Cognitive Impairment: Core Feature of Schizophrenia

Cognitive Impairment: Core Feature of Schizophrenia

Triptish Bhatia

Smita N. Deshpande

Dept. of Psychiatry & De-addiction

PGIMER-Dr. RML Hospital

Type of impairment Outcome Interventions

PLAN

Points to remember Significant decline from premorbid

levels Consistent severe impairment Some aspects unimpaired Upto 2 SD below healthy normal

controls 25% sz unimpaired vs. 85% of controls Unimpaired healthiest premorbidly,

but still below expected(Keefe and Fenton 2007, Keefe & Harvey 2012)

Points to remember Worse than parents or

unaffected twin Men worse than women Deficits stable till age 65, when

they worsen Considering educational,

familial, and socioeconomic background. (Keefe and Fenton 2007)

Points to remember 10 year FUp of 61 first episode

patients in Mumbai:

Further deterioration of Visuomotor integration, working memory, and executive functioning even in ‘good response’ patients

Shrivastava et al 2011

Points to remember May precipitate psychotic and

negative symptoms

Persist on remission of psychotic symptoms

Related to but separate from negative symptoms

Determine functional impairment

(Sharma et al 2003, Tandon et al. 2009)

Categories‘Neuro’ Cognition Social cognition

AttentionMemoryLanguageReasoningLearningProblem solvingDecision making

Social stimuli processing, Drawing inferences about others' mental states, Engaging in social interactions.

Working memory Involves active rehearsing, processing,

manipulating information Difficulty learning new, complicated tasks Cause significant deficits in short term &

long term memory Affects functional outcome

4 SD away from normal mean Hypofunction of prefrontal cortex Significant relationship with positive

symptoms and formal thought disorder

Executive function Use abstract concepts, Plan actions, Work out strategies for problem

solving, Execute them Self-monitoring mental or

physical processes Linked to frontal lobes but not

confined to them

Attention & Information Processing

Identify relevant stimulus in the environment,

Focus only on that stimulus until it is processed

Allow for the transfer of the stimulus to higher level processes

Set-shifting, selective attention, inhibition of inappropriate response

Semantic memory Naming, word-picture matching,

verbal fluency, priming, and categorisation affected.

Uneven profile of impairment Naming and verbal fluency: Large

effect sizes Word-picture matching and

association : Medium effect sizes Categorisation and priming tests:

Small effect sizes Link between FTD & semantic

memory impairments (Doughty & Dane 2009)

Verbal & Visual Memory Recall of verbal material worse

than visual information Recognition less impaired than

recall for both Receptive and expressive

language abilities, visual perceptual, constructional, fine motor skills impaired.

(Kalkstein, Hurford, Gur 2010)

Emotion recognition Impaired in overall emotion

recognition, particularly fear and disgust

Did not benefit from increased emotional intensity.

Misidentify neutral cues as negatively valenced.

(Kohler et al 2003)

Emotional processing, Social perception, Attribution style, and Theory of mind (Green et al., 2005; Green and Horan, 2010

).

Social Skill Domains

Social Cognition Social stimuli processing, Drawing inferences about others'

mental states, and Engaging in social interactions. Impairments are separable from

general neurocognitive impairments, such as attention, memory, and executive functioning

Rules of social world keep changing

Difficult to adjust due to loss of reasoning

Reasoning & problem Solving

Separable cognitive factorsEight factors(FDA)

Speed of Processing Attention/Vigilance Working Memory Verbal Learning and Memory Visual Learning and Memory Reasoning and Problem Solving Verbal Comprehension Social Cognition

(Nuechterlein et al 2004)

McGuffin et al. 2010

Measurement of Cognitive Impairment

Test Battery Large variety of tests measuring

most cognitive domains, sensory, motor skills.

All parts of test battery administered

Identifying problems not mentioned Time consuming Needs expertise

Poor functional outcome: Social

USA- <10% of males with sz ever have a child (Nanko 1993)

India vs. US- no significant gender differences in Indian sample vis a vis reproductive indices (n=224 -I and 144- US) (Bhatia et al 2002)

Poor functional outcome: Occupation

USA- Only 10% working full-time in competitive employment and 20% in supported part-time employment

(Lehman et al 2002 )

New Delhi- 34% lower occupations, + 20% unemployed, 39% drift lower

(Bhatia Chakraborty et al 2008)

Chennai: Social but not cognitive deficits related to work dysfunction

(Srinivasan & Tirupati 2005)

Poor functional outcome: Difficulty in independent

living

High rate of severe schizophrenia among single homeless people (Scott 1993)

Wandering aimlessly: 22% (Jakhar 2012)

Cognitive deficits in chronic sz in India similar to those in Western studies (n=100) (Srinivasan et al 2005)

Patients and Parents performed worse than controls on TMT Test B (Bhatia et al. 2006)

Chennai & Delhi

Poor Cognitive test perf. related to: Self-care, occupational role, social

role, and family role Inversely correlated to negative

symptoms. Poor Social test performance

Predicted by positive, negative symptoms along with verbal fluency.

N=100 Santosh et al

2013

Kolkata

Antipsychotic treatment ? Better therapeutic profiles of newer

antipsychotic agents (eg, higher efficacy and fewer side effects, less anticholinergic effects)

Act directly on cerebral functioning (e.g. by restoring dopamine prefrontal activity)

(Peuskens et al. 2005)

CATIE: Best long term: perphenazine (Keefe 2007)

Establish, maintain therapeutic relationship

Coping strategies to reduce distress of psychotic symptoms

Help to understand illness and deal better with negative self evaluations

(Thara & Anuradha 2007)

N=51, marked improvement in overall adjustment, decreased symptoms, moderate gains sustained at FUp after 9 months (Sriharsh, Sippy et al 2003)

Cognitive Behavioural Therapy

Cognitive enhancement therapy

Small-group approach Combines approximately 75 hours

of progressive software training Exercises in attention, memory,

and problem solving 1.5 hours per week of social

cognitive group exercises (approximately 56 sessions)

Cognitive enhancement therapy

A 2-year, RCT with neuropsychological and behavioral assessments at baseline and at 12 and 24 months (121patients).

Robust CET effects on neurocognition and processing speed composites

(Hogarty et al. 2004)

Learning-based behavioural skills designed to enhance neuro and/ or social cognitive skills,

Based on drills & strategies Ultimate goal: generalization to improve

psychosocial outcomes Innovations:

Incorporate new generation of computerized cognitive training,

Integrate CR with skills training, Apply techniques to enhance motivation and

learning during CR (Saperstein & Kurtz 2013)

Cognitive Remediation (CR)

Associated with medium effect sizes for cognitive and functional outcomes

Better if Integrated with psychosocial

rehabilitation programs Incorporate strategy teaching,

methods to address beliefs and motivation

(Medalia & Saperstein 2013)

Cognitive Remediation (CR)

Positive treatment response: attention, motivation and clinician expertise, along with 'brain reserve’

CR is accompanied by structural and functional neural changes in key frontal and temporal brain regions.

Kurtz 2012

Cognitive Remediation (CR)

Virtual Reality environment (developed via the NeuroVr2.0 software) for shifting, sustained attention and action planning functions (LaPaglia, 2013)

Computer-assisted cognitive remediation

Cognitive adaptation training (Velligan and Bow-Thomas,

2000) Errorless learning, workbook

for memory Skills (Kennedy, 1996)

Goal management training (Robertson et al., 2005)

Psychosocial rehabilitation programmes

Focus on domains of facial affect, emotion recognition (FAR), Theory of Mind (ToM), and attributional bias.

ToM is amenable to change, but not FAR and attributional bias.

(Henderson 2013)

Social Cognition Training

Improvements in  Physical, Subjective and Disorder-specific clinical

outcomes (Zschuke, Gaudlitz, Strohle 2013)

Physical Exercise/Activity

Cognitive impairment and yoga

Adjunctive cognitive remediation for schizophrenia using yoga: an open, non-randomized trial:

Nominally significant improvement in cognitive function in sz after 3 weeks of training

(Bhatia, Agarwal, et al 2012)

Cognitive impairment and viral Cognitive impairment and viral infections?infections?

Exposure to herpes simplex virus, type 1 and reduced cognitive function.

HSV-1 exposure Did not elevate risk for SZ, Associated with reduced

function in specific cognitive domains in both SZ patients and normal controls.

Thomas, Bhatia, et al (2013)