2. Association between Cognitive Functions,
Cortisol Release and Symptoms Severity in
Patients with Schizophrenia
Prof. Hani Hamed Dessoki, M.D.Psychiatry
Prof. Psychiatry
Chairman of Psychiatry Department
Beni Suef University
Supervisor of Psychiatry Department
El-Fayoum University
APA member
HanI Hamed and Heba Fathy*, Khadiga Mohamed Ali **
*Assistant Professor of Psychiatry, Cairo University
**Professor of Clinical and Chemical Pathology, Benisuef University,

3. • Schizophrenia is severe mental disorder with
life time prevalence 1-2%.
• Schizophrenia is ranked within the top five causes
of disability and it is considered to be one of the
leading unsolved disorders affecting humans.

4. Digestive
disorder (6%) Musculoskeletal
disorders (4%)
Endocrine (4%)
Neuropsychiatric
disorders (28%)
Cancer (11%)
Cardiovascular
disease (22%)
Sense organ
impairment (10%)
Other non-communicable
diseases (7%)
Respiratory
disease
(8%)
Schizophrenia
Bipolar disorder
Dementia
Substance-use and
alcohol-use disorders
Other mental disorders
Epilepsy
Other neurological disorders
Other neuropsychiatric disorders
MDD
2%
10%
2%
2%
4%
3%
1%
2%
3%
Prince et al. Lancet 2007;370(9590):859–877
Contribution (%) by different non-communicable diseases to
disability-adjusted life-years (DALYs) worldwide in 2005
Psychiatric disorders
– underestimated and disabling conditions

5. • Researchers have found higher levels of this 'stress
hormone' in people with schizophrenia.
• The system that is responsible for controlling the
production of cortisol is called the HPA –
hypothalamic-pituitary-adrenal – axis.
• Researchers think higher than normal cortisol levels
might mean the HPA axis isn't working properly.
INTRODUCTION

6. • The studies indicate a relation between
hypothalamopituitary adrenal axis (HPA) activity and
symptomatology in schizophrenia.
• Cortical secretion was primarily associated with more
severe positive symptoms .
INTRODUCTION

7. • It has suggested that the relation between
cortisol level and symptoms severity is due to the
augmenting effects of cortisol on dopamine
activity .

8. • To assess the cortisol level, the cognitive
deficits in schizophrenia.
• To assess the correlation between cognitive
functions, severity of positive & negative
symptoms and cortisol level in patients with
schizophrenia.

10. • Thirty patients having the diagnosis of
Schizophrenia diagnosed according to DSM-IV
criteria recruited from the Psychiatric outpatient
clinic and inpatient from Kasr El Aini University
hospitals.

11. • Thirty control subjects (healthy volunteers among
medical and paramedical personnel staff of Kasr
Al-Aini University hospitals.
• All the scales show absence of psychopathology
in the control group.
• They were matched in age and sex.

12. • The interviews were done over 5 months from July 2012 to
November 2012. The interview ranged from one and a
half to two hours.
• Semi-structured interview derived from the psychiatric
sheet of Kasr Al Aini was done for 60 patients. Then, the
diagnosis was confirmed by SCID-I.
• A written informed consent was taken from participants
after discussing with them the aim of the study.

13. • I- Psychiatric examination:
• To assess personal data, positive family history, past
history of neurological or psychiatric
condition, scholastic achievement, duration of
illness, ECT, hospitalization

14. 1. Structured Clinical Interview for DSM IV Axis I
Disorders (SCID I) :It is a diagnostic tool used to
determine the presence of DSM-IV Axis I disorders
(schizophrenia ).

15. • It is a rating scale scored by the researcher according to
his clinical judgment. PANSS is used to estimate the
severity of psychotic symptoms in patients. The scale has
three parts including:
• positive symptoms scale (P 1-7) which assess
delusions, conceptual
disorganization, hallucinations, hyperactivity, grandiosity,
suspiciousness/persecution and hostility.

16. • Negative symptoms scale (N 1-7) which assess blunted
affect, emotional withdrawal, poor rapport, passive/apathetic
social withdrawal, difficulty in abstract thinking, lack of
spontaneity and flow of conversation and stereotyped thinking
• General psychopathology scale (G 1-16) which assess
Somatic concern, anxiety, guilt feelings, tension, mannerisms
and posturing, depression, motor
retardation, uncooperativeness, unusual thought
content, disorientation, poor attention, lack of judgment and
insight, disturbance of volition, poor impulse
control, preoccupation and active social avoidance.

17. • Figural memory, Visual paired association, Delayed
visual reproduction, and Visual memory span. They are
clinical instruments for appraising major dimensions of
memory functions. In this work, we selected the subtests
which assess the visual memory.

18. • In this study researchers choose two of the verbal
subtests (Digit span for auditory verbal short-term
(working) memory and Similarities for verbal concept-
formation) and two of the performance subtests (Digit
symbol to assess problem solving abilities, as an
indicative of executive function ,coordination and attention
and Block design to assess visuo-constructive abilities
and excutive planning)

19. • Salivary samples for cortisol levels assessment were
collected and preserved at -20o C in the clinical
laboratories of chemical pathology Department.
• Free cortisol levels were assessed by using enzyme-
linked immunosorbent assay DRG® Salivary Cortisol
ELISA

20. Results

21. • In viewing the demographic data of the
sample, there were no statistically significant
differences between the patient groups as
regards the sociodemographic data including
age, sex.
• This indicated that the samples were matched
and fit for the study and comparison.

22. • While regarding educational level, occupation and
marital status, the differences were statistically
significant

23. Levels of education of patients.

24. -
Comparison of occupation between both groups.

25. Comparison of marital status in both groups.

26. • 2-psychometric tools
• -Wechsler Memory Revised Subtests in both groups:
Wechsler memory Case control P
Mean SD. Mean SD.
Figural memory 6.47 1.776 8.73 1.081 0.003
Visual memory span (forward) 7.77 1.995 9.90 1.807 <0.001
Visual memory span (backward) 5.73 2.303 11.43 1.654 <0.001
Visual paired association 6.83 2.842 13.73 2.815 <0.001
Visual reproduction 20.53 8.274 35.13 3.441 <0.001

27. • It was reported that Cognitive impairment, particularly in
memory and executive function, is a core feature of
psychosis.
Tyson P, Laws K and Roberts K, (2005)

28. Wechsler Case Control P
Mean SD. Mean SD.
Similarities 9.37 4.173 18.67 3.144 <0.001
Digit span 10.30 2.336 14.40 1.773 <0.001
Block.design 14.63 7.271 26.17 6.276 <0.001
Digit symbols 20.78 14.792 44.43 8.675 <0.001
2-Wechsler Adult Intelligence subtests in both
groups:

29. • Dickinson et al., (2007) who found that digit symbol
coding task is reliable and easy to administer an
information processing inefficiency that is a central
feature of the cognitive deficit in schizophrenia.
• There is generalized cognitive decline in patient with
schizophrenia and they often have pervasive cognitive
deficits ,the cognitive symptoms are a main reason for
disability and dysfunction.

30. Cortisol
level
Case control P
Mean SD. Mean SD.
Cortisol A 29.660 8.2012 5.547 1.8589 <0.001
Cortisol B 17.547 4.8583 2.680 1.0199 <0.001
3-Salivary cortisol level in both groups:

31. • Moreover, psychosis is characterized by a more
prominent history of stress exposure, and by
dysregulation of the hypothalamic-pituitary-adrenal (HPA)
axis.
Tyson P, Laws K and Roberts K, (2005)

33. Wechseler memory Positive Negative Total
Figural memory P R P R P R
0.561 -0.110 0.015 -0.441 0.060 -0.347
Visual memory span forward P R P R P R
0.320 -0.188 0.204 -0.238 0.271 -0.208
Visual memory span backward P R P R P R
0.041 -0.376 0.040 -0.377 0.026 -0.407
Visual paired assossiation P R P R P R
0.073 -0.332 0.002 -0.552 0.008 -0.476
Visual reproduction P R P R P R
0.282 -0.203 0.193 -0.244 0.230 -0.226
Correlation between Positive and Negative Syndrome
Scale and Wechseler Memory Revised Scale.
Correlation between Positive and Negative Syndrome

34. • Krishnadas et al., (2007) found that the forward and
backward digit span tasks tap different cognitive abilities
that are differentially affected with the diathesis for
schizophrenia.

35. Wechseler intelligence positive negative total
Similarities P R P R P R
0.007 -0.480 0.082 -0.323 0.008 -0.473
Digit span P R P R P R
0.184 -0.249 0.029 -0.398 0.044 -0.370
Block design P R P R P R
0.269 -0.208 0.012 -0.451 0.013 -0.488
digit symbols P R P R P R
0.079 -0.326 0.006 -0.491 0.005 -0.497
Correlation between Wechsler Adult Intelligence Subtests and
Positive and Negative Syndrome Scale.

36. • Reichenberg et al. (2010) reported that patients with
schizophrenia had an impaired block design subtest and
lower linear slope values than healthy comparison
subjects.

37. • The sample size is small (30 patients), so the results
couldn’t be generalized.
• The inclusion of Kasr Al Ainy patients, who have poor
educational level and low socioeconomic standard,
may limit the results only to those patients.

39. • The schizophrenic patients have impairment in
cognitive performance.
• The level of cortisol is elevated in patient with
schizophrenia than normal people.
• There is negative correlation between the cognitive
performance and the severity of symptoms

40. • There is no correlation between cortisol level
and symptoms expression.
• There is no correlation between cortisol level
and cognitive performance

41. • Further researches are needed to confirm relation
between cortisol, psychosis and cognitive performance.
• Cortisol level can be considered a measure of severity
and improvement of psychosis.
• More studies using modern technology e.g. MRI and
SPECT.