Do schizophrenia patients make more perseverative than non-perseverative errors on the Wisconsin Card Sorting Test? A meta-analytic study

The Wisconsin Card Sorting Test (WCST) is widely used to explore executive functions in patients with schizophrenia. Among other findings, a higher number of perseverative errors has been suggested to implicate a deficit in task switching and inhibitory functions in schizophrenia. Many studies of patients with schizophrenia have focused on perseverative errors as the primary performance index in the WCST. However, do schizophrenia patients characteristically make more perseverative than non-perseverative errors compared with healthy controls? We reviewed the literature where schizophrenia patients were engaged in the WCST irrespective of the primary goal of the study. The results showed that while both schizophrenia patients and healthy participants made more perseverative than non-perseverative errors, the contrast between perseverative and non-perseverative errors is higher in schizophrenia patients only at a marginal level of significance. This result suggests that schizophrenia patients do make a comparable number of non-perseverative errors and cautions against simplistic interpretation of poor performance of schizophrenia patients in WCST as entirely resulting from impairment in set-shifting or inhibitory functions.     

A process approach to verbal memory assessment: Exploratory evidence of inefficient learning in women remitted from anorexia nervosa

Introduction: Anorexia nervosa (AN) is associated with deficits in set-shifting and cognitive flexibility, yet less is known about the persistence of these deficits after recovery and how they might contribute to reported difficulties organizing and learning new information. To address this question, the current study applied a process-focused approach, that accounts for errors and strategies by which a score is achieved, to investigate the relationship between verbal memory and executive function in women remitted from AN.

Method: Twenty-six women remitted from anorexia nervosa (RAN) and 25 control women (CW) aged 19–45 completed the California Verbal Learning Test, Second edition (CVLT-II) and the Wisconsin Card Sorting Test (WCST). Groups were compared on overall achievement scores, and on repetition, intrusion, and perseverative errors on both tests. Associations between learning and memory performance and WCST errors were also examined.

Results: RAN and CW groups did not differ on overall CVLT-II learning and memory performance or errors on the WCST, though the RAN group trended towards greater WCST non-perseverative and total errors. On the CVLT-II, the RAN group made significantly more repetition errors than CW (p = 0.010), and within-trial perseveration (WTP) errors (p = 0.044). For the CW group, CVLT-II learning and memory performance were negatively associated with errors on the WCST, whereas among RAN, primarily delayed memory was negatively correlated with WCST errors. Notably, for RAN, greater WCST perseverative responses were correlated with greater CVLT-II repetition and WTP errors, showing the convergence of perseverative responding across tasks.

Conclusions: Despite similar overall learning and memory performance, difficulties with executive control seem to persist even after symptom remission in patients with AN. Results indicate an inefficient learning process in the cognitive phenotype of AN and support the use of process approaches to refine neuropsychological assessment of AN by accounting for strategy use.     

精神分裂症患者与其健康同胞的注意和执行功能障碍的对照研究

目的　探讨精神分裂症患者及其健康同胞的注意、工作记忆 /执行功能的特点。方法对 5 0例精神分裂症患者 (患者组 )及其健康同胞 5 0名 (同胞组 ) ,以及 4 5名正常对照者 (正常对照组 )采用威斯康星卡片分类测验 (WCST)和持续操作测验 (CPT) ,评估注意、工作记忆 /执行功能。结果　(1)在WCST中 ,患者组及其同胞组的总测验次数 (分别为 83 4± 2 3 2和 74 1± 2 4 6 )、持续错误数 (分别为 2 5 8± 11 7和 2 2 8± 10 7)、随机错误数 (33 4± 19 2和 2 5 9± 17 1)均高于正常对照组 (分别为6 0 0± 2 1 6、14 8± 8 3和 18 1± 16 0 ;P <0 0 1)。 (2 )在CPT中 ,患者组的评分 [(2 8 4± 4 0 )分 ]低于同胞组 [(30 4± 2 3)分 ]和正常对照组 [(30 9± 2 8)分 ],而同胞组与正常对照组的差异无显著性(P >0 0 5 )。(3)患者组及其同胞组发生执行功能障碍 (分别为 2 9例和 2 5例 )和注意缺陷 (分别为 2 2例和 7例 )的例数均多于正常对照组 (分别为 9例和 4例 ;P <0 0 1) ,其中有工作记忆 /执行功能缺陷的精神分裂症患者 ,其同胞出现这一缺陷的比率 (6 6 % )高于无缺陷的精神分裂症患者的同胞 (2 8% )。(4)WCST中的持续错误数与文化程度呈负相关 (r =- 0 32 ,P <0 0 1) ,CPT与性别 (r=- 0 2     

奥氮平对精神分裂症患者执行功能障碍的影响

目的:探讨奥氮平对精神分裂症患者执行功能障碍的长期疗效。方法:对29例服用奥氮平维持治疗与24例服用氯丙嗪维持治疗的精神分裂症患者进行2年随访,采用威斯康星卡片分类测验(WCST)评估执行功能。结果:维持治疗2年末奥氮平组和氯丙嗪组的WCST测验中的总测验次数、持续错误数、随机错误数均显著下降(P<0.05或P<0.01),但奥氮平组的总测验次数、持续错误数、随机错误数减分率均显著高于氯丙嗪组(P均<0.01)。结论:奥氮平长期维持治疗能显著改善精神分裂症患者的执行功能。     

Impaired Wisconsin card sorting test performance in first-episode schizophrenia: resource or motivation deficit?

Patients with first-episode schizophrenia (n = 27) and age- and education-matched healthy controls (n = 27) were administered the standard version of the Wisconsin Card Sorting Test (WCST), the Wechsler Adult Intelligence Scale-Revised (WAIS-R), and the Rorschach according to the Comprehensive System (CS). Schizophrenic patients achieved a significantly lower full-scale IQ and made more perseverative responses and achieved fewer categories on the WCST than the healthy control group. No significant associations were observed between effort or motivation and WCST performance. Schizophrenic patients who made more perseverative responses tended to be impoverished in terms of available resources, and functioned in a simplistic way when attending to details of the stimulus field. First-episode schizophrenics are able to generate motives and initiate goal-directed activity, but some of them fail to achieve their goals because the cognitive abilities and available resources required for effective planning, purposeful action, or effective performance are impaired.     

Wisconsin Card Sorting Test performance before and after temporal lobectomy

Wisconsin Card Sorting Test (WCST) performance was studied before and after patients underwent right (n = 34) or left (n = 34) temporal lobectomy. Patients had hemisphere language dominance judged on intracarotid amobarbital testing and were free of space-occupying lesional pathology by magnetic resonance imaging (MRI). Right and left lobectomy patients did not differ before or after surgery on WCST parameters: categories completed, perseverative errors, total correct responses, total errors, nonperseverative errors, and perseverative responses. There was no relationship between WCST performance and MRI-determined hippocampal volumes or age of recurrent seizure onset. These findings are contrary to previous reports, suggesting the presence of laterality effects on preoperative WCST performance, relationships between WCST performance and age of seizure onset, and association of WCST performance and degree of mesial temporal sclerosis. Data from this study are consistent with a report on a larger group of temporal lobectomy patients, which found no laterality effect on WCST performance. The WCST seems to be of no value when attempting to lateralize seizure onset in nonlesional temporal lobe epilepsy.     

阿立哌唑对首发精神分裂症患者执行功能障碍的影响

目的 探讨阿立哌唑对首发精神分裂症患者执行功能的影响.方法 入组43例首发精神分裂症患者为研究组,使用阿立哌唑（15-30mg/d）治疗,观察6周.采用阳性和阴性症状量表（PANSS）评定疗效,用威斯康星卡片分类测验（WCST）评定认知功能.与35例健康对照组进行比较分析.结果 ①治疗前,研究组随机错误数、持续错误数高于对照组,正确应答数和完成分类数低于对照组,差异具有统计学意义（t=6.75、3.93、-2.84、-7.70,P〈0.05）.②治疗后研究组随机错误数高于对照组,完成分类数低于对照组,差异具有统计学意义（t=3.91、-7.27,P〈0.05）.③研究组治疗前后比较,治疗后PANSS总分和随机错误数低于治疗前,而完成分类数和正确应答数高于治疗后,差异具有统计学意义（t=13.61、2.91、-2.26、-2.07,P〈0.05）.结论 阿立哌唑可能有利于改善精神分裂症患者的执行功能.     

Spatial working memory performance in patients with schizoaffective psychosis versus schizophrenia: a tale of two disorders?

We explored the relationship between schizophrenia and schizoaffective disorder by comparing the two patient groups in terms of their performance on measures of executive functioning (spatial working memory and Wisconsin Card Sorting Test). Patients with schizophrenia (N=34) and those with schizoaffective disorder (N=23) performed significantly poorer than community controls (N=30). However, the schizoaffective and schizophrenia groups did not differ from each other in terms of working memory accuracy or mean response latencies. Similarly, the two patient groups did not differ in terms of the number of categories achieved or number of perseverative errors on the Wisconsin Card Sorting Test. Among the patients, working memory accuracy was associated with number of WCST perseverative errors and number of categories achieved, though working memory performance was not associated with number of WCST nonperseverative errors. These findings indicate that both schizophrenia and schizoaffective disorder are associated with executive functioning deficits. The findings are discussed in the context of the ongoing debate regarding the conceptualization of schizoaffective disorder.     

The relationship between regional cerebral blood flow and the Wisconsin Card Sorting Test in negative schizophrenia

The purpose of this study was to explore the relationship between regional cerebral blood flow (rCBF) and problem-solving thinking in negative schizophrenia. Twenty-one negative schizophrenic patients and 12 normal controls were studied with single photon emission computed tomography (SPECT). Measures of regional cerebral blood flow (rCBF) were taken both at rest and during a prefrontal activation task using Wisconsin Card Sorting Test (WCST). Compared with controls, poor performances on the WCST of total trials category (TT), perseverative errors (PE) and non-perseverative errors (NE) were found in negative schizophrenic (P < 0.05). During WCST activation, patients showed interhemispheric differences in the prefrontal region, but under rest conditions, no such differences manifested. The negative schizophrenia group had a significantly lower rCBF change rate in profrontal lobe during stimulant WCST than those in normal controls (P < 0.05). The negative schizophrenic patient has executive function deficits and lower rCBF perfusion in left profrontal lobes, which suggest that the negative schizophrenic patient has dysfunction of the left profrontal region.     

Association of muscarinic m1 receptor genetic polymorphisms with psychiatric symptoms and cognitive function in schizophrenic patients

OBJECTIVE: The cholinergic system is important in the search for the pathophysiology of schizophrenia due to its role in cognitive function, interaction with the dopamine system in brain regions relevant to schizophrenia, side effects of antipsychotic medication and potential antipsychotic effect of muscarinic receptor antagonists. This study investigated the association of type I muscarinic receptor (CHRM1) genetic polymorphisms with the clinical characteristics of chronic schizophrenic inpatients. METHODS: We determined the genotype of CHRM1 genetic polymorphisms in 243 schizophrenic patients hospitalized in chronic care wards. Psychotic symptoms were assessed using the Brief Psychiatric Rating Scale (BPRS), and cognitive function was assessed using the Folstein Mini-Mental Status Examination (MMSE) test. Sixty of the 243 subjects also completed the Wisconsin Card Sorting Test (WCST). RESULTS: There was a significant difference in the number of correct responses and the percentage of perseverative errors in the WCST in the CHRM1 C267A genotype group of schizophrenia patients. There was no significant association between age at onset, chlorpromazine equivalents, BPRS scores, MMSE or schizophrenia per se in patients with the CHRM1 C267A genotype. The full exon of the CHRM1 gene was screened out with single-strand conformation polymorphism, and 2 single nucleotide polymorphisms (C267A and C1353T) were identified in our patients and control subjects. These 2 single nucleotide polymorphisms were linked together without exception. CONCLUSION: This study demonstrated that in schizophrenic patients, the heterozygote group of CHRM1 C267A polymorphism (267C/A) had more correct responses and less perseverative errors on the WCST performance than the 267C/C homozygote group, implicating that this polymorphism may be related to prefrontal cortical function. Our results also suggested that the C267A polymorphism plays no major role in the susceptibility to and clinical manifestations of schizophrenia.     

Confirmatory factor analysis in neurophysiological and neuropsychological dimensions of schizophrenia

This study applied confirmatory factor analysis (CFA) to examine the construct of smooth pursuit eye movements (SPEM) and the Wisconsin Card Sorting Test (WCST) in schizophrenia. Participants were assigned to two groups: Group 1 included 27 probands chosen from families with schizophrenia in first-degree relatives, and Group 2 included 54 schizophrenics who had no families with schizophrenia spectrum disorders. There were no differences in the eye tracking pursuit and the WCST between the sporadic and familial schizophrenics. Gender impacted the catch-up saccades (CUS) and anticipatory saccades (AS) indices of the SPEM, and the conceptual level responses (CLR) index of the WCST. Education impacted the CLR and perseverative errors of the WCST. Although there were no correlation between the SPEM and the WCST, but the two instruments showed good content validity, which might be useful in the subtyping of schizophrenia.     

Wisconsin Card Sorting Test: an indicator of vulnerability to schizophrenia?

The Wisconsin Card Sorting Test (WCST) is a neuropsychological test, hypothesized to be an indicator of dorsolateral prefrontal cortex (DLPFC) functioning. The performance of schizophrenic patients in our sample (off medication) was worse than the performance of healthy controls in all variables of the WCST, including perseverative responses (PR) as well as non-perseverative responses (NPR). The rate of perseverative and non-perseverative responses was neither a function of the severity of the illness (measured by SANS/SAPS scales) nor the duration of the disease. Healthy siblings of schizophrenic probands revealed more perseverative responses than healthy controls, but did not show any difference with respect to the non-perseverative responses. This finding suggests that the difficulty to shift a cognitive set, reflected by the frequency of perseverative responses, is in favor of the WCST as a vulnerability marker for schizophrenia, whereas non-perseverative responses presumably indicate a state, but not a trait marker of the disease. However, the usefulness of this indicator may be limited by its association with age, which is worthy of being studied in closer detail.     

The validity and reliability of chinese frontal assessment battery in evaluating executive dysfunction among Chinese patients with small subcortical infarct

OBJECTIVES: Frontal Assessment Battery (FAB) is a valid and reliable screening test for evaluating executive dysfunction among whites with frontal and subcortical degenerative lesions. We studied the properties of a Chinese version of FAB (CFAB) in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. METHODS: Concurrent validity was evaluated using Wisconsin Card Sorting Tst (WCST) and Mattis Dementia Rating Scale-Initiation/Perseveration Subset (MDRS I/P) among 41 controls and 30 stroke patients with small subcortical infarct. Discriminant validities of CFAB and its subitems were compared with those of Mini-Mental State Examination (MMSE). Internal consistency, test-retest, and interrater reliability of CFAB were evaluated. RESULTS: The CFAB had low to good correlation with various executive measures: MDRS I/P (r = 0.63, p < 0.001), number of category completed (r = 0.45, p < 0.001), and number of perseverative errors (r = -0.37, p < 0.01) of WCST. Among the executive measures, only number of category completed had significant but small contribution (6.5%, p = 0.001) to the variance of CFAB. A short version of CFAB using three items yielded higher overall classification accuracy (86.6%) than that of CFAB full version (80.6%) and MMSE (77.6%). Internal consistency (alpha = 0.77), test-retest reliability (rho = 0.89, p < 0.001), and interrater reliability (rho = 0.85, p < 0.001) of CFAB were good. CONCLUSION: Although CFAB is reliable, it is only moderately valid in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. The clinical use of CFAB in the evaluation of executive dysfunction among this group of patients cannot be recommended at this stage.     

Wisconsin Card Sorting Test performance in patients with complex partial seizures of temporal-lobe origin

Wisconsin Card Sorting Test (WCST) performance was investigated in patients with complex partial seizures (CPS) of dominant (n = 16) or nondominant (n = 19) temporal-lobe origin as well as in an epilepsy control group (n = 6) which consisted largely of patients with primary generalized epilepsies. Fifty seven percent of the CPS group (39% of dominant and 74% of nondominant temporal-lobe patients) performed in a manner suggestive of frontal-lobe pathology compared to 17% of the epilepsy controls. There were no differences among the groups in the number of categories achieved, but there were substantial qualitative differences in problem-solving efficiency. Nondominant temporal patients manifested more total errors and perseverative errors relative to both dominant temporal and epilepsy controls, and more perseverative responses relative to epilepsy controls. Dominant temporal-lobe patients showed more perseverative errors than epilepsy controls. Finally, a consecutive series of patients who underwent partial temporal-lobe resection were examined 6 months post-surgically and they were found to manifest significantly fewer perseverative responses. The possible reasons for "frontal-like" performance in CPS patients with documented temporal-lobe pathology are discussed and a specific hypothesis is suggested.     

The effects of clozapine on cognitive function and regional cerebral blood flow in the negative symptom profile schizophrenia

OBJECTIVE: Cognitive function and regional cerebral blood flow (rCBF) were studied in negative symptom profile schizophrenic patients by using WCST and SPECT. METHODS: Twenty-one schizophrenic patients who matched the criteria of Andreason's negative symptom profile received SPECT and WCST, and then were treated with clozapine for 8 consecutive weeks. There were 28 and 12 normal subjects as the control groups of WCST and SPECT, respectively. RESULTS: Compared with controls, significantly poorer performance on total trials of category (TT), persevering errors (PE), and non-persevering errors (NPE) of WCST were found in schizophrenia (p < 0.05). The total score of the scale for assessment negative symptoms (SANS) was significantly related with poor TT (r = 0.45, p < 0.01) and PE performance (r = 0.45, p < 0.01). The poor TT, PE, and NPE tasks of WCST and SANS scores in the negative schizophrenic patients were significantly improved through clozapine treatment (p < 0.05). The schizophrenic patients had a significantly lower rCBF in bilateral frontal and temporal lobes and lower change rate of rCBF in bilateral frontal lobes during WCST compared to normal controls (p < 0.05). CONCLUSIONS: Negative symptom profile schizophrenia has cognitive deficits and lower rCBF in bilateral frontal and temporal lobes, which suggests that negative symptom profile schizophrenic patients have hypofrontality. Clozapine can improve negative symptoms and improve cognitive dysfunction, although it cannot improve reduced rCBF in the frontal lobes.     

The Impact of Executive Function on Emotion Recognition and Emotion Experience in Patients with Schizophrenia

Objective

This study investigated the impact of executive function on the performance of two different affective tasks, the Facial Affect Identification Task (FAIT) and the Iowa Gambling Task (IGT), in patients with schizophrenia.

Methods

Thirty-nine patients with schizophrenia and 33 healthy controls completed the FAIT and the IGT, followed by the Wisconsin Card Sorting Test (WCST) and the intelligence quotient (IQ) test. In addition to correlation analysis, regression analysis was used to determine the extent to which the performance of the WCST, in particular, perseverative error (PE), accounted for the variation in both the FAIT and the IGT.

Results

Relative to normal controls, patients with schizophrenia showed significant impairments in the IGT, the FAIT and the WCST even after controlling for IQ. While normal controls did not show any relationships between the WCST and two affective tasks, patients with schizophrenia showed that variables in the WCST correlated not only with the FAIT total correct score (r=-0.503, p=0.001 for PE) but also with the IGT net score (r=0.385, p=0.016 for PE). The PE score was a better predictor of the performance on the FAIT (R²=0.25) than that of the performance on the IGT (R²=0.15).

Conclusion

Our findings imply that deficits in executive function in schizophrenia can affect performance on facial emotion recognition task more than performance on task based on emotion experience, that is, the feedback from the body. Therefore, more consideration is needed of the impact of executive function when interpreting the result of "conventional" facial affect recognition tests as opposed to interpreting the IGT.     

Wisconsin Card Sorting Test deficits in chronic paranoid schizophrenia. Evidence for a relatively discrete subgroup?

Some, although not all, researchers have reported dramatically increased numbers of perseverative responses on the Wisconsin Card Sorting Test (WCST) in schizophrenic patients compared to normal comparison subjects. The current study was designed to further explore the nature of possible WCST deficits in a group of paranoid schizophrenic patients compared to normal and psychiatric comparison subjects. In the current study, schizophrenic patients had significantly greater numbers of perserverative responses on the WCST than the comparison groups. The sample of patients with schizophrenia appeared to be characterized by a non-Gaussian distribution of perseverative responses on the WCST. WCST-impaired and WCST-nonimpaired schizophrenic subgroups were compared on cognitive and symptom measures, and increased perseverative responding was associated with negative symptoms, slowed reaction time, and more hospitalizations. While additional research is necessary to further investigate hypotheses of frontal versus generalized brain dysfunction in schizophrenic patients, WCST impairment seems to be present in a clinically meaningful subgroup of paranoid schizophrenic patients.     

Electrophysiological evidence of two different types of error in the Wisconsin Card Sorting Test.

The specificity of the Wisconsin Card Sorting Test (WCST) for assessing frontal lobe pathology remains controversial, although lesion and cerebral blood flow studies continue to suggest a role for the dorsolateral prefrontal cortex in WCST performance. Inconsistencies might derive from the extended use of various WCST scores as equivalent indicators of frontal pathology. In this study, event-related potentials (ERPs) were recorded from 32 normal subjects who committed perseverative and non-perseverative errors. Both types of WCST errors evoked anomalous but distinct ERP patterns over frontal lobe regions. Perseverative errors were also associated with a dysfunctional extrastriate response to stimulation. This evidence suggests that perseverative and non-perseverative errors result from disruptions in two different prefrontal neural networks engaged during card sorting.     

Declarative memory and WCST-64 performance in subjects with schizophrenia and healthy controls

The Wisconsin Card Sorting Test (WCST) is a set-switching task used extensively to study impaired executive functioning in schizophrenia. Declarative memory deficits have also been associated with schizophrenia and may affect WCST performance because continued correct responding depends on remembering the outcome of previous responses. This study examined whether performance in visual and verbal declarative memory tasks were associated with WCST performance. Subjects comprised 30 patients with schizophrenia or schizoaffective disorder (SCZ) and 30 demographically matched healthy controls (CON) who were tested on the WCST, the Benton Visual Retention Test (BVRT), the California Verbal Learning Test (CVLT), and the Continuous Performance Test (CPT). SCZ subjects showed significant correlations between visual and verbal declarative memory and performance on the WCST-64 that were in the hypothesized direction such that worse memory performance was associated with worse performance on the WCST. CON subjects did not show a significant relationship between visual or verbal memory and WCST-64 performance. Fisher's r to z transformations indicated that the associations between declarative memory and WCST-64 performance in the SCZ subjects differed significantly from those of CON subjects. The findings suggest that interpretations of WCST-64 scores for subjects with schizophrenia should be considered in light of their declarative memory functioning.     

The executive clock drawing task (CLOX) is a poor screening test for executive dysfunction in Chinese elderly patients with subcortical ischemic vascular disease.

Executive dysfunction (ED) is a prominent feature of subcortical ischemic vascular disease. A screening test for ED is lacking among Chinese. The objective of the study is to investigate the validity and reliability of a Chinese version of the Executive clock drawing task (CLOX) in screening ED among Chinese elderly patients with small subcortical infarct (SSI). The Chinese version of CLOX correlated with MMSE, CDRS I/P, and WCST perseverative errors. However, multivariate regression analysis showed that only education (R(2) change=0.22, p < 0.001 ) and MMSE (R(2) change=0.35, p < 0.001), but none of the standard executive function tests, significantly accounted for the variance in the CLOX. Test-retest (r=0.84) and inter-rater reliability (r=0.84) were high for the CLOX. Conclusions. Although the CLOX is reliable, it is not valid in detecting ED in Chinese elderly patients with SSI.