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associated with self-initiated executed movements. Overall, according to this
model, the lack of representation of the intended and programmed movement
sequences as well as the lack of sensory inhibition during movement execution
lead patients to conclude that the executed movements must be foreign move-
ments. This illusion can also be achieved in healthy people by, for example, feed-
ing back their hand movements to them via a video camera with a certain delay,
so that there is a discrepancy between the visual and the sensory feedback of the
executed movements. In a study by Blakemore et al. (2003), the hypnotically sug-
gested extraneous influence experience was thereby accompanied by increased
activation of the parietal cortex and cerebellum compared to normal self-gener-
ated movements. This underpins the role of the parietal cortex in determining the
authorship of actions, which has now been demonstrated in a number of studies
(e.g. Chambon et al., 2014). There is also a growing body of evidence show-
ing that parietal regions (especially inferior and superior parietal gyrus, angular
gyrus), which play a central role in the representation of the self and its actions,
are conspicuously altered in patients with schizophrenia (see Guo et al., 2014 for
functional imaging findings).
5.3.2 Role of Executive Control Mechanisms
Some studies show that in the context of schizophrenia, the representation and
selection of options for action in the dorsolateral prefrontal cortex may already be
disturbed. This means that patients cannot form clear ideas about the actions they
intend to take, and as a result, actions that are taken are experienced as “alien”.
In contrast, the achievement of an action goal represented as “planned” triggers a
feeling of being “self-generated”. In his model of ego disorders, Behrendt (2004)
states that patients with schizophrenia additionally fail to inhibit action tenden-
cies that are irrelevant or dysfunctional for a given motivational status (e.g., if
one wants to adequately follow a lecture, one should not simultaneously check
Facebook). This insufficient inhibition of inappropriate action tendencies might
be related to an underactivation of the dorsolateral prefrontal cortex. At the same
time, the threshold for selecting action options that reach action execution is low-
ered, which in Behrendt’s model is attributed to a dopaminergic overactivation of
thallamo-cortical networks.
5.3 Ego Disorders
26
5 Neurocognitive Models of Positive Symptoms
Interim Summary
Both a deficient representation of actions and options for action in the fron-
tal brain and a faulty prediction of intended actions due to disturbed efference
copy signals in the parietal lobe are currently associated with ego disorders in
the context of schizophrenic psychoses.
27
Diagnostics and Therapy of Cognitive
Disorders
In recent years, international guidelines and standardized test batteries have been
published that are recommended for the diagnosis of cognitive impairment in
patients with schizophrenia.
6.1 Diagnostics
In recent years, international guidelines and standardized test batteries have
been published that are recommended for the diagnosis of cognitive impairment
in patients with schizophrenia. The development of such psychometrically reli-
able, valid, and objective instruments that can be used uniformly supports the
optimization of treatments for disorders from the schizophrenia spectrum. Fre-
quently, these test batteries are used in studies investigating the effectiveness of
new antipsychotics. One example of such a test battery is the NIMH-MATRICS
Consensus Cognitive Battery (MCCB) developed by the U.S. National Institute of
Mental Health. The acronym MATRICS stands for “Measurement and Treatment
Research to Improve Cognition in Schizophrenia”. The desirable characteristics
of such a test battery were determined by a preliminary survey of international
experts from various disciplines (scientists, clinical practitioners, pharmacists,
etc.) in the diagnosis and treatment of schizophrenia. In addition, all available
factor analytic results regarding the question of which cognitive functions are
particularly impaired in patients with schizophrenia were considered. The test
battery should also be suitable for repeated measurement and be able to relia-
bly map changes due to treatment effects. The final assessment battery now con-
tains ten standard tests selected in an extremely elaborate procedure, which map
seven cognitive domains: processing speed, attention/vigilance, working memory,
6
© Springer Fachmedien Wiesbaden GmbH, part of Springer Nature 2022
P. Thoma, Neuropsychology of Schizophrenia, Springer essentials,
https://doi.org/10.1007/978-3-658-36400-7_6
28
6 Diagnostics and Therapy of Cognitive Disorders
verbal learning, visual learning, logical reasoning and problem-solving, as well as
social cognition. The administration of all tests should take no more than 65 min
in total and is usually well tolerated by patients. Nuechterlein et al. (2008) pro-
vide details of the development and characteristics of the final test battery. The
commercially available version of the MCCB is also available in German (see
www.matricsing.org).
6.2 Therapy: Cognitive Remediation
The treatment of cognitive disorders in the context of schizophrenia is often
referred to as cognitive remediation, which aims to improve cognitive processes
in the long term based on systematic behavioral training. The aim is to general-
ize the training effects as broadly as possible to everyday situations. As is gener-
ally the case in neuropsychological rehabilitation, a distinction is made between
restitutive and compensatory approaches. Restitutive approaches aim to restore
or improve cognitive functions and their neuronal basis through repeated and
intensive training. This principle is based on the neuronal plasticity of the brain,
which states that the brain theoretically has the ability to develop and repair itself
throughout life. Compensatory approaches, on the other hand, take advantage of
the individual's intact cognitive abilities and environmental resources to compen-
sate for the limitations caused by impaired functioning. This may include, for
example, increased use of calendars or mobile apps to compensate for impaired
memory. Restorative approaches can work either “bottom-up” or “top-down”. In
the former case, basal functions such as attention are trained intensively first to
provide a solid foundation for improving more complex functions such as prob-
lem-solving. In the top-down approaches, on the other hand, complex metacog-
nitive strategies, such as error-free learning, are first practiced to improve more
basal neurocognitive functions. The generalization of what is learned dur-
ing therapy to different contexts in everyday life represents the long-term aim.
Cognitive remediation therapies may also differ in whether they address a sin-
gle cognitive domain (e.g., working memory) or a range of functions. It is also
possible in some of these therapies to tailor training specifically to the patient's
difficulties. In the following paragraphs, two computer-assisted programs will
be briefly presented as examples, which are particularly widespread in Ger-
man-speaking countries. These are the training packages Rehacom and Cogpack.
In addition, a new group therapeutic approach, the Integrated neurocognitive
therapy, introduced by Müller and Roder (2013), will be presented. In addition
to these more classical approaches of cognitive remediation, Box 1 will also
29
present the metacognitive training program of the Hamburg working group led
by Steffen Moritz. Based on the cognitive mechanisms described in Sect. 5.1.1,
which promote the genesis and maintenance of delusions, a therapy has been
developed that is intended to teach patients metacognitive strategies to overcome
unfavorable thought patterns.
6.2.1 Rehacom
Rehacom (Hasomed GmbH, 2006) is a program that is most frequently used in
Germany in the context of neuropsychological rehabilitation. It is, therefore, not
specifically geared to the needs of patients with schizophrenia but there is already
a range of evidence suggesting effectiveness for this group of disorders. The pro-
gram does not define a fixed training program for the respective disorders, but
the therapist is required to put together a training program based on the individ-
ual strengths and weaknesses of the patient. The following areas are trained in
20 training procedures with adaptively increasing levels of difficulty: attention
and concentration, memory, reactivity, logical reasoning/action planning, spatial
imagination, visual impairment, visuomotor disorders. The training procedures
can also be grouped into distinct thematic areas, such as the thematic area of
vocational rehabilitation, which includes test procedures on executive functions,
attention, and memory. The exercises can be done not only under the direct guid-
ance of a therapist but also at home. The program is now available in several lan-
guages.
6.2.2 Cogpack
The “Cogpack” program (Marker, 1999) was developed specifically for the cogni-
tive remediation of schizophrenia patients, although it is now used with a number
of psychiatric and neurological patient groups and is also available in other lan-
guages. The Cogpack contains a large number of tasks, from which the so-called
“Olbrich series” with 70 subtasks has been compiled specifically for the treatment
of patients with schizophrenia. Each training unit contains tasks from the func-
tional domains of reaction, concentration, processing of complex material, strat-
egy formation, memory, and logic, whereby only two of these functional areas are
trained in each unit. The level of difficulty can increase over different difficulty
levels as well as within the series and tasks of a level. The task composition con-
tains three levels of increasing difficulty, each comprising six series with four to
6.2 Therapy: Cognitive Remediation
30
6 Diagnostics and Therapy of Cognitive Disorders
six exercises. The course of training is adaptive so that the presentation of the
individual tasks and difficulty levels depends on the achievement of certain per-
formance criteria (for details, see Bender et al., 2003). The training can also be
presented in a group setting, whereby a maximum number of six to seven partici-
pants is recommended.
6.2.3 Integrated Neurocognitive Therapy (INT)
Integrated neurocognitive therapy (INT), developed by Roder and Müller (2013),
addresses the problem areas defined by the MATRICS initiative (Sect. 6.1) and
translates them into therapeutic treatment concepts that are applied in the con-
text of a cognitive-behavioral group training. The aim is to improve both neuro-
cognitive functions (information processing speed, attention/vigilance, verbal and
visual learning, and memory, working memory, thinking, and problem-solving)
and sociocognitive functional areas (emotion perception, social perception, the-
ory of mind, social schemas, social attributions). These eleven cognitive func-
tional areas are assigned to four therapy modules, whose fixed sequence involves
an increase in the degree of difficulty and emotional load of the therapy content
while at the same time decreasing structuring by the therapist. Each module con-
tains cognitive-behavioral therapy exercises in the two domains of neurocognition
and social cognition. In addition to improving the eleven domains of function-
ing identified by the MATRICS initiative, the sessions are designed to promote
insight, knowledge, motivation, and self-efficacy expectations. Reduction of
negative symptoms and improvement in psychosocial functioning are second-
ary goals of therapy. The program is based on both restorative and compensatory
therapy approaches and integrates computer-assisted exercises from the Cogpack
(Sect. 6.2.2) to train the neurocognitive functional areas. In addition, especially
for the training of social cognition, films, worksheets, case vignettes, and infor-
mation sheets are used as therapy materials and classic psychoeducational and
cognitive-behavioral intervention strategies are employed. In any case, the com-
plex structure of the training requires psychotherapeutic skills to ensure success-
ful implementation. A first randomized multicenter study on the effectiveness of
the training was able to demonstrate significant improvements in the trained areas
as well as with regard to the secondary therapy goals.
31
6.2.4 Mode of Action of Cognitive Remediation
and Assessment
Recent reviews (Barlati et al., 2013; Vita et al., 2014) on the use of cogni-
tive remediation therapies in the treatment of schizophrenia patients conclude
that they can indeed effectively improve cognitive and psychosocial functions.
This effect is said to be particularly pronounced for severely and chronically
ill patients. A reduction in psychotic psychopathology per se is not always to
be expected and is most likely to be brought about indirectly. This may occur,
for example, by improved performance in individual functional domains, such
as cognitive flexibility, having an indirect positive effect on specific symptom
domains, such as rigid delusional thinking. It should also be noted that patients
only cope better in their daily lives if cognitive remediation is embedded in
comprehensive rehabilitation programs. These should use the building blocks of
cognitive rehabilitation aimed at training cognitive functions for e.g. vocational
reintegration. It should be critically noted that the computer-assisted therapy pro-
grams in clinics, in particular, are frequently not used by appropriately trained
specialist staff but are carried out by nursing staff or occupational therapists, for
example, and that the potential of the training effects may therefore frequently not
be sufficiently exploited.
Clinical experience of users of cognitive training programs as well as corre-
sponding research studies shows that with schizophrenia patients, increases in test
performance in the individual tasks are indeed achieved with consistent training
and that the training is often well accepted and tolerated by the patients. However,
the generalizability of the successes to everyday functions proves to be problem-
atic, since it could not always be convincingly demonstrated that the performance
improvements also become demonstrable in everyday lives. A cognitive approach
that is nevertheless directly aimed at the targeted improvement of specific symp-
tom areas, known as metacognitive training, is presented in the box of the same
name.
6.2 Therapy: Cognitive Remediation
32
6 Diagnostics and Therapy of Cognitive Disorders
Metacognitive Training (Cf. Moritz Et Al. 2014)
Concept
• Metacognitive training (MCT) for schizophrenia addresses the
described cognitive distortions and impairments that contribute sig-
nificantly to delusions. The main goal is to sow doubt and challenge
entrenched interpretations.
• MCT involves a mixture of psychoeducation and approaches adapted
from cognitive behavioral therapy and cognitive remediation.
• It contains eight modules in two parallel versions, which can be worked
on in the form of exercises using a PowerPoint presentation with
patients in individual therapy (MCT + ) or groups.
• It is available for free download at www.uke.de/mkt. The group training
has now been translated into 33 languages, the individual program into
7 languages.
• Each module contains numerous exercises from which the therapist can
individually compile the most suitable and helpful tasks for the patient/
group.
• “Homework” with further exercises forms another component.
• Patients are given cards with “metacognitive instructions” to carry with
them at all times. These cards contain instructions that help patients to
question their interpretation of situations in which they feel threatened.
Module
Attribution: The learning objective is to consider different explanations
(self, others, circumstances) for positive and negative events. The neg-
ative and positive consequences of self-esteem-serving attributions are
clarified.
Jumping to conclusions I: The negative consequences of jumping to con-
clusions are addressed.
Changes in beliefs: To teach consideration of counter-arguments and alter-
native views. Also, to raise awareness of the need to obtain sufficient
information before changing beliefs.
33
Empathy I: To highlight that facial expressions are sometimes misleading
in social situations and that additional information needs to be taken
into account to arrive at valid interpretations.
Memory: The learning objective is to clarify the “constructive nature” of
memory. Also, confidence in the accuracy of one’s memories should be
linked to the existence of secure clues.
Empathy II: This module teaches that there are often no clear-cut interpre-
tations for social situations and, in turn, a variety of information should
be used to make decisions.
Jumping to conclusions II: The disadvantages of jumping to conclusions
are highlighted.
Mood and self-esteem: Here, general strategies for mood enhancement
and raising self-esteem are taught, which can also be usefully applied in
the context of other disorder groups (e.g. depression).
Evaluation
• MCT shows good patient acceptance, which is an important prerequisite
for treatment compliance.
• Delusional symptoms and the tendency to jump to conclusions can be
demonstrably reduced by the program, with medium to high effect sizes
in some cases.
Interim Summary
In cognitive remediation therapies for schizophrenia, computer-based train-
ing is mostly used to improve classical neuropsychological functional areas,
with unclear generalization effects on everyday functions and psychopathol-
ogy. Integrated neurocognitive therapy, on the other hand, also takes sociocog-
nitive functions into its focus. Metacognitive training is mainly aimed at the
metacognitive modification of thinking styles that predispose to the develop-
ment and maintenance of delusions.
6.2 Therapy: Cognitive Remediation
35
Summary
Schizophrenia is a developmental, neurobiologically determined disorder that is
associated with structural and functional changes in frontotemporal and fronto-
subcortical circuits at the neuronal level.
Schizophrenia is a developmental, neurobiologically determined disease,
which is accompanied at the neuronal level particularly by structural and func-
tional changes in frontotemporal and frontosubcortical circuits. These are partly
associated in a distinct way with the heterogeneous symptoms: Negative symp-
tomats primarily reflect abnormalities in brain regions associated with executive
action control, anticipatory processing of rewarding experiences, and social cog-
nition. Delusion formation is mainly promoted by inadequate processing of con-
textual information and jumping to conclusions, both associated with impaired
communication between frontal and temporal lobes. Auditory-verbal hallucina-
tions and ego disorders are currently explained mainly by impaired prediction
of intended (linguistic) actions, accompanied by abnormalities in frontoparietal
areas. In general, cognitive disturbances often occur long before the onset of the
disease and remain relatively stable after the typical drop in performance shortly
before the onset of psychosis and after the age of 65. The treatment of cognitive
abnormalities with different approaches of cognitive remediation, integrated neu-
rocognitive therapy, and metacognitive training proves to be promising in various
respects.
7
© Springer Fachmedien Wiesbaden GmbH, part of Springer Nature 2022
P. Thoma, Neuropsychology of Schizophrenia, Springer essentials,
https://doi.org/10.1007/978-3-658-36400-7_7