Felicia Gould

The effects of child abuse and neglect on cognitive functioning in adulthood

AIMS Recent research has revealed that early life trauma (ELS), including abuse (sexual and/or physical) and neglect, produce lasting changes in the CNS. We posited that cognitive deficits, often observed in psychiatric patients, result, in part, due to the neurobiological consequences of ELS. Additionally, we hypothesized that the nature and magnitude of cognitive deficits would differ according to the subtype of ELS experienced. METHOD The Cambridge Neuropsychological Test Automated Battery (CANTAB) was used to assess neurocognitive functioning in 93 subjects (60 with ELS and 33 without). In the patients with a history of ELS, 35% and 16.7%, respectively, met criteria for current major depression and PTSD. RESULTS Significant associations between ELS status and CANTAB measures of memory and executive and emotional functioning were found. CONCLUSIONS These data suggest that exposure to ELS results in a cascade of neurobiological changes associated with cognitive deficits in adulthood that vary according to the type of trauma experienced.

Social cognition, social competence, negative symptoms and social outcomes: inter-relationships in people with schizophrenia

Social deficits are common in people with schizophrenia and the treatment of deficits in social competence has been a long-time treatment strategy. However, negative symptoms and social cognitive deficits also contribute to social dysfunction. In this study, we examined the correlations between everyday social outcomes, a performance based measure of social competence, and performance on 8 different social cognition tests in 179 patients with schizophrenia. Social cognition, social competence, and motivation-related negative symptoms accounted for 32% of the variance in real-world social outcomes. In addition, two different social cognition tests, along with expression-related negative symptoms accounted for 32% of the variance in performance-based assessments of social competence. These data suggest that negative symptoms exert an important influence on social outcomes and social competence, but not social cognition, and that social cognition and social competence exert separable influences on real-world social outcomes. Improving social outcomes seems to require a multi-faceted approach which considers social cognition, social competence, and negative symptoms.

Self Assessment in Schizophrenia: Accuracy of Evaluation of Cognition and Everyday Functioning

OBJECTIVE Self-assessment deficits, often referred to as impaired insight or unawareness of illness, are well established in people with schizophrenia. There are multiple levels of awareness, including awareness of symptoms, functional deficits, cognitive impairments, and the ability to monitor cognitive and functional performance in an ongoing manner. The present study aimed to evaluate the comparative predictive value of each aspect of awareness on the levels of everyday functioning in people with schizophrenia. METHOD We examined multiple aspects of self-assessment of functioning in 214 people with schizophrenia. We also collected information on everyday functioning rated by high contact clinicians and examined the importance of self-assessment for the prediction of real-world functional outcomes. The relative impact of performance-based measures of cognition, functional capacity, and metacognitive performance on everyday functioning was also examined. RESULTS Misestimation of ability emerged as the strongest predictor of real-world functioning and exceeded the influences of cognitive performance, functional capacity performance, and performance-based assessment of metacognitive monitoring. The relative contribution of the factors other than self-assessment varied according to which domain of everyday functioning was being examined, but, in all cases, accounted for less predictive variance. CONCLUSION These results underscore the functional impact of misestimating ones current functioning and relative level of ability. These findings are consistent with the use of insight-focused treatments and compensatory strategies designed to increase self-awareness in multiple functional domains.

The influence of demographic factors on functional capacity and everyday functional outcomes in schizophrenia.

Patients with schizophrenia have impaired everyday living and social outcomes. Performance-based measures, including neuropsychological (NP) performance and functional capacity (FC) measures have demonstrated usefulness in predicting these outcomes. We examined the correlation of demographic factors (race, age, and education) and FC measures, and the relative ability of NP performance, FC, and demographic factors to predict real-world outcomes in social, vocational, and residential domains in 194 outpatients with schizophrenia. Age, education, sex, and racial status were significantly, but modestly, associated with performance-based measures of everyday functioning, while, in addition, age and education had a similar modest relationship with social competence. Age, but none of the other demographic variables, contributed to the prediction of all three domains of everyday functioning. Functional capacity variables predicted everyday outcomes even when demographic variables were entered into a predictive equation first. These data suggest a similar and modest but detectable effect of demographic factors on performance-based measures of functional capacity as seen with NP performance in schizophrenia populations. Older age contributed to poorer everyday functioning even after consideration of functional capacity, which seems similar to findings in healthy populations without clinically notable cognitive decline.

Self-assessment of functional ability in schizophrenia: milestone achievement and its relationship to accuracy of self-evaluation.

Between 50% and 80% of patients with schizophrenia do not believe they have any illness, and their self-assessment of cognitive impairments and functional abilities is also impaired compared to other information, including informant reports and scores on performance-based ability measures. The present article explores self-assessment accuracy in reference to real world functioning as measured by milestone achievement such as employment and independent living. Our sample included 195 people with schizophrenia examined with a performance-based assessment of neurocognitive abilities and functional capacity. We compared patient self-assessments across achievement of milestones, using patient performance on cognitive and functional capacity measures as a reference point. Performance on measures of functional capacity and cognition was better in people who had achieved employment and residential milestones. Patients with current employment and independence in residence rated themselves as more capable than those who were currently unemployed or not independent. However, individuals who had never had a job rated themselves at least as capable as those who had been previously employed. These data suggest that lifetime failure to achieve functional milestones is associated with overestimation of abilities. As many patients with schizophrenia never achieve milestones, their self-assessment may be overly optimistic as a result.

The course of vocational functioning in patients with schizophrenia: Re-examining social drift

Vocational functioning is markedly impaired in people with schizophrenia. In addition to low rates of employment, people with schizophrenia have been reported to be underachieved compared to other family members. Among the causes of this vocational impairment may be cognitive deficits and other skills deficits, as well as social factors impacting on opportunities for employment. In this study, we examined two separate samples of people with schizophrenia who differed in their educational and social backgrounds. We compared personal and maternal education in people with schizophrenia attending an outpatient rehabilitation facility (n = 57) or receiving outpatient services at a VA medical center (n = 39). The sample as a whole showed evidence of decline in vocational status from their best job to their most recent job. Patients attending a rehabilitation facility had completed less education than their mothers, while the VA patients completed more. Differences between personal and maternal education predicted the difference in status between best and latest jobs in the sample as a whole. VA patients were more likely to be living independently and performed better on a measure of functional capacity than the rehabilitation sample. These data implicate vocational decline in schizophrenia and also suggest that this decline may originate prior to the formal onset of the illness. At the same time, vocational outcomes appear to be related to social opportunities.

Epidemiology of Anxiety Disorders

It has been revised and enhanced to capitalize on the strengths of the first and second editions while keeping it up-to-date with the field of psychiatry and epidemiology. This comprehensive publication now includes chapters on experimental epidemiology, gene-environment interactions, the use of case registries, eating disorders, suicide, childhood disorders and immigrant populations, and the epidemiology of a number of childhood disorders.

Temporal Stability of Cognitive Functioning and Functional Capacity in Women with Posttraumatic Stress Disorder

OBJECTIVE In addition to clinical symptoms, patients with posttraumatic stress disorder (PTSD) often experience considerable disability and may evidence minor impairments in performance on measures of cognition and functional capacity (FC). The objective of the present study was to determine if cognitive and functional skills manifest temporal stability as observed in other neuropsychiatric conditions in the presence of greater fluctuations in clinical symptoms. METHOD Assessments of cognition, FC, and clinical symptoms were conducted over two time points as part of a pre- and post-treatment assessment in a placebo-controlled clinical trial in 96 women with PTSD. The goal of these analyses was to examine the relative stability of scores and intercorrelations of measures of cognition, FC, and clinical symptoms. RESULTS Cognitive and FC performance manifested considerably greater cross-temporal stability compared to clinical symptoms. FC performance did not change over time. Similar to previous findings in patients with schizophrenia and bipolar disorder measures of symptoms and self-reported disability did not correlate with measures of functional skills or cognitive performance. CONCLUSIONS Cognitive performance and functional capacity were temporally stable in women with PTSD. In contrast, clinical symptoms had much more cross-temporal fluctuation. Self-reported disability was correlated with current symptomatology but unrelated to objective measures of performance. Similar to other neuropsychiatric conditions, mood symptoms likely influence estimates of current level of functioning more than cognitive or functional skills.

Latest Developments in Cognitive Functioning in Mood and Anxiety Disorders

Cognitive impairments are well-documented features of mood and anxiety disorders. Recent developments in research on cognition, assessment techniques, treatments, and comorbidities in cognitive changes across major depression, bipolar disorder, and post-traumatic stress disorder (PTSD) are reviewed. Promising treatments have been reported but are tempered by self-reported cognitive performance and its minimal relationship to objective data. The need for objective assessment as well as assessment of subjective impressions of cognition is discussed. The use of assessment of performance-based measures of everyday functional skills in major depression, bipolar disorder, and PTSD is another critical development highlighted in the present review. The recent success of pharmacological treatments for cognitive impairments in major depressive disorder (MDD) is promising, yet the need for clinicians to assess and consider bias in their treatment outcome data is essential.