Wesleyan University
The Honors College
Neurocognitive and Social Cognitive Predictors of
Change in Objective versus Subjective Quality of Life
Measures in Response to Rehabilitation in Schizophrenia
by
Melanie Bronfeld
Class of 2012
A thesis submitted to the
faculty of Wesleyan University
in partial fulfillment of the requirements for the
Degree of Bachelor of Arts
with Departmental Honors in Psychology
Middletown, Connecticut
April, 2012
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2. Methods
2.1. Design
All procedures met with institutional review board approval. Patients who
participated in the study signed written, informed consent forms prior to beginning
testing. Cognitive remediation was provided to participants coupled with other
rehabilitation programs. All participants were randomly assigned to one of two
groups: cognitive remediation or computer-skills training. The cognitive remediation
procedures consisted of an extensive (100 hour target) program of computer-assisted
exercises, which were ordered hierarchically based on task difficulty. Sessions were
held three times per week, for 30-45 minutes each and focused on sustained visual
and auditory attention, response inhibition, shifting attention, working memory,
semantic processing, verbal recall, and speed of language processing (Kurtz et al.,
2009). For the purpose of the current study the data was collapsed across the two
computer training groups, but their potential effects were controlled for in the data
analysis. In addition to cognitive remediation, participants attended bi-weekly social
skills training groups. These groups targeted the improvement of personal interactions
with others by using role-play scenarios to act out real life situations. Patients also
typically participated in other rehabilitative interventions including vocational
counseling, psychoeducation, groups focused on goal setting and goal attainment and
exercise.
!
2P!
2.2. Participants
Forty-four outpatients diagnosed with schizophrenia or schizoaffective
disorder based on the DSM-IV (APA, 1994) criteria as determined by the Structured
Clinical Interview for DSM-IV (SCID, First et al., 1995) participated. Exclusion
criteria included evidence of mental retardation as indicated by a history of services,
lack of fluency in English, presence or history of neurological illness, traumatic brain
injury with sustained loss of consciousness, and/or current substance abuse or
dependence (Kurtz et al., 2009). Researchers administered a battery of neurocognitive
and psychosocial functioning tests at study entry. The patients in the study were
recruited from two mental health clinics in the greater Hartford area. The majority of
the patients (n=42) were enrolled in an intensive outpatient program at The Institute
of Living, Hartford Hospital’s Mental Health Network (IOL) in Hartford, CT, while
two patients attended community health centers in East Hartford, CT. Participants
were assessed 6-12 months after program entry at the termination of their computer
training. Demographic and clinical characteristics of the sample are presented in
Table 1.
2.3. Neurocognitive measures
Since the current study focused on predictors of objective and subjective
measures of outcome, performance on neurocognitive measures at baseline were
selected for analysis. Measures of neurocognitive function were chosen based on their
validity, reliability, and relationship to social cognitive outcome measures as reported
in the literature (Nuechterlein et al., 2008).
!
2G!
2.3.1. Penn Conditional Exclusion Test (PCET; Kurtz et al., 2004a,b)
The PCET is a computerized measure of executive functioning, mainly
targeting problem solving (Fig.1). Evidence from several other studies shows
construct validity in samples of both healthy controls (Kurtz et al., 2004a) and
patients with schizophrenia (Kurtz et al., 2004b). The task requires participants to
choose one of four items that is different from the others based on one of three sorting
categories, including line thickness, shape, size, location, etc. (Kurtz et al., 2004b).
Participants are given immediate feedback via a screen reading “correct” or
“incorrect” for 500ms and then must infer the sorting rule (Kurtz et al., 2004a). After
10 consecutive “corrects” the sorting category shifts.
Fig. 1. Illustration of forms 1 and 2 from the PCET. The
highlighted items are the objects that do not belong with the other three.
2.3.2. Penn Continuous Performance Test (PCPT; Kurtz et al., 2001)
The PCPT is a computerized test that measures sustained visual attention.
Evidence from Kurtz et al. (2001) has shown high levels of internal stability and
reliability for the PCPT for healthy controls and patients with schizophrenia. In this
task, participants must respond to vertical and horizontal lines arranged to form a
digit. Patients are shown the digits 2, 4 and 5 on target trials and nonsense
configurations on distracter trials (Fig.2). The stimuli are presented at a rate of one
per second and are revealed for 300 ms each.
!
2c!
Fig. 2. Illustration of two stimuli from the PCPT. The left panel
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shows the target stimulus. The right panel shows a distracter.
2.3.3. California Verbal Learning Test-II (CVLT-II; Delis et al., 2000)
The CVLT is a list-learning task that measures verbal learning and memory.
The test consists of a list of 16 words from 4 semantic categories presented 5 times.
After each trial, participants are asked to recall as many words from the list as they
can remember. This examines trial 1 and 5 because they reflect the baseline and final
number of words each participant can remember after all 5 trials.
2.3.4. Digit Symbol Coding (DSS; Wechsler, 1997, 2008)
The Digit Symbol subtest from the Wechsler Adult Intelligence scale (WAISIII & IV; Wechsler, 1997, 2008) measures participants processing speed. Patients
must copy symbols that are paired with numbers into a blank box that is shown below
the corresponding number (Fig. 3).
Fig. 3. Illustration of a line of digit-symbol coding from the WAIS-IV.
!
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2.3.5. Letter Number Sequencing (LNSS; Wechsler, 1997, 2008)
The Letter Number Sequencing subtest from the Wechsler Adult Intelligence
scale measures working memory. Administrators present a sequence of letters and
numbers at a rate of one per second. Participants must repeat the sequence with the
numbers in numerical order, followed by the letters in alphabetical order (Fig. 4).
Fig. 4. Illustration of Letter Number Sequencing from the WAIS-IV. The item is what
is presented to the participant and the correct response is the sequence after it has
been put in numeric and alphabetical order.
2.4. Social cognitive measure
2.4.1. Penn Emotional Acuity Test (PEAT; Gur et al., 2006)
The PEAT is a computerized test that measures social recognition based on
participant’s ability to link emotions to various faces. The test consists of 10 happy,
10 sad, and 20 neutral expressions of Caucasian faces that are rated on a 7-point
Likert scale, from very sad to very happy.
2.5. Satisfaction with Life Scale (SWL; Stein & Test, 1980; Test et al., 2005)
The SWL scale provides a measure of subjective quality of life. It is a 21-item
test answered on a scale of 0 to 4 ranging from not at all to a great deal. Participants
rate each questions based on how they feel about their lives at that moment in terms
!
6B!
of their living situation, work, social relationships and psychological state. Scores
range from 0 to 72 with higher scores indicating a greater satisfaction with self.
2.6. Quality of Life Scale (QOL; Heinrichs et al., 1984)
The QOL scale is a clinician-rated test that measures objective psychosocial
functioning. It is a semi-structured interview containing 21 items with four domains
including intrapsychic foundations, interpersonal relations, instrumental role function
and common objects and activities (Fizdon et al., 2008). The rating is based on a 6point Likert scale and scores range from 0 to 126 with a higher rating meaning a
better quality of life. This study used the abbreviated seven-item version of the test
(Bilker et al., 2003), which has been correlated with scores from the complete version
with coefficients from .96 to .98 in patients with schizophrenia. Interrater reliability
was maintained throughout the study for all raters by achieving a minimum intraclass
correlation coefficient (ICC) of .70 based on four consecutive, independently rated
QOL interviews.
2.7. Symptom Assessment
The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) was
used to assess symptoms. This is an interview-based assessment that measures
symptoms on 30 items based on a 7 point Likert scale. The items were then grouped
into categories based on the Bell et al. (1993) five-factor model (Table A). The
grouping categories include, positive, negative, hostility, cognitive, and emotional
discomfort factors. In order to limit method variance in this study the cognitive
!
6"!
subscale was dropped from the analysis. Bell et al. (1993) created the five factors in
order to offer more realistic symptom data that relates better to genetic, premorbid,
functional and outcome variables. Symptom raters for the study maintained inter-rater
reliability through periodic rater training session, and all raters were trained to a
reliability of .75 ICC.
Table A
The five-component model of schizophrenia symptoms as stated in Bell et al. (1993)
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2.8. Data Analysis
The Statistical Package for the Social Sciences (SPSS 19.0) was used to
compute statistical analyses. All test measures were centered around their mean and
graphed to check for normality prior to analysis. Raw scores for each of the measures
were converted into age-corrected z-scores based on published or local normative
!
62!
data. Paired-sample t-tests were performed for the QOL scale, and the SWL scale to
assess improvement over time.
In stage 1, Pearson’s correlations were calculated between the change scores
in objective (QOL) and subjective (SWL) quality of life. This assessed whether
improvements in QOL were associated with improvements in SWL during
rehabilitation treatment. Pearson’s correlations were also calculated for each of the
neurocognitive and social cognitive variables at baseline and measures of change in
objective and subjective psychosocial functioning (QOL, SWL).
In stage 2, two regressions models were tested using the baseline
neurocognitive, social cognitive and symptom measures that were linked to change in
objective QOL or SWL from stage 1. In step 1 of this model, baseline QOL or SWL
measures were entered, along with group membership, so that the regression results
would take into account any potential differential effect of the two cognitive
rehabilitation programs. In step 2, measures of neurocognitive function linked to
QOL or SWL were entered. In step 3, a measure of social cognition, the PEAT, was
entered to the QOL regression (PEAT was omitted from SWL due to lack of
significance). This step illuminates the unique contribution of social cognition to
QOL beyond that of neurocognitive function. It also determines whether measures of
social cognition mediate the relationship between cognitive function and change in
objective QOL separate from neurocognitive function. If social cognition partially
mediates the relationship between the neurocognitive variables and QOL: (a)
measures of neurocognition would be related to QOL, (b) social cognitive function
would be related to QOL, (c) social cognition would be related to neurocognitive
!
66!
functioning, and (d) when social cognition is controlled for, the relationship between
neurocognition and QOL would be statistically reduced or fully non significant
(Barron and Kenney, 1986). In the final step of each regression, the interaction term
for the main effects of the neurocognitive variables and social cognitive variables was
entered to investigate whether social cognition moderated the relationship between
cognitive function and QOL or SWL. All analyses were computed as two-tailed and
set to an alpha level of .05.
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Table 1
Mean demographic and clinical characteristics of schizophrenia patients (n=44)
Variable
Mean (SD)
Range
Age
30.75 (11.01)
19-56
Percent Male
72.7
Education
12.23 (2.091)
8-16
Duration of Illness (years)
9.1 (9.443)
0-39
Number of hospitalizations
4.51 (4.728)
0-20
Vocabulary Scaled Score (WAIS-III, IV)
8.37 (3.871)
3-17
Percent treated with atypical antipsychotic medication
97.7
WAIS= Wechsler Adult Intelligence Scale.
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