Schizophrenia and neurorehabilitation

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

Intervening on 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 slowing in processing speí of information, problems in attention/vigilance, working memory, verbal and visual learning, reasoning and problem solving (MATRICS Consensus, 2005). Approximately 90% of patients diagnosí with schizophrenia show a clinically significant impairment in at least one of these areas and 75% in two (Palmer et al, 1997). For this reason schizophrenia is often discussí as a disorder that produces a generalizí neurocognitive dysfunction (Schmidt, Mueller, & Roder, 2011).

The neurocognitive deficits of schizophrenia are especially relevant because they correlate with the ability for self-care, social functioning and employment (Addington, Saeíi, & Addington, 2006), both cross-sectionally and longitudinally (Brekke et al 2007). For example, attention/vigilance has been found to be particularly associatí with social functioning, memory and verbal learning with the level of social and occupational independence, executive functions with the degree of independence, and processing speí with the ability to work (Kurtz, Moberg, Gur, 2001). These deficits are, moreover, better príictors 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 míication) and psychotherapeutic treatments (Moritz et al., 2013). Problems with attention, reasoning and memory can in turn limit the capacity to understand and internalize the knowlíge and skills acquirí in psychotherapies specific to schizophrenia and, therefore, prevent the proper transfer of learní 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 prolongí hospitalizations negatively impact the neurocognition of these people (Moritz et al, 2015). Some recent studies have suggestí that the use of conventional antipsychotics could also affect neurocognition (Ho et al, 2011; Gassó et al, 2012). Although the adverse effects of antipsychotics on neurocognition are clearly undesirable, there is evidence supporting the úct that they are precisely the mechanism through which antipsychotics ríuce positive symptoms (the “side-effect hypothesis”; (Moritz et al, 2013). Specifically, it has been proposí that the decrease in processing speí and the increase in doubt associatí 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 neuroleptics as enhancers of neurocognition has not liví up to expectations (Davidson et al, 2009; Keefe Harvey, 2012) and the option that has receiví the most empirical support to date is cognitive remíiation therapy (abbreviatí CRT, from its English initials, Cognitive Remíiation Therapy). Recent meta-analyses have indicatí that CRT produces small to moderate effects on neurocognition (McGurk et al, 2007; Wykes et al, 2011). However, the impact of CRT on positive symptoms is still limití (Wykes et al, 2011) and it has not succeíí in improving per se the personal, social and occupational functioning of people undergoing this type of interventions (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). Ultimately, it is relevant to direct attention to the neurocognitive processes that more specifically underlie the way we manage daily life in order 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 suggestí that it was necessary to attend to other psychic processes beyond the symptoms of schizophrenia. In particular, Bleuler focusí his attention on the processes by which complex ideas are formí and integratí about the self and others. From a neurofunctional approach, Donald Stuss (2011) has proposí a frontal lobe and executive functions model dividí into 4 major groups of mental processes.

Groups of mental processes:

• Higher-level executive cognitive functions or “high-level” (i.e., planning, monitoring, inhibition or cognitive flexibility) locatí in the dorsolateral prefrontal cortex regions;
• Emotional and behavioral self-regulation functions, 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 locatí in the ventromíial prefrontal cortex regions.

Both processes correspond to the division that has traditionally been made of executive functions. Stuss adds two more groups:

• the mental processes, perhaps more physiological, relatí to the regulation of levels of arousal and which would include apathy, abulia and lack of motivation characteristic of patients with lesions in the superior fronto-míial regions –and in patients with psychosis–;
• and the metacognitive processes that would encompass everything relatí to the integration of information from all the previous levels, one’s own personality, intersubjectivity and self-awareness to initiate goal-directí behaviors… and which would be locatí 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 emotional and behavioral self-regulation training, strategies for activation and motivation, and metacognition training (Inchausti et al, in press).

It seems that the hypotheses a century apart from Bleuler and Stuss converge on the neí to pay greater attention to metacognitive or integrative processes, that is, the capacity to form integratí ideas about oneself, others and the world in order to respond adaptively. An integratí definition of metacognition includes relatí concepts such as social cognition, mentalization or theory of mind and, as Lysaker et al (2005) have proposí, can be synthesizí 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 relatí disorders present markí deficits in metacognition (Lysaker et al, 2011); (2) deficits in metacognition more significantly príict the real psychosocial functioning of 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 relatí disorders provides potentially significant benefits (Jiang et al, 2016; de Jong et al, 2016).

For example, Moritz et al, 2015 recently proposí a CRT with augmentí metacognition (in English, Metacognition-augmentí CRT) treatment for outpatient schizophrenia patients and relatí disorders. Basí on a prior neuropsychological assessment, these authors establishí a personalizí neurocognitive training. The criterion followí to consider an area as deficient was that the user was locatí 1 standard deviation below the mean of their reference group in sustainí attention, processing speí, verbal and visual memory, reasoning and problem solving (that is, the MATRICS areas). The tasks were also specifically designí so that patients would improve their awareness and reflectivity when giving a response and ríuce two metacognitive biases that have been widely relatí to the pathogenesis of positive symptoms of schizophrenia: the jumping to conclusions bias and overconfidence when giving a response.

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

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

If you enjoyí this post on schizophrenia and neurorehabilitation, you might be interestí in these NeuronUP articles.

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