Alice Medalia

Cognitive Remediation in Schizophrenia

Cognitive deficits are routinely evident in schizophrenia, and are of sufficient magnitude to influence functional outcomes in work, social functioning and illness management. Cognitive remediation is an evidenced-based non-pharmacological treatment for the neurocognitive deficits seen in schizophrenia. Narrowly defined, cognitive remediation is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning, but from the vantage of the psychiatric rehabilitation field, cognitive remediation is a therapy which engages the patient in learning activities that enhance the neurocognitive skills relevant to their chosen recovery goals. Cognitive remediation programs vary in the extent to which they reflect these narrow or broader perspectives but six meta-analytic studies report moderate range effect sizes on cognitive test performance, and daily functioning. Reciprocal interactions between baseline ability level, the type of instructional techniques used, and motivation provide some explanatory power for the heterogeneity in patient response to cognitive remediation.

Intrinsic motivation and learning in a schizophrenia spectrum sample.

A motivation is a telling hallmark of negative symptomatology in schizophrenia, and it impacts nearly every facet of behavior, including inclination to attempt the difficult cognitive tasks involved in cognitive remediation therapy. Experiences of external reward, reinforcement, and hedonic anticipatory enjoyment are diminished in psychosis, so therapeutics which instead target intrinsic motivation for cognitive tasks may enhance task engagement, and subsequently, remediation outcome. We examined whether outpatients could attain benefits from an intrinsically motivating instructional approach which (a) presents learning materials in a meaningful game-like context, (b) personalizes elements of the learning materials into themes of high interest value, and (c) offers choices so patients can increase their control over the learning process. We directly compared one learning method that incorporated the motivational paradigm into an arithmetic learning program against another method that carefully manipulated out the motivational variables in the same learning program. Fifty-seven subjects with schizophrenia or schizoaffective disorder were randomly assigned to one of the two learning programs for 10 thirty-minute sessions while an intent-to-treat convenience subsample (n=15) was used to account for practice effect. Outcome measures were arithmetic learning, attention, motivation, self competency, and symptom severity. Results showed the motivational group (a) acquired more arithmetic skill, (b) possessed greater intrinsic motivation for the task, (c) reported greater feelings of self competency post-treatment, and (d) demonstrated better post-test attention. Interestingly, baseline perception of self competency was a significant predictor of post-test arithmetic scores. Results demonstrated that incorporating intrinsically motivating instructional techniques into a difficult cognitive task promoted greater learning of the material, higher levels of intrinsic motivation to attempt the demanding task, and greater feelings of self efficacy and achievement to learn.

Does cognitive remediation for schizophrenia improve functional outcomes

Purpose of review Cognitive deficits are recognized as key determinants of functional outcome in schizophrenia. Cognitive remediation for schizophrenia, which is intended to improve both cognition and functional outcome, has been shown to impact cognition regardless of quality of trial methodology used. However, the impact of cognitive remediation on functional outcomes is more variable. A number of recently published articles specifically address the issues impacting the effectiveness of cognitive remediation at improving psychosocial outcomes. Recent findings In this review, studies published since 2011 have been summarized, with a particular focus on psychosocial outcomes. Cognitive remediation may include a focus on neurocognition and/or social cognition, but is increasingly integrative, targeting a range of cognitive skills. Psychosocial outcomes include quality of life, employment outcomes, academic functioning, and social functioning. Summary The reviewed literature indicates that cognitive remediation is most likely to impact functional outcome when individuals are given opportunities to practice the cognitive skills in real-world settings. By integrating a cognitive remediation program with psychosocial rehabilitation programs, functional outcomes are enhanced. Cognitive remediation programs that do not solely rely on drill and practice, but instead incorporate strategy teaching and methods to address beliefs and motivation, are associated with better psychosocial outcomes.

Insight Into Neurocognitive Dysfunction in Schizophrenia

Insight into psychotic symptoms is typically poor in schizophrenia; however, it is not known whether insight into neurocognitive impairment is similarly impaired. Most people with schizophrenia experience cognitive dysfunction, and the deficits in attention, memory, and critical thinking have been associated with poor functional outcome. As new treatments are developed for the cognitive impairments, it will be important to know whether patients will be receptive to yet another therapy. Insight is an important factor in treatment compliance and treatment outcome; however, it is not known if patients have insight into their cognitive dysfunction. In order to assess insight into neuro cognitive dysfunction, 75 subjects were administered the Measure of Insight into Cognition-Clinician Rated, a newly created measure based on the Scale to Access the Unawareness of Mental Disorder, that assesses insight into cognitive impairment. Subjects were also administered the Brief Assessment of Cognition in Schizophrenia and Independent Living Scale-Problem Solving to objectively assess neuropsychological status and problem-solving skills needed for independent living. Results demonstrated that virtually all subjects had cognitive impairment, yet insight into their neuro cognitive symptoms was limited. This finding has potential implications for treatment programs seeking to improve cognitive functioning in schizophrenia.

Intrinsic Motivation Inventory: An Adapted Measure for Schizophrenia Research

This article describes the psychometric validation of a scale designed to measure intrinsic motivation (IM) in schizophrenia. Recent studies have highlighted the relationship between motivation and functional outcome in schizophrenia and identified IM as an important mediating factor between neurocognition and psychosocial outcome. It therefore becomes imperative to have validated measures of IM for empirical use. To that end, we validated a self-report IM scale that gauges the central motivational structures identified by Self-determinism Theory as pertinent to cognitive task engagement, skill acquisition, treatment compliance, and remediation outcome. Participants were schizophrenia outpatients involved in a cognitive remediation study (n = 58), a convenience subsample of clinically stable schizophrenia outpatients (n = 15), and a group of healthy normals (n = 22). The Intrinsic Motivation Inventory for Schizophrenia Research (IMI-SR) is a concise instrument, possessing good internal consistency (alpha = .92) and test-retest reliability (intraclass correlation = .77). Data were analyzed to abridge the original 54 items into a final 21-item questionnaire comprised of 3 domains relevant to motivation for treatments (interest/enjoyment, perceived choice, value/usefulness). The scale was highly associated with germane constructs of motivation for health-related behaviors, including perceived competency for attempting challenging tasks and autonomous treatment engagement. Importantly, the scale was able to distinguish improvers and nonimprovers on a cognitive task and actual learning exercises, delineate high vs low treatment attendance, and demonstrate sensitivity to motivational changes due to intervention variation. The IMI-SR is a viable instrument to measure IM in schizophrenia as part of a cognitive remediation protocol or psychosocial rehabilitation program.

The Neuropsychological Educational Approach to Cognitive Remediation (NEAR) Model: Practice Principles and Outcome Studies

NEAR is an evidence based approach to cognitive remediation which was specifically developed for use with psychiatric patients. NEAR emphasizes the fact that cognitive remediation is essentially a learning activity and therefore instructional techniques incorporate basic educational principles that have been shown to enhance learning. Rather than using a fixed software package, NEAR uses a variety of exercises, which are chosen based on whether they meet the criteria to both address neuropsychological deficits and be motivating and engaging. The theory behind the NEAR program, practice principles and outcome studies are reviewed.

The Role of Motivation for Treatment Success

Learning during skills-based psychosocial treatments for schizophrenia is influenced by the motivating properties of the treatment context and the motivational orientation of the client. Given that motivational impairment is a core feature of schizophrenia with significant functional implications, intervention strategies emphasizing extrinsic and/or intrinsic goals may be prescribed to enhance skill learning and treatment outcomes. The purpose of this article is to consider the role that motivation plays in treatment success by evaluating the relationship between motivation and learning during cognitive remediation for schizophrenia. As intrinsic motivation (IM) is most often associated with learning, we will integrate research findings which address 3 main questions: (1) is IM in schizophrenia static or dynamic, (2) is it possible to manipulate the state of being intrinsically motivated and if so do manipulations of IM affect learning? and (3) can motivation theory be translated into clinical practice? This knowledge can facilitate treatment strategies to address the low base rate of IM that is characteristic of schizophrenia and can be applied to cognitive remediation as well as other psychosocial interventions which require learning for treatment success.

In Search of a Theoretical Structure for Understanding Motivation in Schizophrenia

This themed issue considers different ways to conceptualize the motivational impairment that is a core negative symptom of schizophrenia. Motivational impairment has been linked to poor functional outcome, thus it is important to understand the nature and causes of motivational impairment in order to develop better treatment strategies to enhance motivation and engage patients in the process of recovery. Motivation refers to the processes whereby goal-directed activities are instigated and sustained and can be thought of as the product of a complex interaction of physiological processes and social contextual variables. In this issue, the physiological processes of motivation are the focus of Barch and Dowd, who highlight the role of prefrontal and subcortical mesolimbic dopamine systems in incentive-based learning and the difficulties people with schizophrenia have using internal representations of relevant experiences and goals to drive the behavior that should allow them to obtain desired outcomes. The articles in this issue by Choi et al., Nakagami et al., and Silverstein, focus on social contextual or environmental variables that can shape behavior and motivation. Together, these articles highlight the impact of external cues and goal properties on the expectations and values attached to goal outcomes. Expectancy-value and Self-Determination theories provide an overarching framework to accommodate the perspectives and data provided in all these articles. In the following introduction we show how the articles in this themed issue both support the role of expectancies and value in motivation in schizophrenia and elucidate possible deficiencies in the way expectations and value get assigned.

A comparison of insight into clinical symptoms versus insight into neuro-cognitive symptoms in schizophrenia.

BACKGROUND Schizophrenia is associated with neuropsychological deficits that have been linked to poor functional outcome. To address this problem, pharmacologic and behavioral treatments are being developed for cognitive impairments, but they will not be well utilized if people with schizophrenia do not perceive a need for treatment. AIMS This study compared whether people with schizophrenia have a similar degree of insight into neuro-cognitive symptoms as clinical symptoms, and whether neuro-cognitive and clinical symptoms are similarly related to degree of insight into these two aspects of the illness. METHOD Seventy-one patients with schizophrenia were administered measures of clinical and neuro-cognitive status as well as clinician rated measures of insight into clinical and neuro-cognitive symptoms. RESULTS Patients had significantly less insight into their neuro-cognitive symptoms than their clinical symptoms. On average, patients had good insight into clinical symptoms and partial insight into neuro-cognitive symptoms. Neuropsychological variables were related to insight into clinical symptoms, but not insight into neuro-cognition. Clinical variables were not significantly related to either type of insight. CONCLUSIONS Insight is not a unitary concept and the differences between awareness of neuro-cognition and awareness of clinical symptoms suggest that they have to be addressed separately in treatment. Specific education about cognitive symptoms may be necessary to improve awareness of this aspect of the schizophrenia.

The relationship of trait to state motivation: The role of self-competency beliefs

Even when people with schizophrenia describe themselves as generally motivated and eager to engage in activities, they may not actually be motivated in the present moment. In order to better understand the relationship between trait and state motivation, we aimed to assess trait motivation and state intrinsic motivation, and investigate their relations to each other and to criterion-related variables including cognition, negative symptoms, and beliefs about ones own competency-also known as perceived competency (PC). Further, we investigated whether PC mediates the relationships between state intrinsic motivation (IM) and trait motivation dimensions. Forty individuals with schizophrenia or schizoaffective disorders were administered two self-report measures of motivation, the Motivational Trait Questionnaire (Kanfer, R., Ackerman, P., 2000. Individual differences in work motivation: further explorations of a trait framework. Appl. Psychol. 49 (3), 470-482) and the Intrinsic Motivation Inventory for Schizophrenia Research (Choi, J., Medalia, A., 2010. Intrinsic motivation and learning in a schizophrenia spectrum sample. Schizophr. Res. 118, 12-19), as well as measures of PC, cognition and symptoms. The results showed that in people with schizophrenia, trait approach motivation, but not trait avoidance motivation, is positively correlated with state intrinsic motivation and PC. There was evidence that PC partially mediates the relationship between trait approach motivation and state intrinsic motivation to do the task. These results support the role of therapies that directly address self-competency beliefs and set the groundwork for future investigations on the impact of such treatments on motivation.