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Formal thought disorder (FTD), or disorganized speech, is one of the central signs of schizophrenia.
Despite extensive research, the cognitive processes associated with FTD are still unclear. However, the
authors’ review of FTD theories and research indicates that considerable progress has been made in
identifying possible cognitive impairments associated with FTD. Specifically, FTD is strongly associated
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
with impaired executive functioning and with impaired processing of semantic information. Their review
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indicates that previous research has not yet supported an association between FTD and either an increase
in spreading activation or an impairment within the language production system.
People with schizophrenia often produce speech that is disor- thologists have lamented the lack of progress in understanding
ganized or incoherent (Andreasen, 1979; Rochester & Martin, which cognitive impairments are associated with FTD (Maher,
1979). Examples include switching topics disjointedly, responding 1991), and research on FTD has been described as a “graveyard”
to questions in an oblique manner, using made-up words, and (Rochester & Martin, 1979). Furthermore, it has been some time
being completely incomprehensible (Andreasen, 1979). Collec- since the last comprehensive reviews of FTD models and research
tively, different signs of disorganized speech are referred to as (Rochester, 1980; Schwartz, 1978; recent reviews have focused on
formal thought disorder (FTD; Andreasen, 1982).1 The goal of this specific research programs, e.g., Maher, 1996; M. Spitzer, 1997).
article is to understand what cognitive impairments have been Thus, it seems that a review that can draw clear conclusions in
consistently associated with FTD in individuals with schizophre- summarizing previous FTD research and provide directions for
nia. We examine which of the following four posited cognitive future research is warranted.
impairments of FTD have been supported by previous research: (a) We attempt to draw conclusions about previous FTD research
impaired executive functioning, (b) increased spreading activation, by using the organizing principle that research tests theories.
(c) impaired semantic memory, and (d) impaired language produc- Therefore, we examine previous FTD research to decide which if
tion (i.e., a circumscribed disturbance within the language produc- any theories of FTD have been supported. We contend that four
tion system). We begin by discussing the importance of FTD in cognitive impairments effectively summarize the major common-
understanding schizophrenia, as well as problems interpreting pre- alities and contrasts among existing cognitive models of FTD.
vious FTD research. We then describe and present a meta-analysis Many previous models have suggested that FTD is associated with
of the four posited cognitive impairments of FTD. Finally, we impaired executive functioning (e.g., Barch & Berenbaum, 1997;
provide recommendations for future research. Harrow, Lanin-Kettering, & Miller, 1989; Holzman, 1978;
McGrath, 1991). Other models have suggested that FTD is asso-
Importance of FTD in Understanding Schizophrenia and ciated with increased spreading activation (e.g., Harrow et al.,
Problems in Interpreting Previous FTD Research 1989; M. Spitzer, 1997). Some models have suggested that FTD is
associated with impaired semantic memory (Hoffman, 1987;
Historically, FTD has figured prominently in descriptions (e.g., Nestor et al., 1993), whereas others have explicitly argued that
Fish, 1964) and conceptualizations of schizophrenia (e.g., Bleuler, semantic memory is not impaired in people with FTD (Maher,
1911/1950). Despite the diagnostic and conceptual emphasis on 1983; M. Spitzer, 1997). Some models have also suggested that
FTD, and despite a fair amount of previous research, psychopa- FTD is associated with impaired language production (Berenbaum
& Barch, 1995; Chaika, 1990), whereas others have explicitly
argued that language production is not impaired in people with
John G. Kerns, Department of Psychology, University of Illinois at FTD (Harrow et al., 1989; Holzman, 1978). Hence, our goal was
Urbana–Champaign; Howard Berenbaum, Departments of Psychology and to decide which of these four cognitive impairments have been
Psychiatry, University of Illinois at Urbana–Champaign. consistently associated with FTD in previous research. Ideally, our
Work on this article was supported by National Institute of Mental
Health Grants MH 50531 and MH 12166. We thank Deanna Barch, Gary
1
Dell, Greg Miller, and Marie Banich for comments on drafts of this article. In addition to disorganized speech, FTD has sometimes also included
We also thank Neal Cohen and Wendy Heller for making executive “negative” signs of language disturbance, such as a paucity in the amount
function task ratings. or in the content of speech (Andreasen, 1979). However, researchers have
Correspondence concerning this article should be addressed to Howard consistently found that disorganized speech is distinct from negative
Berenbaum, Department of Psychology, University of Illinois at Urbana– speech signs (e.g., Berenbaum, Oltmanns, & Gottesman, 1985; Harvey et
Champaign, 603 East Daniel Street, Champaign, Illinois 61820. E-mail: al., 1992). In this article, we use FTD to refer to disorganized and not to
hberenba@uiuc.edu negative types of language disturbance.
211
212 KERNS AND BERENBAUM
review allows conclusions to be drawn about previous research Impaired Language Production
that can lead to the development and testing of even more precise
models of FTD. By language production impairment, we mean a deficit within
a circumscribed language production system (e.g., Bock & Levelt,
1994). For example, this might be an impairment with retrieving
Four Posited Cognitive Impairments of FTD
lexical or syntactic information or with encoding phonological
Impaired Executive Functioning information. An impairment in language production might con-
ceivably contribute to FTD by impairing the ability to select
Executive functioning refers to the supervision of complex appropriate words during discourse.
thought, such as planning, decision making, and self-monitoring
(e.g., Banich, 1997; Smith & Jonides, 1998; Stuss, Eskes, &
Previous FTD Research
Foster, 1994; Tranel, Anderson, & Benton, 1994). Executive func-
tioning is associated with the supervision of many types of pro- We conducted meta-analyses to examine the four posited cog-
cesses and is not restricted to a particular domain, such as percep- nitive impairments of FTD. Initially, we conducted a literature
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tion, language, or memory. Moreover, executive functioning is search with the target being any article in which FTD was mea-
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closely associated with the prefrontal cortex; however, other brain sured and its association with a cognitive task was examined. The
regions also are involved (e.g., Tranel et al., 1994). An impairment complete PsycINFO computer database was searched (through
in executive functioning could conceivably contribute to FTD by November 2000) using the following subject terms: formal thought
impairing the monitoring, organization, and planning of discourse. disorder, thought disorder, language and schizophrenia, schizo-
phrenia symptoms, and disorganization. In addition, the reference
Increased Spreading Activation sections of any examined articles or book chapters were searched
to find additional references in which it seemed remotely possible
In neural network models, activation spreads between nodes that that FTD was measured. Furthermore, we examined all issues in
share connections (i.e., the automatic spread of activation between the following journals between 1990 to November 2000 for arti-
two related concepts, such as dog and cat; Dell & O’Seaghdha, cles measuring FTD: Archives of General Psychiatry, American
1991). The end state of an “epoch” of spreading activation is Journal of Psychiatry, Psychological Medicine, Psychiatry Re-
analogous to the completion of a cognitive process or computation, search, Journal of Abnormal Psychology, and Schizophrenia
such as word reading (Rumelhart & McClelland, 1986) or lan- Bulletin.
guage production (Dell & O’Seaghdha, 1991). A potentially im- For each of the four cognitive processes, we computed a single
portant issue in evaluating models positing increased spreading meta-analysis that (a) was weighted by sample size (specifically,
activation in people with FTD is that the total amount of activation the inverse of the variance of each study, n – 3; Hedges, 1994;
and the distance that activation spreads might be somewhat inde- Rosenthal, 1991), (b) used r as the measure of effect size, with
pendent. For example, in neural network simulations of lexical both z and 95% confidence intervals (CI) as the measures of
processing, Dell and O’Seaghdha (1991) found that an increase in statistical significance (for computational procedures in obtaining
the overall amount of spreading activation in a network resulted in effect sizes from published results, see Rosenthal, 1991, 1993;
increased activation only for those words that were strongly related Shadish & Haddock, 1994), and (c) included only one effect size
to an already activated word. An increase in the overall amount of from each study.2 As an estimate of the effect of unpublished
spreading activation had a much smaller effect on the amount of nonsignificant results, for meta-analyses with overall significance
activation that spread to distantly related words. Thus, if people levels of less than .05, we calculated the number of unreported
with FTD have an increase in the overall amount of spreading studies with z ⫽ 0.00 that would result in a significance level of
activation, then they should exhibit increased semantic priming, .05 (Rosenthal, 1991). In addition, we also conducted moderator
especially in tasks involving strongly related words. In contrast, if variable analyses, using regression analyses (Hedges, 1994) with
people with FTD have an increase in the distance that activation each regression weighted by the inverse of the variance of each
spreads (and not in the overall amount of activation), then they study; regressions included multiple effect sizes from a single
should exhibit increased priming only for distantly related infor- study (i.e., the shifting units of analysis approach; see Cooper,
mation. An increase in either the amount or distance of spreading 1998). Moderator variable analysis examined whether any vari-
activation could potentially contribute to FTD by making word and ables moderated the association between FTD and a particular
topic selection in discourse susceptible to extraneous cognitive cognitive process.
associations. One moderator variable we examined was task difficulty. FTD
might be associated with poor performance on difficult tasks
Impaired Semantic Memory (Chapman & Chapman, 1973, 1978, 1989). Thus, FTD might be
associated with a particular cognitive process (e.g., executive
Semantic memory refers to the storage of factual knowledge
functioning) only because tasks that involve that process are dif-
(e.g., “a dog is an animal and has fur”; Kounios, 1996). Intact
ficult. To test this possibility, we examined whether task difficulty
semantic processing requires that information is stored in memory
moderated the relationship between FTD and cognitive processes.
and that it can be retrieved from memory (e.g., Rapp & Cara-
mazza, 1993). People with impaired semantic memory have been
found to exhibit decreased or absent semantic priming (e.g., Moss, 2
If more than one effect size was reported by a single study, then a
Tyler, Hodges, & Patterson, 1995). An impairment in semantic single composite effect size was calculated from the average of the Fisher’s
memory might conceivably contribute to FTD by impairing the transformed correlations of all effect sizes from that single study, as
formation of conceptual messages that guide discourse. recommended by Rosenthal (1991).
COGNITIVE CORRELATES OF FTD 213
As a measure of task difficulty, we used the effect size of the Hence, we used these continuous ratings of context memory,
difference in performance between control participants and people inhibition, and sustained attention as moderator variables to ex-
with schizophrenia on each task; we assumed that this effect size amine whether the level of each component moderated the asso-
would be larger for more difficult tasks. This assumption is based ciation between FTD and executive task performance. We thought
on previous findings that individuals with schizophrenia tend to do this moderator analysis would be particularly important because
more poorly as a group on most cognitive tasks (e.g., Blanchard & executive functioning tasks are likely to involve a number of
Neale, 1994). Given that people with schizophrenia tend to do processing components (Miyake, Friedman, Emerson, Witzki, &
more poorly than control participants on most tasks, then it seems Howerter, 2000). Thus, if context memory or inhibition (which are
plausible to assume that this between-group difference varies in central executive functioning component processes) moderate the
part as a function of task difficulty (i.e., larger between-group association between FTD and executive functioning, then this
differences for more difficult tasks). For studies that did not further supports the association between FTD and executive func-
include control participants, we used an effect size from other tioning impairment.
published studies. If the association between FTD and a cognitive Semantic priming tasks also probably involve multiple cognitive
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process is not the result of task difficulty, then task difficulty processes, such as automatic spreading activation and strategic
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should not moderate the association between FTD and the cogni- factors such as expectancy and semantic matching (Neely, 1991).
tive process. Although this moderator analysis is not a replacement To more precisely test the spreading activation hypothesis, we
for an assessment of task difficulty within each study (Chapman & accounted for the role of strategic factors in priming tasks in two
Chapman, 1973, 1978, 1989), it does provide useful information ways. First, when possible, we limited our review to prime con-
that constrains some explanations for how task difficulty could ditions that involved stimulus onset asynchronies (SOAs) of less
explain the results of the meta-analyses. than 500 ms because expectancy effects are not likely to be
In addition to task difficulty, we examined several other possible operative at SOAs shorter than 500 ms (Neely, 1991). Second, we
moderators. We examined whether the level of involvement of conducted moderator analyses to examine the contribution of
specific executive functions moderated the association between semantic matching to priming in people with FTD. Semantic
matching is the use of relatedness between primes and targets to
FTD and executive functioning. We examined two components of
make a word–nonword decision in lexical decision tasks (Neely,
executive functioning: context memory (the maintenance of goal-
1991). Several studies have found evidence for semantic matching
relevant information in memory; e.g., Cohen, Braver, & O’Reilly,
at short SOAs (Chwilla, Hagoort, & Brown, 1998; de Groot, 1985;
1996; Goldman-Rakic, 1995) and inhibition of information and
Koivisto, 1998); this makes intuitive sense given that semantic
responses (Smith & Jonides, 1998; West, 1996). These two over-
matching occurs after lexical access. The occurrence of semantic
lapping executive function components are widely held to be
matching does vary according to the particular priming task. Se-
important and central aspects of executive functioning (e.g., Smith
mantic matching is thought to be possible only in lexical decision
& Jonides, 1998; Stuss et al., 1994; West, 1996), and we also
tasks but not in word naming tasks (Neely, 1991). In lexical
thought they were likely to be involved in the cognitive tasks used
decision tasks, semantic matching is thought to be likely to occur
in previous FTD research. Executive functioning tasks involve
if there is both (a) a high proportion of related primes and targets
psychological processes other than executive functioning (e.g.,
(a high relatedness proportion) and (b) a high proportion of pairs
Banich, 1997; Stuss et al., 1994; Tranel et al., 1994). Therefore, we of word primes and nonword targets (a high nonword ratio; Kahan,
also assessed effortful or sustained attention in the various exec- Neely, & Forsythe, 1999; Neely, 1991; Neely & Keefe, 1989;
utive function tasks, which (although possibly not an aspect of Neely, Keefe, & Ross, 1989). Hence, to examine the role of
executive functioning) we thought was likely to be involved in the semantic matching in priming, we examined whether relatedness
executive function tasks used in previous FTD research. proportions and nonword ratios were moderators of the association
To assess the level of involvement of these component pro- between FTD and semantic priming in studies that used a lexical
cesses, we obtained continuous ratings (1 ⫽ little involvement; 7 ⫽ decision task. If people with FTD exhibit increased priming be-
great involvement) of the likely level of involvement of these three cause of an increase in the amount of automatic spreading activa-
components in each of the executive function tasks. Raters were tion, then the size of the association between FTD and semantic
given precise details of each task. The following definitions were priming should either not vary by the presence or absence of
provided to raters: context memory ⫽ maintenance of goal- semantic matching or at least the association should be evident
relevant information in performing the task; inhibition ⫽ suppres- when semantic matching is not likely to be occurring.
sion of inappropriate thoughts and/or behaviors; sustained atten-
tion ⫽ vigilant and effortful attention. Ratings were provided by
one of the authors (Kerns) and by two cognitive neuroscientists. Research Examining Executive Functioning and FTD
Interrater reliabilities, measured using intraclass correlations
(Shrout & Fleiss, 1979) and treating the raters as random effects As can be seen in Table 1 and in Figure 1, the association
and the mean of the raters as the unit of reliability, were .48 for between executive functioning task performance and FTD has
context memory, .65 for inhibition, and .78 for sustained attention. been examined in 26 studies. The overall effect size of the 26
Interrater reliability was lowest for context memory; however, this studies is .36, a medium effect.3 The lower and upper bound limits
is only problematic for null results. In addition to conducting
moderator analyses using the mean executive function ratings, we 3
Unfortunately, two relevant studies could not be included. In one study
also conducted separate moderator analyses using each individual (Manschreck, Maher, Redmond, Miller, & Beaudette, 1966), results were
rater’s ratings. The results of these analyses were identical to those simply reported as nonsignificant; in the second study (Kuperberg,
obtained using the mean ratings. McGuire, & David, 1998), reported results were based on regression
214 KERNS AND BERENBAUM
of the 95% CI were .30 and .42. The overall level of significance In summary, there is a sizable and robust association between
is z ⫽ 9.46, p ⬍ .00001, and the number of unpublished nonsig- FTD and impaired executive functioning. The association has been
nificant studies that would increase the significance level to .05 is found across a broad array of executive functioning tasks and in a
930.4 The effect sizes across the 26 studies were statistically sizable number of studies. In addition, current evidence suggests
heterogeneous ( p ⬍ .05; see Rosenthal, 1993, for computational that this cannot be explained by either task difficulty or unpub-
procedures), suggesting the possibility of moderating variables. lished null results. Finally, the association between FTD and
Task difficulty was not a significant moderator of the size of the impaired executive functioning is especially evident when execu-
association between FTD and executive function task performance tive function tasks are likely to involve high context memory and
( ⫽ .11, z ⫽ 0.80, p ⬎ .20).5 Thus, previous research has inhibition demands.
demonstrated a sizable and robust association between impaired
executive functioning and FTD. Additionally, this association does Research Examining Spreading Activation and FTD
not appear to be due to a generalized performance deficit.
We examined the results of semantic and phonemic priming
Next we examined whether the level of involvement of context
studies to assess whether people with FTD have an increase in
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Table 1
Studies Included in Executive Functioning Meta-Analysis
Allen et al., 1993 20 MSI Category fluency errors .39 2.7 4.3 3.0
Barch & Berenbaum, 1996 39 TLC, IR Composite .13
Reality monitoring report say errors .09 4.0 4.0 3.3
Speech planning .17 3.0 3.7 2.0
Barch et al., 1992 25 SAPS Letter fluency total ⴚ.02 3.0 3.0 3.3
Berenbaum & Barch, 1995 21 TLC, TDI, BIT Auditory distraction digit span .18 6.3 6.3 6.3
Docherty & Gordiner, 1999 55 CDI, BPRS, SAPS Auditory distraction digit span .46 6.3 6.3 6.3
Docherty et al., 1994; Docherty,
Hawkins, et al., 1996a 48 IR Composite .26
Letter fluency total ⫺.16 3.0 3.0 3.3
Letter fluency errors .37 3.3 5.0 3.7
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Note. Values in the meta-analysis are presented in bold. The following formal thought disorder (FTD) scales were used: Bizarre-Idiosyncratice Thinking
(BIT; Marengo et al., 1985); Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962); Comprehensive Assessment of Symptoms and History
(CASH: Andreasen, Flaum, & Arndt, 1992); Communication Disturbances Index (CDI; Docherty, De Rosa, & Andreasen, 1996); Case Record Rating Scale
(CRRS; Strauss, 1974); Incompetent References (IR; Rochester & Martin, 1979); Manchester Scale, Incoherence item (MSI; Krawiecka, Goldberg, &
Vaughn, 1977); Schedule for Affective Disorders and Schizophrenia (SADS; R. L. Spitzer & Endicott, 1978); Schedule for the Assessment of Positive
Symptoms (SAPS; Andreasen, 1984); Thought Disorder Index (TDI; Johnston & Holzman, 1979); Thought, Language, and Communication (TLC;
Andreasen, 1979); Type-Token Ratio (TTR; Manschreck, Maher, & Ader, 1981). WCST ⫽ Wisconsin Card Sorting Task; CPT A-X ⫽ Continuous
Performance Task, A-X version; CM ⫽ context memory; INH ⫽ inhibition; SA ⫽ sustained attention.
a
Correlations with individual cognitive tasks are from Docherty et al. (1994); correlations with composite cognitive scores were reported in Docherty,
Hawkins, et al. (1996). b Goldberg et al. (1998) involved largely the same participants as Aloia et al. (1998). c Half of the participants were
unmedicated. d Participants were tested as both inpatients and outpatients.
effect that is in the opposite direction predicted by the increased likely presence of semantic matching (which should occur in
spreading activation hypothesis. lexical decision tasks with high relatedness proportions and high
In three of the eight priming studies, people with FTD exhibited nonword ratios) moderated the association between FTD and se-
hyperpriming, whereas in five other studies, people with FTD mantic matching. Both relatedness proportion and nonword ratio
exhibited hypopriming. Statistically, these eight studies are heter- were significant moderators: for relatedness proportion,  ⫽ 2.30,
ogeneous ( p ⬍ .01), suggesting the presence of moderating fac- z ⫽ 4.59, p ⬍ .0001; for nonword ratio,  ⫽ 2.20, z ⫽ 4.62, p ⬍
tors. We performed moderator analyses to examine whether the .0001; for the summed average of relatedness proportion and
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216
KERNS AND BERENBAUM
Figure 1. Dot plot of effect sizes and 95% confidence intervals (CI). The asterisks represent the effect sizes.
COGNITIVE CORRELATES OF FTD 217
Table 2
Studies in Spreading Activation, Semantic Memory, and Language Production Meta-Analyses
Spreading activation
Aloia et al., 1998 a
20 TLC Naming semantic priming ⫺.41
Barch, Cohen, et al., 1996 100 BPRS Naming semantic priming ⫺.31
Besche et al., 1997 34 TLC LDT semantic priming ⫺.59
Blum & Freides, 1995 18 TLC LDT semantic priming ⫺.12
Passerieux et al., 1997 22 TLC LDT semantic priming ⫺.52
Spitzer et al., 1993 50 BPRS LDT semantic priming .29
Spitzer et al., 1994 70 BPRS LDT semantic & phonemic .30
priming
Weisbrod et al., 1998 40 BPRS LDT semantic priming .31
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Semantic memory
Allen et al., 1993 20 MSI Semantic clustering .55
Andrews et al., 1993 19 SAPS N400 .53
Chen et al., 1994 39 CASH Categorization judgment RT .29
Goldberg et al., 1998a 23 SAPS Peabody Vocabulary; text .40
processing errors; difference
category & letter fluency
Kerns et al., 1999 26 SAPS Verbal fluency clustering .34
Language production
Barch & Berenbaum, 1996 39 TLC, IR Induced nonword errors .14
Docherty et al., 1994, 1996b 48 IR Boston Naming .03
Faber & Reichstein, 1981 24 Derailmentc Boston Diagnostic Aphasia .14
Exam, picture naming, token test
Goldberg et al., 1998a 23 SAPS Boston Naming .24
Landre & Taylor, 1995 37 SAPS, BIT Porch Aphasia Exam .18
Note. The following formal thought disorder (FTD) scales were used: Bizarre-Idiosyncratic Thinking (BIT;
Marengo et al., 1985); Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962); Comprehensive
Assessment of Symptoms and History (CASH; Andreasen, Flaum, & Arndt, 1992); Incompetent References (IR;
Rochester & Martin, 1979); Manchester Scale, Incoherence item (MSI; Krawiecka, Goldberg, & Vaughn, 1977);
Schedule for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984); Thought, Language, and
Communication (TLC; Andreasen, 1979). LDT ⫽ lexical decision task; RT ⫽ reaction time.
a
The Aloia et al. (1998) and Goldberg et al. (1998) studies involved largely the same participants. b Corre-
lations with individual cognitive tasks are presented in Docherty et al. (1994). c Derailment and loose
associations were rated by clinicians.
nonword ratio,  ⫽ 2.82, z ⫽ 5.20, p ⬍ .0001. As can be seen in only in those instances in which semantic matching was likely to
Table 3, the three studies with the highest relatedness proportions be taking place. Thus, previous priming studies do not support an
and nonword ratios, which would likely involve semantic match- association between amount of spreading activation and FTD.
ing, reported hyperpriming. In contrast, the three studies with the We think there are at least three explanations for hyperpriming
lowest relatedness proportions and nonword ratios, which would in previous studies. First, use of semantic matching might have a
likely not involve semantic matching, reported hypopriming.7 greater compensatory benefit for people with FTD than for people
Similarly, the two studies that used naming tasks, which do not without FTD. This is analogous to the hyperpriming exhibited by
involve semantic matching, found that people with FTD exhibited nonpsychiatric participants when target words are visually de-
hypopriming (Aloia et al., 1998; Barch et al., 1996). Thus, the graded (Neely, 1991). Hence, priming effects should be larger for
results of the moderator analysis suggest that when semantic
matching is involved, people with FTD exhibit hyperpriming.
7
Conversely, when semantic matching is minimized, and when the As can be seen in Table 3, although Besche et al. (1997) and Blum and
effects of spreading activation should be most evident, people with Freides (1995) have similar relatedness proportions and nonword ratios,
FTD exhibit hypopriming. there is a sizable difference in the effect size for the association between
The results of the moderator analysis are not easily reconciled FTD and amount of priming in these two studies. However, as can also be
seen in Table 3, these two studies actually found identical effect sizes for
with the hypothesis that FTD is associated with an increase in the
the amount of semantic priming exhibited by people with FTD. Therefore,
amount of spreading activation. As mentioned previously, an in- these two studies do not differ in the amount of priming exhibited by
crease in the amount of automatic spreading activation should people with FTD, but they do differ in the amount of priming exhibited by
produce hyperpriming in all tasks, especially those that minimize people without FTD (possibly because of the high proportion of lateralized,
the influence of other cognitive processes such as semantic match- i.e., only left or right visual field, stimulus presentation trials in the study
ing. However, the opposite pattern was found, with hyperpriming by Blum & Freides).
218 KERNS AND BERENBAUM
nonpriming studies of semantic memory are consistent with prim- imations) might be associated with impaired language production,
ing studies in finding evidence of impaired processing of semantic whereas other facets of FTD (e.g., derailments) might not.
information in people with FTD. If only a minority of people with FTD have a language
In general, there are two plausible explanations for poor perfor- production-specific impairment, then composite measures of FTD
mance in semantic memory tasks: a loss of stored information or should exhibit only modest associations with language production
impaired retrieval (Rapp & Carammazza, 1993). Disentangling measures. The composite effect size of the study by Barch and
these two explanations can be difficult, and previous research on Berenbaum (1996) was small, .14, identical to the overall effect
semantic memory and FTD has not been extensive enough, both in size of all five language production studies. Thus, the composite
terms of the number of studies and in terms of the type of semantic FTD measure in Barch and Berenbaum’s study, taken by itself,
memory measures used (e.g., no research examining association obscures the finding that specific facets of FTD were associated
between FTD and performance on a battery of semantic memory with the language production task. There is a similar pattern in the
tasks), to adequately settle the issue. Impaired retrieval could be results of Landre and Taylor (1995). In that study, one measure of
due to impaired executive functioning, and the semantic memory FTD, the Schedule for the Assessment of Positive Symptoms
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tasks used in previous research also probably involved executive (Andreasen, 1984), was strongly associated with poor performance
This document is copyrighted by the American Psychological Association or one of its allied publishers.
functioning. Thus, future research must still address the integrity on an aphasia battery; however, another measure of FTD, the
of semantic information in people with FTD separate from an Bizarre-Idiosyncratic Thinking (Marengo, Harrow, Lanin-
executive functioning deficit. However, regardless of the cause of Kettering, & Wilson, 1985), was modestly associated with better
impaired semantic processing of people with FTD, we think that performance. Thus, the composite effect size from this study was
the association between FTD and impaired semantic processing small, .18, and comparable to the overall effect size of all five
could still be important in understanding the occurrence of FTD. language production studies. Along the same lines, two studies
In summary, previous research consistently supports an associ- have found that another facet of FTD, incompetent references
ation between FTD and impaired processing of semantic informa- (Rochester & Martin, 1979), is not associated with language pro-
tion. Hypopriming results in some priming studies in people with duction task performance (Barch & Berenbaum, 1996; Docherty et
FTD are consistent with impaired semantic memory processing. al., 1996). Thus, although the effect size of the five language
Furthermore, people with FTD also are impaired in nonpriming production studies was small and argues against a general associ-
semantic memory tasks. Although the association between seman- ation between FTD and language production, these studies do
tic processing and FTD seems consistent (albeit the total number provide some preliminary support to the hypothesis that some
of studies is small), it is unclear whether this is due to a loss of facets of FTD, what Berenbaum and Barch (1995) referred to as
semantic information or to impaired access to and processing of disturbances in fluency, might be associated with deficits within
semantic information (maybe as a result of impaired executive the language production system.10
functioning). In summary, previous research has found (at best) a small
association between FTD and impaired language production. Thus,
current research does not support an association between a broad
Studies Examining Language Production and FTD language production impairment and FTD. However, the possibil-
ity of an association between FTD and a language production
Five studies have examined associations between language pro-
impairment cannot yet be ruled out. First, to date only five studies
duction performance and FTD. The overall effect size was .14, a
have tested this possibility. Second, not all possible language
small effect. The lower and upper bound limits of the 95% CI were
production impairments have been examined, and many that have
–.02 and .30. The overall level of significance was Z ⫽ 1.56, p ⫽
been examined have each been examined in only one or two
.06. Thus, overall, previous research has not supported a general
studies. However, it is also possible that perhaps only a subset of
association between impaired language production and FTD. How-
FTD facets is associated with impaired language production. Con-
ever, previous research does suggest that some particular facets of
sistent with this, there is some initial evidence that some aspects of
FTD might be associated with impaired language production.
FTD (e.g., word approximations and neologisms) are associated
Berenbaum and Barch (1995) posited that only certain facets of
with impairments in some aspects of language production (e.g.,
FTD (what they called disturbances in fluency [p. 358], such as
lexical processing; Barch & Berenbaum, 1996).
neologisms, word approximation, and incoherence), exhibited by
only a minority of people with schizophrenia, are associated with
impaired language production. 10
Landre, Taylor, and Kearns (1992) reported additional evidence for an
In a test of the association of a language production impairment association between FTD and impaired language production. They com-
with particular FTD facets, Barch and Berenbaum (1996) exam- pared 10 people with schizophrenia and FTD with 10 people with aphasia
ined the number of nonword speech errors produced in a speech on the following: Boston naming task, repetition of words and phrases,
error induction task. In this task, as in regular conversation, non- token test, speech fluency, and amount of speech information. There were
word errors are rare and an increase in nonword speech errors no significant differences between people with FTD and people with
aphasia on these language measures. Similarly, Faber et al. (1983) reported
could indicate a language production impairment. Barch and Be-
that on 9 of 14 language abnormalities assessed, people with FTD did not
renbaum found that only people with neologisms and word ap- differ significantly from people with aphasia. Therefore, this study also
proximations produced a much higher number of nonword speech found some similarities between people with FTD and people with aphasia.
errors. In contrast, several other facets of FTD were not associated These similarities between people with FTD and people with aphasia, who
(or were only weakly associated) with nonword speech errors. likely have a language production impairment, suggest that some people
Therefore, some facets of FTD (e.g., neologisms and word approx- with FTD also might have a language production impairment.
220 KERNS AND BERENBAUM
Comparison of Four Cognitive Processes as Predictors something else associated with inhibition deficits, that contribute
of FTD causally to FTD.
consistently associated with FTD in previous research. First, there ularly associated with impaired processing of context (Cohen et
This document is copyrighted by the American Psychological Association or one of its allied publishers.
is consistent evidence for a sizable association between FTD and al., 1996).
impaired executive functioning. Second, there is evidence for an Previous research has found a large association between inhibi-
association between FTD and impaired processing of semantic tion and FTD. It is important to examine the range of inhibitory
information. In contrast, the two other cognitive impairments have deficits in people with FTD. Our review addressed only whether
not been consistently associated with FTD in previous research. FTD is associated with executive inhibition. If FTD is only asso-
Previous research has not consistently found an association be- ciated with executive inhibition, then FTD should not be associ-
tween FTD and increased amount of spreading activation. Some ated with inhibition in nonexecutive inhibition tasks, such as
studies, however, have found some support for increased distance negative priming (Kramer, Humphrey, Larish, & Logan, 1994).
of spreading activation in people with FTD. Previous research has Consistent with this, FTD has not been found to be associated with
not consistently found an association between FTD and a language prepulse inhibition (e.g., Perry & Braff, 1994). Furthermore, re-
production impairment. Instead, previous research suggests that searchers should examine whether FTD is associated with all types
only a subset of FTD facets (i.e., disturbances in fluency) might be of executive inhibition. In a review of the cognitive processes
associated with impaired language production. associated with the prefrontal cortex, West (1996) concluded that
Meta-analysis allows for a principled and quantitative review of two different types of inhibition have been associated with it. One
previous research. However, meta-analysis is not a flawless type of inhibition, interference control, is thought to be involved in
method (for criticisms of meta-analysis, see Cooper & Hedges, managing information within working memory, such as clearing
1994; Rosenthal, 1991, chapter 7). One potential criticism of all inappropriate information in a proactive interference task or a
meta-analyses, including the ones we have conducted, is that the paired associate learning task (e.g., Shimamura, Jurica, Mangels,
quality of any meta-analysis is a function of the studies included. Gershberg, & Knight, 1995). The second type of inhibition, pre-
For example, although differences between FTD measures (Beren- potent inhibition, would be involved in withholding a strongly
baum & Barch, 1995) and FTD facets (Barch & Berenbaum, 1996) activated response, such as in perseverative errors in the Wisconsin
might exist, previous research has not often examined whether Card Sorting Task or errors in the antisaccade task (West, 1996).
cognitive deficits are differentially associated with different FTD FTD might be associated with impairments in only one of these
scales or facets. In addition, our conclusions are dependent in part two types of executive inhibition. Furthermore, given that context
on how we have divided tasks into different categories in conduct- memory deficits probably can produce deficits in inhibition (per-
ing the four different meta-analyses (as well as on the quality of haps especially prepotent inhibition), it is important to examine
our ratings of the involvement of different executive function whether people with FTD have a deficit in inhibition separate from
component processes). We would not be surprised if some inves- a deficit in context memory.
tigators disagreed with our grouping of studies. In part, this is Future research should also examine whether FTD is associated
because some tasks could reasonably be included in more than one with additional components of executive functioning. There might
category (e.g., the sentence verification task used by Chen, be other executive function components not yet adequately exam-
Wilkins, and McKenna, 1994, probably involves both semantic ined that are associated with FTD. For example, task switching
memory processes and executive functioning). However, given the might be an elementary and important aspect of executive control
nature of the results—the robust association with executive func- (e.g., Smith & Jonides, 1998) that has not been adequately exam-
tioning, the inconsistent priming results, the consistent size of all ined in previous FTD research. Also, monitoring and manipulation
associations with semantic memory and language production, re- of information (Petrides, 1996) might be an important component
spectively—we are confident that the overall conclusions of our of executive functioning that is impaired in FTD.
review regarding the four possible cognitive impairments would Previous research has demonstrated a large association between
not change very much even if some changes were made to which FTD and semantic memory. Although this association was found
task was included in which meta-analysis. Another limitation of across a range of tasks, future research must more adequately
meta-analyses is that, like individual correlation studies, the results demonstrate a semantic memory deficit in people with FTD. For
of meta-analyses of correlations are limited in what they can tell us example, research has yet to examine associations between FTD
about causation. For example, although the meta-analysis provided and performance on semantic memory batteries (McKay et al.,
clear evidence that inhibition deficits are associated with FTD, it is 1996). Use of semantic memory batteries would also be relevant
plausible that it is not the inhibition deficits themselves, but rather for further addressing whether people with FTD exhibit a loss of
COGNITIVE CORRELATES OF FTD 221
semantic information or a retrieval deficit, an issue most ade- Andreasen, N. C. (1984). Scale for the assessment of positive symptoms
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cesses in semantic memory tasks (e.g., Thompson-Schill, ing psychopathology and diagnosis. Archives of General Psychiatry, 49,
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Andrews, S., Shelley, A., Ward, P. B., Fox, A., Catts, S. V., & McCon-
ship between executive functioning and semantic memory task aghy, N. (1993). Event-related potential indices of semantic processing
performance in people with FTD. in schizophrenia. Biological Psychiatry, 34, 443– 458.
Explanations for hypopriming and hyperpriming in people with Balota, D. A., & Paul, S. T. (1996). Summation of activation: Evidence
FTD should continue to be explored. For example, research using from multiple primes that converge and diverge within semantic mem-
the same sample of participants and the same stimuli can manip- ory. Journal of Experimental Psychology: Learning, Memory, and Cog-
ulate relatedness proportions and nonword ratios and test directly nition, 22, 827– 845.
whether the relation between FTD and priming effects on lexical Banich, M. T. (1997). Neuropsychology: The neural bases of mental
function. Boston: Houghton Mifflin.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tional converging evidence for an impaired lexical-semantic pro- Barch, D. M., & Berenbaum, H. (1996). Language production and thought
cessing explanation of hypopriming, research examining the rela- disorder in schizophrenia. Journal of Abnormal Psychology, 105, 81– 88.
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tion between semantic priming and FTD should also include other
manipulations on negative thought disorder and discourse coherence
semantic memory measures, such as semantic memory batteries
disturbances in schizophrenia. Psychiatry Research, 71, 115–127.
(Moss et al., 1995) and N400 event-related potentials (Kounios & Barch, D., Berenbaum, H., Stolar, N., Banich, M., & Miller, G. A. (1992,
Holcomb, 1992). November). Neuropsychological correlates of disturbances in fluency
Researchers can use several other methodological tools to fur- and discourse coherence. Paper presented at the meeting of the Society
ther examine semantic memory, spreading activation, and seman- for Research in Psychopathology, Montreal, Quebec, Canada.
tic matching in people with FTD. First, they could use modified Barch, D. M., Cohen, J. D., Servan-Schreiber, D., Steingard, S., Steinhauer,
priming tasks that discourage semantic matching, such as go/no-go S. S., & van Kammen, D. P. (1996). Semantic priming in schizophrenia:
tasks and tasks that require the matching of targets with a probe An examination of spreading activation using word pronunciation and
stimulus (Neely, 1991). Second, researchers could examine sum- multiple SOAs. Journal of Abnormal Psychology, 105, 81– 88.
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a means of testing the activation levels of different words (Balota hemisphere language comprehension. Current Directions in Psycholog-
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& Paul, 1996). Third, spreading activation hypotheses could be
Berenbaum, H., & Barch, D. (1995). The categorization of thought disor-
tested and refined through computational modeling (e.g., Dell &
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O’Seaghdha, 1991; Hoffman, 1987). Berenbaum, H., Oltmanns, T. F., & Gottesman, I. I. (1985). Formal thought
Researchers have found qualified support for an association disorder in schizophrenics and their twins. Journal of Abnormal Psy-
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This might be best further examined by the use of standard Besche, C., Passerieux, C., Segui, J., Sarfati, Y., Laurent, J., & Hardy-
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lexical access could be examined using picture naming and word patients evaluated by lexical-decision tasks. Neuropsychology, 11, 498 –
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