A randomized controlled trial of Goal Management Training for executive functioning in schizophrenia spectrum disorders or psychosis risk syndromes
BMC Psychiatry volume 22, Article number: 575 (2022)
Executive functioning is essential to daily life and severely impaired in schizophrenia and psychosis risk syndromes. Goal Management Training (GMT) is a theoretically founded, empirically supported, metacognitive strategy training program designed to improve executive functioning.
A randomized controlled parallel group trial compared GMT with treatment as usual among 81 participants (GMT, n = 39 versus Wait List Controls, n = 42) recruited from an early intervention for psychosis setting. Computer generated random allocation was performed by someone independent from the study team and raters post-intervention were unaware of allocation. The primary objective was to assess the impact of GMT administered in small groups for 5 weeks on executive functioning. The secondary objective was to explore the potential of the intervention in influencing daily life functioning and clinical symptoms.
GMT improved self-reported executive functioning, measured with the Behavior Rating Inventory of Executive Function – Adult version (BRIEF-A), significantly more than treatment as usual. A linear mixed model for repeated measures, including all partial data according to the principle of intention to treat, showed a significant group x time interaction effect assessed immediately after intervention (post-test) and 6 months after intervention (follow-up), F = 8.40, p .005, r .37. Improvement occurred in both groups in objective executive functioning as measured by neuropsychological tests, functional capacity, daily life functioning and symptoms of psychosis rated by clinicians. Self-reported clinical symptoms measured with the Symptoms Check List (SCL-10) improved significantly more after GMT than after treatment as usual, F = 5.78, p .019, r .29. Two participants withdrew due to strenuous testing and one due to adverse effects.
GMT had clinically reliable and lasting effects on subjective executive function. The intervention is a valuable addition to available treatment with considerable gains at low cost.
Registered at clinicaltrials.gov NCT03048695 09/02/2017.
Executive functioning (EF) is important for education, work and social functioning . EF is a set of interrelated higher-order mental processes involving top-down control of cognition, emotion and behavior necessary for successful navigation of complex everyday situations . Definitions of EF include the core components of inhibition, shifting (also known as set-switching or mental flexibility) and updating of working memory, as well as more complex processes such as planning and problem solving [3, 4].
Executive functioning is among the most consistently impaired cognitive domains in schizophrenia spectrum disorders on tests of inhibition, shifting and planning, as well as manipulation and maintenance of working memory . Compared to healthy controls, persons with schizophrenia also report significantly more complaints of EF difficulties in everyday life on the Behavior Rating Inventory of Executive Function – Adult version (BRIEF-A) [6, 7].
EF impairments are also found among persons with psychosis risk . Psychosis risk syndromes include attenuated positive symptoms, brief intermittent psychotic symptoms and genetic risk combined with deteriorated functioning [9, 10]. Emerging evidence suggests that cognitive remediation in early intervention for psychosis could potentially have a preventative effect on the burden of illness through preserving cognition and everyday functioning [11,12,13,14]. However, there is a lack of evidence for the efficacy of cognitive remediation in psychosis risk syndromes at present .
Lower scores on objective measures of EF (neuropsychological tests) predict poorer everyday functioning, greater need for vocational support and poorer life satisfaction in schizophrenia spectrum disorders and psychosis risk syndromes [16,17,18,19,20]. Fewer subjective EF complaints on the BRIEF-A is associated with greater personal recovery in schizophrenia spectrum disorders .
Goal Management Training (GMT) is a metacognitive strategy training program that aims to improve EF [22, 23]. Metacognitive strategy training is a mode of cognitive remediation that involves top-down learning of a mental strategy, rather than bottom-up learning through repetition of tasks. The strategy training promotes awareness of cognitive deficits, and facilitates increased self-monitoring and control over mental processes . Metacognitive strategy training should not be confused with metacognitive training, which targets bias in thought content, or metacognitive therapy which targets rumination and worry . Due to the complexity of interacting executive functions, metacognitive strategy interventions are recommended for EF impairments . GMT has proved effective in people with different neurological and mental disorders . The theory behind GMT posits that failures in goal-directed behavior often are due to lapses in sustained attention . For example, one of our participants complained that if she were interrupted by the sight of a bill while vacuuming, she would forget to finish vacuuming. Instead, she would pay the bill, get caught up watching videos on the computer, and return later to find the vacuum cleaner in the middle of the room. Such distracted behavior with sudden bursts of activity is a hallmark of executive dysfunction and is often a sign that goal-directed behavior has been replaced by habits (“When I am on the computer, I watch videos”) or reliance on cues in the surroundings (seeing the bill or the vacuum cleaner) . GMT teaches participants to replace automatic, distracted behavior and instead set, prioritize, maintain and perform goals through verbal self-instructions (Table 1).
Several cognitive remediation studies for individuals with schizophrenia spectrum disorders include training in metacognitive strategies in combination with drill and practice or vocational training [28,29,30,31,32]. However, few studies appear to have assessed the effect of a stand-alone metacognitive strategy training on EF in schizophrenia spectrum disorders and none in psychosis risk syndromes [15, 33]. Studies of stand-alone interventions are important to understanding mechanisms behind change in cognitive remediation. Furthermore, most studies have focused on mental strategies tailored to specific individuals or situations. GMT, in contrast, offers guiding principles that can be applied across any number of everyday activities [22, 34]. In addition, GMT is a manualized group intervention that can be administered in only nine sessions. Therefore, GMT could potentially prove to be an easy to implement, cost-effective intervention with a broad impact on everyday functioning . GMT has been introduced for people with schizophrenia with promising results in one case-study and a recent randomized controlled trial (RCT) that combined GMT with occupational therapy [35, 36]. The individual from the case study showed better performance of familiar and novel real-life tasks after intervention. The effects remained after 2 years and he also reported increased self-confidence in performing activities of daily living . The RCT that combined GMT with occupational therapy was aimed at adults with treatment resistant schizophrenia. The participants in the treatment group showed greater improvements in activities of daily living scored by observers .
The aim of the present RCT is to determine the effectiveness of GMT on executive functioning in a sample of young participants with early schizophrenia or psychosis risk. The potential of GMT for improving daily life functioning, symptoms of psychosis and well-being is also explored. A recent master thesis investigated the effects of GMT on measures of wellbeing among participants with a diagnosis in the schizophrenia spectrum in the sample and found that GMT significantly improved self-efficacy, but not self-esteem or quality of life . The present study reports the effect of GMT on subjective EF (self-reported) and objective EF (neuropsychological tasks), symptoms of psychosis, functional capacity and daily life function.
Based on previous GMT research, we hypothesized improved subjective and objective EF following GMT . As GMT is a metacognitive strategy training program, it might be expected to have the largest impact on EF in real-world situations . Thus the trial was powered to detect meaningful differences on the primary subjective outcome measure, the BRIEF-A questionnaire. A computerized test of inattentiveness, Connors Continuous Performance Test (CPT3)  was chosen as a primary outcome measure for objective EF because it has been sensitive to change in previous GMT studies . Given the close link between EF and everyday functioning in schizophrenia and psychosis risk syndromes, we further hypothesized improved functional capacity and independent living [40,41,42]. Even though cognitive remediation for schizophrenia does not target psychotic symptoms, small reductions in symptoms have been seen across previous studies . Cognitive remediation appears to be especially beneficial for the reduction of negative symptoms . Moreover, associations have been found between poor objective EF performance and negative and disorganized symptoms, but not positive symptoms [45, 46]. Thus, we hypothesized a reduction in negative and disorganized symptoms following GMT.
Eighty-one participants, 49 males (60%) and 32 females (40%), were recruited among patients referred for treatment of psychosis at a regional, public hospital, Innlandet Hospital, in Norway 2017–2020. The majority of participants were recruited through the hospital’s specialized early detection and intervention for psychosis clinics, resulting in a young sample between the ages of 16 and 44. Mean age was 25 years (SD 6.35), and 94% of participants were between 16 and 35 years old. Sixteen individuals, aged between 18 and 40 with a mean age of 23 years, were diagnosed with psychosis risk syndromes. The remainder of the sample were diagnosed with a disorder in the schizophrenia spectrum. See Table 5 for further details of participant characteristics.
The inclusion criteria were age (16 to 69 years), diagnosis (schizophrenia spectrum disorder according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV  or psychosis risk syndrome [9, 10]) and self-reported executive dysfunction (Total T-score above 55 on the BRIEF-A, considered clinically relevant in the Norwegian context [6, 48]). Exclusion criteria included comorbid neurological conditions, ongoing alcohol or substance abuse, intellectual impairment (IQ < 70) and treatment for psychosis for more than 5 years.
The study was preregistered at clinicaltrials.gov (NCT03048695 09/02/2017). Due to time consuming and strenuous assessment days, the assessment protocol was reduced after pre-registration so that some measures were only collected at baseline including the Iowa Gambling Task  and Letter Number Sequencing Test from WAIS-IV . Goal Attainment Scale  was used only in the intervention group as it was integrated into the GMT-manual. The everyday functioning questions were simplified. The Cognitive Failures Questionnaire  was left out of the protocol due to an administration error.
The study was approved by the Regional Committee for Medical and Health Research Ethics Norway (2015/2118), and conducted in accordance with the Helsinki declaration. Informed consent was obtained for all participants. Advisers with service-user experience employed by the hospital were consulted during the planning and execution of the study. For instance, they advised on recruitment procedures and adaption of the intervention for a new patient population. An adviser also observed one of the first GMT-sessions gathering feedback from participants.
Participants were assessed for diagnostic eligibility by a trained psychologist using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) Axis I disorders, SCID-I and Structured Interview for Prodromal Symptoms [9, 53]. Symptoms of psychosis were assessed with the Structured Clinical Interview for the Positive and Negative Syndrome Scale for Schizophrenia, the SCI-PANSS . Symptoms were grouped according to a five-factor consensus model with positive, negative, disorganized, depressed and excited symptoms .
Participants were randomly assigned in a parallel group trial design to either GMT (n = 39) or a Wait-List Control condition (WLC; n = 42) by a person independent from the study team using computer-generated random assignment from https://www.randomizer.org. Trained clinicians undertook baseline assessments (T1), post-treatment assessments immediately following GMT completion (T2 at 5 weeks) and follow-up assessments 6 months after GMT completion (T3 at 30 weeks). Conditions were masked from the raters gathering post-intervention and follow-up assessments. The raters were ordinarily employed in a ward separate from the intervention sites both in terms of organization and geography. To our knowledge, no instances of unmasking occurred. Participants received GMT in addition to treatment at usual for psychosis according to Norwegian national guidelines . Treatment frequently involved a combination of medication and psychotherapy. Participants with psychosis risk syndromes received treatment for sub-threshold psychotic or general symptoms where indicated, but did not receive antipsychotics . The control group members were offered GMT after follow-up assessment. The trial ended when a sufficient number of participants had been recruited.
Intervention: Goal Management Training
Goal Management Training was administered to small groups of participants in nine, 2-h sessions (twice weekly). All sessions were held by the same clinical psychologist trained in GMT by a specialist in neuropsychology and GMT methodology, together with a local co-therapist. Co-therapists were given basic training in GMT and were doctors, psychologists, psychiatric nurses or occupational therapists. The training followed a script with accompanying PowerPoint slides and participant workbooks. Participants received a daily text message prompting strategy use between sessions four and nine [58, 59]. The current GMT-manual includes mindfulness breathing exercises to encourage adequate arousal and further improve the focus on goals in the present situation [27, 60]. The Norwegian translation of the GMT-manual  used in previous studies was revised by removing a mindfulness exercise involving sensory scanning of the body to reduce discomfort in case of tactile hallucinations or anmalous self-experiences. An exercise was added where participants developed one individual long-term goal according to the procedures in goal attainment scaling, because a review of GMT studies showed that personal goals increased effect of the intervention [51, 61]. Between-session assignments were reduced from three to two exercises due to the frequency of sessions (twice a week). Examples of assignments between sessions were collecting personal examples of inattentive slips, practicing mindful breathing or rehearsing the strategy for 30 min per day. See Table 2 for content of GMT.
Because the metacognitive strategy is gradually taught by adding steps from session four to nine, all sessions should be attended in order. Therefore, individual sessions were offered in cases of absence. The 33 participants in the intervention group who completed all three assessments points attended all nine sessions. Five participants completed the last three sessions via videoconference due to the outbreak of the Covid-19 pandemic.
An overview of all measures reported in this study is provided in Table 3. The pre-registered primary outcome measures were BRIEF-A (subjective EF), CPT3 (objective EF) and SCI-PANSS (symptoms of psychosis).
Subjective EF in everyday situations was measured using the 75-item questionnaire BRIEF-A . The instrument has shown good test-retest reliability ranging from r .82 to .93 across nine subscales . The scale showed good internal consistency in the present study at baseline with an adequate Cronbach’s Alpha score of α .95 for the total score.
Objective EF was assessed with the following tests: Inattentiveness was measured with the Conners Continuous Performance Test - 3rd edition (CPT3) . The raw score for detectability (d’) analyzed is a signal-to-noise ratio that captures ability to correctly respond to targets while inhibiting responses to non-targets. Higher scores indicate poorer performance. The measures are reported to have adequate split-half reliability in a normative sample r .92 (r .95 for those under 18 years) and test-retest reliability, r .74 .
Total score on the Digit Span task (forwards, backwards and sequential conditions) from the Wechsler Adult Intelligence Scale – 4th edition, WAIS-IV  was used to assess working memory. The test has adequate internal consistency in normative samples with Cronbach Alpha scores of α .84 in the forwards condition, α .78 in the backwards condition and α .89 in the sequential condition . Test-retest reliability ranges from r .71–.77 across the three conditions .
Inhibition and shifting were assessed with the Color-Word Interference Test (CWIT) from the Delis-Kaplan Executive Function System (D-KEFS) . The test-retest reliability correlations for the four conditions in a normative sample were CWIT1 Color naming, r .86, CWIT2 Word reading r .49, CWIT3 Inhibition r .71 and CWIT4 Inhibition/Switching r .52 in the age group 20–49. Among those under 19 years the correlations ranged from r. 77 to r .90 . In the present study, two raw contrast scores for inhibition and shifting were used as outcome measures to separate out the confounding effects of processing speed [68, 69]. A contrast measure of inhibition was created by subtracting the average amount of seconds spent on CWIT1 and CWIT2 from CWIT3. A contrast measure of shifting was created by subtracting time spent on CWIT3 from time spent on CWIT4. Higher contrast scores indicate greater difficulties with inhibition and shifting.
Strategic planning was measured with the total achievement score from the Tower task from D-KEFS . The total achievement score reflects the building of correct towers with as few moves as possible, requiring the ability to plan more than one step ahead. Higher scores indicate better performance. Test-retest reliability in a normative sample was r .41 (r. 51 for those under 18) .
Raw scores on the above neuropsychological tests were converted to z-scores, reversed where appropriate and averaged for a total mean score of objective EF. Positive mean scores indicated better performance.
Symptoms of psychosis were measured using SCI-PANSS . The instrument was scored by a trained clinician and included a structured interview with participants, input from someone who knew the participant well and saw them regularly (e.g., a family member or treating clinician) and observations made during the interview. Thirty items were scored on a scale ranging from 1 (absent) to 7 (extreme). Items referring to hallucinations and delusions with a score higher than 4 (moderate) indicate psychosis. The instrument has shown adequate reliability in both in- and outpatient settings . In the present study, items were grouped according to a five-factor consensus model . The total scores for positive, negative, disorganized, depressed and excited symptoms were used as outcome measures.
A brief, ten-item version of the Symptom Check List, SCL-10, was used to assess self-reported psychological distress . The SCL-10 has shown adequate psychometric qualities equivalent to longer versions of the instrument and it has been validated in the Norwegian population . The questionnaire reflects subjectively experienced anxiety and depressed mood. Items are scored on a scale ranging from 1 (a little bothered) and 4 (very bothered). The total score from the questionnaire was used as an outcome measure.
Functional capacity measures included the brief version of the University of California San Diego Performance-based Skills Assessment, UPSA-B [65, 66] and the Hotel Task . From the UPSA, the total score out of 100 for the Finance and Communication modules was used. The UPSA is a role-playing task imitating activities of daily life including paying a bill and making a telephone call. Higher scores indicate better performance. During the Hotel Task participants are instructed to divide their time equally between five different tasks: Sorting coins, proof reading, creating invoices, using a telephone directory and sorting names alphabetically. The number of seconds deviating from optimal time distribution between the five tasks was used as the outcome measure.
Activities of daily living was assessed with two subscales from the self-reported Social Functioning Scale, SFS . The Norwegian translation of the scale has been shown to be reliable and valid among people with schizophrenia . The two subscales Independence Competence and Independence Performance were considered the most relevant outcome measures . The internal consistency of the Independence Performance subscale, α .81, and Independence Competence subscale, α .65, was adequate. Furthermore, global function was assessed with clinician ratings of the Global Assessment of Functioning - Split version, GAF-F . The scale ranges from 0 to 100 and higher scores indicate better functioning across important areas of life such as school or work, socially and at home. Ratings have been shown to be consistent among experienced raters .
Analyses were performed using SPSS, version 26. In order to describe EF at baseline, one-sample t-tests were run comparing normed scores from the sample to standardized normative means gathered from the test manuals of EF instruments. Main outcome analyses were run using raw scores to retain variance. Outliers more than three standard deviations from the mean or with extreme residuals were excluded. The scores for CWIT Inhibition and SFS Independence Competence were log transformed to account for skewed distributions of scores. Group comparisons at baseline between GMT and WLC, and between completers and non-completers, were done using the Mann-Whitney Test for continuous variables and Pearson Chi Square for categorical variables.
A-priori power calculations based on existing GMT-studies indicated that to detect an effect size on the primary outcome measure of r. 30 (d 0.65), a sample size of n = 60 would be sufficient to render power of 80% with the alpha level set to p .05. Based on the principle of intention-to-treat (ITT), available data for all 81 participants were entered into a linear mixed model analysis for repeated measures . Missing data were assumed to be missing at random. Group, time and group by time interactions were assessed as fixed effects and p-values < .05 were considered statistically significant. A first-order autoregressive covariance matrix was chosen for the repeated measures. Random subject intercepts were allowed for. Post-hoc explorations of change within treatment groups were done by running the models separately for each group.
As a precaution, age, sex, years of education, diagnosis, symptoms and treatment content in TAU (drug therapy and psychotherapy) were added one-by-one as co-variates in the mixed model analysis to control for potential influence on significant group x time interactions.
Effect sizes were expressed as Pearson’s r for the group x time interaction effects:
Reliable Change Index (RCI) was calculated for the primary outcome measure that showed a significant interaction effect, BRIEF-A, to identify individuals with clinically reliable improvement from baseline (T1) to follow-up (T3) .
Baseline characteristics of the sample
At baseline, the sample showed significantly more subjective complaints of EF with a mean total T-score of 68 on BRIEF-A when compared to normative samples . The sample showed comparable performance to normative samples on the Digit Span test. All conditions of the CWIT were performed slower than the normative average, but there was no additional speed reduction on the conditions requiring shifting and inhibition, similar to previous studies . The sample did, however, have more difficulty differentiating between targets and non-targets on the CPT3. Table 4 shows the executive functioning in the sample compared to the standardized means derived from large norming samples with healthy participants listed in the test manuals of the instruments [6, 38, 50, 64].
Group comparisons at baseline
Any baseline differences between the groups were considered incidental due to randomization . The GMT-group reported more subjective EF complaints at baseline, F(1,72) = 6.66, p .012. The GMT-group also showed a significantly lower level of negative symptoms compared to the WLC-group, F(1, 79) = 17.34, p .008. The groups were otherwise comparable, see Table 5.
Nine subjects did not complete testing at T2, and this number increased to 11 at T3 making attrition 13.58% at the end of the study. There were no significant differences between completers and non-completers in demographical or clinical variables.
A linear mixed model analysis showed a significant decrease in self-reported symptoms of executive dysfunction in everyday life in the GMT-group only, BRIEF-A Total score, F(1, 51.94) = 8.40, p .005, r .37. Results for subjective EF can be seen in Table 6. The result remained unchanged when controlling for age, sex, diagnosis, years of education, treatment and severity of psychotic symptoms. In particular, there was no main effect of negative symptoms on subjective EF, and adding the variable did not change the significant interaction effect between group and time on subjective EF. Of note, significantly more participants in the GMT-group (10 of 19, 52.60%) experienced reliable clinical change from baseline to follow-up on this measure compared to the WLC-group (2 of 18, 11.10%), χ2(1) = 7.27, p .007, φc .44 according to the RCI .
The results show no difference in effectiveness between the two groups measured with neuropsychological tasks. However, both groups improved significantly over time on the Tower task and in mean objective EF.
There were no significant differences between treatments in functional capacity, self-reported independent living or clinician ratings of global functioning. Both functional capacity and clinician rated function improved significantly over time in both groups.
Both treatment groups showed a reduction in positive, disorganized and excited symptoms over time, but no significant treatment effect of GMT were registered in psychotic symptoms assessed by a trained clinician with SCI-PANSS. The GMT-group experienced a significantly greater reduction in self-reported symptoms of anxiety and depressed mood measured by the SCL-10, F(1, 64.05) = 5.78, p .019, r .29. See Tables 7, 8 and 9 for results of the mixed model analyses.
Post-hoc explorations of change within each group showed that the GMT-group demonstrated significant improvement on the primary outcome measure for objective EF, the CPT3, over time, F(34.18) = 4.33, p .045, r .33, while the WLC-group did not demonstrate statistically significant improvement, F(35.75) = 1.58, p .216, r .20. The GMT-group also showed significant improvement over time in self-reported performance (SFS Performance GMT F(21.07) = 5.17, p .034, r .44 versus WLC F(29.70) = 0.19, p .666, r .08) and competence in independent activities of daily living (SFS Performance GMT F(32.68) = 4.79, p .036, r .36 versus WLC F(22.73) = 1.39, p .251, r .24). However, improvement was significant in both groups for the Tower task, mean objective EF, GAF-F and the UPSA. None of the groups experienced improvement on the CWIT and, in fact, the WLC-group showed greater improvement on the Digit Span and the Hotel Task, F(40.40) = 9.82, p .003, r .44 compared to the GMT-group, F(25.02) = 1.92, p .176, r .26.
Post-hoc explorations of change within each group showed that the GMT-group demonstrated significant reduction in depressive symptoms, F(37.01) = 12.97, p < .001, r .51, while the WLC-group did not demonstrate statistically significant improvement, F(38.38) = 2.67, p .111, r .26. The opposite was found for excited symptoms. The WLC-group demonstrated a significant reduction in excited symptoms, F(41.80) = 12.01, p .001, r .47, while the reduction in the GMT-group did not reach statistical significance, F(44.51) = 1.78, p .189, r .20.
This study examined the efficacy of GMT in improving EF among people with schizophrenia spectrum disorders or psychosis risk syndromes. To our knowledge this is the first RCT of stand-alone GMT as an early intervention for this patient group. GMT led to a significant and clinically reliable reduction of dysexecutive problems in daily life 6 months after the intervention. The largest effects of GMT on self-reported EF were in initiating activities, planning/ organizing, self-monitoring and shifting focus between activities as assessed with the BRIEF-A subscales. The effect GMT had on increased initiation of activity is especially compelling as this has been reported to be the most impaired domain both in our sample and in a previous schizophrenia study . Difficulty initiating activity is also a challenging symptom to treat in schizophrenia .
We did not find significantly greater improvement on objective EF measures in the GMT-group compared to the WLC-group. Since the post-hoc analysis showed improved scores on overall objective EF and the Tower task in both groups, this likely reflects practice effects due to repetition of measures similar to previous studies in schizophrenia [64, 80]. There could be several possible reasons why GMT changed subjective EF more consistently than objective EF. It may be that GMT primarily had a compensatory, rather than restorative, mechanism within the follow-up period of the present study [33, 81]. A restorative mechanism supposes an improvement in specific cognitive functions (for example through frequent task repetition) leading to improved performance on objective measures . A compensatory mechanism supposes learning to use other, better functioning areas of cognition to work around specific challenges. Metacognitive strategy training programs such as GMT, could potentially have both a compensatory and a restorative effect . The earliest effects of GMT might be expected at the behavioral level as a result of compensatory strategy use in real-world situations. However, there might also be a restorative effect of GMT on specific executive functions over time when the strategy becomes automatized through repetition. Current evidence implies that GMT leads to improved performance on neuropsychological tasks across study populations, especially in a working memory task . It is not certain why the present study failed to show similar effects of GMT on objective EF. The study may have lacked sufficient power to detect small treatment effects, especially considering that our study sample performed as well as normative samples on some of the objective tasks at baseline . It is also possible that people with psychosis require more support outside sessions in order to internalize GMT-strategies. Nonetheless, since GMT is a metacognitive strategy training rehearsed in real-world situations, neuropsychological tests may not have been the most suitable outcome measures in the present study. The end goal for GMT is improving goal-directed behavior in real life. The use of systematic observation of familiar and novel real-life tasks might hold the key to unlocking the real potential of GMT [22, 36].
Furthermore, subjective and objective measures of EF are rarely strongly correlated in neither healthy nor clinical samples [85, 86]. One of the main strengths of objective measures is limiting the influence of confounding factors through control over the test situation. As a consequence, the objective test setting provides too much structure to assess the complexity of interacting components of executive function required in real-life . Subjective measures, on the other hand, are better at capturing complex everyday situations, but are more easily influenced by confounding emotional states . Since the discrepancy between subjective and objective measures of cognition is often larger among persons with schizophrenia than in healthy samples, caution should be exercised in the interpretation of the mechanisms of change in subjective EF in the present study [89,90,91,92]. That is not to say that self-reported executive functioning is not of clinical importance as it has been shown to predict important life outcomes, for example academic performance in college , and impulse control in younger people . In addition, fewer subjective cognitive complaints in schizophrenia are associated with better physical and psychological well-being . Lower scores on the BRIEF-A in particular is associated with greater personal recovery among people with schizophrenia spectrum disorders . Furthermore, it is possible that a reduction in executive difficulties in real-world situations leads to attempting more challenging tasks [21, 96, 97]. Over time this can build increased confidence in the mastery of activities of daily living, similar to what was observed in the first case study of GMT in schizophrenia .
There was no effect of GMT as a stand-alone intervention in functional capacity (UPSA and Hotel Task), self-reported activities of independent living (SFS) or clinician rated global functioning (GAF-F). Some of this may be due to methodological issues. For example, the UPSA may have lacked the sensitivity required to detect meaningful treatment effects, as it has shown ceiling effects in previous studies among younger individuals with a first episode of psychosis [98,99,100]. The Hotel task may have been subject to an inverse treatment effect due to similarities to a practical multi-tasking exercise during GMT. In a demonstration during session six, GMT-participants are instructed to shift quickly between tasks, but not divide their time equally as in the Hotel task. An inverse effect where GMT-participants perform more poorly on the Hotel task after GMT has been observed previously in a GMT study .
The post-hoc analysis of the SFS indicated that change did occur in self-reported performance and competence in activities of independent living in the GMT-group and not the WLC-group, but that the analysis lacked sufficient statistical power to reveal this in the main analysis. The clinician ratings of global function, however, showed that both groups improved their functioning over time showing that GMT did not outperform treatment as usual. Global function as defined in GAF-F is a very broad construct including areas of life not necessarily expected to change in the time span of the present study. Thus, using Goal Attainment Scale as an outcome measure of progress on individual goals of everyday functioning, as originally intended, would likely have been a more appropriate measure .
It is possible the interval of 6 months between intervention and follow-up measurements was not long enough to detect an effect of GMT on daily life function, since the GMT-strategy is internalized through repetition over time. Unfortunately, the present study did not assess the amount of strategy rehearsal each participant engaged in, and therefore it is not known to what degree the strategy was internalized. Nonetheless, our finding is in line with existing evidence indicating that cognitive remediation should be integrated into psychosocial rehabilitation programs in order to improve real-world functioning [11, 102, 103]. Combining GMT with restorative drill training and vocational rehabilitation may offer the most promise for achieving functional gains among people with psychosis and EF impairments [33, 102,103,104]. In a study by Vizzotto and colleagues GMT was combined with occupational therapy where participants with treatment-resistant schizophrenia practiced real-life tasks during sessions lasting a total of 45 h . In that context, GMT improved performance on observed real-life tasks and informant reports of independent living. The aim of the present study was to assess stand-alone metacognitive strategy training as this has rarely been done in schizophrenia [15, 33]. However, the end goal of research on cognitive remediation in schizophrenia is to develop rehabilitation that maximizes the improvement in function, including participation in education and work [105, 106]. Future studies might consider comparing the effects of GMT to other forms cognitive training. Investigating GMT in combination with drill and practice training of executive functions might also further elucidate mechanisms and assist in the search for optimal treatments.
GMT led to improvement in self-reported, but not clinician rated, clinical symptoms. Since clinician rated symptoms were reduced over time in both groups, the reduction was most likely due to treatment as usual. It is possible that an improvement in EF would be associated with better self-regulation and a reduction in stressful experiences in daily life. A bidirectional interplay between EF and psychopathology has been suggested [107, 108]. Executive difficulties among adolescents and young adults with psychosis may exacerbate challenges in meeting the increased expectations of self-organization at home, in school, or in social situations. Failing to meet expectations from parents, peers, or teachers could cause stress and raise the risk of clinical symptoms [109, 110]. Accordingly, the reduction on self-rated symptoms of anxiety after GMT may be an expression of improved self-regulation and fewer stressful encounters. Perhaps it reflects those participants felt less overwhelmed in everyday situations when using the GMT strategies.
Converging evidence of reduced depressive symptoms after GMT from both self-reports and clinician ratings indicate that GMT had a positive effect on depression, as well. However, the change assessed by the clinicians was small and could only be detected in the post-hoc analysis. In addition, excited symptoms were only reduced in the control group, indicating that symptoms fluctuated in the sample over time and that the significant changes could be spurious findings.
The sample in the present study included both persons recently diagnosed with a schizophrenia spectrum disorder and persons with psychosis risk syndromes. Studies on cognitive remediation for psychosis risk are scarce and have not previously investigated metacognitive strategy training . Some have argued that improved EF in everyday life could potentially protect against a worse prognosis by preserving role function during an important phase of life when work, social and family life begins to be established [11, 111]. In our sample, there were not enough participants with psychosis risk syndrome to analyze this subgroup alone. However, effects of GMT were similar in analyses with and without psychosis risk participants. Even though the current study cannot conclude that GMT has a preventative effect on prognosis, improvements in subjective EF among at-risk participants are important nonetheless because it may indicate a reduction of friction in everyday situations . Everyday stressors tends to increase intensity of psychotic symptoms . The relationship between cognition and stress in psychosis is in need of further elucidation . However, improved self-reports of executive problems such as inattentiveness, impulsive behavior or challenges initiating activities may potentially have a protective effect early in psychotic illness [14, 21].
GMT is a valuable addition to early intervention in the schizophrenia spectrum disorders and psychosis risk syndromes, because EF is important in everyday situations and frequently severely impaired in these patient groups [5, 7, 8]. Aside from the associations subjective EF has with personal recovery, experiencing that you are better able to plan, start and organize everyday tasks, monitor yourself and shift focus when required, could have a positive impact on the participants’ everyday life and adherence to treatment for psychosis. GMT proved to have clinically reliable and lasting effects after being administered in groups over a brief period of 5 weeks. Participants also reported less anxiety and depressed mood after intervention. Thus, this suggests that GMT can provide considerable gains at low cost in clinical settings. The standardized manual ensures fidelity and allows for efficient training of clinicians. Future studies should assess maintenance of strategies learnt during GMT .
Strengths and limitations
The robust randomized design featuring masking of conditions and follow-up over 6 months with low attrition rates are important strengths of this study. The sample size ensured sufficient statistical power to detect moderate effects. The extensive assessment protocol with a multimodal approach to the measurement of EF is also a strength of the study. However, the protocol lacked observational measures of real-life situations and community functioning and was a missed opportunity of capturing potential beneficial effects of GMT on functioning [35, 36, 116]. The primary outcome measure that showed the largest treatment effect of GMT was self-reported EF, which may be vulnerable to cognitive deficits in self-evaluation, demand characteristics and social desirability bias . The neuropsychological tests were the same at all assessment points. It would have been preferable to use tests with alternative versions to avoid practice effects.
An important question is whether the study has sufficient generalizability beyond this sample. The sample was young and had received treatment for psychosis for a maximum of 5 years or had psychosis risk syndromes. It is therefore somewhat uncertain if the results may be generalized to older adults who have been living with schizophrenia for a longer period of time. However, a recent study using the GMT protocol in combination with occupational therapy among adults with treatment-resistant schizophrenia and a higher mean age found similar results .
Treatment as usual at the time of participating in the present study varied somewhat since not all patients received both psychotherapy and drug treatment. This heterogeneity may have interfered with treatment effects of GMT. For example, attending psychotherapy may increase metacognitive capacity . However, there were no significant difference between the GMT-group and WLC-group in concomitant treatment after randomization. Also, we did not find that other concomitant treatment moderated the effect of GMT when controlling for this statistically. Another caveat is that the GMT-group had fewer negative symptoms than the WLC-group. Since negative symptoms mediate the relationship between cognition and functional outcome, findings need to be replicated to ensure that the efficacy of GMT also applies to individuals with higher levels of negative symptoms . Nonetheless, we did control for negative symptoms in the statistical analysis in the present study and negative symptoms did not influence the outcome of GMT on subjective EF.
Our sample was selected on the basis of EF complaints. In addition, the GMT-group reported greater difficulties with EF in everyday situations at baseline than the WLC-group, which may have inflated the effect size of the main finding, but the effect of GMT remained significant when controlling for this baseline difference by removing the main effect of treatment group .
To our knowledge, this is the first high-quality RCT of stand-alone metacognitive strategy training in people with schizophrenia spectrum disorders and psychosis risk syndromes. Our main findings demonstrated that a five-week, group-based GMT program was effective in reducing self-assessed, daily-life executive dysfunction. Finally, the study had a low attrition rate, suggesting high participant acceptance of the intervention.
Availability of data and materials
The datasets generated and analyzed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity, but are available from the corresponding author on reasonable request.
Goal Management Training
Randomized controlled trial
Time one, baseline assessment at 0 weeks
Time two, post-intervention assessment after 5 weeks
Time three, follow-up assessment 6 months after intervention (30 weeks)
Behavior Rating Inventory of Executive Function – Adult version
Color Word Interference Test
Conners Performance Test, 3rd edition
University of California San Diego Performance-based Skills Assessment
Social Functioning Scale
Global Assessment of Function, Split version (Function)
Diamond A. Executive functions. Annu Rev Psychol. 2013;64(1):135–68.
Burgess PW, Alderman N, Forbes C, Costello A, Coates LM, Dawson DR, et al. The case for the development and use of “ecologically valid” measures of executive function in experimental and clinical neuropsychology. J Int Neuropsychol Soc. 2006;12(2):194–209.
Miyake A, Friedman NP, Emerson MJ, Witzki AH, Howerter A, Wager TD. The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: a latent variable analysis. Cogn Psychol. 2000;41(1):49–100.
Friedman NP, Miyake A. Unity and diversity of executive functions: individual differences as a window on cognitive structure. Cortex. 2017;86:186–204.
East-Richard C, R-Mercier A, Nadeau D, Cellard C. Transdiagnostic neurocognitive deficits in psychiatry: a review of meta-analyses. Can Psychol. 2020;61(3):190–214.
Roth RM, Gioia GA. Behavior rating inventory of executive function- adult version. Lutz: Psychological Assessment Resources; 2005.
Bulzacka E, Vilain J, Schurhoff F, Meary A, Leboyer M, Szoke A. A self administered executive functions ecological questionnaire (the behavior rating inventory of executive function - adult version) shows impaired scores in a sample of patients with schizophrenia. Ment Illn. 2013;5(1):e4.
Catalan A, Salazar de Pablo G, Aymerich C, Damiani S, Sordi V, Radua J, et al. Neurocognitive functioning in individuals at clinical high risk for psychosis: a systematic review and meta-analysis. JAMA Psychiatry. 2021;78(8):859–67.
Miller T, McGlashan T, Woods S, Stein K, Driesen N, Corcoran C, et al. Symptom assessment in schizophrenic prodromal states. Psychiatr Q. 1999;70(4):273–87.
Yung AR, Phillips LJ, McGorry PD, McFarlane CA, Francey S, Harrigan S, et al. Prediction of psychosis: a step towards indicated prevention of schizophrenia. Br J Psychiatry Suppl. 1998;172(33):14–20.
Barlati S, Deste G, De Peri L, Ariu C, Vita A. Cognitive remediation in schizophrenia: current status and future perspectives. Schizophr Res Treatment. 2013;2013:156084.
Carrión RE, McLaughlin D, Auther AM, Olsen R, Correll CU, Cornblatt BA. The impact of psychosis on the course of cognition: a prospective, nested case-control study in individuals at clinical high-risk for psychosis. Psychol Med. 2015;45(15):3341–54.
Oliver D, Reilly TJ, Baccaredda Boy O, Petros N, Davies C, Borgwardt S, et al. What causes the onset of psychosis in individuals at clinical high risk? A meta-analysis of risk and protective factors. Schizophr Bull. 2020;46(1):110–20.
Bechdolf A, Wagner M, Ruhrmann S, Harrigan S, Putzfeld V, Pukrop R, et al. Preventing progression to first-episode psychosis in early initial prodromal states. Br J Psychiatry. 2012;200(1):22–9.
Glenthøj LB, Hjorthøj C, Kristensen TD, Davidson CA, Nordentoft M. The effect of cognitive remediation in individuals at ultra-high risk for psychosis: a systematic review. NPJ Schizophr. 2017;3:20.
Cowman M, Holleran L, Lonergan E, O'Connor K, Birchwood M, Donohoe G. Cognitive predictors of social and occupational functioning in early psychosis: a systematic review and meta-analysis of cross-sectional and longitudinal data. Schizophr Bull. 2021;47(5):1243–53.
McGurk SR, Mueser KT. Cognitive and clinical predictors of work outcomes in clients with schizophrenia receiving supported employment services: 4-year follow-up. Adm Policy Ment Health Ment Health Serv Res. 2006;33(5):598–606.
Squarcina L, Kambeitz-Ilankovic L, Bonivento C, Prunas C, Oldani L, Wenzel J, et al. Relationships between global functioning and neuropsychological predictors in subjects at high risk of psychosis or with a recent onset of depression. World J Biol Psychiatry. 2022:1–9. Online ahead of print.
Fujii DE, Wylie AM, Nathan JH. Neurocognition and long-term prediction of quality of life in outpatients with severe and persistent mental illness. Schizophr Res. 2004;69(1):67–73.
Eslami A, Jahshan C, Cadenhead KS. Disorganized symptoms and executive functioning predict impaired social functioning in subjects at risk for psychosis. J Neuropsychiatry Clin Neurosci. 2011;23(4):457–60.
Van Aken B, Wierdsma AI, Voskes Y, Pijnenborg G, Weeghel J, Mulder C. The association between executive functioning and personal recovery in people with psychotic disorders. Schizophr Bull Open. 2022;3(1):sgac023.
Levine B, Robertson IH, Clare L, Carter G, Hong J, Wilson BA, et al. Rehabilitation of executive functioning: an experimental-clinical validation of goal management training. J Int Neuropsychol Soc. 2000;6(3):299.
Robertson IH. Goal management training: a clinical manual. Cambridge: PsyConsult; 1996.
Stamenova V, Levine B. Effectiveness of goal management training® in improving executive functions: a meta-analysis. Neuropsychol Rehabil. 2018;29(10):1–31.
Capobianco L, Wells A. Letter to the editor: metacognitive therapy or metacognitive training: what’s in a name? J Behav Ther Exp Psychiatry. 2018;59:161.
Cicerone KD, Goldin Y, Ganci K, Rosenbaum A, Wethe JV, Langenbahn DM, et al. Evidence-based cognitive rehabilitation: systematic review of the literature from 2009 through 2014. Arch Phys Med Rehabil. 2019;100(8):1515–33.
Levine B, Schweizer TA, O'Connor C, Turner G, Gillingham S, Stuss DT, et al. Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Front Hum Neurosci. 2011;5:9.
McGurk SR, Mueser KT, Pascaris A. Cognitive training and supported employment for persons with severe mental illness: one-year results from a randomized controlled trial. Schizophr Bull. 2005;31(4):898–909.
Twamley EW, Vella L, Burton CZ, Heaton RK, Jeste DV. Compensatory cognitive training for psychosis: effects in a randomized controlled trial. J Clin Psychiatry. 2012;73(9):1212–9.
Vauth R, Corrigan PW, Clauss M, Dietl M, Dreher-Rudolph M, Stieglitz RD, et al. Cognitive strategies versus self-management skills as adjunct to vocational rehabilitation. Schizophr Bull. 2005;31(1):55–66.
Farreny A, Aguado J, Ochoa S, Huerta-Ramos E, Marsa F, Lopez-Carrilero R, et al. REPYFLEC cognitive remediation group training in schizophrenia looking for an integrative approach. Schizophr Res. 2012;142(1–3):137–44.
Reeder C, Huddy V, Cella M, Taylor R, Greenwood K, Landau S, et al. A new generation computerised metacognitive cognitive remediation programme for schizophrenia (CIRCuiTS): A randomised controlled trial. Psychol Med. 2017;47(15):2720–30.
Allott K, van-der-El K, Bryce S, Parrish EM, McGurk SR, Hetrick S, et al. Compensatory interventions for cognitive impairments in psychosis: a systematic review and meta-analysis. Schizophr Bull. 2020;46(4):869–83.
Connor LT, Maeir A. Putting executive performance in a theoretical context. OTJR (Thorofare N J). 2011;31(1):3–7.
Vizzotto A, Celestino D, Buchain P, Oliveira A, Oliveira G, Di Sarno E, et al. Occupational goal intervention method for the management of executive dysfunction in people with treatment-resistant schizophrenia: a randomized controlled trial. Am J Occup Ther. 2021;75(3).
Levaux MN, Laroi F, Malmedier M, Offerlin-Meyer I, Danion JM, Van Der Linden M. Rehabilitation of executive functions in a real-life setting: goal management training applied to a person with schizophrenia. Case Rep Psychiatry. 2012;2012:1–15.
Øie MB. Goal management training for schizophrenia spectrum disorders: effects on self-esteem, self-efficacy and quality of life [Master Thesis]. Oslo: University of Oslo; 2021.
Conners KC. Conners continuous performance test. 3rd ed. Toronto: Multi-Health Systems Inc.; 2014.
Stubberud J, Langenbahn D, Levine B, Stanghelle J, Schanke A-K. Goal management training of executive functions in patients with spina bifida: a randomized controlled trial. J Int Neuropsychol Soc. 2013;19(6):672–85.
McGurk SR, Meltzer HY. The role of cognition in vocational functioning in schizophrenia. Schizophr Res. 2000;45(3):175–84.
Bora E, Lin A, Wood SJ, Yung AR, McGorry PD, Pantelis C. Cognitive deficits in youth with familial and clinical high risk to psychosis: a systematic review and meta-analysis. Acta Psychiatr Scand. 2014;130(1):1–15.
Penadés R, Catalán R, Puig O, Masana G, Pujol N, Navarro V, et al. Executive function needs to be targeted to improve social functioning with cognitive remediation therapy (CRT) in schizophrenia. Psychiatry Res. 2009;177(1):41–5.
Vita A, Barlati S, Ceraso A, Nibbio G, Ariu C, Deste G, et al. Effectiveness, core elements, and moderators of response of cognitive remediation for schizophrenia: a systematic review and meta-analysis of randomized clinical trials. JAMA Psychiatry. 2021;78(8):848–58.
Cella M, Preti A, Edwards C, Dow T, Wykes T. Cognitive remediation for negative symptoms of schizophrenia: a network meta-analysis. Clin Psychol Rev. 2017;52:43–51.
Pijnenborg GHM, Van Beilen M, Arends J, Holthausen EAE, Withaar FK. Disturbed cognitive functioning and clinical symptoms: two independent problem areas in schizophrenia. Acta Neuropsychiatr. 2003;15(5):280–3.
Dibben CR, Rice C, Laws K, McKenna PJ. Is executive impairment associated with schizophrenic syndromes? A meta-analysis. Psychol Med. 2009;39(3):381–92.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed., text revision. ed. Washington, DC: American Psychiatric Association; 2000.
Løvstad M, Sigurdardottir S, Andersson S, Grane VA, Moberget T, Stubberud J, et al. Behavior rating inventory of executive function adult version in patients with neurological and neuropsychiatric conditions: symptom levels and relationship to emotional distress. J Int Neuropsychol Soc. 2016;22(6):682–94.
Bechara A, Damasio AR, Damasio H, Anderson SW. Insensitivity to future consequences following damage to human prefrontal cortex. Cognition. 1994;50(1–3):7–15.
Wechsler D. Wechsler adult intelligence scale - fourth edition (WAIS-IV). San Antonio: Pearson Assessment; 2008.
Ashford S, Turner-Stokes L. Goal attainment for spasticity management using botulinum toxin. Physiother Res Int. 2006;11(1):24–34.
Broadbent DE, Cooper PF, FitzGerald P, Parkes KR. The cognitive failures questionnaire (CFQ) and its correlates. Br J Clin Psychol. 1982;21(1):1–16.
First MB, Spitzer RL, Gibbon M, Williams JB. Structured clinical interview for DSM-IV-TR Axis I disorders: patient edition. New York: Biometrics Research Department, Columbia University New York; 2005.
Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261–76.
Wallwork RS, Fortgang R, Hashimoto R, Weinberger DR, Dickinson D. Searching for a consensus five-factor model of the positive and negative syndrome scale for schizophrenia. Schizophr Res. 2012;137(1–3):246–50.
Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332.
Norwegian Health Authority. National guideline for assessment, treatment and follow-up care of persons with psychotic illness. Oslo: Norwegian Health Authority; 2013.
Fish J, Evans JJ, Nimmo M, Martin E, Kersel D, Bateman A, et al. Rehabilitation of executive dysfunction following brain injury: “content-free” cueing improves everyday prospective memory performance. Neuropsychologia. 2007;45(6):1318–30.
Manly T, Hawkins K, Evans J, Woldt K, Robertson IH. Rehabilitation of executive function: facilitation of effective goal management on complex tasks using periodic auditory alerts. Neuropsychologia. 2002;40(3):271.
Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. 15th anniversary ed. New York: Delta Trade; 1990.
Krasny-Pacini A, Evans J, Chevignard M. Goal management training for rehabilitation of executive functions: a systematic review of effectiveness in patients with acquired brain injury. Ann Phys Rehabil Med. 2014;57:67.
Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins symptom checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19(1):1–15.
Wechsler D. Wechsler abbreviated scale of intelligence (WASI). San Antonio: NCS Pearson, Inc; 1999.
Delis DC, Kaplan E, Kramer JH. Delis–Kaplan executive function system. Bloomington: NCS Pearson, Inc.; 2001.
Patterson TL, Goldman S, McKibbin CL, Hughs T, Jeste DV. UCSD performance-based skills assessment: development of a new measure of everyday functioning for severely mentally ill adults. Schizophr Bull. 2001;27(2):235–45.
Patterson TL, Mausbach B. UCSD performance-based skills assessement-brief (UPSA-B). San Diego: University of California; 2006.
Birchwood M, Smith J, Cochrane R, Wetton S, Copestake S. The social functioning scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. Br J Psychiatry. 1990;157(12):853–9.
Neill E, Rossell SL. Executive functioning in schizophrenia: the result of impairments in lower order cognitive skills? Schizophr Res. 2013;150(1):76–80.
Savla GN, Twamley EW, Thompson WK, Delis DC, Jeste DV, Palmer BW. Evaluation of specific executive functioning skills and the processes underlying executive control in schizophrenia. J Int Neuropsychol Soc. 2010;17(1):14–23.
Kay SR, Fiszbein A, Lindenmayer J-P, Opler LA. Positive and negative syndromes in schizophrenia as a function of chronicity. Acta Psychiatr Scand. 1986;74(5):507–18.
Strand BH, Dalgard OS, Tambs K, Rognerud M. Measuring the mental health status of the Norwegian population: a comparison of the instruments SCL-25, SCL-10, SCL-5 and MHI-5 (SF-36). Nord J Psychiatry. 2003;57(2):113–8.
Hellvin T, Sundet K, Vaskinn A, Simonsen C, Ueland T, Andreassen OA, et al. Validation of the Norwegian version of the social functioning scale (SFS) for schizophrenia and bipolar disorder. Scand J Psychol. 2010;51(6):525–33.
Horan WP, Harvey P-O, Kern RS, Green MF. Neurocognition, social cognition and functional outcome in schizophrenia. In: Gaebel W, editor. Schizophrenia: current science and clinical practice. Chichester: Wiley-Blackwell; 2011. p. 67–107.
Pedersen G, Hagtvet KA, Karterud S. Generalizability studies of the global assessment of functioning-split version. Compr Psychiatry. 2007;48(1):88–94.
Gupta SK. Intention-to-treat concept: a review. Perspect Clin Res. 2011;2(3):109–12.
Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991;59(1):12–9.
Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. J Clin Epidemiol. 2010;63(8):e1–37.
Melle I, Larsen TK, Haahr U, Friis S, Johannesen JO, Opjordsmoen S, et al. Prevention of negative symptom psychopathologies in first-episode schizophrenia: two-year effects of reducing the duration of untreated psychosis. Arch Gen Psychiatry. 2008;65(6):634–40.
Aleman A, Lincoln TM, Bruggeman R, Melle I, Arends J, Arango C, et al. Treatment of negative symptoms: where do we stand, and where do we go? Schizophr Res. 2017;186:55–62.
McCaffrey RJ, Westervelt HJ. Issues associated with repeated neuropsychological assessments. Neuropsychol Rev. 1995;5(3):203–21.
Kidd SA, Herman Y, Virdee G, Bowie CR, Velligan D, Plagiannakos C, et al. A comparison of compensatory and restorative cognitive interventions in early psychosis. Schizophr Res Cogn. 2020;19:100157.
Kaneko Y, Keshavan M. Cognitive remediation in schizophrenia. Clin Psychopharmacol Neurosci. 2012;10(3):125–35.
Chung CS, Pollock A, Campbell T, Durward BR, Hagen S. Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage. Cochrane Database Syst Rev. 2013;(4):CD008391.
Fett AJ, Reichenberg A, Velthorst E. Lifespan evolution of neurocognitive impairment in schizophrenia - a narrative review. Schizophr Res Cogn. 2022;28:100237.
Toplak ME, West RF, Stanovich KE. Practitioner review: do performance-based measures and ratings of executive function assess the same construct? J Child Psychol Psychiatry. 2013;54(2):131–43.
Haugen I, Stubberud J, Ueland T, Haug E, Øie MG. Executive dysfunction in schizophrenia: predictors of the discrepancy between subjective and objective measures. Schizophr Res Cogn. 2021;26:100201.
Sbordone RJ. The hazards of strict reliance on neuropsychological tests. Appl Neuropsychol Adult. 2014;21(2):98–107.
Shwartz SK, Roper BL, Arentsen TJ, Crouse EM, Adler MC. The behavior rating inventory of executive function®-adult version is related to emotional distress, not executive dysfunction, in a veteran sample. Arch Clin Neuropsychol. 2020;35(6):701–16.
Medalia A, Thysen J, Freilich B. Do people with schizophrenia who have objective cognitive impairment identify cognitive deficits on a self report measure? Schizophr Res. 2008;105(1–3):156–64.
Potvin S, Pelletier J, Stip E. Neurocognitive insight in schizophrenia: a meta-analysis. Sante Ment Que. 2014;39(2):183.
Raudeberg R, Karr JE, Iverson GL, Hammar Å. Examining the repeatable battery for the assessment of neuropsychological status validity indices in people with schizophrenia spectrum disorders. Clin Neuropsychol. 2021:1–18. Online ahead of print.
Glenthøj LB, Mariegaard L, Kristensen TD, Wenneberg C, Medalia A, Nordentoft M. Self-perceived cognitive impairments in psychosis ultra-high risk individuals: associations with objective cognitive deficits and functioning. NPJ Schizophr. 2020;6(1):31.
Baars MAE, Nije Bijvank M, Tonnaer GH, Jolles J. Self-report measures of executive functioning are a determinant of academic performance in first-year students at a university of applied sciences. Front Psychol. 2015;6:1131.
Piche J, Kaylegian J, Smith D, Hunter SJ. The relationship between self-reported executive functioning and risk-taking behavior in urban homeless youth. Behav Sci (Basel). 2018;8(1):6.
Paudel S, Coman D, Freudenreich O. Subjective experience of cognitive difficulties as an important attribute of quality of life among individuals with schizophrenia spectrum disorders. Schizophr Res. 2020;215:476–8.
Lysaker PH, Glynn SM, Wilkniss SM, Silverstein SM. Psychotherapy and recovery from schizophrenia: a review of potential applications and need for future study. Psychol Serv. 2010;7(2):75–91.
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215.
Heinrichs RW, Statucka M, Goldberg J, McDermid Vaz S. The University of California Performance Skills Assessment (UPSA) in schizophrenia. Schizophr Res. 2006;88(1–3):135–41.
Vesterager L, Christensen TO, Olsen BB, Krarup G, Melau M, Forchhammer HB, et al. Cognitive and clinical predictors of functional capacity in patients with first episode schizophrenia. Schizophr Res. 2012;141(2–3):251–6.
Ostergaard Christensen T, Vesterager L, Krarup G, Olsen BB, Melau M, Gluud C, et al. Cognitive remediation combined with an early intervention service in first episode psychosis. Acta Psychiatr Scand. 2014;130(4):300–10.
Wykes T, Joyce E, Velikonja T, Watson A, Aarons G, Birchwood M, et al. The CIRCuiTS study (Implementation of cognitive remediation in early intervention services): protocol for a randomised controlled trial. Trials. 2018;19(1):183.
Wykes T, Huddy V, Cellard C, McGurk SR, Czobor P. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry. 2011;168(5):472–85.
McGurk SR, Twamley EW, Sitzer DI, McHugo GJ, Mueser KT. A meta-analysis of cognitive remediation in schizophrenia. Am J Psychiatry. 2007;164(12):1791–802.
Medalia A, Saperstein AM. Does cognitive remediation for schizophrenia improve functional outcomes? Curr Opin Psychiatry. 2013;26(2):151–7.
McGurk SR, Xie H, Bond GR, Mueser KT. Impact of cognitive remediation on the prediction of employment outcomes in severe mental illness. Schizophr Res. 2022;241:149–55.
Kharawala S, Hastedt C, Podhorna J, Shukla H, Kappelhoff B, Harvey PD. The relationship between cognition and functioning in schizophrenia: a semi-systematic review. Schizophr Res Cogn. 2022;27:100217.
Zelazo PD. Executive function and psychopathology: a neurodevelopmental perspective. Annu Rev Clin Psychol. 2020;16:431–54.
Romer AL, Pizzagalli DA. Is executive dysfunction a risk marker or consequence of psychopathology? A test of executive function as a prospective predictor and outcome of general psychopathology in the adolescent brain cognitive development study(R). Dev Cogn Neurosci. 2021;51:100994.
Shakoor S, Zavos HM, Haworth CM, McGuire P, Cardno AG, Freeman D, et al. Association between stressful life events and psychotic experiences in adolescence: evidence for gene-environment correlations. Br J Psychiatry. 2016;208(6):532–8.
Freedman D, Brown AS. The developmental course of executive functioning in schizophrenia. Int J Dev Neurosci. 2011;29(3):237–43.
Cornblatt BA, Lencz T, Smith CW, Correll CU, Auther AM, Nakayama E. The schizophrenia prodrome revisited: a neurodevelopmental perspective. Schizophr Bull. 2003;29(4):633–51.
Hakansson U, Watten RG, Soderstrom K, Oie MG. The association between executive functioning and parental stress and psychological distress is mediated by parental reflective functioning in mothers with substance use disorder. Stress Health. 2019;35(4):407–20.
Nuechterlein KH, Dawson ME. A heuristic vulnerability/stress model of schizophrenic episodes. Schizophr Bull. 1984;10(2):300–12.
Aas M, Dazzan P, Mondelli V, Melle I, Murray RM, Pariante CM. A systematic review of cognitive function in first-episode psychosis, including a discussion on childhood trauma, stress, and inflammation. Front Psychiatry. 2014;4:182.
Tornas S, Lovstad M, Solbakk AK, Schanke AK, Stubberud J. Use it or lose it? A 5-year follow-up study of goal management training in patients with acquired brain injury. J Int Neuropsychol Soc. 2019;25(10):1082–7.
Bellack AS, Green MF, Cook JA, Fenton W, Harvey PD, Heaton RK, et al. Assessment of community functioning in people with schizophrenia and other severe mental illnesses: a white paper based on an NIMH-sponsored workshop. Schizophr Bull. 2007;33(3):805–22.
McCambridge J, de Bruin M, Witton J. The effects of demand characteristics on research participant behaviours in non-laboratory settings: a systematic review. PLoS One. 2012;7(6):e39116.
Ventura J, Hellemann GS, Thames AD, Koellner V, Nuechterlein KH. Symptoms as mediators of the relationship between neurocognition and functional outcome in schizophrenia: a meta-analysis. Schizophr Res. 2009;113(2):189–99.
Twisk J, Bosman L, Hoekstra T, Rijnhart J, Welten M, Heymans M. Different ways to estimate treatment effects in randomised controlled trials. Contemp Clin Trials Commun. 2018;10:80–5.
The Authors thank Evelyn Robsahm, Kari Veisten and Tina Sveum Engh for data collection and entry.
The work was supported by the South-Eastern Norway Health Authority (grant number 2017012); Innlandet Hospital Trust (grant number 150602) and University of Oslo (grant number 353139).
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Participants gave informed consent. The study was conducted in accordance with the Helsinki declaration and approved by the Regional Committee for Medical and Health Research Ethics Norway (2015/2118).
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Haugen, I., Stubberud, J., Haug, E. et al. A randomized controlled trial of Goal Management Training for executive functioning in schizophrenia spectrum disorders or psychosis risk syndromes. BMC Psychiatry 22, 575 (2022). https://doi.org/10.1186/s12888-022-04197-3