Neurocognition and Social Cognition in Schizophrenia Patients

Key Issues in Mental Health

Vol. 177

Series Editors

A. Riecher-Rössler Basel
M. Steiner Hamilton
Neurocognition and Social
Cognition in Schizophrenia
Patients
Basic Concepts and Treatment

Volume Editors

Volker Roder Bern

Alice Medalia New York, N.Y.

16 figures, 1 in color, and 11 tables, 2010

Basel · Freiburg · Paris · London · New York · Bangalore ·

Bangkok · Shanghai · Singapore · Tokyo · Sydney
Key Issues in Mental Health
Formerly published as ‘Bibliotheca Psychiatrica’ (founded 1917)

Prof. Volker Roder Prof. Alice Medalia

Head of Therapy Research Director of Psychiatric
University Hospital of Psychiatry Rehabilitation Services
Bern (Switzerland) Columbia University College
of Physicians and Surgeons
New York, N.Y. (USA)

Library of Congress Cataloging-in-Publication Data

Neurocognition and social cognition in schizophrenia patients :

basic concepts and treatment / volume editors, Volker Roder, Alice Medalia.
p. ; cm. -- (Key issues in mental health, ISSN 1662-4874 ; v. 177)
Includes bibliographical references and index.
ISBN 978-3-8055-9338-0 (hard cover : alk . paper)
1. Schizophrenia--Complications. 2. Cognition disorders. 3. Cognition.
4. Social perception. 5. Schizophrenics--Rehabilitation. I. Roder,
Volker. II. Medalia, Alice. III. Series: Key issues in mental health, v.
177 . 1662-4874 ;
[DNLM: 1. Schizophrenia--therapy. 2. Cognition. 3. Cognitive Therapy.
4. Interpersonal Relations. 5. Schizophrenic Psychology. 6. Social
Adjustment. W1 BI429 v. 177 2010 / WM 203 N49313 2010]
RC514 . N4432 2010
362 . 2’6--dc22
2009047073

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© Copyright 2010 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland)
www.karger.com
Printed in Switzerland on acid-free and non-aging paper (ISO 9706) by Reinhardt Druck, Basel
ISSN 1662–4874
ISBN 978–3–8055–9338–0
eISBN 978–3–8055–9339–7
Contents

Foreword VII
Brenner, H.D. (Valparaiso)
Preface IX
Medalia, A. (New York, N.Y.); Roder, V. (Bern)

1 Definition and Measurement of Neurocognition and Social Cognition 1

Kern, R.S.; Horan, W.P. (Los Angeles, Calif.)
2 The Relevance of Neurocognition and Social Cognition for Outcome 23
and Recovery in Schizophrenia
Brekke, J.S.; Nakagami, E. (Los Angeles, Calif.)
3 Treatment Approaches with a Special Focus on Neurocognition: 37
Overview and Empirical Results
Kurtz, M.M. (Middletown, Conn.); Sartory, G. (Wuppertal)
3.1 Compensatory Cognitive Training 50
Twamley, E.W.; Zurhellen, C.H.; Vella, L. (San Diego, Calif.)
4 Treatment Approaches with a Special Focus on Social Cognition: 61
Overview and Empirical Results
Wölwer, W. (Düsseldorf ); Combs, D.R. (Tyler, Tex.); Frommann, N. (Düsseldorf );
Penn, D.L. (Chapel Hill, N.C.)
4.1 Training of Emotional Intelligence in Schizophrenia 79
Vauth, R. (Basel)
5 Combined Treatment Approaches: Overview and Empirical Results 85
Roder, V.; Hulka, L. (Bern); Medalia, A. (New York, N.Y.)
5.1 An Overview of the Neuropsychological and Educational Approach 104
to Remediation
Medalia, A.; Mambrino, E. (New York, N.Y.)

V
 5.2 Integrated Psychological Therapy and Integrated Neurocognitive 118
Therapy
Müller, D.R.; Roder, V. (Bern)
6 Pharmacological Interventions 145
Hofer, A.; Fleischhacker, W.W. (Innsbruck)
7 Motivational Enhancements in Schizophrenia 158
Medalia, A.; Choi, J. (New York, N.Y.)

Author Index 173

Subject Index 175

VI Contents
Foreword

This book comes at a particularly opportune moment and sets an important corner-
stone in this crucial phase of the development of effective cognitive-behavioral treat-
ment strategies for schizophrenia.
If one follows this development over time, the first therapeutic methods mirrored
man’s picture of himself and assumed a one-sided dependency of behavior on envi-
ronmental factors. In the 1970s, improving social competence became increasingly
important, whereby highly structured programs taught the patient both verbal and
non-verbal behavior patterns. It was expected that increased social competence
would lead to a better quality of life with deeper social integration. The fact that only
moderate therapeutic success was witnessed in this area was seen as a result (among
other factors) of the patient’s cognitive deficits not being taken into consideration
adequately enough. Subsequently, social aspects of the training programs were geared
towards overcoming these deficits. As a result, cognitive rehabilitation, which aims to
improve the comprehension and processing of information, gained importance. This
included both cognitive therapy programs as well as combined cognitive-behavioral
approaches. Earlier, cognitive rehabilitation had been neglected for different reasons:
cognitive deficits were either considered as epiphenomena, without any functional
clinical significance, or as being too deeply rooted in the patient and, thus, not
changeable. These assumptions, however, had to be revised when, for example, the
lack of learning aptitude postulated for schizophrenic patients was disproved by the
complex tasks of tests such as the Wisconsin Card Sorting Test, and the so-called ‘vul-
nerability markers’ proved to be modifiable through targeted interventions. Although
the initial results for cognitive and, in particular, computer-aided training were
encouraging, further investigations only showed limited transfer from such programs
to everyday life. The reason for this seemed mainly to be a result of the isolated

VII
training of individual cognitive functions, not taking other cognitive deficits and
social dimensions into account.
Based on new models of schizophrenia, therefore the combination of elements from
cognitive and social therapies appears to be especially promising. On the one hand,
mounting evidence suggests that certain neurocognitive and social cognitive deficits
are more related to certain areas of functional outcome than psychotic symptoms. The
recent advances made in the understanding of these relationships can be directly
linked to the development of innovative treatment approaches. On the other hand, the
ability to implement the skills practiced in therapy into everyday life requires an
implicit knowledge of social situations. In this context, aspects of social perception as
well as the perception and management of emotions have gained importance.
Finally, the developments described above have converged with other influences
calling for professionals to ‘look at the person behind the illness’, which appears to find
the most visible expression in the concept of recovery. This is the view Neurocognition
and Social Cognition in Schizophrenia Patients: Basic Concepts and Treatment focuses
on; particularly as the editors point out that this book is about much more than just
symptomatic relief and stability, but rather the attainment of functional stability and
progress in professional formation, work, independent living and social interaction.
The understanding and effective treatment of schizophrenia-specific problems with
cognition are recognized as central requirements for successful recovery and their var-
ious aspects are illuminated: basic information about the nature, measurement and
meaning of neurocognitive and social cognitive deficits and processes is provided; the
most recent advances in the knowledge about the role of these deficits and processes
on functional recovery are highlighted, and the latest innovative approaches to respec-
tive treatments, as well as practical examples, are outlined.
Thus, Neurocognition and Social Cognition in Schizophrenia Patients: Basic Concepts
and Treatment provides a most timely synopsis of this developing field with an empha-
sis on the integration of neurocognitive and social cognitive functioning in psychiatric
rehabilitation. Last but not least, the efforts required to integrate behavior therapy with
optimal pharmacotherapy are also acknowledged. From whatever perspective, behav-
ior – cognitive, emotional, social, intellectual and instrumental modes of personal
functioning – can be understood as the product of a circular causality between neuro-
physiological, cognitive, emotional, social and environmental variables constantly
interacting with each other. Further advances can only be expected when individual
fields within research and practice utilize the current knowledge available in neighbor-
ing fields. Overall, this book thus is extremely well suited to scientists and practitioners
alike and provides an excellent theoretical and empirical basis for evidence-guided
clinical practice as well as for innovative research.
Hans D. Brenner
Valparaiso, December 2009

VIII Foreword
Preface

People with schizophrenia struggle with an array of positive and negative symptoms,
which together often make it difficult to achieve the common life goals of working,
living independently, finishing school and forging and maintaining rewarding rela-
tionships. The positive symptoms of hallucinations and delusions, disorganization
and agitation have received the bulk of attention over the years, and tremendous
progress has been made in developing pharmacologic treatments that ameliorate
these strikingly abnormal behaviors. With such advances in treatment, more people
with schizophrenia live in the community, and the aspiration of achieving recovery
is no longer dismissed as impossible but recognized as a meaningful and feasible,
although admittedly highly elusive goal.
Why is it that recovery is so difficult to achieve? It is because recovery embraces
more than symptomatic relief and stability. Recovery also refers to the attainment of
functional stability. Recovered people have made progress in their attempts to finish
school, work, live independently and socialize. They are not just living in the com-
munity but actively engaged in community life and able to negotiate the challenges
with some independence. In the last 2 decades, researchers have carefully studied
predictors of functional recovery, and it has become recognized that relief from the
positive symptoms is insufficient to garner progress in the functional arena. Rather
it is a different array of ‘symptoms’ that cobble the efforts of patients as they struggle
toward recovery; it is the problems with cognition, socialization and motivation.
Impairments in cognition, motivation and socialization have been recognized as
core features of schizophrenia for over 100 years. At the turn of the 20th century Emil
Kraeplin wrote about a progressive decline in the cognitive abilities of attention,
problem solving and learning, which he speculated was negatively effecting social,
vocational and independent functioning. Since he identified the problems, numerous

IX
studies have been and continue to be done to characterize the nature of the deficits.
When the role of these deficits in functional outcome had been demonstrated, the
clinical significance of developing treatments for these disabilities gained recognition.
Cognition is a term that broadly refers to thinking abilities. It encompasses the
range of skills from isolated processes like memory and attention, which are the
focus of neuropsychological investigations and therapies, to the form and content of
thought, which are often the focus of cognitive behavioral therapies. The study of
cognitive processes appreciates that while most processes are neuropsychological,
some are primarily in the service of social interactions, and the term social cognition
is used to identify those particular processes. The cognitive ability to perceive, inter-
pret and generate responses to social interactions is included in the term social cog-
nition. Together neurocognition and social cognition refer to the basic processes
that allow one to learn about, understand and know the world one lives in.
This edited volume addresses the neurocognitive and social cognitive processes
that are known to be disrupted in schizophrenia. The focus on these disorders
appreciates that they are a key determinant of functional recovery and that to change
functionally often requires that neurocognition and social cognition be addressed.
The volume is intended to provide practicing clinicians, emerging schizophrenia
researchers and students of psychotic disorders with the latest information about the
neurocognitive and social cognitive deficits in schizophrenia. This way professionals
working with persons with schizophrenia will have the knowledge and tools they
need to develop and provide competent professional care.
This volume is organized to provide information about the characterization of
neurocognitive and social cognitive deficits as well as treatment approaches which
target these symptoms. We invited leading experts – physicians and psychologists –
from Europe and the USA to present the ‘state of the art’ in the different fields. To
start, chapter 1, by Robert S. Kern and William P. Horan, defines what is meant by
these terms and reviews the methods of measurement that are used in different clini-
cal and research settings. Chapter 2, by John S. Brekke and Eri Nakagami, explains
why neurocognition and social cognition are relevant to functional recovery and
reviews the literature which delineated the ways that these deficits impact work,
social and educational outcomes. Given the sobering results on functional outcome
when treatments only focus on positive symptoms, there is a growing interest in alter-
native treatments that target neurocognitive and social cognitive deficits. Chapter 3,
by Matthew M. Kurtz and Gudrun Sartory, provides an overview of the behavioral
approaches to treating neurocognition. The subchapter by Elizabeth W. Twamley,
Cynthia H. Zurhellen and Lea Vella describes a concrete therapy approach for neu-
rocognition, while chapter 4, by Wolfgang Wölwer, Dennis R. Combs, Nicole
Frommann and David L. Penn, synthesizes the literature on behavioral treatments of
social cognitive deficits. The subchapter by Roland Vauth provides an example of a
treatment approach which was designed to train social cognition and thereby
enhance emotional intelligence. Chapter 5 by Volker Roder, Lea Hulka and Alice

X Preface
Medalia gives an overview of treatments integrating neurocognition and social cogni-
tion (and partly social skills). Two subchapters illustrate examples for these integra-
tive approaches: Alice Medalia and Elisa Mambrino present the Neuropsychological
and Educational Approach to Remediation (NEAR); Daniel R. Müller and Volker
Roder describe the Integrated Psychological Therapy (IPT) and the Integrated
Neurocognitive Therapy (INT) with concrete guidelines for their application. The
pharmacologic treatment of cognition is a burgeoning area, and chapter 6, by Alex
Hofer and W. Wolfgang Fleischhacker, reviews the various approaches that are being
taken to drug development. Finally, because amotivation is a core feature of schizo-
phrenia and impacts not only the functional outcome but also the ability to engage
and benefit from therapies, chapter 7, by Alice Medalia and Jimmy Choi, considers
the relevance of motivational theories for understanding how to maximize benefit
from therapies that provide cognitive enhancement.
With the interest in promoting functional recovery in schizophrenia comes the
need for clinicians and researchers to understand the issues that hamper a successful
outcome. Treating symptoms is not enough – the overall goal of any intervention is
to help a person integrate and function adaptively in society. This collection of chap-
ters usefully characterizes the nature of the neurocognitive and social cognitive
deficits known to negatively impact the functional outcome, as well as the efforts
underway to treat them. The terminology, measurement strategies and therapeutic
approaches are thoughtfully considered and reviewed. We would like to express
gratitude to the authors for contributing to this volume and to Professor Anita
Riecher (University Hospital of Psychiatry, Basel, Switzerland) for her vision in
choosing this as a topic of interest. It is hoped that these chapters will promote dis-
cussion, more research and the further development and improvement of interven-
tions for people with schizophrenia.
Alice Medalia
Volker Roder
New York and Bern, August 2009

Preface XI