P.~~hiarr,~ Rrvrurch. 53: 141-151 Elsevier

141

Cognitive Correlates to Social Cue Perception in Schizophrenia

Patrick W. Corrigan, Michael F. Green, and Rosemary Toomey

Received August 13, 1993; revised version received Januar.v 31, 1994; accepted February 24, 1994.

Abstract. Previous research has examined social skill learning in schizophrenic patients in relation to information-processing deficits and psychiatric symptoms. Relationships were examined in the current report between social cue perception, thought to be an early and necessary component of skill learning, and various information-processing deficits and psychiatric symptoms. Twenty-six inpatients with DSM-III-R diagnoses of schizophrenia completed measures of social cue perception, cognitive functioning, and psychiatric symptoms. Results showed that cue perception was significantly related to measures of early visual processing, recognition memory, and psychiatric symptoms of withdrawal/ retardation. Implications of these findings for future research into the social- perceptual deficits of schizophrenic patients are discussed.

Key Words. Social skills training, rehabilitation, information processing, psychiatric symptoms.

The psychosocial deficits of schizophrenia are vast and pervade all stages of the illness (Klorman et al., 1977; Avison and Speechley, 1987). Various social skills training methods have been developed to remediate these deficits by helping patients to augment their repertoire of interpersonal and coping skills (Bellack et al., 1984; Hansen et al., 1985; Liberman et al., 1986). Social skills training is a rehabilitative technique based on principles of behavioral psychology. It includes discrete interventions like modeling, behavioral rehearsal, social reinforcement, and home- work (Liberman et al., 1989). Unfortunately, some patients are unable to acquire targeted behaviors in traditional skills training programs because of cognitive deficits (Liberman et al., 1985; Wong and Woolsey, 1989; Masse1 et al., 1991).

Research has examined the association between various measures of information processing and social skill learning to enhance understanding of the role of cognitive variables in skill acquisition and to suggest cognitive strategies that might augment current skills training methods. Studies have found significant correlations between measures of visual vigilance and social ski11 learning over the short term (Bowen et

Patrick W. Corrigan, Psy.D., is Assistant Professor of Clinical Psychiatry, University of Chicago Pritzker School of Medicine, Chicago, IL. Michael F. Green, Ph.D., is Associate Professor of Psvchiatrv, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles; and tie West Los Anneles Veterans Affairs Medical Center, Los Angeles. CA. Rosemarv Toomev. Ph.D.. is Research Associate at Boston University and the Harvard University Departmen; of Psych&y at ;he Brockton/ West Roxbury VAMC, Brockton, MA. (Reprint requests to Dr. P.W. Corrigan, University of Chicago Center for Psychiatric Rehabilitation, 7230 Arbor Dr., Tinley Park, IL 60477, USA.)

0 165-I 78 I/ 94/ $07.00 @ 1994 Elsevier Science Ireland Ltd.

142

al., in press) and after several months of training (Kern et al., 1992). However, subsequent research failed to find a significant association between social skill learning and several early input functions including visual vigilance and early visual processing (Corrigan et al., 1994). Studies have consistently found a significant association between short-term verbal memory and skills training (Mueser et al., 1991; Kern et al., 1992; Corrigan et al., 1994).

The manner in which psychiatric symptoms affect social skill learning has also been examined. Negative symptoms including social and emotional withdrawal have predicted psychosocial skill learning in schizophrenic patients (Bellack et al., 1989). Interestingly, skills training has not been found to be significantly related to psychotic symptoms such as conceptual disorganization, delusions, or hallucinations (Eckman et al., 1992; Corrigan et al., 1994).

The effect of cognitive deficits and psychiatric symptoms on skill learning may be related to serial models of social cognition in which the first stage of processing is social cue perception (McFall, 1982; Wallace, 1982; Corrigan et al., 1992). Social cue perception is the ability to attend to and accurately encode the salient stimuli that describe interpersonal situations. In an effort to understand social perceptual deficits in schizophrenia, several studies have examined the accuracy of a patient’s ability to recognize interpersonal stimuli. Results have shown that schizophrenic subjects are less accurate than comparison groups in labeling facial affect (Morrison et al., 1988) describing nonverbal body signals (Rosenthal et al., 1979; Monti and Fingeret, 1987), and recognizing the cues that define interpersonal situations (Corrigan et al., 1990; Corrigan and Green, 1993).

The purpose of the study described in this article was to examine the relationship of information processing and psychiatric symptoms to the first stage of social skill acquisition, social cue perception. On the basis of previous studies which examined the influence of information-processing deficits on social skill learning in general (Mueser et al., 1991; Kern et al., 1992; Corrigan et al., 1994), we hypothesize that social cue perception is more clearly associated with cognitive tasks that emphasize sensory input because social cue perception is considered an early component of the cognitive functions related to skill acquisition. We also hypothesize that social cue perception will be significantly associated with negative symptoms and relatively unrelated to psychotic symptoms.

Methods

Subjects. Twenty-six inpatients with DSM-III- R diagnoses of schizophrenia (American Psychiatric Association, 1987) from Camarillo State Hospital in California participated in this study. All diagnoses were based on an expanded version of the Present State Examination (Wing et al., 1974); clinicians conducting the interviews were trained to a minimum agreement of 85% for the presence of symptoms according to criterion ratings of the Diagnosis and Psychopathology Unit of the Clinical Research Center for the Study of Schizophrenia at the University of California, Los Angeles (Robert P. Liberman, principal investigator). Subjects with a history of drug or alcohol abuse, mental retardation, or identifiable neurological conditions were excluded. The schizophrenic subjects also demonstrated at least a fourth grade reading level as measured by the Wide Range Achievement Test-Revised (Jastak and Wilkinson, 1984) and had corrected vision of at least 20/30 as measured on the Snellen eye chart.

143

Mean age of the study group was 34.5 years (SD = 6.9) and mean length of formal education was 12.0 years (SD = 2.2). Subjects were 73.6% male; 18 subjects in the study were white, three were Hispanic, three were Asian, and two were African American. The patients had a long history of illness; the average age at disease onset was 19.8 years (SD = 6.4). All patients received neuroleptic medications, and the average chlorpromazine-equivalent dose was 1223 mg (SD = 854). Twenty-three of the patients received benztropine for side effects, and the average dose was 2.3 mg (SD = 1.7).

Dependent Measures. To assess sensitivity to interpersonal cues, subjects were adminis- tered the Social Cue Recognition Test (SCRT) in which they were instructed to watch eight videotaped vignettes of two or three people interacting (e.g., two friends assembling a puzzle; a husband and wife fighting). Subjects then answered 36 true-false questions per vignette about the interpersonal cues viewed in the interaction (Corrigan et al., 1990; Corrigan and Green, 1993). The test has been shown to have good parallel form reliability across vignettes as well as satisfactory internal consistency (Corrigan and Green, 1993).

SCRT indices included hit rate (percent of true items reported as true) and false alarm rate (percent of false items reported as true). However, because these indices are biased by the perceived payoffs for correct identifications and perceived penalties for incorrect attributions (Davies and Parasuraman, 1982) a nonbiased measure of cue sensitivity was also determined from hit and false alarm rates. The goal of previous research with the SCRT (Corrigan and Green, 1993) has been to determine how cue sensitivity differed across levels of situational arousal and cue abstraction. However, because the purpose of this study was to determine the manner in which cue sensitivity is associated with information-processing deficits and psychiatric symptoms, we only reported overall SCRT scores across all eight vignettes.

Information Processing. Five well-validated tests were included to measure early input and more complex information-processing functions: the Degraded-Stimulus Continuous Perfor- mance Test, the forced choice Span of Apprehension Test, the Digit Span Distractibility Test, the Rey Auditory Verbal Learning Test, and the Wisconsin Card Sorting Test.

The Degraded Stimulus-Continuous Performance Test (DS-CPT) is a measure of visual vigilance (Nuechterlein, 1983) and was assessed using Version 1 of the UCLA CPT computer program (Nuechterlein and Asarnow, 1987). The DS-CPT was presented on an IBM personal computer with a Taxan 720 color monitor. Viewing distance was 1 meter, and subjects responded by pressing the appropriate button on a Gravis joystick. Subjects were instructed to press a response button whenever they saw the target number “O.“Numbers were degraded to a standardized degree by reversing the black/ white setting of 40% of randomly selected pixels. Stimulus degradation places a burden on the early encoding stage of information processing. Subjects were shown 160 practice trials followed by 480 experimental trials presented in three blocks of 160. Stimuli were presented for 60-ms duration at l-second intervals for all trials. The target “0” appeared in quasirandom sequence 20 out of every 80 trials. A nonparametric signal detection index of sensitivity (the ability to discriminate targets from nontargets) was determined from patients’ responses (Davies and Parasuraman, 1982).

The forced choice Span of Apprehension Test (SPAN) is an index of early visual input that includes scanning, iconic memory, and other readout stages of visual processing (Asarnow and MacCrimmon, 1981); it was assessed using Version 1 of the UCLA SPAN computer program (Asarnow and Nuechterlein, 1987). Like the DS-CPT, the SPAN was presented on an IBM personal computer with a Taxan 720 color monitor. Icons were presented for 80 ms. Viewing distance was 1 meter, and subjects responded by pressing the appropriate button on a Gravis joystick. Subjects were told that letters will be flashed on the screen and that either the target letter “T” or “F” will be in each array. Subjects were to press one of the two keys marked “T” or “F” that corresponded with the target letter that they observed. Subjects were instructed to guess if they were not sure. Either 2 or 11 nontarget letters were placed randomly in other positions of the array. Subjects received 20 practice trials to become familiar with the procedure. Each array size during the test was presented in blocks of 16 trials; an equal

144

number of T’s and F’s appeared within each block. Four blocks of each size array were administered. The total number correct on the 3-letter and 12-letter spans was reported.

Subjects completed two versions of the Digit Span Distractibility Test (DSDT) to measure short-term recall during distraction: a short series comprising seven nondistractor lists of six digits interspersed with seven distractor lists of five digits followed by a long series comprising seven nondistractor lists of seven or eight digits interspersed with seven distractor lists of six digits (Oltmanns and Neale, 1975). An audiotaped female voice read the target numbers and a male voice read the distractor numbers. The tape recorder was shut off after each list, and subjects were instructed to write down in order as many numbers as they could remember. We used an overall recall score for the present study that has been previously associated with psychosocial skills learning (Corrigan et al., in press).

Ability to recognize and recall word lists was measured from the Rey Auditory Verbal Learning Test (RAVLT; Rey, 1964). Subjects were instructed to listen to a list of 15 common words read by the examiner. When the examiner finished the list, subjects were to repeat aloud as many of the words as they could remember in any order. The procedure was repeated two more times. The recall score equaled total number of correctly identified words for the three trials. Number of intrusions during recall was also determined; intrusions equaled the total number of words recalled by the subject over the three trials that were not in the 15-word list. After a 15-minute interference task (the SPAN), subjects were read a paragraph and instructed to tap on the table top immediately after hearing words in the stimulus list. Number of correctly identified words represented the recognition score. Number of words incorrectly identified as part of the 15-word list equaled a false alarm score for recognition memory.

,Concept formation and cognitive flexibility were assessed using a computerized version of the Wisconsin Card Sorting Test (WCST; Heaton, 1981) developed by Wang Laboratories. The computerized version of the WCST is comparable to the card version for this population (Hellman et al., 1992). During this task, subjects were instructed to match a series of stimuli to four key cards. Cards can be matched according to one of three rules: color, number, or form. The only feedback the examiner provided was whether each match was correct or incorrect. After matching 10 consecutive cards, the experimenter changed the rule without informing the subject. Number of perseverative errors (i.e., continuing to match items to criteria that were no longer correct) has been of central interest in describing cognitive processes in schizo- phrenia and was reported here (Weinberger et al., 1986; Van der Does and Van den Bosch, 1992).

Symptom Measures. Subjects were also administered a 24-item, expanded version of the Brief Psychiatric Rating Scale (BPRS; Lukoff et al., 1986) to measure the effects of symptoms on social cue perception. Raters who conducted BPRS interviews had been trained to a minimum intraclass correlation coefficient of 0.80 (ICC( 1,l): Shrout and Fleiss, 1979) based on consensus ratings of the Diagnosis and Psychopathology Unit of the UCLA Clinical Research Center. Two summary scores from the BPRS were used (Overall et al., 1967). The Thinking Disturbance factor (conceptual disorganization, hallucinations, and unusual thought content) was used as an index of psychotic symptoms and the Withdrawal/ Retardation factor (blunted affect, emotional withdrawal, and motor retardation) was used to index negative symptoms.

Procedure. Patients were recruited and informed to the purposes of the study. Total testing required 4-6 hours per patient and was completed over several sessions within a 2-week period. Subjects received candy and soft drinks for completing the measures.

Results

SCRT scores showed no significant correlations with either age or education of the

subjects. Moreover, there were no significant correlations between either chronicity

or neuroleptic medication levels and scores on the SCRT.

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Table 1 presents the correlations among measures of cue perception, information processing, and psychiatric symptoms. Significant correlations are indicated by asterisks, and coefficients that met the Bonferroni adjustment’ for significance are italicized.

Examination of the interrelationships among information-processing measures showed some expected patterns. Recall and recognition memory were highly related. Similarly, the two SPAN indices were highly correlated. Regarding the psychiatric symptoms, no significant associations were found between the BPRS Thinking Disturbance factor and information-processing deficits. The Withdrawal/ Retardation factor was found to be significantly associated with both SPAN indices, though these coefficients did not meet the Bonferroni criterion for significance.

Relationships Between Overall Sensitivity on the SCRT and Information- Processing Deficits. Examination of Table 1 showed SCRT sensitivity was significantly correlated with early visual processing as assessed by the two SPAN scores and with recognition memory on the RAVLT; these coefficients met the Bonferroni criterion. A stepwise multiple regression was completed to determine whether these information-processing measures independently accounted for variance of the SCRT sensitivity score. Table 2 summarizes the results of this analysis. Two independent variables-SPAN-3 and RAVLT recognition-were selected for the analysis because they yielded the largest correlations with SCRT sensitivity. Results showed that SPAN-3 and RAVLT recognition independently predicted significant SCRT variance. The subsequent multiple R was 0.81 and accounted for 65% of SCRT sensitivity variance.

Associations of false alarms on the SCRT met the Bonferroni criterion for significance with SPAN-3 and the DSDT. Moreover, intrusions on the recall memory task of the RAVLT were significantly associated with false alarms on the SCRT, though this correlation did not meet the Bonferroni criterion for significance. Three independent variables-SPAN-3, DSDT, and RAVLT intrusions-were sub- sequently included in a stepwise multiple regression. These measures were included because they yielded the largest correlations with SCRT sensitivity. Three of the subjects did not complete the DSDT because of the effort requirements. Therefore, this multiple regression represents data from 23 subjects. Results, summarized in Table 2, showed that DSDT and RAVLT intrusions independently accounted for significant variance in SCRT false alarms. The relationship between SPAN-3 and SCRT false alarms was found not to be significant after the DSDT and RAVLT intrusions were partialed out. No significant relationships were found between hit rate on the SCRT and any of the information-processing measures.

Cue Sensitivity and Psychiatric Symptoms. Table 1 presents the correlation coefficients between SCRT scores and BPRS symptoms. Results showed significant correlations between sensitivity on the SCRT and the Withdrawal/ Retardation factor. The SCRT hit rate was not related to any BPRS score, but false alarm rates

1. a= 0.05

N of correlations.

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le 1

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and

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al c

ue

per

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tion

SP

AN

S

PA

N

BP

RS

DS

- m

atri

x m

atri

x R

AV

LT

R

ecal

l R

AV

LT

R

eco

gn

itio

n

WC

ST

T

hin

kin

g

Wit

hd

raw

al

CP

T

3 12

re

call

intr

u

reco

a F

As

DS

DT

P

E

Dis

turb

ance

R

etar

dat

ion

SCR

T se

nsiti

vity

0.

25

Hit

rate

-0

.09

Fals

e al

arm

ra

te

-0.2

6

Vigi

lanc

e

DS-

CPT

lcon

ic

mem

ory

SPA

N

mat

rix

3

SPA

N

mat

rix

12

Verb

al

mem

ory

RA

VLT

reca

ll

RA

VLT

reca

ll in

tru

RA

VLT

reco

gniti

on

RA

VLT

reco

gniti

on

FAs

Seria

l re

call

DSD

T to

tal

corr

ect

Cog

nitiv

e fle

xibi

lity

WC

ST

PEs

0.72

”’

0.59

**

0.44

* -0

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0.

63**

* -0

.27

0.43

* -0

.30

-0.4

0 -0

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0.13

0.

11

0.28

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17

0.34

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3 0.

24

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0”

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6’

-0.3

3 0.

53**

-0

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0.

10

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3***

0.

48*

0.45

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0.21

0.

25

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08

0.56

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7 0.

33

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37

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0.49

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68**

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00

Not

e. S

CM

= S

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ecog

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est.

DS

-CP

T

= D

egra

ded

Str

mul

us C

ontr

nuou

s P

erfo

rman

ce

Tes

t. S

PA

N =

Spa

n of

App

rehe

nsro

n.

RA

VLT

= R

ey A

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Ver

bal

Lear

ning

T

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lntr

u =

intr

usio

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FA

s =

fals

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DS

DT

= D

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ST

= W

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= pe

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rs.

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= B

rief

Psy

chia

tric

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cale

. T

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umbe

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ject

s fo

r ea

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orre

latio

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effic

ient

va

ried

betw

een

23 a

nd 2

6. H

ence

, cr

iteria

for

sig

nific

ance

m

ay h

ave

chan

ged

from

coe

ffici

ent

to c

oeffi

cien

t.

Sta

tistic

al

sign

ifica

nce:

'p

< 0.

05; l *p < 0

.01;

***

p < 0.0

01. C

oeffi

cien

ts

mee

ting

Bon

ferr

oni

Crit

erio

n fo

r si

gnifi

canc

e ar

e ita

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ed.

Bon

ferr

oni

crite

ria w

ere

dete

rmin

ed

for

each

of f

our

mat

rices

: th

e in

terc

orre

latio

ns

of in

form

atio

n-pr

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va

riabl

es (p

< 0

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) in

form

atro

n-pr

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sing

va

nabl

es

and

psyc

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rrc

sym

ptom

s (p

< 0

.003

). S

CR

T s

core

s an

d in

form

atio

n-

proc

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ng

varia

bles

(p

< O

.M)2

), a

nd S

CR

T s

core

s an

d ps

ychi

atric

sy

mpt

oms

(p < 0

.008

).

147

were correlated with Thinking Disturbance. Only the relationship between sensitivity on the SCRT and Withdrawal/Retardation met criteria for statistical significance

after the Bonferroni adjustment. A multiple regression was conducted to determine whether the Withdrawal/

Retardation factor and information-processing deficits independently accounted for significant variance in sensitivity to social cues. The three independent variables for the analysis were SPAN-3, RAVLT recognition, and the BPRS Withdrawal/ Retardation factor. Table 2 summarizes the results of the multiple regression. Each of the variables independently accounted for significant SCRT variance ( F > 4.00). Thus, the Withdrawal/ Retardation factor independently predicted SCRT sensitivity from recognition memory and early visual processing.

Table 2. Results of simultaneous multiple regression analyses

Dependent variable Independent variables Multiple R

(information-processing variables only)

SCRT sensitivity SPAN matrix 3 0.72

RAVLT recognition 0.81

SCRT false alarms DSDT total correct 0.61

RAVLT recall intrusions 0.73

SPAN matrix 3 0.78’

R2

0.52

0.65

0.37

0.53

0.61

(information processing and symptoms)

SCRT sensitivity SPAN matrix 3 0.72 0.52

RAVLT recognition 0.81 0.65

BPRS Withdrawal/Retardation 0.84 0.71

Note. SCRT = Social Cue Recognition Test. SPAN = Span of Apprehension. RAVLT = Rey Auditory Verbal Learning Test. DSDT = Digit Span Distractor Test.

1. F to enter was not significant.

Discussion

Results of the current study showed that patients’ sensitivity to social cues was significantly associated with early visual processing measured by the SPAN and with recognition memory assessed by the RAVLT. SCRT sensitivity was also significantly associated with the Withdrawal/ Retardation factor. These measures accounted for more than 70% of the variance on the cue perception task.

How does the matrix of correlations between cue perception and information processing in this study compare to the associations between social skills learning and information processing found in previous research (Kern et al., 1992; Corrigan et al., 1994)? The most consistent finding previously has been the independent association between verbal recall memory and social skills learning. In this study, cue perception was found to be significantly related to recognition memory and, to a lesser extent, recall memory; recall memory and recognition memory as measured on the RAVLT were shown to be significantly intercorrelated.

Findings from earlier studies have been mixed about the relationship between early processing functions and skill learning (Corrigan et al., 1994; Bowen et al., in

148

press). A measure of early visual processing (the SPAN) was found in this study to be significantly associated with sensitivity on the social cue perception task. Our results may be explained by the requirements of the cue perception and information- processing tasks: the SPAN assesses input and scanning deficits, which conceivably would be required for cue perception. General measures of skill learning may require more integrative cognitive functions like verbal memory.

The correlation matrix between cue perception and psychiatric symptoms is similar to the associations between skill learning and symptoms. Withdrawal/ Retardation was negatively associated with cue perception in this study and skill learning in previous research (Bellack et al., 1989). One might surmise that the significant association with negative symptoms may represent the deleterious effects of impoverished thought processes that correspond to negative symptoms; patients with negative symptoms may miss many of the cues presented in an interpersonal situation. However, examination of the pattern of correlations between the measures showed that SCRT false alarm rates, but not hit rates, were significantly associated with symptoms and processing variables. Hence, information-processing deficits and negative symptoms may diminish patients’ sensitivity to social cues such that they mistakenly identify absent cues as being present.

Although sensitivity was associated with the BPRS Withdrawal/ Retardation factor, the false alarm rate was more strongly associated with psychotic symptoms. Research that has examined the relationships between information processing and positive and negative symptoms has implications for the understanding of this fairly complex pattern of association. Negative symptoms have been associated with deficits on tasks with large visuomotor demands, whereas positive symptoms have been associated with deficits in measures of verbal memory (Green and Walker, 1985; Mayer et al., 1985). Social cue sensitivity was found in this study to be associated with verbal memory as well as visuomotor demands (i.e., the SPAN). Given the combination of cognitive mechanisms involved with SCRT perfor- mance, it is probably unreasonable to expect associations with only one symptom dimension.

The use of relatively specific information tests allows us to speculate on possible neuroanatomical substrates for social cue recognition. For example, the DSDT, an SCRT correlate, can be considered a type of verbal working memory test (Park and Holzman, 1992) because it requires the subject to hold an auditory representation in memory for a short time and to constantly update the representation with each trial. Working memory has been linked to the inferior regions of the prefrontal cortex in nonhuman primates (Wilson et al., 1993). The critical circuit in an auditory working memory task probably involves the superior regions of the temporal cortex as well as the prefrontal cortex. The use of such cognitive measures, in combination with imaging techniques, may provide a means to determine the neuroanatomical sub- strates involved in processing social information.

Findings from the current study substantiate the benefits of using a signal detec- tion paradigm in data analysis. Although sensitivity on cue perception was found to correlate with information-processing deficits and psychiatric symptoms, hit rate did not correlate significantly with any measure. It might have been concluded, on the

149

basis of hit rate alone, that cue perception was not related to the cognitive deficits of schizophrenia. False alarm rate was similar to sensitivity in its pattern of

interrelationships. Findings from this study may have implications for future research into the

development of rehabilitation programs that attempt to improve social-perceptual deficits (Green, 1993). For example, cognitive rehabilitation strategies might target deficits in early visual processing and recognition memory to enhance social cue recognition. Koh et al. (1976) were able to improve the recognition memory of schizophrenic patients on laboratory-based tasks by using a semantic elaboration technique. Preliminary research by our group led to significant improvement of SCRT scores of schizophrenic patients through the use of a variation of the semantic elaboration method of Koh et al. (1976) that was adapted to the social situation (e.g., “Describe the situation in your own words”) (Nugent-Hirschbeck et al., 1993). Wallace (1982) proposed that cue perception was the first step in more complex skill learning and social functioning. Therefore, enhancing patients’ cue perception may yield secondary rehabilitation effects.

Acknowledgments. The authors thank Sally MacKain, Patty Parlier-Cook, and Daniel Storzbach for help in data collection. The sample was obtained through the excellent coopera- tion of the staff and administration of Camarillo State Hospital. Funding for this project came from a grant from the National Institute of Mental Health (NIMH) to Dr. Green (MH-43292). Diagnostic training and symptom assessment were supported by NIMH Clinical Research Grant MH-30911 (R.P. Liberman, principal investigator). The software for the Continuous Performance Test and the Span of Apprehension was developed by Drs. Keith Nuechterlein and Robert Asarnow with support from the John D. and Catherine T. MacArthur Founda- tion Network for Risk and Protective factors in Major Mental Disorders.

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