Neurocognition, social cognition, rehabilitation in schizophrenia

NEUROCOGNITION, SOCIAL
COGNITION, REHABILITATION IN
SCHIZOPHRENIA
DR.R.G.ENOCH
MD PSYCHIATRY III yr

 Introduction
 History
 Neurobiology
 Cognitive domains – tests & impairments
 Relationship with symptoms
 Treatment
 Cognitive remediation
 Rehabilitation

INTRODUCTION
 Neurocognitive impairment in schizophrenia is clinically relevant and profound.
 Schizophrenia pts perform 1 to 2 SD below controls on various neurocognitive tests.
 The severity of this impairment is greatest in the domains of memory, attention,
working memory, problem solving, processing speed, and social cognition.
 Cognitive deficits are considered to be a trait marker for schizophrenia.
 They are present prior to the initiation of antipsychotic treatment and
 Are not caused by psychotic symptom.

COGNITIVE DEFICITS
 Cognitive deficits
 may precipitate psychotic and negative symptoms;
 are relatively stable, with deterioration only after the age of 65
 persist even on the remission of psychotic symptoms;
 are related to but separate from negative symptoms; and
 Determine the functional impairment
 correlated with measurable brain dysfunction more than any other aspect of
the illness.
 Most importantly, neurocognition is increasingly considered as a primary target for
treatment.

 Research :-
 Cognitive deficit is the core and enduring feature of the illness and is
 more important than positive and to some extent negative symptoms in predicting
functional outcome
 Many of the various neurocognitive deficits in schizophrenia have been shown to be
associated with functional outcomes such as
 difficulty with community functioning,
 problem-solving skills,
 reduced success in psychosocial rehabilitation programs, and
 the inability to maintain successful employment.
COGNITIVE DEFICITS

HISTORY
 Kraepelin named schizophrenia as dementia praecox—early or premature cognitive
e decline.
 In pts he studied - deficits in attention, motivation, problem solving, learning, and
memory.
 Kraepelin also was the first clinician to establish a link between these cognitive
impairments and poor functional outcome.
 Bleuler said cognitive impairment is the ‘‘fundamental’’ symptom.
 Other ‘‘peculiar’’ features, such as hallucination and delusions, were
considered by him to be secondary or ‘‘accessory’’ symptoms.

Prevalence of Neurocognitive Deficits in
Schizophrenia
 According to some estimates, about 98% of schizophrenia pts have impairments.
 About 15% of patients with schizophrenia are rated as “unimpaired”  they have the
highest levels of premorbid functioning.
 Monozygotic twins  all affected twins perform worse than their unaffected twin,
although the unaffected twins are performing more poorly than their educational level.
 Therefore, almost all patients with schizophrenia are functioning below the level that
would be expected in the absence of the illness.
 Cognitive impairments are similar across different countries, educational systems, and
racial groups  minimal influence of environmental and social variables.

NEUROBIOLOGY
Neurodevelopment
 Abnormalities in neurodevelopment might be responsible for the cognitive deficits in
schizophrenia.
 Abnormality of brain development begins as early as in the prenatal life - intensifies
during childhood - continues till adulthood  explains the genesis of schizophrenia.
 Most consistent brain areas with abnormalities  prefrontal cortical areas, inferior
parietal lobule, amygdala, superior temporal gyrus, medial temporal lobe, basal ganglia,
thalamus, corpus callosum and cerebellum.

NEUROBIOLOGY
Neurodevelopmental
changes
alters BDNF
Abnormal synaptic
plasticity
aberrant connection in the
brain
impairment of learning and
information processing
 Neuroplasticity
 The core symptoms of
schizophrenia like negative
symptoms and executive
dysfunction directly result from
altered neuroplasticity.

Genetics
 Neurocognitive impairment in schizophrenia has a clear heritable component.
 Heritability is maximal with working memory and intelligence.
 First-degree relatives impaired on a variety of neurocognitive measures, with effect
sizes ranging from small to medium.
 A number of aspects of neurocognition have been tentatively linked to specific genes or
single nucleotide polymorphisms.
 Most genes associated with cognitive deficits to date implicate the functioning of the
glutamatergic system.
NEUROBIOLOGY

Genetics
 The disrupted in schizophrenia 1 (DISC1) gene affects the neuroplasticity.
 Neuregulin 1 (NRG 1) is a candidate gene, have some role in regulating synaptic
plasticity in schizophrenia.
 “Akt1” gene plays an important role in neurogenesis in hippocampus.
 Human dystrobrevin binding protein 1 (DTNBP1) gene associated with schizophrenia and
is known to determine the general cognitive ability.
 Searches for the genomics of cognition in schizophrenia may lead to clues about the
origin of disability, the etiology of schizophrenia, and similarities and differences
between schizophrenia.
NEUROBIOLOGY

DSM & ICD
 It still is not included as a criterion for diagnosis in the DSM V or the ICD-10 criteria.
 In DSM V  recommends that
 assessment of cognition and everyday functioning should be a routine part of the
assessment of schizophrenia and
 the assessment scales section of the DSM-5 (Section 3) includes assessment of the
severity and types of cognitive deficits.
 In ICD 11  included under
 6A25 Symptomatic manifestations of primary psychotic disorders
 6A25.5 Cognitive symptoms in primary psychotic disorders

COGNITIVE DOMAINS
 The opinion of the experts of the Measurement and Treatment Research to Improve
Cognition in Schizophrenia (MATRICS) Project is that the most important domains of
neurocognitive deficit in schizophrenia are
1. working memory,
2. attention/vigilance,
3. verbal learning and memory,
4. visual learning and memory,
5. reasoning and problem solving,
6. speed of processing, and
7. social cognition.

1. ATTENTION/VIGILANCE
 Attention refers to the set of operations that enable the organism to
 identify relevant stimuli in the environment,
 focus on that stimulus rather than others (selective attention),
 sustain focus on the stimulus until it is processed (sustained attention or vigilance),
and
 allow for the transfer of the stimulus to higher level processes.

ATTENTION/VIGILANCE
Test
Continuous Performance Test (CPT).
 The “Identical Pairs” version of the CPT requires that patients attend to a series of
two- to four-digit numbers presented sequentially on a computer screen at a rate of one
per second.
 Patients respond with a button press on the keyboard each time a number is identical to
the previous number.

ATTENTION/VIGILANCE
Impairment
 CPT reveals moderately severe vigilance impairments in patients with schizophrenia.
 Attention deficits can contribute to deficits in working memory and executive function.
 It causes difficulty in
 following the social conversations
 to follow instructions regarding treatment, or work functions.
 Simple activities such as reading or watching television can become labored

2. VERBAL LEARNING AND MEMORY
 Verbal memory functioning includes, abilities associated with
 learning new information,
 retaining newly learned information over time, and
 recognizing previously presented material.
 In general, patients show larger deficits in learning than in retention.
 The findings for recognition are more equivocal.

VERBAL LEARNING AND MEMORY
Test
The California Verbal Learning Test
 After the first trial
 healthy controls - recall about 8 of 16 words;
 schizophrenia patients - can recall only about 5.
 After five consecutive trials of the same word list,
 healthy controls - recall about 13 words;
 schizophrenia patients - can recall only 9.
 Thus, patients with schizophrenia are impaired in their
 ability to immediately recall verbal material &
 also impaired in their ability to learn over time.

Impairment
Verbal memory impairment is correlated with :
 Employment Status, Job Tenure, Psychosocial Rehabilitation Success, Quality Of Life
Ratings and Functional Capacity
 In social situations, if one cannot learn the names of new friends or remember things
one has shared with a friend  difficult to develop and maintain intimate relationships.
 Difficulty in remembering the names of colleagues, learning work-related skills, and
remembering work-related agendas would reduce one’s chances for occupational success
dramatically.
VERBAL LEARNING AND MEMORY

3. VISUAL LEARNING AND MEMORY
 It is the learning, retaining and recalling visual information in its shape, form, content
and position.
 Visual information is not as easily expressed as verbal information, so only fewer tests
sensitive to the deficits of schizophrenia have been developed.
 This domain is found to be the least impaired in schizophrenia than other domains

VISUAL LEARNING AND MEMORY
Test
 Brief visuo spatial memory test (BVMT)
 It requires the subjects to draw one or more verbal figures from memory which were
exposed earlier or
 to indicate which among an array of figures was previously presented.

Brief visuo spatial memory test

VISUAL LEARNING AND MEMORY
Impairment
 Visual memory has been found to correlate modestly with
 employment status,
 job tenure,
 psychosocial rehabilitation success,
 quality-of-life ratings, and strongly with
 functional capacity.

4. EXECUTIVE FUNCTION
(Reasoning and Problem Solving)
 Executive function refers to the ability
 to use abstract concepts,
 to plan one’s actions,
 to work out the strategies for problem solving, and
 to execute them with self-monitoring of one’s mental or
physical processes.
 Physiologically, executive function is linked to frontal
lobes and also the cortical-subcortical circuits in frontal
functions

EXECUTIVE FUNCTION - TESTS
tests flexibility of thinking

Stroop test
test for response inhibition

Tower of London test
test planning ability for the optimal route to reach the
goal

The Wisconsin Card Sorting Test (WCST)
• to form abstract concepts in regard to the stimuli and
• to generate hypotheses for problem solving while
• shifting strategies in response to the feedback.

EXECUTIVE FUNCTION
 Patients with Schizophrenia or with frontal lobe dysfunction exhibit perseveration on
WCST.
 Poor performance on the WCST and the reduced activity of the dorsolateral prefrontal
cortex during performance  formulation of the “Frontal hypofunction hypothesis of
Schizophrenia”.
 Performance on the WCST also correlate with the lack of insight of illness
 Schizophrenia pts show deficits on all of these tests compared with normal controls.
 The severity of negative symptoms has been found to correlate with poor performance
on measures of executive function.

EXECUTIVE FUNCTION
Impairment
Patients with schizophrenia who are impaired on measures of reasoning and problem-solving
often have
 difficulty adapting to the world.
 poor medication compliance
 self-injurious behavior and
 risk of violence directed toward others
 In the occupational domain, inability to plan one’s working day, to prioritize activities,
and to use problem-solving skills.

5. SPEED OF PROCESSING
 Processing speed is a cognitive ability that could be defined as the time it takes a
person to do a mental task.
 It is related to the speed in which a person can understand and react to the
information they receive, whether it be visual (letters and numbers), auditory
(language), or movement.

SPEED OF PROCESSING
Test
Digit Symbol Test
 Each numeral (1 through 9) is associated with a different simple symbol. Subjects are
required to copy as many of the symbols associated with the numerals as possible in 120
seconds.
 Patients with SZ show severe deficits on this test
 The performance on this test has accounted for the maximum variance in the overall
composite score on the CATIE study.

SPEED OF PROCESSING
Impairment
 Impairment in speed of processing correlate with a variety of clinically important
features of schizophrenia, such as task-oriented jobs, daily life activities, job tenure,
and independent living status.
 It is also sensitive to medication side effects such as somnolence and extrapyramidal
symptoms.
 Psychomotor slowing also hampers performance on many other cognitive testing
measures.

6. VERBAL FLUENCY
 It is a cognitive function that facilitates information retrieval from memory.
 Successful retrieval requires executive control over cognitive processes such as
selective attention, selective inhibition, mental set shifting, internal response
generation and self monitoring.

VERBAL FLUENCY
Test
1. Phonological fluency - patient’s ability to produce as many words as possible
beginning with a particular letter (e.g., “F”) within 60 seconds.
2. Semantic fluency - the ability to produce words within a particular meaning-based
category, such as “animals.”
3. Design fluency – ability to produce maximum designs within a particular time.
Not only do patients with schizophrenia produce fewer words than normal controls but
they are more likely than healthy people to produce words that are not outside the
required category.

VERBAL FLUENCY
Impairment
 Impaired verbal fluency can damage functioning in social and vocational settings by
making communication difficult and awkward.

7. IMMEDIATE/WORKING MEMORY
 Immediate memory – Refers to the ability to maintain a limited amount of information
“online” for a brief period of time (usually a few seconds).
 Working memory – requires some manipulation of the information being held online. (eg.
to dial a telephone number by holding a number in mind after looking it up in the
telephone book).
 Working memory involves active rehearsing, processing, and manipulating of
information.
 Prefrontal cortical regions mediates aspects of working memory functions, and that
this circuitry may be impaired in schizophrenia.

IMMEDIATE/WORKING MEMORY
Test
 Immediate memory – Digit forward
 Working memory – digit backward (requires maintenance of the initial string and an
active manipulation because the information needs to be both held online and then
subsequently reordered)
Schizophrenia patients typically show deficits on both tasks.

IMMEDIATE/WORKING MEMORY
Impairment
 Working memory impairment in schizophrenia is related to functional outcomes such as
employment status and job tenure.
 Working memory deficits can give rise to positive symptoms.
 The impairment in working memory function has been found to correlate significantly
with formal thought disorder.
 Gross working memory impairment  could not monitor one’s own speech  the
individual’s speech filled with loose associations and derailment.
 Causes impairments in other cognitive domains like attention, planning, memory and
intelligence.

SOCIAL COGNITION
 Social cognition is defined as “ the mental operations underlying social interactions,
which include the human ability to perceive the intentions and dispositions of others”
 Ability to perceive and understand relevant social cues:–– Facial expression & voice
tone, Hints and indirect suggestions and Social norms.
 Ability to correctly process information of a socially relevant stimuli and to use it to
generate socially appropriate response in situations.

 There appear to be 4 primary domains:
 1. Emotional perception
 2. Theory of Mind
 3. Attributional bias
 4. Social perception
SOCIAL COGNITION

1. Emotional perception
According to the Mayor and Salove model, emotional perception is the ability to
1. Perceiving emotions – in faces, pictures & voices and also one’s own emotions.
2. Using emotions - to facilitate thinking and problem solving.
3. Understanding emotions – the emotional language & to appreciate complicated
relationships among emotions.
4. Managing emotions – to regulate emotions of oneself and
others.
SOCIAL COGNITION

With regard to emotion perception the following conclusions are drawn
1. Individuals with schizophrenia display deficits.
2. These deficits are more severe relative to pts with other psychiatric disorders.
3. The greatest deficits are evident in the perception of negative emotions.
4. The deficit in emotion perception is stable over time.
5. Performance is worse in identifying what a given individual is thinking but are less impaired on
more concrete social judgments (ie, identifying what a person is wearing or doing).
6. Restricted visual scanning and spend less time examining salient facial features during emotion
perception tasks.
7. Impairments in emotion perception are present early in the course of illness.
SOCIAL COGNITION

2. Theory of Mind
 ToM refers to the ability to make inferences about the thoughts, beliefs, and
intentions of others. Also referred to as Mentalizing or Mind reading
 It includes understanding false beliefs, hints, intentions, deception, metaphor, irony,
and faux pas.
 Over 30 studies have been conducted on ToM in schizophrenia, leading to the following
conclusions
1. In general, individuals with schizophrenia exhibit deficits in ToM relative to nonill
and psychiatric controls. The bulk of research supports it is a trait deficit.
SOCIAL COGNITION

2. First-degree relatives of schizophrenia pts with schizotypy have impaired ToM lending
support for ToM as a potential endophenotype for schizophrenia.
3. ToM deficits are present in both inpatient and outpatient samples, are not accounted
for by deficits in general cognitive functioning and
4. They are not uniquely associated with any specific symptom type (eg, paranoia).
SOCIAL COGNITION

3. Attributional bias
 Attributional style refers to explanations people generate regarding the causes of
positive and negative events in their lives.
 Normally, people attribute responsibility for positive events to themselves and for
negative events to others.
 Types
1. Internal (i.e., due to oneself) or
2. External (i.e., not due to oneself)
 External attributions are either
a) personal (i.e., due to a specific person) or
b) situational (i.e., due to chance or situational factors)
SOCIAL COGNITION

Personalizing bias
 Scz pts with persecutory delusions tend to blame others rather than situations for
negative events, an attributional style known as a ‘‘personalizing bias.’’
 Attributing negative intentions to others maintains a positive self-image  increases
self-esteem.
 However, it comes at the cost of increasingly negative perceptions of others.
Confirmation bias
 Pts with persecutory delusions also have tendency to ‘‘jump to conclusions’’ (seek
confirmatory evidence for a belief rather than disconfirmatory evidence).
SOCIAL COGNITION

4. Social perception
 The ability to understand and appraise social roles, rules, and context.
 Involves using verbal and nonverbal cues in order to make inferences about a
social situation.
 Facilitates interactions with people in social settings or establishing relationships.
 Helps in making critical appraisals, such as judgments of trustworthiness in other
people
 Test
 videotaped scenes that require the viewer to make inferences and judgments
about ambiguous social situations based on verbal and nonverbal social cues.
 Relationships Across Domains task (RAD): Pt has to find the nature of
relationships between people based on short written vignettes
SOCIAL COGNITION

 Negative symptoms might be more associated with the development or maintenance
of social cognition deficits.
 Social cognition involves both emotional and cognitive processing, whereas
neurocognition is relatively affect neutral.
 ToM deficits may be caused due to – Failed empathy or mental simulation of others’
cognitive affect states leading to increased negative symptoms.
 Social cognitive deficits appear to be key determinants of daily functioning in
schizophrenia, including instrumental actions, interpersonal functioning, and
vocational achievement.
SOCIAL COGNITION

NATURAL HISTORY OF NEUROCOGNITIVE
IMPAIRMENT
 In most patients, detectable deficits may be present in childhood, followed by a decline in
neurocognitive function that occurs sometime prior to the first episode.
 High-risk studies  attention deficits in children of biological parents with schizophrenia can
predict which children will develop schizophrenia in the future.
 In cases with prodrome, deficits are present at the time of the detection of prodrome, and those
cases with the greatest impairments are at the highest risk to develop psychosis.
 Neurocognitive impairment is stable over time in majority of patients.
 Progress of deficits over the illness is generally absent, even in very poor outcome cases, until
later life.

NEUROCOGNITIVE IMPAIRMENT & SYMPTOMS
I. Positive Symptoms
 Neurocognitive ability is not strongly correlated with severity of positive symptoms in patients
with schizophrenia.
 In the NIMH CATIE trial – There was no correlations between positive symptoms and
neurocognitive function in five different domains.
 Reasons -
 The low validity - the subjective report of a psychotic patient may not reflect the true level
of the patient’s psychosis
 the symptoms change over time compared to neurocognitive deficits, which are stable.
 Exclusion of patients who are too psychotic to be tested may weaken any potential correlation
 Finally, those patients who have more intact neurocognitive abilities may be better able to recall
delusions and hallucinations.

II. Negative Symptoms
 Neurocognitive dysfunction is correlated with various types of negative symptoms.
 The greater correlation between neurocognition & negative symptoms compared with positive
symptoms may be due to measurement overlap. For eg. When tests of verbal fluency is impaired,
the scale for negative symptom of “poverty of speech” is also decreased.
 Motor functions - Deficient motor skills are represented in both the negative symptom and the
neurocognitive dysfunction domain.
 Motivation - they put forth a normal amount of effort in neurocognitive tests of modest difficulty,
but they are unable to engage in difficult tasks because of the decreased processing capacity. So,
neurocognitive tests is not affected in general by poor motivation
 On the contrary, neurocognitive deficits may cause reduced motivation. Patients with
neurocognitive impairment  failure in employment or social activity  Repeated failures 
reduced motivation.

III. Formal Thought Disorder
 Deficits in semantic memory lie at the heart of the neurocognition – thought disorder
relation.
 Difference between semantic fluency and phonological fluency indicates severity of the
impairment of the “semantic network”  predicted the severity of the formal thought
disorder.
 Individual with gross working memory impairment might find it difficult to remember
the original intention of the sentence spoken, and the individual’s speech might be filled
with loose associations and derailment.

CLINICAL IMPORTANCE
Unemployment
 Poorer baseline scores on verbal memory tests and the WCST  poor work performance
 Better baseline performance can predict improvement in patient work performance after
rehabilitation program.
Quality of Life
 Reductions in quality of life are more strongly associated with neurocognitive deficits. More
severe executive and memory deficits are related to decreased use of coping mechanisms
Relapse Prevention
 Neurocognitive deficits contribute to poor adherence and risk of relapse.
Medical Comorbidity
 Deficits in reasoning and problem solving directly affect patients’ ability to seek treatment
for their medical problems & reduce damaging habits such as smoking

Neurocognitive Batteries
 WAIS - Wechsler Adult Intelligence Scale;
 WMS - Wechsler Memory Scale;
 MCCB - MATRICS Consensus Cognitive Battery;
 SCoRS - Scale for Cognition in Schizophrenia;
 UPSA - University of California Performance-Based Skills Assessment;
 RBANS - Repeatable Battery for Neuropsychological Status;
 BACS - Brief Assessment of Cognition in Schizophrenia;
 BCA - Brief Cognitive Assessment.

TREATMENT OF NEUROCOGNITIVE
IMPAIRMENT
 At present there are no FDA approved treatments of neurocognition in schizophrenia.
 Use of “typical” antipsychotics cause lethargy, somnolence, and extrapyramidal
symptoms  impair neurocognition.
 Anticholinergic medications used to control side effects cause additional neurocognitive
impairment of memory and learning
 Lowering dosages of conventional antipsychotic medications has some modest
neurocognitive benefit, so neurocognitive impairment could be dose dependent.
 Atypical antipsychotics Clozapine, olanzapine, risperidone, and quetiapine have been
found to have superior efficacy in treating cognitive impairments in schizophrenia
compared with conventional antipsychotics.

 Serotonin, dopamine antagonists can increase dopamine release selectively in the
mesocortical pathway  increased dopamine transmission in the prefrontal cortex 
improves cognition.
 According to the CATIE trial neurocognition improved with all treatments used –
olanzapine, quetiapine, risperidone and ziprasidone vs perphenazine.
 However, the amount of improvement was interpreted to be consistent with practice
effects and expectation biases, suggesting that the effect of antipsychotic
medications on these patients was negligible.
 Two industry-sponsored studies have suggested that olanzapine and risperidone
improve neurocognition.

COGNITIVE REMEDIATION
 Cognitive remediation for schizophrenia is defined as “an intervention based on
behavioral training that intends at mending the cognitive processes (executive
functions, attention, memory, social cognition or metacognition) in terms of its
durability and making it more generalized”.
 Keshavan et al has defined it as an intervention that uses specifically designed and
behaviorally constrained cognitive or socio-affective learning events, delivered in a
scalable and reproducible manner, to potentially improve neural systems operation.
 Also called “Cognitive Rehabilitation”, and “Cognitive Training”.

Basic principles
 Remediation training includes training in areas such as attention, memory, executive
functioning, speed of processing and abstraction etc.
 Socio-cognition deficits training gives attention to emotional processing, social
perception, social knowledge, attribution bias and theory of mind.

Classification
1. Wykes and Reeder Classification
 Drill and practice methods.
 Involve repeated exercises in progressively difficult tasks
 Participant learns by trial and error.
 There are no predetermined strategies.
 Drill and strategy coaching
 Involves teaching a predetermined strategy to accomplice a particular task in
graded difficulty level.
 This involves modelling, explanation or role-play

2. Classification based on the understanding of neurocognitive science
 Compensatory model
 Overcome cognitive deficits to improve broader aspects of functioning by
 utilizing the intact cognitive parameters or
 installing the desired behavior of interest through training by using environmental resources.
 It requires that participants to have
1. insight into their difficulties,
2. assessing individuals strengths and weaknesses
3. understanding learning preferences best suited for the person.
 Restorative model
 Based on the knowledge derived from neural plasticity research.
 These strategies involves attempt to correct a specific neural deficit using the capacity of the brain to
develop and repair throughout the whole life.

3. Top-down and bottom-up techniques.
 Top-down (feedback) approach
 Involves single and specific training of higher order metacognitive skills and
executive functions.
 Bottom-up (feed-forward) approaches
 Start with basic neurocognitive skills like attention, pre-attentive perceptual
biasing and perceptual skills.
 Successful cognitive training program involve varying combination of above two
approaches and they often act synergistically.

Learning strategies used in Cognitive remediation
1. Errorless learning
 Training task is broken down into smaller components
 Start training with simple tasks and then to continue with more complex ones.
 To prevent occurrence of any error during training, various methods of teaching are
used and reinforced.
2. Scaffolding
 Another way of errorless learning.
 It minimizes errors through careful regulation of complex task to be learnt.
 The learner is encouraged to use previously established areas of competence, whilst
help is provided with new aspects of learning.

3. Massed practice
 Consists in the frequent exercise of a repeated task (at least 2-3 times per week) in order to
encourage the retention and application of the skills developed.
4. Information processing
 Strategies include
 verbalization (repeating important information mentally or physically to remember),
 information reduction (focusing only on key aspect of information),
 mnemonic strategies,
 categorization (sorting information into classes), and
 self-monitoring,

SPECIFIC TECHNIQUES
 Cognitive training
 Cognitive enhancement therapy (CET)
 NEAR method (Neuropsychological educational approach to rehabilitation)
 Cognitive adaptation training
 Brain fitness program (BFP)

Evidence base for Cognitive Remediation
 Several quantitative reviews  cognitive remediation reduces cognitive deficits and
improves functional outcome with long-term benefits in schizophrenia.
 A meta-analysis of 40 studies conducted over 35 years period (between 1973 and
2009), found modest efficacy in overall cognitive performance, with long term effects,
as shown in follow up studies.
 Moreover, significant small-to-medium effect was also found on functional outcomes at
both post-treatment and follow-up assessment.
 Evidences suggest that significant improvement in social functioning occurs when
cognitive training and other psychosocial rehabilitation programs administered together
with strategy coaching approach based on learning strategies.

MATRICS
 Measurement and Treatment Research to Improve Cognition in Schizophrenia
 Developed by the NIMH
Reasons for developing MATRICS
 Too few new drugs are being developed for illnesses that affect the CNS
 Drugs for CNS disorders have often been accidental discoveries rather than the
products of well developed scientific strategies; and
 There is dissatisfaction with the effectiveness of drugs for schizophrenia – according
to CATIE 74% of patients were discontinued from their antipsychotic treatment due
to lack of efficacy or side effects.

MATRICS
The Goal of the MATRICS
 Is to address important obstacles in the development of new pharmacological
approaches to improve neurocognition. These obstacles include
1. The lack of a well-accepted instrument for measuring neurocognition in trials;
2. The lack of a consensus on the best molecular target for drug development;
3. The lack of a consensus regarding the optimal trial design for either comedication
that improves cognition when added to an antipsychotic or a broad-spectrum agent
that improves cognition and treats psychosis; and
4. The approaches of regulatory agencies such as the US (FDA) to approving and
labeling a new agent.
 The MATRICS group has attempted to address each of these obstacles.

MATRICS
Molecular targets – for drug development
MATRICS developed a consensus regarding the molecular targets that should be a focus
of drug development. The molecular targets are ranked in the following order :-
1. α7-Nicotinic receptor agonists
2. Dopamine D1 receptor agonists
3. AMPA glutamatergic receptor agonists
4. α2-adrenergic receptor agonists
5. NMDA glutamatergic receptor agonists
6. Metabotropic glutamate receptor agonists
7. Glycine reuptake inhibitors
8. M1 muscarinic receptor agonists
9. GABA A - R subtype selective agonists

REHABILITATION IN
SCHIZOPHRENIA

REHABILITATION
 Rehabilitation denotes a wide range of interventions to help people with disabilities improve their
functioning, quality of life, and recovery by enhancing the opportunities, skills, and supports they
need to succeed in regular adult roles and in the environments of their choice.
 emphasizes independence, self-management, self-reliance, and community integration by avoiding
dependence on professionals and segregated settings.
 About 10 to 15 % of schizophrenia pts recover completely, but many continue to have cognitive
difficulties, and psychosocial problems for decades.
 Antipsychotic medications often reduce positive symptoms, but they have limited impact on
negative symptoms, cognitive impairment, and psychosocial functioning. They do not restore
premorbid levels of functioning.
 Therefore, maximizing functional recovery through psychiatric rehabilitation is critical for most
patients.

REHABILITATION
OVERVIEW OF TECHNIQUES
Psychiatric rehabilitation uses three basic approaches:
1. Creating opportunities,
2. providing supports, and
3. increasing skills.

REHABILITATION
1. Creating opportunities
 People with mental disorders have always been
 discriminated, stigmatized
 segregation and lack of opportunity
 Sensationalism in the media  stigma.
 Psychiatrists and other professionals often convey stigmatizing attitudes
 Psychiatric rehabilitation aims to increase opportunities for normative housing,
education, employment, socialization, leisure, and other activities that represent full
citizenship under the rubric of community integration.
 To increase opportunities, rehabilitation specialists use legal mechanisms, regulations,
community action, social networks, family supports, and personal relationships.

REHABILITATION
2. Providing supports
 People with mental illness often need extra supports to succeed initially in functional
roles.
 Once achieving success in a specific setting, such as school or work, supports are
typically withdrawn substantially or completely, as the experience itself increases self
confidence, functional skills, and natural supports.

REHABILITATION
3. Increasing skills
 Due to cognitive, experiential, and neurological difficulties, people with schizophrenia
often need to enhance their abilities to manage their internal experiences, social
environments, and roles they are pursuing in the community.
 Skills training has been a core feature of rehabilitation for decades.
 Presently, most of the learning is now shifting from professionals to technology tools.

COGNITIVE BEHAVIOR THERAPY
 Address positive symptoms that remain after medication treatment has been optimized.
 CBT is focused on helping individuals develop alternative explanations for the delusions and
hallucinations and reduce the impact of these symptoms on their behavior.
 The client and therapist discuss and evaluate the specific content of delusions and hallucinations.
 The therapist works first
 to understand thoroughly the patient’s perspective as to how the beliefs have developed
 Raising questions about the sources of the problem
 And eventually helping the individual conduct behavioral experiments to test explanations and
 suggesting alternative explanations for events.
 CBT approaches have also been applied to individuals who do not comply with medication because of
poor insight into having a mental disorder. Previous treatment failures, contradictory information,
and disappointments in attaining goals are discussed.

SOCIAL SKILLS TRAINING
 Based on a neurodevelopmental model, individuals who go on to develop schizophrenia have cognitive
deficits that may have interfered with the acquisition of adequate social skills during development
 Social skills training teaches specific skills that lead to effective behavior in social interactions.
 Specific skills may include
 nonverbal behavior, such as appropriate eye contact and voice volume,
 conversational skills such as introducing oneself to a new person and taking the perspective of
another person, and
 problem- solving skills such as expressing dissatisfaction and generating solutions to
interpersonal problems
 Participants may be taught in a didactic manner the steps to perform a behavior, watch the
behavior of a model, and then practice the behavior while receiving coaching and corrective
feedback from the group.
 When skills are improved, patients’ interactions with others may become more successful and
rewarding, leading to increased social participation.

INTEGRATED TREATMENTS FOR COMORBID SUBSTANCE ABUSE
 Comorbid substance abuse increases the likelihood of poor adherence to medication and is
associated with more severe positive symptoms
 Integrated treatments make use of many different treatment modalities including intensive case
management, motivational interviewing, 12-Step programs focused on dual diagnosis, CBT, social
skills training, contingency management, and family psychoeducation
 Many successful programs do not have abstinence as a goal but instead use a harm-reduction
 The treatment involves
 Motivational interviewing to develop treatment goals,
 social skills training aimed at providing the patient with the skills necessary to refuse drugs
 to develop friendships with those who do not use drugs,
 education regarding how drugs affect the brain and medications for psychiatric illness, and
 teaching ways to cope with high-risk situations.

FAMILY PSYCHOEDUCATION
 Criticism and overinvolvement by family members can increase the risk of relapse
 Although there are a number of different family treatment strategies, common elements include
 providing education about mental illness,
 helping members develop realistic expectations that take the illness into account, and
 providing training in communication and
 problem-solving skills.
 Family treatment can be provided for individual families or in group settings where members can
learn information and effective coping skills and gain perspective from one another.
 Decades of research indicate that family treatment results in lower rates of relapse in comparison
to standard care or control treatments

Assertive Community Treatment
 Patients are assigned to one multidisciplinary team (e.g., case manager, psychiatrist,
nurse, general physicians).
 The team delivers all services when and where needed by the patient, 24 x 7
 This is mobile and intensive intervention that provides treatment, rehabilitation, and
support activities.
 These include home delivery of medications, monitoring of mental and physical health, in
vivo social skills, and frequent contact with family members.
 There is a high staff-to-patient ratio ( 1 : 12).
 ACT programs can effectively decrease the risk of rehospitalization for persons with
schizophrenia, but they are labor-intensive and expensive.

CURRENT APPROACHES
1. HOUSING FIRST
2. INDIVIDUAL PLACEMENT AND SUPPORT
3. TECHNOLOGY TOOLS

1. HOUSING FIRST
 Mentally ill people become homeless, repeatedly hospitalized, and incarcerated because
of severe mental illness, poor treatment, or a combination of both.
 By contrast, researchers consider homelessness to be primarily due to a lack of
affordable and appropriate housing.
Housing Models
 Traditional approach  housing people with schizophrenia using segregation and linkage
with required clinical services.
 Segregated housing included nursing homes, group homes, boarding homes, and housing
units linked by proximity and closely overseen by mental health workers.
 All of these models assumed that people with serious mental disorders needed constant
supervision, which was most easily provided by grouping them together, and were not
competent to live on their own.

HOUSING FIRST
Supported housing
Core principles included
 Normalized permanent housing (regular tenancy agreements, assurance of privacy,
location in integrated communities),
 client choice in type and location of residence,
 assistance in finding affordable housing,
 individualized and flexible support,
 separation of housing and services.
Most pts preferred living in their own homes, not in supervised congregate housing.

HOUSING FIRST
 The approach does not require that people participate in any mental health program as
a precondition for obtaining housing.
 Instead, Housing First assumes that people need housing as a foundation from which
they can pursue other goals.
 Integrates housing assistance with assertive community treatment, intensive case
management, or some other team based approach to comprehensive services.
 The same team assists people in finding affordable housing and also helps them learn to
live independently and access other services as they express additional needs.
 Services are not mandatory, coercive, or chosen by professionals: tenants learn about
services and make informed decisions, using a shared decision-making model.

HOUSING FIRST
Research on Supported Housing
 Large-scale pragmatic trials have demonstrated that most people with serious mental
disorders can maintain independent housing over the long term when they have safe,
affordable housing and adequate psychosocial supports.
 Housing to people with substance use disorders, again without preconditions, does not
lead to the dire consequences.
 Clients receiving supported housing assistance are more satisfied with their housing and
have reduced use of psychiatric hospitals and emergency rooms.

2. INDIVIDUAL PLACEMENT AND SUPPORT
 Among schizophrenia patients less than 15 percent of patients are employed.
 Vocational rehabilitation has always been a center piece of psychiatric rehabilitation.
 Many previous approaches have involved train-and-place models, with extensive pre-
employment assessments and preparatory experiences, such as day centers, sheltered
workshops, transitional employment, and skills training.
 These aimed to evaluate and improve the patient’s attitudes & skills presumed
necessary to obtain and sustain competitive employment.
 These step-wise approaches to vocational rehabilitation did not improve the rate of
competitive employment; most patients became discouraged during preparatory
experiences.

INDIVIDUAL PLACEMENT AND SUPPORT
Supported Employment
 “Competitive work in integrated work setting consistent with their strengths, and
abilities, for individuals with the most significant disabilities for whom competitive
employment has not traditionally occurred”
 In contrast to other vocational approaches, supported employment programs
a) did not screen people for work readiness, but help anyone who says they want to
work;
b) no extensive pre-employment assessments & training;
c) actively facilitated job acquisition, often accompanying clients on interviews; and
d) provided ongoing support once the person is employed.

SUPPORTED EMPLOYMENT
Features
1. Zero Exclusion. Supported employment services are available for anyone who wants to
work, regardless of symptoms, cognitive impairments, or substance use
2. Competitive Employment. The great majority of patients who seek work want
competitive employment
3. Rapid Job Search. Clients seek employment directly, rather than following lengthy pre-
employment assessment, training, or practice. Typically results in finding a first job
within 4 months.
4. Systematic Job Development. The employment specialist conducts targeted job
development to help find jobs that match people’s skills and preferences.

5. Integration of Rehabilitation and Mental Health Treatment. Employment specialists are
integrated into case management & assertive community treatment teams. They meet regularly
with their teams and collaborate on helping patients to succeed in jobs.
6. Patient Preferences. Services are based on patients’ preferences and choices. Patients report
higher satisfaction and longer job tenure when the jobs are consistent with their preferences.
7. On-going Support. The multidisciplinary team provides a range of supports over time. For example,
 The psychiatrist may alter medications to help with the initial anxiety of working;
 the case manager may meet with the family to help them be supportive; and
 the employment specialist may provide counseling, off-site supports, and skills training.
8. Individualized Benefits Counseling. Many patients who receive disability benefits fear they could
lose them if they work. Individualized, accurate information about benefits often corrects
misconceptions and helps patients make good decisions.

Research on IPS Supported Employment
 The evidence strongly favors IPS supported employment over other approaches to
vocational rehabilitation.
 More than 20 randomized controlled trials show that IPS supported employment
produces higher rates of employment, greater earnings, more hours of work, and longer
tenure in jobs.
 Research also shows that patients themselves express high satisfaction
 they typically stay in first jobs for 5 to 6 months similar to general population.
 Several long-term follow up studies indicate that patients maintain initial high
employment rates over 5 to 10 years. They also report better self esteem, and greater
quality of life.

3. TECHNOLOGY TOOLS
 Schizophrenic pts also use contemporary technologies in a manner similar to the general
population. They use a host of digital resources for mental health reasons:
 obtaining information about mental disorders and treatments,
 searching for mental health services,
 connecting with peers with similar conditions, and
 engaging with online communities and supports.
 they openly disclose their illness and provide first-person accounts of their symptoms
and coping strategies on YouTube. In response many viewers describe their own
experiences with illness, provide positive feedback and share symptom management
suggestions.
 Hence technology helps to erode the stigma that often prevents people from disclosing
their mental health struggles.

TECHNOLOGY TOOLS
Web-Based Interventions
 People with schizophrenia, their family members can access a range of resources -
illness management programs, support groups and informational webpages.
Eg. Coping with Voices
 A self directed web-based Cognitive Behavioral Intervention,
 Addresses the functional impact and distress caused by auditory hallucinations.
 Users progress through an interactive 10-lesson program at their own pace and revisit
content form previous lessons.
 Video tutorials educate people about psychosis and dysfunctional cognitive styles using
interactive games, quizzes, and practice opportunities.
 Participants who complete Coping with Voices experienced reductions in the severity
and intensity of auditory hallucinations as well as other psychotic symptoms and general
psychopathology

TECHNOLOGY TOOLS
Schizophrenia Online Access to Resources (SOAR)
 It is a multifamily intervention for people with schizophrenia and their supports. The key elements
of the SOAR intervention include
 empathic engagement of users,
 education about illness and treatments, and
 use of coping strategies.
 Users can post questions and receive answers from trained clinicians within 24 to 48 hours.
 SOAR also contains a record of responses to previously posted questions, a library of relevant
reading materials, and a list of community events, activities, and resources that may be of
interest.
 People with schizophrenia who engage in SOAR experience a significant reduction in positive
symptoms of psychosis.
 Support persons also showed a significant and sustained increase in knowledge about the course
and prognosis of schizophrenia.

TECHNOLOGY TOOLS
The HORYZONS system
 It is an online platform developed for long-term recovery of people experiencing a first
episode of psychosis.
 The system delivers several evidence-based and interactive psychosocial interventions
and facilitates a moderated online peer-to-peer social networking environment.
 Users respond to a set of standardized questions that target risk factors for
psychotic relapse and other areas that are salient to people in early recovery, including
psychoeducation, early warning signs, depression, social anxiety, and stress
management.
 First-episode patients who used the HORYZONS system reduced depression and found
the approach to be engaging, empowering, and safe.

TECHNOLOGY TOOLS
FOCUS
 The first smartphone intervention specifically designed for people with schizophrenia, was
developed iteratively and in close consultation with patients and clinicians.
 The FOCUS system can be activated to prompt users multiple times a day with questions about
their symptoms, social functioning, mood, medication adherence, and sleep, which appear on the
devices touchscreen.
 Depending on users’ responses, the system launches brief interactive interventions in the form of
written text, images, and cartoon screens, designed to give skills they can use in the moment (e.g.,
relaxation strategies, medication reminders, social skills tips)
 They also train the user in techniques that can be generalizable to a range of scenarios (e.g.,
cognitive restructuring, hypothesis testing, behavioral activation, distress tolerance).
 In addition to prompted interactions, all FOCUS interventions are available on-demand as part of a
toolkit that can be accessed at any time.

TECHNOLOGY TOOLS
Mobile Assessment and Treatment for Schizophrenia (MATS)
 Short Message Service have also been used to support psychiatric rehabilitation with
patients with schizophrenia.
 MATS is a mobile phone intervention employed to administer questions and algorithm-
driven follow-up suggestions to patients in the areas of medication adherence, social
functioning, and management of auditory hallucinations.
 MATS initiates a sequence of brief automated back-and-forth exchanges, including
illness-management suggestions drawn from cognitive behavioral treatments for
psychosis.
 Community-based research has shown that patients with psychosis and co-occurring
substance use find texting to be a highly engaging method for connecting with their
case manager.

TECHNOLOGY TOOLS
Virtual Reality
 Virtual reality (VR) refers to multimedia techniques in which individuals engage in
computer-generated scenarios on a computer screen or head-mounted stereoscopic
display that creates a highly immersive 3D environment.
 VR has been used primarily to facilitate exposure therapy for people with anxiety
disorders, but several studies have demonstrated its potential utility in supporting
rehabilitation for people with psychosis.
 These include help identifying contextual triggers for persecutory ideation, learning
skills, and practicing job interviews.
 Preliminary evidence suggests VR may be an effective tool, including benefits from
continuous feedback from an on-screen virtual coach.

SUMMARY
 Neurocognitive impairment in schizophrenia is greatest in the domains of memory,
attention, working memory, problem solving, processing speed, and social cognition.
 More important in predicting functional outcome
 Social cognition is the human ability to perceive the intentions of others, contains 4
domains.
 Neurocognitive impairment is stable over time in majority of patients.
 Cognitive remediation is the most important treatment
 Rehabilitation involves supported housing, supported employment and use of
technology tools.

CONCLUSION
 relationship between cognitive deficits and functional outcome in schizophrena was
noted first by Kraepelin and Bleuler.
 With the introduction of conventional neuroleptics, the focus shifted toward the
treatment of positive symptoms. ‘
 In the past few decades, cognitive dysfunction has been recognized as a fundamental
feature of schizophrenia and
 has been shown repeatedly to have a negative association with functional outcome.
 Improvement in cognitive functioning has become one of the most important clinical
targets in the treatment of schizophrenia.

REFERENCES
1. Kaplan and Sadocks Comprehensive textbook of Psychiatry – 9, 10th Edition
2. Kaplan and Sadocks Synopsis of Psychiatry – 11th Edition
3. Postgraduate Textbook of Psychiatry – Neeraj Ahuja, 3rd Edition
4. Sharma T, Antonova L. Cognitive function in schizophrenia. Deficits, functional
consequences, and future treatment. Psychiatric Clinics of North America. 2003 Mar.
5. Marder SR. The NIMH-MATRICS project for developing cognition-enhancing agents
for schizophrenia. Dialogues in clinical neuroscience. 2006 Mar;8(1):109.
6. Tripathi A, Kar SK, Shukla R. Cognitive deficits in schizophrenia: Understanding the
biological correlates and remediation strategies. Clinical Psychopharmacology and
Neuroscience. 2018 Feb;16(1):7.
7. Penn DL, Sanna LJ, Roberts DL. Social cognition in schizophrenia: an overview.
Schizophrenia bulletin. 2008 Mar 28;34(3):408-11.

Neurocognition, social cognition, rehabilitation in schizophrenia

Neurocognition, social cognition, rehabilitation in schizophrenia

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