Joanna M. Fiszdon

Neurocognitive enhancement therapy with work therapy: Productivity outcomes at 6- and 12-month follow-ups

Neurocognitive enhancement therapy (NET), which involves computerized cognitive training and other methods, has been shown to improve working memory and executive function in schizophrenia. In the present study, 145 outpatients with diagnoses of schizophrenia or schizoaffective disorder recruited from a Department of Veterans Affairs mental hygiene clinic and from a community mental health center were ran domized to 6 months of paid work therapy (WT) or to NET+WT. Mixed random effects analyses revealed significant increase in hours worked and money earned over time for both conditions (p < 0.0001). NET+WT worked more hours than WT (p < 0.03), with differences emerging after rehabilitation. Responders to NET+WT worked the most during follow-up and tended to have more competitive-wage employment. Results indicate that work outcomes were enhanced by NET training. Effects were greatest for NET responders. Findings support the efficacy of cognitive training when it is integrated into broader rehabilitation programs.

Durability of cognitive remediation training in schizophrenia: performance on two memory tasks at 6-month and 12-month follow-up

Patients with schizophrenia have consistently been found to exhibit cognitive deficits, particularly in memory, which have been suggested to mediate functional outcomes. Several recent reviews of cognitive retraining have concluded that these deficits respond to training, although the sustainability of cognitive improvement following completion of training has not been adequately evaluated. Most studies had small samples and very short follow-up periods. As part of a larger study, we examined performance on two memory tasks in two groups of participants: those who received computerized cognitive remediation training in addition to work therapy (n=45), vs. those who only received work therapy (n=49). Computerized cognitive remediation included hierarchical training on a computerized digit span task and a computerized words serial position task. Assessments using the same computerized tasks were made at three time points: baseline, end of active intervention, and 6-month follow-up. Compared to the active control condition (work therapy only), the group receiving computerized cognitive remediation in addition to work therapy showed significantly greater improvements on the trained digit span task following training. These improvements were maintained at the 6-month follow-up. There were no significant group differences on the word serial position task at any time point. Results indicate that computerized training can lead to sustained improvements on some, but not all, training tasks.

Are self-reports valid for schizophrenia patients with poor insight? Relationship of unawareness of illness to psychological self-report instruments

This investigation aimed to determine whether impaired insight influences the validity of self-report test scores in schizophrenia and schizoaffective disorder. 274 outpatients enrolled in work rehabilitation completed the Beck Depression Inventory (BDI), Eysenck Personality Questionnaire (EPQ), Bell Object Relations and Reality Testing Inventory (BORRTI), and NEO-Five Factor Inventory (NEO-FFI). Self-report scores were compared to clinicians ratings on comparable personality and symptom dimensions on the Positive and Negative Syndrome Scale (PANSS), the Work Behavior Inventory (WBI), and the Quality of Life Scale (QLS). The influence of insight was determined using the Scale for Unawareness of Mental Disorder (SUMD). In the first analysis, clinician SUMD ratings of patient insight were associated with self-report accuracy. In a second analysis, patients were categorized into good and poor insight groups based on SUMD ratings and compared on self-report and clinician report variables. Results suggest that poor insight patients accurately report less Neuroticism and Agreeableness, and more Psychoticism than good insight patients, but individuals with poor insight wish to present themselves as more extraverted than they actually are, and they are likely to be more certain of their perceptions than they should be. It appears that self-report measures may be valid for most personality and symptom domains.

Improved cognitive function in schizophrenia after one year of cognitive training and vocational services.

A year-long program of Neurocognitive Enhancement Therapy (NET) was used to remediate cognitive deficits in people with schizophrenia who were participating in a vocational program. Seventy-two stable outpatients with schizophrenia or schizoaffective disorder, recruited from an urban community mental health center were randomly assigned to a twelve-month vocational program (VOC) or NET+VOC. The vocational program had characteristics of individual placement and support (IPS) programs but also included transitional funding. NET included computer-based cognitive training exercises, a social information processing group and a work feedback group. Sixty-two participants completed a neuropsychological test battery before and after treatment. After one year of treatment, participants receiving NET+VOC had significantly greater improvements on measures of executive function and working memory than did participants in the VOC only condition. Augmenting vocational services with a multifaceted cognitive remediation program may improve cognition in participants with schizophrenia or schizoaffective disorder.

Neurocognitive enhancement therapy with work therapy in schizophrenia: 6-month follow-up of neuropsychological performance.

Cognitive deficits are a major determinant of social and occupational dysfunction in schizophrenia, and new treatments are needed that address these impairments. The current study determined whether neurocognitive enhancement therapy (NET) in combination with work therapy (WT) would show improvement in performance on neuropsychological tests that endured 6 months after completion of training. A total of 145 participants with schizophrenia or schizoaffective disorder were randomly assigned to NET + WT or WT alone. NET included computer-based training on attention, memory, and executive function tasks. WT included paid work activity in job placements at the medical center. Neuropsychological assessment was performed at baseline, at the end of the 6-month active intervention, and 12 months after training began. Repeated measures multivariate analyses of variance revealed greater neuropsychological improvements on working memory (p < 0.05) and executive function (p < 0.05) for the NET + WT group over the 12 months. Both groups showed sustained improvements on verbal and nonverbal memory.

Predictors of remediation success on a trained memory task

Cognitive remediation has led to improvements for some but not all individuals with schizophrenia. The goal of the current investigation was to determine which variables predicted response to cognitive remediation training. In a sample of 58 patients with DSM-IV schizophrenia or schizoaffective disorder, normalization of performance on a trained memory task was selected as the criterion for successful remediation. The contribution of demographic, symptom, treatment process, and cognitive variables in predicting successful remediation was examined using a series of logistic regressions. A final regression evaluated the combined contribution of these variables. From among patients who were impaired before training, 43% reached normal levels of performance. Measures of attention, immediate verbal memory, hostility, and latency between last training and assessment were retained in the final step of the regression, resulting in 83% classification accuracy. Findings suggest that in addition to cognitive factors, motivational and training variables also significantly affect remediation outcomes.

Social Cognitive Impairments and Negative Symptoms in Schizophrenia: Are There Subtypes With Distinct Functional Correlates?

Social cognitive impairments and negative symptoms are core features of schizophrenia closely associated with impaired community functioning. However, little is known about whether these are independent dimensions of illness and if so, whether individuals with schizophrenia can be meaningfully classified based on these dimensions (SANS) and potentially differentially treated. Five social cognitive measures plus Scale for the Assessment of Negative Symptoms (SANS) and Positive and Negative Syndrome Scale (PANSS) scores in a sample of 77 outpatients produced 2 distinct factors--a social cognitive factor and a negative symptom factor. Factor scores were used in a cluster analysis, which yielded 3 well-defined groupings--a high negative symptom group (HN) and 2 low negative symptom groups, 1 with higher social cognition (HSC) and 1 with low social cognition (LSC). To make these findings more practicable for research and clinical settings, a rule of thumb for categorizing using only the Mayer-Salovey-Caruso Emotional Intelligence Test and PANSS negative component was created and produced 84.4% agreement with the original cluster groups. An additional 63 subjects were added to cross validate the rule of thumb. When samples were combined (N = 140), the HSC group had significantly better quality of life and Global Assessment of Functioning (GAF) scores, higher rates of marriage and more hospitalizations. The LSC group had worse criminal and substance abuse histories. With 2 common assessment instruments, people with schizophrenia can be classified into 3 subgroups that have different barriers to community integration and could potentially benefit from different treatments.

Intrinsic motivation as a predictor of work outcome after vocational rehabilitation in schizophrenia.

Intrinsic motivation is a construct commonly used in explaining goal-directed behavior. In people with schizophrenia, intrinsic motivation is usually subsumed as a feature of negative symptoms or underlying neurocognitive dysfunction. A growing literature reflects an interest in defining and measuring motivational impairment in schizophrenia and in delineating the specific role of intrinsic motivation as both an independent predictor and a mediator of psychosocial functioning. This cross-sectional study examined intrinsic motivation as a predictor of vocational outcomes for 145 individuals with schizophrenia and schizoaffective disorder participating in a 6-month work rehabilitation trial. Correlation and mediation analyses examined baseline intrinsic motivation and negative symptoms in relation to work hours and work performance. Data support a significant relationship between intrinsic motivation and negative symptoms and significant correlations with outcome variables, such that lower negative symptoms and greater intrinsic motivation were associated with better work functioning. Moreover, in this sample, intrinsic motivation fully mediated the relationships between negative symptoms, work productivity, and work performance. These results have significant implications on the design of work rehabilitation interventions for people with schizophrenia and support a role for targeting intrinsic motivation directly to influence vocational functioning. Future directions for research and intervention are discussed.

A comparison of basic and social cognition between schizophrenia and schizoaffective disorder

We compared basic and social cognition in individuals with schizophrenia and schizoaffective disorder. 199 individuals with schizophrenia and 73 with schizoaffective disorder were compared on measures of executive function, verbal and nonverbal memory, and processing speed, as well as two measures of social cognition, the Hinting Task and the Bell Lysaker Emotion Recognition Task. The samples did not differ significantly on the basic cognitive measures, however individuals with schizoaffective disorder performed significantly better than those with schizophrenia on the Hinting Task, a measure of Theory of Mind. Results provide limited support for a taxonomic distinction between the two disorders.

Social attribution test — multiple choice (SAT-MC) in schizophrenia: Comparison with community sample and relationship to neurocognitive, social cognitive and symptom measures

This is the first report on the use of the Social Attribution Task - Multiple Choice (SAT-MC) to assess social cognitive impairments in schizophrenia. The SAT-MC was originally developed for autism research, and consists of a 64-second animation showing geometric figures enacting a social drama, with 19 multiple choice questions about the interactions. Responses from 85 community-dwelling participants and 66 participants with SCID confirmed schizophrenia or schizoaffective disorders (Scz) revealed highly significant group differences. When the two samples were combined, SAT-MC scores were significantly correlated with other social cognitive measures, including measures of affect recognition, theory of mind, self-report of egocentricity and the Social Cognition Index from the MATRICS battery. Using a cut-off score, 53% of Scz were significantly impaired on SAT-MC compared with 9% of the community sample. Most Scz participants with impairment on SAT-MC also had impairment on affect recognition. Significant correlations were also found with neurocognitive measures but with less dependence on verbal processes than other social cognitive measures. Logistic regression using SAT-MC scores correctly classified 75% of both samples. Results suggest that this measure may have promise, but alternative versions will be needed before it can be used in pre-post or longitudinal designs.