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Trail Making Test Errors and Executive

Function in Schizophrenia and
Depression
a b c
Roderick K. Mahurin , Dawn I. Velligan , Bonnie Hazleton , J.
d e f
Mark Davis , Stacey Eckert & Alexander L. Miller
a
University of Washington School of Medicine , Seattle, WA, USA
b
University of Texas Health Science Center at San Antonio , San
Antonio, TX, USA
c
San Antonio State Hospital , San Antonio, TX, USA
d
University of Georgia , Athens, GA, USA
e
University of Houston , Houston, TX, USA
f
University of Texas Health Science Center at San Antonio , San
Antonio, TX, USA
Published online: 22 Sep 2006.

To cite this article: Roderick K. Mahurin , Dawn I. Velligan , Bonnie Hazleton , J. Mark Davis , Stacey
Eckert & Alexander L. Miller (2006) Trail Making Test Errors and Executive Function in Schizophrenia
and Depression, The Clinical Neuropsychologist, 20:2, 271-288, DOI: 10.1080/13854040590947498

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 The Clinical Neuropsychologist, 20: 271–288, 2006
Copyright # Taylor and Francis Group, LLC
ISSN: 1385-4046 print=1744-4144 online
DOI: 10.1080/13854040590947498

TRAIL MAKING TEST ERRORS AND EXECUTIVE

FUNCTION IN SCHIZOPHRENIA AND DEPRESSION

Roderick K. Mahurin1, Dawn I. Velligan2, Bonnie Hazleton3,

J. Mark Davis4, Stacey Eckert5, and Alexander L. Miller6
1
University of Washington School of Medicine, Seattle, WA, USA, 2University
of Texas Health Science Center at San Antonio, San Antonio, TX, USA, 3San
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Antonio State Hospital, San Antonio, TX, USA, 4University of Georgia, Athens,
GA, USA, 5University of Houston, Houston, TX, USA, and 6University of Texas
Health Science Center at San Antonio, San Antonio, TX, USA

The Trail Making Test (TMT) frequently is used as a measure of executive cognitive func-
tion. However, traditional use of test completion time as the primary outcome score does
not give the more detailed information on cognitive processes that analysis of test-taking
errors may provide. The present study compared TMT performance of three groups:
patients with schizophrenia, patients with major depression, and healthy control participants
(n ¼ 30 for each group). Three operationally defined error types were examined: (a) track-
ing, (b) perseverative, and (c) proximity. Although both patient groups were slower than the
healthy control group, only the schizophrenia group made significantly more errors, parti-
cularly tracking errors, suggesting a greater degree of cognitive disorganization. Within-
group analysis of a larger group of schizophrenia patients (n ¼ 84) revealed that TMT
time was most strongly associated with the Withdrawal-Retardation factor of the Brief Psy-
chiatric Rating scale. In contrast, TMT errors were most strongly associated with the Con-
ceptual Disorganization factor. Comparisons of TMT scores and other cognitive tests
showed moderate to high associations with tests of working memory, psychomotor speed,
and executive function. Stepwise regression analysis revealed an independent association
between Digit Cancellation and Part B Time, indicating a unique contribution of visuomo-
tor scanning to performance. In contrast, Part B errors were uniquely associated with the
Verbal Series Attention Test and the Token Test, tests of mental tracking and executive-
mediated working memory, respectively. These findings demonstrate the utility of TMT
error analysis in revealing cognitive deficits not traditionally captured using completion
time as the sole outcome variable.

INTRODUCTION
The Trail Making Test (TMT) (Battery, 1994; Partington & Letter, 1949) ranks
among the most frequently used tests in the neuropsychologist’s repertoire. Perform-
ance on Parts A and B of the test involves a variety of cognitive operations, including
visual search, psychomotor speed, sequencing, divided attention, cognitive flexibility,

Address correspondence to: Roderick K. Mahurin, Department of Radiology, Box 357115, Univer-
sity of Washington School of Medicine, 1959 N.E. Pacific, Seattle, WA 98195. E-mail: mahurin@
u.washington.edu
Accepted for publication: October 20, 2004.

271
 272 RODERICK K. MAHURIN ET AL.

and conceptual tracking (Lezak, 1995; Mitrushina, Boone, & D’Elia, 1999). Because
performance on the TMT relies on coordinating a broad spectrum of cognitive
abilities, the test has been used as a measure of executive cognitive function in
a variety of neuropsychiatric and neurologic disorders (Reitan & Wolfson, 1993;
Russell & Starkey, 1993; Spreen & Strauss, 1998).
However, interpretation of TMT performance with regard to executive func-
tion is limited by the conventional reliance on completion time as the single outcome
measure. In standard administrations the examiner is instructed to carefully monitor
the ongoing progress of the testee and intervene to correct mistakes at the time of
their occurrence (Hays, 1995; Reitan, 1992; Reynolds, 2002). Since timing is not
stopped during this intervention, time for correction of errors is added to the total
time for completion of the test. This results in a spuriously high correlation between
time and errors that is difficult to dissociate on a post hoc basis.
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The use of completion time as the only score on the TMT also reveals little of
the specific cognitive processes that may influence test performance (Dugbartey,
Rosenbaum, Sanchez, & Townes, 1999; Reitan & Wolfson, 1995). As Lezak (1995)
notes, ‘‘slow performances . . . point to the likelihood of brain damage, but . . . do not
indicate whether the problem is one of motor slowing, incoordination, visual scan-
ning difficulties, poor motivation, or conceptual confusion’’ (p. 382). Although
qualitative evaluation of test performance can provide useful clinical information,
conventional administration of the TMT does not offer quantified measurement
of either the number or type of errors during test performance.
Several previous studies used TMT error analysis to increase diagnostic speci-
ficity of cognitive testing in clinical samples, for example, with head injured patients
(Lezak, 1989) and polydrug users (McCaffrey, Krahula, & Heimberg, 1989). An
earlier study (Nadler & Ryan, 1984) found that a measure of ‘‘sequence binding,’’
defined as ceasing to alternate between numbers and letters, correctly classified
100% of their sample of ‘‘organic’’ schizophrenic patients. These authors recom-
mended that sequence binding be included in scoring criteria for use in the diagnostic
process. Another study demonstrated the utility of using TMT error analysis for the
discrimination of patients with Alzheimer disease from a healthy comparison group
(Amieva et al., 1998). Results from that study demonstrated how TMT error analysis
can provide information regarding inhibitory cognitive deficits in Alzheimer disease.
Importantly, subsequent to completion of the current study, a newly published
battery of executive tests, the D-KEFS (Delis, Kaplan, & Kramer, 2001a), formally
incorporates TMT error analysis into its scoring procedures and normative database.
Further discussion of the D-KEFS is provided in the Discussion.
Cognitive impairments revealed by TMT error analysis have been associated
with brain regions subserving executive functions. Stuss and colleagues (Stuss
et al., 2001) examined TMT performance in patients with damage to frontal and
nonfrontal regions of the brain. Although slowing was more evident in patients with
frontal involvement (relative to a control group), error analysis was a more sensitive
means of categorizing patients into groups with frontal or non-frontal lesions. All
patients who made more than one error on Part B had frontal lesions. Additionally,
patients with involvement of dorsolateral prefrontal regions showed the greatest
number of errors, while those with inferior medial damage were not significantly
affected (Stuss et al., 2001). A study of executive function in children with fetal
 TRAIL MAKING ERRORS IN SCHIZOPHRENIA AND DEPRESSION 273

alcohol syndrome (FAS) also revealed deficits on the Number-Letter Switching

condition of the D-KEFS Trail Making Test, but no impairments on other baseline
conditions of the test. These findings were associated with neuroimaging results
implicating involvement of subcortical-frontal systems in FAS (Mattson, Goodman,
Caine, Delis, & Riley, 1999).
In order to further explore the relationship of TMT to executive functions, we
undertook a detailed error analysis of TMT performance from testing of patients with
schizophrenia or major depression. TMT performance of the two patient groups was
scored on the basis of operationally defined error types and results compared with those
of a healthy control group. Within-group analysis was carried out on an expanded group
of patients with schizophrenia in order to relate TMT scores to psychiatric symptoms
and cognitive tests, including measures of conceptual reasoning, psychomotor speed,
mental tracking, working memory, and visual scanning. Frequency of errors also was
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examined relative to temporal position in the test (i.e., first, second, or third section).
With regard to primary findings, it was hypothesized that (a) comparisons
between patients with schizophrenia or with major depressive disorder would show
slower TMT times than the healthy group, but not significantly differ from each
other, and (b) both patient groups would show a greater number of TMT errors than
would the healthy control group, but, again, not significantly differ from each other.
With respect to secondary analyses within the schizophrenia group, it was hypothe-
sized that (a) because of their greater sensitivity to cognitive deficits, Part B Time
and Part B Errors, but not Part A Time and Errors, would be significantly associated
with psychiatric symptom ratings; (b) because of their greater sensitivity, Part B
scores, more than Part A scores, would be significantly associated with results from
cognitive testing; (c) tracking and sequencing errors would occur more frequently
than proximity errors (see below for definitions); and (d) TMT Time and Error
scores would worsen as the subject proceeded through the test.

METHOD
Participants
In total, 144 participants were administered the TMT, including 84 patients with
schizophrenia, (SCZ), 30 patients with major depressive disorder (MDD), and 30
healthy control (HC) participants. Thirty patients from the SCZ group were matched
to the MDD and HC groups in terms of both age (HC: M ¼ 31.0 yr., SD ¼ 8.6; MDD:
M ¼ 36.0 yr., SD ¼ 7.1; SCZ: M ¼ 32.9 yr., SD ¼ 6.2, F [2, 87] ¼ 3.05, p > .05) and
education (HC: M ¼ 12.0 yr., SD ¼ .64; MDD: M ¼ 12.0 yr., SD ¼ 2.3; SCZ:
M ¼ 12.1 yr., SD ¼ 0.5, F[2, 87] ¼ 3.12, p > .05). These three matched samples were
used for all between-group comparisons. The SCZ and MDD groups were roughly
equivalent in terms of gender composition, with most patients being male (SZ ¼ 90%
male; MD ¼ 87.5% male). In contrast, the HC group was more equally balanced
between males and females (60% male).
Data for the schizophrenia and healthy control groups were obtained from a
previous study of executive function is schizophrenia (Mahurin, Velligan, & Miller,
1998). Data for the depression group were drawn from a neuroimaging study
examining mood-related changes in brain function (Mayberg et al., 1999).
 274 RODERICK K. MAHURIN ET AL.

Within-group comparisons of the TMT with psychiatric symptoms and other cogni-
tive tests were conducted on data from the entire schizophrenia group (n ¼ 84).
Exclusion criteria for all participants included history of head trauma with accom-
panying loss of consciousness or positive findings on brain scan (CT or MRI),
neurological disease, other Axis 1 psychiatric disorder, substance abuse, and sensory
or motor impairment that would interfere with test performance. All participants
signed informed consent and followed institutionally approved research protocols.
Patients in the SCZ group were hospitalized for evaluation and treatment at
the Clinical Research Unit of a State Psychiatric Hospital. The diagnosis of schizo-
phrenia was determined by the chief psychiatrist of the Clinical Research Unit and
conformed to DSM-IV criteria (APA, 1994). Duration of illness in patients averaged
12.8 years (SD ¼ 7.5). Length of hospitalization at time of testing averaged 14 weeks.
At the time of assessment, all patients were taking neuroleptic medication for
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reduction of psychiatric symptoms. Fifty-seven percent of patients also were receiv-

ing anticholinergic medication (benztropine or diphenhydramine) for control of
extrapyramidal side effects. The patients received weekly ratings with the Expanded
(24-item) Brief Psychiatric Rating Scale (BPRS) (Lukoff, Nuechterlein, & Ventura,
1986; Overall & Gorham, 1962). The BPRS is a well-established psychiatric rating
instrument, with a spectrum of clinical symptoms rated on seven-point scales of
severity ranging from 1 (‘‘not present’’) to 7 (‘‘extremely severe’’). The BPRS has
been shown to have good stability of factor scores during a period in which patients
were receiving treatment with antipsychotic medications (Ligon & Thyer, 2000).
Patients in the MDD group were recruited from the psychiatric unit of a local
Veterans Administration hospital where they were being seen for evaluation and
treatment. Length of hospitalization at time of testing averaged 18 weeks. The diag-
nosis of major depression disorder, unipolar type, was confirmed by two independent
psychiatrists using DSM-IV criteria (APA, 1994). At the time of assessment, patients
were not receiving treatment for their depression. In order to establish the severity of
depression, patients were rated with the Hamilton Rating Scale for Depression
(Hamilton, 1960). Mean rating for the MDD group was 30.9 (SD ¼ 4.9), which indi-
cates a moderate or greater degree of depressive features. Healthy control participants
were volunteers recruited from the local community. These participants were screened
for medical or psychiatric impairment by clinical interview, and were screened for
cognitive impairment by administration of the Mini-Mental Examination (Folstein,
Folstein, & McHugh, 1975) (M ¼ 29.6, SD ¼ .63).

DESIGN AND PROCEDURE

The TMT was administered according to published instructions (Reitan &
Wolfson, 1993) except, unlike conventional administration of the test, the subject
was not interrupted during administration for correction of errors or skipped items.
As described above, this method of test administration attempts to avoid potential
confounds and unreliability caused by increased time necessary to stop the subject
for error correction. This approach allows for greater independence in the measure-
ment of time and error scores.
As in the traditional TMT, for Part A, the subject was presented a sheet of
25 randomly placed circled numbers and instructed to draw a line connecting the
 TRAIL MAKING ERRORS IN SCHIZOPHRENIA AND DEPRESSION 275

numbers in corrects ascending sequence. For Part B, the subject was presented a
sheet with 25 circled letters and numbers, and was instructed to connect the circles
in the alternating number-letter order of 1-A, 2-B, 3-C, and so forth. As with con-
ventional administration, a maximum time limit of 300 s was allotted for completion
of each of the two parts of the test. In instances where one or more items were
skipped, total time was prorated to account for the skipped items.
Errors were scored according to the following criteria (Mahurin, Hazleton,
Velligan, Eckert, & Miller, 1997):

1. Tracking errors were scored each time the participant lost track of the number
sequence in Part A, or the alternating number-letter sequence in Part B. Further
errors were not counted if the participant got back ‘‘on track,’’ although the over-
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all sequence of the series may have been shifted at that point (i.e., ‘‘1-A, 2-C, 3-D,
4-E’’), would be scored as one error (see Figure 1).
2. Perseverative errors, scored only for Part B, entailed connecting a number to a
number or a letter to a letter, thus failing to shift from either the number or letter
category (see Figure 2).
3. Proximity errors entailed stimulus-bound responses in which the drawn line con-
nected an incorrect circle within a 1-cm region on each side of a line directed to
the next correct circle in the sequence (see Figure 3). Infrequently, errors fell into
two categories. In these situations, the errors were not double counted, but were
assigned in accord with the order listed above.

In addition to scoring errors for the whole test, TMT Parts A and B were
divided equally into three sections for error analysis: Section 1 ¼ items 1 through
8, Section 2 ¼ items 9 through 17, and Section 3 ¼ items 18 through 25.
TMT scores then were compared with data from other cognitive tests adminis-
tered to the expanded SCZ group of 84 patients, including the 30 patients used in the
between-group comparisons. The following tests were selected to assess specific cog-
nitive abilities: The Verbal Series Attention Test requires timed recitation of familiar
and unfamiliar verbal sequences. These series include simple counting, subtraction
by serial threes, days of the week forward, days of the week backward, months of
the year forward, months of the year backward, an auditory target identification
task, and an oral sequence modeled after Part B of the TMT (i.e., the testee recites

Figure 1 Example of tracking error: Losing track of number sequence (Part A) or number-letter sequence
(Part B). Dotted line indicates correct path.
 276 RODERICK K. MAHURIN ET AL.

Figure 2 Example of perseverative error: Failing to shift from number to letter, or letter to number
category (Part B only). Dotted line indicates correct path.

the series 1-A, 2-B, etc., up through 10-J). This test measures sustained attention and
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mental tracking, and is sensitive to impairment in a variety of neurological and psychi-

atric disorders (Mahurin & Cooke, 1996). The Modified Card Sorting Test (MCST,
Nelson, 1976) is a shortened form of the standard Wisconsin Card Sorting Test
(Heaton, 1981) with response cards removed that share more than one attribute with
any stimulus card. The test measures certain executive functions including concept
formation and the acquisition, maintenance, and shifting of response set (Caffarra,
Vezzadini, Dieci, Zonato, & Venneri, 2004). The Digit Cancellation Test requires
the visual scanning of a matrix of numbers with the purpose of locating and crossing
out specified target numbers (Lewis & Rennick, 1979). The Symbol Digit Test, which
requires rapid written substitution of numbers for symbols, primarily measures psy-
chomotor speed, accuracy, and attention (Smith, 1982). The Token Test (Smith),
which involves carrying out both simple and complex oral instructions, was included
because of its demands on verbal working memory and syntactical comprehension.
Full descriptions of these tests can be found elsewhere (see Lezak, 1995; Spreen &
Strauss, 1998). Trained psychometrists administered the test battery in standardized
format and sequence to all participants. The Verbal Series Attention Test was counter-
balanced in its administration before and after administration of the TMT.
The BPRS factor scores for the SCZ group were derived in a previous study of
cognitive function involving this same group of patients (Mahurin et al., 1998). The
analysis of the full 24-item rating scale revealed the presence of three major symptom
factors: (a) withdrawal-retardation (motor retardation, emotional withdrawal,
blunted affect), (b) reality distortion (suspiciousness, unusual thought content,

Figure 3 Example of proximity error: Connecting an incorrect circle within a 1-cm region bounding line
(Parts A and B). Dotted line indicates correct path.
 TRAIL MAKING ERRORS IN SCHIZOPHRENIA AND DEPRESSION 277

Hallucinations), and (c) conceptual disorganization (disorganization, distractibility,

bizarre behavior). These three factors consistently are found in other analyses of the
BPRS (e.g., Ventura, Nuechterlein, Subotnik, Gutkind, & Gilbert, 2000). BPRS
raters were trained to a high level of inter-rater reliability (intraclass correlation
coefficients > 0.85). Weekly BPRS ratings used in the analysis were taken from the
week closest to the date of cognitive testing. The range of time between BPRS ratings
and cognitive assessment was from three to five days.

RESULTS
Analysis Strategy
Statistical analysis was performed in three stages. First, TMT performance of
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the three groups was compared with regard to total time, total errors, and error
types. To determine significance, appropriate post hoc correction for multiple com-
parisons (Tukey test) was applied to between-group comparisons of total time, total
errors, and error types. Second, within-group analysis was applied to TMT scores,
psychiatric ratings, and cognitive scores of the expanded SCZ group. Because of
the exploratory nature of this portion of the analysis, alpha correction was not
performed for the multiple correlations. Third, because of the moderate intercorrela-
tions among many of the cognitive tests, all cognitive scores were entered into a step-
wise regression model for each of the four principal TMT scores. (i.e., Part A Time,
Part B Time, Part A Errors, Part B Errors).

Between-Group Analysis
Total scores. Time and total errors for Parts A and B showed a significant
interaction across groups and conditions, MANOVA, F(6, 261) ¼ 27.67, p < .0001.
Because of differences in gender composition between the patient groups and the
HC group, this analysis was redone with inclusion of gender as a covariate, which
did not change the overall outcome. Follow-up one-way ANOVAs revealed significant
between-group differences for TMT Time on both Part A and Part B, F(2, 87) ¼
24.5 and F(2, 87) ¼ 31.1, p < .0001, respectively. Group comparisons of Part A and
Part B total time revealed that the SCZ group was slower than the HC group, the
MDD group also was slower than the HC group, and the SCZ group was slower than
the MDD group. Total errors also significantly differed across groups for Part B, F(2,
87) ¼ 4.6, p < .01 but not Part A, F(2, 87) ¼ 1.2, n.s. Comparisons of Part B total
errors revealed the SCZ group made significantly more errors than the MDD group,
and also significantly more errors than the HC group. The MDD and the HC group
did not significantly differ from each other (see Table 1).
Error types. Part A and Part B error types again showed a significant inter-
action across groups and conditions, MANOVA F(10, 430) ¼ 2.55, p < .005.
Inclusion of gender as a covariate did not affect the overall outcome. Because the
frequency of Part A error types and section errors was considered too low for reliable
statistics (see Table 1) the breakdown of Part A errors was not used further in
between-group analyses. For Part B, the groups significantly differed in tracking
errors, F(2, 87) ¼ 3.0, p < .05, perseverative errors, F(2, 87) ¼ 6.4, p < .003, and
 278 RODERICK K. MAHURIN ET AL.

Table 1 Time and error scores on Trail Making Test Parts A and B for schizophrenia, major depression,
and healthy control groups

Healthy control Depression Schizophrenia

Score M SD M SD M SD

Part A
Time


25.2 6.7 38.8 11.8a 52.9 23.1a,b
Total errors 0.07 0.37 0.19 0.40 0.23 0.50
Tracking 0.07 0.36 0.04 0.19 0.13 0.34
Proximity 0.0 0.0 0.15 0.36 0.07 0.25
Part B
Time


55.7 18.3 81.3 31.5a 151.2 76.3a,b
Total errors
0.50 1.85 0.93 1.92 3.07 5.60a,b
4.59a,b
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Tracking
0.40 1.40 0.63 1.36 2.03

Perseverative
0.03 0.18 0.19 0.62 0.72 1.22a,b
Proximity
0.07 0.37 0.11 0.42 0.38 0.78a,b

Note. Perseverative errors are not applicable to Part A.

n ¼ 30 for each group.
a
Significantly different from control group.
b
Significantly different from depression group.
ANOVA,
p < .05,

p < .01,


p < .001.

proximity errors, F(2, 87) ¼ 3.0, p < .05. Follow-up comparisons revealed that the
SCZ group made significantly more of each Part B error type than did either the
MDD or HC group, which did not significantly differ from each other (see Table 1).

Within-Group Analysis
TMT scores. The larger number of subjects in the expanded SCZ group
(n ¼ 84) allowed for within-group analyses of TMT data in relation to other cogni-
tive test scores as well as symptom ratings. Within that group, Part A Time was
found to significantly correlate with Part B Time. Part B Time (but not Part A Time)
was significantly correlated with Part B Errors. The three error types were signifi-
cantly intercorrelated; proximity errors showed the highest correlation with total
Part B Errors (see Table 2). Part A error types again were not considered stable
because of their very low frequency of occurrence.

Section Scores
Part A Errors showed a trend towards significance across sections (Section 1,
M ¼ 0.012; Section 2, M ¼ 0.048; Section 3, M ¼ 0.04; F, 2,164 ¼ 2.7, p ¼ .06). Part
B section errors showed a significant increase across Sections 1, 2, and 3 (Section 1,
M ¼ 0.27; Section 2, M ¼ 0.55; Section 3, M ¼ 1.21; F, 2,162 ¼ 11.5, p < .001).

Symptom ratings. Part B Time was found to significantly correlate with

factor scores for BPRS withdrawal-retardation and reality distortion ratings. In
contrast, Part A Time significantly correlated only with withdrawal-retardation
 TRAIL MAKING ERRORS IN SCHIZOPHRENIA AND DEPRESSION 279

Table 2 Correlations between Trail Making Test time and error scores

Part A Part B

Total Total Error type

Scores Time Errors Time Errors Tracking Perseverative Proximity

Part A Time —
Part A Errors .11 —
Part B Time .57


.07 —
Part B Errors .12 .13 .28

—
Tracking .11 .33

.12 .54


—
Perseverative .01 .11 .21 .67


.50


—
Proximity .16 .08 .27
.97


.37


.48


—
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Note. Analyses conducted on full schizophrenia group (n ¼ 84).

p < .05;

p < .01;


p < .001 (unadjusted).

scores. Part A Errors significantly correlated only with the reality distortion factor,
and Part B Errors were significantly correlated only with the conceptual disorganiza-
tion factor (see Table 3).

Cognitive test scores. Part A Time was significantly correlated with four test
scores from the cognitive battery: Verbal Series Time, Verbal Series Errors, Digit
Cancellation, and Symbol Digit. Part A Errors were not significantly correlated with
any of the administered cognitive tests. Part B Time was significantly correlated with
all of the other cognitive measures except MCST perseverative errors. In contrast to

Table 3 Exploratory correlations of Trail Making scores with cognitive tests and BPRS factor scores

Part A Part B

Total score Total score Error type

Test Time Errors Time Errors Tracking Perseverative Proximity

Verbal Series Time .26
.02 .44


.13 .11 .19 .01
Verbal Series Errors .30
.01 .52


.48


.50


.25
.18
Digit Cancellation .55


.03 .50


.19 .18 .25
.08
Symbol Digit .42

.06 .56


.27
.28
.18 .03
Token Test .20 .04 .30
.52


.46


.51


.31

MCST Total Correct .16 .01 .26
.37

.31
.37

.22

MCST Perseverative Errors .09 .02 .20 .43


.38

.37

.24

BPRS Factors
Reality distortion .10 .24
.30
.13 .16 .01 .09
Withdrawal-retardation .24
.20 .33
.05 .01 .07 .04
Conceptual disorganization .04 .21 .18 .31
.29
.17 .23

Note. Analyses conducted on full schizophrenia group (n ¼ 84).

MCST: Modified Card Sorting Test; BPRS: Brief Psychiatric Rating Scale.


p < .05;

p < .01;


p < .001 (unadjusted).
 280 RODERICK K. MAHURIN ET AL.

Table 4 Part A Time: Summary of stepwise regression

Step Multiple R Multiple R-square R-square change F to Enter p

Digit Cancellation 1 0.46 0.21 0.21 21.82 .001

Age 2 0.48 0.23 0.02 2.55 .11
Verbal Series Errors 3 0.50 0.25 0.01 1.49 .23
Verbal Series Time 4 0.51 0.26 0.01 1.21 .28

Regression summary

Beta SE Beta B SE B t p

Digit Cancellation 0.48 0.11 2.00 0.45 4.46 .001

Age 0.14 0.10 0.81 0.57 1.42 .16
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Verbal Series Errors 0.22 0.13 0.92 0.56 1.64 .10

Verbal Series Time 0.16 0.15 0.08 0.07 1.10 .28

Note. Analyses conducted on full schizophrenia group (n ¼ 84).

R ¼ .509; R2 ¼ .259; Adjusted R2 ¼ .222; F(4, 79) ¼ 6.925, p < .0001.
No variables successfully met entry criterion (F > 1.0) for Part A errors.

Part A, Part B Errors were significantly correlated with all tests in the battery,
excluding Verbal Series Time and Digit Cancellation (see Table 3).
Because of potentially significant intercorrelations among the cognitive tests,
regression analyses were used to clarify their relative predictive contributions to the
TMT scores. All seven test scores (with the inclusion of age) were regressed in stepwise
fashion on each of the four TMT scores: Part A Time, Part A Errors, Part B Time,
and Part B Errors. Part A Time was uniquely predicted only by Digit Cancellation
( p < .0001). Part A Errors failed to show any significant associations. Part B Time also
was predicted by Digit Cancellation and, in addition, by Verbal Series Errors
( p < .0001). Unique contributions to Part B Errors were demonstrated for Token Test,
Verbal Series Time, and Verbal Series Errors (p < .0001; see Tables 4–6).

Table 5 Part B Time: Summary of stepwise regression

Step Multiple R Multiple R-square R-square change F to Enter p

Verbal Series Errors 1 0.50 0.25 0.25 27.84 .001

Digit Cancellation 2 0.58 0.34 0.08 10.16 .001
Symbol Digit 3 0.59 0.35 0.01 1.18 .28
Token Test 4 0.60 0.36 0.01 1.72 .19

Regression summary

Beta SE Beta B SE B t p

Verbal Series Errors 0.44 0.11 4.42 1.16 3.80 .001

Digit Cancellation 0.23 0.11 2.38 1.12 2.12 .04
Symbol Digit 0.18 0.13 1.80 1.27 1.41 .16
Token Test 0.15 0.11 4.31 3.29 1.31 .19

Note. Analyses conducted on full schizophrenia group (n ¼ 84).

R ¼ .600; R2 ¼ .360 Adjusted R2 ¼ .327; F(4, 79) ¼ 11.120, p < .0001.
 TRAIL MAKING ERRORS IN SCHIZOPHRENIA AND DEPRESSION 281

Table 6 Part B Errors: Summary of stepwise regression

Step Multiple R Multiple R-square R-square change F to Enter p

Token Test 1 0.49 0.24 0.24 26.18 .001

Verbal Series Time 3 0.65 0.43 0.12 17.20 .001
Verbal Series Errors 2 0.55 0.30 0.06 6.97 .01
Digit Cancellation 4 0.67 0.45 0.02 3.16 0.08

Regression summary

Beta SE Beta B SE B t P

Token Test 0.36 0.10 0.55 0.16 3.46 .001

Verbal Series Errors 0.63 0.13 0.35 0.07 5.03 0.001
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Verbal Series Time 0.57 0.13 0.04 0.01 4.56 0.001

Digit Cancellation 0.17 0.09 0.09 0.05 1.78 0.08

Note. Analyses conducted on full schizophrenia group (n ¼ 84).

R ¼ .669; R2 ¼ .447; Adjusted R2 ¼ .419; F(4, 79) ¼ 16.004, p < .0001.

DISCUSSION
Results from this study demonstrate the utility of TMT error analysis as
a means of assessing components of cognitive function in schizophrenia and
depression. The findings are in agreement with Stuss and Colleagues (Sutss et al.,
2001) regarding the potential utility of error analysis in the assessment of frontal-
mediated cognitive functions. Both the SCZ and MDD groups were significantly
slower than the HC group, with the SCZ group slower than the MDD group. How-
ever, in contrast to the SCZ group, the MDD group did not commit significantly
more Part B Errors than did the HC group. The lack of significant difference in error
scores between the MDD and HC groups suggests that, although TMT performance
was slowed in depression, there was not the disorganization of test performance that
was observed in the SCZ group.
Within-group analysis of the expanded SCZ group showed that the proportion
of Part B Errors progressively increased from Section 1 to Section 3. Although over-
all the TMT takes a relatively short period of time (a maximum of 300 s), this finding
suggests that as a greater number of test items were completed, patients experienced
increasing difficulty in visual search, sustained attention and effort, and mentally
tracking two alternating series. It could be argued that, for a given participant, inad-
equate knowledge of the alphabet may have contributed to an increase in errors as
the test progressed. However, it should be noted that patients in this group had at
least a high school education. Furthermore, all patients were able to successfully
recite the letters of the alphabet in a relatively short period of time (usually less than
20 s) on the alphabet item from the Verbal Series Attention Test.
The finding of a positive relationship between Part A and Part B Times with
ratings on the BPRS withdrawal-retardation factor is consistent with previous
reports of an association between psychomotor slowing and negative symptom
expression in schizophrenia (Eaton, Thara, Federman, Melton, & Liang, 1995;
Strauss, 1993). In contrast, Part B Errors were not significantly correlated with
 282 RODERICK K. MAHURIN ET AL.

the withdrawal-retardation factor, but instead were associated with the conceptual
disorganization factor of the BPRS. The contrast between the association of Part B
Errors with conceptual disorganization and Parts A and B Time with withdrawal-
retardation offers further support for a dissociation between the executive and
psychomotor aspects of TMT performance.
Correlations within the SCZ group revealed significant associations between
many of the cognitive tests and TMT scores, particularly for Part B. These tests
included measures of concept formation and working memory (MCST, Token
Test), attention (Verbal Series Attention Test), and psychomotor speed (Digit
Cancellation Test, Symbol Digit Test). As noted above, these results are consistent
with the influence of multiple cognitive functions on TMT performance (Lezak,
1995). Stepwise regression, however, revealed that substantial shared variance
existed among the various cognitive tests, with only a few tests making a unique
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(i.e., unshared) contribution to the regression results (see Tables 3–5). After apply-
ing the regression model, both Part A and Part B Time were significantly predicted
by Digit Cancellation. Cancellation tasks involves directed visual search for targets
embedded in a complex array (Lezak). It is, in this sense, analogous to searching
for the correct ‘‘next’’ number or letter while performing the TMT, consistent with
a strong visual search component for both parts of the test (Fossum, Holmberg, &
Reinvang, 1992).
Part B Time also was predicted by Verbal Series Errors, suggesting that the
added complexity of Part B affected speed of cognitive processing as well as accuracy
of mental tracking. Beyond requiring the cognitive operations of Part A (visual scan-
ning, psychomotor execution, and sustained attention), Part B also demands simul-
taneous mental tracking of two series (i.e., numbers and letters), thus increasing
demands on working memory, allocation of attention, and shifting of response set
(Gaudino, Geisler, & Squires, 1995).
In contrast, Part B Errors were predicted only by scores on the Verbal Series
Attention Test and the Token Test, neither of which directly measures visuomotor
or psychomotor speed. The Verbal Series Attention Test consists of various items
assessing mental tacking ability. This test’s significant association with Part B Errors
is consistent with the role of mental tracking in TMT performance (O’Donnell,
Macgregor, Dabrowski, Oestreicher, & Romero, 1994).
The reason for the significant association between Part B Errors and the Token
Test is not as clearly evident. Although frequently the Token Test is used as a
measure of receptive language, it also appears to measure a broader set of cognitive
abilities. Beyond language functions, accurate performance on the test requires
manipulation of information in working memory as well as conceptualization of
abstract relationships, both of which arguably involve executive mediated abilities
(Baddeley, 1998; Rabbitt, 1997). For example, the Rey Complex Figure, which also
involves executive-mediated abilities, has been shown to be significantly correlated
with the Token Test, but not with other language measures (Meyers & Meyers,
1995). Other investigators explicitly have suggested use of the Token Test as a
measure of general cognitive status (Swihart et al., 1989). This suggestion is
supported by high correlations within the SCZ group between the Token Test, the
Verbal Series Test, and the MCST (Verbal Series Time, r ¼ .67, Verbal Series
Errors, r ¼ .74, MCST, r ¼ .72).
 TRAIL MAKING ERRORS IN SCHIZOPHRENIA AND DEPRESSION 283

Although regression analysis failed to show unique predictive value of Part B

scores from the MCST, the significant correlations between all three Part B error types
and both MCST scores (total correct and perseverative errors, see Table 3) invites specu-
lation as to common cognitive components of the two tests. Specifically, the significant
correlations suggest that problems with maintenance and shifting of response set may
partially account for difficulty with Part B performance. The original Wisconsin
Card Sorting Test been used extensively in neuropsychological studies of schizophrenia
(e.g., Goldman, Axelrod, & Tompkins, 1992), and functional neuroimaging has
demonstrated impairment on the test to be associated with diminished frontal lobe acti-
vation and executive dysfunction (Ragland et al., 1998; Weinberger, Berman, & Zec,
1986). As noted above, studies of brain-damaged patients also have associated TMT
performance with frontal mediated cognitive operations (Stuss et al., 2001).
The nature of executive dysfunction in depression has not been fully clarified.
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Although psychomotor slowing is well documented in (e.g., Goodwin, 1992), and is

one of the diagnostic criteria for the disorder (APA, 1994), additional reported cog-
nitive impairments include deficits in attentional control, working memory, and pro-
cessing speed (Elderkin-Thompson, Boone, Hwang, & Kumar, 2004; Veiel, 1997).
These information processing deficits can, in turn, affect performance on other
cognitive processes, including executive functions (for general discussion, see
Rabbitt, 1997). Evidence from brain imaging studies suggests that cognitive difficult-
ies in depression are associated with frontal lobe dysfunction and disrupted
connectivity to other brain regions (Liotti & Mayberg, 2001; Mayberg, Mahurin, &
Brannan, 1997; Moser et al., 2002), also indicating a possible association with execu-
tive impairment.
In contrast, other studies indicate a dissociable profile of cognitive impairment
between schizophrenia and depression, with poorer performance by patients with
schizophrenia in executive operations such as attention, problem solving, and
abstraction (Goldberg et al., 1993). A previous study of depression and cognition
in multiple sclerosis concluded that the patients with depression showed ‘‘slow infor-
mation processing speed and impaired working memory, whereas executive function-
ing, as measured with the Wisconsin Card Sorting Test, [was] unaffected’’ (Arnett
et al., 1994). Although from a different patient population, this finding is consistent
with current results showing a significant difference in Part B error scores, but not
time scores, between the MDD group and SCZ group. Results from the current
study do not necessarily imply an absence of executive dysfunction in depression.
Rather, they point toward differences in the pattern and degree of executive impair-
ment in depression and schizophrenia as detected by a specific analysis of the TMT.
There are several limitations to the present study. As noted, all SCZ patients
were receiving antipsychotic medication at the time of testing. This is consistent with
many other cognitive studies of schizophrenia, for it can be very difficult to accu-
rately test unmedicated patients, especially those with symptoms severe enough to
warrant acute hospitalization. In addition, the clinical considerations involved in
withdrawing patients from maintenance antipsychotic medication (i.e., solely for
research purposes) are considerable. However, as indicated by BPRS ratings, the
psychiatric symptoms of these patients remained sufficiently severe to warrant con-
tinued treatment. In addition, reports on the effect of antipsychotic medications on
test performance in schizophrenia have been mixed, with some studies indicating an
 284 RODERICK K. MAHURIN ET AL.

interaction (Cleghorn, Kaplan, Szechtman, Szechtman, & Brown, 1990) but others
failing to find a direct association (Goldberg et al., 1990). Cognitive test scores of
patients who were receiving anticholinergic medication did not significantly differ
from those who were not (reported in Mahurin et al., 1998).
In contrast to the SCZ group, patients in the MDD group were not receiving
medication at the time of testing. Use of an unmedicated patient sample arguably
provides a more accurate picture of cognitive functioning in depression than does
assessment of medicated patients that, if sufficiently stabilized, would demonstrate
less prominent symptoms at the time of assessment. Further, both the SCZ group
and the MDD group were recruited from hospitalized inpatients, and the results
may not generalize to outpatients with less severe illness. A similarly constructed
study with outpatient samples of both patient groups would serve to address this
question. Finally, because the TMT scores were based on a modified administration
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of the test, specifically with regard to the absence of error correction, caution should
be taken in interpreting these results in comparison with studies that have employed
conventional test procedures.
It also should be noted that the structured format of the TMT may limit the
test’s sensitivity to more subtle executive problems in depression (for discussion,
see Lezak, 1995). For example, Royall and colleagues demonstrated executive
impairment in major depression by use of an interview-based instrument shown to
be sensitive to executive impairment in other disorders (The EXIT; Royall, Mahurin,
& Gray, 1992). The EXIT involves relatively unstructured responses by the patient
to interactive questions by the examiner and, as such, contrasts with the more struc-
tured format of the TMT (Royall, 1999).
As discussed above, other methods of TMT error analysis have been published.
The D-KEFS, in particular, provides a systematic method of error analysis as an
extension to traditional Trail Making Test scoring (Delis et al., 2001a). A particular
advantage is that error scores are incorporated into the battery’s normative reference
data. The scoring of errors for D-KEFS partially overlaps that of the current study,
including specific criteria for sequencing, set-loss, and time-discontinue errors
(Delis, Kaplan, & Kramer, 2001b). Roughly, a ‘‘sequencing’’ error on the D-KEFS
corresponds to a tracking error and a ‘‘set-loss error’’ is similar to a perseverative
error. The ‘‘time-discontinue’’ error in the D-KEFS provides a means to account
for items that are unfinished at the test’s time limit, in contrast to the method of
pro-rating unfinished items employed in the present study. The D-KEFS does not
use an analogous error to the proximity error. The D-KEFS also differs from the
present study is that in the former the subject is stopped and corrected whenever
an error occurs during the test. Timing is continued during the correction and is
included in the total time. In the current study the subject is not stopped for error
correction; errors are determined and analyzed during post-test analysis.
The current data corroborate previous studies with regard to the clinical utility
of examining patterns of TMT errors. In addition to the assessment of different diag-
nostic groups (i.e., schizophrenia and depression), the current study offers additional
operational definitions of errors, as well as analysis of relationships between TMT
errors and other measures of cognitive function. It is worth reiterating that in order
to include sufficient numbers of subjects from a single diagnostic group for multiple
regression, all within-group analyses were based on scores only from the expanded
 TRAIL MAKING ERRORS IN SCHIZOPHRENIA AND DEPRESSION 285

SCZ group. These results will require replication in healthy subjects and other
patient populations in order to assess their reliability and generalizability.
The proposed method of scoring errors provides a means to dissociate compo-
nent cognitive operations involved in TMT performance, and to identify potentially
meaningful subtypes of task performance for clinical and research purposes. Analy-
sis of TMT errors in patients with other neurologic and psychiatric illnesses would
add data regarding the specificity of the TMT as a measure of executive function
in these disorders. Overall, the present results indicate that analysis of errors that
occur during TMT performance taps aspects of cognitive performance not otherwise
captured using completion time as the sole outcome variable.

ACKNOWLEDGEMENT
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Roderick Mahurin currently is affiliated with the Department of Radiology,

University of Washington School of Medicine. Dawn Velligan and Alexander Miller
currently are affiliated with the Department of Psychiatry, University of Texas Health
Science Center at San Antonio. J. Mark Davis currently is affiliated with the Regents
Center for Learning Disorders, Department of Psychology, University of Georgia.
Stacey Eckert currently is affiliated with the Psychology Graduate Program, Univer-
sity of Houston. The authors gratefully acknowledge Helen Mayberg, Steven Bran-
nan, Art Silva, and Jan Tekell from the University of Texas Health Science Center at
San Antonio for support and assistance in recruitment and psychiatric evaluation of
patients, as well as support from the staff of the Clinical Research Unit at San
Antonio State Hospital.

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