Cognitive Rehabilitation in Schizophrenia and Psychosis
Over the past 30 years, there have been substantial advances in our understanding of the neurobiology and treatment of schizophrenia; these advances have been accompanied by a modest overall improvement in the general condition of the patient diagnosed with schizophrenia.
Cognitive impairment is a core feature of schizophrenia symptomatology. Although this cognitive deficit in patients with schizophrenia has been observed since the earliest descriptions of the condition, first referred to as “dementia praecox” by the German psychiatrist Emil Kraepelin (1896) who described it as a juvenile dementia, all research efforts have focused mainly on reducing symptoms characterised by delusions or hallucinations. The pharmacological treatments developed have failed to treat cognitive impairment in schizophrenia, and have made little improvement in this area.
Recently, symptoms of schizophrenia have been classified into positive, negative, cognitive and affective symptoms. Cognitive symptoms have been recognized as a major symptom domain in schizophrenia. In recent years, research in the field has focused on improving cognitive deficits.
Cognitive impairment in schizophrenia
Cognitive function is a mental process involving several intellectual abilities such as perception, reasoning and memory. Cognitive deficits, especially in information processing speed, attention, memory and executive functions, have been shown to exacerbate severe impairment of patient functionality.
Some people experience cognitive difficulties, such as problems structuring thoughts or memory impairment, impaired problem-solving skills or planning ability, in addition to psychotic-type experiences such as auditory hallucinations or paranoid ideation. Evidence has shown a strong association between cognitive impairment and functioning in everyday life,such as employment, interpersonal relationships and independent living.
Brief description of the cognitive domains that are more commonly affected and reported in people with schizophrenia
Patients with schizophrenia have severe cognitive deficits such asdecreased ability to test reality. Reality testing is the ability to distinguish the source of internal experiences from external reality. During reality-monitoring tasks, patients with schizophrenia make errors in identifying “I made it up” items, they show abnormally low activation of the medial prefrontal cortex (mPFC), a region that supports self-referential cognition.
Furthermore, individuals with impaired cognitive functioning may also have difficulty responding adequately to various self-care activities , with decreased social skills including maintaining interpersonal relationships as well as job skills.
Cognitive deficits can hinder almost all aspects of life and are therefore an important target for interventions to improve quality of life.
Pharmacological treatment of schizophrenia aims to reduce symptoms, but neurocognitive impairment and social cognition, which are not improved by current medications, are more predictive of poor functional outcome than are clinical symptoms of hallucinations and delusions. Drugs used in the treatment of schizophrenia generally do not address cognitive dysfunction, hence the need for alternative interventions. A therapy called “cognitive remediation” has been developed to address these difficulties directly. This type of therapy can help with ‘real life’ challenges such as finding and keeping a job and can sometimes be useful in combination with other psychological therapies, thus reducing the number of therapy sessions needed.
Computer-assisted cognitive stimulation therapy
Studies over the past two decades have shown that computer-assisted cognitive stimulation therapy is a treatment that has been shown to produce improvements in cognition as well as restore brain activity by stimulating neuroplasticity in people with schizophrenia.
This therapy implements learning-based neuroplasticity principles to restore neuromodulatory processes that underlie the structure, function and connections in the brain that support the perceptual, cognitive, social and motor skills often disrupted in psychotic disorders. The basic mechanism of neuroplasticity-based computer cognitive training is designed to induce large-scale changes in both cortical and subcortical representations.
Targeted cognitive training has recently been shown to be moderately to highly effective when administered in carefully controlled environments. The training method targets the auditory and visual processing system of the brain, as cognitive deficits are known to correlate with auditory perception and verbal learning deficits in patients. The cognitive rehabilitation programme also brings significant improvements in patient functionality. Cognitive remediation therapy for schizophrenia is a behavioural therapy, a training-based intervention aimed at improving cognitive processes (attention, memory, executive function, social cognition or metacognition).
Several studies have shown significant cognitive improvement after applying computerized cognitive stimulation
Many approaches have been developed in the last fifteen years, such as computer-assisted cognitive stimulation therapy. Several studies have shown significant cognitive improvement after applying this therapy programme. In recent decades, several cognitive remediation techniques (computerized and non-computerized) have been designed for both individual and group application.
Interventions using computerised cognitive stimulation seem highly relevant in schizophrenia, where neurocognitive changes influence all abilities and strongly influence the quality of life of patients. Studies explain “cognitive remediation” as a set of “thinking skills” teaching methods that focus on the patient’s cognitive deficits. MC Gurk. et al. have reported the effectiveness of cognitive remediation in schizophrenia and improved psychological functioning. In addition, computer-assisted cognitive stimulation therapy is well accepted among patients, and much research has been done in recent years on this therapy to improve functional outcome in patients diagnosed with schizophrenia.
Computerized cognitive stimulation enhances the capacity and efficiency of cognitive function and is beneficial in improving cognitive impairments in patients with schizophrenia. This therapy has shown positive results in enhancing cognitive functions, interpersonal problem-solving skills, as well as achieving autonomy and alleviating symptomatology.
Studies over the past two decades have shown that computer-assisted cognitive stimulation therapy is a treatment that has been shown to produce improvements in cognition as well as Restoring brain activity by stimulating neuroplasticity in people with schizophrenia. This therapy implements learning-based neuroplasticity principles to restore neuromodulatory processes that underlie the structure, function and connections in the brain that support the perceptual, cognitive, social and motor skills often disrupted in psychotic disorders. The basic mechanism of neuroplasticity-based computer cognitive training is designed to induce large-scale changes in both cortical and subcortical representations.
Medical studies and their conclusions
Several studies have shown significant cognitive improvement after the application of computerised cognitive stimulation. Benedict et al. reported the effectiveness of cognitive-behavioral intervention in 15 clients with cognitive impairment associated with behavioral changes. In a randomised trial, patients were randomly assigned to receive neuropsychological counselling or psychotherapy. After 2 weeks, subjects in the active cognitive computer stimulation treatment group showed significant improvements in aggressive behaviour compared to patients receiving standard psychological counselling alone.
A 2014 study aimed to evaluate the effectiveness of a computer-assisted cognitive training program for attention, memory, and executive function in improving neuropsychological performance and functional outcome in clients with schizophrenia. After 3 months, the results showed that patients’ scores improved. Also, a significant improvement favoring the improvement of cognitive impairment was found in several cognitive areas, including reaction time. In conclusion, according to the study the computer-assisted cognitive remediation training program was effective in improving the performance of patients diagnosed with schizophrenia.
Amato et al. conducted a study on a group of 39 patients with schizophrenia for whom they applied individual sessions of 112 hours of computer-assisted cognitive therapy. The results showed that cognitive performance on attention, alertness, verbal working memory and verbal learning memory, and reasoning/problem solving improved significantly following computerized cognitive stimulation.
Furthermore, a number of studies have shown that computer-assisted cognitive stimulation therapy can also influence psychotic symptoms and address interpersonal problems, autonomy and schizophrenia-specific symptoms.
Taking all these factors into account, it has been shown that offering a computer-assisted cognitive stimulation therapy program to patients with schizophrenia improves cognitive functioning.
It has also been shown that the results of computerised cognitive stimulation were maintained over the long term. Thus, a study applying computerised cognitive stimulation therapy consisting of 20 individual sessions, each lasting 60 minutes, with participants completing two sessions per week for approximately 18 weeks, demonstrated maintenance over time of the cognitive improvements achieved as a result of cognitive stimulation.
Subjects in a 2012 study participated in auditory exercises for 1 hour per day for a total of 50 hours (10 weeks), then participated in visual exercises for 1 hour per day for a total of 30 hours (6 weeks), which were combined with 15 minutes per day of emotion identification exercises (total of 10 hours). In the exercises, patients were instructed to make progressively more accurate discriminations of the fine spectro-temporal structure of auditory and visual stimuli under conditions of increasing difficulty of working memory exercises or cognitive stimuli. The auditory and visual exercises were continuously adaptive: they first set precise parameters within each stimulus set required for an individual subject to maintain 80% correct performance, and once that threshold was determined, task difficulty increased systematically and parametrically as performance improved. In computer-assisted cognitive stimulation therapy the difficulty level increased progressively as participants successfully completed blocks of trials at a given difficulty level. The design and implementation of this approach was based on research demonstrating that deficits in basic auditory and visual perceptual processes as well as in working memory and social cognitive functions occur in schizophrenia.
CONCLUSIONS
Study results showed that computer-assisted cognitive stimulation therapy produced significant improvements in auditory perception and verbal learning. Patients also experienced a “significant reduction in auditory hallucinations”. Age, severity of symptoms, dose of medication and duration of illness did not reduce the effectiveness of computer-assisted cognitive stimulation therapy. The findings indicate that even symptomatic, functionally disabled patients with chronic diseases benefit from this emerging treatment,” the team said.
Finally, long-term computer-assisted cognitive stimulation therapy can begin to “normalize” abnormal associations in schizophrenia, and such improvements predict better social functioning. Research therefore raises the exciting likelihood that cognitive impairments in schizophrenia – and, no doubt, associated other neuropsychiatric disorders – can be ameliorated by well-designed interventions aimed at restoring cognitive functioning.
ABOUT COMPUTER-ASSISTED COGNITIVE STIMULATION:
Sources:
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Karuna Subramaniam,Tracy L Luks, Melissa Fisher, Gregory V Simpson, Srikantan Nagarajan, and Sophia Vinogradov. Computerized Cognitive Training Restores Neural Activity within the Reality Monitoring Network in Schizophrenia, Neuron. 2012 Feb 23; 73(4): 842-853.
3. McGurk, S. R., & Mueser, K. T. (2013). Cognition and work functioning in schizophrenia. In P. D. Harvey (Ed.), Cognitive impairment in schizophrenia: Characteristics, assessment and treatment (pp. 98-109). Cambridge University Press.
4. Nathan S. Kline, et all, Advances in Cognitive Remediation Training in Schizophrenia: A Review, Brain Sci. 2022, 12(2), 12;
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5. Thierry d’Amato, et al, – A randomized, controlled trial of computer-assisted cognitive remediation for schizophrenia, Schizophrenia Research, Volume 125, Issues 2-3, February 2011, Pages 284-290.
6. Michael L., et all – Targeted cognitive training improves auditory and verbal outcomes among treatment refractory schizophrenia patients mandated to residential care – Schizophrenia Research, Volume 202, December 2018, Pages 378-384.
7. Mohammadi MR, Keshavarzi Z, Talepasand S. The effectiveness of computerized cognitive rehabilitation training program in improving cognitive abilities of schizophrenia clients. Iran J Psychiatry. 2014 Oct;9(4):209-15. PMID: 25802533; PMCID: PMC4361823.
Authors: Dr. Irina Săcuiu – Primary psychiatrist, Doctor of Medical Sciences and Dr. Mădălina-Ionela Grosu – Resident psychiatrist
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