Showing papers in "Schizophrenia Bulletin in 2006"

The Functional Significance of Social Cognition in Schizophrenia: A Review

Abstract: Deficits in a wide array of functional outcome areas (eg, social functioning, social skills, independent living skills, etc) are marked in schizophrenia. Consequently, much recent research has attempted to identify factors that may contribute to functional outcome; social cognition is one such domain. The purpose of this article is to review research examining the relationship between social cognition and functional outcome. Comprehensive searches of PsycINFO and MEDLINE/PUBMED were conducted to identify relevant published manuscripts to include in the current review. It is concluded that the relationship between social cognition and functional outcome depends on the specific domains of each construct examined; however, it can generally be concluded that there are clear and consistent relationships between aspects of functional outcome and social cognition. These findings are discussed in light of treatment implications for schizophrenia.

The NIMH-MATRICS Consensus Statement on Negative Symptoms

Abstract: The impairments now called negative symptoms have long been noted as common features of schizophrenia, and the concept of negative symptoms itself has a long history.1,2 Patients who exhibit significant negative symptoms have particularly poor function and quality of life,3–8 and this aspect of schizophrenia has been proposed as a separate domain with distinctive pathophysiological and therapeutic implications since at least 1974.9 Despite the attention these problems receive, no drug has received Food and Drug Administration (FDA) approval for an indication of negative symptoms, and available data indicate that second-generation antipsychotic medications have not met early hopes for a highly effective treatment for alleviation of negative symptoms.10 Because of limited progress in the development of effective treatments for negative symptoms, under the auspices of the National Institute of Mental Health (NIMH), Drs. Steve Marder, Wayne Fenton, William T. Carpenter, Jr, and Brian Kirkpatrick initiated a process to examine issues that may interfere with treatment development. The NIMH had previously focused attention on impaired cognition as a therapeutic target with the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) project. The success of the MATRICS process suggested similar progress could be made in the area of negative symptoms and provided a possible model for proceeding in the area of negative symptoms. Marder, Fenton, Carpenter, and Kirkpatrick organized a consensus development conference, which was held at the NIMH Neuroscience Center in Rockville, Maryland, on January 26–27, 2005. Those attending are listed in the appendix. The mission statement of the meeting was: To review the data relating to the existence of separate domains within negative symptoms, as a prerequisite for choosing appropriate measures of these domains in clinical trials. To initiate a process for developing or identifying widely acceptable, evidence-based measures and methodologies needed to establish the efficacy of treatments that target negative symptoms. Prior to the meeting, the organizers asked experts to address a series of questions: What are the separate components of negative symptoms? Are they independent, or components of the same latent construct? Which aspect of each domain belongs to the negative symptom construct? Does this area need a separate assessment? What is the best assessment method for clinical trials? Since research has suggested that both negative symptoms and cognitive impairments were significant determinants of poor outcome in schizophrenia, an additional set of questions related to the relationship between these domains of psychopathology was also addressed at the conference: Which aspects of cognition are part of the negative symptom construct? Which are independent? Which are uncertain? Articles that more fully address the topics of these presentations can be found in this issue of Schizophrenia Bulletin. Those articles address regulatory issues and negative symptoms,11 negative symptoms as a therapeutic target,12 the factor structure of negative symptoms,13 restricted affect,14 anhedonia,15 and the relationship between negative symptoms and cognitive impairment.16 At the conference other presentations were also made: Wayne Fenton spoke on “Meeting Goals and Objectives: The NIMH Perspective,” Robert Buchanan on “Summary of the MATRICS Process,” William Carpenter, Jr, on “Study Design and the “Pseudospecificity' Problem,” Michael Green on “Social Cognition,” Nancy Andreasen on “Alogia,” and Jeffrey Cummings on “Apathy.”

Self-Stigma in People With Mental Illness

Abstract: Persons with mental illnesses such as schizophrenia may internalize mental illness stigma and experience diminished self-esteem and self-efficacy. In this article, we describe a model of self-stigma and examine a hierarchy of mediational processes within the model. Seventy-one individuals with serious mental illness were recruited from a community support program at an outpatient psychiatry department of a community hospital. All participants completed the Self-Stigma of Mental Illness Scale along with measures of group identification (GI), perceived legitimacy (PL), self-esteem, and self-efficacy. Models examining the steps involved in self-stigma process were tested. Specifically, after conducting preliminary bivariate analyses, we examine stereotype agreement as a mediator of GI and PL on stigma self-concurrence (SSC); SSC as a mediator of GI and PL on self-efficacy; and SSC as a mediator of GI and PL on self-esteem. Findings provide partial support for the proposed mediational processes and point to GI, PL, and stereotype agreement as areas to be considered for intervention.

Toward Understanding the Insight Paradox: Internalized Stigma Moderates the Association Between Insight and Social Functioning, Hope, and Self-esteem Among People with Schizophrenia Spectrum Disorders

Abstract: Research has paradoxically linked awareness of illness to both better function outcomes and lesser hope and self-esteem. One possible explanation for these findings is that acceptance of having schizophrenia may impact outcomes differently depending on the meanings the person attaches to this acceptance, particularly whether he or she accepts stigmatizing beliefs about mental illness. To explore this possibility we performed a cluster analysis of 75 persons with schizophrenia spectrum disorders based on single measures of insight using the Positive and Negative Syndrome Scale, internalized stigma using the Internalized Stigma of Mental Illness Scale, and compared groups on concurrent assessments of hope and self-esteem. Three groups were produced by the cluster analyses: low in sight/mild stigma (n = 23), high insight/minimal stigma (n = 25), and high insight/moderate stigma (n = 27). As predicted, analysis of variance-comparing groups revealed that the high insight/moderate stigma group had significantly the lowest levels of hope on the Beck Hopelessness Scale and self-esteem using the Multidimensional Self-esteem Inventory. As predicted, the high insight/minimal stigma group also had significantly less impaired social function than the other groups. Implications for assisting persons to come to cope with awareness of illness and stigma are discussed.

The Structure of Negative Symptoms Within Schizophrenia: Implications for Assessment

Abstract: This review examines the structural validity of negative symptoms focusing on 2 questions: (1) Do negative symptoms represent a domain separate from other symptoms in schizophrenia? and (2) Within negative symptoms, is there a structure that suggests multidimensionality? Results from exploratory and confirmatory factor analytic studies are examined to address these questions. Across studies and symptom instruments, negative symptoms appear to consistently emerge as a factor separate from other dimensions of the illness in schizophrenia. Whether 2-, 3-, or 5-factor models are identified, negative symptoms consistently load on a factor separate from positive symptoms, affective symptoms of depression or anxiety, and symptoms of disorganization. Focusing on negative symptoms themselves, factor analytic findings suggest that this construct is multidimensional with at least 2 factors (involving diminished expression and anhedonia-asociality). Although these factors were replicable, serious limitations were noted in this literature. Thus, 2- (or even 3- or 5-) factor models of negative symptoms should not be considered definitive, but rather all converge to support the general conclusion of the multidimensionality of negative symptoms. The later findings indicate the importance of employing assessments that provide adequate coverage of the broad domain of negative symptoms. Importantly, caution is noted in the interpretability of findings based on existing instruments, and implications for future assessment are discussed.

Neurophysiological Endophenotypes of Schizophrenia: The Viability of Selected Candidate Measures

Abstract: In an effort to reveal susceptibility genes, schizophrenia research has turned to the endophenotype strategy. Endophenotypes are characteristics that reflect the actions of genes predisposing an individual to a disorder, even in the absence of diagnosable pathology. Individual endophenotypes are presumably determined by fewer genes than the more complex phenotype of schizophrenia and would, therefore, reduce the complexity of genetic analyses. Unfortunately, despite there being rational criteria to define a viable endophenotype, the term is sometimes applied indiscriminately to characteristics that are deviant in affected individuals. Schizophrenia patients exhibit deficits in several neurophysiological measures of information processing that have been proposed as candidate endophenotypes. Successful processing of sensory inputs requires the ability to inhibit intrinsic responses to redundant stimuli and, reciprocally, to facilitate responses to less frequent salient stimuli. There is evidence to suggest that both these processes are “impaired” in schizophrenia. Measures of inhibitory failure include prepulse inhibition of the startle reflex, P50 auditory evoked potential suppression, and antisaccade eye movements. Measures of impaired deviance detection include mismatch negativity and the P300 event-related potential. The purpose of this review is to systematically evaluate the endophenotype candidacy of these key neurophysiological abilities. For each candidate, we describe typical experimental procedures, the current understanding of the underlying neurobiology, the nature of the abnormality in schizophrenia, the reliability, stability and heritability of the measure, and any reported gene associations. We conclude with a discussion of the few studies thus far that have employed a multivariate approach with these candidates.

Environment and Schizophrenia: Environmental Factors in Schizophrenia: Childhood Trauma—A Critical Review

Abstract: There is renewed interest in the relationship between early childhood trauma and risk of psychosis in adulthood. There are a large number of studies of psychiatric inpatients, and of outpatients in which a majority have a psychotic disorder, that suggest the prevalence of childhood trauma in these populations is high. However, these are generally small studies of diagnostically heterogeneous and chronic samples and, as such, can tell us very little about whether childhood trauma is of etiological importance in psychosis. A small number of recent population-based studies provide more robust evidence of an association, and there are now plausible biological mechanisms linking childhood trauma and psychosis. However, there remain a number of conceptual and methodological issues, which mean much more research is needed before firm conclusions can be drawn about whether childhood trauma is a cause of psychosis.

DSM and the Death of Phenomenology in America: An Example of Unintended Consequences

Abstract: During the 19th century and early 20th century, American psychiatry shared many intellectual traditions and values withGreatBritainandEurope. Theseincludeprinciplesderived from the Enlightenment concerning the dignity of the individual and the value of careful observation. During the 20th century, however, American psychiatry began to diverge, initially due to a much stronger emphasis on psychoanalytic principles, particularly in comparison with Great Britain. By the 1960s and 1970s, studies such as the US-UK study and the International Pilot Study of Schizophrenia demonstrated that the psychodynamic emphasis had gone too far, leading to diagnostic imprecision and inadequate evaluation of traditional evaluations of signs and symptoms of psychopathology. Diagnostic and Statistical Manual of MentalDisorders,ThirdEdition(DSM-III)wasdeveloped in this context, under the leadership of representatives from institutions that had retained the more traditional BritishEuropean approaches (eg, Washington University, Iowa). The goal ofDSM-IIIwas to create a comprehensivesystem for diagnosing and evaluating psychiatric patients that would be more reliable, more valid, and more consistent with international approaches. This goal was realized in many respects, but unfortunately it also had many unintended consequences. Although the original creators realized that DSM represented a ‘‘best effort’’ rather than a definitive ‘‘ground truth,’’ DSM began to be given total authority in training programs and health care delivery systems. Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation that is targeted to the individual person’s problems and social context and that is enriched by a good general knowledge of psychopathology. Students are taught to memorize DSM rather than to learn complexities from the great psychopathologists of the past. By 2005, the decline has become so severe that it could be referred to as ‘‘the death of phenomenology in the United States.’’

Prenatal Infection as a Risk Factor for Schizophrenia

Abstract: Accumulating evidence suggests that prenatal exposure to infection contributes to the etiology of schizophrenia. This line of investigation has been advanced by birth cohort studies that utilize prospectively acquired data from serologic assays for infectious and immune biomarkers. These investigations have provided further support for this hypothesis and permitted the investigation of new infectious pathogens in relation to schizophrenia risk. Prenatal infections that have been associated with schizophrenia include rubella, influenza, and toxoplasmosis. Maternal cytokines, including interleukin-8, are also significantly increased in pregnancies giving rise to schizophrenia cases. Although replication of these findings is required, this body of work may ultimately have important implications for the prevention of schizophrenia, the elaboration of pathogenic mechanisms in this disorder, and investigations of gene-environment interactions.

Correlates and Long-Term Consequences of Poor Insight in Patients With Schizophrenia. A Systematic Review

Abstract: Between 50 and 80% of the patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder. Although a causal chain connecting poor insight with poor treatment adherence and thus with poorer outcome and functioning is straight forward, numerous studies investigating correlates and long-term impact of insight have provided differing results. In addition, higher levels of insight in schizophrenia have been associated with depression and hopelessness, but the causal direction of the relationship is unclear and the data are inconclusive. The current study provides a critical review of 88 studies on the assessment of insight and its impact on symptoms and functioning. Studies published by June 2006 were selected using a keyword search for English peer-reviewed articles in the databases PsycINFO and MEDLINE. The majority of studies support the assumption that insight is associated with adherence during treatment phase, but the association with long-term adherence remains unclear. Insight correlates with better long-term functioning, but this might be explained by its association with symptoms. There is a positive cross-sectional and longitudinal relationship between insight and depression, but the underlying processes need further clarification. In the concluding discussion, the problems relating to definition and study designs are considered responsible for many of the inconclusive findings. Suggestions for further research are derived.

Negative Symptoms and Cognitive Deficits: What Is the Nature of Their Relationship?

Abstract: Negative symptoms and cognitive deficits in schizophrenia share many features and are correlated in their severity on a cross-sectional basis. The question arises as to the nature of this relationship: are these symptoms the same, caused by the same factor (or factors); or is the nature of their relationship determined by other factors, such as definitional issues and common correlates? In this article we provide a conceptual overview for addressing this question and provide a selective review of the literature on the cross-sectional and longitudinal relationships between these two features of the illness. We describe 4 different models of the "true" relationship between these variables. Some data suggest that the relationship between these variables is determined by the definition of negative symptoms employed and that, in general, the correlation is moderate at the most. Further, path modeling suggests the possibility, to be addressed with later research, that correlations between negative and cognitive symptoms and everyday functional outcomes may influence the observed correlations between these variables. Thus, we conclude that negative and cognitive symptoms may be separable, if not conceptually independent, domains of the illness and that it might be possible to develop treatments that target negative symptoms and cognitive deficits independently.

Deconstructing Schizophrenia: An Overview of the Use of Endophenotypes in Order to Understand a Complex Disorder

Abstract: The genetics of schizophrenia has been approached utilizing a variety of methods. One emerging strategy is the use of endophenotypes in order to understand and identify the functional importance of genetically transmitted, brain-based deficits across schizophrenia kindreds. The endophenotype strategy is a topic of this issue of Schizophrenia Bulletin. Endophenotypes are quantitative, heritable, trait-related deficits typically assessed by laboratory-based methods rather than clinical observation. Endophenotypes are seen as closer to genetic variation than are clinical symptoms of schizophrenia, and are therefore closely linked to heritable risk factors. There has been a broad expansion of opportunities available to psychiatric neuroscientists who use the endophenotype strategy to understand the genetic basis of schizophrenia. In this context, genetic variation such as single nucleotide polymorphisms (SNPs) induces abnormalities in endophenotypic domains such as neurocognition, neurodevelopment, metabolism, and neurophysiology. This article discusses the challenges that abound in genetic research of schizophrenia, including issues in ascertainment, epistasis, ethnic diversity, and the potentially normalizing effects of second-generation antipsychotic medications on neurocognitive and neurophysiological measures. Robust strategies for meeting these challenges are discussed in this review and the subsequent articles in this issue. This article summarizes conceptual advances and progress in the measurement and use of endophenotypes in schizophrenia that form the basis of the multisite National Institute of Mental Health Consortium on the Genetics of Schizophrenia. The endophenotype strategy offers powerful and exciting opportunities to understand the genetically conferred neurobiological vulnerabilities and possible new strong inference and molecularly based treatments for schizophrenia.

Efficacy of Psychological Therapy in Schizophrenia: Conclusions From Meta-analyses

Abstract: Over the past years, evidence for the efficacy of psychological therapies in schizophrenia has been summarized in a series of meta-analyses. The present contribution aims to provide a descriptive survey of the evidence for the efficacy of psychological therapies as derived from these meta-analyses and to supplement them by selected findings from an own recent meta-analysis. Relevant meta-analyses and randomized controlled trials were identified by searching several electronic databases and by hand searching of reference lists. In order to compare the findings of the existing meta-analyses, the reported effect sizes were extracted and transformed into a uniform effect size measure where possible. For the own meta-analysis, weighted mean effect size differences between comparison groups regarding various types of outcomes were estimated. Their significance was tested by confidence intervals, and heterogeneity tests were applied to examine the consistency of the effects. From the available meta-analyses, social skills training, cognitive remediation, psychoeducational coping-oriented interventions with families and relatives, as well as cognitive behavioral therapy of persistent positive symptoms emerge as effective adjuncts to pharmacotherapy. Social skills training consistently effectuates the acquisition of social skills, cognitive remediation leads to short-term improvements in cognitive functioning, family interventions decrease relapse and hospitalization rates, and cognitive behavioral therapy results in a reduction of positive symptoms. These benefits seem to be accompanied by slight improvements in social functioning. However, open questions remain as to the specific therapeutic ingredients, to the synergistic effects, to the indication, as well as to the generalizability of the findings to routine care.

The Consortium on the Genetics of Schizophrenia: Neurocognitive Endophenotypes

Abstract: The Consortium on the Genetics of Schizophrenia (COGS) is a 7-site collaboration that examines the genetic architecture of quantitative endophenotypes in families with schizophrenia. Here we review the background and rationale for selecting neurocognitive tasks as endophenotypic measures in genetic studies. Criteria are outlined for the potential of measures as endophenotypic vulnerability markers. These include association with illness, state independence (ie, adequate test-retest stability, adequate between-site reliability, impairments in patients not due to medications, impairments observed regardless of illness state), heritability, findings of higher rates in relatives of probands than in the general population, and cosegregation within families. The COGS required that, in addition, the measures be “neurocognitive” and thus linked to neurobiology and that they be feasible in multisite studies. The COGS neurocognitive assessment includes measures of attention, verbal memory, working memory, and a computerized neurocognitive battery that also includes facial processing tasks. Here we describe data demonstrating that these neurobehavioral measures meet criteria for endophenotypic candidacy. We conclude that quantitative neurocognitive endophenotypes need further evidence for efficacy in identifying genetic effects but have the potential of providing unprecedented insight into gene-environment interaction related to dimensions of brain and behavior in health and disease.

Development of a brief scale of everyday functioning in persons with serious mental illness.

Abstract: We developed and tested the validity of a brief scale to assess everyday functioning in persons with serious mental illness. A sample of 434 adults with schizophrenia or schizoaffective disorder were administered the University of California, San Diego, Performance-Based Skills Assessment (UPSA), which assesses functional skills in 5 areas of life functioning (eg, finances and planning). Through use of factor analysis, we developed the UPSA-Brief, which consists of 2 subscales (communication and financial) from the original UPSA. UPSA-Brief scores were correlated with cognitive functioning, symptoms of psychosis, age, and education. We further tested the sensitivity and specificity of the UPSA-Brief for predicting residential independence using receiver-operating characteristic (ROC) curves. Finally, sensitivity to change was assessed through comparison of 2 interventions for improving UPSA-Brief scores. UPSA-Brief scores were highly correlated with scores on the full version of the UPSA (r = .91), with overall cognitive functioning (r = .57), and with negative symptoms (r = -.32). The discriminant validity of the UPSA-Brief was adequate (ROC area under the curve [AUC] = 0.73; 95% confidence interval [CI]: 0.67-0.78), with greatest dichotomization for the UPSA-Brief at a cutoff score of 60. The UPSA-Brief was significantly better than the Dementia Rating Scale, Positive and Negative Syndromes Scale positive, and Positive and Negative Syndromes Scale negative at predicting residential independence (all P values < .05). Participants receiving a behavioral intervention also improved significantly compared with a support condition (P = .023). The UPSA-Brief has adequate psychometric properties, predicts residential independence, is sensitive to change, and requires only 10-15 minutes to administer. Therefore, the UPSA-Brief may be a useful performance-based functional outcome scale.

Anhedonia in Schizophrenia: A Review of Assessment Strategies

Abstract: Anhedonia, the diminished capacity to experience pleasant emotions, is a common, treatment-resistant feature of schizophrenia that is often included among the negative symptoms of this disorder. This selective review describes the 3 most commonly used approaches to assess anhedonia in schizophrenia: interview-based measures, self-report trait questionnaires, and laboratory-based assessments of emotional experience. For each assessment approach, psychometric properties, relationships to other symptoms and features of schizophrenia, and relationships with the other assessment approaches are evaluated. It is concluded that anhedonia can be reliably assessed and constitutes a distinctive, clinically important aspect of schizophrenia that should be included in a comprehensive evaluation of negative symptoms. Current efforts to define more precisely the nature of the hedonic deficit in schizophrenia are discussed, and recommendations for optimal assessment of anhedonia in clinical trials of novel treatments for negative symptoms are provided.

The Illness Management and Recovery Program: Rationale, Development, and Preliminary Findings

Abstract: The Illness Management and Recovery (IMR) program was developed based on a comprehensive review of research on teaching illness self-management strategies to clients with schizophrenia and other severe mental illnesses and "packaged" in a resource kit to facilitate dissemination. Despite growing dissemination of this program, it has not yet been empirically validated. This article describes the development and theoretical underpinnings of the IMR program and presents pilot data from the United States and Australia (N = 24, 88% schizophrenia or schizoaffective) on the effects of individual-based and group-based treatment over the 9-month program and over a 3-month follow-up. High satisfaction was reported by participants. Strong improvements over treatment and at follow-up were found in clients' self-reported effectiveness in coping with symptoms and clinicians' reports of global functioning and moderate improvements in knowledge about mental illness, distress related to symptoms, hope, and goal orientation. These findings support the feasibility and promise of the IMR program and point to the need for controlled research to rigorously evaluate its effects.

Recent Advances in Social Skills Training for Schizophrenia

Abstract: Social skills training consists of learning activities utilizing behavioral techniques that enable persons with schizophrenia and other disabling mental disorders to acquire interpersonal disease management and independent living skills for improved functioning in their communities. A large and growing body of research supports the efficacy and effectiveness of social skills training for schizophrenia. When the type and frequency of training is linked to the phase of the disorder, patients can learn and retain a wide variety of social and independent living skills. Generalization of the skills for use in everyday life occurs when patients are provided with opportunities, encouragement, and reinforcement for practicing the skills in relevant situations. Recent advances in skills training include special adaptations and applications for improved generalization of training into the community, short-term stays in psychiatric inpatient units, dually diagnosed substance abusing mentally ill, minority groups, amplifying supported employment, treatment refractory schizophrenia, older adults, overcoming cognitive deficits, and negative symptoms as well as the inclusion of social skills training as part of multidimensional treatment and rehabilitation programs.

Perceptual Anomalies in Schizophrenia: Integrating Phenomenology and Cognitive Neuroscience

Abstract: From phenomenological and experimental perspectives, research in schizophrenia has emphasized deficits in “higher” cognitive functions, including attention, executive function, as well as memory. In contrast, general consensus has viewed dysfunctions in basic perceptual processes to be relatively unimportant in the explanation of more complex aspects of the disorder, including changes in self-experience and the development of symptoms such as delusions. We present evidence from phenomenology and cognitive neuroscience that changes in the perceptual field in schizophrenia may represent a core impairment. After introducing the phenomenological approach to perception (Husserl, the Gestalt School), we discuss the views of Paul Matussek, Klaus Conrad, Ludwig Binswanger, and Wolfgang Blankenburg on perception in schizophrenia. These 4 psychiatrists describe changes in perception and automatic processes that are related to the altered experience of self. The altered self-experience, in turn, may be responsible for the emergence of delusions. The phenomenological data are compatible with current research that conceptualizes dysfunctions in perceptual processing as a deficit in the ability to combine stimulus elements into coherent object representations. Relationships of deficits in perceptual organization to cognitive and social dysfunction as well as the possible neurobiological mechanisms are discussed.

Integrated Psychological Therapy (IPT) for Schizophrenia: Is It Effective?

Abstract: Against the background of evidence-based treatments for schizophrenia, nowadays the implementation of specific cognitive and behavioral interventions becomes more important in the standard care of these patients. Over the past 25 years, research groups in 9 countries have carried out 30 independent evaluations of Integrated Psychological Therapy (IPT), a group program that combines neurocognitive and social cognitive interventions with social skills approaches for schizophrenic patients. The aim of the present study was to evaluate the effectiveness of IPT under varying treatment and research conditions in academic and nonacademic sites. In a first step, all 30 published IPT studies with the participation of 1393 schizophrenic patients were included in the meta-analysis. In a second step, only high-quality studies (HQS) (7 studies including 362 patients) were selected and analyzed to check whether they confirmed the results of the first step. Positive mean effect sizes favoring IPT over control groups (placebo-attention conditions, standard care) were found for all dependent variables, including symptoms, psychosocial functioning, and neurocognition. Moreover, the superiority of IPT continued to increase during an average follow-up period of 8.1 months. IPT obtained similarly favorable effects across the different outcome domains, assessment formats (expert ratings, self-reports, and psychological tests), settings (inpatient vs outpatient and academic vs nonacademic), and phases of treatment (acute vs chronic). The HQS confirmed the results of the complete sample. The analysis indicates that IPT is an effective rehabilitation approach for schizophrenia that is robust across a wide range of patients and treatment conditions.

Psychotic-Like Experiences in Nonpsychotic Help-Seekers: Associations With Distress, Depression, and Disability

Abstract: Psychotic-like experiences (PLEs) increase the risk of schizophrenia and other psychotic disorders yet are common in the community. Some PLEs, such as those associated with depression, distress, and poor functioning, may confer increased risk. The aim of this study is to determine the prevalence of PLEs in a nonpsychotic clinical sample and to investigate whether any subtypes of PLEs are associated with the above factors. Consecutive referrals to a youth psychiatric service (N = 140) were assessed to measure PLEs, depression, and functioning. PLE data were factor analyzed, and the associations of psychotic subtypes and distress, depression, and disability were analyzed. Three subtypes of PLEs were identified: Bizarre Experiences, Persecutory Ideas, and Magical Thinking. Bizarre Experiences and Persecutory Ideas were associated with distress, depression, and poor functioning. Magical Thinking was not, unless accompanied by distress. Bizarre Experiences and Persecutory Ideas may be more malignant forms of psychotic symptoms, as they are associated with current disability, and may confer increased risk of development of full-blown psychotic disorder.

Real-World Cognitive—and Metacognitive—Dysfunction in Schizophrenia: A New Approach for Measuring (and Remediating) More “Right Stuff”

Abstract: While the role of impaired cognition in accounting for functional outcome in schizophrenia is generally established by now, the overlap is far from complete. Moreover, little is known about the potential mechanisms that bridge between cognition and functional outcome. The aim of this article is to aid in closing this gap by presenting a novel, more ecologically valid approach for neuropsychological assessment. The new approach is motivated by the view that metacognitive processes of self-monitoring and self-regulation are fundamental determinants of competent functioning in the real world. The new approach incorporates experimental psychological concepts and paradigms used to study metacognition into current standard neuropsychological assessment procedures. Preliminary empirical data that support and demonstrate the utility of the new approach for assessment, as well as remediation efforts, in schizophrenia are presented and discussed.

The Cardiff Anomalous Perceptions Scale (CAPS): a new validated measure of anomalous perceptual experience

Abstract: The study describes the Cardiff Anomalous Perceptions Scale (CAPS), a new validated measure of perceptual anomalies. The 32-item CAPS measure is a reliable, self-report scale, which uses neutral language, demonstrates high content validity, and includes subscales that measure distress, intrusiveness, and frequency of anomalous experience. The CAPS was completed by a general population sample of 336 participants and 20 psychotic inpatients. Approximately 11% of the general population sample scored above the mean of the psychotic patient sample, although, as a group, psychotic inpatients scored significantly more than the general population on all CAPS subscales. A principal components analysis of the general population data revealed 3 components: “clinical psychosis” (largely Schneiderian first-rank symptoms), “temporal lobe disturbance” (largely related to temporal lobe epilepsy and related seizure-like disturbances) and “chemosensation” (largely olfactory and gustatory experiences), suggesting that there are multiple contributory factors underlying anomalous perceptual experience and the “psychosis continuum.”

Flat Affect in Schizophrenia: Relation to Emotion Processing and Neurocognitive Measures

Abstract: Impaired emotional functioning in schizophrenia is a prominent clinical feature that manifests primarily as flat affect. Studies have examined the perception, experience, and expression of emotions in schizophrenia and reported normal ratings of experience but impaired affect identification. However, the relation between flat affect and performance on facial affect identification and cognitive tasks has not been systematically examined in relation to premorbid adjustment and clinical outcome. We report a prospective study of 63 patients with at least moderate severity of flat affect and 99 patients without flat affect, who were compared on functional domains, emotion processing tasks, and neurocognitive measures. Flat affect was more common in men and was associated with poorer premorbid adjustment, worse current quality of life, and worse outcome at 1-year follow-up. Patients overall performed more poorly on emotion processing tasks, one that required identification of happy and sad emotions and one that required differentiating among intensities within these emotions. They responded inaccurately yet faster than controls for the intensity differentiation task, suggesting a decomposition of the normal relation between accuracy and speed. Flat affect ratings, compared with other negative symptoms, uniquely predicted performance on emotion processing tasks. Patients with flat affect showed greater impairment in both emotion processing tasks, with the most pronounced impairment for the intensity differentiation task. However, the 2 patient groups did not differ in the neurocognitive profile except for verbal memory. We conclude that flat affect is an important clinical feature of schizophrenia that exacerbates the course of illness.

Psychoeducation: A Basic Psychotherapeutic Intervention for Patients With Schizophrenia and Their Families

Abstract: Psychoeducation was originally conceived as a composite of numerous therapeutic elements within a complex family therapy intervention. Patients and their relatives were, by means of preliminary briefing concerning the illness, supposed to develop a fundamental understanding of the therapy and further be convinced to commit to more long-term involvement. Since the mid 1980s, psychoeducation in German-speaking countries has evolved into an independent therapeutic program with a focus on the didactically skillful communication of key information within the framework of a cognitive-behavioral approach. Through this, patients and their relatives should be empowered to understand and accept the illness and cope with it in a successful manner. Achievement of this basic-level competency is considered to constitute an "obligatory-exercise" program upon which additional "voluntary-exercise" programs such as individual behavioral therapy, self-assertiveness training, problem-solving training, communication training, and further family therapy interventions can be built. Psychoeducation looks to combine the factor of empowerment of the affected with scientifically founded treatment expertise in as efficient a manner as possible. A randomized multicenter study based in Munich showed that within a 2-year period such a program was related to a significant reduction in rehospitalization rates from 58% to 41% and also a shortening of intermittent days spent in hospital from 78 to 39 days. Psychoeducation, in the form of an obligatory-exercise program, should be made available to all patients suffering from a schizophrenic disorder and their families.

Data Gathering: Biased in Psychosis?

Abstract: This study examined whether the probabilistic reasoning bias referred to as a “jumping-to-conclusions” (JTC) style of reasoning, which, according to previous research, is associated with particular psychotic symptoms such as delusions, represents a trait that can also be detected in nonpsychotic relatives of patients with schizophrenia and in nonpsychotic individuals with a high level of psychotic experiences. Participants were, in order of level of psychosis liability, 40 patients with schizophrenia or a schizoaffective disorder, 40 first-degree nonpsychotic relatives, 41 participants from the general population with above average expression of psychotic experiences, and 53 participants from the general population with an average level of psychotic experiences. A “jumping-to-conclusions” bias was assessed using the beads task. A dose-response relationship was found in the association between level of psychosis liability and JTC (defined as needing only a single bead to complete the beads task) (odds ratio [OR] linear trend = 1.59, 95% CI: 1.13–2.24), and, independently, alinear association was apparent between JTC and level of delusional ideation (OR linear trend = 2.59, 95% CI: 1.18–5.69). In addition, the association between psychosis liability and JTC was generally much stronger as the level of delusional ideation was higher. JTC is associated with liability to psychosis (trait), in particular if the psychosis phenotype is characterized by delusional ideation (state).

Treatment of Schizophrenia Negative Symptoms: Future Prospects

Abstract: New findings from neuroscience, genetics, and experimental psychology have emerged that provide alternative explanations of many negative symptoms. We review the continuing limitations in treatment and discuss possible sources of heterogeneity among negative symptoms. We also anticipate conceptual uncertainties that may arise with forthcoming treatment developments.

Socioeconomic Status at Birth Is Associated With Risk of Schizophrenia: Population-Based Multilevel Study

Abstract: Background: Inconsistent findings obscure understanding the relationship between socioeconomic status (SES) and schizophrenia. The aim of the current study was to test the association between individual and community SES at birth and risk of schizophrenia. Method: Populationbased longitudinal follow forward study of a 13-year birth cohort (n 5 71 165). Effects of individual and community socioeconomic variables were examined using multilevel regression in MLwiN. Results: Years of education of fathers and mothers, respectively, (0–8 vs 131 odds ratio [OR] 5 1.17, P < .0001; OR 5 1.14, P < .001) lower occupational statusof fathers(OR 5 1.29,P 5 .036), and poorer residential area SES (OR 5 1.26, P 5 .012) were risk factors for schizophrenia. Conclusions: Individual- and community-level SES at the time of birth are associated with an increased risk of schizophrenia.

Cognitive, Emotional, and Social Processes in Psychosis: Refining Cognitive Behavioral Therapy for Persistent Positive Symptoms

Abstract: Psychosis used to be thought of as essentially a biological condition unamenable to psychological interventions. However, more recent research has shown that positive symptoms such as delusions and hallucinations are on a continuum with normality and therefore might also be susceptible to adaptations of the cognitive behavioral therapies found useful for anxiety and depression. In the context of a model of cognitive, emotional, and social processes in psychosis, the latest evidence for the putative psychological mechanisms that elicit and maintain symptoms is reviewed. There is now good support for emotional processes in psychosis, for the role of cognitive processes including reasoning biases, for the central role of appraisal, and for the effects of the social environment, including stress and trauma. We have also used virtual environments to test our hypotheses. These developments have improved our understanding of symptom dimensions such as distress and conviction and also provide a rationale for interventions, which have some evidence of efficacy. Therapeutic approaches are described as follows: a collaborative therapeutic relationship, managing dysphoria, helping service users reappraise their beliefs to reduce distress, working on negative schemas, managing and reducing stressful environments if possible, compensating for reasoning biases by using disconfirmation strategies, and considering the full range of evidence in order to reduce high conviction. Theoretical ideas supported by experimental evidence can inform the development of cognitive behavior therapy for persistent positive symptoms of psychosis.

Randomized Trial of Supported Employment Integrated With Assertive Community Treatment for Rural Adults With Severe Mental Illness

Abstract: Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = $549, interquartile range [IQR] = $0–$5,145, versus Mdn = $0, IQR = $0–$40; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.