Supplemental Materials for “What accounts for poor functioning in people with schizophrenia: a re-evaluation of the contributions of neurocognitive v. attitudinal and motivational factors” paper. For a look at the paper, click here

Evidence Supporting Tests of Neurocognitive Deficits

For the purposes of this review, we will focus on findings from the two test batteries that have been used most widely worldwide: Gur and colleagues’ Penn Computerized Neurocognitive Battery [CNB] (Gur et al., 2001) and the Measurement and Treatment Research to Improve Cognition in Schizophrenia [MATRICS] Consensus Cognitive Battery (MCCB) (Kern, Green, Nuechterlein, & Deng, 2004). The CNB and MCCB are based on reliable and valid tests used to study brain damage (Heinrichs, 2001). The CNB assesses the domains of executive functioning, attention, word memory, facial memory, spatial memory, language, spatial abilities, and sensory-motor abilities (Gur et al., 2001; Gur et al., 2010), while the MCCB measures processing speed, attention, and vigilance, working memory, verbal learning and memory, visual learning and memory, reasoning and problem solving, and social cognition (Schulz & Murray, 2016). These domains have traditionally been identified in schizophrenia, dating back to Kraepelin and Bleuler.

Psychometric Properties of the MCCB and CNB

Reliability. The CNB demonstrates adequate internal consistency (Cronbach’s alphas are usually between 0.70 and 0.90 across studies) and comparable results from separate samples (Swagerman et al., 2016). Similarly, the MCCB exhibits adequate internal consistency (Cronbach’s alpha between 0.70 and 0.90; Kaneda et al., 2013), moderate to strong intercorrelations between the individual domains (August, Kiwanuka, McMahon, & Gold, 2012), and high test-retest reliability (r values greater than 0.70; Green, Harris, & Nuechterlein, 2014).

Convergent validity. The CNB correlates with traditional measures of neurocognition (Gur et al., 2001). The MCCB correlates with the IntegNeuro Test, a highly reliable and validated computerized neurocognitive test (Silverstein et al., 2010).

Criterion validity. The CNB is sensitive to key demographic variables linked with neurocognitive differences, including age and gender (Gur et al., 2001; Gur et al., 2010; Swagerman et al., 2016). Further, the CNB differentiates between individuals with schizophrenia, unaffected relatives, and healthy controls (Gur et al., 2007). Additionally, the test correlates with premorbid adjustment, age of illness onset, illness duration, quality of life, and symptom severity (Grant & Beck, 2009). The MCCB also demonstrates criterion validity, as it correlates with responsiveness to treatments such as cognitive remediation, neuroplasticity-based auditory training, and antipsychotic medication (Green et al., 2014).

Predictive validity. Scores on the CNB correlate with patient and parental education levels (Gur et al., 2010; Swagerman et al., 2016), while scores on the MCCB are associated with education level and employment status (August et al., 2012; Lystad et al., 2014). MCCB performance correlates with community functioning cross-sectionally and longitudinally (Bryson & Bell, 2003; Shamsi et al., 2011). The MCCB performance correlates with self-rated social functioning (Lystad et al., 2014), clinical ratings of social functioning (Shamsi et al., 2011), and social problem solving abilities (Quinlan, Roesch, & Granholm, 2014). Finally, meta-analyses indicate that performance on domains measured by the batteries is associated with functional outcomes (Heinrichs, 2001; Green, Kern, & Heaton, 2004).

Additionally, scores on the CNB and MCCB can predict conversion to psychosis. Individuals with psychosis spectrum disorders showed greater neurocognitive developmental lag on the CNB than individuals with subthreshold psychotic symptoms, detectable as early as age 8 (Gur et al. 2014). Similarly, at-risk individuals who later transitioned to a psychotic disorder exhibited poorer performance on the MCCB than controls and at-risk individuals who did not transition (Seidman et al., 2016). In another recent study, individuals in an at-risk mental state for psychosis performed significantly worse on the MCCB compared to controls (Eisenacher et al., 2016).

 References

August, S. M., Kiwanuka, J. N., McMahon, R. P., & Gold, J. M. (2012). The MATRICS

Consensus Cognitive Battery (MCCB): clinical and cognitive correlates. Schizophrenia Research, 134, 76-82. http://dx.doi.org/10.1016/j.schres.2011.10.015

Bryson, G., & Bell, M. D. (2003). Initial and final work performance in schizophrenia: cognitive

and symptom predictors. The Journal of Nervous and Mental Disease, 191, 87-92. Retrieved from http://journals.lww.com/jonmd/Pages/default.aspx

Eisenacher, S., Rausch, F., Ainser, F., Englisch, S., Becker, A., Mier, D., . . . Zink, M. (2016). Early cognitive basic symptoms are accompanied by neurocognitive impairment in patients with an ‘at-risk mental state’ for psychosis. Early Intervention Psychiatry. doi:10.1111/eip.12350

Grant, P. M., & Beck, A. T. (2009). Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. Schizophrenia Bulletin, 35, 798-806. https://doi.org/10.1093/schbul/sbn008

Green, M. F., Harris, J. G., & Nuechterlein, K. H. (2014). The MATRICS consensus cognitive battery: what we know 6 years later. American Journal of Psychiatry, 171, 1151-1154. http://dx.doi.org/10.1176/appi.ajp.2014.14070936

Green, M. F., Kern, R. S., & Heaton, R. K. (2004). Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS. Schizophrenia Research, 72, 41-51. http://dx.doi.org/10.1016/j.schres.2004.09.009

Gur, R. C., Calkins, M. E., Satterthwaite, T. D., Ruparel, K., Bilker, W. B., Moore, T. M., … & Gur, R. E. (2014). Neurocognitive growth charting in psychosis spectrum youths. JAMA Psychiatry, 71, 366-374. http://dx.doi.org/10.1001/jamapsychiatry.2013.4190

Gur, R. E., Nimgaonkar, V. L., Almasy, L., Calkins, M. E., Ragland, J. D., Pogue-Geile, M. F.,… & Gur, R. C. (2007). Neurocognitive endophenotypes in a multiplex multigenerational family study of schizophrenia. American Journal of Psychiatry, 164, 813-819. http://dx.doi.org/10.1176/ajp.2007.164.5.813

Gur, R. C., Ragland, J. D., Moberg, P. J., Turner, T. H., Bilker, W. B., Kohler, C., … & Gur, R. (2001). Computerized neurocognitive scanning: I. Methodology and validation in healthy people. Neuropsychopharmacology, 25, 766-776.  http://dx.doi.org/10.1016/S0893-133X(01)00278-0

Gur, R. C., Richard, J., Hughett, P., Calkins, M. E., Macy, L., Bilker, W. B., … & Gur, R. E. (2010). A cognitive neuroscience-based computerized battery for efficient measurement of individual differences: standardization and initial construct validation. Journal of Neuroscience Methods, 187(2), 254-262.  http://dx.doi.org/10.1016/j.jneumeth.2009.11.017

Heinrichs, R. W. (2001). In search of madness: Schizophrenia and neuroscience. New York:Oxford University Press.

Kaneda, Y., Ohmori, T., Okahisa, Y., Sumiyoshi, T., Pu, S., Ueoka, Y., … & Sora, I. (2013). Measurement and treatment research to improve cognition in schizophrenia consensus cognitive battery: validation of the Japanese version. Psychiatry and Clinical Neurosciences, 67, 182-188. http://dx.doi.org/10.1111/pcn.12029

Kern, R. S., Green, M. F., Nuechterlein, K. H., & Deng, B. H. (2004). NIMH-MATRICS survey on assessment of neurocognition in schizophrenia. Schizophrenia Research, 72, 11-19. http://dx.doi.org/10.1016/j.schres.2004.09.004

Lystad, J. U., Falkum, E., Mohn, C., Haaland, V. Ø., Bull, H., Evensen, S., … & Ueland, T. (2014). The MATRICS Consensus Cognitive Battery (MCCB): performance and functional correlates. Psychiatry Research, 220(3), 1094-1101. http://dx.doi.org/10.1016/j.psychres.2014.08.060

Quinlan, T., Roesch, S., & Granholm, E. (2014). The role of dysfunctional attitudes in models of negative symptoms and functioning in schizophrenia. Schizophrenia Research, 157, 182-189. http://dx.doi.org/10.1016/j.schres.2014.05.025

Schulz, S. C., & Murray, A. (2016). Assessing Cognitive Impairment in Patients With Schizophrenia. The Journal of Clinical Psychiatry, 77(Suppl. 2), 3-7. http://dx.doi.org/10.4088/JCP.14074su1c.01

Seidman, L. J., Shapiro, D. I., Stone, W. S., Woodberry, K. A., Ronzio, A., Cornblatt, B. A., … & Mathalon, D. H. (2016). Association of neurocognition with transition to psychosis: baseline functioning in the second phase of the North American Prodrome Longitudinal Study. JAMA Psychiatry, 73, 1239-1248. http://dx.doi.org/10.1001/jamapsychiatry.2016.2479

Shamsi, S., Lau, A., Lencz, T., Burdick, K. E., DeRosse, P., Brenner, R., … & Malhotra, A. K. (2011). Cognitive and symptomatic predictors of functional disability in schizophrenia. Schizophrenia Research, 126, 257-264. http://dx.doi.org/10.1016/j.schres.2010.08.007

Silverstein, S. M., Jaeger, J., Donovan-Lepore, A. M., Wilkniss, S. M., Savitz, A., Malinovsky, I., … & Zukin, S. R. (2010). A comparative study of the MATRICS and IntegNeuro cognitive assessment batteries. Journal of Clinical and Experimental Neuropsychology, 32, 937-952. http://dx.doi.org/10.1080/13803391003596496

Swagerman, S. C., de Geus, E. J., Kan, K. J., van Bergen, E., Nieuwboer, H. A., Koenis, M. M., … & Boomsma, D. I. (2016). The Computerized Neurocognitive Battery: Validation, aging effects, and heritability across cognitive domains. Neuropsychology, 30, 53-64. http://dx.doi.org/10.1037/neu0000248

Drs Beck and Grant give keynote address at NASMHPD

Drs Beck and Grant presented on recovery-oriented cognitive therapy at the National Association of State Mental Health Program Directors (NASMHPD) Annual Meeting on Sunday, July 30th, in Washington DC. Dr. Beck appeared via a pre-recorded video. See below to view the video

FELLOWSHIPS IN ADVANCED COGNITIVE THERAPY FOR SCHIZOPHRENIA WITH AARON T. BECK

We offer an exciting opportunity for postdoctoral applicants in the Aaron T. Beck Psychopathology Research Center at the University of Pennsylvania. Specifically, our mission is to develop professionals who will become leaders in the field of psychosocial approaches that promote recovery for individuals with schizophrenia. Under the direction of Aaron T. Beck, M.D., our program includes clinical trials of innovative treatments for the disorder, dissemination, and implementation of these treatment protocols into community mental health centers and psychiatric hospitals, as well as basic research. We have been recognized for our cutting-edge work in this field.

Applicants who have earned a Ph.D., Psy.D., or equivalent in psychology,  social work, medicine or other related field and have had previous training in cognitive therapy, severe mental illness, or recovery-oriented services are encouraged to apply. Bilingual candidates are especially encouraged to apply.

Please send a curriculum vitae with a cover letter and two letters of recommendation via email to Aaron T. Beck, M.D., at abeck@pennmedicine.upenn.edu by January 1st, 2018.

NOTES: 2 openings

Recovery-Oriented Cognitive Therapy: Evidence to Practice

 Recovery-Oriented Cognitive Therapy:

Based on the cognitive model, CT-R is an empirically supported procedure for successfully operationalizing and realizing recovery for individuals with serious mental illness. The approach involves meeting people where they are, accessing their adaptive mode, developing aspirations and steps toward successfully achieving them, strengthening positive beliefs, weakening negative beliefs, and developing resiliency in regards to stress and challenges. CT-R can be delivered as individual therapy, group therapy, as part of a team-based approach, and can form the basis of a therapeutic milieu. CT-R has been successfully applied to individuals across the full range of severity, from early in their course to those who have been chronically institutionalized for decades.

Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients With Schizophrenia: Clinical trial demonstrating the effectiveness of recovery-oriented cognitive therapy to improve everyday functioning, negative symptoms, and positive symptoms for individuals with severe and persistent schizophrenia.

Six-month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Schizophrenia: Follow-up paper shows gains in functioning, negative symptoms, and positive symptoms were maintained six months after treatment was completed; also, individuals with a longer course of illness showed improvement by the follow-up.

Rapid improvement in beliefs, mood, and performance following an experimental success experience in an analogue test of recovery-oriented cognitive therapy: an Analogue study of recovery-oriented cognitive therapy showing that rapid improvement in putative mechanisms of the therapy – reduced dysfunctional beliefs and improved positive beliefs about self and mood – is associated with improvement in performance.

Successfully Breaking a 20-Year Cycle of Hospitalizations With Recovery-Oriented Cognitive Therapy for Schizophrenia: A case study of the successful application of recovery-oriented cognitive therapy (CT-R) to empower an individual with chronic course illness get back to a life of their choosing

Advances in Cognitive Therapy for Schizophrenia: Empowerment and Recovery in the Absence of Insight: a case study in which CT-R is used to produced pulpal success in life without the development of insights into illness.

Recovery-Oriented Cognitive Therapy Shows Lasting Benefits for People with Schizophrenia: American Psychiatric Association (APA) news post describing recovery-oriented cognitive therapy producing sustained improvement among individuals with schizophrenia, even among those with the most chronic illness.

Recovery-Oriented Talk Therapy May Help Curb Schizophrenia: Philly.com feature article about recovery-oriented cognitive therapy and its benefits

Theory and Review Paper:

In and out of schizophrenia: Activation and deactivation of the negative and positive schemas: article about how treatment target for those diagnosed with schizophrenia may be influenced by how they view their experiences and confidence.

What accounts for poor functioning in people with schizophrenia: a re-evaluation of the contributions of neurocognitive v. attitudinal and motivational factors: A look at the literature on the influence of non-neurocognitive factors (decrease in motivation, effort, dysfunctional attitudes, etc.) on performance test in order to clarify their contributions. To access supplemental material that did not make it into the published paper, click here.

Basic Science:

With the cognitive model as the theoretical guide, these studies aim to uncover psychological mechanisms that impair psychosocial functioning for individuals with schizophrenia as well as mechanisms of change to promote successful recovery and resiliency. Mechanisms become targets of treatment.

From neurocognition to community participation in serious mental illness: the intermediary role of dysfunctional attitudes and motivation: Longitudinal study identifies two independent pathways linking defeatist and asocial beliefs to community involvement.

Defeatist Beliefs as a Mediator of Cognitive Impairment, Negative Symptoms, and Functioning in Schizophrenia: Original paper demonstrating Defeatist beliefs as a mechanism connecting poor performance on neurocognitive tests, negative symptoms, and poor functioning in schizophrenia.

Dysfunctional Attitudes and Expectancies in Deficit Syndrome Schizophrenia: Article is demonstrating that individuals diagnosed with schizophrenia who have the most severe and persistent negative symptoms endorse defeatist and asocial beliefs to a greater extent than individuals with less severe negative symptoms.

Asocial beliefs as predictors of asocial behavior in schizophrenia: Manuscript showing that asocial beliefs are associated with poor social functioning.

Evaluation sensitivity as a moderator of communication disorder in schizophrenia: This paper describes how sensitivity to evaluation moderated the relationship between cognitive impairment and communication disorder in schizophrenia.

Cognitive Insight Predicts Favorable Outcome in Cognitive Behavioral Therapy for Psychosis: In the CBT of psychosis in South London improvement in cognitive insight improvement in treatment insight is mediator

Exploring the Temporal Relationship Between Cognitive Insight and Neurocognition in Schizophrenia: A Prospective Analysis: An investigation of prospective links between impairment of cognitive function and cognitive insight, using data from two longitudinal studies of adults diagnosed with schizophrenia. In both studies, cognitive insight predicted changes in neurocognitive performance, suggesting that reductions in cognitive insight temporally preceded by neurocognitive changes. It is essential to note neither study showed the reverse relationship.

Dissemination and Implementation:

CT-R has been implemented at all levels of care for individuals with serious mental illness.

Books

Schizophrenia: Cognitive Theory, Research, and Therapy (2009) Guilford Press.: New York, NY.

Recovery-oriented cognitive therapy for schizophrenia (in press). Guilford Press.: New York, NY.

Articles

Effects of a Recovery-Oriented Cognitive Therapy Training Program on Inpatient Staff Attitudes and Incidents of Seclusion and Restraint: Manuscript describing a successful milieu-wide, multidisciplinary, recovery-oriented cognitive therapy training program on an urban acute inpatient unit treating individuals with serious mental illness.

Training Peer Specialists in Cognitive Therapy Strategies for Recovery: Article explains an innovative recovery-oriented cognitive therapy training program collaboratively developed with peer specialists to promote their effectiveness.

CBT Addresses Most-Debilitating Symptoms in Chronic Schizophrenia: Psychiatric News article details how recovery-oriented cognitive therapy helps mental health providers operationalize recovery work, engaging all individuals with serious mental illness, however challenging, to successfully collaborate and make progress on their self-defined aspirations.

Outreach and Engagement for Early Psychosis: NAMI blog written by Drs. Ellen Inverso and Paul Grant in which they describe Recovery-Oriented Cognitive Therapy framework.

Workshops/Webinars

Recovery-Oriented Cognitive Therapy: Watch Drs. Paul M. Grant and Ellen Inverso present at NAMI NJ 2017 Conference

Recovery-Oriented Cognitive Therapy: Resiliency, Recovery & Flourishing: Watch Drs. Paul M. Grant and Ellen Inverso discuss an approach they have helped to pioneer via 2017 ISPS Webinar.

Mechanism of Training

  • Webinar: 1-3hrs a basic introduction to the principles of CT-R
  • Workshops: 2-30hrs in-depth, in-person or over the web, introducing recovery program and delivers the basics through experiential learning and expert demonstration of skills
  • Consultations: a 1-2 hrs focusing on tailoring strategy, building skills, and promoting recovery with challenging individuals alongside an expert
    • Challenging Case: Expert consultation helps trainees promote progress for low-functioning individuals. Demonstrates benefits of the program and invigorates staff via results.
    • Key personnel: Trainees develop competency in therapeutic strategies to promote recovery. Therapists, psychiatrist, nurses, social workers, drug/alcohol specialists, case managers, and peer specialists can be trained to become agents for change
    • Milieu-wide: This is a full team-wide, unit-wide approach to training that involves tailored workshops and consultation to transform the therapeutic milieu to a recovery orientation.
    • Therapist: trainees learn to formulate individual cases to promote progress toward recovery and resiliency to respect to challenges (negative, positive symptoms, aggression, etc.). The process includes competency determined by means of a standardized method.
  • Innovative Program Evaluation: Operationalized recovery principles are measured throughout to inform treatment and track progress.
  • Train-the-Trainer: Beck staff train trainees to direct implementation of sustainability efforts to continue the work.

 

Training Settings to Date
  • State Hospital (Civil & Forensic)
  • Jail Diversion Team
  • Extended Acute Care (EAC)
  • Assertive Community Treatment Teams (ACT)
  • Long-Term Structured Residences (LTSR)
  • Residential Treatment Facility for Adults (RTFA)
  • Supported Housing
  • Individual Therapy
  • 1st Episode Teams
  • Ultra High Risk
  • Day Treatment Programs

 

Training Locations to Date
  • Philadelphia
  • Pennsylvania
  • Georgia
  • Massachusetts
  • Virginia
  • Utah
  • Delaware
  • New Jersey

 

Dr. Aaron T. Beck Speaks at Georgia State University

Dr. Aaron T. Beck made a special video appearance at the Georgia Beck Initiative Panel discussion. The event was put together to create an opportunity to discuss the current efforts in Georgia to build the capacity of community providers in addressing the needs of individuals with severe and persistent mental illness using Recovery-Oriented Cognitive Therapy.

Disclaimer: The cases discussed in this video are loosely based on actual cases and do not relate to any specific patients or contain any protected health information.

Dr. Aaron T. Beck speaks at 22nd Annual Rosalynn Carter Forum

 

Dr. Aaron T. Beck makes a special video appearance discussing the treatment of schizophrenia at the 22nd Annual Rosalynn Carter Georgia Mental Health Forum. The Carter Forum was established in 1995 and is held each May to address mental health policy issues facing the state of Georgia. Dr. Paul M. Grant was in attendance and presented on the continuing successful efforts to implement Recovery-Oriented Cognitive Therapy state-wide. This initiative empowers mental health providers to partner with individuals with severe mental illness to remain, participate, and flourish in the community.

 

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