Steven M. Silverstein

Social Cognition in Schizophrenia: An NIMH Workshop on Definitions, Assessment, and Research Opportunities

Social cognition has become a high priority area for the study of schizophrenia. However, despite developments in this area, progress remains limited by inconsistent terminology and differences in the way social cognition is measured. To address these obstacles, a consensus-building meeting on social cognition in schizophrenia was held at the National Institute of Mental Health in March 2006. Agreement was reached on several points, including definitions of terms, the significance of social cognition for schizophrenia research, and suggestions for future research directions. The importance of translational interdisciplinary research teams was emphasized. The current article presents a summary of these discussions.

Convergence of biological and psychological perspectives on cognitive coordination in schizophrenia.

The concept of locally specialized functions dominates research on higher brain function and its disorders. Locally specialized functions must be complemented by processes that coordinate those functions, however, and impairment of coordinating processes may be central to some psychotic conditions. Evidence for processes that coordinate activity is provided by neurobiological and psychological studies of contextual disambiguation and dynamic grouping. Mechanisms by which this important class of cognitive functions could be achieved include those long-range connections within and between cortical regions that activate synaptic channels via NMDA-receptors, and which control gain through their voltage-dependent mode of operation. An impairment of these mechanisms is central to PCP-psychosis, and the cognitive capabilities that they could provide are impaired in some forms of schizophrenia. We conclude that impaired cognitive coordination due to reduced ion flow through NMDA-channels is involved in schizophrenia, and we suggest that it may also be involved in other disorders. This perspective suggests several ways in which further research could enhance our understanding of cognitive coordination, its neural basis, and its relevance to psychopathology.

Visual perception and its impairment in schizophrenia

Much work in the cognitive neuroscience of schizophrenia has focused on attention, memory, and executive functioning. To date, less work has focused on perceptual processing. However, perceptual functions are frequently disrupted in schizophrenia, and thus this domain has been included in the CNTRICS (Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia) project. In this article, we describe the basic science presentation and the breakout group discussion on the topic of perception from the first CNTRICS meeting, held in Bethesda, Maryland on February 26 and 27, 2007. The importance of perceptual dysfunction in schizophrenia, the nature of perceptual abnormalities in this disorder, and the critical need to develop perceptual tests appropriate for future clinical trials were discussed. Although deficits are also seen in auditory, olfactory, and somatosensory processing in schizophrenia, the first CNTRICS meeting focused on visual processing deficits. Key concepts of gain control and integration in visual perception were introduced. Definitions and examples of these concepts are provided in this article. Use of visual gain control and integration fit a number of the criteria suggested by the CNTRICS committee, provide fundamental constructs for understanding the visual system in schizophrenia, and are inclusive of both lower-level and higher-level perceptual deficits.

A scientific agenda for the concept of recovery as it applies to schizophrenia

Recovery is now a widely discussed concept in the field of research, treatment, and public policy regarding schizophrenia. As it has increasingly become a focus in mainstream psychiatry, however, it has also become clear both that the concept is often used in multiple ways, and that it lacks a strong scientific basis. In this review, we argue that such a scientific basis is necessary for the concept of recovery to have a significant long-term impact on the way that schizophrenia is understood and treated. The discussion focuses on key issues necessary to establish this scientific agenda, including: 1) differences in definitions of recovery and their implications for studying recovery processes and outcomes; 2) key research questions; 3) the implications of data from outcome studies for understanding what is possible for people diagnosed with schizophrenia; 4) factors that facilitate recovery processes and outcomes, and methods for studying these issues; and 5) recovery-oriented treatment, including issues raised by peer support. Additional conceptual issues that have not received sufficient attention in the literature are then noted, including the role of evidence-based practices in recovery-oriented care, recovery-oriented care for elderly people with schizophrenia, trauma treatment and trauma-informed care, and the role of hospitals in recovery-oriented treatment. Consideration of these issues may help to organize approaches to the study of recovery, and in doing so, improve the impact of recovery-based initiatives.

Histories of childhood maltreatment in schizophrenia: Relationships with premorbid functioning, symptomatology, and cognitive deficits.

A number of studies have demonstrated an increased rate of histories of childhood maltreatment among adults with serious mental illness. The present investigation documented the presence of childhood maltreatment in a sample of 40 psychiatric inpatients with schizophrenia spectrum disorders. The type (neglect, physical abuse, sexual abuse), duration, and severity of childhood maltreatment was examined along with measures of premorbid functioning, current symptomatology, and cognitive functioning. Participants with histories of maltreatment were significantly more likely to have poorer peer relationships in childhood, more difficulty in school, an earlier age at first hospitalization, more previous hospitalizations, elevated symptoms of anxiety, depression, and suicidality on the Brief Psychiatric Rating Scale (BPRS), and more impaired performance on a task of visual-perceptual organization. Severity and frequency of childhood maltreatment were both positively correlated with hallucinations and delusions on the BPRS. Linear trend analysis indicated a pattern of more severe impairment as the number of types of maltreatment increased. No relationships were found between maltreatment and measures of executive functioning, verbal fluency, or verbal processing speed. A history of childhood maltreatment appears to be a significant determinant of premorbid functioning, illness-related symptom expression, and specific forms of cognitive dysfunction.

Perceptual Organization Impairment in Schizophrenia and Associated Brain Mechanisms: Review of Research from 2005 to 2010

Perceptual organization (PO) refers to the processes by which visual information is structured into coherent patterns such as groups, contours, perceptual wholes, and object representations. Impairments in PO have been demonstrated in schizophrenia since the 1960s and have been linked to several illness-related factors including poor premorbid functioning, poor prognosis, and disorganized symptoms. This literature was last reviewed in 2005. Since then, electrophysiological (electroencephalographic, event-related potential, and magnetoencephalographic) and fMRI studies in both patient and nonpatient samples have clarified brain mechanisms involved in the impairment, and additional behavioral studies in patients and nonpatients have clarified the computational mechanisms. In addition, data now exist on the functional consequences of PO impairments, in terms of secondary difficulties in face processing, selective attention, working memory, and social cognition. Preliminary data on drug effects on PO and on changes in response to treatment suggest that anomalies in PO may furnish a biomarker for the integrity of its associated biological mechanisms. All of this recent evidence allows for a clearer picture of the nature of the impairment and how it relates to broader aspects of brain and behavioral functioning in schizophrenia.

Identifying Cognitive Mechanisms Targeted for Treatment Development in Schizophrenia: An Overview of the First Meeting of the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia Initiative

This overview describes the generation and development of the ideas that led to the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia (CNTRICS) initiative. It also describes the organization, process, and products of the first meeting. The CNTRICS initiative involves a series of three conferences that will systematically address barriers to translating paradigms developed in the basic animal and human cognitive neuroscience fields for use in translational research aimed at developing novel treatments for cognitive impairments in schizophrenia. The articles in this special section report on the results of the first conference, which used a criterion-based consensus-building process to develop a set of cognitive constructs to be targeted for translation efforts.

Perceptual Organization in Schizophrenia Spectrum Disorders: Empirical Research and Theoretical Implications

The research into perceptual organization in schizophrenia spectrum disorders has found evidence for and against a perceptual organization deficit and has interpreted the data from within several different theoretical frameworks. A synthesis of this evidence, however, reveals that this body of work has produced reliable evidence for deficits in schizophrenia, as well as for the clinical, stimulus, and task parameters associated with normal and abnormal performance. Recent models of cognition have also advanced understanding of the underlying pathophysiological processes of perceptual organization dysfunction in schizophrenia spectrum disorders. These suggest that deficits in perceptual organization may be one manifestation of a wider disturbance in the integration of contextually related information across space and time.

Stimulus configuration and context effects in perceptual organization in schizophrenia.

Two studies assessed perceptual organization in schizophrenia to determine (a) whether inpatient and outpatient groups with poor premorbid schizophrenia have comparable levels of perceptual organization deficit; and (b) whether the deficit could be eliminated by task manipulations. In Study 1, inpatients demonstrated clear evidence of a perceptual organization deficit, whereas outpatients performed similarly to the control groups. In Study 2, a performance pattern that operationally defined a perceptual organization deficit was eliminated by a task manipulation thought to aid in context processing. The perceptual organization deficit is most pronounced in actively symptomatic patients with poor premorbid schizophrenia, and the deficit reflects, in part, deficient top-down influences to basic perceptual processes.

Perceptual grouping in disorganized schizophrenia

This study evaluated visual perceptual grouping in schizophrenia to test the hypothesis that the disorganization syndrome in schizophrenia is related to a deficit in cognitive coordination. Perceptual grouping was examined with three psychophysically well-controlled tasks in patients with disorganized schizophrenia (n=11), non-disorganized schizophrenia (n=24), psychotic disorders other than schizophrenia (n=31) and non-psychotic psychiatric disorders (n=35). These measures assessed processing of both concurrent and preceding stimulus context. Deficits in perceptual grouping were observed on all three tasks in disorganized schizophrenia patients. Dysfunctional perceptual grouping mechanisms produced both enhanced and impaired task performance suggesting that the pattern of performance observed was the result of a specific deficit in the grouping of stimulus elements. We interpret these data as further support for the hypothesis that the disorganization syndrome in schizophrenia reflects a widespread deficit in the cognitive coordination of contextually related stimuli, leading to dysfunctional grouping of stimulus features in vision, thought and language.