International Journal of Psychiatry in Clinical Practice

ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20

Differences in cognitive function and daily living

skills between early- and late-stage schizophrenia
Sung-Jin Kim, Joo-Cheol Shim, Bo-Geum Kong, Je-Wook Kang, Jung-Joon
Moon, Dong-Wook Jeon, Young-Soo Seo, Min-Kyung Oh & Do-Un Jung
To cite this article: Sung-Jin Kim, Joo-Cheol Shim, Bo-Geum Kong, Je-Wook Kang, JungJoon Moon, Dong-Wook Jeon, Young-Soo Seo, Min-Kyung Oh & Do-Un Jung (2015)
Differences in cognitive function and daily living skills between early- and late-stage
schizophrenia, International Journal of Psychiatry in Clinical Practice, 19:4, 245-251, DOI:
10.3109/13651501.2015.1084328
To link to this article: http://dx.doi.org/10.3109/13651501.2015.1084328

Published online: 21 Sep 2015.

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Date: 09 November 2015, At: 14:11

Int J Psychiatry Clin Pract 2015; 19: 246252. 2015 Informa Healthcare
ISSN 1365-1501 print/ISSN 1471-1788 online. DOI: 10.3109/13651501.2015.1084328

ORIGINAL ARTICLE

Dierences in cognitive function and daily living

skills between early- and late-stage schizophrenia

informahealthcare.com/ijpcp

Sung-Jin Kim1, Joo-Cheol Shim2, Bo-Geum Kong1, Je-Wook Kang1, Jung-Joon Moon1,
Dong-Wook Jeon1, Young-Soo Seo3, Min-Kyung Oh4 & Do-Un Jung1
Department of Psychiatry, Busan Paik Hospital, Inje University, Busan, Korea, 2Shim Joo Cheol Psychiatry
Clinic, Busan, Korea, 3Department of Psychiatry, Sharing and Happiness Hospital, Busan, Korea, and
4
Department of Clinical Pharmacology, Busan Paik Hospital, Inje University, Busan, Korea

Downloaded by [Universita degli Studi di Torino] at 14:11 09 November 2015

Abstract
Objectives. Cognitive dysfunction is a core feature of schizophrenia; deficits often manifest prior to diagnosis and persist throughout the course of the illness. This study was performed to assess the difference
in cognitive function and daily living skills between the early- and late-stage schizophrenia. Methods.
Fifty-five clinically stable patients with schizophrenia were recruited (25 with 5-year and 30 with
5-year disease durations). We evaluated subjects clinical states, cognitive function, and psychosocial
factors. The Korean versions of MATRICS Consensus Cognitive Battery and UCSD Performance-based
Skills Assessment were used for evaluating cognitive function and daily living skills. Chi-square, Wilcoxon rank sum, and t-tests were used to analyze the data. Results. The two groups did not differ for most
demographic variables. No significant differences between groups were found for clinical symptoms,
psychosocial factors, or non-social cognitive domains. However, the early-stage group had higher social
cognition domain scores than the late-stage group (p 0.01). Early-stage patients scored significantly
higher than those in the late-stage group did in the communication and comprehension/planning domains (p 0.037 and 0.027, respectively), and total score (p 0.003) of the Performance-based Skills
Assessment. Conclusions. We observed significant differences between patients with early- and late-stage
illness with regard to social cognition and performance-based skills.
Key words: Cognition, psychosocial factors, schizophrenia
(Received 12 January 2015; accepted 13 August 2015)

Introduction
Schizophrenia is a chronic psychiatric disorder that causes
long-lasting disabilities in major domains of the patients
daily life (Wiersma et al. 2000). Patients with schizophrenia
typically manifest symptoms in early adulthood and experience difficulties in social and occupational functions and
independent living thereafter (McGlashan 1988). Many
chronic patients with schizophrenia live in assisted living
facilities and long-stay institutions (Cohen et al. 2000). Less
than 15% patients with schizophrenia are engaged in paid
employment (Slade and Salkever 2001).
Cognitive dysfunction is one of the core symptoms of
schizophrenia, and is closely related to everyday functioning, prognosis, and quality of life (Green et al. 2004).
Patients with schizophrenia exhibit deficits in most cognitive domains, showing significant differences compared with
control subjects with regard to attention, memory, and executive function (Sharma and Antonova 2003). Approximately
90% of patients with schizophrenia have a deficit at least in
one cognitive domain, and 75% suffer from deficiencies in
two or more cognitive domains (Palmer et al. 1997). Cognitive deficits are prominent in the first schizophrenic episode, but they are more conspicuous in patients with an early
Correspondence: Do-Un Jung, Department of Psychiatry, Busan Paik
Hospital, Inje University, 75, Bokji-ro, Busanjin-Gu, Busan, Republic
of Korea, 614735. Tel: 82-51-890-6189. Fax: 82-51-894-2532.
E-mail: gabriel.jdu@gmail.com

disease onset (Rajji et al. 2009). Additional cognitive deficits

after the first episode were rare (Addington et al. 2005). Cognitive deficits are stable throughout the lifetime for most of
the patients (Heaton et al. 2001). There is some evidence for
cognitive decline in executive functions in elderly patients
with schizophrenia (Fucetola et al. 2000). Sponheim et al.
(2010) compared cognitive functions in early- and late-stage
patients with schizophrenia, and both groups showed similar cognitive deficits. However, there was a significant correlation between worse episodic memory recall and illness
duration.
Cognitive deficits in patients with schizophrenia have
shown a relationship with functional impairments (Green
et al. 2000). However, findings are limited in that they do
not clearly assess the actual functions required for successful everyday living. This is because social and occupational
activities are affected not only by the patients clinical symptoms and cognitive functions, but also by their motivation,
needs, and other psychosocial factors. Social cognition
relates to the involvement of cognitive operations on social
contexts, such as perceiving, interpreting, and managing the
social event (Penn et al. 2008). Green et al. (2012) investigated social cognition related to emotion processing, Theory of Mind (ToM), and social relationship perception and
found no differences between the early- and late-stage
patients with schizophrenia. Another study that investigated
social cognition and metacognition in patients with first episode and prolonged psychoses showed greater metacognitive

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DOI: 10.3109/13651501.2015.1084328

capacities in the understanding of others minds and decentration during prolonged psychoses (Vohs et al. 2014). In that
study, social cognition did not differ between two groups.
Functional impairments have worsened over the disease
course in interpersonal functioning, vocational functioning,
and everyday functioning (Reichenberg et al. 2014).
While positive schizophrenia symptoms are relatively
well controlled with drug treatment, cognitive functions
show constant degradation in the early stages of disease, and
social, occupational, and other everyday functions continue
to decrease. These deficits can lead to recurrent episodes
(Lauriello et al. 1999), and failure during psychosocial rehabilitation programs (Green et al. 2000). Therefore, one of
the goals of schizophrenia treatment is to improve everyday
functions rather than the symptoms themselves. Studies have
been conducted to assess these functions (Harvey 2013).
Improved cognitive function is one of the major goals of
schizophrenia treatment. In related studies, assessment tools
have played important roles. The National Institute of Mental
Health (NIMH) announced a standardized tool for evaluating cognitive functions and potential treatment response in
patients with schizophrenia called the MATRICS Consensus Cognitive Battery (MCCB) (Nuechterlein et al. 2008).
The MCCB is a sensitive tool for the detailed evaluation of
patients cognitive functions. For evaluating the everyday
functioning of patients with schizophrenia, assessments have
been proposed that involve observing the patients actual
living situation or assessing the patients functions through
role-playing. The University of California San Diego (UCSD)
Performance-based Skills Assessment (UPSA) is a widely
used role-playing tool for evaluating the everyday functions
of patients with schizophrenia (Patterson et al. 2001). It is
easy to apply, and its validity and reliability are supported
by various reports (Figueira and Brissos 2011; Mausbach
et al. 2008; Mausbach et al. 2011). Thus, the UPSA is a leading measure for studies of cognition in schizophrenia. The
MCCB composite scores have substantial association with
the UPSA composite score (Keefe et al. 2011), and as reported
by Burton et al (2013), the MCCB three-factor model shows
an association with the UPSA composite score.
Numerous studies have been conducted to assess differences in cognitive functions in subjects with different stages
of schizophrenia. However, these investigations only evaluated basic cognitive functions. The objective of this study
was to examine cognitive functions across different stages of
schizophrenia by evaluating basic cognitive functions with
the MCCB and daily living skills with the UPSA.
Methods
Subjects
This study included patients diagnosed with schizophrenia
based on the Diagnostic and Statistical Manual of Mental
Disorders 4th edition (DSM-IV) (APA 1994), who satisfied the following conditions: 1) age between 18 and 65
years, 2) outpatients with a stable condition for the previous
3 months, 3) no changes in medications for the past 3
months, and 4) willing to provide informed consent and participate in the study. The exclusion criteria were as follows: 1)

Early- and Late-Stage Cognitive Function 247

history of organic brain disease, 2) history of substance
dependency, and 3) low intellectual level that precluded
cognitive function testing. Patients were divided into two
disease stage groups with regard to illness duration. Illness
duration was calculated from the point that patients were
diagnosed with schizophrenia and began taking antipsychotic medications. Those with a disease duration less than
and more than 5 years were divided into early-stage and
late-stage groups, respectively. We obtained signed written
consent forms from all patients who agreed to participate in
the study, and the study protocol was approved by the Institutional Review Board.
Demographic data
The authors examined patient interviews and medical
records to investigate the patients sex, age, level of education, illness duration, number of hospitalizations, vocational/psychosocial rehabilitation status, smoking status,
and medication type/dose. The patients who currently work
were classified into the vocational/psychosocial rehabilitation. Antipsychotic medication dosages were converted
into chlorpromazine equivalent doses (Gardner et al. 2010;
Rey et al. 1989).
Clinical assessments
To assess clinical symptoms, psychiatrists conducted interviews using the Positive and Negative Syndrome Scale
(PANSS) (Kay et al. 1987) and Clinical Global ImpressionSchizophrenia scale (CGI-SCH) (Haro et al. 2003).
The CGI-SCH was originally developed as a brief, standardized method to evaluate the overall functions of patients
with schizophrenia from a clinical perspective. The functions are categorized into four domains of positive, negative,
depressive, and cognitive symptoms, each assessed using a
7-point scale (Haro et al. 2003).
Evaluation of psychosocial factors
For evaluating psychosocial factors, the Personal and Social
Performance Scale (PSP) (Morosini et al. 2000), the Schizophrenia Quality of Life Scale (SQLS) (Wilkinson et al. 2000),
and the Insight Scale for Psychosis (ISP) (Markova et al.
2003) were conducted by psychiatrists. The PSP is a tool
for evaluating overall functions that uses a questionnaire to
assess socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behaviors. The
SQLS is a clinical research tool for assessing subjective quality of life in patients with schizophrenia. The ISP evaluates
the insights of patients with schizophrenia using a self-report
format.
Cognitive function evaluation
The MCCB was announced by the NIMH as a standardized
tool for evaluating basic cognitive functions in patients with
schizophrenia. It is recommended for clinically testing the
effect of new drugs designed to improve cognitive functions
of patients with schizophrenia (Nuechterlein et al. 2008).
This tool evaluates functions in the seven major cognitive
domains: processing speed (Brief Assessment of Cognition

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248 S.J. Kim et al.

in Schizophrenia (BACS): Symbol Coding, Category Fluency: Animal Naming, Trail Making Test: Part A), attention/vigilance (Continuous Performance Test-Identical Pairs
(CPT-UIP)), working memory (Wechsler Memory Scale-3rd
Ed. (WMS-III): Spatial Span, Letter-Number Span), verbal
learning (Hopkins Verbal Learning Test-Revised (HVRT-R)),
visual learning (Brief Visuospatial Memory Test-Revised
(BVMT-R)), reasoning and problem solving (Neuropsychological Assessment Battery (NAB): Mazes), and social
cognition (MayerSaloveyCaruso Emotional Intelligence
Test (MSCEIT): Managing Emotions). The social cognition
domain measures how well subjects perform tasks and solve
emotional problem while managing emotions. In the selfmanagement subscale, subjects indicate how effective certain
actions might be in regulating their mood, such as prolonging joy and reducing anger. In the social management subscales, subjects are asked to indicate how effective the actions
of a person might be in regulating or managing emotions of
other people (Mayer et al. 2003). We adapted the tool for use
in a Korean population after acquiring authorization from
the copyright holder.
Daily living skills
The UPSA was designed to assess basic everyday living
skills. Specifically, it examines functions in five domains:
1) finance: skills to count money, give change, and pay
bills; 2) communication: skills to understand specific situations, use the telephone or postal correspondence, and
perform appropriate expressions; 3) comprehension/planning: skills to understand newspaper articles and identify
the required items; 4) transportation: skills to use public
transportation systems considering transfer and time; and
5) household skills: skills to select ingredients required for
cooking (Patterson et al. 2001). For evaluating communication, the subjects are provided a telephone and asked to
use the telephone to get help as if there were an emergency.
They are given a letter about a medical appointment confirmation and asked to call the hospital to reschedule the
appointment. They are questioned about the notice and the
details of medical appointment. For evaluating comprehension/planning, the subjects are given a newspaper article
about a water park and asked to recall some activities in
the water park. They are questioned about the items they
would need to bring to spend a day at the water park. The
test is conducted using the role-playing method and takes
approximately 30 min. This study used the standardized
Korean version of the UPSA with written consent from the
copyright holder.
Statistical analysis
All continuous variables are reported as means, standard
deviations, and ranges, and discrete variables are given
as frequencies and percentages. Comparison between the
early- and late-stage groups was performed using t-tests, chisquare tests, and Wilcoxon rank sum tests, depending on the
characteristics of each variable. All analyses were carried out
using SAS 9.3 software (SAS Institute Inc., Cary, NC, USA),
and the significance level was set at 0.05 or below.

Int J Psychiatry Clin Pract 2015;19:246252

Results
Demographic data
A total of 55 subjects participated, with 25 and 30 subjects in
the early- and late-stage groups, respectively. The early-stage
group included 16 males (64%) and 9 females (36%), and the
late-stage group consisted of 18 males (60%) and 12 females
(40%). The average age of subjects in the late-stage group was
41.97 6.67, which was significantly higher than the average
age in the early-stage group (29.08 7.10, p 0.001). Subjects in the early-stage group received a mean 13.64 2.23
years of education, compared with 12.40 2.30 years in the
late-stage group (p 0.041). The average illness durations
were 33.52 19.46 and 224.43 69.92 months for the earlyand late-stage groups, respectively (p 0.001). The number
of hospitalizations was also significantly different between the
two groups: 2.00 1.29 and 6.24 5.34 hospitalizations for
the early- and late-stage groups, respectively (p 0.001). The
late-stage group was more involved in vocational/psychosocial rehabilitation (p 0.006). The chlorpromazine equivalent doses were 501.89 250.15 mg and 542.23 347.56 mg
for the early- and late-stage groups, respectively (p 0.05).
There were 22 (88%) subjects in the early-stage group who
took antiparkinsonian medications, compared with 19 (63%)
subjects in the late-stage group (p 0.037). There were 6
smokers (24%) and 19 non-smokers (76%) in the early-stage
group, compared with 14 smokers (46.67%) and 16 nonsmokers (53.33%) in the late-stage group (Table I).
Clinical symptoms
The total PANSS scores did not reveal a significant difference
between the two groups; the early- and late-stage group scores
were 70.32 12.86 and 69.40 12.96 points, respectively.
However, there was a significant difference (p 0.048) in the
positive symptom subscale (early-stage group: 16.60 4.56
and late-stage group: 19.13 4.69) but not the other subscales. There was no significant difference between the two
groups on the CGI-SCH (Table I).
Psychosocial factor characteristics
PSP, SQLS, and ISP results were not significantly different
between the two groups (Table I).
Cognitive function characteristics
Assessment of basic cognitive functions using the Korean
version of MCCB showed no significant difference between
the two groups in terms of the total score and most subscale
items. However, the early-stage group social cognition domain
score was 30.92 9.07, which was significantly higher than
the score of the late-stage group (24.14 9.28, p 0.010).
The early-stage group also scored significantly higher in the
assessment of everyday functions using the Korean version
of UPSA. Specifically, the total score was significantly higher
for the early-stage group (75.59 12.54) compared with the
late-stage group (65.19 14.00, p 0.003). Specifically, the
early-stage group scored significantly higher than the latestage group in the communication domain (13.61 3.10 vs.
11.55 3.78, respectively, p 0.037) and comprehension/

Early- and Late-Stage Cognitive Function 249

DOI: 10.3109/13651501.2015.1084328

Table I. Demographic and clinical characteristics of early- and late-stage patients with schizophrenia.

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Characteristics
Gender
Male, n (%)
Female, n (%)
Age (years)
Education (years)
Duration of illness (months)
Number of hospitalization
Vocational/psychosocial rehabilitation, n (%)
Antipsychotic medication
Monotherapy, n (%)
Polytherapy, n (%)
Antiparkinsonian medication, n (%)
Benzodiazepine medication, n (%)
Average daily neuroleptic dose (mg, CPZE)
Smoking
Smoker, n (%)
Non-smoker, n (%)
PANSS
Positive subscale
Negative subscale
General psychopathology subscale
Total score
CGI-SCH
Positive symptoms
Negative symptoms
Depressive symptoms
Cognitive symptoms
PSP
SQLS
ISP

Early stage
(n 25,
mean SD)

Late stage
(n 30,
mean SD)

16 (64)
9 (36)
29.08 7.10
13.64 2.23
33.52 19.46
2.00 1.29
11 (44)

18 (60)
12 (40)
41.97 6.67
12.40 2.30
224.43 69.92
6.24 5.34
24 (80)

15 (60)
10 (40)
22 (88)
16 (64)
501.89 250.15

15 (50)
15 (50)
19 (63)
18 (60)
542.23 347.56

6 (24)
19 (76)

14 (46.67)
16 (53.33)

0.082

16.60 4.56
18.80 3.94
34.37 6.72
70.32 12.86

19.13 4.69
17.10 4.33
33.17 6.29
69.40 12.96

0.048
0.137
0.513
0.793

3.16 1.25
3.00 1.04
2.24 0.78
2.72 1.02
60.92 11.24
42.52 16.26
14.28 5.17

3.53 1.33
2.73 0.74
2.33 0.71
2.60 0.76
60.23 10.42
39.17 20.36
13.90 5.73

0.292
0.273
0.645
0.604
0.822
0.509
0.653

p value
0.761
0.001
0.041
0.001
0.001
0.006
0.458
0.037
0.761
0.872

CGI-SCH, Clinical Global Impression-Schizophrenia scale; CPZE, chlorpromazine equivalent; ISP, Insight Scale for
Psychosis; K-WAIS, Short-form of Korean-Wechsler Adult Intelligence Scale; PANSS, Positive and Negative Syndrome
Scale; PSP, Personal and Social Performance Scale; SD, standard deviation; SOFAS, Social and Occupational Functioning
Assessment Scale; SQLS, Schizophrenia Quality of Life Scale.

planning domain (12.56 3.01 vs. 10.44 3.64, respectively,

p 0.027, Table 2).
Discussion
The results of this study demonstrate that cognitive function varies across different stages of schizophrenia as demonstrated with the MCCB, a tool specifically designed for
cognitive function assessment, and the UPSA, which reflects
everyday functions. In addition, assessments for differences
between clinical symptoms and psychosocial factors were
also conducted, although there were no significant differences between the two groups.
The participants were divided into two groups based on
illness duration. In terms of clinical symptoms, there was no
significant difference between the two groups except for the
positive symptom subscale in the PANSS. Kay et al. (1986)
used the PANSS to assess 134 patients with schizophrenia
in a cross-sectional study, but they were not able to detect
significant differences across different stages. Our findings
indicate that clinical symptom scales are affected by the types
and degrees of each clinical symptom, drugs being used,
and other factors involved in the patients prognosis, rather
than the stage of psychosis itself. Many studies have been

Table 2. Comparison of early- and late-stage patients with schizophrenia

in cognitive measures.

MCCB
Speed of processing
Attention/Vigilance
Working memory
Verbal learning
Visual learning
Reasoning and
problem-solving
Social cognition
Composite score
UPSA
Finance
Communication
Comprehension/Planning
Transportation
Household skills
Total score

Early stage
(N 25,
mean SD)

Late stage
(N 30,
mean SD)

p value

33.80 11.83
36.29 10.85
32.68 11.29
34.20 7.48
40.76 14.23
42.32 10.51

34.34 11.89
38.69 10.35
31.76 10.82
31.52 5.99
35.69 13.83
39.11 6.68

0.867
0.449
0.761
0.149
0.191
0.309

30.92 9.07
26.70 12.07

24.14 9.28
24.12 8.61

0.010
0.408

17.20 2.89
13.61 3.10
12.56 3.01
14.72 2.52
17.50 5.11
75.59 12.54

16.74 2.93
11.55 3.78
10.44 3.64
13.18 2.84
13.28 8.37
65.19 14.00

0.467
0.037
0.027
0.059
0.052
0.003

MCCB, Measurement and Treatment Research to Improve Cognition in

Schizophrenia (MATRICS) Consensus Cognitive Battery; SD, standard
deviation; UPSA, University of California San Diego (UCDS) Performancebased Skills Assessment.

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250 S.J. Kim et al.

conducted to assess the correlation between clinical schizophrenia symptoms and patients cognitive functions. Liddle
(1987) concluded that negative symptoms are usually correlated with cognitive functions, Moritz et al. (2001) reported
that negative symptoms are related with verbal working
memory, and another study found that disorganized symptoms are related with cognitive dysfunction (Eckman and
Shean 2000). These studies demonstrate that clinical symptoms of patients with schizophrenia are closely related with
their cognitive function. Since the present study revealed
no significant difference between the two groups of patients
with schizophrenia in terms of negative symptoms and other
factors closely related with cognitive function, the possibility
of clinical symptoms having affected the results of cognitive
function tests can be eliminated to some degree.
In terms of psychosocial factors, the PSP, SQLS, and ISP
did not reveal any significant differences between the earlyand late-stage groups. It is thought that SQLS and ISP results
may be affected by factors related to family, occupation, and
the treatments that the patient received, rather than the stage
of psychosis. Numerous studies have verified the validity and
usefulness of PSP as a tool for assessing the overall functions
of patients with schizophrenia (Figueira and Brissos 2011).
In this study, however, PSP revealed no significant differences between the two groups, while UPSA and MCCB demonstrated significant differences between the patients with
early- and late-stage schizophrenia in terms of social cognition domain and everyday functioning. The PSP assesses
four categories: useful social activities, personal and social
relationships, self-care, and disturbing and aggressive behaviors. It determines the total score by combining the results
of each category. While this method is suitable for assessing
overall patient functionality, it seems that it would be difficult to assess the patients social functions in detail using
the PSP compared with the MCCB and UPSA. In addition,
the PSP questions regarding social functions focus more on
the patients participation in social activities rather than their
actual skills, which may explain the different results compared with the MCCB and UPSA.
Our cognitive function assessments revealed several significant differences between the early- and late-stage groups.
No difference was found in the seven cognitive function
domains assessed with the MCCB, except for the social cognition domain for which the early-stage group scored significantly higher than the late-stage group. Similarly, a study
comparing the MCCB results of early- and late-stage groups
conducted by McCleery et al. (2014) also found that the early-stage group scored higher in questions on social cognition domain and working memory. This demonstrates that
patients in the early stages of schizophrenia are able to relate
to and interact with others more effectively than those in the
late stages. Penn et al. (2008) maintains that social cognition
in patients with schizophrenia consists of three subfactors:
emotion perception, ToM, and attributional style. In the
expert surveys about the domains of social cognition, four
core domains are selected (Pinkham et al. 2014). The first is
emotion processing, which relates to perceiving and using
emotions. It includes both lower- and higher-level processes.
The lower-level process is about recognizing the emotions

Int J Psychiatry Clin Pract 2015;19:246252

contained in others facial expressions and voices. Understanding and managing emotions is involved in the higherlevel process. The second is social perception: decoding and
interpreting social cues in others. The third is ToM/mental
state attribution, which involves recognizing certain intentions or behaviors that may affect his/her behaviors and those
of others. The fourth is attributional style/bias, which is the
way of determining positive or negative reasons for a certain
life event. On the managing emotions part of the MSCEIT
in the MCCBs social cognition domain, it was about how
effective the actions might be in managing their emotions
or others emotions. Thus, the social cognition domain in
the MCCB seems to have a relationship mainly with emotion processing. One study found that social cognition in
patients with schizophrenia are closely related with everyday functions and interpersonal and social/occupational
skills (Couture et al. 2006). This was classified as an important prognostic factor and a treatment goal for patients with
schizophrenia (Kee et al. 2003).
In the assessment of everyday functions using the UPSA,
the early-stage group scored higher than the late-stage
group in communication, comprehension/planning, and
total scores. Many patients with schizophrenia have difficulties communicating with and comprehending conversations with other people; some of them even have difficulties
understanding basic phrases and jokes (Brune et al. 2007).
Among the UPSA domains, the communication and comprehension/planning categories are closely related with social
functions. Therefore, the above findings can be regarded as
supporting the results of the social cognition test using the
MCCB. Since the UPSA uses role-playing based on everyday
situations, it can be inferred that patients in the early stages
of schizophrenia are more socially functional in their everyday living compared with those in later stages. Mausbach
et al. (2008) proposed that the UPSA can be used to predict
the residential independence of patients with schizophrenia,
and another study verified a significant correlation between
UPSA results and patients occupational skills (Mausbach
et al. 2011). Taking all of these results into consideration,
it can be inferred that the constant difficulties in everyday
living and social occupational skills experienced by patients
with late-stage schizophrenia may be related to degradation
of social cognition and functions.
Some studies have also shown that everyday functions
decline throughout the lifetime in the patients with schizophrenia (Harvey et al. 2010; Reichenberg et al. 2014). All
subjects in the late-stage group were outpatients with a stable
condition, and most of them participated in the vocational/
psychosocial rehabilitation in this study. Thus, it seems that
the late-stage group experiences everyday function deficits
despite continued social stimulation.
There are several limitations of this study. First, we classified the subjects into early- and late-stage groups in a
cross-sectional study designed to compare cognitive functions across different stages of psychosis. Therefore, while
our findings are useful for assessing differences between the
two groups, it is limited in determining why there are cognitive function differences between disease stages. These limitations could be partially overcome if follow-up studies are

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DOI: 10.3109/13651501.2015.1084328

conducted with the same patient groups. Second, the lack of

a healthy control group makes it difficult to distinguish cognitive function changes due to normal aging processes from
those unique to schizophrenia. Third, the small number of
subjects makes it difficult to generalize the findings. Fourth,
the medications taken by the patients with schizophrenia
were not controlled. It is thought that many drugs including
antipsychotic medications can affect patient cognitive function. Fifth, we assessed social cognition with limited tools
and only investigated managing emotions and daily living
skills. Future research needs to investigate various domains
of social cognition.
The findings of this study indicate that patients with early-stage schizophrenia exhibit higher social cognition and
social functions in everyday living compared with the latestage patients despite similar clinical symptoms. These skills
deteriorate as psychosis progresses. It is therefore important
to identify treatment strategies for patients with early-stage
schizophrenia, which will preserve and improve their social
cognition and everyday functions.
Key points

Cognitive dysfunction is one of the core symptoms of

schizophrenia.
We assessed the difference in cognitive function
between early- and late-stage schizophrenia using the
MCCB and UPSA.
The early-stage group had higher social cognition
domain of the MCCB and communication and comprehension/planning domains, and total score of the
UPSA.
The early-stage schizophrenia exhibits higher social
cognition and social functions in everyday living.

Acknowledgements
The authors thank the staff of the Sharing and Happiness
Hospital for their assistance with the process of this study.
Statement of interest
The authors declare no conflict of interest with any commercial or other associations in connection with the submitted
article.
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