SCHRES-04820; No of Pages 5

Schizophrenia Research xxx (2011) xxx–xxx

Contents lists available at SciVerse ScienceDirect

Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

The association between self-disorders and neurocognitive

dysfunction in schizophrenia
Elisabeth Haug a,⁎, Merete Øie a, Ingrid Melle b, c, Ole A. Andreassen b, c, Andrea Raballo d, e, f, Unni Bratlien a,
Lars Lien a, b, c, Paul Møller g
a
Division of Mental Health, Innlandet Hospital Trust, Norway
b
Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
c
Institute of Clinical Medicine, University of Oslo, Oslo, Norway
d
Department of Psychiatry, Psychiatric Center Hvidovre, University of Copenhagen, Denmark
e
Psychiatric Intensive Care Unit, Department of Mental Health, AUSL di Reggio Emilia, Reggio Emilia, Italy
f
Danish National Research Foundation, Center for Subjectivity Research, University of Copenhagen, Denmark
g
Department of Mental Health Research and Development, Division of Mental Health and Addiction,Vestre Viken Hospital Trust, Drammen, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Background: Neurocognitive deficits and self-disorders (i.e. altered basic self-awareness or — sense of self)
Received 2 June 2011 have both been suggested as fundamental trait features of schizophrenia. However, no study until now has
Received in revised form 10 November 2011 investigated the relationship between these two core features.
Accepted 13 November 2011 Aim: To investigate the relationship between self-disorders and neurocognitive performance in patients with
Available online xxxx
schizophrenia.
Method: Self-disorders were assessed in 57 patients in the early phase of schizophrenia by means of the
Keywords:
Schizophrenia
Examination of Anomalous Self-Experience (EASE) instrument. The neurocognitive assessments included
Neurocognition measures of psychomotor speed, working memory, executive- and memory functions.
Verbal memory Results: There were few associations between self-disorders and neurocognitive impairments. However,
Self-disorders high levels of SDs were significantly associated with impaired verbal memory.
Self-experience Conclusion: The reason for the general lack of associations between self-disorders and neurocognition
Phenomenology could be that they represent different basic features of the illness. Verbal memory may however be linked
to deficits in the patients' ability to comprehend, direct, remember and reason about their thoughts, functions
that are intimately related to the basic sense of self.
© 2011 Elsevier B.V. All rights reserved.

1. Introduction Self-disorders (SDs) are subtle disturbances of the person's spon-

Neurocognitive impairments are widely documented as important
features of schizophrenia, with potential implication for prognosis,
real-world functioning and long term outcome (Heinrichs, 2005;
Keefe et al., 2006). They have been documented in both early and
late phases of the disorder, as well as in high risk populations and un-
affected first degree relatives (Staal et al., 2000; Mesholam-Gately
et al., 2009; Cole et al., 2011). Impairments in the domains of verbal
learning and memory, psychomotor speed and attention have been
specifically reported in first episode schizophrenia spectrum disor-
ders (Townsend and Norman, 2004; Skelley et al., 2008). The impair-
ments remain stable over the course of illness and do not appear to be
secondary to symptoms or medications (Nieuwenstein et al., 2001).
Thus, neurocognitive impairments are considered as endophenotypic
traits of schizophrenia.
⁎ Corresponding author at: Division of Mental Health, Innlandet Hospital Trust, 2312
Ottestad, Norway. Tel.: + 47 95781487; fax: + 47 62581401.
E-mail address: elisabeth.haug@sykehuset-innlandet.no (E. Haug).
taneous identity feeling, the experience of him- or herself as a vital
subject, naturally immersed in the world (Parnas and Handest,
2003; Parnas et al., 2005b). They affect the fundamental levels of con-
sciousness, and include characteristic forms of depersonalization,
anomalous experiences of cognition and stream of consciousness,
self-alienation, pervasive difficulties in grasping the familiar and
taken-for-granted meanings, communicational and social inadequa-
cies, unusual bodily feelings and existential reorientation (Parnas
and Handest, 2003; Sass and Parnas, 2003). Some SDs are related,
but not equal, to other subjectively experienced phenomena such as
Basic Symptoms (BS). BS are subclinical disturbances in drive, affect,
thinking, speech, (body) perception, motor action, central vegetative
functions, and stress tolerance (Schultze-Lutter, 2009). Recent empir-
ical evidence suggests that SDs selectively aggregate in both subpsy-
chotic (schizophrenia prodromes and schizotypal disorder) and
psychotic forms of schizophrenia spectrum disorders. Both qualitative
(Parnas et al., 1998; Møller and Husby, 2000) and quantitative
(Parnas et al., 2003, 2005a; Raballo et al., 2011) studies have shown
that SDs characterize both the prodromal, early psychotic and the

0920-9964/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2011.11.015

Please cite this article as: Haug, E., et al., The association between self-disorders and neurocognitive dysfunction in schizophrenia, Schizophr.
Res. (2011), doi:10.1016/j.schres.2011.11.015
2 E. Haug et al. / Schizophrenia Research xxx (2011) xxx–xxx

more chronic phases of schizophrenia. As non-psychotic, mainly trait- overtly psychotic that they had problems participating in a lengthy in-
like disturbances of pre-reflective self-awareness, SDs antedate the terview or in the neurocognitive assessments. The neurocognitive test-
development of clearly delusional experiences (Parnas and Handest, ing was done as close to the assessment of SDs as possible, and not later
2003; Sass and Parnas, 2003; Parnas, 2005). Thus, SDs may also be a than 4 weeks. Fifty seven patients with schizophrenia completed the
candidate phenotype for schizophrenia (Sass and Parnas, 2003; full protocol including assessments of self-disorders and neurocognitive
Raballo and Parnas, 2010). SDs are assessed with the Examination of testing (Table 1). All patients were early in their treatment course, 49
Anomalous Self-Experience (EASE) (Parnas et al., 2005b), an instru- (86%) at the start of first adequate treatment.
ment that does not cover all potential anomalies of experience, but fo- All participants gave written, informed consent to participate. The
cuses specifically on SDs. Both SDs and neurocognitive deficits have study was approved by the Regional Committee for Medical Research
thus been suggested as fundamental trait features of schizophrenia. Ethics and the Norwegian Data Inspectorate.
A few small studies have investigated the relationship between BS
and neurocognitive deficits, but no study has specifically investigated 2.2. Clinical assessments
this relationship for SDs in patients with psychotic disorders. A study
of 32 inpatients with schizophrenia revealed associations between BS Diagnoses were ascertained by two experienced psychiatrists (EH
(measured with the Frankfurt Complaint Questionnaire (FCQ)) and and UB) using the Structural Clinical Interview for the Diagnostic and
impairments of executive functioning, psychomotor speed and sub- Statistical Manual of Mental Disorders, fourth edition (SCID-IV)
tests of Wechsler Adult Intelligence Scale (WAIS) (Cuesta et al., (1994). Symptom severity and psychosocial function were assessed
1996). However, another study of 50 outpatients with chronic schizo- using standard psychiatric measures including the Structured Clinical
phrenia reported BS (also measured with the FCQ) to be unrelated to Interview for the Positive and Negative Syndrome Scale (SCI-PANSS)
measures of executive functioning (Zanello and Huguelet, 2001). A (Kay et al., 1987) and the Global Assessment of Functioning–Split
large third study focusing on neurocognition and selected BSs in Version (GAF-S) (Endicott et al., 1976; Pedersen et al., 2007). Dura-
102 prodromal patients (using the Schizophrenia Proneness Instru- tion of untreated psychosis (DUP) was measured as time from onset
ment, Adult version (SPI-A)) (Schultze-Lutter et al., 2007a) did also of psychosis (first week with symptoms that corresponded with a
not find any significant correlation between the subjective distur- score of four or more on one of the of the PANSS subscale items: delu-
bances and objective neurocognitive function (pattern recognition, sions, hallucinatory behavior, grandiosity, suspiciousness/persecution
attention, working memory, verbal and visual memory, psychomotor or unusual thought content).
speed, and executive functions) (Schultze-Lutter et al., 2007b). It is Both investigators completed the TOP study group's training and
not known how many of these “at-risk” patients who eventually de- reliability program with SCID training based on- and supervised by
veloped psychotic disorders. the UCLA training program (Ventura et al., 1998). For DSM-IV diag-
Few studies have investigated the relationship between the sub- nostics, mean overall kappa for the standard diagnosis of training
jective experience of the self and neurocognitive functions in schizo- videos was 0.77, and mean overall kappa for a randomly drawn sub-
phrenia. Results so far have been inconsistent, underlining the need set of the present study patients was also 0.77 (95% CI 0.60–0.94).
for further research. Moreover, SPI-A and FCQ do not target SDs spe- Intra Class Coefficients (ICC 1.1) for the other scales was: PANSS pos-
cifically, so new studies using comprehensive measures of SDs is itive subscale 0.82 (95% CI 0.66–0.94), PANSS negative subscale 0.76
also preferable. (95% CI 0.58–0.93), PANSS general subscale 0.73 (95% CI 0.54–0.90),
The main purpose of the current study is therefore to explore the and GAF-F 0.85 (95% CI 0.76–0.92).
relationships between SDs, as measured by the EASE, and neurocogni-
tive test performance in the early phase of schizophrenia. The research Table 1
literature so far is slightly more against than in favor of an association. Demographic and clinical characteristics.
However, both SDs and neurocognitive deficits have been suggested as
Number of patients 57
fundamental trait features of schizophrenia. Neurocognitive functions
are subserving consciousness, and at a more phenomenological level Demographics
Male gender, n (%) 29 (51)
SDs affect deleteriously the integration of affect, will, volition, and neu-
Age years, mean (SD) 25.4 (7.3)
rocognition that gives the person a sense of unity (Fabrega, 1989). Education years, mean (SD) 11.3 (2.3)
Thus our hypothesis is that there are some associations between SDs NART total error, mean (SD) 25.5 (9.5)
and neurocognitive deficits, and that higher SDs would correlate with NART IQ, mean (SD) 104.7 (6.7)
poorer neurocognitive performance. DUP weeks, median (range) 122 (4–2040)
PANSS, mean (SD)
PANSS total 76.4 (16.8)
2. Material and methods PANSS positive 18.7 (4.6)
PANSS negative 18.2 (7.1)
2.1. Design and sample PANSS general 40.4 (8.3)
Functional level, mean (SD)
GAF symptom 34.9 (8.9)
The current study is part of the Norwegian Thematically Organized GAF function 35.8 (5.7)
Psychosis (TOP) Study (Romm et al., 2010) and involved all psychiatric Patients on medication, n (%)
treatment facilities in two neighboring Norwegian counties (Hedmark Antipsychotic 36 (63)
and Oppland, population 375.000 people). Inclusion criteria were: age Antiepileptic/mood stabilizer 9 (16)
Lithium 1 (2)
between 18 and 65 years; consecutive in- or outpatients referred to
Antidepressant 16 (28)
treatment for a DSM-IV diagnosis of schizophrenia. Exclusion criteria Substance abuse, n (%)
were: head injury with neurological complications, neurological Last 6 months
disorder and mental retardation (IQ b 70, Wechsler Abbreviated Scale Alcohol abuse 7 (12)
Drug abuse 6 (11)
of Intelligence WASI) (Wechsler, 2003, 2007). Patients with concurrent
Lifetime
substance use disorders were not excluded as long as they did not meet Alcohol abuse 7 (12)
the criteria for DSM-IV substance induced psychotic disorder. To assure Drug abuse 6 (11)
valid assessment of neurocognitive test performance all participants IQ, mean (SD)
had to score 15 or above on the forced recognition trial of the California WASI Verbal IQ 90.7 (14.3)
WASI Performance IQ 95.7 (14.1)
Verbal Learning Test (CVLT II). The patients were required not be so

Please cite this article as: Haug, E., et al., The association between self-disorders and neurocognitive dysfunction in schizophrenia, Schizophr.
Res. (2011), doi:10.1016/j.schres.2011.11.015
 E. Haug et al. / Schizophrenia Research xxx (2011) xxx–xxx
2.3. Neurocognitive assessment
The assessments were performed by clinical psychologists trained
and supervised by an experienced neuropsychologist and researcher
(MØ). All subjects were tested individually but received the tests in
the same fixed order. Total time for all assessments was about 3 h, in-
cluding breaks. Premorbid IQ was assessed with a Norwegian Re-
search version of the National Adult Reading Test (NART) (Crawford
et al., 2001; Vaskinn and Sundet, 2001) and current estimated IQ
with WASI (Wechsler, 2003, 2007). The other tests cover domains
shown to be sensitive to the neurocognitive dysfunction in psychosis
(Green et al., 2004):
Psychomotor speed: Digit Symbol from WAIS-III (Wechsler, 1997).
The task is to fill in blank spaces with the symbol that is paired to
the number above the blank space as quickly as possible for 120 s.
The score is the number of squares filled in correctly.
Working memory: Letter Number Span from WAIS-III (Wechsler,
1997). This test consists of six items. Each contains three trails
with the same number of digits and letters. The examinee reads
each trail, and the patient is asked to recall the letters in alphabetical
order and the numbers in ascending order. This task is sensitive to
auditory working memory. Outcome is total correct recalled trails.
Verbal memory: Logical Memory Test from the Wechsler Memory
Scale [WMS] III (Wechsler et al., 2008). This is a verbal test asses-
sing immediate and delayed memory for two short stories orally
presented. Immediate memory was used here.
Visual memory: Rey–Oesterrieth Complex Figure Test (Meyers and
Meyers, 1995). The subject observes a complex geometric figure
for 30 s and then reproduces it from memory, immediately and
after a brief delay (20 min) without prompting. Delayed memory
of the figure was used here.
Executive functions: The Colour-Word Interference subtests from
the Delis–Kaplan Executive Function System (D-KEFS) (Delis et al.,
2001). This test includes four conditions: Colour Naming, Word
Reading, Inhibition, and Inhibition/Switching. In the first condition
the subject has to name different colors, before reading the printed
words of these colors in the second condition. In the third condition
the subject need to inhibit this overlearned verbal response when
naming the dissonant ink colors in which the words are printed. In
the fourth condition the subject is asked to switch back and
forth between naming the dissonant ink colors and reading the
words. Executive functions used in the present study were inhibi-
tion (3. condition) and cognitive flexibility (4. condition), and com-
pletion time in seconds was examined.
Standard scores or T-scores (Rey) according to norms were used
for all tests (Table 2).
2.4. Assessment of self-disorders
SDs were assessed with the EASE manual (Parnas et al., 2005b),
comprising five domains: 1. Cognition and stream of consciousness.
2. Self-awareness and presence. 3. Bodily experiences. 4. Demarca-
tion/transitivism. 5. Existential reorientation. This represents a wide
variety of anomalous self-experiences condensed into 57 main items
and scored on a 5-point Likert scale (0–4), in which 0 = absent; 1 =
questionably present; 2 = definitely present, mild; 3 = definitely
present, moderate; 4 = definitely present, severe. For the purpose
of the analyses, the Likert scale was dichotomized as 0 (absent or
questionably present) and 1 (definitely present, all severity levels).
With the EASE, we measure life-time prevalence of SDs.
Each EASE interview took 30–90 min, all conducted by EH after
training by one of the authors of the EASE (PM). The inter-rater
Please cite this article as: Haug, E., et al., The association between self-disorders and neurocognitive dysfunction in schizophrenia, Schizophr.
Res. (2011), doi:10.1016/j.schres.2011.11.015
3
Table 2
Neurocognitive performance.
Neurocognitive function (test name) Scorea
Psychomotor speed (S-score) mean (SD) 7.0 (2.3)
(Digit Symbol from WAIS-III)
Working memory (S-score) mean (SD) 7.4 (2.2)
(Letter Number Span from WAIS-III)
Verbal memory mean (S-score) (SD) 7.9 (3.0)
(Logical Memory Test Wechsler Memory Scale [WMS] III)
Visual memory mean (T- score) (SD) 38.4(15.3)
(Rey-Oesterrieth Complex Figure Test)
Executive functions (S-score)
(The Colour-Word Interference subtests from the
Delis-Kaplan Executive Function System (DKEFS)
Inhibition mean (SD) 7.8 (3.0)
Cognitive flexibility mean (SD) 7.4 (3.5)
a
For the normal population mean S-score = 10 (SD = 3) and mean T-score = 50
(SD = 10).
reliability (IRR) for the EASE items was examined on the basis of 25
randomly drawn videotaped interviews examined by PM, who was
blind to diagnostic and other clinical information. The IRR was
found to be very good with an overall inter-rater correlation of the
EASE total score above 0.80 (Spearman's coefficient, p b 0.001), and
kappa= 0.65. The internal consistency of the EASE scale was found to
be very good across the two raters, with a Cronbach's alpha for the
whole scale above 0.85 (Møller et al., 2011).
2.5. Statistical analysis
All analyses were performed with the statistical package SPSS,
version 15.0. Mean and standard deviations are reported for continu-
ous variables and percentages for categorical variables. Spearman's
rank order correlation analyses were used to investigate possible asso-
ciations between different neurocognitive measures and SDs (EASE
total score). Independent t-tests or Mann–Whitney U tests (dependent
on the distribution of data) were used to investigate group differences
for continuous data. Linear regression analyses were used to explore if
there were possible confounders of the relationship between SDs and
neurocognitive measures.
3. Results
The mean EASE total score was 25.3 (±9.6). This means that al-
most half of the items are scored as present, indicating definitely
high levels of SDs in the current sample. There is no specific compar-
ison point here, but simply a clinical experience and judgment that
such a “prevalence” of SDs should be seen as quite massive. The pa-
tients as a group had neurocognitive test results ranging from 0.75
to 1 SD under norms (Table 2).
The EASE total score was significantly associated with verbal
memory, meaning that high levels of SDs were associated with im-
paired verbal memory (Table 3). There were however no other signif-
icant association between SDs and neurocognitive measures,
including psychomotor speed, working memory, executive functions
and visual memory.
There were also statistically significant associations (r = 0.663 to
0.902) between the EASE total score and all EASE domain scores (1,
2, 3, 4 and 5). EASE domain 2 and 3 scores had a statistically signifi-
cant association with verbal memory in line with the EASE total
score. The main analyses of the current paper thus focus on the
EASE total score.
There were no significant gender differences in EASE total scores,
verbal IQ (WASI VIQ), performance IQ (WASI PIQ) or verbal memory
and no significant associations between SDs and current symptom
levels as measured by the PANSS. We did however find significant
correlations between PANSS positive score and working memory,
4 E. Haug et al. / Schizophrenia Research xxx (2011) xxx–xxx
Table 3
Correlation between SDs (EASE total score) and neurocognitive function.
Neurocognitive function (test name)
Psychomotor speed (Digit Symbol Coding)
Working memory (Letter Number Span)
Verbal memory (Logical Memory Test; WMS III)
Visual memory (Rey–Oesterrieth Complex Figure Test)
Executive functions (C-W interference; D-KEFS)
Inhibition
Cognitive flexibility
a
Correlation is significant at the .05 level (2-tailed).
executive functions and visual memory, and between PANSS total
score and visual memory, indicating that high levels of psychotic
symptoms were associated with impaired neurocognitive perfor-
mance. We did not find any significant association between any
PANSS scores and verbal memory. In follow-up analyses we did not
find any indications that the association between SDs and verbal
memory was confounded by differences in gender or in psychotic
symptoms. In a final follow-up analysis we additionally explored
the relationship between EASE domain 1 (Cognition and stream of
consciousness) and neurocognitive function, to look for more specific
associations between subjective and objective cognitive dysfunctions,
but did not find any (data not shown).
4. Discussion
4.1. General discussion
Our main finding was that the level of SDs is significantly associ-
ated with verbal memory but not with working memory, executive
function, psychomotor speed or visual memory in these patients
with early phase schizophrenia.
A possible explanation for the general lack of associations between
SDs and neurocognition is that SDs and these specific neurocognitive
functions could represent different basic expressions of the illness.
This also seems to be supported by the fact that SDs and these ob-
jective neurocognitive functions activate different CNS networks. The
neurocognitive functions measured in the present study are supposed
to be mediated by activation of the dorsolateral prefrontal cortex,
temporal- and unspecific subcortical regions of the brain. The neuro-
cognitive test situation is structured with little affective- and somato-
sensory salience. In contrast, the questions asked in the EASE have
focus on more subjective experiences in everyday situations where
somatosensory and affective processes interact with neurocognition.
These processes have been associated with activation of other areas
of the brain such as the thalamus, orbito-frontal cortex, the limbic
system and several distinct somatosensory corties in the insular and
parietal regions (Damasio, 1994). It is possible that if we had included
neurocognitive tests that also activate multiple sensory systems such
as memory-prediction tests (Corlett et al., 2007; Keefe and Kraus,
2009; Kraus et al., 2009) more significant associations between neu-
rocognition and SDs may have been revealed.
SDs were, however, significantly correlated with verbal memory.
The self is a dynamic structure with set of multidimensional repre-
sentations stored in memory. New information and new thoughts
are processed in relation with preexisting self-knowledge. The verbal
memory test used in the current study requires rapid cognitive pro-
cessing of incoming verbal information and efficient organization
for accurate recall. It is possible that deficits in verbal memory may
cause deficits in the ability to comprehend, direct, remember and rea-
son about one's own thoughts and self-knowledge, functions that can
be seen as related to several aspects of SDs, or the sense of self. It is
also possible that SDs may be the primary deficit, causing impaired
verbal memory.
Please cite this article as: Haug, E., et al., The association between self-disorders and neurocognitive dysfunction in schizophrenia, Schizophr.
Res. (2011), doi:10.1016/j.schres.2011.11.015
Even though we found associations between clinical symptom-
atology (primarily PANSS positive scores) and working memory, exec-
Corr. (sign) utive functions and visual memory, we did not find any significant
associations between PANSS scores and verbal memory or SDs. Thus,
.003 (.983)
−.100 (.461) there were no indications that the relationship between SDs and verbal
−.316 (.017)a memory was mediated through clinical symptoms. Some studies have
−.065 (.631) shown that neurocognitive impairment may be more severe in males
than in females with schizophrenia (Heinrichs, 2005). Theoretically,
−.066 (.627)
.119 (.381) the lack of association between SDs and neurocognition could be a
result of gender differences. However, our results showed no gender
differences in SDs, estimated IQ or verbal memory and follow-up
analyses also indicated that gender was not a confounder.
As far as we know, there are no previous studies on the relation-
ship between SDs (measured by the EASE) and neurocognitive im-
pairments. The two previously mentioned studies (Cuesta et al.,
1996; Zanello and Huguelet, 2001) looked at BS (measured by the
FCQ) and showed diverging results. The study of prodromal patients
(Schultze-Lutter et al., 2007b) did not show any significant correla-
tions between neurocognitive function (including verbal memory)
and experiential disturbances of the BS type (measured with the
SPI-A). Differences might be due to discrepancies in the features mea-
sured by the different scales or differences in sample characteristics.
The SPI-A and FCQ are both based on the BS concept, measuring
self-experienced complaints quite broadly and covering limited as-
pects of SDs, while the EASE is a specific instrument that allows a
comprehensive clinical mapping of several domains of SDs (EASE
total score is a sum score of 57 SD items). Additionally, BS are concep-
tualized as partly independent symptom-like features, whereas
SDs, as measured by the EASE, are seen as overlapping expressions
of a fundamental, implicit quality of human consciousness, namely
subjectivity.
Further, the three previously mentioned studies focused on dif-
ferent patient groups, chronic patients (Zanello and Huguelet, 2001),
patients consecutively admitted due to symptomatic relapse, but
not first-treatment (Cuesta et al., 1996), and prodromal patients
with some uncertainty if all of them would develop schizophrenia
(Schultze-Lutter et al., 2007b).
The patients in the current study were early in their treated course,
so findings are not confounded by selection of non-responders, chronic-
ity, hospitalization or medication effects.
To conclude: We found that higher levels of SDs were associat-
ed with impaired verbal memory in the early treatment phase of
schizophrenia. Except for that, no significant associations between
SDs and neurocognitive impairments were found. The individuals
in the study had high levels of SDs and simultaneously reduced
neurocognition. This mainly seems to be different types of prob-
lems that do not correlate much. Therefore, early assessment of
neurocognitive impairments as well as SDs will be important, for
therapeutic and diagnostic reasons.
More and larger studies, in the early illness phases of schizophre-
nia, are required to further clarify the relationship between SDs and
neurocognitive deficits.
4.2. Strengths and limitations of the study
4.2.1. Strengths
1) We included patients in the early phase of the treated course
of the disorder, thereby minimizing potential confounding effects
such as selection of non-responders, chronicity and substance use
or medication use that might impact on the assessment of SDs
and neurocognitive functioning; 2) the neurocognitive assess-
ments were done by psychologists who were blind to information
about the EASE score; 3) we enrolled patients consecutively from
all treatment facilities in a large combined rural/urban catchment
area, so the study population has a relatively high degree of
representativity.
 E. Haug et al. / Schizophrenia Research xxx (2011) xxx–xxx
4.2.2. Limitations
Since we wanted to investigate the patients as early as possible in
the treated phase of schizophrenia, some of the patients – although
able to give informed consent – were not in full remission at the
time of neurocognitive testing. This may have confounded the results
with potential effects of psychotic symptoms. However, all partici-
pants scored 15 or above on the forced recognition trial of the CVLT
II indicating adequate valid test performance.
Role of funding source
Funding for this study was provided by Innlandet Hospital Trust (grant numbers
150096, 150102, 150119, 150135); South-East Health Authority (grant number
2008–058); (grant number 2004–123, 2006–258). The funding sources had no further
role in study design; in the collection, analysis and interpretation of data; in the writing
of the report; and in the decision to submit the paper for publication.
Contributors
EH and PM planned the current study, and MØ, IM, OAA and LL contributed to the
study design. EH and UB contributed to data collection. EH conducted the statistical an-
alyses and also wrote the first draft of the manuscript. EH, MØ, PM, IM and AR contrib-
uted to the analyses. PM was the main supervisor of the study, and introduced the
concept of self-disorders. All authors participated in critical revision of manuscript
drafts and approved the final version.
Conflict of interest
All the authors declare no conflict of interest.
Acknowledgments
The authors thank the patients for participating in the study. We also thank Innlan-
det Hospital Trust for making convenient and necessary arrangements for the work on
this article.
References
Cole, V.T., Weinberger, D.R., Dickinson, D., 2011. Intra-individual variability across neu-
ropsychological tasks in schizophrenia: a comparison of patients, their siblings,
and healthy controls. Schizophr. Res. 129, 91–93.
Corlett, P.R., Honey, G.D., Fletcher, P.C., 2007. From prediction error to psychosis: keta-
mine as a pharmacological model of delusions. J. Psychopharmacol. 21, 238–252.
Crawford, J.R., Deary, I.J., Starr, J., Whalley, L.J., 2001. The NART as an index of prior
intellectual functioning: a retrospective validity study covering a 66-year interval.
Psychol. Med. 31, 451–458.
Cuesta, M.J., Peralta, V., Juan, J.A., 1996. Abnormal subjective experiences in schizo-
phrenia: its relationships with neuropsychological disturbances and frontal signs.
Eur. Arch. Psychiatry Clin. Neurosci. 246, 101–105.
Damasio, A., 1994. Descartes error. Emotion, Reason and the Human Brain. Vintage
books, London.
Delis, D., Kaplan, E., Kramer, J., 2001. Delis–Kaplan Executive FunctionSystem. Examiner's
Manual. The Psychological Corporation; Harcourt Assessment Company, San Antonio,
Texas.
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), ed 4, 1994. APA.
American Psychiatric Association, Washington DC.
Endicott, J., Spitzer, R.L., Fleiss, J.L., Cohen, J., 1976. The Global Assessment Scale. A
Procedure for Measuring Overall Severity of Psychiatric Disturbance. Arch. Gen.
Psychiatry 33 (6), 766–771.
Fabrega Jr., H., 1989. The self and schizophrenia: a cultural perspective. Schizophr. Bull.
15, 277–290.
Green, M.F., Nuechterlein, K.H., Gold, J.M., Barch, D.M., Cohen, J., Essock, S., Fenton, W.S.,
Frese, F., Goldberg, T.E., Heaton, R.K., Keefe, R.S., Kern, R.S., Kraemer, H., Stover, E.,
Weinberger, D.R., Zalcman, S., Marder, S.R., 2004. Approaching a consensus cogni-
tive battery for clinical trials in schizophrenia: the NIMH-MATRICS conference to
select cognitive domains and test criteria. Biol. Psychiatry 56, 301–307.
Heinrichs, R.W., 2005. The primacy of cognition in schizophrenia. Am. Psychol. 60, 229–242.
Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome scale
(PANSS) for schizophrenia. Schizophr. Bull. 13, 261–276.
Keefe, R.S., Kraus, M.S., 2009. Measuring memory-prediction errors and their conse-
quences in youth at risk for schizophrenia. Ann. Acad. Med. Singapore 38, 414–416.
Keefe, R.S., Bilder, R.M., Harvey, P.D., Davis, S.M., Palmer, B.W., Gold, J.M., Meltzer, H.Y.,
Green, M.F., Miller, D.D., Canive, J.M., Adler, L.W., Manschreck, T.C., Swartz, M.,
Rosenheck, R., Perkins, D.O., Walker, T.M., Stroup, T.S., McEvoy, J.P., Lieberman,
Please cite this article as: Haug, E., et al., The association between self-disorders and neurocognitive dysfunction in schizophrenia, Schizophr.
Res. (2011), doi:10.1016/j.schres.2011.11.015
5
J.A., 2006. Baseline neurocognitive deficits in the CATIE schizophrenia trial. Neu-
ropsychopharmacology 31, 2033–2046.
Kraus, M.S., Keefe, R.S., Krishnan, R.K., 2009. Memory-prediction errors and their
consequences in schizophrenia. Neuropsychol. Rev. 19, 336–352.
Mesholam-Gately, R.I., Giuliano, A.J., Goff, K.P., Faraone, S.V., Seidman, L.J., 2009. Neuro-
cognition in first-episode schizophrenia: a meta-analytic review. Neuropsychology
23, 315–336.
Meyers, J., Meyers, K., 1995. Rey Complex Figure tests and Recognition Trial. Profes-
sional Manual. Psychological AssessmentResources.
Møller, P., Husby, R., 2000. The initial prodrome in schizophrenia: searching for
naturalistic core dimensions of experience and behavior. Schizophr. Bull. 26,
217–232.
Møller, P., Haug, E., Raballo, A., Parnas, J., Melle, I., 2011. Examination of Anomalous
Self-Experience (EASE) in first-episode psychosis: interrater reliability. Psychopa-
thology 44, 386–390.
Nieuwenstein, M.R., Aleman, A., de Haan, E.H., 2001. Relationship between symptom
dimensions and neurocognitive functioning in schizophrenia: a meta-analysis of
WCST and CPT studies. Wisconsin Card Sorting Test. Continuous Performance
Test. J. Psychiatr. Res. 35, 119–125.
Parnas, J., 2005. Clinical detection of schizophrenia-prone individuals: critical appraisal.
Br. J. Psychiatry Suppl. 48, 111–112.
Parnas, J., Handest, P., 2003. Phenomenology of anomalous self-experience in early
schizophrenia. Compr. Psychiatry 44, 121–134.
Parnas, J., Jansson, L., Handest, P., 1998. Self-experience in the prodromal phases of
schizophrenia:a pilot stydy of first admissions. Neurol. Psychiatry Brain Res. 6,
107–116.
Parnas, J., Handest, P., Saebye, D., Jansson, L., 2003. Anomalies of subjective experience
in schizophrenia and psychotic bipolar illness. Acta Psychiatr. Scand. 108, 126–133.
Parnas, J., Handest, P., Jansson, L., Saebye, D., 2005a. Anomalous subjective experience
among first-admitted schizophrenia spectrum patients: empirical investigation.
Psychopathology 38, 259–267.
Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., Zahavi, D., 2005b.
EASE: Examination of Anomalous Self-Experience. Psychopathology 38, 236–258.
Pedersen, G., Hagtveit, K.A., Karterud, S., 2007. Generalizability studies of the global
assessment of functioning-split version. Compr. Psychiatry 48, 88–94.
Raballo, A., Parnas, J., 2010. The silent side of the spectrum: schizotypy and the schizo-
taxic self. Schizophr. Bull. 37, 1017–1026.
Raballo, A., Saebye, D., Parnas, J., 2011. Looking at the schizophrenia spectrum through
the prism of self-disorders: an empirical study. Schizophr. Bull. 37, 344–351.
Romm, K.L., Rossberg, J.I., Berg, A.O., Barrett, E.A., Faerden, A., Agartz, I., Andreassen,
O.A., Melle, I., 2010. Depression and depressive symptoms in first episode psycho-
sis. J. Nerv. Ment. Dis. 198, 67–71.
Sass, L.A., Parnas, J., 2003. Schizophrenia, consciousness, and the self. Schizophr. Bull.
29, 427–444.
Schultze-Lutter, F., 2009. Subjective symptoms of schizophrenia in research and the
clinic: the basic symptom concept. Schizophr. Bull. 35, 5–8.
Schultze-Lutter, F., Addington, J., Ruhrmann, S., Klosterkötter, J., 2007a. Schizophrenia
proneness instrument, adult version (SPI-A). Rome, Giovanni Fioriti Editore.
Schultze-Lutter, F., Ruhrmann, S., Picker, H., von Reventlow, H.G., Daumann, B., Brockhaus-
Dumke, A., Klosterkkotter, J., Pukrop, R., 2007b. Relationship between subjective and
objective cognitive function in the early and late prodrome. Br. J. Psychiatry Suppl.
51, 43–51.
Skelley, S.L., Goldberg, T.E., Egan, M.F., Weinberger, D.R., Gold, J.M., 2008. Verbal and visual
memory: characterizing the clinical and intermediate phenotype in schizophrenia.
Schizophr. Res. 105, 78–85.
Staal, W.G., Hijman, R., Hulshoff Pol, H.E., Kahn, R.S., 2000. Neuropsychological dysfunc-
tions in siblings discordant for schizophrenia. Psychiatry Res. 95, 227–235.
Townsend, L.A., Norman, R.M., 2004. Course of cognitive functioning in first episode
schizophrenia spectrum disorders. Expert Rev. Neurother. 4, 61–68.
Vaskinn, A., Sundet, K., 2001. Estimating premorbid IQ: a Norwegian version of National
Adult Reading Test. J. Norw. Psychol. Assoc. 38, 1133–1140.
Ventura, J., Liberman, R.P., Green, M.F., Shaner, A., Mintz, J., 1998. Training and quality
assurance with the Structured Clinical Interview for DSM-IV (SCID-I/P). Psychiatry
Res. 79, 163–173.
Wechsler, D., 1997. WAIS III. Wechsler Adult Intelligence Scale In Manual. The Psycho-
logical Corporation.
Wechsler, D., 2003. Wechsler Adult Intelligence Scale — Third Edition (WAIS-III). Manual,
Norwegian version. Harcourt Assessement, Inc, Stockholm.
Wechsler, D., 2007. Wechsler Abbreviated Scale of Intelligence. Norwegian version -
manual supplement. Harcourt Assessment, Stockholm.
Wechsler, D., Wycherley, R.J., Benjamin, L., 2008. Wechsler Memory Scale: WMS-III.
Pearson Assessment, Stockholm, Sweden.
Zanello, A., Huguelet, P., 2001. Relationship between subjective cognitive symptoms
and frontal executive abilities in chronic schizophrenic outpatients. Psychopathology
34, 153–158.