Psychiatric rehabilitation of schizophrenia: Unresolved issues, current trends, and future directions

Psychiatric rehabilitation refers to a treatment philosophy and to a set of assessment and treatment techniques designed to reduce disability and maximize environmental adaptation. The field of psychiatric rehabilitation of schizophrenia is now well developed, and successful interventions exist for teaching many essential community-living skills and for promoting maintenance and generalization of these gains. Recent developments include the creation of new skills-training interventions and cognitive rehabilitation techniques and improvements in the delivery of vocational and substance abuse treatments. As a field, psychiatric rehabilitation is continuing to develop in a manner that is responsive to perceived treatment needs, shortcomings of existing interventions, and developments in related fields (e.g., social psychology, neuroscience of schizophrenia). Some of these developments in theory and research point to areas of conceptual/theoretical weaknesses in existing treatments and assessment measures and suggest directions for further development. This article reviews the current status of a number of areas within the psychiatric rehabilitation of schizophrenia, highlighting future needs.     

Cognitive function and depression in symptom resolution in schizophrenia patients treated with an atypical antipsychotic

OBJECTIVE: To investigate which cognitive and affective features contribute most to responder/non-responder group separation during a switching trial with atypical antipsychotic. DESIGN: A prospective open trial with an atypical antipsychotic (olanzapine). PATIENTS: One hundred and thirty-four patients meeting diagnostic criteria for schizophrenia, schizophreniform or schizoaffective disorder began an 8-week open-label olanzapine treatment at a dose of 5 mg/day which was increased to 10 mg/day after one week. INTERVENTIONS: Olanzapine during 8 weeks. Patients were considered as responders if their BPRS score decreased of at least 20% (n = 96) and non-responders if it did not (n = 38). Neuropsychological assessments were carried out at baseline, at four and at eight weeks. RESULTS: Neurocognitive measures were analyzed for discriminate factors between responder and non-responder groups. A regression analysis was applied to explain the effects of depression on each cognitive variable. Depression was found to be a weak discriminant factor, however this finding could not firmly establish that depression is a potential factor in explaining deficits and improvements in cognition.     

Multiple memory systems: the power of interactions

Two relatively simple theories of brain function will be used to demonstrate the explanatory power of multiple memory systems in your brain interacting cooperatively or competitively to directly or indirectly influence cognition and behaviour. The view put forth in this mini-review is that interactions between memory systems produce normal and abnormal manifestations of behaviour, and by logical extension, an understanding of these complex interactions holds the key to understanding debilitating brain and psychiatric disorders.     

Obsessive-compulsive disorder patients display enhanced latent inhibition on a visual search task

Latent inhibition (LI) is a phenomenon that reflects the ability to ignore irrelevant stimuli. LI is attenuated in some schizophrenic patient groups and in high schizotypal normal participants. One study has found enhanced LI in patients with obsessive-compulsive disorder (OCD [Swerdlow, N. R., Hartston, H. J., & Hartman, P. L., 1999. Enhanced visual latent inhibition in obsessive-compulsive disorder. Biological Psychiatry, 45, 482-488]). The present experiment replicated this finding using a within-subject visual search LI task, with OCD patients displaying more LI than healthy controls. The contrasting LI effects in schizophrenia and OCD are discussed in terms of how these groups differentially process relevant and irrelevant stimuli, and how that outcome affects subsequent behavior.     

Multiple-family group treatment of outpatients with schizophrenia: impact on service utilization

The impact of multiple-family group treatment (MFGT) on outpatient and inpatient mental health service utilization of 97 persons with schizophrenia was investigated. Participants were randomly assigned to standard care (n = 44) or standard care plus MFGT (n = 53). Service use for a year prior to randomization, the 2-year study period, and a 1-year follow-up were examined. Relative to standard care participants, the MFGT group had reduced community hospitalization during year 1 of the intervention and reduced state hospitalization at follow-up. During the intervention period, MFGT participants demonstrated a significant increase in outpatient utilization as a direct consequence of the intervention. However, when service use was summed across 3 years post-randomization, no group differences were observed. Results suggest that implementation of MFGT in a community mental health setting reduces inpatient service at specific time periods, without significantly increasing outpatient service utilization. These findings add to other outcomes from this study that demonstrate decreased psychiatric symptoms and caregiver distress.     

The self in action: lessons from delusions of control

Patients with delusions of control are abnormally aware of the sensory consequences of their actions and have difficulty with on-line corrections of movement. As a result they do not feel in control of their movements. At the same time they are strongly aware of the action being intentional. This leads them to believe that their actions are being controlled by an external agent. In contrast, the normal mark of the self in action is that we have very little experience of it. Most of the time we are not aware of the sensory consequences of our actions or of the various subtle corrections that we make during the course of goal-directed actions. We know that we are agents and that we are successfully causing the world to change. But as actors we move through the world like shadows glimpsed only occasional from the corner of an eye.     

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.     

Effects of interval duration on temporal processing in schizophrenia

INTRODUCTION: Temporal processing has received scant attention in the literature pertaining to cognitive deficits in patients with schizophrenia. Previous research suggests that patients with schizophrenia exhibit temporal perception deficits on both auditory and visual stimuli. The current study investigated the effects of interval manipulation to (1) replicate the original findings with a larger sample and an increased number of trials (2) assess the degree to which both patients and controls can differentiate temporal changes in a range of experimental interstimulus intervals, and (3) explore whether different interstimulus interval durations pose different levels of difficulty for the patients with schizophrenia. METHODS: Participants were asked to decide whether temporal intervals were shorter or longer than standard intervals on a computer-based auditory temporal perception task. The standard interval remained the same duration throughout the various tasks. The interstimulus interval separating the standard and experimental intervals varied in the range of 500, 1000, or 3000 ms. Data are presented for a sample of 16 patients with schizophrenia and 15 controls. RESULTS: Data suggest that patients with schizophrenia exhibit deficits in differentiating interval durations across all paradigms compared to their control-group peers on a range of auditory tasks (p<.001). CONCLUSIONS: These results are consistent with a general temporal deficit in schizophrenia. However, the roles of medication and localization are also addressed.