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Cognitive Functioning in Schizophrenia:

Implications for Psychiatric Rehabilitation


by William D. Spaulding, Shelley K. Fleming, Dorie Reed,
Mary Sullivan, Daniel Storzbach, and Mona Lam

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Abstract Green 1996; Meltzer et al. 1996), and as targets for direct
treatment (Brenner et al. 1983, 1992; Spaulding et al.
Research in psychopathology and the cognitive neuro- 1986, 1998; Corrigan and Storzbach 1993; Lee et al.
sciences suggests new applications in psychiatric reha- 1994). These proposals reflect a convergence, on the one
bilitation. Analysis of performance deficits on labora- hand, of research in the neurosciences, experimental psy-
tory tasks can contribute to treatment planning, chopathology, neuropsychology, and cognitive-behavioral
individual and family counseling, and staff consulta- psychotherapy and, on the other hand, a perceived need to
tion, much like it does in cases of brain injury and translate the methods, principles, and insights of cognitive
other types of central nervous system neuropathology. psychopathology into practice.
Recognition of the nature of cognitive impairments in New roles for cognitive psychopathology suggest
schizophrenia can inform design of psychosocial tech- new applications for a number of familiar clinical tech-
niques such as social and living skills training. nologies in the domain of psychological and neuropsy-
Cognitive impairments are increasingly seen as poten- chological assessment. For example, analysis of perfor-
tial targets for pharmacological and psychosocial mance deficits on laboratory tasks can contribute to
treatment and rehabilitation. In this article, three key treatment planning, individual and family counseling, and
issues for application of cognitive technology in psychi- staff consultation, much like it does in cases of brain
atric rehabilitation of schizophrenia and related disor- injury and other types of central nervous system neu-
ders are formulated as straightforward, clinically rele- ropathology (Erickson and Binder 1986; Erickson 1988,
vant questions: (1) What is the prognostic significance 1994). Similarly, recognition of the nature of schizo-
of cognitive impairment in acute psychosis? (2) Can phrenic cognitive impairments can inform design of psy-
cognitive functioning improve in the chronic, residual chosocial techniques such as social and living skills train-
course? (3) How does cognitive improvement benefit ing (Liberman et al. 1982; Kern and Green 1994).
other aspects of recovery and rehabilitation? These The issues for application of cognitive technology
questions are addressed through review of previous are not necessarily the same as those that drive develop-
findings and new multivariate analyses of cognitive ment of etiological models. Also, the issues raised by
functioning in the acute, post-acute, and chronic resid- cognitive applications in classical neuropsychology do
ual phases of schizophrenia. not overlap completely with issues raised in assessment
Key words: Cognitive rehabilitation. and treatment of schizophrenic impairments. For exam-
Schizophrenia Bulletin, 25(2):275-289,1999. ple, some parameters that give necessary context to tradi-
tional neuropsychological assessment, such as time since
injury, are poorly understood and possibly irrelevant in
Historically, the preponderance of scientific interest in the schizophrenia.
cognitive aspects of schizophrenia has been directed
In the following sections, three key issues applicable
toward illuminating the disorder's etiology, with only
to psychiatric rehabilitation of schizophrenia and related
indirect consideration of clinical applications. Never-
disorders are formulated as straightforward, clinically rel-
theless, cognitive measures and models are increasingly
evant questions:
proposed as potentially useful prognostic indicators
(Wykes et al. 1990; Wykes and Dunn 1992; Bowen et al.
1994), as limiting factors in social functioning (Penn Reprint requests should be sent to Dr. W.D. Spaulding, Dept. of
1991; Kern and Green 1994; Penn et al. 1995, 1996; Psychology, University of Nebraska-Lincoln, Lincoln, NE 68588-0308.

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1. What is the prognostic significance of cognitive During the study, 31 patients were admitted, and subse-
impairment in acute psychosis? quently discharged or transferred to a long-term inpatient
2. Can cognitive functioning improve in the chronic, unit; 19 (61%) had a diagnosis of schizophrenia, 10 (32%)
residual course? had a diagnosis of major depression or bipolar disorder, 1
3. How does cognitive improvement benefit other aspects had an eating disorder, and 1 had substance abuse-related
of recovery and rehabilitation? psychosis. Each was assessed with a structured interview,
Recent research findings from our laboratory and others the Brief Psychiatric Rating Scale (BPRS; Ventura et al.
are marshaled to help clarify the nature of the questions 1993); a self-report symptom and problem inventory,
and in some cases provide preliminary answers. In some Symptom Checklist-90R (SCL-90R; Peveler and Fairburn
instances, contemporary theoretical frameworks are help- 1990); and a neurocognitive test battery (COGLAB;
ful or even essential for informing application strategies. Spaulding et al. 1989). Assessment was performed twice:
Neurodevelopmental models of schizophrenia (e.g., within 14 days of hospitalization and 4 weeks later. Two
Walker 1994; Weinberger and Lipska 1995; Weinberger assessments were included to determine whether cogni-
1996) are especially important in this regard. In other tive functioning at the start of treatment has different

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instances, clinical considerations, observations, or impera- prognostic significance than later. Two indices of short-
tives suggest a need for further development of theoretical term outcome were analyzed: length of stay in the acute
models. In the final section we propose theoretical mod- unit and discharge destination. The latter is the setting to
els to account for the important new finding that cognitive which the patient went upon discharge, coded as a scale
impairments respond to psychosocial interventions in the reflecting graduated levels of restrictiveness from inde-
chronic course of schizophrenia. pendent living to locked, long-term inpatient care.
With data available at the first assessment, including
demographic characteristics, it was possible to construct a
What Is the Prognostic Significance of multiple regression equation that predicted about 65 per-
Cognitive Impairment in Acute cent of the variance in length of stay (adjusted R2 = 0.647,
F = 11.28, p < 0.00005). The regression statistics for this
Psychosis? formula are shown in table 1. Interestingly, diagnosis is
Gross disruption of cognitive functioning is usually part not significantly associated with outcome in this context
of the clinical picture of acute psychosis, and reduction of The patient's age, age at onset, and marital status are
cognitive impairment usually accompanies resolution of powerful predictors of length of stay; a BPRS and an
the acute episode. Experimental studies of the relation- SCL-90R subscale also contribute to a statistically signifi-
ship between symptomatology and cognitive functioning cant degree. Even after those factors are taken into
in acute psychosis may provide clues about the neuro- account, the perseverative error score on the COGLAB
physiological and neuropsychological mechanisms that card sorting task contributes uniquely to the prediction.
produce them (e.g., Gilbertson et al. 1994). However, That is the only score of the 11 derived from the
what is known about the long-term prognostic signifi- COGLAB battery that was associated with outcome, but
cance of cognitive impairment is generally limited to the the size of its beta weight is sufficient to allow confidence
severity of residual impairment after resolution of acute that it is not an artifact of multiple correlational tests.
psychosis (for a review, see Meltzer et al. 1996).
Cognitive functioning at the point of hospitalization has Table 1. Multiple regression statistics for
been found to predict some important consequences, for predicting length of stay from demographic,
example, emotional blunting after remission of the acute clinical, and cognitive characteristics at
admission
psychosis (Silverstein et al. 1994), but little more is
known about the portent of cognitive functioning during Variable Beta Significance1
exacerbations. Hospitalization during acute psychosis is Age 0.34 0.0248
often the starting point for long-term treatment and reha- Age at onset 0.39 0.0057
bilitation. A better understanding of the prognostic impli- Marital status 0.56 0.0002
cations of cognitive functioning at this point could
BPRS paranoia factor 0.31 0.0126
enhance the planning process.
COGLAB Card Sort
To determine whether cognitive measures during an perseverative errors 0.52 0.0002
acute episode have prognostic value over and above diag-
Note.BPRS = Brief Psychiatric Rating Scale.
nostic, symptomatic, and behavioral indicators, we reana- 1
Significance of T, reflecting the probability that the variable's
lyzed data collected in a recent study of patients admitted unique contribution to the overall prediction of the dependent vari-
to an acute short-term unit in a State hospital (Lam 1997). able is zero.

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Cognitive Functioning Schizophrenia Bulletin, Vol. 25, No. 2, 1999

The demographic variables were not so effective for Table 3. Multiple regression statistics for
predicting discharge destination, but card sorting perfor- predicting length of stay from demographic,
mance was (see table 2). The equation still accounted for clinical, and cognitive data available after 6
37 percent of the variance in discharge destination weeks of hospitalization
(adjusted R2 = 0.365, F = 4.34, p < 0.006). These analy- Variable Beta Significance1
ses indicate that patients with more impaired card sorting Age at onset 0.24 0.0234
performance shortly after acute hospitalization stayed in Marital status 0.45 0.0001
the acute ward longer and were more likely to be dis- BPRS paranoia factor at
charged to a residential or long-term hospital unit than to admission 0.28 0.0104
supported or independent community living. COGLAB Card Sort
perseverative errors at
Table 2. Multiple regression statistics for admission 0.49 0.0001
predicting discharge destination from COGLAB Backward Masking
demographic, clinical, and cognitive task at second assessment 0.41 0.0005

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characteristics at admission Note.BPRS = Brief Psychiatric Rating Scale.
Variable Beta Significance1 1
Significance of T, reflecting the probability that the variable's
unique contribution to the overall prediction of the dependent vari-
Age 0.11 0.5434 able is zero.
Age at onset 0.03 0.8519
Marital status 0.03 0.8687
BPRS paranoia factor 0.51 0.0025 schizophrenia, but they are not necessarily associated with
COGLAB Card Sort paranoia.) It would make sense that a syndrome of rigid
perseverative errors 0.43 0.0100 thinking and hostile, suspicious, and uncooperative social
NoteBPRS = Brief Psychiatric Rating Scale.
behavior would inhibit efficacious treatment and disposi-
Significance of T, reflecting the probability that the variable's tion in a psychiatric treatment setting, but the current
unique contribution to the overall prediction of the dependent vari-
able is zero. analyses indicate that the behavioral and the cognitive
aspects of this syndrome contribute independently to out-
Data from the second assessment were then analyzed come. The role of the masking measure at the second
for additional predictive value. The contribution of age assessment is also interesting. Masking measures an early
was eclipsed by other predictors at the second assessment, stage of visual information processing, but it is known to
so it was excluded from the prediction equation. Card be responsive to antipsychotic drug interventions (Braff
sorting performance at the second assessment no longer and Sacuzzo 1982). In this analysis, the masking measure
contributed either, but another COGLAB measureper- may be detecting a subgroup of patients who respond less
formance on a backward visual masking taskdid con- well to antipsychotic medication, who remain more
tribute. The best equation including these variables, and actively psychotic after several weeks of treatment, and
the remaining variables from the first assessment, who therefore require a longer hospitalization.
accounted for almost 75 percent of the variance in length These analyses provide some encouragement that
of stay (adjusted R2 = 0.744, F = 17.28, p < 0.00005). As cognitive assessment in the acute and early post-acute
table 3 shows, card sorting performance at the first assess- phase can be made useful for predicting post-acute and
ment and masking performance at the second assessment chronic baseline functioning, at least to the degree that
contributed uniquely to this prediction. length of hospital stay and discharge destination reflect
It is interesting that both paranoid behavior and card baseline functioning. This prediction is likely to be easier
sorting perseverative errors contributed to outcome in this in a mixed sample that includes patients with both high
situation. Perseverative errors have long been associated and low levels of baseline functioning. Within a group of
with paranoia (Spaulding 1978), presumably because the patients with more impaired baseline functioning, higher
rigidity of thinking that produces this type of error also levels of symptoms between episodes, and suboptimal
produces the inflexible beliefs and attributions of para- medication response, it may be extremely difficult to pre-
noia. (The perseverative error score here uses the original dict baseline and residual levels of cognitive impairment.
criteria of the Wisconsin Card Sorting Task (WCST), It may be difficult even to determine when the patient has
which are different from the criteria used by WCST ver- reached stabilization of the acute state. In such cases, sys-
sions in most common use today; see Wagman and tematic longitudinal assessment may be necessary to
Wagman (1992). Perseverative errors as scored by the determine the significance of cognitive impairments for
current criteria may be differentially associated with longer-term treatment planning.

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Can Cognitive Functioning Improve in help recover more impaired ones? The answers to these
questions would provide important clues about how cog-
the Chronic, Residual Course? nitive recovery can come about.
Apart from those examining treatment of residual depres- For the present article, in order to further articulate
sion or negative symptoms (e.g., Plasky 1991; Silver and the nature of the cognitive changes observed in the
Nassar 1992; Siris 1994), there are relatively few system- Spaulding et al. (1998) study, we performed a principal
atic studies showing cognitive recovery independent of components analysis of the data from that study. The
resolution of acute psychosis ("recovery" in this context analysis included change scores for the nine measures that
means regaining some degree of premorbid functioning, showed a change over the 6-month study period. The
not necessarily full return to premorbid levels). Studies of change scores are simply the arithmetic difference
long-term outcome of schizophrenia and related disorders between pre and posttreatment scores adjusted for initial
(Harding et al. 1992) have found surprisingly high levels values effects by residualization in linear regression (a
of recovery of personal and social functioning, indirectly statistical procedure to control for the problem that
suggesting that some degree of cognitive recovery under- change scores may have different meanings at different

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lies this. On the other hand, long-term behavioral recov- levels of a measure). The results are summarized in
ery could also reflect the cumulative effects of socializa- table 4.
tion uninterrupted by acute episodes, without any changes Using conventional extraction and rotation parame-
in cognition per se. The atypical antipsychotics, espe- ters, the analysis identifies three separate sources of vari-
cially risperidone, may produce somewhat better cogni- ance that collectively account for about half of the total
tive functioning than typicals in stabilized patients variance in cognitive change. Although there is some
(Green 1998). This finding suggests the possibility of overlap, the three factors clearly differentiate changes in
some remediational process independent of episode reso- different domains of functioning. The first factor is pre-
lution, and the search is on for pharmacotherapeutic dominantly a verbal processing factor that spans elemen-
strategies that minimize residual impairment while maxi- tal and complex levels of cognition. (The backward mask-
mizing stabilization and symptom control. Meanwhile, ing task requires subjects to identify alphanumeric
the search also continues for psychosocial strategies to characters presented in a preattentional time frame, while
counteract residual cognitive impairment. verbal memory tasks require integrated storage and
A previous analysis in our laboratory (Spaulding
1993) of 110 severely disabled but stabilized patients in a
State hospital long-term unit showed that cognitive func- Table 4. Structure matrix of neurocognltlve
tioning undergoes little or no change over a 6-month change scores, oblique rotation of principal
period. A more recent longitudinal study, also completed component extraction
in our lab (Spaulding et al. 1998), assesses cognitive Factor Factor Factor
changes in equally disabled and stabilized chronic Measure 1 2 3
patients over the same time period but in an enriched psy- Rey Verbal Learning
chosocial treatment environment. The second study Test -Visual 1 0.76 0.12 0.01
showed improvements in 9 of 12 measures of cognitive COG LAB Backward
functioning in chronic schizophrenia patients with espe- Masking 0.75 0.00 0.09
cially severe residual impairments. Measures of memory Denman Verbal Memory
and executive functioning showed improvement, while Quotient 0.55 0.41 0.25
Rey Verbal Learning
measures of reaction time and continuous attention did
Test-Auditory1 0.46 0.42 0.01
not. One measure of preattentional visual processing
Halstead Reitan
backward maskingchanged, while another measure of Trailmaking B 0.09 0.79 0.25
preattentional processinga span of apprehension task Halstead Reitan Tactile
did not. Thus, there is evidence that at least under certain Performance Test 0.07 0.71 0.17
conditions, some aspects of impaired schizophrenic cog- Denman Nonverbal Memory
nition are subject to improvement in the chronic course. Quotient 0.49 0.60 -0.33
What is the qualitative nature of the observed cogni- COGLAB Card Sorting Task 0.00 0.27 0.77
tive change? Are some aspects of cognitive functioning Halstead Reitan Categories 0.37 0.15 0.76
1
more amenable to recovery than others? Does the The Rey Verbal Learning Test in its standard form uses auditory
presentation of the stimulus words. The nonstandard visual form
improvement simply reflect a general, overall improve- uses presentation of printed words. Change scores are residual-
ment in neurophysiological, cognitive, and behavioral ized for initial values (i.e., the effect of the initial overall severity of
functioning? Do patients use less impaired abilities to the impairment has been statistically removed).

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Cognitive Functioning Schizophrenia Bulletin, Vol. 25, No. 2, 1999

retrieval of verbal information in a much longer time one's own strengths and weaknesses into account. If
frame, in both visual and auditory modalities.) The sec- enduring deficits were lateralized, better executive reallo-
ond factor is a spatial information processing factor (all cation would produce inverse relationships, as with
the tasks require processing of spatial relations, whether Factors 1 and 2.
or not memory is also involved), and the third is a concept To further explore the implications of lateralization,
formation and manipulation factor. These results indicate we identified left- and right-lateralized deficits in this
that, in addition to the predominance of more global sample with a crude but clinically useful convention, a
changes, cognitive change in the chronic residual phase is difference between Wechsler Adult Intelligence Scale
somewhat segregated into verbal, spatial, and conceptual 1981 (WAIS) Vocabulary and Picture Arrangement of
domains. three standardized subscale points in either direction.
Segregation of verbal and spatial functions suggests With this criterion, 34 percent of the sample showed later-
lateralized hemispheric differences. The findings on later- alization to the right hemisphere, and 12 percent showed
alized neuropsychological deficits in schizophrenia lateralization to the left. The patients with left lateraliza-

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(Gruzelier 1979, 1991; see also Gold et al. 1994) suggest tion had a strikingly poor outcome. Whereas the entire
that both right and left lateralization can occur in a hetero- sample showed significant gains in social competence as
geneous schizophrenia population. The segregation of measured by the Assessment of Interpersonal Problem
verbal and nonverbal performance into separate factors, as Solving Skills (AIPSS; Donohoe et al. 1990) over the
in the table 1 factor structure, would be consistent with a course of the study (discussed further below), the sub-
mixed population of individuals with varying degrees of group of left-lateralized patients showed no change.
impairment lateralized to one or another cerebral hemi- Explicit targeting of cognitive impairment in psy-
sphere. However, the segregation of cognitive processes chosocial rehabilitation enhances cognitive improvement.
into factors could also reflect purely functional relation- The Spaulding et al. (1998) outcome study included a ran-
ships between various aspects of behavioral performance, domized controlled comparison of comprehensive biopsy-
independent of hemispheric or any other kind of anatomi- chosocial rehabilitation with and without a group treat-
cal localization. They could also reflect relationships ment modality designed to exercise cognitive abilities
between specific cognitive abilities and anatomically dis- believed to be prerequisite to sociobehavioral functioning.
persed neurophysiological mechanisms (e.g., neurotrans- The modality was constructed from the cognitive subpro-
mitter or neuroendocrine systems). Changes in these cog- grams of Integrated Psychological Therapy (IPT; Brenner
nitive abilities could reflect slowly occurring changes in et al. 1994), which combine social skills training with
lateralized neurophysiological processes, or functional other psychosocial techniques. Control subjects received
organization of cognitive processes, or combinations of supportive group therapy in identical doses, and all sub-
the two. jects received a standard regimen of intensive pharma-
Interestingly, Factors 1 and 2 are inversely correlated cotherapy, social and living skills training, contingency
(r = -0.23), meaning improvement on one is associated management, and other rehabilitation modalities. Over
with a lack of improvement, or deterioration, on the other. the course of 6 months of rehabilitation, patients who
This correlation could occur because in patients with lat- received the cognitive treatment showed improvement in
eralized impairments, recovery from episode-linked some domains of cognition, but the subjects receiving
deficits in the more impaired hemisphere is quantitatively intensive rehabilitation without the cognitive component
greater, and therefore more apparent on neuropsychologi- did not. There was strong evidence for differential
cal tasks, or because vulnerability-linked deficits prevent improvement in span of apprehension, a preattentional
recovery in the more impaired hemisphere. Also, there level of cognitive processing. (The overall change on this
may be "trade-offs" involved in recovery processes. In measure was not significant because of the complete lack
Factor 3, there appears to be such a trade-off between of improvement in the control subjects, and. so this mea-
nonverbal memory and concept manipulation perfor- sure was not included in the factor analysis of changes
mance, evidenced by the negative factor loading of the described above.) This particular domain of cognition is
nonverbal memory measure. Such a trade-off could be known to be sensitive to "top-down" information process-
the result of reallocating limited processing capacity from ing factors (Silverstein et al. 1996), so it is possible that
one functional domain to another (Knight and Russell the differential improvement reflects better executive-
1978; Gjerde 1983). In that sense, cognitive recovery level modulation of preattentional processing routines, as
may in part represent more efficient allocation of cogni- opposed to improvement in the rate or efficiency of the
tive capacity in response to environmental demands. In routines themselves. There was weaker evidence of dif-
cases where there are significant enduring deficits, reallo- ferential change in more global cognitive functions, as
cation of capacity would be further improved by taking measured by the COGLAB card sorting task. In the con-

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Schizophrenia Bulletin, Vol. 25, No. 2, 1999 W.D. Spaulding et al.

text of the large improvements in global functions in both practice, special training, or other treatment-like proce-
groups, further enhancement by cognitive treatment in dures (reviewed by Reed et al. 1992; Corrigan and
this domain may be less significant, or simply more diffi- Storzbach 1993). There can be little doubt that people
cult to detect. Taken together, these findings suggest that with stabilized chronic schizophrenia can achieve perfor-
part of the effect of the cognitive treatment was to con- mance improvements on a variety of cognitively challeng-
tribute a unique effect on the ability of higher-level func- ing tasks. However, the improvements observed in previ-
tions to optimally activate specialized elemental processes ous studies may not be any different from changes in
in response to particular environmental demands. normal subjects who practice an unfamiliar task, and there
In summary, cognitive recovery can occur in stabi- are no previous indications that such changes confer eco-
lized patients, and it appears to involve a spectrum of spe- logically significant benefits in personal or social func-
cific processes. Generally, the changes appear more tioning. The Spaulding et al. (1998) study is the first
robustly in higher levels of cognition. For both post-acute large-scale controlled treatment trial to show that treat-
and chronic course recovery, the predominance of ment-induced cognitive changes in the chronic phase have

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changes in measures of more complex cognition in the important objective benefits.
available research data is consistent with the hypothesis The primary outcome measure in that study, the
that recovery primarily involves improvements in execu- AIPSS, is an elaborate assessment of social competence.
tive-level organization, modulation, and integration of In the AIPSS, the subject is shown a series of videotaped
elemental cognitive processes, as opposed to better opera- vignettes of people engaged in some interpersonal prob-
tion of the elemental processes themselves. (Medication- lem or conflict. After each vignette the subjects are inter-
related improvement in backward masking may be a sig- viewed to ascertain their understanding of the portrayed
nificant exception to this rule.) Differential recovery of problem and their ability to resolve it. Finally, they are
different brain functions, related to each other through asked to role-play a solution. The entire assessment is
anatomical, neurophysiological, or functional organiza- itself videotaped and later scored by trained observers
tion, may produce individual differences in the recovery using a structured protocol. Assessments like the AIPSS
process as well. Lateralization of impairments may be detect improvements in social competence that are known
especially significant in this regard. Recovery is subject to have implications for long-term outcome, including
to enhancement by environmental and psychosocial fac- relapse and hospital recidivism (Wallace and Liberman
tors, which may range from "therapeutic milieu" condi- 1985; Hogarty et al. 1987). The size of the treatment
tions to therapeutic procedures that explicitly target cogni- effect of the cognitive intervention, as measured by the
tive functioning. AIPSS, is comparable to the effect size of atypical
antipsychotics over typicals in suppressing symptoms and
enhancing behavioral functioning. Longer-term appraisal
How Does Cognitive Improvement of overall rehabilitation outcome (Weilage 1997) confirms
Benefit Other Aspects of Recovery and that the Spaulding et al. (1998) cognitive treatment group
Rehabilitation? showed higher levels of rehabilitation success, as mea-
sured by judgment of staff who were blind to treatment
Whether or not cognitive change can be enhanced by group assignment.
treatment and rehabilitation, it is important to know There are a number of possible causal relationships
whether recovery of specific functions has meaningful between the domains of functioning measured in the
benefits for the patient. Such benefits could logically lie Spaulding et al. (1998) study. Cognitive changes may be
in either objective or subjective domains. Subjectively, it links in a cascade of changes, from stabilization of the
would be logical to expect that better cognitive function- neurophysiological level of acute psychosis to social
ing would be associated with reductions in distress or behavior, or they may be incidental "markers" of neuro-
greater self-efficacy. However, it would be difficult to physiological changes, unrelated to behavioral conse-
demonstrate this empirically because subjective expres- quences. In addition to having different roles in the
sions could be influenced by many factors, including causal sequence of recovery, beneficial effects of cogni-
symptom reduction and improvement in behavioral func- tive recovery may logically be expected to be direct or
tioning unrelated to cognitive changes. The systematic indirect. The latter would require interaction with some
studies needed to determine the true subjective value of other condition. For example, improvement in specific
cognitive recovery in schizophrenia have not been per- attentional or memory capabilities may have no direct
formed. effects on behavioral functioning, but may nevertheless
Many experimental and case studies show perfor- enhance a patient's response to social skills training or
mance improvements in cognitive domains in response to related rehabilitation interventions. This could be because

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Cognitive Functioning Schizophrenia Bulletin, Vol. 25, No. 2, 1999

the cognitive abilities in question have limited importance available data can provide information about how specific
to ongoing performance of social skills but are critical to sets of variables influence an outcome.
acquisition or reacquisition of those skills. The path model in figure 1 shows that the amount of
For the purposes of this article, we conducted a series cognitive treatment (i.e., the "dose" of cognitive therapy,
of analyses to explore in greater detail the mechanisms of expressed as a dosage unit of 1 or 0) directly influences
the cognitive treatment effect reported by Spaulding et al. AIPSS performance, without mediation by any of the cog-
(1998). The first step in these analyses was to identify all nitive measures in the protocol. This means that whatever
statistically significant bivariate correlations between the the cognitive mechanism of the treatment effect may be, it
degree of improvement in social competence and mea- is not identified in this model. Changes in COGLAB card
sures of cognition, behavioral functioning, and symptoms. sorting random errors and performance on the Halstead
The measure of social competence change is the change Reitan Trailmaking-Test B (Trails B) (Goldstein 1991)
score on the ATPSS overall performance scale, residual- performance are also associated with AIPSS change, but
ized by linear regression to remove variance attributable this happens independently of the cognitive treatment.
to the initial value of the score. Five measures of clinical Trails B change is associated in turn with pretreatment

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status (the five factors of the BPRS) and 13 neurocogni- levels of the visual form of the Rey Verbal Learning Test
tive measures were analyzed as predictor variables. The (VLT; Kern and Green 1994) and the false alarm rate on
initial value and the residualized change score for each the COGLAB continuous performance test/Span of
brought the total in the predictor pool to 36. Five of the Apprehension Test. The sizes of the correlations do not
pretreatment measures and two residualized change scores permit much confidence in the relative contributions of
showed significant correlations with the AIPSS change the pretreatment variables or the Trails B change. The
score (p < 0.05, uncorrected for multiple correlations). In contributions of the card sorting change score and treat-
addition, as expected from the significant cognitive treat- ment type, however, do permit a confident conclusion that
ment effect, the amount of cognitive treatment provided these two variables are independently associated with
(expressed as a dose unit of 0 or 1, reflecting whether or change in AIPSS performance. This would be consistent
not the patient received 6 months of cognitive treatment) with (but does not prove) the hypothesis that improve-
was correlated with AIPSS change. Together, these eight ments in the cognitive functions measured by the card
measures account for about 21 percent of the total change sorting task enhance acquisition of social competence in
in AIPSS performance (adjusted R2 = 0.206, p < 0.0036). the course of rehabilitation. However, what is most sig-
The measures fall in four separate domains: four mea- nificant about this analysis is what it does not show: The
sures of cognitive functioning at the start of treatment, cognitive treatment effect does not operate through any of
one measure of behavioral functioning before and during the measured cognitive functions, and so its cognitive
treatment (the Nurses Observation Scale for Inpatient mechanisms remain unknown.
Evaluation (NOSIE-30) Total Assets Scale; Honigfeld et The final step in these analyses was to employ inter-
al. 1966), two measures of change in cognitive function- action terms (Downs and Robertson 1991; Cortina 1993)
ing, and the "dose" of cognitive treatment. as independent (predictor) variables. An interaction term
The sequence and direction of possible causal rela- in this context is the arithmetic product of a quantitative
tionships among measures in the different domains can be expression of the treatment condition (the quantitative
logically assumed; for example, the sequence of pretreat- "dose" of treatment) and any organismic variable (e.g., a
ment functioning, administration of treatment, and measure of cognitive functioning). The organismic vari-
changes during treatment is known. This allows construc- able can be analyzed as it existed at the outset of treat-
tion of the path model shown in figure 1. A path model is ment, or it can be converted to a change score, that is, the
a sequentially ordered set of multiple regression formulae difference between pre and posttreatment scores. When
constructed to represent causal, as opposed to merely cor- included as an independent (or "predictor") variable in a
relational, relationships among variables. The strengths multiple regression equation whose dependent (or "tar-
of such relationships are expressed as beta weights, as in get") variable is also a change score, the interaction term
conventional multiple regression, and they represent the shows how the two different factors (the treatment and the
unique contribution of each independent variable to the organismic variable) work together to produce change.
dependent variables. When causal sequences are Interaction terms allow the possibility that a variable may
unknown, alternative path models can be constructed and behave differently in the presence of another variable. For
evaluated to determine which model best fits the available example, cognitive functioning may affect acquisition of
correlational data. When the possible causal pathways are social competence only in the presence of cognitive treat-
constrained by a known sequence of events in real time, ment. This contrasts with conventional multiple regres-
as in the present case, the path model that best fits the sion, which can show only the unique contributions of the

281
Schizophrenia Bulletin, Vol. 25, No. 2, 1999 W.D. Spaulding et al.

Figure 1. Path model constructed from bivarlate correlations between change on the AlPSS total
score, other measures in the assessment protocol, and the "dose" (1 or 0 dose units) of cognitive
therapy

Pre-treatment status Changes during treatment Outcome

Change in COGLRB
Card Sorting

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Change
Rey ULT Trails B
uisual form

/ False alarms on \ Change In


\COGLRB CPT/Span / ~ HIPSS Total

[ N0SIE-3B thru
v. treatment period

WfllS arithmetic

Dose of cognitive
treatment
LURIS Digit Span

Note.Numbers on paths indicate beta weights. AlPSS = Assessment of Interpersonal Problem Solving Skills; CPT =. continuous perfor-
mance test; NOSIE = Nurses Observation Scale for Inpatient Evaluation; Trails B = Halstead Reitan Trailmaking Test B; VLT = Verbal
Learning Test; WAIS = Wechsler Adult Intelligence Scale.
*p < 0.05.
"p < 0.02.
*"p<0.01.

individual variables. Interactions are assumed to operate ment dose, and indicates how those factors work together
over the course of the treatment period, so regression val- over time.
ues cannot be ordered or sequenced, as in a path model. In the Spaulding et al. (1998) data, 36 residualized
However, a single regression formula can be constructed change scores can be computed including interactions
that includes change scores, interaction terms, and treat- between treatment and pretreatment measures, and inter-

282
Cognitive Functioning Schizophrenia Bulletin, Vol. 25, No. 2, 1999

actions between treatment and residualized change scores. memory functioning in situations demanding social com-
Five of these were found to have significant bivariate cor- petence.
relations with the AIPSS change score, and four are inter- We repeated these analyses using a different outcome
actions between pretreatment cognitive functioning and variable, a composite measure of performance on four
treatment. The fifth is an interaction between changing assessments of information acquisition associated with
cognitive functioning and treatment. A multiple regres- social and living skills training. These consisted of paper-
sion equation including these, the card sorting and Trails and-pencil quizzes and brief role plays, designed specifi-
B change scores, and treatment dose accounts for about cally to assess assimilation of information presented in
28 percent of the change in the AIPSS (adjusted R2 = skill training modalities. Such assessments lack the eco-
0.275, p < 0.0003). The regression statistics are summa- logical validity of the AIPSS, but they are commonly used
rized in table 5. to monitor progress in treatment and may reflect more
directly patients' ability to benefit from particular modali-
Table 5. Multiple regression statistics for ties. The path model constructed from measures showing

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prediction of AIPSS change (residualized to significant bivariate correlations with the skill acquisition
remove initial value effects) by Interaction terms, change score is shown in figure 2. Unlike the AIPSS
cognitive change, and treatment dose model, no pretreatment measures predicted the outcome
Variable Beta Significance1 measure, and cognitive treatment did not affect outcome.
Behavioral functioning had a significant impact on out-
Dose of cognitive treatment 0.25 0.018
come, part of which was mediated by reductions in the
Change on COG LAB Card
Sort task 0.18 0.090 BPRS disorganization and paranoia dimensions and part
Change on Trails B 0.13 0.214 by change on the Denman verbal memory score (Denman
Change on Rey VLT auditory 1984). The amount of change in paranoia and verbal
form x treatment dose 0.27 0.010 memory was associated in turn with behavioral function-
Pretreatment COGLAB false ing as measured by the NOSIE-30. The size of the beta
alarms x treatment dose 0.20 0.067 weight of the Denman score is sufficient to allow some
Pretreatment Denman confidence that it reflects a real benefit of cognitive
Nonverbal x treatment dose 0.11 0.383 change for performance on the skill measure.
Pretreatment NOSIE-30 x
Taken together, these analyses suggest that cognitive
treatment dose 0.09 0.486
Pretreatment Rey VLT visual recovery, especially of verbal learning and memory, has
form x treatment dose 0.02 0.904 beneficial effects on various aspects of acquisition of
Note.AIPSS o Assessment of Interpersonal Problem Solving social skill and competence in the course of rehabilitation.
Skills; Trails B - Halstead Reltan Trailmaking B; VLT = Verbal In some cases, exposure to cognitive treatment may be
Learning Test; NOSIE = Nurses Observation Scale for Inpatient necessary for patients to fully realize these benefits.
Evaluation.
However, substantial portions of the improvement in
'Significance of T, reflecting the probability that the variable's social skill and competence remain unexplained, whether
unique contribution to the overall prediction of the dependent vari-
able is zero. or not the improvement is associated with cognitive treat-
ment. It is hoped that further application of this analytic
The sizes of most of the interaction terms' beta strategy, with increasingly sophisticated cognitive assess-
weights do not allow confidence that they contribute ment protocols and with other outcome measures, will
uniquely to prediction of AIPSS change, but the size for identify additional mechanisms and will articulate the
the interaction of cognitive treatment with change on the importance of additional aspects of cognitive recovery.
auditory form of the Rey Verbal Learning Test allows For the time being, it appears that verbal learning and
confidencejhat at least one interaction term is associated memory are particularly importanLtargets fortreatment.
with outcome. The Rey VLT is also one of the measures
that showed nonspecific improvement (i.e., unrelated to
treatment condition) in the outcome study. While learning Possible Mechanisms of the Effects of
and memory performance as measured by the Rey Psychosocial Interventions in Chronic
improves independently of cognitive treatment, the signif- Schizophrenia
icant interaction term indicates that the improvement is
associated with outcome only if cognitive treatment is The foregoing results and discussion indicate a need for
provided. This suggests that cognitive therapy works in theoretical models to account for how and why cognitive
part by helping patients to use improving learning and improvements occur in response to psychosocial treat-

283
Schizophrenia Bulletin, Vol. 25, No. 2, 1999 W.D. Spaulding et al.

Figure 2. Path model constructed from bivariate correlations between the skill acquisition outcome
measure and other variables In the assessment protocol

Pre-treatment status Changes during treatment Outcome

Change In BPRS
Disorganization

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Change In BPRS
Paranoia
.33**
/ N 0 S I E - 3 B thru Change In composite
V treatment period skill acquisition
assessment
.34**
f Change in Denman
V Uerbal Memory

Note.Numbers on paths indicate beta weights. BPRS = Brief Psychiatric Rating Scale; NOSIE = Nurses Observation Scale for Inpatient
Evaluation.
*p < 0.05.
"p < 0.01.

ment in chronic schizophrenia. Discussions of cognitive account for normalization of an otherwise stable neu-
treatment effects (e.g., Bellack 1992; Corrigan and rocognitive impairment. Mechanisms to account for cog-
Storzbach 1993; Brenner et al. 1994; Spaulding et al. nitive disorganization and reorganization in schizophrenia
1998; Bellack et al. 1999, this issue) raise the possibility have been proposed, in terms of learned behavioral
of at least three types of mechanisms: prosthetic mecha- response hierarchies (e.g., Broen and Storms 1966). At
nisms, in which new skills are established to replace or least one specific brain mechanism is involved in con-
compensate for impaired abilities; remediational mecha- struction and maintenance of such organizational hierar-
nisms, in which the impaired processes undergo actual chies (Houk and Wise 1993; Houk 1995), and it lies in
repair; and reorganizational mechanisms, in which envi- brain structures implicated in the etiology of schizophre-
ronmental conditions enhance functional reorganization of nia. Transient physiological dysregulation of such a brain
processes disrupted by acute psychosis. In addition, edu- mechanism, as in acute psychosis, could produce a linger-
cational, attributional, and self-instructional mechanisms ing disorganization of response hierarchies, whose reorga-
have been proposed, although these are usually associated nization is enhanced by the environmental contingencies
with cognitive-behavioral therapy aimed at the content of and demands associated with psychosocial treatment.
cognition, independent of neurocognitive impairments Thus, the prospects seem good for credible models to
(for a review, see Alford and Correia 1994). explain prosthetic and reorganizational cognitive treat-
Prosthetic, educational, attributional, and self-instruc- ment effects, especially models that integrate neurophysi-
tional mechanisms could operate according to familiar ological and neuropsychological mechanisms of learning,
models of learning, conditioning, and cognitive develop- conditioning, and behavioral organization.
ment. Remediational mechanisms pose a greater concep- A possible neuroendocrine mechanism of chronic-
tual problem, and it is unclear what kind of model could course cognitive recovery has emerged from studies of

284
Cognitive Functioning Schizophrenia Bulletin, Vol. 25, No. 2, 1999

hypothalamic-pituitary-adrenal (HPA) functioning in associated with intensive psychiatric rehabilitation. The


schizophrenia. The HPA axis has been increasingly impli- third (Fleming 1998) showed that patients with low corti-
cated in the etiology of schizophrenia, most extensively in sol activity also show especially severe impairment in
Walker and Diforio's (1997) neural diathesis-stress elabo- some aspects of cognitive functioning. Taken together,
ration of Walker's (1994) more general neurodevelopmen- these findings suggest that in the chronic course of schizo-
tal model. In this model, prenatal stress leads to high lev- phrenia, some patients experience a disruption of the reg-
els of cortisol, causing hippocampal cellular dysplasia. ulatory relationship between cognitive and HPA function-
This renders the individual vulnerable to environmental ing that produces a hypoactivation syndrome. This could
stress by creating a predisposition to HPA axis hyperactiv- be the result of medication, environmental controls,
ity. HPA hyperactivity continues to interact with hip- and/or the patient's appraisals and attributions all interact-
pocampal lesions, leading to further cellular damage. ing with an already compromised HPA system. The con-
HPA hyperactivity also contributes to expression of psy- sequences include residual cognitive impairment. A reha-
chotic symptoms through activation of subcortical bilitative environment, with systematic and graduated

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dopamine systems. Cortisol hyperactivity is associated environmental demands for physiological and cognitive
with acute schizophrenia (Albus et al. 1982; Christie et al. activation and attention to the patient's attributions and
1986; Copolov et al. 1989). appraisals, may help reverse this process.
The neural diathesis-stress model describes the HPA's The data showing recovery of cognitive functioning
role in onset and acute psychosis, but the model's implica- in schizophrenia, and the models that account for that
tions for the chronic course are largely unexplored. HPA data, suggest a number of conditions that should be
activity is affected by antipsychotic drugs. Treatment and expected to maximize recovery. These include environ-
rehabilitation environments are usually designed to reduce mental engineering that maximizes the clarity and pre-
"stress" and thereby affect HPA activity. Patients' beliefs, dictability of behavioral performance demands and conse-
attributions, and appraisals about themselves and their quences, psychosocial interventions that exercise key
control over their environment may undergo dramatic behavioral repertoires and their supporting executive-
changes after onset, and these factors are known to have level cognitive abilities, interventions that address
significant impact on HPA activity (Lazarus and Folkman patients' appraisals of stressful events and their control
1984). HPA dysregulation can produce a failure of the over them, and daily routines that enhance regulatory
activating function of cortisol, resulting in a hypoactiva- cycles of organismic activation. Significant cognitive
tion syndrome different in expression from the more
benefits appear to accrue from conventional rehabilitation
familiar hyperactivation/stress syndrome (Chrousos and
modalities, including contingency management and skill
Gold 1992). It would not be inconsistent with the neural
training, but modalities that specifically target cognitive
diathesis-stress model to expect that a poorly regulated
abilities have added value. However, the heterogeneity of
HPA axis could result in cortisol hypoactivity in the
cognitive impairment suggests that individual differences
chronic, residual phase of schizophrenia, at least in some
must be taken into account for optimal effect. Despite the
patients. In fact, abnormally low levels of cortisol, some-
overriding role of executive-level cognitive reorganiza-
times to the point of obliterating normal diurnal cycles,
tion, different patients rely on different cognitive
have been observed in chronic, stable schizophrenia
resources and cope with different cognitive liabilities in
patients in institutional settings (Bhadrinath and
Girijashanker 1984; Spaulding et al. 1990; Partridge the reorganization process. A cognitive technology is
1992; Fleming 1998). needed that is sensitive to such individual differences and
allows their consideration in construction of individual-
The recent discovery of cortisol receptors in cortical ized rehabilitation strategies.
neurons (for a review, see Newcomer et al. 1994) indi-
cates that the activating function of cortisol involves cog-
nitive as well as physiological resources. Experimental Conclusions
suppression of cortisol with dexamethasone in normal
subjects is associated with temporary impairments in Potential applications of cognitive science and technology
memory (Newcomer et al. 1994). Cortisol deficiencies to schizophrenia go far beyond elucidation of develop-
produce potentially reversible cognitive deficits in elderly mental etiological processes. Cognitive functioning is a
patients (Basavaraju and Phillips 1989). significant source of individual variation among patients
Of the three studies in our lab that identified institu- and is importantly related to outcome. Cognitive impair-
tionalized schizophrenia patients with cortisol hypoactiv- ments can change over the acute, post-acute, and chronic
ity, two (Spaulding et al. 1990; Partridge 1992) showed course of schizophrenia, in response to psychosocial as
some normalization of cortisol levels and fluctuations well as pharmacological treatment and rehabilitation. The

285
Schizophrenia Bulletin, Vol. 25, No. 2, 1999 W.D. Spaulding et al.

findings of research using the paradigms of experimental Brenner, H.D.; Hodel, B.; Roder, V.; and Corrigan, P.
psychopathology and neuropsychology suggest that a cog- Treatment of cognitive dysfunctions and behavioral
nitive technology can be perfected that would contribute deficits in schizophrenia. Schizophrenia Bulletin,
significantly to diagnosis, treatment and rehabilitation 18:21-26,1992.
planning, evaluation of patients' response to treatment, Brenner, H.; Roder, V.; Hodel, B.; Kienzle, N.; Reed, D.;
and the design of future treatment modalities. For some and Liberman, R. Integrated Psychological Therapy for
applications, it may be important to revise traditional Schizophrenic Patients. Toronto, Ontario: Hogrefe &
approaches to behavioral, psychological, and neuropsy- Huber, 1994.
chological assessment to accommodate the need for longi-
tudinal tracking of recovery over the time frames in which Brenner, H.D.; Stramke, W.; Hodel, B.; and Rui, C. "A
pharmacological and psychosocial treatments exert their Treatment Program for Impaired Cognitive Functions
effects. Models for systematically applying this technol- Aimed at Preventing Chronic Disability Among
ogy to clinical assessment and decision making are Schizophrenic Patients." Paper presented at World
Psychiatric Association Symposium, Baltimore, MD,

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already beginning to appear (see Spaulding et al. 1994).
To fully realize these potentials, we need research on the 1983.
cognitive psychopathology and neuropsychology of schiz- Broen, W., and Storms, L. Lawful disorganization: The
ophrenia that systematically addresses the longitudinal process underlying a schizophrenic syndrome.
course of the disorder, within and across its acute, post- Psychological Review, 73:265-279, 1966.
acute, and chronic residual phases, in the context of state- Christie, J.; Whalley, L.; Blackwood, H.; Bennie, J.;
of-the-art biopsychosocial treatment and rehabilitation. Blackburn, I.; and Fink, G. Disturbed endocrine function
in psychosis. British Journal of Psychiatry, 155:455^61,
1986.
References Chrousos, G., and Gold, P. The concepts of stress and
Albus, M.; Ackenheil, M.; Engel, R.; and Mueller, F. stress system disorders. Journal of the American Medical
Situational reactivity of autonomic functions in schizo- Association, 267:1244-1252, 1992.
phrenic patients. Psychiatry Research, 6:361-370, 1982. Copolov, D.; Rubin, R.; Stuart, G.; Poland, R.; Mander,
Alford, B., and Correia, C. Cognitive therapy of schizo- A.; Sashidharan, S.; Whitehouse, A.; Blackburn, I.;
phrenia: Theory and empirical status. Behavior Therapy, Freeman, C ; and Blackwood, D. Specificity of the sali-
25:17-33, 1994. vary dexamethesaone suppression test across psychiatric
diagnoses. Biological Psychiatry, 25:879-893, 1989.
Basavaraju, N., and Phillips, S. Cortisol deficient state:
A cause of reversible cognitive impairment and delirium Corrigan, P., and Storzbach, D. The ecological validity of
in the elderly. Journal of the American Geriatric Society, cognitive rehabilitation for schizophrenia. Journal of
37:49-51, 1989. Cognitive Rehabilitation, 11:14-21, 1993.
Bellack, A.S. Cognitive rehabilitation for schizophrenia: Cortina, J. Interaction, nonlinearity, and multicollinearity:
Is it possible? Is it necessary? Schizophrenia Bulletin, Implications for multiple regression. Journal of
18:43-50, 1992. Management, 19:915-922, 1993.
Bellack, A.S.; Gold, J.M.; and Buchanan, R.W. Cognitive Denman, S. Denman Neuropsychological Memory Scale:
rehabilitation for schizophrenia: Problems, prospects, and A clinical assessment of immediate recall, short-term
strategies. Schizophrenia Bulletin, 25:257-274, 1999. memory and long-term memory in verbal and nonverbal
areas. Charleston, SC: Sydney B. Denman, 1984.
Bhadrinath, B., and Girijashanker, K. DST in mania:
Prolonged suppression? British Journal of Psychiatry, Donohoe, C ; Carter, M.; Bloem, W.; Hirsch, G.; Laasi,
145:555-559, 1984. N.; and Wallace, C.J. Assessment of interpersonal prob-
lem solving skills. Psychiatry, 53(4):329-339, 1990.
Bowen, L.; Wallace, C ; Glynn, S.; Nuechterlein, K.;
Lutzger, J.; and Kuehnel, T. Schizophrenics' cognitive Downs, W., and Robertson, J. Random versus clinical
functioning and performance in interpersonal interactions samples: A question of inference. Journal of Social
and skills training procedures. Journal of Psychiatry Service Research, 14:57-83, 1991.
Research, 28:289-301, 1994. Erickson, R.C. Neuropsychological assessment and the
Braff, D.L., and Sacuzzo, D.P. The effect of antipsychotic rehabilitation of persons with severe psychiatric disabili-
medication on speed of information processing in schizo- ties. Rehabilitation Psychology, 33:15-25, 1988.
phrenia. American Journal of Psychiatry, 139:1127-1130, Erickson, R. Neuropsychological assessment and consul-
1982. tation in psychiatric rehabilitation. In: Spaulding, W., ed.

286
Cognitive Functioning Schizophrenia Bulletin, Vol. 25, No. 2, 1999

Cognitive Technology in Psychiatric Rehabilitation. schizophrenia: The long and short of it. Psychopharma-
Lincoln, NE: University of Nebraska Press, 1994. cology Bulletin, 23:12-13, 19.87.
pp. 2 7 ^ 8 . Honigfeld, G.; Gillis, R.; and Klett, J. NOSIE-30: A treat-
Erickson, R.C., and Binder, L.M. Cognitive deficits ment-sensitive ward behavior scale. Psychological
among functionally psychotic patients: A rehabilitative Review, 19:180-182, 1966.
perspective. Journal of Clinical and Experimental Houk, J. Information processing in modular circuits link-
Neuropsychology, 8:257-274, 1986. ing basal ganglia and cerebral cortex. In: Houk, J.; Davis,
Fleming, S. "Neuroendocrine Concomitants of Neuro- J.; and Bieser, D., eds. Models of Information Processing
cognitive Impairment in Chronic Schizophrenia." in the Basal Ganglia. Cambridge, MA: MIT Press, 1995.
Doctoral dissertation, University of NebraskaLincoln, pp. 3-9.
1998.
Houk, J., and Wise, S. Outline for a theory of motor
Gilbertson, M.; Yao, J.; and Van Kammen, D. Memory behavior. In: Rudomin, P.; Arbib, M.; and Cervantes-
and plasma HVA changes in schizophrenia: Are they

Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on December 12, 2016


Perez, F., eds. From Neural Networks to Artificial
episode markers? Biological Psychiatry, 35:203-206, Intelligence. Heidelberg, Germany: Springer-Verlag,
1994. 1993. pp. 452-470.
Gjerde, P.F. Attentional capacity dysfunction and arousal Kern, R.S., and Green, M.F. Cognitive prerequisites of
in schizophrenia. Psychological Bulletin, 93:57-72, 1983. skill acquisition in schizophrenia: Bridging micro- and
Gold, J.; Hermann, B.; Randolph, C ; and Wyler, A. macro-levels of processing. In: Spaulding, W., ed.
Schizophrenia and temporal lobe epilepsy: A neuropsy- Cognitive Technology in Psychiatric Rehabilitation.
chological analysis. Archives of General Psychiatry, Lincoln, NE: University of Nebraska Press, 1994.
51:265-272, 1994. pp. 49-66.
Goldstein, G. Comprehensive neuropsychological test Knight, R.G., and Russell, P.N. Global capacity reduction
batteries and research in schizophrenia. In: Steinhauer, S.; and schizophrenia. British Journal of Social and Clinical
Gruzelier, J.; and Zubin, J., eds. Handbook of Schizo- Psychology, 17:275-280, 1978.
phrenia: Neuropsychology, Psychopathology and In-
Lam, M. "Evaluating the Utility of a Card Sorting Task
formation Processing. Vol. 5. Amsterdam, The Nether-
as a Prognostic Indicator for Psychiatric Rehabilitation
lands: Elsevier, 1991.
Over the Course of Schizophrenia." Doctoral disserta-
Green, M. What are the functional consequences of neu- tion, Department of Psychology, University of
rocognitive deficits in schizophrenia? American Journal NebraskaLincoln, 1997.
of Psychiatry, 153:321-330, 1996.
Lazarus, R.S., and Folkman, S. Stress, Appraisal, and
Green, M. Schizophrenia From a Neurocognitive Per- Coping. New York, NY: Springer, 1984.
spective: Probing the Impenetrable Darkness. Boston,
Lee, M.; Thompson, P.; and Meltzer, H. Effects of cloza-
MA: Allyn & Bacon, 1998.
pine in cognitive function in schizophrenia. Journal of
Gruzelier, J. Synthesis and critical review of the evidence Clinical Psychiatry, 55(Suppl. B):82-87, 1994.
for hemisphere asymmetries of function in psychopathol-
ogy. In: Gruzelier, J., and Flor-Henry, P., eds. Hemisphere Liberman, R.P.; Nuechterlein, K.H.; and Wallace, C.J.
Asymmetries of Function in Psychopathology. New York, Social skills training and the nature of schizophrenia. In:
NY: Elsevier/North-Holland, 1979. Curran, J.P., and Monti, P.M., eds. Social Skills Training:
A Practical Handbook for Assessment and Treatment.
Gruzelier, J.H. Hemispheric imbalance: Syndromes of
New York, NY: Guilford, 1982. pp. 5-56.
schizophrenia, premorbid personality, and neurodevelop-
mentaHnfluences.-In; Steinhauerr S.R.; Gruzelier, J.H.; Meltzer, H.; Thompson, P.; Lee, M.; and Ranjan, R.
and Zubin, J., eds. Handbook of Schizophrenia: Vol. 5. Neuropsychological deficits in schizophrenia: Relation to
Neuropsychology, Psychopathology, and Information social function and effect of antipsychotic drug treatment.
Processing. Amsterdam, The Netherlands: Elsevier Neuropsychopharmacology, 14(Suppl. 3):27-33, 1996.
Science, 1991. pp. 599-650. Newcomer, J.; Craft, S.; Hershey, T.; Askins, K.; and
Harding, C ; Zubin, J.; and Strauss, J. Chronicity in Bardgett, M. Glucocorticoid-induced impairment in
schizophrenia: Revisited. British Journal of Psychiatry, declarative memory performance in adult humans.
161(Suppl. 18):27-37, 1992. Journal of Neuro science, 14:2047-2053, 1994.
Hogarty, G.; Anderson, C ; and Reiss, D. Family psy- Partridge, S. "Cortisol Functioning and the Treatment
choeducation, social skills training, and medication in Environment in Chronic Schizophrenia." Doctoral disser-

287
Schizophrenia Bulletin, Vol. 25, No. 2, 1999 W.D. Spaulding et al.

tation, Department of Psychology, University of Spaulding, W.; Reed, D.; Storzbach, D.; Sullivan, M.;
NebraskaLincoln, 1992. Weiler, M; and Richardson, C. The effects of a remedia-
Penn, D. Cognitive rehabilitation of social deficits in tional approach to cognitive therapy for schizophrenia. In:
schizophrenia: A direction of promise or following a Wykes, T, ed. Outcome and Innovation in Psychological
primrose path? Psychosocial Rehabilitation Journal, Treatment of Schizophrenia. London, England: John
15:27-41, 1991. Wiley, 1998. pp. 145-160.
Penn, D.; Mueser, K.; Spaulding, W.; Hope, D.; and Reed, Spaulding, W.D.; Storms, L.; Goodrich, V.; and Sullivan,
D. Information processing and social competence in M. Applications of experimental psychopathology in psy-
chronic schizophrenia. Schizophrenia Bulletin, 21:269- chiatric rehabilitation. Schizophrenia Bulletin, 12:560-
281, 1995. 577, 1986.
Penn, D.; Spaulding, W.; Reed, D.; and Sullivan, M. The Spaulding, W.; Sullivan, M.; Weiler, M.; Reed, D.;
relationship of social cognition to ward behavior in Richardson, C ; and Storzbach, D. Changing cognitive

Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on December 12, 2016


chronic schizophrenia. Schizophrenia Research, 20:327- functioning in rehabilitation of schizophrenia. Acta
335, 1996. Psychiatrica Scandinavica, 90(Suppl. 384): 116-124,
1994.
Peveler, R., and Fairburn, C. Measurement of neurotic
symptoms by self-report questionnaire: Validity of the Spaulding, W.; Wyss, H.; and Littrell, R. Training
SCL-90R. Psychological Medicine, 20:873-879, 1990. psychophysiological self-regulation skills in psychiatric
Plasky, P. Antidepressant usage in schizophrenia. rehabilitation. Psychosocial Rehabilitation Journal,
Schizophrenia Bulletin, 17:649-657, 1991. 13:37-39,1990.
Reed, D.; Sullivan, M.; Penn, D.; Stuve, P.; and Ventura, J.; Green, M.; Shaner, A.; and Liberman, R.
Spaulding, W. Assessment and treatment of cognitive Training and quality assurance with the BPRS.
impairments. In: Liberman, R.P., ed. Effective Psychiatric International Journal of Methods in Psychiatric Research,
Rehabilitation. San Francisco, CA: Jossey-Bass, 1992. 3:221-244, 1993.
pp. 7-20. Wagman, A., and Wagman, W. On the Wisconsin. In:
Silver, H., and Nassar, A. Fluvoxamine improves nega- Walker, E.; Dworkin, R.; and Cornblatt, B., eds. Progress
tive symptoms in treated chronic schizophrenia. in Experimental Personality Research. New York, NY:
Biological Psychiatry, 31:698-704, 1992. Springer, 1992. pp. 162-182.
Silverstein, M.; Harrow, M.; and Bryson, G. Neuro- Walker, E. Developmentally moderated expressions of
psychological prognosis and clinical recovery. Psychiatry the neuropathology underlying schizophrenia.
Research, 52:265-272, 1994. Schizophrenia Bulletin, 20:453^180, 1994.
Silverstein, S.; Knight, R.; Schwartzkopf, S.; West, L.; Walker, E., and Diforio, D. Schizophrenia: A neural
Osborne, L.; and Kamim, D. Configuration and context diathesis-stress model. Psychological Review, 104:667-
effects in perceptual organization in schizophrenia. 684, 1997.
Journal of Abnormal Psychology, 105:410-420, 1996. Wallace, C.J., and Liberman, R.P. Social skills training
Siris, S. Assessment and treatment of depression in schiz- for patients with schizophrenia: A controlled clinical trial.
ophrenia. Psychiatric Annals, 24:463467, 1994. Psychiatry Research, 15:239-247, 1985.
Spaulding, W. The relationships of some information pro- Weilage, M. "Cost Effectiveness of an Intensive
cessing factors to severely disturbed behaviors. Journal of Psychiatric Rehabilitation Program." Doctoral disserta-
Nervous and Mental Disease, 166:417^28, 1978. tion, Department of Psychology, University of
Spaulding, W. Spontaneous and induced changes in cog- NebraskaLincoln, 1997.
nition during psychiatric rehabilitation. In: Cromwell, Weinberger, D. On the plausibility of "the neurodevelop-
R.L., and Snyder, C.R., eds. Schizophrenia: Origins, mental hypothesis" of schizophrenia. A new understand-
Processes, Treatment, and Outcome. New York, NY: ing: Neurological basis and long-term outcome of schizo-
Oxford Press, 1993. pp. 299-312. phrenia. Neuropsychopharmacology, 14:1-11, 1996.
Spaulding, W.; Garbin, C ; and Dras, S. Cognitive func- Weinberger, D., and Lipska, B. Cortical maldevelopment,
tioning in chronic psychiatric patients and schizotypal antipsychotic drugs, and schizophrenia: A search for
college students. Journal of Nervous and Mental Disease, common ground. Schizophrenia Research, 16:87-110,
177:717-728, 1989. 1995.

288
Cognitive Functioning Schizophrenia Bulletin, Vol. 25, No. 2, 1999

Wykes, R., and Dunn, G. Cognitive deficit and the pre- The Authors
diction of rehabilitation success in a chronic psychiatric
group. Psychological Medicine, 22:389-398, 1992. William D. Spaulding, Ph.D., is Professor of Psychology,
University of NebraskaLincoln, and Clinical Psycholo-
Wykes, T.; Start, E.; and Katz, R. The prediction of reha-
gist, Community Transition Program, Lincoln Regional
bilitative success after three years: The use of social,
Center, Lincoln, NE. Shelley K. Fleming, M.A., is a grad-
symptom, and cognitive variables. British Journal of
uate student in the Department of Psychology, University
Psychiatry, 157:865-870, 1990.
of NebraskaLincoln. Done Reed, Ph.D., is a clinical
research associate, Department of Psychology, University
Acknowledgments of NebraskaLincoln, and clinical psychologist, Com-
munity Transition Program, Lincoln Regional Center.
This article was supported in part by National Institute of Mary Sullivan, M.S.W., is a clinical associate, Department
Mental Health grant R01 MH-44756-01. The authors also of Psychology, University of NebraskaLincoln, and
acknowledge the cooperation and support of the adminis- Program Director, Community Transition Program,

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tration of Lincoln Regional Center and the staff of the Lincoln Regional Center. Daniel Storzbach, Ph.D., is a
Center's Community Transition Program and Short-term research fellow, Department of Psychiatry and Behavioral
Care Program. Science, Veterans Affairs Medical Center, Portland, OR.
Mona Lam, M.A., is a graduate student in the Department
of Psychology, University of NebraskaLincoln.

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