The causal relationships between neurocognition, social cognition and functional outcome over time in schizophrenia: a latent difference score approach.

BACKGROUND: Social cognition has been identified as a significant construct for schizophrenia research with relevance to diagnosis, assessment, treatment and functional outcome. However, social cognition has not been clearly understood in terms of its relationships with neurocognition and functional outcomes. The present study sought to examine the empirical independence of social cognition and neurocognition; to investigate the possible causal structure among social cognition, neurocognition and psychosocial functioning. METHOD: The sample consists of 130 individuals diagnosed with schizophrenia. All participants were recruited as they were admitted to four community-based psychosocial rehabilitation programs. Social cognition, neurocognition and psychosocial functioning were measured at baseline and 12 months. The empirical independence of social cognition and neurocognition was tested using confirmatory factor analysis (CFA) and the possible causal structure among social cognition, neurocognition and psychosocial functioning was investigated using latent difference score (LDS) analysis. RESULTS: A two-factor model of social cognition and neurocognition fit the data very well, indicating the empirical independence of social cognition, whereas the longitudinal CFA results show that the empirical independence of neurocognition and social cognition is maintained over time. The results of the LDS analysis support a causal model that indicates that neurocognition underlies and is causally primary to social cognition, and that neurocognition and social cognition are causally primary to functional outcome. CONCLUSIONS: Social cognition and neurocognition could have independent and distinct upward causal effects on functional outcome. It is also suggested that the approaches for remediation of neurocognition and social cognition might need to be distinct.

Neurocognitive change, functional change and service intensity during community-based psychosocial rehabilitation for schizophrenia.

BACKGROUND: This study examined the magnitude of neurocognitive change during 1 year of community-based psychosocial intervention, whether neurocognitive change and functional change were linked, and how neurocognitive change combined with service intensity to facilitate functional change. METHOD: A total of 130 individuals diagnosed with schizophrenia were recruited upon admission to four community-based psychosocial rehabilitation programs. Subjects were assessed at baseline, 6 and 12 months on role functioning and symptom measures. Neurocognition was measured at baseline and 12 months. Service intensity was the number of days of treatment attendance during the study period. Latent mean difference tests and Latent Growth Curve Models (LCGMs) were used to examine the study hypotheses. RESULTS: There was statistically and clinically significant functional improvement over 12 months. Neurocognition improved significantly over time. Seventy-six (58%) of the sample showed neurocognitive improvement and 54 (42%) did not. There was a significant rate of functional enhancement in the neurocognitive improver group. There was a non-significant rate of functional change in the neurocognitive non-improver group. Neurocognitive improvers showed functional improvement that was 350% greater than neurocognitive non-improvers. Service intensity did not vary between neurocognitive improvers and non-improvers but there was a strong interaction between neurocognitive improvement, service intensity and rate of functional improvement such that service intensity was strongly related to functional improvement for neurocognitive improvers but not for neurocognitive non-improvers. Medication usage and symptomatology did not confound these findings. CONCLUSIONS: These findings suggest that neurocognitive improvement may be a foundation for functional change and treatment responsiveness during community-based psychosocial rehabilitation for individuals with schizophrenia.

Risks for individuals with schizophrenia who are living in the community.

OBJECTIVE: This study examined the incidence and predictors of police contact, criminal charges, and victimization among noninstitutionalized individuals with schizophrenia living in the community. METHODS: A total of 172 individuals with schizophrenia or schizoaffective disorder were recruited from community-based programs in urban Los Angeles between 1989 and 1991 and were monitored for three years. At baseline, all participants were housed and did not have co-occurring substance use disorders. Face-to-face interviews were conducted every six months. RESULTS: Eighty-three individuals (48 percent) had contact with the police during the study period. A small percentage of the contacts involved aggressive behavior against property or persons. Being younger, having had more address changes at baseline, and having a history of arrest and assault were significant predictors of police contact. Thirty-seven individuals (22 percent) reported that charges had been filed against them. Poorer social functioning, more address changes, fewer days of taking medication at baseline, and a history of arrest and assault were significant predictors of criminal charges. Sixty-five participants (38 percent of the sample) reported having been the victim of a crime during the three years, 91 percent of which was violent. Having more severe clinical symptoms and more substance use at baseline were significant predictors of victimization. CONCLUSIONS: Individuals in this sample were at least 14 times more likely to be victims of a violent crime than to be arrested for one. In general, the risk associated with being in the community was higher than the risk these individuals posed to the community

Neuropsychological functioning as a moderator of the relationship between psychosocial functioning and the subjective experience of self and life in schizophrenia.

Psychosocial interventions and models of quality of life in schizophrenia are based on the notion that increases in psychosocial functioning will be related to improvements in subjective experience outcomes such as self-esteem and satisfaction with life. However, studies have repeatedly failed to demonstrate a direct relationship between psychosocial functioning and subjective experience in schizophrenia. This study of 40 individuals diagnosed with schizophrenia examined whether neurocognitive measures of executive functioning moderated the relationship between psychosocial functioning and subjective experience. Subjective experience was represented by measures of satisfaction with life and self-esteem. The Global Assessment Scale measured psychosocial functioning, and the Wisconsin Card Sorting Test measured executive functioning. Multiple regression and correlation analyses indicated that executive functioning was a strong moderator. Specifically, individuals with schizophrenia with impaired executive functioning displayed a positive and statistically significant association between psychosocial functioning and both measures of subjective experience (r = 0.55 and 0.61). However, among schizophrenia patients with intact executive performance, psychosocial functioning was negatively associated with self-esteem and satisfaction with life (r = -0.24 and -0.46). And the findings were internally replicated using two other neuropsychological measures relevant to executive functioning. These findings indicate that executive functioning plays a major role in moderating the relationship between subjective experience and psychosocial functioning in schizophrenia. Implications for biosocial models, psychosocial interventions, and models of quality of life in schizophrenia are discussed.

Community-based psychosocial rehabilitation and prospective change in functional, clinical, and subjective experience variables in schizophrenia.

In a previous study, we found that the intensity, specificity, and longitudinality of community-based psychosocial rehabilitation services were related to superior functional outcomes for individuals diagnosed with schizophrenia. The purpose of this study was to assess the degree to which the intensity and longitudinality of services were related to improvements in subjective experience and clinical outcomes, and to examine the relationships among prospective changes in functional, clinical, and subjective experience variables. One hundred seventy-two individuals diagnosed with a schizophrenia spectrum disorder were followed for 36 months in three distinct models of community-based care. Functional, clinical, and subjective experience outcome data were gathered every 6 months over a 3-year period. Data were analyzed using hierarchical linear modeling (HLM) and P-technique factor analysis. The results indicated that (1) greater service intensity and the longitudinality of services were associated with improvement in client self-esteem; (2) there was evidence for three distinct factors of prospective rehabilitative change that corresponded to the conceptual domains of clinical, functional, and subjective experience outcomes; and (3) there was no differential program impact on symptom levels or the intrapsychic deficits. In addition, the three-factor model of outcome consisting of functional change, clinical change, and subjective experience change was similar to Strauss and Carpenter's "open-linked" system of outcome in schizophrenia. The implications of these findings for research and practice in the area of community-based rehabilitation for individuals with schizophrenia are discussed.

Subjective experience in schizophrenia: factors influencing self-esteem, satisfaction with life, and subjective distress.

The relative and combined effects of individual characteristics, severity of illness, psychosocial functioning, treatment intensity, and milieu variables on self-esteem, distress and satisfaction with life were examined in a study of 103 subjects diagnosed with schizophrenia or schizoaffective disorder, all of whom had been in either high-intensity or low-intensity community-based interventions for at least six months. Implications of the findings for treatment and for research on subjective experience in schizophrenia are discussed.

Intensity and continuity of services and functional outcomes in the rehabilitation of persons with schizophrenia.

OBJECTIVE: The intensity and continuity of services delivered to individual clients in a community-based psychosocial rehabilitation program were examined in relationship to functional changes in the clients that occurred during the first 12 months of the program. METHODS: Subjects were 41 clients with schizophrenia or schizoaffective disorder who were admitted to an intensive psychosocial rehabilitation program. Measures of clinical and psychosocial functioning were derived from client interviews administered at baseline and six and 12 months later. Measures of service intensity and continuity came from data gathered daily by staff over 12 months. RESULTS: The results supported the hypotheses that greater intensity and longitudinal continuity of services are related to more client improvement as indicated by reduced rates of hospitalization and improved psychosocial functioning after both six and 12 months. Although clients' symptom levels increased over time, a significant relationship was noted between service intensity and continuity and better symptom outcomes after 12 months. Multiple regression analyses indicated that an average of 22 percent, and as much as 28 percent, of the change in clinical and functional outcomes after 12 months of rehabilitation was explained by the intensity and longitudinal continuity of services. CONCLUSIONS: Clients who received more contact hours with staff and who had fewer gaps in service delivery achieved greater rehabilitative improvement in social, work, and independent-living domains and had fewer days of hospitalization. Based on these findings, clinicians, administrators, and researchers can assume that the intensity and longitudinal continuity of services are important to achieving rehabilitative outcomes in some community-based psychosocial rehabilitation models.

The impact of service characteristics on functional outcomes from community support programs for persons with schizophrenia: a growth curve analysis.

A total of 172 individuals diagnosed with a schizophrenia spectrum disorder were followed for 36 months in 3 distinct models of community-based care. Functional outcome data gathered every 6 months were combined with service implementation data to test hypotheses concerning the impact of service characteristics on prospective client outcomes. The results using hierarchical linear modeling supported associations between the intensity, specificity, and longitudinality of services and improved client outcomes. Specifically, more intense services were associated with higher levels or rates of improvement on all indices of clinical and psychosocial functioning. The specificity results suggested that services needed to be targeted to specific areas of functioning in order for improvement to occur. The effect of longitudinality was contingent on the outcome domain examined.

Cross-ethnic symptom differences in schizophrenia: the influence of culture and minority status.

The two objectives of this tri-ethnic study were (1) to test competing hypotheses from the minority status and ethnic culture perspectives in examining cross-ethnic symptom differences in schizophrenia and (2) to test cultural mediators of the symptom differences. Analyses were done on samples of minority (African-American and Latino) and nonminority (white) groups. Hypothesized cross-ethnic symptom differences were tested, and indicators of sociocentricity were examined as cultural mediators of symptom differences. The sample consisted of 184 individuals (51.6% white, 32.6% African-American, 15.8% Latino, 75% male) diagnosed with schizophrenia in an outpatient, urban setting. Symptom variables were obtained from the Brief Psychiatric Rating Scale and the Quality of Life Scale. Two sociocentric indicators (empathy and social competence) were used to differentiate minority from nonminority groups. Multiple regression was used to test the mediational influence of the sociocentric indicators on the symptom differences. After controlling for social class, significant differences were found in eight symptom variables. These showed the nonminority group to be consistently more symptomatic than the ethnic minority groups, findings which supported the ethnic culture hypothesis. Sociocentric indicators were found to be significant mediators of the cross-ethnic symptom differences. This study supported the ethnic culture hypothesis, which predicted lower symptoms for the ethnic minority groups, and showed that sociocentric variables strongly mediated the more benign symptom profile for the ethnic minority groups. The study indicates that culture should be more fully integrated into current biopsychosocial models of schizophrenia.

Neuropsychological and psychophysiological correlates of psychosocial functioning in schizophrenia.

This study tested hypothesized relationships between neuropsychological and psychophysiological variables and concurrent levels of clinical and psychosocial functioning in schizophrenia. The sample consisted of 40 subjects diagnosed with a chronic schizophrenia spectrum disorder and living in community-based settings. The psychophysiological variables were tonic skin conductance (SC) level, SC reactivity to stressors, and SC response to orienting stimuli. The neuropsychological measures were the Stroop, the Controlled Word Association Test, and four subtests of the Wechsler Adult Intelligence Scale-Revised (block design, digit symbol, digit span, and arithmetic). The psychosocial variables were measures of symptomatology, independent living, work, and social functioning. The results suggested that higher symptoms were associated with higher resting arousal, lower stress reactivity, status as an electrodermal responder, and deficits in verbal fluency and visuo-motor functioning. The pattern for better social functioning was higher resting arousal, lower stress reactivity, and more responses to orienting stimuli. Higher levels of independent living were associated with better visuo-motor and verbal processing. Increased work functioning was associated with better complex visuo-spatial processing. These findings are discussed in terms of (1) the specificity of associations between psychosocial, psychophysiological, and neuropsychological variables and (2) a holistic perspective toward understanding these relationships and their relevance to rehabilitation in schizophrenia.

Effects of parental involvement on the functioning of noninstitutionalized adults with schizophrenia.

OBJECTIVES: The study described the nature and extent of parental families' involvement with adult children with schizophrenia who lived in noninstitutional settings in the community and examined the association between families' involvement and the adult children's clinical and psychosocial functioning. METHODS: A total of 193 subjects with schizophrenia were interviewed to obtain data on their contact with their families, clinical and psychosocial functioning, risk of victimization and substance use, and global functioning. RESULTS: Twenty-three percent of the subjects lived with their parental families on some time during the previous six months. Nearly two-thirds of those who did not live with their families had contact with them an average of twice a week. Subjects who did not live with their families scored significantly higher on global functioning and on measures of contact with friends, dating, number of days worked, independence from family, and stability of living situation. Those who lived with their families were less likely to have been victimized or to have used substances. Among subjects who did not live with their families, those who maintained contact scored higher than those without contact on measures of days worked and overall role functioning. CONCLUSIONS: The nature of parental families' involvement with adult children with schizophrenia varied widely. Whether families' involvement was associated with higher levels of functioning varied with the subjects' living situation.

Cognitive and psychophysiological correlates of positive, negative, and disorganized symptoms in the schizophrenia spectrum.

This study examined the cross-sectional and prospective relationships between cognitive and psychophysiological variables and positive, negative, and disorganized symptoms in 40 outpatients with diagnoses of schizophrenia or schizoaffective disorder. The results indicated that disorganized symptoms were related to deficits in auditory and visuomotor attentional processing, increased skin conductance orienting response, and lower stress reactivity. Negative symptoms were related to reduced resting heart rate, increased stress reactivity, and deficits in visuomotor processing. Prospective findings indicated that both the cognitive and heart-rate variables might be trait-related aspects of the negative symptoms, while the skin conductance, but not the cognitive, variables might be trait-related aspects of the disorganized symptoms. Positive symptoms were not related to any of the cognitive or psychophysiological variables.

A latent structure analysis of the positive and negative symptoms in schizophrenia.

Although previous studies have suggested the inadequacy of the two-factor models of positive and negative symptoms in schizophrenia, confirmatory testing of the putative three-factor models is needed. Using a sample of 193 individuals diagnosed with schizophrenia, this study tested the relative goodness-of-fit of one-, two-, and three-factor models of the positive and negative symptoms. Using confirmatory factor analysis (CFA), the three-factor model of Addington et al., Arndt et al., and Liddle and Barnes that specifies positive, negative, and disorganized factors had the best fit with the data. Allowing the factors to co-vary and specifying dimensionality to the negative symptoms substantially improved the fit of the model. The study addressed several other issues. First, whereas the correlation between positive and negative symptoms was modest, the disorganized symptoms were significantly and more strongly related to both the positive and negative symptoms. Second, depression was not correlated with negative symptoms, but was significantly related to both the positive and disorganized symptoms. Third, the relationships between the three factors and levels of global, social, and work functioning in the sample supported the criterion-related validity of the three-factor model.

Factors related to integrating persons with chronic mental illness into a peer social milieu.

Client characteristics and their perceptions of the milieu in a psychosocial rehabilitation program were used to predict the clients' level of involvement in the peer-based social network. 81 clients in a psychosocial rehabilitation program participated in the study. The results indicated that client perceptions of higher support and clarity in the staff-client milieu, and being female, were strongly related to higher peer social involvement. Milieu factors were generally more important than client characteristics in predicting client social functioning. The implications of these findings for psychosocial intervention and for research on the social functioning of this population are discussed.

Psychosocial functioning and subjective experience in schizophrenia.

This study examines the relationship between psychosocial functioning and subjective experience in 193 individuals diagnosed with schizophrenia or schizoaffective disorder according to Research Diagnostic Criteria. Psychosocial functioning was measured as work functioning, social functioning, living situation, symptomatology, and intrapsychic aspects of the deficit syndrome. Subjective experience consisted of measures of self-esteem, satisfaction with life, and subjective distress. Multivariate analyses resulted in two major findings. The first finding is a model of psychosocial functioning that consists of two factors: disorder-related variables (symptomatology and intrapsychic deficits) and functional status variables (work, social, and living situation). The second major finding is a two-tiered model of the relationship between psychosocial functioning and subjective experience. The model suggests a primary and pervasive relationship between the disorder-related variables and subjective experience and a secondary and less pronounced relationship between functional status variables and subjective experience. The implications of these findings for treatment and rehabilitation and for the study of subjective experience in schizophrenia are discussed.

A model for measuring the implementation of community support programs: results from three sites.

We present and test a model for measuring the implementation of Community Support Programs (CSPs) for persons with severe mental illnesses. The model is intended to facilitate the description and replication of these programs and the future study of their critical ingredients. The model defines important implementation variables in seven areas of program functioning; we then suggest instruments to measure each of these variables. Results of a study examining the application of the model and measures to three conceptually distinct CSPs illustrate the utility of the model and measures for implementation analysis of CSPs. Importantly, findings revealed that a priori hypotheses about how the programs were expected to differ on the implementation variables were largely supported.

An examination of the relationships among three outcome scales in schizophrenia.

The functioning of 94 schizophrenic subjects was rated using the Global Assessment Scale, the Strauss and Carpenter Outcome Scale, and the Role Functioning Scale. The convergent validity among the scales was quite modest and highly variable. Solid empirical convergence only occurred when two of the scales each measured social and vocational dimensions of functioning. It is argued that these findings strongly illustrate the need for conceptual and operational consensus in this area. The findings also support the notion of outcome in schizophrenia as a set of distinct, yet linked, dimensions. Other implications of the findings for the definition and measurement of outcome in schizophrenia when using global and multidimensional scales are discussed.

A controlled comparison of involuntarily hospitalized medication refusers and acceptors.

Involuntarily hospitalized psychiatric patients consecutively admitted over a six-month period who successfully refused medication (n = 37) are compared with a randomly selected group of medication-accepting patients committed during the same time period (n = 37). The overall refusal rate was 15.6 percent during the study period. Acceptors and refusers did not differ on age, sex, diagnosis, ethnicity, marital status, or preadmission living status. Differences between the groups indicate that refusers are sicker and lower functioning, are more behaviorally acute on the ward, and stay in the hospital twice as long as acceptors. Refusers also have a significantly negative impact on the overall ward milieu. The impact of institutional factors on the rate and outcome from mediation refusal are discussed.

The Client Interaction Scale. A method for assessing community support programs for persons with chronic mental illness.

The Client Interaction Scale (CIS) is a brief assessment tool for measuring client integration into the client-to-client interactive milieu in Community Support Programs (CSPs) for persons with chronic mental illness. Using a sample of 95 clients from three different CSPs, the scale shows excellent inter-item reliability. A factor analysis indicates that it measures the clients' level of integration on unique affective and instrumental dimensions. The scale also discriminates among environments known to differ on their interactive qualities. Its application to the evaluation of CSPs and other program environments is discussed.

Monitoring program implementation in community mental health settings.

Evaluations that monitor program implementation provide an empirical description of a program's services, the population served, and a method for assessing whether the program as delivered matches the conceptual model on which it is based. This article presents the Daily Contact Log (DCL), an instrument that has been used to monitor the longitudinal form and content of services delivered in several community mental health care programs for persons with chronic mental illness. The instrument is described and directions for its use are detailed. The psychometric properties of the instrument are discussed, as is its evolution in multisite applications in various mental health care settings. The usefulness of the DCL for programmatic and research purposes is outlined, as are some secondary benefits to staff who use the instrument. While the viability and versatility of the DCL as an instrument for measuring important aspects of program implementation are stressed, its appropriateness for quality assurance analyses is also suggested.