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Abstract
Several studies have considered psychophysiological predictors of symptomatic outcome in schizophrenia. Zahn et
al. (1981) found that the patients who remained clinically
ill after a 4-month hospital stay were characterized by a
high baseline arousal (heart rate and spontaneous skin
conductance response) and reduced reactivity to demanding stimuli. These findings were only partly replicated by
Straube et al. (1987), who found that patients with minimal improvement over a 28-day treatment period showed
relatively low levels of electrodermal responsivity to
demanding stimuli but more responsivity on cardiovascular measures. In another partial replication of the Zahn et
al. findings, Mussgay et al. (1993) reported that patients
who relapsed over a 1-year followup period tended to
have lower levels of arousal and less responsivity than
patients who did not relapse. Concerning symptomatic
outcomes, Dawson et al. (1992a, 1992>) found that higher
tonic skin conductance (SC) arousal, slower SC habituation to orienting stimuli, and being an electrodermal
responder during an inpatient testing were predictive of
higher symptom scores during a subsequent outpatient
assessment. Although these studies are not entirely consistent (perhaps due to methodological differences in responsivity and outcome measures), they suggest that increased
baseline arousal, slow habituation, and reduced responsivity to stressful or demanding stimuli may predict poor
symptomatic outcomes.
Concerning the relationship between neuropsychological deficits and symptom levels in schizophrenia, most
studies have examined the positive or negative symptom
subtypes (Gold and Harvey 1993). With regard to general
symptom levels, the literature is sparse and inconsistent
(Dickerson et al. 1991). Some studies have found no relationship between neuropsychological deficits and general
symptomatology, and others have found that deficits on
measures of frontal functioning are related to higher overall symptom levels.
Based on the findings cited above, we would predict
that higher symptom levels in schizophrenia will be associated with higher resting SC arousal, lower SC stress reactivity, status as an electrodermal responder, and deficits on
neuropsychological measures of frontal functioning.
Psychophysiological and
Neuropsychological Correlates of
Functional Outcomes
We are aware of only two studies that examine the rela-
20
tionship between psychophysiological variables and functional outcomes in schizophrenia. Ohman et al. (1989)
used a sample of male schizophrenia subjects and found
that electrodermal nonresponders to orienting stimuli had
worse outcomes over a 2-year period in terms of social
and occupational functioning. Wieselgren et al. (1994)
found that among female schizophrenia subjects poorer
functioning was related to higher tonic SC levels. Two
issues should be noted with regard to these findings. First,
these gender effects co-occur with differences in the specific SC measures used; second, the measure of psychosocial functioning used in these studies was a combined
index of social and occupational variables. Relevant to
this, Tarrier and Turpin (1992) and Dawson et al. (1992a)
speculate that different electrodermal variables (e.g., phasic or tonic measures) might have distinct relationships
with various aspects of clinical or psychosocial functioning. This suggests that it is important to consider specific
electrodermal measures and their relationships to distinct
aspects of psychosocial functioning.
There have been a few studies concerning the neuropsychological predictors of successful outcome for psychiatric patients in the community. Wykes et al. (1990)
and Wykes (1994) administered a complex reaction time
test to a group of 49 chronic psychiatric patients and followed them for 3 to 6 years. Better performance on the
response measure was a strong predictor of higher levels
of independent living during the followup period.
Silverstein et al. (1991) found that better performance on
cognitive measures of reading, writing, expressive speech,
and arithmetic were associated with better work outcomes
over a 2-year period. Buchanan et al. (1994) found that
changes in verbal memory were correlated with changes
in social and occupational functioning. Lysaker et al.
(1995) found a relationship between better performance
on the Wisconsin Card Sorting Task and amount of work.
Two other studies found that poorer performance on neuropsychological measures of frontal functioning was
related to decrements in social and work functioning
among chronic schizophrenia sufferers (Allen 1990;
Breier et al. 1991). Unlike the studies just cited, Johnstone
et al. (1990) failed to find a significant relationship
between two cognitive measures (digit symbol from the
Wechsler Adult Intelligence Scale-Revised [WAIS-R;
Wechsler 1981] and a vocabulary test) and occupational
outcome at 2 years in a sample of first-episode schizophrenia subjects.
Even though it is difficult to draw clear conclusions
across these studies because of the wide variability in the
selection of measures, we would predict that neuropsychological deficits will be related to poorer work, independent living, and social functioning.
In addition to these empirical findings, there has been
Psychophysiological and
Neuropsychological Correlates of
Symptomatic Outcomes
Psychosocial Functioning
Methods
A cross-sectional design was used to assess the relationships between the neuropsychological and psychophysiological variables and concurrent levels of clinical and psychosocial functioning. Symptomatology ratings were
completed on the same day as the neuropsychological and
psychophysiological testing, and psychosocial data were
gathered on the same day or generally within 2 weeks of
the testing date as part of an existing protocol.
Subjects. Forty subjects were selected from a study of
193 individuals diagnosed with schizophrenia or schizoaffective disorder and living in community-based care.
Ongoing checks of subject characteristics during sample
recruitment yielded 40 subjects who did not differ from
the larger sample on psychosocial functioning or demographic characteristics (p > 0.05 on all variables). The
sample was made up of 15 women and 25 men. The ethnic composition of the sample was 19 whites, 9 African
Americans, 7 Latinos, 1 Asian, and 4 other. The mean age
was 33.2 (standard deviation [SD] = 7.4); the mean years
21
J.S. Brckkeetal.
Neuropsychological measures.
Results
Descriptive data on the study variables are presented in
table 1. The indices of skewness and kurtosis were within
acceptable levels except on the number of SCORs. This
measure reflects that 21 (53%) of the subjects were electrodermal nonresponders, having zero orienting responses.
On the BPRS, higher scores reflect higher symptom levels.
On the social, work, and independent living items, higher
scores reflect better functioning. These results suggest that
this was a moderately symptomatic outpatient sample,
with moderate residual impairment in social functioning
and independent living and greater deficits in work functioning. Table 2 presents the correlations between the functional variables; they suggest that the psychosocial variables were largely independent of one another.
Table 3 presents the correlations that were used to
test the hypotheses of this study. Given the directionality
of the hypotheses, one-tailed tests of significance were
used. In contrast, when exploratory analyses were done,
two-tailed significance tests were reported. Overall in this
study, the number of statistically significant findings far
exceeds what would be expected by chance.
Six measures of
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an SC response to all six tones. This is a more strict definition of nonresponding than the more conventional threetone criterion. We used it because it yielded a better distribution of nonresponding in this sample (53% nonresponders) than when a three-tone criterion was used (70%
nonresponders). Recently, Dawson et al. (1994) used a 12tone criterion as a strict definition of nonresponding. The
second SCOR variable was the number of SC responses
given to the orienting stimuli. Low scores on this frequency measure indicate hyporesponsivity, which is a
dimensional analog to the responding-nonresponding
dichotomy. Both of the SCOR variables were indicators
of the allocation of attention resources to external stimuli.
SC and SF measures of stress reactivity were recorded
during two stressors. The first consisted of administration
of the arithmetic subscale of the WAIS-R, which reliably
elicits strong psychophysiological responses and leads to
significant increases in heart rate (e.g., Linden 1991). This
test was administered using manual guidelines (Wechsler
1981). The second paradigm consisted of the subject being
asked to prepare a 2-minute speech about his or her faults
(Rozanski et al. 1988). This manipulation produces significantly greater physiological responsiveness than other
mental stressors (e.g., Stroop task).
The SC level index of stress reactivity was measured
as the increase in SC assessed at the end of the stress
manipulations relative to the lowest value during the resting periods. The index of SF stress reactivity was measured as the frequency of nonspecific SC responses during
the stressor period minus the frequency during rest.
Higher values indicate greater stress reactivity. A
repeated-measures analysis of variance found that the SC
stress manipulations resulted in statistically significant
increases in SC (F = 44; df = 3,34; p < 0.0001) and SF
(F = 23; df= 3,36; p < 0.0001) from resting rates.
Psychosocial Functioning
Variable
3.3
0.55
4.5
3.9
0.15
4.7
0.63
1.2
29.2
36.5
13.3
11.9
7.8
6.9
7.5
6.4
2.5
2.3
2.7
2.3
45.6
14.1
2.5
1.2
4.1
1.7
Variable
Resting arousal
SC
SF
0.302
Stress reactivity
SC
-0.39 3
SF
-0.29 2
Orienting
Responder
0.352
SCOR
Neuropsychological
Verbal fluency -0.27 2
Stroop
Digit symbol -0.45 3
Block design
Digit span
Arithmetic
1.2
1.3
BPRS
-0.04
(0.8)
Social
Work
Work
-0.28
(0.08)
-0.03
(0.8)
Work
Independent
living
0.361
0.30
-0.30 2
0.393
0.30 2
0.513
0.42 3
0.35 2
Social
Variable
BPRS
Independent
living
-0.22
(0.16)
-0.06
(0.7)
0.14
(0.4)
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Psychophysiological measures
SF rest
SCL rest
0.34
SF reactivity
SCL reactivity
0.19
SCOR
Neuropsychological measures
Verbal fluency
Stroop
Digit span
Arithmetic
Block design
Digit symbol
Functional measures
BPRS
Social
Work
Independent living
J.S. Brekkectal.
These results also indicated some specificity of associations between the psychosocial and the neuropsychological or psychophysiological variables. Specifically,
social functioning was related to a pattern of electrodermal variables but not to any of the neuropsychological
variables. On the other hand, work and independent living
were related only to the neuropsychological variables and
not to any electrodermal measures. This might suggest
that the capacities necessary for adequate functioning in
these areas are distinct. For example, the more intensive,
interpersonal, and reciprocally interactive nature of social
Discussion
To our knowledge, this is the first study to examine the
relationships between both neuropsychological and psychophysiological variables and distinct aspects of psychosocial functioning in schizophrenia. The results provided support for hypothesized patterns of relationships
24
Psychosocial Functioning
25
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Acknowledgments
This research was supported in part by grant MH-43640
awarded to the first author, and a Research Scientist
Development Award MH-01114 to the second author from
the National Institute of Mental Health.
The Authors
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