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Int J Psychiatry Clin Pract 2015; 19: 246–252.

© 2015 Informa Healthcare


ISSN 1365-1501 print/ISSN 1471-1788 online. DOI: 10.3109/13651501.2015.1084328

ORIGINAL ARTICLE

Differences in cognitive function and daily living informahealthcare.com/ijpcp

skills between early- and late-stage schizophrenia


Sung-Jin Kim1, Joo-Cheol Shim2, Bo-Geum Kong1, Je-Wook Kang1, Jung-Joon Moon1,
Dong-Wook Jeon1, Young-Soo Seo3, Min-Kyung Oh4 & Do-Un Jung1
1
Department of Psychiatry, Busan Paik Hospital, Inje University, Busan, Korea, 2Shim Joo Cheol Psychiatry
Clinic, Busan, Korea, 3Department of Psychiatry, Sharing and Happiness Hospital, Busan, Korea, and
4
Department of Clinical Pharmacology, Busan Paik Hospital, Inje University, Busan, Korea

Abstract
Objectives. Cognitive dysfunction is a core feature of schizophrenia; deficits often manifest prior to diag-
nosis and persist throughout the course of the illness. This study was performed to assess the difference
in cognitive function and daily living skills between the early- and late-stage schizophrenia. Methods.
Fifty-five clinically stable patients with schizophrenia were recruited (25 with ⬍ 5-year and 30 with ⬎
5-year disease durations). We evaluated subjects’ clinical states, cognitive function, and psychosocial
factors. The Korean versions of MATRICS Consensus Cognitive Battery and UCSD Performance-based
Skills Assessment were used for evaluating cognitive function and daily living skills. Chi-square, Wil-
coxon rank sum, and t-tests were used to analyze the data. Results. The two groups did not differ for most
demographic variables. No significant differences between groups were found for clinical symptoms,
psychosocial factors, or non-social cognitive domains. However, the early-stage group had higher social
cognition domain scores than the late-stage group (p ⫽ 0.01). Early-stage patients scored significantly
higher than those in the late-stage group did in the communication and comprehension/planning do-
mains (p ⫽ 0.037 and 0.027, respectively), and total score (p ⫽ 0.003) of the Performance-based Skills
Assessment. Conclusions. We observed significant differences between patients with early- and late-stage
illness with regard to social cognition and performance-based skills.
Key words: Cognition, psychosocial factors, schizophrenia
(Received 12 January 2015; accepted 13 August 2015)

Introduction disease onset (Rajji et al. 2009). Additional cognitive deficits


Schizophrenia is a chronic psychiatric disorder that causes after the first episode were rare (Addington et al. 2005). Cog-
long-lasting disabilities in major domains of the patient’s nitive deficits are stable throughout the lifetime for most of
daily life (Wiersma et al. 2000). Patients with schizophrenia the patients (Heaton et al. 2001). There is some evidence for
typically manifest symptoms in early adulthood and expe- cognitive decline in executive functions in elderly patients
rience difficulties in social and occupational functions and with schizophrenia (Fucetola et al. 2000). Sponheim et al.
independent living thereafter (McGlashan 1988). Many (2010) compared cognitive functions in early- and late-stage
chronic patients with schizophrenia live in assisted living patients with schizophrenia, and both groups showed simi-
facilities and long-stay institutions (Cohen et al. 2000). Less lar cognitive deficits. However, there was a significant cor-
than 15% patients with schizophrenia are engaged in paid relation between worse episodic memory recall and illness
employment (Slade and Salkever 2001). duration.
Cognitive dysfunction is one of the core symptoms of Cognitive deficits in patients with schizophrenia have
schizophrenia, and is closely related to everyday func- shown a relationship with functional impairments (Green
tioning, prognosis, and quality of life (Green et al. 2004). et al. 2000). However, findings are limited in that they do
Patients with schizophrenia exhibit deficits in most cogni- not clearly assess the actual functions required for success-
tive domains, showing significant differences compared with ful everyday living. This is because social and occupational
control subjects with regard to attention, memory, and exec- activities are affected not only by the patient’s clinical symp-
utive function (Sharma and Antonova 2003). Approximately toms and cognitive functions, but also by their motivation,
90% of patients with schizophrenia have a deficit at least in needs, and other psychosocial factors. Social cognition
one cognitive domain, and 75% suffer from deficiencies in relates to the involvement of cognitive operations on social
two or more cognitive domains (Palmer et al. 1997). Cog- contexts, such as perceiving, interpreting, and managing the
nitive deficits are prominent in the first schizophrenic epi- social event (Penn et al. 2008). Green et al. (2012) investi-
sode, but they are more conspicuous in patients with an early gated social cognition related to emotion processing, The-
ory of Mind (ToM), and social relationship perception and
found no differences between the early- and late-stage
Correspondence: Do-Un Jung, Department of Psychiatry, Busan Paik
Hospital, Inje University, 75, Bokji-ro, Busanjin-Gu, Busan, Republic patients with schizophrenia. Another study that investigated
of Korea, 614–735. Tel: ⫹ 82-51-890-6189. Fax: ⫹ 82-51-894-2532. social cognition and metacognition in patients with first epi-
E-mail: gabriel.jdu@gmail.com sode and prolonged psychoses showed greater metacognitive
DOI: 10.3109/13651501.2015.1084328 Early- and Late-Stage Cognitive Function 247

capacities in the understanding of other’s minds and decen- history of organic brain disease, 2) history of substance
tration during prolonged psychoses (Vohs et al. 2014). In that dependency, and 3) low intellectual level that precluded
study, social cognition did not differ between two groups. cognitive function testing. Patients were divided into two
Functional impairments have worsened over the disease disease stage groups with regard to illness duration. Illness
course in interpersonal functioning, vocational functioning, duration was calculated from the point that patients were
and everyday functioning (Reichenberg et al. 2014). diagnosed with schizophrenia and began taking antipsy-
While positive schizophrenia symptoms are relatively chotic medications. Those with a disease duration less than
well controlled with drug treatment, cognitive functions and more than 5 years were divided into “early-stage” and
show constant degradation in the early stages of disease, and “late-stage” groups, respectively. We obtained signed written
social, occupational, and other everyday functions continue consent forms from all patients who agreed to participate in
to decrease. These deficits can lead to recurrent episodes the study, and the study protocol was approved by the Insti-
(Lauriello et al. 1999), and failure during psychosocial reha- tutional Review Board.
bilitation programs (Green et al. 2000). Therefore, one of
the goals of schizophrenia treatment is to improve everyday Demographic data
functions rather than the symptoms themselves. Studies have The authors examined patient interviews and medical
been conducted to assess these functions (Harvey 2013). records to investigate the patients’ sex, age, level of edu-
Improved cognitive function is one of the major goals of cation, illness duration, number of hospitalizations, voca-
schizophrenia treatment. In related studies, assessment tools tional/psychosocial rehabilitation status, smoking status,
have played important roles. The National Institute of Mental and medication type/dose. The patients who currently work
Health (NIMH) announced a standardized tool for evaluat- were classified into the vocational/psychosocial rehabilita-
ing cognitive functions and potential treatment response in tion. Antipsychotic medication dosages were converted
patients with schizophrenia called the “MATRICS Consen- into chlorpromazine equivalent doses (Gardner et al. 2010;
sus Cognitive Battery (MCCB)” (Nuechterlein et al. 2008). Rey et al. 1989).
The MCCB is a sensitive tool for the detailed evaluation of
patients’ cognitive functions. For evaluating the everyday
Clinical assessments
functioning of patients with schizophrenia, assessments have
To assess clinical symptoms, psychiatrists conducted inter-
been proposed that involve observing the patient’s actual
views using the Positive and Negative Syndrome Scale
living situation or assessing the patient’s functions through
(PANSS) (Kay et al. 1987) and Clinical Global Impression-
role-playing. The University of California San Diego (UCSD)
Schizophrenia scale (CGI-SCH) (Haro et al. 2003).
Performance-based Skills Assessment (UPSA) is a widely
The CGI-SCH was originally developed as a brief, stan-
used role-playing tool for evaluating the everyday functions
dardized method to evaluate the overall functions of patients
of patients with schizophrenia (Patterson et al. 2001). It is
with schizophrenia from a clinical perspective. The func-
easy to apply, and its validity and reliability are supported
tions are categorized into four domains of positive, negative,
by various reports (Figueira and Brissos 2011; Mausbach
depressive, and cognitive symptoms, each assessed using a
et al. 2008; Mausbach et al. 2011). Thus, the UPSA is a lead-
7-point scale (Haro et al. 2003).
ing measure for studies of cognition in schizophrenia. The
MCCB composite scores have substantial association with
the UPSA composite score (Keefe et al. 2011), and as reported Evaluation of psychosocial factors
by Burton et al (2013), the MCCB three-factor model shows For evaluating psychosocial factors, the Personal and Social
an association with the UPSA composite score. Performance Scale (PSP) (Morosini et al. 2000), the Schizo-
Numerous studies have been conducted to assess differ- phrenia Quality of Life Scale (SQLS) (Wilkinson et al. 2000),
ences in cognitive functions in subjects with different stages and the Insight Scale for Psychosis (ISP) (Markova et al.
of schizophrenia. However, these investigations only evalu- 2003) were conducted by psychiatrists. The PSP is a tool
ated basic cognitive functions. The objective of this study for evaluating overall functions that uses a questionnaire to
was to examine cognitive functions across different stages of assess socially useful activities, personal and social relation-
schizophrenia by evaluating basic cognitive functions with ships, self-care, and disturbing and aggressive behaviors. The
the MCCB and daily living skills with the UPSA. SQLS is a clinical research tool for assessing subjective qual-
ity of life in patients with schizophrenia. The ISP evaluates
Methods the insights of patients with schizophrenia using a self-report
format.
Subjects
This study included patients diagnosed with schizophrenia Cognitive function evaluation
based on the Diagnostic and Statistical Manual of Mental The MCCB was announced by the NIMH as a standardized
Disorders 4th edition (DSM-IV) (APA 1994), who satis- tool for evaluating basic cognitive functions in patients with
fied the following conditions: 1) age between 18 and 65 schizophrenia. It is recommended for clinically testing the
years, 2) outpatients with a stable condition for the previous effect of new drugs designed to improve cognitive functions
3 months, 3) no changes in medications for the past 3 of patients with schizophrenia (Nuechterlein et al. 2008).
months, and 4) willing to provide informed consent and par- This tool evaluates functions in the seven major cognitive
ticipate in the study. The exclusion criteria were as follows: 1) domains: processing speed (Brief Assessment of Cognition
248 S.J. Kim et al. Int J Psychiatry Clin Pract 2015;19:246–252

in Schizophrenia (BACS): Symbol Coding, Category Flu- Results


ency: Animal Naming, Trail Making Test: Part A), atten-
tion/vigilance (Continuous Performance Test-Identical Pairs Demographic data
(CPT-UIP)), working memory (Wechsler Memory Scale-3rd A total of 55 subjects participated, with 25 and 30 subjects in
Ed. (WMS-III): Spatial Span, Letter-Number Span), verbal the early- and late-stage groups, respectively. The early-stage
learning (Hopkins Verbal Learning Test-Revised (HVRT-R)), group included 16 males (64%) and 9 females (36%), and the
visual learning (Brief Visuospatial Memory Test-Revised late-stage group consisted of 18 males (60%) and 12 females
(BVMT-R)), reasoning and problem solving (Neuropsy- (40%). The average age of subjects in the late-stage group was
chological Assessment Battery (NAB): Mazes), and social 41.97 ⫾ 6.67, which was significantly higher than the average
cognition (Mayer–Salovey–Caruso Emotional Intelligence age in the early-stage group (29.08 ⫾ 7.10, p ⬍ 0.001). Sub-
Test (MSCEIT): Managing Emotions). The social cognition jects in the early-stage group received a mean 13.64 ⫾ 2.23
domain measures how well subjects perform tasks and solve years of education, compared with 12.40 ⫾ 2.30 years in the
emotional problem while managing emotions. In the self- late-stage group (p ⫽ 0.041). The average illness durations
management subscale, subjects indicate how effective certain were 33.52 ⫾ 19.46 and 224.43 ⫾ 69.92 months for the early-
actions might be in regulating their mood, such as prolong- and late-stage groups, respectively (p ⬍ 0.001). The number
ing joy and reducing anger. In the social management sub- of hospitalizations was also significantly different between the
scales, subjects are asked to indicate how effective the actions two groups: 2.00 ⫾ 1.29 and 6.24 ⫾ 5.34 hospitalizations for
of a person might be in regulating or managing emotions of the early- and late-stage groups, respectively (p ⬍ 0.001). The
other people (Mayer et al. 2003). We adapted the tool for use late-stage group was more involved in vocational/psychoso-
in a Korean population after acquiring authorization from cial rehabilitation (p ⫽ 0.006). The chlorpromazine equiva-
the copyright holder. lent doses were 501.89 ⫾ 250.15 mg and 542.23 ⫾ 347.56 mg
for the early- and late-stage groups, respectively (p ⬎ 0.05).
Daily living skills There were 22 (88%) subjects in the early-stage group who
The UPSA was designed to assess basic everyday living took antiparkinsonian medications, compared with 19 (63%)
skills. Specifically, it examines functions in five domains: subjects in the late-stage group (p ⫽ 0.037). There were 6
1) finance: skills to count money, give change, and pay smokers (24%) and 19 non-smokers (76%) in the early-stage
bills; 2) communication: skills to understand specific situ- group, compared with 14 smokers (46.67%) and 16 non-
ations, use the telephone or postal correspondence, and smokers (53.33%) in the late-stage group (Table I).
perform appropriate expressions; 3) comprehension/plan-
ning: skills to understand newspaper articles and identify Clinical symptoms
the required items; 4) transportation: skills to use public The total PANSS scores did not reveal a significant difference
transportation systems considering transfer and time; and between the two groups; the early- and late-stage group scores
5) household skills: skills to select ingredients required for were 70.32 ⫾ 12.86 and 69.40 ⫾ 12.96 points, respectively.
cooking (Patterson et al. 2001). For evaluating communi- However, there was a significant difference (p ⫽ 0.048) in the
cation, the subjects are provided a telephone and asked to positive symptom subscale (early-stage group: 16.60 ⫾ 4.56
use the telephone to get help as if there were an emergency. and late-stage group: 19.13 ⫾ 4.69) but not the other sub-
They are given a letter about a medical appointment con- scales. There was no significant difference between the two
firmation and asked to call the hospital to reschedule the groups on the CGI-SCH (Table I).
appointment. They are questioned about the notice and the
details of medical appointment. For evaluating comprehen- Psychosocial factor characteristics
sion/planning, the subjects are given a newspaper article PSP, SQLS, and ISP results were not significantly different
about a water park and asked to recall some activities in between the two groups (Table I).
the water park. They are questioned about the items they
would need to bring to spend a day at the water park. The
test is conducted using the role-playing method and takes Cognitive function characteristics
approximately 30 min. This study used the standardized Assessment of basic cognitive functions using the Korean
Korean version of the UPSA with written consent from the version of MCCB showed no significant difference between
copyright holder. the two groups in terms of the total score and most subscale
items. However, the early-stage group social cognition domain
score was 30.92 ⫾ 9.07, which was significantly higher than
Statistical analysis the score of the late-stage group (24.14 ⫾ 9.28, p ⫽ 0.010).
All continuous variables are reported as means, standard The early-stage group also scored significantly higher in the
deviations, and ranges, and discrete variables are given assessment of everyday functions using the Korean version
as frequencies and percentages. Comparison between the of UPSA. Specifically, the total score was significantly higher
early- and late-stage groups was performed using t-tests, chi- for the early-stage group (75.59 ⫾ 12.54) compared with the
square tests, and Wilcoxon rank sum tests, depending on the late-stage group (65.19 ⫾ 14.00, p ⫽ 0.003). Specifically, the
characteristics of each variable. All analyses were carried out early-stage group scored significantly higher than the late-
using SAS 9.3 software (SAS Institute Inc., Cary, NC, USA), stage group in the communication domain (13.61 ⫾ 3.10 vs.
and the significance level was set at 0.05 or below. 11.55 ⫾ 3.78, respectively, p ⫽ 0.037) and comprehension/
DOI: 10.3109/13651501.2015.1084328 Early- and Late-Stage Cognitive Function 249

Table I. Demographic and clinical characteristics of early- and late-stage patients with schizophrenia.
Early stage Late stage
(n ⫽ 25, (n ⫽ 30,
Characteristics mean ⫾ SD) mean ⫾ SD) p value
Gender
Male, n (%) 16 (64) 18 (60) 0.761
Female, n (%) 9 (36) 12 (40)
Age (years) 29.08 ⫾ 7.10 41.97 ⫾ 6.67 ⬍ 0.001
Education (years) 13.64 ⫾ 2.23 12.40 ⫾ 2.30 0.041
Duration of illness (months) 33.52 ⫾ 19.46 224.43 ⫾ 69.92 ⬍ 0.001
Number of hospitalization 2.00 ⫾ 1.29 6.24 ⫾ 5.34 ⬍ 0.001
Vocational/psychosocial rehabilitation, n (%) 11 (44) 24 (80) 0.006
Antipsychotic medication
Monotherapy, n (%) 15 (60) 15 (50) 0.458
Polytherapy, n (%) 10 (40) 15 (50)
Antiparkinsonian medication, n (%) 22 (88) 19 (63) 0.037
Benzodiazepine medication, n (%) 16 (64) 18 (60) 0.761
Average daily neuroleptic dose (mg, CPZE) 501.89 ⫾ 250.15 542.23 ⫾ 347.56 0.872
Smoking
Smoker, n (%) 6 (24) 14 (46.67) 0.082
Non-smoker, n (%) 19 (76) 16 (53.33)
PANSS
Positive subscale 16.60 ⫾ 4.56 19.13 ⫾ 4.69 0.048
Negative subscale 18.80 ⫾ 3.94 17.10 ⫾ 4.33 0.137
General psychopathology subscale 34.37 ⫾ 6.72 33.17 ⫾ 6.29 0.513
Total score 70.32 ⫾ 12.86 69.40 ⫾ 12.96 0.793
CGI-SCH
Positive symptoms 3.16 ⫾ 1.25 3.53 ⫾ 1.33 0.292
Negative symptoms 3.00 ⫾ 1.04 2.73 ⫾ 0.74 0.273
Depressive symptoms 2.24 ⫾ 0.78 2.33 ⫾ 0.71 0.645
Cognitive symptoms 2.72 ⫾ 1.02 2.60 ⫾ 0.76 0.604
PSP 60.92 ⫾ 11.24 60.23 ⫾ 10.42 0.822
SQLS 42.52 ⫾ 16.26 39.17 ⫾ 20.36 0.509
ISP 14.28 ⫾ 5.17 13.90 ⫾ 5.73 0.653

CGI-SCH, Clinical Global Impression-Schizophrenia scale; CPZE, chlorpromazine equivalent; ISP, Insight Scale for
Psychosis; K-WAIS, Short-form of Korean-Wechsler Adult Intelligence Scale; PANSS, Positive and Negative Syndrome
Scale; PSP, Personal and Social Performance Scale; SD, standard deviation; SOFAS, Social and Occupational Functioning
Assessment Scale; SQLS, Schizophrenia Quality of Life Scale.

planning domain (12.56 ⫾ 3.01 vs. 10.44 ⫾ 3.64, respectively, Table 2. Comparison of early- and late-stage patients with schizophrenia
p ⫽ 0.027, Table 2). in cognitive measures.
Early stage Late stage
(N ⫽ 25, (N ⫽ 30,
Discussion mean ⫾ SD) mean ⫾ SD) p value
The results of this study demonstrate that cognitive func-
MCCB
tion varies across different stages of schizophrenia as dem- Speed of processing 33.80 ⫾ 11.83 34.34 ⫾ 11.89 0.867
onstrated with the MCCB, a tool specifically designed for Attention/Vigilance 36.29 ⫾ 10.85 38.69 ⫾ 10.35 0.449
cognitive function assessment, and the UPSA, which reflects Working memory 32.68 ⫾ 11.29 31.76 ⫾ 10.82 0.761
everyday functions. In addition, assessments for differences Verbal learning 34.20 ⫾ 7.48 31.52 ⫾ 5.99 0.149
between clinical symptoms and psychosocial factors were Visual learning 40.76 ⫾ 14.23 35.69 ⫾ 13.83 0.191
also conducted, although there were no significant differ- Reasoning and 42.32 ⫾ 10.51 39.11 ⫾ 6.68 0.309
problem-solving
ences between the two groups. Social cognition 30.92 ⫾ 9.07 24.14 ⫾ 9.28 0.010
The participants were divided into two groups based on Composite score 26.70 ⫾ 12.07 24.12 ⫾ 8.61 0.408
illness duration. In terms of clinical symptoms, there was no UPSA
significant difference between the two groups except for the Finance 17.20 ⫾ 2.89 16.74 ⫾ 2.93 0.467
positive symptom subscale in the PANSS. Kay et al. (1986) Communication 13.61 ⫾ 3.10 11.55 ⫾ 3.78 0.037
used the PANSS to assess 134 patients with schizophrenia Comprehension/Planning 12.56 ⫾ 3.01 10.44 ⫾ 3.64 0.027
in a cross-sectional study, but they were not able to detect Transportation 14.72 ⫾ 2.52 13.18 ⫾ 2.84 0.059
Household skills 17.50 ⫾ 5.11 13.28 ⫾ 8.37 0.052
significant differences across different stages. Our findings
Total score 75.59 ⫾ 12.54 65.19 ⫾ 14.00 0.003
indicate that clinical symptom scales are affected by the types
and degrees of each clinical symptom, drugs being used, MCCB, Measurement and Treatment Research to Improve Cognition in
and other factors involved in the patient’s prognosis, rather Schizophrenia (MATRICS) Consensus Cognitive Battery; SD, standard
deviation; UPSA, University of California San Diego (UCDS) Performance-
than the stage of psychosis itself. Many studies have been based Skills Assessment.
250 S.J. Kim et al. Int J Psychiatry Clin Pract 2015;19:246–252

conducted to assess the correlation between clinical schizo- contained in others’ facial expressions and voices. Under-
phrenia symptoms and patients’ cognitive functions. Liddle standing and managing emotions is involved in the higher-
(1987) concluded that negative symptoms are usually corre- level process. The second is social perception: decoding and
lated with cognitive functions, Moritz et al. (2001) reported interpreting social cues in others. The third is ToM/mental
that negative symptoms are related with verbal working state attribution, which involves recognizing certain inten-
memory, and another study found that disorganized symp- tions or behaviors that may affect his/her behaviors and those
toms are related with cognitive dysfunction (Eckman and of others. The fourth is attributional style/bias, which is the
Shean 2000). These studies demonstrate that clinical symp- way of determining positive or negative reasons for a certain
toms of patients with schizophrenia are closely related with life event. On the managing emotions part of the MSCEIT
their cognitive function. Since the present study revealed in the MCCB’s social cognition domain, it was about how
no significant difference between the two groups of patients effective the actions might be in managing their emotions
with schizophrenia in terms of negative symptoms and other or other’s emotions. Thus, the social cognition domain in
factors closely related with cognitive function, the possibility the MCCB seems to have a relationship mainly with emo-
of clinical symptoms having affected the results of cognitive tion processing. One study found that social cognition in
function tests can be eliminated to some degree. patients with schizophrenia are closely related with every-
In terms of psychosocial factors, the PSP, SQLS, and ISP day functions and interpersonal and social/occupational
did not reveal any significant differences between the early- skills (Couture et al. 2006). This was classified as an impor-
and late-stage groups. It is thought that SQLS and ISP results tant prognostic factor and a treatment goal for patients with
may be affected by factors related to family, occupation, and schizophrenia (Kee et al. 2003).
the treatments that the patient received, rather than the stage In the assessment of everyday functions using the UPSA,
of psychosis. Numerous studies have verified the validity and the early-stage group scored higher than the late-stage
usefulness of PSP as a tool for assessing the overall functions group in communication, comprehension/planning, and
of patients with schizophrenia (Figueira and Brissos 2011). total scores. Many patients with schizophrenia have diffi-
In this study, however, PSP revealed no significant differ- culties communicating with and comprehending conversa-
ences between the two groups, while UPSA and MCCB dem- tions with other people; some of them even have difficulties
onstrated significant differences between the patients with understanding basic phrases and jokes (Brune et al. 2007).
early- and late-stage schizophrenia in terms of social cog- Among the UPSA domains, the communication and com-
nition domain and everyday functioning. The PSP assesses prehension/planning categories are closely related with social
four categories: useful social activities, personal and social functions. Therefore, the above findings can be regarded as
relationships, self-care, and disturbing and aggressive behav- supporting the results of the social cognition test using the
iors. It determines the total score by combining the results MCCB. Since the UPSA uses role-playing based on everyday
of each category. While this method is suitable for assessing situations, it can be inferred that patients in the early stages
overall patient functionality, it seems that it would be dif- of schizophrenia are more socially functional in their every-
ficult to assess the patient’s social functions in detail using day living compared with those in later stages. Mausbach
the PSP compared with the MCCB and UPSA. In addition, et al. (2008) proposed that the UPSA can be used to predict
the PSP questions regarding social functions focus more on the residential independence of patients with schizophrenia,
the patient’s participation in social activities rather than their and another study verified a significant correlation between
actual skills, which may explain the different results com- UPSA results and patients’ occupational skills (Mausbach
pared with the MCCB and UPSA. et al. 2011). Taking all of these results into consideration,
Our cognitive function assessments revealed several sig- it can be inferred that the constant difficulties in everyday
nificant differences between the early- and late-stage groups. living and social occupational skills experienced by patients
No difference was found in the seven cognitive function with late-stage schizophrenia may be related to degradation
domains assessed with the MCCB, except for the social cog- of social cognition and functions.
nition domain for which the early-stage group scored sig- Some studies have also shown that everyday functions
nificantly higher than the late-stage group. Similarly, a study decline throughout the lifetime in the patients with schizo-
comparing the MCCB results of early- and late-stage groups phrenia (Harvey et al. 2010; Reichenberg et al. 2014). All
conducted by McCleery et al. (2014) also found that the ear- subjects in the late-stage group were outpatients with a stable
ly-stage group scored higher in questions on social cogni- condition, and most of them participated in the vocational/
tion domain and working memory. This demonstrates that psychosocial rehabilitation in this study. Thus, it seems that
patients in the early stages of schizophrenia are able to relate the late-stage group experiences everyday function deficits
to and interact with others more effectively than those in the despite continued social stimulation.
late stages. Penn et al. (2008) maintains that social cognition There are several limitations of this study. First, we clas-
in patients with schizophrenia consists of three subfactors: sified the subjects into early- and late-stage groups in a
emotion perception, ToM, and attributional style. In the cross-sectional study designed to compare cognitive func-
expert surveys about the domains of social cognition, four tions across different stages of psychosis. Therefore, while
core domains are selected (Pinkham et al. 2014). The first is our findings are useful for assessing differences between the
emotion processing, which relates to perceiving and using two groups, it is limited in determining why there are cogni-
emotions. It includes both lower- and higher-level processes. tive function differences between disease stages. These limi-
The lower-level process is about recognizing the emotions tations could be partially overcome if follow-up studies are
DOI: 10.3109/13651501.2015.1084328 Early- and Late-Stage Cognitive Function 251

conducted with the same patient groups. Second, the lack of Couture SM, Penn DL, Roberts DL. 2006. The functional significance
a healthy control group makes it difficult to distinguish cog- of social cognition in schizophrenia: a review. Schizophr Bull
32 Suppl 1:S44–63.
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those unique to schizophrenia. Third, the small number of and symptom dimensions of schizophrenia. J Psychiatr Res 34:
subjects makes it difficult to generalize the findings. Fourth, 147–153.
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were not controlled. It is thought that many drugs including schizophrenia patients. Curr Opin Psychiatry 24:91–99.
Fucetola R, Seidman LJ, Kremen WS, Faraone SV, Goldstein JM,
antipsychotic medications can affect patient cognitive func-
Tsuang MT. 2000. Age and neuropsychologic function in schizo-
tion. Fifth, we assessed social cognition with limited tools phrenia: a decline in executive abilities beyond that observed in
and only investigated managing emotions and daily living healthy volunteers. Biol Psychiatry 48:137–146.
skills. Future research needs to investigate various domains Gardner DM, Murphy AL, O’Donnell H, Centorrino F, Baldessarini
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The findings of this study indicate that patients with ear-
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“right stuff ”? Schizophr Bull 26:119–136.
to identify treatment strategies for patients with early-stage
Green MF, Kern RS, Heaton RK. 2004. Longitudinal studies of
schizophrenia, which will preserve and improve their social cognition and functional outcome in schizophrenia: implications
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Haro JM, Kamath SA, Ochoa S, Novick D, Rele K, Fargas A, et al. 2003.
The Clinical Global Impression-Schizophrenia scale: a simple
Key points
instrument to measure the diversity of symptoms present in schiz-
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Statement of interest 29:487–497.
The authors declare no conflict of interest with any commer- Keefe RS, Fox KH, Harvey PD, Cucchiaro J, Siu C, Loebel A. 2011.
cial or other associations in connection with the submitted Characteristics of the MATRICS Consensus Cognitive Battery in
a 29-site antipsychotic schizophrenia clinical trial. Schizophr Res
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