cognitive impairment: core feature of schizophrenia
DESCRIPTION
Cognitive Impairment: Core Feature of Schizophrenia. Triptish Bhatia Smita N. Deshpande Dept. of Psychiatry & De-addiction PGIMER-Dr. RML Hospital. PLAN. Type of impairment Outcome Interventions. Points to remember. Significant decline from premorbid levels - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/1.jpg)
Cognitive Impairment: Core Feature of Schizophrenia
Triptish Bhatia
Smita N. Deshpande
Dept. of Psychiatry & De-addiction
PGIMER-Dr. RML Hospital
![Page 2: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/2.jpg)
Type of impairment Outcome Interventions
PLAN
![Page 3: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/3.jpg)
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)
![Page 4: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/4.jpg)
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)
![Page 5: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/5.jpg)
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
![Page 6: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/6.jpg)
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)
![Page 7: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/7.jpg)
![Page 8: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/8.jpg)
Categories‘Neuro’ Cognition Social cognition
AttentionMemoryLanguageReasoningLearningProblem solvingDecision making
Social stimuli processing, Drawing inferences about others' mental states, Engaging in social interactions.
![Page 9: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/9.jpg)
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
![Page 10: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/10.jpg)
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
![Page 11: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/11.jpg)
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
![Page 12: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/12.jpg)
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)
![Page 13: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/13.jpg)
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)
![Page 14: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/14.jpg)
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)
![Page 15: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/15.jpg)
Emotional processing, Social perception, Attribution style, and Theory of mind (Green et al., 2005; Green and Horan, 2010
).
Social Skill Domains
![Page 16: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/16.jpg)
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
![Page 17: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/17.jpg)
Rules of social world keep changing
Difficult to adjust due to loss of reasoning
Reasoning & problem Solving
![Page 18: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/18.jpg)
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)
![Page 19: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/19.jpg)
![Page 20: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/20.jpg)
McGuffin et al. 2010
![Page 21: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/21.jpg)
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
![Page 22: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/22.jpg)
![Page 23: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/23.jpg)
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)
![Page 24: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/24.jpg)
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)
![Page 25: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/25.jpg)
Poor functional outcome: Difficulty in independent
living
High rate of severe schizophrenia among single homeless people (Scott 1993)
Wandering aimlessly: 22% (Jakhar 2012)
![Page 26: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/26.jpg)
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
![Page 27: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/27.jpg)
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
![Page 28: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/28.jpg)
![Page 29: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/29.jpg)
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)
![Page 30: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/30.jpg)
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
![Page 31: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/31.jpg)
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)
![Page 32: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/32.jpg)
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)
![Page 33: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/33.jpg)
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)
![Page 34: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/34.jpg)
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)
![Page 35: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/35.jpg)
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)
![Page 36: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/36.jpg)
Virtual Reality environment (developed via the NeuroVr2.0 software) for shifting, sustained attention and action planning functions (LaPaglia, 2013)
Computer-assisted cognitive remediation
![Page 37: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/37.jpg)
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
![Page 38: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/38.jpg)
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
![Page 39: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/39.jpg)
Improvements in Physical, Subjective and Disorder-specific clinical
outcomes (Zschuke, Gaudlitz, Strohle 2013)
Physical Exercise/Activity
![Page 40: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/40.jpg)
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)
![Page 41: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/41.jpg)
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)
![Page 42: Cognitive Impairment: Core Feature of Schizophrenia](https://reader036.vdocuments.us/reader036/viewer/2022062309/568157cf550346895dc5554e/html5/thumbnails/42.jpg)