Many people assume that it is the emotional and psychotic symptoms that make it difficult for a person with schizophrenia to function in everyday life. In fact, research indicates that cognitive impairment is a major reason why functional outcome is so poor.1 Impairments in attention, memory, processing speed, and problem-solving ability are commonly seen in patients with schizophrenia, depression, bipolar disorder, and alcohol and substance abuse disorders.2 While the severity and profile of these deficits vary depending on factors such as diagnosis, course of illness, and socioenvironmental variables, patients with schizophrenia spectrum disorders typically score below 85% of the general population on cognitive tests. These cognitive deficits are persistent and are not simply related to an episode of illness. Therefore, even when the person is psychiatrically stable, cognitive impairment remains evident.
Cognition and daily functioning
Cognitive deficits make it difficult to work, study, live independently, socialize, and manage one’s illness. These daily living tasks all require an ability to attend and remember, to identify goals and the steps to reach them, to prioritize and organize activities, and to integrate feedback to monitor performance. Take the example of illness management. Many patients do not take medications as prescribed because they have difficulty organizing their pills or forget their dosing schedule or whether they already took their medication.3
Some patients may be referred to psychiatric skills training programs, but it is difficult for them to process and remember the information given in groups if they have cognitive problems. In the arena of independent living, patients with cognitive deficits struggle to remember appointments and where they put their keys and other personal items. People with problem-solving deficits have trouble organizing their living space so that they can find things and may have difficulty in maintaining a budget or negotiating public transportation. Sometimes patients are labeled as unmotivated and uncooperative when, in fact, they want to remember but simply are not able to.
Patients with cognitive impairment require specific therapeutic interventions so they can achieve a good functional outcome. Careful attention should be paid to the potential cognitive toxicity of pharmacotherapeutic regimens. Psychoeducation about cognitive symptoms should be provided for the patient and his or her family so that they understand the basis of the forgetful, inattentive behaviors and can strategize ways to support improved cognitive functioning.4 There are no FDA-approved medications to improve neurocognitive functions in patients with schizophrenia and affective disorders, but patients may benefit from participation in a cognitive remediation (CR) program. These programs can strengthen impaired cognitive skills that interfere with daily functioning and teach strategies that can be used to compensate for deficits (Table).
Behavioral treatment for cognitive impairments
CR is a behavioral treatment that engages the patient in exercises intended to improve the neuropsychological skills that underlie thinking. It differs from cognitive-behavioral therapy (CBT) in both focus and methodology. The focus of CR is on the neuro- psychological processes that underpin thinking, while the focus of CBT is on the form and content of thought. For example, while CBT might focus on a patient’s reasoning and attributional style of jumping to conclusions or being quick to self-blame, CR focuses on improving working memory capacity and ability to sustain attention. CBT might focus on a patient’s belief that there is a plot to harm him, whereas CR focuses on improving attention, executive functioning, and verbal memory.
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Medalia A, Revheim N, Casey M. Remediation of problem-solving skills in schizophrenia: evidence of a persistent effect. Schizophr Res. 2002;57:165-171.