|Year : 2015 | Volume
| Issue : 2 | Page : 129-134
Cognitive self-regulation, social functioning and psychopathology in schizophrenia
Shivani Santosh1, Debdulal Dutta Roy1, Partha Sarathi Kundu2
1 Department of Psychology, n Statistical Institute, Kolkata, West Bengal, India
2 Department of Psychiatry, Malda Medical College, Malda, West Bengal, India
|Date of Web Publication||4-May-2016|
Psychology Research Unit, Indian Statistical Institute, 203, B.T Road, Kolkata - 700 108, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To explore relation between cognitive self-regulation, social functioning, and psychopathology in schizophrenia. Materials and Methods: A total of 100 patients diagnosed with schizophrenia according to International Classification of Diseases (ICD)-10 were taken from Department of Psychiatry of two postgraduate hospitals of Kolkata, India. All subjects gave informed consent. After recording sociodemographic and clinical details, the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Schizophrenia Research Foundation India-Social Functioning Index (SCARF-SFI), and specially designed questionnaire on cognitive self-regulation was administered. Results: All the four subtests of SCARF-SFI, that is, self-concern, occupational role, social role and family role, and symptoms scale of PANSS were significantly correlated with cognitive self-regulation. Cognitive self-regulation along with positive and negative symptoms was able to predict social functioning. Conclusion: Cognitive self-regulation is significantly and positively correlated to social functioning. Cognitive self-regulation along with positive and negative symptoms is a significant predictor of social functioning.
Keywords: Cognitive self-regulation, psychopathology, schizophrenia, social functioning
|How to cite this article:|
Santosh S, Roy DD, Kundu PS. Cognitive self-regulation, social functioning and psychopathology in schizophrenia. Ind Psychiatry J 2015;24:129-34
Cognitive self-regulation involves the development of a set of constructive behaviors that affect one's use of cognitive abilities to integrate learning processes. These processes are planned and adapted to support the pursuit of personal goals in changing environments. It involves the control of various mental strategies for better cognitive performance. It is the regulation of one's own thinking process, and thus can fall in the domain of metacognition., Cognitive self-regulation is not isolated method of learning, but comprise of personal initiative, perseverance, and adaptive skill. If considerable attention can be given to the improvement of cognitive self-regulation skills in patients with schizophrenia, cognitive impairment in patients can be mitigated.,,
Cognitive functions enable humans to perform in everyday life in the spheres of personal, social, and occupational activities. Mental processes that are referred to as cognitive function include the ability to attend to things in a selective and focused way, to concentrate over a period of time, to learn new information and skills, to plan, to determine strategies for actions, to execute them, to comprehend language, to use verbal skills for communication and self-expression, and to retain information and manipulate it to solve complex problems. While almost all of these are taken for granted in most persons, they get impaired in schizophrenia. These impairments also effect the social functioning of the patients.
“Schizophrenia is a major mental illness characterized by psychosis, apathy and social withdrawal, and cognitive impairment, which results in impaired functioning in work, school, parenting, self-care, independent living, interpersonal relationships, and leisure time.” By definition, social impairments characterize schizophrenia, given that current diagnostic criteria require a disturbance or deficit in one or more major areas of functioning, such as work, interpersonal relations, or self-care. Few studies have reported an association between cognitive functioning and functional outcome, and that an improvement in cognitive function may also result in improvement of social functioning.,
Most studies use a wide range of cognitive variables and outcome measures, some studies even use laboratory assessment of social skills as outcome measures. These studies in general find highly significant correlations showing the effect of cognitive impairment on the functional outcome., It also signifies that improvement in cognitive impairment also effect social functioning positively. Performance in cognitive functions requires self-regulatory skills, for example skills to regulate thoughts, behavior, anticipating appropriate responses, and modifying one's responses when circumstances are subtly different. Cognitive self-regulation process enables the cognitive system to be effectively and accurately activated according to the requirement of the moment. Most of the schizophrenia patients lack these skills which further contribute to cognitive impairment and hence, low social functioning.,
In recent research on schizophrenia, to counter effects of cognitive impairment, considerable attention has been paid in cognitive rehabilitation therapy where cognitive self-regulation skills are not emphasized. In fact, it is observed that despite increased acceptance, the evidence based on its effectiveness is not impressive as the process is slow. The slow progress has been suggested to be due to several critical issues including: (1) Manipulating stimulus and context structure in rehabilitative interventions; (2) basing cognitive rehabilitation of schizophrenia on cognitive neuroscience; (3) systematically addressing motivation, self-esteem, and affective factors when designing cognition-enhancing interventions; (4) the need to develop individualized treatments; and (5) the need to address abnormalities in the experience of the self when designing interventions to optimize cognitive and behavioral performance. Besides the above factors, slow progress is due to less attention to different strategies of cognitive self-regulation like selective attention to self and to others, planning, self-motivation to work, behavior regulation, and self-evaluation. These strategies can be taught to patient through modeling and practice to improve cognitive abilities of the patients. These are important as cognitive abilities are impaired in schizophrenia in both positive and negative types.,
The present study examined self-regulation of cognitive abilities as perceived by the schizophrenia patients and also examined relationship between psychopathology, cognitive self-regulation, and social functioning in schizophrenia.
| Materials and Methods|| |
The present study is a hospital-based cross sectional analytical study.
One hundred patients diagnosed with schizophrenia according to International Classification of Diseases (ICD)-10 attending the Psychiatry outpatient department (OPD) of two postgraduate hospitals of Kolkata, were recruited by the purposive sampling method as per the inclusion and exclusion criteria. All participants were included in the study after giving written informed consent. They were cooperative and clinically stable with history of treatment for 6months. Other inclusion criteria were (i) age range from 18 to 50 years, (ii) completed at least 7 years of full time education. Exclusion criteria included: (i) Any comorbid psychiatric disorder, any neurological disorder, or significant medical condition. (ii) Mental retardation or substance dependence except nicotine and caffeine. (iii) Electroconvulsive therapy (ECT) in last 6 months.
Sociodemographic and clinical data sheet
Semistructured checklist used to record patient's sociodemographic particulars, along with clinical variables like diagnosis and duration of illness.
Schizophrenia Research Foundation India-Social Functioning Index
This interview based scale is intended for administration on persons suffering from psychiatric illnesses and the items are rated on a five-point scale; higher the score, the better is the social functioning. Social functioning is measured over four domains: Self-concern, occupational role, role in the family, and other social roles. Information was obtained from the subject and/or informant and a global assessment of social functioning (GASF) score was computed. GASF scores were categories into three categories as per norms: Mild (GASF > 60), moderate (GASF 30–60), and severe (GASF < 30).
Positive and Negative Syndrome Scale for Schizophrenia
The PANSSis a 30-item scale used to assess extent of severity on positive and negative symptoms and general psychopathology. Higher score represents higher level of severity. It is specifically developed to assess individuals with schizophrenia and is used widely in research settings.
Cognitive self-regulation questionnaire
The CSR for individual with schizophrenia comprised of 10 items that require respondents to answer in either “yes” or “no” was administered. The total score will be the total number of correct responses and will present the overall cognitive self-regulation. The CSR was administered as a pencil-and-paper measure, after initial rapport formation and detailed instructions given by interviewer.
The questionnaire was constructed after recording difficulties due to cognitive impairment faced by 15 patients diagnosed with schizophrenia and taking treatment from the outpatient of psychiatry department of postgraduation hospital of Kolkata by means of semistructured interviews and by taking opinions of experts who are in treating team of patients. Questions were framed upon the behavioral regulation required to deal with these difficulties. Based on these difficulties, 20 items were framed and administered to 17 patients of psychiatric departments of hospitals and their feedback was taken to know whether they are able to understand the content of questions or not. After necessary changes and dropping of four irrelevant items, the questionnaire with 16 items was sent to three experts (two psychiatrists and one psychologist) for their feedback. They were asked to rate the items. After analyzing the rating of three independent experts and the author, 14 items were kept. Then the questionnaire was administered to 100 patients and following psychometric properties were found.
Psychometric properties of CSR
The Kuder–Richardson coefficient of the responses to the CSR was found to be 0.76. However, four items with low item-total correlations with values less than 0.30 were dropped. The alpha for the remaining 10 items computed was found to 0.82. The correlation coefficient between the cognitive function and CSR was: Attention (test used Digit span, Trail making A), it was found to be 0.55 and − 0.32; verbal ability (verbal fluency test semantic), it was found to be 0.67, mental flexibility (Trail making B), it was found to be − 0.35; and for stimulus inhibition (Stroop test), it was found to be − 0.45;thus, demonstrating a good concurrent validity.
Initially, hospitals with psychiatric department were approached with request to give permission to collect data from patients in OPD. Once patient's diagnosis was confirmed by psychiatrist, they were contacted for informed consent. Out of 170 diagnosed patients, 100 gave informed consent. Then after initial rapport was formed, the necessary instructions were provided and abovementioned instruments were administered.
Data were analyzed using Statistical Package for Social Sciences (SPSS) 16 version. Initially, association between psychopathology, cognitive self-regulation, and social functioning was computed through Pearson correlation coefficient and then multiple regression was done to study variables which were able to predict social functioning in schizophrenia.
| Results|| |
Demographic characteristics of the sample
The mean (± standard deviation (SD)) age of the schizophrenia patients was 31.89 (± 8.13) years. Range of age was 19–55 years. The sample comprised of 74 males and 26 females. Only 45 patients were employed, while rests were unemployed. Of the total sample, 67 were educated for 7–11 years, 28 for 12–14 years, and five between 15 and 17 years. Fifty-five patients were diagnosed as paranoid schizophrenia and 45 as undifferentiated schizophrenia. The mean (± SD) duration of illness was 3.00 (± 1.40) years.
Sample mean rating on the PANSS was 2.62, (SD = 0.70) for positive symptom scale (mean = 2.69, SD = 0.92), negative symptoms scale (mean = 3.08, SD = 1.14), and for general psychopathology (mean = 2.47, SD = 0.68) scores fall around mild level of severity.
Sample mean rating for SCARF–social functioning scale lies between rarely concerned to occasional lapses in concern level of function in different domains of social functioning, that is, self-concern (mean = 3.17, SD = 1.05), occupational role (mean = 2.29, SD = 1.05), family role (mean = 2.23, SD = 1.05), social role (mean = 2.48, SD = 0.91), and overall score (mean = 2.54, SD = 0.85).
Sample mean for CSR questionnaire which consists of 10 questions and the response is in “yes” or “no” was 5.03 (SD = 3.12).
Correlation and regression
To examine the relation between the cognitive self-regulation, psychopathology, and social functioning; Pearson correlations coefficients were computed as shown in [Table 1]. All the four subtests of social functioning were positively and significantly related with cognitive self-regulation. Total social functioning also found to be significantly and positively correlated with cognitive self-regulation. This implies higher level of cognitive self-regulation is associated with the higher social functioning in the patient with schizophrenia and also associated with the higher levels of self-care, family roles, occupational role, and social role. [Table 1] also shows significant negative correlation of four subscale of social functioning scale with symptoms scales of PANSS. Cognitive self-regulation was also found to have significant negative correlation with symptoms scales of PANSS. Further result of multiple regression with social functioning as a predicted variable revealed that cognitive self-regulation along with positive and negative symptoms was able to predict social functioning where R 2 = 0.66, F = 60.72, P < 0.000 [Table 1].
|Table 1: Intercorrelation matrix of Pearson correlation coefficients between cognitive self-regulation, psychopathology, and social functioning (n=100)|
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| Discussion|| |
Previous studies have shown that cognitive impairments in schizophrenia result in difficulties in the ability to work, to engage in social relationship, to attend to self-care, and to participate in recreational and community activities.,, The present study shows the relation of regulation of one's own cognitive abilities with social functioning in schizophrenia. Social functioning was measured along with the subtests of self-concern, occupational role, family role, and social role in this study. The result does not show a higher level of cognitive self-regulation among the patients. Result also shows the sample mean for overall social functioning to be moderate in global assessment of functioning, as this score falls within the moderate functioning range. Moreover, the mean rating on the subscales of social functioning and social concern falls between average and good; while for occupational role, family role, and social roles it falls between poor and average. These findings indicate that patients were better in self-concern in comparison to the other domains of social functioning, while the social roles were found to be most affected.
The findings of the present study reveal that cognitive self-regulation shares a significant positive relation with self-concern. For proper self-concern, person needs to give attention to one's own personal belongings and taking care of own health by planning doctor visit, if faced with any health complication. It also requires that the patient takes medicines properly, remembering proper timing and right dose. All these activities require cognitive abilities, and thus cognitive self-regulation comes to play a significant role here.
Similarly, in order to carry out occupational role, social role, and family role; individuals need to pay attention to the various information, remember them, and need to use it properly when required; all these activities involve a great deal of cognitive abilities. For better performance on these roles, cognitive self-regulation can play a crucial role as this study findings shows significant positive association between cognitive self-regulation and occupational role, social role, and family role. Higher the cognitive self-regulation higher is the individual functioning in occupational role, social role, and family role.
Cognitive self-regulation was also found to share a significant positive correlation with overall social functioning. This relationship becomes more important in schizophrenia where social functioning is highly compromised and where the association between the cognitive impairment and social functioning is high., A number of intervention studies, primarily of cognitive remediation also have shown that some executive and memory improvements are associated with subsequent social functioning change.,,,, Cognitive self-regulation was negatively correlated with PANSS negative symptom scale, positive symptom scale, and also with overall symptoms. Domains of social functioning were also significantly negatively correlated with PANSS negative symptom scale, positive symptom scale, and also with overall symptoms. It simply implies that more severe the symptoms of schizophrenia, the more impaired a patient's social functioning will become. As patient symptoms gets more severe, he will have more impairment in carrying out functions of his self-concern, occupational role, family role, and social role.
The training program to teach skills and strategies for cognitive self-regulation would also help in increasing the overall social functioning of the patient as present study has shown a significant positive correlation between the cognitive self-regulation and social functioning.
In order to understand further, the relation between among cognitive self-regulation, psychopathology, and social functioning; multiple regression was done with social functioning as a predicted variable. Results shows that cognitive self-regulation along with positive and negative symptoms were able to predict the social functioning with R 2 = 0.66, F = 60.72, P < 0.000.
The aim of all treatment modules of schizophrenia is to improve social functioning of the patients and when cognitive self-regulation is being identified as a significant predictor of social functioning, the psychosocial rehabilitation focusing on the training in regulation strategies to control the behavior to be able to use cognitive abilities effectively can be develop, to help patient to improve their social functioning. The training program based on Bandura's model of health efficacy can be helpful to increase the cognitive self-regulation. The training problem consists of strategies for self-observation of behavior for example: What I do to remember the way when go to a new place? Judgment: What should be done in the above situation? Try to remember the landmarks, etc., and then the self-response: At last some rewarding self-response should be given to oneself. To summarize, if cognitive self-regulation strategies are included to counter cognitive impairment in schizophrenia, it can help patients to not only improve their cognitive functions, but it would also result in improved social functioning.
| Conclusion|| |
From the present study it could be concluded that cognitive self-regulation is significantly and positively correlated to social functioning. In addition, cognitive self-regulation, along with positive and negative symptoms, is a significant predictorof social functioning.
The study had various limitations. It was conducted in a tertiary care hospital setting where mainly assessment of severely ill patients is done. Females were under represented in the study which is a primary limitation in the applicability of the present findings to female schizophrenia patients.
Future studies should include larger samples from multiple centers with equal gender representation. One clear priority for future research is to evaluate whether teaching cognitive self-regulation strategies to patients with schizophrenia can help improve their cognitive and social functioning. On a broader scale, another priority is to examine other forms of self-regulation–like cognitive regulation–that shape the trajectory from impulse to action.
| References|| |
Flavell JH. Metacognition and cognitive monitoring. A new area of cognitive – Developmental enquiry. Am Psychol 1979;34:906-11.
Dinsmore DL, Alexander PA, Loughlin SM. Focusing the conceptual lens on metacognition, self-regulation, and self-regulated learning. Educ Psychol Rev 2008;20:391-409.
Keefe RS, Harvey PD. Cognitive impairment in schizophrenia. Handb Exp Pharmacol 2012;213:11-37.
Singh JP, Serper M, Reinharth J, Fazel S. Structured assessment of violence risk in schizophrenia and other psychiatric disorders: A systematic review of the validity, reliability, and item content of 10 available instruments. Schizophr Bull 2011;37:899-912.
Thara R, Anuradha. Cognitive functioning in schizophrenia: Its relevance to rehabilitation. Indian J Med Res 2007;126:414-6.
Mueser KT, McGurk SR. Schizophrenia. Lancet 2004;363:2063-72.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th
ed. Washington: American Psychiatric Association; 2013. p. 87-122.
Green MF, Kern RS, Braff DL, Mintz J. Neurocognitive deficits and functional outcome in schizophrenia: Are we measuring the right stuff? Schizophr Bull 2000;26:119-36.
Addington J, Addington D. Neurocognitive and social functioning in schizophrenia. A 2.5 year follow up. Schizophr Res 2000;44:47-56.
Green MF, Olivier B, Crawley JN, Penn DL, Silverstein. Social cognition in schizophrenia: Recommendations from the measurement and treatment research to improve cognition in schizophrenia new approaches conference. Schizophr Bull 2005;31:882-7.
Silverstein SM, Wilkniss SM. At issue: The future of cognitive rehabilitation of schizophrenia. Schizophr Bull 2004;30:679-92.
Crow TJ. Molecular pathology of schizophrenia: More than one disease process? Br Med J 1980;280:66-8.
Talreja BT, Shah S, Kataria L. Cognitive function in schizophrenia and its association with socio-demographics factors. Indian Psychiatry J 2013;22:47-53.
Padmavathi P, Thara R, Srinivasan L, Kumar S. Scarf social functioning index. Indian J Psychiatry 1995;37:161-4.
Kay SR, Opler LA. The positive-negative dimension in schizophrenia: Its validity and significance. Psychiatr Dev 1987;2:79-103.
Leary J, Johnstone EC, Owens DG. Social outcome. Br J Psychiatry 1991;159:13-20.
Liu D, Wang Y, Xu Y, Jiang K. Research progress of cognitive function in schizophrenia in China. Shanghai Arch Psychiatry 2013;25:266-75.
Mueser KT, Bellack AS, 1998. Social skills and social functioning. In Mueser KT, Tarrier N. (eds) Handbook of social functioning in schizophrenia. Needham Heights: Allyn and Bacon; 1998.p. 79-96.
Wykes T, Reeder C, Landau S, Everitt B, Knapp M, Patel A, Romeo R. Cognitive remediation therapy in schizophrenia: Randomised controlled trial. British Journal of Psychiatry, 2007;190: 421-7.
Reeder C, Newton E, Frangou S, Wykes T. Which executive skills should we target to affect social functioning and symptom change? A study of a cognitive remediation therapy program. Schizophr Bull 2004;30:87-100.
Spaulding WD, Reed D, Sullivan M, Richardson C, Weiler M. Effects of cognitive treatment in psychiatric rehabilitation. Schizophr Bull 1999;25:657-76.
Penades R, Boget T, Catalan R, Bernardo M, Gasto C, Salamero M. Cognitive mechanisms, psychosocial functioning, and neurocognitive rehabilitation in schizophrenia. Schizophr Res 2003;63:219-27.
Wykes T, Reeder C, Corner J, Williams C, Everitt B. The effects of neurocognitive remediation on executive processing in patients with schizophrenia. Schizophr Bull 1999;25:291-307.
Bandura A. Self–efficacy: The exercise of control. New York: W.H. Freeman and company; 1997. p. 16-27.