Assessing cognitive-related disability in schizophrenia: Reliability, validity and underlying factors of the evaluation of cognitive processes involved in disability in schizophrenia scale.

PURPOSE: We have developed a new scale that assesses disability caused by cognitive impairments in schizophrenia, in order to evaluate the functional impact of schizophrenia and help the prescription of rehabilitation interventions. The aim of the study was to assess its psychometrical properties. MATERIALS AND METHODS: Mental healthcare professionals and relatives of individuals with schizophrenia developed and rated the evaluation of cognitive processes involved in disability in schizophrenia scale, which included 13 items. Its construct validity was assessed through a factorial analysis; its concurrent validity was evaluated based on ecological outcomes, its convergent validity was tested against the World Health Organization Disability Assessment Schedule (WHODAS II), and its reliability was estimated based on internal consistency and inter-rater reliability. RESULTS: Overall, 215 patients were included. Our findings supported a two-factor structure which accounted for 46% of the variance. The internal consistency and inter-rater reliability were good. The convergent validity showed a strong correlation with the WHODAS II. The concurrent validity showed strong relationships with work status, independent living, level and adequacy of institutional care. CONCLUSIONS: The good psychometric properties of the scale suggest a role for this tool in assessing schizophrenia-related disability and evaluating the need for cognitive remediation. Implication for Rehabilitation Schizophrenia is a chronic disorder leading to a severe psychiatric handicap. The scale showed good psychometric properties in individuals with schizophrenia and severe psychiatric disability. The scale is easy and quick to administer (about 15 min). The scale may help to identify targets for rehabilitation interventions in individuals with schizophrenia.

Behavioral and brain measures (N400) of semantic priming in patients with schizophrenia: test-retest effect in a longitudinal study.

AIM: The purpose of this study was to investigate whether deficits in the behavioral and/or N400 semantic priming (SP) effect observed in patients with schizophrenia constitute a stable cognitive feature of the disorder or whether they may be influenced by the severity of each individual's symptomatology. METHODS: A 1-year test-retest study was conducted on 15 patients with schizophrenia and 10 healthy participants who performed an SP task. Both behavioral measures and event-related potentials measures of SP were recorded twice (test and retest sessions). RESULTS: At test, patients exhibited a deficit in SP as was revealed by both the behavioral and the event-related potentials measures of the amplitude of the N400 component. At retest, behavioral SP remained impaired, whereas N400 SP was significantly improved. CONCLUSION: These results provide evidence that SP impairments in schizophrenia as measured by N400 should not be considered as stable cognitive markers of the disorder. The behavioral and the N400 measures of SP indicated different levels of sensitivity to subtle cognitive and brain processes, which are subject to change over the clinical course of schizophrenic disorder.

Correlations of theory of mind deficits with clinical patterns and quality of life in schizophrenia.

BACKGROUND: Numerous studies have demonstrated the existence of theory of mind (ToM) impairments in patients with schizophrenia. The clinical consequences of these impairments are currently under debate. Accumulated evidence suggests that ToM deficits are linked to negative and disorganization symptoms, but direct correlations are lacking. Moreover, it is unclear whether ToM deficits are related to reduced quality of life (QoL). METHODS: To extend the understanding of objective (i.e., clinical symptoms) and subjective (QoL) correlates of impaired ToM, we assessed 206 patients with schizophrenia based on performance of an ecological task (Versailles-Situational Intention Reading, V-SIR), a Communication Disorders Scale (SCD), the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression rating, and a QoL questionnaire (S-QoL). Statistical inferences were drawn from correlations analyses considering both factors/subscales aggregates and single items. RESULTS: ToM performance was negatively correlated to disorganization and negative PANSS factors. Poor V-SIR performance was correlated with "conceptual disorganization," "difficulties in abstract thinking," and "apathy/social withdrawal." The SCD was correlated with "negative," "disorganization," and "anxiety/depression" PANSS factors. The S-QoL total score was not significantly correlated with ToM performance. Only the item "difficulties in expressing feelings" was significantly correlated with poorer V-SIR performance. CONCLUSION: We discuss the intriguing paucity of the results and what they reveal about the difficulties faced by psychiatrists with patients not expressing complaints about lack of social skills.

Neural basis of semantic priming in schizophrenia during a lexical decision task: a magneto-encephalography study.

Numerous behavioral and electrophysiological studies have provided evidence of abnormal semantic processing in schizophrenia. However, the neural basis of these deficits is poorly understood. We investigated magnetic cortical responses elicited by a word-pair lexical decision task in 20 patients with schizophrenia and 12 healthy control subjects. The task involved presentation of a prime word (200 ms), followed by a blank (250 ms), and then a target stimulus (1200 ms); the subject had to decide whether the target was a real word or not. During this task, bilateral temporal and left prefrontal activations were observed in both groups. However, in contrast to controls, patients with schizophrenia did not show increased activation in the left temporal and anterior cingulate cortices between 200 and 450 ms in response to semantic incongruity. These results suggested that schizophrenia was associated with a functional disturbance in some semantic regions that gave rise to the N400 component. Moreover, a significant modulation in the right temporal cortex was observed in patients, but not in controls. This suggested the existence of alternative processes in patients because both groups showed similar behavioral priming. Finally, we elucidated some functional abnormalities in the semantic network during prime word processing in patients, indicated by prolonged activation compared to healthy controls. Thus, in addition to context integration impairment, abnormal activations during the prime word provided new evidence of context processing deficits in schizophrenia.

Abnormal temporal and parietal magnetic activations during the early stages of theory of mind in schizophrenic patients.

Schizophrenia is associated with abnormal cortical activation during theory of mind (ToM), as demonstrated by several fMRI or PET studies. Electrical and temporal characteristics of these abnormalities, especially in the early stages, remain unexplored. Nineteen medicated schizophrenic patients and 21 healthy controls underwent magnetoencephalography (MEG) recording to measure brain response evoked by nonverbal stimuli requiring mentalizing. Three conditions based on comic-strips were contrasted: attribution of intentions to others (AI), physical causality with human characters (PCCH), and physical causality with objects (PCOB). Minimum norm localization was performed in order to select regions of interest (ROIs) within bilateral temporal and parietal regions that showed significant ToM-related activations in the control group. Time-courses of each ROI were compared across group and condition. Reduced cortical activation within the 200 to 600 ms time-window was observed in the selected regions in patients. Significant group by condition interactions (i.e., reduced modulation in patients) were found in right posterior superior temporal sulcus, right temporoparietal junction, and right inferior parietal lobule during attribution of intentions. As in healthy controls, the presence of characters elicited activation in patients' left posterior temporal regions and temporoparietal junction. No group difference on evoked responses' latencies in AI was found. In conclusion, ToM processes in the early stages are functionally impaired in schizophrenia. MEG provides a promising means to refine our knowledge on schizophrenic social cognitive disorders.

Anatomical and temporal architecture of theory of mind: a MEG insight into the early stages.

Representation of others' actions and mental states leads to the activation of several brain networks: the mentalizing and the "mirror neuron" systems as well as a "low level" social perception component. However, respective activations of the regions belonging to these networks remain unknown with respect to chronometrical data when static drawing stimuli are presented. To determine anatomical and temporal characteristics of theory of mind processes, magnetic signals were measured in 21 subjects during a validated nonverbal attribution of intentions task. Minimum norm estimation provides chronometric and localization data showing that regions known to be involved in the mentalizing, "mirror neuron" and social perception networks have simultaneous activations between 100 and 700 ms post-stimulus, a period which may be thought as corresponding to early stages of social processes. Among some regions, different profiles as well as modulations regarding experimental conditions suggest functional distinctions between these structures, pleading for a cooperative nature of these networks. While the left temporo-parietal area and superior temporal sulcus seem more specialized in social cues coding, we demonstrate that their right homologues, as well as the right inferior parietal cortex, are preferentially recruited during attribution of intentions stimuli compared to scenarios based on physical causality from 200 to 600 ms.

The study of social cognition with neuroimaging methods as a means to explore future directions of deficit evaluation in schizophrenia?

This article discusses the important advances in a recent field of science dealing with the brain processes implicated in understanding social situations and interacting with others. Many behavioral studies on schizophrenia have shown the impairment of these processes and their preferential relation with disorganization and negative syndromes. Brain imaging is a powerful method to identify brain systems participating in these processes in healthy subjects and will be used increasingly to study mental disorders such as schizophrenia. A few preliminary studies have opened this field of research and allowed for the drawing of some limited conclusions. We emphasize the importance of developing an integrated neurocognitive framework to account for the multifaceted nature of social cognition deficits in schizophrenia. Inspired by contemporary models of empathy and social cognition that identify different components such as shared representation, mentalizing, self/other distinction, we show how schizophrenia affects these components at the behavioral and functional levels. We also outline the interest of this model to understand putative abnormalities of contextual integration within the area of mentalization. Finally, we discuss how specialized measures of brain functions during the performance of these precisely defined mental processes might be used as outcome predictors.

The influence of idiomatic salience during the comprehension of ambiguous idioms by patients with schizophrenia.

This study investigates whether figurative comprehension in schizophrenia is influenced by the salience of idiomatic meaning, and whether it is affected by clinical and demographic factors and IQ. Twenty-seven schizophrenic patients and 25 healthy participants performed a semantic relatedness judgement task which required the comprehension of idioms with two plausible meanings (literal and figurative). The study also used literal expressions. The figurative meaning of the idioms was less salient (ILS), more salient (IFS), or equally salient (IES) compared to the literal meaning. The results showed "a salience effect" (i.e., all participants understood the salient meanings better than the less salient meanings). There was also a "figurativeness effect" (i.e., healthy individuals understood the figurative meaning of IES better than the literal meaning but not schizophrenic patients). In patients, their thought disorder influenced the figurative comprehension of IFS. The verbal IQ influenced the figurative comprehension of ILS. The thought disorder, the verbal IQ, and the educational level influenced the figurative comprehension of IES. The patients' clinically evaluated concretism was associated with a reduced figurative comprehension of IFS and IES evaluated at a cognitive level. The results are discussed in relation to cognitive mechanisms which underscore figurative comprehension in schizophrenia.

Quantitative assessment of attribution of intentions to others in schizophrenia using an ecological video-based task: a comparison with manic and depressed patients.

Schizophrenia is characterized by the impairment of several facets of social cognition. This has been demonstrated in numerous studies that focused on specific aspects of social cognition such as the attribution of intentions, emotions, or false beliefs to others. However, most of these studies relied on complex verbal descriptions or impoverished social stimuli. In the present study, we evaluated a new task (Versailles-Situational Intention Reading, V-SIR) that is based on video excerpts depicting complex real-life scenes of social interactions. Subjects were required to rate the probabilities of several affirmations of the intentions of one of the characters. The V-SIR task was administered to schizophrenic patients (N=15), depressed patients (N=12), manic patients (N=15), and healthy controls (N=15). The performance of schizophrenic patients was significantly impaired in comparison to healthy and depressed subjects. There was a trend toward a significant difference between schizophrenic and manic patients. Manic patients also demonstrated impaired performance relative to healthy subjects. Schizophrenic patients' V-SIR scores were significantly correlated with their scores on another attribution of intentions task that used comic strips. These results show that tasks based on more ecological stimuli are powerful enough to detect theory-of-mind abnormalities in pathological populations such as schizophrenic patients.

Long term GP opinions and involvement after a consultation-liaison intervention for mental health problems.

BACKGROUND: Shared Mental Health care between Psychiatry and Primary care has been developed to improve the care of common mental health problems but has not hitherto been adequately evaluated. The present study evaluated a consultation-liaison intervention with two objectives: to explore long-term GP opinions (relating to impact on their management and on patient medical outcome) and to determine the secondary referral rate, after a sufficient time lapse following the intervention to reflect a "real-world" primary care setting. METHODS: All the 139 collaborating GPs (response rate: 84.9%) were invited two years after the intervention to complete a retrospective telephone survey for each patient (181 patients; response rate: 69.6%). RESULTS: 91.2% of GPs evaluated effects as positive for primary care management (mainly as support) and 58.9% noted positive effects for patient medical outcome. Two years post-intervention, management was shared care for 79.7% of patients (the GP as the psychiatric care provider) and care by a psychiatrist for 20.3% patients. Secondary referral occurred finally in 44.2% of cases. CONCLUSION: The intervention supported GP partners in their management of patients with common mental health problems. Further studies are required on the appropriateness of the care provider.

Impact of shared mental health care in the general population on subjects' perceptions of mental health care and on mental health status.

OBJECTIVE: A community survey evaluated whether the development of a shared mental health care intervention had an impact on health care perceptions and mental health status of subjects with common mental health problems (MHP). METHODS: Adults <70 years old with common MHP (DSM-IV/CIDI-SF major depressive disorder, generalized anxiety or MHI-SF 36 psychic distress diagnoses), were randomly drawn from the general population in the intervention area (IA, n = 349) and in a control area (CA, n = 360), and evaluated twice at an interval of 18 months (percentage of follow-up: IA = 69.3%, CA = 71.9%, P = .44). CA and IA groups did not differ for the criteria of interest at baseline. RESULTS: At 18 months, compared to CA, IA reported significantly different help-seeking attitudes or behaviours (P = .02 for all subjects and .006 for subjects with current MHP) and greater general satisfaction with care (P = .03 for both). Remission rates and daily life functioning did not differ. CONCLUSIONS: After 4 years of development of a mental health network based on a consultation-liaison model, Shared Mental Health Care was associated with greater satisfaction and access with care among subjects with common MHP. The association was not found with mental health status, but the study lacked power to adequately address the issues.

What makes people decide who to turn to when faced with a mental health problem? Results from a French survey.

BACKGROUND: The unequal use of mental health care is a great issue, even in countries with universal health coverage. Better knowledge of the factors that have an impact on the pathway to mental health care may be a great help for designing education campaigns and for best organizing health care delivery. The objective of this study is to explore the determinants of help-seeking intentions for mental health problems and which factors influence treatment opinions and the reliance on and compliance with health professionals' advice. METHODS: 441 adults aged 18 to 70 were randomly selected from the general population of two suburban districts near Paris and agreed to participate in the study (response rate = 60.4%). The 412 respondents with no mental health problems based on the CIDI-SF and the CAGE, who had not consulted for a mental health problem in the previous year, were asked in detail about their intentions to seek help in case of a psychological disorder and about their opinion of mental health treatments. The links between the respondents' characteristics and intentions and opinions were explored. RESULTS: More than half of the sample (57.8%) would see their general practitioner (GP) first and 46.6% would continue with their GP for follow-up. Mental health professionals were mentioned far less than GPs. People who would choose their GP first were older and less educated, whereas those who would favor mental health specialists had lower social support. For psychotherapy, respondents were split equally between seeing a GP, a psychiatrist or a psychologist. People were reluctant to take psychotropic drugs, but looked favorably on psychotherapy. CONCLUSION: GPs are often the point of entry into the mental health care system and need to be supported. Public information campaigns about mental health care options and treatments are needed to educate the public, eliminate the stigma of mental illness and eliminate prejudices.

Outcome revealed by preference in schizophrenia (OPS): development of a new class of outcome measurements.

The objective of this paper is to describe the development of a new type of outcome measurement, based on revealed preference, which can be used in serious chronic illnesses. Fifteen texts of about 200 words each were written by one of the authors on the day-to-day life of 15 schizophrenic patients. These 15 'slices of life' thus described were then ranked in terms of acceptability by a second group of 10 schizophrenic patients and by a group of 12 relatives of schizophrenic patients. From these rankings, six situations were selected so as to obtain evenly distributed positioning on an axis of acceptability. These six situations comprised the final instrument. In administration, the patients were first asked if the 'slices of life' that were described were acceptable or not, then if the 'slices of life' described were more or less acceptable than their own lives. Two scores were derived, one for an absolute level and the other for a relative level of the patient's satisfaction with his or her existence. Validation results were presented to a new sample of 229 schizophrenic patients. Internal consistency appeared good and the initial ranking of the six situations in terms of acceptability was confirmed. This study encourages the development of global outcome measures based on revealed preference in chronic serious illnesses.

Interpretation of ambiguous idiomatic statements in schizophrenic and depressive patients. Evidence for common and differential cognitive patterns.

BACKGROUND: This study is concerned with the comprehension of ambiguous idiomatic statements in schizophrenic and depressive patients. AIMS: Using a multiple-choice procedure, we simultaneously tested the presence of concrete and literal elements in the understanding of idiomatic statements. METHOD: Fourteen schizophrenic and 10 patients undergoing a major depressive episode as well as 14 control subjects completed a questionnaire with 10 idiomatic expressions with two possible interpretations (figurative and literal) of equivalent prominence. The participants had to choose one word linked with the different interpretations of these idioms (figurative, literal, concrete or inappropriate meaning). RESULTS: The main results show that, in all the subjects, the contextual characteristics of the task induced a bias in favor of figurative interpretations despite the equivalent prominence of the literal interpretations of the idioms. The selection of responses relating to the concrete meaning of a single word in the idiom constituted a response mode common to both the schizophrenic and depressed patients. Despite the contextual constraints of the task, the schizophrenics opted for the literal responses more often than the other participants. The descriptive analysis argues in favor of a cognitive and clinical heterogeneity of schizophrenic patients. CONCLUSION: Results support the idea that literality and concreteness in idiomatic interpretation are possibly due to distinct cognitive impairments, though only some are specific to schizophrenic patients.

Elaboration of a rehabilitation method based on a pathogenetic hypothesis of "theory of mind" impairment in schizophrenia.

"Theory of mind" skills have repeatedly been shown to be impaired in schizophrenic patients. The purpose of this paper is to develop a therapeutic intervention targeting schizophrenic patients' abilities to attribute mental states to others. This preliminary study tried to test the hypothesis that this kind of intervention should improve patients' communication abilities; we also wondered if this would have a positive impact on their more general psychopathology. Eight chronic schizophrenic patients were asked to analyse video scenes (showing interactions between two or more persons), with particular attention being paid to the characters' mental states. Their clinical assessments (general clinical symptoms, communication, and the ability to attribute intentions to others, rated before and after two training sessions, over a one-week period) were compared with those of a control group of six chronic schizophrenic patients. The results support our hypothesis of a possible improvement of patients' communication disorders and an improvement of their abilities to attribute intentions to others. The more general psychopathology ratings, however, remained unchanged. Although these results need further development and confirmation, they suggest a possible promising approach for psychosocial rehabilitation therapies based on "theory of mind" skills.

On understanding idiomatic language: The salience hypothesis assessed by ERPs.

Giora's [Giora, R., 1997. Understanding figurative and literal language: the Graded Salience Hypothesis. Cogn. Linguist. 7 (1), 183-206; Giora, R., 2003. On Our Mind: Salience Context and Figurative Language. Oxford Univ. Press, New York] Graded Salience Hypothesis states that more salient meanings-coded meanings foremost on our mind due to conventionality, frequency, familiarity, or prototypicality-are accessed faster than and reach sufficient levels of activation before less salient ones. This research addresses predictions derived from this model by examining the salience of familiar and predictable idioms, presented out of context. ERPs recorded from 30 subjects involved in reading and lexical decision tasks to (strongly/weakly) salient idioms and (figurative/literal) targets indicate that N400 amplitude was smaller for the last word of the strongly salient idioms than for the weakly salient idioms. Moreover, N400 amplitude of probes related to the salient meaning of strongly salient idioms was smaller than those of the 3 other conditions. In addition, response times to salient interpretations (the idiomatic meanings of highly salient idioms and the literal interpretations of less salient idioms) were shorter compared to the other conditions. These findings support Giora's Graded Salience Hypothesis. They show that salient meanings are accessed automatically, regardless of figurativity.

Double-decision lexical tasks in thought-disordered schizophrenic patients: a path towards cognitive remediation?

It has been shown that schizophrenics have certain difficulties in the processing of semantic context. These difficulties have usually been evaluated using lexical decision tasks with semantic priming. In this study, we chose to examine the idea of an abnormality in the early stages of semantic context processing in thought-disordered schizophrenics using two double lexical decision tasks: one with a high (25%) and one with a low (15%) proportion of related words to assess the participants' competency in controlled and possibly also more automatic context processing. The results obtained in 40 control participants and 40 schizophrenic patients revealed no significant differences in the amplitude of semantic priming between the two groups. These results suggest that, in the disorganized schizophrenic subjects evaluated in this study, the context processing processes mobilized by the employed tasks were unimpaired.