Pergamon .I p,,chror R<zs., Vol. 28. No 3. 289 301. 1994 pp

Elsevm Saencc Ltd Prmed in Great Bntam

0022 3956.‘94 57.00+ 00

0022-3956(94)E0008-E

SCHIZOPHRENIC INDIVIDUALS’ COGNITIVE FUNCTIONING AND PERFORMANCE IN INTERPERSONAL INTERACTIONS

AND SKILLS TRAINING PROCEDURES

LINDA BOWEN,* CHARLES J. WALLACE,*? SHIRLEY M. GLYNN,*

KEITH H. NUECHTERLEIN,* JOHN R. LUTZKER,~ and TIMOTHY G. KUEHNEL*

*UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation and UCLA Department of Psychiatry and Biobehavioral Sciences; ICalifornia School of Professional Psychology, CA. U.S.A.

Summary-The purpose of this research was to determine the relatlonship between schizophrenic individuals‘ cognitive functioning and their performance in interpersonal interactions and skills training procedures. Thirty schizophrenic individuals and 15 non-mentally ill Individuals were administered two versions of the Continuous Performance Test. the Span of Apprehension Test. the Digit Span Distractibility Test. the Assessment of Interpersonal Problem Solving Skills, and three elemental skills training tasks. Vigilance level as measured by the Continuous Performance Test was substantially correlated with performance in both roleplayed interactlons and skills training tasks. while recall memory as measured by the Digit Span Distractibility Test was correlated with performance in the skills training tasks independently of vigilance level. Thus, the results indicated that the cognitive dysfunctions of schizophrenia are associated with poorer social functioning and with reduced performance in the elemental procedures that constitute efforts to improve that functioning.

SEVERAL prominent clinicians and researchers recently assessed the “state of the art” of cognitive rehabilitation of individuals with schizophrenia (Liberman & Green, 1992 ; Spring & Ravdin, 1992). Some optimistically concluded that the results of several case reports (e.g. Adams et al., 198 1 ; Spaulding, 1989 ; Spaulding & Sullivan, 1992 ; Goldberg, in press) and group studies (e.g. Brenner, 1987 ; Brenner et al., 1992 ; Hubmann et al., 1989 ; Kraemer, 1991 ; Stuve, 1988), albeit methodologically flawed, pointed to the eventual development of techniques that will improve individuals’ cognitive functioning and thereby improve their long-term clinical outcomes.

Others were more cautious, noting that such optimism is unwarranted until there is information that cognitive functions are related to clinically relevant outcomes (e.g. inter- personal and role functioning) and clinically relevant treatments (e.g. skills training). Bellack, for example, (1992) concluded that “little is known about precisely which infor- mation-processing deficits compromise social behavior in schizophrenia, [and] it seems premature to undertake rehabilitation when we do not know what to correct.” (pp. 44-46).

t Author to whom correspondence should be addressed at : Camarillo-NPI Research Program, Box 60222. Camarillo, CA 9301 l-6022, U.S.A.

289

290 L. BOWEN et al

Similarly, Hogarty and Flescher (1992) concluded that “it is not at all clear how elementary or hierarchical [cognitive] deficits per se unilaterally or interactively relate to the specific instrumental and expressive role disabilities of schizophrenia. Before one embarks on the remediation of cognitive deficits, it would help to know how a specific deficit or pattern of deficits relates to schizophrenic disability.” (p. 53).

Thus. the purpose of the research reported in this paper was to determine if schizophrenic individuals’ cognitive functioning is related to two clinically relevant areas; (1) their inter- personal functioning; and (2) their performance in elemental skills training procedures. Several methodological precautions were taken to ensure that the results would be appli- cable to schizophrenic individuals. Interpersonal performance was assessed in interactions that specifically portrayed the “diverse social contexts related to [schizophrenic individuals’] interpersonal relationships” (Hogarty & Flescher, 1992, p. 53). Performance in elemental skills training procedures was assessed with material (medication management skills) specifically relevant for schizophrenic individuals (Wallace et al.. 1992). The cognitive measures assessed processes considered to be indicators of vulnerability to schizophrenia; i.e. deficits that are characteristic of schizophrenia. persist despite variations in symptoms and medications, and are found among individuals’ first degree relatives (Nuechterlein & Dawson, 1984; Nuechterlein et al.. 1992). Furthermore, the cognitive measures emphasize sustained concentration and early perceptual processes that typically show little relationship to general intelligence (Asarnow et al.. 1991; Nuechterlein, 1991).

Method

A total of 45 individuals participated in the research : 30 schizophrenic individuals. 24 males and six females, and 15 non-mentally ill individuals. 12 males and three females. All of the schizophrenic individuals fulfilled DSM-III R criteria for a diagnosis of schizophrenia with no evidence of chronic substance abuse or organic brain syndrome ; all were in-patients at a state hospital ; all had been stabilized on individualized doses of neuroleptic medication that had not been changed for at least 1 month prior to their participation in the study ; all scored at least 5 (moderately severe) on at least one of three psychotic subscales (hal- lucinations, conceptual disorganization, or unusual thought content) of the expanded UCLA version of the Brief Psychiatric Rating Scale (BPRS, Lukoff et al.. 1986) ; all were between 18 and 55 years of age (mean = 36, SD = 8.6); most had completed high school (mean grade = 12.94, SD = 1.38) ; and all were assessed as having visual acuity of 20!‘50 or better on a miniature Snellen Eye Chart read at a distance of 4 ft.

A research assistant reviewed individuals’ hospital charts to confirm diagnoses, and administered the three subscales of the BPRS to assess their current psychotic symptoms. The assistant had been trained to an interrater reliability of ICC = .X on the three scales by senior personnel of the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation who also monitored his performance during the course of the research.

The non-mentally ill individuals, matched for sex. age (mean = 31, SD = 10.7) and educational level (mean grade = 13.47, SD = 2.14) with the schizophrenic individuals, were personally recruited from the pool of non-nursing personnel and volunteers who worked

COGNITIVE FUNCTIONING INTERPERSONAL INTERACTIONS. AN) SKILLS TRAINING 291

at the state hospital. None had a history of major mental illness, chronic substance abuse, or organic brain syndrome ; and all had visual acuity of at least 20/50 based on the miniature Snellen Eye Chart.

Cognitive n~easwes

Four measures were administered to assess cognitive functioning ; a Conventional “0” Continuous Performance Test (“0” CPT), Degraded-Stimulus Continuous Performance Test (DS-CPT), Digit Span Distractibility Test (DSDT), and Span of Apprehension Test.

“0” CPT and DS-CPT. These two versions of the Continuous Performance Test measure deficits in signal detection over sustained periods of visual monitoring with minimal short- term memory load (Nuechterlein et al., 1983). Both require individuals to attend to a series of single digits presented one at a time, and press a button whenever the target digit, “O”, is presented. The target digit appears in a quasirandom 20 out of every 80 trials ; the digits immediately preceding “0” are balanced to eliminate recognition of sequences, and no two identical digits follow each other. Digits are presented at the rate of 1 per set with an exposure duration of 60 m. Button presses are scored to yield an overall A’level, a signal/ noise discrimination index from signal detection theory (McNicol, 1972). Because of the skewed distributions of A’, the scores for both versions are transformed to twice the arcsine of the square root of A’ as recommended by McNicol (1972). Button presses within 200 msec of stimulus onset are scored as responses to the previous stimulus.

The Degraded Stimulus version presents the same quasirandom numerical sequence as the Conventional version, but the images are perceptually degraded. Perceptual degradation increases the burden on initial perceptual processes, and makes the CPT more sensitive to schizophrenia-related deficits in some situations (Nuechterlein, 1983). Therefore. both a conventional and degraded-stimulus CPT were included.

For this study. each version was given separately using the IBM-PC compatible computer program developed by Nuechterlein and Asarnow (Version I, 1987). The degradation of the DS-CPT version was accomplished by reversing the black/white pixel values on the computer monitor for a random 40% of the pixels. Each version had 160 practice trials immediately followed by 480 experimental trials.

DSDT. The DSDT measures short-term auditory recall and auditory distractibility (Oltmanns & Neale, 1975). The measure requires individuals to listen to strings of digits presented on audiotape by a female narrator at the rate of one every 2 set and, at the end of each string, write down as many correctly ordered digits as they remember. Distraction is introduced for half of the strings by interspersing a male voice reading four irrelevant digits during each 2-see inter-digit interval. Individuals are presented with two sets of 14 strings, each involving seven nondistractor and seven distractor strings matched for diffi- culty level and internal consistency reliability (Oltmanns & Neale, 1975). One set consists of strings with more digits than the other ; the distractor and non-distractor strings for each set are presented randomly to balance practice effects. Two practice distractor and two practice nondistractor strings are administered first. To ensure that individuals are prepared to listen to a string, they tell the examiner when to start each.

202 L. BOWEN et al.

Individual’s responses for each of the 28 strings are scored to yield the proportion of correctly remembered ordered digits for the first two serial positions in a string (primacy), for the last two serial positions (recency), and for all positions (Harvey et al., 1981 ; Oltmanns. 1978). These are then combined to obtain proportions for the seven short nondistractor, seven short distractor, seven long nondistractor. and seven long distractor strings.

t;ijucecl-Cl1oic.e Sprr17 c?f’ Appwlmsion Test. The Forced-Choice Span of Apprehension Test measures the efficiency of early iconic memory and readout stages of visual information processing relatively independent of active, short term memory (Asarnow et al., 199 I ). The measure presents arrays of letters that contain either a “T” or an “F”; the individual places the index finger of his dominant hand between two buttons. and presses one to indicate that the array contains a T and the other to indicate that it contains an F. Each array consists of 16 possible locations arranged in an 4 x 4 matrix. One of the 16 locations contains a T or an F. and the other 15 may contain any other letter. with the constraint that all of these letters are different from one another. A total of 64 arrays are presented with 32 (plus IO practice) having three letters (T or F plus letters in two other locations) and 32 (plus 10 practice) having 12 letters (T or F plus letters in 11 other locations). The 64 are administered in four counterbalanced blocks of 16 each ; each block has eight arrays with a T and eight with an F. Like the DSDT. individuals tell the examiner when to start a trial. Responses are scored to obtain the number of correct detections per array size.

For this study. the Span was administered using the IBM-PC compatible computer program developed by Asarnow and Nuechterlein (Version 1. 1987); the dependent variable was the number of correct detections for the 12-letter arrays.

I~~te~personul pe~~~,mur1ce. The measure of interpersonal performance was a subset of items from the Assessment of interpersonal Problem Solving Skills Test (AIPSS; Donahoe et al., 1990). The AIPSS is an interview and role play test that presents individuals with 13 videotaped interpersonal scenes, 10 of which portray interpersonal problems defined as one person acting as an obstacle to the achievetnent of the other’s goal (e.g. a salesclerk refuses to take back incorrect merchandise; an individual cuts in line and refuses to go the end) and three of which present no problem. After viewing each scene. individuals are asked questions to determine if they recognize the presence and nature of the problem (“receiving” skills), generate an effective solution (“processing” skills). and deliver it in the most effective manner (“sending” skills). Before each scene is presented, respondents are told with whom to identify, and are reminded to pay close attention since the scene will be presented only once.

Receiving skills are assessed with two questions; “Is there a problem in this scene?“, and “Please explain the problem to me as if I have never seen the videotape before.” Answers to the first question are scored 1 (correct) or 0 (incorrect). and sutnmed across the scenes to obtain a total for the Identification scale. Respondents who give a “false negative” answer (i.e. do not recognize that a problem has been shown) are not questioned further. and are scored as incorrect for all additional questions. Respondents who give a “false

COGNITIVE FUNCTIONING. INTERPERSONAL INTERAC‘TIONS.AND SKILLS TRAINIKG 293

positive” answer (i.e. identify a problem that has not been shown) are questioned further, but their responses are not scored.

Answers to the second receiving skills question are scored 2 (both obstacle and goal correctly mentioned), 1 (only obstacle or goal correctly mentioned), 0 (neither correctly mentioned). These scores are summed across the scenes to obtain a total for the Articulation scale.

Processing skills are assessed with the question “If you were in this situation what would you say or do now?” Answers are scored 2 (best solution), 1 (not the best solution but there may be a substantial chance that the response would obtain the goal), or 0 (unlikely to obtain the goal or would lead to a serious negative consequence or bizarre). These scores are summed across the scenes to obtain a total for the Processing scale.

Sending skills are assessed with the request “Now I’d like you to show me what you would say or do in this situation.” The resulting roleplay is scored for content quality (would the content of the response solve the problem?), delivery quality (irrespective of content, would the volume, tone, pitch, eye contact, body posture, etc. be considered appropriate?), and overall quality (considering both content and delivery, would the response solve the problem?). All three qualities are scored from 0 to 2.0 in 0.5 increments, and then summed across the scenes to obtain totals on the Content, Performance, and Overall scales.

For this study, seven of the 13 scenes were administered, five randomly selected with problems and two without. The subset was administered to meet time constraints.

Elenlentul skills training procedures. Three measures were administered to assess indi- viduals’ performance in elemental skills training procedures ; comprehension of verbal information (“Listen”), comprehension of information presented on videotape (“Look”), and roleplay practice of behaviors demonstrated on videotape (“Do”). These three were chosen since they assess performance in the procedures that are the building blocks of all skills training programs. Successful training requires accurate processing of numerous and often complex exchanges of verbal and visual stimuli. The trainee must decode the trainer’s description and demonstration of the skills to be learned (Listen and Look), encode a behavioral approximation of the skills (Do), and then decode the trainer’s feedback and verbal reinforcement (Listen and Look).

The material for the three measures was adapted from the Medication Management Module (MMM) developed by the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation (Liberman, 1986; Wallace et al., 1985, 1992). The MMM, which is one of several training modules, is a highly structured curriculum that teaches individuals to become proficient in four skills ; obtaining information about antipsychotic medication, self-administering medication, identifying side effects, and negotiating medication issues with health-care providers. The specific behaviors of each skill are taught with seven “learning activities;” introduction, videotaped demonstration. roleplayed practice, solving resource management problems, solving outcome problems, in z-iv0 practice, and homework exercises.

The first elemental training measure, Listen, required individuals to listen to two para- graphs read from the material of skills 1 and 4, and answer four questions per paragraph

294 L. BOWEN et al.

that assessed their comprehension of the information. The second measure, Look, required individuals to view five 3-minute segments of the videotape demonstration of the specific behaviors of skill 2, and answer one or more questions after each segment (total of eight) that assessed their comprehension of the material. The third measure, Do, required individuals to view the segment of the skill 2 videotape that demonstrated the six behaviors of correct self-administration of medication. They were then asked to roleplay the six behaviors they had just viewed.

Answers to each of the eight Listen and the eight Look questions were scored as I (correct) or 0 (incorrect) and summed to obtain totals for each procedure. Roleplays were scored for the presence (1) or absence (0) of each of the six modeled behaviors and then summed to obtain a total for the Do procedure. The totals for the Listen, Look, and Do measures were then summed to obtain a Total score.

All measures were administered to the schizophrenic individuals in two 2-hour sessions. conducted in the morning and afternoon of the same day. The cognitive measures were administered in the morning session in a randomly determined order for each individual except that the conventional “0” CPT was always administered before the DS-CPT. Five- minute rest intervals were given between measures as needed and/or requested. The skills training measures and the AIPSS were administered during the afternoon session in a randomly determined order except that the skills training measures were administered in the same order (Listen, Look, Do) as were the seven scenes of the AIPSS. The procedures for administering the measures to the non-mentally ill individuals were the same. except that the schedule and duration of the sessions were arranged to fit each individual’s needs.

Results

Interrater rcliuhilit~

Individuals’ responses to the interpersonal performance and skills training measures were videotaped for later scoring and determination of interrater reliability. Ten randomly selected tapes of schizophrenic individuals were independently scored by a second rater who was experienced in administering and scoring the AIPSS and conducting the MMM. Interrater agreement averaged across the 10 sets of scores exceeded 90% exact agreement for each AIPSS scale, and was 90% for the Listen. 89% for the Look, and 95% for the Do measures.

The scores for the schizophrenic and non-mentally ill individuals were analyzed to determine if the differences between them replicated previous findings. All analyses were conducted with selected programs from the BMDP package of statistical programs.

“0” CPT arzd DS-CPT. Scores for two non-mentally ill individuals on the DS-CPT were excluded from the analyses; one was mistakenly not given practice trials until the end of

COGNITIVE FUNCTIONING, INTERPERSONAL INTERACTIONS. AND SKILLS TRAINING 295

the task, and the other stopped responding completely in the middle of the task. The differences between the groups were analyzed with a f-test for independent samples. Results showed poorer signal/noise discrimination during vigilance for schizophrenic individuals than for non-mentally ill individuals on both versions (conventional version t = 4.45, 4f= 43, p = ,001 ; degraded version t = 2.23, #= 41, p = .0324).

DSDT. The data were analyzed with three ANOVAs; a three-way split-plot factorial ANOVA with one between-subjects variable (group) and two within-subjects variables (recency vs primacy ; distractor vs nondistractor) for the short strings, the same for the long strings, and a two-way split plot factorial with one between subjects variable (group) and one within subjects variable (long vs short) with the all-positions proportion correctly recalled as the dependent variable.

For the short strings. the main effect of group was significant (F = 24.11, @= 1,43, p < .OOOl) with the schizophrenic individuals correctly remembering a lower proportion of digits (m = 0.621) than the non-mentally ill individuals (m = 0.922). The two-way inter- action of group x recencyiprimacy and the three-way interaction (group x recency/ primacy x distraction/non-distraction) both approached significance (both F = 3.99, both #‘= 1,43. both p = .0522). Since th e t wo-way interaction is qualified by the three-way interaction, the latter was further analyzed with tests of simple interactions and simple simple main effects. The results of these analyses indicated that for non-mentally ill indi- viduals, distraction did not significantly reduce the proportion of digits they correctly remembered for either the beginning or the end of a string. For schizophrenic individuals, however, distraction significantly reduced the proportion of digits they correctly remem- bered at the beginning of a string (from 0.686 to 0.538) but not at the end of the string (0.631 to 0.628). This is similar to previous findings (Oltmanns, 1978) that schizophrenic individuals’ recall is most impaired by distraction on the early digits in a string, a pattern also found among children of schizophrenic individuals (Harvey et al., 1981).

The three-way interaction was not significant for the long strings but the pattern of results was much the same; i.e. no effects of distraction for digits at the beginning or end of the string for non-mentally ill individuals, while schizophrenic individuals tended to show a reduction in the proportion of correctly remembered digits at the beginning of a string (0.46220.369) but not at the end (reduction from 0.473 to 0.462). As with the short strings, the main effect of group was significant (F = 27.71, df= I .43. p < .OOOl) with the schizophrenic individuals remembering a of lower proportion of digits (~7 = 0.441) than the non-mentally ill individuals (~77 = 0.8 13).

The results of the two-way ANOVA with the all-positions proportion correctly recalled as the dependent variable indicated that the groups were significantly different from one another (F = 31.5. crf’= 1,43, p < .OOOl) with the schizophrenic individuals remembering a lower proportion (177 = 0.482) of digits than non-mentally ill individuals (m = 0.830). As expected, the longer strings were significantly more difficult (F = 64.03. $= 1.43, p < .OOOl) for both groups (nz = 0.507) than the shorter ones (no = 0.681). In this study the DSDT was primarily used as an index of short-term auditory memory. Therefore. the proportion of correctly recalled digits across all serial positions was averaged for the long and short strings to obtain a total recall score which was used in subsequent analyses.

296 L. Bown et al

ForcedChoicr Span of’ Appwhension Test. The differences between the groups were analyzed with a t-test for independent samples. As expected. the number of correctly detected target letters within 12-letter arrays for schizophrenic individuals’ (m = 46.5) was significantly poorer (t = 3.80. &= 43, p < .OOOl) than non-mentally ill individuals (I?? = 55.4).

Int?rer-personul pr~fimmuwr. The differences between the groups were also analyzed sep- arately for each scale with a t-test for independent samples. Similar to the results reported by Donahoe et al. (1990), the schizophrenic individuals performed significantly poorer than the non-mentally ill individuals on all scales (smallest t = 3.01. df’= 43. p < .OOOl).

Elmerztul skills truininy pm~~hw,s. The group differences were again analyzed with t- tests for independent samples for each measure and for the Total. The results were the same as those of the interpersonal performance analyses ; schizophrenic individuals performed poorer on all three measures and the Total score (smallest t = 4.28. df’= 43. p < ,000 I ).

Table 1 presents the bivariate correlations between the cognitive measures and the interpersonal performance scales for the schizophrenic individuals. The level of significance for each correlation was set at .02 to adjust for the inflation of alpha across the 24 correlations. Signal/noise discrimination level (A’) on the DS-CPT was the cognitive mea- sure most strongly correlated with the six interpersonal performance scales, significantly so for all but the Identification scale (although it did approach the .02 adjusted alpha level: actual p = ,023). Correlations were quite similar for the “0” CPT given the correlation of .84 between the A’levels for the two CPTs (see Table 2 for the correlations among the cognitive measures).

In contrast. the correlations between the six interpersonal performance scales and the number correct on the 12-letter array of the Span of Apprehension test and total recall on

Cognitive me;isure “0” CPTt DS-CPT: $Xlll: DSDT$

0.2 I 0.40 0.28 -0. I 0.51** 0.53** 0.3x 0. I 0.43* 0.51** 0.25 0. I 0.37 0.49** 0.3x 0.1 o.so** 0.5x** o.m** 0.1 0.37 0.49** 0.40 0.3

* =p c .02: ** =p < .Ol

i-A’. iCorrect 17.letter array. ffO\erall recall.

COGNITIW FUNCTIONING. INTERPERSONAL INTERACTIONS, AKD SKILLS TRAINING; 297

Table 2 Correlations An~ong thr Cogniticr Measures Within the Schi:ophrmic Sample

Cognitive measure

“0” CPT_F DS-CPTt span: DSDTg

Cognitive measure “0” CPTt DS-CPTI- Spani DSDT$

o.g4** 0.60** 0.53** 0.62** 0.4s**

_ 0.52”

**=p<.o1. +A’. fCorrect 12.letter array. coverall recall.

the DSDT were somewhat lower and nonsignificant, except for the correlation between the Span and the Performance scale. To explore the joint and additive relationships of the cognitive measures with the six interpersonal performance scales, step-wise multiple regression analyses were conducted separately for each interpersonal performance scale, using the same four cognitive measures as the independent variables in each analysis. The results of each analysis essentially duplicated the bivariate correlations due to the substantial and significant correlations among the cognitive measures as presented in Table 2. In all analyses, DS-CPT signal/noise discrimination level (A’) entered first, and no other measure entered the predictive equation.

Relationship hetu,een cognitive and elementul skills tvai&g nzeasure.s,for schizophrenic indi- r iduua1.s

Table 3 presents the bivariate correlations between the cognitive and the elemental skills training measures for the schizophrenic individuals. Similar to the results on the interpersonal performance scales, the correlations between signal/noise discrimination level on both versions of the CPT and the three measures and the Total were significant and substantial. However, unlike the interpersonal performance results, the correlations with the DSDT were significant for all individual measures and the Total score. The results for

Cognitive measure Elemental training measure “0” CPTt DS-CPTt Span$ DSDT$

Listen 0.56** o-58** 0.67** 0.61** Look 0.49** 0.50** 0.31 0.46* Do 0.55** 0.59** 0.38 0.44* Total 0.63** 0.66** 0.55** 0.60**

* =‘u < .02: ** =p < .Ol. i-A’. $Correct 12.letter array. t;Overall recall.

298 L. BOWEN et al

the Span of Apprehension indicated significant and substantial correlations with the Listen and Total measures and nonsignificant correlations with the Look and Do measures.

Step-wise multiple regression analyses were conducted separately for each elemental skills training measure and the Total score with the four cognitive measures as the independent variables in each analysis. The results for the Look and Do measures were the same as the multiple regression results for the interpersonal performance scales ; DS-CPT signal,‘noise discrimination level entered first into each analysis, and no other measure entered second. Results for the Listen and Total measures were more complex. however. For the Listen measure. the Span of Apprehension score entered first into the analysis. accounting for 45.36% of the variance; the DSDT recall score entered second accounting for an additional 9.3% of the variance. For the Total score, DS-CPT signal/noise discrimination level entered first. accounting for 43% of the variance ; the DSDT recall score entered second accounting for an additional 1 1 TO of the variance.

All of the schizophrenic individuals were receiving maintenance doses of various anti- psychotic medications. These were converted to Thorazine-equivalent daily doses, and correlated with scores on the cognitive, interpersonal performance scales, and elemental skills training measures. None of the correlations was significant. Fourteen individuals were also receiving anticholinergic medication (13 Cogentin and I Artane). The differences between their scores and those of individuals not receiving anticholinergic medication were compared for each measure with independent samples t-tests. There were no significant differences.

Discussion

These data focus on cognitive functions of schizophrenic individuals that have been implicated as enduring vulnerability factors for this disorder. Means and variances on the cognitive measures were quite similar to those reported in other studies: the differences between this study’s samples of schizophrenic and non-mentally ill individuals were also similar to those reported in other studies; and there were no outliers on any measure.

The results indicate that there were significant relationships between schizophrenic indi- viduals’ cognitive functioning, interpersonal skills, and performance in elemental skills training tasks. The cognitive function most related to performance in the roleplays of interpersonal skills was vigilance level (signal/noise discrimination level) as measured by the two versions of the CPT. Since each roleplay began with a 20-40-second videotape that “set the scene.” impaired sustained concentration was quite relevant and may have resulted in incomplete information and subsequently inadequate responding.

Vigilance level was also substantially related to performance in the elemental skills training measures. Since the three measures presented relatively detailed information. albeit in a familiar topic area. impairment in sustained concentration may have resulted in incomplete intake and initial processing of information and inaccurate answers to the assessment questions. But unlike interpersonal performance, immediate recall memory as

COGNITIVE FUNCTIONING, INTEKPEKSONAL INTEKACTIONS, AND SKILLSTRAINING 299

measured by the DSDT was also significantly related to performance on the elemental skills independently of vigilance. Each measure’s detailed information was presented in a “chunk” with the assessment questions administered immediately afterward ; correct responding in this situation apparently required both sustained concentration on incoming information and its accurate recall.

Mueser et al. (1991) reported a similar relationship between memory, as measured by the Weschler Memory Scale (WMS), and performance in skills training. Two social skills, compromise/negotiation and expressing negative feelings, were taught in six l-hour sessions distributed across 2 weeks. WMS scores Memory Quotient and Verbal Memory (sum of Logical Memory and Associate Learning subtests) in particular, were significantly cor- related with residualized preepost and pretest to one month follow up improvements for schizophrenic and schizoaffective but not for affectively disordered participants.

Several methodological differences, however, mitigate the comparison between the cur- rent and Mueser et al. studies. Participants in the latter study were acutely ill in-patients whose psychopathology improved significantly during the course of the training, while participants in the current study were stable, chronically ill in-patients who had been hospitalized continuously for several months before their participation. There was an approximately equal distribution of males and females in Mueser et al.‘s combined schizo- phrenic and schizoaffective participants compared to an 80/20 male/female distribution in the current study, and none of the participants in the current study had been married compared to almost 30% in the Mueser et al. study. Thus. participants in the Mueser et al. study were acutely disturbed but higher functioning, community-based individuals whose memory may have been the primary cognitive function related to skills training compared to the combination of sustained concentration and memory found in the current study.

Furthermore, Baddeley (1990) has noted that the version of the WMS used in the Mueser et al. study may actually measure a combination of attention and memory since short-term, working memory is closely affiliated with attention-demanding, effortful processing. Thus. it is difficult to determine whether only memory or both attention and memory contribute to Mueser et al.‘s findings.

The current study was designed to include measures specifically relevant for schizophrenic individuals. The Span and the CPT tasks assessed cognitive functions that have been described as “vulnerability indicators ;” functions in which schizophrenic individuals remain deficient even when their symptoms have remitted (Nuechterlein et al., 1992). The inter- personal measure assessed performance in roleplays specifically designed to represent the common. brief, problematic. and impersonal interactions that characterize community living for most schizophrenic individuals (Donahoe et al., 1990). The three elemental skills training measures assessed individuals’ assimilation of instructional material that was particularly relevant for them (use of antipsychotic medication). and has been found to result in substantial and significant improvement in individuals’ medication self-man- agement skills (Wallace et al., 1992).

Thus, the results suggest that the enduring cognitive dysfunctions that characterize schizophrenia are not only associated with poorer social functioning, but may decrease the efficiency of efforts to improve that functioning. Hence, the results provide support for the potential value of cognitive rehabilitation. and point to the importance of considering

300 L. hWEN Ct d.

vigilance and recall memory in the rehabilitative process. Of course, these conclusions are qualified by the study’s limited ranges of schizophrenic individuals, cognitive measures, and interpersonal and skills training procedures. More definitive conclusions and any recommendations for the foci of cognitive rehabilitation require further research with a larger number of individuals who have a wide range of symptoms, assessed with a wide range of cognitive and social measures during periods of varying symptom intensity, using stimuli and contextual conditions of varying emotional intensity. Furthermore, the influence of these cognitive conditions should be monitored as skills training is conducted; this study measured performance in elemental skills training procedures, but did not assess the relationship between cognitive dysfunctions and the extent of pre-post changes in skills.

.4~,knorl,/r~~en?c~f~Thls research was supported in part by NIMH grant MH-3091 I and California Department of Mental Health Research contract 90-79054.

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