Clinical Rehabilitation

Screening for Cognitive Deficits in Schizophrenia with the

Evaluation of Cognitive Processes involved in Disability
Scale

Journal: Clinical Rehabilitation

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Manuscript ID CRE-2018-7011.R2

Manuscript Type: Original Article

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Date Submitted by the Author: 16-Jun-2018

Complete List of Authors: Roux, Paul; Fondation FondaMental, Academic Centres of Expertise for
Schizophrenia; Versailles Hospital, Department of Adult Psychiatry;
ee

University of Versailles Saint-Quentin-En-Yvelines, HandiRESP Laboratory,

EA4047, Health Sciences Department Simone Veil
Urbach, Mathieu; Fondation FondaMental, Academic Centres of Expertise
for Schizophrenia; Versailles Hospital, Department of Adult Psychiatry;
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University of Versailles Saint-Quentin-En-Yvelines, HandiRESP Laboratory,

EA4047, Health Sciences Department Simone Veil
Fonteneau, Sandrine; Fondation FondaMental, Academic Centres of
Expertise for Schizophrenia; Versailles Hospital, Department of Adult
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Psychiatry; University of Versailles Saint-Quentin-En-Yvelines, HandiRESP

Laboratory, EA4047, Health Sciences Department Simone Veil
Berna, Fabrice; Fondation FondaMental, Academic Centres of Expertise for
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Schizophrenia; Strasbourg University Hospital, INSERM U1114, Strasbourg

Federation of Translational Psychiatry
Brunel, Lore; Fondation FondaMental, Academic Centres of Expertise for
Schizophrenia; Université Paris-Est Créteil (UPEC), INSERM U955,
Translational Psychiatry team, AP-HP, DHU Pe-PSY, Department of Adult
Psychiatry, University Hospitals H Mondor
Capdevielle, Delphine; Fondation FondaMental, Academic Centres of
Expertise for Schizophrenia; University of Montpellier 1, fAcademic
Department of Adult Psychiatry, La Colombière Hospital, CHU Montpellier,
INSERM 1061
Chereau, Isabelle; Fondation FondaMental, Academic Centres of Expertise
for Schizophrenia; Auvergne University, CMP B, Clermont-Ferrand
University Hospital, EA 7280, Faculty of Medicine
Dubreucq, Julien; Fondation FondaMental, Academic Centres of Expertise
for Schizophrenia; Alpes Isère Hospital, Psychosocial Rehabilitation
Reference Centre
Faget-Agius, Catherine; Fondation FondaMental, Academic Centres of
Expertise for Schizophrenia; Sainte-Marguerite University Hospital,
Academic Department of Psychiatry (AP-HM)
Fond, Guillaume; Fondation FondaMental, Academic Centres of Expertise
for Schizophrenia
Leignier, Sylvain; Fondation FondaMental, Academic Centres of Expertise
for Schizophrenia; Alpes Isère Hospital, Psychosocial Rehabilitation

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Page 1 of 35 Clinical Rehabilitation

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2
3
Reference Centre
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Perier, Claire-Cécile ; Fondation FondaMental, Academic Centres of
5 Expertise for Schizophrenia; Alpes Isère Hospital, Psychosocial
6 Rehabilitation Reference Centre
7 Richieri, Raphaëlle; Fondation FondaMental, Academic Centres of Expertise
8 for Schizophrenia; Sainte-Marguerite University Hospital, Academic
9 Department of Psychiatry (AP-HM)
Schneider, Priscille; Fondation FondaMental, Academic Centres of Expertise
10
for Schizophrenia; Strasbourg University Hospital, INSERM U1114,
11 Strasbourg Federation of Translational Psychiatry
12 Schürhoff, Franck; Fondation FondaMental, Academic Centres of Expertise
13 for Schizophrenia; Université Paris-Est Créteil (UPEC), INSERM U955,
14 Translational Psychiatry team, AP-HP, DHU Pe-PSY, Department of Adult
15 Psychiatry, University Hospitals H Mondor
16 Tronche, Anne Marie ; Fondation FondaMental, Academic Centres of
Expertise for Schizophrenia; Auvergne University, CMP B, Clermont-
17 Ferrand University Hospital, EA 7280, Faculty of Medicine
18 Yazbek, Hanan; Fondation FondaMental, Academic Centres of Expertise for
19 Schizophrenia; University of Montpellier 1, fAcademic Department of Adult
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20 Psychiatry, La Colombière Hospital, CHU Montpellier, INSERM 1061
21 Zinetti-Bertschy, Anna; Fondation FondaMental, Academic Centres of
22 Expertise for Schizophrenia; Strasbourg University Hospital, INSERM
U1114, Strasbourg Federation of Translational Psychiatry
23
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Passerieux, Christine; Fondation FondaMental, Academic Centres of

24 Expertise for Schizophrenia; Versailles Hospital, Department of Adult
25 Psychiatry; University of Versailles Saint-Quentin-En-Yvelines, HandiRESP
26 Laboratory, EA4047, Health Sciences Department Simone Veil
ee

27 Brunet-Gouet, Eric; Fondation FondaMental, Academic Centres of Expertise

28 for Schizophrenia; Versailles Hospital, Department of Adult Psychiatry;
University of Versailles Saint-Quentin-En-Yvelines, HandiRESP Laboratory,
29
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EA4047, Health Sciences Department Simone Veil

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31 chronic disability, Cognitive impairment, Psychiatric Rehabilitation,
Keywords:
32 Sensitivity, Specificity, schizophrenia
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 Clinical Rehabilitation Page 2 of 35

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3 1 ABSTRACT
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5 2 Objective. The study aimed to evaluate the validity of the Evaluation of Cognitive Processes
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7 3 involved in Disability in Schizophrenia scale (ECPDS) to discriminate for cognitive
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9 4 impairment in schizophrenia.
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5 Design. This multicentre cross-sectional study used a validation design with receiver
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14 6 operating characteristic (ROC) curve analysis.
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16 7 Settings. The study was undertaken in a French network of seven outward referral centres.
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18 8 Subjects. We recruited individuals with clinically stable schizophrenia diagnosed based on
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20 9 the Structured Clinical Interview for assessing DSM-IV-R criteria.
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22 10 Main measures. The index test for cognitive impairment was ECPDS (independent variable),
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11 a 13-items scale completed by a relative of the participant. The reference standard was a
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27 12 standardised test battery evaluated seven cognitive domains. Cognitive impairment was the
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29 13 dependent variable and was defined as an average z-score more than 1 SD below the
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31 14 normative mean in two or more cognitive domains.
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33 15 Results. Overall, 97 patients were included (67 with schizophrenia, 28 with schizo-affective
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35 16 disorder, and 2 with schizophreniform disorder). Mean age was 30.2 (SD 7.7) years, and there
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37 17 were 75 men (77.3%). There were 59 (60.8%) patients with cognitive impairment on the
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18 neuropsychological battery, and mean ECPDS score was 27.3 (SD 7.3). The ROC curve
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42 19 analysis showed that the optimal ECPDS cut-off was 29.5. The area under the curve was 0.77,
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44 20 with 76.3% specificity and 71.1% sensitivity to discriminate against cognitive impairment.
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46 21 Conclusions. The ECPDS is a valid triage tool for detecting cognitive impairment in
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48 22 schizophrenia, before using an extensive neuropsychological battery, and holds promise for
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50 23 use in everyday clinical practice.
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3 1 Screening for Cognitive Deficits with the Evaluation of Cognitive Processes involved in
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5 2 Disability in Schizophrenia Scale
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7 3 Screening for Cognitive Deficits in Schizophrenia
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10 4
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12 5 INTRODUCTION
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14 6 Cognitive impairment is a core feature of schizophrenia (1) and has emerged as an
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7 essential treatment target (2), given its major adverse impact on everyday functioning (3).
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19 8 Prevalence of cognitive impairment usually ranges between 50 and 80% and affects several
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21 9 cognitive domains like processing speed, executive functions, memory and learning,
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23 abstraction and attention (4). One barrier to the implementation of cognitive training is that
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25 11 the extensive neuropsychological assessment used to diagnose objective cognitive deficits is
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27 12 time-consuming and costly. Moreover, some individuals with schizophrenia are not able to
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complete this extensive assessment because of a lack of motivation due to the illness. Tools
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14 for selecting those patients in whom specific rehabilitation interventions such as cognitive
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34 15 training are most likely to decrease the level of disability during everyday life would,
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16 therefore, be expected to improve the management of their cognitive symptoms in everyday

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38 17 activities.
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40 18 The cognitive items of psychopathological scales have only limited validity when used
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42 19 to screen for objective cognitive impairment (5). Interview-based cognitive assessments
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20 showed stronger associations with objective cognitive performance, with correlation
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47 21 coefficients ranging from 0.27 to 0.54 (6–8). However, these interview-based scales have
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49 22 two notable limitations. First, they missed evaluating behavioural and social aspects of
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51 23 cognitive dysfunction including motivation, social cognition, and metacognition. Second,
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53 24 they require an interview with a trained clinician. A scale that could be directly rated by
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55 25 close contacts of patients would be easier to use.
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 Clinical Rehabilitation Page 4 of 35

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3 1 We recently developed such a scale: the Evaluation of Cognitive Processes involved in
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5 2 Disability in Schizophrenia scale (ECPDS) (9) can be completed within 15 minutes by the
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7 3 relatives or friends of the patient, who require no specific training. An original feature of the
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4 ECPDS is that it covers a broad array of neuro-cognitive, motivational, socio-cognitive, and
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12 5 meta-cognitive impairments that result in schizophrenia-related disability.
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14 6 Here, we aimed to determine the validity of the ECPDS for detecting objective
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16 7 cognitive impairment diagnosed using a full battery of neuropsychological tests. One
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18 8 objective of this study was to establish a threshold in psychiatric disability measured with
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20 9 ECPDS at which the presence of objective cognitive impairment was predicted with enough
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10 sensitivity and specificity.
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25 11
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27 12 METHODS
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29 13 The study patients were members of the FondaMental Academic Centres of Expertise
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31 14 for Schizophrenia cohort established by a French network of seven schizophrenia referral
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33 15 centres. General practitioners or psychiatrists referred the patients who were assessed in
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16 Centres of Expertise. The goal was to improve global care by delivering personalised care
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38 17 plans, after a systematic set of comprehensive assessment tools, including a
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40 18 neuropsychological battery (10). The sample was not selected based on the suspected
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42 19 presence or absence of cognitive impairment.
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44 20 They were outpatients between 18 and 65 with clinically stable schizophrenia,
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46 21 schizoaffective or schizophreniform disorder diagnosed based on the Structured Clinical
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22 Interview for assessing Diagnostic Statistical Manual IV-R criteria. Stability was defined as
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51 23 no admission or treatment change in the past four weeks. Patients were interviewed by senior
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53 24 psychiatrists, or psychologists specialised in schizophrenia, who were all members of the
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55 25 specialised multidisciplinary teams of the Expert Centres.
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3 1 Our local medical ethics committee (Comité de Protection des Personnes Ile-de-
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5 2 France XI) approved the study (2012-A00387-36). Each participant received a complete
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7 3 description of the study in oral and written form and gave written informed consent before
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4 study inclusion. The study was registered on ClinicalTrials.gov (EVACO, NCT02901015).
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14 6 French and English versions of ECPDS are reported in Supplement Information 1. The
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16 7 ECPDS includes 13 items rated by a relative of the participant on a seven-level Likert scale
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18 8 (from 0, severe disability; to 3, no disability; 0.5 points per level). The ECPDS has good
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20 9 internal consistency (Cronbach’s alpha: 0.88) and excellent interrater reliability (9).
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10 Schizophrenic symptoms were assessed with the Positive and Negative Syndrome
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25 11 Scale (11) and the Clinical Global Impression-Severity (12). A mean hospitalisation time
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27 12 was calculated by summing the duration of all lifetime hospitalisations in a psychiatric ward.
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29 13 The reference standard was a standardised test battery evaluated seven cognitive
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31 14 domains: processing speed, attention/vigilance, working memory, verbal memory, visual
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33 15 memory, reasoning and problem solving, and executive functioning (see Supplement
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16 Information 2 for a complete description of the battery). Clinically significant cognitive
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38 17 impairment was defined as an average standard score more than 1 SD below the normative
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40 18 mean in two or more cognitive domains (13).
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44 20 Statistical analyses
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46 21 We performed a Pearson correlation between ECPDS score and the average
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22 neuropsychological performance across the seven domains. To test the association between
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51 23 cognitive impairment and psychiatric disability, we performed bivariate logistic regression
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53 24 with clinically significant cognitive impairment on the whole neuropsychological battery (status:
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55 25 present or absent) as the dependent variable and the ECPDS total score as the independent
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3 1 variable. We also conducted a receiver operating characteristic curve analysis. The area
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5 2 under the curve reflected the validity of the ECPDS to discriminate cognitive impairment and
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7 3 was interpreted as follows: 0.5, non-predictive; 0.5-0.7, poorly predictive; 0.7-0.9,
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4 moderately predictive; and 0.9-1, strongly predictive (14). The optimal score cut-off was
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12 5 determined by maximising the sum of sensitivity and specificity.
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16 7 RESULTS
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18 8 We included 97 participants, 75 men (77.3%), between April 2013 and July 2017.
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20 9 Mean age was 30.2 (SD 7.7) years and mean time in formal education was 12.7 (SD 2.2)
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10 years. The diagnosis was schizophrenia in 67 (69.1%), schizo-affective disorder in 28
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25 11 (28.9%), and schizophreniform disorder in 2 (2.1%) patients. Mean total hospitalisation time
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27 12 was 6.1 (SD 8.0) months. Mean total Positive and Negative Syndrome Scale score was 68
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29 13 (SD 19.7), mean chlorpromazine-equivalent was 649 (SD 692) mg/24h, and mean Clinical
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31 14 Global Impression-Severity was 4.2 (SD 1.5). The mean ECPDS score was 27.3 (SD 7.3),
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16 Table 1 reports the cognitive test results. Mean standard score was -0.9 for processing
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38 17 speed (SD 0.8), -0.3 for attention/vigilance (SD 0.4), -0.5 for working memory (SD 0.7), -1.2
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40 18 for verbal memory (SD 1.1), -1.3 for visual memory (SD 0.9), -0.4 for reasoning and
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42 19 problem solving (SD 0.9), and -1.3 for executive functioning (SD 1.8). The number of
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44 20 participants clinically significant cognitive impairment was 59 (60.8%).
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46 21 Psychiatric disability measured with ECPDS was significantly lower for patients
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22 without clinically significant cognitive impairment compared with patients with clinically
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51 23 significant cognitive impairment (see Supplement Information 3). The correlation between
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53 24 ECPDS score and the average neuropsychological performance across the seven domains
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55 25 was significant (r = .38, t(95) = 4, p < 0.001). Bivariate logistic regression showed a
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Page 7 of 35 Clinical Rehabilitation

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3 1 significant association between cognitive impairment and the ECPDS score (coefficient 0.13,
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5 2 SD 0.04, z=3.4, p<0.001). The area under the curve (Figure 1) was 0.77 (95% CI: 0.65-0.87),
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7 3 suggesting moderate validity of the ECPDS score for detecting cognitive impairment. The
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4 optimal total ECPDS score cut-off was 29.5, with 76.3% specificity and 71.1% sensitivity.
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12 5 The associations between ECPDS score and the neuropsychological performance in each of
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14 6 the seven cognitive domains are analysed in Supplement Information 4. These analyses
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16 7 showed that the validity of ECPDS was lower to discriminate impairment in specific
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18 8 cognitive domains than a general cognitive impairment diagnosed with the whole
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25 11 DISCUSSION
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27 12 We showed that ECDPS might be a useful screening tool for clinically significant
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29 13 cognitive impairment in patients with schizophrenia, using a comprehensive
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31 14 neuropsychological battery as the reference standard.
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33 15 The 60.8% prevalence of cognitive impairment in our study is at the lower end of the
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16 previously reported range (4). The sample recruited in this study was representative of
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38 17 outpatients population of with moderate symptoms and stabilised schizophrenia.
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40 18 The ECPDS was moderately accurate in detecting cognitive impairment and was more
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42 19 accurate in detecting general cognitive impairment (i.e. impairment in at least two cognitive
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44 20 functions) than impairment in a specific cognitive domain. When a cognitive impairment is
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46 21 suspected according to ECPDS, we thus recommend performing comprehensive
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22 neuropsychological testing to identify which cognitive domain is impaired and propose the
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51 23 appropriate cognitive training program. To our knowledge, there is no comparable screening
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53 24 test for schizophrenia, and the accuracy of interview-based cognitive assessments in
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3 1 Several limitations should be borne in mind when interpreting our results. We had no
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5 2 control group of healthy individuals, and the cognitive data were adjusted for several
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7 3 variables (age, sex, and education, according to published reference values). Finally, our
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4 definition of clinically significant cognitive impairment did not take premorbid ability into
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12 5 account.
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14 6 Our results show that is possible to adequately predict a cognitive deficit diagnosed from
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16 7 objective cognitive performances on neuropsychological tests with a subjective evaluation of
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18 8 psychiatric disability run by individuals without any training. According to the International
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20 9 Classification of Functioning, Disability, and Health (ICF), neurocognitive deficits should be
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10 classified as impairments in functions, whereas psychiatric disability measured with ECPDS
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25 11 describes activity limitations (15). Our results thus emphasise the strong link between
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27 12 impairment in cognitive functions and activity limitations in schizophrenia. Further studies

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29 13 should test whether schizophrenia-induced disability measured with ECPDS would mediate
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31 14 the relationship between impairment in cognitive functions and restricted participation in life
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33 15 situations. The ECPDS may be useful in people with diffuse brain injury and dementia, but
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16 further studies are needed to validate its validity in the field of neurological rehabilitation.
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38 17 In conclusion, the ECPDS shows satisfactory diagnostic validity for detecting
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40 18 cognitive impairment in patients with schizophrenia. The ease of ECPDS completion by
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42 19 relatives suggests a role, as part of the standard evaluation of schizophrenia, in identifying
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44 20 patients likely to benefit from a complete neuropsychological battery. The ECPDS may
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46 21 make an essential contribution to the care of individuals with schizophrenia, by improving
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22 access to cognitive training.
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51 23
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53 24 CLINICAL MESSAGE
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55 25 The Evaluation of Cognitive Processes involved in Disability in Schizophrenia scale seems a
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Page 9 of 35 Clinical Rehabilitation

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3 1 reasonable screening tool for cognitive deficit worthy of further investigation.
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4 ACKNOWLEDGEMENTS
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12 5 We thank the Centre Hospitalier de Versailles and A. Wolfe for editorial assistance, K.
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14 6 Souyris at the Fondation Fondamental for data managing, and A. Cattenoy and L. Morisset
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16 7 at the Maison de la Recherche at Versailles Hospital for their administrative support.
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20 9 AUTHOR CONTRIBUTIONS
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10 EBG designed the study and wrote the protocol. EBG and PR undertook the statistical
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25 11 analysis. PR wrote the first draft of the manuscript. All authors contributed to and had
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27 12 approved the final manuscript.

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31 14 COMPETING INTERESTS
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33 15 None
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38 17 FUNDING SUPPORT
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40 18 This work was supported by the Versailles Hospital, Le Chesnay, France; Fondation
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42 19 FondaMental, Créteil, France; Programme Hospitalier de Recherche Clinique
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44 20 (AOM11233); Investissements d’Avenir programme managed by the Agence Nationale de la
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46 21 Recherche (ANR-11-IDEX-0004-02 and ANR-10-COHO-10-01); and Institut National de la
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22 Santé et de la Recherche Médicale.
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3 1 FIGURE LEGENDS
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5 2 Figure 1. Receiver operating characteristic curve showing the sensitivity and specificity of
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7 3 the Evaluation of Cognitive Processes involved in Disability in Schizophrenia Scale
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4 (ECPDS) score in detecting clinically significant cognitive impairments. The diagonal
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12 5 reference line (grey) represents the prediction value of 0.5 produced by chance alone. The
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14 6 triangle shows the optimal cut-off, obtained by maximising the sum of sensitivity and
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16 7 specificity.
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2
3 1 15. World Health Organization. International Classification of Functioning, Disability and
4
5 2 Health: ICF. World Health Organization; 2001.
6
7
8 3
9
10 4
11
12
13 5
14
15 6
16
17 7
18
19
Fo
20
21
22
23
rP

24
25
26
ee

27
28
29
rR

30
31
32
ev

33
34
35
36
iew

37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
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 Receiver operating characteristic curve
Clinical Rehabilitation Page 14 of 35

1.0
1
2
3
4
5
6

Fo
0.8

7
8

rP
9
10
11

ee
12
13
0.6

14
Sensitivity

rR
15
16

ev
17
18
19

iew
0.4

20
21
22
23
24
25
0.2

26
27
28
29
30
31
32 Optimal cut-off for ECPDS total score: 29.5
0.0

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0.6 0.4 0.2 0.0
37
38 Specificity
Page 15 of 35 Clinical Rehabilitation

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2
3 Table 1. Performance on the neuropsychological tests in the study population
4
5
Function Test Variable Mean SD Min. Max.
6
7 Processing Speed Digit / Symbol Coding -1.2 1 -3 1
8 TMT Part A -0.6 1.1 -4.7 1.2
9 Verbal Fluency Phonemic -0.6 0.9 -2.7 1.2
10 Semantic -1.1 0.9 -2.7 2.2
11

Fo
Attention/Vigilance CPT-IP Mean D prime -1.1 1 -3.1 1.2
12 TAP - Alertness Reaction Time SD - without warning -0.2 0.3 -0.9 0.4
13
TAP - Alertness Reaction Time SD - with warning -0.1 0.3 -0.8 0.5

rP
14
15 TAP - Alertness Alertness index 0 0.3 -0.6 0.8
16 TAP - Flexibility Number of errors 0 0.3 -0.7 0.3

ee
17 Global Performance Index -0.2 0.3 -0.9 0.4
18 TAP - Divided Attention Number of errors -0.1 0.2 -0.9 0.2

rR
19 Number of omissions -0.2 0.3 -0.9 0.2
20 TAP - Go / No Go 1 Standard Deviation of Reaction Time -0.2 0.3 -0.7 0.4
21

ev
TAP - Go / No Go 2 Standard Deviation of Reaction Time -0.1 0.2 -0.8 0.2
22
23
Working Memory Digit Span Forwards -0.2 1.1 -2.6 2.8

iew
24 Backwards -0.4 1 -2.3 2.9
25 Arithmetic -0.7 1.1 -2.7 2.3
26 Letter-Number Sequencing -0.8 0.8 -2.3 1.3
27 Verbal Memory CVLT Immediate Recall -1.8 1.5 -4.8 1.4
28 Short-Delay Free Recall -1.3 1.1 -4.8 1.6
29 Long-Delay Free Recall -1.2 1.2 -4.2 1.6
30
Total Recognition -0.4 1.3 -2.6 1.2
31
32 Visual Memory Doors Test -1.3 0.9 -2.3 1.4
33 Reasoning and Problem Perceptual - Matrix Reasoning -0.4 1.1 -3 1.7
34 Solving
35 Perceptual - Picture Completion -0.7 1.1 -3 2
36 Verbal - Similarities -0.1 1.1 -3 2
37 Executive Functioning Trail Making Test Part B -1.4 2.3 -10.9 1.4
38 Multiple Errands Test Total Error Score -1.2 2.1 -17.7 0.7
39
All performances are standard score against population norm. The WAIS-III was administered to 70.2% and the WAIS-IV to 29.8% of participants.
40
TMT: Trail Making Test; TAP: Tests of Attentional Performance; CVLT: California Verbal Learning Test
41
42
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 Clinical Rehabilitation Page 16 of 35

1
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3 Supplement Information 1. Full English and French versions of the Evaluation of Cognitive
4 Processes involved in Disability in Schizophrenia scale
5
6
7
8 Evaluation of Cognitive Processes involved in Disability in Schizophrenia
9 (ECPDS) scale (Version for family or the immediate circle)
10
11
12
13 This version was created with the intention of being filled out by anyone in the immediate circle of the
14 individual with a disability, be it a family member, a close friend, or a staff member (social worker, care
worker, etc.). It can also be used by a healthcare professional, under the condition that they know the
15
individual sufficiently well in their daily life and routine.
16
17 Introduction and general scoring principles:
18 This scale is based on the description of expressions in daily life of cognitive impairment which seems
19 to be implicated in functional difficulties and disability for people suffering from schizophrenia.
Fo
20 These cognitive impairments are frequently observed in people suffering from a disorder on the
21 schizophrenia spectrum; they are known to be quite specific to these disorders and to have an
22 important impact on their daily life.
23
rP

They were brought together under four categories:

24
- neuro-cognition
25
- motivation
26
ee

- communication abilities and capacity to comprehend other people

27 - awareness of one’s own abilities and limitations
28
29
rR

Each category is comprised of multiple questions (totaling 13) that are scored on a seven-point
30 severity scale from 0 (extremely severe level of difficulty) to 6 (no difficulty).
31
32 Scoring must be carried out by selecting the level of severity closest to that presented by the
person being evaluated, based on the descriptions provided. Descriptions of levels 1, 3, and 5 are
ev

33
not provided and must be selected only if the person’s level of difficulty is located between two
34 surrounding levels.
35
36 Beware: you must only select one response per question.
iew

37 For people living with a psychiatric condition such as schizophrenia, it is common that their levels of
38 ability fluctuate, from one day to another, or depending on current context, level of stress, etc.
39 Here, the leading principle is that the assessor must select the level that corresponds with the
40 best level of achievement possible for the person, their best capacity, and must think regarding
41 situations where the person is most successful and capable.
42 The reason for this choice rests upon the functional orientation of this evaluation: its aim is to establish
43 the full potential of the person evaluated and thus the mobilizing potential, in order to stimulate useful
44 and appropriate actions, for example on their environment or care.
45 Moreover, given the often singular relation of individuals on the schizophrenia spectrum to the world
46 around them, their abilities can be expressed in areas which are not usually considered a priority in
47 light of social norms. If this is the case, these abilities must be taken into account during the
48 evaluation.
49 The evaluation must refer to the period of the last few weeks or the last month.
50
51 The case may be that you do not have access to enough information to be able to answer one
of the questions or categories (for example if you do not live with the person evaluated). In
52
these cases, you can respond by ticking the box for “Cannot be assessed.”
53
54 In all other cases, you must select the level of severity closest to the difficulties you have observed.
55
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3 A. Neuro-cognition
4
5 This category refers to the way cognitive abilities (capacities of organisation, adaptation to new
6 situations/ context, attention, memory) interfere with daily activities and routines.
7 For the questions below, two criteria must be respected:
8 - The score selected must be based on the best level of achievement possibly reached by the
9 subject, even if they received external stimulation or help (encouragement, reassurance,
10 preparatory role-playing situations, etc.) to achieve it.
11 - The situational examples used as a reference must not be based on any activities involving
12 direct social interaction with another person, in order to avoid confusion with the category
13 related to difficulties in social interactions and relationships
14
15 1 - Ability to organize oneself in a daily activity, i.e. that is part of the subject’s routine (for
16 example, running an errand, preparation of a meal, etc.)
17
18
0. ❑ The difficulty in organizing oneself is observed for all simple tasks of daily life.
19
1. ❑
Fo
20
2. ❑ The subject is capable of carrying out very simple tasks (run an errand, cooking a
21
steak) but cannot adapt to basic contextual changes (opening hours of shops, using a
22
different pan when the usual one is not available) and/or cannot do two things at once
23
rP

(do another errand at the same time as the first, preparing a side to be served at the
24 same time as the steak…)
25 3. ❑
26
ee

4. ❑ The subject is capable of carrying out more complex daily tasks that potentially
27 involve doing two things at once, as long as nothing interferes with the usual
28 sequence of events (for example, the preparation of a full meal in which each course
29 is ready to be served at the right time which includes a main dish with a side and a
rR

30 dessert or starter).
31 5. ❑
32 6. ❑ The subject is capable of carrying out all daily activities and routines, including
ev

33 ones that involve numerous successive sequences of action, even if this is only
34 possible when the immediate circle provides regular and substantial stimulation.
35 7. ❑ Cannot be assessed
36
iew

37 2 - Ability to manage a non-routine activity, i.e. an activity which represents a new

38 situation for the person. This item must refer to the abilities that the subject manages to
39 apply in a new or unusual situation (for example, taking a new route by car or public transport;
40 repairing an object or having it repaired; preparing a meal if not usually done, etc.). This item
41 does not refer to the capacity to acquire new abilities, which is addressed in the following
42 question.
Beware: the aim is not to evaluate the relevance of these actions according to what is socially
43
expected or useful.
44
45
46 0. ❑ No new activities, in any situation, even simple, can be correctly completed.
47 1. ❑
48 2. ❑ The subject is capable of undertaking very simple non-routine actions such as
49 planning an unusual but simple journey, changing a battery, charging the battery of a
50 new acquisition, etc.
51 3. ❑
52 4. ❑ The subject is capable of carrying out more complex non-routine activities.
53 5. ❑
54 6. ❑ The subject is capable of a high level of achievement in complex, non-routine
55 situations, such as Do It Yourself (DIY) home improvement jobs that involve the use of
56
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 Clinical Rehabilitation Page 18 of 35

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2
3 multiple tools and materials, creating a website, or organizing an event such as a trip
or an exhibit.
4
5 7. ❑ Cannot be assessed
6
7 3 - Learning abilities. Generally, learning can be divided into two main categories: one that
8 concerns general knowledge (learning new facts with regards to an interest: history, art,
9 animals, the highway code, etc.) and one that concerns learning a skill (changing a punctured
10 tire, knowing how to cook, etc.). However, both types of learning are important for determining
the potential for progress or adaptation to a new environment. Consequently, both types of
11
learning are considered simultaneously here.
12
13
14 0. ❑ The subject never manages to acquire new knowledge or learn a new skill, even as
15 simple as starting a washing machine cycle or working a microwave.
16 1. ❑
17 2. ❑ The subject is capable of acquiring new knowledge or skills, but it is a very slow,
18 limited process and/or requires intense and lengthy support.
19 3. ❑
Fo
20 4. ❑ The subject is capable of acquiring new knowledge or skills in certain areas, but
21 progress can easily be stunted and/or they are slower than what could be expected.
22 5. ❑
23 6. ❑ The subject is capable of excellent learning acquisitions (such as learning a new
rP

24 language, becoming a good chess player, or reaching a good computing level) even if
25 he/she does not put it to use for improving social integration.
26 7. ❑ Cannot be assessed
ee

27
28 4 - Ability to maintain attention and memorize. This question relates to basic cognitive
29 functions such as orienting and maintaining attention, not losing track of a discussion, of a
rR

30 television program, of a book, etc., and being capable of summarizing it in an adapted

31 manner. These difficulties are often very important in people presenting a severe mental
32 illness/a psychiatric disability and are often under-estimated by the individual’s immediate
circle. Naturally the interest held for the subject matter has an impact on attentional levels;
ev

33
however, the motivation factor will be assessed in the next category and so must not be taken
34 into account here. As before, the subject’s highest level of capacity must be used to score.
35
36
iew

37 0. ❑ The subject cannot maintain their attention for more than a few seconds, such that
38 all instructions, even simple ones, must be repeated because they are instantly
forgotten.
39
1. ❑
40
41 2. ❑ The subject manages to maintain their attention for a few minutes on an activity
(reading a newspaper article, even a short one, watching a television program, etc.)
42
but has a tendency to lose track of it and/or does not manage to make an even basic
43 summary of it.
44 3. ❑
45
4. ❑ The subject manages to maintain their attention adequately in front of a movie or
46 television program, or reading a text, but is evidently fatigued by it and cannot
47 memorize all of its the relevant information.
48 5. ❑
49 6. ❑ The subject has no significant/noteworthy difficulty in maintaining their attention or
50 memorizing, at least in situations in which he/she is motivated to use these abilities.
51 7. ❑ Cannot be assessed.
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3 B. Motivation
4
5 5 - Difficulty initiating a basic action, referring to fundamental daily actions such as getting up,
6 making one’s bed, taking out the rubbish, going on an errand, etc. The general lifestyle of the
7 subject must be taken into account with regards to what he/she would be logically expected to
8 do spontaneously. The amount of stimulation necessary for these actions to be undertaken
9 must also be taken into consideration.
10
11 0. ❑ The difficulty in initiating a task has a considerable impact on daily life, and/or
12 constant help or stimulation is necessary in order for basic needs to be globally
13 satisfied.
14 1. ❑
15 2. ❑ The subject is generally capable of satisfying basic needs of daily living, but his/her
16 difficulty to initiate tasks strongly impacts on their level of activity. The subject needs a
17 very high level of stimulation and/or gives the impression of significant susceptibility to
18 fatigue.
19 3. ❑
Fo
20 4. ❑ The subject is enterprising enough to face regular needs of daily life. However,
21 difficulties are nonetheless expressed in lack of initiative and perseverance and/or
attempts to get the task over with rapidly and/or by a need for important stimulation or
22
encouragement. The general impression remains that of significant susceptibility to
23
rP

fatigue.
24 5. ❑
25 6. ❑ The subject does not seem to have any specific difficulty with engaging in a task
26
ee

and pursuing it until the objective has been reached. On the whole, energy levels are
27 adequate.
28 7. ❑ Cannot be assessed
29
rR

30
6 - Difficulty in the anticipation of and involvement with a project, i.e. planning, starting, or
31
pursuing it, because of a lack of motivation, of energy, of enthusiasm, or an excessive
32 sensitivity to stress. This difficulty can be expressed in different ways – for example when the
ev

33 subject does not plan actions to reach the goals that they seemed to desire, or when any new
34 or unplanned situation is perceived as extremely difficult to manage or exhausting. This item
35 also evaluates to what extent some achievements are only possible with the support and
36
iew

encouragements of the immediate circle. The degree of relevance or social utility of the
37 subject’s projects are not to be taken into account.
38
39 0. ❑ The difficulty is such that any commitment to even a simple project (such as doing
40 some shopping with a close relation or occasionally participating in an adapted
41 activity) is impossible.
42 1. ❑
43 2. ❑ The subject is capable of making plans but only takes isolated and insufficient
44 steps to reach them, and severely lacks dynamism. The subject can have a tendency
45 to perceive any future action as being extremely difficult and thus can be prematurely
46 exhausted, and/or may not uphold commitments despite support from the immediate
47 circle
48 3. ❑
49 4. ❑ The subject is capable of taking real initiatives to attain goals but lacks
50 perseverance which often jeopardizes projects, even with support and
51 encouragement. The subject’s sensitivity to unplanned or difficult events often
52 compromises their capacity to carry out their project in full.
53 5. ❑
54 6. ❑ The subject does not seem to lack motivation, and demonstrates the capacity for
initiating actions in a coherent way with regards to their projects, and is able to
55
persevere even in the face of difficulties.
56
7. ❑ Cannot be assessed
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 Clinical Rehabilitation Page 20 of 35

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3 7 - Use of time. This item aims to evaluate time spent aimlessly, doing nothing in particular (such
4 as sleeping during the day, staying in bed or sitting without doing anything, staying in front of
5 the television or listening to music without paying attention to it, etc.)
6
7 0. ❑ The subject spends practically all day not doing anything.
8 1. ❑
9
2. ❑ The subject spends approximately half of the day doing nothing.
10
11 3. ❑
12 4. ❑ The subject spends too much time, but less than half of the day, doing nothing.
13 5. ❑
14 6. ❑ No signs of excessive inactivity (the inactivity does not exceed a normal amount of
15 time devoted to rest)
16 7. ❑ Cannot be assessed
17
18 8 - Curiosity. This item aims to evaluate to what extent the subject shows interest in his/her
19 environment and is present to the world and others. This comprises showing interest in the
Fo
20 world in which he/she lives in and questions asked in this respect. Curiosity can be expressed
21 by reading the news, by following certain current events, by enjoying staying informed on
22 societal issues, or staying informed about what happens to close relations or in one’s direct
environment. Obsessional fixed ideas, delusional or bizarre thoughts, and hallucinations are to
23
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be excluded.
24
25
26 0. ❑ Practically no curiosity or no curiosity whatsoever for one’s environment.
ee

27 1. ❑
28 2. ❑ Sporadic curiosity only reaching a certain extent but no follow-up thoughts or
29 actions.
rR

30 3. ❑
31 4. ❑ Some topics exist that foster curiosity, topics upon which the subject spends time
32 reflecting and makes an effort to know more about.
ev

33 5. ❑
34 6. ❑ Curiosity exists for multiple topics, with an obvious effort to get to know some of
35 them better (for example through reading, asking questions, gathering information,
36 observation, etc.)
iew

37 7. ❑ Cannot be assessed
38
39
40
41
42 C. Communication abilities and capacity to comprehend other people
43 9 - Cognitive empathy abilities. This item aims to evaluate the subject’s ability to understand
44 that others are different from him or herself – that they hold beliefs, desires, have intentions
45 that are their own – and the ability to take these differences into account. Thus it is an
46 evaluation of the subject’s ability to see the world through another’s eyes, to understand
47 someone else’s point of view, to put themselves in their shoes, and to take this understanding
48 of others into account when relating or communicating with them.
49
50 0. ❑ The subject is incapable of putting themselves in another’s shoes.
51 1. ❑
52 2. ❑ The subject is very limited in their ability to put themselves in another’s shoes.
53 He/She can sometimes understand another’s point of view but only intermittently, or
54 when certain codes have been firmly established beforehand (e.g. knowing that a
55 close relative is making a joke, even if the joke itself is not understood).
56 3. ❑
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Page 21 of 35 Clinical Rehabilitation

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3 4. ❑ The subject can regularly put themselves in someone else’s shoes. However,
4 mistakes are often made and/or it remains moderately difficult to put this knowledge to
5 good use during the interaction.
6 5. ❑
7 6. ❑ The subject spontaneously takes into account the point of view of others in most
8 cases. The subject can bear in mind that others may not have the same information or
views as him or herself and can use this knowledge to improve communication or on
9
the contrary, can take advantage of this information for personal benefit.
10
7. ❑ Cannot be assessed.
11
12
13 10 - Emotional empathy abilities. This item aims to assess a person’s ability to be sensitive to
14 someone else’s emotions, to perceive them and take them into consideration, to understand
that each person can have their own emotions, to be understanding and capable of tact and
15
respect.
16
17
18 0. ❑ The subject is not capable of perceiving someone else’s emotions and of reacting
19 to them with empathy.
Fo
20 1. ❑
21 2. ❑ The subject can sometimes perceive another person’s emotions but generally
22 seems indifferent or relatively uncaring about them.
23 3. ❑
rP

24 4. ❑ The subject regularly expresses their sensitivity to other people’s emotions. They
25 can sometimes demonstrate warmth and/or can show that they care for what the other
26 person is feeling.
ee

27 5. ❑
28 6. ❑ The subject can instinctively sense what another person is feeling, can
29 spontaneously take into consideration their emotions and modulate their attitude,
rR

behavior, or communication in response. The subject is capable of showing warmth,

30
tolerance, understanding, can perceive when someone is moved or embarrassed,
31 and/or can be tactful.
32 7. ❑ Cannot be assessed.
ev

33
34
35
36
iew

11 - Ability to identify social roles and to understand the meaning of social situations. This
37 item refers to the ability to identify and differentiate social roles in a given situation. It also
38 refers to the ability to identify the way these social roles influence the behaviour of those
39 involved (such as the ability to recognise that someone is in a position of authority and
40 understand the basis for this position; the ability to make an assessment of the friendly attitude
of someone in a customer services job; the ability to understand who to ask for information or
41
help relative to their job or their access to certain information, etc).
42
0. ❑ The subject is incapable of analyzing and understanding social situations.
43
44 1. ❑
45 2. ❑ The subject is capable of identifying certain simple or stereotypical social situations,
but nonetheless does not manage to understand the roles held by people in this
46
situation.
47
3. ❑
48
4. ❑ The subject is capable of identifying common social situations and of having a
49
moderate degree of comprehension of the different social roles of those involved.
50
5. ❑
51
6. The subject had no difficulty in getting their bearings in social interactions nor in
52 understanding the roles and motives of each individual involved, in a wide range of
53 social situations.
54 7. ❑ Cannot be assessed.
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3 D. Awareness of one’s own abilities and limitations
4 This item is comprised of two levels that must be distinguished:
5 - Firstly, the ability to correctly assess one’s own capacities, the quality of one’s undertakings, and
6 one’s limitations in different areas of life;
7
- Secondly, the ability to take this personal assessment into consideration in order to request
8 assistance, whether the assistance is needed in daily life, activities, relations with others, or health.
9
10 Even though these two levels are highly interdependent, they can be differentially affected in certain
situations pertaining to psychiatric disability.
11
12 The question of work, often at the forefront of the preoccupations and demands of people with
13 disabilities, must not be taken into account for this category, because of the potentially biased
14 influence of what is perceived as the social norm and/or of the mourning process potentially involved
in the comparison of “what could have been” without the mental illness.
15
16
17 12 - Ability to assess one’s own capacities and to recognize one’s limitations
18
19
0. ❑ The subject has no awareness of their own difficulties and shortcomings, be it in
Fo
20
daily life, social life, etc. The gap between what the subject says he/she can do and
21
reality is significant.
22
1. ❑
23
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2. ❑ The subject has a limited awareness of his or her difficulties. The subject
24
overestimates their level of independence and/or is convinced of having considerable
25 abilities and/or does not recognize certain of his or her maladaptive behaviors.
26 3. ❑
ee

27 4. ❑ The subject is capable of perceiving their own difficulties or limitations in a number

28 of areas but has a tendency to minimize them, exaggerate them or both
29 5. ❑
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30 6. The subject has a true understanding of their difficulties or the quality of their
31 undertakings and is capable of describing precisely what they can do, as well as the
32 areas, actions, or situations for which they present difficulties.
ev

33 7. ❑ Cannot be assessed
34
35 13 - Ability to ask for help and to cooperate with care.
36
iew

37
38 8. ❑ The subject is incapable of asking for assistance, whether in daily life or in terms of
39 their health. Typically, the subject is reluctant or expresses a total lack of
understanding in the face of an offer of assistance or care.
40
9. ❑
41
10. ❑ The subject does not spontaneously ask for any assistance but can passively
42
accept or intermittently agree to some assistance in daily living or for certain
43 treatments. In other cases, the subject is capable of making certain requests for
44 assistance but not maintaining them in a stable manner.
45 11. ❑
46 12. ❑ The subject is capable of asking for assistance, expressing expectations (such as
47 of being accompanied in a stressful situation or being stimulated in order to start the
48 day) and/or is consistently cooperative for certain treatment endeavors.
49 13. ❑
50 14. ❑ The subject is capable of asking for assistance in an appropriate manner, regularly
51 uses strategies or organises themselves in order to compensate for their main
52 difficulties (such as paying for an aid to help with cleaning their home or leaning on
53 the help of the immediate circle to be able to start the day), and collaborates actively
54 in their necessary care.
55 15. ❑ Cannot be assessed
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2
3
4 Echelle d’Evaluation des Processus cognitifs impliqués dans le Handicap
5 Psychique dans la schizophrenie (Version famille ou entourage)
6
7
8
9 Introduction et principes généraux de cotation :
10
11
12 Cet instrument repose sur la description de l’expression dans la vie quotidienne de
13 dysfonctionnements supposés impliqués dans la « production » de la situation de handicap psychique.
14
15 Ces dysfonctionnements sont connus pour être fréquemment observés chez les personnes souffrant
16 de trouble schizophrénique ou apparenté, pour leur être assez spécifiques et pour avoir un
17 retentissement important dans leur vie quotidienne.
18
19
Fo
20 Ils sont regroupés en 4 rubriques :
21 - capacités cognitives,
22 - motivation,
23 capacités de communication et de compréhension des autres,
rP
-
24 - capacités d’autoévaluation et de prise en compte de ses limites.
25
26 Chacune de ces rubriques se décline en plusieurs items (13 au total) qui comportent 7 niveaux de
ee

27 gravité de 0 (difficulté extrêmement sévère) à 6 (pas de difficulté).

28 La cotation doit se faire en choisissant, à partir des exemples donnés, le degré de difficulté le plus
29 proche de celui présenté par la personne. Les degrés 1, 3 et 5 ne comportent pas d’exemple et
rR

30 doivent être retenus lorsque le niveau de difficulté de la personne se situe entre les deux degrés qui
31 l’encadrent.
32
ev

33 Attention, vous ne devez choisir qu’une seule réponse par item.

34
35
36
iew

37 Il est habituel chez les personnes souffrant de handicap psychique que leurs capacités soient
38 fluctuantes, d’un jour à l’autre ou en fonction du contexte, du degré de stress, etc.
39
Le principe retenu ici est de retenir la cotation qui correspond au meilleur niveau de réalisation
40 ou de capacité de la personne et en particulier de se situer dans le domaine dans lequel la
41 personne réussit le mieux.
42
43
44 La raison de ce choix tient à l’orientation fonctionnelle de l’évaluation : il s’agit de connaître les
45 potentialités de la personne et les possibilités de mobilisation, afin d’aider à penser les actions utiles,
46 par exemple sur son environnement et son accompagnement.
47
48 D’autre part, compte tenu de la relation au monde souvent singulière de ces personnes, leurs
49 compétences peuvent s’exprimer dans des domaines qui ne sont pas considérés comme prioritaires
50 au vu d’une certaine « norme sociale ». Si tel est le cas, ces compétences doivent être prises en
51 compte dans l’évaluation.
52
53
54
55 L’évaluation doit porter sur les dernières semaines ou le dernier mois.
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3 Il peut arriver que vous n’ayez pas accès aux informations permettant de répondre à l’une des
rubriques (par exemple si vous ne vivez pas au quotidien avec votre proche). Dans ce cas, vous
4
pouvez répondre en cochant la case : ❑ Non évaluable.
5
6 Dans tous les autres cas, il faut choisir le degré de gravité le plus proche des difficultés que vous
7 avez observées.
8
9
10
A - Capacités cognitives
11
12 Cette rubrique concerne la manière dont les aptitudes cognitives (capacités d’organisation, adaptation
13 au contexte de la situation, attention, mémorisation) interfèrent avec les activités de la vie quotidienne.
14 Pour l’ensemble des items ci-dessous, deux critères doivent être respectés :
15 - le score retenu doit se baser sur le meilleur niveau de réalisation atteint, même si la personne a
16 bénéficié d’une stimulation extérieure (encouragement, réassurance, mise en situation, etc.) pour y
17 parvenir.
18
- les exemples de situations retenus ne doivent pas impliquer directement d’interaction avec
19 autrui, afin d’éviter la confusion avec les difficultés à entrer en relation avec autrui qui concernent une
Fo
20 autre rubrique.
21
22
23 1 - Capacité à s’organiser dans une activité habituelle c'est-à-dire qui s’inscrit dans une
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24 certaine routine de la vie de la personne (par exemple, faire une course habituelle, préparer un
repas, etc.)
25
26
ee

27 0. ❑ La difficulté à s’organiser concerne toutes les actions simples de la vie quotidienne.

28
1. ❑
29
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30 2. ❑ La personne est capable de réaliser des actes quotidiens très simples (faire une course,
31 faire cuire un steak) mais ne s’adapte pas aux changements contextuels banals (les horaires
32 d’ouverture du magasin, remplacer la poêle habituelle qui n’est pas disponible par une autre)
et/ou ne parvient pas à faire deux choses en même temps (faire une autre course en même
ev

33
temps que la première, préparer de la purée servie en même temps que le steak…).
34
35 3. ❑
36
iew

4. ❑ Le sujet est capable de réaliser des activités quotidiennes plus complexes et qui impliquent
37 la possibilité de faire deux choses en même temps, dans la mesure où rien ne vient perturber
38 leur déroulement (par exemple, préparer un repas de telle sorte que chaque plat soit prêt à
39 servir au bon moment et comportant un plat avec son accompagnement et un dessert ou une
40 entrée).
41 5. ❑
42
6. ❑ Le sujet est capable de réaliser tous les actes routiniers de la vie quotidienne, y compris
43
lorsqu’ils impliquent de nombreuses séquences successives, même si ce n’est possible qu’au
44 prix d’une stimulation régulière et importante par l’entourage.
45
46 7. ❑ Non évaluable.
47
48
2 - Capacité à s’organiser dans une activité inhabituelle c'est-à-dire qui correspond à une
49
situation nouvelle pour la personne. Cet item doit porter sur les capacités que la personne parvient
50 à mettre en œuvre dans une situation nouvelle ou inhabituelle, (par exemple, faire un trajet nouveau
51 en voiture ou en transport en commun ; réparer ou faire réparer un objet, préparer un repas si elle ne
52 le fait pas habituellement, etc.). Il ne s’agit pas de la capacité à acquérir des compétences nouvelles
53 qui est abordée dans l’item suivant.
54 Attention, il ne s’agit pas d’évaluer le degré de pertinence de ces réalisations par rapport à ce qui est
55 socialement attendu ou utile.
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3 0. ❑ Aucune situation nouvelle, même simple, ne peut être correctement réalisée.
4 1. ❑
5
2. ❑ La personne est capable de réaliser des actes non routiniers très simples comme planifier
6 un trajet simple mais inhabituel, changer une pile ou charger la batterie d’un objet nouveau,
7 etc.
8
9 3. ❑
10 4. ❑ Le sujet est capable de réaliser des activités non routinières plus complexes.
11 5. ❑
12
13 6. ❑ Le sujet est capable d’un très bon niveau de réalisation dans des situations non routinières
14 complexes comme entreprendre un travail de bricolage impliquant l’utilisation de plusieurs
outils et de divers matériaux, réaliser un site internet ou organiser un évènement comme une
15
exposition ou un voyage.
16
17 7. ❑ Non évaluable
18
19
3 – Capacités d’apprentissage. On considère qu’il existe deux grands types d’apprentissage : ceux
Fo
20 qui concernent les connaissances générales (acquérir de nouvelles connaissances sur tel ou tel
21 domaine, histoire, art, vie de animaux, code de la route, etc.) et les apprentissages de savoir faire
22 (changer un pneu crevé, savoir faire la cuisine, etc.). Cependant quel que soit le type de capacité
23
rP
d’apprentissage, ces compétences sont importantes pour anticiper le potentiel d’évolution ou
24 d’adaptation à un nouvel environnement. Les deux types d’apprentissage sont ici pris en compte
25 simultanément.
26
ee

27
0. ❑ La personne ne parvient jamais à acquérir une nouvelle connaissance ou une nouvelle
28
habileté même aussi simple que mettre en route une machine à laver ou savoir faire marcher
29
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un micro-onde.
30
31 1. ❑
32 2. ❑ La personne est capable d’acquérir de nouvelles connaissances ou capacités mais de
ev

33 manière très lente et limitée et/ou au prix d’une aide intense et durable
34
3. ❑
35
36 4. ❑ Le sujet est capable de capacités d’apprentissage réelles dans certains domaines mais les
iew

37 progrès sont facilement remis en cause et/ou sont plus lents qu’on l’attendrait.
38 5. ❑
39
6. ❑ Le sujet est capable d’excellentes capacités d’apprentissage – même si il ne les met pas au
40 service d’une meilleure insertion sociale - comme apprendre une langue étrangère, devenir un
41 bon joueur d’échec ou acquérir un bon niveau en informatique.
42
7. ❑ Non évaluable
43
44
45
46
4 - Capacité à fixer son attention et à mémoriser. Cet item porte sur les capacités cognitives de
47
base que sont le fait de pouvoir fixer son attention, ne pas perdre le fil d’une discussion, d’une
48 émission de télévision, d’une lecture, etc., et être capable d’en faire un résumé adapté. Ces difficultés
49 sont souvent très importantes chez les personnes souffrant d’un handicap d’origine psychique et
50 largement sous-estimées par leur entourage. L’intérêt que la personne porte à une situation influe
51 bien sûr sur son niveau d’attention ; cependant, ce facteur (la motivation) est évalué dans la rubrique
52 suivante et ne doit pas être pris en compte. Il faut donc coter en fonction du meilleur niveau de la
53 personne.
54
55
0. ❑ La personne ne peut fixer son attention plus de quelques secondes de telle sorte que toute
56
consigne même simple doit lui être répétée car elle les oublie aussitôt.
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2
3 1. ❑
4 2. ❑ La personne parvient à fixer son attention quelques minutes sur une activité (lire un article
5 de journal même court, regarder une émission de télévision, etc.) mais a tendance à perdre le
6 fil et/ ne parvient pas à en faire un résumé même sommaire ou incomplet.
7 3. ❑
8
9 4. ❑ La personne est capable de fixer son attention correctement le temps de voir un film ou
une émission, de lire un texte mais est à l’évidence fatigable et ne retient pas toujours les
10
informations principales.
11
12 5. ❑
13 6. La personne n’a pas de difficulté notable pour fixer son attention et mémoriser, du moins dans
14 les situations dans lesquelles elle est motivée pour utiliser ses capacités.
15
7. ❑ Non évaluable
16
17
18
19
Fo
20
B – Motivation
21
22
23
rP
5 - Difficulté à initier une action de base, c'est-à-dire les gestes élémentaires de la vie quotidienne
24 comme se lever, faire son lit, descendre la poubelle, faire une course, etc. Il convient de tenir
25 compte du mode de vie de la personne et de ce qu’il serait logique qu’elle fasse spontanément et de
26 prendre en compte l’importance des stimulations nécessaires pour que ces actions soient réalisées.
ee

27
28 0. ❑ La difficulté à initier une action retentit de manière considérable sur la vie quotidienne et/ou
29 une stimulation ou une aide constante est nécessaire pour que les besoins fondamentaux
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30 soient globalement satisfaits.

31 1. ❑
32
2. ❑ Le sujet est globalement capable de faire face aux besoins fondamentaux de la vie
ev

33
34 quotidienne, mais sa difficulté à se mettre en route retentit très fortement sur son niveau
d’activité. Il a besoin d’un niveau de stimulation très élevé et/ou donne l’impression d’une
35
extrême fatigabilité.
36
iew

37 3. ❑
38 4. ❑ Le sujet est suffisamment entreprenant pour faire face aux besoins courants de la vie
39 quotidienne. Ses difficultés se manifestent par un manque d’initiative et de persévérance et/ou
40 par le fait qu’il a tendance à se débarrasser au plus vite de ce qu’il a à faire et/ou par un
41 besoin de stimulation ou d’encouragement important. L’impression générale reste celle d’une
42 importante fatigabilité.
43 5. ❑
44
6. ❑ Le sujet ne semble pas avoir de difficulté particulière pour s’engager dans une activité et
45 persévérer jusqu’à ce que son but soit atteint. Globalement son niveau d’énergie semble
46 correct.
47
48 7. ❑ Non évaluable
49
50
51
52
53
54 6 - Difficulté à anticiper et à s’impliquer dans un projet, à entreprendre ou à persévérer, du fait
55 d’un manque de motivation, de dynamisme, d’enthousiasme ou d’une excessive sensibilité au
56 stress. Cela peut correspondre au fait que la personne ne met rien en œuvre pour des objectifs
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3 qu’elle semble souhaiter ou au fait que toute situation nouvelle ou imprévue est ressentie comme
extrêmement difficile ou épuisante. Cet item évalue également dans quelle mesure certaines
4
réalisations ne sont possibles que grâce au soutien et aux encouragements de l’entourage. Le
5 degré de pertinence ou d’utilité sociale des projets dans lesquelles s’implique la personne n’est pas
6 à prendre en compte.
7
8
9 0. ❑ La difficulté est telle que tout engagement dans un projet même simple (comme faire
quelques achats avec un proche ou participer ponctuellement à une activité dans un
10
environnement protégé) est impossible.
11
12 1. ❑
13 2. ❑ Le sujet est capable de faire quelques projets mais ne met en œuvre que de rares actions
14 isolées pour y parvenir et manque gravement de dynamisme. Il peut avoir tendance à
15 anticiper toute action nouvelle comme extrêmement difficile de telle sorte qu’il parait épuisé
16 d’avance et/ou ne tient pas ses engagements, le cas échéant malgré le soutien de son
17 entourage.
18 3. ❑
19
4. ❑ Le sujet est capable de faire preuve d’initiatives pour atteindre ses objectifs mais manque
Fo
20 de persévérance ce qui compromet souvent ses projets, même lorsqu’il est soutenu et
21 encouragé. Sa sensibilité aux évènements imprévus ou difficiles met souvent en cause sa
22 capacité à entreprendre.
23
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5. ❑
24
25 6. ❑ Le sujet ne semble pas manquer notablement de motivation et se montre capable d’initier
26 des actions de manière suivie et cohérente avec ses projets et de persévérer même lorsque
ee

27 des difficultés surviennent.

28 7. ❑ Non évaluable
29
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30
31 7 – Utilisation du temps. Cet item a pour but de coter le temps passé sans but précis, à ne rien faire
32 (comme dormir dans la journée, rester au lit ou assis sans rien faire, rester devant la télévision ou
écouter de la musique sans y faire attention, etc.).
ev

33
34
35 0. ❑ Le sujet passe toute sa journée ou presque à ne rien faire.
36
iew

1. ❑
37
38 2. ❑ Le sujet passe à peu près la moitié de ses journées à ne rien faire.
39 3. ❑
40
4. ❑ Le sujet passe trop de temps, mais moins de la moitié de ses journées, à ne rien faire.
41
42 5. ❑
43 6. ❑ Absence d'inactivité excessive (l'inactivité ne dépasse pas le temps normal nécessaire au
44 repos).
45
7. ❑ Non évaluable
46
47
48
49
50
51
52
53 8 – Curiosité. Cet item a pour but de coter dans quelle mesure le sujet s’intéresse à son
54 environnement, est présent au monde et aux autres, c'est-à-dire s'intéresse au monde dans lequel il
55 vit et se pose des questions à ce propos. Sa curiosité peut s’exprimer par la lecture de la presse,
56 par le suivi de certaines questions d’actualité, par une tendance à s’informer sur des faits de société
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3 ou sur des faits concernant son entourage ou son environnement. Il convient d'exclure les idées
fixes obsessionnelles, délirantes ou bizarres et les hallucinations.
4
5
6 0. ❑ Aucune ou quasi aucune curiosité pour son environnement.
7 1. ❑
8
9 2. ❑ Une certaine curiosité sporadique mais non suivie en pensée ou en actes.
10 3. ❑
11 4. ❑ Quelques sujets de curiosité, sur lesquels le sujet passe du temps à réfléchir et fait un
12 certain effort pour mieux les connaître.
13
14 5. ❑
15 6. ❑ Curiosité pour de nombreux sujets avec un effort évident pour mieux connaître quelques-
16 uns d'entre eux (par exemple par la lecture, le fait de poser des questions, se renseigner,
17 observer de façon méthodique, etc.)
18 7. ❑ Non évaluable
19
Fo
20
21
22
23
rP

C - Capacités de communication et de compréhension des autres

24
25
26 9 – Capacités d’empathie cognitive. Cet item a pour but d’évaluer la capacité de la personne à
ee

27 comprendre que les autres sont différents d’elle-même - qu’ils ont des croyances, des désirs, des
28 intentions qui leur sont propres – et à tenir compte de ces différences. Il s’agit donc d’évaluer la
29 capacité de la personne à adopter le point de vue de l’autre, à se mettre à sa place et à tenir compte
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30 de cette compréhension dans sa relation et sa communication avec autrui.

31
32 0. ❑ Le sujet est incapable de se mettre à la place des autres.
ev

33 1. ❑
34
35 2. ❑ Le sujet est très peu capable de se mettre à la place des autres. Il peut parfois comprendre
36 la position d’autrui mais de manière sporadique ou lorsque des « codes » ont préalablement
iew

été solidement établis (par exemple, savoir qu’un proche plaisante sans pour autant
37
comprendre le fond de la plaisanterie).
38
39 3. ❑
40 4. ❑ Le sujet parvient plus régulièrement à se mettre à la place des autres. Cependant il commet
41 souvent des erreurs et/ou ne parvient que modérément à tenir compte de cette
42 compréhension dans sa relation ou sa communication avec autrui.
43 5. ❑
44
45 6. ❑ Le sujet prend spontanément en considération la situation d'autrui dans la plupart des cas.
46 Il peut prendre en compte le fait qu’autrui n’a pas les mêmes informations ou les mêmes
croyances et en tenir compte pour l’aider ou au contraire en tirer des bénéfices pour lui-
47
même.
48
49 7. ❑ Non évaluable
50
51
52
10 Capacités d’empathie émotionnelle. Cet item a pour but d’évaluer la capacité de la
53
personne à se montrer sensible aux émotions d’autrui, à les percevoir et à en tenir compte, à
54 comprendre qu’autrui peut avoir des émotions qui lui sont propres, à se montrer compréhensif et
55 capable de tact et de respect.
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3 0. ❑ Le sujet est incapable de percevoir les émotions d’autrui et d’y réagir émotionnellement.
4 1. ❑
5
2. ❑ Le sujet perçoit parfois l’émotion d’autrui mais se montre globalement peu chaleureux ou
6 indifférent dans la plupart des situations.
7
8 3. ❑
9 4. ❑ Le sujet manifeste plus régulièrement sa sensibilité aux émotions d’autrui. Il peut se montrer
10 parfois chaleureux ou sembler se soucier de ce que l’autre ressent.
11 5. ❑
12
13 6. ❑ Le sujet peut ressentir intuitivement ce que l’autre ressent, prend spontanément en
14 considération les émotions d’autrui et en tient compte dans son attitude, son comportement ou
sa communication. Il est capable de se montrer chaleureux, tolérant et compréhensif, de
15
percevoir lorsque l’autre est ému ou gêné et/ou de faire preuve de tact.
16
17 7. ❑ Non évaluable
18
19
11 – Capacités à identifier les rôles sociaux, la signification des situations sociales. Cet
Fo
20 item concerne la capacité à identifier dans une situation donnée les principaux rôles sociaux et la
21 manière dont ces rôles sociaux influencent le comportement de ceux qui les occupent (comme
22 reconnaître une position d’autorité et sur quoi se fonde cette position d’autorité, identifier l’attitude
23
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aimable de quelqu’un qui exerce un métier de service, comprendre à qui demander telle ou telle
24 information ou aide du fait de son métier ou de son accès à certaines connaissances, etc.)
25
26 0. ❑ Le sujet est incapable d’identifier et de comprendre les situations sociales.
ee

27
28 1. ❑
29 2. ❑ Le sujet est capable d’identifier certaines situations sociales simples et stéréotypées sans
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30 pour autant bien comprendre le rôle joué par l’autre dans ces situations sociales.
31 3. ❑
32
4. ❑ Le sujet est capable d’identifier les situations sociales les plus courantes et d’avoir un
ev

33
certain degré de compréhension des différents rôles sociaux
34
35 5. ❑
36
iew

6. ❑ Le sujet n’a aucune difficulté pour se repérer dans les interactions sociales et pour
37 comprendre les motifs de chacun dans les situations les plus diverses.
38
39 7. ❑ Non évaluable
40
41
42
43 D – Capacité d’autoévaluation de ses capacités et de prise en compte de ses limites
44
45 Cet item implique deux niveaux qu’il conviendra de distinguer :
46
- le premier est la capacité à évaluer correctement ses capacités, la qualité de ses réalisations
47
et ses limites dans différents domaines de la vie ;
48 - le second niveau concerne le fait de tenir compte de cette évaluation pour demander de l’aide,
49 que ce soit dans le domaine de la vie quotidienne, des activités, des relations à autrui ou de la
50 santé.
51 Même si ces deux niveaux sont fortement interdépendants, ils peuvent être différemment atteints dans
52 certaines situations de handicap psychique.
53 La question du travail, souvent au premier plan de la demande et des préoccupations des personnes
54 handicapées, ne doit pas ici être prise en compte car elle est trop parasitée par la problématique
55 d’une certaine norme sociale et/ou du deuil par rapport à ce qui aurait été sans la maladie.
56
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3 12 – Capacité à savoir évaluer ses capacités et à reconnaître ses limites
4
5 0. ❑ Le sujet n’a aucune conscience de ses difficultés et de ses incapacités dans la vie
6 quotidienne, sociale, etc. L’écart entre ce que la personne dit faire ou savoir faire et la réalité
7 est considérable.
8 1. ❑
9
10 2. ❑ Le sujet n’a qu’une conscience limitée de ses difficultés. Il est convaincu d’avoir un degré
d’autonomie supérieur à celui qui est le sien en réalité et/ou d’avoir des capacités importantes
11
et/ou méconnait certains comportements très inadaptés.
12
13 3. ❑
14 4. ❑ Le sujet est capable dans un certain nombre de domaines de percevoir ses difficultés ou
15 ses limites mais a tendance à les minimiser ou au contraire à les amplifier, voire les deux à la
16 fois.
17 5. ❑
18
19 6. ❑ Le sujet a une réelle connaissance de ses difficultés ou de la qualité de ses réalisations et
Fo
20 se montre capable de décrire avec précision ce qu’il sait faire et les domaines, actions, et
situations dans lesquels il se trouve en difficulté.
21
22 7. ❑ Non évaluable
23
rP

24
25 13 – Capacité à savoir demander de l’aide en cas de besoin et à coopérer aux soins
26
ee

27 0. ❑ Le sujet se montre incapable de demander de l’aide, que ce soit dans le domaine de la vie
28 quotidienne ou de sa santé. Typiquement, il se montre réticent ou manifeste une totale
29 incompréhension par rapport à toute proposition d’aide ou de soin.
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30 1. ❑
31
2. ❑ Le sujet ne demande à peu près rien spontanément mais peut accepter passivement ou de
32 manière intermittente quelques aides dans la vie quotidienne et/ou certains soins. Dans
ev

33 d’autres cas, le sujet est capable de formuler quelques demandes d’aides mais pas de les
34 maintenir de manière stable.
35
3. ❑
36
iew

37 4. ❑ Le sujet est capable de demander de l’aide, d’exprimer des attentes (comme être
38 accompagné dans des situations stressantes, ou être stimulé pour parvenir à se mettre en
39 route) et/ou se montre coopérant de manière stable pour certains soins.
40 5. ❑
41
6. ❑ Le sujet est capable de demander de l’aide de manière adaptée, utilise régulièrement des
42 stratégies ou a mis en place des organisations pour pallier ses principales difficultés (comme
43 financer une aide pour le ménage de son domicile ou s’appuyer sur l’aide de son entourage
44 pour démarrer la journée) et collabore de manière active aux soins qui lui sont nécessaires.
45
7 ❑ Non évaluable
46
47
48
49
50
51
52
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3 Supplement Information 2. Battery of neurocognitive tests
4
5 Experienced psychologists administered the tests in a fixed order. The standardised test
6 battery evaluated seven neurocognitive domains. Six of these domains were those
7 recommended for inclusion in cognitive test batteries for patients with schizophrenia,
8 according to a consensus of international experts:(1)
9 - processing speed, assessed using the digit symbol coding subtest from the Wechsler Adult
10 Intelligence Scale (WAIS) version III(2) or the coding subtest from the WAIS-IV,(3) the Trail
11
Making Test part A,(4) and semantic and phonemic fluencies;(5)
12
13
- attention/vigilance, assessed using the identical pairs version of the Continuous Performance
14 Test(6) and the alertness, flexibility, divided attention, and go/no-go tests of the Test of
15 Attentional Performance;(7)
16 - working memory, assessed using the digit span, arithmetic, and letter-number sequencing
17 WAIS subtests;
18 - verbal memory, assessed using the California Verbal Learning Test(8);
19 - visual memory, assessed using the doors test(9); and
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20 - reasoning and problem solving, using matrix reasoning and picture completion (WAIS) for
21 perceptual reasoning and similarities (WAIS) for verbal reasoning.
22 The battery also investigated a seventh neurocognitive dimension, executive
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functioning, which was assessed with the TMT part B and the Multiple Errands Test.(10)
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Raw scores were transformed to demographically corrected standardised (z) scores based on
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normative data for each test.(11–14) Patients with missing data for more than three cognitive
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27 domains were excluded from the analysis, according to recommendations (15).

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29 REFERENCES
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31 1. Green MF, Nuechterlein KH, Gold JM, Barch DM, Cohen J, Essock S, et al.
32 Approaching a consensus cognitive battery for clinical trials in schizophrenia: the
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33 NIMH-MATRICS conference to select cognitive domains and test criteria. Biol

34 Psychiatry. 2004;56(5):301 7.
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36
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2. Wechsler D. WAIS-III, Wechsler adult intelligence scale: Administration and scoring

37 manual. Psychological Corporation; 1997.
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39 3. Wechsler D, Coalson DL, Raiford SE. WAIS-IV: Wechsler adult intelligence scale.
40 Pearson San Antonio, TX; 2008.
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42 4. Reitan RM. Validity of the Trail Making Test as an indicator of organic brain damage.
43
Percept Mot Ski. 1958;8(3):271 6.
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5. Lezak MD. Neuropsychological assessment. Oxford University Press, USA; 2004.
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6. Cornblatt BA, Risch NJ, Faris G, Friedman D, Erlenmeyer-Kimling L. The Continuous
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49 Performance Test, identical pairs version (CPT-IP): I. New findings about sustained
50 attention in normal families. Psychiatry Res. 1988;26(2):223 38.
51
52 7. Zimmermann P, Fimm B. A test battery for attentional performance. In: Applied
53 neuropsychology of attention. ed M Leclercq, P Zimmermann. London: Psychology
54 Press; 2002. p. 110 51.
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3 8. Delis DC. CVLT-II: California verbal learning test: adult version. Psychological
4 Corporation; 2000.
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6 9. Baddeley AD, Emslie H, Nimmo-Smith I. Doors and people: a test of visual and verbal
7 recall and recognition. Harcourt Assessment; 2006.
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9 10. Shallice T, Burgess PW. Deficits in strategy application following frontal lobe damage
10 in man. Brain. 1991;114(2):727 41.
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12 11. Wechsler D. WAIS III: Echelle d’intelligence pour adultes. 1997;
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14 12. Wechsler D. WAIS-IV: échelle d’intelligence de Wechsler pour adultes. Pearson; 2010.
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16 13. Poitrenaud J, Deweer B, Kalafat M, Van der Linden M. Adaptation en langue française
17 du California Verbal Learning Test. Paris: Les Editions du Centre de Psychologie
18 Appliquée; 2007.
19
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20 14. Godefroy O. La batterie GREFEX: données normatives. Fonctions exécutives et
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pathologies neurologiques et psychiatriques: Évaluation en pratique clinique. Marseille:
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Solal, 2008:231-52.
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24
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15. Reichenberg A, Harvey PD, Bowie CR, Mojtabai R, Rabinowitz J, Heaton RK, et al.
26 Neuropsychological function and dysfunction in schizophrenia and psychotic affective
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27 disorders. Schizophr Bull. 2009;35(5):1022 9.

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3 Supplement Information 3. Comparison of ECPDS score between patients with and without
4 clinically significant cognitive impairment
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6 In order to test the validity of the ECPDS to differentiate the degree of cognitive impairment
7 within individuals with schizophrenia, we have run a two-sided t-test comparing ECPDS
8 score between patients with and without clinically significant cognitive impairment (defined
9 as an average z-score more than 1 SD below the normative mean in two or more cognitive
10 domains). The variance was estimated separately for both groups and the Welch-Satterthwaite
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modification to the degrees of freedom was used (1).
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14 The mean ECPDS score was 25 (SD 6.5) for patient with clinically significant cognitive
15 impairment and 30.8 (SD 7.3) for patients without clinically significant cognitive impairment.
16 Psychiatric disability was significantly lower for patients without clinically significant
17 cognitive impairment compared with patients with clinically significant cognitive impairment
18 (t(72.4) = -3.9; p < 0.001).
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20 This result thus confirms the validity of the ECPDS to differentiate the degree of cognitive
21 impairment within individuals with schizophrenia
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1. Welch BL. The generalization of student’s’ problem when several different population
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variances are involved. Biometrika. 1947;34(1/2):28 35.
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3 Supplement Information 4. Associations between ECPDS score and the neuropsychological
4 performance in each of the seven cognitive domains
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6 We first have run Pearson correlations between ECPDS score and the average
7 neuropsychological performance within the seven different domains. The results are reported
8 in the table below.
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Cognitive domain r Statistic p
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12 Processing speed 0.22 t(95) = 2.2 0.031
13 Attention/vigilance 0.15 t(93) = 1.4 0.15
14 Working memory 0.25 t(90) = 2.5 0.016
15 Verbal memory 0.25 t(82) = 2.3 0.021
16 Visual memory 0.26 t(86) = 2.5 0.015
17 Reasoning and problem-solving 0.4 t(90) = 4.1 <0.001
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Executive functioning 0.27 t(86) = 2.6 0.011
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21 The correlations with ECPDS were significant for all cognitive domains except
22 attention/vigilance.
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25 We have defined a cognitive domain as impaired if the average z-score of cognitive variables
26 within this domain was lower than - 1 SD below the normative mean. We then have
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27 performed successive logistic regressions between cognitive impairment in a specific

28 cognitive domain as the dependent variable and ECPDS score as the independent variable.
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These logistic regressions were performed only for cognitive domains which significantly
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correlated with ECDPS, i.e. every domain except attention/vigilance. The results are reported
32 in the table below.
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34 Cognitive domain Coeff. Coeff. SD z p
35 Processing speed 0.07 0.03 2.2 0.026
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Working memory 0.06 0.03 1.9 0.063

37 Verbal memory 0.11 0.04 2.8 0.006
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Visual memory 0.06 0.03 1.9 0.056
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40 Reasoning and problem-solving 0.09 0.03 2.7 0.007
41 Executive functioning 0.1 0.04 3 0.003
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43 The logistic regressions showed significant associations between cognitive impairment and
44 ECPDS score for processing speed, verbal memory, reasoning and problem-solving, and
45 executive functioning.
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Finally, we have conducted receiver operating characteristic (ROC) curve analyses for the
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cognitive domains showing significant associations with ECPDS score in the previous logistic
51 regressions, i.e. processing speed, verbal memory, reasoning and problem solving, and
52 executive functioning. The results are presented in the table below.
53 The AUC was above the 0.7 threshold for verbal memory and executive functioning, meaning
54 a moderate validity of ECPDS to predict a cognitive impairment for these two domains. All
55 the AUC computed for the different cognitive domains were lower than the one obtained for
56 the whole cognitive battery (0.77).
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3 Cognitive domain AUC 95% CI Threshold Specificity Sensitivity
4 Processing speed 0.66 [0.55-0.77] 27 54.5 73.6
5 Verbal memory 0.71 [0.59-0.82] 30 79.5 57.5
6 Reasoning and problem- 0.69 [0.57-0.81] 27 58.3 67.6
7 solving
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Executive functioning 0.7 [0.59-0.81] 24 48.8 84.4
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11 The ROC curves for the four cognitive domains are plotted in the figures below.
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3 In conclusion, the validity of ECPDS was lower to discriminate impairment in specific
4 cognitive domains than a general cognitive impairment diagnosed with the whole
5 neuropsychological battery.
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