schizophrenia. Where players use bodily movements to control the game (exergames), there is very limited evidence suggesting a possible benefit of exergames compared to standard care in terms of cognitive functioning and aerobic fitness. However, this finding must be replicated in trials with a larger sample size and that are conducted over a longer time frame. We cannot draw any firm conclusions regarding the effects of video games until more high-quality evidence is available. There are ongoing studies that may provide helpful data in the near future.

The effects of background music tempo on the work attention performance of workers with schizophrenia

BACKGROUND

Work attention in employees with schizophrenia is a significant issue in vocational rehabilitation. Background music is very popular in workplaces, and according to some investigations, can help increase attention at work if utilized appropriately.

OBJECTIVE

This study investigates the influence of background music tempo on attention performance in employees with chronic schizophrenia.

METHODS

A randomized controlled trial (RCT) study was performed to test the attention of 240 participants with chronic schizophrenia under four conditions, namely no music, fast tempo, slow tempo and white noise.

RESULTS

Employees with schizophrenia achieved higher attention scores under background music than in a no-music environment. Additionally, slow-tempo music produced higher attention scores than fast-tempo music.

CONCLUSIONS

Observational results indicate that slow-tempo background music is more desirable than fast-tempo background music in a work environment involving schizophrenic individuals.

The impact of video gaming on cognitive functioning of people with schizophrenia (GAME-S): study protocol of a randomised controlled trial

BACKGROUND

Video gaming is a promising intervention for cognitive and social impairment in patients with schizophrenia. A number of gaming interventions have been evaluated in small-scale studies with various patient groups, but studies on patients with schizophrenia remain scarce and rarely include the evaluation of both clinical and neurocognitive outcomes. In this study, we will test the effectiveness of two interventions with gaming elements to improve cognitive and clinical outcomes among persons with schizophrenia.

METHODS

The participants will be recruited from different outpatient units (e.g., outpatient psychiatric units, day hospitals, residential care homes). The controlled clinical trial will follow a three-arm parallel-group design: 1) cognitive training (experimental group, CogniFit), 2) entertainment gaming (active control group, SIMS 4), and 3) treatment as usual. The primary outcomes are working memory function at 3-month and 6-month follow-ups. The secondary outcomes are patients' other cognitive and social functioning, the ability to experience pleasure, self-efficacy, and negative symptoms at 3-month and 6-month follow-ups. We will also test the effectiveness of gaming interventions on neurocognitive outcomes (EEG and 3 T MRI plus rs-fMRI) at a 3-month follow-up as an additional secondary outcome. Data will be collected in outpatient psychiatric services in Hong Kong. Participants will have a formal diagnosis of schizophrenia and be between 18 and 60 years old. We aim to have a total of 234 participants, randomly allocated to the three arms. A sub-sample of patients (N = 150) will be recruited to undergo an EEG. For neuroimaging assessment, patients will be randomly allocated to a subset of patients (N=126). We will estimate the efficacy of the interventions on the primary and secondary outcomes based on the intention-to-treat principle. Behavioural and EEG data will be analysed separately.

DISCUSSION

The study will characterise benefits of gaming on patients' health and well-being, and contribute towards the development of new treatment approaches for patients with schizophrenia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03133143 . Registered on April 28, 2017.

Changes in Error Patterns during N-back Training Indicate Reliance on Subvocal Rehearsal

Contemporary cognitive training literature suggests that training on an adaptive task produces improvements only in the trained task or near transfer effects. No study has yet systematically explained the mechanism behind improved performance on the N-back. In this study, we first investigated how improvements in an N-back task using eight pairs of phonologically similar words as stimuli occurred by examining error distributions of the task over training sessions. Nineteen participants (non-native English speakers) trained for 20 sessions over 5 weeks. We observed a reduction in false alarms to non-target words and fewer missed target words. Though the absolute number of phonological-based errors reduced as training progressed, the proportion of this error type did not decrease over time suggesting participants increasingly relied on subvocal rehearsal in completing the N-back. In the second experiment, we evaluated if improvements developed during N-back training transferred to tasks that relied on serial order memory using simple span tasks (letter span with phonologically distinct letters, letter span with phonologically similar letters, digit span forward, and digit span backward). Twenty-nine participants trained on the N-back and 16 trained on the Operation Span (OSPAN) for 15 sessions over 4 weeks. Neither group of participants showed improvements on any of the simple span tasks. In the third experiment, 20 participants (16 native English speakers) trained on the N-back for 15 sessions over 4 weeks also showed increasing reliance on subvocal rehearsal as they progressed through training. Self-report strategy use did not predict improvements on the N-back.

Are working memory and glutamate concentrations involved in early-life stress and severity of psychosis?

OBJECTIVE

Occurrences of early-life stress (ELS) are associated with the severity of psychotic symptoms and working memory (WM) deficits in patients with psychosis (PSY). This study investigated potential mediation roles of WM behavioral performance and glutamate concentrations in prefrontal brain regions on the association between ELS and psychotic symptom severity in PSY.

METHOD

Forty-seven patients with PSY (established schizophrenia, n = 30; bipolar disorder, n = 17) completed measures of psychotic symptom severity. In addition, data on ELS and WM performance were collected in both patients with PSY and healthy controls (HC; n = 41). Resting-state glutamate concentrations in the bilateral dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC) were also assessed with proton magnetic resonance spectroscopy for both PSY and HC groups. t tests, analyses of variance, and regression analyses were utilized.

RESULTS

Participants with PSY reported significantly more ELS occurrences and showed poorer WM performance than HC. Furthermore, individuals with PSY displayed lower glutamate concentrations in the left DLPFC than HC. Neither ELS nor WM performance were predictive of severity of psychotic symptoms in participants with PSY. However, we found a significant negative correlation between glutamate concentrations in the left DLPFC and ELS occurrence in HC only.

CONCLUSION

In individuals with PSY, the current study found no evidence that the association between ELS and psychotic symptoms is mediated by WM performance or prefrontal glutamate concentrations. In HC, the association between ELS experience and glutamate concentrations may indicate a neurometabolite effect of ELS that is independent of an illness effect in psychosis.

Attention modulates topology and dynamics of auditory sensory gating

This work challenges the widely accepted model of sensory gating as a preattention inhibitory process by investigating whether attention directed at the second tone (S2) within a paired-click paradigm could affect gating at the cortical level. We utilized magnetoencephalography, magnetic resonance imaging and spatio-temporal source localization to compare the cortical dynamics underlying gating responses across two conditions (passive and attention) in 19 healthy subjects. Source localization results reaffirmed the existence of a fast processing pathway between the prefrontal cortex (PFC) and bilateral superior temporal gyri (STG) that underlies the auditory gating process. STG source dynamics comprised two gating sub-components, Mb1 and Mb2, both of which showed significant gating suppression (>51%). The attention directed to the S2 tone changed the gating network topology by switching the prefrontal generator from a dorsolateral location, which was active in the passive condition (18/19), to a medial location, active in the attention condition (19/19). Enhanced responses to the attended stimulus caused a significant reduction in gating suppression in both STG gating components (>50%). Our results demonstrate that attention not only modulates sensory gating dynamics, but also exerts topological rerouting of information processing within the PFC. The present data, suggesting that the cortical levels of early sensory processing are subject to top-down influences, change the current view of gating as a purely automatic bottom-up process.

Observation and Imitation of Social Emotions Are Essential for Improving Cognitive and Affective Theory of Mind in Schizophrenia: A Meta-analysis

People with schizophrenia often demonstrate deficits in theory of mind (ToM), which may be addressed via social cognition training that includes observation and imitation of social emotions. We examined the effect of observation and imitation on ToM and whether computerized cognitive training (CCT) can improve ToM. Among 14 controlled trials, 264 of 494 people with schizophrenia received treatment. Observation and imitation of social emotions improved cognitive (g = 0.53; 95% confidence interval [CI], 0.29-0.76) and affective ToM (g = 0.54; 95% CI, 0.34-0.73), versus treatment as usual or cognitive rehabilitation alone. CCT did not significantly enhance affective ToM (p = 0.42); however, cognitive ToM improvements without CCT (g = 1.20; 95% CI, 0.78-1.61) were superior to those with CCT (g = 0.33; 95% CI, 0.02-0.64; p < 0.01). Observation and imitation of social emotions are essential for improving ToM in schizophrenia, but CCT may not improve ToM.

Improving emotion recognition in schizophrenia with "VOICES": An on-line prosodic self-training

Introduction

Emotion recognition (ER) deficits have been extensively demonstrated in schizophrenia. These deficiencies are not only restricted to facial emotion recognition but also include emotional prosody (tone of the voice) recognition deficits. They have been significantly associated with symptom severity and poor social functioning. The aim of this study was to test the efficacy, in real clinical conditions, of an online self-training prosodic game included in the Social Cognition rehabilitation program e-Motional Training.

Method

A randomized, single-blind multicenter clinical trial was conducted with 50 outpatients with schizophrenia or schizoaffective disorder. The control group was treated with Treatment-as-usual (TAU), based on drug therapy, case management and individual and group psychotherapy (not focused on Social Cognition). The intervention group was treated with TAU plus the employment of Voices, an online self-training program devised for prosodic rehabilitation.

Statistical analysis

Linear regression was used to evaluate the effectiveness of the intervention in emotion recognition measured with the Reading the Mind in the Voice–Spanish Version (RMV-SV).

Results

There were statistically significant differences between the intervention and control group measured with RMV-SV (β = 3,6[IC 95%], p<0.001), with a response variable in RMV post R² = 0,617.

Discussion

Voices, a prosodic rehabilitation game included in e-Motional Training, seems to be a promising tool for improving emotional voice recognition deficits in schizophrenia, filling the need for such interventions.

Factors Associated With Response and Resistance to Cognitive Remediation in Schizophrenia: A Critical Review

Cognitive impairment is a central feature of schizophrenia and has shown to play a crucial role in the psychosocial function of the disorder. Over the past few years, several cognitive remediation (CR) interventions have been developed for schizophrenia, whose effectiveness has also been widely demonstrated by systematic reviews and meta-analysis studies. Despite these evidences, many questions remain open. In particular, the identification of CR response predictors in patients with schizophrenia is still a topic with equivocal findings and only a few studies have looked for the relationship between CR response or resistance and the biological, socio-demographic, clinical and cognitive features in schizophrenia. The current knowledge on positive or negative response predictors to CR treatment in schizophrenia include: age, duration of illness, premorbid adjustment, baseline cognitive performance, intrinsic motivation, hostility, disorganized symptoms, neurobiological reserve, genetic polymorphisms, the amounts of antipsychotics, the type of CR, etc. The aim of this review is to identify neurobiological, psychopathological, cognitive, and functional predictors of CR response or resistance in schizophrenia, taking into account both cognitive and functional outcome measures. The information obtained could be very useful in planning integrated and personalized interventions, also with a better use of the available resources.

Neural correlates of cognitive deficits across developmental phases of schizophrenia

Schizophrenia is associated with cognitive deficits across all stages of the illness (i.e., high risk, first episode, early and chronic phases). Identifying the underlying neurobiological mechanisms of these deficits is an important area of scientific inquiry. Here, we selectively review evidence regarding the pattern of deficits across the developmental trajectory of schizophrenia using the five cognitive domains identified by the Research Domain Criteria (RDoC) initiative. We also report associated findings from neuroimaging studies. We suggest that most cognitive domains are affected across the developmental trajectory, with corresponding brain structural and/or functional differences. The idea of a common mechanism driving these deficits is discussed, along with implications for cognitive treatment in schizophrenia.

Strategy for Semantic Association Memory (SESAME) training: Effects on brain functioning in schizophrenia

Self-initiation of semantic encoding strategies is impoverished in schizophrenia and contributes to memory impairments. Recently, we observed that following a brief training, schizophrenia patients had the potential to increase the self-initiation of these strategies. In this study, we investigated the neural correlates underlying such memory improvements. Fifteen schizophrenia patients with deficits in self-initiation of semantic encoding strategies were enrolled in a Strategy for Semantic Association Memory (SESAME) training. Patients underwent a memory task in an fMRI scanner. Memory performance and brain activity during the task were measured pre- and post- training, and changes following training were assessed. We also investigated if structural preservation measured by the cortical thickness of the left dorsolateral prefrontal cortex (DLPFC) predicted memory improvement post-training. Memory training led to significant improvements in memory performance that were associated with increased activity in the left DLPFC, during a task in which patients needed to self-initiate semantic encoding strategies. Furthermore, patients with more cortical reserve in their left DLPFC showed greater memory improvement. Our findings provide evidence of neural malleability in the left DLPFC in schizophrenia using cognitive strategies training. Moreover, the brain-behavioural changes observed in schizophrenia provide hope that memory performance can be improved with a brief intervention.

Using EEG-Guided Basket and Umbrella Trials in Psychiatry: A Precision Medicine Approach for Cognitive Impairment in Schizophrenia

Due to advances over the last several decades, many fields of medicine are moving toward a precision medicine approach where treatments are tailored to nuanced patient factors. While in some disciplines these innovations are commonplace leading to unique biomarker-guided experimental medicine trials, there are no such analogs in psychiatry. In this brief review, we will overview two unique biomarker-guided trial designs for future use in psychiatry: basket and umbrella trials. We will illustrate how such trials could be useful in psychiatry using schizophrenia as a candidate illness, the EEG measure mismatch negativity as the candidate biomarker, and cognitive impairment as the target disease dimension.

Verbal working memory and functional large-scale networks in schizophrenia

The aim of this study was to test whether bilinear and nonlinear effective connectivity (EC) measures of working memory fMRI data can differentiate between patients with schizophrenia (SZ) and healthy controls (HC). We applied bilinear and nonlinear Dynamic Causal Modeling (DCM) for the analysis of verbal working memory in 16 SZ and 21 HC. The connection strengths with nonlinear modulation between the dorsolateral prefrontal cortex (DLPFC) and the ventral tegmental area/substantia nigra (VTA/SN) were evaluated. We used Bayesian Model Selection at the group and family levels to compare the optimal bilinear and nonlinear models. Bayesian Model Averaging was used to assess the connection strengths with nonlinear modulation. The DCM analyses revealed that SZ and HC used different bilinear networks despite comparable behavioral performance. In addition, the connection strengths with nonlinear modulation between the DLPFC and the VTA/SN area showed differences between SZ and HC. The adoption of different functional networks in SZ and HC indicated neurobiological alterations underlying working memory performance, including different connection strengths with nonlinear modulation between the DLPFC and the VTA/SN area. These novel findings may increase our understanding of connectivity in working memory in schizophrenia.

The Role of Working Memory for Cognitive Control in Anorexia Nervosa versus Substance Use Disorder

Prefrontal cortex executive functions, such as working memory (WM) interact with limbic processes to foster impulse control. Such an interaction is referred to in a growing body of publications by terms such as cognitive control, cognitive inhibition, affect regulation, self-regulation, top-down control, and cognitive–emotion interaction. The rising trend of research into cognitive control of impulsivity, using various related terms reflects the importance of research into impulse control, as failure to employ cognitions optimally may eventually result in mental disorder. Against this background, we take a novel approach using an impulse control spectrum model – where anorexia nervosa (AN) and substance use disorder (SUD) are at opposite extremes – to examine the role of WM for cognitive control. With this aim, we first summarize WM processes in the healthy brain in order to frame a systematic review of the neuropsychological, neural and genetic findings of AN and SUD. In our systematic review of WM/cognitive control, we found n = 15 studies of AN with a total of n = 582 AN and n = 365 HC participants; and n = 93 studies of SUD with n = 9106 SUD and n = 3028 HC participants. In particular, we consider how WM load/capacity may support the neural process of excessive epistemic foraging (cognitive sampling of the environment to test predictions about the world) in AN that reduces distraction from salient stimuli. We also consider the link between WM and cognitive control in people with SUD who are prone to ‘jumping to conclusions’ and reduced epistemic foraging. Finally, in light of our review, we consider WM training as a novel research tool and an adjunct to enhance treatment that improves cognitive control of impulsivity.

Perspectives on the Use of eHealth in the Management of Patients With Schizophrenia

Mobile devices, digital technologies, and web-based applications-known collectively as eHealth (electronic health)-could improve health care delivery for costly, chronic diseases such as schizophrenia. Pharmacologic and psychosocial therapies represent the primary treatment for individuals with schizophrenia; however, extensive resources are required to support adherence, facilitate continuity of care, and prevent relapse and its sequelae. This paper addresses the use of eHealth in the management of schizophrenia based on a roundtable discussion with a panel of experts, which included psychiatrists, a medical technology innovator, a mental health advocate, a family caregiver, a health policy maker, and a third-party payor. The expert panel discussed the uses, benefits, and limitations of emerging eHealth with the capability to integrate care and extend service accessibility, monitor patient status in real time, enhance medication adherence, and empower patients to take a more active role in managing their disease. In summary, to support this technological future, eHealth requires significant research regarding implementation, patient barriers, policy, and funding.

A Case Study on Promoting Neuroplasticity in a Patient With Schizophrenia

PURPOSE

The purpose of this study is to introduce the concept of neuroplasticity, explore strategies that psychiatric nurse practitioners can use to improve cognitive functioning, and apply these strategies to a case study of a patient diagnosed with schizophrenia.

DESIGN AND METHODS

This study used an explanatory descriptive approach with a single-case study to describe cognitive functioning in people with schizophrenia and to illustrate practical implications.

FINDINGS

Schizophrenia is a severe mental illness with typical onset in late adolescence and young adulthood. Cognitive impairment often accompanies schizophrenia and may lead to significant functional impairment. Research demonstrates that the brain is able to change (neuroplasticity) in response to environmental stimuli either negatively or positively. Evidence suggests intervention, including cognitive remediation, physical activity, and sleep, can positively modify neuroplasticity in schizophrenia and improve cognitive function, which may lead to improved quality of life.

PRACTICE IMPLICATIONS

Psychiatric mental health nurses need to offer cognitive enhancing strategies to take advantage of neuroplasticity. Ongoing nursing education regarding therapeutic neurocognitive approaches from basic research should be emphasized.

Task-independent effects are potential confounders in longitudinal imaging studies of learning in schizophrenia

Learning impairment is a core deficit in schizophrenia that impacts on real-world functioning and yet, elucidating its underlying neural basis remains a challenge. A key issue when interpreting learning-task experiments is that task-independent changes may confound interpretation of task-related signal changes in neuroimaging studies. The nature of these task-independent changes in schizophrenia is unknown. Therefore, we examined task-independent “time effects” in a group of participants with schizophrenia contrasted with healthy participants in a longitudinal fMRI learning-experiment designed to allow for examination of non-specific effects of time. Flanking the learning portions of the experiment with a task-of-no-interest allowed us to extract task-independent BOLD changes. Task-independent effects occurred in both groups, but were more robust in the schizophrenia group. There was a significant interaction effect between group and time in a distributed activity pattern that included inferior and superior temporal regions, frontal areas (left anterior insula and superior medial gyri), and parietal areas (posterior cingulate cortices and precuneus). This pattern showed task-independent linear decrease in BOLD amplitude over the two scanning sessions for the schizophrenia group, but showed either opposite effect or no activity changes for the control group. There was a trend towards a correlation between task-independent effects and the presence of more negative symptoms in the schizophrenia group.

The strong interaction between group and time suggests that both the scanning experience as a whole and the transition between task-types evokes a different response in persons with schizophrenia and may confound interpretation of learning-related longitudinal imaging experiments if not explicitly considered.

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A robust method was used to identify task-independent fMRI BOLD changes in a multiday learning experiment in schizophrenia

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Task-independent effects were apparent in healthy control group and schizophrenia but differed in direction and magnitude

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In schizophrenia they were greater in magnitude and most prominent in areas of the salience and default mode networks

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Unless properly accounted for, these effects will compromise precise interpretation of fMRI learning data in schizophrenia.

The effect of computer-based cognitive flexibility training on recovery of executive function after stroke: rationale, design and methods of the TAPASS study

BACKGROUND

Stroke survivors frequently suffer from executive impairments even in the chronic phase after stroke, and there is a need for improved rehabilitation of these functions. One way of improving current rehabilitation treatment may be by online cognitive training. Based on a review of the effectiveness of computer-based cognitive training in healthy elderly, we concluded that cognitive flexibility may be a key element for an effective training, which results in improvements not merely on trained tasks but also in untrained tasks (i.e., far transfer). The aim of the current study was to track the behavioral and neural effects of computer-based cognitive flexibility training after stroke. We expected that executive functioning would improve after the cognitive flexibility training, and that neural activity and connectivity would normalize towards what is seen in healthy elderly.

METHODS/DESIGN

The design was a multicenter, double blind, randomized controlled trial (RCT) with three groups: an experimental intervention group, an active control group who did a mock training, and a waiting list control group. Stroke patients (3 months to 5 years post-stroke) with cognitive complaints were included. Training consisted of 58 half-hour sessions spread over 12 weeks. The primary study outcome was objective executive function. Secondary measures were improvement on training tasks, cognitive flexibility, objective cognitive functioning in other domains than the executive domain, subjective cognitive and everyday life functioning, and neural correlates assessed by both structural and resting-state functional Magnetic Resonance Imaging. The three groups were compared at baseline, after six and twelve weeks of training, and four weeks after the end of the training. Furthermore, they were compared to healthy elderly who received the same training.

DISCUSSION

The cognitive flexibility training consisted of several factors deemed important for effects that go beyond improvement on merely the training task themselves. Due to the presence of two control groups, the effects of the training could be compared with spontaneous recovery and with the effects of a mock training. This study provides insight into the potential of online cognitive flexibility training after stroke. We also compared its results with the effectiveness of the same training in healthy elderly.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR5174. Registered 22 May 2015.

Changing facial affect recognition in schizophrenia: effects of training on brain dynamics

Deficits in social cognition including facial affect recognition and their detrimental effects on functional outcome are well established in schizophrenia. Structured training can have substantial effects on social cognitive measures including facial affect recognition. Elucidating training effects on cortical mechanisms involved in facial affect recognition may identify causes of dysfunctional facial affect recognition in schizophrenia and foster remediation strategies. In the present study, 57 schizophrenia patients were randomly assigned to (a) computer-based facial affect training that focused on affect discrimination and working memory in 20 daily 1-hour sessions, (b) similarly intense, targeted cognitive training on auditory-verbal discrimination and working memory, or (c) treatment as usual. Neuromagnetic activity was measured before and after training during a dynamic facial affect recognition task (5 s videos showing human faces gradually changing from neutral to fear or to happy expressions). Effects on 10–13 Hz (alpha) power during the transition from neutral to emotional expressions were assessed via MEG based on previous findings that alpha power increase is related to facial affect recognition and is smaller in schizophrenia than in healthy subjects. Targeted affect training improved overt performance on the training tasks. Moreover, alpha power increase during the dynamic facial affect recognition task was larger after affect training than after treatment-as-usual, though similar to that after targeted perceptual–cognitive training, indicating somewhat nonspecific benefits. Alpha power modulation was unrelated to general neuropsychological test performance, which improved in all groups. Results suggest that specific neural processes supporting facial affect recognition, evident in oscillatory phenomena, are modifiable. This should be considered when developing remediation strategies targeting social cognition in schizophrenia.

A randomized, placebo-controlled study investigating the nicotinic α7 agonist, RG3487, for cognitive deficits in schizophrenia

Effective treatments for cognitive impairment associated with schizophrenia (CIAS) remain an unmet need. Nicotinic α7 receptor agonists may be effective in CIAS. This 8-week (week 1, inpatient; weeks 2-8, outpatient), double-blind, randomized study used Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) guidelines to investigate the nicotinic α7 partial agonist RG3487 (formerly MEM3454) in CIAS; 215 patients with chronic stable schizophrenia received placebo or RG3487 (5, 15, or 50 mg) added to ongoing treatment with risperidone, paliperidone, or aripiprazole. Primary end point was baseline to week 8 change in MATRICS Consensus Cognitive Battery (MCCB) composite t-score. Secondary outcomes were change in MCCB domain and negative symptom assessment (NSA) scores. The study did not allow for evaluation of nonsmokers. Each RG3487 dose was evaluated using a mixed-effects model repeated measures approach. Mean (SD) baseline MCCB composite t-score was 28.3 (12.0). No significant effect on MCCB composite t-scores was observed with RG3487 (adjusted mean difference (SE) vs placebo: 5 mg: 0.11 (1.39); 15 mg: -1.95 (1.39); 50 mg: -1.13 (1.37); p = 0.2-0.9). RG3487 did not improve MCCB domain scores. In a post hoc analysis of patients with moderate negative symptoms, 5 and 50 mg RG3487 vs placebo significantly improved NSA total (-4.45 (p = 0.04) and -4.75 (p = 0.02), respectively) and global (-0.39 (p = 0.04) and -0.55 (p = 0.003), respectively) scores. The MCCB did not lead to higher than expected patient withdrawal. RG3487 was generally well tolerated. In patients with stable schizophrenia, RG3487 did not improve cognitive deficits, as assessed by the MCCB; however, in patients with moderate negative symptoms, a post hoc analysis revealed significant improvement of negative symptoms.

A pilot study of iPad-assisted cognitive training for schizophrenia

In this pilot study, we aimed to examine whether iPad-assisted cognitive training could be beneficial in ameliorating some of the cognitive impairment that accompany schizophrenia. Totally, 20 first-episode schizophrenia patients were randomly assigned to an experiment group (with cognitive training) or to a control group (without cognitive training). The N-back task was assessed at baseline and after intervention, to see what effects iPad-assisted training might have (week 4). The experimental group exhibited significant improvement in the accuracy rate at 2-back, and reaction time at 0, 1 and 2-back tasks. These findings suggest that iPad- or other technically-assisted cognitive training may potentially be a valid strategy for pursuing cognitive rehabilitation among those with schizophrenia.

Computational neuropsychiatry - schizophrenia as a cognitive brain network disorder

Computational modeling of functional brain networks in fMRI data has advanced the understanding of higher cognitive function. It is hypothesized that functional networks mediating higher cognitive processes are disrupted in people with schizophrenia. In this article, we review studies that applied measures of functional and effective connectivity to fMRI data during cognitive tasks, in particular working memory fMRI studies. We provide a conceptual summary of the main findings in fMRI data and their relationship with neurotransmitter systems, which are known to be altered in individuals with schizophrenia. We consider possible developments in computational neuropsychiatry, which are likely to further our understanding of how key functional networks are altered in schizophrenia.

Neurocognitive features in subgroups of bipolar disorder

OBJECTIVE

To examine which subgroups of DSM-IV bipolar disorder (BD) [BD type I (BD-I) or BD type II (BD-II), and subgroups based on history of psychosis, presenting polarity, and age at onset] differentiate best regarding neurocognitive measures.

METHODS

A total of 199 patients with BD were characterized by clinical and neurocognitive features. The distribution of subgroups in this sample was: BD-I, 64% and BD-II, 36%; 60% had a history of psychosis; 57% had depression as the presenting polarity; 61% had an early onset of BD, 25% had a mid onset, and 14% had a late onset. We used multivariate regression analyses to assess relationships between neurocognitive variables and clinical subgroups.

RESULTS

Both BD-I diagnosis and elevated presenting polarity were related to impairments in verbal memory, with elevated presenting polarity explaining more of the variance in this cognitive domain (22.5%). History of psychosis and BD-I diagnosis were both related to impairment in semantic fluency, with history of psychosis explaining more of the variance (11.6%).

CONCLUSION

Poor performance in verbal memory appears to be associated with an elevated presenting polarity, and poor performance in semantic fluency appears to be associated with a lifetime history of psychosis.

An Overview of Cognitive Remediation Therapy for People with Severe Mental Illness

Cognitive remediation refers to nonpharmacological methods of improving cognitive function in people with severe mental disorders. Cognitive remediation therapy (CRT) can be delivered via computerised programs, of varying length and complexity, or can be undertaken one-on-one by a trained clinician. There has been a considerable interest in cognitive remediation, driven by recognition that cognitive deficits are a major determinant of outcome in people with severe, chronic mental illnesses. CRT has been shown to be effective, especially if combined with vocational rehabilitation.

Cognitive remediation in schizophrenia: current status and future perspectives

Objectives. This study is aimed to review the current scientific literature on cognitive remediation in schizophrenia. In particular, the main structured protocols of cognitive remediation developed for schizophrenia are presented and the main results reported in recent meta-analyses are summarized. Possible benefits of cognitive remediation in the early course of schizophrenia and in subjects at risk for psychosis are also discussed. Methods. Electronic search of the relevant studies which appeared in the PubMed database until April 2013 has been performed and all the meta-analyses and review articles on cognitive remediation in schizophrenia have been also taken into account. Results. Numerous intervention programs have been designed, applied, and evaluated, with the objective of improving cognition and social functioning in schizophrenia. Several quantitative reviews have established that cognitive remediation is effective in reducing cognitive deficits and in improving functional outcome of the disorder. Furthermore, the studies available support the usefulness of cognitive remediation when applied in the early course of schizophrenia and even in subjects at risk of the disease. Conclusions. Cognitive remediation is a promising approach to improve real-world functioning in schizophrenia and should be considered a key strategy for early intervention in the psychoses.

Neuroplasticity-based computerized cognitive remediation for geriatric depression

OBJECTIVE

This article describes a novel treatment model designed to target specific neurocognitive deficits in geriatric depression with neuroplasticity-based computerized cognitive remediation (NBCCR).

METHOD

The recent National Institute of Mental Health (NIMH) report "From Discovery to Cure" calls for studies focusing on mechanisms of treatment response with the goal of arriving at new interventions for those who do not respond to existing treatments. We describe the process that led to the identification of specific executive deficits and their underlying neurobiology, as well as the rationale for targeting these symptoms as a part of a strategy intended to improve both executive dysfunction and depression. We then propose a strategy for further research in this emerging area.

RESULTS AND CONCLUSIONS

Despite significant developments, conventional antidepressant treatments leave many older adults still depressed and suffering. Psychotherapy may be effective in some depressed elders, although a recent review concluded that none of the available treatment studies meets stringent criteria for efficacy in the acute treatment of geriatric depression. Appropriately developed and targeted NBCCR, has the potential to serve as a novel treatment intervention for geriatric depression. Pathophysiological changes associated with executive dysfunction may be an appropriate target for NBCCR. Examining both behavioral changes and indices of structural integrity and functional change of networks related to cognitive and emotional regulation may lead to a novel treatment and elucidate the role of specific cerebral networks in geriatric depression.

Adjusting brain dynamics in schizophrenia by means of perceptual and cognitive training

BACKGROUND

In a previous report we showed that cognitive training fostering auditory-verbal discrimination and working memory normalized magnetoencephalographic (MEG) M50 gating ratio in schizophrenia patients. The present analysis addressed whether training effects on M50 ratio and task performance are mediated by changes in brain oscillatory activity. Such evidence should improve understanding of the role of oscillatory activity in phenomena such as M50 ratio, the role of dysfunctional oscillatory activity in processing abnormalities in schizophrenia, and mechanisms of action of cognitive training.

METHODOLOGY/PRINCIPAL FINDINGS

Time-locked and non-time-locked oscillatory activity was measured together with M50 ratio in a paired-click design before and after a 4-week training of 36 patients randomly assigned to specific cognitive exercises (CE) or standard (comparison) cognitive training (CP). Patient data were compared to those of 15 healthy controls who participated in two MEG measurements 4 weeks apart without training. Training led to more time-locked gamma-band response and more non-time-locked alpha-band desynchronization, moreso after CE than after CP. Only after CE, increased alpha desynchronization was associated with normalized M50 ratio and with improved verbal memory performance. Thus, both types of cognitive training normalized gamma activity, associated with improved stimulus encoding. More targeted training of auditory-verbal discrimination and memory additionally normalized alpha desynchronization, associated with improved elaborative processing. The latter presumably contributes to improved auditory gating and cognitive function.

CONCLUSIONS/SIGNIFICANCE

Results suggest that dysfunctional interplay of ocillatory activity that may contribute to auditory processing disruption in schizophrenia can be modified by targeted training.

Spatial memory deficits in a virtual reality eight-arm radial maze in schizophrenia

Learning and memory impairments are present in schizophrenia (SZ) throughout the illness course and predict psychosocial function. Abnormalities in prefrontal and hippocampal function are thought to contribute to SZ deficits. The radial arm maze (RAM) is a test of spatial learning and memory in rodents that relies on intact prefrontal and hippocampal function. The goal of the present study was to investigate spatial learning in SZ using a virtual RAM. Thirty-three subjects with SZ and thirty-nine healthy controls (HC) performed ten trials of a virtual RAM task. Subjects attempted to learn to retrieve four rewards each located in separate arms. As expected, subjects with SZ used more time and traveled more distance to retrieve rewards, made more reference (RM) and working memory (WM) errors, and retrieved fewer rewards than HC. It is important to note that the SZ group did learn but did not reach the level of HC. Whereas RM errors decreased across trials in the SZ group, WM errors did not. There were no significant relationships between psychiatric symptom severity and maze performance. To our knowledge, use of a virtual 8-arm radial maze task in SZ to assess spatial learning is novel. Impaired virtual RAM performance in SZ is consistent with studies that examined RAM performance in animal models of SZ. Results provide further support for compromised prefrontal and hippocampal function underlying WM and RM deficits in SZ. The virtual RAM task could help bridge preclinical and clinical research for testing novel drug treatments of SZ.

Prediction and prevention of psychosis in youth at clinical high risk

Most individuals with schizophrenia retrospectively report a prodromal period characterized by increasing problems in thinking, feeling, and behaving. However, it is less clear how many individuals who display prodromal symptoms will subsequently develop a psychotic illness. Thus, a precondition for early intervention in psychosis is the accurate detection of those who may be at true risk of developing a psychotic illness. The aim of this article is to review current work addressing prediction and prevention in the prodrome to psychosis. First, we describe research efforts to develop and test operational criteria for prospectively assessing psychosis liability over time. Second, the clinical, functional, and biological features of the prodrome are presented, along with a discussion of the variables most frequently associated with psychosis onset. Next, treatment studies are reviewed. The review concludes with a framework for future early identification and treatment studies.

Delayed procedural learning in α7-nicotinic acetylcholine receptor knockout mice

The α7-nicotinic acetylcholine receptor (nAChR) has long been a procognitive therapeutic target to treat schizophrenia. Evidence on the role of this receptor in cognition has been lacking, however, in part due to the limited availability of suitable ligands. The behavior of α7-nAChR knockout (KO) mice has been examined previously, but cognitive assessments using tests with cross-species translatability have been limited to date. Here, we assessed the cognitive performance of α7-nAChR KO and wild-type (WT) littermate mice in the attentional set-shifting task of executive functioning, the radial arm maze test of spatial working memory span capacity and the novel object recognition test of short-term memory. The reward motivation of these mutants was assessed using the progressive ratio breakpoint test. In addition, we assessed the exploratory behavior and sensorimotor gating using the behavioral pattern monitor and prepulse inhibition, respectively. α7-nAChR KO mice exhibited normal set-shifting, but impaired procedural learning (rule acquisition) in multiple paradigms. Spatial span capacity, short-term memory, motivation for food, exploration and sensorimotor gating were all comparable to WT littermates. The data presented here support the notion that this receptor is important for such procedural learning, when patterns in the environment become clear and a rule is learned. In combination with the impaired attention observed previously in these mice, this finding suggests that agonist treatments should be examined in clinical studies of attention and procedural learning, perhaps in combination with cognitive behavioral therapy.