neuropsychological assessment in SMI

Presenter- Dr. Harneet kaur
Moderator - Dr. Nitin Gupta
Department of Psychiatry GMCH 32 Chandigarh

1. PRESENTER – Dr. Harneet MODERATOR- Dr. Nitin Gupta 23/7/2016 NEUROPSYCHOLOGICAL ASSESSMENT IN SEVERE MENTAL ILLNESS

2. NEUROPSYCHOLOGY Neuropsychology is a specialty in professional psychology that applies principles of assessment and intervention based upon the scientific study of human behavior as it relates to normal and abnormal functioning of the central nervous system. The specialty is dedicated to enhancing the understanding of brain‐behavior relationships and the application of such knowledge to human problems. American Psychological Association, 2010

3. NEUROPSYCHOLOGICAL ASSESSMENT Neuropsychological assessment/testing is a process by which a person’s cognitive, psychological/emotional and behavioural functioning is comprehensively assessed. FOCUS is on cognitive functioning. DETAILED INTERVIEW STANDARDIZED TESTING of areas relevant to presenting problems SCORES COMPARED TO NORMATIVE TEST DATA GENERATION OF A PROFILE IDENTIFICATION OF AREAS OF STRENGTHS AND WEAKNESSES

4. COGNITION & COGNITIVE FUNCTIONS Cognition refer to set of vastly complex processes, such as language, problem solving and thinking, that apply plans and strategies to sensations and perceptions. 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, determine strategies for actions and execute them, to comprehend language and use verbal skills for communication and self-expression, and to retain information and manipulate it to solve complex problems are examples of mental processes that are referred to as cognitive functions. Trivedi et al 2007 , Santosh et al 2015

5. COGNITIVE DOMAIN TESTS USED ATTENTION patient’s ability to attend to a specific stimulus without being distracted by internal or external environmental stimuli. Three types of attention- Selective attention/focused attention Sustained attention Divided attention Digit span distraction test Continuous performance test Dual task test Brief test of attention (BTA) D2 test of attention Gordon diagnostic system Paced auditory serial addition task (PASAT) Quotient test of attention Stroop color naming Symbol digit modalities test Test of variables of attention Trail making test

6. COGNITIVE DOMAIN TESTS USED 2. MEMORY refers to a process of encoding, storage and retrieval of learnt material. Immediate Recent Remote (Long term memory divided into Explicit and implicit memory) WORKING MEMORY refers to the ability to hold the stimuli ‘online’ for a short time, then either use it directly after a short delay or process or manipulate it mentally to solve cognitive and behavioral tasks. California verbal learning test Wechsler memory scale Benton visual retention test Rey’s complex figure test Boston remote memory battery Remote memory battery by squire and co workers PGI memory scale

7. COGNITIVE DOMAIN TESTS USED 3. INTELLIGENCE Capacity for learning and ability to recall, to integrate constructively, and to apply what one has learned; the capacity to understand and to think rationally Wechsler adult intelligence performance and verbal scale – indian adaptation. Stanford binet intelligence test Bhatia’s battery of performance of intelligence Proteus maze test Raven’s standard progressive matrices Reynold’s intellectual assessment scale Peabody pictute vocabulary test Kaufmann intelligence test

8. COGNITIVE DOMAIN TESTS USED 4. EXECUTIVE FUNCTIONS refers to the ability to use abstract concepts, to form an appropriate problem-solving test for the attainment of future goals, to plan one's actions, to work out strategies for problem-solving, and to execute these with the self-monitoring of one's mental and physical processes. Planning, sequencing, problem solving, decision making, emotional regulation. Wisconsin card sorting test (WCST) Verbal and visual fluency test Categories test and Trail making tests Stroop colour word interference test Tower of london tasks Problem solving- Porteus maze test Psychomotor Skills-Grooved peg board,Finger tapping.  

9. COGNITIVE SCREENING TOOLS FROM INDIA 1. PGI BATTERY OF BRAIN DYSFUNCTION (PGIBBD) Parshad and Verma,1990 Revised Bhatia’s Short Battery of Performance Tests of Intelligence Verbal Adult Intelligence Scale PGI-Memory Scale Nahor Benson Test Bender Visual Motor Gestalt Test 2. Hindi Mental State Examination (HMSE) Ganguli et al., 1996 DOMAINS ASSESSED - HMSE total Calculation Word list learning, recall & recognition Object Naming Verbal fluency (category – animals & fruits) Constructional praxis 3. NIMHANS Neuropsychological Battery, 2004 SL, Subbakrishnan DK Gopulkumar K,Bangalore .

10. TESTS INCLUDED IN NIMHANS BATTERY LOBES FUNCTIONS TESTS FRONTAL LOBE Motor functions Motor speed Motor coordination Finger tapping test ( reitan 1970) Hand tapping ( luria 1966) Attention Sustained attention Focused attention Colour cancellation Color trails test trail A and B Expressive speech Repetitive speech   Nominative speech   Narrative speech  Repeating sounds Repeating words Categorical naming Object naming Sentence construction

11. LOBES FUNCTIONS TESTS Contd … Executive functions Verbal fluency Design fluency   Verbal working memory Visuospatial working memory   Planning Shift of set Phenomic fluency ( Lezak 1995) Design fluency (Jones gotman and miner 1977) N back test verbal (Smith and jonides 1996) VSWM span task (Miner 1971) N back test visual (Smith and jonides ) 1995 Proteus maze (Proteus 1965) Wisconsin card sorting test (Heaton chelune , talley , kay and Curtis 1993)

12. LOBES FUNCTIONS TESTS PARIETAL LOBE Visuo perceptual ability Motor free visual perception test ( collarusso and Hammil , 1972) Visuo conceptual ability Picture completion (MISIC 1969) Visuo constructive ability Block design (MISIC 1969) Visual recognition Recognition pictured objects ( lezak 1995) Apraxia Symbolic and sequential acts ( lezak 1995) Somatosensory perception Tactile finger localization Tactile form perception Finger localization (Boil 1974) Tactile form perception ( lezak 1995) Reading Reading a passage,Reading comprehension Writing Writing to dictation copying Calculation Age appropriate sums

13. LOBES FUNCTIONS TESTS TEMPORAL LOBE Verbal comprehension Token test ((De Renzi and Vignolo , 1962) Verbal language and memory Rey ‘s auditory verbal learning test( maj et al 1993) Visual learning and memory Memory for designs ( jone sgotman and miner 1986)

14. PURPOSE OF NEUROPSYCHOLOGICAL ASSESSMENT DIAGNOSIS & SCREENING NOT A PRIMARY DIAGNOSTIC TOOL BUT CAN AID IN PREDICTION PROVIDES BEHAVIORAL DATA FOR LOCALIZING THE SITE OF A LESION USEFUL IN DISCRIMINATING BETWEEN PSYCHIATRIC AND NEUROLOGICAL SYMPTOMS TO DISTINGUISH BETWEEN DIFFERENT NEUROLOGICAL CONDITIONS

15. PATIENT CARE & PLANNING COGNITIVE STATUS & PERSONALITY CHARACTERISTICS UNDERSTANDING OF PATIENT’S CAPABILITIES AND LIMITATIONS + PSYCHOLOGICAL CHANGES SUCCESSIVE NEUROPSYCHOLOGICAL ASSESSMENTS REPEATED AT REGULAR INTERVALS THROUGH OUT THE COURSE OF AN ILLNESS RELIABLE INDICATOR OF IMPROVEMENT ; EARLY PREDICTOR OF DEMENTING COURSE

16. PSYCHOSOCIAL REPURCUSSIONS DEFECTS IN MOTIVATION DEFECT IN ABILITY TO PLAN DEFECT IN ORGANIZING AND CARRYING OUT ACTIVITIES IMPAIRED CAPACITY TO EARN A LIVING SOCIAL DEPENDENCE Disorder of complex thinking and ideation, resulting in difficulty in dealing with ‘psychological and social challenges’ in daily life. Lysaker et al 2015 .

17. REHABILITATION & FUNCTIONAL SKILLS ASSESSMENT PREDICTION OF REHABILITATION NEEDS PREDICTION OF ABILITY OF PATIENT TO FUNCTION INDEPENDENTLY PREDICTS PATIENT’S ABILITY TO RESUME NORMAL ROUTINE ACTIVITIES managing a family Returning to home from work Resuming school

18. The importance of early assessment and intervention A comprehensive neuropsychological assessment evaluating a full range of behavior should be completed early. Reitan and wolfson 2001 Decreases the likelihood of patient’s learning maladaptive responses as he or she attempts to cope with cognitive impairments. Decreases the likelihood of a reactive depression developing consequent to feelings of helplessness and hopelessness. Determine change of function over time, for example as a consequence of treatment or spontaneous recovery or alternatively to monitor deterioration.

19. RESEARCH TO STUDY ORGANISATION OF BRAIN ACTIVITIES AND ITS TRANSLATION TO BEHAVIOR INVESTIGATING PSYCHIATRIC ILLNESSES DEVELOPMENT, EVALUATION AND STANDARDIZATION OF NEUROPSYCHOLOGICAL ASSESSMENT TECHNIQUES

20. MEDICOLEGAL PURPOSES PERSONAL INJURY ACTIONS  SEEKING OF MONETARY COMPENSATION FOR CLAIMS OF BODILY INJURY AND LOSS OF FUNCTION EVALUATION BY NEUROPSYCHOLOGIST To examine the type and amount of behavioral impairment sustained. To estimate claimants rehabilitation potential. To estimate the extent of need of future care . IN CRIMINAL CASES , ASSESSMENT OF DEFENDANT BY NEUROPSYCHOLOGIST To rule out any brain dysfunction or any underlying pathology contributing to the incident.

21. In president Kennedy’s murder investigations, a neuropsychologist determined that the defendant’s capacity for judgment and self control was impaired by brain dysfunction. The fact that the defendant had psychomotor epilepsy was interpreted by Doctor in charge after going through the psychological test findings and was then confirmed by an EEG.

22. DISABILITY ASSESSMENT ASSESSMENT OF PERSON WITH PHYSICAL DIFFICULTY Motor impairment and comorbidities ASSESSMENT OF PERSONS WITH VISUAL IMPAIRMENT OR BLINDNESS Verbal spatial factor, perceptual motor factor and emotional coping factor ASSESSMENT OF PERSONS WITH HEARING IMPAIRMENT ASSESSMENT IN SCHOOLS FOR LEARNING DISABILITY

23. 7. OTHERS Recruitment in defense, federal aviation, govt setups including arithematic performances , sports medicine which includes assessment of General Cognitive abilities Academic Achievement Sensory Perceptual Skills Motor speed, coordination, and planning Attention, Concentration and mental processing speed in visual and auditory modalities Comparison of right and left hand performance Assessment of language functions such as fluency and naming Assessment of nonverbal skills such as construction Assessment of verbal and nonverbal memory including retention and learning rates Assessment of executive functions and cognitive flexibility Assessment of personality and emotional adjustment.

24. COGNITIVE DEFICITS Cognitive deficits may result in inability to: Pay attention Process information quickly Remember and recall information Respond to information quickly Think critically, plan organize and solve problems Initiate speech

25. WHAT IS SEVERE MENTAL ILLNESS?  A patient has severe mental illness when he or she has the following: a DIAGNOSIS of any non-organic psychosis a DURATION of treatment of two years or more DYSFUNCTION , as measured by the Global Assessment of Functioning (GAF)( American Psychiatric association, 1987). Ruggeri et al, 2006 The broad definition (the ‘ two-dimensional definition’) is based on the fulfillment of the latter two criteria only.

26. Specifically, the two levels of dysfunction defined by cut-off points of the GAF are tested: moderate or severe dysfunction (a GAF score of 70 or less, indicating mild symptoms or some difficulty in social, occupation or school functioning); or only severe dysfunction (a GAF score of 50 or less, indicating severe symptoms or severe difficulty in social, occupational or school functioning). Ruggeri et al, 2006

27. COGNITIVE DEFICITS IN SCHIZOPHRENIA Cognitive deficits are a core and stable characteristic (i.e. trait) of schizophrenia, and they are independent of psychotic symptoms Banaschewski et al 2001 More severe cognitive deficits at the time of first episode →more likely to develop chronic and severe functional impairment. Keefe et al, 1989 may precipitate psychotic and negative symptoms Crow et al 1995 are relatively stable over time, with progressive deterioration after the age of 65 years in some patients. Friedman et al 2001

28. Although cognitive deficits is not the part of current diagnostic system for schizophrenia i.e. ICD-10 or DSM-IV TR, it is a core feature of schizophrenia. In the recent years extensive research has suggested that cognitive deficits associated with schizophrenia are not a consequence of psychotic symptoms and its treatment but rather a distinct dimension of illness . IT IS RELATED TO BUT NOT CAUSED BY NEGATIVE SYMPTOMS .

29. Some rating scales consider cognitive process as negative symptoms Functional deficits included in negative symptoms rating scale Improvement in both not proportionate to each other Gold et al 1992; Leffe et al 1994 Even prior to onset of psychotic symptoms neuropsychological abnormalities are present. persist on the remission of psychotic symptoms. Heaton,2010

30. Deficits have also been documented in studies in which sibling controls were examined. Off-springs of patients with schizophrenia show deficits in overall IQ and in specific cognitive functions of attention and short term memory in childhood and adolescence. A meta analysis of 37 studies found that unaffected first degree relatives of patients with schizophrenia have a similar profile of neurocognitive deficits found in the patients themselves although magnitude of the deficits was smaller. Thus there can be a genetic component of this symptoms domain of schizophrenia.

31. COGNITIVE DEFICITS IN SCHIZOPHRENIA Developmentally based subtle deficits Illness onset related severe deficits Limit normal acquisition of cognitive skill Compromise cognitive skill already acquired

32. ASSESSMENT IN SCHIZOPHRENIA

33. FOR MEMORY FOR ATTENTION PGI memory scale/verbal and visual memory ( Pershad and Verma 1990) Visual memory- complex figure test and design learning test by NIMHANS Battery – Rao et al 2004 California verbal learning test Wechsler memory scale Benton visual retention test Rey’s complex figure test Boston remote memory battery Remote memory battery by squire and co workers Digit span test Focused attention by Color trials test Sustained attention by Digit vigilance test Divided attention by triad test by NIMHANS Battery- ( Rao et al 2004) Continuous performance test Stroop color naming Symbol digit modalities test Trail making test Brief test of attention (BTA) D2 test of attention Gordon diagnostic system Paced auditory serial addition task (PASAT) Quotient test of attention Symbol digit modalities test

34. FOR INTELLIGENCE FOR EXECUTIVE FUNCTONS Wechsler adult intelligence performance and verbal scale – indian adaptation. ( Prabhalnga swami) Stanford binet intelligence test Bhatia’s battery of performance of intelligence Proteus maze test Raven’s standard progressive matrices Reynold’s intellectual assessment scale Peabody pictute vocabulary test Kaufmann intelligence test Wisconsin card sorting test (WCST) Verbal and visual fluency test Categories test and Trail making tests Stroop colour word interference test Tower of london tasks Problem solving- Porteus maze test Psychomotor Skills-Grooved peg board,Finger tapping.

35. BATTERIES USED IN SCHIZOPHRENIA MCCB ( MATRICS consensus cognitive battery) BACS ( brief assessment of cognition in schizophrenia)

36. SPECIFIC COGNITIVE DEFICITS IN SCHIZOPHRENIA

37. I. MEMORY DEFICITS PATIENT PRESENTATION Disorientation and forgetting intervening events Inability to recall everyday information: dependent living Difficulty learning demands of job or learning new information Social deficits worsened (learn names & details of acquaintances) Green et al, 2000

38. Working Memory (WM) Definition: System for transient holding, storing and manipulating information in the execution of complex cognitive tasks such as learning , reasoning and comprehension. Brandt et al 2014 Relevance: There is increasing evidence that WM dysfunction, particularly verbal WM, is a core cognitive deficit in schizophrenia. Proposed Mechanism: As opposed to simple attention span, this skill carries more of a “cognitive load” due to the additional demands of manipulating the information. The information must be held on-line for processing, but does not necessarily transfer to long-term storage, unlike episodic memory. Findings: Verbal memory impairments are quite common and often moderate to severe in magnitude in schizophrenia. Gold et al 1997; McGurk et al 2004

39. Due to impairment in stimulus modality, verbal characteristics, sequence and generation status- social, occupational and communication impairment Hofer et al, 2005 Working memory – same brain areas(PFC) activated but intensity Schizo > BPAD> controls i.e Patient will show stronger activation even if the task difficulty is low. Patients had to use more cognitive resources to perform the same task. Brandt et al 2014

40. Neuropsychological and imaging studies suggest that the WM system is of a limited capacity in patients with schizophrenia.  Deficits in strategic long-term memory (e.g. free recall, memory for temporal order) could be accounted for by deficits in WM. Schizophrenia res treatment, 2011

41. II. ATTENTION DEFICITS PATIENT PRESENTATION Difficulty to identify and focus on information in environment. Living in world where every stimulus is a new stimulus Inability to adjust physiological reactivity to experience. Harvey et al, 2002

42. Impaired attention is considered a primary cognitive deficit in schizophrenia. Individuals who are genetically predisposed to schizophrenia have poor ability to maintain their attention even prior to the first psychotic episode Cornblatt et al 1985 By the time patients experience their first episode of psychosis, attentional impairments are typically present and of moderate severity Caspi et al 2003

43. Meta-analytic studies suggest moderate to severe impairments in this attention domain. Reichenberg ,2010 Deficits in attention and information processing might be central to schizophrenia because these can contribute to deficits in EF and WM. Attention deficits are also trait and vulnerability markers seen during remission and in children of schizophrenic parents. Nuechterlein , 1986 Attention deficits have been found to be robustly associated with deficit syndrome. Ross et al , 1997

44. III. EXECUTIVE FUNCTIONS PATIENT PRESENTATION Functional disability related to all aspects and much more severe comparative to IQ level. Executive functions encompass a wide range of cognitive processes that ultimately result in purposeful, goal-directed behavior . Studies using formal neuropsychological instruments have found that many schizophrenia patients have difficulties with most or all of these component processes. Schizophrenia patients have trouble adapting to changes in the environment that require different behavioral responses Koren et al 1998; Pantelis et al 1999

45. This tendency toward inflexible thinking is found in a number of studies and is highly correlated with occupational difficulties Lysaker et al 1995 Another component of executive functioning often found to be impaired in schizophrenia is planning Goldberg et al 1990; Pantelis et al 1997; Bustini et al 1999 Perhaps because they encompass so many sub-component processes, the executive functioning tasks are consistently among the best predictors of functional performance.

46. Neurocognition , specifically the ability to perceive and understanding the surrounding environment, along with visuospatial processing,planning and problem solving skills are impaired in people with schizophrenia. Also have social cognitive deficits they lack the ability to detect a faux pas and identify the person who has committed a faux pas in the interaction. Lam et al 2014

47. Self-care, social, interpersonal and occupational functions are all associated with executive functioning in schizophrenia Lysaker et al 1995; Velligan et al 2000; McGurk et al 2003; Evans et al 2004 Importantly, executive functions are also associated with treatment success. Impairments in this domain are associated with less engagement in therapy ( McKee et al 1997 ), medication compliance ( Robinson et al 2002; Jeste et al 2003 ), and longer hospital stays ( Jackson et al 2001).

48. GENERAL INTELLIGENCE Patients with schizophrenia have, as a group, lower Intelligence Quotient (IQ) scores than the general population. This difference is evident prior to the first episode of psychosis, with patients on the schizophrenia spectrum showing poorer performance on general IQ and non-verbal reasoning in particular Reichenberg et al 2006 As young as age 8, poor performance on the Coding subtest of the Wechsler Intelligence Scale for Children, which is a measure of processing speed, distinguishes individuals who later develop schizophrenia spectrum disorders from those who do not Sorensen et al 2006

49. Further evidence suggests that patients not only have lower IQ prior to and at first episode, but declines in IQ occur after the diagnosis Seidman et al 2006 Further, when matched to healthy control subjects on full scale IQ score, patients with schizophrenia still evidence impairment in specific neuropsychological domains not traditionally assessed with standardized IQ batteries Wilket al 2005

50. VERBAL FLUENCY Patients with schizophrenia have difficulties producing speech on demand. Verbal fluency tests assess their ability to produce words from a specific phonological or semantic category. These tests reveal both poor storage of verbal information (Kerns et al 1999) as well as inefficient retrieval of information from semantic networks Aloia et al 1996; Goldberg et al 1998 Not surprisingly, deficits in verbal fluency are associated with poor interpersonal functioning ( Addington and Addington 2000) and community functions ( Rempferet al 2003 ).

51. VERBAL LEARNING AND MEMORY Poor learning and retention of verbal information is a hallmark cognitive impairment in schizophrenia. Along with executive functioning deficits, impaired ability to encode and retain verbally presented information is one of the most consistent findings across research studies. These deficits tend to be more severe than other cognitive ability domains Saykin et al 1991; Saykin et al 1994

52. The pattern of deficits in schizophrenia tends to be reduced rates of learning over multiple exposure trials and poor recall of learned information, while encoding of the information appears spared Harvey et al 2002; Bowie et al 2004 Verbal memory performance predicts success in various forms of verbal therapy ( Smith et al 1999) and is associated with social, adaptive, and occupational success. Green et al, 2000

53. WORKING MEMORY DEFICIT Impaired planning, reasoning and problem solving Impaired verbal fluency Lower intelligence Impaired attention Impaired verbal fluency Impaired visuospatial processing

54. ROLE IN FUNCTIONAL OUTCOME

55. MANAGEMENT Need for intervention :- Negative features and neuro -cognitive impairments can cause the greatest problems in terms of rehabilitation. Better predictors of functional outcome. Both pharmacological and non pharmacological interventions are applied.

56. Pharmacological Antipsychotics 1 st generations or typical or conventional. 2 nd generations or atypical. Cognitive enhancers

57. PHARMACOLOGICAL-TYPICAL Typical antipsychotics: little benefit ( Mishara and Goldberg 2004 ) additional requirement of anticholinergics that impairs memory ( Strauss et al 1990 ). provides modest-to-moderate gains in multiple cognitive domains. Mishara et al 2004

58. Pharmacological-typical Compound Effect Authors Chlorpromazine Mixed, usually no effect Pigache 1993 Solo et al 1997 Haloperidol Mixed, usually no effect Gilbertson et al 1997 Serper et al 1990 Fluphenazine + thioridaziene No effect/ worsened Strauss et al 1990 Zahn et al 1994 Flupenthixol depot Mixed David 1995

59. Pharmacological-atypical Cognitive improvements are reported Keefe and McEvoy 2001 These changes were greater than placebo and the conventional antipsychotic medications and found in a number of cognitive domains. Clozapine , tends to result in improved motor functions but not other cognitive domains Bilder et al 2002

60. Atypical antipsychotics Drugs Functions improved Quetiapine Verbal fluency, recall, cognitive flexibility, visuo - motor tracking Olanzapine Verbal fluency, memory , vigilance, working memory Risperidone Episodic memory, verbal fluency, vigilance, executive skills, visuo -motor speed Clozapine Working memory, executive skills, motor function

61. Nonpharmacological - Cognitive rehabilitation Cognitive rehabilitation is a confluence of therapeutic activities based on brain behavior relationships. Hedge 2014 Includes training on computerized tasks similar to existing cognitive tests, teaching new learning strategies, training on novel tasks, and/or performing tasks repetitively. Ultimate goal is to improve day to day social functions as well as occupational rehabilitation. Zaytseva et al, 2013 CR improves attention and verbal working memory. D’souza et al,2013 Significant improvement in attention, abstraction and mental flexibility. Bhatia et al, 2012

62. HOW DOES IT WORK? CR induced hyperactivity in PFC, cortical midline regions , parietal and temporal cortex . Increased inter hemispheric information transfer by the bilateral PFCs via the corpus callosum . Promotes neuroplasticity Neuroprotective effects against grey matter loss in temporal brain regions associated with cognition + Increased serum BDNF levels Thorsen et al, 2014 Michalopoulou et al, 2015 Penades et al, 2013

63. INDIAN STUDIES IN COGNITIVE REHABILITATION AUTHOR SAMPLE INTERVENTION RESULT D’souza et al, 2013 India: 104 randomized Mixed, double-blind, placebo-controlled, Stratified random sampling by IQ. Assessments: at 12 and 24 weeks CRT, Computerized (20 computer- assisted tasks And placebo Improved attention/vigilance and verbal working memory only, high placebo response. No effect of CRT on global cognitive index. Suresh kumar , 2008 DSM IV schizophrenia attending vocational rehabilitation for 6 months, controls: no vocational rehabilitation Vocational activities, fullday , as per ability, in the hospital. Cognitive functioning positively correlated With occupational role In patients and negative correlation in controls.

64. AUTHOR SAMPLE INTERVENTION RESULT Hegde et al, 2012 First episode schizophrenia: ICD10 criteria, duration of illness <2 2-month-long home-based cognitive retraining ( TAU;psychoeducation And drug therapy) for subjects, only TAU for controls. Cognitive retraining: improved cognition; better motor speed, Verbal working memory,concept formation and set-shifting ability, Verbal learning, visuo - constructive ability, divided attention, planning, and reduced negative symptoms. Bhatia et al, 2012 DSM-IV schizophrenia, outpatients, over 18 years of age, no comorbidity 21 days, daily one hour yoga protocol (combinations of Asanas and Pranayam ), Or treatment as usual. Significant improvement in attention (speed)Improvement In abstraction and Mental flexibility .

65. YOGA as cognitive enhancement therapy Number of yoga therapists exceed the number of mental health professionals in India. Jagannathan et al, 2015 Practice of yoga emphasizes in focusing ones attention on breathing so improves general attentional abilities. Studies available in India include studies from NIMHANS and RMLH, New Delhi on yoga as an adjunctive intervention in schizophrenia. Duraiswamy et al, 2007, Jayaram et al 2013, Gangadhar 2014, Talwadkar et al, 2014 According to these studies yoga group as a whole shows greater improvement in attention, abstraction, mental flexibility.

66. ASSESSMENT IN BIPOLAR AFFECTIVE DISORDER

67. FOR MEMORY FOR ATTENTION PGI memory scale/verbal and visual memory ( Pershad and Verma 1990) Visual memory- complex figure test and design learning test by NIMHANS Battery – Rao et al 2004 California verbal learning test Wechsler memory scale Benton visual retention test Rey’s complex figure test Boston remote memory battery Remote memory battery by squire and co workers Digit span test Focused attention by Color trials test Sustained attention by Digit vigilance test Divided attention by triad test by NIMHANS Battery- ( Rao et al 2004) Continuous performance test Stroop color naming Symbol digit modalities test Trail making test Brief test of attention (BTA) D2 test of attention Gordon diagnostic system Paced auditory serial addition task (PASAT) Quotient test of attention Symbol digit modalities test

68. FOR INTELLIGENCE FOR EXECUTIVE FUNCTONS Wechsler adult intelligence performance and verbal scale – indian adaptation. ( Prabhalnga swami) Stanford binet intelligence test Bhatia’s battery of performance of intelligence Proteus maze test Raven’s standard progressive matrices Reynold’s intellectual assessment scale Peabody pictute vocabulary test Kaufmann intelligence test Wisconsin card sorting test (WCST) Verbal and visual fluency test Categories test and Trail making tests Stroop colour word interference test Tower of london tasks Problem solving- Porteus maze test Psychomotor Skills-Grooved peg board,Finger tapping.

69. SPECIFIC COGNITIVE DEFICITS IN BIPOLAR AFFECTIVE DISORDER

70. INTRODUCTION Evidence suggests that the presence of cognitive dysfunction in BPAD is a core and enduring deficits of the illness. Ferrier and Thompson,2002 “debilitating” cognitive impairment in different stages of the disease. Torres, 2010 Deficits in cognitive function are both transitory (acute phase of illness) and persistent (chronic/residual symptoms) Elshahawi,2011

71. COGNITIVE DEFICITS PROCESSING PROCESSING PSYCHOMOTOR SPEED SPEED VISUAL MEMORY VERBAL LEARNING MEMORY ATTENTION ;SUSTAINED ATTENTION EXECUTIVE FUCNTIONS Such as set shifting, response inhibition, verbal fluency and working memory Arts et al,2008; Bora et al,2009; Mann- Wrobel et al,2011; Bourne et al,2013; Robinson et al,2006; Torres et al,2007

72. MANIA MEMORY IMPAIRMENT- Difficulty in encoding, consolidating and retrieving the information leads to poor performance in neuropsychological tests of memory. T.H.Ha et al, 2014 ATTENTION – difficulty in sustaining attention leads to poor performance in continuous performance tasks. Clark et al 2005 IMPAIRED DECISION MAKING – disturbances in the decision making process, leads to increased impulsivity. lewandowski ., 2009 manic patients seem to have difficulty in concentrating and to be more impulsive when making decisions. bearden et al 2006 Specific distortions of thinking occur (" anastrophic " thinking).

73. PROCESSING SPEED AND VERBAL LEARNING is impaired along with attention,memory and executive functions in patients relative to HCs. Lee et al, 2014 IMPAIRED RESPONSE INHIBITION as seen in performance in Stroop test as compared to healthy controls. Daglas et al, 2015 AFFECTIVE BIAS a change of information processing of affective type, mostly a lower ability for perception and recognition of negative emotions. Lewandowski, 2009 IMPAIRED REASONING & PROBLEM SOLVING SKILLS as patients in mania score lower than HCs exposed to neuropsychological tests for the same. Clark et al 2001 Even though hyper verbosity is a common feature of acute mania, a similar level of phonemic and semantic verbal fluency was reported between acute patients and HCs. Daglas et al 2015

74. MANIA VS HYPOMANIA DOMAIN COMPARISON COGNITIVE DYSFUNCTION BIPOLAR 1 >BIPOLAR 2 VERBAL MEMORY BIPOLAR 1 >BIPOLAR 2 WORKING MEMORY BIPOLAR 1 >BIPOLAR 2 Patients with bipolar 2 > bipolar 1 more perseverative errors on WCST which can be relate to greater impulsivity. Could be related to higher comorbidity related to the impulsivity spectrum in type ii disorder Goldberg et al 1999, vieta et al 2000 Torrent et al, 2006

75. EUTHYMIA Euthymia may not be a period of complete recovery. Clark et al. 2002; Quraishi and FrangoU 2002; Latalova et al,2011; Malhi et al,2007; Martinez- Aran et al,2004; Lewandowski et al, 2011 Euthymic patients perform well on memory attention and problem solving tasks than all the stages of illness, but significantly lower scores than controls. Bourne et al 2013 WORKING MEMORY – patients have poorer working memory capacity and spatial working memory than HCs including declarative or long-term memory impairments. Bora et al 2010

76. patients in remission show a relatively specific impairment in memory .The increased response latency on the executive tasks suggests a possible small residual impairment. Rubinzstien 2000 Deficits are seen in PROCESSING SPEED and ATTENTION in euthymic stage of illness. lee et al 2014 DEFICITS IN EXECUTIVE FUNCTIONING AND VERBAL LEARNING are seen in euthymic patients of BPAD, patients performed worse than HCs in the same cognitive flexibility task. Fleck et al,2008

77. DEPRESSION MEMORY IMPAIRMENT Reduced hippocampal volumes observed in major depression consistent with temporal lobe dysfunction and contributes to memory impairment. poorer performances on total, short delayed free recall, long delayed free recall, and recognition of the CVLT. These memory problems persists into the euthymic stage of bipolar illness. T.H.Ha et al,2014 ATTENTION DEFICITS Patients in the depressive stage of illness find it difficult to maintain the concentration for even short periods. VERBAL FLUENCY is a cognitive domain specifically affected in depressive patients.

78. depressed patients have poorer performances on tests for assessing verbal fluency: ‘category instances’ (semantic fluency) and ‘controlled oral word association test’ (letter fluency) Van der Werf-Eldering et al,2010 IMPAIRED PROCESSING SPEED AND DECISION MAKING On Cambridge decision making task , depressed patients show slower decision making times than HCs. Clark et al 2005 PLANNING AND RESPONSE TO NEGATIVE FEED BACK Depressed patients show an abnormal response to negative feedback , when informed that they have just failed to solve a problem they are far more likely to fail the next. AFFECTIVE PROCESSING BIAS bias towards the recall of negative autobiographical material and lacking details when it comes to recall the positive. Murphy et al 2002, Mclean et al 2004, Chamberlain et al 2005

79. ENDOPHENOTYPES The findings of cognitive deficits in relatives of patients with bipolar disorder are suggestive of pre-existing developmental or genetic vulnerability. Ferrier et al,2004; Zalla et al,2004   Unaffected relatives of patients with bipolar disorder may have deficits in specific cognitive tasks compared to HCs. Bora et al,2009; Ferrier et al.2004; Robinson and Ferrier 2006; Arts et al,2008 Different authors have given statements in the past decade with evidence most in the favor of – -VERBAL WORKING MEMORY -EXECUTIVE FUNCTIONS Arts et al,2009; Emre et al 2008; Vicent et al 2008

80. Whereas according to some, Response inhibition deficit is the most prominent endophenotype of BPAD Bora et al 2009, Frangou 2005 Trait related deficits appear to be present in verbal memory and sustained attention Quraishi S 2002

81. FUNCTIONAL OUTCOME 30 – 50% of patients with BPAD experience significant social disability that may be related to persistent cognitive impairment. Dickerson et al 2004 no evidence of dysfunction in verbal fluency during both the acute state and remission period of a FEM, and non-verbal memory does not appear impacted during remission. This suggests a finite window for potentially neuroprotective effects as past literature on chronic bipolar disorder has identified deficits in both these domains, highlighting the theoretical importance of early intervention and treatment adherence. Daglas et al 2015

82. chronic disorder with a high relapse rate, significant general disability, personal and social burden, and psychosocial impairment. Miziou et al, 2015 Cognitive impairment has serious consequences for patients and caregivers, by impacting on the quality of life . Sapouna 2013

83. ILL EFFECT OF MEDICATION ON COGNITION STUDIES FOREMOTION lithium has mild but adverse effects on long-term memory that involves the acquisition of new information Judd, 1995 medication effects contributed to psychomotor slowing in bipolar disorder, processing speed impairment. Bora et al 2009 an increase in the daily dose of antipsychotic medication trended towards poorer processing speed in FEM patients Hellvin et al,2012 AGAINST THE MOTION long-term lithium usage is unlikely to cause progressive cognitive decline David et al 2007 Strakowski et al, 2008 reported no difference in response inhibition between medicated and unmedicated patients. Patients treated with lithium outperformed patients on divalproex on several cognitive tasks Torres et al,2010

84. SCOPE OF RESEARCH The relationships between neuroimaging and neurocognitive abnormalities in BPD are worthy of additional investigation. Phenotyping neuropsychiatric disorders. Relevance - may yield important insights into the development, nature, and course of illness. better identification of individuals who may be prone to greater cognitive impairment or decline and those who might be more responsive to specific treatments. Osuji 2005

85. To date there are no longitudinal studies to assess whether cognitive deficits in BPAD show a progressive course or their association with the age of illness onset Ferrier and Thompson,2002 differences in cognition in the manic state, depressed state, or euthymic (normal) state have not been dissected. These areas should be researched further. Torrent et al 2006 Patterns of sustained attention and processing speed impairments differ from schizophrenia. Future work in this area should differentiate cognitive deficits associated with disease genotype from impairments related to other confounding factors. Daglas et al 2015

86. summary Poor performance on verbal memory, working memory, processing speed, verbal fluency, attention and executive function/reasoning and problem solving. cognitive impairment were identified in all phases of the disorder but mainly during manic episodes. Correlates like longer length of illness, younger age of onset, and higher number of hospitalizations may contribute to the intensity of cognitive deficits. need for clinical assessment and cognitive tests dynamically applied in order to be able to determine the stability or evolution of cognitive impairment in time.

87. INDIAN RESEARCH

88. I. SCHIZOPHRENIA STUDY SAMPLE ASSESSMENT RESULT NIZAMI ET AL 1992 40 schizophrenic (DSM III) patients, 30 brain damaged patients and 30 Luria Nebraska neuropsychological battery Schizophrenic patients perform better than brain-damaged but had poor performance than in comparison to normal controls. ANANTHNARAYAN ET AL 1993 24 remitted schizophrenics, 25 currently ill neurotic depressives (ICD-9) Computer based tests for visual information processing: Simple reaction time, choice reaction time, forced choice span of apprehension test Remitted schizophrenics performed poorly on all these measures as compared to neurotic depressives.

89. STUDY SAMPLE ASSESSMENT RESULT MANDAL ET AL 1999 12 schizophrenics (DSM-III R) each with predominantly positive and negative phenomenology; 12 healthy controls Recognition of Emotion’ sub-test of the Penn Facial Discrimination Task Schizophrenic patients with negative symptoms exhibited a generalized emotion- recognition deficit. Schizophrenic patients with positive symptoms showed a deficit in recognition of ‘sad’ emotion. MISHRA ET AL 2002 60 schizophrenic patients (ICD-9) Luria Nebraska neuropsychological battery Pattern of performance in tests indicated possibility of combined cerebral dysfunction, more towards left hemisphere functions

90. STUDY SAMPLE ASSESSMENT RESULT SABHESAN ET AL 2005 31 schizophrenic patients (ICD-10) Executive functions assessment schedule, trail making test, Raven’s matrices, fluency tests Patients had varying degrees of involvement of different dimensions of executive function tests. Poor performance on TMT and ravens matrices. DAS ET AL 2005 15 chronic schizophrenic patients (DSM-IIIR) 15 controls continuous performance task, Stroop test, Spatial task Positive correlation between negative symptoms and neurocognitive functions especially card sort test.

91. STUDY SAMPLE ASSESSMENT RESULT SHRINIVASAN & THARA ET AL 2005 100 chronic schizophrenic (DSM-IV) patients and 100 normal controls Tests from Wechsler memory scale, Wechsler adult intelligence scale, San Diego neuropsychological test battery, NIMHANS Schizophrenic patients performed poorly on all cognitive tests in comparison to normal controls. Cognitive deficits were related to gender, education, age, duration of illness, and presence of positive and negative symptoms. MALHOTRA ET AL 2006 14 childhood onset schizophrenia (COS) patients (ICD-10 DCR) Wisconsin card sorting test COS patients have difficulty in executive functioning Deficits similar to those of adult schizophrenia

92. STUDY SAMPLE ASSESSMENT RESULT KRISHAN DAS ET AL 2007 25 schizophrenic (DSM-IV) patients in remission and 25 normal controls Tests from PGI battery of memory dysfunction, NIMHANS neuropsychological battery, Rey- Osterrieth complex figure test, Frontal Assessment battery Patients with schizophrenia showed significant deficits on tests of attention, concentration, verbal and visual memory and tests of frontal lobe/executive function as compared to normal controls. No relationship was found between age, duration of illness, number of years of education and cognitive function. No statistically significant relationship between cognitive function and scores on the disability scale

93. STUDY SAMPLE ASSESSMENT RESULT TRIVEDI ET AL 2008 36 non-affected first degree full biological siblings of schizophrenic (DSM-IV) patients and 36 controls Wisconsin’s Card Sorting Test, Spatial Working Memory Test, Continuous Performance Test Sibling group had substantial cognitive deficits as compared to control group. Siblings from multiples families (>1 schizophrenic patient in a family) performed poorer as compared to simple families. BHATIA ET AL 2009 172 schizophrenic and schizoaffective patients (DSM-IV) and their parents (n =196) ; 120 controls TMT Cases as well as their parents showed more cognitive impairment than controls on the TMT

94. SUMMARY Poor cognitive function as compared to HCs and remitted schizophrenia patients perform poor on cognitive tasks as compared to active depressive patients. Left hemisphere involvement in the dysfunction primarily Significant deficits on attention, concentration, verbal and visual memory. Cases as well as their parents showed more cognitive impairment as compared to HCs.

95. II. BIPOLAR AFFECTIVE DISORDER STUDY SAMPLE ASSESSMENT RESULT TAJ ET AL 2005 30 bipolar disorder patients in remission 30 normal subjects Digit symbol test, Trail making test part A and B, Verbal fluency test, Digit span forward and backward test, Logical memory test, Paired association learning test, Visual design reproduction test Patients with bipolar disorder, in remission, have neuropsychological impairment in attention, memory and executive functioning TRIVEDI ET AL 2008 15 euthymic bipolar 1 patients 15 controls Wisconsin’s Card Sorting Test, Spatial Working Memory Test, Continuous Performance Test Euthymic bipolar patients showed significant deficits in executive functions.

96. STUDY SAMPLE ASSESSMNET RESULT SAREEN ET AL 2009 25 first degree non affected full biological siblings of bipolar affective disorder patients 25 controls Wisconsin’s Card Sorting Test, Spatial Working Memory Test, Continuous Performance Test. The sibling group performed poorly on cognitive domains studied as compared to controls.

97. SUMMARY Overall impairment in attention, memory and executive functioning Euthymic bipolar patients showed significant deficits in executive functions. First degree relatives of cases perform poorly than HCs.

98. INDIAN STUDIES COMPARING COGNITION IN SCHIZOPHRENIA AND BIPOLAR AFFECTIVE DISORDER

99. STUDY SAMPLE ASSESSMENT RESULT TRIVEDI ET AL 2006 15 stable maintained schizophrenia (DSM-IV) patients; 15 euthymic bipolar-1 (DSM-IV) patients; 15 controls Stable schizophrenia patients performed poorly on all the neurocognitive parameters as compared to both control and bipolar euthymic patients. PRADHAN ET AL 2008 48 euthymic bipolar (ICD-10) patients; 32 schizophrenia (ICD-10) patients in remission; 23 normal controls Wisconsin’s Card Sorting Test (WCST), Trail making test-B, Controlled words association test, PGI memory scale, Bhatia battery of performance tests of intelligence-Short scale, Bender visual motor Gestalt test, Trail A test When compared to controls, both bipolar disorder and schizophrenia patients were significantly impaired on different tests of executive function, memory, IQ and perceptuomotor functions. Schizophrenic patients consistently performed worse than bipolar disorder patients

100. SUMMARY Stable schizophrenia patients performed poorly on all the neurocognitive parameters as compared to both control and bipolar euthymic patients. Performance on cognitive tasks impaired in order: Active schizophrenia> remmision in schizophrenia> bipolar affective disorder> healthy controls

101. LIMITATIONS OF NEUROPSYCHOLOGICAL ASSESSMENT Varying Interpretations and Uses - Responsibility of the administering psychologist . - Two psychologists may interpret the results differently and take different courses of action. Uncertainty of Measurements a gap between what a test is attempting to measure and what it actually measures. nature of the tests often rely on indirect measures such as an individual responding to hypothetical situations. Decisions made in a testing situation are not always the same actions people would take when faced with the situation in reality

102. Changing Circumstances -continual development or refinement of psychological theories, development of technology and passage of time, psychological tests only remain relevant for a time. -Social or cultural changes can lead to test items becoming obsolete, or new psychological theories may replace the founding theories of the tests. - To remain valid and reliable, psychological tests must be updated often and norm samples should be kept current. 

103. Cultural Bias Once translated, the tests are no longer truly standardized. Anne et al 2006 cultural background of psychologist may hamper the results. Labelling and self fulfilling prophesy Stigma associated with labels such as Learning Disabled, ADHD, schizophrenia. Can result in a self-fulfilling prophesy E.g., person labeled as learning disabled is not expected to learn easily, resulting in lowered expectations, which in turns results in lesser opportunities. Costly and time consuming

104. A WORD ABOUT FUTURE “In no other area of science or technology has so little change been seen in the last 65 years”   Roger L. Greene,2011  Breaking free from current best practice might lead to advances in measurement procedures, the competing definitions and multiple valuations of reliability and validity, and identification and analysis. Integration of cognitive science and computer science is going on and hopefully will lead to several innovations in testing.

105. THANKYOU