Abnormal negative feedback processing in first episode schizophrenia: evidence from an oculomotor rule switching task

Background. Previous studies have shown that patients with schizophrenia are impaired on executive tasks, where positive and negative feedbacks are used to update task rules or switch attention. However, research to date using saccadic tasks has not revealed clear deficits in task switching in these patients. The present study used an oculomotor ‘ rule switching ’ task to investigate the use of negative feedback when switching between task rules in people with schizophrenia. Method. A total of 50 patients with first episode schizophrenia and 25 healthy controls performed a task in which the association between a centrally presented visual cue and the direction of a saccade could change from trial to trial. Rule changes were heralded by an unexpected negative feedback, indicating that the cue-response mapping had reversed. Results. Schizophrenia patients were found to make increased errors following a rule switch, but these were almost entirely the result of executing saccades away from the location at which the negative feedback had been presented on the preceding trial. This impairment in negative feedback processing was independent of IQ. Conclusions. The results not only confirm the existence of a basic deficit in stimulus–response rule switching in schizophrenia, but also suggest that this arises from aberrant processing of response outcomes, resulting in a failure to appropriately update rules. The findings are discussed in the context of neurological and pharmacological abnormalities in the conditions that may disrupt prediction error signalling in schizophrenia

Individual psychological therapy in an acute inpatient setting : service user and psychologist perspectives

Objectives The acute inpatient setting poses potential challenges to delivering one‐to‐one psychological therapy; however, there is little research on the experiences of both receiving and delivering therapies in this environment. This qualitative study aimed to explore service users’ and psychologists’ experiences of undertaking individual therapy in acute inpatient units. It focused on the relationship between service users and psychologists, what service users found helpful or unhelpful, and how psychologists attempted to overcome any challenges in delivering therapy. Design The study used a qualitative, interview‐based design. Methods Eight service users and the six psychologists they worked with were recruited from four acute inpatient wards. They participated in individual semi‐structured interviews eliciting their perspectives on the therapy. Service users’ and psychologists’ transcripts were analysed together using Braun and Clarke's (2006, Qualitative Research in Psychology, 3, 77) method of thematic analysis. Results The accounts highlighted the importance of forming a ‘human’ relationship – particularly within the context of the inpatient environment – as a basis for therapeutic work. Psychological therapy provided valued opportunities for meaning‐making. To overcome the challenges of acute mental health crisis and environmental constraints, psychologists needed to work flexibly and creatively; the therapeutic work also extended to the wider context of the inpatient unit, in efforts to promote a shared understanding of service users’ difficulties. Conclusions Therapeutic relationships between service users and clinicians need to be promoted more broadly within acute inpatient care. Psychological formulation can help both service users and ward staff in understanding crisis and working collaboratively. Practice‐based evidence is needed to demonstrate the effectiveness of adapted psychological therapy models

Feasibility and patient experiences of method of levels therapy in an acute mental health inpatient setting

This study sought to investigate the feasibility and acceptability of a flexible psychotherapeutic approach – the Method of Levels (MOL) – in an acute mental health inpatient setting. A multi methods approach was used. The feasibility of implementation was investigated by examining the referral rate and the attendance patterns of participants. The acceptability of MOL was explored using a thematic analysis of participant interviews and by recording attendance patterns of participants. Inpatient staff consistently referred patients and the majority of eligible people accepted invitations for therapy. Thematic analysis of peoples’ experiences of the therapy generated themes that described participants’ experiences of MOL in contrast to routine NHS care, having spent meaningful time with the therapist, and having gained something from the session. The referral rate and uptake of MOL therapy indicates that the resource was appropriate for the setting and acceptable to most participants. Qualitative analyses indicated that participants were comfortable with the therapists’ approach, felt understood, and there was a meaningful quality to their interaction. Participants also valued the opportunity to reflect and generate new perspectives of their difficulties. Further research is required to determine the effectiveness of the approach and its translational value beyond this pilot investigation

Impaired conscious and preserved unconscious inhibitory processing in recent onset schizophrenia

Background. Impairments in inhibitory function have been found in studies of cognition in schizophrenia. These have been linked to a failure to adequately maintain the task demands in working memory. As response inhibition is known to occur in both voluntary and involuntary processes, an important question is whether both aspects of response inhibition are specifically impaired in people with schizophrenia. Method. The subjects were 33 patients presenting with a first episode of psychosis (27 with schizophrenia and six with schizo-affective disorder) and 24 healthy controls. We administered two motor response tasks: voluntary response inhibition was indexed by the stop-signal task and involuntary response inhibition by the masked priming task. We also administered neuropsychological measures of IQ and executive function to explore their associations with response inhibition. Results. Patients with schizophrenia compared to healthy controls showed significantly increased duration of the voluntary response inhibition process, as indexed by the stop-signal reaction time (SSRT). By contrast, there were no group differences on the pattern of priming on the masked priming task, indicative of intact involuntary response inhibition. Neuropsychological measures revealed that voluntary response inhibition is not necessarily dependent on working memory. Conclusions. These data provide evidence for a specific impairment of voluntary response inhibition in schizophrenia

A new generation computerised metacognitive cognitive remediation programme for schizophrenia (CIRCuiTS): a randomised controlled trial

Background: Cognitive remediation (CR) is a psychological therapy which improves cognitive and social functioning in people with schizophrenia. It is now being implemented within routine clinical services and mechanisms of change are being explored. We designed a new generation computerised CR programme, CIRCuiTS, to enhance strategic and metacognitive processing, with an integrated focus on the transfer of cognitive skills to daily living. This large trial tested its feasibility to be delivered in therapist-led and independent sessions, and its efficacy for improved cognitive and social functioning. Methods: A two arm single blind randomised superiority trial comparing CIRCuiTS plus treatment-as-usual (TAU) with TAU alone in 93 people with a diagnosis of schizophrenia. Cognitive, social functioning and symptom outcomes were assessed at pre- and post-therapy and three months later. Results: 85% adhered to CIRCuiTS, completing a median of 28 sessions. There were significant improvements in visual memory at post-treatment (p=0.009) and follow-up (p=0.001), and a trend for improvements in executive function at post-treatment (p=0.056) in favour of the CIRCuiTS group. Community function was also differentially and significantly improved in the CIRCuiTS group at post-treatment (p=0.003) but not follow-up, and was specifically predicted by improved executive functions. Conclusions: CIRCuiTS was beneficial for improving memory and social functioning. Improved executive functioning emerges as a consistent predictor of functional gains and should be considered an important CR target to achieve functional change. A larger-scale effectiveness trial of CIRCuiTS is now indicated

Substance use and at-risk mental state for psychosis in 2102 prisoners: the case for early detection and early intervention in prison

Aim Prisoners exhibit high rates of substance use and mental health problems. In the present study, we sought to gain a detailed understanding of substance use amongst young prisoners to inform early detection and early intervention strategies in a prison setting. Methods This is a cross‐sectional study of 2102 prisoners who were screened by the London Early Detection and Prevention in Prison Team (LEAP). Data on the use of substances were collected including age of first use, recent use, duration of use and poly‐drug use. The Prodromal Questionnaire – Brief Version was used to screen for the at‐risk mental state. Results We found high rates of lifetime and recent use and low age of first use of a number of substances. We also found strong associations between substance use and screening positive for an at‐risk mental state. Logistic regression analysis confirmed that use of any drug in the last year, poly‐drug and early use, as well as heavy alcohol use, were related to an increased risk of screening positive. Conclusions Substance use in the prison population is not only widespread and heavy but is also strongly linked with a higher risk of developing mental health problems. The need for early detection and early intervention in prison is discussed

Early detection and early intervention in prison : improving outcomes and reducing prison returns

Our aim was to investigate whether early detection was feasible in prison and whether it could improve mental health outcomes in young prisoners. A secondary aim was to explore whether it can reduce returns to prison. Between 2011 and 2014, a total of 2115 young prisoners were screened, 94 (4.4%) met criteria for ultra-high risk for psychosis and were offered an intervention, 52 actually received it. Return to prison data were sought on the 52 participants, receiving a formal intervention. Of the 52 prisoners who received an intervention, 30.8% returned to custody compared to national average reconviction rates of between 45.4 and 66.5%. Our results suggest that early detection is a feasible option in a prison setting, improving mental health outcomes and reducing returns to prison. Mental health outcomes were recorded for a sub-sample of those receiving the intervention. The results indicated statistically significant improvements on measures of depression, anxiety and psychological distress

Self-report and behavioural measures of impulsivity as predictors of impulsive behaviour and psychopathology in male prisoners

Impulsivity is an important factor in adverse outcomes such as substance use, problem gambling and psychopathology. Extensive research has shown these negative outcomes are associated with both self-report and behavioural measures of impulsivity but these two measurement domains are not themselves associated. There has been limited research in prison samples. This is surprising given the high variability in impulsive behaviours that should make them ideal for investigating the convergence of impulsivity measures. Using a cross sectional design we investigated the associations of impulsivity – measured by self-report and two behavioural indices - with substance misuse and psychopathology in a sample of 72 male prisoners. We found higher self-reported impulsivity was associated with crack/cocaine use, problem gambling and a positive screen for personality disorder. Behavioural measures of impulsivity showed fewer associations with problematic behaviours; they were also not independent predictors of impulsive behaviour in multivariate analyses. These data suggest that self-reported impulsivity is a more consistent predictor of problematic behaviours than behavioural measures in a sample of people with significant levels of substance use and psychopathology. This difference could reflect relevance of self-reported measures to emotionally charged decision-making in daily life compared to more neutral behavioural measures

The Relationship Between IQ, Memory, Executive Function, and Processing Speed in Recent-Onset Psychosis: 1-Year Stability and Clinical Outcome

Studies commonly report poor performance in psychotic patients compared with controls on tasks testing a range of cognitive functions, but, because current IQ is often not matched between these groups, it is difficult to determine whether this represents a generalized deficit or specific abnormalities. Fifty-three first-episode psychosis patients and 53 healthy controls, one-to-one matched for sex, age, and full-scale current IQ, were compared on Wechsler Adult Intelligence Scale (WAIS) subtests representing indices of perceptual organization, verbal comprehension, processing speed, and working memory as well as other tests of executive function and episodic memory. The groups showed an equivalent pattern of performance on all WAIS subtests except digit symbol processing speed, on which the patients were significantly worse. Patients were also worse on measures where performance correlated with digit symbol score, namely working and verbal memory tasks. Standardized residual scores for each subtest were calculated for each patient using the difference between their actual subtest score and a predicted subtest score based on their full-scale IQ and the performance of controls. Scaled scores and residual scores were examined for relationships with clinical measures. Digit symbol–scaled score was significantly correlated with concurrent negative syndrome score at baseline, and digit symbol residual score significantly predicted residual negative symptoms at 1-year follow-up. In summary, our comparison of patients and controls precisely matched for IQ revealed that processing speed was attenuated in recent-onset schizophrenia, contributed significantly to working and episodic memory deficits, and was a prognostic factor for poor outcome at 1 year