Shayden Bryce

Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders: A systematic review

A large body of research has implicated difficulties in emotion regulation as central to the development and maintenance of psychopathology. Emotion regulation has therefore been proposed as a transdiagnostic construct or an underlying mechanism in psychopathology. The transdiagnostic role of emotion regulation has yet to be systematically examined within the psychological treatment outcome literature. It can be proposed that if emotion regulation is indeed a transdiagnostic construct central to the maintenance of psychopathology, then changes in emotion regulation difficulties will occur after effective treatment and this will occur for different disorders. We conducted a systematic review, identifying 67 studies that measured changes in both emotion regulation and symptoms of psychopathology following a psychological intervention for anxiety, depression, substance use, eating pathology or borderline personality disorder. Results demonstrated that regardless of the intervention or disorder, both maladaptive emotion regulation strategy use and overall emotion dysregulation were found to significantly decrease following treatment in all but two studies. Parallel decreases were also found in symptoms of anxiety, depression, substance use, eating pathology and borderline personality disorder. These results contribute to the growing body of evidence supporting the conceptualization of emotion regulation as a transdiagnostic construct. The present study discusses the important implications of these findings for the development of unified treatments that target emotion regulation for individuals who present with multiple disorders.

Does cognitive performance map to categorical diagnoses of schizophrenia, schizoaffective disorder and bipolar disorder? A discriminant functions analysis

OBJECTIVES Despite known overlaps in the pattern of cognitive impairments in individuals with bipolar disorder (BD), schizophrenia (SZ) and schizoaffective disorder (SZA), few studies have examined the extent to which cognitive performance validates traditional diagnostic boundaries in these groups. METHOD Individuals with SZ (n=49), schizoaffective disorder (n=33) and BD (n=35) completed a battery of cognitive tests measuring the domains of processing speed, immediate memory, semantic memory, learning, working memory, executive function and sustained attention. RESULTS A discriminant functions analysis revealed a significant function comprising semantic memory, immediate memory and processing speed that maximally separated patients with SZ from those with BD. Initial classification scores on the basis of this function showed modest diagnostic accuracy, owing in part to the misclassification of SZA patients as having SZ. When SZA patients were removed from the model, a second cross-validated classifier yielded slightly improved diagnostic accuracy and a single function solution, of which semantic memory loaded most heavily. CONCLUSIONS A cluster of non-executive cognitive processes appears to have some validity in mapping onto traditional nosological boundaries. However, since semantic memory performance was the primary driver of the discrimination between BD and SZ, it is possible that performance differences between the disorders in this cognitive domain in particular, index separate underlying aetiologies.

Screening for Substance Use Disorders Following Traumatic Brain Injury: Examining the Validity of the AUDIT and the DAST.

Objective:To examine the validity of the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST)—2 widely recommended rating scales—in a traumatic brain injury (TBI) population at 24 months following injury. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders was used as the gold standard criterion. Setting:TBI rehabilitation program at Epworth Hospital, Victoria, Australia. Participants:A total of 113 individuals, 87 males and 26 females, with complicated mild to severe TBI. Design:Prospective study documenting substance use following TBI. Main measures:AUDIT, DAST, and Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Results:In individuals with TBI, a cutoff score of 11 on the AUDIT may be the most appropriate indicator of an alcohol use disorder whereas a cutoff score of 6 on the DAST may be the most appropriate indicator of drug use disorder. Both screening measures demonstrated excellent diagnostic accuracy at 24 months following injury. Conclusion:The optimal cutoff score for the AUDIT may need to be elevated for use following TBI. Nevertheless, both the AUDIT and the DAST are suitable measures for assessing substance use following TBI. Given the importance of uniformity in postinjury assessment, the AUDIT and the DAST may serve as future screening standards in TBI research.

The impact of intrinsic motivation on session attendance and reliable cognitive improvement in cognitive remediation in schizophrenia

OBJECTIVE Cognitive remediation (CR) is considered a potentially effective method of improving cognitive function in people with schizophrenia. Few studies, however, have explored the role of intrinsic motivation on treatment utilization or training outcomes in CR in this population. This study explored the impact of task-specific intrinsic motivation on attendance and reliable cognitive improvement in a controlled trial comparing CR with a computer game (CG) playing control. METHODS Forty-nine participants with schizophrenia or schizoaffective disorder, allocated to 10 weeks of group-based CR (n = 25) or CG control (n = 24), provided complete outcome data at baseline. Forty-three participants completed their assigned intervention. Cognition, psychopathology and intrinsic motivation were measured at baseline and end-treatment. Regression analyses explored the relative contribution of baseline motivation and other clinical factors to session attendance as well as the association of baseline and change in intrinsic motivation with the odds of reliable cognitive improvement (calculated using reliable change indices). RESULTS Baseline reports of perceived program value were the only significant multivariable predictor of session attendance when including global cognition and psychiatric symptomatology. The odds of reliable cognitive improvement significantly increased with greater improvements in program interest and value from baseline to end-treatment. Motivational changes over time were highly variable between participants. CONCLUSION Task-specific intrinsic motivation in schizophrenia may represent an important patient-related factor that contributes to session attendance and cognitive improvements in CR. Regular evaluation and enhancement of intrinsic motivation in cognitively enhancing interventions may optimize treatment engagement and the likelihood of meaningful training outcomes.

S89. THE IMPACT OF COGNITIVE REMEDIATION ON COGNITIVE AND PSYCHOSOCIAL OUTCOMES IN SCHIZOPHRENIA AND THE ROLE OF INTRINSIC MOTIVATION

Abstract Background Cognitive remediation (CR) therapies are upheld as promising methods of reducing cognitive impairment in schizophrenia. However, controlled trials with blind assessors and active comparison conditions are lacking, along with evidence of generalization of CR to everyday function and self-efficacy. In addition, the role of patient-specific factors such as motivation in predicting adherence and training outcomes has not been investigated. This assessor-blinded, randomized controlled trial compared the impact of ‘drill-and-strategy’ CR with a computer game (CG) control delivered in a group-setting on cognitive function, independent living skills and self-efficacy, and examined the impact of intrinsic motivation on group attendance and treatment response. Methods Fifty-six people with schizophrenia or schizoaffective disorder were randomized into CR or CG, and offered 20 one-hour sessions over 10 weeks. Measures of cognition (MATRICS consensus cognitive battery), psychopathology (Positive and Negative Syndrome Scale), self-efficacy (Revised Self Efficacy Scale) and independent living skills (Independent Living Skills Survey) were administered at baseline, end-group and three-months post-group. Intrinsic motivation (Intrinsic Motivation Inventory-Schizophrenia Research) was measured in-session at baseline and end-group. Results Primary analysis was conducted for participants who completed end-therapy assessment (CR=22; Control=21). Linear mixed-effect analysis found a significant interaction effect for cognition (p=.028). Pairwise comparisons revealed that cognition was better at end-group and three-month follow-up than baseline for CR completers, with no differences between timepoints for controls. Three-quarters (77%) of CR completers showed a reliable improvement in at least one cognitive domain. A significant time effect was also evident for self-efficacy (p=.028), with the combined groups showing higher self-efficacy at end-group than baseline. No changes in independent living skills were observed. Early reports of program value predicted session attendance above baseline cognitive and clinical symptoms. Enhanced program interest and value over time increased the likelihood of reliable cognitive improvement. Discussion Drill-and-strategy CR, delivered as a stand-alone treatment in a group setting, may improve cognition in schizophrenia when compared to active controls. Enhancing motivation may increase the likelihood of achieving meaningful cognitive improvements. This type of CR, however, may not translate to independent living domains, even if enhanced cognition and confidence in completing everyday behaviors is achieved. Independent living skills may need to be targeted directly to achieve meaningful changes in this domain.

S203. COMPENSATORY COGNITIVE APPROACHES TO IMPROVING FUNCTIONING IN PSYCHOSIS: SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background Cognitive impairments in domains such as attention, memory, processing speed and executive functions are a central feature of psychotic disorders that have significant negative consequences for daily functioning, including activities of daily living, social and vocational roles. Compensatory approaches aim to minimise the impact of cognitive impairment on daily functioning through the use of aids or strategies to reduce cognitive load, in much the same way as glasses reduce the impact of vision impairment. The primary treatment target is real world community functioning and functional capacity, rather than cognition. There is now a need to synthesise the available evidence in this field so that treatment recommendations and future research directions can be better informed. A large body of research into compensatory approaches to cognition in psychosis exists, but this has never been comprehensively synthesised. The aim of this systematic review and meta-analysis is to examine the effects of compensatory approaches for cognitive deficits in psychotic disorders on i) functional outcomes and ii) other outcomes such as symptoms and quality of life. Methods A systematic review and meta-analysis was conducted according to PRISMA guidelines. PsycINFO and MEDLINE electronic databases were searched from inception to October 2017 using multiple terms for ‘psychosis’, ‘cognition’ and ‘compensatory’. All papers retrieved from this search were double-screened and final inclusion/exclusion was determine by consensus. Data were double-extracted and risk of bias rated by two independent authors. Meta-analysis only included randomised-controlled trials. Standardised Mean Differences (SMD) were calculated to produce a single summary estimate using the random-effects model with 95% Confidence Intervals using Comprehensive Meta-Analysis (CMA) software. When means or standard deviations were not reported in the original articles, SMDs were calculated from data provided by the study authors. Results 2192 articles were identified via electronic and manual searches. Forty-two papers describing 40 independent studies were included in the review: case studies (n=4), case series (n=2), uncontrolled single arm pilot studies (n=5), within-subjects designs (n=1), quasi-randomised trials (n=2), and randomised controlled trials (n=26). The types of compensatory interventions included environmental adaptation and supports, internal and external self-management strategies, and errorless learning. Compensatory interventions were associated with improvements in global functioning post intervention (N=1,449; SMD=0.506; 95%CI=0.347, 0.665; p<.001). Improvements in global symptoms (N=849; SMD=-0.297; 95%CI=-0.484, -0.111; p=.002) and positive symptoms (N=784; SMD=-0.227; 95%CI=-0.416, -0.038; p=.018) were also found. Compensatory interventions were not associated with improvements in negative symptoms (N=736; SMD=-0.162; 95%CI=-0.382, 0.058; p=.150). The heterogeneity of findings was low. Discussion Compensatory approaches are effective for improving functioning in psychosis, with a medium effect size. General symptoms and positive symptoms appear to benefit from compensatory approaches, but compensatory approaches are not effective for improving negative symptoms. Future analyses will examine the durability of effects, effects of study quality and moderating factors such as pure vs. partially compensatory, treatment intensity/length, mode of delivery (group vs. individual), baseline functioning level and age of participants.

Understanding the lived experience of cognitive remediation in schizophrenia: A qualitative comparison with an active control.

Objective: Cognitive remediation (CR) is a promising method of improving cognitive functioning in people with schizophrenia. Nevertheless, the lived experience of participation, and whether this differs from computer game (CG) playing control conditions, remains poorly understood. This study aimed to qualitatively compare the experience of participating in these 2 interventions. Method: Forty-two outpatients with schizophrenia or schizoaffective disorder completed a qualitative survey with 7 open-ended questions after completing 10 weeks of CR (n = 22) or CG (n = 20). An iterative and inductive thematic analysis was used to identify and tally reoccurring codes and facilitate their organization into overarching themes. Results: Four high-order themes summarized the data: (a) Perceived benefits; (b) Experience of group; (c) Operation of group; and (d) Suggestions for improvement. Participation was described as enjoyable with similar levels of social and intrinsic benefits reported by study completers in both CR and CG groups. CR completers were more likely to report improvements in memory and everyday functioning as well as greater opportunities to acquire new cognitive skills and experience personal and cognitive challenge. CR completers also described the pursuit of shared goals with other peers. Conclusions and Implications for Practice: CR and CG share qualitative benefits in schizophrenia. CR may, however, offer a supportive environment where participants can encounter and surmount personal challenges, learn new abilities that may be functionally relevant and experience team-based success. These benefits may be unique to CR and contribute to increases in self-efficacy, which could bridge the gap between capacity and real world functioning in schizophrenia.

Desire for greater clarity when defining 'cognitive remediation' in reviews of treatment efficacy for schizophrenia.

In the last 15 years, cognitive remediation (CR) has emerged as a promising therapeutic intervention for improving cognitive and psychosocial outcomes in people with schizophrenia. As defined by the Cognitive Remediation Experts Working Group (2012), CR represents a training-based therapy ‘targeting cognitive deficits (attention, memory, executive function, social cognition, or meta-cognition) ... with the ultimate goal of improving functional outcomes’ that are durable over time (McGurk et al., 2013: 134). Similar iterations have been cited previously. Nevertheless, we raise the possibility of inconsistencies in the application of this definition. Cognitive rehabilitation, at least in the context of traumatic brain injury, can be grouped according to three general approaches: restorative, compensatory (internal compensation) and environmental (external compensation; Velikonja et al., 2014). In the psychiatric literature, while the greatest outcomes may involve a combination of these approaches, it is generally accepted that CR involves directly targeting an area, or areas, of cognitive impairment and/or teaching strategies for the self-management of these skills. Therefore, by definition, a CR intervention in schizophrenia could involve a restorative ‘drill-and-practice’ programme that theoretically targets distributed neural circuitry underpinning specific cognitive functions and/or a ‘strategy-based’ intervention providing internal strategies to support cognitive difficulties (i.e. contextualisation and semantic clustering for verbal learning and memory). Importantly, interventions that use ‘alternate strategies for teaching psychosocial skills (e.g. Work skills), such as errorless learning’, or those involving environmental modification, are considered to be distinct from CR (McGurk et al., 2013: 134). This becomes problematic, therefore, when reviews of treatment efficacy, such as one of the most cited by Wykes et al. (2011), include an errorless learning paradigm as well as a combined internal and external compensatory intervention. This is further problematic given that the weighted effect sizes of these types of studies are among those providing evidence in support of functional generalisation of CR (i.e. 0.32–0.99). It is noted that CR is a broad concept and that multiple interventions fall under this umbrella. Nevertheless, consistency between commonly accepted definitions of CR and the therapeutic elements of studies considered for systematic review or meta-analyses will be essential during ongoing discussions of treatment effectiveness and suitability for clinical translation. In the interest of transparency going forward, we encourage the authors of new reviews to explicitly detail the type(s) of interventions they are evaluating (as well as the types excluded) to promote greater clarity and specificity of reviewed research findings.