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Shaping Attention Span: an Operant Conditioning Procedure to Improve Neurocognition and Functioning in Schizophrenia

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Shaping Attention Span: an Operant Conditioning Procedure to Improve Neurocognition and Functioning in Schizophrenia Shaping Attention Span: An Operant Conditioning Procedure to Improve Neurocognition and Functioning in Schizophrenia by Steven M. Silverstein, Anthony A. htenditto, and Paul Stuve Abstract treatments are typically grouped together under the rubric "cognitive rehabilitation." To date, this term has been applied The high prevalence of neurocognitive deficits in schizo- to treatments such as practicing of cognitive skills in individ- phrenia, and their association with poorer outcomes, has ual (Spaulding et al. 1986; van Der Gaag 1992) or group created interest in treatments that can improve neu- (Brenner et al. 1994; Spaulding et al. 1999fc) formats, and rocognitive functioning hi this illness. While a variety of computer-assisted training (Medalia and Revheim 1999). rehabilitation interventions have been developed, many Because of the early stage of development of neu- are not appropriate for the most severely ill patients, rocognitive rehabilitation technology for schizophrenia, whose attention spans are so short that they cannot guidelines have yet to be established regarding which attend to the material being presented. For this popula- treatments are appropriate for which patients. Thus, treat- tion, the only neurocognitive rehabilitation methods with ments have not necessarily been targeted to specific pro- demonstrated effectiveness are those that involve the files or severity levels of neurocognitive deficits. This lack operant conditioning technique known as shaping. In of specificity is most problematic for chronic, severely ill, this article, we review the rationale for the use of shap- and treatment-refractory patients, such as those who are ing-based methods as neurocognitive retraining tech- unable to be discharged from state-hospital settings; these niques for treatment-refractory schizophrenia patients, patients typically have the most severe attentional and review published reports using this intervention, and other neurocognitive deficits, and these deficits are related offer suggestions for the future development of this to particularly poor outcomes. Despite the enormity of this method from both clinical and research perspectives. problem, scattered reports throughout the literature suggest Keywords: schizophrenia, attention, cognition, cog- that one form of neurocognitive rehabilitation, based on nitive rehabilitation, psychiatric rehabilitation the behavioral principle of shaping, has consistently Schizophrenia Bulletin, 27(2):247-257, 2001. demonstrated effectiveness in increasing the attention spans of such patients. In this article, we discuss issues Data on the high prevalence of neurocognitive deficits in related to the use of shaping procedures as neurocognitive schizophrenia (Palmer et al. 1997) and their association with retraining methods. We begin by providing a rationale for poorer outcomes (Green 1996; Silverstein et al. 1998«) has addressing attentional impairment in schizophrenia and for created interest in treatments that can improve neurocognitive using behavioral techniques to do so. This is followed by a functioning in this illness. Because traditional antipsychotic rationale for choosing shaping over other behavioral tech- medications have had minimal or sometimes deleterious niques, a review of published reports using shaping meth- effects on cognition after the acute phase (Corrigan and Penn ods to improve attention, and a review of future needs. 1995; Schwarzkopf et al. 1999), the majority of direct neu- rocognitive enhancement efforts thus far have focused on 1 Rationale for Addressing Attentional psychological interventions. These nonpharmacological Deficits in Schizophrenia 1 More recently, data on the effects of atypical amipsychotic medications on A growing body of evidence indicates that deficits in neurocognition have been repotted (cg^ see reviews in Schizophrenia Bulletin sustained attention and verbal memory are associated 25[2Tj. While a consensus appears to be building that neurocognitive function- ing is better on these medications compered to older drugs, the mechanisms of this improvement (e.g^ real improvement versus removal of sfrintinn and other side effects that worsened cognition on "typical" medications) as well as the Send reprint requests to Dr. Steven M. Silverstein, Weill Medical magniturir of the changes are still under debate. Therefore, this literature will College of Cornell University, 21 Bloomingdale Rd., White Plains, NY not be a focus of this article. 10605; e-mail: [email protected]. 247 Schizophrenia Bulletin, Vol. 27, No. 2, 2001 S.M. Silverstein et al. with less skill acquisition in treatments such as the Another recent approach utilizes computers to University of California at Los Angeles Social and administer tasks based on neuropsychological tests or Independent Living Skills modules (Mueser et al. 1991; exercises developed for remediation of cognitive deficits Kern et al. 1992; Wallace et al. 1992; Bowen et al. 1994; in learning disabilities. Data from studies of neuropsy- Corrigan et al. 1994; Silverstein et al. 19986; Silverstein chologically oriented computer exercises indicate that et al. 1998e). One conclusion that can be drawn from improvement in neurocognitive functioning occurs, as these studies is that patients who are impaired in their assessed via laboratory procedures (e.g., Burda et al. ability to sustain attention or to remember material pre- 1994). As with the approach discussed above, there is lit- sented to them will benefit little from the treatment. tle evidence that the improvements generalize to other Neurocognitive deficits, including poor attention span, areas of functioning or that they enhance response to are also predictive of poorer outcome in other domains, other rehabilitation efforts. Studies using a neuropsycho- including community outcomes, work performance, and logical educational approach to rehabilitation (NEAR) social problem solving (reviewed in Green 1996). (e.g., Medalia et al. 1998; Medalia and Revheim 1999) Moreover, the relationships between neurocognitive have shown promise in improving cognitive abilities, but deficits and outcomes are relatively independent of their effects outside of the laboratory are as yet unknown. symptom effects, and neurocognitive functioning is While it is likely that these methods will continue to be more predictive of level of functioning and outcome developed and refined, a problem with using them with than are symptoms (e.g., Mueser et al. 1991; Green severely impaired patients is that they require significant 1998). All of these data suggest that finding a method to intrinsic motivation on the part of the patient. This has improve neurocognitive functioning is an important step been recognized, and one of the strengths of the NEAR in improving rehabilitation outcomes. When neurocogni- approach is its selection of exercises that patients seem to tive deficits are targeted for direct intervention, it is enjoy (Medalia and Revheim 1999). However, at this thought that gains in functioning may be made and that point, it is not known whether this approach would be such gains will enhance the success of other rehabilita- effective with patients who are unmotivated to participate tion efforts. in rehabilitative treatment. The most widely reported approach to neurocognitive remediation of schizophrenia has been group-based ther- Neurocognitive Remediation for apy. The most popular of these treatments is Integrated Schizophrenia Psychological Therapy (IPT), developed by Brenner et al. (1994). This intervention targets skills in a hierarchical A comprehensive review of the growing field of neu- fashion, beginning with conceptual differentiation (execu- rocognitive remediation for schizophrenia is beyond the tive functioning) and moving through social perception, scope of this article, and the reader is referred to several verbal communication, basic social skills, and interper- excellent recent reviews and reports of individual studies sonal problem-solving segments. Skills are targeted (e.g., Kern 1996; Bellack et al. 1999; Spaulding et al. through group practice and problem solving using a series 1999a). The purpose of this brief section, rather, is to of exercises that increase in complexity over time. Results describe the approaches that are currently in use, in order from studies of IPT have been mixed (Brenner et al. 1992; to distinguish them from the behavioral approach of Brenner et al. 1994; Spaulding et al. 19996). In Brenner's shaping that is the focus of this article. studies, little evidence of generalizability of the effects to One approach to treating neurocognitive deficits real-world behavior was observed. Spaulding et al. involves the adaptation of methods from experimental (19996) reported improvement on a measure of social psychology. For example, while dichotic listening proce- cognition; however, behavioral effects outside of labora- dures have been used to demonstrate auditory selective tory-based assessment procedures were not studied. The attention deficits in schizophrenia, they have also been current status of IPT for schizophrenia remains controver- adapted to enable patients to practice attending to rele- sial, with some (e.g., Bellack et al. 1999) suggesting that vant stimuli and ignoring irrelevant stimuli (e.g., the effect sizes from published reports are not clinically Spaulding et al. 1986). To date, the total number of significant, and others (e.g., Spaulding et al. 19996) dis- patients treated using such techniques, as reported
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