Cognitive remediation Flashcards
What is a cost-effective psychological treatment?
In which the cost of the therapist’s time is outweighed by the benefits (e.g. time in hospital, QoL)
What are the three psychological treatment that have a long history of development and evidence collection?
- Cognitive behaviour therapy (CBT)
- Family therapy
- Social skills training
Why was family therapy developed?
- Individuals returning to their family had higher relapse rate
- Higher stress produced by expressed emotion
What is the aim of family therapy?
- For the family and the Individual to understand the nature and symptoms of psychosis (e.g. apathy)
- Negotiate a new relationship
- > Reducing interpersonal stress and decreasing the risk of relapse
Why was social skills training developed?
Individuals removed from large hospitals and then back into the community lacked social skills
What is the aim of social skills training?
Teach individuals how to:
- recognise expressions
- initiate conversations
- respond appropriately
What is the aim of CBT?
Explore the beliefs of patients and come to a resolution so these beliefs do not interfere with personal goals
What does the evidence on the efficacy of CBT for psychosis suggest?
Very strong evidence
- particularly for those with chronic disorders
- delusional conviction is reduced
- relapse is reduced
Why was cognitive remediation developed?
As a response to cognitive problems, notably in psychosis
What did Emil Kraepelin and Eugen Bleuler think about cognition and psychosis?
Individuals with psychosis have cognitive difficulties
- but no knowledge if problems worsen over time
What does the literature suggest on cognition and psychosis?
People suffering from schizophrenia have cognitive problems in many domains
- verbal memory
- visual memory
- executive functions
- attention / processing speed
- language
- sensory motor
- general verbal ability
- visual processing
In early stages, Individuals experiencing psychotic illness are aware of changes in their cognition
Is there a difference in the severity of cognitive problems in the early stages of psychotic illness and in chronic schizophrenia (McCleery et al., 2014)?
- Little change in cognition over time
- Little difference between those who were tested on various cognition domains at early stage (first episode) and those with chronic schizophrenia
What does newer evidence suggest about cognitive difficulties in children that are going to develop psychosis?
- Cognitive development 6-18 months behind typical development between age 8 to 21
- Higher symptom severity related to more cognitive impact
- Children who later develop psychosis demonstrate significant cognitive impairments from 3 years old
- Those who go on to develop psychosis show severe cognitive difficulties years prior to acute episode, to a point of cognitive deficit
(1 standard deviation below average)
In longitudinal studies, why is it important to collect the data before the appearance of psychotic symptoms and before pharmacological treatment?
Psychotic symptoms and medication may affect cognition
-> confounding factors
How is cognition related to the costs of care (Patel et al., 2006; Wykes et al. 2003)?
Cognitive problems predict the cost of care
- cognitive impairments -> use more residential / inpatient services
= higher costs - Severity of cognitive difficulties predicts cost of health and social care
What did the study of Goldberg and colleagues (1987) reveal about cognitive training?
Wisconsin Card Sorting Task
- without support individuals went back to poor performance
- > this study produced an industry of studies for different types of training, some showing improvements even after end of training
- > Therapeutic optimism -> Cognitive remediation
What do people with psychosis want (Rethink, 2009)?
- Work
- Social skills
- Life skills
- Independence
- > functional outcomes
How does cognition play a part in work (Bell and Bryson, 2001)?
Rehabilitation programme at Yale, for a year
- aimed to get people into paid employment
- > improved cognitive variables: memory, attention, flexibility, learning
How does cognition play a part in social skills (Smith et al., 2002)?
- Social behaviour during recovery
- 1 year follow-up after inpatient treatment
- Individuals with poor working memory recover less in social functioning
- > Maximise recovery by incorporating cognitive skills (e.g. memory) as targets for improvement in rehabilitation programmes
What is working memory important for?
- Holding complex social cues
- Integrating various information in order to select appropriate social responses
How does cognition play a part in life skills (Velligan et al., 1997)?
Cognition play a part in cooking, catching the bus, paying bills
- cognitive problems limit the amount that individuals learnt from a rehabilitation programme
How does cognition play a part in independence (Wykes et al., 1992)?
Effects of good rehabilitation programme following closure of Netherne hospital:
- level of independence achieved depended on specific aspects of cognition, particularly mental flexibility
- psychotic symptoms accounted less than cognition for the variance in outcome
- ability to benefit from good recovery programmes depend a lot on cognition
What does cognitive remediation therapy (CRT) consist of?
- Helping someone achieve functional, recovery-based goals
- Teaching individuals how to make use of their personal strengths, how to develop new cognitive skills and strategies to improve performance
What is the role of the therapist in cognitive rumination therapy (CRT)?
- Ensures the learning is personalised and motivating
- That the clients have the opportunities to transfer and practice new skills in everyday life
What is the role of learning principles in cognitive remediation therapy (CRT)?
Learning principles:
- underlie cognitive remediation
- provide optimal learning environment
- particularly effective for learners with psychosis
What are the learning principles in cognitive remediation therapy (CRT)?
- Massed practice
- Errorless learning
- Verbal monitoring
- Scaffolding
- Using strategies
What is the learning principle of massed practice?
- Tasks repeated
- Difficulty gradually increases
- Develop cognitive skills that become automatic
- Learn broad principles applicable to numerous situations
What is the principle of errorless learning?
- Ensure that individuals do not learn errors
- Correct performance is clear
- Keep the learning accurate
- Keep reinforcement and motivation high
What is the learning principle of verbal monitoring?
Remember tasks instructions by encouraging individuals to overly and eventually internally verbalise them
What is the learning principle of scaffolding?
- Learning support so tasks are manageable but challenging
- Learning support is gradually withdrawn and people learn to self-scaffold
What is the learning principle of using strategies?
Teaching people how to improve task performance through the use of strategies
(e.g. visualise, rehearse)
What is the effectiveness of cognitive remediation therapy (CRT) (Wykes et al., 2011)?
Meta-analysis: lots of different types of cognitive remediation, using pencil and paper or computer
- overall, cognitive remediation improved cognition (ES: 0.45)
What is the effect of cognitive remediation therapy (CRT) on functioning (Wykes et all., 2011)?
CRT improves overall functioning and symptoms
What is the durability of the outcomes of cognitive remediation therapy (CRT) (Wykes et all., 2011)?
Durable changes in cognition and functioning
What is required of cognitive remediation programmes so they have a significant functional effect (Wykes et al., 2011)?
A strategic approach to cognitive remediation
-> must teach strategy
What is the benefit of adding rehabilitation to cognitive remediation (Wykes et al., 2011)?
Adding psychiatric rehabilitation to cognitive rehabilitation increases functional gains
To whom is cognitive remediation most beneficial (Bell et al., 2014)?
More effective for low-functioning individuals
- improves work outcome for those who are likely to fail in supported work programmes
What is the benefit of providing cognitive remediation therapy and a second course of supported employment in people who failed in a supported work programme (McGurk et al., 2015)?
These people were
- more likely to get and keep a job
- achieved higher pay
- worked more hours
What is the effect of cognitive remediation therapy (CRT) on cost outcomes (Reeder et al., 2014)?
Improved cognition changes costs of care
What are the effects of cognitive remediation therapy (CRT) on the brain (Penadés et al., 2013; Eack et al., 2010; Wykes et al., 2002)?
- Amount of cognitive improvement is related to amount of change in brain activity
- Those who received cognitive remediation had preserved grey matter compared to loss of grey matter in those who only received support
What may mediate the effect of improved cognition on improved functioning (Wykes et al., 2012)?
Model needs to take into account metacognition
What is metacognition?
“thinking about thinking”
- knowledge and beliefs about your own thinking
What is metacognitive knowledge?
Knowledge of what affects your thinking and others tinking
What is metacognitive regulation?
Ability to reflect on your thinking skills, and plan, monitor, evaluate and adjust them
What is the role of metacognition in change (Wykes and Reeder, 2005)?
Metacognition knowledge and regulation both play a role in helping people apply strategies in real life
-> change their behaviour
-> Improving metacognition might be incorporated into therapy process and then transferred into everyday life in order to achieve goals
What is the state of metacognition in people with psychosis?
They do not recognise that they have cognitive difficulties
- regulation often difficult
- they exhibit a lack of strategy use, rather than an inability to use strategies
- > if you provide them with a strategy, they will be able to remember
What is CIRCuiTS (Reeder et al., 2016)?
Computerised Interactive Remediation of Cognition and Thinking Skills
- computerised training programme based on empirical evidence on what is useful
What does CIRCuiTS consist of (Reeder et al., 2016)?
Tasks relating to 4 main cognitive domains:
- executive functioning
- working memory
- long-term memory
- attention
Client learns cognitive skills in basic tasks (to aid transfer)
What is the role of metacognition in the effect of cognitive remediation on functioning?
Metacognition has an effect on how cognitive improvements are used in everyday life
What are other important factors, besides metacognition, in the effect of cognition on functioning?
Motivation and age
