CLINICAL ASSESSMENT ON

COGNITIVE FUNCTIONING II
(LECTURE, 8 OCT 2018)
Prepared by Panmi Lo, OT of Castle Peak Hospital
Content
 Definition of key terms

 Why cognition is a concern for persons with mental illness?

 Cognitive Functional Evaluation (CFE) for persons with mental

illnesses * the MATRICS Consensus Cognitive Battery (MCCB)

 Case illustration
(A) Background
Definition of Key Terms
Cognition

Neurocognition (Non-Social Cognition) Social Cognition

 Speed of processing  Emotion Perception

 Attention/Vigilance  Social Perception
 Working Memory  Theory-of-mind
 Verbal Learning  Attributional Style
 Visual Learning
 Executive Functioning
 Prospective Memory

NC and SC are related but distinct construct

Social Cognition in details
Definition
 Refers to how people think about themselves and others in the social
world (Marcopulos & Kurtz, 2012)
 Formally defined as the mental operation that underlies social
interactions, including perceiving, interpreting, and responding to the
intentions, dispositions, and behaviors of others (Friske & Taylor, 1991)

Relationship with NC
 Related but distinct construct with NC from CFA
 Path coefficients between NC and SC were 0.79 and 0.83
 2-factors model of NC and SC had a better model fit
(Hoe et al., 2012, Sergi et al., 2007)
Social cognition - construct
Complex, multifaceted
Based on CONSENSUS/EXPERT SURVERY, rather than on
empirical ground
US NIMH workshop in 2008 + SCOPE Study in 2013 – top 4 SC
domains
• Emotion Perception/Emotion Processing
• Social Perception Social Cognitive
Deficit
• Theory-of-mind/mental state attribution
• Attributional style/bias
Social
Cognitive Bias
• Jump-to-conclusion tendency
 Effect size for between
group differences
SC - Emotion perception (Cohen, 1977)
Small = 0.2
Medium = 0.5
Large = 0.8
Definition Details/subdomains Systematic Review/
Meta-analysis
Effect Size
the ability to infer • Overall impairment • Kohler, Walker, Total sample:
emotional across emotions Martin, Healey & -0.91
information (i.e. Moberg, 2010
what a person is • Non-uniform pattern of - 86 studies
feeling) from impairment across -1970-2007
facial expression, emotions (Pomarol-
vocal reflection or Clotet, et al., 2010)
a combination of
both • Negative bias in
perceiving neutral
facial expression
(Kohler et al., 2007)
 Most commonly mentioned

SC - Theory-of-mind treatment target in social

cognitive intervention (Roberts
& Penn, 2009; Horan et al.,
2009)

Definition Subdomains Systematic Effect Size

Review/
Meta-analysis
the cognitive ability to • false • Sprong et al., Total sample:
attribute thoughts, belief/deception 2007 & -0.9 to -1.08
beliefs and intentions tasks Brune, 2005
to people, allowing an
individual to explain, • comprehension of • Bora, Yucel &
manipulate and indirect speech Pantelis, 2009
predict behavior - 36 studies
(Sprong, Schothorst, Vos, • intention- - 1990-2008
Hox, & Engeland, 2007)
inferencing tasks

• eye tasks
 SC - Attributional style
Definition Subdomains Systematic Effect Size
Review/
Meta-
analysis
an individual’s • external-personal Nil • No data from
characteristic attribution systematic
tendencies in review/meta-
explaining the • Hostile/paranoid analysis
causes of events attributional style
(social events) in • Combs et al. 2009
their lives Persons with
paranoid delusion
had sig. higher
hostile attributional
style than controls
 The social cognitive process

Work-Related Conclusion
Perception Consequence
Social Stimulus Behavior s:
My colleague He was angry
He was angry because he Poor
asked me to Avoidance or
He wanted to pinpointed me relationship
redo an Conflict
blame me He will put me in with
assignment and difficult situation colleague,
passed it back to
work stress,
me without much
possibly quit
facial expression
the job

Emotion/Social Perception
Attributional Style (AS)
Deficit (EP/SP)

Deficits in theory-of-mind Jumping To Conclusion

Adapted from Couture, Penn & Roberts (2006): Conceptual Framework for Understanding the Interplay between
Social Cognition and Social Functioning
Common Psychiatric Conditions with
Cognitive Impairments
 Schizophrenia
 Bipolar affective disorder
 Depression
 Anxiety disorder
 Obsessive compulsive disorder
 ADHD
 Autism
 Pervasive developmental disorders
 Neurocognitive disorder
(A) Background
Why Cognition is a Concern for Persons with
Mental Illnesses
Why Cognition is a Concern? - 1
1. Cognitive impairment is a primary and core feature of
schizophrenia and is common among other psychiatric
diagnoses such as bipolar affective disorder, depression
or PTSD
Prevalence of cognitive impairment
 70-75% schizophrenia (Keefe & Harvey, 2012)
 5.3–57.7% in euthymic BD (Cullen et al., 2016)
Degree of cognitive impairment
 0.9 to 2 S.D. below mean of healthy population in schizophrenia
(Heinrichs, 2005 ; Harvey and Keefe 1997; Saykin et al. 1991; Keefe et al. 2011;
Keefe et al., 2006)
 0.5 to 1 S.D. below mean of healthy population in BAD (Lee et al., 2013;
Burdick et al., 2013)
Clinical stable Bipolar group N=68
Clinical stable SCZ group N= 38
Healthy control N=31
Why Cognition is a Concern? - 2
2. Cognition is an essential determinant of functional
outcomes (work, independent living, social)
 Mean effect size = 0.50 (Green, 1996; Green et al., 2000)
An Example of Functional Implications

 Ms J is a 18y.o. lady, student studying higher diploma in

nursing, working as a part-time cashier in supermarket
 Ms J’s complaints:
 Failed to meet deadlines of assignments
 Failed to prepare the required materials for “dressing practice” during
placement
 Forgot to attend meeting with classmates
 Being complained by supervisor for “working too slowly”
 Made mistakes or errors when entering the product codes
 Forgot the procedures in collecting coupons
 Recalled colleagues reacted to her with blunt affect when she asked for
help, believed colleagues not helpful
 Recalled friends did not reply her message promptly, concluded her
friends disliked or pinpointed her
Why Cognition is a Concern? 3
3. Changes in cognition leading to changes in outcomes
 Experimental, longitudinal study, review and meta-analysis
 Conceptual Framework on Cognition
and Functioning in Schizophrenia
Positive Symptoms

Functional Outcomes
Neurocognition
• Speed of processing
• Independent Living
• Attention
• Memory (working
memory, verbal learning,
• Work
visual learning,
prospective memory) • Social
• Reasoning & Problem
Solving
• Executive Function Social Cognition
• Emotion Perception
• Social Perception
• Theory-of-mind
• Attributional Style
Predictor
Mediator
Negative Symptoms Relationship
(B) Cognitive Functional Evaluation (CFE)
What is CFE?
 Role of OT in Cognitive Assessment
  Assess key cognitive constructs in the performance of daily life
(capacity to live alone, work, or do any task that is important and
meaningful) (Baum & Edwards, 1993; Katz & Hartman-Maeir, 2005)
  “attention” “memory”
 Challenges
 Complex processing (Burgess et al., 2006)
 Client’s low awareness of their cognitive problems and implications in
daily life (Fleming et al., 1996; Katz & Hartman-Maeir, 2005)
 The CFE process
 Yields client’s cognitive strengths and weaknesses in OP
 Uses by different disciplines: CFE for M&G, PG and SMI (cognitive seminar
Dec 2016)
 The CFE Process
• Ascertain basic cognitive abilities
underlying OP
• Assessments are chosen according to
client’s characteristics

In-depth assessment

(Hartman-Maeir, Katz & Baum, 2009)

CFE Process for SMI
CFE
Stage 1: Stage 2: Stage 3:
Interview & background Cognitive screening and General measures of
information baseline status tests cognition in occupations
e.g. CAI e.g. SCIP, BACS e.g. MCCB

Stage 4:
Tests for specific domains
e.g. TEA, RBMT, Stroop
Test, WCST, mWCST
Stage 5:
Measures of specific
cognitive domains in
occupations
e.g. MIST/CAMPROPMT,
VCRS, SCSQ, FEIT

Stage 6:
Environmental assessment
Adopted from
Hartman-Maeir, Katz & Baum (2009)
CFE - Stage 1
 CFE Process Stage 1
Interview and background information incl. an occupational history
Purposes Methods Choices of
Assessment
- Constructs client’s - Questionnaire - SCoRS (Keefe et al.,
OP profile 2006; 20 items)
* past - Comparison
* current between the - CGI-CogS (Ventura
et al., 2008; 21 items)
* future answers of the
client and a proxy
- CAI (Ventura et al.,
- Constructs client’s 2010; 10 items)
self-awareness - Comparison to test
performance
 Cognitive Assessment Inventory (CAI)
 FDA requests for functionally-relevant measure and Patient-
Reported Outcome on top of objective measure

 Derived from SCoRS and CGI-CogS using factor analyses and IRT
 Shorten version (10 item); Est time of adm.: 15+15 mins

 Link cognitive fx with activities of daily living such as school

performance, work, social

 Expert judgment based on patient’s report, informant-report and all

sources of information

Sources: Guide to assessment scales in schizophrenia

https://zh.scribd.com/document/323596531/Guide-to-Assessment-Scales-in-Schizophrenia
 Structure and Rating Scales of CAI
7-point rating scales and anchors
Observations / Evaluation
Compliance
General Orientation
Relevant History / Demographics
1. Normal, not at all impaired
Category: Neurocognitive State
(6 domains)
(10 items)
2. Minimal cognitive deficits but functioning is generally
effective
Domain
Working Memory
(2 items)
3. Mild cognitive deficits with some consistent effect on
Domain functioning
Attention-Vigilance
(2 items)
4. Moderate cognitive deficits with clear and consistent
Domain
Verbal Learning-Memory
(2 items)
effects on functioning
Domain
Reasoning & Problem Solving
5. Serious cognitive deficits that interfere with day-to-
(2 items)
day functioning, including activities of daily living
Domain
Speed of Processing
(1 item)
6. Severe cognitive deficits that jeopardize independent
Domain living
Social Cognition
(1 item)
7. Cognitive deficits are so severe as to present danger to
Global Severity self/others
of Cognitive Impairment
Past month (often need to broaden)
Working Memory
Attention/Vigilance
Verbal Learning and Memory
Reasoning and Problem Solving
Speed of Processing
Social Cognition
Global
Assessment of
Function
A case illustration
 F/28
 Dx: Schizophrenia
 Mentally stable, maintain on abilify 30mg
 Life role: part-time accounting clerk and part-time
study on top-up degree in accounting
 Client’s chief complaints: coped with job demand,
but complained difficulty to memorize content of
textbooks (needed to read the content twice),
perceived problems in memory and comprehension
Working Memory

No problem to remember verbal information

But need to read a few times to follow content of textbooks (study) /Facebook (leisure)

No problems in calculation during IADL/study/work

 Attention/Vigilance

Difficulty to read long paragraphs in textbooks, manuals and Facebook

No problems to sustain attention in following conversation with others or watching TV/film

Managed to shift attention when asked to do other tasks while performing an ongoing task
Required extra time to focus again
Verbal Learning and Memory
 Reasoning and Problem Solving

Did not perceive any problems, e.g. she could think of alternatives to go to other restaurants
during peak hours and changed plan quite efficiently

Managed to answer all the questions as well as judgment questions from NCSE
 Speed of Processing

Coped with work speed in current job (low job demand)

Recalled being commented by supervisors/colleagues to have below average work speed
In her last full time job, finally quitted the job
Social Cognition
Result of CAI
 1 (normal): VerL, R & PS
 1-2 (normal to mild): WM, social
cognition
 2-3 (min to mild): Attention
 3 (mild): SoP
Result of MCCB
 High average in R & PS
 Relatively weaker in SoP, WM
 Weak in VisL
 Observed to be fairly attentive
at times while preforming
forward spatial WM task
 Sources: Guide to assessment scales in schizophrenia
https://zh.scribd.com/document/323596531/Guide-to-
Assessment-Scales-in-Schizophrenia

 Careful and mindful ** expert judgment

 Enhance client’s awareness on the links of cognitive

problems and functional performance
 motivation to CR (Choi, 2010)
 learning and generalization (Cella et al., 2015)
CFE - Stage 2
Cognitive Screening
Stage 2 – Cognitive Screening
 Screen for Cognitive Impairment in Psychiatry (SCIP)
 Brief Assessment of Cognition in Schizophrenia
(BACS)

 Montreal Cognitive Assessment (MoCA-HK)

CFE - Stage 3
General Measure of Cognition
CFE Process for SMI
CFE
Stage 1: Stage 2: Stage 3:
Interview & background Cognitive screening and General measures of
information baseline status tests cognition in occupations
e.g. CAI e.g. SCIP, BACS e.g. MCCB

Stage 4:
Tests for specific domains
e.g. TEA, RBMT, Stroop
Test, WCST, mWCST
Stage 5:
Measures of specific
cognitive domains in
occupations
e.g. MIST/CAMPROPMT,
VCRS, SCSQ, FEIT

Stage 6:
Environmental assessment
Adopted from
Hartman-Maeir, Katz & Baum (2009)
MATRICS Consensus Cognitive Battery (MCCB)

 Measurement and Treatment Research to Improve Cognition in

Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) ,
established by The National Institute of Mental Health (NIMH)
 Development Procedures
Selection of Identify 6 cognitive domains from factor-analysis studies and
Cognitive Domains addition of 1 social cognition domain

90 tests were nominated

Test Nominations 36 tests were selected based reliability, validity & adm. time (15 mins)
Expert panel rated the 36 tests based on 5 criteria:
1. Test-retest reliability
2. High utility as a repeated measure
Beta Version 3. Relationship to functional outcome
(20 tests) 4. Potential changeability in response to pharmacologic agents
5. Tolerability and practicality

Final Battery Beta Version was administered to N=176 SCZ samples

(10 tests) Final Battery was chosen based on data supporting the 5 criteria

Co-norming and Establish normative data (T-score, percentile score)

Standardization
 Final Battery
Domains
Speed of Processing
Attention/Vigilance
Working Memory
Verbal Learning
Visual Learning
Reasoning & Problem Solving
Social Cognition
Tests
1. Verbal fluency: the Brief Assessment of Cognition in
Schizophrenia symbol coding subtest
2. Graphomotor speed: the Trail Making Test, Part A
3. Category fluency test
4. The Continuous Performance Test – Identical Pairs
Version
5. Non verbal: the Wechsler Memory Scale spatial
span subtest
6. Verbal: the Letter-Number Span test (not in Chin ver)
7. Hopkins Verbal Learning Test – Revised
8. Brief Visuospatial Memory Test – Revised
9. Neuropsychological Assessment Battery (NAB) mazes
subtest
10. Mayer-Salovey-Caruso Emotional Intelligence Test
(managing emotions component)
Overall Features of MCCB
 Standardized Battery
 Co-norming of 10 component tests
 High test-retest reliability
 High utility as a repeated measure

 Demonstrated relationship to functional outcome

 High tolerability by respondents (administration time within 90

mins)

 Provides convenient administration, scoring and conversion to

standardized scores
 a computer data file of summary scores
2. Brief Assessment of Cognition in Schizophrenia
(BACS): Symbol Coding
 Cognitive domain measured:
 Speed of processing

 Instructions:
 Writing numbers that
correspond to nonsense
symbols as quickly as
possible for a 90-second
period

 Scoring:
 Total number of corrected
coding
3. Hopkins Verbal Learning Test - Revised

 Cognitive Domain Measured:

 Verbal Learning

 Instructions
 Administrator read the word list at the rate of approx. one
word every 2 seconds; 2 seconds interstimulus interval
 Respondent is required to tell administrator the list of word
which the administrator read in all three learning trials
 我要唸一些詞語給你聽。仔細聽，因為我唸完的時候會請
你告訴我你所記得的詞語。你可以用任何順序來告訴我那
些詞語。準備好了嗎?

 Scoring:
 Number of correctly reported words in 3 trials
6. Brief Visuospatial Memory Test-Revised
(BVMT-R)

 Cognitive domain measures:

 Visual learning

 Instructions
 Respondent is given a sheet containing
six figures and he/she is required to
remember as many of figures as
possible in 10 seconds in 3 trials
 Place hand at eye level appx. 16
inches in front of the respondent
9. Continuous Performance Test – Identical Paris (CPT-
IP), MATRICS Version

 Cognitive domain measured: Attention/vigilance

 A computerized measure of sustained, focused attention or

vigilance

 The MATRICS version involves monitoring a series of

multiple digits as they appear briefly on a computer
monitor and responding with a button press each time
that tow stimuli in a row are identical
331
241
Administration and Scoring
 To be discussed in details during Lab Session

 Computer Scoring System

 Selection of Norms
 English-U.S.norms
 Correction for age and gender
 Correction for age, gender and educational level
 No demographic correction
Report

 Provides raw score and

nominative scores for each
of the 9 MCCB

 Provides the nominative

scores for the 7 cognitive
domains and the overall
composite score
Report
Descriptors

Low
average

Borderline

Very poor

Average
References: Spreen, O. & Strauss, E. (1997). A
Compendium of Neuropsychological Tests: Second Edition.
Administration, Norms and Commentary. Oxford: New
York
Profile of Schizophrenia
 Profiles
100
90
80
70
60
T-score

50 Average range
40
30 Healthy 1
20
Schizophrenia Healthy 2
10
Profile Mean out-pt, M/3x
0
out-pt, M/2x
Interpretation of Results
CFE - Stage 4
CFE Process for SMI
CFE
Stage 1: Stage 2: Stage 3:
Interview & background Cognitive screening and General measures of
information baseline status tests cognition in occupations
e.g. CAI e.g. SCIP, BACS e.g. MCCB

Stage 4:
Tests for specific domains
e.g. TEA, RBMT, Stroop
Test, WCST, mWCST
Stage 5:
Measures of specific
cognitive domains in
occupations
e.g. MIST/CAMPROPMT,
VCRS, SCSQ, FEIT

Stage 6:
Environmental assessment
Adopted from
Hartman-Maeir, Katz & Baum (2009)
CFE - Stage 5
Measures of specific cognitive domains in
occupations
CFE Process for SMI
CFE
Stage 1: Stage 2: Stage 3:
Interview & background Cognitive screening and General measures of
information baseline status tests cognition in occupations
e.g. CAI e.g. SCIP, BACS e.g. MCCB

Stage 4:
Tests for specific domains
e.g. TEA, RBMT, Stroop
Test, WCST, mWCST
Stage 5:
Measures of specific
cognitive domains in
occupations
e.g. MIST/CAMPROPMT,
VCRS, SCSQ, FEIT

Stage 6:
Environmental assessment
Adopted from
Hartman-Maeir, Katz & Baum (2009)
Stage 5

Social Work Daily

Living Task
Facial Emotion Vocational Memory for
Identification Cognitive Rating Intention
Test (FEIT) Scale (VCRS) Screening Test
(MIST)

Social Cognition Cambridge

and Screening Prospective
Questionnaire Memory Test
(SCSQ) (CAMPROMT)
Chinese Facial Emotion Identification Test
(C-FEIT)
 Common ax procedure in assessing EP ability in persons with
schizophrenia (Kerr & Naele, 1993)

 C-FEIT
 21 photos from JACFEE and JACNeuF
 2 photos of each of 6 basic emotions (happiness, sadness, fear, anger, surprise, disgust)
 9 photos of neutral faces
 Photos are presented in random order using PowerPoint shown on computer
 Time of exposure of each photo and time of rest between photos set at 10sec
 Participants will be asked to choose the displayed emotion using on an answer
sheet
 Total administration time: around 7 mins
C-FEIT – test construction

• 6 basic emotions (Ekman, Friesen & Ellsworth,

Choices of emotions 1972) that is well-documented in SCZ researches
• Possible bias in perception of neutral facial
(6 emotions + neutral) expression

• Gold standard
• A similar photo set validated in Chin population
Choice of photo set (N=120; Yip & Lee, 2003)
(JACFEE and JACNeuF) • No validated comprehensive photo set that used
Chin faces (Gao et al., 2008)

• Chinese-language instruction
Standardized • Several parameters were standardized during
administrative administration (the time of exposure and time of
rest in between two photos were each fixed at
procedures 10 seconds; screen size of less than 18 inches,
and with an arm’s length)
Chinese Social Cognitive Screening
Questionnaire (C-SCSQ)

 Aims
 Assess three key domains of social cognition
 Screen for neurocognitive deficits and client’s needs
for social-cognitive intervention
 Content
 10 second-person interpersonal vignettes (ambiguous
interpersonal situation)
 Four questions (A, B, C, D) in each vignette
 A&B: screening of neurocognitive fx
 C: theory-of-mind
 D: jump-to-conclusion
 5 vignettes to assess paranoid attributional style
C-SCSQ
 Administration
 Verbally present
 Non-judgmental tone

 Check for attention

 Administrative time:20 mins – 25 mins

Example of a vignette

 A. 那些穿白袍的是護士嗎？
 B. 你親友的病房是否位於三樓嗎？
 C. 那女士想你離開那房間嗎？
 D. 對於最後一個答案，你有多肯定你是正確的？
 1. 完全不肯定
 2. 少少不肯定

 3. 相當肯定

 4. 非常肯定
Psychometrics properties of
C-FEIT and C-SCSQ
 Content-related validity of C-SCSQ : satisfactory relevancy
and representativeness as rated by expert panel

 Test-retest reliability of C-FEIT and C-SCSQ: ICC ranging from

0.76 to 0.85

 Concurrent validity of C-FEIT and C-SCSQ: Low to medium

correlations with NC measures, r ranging from 0.22 to 0.46

 Known-group validity: ToM and PAS subscales of C-SCSQ

differentiated SCZ and HC (matched with age and gender)
with a large effect sizes (d = 1.26; d = -3.27)

(Lo and Siu, 2018)

Vocational Cognitive Rating Scale (VCRS)

 An instrument to measure cognitive impairment at workplace

 Based on items in the Cognitive Functional Assessment with
items created from the following categories,
 attention, memory and learning
 organization and flexibility
 initiation
 Behavioral anchors in a 5-point scale (1-Never, 5-Always)
 16 items (total score: 16 to 80)
 Rated by trained staff (usually job specialist) after behavioral
observation for at least 15 mins + interview with job trainer
(C) Case illustration
Referral Information
 Annie, F/29
 Dx: Schizophrenia
 Mentally stable
 Was referred for vocational counseling
 Recently fired due to slowness
 Unsteady job record as data-entry clerk (around 1 week),
packaging worker (2 months)
 Client showed interest in clerical type of jobs and found a new
job as clerk which would be started next week
 However, client was not confident to cope with the job
 CMO and client wish to seek expert advice from OT
Application of CFE
 Annie’s case OT planned to conduct 2-3 assessment
sessions for Annie

 Try to use the CFE to plan and select appropriate

assessments to be conducted,
 Session 1:
 Session 2:
 Session 3:

 What’s your recommendation for Annie?

Key Summary
Summary
 Cognitive impairment is a primary and core feature of schizophrenia and is
common among psychiatric conditions

 Neurocognition and social cognition are two related but distinct constructs

 Cognitive impairment limits one’s functional outcomes including independent

living, social, study and work

 Cognitive Functional Evaluation (CFE) is an assessment framework to guide

OT to understand a client’s cognitive functions and cognitive dysfunction in
the context of his or her occupational performance
Q&A