Schizophrenia and Neurorehabilitation

Clinical psychologist and Neuropsychology professor, Feliz Inchausti, presents in this article an approach to schizophrenia and neurorehabilitation.

Intervention targeting neurocognitive deficits is an essential element in current psychosocial rehabilitation programs for psychotic spectrum disorders and especially for schizophrenia (Gold, 2004). Among the most common neurocognitive deficits in schizophrenia are slowed processing speed of information, problems with attention/vigilance, working memory, verbal and visual learning, reasoning and problem solving (MATRICS Consensus, 2005). Approximately 90% of patients diagnosed with schizophrenia show clinically significant impairment in at least one of these areas and 75% in two (Palmer et al, 1997). For this reason it is common to refer to schizophrenia as a disorder that causes a widespread neurocognitive dysfunction (Schmidt, Mueller, & Roder, 2011).

The neurocognitive deficits of schizophrenia are especially relevant because they correlate with the capacity for self-care, social functioning and employment (Addington, Saeedi, & Addington, 2006), both cross-sectionally and longitudinally (Brekke et al 2007). For example, attention/vigilance has been found to be particularly associated with social functioning, memory and verbal learning with level of social and occupational independence, executive functions with degree of independence, and processing speed with work capacity (Kurtz, Moberg, Gur, 2001). These deficits are, moreover, better predictors of functioning than the positive symptoms of schizophrenia (Green, Kern, Heaton, 2004) and can determine the clinical course of the disorder. For example, memory problems –especially prospective memory– can affect adherence to pharmacological treatments (e.g., not remembering when and why to take the medication) and psychotherapeutic treatments (Moritz et al., 2013). Problems with attention, reasoning and memory can, in turn, limit the ability to understand and internalize the knowledge and skills acquired in psychotherapies specific to schizophrenia and, therefore, prevent the proper transfer of learned skills to everyday life.

The causes underlying these neurocognitive deficits are multiple. Aside from early deficits (or neurodevelopmental ones) that usually manifest before the onset of a first psychotic episode (Bang et al, 2014 Corigliano et al, 2014), abulia, apathy, lack of stimulating environments or prolonged hospitalizations have a negative impact on these individuals’ neurocognition (Moritz et al, 2015). Some recent studies have suggested that the use of (conventional) antipsychotics might also affect neurocognition (Ho et al, 2011; Gassó et al, 2012). Although the adverse effects of antipsychotics on neurocognition are clearly undesirable, there is data supporting the fact that they are precisely the mechanism through which antipsychotics reduce positive symptoms (the “effect by default” hypothesis; (Moritz et al, 2013). Specifically, it has been proposed that the decrease in processing speed and the increase in doubt associated with the use of antipsychotics could be a prerequisite for being able to work on positive symptoms (delusions and hallucinations).

Unfortunately, there are still no completely effective treatment options to reverse neurocognitive deficits. The use of atypical antipsychotics as enhancers of neurocognition has not met expectations (Davidson et al, 2009; Keefe Harvey, 2012) and the option that has received the most empirical support to date is cognitive remediation therapy (abbreviated CRT in English, Cognitive Remediation Therapy). Recent meta-analyses have indicated that CRT produces small to moderate effects on neurocognition (McGurk et al, 2007; Wykes et al, 2011). Nevertheless, the impact of CRT on positive symptoms is still limited (Wykes et al, 2011) and it has not managed to improve per se the personal, social and occupational functioning of people undergoing this type of intervention (Piskulic et al, 2015). In any case, it seems that presenting good neurocognitive functioning is a “necessary but not sufficient prerequisite” for good psychosocial functioning (Mehta et al, 2013). In short, it is relevant to direct attention to the neurocognitive processes that more specifically underlie the way we function day-to-day to improve current CRT programs. For example, more than a century ago, Eugen Bleuler (1911), in his well-known model of the 4 A’s (i.e., disturbances in association, affectivity, autism and ambivalence), already suggested that it was necessary to attend to other psychic processes beyond the symptoms of schizophrenia. Specifically, Bleuler focused his attention on the processes by which complex ideas about oneself and others are formed and integrated. From a neurofunctional approach, Donald Stuss (2011) has proposed a frontal lobe and executive functions model divided into 4 major groups of mental processes.

Groups of mental processes:

• High-level executive cognitive functions (i.e., planning, monitoring, inhibition or cognitive flexibility) located in the regions of the dorsolateral prefrontal cortex;
• Functions of emotional and behavioral self-regulation, that is, the mental processes underlying decision-making and responding in contexts of gain and loss where experience or environmental cues are not useful, and which are located in regions of the ventromedial prefrontal cortex.

Both processes correspond to the traditional division of executive functions. Stuss adds two more groups:

• the mental processes, perhaps more physiological, related to the regulation of levels of activation or arousal and which would include apathy, abulia and the lack of motivation characteristic of patients with lesions in the superior fronto-medial regions –and in patients with psychosis–;
• and the metacognitive processes that would encompass everything related to integrating information from all the previous levels, one’s own personality, intersubjectivity and self-awareness to initiate behaviors aimed at long-term goals… and that would be located in the frontopolar areas, especially of the right hemisphere.

This model emphasizes that it is most desirable for training programs in neurocognitive functions of high (planning, cognitive flexibility…) and low level (attention, memory…) to occupy at most 1/4 of the total intervention time. Thus, a holistic intervention should include programs for training in emotional and behavioral self-regulation, strategies for activation and motivation, and metacognition (Inchausti et al, in press).

It seems that Bleuler’s and Stuss’s hypotheses, a century apart, converge on the need to pay more attention to metacognitive or integrative processes, that is, the ability to form integrated ideas about oneself, others and the world to respond adaptively. An integrated definition of metacognition includes related concepts such as social cognition, mentalization or theory of mind and, as Lysaker et al (2005) have proposed, can be synthesized into 4 mental abilities.

Mental abilities:

• Self-reflectivity or the ability to think about one’s own mental states;
• Differentiation or the ability to think about others’ mental states;
• Decentering or the ability to understand that one is not the center of the world and that there are different ways of understanding reality;
• Mastery or the ability to integrate intersubjective information into broad definitions of problems that allow adaptive responses.

If we focus specifically on this set of abilities in individuals with schizophrenia, the literature highlights three key aspects: (1) individuals with schizophrenia and related spectrum disorders present marked deficits in metacognition (Lysaker et al, 2011); (2) deficits in metacognition more significantly predict real-world psychosocial functioning in this group of individuals (Lysaker et al, 2015); and (3) including some type of metacognitive training in current psychological therapies, including CRT, for schizophrenia and related disorders provides significant potential benefits (Jiang et al, 2016; de Jong et al, 2016).

For example, recently Moritz et al, 2015 proposed a CRT treatment with augmented metacognition (in English, Metacognition-augmented CRT) for outpatient individuals with schizophrenia and related spectrum disorders. Based on a prior neuropsychological assessment, these authors established a personalized neurocognitive training. The criterion used to consider an area deficient was that the user scored 1 standard deviation below the mean of their reference group in sustained attention, processing speed, verbal and visual memory, reasoning and problem solving (that is, the MATRICS Consensus areas). The tasks were also specifically designed for patients to improve their awareness and reflectivity when giving a response and to reduce two metacognitive biases that have been widely related to the pathogenesis of the positive symptoms of schizophrenia: jumping to hasty conclusions and excessive confidence when giving a response.

To this end, after each item users were asked their confidence level in the given answer; that is, from 1 to 10 how sure they were that their answer was correct. If the response was incorrect because the user had answered very quickly (i.e., in less than half of the time allocated for the item) or with excessive confidence (when the subject rates their answer above 6), they were automatically encouraged to take more time to complete the item and/or to reduce their confidence in the response given.

The most clinically relevant results of this study were that the CRT program with augmented metacognition produced significant improvements in both metacognitive biases and the authors conclude that these types of tasks can be very useful for increasing these patients’ ability to reflect on their own responses, an element certainly important when working psychologically with positive symptoms, especially those of a delusional nature.

If you liked this post about schizophrenia and neurorehabilitation, you may be interested in these articles from NeuronUP.

“This article has been translated. Link to the original article in Spanish:”
Esquizofrenia y neurorrehabilitación