Metacognition, social cognition, and mentalizing in psychosis: are these distinct constructs when it comes to subjective experience or are we just splitting hairs?

Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised - as often occurs in psychosis - results in the loss of persons' sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.

Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial

Background

Self-stigma is highly prevalent in serious mental illness (SMI) and is associated with poorer clinical and functional outcomes. Narrative enhancement and cognitive therapy (NECT) is a group-based intervention combining psychoeducation, cognitive restructuring and story-telling exercises to reduce self-stigma and its impact on recovery-related outcomes. Despite evidence of its effectiveness on self-stigma in schizophrenia-related disorders, it is unclear whether NECT can impact social functioning.

Methods

This is a 12-centre stepped-wedge cluster randomized controlled trial of NECT effectiveness on social functioning in SMI, compared to treatment as usual. One hundred and twenty participants diagnosed with schizophrenia, bipolar disorder or borderline personality disorder will be recruited across the 12 sites. The 12 centres participating to the study will be randomized into two groups: one group (group 1) receiving the intervention at the beginning of the study (T0) and one group (group 2) being a control group for the first 6 months and receiving the intervention after (T1). Outcomes will be compared in both groups at T0 and T1, and 6-month and 12-month outcomes for groups 1 and 2 will be measured without a control group at T2 (to evaluate the stability of the effects over time). Evaluations will be conducted by assessors blind to treatment allocation. The primary outcome is personal and social performance compared across randomization groups. Secondary outcomes include self-stigma, self-esteem, wellbeing, quality of life, illness severity, depressive symptoms and personal recovery.

Discussion

NECT is a promising intervention for reducing self-stigma and improving recovery-related outcomes in SMI. If shown to be effective in this trial, it is likely that NECT will be implemented in psychiatric rehabilitation services with subsequent implications for routine clinical practice.

Trial registration

ClinicalTrials.gov NCT03972735. Trial registration date 31 May 2019.

Measuring empathy in schizophrenia: The Empathic Accuracy Task and its correlation with other empathy measures

INTRODUCTION

Empathy is an interpersonal process impaired in schizophrenia. Past studies have mainly used questionnaires or performance-based tasks with static cues to measure cognitive and affective empathy. We used the Empathic Accuracy Task (EAT) designed to capture dynamic aspects of empathy by using videoclips in which perceivers continuously judge emotionally charged stories. We compared individuals with schizophrenia with a healthy comparison group and assessed correlations among EAT and three other commonly used empathy measures.

METHOD

Patients (n = 92) and a healthy comparison group (n = 42) matched for age, gender and education completed the EAT, the Interpersonal Reactivity Index, Questionnaire of Cognitive and Affective Empathy and Faux Pas. Differences between groups were analyzed and correlations were calculated between empathy measurement instruments.

RESULTS

The groups differed in EAT performance, with the comparison group outperforming patients. A moderating effect was found for emotional expressivity of the target: while both patients and the comparison group scored low when judging targets with low expressivity, the comparison group performed better than patients with more expressive targets. Though there were also group differences on the empathy questionnaires, EAT performance did not correlate with questionnaire scores.

CONCLUSIONS

Individuals with schizophrenia benefit less from the emotional expressivity of other people than the comparison group, which contributes to their impaired empathic accuracy. The lack of correlation between the EAT and the questionnaires suggests a distinction between self-report empathy and actual empathy performance. To explore empathic difficulties in real life, it is important to use instruments that take the interpersonal perspective into account.

Measuring disorganized speech in schizophrenia: automated analysis explains variance in cognitive deficits beyond clinician-rated scales

BACKGROUND

Conveying information cohesively is an essential element of communication that is disrupted in schizophrenia. These disruptions are typically expressed through disorganized symptoms, which have been linked to neurocognitive, social cognitive, and metacognitive deficits. Automated analysis can objectively assess disorganization within sentences, between sentences, and across paragraphs by comparing explicit communication to a large text corpus.

METHOD

Little work in schizophrenia has tested: (1) links between disorganized symptoms measured via automated analysis and neurocognition, social cognition, or metacognition; and (2) if automated analysis explains incremental variance in cognitive processes beyond clinician-rated scales. Disorganization was measured in schizophrenia (n = 81) with Coh-Metrix 3.0, an automated program that calculates basic and complex language indices. Trained staff also assessed neurocognition, social cognition, metacognition, and clinician-rated disorganization.

RESULTS

Findings showed that all three cognitive processes were significantly associated with at least one automated index of disorganization. When automated analysis was compared with a clinician-rated scale, it accounted for significant variance in neurocognition and metacognition beyond the clinician-rated measure. When combined, these two methods explained 28-31% of the variance in neurocognition, social cognition, and metacognition.

CONCLUSIONS

This study illustrated how automated analysis can highlight the specific role of disorganization in neurocognition, social cognition, and metacognition. Generally, those with poor cognition also displayed more disorganization in their speech-making it difficult for listeners to process essential information needed to tie the speaker's ideas together. Our findings showcase how implementing a mixed-methods approach in schizophrenia can explain substantial variance in cognitive processes.

Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia

BACKGROUND

Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition.

METHODS

This study is a randomized controlled trial. Patients in the active condition (n = 35) received forty MERIT sessions, the control group (n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness).

RESULTS

Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition (N = 5) or before the first session (N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes.

CONCLUSIONS

On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.

[Metacognition in psychotic disorders: from concepts to intervention]

BACKGROUND

Persons with a psychotic disorder commonly experience difficulties with what is considered to be metacognitive capacity. In this article we discuss several definitions of this concept, the measurement instruments involved and the clinical interventions that target this concept.

AIM

To present a review of various frequently used definitions of metacognition and related concepts and to describe the measurement instruments involved and the treatment options available for improving the metacognitive capacity of persons with a psychotic disorder.

METHOD

We present an overview of several definitions of metacognition in psychotic disorders and we discuss frequently used measurement instruments and treatment options. The article focuses on recent developments in a model devised by Semerari et al. The measurement instrument involved (Metacognition Assessment Scale - A) is discussed in terms of it being an addition to existing methods.

RESULTS

On the basis of the literature it appears that metacognition and related concepts are measurable constructs, although definitions and instruments vary considerably. The new conceptualisation of social information processing also leads to the development of a new form of psychotherapy that aims to help patients suffering from psychotic disorders to improve metacognitive capacity.

CONCLUSION

There seems to be evidence that metacognitive abilities are a possible target for treatment, but further research is needed.

The influence of adjunctive treatment and metacognitive deficits in schizophrenia on the experience of work

Enhancing work function is now widely considered a core element of comprehensive schizophrenia treatment. While research efforts have illuminated factors that influence how well patients perform at work, less is known about the factors influencing the subjective experience of work. It is not known how, and to what extent, symptoms, cognitive deficits or metacognitive capacities impact job satisfaction and whether treatment can have an effect on job satisfaction. To explore this issue, data from a trial in which participants in a six-month vocational program were assigned to either a standard support group or a cognitive behavioral group therapy, and asked to fill in weekly self-reports of job satisfaction was analyzed. Work satisfaction and the consistency of these ratings were compared between the two groups and the moderating influence of metacognitive capacity was analyzed. A significant interaction effect revealed that higher metacognitive capacity predicted higher average job satisfaction only in the CBT group. Additionally, higher metacognitive capacity led to a more varied appraisal of work satisfaction only in the support group.

Social cognition and metacognition in schizophrenia: evidence of their independence and linkage with outcomes

OBJECTIVE

Research suggests that many with schizophrenia experience deficits in the ability to make discrete judgments about the thoughts and feelings of others as well as to form larger integrated representations of themselves and others. Little is known about whether these difficulties may be distinguished from one another and whether they are linked with different outcomes.

METHOD

We administered three assessments of social cognition which tapped the ability to identify emotions and intentions and two metacognitive tasks which called for the formation of more integrated and flexible representations of the self and others. We additionally assessed symptoms, social functioning and neurocognition. Participants were 95 individuals with a schizophrenia spectrum disorder.

RESULTS

A principle components analysis followed by a varimax rotation revealed two factors which accounted for 62% of the variance. The first factor was comprised of the three social cognition tests and the second of two tasks that tapped the ability to create representations of oneself and others which integrate more discreet information. The first factor was uniquely correlated with negative symptoms, and the second was uniquely correlated with social function.

CONCLUSION

Results suggest that deficits in social cognition and metacognition represent different forms of dysfunction in schizophrenia.

Anxiety symptoms in schizophrenia spectrum disorders: associations with social function, positive and negative symptoms, hope and trauma history

OBJECTIVE

Anxiety is commonly observed in schizophrenia, but its relationship with other features of illness is unclear.

METHOD

We examined correlations between measures of anxiety, positive and negative symptoms, hope, psychosocial function and trauma history among 128 participants with schizophrenia or schizoaffective disorder. Cluster analyses were conducted to determine whether we could detect a subgroup with severe anxiety.

RESULTS

Higher levels of anxiety were associated with greater hallucinations, withdrawal, depression, hopelessness, better insight and poorer function. Cluster analyses produced three groups according to anxiety level: subclinical anxiety (n = 37), moderate anxiety (n = 55) and severe anxiety (n = 36). anova revealed that the severe anxiety group had more severe hallucinations, poorer psychosocial function and less hope than either of the other two groups. Self-report of sexual trauma predicted higher levels of anxiety overall.

CONCLUSION

A subgroup of persons with severe anxiety may be identifiable in schizophrenia with a unique clinical profile.

Metacognition amidst narratives of self and illness in schizophrenia: associations with neurocognition, symptoms, insight and quality of life

OBJECTIVE

Impairments in laboratory tasks of metacognition appear to be associated with symptoms, functioning, and neurocognition in schizophrenia. We sought to replicate these results in a study of metacognition within personal narratives of self and illness.

METHOD

Narratives of 61 men with schizophrenia were rated using the Metacognition Assessment Scale and correlated with concurrent assessment of symptoms, quality of life, neurocognition and insight.

RESULTS

Controlling for age and education, understanding of one's own mind was linked with better neurocognition across multiple domains, and lesser emotional withdrawal. Greater understanding of other's mind was linked with better verbal memory and less emotional withdrawal. Greater metacognition in the context of purposeful problem solving was associated with better verbal memory, insight and social function, and less emotional withdrawal and paranoia.

CONCLUSION

Deficits in metacognition within the narratives of persons with schizophrenia are linked with symptoms, quality of life, neurocognition and poorer awareness of illness.

Childhood sexual trauma and psychosocial functioning in adults with schizophrenia

OBJECTIVE

This study explored the association between sexual abuse in childhood and the severity of psychosocial deficits in adults with schizophrenia.

METHODS

The Quality of Life Scale, which assesses current interpersonal and work function, and the NEO personality inventory, which assesses personality dimensions relevant to social functioning, were administered to 54 individuals who had been diagnosed as having schizophrenia. Nineteen of the individuals reported having been sexually abused as children, and 35 reported no history of abuse.

RESULTS

A multiple analysis of variance indicated that there were differences between the group of individuals who had a history of sexual trauma and the group that did not. Subsequent univariate analysis of variance indicated that the individuals with a history of abuse had poorer current role functioning and fewer of the basic psychological building blocks necessary for sustaining intimacy. They also demonstrated higher levels of neuroticism, which is a measure of vulnerability to emotional turmoil. The two groups did not differ in frequency of interpersonal contacts or level of extroversion.

CONCLUSIONS

Sexual abuse in childhood is associated with poorer psychosocial functioning in adults with schizophrenia.

Neurocognitive correlates of helplessness, hopelessness, and well-being in schizophrenia

Persons with schizophrenia are widely recognized to experience potent feelings of hopelessness, helplessness, and a fragile sense of well-being. Although these subjective experiences have been linked to positive symptoms, little is known about their relationship to neurocognition. Accordingly, this study examined the relationship of self-reports of hope, self-efficacy, and well-being to measures of neurocognition, symptoms, and coping among 49 persons with schizophrenia or schizoaffective disorder. Results suggest that poorer executive function, verbal memory, and a greater reliance on escape avoidance as a coping mechanism predicted significantly higher levels of hope and well being with multiple regressions accounting for 34% and 20% of the variance (p < .0001), respectively. Self-efficacy predicted lower levels of positive symptoms and greater preference for escape avoidance as a coping mechanism with a multiple repression accounting for 9% of the variance (p < .05). Results may suggest that higher levels of neurocognitive impairment and an avoidant coping style may shield some with schizophrenia from painful subjective experiences. Theoretical and practical implications for rehabilitation are discussed.

Neurocognitive and symptom correlates of self-reported childhood sexual abuse in schizophrenia spectrum disorders

This study examined whether self-reported childhood sexual abuse in schizophrenia spectrum disorders is linked with severity of neurocognitive deficits. The Wisconsin Card Sorting Test, California Verbal Learning Test, and select WAIS III subtests were administered to 15 participants with schizophrenia or schizoaffective disorder who had been sexually abused and to 28 participants with no abuse history. Controlling for age and premorbid IQ, a MANCOVA indicated there were group differences (f(9, 31) = 5.53, p < .001). Subsequent ANCOVA indicated that the sexual abuse group performed more poorly on tests of working memory and information processing speed. Childhood sexual abuse is associated with more severe working memory deficits in adults with schizophrenia spectrum disorders.

Psychosis and the disintegration of dialogical self-structure: problems posed by schizophrenia for the maintenance of dialogue

Researchers and theoreticians across widely varying disciplines have increasingly stressed how sense of self is inherently 'dialogical', or the product of ongoing dialogue both within the individual and between the individual and others. This perspective emphasizes that self-awareness is not an awareness of an isolated or seamless viewpoint, but a collective of numerous complementary, competing, and sometimes contradictory, voices. In this paper we suggest that changes in subjective sense of self in schizophrenia spectrum disorders may represent the collapse of this essential dialogue. We suggest that this collapse can have the end-result of mentally ill persons either coming to embrace a singular, all-incorporating self-position or standing precariously on the brink of cacophony which is experienced as self-dissolution. We point to two phenomena associated with schizophrenia that could contribute to the derailment of internal and external dialogue: impairments in associative processes and affect dysregulation. Illustrated with a case example, we finally suggest how psychotherapy has the potential to revive internal dialogue through its explicit use of external dialogue helping to restore previous levels of social function.

Emotional discomfort and impairments in verbal memory in schizophrenia

Research has demonstrated that impairments in verbal memory in schizophrenia are linked with psychosocial deficits. Less is known, however, about their relationship to clinical features of illness. This study explores the hypothesis that impairments in verbal memory, particularly forms of memory requiring deeper levels of encoding, are uniquely linked to symptoms of dysphoria or emotional discomfort. Accordingly, we examined the association between concurrent measures of symptoms and verbal memory for 84 subjects with schizophrenia. Measures of positive, negative, cognitive, excitement and emotional discomfort symptoms were derived from factor scores of the Positive and Negative Syndrome Scale. Verbal memory was assessed using two tests requiring relatively superficial levels of encoding: The Hopkins Verbal Memory Test and the Digit Span subtest; and one test requiring deeper levels of encoding: the Logical Memory subtests I and II. As predicted, multiple regressions controlling for age, education and attention revealed that poorer performance on Logical Memory was strongly associated with greater levels of emotional discomfort (R(2)=0.22 and 0.25, respectively) while performance on the Hopkins test was related to cognitive symptoms scores (R(2)=0.08 and 0.09, respectively). Implications for the conceptualization of verbal memory deficits in schizophrenia are discussed.

Self-Appraisal of Illness Questionnaire (SAIQ): relationship to researcher-rated insight and neuropsychological function in schizophrenia

The Self-Appraisal of Illness Questionnaire (SAIQ) is a self-report instrument designed to assess attitudes toward mental illness among persons receiving psychiatric treatment. This instrument was developed for use in community settings, adapted closely from the Patient's Experience of Hospitalization questionnaire. In order to examine the validity of the SAIQ, a factor analysis was first conducted on the items of this instrument in a sample of 59 outpatients with schizophrenia or schizoaffective illness. Three factors emerged: Need for Treatment, Worry, and Presence/Outcome of Illness. Next, to examine the concurrent validity of these three SAIQ subscales, they were correlated with researcher rated insight scales and neuropsychological tests. Results indicated that the Need for Treatment and Presence/Outcome subscales were significantly correlated with both researcher-rated insight scales and with neuropsychological tests of executive functioning. The Worry subscale was not associated with either researcher-rated insight scales or neuropsychological tests. It was concluded that the Need for Treatment and Presence/Outcome subscales may be used in combination as a brief screening instrument for clients with schizophrenia receiving outpatient psychiatric treatment who may be at risk for treatment non-compliance due to a lack of insight into illness.

Obsessive and compulsive symptoms in schizophrenia: clinical and neurocognitive correlates

Although research suggests that the presence of obsessive and compulsive symptoms in schizophrenia is associated with graver levels of psychosocial dysfunction, it is unclear whether it is also related to clinical features of illness. Accordingly, the present study compared the symptom levels and neurocognitive function of participants with schizophrenia who had and did not have significant obsessive or compulsive symptoms. Analyses of variance revealed that participants with significant levels of either obsessive or compulsive symptoms (N = 21) had higher levels of positive and emotional discomfort symptoms on the Positive and Negative Syndrome Scale (PANSS) and performed more poorly on the Wisconsin Card Sorting Test, a measure of executive function, than participants without obsessions or compulsions (N = 25). ANCOVAs controlling for level of obsessions also revealed that participants with significant levels of compulsions (N = 12) in particular had higher levels of negative and positive symptoms on the PANSS than participants without compulsions (N = 34). The impact of obsessive-compulsive phenomena on the course and outcome of schizophrenia is discussed.

Personality and psychopathology in schizophrenia: the association between personality traits and symptoms

Research has indicated that stable individual differences in personality exist among persons with schizophrenia, and that they likely predate the onset of illness. Little is known, however, about whether individual differences in personality are related to levels of psychopathology. This study tested the hypotheses that levels of Extroversion, Neuroticism, and Psychoticism are associated with symptomatology. Accordingly, measures of these dimensions of personality and of symptomatology were obtained simultaneously for 113 male subjects with schizophrenia or schizoaffective disorder. Next, subjects were characterized as having high or low levels on each personality dimension and their scores on the five components of the Positive Negative Syndrome Scale were compared using multivariate and univariate procedures. Results indicate that extroverted subjects had lower levels of Positive, Negative, and Emotional Discomfort symptoms, and higher levels of Excitement symptoms than introverted subjects. Subjects with higher levels of Neuroticism had higher levels of Positive and Emotional Discomfort symptoms than subjects with lower levels of Neuroticism. No differences in symptoms were found among subjects with higher versus lower levels of Psychoticism. Results suggest individual differences in personality are associated with psychopathology in schizophrenia and may help further explain the heterogeneity widely observed in this disorder.

Psychotherapy as an element in supported employment for persons with severe and persistent mental illness

Recent literature has urged that vocational and clinical services for persons with severe and persistent mental illness should be integrated. Unclear in this model is what role psychotherapy could play. In particular, it is unknown whether psychotherapy can make a unique contribution and whether there are issues it might systematically address in the context of vocational rehabilitation. To examine these questions we report on the psychotherapy of six consumers enrolled in supported employment, a prominent form of vocational rehabilitation. Using these cases as illustrations, we suggest that in an integrative team approach, psychotherapy can facilitate vocational rehabilitation by helping consumers reconstruct aspects of personal narratives related to disability and work and by processing painful affects evoked by work. We report how within a reflective and nonhierarchical relationship consumers were allowed to reframe old ideas, question inconsistencies, and keep track of the structure and content of revised narrative until fully integrated into memory. Despite a wide range of severe impairments, this process enabled consumers to incorporate work into a now more complete and coherent life narrative. Implications for practice and research are discussed.

Personality and psychosocial dysfunction in schizophrenia: the association of extraversion and neuroticism to deficits in work performance

Research on vocational dysfunction in schizophrenia has as yet only examined associated features of illness. We hypothesized that personality variables may be also associated with work function. We reasoned that higher levels of extraversion and neuroticism would predict poor function by virtue of the social support seeking and passive/avoidant coping styles associated with each. To test this, multiple regressions were conducted in which measures of extraversion and neuroticism predicted work performance among 43 subjects with schizophrenia or schizoaffective disorder. Higher levels of extraversion and neuroticism significantly predicted poorer function, accounting for between 7% and 27% of the variance in global cooperativeness, work quality, work habits and personal presentation measures of work behavior. The potential importance of assessing personality in rehabilitation is discussed.

Insight and interpersonal function in schizophrenia

Research has linked impaired insight in schizophrenia to poorer medication compliance and treatment outcome. It is unclear, however, whether poorer interpersonal function is also associated with impaired insight. To examine this question, subjects with schizophrenia or schizoaffective disorder were classified as having unimpaired (N = 44) or impaired (N = 57) insight, and their scores on Heinrichs et al.'s Quality of Life (QOL) Scale were compared. Multiple regressions were conducted to determine the relationship between individual components and social function. Results indicate that subjects with impaired insight had significantly poorer QOL interpersonal relation and intrapsychic foundation scores than unimpaired subjects, despite having equivalent deficit symptoms. Unawareness of the social consequences of illness was found to be the component of insight more closely linked to social dysfunction. This suggests that impairments in insight may be uniquely associated with social dysfunction.

Neurocognitive function and insight in schizophrenia: support for an association with impairments in executive function but not with impairments in global function

It remains unclear how impaired insight and neurocognitive impairment are related to one another in schizophrenia. In order to examine this relationship, subjects with schizophrenia or schizoaffective disorder were classified as having 'impaired' (n=38) or 'unimpaired' (n=43) insight based on their insight rating on the Positive and Negative Syndrome Scale (PANSS). Their performance on neuropsychological tests of global function, executive function, memory and vigilance was then compared. Multivariate analyses followed by Scheffe tests indicated that subjects with impaired insight performed less well on the Wisconsin Card Sorting Test, demonstrating poorer abstract flexibility and heightened perseveration. No differences were found between the groups with regard to global cognitive function, memory or vigilance. This suggests that insight is closely linked to deficits in executive function, and that it may be associated with the compromise of frontal lobe function.

Cognitive impairment and substance abuse history as predictors of the temporal stability of negative symptoms in schizophrenia

Research has not consistently indicated that negative symptoms in schizophrenia are temporally stable. One possible explanation for this is that stable negative symptoms are a characteristic of only some individuals with schizophrenia. The current study explored whether cognitive impairment and stimulant abuse history were associated with amount of change in negative symptom level over a 1-year period. Results indicated that among 72 subjects with schizophrenia, performance on the Wisconsin Card Sorting Test and history of stimulant abuse significantly accounted for 18% of the variance in symptom variability after age, intelligence quotient, and initial symptom severity were controlled. As hypothesized, poorer performance on the Wisconsin Carding Sorting Test was associated with less symptom variability, whereas a more extensive stimulant abuse history was associated with greater variability. A discriminant function analysis was able to correctly classify 96% of subjects as having stable symptoms but only 30% as having unstable symptoms indicating a sensitive, but not specific, classification. This finding suggests that cognitive deficits may be a necessary but insufficient condition for temporal stability of negative symptoms and that negative symptoms in schizophrenia are a complex phenomenon best understood in the context of other features of illness and psychosocial variables.

Clinical benefits of paid work activity in schizophrenia: 1-year followup

In a previous article in the Schizophrenia Bulletin (Vol. 22, No. 1, 1996), we presented findings of a study on the clinical and rehabilitative effects of work activity on 150 subjects diagnosed with schizophrenia or schizoaffective disorder. Subjects were randomly assigned to either a Pay ($3.40/hr) or No-Pay group and given 6-month work placements in a Department of Veterans Affairs medical center. At the 5-month followup, Pay subjects had worked more hours and earned more money (from any employment) than No-Pay subjects. Pay subjects also had significantly greater improvement in symptoms and lower rehospitalization rates. Clinical improvement was closely linked to amount of participation. We concluded that pay increased participation. The current study examined clinical and rehabilitative outcomes at 1-year followup, 6 months after the conclusion of the work program. Results indicated that the Pay subjects had a significant decrease in work activity once they had completed the work program. However, 75 percent of those who had fully participated in the program continued working during the subsequent 6 months, either as volunteers or for pay. Clinical outcomes for subjects in the Pay condition were attenuated at 1-year followup but still significantly better than for subjects in the No-Pay condition. More than 40 percent of participants continued to be "much improved" on total symptoms, and more than 50 percent were "much improved" on positive symptoms. Discussion focuses on the importance and limitations of work for pay as a clinical intervention and concludes that continuous work services are necessary and beneficial for many people with schizophrenia.

Clinical benefits of paid work activity in schizophrenia

Although indirect support can be found for the clinical benefits of work, it has not been studied in randomized designs, nor have critical variables been manipulated. One such variable is pay incentive. The authors present a study of 150 subjects with schizophrenia or schizoaffective disorder who were randomized into Pay ($3.40/hour) and No-Pay conditions and offered 6-month work placements within a Department of Veterans Affairs medical center. Subjects participated in a work-related support group and were evaluated weekly on symptom measures. Results indicated that Pay subjects worked more hours and earned more money than No-Pay subjects. Pay subjects showed more total symptom improvement at followup, and more improvement, particularly on positive and emotional discomfort symptoms. They also had a significant lower rate of rehospitalization than No-Pay subjects. Participation in work activity was closely associated with symptom improvement. Participators showed more total symptom improvement at followup than partial participators or nonparticipators, and more improvement, particularly on positive, hostility, and emotional discomfort symptoms. We concluded that pay increased participation and that, in this study, participation in work activity was primarily responsible for symptom reduction.

Social skills at work. Deficits and predictors of improvement in schizophrenia

While the impact of social learning programs upon social deficits in schizophrenia has been widely studied, less is understood about which patients have the poorest social skills, and among those which patients have deficits most refractory to rehabilitation. To explore these questions, this study compared the symptom levels and performance on neuropsychological testing of 91 subjects with impaired and unimpaired social skills enrolled in a vocational rehabilitation program. After 10 weeks of rehabilitation and a supportive group treatment, social skills among a subsample of 41 subjects with initially impaired social skills were reassessed. Results indicate that subjects with initially impaired social skills had significantly higher levels of negative symptoms. However, multiple regression analysis revealed that cognitive impairments at intake, rather than level of negative symptoms, predicted improvement among subjects with initially impoverished social skills (R2 = .35). Results suggest that level of cognitive impairment is associated with the persistence of social skills deficits in schizophrenia.

Psychiatric symptoms and work performance among persons with severe mental illness

The study examined the relationship between psychiatric symptoms and work performance for 61 subjects with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder who participated in a work rehabilitation program. Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) to predict performance on the Work Personality Profile at three and 13 weeks of the program. Twenty-seven percent of the variance in work performance measures could be explained by symptom components measured by the PANSS, including the cognitive, negative, and hostility components, but the positive component did not predict work performance. Ratings of symptoms done concurrently with ratings of work performance were more powerful predictors than ratings of symptoms done at three and 13 weeks before ratings of work performance.

Cognitive deficits in schizophrenia. Prediction of symptom change for participators in work rehabilitation

While recent studies have found that most patients with schizophrenia who participate in work rehabilitation experience symptom improvement, there appears to be a subgroup of patients whose symptoms remain stable or even worsen. The present study explores the hypothesis that cognitive impairment is one factor which reduces the clinical effectiveness of rehabilitation and accounts for a lack of improvement in some patients. To explore this question, performance on two neuropsychological tests was used to predict improvement on six symptom dimensions for 59 subjects who completed 5 months of work in a rehabilitation program. Discriminant function analyses indicated that quadratic combinations of standardized scores on the Wisconsin Card Sorting Test and thought disorder scores from the Gorham Proverbs Test could correctly classify 83% of subjects as improved or unimproved on a total symptom measure, and between 84% and 100% of subjects as improved or unimproved on various symptom dimensions, with greater levels of cognitive impairments at intake predicting no symptom improvement. Implications for the potential role of cognitive remediation in rehabilitation are discussed.

The frequency of associations between positive and negative symptoms and dysphoria in schizophrenia

Weekly assessments of depression, anxiety, and positive and negative symptoms were performed on 80 subjects with schizophrenia or schizoaffective disorder. Using procedures previously reported in another study, the frequency of significant correlations between the sum of anxiety and depression ratings and positive symptoms was compared with the frequency of significant correlations between the sum of anxiety and depression ratings and negative symptoms. Results confirm that dysphoria in schizophrenia tends to be more frequently associated with positive versus negative symptoms, regardless of diagnostic subtype or symptom type. This provides further evidence of the independence of negative symptoms from dysphoria and suggests that the level of positive symptoms and level of dysphoria may mutually influence one another.

Concurrent validity of the cognitive component of schizophrenia: relationship of PANSS scores to neuropsychological assessments

Cognitive symptoms of schizophrenia may represent a separate component of the disorder that is distinct from positive or negative syndromes. In a previous study, we reported a factor analysis of the Positive and Negative Syndrome Scale (PANSS) that revealed five components, one of which we labeled the Cognitive component. In the present study, we explored the validity of the PANSS Cognitive component by examining correlations between neuropsychological measures and the five factor-analytically derived PANSS scores for 147 subjects with diagnoses of schizophrenia or schizoaffective disorder. Higher scores on the PANSS Cognitive component were significantly correlated with poorer performance on all neuropsychological tests, including the Wisconsin Card Sorting Test (WCST), the Digit Symbol Substitution Task, the Slosson Intelligence Test, and the Gorham Proverbs Test. Multiple regression revealed that these test scores explained 37% of the variance in the Cognitive component score. Neuropsychological tests have very limited associations with the other PANSS components. These results suggest that the Cognitive component of the PANSS is a valid measure of cognitive deficits in schizophrenia, and they support the hypothesis that Cognitive impairment is a distinctive feature of schizophrenia independent of positive and negative syndromes.

Five-component model of schizophrenia: assessing the factorial invariance of the positive and negative syndrome scale

A five-component model of schizophrenia has been presented by Kay and Sevy based upon an analysis of the Positive and Negative Syndrome Scale. Kay and Sevy found factorial validity for negative and positive syndromes, and they identified excitement, depressive, and cognitive components as well. They suggested that subtypes and syndromes can be mapped along dimensions presented in their model. The present study compares the five-component solution for a new sample of 146 subjects to a reanalysis of the Kay and Sevy data. Despite divergent demographic characteristics, the two samples produce similar dimensions. Correlations of component loadings and subject scores as well as confirmatory factor analysis are presented. Discussion focuses on points of agreement and important differences in the symptoms assigned to each component. How the dimensions relate to rationally derived models of positive and negative syndromes is reviewed, and implications for subtyping and other methods of examining the heterogeneity of schizophrenia are considered.