Transcript Cognitive training

Psychosocial intervention to
optimal treatment to patients with
schizophrenia: neurocognitive
perspectives
TANG Tze-Chun
Department of psychiatry
KMUH
Pharmacotherapy alone or
combination with psychotherapy?
Pharmacotherapy: optimal dose and
strategies to the titration of
antipsychotics
Psychosocial intervention: addon therapy
• Meta-analyses of the efficacy of
psychotherapeutic interventions
for schizophrenia.
Longer intervention period required
• Psychosocial family interventions, regarding
the outcome measure "leaving study early" in
the time period between 13 /24months,
shown to be efficacious
Schizophr Res. 2012.
Cognitive therapy (CT) and antidepressant (ADM):
response rate after 8 and 16 weeks-- DeRubeis RJ et al.,2008
Changes in blood-oxygen-level-dependent (Bold) signal in
response to cognitive and emotional tasks associated with
cognitive therapy --- DeRubeis RJ et al.,2008
Less relapse after cognitive therapy compared to
antidepressant medication:
Compliant, nice adherence
subgroup
DeRubeis RJ et al.,2008
Schizophrenia: hyper-arousal response
dissociated with reduced amygdala activities
• arousal dissociated amygdala/medial prefrontal
("visceral") networks and hippocampus/lateral
prefrontal ("context") networks for fear perception.
• Excessive arousal responses elicited in schizophrenia
subjects, but an associated reduction in
amygdala/medial prefrontal activity.
• Paranoid patients also showed a relatively greater
prefrontal deficit for "without-arousal" responses.
• Am J Psychiatry. 2004 Mar;161(3):480-9.
Social cognition, meta-cognition and
social intervention
• Social function training
– affect recognition
– Cognitive Behavioral Social Skills Training
– Meta-cognition training: CBT + social skills training
• Cognitive training
– Cognitive behavior therapy/group
– Cognitive remediation therapy
• Mindfulness training
Facial recognition and social
function
Social cognition inferences
Voice and facial recognition
• Communication and interpersonal deficits are
major stumbling blocks that stand between
persons with severe mental illness
Hasson-Ohayon I, Kravetz S, Levy I, Roe D.(2009)
• these communication
and interpersonal limitations of persons with
psychosis to impairments of metacognition
– empathy
– theory of mind [ToM]
– mind reading
• Training of affect recognition (TAR)
in schizophrenia-Impact on functional
outcome.
Schizophr Res. 2012 Mar 28
Mechanism of TAR
• Training of Affect Recognition (TAR) effects on
– prosodic affect recognition
– theory of mind (ToM) performance
– social competence in a role-play task
– more general social and occupational functioning
Facial recognition training
• 40 stabilized schizophrenic patients
randomized to a 6-week training on affect
recognition (TAR) or TAU
• assessments of emotion recognition,
cognition, quality of life and clinical
symptoms.
Facial recognition training
• TAR group significant improvements in
– facial affect recognition, in particular in
recognizing sad faces
– in quality of life domain social relationship
– changes were not found in TAU group
Social and cognitive training
• Randomized Controlled Trial of Cognitive Behavioral
Social Skills Training for Older Consumers
With Schizophrenia: Defeatist Performance
Attitudes and Functional Outcome.
Am J Geriatr Psychiatry. 2012 Jan 10.
• cognitive behavioral social skills training
(CBSST) is an effective psychosocial
intervention to improve functioning in older
consumers with schizophrenia
• age 45-78
• 36-session, weekly group therapy that
combined cognitive behavior therapy with
social skills training (CBTSST)
• TAU : goal-focused supportive contact (GFSC)
• Functioning trajectories over time were
significantly more positive in CBSST than in
GFSC
– especially for participants with more severe
defeatist attitudes
• Defeatist Beliefs as a Mediator of Cognitive
Impairment, Negative Symptoms, and
Functioning in Schizophrenia
Schizophrenia Bulletin, (35): 798-806
• Clinical Measures
• Dysfunctional Attitude Scale (DAS)
• Neurocognitive Performance
Path Analysis (N = 54).
Grant P M , Beck A T Schizophr Bull 2008;35:798-806
© The Author 2008. Published by Oxford University Press on behalf of the Maryland Psychiatric
Research Center. All rights reserved. For permissions, please email:
[email protected].
Cognitive enhancement training
(cognitive remediation therapy,CRT)
• Compensatory cognitive training for
psychosis: who benefits? Who stays in
treatment?
Schizophr Bull. 2011 Sep;37 Suppl 2:S55-62.
• primary psychotic disorder who enrolled in a
randomized controlled trial of compensatory
CT (cognitive training) and assessed at
baseline, 3 months (posttest), and 6 months
(follow-up)
• Study completers had more formal education
and lower daily doses of antipsychotic
medications
• lower baseline functioning may have more
room to improve following CT
Cognitive remediation therapy: design
and efficacy
• CRT is a therapy engages the patient in
learning activities enhance neurocognitive
skills to chosen recovery goals
• vary in extent and reflect narrow or broader
perspectives
• Meta-analytic study reports moderate range
effect sizes on cognitive test performance, and
daily functioning
•
Encephale. 2011 Dec;37 Suppl 2:S155-60.
Interaction and motivation for CRT
• type of instructional techniques ,member’s
interaction, and motivation provide
explanatory power for heterogeneity in
patient response to cognitive remediation
• results of studies suggest intrinsic motivation
be a viable treatment target in CRT
• Dorsolateral Prefrontal Cortex Activity
Predicts Responsiveness to Cognitive–
Behavioral Therapy in Schizophrenia
•
Biological Psychiatry 66, (6), 2009, P 594–602
• DLPFC activity of
both hemispheres
predictive of CBT
responsiveness
• left DLPFC showed
more robust pattern
of activity and
connectivity with
the cerebellum in
association with CBT
responsiveness.
Left hemisphere benefit from CBT more
• left hemisphere is more strongly associated
with a beneficial outcome of CBT in
schizophrenia, as reported previously in
depression
• Although cerebellum has traditionally
implicated in motor control, stronger
cerebellar projections from PFC in humans
(30.85%) than in nonhuman primates (16.4%)
DLPFC and cerebellum
• recent data demonstrate cerebellar contributions to
higher-order cognitive functions
– especially task management and multitasking components
of executive processing
• DLPFC-cerebellum connectivity and CBT
responsiveness association explained by PFC–
cerebellum contributions to executive control,
facilitating CBT responsiveness in same way as
DLPFC activity itself
corticocerebellar-thalamo-cortical
circuitry deficits in schzophrenia
• disruption in the corticocerebellar-thalamocortical circuitry results in
– deficient processing, prioritizing, retrieval,
coordination
– responding to information processing deficits in
schizophrenia
Poor attention and poor responsive CBT
• Low response to CBT and reduced
deactivation of regions deactivated during
rest/0-back, relative to the memory load
• reduced ability to maintain focus on, or switch
to, a goal (task in this case) associated with a
less favorable response to CBT
default network and CBT
• default network is a network of brain regions that
are active when individual is not focused on the
outside world and brain is at wakeful rest
– preferentially activates when individuals focus on internal
tasks such as daydreaming, envisioning the future,
retrieving memories, and gauging others' perspectives
• The findings suggest that default mode of brain
action has a role in CBT efficacy in schizophrenia
CBT vs. CRT
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Multicenter, RCT showed both feasible for negative symptom control
Moderate improvement of negative symptoms
no indication for specific effects of CBT compared with CRT
Patients receiving CBT showed a greater mean reduction in avolitionapathy
• CBT promoting clinically meaningful improvements in
– functional outcome,
– motivation, and positive symptoms
– in low-functioning patients with significant cognitive impairment
Schizophr Bull. 2011 Sep;37 Suppl 2:S98-110
Arch Gen Psychiatry. 2012 Feb;69(2):121-7.
Mindfulness training
• Mindfulness-induced changes in gamma band
activity - implications for the default mode
network, self-reference and attention.
•
Clin Neurophysiol. 2012 Apr;123(4):700-10
Task deactivate default mode
• default mode network (DMN) deactivation
identified during transition from resting state
to a time production task
mindfulness meditation (MM) practitioners
– exhibited a trait lower frontal gamma activity
– related to narrative self-reference and DMN
activity, producing longer durations
– negatively correlated with frontal gamma activity
Frontal DMN vs. posterior mindfulness
• MM practitioners exhibit lower trait frontal
gamma activity (as well as a state and trait)
increases in posterior gamma power
– increased attention and sensory awareness
Duration of effective treatment
• Effect of antipsychotic medication alone vs
combined with psychosocial intervention on
outcomes of early-stage schizophrenia: A
randomized, 1-year study
Arch Gen Psychiatry. 2010 Sep;67(9):895-904.
• Intervention Patients randomly assigned to
– receive antipsychotic medication only
– antipsychotic medication plus 12 months
of psychosocial intervention
• psychoeducation, family intervention, skills training,
and cognitive behavior therapy
• during 48 group sessions
• The rates of treatment discontinuation
– 32.8% in combined treatment group
– 46.8% in the medication-alone group.
• lower risk of relapse with combined treatment
(0.57; 0.44-0.74; P < .001)
• greater improvement in combination
treatment
– insight (P < .001),
– social functioning (P = .002),
– activities of daily living (P < .001),
– 4 domains of quality of life
• a significantly higher proportion of patients
receiving combined treatment
– obtained employment
– accessed education
• Neurocognitive enhancement therapy with
vocational services: Work outcomes at twoyear follow-up
Schizophrenia Research 105, Issues 1–3, 2008, P18–29
NET(CRT) enhance competitive
employment
Treatment recommendations
Schizophrenia psychosocial treatment
recommendations
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employment
cognitive behavioral therapy
family-based services
token economy
skills training
psychosocial intervention
» Schizophr Bull. 2010 Jan;36(1):48-70
Philippe Pinel (1745-1826)
Thank you