Background: Cognitive remediation is a behavioural intervention that aims to improve cognitive functioning with the goal of durability and generalisation. Although evidence suggests that computer-assisted cognitive remediation (CACR) improves cognitive functioning in individuals with schizophrenia, it remains unclear whether these effects generalise and lead to improvements in clinical symptoms and psychosocial functioning. The current study aimed to investigate the effects of CACR on clinical symptoms, cognitive functioning and psychosocial functioning in individuals with schizophrenia or schizoaffective disorder. Method: A systematic review was performed using the quality assessment criteria defined by Scottish Intercollegiate Guidelines Network (SIGN 50) to investigate the effects of CACR on clinical symptoms in individuals with a diagnosis of schizophrenia or schizoaffective disorder. Additionally, a within subjects repeated measures design was used to investigate the effects of CACR on cognitive functioning, functional capacity and everyday social functioning. Results: There was some evidence to suggest that CACR improves clinical symptoms, but the majority of studies reviewed did not report a significant effect, and a number of methodological weaknesses were identified in the literature. Results of the experimental study revealed improvements in speed of processing, reasoning and problem solving and the overall composite score for cognition, but these improvements could not be attributed solely to the CACR intervention. No improvements in functional capacity or everyday social functioning were observed. Conclusions: Further, more rigorous research is required to develop a clearer understanding of the effects of CACR on clinical symptoms. The results of the experimental study support previous literature which has identified that a pure CACR intervention does not improve psychosocial functioning. The results are discussed in relation to the relevant literature.

Introduction This thesis has two aims. The first was to systematically review the literature on the effect of computer assisted cognitive remediation (CACR) for schizophrenia on psychosocial functioning, with a focus on methodological quality and efficacy. The second aim was to evaluate the implementation of CACR in a high secure forensic setting. Method Database searches and hand searches returned 16 randomised controlled trials of CACR that included a functional outcome measure. These were reviewed against predefined quality criteria and effect sizes were calculated. In addition, an uncontrolled pre-post test design was used to evaluate the implementation of CACR in a high secure forensic hospital. Attrition rates, predictors of attrition, and participant feedback were evaluated, along with symptom and functional outcomes. Results The systematic review found a range of methodological limitations. Studies that did not share these limitations did not provide evidence that CACR improves psychosocial functioning. However, CACR may be effective in improving functional outcomes when delivered alongside interventions targeting functional skills. The experimental study found a high attrition rate; poor adherence to the treatment protocol; no clinical, risk or demographic factors to distinguish treatment completers from those dropping out during treatment; and few improvements to performance on treatment activities or functional outcome measures. Conclusion The systematic review indicates that more methodologically rigorous research is required. Future studies with a general psychiatric population should examine the effect of CACR delivered in conjunction with interventions that aim to develop functional skills. Motivational deficits may have undermined the outcomes of the experimental study and it will be important to ensure the delivery of CACR in forensic psychiatric settings is designed to incorporate strategies for enhancing motivation. In addition, using CACR to target functional outcomes may be inappropriate within a high secure forensic setting. The role of CACR as in managing risk and enhancing the outcomes of other interventions should be explored.

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Posttraumatic stress disorder (PTSD) is associated with significant functional impairments and disruptions in cognitive functioning. Functional recovery and remediation of cognitive difficulties are oft over-looked treatment targets in this population, despite their significant contribution to the burden of PTSD to the individual and to society. Existing literature suggests that functional impairment and cognitive dysfunction may not respond to first-line treatments for PTSD. Thus, the focus of this thesis was to examine symptom dimensions associated with cognitive dysfunction and functional impairment among individuals with PTSD, and to investigate a novel approach to cognitive remediation, Goal Management Training (GMT), in this population. Study one in this thesis is a review in which we identified a strong relation between dissociative symptoms and neuropsychological functioning, transdiagnostically and among individuals with PTSD. The hypothesis that dissociative symptoms would be strongly related to functional impairment among individuals with PTSD was explored in study two. We found that dissociative symptoms mediated the relation between PTSD symptoms and functional impairment among a sample of military members, veterans, and first responders with PTSD. Study three identified that emotion regulation difficulties and dissociative symptoms most strongly predicted functional impairment among civilians with PTSD and high rates of exposure to childhood abuse and neglect. In study four we investigated the effectiveness of a cognitive training program, Goal Management Training (GMT), in improving cognitive functioning, clinical symptoms, and functional impairment among inpatients with PTSD. Participation in GMT was associated with improved cognitive functioning and increased ability to engage in goal directed behaviours when highly emotional. This thesis highlights the importance of assessing emotion regulation difficulties and dissociative symptoms in order to target functional impairment and cognitive dysfunction among individuals with PTSD. Moreover, it provides evidence for a potential treatment approach to ameliorate these difficulties. / Thesis / Doctor of Philosophy (PhD) / Posttraumatic stress disorder (PTSD) is a mental health condition that develops after exposure to a traumatic event. It is associated with reduced functioning in important areas of life, including social relationships, work performance, and self-care. PTSD is also associated with reduced cognitive functioning in areas such as memory, planning, and organization. This thesis focuses on examining variables that may be related to these difficulties, including specific symptoms such as difficulty managing emotions and difficulties remaining in the present moment (dissociation). We also investigate a treatment program, Goal Management Training (GMT), aimed at teaching skills to improve cognitive and daily functioning. By understanding what contributes to cognitive functioning and functional difficulties in individuals with PTSD and by providing evidence for a treatment that can improve these difficulties, we hope to improve the lives of individuals with PTSD.

Objectives: To evaluate the effectiveness of cognitive rehabilitation therapy with patients with schizophrenia within a forensic population. The intervention aimed to improve domains of cognitive functioning which have been found to be impaired as a result of schizophrenia. Forensic patients with schizophrenia have been found to have greater impairments in cognitive functioning relative to non-violent patients. Therefore interventions which target these deficits are important in rehabilitation interventions. Design: A within subject repeated design was used. A control measure was also implemented which involved patients being used as their own control. Method: 17 participants successfully completed the cognitive rehabilitation intervention. Initially 23 participants were recruited. Participants received approximately five hours of the computer-assisted cognitive remediation administered over seven weekly sessions. Outcome measures were cognitive assessments measuring executive functioning, attention, verbal learning and memory, perceptual organisation and visual memory. Outcome measures were administered pre-intervention, during treatment, post treatment and at three months follow up. A control assessment was also administered prior to the commencement of the intervention. Results: Post treatment measures on attention, perceptual organisation, visual memory and aspects of executive functioning were found to be significantly improved in comparison to pre intervention and control assessments. At 3 month follow up these improvements in cognitive functioning were found to be sustained. Conclusion: The pilot study indicated that cognitive rehabilitations are effective in improving cognitive functioning within forensic populations with schizophrenia. These results have the potential to improve functional outcomes and recovery, which could indirectly improve symptoms and risk of future violence. Further research is required in this area to provide additional evidence for this intervention to be available to forensic patients with schizophrenia.

Introduction: Impaired neurocognition, especially social cognition, predicts disability in schizophrenia. Early intervention to target impairment is theoretically attractive as a means to minimise chronic disability. Many trials confirm that Cognitive Remediation (CR) produces meaningful, durable improvements in cognition and functioning but few interventions remediate social cognition or focus on the early stages of schizophrenia. Methods: A systematic review and meta-analysis of 11 randomised controlled trials (RCTs) of CR in first episode psychosis (FEP) was completed. A randomised controlled pilot trial was then conducted to investigate a combined CR and social cognition training (CR+SCT) intervention in FEP compared to CR alone, assessing cognition, functioning and symptoms at baseline and follow-up. Qualitative feedback was also obtained in a nested feasibility and acceptability study to assess engagement, intervention suitability and attrition. Results: In the systematic review and meta-analysis, random effects models revealed a non-significant effect of CR on global cognition in FEP. However, there was a significant effect on functioning and symptoms, which was larger in trials with adjunctive psychiatric rehabilitation and small group interventions. In the pilot trial, the CR+SCT group had significantly better social functioning scores post-treatment, especially on the interpersonal relationships scale, however there was no significant effect on social cognition. CR+SCT also improved visual learning and set-shifting. There was no specific effect on symptoms. The nested feasibility and acceptability study found CR and CR+SCT to be acceptable and feasible for early intervention in psychosis service users, with high engagement rates and high user-reported satisfaction. Users perceived improvements in neurocognition and reported using strategies learnt during CR in daily life. Conclusions: Meta-analysis suggests that CR is beneficial in FEP. Evidence from the pilot trial shows that a CR intervention enhanced with SCT can improve functioning more than CR alone and that such an intervention is feasible and acceptable. A larger RCT is required to explore the full benefits of a CR+SCT intervention compared to CR and treatment as usual.

The purpose of this study was to evaluate the efficacy of a cognitive and metacognitive intervention program (Caribbean Quest; CQ), on improving cognitive and social self-concepts (i.e., evaluative self-perceptions, including self-efficacy beliefs), executive function (EF), and attention. The effect of motivation on cognitive training derived benefits also was assessed. Motivation was examined both in terms of motivation specific to engagement in the CQ intervention (i.e., state motivation) and children’s intrinsic motivation for learning situations in general. In addition, the relationship between age, motivation, and self-concept was investigated. Participants included fifty-five male children, ranging in age from 6 to 12 years, with teacher reported deficits in EF and attention (29 controls, M = 8.38 years; 26 intervention, M = 8.35 years). The CQ intervention was delivered to children at school by trained educational assistants (EAs). On average, children completed 12 hours of intervention over 6 weeks. During CQ training sessions, EAs provided support to children in their game play, helping them to monitor their performance and utilize cognitive and metacognitive strategies. Each participant completed a battery of tests before and after the intervention, including measures of cognitive function, self-concept, working memory (WM), sustained attention, and intrinsic motivation. Teachers also provided ratings of children’s intrinsic motivation. Following CQ sessions, children’s state motivation was assessed. Pre- and post-test analyses did not reveal significant intervention effects for self-concept. However, given known developmental differences in self-evaluations for children less than eight years of age as compared to children aged eight years and older, self-concept was analyzed separately within younger and older age groups. Results indicated that children younger than eight years of age showed significant improvements on cognitive and social self-concept compared to the control group, suggesting that self-concept may be more amenable to change in younger children. Transfer effects of cognitive training to neuropsychological measures of WM and attention were not significant, although findings trended in the direction of higher benefit for the intervention group. For participants in the intervention group, child-reported intrinsic motivation, but not teacher-reported or state motivation, predicted the extent of change on the self-concept questionnaire and the sustained attention task. Results indicated cognitive self-concept and state motivation increased with age for the younger group of children; for the older group of children, state motivation decreased with age. In sum, results support the use of a cognitive and metacognitive training intervention for improving cognitive and social self-concepts in younger boys with EF and attention deficits. These findings highlight the importance of motivation as a key determinant of change and training derived gains. Future studies should further explore the relationship between motivation and training derived gains to better understand factors that might limit or enhance the effectiveness of cognitive intervention, as well as examine the value of concurrently targeting motivational factors in cognitive intervention. / Graduate

Introduction: An increased incidence of schizophrenia among migrant and ethnic minority groups has been established. Ethnic minorities have poorer access to and outcomes from evidence based psychosocial interventions compared to the majority population. The overall aims of this thesis was to explore culturally adapted psychosocial interventions for migrant and ethnic minority schizophrenia sufferers, and use the results of these investigations to develop culturally adapted cognitive remediation (CR) to meet the needs of South Asian first episode sufferers. Methods: A systematic review and meta-analysis of previous randomised controlled trials (RCTs) investigated the quality, methods and effectiveness of culturally adapted psychosocial interventions for schizophrenia. Interviews, analysed using framework analysis, explored the acceptability, and perceived accessibility, of CR to the target population. CR for first episode psychosis was then adapted to target South Asian sufferers' needs and participants' satisfaction and engagement measured in a feasibility study. Results: The systematic review identified 17 RCTs of culturally adapted psychosocial interventions for schizophrenia. Meta-analysis of culturally adapted Family Intervention (caFI) compared to Treatment As Usual (TAU) showed no reduction in relapse risk. There were non-significant reductions in risk and number of hospitalisations during the intervention and significant shortening of total time in hospital. Meta-analysis of culturally adapted Social Skills Training (caSST), compared to TAU showed improvements in medication and symptom management but no effects when compared to a time-matched psychosocial intervention. Results must be interpreted with caution due to the small number of trials included and limitations in their analyses. Cultural adaptations made to the interventions were similar across trials. This allowed for the development of a measure systematically recording the methods used in culturally adapting interventions. Scale items included: language, therapeutic alliance, teaching style, manual content, family, treatment goals, explanatory models of illness, help seeking behaviour, delivery, stigma, societal context and cultural tenets. Emergent themes from qualitative interviews with ten South Asian first episode schizophrenia sufferers included: help seeking for psychosis, sociocultural influences on help seeking, experience of cognitive deficits, and recommended cultural adaptations to CR. CR was well received by all respondents. Level of acculturation and the influence of family and illness beliefs were associated with distinct pathways to care. A feasibility study of culturally adapted cognitive remediation (caCR) for first episode South Asian psychosis patients resulted in high levels of service user satisfaction, therapeutic alliance and participant retention rates. The majority (87.5%) reported cognitive benefits and a boost in self-esteem. Conclusions: The scale of cultural adaptations for psychosocial interventions for schizophrenia will provide a framework for those developing culturally adapted interventions for migrant or ethnic minority communities and a means to record the degree and type of adaptation. CaCR was acceptable to first episode South Asian psychosis sufferers. A larger trial is required to investigate this intervention's efficacy in terms of cognitive and global functioning.

<p>This thesis presents research documenting the effectiveness of computer-assisted cognitive remediation for patients with mood disorders. The first chapter provides an overview of cognitive impairment in patients with bipolar disorder (BD) and major depressive disorder (MDD), and a concise review of cognitive remediation in patients with schizophrenia, where the efficacy of these interventions has been reasonably well studied. The results of an analysis comparing neuropsychological test performance in patients with BD, MDD, and healthy controls is presented in Chapter 2, where we show a similar degree of deficit in both patient groups on processing speed, working memory, and mental flexibility tasks, and a greater degree of deficit in patients with BD on delayed recall and verbal fluency tasks. In Chapter 3 we present the results of our primary analysis examining the effectiveness of CACR for patients with BD and MDD; we show significant improvement on neuropsychological tests of working memory and delayed memory following remediation, and positive associations between improvement in neuropsychological test performance, and improvement in subjectively-rated cognitive and psychosocial functioning. Finally, in Chapter 4 we present functional neuroimaging evidence that shows increased activation following cognitive remediation in frontal control regions supporting working memory and in the right hippocampus supporting recollection memory. Although behavioural performance on the corresponding tasks was stable, the observation of increased activation in frontal and medial temporal brain regions following remediation is in line with our finding of improvement on neuropsychological tests of working memory and delayed recall post-training. Taken together, the results presented in this thesis provide convergent behavioural and neural evidence to demonstrate the efficacy of computer-assisted cognitive remediation for patients with mood disorders. These novel findings contribute to a growing body of literature that shows cognitive remediation to be an effective cognitive management strategy across a range of psychiatric and neurological disorders.</p> / Doctor of Philosophy (PhD)

Objectives: The first objective of this research was to examine whether symptom dimensions in obsessive-compulsive disorder (OCD) are associated with unique neuropsychological performance profiles. The second objective of this research was to further understand the strengths and weaknesses of two models of symptom dimensions in OCD from a quantitative perspective—conventional subtyping by overt symptom, and the core dimensions model. Finally, the third objective of this research was to investigate the efficacy and treatment acceptability of a cognitive remediation program targeting neurocognitive deficits associated with OCD. Methods: Study 1 reviewed critically studies describing the assessment of differences in neuropsychological functioning between symptom dimensions of OCD, the results of which informed succeeding studies examining: i) the characterization of symptom dimensions in OCD and; ii) the remediation of neuropsychological domains commonly affected in OCD. Accordingly, study 2 compared the suitability of two common statistical approaches, factor analysis and cluster analysis, commonly used in the existing literature to define symptom dimensions based on responses collected from the industry-standard symptom questionnaire, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), in characterizing symptom dimensions in OCD. Neuropsychological task data were then used to examine the validity of an alternative model of symptom dimensions in OCD (Study 3). Finally, we conducted a feasibility study (Study 4) examining the use of an established cognitive remediation protocol, Goal Management Training (GMT), to target the deficits in neurocognitive function identified in the preceding studies. Results: Much of the existing literature on neuropsychological task performance differences between symptom dimensions of OCD is limited by methodological issues, primarily those concerning methods for defining symptom dimensions. Here, a comparison of the two most common methods for defining dimensions revealed that neither cluster analysis nor factor analysis produced conceptually meaningful subgroups. By exemplifying differences in neuropsychological task performance between those with harm avoidance and those with incompleteness symptoms, however, concrete evidence was provided to support the core dimensions model of OCD. Pilot data point towards the feasibility and efficacy of GMT as a cognitive remediation program for OCD. Conclusions: Pursuing the definition of meaningful, distinct symptom dimensions of OCD is not recommended with the combination of current statistical practices and symptom measures. The early evidence presented here shows promise for the validity of the core dimensions model. Preliminary evidence suggests that the neuropsychological impairments observed in this population, although subtle, may be effectively addressed using Goal Management Training. / Thesis / Doctor of Philosophy (PhD)