Neurocognitive deficits are often seen as core features of schizophrenia, and as primary determinants of poor functioning. Yet, our clinical observations suggest that individuals who score within the impaired range on standardized tests can reliably perform better in complex real-world situations, especially when performance is embedded within a positive socio-affective context.

We analyzed literature on the influence of non-neurocognitive factors on test performance in order to clarify their contributions.

We identified seven non-neurocognitive factors that significantly contribute to neurocognitive test performance: avolition, dysfunctional attitudes, effort, stress, negative emotions, asociality, and disorganized symptoms. We then proposed an alternative model based on dysfunctional (e.g. defeatist) attitudes and their consequences for motivation and sustained task engagement. We demonstrated that these factors account for substantial variance in negative symptoms, neurocognitive test performance, and functional outcomes. We then demonstrated that recovery-oriented cognitive therapy – which is derived from this alternative model and primarily targets dysfunctional beliefs – has been successful in the treatment of low functioning individuals with schizophrenia.

The contributions of neurocognitive impairments to poor real-world functioning in people with schizophrenia may be overstated in the literature, and may even be limited relative to non-neurocognitive factors. We offer suggestions for further research to more precisely quantify the contributions of attitudinal/motivation v. neurocognitive factors in schizophrenia.

Depression measures that include somatic symptoms may inflate severity estimates among medically ill patients, including those with cardiovascular disease.

To evaluate whether people receiving in-patient treatment following acute myocardial infarction (AMI) had higher somatic symptom scores on the Beck Depression Inventory–II (BDI–II) than a non-medically ill control group matched on cognitive/affective scores.

Somatic scores on the BDI–II were compared between 209 patients admitted to hospital following an AMI and 209 psychiatry out-patients matched on gender, age and cognitive/affective scores, and between 366 post-AMI patients and 366 undergraduate students matched on gender and cognitive/affective scores.

Somatic symptoms accounted for 44.1% of total BDI–II score for the 209 post-AMI and psychiatry out-patient groups, 52.7% for the 366 post-AMI patients and 46.4% for the students. Post-AMI patients had somatic scores on average 1.1 points higher than the students (P<0.001). Across groups, somatic scores accounted for approximately 70% of low total scores (BDI–II <4) v. approximately 35% in patients with total BDI–II scores of 12 or more.

Our findings contradict assertions that self-report depressive symptom measures inflate severity scores in post-AMI patients. However, the preponderance of somatic symptoms at low score levels across groups suggests that BDI–II scores may include a small amount of somatic symptom variance not necessarily related to depression in post-AMI and non-medically ill respondents.