This document discusses neurocognition, social cognition, and rehabilitation in schizophrenia. It covers the introduction, history, neurobiology, cognitive domains, and relationship to symptoms and treatment. The key points are:
- Neurocognitive impairment in schizophrenia is profound and impacts domains like memory, attention, problem solving, and social cognition. Deficits are present prior to treatment and not caused by symptoms.
- Cognitive deficits are stable over time, persist even when symptoms remit, and are better predictors of functional impairment than symptoms. Neurocognition is now a primary treatment target.
- Tests are used to assess specific cognitive domains like attention, verbal learning and memory, visual learning and memory, executive function/problem solving
Cognitive changes have been a defining feature of Sz since onset. A lot of research has been done in understanding these changes and its implication in developing novel methods of treatments. This ppt summarises the cognitive changes occurring in the brain.
Cognitive changes have been a defining feature of Sz since onset. A lot of research has been done in understanding these changes and its implication in developing novel methods of treatments. This ppt summarises the cognitive changes occurring in the brain.
This is a presentation done on 4/6/11 for the Grand Rounds at Wayne State university by Pallav Pareek M.D.
This presentation talks about the concept of prdrome as it is(if?) applicable to schizophrenia, and if schizophrenia is becoming more of a preventable illness as science progresses. If so what are the various ways and means in which we can accomplish this prevention.
Amidst so much controversy on the issue , whether there is a prodrome for this illness or not, here I have tried to present the recent advances in this field and the recent scientific literature in this regard.
The association of neuropsychiatric disorders with cerebrovascular disease has been recognized by clinicians for over 100 years. Disease of the vascular system contribute greatly to the sum total of psychiatric disability, chiefly in the elderly population, mainly as a result of stroke, cerebrovascular accidents & subarachnoid haemorrhage.
DISORDER CONTENTOF THOUGHT -DELUSION
BY DR.WASIM
UNDER GUIDANCE OF
DR.SANJAY.JAIN
Definition of delusion:
Delusions are categorized into four different groups
THERE ARE 2 TYPES OF DISORDERS OF THOUGHT CONTENT
1.DELUSION
2.OVERVALUED IDEAS
DISTINGUISED
DELUSION
OTHER MEMBERS OF THE CULTURE DONOT SHARE THE BELIEF.
NEED NOT BE ASSOCIATED WITH AFFECT.
FIRMLY SUSTAINED BELIEF.
CONVINCED THAT DELUSION IS REAL.
RECOGNIZED AS ABSURED.
CANNOT BE ACCEPTED.
OCCUR IN MENTALLY ILL PATIENTS.
OVERVALUED IDEAS
OTHER MEMBERS OF THE CULTURE SHARE THE BELIEF.
ASSOCIATED WITH VERY STRONG AFFECT.
NOT HELD FIRMLY.
ATLEAST SOME LEVEL OF DOUBT AS TO ITS TRUTHFULNESS.
NOT RECOGNIZED AS ABSURED.
ACCEPTABLE.
CAN OCCUR IN BOTH HEALTHY AND MENTALLY ILL PATIENTS.
KENDLER’S VECTORS FOR DELUSION:
five stages in the development of delusion(FISH & CONRAD)
FACTORS CONCERNED WITH GENERATION OF DELUSIONS
PATHPOPHYSIOLOGY OF DELUSIONS
PRIMARY DELUSIONS
SECONDARY DELUSIONS
SYSTEMATIZATION
DELUSIONS ON THE BASIS OF CONTENT OF DELUSIONS
THANK YOU
This is a presentation done on 4/6/11 for the Grand Rounds at Wayne State university by Pallav Pareek M.D.
This presentation talks about the concept of prdrome as it is(if?) applicable to schizophrenia, and if schizophrenia is becoming more of a preventable illness as science progresses. If so what are the various ways and means in which we can accomplish this prevention.
Amidst so much controversy on the issue , whether there is a prodrome for this illness or not, here I have tried to present the recent advances in this field and the recent scientific literature in this regard.
The association of neuropsychiatric disorders with cerebrovascular disease has been recognized by clinicians for over 100 years. Disease of the vascular system contribute greatly to the sum total of psychiatric disability, chiefly in the elderly population, mainly as a result of stroke, cerebrovascular accidents & subarachnoid haemorrhage.
DISORDER CONTENTOF THOUGHT -DELUSION
BY DR.WASIM
UNDER GUIDANCE OF
DR.SANJAY.JAIN
Definition of delusion:
Delusions are categorized into four different groups
THERE ARE 2 TYPES OF DISORDERS OF THOUGHT CONTENT
1.DELUSION
2.OVERVALUED IDEAS
DISTINGUISED
DELUSION
OTHER MEMBERS OF THE CULTURE DONOT SHARE THE BELIEF.
NEED NOT BE ASSOCIATED WITH AFFECT.
FIRMLY SUSTAINED BELIEF.
CONVINCED THAT DELUSION IS REAL.
RECOGNIZED AS ABSURED.
CANNOT BE ACCEPTED.
OCCUR IN MENTALLY ILL PATIENTS.
OVERVALUED IDEAS
OTHER MEMBERS OF THE CULTURE SHARE THE BELIEF.
ASSOCIATED WITH VERY STRONG AFFECT.
NOT HELD FIRMLY.
ATLEAST SOME LEVEL OF DOUBT AS TO ITS TRUTHFULNESS.
NOT RECOGNIZED AS ABSURED.
ACCEPTABLE.
CAN OCCUR IN BOTH HEALTHY AND MENTALLY ILL PATIENTS.
KENDLER’S VECTORS FOR DELUSION:
five stages in the development of delusion(FISH & CONRAD)
FACTORS CONCERNED WITH GENERATION OF DELUSIONS
PATHPOPHYSIOLOGY OF DELUSIONS
PRIMARY DELUSIONS
SECONDARY DELUSIONS
SYSTEMATIZATION
DELUSIONS ON THE BASIS OF CONTENT OF DELUSIONS
THANK YOU
Today Schizophrenia awareness week starts. (From 22 May 2022 to 28th May 2022). Theme for this year is "Connecting with Hope". I have tried my best to cover everything about schizophrenia a type of severe mental illness.
Systematic assessment of early symptoms of unspecified dementias in people wi...Premier Publishers
Researchers have shown that individuals with mental retardation or with developmental disabilities are at a greater risk of developing health problems and among others dementia than the general population. As the literature points out, dementia is characterized by progressive loss of cognitive functions, until the individual has lost all independency and ability in daily life. It is therefore necessary to carry out a systematic assessment throughout the developmental phases at the beginning of these signs. The purpose of this paper is to present the importance of systematic assessment of early symptoms of unspecified dementias in people with developmental disabilities. The methodology is based on the pre-dementia analysis of two study cases followed by a 2-year period. In conclusion, it can be argued that the diagnosis of dementia in people with developmental disabilities, in the early stages, has become difficult because of the lack of reliable and standardized criteria and diagnostic procedures and difficulties to investigate cognitive decline versus an already vulnerable developmental disability base. Therefore, in people with developmental disabilities, a diagnosis of dementia needs to be done based on changes in mental status from basic functioning. This helps a clinician to determine an accurate diagnosis in later years as hypothetically results from two case studies with later subcortical dementia. However, this endeavour remains to be discussed widely by mental health specialists, public health and cognitive neuroscience in order to determine whether this contribution provided actually has the power of explanation understandable or is understandable by the part of interest.
Nelson is the reference of choice for all those who decide to specialize or sub-specialize in pediatrics. While the field of general pediatrics moves relatively slowly, the sub-specialty areas – most of which have a great impact on the practice of general pediatrics – tend to move more quickly. Nelson offers thorough coverage of the entire specialty
Check out a sample of Chapter 30 in the latest 19th edition. For purchase, please visit www.asia.elsevierhealth.com
Developmental delay is the spectrum of problems encompassing delay in the cognitive, social, emotional, sexual and physical developmental skills. This presentation briefs the Cognitive developmental delay
Neuroprogression and Cognitive Functioning in Bipolar Disorders - Eleonora Lo...Eleonora Lombardi
Bipolar disorder (BD) has been associated with impairments
in a range of cognitive domains including attention, verbal learning, and mental flexibility. These deficits are increased during the acute phases of the illness and worsen over the course of BD. This review will examine the literature in relation to potential mechanisms associated with cognitive decline in BD. Scopus (all databases), Pubmed, and Ovid Medline were systematically searched with no language or year restrictions, up to January 2015, for human studies that collected cross-sectional and longitudinal cognitive data in adults with BD and matched healthy controls (HC). Selected search terms were “bipolar,” “cognitive,” “aging,” “illness duration,” “onset,” and “progression.” Thirty-nine studies satisfied the criteria for consideration. There is evidence that cognitive function in BD is negatively associated with features of illness progression such as number of mood episodes, illness duration, and hospitalizations. Aging does not appear to affect cognitive functioning to a greater extent than in HC. Furthermore, the small number of longitudinal studies in this field does not allow to reaching firm conclusion in terms of which sub-populations would be more prone to cognitive decline in BD. The decline in cognitive abilities over the course of the BD seems to be associated with the number of episodes and number of hospitalizations. No meaningful interaction of age and bipolar disorder has been found in terms of cognitive decline. Future large-scale longitudinal studies are necessary to confirm these findings and assist in the development of preventive interventions in vulnerable individuals.
How much do we really understand about Schizophrenia and to what extent is so...Pırıl Erel
This essay analyses what the mental disorder Schizophrenia (SZ) is, examining in detail medical research such as; symptoms and behaviour of patients, how to identify this mental disorder what type of treatment is available. Furthermore it will explore society’s behaviour towards this disorder and scrutinising the question ‘To what extent are we responsible for the nurture and care of vulnerable individuals?’
Neuropsychology of OCD 1Running Head Neuropsychology o.docxvannagoforth
Neuropsychology of OCD 1
Running Head: Neuropsychology of OCD
Neuropsychological Profile of Childhood-Onset Obsessive-Compulsive Disorder
Metehan Irak & Martine M. Flament
University of Ottawa Institute Mental Health Research
September 16th , 2006
Neuropsychology of OCD 2
Summary
In this review paper, studies focusing on the neuropsychological characteristics of childhood-onset obsessive-
compulsive disorder (OCD) were evaluated. Systematic electronic searches were undertaken using MEDLINE
and Psycinfo databases (until June 2006). The presented results are of those that focus on the processes of
attention, memory, and executive functions related to the aspects of the measured instruments used. The aim of
this review was to provide a general neuropsychological profile of childhood-onset OCD based on the reviewed
studies. In general, results showed that there is no clear evidence that the neuropsychological aspects of
childhood-onset OCD differ from those of adult-onset OCD. In parallel with this, the processes of attention and
memory in childhood-onset OCD are observed to be selective and biased, and this bias is directed towards
threat-relevant stimuli related to obsessions and compulsions. In addition, dysfunction in memory and
visuospatial processes in OCD patients do not result from memory impairment per se, but rather from an
impaired ability to apply efficiently elaborated memory strategies. In childhood-onset OCD, the various lines of
evidence consistently include impairment of response suppression and motor inhibition abilities; there is less
consistent evidence for reduced set shifting, fluency, conceptual thinking, and planning ability. Whereas clinical
observation suggests that a central problem in OCD is at the meta-memory level and that people with OCD have
less meta-cognitive ability, processing of meta-cognition in childhood-onset OCD has not yet been investigated
adequately. Finally, the results of the reviewed studies were evaluated in terms of the effects of basic co-
morbidity, such as depression, Tourette’s disorder, tic disorder, and other confounding variables.
Key words: childhood-onset obsessive-compulsive disorder, attention, memory, executive functions
Neuropsychology of OCD 3
Clinical Characteristics of Childhood-Onset OCD
Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by repetitive obsessions
and compulsions. It is chronic, but can be cyclic, significantly affecting an individual’s social and daily
functioning. Although OCD has been recognized as a disorder commonly observed in adulthood, studies have
shown that the prevalence rate of OCD is 1%-4 % among adolescents (Douglass et al., 1995; Flament et al.,
1988), with more than 80% of OCD patients reporting relevant symptoms starting before the age of 18 years
(Pauls et al., 1995). OCD is often comorbid with other psychiatric disorders, namely depression, t ...
Specific learning disorder - reading disorder, mathematics disorder, and disorder of written expression and learning disorder NOS .
neurodevelopmental disorder produced by the interactions of genetic and environmental factors that influence the brain's ability to perceive or process verbal and nonverbal information efficiently.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
3. 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.
4. 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.
5. 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
6. 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.
7. 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.
8. 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.
10. 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
11. 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
12. 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
13. 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.
14. 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.
15. 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.
16.
17. 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
18. 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.
19. 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.
20.
21. 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
22. 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
23. 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.
25. 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.
26. 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
29. Tower of London test
test planning ability for the optimal route to reach the
goal
30. 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.
31. 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.
32. 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.
33. 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.
34. 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.
36. 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.
37. 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.
38. 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.
40. VERBAL FLUENCY
Impairment
Impaired verbal fluency can damage functioning in social and vocational settings by
making communication difficult and awkward.
41. 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.
42. 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.
43. 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.
44. 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.
45. There appear to be 4 primary domains:
1. Emotional perception
2. Theory of Mind
3. Attributional bias
4. Social perception
SOCIAL COGNITION
46. 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
47.
48. 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
49. 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
50. 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
51. 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
52. 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
53. 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
54. 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
55. 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.
56.
57. 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.
58. 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.
59. 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.
60. 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
61. 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.
62. 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.
63. 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.
64. 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”.
65. 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.
COGNITIVE REMEDIATION
66. 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
COGNITIVE REMEDIATION
67. 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.
COGNITIVE REMEDIATION
68. 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.
COGNITIVE REMEDIATION
69. 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.
COGNITIVE REMEDIATION
70. 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,
COGNITIVE REMEDIATION
71. SPECIFIC TECHNIQUES
Cognitive training
Cognitive enhancement therapy (CET)
NEAR method (Neuropsychological educational approach to rehabilitation)
Cognitive adaptation training
Brain fitness program (BFP)
COGNITIVE REMEDIATION
72. 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.
COGNITIVE REMEDIATION
73. 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.
74. 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.
75. 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
77. 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.
79. 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.
80. 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.
81. 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.
82. 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.
83. 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.
84. 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.
85. 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
86. 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.
88. 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.
89. 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.
90. 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.
91. 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.
92. 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.
93. 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.
94. 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.
95. SUPPORTED EMPLOYMENT
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.
96. SUPPORTED EMPLOYMENT
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.
97. 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.
98. 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
99. 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.
100. 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.
101.
102.
103. 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.
104.
105.
106. 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.
107.
108.
109. 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.
110.
111. 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.
112. 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.
113. 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.
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