Neuropsychology and Schizophrenia

1. Neuropsychology and Schizophrenia Jennifer Badgley Fleeman, Psy.D. Licensed Clinical Psychologist Shrink.inc@frontiernet.net

2. Outline • Schizophrenia – brief overview • Nature of assessment with the mentally ill • Common neuropsychological findings in schizophrenia • Medication effects • Insight and outcome

3. Schizophrenia • Chronic psychiatric disorder • characterized by disruption in affective, cognitive, behavioral, and social domains • that results in poor ability to maintain adaptive functioning in the community.

4. Schizophrenia • Lifetime prevalence from 0.5% to 1.0% of the population (APA, 1994) • Usually manifests itself between ages 18 and 25 • No gender discrepancy (prevalence)

5. Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms Social/occupational dysfunction >= 1 month active sx; signs for >= 6 months Positive symptoms Excess Delusions, hallucinations, loose associations Negative symptoms Lacking Poor motivation, social withdrawal, flat affect, diminished speech content Symptoms of schizophrenia

6. DSM-IV Paranoid Disorganized Catatonic Undifferentiated Residual Distinction between “Functional” and “Organic” etiology is outdated Psychiatric disorder with neuropsychological correlates Subtypes

7. Schizophrenia-Theories of Etiology • Immunologic/Viral factors • Disruption of neuroanatomical development in embryo • Dopamine Hypothesis: Excessive dopamine • Structural brain abnormality: Enlarged lateral and third ventricles found in neuroimaging and post-mortem studies • Cortical atrophy/ volume loss: atrophy in hippocampus and amygdala, left temporal lobe • Functional brain abnormality: Hypometabolism in dorsolateral pre-frontal cortex and hippocampal regions noted during certain cognitive tasks • Genetics with influence from environment

8. Nature of Assessment • 1) Multiple factors to consider (medical, emotional, behavioral, cognitive) • 2) Contribution of mental illness, neurological disorder (if present), and medical illnesses (if present) to their symptom presentation • 3) Assessment issues (attention/concentration, behavioral/compliance, motivational issues) and time factor

9. Common Referral Questions • Change in cognitive functioning not associated with psychiatric decompensation • Deficits in cognition disproportionate to mental illness • Sudden onset of cognitive dysfunction • Assessment of cognitive functioning to assist with treatment/discharge planning; evaluate strengths/weaknesses • Provide baseline against which future performance can be compared • Re-assessment of cognitive function (progress, decline) • Evaluation of specific areas of functioning (e.g., memory) • Rule out dementia • Competency (e.g., independent functioning, forensic)

10. Tests Used to Answer Referral Questions • Use common neuropsychological and cognitive tests • The tests may or may not have norms for individuals with particular mental illnesses • Look at pattern of scores and degree of impairment

11. Schizophrenia and Cognitive Impairment • Cognitive deficits are heterogeneous, but impairment in three functional domains are most often identified: • Attention • Memory • Executive Functioning • Negative symptoms associated with greater cognitive impairment • Typical course of cognitive impairment: • Initial decline in cognitive functioning soon after the illness onset, then fairly stable.

12. Attention • Attention: • Automatic stimulus processing (without awareness): • Ex:Acoustic startle • Ex: P300 • Difficulty with other attention functions: • Initially focusing (irrelevant details) • Divided attention/ Working Memory • Vigilance (maintaining attention) • CPT (A X paradigm) • Selective attention o.k.

13. Memory • Working Memory: • Memory: • Impairment in both verbal and nonverbal memory • Difficulty with encoding/learning (organization/ integration of current input with past experience) and retrieval; Recognition superior to recall • Able to benefit from repetition to learn and cues to recognize

14. Executive Functioning • Executive Functioning: • Poor planning, organization, problem-solving, cognitive flexibility, self-monitoring • Impaired insight and social judgment • Lack of initiative/ motivation

15. Intelligence • Decrease due to pathological changes • Estimating pre-morbid IQ • Previous testing • Certain cognitive measures • School records • Algorithms

16. Other Cognitive Findings • Language: • Language generation problems • No problems understanding single words/simple sentences, but difficulty comprehending longer sequences

17. Schizophrenia:Other Cognitive Findings • Visuospatial/Constructional: • Generally no impairment copying simple designs • Difficulty with complex figures/ construction (e.g., Block Design, Object Assembly, Rey Copy) • Data suggests problems in organization rather than visuospatial processing

18. Schizophrenia:Other Cognitive Findings (cont.) • Motor: • Slow reaction time is most common finding • Incoordination, clumsiness, tremors, posturing

19. Type I (positive sx): Not associated with global cognitive dysfunction Hallucinations/ delusions not sig related to cognitive performance Thought disorder disrupts attention and language performance Type II (negative sx): More associated with global cognitive dysfunction More problems with visual-motor, visual-spatial, and attention Transient negative symptoms vs. “deficit syndrome” Cognitive Patterns in Type I vs II

20. Basic Demographics 45 y.o. male 14 years education Chronic Paranoid Schiz; Polysubstance Abuse Psych history Multiple psych hospitalizations since age 25 ?head injury Symptoms at admit: Paranoia ?auditory hallucinations Guardedness Thought disorder Social isolation Flat affect Med. Non-compliance Example: Mr. X

21. IQ----------------------------- Attention/Working Mem-- Verbal Memory Immediate Recall--------- Delayed Recall------------ Recognition---------------- Visual Memory Immediate Recall--------- Delayed Recall------------ Average Low average – borderline Impaired Borderline Average Low average – borderline Low average - borderline Mr. X’s scores

22. Language-------------------- Visuospatial/Visual-motor Executive Functioning Cognitive Flexibility----- Reasoning------------------ Processing Speed--------- Average Average Low average Average Low average - borderline Mr. X’s scores (cont.)

23. Mr. X - Impressions • Relative cognitive weaknesses: • Auditory and visual attention • Memory encoding/retrieval • Working memory/cognitive flexibility • Processing speed • Relative cognitive strengths: • IQ • Language • Memory Retention and recognition • Visuospatial/Visual-motor integration • Reasoning • Consistent with schizophrenia

24. Basic Demographics 55 y.o. male 10th grade education Schizophrenia, Undifferentiated Type; hx Alcohol Dependence Psych history Multiple psych hospitalizations since age 16 No hx LOC COPD; Psychogenic Polydypsia Symptoms at admit: Prominent negative sx Confused; disorganized Polydypsia; dysruptive Increased forgetfulness & confusion since admit Example: Mr. Y

25. Current results Mental Status (20/30) Simple Attention----------- Working Memory---------- Verbal Memory Immediate Recall--------- Delayed Recall------------ Recognition---------------- Visuospatial/Visual-motor Changes? Past/ Present No change Low avg/ severe impaired Mild Impair/ severe impaired Mild Impair/ severe impaired Low avg/ severe impaired Borderline/ severe impaired Mr. Y’s scores

26. Current results Language-------------------- Executive Functioning Cognitive Flexibility----- Planning------------------- Processing Speed--------- Changes? Average/ mod impaired Low avg/ severe impaired No change (impaired) No change (impaired) Mr. Y’s scores (cont.)

27. Mr. Y - Impressions • Pattern of results: • Global difficulties that cannot be fully explained by presence of chronic schizophrenia and COPD • Severity, pattern (language, recognition) • Decline: • Global (verbal & visual memory, working memory, cognitive flexibility, language, etc.) • No decline in simple attention, planning, processing speed • Consistent with combination of factors, including long-standing alcohol abuse, chronic schizophrenia, COPD, and dementia

28. Medication effects:Antipsychotics • Conventional Antipsychotics: • Anticholinergic effects (memory, concentration) • Impaired motor functioning; slowed processing speed; anticholinergic meds to control extrapyramidal symptoms can also adversely affect memory • Atypical/Novel Antipsychotics: • Some evidence that they work to decrease negative symptoms (including cognitive impairment) as well as positive symptoms

29. Medication & Cognitive Functioning-Current Literature • Atypical antipsychotics may have a beneficial effect on negative symptoms of schizophrenia, but this is controversial; • Conventional antipsychotics are usually noted as being only effective for positive symptoms • Newer medications (e.g., Ability) may hold promise for negative sx and cognition

30. Basic Demographics 32 y.o. male 11th grade education + GED Schizoaffective; ETOH + THC dependence; Antisocial Personality Disorder Legal History: Extensive Psych history No prior psych hospitalizations; Hx depression, hypomania, aggression, poor impulse control, poor insight Medical history Multiple concussions Example: Mr. Z

31. Current results Attention-------------------- Working Memory---------- Verbal Memory------------ Visual Memory------------- Changes? Past/ Current Avg/ low avg Avg/ borderline Largely consistent, except more vulnerability to distraction No changes Mr. Z’s scores

32. Current results Visuospatial/Visual-motor Language-------------------- Executive Functioning Problem-solving--------- Reasoning----------------- Planning------------------- Processing Speed-------- Changes? Past/ Current: No changes except decreased for tasks requiring speed No changes except verbal fluency decline No changes No changes No changes Borderline/ extremely low Mr. Z’s scores (cont.)

33. Mr. Z - Impressions • Pattern of results: • Declines: • Complex attention/working memory, susceptibility to distraction, processing speed, verbal fluency • No declines: • Reasoning, verbal learning and memory, visual learningand memory, abstract reasoning, problem-solving, planning • Consistent with common side effects of antipsychotic and anti-convulsant medications

34. Remediation, compensatory strategies, medication, etc. • Cognitive strategies: retraining • Compensatory: utilize strengths, use modifications • Environmental modifications • Medication: Aricept, etc.

35. Insight into illness and outcome • Insight into psychiatric illness critical to outcome (probably #1 for many of these patients) • Cognitive dysfunction highly predictive of prognosis (as important as “typical” psychotic sxs) • Cognitive dysfunction sometimes linked to excess medication dose as evidenced by EEG changes

36. Cognitive Impairment & Insight-Literature • (Amador et al., 1991; Lysaker & Bell, 1994): • Poor recognition of illness secondary to deficits in abstract and flexible thinking • (Amador et al., 1994): • Poor insight is a prevalent feature of schizophrenia, and may stem from neuropsychological dysfunction; • Increased formal thought disorder correlated with lower insight into mental illness and social consequences of it.

37. Cognitive Impairment & Insight-Current Literature (cont.) • Severity of poor insight strongly correlated with degree of structural dysfunction (frontal lobes) and executive dysfunction (WCST, verbal fluency, Trails)

38. Cognitive Deficits and Daily Functioning • (Green, 1996) Functional outcome of cognitive deficits: • Verbal Memory associated with all types of functional outcome (e.g., social skills acquisition, community outcome, social problem-solving) • Vigilance related to social problem solving and skill acquisition • Card Sorting predicted community functioning.

39. Conclusions • Questions? • Comments?