Disorganization and Individual Psychotherapy for Schizophrenia: A Case Report of Metacognitive Reflection and Insight Therapy

Despite being a characteristic symptom of schizophrenia, implications for therapy with persons experiencing prominent disorganization have received less attention in the psychotherapy literature than have other aspects of the disorder. As such, formal thought disorder may be viewed largely as a barrier to effective participation in therapy. In contrast, though, a range of writers from varied traditions have stressed that this feature of schizophrenia is meaningful and improved coherence of speech is an important and viable component of treatment and recovery. This paper suggests that an emergent integrative psychotherapy, metacognitive reflection and insight therapy (MERIT), may be well-suited for work with persons experiencing disorganization symptoms. A brief overview of MERIT is provided, followed by a case report of an 18-month course of therapy with a man with severely disorganized speech.     

Verbal communication impairments and cognitive control components in people with schizophrenia

Schizophrenia involves multiple communication impairments, including (a) disorganized speech, or formal thought disorder (FTD); and (b) decreased speech output, or poverty of speech. Both FTD and poverty of speech have been hypothesized to be associated with deficits in executive functioning or cognitive control. The current study examined whether FTD and poverty of speech were differentially associated with two distinct aspects of cognitive control, working memory and controlled retrieval. Compared with control participants (n = 30), people with schizophrenia (n = 47) exhibited poorer performance on both working memory and controlled retrieval tasks. However, only FTD (and not poverty of speech) was associated with poor working memory. In contrast, only poverty of speech (and not FTD) had a significant zero-order association with poor controlled retrieval. At the same time, working memory and controlled retrieval interacted to predict FTD, with the highest amount of FTD associated with both poor working memory and poor controlled retrieval. In contrast, psychometric control tasks were not associated with FTD or poverty of speech. This research suggests that FTD and poverty of speech are differentially associated with deficits in distinct aspects of cognitive control.     

Optimizing treatment of schizophrenia. Enhancing affective/cognitive and depressive functioning

Recognition and treatment of schizophrenia has largely focused on positive symptoms of the disorder, such as delusions, hallucinations, and disorganization. However, other important symptoms, such as depression, cognition, and social functioning, have not received comparable attention. Fifty percent of schizophrenic patients suffer from comorbid depression, which is a major risk factor for suicide in this population, while 10% to 25% suffer from comorbid obsessive-compulsive disorder. Cognitive deficits commonly observed in patients with schizophrenia include problems with concentration, attention, and memory, as well as problem-solving and verbal skills. These deficits are observed at early stages of the illness and can predict deficits in functional capabilities, such as occupational and social skills, educational attainment, and the ability to live independently. The severity of such impairments affects all patient in this population, including up to 10% of patients working full time and up to one third of those working part time. In light of the debilitating effects of depression, cognitive impairment, and other aspects of affective functioning on the quality of life of patients with schizophrenia, physicians need to partner with their patients to address these concerns and determine an appropriate treatment regimen. This can be done with simple functional-based cognitive questioning, the use of evidence-based psychosocial practices, and psychoeducation on the many pharmacotherapeutic options. It is recommended that depressive or suicidal symptoms of schizophrenia be treated with an antidepressant or mood stabilizer only if the symptoms have not subsided after treatment of the psychosis with an atypical antipsychotic. Additionally, relative to older medications, atypicals have demonstrated benefit in improving some of the cognitive impairments.     

Cognitive impairments associated with formal thought disorder in people with schizophrenia

Formal thought disorder (FTD), or disorganized speech, is one of the central signs of schizophrenia. Despite extensive research, the cognitive processes associated with FTD are still unclear. However, the authors' review of FTD theories and research indicates that considerable progress has been made in identifying possible cognitive impairments associated with FTD. Specifically, FTD is strongly associated with impaired executive functioning and with impaired processing of semantic information. Their review indicates that previous research has not yet supported an association between FTD and either an increase in spreading activation or an impairment within the language production system.     

Pragmatic Competency and Obsessive–Compulsive Disorder: A Comparative Assessment with Normal Controls

Unlike such cognitive impairments as autism and schizophrenia, the speech pattern in obsessive–compulsive disorder (OCD) has largely remained underrepresented. We examined the pragmatic competence of OCD-affected individuals under two variant modes: pragmatic recognition and pragmatic production. In the recognition phase, the informants completed a discourse completion test around two speech acts of request and apology (20 high power distance situations). The production phase was carried out through an interview during which the informants’ communication behaviors were rated on the basis of the Orion’s pragmatic language skills checklist (OPLS) subscales. No significant difference was observed between the normal and OCD groups in terms of pragmatic recognition. Moreover, considering the OPLS subscales, although the normal controls significantly outperformed in non-verbal communication and expressive skills, the overall pragmatic production ability of the two groups was statistically alike. The results are discussed in relation to the two competing disorders of autism and social anxiety.     

Self-consciousness, self-agency, and schizophrenia

Empirical approaches on topics such as consciousness, self-awareness, or introspective perspective, need a conceptual framework so that the emerging, still unconnected findings can be integrated and put into perspective. We introduce a model of self-consciousness derived from phenomenology, philosophy, the cognitive, and neurosciences. We will then give an overview of research data on one particular aspect of our model, self-agency, trying to link findings from cognitive psychology and neuroscience. Finally, we will expand on pathological aspects of self-agency, and in particular on psychosis in schizophrenia. We show, that a deficient self-monitoring system underlies, in part, hallucinations and formal thought (language) disorder in schizophrenia. We argue, that self-consciousness is a valid construct and can be studied with the instruments of cognitive and neuroscience.     

RT distributional analysis of cognitive-control-related brain activity in first-episode schizophrenia

Impairments in cognitive control are a defining feature of schizophrenia. Aspects of cognitive control include proactive control—the maintenance of task rules or goals to bias attention and maintain preparedness—and reactive control—the engagement of attention in reaction to changing cognitive demands. Proactive control is thought to be particularly impaired in schizophrenia. We sought to examine proactive and reactive control in schizophrenia, as measured by reaction time (RT) variability, and especially long RTs, which are thought to represent lapses in proactive control, during the Stroop paradigm. Furthermore, we sought to examine the neural underpinnings of lapses in proactive control and the subsequent engagement of reactive control in those with schizophrenia, as compared to healthy controls, using fMRI. We found that patients with schizophrenia displayed greater RT variability and more extremely long RTs than controls suggesting that proactive control was weaker in the schizophrenia than in the control group. All of the subjects engaged regions of the cognitive control network during long RTs, consistent with an engagement of reactive control following a failure in proactive control on these trials. The schizophrenia group, however, displayed significantly diminished activity in these regions relative to controls. Our results suggest increased failures in proactive control, but also impaired reactive control, in schizophrenia as compared to healthy subjects.     

Neuropsychological profile in patients with schizotypal personality disorder or schizophrenia

Neuropsychological impairments have been consistently reported in patients with schizophrenia. As little is known whether subjects with schizotypal personality disorder exhibit neurocognitive dysfunction similar to that in schizophrenia, we assessed the neuropsychological profile of 15 subjects with schizotypal personality disorder and compared it with that for 15 patients with schizophrenia and for 15 psychiatrically normal volunteers. All participants were administered a standard neuropsychological battery assessing language ability, spatial ability, visuomotor function, verbal memory, visual memory, auditory attention, visual attention, and executive function. Performance on most of the cognitive domains was impaired in patients with schizotypal personality disorder but less than patients with schizophrenia. Specifically, impairment in verbal memory and visuomotor ability in patients with schizotypal personality disorder and patients with schizophrenia were comparable, while patients with schizophrenia performed worse on the test of executive function than did patients with schizotypal personality disorder. As a whole, cognitive deficits in patients with schizotypal personality disorder were qualitatively similar to, but quantitatively milder than, those for patients with schizophrenia. The results suggest that cognitive abilities related to frontotemporal lobe function are disturbed across these schizophrenia-spectrum disorders.     

精神分裂症患者的语音感知

精神分裂症是一种常见的精神疾病, 表现为多方面的症状, 其中, 语言异常是精神分裂症患者认知损伤的核心症状之一。本文关注精神分裂症患者的语音感知, 从音段和超音段两方面简述国内外对精神分裂症患者语音感知开展的行为和神经科学实验, 指出中国应加大对中国精神分裂症患者的汉语语音感知探索。     

Schizophrenia: refining the phenotype, resolving endophenotypes

The conceptual history of the diagnosis of schizophrenia is reviewed and the current definition of the illness is examined (e.g. DSM-IV). A dimensional alternative to the traditional categorical model of diagnosis is discussed with a specific emphasis on the four dimensions of psychopathology represented by reality distortion (hallucinations, delusions), disorganization (positive formal thought disorder, bizarre behavior), negative symptoms (flattened affect, avolition, alogia, asociality), and premorbid social functioning. Also discussed is the development of structured psychiatric interviews that emerged from the clinical/research context that gave rise to explicit (i.e. operational) diagnostic criteria for schizophrenia. The general methodological approach used to detect valid endophenotypes for schizophrenia liability--i.e. indicators of liability not visible to the unaided naked eye--as well as their potential diagnostic and research utility is presented in overview. The rationale for linking such indicators to schizophrenia liability, which is conceptualized as a latent construct, is also reviewed. Future directions in the development and refinement of the diagnostic approach to schizophrenia and schizophrenia liability are highlighted.     

Neuropsychological impairments in schizophrenia: Integration of performance-based and brain imaging findings

Until recently, the dominant view was that schizophrenia patients have limited, if any, neuropsychological impairments, and those that are observed are only secondary to the florid symptoms of the disorder. This view has dramatically changed. This review integrates recent evidence demonstrating the severity and profile of neuropsychological impairments in schizophrenia. We present quantitative evaluation of the literature demonstrating that the most severe impairments are apparent in episodic memory and executive control processes, evident on a background of a generalized cognitive deficit. The neuropsychological impairments potentially represent genetic liability to the disorder, as similar, yet milder, impairments are evident in schizophrenia patients even before the onset of psychotic symptoms, as well as in the nonpsychotic relatives of schizophrenia patients. Corresponding cognitive neuroimaging literature on executive functions, episodic memory, and working memory in schizophrenia documenting abnormalities in frontal and medial temporal lobes is summarized, and current models integrating neuropsychological and neuroimaging data are discussed.     

关于自闭症的临床、实验心理学的研究

最近,国际上的临床心理学、实验心理学对自闭症的诊断、分类、发生率以及教育与治疗等,从各个角度展示了许多新的研究结果。实验心理学的调查结果表明,自闭症儿童的注意力异常,对视、听、触等感觉反应处理样式,不同于弱智儿童和正常儿童。语言障碍是自闭症儿童发展障碍中的核心症侯,这与自闭症在社会性和人际关系上存在障碍有着密切的关系。进入９０年代以后,对自闭症“心的理论”的各种实验研究,引起各国研究者的注目和争论     

Stability of formal thought disorder and referential communication disturbances in schizophrenia

This study examined the degree to which different types of communication disturbances in the speech of 48 schizophrenia patients and 28 controls were variable and state related versus stable and traitlike. Clinically rated formal thought disorder and 5 types of referential disturbance showed substantial stability within participants over time. The sixth type of referential disturbance, the vague reference, was not stable over time. Formal thought disorder was associated with the severity of core psychotic symptoms in patients. whereas referential disturbances showed little or no association with positive or negative symptom severity. Furthermore, changes in psychotic symptoms over time were accompanied by corresponding changes in formal thought disorder but not referential disturbances. These results support the idea that some types of referential disturbances are traitlike and may be reflective of vulnerability as well as manifest illness.     

Referential communication disturbances in the speech of nonschizophrenic siblings of schizophrenia patients

Several different types of communication disturbances have been identified in the speech of schizophrenia patients. This study assessed 6 types of referential communication disturbances in the speech of 32 stable outpatients, 23 of their nonschizophrenic siblings, and 27 control subjects. The siblings made more frequent reference failures of all types than control subjects and did not differ from the patients on most types of disturbance. Only on the arguably most "schizophrenic" type of disturbance, the missing information reference, did patients show more deviance than siblings. On the vague reference, siblings showed more deviance than patients. These results, which are very similar to those previously reported on parents of patients, support the idea that referential disturbances reflect vulnerability to schizophrenia.     

Understanding the executive functioning heterogeneity in schizophrenia

Schizophrenia is characterized by heterogeneous brain abnormalities involving cerebral regions implied in the executive functioning. The dysexecutive syndrome is one of the most prominent and functionally cognitive features of schizophrenia. Nevertheless, it is not clear to what extend executive deficits are heterogeneous in schizophrenia patients. Furthermore, it is still unknown if the executive impairments observed in schizophrenia are better characterized as specific or as reflecting generalized cognitive factors. The four executive processes (i.e. updating, inhibition, shifting and divided attention) described in Miyake et al.'s (2000) theoretical model were examined in 62 individuals with schizophrenia and 49 healthy controls. At group level, impairments in all four executive processes confirmed the marked impairment in executive functioning in patients with schizophrenia. Statistical analysis indicated that executive performances in schizophrenia patients were more heterogeneous than in healthy controls. Compared with standardized norms, 94% of patients exhibited impairment in at least one of the executive tasks. Twenty-one percent of patients exhibited impairment in one executive task, 27% in two tasks, 23% in three executive tasks and 23% exhibited impairments in the four executive tasks. Six percent of patients had normal executive profile. Regression analysis indicated that only premorbid intellectual quotient and a general slowing in processing speed predicted the executive dysfunction severity. Executive functioning was not affected by age, duration of illness, psychotic status, or by antipsychotic dosage. Our results emphasize the heterogeneity of the dysexecutive syndrome in schizophrenia when individual profile analysis is considered, and extend the view that individual cognitive differences in schizophrenia are largely underlined by general cognitive factors such as intellectual level and general processing speed.     

Distinct conflict resolution deficits related to different facets of Schizophrenia

An important issue in understanding the nature of conflict processing is whether it is a unitary or multidimensional construct. One way to examine this is to study whether people with impaired conflict processing exhibit a general pattern of deficits or whether they exhibit impairments in distinct aspects of conflict processing. One group who might exhibit conflict deficits are people with schizophrenia. Schizophrenia is a heterogeneous disorder, with one way to break down the heterogeneity of schizophrenia is to examine specific symptoms. Previous research has found that specific symptoms of schizophrenia are associated with specific deficits in conflict processing. In particular, disorganization is associated with increased response conflict, alogia is associated with increased retrieval conflict, and anhedonia is associated with increased emotional conflict. Moreover, there is evidence that different types of conflict processing are unassociated with each other. This evidence suggests that conflict processing is a multidimensional construct and that different aspects of schizophrenia are associated with impairments in processing different types of conflict.     

精神分裂症患者在听觉掩蔽环境下的言语识别

深入研究精神分裂症患者特异性的认知障碍有助于精神分裂症的早期发现、早期诊断和早期治疗.本综述在总结精神分裂症患者的听觉和言语识别异常以及听觉注意和听觉工作记忆缺陷的同时,重点阐述了精神分裂症患者完成言语听觉任务时的对掩蔽刺激特别信息掩蔽刺激的异常易感性.本文还特别指出,精神分裂症患者仍然具有利用言语内容启动线索来提高掩蔽下言语识别的能力.本文所总结的研究成果对探讨精神分裂症的病因学基础、寻找新的临床诊断以及治疗和康复手段都具有参考价值.     

Motor, Emotional, and Cognitive Empathy in Children and Adolescents with Autism Spectrum Disorder and Conduct Disorder

It is unclear which aspects of empathy are shared and which are uniquely affected in autism spectrum disorder (ASD) and conduct disorder (CD) as are the neurobiological correlates of these empathy impairments. The aim of this systematic review is to describe the overlap and specificity of motor, emotional, and cognitive aspects of empathy in children and adolescents with ASD or CD. Motor and cognitive empathy impairments are found in both ASD and CD, yet the specificity seems to differ. In ASD facial mimicry and emotion recognition may be impaired for all basic emotions, whereas in CD this is only the case for negative emotions. Emotional empathy and the role of attention to the eyes therein need further investigation. We hypothesize that impaired motor and cognitive empathy in both disorders are a consequence of lack of attention to the eyes. However, we hypothesize major differences in emotional empathy deficits between ASD and CD, probably due to emotional autonomic and amygdala hyper-responsivity in ASD versus hypo-responsivity in CD, both resulting in lack of attention to the eyes.     

Dichotic listening,executive functions and grey matter cortical volume in patients with schizophrenia and healthy controls

Schizophrenia is characterized by cognitive impairment, especially in relation to executive functions. Brain structural abnormalities are also often seen in schizophrenia although little is known of the relationship between cognitive impairment and structural brain changes. Our aim was therefore to investigate this relationship further using MRI and a dichotic listening (DL) task with simple speech sounds and with instructions to focus attention and report only from the left or right ear stimulus. When instructed to focus attention on the left ear syllable a cognitive conflict is induced requiring the allocation of executive resources to be resolved. Grey matter (GM) volume was measured with MRI from four volumes of interests (VOIs), left and right frontal and temporal cortex, respectively, and correlated with DL performance. The results showed significant differences between the groups in their ability to focus attention on and report the left ear stimulus, which was accompanied by reduced GM volume in the left frontal and right temporal lobe VOIs. There was also a significant positive correlation between left frontal GM volume and performance on the DL task, for the groups combined. The results did not support a conclusion that an impairment in cognitive function in schizophrenia was driven by an corresponding impairment in brain structure, since there were no significant correlations when the groups were analyzed separately. It is however concluded that patients with schizophrenia are impaired in executive functions and that they also show reduced GM volumes in left frontal and right temporal lobe areas, compared to healthy controls.     

CANTAB explicit memory is less impaired in addicted schizophrenia patients

It has been suggested that in order to sustain the lifestyle of substance abuse, addicted schizophrenia patients would have less negative symptoms, better social skills, and less cognitive impairments. Mounting evidence supports the first two assumptions, but data lack regarding cognition in dual diagnosis schizophrenia. Seventy-six schizophrenia outpatients (DSM-IV) were divided into two groups: with (n = 44) and without (n = 32) a substance use disorder. Motor speed and visuo-spatial explicit memory were investigated using CANTAB. As expected, dual diagnosis patients showed a better cognitive performance. Our results suggest either that substance abuse relieves the cognitive deficits of schizophrenia or that the patients with less cognitive deficits are more prone to substance abuse.