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Таблица 8 Диагностические коэффициенты при определении степени выраженности психического дефекта через оценку когнитивных функцийПримечания: 0 — отсутствие нарушений; 1 — нарушение/снижение признака в легкой степени; 2 — нарушение/снижение признака в умеренной степени; 3 — нарушение/снижение признака в выраженной степени.
Таблица 9 Значение пороговых диагностических коэффициентов при разных процентах вероятности ошибок первого и второго рода
Для оценки прогностичности разработанного алгоритма степени выраженности психического дефекта через оценку состояния когнитивных функций был проведен расчет эффективности полученной таблицы на материале экспериментальной и контрольной групп, составивших основу для разработки диагностических таблиц, на пороге ДК = ±13, при p<0,05 (табл. 10, табл. 11, табл. 12).
Таблица 10 Результаты проверки диагностической таблицы на материале экспериментальной и контрольной групп для дифференциальной диагностики легкой — умеренной степени выраженности психического дефекта
Таблица 11 Результаты проверки диагностической таблицы на материале экспериментальной и контрольной групп для дифференциальной диагностики легкой — высокой степени выраженности психического дефекта
Таблица 12 Результаты проверки диагностической таблицы на материале экспериментальной и контрольной групп для дифференциальной диагностики умеренной — высокой степени выраженности психического дефекта
В группах с разной степенью выраженности психического дефекта можно различить с долей вероятности ошибок (5%) следующие группы больных: с легкой — умеренной степенью выраженности психического дефекта, с легкой — высокой степенью выраженности психического дефекта, с умеренной — высокой степенью выраженности психического дефекта. Приведем пример применения разработанного алгоритма на конкретном клиническом случае. Пациент Д., 1983 г. р., диагноз: F 20.08 (согласно МКБ-10), стаж заболевания — 5 лет, группа инвалидности отсутствует. Задача: определение степени выраженности психического дефекта (легкая/умеренная/выраженная при допустимом уровне ошибок первого и второго рода 5%). Оценка экспертной комиссии: легкая. Оценка степени выраженности психического дефекта посредством диагностических таблиц: легкая (табл. 13).
Таблица 13 Применение диагностических таблиц определения степени выраженности психического дефекта: результаты проверки, клинический случай
Определение степени выраженности психического дефекта — важная задача медико-социальной экспертизы [6; 23]. На сегодняшний день «зоной ближайшего развития» современной патопсихологической диагностики является комплексное изучение психологических и социальных факторов, связи между степенью выраженности функциональных (в том числе когнитивных) нарушений и тяжестью социальной дезадаптации, что обусловливает необходимость объективации традиционного феноменологического подхода и разработки детального алгоритма перевода качественных оценок нарушений в количественные показатели. Определение степени выраженности психического дефекта в нашем исследовании основывалось на оценке состояния когнитивных функций. Установлено, что когнитивные дисфункции вносят существенный и дифференцированный вклад в состояние психического дефекта у больных шизофренией. Предложенная схема проведения патопсихологической диагностики благодаря применению таблиц диагностического коэффициента позволяет объективировать процесс оценки степени выраженности психического дефекта у больных шизофренией. Разработанные в процессе исследования таблицы диагностических коэффициентов (ДК) по определению степени выраженности психического дефекта подтверждают свою эффективность при исследовании контрольной группы на 5-процентном пороге достоверности значимости. Вместе с тем, при определении ограничений жизнедеятельности и уровня социальной дезадаптированности особое значение имеет также оценка степени выраженности эмоционально-волевых расстройств. Исследования, направленные на уточнение показателей и методик, позволяющих производить дифференцированную диагностику нарушений эмоциональной и волевой сферы у больных шизофренией, позволили бы в значительной степени усовершенствовать алгоритм оценки психического дефекта при проведении патопсихологического обследования и потому представляются перспективными направлениями развития медицинской психодиагностики.
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Ссылка для цитирования УДК 159.9:616.895.8 Мухитова Ю.В. Диагностика когнитивных дисфункций у больных шизофренией при оценке степени выраженности психического дефекта // Медицинская психология в России: электрон. науч. журн. – 2017. – T. 9, № 2(43). – C. 7 [Электронный ресурс]. – URL: http://mprj.ru (дата обращения: чч.мм.гггг).
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Diagnostics of cognitive dysfunctions in patients with
schizophrenia
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Abstract
The issue of mental functions diagnostics in patients with schizophrenia in assessing the intensity of a mental defect is conditioned by the necessity of making the obtained data objective. To fulfil this task, we need to elaborate a system of diagnostics, to simplify the definition of mental defect intensity, and to elaborate an algorithm for assessing cognitive dysfunctions in case of various intensity of a mental defect in patients with schizophrenia. To elaborate the algorithm, we have examined 104 persons diagnosed with schizophrenia with a light, moderate and severe mental defect. In assessing the efficiency of our algorithm for defining mental defect intensity by assessing the cognitive sphere, the control group encompassed 60 persons diagnosed with schizophrenia. To evaluate the cognitive impairments, we have used standard pathopsychological instruments: Schulte Tables, 10 Words Memorization, Object Exclusion, Comparison of Notions, Proverbs, and Ebbinghaus Probe. Our algorithm is based on G.V. Gubler’s algorithm for calculating diagnostic coefficients. It enables to make the obtained data formal and objective. During the study, we have revealed that the assessment of thinking impairments intensity should include both qualitative and quantitative analysis of thinking dysfunction and take into account the difficulty of tasks. The intensity of a mental defect in patients with schizophrenia can be defined by assessing such indices of cognitive activity as the state of a motivational and personal component of thinking, dynamics and exhaustion of thinking, distortion of the process of generalization, memory and attention. With account for the assessment of cognitive functions state, we have specified the diagnostic algorithm for defining a mental defect in patients with schizophrenia. The diagnostic coefficient (DC) tables for the definition of mental defect efficiency elaborated during the study confirm their efficiency in the investigation of study and control groups at the 5% statistical significance threshold. Our scheme of pathopsychological diagnostics enables to make the assessment of mental defect intensity in patients with schizophrenia objective due to the application of diagnostic coefficient tables.
In further research, we are going to assess the intensity of emotional and volitional disorders, which would enable to conduct a complex assessment of an algorithm of mental defect assessment and to improve it during the pathopsychological study.
Key words: schizophrenia; cognitive dysfunctions; pathopsychological study; the assessment of cognitive functions; mental defect intensity; algorithm for the assessment of mental defect intensity.
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Introduction
The study of schizophrenia is relevant due to a unique picture of a phenomenological polymorphism of mental disorders and the issue of nosological unity of schizophrenia [9]; high index of prevalence (within 0.8—1%, which constitutes 15 for 100 000 people in the world), high percentage of in-hospital treatment and a level of disability (39.9% of cases from the general number of disabled persons with mental disorders; as reported by WHO, schizophrenia is included in the list of the top ten reasons of disability) [1]; pathomorphosis and pathoplastics of a disease [22; 30], the emergence and application of new pharmaceuticals, the elaboration of a complex approach in treatment and rehabilitation, the improvement of their efficiency and quality, the extension of patients’ adaptational and compensatory abilities [3; 5; 13; 17; 19], the necessity of elaborating more accurate experimental material and diagnostic criteria for assessing the intensity of mental functions impairments in case of schizophrenia [10; 28; 31; 32], the changes in the consideration of the structural components in the complex of pathopsychological syndromes and a need for the integral study of schizophrenia-related pathology [21].
At present, schizophrenia is understood as a multifactor polymorphic endogenous disorder or a group of mental disorders with a polygenic mechanism of inheritance (genetic factors, factors of individual’s external and internal environment) associated with the disintegration of thinking processes and emotional responses and the development of a defect with inconvertible changes of personality and the inhibition of mental activity [8]. Besides, there is no single idea of a "defect" in case of schizophrenia, since there are two initial positions in psychiatry: the assessment of impairments as a result of neural substrate destruction (negative disorders) and assessment of the psyche transformed by a disease in general (a defect) [23]. The ideas of a mental defect in case of schizophrenia were developed in several stages: from the defect as a sign of the outcome of a disease and early dementia described by E. Kraepelin and the shift of an accent to the study of psychopathological states and mechanisms that underlie them, with the occurrence of the concept of autism, to the search for elementary, nuclear units of the pathology of psyche functioning in case of schizophrenia identified now as the elements of cognitive functioning and emotional and volitional sphere [16; 23]. In case of schizophrenia, a defect is treated as an intellectual decrease (dementia) developed during the disease as a consequent chain of negative changes from the insignificant deformation of the personality structure to thinking disorders in case of reduced energetic potential. Its main characteristics involve low convertibility of impairments, resistant symptoms, and low prognosis of the efficiency of curative or rehabilitation activities [1; 15; 24; 29].
Cognitive disorders (impairments of attention, perception, thinking and a regulatory function) described in the works of E. Kraepelin and E. Bleuler are treated as a particular cluster of pathological impairments together with positive and negative symptoms. They are defined as one of the components of a schizophrenia-related defect, which makes social adaptation more difficult and leads to the development of some secondary impairments and disability. They restrict the success of psychosocial rehabilitation and condition the reduction of social competence and reintegration in society [12; 15; 16; 25; 36; 38; 39].
The impairments of cognitive functions were initially treated as minor impairments in the structure of early dementia. Further, the cognitive functions in patients with schizophrenia were treated as independent impairments, which made their own contribution to the general picture of a disease, with the attempts to reveal and describe the mechanism of their development within a framework of a pathopsychological approach. Then, the accent in studying the cognitive dysfunctions in patients with schizophrenia shifted to the study of neurocognitive impairments treated as the leading factors in the symptoms of schizophrenia during its diagnostics and to the search for brain mechanisms of these impairments. The neuropsychological approach enabled to widen the representations of physiological mechanisms of pathological processes in case of schizophrenia, to describe the cognitive impairments and to develop the methods of impact aimed at compensating the impairments [2; 12; 15; 16; 18; 20; 25; 27; 31; 34; 35; 40]. As shown by T.V. Cherednikova, the research directions are changed from classic (pathopsychological and pathophenomenological) to neuropsychological, neurocognitive, neurogenetic, psycholinguistic and neurocomputer, since the latter are more perspective, accurate and objective. Besides, these methods enable to model the processes of thinking within a framework of neurodisciplines [32]. The neurocognitive deficit is diagnosed with account for the speed of mental processes, readiness to action, verbal and non-verbal working memory, ability to take a decision, and social and emotional intelligence using some complex multidimensional batteries of neuropsychological instruments: BACS (Brief Assessment of Cognitionin Schizophrenia), MCCB (MATRIX Consensus Cognitive Battery), CANTAB eclipse, InterNeuro and others [18; 28].
The intensity of a mental defect is evaluated within a framework of the expert and rehabilitation diagnostics during the medical and social expertise. The definition of psychological defect intensity is an important objective of the medico-social expertise during the assessment of clinical and functional impairments intensity, clinical-expert-rehabilitation significance of the current disorders and restrictions of the main categories of activity (movement, training, labor activity, orientation, control over one’s behavior, self-service). It is also important for identifying the group of disability defined as "social insufficiency due to health impairments with a permanent disturbance of body functions and social insufficiency that restricts activity and leads to a need for social defense" [6, p. 10]. We should improve this process, since we need to study psychological and social factors and correlations between the intensity of functional impairments, restrictions of activity and difficulty of social maladaptation in a holistic manner. Besides, we need to make the approach objective and to develop a detailed algorithm [7]. In Russian medical psychodiagnostics, a pathopsychological approach to the definition of the nature of cognitive functions impairments and their reasons is quite developed. However, medical psychologists do not perform a qualitative assessment of the defect intensity and do not evaluate the state of each of them in the structure of a mental defect in patients with schizophrenia [10]. Nowadays, there are some contradictions: the assessment of mental defect intensity is treated in the MSE as one of the important issues in the definition of the disease stage and the type of remission, the degree and persistence of activity restrictions and rehabilitation tasks; however, the psychiatrist’s assessment is mostly phenomenological from the psychopathological viewpoint, while a pathopsychologist can define the structure and intensity of cognitive functions impairment using both a qualitative and quantitative analysis.
The goal of the study is to elaborate an algorithm for assessing cognitive dysfunctions in case of various intensity of a mental defect in patients with schizophrenia.
Materials and methods
The experimental group consisted of 104 persons aged 25—40 (52 men and 52 women) diagnosed with "paranoid schizophrenia" (F 20.0, IDC-10), "catatonic schizophrenia" (F 20.2, IDC-10), and "simple schizophrenia" (F 20.6, IDC-10) with the duration of the disease from 1 to 15 years. The diagnosis was made by a psychiatrist according to the IDC-10 criteria. The intensity of a mental defect was determined by the MSE or medical commission. The group of patients with a light defect consisted of 12 persons or 14% of the total number of the experimental group (6 men and 6 women aged 25—40) with the duration of the disease from 1 to 9 years. The group of patients with a moderate defect consisted of 30 persons or 40% of the total number of the experimental group (12 men and 18 women aged 25—40) with the duration of the disease from 1 to 15 years. The group of patients with a severe defect consisted of 62 persons or 46% from the total number of the experimental group (34 men and 28 women aged 25—40) with the duration of the disease from 1 to 15 years. All the patients were examined in the state of remission and were sent to experimental psychological examination by their doctor. In all the cases, we collected medical histories and studied medical records.
During the assessment of the efficiency of our algorithm for defining the mental defect intensity by assessing the cognitive sphere, the control group consisted of 60 persons (40 men 20 women) diagnosed with "paranoid schizophrenia" (F 20.0, IDC-10) and "simple schizophrenia" (F 20.6, IDC-10) with the duration of the disease from 1 to 15 years. The intensity of a mental defect in the control group was distributed as follows: a light mental defect — 20 persons (12 men and 8 women), a moderate mental defect — 20 persons (15 men and 5 women), a severe mental defect — 20 persons (13 men and 7 women).
To evaluate the cognitive impairments, we used standard pathopsychological instruments: Schulte Tables for studying the specific features of attention, 10 Words Memorization, Object Exclusion, Comparison of Notions, Proverbs, Ebbinghaus Probe for studying thinking [4; 26]. The algorithm for assessing the mental defect intensity by studying cognitive functions is based on G.V. Gubler’s algorithm for calculating diagnostic coefficients. It enables to make the obtained data formal and objective [11].
Results and discussion
The experimental material enabled us to reveal the intervals for assessing the intensity of cognitive functions impairments and to identify a particular experimental material. Therefore, we are more to reveal these diagnostic signs.
We suggest applying V.G. Sakovskaya’s scheme for indices assessment to diagnose attention and memory functions: Schulte Tables — a recommended time in norm depending on age should not exceed 45—60 sec, a light decrease of attention will correspond to a range of 60—90 sec, a moderate decrease of attention correspond to a range of 90—120 sec, a severe disturbance of attention corresponds to range of over 120 sec [7].
The Ten Words Memorization — the volume of short-term memory is defined in norm by the range of 7±2 words after the first representation, a light decrease of the volume of short-term memory — 4 words after the first representation, a moderate decrease of the volume of short-term memory — 2-3 words after the first representation, a severe decrease of the volume of short-term memory — 0-1 words after the first representation. The volume of short-term memory and the ntensity of its decrease will be defined by the appropriate ranges: normative value of a function — 9-10 words in case of delayed representation (90—100%), light decrease — 7-8 words in case of delayed representation (70—80%), moderate decrease — 4—6 in case of delayed representation (40—60%), severe decrease — 0—3 words in case of delayed representation (0—30%).
To evaluate the characteristics of thinking, we have used B.V. Zeigarnik’s classification of thinking impairments: concreteness, distortion of a generalization process, dynamics and tempo of thinking, and impairment of a motivational-personal component with the additional characteristic "criticism" [14].
In assessing the intensity of thinking impairments, we should make both qualitative and quantitative analysis of disturbances and take into account the difficulty of tasks. We know that in case of light thinking impairments, more advanced tasks are the most difficult to solve, in case of moderate thinking impairments, it is difficult to solve intermediate-level tasks, while the severe thinking impairments are manifested when patients try to solve simple tasks. We also know that in case of schizophrenia, the impairments of cognitive functions can be manifested on the material of simple tasks, though patients are still capable of solving advanced tasks due to the peculiarities of cognitive functions impairments [7].
During the study, we have revealed significant differences in the frequency of thinking impairments during the solution of simple and advanced tasks in case of a light, moderate and severe mental defect in the Object Exclusion (table 1, table 2, table 3). Patients with a light mental defect more often demonstrate the distortion of generalization process (р<0.05) and diversity (p<0.01) on the material of advanced tasks than on the material of simple tasks. Patients with a moderate and severe mental defect in case of thinking impairment more often show concreteness, distortion of a generalization process, empty rhetoric, and diversity, — (р<0.01, р<0.05).
Table 1
Table 2
Table 3
The data analysis by means of Comparison of Notions has enabled to reveal similar tendencies: in patients with a light mental defect in case of thinking impairment, the distortion of a generalization process is more often manifested on the material of advanced tasks solution (р<0.05), the cases of diversity and empty rhetoric are more often revealed during the solution of simple tasks (р<0.01); patients with a moderate mental defect are more likely to demonstrate concreteness, distortion of a generalization process, and diversity on the material of advanced tasks; patients with a severe mental defect are more likely to reveal thinking impairments (concreteness, distortion of a generalization process, empty rhetoric and diversity) on the material of advanced tasks (р>0.01, р>0.05), (table 4, table 5, table 6).
Table 4
Table 5
Table 6
Thus, advanced tasks are important for identifying thinking impairments in cases of various intensity of a mental defect in patients with schizophrenia.
The results of the discriminant analysis show that the indices of the cognitive functions used to define the intensity of a mental defect in patients with schizophrenia may be referred to two functions: function 1 — the impairment of a personal component (69% of the explaining dispersion, p<0.001); function 2 — the impairment of mental functions (31% of the explaining dispersion, p<0.05), (in case of 72.1% of properly classified original grouped observations). Function 1 is determined by more informative indices of a "motivational and personal component of thinking" and "dynamics of thinking", while function 2 is determined by the indices "distortion of a generalization process", "attention", "memory" (represented by the degree of awareness from maximum to minimum), (table 7). According to the results of a discriminant analysis, the index "level of generalization/concreteness of thinking" is excluded from the factors that influence the involvement into a group of defect intensity in patients with schizophrenia. The involvement into the group with a light mental defect is expressed by negative poles of the first and the second functions; the involvement into the group with a moderate mental defect is expressed by a negative pole of the first function and a positive pole of the second function; the involvement into the group with a severe mental defect is expressed by positive poles of the first and second functions.
Table 7
Thus, the degree of mental defect intensity in patients with schizophrenia can be defined by assessing such indices of cognitive activity as the state of a motivational and personal component of thinking, dyna process, memory and attention.
The assessment of the state of cognitive functions enables us to elaborate the diagnostic algorithm for defining a mental defect in patients with schizophrenia. We have applied here G.V. Gubler’s calculation of diagnostic coefficients.
Our algorithm for assessing the intensity of a mental defect by assessing the state of cognitive functions:
1. |
To define the intensity of impairments (light, moderate, severe) of the following cognitive functions: attention, memory, dynamics of thinking, exhaustion of thinking, criticism, decrease of a generalization level, distortion of a generalization process, decrease of a motivational and personal component. |
2. |
To define the cognitive functions of diagnostic coefficients corresponding to each value and to sum them with the preservation of a sign (table 8). |
3. |
To juxtapose the obtained sum of diagnostic coefficients with a threshold value and to define the intensity of a mental defect (table 9). |
Table 8
Notes: 0 — no impairments; 1 — impairment/light decrease of a sign; 2 — impairment/moderate decrease of a sign; 3 — impairment/severe decrease of a sign.
Table 9
To assess the efficiency of our algorithm of mental defect intensity by assessing the state of cognitive functions, we have calculated the efficiency of the obtained table on the material of experimental and control group. We have used them to elaborate diagnostic tables, which provide 5% of errors at the DC threshold=±13 (table 10, table 11, table 12).
Table 10
Table 11
Table 12
In the groups with different intensity of a mental defect, we can reveal the groups of patients with a light — moderate mental defect, with a light — severe mental defect and with a moderate — severe mental defect with 5% error rates.
Let us give the example of our algorithm in a particular clinical case. Patient D., born in 1983, diagnosed with F 20.08 (according to the IDC-10), duration of a disease: 5 years, no group of disability. Objective: to define the intensity of a mental defect (light — moderate — severe) in case of 5% acceptable level of mistakes of the first and the second type. The assessment of the expert commission: light. The assessment of mental defect intensity using diagnostic tables: light (table 13).
Table 13
The definition of mental defect intensity is an important objective of a medical and social expertise [6; 23]. Nowadays, "the area of proximal development" in modern pathopsychological diagnostics is represented by a complex study of psychological and social factors, the association between the intensity of functional (including cognitive) impairments and the severity of social maladaptation. Therefore, we need to make a traditional phenomenological approach objective and elaborate a detailed algorithm for transforming qualitative evaluations of impairments into quantitative indices.
In our study, the definition of mental defect intensity was based on the assessment of cognitive functions state. We have found that cognitive dysfunctions make an essential and differentiated contribution to the state of a mental defect in patients with schizophrenia. Our scheme of pathopsychological diagnostics enables to make the assessment of mental defect intensity in patients with schizophrenia objective due to the application of diagnostic coefficient tables. The diagnostic coefficient (DC) tables for the definition of mental defect efficiency elaborated during the study confirm their efficiency in the investigation of the control groups at the 5% statistical significance threshold.
Besides, such assessment of the intensity of emotional and volitional disorders is of special importance in the definition of activity restrictions and the level of social maladaptation. The research aimed at specifying indices and instruments for differentiated diagnostics of the impairments of emotional and volitional spheres in patients with schizophrenia would enable to improve the algorithm of mental defect assessment largely in case of a pathopsychological examination. It seems a perspective area of medical psychodiagnostics development.
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For citation
Mukhitova Yu.V. Diagnostics of cognitive dysfunctions in patients with schizophrenia in assessing the intensity of a mental defect. Med. psihol. Ross., 2017, vol. 9, no. 2(43), p. 7 [in Russian, in English]. Available at: http://mprj.ru ↑
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