Lecardeur L, Meunier-Cussac S, Dollfus S
Équipe mobile de soins intensifs, centre Esquirol, centre hospitalier universitaire de Caen, avenue Côte-de-Nacre, 14033 Caen, France.
Encephale. 2013 May;39 Suppl 1:S64-71. doi: 10.1016/j.encep.2012.10.011. Epub 2013 Mar 23.
Up to now, studies have not demonstrated significant efficacy of antipsychotics on cognitive impairments in patients with psychotic disorders. These cognitive deficits are of particular interest since they traditionally start early before the diagnosis of psychosis. They are observed during premorbid and prodromal stages, and during the first episode of psychosis. Moreover, cognitive impairments may be detected without any psychotic symptoms (such as positive symptoms) suggesting their development independently of the psychotic symptoms. Cognitive disturbances consist of impairments of episodic and working memories, intellectual functioning, executive functions (planning, inhibition, and cognitive flexibility), selective and sustained attentions and social cognition (emotion, recognition, theory of mind). The altered cognitive functions observed in schizophrenia are the same as in earlier stages but at a lower level of severity.
Data suggest that cognitive deficits can be considered as vulnerability markers of psychosis since they have been described in healthy relatives of psychotic patients with high genetic risk. Cognitive deficits might also be considered as predictive of the occurrence of the disease after the first episode of psychosis. Indeed, retrospective studies suggest cognitive impairments in patients with schizophrenia during premorbid and prodromal phases but not in bipolar patients. Cognitive assessment might be of particular interest in people at risk for psychosis, in order to differentiate diagnostic outcomes. Cognitive functioning impairs until the diagnosis of first episode psychosis, even though cognitive profiles are quite heterogeneous in these patients. Once the diagnosis of schizophrenia is considered, cognitive deficits may be stable, although the literature is still controversial. Several factors such as symptoms and gender can contribute in diversifying the cognitive profiles. Moreover, age of onset might worsen the prognosis because of a disruption of the cognitive development and the disturbance of scholarship in young individuals.
Considering these results, the treatment of cognitive deficits should be initiated as soon as possible, e.g. in people at risk for psychosis in order to reinforce the normal cognitive development, prevent cognitive decline and to preserve the educational, professional and social status. Since antipsychotic medications do not impact on cognitive functioning, alternative therapeutics should be developed such as cognitive remediation. Several studies and meta-analyses have shown that cognitive remediation programs are particularly efficient in patients with schizophrenia or bipolar disorders. Contrary to antipsychotics, these techniques should be used in patients with a first psychotic episode, but also in individuals with subpsychotic symptoms, subthreshold to the diagnosis of schizophrenia.
到目前为止，研究尚未证明抗精神病药物对精神障碍患者的认知障碍具有显著疗效。这些认知缺陷尤其值得关注，因为它们传统上在精神病诊断之前就早早开始出现。在病前和前驱期以及精神病首次发作期间均可观察到这些缺陷。此外，在没有任何精神病症状（如阳性症状）的情况下也可检测到认知障碍，这表明它们的发展独立于精神病症状。认知障碍包括情景记忆和工作记忆受损、智力功能、执行功能（计划、抑制和认知灵活性）、选择性和持续性注意力以及社会认知（情感、识别、心理理论）受损。在精神分裂症中观察到的认知功能改变与早期阶段相同，但严重程度较低。
数据表明，认知缺陷可被视为精神病的易感性标志物，因为在具有高遗传风险的精神病患者的健康亲属中也有相关描述。认知缺陷也可能被认为可预测精神病首次发作后疾病的发生。事实上，回顾性研究表明，精神分裂症患者在病前和前驱期存在认知障碍，但双相情感障碍患者不存在。为了区分诊断结果，对有精神病风险的人进行认知评估可能特别有意义。在首次发作精神病的诊断之前，认知功能都会受损，尽管这些患者的认知特征差异很大。一旦考虑诊断为精神分裂症，认知缺陷可能会稳定下来，尽管文献对此仍存在争议。症状和性别等几个因素可能导致认知特征多样化。此外，发病年龄可能会使预后恶化，因为它会干扰年轻人的认知发展和学业。
考虑到这些结果，应尽早开始治疗认知缺陷，例如对有精神病风险的人进行治疗，以加强正常的认知发展、预防认知衰退并维持教育、职业和社会地位。由于抗精神病药物对认知功能没有影响，应开发替代疗法，如认知矫正。多项研究和荟萃分析表明，认知矫正项目对精神分裂症或双相情感障碍患者特别有效。与抗精神病药物不同，这些技术不仅应用于首次发作精神病的患者，也应用于有亚精神病症状、低于精神分裂症诊断阈值的个体。
