On the distinction between access and store disorders in schizophrenia: a question of deficit severity?

Exploring the conceptualisation, measurement, clinical utility and treatment of formal thought disorder in psychosis: A Delphi study

BACKGROUND

Formal Thought Disorder (FTD) is a recognised psychiatric symptom, yet its characterisation remains debated. This is problematic because it contributes to poor efficiency and heterogeneity in psychiatric research, with salient clinical impact.

OBJECTIVE

This study aimed to investigate expert opinion on the concept, measurement and clinical utility of FTD using the Delphi technique.

METHOD

Across three rounds, experts were queried on their definitions of FTD, methods for the assessment and measurement of FTD, associated clinical outcomes and treatment options.

RESULTS

Responses were obtained from 56 experts, demonstrating varying levels of consensus across different aspects of FTD. While consensus (>80 %) was reached for some aspects on the concept of FTD, including its definition and associated symptomology and mechanisms, others remained less clear. Overall, the universal importance attributed to the clinical understanding, measurement and treatment of FTD was clear, although consensus was infrequent as to the reasons behind and methods for doing so.

CONCLUSIONS

Our results contribute to the still elusive formal definition of FTD. The multitude of interpretations regarding these topics highlights the need for further clarity with this phenomenon. Our findings emphasised that the measurement and clinical utility of FTD are closely tied to the concept; hence, until there is agreement on the concept of FTD, difficulties with measuring and understanding its clinical usefulness to inform treatment interventions will persist. Future FTD research should focus on clarifying the factor structure and dimensionality to determine the latent structure and elucidate the core clinical phenotype.

Graph Analysis of Verbal Fluency Tests in Schizophrenia and Bipolar Disorder

Verbal Fluency Tests (VFT) are one of the most common neuropsychological tasks used in bipolar disorder (BD) and schizophrenia (SZ) research. Recently, a new VFT analysis method based on graph theory was developed. Interpreting spoken words as nodes and every temporal connection between consecutive words as edges, researchers created graph structures, allowing the extraction of more data from participants’ speech, called Speech Graph Attributes (SGA). The aim of our study was to compare speech graphs, derived from Phonemic and Semantic VFT, between SZ, BD, and healthy controls (HC). Twenty-nine SZ patients, twenty-nine BD patients, and twenty-nine HC performed Semantic and Phonemic VFT. Standard measures (SM) and 13 SGA were analyzed. SZ patients’ Semantic VFT graphs showed lower total word count and correct responses. Their graphs presented less nodes and edges, higher density, smaller diameter, average shortest path (ASP), and largest strongly connected component than the HC group. SM did not differentiate BD and HC groups, and patients’ Semantic VFT graphs presented smaller diameter and ASP than HC. None of the parameters differentiated BD and SZ patients. Our results encourage the use of speech graph analysis, as it reveals verbal fluency alterations that remained unnoticed in the routine comparisons of groups with the use SM.

Semantic Memory Impairment Across the Schizophrenia Continuum: A Meta-Analysis of Category Fluency Performance

Semantic memory (SM) impairments are a core feature of schizophrenia and are present along the psychosis continuum. It is, however, unclear whether the degree of SM impairments vary along this continuum and if demographic and clinical factors affect impairment severity. This study performed meta-analyses of category fluency task performance (a task commonly used to assess SM) in 4 groups along the schizophrenia continuum: high schizotypes (HSZT), first-degree relatives (FDR), recent-onset patients (≤2 y; ROP) and chronic patients (CSZ). Electronic databases were searched for relevant studies published up to October 2019 resulting in the inclusion of 48 articles. The main analyses assessed fluency productivity scores in 2978 schizophrenia spectrum disorder patients, 340 first-degree relatives of schizophrenia spectrum disorder patients, and 3204 healthy controls. Further analyses assessed errors, mean cluster size, and switching data that were available in the CSZ group only. Results revealed significant impairments in fluency productivity were present in the FDR, ROP, and CSZ groups relative to healthy controls, but not in HSZT. In the CSZ group, significant differences relative to healthy controls were also observed in non-perseverative errors, mean cluster size, and number of switches. The findings collectively suggest that SM deficits are present at each stage of the continuum and are exacerbated post-illness onset. They also support the centrality of SM impairments in schizophrenia and most elevated risk groups. Future studies with more diverse measures of SM function are needed to replicate and extend this research.

Cued fluency protocol reveals dynamic symptomatic-dependent processes of goal-directed behaviours in schizophrenia

INTRODUCTION

Differential impairments of willed actions and routine behaviours are the subject of many studies into schizophrenia. These impairments in generating and controlling goal-directed behaviours are reported in studies showing the effect of cueing in cognitive or motor tasks in people with schizophrenia. The aim of this study was to assess the performance of people with schizophrenia in a cued fluency protocol reworked to fit the concept of goal-directed behaviour. The extent to which results could be better explained by goal-directed generation issues, according to a symptomatic framework, than by semantic retrieval or semantic processing impairments, was also investigated.

METHODS

We compared the performance of 43 individuals with schizophrenia to a control group of 26 participants. Participants were assessed with neuropsychological tests. The dominance of positive and negative symptoms, and apathetic profile, were also evaluated. All participants completed a cued fluency protocol.

RESULTS

Despite a significant improvement, not all people with schizophrenia exhibited equal cueing benefits. The participants with negative symptom dominance appeared to benefit more from cueing, even though their baseline performance was lower.

CONCLUSIONS

These results suggest that, in addition to semantic memory impairments, some cognitive tasks may be more broadly influenced by difficulties in generating goal-directed behaviours.

Neuropsychology, autobiographical memory, and hippocampal volume in "younger" and "older" patients with chronic schizophrenia

Despite a wide range of studies on neuropsychology in schizophrenia, autobiographical memory (AM) has been scarcely investigated in these patients. Hence, less is known about AM in older patients and hippocampal contribution to autobiographical memories of varying remoteness. Therefore, we investigated hippocampal volume and AM along with important neuropsychological domains in patients with chronic schizophrenia and the respective relationships between these parameters. We compared 25 older patients with chronic schizophrenia to 23 younger patients and an older healthy control group (N = 21) with respect to AM, additional neuropsychological parameters, and hippocampal volume. Personal episodic and semantic memory was investigated using a semi-structured interview. Additional neuropsychological parameters were assessed by using a battery of standard neuropsychological tests. Structural magnetic resonance imaging data were analyzed with an automated region-of-interest procedure. While hippocampal volume reduction and neuropsychological impairment were more pronounced in the older than in the younger patients, both groups showed equivalent reduced AM performance for recent personal episodes. In the patient group, significant correlations between left hippocampal volume and recent autobiographical episodes as well as personal semantic memories arose. Verbal memory and working memory were significantly correlated with right hippocampal volume; executive functions, however, were associated with bilateral hippocampal volumes. These findings underline the complexity of AM and its impairments in the course of schizophrenia in comparison to rather progressive neuropsychological deficits and address the importance of hippocampal contribution.

Semantic memory impairment in schizophrenia--deficit in storage or access of knowledge?

This study evaluates whether patients with schizophrenia have a degraded memory store for semantic knowledge. 20 patients with a chronic history of schizophrenia and evidence of cognitive impairment were selected, since the literature indicates that this subgroup is most likely to manifest a degraded semantic knowledge store. Their profile of semantic memory impairments was compared to that of a group of Alzheimer's Dementia (AD) patients (n=22), who met neuropsychological criteria for degraded semantic store. Both groups were matched for Performance IQ. 15 elderly healthy controls were also included in the study. The AD and schizophrenia groups produced substantially different profiles of semantic memory impairment. This is interpreted as indicating that the semantic impairments in this subgroup of patients with schizophrenia do not result from a degraded store. This is corroborated by an analysis of the data using other neuropsychological criteria for determining degraded store. We conclude that there is little evidence for a classic degradation of semantic knowledge in schizophrenia, and it appears that impairments result from an inability to use semantic knowledge appropriately, particularly when selection of salient semantic relations is required.

Formal thought disorder is characterised by impaired lexical access

Recent studies have proposed that difficulty with accessing the lexical-semantic memory store may underpin some of the specific linguistic problems associated with formal thought disorder (FTD). We examined the consistency of name retrieval as an indicator of the ability to access lexical-semantic knowledge in patients with and without marked FTD to see if problems are specific to the former or common to schizophrenic patients in general. A graded naming test was administered on two separate occasions 8-16 weeks apart to 48 participants in three groups: 16 schizophrenic patients with high ratings of FTD, 16 schizophrenic patients with low ratings of FTD and 16 healthy controls. We compared the groups for naming consistency across time and the relationship between naming consistency and specific symptoms of FTD. Both patient groups had impaired naming and this was significantly greater in high than low FTD patients. The high FTD patients showed a profile that differed from both low FTD patients and healthy controls insofar as their naming was inconsistent across time, characteristic of an access disorder. Specifically, the FTD symptoms of derailment, tangentality and incoherence were related to the ability to access the lexical-semantic store. In conclusion, most patients with schizophrenia show an impaired semantic memory store. Nevertheless, FTD is associated with additional lexical-semantic difficulties that are quantitatively different to those seen in patients without FTD, and which may reflect disorganized semantic access.

Levels-of-processing effect on internal source monitoring in schizophrenia

BACKGROUND

Recognition can be normalized in schizophrenia by providing patients with semantic organizational strategies through a levels-of-processing (LOP) framework. However, patients may rely primarily on familiarity effects, making recognition less sensitive than source monitoring to the strength of the episodic memory trace. The current study investigates whether providing semantic organizational strategies can also normalize patients' internal source-monitoring performance.

METHOD

Sixteen clinically stable medicated patients with schizophrenia and 15 demographically matched healthy controls were asked to identify the source of remembered words following an LOP-encoding paradigm in which they alternated between processing words on a 'shallow' perceptual versus a 'deep' semantic level. A multinomial analysis provided orthogonal measures of item recognition and source discrimination, and bootstrapping generated variance to allow for parametric analyses. LOP and group effects were tested by contrasting recognition and source-monitoring parameters for words that had been encoded during deep versus shallow processing conditions.

RESULTS

As in a previous study there were no group differences in LOP effects on recognition performance, with patients and controls benefiting equally from deep versus shallow processing. Although there were no group differences in internal source monitoring, only controls had significantly better performance for words processed during the deep encoding condition. Patient performance did not correlate with clinical symptoms or medication dose.

CONCLUSIONS

Providing a deep processing semantic encoding strategy significantly improved patients' recognition performance only. The lack of a significant LOP effect on internal source monitoring in patients may reflect subtle problems in the relational binding of semantic information that are independent of strategic memory processes.

Are semantic deficits in schizophrenia due to problems with access or storage?

Semantic processing deficits are central to cognitive abnormalities in schizophrenia. Such semantic deficits may be related to either poor access or poor storage of semantic knowledge. 32 schizophrenia patients and 32 matched normal controls performed five semantic processing tasks that examined item-specific consistency over time, the word frequency effect and semantic priming. A subgroup of patients performed tasks on three separate occasions. It is generally assumed that a storage deficit is signalled by item-specific consistent performance, an exaggerated effect of word frequency, and the occurrence of hyperpriming; an access deficit is signalled by the absence of these effects. The data demonstrated item-specific consistency, a frequency effect and significant hyperpriming. The pattern is consistent with a storage deficit of semantic memory in schizophrenia.

Name relearning in elderly patients with schizophrenia: episodic and temporary, not semantic and permanent

INTRODUCTION

Recent reports of lexical-semantic deficits in patients with schizophrenia (Laws, Al-Uzri, & Mortimer, 2000; Laws, McKenna, & Kondel, 1998) suggest that younger patients have problems accessing intact memories and older patients show apparent "loss" of the lexical-semantic memory representations themselves.

METHODS

Picture naming for everyday items was examined in a unique series of elderly patients with schizophrenia (n = 10) with a mean illness duration of 45.5 years; and compared with that in patients with probable Alzheimer's disease (n = 18) and elderly healthy controls (n = 27). Naming consistency across time was used as an indicator of whether the schizophrenic patients had difficulty accessing representations or a loss of the representations themselves. Finally, we examined the ability of the schizophrenic patients to relearn the names of unnamed items across four weekly retraining sessions and to retain them at a one month follow-up.

RESULTS

The elderly schizophrenic patients were as anomic as patients with probable Alzheimer's disease. Consistency analysis revealed that the patients had storage deficits. Analysis of patient error types was consistent with a semantic deficit. Finally, the schizophrenic patients showed significant improvement with relearning, but this was not maintained at follow-up.

CONCLUSIONS

Elderly patients with schizophrenia show a profound and stable anomia. Although name relearning induced some significant gains in naming, these were short-term and reflect episodic rather than semantic reinstatement of representations. Implications for cognitive remediation are discussed.

Organization of semantic category exemplars in schizophrenia

Semantic memory was investigated in 27 individuals with schizophrenia and 30 healthy controls using an animal similarity judgment and organization test with reduced retrieval demands. Participants arranged 12 common animal names according to similarity on a computer screen and provided verbal descriptions of organizational strategies. Distance between each animal pair was compared to the number of shared semantic attributes between the pairs (e.g., size, diet, habitat). The three primary organizational strategies included single animals not related to other exemplars, isolated clusters of animals that shared a single strategic relationship (e.g., pets), and overlapping clusters that combined more than one strategic relationship (e.g., cats and mammals). A strong negative correlation was observed between distance ratings and number of shared semantic attributes, confirming that semantic features related to visual distances in both groups. Animal pairs that shared few semantic attributes were placed in closer proximity in the schizophrenia group, whereas the groups placed animal pairs sharing more features equidistantly. Analyses of clustering strategies revealed a double dissociation, with patients relying on isolated, non-overlapping clusters and controls producing more overlapping semantic clusters. Results suggest that performance differences on semantic tasks with limited retrieval demands in schizophrenia relate to difficulties utilizing higher-order categorization strategies.

Storage and access procedures in schizophrenia: evidence for a two phase model of lexical impairment

Evidence has accumulated to show that schizophrenia is characterized by lexical-semantic difficulties; however, questions remain about whether schizophrenics have problems in accessing intact representations or a loss of the representations themselves. Both access and storage types of disorder have been reported and it has been speculated that this may reflect a transition from the former to latter with increasing length of illness. This study investigated whether illness duration, age or estimated premorbid IQ predict the size and accessibility of the lexical store. Fifty-six schizophrenic patients (chosen to represent a wide range of illness duration from 3-40 years) and 24 matched healthy controls were asked to name 120 pictures on two occasions. Estimates of store size and retrieval probability were derived from a two parameter stochastic Markov chain model. This revealed that even early in the course of illness, schizophrenics appear to have suffered a reduction in lexical store size and that those with longer length of illness show deficits in both their store size and their ability to retrieve names from that store.

Validation of distinct amnesic and executive type memory deficit in a psychiatric sample based on retrieval performance

Studies of localized brain dysfunctions have revealed connections between patterns of cognitive dysfunction and specific profiles of memory impairment. The amnesic type of memory impairment is defined by deficits in both free recall and recognition memory, whereas the dysexecutive memory impairment is characterized by retrieval deficits, i.e. a disproportional impairment in free recall relative to recognition memory. The present study tests whether classifications of psychiatric patients into recall impaired only (= RO group) and Recall and Recognition impaired (= RR group) correspond to the executive type and amnesic type of memory impairment. The alternative hypothesis is that the two groups merely differ in degree of neuropsychological and psychiatric disturbance. Forty-four subjects impaired on California Verbal Learning Test (CVLT) were selected from a larger database of 103 impaired and non-impaired subjects with schizophrenia or recurrent major depression. Subjects were classified into RO and RR groups and compared on measures of memory strategy (recency effect and interference on CVLT), overall neuropsychological function (Stroop Test and WAIS-R similarity) and psychiatric symptom load (positive and negative symptoms). Repeated measures ANOVA showed no effects of group, i.e. the RR group did not perform consistently below the RO group with regard to memory strategy, neuropsychological function or psychiatric symptom load. Two out of three analyses showed group x test interaction, supporting the dissociation of distinct executive and amnesic profiles among psychiatric patients. The RO group was more susceptible to interference but had better recency score than the RR group. The RO had higher negative symptoms while the RR group had higher positive symptoms.

Category Content and Structure in Schizophrenia: An Evaluation Using the Instantiation Principle

In numerous studies, researchers have suggested anomalies in semantics in patients with schizophrenia. In this study, the authors addressed whether one such anomaly might reflect a difference in knowledge content or in the structure or organization of this information. Using a category member production task and a typicality rating task, the authors assessed knowledge content and found that patients' and control participants' knowledge about categories of foods and animals was very similar. In terms of structure, their findings from a mathematical model of category judgment (the instantiation model; E. Heit & L. W. Barsalou, 1996) revealed a similar category structure in patients and control participants. In conclusion, the authors suggest that the content and organization of categories in patients with schizophrenia is similar to that in healthy control participants.

An early marker for semantic memory impairment in patients with schizophrenia

INTRODUCTION

Semantic memory impairment is now a well-documented phenomenon in patients with schizophrenia. Nevertheless, the characteristics of this deficit and any early markers remain contentious.

METHODS

In this preliminary study, 12 schizophrenic patients underwent longitudinal assessment using a battery of semantic memory tests. Patient performance was compared to 12 matched controls. Using set criteria (derived from Warrington & Shallice, 1979), we examined whether the patients had a disorder affecting access to intact representations, or a degradation/loss of the representations themselves. The criteria were: consistency across time and modality, level of attribute information, and responsiveness to cueing. Finally, we compared patient naming for the same items across two naming tests (naming-to-description and picture naming) to determine cross-modality consistency.

RESULTS

As expected, normal controls outperformed the patients on all tests. Naming-to-description was the most significant differentiator between patients and controls. Patients were inconsistent across both time and modality, showed minimal attributional knowledge impairment, and improved significantly with cueing on two naming tests.

CONCLUSION

The profile of results indicates an access-type semantic deficit in this cohort of patients with schizophrenic. Finally, on a naming-to-description task, the patients failed to name up to 20% of items that they could name to picture. This suggests that naming-to-definition may act as an early marker of semantic memory impairment.

Scaling and clustering in the study of semantic disruptions in patients with schizophrenia: a re-evaluation

Some recent studies of semantics in schizophrenia have employed multidimensional scaling and clustering techniques to analyse verbal fluency and triadic comparison data. The conclusions have been: (i) patients generate fewer words in fluency tasks and display more variable similarity groupings of words in triadic tasks, and (ii) this is due to deficits in semantics. We analysed data from both tasks. On the verbal fluency task, patients produced significantly fewer responses than controls. The results also showed little patient-specific inter-individual consistency. Similarly, for triadic comparison data, we did not find much patient-specific inter-individual consistency. When correlating patients' results at different measurement times with means of controls, the data of individual patients (at either of the two measurement times) were not predicted better from their data at the other measurement time than from controls. This latter finding suggests little patient-specific intra-individual consistency and, thus, pleads against idiosyncratic semantic deficits. Our findings do not refute the hypothesis that schizophrenia is associated with semantic disruptions. However, our results demonstrate that because of severe statistical restrictions and requirements associated with some scaling and clustering techniques, these methods may not be as useful in this enterprise as previously thought.

Consciousness in schizophrenia: a metacognitive approach to semantic memory

Recent studies have shown that schizophrenia may be a disease affecting the states of consciousness. The present study is aimed at investigating metamemory, i.e., the knowledge about one's own memory capabilities, in patients with schizophrenia. The accuracy of the Confidence level (CL) in the correctness of the answers provided during a recall phase, and the predictability of the Feeling of Knowing (FOK) when recall fails were measured using a task consisting of general information questions and assessing semantic memory. Nineteen outpatients were paired with 19 control subjects with respect to age, sex, and education. Results showed that patients with schizophrenia exhibited an impaired semantic memory. CL ratings as well as CL and FOK accuracy were not significantly different in the schizophrenic and the control groups. However, FOK ratings were significantly reduced for the patient group, and discordant FOK judgments were also observed more frequently. Such results suggest that FOK judgments are impaired in patients with schizophrenia, which confirms that schizophrenia is an illness characterized by an impaired conscious awareness of one's own knowledge.

Lexical knowledge degradation in schizophrenia

This study documents a severe picture naming impairment in a series of 22 chronically hospitalised schizophrenics. The pattern and level of naming impairment were comparable in degree and type to that seen neurological patients with left hemisphere lesions. This deficit was further examined to determine whether it conformed to a disorder affecting access to the lexical representations or some degradation of the stored representations themselves. Patient naming was examined twice (18months apart) for evidence of consistency and for word frequency effects. The pattern of individual patient performance on these criteria showed that the majority had storage disorders; access disorders alone occurred in only a small minority of patients. A subset of 11 of the same patients that were tested on three occasions (across 30months) showed the same pattern but further indicated that when access problems are present, they reflect difficulty with deliberate, rather than automatic, access to the lexicon.