Vidailhet P
Pôle de psychiatrie et de santé mentale, Hôpitaux universitaires de Strasbourg INSERM U1114, Neuropsychologie cognitive et physiopathologie de la schizophrénie.
Encephale. 2013 Sep;39 Suppl 2:S83-92. doi: 10.1016/S0013-7006(13)70101-5.
Cognitive difficulties are a core feature of schizophrenia. They are frequent, severe, and clearly associated with functional disabilities. They have been explored during different phases of the disease, but what we know essentially concerns the chronic period in middle-age patients. In this article we will specifically focus on cognition at the time of first episode. First episode is a key life period, occurring while social demands are increasing and more complex on the one hand, and while there are important changes in structural and functional cerebral anatomy on the other hand. Exploring cognitive difficulties at the time of first episode offers the opportunity to better know their time course, to avoid interpretative difficulties due to the chronicity of the disease and its treatments, and to develop early therapeutics in order to improve outcome. Cognitive difficulties are clearly present at the time of first episode; their nature and severity appear similar to those observed in more chronic patients. Therefore, they cannot be entirely explained by treatments, hospitalizations or chronicity, and appear more as an intrinsic feature of the disease. The course of their trajectory through the progression of the disease remains uncertain; while they are already present during childhood or adolescence in some subjects who will later declare schizophrenia, they seem to worsen during the period of early prodroms, that is years before psychotic symptoms emerge. Whether they aggravate again during the first episode process is still a matter of debate. While longer DUP is associated with a poor outcome, this does not seem to hold true for cognitive impairments. Cannabis or tobacco use are neither associated with worse cognitive abilities in first-episode patients; a reverse relationship even sometimes exists. Cognitive impairment appears as largely independent from other clinical dimensions, acknowledging its own physiopathology and requiring specific evaluation and treatment. Several cognitive batteries can be used in clinical practice to explore cognitive abilities in first-episode patients; this is a necessary step before treating. While current pharmacological treatments display little or no efficacy for treating cognitive impairments, new medications offer some hope for the future. Still, efforts especially concern cognitive remediation for the moment. Several programs can be used in patients following their first episode, and some studies suggest that deficits in cognition are more amenable to remediation during earlier phases of the illness especially when cognitive remediation is associated with psychosocial rehabilitation, including school or work support. In the future, exploring and treating cognitive difficulties in first episode patients appear as a matter of collaborative work between psychiatrists and cognitive psychologists and between health and social services.
认知障碍是精神分裂症的核心特征。它们很常见、严重，且明显与功能残疾相关。在疾病的不同阶段都对其进行了探索，但我们所了解的基本上是中年患者的慢性期情况。在本文中，我们将特别关注首次发作时的认知情况。首次发作是一个关键的生命阶段，一方面此时社会需求不断增加且更为复杂，另一方面大脑的结构和功能解剖也发生着重要变化。探索首次发作时的认知障碍，为更好地了解其病程、避免因疾病及其治疗的慢性化导致的解释困难，以及开发早期治疗方法以改善预后提供了机会。首次发作时认知障碍明显存在；其性质和严重程度似乎与在病程更长的患者中观察到的情况相似。因此，它们不能完全由治疗、住院或慢性化来解释，而更像是疾病的固有特征。随着疾病进展，其轨迹的发展过程仍不确定；虽然在一些后来被诊断为精神分裂症的个体中，童年或青少年时期就已存在认知障碍，但在早期前驱期，即精神病症状出现前的数年里，这些障碍似乎会恶化。在首次发作过程中它们是否会再次加重仍存在争议。虽然较长的未治疗期与不良预后相关，但这似乎不适用于认知障碍。在首次发作的患者中，使用大麻或烟草与较差的认知能力无关；甚至有时存在相反的关系。认知障碍在很大程度上似乎独立于其他临床维度，有其自身的病理生理学，需要进行特定的评估和治疗。在临床实践中，可以使用几种认知测试组合来探索首次发作患者的认知能力；这是治疗前的必要步骤。虽然目前的药物治疗对治疗认知障碍几乎没有效果，但新药物为未来带来了一些希望。目前，尤其关注认知康复。有几个项目可用于首次发作后的患者，一些研究表明，认知缺陷在疾病的早期阶段更易于康复，特别是当认知康复与心理社会康复相结合，包括学校或工作支持时。未来，探索和治疗首次发作患者的认知障碍似乎需要精神科医生与认知心理学家以及健康与社会服务部门之间的合作。
