Elsevier

Schizophrenia Research

Volume 55, Issue 3, 1 June 2002, Pages 229-237
Schizophrenia Research

Recovery from psychosis in schizophrenia and schizoaffective disorder: symptoms and neurocognitive rate-limiters for the development of social behavior skills

https://doi.org/10.1016/S0920-9964(01)00231-6Get rights and content

Abstract

Neurocognitive deficits are believed to be important predictors of functional outcome in chronic psychotic disorders, but few supporting studies have utilized prospective designs and adequate control. The aim of this study was to estimate the relative influence of symptoms and neurocognitive deficits on the development of social behavior skills in a cohort of individuals with schizophrenia or schizoaffective disorder recovering from acute symptom exacerbations. Forty-six individuals were recruited upon discharge from an inpatient unit and completed assessments of symptoms, neurocognitive function, and social behavior at 3-month intervals for 1 year. Correlational analyses and random regression models were used to model social behavioral capacities longitudinally. Social behavior improved modestly (10% improvements in ratings) over the follow-up period for the group as a whole. Disorganized and negative symptoms, as well as neurocognitive deficits in short-term and working memory predicted changes in social behavior over time. Individuals with better working memory function showed significantly greater abilities to recover social behavior skills, whereas those with working memory deficits showed no functional improvement over time. Both symptoms and neurocognitive deficits are important determinants of functional outcome in schizophrenia. It is proposed that clinicians should consider neurocognitive thresholds for treatment response when developing rehabilitation plans.

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.

References (62)

  • A.J.W. Van der Does et al.

    Symptoms, cognitive and social functioning in recent-onset schizophrenia: a longitudinal study

    Schizophr. Res.

    (1996)
  • J. Addington et al.

    Neurocognitive and social functioning in schizophrenia

    Schizophr. Bull.

    (1999)
  • G.S. Alexopoulos et al.

    Executive dysfunction and long-term outcomes of geriatric depression

    Arch. Gen. Psychiatry

    (2000)
  • N.C. Andreasen

    Scale for the Assessment of Positive Symptoms (SAPS)

    (1984)
  • N.C. Andreasen

    Scale for the Assessment of Negative Symptoms (SANS)

    (1984)
  • N.C. Andreasen et al.

    Symptoms of schizophrenia: methods, meanings, and mechanisms

    Arch. Gen. Psychiatry

    (1995)
  • W.A. Anthony et al.

    Relationships between psychiatric symptomatology, work skills, and future vocational performance

    Psychiatr. Serv.

    (1995)
  • M.D. Bell et al.

    Psychiatric symptoms and work performance among persons with severe mental illness

    Psychiatr. Serv.

    (1995)
  • A.S. Bellack et al.

    An analysis of social competence in schizophrenia

    Br. J. Psychiatry

    (1990)
  • A.S. Bellack et al.

    Cognitive rehabilitation for schizophrenia: problems, prospects, and strategies

    Schizophr. Bull.

    (1999)
  • A. Breier et al.

    National Institute of Mental Health longitudinal study of chronic schizophrenia. Prognosis and predictors of outcome

    Arch. Gen. Psychiatry

    (1991)
  • J.S. Brekke et al.

    Neuropsychological and psychophysiological correlates of psychosocial functioning in schizophrenia

    Schizophr. Bull.

    (1997)
  • M. Davidian et al.

    Nonlinear Models for Repeated Measurement Data

    (1995)
  • F.B. Dickerson

    Assessing clinical outcomes: the community functioning of persons with serious mental illness

    Psychiatr. Serv.

    (1997)
  • F.B. Dickerson et al.

    Predictors of residential independence among outpatients with schizophrenia

    Psychiatr. Serv.

    (1999)
  • N.M. Docherty et al.

    Working memory, attention, and communication disturbances in schizophrenia

    J. Abnormal Psychol.

    (1996)
  • M.B. First et al.

    Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P, Version 2.0)

    (1995)
  • R.D. Gibbons et al.

    Some conceptual and statistical issues in longitudinal analysis of psychiatric data

    Arch. Gen. Psychiatry

    (1993)
  • T.E. Goldberg et al.

    Thought disorder, working memory and attention: interrelationships and the effects of neuroleptic medications

    Int. Clin. Psychopharmacol.

    (1995)
  • T.E. Goldberg et al.

    Neuropsychological assessment of monozygotic twins discordant for schizophrenia

    Arch. Gen. Psychiatry

    (1990)
  • W.G. van Gorp et al.

    Declarative and procedural memory functioning in abstinent cocaine abusers

    Arch. Gen. Psychiatry

    (1999)
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