Kee-Hong Choi

Benefits of Cognitive Remediation and Supported Employment for Schizophrenia Patients With Poor Community Functioning

OBJECTIVE This study was conducted to determine whether augmenting supported employment with cognitive remediation can improve vocational outcomes and whether augmentation is more important for participants with lower community functioning. METHODS In this secondary analysis of data from two related, single-blind, randomized controlled trials, 175 participants with schizophrenia or schizoaffective disorder received supported employment or supported employment plus cognitive remediation and were classified into higher or lower community functioning according to a median split of their quality-of-life scores at baseline. Participants received one year of active intervention and follow-up a year later. Primary outcome measures were competitive employment rates and total hours of work. RESULTS Employment rates over two years for participants with lower community functioning were significantly different for the two conditions (supported employment=20%, plus cognitive remediation=49%, p<.005), whereas participants with higher functioning showed equivalent rates of employment (62% versus 54%, ns). Among lower-functioning participants, those who received cognitive remediation also worked significantly more hours over two years than those who received supported employment only, but higher-functioning participants worked similar amounts of hours in both conditions. Improvements in cognitive functioning and intrinsic motivation were related to employment outcomes but only for the lower-functioning group in the supported employment plus cognitive remediation condition, suggesting possible mechanisms for the observed effects. CONCLUSIONS Augmenting supported employment with cognitive remediation may boost vocational outcomes for participants with lower community functioning but may not be necessary for those functioning better in their communities.

Measuring motivation in schizophrenia: Is a general state of motivation necessary for task-specific motivation?

Despite the important role of motivation in rehabilitation and functional outcomes in schizophrenia, to date, there has been little emphasis on how motivation is assessed. This is important, since different measures may tap potentially discrete motivational constructs, which in turn may have very different associations to important outcomes. In the current study, we used baseline data from 71 schizophrenia spectrum outpatients enrolled in a rehabilitation program to examine the relationship between task-specific motivation, as measured by the Intrinsic Motivation Inventory (IMI), and a more general state of volition/initiation, as measured by the three item Quality of Life (QLS) motivation index. We also examined the relationship of these motivation measures to demographic, clinical and functional variables relevant to rehabilitation outcomes. The two motivation measures were not correlated, and participants with low general state motivation exhibited a full range of task-specific motivation. Only the QLS motivation index correlated with variables relevant to rehabilitation outcomes. The lack of associations between QLS motivation index and IMI subscales suggests that constructs tapped by these measures may be divergent in schizophrenia, and specifically that task-specific intrinsic motivation is not contingent on a general state of motivation. That is, even in individuals with a general low motivational state (i.e. amotivation), interventions aimed at increasing task-specific motivation may still be effective. Moreover, the pattern of interrelationships between the QLS motivation index and variables relevant to psychosocial rehabilitation supports its use in treatment outcome studies.

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.

Beyond cognition: a longitudinal investigation of the role of motivation during a vocational rehabilitation program.

Abstract Studies that have specifically examined the effects of motivation on work have been limited to evaluations of baseline motivation and have not accounted for cognition. These have also not examined whether motivation changes over time. In the current analyses, we examined how baseline motivation and longitudinal changes in motivation, along with the effects of baseline cognition, related to work function in a sample of 123 individuals with schizophrenia or schizoaffective disorder participating in a 26-week vocational rehabilitation program. Our results indicate that cognition at baseline was a significant predictor of work outcomes over time. Baseline motivation and changes in motivation were significantly linked to work outcomes. The impact of motivation remained significant even after accounting for baseline cognition. These findings provide evidence that motivation is malleable during vocational rehabilitation and has an important impact on vocational function above and beyond the impact of cognition.

A Two-Factor Model Better Explains Heterogeneity in Negative Symptoms: Evidence from the Positive and Negative Syndrome Scale.

Acknowledging separable factors underlying negative symptoms may lead to better understanding and treatment of negative symptoms in individuals with schizophrenia. The current study aimed to test whether the negative symptoms factor (NSF) of the Positive and Negative Syndrome Scale (PANSS) would be better represented by expressive and experiential deficit factors, rather than by a single factor model, using confirmatory factor analysis (CFA). Two hundred and twenty individuals with schizophrenia spectrum disorders completed the PANSS; subsamples additionally completed the Brief Negative Symptom Scale (BNSS) and the Motivation and Pleasure Scale—Self-Report (MAP-SR). CFA results indicated that the two-factor model fit the data better than the one-factor model; however, latent variables were closely correlated. The two-factor model’s fit was significantly improved by accounting for correlated residuals between N2 (emotional withdrawal) and N6 (lack of spontaneity and flow of conversation), and between N4 (passive social withdrawal) and G16 (active social avoidance), possibly reflecting common method variance. The two NSF factors exhibited differential patterns of correlation with subdomains of the BNSS and MAP-SR. These results suggest that the PANSS NSF would be better represented by a two-factor model than by a single-factor one, and support the two-factor model’s adequate criterion-related validity. Common method variance among several items may be a potential source of measurement error under a two-factor model of the PANSS NSF.

Early visual processing for low spatial frequency fearful face is correlated with cortical volume in patients with schizophrenia

Patients with schizophrenia present with dysfunction of the magnocellular pathway, which might impair their early visual processing. We explored the relationship between functional abnormality of early visual processing and brain volumetric changes in schizophrenia. Eighteen patients and 16 healthy controls underwent electroencephalographic recordings and high-resolution magnetic resonance imaging. During electroencephalographic recordings, participants passively viewed neutral or fearful faces with broad, high, or low spatial frequency characteristics. Voxel-based morphometry was performed to investigate brain volume correlates of visual processing deficits. Event related potential analysis suggested that patients with schizophrenia had relatively impaired P100 processing of low spatial frequency fearful face stimuli compared with healthy controls; patients’ gray-matter volumes in the dorsolateral and medial prefrontal cortices positively correlated with this amplitude. In addition, patients’ gray-matter volume in the right cuneus positively correlated with the P100 amplitude in the left hemisphere for the high spatial frequency neutral face condition and that in the left dorsolateral prefrontal cortex negatively correlated with the negative score of the Positive and Negative Syndrome Scale. No significant correlations were observed in healthy controls. This study suggests that the cuneus and prefrontal cortex are significantly involved with the early visual processing of magnocellular input in patients with schizophrenia.

Understanding Social Situations (USS): A proof-of-concept social-cognitive intervention targeting theory of mind and attributional bias in individuals with psychosis

Objectives: In this proof-of-concept trial, we examined the feasibility and preliminary efficacy of Understanding Social Situations (USS), a new social–cognitive intervention that targets higher level social–cognitive skills using methods common to neurocognitive remediation, including drill and practice and hierarchically structured training, which may compensate for the negative effects of cognitive impairment on learning. Method: Thirty-eight individuals with schizophrenia spectrum disorders completed the same baseline assessment of cognitive and social–cognitive functioning twice over a 1-month period to minimize later practice effects, then received 7–10 sessions of USS training, and then completed the same assessment again at posttreatment. Results: USS training was well tolerated and received high treatment satisfaction ratings. Large improvements on the USS Skills Test, which contained items similar to but not identical to training stimuli, suggest that we were effective in teaching specific training content. Content gains generalized to improvements on some of the social–cognitive tasks, including select measures of attributional bias and theory of mind. Importantly, baseline neurocognition did not impact the amount of learning during USS (as indexed by the USS Skills Test) or the amount of improvement on social–cognitive measures. Conclusions and Implications for Practice: USS shows promise as a treatment for higher level social–cognitive skills. Given the lack of relationship between baseline cognition and treatment effects, it may be particularly appropriate for individuals with lower range cognitive function.

Heterogeneity and the Longitudinal Recovery of Functioning During Inpatient Psychiatric Rehabilitation for Treatment-Refractory Severe Mental Illness

Introduction. Few studies adequately capture the heterogeneity of severe mental illness (SMI) in recovery outcomes. In this study, we examine the between-person and within-person variance in the longitudinal recovery of key functional domains during a comprehensive inpatient psychiatric rehabilitation program for a severe, treatment-refractory population with SMI. Method. We reviewed clinical assessment data collected over 10 years from an inpatient psychiatric rehabilitation program in the Midwestern United States. Multilevel modeling techniques were applied to examine the between-person and within-person variance in baseline functioning, rates of change, and recovery of social functioning, neurocognition, social cognition, and the reduction of psychiatric symptoms in participants with schizophrenia-spectrum disorders (N = 180) over a 12-month period. Results. After considering heterogeneous features at admission, significant overall improvement was evident in social functioning, neurocognition, and psychiatric symptoms. The recovery of social cognition improved at different rates across individuals, and there was an overall improvement in this domain over time. Discussion. SMI is characterized by significant heterogeneity in the recovery of functioning. Despite the between-person and within-person variance at baseline and over time, individualized comprehensive psychiatric rehabilitation can effectively enable the most disabled persons with SMI recover key domains of functioning.

The efficacy of a brief psycho-educational intervention to improve awareness of cognitive dysfunction in schizophrenia.

People with schizophrenia have neuro-cognitive deficits that are associated with poor functional outcome, yet their awareness of their cognitive deficiencies is variable. As new treatments for cognition are developed, it will be important that patients are receptive to the need for more therapy. Since insight into symptoms has been associated with treatment compliance, it may be of value to provide psycho-education to improve understanding about cognition in schizophrenia. We report a randomized controlled trial that enrolled 80 subjects in either a brief psycho-education intervention about cognition, or a control condition. Subjects in the two conditions did not differ at baseline in insight or receptiveness to treatment, or on demographic, cognitive, or psychiatric variables. Current cognitive impairment of subjects was evidenced by the indice of working memory, attention and executive functioning abilities, (X=77.45 intervention group; 82.50 control condition), that was significantly below both the normative mean and estimated average premorbid IQs (X=101.3 intervention group; X=104.57 control condition). Multivariate repeated measures ANOVAs indicated that subjects who received the psycho-education did not improve insight into their cognitive deficits or willingness to engage in treatment for cognitive dysfunction. While the failure to find a significant impact of this intervention on awareness of cognitive deficit and receptiveness to cognitive treatment raises questions about the malleability of insight into neuro-cognitive deficits, the intervention was briefer than most reported psycho-education programs and multi-session formats may prove to be more effective.

Social cognition moderates the influence of child physical abuse on inpatient psychiatric rehabilitation.

Moderating effects of social cognition in the relationship between the severity of history of child physical abuse (CPA) and social functioning were examined using 12-month longitudinal data among 143 participants with severe mental illness (SMI) in an inpatient psychiatric rehabilitation program. The adverse effects of the severity of history of CPA on social functioning were compensated for by greater social inference and lower external locus of control. Specifically, despite the severity of history of CPA, individuals with intact or greater social inference showed greater social functioning than did those with lower social inference. The decrease in externality, regardless of the history of CPA, seemed to be therapeutic for individuals with SMI. Considering the heterogeneity in both SMI and CPA, the current finding sheds light on providing trauma-informed, individualized treatment and assessment planning for individuals with SMI and a history of CPA.