Cognitive Disorder And Schizophrenia Essay

Cognitive Disorder And Schizophrenia Essay

Cognitive Disorder And Schizophrenia Essay

SCENARIO: Mr. Pritchett is a 71-year-old man. Mr. Pritchett has a cognitive disorder and schizophrenia. He’s also a diabetic. Mr. Pritchett lives alone. Mr. Pritchett received a flyer in the mail stating he won a prize from a local car dealership, he was advised that he had to come to the dealership to claim his prize. Mr. Pritchett visited the car dealership. Mr. Pritchett said the salesmen were very friendly and told him he could get a vehicle. They asked him what would he be interested in getting. Mr. Pritchett informed the salesperson that he only wants to get his prize. He was told that he qualified for a truck. The salesman showed him a 2016 track. Mr. Pritchett liked the truck but he told the salesman that his credit what’s good enough to qualify but the salesman keep telling him they could get him approved. Mr. Pritchett wasn’t told by the finance offer that his payments were going to be $700 a month. Mr. Pritchett drove away with a $30,000 truck $700 car payment. The salesman falsified his documentation.Cognitive Disorder And Schizophrenia Essay

Based on your medical expertise please write a note to the General Manager explaining how Mr. Pritchett’s medical condition may have played a factor in his decision to purchase this vehicle.

No citations, no quotes. It must be written in a letter format. One paragraph.

There is considerable evidence of the presence of cognitive deficits in schizophrenic disorder that are unfavorably correlated to the daily functioning of these patients [1]. These dysfunctions are present before the beginning of the psychotic symptomatology [2]. Cognitive déficits in schizophrenia affect most of cognitive functions and are especially relevant in: memory and learning; abstraction and executive functions; processing speed and attention Cognitive Disorder And Schizophrenia Essay

It is important to point out that there are similar cognitive impairments, in much lower intensity, in close relatives, and these deficits can be considered as potential cognitive endophenotype markers of the disorder [8, 9, 10, 11, 12, 13]. From this data, it can be accepted that, in many cases, the effect of these alterations, potentially, may be affecting the functioning of any family nucleus and not only the patient or relative at risk of developing disease.

These data show the existence of a biological basis, despite the undeniable influence of environmental factors on the development and course of both pathologies. In this sense, the DSMIV-TR [14] notes that: “Although numerous data suggest the importance of genetic factors in the etiology of schizophrenia, the existence of a substantial discrepancy in the frequency of monozygotic twins also indicates the importance of environmental factors”.Cognitive Disorder And Schizophrenia Essay


As expected, this cognitive dysfunction has influence in the main aspects of daily life [15]. Respecting the family point of view, there is also a great ignorance of the existence and influence of these cognitive symptoms present in the affected relatives. In general, it is suggested that the psychoeducational programs made for this subject directed to family members provide them with an important first step. These programs provides means in order to understand these factors, which make an important stain in their overall functioning, and therefore, in the daily life of these patients [16, 17, 18, 19]. On the other hand, it is important to point out that the same patients do not usually present insight of their deficits, and when they do, although they are usually associated with higher levels of adherence to treatment, they also tend to do so with a loss of self-confidence [20]. This fact indicates that family interventions in the education of cognitive aspects should not only stay there and should also involve a research for solutions of family support in other ways. At this point, it cannot be ignored the effect on the family dynamics of the probable presence (even being slight) of these deficits in any of the relatives of the affected subjects. Their awareness and identification are important in order to carry out a family intervention.Cognitive Disorder And Schizophrenia Essay

2. Cognitive deficit in schizophrenia

One of the main recently advances of the concept of schizophrenia has been the confirmation that this disorder is primarily associated to cognitive deficits, do not being a consequence to symptoms or drugs [21]. Nevertheless, the idea that cognitive domains played a fundamental role in this disorder was not so recent. Since the first descriptions of schizophrenia, which was known under the Dementia praecox label, the aspects related to what it is now understood as cognitive deficit were considered as central symptoms of the picture. Besides the essential idea of Bleuler was that the core of schizophrenia, its fundamental symptoms, was the fragmentation of the thought process and delusions and hallucinations were accessory symptoms, a consequence of the main process [22, 23]. It has also been shown that this cognitive deficit has not only been described in long-standing schizophrenic patients [24], but is also present in patients with a first psychotic episode [25, 26, 27], in remission [28], in patients without antipsychotic medication [21, 29] and even in studies in high-risk subjects [30] and in close relatives and healthy patients with schizophrenia [12].

It is estimated that among 61–78% of patients with schizophrenia manifest a significant level of cognitive deficit [1] reaching between 1 and 2 standard deviations below the control groups of the same age [6, 31]. These cognitive deficits seem independent of positive symptoms [32] and are maintained throughout the course of the disease.Cognitive Disorder And Schizophrenia Essay

Although some early investigations [33] showed that about 27% of schizophrenic patients, after neuropsychological evaluation, could not be considered deficit, in fact, it has been proven that they would continue to present neuropsychological deficit compared to healthy subjects, even matching IQ measurements [34]. This group of patients, without supposed deterioration, would show high levels of premorbid functioning, but once the disease was diagnosed, this would be considerably lower [35]. In addition, discordant monozygotic twin comparisons for schizophrenia suggest that almost all affected twins perform worse on cognitive tests than their unaffected twin [36]. In this sense, it can be safely talked about cognitive deficits in schizophrenic patients although, in any case, it is very likely that their cognitive performance is below than what was expected in the absence of disease. It is also interesting to mention that several authors have found a worse performance in tasks of work memory (especially in visual) and in learning verbal tests and free memories in unaffected monozygotic twin brothers and, even a lesser degree, in not affected dizygotic twin brothers against controls [37, 38, 39, 40].Cognitive Disorder And Schizophrenia Essay

It is interesting to point out that many patients have a lack of awareness of cognitive dysfunction. Those who are better aware of their deficits are not associated with a lower use of treatment, nor with a lesser deterioration of executive function. But they do have better results in the rehabilitation of some cognitive domains, in adherence to treatment and in their functional capacity [41, 42].

The neurocognitive dysfunction affects the ability to perform activities of daily living, impairs the ability to solve social problems [15, 16] and has proved to be the better predictor of reincorporation to activities in social and community settings [43, 44] and, especially, in terms of work rehabilitation and maintenance works [45, 46, 47, 48]. These data review the importance of cognitive domains as a reliable scale of clinical improvement [15, 49, 50, 51, 52] and, as is to be expected, the degree of cognitive impairment implies a worse adjustment in the quality of life of these patients [52, 53, 54]. Some authors also consider cognitive functions as an integral part of the concept of resistance to treatment [55]. On the other hand, several studies emphasize the importance and efficacy of cognitive rehabilitation treatments in early stages of psychosis [56, 57].Cognitive Disorder And Schizophrenia Essay

As expected with these data, the cognitive alteration in schizophrenia is the current focus of attention for the research of therapeutic strategies, both pharmacological and psychological. Regarding the interventions on cognitive domains, the pharmacological treatment, although it has offered certain results, has not been very encouraging [58], however studies using cognitive stimulation (training in executive skills, memory and other cognitive processes) have achieved more hopeful data [59, 60, 61, 62].

2.1. Cognitive domains affected
Patients with schizophrenia have, comparing with healthy subjects, problems in performing almost all conventional neuropsychological tests. The most widely affected functions are executive tasks. Memory and attention, in their different modalities, are not the only ones affected, but it is these domains that stand out especially about a generalized cognitive dysfunction. The functions relatively preserved in schizophrenia are usually verbal knowledge and linguistic comprehension and naming. Cognitive functioning in schizophrenia is considered a primary or essential characteristic of the disorder [15, 63], so that schizophrenia is now considered to be a complex disorder whose base is fundamentally neurocognitive [64, 65].Cognitive Disorder And Schizophrenia Essay

In schizophrenia, cognitive deficits are recognized as a core feature of the disorder [1–3], with 80% of patients exhibiting deficits in at least one cognitive domain [1, 4]. These deficits do not typically resolve following antipsychotic treatments [1, 2]. The impact of these deficits on interpersonal and occupational functioning is well-established [5, 6], leading to major efforts to further understand and treat these barriers to functional recovery. In this paper, we refer to cognition as including all nonsocial cognitive functions such as memory or executive functions. Along with cognitive deficits, patients with schizophrenia also present with social cognitive deficits [3]. Social cognition refers to the mental processes underlying social interactions, including the abilities involved in perceiving and interpreting social information in order to guide social interactions [7].Cognitive Disorder And Schizophrenia Essay

Among all cognitive and social cognitive functions, theory of mind (ToM) is most strongly associated with functioning in schizophrenia [5, 8–11] and is therefore an important treatment target. ToM can be defined as the ability to represent and infer the mental states of other people such as their intentions, emotions, or beliefs [7–9]. Even though ToM judgments are by definition social judgments, several nonsocial cognitive functions likely contribute to making correct inferences about other people’s mental states. In real life, a poor memory could, for instance, make it harder to use relevant cues from previous encounters with the same person [12]. In line with this idea, several studies have reported significant associations between ToM and a range of cognitive abilities, including verbal memory, speed of processing, verbal fluency, cognitive flexibility, inhibition, and reasoning [13–21]. However, it remains unclear if one or a few cognitive functions are more strongly associated with ToM than the others. There is evidence that ToM acts as a mediator between cognition and different spheres of functioning such as social [9, 22, 23] or occupational functioning [9, 23, 24], with cognition influencing ToM, which in turn influences functioning. Therefore, ToM abilities may in fact be more proximal to functioning than cognitive abilities. Given that ToM is largely impaired in schizophrenia [3, 25–27], it is recognized as an important treatment target to promote better functioning in these patients.Cognitive Disorder And Schizophrenia Essay

Patients with schizophrenia often also present with metacognitive impairments, including difficulties in estimating the difficulty of a task (metacognitive knowledge) [28–30], monitoring their performance during a task, or regulating their cognition using efficient strategies (metacognitive regulation) [30]. Metacognitive skills are thought to contribute to ToM, for instance, by enabling the flexibility required to “shift back and forth from one’s own perspective to the valid and differing perspectives of others” ([31], page 387). The improvement of metacognitive abilities could thus be useful for cognitive and social cognitive functioning.Cognitive Disorder And Schizophrenia Essay

Given the association between cognition and ToM abilities [13–21] and between metacognition and ToM [31–33], we could expect that addressing cognition and metacognition with a cognitive remediation therapy (CRT) could help improve ToM abilities in patients with schizophrenia. CRT is defined as a “behavioral training-based intervention that aims to improve cognitive processes with the goal of durability and generalization” [34]. Multiple CRT programs targeting various cognitive domains and using different methodology have been tested, revealing positive effects on cognitive performance (reviewed in [34, 35]). Other CRT programs targeting social cognition have led to improved social cognition performance (reviewed in [36]). However, despite the recognized relationship between cognition and ToM, no study has yet investigated if a CRT targeting only cognition and metacognition can also improve ToM performance. Furthermore, few studies have yet considered the cognitive profile at baseline (i.e., having a deficit in cognition or ToM) as an inclusion criterion. This in an important question given that cognitive deficits could act as a limiting factor for ToM.Cognitive Disorder And Schizophrenia Essay

The aim of this study was to investigate the effect of a CRT program (Computerized Interactive Remediation of Cognition Training for Schizophrenia; CIRCuiTS) that targets cognitive functions and metacognitive skills on ToM abilities in patients with schizophrenia. CIRCuiTS relies on a drill and strategy approach and puts a strong focus on the development of metacognitive skills and cognitive functions using nonemotive material. In addition, we also explored the changes in cognitive and metacognitive functions as well as clinical symptoms and global functioning following the CRT. We hypothesized that developing cognitive and metacognitive abilities with CIRCuiTS would lead to improvements in ToM.Cognitive Disorder And Schizophrenia Essay

2. Materials and Methods
2.1. Context
This multiple case study was conducted in parallel with a previous study [37] that assessed the feasibility of CIRCuiTS with young adults with schizophrenia. Four patients with ToM deficits at baseline were included in the present study, including two patients (Cases A and B) who were included in our previously published feasibility study (resp., designated as Cases A and C in the previous report [37]). ToM performance was assessed as part of the same study protocol, but these results were not previously published. None of the participants presented with a current developmental disorder that could have affected the performance, such as autism or attention deficit hyperactivity disorder.

2.2. Participants
All four participants had (1) a confirmed DSM-IV diagnosis of schizophrenia; (2) a duration of illness that did not exceed 10 years; (3) a clinical status that permitted reliable cognitive assessment (i.e., the patient did not present with acute psychotic symptoms that may affect the neuropsychological assessment and their psychiatrist considered that the collaboration and the medication were adequate for the patient); (4) cognitive difficulties defined as a performance equal to or below the 16th percentile either on the Rey Complex Figure Test [38] or on the California Verbal Learning Test-II [39]; and (5) a ToM deficit defined as a performance equal or below the 16th percentile on the Combined Stories Task (COST) [8].Cognitive Disorder And Schizophrenia Essay

Exclusion criteria for the study were (1) brain and metabolic disorders known to cause neuropsychological impairments; (2) substance dependence in the last six months; and (3) intellectual quotient (IQ) below 70 based on the Wechsler Adult Intelligence Scale third edition [40].

This study was approved by the ethics committee of the Centre de Recherche de l’Institut Universitaire en Santé Mentale de Québec in Québec, Canada, and all participants provided informed written consent.

2.3. Procedure
Baseline assessments included a ToM task and a battery of cognitive and metacognitive tasks, administered by a research assistant, as well as measures of clinical symptoms and global functioning, which were completed by the treating psychiatrist. Following baseline assessment, CRT was provided with the program CIRCuiTS, for a total of 40 sessions of approximately one hour each, at least three days per week (mean duration = 17.4 weeks, or about 4 months). The same assessment battery used at baseline was again administered after the end of the treatment. Furthermore, two follow-up assessments were conducted; the first one was conducted three months after the end of the treatment (and hence about 7 months after baseline assessment) and the second one was conducted 1 year after the end of the treatment (hence about 1 year and 4 months).Cognitive Disorder And Schizophrenia Essay

2.4. Material
2.4.1. ToM Assessment
ToM was assessed with the Combined Stories Task (COST) [8], which requires participants to read short stories out loud and to answer one or two questions that require taking into account the characters’ mental states (i.e., their intentions, beliefs, or emotions), for a total of 26 second-order ToM questions. Answers are rated as 0, 1, or 2 points for a total of 52 points. Participants are encouraged to refer back to the written story to answer the questions if they need, which is done to minimize the impact of potential difficulties in being attentive to the text or in remembering the story. Previous studies documented the excellent validity [8] and test-retest reliability [41] of the COST.Cognitive Disorder And Schizophrenia Essay

2.4.2. Neuropsychological Assessment
The Wechsler Adult Intelligence Scale third edition was used to provide a full assessment of IQ (WAIS-III; [40]). The cognitive battery included tests assessing different functions addressed by CIRCuiTS: the digit span subtest (total) from the WAIS-III [40] for verbal working memory and the spatial span (total) [42] for visual working memory. Episodic memory (verbal and visual) was assessed using the long-delay free recall of the California Verbal Learning Test-II (CVLT-II) [39] and of the Rey Complex Figure Test (RCFT) [38]. The Continuous Performance Test-II (CPT-II) [43] was used to assess selective attention (omission and commission) and sustained attention (HRTBC and HSEBC). Cognitive flexibility was assessed with the Wisconsin Card Sorting Test, 128 cards (WCST) (number of categories completed) [44], the Stroop from the Delis-Kaplan Executive Function System [45] condition 3 (total time) was used to assess inhibition, the Tower of London (TOL) (total problems solved correctly with the minimum move) [46] was used to assess planning and organization, and the Matrix reasoning subtest from the WAIS-III [40] was used to assess reasoning. In the present study, a performance below the 16th percentile was considered as a deficit.

2.4.3. Metacognitive Assessment
Metacognitive knowledge (i.e., the knowledge about one’s own cognition) was assessed with the Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS) [47]. This 21 items’ questionnaire measures the patients’ understanding of his own cognitive functioning [47]. The SSTICS score needs to be interpreted in the broader context of cognitive and behavioral performance. While an increased score can be interpreted as an increased impairment in these cognitive functions in daily life; it can also be interpreted like a better metacognitive knowledge about one’s own cognition in daily life. Metacognitive regulation (i.e., the ability to monitor and regulate one’s own cognition) was assessed with the Behavior Rating Inventory of Executive Function-Executive Global Index (BRIEF-A) [48]. This index includes a self and an informant report (i.e., a first-degree family member in the current study), and both were included in this protocol. The BRIEF-A can be used as an indicator of the patient awareness of his self-regulation [48]. A performance below the 16th percentile was considered as a deficit.Cognitive Disorder And Schizophrenia Essay

2.4.4. Clinical Assessment
Global functioning was rated by the treating psychiatrist using the Global Assessment of Functioning (GAF) [49], which provides a single rating (0–100) encompassing psychological, social, and occupational functioning. Symptoms were rated with the Positive and Negative Syndrome Scale (PANSS) [50], which allows a distinction between the following five symptom factors: positive, negative, cognitive/disorganization, depression/anxiety, and excitability/hostility [51].

2.4.5. CRT Program
The CRT program used in this study was the French Canadian adaptation of CIRCuiTS [37, 52, 53], an individual computerized CRT program that aims to improve cognition (attention, memory, and executive functions) and metacognitive skills. CIRCuiTS aims to improve metacognitive skills by promoting the constant monitoring, regulation, and revision of performance during a task [28]. The development of metacognitive skills is based on the metacognitive model presented by Wykes and Reeder [30] in which metacognitive knowledge and regulation are useful in the transfer of cognitive skills in everyday life. Metacognitive knowledge (knowledge about how cognition works in general and one’s own cognition) can be helpful, for example, to remembering a grocery list by knowing that classifying items of a list in different categories facilitates remembering the information. Similarly, metacognitive regulation (monitoring and regulation of one’s own cognition) can, for example, be used to adapt strategies in scheduling, such as “I struggle to remember my appointment, so I will set an alarm on my cellphone.”Cognitive Disorder And Schizophrenia Essay

This program trains cognitive functions using a drill/practice and strategies method using 27 different tasks, each with at least 12 levels of difficulty. A more complete description of the CRT program is provided elsewhere [37, 52].

2.5. Statistical Analyses
To investigate the effect of CIRCuiTS on ToM abilities, Reliable Change Indices (RCIs) were calculated for ToM performance as assessed with the COST. RCIs can be used to assess if the score of an individual has statistically changed after an intervention. They correspond to the difference between two measures of the same individual, divided by the standard error of the difference of the test [54, 55]:Cognitive Disorder And Schizophrenia Essay
This figure is the equation published by Zahra and Hedge in 2010 based on Jacobson and Truax (1991) where signifies a participant pretest score and signifies the posttest score of the same participant. This score is divided by the Sdiff, or standard error of the change score, that is the difference between the scores ( and ), corrected for the reliability of the instrument. The Sdiff represents the range of distribution of change scores that could be expected if no intervention was done and is further explained in Jacobson & Truax (1991). Briefly, refers to the standard deviation of a normative group at baseline and refers to the test-retest reliability of the measure. Consequently, normative data were gathered from a comparative sample of patients diagnosed with schizophrenia, and standard deviations were computed for each variable in order to estimate the SE in the RCI formula.

Here, an RCI was calculated (1) between baseline and posttreatment, (2) between baseline and three months after treatment, and (3) between baseline and 1 year after treatment. RCIs are very conservative and can be interpreted like -change scores, hence being considered statistically significant at if equal or superior to 1.64 (one-tailed hypothesis) [54]. RCIs can be complemented by further calculating the clinical significance of the change, that is, whether the performance of a patient is in the range of the healthy control population or of the schizophrenia population after the treatment [56]. This is done by calculating a cut-off considering the means and standard deviations from a schizophrenia population and a healthy control population [56]. With this equation, the clinical cut-off score for the COST was 42.2/52. If the patient’s score surpasses the cut-off point after the treatment, the change is considered clinically significant [56].Cognitive Disorder And Schizophrenia Essay

In addition to ToM, RCIs were also calculated for all cognitive and metacognitive measures, as well as for symptoms ratings and functioning ratings. To facilitate the interpretation of the RCIs for cognitive measures for which a decrease in scores reflects an improvement (CPT omission, commission, HRTBC, HSEBC, Stroop, BRIEF, SSTICS, and PANSS), these RCIs were multiplied by −1 such that positive RCIs always reflected improvements. To assess the clinical significance of changes in symptoms, changes of at least 25% on the PANSS total or subscale scores compared to baseline were considered as clinically significant, as proposed by Leucht [57]. For the GAF, a score above 59 was considered as a remission state, as proposed by Bertelsen et al. [58].

3. Results: Case Presentation
3.1. Case A
Case A is a 26-year-old man who was diagnosed with schizophrenia 7 years ago. At the time of testing, he was taking clozapine and lamotrigine and presented with mild to moderate positive (range of PANSS scores = 1–4; mean = 2.8) and cognitive/disorganization symptoms (range of PANSS scores = 1–5; mean = 2.8). He presented moderate difficulties in global functioning (GAF = 42). His symptom ratings at each time point are presented in the Supplementary Material (see Table S1 in Supplementary Material available online at He completed 12 years of education and was working part-time and going to school full-time. His IQ at baseline was 78.

At baseline, Case A showed a severe ToM deficit, with a performance below the 1st percentile. Case A also showed cognitive deficits for visual and verbal episodic memory and cognitive flexibility and also showed impairment for the informant-rated metacognitive regulation. The scores and percentiles at each time point are presented in the Supplementary Material (Table S2). The evaluator reported that Case A did not seem aware of his cognitive deficits at the baseline. Case A completed 40 CRT sessions.Cognitive Disorder And Schizophrenia Essay

3.1.1. Changes in ToM Performance

Cognitive Dysfunction Relating to Schizophrenia Schizophrenia is often a chronic relapsing psychotic disorder that disrupts normal thought, speech, and behavior. It is a cluster of severe prolonged mental disturbances that “…is by far the most chronic and disabling of the major mental disorders. This disease may be one disorder, or it may be many disorders, with different causes” (Andreasen & Schutlz, 1999). It is a disease that makes it difficult for a person to tell the difference between real and unreal experiences. In addition, “it enables the person to think logically, to have normal emotional responses to others, and to behave normally in social situations” (Andreasen, 1999). Cognitive Disorder And Schizophrenia Essay
However, usually the illness develops slowly over months or even years. At first, the symptoms may not be noticed or may be confused with those of other conditions. “Schizophrenia is characterized by a constellation of distinctive and predictable symptoms. The symptoms that are generally associated with the disease are called positive “psychotic” symptoms, which denote the presence of grossly abnormal behavior. These abnormal behaviors include thought disorder, delusions, and hallucinations” (Frith, 1995). The positive symptoms of schizophrenia are among its most striking features and they are the most difficult to understand. Hearing voices talking to you, experiencing alien thoughts being inserted into your mind, and believing that alien forces are controlling your most trivial actions are as well outside the normal range of experience. In addition, such experiences are very rarely reported by neurological patients.  Cognitive Disorder And Schizophrenia Essay