| Cognitive limitations are nowadays recognised as one of the core deficits in schizophrenia. However, until now diagnostic procedures have not proven sufficiently effective in predicting social and vocational role functioning. Therefore, the first part of the project is aimed at a better understanding of the impact of social cognitive impairment on daily life. Measures of social cognition (emotional prosody, recognition of facial affect, empathy and mind-reading skills) will be incorporated in standard neuropsychological assessment. By combining the performance on measures of (social) cognition with measures of social and vocational role functioning and sophisticated observation procedures of every day memory and executive functioning, we will try to enhance the understanding of the complexity of cognitive functioning in everyday life in schizophrenia. The second, and major part of the project is aimed at reducing the impact of cognitive deficits on independent daily living. This part of the project is concerned with the development of a new cognitive rehabilitation method. Schizophrenia patients are particularly impaired in the domain of executive functions that involve planning and regulation in unstructured and socially demanding situations. In contrast to earlier drill and practice methods and cognitive strategy training, we propose the use of an electronic compensational aid (mobile telephone and SMS-message) to enhance the daily planning routine of the patients. By using a compensational aid, impaired cognitive functions, including social-cognitive functions, are only mildly taxed. In the proposed project, called MEMEX, patients will receive SMS-messages at scheduled times, to remind them of their appointments and daily obligations, like work, social functioning, training attendance and the use of medication. Schizophrenia is considered as a chronic psychiatric disease. The prevalence of schizophrenia is about 0.5 % of the total population, while the incidence is approximately 0.2 per thousand inhabitants in the age of fifteen to forty-five (Eaton et al. 1995). Cognitive limitations are nowadays recognised as one of the core deficits in schizophrenia. Deficits on cognitive tests are not caused by other aspect of the illness (Harvey and Sharma, 2002; Pijnenborg et al. 2003) and may be the most common symptom of the disease. Only 20-30% of the patients have no cognitive deficits (respectively Holthausen, 2003 and Harvey and Keefe, 1997). However, until now diagnostic procedures have not proven sufficiently effective in predicting problems in social and vocational role functioning. Including measures of social cognition may increase predictive validity of neuropsychological assessments. In a recent publication "mind reading" capacity or "Theory of Mind" was found to predict outcome better than most other cognitive measures (Pollice et al., 2002). Therefore, the first part of the project is aimed at a better understanding of the impact of social cognitive impairment on daily life. In the proposed project, measures of social cognition will be included in standard neurospychological assessment. By combining the performance on measures of (social) cognition with measures of social and vocational role functioning and sophisticated observation procedures of every day memory, executive functioning and social cognition, we will try to enhance the understanding of the complexity of cognitive functioning in everyday life in schizophrenia. Reducing the impact of cognitive limitations on independent living is the second goal of the proposed project. Until today, rehabilitation of cognitive deficits in schizophrenia has yielded only modest results in enhancing independent daily living and quality of life. In the past decade, a number of cognitive rehabilitation methods were developed or adapted from the rehabilitation practice of neurological patients. These interventions were generally aimed at the function-level and failed to work effectively in the sense that the rehabilitation effect did not generalise to the activity and participation levels. In other words, cognitive functions were thoroughly trained, but patients failed to use their (improved) functions in applied tasks or social role functioning. Also, the social-cognitive functional limitations were not systematically taken into account. E.g. poor recognition of emotional expressions may imply a reduced sensitivity to social reinforcement. The theoretical background of this approach is an extended version of Tim Shallice's mental schema-theory, also accommodating social, motivational and emotional factors (Brouwer and Schmidt, 2002). The major part of this project is concerned with the development of a new cognitive rehabilitation method. In contrast to earlier used drill and practice methods and strategy training, we propose the use of electronic compensational aids (mobile phone and SMS messages) in the daily planning routine of the patients.Our clinical intervention is modelled after the Neuropage, which has successfully been applied in the rehabilitation of patients with very severe traumatic brain injury (Evans et al., 1998; Wilson et al., 1997; Wilson et al. 1999), particularly patients with the so-called dysexecutive syndrome. Given similarities in cognitive dysfunction between these patients and schizophrenia patients, it is expected that schizophrenia patients will comparably profit from these interventions. The diagnostic part of this project will contribute to the body of knowledge on cognitive functioning in schizophrenia by combining laboratory assessments with observations in daily life and will help to gain insight in the role of social cognition and motivation in schizophrenia patients.The ecological validity of neuropsychological tests addressing social cognition will be evaluated. In the MEMEX part of the project, the efficacy of mobile telephones using SMS messages as a prosthetic aid in the cognitive rehabilitation of schizophrenia patients will be studied. The department of psychotic disorders of GGZ Drenthe participates in the psychose-geestkracht program. This specific project focuses on the assessment and treatment of cognitive limitations in patients with schizophrenia. Schizophrenia (psychoses) is one of the major themes of the large-scale Geestkracht program. This specific project is aimed at the daily problems due to cognitive limitations as experienced by many schizophrenia patients. The goal of the project is twofold. First, to gain more insight in the daily problems in schizophrenia, measures of social cognition (emotional prosody, recognition of facial affect, empathy and mind-reading skills) will be incorporated in the standardized neuropsychological assessment of our patients. By adding social aspects of cognition, we hope to gain more insight in the processes underlying daily problems in schizophrenia. We expect that patients whose performance on measures of social cognition is impaired, have more problems in role functioning, e.g. social and vocational. Furthermore, we expect that insight on the sensitivity to social reinforcement and recognition of emotional expressions will contribute to a better understanding of motivational problems observed in many schizophrenia patients. Our expectation is that impaired social cognition leads to insensitivity to social reinforcement and may cause a lack of motivation to avoid situations with negative social consequences, such as rejection by others. The assessment and intervention parts of the proposed project has been implemented in current clinical practice. Neuropsychological data collection is carried out at the Diagnostic Centre of the department of Psychotic Disorders of GGZ Drenthe. All patients (new referrals and change of treatment/medication) receive a neuropsychological and medical-psychiatric evaluation. Patients diagnosed with schizophrenia according to DSM IV criteria are included in the study. The tests for this project will be embedded in the standard assessment procedure. For all patients results will be available on classic neuropsychological tests (intellectual ability, memory, information processing, attention, executive functions) and psychiatric rating scales (positive and negative symptoms, general psychopathology). The classic neuropsychological test battery will comprise the following tests: general ability: Groninger Intelligence Test, memory: WAIS Digit Span and 15 Words Test, information processing and attention: Trailmaking A, Continuous Performance Test, WAIS substitution and Stroop Color-Word Test and executive functioning: Trailmaking B, Six Elements Test of the BADS and SART. Symptoms of schizophrenia will be assessed with the Positive and negative syndrome scale (PANSS). The tests included for this project yield information concerning the recognition of emotional prosody and emotion in facial expression, empathy and mind-reading skills and will also provide insight in everyday memory and planning problems. These social aspect of cognition will be tested with the following tests: prosody: Prosody test , recognition of facial affect: Feest test, empathy: EMP questionnaire and mindreading skills: Faux Pas Test. Relevant outcome measures will also be assessed. Social functioning will be assessed with to Social Functioning Questionnaire and level of education and current occupation/ training will be systematically registered. |
