Cognitive rehabilitation in schizophrenia

 WHO classifies schizophrenia as one of the ten most debilitating illnesses

WHO classifies schizophrenia as one of the ten most debilitating illnesses

Cognitive rehabilitation in schizophrenia has become of greater interest in recent years and cognition is now widely considered a core deficit in this disorder.  Remediation therapies aim to improve functional outcomes and RehaCom is widely used as an approach to computer-based cognitive training.  A number of studies have have shown it's efficacy with respect to attention, aspects of memory and problem solving. (D'Amato et al., 2011)

Before we get into the details of a recent study we should explain a few things about schizophrenia which the WHO classifies as one of the ten most debilitating illnesses.

Some effects of schizophrenia, such as unusual behavior, delusions, visual or auditory hallucinations are easy to see.  What may be less obvious is how the illness affects the persons ability to think and reason - their cognition.  One common cognitive symptom is a lack of insight into the illness, also called anosognosia. People with anosognosia aren’t aware they have an illness or don’t understand how serious it is.  Cognitive problems related to memory or an ability today attention can interfere with holding down a job, communicating with others, or even performing basic activities such as taking medication.

The onset of schizophrenia usually occurs during adolescence or early adulthood. The average delay in diagnosis is more than 5 years which is serious because of the potential for inappropriate treatment, associated illness that go untreated and an increased risk of suicide.  It is a major factor of de-socialisation and employment insecurity and the average life expectancy of patients is ten years less than that of the general population. 

At present, the progression of the illness and the quality of life of patients depend on a number of factors.  The quality of psychosocial support, access to care and sticking to the treatments proposed are all important.  Psycho social treatment such as psycho-education, cognitive remediation and cognitive behaviour therapies are also of great importance to improve the prognosis.

Scientific study applying RehaCom in schizophrenia - see link below

A recent study by Jamin et al posed the interesting question of whether cognitive rehabilitation in schizophrenia should be Computer-based or Computer-assisted.  The comparison here is on whether the emphasis is largely placed on the training delivered by the software (computer-based) or whether the software is used as a tool by the therapist - in other words, computer-assisted.

The authors used four RehaCom modules - Attention and Concentration, Divided Attention, Logical Reasoning and Verbal Memory with 30 patients aged between 17 and 44 years of age. These individuals had a diagnosis of either schizophrenia or schizoaffective disorder and a comprehensive cognitive assessment both before and after working with RehaCom.  The training programme consisted of twice weekly, 30 minute sessions with the total number of sessions depending on each persons cognition profile and performance.  

The authors point out some of the methodological issues with their study such as the lack of a control group but importantly their findings showed significant improvement in all cognitive variables with the exception of the WCST (Wisconsin Card Sorting Test-64).

The following variables were reviewed as part of the assessment 

1) General Efficiency - FSIQ,VIQ, PIQ (Wechsler Adult Intelligence Scale - 3rd edition)
2) Speed of processing - Processing Speed Index (WAIS-III), Trail Making Test - Part A
3) Executive functions and logical reasoning: Matrix reasoning subtest (WAIS-III) and WCST
4) Verbal learning and memory: California Verbal Learning Test, Free/Cued Recall Test (16 RL/RI)

Their findings actually reinforce what we always say about RehaCom.  The core of any rehabilitation programme should be the patient - therapist relationship and not the patient - computer interaction.

The authors conclude by recommending an approach that had previously been described by Wykes & Reeder (2005)

This means

  • having a clear formulation of the individual's cognitive profile, strengths, difficulties and treatment goals
  • a scaffolding approach to strategy - shifting from a restoration approach to a reorganisation approach as necessary and as the preserved/restored cognitive functions are used to construct a new problem solving strategy
  • the therapist stressing compensatory strategies for everyday life - the context and content of each RehaCom training session being explained in terms of it's pertinence to real-life situations.

    This to us makes perfect sense.  The use of rehabilitation software like RehaCom can be very beneficial as long as the neuropsychologist or therapist provides the cognitive reorganisation strategies that are suitable for each person and actively encourages patient reflection so that the skills learned are transferred to everyday life.

See a Poster on the study at this link

http://www.fondation-fondamental.org/upload/pdf/2013_poster_strasbourg_rehacom_final.pdf

Reference
D’Amato et al. (2011). A randomized, controlled trial of computer-assisted cognitive remediation for schizophrenia. Schizophrenia research, 125, 284-290. 

Wykes and Reeder (2005). Cognitive Remediation Therapy for Schizophrenia. Theory & Practice. Routledge Eds.