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Attention in Patients with Chronic Schizophrenia: Deficit in Inhibitory Control and Positive Symptoms

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Attention in Patients with Chronic Schizophrenia: Deficit in Inhibitory Control and Positive Symptoms Eur. J. Psychiat. Vol. 26, N.° 3, (185-195) 2012 Keywords: Chronic schizophrenia; Positive symp- toms; Inhibitory control; Attentional deficit. Attention in patients with chronic schizophrenia: Deficit in inhibitory control and positive symptoms Flavia S. Galaverna*,**,*** Carlos A. Morra*** Adrián M. Bueno*,** * Laboratorio de Psicología, Facultad de Psicología, Universidad Nacional de Córdoba, Córdoba ** Carrera de Psicología, Facultad de Filosofía y Humanidades, Universidad Católica de Córdoba, Córdoba *** Sanatorio “Profesor León Morra”, Córdoba ARGENTINA ABSTRACT – Background and Objectives: Attention is a central mechanism controlling information processing, activating and inhibiting processes, and forming a complex sys- tem including diferent networks in specific areas of the brain1. To correctly assess the role of attention in schizophrenia it is necessary to discriminate its different attentional com- ponents, which may by selectively altered. Attention span, focused attention, selective at- tention, sustained attention and inhibitory response, were assessed in patients with chron- ic schizophrenia and healthy matched controls. Methods: The study included 32 patients diagnosed with chronic schizophrenia and 32 healthy subjects. The groups were matched in age, sex, and level of education. Symptom severity (positive symptoms, negative symptoms, and general psychopathology) was as- sessed with the Scale for the Assessment of Positive and Negative Symptoms (SAPS and SANS). Attentional components were measured by Forward Digit Span, Symbol Search, Digit Symbol Coding, Stroop Test and Picture Completion. Results: Schizophrenic patients exhibited lower attentional scores in all tests compared to the control group. Inhibitory control and sustained attention were the most affected traits in schizophrenic patients. An inverse correlation was observed between inhibitory control and delusions and disorganized thinking. No significant correlations were ob- served between negative symptoms and attentional performance. Conclusions: The pattern of results obtained in this paper evidences the role of an in- hibitory control deficit in patients with chronic schizophrenia that could also be involved in other attentional and cognitive failures, and also be connected to positive symptoms. Received: 8 September 2011 Revised: 1 April 2012 Accepted: 29 May 2012 186 FLAVIA S. GALAVERNA, CARLOS A. MORRA AND ADRIÁN M. BUENO Introduction On the contrary, there is consistent evi- dence regarding alterations in sustained at- tention. Sustained attention is the ability to Attention deficits are a main neurocogni- maintain attention and remain in a state of tive feature of schizophrenia. These disor- vigilance during a determined period of ders have been observed in children with time11. Some studies suggest that sustained high genetic risk of schizophrenia and in the 2-4 attention is a valuable endophenotype for direct relatives of patients . Moreover, at- schizophrenia12. However recently, Carter tention seems to be the neurocognitive pre- et al.13 argued that the attention deficits of dictor of motor skill ability and social prob- 5 patients with schizophrenia probably reflect lem solving . a deficit in the modulation of the brain ac- Given the conceptual, neuroanatomical tivity in response to transitory variations in- and neurofunctional complexity of atten- stead of a deficit in sustained attention. tion, it cannot be reduced to a simple defini- tion, linked to a single anatomic structure, Failures in both these components of at- or assessed by a single test6. Attention is a tention, selective and sustained attention, central mechanism for the control of infor- are based on the incapacity of eliminating mation processing, activating and inhibiting irrelevant stimuli, which in turn is associat- processes, and constituting a complex sys- ed with inhibitory control. Different studies showed that inhibitory control is affected in tem that involves different networks in spe- 14-17 cific areas of the brain1. schizophrenic patients . This component has been related to the correct function of Attention is constituted by several subsys- the executive attention system that partici- tems, each of which is responsible for differ- pates in tasks involving conflicts within sys- ent operations including selection or focal- tems, where it is necessary to inhibit usual ization, sustained attention and inhibitory responses18. attentional control. It is important to dis- criminate these different components of at- These deficits in attention have been relat- tention to correctly assess its role in schizo- ed to psychotic symptoms and this associa- phrenia, as they may be altered selectively. tion is widely discussed. Some authors have found an inverse relation between the severi- The components most studied in schizo- ty of negative symptomatology and the per- phrenia are selective attention and sustained formance of schizophrenic patients in atten- 7 attention. Posner established that selective tion tasks, with no significant relation to attention involves performance when there positive symptomatology19. On the contrary, are conflicts between signals. Attention has other authors, like Krabbendam et al.20, have the role of selecting some signals for higher observed an inverse relation between posi- levels of processing while preventing other tive symptoms, especially disorganization, signals to access those same high levels of and failures in inhibitory attentional control. processing. Studies on the function of this component in schizophrenia are still contro- Based on this contradictory background versial. Some authors have found that selec- regarding the importance of the different tive attention is intact for visual tasks8,9, components of attention in schizophrenic pa- while others show that it has a specific role tients, the object of the present study was to in the inability to correctly perceive reality assess and compare the role of attention span, in schizophrenia10. selective attention, sustained attention and ATTENTION IN PATIENTS WITH CHRONIC SCHIZOPHRENIA: DEFICIT IN INHIBITORY... 187 inhibitory attentional control processing in Neuropsychological Tasks. The tests have chronic schizophrenia. Our main hypothesis been chosen to investigate the attentional was that patients with chronic schizophrenia components involved in schizophrenia are show general attention alterations, with the multicomponent, being that each of these inhibitory component being the most affect- involves the coordinated participation of ed. Additionally, any connections observed several functions. For example, in most tests between the function of each attentional used here in addition to assessing attention- component and positive ad negative schizo- al function, also assess processing speed phrenic symptomatology were also studied. (Stroop Tests, Symbol Search, Digit Sym- bol). However, try to isolate certain compo- nents as reported in the literature. – Digit Span Forward23. In this task, the Materials and methods participant has to repeat a sequence of numbers exactly as the examiner reads Subjects them. If correctly repeated, the exam- iner reads the next set of numbers, and The present study included 64 individu- continues until the participant fails in als; 32 hospitalized patients diagnosed with two series. The amount of digits in- chronic schizophrenia (Schizophrenic Group), creases in each subsequent sequence. and 32 healthy matched individuals (ages 30 The test score is the highest number of to 65 of both sexes) (Control Group). All digits repeated correctly. The forward patients were hospitalized at the Sanatorio digit span was used to measure the ef- Profesor León Morra and the Clínica San fectiveness of attention, especially the Nicolás. The patients had to be psychiatri- attention span24, 25. cally stable for at least two weeks on their 23 treatment with antipsychotic drugs before – Symbol Search . The participant is pre- participating in the study. Healthy partici- sented with a series of paired groups, each consisting of a target group and pants were included considering the follow- search group. The participant must de- ing criteria: a) they had no history of any cide whether either of the target sym- neurological or psychiatry disorders or head bols is in the search group, made up of injuries; b) they had no history of substance five search symbols. The total score is abuse/dependence. All participants were the number of correct answers minus clearly informed regarding the aim of the the number of incorrect answers. This study and assessment manipulations, and test was used for assessing sustained gave their written informed consent prior attention26. the beginning of the study. – Stroop Color-Word Test27. This task has three parts. First, the participant Measures must read outloud the names of the col- ors ‘red’, ‘green’ and ‘blue’, printed in Symptom assessment. A Spanish version black, during 45 seconds. Secondly, of the Scale for the Assessment of Positive the participant is shown rows of ‘x’ Symptoms (SAPS)21 and the Scale for the printed in different colors, and he must Assessment of Negative Symptoms (SANS)22 name the the colors of each row of ‘x’ were used for assessing the severity of the for 45 seconds. Thirdly, the words “red”, clinical syndrome. “green” and “blue” are printed in dif- 188 FLAVIA S. GALAVERNA, CARLOS A. MORRA AND ADRIÁN M. BUENO ferent colors, and the participant must ferent attentional tests in a group of patients name the
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