الفهرس 
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Abstract
Cognitive impairment is recognized as a core feature of schizophrenia that influences patients’ daily functioning. Cognitive deficits appear early in the disease course and might exist before the first positive or even negative symptoms of schizophrenia become manifested. Cognitive impairment is thought to be central to the pathology, and in particular, the areas to be impaired in schizophrenia that include executive functioning (problem solving, planning, abstract thinking), long term memory, cognitive flexibility, attention, and working memory (Nuechterlein et al, 2004; Wykes & Redeer, 2005). Thus, cognitive deficits have a significant impact on the quality of life of sufferers, their symptoms and functional outcome (Wykes & Redeer, 2005). Among cognitive functions, cognitive flexibility and working memory are prevalent in chronic schizophrenia. Patients with schizophrenia need to participate in rehabilitative program including Cognitive Remediation Therapy (CRT) which is a behaviorally based treatment for the cognitive deficits associated with schizophrenia.
The present study aimed to determine the effect of implementing cognitive remediation therapy on cognitive flexibility, working memory, and psychiatric symptoms of patients with schizophrenia.
The study was conducted at El-Maamoura Hospital for Psychiatric Medicine, in Alexandria. 12 male and female patients diagnosed with schizophrenia were recruited in the study. The subjects were selected according to following Inclusion criteria:
Patients diagnosed with schizophrenia by EL-Maamoura hospital medical staff.
Duration of illness more than two years since 1st diagnosis.
Age between 20-50 years (to avoid the impact of aging on the cognitive ability of the study subjects).
Completed at least a basic level of education (nine years of education).
Able to communicate in a coherent and relevant manner.
Haven’t undergone ECT treatment for the last 6 months.
Exclusion Criteria:
Having history of organic brain disease or head injury.
Having primary diagnosis of substance abuse.
The data for this study was obtained using the following tools:
Tool I: A Socio-Demographic and Clinical Data Structured Interview Schedule was developed by the researcher to elicit data about patient’s age, sex, marital status, educational level, employment, living situation, area of residence, age of onset of schizophrenia, duration of illness, number of previous psychiatric hospitalization, and medications presently taken.
Tool II: Wisconsin Card Sorting Test (WCST) was first developed by Berg (1948) as a measure of abstraction and cognitive flexibility. Later WCST was revised and expanded by Heaton et al (1993).The test is composed of response cards and stimulus cards. There are 128 cards divided into two identical decks of 64 cards each. Each card has one to four figures (plus sign, star, circle, or triangle) in one of four colors: red, green, yellow, blue”. No two response cards have the same color, form or number”. In addition to the two identical decks of response cards, four stimulus cards with the following stimulus characteristics will also be placed in front of the subject.
Tool III: The Forward and Backward Digit Span Test developed by Weschler (1981) to measure immediate verbal recall, attentional capacity, and working memory.The digit span test includes two components namely; digit forward and digit backward in a single subset. The test comprises seven levels and each level consists of a number of digits that increases with the rate of one number per each level. Scoring of the digit span test is based on the sum of the forward and backward correctly repeated items.
Tool IV: The Brief Psychiatric rating scale (BPRS- version 4.0) is a semi-structured interview that comprises 24 items. That was developed by Ventura et al. (1993) to measure psychiatric symptoms (41). The presence and severity of psychiatric symptoms are rated on a 7 point Likert scale ranging from 1 (not present) to 7 (extremely severe).
- The researcher undergone a period of 2 months online training on Cognitive Remediation Therapy under the supervision of the CRT administrators from the Institute of Psychiatry, Psychology & Neuroscience, King’s College London.
- A pilot study was carried out on 5 patients with schizophrenia. The internal consistency and reliability of tool (II) was tested on a sample of 7 patients with schizophrenia. Using Cronbach’s Alpha test, the tool proved to be reliable (r= 0.988). Tool III was tested for reliability very recently on patients with schizophrenia using test- retest reliability, the tool proved to be reliable (Eweida, 2017).
- The Cognitive Remediation Program was applied on patients with chronic schizophrenia. It was developed by Delahunty and Morice (1996) in Australia and revised by Delahunty et al. (2000). The content of the program sessions were translated into Arabic language. The materials required for CRT training intervention were prepared. The training program was conducted through-out 24 training sessions (8 sessions for cognitive shift module, 8 sessions for working memory A module, and 8 sessions for working memory B module). Each session consumed one hour on an individual basis for each patient, 4 times per week for six weeks.
The field work in the present study was implemented in three phases:
Phase I: selection of the subjects:
- Hospital wards for male and female psychotic patients were ranked randomly using simple randomization.
- Patients’ medical charts in the 1st ranked ward were reviewed to identify those who meet the inclusion criteria.
- Out of those meeting the inclusion criteria, four patients were randomly selected using simple randomization.
- Study tools (II, III) were applied on an individual basis to the recruited patients. This was done twice prior to the application of CRT training program (with two-week interval).
Throughout recruiting process of the study subjects, 30 patients of those meeting study inclusion criteria were subjected to study tools II, III ( pre -test). Out of this number 19 patients (63.3%) were cognitively impaired (eligible for CRT application). However 7 patients dropped at different stages of the training program application for various reasons.
- Tool (I) was then applied on each of these patient.
- Tool (IV) was applied on these patients on individual basis using both interview and observation techniques.
- The CRT program was then applied on each patient on an individual basis.
Phase II: Implementing the Cognitive Remediation Therapy program:
• Each session of the training intervention consumed about one hour, which increased or decreased according to patient’s response.
• The researcher met each study subject on an individual basis in a quiet room (doctors’ room) in the assigned patient’s ward.
• The researcher established rapport and explained the purpose of the study to each patient participating in the program.
• The Cognitive Remediation Therapy Program was conducted by covering two modules namely ”the cognitive shift module” and ”the working memory (A, B) module”.
• Throughout the training program, the researcher used a number of techniques with patients. These were: massed practice, errorless learning, scaffolding and positive reinforcement.
Phase III: Evaluation of the effectiveness of the Cognitive Remediation Therapy program:
At the end of the intervention a post -test was implemented using study tools (II, III, IV) for each study subject.
The following are the main results yielded by the present study:
Socio-demographic and clinical characteristics:
The total number of the studied subjects were 12, with 50% being females.
The age of the study subjects ranged between 20-50 years, with a mean age of 44.2 ± 10.6, with 66.7% falling in the age group of 40-50 years.
Out of the total subjects, 91.7% were unemployed.
Those who had secondary education represented 58.3%, while those who completed preparatory education constituted 25.0 %.
Single patients constituted 83.3% of the study subjects.
Concerning the place of residence, 75.0% of study subjects were living in urban areas, and 91.7% were living with their families/relatives.
As for clinical description, all of the study subjects had a duration of illness that ranged between 10 to 16 years, with a number of psychiatric hospitalizations ranging between 1- 20 times with a mean of 7.9 ± 6.5 times.
Those who were hospitalized from 1-5 times constituted 33.3%, those who were admitted from 6 - 10 times and also for 16 and more times represented 25.0% each.
Atypical antipsychotic medications were prescribed for 75.0% of the studied subjects, A mixed antipsychotic type of medications for 25% of them.
Regarding the cognitive flexibility according to their perseverative errors, the difference between the mean scores on pre-intervention phase 2 and post intervention phase was statistically significant (Zwil= 4.1, P= 0.001), denoting great improvement in patients’ cognitive flexibility.
The number of categories achieved on the Wisconsin Card Sorting Test among study subjects at pre intervention phase 2 ranged from 1.0 – 4.0 and a mean number of 3.0± 1.0 and median 3.0 compared to 2.0-10.0 and a mean number of 5.6± 2.9 and median of 6.0 at post intervention, which was statistically significant ( Zwil= 2.4, P= 0.006).
Concerning working memory, all of the study subjects (100%) scored as having moderate working memory with a statistical significant difference between pre 2 and post intervention phase (P= 0.001), reflecting the positive impact of the intervention program on patients’ working memory.
In relation to psychiatric symptoms, before the intervention, all of the study subjects (100%) had moderate level of psychiatric symptoms, while on post - intervention the level of psychiatric symptoms dropped to mild level in 75.0% of the study subjects. The rest of the patients (25%), still had moderate level of psychiatric symptoms. The variation was statistically significant ( x2mc= 6.9, P= 0.001), indicating general decrease in psychiatric symptoms severity as a function of the cognitive remediation program.
No statistically significant relationship was found between subjects’ cognitive flexibility, working memory, psychiatric symptoms and each of the socio demographic and clinical characteristics.
According to the multiple linear regression analysis. The model accounted for 47% of variance in the studied patients with schizophrenia who had cognitive flexibility (perseverative error). Psychiatric symptoms significantly increased with the increased patients’ perseverative error as one aspects of cognitive flexibility (p= 0.016) with regression coefficient 0.51 and SE = 0.2. Other aspects of cognitive flexibility (categories achieved) as well as their working memory were not significant predictors of psychiatric symptoms in the model.
Accordingly the following are the main recommendations of the present study:
Psychiatric hospitals may consider the application of Cognitive Remediation Therapy (CRT) intervention as an integral component in the hospital routine care of patients with schizophrenia.
A discharge plan for patients with schizophrenia may include tasks of CRT program to promote cognitive abilities, decrease psychiatric symptoms, and thus decrease patients’ relapses and foster their adaptation back to community.
The CRT intervention program can be incorporated in the psychiatric hospital’s protocol of care including appropriate tools needed for CRT applications (pictures, videos,… etc).
Further research is clearly needed to cover and complement the following points:
o Extend the application of CRT to cover all this modules (cognitive flexibility, working memory, and planning)
o Extend the application of CRT to test its impact on patients’ social functioning.
o Because of the limitation of time in the present study, further studies are needed to cover larger number of patients, larger period, and to determine the efficiency of the program.