Recovery from psychosis in schizophrenia and schizoaffective disorder: symptoms and neurocognitive rate-limiters for the development of social behavior skills
Introduction
A number of new treatments for schizophrenia have been introduced and tested over the past 10 years. Novel antipsychotic medications offer clear benefits as compared to conventional agents, and psychiatric rehabilitation treatments provide the opportunity for improved social and vocational functioning. The availability of these new treatments has stimulated discussions regarding the factors that predict recovery and rehabilitation success in schizophrenia. For example, positive symptoms appear to have little influence on functional capacity, whereas negative symptoms have been associated with poor long-term functional outcome (Anthony et al., 1995, Bell and Lysaker, 1995, Bellack et al., 1990, Dickerson et al., 1999, Hoffman and Kupper, 1997, Smith et al., 1999a, Van der Does et al., 1996).
Other research suggests that neurocognitive deficits are more predictive of treatment response and functional capacity than core symptoms of schizophrenia. Reviews of this literature by Green (Green, 1996, Green et al., 2000.) revealed that deficits in short-term memory, vigilance, and executive functioning are consistently associated with poor outcome. Memory deficits have been associated with reduced levels of elementary social skills and learning capacity (Bowen et al., 1994, Kern et al., 1992, Smith et al., 1999b, Silverstein et al., 1998a ), while deficits in attention/vigilance have been more commonly associated with poor self-care and organizational skills (Wykes, 1994, Brekke et al., 1997, Addington and Addington, 1999, Ikebuchi et al., 1999, Silverstein et al., 1998a). A number of other studies have found that executive deficits consistently predict role performance and global adjustment (Bellack et al., 1999, Breier et al., 1991, Goldberg et al., 1990, Jaeger and Douglas, 1992, Lysaker et al., 1995, Kopelowicz et al., 2000).
Many of these studies used only retrospective data analyses, however, or failed to use longitudinal assessments of positive, negative, and disorganized symptoms. Norman et al. (1999) critiqued several of these studies, noting that symptom assessments were conducted when subjects were acutely ill and then were used to predict functioning at a later point in time. Studies using more detailed symptom measures have suggested that disorganized and negative symptoms are more predictive of functional skills than neurocognitive deficits in outpatients with schizophrenia (Norman et al., 1999, Malla et al., 1999, Dickerson et al., 1996, Hoffman and Kupper, 1997). Clearly, questions remain regarding the relative influence of symptoms and neurocognitive deficits on functional outcome in schizophrenia.
Our group recently finished a prospective study of individuals with chronic psychotic disorders recovering from acute symptom exacerbations, which aimed to identify illness characteristics that predict recovery and response to rehabilitation treatments. In a previous report, we documented the differential influence of symptoms and neurocognitive deficits on aspects of social adjustment in a cross-sectional analysis (Smith et al., 1999a). Here we report data on the rate of improvement in social behavior skills in the first year following stabilization of acute psychotic symptoms.
Section snippets
Sample
Subjects were recruited from consecutive admissions to an outpatient treatment program, with inclusion criteria including: a) age 18–50; b) diagnosis of schizophrenia or schizoaffective disorder; and c) having been in the hospital for treatment of an acute psychotic exacerbation within 30 days of recruitment. Exclusion criteria included: a) comorbid diagnosis of substance dependence within past 3 months; b) estimated IQ less than 70; and c) any history of serious traumatic brain injury (defined
Results
Table 1 lists the means and standard deviations for the symptom, neurocognitive, and Social Behavior Scale (SBS) scores over the 12-month recovery period. Positive symptoms fluctuated over time, with no clear trend towards improvement or worsening. Disorganized symptoms improved over the first 4 time points before worsening somewhat at the final assessment. Negative symptoms increased over time in the cohort, although to a minimal degree. SBS scores improved by 10% over the follow-up period in
Discussion
This is one of the first prospective follow-up studies using repeated measures to track the relative influences of symptoms and neurocognitive deficits on functional outcome in schizophrenia. We recruited individuals who were recently hospitalized, and our goal was to track the evolution of social behavior skills during recovery from an acute symptom exacerbation. Our results indicate that neurocognitive deficits in verbal learning and working memory are strong predictors of social behavior,
Acknowledgements
This research was supported by National Institute of Mental Health grant MH 01359 to Dr Smith, and by funds established in The New York Community Trust by DeWitt-Wallace. The authors wish to thank Lorna Starkey, Sarah Pratt, and Rosa Lim for valuable assistance with the project.
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