NEUROPSYCHOLOGICAL ASSESSMENT IN SEVERE MENTAL ILLNESS

PRESENTER Dr. HarneetMODERATOR- Dr. Nitin Gupta

23/7/2016NEUROPSYCHOLOGICAL ASSESSMENT IN SEVERE MENTAL ILLNESS

NEUROPSYCHOLOGYNeuropsychology 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 brainbehavior relationships and the application of such knowledge to human problems.American Psychological Association, 2010

NEUROPSYCHOLOGICAL ASSESSMENTNeuropsychological assessment/testing is a process by which a persons 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

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

COGNITIVE DOMAINTESTS USEDATTENTION patients ability to attend to a specific stimulus without being distracted by internal or external environmental stimuli.Three types of attention- Selective attention/focused attentionSustained attentionDivided attention

Digit span distraction testContinuous performance testDual task testBrief test of attention (BTA) D2 test of attentionGordon diagnostic systemPaced auditory serial addition task (PASAT)Quotient test of attentionStroop color namingSymbol digit modalities testTest of variables of attentionTrail making test

COGNITIVE DOMAINTESTS USED2. MEMORYrefers to a process of encoding, storage and retrieval of learnt material.Immediate RecentRemote (Long term memory divided intoExplicit and implicit memory)WORKING MEMORYrefers 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 testWechsler memory scaleBenton visual retention testReys complex figure testBoston remote memory batteryRemote memory battery by squire and co workersPGI memory scale

COGNITIVE DOMAINTESTS USED3. INTELLIGENCECapacity for learning and ability to recall, to integrate constructively, and to apply what one has learned; the capacity to understand and to think rationallyWechsler adult intelligence performance and verbal scale indian adaptation.Stanford binet intelligence testBhatias battery of performance of intelligenceProteus maze testRavens standard progressive matricesReynolds intellectual assessment scalePeabody pictute vocabulary testKaufmann intelligence test

COGNITIVE DOMAINTESTS USED4. EXECUTIVE FUNCTIONSrefers 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 testCategories test and Trail making testsStroop colour word interference testTower of london tasksProblem solving-Porteus maze testPsychomotor Skills-Grooved peg board,Finger tapping.

COGNITIVE SCREENING TOOLS FROM INDIA1. PGI BATTERY OF BRAIN DYSFUNCTION(PGIBBD)Parshad and Verma,1990Revised Bhatias Short Battery of Performance Tests of Intelligence Verbal Adult Intelligence Scale PGI-Memory Scale Nahor Benson Test Bender Visual Motor Gestalt Test2. Hindi Mental State Examination (HMSE) Ganguli et al., 1996DOMAINS ASSESSED - HMSE total Calculation Word list learning, recall & recognition Object Naming Verbal fluency (category animals & fruits) Constructional praxis3. NIMHANS Neuropsychological Battery, 2004 SL, Subbakrishnan DK Gopulkumar K,Bangalore.

TESTS INCLUDED IN NIMHANS BATTERYLOBESFUNCTIONSTESTSFRONTAL LOBEMotor functionsMotor speedMotor coordinationFinger tapping test (reitan 1970)Hand tapping (luria 1966)AttentionSustained attention Focused attentionColour cancellationColor trails test trail A and BExpressive speech Repetitive speechNominative speechNarrative speechRepeating soundsRepeating wordsCategorical namingObject namingSentence construction

LOBES FUNCTIONS TESTSContdExecutive functionsVerbal fluencyDesign fluencyVerbal working memoryVisuospatial working memoryPlanningShift of setPhenomic 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) 1995Proteus maze (Proteus 1965)Wisconsin card sorting test (Heaton chelune, talley, kay and Curtis 1993)

LOBESFUNCTIONSTESTSPARIETAL LOBEVisuo perceptual ability Motor free visual perception test(collarusso and Hammil, 1972)Visuo conceptual abilityPicture completion (MISIC 1969)Visuo constructive abilityBlock 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 comprehensionWriting Writing to dictation copyingCalculation Age appropriate sums

LOBESFUNCTIONSTESTSTEMPORAL LOBE Verbal comprehension Token test ((De Renzi and Vignolo, 1962)Verbal language and memoryRey s auditory verbal learning test(maj et al 1993)Visual learning and memory Memory for designs (jone sgotman and miner 1986)

PURPOSE OF NEUROPSYCHOLOGICAL ASSESSMENT

DIAGNOSIS&SCREENING

NOT A PRIMARY DIAGNOSTIC TOOL BUT CAN AID IN PREDICTIONPROVIDES BEHAVIORAL DATA FOR LOCALIZING THE SITE OF A LESIONUSEFUL IN DISCRIMINATING BETWEEN PSYCHIATRIC AND NEUROLOGICAL SYMPTOMSTO DISTINGUISH BETWEEN DIFFERENT NEUROLOGICAL CONDITIONS

PATIENT CARE & PLANNINGCOGNITIVE STATUS & PERSONALITY CHARACTERISTICSUNDERSTANDING OF PATIENTS CAPABILITIES AND LIMITATIONS+PSYCHOLOGICAL CHANGES

SUCCESSIVE NEUROPSYCHOLOGICAL ASSESSMENTS REPEATED AT REGULAR INTERVALS THROUGH OUT THE COURSE OF AN ILLNESSRELIABLE INDICATOR OF IMPROVEMENT ; EARLY PREDICTOR OF DEMENTING COURSE

PSYCHOSOCIALREPURCUSSIONSDEFECTS IN MOTIVATIONDEFECT IN ABILITY TO PLANDEFECT 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.

REHABILITATION & FUNCTIONAL SKILLS ASSESSMENTPREDICTION OF REHABILITATION NEEDSPREDICTION OF ABILITY OF PATIENT TO FUNCTION INDEPENDENTLY

PREDICTS PATIENTS ABILITY TO RESUME NORMAL ROUTINE ACTIVITIES

managing a familyReturning to home from workResuming school

The importance of early assessment and interventionA comprehensive neuropsychological assessment evaluating a full range of behavior should be completed early.Reitan and wolfson 2001Decreases the likelihood of patients 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.

RESEARCHTO STUDY ORGANISATION OF BRAIN ACTIVITIES AND ITS TRANSLATION TO BEHAVIORINVESTIGATING PSYCHIATRIC ILLNESSESDEVELOPMENT, EVALUATION AND STANDARDIZATION OF NEUROPSYCHOLOGICAL ASSESSMENT TECHNIQUES

MEDICOLEGAL PURPOSESPERSONAL 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 NEUROPSYCHOLOGISTTo rule out any brain dysfunction or any underlying pathology contributing to the incident.

In president Kennedys murder investigations, a neuropsychologist determined that the defendants 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.

DISABILITY ASSESSMENTASSESSMENT OF PERSON WITH PHYSICAL DIFFICULTYMotor impairment and comorbiditiesASSESSMENT OF PERSONS WITH VISUAL IMPAIRMENT OR BLINDNESSVerbal spatial factor, perceptual motor factor and emotional coping factorASSESSMENT OF PERSONS WITH HEARING IMPAIRMENTASSESSMENT IN SCHOOLS FOR LEARNING DISABILITY

7. OTHERS

Recruitment in defense, federal aviation, govt setups including arithematic performances , sports medicine which includes assessment of General Cognitive abilitiesAcademic AchievementSensory Perceptual SkillsMotor speed, coordination, and planning Attention, Concentration and mental processing speed in visual and auditory modalities Comparison of right and left hand performanceAssessment 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.

COGNITIVE DEFICITSCognitive deficits may result in inability to:Pay attention Process information quicklyRemember and recall informationRespond to information quicklyThink critically, plan organize and solve problemsInitiate speech

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.

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

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

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.

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

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.

COGNITIVE DEFICITS IN SCHIZOPHRENIA

Developmentally based subtle deficitsIllness onset related severe deficitsLimit normal acquisition of cognitive skillCompromise cognitive skill already acquired

ASSESSMENT IN SCHIZOPHRENIA

FOR MEMORYFOR 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 2004California verbal learning testWechsler memory scaleBenton visual retention testReys complex figure testBoston remote memory batteryRemote memory battery by squire and co workers

Digit span testFocused attention by Color trials testSustained attention by Digit vigilance testDivided attention by triad test by NIMHANS Battery- (Rao et al 2004)Continuous performance testStroop color namingSymbol digit modalities testTrail making testBrief test of attention (BTA)D2 test of attentionGordon diagnostic systemPaced auditory serial addition task (PASAT)Quotient test of attentionSymbol digit modalities test

FOR INTELLIGENCEFOR EXECUTIVE FUNCTONSWechsler adult intelligence performance and verbal scale indian adaptation. (Prabhalnga swami)Stanford binet intelligence testBhatias battery of performance of intelligenceProteus maze testRavens standard progressive matricesReynolds intellectual assessment scalePeabody pictute vocabulary testKaufmann intelligence test

Wisconsin card sorting test (WCST)Verbal and visual fluency testCategories test and Trail making testsStroop colour word interference testTower of london tasksProblem solving-Porteus maze testPsychomotor Skills-Grooved peg board,Finger tapping.

BATTERIES USED IN SCHIZOPHRENIA

MCCB ( MATRICS consensus cognitive battery)BACS ( brief assessment of cognition in schizophrenia)

SPECIFIC COGNITIVE DEFICITS IN SCHIZOPHRENIA

I. MEMORY DEFICITS

PATIENT PRESENTATIONDisorientation and forgetting intervening eventsInability to recall everyday information: dependent livingDifficulty learning demands of job or learning new information Social deficits worsened (learn names & details of acquaintances) Green et al, 2000

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

Due to impairment in stimulus modality, verbal characteristics, sequence and generation status- social, occupational and communication impairment Hofer et al, 2005Working 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

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

II. ATTENTION DEFICITS

PATIENT PRESENTATIONDifficulty to identify and focus on information in environment.Living in world where every stimulus is a new stimulusInability to adjust physiological reactivity to experience.Harvey et al, 2002

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 1985By the time patients experience their first episode of psychosis, attentional impairments are typically present and of moderate severity Caspi et al 2003

Meta-analytic studies suggest moderate to severe impairments in this attention domain.Reichenberg ,2010Deficits 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 andin children of schizophrenic parents.Nuechterlein, 1986Attention deficits have been found to be robustly associated with deficit syndrome.Ross et al , 1997

III. EXECUTIVE FUNCTIONSPATIENT PRESENTATIONFunctional 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

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 1999Perhaps because they encompass so many sub-component processes, the executive functioning tasks are consistently among the best predictors of functional performance.

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

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 2004Importantly, 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).

GENERAL INTELLIGENCEPatients 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 2006As 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

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 2006Further, 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

VERBAL FLUENCYPatients 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 1998Not surprisingly, deficits in verbal fluency are associated with poor interpersonal functioning (Addington and Addington 2000) and community functions (Rempferet al 2003).

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

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 2004Verbal 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

WORKING MEMORY DEFICITImpaired planning, reasoning and problem solvingImpaired verbal fluencyLower intelligenceImpaired attention Impaired verbal fluencyImpaired visuospatial processing

ROLE IN FUNCTIONAL OUTCOME

MANAGEMENTNeed 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.

Pharmacological Antipsychotics1st generations or typical or conventional.2nd generations or atypical.Cognitive enhancers

PHARMACOLOGICAL-TYPICALTypical 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

Pharmacological-typical Compound Effect AuthorsChlorpromazine Mixed, usually no effectPigache 1993Solo et al 1997Haloperidol Mixed, usually no effectGilbertson et al 1997Serper et al 1990 Fluphenazine+ thioridazieneNo effect/ worsenedStrauss et al 1990Zahn et al 1994Flupenthixol depotMixed David 1995

Pharmacological-atypicalCognitive improvements are reported Keefe and McEvoy 2001These 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

Atypical antipsychotics

Drugs Functions improved Quetiapine Verbal fluency, recall, cognitive flexibility, visuo- motor trackingOlanzapine Verbal fluency, memory, vigilance, working memoryRisperidone Episodic memory, verbal fluency, vigilance, executive skills, visuo-motor speedClozapine Working memory, executive skills, motor function

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. Dsouza et al,2013Significant improvement in attention, abstraction and mental flexibility.Bhatia et al, 2012

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 neuroplasticityNeuroprotective effects against grey matter loss in temporal brain regions associated with cognition +Increased serum BDNF levelsThorsen et al, 2014Michalopoulou et al, 2015Penades et al, 2013

INDIAN STUDIES IN COGNITIVE REHABILITATIONAUTHORSAMPLEINTERVENTION RESULTDsouza et al, 2013India: 104 randomized Mixed, double-blind, placebo-controlled, Stratied random sampling by IQ. Assessments: at 12 and 24 weeksCRT, Computerized (20 computer- assistedtasks And placebo

Improved attention/vigilance and verbal working memory only, high placebo response. No effect of CRT on global cognitive index.Suresh kumar, 2008DSM IV schizophreniaattending vocational rehabilitation for 6 months, controls: no vocational rehabilitationVocational activities, fullday, as per ability, in the hospital.Cognitive functioningpositively correlated With occupational role In patients and negativecorrelation in controls.

AUTHORSAMPLEINTERVENTION RESULT

Hegde et al, 2012First episode schizophrenia: ICD10 criteria, duration of illness BIPOLAR 2VERBAL MEMORYBIPOLAR 1 >BIPOLAR 2WORKING MEMORYBIPOLAR 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 2000Torrent et al, 2006

EUTHYMIAEuthymia 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, 2011Euthymic 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 2013WORKING MEMORY patients have poorer working memory capacity and spatial working memory than HCs including declarative or long-term memory impairments. Bora et al 2010

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 2000Deficits are seen in PROCESSING SPEED and ATTENTION in euthymic stage of illness. lee et al 2014DEFICITS 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

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,2014ATTENTION DEFICITSPatients 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.

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,2010IMPAIRED PROCESSING SPEED AND DECISION MAKINGOn Cambridge decision making task , depressed patients show slower decision making times than HCs.Clark et al 2005PLANNING AND RESPONSE TO NEGATIVE FEED BACKDepressed 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 BIASbias 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

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,2004Unaffected 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,2008Different authors have given statements in the past decade with evidence most in the favor of -VERBAL WORKING MEMORY-EXECUTIVE FUNCTIONSArts et al,2009; Emre et al 2008; Vicent et al 2008

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

FUNCTIONAL OUTCOME 30 50% of patients with BPAD experience significant social disability that may be related to persistent cognitive impairment. Dickerson et al 2004no 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

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

ILL EFFECT OF MEDICATION ON COGNITIONSTUDIES 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 2009an increase in the daily dose of antipsychotic medication trended towards poorer processing speed in FEM patients Hellvin et al,2012

AGAINST THE MOTIONlong-term lithium usage is unlikely to cause progressive cognitive declineDavid et al 2007Strakowski 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

SCOPE OF RESEARCHThe 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

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,2002differences 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 2006Patterns 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

summaryPoor 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.

INDIAN RESEARCH

I. SCHIZOPHRENIASTUDYSAMPLE ASSESSMENTRESULTNIZAMI ET AL1992 40 schizophrenic (DSM III) patients, 30 brain damaged patients and 30Luria Nebraska neuropsychological batterySchizophrenic patients perform better than brain-damaged but had poor performance than in comparison to normal controls.ANANTHNARAYAN ET AL 199324 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 testRemitted schizophrenics performed poorly on all these measures as compared to neurotic depressives.

STUDY SAMPLE ASSESSMENT RESULTMANDAL ET AL 199912 schizophrenics (DSM-III R) each with predominantly positive and negative phenomenology; 12 healthy controlsRecognition of Emotion sub-test of the Penn Facial Discrimination TaskSchizophrenic 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 200260 schizophrenic patients (ICD-9)Luria Nebraska neuropsychological batteryPattern of performance in tests indicated possibility of combined cerebral dysfunction, more towards left hemisphere functions

STUDYSAMPLE ASSESSMENTRESULTSABHESAN ET AL 200531 schizophrenic patients (ICD-10)Executive functions assessment schedule, trail making test, Ravens matrices, fluency testsPatients had varying degrees of involvement of different dimensions of executive function tests. Poor performance on TMT and ravens matrices.DAS ET AL 200515 chronic schizophrenic patients (DSM-IIIR) 15 controlscontinuous performance task, Stroop test, Spatial taskPositive correlation between negative symptoms and neurocognitive functions especially card sort test.

STUDYSAMPLE ASSESSMENTRESULTSHRINIVASAN & THARA ET AL 2005100 chronic schizophrenic (DSM-IV) patients and 100 normal controlsTests from Wechsler memory scale, Wechsler adult intelligence scale, San Diego neuropsychological test battery, NIMHANSSchizophrenic 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 200614 childhood onset schizophrenia (COS) patients (ICD-10 DCR)Wisconsin card sorting testCOS patients have difficulty in executive functioning Deficits similar to those of adult schizophrenia

STUDYSAMPLE ASSESSMENTRESULTKRISHAN DAS ET AL 200725 schizophrenic (DSM-IV) patients in remission and 25 normal controlsTests from PGI battery of memory dysfunction, NIMHANS neuropsychological battery, Rey-Osterrieth complex figure test, Frontal Assessment batteryPatients 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

STUDY SAMPLEASSESSMENTRESULTTRIVEDI ET AL 200836 non-affected first degree full biological siblings of schizophrenic (DSM-IV) patients and 36 controlsWisconsins Card Sorting Test, Spatial Working Memory Test, Continuous Performance TestSibling 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 2009172 schizophrenic and schizoaffective patients (DSM-IV) and their parents (n =196) ; 120 controlsTMTCases as well as their parents showed more cognitive impairment than controls on the TMT

SUMMARYPoor 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 primarilySignificant deficits on attention, concentration, verbal and visual memory.Cases as well as their parents showed more cognitive impairment as compared to HCs.

II. BIPOLAR AFFECTIVE DISORDERSTUDYSAMPLEASSESSMENTRESULTTAJ ET AL 200530 bipolar disorder patients in remission 30 normal subjectsDigit 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 testPatients with bipolar disorder, in remission, have neuropsychological impairment in attention, memory and executive functioningTRIVEDI ET AL 200815 euthymic bipolar 1 patients 15 controlsWisconsins Card Sorting Test, Spatial Working Memory Test, Continuous Performance TestEuthymic bipolar patients showed significant deficits in executive functions.

STUDYSAMPLEASSESSMNETRESULTSAREEN ET AL 200925 first degree non affected full biological siblings of bipolar affective disorder patients 25 controlsWisconsins Card Sorting Test, Spatial Working Memory Test, Continuous Performance Test.The sibling group performed poorly on cognitive domains studied as compared to controls.

SUMMARYOverall impairment in attention, memory and executive functioningEuthymic bipolar patients showed significant deficits in executive functions.First degree relatives of cases perform poorly than HCs.

INDIAN STUDIES COMPARING COGNITION IN SCHIZOPHRENIA AND BIPOLAR AFFECTIVE DISORDER

STUDY SAMPLE ASSESSMENTRESULTTRIVEDI ET AL 200615 stable maintained schizophrenia (DSM-IV) patients; 15 euthymic bipolar-1 (DSM-IV) patients; 15 controlsStable schizophrenia patients performed poorly on all the neurocognitive parameters as compared to both control and bipolar euthymic patients.PRADHAN ET AL 200848 euthymic bipolar (ICD-10) patients; 32 schizophrenia (ICD-10) patients in remission; 23 normal controlsWisconsins 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 testWhen 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

SUMMARYStable 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

LIMITATIONS OF NEUROPSYCHOLOGICAL ASSESSMENTVarying Interpretations and Uses- Responsibility of the administering psychologist .- Two psychologists may interpret the results differently andtake different courses of action.Uncertainty of Measurementsagap 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

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 testsmust be updated often and norm samples should be kept current.

Cultural BiasOnce translated, the tests are no longer truly standardized. Anne et al 2006cultural background of psychologist may hamper the results.Labelling and self fulfilling prophesyStigma associated with labels such as Learning Disabled, ADHD, schizophrenia.Can result in a self-fulfilling prophesyE.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

A WORD ABOUT FUTUREIn no other area of science or technology has so little change been seen in the last 65 yearsRoger L. Greene,2011Breaking 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.

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