Determinants of everyday outcomes in schizophrenia: The influences of cognitive impairment, functional capacity, and symptoms

Emory University School of Medicine, Atlanta, GA 30322, USA.
Schizophrenia Research (Impact Factor: 3.92). 09/2009; 115(1):82-7. DOI: 10.1016/j.schres.2009.09.004
Source: PubMed


Deficits in everyday living skills and social skills are associated with the pervasive disability seen in schizophrenia. Cognitive impairments are determinants of these skills deficits and it is known that positive and negative symptoms add to the influence of cognitive impairments for prediction of real-world outcomes. This study examined the relative importance of cognitive impairments measured with a neuropsychological battery, performance-based measures of social and everyday living skills, and positive and negative symptoms for the prediction of real-world outcomes in social and residential domains. In contrast to most previous studies, we examined the importance of individual symptoms, as well as total subscale scores, for predicting clinician rated outcomes in 194 older outpatients with schizophrenia. Symptoms were rated with the Positive and Negative Syndrome Scale; everyday living skills were measured by the UCSD Performance-based Skills Assessment; and social skills were measured with the Social Skills Performance Assessment. For prediction of real-world social outcomes, blunted affect and passive-apathetic social withdrawal accounted for all of the predicted variance, while social competence and cognitive impairments did not enter the final equation. For residential functioning, everyday living skills were the most important predictor, followed by lack of spontaneity. The positive symptoms of hallucinatory behavior and suspiciousness also predicted real-world residential outcomes. These results suggest that real-world disability is the product of a complex array of ability deficits and symptoms, indicating interventions will need to be carefully targeted. For social and everyday living outcomes, variance accounted for by the entire array of predictive variables was less than 40%, suggesting that other factors, such as social and cultural influences, are involved as well.

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    • "However, clinical stabilization with pharmacotherapy explains minimal variation in community functioning (Tandon et al., 2010). While some studies suggest that both neurocognitive and social cognitive processes facilitate improved community functioning (Brekke et al., 2005; Leifker et al., 2009), others suggest that social cognition is a more proximal treatment target than neurocognition (Fett et al., 2011; Reichenberg et al., 2014). Yet other studies suggest that neurocognitive deficits predict poorer community functioning independently from social cognition (Hofer et al., 2011). "
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    ABSTRACT: Schizophrenia is characterized by impairment in multiple aspects of community functioning. Available literature suggests that community functioning may be enhanced through cognitive remediation, however, evidence is limited regarding whether specific neurocognitive domains may be treatment targets. We characterized schizophrenia subjects based on their level of community functioning through cluster analysis in an effort to identify whether specific neurocognitive domains were associated with variation in functioning. Schizophrenia (SCZ, n=60) and control (CON, n=45) subjects completed a functional capacity task, social competence role-play, functional attainment interview, and a neuropsychological battery. Multiple cluster analytic techniques were used on the measures of functioning in the schizophrenia subjects to generate functionally-defined subgroups. MANOVA evaluated between-group differences in neurocognition. The cluster analysis revealed two distinct groups, consisting of 36 SCZ characterized by high levels of community functioning (HF-SCZ) and 24 SCZ with low levels of community functioning (LF-SCZ). There was a main group effect for neurocognitive performance (p<0.001) with CON outperforming both SCZ groups in all neurocognitive domains. Post-hoc tests revealed that HF-SCZ had higher verbal working memory compared to LF-SCZ (p≤0.05, Cohen's d=0.78) but the two groups did not differ in remaining domains. The cluster analysis classified schizophrenia subjects in HF-SCZ and LF-SCZ using a multidimensional assessment of community functioning. Moreover, HF-SCZ demonstrated rather preserved verbal working memory relative to LF-SCZ. The results suggest that verbal working memory may play a critical role in community functioning, and is a potential cognitive treatment target for schizophrenia subjects. Copyright © 2015 Elsevier B.V. All rights reserved.
    Schizophrenia Research 07/2015; DOI:10.1016/j.schres.2015.07.011 · 3.92 Impact Factor
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    • "An open question regarding connectome abnormalities in schizophrenia (Dauvermann et al., 2014)—altered hub connectivity in particular (Van den Heuvel and Kahn, 2011)—is whether, and if so how, alterations in macroscale connectome wiring relate to illness progression and outcome. Persistent symptoms (Lieberman, 1999)a n d real-world deficits in areas such as employment (Harvey and Velligan, 2011) and everyday living (Harvey et al., 2009; Leifker et al., 2009)are common in patients, but prognosis at the individual level is heterogeneous (Schultz and Andreasen, 1999). Relating connectome architecture to progression of illness and functional deficits might inform prognostic estimations. "
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    ABSTRACT: Emerging evidence suggests schizophrenia to involve widespread alterations in the macroscale wiring architecture of the human connectome. Recent findings of attenuated connectome alterations in unaffected siblings of schizophrenia patients suggest that altered connectome organization may relate to the vulnerability to develop the disorder, but whether it relates to progression of illness after disease onset is currently unknown. Here, we examined the interaction between connectome structure and longitudinal changes in general functioning, clinical symptoms and IQ in the 3years following MRI assessment in a group of chronically ill schizophrenia patients. Effects in patients were compared to associations between connectome organization and changes in subclinical symptoms and IQ in healthy controls and unaffected siblings of schizophrenia patients. Analyzing the patient sample revealed a relationship between structural connectivity-particularly among central 'brain hubs'-and progressive changes in general functioning (p=0.007), suggesting that more prominent impairments of hub connectivity may herald future functional decline. Our findings further indicate that affected local connectome organization relates to longitudinal increases in overall PANSS symptoms (p=0.013) and decreases in total IQ (p=0.003), independent of baseline symptoms and IQ. No significant associations were observed in controls and siblings, suggesting that the findings in patients represent effects of ongoing illness, as opposed to normal time-related changes. In all, our findings suggest connectome structure to have predictive value for the course of illness in schizophrenia. Copyright © 2015. Published by Elsevier B.V.
    Schizophrenia Research 04/2015; 38. DOI:10.1016/j.schres.2015.03.012 · 3.92 Impact Factor
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    • "Accordingly, UPSA-1-BR total scores correlated positively and moderately with both PSP (rho = 0.5) and GAF (rho = 0.46). Similar results were presented by Keefe et al. (2006) (r = 0.4), Leifker et al. (2009) (r = 0.48) and Bowie et al. (2006) (ranging from r = 0.34 to r = 0.61) when analyzing the relationship between total scores of UPSA and Real-World Functioning scales. Further studies including UPSA-1-BR and multiple-domain Real-World Functioning scales are necessary to unveil if these correlations get stronger when specific skills are matched with particular situations in daily activities. "
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    ABSTRACT: The UCSD Performance-based Skills Assessment (UPSA) is a measure of Functional Capacity and assesses skills involved in community tasks. It has good psychometrics properties, and is currently recommended as a co-primary assessment of cognition in the MATRICS Project. To our knowledge so far, there are no studies in western developing countries concerning Functional Capacity in Schizophrenia. The aims of this study were to translate, culturally adapt and validate the UPSA to assess Functional Capacity in community-dwelling patients with Schizophrenia living in Brazil. Eighty-two subjects (52 patients, 30 controls) were evaluated using: the Brazilian version of the UPSA (UPSA-1-BR), PANSS, Personal and Social Performance (PSP) and Global Assessment of Functioning (GAF). In the reliability test, UPSA-1-BR showed good Internal Consistency (Cronbach’s alpha of 0.88) and strong correlation between test and retest (4-month gap; r = 0.91; p < 0.01). Spearman’s rho values showed a moderate correlation between UPSA-1-BR and both PSP (0.50; p < 0.01) and GAF (0.46; p < 0.01) scores. UPSA-1-BR is capable of differentiating people with and without Schizophrenia. Patients scored lower than controls (58.9 versus 79.1), with an AUC of 0.79 (95%IC: 0.69–0.89). Sensitivity and specificity values of 0.71 and 0.70, respectively, were found in the cut-off point of 73.5, for separation of patients and controls, with predictive values of 80% (positive) and 58% (negative). UPSA-B-BR was also evaluated. UPSA-1-BR and its brief version presented adequate psychometric properties and proved to be valid and reliable instruments in the assessment of Functional Capacity in subjects with Schizophrenia.
    Schizophrenia Research: Cognition 01/2015; 22(1). DOI:10.1016/j.scog.2014.12.002
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