Improving the Methodology for Assessing Cognitive Impairment in People with Schizophrenia Spectrum Disorders

Cognitive dysfunctions in patients with schizophrenia disorders are common, have prognostic value, informs treatment planning and rehabilitation, and provide a basis for targeted cognitive remediation. Consequently, current Norwegian guidelines recommend that neuropsychological assessments should be conducted as soon as possible for all patients with psychotic symptoms. This recommendation warrants a neuropsychological method that can be used to assess large numbers of patients having a broad spectrum of cognitive functioning, which is efficient and cost effective without compromising the quality of the assessment, and that is not too taxing for the most severely afflicted patients. A method that meets these criteria is the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), primarily developed to detect and track cognitive decline over time in elderly people, and to identify neuropsychological deficits in acute care and rehabilitation settings. The main aim of this thesis is to examine the applicability and quality of the Norwegian version of the RBANS in assessing cognitive impairment in Norwegian young adults with schizophrenia spectrum disorders. The first paper investigated how different normative systems influenced the accuracy of identifying cognitive impairment in 315 Norwegian younger adults with a schizophrenia spectrum diagnosis. Applying U.S. normative data resulted in underestimation of cognitive impairment in one out of five patients compared to applying Scandinavian normative data. Patients with comorbid substance abuse disorders did not differ in overall test performance compared to those not abusing substances regardless of normative systems applied. There were significant effects of gender, educational levels, and intelligence on test performance for both normative systems. In the second paper, RBANS clinical normative tables for Norwegian patients with schizophrenia spectrum disorders were constructed, using a patient sample of 335 participants. Normative tables were stratified by educational attainment, by intelligence levels, and by gender. Normative tables were not stratified by substance abuse, as there were no significant differences between these patients’ test scores compared to those not abusing substances. The Norwegian clinical normative data did not differ from previous clinical norms derived from comparable patient groups in the U.S. and Canada. Tables of base rates of low scores on the RBANS indices were constructed, which facilitates interpretation of all five RBANS index scores simultaneously and can improve clinical judgement of patients’ cognitive impairment. The third paper investigated possible relationships between patients’ self-report of motivational and effort problems with several RBANS embedded performance validity tests (PVTs). Decreased motivation and interest are common symptoms in schizophrenia spectrum disorders and might adversely affect test performance. Thus, indicators of invalid test performance may correspond to symptoms of the disorder and not to purposeful underperformance. Of 250 patients, 51% reported severe problems with initiation, as measured with the self-report version of the Behavior Rating Inventory of Executive Function–Adult Version (BRIEF–A) Initiate Scale, compared to 6–28% having PVT scores indicating invalid RBANS test performance. However, RBANS PVTs did not explain a significant amount of variance in self-reported initiation problems but had moderate to high correlations with measures of cognitive impairment. Thus, the RBANS PVTs are probably not good indicators of avolition and likely reflects degree of cognitive impairment in this patient group. In sum, the findings from this thesis suggest that the Norwegian version of the RBANS is robust to effects of patients’ self-reported motivational problems on test performance, and reliably assesses cognitive impairment and functions in younger Norwegian patients with schizophrenia spectrum disorders. The clinical normative data and base rates of low RBANS Index scores for Norwegian patients with schizophrenia disorders facilitate clinicians’ judgment of patients’ cognitive functions, enhancing the RBANS’ clinical utility in assessing cognitive impairment in schizophrenia spectrum disorders.Doktorgradsavhandlin

Norms matter: U.S. normative data under-estimate cognitive deficits in Norwegians with schizophrenia spectrum disorders

Objective: To illustrate and quantify how using different normative systems influences the accuracy of identifying cognitive impairment in people with schizophrenia spectrum disorders. Participants and methods: A convenience sample of 315 patients between 18 and 38 years of age referred for neuropsychological assessment at a psychiatric inpatient hospital in Bergen, Norway, was included. All completed the Norwegian version of the Repeatable Battery for the Assessment of Neuropsy-chological Status (RBANS). Results: There were statistically significant differences between the Immediate Memory, Visuospatial/Constructional, Language, Delayed Memory, and Total Scale Index scores when comparing the U.S. normative scores with the Scandinavian normative scores. The effect sizes were medium. The patient samples scored higher when using the U.S. normative data, suggesting less cognitive impairment. Conclusions: United States normative data yielded less impaired scores for Norwegians with schizophrenia spectrum disorders. The implications of using U.S. versus Scandinavian normative data are discussed.acceptedVersio

Improving the Methodology for Assessing Cognitive Impairment in People with Schizophrenia Spectrum Disorders

Cognitive dysfunctions in patients with schizophrenia disorders are common, have prognostic value, informs treatment planning and rehabilitation, and provide a basis for targeted cognitive remediation. Consequently, current Norwegian guidelines recommend that neuropsychological assessments should be conducted as soon as possible for all patients with psychotic symptoms. This recommendation warrants a neuropsychological method that can be used to assess large numbers of patients having a broad spectrum of cognitive functioning, which is efficient and cost effective without compromising the quality of the assessment, and that is not too taxing for the most severely afflicted patients. A method that meets these criteria is the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), primarily developed to detect and track cognitive decline over time in elderly people, and to identify neuropsychological deficits in acute care and rehabilitation settings. The main aim of this thesis is to examine the applicability and quality of the Norwegian version of the RBANS in assessing cognitive impairment in Norwegian young adults with schizophrenia spectrum disorders. The first paper investigated how different normative systems influenced the accuracy of identifying cognitive impairment in 315 Norwegian younger adults with a schizophrenia spectrum diagnosis. Applying U.S. normative data resulted in underestimation of cognitive impairment in one out of five patients compared to applying Scandinavian normative data. Patients with comorbid substance abuse disorders did not differ in overall test performance compared to those not abusing substances regardless of normative systems applied. There were significant effects of gender, educational levels, and intelligence on test performance for both normative systems. In the second paper, RBANS clinical normative tables for Norwegian patients with schizophrenia spectrum disorders were constructed, using a patient sample of 335 participants. Normative tables were stratified by educational attainment, by intelligence levels, and by gender. Normative tables were not stratified by substance abuse, as there were no significant differences between these patients’ test scores compared to those not abusing substances. The Norwegian clinical normative data did not differ from previous clinical norms derived from comparable patient groups in the U.S. and Canada. Tables of base rates of low scores on the RBANS indices were constructed, which facilitates interpretation of all five RBANS index scores simultaneously and can improve clinical judgement of patients’ cognitive impairment. The third paper investigated possible relationships between patients’ self-report of motivational and effort problems with several RBANS embedded performance validity tests (PVTs). Decreased motivation and interest are common symptoms in schizophrenia spectrum disorders and might adversely affect test performance. Thus, indicators of invalid test performance may correspond to symptoms of the disorder and not to purposeful underperformance. Of 250 patients, 51% reported severe problems with initiation, as measured with the self-report version of the Behavior Rating Inventory of Executive Function–Adult Version (BRIEF–A) Initiate Scale, compared to 6–28% having PVT scores indicating invalid RBANS test performance. However, RBANS PVTs did not explain a significant amount of variance in self-reported initiation problems but had moderate to high correlations with measures of cognitive impairment. Thus, the RBANS PVTs are probably not good indicators of avolition and likely reflects degree of cognitive impairment in this patient group. In sum, the findings from this thesis suggest that the Norwegian version of the RBANS is robust to effects of patients’ self-reported motivational problems on test performance, and reliably assesses cognitive impairment and functions in younger Norwegian patients with schizophrenia spectrum disorders. The clinical normative data and base rates of low RBANS Index scores for Norwegian patients with schizophrenia disorders facilitate clinicians’ judgment of patients’ cognitive functions, enhancing the RBANS’ clinical utility in assessing cognitive impairment in schizophrenia spectrum disorders

Rubrikkvurdering av klinisk praksis for profesjonsstudenter i psykologi

Prosjektet tar utgangspunkt i rubrikkvurdering som metode for å oppnå to hovedmål: 1) gjøre studentene i stand til å vite mer nøyaktig hva de må gjøre for å oppnå læringsmålene for kurset, og 2) gi veileder et bedre verktøy for å kunne vurdere om læringsmålene for kurset ble nådd. Metoden ble anvendt på et kurs som har 25 læringsmål. Tre sentrale læringsmål ble valgt og krav for å oppnå Noe kompetanse, God kompetanse og Høy kompetanse i de ulike læringsmålene ble definert. For å øke involvering, øke dybdeforståelsen læringsmålene, og øke forståelse for hva studentene konkret blir målt opp mot, ble studentene involvert i å definere hva de tre kategoriene skulle inneholde første dag av kurset. Til en viss grad ville ikke eller kunne ikke studentene godta at de selv var i stand til å ha en mening om hva som skulle kjennetegne de tre kompetansenivåene (noe kompetanse, god kompetanse og høy kompetanse) innenfor de læringsmålene som var satt opp. Den tilsiktede involvering av studentene fungerte derfor bare delvis. Metoden ga likevel nyttig informasjon om studentenes kompetansenivå. Denne informasjonen gjorde det mulig å bedre tilpasse undervisningen til et nivå som var mer i overensstemmelse med studentenes faktiske kompetanse ved kursstart

Norms matter: U.S. normative data under-estimate cognitive deficits in Norwegians with schizophrenia spectrum disorders

Objective: To illustrate and quantify how using different normative systems influences the accuracy of identifying cognitive impairment in people with schizophrenia spectrum disorders. Participants and methods: A convenience sample of 315 patients between 18 and 38 years of age referred for neuropsychological assessment at a psychiatric inpatient hospital in Bergen, Norway, was included. All completed the Norwegian version of the Repeatable Battery for the Assessment of Neuropsy-chological Status (RBANS). Results: There were statistically significant differences between the Immediate Memory, Visuospatial/Constructional, Language, Delayed Memory, and Total Scale Index scores when comparing the U.S. normative scores with the Scandinavian normative scores. The effect sizes were medium. The patient samples scored higher when using the U.S. normative data, suggesting less cognitive impairment. Conclusions: United States normative data yielded less impaired scores for Norwegians with schizophrenia spectrum disorders. The implications of using U.S. versus Scandinavian normative data are discussed

The importance of clinical normative data for conceptualizing neuropsychological deficits in people with schizophrenia spectrum disorders

Objective: To create clinical normative data tables for Norwegian patients with schizophrenia spectrum disorders, to examine whether clinical normative data from Norway differs from similar normative data from Canada and the U.S., and to illustrate the usefulness of such data. Method: A nationally representative sample of 335 patients from psychiatric hospitals in Bergen, Norway was included. Inclusion criteria were 18–39 years of age, Norwegian as first language, and symptoms of schizophrenia, psychosis, or hallucinations. Comorbid substance abuse was recorded in 134 (40.0%). All completed the Norwegian version of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Results: The average scores of patients with schizophrenia spectrum disorders were approximately one to two standard deviations below the mean for healthy adults. There were no significant differences in scores between patients with or without comorbid substance abuse. Men had higher scores than women. Clinical normative reference value look-up tables were created. Conclusions: Clinical normative values were very similar to values from Canada and the U.S. Clinical normative data, as a supplement to standard healthy normative data, can be used to describe patients’ cognitive performance in terms of expectation for their peer group which can be useful for multidisciplinary treatment planning

The importance of clinical normative data for conceptualizing neuropsychological deficits in people with schizophrenia spectrum disorders

Objective: To create clinical normative data tables for Norwegian patients with schizophrenia spectrum disorders, to examine whether clinical normative data from Norway differs from similar normative data from Canada and the U.S., and to illustrate the usefulness of such data. Method: A nationally representative sample of 335 patients from psychiatric hospitals in Bergen, Norway was included. Inclusion criteria were 18–39 years of age, Norwegian as first language, and symptoms of schizophrenia, psychosis, or hallucinations. Comorbid substance abuse was recorded in 134 (40.0%). All completed the Norwegian version of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Results: The average scores of patients with schizophrenia spectrum disorders were approximately one to two standard deviations below the mean for healthy adults. There were no significant differences in scores between patients with or without comorbid substance abuse. Men had higher scores than women. Clinical normative reference value look-up tables were created. Conclusions: Clinical normative values were very similar to values from Canada and the U.S. Clinical normative data, as a supplement to standard healthy normative data, can be used to describe patients’ cognitive performance in terms of expectation for their peer group which can be useful for multidisciplinary treatment planning

Examining the repeatable battery for the assessment of neuropsychological status validity indices in people with schizophrenia spectrum disorders

Objective: We examined the frequency of possible invalid test scores on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in patients with schizophrenia spectrum disorders, and whether there was an association between scores on the embedded RBANS performance validity tests (PVTs) and self-reported symptoms of apathy as measured by the Initiate Scale of the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A). Methods: Participants included 250 patients (M = 24.4 years-old, SD = 5.7) with schizophrenia spectrum disorders. Base rates of RBANS Effort Index (EI), Effort Scale (ES), and Performance Validity Index (PVI) test scores were computed. Spearman correlations were used to examine the associations between the RBANS PVTs, the RBANS Index scores, and the BRIEF-A Initiate Scale. Regression analyses were used to investigate how well the RBANS PVTs predicted scores on the BRIEF-A Initiate Scale. Results: The frequency of invalid scores on the EI (>3) and the PVI (<42) in participants with schizophrenia spectrum disorders was 6%. The frequency of invalid ES scores (<12) was 28% in the patients compared to 15% in the U.S. standardization sample. There was a small significant correlation between the EI and the BRIEF-A Initiate Scale (rho=.158, p<.05). Conclusions: The rates of invalid scores were similar to previously published studies. Invalid scores on the BRIEF-A were uncommon. Apathy measured with the BRIEF-A Initiate Scale was not associated with performance on the RBANS validity measures or with measures of cognition

Nonsocial cognitive underpinnings of theory of mind in schizophrenia

Social cognition is a mediator between nonsocial cognition and functional outcome in schizophrenia. However, the relationship between specific nonsocial cognitive and social cognitive domains is less clear. The aim of this study was to investigate which specific nonsocial cognitive domains best predict theory of mind (ToM) performance in schizophrenia. We indexed ToM by a composite score of the video-based Movie for the Assessment of Social Cognition test (MASCtot) in a sample of 91 individuals with schizophrenia. Nonsocial cognition was measured with the nonsocial cognitive subtests of the MATRICS Consensus Cognitive Battery (MCCB) and the Wechsler Abbreviated Scale of Intelligence (WASI IQ). Bivariate and multiple regression analyses were applied. We found statistically significant bivariate associations between MASCtot and five nonsocial cognitive tests, measuring intelligence, speed of processing, verbal or visual memory, and non-verbal working memory. Together, they accounted for 17% of the variation in MASCtot, but none of the five tests made significant unique contributions to MASCtot in the regression analysis. Our results confirm that nonsocial cognition and ToM are associated, albeit distinct, constructs. The findings suggest that cognitive remediation must include social cognitive targets in order to achieve improved ToM and better functioning

β-Amyloid may accumulate in the human brain after focal bacterial infection: a 18F-flutemetamol positron emission tomography study

Background and purpose β‐Amyloid formation has been suggested to form part of the brain's response to bacterial infection. This hypothesis has been based on experimental animal studies and autopsy studies in humans. We asked if β‐amyloid accumulates locally around a bacterial brain abscess in living human patients. Furthermore, because brain abscess patients may suffer from chronic cognitive symptoms after abscess treatment, we also asked if a brain abscess precipitates accumulation of β‐amyloid in the neocortex in a manner that could explain abscess‐related cognitive complaints. Methods In a prospective study, we investigated 17 brain abscess patients (age 24–72 years) with 18F‐flutemetamol positron emission tomography on one occasion 1 to 10 months after brain abscess treatment to visualize β‐amyloid accumulation. Results 18F‐flutemetamol uptake was reduced in the edematous brain tissue that surrounded the abscess remains. On this background of reduced 18F‐flutemetamol signal, three out of 17 patients showed a distinctly increased 18F‐flutemetamol uptake in the tissue immediately surrounding the abscess remains, suggesting accumulation of β‐amyloid. These three patients underwent 18F‐flutemetamol positron emission tomography significantly earlier after neurosurgical treatment (p = 0.042), and they had larger abscesses (p = 0.027) than the rest of the patients. All 17 patients suffered from mental fatigue or some subjective cognitive symptom, such as attention difficulties or memory problems, but in none of the patients was there an increase in neocortical 18F‐flutemetamol signal. Conclusions β‐Amyloid may accumulate locally around the abscess remains in some patients with a brain abscess