Cognitive Rehabilitation for Schizophrenia:

Problems, Prospects, and Strategies

by Alan S. BeUack, James M. Qold, and Robert W. Buchanan

Abstract provocative studies, he generated considerable interest in

the possibility of teaching patients to use self-talk to guide
Increasing awareness of the importance of neurocogni- problem solving. Platt and Spivack (1972a, 1972fc) pro-
tive impairments in schizophrenia has fostered consid- vided some thought-provoking data on problem solving
erable interest hi the prospects for cognitive rehabilita- during that period that also pointed to a role for cognitive
tion. Nevertheless, optimism has outpaced progress. rehabilitation. These somewhat anomalous studies were
We first review recent literature on the central not replicated, however, and interest in cognitive training
assumptions that underlie cognitive rehabilitation, languished as the emphasis of psychosocial treatment
including the hypothesis that cognitive deficits play a shifted to more promising interventions that were more
central role in social disability and other problems consistent with the increasingly sophisticated neurobio-
schizophrenia patients experience In daily living, and logical models of schizophrenia: namely, behavioral skills
that these impairments must be rectified if we are to training and family psychoeducation. Frustration contin-
achieve effective rehabilitation. We next discuss devel- ued with the failure of these techniques and available
opments hi knowledge about the neurobiology of schiz- medications to substantially enhance daily functioning in
ophrenia that bear on the potential for cognitive reha- the community. It was certainly possible to reduce psy-
bilitation and the selection of appropriate targets for chotic symptomatology, family conflict, and relapse and
intervention. Third, we propose a new research strat- rehospitalization, as well as to improve social skills, but
egy for investigating cognitive functioning in schizo- patients continued to suffer from poor role functioning. It
phrenia and for examining the relationship of cogni- was also becoming increasingly apparent that schizophre-
tive deficits to role functioning in the community: nia was marked by significant cognitive impairments that
examining patients who have good vocational out- were not ameliorated by psychopharmacological interven-
comes in order to identify strengths or compensatory tions (Spohn and Strauss 1989).
factors that compensate for core deficits. We present Two studies in the late 1980s rekindled dormant
new data that lend support to our proposed approach. interest in cognitive rehabilitation: Brenner and his col-
We next discuss putative limits to cognitive rehabilita- leagues (1990) described Integrated Psychological
tion based on data documenting cognitive deficits in Therapy (IPT), a comprehensive program to improve
healthy siblings and parents. Finally, we briefly social competence by first enhancing basic cognitive
describe an Interim rehabilitation strategy that mini- skills, and Goldberg and colleagues (1987) reported that
mizes the load on cognitive processes rather than patients with schizophrenia were unable to benefit from
attempting to improve cognitive functioning. explicit instructions and practice on the Wisconsin Card
Key words: Rehabilitation, neuropsychology. Sorting Test (WCST), a putative neuropsychological
Schizophrenia Bulletin, 25(2):257-274,1999. marker of prefrontal function. This failure to benefit from
training, combined with data on diminished blood flow,
was interpreted as evidence of an unmodifiable abnormal-
This special issue of the Bulletin is an exciting and timely ity of the dorsolateral prefrontal cortex. The first of these
update on a persistent topic in the literature on schizo- reports held out the promise for effective cognitive reha-
phrenia over the past decade: cognitive rehabilitation. The
history of interest in this topic dates back at least as far as
Meichenbaum's seminal work in the early 1970s Reprint requests should be sent to Dr. A.S. Bellack, UMAB, 737 W.
(Meichenbaum and Cameron 1973). With a pair of Lombard Street, Suite 551, Baltimore, MD 21201.

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 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

bilitation, while the second implied that a basic neuro- tive rehabilitation. (3) The prognosis for cognitive reha-
physiological impairment made such rehabilitation impos- bilitation, as reflected in preliminary studies, is quite posi-
sible. The field quickly mobilized to either replicate and tive" (Bellack 1992, p. 44). Each of these assumptions
expand upon the innovative work of the Swiss group or to was judged to be conjectural and preliminary at best.
refute the pessimistic conclusions of the National
Institutes of Health (NTH) group. The NIH work stimu- The Role of Cognitive Impairments in Social Disability
lated a spate of mostly successful demonstrations that and Problems in Daily Living, hi discussing the first
WCST performance deficits, albeit widespread, are nei- assumption, we agreed in 1992 that there was strong evi-
ther endemic to the illness nor immutable; we will discuss dence for the existence of substantial cognitive impair-
some of that literature below. The Brenner project stimu- ments in schizophrenia, but indicated that there was scant
lated a lively, thought-provoking debate in a previous spe- evidence to demonstrate which, if any, specific deficits
cial issue of the Bulletin in 1992 (vol. 18, no. 1). As will accounted for a significant proportion of the variance in
also be discussed below, Brenner's results were not partic- functional behavior in the community or which should be
ularly robust and have not yet evolved into a more effec- the targets of rehabilitation efforts. Much of the rehabilita-
tive iteration. Nevertheless, that work has had tremendous tion literature focuses on social competence, a domain
heuristic value and still serves as the most systematic test that is critical for effective role functioning in the commu-
of the feasibility of cognitive rehabilitation to date. nity and in which schizophrenia patients have well-docu-
One of us (A.S.B.) contributed a paper to the 1992 mented deficits (Bellack et al. 1990a). As summarized in
special issue entitled, "Cognitive Rehabilitation for a seminal paper by Michael Green (1996), a number of
Schizophrenia: Is It Possible? Is It Necessary?" (Bellack studies in the intervening years have documented a rela-
1992). As might be inferred from the title, we were not tionship between diverse measures of neuropsychological
particularly sanguine about the prospects for either capacity and both social functioning and performance in
Brenner's program or then-current thinking about cogni- skills training programs. There appears to be a replicable
tive rehabilitation, notwithstanding our view that association between analogue measures of social compe-
Goldberg et al.'s (1987) even more pessimistic conclusion tence and measures of verbal memory and attention
was not empirically justified. Our intention in this article (Green 1996). For example, we found relationships
is to revisit the issues addressed in 1992 in light of subse- between verbal memory and social problem solving,
quent research and to propose new directions for the field. social skill, and response to social skills training (Mueser
First, we review the basic arguments made in the earlier et al. 1991; Bellack et al. 1994). We are currently con-
article and discuss relevant findings from the intervening ducting a study on substance abuse in people with schizo-
years that bear on the conclusions. Second, we discuss phrenia that replicates our previous findings on the rela-
developments in understanding of the neurobiology of tionship between social skill and verbal memory.
schizophrenia that bear on the potential for cognitive
Correlations were calculated between scores on our prob-
rehabilitation and the selection of appropriate targets for
lem-solving battery (Sayers et al. 1995) and IQ (based on
intervention. Third, we will propose a new research strat-
the vocabulary and information scales on the Wechsler
egy for investigating cognitive functioning in schizophre-
Adult Intelligence Scale-Revised [WAIS-R]) and the
nia and for examining the relationship of cognitive
Wechsler Memory Scale-Revised (logical memory I,
deficits to role functioning in the community. We will then
digits forward, and digits backward). Role-play perfor-
present some new data that lend support to our proposed
mance on our battery was significantly correlated with IQ
approach. Finally, we will briefly describe an interim
(r[27] = 0.34, p < 0.04) and with logical memory (r[27] =
rehabilitation strategy that minimizes the load on cogni-
0.40, p < 0.02). Role-play skill was not correlated with
tive processes rather than attempting to improve cognitive
functioning. digit span, and none of the correlations between the cog-
nitive measures and the problem-solving component of
our battery were significant.
Pertinent Issues in 1992 Similar results have been reported by Green and col-
leagues (Kem et al. 1992; Bowen et al. 1994; Corrigan et
Bellack's 1992 article identified three assumptions that al. 1994), who found significant relationships between
appeared to be common to much of the work on cognitive measures of verbal memory and visual information pro-
rehabilitation: "(1) Cognitive impairments play a central cessing and measures of social skill. While the effect sizes
role in the social disability and other problems schizo- in these small sample studies have been modest, there is a
phrenia patients experience in daily living. (2) These fair degree of consistency across studies in terms of which
impairments must be rectified if we are to achieve effec- specific cognitive measures correlate with which specific

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 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

measures of social skill. Two important limitations to prisingly, both studies found significant correlations
these data relate to the analogue nature of the measures of between performance on these measures and verbal mem-
social skill. Social competence in each of these studies ory (Rey Auditory Verbal Learning Test) and vigilance
was assessed with some form of simulated social interac- (Continuous Performance Test and Digit Span distractibil-
tion, rather than by observing patients in the community. ity), tests that require substantially the same cognitive
For example, our studies are based on tlie Social Problem operations.
Solving Assessment Battery, in which subjects engage in The hypothesis that social performance and skill
a series of simulated 3-minute conversations with a staff learning depend, at least in part, on verbal memory and
member portraying someone from the outside environ- vigilance has considerable face validity. It seems implau-
ment (e.g., a parent, a landlord). The interactions are sible that someone could effectively negotiate a rapidly
videotaped and subsequently rated on a variety of specific unfolding social encounter without being able to carefully
verbal and nonverbal response attributes (e.g., speech flu- monitor the partner's behavior and remember what has
ency, ability to negotiate). There is extensive empirical been communicated earlier in the conversation. Reduction
support for this approach to rating social skill (Bellack et in working memory capacity, which appears endemic to
al. 1990£J). Analogue measures are robust markers of schizophrenia (Gold et al. 1997), would also place limits
social skills in the person's response repertoire. But social on an individual's ability to engage in negotiation, social
performance in the community depends on a number of problem solving, and other complex conversational
factors in addition to having the capacity to perform a processes. However, it is still unclear how much variance
behavior in controlled circumstances, such as motivation each of these cognitive processes accounts for, or (as dis-
to engage in social interaction and prior experience in cussed below, in the context of good vocational outcome
similar encounters. It would be very tenuous to conclude patients) the extent to which some people with the illness
that modest correlations between neurocognitive mea- may learn to compensate for the deficits.
sures and analogue measures of social skill document a Another example of the effects of method variance
meaningful relationship between neuropsychological comes from the literature on social perception deficits. A
deficits and functional behavior in the community. Few number of studies have reported that people with schizo-
data directly support the thesis that the replicable deficits phrenia have difficulty correctly labeling affect depicted
in information processing have an impact "downstream" in photographs of faces or in brief videotapes of social
and substantially account for the deficits in community interactions (Morrison et al. 1988; Bellack et al. 1992;
functioning in general, or social functioning in particular Cramer et al. 1992; Heimberg et al. 1992; Kerr and Neale
(Benedict et al. 1994). We present preliminary data below 1993). Based on this literature, it was assumed that schiz-
to suggest that neuropsychological deficits may play a sig- ophrenia is marked by focal deficits in social perception
nificant role in the capacity to work, but that the contribu- (especially the perception of negative affect) and that this
tion of neuropsychological functioning may differ in deficit should be a critical target for cognitive rehabilita-
patient groups with good versus poor vocational outcome. tion efforts. For example, social perception training is an
Nevertheless, the widely held assumption that neuropsy- important component of Brenner's IPT.
chological deficits have important functional conse- The assessment methods employed in many of the
quences has not been adequately investigated. studies finding perception deficits placed a premium on
A second factor that limits conclusions about the rela- attention as well as affect perception per se, and/or only
tionship between social and neuropsychological function- assessed perception on a narrow range of situational con-
ing is shared "method variance." Several of the studies in tent. In response, we conducted a study that examined the
this area have used measures of social skill and social parameters of social perception more extensively (Bellack
skill learning that place heavy demands on memory and et al. 1996). The primary measure of affect perception
attention. For example, the Bowen et al. (1994), Corrigan was a videotape that was empirically developed for this
etTair(1994), and Kern et al. (1992) studies assessed study. It consisted of 30 brief (mean = 15 second) video-
acquisition of medication management skills on an assess- taped segments of conversations abstracted from movies
ment battery that required subjects to listen to an exam- and television shows. The test was first administered with-
iner read two paragraphs about the topic and then answer out sound and then readministered 30 minutes later with
a series of questions about the material, answer additional the soundtrack to determine if performance was improved
questions after watching videotapes about medication when the additional information, provided by the auditory
management, and then demonstrate a series of specific cues, was available.
steps that had been illustrated on another videotape. These Contrary to expectations, schizophrenia (and
tasks require subjects to pay close attention to the video- schizoaffective) patients did not exhibit a consistent, spe-
taped presentations and then recall the material. Not sur- cific deficit in the ability to perceive affect. A subsequent

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 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

reexamination of the literature indicated that support for Cognitive Impairments Must Be Rectified If We Are to
the hypothesis that there is a focal deficit in affect percep- Achieve Effective Rehabilitation. The status of this
tion is actually quite tenuous. Most studies that found per- second assumption is more tenuous than the status of the
ception deficits used very brief stimuli, thereby placing previous assumption about the relationship between neu-
high attentional demands on subjects, or tested highly ropsychological and social/role functioning. As indicated,
impaired chronic patients whose motivation and atten- a number of studies have reported robust relationships
tional capacity was suspect. With the exception of a study between skill acquisition in training programs and verbal
by Heimberg et al. (1992), studies that included nonaffect memory and vigilance. The studies by Green and col-
perception control tasks found that schizophrenia patients leagues are limited by method variance, while our studies
have a generalized performance deficit rather than a spe- were based on brief trials with either acutely ill (Mueser
cific deficit in affect perception. Overall, the data indicate et al. 1991) or highly chronic patients (Mueser et al.
that, with the possible exception of highly impaired 1995a). Despite the specific limitations, the cumulative
chronic patients, schizophrenia patients can make accu- impact of these studies does provide convergent support
rate judgments about affect when they are given adequate for the thesis that amelioration of cognitive deficits could
time and information (Gessler et al. 1989; Joseph et al. be helpful. Conversely, there is no support for the con-
1992; Bellack etal. 1996). tention that cognitive remediation is essential. This
These findings on social perception are consistent assumption of necessary remediation is consistent with
with another concern raised in our 1992 article: Decisions the restorative model that has long dominated treatment
about which aspect of information processing to target of mental illness, including schizophrenia. This restora-
were premature. More extensive information is now avail- tive model assumes that impairments can and should be
able about the nature of cognitive deficits in schizophre- corrected in order to achieve an effective rehabilitation
nia. Nevertheless, the most appropriate targets for rehabil- outcome. Failure to eliminate the underlying impairment
itation remain unclear. Liberman and Green (1992) and is thought to be akin to palliative attempts to reduce fever
Spring and Ravdin (1992) both addressed this issue in dis- and headache, rather than eliminating a viral infection.
cussing appropriate "levels" of intervention. Liberman While this model is quite viable in the realm of infectious
and Green, for example, wondered whether Brenner's disease and orthopedics (e.g., repair of broken bones), it
focus on problem solving initiated training too far "down- has not proven to be useful for mental health. There is lit-
stream from the source of the problem" (p. 30). The criti- tle evidence that either psychopharmacological or psy-
cal question in selecting neurocognitive targets is one of chosocial interventions have been effective in eliminating
generalizability: How far reaching are the effects of train- any disorder, let alone schizophrenia and its sequelae.
ing on any basic information-processing domain? This The compensatory model common to many areas of reha-
issue is not unique to schizophrenia, but has been the sub- bilitation medicine is much more appropriate. The
ject of extensive research on thinking and skill and the emphasis is not on eliminating impairment so much as
acquisition of cognitive skills in nonimpaired populations minimizing the resultant disability. Individuals who are
as well. The problem is encapsulated in a recent review by blind or have paraplegia are taught to use prosthetics for
Ericsson and Hastie (1994): "Consistent with human mobilization and to adjust physical aspects of their envi-
information processing theory, the attainment of skill and ronment to facilitate performance of activities of daily
expertise appears to entail only the acquisition of domain- living (ADLs) as well as recreational and occupational
specific knowledge and pattern-action connections with- activities. A parallel strategy for people with schizophre-
out changing basic processes and information-processing nia would entail reducing demands on verbal memory
capacity limits" (p. 48). They go on to state that, "contrary and vigilance, rather than reducing impairments in these
to expectations, the search for measures of basic capacity domains. For example, extensive evidence suggests that
that correlate with performance in complex tasks of over-learned skills become automatic, thereby reducing
everyday life have been mostly unsuccessful" (Ericsson the load on working memory (Ericsson and Hastie 1994).
and Hastie 1994, p. 55). If more than 30 years of research Improving working memory may be necessary to enable
on normal populations has failed to identify a critical role patients to deal with novel situations, but the skills
for modification of basic processes, serious questions needed for many ADLs and daily tasks and demands can
must be raised about the prospects for people with schizo- be anticipated. Over-learning of key skills and compen-
phrenia. The point here is not that basic processes do not satory strategies could be sufficient to enhance compe-
serve as critical building blocks for complex, functional tence in these routinized activities. Similarly, the role of
behaviors and skills, but rather that their contribution to attention and working memory in learning may be mini-
highly skilled and highly routinized behavior may not be mized by modifying the format and content of training.
linear or additive. We provide an example of such a program below.

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 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

The Prognosis for Cognitive Rehabilitation Is Quite exhibited marked deficits in WCST performance at the
Positive. The third assumption in 1992 was that opti- baseline assessment, and there were virtually no pre-post
mism about the potential for cognitive rehabilitation was changes in the clozapine condition on any WCST variable
justified. Disputing this optimistic forecast essentially (or treatment-by-time interactions) despite marked
entails the fruitless task of proving the null hypothesis that improvements in psychopathology. Conversely, our
cognitive rehabilitation is not possible. However, we can WCST training protocol was highly effective in improv-
determine the level of optimism that is justified today by ing WCST performance for clozapine patients, and there
examining the accumulating evidence in two domains: the was no differential learning benefit. Seventy-seven per-
efficacy of interventions developed to date and the nature cent of subjects increased the number of correct responses
and basis of the cognitive impairments in the disorder. from pre- to post-training, with the mean increase being
Much of the work on cognitive rehabilitation in the 23.09 percent; 65.38 percent of subjects exhibited a
past 6 years has focused on the WCST, a measure of com- decrease in the number of perseverative errors, with a
plex problem solving and "executive" capacity that is a mean decline of 16.57 percent. In addition, neither pre- to
putative marker of metabolic activity in the dorsolateral post-treatment changes on the WCST nor performance in
prefrontal cortex. The initial Goldberg et al. (1987) publi- the WCST training protocol was correlated with sympto-
cation concluded that schizophrenia patients have tremen- matology (Brief Psychiatric Rating Scale and Scale for
dous difficulty improving their WCST performance the Assessment of Negative Symptoms). In addition to
despite explicit instruction. In contrast, a series of subse- replicating our previous findings on the training protocol,
quent studies has shown that deficits exhibited by schizo- these data also highlight the importance of individual dif-
phrenia patients on the WCST are not immutable. In an ferences in both baseline performance and response to
initial study, we demonstrated that a brief cognitive- training (e.g., 23% of subjects failed to improve on num-
behavioral intervention could produce significant ber of correct responses, and 34.62% failed to decrease
improvement in WCST performance that was maintained perseverative errors). We discuss this variability at greater
at least until the following day (Bellack et al. 1990c). length below.
Similar to other variations in the literature (see below), Other laboratories have been able to produce compa-
our technique involved an iterative teaching paradigm in rable effects using our training strategy (Vollema et al.
which information about the test was explained in small 1994; Nisbet et al. 1996) and slightly different variations,
units, after which subjects were required to express the with improvements lasting from several weeks (Kern et
same information in their own words. Once they under- al. 1992; Metz et al. 1994) to 1 month (Young and
stood the task, correct performance was modeled and sub- Freyslinger 1995). These data document that training can
jects were required to demonstrate their ability to respond produce robust changes in WCST performance. The inter-
correctly. Incorrect responses were followed by corrective ventions were not designed to produce a meaningful
feedback and additional practice. They were also required change in general problem-solving style or capacity (i.e.,
to verbalize their strategy after the first few correct on tasks other than the WCST), however. The findings
responses; corrective feedback was given if the reasoning would have limited heuristic or clinical value if they illus-
was faulty even when the card placement was correct. trate only that patients can be taught a circumscribed rule
We recently replicated this finding in the context of a that clarifies the somewhat anomalous WCST procedure.
multi-site collaborative trial of clozapine. ,The study was In fact, some support for the latter possibility is provided
conducted at the University of California at Los Angeles by several studies in which appropriate instructions, with-
(Steven Marder), University of Pittsburgh (Nina out training per se, were shown to be sufficient to produce
Schooler), and Hillside Hospital (John Kane). Schizo- significant improvements in WCST scores (Goldman et
phrenia patients were recruited for a comparative trial of al. 1992; Stratta et al. 1994). These findings suggest that
clozapine and baloperidol. They were assessed on a large at least some patients may perform poorly primarily
battery of measures, including the WCST, at baseline and because they are confused by the vague instructions.
at the conclusion of a 24-week double-blind medication While inability to comprehend the instructions might
trial. After completing the followup assessment, subjects itself reflect some impairment, it is not consistent with
received the WCST training protocol employed in our hypotheses about focal (e.g., frontal) impairments in prob-
prior study. The procedure was manualized to facilitate lem solving or ability to maintain set. Alternatively, either
dissemination across the three sites, and all sessions were the simple instructions or the brief training may circum-
videotaped to ensure fidelity. The WCST was readminis- vent the need for subjects to generate a model for solving
tered in standard fashion die day after training, and these the task, thus vitiating the purpose of the test, which is to
data were used to evaluate the effects of training and the evaluate the subject's ability to develop and sustain focus
contribution of clozapine to training effects. Subjects on a model. In either case, these data do not verify any

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 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

substantive change in information-processing style or on the dexterity task as well. These results are consistent
capacity. with other studies (e.g., Goldman et al. 1992; Stratta et al.
Two recent studies have attempted to explicate the 1994) that demonstrate that modest improvements can be
significance of these training analogues by examining the observed on a variety of tasks with practice alone or prac-
generalizability of training effects across problem-solving tice supplemented by incentives.
tasks that require comparable cognitive operations but One possible explanation for this effect is suggested
that present different types of stimuli and operate accord- in an innovative study by Schmand et al. (1994). They
ing to different rules. We conducted a pilot study in which demonstrated that performance on putative "trait" markers
subjects were first tested on the WCST and the Vygotsky of schizophrenia (including measures of vigilance, verbal
Category Test (Wang 1987), a problem-solving task in memory, and distractibility) was related to independent
which subjects sort three-dimensional wooden blocks. measures of motivation on cognitive tasks, and that per-
They were then trained on one of the two instruments, and formance on the motivation measure could be enhanced
then retested on both. The WCST training was highly with accurate feedback. These findings do not indicate
effective, but we were unable to demonstrate cross-test that replicated findings on the existence of cognitive
generalization with our small sample as the Vygotsky test deficits are artifacts, but rather that transient practice-
proved to be comparatively easy and all groups exhibited based improvements can result from enhanced effort and
some pre-post improvement. In contrast, Young and motivation. People with schizophrenia can, apparently,
Freyslinger (1995) recently reported that improvement in mobilize resources to perform better in special circum-
a WCST training protocol was associated with better per- stances, whether by compensatory strategies or as a result
formance on the Halstead Category Test. Their small sam- of decreased demand on processing capacity. This hypoth-
ple study did not include a baseline measure of category esis was supported in a recent study by Kern et al. (1995)
test performance, so it is not certain that subjects in which simple instructions and monetary reinforcement
improved after being trained on the WCST (i.e., general- were sufficient to increase performance on a measure of
ized); better performers on the category test may simply span of apprehension, a putative trait marker of schizo-
have been more able to benefit from WCST training. This phrenia that is thought to be highly stable. These findings
important issue should be examined further in larger scale should temper overly optimistic interpretations of data on
trials employing appropriate controls for practice effects. analogue studies of rehabilitation techniques. The accu-
In a handful of published studies, cognitive training mulated findings provide clear evidence that performance
strategies have been employed to improve performance can be enhanced on a range of cognitive tasks through
on other measures of information processing. Benedict et practice, instruction, and provision of incentives. Thus,
al. (1994) employed a computer-based training program the extent of impairment observed on initial formal testing
that had been developed to enhance attention in brain- may not provide an accurate assessment of potential com-
injured patients. While subjects improved their perfor- petence. However, these practice-related changes typi-
mance on the computerized tasks, there was no associated cally fall short of full normalization of performance and
improvement on Asarnow and Nuechterlein's Span of may not be long lived. Such results do suggest that the
Apprehension Test or degraded stimulus Continuous deficits present on formal testing likely represent a combi-
Performance Test (CPT). Consistent with our position nation of stable as well as more plastic factors (e.g.,
stated above, the authors concluded that compensatory demoralization and lack of motivation). However, the
approaches were more advisable than attentional retrain- more important issue remains that the gains achieved in
ing until more powerful cognitive intervention strategies these studies do not appear to have had large clinical
were developed. Burda et al. (1994) employed a different effects on other aspects of functioning. If it were that easy
computer-driven cognitive retraining protocol and to produce meaningful change, industrious clinicians or
reported pre- to posttraining improvements on the overall creative researchers would have solved the problem long
score from the Wechsler Memory Scale and the ago!
Trailmaking Test (both Trails A and B). These data are These analogue studies can shed considerable light
somewhat difficult to interpret as their VA sample did not on the potential for changing information-processing style
exhibit the expected cognitive deficits at baseline. In a or capacity, but they do not resolve questions about the
recent study by Wexler et al. (1997), subjects were given impact of any such changes on community functioning.
extensive practice on a motor dexterity task and either a Unfortunately, there has been a dearth of new data on
visual reading task or a dot spatial memory task. clinical applications of cognitive rehabilitation strategies.
Improved performance was gradually shaped over 10 Brenner and his colleagues have conducted several small
weeks. A majority of subjects reached normative levels on sample studies on IPT (Brenner et al. 1994). This sophisti-
the reading and dot tasks, and most showed improvement cated, multi-layered program was "state of the art" when

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 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

first described at scientific meetings in the late 1980s, and assumed that if patients do worse than controls on some
it remains the most ambitious effort to date. The program capacity X, improving performance in X would result in
has considerable face validity and has had great heuristic improvements in some important dimension of role func-
value. However, the results have been modest at best. tioning. This approach has two potential drawbacks: (1)
There have been improvements on several of the neu- the remediable deficits may not account for much vari-
ropsychological tasks targeted in training, akin to the ance in role functioning, in which case even effective
practice effects reported in several of the analogue studies rehabilitation would have little functional impact, and (2)
referred to above. However, there has not been evidence some early onset deficits or phenotypic characteristics
of widespread improvements in cognitive functioning or may not be remediable.
generalization to higher level domains (e.g., social skill). We propose a different approach to the selection of
Spaulding and colleagues (Spaulding et al. 1997; rehabilitation "targets": the study of "expert" perfor-
1999, this issue) have translated the Brenner materials mance, an approach common in cognitive psychology
into English and have been engaged in a replication trial (Steinberg 1994). The study of unusually competent sub-
at a long-term hospital for chronic patients in Nebraska. jects sharpens the focus to the traits and abilities associ-
The preliminary results appear to be no better than the ated with success, as opposed to the correlational litera-
results of the Brenner trial. Modest improvements were ture examining schizophrenia outcome, which has been
made on a few tests from a comprehensive neuropsycho- most revealing of deficits linked to failure. Clearly, our
logical assessment, but these results could have been due use of the term expert is somewhat loose. However, this
to chance, given the number of statistical tests conducted. framework has several advantages. First, there is broad
In discussing the prior literature, Spaulding et al. (1999, agreement that outcome in schizophrenia is multidimen-
this issue) conclude, "the improvements observed in pre- sional, with only modest correlation across the sympto-
vious studies may not be any different from changes in matic, social, and vocational domains (Strauss and
normal subjects who practice an unfamiliar task, and there Carpenter 1972, 1977; Carpenter and Strauss 1991). The
are no previous indications that such changes confer eco- contrast of patients who demonstrate unusually good out-
logically significant benefits in personal or social func- comes in each of these different domains or other dimen-
tioning" (p. 280). Spaulding et al. are more sanguine sions of interest (e.g., ability to live independently) to
about the implications of their own recent findings. While
those with poorer functioning is the most direct method of
we agree with their interpretation of the previous litera-
examining the specific determinants of each outcome
ture, their preliminary reports do not lead us to share their
dimension. In addition, in the cognitive literature, the
optimism about their program.
study of expertise emphasizes that the cognitive functions
Judging the potential for cognitive rehabilitation involved in "novice" versus expert performance often dif-
based on existing trials (analogue or clinical) is difficult fer (Ericsson and Hastie 1994). For example, chess mas-
due to the risk of Type II error. It may be safe to conclude ters plan their tactics many moves further ahead than
that a particular strategy is not effective, but one cannot novices, and they can scan a chess board much more
extrapolate from any single trial or group of trials to the quickly to evaluate options. They do not necessarily have
broader domain. For example, a particular technique that greater reasoning skills or visual memory than novices;
fails to produce an effect in 10 training sessions might be rather they have so much experience in game situations
effective after 50. Ten sessions of practice on computer-
that they have developed a large knowledge store of char-
ized memory tasks may not be sufficient to produce a
acteristic game sequences and patterns that they access in
generalizable increase in processing capacity, but mean-
a relatively automatic, non-attention-demanding fashion.
ingful changes might begin to occur after 100 sessions.
In fact, they are no better than novices at remembering the
Alternatively, an innovative program based on a different
configuration of pieces placed on the board randomly
conceptual model could produce results that the simpler
rather than in prototypical game configurations.
practice/rehearsal strategies currently in vogue do not.
Some people with schizophrenia may have impair-
Nevertheless, the current literature does not provide
strong grounds for optimism. ments (e.g., in working memory or visual scanning) that
make it impossible to advance beyond the novice (i.e.,
impaired) level; however, some deficits may not actually
Selection of Targets for Rehabilitation be critical for higher level performance. Continuing with
the chess analogy, some patients may be able to become
For the most part, the targets for rehabilitation have been highly familiar with typical game configurations (an
selected based on replicated evidence of deficits com- applied skill), thereby enabling them to become better at
pared with nonpatient controls. Essentially, it has been predicting the opponent's next move (a cognitive skill),

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 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

without any fundamental improvement in their general year of full-time work while in treatment at the MPRC.
problem solving or reasoning capacity: They may simply Any patient who had only one rating done while at the
have learned that X frequently follows Y. This skill might MPRC and received a rating of 4 on that occasion was
correspond to a vocational situation in which a patient also classified as GVO (a single rating covers a 6-month
learns to efficiently deliver packages to a series of specific period). The cognitive performance of the GVO group
addresses but is unable to plan a daily route or determine was contrasted with all other schizophrenia patients (here
what to do if a recipient is not there to take delivery. The considered PVO). Thus, this is a conservative approach,
patient could be an expert in following a predetermined including in the PVO group some patients who might be
route plan, but a novice in developing a delivery schedule. considered to have at least a moderately good vocational
Training that focuses on the latter might be fruitless if the outcome because they may have had some part-time
person has deficits in sustained attention or working mem- work.
ory that make it impossible to deal with multiple variables The Outpatient Research Program at MPRC is an out-
at once. patient clinic where patients receive their primary psychi-
In our view, studying the characteristics of good out- atric care and participate in a variety of neuroimaging and
come or "expert" patients may reveal the skills needed to neuropsychological studies. To be admitted into the clinic,
succeed in the face of schizophrenia. A parallel approach patients must meet diagnostic criteria for schizophrenia
would be to compare patients with their well siblings who (established using a best-estimate approach combining
share vulnerability indicators but are able to function well structured interview data, medical records, and family
in the community. Such skills are clearly logical targets informants when available) and be free of serious medical
for rehabilitation, and it remains an empirical question or neurological illness that would complicate their research
whether this training will prove possible to achieve levels participation, including substance dependence. Length of
of expert or simply more competent performance in the participation varies widely, ranging from patients who
more typical patient with schizophrenia who presents with come to the clinic to participate in a specific clinical trial
multiple cognitive and social deficits. to those who have received their care at the MPRC for 10
We (J.G. and R.W.B.) have adopted this hypothesis in or more years. The majority of patients maintain involve-
addressing vocational functioning in patient samples ment with the clinic for a number of years, allowing for
drawn from the Maryland Psychiatric Research Center the clinical-research staff to develop a clear, detailed pic-
(MPRC). Several relatively recent North American fol- ture of the longitudinal course of their illness.
low-up studies have documented that a small minority of The sample on which we present data below did not
patients with schizophrenia are able to hold competitive differ significantly in age (GVO = 35.9 [standard devia-
employment, with variation across studies likely ex- tion 6.7], PVO = 36.0 [8.1]), gender (male GVO = 70%,
plained by differing sample characteristics and rating cri- male PVO = 65%), or race (33% and 36% African
teria (Harding et al. 1987; McGlashan 1988; Breier et al. American in GVO and PVO, respectively). There were
1991; Harrow et al., in press). Results from the Chestnut significant differences in education (GVO = 13.8 years
Lodge study, Chicago followup study, and a survey of the [2.3], PVO = 11.9 [2.1]; t = 4.02, p < 0.01) and age at
current patient census at the Outpatient Research Program onset (GVO = 24.6 [6.2], PVO = 21.1 [5.9]; / = 2.53, p <
of the MPRC all suggest that 10 percent to 20 percent of 0.05). Thus, despite being well matched on gender and
patients demonstrate a relatively good vocational out- ethnicity, the good outcome group had a later age at onset
come. The actual employment of these patients often and more years of education, as expected on the basis of
appears to be at a lower level than might be expected on the prior literature. We then examined the neurocognitive
the basis of familial demographic features. However, in archival data. We had degraded stimulus CPT data avail-
our view, any successful competitive employment is an able on 25 GVO and 78 PVO; span of apprehension
important achievement for a patient with schizophrenia (SOA) data on 27 GVO and 94 PVO; WAIS-R subtest
and demonstrates that the diagnosis of the illness is not data on 27 GVO and 103 PVO; and neuropsychological
fully synonymous with functional disability. test data on 22 GVO and 84 to 89 PVO (depending on the
To examine the relationship of cognitive measures variable). It is important to note that these GVO-PVO
and outcome, we examined archival data from the proportions are not representative; these data were col-
Outpatient Research Program at MPRC and classified lected over several years and many PVO patients were
patients as having a good or poor vocational outcome never assessed. Specific descriptions of the CPT and SOA
(GVO and PVO, respectively). Patients were classified as task parameters have previously been published (Strauss
GVO if they had two or more ratings of 4 on the Strauss- et al. 1993).
Carpenter Level of Functioning Scale (Strauss and The WAIS-R and neuropsychological measures are
Carpenter 1972) work item, indicating they had at least 1 shown in table 1, along with effect sizes (ES) for the

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 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

Table 1. Differences in neuropsychologlcal test Table 2. Discriminant function analyses for

performance between good vocational outcome classifying good vocational outcome (GVO) and
(GVO) and poor vocational outcome (PVO) poor vocational outcome (PVO) patients
patients % correctly classified
GVO, PVO, Effect Variable GVO PVO Total
Test meari(SD) mean (SD) size
C 59.3 66.1 64.7
V 9.5 (2.8) 7.8 (2.9) 0.57 VR 72.7 58.4 61.3
C 8.6 (3.2) 6.7 (2.5) 0.74 TA 72.7 51.2 55.6
PC 9.0 (2.6) 7.4 (2.8) 0.61 TB 72.7 42.4 48.6
PA 9.4 (2.7) 7.2 (2.5) 0.87 71.4
SCW 60.2 62.4
VF 50.7 (14.0) 40.2 (13.1) 0.76 SW 71.4 62.5 64.2
we 4.3 (2.2) 2.9 (2.1) 0.68 68.2
WC 61.9 63.2
WP 22.3 (14.9) 29.6 (20.1) 0.38 WP 68.2 46.4 50.9
LM 21.0 (8.1) 16.2 (9-3) 0.53 V 66.7 67.0 66.9
VR 31.8 (6.7) 26.2 (8.1) 0.72 LM 63.6 66.3 64.7
TA 38.9 (16.8) 45.8 (20.1) 0.35 VF 59.1 69.3 67.3
TB 106.9 (54.6) 134.1 (83.7) 0.35 CPT 56.0 52.6 53.4
SW 90.6 (20.8) 76.5 (17.2) 0.79 JL 50.0 6.5 55.1
SC 63.3 (15.7) 54.1 (13.0) 0.68 SOA 48.1 53.2 52.1
sew 32.7 (9.2) 27.2 (9.4) 0.58 44.4 66.1
PC 61.8
JL 23.6 (5.4) 20.9 (6.3) 0.44 61.9
SC 63.6 63.3
CPT 2.23 (1.27) 2.38 (1.05) 0.14 PA 59.3 76.9 73.3
SOA% 69.35 (10.29) 70.9 (10.3) 0.15
Note.—C o comprehension; VR = visual reproduction; TA - Trails
Note.—SD m standard deviation; V = vocabulary; C = compre- A; TB = Trails B; SCW - interference condition; SW = Stroop
hension; PC = picture completion; PA = picture arrangement; Word Reading; WC = Wisconsin Card Sorting Test (WCST) cate-
VF =. verbal fluency; WC = Wisconsin Card Sorting Test (WCST) gories; WP - WCST percent perseverative error; V = vocabulary;
categories; WP = WCST percent perseverative error; LM = logical LM = logical memory; VF - verbal fluency; CPT =• Continuous
memory; VR = visual reproduction; TA » Trails A; TB =• Trails B; Performance Test; JL = judgment of line orientation; SOA = span
SW = Stroop Word Reading; SC = color naming; SCW - interfer- of apprehension; PC - picture completion; SC - color naming;
ence condition; JL =• judgment of line orientation; CPT •= PA - picture arrangement.
Continuous Performance Test; SOA = span of apprehension.

group differences (calculated as the between-group mean Of note, variables that best classified GVO patients
difference divided by the mean standard deviation [SD], differed from those that best classified PVO. For example,
weighted by group size). Trails B correctly classified 72.7 percent of GVO patients
The GVO group clearly performed better than the but only 42.4 percent of the PVO. Picture arrangement
PVO group on nearly every test, except for the degraded (PA) correctly classified 76.9 percent PVO, but only 59.3
stimulus CPT and span of apprehension. The effect sizes percent of the GVO. This variance may suggest that dif-
are generally in the medium range, with several near d = ferent cognitive functions mediate good and poor out-
0.8, Cohen's (1987) criteria for a large effect. These dif- come, with strengths in certain cognitive functions facili-
ferences do not simply reflect premorbid differences: All tating competence, while deficits in others have important
the neuropsychological and WAIS-R variables (with the negative functional consequences. Four of the top five
exception of the WCST percentage perseverative errors discriminators of GVO are measures involving processing
and Trails A) remained significant predictors (p < 0.05) of speed, a construct rarely the focus of recent neuropsycho-
vocational outcome group in regressions with Cannon- logical discussions of schizophrenia. The top four dis-
Spoot Premorbid Scale total score forced to enter first. criminators of PVO include measures of social problem
Thus, there is evidence that neuropsychological perfor- solving and knowledge (PA, Comprehension), verbal abil-
mance is associated with vocational outcome, above and ity (vocabulary), and response generation (verbal flu-
beyond the influence of premorbid competence. ency); other than verbal fluency, few of these tests have
We next performed a series of discriminant function been the focus of much discussion in the literature.
analyses (DFA) examining the correct classification We repeated the DFA in only those patients with
results for each individual variable as seen in table 2, complete WAIS, neuropsychological, CPT, and span of
which presents the percentage of cases correctly classified apprehension data (21 GVO, 68 PVO). A six-variable
in each group as well as the total correct classification solution emerged that correctly classified 85.7 percent of
rate. Variables are displayed in descending sensitivity to the GVO and 75 percent of the PVO cases, for a total
GVO. classification accuracy of 77.5 percent. Jackknifed correct

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 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

classification rates were total, 70.8 percent, GVO, 81.0 controls from archival magnetic resonance imaging (MRI)
percent, and PVO, 67.6 percent. This optimal solution data sets collected by Breier et al. (1992) and Buchanan et
contained picture arrangement, vocabulary, Stroop word al. (1993). The MRI scans were obtained using a 1.5 T
reading, WCST categories and percent preservative error, Siemans Magnetom scanner. The whole brain was evalu-
and Trails B. Clearly, picture arrangement as a single vari- ated in the coronal plane with 3-mm contiguous coronal
able is accounting for most of the classification success, sections, using the spin-echo technique with a TR of 600
given that it achieved a total correct classification rate of milliseconds and TE of 17 milliseconds with two excita-
73.3 percent by itself in the larger sample shown above, tions and a 256 X 256 pixel matrix. Image analyses were
with the other variables mostly increasing sensitivity to performed using the Loats image analyses system. Details
GVO. of measurement methods are described in the studies cited
Two aspects of these results are particularly notewor- above. From the pool of available data, we individually
thy. First, cognitive measures do appear to be robustly matched right-handed GVO, PVO, and normal subjects
related to vocational outcome. Second, several of the vari- for gender, race, and age (± 3 yrs). Each group comprised
ables most often studied in the schizophrenia literature, 10 males and 4 females. Mean ages (SDs) of the three
including the CPT and WCST, do not appear to have a groups were GVO, 34.54 (4.5); PVO, 33.58 (4.9); and
unique relationship to functional outcome. Indeed, mea- normal controls, 36.04 (4.3). The results are presented in
sures of processing speed and social judgment appear to table 3.
be more discriminating. Of note, the two tests most often Although the groups had grossly similar total vol-
considered vulnerability markers (CPT and span of appre- umes for the temporal and frontal lobes, there appears to
hension; Nuechterlein and Dawson 1984) did not appear be a basic difference in the extent of cortical asymmetry.
to be related to outcome, consistent with the distinction We contrasted the right and left temporal and frontal lobes
between cognitive deficits related to risk and those related of each group using matched-pair t tests. In normal con-
to illness presence (see below). trols, right frontal and right temporal lobes were larger
These data have a number of important limitations, than left ones (r = 3.39, p < 0.005 and / = 2.96, p < 0.011,
expected of archival data that should temper our confi- respectively). The same asymmetry pattern was observed
dence in the results. Patient classification was done in the GVO group for the frontal and temporal lobes (r =
crudely and the cognitive data set has many missing val- 3.35 and t = 3.47, respectively; both/? < 0.01). This asym-
ues, limiting the sample size for some of the multivariate metry was absent in the PVO group (frontal lobe, t = 0.31;
analyses. The results, however, demonstrate that it may be temporal lobe, t - -0.34). The PVO group apparently
possible to correctly classify most GVO patients, a result lacks normal cortical asymmetry patterns, a possible
of great clinical relevance. The delineation of a pattern of marker of neurodevelopmental compromise. Such find-
cognitive strengths associated with good outcome in ings of abnormalities of asymmetry have previously been
schizophrenia could then be used to identify patients who reported in schizophrenia with a mixed history of replica-
are currently functioning poorly for more careful clinical tion (Luchins et al. 1982; Bilder et al. 1994; Flaum et al.
evaluation. In essence, such patients appear to have "what 1995; Kulynych et al. 1995). Our data suggest that an
it takes" but are not succeeding. In such cases, sympto- abnormality of asymmetry is not necessarily characteristic
matic features, which are not strongly related to voca- of schizophrenia, but may be related to outcome.
tional functioning in most studies, may be important and We next examined amygdala-hippocampus (AHC)
indicate a need for aggressive pharmacological treatment
volumes and calculated effect sizes using the normal con-
and enhanced psychosocial intervention. In addition, this
type of data, if replicated, provides a rational and empiri- Table 3. MRI comparisons of good vocational
cal framework for targeting cognitive functions for reha- outcome (GVO) and poor vocational outcome
bilitative or pharmacological interventions with the hope (PVO) patients with normal controls (NC)
of reducing the vocational disability common in the ill- PVO GVO NC
ness. An issue of interest here is whether it is more effec- PFC-R 79.75(17.25) 82.72(16.61) 81.21 (10.91)
tive to build competencies related to success or to amelio- PFC-L 78.97(15.35) 75.29(13.87) 75.29(10.26)
rate deficits related to failure. This conceptual approach TL-R 56.66(10.98) 56.46 (8.05) 58.98 (7.53)
also suggests that patients lacking critical competencies TL-L 57.45(9.16) 52.34 (7.63) 55.93 (7.99)
may be in need of a different rehabilitation approach. AHC-R 6.17(0.61) 6.29 (0.99) 6.59 (0.60)
We next addressed the question of whether the robust AHC-L 6.15(0.59) 6.29 (0.88) 6.67 (0.60)
neuropsychological differences between GVO and PVO Note.—Group mean raw data (with standard deviation) are shown
for total volume in cubic centimeters of the right (R) and left (L)
patients might reflect differences in brain morphology. We hemisphere measurements of the prefrontal cortex (PFC), tempo-
identified a sample of GVO and PVO patients and normal ral lobe (TL). and amygdala-hippocampus (AHC).

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 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

trol standard deviation. Both patient groups demonstrated 1992 Schizophrenia Bulletin At Issue series point to the
moderate to large effect sizes relative to controls, suggest- challenges confronting interventions that are designed to
ing left AHC volume reduction (PVO ES = 0.86; GVO enhance cognitive functioning. Further evidence has accu-
ES = 0.62), with somewhat less marked findings on the mulated that many patients demonstrate subtle attentional,
right (PVO ES = 0.70; GVO ES = 0.50; R+L GVO ES = cognitive, and neuromotor abnormalities in early child-
0.63; R+L PVO ES = 0.88). Thus, in contrast to cortical hood, long before the onset of overt psychotic illness, in
asymmetry, volume reduction of the amygdala-hippocam- keeping with "neurodevelopmental" models of the illness
pus does not appear to be related to outcome: Both groups (Cornblatt and Keilp 1994; Walker et al. 1994;
demonstrate the finding, previously reported by multiple Weinberger 1995).
laboratories (Suddath et al. 1990; Falkai and Bogerts Perhaps the most remarkable investigation demon-
1995; Pearlson et al. 1984). The fact that the GVO strating this trend was performed by Jones et al. (1994),
patients have smaller left temporal and frontal volumes who followed subjects originally studied as part of the
than the PVO patients is incompatible with the view that Medical Research Council National Survey of Health and
the GVO group simply has a less severe form of the dis- Development, a study of all births in England, Scotland,
ease than the PVO group. Instead, these data suggest that and Wales during the week of March 3-9, 1946. These
subgrouping patients on vocational status reveals qualita- children were assessed multiple times (beginning at 6
tive differences in brain morphology. weeks) with measures of developmental milestones, edu-
As with the cognitive data, we consider these MRI cational achievement, and social-behavioral assessments.
results to be preliminary but provocative. The results sug- Of the 4,746 English subjects, 30 developed schizophre-
gest that the large cognitive differences observed between nia by the age of 43, with cases identified and diagnosed
outcome groups may reflect basic differences in brain on the basis of multiple medical record sources, case reg-
morphology. The fact that the poor outcome patients isters, and direct interview data using an abbreviated
appear to lack normal cortical asymmetries is not surpris- Present State Examination when subjects were age 36.
ing when considered in the context of their poor neu- These subjects demonstrated delayed achievement of
ropsychological performance. motor and speech milestones in infancy, lower estimated
These results have two implications to consider in IQ scores by middle childhood, and increased social anxi-
schizophrenia rehabilitation. First, the fact that good out- ety by early adolescence in comparison with the 4,716
come may be associated with particular patterns of brain controls. These data suggest that adult schizophrenia is
morphology, as with the cognitive findings discussed preceded by multiple manifestations of subtle develop-
above, is evidence that certain strengths and basic compe- mental compromise across neurological, intellectual, and
tencies may be critical for a good outcome in schizophre- social domains.
nia. It is important to be able to identify patients who The intellectual and educational testing deficits
appear to have these competencies, but are not currently observed in the Jones et al. (1994) study are statistically
functioning, for special clinical attention. Second, the fact significant but small, in marked contrast to the substantial
that poor outcome is associated with greater abnormality cognitive deficits found in samples of adult schizophrenia
of brain morphology is neither surprising—previous patients (Goldberg and Gold 1995). Thus, strong inferen-
reports have documented relationships between poor out- tial evidence suggests that the extent of cognitive impair-
come and ventricular size (Pearlson et al. 1984; Vita et al. ment (both breadth and severity) widens sharply with the
1991; van Os et al. 1995)—nor cause for nihilism. It onset of psychotic illness. Whether this change is a simple
appears likely that such patients may require very differ- quantitative amplification of the early deficit pattern or
ent services to achieve maximum independence than involves a qualitative change suggesting the compromise
patients who have much more intact cognitive perfor- of additional neural systems remains an unanswered but
mance. However, such services cannot be_developed critical question for adequately conceptualizing the patho-
effectively until we have achieved a clearer understanding physiology of cognitive impairment in schizophrenia. At
of the determinants of disability in schizophrenia. this point it is reasonable to speculate that the impair-
ments observed in adult patients are of at least two types:
(1) those present from early in development, and (2) those
What Are the Upper Limits to related to clinical psychotic illness. The existence of such
early, developmentally based impairments suggests that
Cognitive Enhancement? the concept of "premorbid" functioning in schizophrenia
While we are optimistic that our proposed research strat- may no longer be tenable; rather, there is a prepsychotic
egy will improve the prospects for effective rehabilitation, period characterized by subtle evidence of the "morbid"
a number of findings reported in the literature since the process. The challenge confronting attempts at cognitive

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 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

enhancement may not be "rehabilitation," which implies A study consistent with this perspective was recently
restoration of function, but instead the development of reported by Harris et al. (1996), who examined the neu-
critical competencies and strategies for coping with ropsychological performance of 14 patients with schizo-
deficits. phrenia, their 28 parents, and a group of normal controls.
Consistent with the notion that cognitive impairment Eight parents had a positive family history for schizophre-
may be a risk marker for schizophrenia is the developing nia but were married to a spouse with a negative family
literature documenting subtle impairments in first-degree history. The attentional and learning/memory performance
relatives of patients, suggesting that some types of cogni- of the schizophrenia proband was compared with that of
tive impairment may mark the genetic phenotype (Cannon their parents using demographically corrected scores. The
et al. 1994; Kremen et al. 1994; Faraone et al. 1995; family history positive parents and their children demon-
Mirsky 1996). These data may also have important impli- strated similar degrees of attention impairment relative to
cations for rehabilitative approaches to schizophrenia, as controls and to family history negative spouses. In con-
some of the deficits observed in patients are the result of trast, the schizophrenia probands scored more poorly than
genetic factors, which are largely independent of clinical either parent on learning/memory measures, suggesting a
illness. Although patients may perform at lower levels fundamental distinction between attention and memory
than their relatives on some putative genetic risk markers, impairments in terms of their relationship to genetic risk
possibly as a consequence of the additional impairment as opposed to clinical illness. Although this study is based
that accrues with illness, such genetically mediated neu- on a very small sample, the results are provocative. If the
rocognitive impairments may be fundamentally stable goal is to enhance the cognitive function of patients with
deficits. Following from this, it seems improbable schizophrenia, it would seem logical to start with the
(although not logically impossible) that any form of inter- deficits most clearly related to clinical illness, rather than
vention is capable of enhancing the functioning of those shared with nonpsychotic, functioning first-degree
patients beyond the level of deficit seen in nonpsychotic relatives.
relatives. There is likely a ceiling to how much improve- Unfortunately, there is no shortage of potential reha-
ment can be hoped for, a ceiling below the performance bilitation targets. The literature since 1992 has clearly
level of normal controls. Indeed, treatment-related documented that "illness-related" impairments are quite
enhancements that even approach this level would involve broad on standard neuropsychological batteries. Thus,
a remarkable degree of change in cognitive performance. performance tends to be one or more standard deviations
Of course, this argument is conjectural and based on below normative levels across measures of attention,
existing psychosocial and pharmacological treatments, memory, problem solving, motor performance, language,
and expectations based on our short-term crystal ball. and visual processing in many studies (Saykin et al. 1991,
New medications or innovative rehabilitation techniques 1994; Braff et al. 1991). Although several demonstrations
could, conceivably, produce greater remediation than cur- and discussions have centered on the possible differential
rently seems possible. impairment of memory, verbal memory particularly,
The distinction between impairments linked to risk memory impairment clearly occurs on the background of
for illness and those related to presence of clinical illness other deficits that may be only slightly less severe (Saykin
has implications for the selection of treatment targets. The et al. 1991; Gold et al. 1992; Tamlyn et al. 1992). Such
risk status of a patient cannot be changed: They were once results raise two possibilities: that (1) schizophrenia
at risk and now have developed the illness. Targeting the involves multiple discrete impairments, or (2) the general
cognitive processes thought to reflect genetic risk would deficit pattern may be the result of a smaller number of
therefore be an unproductive strategy. For example, specific impairments with broad consequences. These two
abnormalities of attention are clear in patients, and similar perspectives have radically different implications for
abnormalities (albeit perhaps of lesser severity) appear to rehabilitation. The first possibility suggests that patients
be present in a large number of relatives who are not clini- will require a very broad form of cognitive training,
cally ill and who manage to function in the social and addressing most forms of complex cognition that are
vocational domains, as well as in prepsychotic children. It involved in everyday functioning. The second suggests
seems unlikely that attention training, such as that used in that a more focused approach based on a conceptual
many settings with traumatic brain injury patients, would model of the origins of general impairment could be more
have great benefits for patients with schizophrenia. efficient and effective.
Instead, we propose that treatment targets be selected We (J.G.) have previously published data demonstrat-
from among those impairments that are most evident in ill ing that a measure of working memory (letter-number
patients and where patients diverge most clearly from span) was highly correlated with Wisconsin Card Sorting
their nonpsychotic relatives. Test performance in schizophrenia and that co-varying,

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 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

between-group working memory differences eliminated improve in cognitive functioning. In our view, several
patient-normal control differences on the WCST (Gold et important questions remain largely unanswered: (1)
al. 1997). These results suggested that basic working Which impairments are specifically related to different
memory deficits might account for the more complex aspects of outcome? (2) Are there important individual
problem-solving and "executive" function deficits in differences in the type of rehabilitation strategy that may
schizophrenia. Although that study focused on the WCST, be effective? and (3) Does the enhancement of specific
the data also revealed substantial correlation between cognitive functions lead to larger clinical and functional
working memory and full scale IQ (FSIQ) (r = 0.58), benefits? We suggest that a new perspective on the selec-
Trails B (r = -0.45), and Wechsler Memory Scale— tion of treatment targets, that is, the study of good out-
Revised General Memory Index (r = 0.39). Thus, working come patients, may be more appropriate than current
memory may in fact be a critical determinant of the gen- strategies for answering these questions.
eral deficit in schizophrenia. Indeed this possibility is bol- The fact that schizophrenia is a heterogeneous disor-
stered by the fact that working memory demonstrates a der has had much more impact on discussions of diagno-
robust relationship to full scale IQ in the 2,450 normal sis and etiology than on rehabilitation. Our data on work
subject standardization sample for the WAIS HI; the let- outcome suggest that important functional differences
ter-number sequencing correlation with FSIQ was 0.64 should be considered in planning treatment. This hypothe-
(Psychological Corporation 1997). Working memory sis is consistent with several recent studies on the WCST.
appears to be a critical building block for many forms of As many as 20 percent of patients may perform within
cognition; an impairment in this function should have normal levels on the WCST, and poor-performing patients
broad consequences. Although the available data mostly
appear to have a broader pattern of neuropsychological
suggest that working memory has such a broad role, other
deficits than those who can perform at normative levels
variables may also be critical determinants of the general
(Braff et al. 1991; Goldstein et al. 1996). Stratta and col-
deficit in schizophrenia. For example, in the cognitive
leagues (1997) suggest that there are important differ-
aging literature, Salthouse (1993) has demonstrated that
ences in how patients perform the task, as well as in how
perceptual processing speed may be the primary mediator
well they do. They subdivided patients into good and poor
of the broad age-related cognitive changes.
performing groups on the basis of categories correct at
From a rehabilitation perspective, such findings may baseline, and then requested them to enunciate their selec-
be cause for optimism: If it is possible to enhance (either tion strategy on readministration. The good baseline per-
pharmacologically or through a behavioral intervention) formers improved significantly with this technique, while
the cognitive processes that contribute to the generalized the poor performers got worse. The additional task
deficit, it may be possible to produce broad effects from a demand apparently further disrupted their already
focused intervention. Clearly this remains an empirical impaired ability to solve the task.
question and challenge. However, we do think that expec- Until we can identify the most relevant targets for
tations about the effects of cognitive rehabilitation and
rehabilitation and determine which patients require which
models of which cognitive functions may be critical in
types of interventions, we propose that efforts at rehabili-
mediating impairment must be qualified by the substantial
tation focus more on improving functional skills than on
recent evidence that some impairment precedes psychosis,
enhancing cognitive capacities. The extensive knowledge
some impairments are found in good-functioning rela-
that has been accumulated about these underlying deficits
tives, and illness-related neuropsychological deficits are
should be used to guide the format and structure of func-
superimposed on a background level of dysfunction.
tional skills training.
We have employed this strategy in a skills-based
Conclusions intervention for substance abuse by people with schizo-
phrenia. Drug and alcohol abuse has become one of the
The subject of cognitive impairment in schizophrenia, the most significant problems facing agencies and clinicians
role of such impairments in mediating disability, the involved in treatment of people with schizophrenia. The
impact of new pharmacological agents on cognition, and lifetime prevalence rate of substance abuse in schizophre-
the possibility of psychosocial interventions to enhance nia is close to 50 percent (Regier et al. 1990; Mueser et al.
cognitive performance have become central issues in the 1995b) and estimates of recent or current substance abuse
literature on schizophrenia, with interest growing rapidly range from 20 percent to 65 percent (Drake et al. 1989;
since 1992. While much has been learned about these Mueser et al. 1992). We have developed a treatment pro-
issues in the past 5 years, there has been modest progress, tocol containing four modules that are implemented
at best, in the development of rehabilitation strategies to sequentially: (1) social skills and problem-solving training

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 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

to enable patients to develop non-substance-using social urine samples. This reward serves to increase the salience
contacts and to be able to refuse social pressure to use of the weekly goal. Anecdotal reports from patients and
substances; (2) education about the reasons for substance their primary clinicians suggest that they retain and
use (e.g., habits, triggers, and craving) and the particular employ the information and skills we teach between ses-
dangers of substance use for people with schizophrenia; sions. Nevertheless, they continue to exhibit deficits in
(3) motivational interviewing and goal setting for abstraction and in the ability to apply newly learned skills
decreased substance use; and (4) training in behavioral to novel situations, even in simulated interactions during
skills for coping with urges and high-risk situations. sessions. It remains to be determined whether these com-
Several steps are taken in consideration of cognitive partmentalized skills will be effective in reducing sub-
deficits. Sessions are highly structured and the predomi- stance use or if a more generalizable set of coping abili-
nant activity is behavioral rehearsal. The material is bro- ties is required.
ken down into small units, and everything is supple- In conclusion, we remain optimistic that effective
mented by illustrative posters and handouts. Complex rehabilitation techniques can be developed and that the
social repertoires required for making friends and refusing most efficacious strategy for enhancing community func-
substances are divided into component elements such as tioning involves complementary psychopharmacological
maintaining eye contact and how to say "No." Patients are and psychosocial approaches. We also believe that cogni-
first taught to perform the elements and then gradually tive impairments are central to the illness and must be
learn to smoothly combine them. The intervention empha- taken into account in planning treatment and evaluating
sizes overlearning of a few specific and relatively narrow treatment outcome. However, we believe that (a) the neu-
skills that can be used automatically, thereby minimizing rodevelopmental nature of the impairments defies simple
the cognitive load for decision making during stressful solutions and (b) cognitive rehabilitation strategies that
interactions. Extensive use is made of learning aides, depend primarily on repeated practice of neuropsycholog-
including handouts and flip charts, to reduce memory and ical tasks are unlikely to yield much improvement in the
attention requirements. Patients are prompted as many underlying cognitive operations (e.g., working memory)
times as necessary, and extensive repetition is used within or have much benefit for community functioning.
and across sessions. Patients repeatedly rehearse both
behavioral skills (e.g., refusing unreasonable requests)
and didactic information (e.g., the role of dopamine in References
schizophrenia and substance use) and receive social rein-
forcement for effort. Training is done in a small group for- Annis, H.M., and Davis, C.S. Relapse prevention. In:
mat (6-8) to ensure sufficient individual attention and Hester, R.K., and Miller, W.R., eds. Handbook of
opportunities to rehearse skills within the session. Alcoholism Treatment Approaches. New York, NY:
Content on coping skills and relapse prevention is Pergamon Press, 1995. pp. 170-182.
adapted from substance abuse programs based on social Bellack, A.S. Cognitive rehabilitation for schizophrenia:
learning theory that have proven effective with less Is it possible? It is necessary? Schizophrenia Bulletin,
impaired patients (Marlatt and Gordon 1985; Annis and 18:43-50, 1992.
Davis 1995). However, rather than teaching generic prob- Bellack, A.S.; Blanchard, J.J.; and Mueser, K.T. Cue
lem-solving skills and coping strategies that can be availability and affect perception in schizophrenia.
adapted to a host of diverse situations, we focus on spe- Schizophrenia Bulletin, 22:535-544, 1996.
cific skills effective for handling a few key high-risk situ-
Bellack, A.S.; Morrison, R.L.; Mueser, K.T; Wade, J.H.;
ations (e.g., what do you do when you are offered coke by
and Sayers, S.L. Role play for assessing the social compe-
your brother or by one specific friend, rather than what to
tence of psychiatric patients. Psychological Assessment: A
do when anyone offers it to you). Similarly, goals and rea-
Journal of Consulting and Clinical Psychology,
sons for reduced use are very concrete and short term. "I
2:248-255, 19906.
want to stop using crack between today and the weekend"
is more typical than "I need to use less crack." Similarly, a Bellack, A.S.; Morrison, R.L.; Wixted, J.T.; and Mueser,
modal reason for reduced use is avoiding arrest rather K.T. An analysis of social competence in schizophrenia.
than "getting a good job and getting my life in order." British Journal of Psychiatry, 156:809-818, 1990a.
Our subjects have been uniformly unable to generate Bellack, A.S.; Mueser, K.T; Morrison, R.L.; Tiemey, A.;
abstract goals and reasons to reduce drug use. Con- and Podell, K. Remediation of cognitive deficits in schiz-
sequently, we have recently added a urinalysis contin- ophrenia. American Journal of Psychiatry, 147:1650-
gency in which patients receive money if they have clean 1655, 1990c.

270
Downloaded from https://academic.oup.com/schizophreniabulletin/article-abstract/25/2/257/1919043
by guest
on 20 February 2018
 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

Bellack, A.S.; Mueser, K.T.; Wade, J.; Sayers, S.; and Burda, P.C.; Starkey, T.W.; Dominguez, F.; and Vera, V.
Morrison, R.L. The ability of schizophrenics to perceive Computer-assisted cognitive rehabilitation of chronic psy-
and cope with negative affect. British Journal of chiatric inpatients. Computers in Human Behavior,
Psychiatry, 160:473-480, 1992. 10:359-368, 1994.
Bellack, A.S.; Sayers, M.; Mueser, K.T.; and Bennett, M. Cannon, T.D.; Zorrilla; L.E.; Shtasel, D.; Gur, R.E.; Gur,
An evaluation of social problem solving in schizophrenia. R.C.; Marco, E.J.; Moberg, P.; and Price, R.A.
Journal of Abnormal Psychology, 103:371-378, 1994. Neuropsychological functioning in siblings discordant for
Benedict; R.H.B.; Harris, A.E.; Markow, T.; McCormick, schizophrenia and healthy volunteers. Archives of General
J.; Nuechterlein, K.H.; and Asarnow, R.F. Effects of atten- Psychiatry, 51:651-661, 1994.
tion training on information processing in schizophrenia. Carpenter, W.T. Jr., and Strauss, J.S. The prediction of
Schizophrenia Bulletin, 20:537-546, 1994. outcome in schizophrenia: IV. Eleven-year follow-up of
Bilder, R.M.; Wu, H.; Bogerts, B.; Degreef, G.; Ashtari, the Washington IPSS cohort. Journal of Nervous and
M.; Alvir, J.M.J.; Snyder, P.J.; and Lieberman, J.A. Mental Disease, 179:517-525, 1991.
Absence of regional hemispheric volume asymmetries in Cohen, J. Statistical Power Analysis for the Behavioral
first-episode schizophrenia. American Journal of Sciences. Hillsdale, NJ: Lawrence Erlbaum, 1987.
Psychiatry, 151:1437-1447,1994. Cornblatt, B.A., and Keilp, J.G. Impaired attention, genet-
Bowen, L.; Wallace, C.J.; Glynn, G.M.; Nuechterlein, ics, and the pathophysiology of schizophrenia.
K.H.; Lutzker, J.R.; and Kuehnel, T.G. Schizophrenic Schizophrenia Bulletin, 20:31-46, 1994.
individuals' cognitive functioning and performance in Corrigan, P.W.; Wallace, C.J.; Schade, M.L.; and Green,
interpersonal interactions and skills training procedures. M.F. Learning medication self-management skills in
Journal of Psychiatry Research, 28:289-301, 1994. schizophrenia: Relationships with cognitive deficits and
Braff, D.L.; Heaton, R.; Kuck, P.; Cullum, M.; psychiatric symptoms. Behavior Therapy, 25:5-15, 1994.
Moranville, J.; Grant, I.; and Zisook, S. The generalized Cramer, P.; Bowen, J.; and O'Neill, M. Schizophrenics
pattern of neuropsychological deficits in outpatients with and social judgement: Why do schizophrenics get it
chronic schizophrenia with heterogeneous Wisconsin wrong? British Journal of Psychiatry, 160:481^87, 1992.
Card Sorting Test results. Archives of General Psychiatry, Drake, R.E.; Osher, F.C.; and Wallach, M.A. Alcohol use
48:891-898, 1991. and abuse in schizophrenia: A prospective community
Breier, A.; Buchanan, R.W.; Elkashef, A.; Munson, R.C.; study. Journal of Nervous and Mental Disease, 177:408-
Kirkpatrick, B.; and Gellad, F. Brain morphology and 414, 1989.
schizophrenia: An MRI study of limbic, prefrontal cortex, Ericsson, K.A., and Hastie, R. Contemporary approaches
and caudate structures. Archives of General Psychiatry, to the study of thinking and problem solving. In:
49:921-926, 1992. Steinberg, R.J., ed., Thinking and Problem Solving. San
Breier, A.; Schreiber, J.L.; Dyer, J.; and Pickar, D. Diego, CA: Academic Press, 1994. pp. 37-82.
National Institute of Mental Health longitudinal study of Falkai, P., and Bogerts, B. The neuropathology of schizo-
chronic schizophrenia: Prognosis and predictors of out- phrenia. In: Hirsch, S.R., and Weinberger, D.R., eds.
come. Archives of General Psychiatry, 48:239-246, 1991. Schizophrenia. Cambridge, England: Blackwell Science,
Brenner, H.D.; Kraemer, S.; Hermanutz, M.; and Hodel, 1995. pp. 275-292.
B. Cognitive treatment in schizophrenia. In: Straube, Faraone, S.V.; Seidman, LJ.; Kremen, W.S.; Pepple, J.R.;
E.R., and Hahlweg, K., eds. Schizophrenia: Concepts, Lyons, M.J.; and Tsuang, M.T. Neuropsychological func-
Vulnerability, and Intervention. Berlin, Germany: tioning among the nonpsychotic relatives of schizophrenic
Springer-Verlag, 1990. pp. 161-191. patients: A diagnostic efficacy analysis. Journal of
Brenner, H.D.; Roder, V.; Hodel, B.; Kienzle, N.; Reed, Abnormal Psychology, 104:286-304, 1995.
D.; and Liberman, R.P. Integrated Psychological Therapy Flaum, M.; Swayze, V.W.; O'Leary, D.S.; Yuh, W.T.C.;
for Schizophrenic Patients. Seattle, WA: Hogrefe & Ehrhardt, J.C.; Arndt, S.V.; and Andreasen, N.C. Effects
Huber Publishers, 1994. of diagnosis, laterality, and gender on brain morphology
Buchanan, R.W.; Breier, A.; Kirkpatrick, B.; Elkashef, A.; in schizophrenia. American Journal of Psychiatry,
Munson, R.C.; Gellad, F.; and Carpenter, W.T. Jr. 152:704-714, 1995.
Structural abnormalities in deficit vs. non-deficit schizo- Gessler, S.; Cutting, J.; and Frith, C D . Schizophrenic
phrenia. American Journal of Psychiatry, 150:59-65, inability to judge to facial emotion: A controlled study.
1993. British Journal of Clinical Psychology, 28:19-29, 1989.

271
Downloaded from https://academic.oup.com/schizophreniabulletin/article-abstract/25/2/257/1919043
by guest
on 20 February 2018
 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

Gold, J.M.; Carpenter, C.J.; Randolph, C ; Goldberg, T.; Joseph, PL.A.; Sturgeon, D.A.; and Leff, J. The percep-
and Weinberger, D.R. Auditory working memory and tion of emotion by schizophrenic patients. British Journal
Wisconsin Card Sorting Test performance in schizophre- of Psychiatry, 161:603-609, 1992.
nia. Archives of General Psychiatry, 54:159-165, 1997. Kern, R.S.; Green, M.F; and Goldstein, M.J. Modification
Gold, J.M.; Randolph, C ; Carpenter, C.J.; Goldberg, T.; of performance on the span of apprehension, a putative
and Weinberger, D.R. Forms of memory failure in schizo- marker of vulnerability to schizophrenia. Journal of
phrenia. Journal of Abnormal Psychology, 101:487-494, Abnormal Psychology, 104:385-389, 1995.
1992. Kern, R.S.; Green, M.F; and Satz, P. Neuropsychological
Goldberg, T.E., and Gold, J.M. Neurocognitive deficits in predictors of skills training for chronic psychiatric
schizophrenia. In: Hirsch, S.R., and Weinberger, D.R., patients. Psychiatric Research, 43:223-230, 1992.
eds. Schizophrenia. Cambridge, England: Blackwell Kerr, S.L., and Neale, J.M. Emotion perception in schizo-
Science, 1995. pp. 146-162. phrenia: Specific deficit or further evidence of generalized
Goldberg, T.E.; Weinberger, D.R.; Berman, K.F.; Pliskin, poor performance? Journal of Abnormal Psychology,
N.H.; and Podd, M.H. Further evidence for dementia of 102:312-318, 1993.
the prefrontal type in schizophrenia? Archives of General Kremen, W.S.; Seidman, L.J.; Pepple, J.R.; Lyons, M.J.;
Psychiatry, 44:1008-1014, 1987. Tsuang, M.T.; and Faraone, S.V. Neuropsychological risk
indicators for schizophrenia: A review of family studies.
Goldman, R.S.; Axelrod, B.N.; and Tompkins, L.M.
Schizophrenia Bulletin, 20:103-119, 1994.
Effect of instructional cues on schizophrenic patients' per-
formance on the Wisconsin Card Sorting Test. American Kulynych, J.J.; Vladar, K.; Fantie, B.D.; Jones, D.W.; and
Journal of Psychiatry, 149:1718-1722, 1992. Weinberger, D.R. Normal asymmetry of the planum tem-
porale in patients with schizophrenia: Three-dimensional
Goldstein, G.; Beers, S.R.; and Shemansky, WJ. Neuro-
cortical morphometry with MRI. British Journal of
psychological differences between schizophrenic patients
Psychiatry, 166:742-749, 1995.
with heterogeneous Wisconsin Card Sorting Test perfor-
mance. Schizophrenia Research, 21:13-18, 1996. Liberman, R.P., and Green, M.F. Whither cognitive-
behavioral therapy for schizophrenia? Schizophrenia
Green, M.F. What are the functional consequences of neu- Bulletin, 18:27-35, 1992.
rocognitive deficits in schizophrenia? American Journal
of Psychiatry, 154:321-330, 1996. Luchins, DJ.; Weinberger, D.R.; and Wyatt, R.J. Schizo-
phrenia and cerebral asymmetry detected by computed
Harding, CM.; Brooks, G.W.; Ashikaga, T; Strauss, J.S.; tomography. American Journal of Psychiatry,
and Breier, A. The Vermont longitudinal study of persons 139:753-757, 1982.
with severe mental illness: II. Long term outcome of sub-
Marlatt, G.A., and Gordon, J.R. Relapse Prevention:
jects who retrospectively met DSM-HI criteria for schizo-
Maintenance Strategies in the Treatment of Addictive
phrenia. American Journal of Psychiatry, 144:727-735,
Behaviors. New York, NY: Guilford, 1985.
1987.
McGlashan, T.H. The prediction of outcome in chronic
Harris, J.G.; Adler, L.E.; Young, D.A.; Cullum, CM.; schizophrenia: IV. The Chestnut Lodge follow-up study.
Rilling, L.M.; Cicerello, A.; Intemann, P.M.; and Archives of General Psychiatry, 43:167-176, 1988.
Freedman, R. Neuropsychological dysfunction in parents
of schizophrenics. Schizophrenia Research, 20:253—260, Meichenbaum, D.H., and Cameron, R. Training schizo-
1996. phrenics to talk to themselves: A means of developing
attentional controls. Behavior Therapy, 4:515-534, 1973.
Harrow, M.; Sands, J.R.; Silverstein, M.L.; and Goldberg,
Metz, J.T.; Johnson, M.D.; Pliskin, N.H.; and Luchins,
J.F. Course and outcome for schizophrenia vs. other psy-
D.J. Maintenance of training effects on the Wisconsin
chotic patients: A longitudinal study. Schizophrenia
Card Sorting Test by patients with schizophrenia or affec-
Research, in press.
tive disorders. American Journal of Psychiatry,
Heimberg, C ; Gur, R.E.; Erwin, R.J.; Shtasel, D.L.; and 151:120-122, 1994.
Gur, R.C Facial emotion discrimination: III. Behavioral Mirsky, A.F. Familial factors in the impairment of atten-
findings in schizophrenia. Psychiatry Research, 42:253- tion in schizophrenia: Data from Ireland, Israel, and the
265, 1992. District of Columbia. In: Matthysse, S.; Levy, D.L.;
Jones, P.; Rodgers, B.; Murray, R.; and Marmot, M. Child Kagan, J.; and Benes, F.M., eds. Psychopathology: The
development risk factors for adult schizophrenia in the Evolving Science of Mental Disorder. New York, NY:
British 1946 birth cohort. Lancet, 344:1398-1402, 1994. Cambridge University Press, 1996. pp. 364-406.

272
Downloaded from https://academic.oup.com/schizophreniabulletin/article-abstract/25/2/257/1919043
by guest
on 20 February 2018
 Cognition and Rehabilitation Schizophrenia Bulletin, Vol. 25, No. 2, 1999

Morrison, R.L.; Bellack, A.S.; and Bashore, T.R. Sayers, M.; Bellack, A.S.; Wade, J.H.; Bennett, M.; and
Perception of emotion among schizophrenic patients. Fong, P. An empirical method for assessing social prob-
Journal of Psychopathology and Behavior Assessment, lem solving in schizophrenia. Behavior Modification,
10:319-332, 1988. 19:267-289, 1995.
Mueser, K.T.; Bellack, A.S.; Douglas, M.S.; and Wade, Saykin, A.J.; Gur, R.C.; Gur, R.E.; Mozley, P.D.; Mozley,
J.H. Prediction of social skill acquisition in schizophrenic L.H.; Resnick, S.M.; Kester, D.B.; and Stafiniak, P.
and major affective disorder patients from memory and Neuropsychological function in schizophrenia: Selective
symptomatology. Psychiatry Research, 37:281-2%, 1991. impairment in memory and learning. Archives of General
Mueser, K.T.; Bennett, M.; and Kushner, M.G. Psychiatry, 48:618-624, 1991.
Epidemiology of substance use disorders among persons Saykin, A.J.; Shtasel, D.L.; Gur, R.E.; Kester, D.B.;
with chronic mental illnesses. In: Lehman, A.F., and Mozley, L.H.; Stafiniak, P.; and Gur, R.C.
Dixon, L.B., eds. Double Jeopardy: Chronic Mental Neuropsychological deficits in neuroleptic naive patients
Illness and Substance Use Disorders. Chur, Switzerland: with first-episode schizophrenia. Archives of General
Harwood Academic Publishers, 1995fc. pp. 520-528. Psychiatry, 51:124-131,1994.
Mueser, K.T.; Blanchard, J.J.; and Bellack, A.S. Memory Schmand, B.; Kuipers, T.; Van Der Gaag, M.; Bosveld, J.;
and social skill in schizophrenia: The role of gender. Bulthuis, F.; and Jellema, M. Cognitive disorders and neg-
Psychiatry Research, 57:141-153, 1995a. ative symptoms as correlates of motivational deficits in
psychotic patients. Psychological Medicine, 24:869-884,
Mueser, K.T.; Yarnold, P.R.; and Bellack, A.S. Diagnostic
1994.
and demographic correlates of substance abuse in schizo-
phrenia and major affective disorder. Acta Psychiatrica Spaulding, W.D.; Fleming, S.K.; Reed, D.; Sullivan, M.;
Scandinavian 85:48-55, 1992. Storzbach, D.; and Lam, M. Cognitive functioning in
schizophrenia: Implications for psychiatric rehabilitation.
Nisbet, H.; Siegert, R.; Hunt, M.; and Fairley, N. Im- Schizophrenia Bulletin, 25(2):275-289, 1999.
proving Wisconsin card-sorting performance. British
Journal of Clinical Psychology, 35:631-633, 19%. Spaulding, W.; Reed, D.; Elting, D.; Sullivan, M.; and
Penn, D. Cognitive changes in the course of rehabilita-
Nuechterlein, K.H., and Dawson, M.E. A heuristic vulner- tion. In: Brenner, H.D.; Boker, W.; and Genner, R., eds.
ability/stress model of schizophrenic episodes. Schizo- Towards a Comprehensive Therapy for Schizophrenia.
phrenia Bulletin, 10:300-312, 1984. Seattle, WA: Hogrefe & Huber, 1997. pp. 106-117.
Pearlson, CD.; Garbacz, D.J.; Breakey, W.R.; Ann, H.S.; Spohn, H.E., and Strauss, M.E. Relation of neuroleptic
and DePaulo, J.R. Lateral ventricular enlargement associ- and anticholinergic medication to cognitive functions in
ated with persistent unemployment and negative symp- schizophrenia. Journal of Abnormal Psychology,
toms in both schizophrenia and bipolar disorder. 4:367-380, 1989.
Psychiatry Research, 12:1-9, 1984.
Spring, B.J., and Ravdin, L. Cognitive remediation in
Platt, J.J., and Spivack, G. Problem-solving thinking of schizophrenia: Should we attempt it? Schizophrenia
psychiatric patients. Journal of Consulting and Clinical Bulletin, 18:15-20, 1992.
Psychology, 39:148-151, 1972a.
Sternberg, R.J. Intelligence. In: Sternberg, R.J., ed.
Platt, J.J., and Spivack, G. Social competence and effec- Thinking and Problem Solving. New York, NY: Academic
tive problem-solving thinking in psychiatric patients. Press, 1994. pp. 263-288.
Journal of Clinical Psychology, 28:3-5, 1972*. Stratta, P.; Mancini, F ; Mattei, P.; Bustini, M.; Casacchia,
The Psychological Corporation. WAIS-III, WMS-III. M.; and Rossi, A. Remediation of Wisconsin Card Sorting
Technical Manual. San Antonio, TX: Harcourt Brace & Test performance in schizophrenia. Psychopathology,
Company, 1997: 30:59-66, 1997.
Regier, D.A.; Farmer, M.E.; Rae, D.S.; Locke, B.Z.; Stratta, P.; Mancini, F.; Mattei, P.; Casacchia, M.; and
Keith, S.J.; Judd, L.L.; and Goodwin, F.K. Comorbidity of Rossi, A. Information processing strategy to remediate
mental disorders with alcohol and other drug abuse. Wisconsin Card Sorting Test performance in schizophre-
Journal of the American Medical Association, nia: A pilot study. American Journal of Psychiatry,
264:2511-2518, 1990. 151:915-918, 1994.
Salthouse, T.A. Speed mediation of adult age differences Strauss, J.S., and Carpenter, W.T. The prediction of out-
in cognition. Developmental Psychology, 29:722-738, come in schizophrenia: I. Characteristics of outcome.
1993. Archives of General Psychiatry, 27:739-746, 1972.

273
Downloaded from https://academic.oup.com/schizophreniabulletin/article-abstract/25/2/257/1919043
by guest
on 20 February 2018
 Schizophrenia Bulletin, Vol. 25, No. 2, 1999 A.S. Bellack et al.

Strauss, J.S., and Carpenter, W.T. The prediction of out- Wang, P.L. The search for a clinical frontal lobe test. In:
come in schizophrenia: HI. Five-year outcome and its pre- Perecman, E., ed. Concept Formation and Frontal Lobe
dictors. Archives of General Psychiatry, 34:159-163, Function. New York, NY: The IRBN Press, 1987.
1977. pp. 189-205.
Strauss, M.E.; Buchanan, R.W.; and Hale, J. Relations Weinberger, D.R. Neurodevelopmental perspectives on
between attentional deficits and clinical symptoms in schizophrenia. In: Bloom, F.E., and Kupfer, D.J., eds.
schizophrenic outpatients. Psychiatry Research, Psychopharmacology: The Fourth Generation of Progress.
47:205-213, 1993. New York, NY: Raven Press, 1995. pp. 1171-1183.
Suddath, R.L.; Christison, G.W.; Torrey, E.F.; Casanova, Wexler, B.E.; Hawkins, K.A.; Rounsaville, B.; Anderson,
M.F.; and Weinberger, D.R. Anatomical abnormalities in M.; Sernyak, M.J.; and Green, M.F. Normal neurocogni-
the brains of monozygotic twins discordant for schizo- tive performance after extended practice in patients with
phrenia. New England Journal of Medicine, 322:789-794, schizophrenia. Schizophrenia Research, 26:173-180,
1990. 1997.
Tamlyn, D.; McKenna, P.I.; Mortimer, A.M.; Lund, C.E.; Young, D.A., and Freyslinger, M.G. Scaffolded instruc-
Hammond, S.; and Baddeley, A.D. Memory impairment tion and the remediation of Wisconsin Card Sorting Test
in schizophrenia: Its extent, affiliations, and neuropsycho- deficits in chronic schizophrenia. Schizophrenia Research,
logical character. Psychiatric Medicine, 22:101-115, 16:199-207, 1995.
1992.
van Os, J.; Fahy, T.A.; Jones, P.; Harvey, I.; Lewis, S.; Acknowledgment
Williams, M.; Toone, B.; and Murray, R. Increased intra-
cerebral cerebrospinal fluid spaces predict unemployment Preparation of this manuscript was supported by U.S.
and negative symptoms in psychotic illness: A prospective Public Health Service grants DA09406 from the National
study. British Journal of Psychiatry, 166:750-758, 1995. Institute of Drug Abuse (A.S.B.); MH-40279 (J.M.G. and
R.W.B.) and MH-48225 (R.W.B.) from the National
Vita, A.; Dieci, M.; Giobbio, G.M.; Azzone, P.; Garbarini,
Institute of Mental Health; and grants from the National
M.; Sacchetti, E.; Cesana, B.M.; and Cazzullo, C.L. CT
Alliance for Research on Schizophrenia and Depression,
scan abnormalities and outcome of chronic schizophrenia.
the Stanley Foundation, and MH-57749 (J.M.G.).
American Journal of Psychiatry, 148:1577-1579,1991.
Vollema, M.G.; Geurtsen, G.J.; and van Voorst, A.J.P.
Durable improvements in Wisconsin Card Sorting Test The Authors
performance in schizophrenic patients. Schizophrenia Alan S. Bellack, Ph.D., is Professor of Psychiatry, James
Research, 16:209-215, 1994. M. Gold, Ph.D., is Associate Professor of Psychiatry, and
Walker, E.F.; Savoie, T.; and Davis, D. Neuromotor pre- Robert W. Buchanan, M.D., is Associate Professor of
cursors of schizophrenia. Schizophrenia Bulletin, Psychiatry at the University of Maryland School of
20:441-451, 1994. Medicine, Baltimore, MD.

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