Michi Hatashita-Wong

Effectiveness of a two-phase cognitive rehabilitation intervention for severely impaired schizophrenia patients

BACKGROUNDnSeveral small-N, uncontrolled reports have demonstrated that the behavioral technique of attention shaping has significantly increased attention span among severely ill schizophrenia patients.nnnMETHODnIn this study, we evaluated the effectiveness of using an individually administered intervention for improving sustained attention, Attention Process Training (APT), followed by an attention-shaping procedure within the context of an ongoing skills training group. Patients were randomly assigned to receive either the APT and attention-shaping sequence (n = 18) or equivalent hours of treatment in the same intensive behavioral rehabilitation program (n = 13).nnnRESULTSnResults indicated dramatic improvements in attentiveness in the cognitive rehabilitation condition compared with the control condition, which demonstrated essentially no change in attentiveness over the 12 weeks of treatment. The attention-shaping intervention appeared to account for the majority of the effect. In contrast to the observational data, performance on neuropsychological tests was unaffected by the cognitive interventions.nnnCONCLUSIONSnThis two-phase intervention demonstrated effectiveness in promoting attentive behavior among chronic schizophrenia patients with severe attentional impairment.

Reduced top-down influences in contour detection in schizophrenia

Introduction. Chronic schizophrenia patients have previously demonstrated performance deficits in contour integration tasks. The purpose of this study was to investigate whether schizophrenia patients, spanning a range of illness severity, would demonstrate responsiveness to manipulations that recruit top-down processing strategies involving learning and sequencing effects in a contour integration task. Methods. We administered a contour integration test over four consecutive days and in two different presentation conditions each day. In one condition, the stimuli were administered in order of increasing difficulty, and in the other they were presented in random order. The order in which these two conditions were presented was counterbalanced across days and participants. In addition, a nonschizophrenia psychotic disorders control group was included to determine if past findings of a contour integration deficit in schizophrenia could be replicated in the presence of a symptomatically similar control group. Results. All groups demonstrated similar learning curves across the four days and generally similar overall levels of performance, with the exception of the group of the most chronic schizophrenia patients. In addition, the order in which the stimuli were presented to subjects affected their performance, with higher scores achieved for all groups in the condition where the stimuli were presented in increasing order of difficulty. Interaction effects revealed that the effects of order presentation were greater for nonpatient than for psychotic patients. Conclusions. These data are further evidence that perceptual organization impairments in schizophrenia are illness severity-related, and that schizophrenia patients as a whole are less sensitive to top-down manipulations in this type of task.

Behavioral Rehabilitation of the "Treatment-Refractory" Schizophrenia Patient: Conceptual Foundations, Interventions, and Outcome Data

This article describes an intensive, inpatient behavioral rehabilitation program for patients with schizophrenia who have been considered “treatment-refractory” at state hospitals. The program is a public–private partnership involving state and private hospitals and community residence providers. The essential elements of this program are described, along with the conceptual and philosophical bases of its treatment and examples of staff behaviors critical to treatment success. Outcome data are then discussed to emphasize the point that when evidence-based psychological treatment is implemented with this population, outcomes can be positive in most cases, and therefore, the number of treatment-refractory patients is actually far less than is estimated on the basis of response to medication alone. Schizophrenia is a serious mental disorder that affects approximately 1% of the population worldwide, with a current global incidence calculated at over 20 million people (Jablensky, 2000). The consequences of schizophrenia, in terms of both public health costs and effects on lives are enormous. For example, it has been estimated that as many as 10% of all disabled persons in the United States have schizophrenia (Rupp & Keith, 1993), and the disorder accounts for 75% of all mental health expenditures and approximately 40% of all Medicaid reimbursements (Martin & Miller, 1998). Among people with the disorder, only between 10%–30% are employed at any one time (Attkisson et al., 1992), and few of these people are able to maintain consistent employment (Policy Study Associates, 1989). Studies have consistently found that quality of life among people with schizophrenia is significantly poorer than among the rest of the population (Lehman, Ward, & Linn, 1982). Schizophrenia typically is diagnosed in late adolescence or early adulthood, and traditionally, approximately 50 –70% of cases are characterized by a chronic, relapsing course with high morbidity and permanent disability. In addition, rates of mortality and somatic morbidity are higher in schizophrenia than in the general population (Lieberman & Coburn, 1986), and the rate of attempted suicide equals that of major depression (Simpson & Tsuang, 1996). The economic costs of treating schizophrenia have been estimated to be

Coping with Voices: Selective Attention Training for Persistent Auditory Hallucinations in Treatment Refractory Schizophrenia

62.7 billion (e.g., including direct treatment costs and lost business productivity due to patient and family caretaker work absence; Wu et al.,

Cognitive functioning and social problem-solving skills in schizophrenia.

Abstract Attentional difficulties in people with schizophrenia are common and can be disabling. Anumber of cognitive rehabilitation interventions aim to improve attention span by having patients practice paying attention to various types of stimuli for increasing lengths of time. However, such interventions typically assume that the attention deficit is a form of negative symptom, reflecting a reduced ability to maintain an attentional focus. In the following case study, we describe a cognitive intervention for a patient whose inability to pay attention was the result of persistent, distracting, and disabling auditory hallucinations. The dichotic listening paradigm was modified to enable the patient to repeatedly practice attending to a source of relevant information, while ignoring irrelevant information that was gradually introduced to one, two, and then three spatial locations. A graded technique was used wherein difficulty level (i.e., numberof stimulus sources and stimulus intensity) was increased only after near perfect performance was achieved on prior trials. Embedding this intervention within the context of a therapeutic relationship led to clear improvement in task performance over time, with concomitant better attentiveness on the inpatient unit, and an improved ability to engage ininterviews at residential settings, leading to subsequent hospital discharge.

Procedures for Improving Attention in Treatment of Refractory Schizophrenia

Introduction. This study examined the relationships between symptoms, cognitive functioning, and social skill deficits in schizophrenia. Few studies have incorporated measures of cognitive functioning and symptoms in predictive models for social problem solving. Method. For our study, 44 participants were recruited from consecutive outpatient admissions. Neuropsychological tests were given to assess cognitive function, and social problem solving was assessed using structured vignettes designed to evoke the participants ability to generate, evaluate, and apply solutions to social problems. A sequential model-fitting method of analysis was used to incorporate social problem solving, symptom presentation, and cognitive impairment into linear regression models. Predictor variables were drawn from demographic, cognitive, and symptom domains. Because this method of analysis was exploratory and not intended as hierarchical modelling, no a priori hypotheses were proposed. Results. Participants with higher scores on tests of cognitive flexibility were better able to generate accurate, appropriate, and relevant responses to the social problem-solving vignettes. Conclusions. The results suggest that cognitive flexibility is a potentially important mediating factor in social problem-solving competence. While other factors are related to social problem-solving skill, this study supports the importance of cognition and understanding how it relates to the complex and multifaceted nature of social functioning.

A second chance for people with "treatment-refractory" psychosis.

Due to the early stage of development of neurocognitive. rehabilitation technology for schizophrenia, guidelines have yet to be established regarding which treatments are appropriate for which patients. Thus, treatments have not necessarily been targeted to specific profiles, or severity levels of neurocognitive deficits. This lack of specificity is most problematic for chronic, severely ill and treatment-refractory patients, such as those who are unable to be discharged from state-hospital settings. This is because these patients are typically characterized by the most severe attentional deficits, and these deficits are related to an inability to participate in many treatments, and thus to particularly poor outcomes. Despite the enormity of this problem, scattered reports throughout the literature suggest that one form of neurocognitive rehabilitation, based on the behavioral principle of shaping, has consistently demonstrated effectiveness in increasing the attention spans of such patients.