Do better communication skills promote sheltered employment in schizophrenia?

Abstract

Alongside various psychopathological symptoms and neurocognitive dysfunctions, communication skill impairments may be considered core feature of schizophrenia. Although many studies examined the relation between employment status and neurocognition in schizophrenia, we still know very little about the role of communication skills in vocational status among people with schizophrenia. The purpose of this study is to identify the most characteristic communication, neurocognitive and social cognition differences which separate the employed schizophrenia outpatients from those who do not work. The study included three groups: 33 schizophrenia outpatients employed in social firms, 29 unemployed schizophrenia outpatients participating in occupational therapy and sex & age matched 31 healthy controls. We assessed communication skills, global cognitive functioning, executive functions, memory, social cognition as well as severity of psychopathology. Our results indicate that the most characteristic differences between employed and unemployed schizophrenia outpatients are associated with selective language and communication skills, i.e. paralinguistic aspects of communication, understanding of discrete meaning of linguistic context and figurative meaning of language. We find no significant differences between both clinical groups with regard to neurocognition and social cognition. Moreover, unemployed group had more severe psychopathology than the employed group, so we re-analyzed results controlling for symptom severity. The only differences that endured were related to general communication skills and explanation of pictured metaphors, but only when controlling solely for positive or negative syndrome. In conclusion, the present study indicates that employment in schizophrenia is associated with better symptomatic remission and communication skills, but not with better neurocognition and social cognition.

Introduction

Neurocognitive deficits, alongside clinical symptoms, influence social functioning of people with schizophrenia and have a powerful impact on quality of life (Bora and Murray, 2014, Cichocki et al., 2015, Wible, 2012). The most characteristic cognitive impairments in schizophrenia are essentially associated with processing speed, vigilance/attention, verbal/visual learning, working memory, executive functions, reasoning/problem solving and social cognition (Barlati et al., 2013, Green et al., 2015, Lesh et al., 2011, Lewis, 2012). Occurrence of the cognitive deficits was observed before the onset of psychosis and/or despite significant reduction of positive symptoms (Bora and Murray, 2014, Nielsen, 2011, Nuechterlein et al., 2014a). At the same time, negative symptoms seem to be related to impairments in verbal fluency, problem solving, inference, information processing and attention (Hanuszkiewicz et al., 2007, Nielsen, 2011). Similarly, some authors indicate that social skills deficiencies in schizophrenia seem to be semi-independent from psychopathological symptoms (e.g. weak correlations with positive and negative symptoms and occurrence of the social competence deficits in the absence of negative symptoms), however, more severe negative symptoms were related to worse social skills and social functioning (e.g. work adjustment) (Bellack et al., 1990).

Apart from the findings on neurocognitive deficits in schizophrenia, some investigators suggest that communication skills play a pivotal role in good social interactions, so their impairment can be considered a core feature of schizophrenia (Bowie and Harvey, 2008, Kuperberg and Caplan, 2003). Consequently, schizophrenia can be regarded as communication disorder (Niznikiewicz et al., 2013, Wible, 2012). People with schizophrenia exhibit deficits in language production and comprehension (Kim et al., 2015). They rarely initiate spontaneous conversation and their statements have less content, often being inadequate in a given social context, with loose associations confusing the listener (Caplan, 1994). People with schizophrenia exhibit impairments connected with perception, comprehension and use of figurative meaning of language, e.g. humor (Bozikas et al., 2007, Corcoran et al., 1997, Polimeni and Reiss, 2006), metaphor (Kircher et al., 2007, Mashal et al., 2014, Mossaheb et al., 2014) sarcasm or irony (Rapp et al., 2013, Rapp et al., 2014).

Since the antipsychotic treatment alone does not improve cognitive functions (Nielsen, 2011, Opler et al., 2014) and social cognition (Kucharska-Pietura and Mortimer, 2013), non-pharmacological methods, such as cognitive remediation or meta-cognitive trainings, play an important role in rehabilitation (Gaweda et al., 2009a, Gaweda et al., 2009b, Keefe et al., 2016, Medalia and Choi, 2009). Similarly, psycho-social rehabilitation and community treatment seem to facilitate the process of recovery (Cechnicki, 2011, Cechnicki and Bielańska, 2008). Importantly, appropriate social support (e.g. sheltered employment) and professional activity of people with schizophrenia have been associated with improvement in the quality of life and daily functioning (Charzyńska et al., 2015) and with reduction of negative symptoms (McGurk and Meltzer, 2000, McGurk and Mueser, 2004). This is important, since elevation of negative symptoms was reported as a factor negatively influencing social skills (e.g. work adjustment) (Bellack et al., 1990). Finally, social support was found to be one's of the most prominent vocational outcome predictors, next to cognitive functioning, social skills and negative symptoms (Tsang et al., 2010b). Despite the existence of many studies examining the relationship between employment and non-social cognition (e.g. attention, executive functions, verbal memory) (Evans et al., 2004, Lystad et al., 2016, McGurk and Meltzer, 2000, McGurk and Mueser, 2004, Midin et al., 2011) or the improvement in neurocognitive functioning (Bell et al., 2008, Bio and Gattaz, 2011, Greig et al., 2007; but see: Tandberg et al., 2012, Tandberg et al., 2013), we still know very little about the role of specific language and communication skills in employment in schizophrenia. However, some evidence indicates that social cognition has greater impact on vocational functioning than non-social cognition does, although they are highly interrelated (Vauth et al., 2004), and communication skills may predict vocational outcome independently of cognitive performance (Dickinson et al., 2007).

The purpose of this study is to identify the most characteristic communication, neurocognitive and social cognition differences which separate the employed schizophrenia outpatients from those who do not work. In order to attain this goal we measured communication skills, global cognitive functioning, executive functioning, declarative memory and social-cognition. Since previous studies indicate that symptom severity is an important factor which may moderate the relationship between vocational status and cognition, thus we controlled the psychopathology in the analyses.