Functional Outcome In Schizophrenia Research Articles

P50 gating in deficit and nondeficit schizophrenia

Dysfunctional auditory sensory processing has generally been found in schizophrenia and it has been suggested that these deficits might be related to clinical and psychosocial variables. The present study included P50 recordings using a simple-paired click auditory evoked potential paradigm in sixty patients with deficit schizophrenia (DS), sixty patients with nondeficit schizophrenia (NDS), and sixty comparison subjects. The Schedule for the Deficit Syndrome was used to categorize patients as DS or NDS. The two patient groups did not differ in clinical variables, except for higher negative dimension and lower community outcome scores in DS than in NDS patients. There were no differences in P50 ratios between deficit and nondeficit subgroups; compared with normal subjects both groups of schizophrenia patients showed impaired P50 ratios ( p < 0.0001). This ratio appears to be independent of positive and negative symptoms. However, impairment in P50 gating correlated with poorer community outcome. The data document the existence of early auditory sensory processing abnormalities in DS and NDS, and might suggest that common neuronal network abnormalities underlie both forms of schizophrenia. Deficient P50 gating may be associated with impaired functional outcome in schizophrenia.

Emotion responsivity, social cognition, and functional outcome in schizophrenia.

Social functioning deficits have long been a defining feature in schizophrenia, but relatively little research has examined how emotion responsivity influences functional outcome in this disorder. The goal of the current study was to begin to elucidate the relationships between emotion responsivity, social cognition, and functional outcome in schizophrenia. Participants were 40 outpatients diagnosed with schizophrenia or schizoaffective disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) and 40 controls. Each participant completed measures of emotion responsivity, social cognition (both emotion and social perception), and functional outcome. Individuals with schizophrenia demonstrated somewhat reduced emotion responsivity for positive and negative stimuli, as well as deficits in both social cognition and functional outcome, in comparison with controls. Additionally, results indicated that both social perception and emotion responsivity were positively correlated with functional outcome. Importantly, the relationship of emotion responsivity to functional outcome was not mediated by social perception and showed a significant relationship to functional outcome independent of social cognition. This finding suggests that emotion responsivity is an important factor in understanding functional outcome in schizophrenia.

Mismatch Negativity, Social Cognition, and Functioning in Schizophrenia Patients

Cognition and social cognition have been found to influence functional outcome in schizophrenia patients. However, little is known about the underlying neural substrates that are associated with social cognition or daily functioning. Prior studies found associations between mismatch negativity (MMN), an event-related potential response indexing early auditory processing, and functioning in schizophrenia patients. In this study, we examined MMN, social cognition (social perception and theory of mind), and four domains of functioning (work, independent living, social networks, and family networks) in 33 schizophrenia patients and 42 demographically comparable healthy control subjects. Schizophrenia patients exhibited reduced MMN activity at frontocentral electrode sites compared with healthy control subjects. Within the schizophrenia sample, greater MMN activity at frontocentral sites correlated with better work and independent living (but not social or family networks) and with better social perception. These results suggest that MMN activity is more closely tied to some outcome domains (work and independent living) than others. Mismatch negativity has been previously shown to be associated with basic cognition and functional outcome in schizophrenia, but these findings are the first, to our knowledge, to show MMN associations with social cognition. These results are consistent with cascade models of information processing in which deficits in early perceptual processing have a downstream impact on higher order social cognition and community functioning.

Emotional experience predicts social adjustment independent of neurocognition and social cognition in schizophrenia

BackgroundEmotional abnormalities are prominent features of schizophrenia. While the capacity for emotions is essential to social adaptation, little is known about the role of emotional experience in the social dysfunction observed in schizophrenia. ObjectiveThis study examined the contribution of emotional experience, neurocognition, and social cognition to functional outcome in schizophrenia. MethodSelf-reported emotional experience (anhedonia, affect intensity, and emotion frequency) was assessed in 33 stable schizophrenic/schizoaffective patients and 33 healthy controls. Symptoms, neurocognition, social cognition, and functional outcome were also assessed. ResultsPatients and controls exhibited good internal reliability on all self-report scales, except for negative affect intensity. Patients reported equally intense but less frequent positive emotions, more intense and frequent negative emotions, and more anhedonia. Results of hierarchical regression analyses showed that emotional experience accounted for significant amounts of variance of social adjustment independent of neurocognition and social cognition. ConclusionThese data show that emotional experience can be reliably assessed and is an important determinant of functional outcome in schizophrenia.

P03-107 - Clinical remission, cognitive functions and functional outcome in schizophrenia

ObjectivesAn impairment of several cognitive domains has been largely documented in patients with schizophrenia. The present study aimed to investigate the relationships between cognitive functioning, symptomatic remission and functional outcome in schizophrenia.MethodsThe performance on the neuropsychological battery “Brief Assessment of Cognition in Schizophrenia (BACS)” has been investigated in clinically remitted (R) and non-remitted (NR) schizophrenic patients. The associations of neuropsychological performance with psychopathological dimensions derived from PANSS and indices of social functioning (as assessed by the Global Assessment of Functioning scale, the Personal and Social Performance scale, the Quality of Life Scale, the UCSD Performance-Based Skills Assessment-Brief Version and the Psychosocial Remission in Schizophrenia scale) were also explored by means of multiple regression (MR) analyses.ResultsCompared with NR, R patients showed a better performance on tests exploring executive functions, processing speed and verbal fluency. Residual negative symptoms and processing speed were independent predictors of functional outcome, while remission status did not enter the MR function.ConclusionsOur findings suggest that cognitive abilities, in particular processing speed and executive functions, are preserved in patients who are able to reach clinical remission. Independently from the remission state or residual negative symptomatology, processing speed also predicts functional outcome in schizophrenia. Our findings support the view that cognitive dysfunctions in schizophrenia should be targeted by specific treatment intervention, such as neurocognitive rehabilitation.

P03-116 - Training of affect recognition (TAR) and functional outcome in schizophrenia

ObjectivesAn increasing number of studies focus on general deficits in identifying, differentiating and recalling of facial emotions in schizophrenia. According to preliminary results antipsychotics alone show only little effect on social cognition. We investigated the effects of new antipsychotics when combined with a computer-based training on affect recognition.MethodsSchizophrenic patients (n=20) receiving treatment with new antipsychotics in combination with a six-week Training on Affect Recognition (TAR) were compared with a randomized group of patients (n=18) receiving Treatment As Usual (TAU). Effects on social cognition were tested with the Vienna Emotion Recognition Tasks (VERT-K). In addition, we investigated neurocognitive performance using the Wisconsin Card Sorting Test (WCST), Testbattery for Attentional Performance (TAP): “Alertness”, “Vigilance” and “Working memory”. Negative symptoms and quality of life were assessed using the Positive and Negative Syndrome Scale (PANSS) and the short version of the WHO-Quality of Life Questionnaire (WHOQOL-Bref).ResultsIn comparison to the control group the TAR group showed significant improvements in regard to affect recognition in general as well as in recognizing sad and happy faces. In addition, we found significant improvements for the TAR group regarding executive functions, quality of life and negative symptoms.DiscussionTreatment with new antipsychotics alone has only a limited impact on social cognition. A specific combined treatment of new antipsychotics and TAR leads to improved cognition and emotional performance with additional positive effects on functional outcome.

Motivation and its Relationship to Neurocognition, Social Cognition, and Functional Outcome in Schizophrenia

Objective A burgeoning area of research has focused on motivational deficits in schizophrenia, producing hypotheses about the role that motivation plays in the well-known relationship between neurocognition and functional outcome. However, little work has examined the role of motivation in more complex models of outcome that include social cognition, despite our increased understanding of the critical role of social cognition in community functioning in schizophrenia, and despite new basic science findings on the association between social cognitive and reward processing in neural systems in humans. Using path analysis, we directly contrasted whether motivation 1) causally influences known social cognitive deficits in schizophrenia, leading to poor outcome or 2) mediates the relationship between social cognitive deficits and outcome in this illness. Method Ninety one patients with schizophrenia or schizoaffective disorder completed interview-based measures of motivation and functional outcome as well as standardized measures of neurocognition and social cognition in a cross-sectional design. Results In line with recent research, motivation appears to mediate the relationship between neurocognition, social cognition and functional outcome. A model with motivation as a causal factor resulted in poor fit indicating that motivation does not appear to precede neurocognition. Conclusions Findings in the present study indicate that motivation plays a significant and mediating role between neurocognition, social cognition, and functional outcome. Potential psychosocial treatment implications are discussed, especially those that emphasize social cognitive and motivational enhancement.

Association between changes on the Negative Symptom Assessment scale (NSA-16) and measures of functional outcome in schizophrenia

We examined whether changes in negative symptoms, as measured by scores on the 16-item Negative Symptom Assessment scale (NSA-16), were associated with changes in functional outcome. A group of 125 stable outpatients with schizophrenia were assessed at baseline and at 6 months using the NSA-16, the Brief Psychiatric Rating Scale, and multiple measures of functional outcome. Baseline adjusted regression coefficients indicated moderate correlations between negative symptoms and functional outcomes when baseline values of both variables were controlled. Results were nearly identical when we controlled for positive symptoms. Cross-lag panel correlations and Structural Equation Modeling were used to examine whether changes in negative symptoms drove changes in functional outcomes over time. Results indicated that negative symptoms drove the changes in the Social and Occupational Functioning Scale (SOFAS) rather than the reverse. Measures of Quality of Life and measures of negative symptoms may be assessing overlapping constructs or changes in both may be driven by a third variable. Negative symptoms were unrelated over time to scores on a performance-based measure of functional capacity. This study indicates that the relationship between negative symptom change and the change in functional outcomes is complex, and points to potential issues in selection of assessments.

Social Disinterest Attitudes and Group Cognitive-Behavioral Social Skills Training for Functional Disability in Schizophrenia

The majority of clinical trials of cognitive-behavioral therapy (CBT) for schizophrenia have used individual therapy to target positive symptoms. Promising results have been found, however, for group CBT interventions and other treatment targets like psychosocial functioning. CBT for functioning in schizophrenia is based on a cognitive model of functional outcome in schizophrenia that incorporates dysfunctional attitudes (eg, social disinterest, defeatist performance beliefs) as mediators between neurocognitive impairment and functional outcome. In this report, 18 clinical trials of CBT for schizophrenia that included measures of psychosocial functioning were reviewed, and two-thirds showed improvements in functioning in CBT. The cognitive model of functional outcome was also tested by examining the relationship between social disinterest attitudes and functional outcome in 79 people with schizophrenia randomized to either group cognitive-behavioral social skills training or a goal-focused supportive contact intervention. Consistent with the cognitive model, lower social disinterest attitudes at baseline and greater reduction in social disinterest during group therapy predicted better functional outcome at end of treatment for both groups. However, the groups did not differ significantly with regard to overall change in social disinterest attitudes during treatment, suggesting that nonspecific social interactions during group therapy can lead to changes in social disinterest, regardless of whether these attitudes are directly targeted by cognitive therapy interventions.

Symptoms as mediators of the relationship between neurocognition and functional outcome in schizophrenia: A meta-analysis

BackgroundNeurocognitive functioning in schizophrenia has received considerable attention because of its robust prediction of functional outcome. Psychiatric symptoms, in particular negative symptoms, have also been shown to predict functional outcome, but have garnered much less attention. The high degree of intercorrelation among all of these variables leaves unclear whether neurocognition has a direct effect on functional outcome or whether that relationship to functional outcome is partially mediated by symptoms. MethodsA meta-analysis of 73 published English language studies (total n=6519) was conducted to determine the magnitude of the relationship between neurocognition and symptoms, and between symptoms and functional outcome. A model was tested in which symptoms mediate the relationship between neurocognition and functional outcome. Functional outcome involved measures of social relationships, school and work functioning, and laboratory assessments of social skill. ResultsAlthough negative symptoms were found to be significantly related to neurocognitive functioning (p<.01) positive symptoms were not (p=.97). The relationship was moderate for negative symptoms (r=–.24, n=4757, 53 studies), but positive symptoms were not at all related to neurocogniton (r=.00, n=1297, 25 studies). Negative symptoms were significantly correlated with functional outcome (r=–.42, p<.01), and again the correlation was higher than for positive symptoms (r=–.03, p=.55). Furthermore, our findings support a model in which negative symptoms significantly mediate the relationship between neurocognition and functional outcome (Sobel test p<.01). ConclusionsAlthough neurocognition and negative symptoms are both predictors of functional outcome, negative symptoms might at least partially mediate the relationship between neurocognition and outcome.

Multimodal cognitive therapy: combining treatments that bypass cognitive deficits and deal with reasoning and appraisal biases.

The process of recovery in schizophrenia involves resolving persistent symptoms, addressing cognitive impairments, and improving functional outcomes. Our research group has demonstrated the efficacy of cognitive adaptation training (CAT)--a home-based psychosocial treatment utilizing environmental supports such as medication containers, signs, checklists, and the organization of belongings to bypass deficits in cognitive functioning and cue and sequence adaptive behavior) for improving adherence to medications and functional outcomes in schizophrenia. Early CAT pilot studies utilizing some therapists with training in cognitive behavior therapy (CBT) techniques for psychosis found significant improvements in positive symptoms. More recent larger scale randomized clinical trials failed to replicate this finding with CAT therapists not trained in CBT techniques. Persistent psychotic symptoms substantially impair patients' ability to adapt to life in the community. Cognitive behavior therapy for psychosis (CBTp) is an evidence-based practice for addressing persistent positive symptoms and the distress associated with them. CBTp decreases symptomatology and minimizes the negative effect of persisting symptoms upon individuals with this disorder. We now describe a home-delivered, multimodal cognitive treatment targeting functional outcomes and persistent positive symptoms for individuals with schizophrenia by utilizing both CAT and CBT techniques. We discuss the advantages and challenges of combining these 2 interventions, present a small retrospective data analysis to support their combination into a multimodal treatment, and describe the design of an ongoing randomized trial to investigate efficacy.

Defining and predicting functional outcome in schizophrenia and schizophrenia spectrum disorders

Background:To assess criteria and to identify predictive factors for functional outcome. The criteria should cover all domains proposed by the Remission in Schizophrenia Working Group. Method:PANSS ratings were used to evaluate the symptomatic treatment outcome of 262 inpatients with schizophrenia spectrum disorders within a naturalistic multicenter trial. Functional remission was defined as a GAF score >61 (Global Assessment of Functioning Scale), SOFAS score >61 (Social and Occupational Functioning Scale) and a SF-36 mental health subscore >40 (Medical Outcomes Study—Short Form Health Survey). Multivariate logistic regression and CART analyses were used to determine valid clinical and sociodemographic predictors. Results:In total, 52 patients (20%) fulfilled the criteria for functional remission, 125 patients (48%) achieved symptomatic resolution and when criteria for functional remission and symptomatic resolution were combined 33 patients (13%) achieved complete remission. Younger age, employment, a shorter duration of illness, a shorter length of current episode, less suicidality, and a lower PANSS negative and global subscore at admission were predictive of functional remission. The regression model showed a predictive value of more than 80%. Conclusions:A significant association was found between functional remission and symptomatic resolution, indicating reasonable validity of the proposed definition for functional outcome. The revealed predictors for functional treatment outcome emphasize the need for psychosocial and vocational rehabilitation in schizophrenic patients.

Intrinsic Motivation Inventory: An Adapted Measure for Schizophrenia Research

This article describes the psychometric validation of a scale designed to measure intrinsic motivation (IM) in schizophrenia. Recent studies have highlighted the relationship between motivation and functional outcome in schizophrenia and identified IM as an important mediating factor between neurocognition and psychosocial outcome. It therefore becomes imperative to have validated measures of IM for empirical use. To that end, we validated a self-report IM scale that gauges the central motivational structures identified by Self-determinism Theory as pertinent to cognitive task engagement, skill acquisition, treatment compliance, and remediation outcome. Participants were schizophrenia outpatients involved in a cognitive remediation study (n = 58), a convenience subsample of clinically stable schizophrenia outpatients (n = 15), and a group of healthy normals (n = 22). The Intrinsic Motivation Inventory for Schizophrenia Research (IMI-SR) is a concise instrument, possessing good internal consistency (alpha = .92) and test-retest reliability (intraclass correlation = .77). Data were analyzed to abridge the original 54 items into a final 21-item questionnaire comprised of 3 domains relevant to motivation for treatments (interest/enjoyment, perceived choice, value/usefulness). The scale was highly associated with germane constructs of motivation for health-related behaviors, including perceived competency for attempting challenging tasks and autonomous treatment engagement. Importantly, the scale was able to distinguish improvers and nonimprovers on a cognitive task and actual learning exercises, delineate high vs low treatment attendance, and demonstrate sensitivity to motivational changes due to intervention variation. The IMI-SR is a viable instrument to measure IM in schizophrenia as part of a cognitive remediation protocol or psychosocial rehabilitation program.

Pathways to functional outcomes in schizophrenia: The role of premorbid functioning, negative symptoms and intelligence

Background Social and intellectual premorbid functioning are generally estimated retrospectively, and related to clinical or hospitalization outcomes in schizophrenia. Yet the relationship between premorbid functioning assessed prior to psychiatric hospitalization and postmorbid functional outcomes has not been examined. Objectives To test competing models of the relationship between (a) functional outcomes with (b) premorbid functioning assessed on nationally administered tests prior to psychiatric hospitalization, postmorbid intellectual functioning and symptomatology using a historical prospective design. Methods Ninety one inpatient and outpatient males with schizophrenia or schizoaffective disorder, aged 19 to 35, were examined using the Positive and Negative Syndrome Scale, the WAIS-III and Strauss and Carpenter social and occupational functional outcome scale. Premorbid intelligence and social functioning data were obtained from national standardized tests administered during high school prior to first hospitalization for schizophrenia. Results Path modeling showed that premorbid intelligence and behavioral functioning directly predicted postmorbid IQ and negative symptoms, and indirectly predicted postmorbid social and occupational functioning via negative symptoms. Item level analysis indicated that better social and occupational outcomes occurred in a group with few negative symptoms. Conclusions Premorbid functioning, postmorbid IQ and negative symptoms are related, yet the relationship between premorbid functioning and postmorbid functional outcomes appears to be mediated by postmorbid negative symptoms.

Psychopathology and cognition in divergent functional outcomes in schizophrenia

Cognitive performance rather than symptoms, especially positive symptoms, is regarded as the primary predictor of functional outcome in schizophrenia. However, contradictory evidence exists and many studies fail to sample from the extremes of outcome measures. This study tested whether the differential importance assigned to symptoms and cognitive impairment is supportable in patients with high and low levels of community independence. Schizophrenia patients with highly unfavorable ( n = 24) and highly favorable ( n = 28) functional outcomes as defined by community support requirements were studied. Standard cognitive and psychopathology measures were analyzed using independent groups comparisons and outcome prediction with logistic regression methods. Symptom severity and cognitive data separately accounted for significant amounts of variance in community independence. Positive as well as negative symptoms, non-psychotic psychopathology and cognition generated large effect sizes between highly unfavorable and favorable outcome groups. The conditional validity of both overall psychopathology and positive symptoms was significant over and above the contribution of cognition to outcome prediction. Results suggest researchers may have underestimated the role of psychopathology in general and positive symptoms in particular as potential determinants of functional status in schizophrenia.

Insight and treatment outcome with cognitive-behavioral social skills training for older people

Poor insight (awareness of having a mental illness that requires treatment) is common in schizophrenia and typically predicts poor outcome, yet greater insight has been linked to negative outcomes, including hopelessness. This study focused on two questions: (1) Does insight moderate the effects of cognitive-behavioral social skills training (CBSST) on functional outcomes in schizophrenia? (2) Does a specific type of insight (e.g., awareness of illness, need for treatment) predict benefit from CBSST? We examined insight as a predictor of everyday functioning in a randomized controlled trial of CBSST versus treatment as usual (TAU) for middle-aged and older people with schizophrenia (n = 62). We used linear regression models to examine moderators of the relationship between baseline insight and everyday functioning measured 12 months following completion of the 6-month intervention. Insight, especially insight into the need for treatment, moderated the relationship between treatment group and everyday functioning (Independent Living Skills Survey), such that CBSST offset the negative effect of insight on functioning observed with TAU (wherein greater insight was related to poorer everyday functioning). Post hoc analyses showed that reduction of insight-linked hopelessness may have accounted for the positive effect of CBSST on functioning relative to TAU.

Cognitive Function and Functional Outcome in Schizophrenia

Cognitive Function and Functional Outcome in Schizophrenia

Comprehension of Affective Prosody in Veterans With Chronic Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is one of the few psychiatric conditions in which a subjective decrease in emotional range serves as a diagnostic criterion. In order to investigate whether veterans with chronic PTSD also experienced objective limitations in emotional perception, the authors administered the Aprosodia Battery to a group of 11 veterans with chronic PTSD, nine subjects with right hemisphere damage, seven subjects with left hemisphere damage, and 12 comparison subjects. The patients with PTSD displayed significant deficiencies in the comprehension and discriminative components of affective speech, similar in severity and performance profile on the Aprosodia Battery to the individuals with focal right hemisphere damage due to ischemic infarction.

Restoring GABAergic Signaling and Neuronal Synchrony in Schizophrenia

Restoring GABAergic Signaling and Neuronal Synchrony in Schizophrenia

Development and psychometric performance of the schizophrenia objective functioning instrument: An interviewer administered measure of function

Existing measures for functional assessment do not adequately address the relationship between cognitive impairment and function. The Schizophrenia Outcomes Functioning Interview (SOFI) was developed to measure community functioning related to cognitive impairment and psychopathology. Following review of existing measures and discussion with experts, caregivers, and patients, content was generated for four domains: 1) living situation; 2) IADLs; 3) productive activities; and 4) social functioning. The final SOFI was constructed with items informing domain scores, and an interviewer-completed global rating for each domain. Psychometric characteristics of the SOFI were evaluated in a sample of 104 community residing patients with schizophrenia and their informants. Test–retest reliability was evaluated in a sub-sample of patient–informant dyads using ICC; all values were > 0.70 for both patient-interviews (SOFI-P) and informant-interviews (SOFI-I). Inter-rater reliability ICCs ranged from 0.50 to 0.79 on a different sub-sample. The SOFI demonstrated adequate construct validity based on correlations with the PSP (range 0.58 to 0.76; p < 0.0001) and the QLS ( p < 0.001). Some correlations between SOFI and PETiT scores were low to moderate ( p < 0.05). Discriminant validity was supported based on SOFI score comparisons for patient groups based on PANSS and BACS scores ( p < 0.05); SOFI scores differed between borderline and moderately ill patients as measured by the CGI-S ( p < 0.05). The SOFI expands on existing measures and more comprehensively captures functioning of patients in the real world than other performance-based (proxy) measures. The SOFI has good evidence supporting reliability and construct validity, and may be a useful measure of functional outcomes in schizophrenia.