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What accounts for poor functioning in people with schizophrenia: a re-evaluation of the contributions of neurocognitive v. attitudinal and motivational factors

Published online by Cambridge University Press:  04 March 2018

Aaron T. Beck ,
Robyn Himelstein ,
Keith Bredemeier ,
Steven M. Silverstein  and
Paul Grant
Aaron T. Beck
Affiliation:
Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Robyn Himelstein
Affiliation:
Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Keith Bredemeier
Affiliation:
Center for Assessment Research and Translation, University of Delaware, Newark, Delaware, USA
Steven M. Silverstein
Affiliation:
Department of Psychiatry, Rutgers – Robert Wood Johnson Medical School, Piscataway Township, New Jersey, USA
Paul Grant*
Affiliation:
Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
*
Author for correspondence: Paul Grant, E-mail: pgrant@mail.med.upenn.edu
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Abstract

Background

Neurocognitive deficits are often seen as core features of schizophrenia, and as primary determinants of poor functioning. Yet, our clinical observations suggest that individuals who score within the impaired range on standardized tests can reliably perform better in complex real-world situations, especially when performance is embedded within a positive socio-affective context.

Methods

We analyzed literature on the influence of non-neurocognitive factors on test performance in order to clarify their contributions.

Results

We identified seven non-neurocognitive factors that significantly contribute to neurocognitive test performance: avolition, dysfunctional attitudes, effort, stress, negative emotions, asociality, and disorganized symptoms. We then proposed an alternative model based on dysfunctional (e.g. defeatist) attitudes and their consequences for motivation and sustained task engagement. We demonstrated that these factors account for substantial variance in negative symptoms, neurocognitive test performance, and functional outcomes. We then demonstrated that recovery-oriented cognitive therapy – which is derived from this alternative model and primarily targets dysfunctional beliefs – has been successful in the treatment of low functioning individuals with schizophrenia.

Conclusion

The contributions of neurocognitive impairments to poor real-world functioning in people with schizophrenia may be overstated in the literature, and may even be limited relative to non-neurocognitive factors. We offer suggestions for further research to more precisely quantify the contributions of attitudinal/motivation v. neurocognitive factors in schizophrenia.

Type
Original Articles
Information
Psychological Medicine , Volume 48 , Issue 16 , December 2018 , pp. 2776 - 2785
Copyright
Copyright © Cambridge University Press 2018 

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