SCHIZOPHRENIA

RESEARCH

ELSEVIER Schizophrenia Research 22 (1996) 173-180

Reality monitoring failure in schizophrenia: The role of selective

attention
Gildas Brrbion a,,, Mark J. Smith b, Jack M. Gorman a, Xavier Amador a

a Schizophrenia Research Unit, Department of Clinical Psychobiology, New York State Psychiatric Institute, unit #2,
722 West 168th street, New York, N Y lO032, USA
b Department of Psychiatry, Mount Sinai Medical Center, New York, NY, USA
Received 8 February 1996; accepted 29 April 1996

Abstract

Reality monitoring and selective attention have been repeatedly shown to be impaired in schizophrenia. Positive
symptomatology has been found to be associated with deficits in both reality monitoring and selective attention.
Therefore, a direct link between reality monitoring and selective attention was hypothesized. Thirty-two schizophrenic
patients and 32 normal controls were administered the Stroop test as a measure of selective attention along with a
test of three indices of reality monitoring, involving discrimination of: events vs. non-events, self- vs. externally-
generated events, and oral vs. pictorial sources. A global memory test was administered for comparison. Results
showed that schizophrenic patients were impaired in both reality monitoring and selective attention, and that these
two were significantly correlated with each other in the schizophrenic sample. On the contrary, selective attention was
not significantly correlated with memory efficiency in either group. Further, multiple regression analyses in schizophrenic
patients showed that only selective attention contributed significantly to the variance in reality monitoring measures.
Therefore, the results argue in favor of a specific role of a selective attention deficit in reality monitoring failure in
schizophrenia.

Keywords: Reality monitoring; False alarms; Selective attention; Schizophrenia

1. Introduction nation and reality. The term 'reality monitoring',

A m o n g the cognitive impairments observed in
schizophrenia, one o f the characteristic features is
a failure of reality monitoring. Reality monitoring
generally refers to the function of discriminating
between events generated intra-psychically and
events generated by an external source (Johnson
and Raye, 1981). In daily living this function is
what enables subjects to distinguish between imagi-
* Corresponding author. Fax: (1-212)927-4629.
however, can be used to describe any decision-
making process where subjects must make a dis-
tinction regarding the origin of the information
(Bentall, 1990; Keefe, in press). Various types of
distinctions fall into this category: between actual
events and non-events, potentially leading to 'false
alarms' types o f errors, between real events that
are either self-generated or externally-generated,
or between two different external sources of real
events.
Some authors have suggested that hallucinations

0920-9964/96/$15.00 © 1996 Elsevier Science B.V. All rights reserved

PII S0920-9964 (96)00054-0
174 G. Brrbion et al. ~Schizophrenia Research 22 (1996) 173 -180
in schizophrenic patients may be explained by
reality monitoring failure, e.g., the misattribution
to an external source of a self-generated event
(Bentall, 1990). Accordingly, links have been
found between deficit in a reality monitoring task
and hallucinations (Heilbrun, 1980; Bentall et al.,
1991) and global positive symptomatology
(Brrbion et al., submitted) in schizophrenic
patients, and predisposition to hallucinations in
normal controls (Rankin and O'Carroll, 1995).
Finally, an increased rate of false alarms has been
linked to hallucinations (Bentall and Slade, 1985)
and thought disorders (Harvey, 1985; Harvey
et al., 1988) in schizophrenic patients.
Nevertheless, the elementary cognitive perturb-
ations underlying reality monitoring failure are
still largely unknown.
One cognitive perturbation that could be rele-
vant is in inhibitory processes, which have been
shown to be weakened in schizophrenia (Beech
et al., 1989b; Carter et al., 1992, 1993; Laplante
et al., 1992; Spitzer et al., 1993). It has been
suggested that positive symptomatology in schizo-
phrenia is linked to this weakening (Frith, 1979).
Weakened inhibition has been linked to positive
symptomatology in schizotypal patients (Beech
and Claridge, 1987; Bullen et al., 1987; Baruch
et al., 1988; Beech et al., 1989a, 1991; Peters et al.,
1994; Williams, 1995), but not to their negative
symptomatology (Peters et al., 1994; Williams,
1995). In schizophrenic patients, it has similarly
been linked to thought disorders (Manschreck
et al., 1988; Spitzer et al., 1994) and to the
disorganization syndrome (Liddle and Morris,
1991).
Given the link between positive symptomatology
and reality monitoring deficit on one hand, and
between positive symptomatology and weakened
inhibition on the other hand, it follows that weak-
ened inhibitory processes could also be linked to
failure in reality monitoring. However, a weaken-
ing of inhibitory mechanisms should imply a deficit
in selective attention, since selective attention con-
sists in the ability to focus on a specific target
while inhibiting non-relevant information.
Unfortunately, the direct link between impair-
ments in selective attention and positive symptom-
atology has rarely been tested in schizophrenia. A
link between positive thought disorder and impair-
ment in selective attention has been suggested
(Serper, 1993). Increased sensitivity to distractibil-
ity has also been found in schizophrenic patients
(Grillon et al., 1990), and linked to positive symp-
tomatology (Cornblatt et al., 1985; Green and
Walker, 1986; Walker and Harvey, 1986).
The psychological meaning of a relation between
selective attention and reality monitoring could be
understood as follows: a defect in selective atten-
tion would dim the characteristics of the features
of the events. Indeed, one of the major determi-
nants of reality monitoring function is that exter-
nally generated events have more perceptual and
contextual information, thus setting them apart
from the less richly detailed imaginary events
(Johnson et al., 1993). Therefore, if the features
of the events were dimmed, it would be more
difficult to discriminate them from imaginary
events, or to distinguish between the perceptual
properties of external events.
This experiment was an attempt to directly
demonstrate a link between a defect in selective
attention and reality monitoring impairment in
schizophrenia. We designed a test that enabled us
to assess three different types of reality monitoring:
the distinction between events that happened and
events that did not happen, the distinction between
self-generated and externally-generated events, and
the distinction between two external sources, i.e.,
orally and pictorially generated events. The Stroop
test was used as a measure of selective attention,
in that it requires the subject to name the color in
which a word is printed, while inhibiting the
reading of this word. Lastly, memory efficiency
was used as a comparative measure, to rule out
the hypothesis that a selective attention deficit
disturbs all cognitive functions indiscriminately.
We hypothesized that selective attention in the
schizophrenic sample would be correlated with the
following reality monitoring functions: (1) failure
in discriminating whether an event has happened
or not, as manifested by 'false alarms' type errors;
(2) failure in discriminating internally from exter-
nally generated events; (3) failure in discriminating
the modality, e.g., oral vs. pictorial events. On the
contrary, the selective attention measure was not
expected to be related to general cognitive effi-
 G. Brbbion et al./Schizophrenia Research 22 (1996) 173-180
ciency as assessed by the global memory test. This
would argue in favor of a specific link between a
defect in selective attention and reality monitor-
ing failure.
2. Method
2.1. Participants
Thirty-two inpatients meeting DSM-IV criteria
for schizophrenia were included in the schizophre-
nic sample (21 males, 11 females; age: mean=
35.6, SD= 10.5; years of education: mean= 12.4,
SD=2.7). They were recruited from the
Schizophrenia Research Unit (SRU) at the New
York State Psychiatric Institute and Creedmore
Psychiatric Center. All were on anti-psychotic
medication and were at fixed doses at testing.
Thirty-two normal controls matched for age,
gender and years of education were recruited from
a pool of normal volunteers from the Mental
Health Clinical Research Center at the New York
State Psychiatric Institute and from advertising
(22 males, l0 females; age: mean= 37.1, SD = 10.0;
years of education: mean= 13.0, SD=2.0). They
were screened to rule out any current or recent
psychiatric history, alcohol abuse or drug
addiction.
2.2. Materials and procedure
2.2.1. Reality monitoring
Eight categories, and two examples within each
category, were selected. The categories were the
following: fruits, sports, furniture, animals, states
of the USA, grains, transport, famous monuments.
A picture of each of the category examples was
available. In order to counterbalance the material
among subjects, two conditions of experimentation
were alternatively used. In the first condition, one
of the two examples of the category was presented
as a picture and the other one was orally produced
by the experimenter. The reverse was true for the
other condition. Subjects were randomly assigned
to one of these conditions. For each category, a
third example was required to be produced by the
subject, leading to 24 produced items.
175
A recognition score sheet for use by the experi-
menter was prepared for each condition. It dis-
played, in a random order, the eight items orally
produced by the experimenter, the eight items
presented as pictures, eight empty spaces that were
to be filled out with the items produced by the
subjects, and 24 distractors. These distractors were
made up of three other examples of each of the
eight categories. One supplementary item was
available for each category. It was to be used as a
replacement in the case where the item produced
by the subject was one of those previously selected
as distractors.
The procedure was as follows: the experimenter
first indicated the name of the category (e.g.,
'fruits'), then orally produced an example of the
category (e.g., plum). He subsequently showed a
picture of a second example (e.g., a picture of
grapes) and the subject was required to provide
by him/herself a third example of the category.
The experimenter wrote down this third example
on the recognition score sheet. This procedure was
repeated for the eight categories. The order of
administration of the categories was randomized
for each subject. The subjects were not warned
that they would be asked to remember the source
of the information afterwards. After a delay of
about 5 min, during which the Stroop test was
administered, the experimenter read out loud the
items of the recognition score sheet in sequence.
For each, the subjects were required to indicate
whether it was new, produced by the experimenter,
produced by themselves or presented as a picture.
A discrimination index was computed for each of
the three types of reality monitoring (see below).
The comparison between schizophrenic patients
and normal controls in reality monitoring perfor-
mance has been fully described and discussed in a
previous paper (Br6bion et al., submitted).
2.2.2. Selective attention
The Stroop color-word test was used. Subjects
first had to call out names of blocks of colors
displayed on a sheet as quickly as they could,
constituting the 'color naming' condition. Then,
they were given a sheet displaying names of colors
printed in a different color, and they had to name
the color of the ink as quickly as they could,
176 G. Brbbionet al./Schizophrenia Research22 (1996) 173-180

inhibiting the reading of the words, constituting
the 'color-word naming' condition. The times for
both conditions ('color time' and 'color-word
time') were recorded.
2.2.3. Memory efficiency
A long-term m e m o r y task (free recall of four
lists of 16 words) was administered. The total
number of recalled words was used as a measure
of m e m o r y efficiency. Full results are reported
elsewhere (Br6bion et al., 1996).
D a t a analysis was carried out by means of the
SPSS for Windows program, release 6.0.1. An c~-
level of 0.05 was used for all statistical tests.
3. R ~
3.1. Comparison between groups
Results for measures of reality monitoring, selec-
tive attention and global m e m o r y are presented
in Table 1.
3.1.1. Discrimination oM items~new items
This was evaluated using the proportion of items
properly identified as old or new out of the 48
items. Unlike the other types of reality monitoring,
which involve a decision about the events' origin,
this discrimination involves determination of
whether the event happened or not. Accordingly,
the salient parameter is not so much how often a
subject fails to recognize a previously seen event
('omissions'), but rather how often a subject
believes he/she recognizes an event that had not
in fact previously occurred ('false alarms').
3.1.2. Discrimination self-/externally-generated
This was evaluated using the proportion of items
correctly attributed either to oneself or to an
external source (even if the wrong external source
was given) out of the items properly recognized
as old.
3.1.3. Discrimination oral/picture
This was evaluated using the proportion of items
correctly attributed either to the oral (even if the
wrong person was given) or pictorial modality out
of the items properly recognized as old.
Schizophrenic patients appeared to be signifi-
cantly impaired on all three indices.
Both Stroop conditions, e.g., color time and
color-word time, were significantly impaired in
patients. The specific index of selective attention,
assessed by computing the difference between
groups in color-word time (conflictual situation),
after controlling for color time (non-conflictual
situation), was significantly impaired (p < 0.02).
Patients were also impaired on the total number
of recalled words in the global m e m o r y measure.
3.2. Correlations between reality monitoring and
selective attention
Correlations were computed in both groups
between reality monitoring measures and selective
attention, e.g., correlation with the Stroop color-

Table 1
Mean scores in reality monitoring, Stroop test and memory, in schizophrenic patients and normal controls

Schizophrenic patients (n = 32) Normal controls (n = 32) Significance

level (p value)

Discrimination
old items/new items 0.84 (0.09) 0.93 (0.06) O.O001
self/external 0.93 (0.08) 0.99 (0.03) 0.0001
oral/picture 0.89 (0.11) 0.96 (0.05) O.OO1
Stroop
color time (s) 96.0 (30.8) 70.8 (19.7) 0.0001
color-word time (s) 186.5 (60.3) 126.3 (35.4) 0.0001
Memory
recalled words 13.9 (7.3) 24.3 (7.5) 0.0001
 G. Br~bion et al./Schizophrenia Research22 (1996) 173-180
Table 2
Correlations of reality monitoring and memory with selectiveattention, in schizophrenicpatients and normal controls
Discrimination: old items/new items
Omissions
False alarms
Discrimination: self/external
Discrimination: oral/picture
Memory
*p<0.10; **p<0.05.
word time after partialling out the Stroop color
time. The results are presented in Table 2.
As predicted, the three types of reality monitor-
ing were linked to selective attention in schizophre-
nic patients. N o significant correlation between
selective attention and the old/new discrimination
index appeared in schizophrenic patients, but selec-
tive attention was linked to the number of false
alarms. The correlation between self/external
discrimination index and selective attention was
only marginally significant, whereas the correlation
was significant with oral/picture discrimination.
On the contrary, no significant correlation or trend
for a correlation between selective attention and
reality monitoring measures appeared in the con-
trol group.
Memory efficiency was used as a discriminant
measure to test the specificity of the link between
selective attention and reality monitoring in schizo-
phrenia. As expected, no significant correlation
appeared between memory and selective attention
measure in the schizophrenic sample (see Table 2).
To confirm the involvement of selective attention
in reality monitoring, several multiple regression
analyses were carried out in both samples. The
three reality monitoring discrimination indices, as
well as the number of false alarms and omission
errors, were entered separately as dependent vari-
ables. Four measures were used as independent
variables. The time difference between the conflic-
tual (Stroop color-word) and non-conflictual
(Stroop color) conditions of the Stroop test was
used as the measure of selective attention. The
Stroop color time was also included, to ensure
177
Selectiveattention (interferencein Stroop test)
Schizophrenicpatients (n = 32) Normal controls (n = 32)
-0.26 0.04
- 0.02 0.04
0.45** -0.25
-0.32* 0.16
-0.44** 0.09
- 0.15 -0.21
that the effect observed on the Stroop time differ-
ence was actually due to selective attention, and
was not an artifact linked to the Stroop test itself.
This color time could be considered as a measure
of speed. Number of years of education and global
memory efficiency were entered as well, since they
were considered as factors possibly affecting the
dependent variables. The results are presented in
Table3 (schizophrenic patients) and Table4
(normal controls).
In the schizophrenic sample, selective attention
significantly contributed to the variance in false
alarms and oral/picture discrimination. On the
contrary, none of the other measures significantly
contributed, or tended to contribute, to the vari-
ance of any of the reality monitoring scores. In
the control sample, the pattern was quite different:
memory efficiency and speed assessed by the
Stroop color time significantly contributed to the
different measures of reality monitoring, whereas
selective attention made no significant contribution
to any o f these measures.
Lastly, the measure of selective attention did
not contribute to the variance of the memory
measure in either group.
4. Discussion
As expected, schizophrenic patients showed
deficits on all cognitive measures considered in this
experiment: selective attention, memory and all
the reality monitoring measures. In addition, in
accordance with our hypothesis, selective attention
178 G. Brdbion et al./Schizophrenia Research 22 (1996) 173-180

Table 3
Regression analyses:significance(p value) of the contribution of the differentvariables to realitymonitoring and memoryperformances
in schizophrenicpatients (n = 32)

Years of education Memoryefficiency Stroopcolor time Selectiveattention

Discrimination: old items/new items 0.38 0.40 0.52 0.31

Omissions 0.22 0.41 0.51 0.64
False alarms 0.83 0.75 0.86 0.02
Discrimination: self/external 0.84 0.32 0.85 0.15
Discrimination: oral/picture 0.89 0.67 0.17 0.03
Memory 0.31 0.12 0.31

Table 4
Regression analyses:significance(p value) of the contribution of the different variables to reality monitoringand memoryperformances
in normal controls (n=32)

Years of education Memoryefficiency Stroopcolor time Selectiveattention

Discrimination: old items/new items 0.64 0.03 0.10 0.50

Omissions 0.98 0.02 0.28 0.77
False alarms 0.19 0.40 0.03 0.21
Discrimination: self/external 0.19 0.006 0.001 0.62
Discrimination: oral/picture 0.03 0.10 0.05 0.59
Memory 0.10 - 0.49 0.36

was linked to all three reality monitoring measures.
Significant correlations appeared between selective
attention and both the number of false alarms and
the index of discrimination between orally and
pictorially produced events. The correlation
between self/external discrimination and selective
attention did not reach the level of significance.
This lack of significance could be due to a ceiling
effect, given that discrimination between self and
externally generated items resulted in a very high
level of performance.
The absence of any significant correlation
between selective attention and memory suggests
that a deficit in selective attention played a specific
role in cognitive distortion, rather than a general
role in cognitive efficiency.
In the schizophrenic group, the regression analy-
ses confirmed these results: neither memory effi-
ciency nor color naming time significantly
contributed to the variance of any of the reality
monitoring measures. On the contrary, selective
attention significantly contributed to the variance
of two of the three reality monitoring functions.
It was not, however, involved in reality monitoring
performance in controls: there was not even a
trend of a correlation between the selective atten-
tion measure and any of the measures of reality
monitoring. Furthermore, when different variables
were considered in regression analyses, selective
attention made no significant contribution to the
variance of any of the reality monitoring measures
in controls. On the contrary, the efficiency of
memory seemed to account for this performance,
as well as the color time in the non-conflictual
condition of the Stroop test, which can be consid-
ered as a measure of psychomotor speed.
Therefore, the results argue in favor of our
hypothesis that reality distortion commonly
observed in schizophrenia is linked to an inability
to inhibit non-relevant stimuli. This may lead to
difficulty in distinguishing between an event that
has occurred and one that has not, resulting in an
increased rate of false alarms. Also, this may lead
to a confusion between the features of the real
events. The observation of the pattern in normal
controls suggests that this involvement of selective
attention in reality monitoring does not exist as
long as selective attention is not impaired.
Still, the correlations between selective attention
and reality monitoring in schizophrenic patients
 G. Brbbion et al./Schizophrenia Research 22 (1996) 173-180
are rather weak. M a y b e m o r e striking results
w o u l d be f o u n d with a n o t h e r p a r a d i g m such as
negative priming (Tipper, 1985), which m a y be a
m o r e sensitive measure o f inhibitory processes.
Negative priming, i.e., longer response latencies,
occurs in normals when a stimulus that has just
been inhibited as a distractor in a first trial becomes
a target in the next trial. It is negative priming in
the S t r o o p test, rather that the simple interference
created by the conflictual condition, that has been
shown to be linked to positive schizotypy (Beech
and Claridge, 1987; Beech et al., 1989a; Peters
et al., 1994; Williams, 1995).
The stage where selective attention deficit
impairs reality m o n i t o r i n g is unclear. It m a y be at
the very m o m e n t o f the encoding that confusion
occurs. We can imagine that schizophrenic
patients, being distractible and unable to focus on
the task, encode only sketchy features o f the
stimuli. A n o t h e r alternative would be that the
encoding is n o t impaired, but overwhelming due
to non-relevant stimulation during the storage
phase confuses the m e m o r y o f the context in which
the items have been encoded.
It has p r o v e n difficult to determine the elemen-
tary cognitive perturbations responsible for
impairment in higher cognitive functions in schizo-
phrenia. The suggestion o f an involvement o f
selective attention in reality m o n i t o r i n g deficit
might thus be relevant for clinical research and
treatment. Indeed, p s y c h o p h a r m a c o l o g i c a l inter-
ventions are m o r e likely to act on the level o f
elementary cognitive parameters rather than the
level o f complex cognitive functions such as reality
monitoring. Further psychopharmacological
research should focus on the ability o f antipsy-
chotic drugs to improve selective attention a n d / o r
reality monitoring.
Acknowledgment
This w o r k was supported by a Fulbright grant
and a Schizophrenia Research fund to the first
author, and by an N I M H Developing Center grant
no. 5P20MH50727. The assistance o f Ivan A m o d t ,
H e n r y K r o n e n g o l d , L y n n M a r c i n k o and Scott
Yale is gratefully acknowledged.
179
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