Programs for the Treatment of Social Cognition in Schizophrenia

Over the last few years, there have been many programs aimed at the treatment of deficits in social cognition that usually occur in the case of schizophrenia and which, in turn, have been scientifically validated. In this second article related to this topic, some of them will be discussed.

Integrated Neurocognitive Therapy for Patients with Schizophrenia

According to Durá et al (2008) Integrated Neurocognitive Therapy for Patients with Schizophrenia (INT) (Roder et al, 2007) works in a similar way to Integrated Psychological Therapy (IPT) (Roder et al, 1996). It has two major modules, one on neurocognition and the other on social cognition. The interventions to be applied in each module are selected according to the individual assessment carried out. The difficulty and emotional load increases as the program progresses, while the structuring progressively decreases. And also, as something differential with respect to IPT, the degree of importance of emotional activation and reference to oneself increases progressively, considering insight as another component of social cognition.

Several recent studies have proven the efficacy of this therapy (e.g., De Mare et al., 2018; Mueller et al., 2017; Mueller, Schmidt, & Roder, 2015)

Cognitive Enhancement Therapy

It consists of a second part, Cognitive Enhancement Therapy (CET) Hogarty and Flesher, 1999; Hogarty et al, 2004), in which various aspects of social cognition are intervened. In this second stage of the intervention, the exercises are developed in a structured group format of one and a half hours per week, for a period of fifty-five to sixty weeks, plus an additional six weeks in which the structure of the plan is faded out to favor gradual completion.

The basic objective is the development of the cognitive and metacognitive skills necessary for an adequate understanding and management of social situations, as well as, of the problems derived from daily life. The exercises include situations derived from the real life of the patients and which are posed as problems by them. Each activity has several levels of participation, from the level of observer to being the central subject, as well as multiple cognitive objectives ranging from maintaining attention to developing an adequate perspective of thinking in social situations. In this phase of training, the patient’s active participation is solicited through homework assignments, the review and discussion of which usually occupies the first part of the session.

Differences between IPT and CET

According to Ruiz et al (2006), some differences between IPT and CET lie in the treatment effects of social cognition in schizophrenia. In IPT, treatment effects are supposed to occur in a stepwise fashion. First, molecular cognitive processes are exercised, so that these molecular processes can then enhance the acquisition of molar skills. Thus the rehabilitative process progresses from training basic cognitive processes to more conventional social skills and interpersonal problem solving. CET, on the other hand, is less linear and stepwise. In controlled studies, both IPT and CET have been shown to be effective in improving social functioning (Hogarty and Flesher, 1999; Spaulding et al ,1999).

Finally, it should be noted that several recent studies corroborate the efficacy of CET (e.g., Eack et al, 2015, 2016; Keshavan et al, 2017).

Social Cognition and Interaction Training

According to Durá et al (2008) the Social Cognition and Interaction Training (SCIT) (Penn et al, 2005) is one of the most recent programs, together with the Integrated Neurocognitive Therapy (INT), to work on social cognition, being the two most complete so far.

SCIT is divided into three parts, each with a series of sessions and concepts to work on. Throughout the training, a multitude of exercises are performed in the sessions and tasks are proposed to be performed outside the sessions in order to achieve generalization. These parts are the following:

• The first part is called understanding emotions and consists of 6 sessions. In these sessions the functioning of the program is explained, what is social cognition, the alliance in the group is established and the role of emotions in social situations is reviewed.
• The second part called social cognition style, goes from session 7 to 13, and aims to train not jumping to conclusions hastily, attributional style, tolerance to ambiguity, distinction between facts and assumptions, and data collection to improve the previous distinction.
• The third part, called integration, runs from session 14 to 18, and aims to consolidate skills and generalize them to everyday problems through exercises.

Differences between SCIT, IPT and CET

According to Ruiz et al (2006) there are differences between SCIT, IPT and CET, since the first program is focused on social cognition, while IPT and CET are broader since they also work on the rehabilitation of other cognitive areas such as attention or memory. Hence, they are also longer programs.

To highlight that there are multiple recent studies that continue to corroborate the effectiveness of this intervention (e.g., Gordon et al, 2018; Hasson-Ohayon et al, 2019; Voutilainen et al, 2016).

Bibliography

De Mare, A., Cantarella, M., y Galeoto, G. (2018). Effectiveness of integrated neurocognitive therapy on cognitive impairment and functional outcome for schizophrenia outpatients. Schizophrenia research and treatment, https://doi.org/10.1155/2018/2360697

Eack, S. M., Hogarty, S. S., Greenwald, D. P., Litschge, M. Y., McKnight, S. A., Bangalore, S. S., … y Cornelius, J. R. (2015). Cognitive Enhancement Therapy in substance misusing schizophrenia: Results of an 18-month feasibility trial. Schizophrenia research, 161(2-3), 478-483.

Eack, S. M., Newhill, C. E., y Keshavan, M. S. (2016). Cognitive enhancement therapy improves resting-state functional connectivity in early course schizophrenia. Journal of the Society for Social Work and Research, 7(2), 211-230.

Gordon, A., Davis, P. J., Patterson, S., Pepping, C. A., Scott, J. G., Salter, K., y Connell, M. (2018). A randomized waitlist control community study of Social Cognition and Interaction Training for people with schizophrenia. British Journal of Clinical Psychology, 57(1), 116-130

Hasson-Ohayon, I., Mashiach-Eizenberg, M., Lavi-Rotenberg, A., y Roe, D. (2019). Randomized controlled trial of adjunctive Social Cognition and Interaction Training (SCIT), adjunctive Therapeutic Alliance Focused Therapy (TAFT) and treatment as usual among persons with serious mental illness. Frontiers in Psychiatry, 10, 364.

Hogarty, G.E. y Flesher, S. (1999). Practice Principles of Cognitive Enhancement Therapy for Schizophrenia. Schizophrenia Bulletin, 25 (4), 693-708.

Hogarty, G.E., Flesher, S., Ulrich, R., Carter, M., Greenwald, D., Pogue-Geile, M., Kechavan, M., Cooley, S., DiBarry, L., Garrett, A., Parepally, H. y Zoretich, R. (2004). Cognitive Enhancement Therapy for Schizophrenia. Archives General Psychiatry, 61, 866-876.

Keshavan, M. S., Eack, S. M., Prasad, K. M., Haller, C. S., y Cho, R. Y. (2017). Longitudinal functional brain imaging study in early course schizophrenia before and after cognitive enhancement therapy. Neuroimage, 151, 55-64

Roder, V., Brenner, H.D., Hodel, B. y Kienzle, N. (1996). Terapia integrada de la esquizofrenia [Integrated therapy of schizophrenia]. Barcelona: Ariel.

More references of social cognition treatment in schizophrenia

Durá, I. F., Ruiz, J. C. R., Ferrer, S. G., Boada, M. J. S., y Vivo, C. D. (2008). Esquizofrenia: déficit en cognición social y programas de intervención [Schizophrenia: deficits in social cognition and intervention programs]. Informació Psicológica, (93), 53-64.

Lahera, G., Benito, A., Montes, J. M., Fernandez-Liria, A., Olbert, C. M., y Penn, D. L. (2013). Social cognition and interaction training (SCIT) for outpatients with bipolar disorder. Journal of affective disorders, 146(1), 132-136.

Mueller, D. R., Khalesi, Z., Benzing, V., Castiglione, C. I., y Roder, V. (2017). Does Integrated Neurocognitive Therapy (INT) reduce severe negative symptoms in schizophrenia outpatients?. Schizophrenia research, 188, 92-97.

Mueller, D. R., Schmidt, S. J., y Roder, V. (2015). One-year randomized controlled trial and follow-up of integrated neurocognitive therapy for schizophrenia outpatients. Schizophrenia bulletin, 41(3), 604-616.

Ruiz, J. C., García, S., y Fuentes, I. (2006). La relevancia de la cognición social en la esquizofrenia [The relevance of social cognition in schizophrenia]. Apuntes de Psicología, 24(1-3), 137-155

Penn, D. L., Roberts, D. L., Munt, E. D., Silverstein, E., Jones, N., y Sheitman, B.  (2005). A pilot study of Social Cognition and Interaction Training (SCIT) for schizophrenia. Schizophrenia Research, 80(2-3), 357-359.

Roder, V., Brenner, H. D., Kienzle, N. y Fuentes, I. (2007) Terapia Psicológica Integrada de la Esquizofrenia [Integrated Psychological Therapy for Schizophrenia]. Granada: Alborán.

Spaulding, W.D., Reed, D., Sullivan, M., Richardson, C. y Weiler, M. (1999). Effects of cognitive treatment in psychiatric rehabilitation. Schizophrenia Bulletin, 25, 657-676.

Voutilainen, G., Kouhia, T., Roberts, D. L., y Oksanen, J. (2016). Social Cognition and Interaction Training (SCIT) for adults with psychotic disorders: a feasibility study in Finland. Behavioural and cognitive psychotherapy, 44(6), 711-716