Cognitive flexibility in adults with schizophrenia: A scoping review

Cognitive flexibility, defined as the ability to switch cognitive sets to adapt to changing environmental stimuli, is markedly impaired in schizophrenia, contributing to poor functional outcomes. However, research on cognitive flexibility in schizophrenia remains fragmented. This scoping review aims to condense current literature by systematically mapping existing research on cognitive flexibility in adults with schizophrenia.

This review was conducted in accordance with PRISMA-ScR guidelines, and included empirical studies from 2015 to 2025 in English on cognitive flexibility in adults with schizophrenia. It excluded animal studies, pediatric samples, books, narrative reviews, conference abstracts, and commentaries. Studies were screened using the TIT-ABS-KEY (title-abstract-keywords) method, followed by data extraction and analysis of the selected 47 studies.

Cognitive flexibility has been found to be significantly impaired in schizophrenia; markedly so in certain illness presentations. It can be enhanced through cognitive remediation and physical activity. Neuroimaging findings in patients show brain activation in the frontoparietal regions while performing cognitive flexibility tasks. The Trail-Making Test was used most prominently throughout the studies. The major gaps identified were methodological and population-related in nature; specifically, methodological gaps include small sample size and study design limitations.

This review helps us map the current frameworks underlying cognitive flexibility impairments in schizophrenia, and how that links to other psychopathological symptoms and interventions. The translational impact of this encourages outpatient clinics, inpatient psychiatric facilities, as well as rehabilitation centers to use cognitive remediation and physical exercise to improve cognitive flexibility in patients with schizophrenia.