Research Methods, psychology homework help

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As you have likely noticed when reading research studies, research articles start with an introductory section. This section summarizes prior research on the topic that the research study is about. This is important because prior research can inform reasons for the present study. Perhaps there are some findings that are controversial or gaps in what is known in a particular area or further questions that result from existing study results. Additionally, sometimes clinical professionals working in the field research what is known on a disorder or a treatment to present to colleagues and/or students working with them. For example, many hospitals and clinics have Grand Rounds where information is presented to the students and professionals who work in the setting. Given this, being able to summarize results from studies is important for researchers and clinicians in the field. You will have an opportunity to practice this skill in this week’s learning activity.

Use the information gathered for the Unit 4 Assignment to complete the following:

  • Summarize the studies, similar to the introductory section of a research paper. Follow this with a research question you would want to study that follows from these studies and a hypothesis to accompany the research question.
  • Write the Methods Section of your paper- consider who would be in the study, how they would be recruited, and the study measure you would use.
  • Add a cover page and reference page to your paper. Using APA format, also include a Running Head.

Your paper should be a minimum of two pages.


Below are attached the articles along with a sample of how the paper should look like

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Unit 5 Learning Activity • Using the articles gathered for the unit 4 learning activity, summarize the studies, similar to the introductory section of a research paper. You can find five different articles if you prefer • Follow this with a research question you would want to study that follows from these studies and a hypothesis to accompany the research question. • Write the Methods Section of your paper- consider who would be in the study, how they would be recruited, and the study measure you would use • Add a cover page and reference page to your paper. Using APA format, also include a Running Head Let’s talk through an example… • Let’s say your overarching topic was treatments for autism and you found articles on ABA, Pivotal Response, and LEND. You would summarize these articles and INTEGRATE them (what were overarching similarities/differences in the methods? What were the overall findings?). The next slides will show an example of how this can be done. One sample paragraph • Different studies have assessed the efficacy of different treatments for autism, finding some support for a range of treatments, such as ABA, Pivotal Response, and LEND. These results were found in samples ranging in age from 3-15, including boys and girls. The predominant ethnicity of participants in the studies was Caucasian (A, 2015, B, 2014, C, 2000, D, 2005, E, 1999). Sample next paragraph • A (2015) and B (2014) found that LEND was associated with increased social interaction and daily functioning in children and adolescents in their studies. A (2015) used a sample of 100 adolescents and B (2014) used a sample of 50 fifth graders. D (2005) found that pivotal response increased verbal ability in a sample of 3rd graders. C (2000) and E (1999) showed that ABA was effective at teaching adaptive skills and reducing aggressive behavior. C (2000) used a sample of 3 year olds and E (1999) used a sample of 12 year olds. Sample next paragraph • Overall, from these studies, it seems that different therapies can be effective in different ways. These studies did not compare these three treatment techniques in terms of their effectiveness on a single behavior. As such, it could be interesting to explore whether ABA, Pivotal Response, or LEND is most effective with a specific behavior, such as with increasing the range of foods eaten by autistic children who have a restricted range of foods that they will eat. Thus, for the following study, I will explore the question: is ABA, Pivotal Response, or LEND most effective at increasing the range of foods eaten in autistic children who have a restricted range of foods that they will eat? My hypothesis is that all three treatments will show some efficacy, with ABA showing the most effectiveness in increasing the range of foods that these children will eat. Sample methods section • For this study, I will recruit 150 children, aged 5-7, who are diagnosed with autism and who have a restricted range of foods that they will eat. I will send fliers about this study to special education schools that focus on children with autism within Syracuse, providing contact information for interested parents. Parents will undergo a brief phone screening, assessing when and how their child was diagnosed with autism, the current foods their child will eat, and any medical or dietary restrictions. Children who eat fewer than 15 different foods and who have a valid diagnosis of autism will be included in the study. Children whose parents are implementing dietary restrictions or who have medical issues that restrict the foods they can eat will be excluded from the study. Sample methods section continued • Once 150 children are enrolled in the study, they will be randomly assigned to receive ABA, Pivotal response, or LEND treatment focused on increasing the range of foods they will eat, with 50 children assigned to each group. Foods eaten will be tracked through a food diary that parents and teachers will complete daily. Baseline data will be collected for two weeks prior to the start of treatment, with parents asked to complete the food diaries daily starting two weeks prior to receiving the treatment. The children will receive treatment for 3 weeks and parents will be asked to continue to complete the food diaries for 2 weeks after the end of treatment. To compensate parents for their time and effort, and to encourage continued participation in the study, treatment will be provided at no cost and participating families will receive $10/week. Teachers who participate in the study for enrolled children will receive $50 toward new classroom supplies at the end of the study. Sample methods continued • I will count the different types of food eaten per week and will run analyses to see if the number of different foods eaten during the first two weeks of data collection differed from the number of different foods eaten during the last two weeks of data collection. Additional analyses on different foods eaten while the treatment was ongoing will also be conducted to explore the rate of change in the different groups. From your Unit 5 Learning Activity, it should be clear: • Overall, what was found from prior studies- give the reader the big picture. DON’T list studies (study A did…. And found…. Study B did…. And found….Study C did…. And found…)- that is not integration! • What one might be left curious about- what more is there to know on the topic? • Your question and hypothesis related to what more there is to know on the topic • An overview of how you would structure a study of this question (Consider: who would be in it? How recruited? What data would you collect and how? How long would the study last? Would there be any incentives? What might you do with the data?) Neuropsychology 2017, Vol. 31, No. 2, 209 –219 © 2016 American Psychological Association 0894-4105/17/$12.00 http://dx.doi.org/10.1037/neu0000309 The Effect of Positive Symptoms on Social Cognition in First-Episode Schizophrenia Is Modified by the Presence of Negative Symptoms Vibeke Bliksted Poul Videbech and Birgitte Fagerlund Aarhus University Hospital Risskov, Denmark, and Aarhus University Mental Health Centre Glostrup, Denmark Chris Frith This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Aarhus University and University College London Objective: There is considerable evidence that patients with schizophrenia have neurocognitive and social– cognitive deficits. It is unclear how such deficits in first-episode schizophrenia relate to current clinical symptoms. Method: Fifty-nine patients with first-episode schizophrenia (FES) were tested using the Danish version of NART (premorbid IQ), subtests from WAIS-III (current IQ), and global cognition using Brief Assessment of Cognition in Schizophrena (BACS), a neurocognitive test battery. Social perception was tested using film clips of everyday interactions (TASIT). Theory of mind (ToM) was tested using silent animations (Animated Triangles Task). The FES subjects had been experiencing psychotic symptoms for several years (mean duration 9.5 years 95% confidence interval (CI [7.6;11.3]). The FES patients were divided into clinical subgroups based on their level of positive and negative symptoms (using SANS and SAPS). Healthy controls were matched to the patients. Results: High levels of negative symptoms were associated with low estimated functional IQ and poor neurocognition and social cognition. All SANS subscales, but Avolition-Apathy, had significant negative impact on social cognition. The effects of positive symptoms were complex. High levels of delusions were associated with higher premorbid IQ. In the presence of high levels of negative symptoms, high levels of positive symptoms were associated with the most comprehensive deficits in social perception, while, in the absence of negative symptoms, high levels of positive symptoms were not associated with such deficits. Conclusion: The results suggest that social– cognitive training will need to take account of the above mentioned effects of symptoms. Keywords: social cognition, neurocognition, negative symptoms, positive symptoms, theory of mind deficit in the patients’ theory of mind abilities (Frith, 1992). Frith et al. proposed four subgroups of schizophrenia with different theory of mind abilities (Corcoran, Cahill, & Frith, 1997; Frith & Corcoran, 1996; Pickup & Frith, 2001). Most severely affected were patients with behavioral signs of negative symptoms and/or incoherence. Patients with paranoid symptoms such as delusion of persecution, delusions of reference, and third-person hallucinations were thought to be only moderately affected. Patients with passivity experiences such as delusions of control, thought insertion, and thought broadcasting and finally patients in remission were thought to have normal theory of mind abilities. Sprong et al. (Sprong, Schothorst, Vos, Hox, & van Engeland, 2007) looked at subgroups according to Frith et al.’s suggestion in 29 studies of theory of mind in schizophrenia. They found deficits of theory of mind in all the subgroups, including remitted patients (patients with no behavioral signs and no positive symptoms on the day of testing), indicating that these deficits are trait related and even more comprehensive than in the model from 1992. Patients with symptoms of disorganization had more severe theory of mind deficits than the other patient subgroups. Besides Theory of Mind (ToM), the social– cognitive domains most affected in schizophrenia are social perception, social knowledge, attributional bias, and emotional processing (Green et al., 2008; Penn et al., 2008). A meta-analysis of the above-mentioned social– cognitive domains concluded that ToM and social percep- In recent years, there has been an increasing interest in the importance of social– cognitive deficits in schizophrenia and how aspects of social cognition might be able to explain the heterogeneity of symptoms in people with this disorder (Bliksted, Fagerlund, Weed, Frith, & Videbech, 2014; Fletcher & Frith, 2009; M. F. Green & Leitman, 2008; Green et al., 2008; Penn, Sanna, & Roberts, 2008). In 1992, Chris Frith proposed a model suggesting that specific psychotic symptoms in schizophrenia could be explained by a This article was published Online First November 3, 2016. Vibeke Bliksted, Psychosis Research Unit, Aarhus University Hospital Risskov, Denmark, and Interactive Minds Centre, Aarhus University; Poul Videbech, Mental Health Services, Capital Region of Denmark, Mental Health Centre Glostrup, Denmark; Birgitte Fagerlund, Mental Health Centre, Mental Health Services, Capital Region of Denmark, Glostrup, and Lundbeck Foundation Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), Mental Health Centre Glostrup; Chris Frith, Interactive Minds Centre, Aarhus University, and Leopold Müller Functional Imaging Laboratory, Wellcome Trust Centre for Neuroimaging, University College London. Correspondence concerning this article should be addressed to Vibeke Bliksted, Psychosis Research Unit, Aarhus University Hospital Risskov, Denmark, Skovagervej 2, 8240 Risskov, Denmark. E-mail: vibeke.bliksted@ ps.rm.dk 209 BLIKSTED, VIDEBECH, FAGERLUND, AND FRITH This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 210 tion were the social– cognitive domains most affected in schizophrenia (Savla, Vella, Armstrong, Penn, & Twamley, 2012). Recent studies have suggested that social– cognitive deficits in schizophrenia are trait related and independent of the phase and duration of the illness (Bliksted, Ubukata, & Koelkebeck, 2016; Green et al., 2012; Horan et al., 2012). Similar impairments of social cognition have been found in first-episode and chronic schizophrenia and their first degree relatives, and no changes in the social– cognitive deficits were seen at 12 months follow-up in first-episode schizophrenia (Bora & Pantelis, 2013; Bora, Yucel, & Pantelis, 2009; Green et al., 2012; Horan et al., 2012). This adds to the complexity of understanding the interaction between specific social– cognitive domains and the clinical symptoms of schizophrenia such as psychotic and negative symptoms. It also raises the question of social– cognitive subgroups in schizophrenia. Bell et al. found that patients with schizophrenia could be divided into three subgroups: (a) Patients with high levels of negative symptoms, (b) patients with low levels of negative symptoms but high social– cognitive scores, and (c) patients with low levels of negative symptoms and low social– cognitive scores (Bell, Corbera, Johannesen, Fiszdon, & Wexler, 2013). These subgroups were based on a principal component analysis of the subscales of negative symptoms and the social– cognitive tests that was followed by a cluster analysis that specified the above subgroups. Other researchers argue that there is no simple delineation of deficit profiles, but instead a complex matrix of correlations between clinical symptoms, neurocognitive domains, social– cognitive domains, and functional outcome (Bliksted et al., 2014; Mancuso, Horan, Kern, & Green, 2011). It has furthermore been argued that patients with schizophrenia show deficits in all aspects of neurocognitive and social– cognitive domains compared with healthy controls, but to varying degrees (Green, Horan, & Sugar, 2013). However, a recent review suggests that some reflexive aspects of social cognition, such as emotion experience, might be intact in patients with schizophrenia (Green, Horan, & Lee, 2015). In this study, we examined 59 patients with first-episode schizophrenia to account for the correlations between aspects of negative and positive symptoms as well as neurocognition and social cognition. For this purpose we divided the patients into four groups with high versus low levels of negative symptoms, and high versus low levels of positive symptoms. A healthy control group was included. It was hypothesized that patients in general would perform worse than the healthy control subjects on all neurocognitive and social– cognitive tasks. We expected the social– cognitive deficits to be most pronounced in patients with many negative symptoms (Bell et al., 2013; Frith, 1992), and in very paranoid patients (Frith, 1992). Method Subjects The patients were recruited from OPUS which is an intensive 2-year assertive community treatment program for first-episode schizophrenia (Bertelsen et al., 2008). The patients had recently been diagnosed with first-episode schizophrenia (FES) by experienced psychiatrists according to ICD-10 criteria. The patients were included during two time periods: from January 1, 2009 until February 1, 2010, and from August 1, 2011 until August 1, 2012 as consecutive parts of the same study. Some of the data from time period one have been used in statistical analyses that differ from the analyses in this article (Bliksted et al., 2014). Healthy control subjects were recruited via advertisements in four local newspapers and were tested during the same time period as their patient match. FES Subjects The first-episode schizophrenia (FES) patients were from 18 to 34 years old. Thirty-six patients were included during 2009 and 2010. None of the patients had received any antipsychotic medication for more than 3 months before inclusion. Twenty-three patients were included during 2011 and 2012. These patients were either antipsychotic-naïve or had received no more than 6 weeks’ lifetime psychopharmacological treatment at inclusion. Twenty-nine from the entire group of patients received atypical antipsychotics; 13 atypical antipsychotics and antidepressants; 4 atypical antipsychotics and other medication; 1 typical antipsychotic and other medication; 1 atypical antipsychotic, antidepressant, and benzodiazepine; 1 antidepressant; 1 patient had stopped taking his atypical antipsychotic two weeks ago; and 9 patients were antipsychotic-naïve. Other medication was for example, insulin and gastric ulcer medication. Exclusion criteria were a history of neurological disorder, severe head trauma, or drug- and alcohol dependency according to ICD10. Patients were excluded if they did not understand spoken Danish sufficiently to understand the testing procedures or if they had an estimated premorbid IQ below 70 based on their history. Healthy Control Subjects The healthy controls and patients were individually matched to the patients based on age, gender, handedness, educational level (based on the last commenced education), community of residence, and parental socioeconomic status (based on the highest parental education and expected parental income regarding wages according to Statistics Denmark). Parental educational level (rather than the patients’s educational level) was chosen as the matching variable because the onset of a mental illness interferes with education. Thus, we presumed that the parental educational level would reflect the potential level of function of the FES patients more presisely. The parental socioeconomic groups were divided into high (N ⫽ 19; 32.20%), middle (N ⫽ 30; 50.85%), and low (N ⫽ 10; 16.95%). In two cases the patients and healthy control subjects did not match perfectly one-to-one. This meant that there was one more female in the healthy subject population than in the FES patient group. The 59 healthy control subjects had no history of mental illness and neither had their first-degree relatives. They did not have a history of neurological illness, severe head injury or drug- or alcohol dependence according to ICD-10 criteria. This was controlled for by blood and urine tests. Ethics The participants received written and oral information about the project, and written informed consent was obtained before inclu- SOCIAL COGNITIVE SUBGROUPS IN SCHIZOPHRENIA sion. The study was approved by The Central Denmark Region Committees on Biomedical Research Ethics (Ref: M-2009 – 0035) and the Danish Data Protection Agency. The project complied with the Helsinki-II-declaration. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Measures Social– cognitive measures. Social perception. We used five sincere and five simple sarcastic film clips from the Danish translation of TASIT (The Awareness of Social Inference Test—Part A2 Social Inference minimal; Bliksted et al., 2014). The test is composed of small video clips with professional actors performing everyday interactions (McDonald et al., 2006; McDonald, Flanagan, Rollins, & Kinch, 2003). The clips last for 16 –53 s. After seeing each clip one has to figure out if the people were being sincere or sarcastic based on paralinguistic cues such as tone of voice, facial expressions, and verbal content. Each clip was followed by four questions concerning the communicative intentions of the persons (what they were doing, saying, thinking, and feeling; max score of each clip was 4 points). The TASIT film clips can also be analyzed as a signal detection task, that is, how good the subjects are at distinguishing sarcastic from sincere behavior. For this purpose we developed a sensitivity score. We also constructed a bias score that measured whether subjects were neutral (⫽0) or biased toward interpreting the clips sincerely (⬎0) or sarcastic (⬍0). The TASIT film clips were translated and back-translated for the purpose of this project in agreement with Pearson Assessment in London. Theory of mind. The Animated Triangles (Abell, Happé, & Frith, 2000; Castelli, Happe, Frith, & Frith, 2000) were used to measure ToM. We used four random clips where the two triangles had no intended interaction (e.g., bouncing about) and four ToM clips where the triangles interacted intentionally (e.g., the large triangle trying to persuade the small triangle to come outside). The duration of the animations is 38 – 41 s. The subjects were asked to interpret what was going on in each animation and their answers were recorded, transcribed, and scored according to the level of intentionality (degree of mental state attribution, range 0 –5 per animation, where a score of 4 or 5 meant use of words describing different degrees of mental interaction), and appropriateness (accuracy of the description, range 0 –3 per animation, where 3 meant a perfect description of the interaction intended by the animator; Castelli et al., 2000). Also target items were recorded referring to whether the right type of description was used to tell the degree of intentionality being used in the animations (e.g., score 4 or 5 in intentionality of the ToM clips and score 0 or 1 in the random clips), no matter if the subject’s answer was appropriate or not (max score of 4 per type of animation; Russell, Reynaud, Herba, Morris, & Corcoran, 2006). VB and a research student (MLT) evaluated each answer from the 59 FES patients and 59 controls separately, and their mean scores were calculated. Interrater agreement was substantial to almost perfect (Random animations: ␬ ⫽ 0.75; ToM animations: ␬ ⫽ 0.84; ToM Appropriateness: ␬ ⫽ 0.63; Random Appropriateness: ␬ ⫽ 0.72). Neuropsychological measures. Neurocognition. We used the Danish translation of the Brief Assessment of Cognition in Schizophrenia (BACS-DK), to measure verbal memory, working memory, motor speed, verbal flu- 211 ency, executive functions, attention, and speed of processing (Keefe et al., 2004, 2008; Keefe, Poe, Walker, & Harvey, 2006). Intelligence. Current functional intelligence was estimated by the four following subtests from WAIS-III (Wechsler Adult Intelligence Scale, Third version; Wechsler, 1997), chosen because of their high correlation with the total WAIS-III IQ score: Matrix Reasoning, Block Design, Vocabulary, Similarities (Wechsler, 1997). Premorbid intelligence was estimated using DART (Danish Adult Reading Test), which is the Danish version of the NART (The Nelson Adult Reading Test; Nelson & O’Connell, 1978). Psychopathology, Clinical Measures, and Drugs Screening During inclusion at the OPUS clinic, all FES patients were interviewed with the PSE-interview (Present State Examination, ICD-10) by experienced psychiatrists regarding schizophrenia and drug dependence (WHO, 1994). All healthy control subjects were interviewed by VB using the entire PSE interview. All subjects were SANS and SAPS rated by VB (Andreasen, 1984a, 1984b). SANS (Scale for the Assessment of Negative Symptoms) consists of 25 items divided into 4 subscales: Affective flattening or blunting, Alogia, Avolition-Apathy, Anhedonia-Asociality. SAPS (Scale for the Assessment of Positive Symptoms) consists of 34 items which measure 4 psychotic domains: Hallucinations, Delusions, Bizarre behavior, Positive formal thought disorder. The severity of each symptom is rated from 0 –5 and an overall global score of each subscale is found (range 0 –5). Urine samples were collected on the day of psychological testing measuring use of amphetamine, benzodiazepines, cannabis, codeine, morphine, and cocaine. The subjects tested during 2009 and 2010 were also tested for potential alcohol dependence by blood samples (P-Carbohydrat-Deficient-Transferrin). Data Analysis Statistical analyses were carried out with Stata IC 11.2 software. The data were examined for distribution and outliers. Continuous variables were examined by Wilcoxon’s rank sum test (Mann–Whitney) and effect size in terms of Harrell’s C. Harrell’s C is a rank parameter measuring the ordinal predictive power of a model. Categorical variable were examined by Fisher’s exact test and reported with the counts and proportions of the group total. Means and 95 or 99% confidential intervals plus effect sizes were calculated in accordance with the data distribution of each variable. Composite scores of the BACS-DK were calculated as the weighted mean of z-scores, separately computed for each subtest relative to the mean and standard deviation of the healthy control subjects (M ⫽ 0, SD ⫽ 1) as described by Keefe et al. (Keefe et al., 2004). The same procedure was followed regarding the calculation of the social– cognitive composite score. Correlations between social cognition, neurocognition, IQ, and symptoms in the FES patients were calculated by Spearman’s rank correlation (because not all variables were normally distributed). Social– cognitive patient subgroups were found by dividing the 59 patients into subgroups on the basis of SANS and SAPS. Data were split at the mean (SANS: ⱕ10 vs. ⬎10; SAPS: ⱕ12 vs. ⬎12) BLIKSTED, VIDEBECH, FAGERLUND, AND FRITH 212 resulting in four groups. Results were adjusted for multiple testing using Bonferroni corrections. Comparison between symptom subgroups within patients and controls was done using Kruskal-Wallis rank test. These p values were from 3 df ␹2 tests corrected. Subgroup analyses were performed by comparing patients with their matched controls on a group basis. This procedure lead us to the exclusion of two control subjects who could not be directly matched to a patient (Table 1). Correlations Between SANS/SAPS Subscales and Neurocognition, Social Cognition, and IQ Results Demographics, Psychopathology, and IQ This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. no correlation between positive symptoms (SAPS total score) and the social– cognitive composite score (␳ ⫽ 0.14, p ⫽ .29). The application of TASIT as a detection task showed that the patients were poor at making the distinction between sincerity and sarcasm (TASIT sensitivity), t(96.37) ⫽ 4.33, p ⬍ .0001; d ⫽ 0.80 95% CI (0.42;1.17), but also had a bias toward treating the sarcastic behavior as sincere (TASIT bias), t(116) ⫽ ⫺2.77, p ⫽ .0066; d ⫽ ⫺0.51 95% CI (⫺0.87; ⫺0.14; Figure 2). Demographics and psychopathology are summarized in Table 2. Patients and controls did not differ in age and sex. The age range in the FES subjects was 18 –34 years with a mean age of 22.9 years. Twenty-three of the patients were women (39%). As expected, the educational level of the patients was lower, probably because the illness had interfered with their educational plans. The patients reported having had psychotic symptoms on average 9.5 years before inclusion. As expected, the FES patients had lower premorbid IQ and lower estimated current functional IQ than the controls. Neurocognition The FES patients performed significantly worse in all 6 BACS subtests compared with the healthy controls (p ⬍ .0003). The BACS composite score was 1.80 SDs below the healthy controls (p ⫽ 1.6e-9; Harrell’s C (0.83) 99% CI (0.73;0.92)). There was a significant negative correlation between negative symptoms (SANS total score) and neurocognition (␳ ⫽ ⫺0.36, p ⫽ .005), but no correlation between positive symptoms (SAPS total score) and neurocognition (␳ ⫽ 0.16, p ⫽ .22; Figure 1). Social Cognition A social– cognitive composite score was derived based on the statistically significant subscores of the social– cognitive tests. This composite score was 1.91 SDs below the mean of the healthy controls (p ⫽ 2.2e-11; Harrell’s C 0.86 99% CI (0.77;0.95), which is remarkably similar to the BACS composite score. There was a significant negative correlation between negative symptoms (SANS total score) and the social– cognitive composite score (␳ ⫽ ⫺0.39; p ⫽ .002), but Table 1 FES Subgroups Based on SANS and SAPS Symptom Scores Measure SANS Measure Low High Total SAPS Low High Total 17 13 30 12 17 29 29 30 59 Note. FES ⫽ first-episode schizophrenia; SANS ⫽ Scale for Assessment of Negative Symptoms; SAPS ⫽ Scale for Assessment of Positive Symptoms. We started our subgroup analyses by looking at correlations (using Spearmann’s Rank Correlations) between the subscales of SAPS and SANS and neurocognition, social cognition, and IQ (see Table 3). In the SAPS subscales, the only significant correlation was a positive correlation between the global score of delusion and premorbid IQ (DART) (␳ ⫽ 0.32, p ⫽ .01), with the presence of delusions being associated with higher IQ. The Four SANS Subscores All Showed Numerous Significant Correlations Global rating of Affective flattening (e.g., unchanging facial expression, poor eye contact, and lack of vocal inflections) correlated negatively with the Animated Triangles total Appropriateness scores (␳ ⫽ ⫺0.30, p ⫽ .02) and the Appropriateness score of the random animations (␳ ⫽ ⫺0.33, p ⫽ .01), the Social– cognitive composite score (␳ ⫽ ⫺0.29, p ⫽ .03), and estimated functional IQ (WAIS-III; ␳ ⫽ ⫺0.33, p ⫽ .01). However, no correlations were found between Affective flattening and social perception (TASIT: Sincere ␳ ⫽ ⫺0.03, p ⫽ .83; Simple sarcasm ␳ ⫽ ⫺0.16, p ⫽ .22). Global rating of Alogia (e.g., poverty of content of speech, blocking, and increased latency of response) correlated negatively with several aspects of social perception (TASIT: Sincere ␳ ⫽ ⫺0.27, p ⫽ .04; Simple sarcasm ␳ ⫽ ⫺0.29, p ⫽ .03; Sensitivity ␳ ⫽ ⫺0.32, p ⫽ .01) and the Animated Triangles total Appropriateness score (␳ ⫽ ⫺0.32, p ⫽ .01) and the overall level of social cognition (Social– cognitive composite score ␳ ⫽ ⫺0.28, p ⫽ .03) and estimated functional IQ (WAIS-III; ␳ ⫽ ⫺0.44, p ⬍ .001). Global rating of Avolition-Apathy (e.g., impersistence at work or school, poor personal hygiene, and physical anergia) correlated negatively with the neurocognitive BACS composite score (␳ ⫽ ⫺0.30, p ⫽ .02). Finally, the global rating of Anhedonia-Asociality (e.g., problems regarding ability to feel intimacy and closeness and have relationships with friends and peers) correlated negatively with social perception (TASIT: Simple sarcasm ␳ ⫽ ⫺0.32, p ⫽ .01; Sensitivity ␳ ⫽ ⫺0.31, p ⫽ .02). There was also a negative correlation with neurocognition (BACS composite score ␳ ⫽ ⫺0.38, p ⫽ ⬍0.01), estimated functional IQ (WAIS-III; ␳ ⫽ ⫺0.36, p ⬍ .01) and the Social– cognitive composite score (␳ ⫽ ⫺0.39, p ⬍ .01). We adjusted the data for multiple comparisons (nine tests) using the Bonferroni methods after which only four correlations remained significant: Alogia and estimated functional IQ; Anhedonia-Asociality (AA) and estimated functional IQ; AA and BACS composite score and AA and the social– cognitive composite score. SOCIAL COGNITIVE SUBGROUPS IN SCHIZOPHRENIA 213 Table 2 Comparison of Patients With First-Episode Schizophrenia (FES) and Controls on demographics, Psychopathology, and IQ Age Females Years of education Current occupation Unemployed Work Student Sick leave Pension Vocational training Days of FES-diagnosis Years of untreated illness SANS SAPS DART (estimated premorbid IQ) WAIS-III (estimated functional IQ) First-episode schizophrenia (N ⫽ 59) Healthy controls (N ⫽ 59) 22.9 [22.0;23.8] 23 (39.0%) 12.1 [11.4;12.7] 23.1 [22.2;23.9] 24 (40.7%) 14.1 [13.4;14.7] 31 (52.5%) 1 (1.7%) 12 (20.3%) 5 (8.5%) 1 (1.7%) 9 (15.3%) 129.1 [98.3; 159.9] 9.5 [7.6; 11.3]c 10.1 [8.8;11.3] 12.1 [10.9; 13.3] 29.2 [27.3; 31.2]d 87.7 [82.7; 92.7] 4 (6.8%) 22 (37.3%) 33 (55.9%) 0 0 0 0 0 0 0 32.9 [31.5; 34.3] 103.0 [99.3; 106.7] Harrell’s C p value .51 (.41–.62) .81a 1.00b 2.1e-5a 1.7e-15b .73 (.63–.82) .66 (.56–.76) .74 (.65–.83) 2.4e-3a 8.9e-6a Note. Continuous variables were examined by Wilcoxon Rank-Sum Test (Mann-Whitney) and reported with mean (95% CI, confidence interval) and effect size by terms of Harrell’s C (95% CI). Categorical variables were examined by Fisher’s Exact Test and reported with the counts and proportions of group total, N (Percentage). FES ⫽ first-episode schizophrenia; SANS ⫽ Scale for Assessment of Negative Symptoms; SAPS ⫽ Scale for Assessment of Positive Symptoms; DART ⫽ Danish Adult Reading Test; WAIS-III ⫽ Wechsler Adult Intelligence Scale-III (Matrix Reasoning, Block Design, Vocabulary, and Similarities). a Mann-Whitney test. b Fisher’s exact test. c N ⫽ 58. d N ⫽ 57. Based on the above findings, we concluded that various aspects of social cognition, neurocognition, and functional IQ had significant associations with different aspects of negative symptoms in our FES sample. FES Subgroups We compared the patients from the four symptom subgroups with their matched controls on a subgroup basis. Two patients were not matched one to one to a control subject which made us leave out two nonmatched controls from the analysis (see Table 4). Patients with a combination of high levels of positive symptoms and high levels of negative symptoms had the most severe deficits in -4 -2 0 2 As mentioned in the data analysis section, the FES patients were divided into four subgroups of high and low negative and positive SANS and SAPS scores. Combined High Levels of Negative and Positive Symptoms -6 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Measure Z_VeMeTo Z_Token Z_SymCod Z_comp Z_Digit Z_VFIuTo Z_ToLTot Figure 1. Brief Assessment of Cognition in Schizophrenia (BACS) box and whiskers plot. Performance of first episode schizophrenia patients on the Danish BACS subtests and composite score standardized to healthy controls. All differences between patients and controls were statistically significant (p ⬍ 0.0003). See the online article for the color version of this figure. BLIKSTED, VIDEBECH, FAGERLUND, AND FRITH -10 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. -5 0 5 214 Z_TASSin Z_InteToM Z_NoejTot Z_TarRan Z_TASSim Z_invInteRan Z_TarToM Z_socomp Figure 2. Social cognitive composite score. Performance of first episode schizophrenia patients on the social cognitive subtests and composite score standardized to healthy controls. All differences between patients and controls were statistically significant (p ⬍ 0.01). The Awareness of Social Inference Test (TASIT) Bias scores were inverted so that higher scores indicated better performances as for all other tests. See the online article for the color version of this figure. social perception and ToM, while those with high levels of positive symptoms and low levels of negative symptoms had the least severe deficits, and in fact did not differ from their matched controls. In general, patients with many negative symptoms also had more severe social– cognitive and neurocognitive deficits. Patients with low levels of positive and negative symptoms (resembling remission) had more severe deficits in composite scores of neurocognition and social cognition compared to their matched controls. A majority of results remained significant when data were adjusted for multiple comparisons via the Bonferroni methods (see Table 4). Comparison of Clinical Subgroups We compared the four clinical subgroups by Wilcoxon’s rank sum test (see Table 5). Patients dominated by many negative symptoms had more severe social– cognitive and neurocognitive deficits than the other subgroups. It did not make a difference whether the high level of negative symptoms were accompanied by high levels of positive symptoms or not. On the contrary, patients dominated by many positive symptoms and few negative symptoms had better social– cognitive and neuro- Table 3 Spearman’s Rank Correlations Between Clinical Symptoms, IQ, Social Cognition, and Composite Scores in First-Episode Schizophrenia Patients Measure Intelligence DART (estimated premorbid IQ) WAIS-III (estimated functional IQ) Animated triangles Appropriateness, total score Appropriateness, random TASIT Sincere Simple sarcasm Sensitivity Composite scores BACS composite score Social cognitive composite score Delusion (SAPS) Affective flattening (SANS) Alogia (SANS) Avolition-Apathy (SANS) Anhedonia-Asociality (SANS) ⫺.20 ⫺.33ⴱⴱ ⫺.14 ⫺.44ⴱⴱ† .16 ⫺.20 .04 ⫺.36ⴱⴱ† ⫺.19 ⫺.22 ⫺.30ⴱ ⫺.33ⴱⴱ ⫺.32ⴱⴱ ⫺.25 ⫺.07 ⫺.07 ⫺.24 ⫺.23 ⫺.04 ⫺.09 ⫺.08 ⫺.03 ⫺.16 ⫺.09 ⫺.27ⴱ ⫺.29ⴱ ⫺.32ⴱⴱ .02 ⫺.12 ⫺.04 ⫺.19 ⫺.32ⴱⴱ ⫺.31ⴱ ⫺.25 ⫺.29ⴱ ⫺.21 ⫺.28ⴱ ⫺.30ⴱ ⫺.26 ⫺.38ⴱ† ⫺.39ⴱⴱ† .32ⴱ .11 .09 .06 Note. N ⫽ 59. TASIT ⫽ The Awareness of Social Inference Test; SAPS ⫽ Scale for Assessment of Positive Symptoms; SANS ⫽ Scale for Assessment of Negative Symptoms; DART ⫽ Danish Adult Reading Test; WAIS-III ⫽ Wechsler Adult Intelligence Scale-III (Matrix Reasoning, Block Design, Vocabulary, and Similarities); BACS ⫽ Brief Assessment of Cognition in Schizophrenia. † Bonferroni corrected p-values (p ⬍ .0056) adjusted for nine tests. ⴱ p ⱕ .05. ⴱⴱ p ⱕ .01. 11.5 [10.7; 12.3] 11.4 [10.6; 12.2] .46 [.16; .75] 18.2 [16.7; 19.6] 18.0 [16.5; 19.5] .46 [.12; .81] 15.8 [14.0; 17.7] 15.7 [13.5; 17.8] .47 [.13; .81] ⫺.8 [⫺1.8; .1]ⴱ ⫺.1 [⫺.9; .8] .69 [.38; 1.0] ⫺.6 [⫺1.5; .4]ⴱ .2 [⫺.6; 1.0] .71 [.40; 1.0] 15.7 [13.4; 18.0]ⴱ 18.1 [17.0; 19.2] .71 [.45; .96] 11.1 [7.7; 14.4]ⴱ 14.9 [11.9; 18.0] .75 [.51; 1.0] ⫺1.7 [⫺2.7; ⫺.7]ⴱⴱⴱ .1 [⫺.6; .9] .86 [.69; 1.0] ⫺1.7 [⫺2.9; ⫺.5]ⴱⴱⴱ .5 [⫺.3; 1.3] .85 [.67; 1.0] 98.1 [86.9; 109.2] 104.4 [94.8; 114.1] .67 [.35; .99] (NFES 10.9 [9.8; 12.0] 11.6 [11.0; 12.3] .65 [.42; .88] 89.8 [75.3; 104.4]ⴱ 104.1 [94.1; 114.0] .71 [.46; .97] (NFES Low SANS High SAPS ⫽ 13; NCON ⫽ 12) ⫺2.4 [⫺4.0; ⫺.9]ⴱⴱ .2 [⫺1.0; 1.3] .88 [.67; 1.0] ⫺2.4 [⫺3.9; ⫺.9]ⴱⴱ ⫺.3 [⫺1.5; 1.0] .83 [.58; 1.0] 12.2 [7.8; 16.6] 14.7 [11.8; 17.6] .66 [.32; 1.0] 15.8 [13.0; 18.7]ⴱⴱ 18.9 [17.3; 20.5] .83 [.57; 1.0] 10.4 [8.4; 12.4] 11.3 [10.1; 12.4] .61 [.30; .91] 80.1 [62.1; 98.1] 92.7 [81.1; 104.2] .69 [.35; 1.0] (NFES High SANS Low SAPS ⫽ 12; NCON ⫽ 12) ⫺2.6 [⫺4.1; ⫺1.1]ⴱⴱⴱ .4 [⫺.1; 1.0] .97 [.90; 1.0] ⫺2.2 [⫺3.5; ⫺1.0]ⴱⴱⴱ .1 [⫺.5; .6] .91 [.78; 1.0] 9.4 [4.4; 14.5]ⴱⴱ 16.8 [14.4; 19.1] .82 [.62; 1.0] 13.2 [9.2; 17.1]ⴱⴱⴱ 18.7 [17.3; 20.1] .85 [.67;1.0] 10.1 [9.5; 10.8]ⴱ 11.7 [11.3; 12.1] .71 [.48; .95] 83.1 [70.1; 96.1]ⴱⴱⴱ 108.2 [97.1; 119.2] .87 [.70; 1.0] (NFES High SANS High SAPS ⫽ 17; NCON ⫽ 16) .03 (.15) .72 (1.0) .041 (.21) .57 (1.0) .012 (.062) .29 (1.0) .024 (.12) .20 (1.0) .31 (1.0) .69 (1.0) .058 (.35) .043 (.26) Kruskal-Wallis p value (adj. p) Note. Comparison within SANS/SAPS subgroups was done by Wilcoxon Rank-Sum Test and the effect size is given in terms of Harrell’s C (HC). To account for multiple testing we adjusted p values for five tests with the Bonferroni Method and correspondingly 99% confidence intervals (CIs) are used. The two composite scores are highly correlated and adjusting for six tests would be too conservative. comparison by Kruskal-Wallis Rank Test between subgroups within patients and controls, respectively. These p values are from 3 df ␹2 tests corrected for ties. SANS ⫽ Scale for Assessment of Negative Symptoms; SAPS ⫽ Scale for Assessment of Positive Symptoms. Wechsler Adult Intelligence Scale-III (Matrix Reasoning; Block Design, Vocabulary, and Similarities). TASIT ⫽ The Awareness of Social Inference Test; BACS ⫽ Brief Assessment of Cognition in Schizophrenia. Wilcoxon rank-sum test: ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001; Bonferroni corrected p-values adjusted for five tests p ⬍ .01. Animated triangles Appropriateness, random FES CON HC TASIT Simple sarcasm FES CON HC Sensitivity FES CON HC Composite scores BACS composite score FES CON HC Social cognitive composite score FES CON HC Intelligence WAIS-III (estimated functional IQ) FES CON HC Mean (99% CI) Low SANS Low SAPS ⫽ 17; NCON ⫽ 17) Sysptom subgroups versus CON Table 4 Clinical First-Episode Schizophrenia (FES) SANS/SAPS Subgroups Compared With Healthy Controls (CON) This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SOCIAL COGNITIVE SUBGROUPS IN SCHIZOPHRENIA 215 .21 1.00 .36 [.05; .67] .67 1.00 .46 [.15; .76] .79 1.00 .53 [.21; .84] .58 1.00 .56 [.24; .88] .23 1.00 .37 [.06; .68] .22 1.00 .36 [.06; .66] .19 .97 .64 [.34; .94] .37 1.00 .59 [.32; .85] .042 .21 .72 [.45; .98] .0025 .013 .82 [.59; 1.00] .075 .38 .69 [.42; .97] .057 .28 .71 [.43; .98] Subgroups LNLP vs HNLP .46 1.00 .43 [.14; .71] .40 1.00 .42 [.13; .70] .52 1.00 .44 [.15; .72] .23 1.00 .38 [.11; .65] .30 1.00 .40 [.14; .66] .22 1.00 .38 [.10; .65] .0077 .038 .19 [.00; .45] .011 .053 .20 [.00; .46] .029 .14 .24 [.00; .56] .038 .19 .26 [.00; .56] .21 1.00 .37 [.07; .66] .022 .11 .23 [.00; .52] Subgroups LNHP vs HNLP Comparison of symptoms subgroups Subgroups LNLP vs HNHP .018 .090 .24 [.00; .50] .025 .13 .26 [.00; .51] .0098 .049 .22 [.00; .48] .0049 .025 .20 [.00; .43] .062 .31 .31 [.07; .56] .024 .12 .26 [.00; .53] Subgroups LNHP vs HNHP .89 1.00 .51 [.18; .85] .69 1.00 .54 [.22; .87] .30 1.00 .38 [.08; .68] .27 1.00 .38 [.08; .68] .71 1.00 .46 [.23;.69] .64 1.00 .55 [.21; .89] Subgroups HNLP vs HNHP Note. Comparison within SANS/SAPS subgroups was done by Wilcoxon Rank-Sum Test and the effect size is given in terms of Harrell’s C (HC). To account for multiple testing we adjusted p values for five tests with the Bonferroni method and correspondingly 99% confidence intervals (CIs) are used. The two composite scores are highly correlated and adjusting for six tests would be too conservative. Clinical subgroups: LNLP ⫽ Low SANSa ⫹ Low SAPSb (N ⫽ 17); LNHP ⫽ Low SANS ⫹ High SAPS (N ⫽ 13); HNLP ⫽ High SANS ⫹ Low SAPS (N ⫽ 12); HNHP ⫽ High SANS ⫹ High SAPS (N ⫽ 17). SANS ⫽ Scale for Assessment of Negative Symptoms; SAPS ⫽ Scale for Assessment of Positive Symptoms; WAIS-III ⫽ Wechsler Adult Intelligence Scale-III (Matrix Reasoning; Block Design, Vocabulary, and Similarities); BACS ⫽ Brief Assessment of Cognition in Schizophrenia; TASIT ⫽ The Awareness of Social Inference Test. Intelligence WAIS-III (estimated functional IQ) p Adj. p HC Animated triangles Appropriateness, random p Adj. p HC TASIT Simple sarcasm p Adj. p HC Sensitivity p Adj. p HC Composite scores BACS composite score p Adj. p HC Social cognitive composite score p Adj. p HC Mean (99% CI) Subgroups LNLP vs LNHP Table 5 Comparison of the Clinical First-Episode Schizophrenia (FES) SANS/SAPS Subgroups This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 216 BLIKSTED, VIDEBECH, FAGERLUND, AND FRITH SOCIAL COGNITIVE SUBGROUPS IN SCHIZOPHRENIA cognitive functioning even than the subgroup with few positive and negative symptoms. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Discussion In this study, we found significant differences in social cognition and neurocognition between clinical subgroups of patients with FES based on the level of their negative and positive symptoms. The results showed that patients with high levels of negative symptoms had significant cognitive and social– cognitive deficits irrespective of their level of positive symptoms compared to the other subgroups of FES patients. FES patients with high levels of negative symptoms combined with high levels of positive symptoms had the most pronounced difficulties perceiving sarcasm and discriminating between sincerity and sarcasm. In the presence of low levels of negative symptoms, high levels of positive symptoms were associated with the least impairment of all the subgroups. In fact, the patients dominated by high levels of positive symptoms and low levels of negative symptoms did not differ from their matched healthy controls. These results could imply that premorbid social– cognitive and neurocognitive deficits could be a predictor of future development of schizophrenia dominated by negative symptoms but not necessarily accompanied by high levels of positive symptoms. Patients with high levels of alogia (e.g., poverty of content of speech, blocking, and increased latency of response) and anhedonia-asociality (e.g., problems regarding ability to feel intimacy and closeness and have relationships with friends and peers) had greater deficits in social perception. Alogia and affective flattening (e.g., unchanging facial expression, poor eye contact, affective nonresponsivity, inappropriate affect, and lack of vocal inflections) were associated with the most inaccurate descriptions of the Animated triangles film clips. This could imply that expressive linguistic difficulties impair the ability to analyze input from the surroundings correctly. However, we did not find any correlation between affective flattening and social perception which is surprising as it is reasonable to presume that the items measured in the affective flattening subscale are involved in expressing aspects of social perception, for example, sarcasm. Our results are in accordance with the findings of Bell et al. (Bell et al., 2013) who made a principal component analysis based on subscales of negative symptoms and five social– cognitive tests. They found that patients could be divided into three subgroups: One group dominated by high levels of overall negative symptoms and two groups with low levels of negative symptoms combined with high versus low social– cognitive functioning. Bell et al. suggested that patients with high social– cognitive functioning combined with few negative symptoms had the best community functioning compared to the other subgroups. The findings in our study are also consistent with Friths ToM subgroups (Frith, 1992) where the most affected subgroup of patients with schizophrenia was thought to be patients dominated by negative symptoms. However, our results could not confirm the hierarchical structure of the Frith model since the most remitted patients (low SANS and low SAPS scores) in fact had more social– cognitive deficits than the patients dominated by positive symptoms (high SAPS and low SANS scores). Our findings regarding the relationship between high levels of negative symptoms and severe deficits in IQ imply that these 217 patients could be comparable with deficit schizophrenia, which is a subgroup of patients with poor prognosis (Carpenter, Heinrichs, & Wagman, 1988; Galderisi, Bucci, et al., 2013). Aspects of negative symptoms such as affective flattening, alogia, and anhedonia might be connected to deficits in ToM and social perception or perhaps even be a result of such social– cognitive deficits. In line with this assumption a recent multicenter study found that blunted affect was the most persistent negative symptom in firstepisode schizophrenia at 12 month follow-up (Galderisi, Mucci, et al., 2013). Lin et al. (Lin et al., 2013) suggest that negative symptoms mediate the influence of neurocognition and social cognition on functional outcome. Moreover, they suggest that negative symptoms impair neuro- and social cognition by lowering the motivation to attend to psychological tasks. They also hypothesize that negative symptoms decrease the motivation to participate in social activities and thereby influence functional outcome. A similar hypothesis regarding a mediating effect of negative symptoms with respect to the correlation between second-order ToM and social functioning was suggested by Mehta et al. (Mehta, Thirthalli, Kumar, Kumar, & Gangadhar, 2014). Because we did not measure social functioning in our study, we were not able to test if the same mediating effect was found in our sample. However, research has shown that ultra-high risk (UHR) subjects who later develop psychosis have more pronounced social– cognitive deficits compared with the other UHR subjects (Cornblatt et al., 2012; Kim et al., 2011). These results are in accordance with our findings that FES subjects with the most pronounced social– cognitive and neurocognitive had the most severe levels of negative and positive symptoms. Similar results were found in a recent study by Ventura et al. (Ventura, Wood, & Hellemann, 2013). These results could imply that prodromal social– cognitive and neurocognitive deficits enhances the risk of later development of psychosis and/or schizophrenia. It is of note that Galderisi et al.(Galderisi, Mucci, et al., 2013) did not find any difference in neurocognition between FES subgroups dominated by persistent negative symptoms (deficit schizophrenia) and remitted negative symptoms. The effects of positive symptoms depended upon the context in which they occurred. Regarding detection of sarcasm in TASIT (sensitivity), the FES patients with high levels of positive symptoms had the best social perception skills (regarding perception of sarcasm and discriminating sarcasm from sincerity) in the presence of low levels of negative symptoms, but the worst social perception in the presence of high negative symptoms. In other words, patients with many negative symptoms had poor social perception, but the presence of positive symptoms made their performance even worse. These results suggest that the understanding of social– cognitive deficits in schizophrenia is closely linked to a detailed account of symptomatology. A significant positive correlation was found between the global SAPS Delusion subscale score and functional IQ. Our results contradict the notion that patients become increasingly paranoid because of deficits in ToM and social perception. Recent studies have suggested that instead of ToM deficits (hypomentalizing) paranoid patients may in fact be hypermentalizing attributing too much idiosyncratic meaning to social interactions (Abu-Akel & Bailey, 2000; Ciaramidaro et al., 2015; Crespi & Badcock, 2008; Fretland et al., 2015; Frith, 2004; Montag et al., 2011). Patients dominated by negative symptoms have been hypothesized to have ToM deficits (hypomentalizing) resem- BLIKSTED, VIDEBECH, FAGERLUND, AND FRITH This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 218 bling patients with autism spectrum disorder (Abu-Akel & Bailey, 2000; Bliksted et al., 2016; Crespi & Badcock, 2008; Frith, 2004; Kästner et al., 2015). The results of the present study imply that patients with FES is not a clinically homogeneous group in terms of neurocognitive and social– cognitive deficits, and that subtypes are differentially related to clinical symptoms. If the present results are replicated in a larger sample of FES subjects (with more statistical power), this would imply that there is no such thing as an average FES patient with regard to social– cognitive and neurocognitive deficits. The results of the present study indicate that a careful evaluation of social– cognitive and neurocognitive skills is needed in subjects with UHR and first-episode psychosis because such deficits tend to make the subject more vulnerable to a future development of psychotic and negative symptoms. Strengths and Limitations All patients were tested by the same psychologist and patients were recruited from the same mental health clinic on both occasions. The two patient populations did not differ regarding age (t(57) ⫽ ⫺0.73), gender (␹2(1) ⫽ 2.64, p ⫽ .10) or years of education, t(57) ⫽ 0.06, p ⫽ .95. The patients from time period two had only received medication for a few weeks or were antipsychotic-naïve. The patients from the first time period had been medicated for a longer period of time. However, given the limited effects of antipsychotics on neurocognition, and the relative stability of social– cognitive deficits across illness phases in schizophrenia (Green et al., 2012; Horan et al., 2012), we do not expect this difference between previous antipsychotic medication to have affected our results. The fact that sample one had received antipsychotic medication for a longer period of time than sample two probably explains why sample one had significantly fewer positive symptoms, t(57) ⫽ 0.03, p ⫽ .0009 than study two. No significant difference in negative symptoms, t(57) ⫽ 0.03, p ⫽ .98 was found between the two samples. Clinical Implications of the Results In this study, we found that FES patients by no means are alike regarding cognitive and social– cognitive deficits. 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Received May 22, 2015 Revision received June 22, 2016 Accepted July 21, 2016 䡲 Psychiatric Rehabilitation Journal 2017, Vol. 40, No. 1, 4 –11 © 2017 American Psychological Association 1095-158X/17/$12.00 http://dx.doi.org/10.1037/prj0000232 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Efficacy of Cognitive Rehabilitation Using Computer Software With Individuals Living With Schizophrenia: A Randomized Controlled Trial in Japan Kazuhiko Iwata Yasuhiro Matsuda Osaka Psychiatric Medical Center, Osaka, Japan Nara Medical University Sayaka Sato Shunichi Furukawa National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan Tokyo Metropolitan Police Hospital, Tokyo, Japan Yukako Watanabe, Norifumi Hatsuse, and Emi Ikebuchi Teikyo University School of Medicine Objective: Cognitive impairment is common in schizophrenia, and is associated with poor psychosocial functioning. Previous studies had inconsistently shown improvement in cognitive functions with cognitive remediation therapy. This study examined whether cognitive remediation is effective in improving both cognitive and social functions in schizophrenia in outpatient settings that provide learning-based psychiatric rehabilitation. This study is the first randomized controlled trial of cognitive remediation in Japan. Method: Study participants were individuals with schizophrenia from 6 outpatient psychiatric medical facilities who were randomly assigned either a cognitive remediation program or treatment as usual. The cognitive remediation intervention includes Cognitive training using computer software (CogPack; Japanese version) administered twice a week and a weekly group over 12 weeks and was based on the Thinking Skills for Work program. Most study participants were attending day treatment services where social skills training, psychoeducation for knowledge about schizophrenia, group activities such as recreation and sport, and other psychosocial treatment were offered. Cognitive and social functioning were assessed using the Brief Assessment of Cognition in Schizophrenia (BACS) and Life Assessment Scale for Mentally Ill (LASMI) at pre- and postintervention. Results: Of the 60 people with schizophrenia enrolled, 29 were allocated to the cognitive remediation group and 31 were allocated to the treatment as usual group. Processing speed, executive function, and the composite score of the BACS showed significantly greater improvement for the cognitive remediation group than the treatment as usual group. In addition, there was significant improvement in interpersonal relationships and work skills on the LASMI for the cognitive remediation group compared with the treatment as usual group. Changes from pretreatment to posttreatment in verbal fluency and interpersonal relationships were significantly correlated, as well as changes in attention and work skills. Conclusions and Implications for Practice: The present findings showed that providing cognitive remediation on addition to psychiatric rehabilitation contributed to greater improvement in both cognitive and social functioning than psychiatric rehabilitation alone. Cognitive remediation may enhance the efficacy of psychiatric rehabilitation improving social functioning. Keywords: schizophrenia, cognition, social functioning, cognitive remediation, psychosocial treatment Most people with schizophrenia continue to have cognitive deficits even after their psychotic symptoms improve. Previous studies (Green & Nuechterlein, 1999) have demonstrated an asso- ciation between poor cognitive functioning and poor functional outcomes. Therefore, improving both social and cognitive functioning is a very important goal in the treatment of schizophrenia. This article was published Online First February 9, 2017. Kazuhiko Iwata, Osaka Psychiatric Medical Center, Osaka, Japan; Yasuhiro Matsuda, Department of Psychiatry, Nara Medical University; Sayaka Sato, Department of Psychiatric Rehabilitation, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan; Shunichi Furukawa, Department of Psychiatry, Tokyo Metropolitan Police Hospital, Tokyo, Japan; Yukako Watanabe, Norifumi Hatsuse, and Emi Ikebuchi, Department of Psychiatry, Teikyo University School of Medicine. The institutional review boards at each site approved this study. This study is supported by Health Labour Sciences Research Grant of the Ministry of Health, Labor and Welfare, Japan. We appreciate the help received from Shunichi Fukuhara and Takeo Nakayama at Kyoto University School of Public Health with advice about study design and statistical analysis. Correspondence concerning this article should be addressed to Emi Ikebuchi, 2-11-1 Kaga, Itabashi-Ku, Tokyo 173-8605, Japan. E-mail: PXM06766@nifty.com 4 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. RCT OF COGNITIVE REHABILITATION FOR SCHIZOPHRENIA Many different methods for cognitive rehabilitation or cognitive remediation have been implemented by different researchers. Some researchers have used puzzles (e.g., Tower of Hanoi), while others have used neuropsychological tests (e.g., the Wisconsin Card Sorting Test; Bell, Bryson, Greig, Corcoran, & Wexler, 2001; Young & Freyslinger, 1995). In recent years there has also been the increasing use of computer software programs for cognitive remediation (Garrido et al., 2013; Kurtz, Seltzer, Shagan, Thime, & Wexler, 2007; Lee, 2013; Rass et al., 2012). Some studies have already shown that cognitive remediation is effective in improving cognitive functioning in schizophrenia. However, it remains unclear whether cognitive remediation improves social functioning in schizophrenia. Social functioning means real world competence to live effectively and adaptably, which includes several domains: social and interpersonal relationships, work and school activities, independent community living skills, enduring family activities, and so on. Bowie, McGurk, Mausbach, Patterson, and Harvey (2012) presented the results that cognitive remediation produces robust improvements in neurocognition and generalization to functional competence and real-world behavior was more likely when supplemental skills training and cognitive remediation was combined. Therefore our study was planned so that cognitive remediation added to psychiatric rehabilitation. Kiwanuka et al. (2014) showed that neuropsychological impairment was associated with vocational outcomes, whereas most of the self-reported measures were related to social outcomes. Green et al. (2015) discussed the determinants of daily functioning in schizophrenia: nonsocial and social cognition, which were mediated with defeatist beliefs and experimental negative symptoms influencing functional outcomes. Further studies are needed to make clear influences of neurocognitive functioning in a variety of domains of social functioning. There have been some interventional studies of cognitive remediation recently in urban areas of East Asia. Au et al. (2015) reported that supported employment and cognitive remediation demonstrated improvement in vocational, clinical, psychological, and neurocognitive outcomes. However, there was no evidence to show that that cognitive improvement in these domains beyond gains associated with supported employment alone. A metaanalysis on working memory training studies suggested activation of the dorsolateral prefrontal cortex in patients with schizophrenia (Li et al., 2015). Another meta-analysis of prospective controlled trials conducted in Singapore, Japan, and other nations showed that patients receiving cognitive remediation had better work outcomes than those not receiving cognitive remediation (Chan, Hirai, & Tsoi, 2015). There have been few interventional studies in Japan that have used comparison groups in examining the efficacy of cognitive remediation with computer software (Ikezawa et al., 2012; Sato et al., 2014). Therefore we conducted a randomized controlled trial to evaluate whether cognitive remediation using cognitive training software improves both cognitive and social functions in people with schizophrenia. In Japan, social skills training, psychoeducation for patients, group meetings, individual work therapy, and group activities such as recreation, sports, and cooking were widely disseminated services in day treatment programs. We sought to evaluate whether cognitive remediation would enhance the effects of rehabilitation on improving social functioning in this enriched learning environment. We also sought 5 to evaluate the associations between changes in cognitive functioning and changes in social functioning. Method Participants Inclusion criteria for participation in this study were: (a) diagnosis of schizophrenia, based on the ICD-10 diagnostic criteria for research (World Health Organization, 1990); (b) age from 20 to 50; (c) outpatients of psychiatric medical facilities participating in this study; (d) willingness and capability to give informed consent to participate in this study; (e) clients not receiving old and conventional antipsychotics as their primary medication; and (f) clients who have hope to work in the real world setting, and have not worked yet during participation of the study. Antipsychotic medications can affect cognitive functioning, especially the older, conventional antipsychotics. For this reason, we limited study participation to clients receiving second generation antipsychotics as their primary medication. Exclusion criteria for participation were: (a) other comorbid mental illness, (b) history of organic brain disorder, (c) comorbid substance use disorders, (d) complicating congenital mental retardation, and (e) existence of severe psychiatric symptoms that would preclude regular attendance at sessions. Participants were recruited through referrals from attending psychiatrists or clinical staff at the psychiatric medical facilities where the study was conducted. Almost all of the participants were attending day treatment services in both groups, where social skills training, psychoeducation for patients (teaching information about schizophrenia in an interactive way), community meetings, individual work therapy, and group activities such as recreation, sports, and cooking were provided for 6 hr/day, 5 days per week. Clients can choose to attend these programs after discussion with their care-manager, and the total number of hours they attended depended on individual preferences and conditions. These learning-based rehabilitation programs are popular in Japan. Efforts were made to avoid changing clients’ pharmacological treatment during the study unless it was clinically necessary. Design and Setting This study was designed as a multicenter randomized controlled trial, conducted at six psychiatric facilities in Japan: two sites in Osaka (one hospital and one clinic), and one hospital each in Fukushima, Tokyo, Saitama, and Niigata prefecture. After completion of the baseline evaluations, clients were randomly assigned to either the cognitive remediation group or control treatment as usual group after stratification by age and sex. To minimize potential disappointment for people assigned to the control group, they served as a “waiting list” control group, and were provided the cognitive remediation after 12 weeks. Interventions Cognitive remediation group. Cognitive remediation was provided using the computer software: CogPack (Marker software, Germany). This program was developed for rehabilitation of higher brain dysfunction, and it contains 64 cognitive tasks to train This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 6 IWATA ET AL. verbal memory, working memory, attention/vigilance, psychomotor speed, and executive function. Marker software gave us permission to develop a Japanese language version of the program for use in research settings. Our cognitive remediation method is theoretically based on the Thinking Skills for Work program (McGurk, Mueser, et al., 2007; McGurk, Mueser, & Pascaris, 2005). We conducted 24 cognitive training sessions using CogPack, twice a week, with each session lasting about 45– 60 min. We also conducted a weekly group session designed to promote the transfer of improved cognitive functioning to real-world situations. The trained therapists described below also provided participants teaching compensation strategy or prompting additional practice if needed. We developed a cognitive remediation manual for practitioners in order to standardize treatment across sites. Additionally, at least one therapist at each site had to take two 1-day training courses to learn the cognitive remediation program before the study was started. Therapists involved in the intervention were psychologists, nurses, social workers, and occupational therapists who were familiar with psychiatric rehabilitation for schizophrenia, and supervised during the study period by members of the research team who had several years of experience with cognitive remediation. Internet conferences between members of the research team were also held during the study period. Using computer software and the manual also minimizes the disparity of efficacy in cognitive remediation. In the computer cognitive training, participants were directed to practice a wide range of cognitive domains in both the early and later phases of remediation with adherence to the Thinking Skills for Work program, and each participant could choose either preferable tasks or unskilled tasks to enhance their interests or selfefficacy in the later phase. In the groups, participants talked about their weak tasks, and discussed with each other strategies to complete tasks using some cognitive functioning in the early phase. In the middle and later phases, they also discussed social goals and how to transfer gained cognitive skills to achieve their goals. Treatment as usual group. All participants received standard (treatment as usual) outpatient treatment. Outcomes Both the cognitive remediation group and the treatment as usual group were evaluated using the following assessments in the preand postintervention phases (after 4 months from baseline) within 1 month. Primary outcome. We assessed cognitive functioning as the primary outcome in this study. Cognitive functioning was assessed using the Brief Assessment of Cognition in Schizophrenia—Japanese version (BACS-J) preintervention. The BACS-J includes six measures of cognitive functioning in the following domains: verbal memory, attention, verbal fluency, working memory, executive functioning, and psychomotor processing. Composite score of overall cognitive performance is also provided. The BACS-J has established reliability and validity and has good sensitivity for the types of cognitive deficits associated with schizophrenia. Normalized standard scores of the BACS-J for each age category have already been reported in Japan (Kaneda et al., 2007; Keefe, Poe, Walker, Kang, & Harvey, 2006). Secondary outcome. Social functioning and psychopathology were assessed as secondary outcomes. Social functioning was assessed with the LASMI (Ikebuchi, Iwasaki, Miyauchi, Oshima, & Sugimoto, 1995; Iwasaki et al., 1994), which was rated based on reports from clients, information of caregivers, and therapist observations during this study in day treatment activities or other outpatient programs over the previous month. The LASMI yields rating functioning in five domains: daily living, interpersonal relations, work, endurance and stability, and self-recognition. We used the Interpersonal Relations and Work subscales of the LASMI in this study (Kay, Opler, & Fiszbein, 1991), because the aim of the study was improving vocational abilities through cognitive remediation. The Interpersonal Relations subscale consists of 13 items which are derived from basic communication skills such as facial expression to informal relations with family or friends. The Work subscale consists of 10 items, which include abilities of work skills and the employee’s role which might expected in a company. These abilities were rated in a simulation setting of outpatients’ programs. Each item of the LASMI is evaluated on a 5-point Likert scale, and more score points mean more need for support for each activity. The score of each subscale is calculated by summing all of the items in the subscale. Symptom severity was rated using the Positive and Negative Syndrome Scale (PANSS), which was scored according to the three-factor model (Positive scale, Negative scale, and General Psychopathology scale). The PANSS is composed of 30 items, and each item is rated on a 7-point Likert scale from 1 (Absent) to 7 (Extreme). We conducted two training sessions for the raters at each site who assessed the primary and secondary outcomes. Statistical Analysis Analyses were performed on an intention-to-treat basis. Participants who had at least one assessment made up the intention-totreat sample. First we compared baseline demographic and clinical characteristics between the cognitive remediation group and the treatment as usual group with t tests or chi-square tests. After comparing the two groups on demographic and baseline clinical characteristics, we performed following analyses as described below. For the statistical analysis, we used JMP ver.10 (SAS Institute Japan, Tokyo Japan). Comparing primary and secondary outcomes between the two groups. At first, improvements in cognitive and social functioning and psychotic symptoms were compared between two groups. The groups were compared using analysis of covariance (ANCOVA) with group as the independent variable, changes in cognitive or social functioning of posttreatment as the dependent variables, and baseline functioning and age as covariates. The linear regression model of the analysis is used. We entered five baseline characteristics as covariates (age, duration of illness, premorbid IQ, dose of antipsychotics, and baseline score of clinical scales). We found no significant group difference of demographic and clinical variables by random allocation. However, “allocation bias” remains because four variables (age, duration of illness, premorbid IQ, dose of antipsychotics) and baseline score of clinical scales have some effect on primary and secondary outcomes. Thus, adjusting these factors could minimize the allocation bias and boosted the statistical power for the efficacy of the RCT OF COGNITIVE REHABILITATION FOR SCHIZOPHRENIA cognitive remediation. Finally, we set up the parameter (␤) of “allocation group” and its 95% confidence interval (95% CI) to determine the efficacy of cognitive rehabilitation. Correlational analysis. The objective of the correlational analyses was to explore whether changes in cognitive functioning from pretreatment to posttreatment were correlated with changes in social functioning, and, if so, which areas of cognitive functioning were most strongly associated with improvement in social functioning. Therefore we calculated Spearmen correlations between the changes of each domain in the BACS-J and LASMI. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Study Ethics We administered this trial in accordance with Declaration of Helsinki and Ethical Guidelines for Clinical Studies of the Ministry of Health, Labor, and Welfare. This study was approved by the institutional review board or ethics committee at each site, and oral and written informed consent was obtained from all participants. We registered this study in UMIN Clinical trial registration (UMIN CTR ID: UMIN000002775). 7 functioning, and psychiatric symptoms did not differ between the groups. Fifty-five clients (91.7% of participants) were using the day treatment program or psychosocial treatment programs for outpatients, which were open to attendance every day. The percentage of attendance did not differ between the groups. The Efficacy of Cognitive Rehabilitation in Improving Cognitive Functioning Analyses were performed on an intention-to-treat basis. Participants who had at least one assessment made up the intention-totreat sample. We used the last observation carried forward method, and we assigned the pretest data into missing posttest data of four participants who declined to posttest. Table 2 shows the changes in cognitive functioning on the BACS-J before and after the intervention with cognitive remediation. ANCOVA indicated that there was a significantly greater improvement for the cognitive remediation group on three domains of the BACS-J: composite score (F ⫽ 8.209, df ⫽ 59, p ⫽ .006), processing speed (F ⫽ 6.345, df ⫽ 59, p ⫽ .015), and executive functioning (F ⫽ 4.203, df ⫽ 59, p ⫽ .045). Results Patient Flow and Baseline Characteristics The Efficacy of Cognitive Remediation in Improving Social Functioning and Psychotic Symptoms Among clients of the six hospitals, 61 clients met the inclusion/ exclusion criteria and provided informed consent. However, one patient declined to complete the pretest, therefore 60 clients were randomized. Of these, 29 clients were assigned to receive cognitive remediation, and 31 were assigned to the treatment as usual group. Figure 1 shows a flow diagram of the clients through the study. Table 1 shows the patient characteristics and baseline scores in both groups before intervention. There was no significant difference in baseline characteristics between the groups. In addition, the baseline evaluation scores for cognitive functioning, social Table 3 shows the changes in social functioning and psychotic symptoms evaluated with the LASMI and PANSS at baseline and posttreatment for both groups. The evaluation of changes in social functioning indicated significantly greater improvements in interpersonal relationships on the LASMI (F ⫽ 12.817, df ⫽ 59, p ⬍ .001) and work skills (F ⫽ 8.037, df ⫽ 59, p ⫽ .007) in the cognitive remediation group compared with the treatment as usual group. In addition, psychiatric symptoms including the total PANSS score and all of these subscales also showed significantly greater improvements in the cognitive remediation group compared with the treatment as usual group (see Table 3). Assessed for eligibility and obtained participants' consent (n=61) Excluded (n=1) ・Declined to pre-test(n=1) Randomized(n=60) Cognitive Remediation Group(n=29) Treatment as Usual Group(n=31) Intervention(n=29) ・Received cognitive remediation(n=29) ・Did not receive cognitive remediation(n=0) Intervention (n=31) Follow Up(n=29) Follow Up(n=31) ・Lost to follow-up(n=0) ・Discontinued intervention (relapse, readmission etc.) (n=0) ・Received treatment as usual in outpatient unit(n=31) ・Did not receive treatment as usual in outpatient unit(n=0) ・Lost to follow-up(n=0) ・Discontinued intervention (relapse, readmission etc.) ( n=0 ) Analysed (n=28) Analysed (n=28) ・Excluded from analysis ( declined to post-test ) ( n=1 ) ・Excluded from analysis ( declined to post-test ) ( n=3 ) Figure 1. CONSORT diagram of patient flow through study. IWATA ET AL. 8 Table 1 Baseline Characteristics: Demographic Data This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Cognitive remediation group (N ⫽ 29) Baseline data Avg. Age (years) Sex (male/female) Duration of Illness (month) IQ (JART Score) Dose of antipsychoticsa (mg) 34.2 Treatment as usual group (N ⫽ 31) SD Avg. 7.11 34.5 7/22 140.9 98.7 672.6 SD 6.73 8/23 96.8 9.59 618.3 144.5 97.2 674 83.1 10.2 417.5 Note. No significant differences between groups on any variables with t test or chi square test. JART ⫽ Japanese Adult Reading Test. a Chlorpromazine equivalent. Correlations Between Improvements on Cognitive and Social Functioning All clients were included in the analysis of the correlation between cognitive and social functioning improvement. Table 4 shows the correlations between LASMI interpersonal relationships and work skills, respectively, with the BACS-J composite score and each cognitive functioning domain. We found significant correlations between changes in BACS-J verbal memory and changes in LASMI interpersonal relationships (Spearman’s rank correlation coefficient; ␳ ⫽ ⫺0.315, p ⫽ .018), between changes in BACS-J verbal fluency and changes in LASMI interpersonal relationships (Spearman’s ␳ ⫽ ⫺0.263, p ⫽ .049), between changes in BACS-J attention/vigilance and changes in LASMI work skills (Spearman’s ␳ ⫽ ⫺0.311, p ⫽ .02), and between changes in BACS-J executive functioning and changes in LASMI work skills (Spearman’s ␳ ⫽ ⫺0.265, p ⫽ .049). Discussion Providing cognitive remediation in addition to the usual treatment involving psychiatric rehabilitation approaches such as social skills training and other learning-based rehabilitation programs was associated with greater improvement in cognitive functioning, social functioning, and psychiatric symptoms in people with schizophrenia, compared with the usual services alone. Research has previously established the effectiveness of traditional psychi- atric rehabilitation methods such as social skills training and psychoeducation programs (Dixon et al., 2010), which are widely used today in psychiatric practice in Japan. However, many clients who receive psychiatric rehabilitation have difficulty achieving their treatment goals. Cognitive remediation may impose cognitive functioning which could enhance the benefits of rehabilitation programs. Our findings are consistent with previous research on cognitive remediation showing significant improvements in cognitive functioning, as well as improvements in social functioning, when cognitive remediation was added to psychiatric rehabilitation compared with psychiatric rehabilitation alone (McGurk et al., 2013; McGurk et al., 2015). In our analysis, significant correlation between improvement in cognitive functioning and improvement in social functioning were observed for some outcomes. As previously reviewed (Green, Kern, Braff, & Mintz, 2000; Green & Nuechterlein, 1999), neurocognition strongly influences psychosocial functioning. However, this interpretation does not take into account the fact that cognitive remediation programs that are provided in the absence of psychiatric rehabilitation (e.g., social skills training) tend to produce weaker (or nonsignificant) effects on psychosocial functioning, despite showing beneficial effects on cognitive functioning. Although previous studies of cognitive remediation report efficacy in improving cognitive functioning, the findings have been inconsistent that improvement of cognitive functioning did not translate into improved social functioning directly (Lu et al., 2012; Medalia & Saperstein, 2013). However, some studies that added cognitive remediation to psychiatric rehabilitation showed the greatest impact on psychosocial functioning (Franck et al., 2013; Krabbendam & Aleman, 2003; Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). It is possible that cognitive remediation improves capacity to learn through increased verbal memory or executive functioning, and in the absence of concerted learning opportunities, improved cognitive functioning does not automatically lead to improved psychosocial functioning, as discussed in McGurk et al. (2013, 2015). The present results suggest that improved cognitive functioning could facilitate improvement in social functioning in the context of a social learning environment through transferring skills from laboratory to real world. Subramaniam et al. (2014) showed that task performance of cognitive training of working memory and brain activity within the bilateral middle frontal gyri predicted better occupational functioning at 6-month follow-up. Table 2 The Changes of Cognitive Functions After Intervention Cognitive remediation group (N ⫽ 29) Treatment as usual group (N ⫽ 31) BACS Pre (SD) Post (SD) Pre (SD) Post (SD) F ␤ p value Verbal memory Digit sequencing Verbal fluency Token Motor Task Symbol-Coding Task Tower of London Composite score .18 (.82) .10 (.99) .11 (.74) .19 (1.02) .25 (1.09) .08 (1.08) .15 (.48) .63 (.82) .49 (1.01) .64 (.99) .53 (.94) .54 (1.12) .32 (.74) .55 (.64) ⫺.17 (1.12) ⫺.09 (1.02) ⫺.10 (1.20) ⫺.18 (.96) ⫺.24 (.86) ⫺.08 (.93) ⫺.14 (.70) .07 (1.09) .11 (1.14) .09 (1.28) ⫺.18 (.88) ⫺.10 (1.00) ⫺.05 (.88) .01 (.69) 3.150 1.487 3.129 6.345 1.467 4.203 8.209 .314 .227 .353 .466 .190 .239 .300 .082 .228 .087 .015ⴱ .231 .045ⴱ .006† ANCOVA Note. Analysis by analysis of covariance (ANCOVA) and last observation carried forward (LOCF). df ⫽ 59. BACS ⫽ Brief Assessment of Cognition in Schizophrenia (Japanese version). † p ⬍ .01. ⴱ p ⬍ .05. RCT OF COGNITIVE REHABILITATION FOR SCHIZOPHRENIA 9 Table 3 The Changes of Social Functions and Psychotic Symptoms After Intervention Cognitive remediation group (N ⫽ 29) This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. ANCOVA Pre (SD) Post (SD) Pre (SD) Post (SD) F ␤ p value 14.14 (5.47) 12.93 (5.17) 9.69 (5.41) 9.41 (5.52) 14.51 (7.38) 14.87 (6.10) 14.32 (7.45) 13.87 (6.20) 12.817 8.037 ⫺4.317 ⫺3.120 ⬍.001† .007† 12.93 (4.95) 14.83 (4.80) 29.48 (8.83) 57.27 (16.53) 11.38 (4.78) 12.66 (4.52) 26.72 (9.10) 50.76 (17.03) 12.77 (4.40) 16.55 (5.03) 31.12 (8.44) 60.45 (14.8) 13.03 (4.43) 15.87 (5.66) 31.39 (9.02) 60.29 (17.42) 7.996 5.215 9.015 9.407 ⫺1.788 ⫺1.871 ⫺3.231 ⫺6.691 .007† .026ⴱ .004† .003† The changes after intervention LASMI Interpersonal relationship Work PANSS Positive scale Negative scale General Psychopathology Scale Total Treatment as usual group (N ⫽ 31) Note. Analysis by analysis of covariance (ANCOVA) and last observation carried forward (LOCF). df ⫽ 59. LASMI ⫽ Life Assessment Scale for Mental Illness; PANSS ⫽ Positive and Negative Syndrome Scale. † p ⬍ .01. ⴱ p ⬍ .05. The program of this study also focused on enhancing executive functioning and working memory, and transferring learned abilities to the real world with group sessions and daily activities of day treatment programs. Therefore, not only cognitive remediation but also traditional psychiatric rehabilitation focused on social functioning may be necessary for some clients with schizophrenia. To achieve social goals such improvements in both cognitive and social functioning may be critical to facilitate the reintegration of persons with schizophrenia in the community. Psychiatric symptoms assessed on the PANSS also improved significantly more in the cognitive remediation group than the treatment as usual group. Meta-analyses of controlled studies of cognitive remediation have showed small effect sizes on the reduction of psychiatric symptoms (Kurtz, 2012; McGurk, Twamley, et al., 2007; Medalia & Choi, 2009). It is possible that the reduction in psychiatric symptoms found in this study were influenced by the improvement in social functioning. In this study, a standardized cognitive remediation program provided for about 24 sessions over 12 weeks was found to be effective at improving cognitive and social functioning. This result Table 4 Correlation Between Improvements of Cognitive and Social Functions Change of subscales in LASMI Interpersonal relationship (N ⫽ 60) Work (N ⫽ 60) Change of subscales in BACS (N ⫽ 60) Spearman’s ␳ p value Spearman’s ␳ p value Verbal memory Digit sequencing Verbal fluency Token Motor Task Symbol-Coding Task Tower of London ⫺.315 ⫺.158 ⫺.263 ⫺.138 ⫺.106 ⫺.045 .018ⴱ .246 .049ⴱ .309 .438 .740 ⫺.133 ⫺.169 ⫺.151 .056 ⫺.311 ⫺.265 .330 .212 .267 .681 .02ⴱ .049ⴱ Note. Analysis by correlational analysis and last observation carried forward (LOCF). LASMI ⫽ Life Assessment Scale for Mental Illness; BACS ⫽ Brief Assessment of Cognition in Schizophrenia Japanese version. ⴱ p ⬍ .05. is consistent with the findings from Bowie et al. (2012) that real-world behavior was more likely when supplemental skills training and cognitive remediation were combined. It is possible that some clients in the cognitive remediation group who did not improve in cognitive or social functioning would have improved from a longer program. Strengths and Limitations of This Study Some strengths of this study should be noted. The computer software program used to engage clients in cognitive exercises was designed to improve cognitive functioning. Moreover, the cognitive remediation procedures, which were mainly strategy coaching and compensating methods by trained therapists, wer...
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Treatment for Autism
Thesis statement: Autism can be treated and reduced through the process of feeding well as well
as having different feeding strategies.
1. The relationship between current researchers that have been done as well as the research
that I am going to do
2. The implementation of the system in my own research


Running head: TREATMENT FOR AUTISM

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Treatment for Autism
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TREATMENT FOR AUTISM

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There have been several research items that have been conducted in the past to identify
the effectiveness of different treatment methods. According to Fisher et al. (2017), the
information that has been gained from such activities is very good and assists in understanding
my topic in a better manner. In all the studies, it is clear that majority of the participant were
between the age of 18 years and 30 years. It was also notable that majority of the participants
were not able to be involved in taking further education as the majority of the people were
affected by the jobs they were taking. It is also notable t...


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