Community dysfunction in schizophrenia: rate-limiting factors

A Systematic Review and Meta-Analysis of the Association Between Psychopathology and Social Functioning in Schizophrenia

BACKGROUND

Impaired social functioning is a major, but under-elucidated area of schizophrenia. It's typically understood as consequential to, eg, negative symptoms, but meta-analyses on the subject have not examined psychopathology in a broader perspective and there's severe heterogeneity in outcome measures. To enhance functional recovery from schizophrenia, a more comprehensive understanding of the nature of social functioning in schizophrenia is needed.

STUDY DESIGN

In this systematic review and meta-analysis, we searched PubMed, PsycInfo, and Ovid Embase for studies providing an association between psychopathology and social functioning. Meta-analyses of the regression and correlation coefficients were performed to explore associations between social functioning and psychopathology, as well as associations between their subdomains.

STUDY RESULTS

Thirty-six studies with a total of 4742 patients were included. Overall social functioning was associated with overall psychopathology (95% CI [-0.63; -0.37]), positive symptoms (95% CI [-0.39; -0.25]), negative symptoms (95% CI [-0.61; -0.42]), disorganized symptoms (95% CI [-0.54; -0.14]), depressive symptoms (95% CI [-0.33; -0.11]), and general psychopathology (95% CI [-0.60; -0.43]). There was significant heterogeneity in the results, with I2 ranging from 52% to 92%.

CONCLUSIONS

This is the first systematic review and meta-analysis to comprehensively examine associations between psychopathology and social functioning. The finding that all psychopathological subdomains seem to correlate with social functioning challenges the view that impaired social functioning in schizophrenia is mainly a result of negative symptoms. In line with classical psychopathological literature on schizophrenia, it may be more appropriate to consider impaired social functioning as a manifestation of the disorder itself.

Dissociation of Proactive and Reactive Cognitive Control in Individuals with Schizotypy: An Event-Related Potential Study

OBJECTIVE

Patients with schizophrenia and individuals with schizotypy, a subclinical group at risk for schizophrenia, have been found to have impairments in cognitive control. The Dual Mechanisms of Cognitive Control (DMC) framework hypothesises that cognitive control can be divided into proactive and reactive control. However, it is unclear whether individuals with schizotypy have differential behavioural impairments and neural correlates underlying these two types of cognitive control.

METHOD

Twenty-five individuals with schizotypy and 26 matched healthy controls (HCs) completed both reactive and proactive control tasks with electroencephalographic data recorded. The proportion of congruent and incongruent trials was manipulated in a classic colour-word Stroop task to induce proactive or reactive control. Proactive control was induced in a context with mostly incongruent (MI) trials and reactive control in a context with mostly congruent (MC) trials. Two event-related potential (ERP) components, medial frontal negativity (MFN, associated with conflict detection) and conflict sustained potential (conflict SP, associated with conflict resolution) were examined.

RESULTS

There was no significant difference between the two groups in terms of behavioural results. In terms of ERP results, in the MC context, HC exhibited significantly larger MFN (360-530 ms) and conflict SP (600-1000 ms) amplitudes than individuals with schizotypy. The two groups did not show any significant difference in MFN or conflict SP in the MI context.

CONCLUSIONS

The present findings provide initial evidence for dissociation of neural activation between proactive and reactive cognitive control in individuals with schizotypy. These findings help us understand cognitive control deficits in the schizophrenia spectrum.

Predictors of life skills in people with schizophrenia

Objective : The purpose of the present study is to examine clinical factors related to life skills in people with schizophrenia. Method : The participants were 51 stabilized outpatients with schizophrenia. Their mean age was 38.91 (SD = 10.73) years. Life skills were assessed using the Life skills profile (LSP). Cognitive function was evaluated with the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB). Clinical symptoms were assessed using the Positive and Negative Syndrome scale (PANSS), the Calgary Depression Scale for Schizophrenia (CDSS) and the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS). Results : Cognitive function was not correlated with the LSP scores at all. Among clinical symptoms, scores of the PANSS positive and negative syndrome scales, the CDSS, and the DIEPSS had negative correlations with the LSP total score and the subscales. Stepwise regression analyses showed that the CDSS and PANSS negative syndrome scale scores were independent predictors of the LSP total score and two of the subscales. Conclusions : These results indicate that cognitive function is not associated with life skills but clinical symptoms such as depressive and negative symptoms have considerable impacts on life skills in people with schizophrenia. J. Med. Invest. 67 : 75-82, February, 2020.

Impact of primary negative symptoms on functional outcomes in schizophrenia

Objective

Negative symptoms are known to undermine functional outcomes in people with schizophrenia; however, most studies have not accounted for whether these symptoms were primary or secondary to other psychopathological factors. The present study examined the impact of primary negative symptoms on functional outcomes in patients with schizophrenia.

Method

The sample included 1427 patients with schizophrenia who completed the baseline visit in the CATIE study. Symptoms were assessed with the Positive and Negative Syndrome Scale and Calgary Depression Scale, extrapyramidal side effects with the Simpson-Angus scale, and functional status with the Heinrichs-Carpenter Quality of Life Scale.

Results

Negative symptoms were significantly and inversely related to each domain of functioning examined. These relationships remained after statistically controlling for the influence of potential sources of secondary negative symptoms. In addition, the relationships between negative symptoms and specific domains of functioning remained in patients who had mild/absent positive, depressive, anxiety and extrapyramidal symptoms. Negative symptoms were associated with functional outcomes even in antipsychotic-free patients.

Conclusions

Primary negative symptoms significantly contribute to the functional impairment seen in people with schizophrenia. A better understanding of the etiology and pathobiology of these symptoms is required to guide the search for effective therapeutics that promote functional recovery.

Neural correlates of cognitive deficits across developmental phases of schizophrenia

Schizophrenia is associated with cognitive deficits across all stages of the illness (i.e., high risk, first episode, early and chronic phases). Identifying the underlying neurobiological mechanisms of these deficits is an important area of scientific inquiry. Here, we selectively review evidence regarding the pattern of deficits across the developmental trajectory of schizophrenia using the five cognitive domains identified by the Research Domain Criteria (RDoC) initiative. We also report associated findings from neuroimaging studies. We suggest that most cognitive domains are affected across the developmental trajectory, with corresponding brain structural and/or functional differences. The idea of a common mechanism driving these deficits is discussed, along with implications for cognitive treatment in schizophrenia.

Factors limiting romantic relationship formation for individuals with early psychosis

BACKGROUND

Although many young adults with early psychosis (EP) desire to engage in a romantic relationship, many report having difficulties in engaging in such a relationship. However, almost no research has been conducted on factors potentially explaining impairments in their ability to form romantic relationships.

AIM

To compare an EP single young adult sample with single students or students in stable romantic relationships on factors that can cause difficulties in romantic relationship initiation processes METHODS: Cross-sectional study comparing these three groups (n = 83) on self-esteem, attachment, social functioning and perceived difficulties in dating.

RESULTS

No significant group differences were found on self-esteem, although lack of confidence was the second most frequent reason evoked by EP participants when asked why they were single. EP participants had greater attachment preoccupation than students involved in a relationship. Single EP individuals rated their social interaction abilities higher compared with single students, but did not engage in social interactions more often. Both single EP participants and single students had more negative perceptions of their intimacy abilities and fewer intimacy behaviours compared with participants involved in a relationship.

CONCLUSIONS

Potential interventions to improve EP young adult's capacity to engage in romantic relationships could target perception of their interaction skills, preoccupation about being loved, negative perception of their intimacy abilities, frequency of intimacy related behaviours and lack of confidence.

Interview-based assessment of cognition is a strong predictor of quality of life in patients with schizophrenia and severe negative symptoms

OBJECTIVE

To analyze the correlation between quality of life, symptoms, and cognition assessed by the interview-based Schizophrenia Cognition Rating Scale (SCoRS).

METHODS

Seventy-nine outpatients diagnosed with schizophrenia were evaluated with the Quality of Life Scale - Brazilian version (QLS-BR), the SCoRS, and symptoms scales (Positive and Negative Syndrome Scale [PANSS]). After determining the potential explanatory variables using Spearman's correlation and Student's t test results, we ran simple, multivariate, and decision-tree regression analyses to assess the impact of SCoRS and PANSS ratings on mean overall quality of life.

RESULTS

Cognitive deficits and negative symptoms were the best predictors of quality of life. A low degree of negative symptoms (PANSS negative < 11) was a strong predictor of better quality of life (QLS ∼ 75), regardless of SCoRS rating. Among participants with more severe negative symptoms, elevated cognitive impairment (interviewer SCoRS ∼ 44) was a predictor of worse quality of life (QLS ∼ 44).

CONCLUSIONS

Cognitive impairment determined by interview-based assessment seems to be a strong predictor of quality of life in subjects with severe negative symptoms. These results support the usefulness of SCoRS for cognitive assessment that is relevant to the everyday life of patients with schizophrenia.

Postsecondary academic achievement and first-episode psychosis: A mixed-methods study

Background.

Postsecondary academic achievement as an area of functional recovery for young adults living with mental illness has received little research attention.

Purpose.

This study had three purposes: to compare rates of participation, performance, and satisfaction in postsecondary education between young adults with first-episode psychosis and closely matched young adults; to identify characteristics associated with academic participation; and to explore the processes associated with educational experiences.

Method.

One hundred young adults ages 18 to 30 participated in the study. Quantitative data on academic engagement, performance, and satisfaction, and qualitative data ( n = 52) on academic experiences were integrated through pattern analyzes.

Findings.

Young adults with psychosis were significantly less likely to be engaged in postsecondary education. No difference appeared for the extent of engagement, but performance and satisfaction were lower among participants with psychosis. Participants engaged in reflexive decision making to access postsecondary education and to maintain adequate academic performance. Strategies used by successful students with mental illness were identified.

Implications.

Assessment and intervention focused on educational needs and skills should become landmark practices for psychiatric rehabilitation practitioners, including occupational therapists.

Cognitive control and schizophrenia: The greatest reliability of the Stroop task

Three components of cognitive inhibition were compared in patients with schizophrenia and healthy controls. Nineteen patients with schizophrenia were compared to 30 healthy controls, matched for age, sex, and educational level. Cognitive inhibition was examined by (i) access to relevant information (Reading with distraction task), (ii) suppression of no longer relevant information (Trail Making Test B), and (iii) restraint of cognitive resources to relevant information (Stroop Test, Hayling Sentence Completion Test, Go/No-Go Test). Beck Depression Inventory, and Positive and Negative Syndrome Scale were also used. Compared to healthy controls, patients with schizophrenia and stabilized for at least 6 months were slower in the inhibition condition at the Stroop task, read more distractors at the RWD, and made more perseverative errors at the TMT, even after controlling for age, Mini-Mental State Examination score, information speed processing, and accuracy. This difference remained significant after taking into account the level of depressive symptoms and the severity of psychotic symptoms. In multivariate analyses, only the Stroop interference index explained cognitive inhibition deficit in patients with schizophrenia. The abnormal cognitive inhibition process observed in patients with schizophrenia could therefore concerns the ability to restraint, rather than the access or the suppression processes.

Investigation of the role of the jumping-to-conclusions bias for short-term functional outcome in schizophrenia

Symptom severity and neuropsychological deficits negatively influence functional outcomes in patients with schizophrenia. Recent research implicates specific types of biased thinking styles (e.g. jumping-to-conclusions) in the pathogenesis of schizophrenia. This is the first study to test the impact of jumping-to-conclusions on functional outcome in schizophrenia. The aim of the study was to investigate the association of psychopathology, neuropsychology and JTC with subjective quality of life, vocational outcome and housing status in schizophrenia. Analyses were carried out both cross-sectionally at baseline, and longitudinally over the course of symptomatic improvement in the immediate aftermath of a psychotic exacerbation. Seventy-nine patients with schizophrenia were included in the study. Data concerning the variables of interest were collected at baseline, after one month, and after six months. Positive symptomatology was the most significant predictor of subjective and vocational outcome and changes across time. Verbal memory deficits were associated with functional status cross-sectionally, whereas general cognitive capacity significantly predicted functional changes over time. Improvement of the jumping-to-conclusions bias positively affected vocational outcome. Though limited, the observed effect of this bias on real-world functioning highlights the possible usefulness of interventions aimed at improving (meta)cognitive deficits in schizophrenia.

Predictors of community functioning in schizophrenia and substance use disorder patients

Community functioning is a broad term that encompasses various 'real world' measures of disability among schizophrenia patients. It includes outcomes such as independent living, social competence and behavioural problems-all of which are priorities for treatment among schizophrenia patients, mental health care providers, and family members. An important goal for rehabilitation programs is to identify predictors of community functioning which, in turn, could be used as targets for intervention. The present case-control study examined socio-demographic and substance use disorder (SUD) variables as well as psychiatric, extrapyramidal, and cognitive symptoms as predictors of community functioning in schizophrenia patients with (DD patients; n=31) and without comorbid SUDs (SCZ patients; n=31), and non-psychosis substance abusers (SUD patients; n=39). Psychiatric and extrapyramidal symptoms were evaluated with the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia and the Extrapyramidal Symptoms Rating Scale. Cognition was evaluated using the Cambridge Neuropsychological Test Automated Battery (speed of processing, explicit and working memory). In SCZ patients, community functioning was predicted by explicit memory performance. In DD patients, community functioning was predicted by substance abuse, depression and speed of processing. In SUD patients, community functioning was predicted by substance abuse, positive symptoms and education. Our results suggest that cognition should be among the top treatment priorities in SCZ patients, whereas the key treatment targets in DD patients should be substance abuse and depression. Future studies will need to replicate the current findings, using prospective research designs.

Transitions to adulthood in first-episode psychosis: a comparative study

AIM

The first aim of this study is to compare attainment of five markers of transition to adulthood between young adults with first-episode psychosis and young adults without any psychopathology. The second aim is to examine if the association between age group and transition to adulthood is similar for individuals who experience first-episode psychosis versus those who do not.

METHODS

Participants were 50 young adults with first-episode schizophrenia aged between 18 and 30 years old, and 50 volunteers without any psychopathology matched for sex and age. Participants were assessed with the Quality of Life Scale and a questionnaire on markers of transition to adulthood.

RESULTS

Significant differences appear between the groups for three of the five markers of transition to adulthood, namely: residential/financial independence, educational attainment and involvement in a romantic relationship. The effect of age on several markers is significant for the comparison group only.

CONCLUSION

Rehabilitation interventions should be informed by a developmental perspective on community functioning for young adults with first-episode schizophrenia. Vocational rehabilitation should be extended to focus more extensively on supported education and not only on supported employment, and interventions targeting residential independence should be granted more attention.

Is the GABA System Related to the Social Competence Improvement Effect of Aripiprazole? An (18)F-Fluoroflumazenil PET Study

OBJECTIVE

Patients with schizophrenia who are treated with aripiprazole experience some benefits including an improvement of social competence, but the underlying mechanism of this improvement has not been investigated yet. This study aimed to provide preliminary evidence that the GABA system may be involved in the effect of aripiprazole on social competence.

METHODS

Seventeen outpatients with schizophrenia (9 taking aripiprazole and 8 taking risperidone) and 18 healthy controls underwent (18)F-fluoroflumazenil PET, and GABAA receptor binding potential was compared between the three groups.

RESULTS

Voxelwise one-way ANOVA showed that GABAA receptor binding potentials in the right medial prefrontal cortex (p=0.04) and right dorsolateral prefrontal cortex (p=0.02) were significantly lower in the aripiprazole group than the risperidone group, and those in the left frontopolar cortex (p=0.03) and right premotor cortex (p=0.02) were significantly lower in the aripiprazole group than the risperidone and control groups.

CONCLUSION

Our results suggest that aripiprazole administration results in increased GABA transmission in the prefrontal regions, and that these increases may be a neural basis of aripiprazole's clinical benefits on an improvement of social competence.

Cognitive inhibition and quality of life in schizophrenia: a pilot study

AIM

To compare cognitive inhibition and quality of life in patients with schizophrenia and healthy controls.

METHODS

Ten patients with schizophrenia were compared to 10 healthy controls, matched for age, sex, and educational level. Cognitive inhibition was examined by: 1) access to relevant information (Reading with distraction task), 2) suppression of no longer relevant information (Trail Making Test), and 3) restraint of cognitive resources to relevant information (Stroop Test, Hayling Sentence Completion Test, Go/No-Go Test). Montgomery Asberg Depression Rating Scale, Positive and Negative Syndrome Scale, and Schizophrenia-Quality of Life scale (S-QoL) were also used.

RESULTS

Patients with schizophrenia showed a significant impairment in the suppression function of cognitive inhibition only, in comparison to the control group. Their access and restraint functions of cognitive inhibition were preserved. No relationship between quality of life and cognitive inhibition was found in patients with schizophrenia.

CONCLUSIONS

During the stabilization phase of schizophrenia, the ability to inhibit neutral information access to working memory, and to restrain and suppress irrelevant information may not impair the patient's capacity to respond adequately to stressful situations, and thus would do not impact their quality of life.

Typology of schizophrenic symptoms and quality of life in patients and their main caregivers in northern Chile

BACKGROUND

Schizophrenia is a serious mental disorder characterized by the presence of both 'positive' and 'negative' symptoms that affect the essential functions through which a person gains his or her sense of individuality and capacity for independent functioning.

AIMS

To describe the typology of schizophrenic symptoms and their relationship to quality of life in patients with schizophrenia and their main caregivers.

METHODS

Participants were 45 patients and 45 relatives seen by the mental health services in Arica, Chile. Patients were assessed using the Positive and Negative Syndrome Scale (PANSS), the Seville Quality of Life Questionnaire (SQLQ), and the Social Functioning Scale (SFS). The latter was also administered to caregivers, along with the Zarit Burden Interview.

RESULTS

Patients reported moderate levels of quality of life, there being a strong relationship with the negative syndrome and the general psychopathology of the disorder. The quality of life of main caregivers was related with the general psychopathology of patients. The results regarding social functioning and the caregivers' perceptions of patients' functional capacity showed that patients had a very limited degree of social integration.

CONCLUSIONS

Negative symptoms and general psychopathology are the main predictors of quality of life in both patients and their caregivers.

Psychopathology, rehospitalization and quality of life among patients with schizophrenia under home care case management in Taiwan

BACKGROUND/PURPOSE

To study the outcome of a group of patients with schizophrenia receiving community home care case management programs by delineating the relationship among their psychopathology, rehospitalization rates and health-related quality of life (HRQoL).

METHODS

This is a cross-sectional study on HRQoL, functioning and associating factors and a retrospectivehistorical control study by comparing the frequency and duration of rehospitalization in a sample of 60 patients with schizophrenia under nonintensive case management (non-ICM) in Taiwan. All participants were assessed on the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) for psychopathology, on EuroQoL-5D (EQ-5D) and EQ visual analogue (EQ-VAS) for HRQoL, andGlobal Assessment of Functioning (GAF) for socio-occupational dysfunction. Other clinical characteristics are also gathered.

RESULTS

Patients with schizophrenia treated with non-ICM had a significant reduction in admission frequency (-0.10 ± 0.36 times per year, p = 0.042) and length of inpatient stay (-27.8 ± 78.0 days per year, p = 0.008). Better EQ-5D and EQ-VAS are significantly associated with lower general psychopathology score, while better EQ-VAS is significantly associated with older age and higher negative symptoms subscale score. GAF is negatively associated with higher positive symptoms and negative symptoms subscale scores, while positively correlated with a greater reduction in number and frequency of admission.

CONCLUSION

Non-ICM can help to decrease rehospitalization of home care patients. HRQoL and functioning can be assessed by the three perspectives we used, and each measure was correlated to different dimensions of patient psychopathology. It will be better if we include baseline and post-intervention PANSS scores, HRQoL and functioning as outcome indicators.

Quality of life and its predictors in people with schizophrenia

The author reviewed measurement of quality of life (QOL) of schizophrenia patients and the clinical factors related to their QOL. As schizophrenia patients were thought to be unable to assess their own QOL because of their cognitive impairment, objective QOL measures had been frequently used. However, nowadays, there is general agreement that symptomatically stabilized patients could assess their QOL by themselves. Therefore, researchers gradually have become interested in subjective QOL measure. Although most researchers often evaluate schizophrenia patients' QOL using only subjective or objective QOL measure, considering the fact that there is a discrepancy between the two types of measures, it is recommended to use both of them as complementary measures. As for clinical factors related to lowered QOL, several studies reported that depressive symptom was most associated with lowered subjective QOL, negative symptom was strongly related to lowered objective one and poor life skill was associated with both. Moreover, several studies found that cognitive dysfunctions in some cognitive domains were related to lowered objective QOL but the effects of them were much smaller than those of negative symptoms. It is suggested that improving depressive and negative symptoms and life skills may contribute to enhancement of QOL of schizophrenia patients.

The impact of impaired "Theory of Mind" on social interactions in schizophrenia

Given the importance of social dysfunction in schizophrenia, many studies have explored how social cognition, and, particularly, Theory of Mind (ToM) may affect patients' social interactions. In the present study, we investigated the impact of ToM deficits on social interactions, taking into account overall neuropsychological functioning as well as clinical and demographic characteristics. We assessed 28 patients with schizophrenia and 30 healthy participants on a series of tasks including tests of ToM, neuropsychological tests focused on functions potentially relevant to ToM and role plays as an indicator of social interactions. Patients performed more poorly than healthy controls across most ToM and some of the neuropsychological tests. Correlations and hierarchical regression analyses indicated the impact of some, but not all, facets of ToM on patients' social interactions, over and above neuropsychological functioning, positive and negative symptom ratings, duration of illness and demographic characteristics. These findings suggest that remediation of ToM deficits in patients with schizophrenia may help to improve their social interactions.

Subjective quality of life in patients with chronic schizophrenia: relationships between psychosocial and clinical characteristics

BACKGROUND

Using the theoretical framework of quality of life (QOL), many studies have demonstrated that the beliefs individuals hold about their QOL are important in predicting health outcomes. This study tested the Taiwanese version of the World Health Organization Quality of Life-Brief (WHOQOL-BREF) assessment in schizophrenia patients. The WHOQOL-BREF is a cross-cultural and widely used measure for assessing health-related QOL. This brief version of the questionnaire derived from the concepts included in the 100-item WHOQOL questionnaire was adapted for use in Taiwan.

METHODS

In the current cross-sectional study, 104 patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for schizophrenia or schizoaffective disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria were recruited and independently interviewed using the Taiwanese version of the WHOQOL-BREF. Patients were also examined using various other scales assessing insight, symptom severity, general psychopathology, and antipsychotic-induced side effects. In addition, we analyzed demographic data, clinical variables, and several self-rating scales as correlates of the Taiwanese version of the WHOQOL-BREF.

RESULTS

As predicted, age, onset of illness, insight measures, symptom severity, general psychopathology, and antipsychotic-induced side effects were all significantly related to the QOL scores. Multiple regression analyses revealed that depressive symptoms, antipsychotic-induced parkinsonism side effects, hopelessness, and age at illness onset were the 4 strongest predictors of subjective QOL in schizophrenia patients. These variables accounted for 39.2% of the total variance of this QOL model.

CONCLUSIONS

The results suggest that the WHOQOL-BREF is a promising model for mental assessing health problems in schizophrenia patients. Furthermore, the present findings highlight the importance of understanding the complex nature of the concept of QOL. Our study also supports the belief that different domains of QOL are likely to have different predictors.

Longitudinal studies of cognition in first episode psychosis: a systematic review of the literature

Although cognitive deficits are recognized as a core feature in schizophrenia, their evolution over the course of the illness is still debated. Longitudinal studies of cognition in patients after a first episode of psychosis (FEP) provide extremely useful information, in that they include an adequate and realistic baseline measure of cognitive performance, while at the same time minimizing the effect of confounding variables associated with chronicity. The aim of this systematic review was to summarize findings of studies assessing the longitudinal course of neuropsychological deficits in patients with FEP for durations of at least one year. Overall, the neuropsychological deficits that are present following a first episode of psychosis appeared to remain stable over time for periods of up to ten years, the only possible exception being verbal memory deficits, where there is some evidence of further deterioration over the long term. However, further studies are needed to confirm this conclusion, especially in the (somewhat inconsistently defined) domain of executive function. Improvements in psychopathology appear to positively influence the course of cognitive deficits, although the effects of antipsychotic medication are not as clear.

Quality of life and cognitive dysfunction in people with schizophrenia

The main purpose of the present study was to examine the relationship between quality of life (QOL) and cognitive dysfunction in schizophrenia. Subjects were 61 stabilized outpatients. Quality of life and cognitive function were assessed using the Quality of Life Scale (QLS) and the Brief Assessment of Cognition in Schizophrenia (BACS), respectively. Clinical symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS). The BACS composite score and the BACS Verbal memory score were positively correlated with the QLS total score and two subscales. The BACS Attention and speed of information processing score had positive correlation with the QLS total and all the subscales scores. The PANSS Positive and Negative syndrome scores also had significant correlations with the QLS total score and all of the subscales. In addition, the CDSS score was negatively correlated with the QLS total score and some of the subscales. Stepwise regression analysis showed that the BACS Attention and speed of information processing score was an independent predictor of the QLS total score but it was less associated with the QLS than the PANSS Negative syndrome score and the CDSS score. The results suggest that negative and depressive symptoms are important factors on patients' QOL and also support the view that cognitive performance provides a determinant of QOL in patients with schizophrenia.

Psychosocial function in schizophrenia and bipolar disorder: Relationship to neurocognition and clinical symptoms

In line with a dimensional approach to psychopathology, we examined whether psychosocial function and its relationship to neurocognition and clinical symptoms differ across schizophrenia and bipolar disorder subgroups with and without a history of affective or psychotic episodes. From the TOP study, a heterogeneous sample of individuals with schizophrenia spectrum disorders without (n = 60) and with a history of affective episodes (n = 54); individuals with bipolar spectrum disorders with (n = 64) and without a history of psychosis (n = 56) and healthy controls (n = 268) participated. Psychosocial functioning was measured with the Social Functioning Scale (self-rated) and the Global Assessment of Functioning Scale (clinician-rated), neurocognition with a comprehensive neuropsychological test battery, and symptoms with Inventory of Depressive Symptomatology, Young Mania Rating Scale, and Positive and Negative Syndrome Scale. Clinician-rated functioning was poorer in schizophrenia groups than in bipolar groups, but self-rated functioning was similar across all clinical groups and poorer than in controls. Neurocognition and current clinical symptoms were associated with psychosocial function in bivariate analyses, but current symptoms had a greater independent contribution to functioning than neurocognition across clinical groups in multivariate analyses. Despite differences in neurocognition and psychosocial function, groups showed the same pattern in prediction of functioning irrespective of DSM-IV or clinical definition.

The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis

The current systematic review and meta-analysis provides an extended and comprehensive overview of the associations between neurocognitive and social cognitive functioning and different types of functional outcome. Literature searches were conducted in MEDLINE and PsycINFO and reference lists from identified articles to retrieve relevant studies on cross-sectional associations between neurocognition, social cognition and functional outcome in individuals with non-affective psychosis. Of 285 studies identified, 52 studies comprising 2692 subjects met all inclusion criteria. Pearson correlations between cognition and outcome, demographic data, sample sizes and potential moderator variables were extracted. Forty-eight independent meta-analyses, on associations between 12 a priori identified neurocognitive and social cognitive domains and 4 domains of functional outcome yielded a number of 25 significant mean correlations. Overall, social cognition was more strongly associated with community functioning than neurocognition, with the strongest associations being between theory of mind and functional outcomes. However, as three-quarters of variance in outcome were left unexplained, cognitive remediation approaches need to be combined with therapies targeting other factors impacting on outcome.

Pergolide treatment of cognitive deficits associated with schizotypal personality disorder: continued evidence of the importance of the dopamine system in the schizophrenia spectrum

Cognitive deficits observed in schizophrenia are also frequently found in individuals with other schizophrenia spectrum disorders, such as schizotypal personality disorder (SPD). Dopamine appears to be a particularly important modulator of cognitive processes such as those impaired in schizophrenia spectrum disorders. In a double-blind, placebo-controlled clinical trial, we administered pergolide, a dopamine agonist targeting D(1) and D(2) receptors, to 25 participants with SPD and assessed the effect of pergolide treatment, as compared with placebo, on neuropsychological performance. We found that the pergolide group showed improvements in visual-spatial working memory, executive functioning, and verbal learning and memory. These results suggest that dopamine agonists may provide benefit for the cognitive abnormalities of schizophrenia spectrum disorders.

Sex differences in neuropsychological functioning among schizophrenia patients

OBJECTIVES

Evidence from the literature addressing sex differences in cognition in schizophrenia remains equivocal, with some researchers suggesting that male schizophrenia patients are more impaired than female subjects, while others report no significant sex differences in cognitive functioning. The aim of the present study was to investigate whether the differential pattern of cognitive performance observed in healthy men and women is preserved in male and female schizophrenia patients.

METHOD

Ninety-six schizophrenia patients (56 men) were compared with 62 age- and gender-ratio matched healthy controls (31 men), on a battery of neuropsychological tests that assessed basic cognitive abilities: attention, working memory, abstraction, inhibition, fluency, verbal learning and memory, visual memory, visuospatial skills, and psychomotor speed.

RESULTS

As a group, schizophrenia patients were significantly impaired in each of the cognitive domains assessed, with the exception of psychomotor speed. The effect of sex was significant for verbal learning and memory, wherein women outperformed men. No significant group x sex interactions were found in any cognitive domains, indicating that the female advantage typically observed in verbal learning and memory remained the same in the schizophrenia patients.

CONCLUSION

The degree of cognitive impairment is the same for male and female schizophrenia patients. Those sex differences found among the patients were typical of the healthy population as well. Therefore, differential decrements in basic cognitive domains do not appear to account for the favourable course of schizophrenia in women relative to men.

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

BACKGROUND

Neurocognitive 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.

METHODS

A 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.

RESULTS

Although 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).

CONCLUSIONS

Although neurocognition and negative symptoms are both predictors of functional outcome, negative symptoms might at least partially mediate the relationship between neurocognition and outcome.

Relative contribution of antipsychotics, negative symptoms and executive functions to social functioning in stable schizophrenia

The purpose of this study was to examine the relative contributions of antipsychotic medication, negative symptoms and executive functions to impairment in social functioning in a sample of outpatients with stable schizophrenia. One-hundred and sixty-eight consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. We performed a path analysis using multiple regression technique in order to assess the specific effect of antipsychotic type (first-generation antipsychotics versus second-generation antipsychotics) on social functioning and the possible mediating role of executive functions and negative symptoms. Our findings suggested that (i) second generation antipsychotics (SGAs) use predicted better social functioning (Beta=.24, p=.003) and better executive functions (Beta=.25, p=.003); conversely SGAs use was not associated with lesser negative symptoms (Beta=.00, p=.981); (ii) impaired executive functions and severity of negative symptoms were associated with worse social functioning (Beta=.19, p=.016; Beta=.28, p=.001); (iii) when we inserted in the model Positive and Negative Syndrome Scale - Negative Symptom subscale (PANSS-N) and Wisconsin Card Sorting Test - number of achieved sorting categories (WCST-cat), the former failed to show a mediation effect, while the latter seemed to mediate partially the effect of SGAs on social functioning. Taken together, the present results suggest that it is critical to examine individually executive functions and negative symptoms because they seem to relate to social functioning in different and independent ways and thus might represent separable treatment targets. Furthermore, social functioning appears a complex outcome multiply determined with no single predictor variable explaining a sufficient amount of variance.

Relationship between psychosocial adjustment and executive function in patients with bipolar disorder and schizophrenia in remission: the mediating and moderating effects of insight

OBJECTIVES

The aims of this study were to examine the relationships between executive function and psychosocial adjustment, and the mediating and moderating effects of insight on the association between executive function and psychosocial adjustment in patients with bipolar disorder and schizophrenia in clinical remission.

METHODS

The level of psychosocial adjustment was assessed in 96 subjects with bipolar disorder and 96 subjects with schizophrenia who were in remitted state. The association between executive function and psychosocial adjustment and the mediating and moderating effects of insight were examined by multiple regression analysis models and the Goodman test.

RESULTS

The results indicated that executive function had direct effect on psychosocial adjustment in both subjects with bipolar disorder and schizophrenia. However, the mediating effect of insight on the association between executive function and psychosocial adjustment was only found in subjects with schizophrenia, but not in subjects with bipolar disorder. No moderating effect of insight on the association between executive function and psychosocial adjustment was found in subjects with schizophrenia or bipolar disorder.

CONCLUSIONS

The results of this study indicated that executive function has an important role in psychosocial adjustment in both patients with bipolar disorder and schizophrenia. Meanwhile, insight has a different role in the association between executive function and psychosocial adjustment between patients with bipolar disorder and schizophrenia.

Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia

OBJECTIVE

The quality of life (QOL) for individuals with schizophrenia is determined by a number of factors, not limited to symptomatology. The current study examined lack of insight as one such factor that may influence subjective QOL or functional capacity. It was hypothesized that insight would significantly interact with symptom severity to influence subjective QOL. Insight was not expected to influence the relation between symptom severity and functional capacity.

METHODS

Participants were middle-aged and older outpatients who met diagnostic criteria for schizophrenia or schizoaffective disorder, and subsyndromal depression. Insight, psychopathology, and subjective QOL were assessed via semi-structured interviews and functional capacity was assessed via performance-based measures.

RESULTS

Insight interacts with negative symptom severity to predict subjective QOL. Severity of negative symptoms and insight contribute directly to functional capacity.

CONCLUSIONS

Individuals with intact insight may be better able to manage their symptoms, resulting in improved QOL. Treatment implications for improving the QOL of middle age and older adults with schizophrenia are discussed.

Self-stigma, self-esteem and age in persons with schizophrenia

BACKGROUND

The relationship between self-stigma and self-esteem in patients with schizophrenia is receiving increased attention. However, studies to date have been limited to samples of persons under the age of 65.

AIM

To examine the relationship between self-stigma and self-esteem in people with schizophrenia in both younger and older age groups.

METHODS

Face-to-face interviews were completed with 86 inpatients with schizophrenia in a psychiatric hospital (mean age = 54, 55% female). Self-esteem was assessed using Rosenberg's Self Esteem Scale. Self-stigma was assessed using an adapted version of the Internalized Stigma of Mental Health (ISMI) scale. Information regarding socio-demographic characteristics and psychiatric history and symptomatology was collected.

RESULTS

Self-stigma was moderate with only 20-33% of the participants reporting high levels of stigmatization. Older participants reported lower levels of self-stigma than younger participants. A relatively strong association between self-stigma and self-esteem was found.

CONCLUSIONS

The findings point to the complexity of the association between self-stigma, self-esteem and age in people with schizophrenia. This study stresses the importance of clinicians taking the issue of self-stigma into consideration when treating young and old patients with schizophrenia.

Contribution of divergent thinking to community functioning in schizophrenia

Fluency deficits have been associated with poor community functioning in patients with schizophrenia. In our previous study we demonstrated that the ability to generate higher-quality responses on tasks of divergent thinking as measured by several fluency tests was impaired in patients with schizophrenia. The purpose of the present study was to investigate the contribution of the deficits in divergent thinking to community dysfunction in schizophrenia. Forty Japanese outpatients with schizophrenia and 32 healthy control subjects were recruited for this study and assessed over a broad spectrum of the neurocognitive domain. Their capacity for divergent thinking was assessed by idea, design, and word fluency tests. Community functioning was assessed by using the Global Assessment of Functioning (GAF), the Life Assessment Scale for the Mentally Ill (LASMI), and the Social Functioning Scale (SFS). The results confirmed the qualitative deficits of divergent thinking in schizophrenia. Stepwise multiple regressions using neurocognitive and demographic/clinical variables as predictors revealed that the higher-quality response scores on the tasks of divergent thinking significantly contributed to community functioning. Moreover, the deficit on the verbal task of divergent thinking significantly contributed to impairment in the area of daily living, and the deficit on the nonverbal task of divergent thinking significantly contributed to impairment in the area of interpersonal relations. The results of this study reveal the importance and the possibility of cognitive remediation and cognitive training with strategies that target capacity for divergent thinking to improve community functioning in patients with schizophrenia.