Social cognition and functional capacity in bipolar disorder and schizophrenia

Functioning Management and Recovery, a psychoeducational intervention for psychiatric residential facilities: a multicenter follow-up study

AIM

Functional Management and Recovery is a standardized Psychoeducational Intervention, derived from "Integro", an effective salutogenic-psychoeducational intervention for people in recovery journey, designed to improve recovery and functioning of individuals with psychotic disorders in Psychiatric Residential Facilities (PRFs). The aim of this study is to evaluate the primary and secondary outcomes of this intervention elaborated specifically for PRFs where evidence based structured interventions seem rare and desirable.

METHODS

66 individuals with psychotic disorders were recruited in 9 PRFs dislocated in the North, Center and South Italy and 63 underwent a multicenter follow-up study with a two time-point evaluation (t0, pre-treatment and t1, 6 months; ). At each time point, social functioning was assessed as primary outcome by the Personal and Social Performance scale (PSP); furthermore, psychopathological status was assessed by Brief Psychiatric Rating Scale (BPRS), Recovery by Recovery Assessment Scale (RAS), Cognitive Functioning by Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Stress management by Stress-Scale, Cognitive Flexibility by Modified Five-Point Test (M-FPT), Emotional Intelligence by Emotional Intelligence Index (EI-I), the PRF Atmosphere and the Opinion of users about the PFR by an ad hoc questionnaire. The Abilities Knowledge, the Utility and Pleasantness of sessions were measured by an ad hoc list of items.

RESULTS

63 individuals out of 66, 52 (82,5%) affected by schizophrenia and 11 (17,5%) by bipolar I disorder with psychotic symptoms according to DSM-5-TR completed the study. At the end of the study, 43 (68,3%) were male, 57 (90.5%) were single, 5 (7.9%) engaged, 1 (1.6%) married; 45 (71.4%) unemployed. The total scores of PSP, RAS, BPRS, BANS, Stress management, Abilities Knowledge, Utility and Pleasantness of sessions showed a statistically significant improvement at t1 vs. t0. Two sub-scales out of 5 of M-FPT showed a statistically significant improvement. The Emotional Intelligence, the Unit Atmosphere and the Opinion of Users about PFR improved without statistical significance. Six months after the end of the follow-up study 22 individuals of the sample were dismissed with a very high turnover.

CONCLUSIONS

After a six-month follow-up (a short period of time), these results showed improvement in functioning, the primary outcome, as well as in the following secondary outcome variables: RAS, BPRS, BANS, Stress management, Abilities Knowledge, two sub-scales out of 5 of M-FPT, Utility and Pleasantness of sessions. Overall, a remarkable impact of psychoeducational structured intervention on the key Recovery variables is observed. Further studies are needed to address extent and duration of these improvements.

Social Cognition in Children With ADHD

Objective: Despite evidence of social skill deficits in children with ADHD, there is no consensus regarding a social cognitive profile and whether these skills predict behavior. Therefore, a comprehensive battery was used to investigate the relationship between social cognition and behavioral functioning. Method: Children ages 7 to 13 with ADHD (n = 25) and controls (n = 25) completed tests assessing social cognitive domains (affect recognition and theory of mind [ToM]). Parents completed measures of social cognition (pragmatic language ability and empathy), behavioral symptoms, and adaptive functioning. Results: Children with ADHD performed significantly worse on measures of cognitive ToM and affect recognition and received lower ratings of pragmatic language and cognitive empathy than typically developing peers. These domains, particularly pragmatic language, predicted parent ratings of problematic and adaptive behaviors. Conclusion: Results establish a relationship between specific social cognitive abilities and daily functioning, which has implications for treatment.

Effects of vortioxetine on functional capacity across different levels of functional impairment in patients with major depressive disorder: a University of California, San Diego Performance-based Skills Assessment (UPSA) analysis

Objective: To evaluate the consistency of vortioxetine's effects on functional capacity in adults with major depressive disorder (MDD) and self-reported cognitive symptoms at different levels of functional impairment.Methods: An exploratory analysis of data from a randomized, placebo-controlled, duloxetine-referenced study (NCT01564862) involving 529 patients with moderate to severe MDD treated once-daily with vortioxetine 10/20 mg, duloxetine 60 mg, or placebo for 8 weeks. Analysis of the University of California, San Diego Performance-based Skills Assessment (UPSA) composite scores stratified patients into subgroups by baseline functional impairment and assessed clinically important differences using several cutoffs for change from baseline (CFB) (least-square means) in UPSA composite score. A path analysis was also conducted to determine the proportion of direct versus indirect effects of vortioxetine on functional capacity.Results: Vortioxetine significantly separated from placebo across different baseline levels of functional impairment, particularly at the ≤70 cutoff (mean difference = 5.9, 95% confidence interval, 1.5-10.4). A greater proportion of patients treated with vortioxetine than placebo exhibited UPSA composite score response at each threshold analyzed and were classified as responders based on UPSA CFB of ≥7 (p = 0.006) or ≥9 (p = 0.016). No significant effects were observed for duloxetine versus placebo for any baseline levels of functional impairment or response thresholds. Path analysis demonstrated that 96.9% of the effects on functional capacity can be directly attributed to the treatment effect of vortioxetine and are not mediated by improvements in depressive symptoms as measured by MADRS.Conclusion: The effects of vortioxetine on functional capacity is robust across different level of functional impairment in patients with MDD. The effect on functional capacity was largely independent of the effect on depressive symptoms. Trial Registration: ClinicalTrials.gov identifier: NCT01564862: https://clinicaltrials.gov/ct2/show/NCT01564862; European Clinical Trials Database [EudraCT] Number 2011-005298-22: https://www.clinicaltrialsregister.eu/ctr-search/trial/2011-005298-22/DE.

Alexithymia predicts poorer social and everyday functioning in schizophrenia and bipolar disorder

Alexithymia, or the inability to identify and describe one's emotions, is significantly higher in bipolar disorder (BD) and schizophrenia (SZ), compared to healthy controls (HC). Alexithymia has also been observed to predict psychosocial functioning in SZ. We investigated whether alexithymia predicted social and everyday functioning in BD, as well as transdiagnostically in HC, BD, and SZ patients. 56 BD, 45 SZ, and 50 HC were administered and compared on tests measuring neurocognition, social cognition, functioning and alexithymia. We conducted linear regressions assessing whether alexithymia predicted functional outcomes in BD. Next, we conducted hierarchical stepwise linear regressions investigating the predictive ability of neurocognition, social cognition and alexithymia on everyday and social functioning in our overall sample. BD and SZ patients were comparable on most demographics and demonstrated higher alexithymia compared to HCs. In BD, alexithymia predicted social functioning only. In the overall sample, difficulty identifying and describing feelings predicted everyday functioning; difficulty describing feelings predicted social functioning. Results suggest that aspects of alexithymia significantly predict functioning among these psychiatric groups, above and beyond the contributions of previously identified factors such as neurocognition and social cognition. Results may aid in developing proper interventions aimed at improving patients' ability to articulate their feelings.

A systematic review of a functional assessment Tool: UCSD Performance-based skill assessment (UPSA)

Performance based assessment instruments have been employed in functional capacity measurement of mental disorders. The aim of this systematic review was to identify the psychometric properties of the UCSD Performance-based Skill Assessment (UPSA). A search was conducted using the PRISMA protocol and 'UPSA' as key word term on electronic databases, with a date range for articles published from 2001-2017. Published studies involving community-dwelling adults were included. Pharmacological and/or clinical interventions involving clinical outcomes and/or institutionalized samples were excluded. Data related to construct validity, test-retest reliability and sensitivity/specificity were extracted, summarized and analyzed according to UPSA versions and psychiatric disorders. Fifty-eight studies including 8782 Community-dwelling adults met selection criteria. Data supporting the construct and known-groups validity were extracted from 41 studies involving Schizophrenia and schizoaffective disorders and 17 studies involving other metal illness. The UPSA was culturally adapted to 8 different languages and employed in 17 countries. Few studies reported sensitivity and specificity and the cut-off points could not be generalized. Moderate to strong evidence of construct validity and test-retest reliability was found. Few studies proposed cut-off points. The UPSA showed good psychometric properties in different versions including those culturally adapted.

Social cognition moderates the relationship between neurocognition and community functioning in bipolar disorder

BACKGROUND

Schizophrenia (SZ) studies suggest that neurocognition predicts functional outcome and that social cognition mediates this relationship. Bipolar disorder (BD) patients also have cognitive, social, and functional impairments but the relationship among these factors in BD is not well established. We assessed whether social cognition modulates the influence of neurocognition on community functioning in BD, as found in SZ.

METHODS

200 BD patients and 49 healthy controls (HC) were administered and compared on a battery of tests assessing neurocognition, social cognition, and community functioning. We conducted a series of regression analyses to investigate potential mediation or moderation of social cognition on the relationship between neurocognition and community functioning.

RESULTS

BD patients performed worse on neurocognitive domains of processing speed, attention, verbal learning, and global neurocognition. Also, BD patients performed worse on theory of mind, the social cognition composite score, and community functioning. Neurocognition did not significantly predict functional outcome in our BD sample. However, we found a moderating effect of social cognition: among patients with poor social cognition, better neurocognition was associated with better community functioning, a relationship not seen in BD patients with good social cognition.

LIMITATIONS

The study was limited by a relatively small HC group and assessing one subtype of functioning status.

CONCLUSIONS

The relationship between neurocognition and community functioning in BD may be dependent on social cognition status, implying the presence of social cognitive heterogeneity. Results may be relevant to choosing proper treatment interventions depending on the patient's social cognitive level.

Interplay Among Psychopathologic Variables, Personal Resources, Context-Related Factors, and Real-life Functioning in Individuals With Schizophrenia: A Network Analysis

Importance

Enhanced understanding of factors associated with symptomatic and functional recovery is instrumental to designing personalized treatment plans for people with schizophrenia. To date, this is the first study using network analysis to investigate the associations among cognitive, psychopathologic, and psychosocial variables in a large sample of community-dwelling individuals with schizophrenia.

Objective

To assess the interplay among psychopathologic variables, cognitive dysfunctions, functional capacity, personal resources, perceived stigma, and real-life functioning in individuals with schizophrenia, using a data-driven approach.

Design, Setting, and Participants

This multicenter, cross-sectional study involved 26 university psychiatric clinics and/or mental health departments. A total of 921 community-dwelling individuals with a DSM-IV diagnosis of schizophrenia who were stabilized on antipsychotic treatment were recruited from those consecutively presenting to the outpatient units of the sites between March 1, 2012, and September 30, 2013. Statistical analysis was conducted between July 1 and September 30, 2017.

Main Outcomes and Measures

Measures covered psychopathologic variables, neurocognition, social cognition, functional capacity, real-life functioning, resilience, perceived stigma, incentives, and service engagement.

Results

Of 740 patients (221 women and 519 men; mean [SD] age, 40.0 [10.9] years) with complete data on the 27 study measures, 163 (22.0%) were remitted (with a score of mild or better on 8 core symptoms). The network analysis showed that functional capacity and everyday life skills were the most central and highly interconnected nodes in the network. Psychopathologic variables split in 2 domains, with positive symptoms being one of the most peripheral and least connected nodes. Functional capacity bridged cognition with everyday life skills; the everyday life skills node was connected to disorganization and expressive deficits. Interpersonal relationships and work skills were connected to avolition; the interpersonal relationships node was also linked to social competence, and the work skills node was linked to social incentives and engagement with mental health services. A case-dropping bootstrap procedure showed centrality indices correlations of 0.75 or greater between the original and randomly defined samples up to 481 of 740 case-dropping (65.0%). No difference in the network structure was found between men and women.

Conclusions and Relevance

The high centrality of functional capacity and everyday life skills in the network suggests that improving the ability to perform tasks relevant to everyday life is critical for any therapeutic intervention in schizophrenia. The pattern of network node connections supports the implementation of personalized interventions.

Impairment in emotion perception from body movements in individuals with bipolar I and bipolar II disorder is associated with functional capacity

Background

Individuals with bipolar disorder present with moderate impairments in social cognition during the euthymic state. The impairment extends to theory of mind and to the perception of emotion in faces and voices, but it is unclear if emotion perception from body movements is affected. The main aim of this study was to examine if participants with bipolar disorder perform worse than healthy control participants on a task using point-light displays of human full figures moving in a manner indicative of a basic emotion (angry, happy, sad, fearful, neutral/no emotion). A secondary research question was whether diagnostic subtypes (bipolar I, bipolar II) and history of psychosis impacted on this type of emotion perception. Finally, symptomatic, neurocognitive, and functional correlates of emotion perception from body movements were investigated.

Methods

Fifty-three individuals with bipolar I (n = 29) or bipolar II (n = 24) disorder, and 84 healthy control participants were assessed for emotion perception from body movements. The bipolar group also underwent clinical, cognitive, and functional assessment. Research questions were analyzed using analyses of variance and bivariate correlations.

Results

The bipolar disorder group differed significantly from healthy control participants for emotion perception from body movements (Cohen’s d = 0.40). Analyses of variance yielded no effects of sex, diagnostic subtype (bipolar I, bipolar II), or history of psychosis. There was an effect of emotion, indicating that some emotions are easier to recognize. The lack of a significant group × emotion interaction effect points, however, to this being so regardless of the presence of bipolar disorder. Performance was unrelated to manic and depressive symptom load but showed significant associations with neurocognition and functional capacity.

Conclusions

Individuals with bipolar disorder had a small but significant impairment in the ability to perceive emotions from body movement. The impairment was global, i.e., affecting all emotions and equally present for males and females. The impairment was associated with neurocognition and functional capacity, but not symptom load. Our findings identify pathopsychological factors underlying the functional impairment in bipolar disorder and suggest the consideration of social cognition training as part of the treatment for bipolar disorder.

Association of Fluid Intelligence and Psychiatric Disorders in a Population-Representative Sample of US Adolescents

IMPORTANCE

Despite long-standing interest in the association of psychiatric disorders with intelligence, few population-based studies of psychiatric disorders have assessed intelligence.

OBJECTIVE

To investigate the association of fluid intelligence with past-year and lifetime psychiatric disorders, disorder age at onset, and disorder severity in a nationally representative sample of US adolescents.

DESIGN, SETTING, AND PARTICIPANTS

National sample of adolescents ascertained from schools and households from the National Comorbidity Survey Replication-Adolescent Supplement, collected 2001 through 2004. Face-to-face household interviews with adolescents and questionnaires from parents were obtained. The data were analyzed from February to December 2016. DSM-IV mental disorders were assessed with the World Health Organization Composite International Diagnostic Interview, and included a broad range of fear, distress, behavior, substance use, and other disorders. Disorder severity was measured with the Sheehan Disability Scale.

MAIN OUTCOMES AND MEASURES

Fluid IQ measured with the Kaufman Brief Intelligence Test, normed within the sample by 6-month age groups.

RESULTS

The sample included 10 073 adolescents (mean [SD] age, 15.2 [1.50] years; 49.0% female) with valid data on fluid intelligence. Lower mean (SE) IQ was observed among adolescents with past-year bipolar disorder (94.2 [1.69]; P = .004), attention-deficit/hyperactivity disorder (96.3 [0.91]; P = .002), oppositional defiant disorder (97.3 [0.66]; P = .007), conduct disorder (97.1 [0.82]; P = .02), substance use disorders (alcohol abuse, 96.5 [0.67]; P < .001; drug abuse, 97.6 [0.64]; P = .02), and specific phobia (97.1 [0.39]; P = .001) after adjustment for a wide range of potential confounders. Intelligence was not associated with posttraumatic stress disorder, eating disorders, and anxiety disorders other than specific phobia, and was positively associated with past-year major depression (mean [SE], 100 [0.5]; P = .01). Associations of fluid intelligence with lifetime disorders that had remitted were attenuated compared with past-year disorders, with the exception of separation anxiety disorder. Multiple past-year disorders had a larger proportion of adolescents less than 1 SD below the mean IQ range than those without a disorder. Across disorders, higher disorder severity was associated with lower fluid intelligence. For example, among adolescents with specific phobia, those with severe disorder had a mean (SE) of 4.4 (0.72) points lower IQ than those without severe disorder (P < .001), and those with alcohol abuse had a mean (SE) of 5.6 (1.2) points lower IQ than those without severe disorder (P < .001).

CONCLUSIONS AND RELEVANCE

Numerous psychiatric disorders were associated with reductions in fluid intelligence; associations were generally small in magnitude. Stronger associations of current than past disorders with intelligence suggest that active symptoms of psychiatric disorders interfere with cognitive functioning. Early identification and treatment of children with mental disorders in school settings is critical to promote academic achievement and long-term success.

Evidence for social cooperation in rodents by automated maze

Social cooperation is defined as a joint action for mutual benefit that depends on the individual and the counterparts’ behaviors. To gain valid evidence for social cooperation behavior we conducted a series of experiments in our suggested fully automated non-conditioned maze and depicted three major findings: (i) During 18 days of training the rats showed a progressive social learning curve as well as latent social learning; (ii) Examining the perceptual communication between the cooperating partners, we found a correlation between the available perceptual modalities and the social cooperation performance; and (iii) Investigating contextual learning as a competing process to the social cooperation, we found that additional contextual cues impaired the social cooperation performance. In conclusion, our suggested automated cooperation maze is designed to further our understanding of social cooperation under normal conditions, such as decision-making, and to examine the neural basis of social cooperation. A variety of neuropsychiatric disorders are characterized by disruptions in social behavior and social cognition, including depression, autism spectrum disorders, obsessive-compulsive disorder, and schizophrenia. Thus, on the pathological end, our maze for social cooperation evaluation can contribute significantly to the investigation of a wide range of social cooperation impairments in a rodent model.

Auditory processing deficits in bipolar disorder with and without a history of psychotic features

OBJECTIVES

Auditory perception deficits have been identified in schizophrenia (SZ) and linked to dysfunction in the auditory cortex. Given that psychotic symptoms, including auditory hallucinations, are also seen in bipolar disorder (BD), it may be that individuals with BD who also exhibit psychotic symptoms demonstrate a similar impairment in auditory perception.

METHODS

Fifty individuals with SZ, 30 individuals with bipolar I disorder with a history of psychosis (BD+), 28 individuals with bipolar I disorder with no history of psychotic features (BD-), and 29 normal controls (NC) were administered a tone discrimination task and an emotion recognition task.

RESULTS

Mixed-model analyses of covariance with planned comparisons indicated that individuals with BD+ performed at a level that was intermediate between those with BD- and those with SZ on the more difficult condition of the tone discrimination task and on the auditory condition of the emotion recognition task. There were no differences between the BD+ and BD- groups on the visual or auditory-visual affect recognition conditions. Regression analyses indicated that performance on the tone discrimination task predicted performance on all conditions of the emotion recognition task. Auditory hallucinations in BD+ were not related to performance on either task.

CONCLUSIONS

Our findings suggested that, although deficits in frequency discrimination and emotion recognition are more severe in SZ, these impairments extend to BD+. Although our results did not support the idea that auditory hallucinations may be related to these deficits, they indicated that basic auditory deficits may be a marker for psychosis, regardless of SZ or BD diagnosis.

Theory of Mind in Bipolar Disorder, with Comparison to the Impairments Observed in Schizophrenia

Our ability to make sense of information on the potential intentions and dispositions of others is of paramount importance for understanding their communicative intent, and for judging what an appropriate reaction might be. Thus, anything that impinges on this ability has the potential to cause significant social impairment, and compromise an individual's level of functioning. Both bipolar disorder and schizophrenia are known to feature theory of mind impairment. We conducted a theoretical review to determine the extent and types of theory of mind impairment in bipolar disorder, and evaluate their relationship to medication and symptoms. We also considered possible mediatory mechanisms, and set out to discover what else could be learnt about the impairment in bipolar disorder by comparison to the profile of impairment in schizophrenia. The literature established that in bipolar disorder (i) some form of theory of mind impairment has been observed in all mood states, including euthymia, (ii) the form of theory of mind assessed and task used to make the assessment influence the impairment observed, and (iii) there might be some relationship to cognitive impairment, although a relationship to standard clinical variables was harder to establish. What also became clear in the literature on bipolar disorder itself was the possible relationship of theory of mind impairment to history of psychotic symptoms. Direct comparative studies, including patients with schizophrenia, were thus examined, and provided several important directions for future research on the bases of impairment in bipolar disorder. Particularly prominent was the issue of whether theory of mind impairment could be considered a candidate endophenotype for the psychoses, although current evidence suggests that this may be premature. The differences in impairment across schizophrenia and bipolar disorder may, however, have genuine differential effects on social functioning and the likely success of remediation.