Predicting Attention-Shaping Response in People With Schizophrenia

ABSTRACT

People with schizophrenia often experience attentional impairments that hinder learning during psychological interventions. Attention shaping is a behavioral technique that improves attentiveness in this population. Because reinforcement learning (RL) is thought to be the mechanism by which attention shaping operates, we investigated if preshaping RL performance predicted level of response to attention shaping in people with schizophrenia. Contrary to hypotheses, a steeper attentiveness growth curve was predicted by less intact pretreatment RL ability and lower baseline attentiveness, accounting for 59% of the variance. Moreover, baseline attentiveness accounted for over 13 times more variance in response to attention shaping than did RL ability. Results suggest attention shaping is most effective for lower-functioning patients, and those high in RL ability may already be close to ceiling in terms of their response to reinforcers. Attention shaping may not be a primarily RL-driven intervention, and other mechanisms of its effects should be considered.

An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients

PURPOSE

This study aimed to examine the relationship between behavioral variables and aggression among severely and chronically mentally ill inpatients in a Social Learning Program (SLP) at a state psychiatric facility.

METHODS

Using archival data over a 24-month period, a total of 23 severely and chronically mentally ill inpatients comprised the sample in this study. The predictor variables included length of current hospitalization; length of stay on SLP; basic activities of daily living (ADLs); instrumental ADLs; attendance in programming; participation in programming; and the number of minor, major, and intolerable infractions received. The criterion variable was number of aggressive episodes (e.g., hitting persons or objects).

RESULTS

Results of a standard multiple regression analysis indicated an overall model of two predictors (intolerable infractions and instrumental ADLs) that significantly predicted number of aggressive episodes. Findings suggested that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities.

DISCUSSION

Our findings provide valuable information regarding aggressive tendencies that can inform treatment planning. Specifically, our results suggested there are not necessarily obvious warning signs for aggression among severely and persistently mentally ill inpatients. Rather, other individualized patient factors may be at play in the expression of aggressive impulses, emphasizing the importance of adequate staff-to-patient ratios so that care planning and implementation can be appropriately individualized.

Neural Correlates for Intrinsic Motivational Deficits of Schizophrenia; Implications for Therapeutics of Cognitive Impairment

The ultimate goal of the treatment of schizophrenia is recovery, a notion related to improvement of cognitive and social functioning. Cognitive remediation therapies (CRT), one of the most effective cognition enhancing methods, have been shown to moderately improve social functioning. For this purpose, intrinsic motivation, related to internal values such as interest and enjoyment, has been shown to play a key role. Although the impairment of intrinsic motivation is one of the characteristics of schizophrenia, its neural mechanisms remain unclear. This is related to the lack of feasible measures of intrinsic motivation, and its response to treatment. According to the self-determination theory (SDT), not only intrinsic motivation, but extrinsic motivation has been reported to enhance learning and memory in healthy subjects to some extent. This finding suggests the contribution of different types of motivation to potentiate the ability of the CRT to treat cognitive impairment of schizophrenia. In this paper, we provide a review of psychological characteristics, assessment methods, and neural correlates of intrinsic motivation in healthy subjects and patients with schizophrenia. Particularly, we focus on neuroimaging studies of intrinsic motivation, including our own. These considerations are relevant to enhancement of functional outcomes of schizophrenia.

An examination of neurocognition and symptoms as predictors of post-hospital community tenure in treatment resistant schizophrenia

Neurocognition and psychopathology are robust predictors of community functioning and relapse/rehospitalization in schizophrenia. Existing studies are however limited because they have ignored the most chronic, treatment-resistant patients. Moreover, the prediction of functional outcomes has yet to be extended to the duration of community tenure, an indicator of the capacity of chronically-hospitalized patients to gain traction in the community. The current study examined neurocognition and symptom severity at discharge as potential predictors of community tenure in chronically-hospitalized treatment-resistant patients. The study recruited 90 people with treatment-resistant schizophrenia who received services on an inpatient unit. Participants completed measures of psychopathology and neurocognition prior to discharge. Following discharge, participants were tracked at current residences six months and one year post-discharge to assess community tenure. The percentage of individuals who continued to live in the community at 12-month follow-up was 51%. Severe negative symptoms but not neurocognitive impairment or positive symptoms was a significant predictor of shorter post-hospital community tenure. Of the negative symptoms domain, anhedonia-asociality proved to be the most relevant predictor of community tenure in the sample. The capacity to elicit goal-directed behaviors in response to anticipated physical and social rewards may be an important treatment target for sustaining community tenure.

The role of academic psychiatry in leading health policy reform

The authors discuss the current state of mental health care reform and the opportunity for academic psychiatry to emerge in a leadership role in the organization and delivery of mental health care.

Enhancing and Promoting Recovery In Attentionally Impaired People Diagnosed With Schizophrenia: Results From A Randomized Controlled Trial Of Attention Shaping In A Partial Hospital Program

The attentional impairments associated with schizophrenia are well-documented and profound. Psychopharmacological and most psychosocial interventions have been shown to have limited effect in improving attentional capacity. That said, one form of psychosocial treatment, attention shaping procedures (ASP), has been repeatedly demonstrated to produce significant and meaningful change in various aspects of participant attentiveness behaviors. To date, studies of ASP have been limited in that they have been conducted primarily with inpatients, have not assessed the generalizability of ASP's effects, and have not explored whether reinforcement is required to be contingent on performance of attentive behaviors. To address these limitations we conducted the first randomized clinical trial of ASP with people diagnosed with schizophrenia who are being treated in a partial hospital program. Our results indicate that ASP is effective in improving attention in people with schizophrenia in these types of programs, the effects of ASP generalize outside of the immediate treatment context to both other treatment groups and real world functioning, and contingent reinforcement is a critical ingredient of ASP. This project provides further evidence for the benefits of use of ASP in the recovery-oriented treatment of people diagnosed with schizophrenia who have significant attentional impairments.

Jung's views on causes and treatments of schizophrenia in light of current trends in cognitive neuroscience and psychotherapy research II: psychological research and treatment

Jung was the first to emphasize the importance of psychological factors in the aetiology and treatment of schizophrenia. Despite this, and other seminal contributions, his work on schizophrenia is almost completely ignored or forgotten today. This paper, a follow-up to one on Jung's theories of aetiology and symptom formation in schizophrenia (Journal of Analytical Psychology, 59, 1) reviews Jung's views on psychological approaches to research on, and treatment of, the disorder. Five themes are covered: 1) experimental psychopathology; 2) attentional disturbance; 3) psychological treatment; 4) the relationship between the environment (including the psychiatric hospital) and symptom expression; and 5) heterogeneity and the schizophrenia spectrum. Review of these areas reveal that Jung's ideas about the kind of research that can elucidate psychological mechanisms in schizophrenia, and the importance of psychotherapy for people with this condition, are very much in line with contemporary paradigms. Moreover, further exploration of several points of convergence could lead to advances in both of these fields, as well as within analytical psychology.

Alogia and formal thought disorder: differential patterns of verbal fluency task performance

BACKGROUND

There is evidence that alogia and formal thought disorder (FTD), two prominent speech symptoms in schizophrenia, are associated with different patterns of verbal fluency task deficits. Verbal fluency is thought to involve several cognitive mechanisms, including controlled retrieval, semantic memory, and context processing.

METHODS

The current research examined whether alogia and FTD were associated with different patterns of verbal fluency performance and whether these patterns of verbal fluency performance would implicate deficits in controlled retrieval, semantic memory, or context processing. In the current research, 34 people with schizophrenia completed letter and category fluency tasks and detailed ratings of alogia and FTD symptoms were made from typed transcripts.

RESULTS

Overall, alogia was associated with increased response latency between each word on the category fluency task, suggesting an association between alogia and poor controlled retrieval. In contrast, FTD was associated with a decreased proportion of semantically-related words on letter fluency, suggesting an association between FTD and poor context processing.

CONCLUSIONS

Alogia and FTD appear to be associated with unique patterns of fluency performance, implicating separate cognitive mechanisms.

Bridging the gap between extrinsic and intrinsic motivation in the cognitive remediation of schizophrenia

An important development in cognitive remediation of schizophrenia is a focus on motivation. However, following a distinction between the concepts of intrinsic motivation (IM) and extrinsic motivation, discussions of IM-based methods have downplayed or misrepresented the role that extrinsic rewards can, and actually do, serve to promote positive treatment outcomes in cognitive remediation. Therefore, the purpose of this article is to explore the rationale for using techniques incorporating extrinsic rewards into cognitive treatment of people with schizophrenia. To do this, evidence is presented on each of the following points: (1) there is a long history of research demonstrating that delivery of extrinsic reward is associated with positive outcomes in both behavioral and cognitive rehabilitation; (2) basic human brain systems respond strongly to tangible rewards, and this can directly enhance attention, working memory, and other cognitive functions; (3) nearly all data on the negative effects of extrinsic reward on IM have come from studies of healthy children and adults in school or work settings who have adequate IM for target tasks; these findings do not generalize well to cognitive remediation settings for people with schizophrenia, who often have abnormally low levels of IM and low base rates of attentive behaviors; and (4) in real-world situations, cognitive remediation interventions already utilize a combination of intrinsic and extrinsic reinforcers. Future studies are needed to clarify state and trait factors responsible for individual differences in the extent to which extrinsic rewards are necessary to set the conditions under which IM can develop.

The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

The effects of antipsychotic medications on emotion perception in patients with chronic schizophrenia in the CATIE trial

Few pharmacological intervention studies have examined the impact of medication on social cognition, particularly emotion perception. The goal of this randomized, double-blind study is to compare the effects of several second generation antipsychotics and a first generation antipsychotic, perphenazine, on emotion perception in individuals with schizophrenia. Patients were assigned to receive treatment with olanzapine, queitapine fumarate, risperidone, ziprasidone or perphenazine for up to 18 months. Eight hundred and seventy three patients completed an emotion perception test immediately prior to randomization and after 2 months of treatment. We also examined baseline predictors of emotion perception change. Most treatments were associated with a small, non-statistically significant improvement in emotion perception at two months, although they did not differ from one another. Greater improvement in emotion perception at 2 months was significantly predicted by lower baseline emotion perception and higher baseline neurocognitive functioning, and marginally predicted by less time on an antipsychotic.

Attention shaping: a reward-based learning method to enhance skills training outcomes in schizophrenia

Disturbances in sustained attention commonly interfere with the ability of persons with schizophrenia to benefit from evidence-based psychosocial treatments. Cognitive remediation interventions have thus far demonstrated minimal effects on attention, as have medications. There is thus a gap between the existence of effective psychosocial treatments and patients' ability to effectively engage in and benefit from them. We report on the results of a multisite study of attention shaping (AS), a behavioral intervention for improving attentiveness and learning of social skills among highly distractible schizophrenia patients. Patients with chronic schizophrenia who were refractory to skills training were assigned to receive either the UCLA Basic Conversation Skills Module (BCSM) augmented with AS (n = 47) or in the standard format (n = 35). AS, a reward-based learning procedure, was employed to facilitate patients' meeting clearly defined and individualized attentiveness and participation goals during each session of a social skills training group. Primary outcome measures were observational ratings of attentiveness in each session and pre- and post-BCSM ratings of social skill and symptoms. Patients receiving social skills training augmented with AS demonstrated significantly more attentiveness in group sessions and higher levels of skill acquisition; moreover, significant relationships were found between changes in attentiveness and amount of skills acquired. Changes in attentiveness were unrelated to level or change in antipsychotic medication dose. AS is an effective example of supported cognition, in that cognitive abilities are improved within the environmental context where the patient is experiencing difficulty, leading to gains in both attention and functional outcome.

Measuring specific, rather than generalized, cognitive deficits and maximizing between-group effect size in studies of cognition and cognitive change

While cognitive impairment in schizophrenia is easy to demonstrate, it has been much more difficult to measure a specific cognitive process unconfounded by the influence of other cognitive processes and noncognitive factors (eg, sedation, low motivation) that affect test scores. With the recent interest in the identification of neurophysiology-linked cognitive probes for clinical trials, the issue of isolating specific cognitive processes has taken on increased importance. Recent advances in research design and psychometric theory regarding cognition research in schizophrenia demonstrate the importance of (1) maximizing between-group differences via reduction of measurement error during both test development and subsequent research and (2) the development and use of process-specific tasks in which theory-driven performance indices are derived across multiple conditions. Use of these 2 strategies can significantly advance both our understanding of schizophrenia and measurement sensitivity for clinical trials. Novel data-analytic strategies for analyzing change across multiple conditions and/or multiple time points also allow for increased reliability and greater measurement sensitivity than traditional strategies. Following discussion of these issues, trade-offs inherent to attempts to address psychometric issues in schizophrenia research are reviewed. Finally, additional considerations for maximizing sensitivity and real-world significance in clinical trials are discussed.

A scientific agenda for the concept of recovery as it applies to schizophrenia

Recovery is now a widely discussed concept in the field of research, treatment, and public policy regarding schizophrenia. As it has increasingly become a focus in mainstream psychiatry, however, it has also become clear both that the concept is often used in multiple ways, and that it lacks a strong scientific basis. In this review, we argue that such a scientific basis is necessary for the concept of recovery to have a significant long-term impact on the way that schizophrenia is understood and treated. The discussion focuses on key issues necessary to establish this scientific agenda, including: 1) differences in definitions of recovery and their implications for studying recovery processes and outcomes; 2) key research questions; 3) the implications of data from outcome studies for understanding what is possible for people diagnosed with schizophrenia; 4) factors that facilitate recovery processes and outcomes, and methods for studying these issues; and 5) recovery-oriented treatment, including issues raised by peer support. Additional conceptual issues that have not received sufficient attention in the literature are then noted, including the role of evidence-based practices in recovery-oriented care, recovery-oriented care for elderly people with schizophrenia, trauma treatment and trauma-informed care, and the role of hospitals in recovery-oriented treatment. Consideration of these issues may help to organize approaches to the study of recovery, and in doing so, improve the impact of recovery-based initiatives.

Heterogeneity in behavioral treatment response in severe mental illness

An exploratory investigation of behavioral treatment response during inpatient rehabilitation for severe mental illness is presented. Archival data from 26 weeks of behavioral contingency management (CM) programs targeting treatment nonadherence for 2 cohorts of participants were analyzed. For cohort 1 (N = 39), a multivariate analysis of longitudinal behavioral data identified 4 qualitatively and quantitatively distinct patterns of CM response and these groups differed in verbal memory ability. Analysis of cohort 2 (N = 45) replicated the finding of 4 patterns of CM response. We further clarified behavioral heterogeneity in cohort 2 by using hierarchical linear modeling with neurocognitive and social cognitive covariates. Results indicated that memory, attention, and a high external locus of control (LOC) were associated with level of nonadherence at baseline. Reductions in external locus of control were associated with greater CM response during the course of rehabilitation. Implications for understanding individual responses to the rehabilitation process are discussed.

Heterogeneity in recovery of psychosocial functioning during psychiatric rehabilitation: an exploratory study using latent growth mixture modeling

Research in schizophrenia and related severe mental illness (SMI) suggests that psychiatric rehabilitation facilitates recovery of psychosocial functioning although there is considerable heterogeneity in outcomes. The present study used growth mixture modeling (GMM), a longitudinal latent variable modeling strategy, to identify classes of psychosocial functioning recovery trajectories. Archival clinical assessment data representing the first 18 months of an inpatient psychiatric rehabilitation program were analyzed from a sample of participants with schizophrenia spectrum disorders (N=162). Based on a GMM analysis of monthly Nurse Observation Scale for Inpatient Evaluation (NOSIE) scores two classes were identified that differed in overall level of psychosocial functioning, rate and nonlinear shape of change. The identified lower functioning group was characterized by poorer neurocognitive functioning at admission, a history of negative symptoms, more previous inpatient psychiatric days, and a longer length of stay in the rehabilitation program. However, this group showed significantly greater positive change in the NOSIE domains directly targeted by behavioral treatment: daily schedule competence, neatness, and irritability. Methodological and theoretical implications of these modeling strategies are discussed in the context of understanding the rehabilitation process.