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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. PLAN. Type of impairment Outcome Interventions. Points to remember. Significant decline from premorbid levels

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Cognitive Impairment: Core Feature of Schizophrenia

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  1. Cognitive Impairment: Core Feature of Schizophrenia Triptish Bhatia Smita N. Deshpande Dept. of Psychiatry & De-addiction PGIMER-Dr. RML Hospital

  2. PLAN • Type of impairment • Outcome • Interventions

  3. Points to remember • Significant decline from premorbid levels • Consistent severe impairment • Some aspects unimpaired • Upto2 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)

  4. 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)

  5. 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

  6. 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) Points to remember

  7. Categories

  8. 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

  9. 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

  10. 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

  11. 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)

  12. 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)

  13. 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)

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

  15. 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

  16. Reasoning & problem Solving • Rules of social world keep changing • Difficult to adjust due to loss of reasoning

  17. Separable cognitive factors Eight 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)

  18. McGuffin et al. 2010

  19. 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 Measurement of Cognitive Impairment

  20. 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)

  21. 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)

  22. Poor functional outcome: Difficulty in independent living • High rate of severe schizophrenia among single homeless people (Scott 1993) • Wandering aimlessly: 22% (Jakhar2012)

  23. Chennai & Delhi • 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)

  24. Kolkata • 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

  25. 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)

  26. Cognitive Behavioural Therapy • 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 FUpafter 9 months(Sriharsh, Sippy et al 2003)

  27. 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)

  28. 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 neurocognitionand processing speed composites (Hogarty et al. 2004)

  29. Cognitive Remediation (CR) • 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)

  30. 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)

  31. 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

  32. Computer-assisted cognitive remediation Virtual Reality environment (developed via the NeuroVr2.0 software) for shifting, sustained attention and action planning functions (LaPaglia, 2013)

  33. Psychosocial rehabilitation programmes • Cognitive adaptation training (Velligan and Bow-Thomas, 2000) • Errorless learning, workbook for memory Skills (Kennedy, 1996) • Goal management training (Robertson et al., 2005)

  34. Social Cognition Training • 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)

  35. Physical Exercise/Activity • Improvements in  • Physical, • Subjective and • Disorder-specific clinical outcomes (Zschuke, Gaudlitz, Strohle 2013)

  36. 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)

  37. Cognitive impairment and viral 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)

  38. THANK YOU

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