Effect of Instructional Cues on Schizophrenic Patients’ Performance on the Wisconsin Card Sorting Test Robert
S. Goldman, Ph.D., Bradley and Lauren M. Tompkins,
Objective: Schizophrenic patients tioning, notably the Wisconsin Card efficacy ofa ofprefrontal
deficient This study
with
affective
Test
Ph.D.,
on measures was conducted
cuing strategy in facilitating performance on this cognitive brain structures and functioning. Method: Twenty-four
and 24 demographically consin Card Sorting standard administration patients
are particularly Sorting Test.
N. Axetrod, Ph.D.
of executive to determine
measure ofthe integrity schizophrenic inpatients
matched inpatients with mood disorders were administered the Wiseither with instructional cues at the beginning ofthe task or with the procedure. Results: There was a significant benefit of cues for the
disorders
as well
as for
the
schizophrenic
patients.
The
schizophrenic
subjects in the uncued condition maintained poor but stable performance throughout course ofthe task. Conclusions: The study suggests that the deficit in executive functioning schizophrenic patients may lie in the formation of concepts, not in their application.
J
(Am
Psychiatry
1 992;
149:1
eficient cognitive functioning is a well-documented phenomenon in schizophrenia (1, 2). Recent advances in neunonadiological techniques have confirmed frontal lobe dysfunction in schizophrenia; varying degrees of hypofrontality have been found on measures of both structure and functioning-magnetic resonance imaging (MRI) and regional cerebral blood flow (3-6). While many neuropsychological studies have demonstrated generalized, nonspecific cognitive impairment in schizophrenic subjects relative to normal control subjects (7-9), other studies have shown the presence of more specific neuropsychological dysfunction in schizophrenia, namely, impairment in executive functioning ( 1 0, 1 1 ). Abilities that reflect executive functioning include planning, sequencing, concept formation, cognitive set shifting, and cognitive set maintenance (12). Executive functions are thought to be mediated primarily by the prefrontal cortex (13, 14). The Wisconsin Card Sorting Test has been extensively used as a measure of executive functioning. Nonschizophrenic patients with focal frontal lesions pen-
Received
Oct.
23,
Mich.;
the
Arbor;
the VA Medical
Medical
23,
1991;
April
1992.
Department
Center
and
revision
From of
received
the VA Medical
Psychiatry,
Center,
Michigan
State
March
Park,
University,
23,
Center,
University
Allen
1992;
Ann
of Michigan,
Mich.;
and
East
Lansing.
ac-
Arbor, Ann
the Hurley Address
reprint requests to Dr. Goldman, VA Medical Center (1 16B), 2215 Fuller Rd., Ann Arbor, MI 48105. The authors thank Dr. John L. Woodard for assistance with statistics and tainment
methodology, of subjects,
Sleeford
for help with
1718
Dr. Alan and James
data
Douglass for cooperation Jones, Marla Mikelait,
collection.
the of
71 8-1 722)
D
cepted
functhe
and
in the obElizabeth
form poorly on this task relative to other brain-injured patients with nonfrontal lesions and normal control subjects (15-17). Performance by schizophrenic patients on the test typically reveals more perseverative errors, more persevenative responses, and fewer obtamed categories in comparison to other psychiatric patients and nonpsychiatnic control subjects (18-20). Several researchers have used the Wisconsin Card Sorting Test to examine whether training can improve executive functioning performance in severely impaired schizophrenic populations. Stuss and Benson (13) modified the standard 128-card test procedure by including instructional intervention after the first 64 cards had been presented. The instructional intervention varied from the traditional administration of the test by informing the patients of the sorting principles and also informing them that the sorting principles change throughout the course of the task. Following the instructional intervention, the performance of leukotomized schizophrenic subjects did not improve with the second deck of cards, whereas the performance of the normal subjects did. Recent studies using the Stuss modification with nonleukotornized but chronic, medicated schizophrenic patients have reported a similar inability of these patients to profit from instructional feedback. Card-by-card instruction on the Wisconsin Card Sorting Test (21, 22) failed to produce an enduring
learning
effect
after
lack et at. (23) also training on the test population and found tive produced stable
Am
J
termination
of
instruction.
Bel-
provided intensive instructional for a less chronic schizophrenic that cuing plus a monetary incenimprovement in performance,
Psychiatry
149:12,
December
1992
GOLDMAN,
TABLE 1. Demographic Characteristics Card Sorting Test in Cued and Uncued
and Test Scores of Schizophrenic Conditions Patients
With
Affective
Uncued Condition (N=11) Variable
Age (years) Education
(years)
WAIS-R
vocabulary
subtest
score
Mini-Mental
State examination BPRS total score Wisconsin Card Sorting Test
Total
score
errors
Perseverative responses Perseverative errors Nonperseverative errors Categories obtained aSignificant bSignificant
difference difference
Disorders
comparison
after
completion
ated a cognitive formance, thereby this
study
we
of
initiated
SD
Mean
SD
37.7 11.4 9.2 27.4 36.4
9.2 1.2 3.6 2.2 6.7
40.5 11.9 10.4 27.7 36.7
9.2 0.4 3.3 2.1 5.2
37.8 11.7 8.0 27.1 39.2
6.4 0.9 2.1 1.6 7.2
35.8 11.3 9.4 28.3 43.0
6.0 1.8 2.0 1.9 7.6
1.12 0.13 1.70 1.97 5.52
48.2
19.9 21.5 16.1 10.4 3.3
34.5 19.0 17.4 17.1 6.0
19.7 11.3 9.6 10.9 3.7
62.8 53.2 43.8 18.1 3.1
24.0 35.2 25.3 12.6 2.8
32.3 17.2 16.0 16.3 5.5
14.6 9.1 7.8 8.2 2.2
14.88 14.82 16.06 1.05 3.87
to external
inter-
several
trials
may
have
cre-
altered subsequent penthe effects of cuing. In
training
at
the
beginning
of the
The study group consisted of 48 male patients hospitalized in the general psychiatric units at a Department of Veterans Affairs medical center. Twenty-four patients met the DSM-III-R criteria for schizophrenia, and 24 met the criteria for mood disorders ( 1 1 had bipolar disorder and 13 had a major depressive episode). Diagnoses were formulated on the basis of independent clinical interviews conducted by a three-member psychiatnic team. Final diagnoses for the patients included
Psychiatry
F (df=3,
44)
p n.s. n.s. n.s. n.s.
S. Goldman, Ph.D., Bradley and Lauren M. Tompkins,
Objective: Schizophrenic patients tioning, notably the Wisconsin Card efficacy ofa ofprefrontal
deficient This study
with
affective
Test
Ph.D.,
on measures was conducted
cuing strategy in facilitating performance on this cognitive brain structures and functioning. Method: Twenty-four
and 24 demographically consin Card Sorting standard administration patients
are particularly Sorting Test.
N. Axetrod, Ph.D.
of executive to determine
measure ofthe integrity schizophrenic inpatients
matched inpatients with mood disorders were administered the Wiseither with instructional cues at the beginning ofthe task or with the procedure. Results: There was a significant benefit of cues for the
disorders
as well
as for
the
schizophrenic
patients.
The
schizophrenic
subjects in the uncued condition maintained poor but stable performance throughout course ofthe task. Conclusions: The study suggests that the deficit in executive functioning schizophrenic patients may lie in the formation of concepts, not in their application.
J
(Am
Psychiatry
1 992;
149:1
eficient cognitive functioning is a well-documented phenomenon in schizophrenia (1, 2). Recent advances in neunonadiological techniques have confirmed frontal lobe dysfunction in schizophrenia; varying degrees of hypofrontality have been found on measures of both structure and functioning-magnetic resonance imaging (MRI) and regional cerebral blood flow (3-6). While many neuropsychological studies have demonstrated generalized, nonspecific cognitive impairment in schizophrenic subjects relative to normal control subjects (7-9), other studies have shown the presence of more specific neuropsychological dysfunction in schizophrenia, namely, impairment in executive functioning ( 1 0, 1 1 ). Abilities that reflect executive functioning include planning, sequencing, concept formation, cognitive set shifting, and cognitive set maintenance (12). Executive functions are thought to be mediated primarily by the prefrontal cortex (13, 14). The Wisconsin Card Sorting Test has been extensively used as a measure of executive functioning. Nonschizophrenic patients with focal frontal lesions pen-
Received
Oct.
23,
Mich.;
the
Arbor;
the VA Medical
Medical
23,
1991;
April
1992.
Department
Center
and
revision
From of
received
the VA Medical
Psychiatry,
Center,
Michigan
State
March
Park,
University,
23,
Center,
University
Allen
1992;
Ann
of Michigan,
Mich.;
and
East
Lansing.
ac-
Arbor, Ann
the Hurley Address
reprint requests to Dr. Goldman, VA Medical Center (1 16B), 2215 Fuller Rd., Ann Arbor, MI 48105. The authors thank Dr. John L. Woodard for assistance with statistics and tainment
methodology, of subjects,
Sleeford
for help with
1718
Dr. Alan and James
data
Douglass for cooperation Jones, Marla Mikelait,
collection.
the of
71 8-1 722)
D
cepted
functhe
and
in the obElizabeth
form poorly on this task relative to other brain-injured patients with nonfrontal lesions and normal control subjects (15-17). Performance by schizophrenic patients on the test typically reveals more perseverative errors, more persevenative responses, and fewer obtamed categories in comparison to other psychiatric patients and nonpsychiatnic control subjects (18-20). Several researchers have used the Wisconsin Card Sorting Test to examine whether training can improve executive functioning performance in severely impaired schizophrenic populations. Stuss and Benson (13) modified the standard 128-card test procedure by including instructional intervention after the first 64 cards had been presented. The instructional intervention varied from the traditional administration of the test by informing the patients of the sorting principles and also informing them that the sorting principles change throughout the course of the task. Following the instructional intervention, the performance of leukotomized schizophrenic subjects did not improve with the second deck of cards, whereas the performance of the normal subjects did. Recent studies using the Stuss modification with nonleukotornized but chronic, medicated schizophrenic patients have reported a similar inability of these patients to profit from instructional feedback. Card-by-card instruction on the Wisconsin Card Sorting Test (21, 22) failed to produce an enduring
learning
effect
after
lack et at. (23) also training on the test population and found tive produced stable
Am
J
termination
of
instruction.
Bel-
provided intensive instructional for a less chronic schizophrenic that cuing plus a monetary incenimprovement in performance,
Psychiatry
149:12,
December
1992
GOLDMAN,
TABLE 1. Demographic Characteristics Card Sorting Test in Cued and Uncued
and Test Scores of Schizophrenic Conditions Patients
With
Affective
Uncued Condition (N=11) Variable
Age (years) Education
(years)
WAIS-R
vocabulary
subtest
score
Mini-Mental
State examination BPRS total score Wisconsin Card Sorting Test
Total
score
errors
Perseverative responses Perseverative errors Nonperseverative errors Categories obtained aSignificant bSignificant
difference difference
Disorders
comparison
after
completion
ated a cognitive formance, thereby this
study
we
of
initiated
SD
Mean
SD
37.7 11.4 9.2 27.4 36.4
9.2 1.2 3.6 2.2 6.7
40.5 11.9 10.4 27.7 36.7
9.2 0.4 3.3 2.1 5.2
37.8 11.7 8.0 27.1 39.2
6.4 0.9 2.1 1.6 7.2
35.8 11.3 9.4 28.3 43.0
6.0 1.8 2.0 1.9 7.6
1.12 0.13 1.70 1.97 5.52
48.2
19.9 21.5 16.1 10.4 3.3
34.5 19.0 17.4 17.1 6.0
19.7 11.3 9.6 10.9 3.7
62.8 53.2 43.8 18.1 3.1
24.0 35.2 25.3 12.6 2.8
32.3 17.2 16.0 16.3 5.5
14.6 9.1 7.8 8.2 2.2
14.88 14.82 16.06 1.05 3.87
to external
inter-
several
trials
may
have
cre-
altered subsequent penthe effects of cuing. In
training
at
the
beginning
of the
The study group consisted of 48 male patients hospitalized in the general psychiatric units at a Department of Veterans Affairs medical center. Twenty-four patients met the DSM-III-R criteria for schizophrenia, and 24 met the criteria for mood disorders ( 1 1 had bipolar disorder and 13 had a major depressive episode). Diagnoses were formulated on the basis of independent clinical interviews conducted by a three-member psychiatnic team. Final diagnoses for the patients included
Psychiatry
F (df=3,
44)
p n.s. n.s. n.s. n.s.
