"Thinking" symptoms may be more important than "positive" or "negative"
symptoms in determining outcomes for people with schizophrenia.

by D.J. Jaffe

The following is taken from a speech by Dr. Judith Jaeger at the AMI/NYS
Conference. NARSAD is funding her research.

Dr. Jaeger is a 'neuro-psychologist' who studies the effect of
"neuro-cognitive" deficits in individuals with schizophrenia. This is a new,
and emerging field in Sz research. Basically, we used to refer to
individuals with Sz as having two clusters of symptoms: positive
(hallucinations, psychosis, etc.) and negative (withdrawal, apathy, etc.).
While it has long been noticed that individuals with SZ also developed
problems thinking (performing simple tasks) this was historically thought to
be a side effect of the positive and negative symptoms and not a cluster of
symptoms in their own right. This is changing. These problems are described
as neurocognitive deficits.

Dr. Jaeger claims that severity of positive and negative symptoms has little
to do with whether or not an individual with schiz can function successfully
in the community. She says there is a large body of research that shows that
people with differing levels of symptoms have differing abilities to be
self-sufficient. Therefore she concludes, something other than the presence
of positive or negative symptoms has to account for why some people can live
alone, and others can't. She believes the factor is 'neuro-cognitive'
deficits: the ability to think clearly.

For many years, people have studied neurocognitive deficits in people with
brain injuries, but only recently has this research been applied to
individuals with schizophrenia. She notes that most psychiatric
rehabilitation programs focus on 'skills training' but do not focus at all on
the underlying disease which is responsible for the impairments rehab
training is trying to address. She points out that Vocational Rehab only
works for 27% of individuals with sz, and of the remaining, only 1/2-1/3 of
those who were 'successes' are working two years later. She calls Voc Rehab
a "prosthesis for the frontal lobe", meaning it may help (and is therefore
good) but does not address the core issue (the thinking problems associated
with frontal lobe damage). From this she concludes that vocational training
and/or rehab that fails to address the underlying neurocognitive deficits is
not the optimal approach.

There are four kinds of neurocognitive deficits found in people, including
those with SZ.
1. Attention deficits
2. Memory deficits
3. Executive function deficits
4. Neuromotor deficits

Dr. Jaeger has focused on Executive Function. This is defined as the ability
to 'plan, organize, sequence, modulate (start/stop)' activities. It is the
Executive Function which is most often impaired in individuals with SZ. In
order to test her hypothesis, that problems in executive function are more
important than positive or negative symptoms in determining how well someone
functions, she used a Wisconsin Card Sort, which tests executive function.

In this test, an individual is given a stack of cards that can be sorted
either by color, number or shape. The individual is asked to sort the cards.
If they do it by number, the tester says they are wrong. Most people will
then attempt to sort by either size or shape. Again, the researcher says
they are wrong. Finally, the person will sort the cards by whatever they
haven't already tried. Most 12 year olds can succeed at this, as can most
people who do not have, but later develop schiz.

She found that even when you account for positive and negative symptoms, the
ability to perform well on the Wisconsin Card Sort is a much better predictor
than any other of how well people can function. It predicted better than
symptoms, better than presence of positibe symptoms, negative symptoms,
attention, language or memory deficits.

Having come to the belief that Executive Function deficit is the most
important factor in determining how well someone functions in the community,
she is now working to determine whether or not Ececutive Functioning deficits
can be improved or compensated for. She has two hopeful lines of pursuit:
1. Electronic Techniques
2. Mental Exercises.

Electronic techniques use things like watches that beep, personal organizers,
and automated telephone calls as prosthetic devices to help people cope with
Executive Function Deficits. This has been done in people with brain

The second area of investigation has to do with using mental exercises to
rebuild the brain. She believes that sustaining and modulating attention is
a big problem for people with Sz. (If you can't pay attention, it's hard to
do anything.) There are numerous studies that show that a large portion of
the brain is involved in attention deficits. The brain has numerous
redundant systems to deal with attention. She believes that it would be
unusual for all these multiple redundant systems to be simultaneously broke,
and therefore a way can be developed to have some of the systems compensate
for others. She is currently testing a "Attention Processing Training
Program" developed in Washington. It is an intensive 10 week program using
audio tapes to help someone develop better attention. The tapes say "Press a
button when you hear such and such". Later tapes require you to press the
button when you hear a more complicated series. The hope is that by
increasing the difficulty of what you have to listen for, before you press
the button, that attention deficits can be eliminated or minimized.

It was a fascinating presentation on an area that has long interested me (My
own sis-in-law, Lynn, a former top performer in H.S., now has difficulties
with simple tasks like putting on and tieing shoes. This occurs regardless
of whether the meds are or are not controlling any neg symptoms she may
have.). Her research shows the importance of supporting NARSAD.

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