COGNITIVE REHABILITATION

The first descriptions and studies on cognitive impairment in schizophrenia were created over a hundred years ago. However, most of this period was characterised by misconceptions of the causes of the impairment, as well as a clear lack of understanding of the impact this cognitive dysfunction had on other areas of functioning in a patient. Recent studies have shown that cognitive impairment is a core feature of schizophrenia. For example, Fiovaranti et al. (2005), in a review on cognitive deficits in adults with schizophrenia, identified 1275 studies made in this field between 1990 and 2003 (see also Heinrichs, 2005 for a comprehensive view of quantative evidence demonstrating the relevance of cognition as integral part of schizophrenia). Indicating that the deficits are not caused by other collateral aspects of the disorder, but by the illness itself. In fact, for several authors, schizophrenia is largely an essentially neurocognitive disorder (Andreasen, Paradiso & O’Leary, 1998; Green & Nuechterlein, 1999; Elvevag & Goldberg, 2000; Saykin, Shtasel, Gur, Kester, Mozley, & Stafiniak, 1994; Sharma & Harvey, 2000). Although cognitive deficits had already been described when Kraepelin referred to the decline in mental abilities of his patients, it is only recently that professionals have identified and agreed on the areas affected. The implementation of various initiatives in the United States such as the MATRICS project (Measurement and Treatment Research to Improve Cognition in Schizophrenia) has made it clear that there is still an issue as yet to be resolved: how to improve cognition. In addition to the project’s interest in improving cognition by discovering new drugs, professionals active in this field are also looking into how to improve psychological treatment focussed on rehabilitation or cognitive training for schizophrenia. The professionals involved in the MATRICS project have reached consensus on the cognitive areas that are impaired in patients with schizophrenia: Attention/Vigilance; Speed of Processing; Working Memory; Verbal Learning and Memory; Visual Learning and Memory; Reasoning and Problem Solving and Social Cognition (Kern, Green, Nuechterlein & Deng, 2004; Marder & Fenton, 2004). In the third meeting of the CNTRICS project (Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia), it was agreed (Barch, Braver, Carter, Poldrack & Robbins, 2009) that 6 areas or cognitive domains suffered impairment in schizophrenia: perception, working memory, attention, executive functions, long-term memory and social cognition. Yet however important it may well be to agree on areas, the cognitive deficits that have been shown to have a consistent relationship with the evolution of the illness in the long-term are the following: memory, executive functions and attention (Muñoz & Tirapu, 2001). In recent decades interest in these deficits has been growing rapidly, judging, for example, by the number of empirical research papers published in recent years in journals such as Schizophrenia Bulletin, Schizophrenia Research and Psychiatry Research,aiming to discover which cognitive functions are affected, to what extent, with which consequences and how these relate to disease factors (symptoms, social functioning,duration, hospitalization, etc.). Similarly, in recent decades a whole host of programs has been developed to improve cognitive functioning in schizophrenia, and cognition training has become a regular component of treatment programs for people suffering from schizophrenia (Be- llack, Gold, & Buchanan, 1999; Green, Kern, Braff, & Mintz, 2000). This review aims to describe the principal intervention programs currently available in this field and to present empirical data substantiating their efficiency. Assuming that a broad and intensive activation of neural processing systems can stimulate neural resources to improve their functioning (neuroplasticity), one could expect that intense activation of the cognitive systems damaged in patients with schizophrenia would lead to a general and lasting functional improvement. It is from this basic premise that several cognitive training strategies have been developed (Wexler & Bell, 2005). Although researches have used different terminology to describe them, the three most commonly used strategies are “Cognitive Remediation”, “Cognitive Rehabilitation” and “Cognitive Training” (Twamley, Jeste, & Bellack, 2003). “Remediation” implies a curative treatment. Webster (1986) defines “rehabilitation” as to restore to a state of health or normal activity. In medical terms, “rehabilitation” implies restoring functionality to premorbid levels or to a normal or near normal condition with regard to operation, performance and execution. Brain developmental disorders associated with schizophrenia (Green & Nuechterlein, 1999) mean that it is difficult to easily identify premorbid levels of functioning and normal or near normal functioning may rarely be possible. Thus, “remediation” and “rehabilitation” do not seem to be the most satisfactory terms. The term “habilitation”, meaning educating or training persons with disability to improve their ability to function in society" (Taber, 1997) may be more appropriate. “Training” is defined as “an organised system of education, instruction or discipline” (Stedman, 1995) or “the teaching, drill or discipline by which powers of mind or body are developed” (Webster, 1986). These reflections illustrate that the most fitting term in this field of work could well be cognitive training.