Q: Do you see any difference between cognitive deficit in ADHD and schizophrenia? In Sweden, we have seen large positive effects on adult ADHD with ADHD medication. Could a schizophrenic patient benefit similarly, when in stable condition after psychosis?

A: ADHD and schizophrenia are quite different in their clinical presentation, with the most apparent distinction being the manifestation of psychotic symptoms, but there are some commonalities in these disorders. Both are heterogenous, neurodevelopmental disorders, and as you note, both present with impaired attention. While, working memory, sustained attention and information processing are impaired in both schizophrenia and ADHD, people with schizophrenia also show deficits in other areas of cognition. The course of the cognitive deficits differ and there is debate about whether different basic cognitive processes underlie the working memory deficit in schizophrenia and ADHD.

The potential of psychostimulants to produce psychotic symptoms has been a significant deterrent to the use of this class of medications for people with schizophrenia.

Posted on April 19, 2012

Q: Would CRT be helpful for students, for example, or others who have not been diagnosed with a mental disorder but have difficulty focusing and retaining material?

A: There is increasing interest in applying CRT to people without diagnosed mental disorders, who want to maintain or improve their cognitive skills. Cognitive skills training is being studied in the context of normal aging, with the goal of maintaining cognitive abilities to prolong productive, independent living. There is also interest in providing CRT within educational settings, although the focus to date has been on students with learning problems and attention deficit disorder.

Posted on February 1, 2012

Q: Have there been any studies done with siblings or relatives of people with schizophrenia to test whether they show some of the same cognitive difficulties, such as speed of processing, working memory, attention and so on, as their affected relatives?

A: There have been a number of studies addressing this question. A large body of data suggests that unaffected relatives of people with schizophrenia do have various types of cognitive difficulties. For example, unaffected siblings have been found to score significantly below healthy controls on measures of processing speed and mental flexibility. However, relatives do score higher on cognitive tests than the affected family members.

Posted on February 1, 2012

Q: Do nurturing, engaging environments promote better cognitive functioning?

A: There is scientific evidence that learning environments that are engaging and autonomy supportive do foster more learning than environments where the learner feels controlled and unsuccessful.

Posted on February 1, 2012

Q: What is the best way to identify a Condition? Should the individual be assessed based on DSM?

A: Indeed it can sometimes be difficult to identify a condition like schizophrenia and so your question is an important one. The diagnosis of schizophrenia is best made by a trained mental health diagnostician who uses DSM IV criteria and information gathered from a careful interview with the patient, as well as information gathered from medical records, family and support people. Sometimes several meetings with a patient are needed to clarify a diagnosis.

Posted on September 26, 2011

Q: Are patients ever turned off by cognitive remediation because the elementary tasks seem infantilizing (from their perspective)?

A: This question is an excellent one because it indicates an appreciation of how important it is to personalize care. Indeed, people would disengage from treatment if they felt infantilized, under-challenged or over-challenged. Some patients are very sensitive to any indication that a task is playful or elementary (or for that matter overly challenging) and others are far less sensitive. So the quick answer is yes, occasionally patients will say - this is boring, or childish - and then it is the clinician's job to figure out why they say that, and to personalize the remediation experience by finding tasks that both address relevant areas of deficit and do so in a non threatening way. Fortunately there is an ever increasing array of cognitive remediation tasks available to choose from so it is always possible to find one that will be acceptable. It is precisely because there is no one task that is right for everyone that it is essential that cognitive remediation clinicians be conversant in the wide range of tasks that can be used.

The following reference has a chapter devoted to this topic:
Cognitive remediation for psychological disorders, therapist guide.
Medalia, A., Revheim, N., & Herlands, T. (2009). Oxford University Press: New York.

Posted on September 26, 2011

Q: Is there any other breakthrough in the medication besides the anti-psychotic drugs that are prescribed which are targeting the neurotransmitters? What about the hippocampus?

A: This is an excellent question - we are examining that very question ourselves, as to whether targeting the hippocampus will improve outcome. My colleague Dr. Scott Schobel documented increased activity in the hippocampus as a risk biomarker for psychosis outcome in our high-risk cohort (reference 1). He now has trials underway to determine which medications may reduce this brain activity, which seems to be related to increased glutamate, and also hopefully improve symptoms and cognition. It is not far-fetched to consider that reducing glutamate may help with psychotic symptoms - see the article in Nature on a new antipsychotic that does not target dopamine but instead glutamate receptors (reference 2):

1) Differential targeting of the CA1 subfield of the hippocampal formation by schizophrenia and related psychotic disorders.
Schobel SA, Lewandowski NM, Corcoran CM, Moore H, Brown T, Malaspina D, Small SA.
Arch Gen Psychiatry. 2009 Sep;66(9):938-46.

2) Activation of mGlu2/3 receptors as a new approach to treat schizophrenia: a randomized Phase 2 clinical trial.
Patil ST, Zhang L, Martenyi F, Lowe SL, Jackson KA, Andreev BV, Avedisova AS, Bardenstein LM, Gurovich IY, Morozova MA, Mosolov SN, Neznanov NG, Reznik AM, Smulevich AB, Tochilov VA,Johnson BG, Monn JA, Schoepp DD.
Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285, USA.
Nat Med. 2007 Sep;13(9):1102-7. Epub 2007 Sep 2.

Posted on September 26, 2011

Q: Could the prodomal symptoms be considered dissociation? (e.g. feeling as if in a fantasy video world, feeling the world is not real.) Could it be said that dissociation may precede psychosis?

A: This is an excellent question. We certainly do see plenty of patients who have some dissociative symptoms, though not all do. Dissociative symptoms seem in our cohort to be more common in youths who have experienced interpersonal trauma (i.e. sexual abuse) or a major life event (a teenaged boy learning his best friend was shot and killed). It is an oversight on our part that we do not use standard measures of dissociation in our cohort to examine this more systematically, though perhaps now we should start! We published on the high prevalence of early trauma in prodromal patients, and its association with anxiety and subthreshold positive symptoms (reference 1); we did not examine dissociation.

In patients with established psychotic disorder, dissociative symptoms are related both to past trauma exposure as well as to hallucinations and delusions (reference 2,3,4). There is little research on dissociative symptoms in prodromal or clinical high risk patients per se. However, in youths with "atypical" psychotic symptoms, there were high rates of trauma exposure and dissociative symptoms, and these individuals were more likely to receive a diagnosis of PTSD (reference 5).

To be categorized as at heightened clinical risk for psychosis, the symptoms cannot be better accounted for by another disorder. This is a common quandary in our research as there is high comorbidity in both schizophrenia and its risk states. This includes OCD, social anxiety disorder, major depression, and even autism spectrum symptoms. Trauma is prevalent in at-risk patients (reference 1). In our cohort, among those who experienced trauma, the re-experiencing (and hyperarousal) symptoms of PTSD seem to be very uncommon, whereas the avoidance cluster is far more common.

I do not think however that dissociation is part and parcel of positive symptoms. In our cohort, patients report commonly that they are attracted to fantasy and nihilism, which they find compelling as an alternative to real life. The voluntary aspect of many of these experiences seem in my mind to argue against their being dissociative per se. But I would be glad to be corrected.

Excellent question. In sum, I think dissociation may in some cases (especially in the context of trauma) be inherent to the evolution of psychotic symptoms. Whether it precedes psychosis is an open question. You will have to come to New York and study dissociative symptoms prospectively in our cohort!

References:
1) Childhood trauma and prodromal symptoms among individuals at clinical high risk for psychosis.
Thompson JL, Kelly M, Kimhy D, Harkavy-Friedman JM, Khan S, Messinger JW, Schobel S, Goetz R, Malaspina D, Corcoran C.
Schizophr Res. 2009 Mar;108(1-3):176-81. Epub 2009 Jan 25.

2) A preliminary exploration of trauma, dissociation, and positive psychotic symptoms in a Spanish sample.
Perona-Garcelan S, Garcia-Montes JM, Cuevas-Yust C, Perez-Alvarez M, Ductor-Recuerda MJ, Salas-Azcona R, Gomez-Gomez MT.
J Trauma Dissociation. 2010;11(3):284-92.

3) Relationships between trauma and psychosis: an exploration of cognitive and dissociative factors.
Kilcommons AM, Morrison AP.
Acta Psychiatr Scand. 2005 Nov;112(5):351-9.

4) The prevalence and correlates of trauma-related symptoms in schizophrenia spectrum disorder.
Lysaker PH, Larocco VA.
Compr Psychiatry. 2008 Jul-Aug;49(4):330-4. Epub 2008 Mar 19.

5) Phenomenology and diagnostic stability of youths with atypical psychotic symptoms.
Hlastala SA, McClellan J.
J Child Adolesc Psychopharmacol. 2005 Jun;15(3):497-509.

Posted on September 26, 2011