Neuropsychology and
Schizophrenia
Jennifer Badgley Fleeman, Psy.D.
Licensed Clinical Psychologist
Shrink.inc@frontiernet.net
Outline
• Schizophrenia – brief overview
• Nature of assessment with the mentally ill
• Common neuropsychological findings in
schizophrenia
• Medication effects
• Insight and outcome
Schizophrenia
• Chronic psychiatric disorder
• characterized by disruption in affective,
cognitive, behavioral, and social domains
• that results in poor ability to maintain
adaptive functioning in the community.
Schizophrenia
• Lifetime prevalence from 0.5% to 1.0% of
the population (APA, 1994)
• Usually manifests itself between ages 18
and 25
• No gender discrepancy (prevalence)
Symptoms of schizophrenia
•
•
•
•
Delusions
Hallucinations
Disorganized speech
Grossly disorganized
or catatonic behavior
• Negative symptoms
• Social/occupational
dysfunction
• >= 1 month active sx;
signs for >= 6 months
• Positive symptoms
– Excess
– Delusions,
hallucinations, loose
associations
• Negative symptoms
– Lacking
– Poor motivation, social
withdrawal, flat affect,
diminished speech
content
Subtypes
• DSM-IV
–
–
–
–
–
Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
• Distinction between
“Functional” and
“Organic” etiology is
outdated
• Psychiatric disorder
with
neuropsychological
correlates
Schizophrenia
-Theories of Etiology
•
•
•
•
Immunologic/Viral factors
Disruption of neuroanatomical development in embryo
Dopamine Hypothesis: Excessive dopamine
Structural brain abnormality: Enlarged lateral and third
ventricles found in neuroimaging and post-mortem studies
• Cortical atrophy/ volume loss: atrophy in hippocampus and
amygdala, left temporal lobe
• Functional brain abnormality: Hypometabolism in
dorsolateral pre-frontal cortex and hippocampal regions
noted during certain cognitive tasks
• Genetics with influence from environment
Nature of Assessment
• 1) Multiple factors to consider (medical,
emotional, behavioral, cognitive)
• 2) Contribution of mental illness, neurological
disorder (if present), and medical illnesses (if
present) to their symptom presentation
• 3) Assessment issues (attention/concentration,
behavioral/compliance, motivational issues) and
time factor
Common Referral Questions
• Change in cognitive functioning not associated with
psychiatric decompensation
• Deficits in cognition disproportionate to mental illness
• Sudden onset of cognitive dysfunction
• Assessment of cognitive functioning to assist with
treatment/discharge planning; evaluate strengths/weaknesses
• Provide baseline against which future performance can be
compared
• Re-assessment of cognitive function (progress, decline)
• Evaluation of specific areas of functioning (e.g., memory)
• Rule out dementia
• Competency (e.g., independent functioning, forensic)
Tests Used to Answer Referral
Questions
• Use common neuropsychological and
cognitive tests
• The tests may or may not have norms for
individuals with particular mental illnesses
• Look at pattern of scores and degree of
impairment
Schizophrenia and
Cognitive Impairment
• Cognitive deficits are heterogeneous, but
impairment in three functional domains are most
often identified:
– Attention
– Memory
– Executive Functioning
• Negative symptoms associated with greater
cognitive impairment
• Typical course of cognitive impairment:
– Initial decline in cognitive functioning soon after the
illness onset, then fairly stable.
Attention
• Attention:
– Automatic stimulus processing (without awareness):
• Ex:Acoustic startle
• Ex: P300
– Difficulty with other attention functions:
• Initially focusing (irrelevant details)
• Divided attention/ Working Memory
• Vigilance (maintaining attention)
– CPT (A X paradigm)
– Selective attention o.k.
Memory
• Working Memory:
• Memory:
– Impairment in both verbal and nonverbal memory
– Difficulty with encoding/learning (organization/
integration of current input with past experience)
and retrieval; Recognition superior to recall
– Able to benefit from repetition to learn and cues to
recognize
Executive Functioning
• Executive Functioning:
– Poor planning, organization, problem-solving,
cognitive flexibility, self-monitoring
– Impaired insight and social judgment
– Lack of initiative/ motivation
Intelligence
• Decrease due to pathological changes
• Estimating pre-morbid IQ
–
–
–
–
Previous testing
Certain cognitive measures
School records
Algorithms
Other Cognitive Findings
• Language:
– Language generation problems
– No problems understanding single
words/simple sentences, but difficulty
comprehending longer sequences
Schizophrenia:
Other Cognitive Findings
• Visuospatial/Constructional:
– Generally no impairment copying simple designs
– Difficulty with complex figures/ construction (e.g.,
Block Design, Object Assembly, Rey Copy)
– Data suggests problems in organization rather than
visuospatial processing
Schizophrenia:
Other Cognitive Findings (cont.)
• Motor:
– Slow reaction time is most common finding
– Incoordination, clumsiness, tremors, posturing
Cognitive Patterns in Type I vs II
• Type I (positive sx):
– Not associated with
global cognitive
dysfunction
– Hallucinations/
delusions not sig
related to cognitive
performance
– Thought disorder
disrupts attention and
language performance
• Type II (negative sx):
– More associated with
global cognitive
dysfunction
– More problems with
visual-motor, visualspatial, and attention
– Transient negative
symptoms vs. “deficit
syndrome”
Example: Mr. X
• Basic Demographics
– 45 y.o. male
– 14 years education
• Chronic Paranoid Schiz;
Polysubstance Abuse
• Psych history
– Multiple psych
hospitalizations since age
25
• ?head injury
• Symptoms at admit:
– Paranoia
– ?auditory
hallucinations
– Guardedness
– Thought disorder
– Social isolation
– Flat affect
– Med. Non-compliance
Mr. X’s scores
• IQ----------------------------• Attention/Working Mem-• Verbal Memory
– Immediate Recall--------– Delayed Recall-----------– Recognition----------------
• Average
• Low average – borderline
• Impaired
• Borderline
• Average
• Visual Memory
– Immediate Recall--------– Delayed Recall------------
• Low average – borderline
• Low average - borderline
Mr. X’s scores (cont.)
• Language-------------------• Visuospatial/Visual-motor
• Executive Functioning
– Cognitive Flexibility----– Reasoning-----------------– Processing Speed---------
• Average
• Average
• Low average
• Average
• Low average - borderline
Mr. X - Impressions
• Relative cognitive weaknesses:
–
–
–
–
Auditory and visual attention
Memory encoding/retrieval
Working memory/cognitive flexibility
Processing speed
• Relative cognitive strengths:
–
–
–
–
–
IQ
Language
Memory Retention and recognition
Visuospatial/Visual-motor integration
Reasoning
• Consistent with schizophrenia
Example: Mr. Y
• Basic Demographics
– 55 y.o. male
– 10th grade education
• Schizophrenia,
Undifferentiated Type;
hx Alcohol Dependence
• Psych history
– Multiple psych
hospitalizations since age
16
• No hx LOC
• COPD; Psychogenic
Polydypsia
• Symptoms at admit:
–
–
–
–
Prominent negative sx
Confused; disorganized
Polydypsia; dysruptive
Increased forgetfulness
& confusion since
admit
Mr. Y’s scores
•
•
•
•
•
Current results
Mental Status (20/30)
Simple Attention----------Working Memory---------Verbal Memory
– Immediate Recall--------– Delayed Recall-----------– Recognition----------------
• Visuospatial/Visual-motor
• Changes? Past/ Present
• No change
• Low avg/ severe impaired
• Mild Impair/ severe impaired
• Mild Impair/ severe impaired
• Low avg/ severe impaired
• Borderline/ severe impaired
Mr. Y’s scores (cont.)
• Current results
• Language--------------------
• Changes?
• Average/ mod impaired
• Executive Functioning
– Cognitive Flexibility----– Planning------------------– Processing Speed---------
• Low avg/ severe impaired
• No change (impaired)
• No change (impaired)
Mr. Y - Impressions
• Pattern of results:
– Global difficulties that cannot be fully explained by presence
of chronic schizophrenia and COPD
• Severity, pattern (language, recognition)
• Decline:
• Global (verbal & visual memory, working memory, cognitive
flexibility, language, etc.)
• No decline in simple attention, planning, processing speed
• Consistent with combination of factors, including
long-standing alcohol abuse, chronic schizophrenia,
COPD, and dementia
Medication effects:
Antipsychotics
• Conventional Antipsychotics:
– Anticholinergic effects (memory, concentration)
– Impaired motor functioning; slowed processing speed;
anticholinergic meds to control extrapyramidal
symptoms can also adversely affect memory
• Atypical/Novel Antipsychotics:
– Some evidence that they work to decrease negative
symptoms (including cognitive impairment) as well as
positive symptoms
Medication & Cognitive Functioning
-Current Literature
• Atypical antipsychotics may have a
beneficial effect on negative symptoms of
schizophrenia, but this is controversial;
• Conventional antipsychotics are usually
noted as being only effective for positive
symptoms
• Newer medications (e.g., Ability) may hold
promise for negative sx and cognition
Example: Mr. Z
• Basic Demographics
– 32 y.o. male
– 11th grade education + GED
• Schizoaffective; ETOH +
THC dependence;
Antisocial Personality
Disorder
• Legal History:
– Extensive
• Psych history
– No prior psych
hospitalizations;
– Hx depression,
hypomania,
aggression, poor
impulse control, poor
insight
• Medical history
– Multiple concussions
Mr. Z’s scores
Current results
• Attention--------------------
Changes? Past/ Current
• Avg/ low avg
• Working Memory----------
• Avg/ borderline
• Verbal Memory------------
• Largely consistent, except
more vulnerability to
distraction
• Visual Memory-------------
• No changes
Mr. Z’s scores (cont.)
Current results
• Visuospatial/Visual-motor
Changes? Past/ Current:
• No changes except decreased
for tasks requiring speed
• Language--------------------
• No changes except verbal
fluency decline
• Executive Functioning
– Problem-solving--------– Reasoning----------------– Planning------------------– Processing Speed--------
•
•
•
•
No changes
No changes
No changes
Borderline/ extremely low
Mr. Z - Impressions
• Pattern of results:
– Declines:
• Complex attention/working memory, susceptibility
to distraction, processing speed, verbal fluency
– No declines:
• Reasoning, verbal learning and memory, visual
learning and memory, abstract reasoning, problemsolving, planning
• Consistent with common side effects of antipsychotic
and anti-convulsant medications
Remediation, compensatory
strategies, medication, etc.
• Cognitive strategies: retraining
• Compensatory: utilize strengths, use
modifications
• Environmental modifications
• Medication: Aricept, etc.
Insight into illness and outcome
• Insight into psychiatric illness critical to outcome
(probably #1 for many of these patients)
• Cognitive dysfunction highly predictive of
prognosis (as important as “typical” psychotic sxs)
• Cognitive dysfunction sometimes linked to excess
medication dose as evidenced by EEG changes
Cognitive Impairment & Insight
-Literature
• (Amador et al., 1991; Lysaker & Bell, 1994):
– Poor recognition of illness secondary to deficits in
abstract and flexible thinking
• (Amador et al., 1994):
– Poor insight is a prevalent feature of schizophrenia, and
may stem from neuropsychological dysfunction;
– Increased formal thought disorder correlated with lower
insight into mental illness and social consequences of it.
Cognitive Impairment & Insight
-Current Literature (cont.)
• Severity of poor insight strongly correlated
with degree of structural dysfunction
(frontal lobes) and executive dysfunction
(WCST, verbal fluency, Trails)
Cognitive Deficits and Daily
Functioning
• (Green, 1996) Functional outcome of cognitive
deficits:
– Verbal Memory associated with all types of functional
outcome (e.g., social skills acquisition, community
outcome, social problem-solving)
– Vigilance related to social problem solving and skill
acquisition
– Card Sorting predicted community functioning.
Conclusions
• Questions?
• Comments?