Loneliness is associated with mentalizing and emotion recognition abilities in schizophrenia, but only in a cluster of patients with social cognitive deficits.

OBJECTIVE: Loneliness is a concern for patients with schizophrenia. However, the correlates of loneliness in patients with schizophrenia are unclear; thus, the aim of the study is to investigate neuro- and social cognitive mechanisms associated with loneliness in individuals with schizophrenia. METHOD: Data from clinical, neurocognitive, and social cognitive assessments were pooled from two cross-national samples (Poland/USA) to examine potential predictors of loneliness in 147 patients with schizophrenia and 103 healthy controls overall. Furthermore, the relationship between social cognition and loneliness was explored in clusters of patients with schizophrenia differing in social cognitive capacity. RESULTS: Patients reported higher levels of loneliness than healthy controls. Loneliness was linked to increased negative and affective symptoms in patients. A negative association between loneliness and mentalizing and emotion recognition abilities was found in the patients with social-cognitive impairments, but not in those who performed at normative levels. CONCLUSIONS: We have elucidated a novel mechanism which may explain previous inconsistent findings regarding the correlates of loneliness in individuals with schizophrenia.

Development of an UPSA Short Form for Use in Longitudinal Studies in the Early Alzheimer's Disease Spectrum.

BACKGROUND: In individuals with only mild or very mild cognitive attenuations (i.e., so-called pre-clinical AD), performance-based measures of function may be superior to informant-based measures because of increased sensitivity, greater reliability, and fewer ceiling effects. OBJECTIVE: We sought to determine if a performance-based measure of everyday function would demonstrate adequate psychometric properties and validity in the context of serial assessment over a one-year period in patients with Mild Cognitive Impairment (MCI) and early stage Alzheimer's disease (AD). DESIGN: Participants were assessed with the performance-based measure at baseline, six weeks, and one year. SETTING: A specialized center for the assessment and treatment of AD. PARTICIPANTS: Three groups of subjects participated: a healthy subjects (HS) older cognitively intact group (N=43), an MCI group (N=20), and an AD group (N=26). MEASUREMENTS: A three subtest short form of the UCSD Performance-Based Skills Assessment (UPSA) (called the UPSA-3) was the measure of interest. It consisted of the Communication, Planning, and Finance subtests. RESULTS: Mixed model repeated measures were used to assess performance over time. Large group effects were present (HS>MCI>AD). Additionally, the AD and MCI groups demonstrated declines over one year, while the HS group remained stable (group x time interaction p=.11). The MCI/AD group demonstrated adequate test-retest reliability and did not demonstrate ceiling or floor effects. CONCLUSION: Our data indicate that the UPSA-3 is suitable for clinical trials in that it has adequate ecological coverage and reasonable psychometric properties, and perhaps most importantly, demonstrates validity in serial assessments.

Which levels of cognitive impairments and negative symptoms are related to functional deficits in schizophrenia?

BACKGROUND: Negative symptoms and cognitive impairments predict difficulties in aspects of everyday functioning in schizophrenia, with little research to date attempting to determine if there are threshold levels of impairment required to predict the severity of functional deficits. METHODS: People diagnosed with chronic schizophrenia (n = 821) were assessed with the MCCB and PANSS, and rated by high contact informants with SLOF. Negative symptoms of reduced emotional experience were specifically targeted for analysis because of their previously identified relationships with social outcomes. We identified patients with moderate negative symptoms (at least one PANSS item ≥4) versus less severe symptoms (PANSS items ≤3) and divided patients on the basis of a single latent-trait global cognition score (neuropsychologically normal vs neuropsychologically impaired; performance at or below 1.0 SD from the normative population mean, T = 40), then examined correlations between cognition, negative symptoms and everyday functioning in the groups with lower and higher negative symptoms and those with/without cognitive impairment. RESULTS: Even low levels of negative symptoms were correlated with ratings of social functioning. Cognitive performance in the neuropsychologically normal range, in contrast, was not correlated with any aspects of everyday functioning while more impaired performance predicted greater functional impairments. CONCLUSIONS: Even minimal symptoms may be a target for clinical attention in the domains of negative symptoms, consistent with previous findings regarding social deficits in populations with modest negative symptoms (e.g., schizotypal personality disorder). Cognitive rehabilitation treatments might not improve social functioning if even low levels of negative symptoms (social amotivation) are present.

Associations of independent living and labor force participation with impairment indicators in schizophrenia and bipolar disorder at 20-year follow-up.

BACKGROUND: Since the Iowa 500 study, residential and occupational status have been frequently used as indicators of everyday achievements in research on schizophrenia and bipolar disorder. The relationships of residential and occupational status with impairment in multiple domains including physical health indicators across these two diagnoses, however, have rarely been studied. We examined these relationships at the 20-year follow-up assessment of a first-admission sample. METHODS: We included 146 participants with schizophrenia and 87 with bipolar disorder with psychosis who participated in the 20-year follow-up of the Suffolk County Mental Health Project. In addition to interviewer-based ratings of employment and residential independence, we examined self-reported impairment derived from the WHODAS, standard measures of current psychopathology, indicators of obesity, as well as performance-based measures of physical and cognitive functioning. RESULTS: Participants with bipolar disorder were more likely to live independently and be gainfully employed; they also performed significantly better on each indicator of impairment apart from balance ability. In both groups, unemployment, but not residential independence, was associated with greater self-reported disability on the WHODAS. Residential independence, gainful employment, and subjective disability were also associated with better physical functioning. Across the two groups, psychiatric symptoms and physical functioning were the major determinants of subjective disability. DISCUSSION: People with psychotic bipolar disorder were more likely to be gainfully employed and living independently than participants with schizophrenia but as a group, much less frequently than population standards. Interventions aimed at physical fitness may have the potential to improve both objective functioning and perceived disability.

Health status and mobility limitations are associated with residential and employment status in schizophrenia and bipolar disorder.

INTRODUCTION: Schizophrenia (SCZ) and bipolar disorder (BP) are linked to multiple impairments in everyday functioning which share cognitive and symptom risk factors. Other risk factors for critical aspects of every day functioning (e.g., gainful employment; residential independence) such as physical health have not been evaluated, despite poor health in SCZ and BP. METHODS: We analyzed 20-year follow-up data from the Suffolk County Mental Health Project cohort of consecutive first admissions with a psychotic disorder to 12 psychiatric facilities in Suffolk County, NY, between September 1989 and December 1995. Both 20-year symptom, health, and cognition data, and the 20-year course of weight gain were included as predictors of employment and residence status. RESULTS: The analysis sample consisted of 122 participants with SCZ ad BP, with SCZ participants less likely to work or live independently. Correlational analyses showed symptoms and cognition predicted vocational outcomes in both samples. The effect of diagnosis was significant for both gainful employment and independence in residence. After consideration of diagnosis, mobility and negative symptoms predicted gainful employment in both samples, but there were no additional predictors of residential independence. Prospective analysis of BMI found that baseline BMI, but not changes during the 20-year follow up, predicted labor force participation. DISCUSSION: Health status limitations were associated with residential and, particularly, employment status independent from other, previously established predictors of everyday outcomes, including cognition and symptoms. The importance of health status limitations for predicting outcome was confirmed in both SCZ and BP, with schizophrenia representing the more impaired group.

Assessment of Age-Related Differences in Functional Capacity Using the Virtual Reality Functional Capacity Assessment Tool (VRFCAT).

Clinical trials for primary prevention and early intervention in preclinical AD require measures of functional capacity with improved sensitivity to deficits in healthier, non-demented individuals. To this end, the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) was developed as a direct performance-based assessment of functional capacity that is sensitive to changes in function across multiple populations. Using a realistic virtual reality environment, the VRFCAT assesses a subject's ability to complete instrumental activities associated with a shopping trip. The present investigation represents an initial evaluation of the VRFCAT as a potential co-primary measure of functional capacity in healthy aging and preclinical MCI/AD by examining test-retest reliability and associations with cognitive performance in healthy young and older adults. The VRFCAT was compared and contrasted with the UPSA-2-VIM, a traditional performance-based assessment utilizing physical props. Results demonstrated strong age-related differences in performance on each VRFCAT outcome measure, including total completion time, total errors, and total forced progressions. VRFCAT performance showed strong correlations with cognitive performance across both age groups. VRFCAT Total Time demonstrated good test-retest reliability (ICC=.80 in young adults; ICC=.64 in older adults) and insignificant practice effects, indicating the measure is suitable for repeated testing in healthy populations. Taken together, these results provide preliminary support for the VRFCAT as a potential measure of functionally relevant change in primary prevention and preclinical AD/MCI trials.

Current smoking is associated with worse cognitive and adaptive functioning in serious mental illness.

OBJECTIVE: Cigarette smoking is highly prevalent among people with bipolar disorder or schizophrenia. Few studies have examined whether smoking history is associated with adaptive functioning among individuals diagnosed with these serious mental illnesses. METHOD: In a large relatively homogenous cohort of patients with either bipolar disorder (n=363) or schizophrenia (n=400), we investigated the association between cigarette smoking status, intensity, and cumulative exposure and performance on a comprehensive battery of neurocognitive, functional capacity, and informant-rated functional measures. The associations were adjusted for variation in sociodemographic indicators, psychopathologic symptoms, and substance use. RESULTS: There was an average of 12 pack years of smoking across the sample. People with schizophrenia reported double the rate of current smoking compared to patients with bipolar disorder. Adjusting for demographic covariates, current smokers had worse composite cognitive functioning and poorer functional outcome than past or never smokers. There were no significant differences between never and past smokers, and these effects were evident in both bipolar disorder and schizophrenia. CONCLUSION: Current smokers with either schizophrenia or bipolar disorder evidence worse cognitive and adaptive functioning functional outcome, even when demographic covariates are considered.

Physical performance and disability in schizophrenia.

Despite 50 years of pharmacological and psychosocial interventions, schizophrenia remains one of the leading causes of disability. Schizophrenia is also a life-shortening illness, caused mainly by poor physical health and its complications. The end result is a considerably reduced lifespan that is marred by reduced levels of independence, with few novel treatment options available. Disability is a multidimensional construct that results from different, and often interacting, factors associated with specific types and levels of impairment. In schizophrenia, the most poignant and well characterized determinants of disability are symptoms, cognitive and related skills deficits, but there is limited understanding of other relevant factors that contribute to disability. Here we conceptualize how reduced physical performance interacts with aging, neurobiological, treatment-emergent, and cognitive and skills deficits to exacerbate ADL disability and worsen physical health. We argue that clearly defined physical performance components represent underappreciated variables that, as in mentally healthy people, offer accessible targets for exercise interventions to improve ADLs in schizophrenia, alone or in combination with improvements in cognition and health. And, finally, due to the accelerated aging pattern inherent in this disease - lifespans are reduced by 25 years on average - we present a training model based on proven training interventions successfully used in older persons. This model is designed to target the physical and psychological declines associated with decreased independence, coupled with the cardiovascular risk factors and components of the metabolic syndrome seen in schizophrenia due to their excess prevalence of obesity and low fitness levels.

Impact of environmental olfactory cues on hand hygiene behaviour in a simulated hospital environment: a randomized study.

This study investigated the impact of a fresh scent on the rate of hand hygiene compliance (HHC) among novice healthcare providers. In all, 165 participants examined a standardized patient with one sample exposed to fresh scent (N = 79) and the other exposed to the standard environment (N = 86). Hand hygiene behaviours were tracked before patient contact using video surveillance. The standard environment group had an HHC rate of 51% whereas participants in the fresh scent group had a higher HHC rate of 80% (P < 0.001). These data demonstrate that hand hygiene behaviour may be subconsciously influenced by cues in the environment.

New insights into the link between cardiovascular disease and depression.

INTRODUCTION: Although the association between depression and cardiovascular disease (CVD) is well documented, the underlying mechanisms for this relationship remain unclear. In this paper, we present three possible models which account for the comorbidity between depression and cardiovascular disease. MODELS: The first model outlines depression as a risk factor for CVD and the second model presents CVD as a risk factor for depression. The third model proposes a common underlying pathway related to the effects of chronic stress on the body in manifesting as depression or cardiovascular disease. CONCLUSIONS: If the proposed model holds true, it may be possible that an intervention initiated before overt manifestations of CVD or depression become apparent, may delay or prevent the onset of these serious clinical entities.

Use of atypical antipsychotic medications in adolescent psychiatric inpatients: a comparison with inpatients who did not receive antipsychotic medications during their stay.

The use of atypical antipsychotic medications has been reported to be increased in adolescent psychiatric outpatients and to include many patients with non-psychotic disorders. This study examined the correlates of antipsychotic usage in adolescent inpatients and compared their characteristics with a sample of adolescent inpatients who did not receive antipsychotics during their hospitalisation. A total of 159 consenting consecutive patients treated with atypical antipsychotic medications were compared with 150 patients who were admitted during the same time period and not treated with antipsychotics. The samples were compared for demographic factors, clinical diagnoses, clinical symptoms at admission and other medications received during their inpatient stay. Sex and ethnicity did not differ significantly as a function of antipsychotic mediation status. Significantly few patients with an admission diagnosis of major depression received antipsychotic medications and more patients with admission diagnosis of bipolar and/or conduct disorder were treated with antipsychotic medications. Clinical symptom differences and additional medications received were consistent with the differences in admission diagnoses. Despite the fact that significantly fewer patients with major depression received antipsychotic medications, 47% of the patients who did receive antipsychotic medications in this study had an admission diagnosis of major depression. There are several differences between these inpatient data and previous studies of outpatient claims databases, the majority of adolescent inpatient cases treated with antipsychotic medications had admission diagnoses consistent with both adult indications and previous research with adolescent patients. These data suggest an urgent need to study the safety and efficacy of atypical antipsychotic medications on aspects of depression in adolescents.

Effects of rivastigmine on cognitive function in patients with traumatic brain injury.

OBJECTIVE: To compare the efficacy and safety of rivastigmine (3 to 6 mg/day) vs placebo over 12 weeks in patients with traumatic brain injury and persistent cognitive impairment. METHODS: This prospective, randomized, double-blind, placebo-controlled study was conducted in 157 patients at least 12 months after injury. The primary efficacy measures were the Cambridge Neuropsychological Test Automated Battery (CANTAB) Rapid Visual Information Processing (RVIP) A' subtest and the Hopkins Verbal Learning Test (HVLT). The primary efficacy outcome was the proportion of patients who demonstrated 1.0 SD or greater improvement from baseline at week 12 on CANTAB RVIP A' or HVLT. RESULTS: The percentage of responders at week 12 on either the CANTAB RVIP A' or HVLT was 48.7% for rivastigmine and 49.3% for placebo (p = 0.940). Furthermore, for the overall study population, there were no significant differences for any of the secondary efficacy variables. In a subgroup of patients with moderate to severe memory impairment (n = 81), defined as 25% impairment or greater on HVLT at baseline, rivastigmine was significantly better than placebo for a number of measures, including the proportion of HVLT responders and CANTAB RVIP mean latency. CONCLUSIONS: Rivastigmine was safe and well tolerated in patients with traumatic brain injury with cognitive deficits. Rivastigmine shows promising results in the subgroup of patients with traumatic brain injury with moderate to severe memory deficits.

A comprehensive analysis of verbal fluency deficit in geriatric schizophrenia.

Deficits in verbal fluency are common in schizophrenia and may provide keys to some of the abnormalities in the semantic system in schizophrenia. While a number of studies have outlined the severity and implications of verbal fluency deficits in younger schizophrenia patients, these findings have not yet been extended to older patients with schizophrenia. In this study, 392 older (age >/= 50) patients with schizophrenia were administered phonological and semantic (i.e., category) fluency examinations, as well as tests of learning, memory, language, and praxic skills, and rated for clinical symptoms and functional status. When compared to normative standards, 82% of the patients were impaired in semantic fluency and 83% were impaired in phonological fluency. Both semantic and phonological fluency impairment were significantly correlated with other cognitive variables, total scores on the functional status measure, and with the social and self-care subscales. Scores were uncorrelated with the severity of psychosis, but were correlated with the severity of negative symptoms. Furthermore, the severity of poverty of speech (a clinical measure of verbal underproductivity) was moderate in magnitude and failed to enter as a predictor of verbal fluency, indicating that impaired fluency scores are not simply an artifact of general underproductivity or mutism. The findings support conclusions from studies with younger schizophrenia patients that suggest that verbal fluency impairment is a consequence of a disorganized semantic system. Verbal fluency impairment remains common and functionally relevant in schizophrenia patients in late life.

Cognitive impairment in elderly patients with schizophrenia: age related changes.

Cognitive impairment in schizophrenia is a major feature of the illness. Like many of the other aspects of the illness, however, it has not been studied extensively in older patients. Several studies of older patients with a lifetime course of poor outcome and chronic institutional stay have indicated that some patients manifest evidence of profound cognitive impairments on a cross-sectional basis and cognitive and functional decline over longitudinal follow-ups of 30 months or longer. Risk factors for this decline include lower educational attainment and more severe positive symptoms, but do not include more severe symptoms of physical illness. These impairments have been shown to be discriminable from normal age-related changes and from the changes associated with Alzheimer's Disease. In contrast, studies of patients with no history of lifetime institutional stay find no such evidence of either age-related changes in cognitive functioning or longitudinal decline in cognitive or functional status. Since there is accumulating evidence of progressive brain changes over the lifespan in patients with schizophrenia, the course of cognitive deficits in later life will remain an important topic, both for understanding the lifetime course of schizophrenia and for developing interventions aimed at reduction of disability in the illness.

Convergent validity and neuropsychological correlates of the schedule for the assessment of negative symptoms (SANS) attention subscale.

Cognitive deficits have come to be viewed as a hallmark feature of schizophrenic illness. Although laboratory based assessment of patients' cognitive deficits has been well investigated, few studies to date have examined the utility of clinical ratings of cognitive symptoms using the Schedule for the Assessment of Negative Symptoms (SANS) attention subscale. In this report, we examined the convergence between clinical ratings of cognitive impairment using the SANS attention subscale and performance on a variety of neurocognitive tests designed to measure attentional impairment, as well as other cognitive constructs such as working memory and executive functioning. A total of 56 acute schizophrenic inpatients were clinically rated with the SANS and completed the Continuous Performance Test, Digit Span Distraction Test, Wisconsin Card Sorting Task, and the Trailmaking Test. A series of correlational and regression analyses were conducted to test the concurrent and discriminant validity of the SANS attention subscale. Performance measures of attention, but not working memory or executive functioning, were significantly correlated with and moderately predicted the severity of SANS rated inattention. Additionally, the attention subscale was discriminated from the other SANS negative symptom subscales in predicting a laboratory measure of attentional functioning. The SANS attention subscale demonstrated both concurrent and discriminant validity. These data indicate that attentional dysfunction in schizophrenia can be meaningfully rated and interpreted using the SANS.

Are the interpersonal and identity disturbances in the borderline personality disorder criteria linked to the traits of affective instability and impulsivity?

This study examines the degree to which two putative biologically influenced personality traits, affective instability and impulsive aggression, are associated with some of the interpersonal and intrapsychic disturbances of borderline personality disorder (BPD) and with choice of defense mechanism. In a sample of 152 personality disorder patients, affective instability and impulsive aggression were measured. Defense mechanisms were assessed in 140 of these patients using the Defensive Style Questionnaire (DSQ). The correlations between the traits of affective instability and impulsive aggression and the eight DSM-III-R criteria for borderline personality disorder and 20 DSQ defenses were examined. Affective instability was significantly correlated with the DSM-III-R criteria of identity disturbance, chronic emptiness or boredom, inappropriate anger, suicidality, and the affective instability criteria. It also was associated with the defenses of splitting, projection, acting out, passive aggression, undoing, and autistic fantasy. Impulsive aggression was related to unstable interpersonal relationships, inappropriate anger and impulsiveness and with the defense of acting out. It was negatively correlated with the defenses of suppression and reaction formation. A number of the interpersonal and experiential disturbances and defense mechanisms that are features of BPD are associated with the traits of affective instability and impulsive aggression among patients with personality disorders.

Six-year follow-up study of cognitive and functional status across the lifespan in schizophrenia: a comparison with Alzheimer's disease and normal aging.

OBJECTIVE: Follow-up studies of cognitive functions of poor-outcome (long-term institutionalized) elderly patients with schizophrenia have demonstrated deterioration over time, while stable cognitive functions over time have been reported for younger, better-outcome schizophrenic patients. This study examined whether cognitive changes in elderly schizophrenic patients with a history of long-term institutional stay extended to institutionalized younger patients. The rate of decline was compared to changes associated with Alzheimer's disease. METHOD: Patients with schizophrenia (N=107) age 20-80 years were followed over 6 years and assessed with the Clinical Dementia Rating and the Mini-Mental State Examination. The schizophrenic subjects age 50 and older were compared to 136 healthy comparison subjects and 118 Alzheimer's disease patients age 50 and older who were assessed over a similar follow-up period. RESULTS: There was a significant age group effect on the magnitude of cognitive decline for the schizophrenic subjects, with older subjects experiencing greater levels of decline over the follow-up. Neither the healthy individuals nor the Alzheimer's disease patients demonstrated similar age-related differences in the magnitude of cognitive change over the follow-up, with healthy comparison subjects showing no change and Alzheimer's disease patients manifesting decline regardless of age at the initiation of the follow-up. CONCLUSIONS: Institutionalized schizophrenic patients demonstrated an age-related pattern of cognitive change different from that observed for Alzheimer's disease patients and healthy individuals. The cognitive and functional status of these schizophrenic patients was fairly stable until late life, suggesting that cognitive change may not be occurring in younger patients over an interval as long as 6 years.

Cognition in schizophrenia.

Cognitive dysfunction has been described as a hallmark feature of schizophrenia since the first descriptions of the illness. Kraepelin described a number of features of the disorder that he thought reflected impairments in cognition and attention. He also speculated that cognitive impairments were mediated by neurobiologic dysfunction, specifically impairments in the functions of the frontal lobe. Since Kraepelin's time, there have been many changes in the general conceptions of schizophrenia, including ideas regarding the status and importance of cognitive impairment in the illness. Due to increased sophistication of neuropsychologic assessment and neuroimaging techniques, cognitive impairment has again has risen to the forefront of importance in terms of theories regarding the etiology and treatment of schizophrenia.