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The Capital Region of Denmark - a part of Copenhagen University Hospital

The basic subjective disturbance of schizophrenia illuminated by clinically developed tests. – Objective self-deficits in subjective “Perspectival Abridgement”.

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  1. Creativity and Mental Illness

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  2. Diagnostiske konsekvenser af den valgte interviewteknik

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For further information, please contact Rasmus Revsbech, M.Sc. Pscyh., Ph.D.-Candidate at rasmus.revsbech@regionh.dk or by phone on: 0045  60929542 

1. Introduction

Neuro cognitive test with the success of illuminating the subjective disturbance in schizophrenia are not currently available. This is due to the trend of cognitive tests being imported from neurology and thus does not have their basis in clinical observations and psychological more ecologically valid heuristics. We need tools to find endophenotypes that are more founded in clinical observations and real world situations than in isolated cognitive processes. We view the syndrome of schizophrenia as a multimodal gestalt with a subjectively and objectively global impact and whose method of investigation suffers from a reductionism, which needs to be reconsidered.

1.2 Conceptual hypothesis: The Perspectival Abridgement à Adaptational deficits

We want to investigate what we call a “perspectival abridgement”(PA) introduced by Sass and Parnas in 2003 (1) as something central to the definition of schizophrenia as a basic global disturbance of the subjectivity which manifests in the relation to the self, others and the world (1-5). “Abridgement” refers to condensing or sorting out the most adequate or important information in any given situation and “perspectival” refers to naturally navigating and interacting undisturbed in relation to the self, others and the world in accordance with a focus on the situational information (1). One could in short say that this phenomenon if disturbed might result in a bad “common sense”, “adaptational deficit” or perplexity(5). This implies modalities of sensing, precognitive functioning and modes of reasoning. In short, normal PA can be seen as an underlying (mostly automatized) or precognitive multimodal ability to naturally and immediately change and maintain informational adequacy of experienced perspectives of being in different settings as part of the undisturbed subjectivity (1). A schizophrenic deficit in perspectival abridgement is comparable to the concept of schizophrenic sejunction described first by Wernicke and later like a more multimodal concept by Otto Gross. In his episteme, it is a […] simultaneous collapse of several functionally separate series of associations.[and] The most important component of the concept is that the activity of consciousness always has to be seen as the product of many simultaneously ongoing psychophysical processes (6) - much as ours. We have chosen and seek to measure the schizophrenic visual, semantic and social cognitive perspectival abridgement and compare it to the normal, fluid, natural and common way of acting, reasoning and being in the world. Thus we generally hypothesize that aspects of processing visual information, semantic reasoning and intersubjective experience have a common way of subjectively appearing in non-schizophrenics, which is, qua schizophrenic sejunction, different than otherwise when one suffers from schizophrenia.

1.2 Research Hypotheses

1) The first hypothesis is regarding syllogisms. Here it is expected on the grounds of a British study that the schizophrenic patient might do better than normal controls at deducting formal logically (7). Doing better means that the connection between premises and conclusion of a formal logic statement might be more transparent to the schizophrenic, in spite of an absurd or normative qualitative content. The explanation could be that they are less “focused” in their perception of the world and is preceded by the idea that there are two ways of perception: A logical deductive versus a more fluid way of perception bounded in experience and context. Clinically it is founded in the notion that the schizophrenic is marked by perplexity and lack of common sense and that common sense might have less to do with logics than one tends to think (3, 5, 8, 9).

2) The second hypothesis concerns ambiguous figures and how they appear to the schizophrenic mind versus the healthy mind. We hypothesize that the schizophrenic might have an unstable perspective on the world(1) and on that basis we want to see if the schizophrenic have a diverse experience more than a ambiguous experience. This implies that he/she might have a perceived ability to experience both aspects of the ambiguous figure simultaneously, which is normally not possible. We expect the healthy controls to experience the aspects of the ambiguous figures as something that, by will, can change and be withheld by the personal intention of the mind.

3) The third hypothesis is about the schizophrenic rationalizing differently from healthy controls. And that this is detectable in social cognition. We hypothesize that the schizophrenic will have a tendency towards viewing others more as situational variables than interpersonal beings with a relevant biographical aspect. Thus the schizophrenic might have a more logical approach to others than a “bounded rational” approach, which denotes a healthy person(9-12).

4) The fourth hypothesis is concerned with the idea that schizophrenics mentalize differently and have a different everyday thinking. Everyday thinking is to be regarded as the fluid intuitive way of perceiving the world and others and which normally helps the healthy person conserve energy in regards to automatically sort out irrelevant stimuli and apply normal social knowledge to their everyday life(13). We hypothesize that this ability is in someway inhibited in schizophrenics(13).

5) The fifth hypothesis postulates a correlation between syllogisms, ambiguous figures, schizophrenic rationalizing and mentalizing and formal thought disorder measured with EASE, EAWE and proverb testing. By thought disorder it is meant to focus on the fact that the schizophrenic disorganisation often results in semantic or linguistic confusion when the patient tries to describe his/her subjective experiences and cognitions verbally(14). Clinically the schizophrenic appears special or hard to understand, when communicating subjective experiences. There is a wide clinical agreement on thought disorder being one of the strongest cognitive endophenotypes of schizophrenia and this is sought to be empirically further investigated.

6) The sixth hypothesis postulates a correlation between syllogisms, ambiguous figures, schizophrenic rationalizing and mentalizing, formal thought disorder measured with EASE, EAWE & proverb testing and MATRICS recommended CANTAB testing

7) The seventh hypothesis postulates that the schizophrenic self-disturbance as perplexity is clinically qualitatively traceable throughout the entire testsession.

1.2.1 Further epistemological precursors
The epistemological precursor of the project is to be seen in context of basic psychological and phenomenological epistemological reflections on how a psyche in interaction works and is constituted. Moreover another precursor is of a pragmatic nature: we seek to develop something, which could be of such a valid nature, so that it would be valuable in a clinical and diagnostic setting. On this basis we look for sensory, cognitive, social cognitive and biological markers in order to reflect the multimodality of schizophrenia as something that should mainly be viewed as a biologically dependent, phenomenologically gestalt manifested and conceptually complex.

2. Methods

2.1 Participants

The 30 sample participants are all first-time admitted ICD-10 diagnosed schizophrenics. The group has a mean age of 27,5 years and there is a slight over-representation of women. The sample has been chosen as part of another project at Psychiatric Centre Hvidovre, which has the aim of diagnostic precision. As part of that project the patients have been clinically interviewed quite thoroughly and given a diagnosis on basis of at least two trained interviewers and many even three and MMPI data. The group has been screened for substance abuse and organic syndromes such as brain damage.
The control group consist of 30 orthopaedic patients who have no prior psychiatric history, nor relevance. The two groups are matched on age, (preferably) gender and IQ.

2.1.1 Design
The project has an in-between group design containing a group of young patients (N= 30 age= 18 to 35 yrs) suffering from schizophrenia, which we compare to a group of healthy controls of equal number and age. The independent variables are gender, age, IQ, different types of rationality and occurrence & non-occurrence of schizophrenic symptomatology.

2.2 Materials

The test materials consist of a manual proverb test, computerised tests and a short interview guide. The computer used is a CANTAB tablet The CANTAB is a small portable test computer, which uses response box and touch screen technology. It is recommended and widely used in numerous studies with testing cognitive domains in schizophrenia research (15). Moreover we are going to install Superlab for the advanced cognitive testing and Hogrefe testsystem for IST 2000-R on the same computer. All test sessions will be recorded on camera w. audio in order to test the eighth hypothesis.

2.2.1 Basic Computerized Cognitive Testing: Basic CANTAB testing: (1 hour 15 minutes.)

The basic digital testing consists of basic cognitive tests using the CANTAB from Cambridge Cognition and in addition for the healthy controls parts of the IQ-tests from Hogrefe testsystem IST 2000-R. It is expectable that the schizophrenic group will have longer reaction times and general lower performance on the assignments given on cognitive domains (15-17). In order to make sure, that the dependent variables can be thoroughly examined in the light of schizophrenia, we are going to use the basic CANTAB battery recommended for schizophrenic samples, which is based on the recommendations of MATRICS (15). Detailed overview of the battery:

The Motor Screening test: (MOT) is a training procedure designed to relax the subject and to introduce them to the computer and touch screen. It should always be given at the beginning of a test session. It simultaneously screens for difficulties with:Vision, movement and comprehension And ascertains that the subject can follow simple instructions (5 min). Motor skills and introduction to machinery.

Attention/Vigilance: Rapid Visual Information Processing (RVP) Continuous performance test of sustained attention. Participants monitor a stream of single digits for a sequence of three-digit numbers (9 min) Sustained attention, signal detection, impulsivity

Working Memory: Spatial Working Memory (SWM) Self-ordered search task based on foraging behaviour. Participants search array for tokens without returning to previous token locations. Measures include both efficacy and use of heuristic strategy (10 min). Working Memory, strategy use

Visual Learning: Paired Associates Learning (PAL) Object-location associative learning test. Participants learn to associate patterns which cannot be verbalised with locations on the screen. Reminding occurs between each successive attempt (10 min).

Associative learning, short term visual memory

Speed of Processing: Simple and 5-Choice Reaction Time (RTI) Human analogue of five-choice serial reaction time task. In first stage, participant monitors a single location; in second stage five locations. Reaction time and movement time are measured separately (5 min). Processing speed, motor speed, divided attention

Verbal Learning Verbal Recognition/Recall Memory (VRM) Verbal list learning task, recently added to enable comparison of verbal and non-verbal memory. Delayed recognition after 20 min. Available in multiple languages (7 min). Verbal learning, immediate recall and recognition, delayed recognition

Social Cognition Emotion Recognition Test (ERT) Facial emotion labelling task, recently added to the battery to enable assessment of social cognition. Participants choose between six primary emotions and neutral (10 min). Emotion recognition, decision latency

Reasoning/Problem Solving Intra/Extra-Dimensional Set-Shifting (IED) Test of cognitive flexibility, analogous to the Wisconsin Card Sort Test, with multiple stages segregating cognitive processes. Novel problem-solving element, so test should be used only once (10 min). Rule learning, rule reversal, attentional set shifting

One-Touch Stockings of Cambridge (OTS) Visual planning task based on the Tower of London and the CANTAB Stockings of Cambridge (SOC). One-touch version is simpler to administer and reduces guessing (9 min). Visual planning, reasoning, impulsivity

2.2.1.1 IQ for healthy controls (35 min)

Moreover, the battery for the healthy controls will include four subtests from the IST2000-R IQ-test testing similarities, information, matrix reasoning and arithmetic ability. These have already been administered to the schizophrenic group. This means additional testing of 30-35 min, making the basic computerized healthy control test last around 2 hours.

2.2 Basic Manual Testing

2.2.1 Thought disorder –proverb test (15 min)

The basic manual testing will be a proverb test for thought disorder. Culturally adequate proverbs will be qualitatively rated in accordance with normal standards (18, 19).

2.3 Advanced computerized Testing

2.3.1 Visual Perspectival Abridgement –seeing aspects (30 min)

For the visual testing, we want to develop an original test based on inspiration from reflections on Wittgenstein’s phenomenology of visual perception. This has been described by Stephen Mulhall in his book “Seeing Aspects”(20). Here he proposes that an aspect and perspective on visual stimuli follows a certain pattern of normalcy. This pattern includes that normal visual experience impressionistically “dawns” in certain phases of conscious experience thus constituting the normal subjective experience of visual information processing (20). To test this hypothesis, we have designed a test using ambiguous figures. The test person will be instructed to view a picture of an ambiguous picture with different degrees of artistic (high/low) complexity and of ambiguous/non-ambiguous nature. The person will then get an on-screen multiple choice form in order to fill out what level of ambiguity they see in the picture. The multiple-choice form will give the possibility of rating what most people will see being i.e. when presented the picture on the right, the following would be the possibilities:

A duck (Aspect a)
A rabbit (Aspect b)
I can decide to see either the duck or the rabbit if I choose to
I can see both at the same time without having to choose
(It changes between the duck and the rabbit by itself (?))
I see something other than a duck or a rabbit/Nothing

We hypothesize, that schizophrenics will chose one of the three latter more than healthy controls. This should be due to them abridging visual information in a different way thus not perceiving aspects normally. Moreover, a small qualitative study will be applied to this particular test, as we will pay specific attention to how all persons immediately react verbally to the pictures. Thus in addition to rating the multiple-choice form, they will be instructed to speak out the first thing that comes into mind during the presentations so that we can record crucial data on their first ausserungen in order to make some further phenomenological analyses (20). We want to do 28 presentations: 7 pictures of no ambiguity/high complexity, 7 of no ambiguity/low complexity, 7 of ambiguity/high complexity and 7 of ambiguity/low complexity. The picture in the example is of ambiguity/high complexity.

2.3.2 Semantic perspectival abridgement – rationality (30 min)

For the semantic test we want our test persons to rate syllogisms false or true. This is done as a replicate study of Owen et al. in 2007 (7). Here different syllogisms with absurd or common qualitative content will be presented. There will be a 50% distribution of true or false and of common and absurd. An example can be:
-All buildings can sing
-A hospital is a building
-A hospital can sing
This is a logically correct statement due to a conclusion drawn from exclusively logically valid premises (21). However, our hypothesis will be in coherence with the findings of Owen et al, 2007 that the schizophrenic patient will be better or faster at determining whether this statement is syllogistically true or false. A theoretical explanation can be that the atypical perspectival abridgement manifests semantically as the schizophrenic patient is not as disturbed by the absurd content of the syllogism in the same way as the healthy control, whose heuristics are more based on intuition than on logical reasoning. There will be 28 syllogisms included. 7 true + 7 false with no absurdity in content & 7 true + 7 false with absurd content.

2.3.3 Social cognitive/intersubjective perspectival abridgement (45min)

2.3.3.1 “Bounded Rationality” (30 min)

On this level we want to subject the test persons to some social cognitive testing which illuminates how the point of the semantic perspectival abridgment also manifests in the schizophrenic thinking of persons as situational variables more than interpersonal beings.
In this test we want to test if the schizophrenic heuristic differs from the normal. A classical test for heuristics is what Gerd Gigerenzer calls “Bounded Rationality” (10, 12). This refers to a basic neuro-economic heuristic that make the normal mind make decisions and calculate probability mainly from experience and environmental variables more than making a mathematical calculation of probability. Thus making a conjunction fallacy in a strict mathematical sense (9, 10, 12). A famous example is that of the “Linda problem” (9, 22):
“Linda is 31 years old, single, outspoken, and very bright. She majored in philosophy. As a student, she was deeply concerned with issues of discrimination and social justice, and also participated in anti-nuclear demonstrations.
Which is more probable?
Linda is a bank teller.
Linda is a bank teller and is active in the feminist movement” (22).
Most people will intuitively answer that option 2 probably is the correct answer. However, from a probability point of view in a strict mathematical sense, option 1 would be correct, as it only contains one variable and thus decreases uncertainty (9). However, as it would be natural for healthy controls to draw in biographic information in their conclusions (10), we hypothesize that schizophrenics might do better on this task in a mathematical sense, as their rationality might be more bounded in thought than emotion or experience and their social cognitive perspectival abridgement hence less ecologically useful however, maybe more logically correct.

2.3.3.2 Mentalizing/ToM (15 min)

Another test that we will apply is based on the idea, that schizophrenics does not mentalize or use an adequate theory of mind. The test present situational replies to a statement. There are four statements to choose from and the task is to figure out which statement goes best or most adequate with the presented reply. An example can be as follows:

Situation: Old men on park bench
Second man replies: Yes. Things are not what they used to be
First man has said:

a) There’ been a change in the weather
b) There’s no good going to see that doctor
c) There’s a lot of crime about these days
d) There’s many a day I think of my late wife

(13)

The most appropriate possibility here would be c. However, we hypothesize in accordance with Cutting & Murphy, 1990 that due to the lack of perspectival abridgement, the schizophrenic will be more tempted or confused by the other possibilities.

2.4 Advanced Manual Testing

2.4.1 EAWE (45 min)

Moreover, we want to do a short interview with the patient on how the patient functions existentially and intersubjectively in regards of being in the world using items from an interview under development called the EAWE. The EAWE is in structure and epistemological foundation much like the EASE, which has a focus on self-disorders (23). However, as opposed to the interior focus on abnormal experiences of the self in EASE the EAWE focuses more on the exterior existentially and worldly, inter-subjectively situated being. The EAWE should be seen as having a focus on the experiencing of the self in relation to others.

2.5 Biomarkers

None

2.6 Procedure and timeplan

All test sessions will be recorded on camera w. audio.
The test sessions are going to be divided into two different days.

Day 1:
10 pm, arrival: Briefing
10:15-10:30: The participant is going to be subjected to the basic manual testing first being the proverb test.
10:30-12:30 The participant is going to be subjected to the advanced computerised testing being the seeing aspects, syllogism, social cognition/rationality and ToM.
12:30-12:45: Lunch break
12:45-13:45: EAWE and debriefing

Day 2:
10 pm, arrival: Briefing
10:15-11:30: CANTAB testing
11:30-12:00: Lunch break
12:30-13:00: Debriefing

References

1. Sass LA, Parnas J. Schizophrenia, consciousness, and the self. Schizophrenia Bulletin. 2003;29(3):427-44.
2. Parnas J, Glenthøj B. Skizofreni, skizotypisk sindslidelse, paranoide psykoser, akutte forbigående psykoser samt skizoaffektive psykoser. Klinisk Psykiatri. 3 ed. København: Munksgaard; 2009. p. 247-361.
3. Parnas J, Handest P, Jansson L, Saebye D. Anomalous subjective experience among first-admitted schizophrenia spectrum patients: Empirical investigation. Psychopathology. 2005;38(5):259-67.
4. Urfer-Parnas A, Mortensen EL, Parnas J. Core of Schizophrenia: Estrangement, Dementia or Neurocognitive Disorder? Psychopathology. 2010 Jul 15;43(5):300-11.
5. Störring G. Perplexity. In: Cutting J, Shepherd M, editors. The clinical roots of the schizophrenia concept - Translations of seminal european contributions on schizophrenia. Cambridge: Cambridge University Press; 1939. p. 79-82.
6. Gross O. Dementia Sejunctiva. Neurologisches Centralblatt. 1904(23):1144-6.
7. Owen GS, Cutting J, David AS. Are people with schizophrenia more logical than healthy volunteers? Br J Psychiatry. 2007 Nov;191:453-4.
8. Parnas J, Bovet P. Autism in Schizophrenia Revisited. Compr Psychiat. 1991 Jan-Feb;32(1):7-21.
9. Stanovich KE, West RF. On the relative independence of thinking biases and cognitive ability. J Pers Soc Psychol. 2008 Apr;94(4):672-95.
10. Gigerenzer G. Gut Feelings: The Intelligence of the Unconscious London, UK: The Penguin Group; 2007.
11. Gigerenzer G, Goldstein DG. Reasoning the fast and frugal way: Models of bounded rationality. Psychol Rev. 1996 Oct;103(4):650-69.
12. Gigerenzer G, Todd P, Group AR. Simple Heuristics That Make Us Smart OUP USA; New Ed edition 2000.
13. Cutting J, Murphy D. Impaired Ability of Schizophrenics, Relative to Manics or Depressives, to Appreciate Social Knowledge About Their Culture. British Journal of Psychiatry. 1990 Sep;157:355-8.
14. Vaever MS, Licht DM, Moller L, Perlt D, Jorgensen A, Handest P, et al. Thinking within the spectrum: schizophrenic thought disorder in six Danish pedigrees. Schizophr Res. 2005 Jan 1;72(2-3):137-49.
15. Barnett JH, Robbins TW, Leeson VC, Sahakian BJ, Joyce EM, Blackwell AD. Assessing cognitive function in clinical trials of schizophrenia. Neurosci Biobehav Rev. 2010 Jul;34(8):1161-77.
16. Kim KR, Park JY, Song DH, Koo HK, An SK. Neurocognitive performance in subjects at ultrahigh risk for schizophrenia: a comparison with first-episode schizophrenia. Compr Psychiatry. 2011 Jan-Feb;52(1):33-40.
17. Heinrichs RW, Zakzanis KK. Neurocognitive deficit in schizophrenia: A quantitative review of the evidence. Neuropsychology. 1998 Jul;12(3):426-45.
18. Sponheim SR, Surerus-Johnson C, Leskela J, Dieperink ME. Proverb interpretation in schizophrenia: the significance of symptomatology and cognitive processes. Schizophrenia Research. 2003 Dec 15;65(2-3):117-23.
19. Gorham DR. Use of the Proverbs Test for differentiating schizophrenics from normals. Journal of Consulting Psychology. 1956;20(6):435-40.
20. Mulhall S. On Being in the World - Wittgenstein and Heidegger on Seeing Aspects. London: Routledge; 1990.
21. Forbes G. Modern Logic - A Text in Elementary Symbolic Logic. New York: Oxford University Press; 1994.
22. Tversky A, Kahneman D. Extensional Versus Intuitive Reasoning - the Conjunction Fallacy in Probability Judgment. Psychol Rev. 1983;90(4):293-315.
23. Parnas J, Moller P, Kircher T, Thalbitzer J, Jansson L, Handest P, et al. EASE: Examination of anomalous self-experience. Psychopathology. 2005;38(5):236-58.

StatusCompleted
Period01/02/201101/02/2014
URLhttp://forskning.regionh.dk/psykiatrien/da/projects/den-skizofrene-grundfortyrrelse-belyst-via-neurokognitive-test-udviklet-herfor(deb02617-9f72-49dc-a522-581f51730899).html
Financing sourceOther public support (public)
Research programmeSundhedvidenskabeligt Fakultet, København Universitet
Amount750.00 Danish Kroner
Approval year2010
Financing sourceOther public support (public)
Research programmeRegionH
Amount630.00 Danish Kroner
Approval year2010

ID: 32211922