John J. Miller, MD: Carlos, I’d like to turn to you. What we know is in terms of the cognitive symptoms of schizophrenia, usually they’re the very first. And in the prodromal phase before someone progresses to what we call schizophrenia, the first 2 symptoms are most commonly difficulty with attention and memory. Having said that, what are some examples of cognitive impairments associated with schizophrenia once the person has had their first episode? What might patients experience, and how are these symptoms typically managed?

Carlos Larrauri, APRN: You’re absolutely right, Dr Miller. Often the first symptoms that present, the first signs that precede the onset of florid psychosis, often by years are cognitive symptoms like you mentioned, trouble with memory or attention. The symptom domains for schizophrenia fall into 3 big buckets, and I think it’s important to take a step back and understand that context first. We have positive symptoms, such as hallucinations or delusions. Not anything good, but the addition of something that often affects someone’s interpretation and relationship with reality. We have negative symptoms, which could be understood maybe as the absence of something, such as the absence of motivation or the absence of pleasure, amotivation, or anhedonia. Then we have cognitive symptoms, of which there are several examples. And those are often the most debilitating aspects of the symptoms of the disease presentation.

Some examples of cognitive impairments associated with schizophrenia can include attention deficits, such as people finding it hard to focus or concentrate. As you mentioned, it can include memory problems, both short-term working memory and long-term, which can make it challenging for patients to remember information or attend appointments and things of that nature. There are also problems with executive functioning, our higher-level cognitive processes, kind of like the CEO of our brain that’s involved in planning, problem-solving, and decision-making. This can make it very difficult for people with schizophrenia to plan for the future or solve complex problems. There’s also social cognition, which affects people’s understanding of how they interpret the emotions and intentions of other people, making it difficult for people with schizophrenia to interpret social cues or relate to others.

You asked how these symptoms are typically managed; it’s a combination of interventions. Medication is still the mainstay treatment for schizophrenia, antipsychotic medication. That could address some cognitive impairment, but it’s often limited. In addition, medication may be necessary, but it’s often insufficient. It takes a slew of other interventions. With respect to cognition, this could include things like cognitive remediation therapy, a behavioral treatment that focuses on improving cognitive skills through practice and learning strategies, often in a computerized exercise format. This can involve environmental modifications, adjustment to a person’s environment or routine to reduce distraction and provide reminders for important tasks. This could be a student for example in higher education advocating for accommodations, private testing rooms, or things of that nature. Also, general supportive services in education and employment that allow an individual to achieve the most optimal level of functioning given their post-psychotic episode.

It’s important to note that management of cognitive impairment associated with schizophrenia should be highly individualized, as the degree of cognitive impairments vary across people with schizophrenia. This can range from some folks who will achieve a premorbid baseline level of functioning, to other folks who will struggle with some degree of cognitive impairment, but may be able to achieve developmental and functional goals or milestones with these supportive services and these interventions in place.

John J. Miller, MD: Do any other panel members have input on what Carlos said?

Sandy Dimiterchik: I have a comment about cognitive impairment.

John J. Miller, MD: Sandy, yes.

Sandy Dimiterchik: Back in 2008 when I was diagnosed with paranoid schizophrenia, they told me [about] the symptom of cognitive decline. That was probably one of the most frightening things because I didn’t know what it would mean. You think of Alzheimer disease and dementia, like you mentioned earlier, and I didn’t know what my life would be like. I was very fortunate to get on medication that helped with cognition.

John J. Miller, MD: Thank you for sharing that.

Transcript edited for clarity.