Foresight in Schizophrenia: A Unique and Relevant Factor to Functional Disability

Background and Purpose: The factors that contribute to functional disability in schizophrenia are only partially known and likely consist of an array of biopsychosocial constructs. If social work treatment development efforts are to proceed with this population, a greater understanding of the biopsychosocial factors that limit functional recovery from schizophrenia is needed. This research sought to further our understanding of the contributors to functional disability in schizophrenia by introducing the concept of foresight, or the ability to think of the long-term consequences of one's behavior and use this information to guide present and future actions. The relevance of this novel social-cognitive domain to functional disability is examined in two studies that investigated the presence of a foresight deficit among persons with early course schizophrenia, the unique longitudinal contribution of foresight deficits to functional outcome and the neurobiological correlates of impaired foresightfulness.

Methods: Fifty-eight individuals with early course schizophrenia were studied over the course of 1 year as part of a clinical trial of Cognitive Enhancement Therapy. Participants were assessed using measures of foresight, functional outcome, neurocognitive function, and psychopathology at baseline and 1 year follow-up. In addition, 50 participants underwent structural magnetic resonance imaging at baseline. Hierarchical linear regression models examined the unique contribution of foresight to functional outcome, above and beyond two of the strongest predictors of functional disability (neurocognitive dysfunction and psychopathology) among this population. Voxel-based morphometry was used to examine the neurobiological correlates of impaired foresightfulness.

Results: Participants displayed significant deficits in foresightfulness throughout the study period. Cross-sectionally, these impairments in foresight were significantly related to functional disability at both baseline (β = .33, p < .01) and 1 year follow-up (β = .27, p < .05), after adjusting for neurocognitive impairment and psychopathology. Longitudinal analyses also revealed that baseline levels of foresight were significantly predictive of future functional outcome (β = .26, p < .05), after adjusting for neurocognitive function, psychopathology, and treatment assignment. Neurobiologic analyses indicated that patients with poorer foresight demonstrated reduced gray matter volume in areas of the brain typically associated with social cognition, particularly the right orbitofrontal/ventromedial prefrontal cortex (z = 3.90, p < .01, pFDR < .05).

Conclusions and Implications: Foresight may be an important determinant of functional disability in schizophrenia, and its impairment may be associated with gray matter anomalies in the social cognition network of the brain. Social-cognitive remediation approaches designed to capitalize on brain plasticity and reduce impairments in foresightfulness, such as Cognitive Enhancement Therapy, may facilitate functional recovery by addressing impairments in this domain and its underlying neurobiological correlates. Social work researchers seeking to develop promising new approaches to reduce disability in schizophrenia should consider focusing their efforts on addressing problems in foresight and related domains of social cognition. Interdisciplinary involvement of social work psychosocial treatment developers with basic science researchers in social psychology, neurobiology, and social and decisions sciences will be necessary to advance a translational research agenda in this domain, that could ultimately improve the lives of the many individuals who suffer from this disease.