patient care perspectives

Cognition and Socio-Cognitive Skills in Patients With Schizophrenia

by John M. Kane, MD

Overview

Patients with schizophrenia usually exhibit significant cognitive impairment. These deficits begin years before the onset of psychotic symptoms and typically persist throughout the disease course.

Expert Commentary

John M. Kane, MD

Senior Vice President, Behavioral Health Services
Northwell Health
Zucker Hillside Hospital
Professor and Chairman, Department of Psychiatry
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
New Hyde Park, NY

Social cognition has not received the same degree of attention as neurocognition, even though the ability to relate to others can be quite impaired in patients with schizophrenia.”

John M. Kane, MD

Cognitive dysfunction should be considered a core feature of schizophrenia, with approximately 75% of patients experiencing moderate to severe cognitive deficits across multiple domains, including attention, working memory, verbal learning, and executive function. Cognitive deficits typically predate the onset of frank psychosis, which is consistent with schizophrenia being thought of as a neurodevelopmental disorder. For example, a young child who will not develop schizophrenia for years may perform poorly on cognitive measures such as processing speed. As with negative symptoms, cognitive dysfunction is predictive of functional status.

There are many different aspects of cognitive dysfunction in schizophrenia, including social cognition and neurocognition (eg, attention, memory, and executive function). Examples of a neurocognitive impairment include a patient forgetting why they went to the grocery store or a patient forgetting a once-familiar phone number. Social cognition involves how one interacts with people (eg, a patient not recognizing a facial expression as a smile). It has not received the same degree of attention as neurocognition, even though the ability to relate to others can be quite impaired in patients with schizophrenia. Cognitive function should be considered across all of the domains and addressed accordingly. As with other symptoms of schizophrenia, cognitive symptoms vary among patients.

Although neurocognitive remediation may be somewhat helpful, cognitive issues will remain. In addition, these interventions tend to be labor intensive, and not all patients have access to this level of care. Social cognition training, which is considered a specialized modality, focuses on developing the patient’s ability to react to social stimuli and improve psychosocial functioning. The improvements observed following social cognition training seem to be more encouraging than those seen after neurocognitive remediation.

Some patients with schizophrenia are open to participating in these cognitive programs because they realize that they need help. However, others often lose insight into their condition. Therefore, it is helpful if the clinician engages in conversations with the patient’s family about cognitive interventions, as they can encourage the patient to participate in, and continue with, cognitive therapies.

Presently, cognitive therapy is an area of research that has not evolved into standardized therapies. Treatment facilities typically have more resources available to address cognition in patients with early phase or first-episode disease than in patients with chronic disease.

References

Green MF, Horan WP, Lee J. Nonsocial and social cognition in schizophrenia: current evidence and future directions. World Psychiatry. 2019;18(2):146-161. doi:10.1002/wps.20624

Meier MH, Caspi A, Reichenberg A, et al. Neuropsychological decline in schizophrenia from the premorbid to the postonset period: evidence from a population-representative longitudinal study. Am J Psychiatry. 2014;171(1):91-101. doi:10.1176/appi.ajp.2013.12111438

Nijman SA, Veling W, van der Stouwe ECD, Pijnenborg GHM. Social cognition training for people with a psychotic disorder: a network meta-analysis. Schizophr Bull. 2020;46(5):1086-1103. doi:10.1093/schbul/sbaa023

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