Mind
Cognitive stimulation in Schizophrenia

Cognitive stimulation in Schizophrenia

The low sensitivity of drugs to the enhancement of cognitive functions has prompted researchers and clinicians to place emphasis on the introduction of non-pharmacological techniques and strategies for cognitive stimulation aimed at people with schizophrenia.

Mirto Anna Maria – OPEN SCHOOL Cognitive Studies, Modena

 

Advertising message In recent years, the attention placed by clinicians on the importance of cognitive rehabilitation in the treatment of cognitive deficits in neurodegenerative pathologies, such as Alzheimer’s disease, in particular, and other forms of dementia has become growing. Even the recent guidelines of the Health Organization (WHO) (2019) recommend rehabilitation and / or cognitive stimulation in order to prevent cognitive impairment and / or slow down the decline over time in cases where the dementigenic pathology has already arisen .

Nonetheless, it should be stressed that cognitive deficits do not represent a risk only for the elderly population or a problem that affects only people suffering from dementia, stroke or head injuries. They also affect other mental disorders, including psychosis, thus posing a challenge especially for young adults who are affected. Although current diagnostic systems do not include cognitive impairment among the diagnostic criteria of schizophrenia, which represents the main psychotic syndrome, the centrality of this deficit in disease is confirmed and proven in the literature (Carcione et al., 2012)

Not surprisingly, in fact, the first classification of schizophrenia, dating back to the early 1900s and attributed to Emil Kraepelin, was “dementia praecox” precisely by virtue of the presence of alterations in the cognitive sphere, which were therefore included among the nuclear characteristics of the disease ( Kraepelin, 1917).

Once recognized the presence of cognitive deficits also in psychiatric pathologies, it is essential not to run into the error of generalizing and indistinctly applying the cognitive interventions proven effective in the treatment of neuropsychological disorders following traumatic, cerebrovascular and neurodegenerative events in the field of rehabilitation of patients with psychiatric conditions.

The cognitive alterations of schizophrenia patients are different from those found in other neurological pathologies and have their own specificity. They have a high prevalence but are not universal: in fact about 27% of these patients are not deficient in the neuropsychological evaluation; moreover, they occur with interindividual variability, so that the level and severity of neurocognitive impairment differs between patients (Carcione et al., 2012).

The cognitive domains that are compressed are: processing speed, attention, executive functions, working memory, learning and verbal memory, learning and visual memory, reasoning, language, visual-spatial skills and social cognitiveness (Reichenberg and Harvey, 2007; Heinrichs and Zakzanis, 1998). These deficits, albeit in a milder form, are already present in the premorbid phase, before the full-blown manifestation of the disease and persist over time even when the symptoms, positive and negative, undergo remission (Carcione et al., 2012). Therefore, these cognitive alterations, since present before onset and for the entire duration of the disease, significantly impact on the autonomy of the subject, thus representing a negative predictive factor of social and work functioning for the individual himself (Milev et al., 2005). This entailed the need to develop interventions aimed at remedying cognitive deficits.

For a long time, attempts have been made to find psychopharmacological treatments which, however, have proven ineffective in promoting the improvement of neuropsychological capacity in psychiatric patients. In particular, it has been shown that first generation antipsychotics have a negative impact especially on psychomotor performance, while second generation antipsychotics have shown only slight improvements on neurocognitive functioning (Davidson et al., 2009; Woodward et al., 2005) .

The low sensitivity of drugs on the enhancement of cognitive functions has prompted researchers and clinicians to place emphasis on the introduction of non-pharmacological cognitive training techniques and strategies, aimed at improving cognitive performance and therefore, indirectly, also of the individual’s psychosocial functioning ( Velligan et al., 2006).

The internationally recognized treatment as most effective in cognitive rehabilitation in patients with schizophrenia is Cognitive Remediation (CR).

It is a cognitive behavioral intervention specifically designed for the rehabilitation of cognitive processes in psychiatric disorders, such as bipolar disorder, schizophrenia and other forms of psychosis (Franza et al., 2018). At the Cognitive Remediation Expert Workshop, held in Florence in 2010, it was defined “a behavioral training-based intervention that aims to improve cognitive processes (attention, memory, executive functions, social cognition or metacognition) with the goal durability and generalization” (Wykes and Spaulding, 2011). This is to underline how the improvement of cognitive performance represents, for the CR, a primary objective, which however is instrumental to the achievement of the main objective of increasing and enhancing the patient’s overall functioning and quality of life (Vita and Barlati,

Advertising message There are two main CR models: compensatory and restorative / restaurateur. The first aims to make the patient learn new skills by leveraging the residual skills and environmental resources, also modifying and adapting the context in which the person lives, in order to help him overcome his disabilities. External environmental aids are therefore used, such as calendars, customized containers for medicines, or taught mnemonic strategies to remember tasks / objects (Vita e Barlati, 2013). It is therefore clear that the compensatory model has strong implications for the functional improvement of the individual. The restarting model, on the other hand, being particularly focused on neurocognitive performance,

The CR interventions differ from each other according to the individual / group modality and the type of materials used (paper-pencil / computer programs). These, together with the frequency and duration of the sessions and the patient’s motivation to follow CR therapy, are the factors that mediate the effect and effectiveness of the intervention (Wykes and Spaulding, 2011).

In defining the CR program it is important to keep in mind how some learning techniques have demonstrated greater efficacy both cognitively and functionally. In particular, several studies by Kern (2005, 2008) conducted with patients with schizophrenia, showed how errorless learing, developed by Baddeley and Wilson (1994), improved their problem-solving skills in contexts social and work performance, as well as improving memory skills (Mulholland, 2008). Modify the difficulty of a task according to the patient’s ability, ensuring that the newly learned ones can allow him to develop new ones (scaffolding technique), an effective learning strategy has been demonstrated both for the improvement of abstract reasoning and for the strengthening and increase of the level of self-esteem in patients with schizophrenia (Young et al., 200). Other useful techniques concern the repeated practice of a task (massed practice), which favors memorization; reinforcement, which increases or reduces the appearance of a behavior, thus providing information about whether or not an improvement has occurred and directing the person’s motivation to achieve that improvement; chuncking, i.e. the simplification and division of a task into several steps in order to reduce the amount of information to be processed (Vita and Barlati, 2013). Other useful techniques concern the repeated practice of a task (massed practice), which favors memorization; reinforcement, which increases or reduces the appearance of a behavior, thus providing information about whether or not an improvement has occurred and directing the person’s motivation to achieve that improvement; chuncking, i.e. the simplification and division of a task into several steps in order to reduce the amount of information to be processed (Vita and Barlati, 2013). Other useful techniques concern the repeated practice of a task (massed practice), which favors memorization; reinforcement, which increases or reduces the appearance of a behavior, thus providing information about whether or not improvement has occurred and directing the person’s motivation to achieve that improvement; chuncking, i.e. the simplification and division of a task into several steps in order to reduce the amount of information to be processed (Vita and Barlati, 2013).

In the last thirty years, different and multiple cognitive remedy protocols have been structured specifically for schizophrenia, of which a detailed description has been proposed by Vita and Barlati (2013), which have provided exhaustive treatment of the various techniques of cognitive remedy. , starting from programs that use paper supports and materials, to computerized ones up to multimedia cognitive rehabilitation software.

There are several meta-analyzes that conclude towards the effectiveness of CR in the cognitive rehabilitation of schizophrenia (Wykes et al., 2011; McGurk et al., 2007). However, the use of this intervention in daily clinical practice is still scarce, probably due to the limited knowledge about predictors (biological, socio-demographic, clinical and cognitive factors), and their interaction, of positive or negative response to treatment CR (Wykes, 2018). In response to this lack of knowledge, the recent review by Barlati and collaborators (2019) arrives, in which an initial identification of the factors that best predict the outcome of CR in schizophrenia was attempted, taking into account the implication both on cognitive performance and on social functioning. In particular, there was a greater efficacy of CR in patients with schizophrenia with the following characteristics: young age, short disease history, few disorganized symptoms, high cognitive reserve at pre-treatment, greater improvement at post-treatment CR, low dosage of antipsychotics during the treatment. Furthermore, there were greater effects when the CR constitutive a part of the treatment implemented within a psychosocial rehabilitation intervention. It is necessary to specify, however, how scholars emphasize the importance of still working to better identify the potential outcome predictors that favor the development of personalized interventions on the characteristics of the patients. few disorganized symptoms, high cognitive reserve at pre-treatment, greater improvement at post-treatment CR, low dose of antipsychotics during treatment. Furthermore, there were greater effects when the CR constitutive a part of the treatment implemented within a psychosocial rehabilitation intervention. It is necessary to specify, however, how scholars emphasize the importance of still working to better identify the potential outcome predictors that favor the development of personalized interventions on the characteristics of the patients. few disorganized symptoms, high cognitive reserve at pre-treatment, greater improvement at post-treatment CR, low dose of antipsychotics during treatment. Furthermore, there were greater effects when the CR constitutive a part of the treatment implemented within a psychosocial rehabilitation intervention. It is necessary to specify, however, how scholars emphasize the importance of still working to better identify the potential outcome predictors that favor the development of personalized interventions on the characteristics of the patients. greater effects were found when the CR constituting a part of the treatment implemented within a psychosocial rehabilitation intervention. It is necessary to specify, however, how scholars emphasize the importance of still working to better identify the potential outcome predictors that favor the development of personalized interventions on the characteristics of the patients. greater effects were found when the CR constituting a part of the treatment implemented within a psychosocial rehabilitation intervention. It is necessary to specify, however, how scholars emphasize the importance of still working to better identify the potential outcome predictors that favor the development of personalized interventions on the characteristics of the patients.