Assessing Cognitive Dysfunction as Part of a Schizophrenia Treatment Plan

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Among the constellation of symptom types experienced by individuals living with schizophrenia, more easily observable positive symptoms (hallucinations, delusions, disorganized behavior) tend to draw the most attention and be the most responsive to treatment. However, when it comes to long-term outcomes, these symptoms are only part of the picture. To support meaningful recovery, clinicians and family members must broaden their perspective beyond acute symptom management to include consideration of the entire spectrum of a person’s experience.¹ The less visible symptoms—particularly cognitive deficits and negative symptoms—can significantly shape a person’s ability to function day to day but may be more nuanced to first identify and then treat.

Among these, cognitive dysfunction stands out as one of the most debilitating and least addressed aspects of the illness. While cognitive impairments can be quiet, their impact can be insidious and profound. Often among the preliminary indicators of emerging schizophrenia, and relevant throughout the course of treatment due to both disease progression and the potential effects of medications, cognitive dysfunction warrants thoughtful clinical attention as part of an individualized treatment plan.

Understanding the Scope and Impact of Cognitive Dysfunction

Cognitive dysfunction in schizophrenia refers to impairments in executive functioning, attention, working memory, planning, abstraction and processing speed. These are among the tools individuals rely on to plan ahead, recognize patterns, stay focused and engage meaningfully in social settings.² Cognitive impairments may not be immediately visible, as disorganized thinking or trouble grasping the nuances of a conversation can be easy to miss, particularly in acute care settings where a patient-provider relationship may not be well established.

While these deficits do not always demand the most urgent concern or intervention, they should be assessed as relevant in medical histories and treatment planning, as they often underlie the everyday challenges faced by individuals living with schizophrenia. Difficulties with executive functioning, attention, and memory can interfere with the ability to maintain relationships, fulfill employment obligations, or even live independently, all of which are essential components of recovery.³ Even when positive symptoms like hallucinations and delusions are well controlled, cognitive difficulties frequently persist. These can detract from a person’s self-reported quality of life and have downstream ramifications for important elements of care, such as medication adherence.

When and How Cognitive Symptoms Emerge
Cognitive symptoms can emerge well before a formal diagnosis of schizophrenia is made. Retrospective studies often reveal preliminary indicators of cognitive impairment, such as difficulty with eye movement, abstract thinking, or understanding metaphors, that appear even before the onset of the positive or negative symptoms clinically associated with schizophrenia.⁴

For example, when asked to interpret a proverb like “a bird in the hand is worth 2 in the bush,” a typically developing adolescent might explain that it is better to hold onto something you have than to risk it for more. But someone in the prodromal phase of schizophrenia—a period marked by subtle, early changes before full-blown symptoms appear—is more likely to interpret the proverb literally, suggesting that catching 1 bird is better than chasing 2 still in the bush. This diminished capacity for abstraction can reflect evolving neurological pattern changes.

For individuals with a genetic predisposition to schizophrenia, the illness may unfold gradually. Although the DSM-5 recognizes cognitive symptoms as a core component of schizophrenia, these impairments often do not present in ways that are immediately obvious.⁵ Even the hallucinations and delusions that are considered so emblematic of a schizophrenia diagnosis do not appear overnight but rather develop over time alongside a slow erosion of cognitive function.

Understanding the Layers of Cognitive Impairment

To properly address cognitive impairment, we must explore its various causes. While the processing differences described above may develop independently, either in advance of or alongside other symptoms, it is important to recognize that cognitive dysfunction in schizophrenia may equally be influenced by other coexisting conditions or stimuli. For example, individuals living with schizophrenia often experience comorbidities including depression, anxiety, and substance use disorders, all of which can directly contribute to cognitive impairment.⁶

Certain medications may further complicate the assessment of how cognitive challenges arise or progress. Benztropine is frequently prescribed to help manage the side effects of antipsychotics, but as an anticholinergic agent it can impair cognition by disrupting the acetylcholine system, which is a key player in memory and learning.⁷ For some patients, this creates a cognitive triple hit: impairments stemming from schizophrenia itself compounded by comorbidities and further intensified by medication side effects. Discerning how much different factors contribute to cognitive impairment is a seemingly impossible task.

Formal neuropsychological testing, such as assessing intelligence quotient, processing speed, memory, and problem-solving skills, can offer valuable insights. However, these tactics in context of schizophrenia remain underutilized and, even when employed, cannot always disentangle the overlapping sources of cognitive dysfunction. This is an aspect of care management that necessitates a longitudinal view and benefits from close communication between patients and care teams to have the best chance of elucidating causation and therefore an appropriate intervention.

Spotting the Early Signs: What Clinicians Should Watch For

Early identification and intervention for schizophrenia are critical in terms of long-term outcomes and meaningful for ongoing recovery; shifts in cognitive processing may be among the first observable signs of disease onset. Because the age of onset for schizophrenia is often in the late teens into early adulthood, clinicians should also take note of cognitive or behavioral changes during those early years of development. For example, 2 common, but nonspecific, early warning signs of schizophrenia include a noticeable drop in academic performance and a sudden shift in social connections. If a student who once earned straight As suddenly begins failing classes or if they abruptly withdraw from a long-standing friend group, it is worth paying attention. These changes could be attributed to a range of factors, but in individuals with a family history of schizophrenia or other risk factors, or with other emerging concerns, they should prompt a deeper look.

In such cases, tools like the Structured Interview for Prodromal Syndromes (SIPS) can be useful. SIPS assesses domains like abstraction, planning, executive function, and memory, offering insight into whether someone may be showing early signs of psychosis.⁸ This is not a general screening tool¾its use is largely limited to specialists working with high-risk populations. At this point, there is no universal screening or primary prevention method for schizophrenia. We are not yet at a place where we can assess risk proactively the way we do with some other conditions, but that remains a goal for the field. In the meantime it does not preclude use of the qualitative and quantitative tools currently available to us as psychiatric care professionals.

A Holistic Approach to Cognitive Health

There are several complementary avenues of intervention I consider when working with someone living with schizophrenia for whom cognitive impairment is a factor. Pharmacological treatments are important, but represent only part of a comprehensive, holistic approach. Cognitive remediation training, which I refer to as “cognitive training,” has shown significant benefits. This therapeutic intervention utilizes structured, repetitive cognitive exercises to enhance neurocognitive abilities, such as attention, memory, and executive function.⁹ The goal is not just to restore lost function, but to build cognitive resilience over time. Regular participation, even as little as 30 minutes a few times per week, can lead to measurable improvements in these cognitive domains.

Lifestyle interventions also play a crucial role in managing cognitive symptoms. Exercise, for instance, offers substantial benefits. Cardiovascular exercise appears to have the greatest positive impact on cognition in individuals with schizophrenia.¹⁰ Nutrition is another important factor. The Mediterranean diet, for example, emphasizes whole foods, healthy fats, fish, nuts, and olives, and has been linked to improvements in cognitive performance, generally.¹¹These potential neuroprotective benefits are valuable regardless of whether a person is living with a serious mental health condition or not. However, the advantages may be felt more acutely by those facing both genetic and environmental risk factors that exacerbate cognitive dysfunction, such as those with schizophrenia. While not a replacement for clinical treatment, dietary changes can offer patients an accessible way to support brain health alongside medication and other clinical therapies.

Early and accurate identification remains one of the most powerful tools we have. Starting evidence-based pharmacologic treatment as early as possible increases the likelihood of preserving neurophysiology and minimizing cognitive decline. Early intervention is not just about managing symptoms; it is about laying the groundwork for long-term recovery and resilience.

Talking to Patients and Families About Cognitive Symptoms

Under any circumstances, talking openly about schizophrenia can be challenging. These discussions, especially when trying to avoid unnecessary alarm, can become even more delicate when broaching cognitive decline. The key is to be honest and let science guide the conversation. In psychiatry, we have evolved in how we talk about mental illness. These conditions were once framed as behavioral disorders, then brain disorders. Now, we recognize that mental illness affects the whole person—not just behavior or brain function, but the body as a whole. Individuals with schizophrenia are at increased risk for a range of physical health issues as schizophrenia does not just change how someone behaves, it literally alters their physiology.

Part of this evolving understanding is helping patients and families grasp how schizophrenia affects the brain itself. For example, I walk patients and their care partners through the science of how schizophrenia can impact neuroanatomy and neurophysiology over time, contributing to cognitive dysfunction. I explain that while early and consistent treatment may help preserve brain function and slow decline, the illness itself is associated with progressive cognitive changes in many individuals. Educating families about these neurological effects can help them understand why it is important to adopt a management approach that addresses not only symptom stabilization, but also the cognitive challenges that shape a person’s long-term trajectory.¹²

To avoid inadvertently frightening patients and families, information about cognitive changes can be framed in ways designed to motivate action. If people are justifiably concerned about the impact of an illness on their brain, then that can become a powerful entry point to shared discussions about treatment. When we are able to get patients, their care partners, and their health care providers on the same team and focused on the same goals, we are often able to expedite the process of getting patients started on medications and supplements, enrolled in cognitive training, connected with extra support in school or work, and taught the skills they need to stay engaged and succeed.

It is not just about biology. It is about building a plan that supports the whole person and increases the brain’s resilience. These psychosocial interventions, including educational accommodations and skills-building, are essential tools to help prevent further cognitive decline and support long-term recovery.

Shifting the Clinical Mindset

In acute psychiatric settings, the immediate goal is often clear: ensure safety, stabilize the environment, and deescalate the crisis. While this focus is necessary, it can lead to a narrow view of what long-term success looks like. In busy hospitals, where clinicians are trying to maintain order and managing multiple patients with whom they may not have consistent familiarity, the priority is often treating the visible, disruptive symptoms (namely the positive ones like hallucinations and agitation). Once those are under control, the patient may seem better simply because they are no longer drawing attention.

But that sense of calm can be misleading, as insidious cognitive deficits and negative symptoms often persist, with substantial impact on long-term recovery. Clinicians and family members alike must look beyond the absence of acute positive symptomology and ask: is this person truly on a path to improved quality of life?

For a person who has experienced a mental health crisis, stabilization is only the beginning. The next step is setting up ongoing care supported by clinical experts, including medication management and psychosocial support, to help them acquire the skills, confidence, and cognitive capacity to function at the highest level possible. Long-term outcomes are not defined only by how quickly positive symptoms resolve, but also by how well cognitive and negative symptoms are addressed.

Cognitive dysfunction in schizophrenia is one of the most disabling and underrecognized aspects of the illness. It does not present the urgency of psychosis, but it profoundly shapes a person’s future. By identifying early signs, applying a holistic treatment model and shifting our clinical focus from acute symptom control to quality of life, we can better support meaningful, sustained recovery.

Dr Kotwicki is the chief medical officer at Hightop Health.

References

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