www.elsevier.com/locate/psychres

Psychiatry Research 1

Cognitive functions related to interpersonal problem-solving skills

in schizophrenic patients compared with healthy subjects

Adriano Zanello *, Lisa Perrig, Philippe Huguelet

Departement de Psychiatrie, Hopitaux Universitaires de Geneve, 8, rue du XXXI Decembre, 1207 Geneve, Switzerland

Received 28 March 2002; received in revised form 25 April 2003; accepted 25 July 2003

Abstract

Subjects with schizophrenia have cognitive alterations. The functional consequences of these deficits need to be fully

determined, in order to implement more effective rehabilitation programs for patients with schizophrenia. This research explores

the relationships between cognitive functioning and social problem-solving skills in a group of 20 chronic schizophrenic

patients compared with those found in a group of 20 healthy subjects. The following cognitive domains were evaluated: verbal

memory (Rey Auditory-Verbal Test; RAVLT), visuo-spatial organization and visuo-spatial memory (Rey-Osterrieth complex

figure test; RF), executive functioning (semantic verbal fluency test; VF, design fluency task; DF and Wisconsin Card Sorting

Test; WCST), attention (d 2 cancellation test) and general intellectual ability (Standard Progressive Matrices of Raven; SPM).

Social problem-solving skills were assessed with a video-based test; the Assessment of Interpersonal Problem-Solving Skills

(AIPSS). As a group, patients performed significantly worse than control subjects on every cognitive variable and on AIPSS

receiving, processing and sending constructs. Among schizophrenic patients, correlations between AIPSS constructs and

neuropsychological tests were observed for VF, DF, d2 and SPM whilst these associations were not replicated in healthy

subjects. However, in the whole sample, after adjusting for age, gender and education, SPM displayed significant associations

with all three AIPSS constructs. Moreover, after taking SPM into account, neither diagnostic groups (patients versus control)

nor cognitive variables, except d2, provided an additional contribution to AIPSS performance. Cognitive impaired perfor-

mances, mainly frontal, have a deleterious effect on social problem-solving skills in the schizophrenic group. It is suggested that

alterations in social problem-solving skills may reflect social anxiety and/or b theory of mind Q impairment. These factors may

explain the lack of association among healthy subjects. The results support the inclusion of cognitive remediation programs

designed to enhance social skills for patients where a cognitive deficit is clearly ascertained.

D 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Schizophrenia; Neuropsychology; Social problem solving; AIPSS

0165-1781/$ - s

doi:10.1016/j.ps

* Correspondi

E-mail addre

42 (2006) 67–78

ee front matter D 2005 Elsevier Ireland Ltd. All rights reserved.

ychres.2003.07.009

ng author. Tel.: +41 22/718 45 11; fax: +41 22/718 45 99.

ss: adriano.zanello@hcuge.ch (A. Zanello).

A. Zanello et al. / Psychiatry Research 142 (2006) 67–7868

1. Introduction

Cognitive and social problem-solving (SPS)

impairments are common characteristics in patients

with schizophrenia. Still, the precise link between

these two domains is not clearly understood (Bellack

et al., 1999). Answering this question could help not

only to improve current cognitive and social skills

rehabilitation treatments (Bellack et al., 1994, 1999)

but also to determine the suitability of these treat-

ments for patients affected by different sub-types of

schizophrenia.

1.1. Neuropsychological and social skills impairments

Clinical and experimental neuropsychological find-

ings accumulated over many decades support the

hypothesis that schizophrenia is characterized by a

broad range of heterogeneous cognitive impairments

that vary in their magnitude (Nuechterlein and Daw-

son, 1984; Braff, 1993; Goldberg and Gold, 1995;

Gold and Harvey, 1993; Heinrichs and Zakzanis,

1998). Abnormalities are particularly obvious in the

following cognitive domains: attention (Mirsky,

1988), memory (Saykin et al., 1991) and executive

functions (Braff et al., 1991). Association between

neuropsychological deficits and specific morphologi-

cal and functional alterations support the involvement

of a frontal-temporal dysfunction in schizophrenic

patients (Weinberger et al., 1992). Cognitive impair-

ment is considered as a brate-limiting factorQ (Green,1993). It restricts general community outcome func-

tioning, specific SPS skills, and remediation or acqui-

sition of skills (Green, 1996). Community outcome

functioning is related to interpersonal SPS skills (Sul-

livan et al., 1990). These latter are generally examined

by standardized videotaped tasks. Several instruments

have been developed to evaluate social skills, e.g.,

Mean-Ends Problem Solving (Platt and Spivack,

1972), Assessment of Interpersonal Problem Solving

Skills (Donahoe et al., 1990), the Social Problem

Solving Assessment Battery (Bellack et al., 1994),

the Structured Role Play Test (Ikebuchi et al., 1996)

and the Conversation Probe Role Tests (Penn et al.,

1995). Such tests consist generally of a brief proble-

matic social interaction, which has to be identified,

solved and enacted. The AIPSS is one of the most

commonly used paradigms (Green et al., 2000). It is

based on a Receiving–Processing–Sending (RPS) SPS

model (Wallace et al., 1980). To our knowledge, six

studies have tried to determine whether the AIPSS

RPS constructs or the scale on which they rely are

related to cognitive impairment in schizophrenic

patients.

1.2. AIPSS studies

AIPSS studies have examined the relationships

between various cognitive functions and SPS skills.

Some studies found that certain AIPSS constructs or

sub-scales were associated with visual or auditory

attention measures (Bowen et al., 1994; Addington

et al., 1998; Addington and Addington, 2000), execu-

tive functioning tests (Addington et al., 1998; Adding-

ton and Addington, 1999, 2000), organization and

visuo-spatial memory (Addington and Addington,

1999) and verbal memory aspects, such as recogni-

tion, verbal learning, and memory for prose passages

(Corrigan and Toomey, 1995; Addington and Adding-

ton, 1999, 2000). However, other studies using the

same or different cognitive measures did not confirm

these associations. Attention (Corrigan and Toomey,

1995; Addington and Addington, 1999), executive

functioning (Addington and Addington, 1999, 2000;

Corrigan and Toomey, 1995; Addington et al., 1998),

visual organisation and visuo-spatial memory

(Addington et al., 1998; Addington and Addington,

2000) and verbal memory (Bowen et al., 1994; Corri-

gan and Toomey, 1995; Addington et al., 1998) were

not found to be related to AIPSS. Estimated intelli-

gence quotient (IQ) or indicators of premorbid IQ

(e.g., verbal ability as measured by Vocabulary, Infor-

mation, Comprehension or Similarities subtests of the

Wechsler Adult Intelligence Scale-Revised; WAIS-R)

were found to be significantly associated with AIPSS

constructs, mainly processing and sending skills

(Donahoe et al., 1990; Addington et al., 1998;

Addington and Addington, 1999, 2000).

Some of these studies also considered patients’

psychiatric symptoms. The Positive and Negative

Syndrome Scale (PANSS; Kay et al., 1987) has

been significantly correlated with all AIPSS con-

structs (Addington and Addington, 1999, 2000).

Such findings challenge the negative results found

with the positive and negative factors of the Brief

Psychiatric Rating Scale (Corrigan and Toomey,

A. Zanello et al. / Psychiatry Research 142 (2006) 67–78 69

1995). In the later study, only positive symptoms were

correlated with bprocessingQ skills.Altogether, it remains unclear which specific cog-

nitive functions and/or psychiatric symptoms alter

AIPSS performances in schizophrenic patients.

Furthermore, whether healthy subjects’ cognitive

functioning is also related to a specific SPS construct

is still to be determined. If poor SPS skills are

related to cognitive impairment, as found in schizo-

phrenic patients, one could conversely argue that

higher cognitive functioning may be related to higher

SPS skills as one might expect in healthy subjects.

None of the bAIPSS studiesQ reviewed above and

including a non-patients group (e.g., Bowen et al.,

1995; Donahoe et al., 1990) have considered this

issue. A better knowledge of this relationship could

also contribute in defining possible targets of reha-

bilitation for schizophrenic patients and avoid

emphasizing the remediation of a cognitive function

that does not contribute to the SPS difficulties of

schizophrenic patients.

This study was undertaken to explore these ques-

tions. First, we examined which specific cognitive

functions were altered and related to interpersonal

problem-solving skills in a group of chronic schizo-

phrenic outpatients compared with a control group of

healthy matched subjects. Secondly, we explored

which symptoms or demographic variables explained

the differences found in the patients group.

2. Methods

2.1. Subjects

A total of 40 subjects divided into two demogra-

phically comparable groups participated in this study:

a group of patients diagnosed with schizophrenia and

a group of healthy subjects.

2.1.1. Patients group

All schizophrenic patients were recruited before

participating in the Integrated Psychological Treatment

(IPT; Brenner et al., 1994). Twenty stable outpatients

(10 Females; 10 Males), 23–44 years-old, with a

diagnosis of schizophrenic disorder were included.

Patients’ schizophrenia subtypes, as defined by DSM-

IV (American Pyschiatric Association, 1994) were dis-

organized (295.1, n =3), paranoid (295.3, n =9), undif-

ferentiated (295.9, n =2), residual (295.6, n =2) and

schizoaffective (295.7, n =4). Diagnoses were made

by at least two clinicians, i.e., a ward psychiatrist and

a senior psychiatrist, following reviews of medical

records, interviews with the patients and an extended

period of clinical observation. Exclusion criteria were

another primary diagnosis other than schizophrenia or

schizoaffective disorder, duration of illness of less

than 2 years since the first admission, evidence of

current or past abuse of or dependence on drugs or

alcohol, neurological illness, an acute medical illness,

mental retardation, age under 18 or above 60, or an

absence of social skills impairments as subjectively

expressed by patients or as clinically observed by their

physician. All but two patients were treated with

neuroleptics. The doses of neuroleptics were con-

verted into equivalent doses of chlorpromazine milli-

grams per day (Calanca et al., 1997). The average

chlorpromazine-equivalent antipsychotic dose was

168 mg/day (S.D.=146.47 mg). Length of illness

was defined as the duration since the first admission

to an inpatient psychiatric unit; average duration was

99 months (S.D.=74.42). First psychiatric admission

occurred on average at 24 years (S.D.=4.7). Mean

number of hospitalizations was 5.0 (S.D.=5.63; range:

1 to 9). Most patients were single (N =16; 80%), one

was married, and three were divorced. A large propor-

tion of patients benefited from financial assistance

(N =18; 90%). Educational level was stratified into

low (9–13 years; n =15) and high (N13 years; n =5)

education groups.

2.1.2. Healthy control group

Twenty healthy subjects (11 females, 9 males, age

range: 23–51) were recruited for comparison by per-

sonal contact among staff members not involved in

the IPT program (n=10) or among friends of the

researchers (n=10). Educational level was stratified

as low (9–13 years; n =9) and high (N 13 years;

n=11). Exclusion criteria were a history of mental

illness, evidence of current or past drug or alcohol

abuse or dependence, neurological illness, an acute

medical illness, mental retardation, age under 18 or

above 60, or the presence of social skills complaints

or social anxiety as expressed by subjects. None of

them had a first-degree relative with schizophrenia or

any other psychiatric disease.

A. Zanello et al. / Psychiatry Research 142 (2006) 67–7870

All subjects had a good understanding of spoken

and written French. This study was approved by the

ethical committee of the Department of Psychiatry of

Geneva. All subjects gave their written informed con-

sent before their inclusion in the study. Clinical and

demographic characteristics of the two groups are

shown in Table 1. Preliminary statistical analysis con-

firmed that the two groups were statistically compar-

able for age, gender and educational level.

2.2. Cognitive assessment

We selected some of the tests to compare our results

with those from previous studies, and added some

others to explore other possible relationships bet-

ween cognitive functioning and interpersonal problem-

solving skills. Neuropsychological tests addressed the

following functions:

2.2.1. Verbal memory

The Rey Auditory-Verbal Test (RAVLT; Rey, 1964)

was used to assess: i) verbal learning (total of words):

the examiner reads aloud a list of 15 common words

to the subjects; then the subjects have to recall the

words they remember (RAVLT learning). This proce-

dure is repeated five times (minimum=0, maxi-

mum=75) and ii) verbal delayed recall (RAVLT

delayed recall): after a 45-min delay, each patient is

required to recall again the words of the list (mini-

mum=0, maximum=15).

2.2.2. Visuo-spatial organization and visuo-spatial

memory

In the Rey-Osterrieth complex figure test (RF; Rey,

1959), subjects are first required to copy the complex

figure and then, without prior notice, to reproduce it

Table 1

Sociodemographic characteristics of the sample

Characteristics Schizophrenic

patients (n =20)

Healthy subjects

(n =20)

Age, mean (S.D.)* 32.6 (5.6) 33.8 (9.5)

Gender (M/F)** 10/10 11/9

Education***: 9–13 years 15 9

N13 years 5 11

*Student t-test, t =�0.49, df =30.8, P=0.63.

** Fisher Exact test, P=1.00.

*** Fisher Exact test, P=0.11.

without access to the original, immediately and then

after a lapse of 45 min. Three measures are derived: i)

the accuracy score of copy for the visuo-spatial skills

(RF copy), ii) visual memory immediate (RF immedi-

ate recall) and iii) visual memory delayed (RF delayed

recall). The scores of these variables vary from 0

(minimum) to 36 (maximum). Scoring was done fol-

lowing Rey’s criteria (Rey, 1959).

2.2.3. Executive functioning

The semantic verbal fluency test (VF) and the

design fluency task (DF) and Wisconsin Card Sorting

Test (WCST) were used to assess executive function.

In the VF test, subjects are told to generate in 60 s as

many words as possible belonging to the semantic

category of animals (Thuillard and Assal, 1991). In

the DF test, subjects are asked to produce a maximum

of different non-sense shaped drawings without repe-

tition, in 5 min (Jones-Gotman and Milner, 1977;

Thuillard and Assal, 1991). The WCST (Heaton et

al., 1993) assesses cognitive flexibility. Patients are

required to sort 128 cards according to one of three

dimensions (colour, shape, number) of stimuli. Sub-

jects are not aware of the current classification criteria

and have to discover it. After 10 correct responses, the

examiner changes the criterion without informing the

subject, who has to discover the new classification

criteria according to the feedback given by the exam-

iner. The test ends when the subjects have classified

all 128 cards or when they have completed six correct

series. As the number of cards to achieve the test

varied among subjects, the percentage of persevera-

tive answers was considered as the main variable.

WSCT was administered by hand.

2.2.4. Attention

Was assessed with the d2 test (Brickenkamp,

1978), which is a letter cancellation paper-and-pencil

test composed of 14 lines of 47 letters each. Subjects

are asked to slash out as many targets as they can

among distracters in 4V40W (20W for each line). The

target letter is bdQ with two marks above, two marks

below or one mark above and one below. The total

number of correct cancellations is computed.

2.2.5. General intellectual ability

Intellectual ability was evaluated with the Standard

Progressive Matrices (SPM; Raven, 1956), in its short

A. Zanello et al. / Psychiatry Research 142 (2006) 67–78 71

form version (Thuillard and Assal, 1991). The SPM

comprises 30 items, each of them showing a pattern

problem in which one part is removed. Subjects have

to choose one correct answer among six to eight

alternatives. As the SPM score is correlated with

conventional batteries such as the Wechsler/Adult

Intelligence Scale (Spreen and Strauss, 1991), it

gives an estimate of non-verbal current bIQQ.

2.3. Social problem solving assessment

Social problem-solving skills were assessed with the

French adaptation of the AIPSS (Donahoe et al., 1990;

Favrod and Lebigre, 1995). The AIPSS is based on the

conceptual Receiving, Processing and Sending model

of social skills (Wallace et al., 1980). In this model,

the Receiving construct includes bidentificationQ andbdescription (of the problem)Q. The Processing con-

struct includes the bprocessingQ score, and the Sendingconstruct is composed of bcontentQ, bperformanceQ andboverallQ scores (all measuring the effectiveness of the

response). The AIPSS is composed of 14 short video-

taped interpersonal interactions. First, a practice scene

is presented as many times as necessary. Then, the 13

test scenes are presented once. Ten scenes reflect a

problematic social situation between two actors, where

one obstructs the other in achieving his goal (e.g., a

person has to deal with a friend who insists on offering

alcoholic drinks to him). Three scenes are problem free

(e.g., two friends playing cards). Subjects are told to

identify with one of the actors, and after viewing the

scene, subjects are questioned from the perspective of

that actor. The following scales are assessed: 1) Iden-

tification. Patients answer the question bIs there a

problem in the scene ?Q; responses (YES or NO) are

scored 0 if incorrect or 1 if correct. 2) Description.

Patients are asked to explain the problem to the exam-

iner. Answers are scored 2 if the patient correctly

identifies the goal and the obstacle to reach it, 1 if

only the goal or the obstacle is identified, and 0 if

neither the goal nor the obstacle is identified. 3) Pro-

cessing. Patients describe what they would say and/or

do if they were in the place of the actor they must

identify with. Solutions are scored 2 if they reach the

goal (best solution), 1 if they have a substantial chance

to reach the goal, or 0 if they bring negative conse-

quences or cannot allow the patient to reach the goal.

Then subjects have to enact their solution in a short

role play with the examiner. The role play is scored 4)

for content (did the answer solve the problem ?), 5) for

performance (eye contact, posture, and volume, tone

pitch (of voice) . . .appropriate ?) and 6) for overall

quality of content and performance (did the response

solve the problem ?). These last three skills are rated

on a same scale, from 0 to 2 (best score) with 0.5

increment. The responses and role plays were video-

recorded for later scoring. AIPSS French version has

adequate psychometric properties (D’Abbraccio and

Siegrist, 1996). For this study, each skill expresses

the percentage of social appropriateness of answers.

This was calculated by summing the scene scores

before dividing it by the highest score possible for

that construct.

2.4. Clinical assessment

Psychiatric symptoms were assessed in the patients

group using the Brief Psychiatric Rating Scale

(BPRS; Overall and Gorham, 1962). Two summary

scores were considered: 1) BPRS negative symptoms

(or withdrawal/retardation factor) representing the

sum of bEmotional WithdrawalQ, bMotor RetardationQand bBlunted affectQ and 2) BPRS positive symptoms

(or thinking disturbance factor) obtained adding the

scores of bConceptual DisorganizationQ, bHallucinatoryBehaviorQ and bUnusual Thought ContentQ (Nichol-

son et al., 1995; Corrigan and Toomey, 1995). BPRS

symptoms were assessed by a clinician following the

criteria for the BPRS expanded version (Lukoff et al.,

1986). Interrater reliability was first trained in an

independent sample of at least four subjects. Each

BPRS symptom was discussed until raters showed

no more than a 1-point difference.

2.5. Procedure

All assessments were completed within 2 weeks.

Patients were administered cognitive and clinical test-

ing in two to four sessions of about 1 hour each.

Healthy subjects’ psychiatric screening interviews

and cognitive assessments were partitioned into sev-

eral sessions, arranged according to their individual

needs. For all subjects, the AIPSS was carried out in

one session lasting about 45 to 60 min. Several

research assistants and a trained neuropsychologist

administered the cognitive and clinical assessments.

Table 2

Neuropsychological performances

Neuropsychological

tests

Schizophrenic

patients

(n =20)

Healthy

subjects

(n =20)

P

Mean S.D. Mean S.D.

Visuospatial organization

RF copy 32.5 (3.8) 35.2 (0.9) 0.004*

Visuospatial memory

RF immediate recall 17.5 (6) 27.3 (4) 0.000*

RF delayed recall 15.2 (6.5) 26.4 (4.4) 0.000*

Verbal memory

RAVLT learning (trials

1 to 5)

48.8 (11.7) 64.1 (5.7) 0.000*

RAVLT delayed recall 10.9 (3.6) 14 (1.5) 0.005*

Executive functioning

VF 15.6 (5.1) 19.8 (3.0) 0.004*

DF 12.0 (6.0) 24.8 (13.3) 0.001*

WSCT (% perseverative

errors)

13.5 (8.0) 8.7 (3.5) 0.02*

Attention

d2 correct cancellations 273.9 (81.9) 461.6 (64.2) 0.000*

Global intellectual ability

SPM 20.0 (4.4) 25.8 (2.4) 0.000*

AIPSS

Receiving skills (%) 76.7 (15.6) 86.7 (9.8) 0.02*

Processing skills (%) 40.7 (23.9) 64.3 (17.5) 0.001*

Sending skills (%) 41.7 (23.6) 72.5 (15.9) 0.000*

S.D.: standard deviation, RAVLT: Rey Auditory Verbal Learning

Test, RF: Rey-Osterrieth Complex Figure, VF: Verbal fluency, DF:

Design Fluency, WCST: Wisconsin Card Sorting Test, d2 encum-

brance test, SPM: Standard Progressive Matrices 1938, AIPSS:

Assessment of Interpersonal Problem-Solving Skills.

*P b0.05 with Bonferroni layering method correction. Student t-test

separate variance was used for comparison.

A. Zanello et al. / Psychiatry Research 142 (2006) 67–7872

Current psychiatric symptoms in the patients were

assessed immediately before neuropsychological

assessment. A therapist, expert in social skills assess-

ment, administered the AIPSS. All subjects’ responses

were videotaped for later scoring and determination of

interrater reliability. Videotapes were evaluated by

three independent judges (i.e., the AIPSS examiner

and two members of the staff of the rehabilitation

program). To avoid any possible interference with

AIPSS ratings, they were blind to clinical or neurop-

sychological results. AIPSS assessments and scoring

were done according to the French adaptation (Favrod

and Lebigre, 1995) of the manual of instructions

(Donahoe et al., 1990). Interrater agreement among

the three raters on the AIPSS was calculated with the

intraclass correlation coefficient. High reliabilities

were found for each AIPSS construct: 0.93 for the

Receiving, 0.90 for Processing and 0.95 for Sending

constructs. Findings on AIPSS constructs presented in

Table 2 are the means for the three raters.

Categorical variables were analyzed by the Fisher

exact test. For continuous variables, comparisons

between groups were carried out by Student t-test

for independent samples that adjusted the degrees of

freedom for unequal variances. All correlations be-

tween continuous variables were calculated by Pear-

son product-moment correlation coefficients. Multiple

regression analyses were performed with scores on

Receiving, Processing and Sending AIPSS constructs

as dependent variables. Age, gender, educational level

and Standard Progressive Matrices (SPM) were forced

into the model, whereas diagnostic group and cogni-

tive measures (VF, DF, WCST, RAVLT learning,

RAVLT delayed recall, RF copy, RF recall, RF

delayed recall and d2) were entered in a stepwise

manner. The significance level was set at 0.05.

To reduce the risk of type I error, the statistical

significance of a test was defined according to the

Bonferroni layering method at PV0.05, which is

less conservative than the usual Bonferroni correc-

tion. In the Bonferroni layering method, the cor-

rected significance level is obtained by successive

layered multiplications. Firstly, a factor of correc-

tion (FC) is derived; this FC corresponds to the

number of comparisons made. Then the P of the

most significant result is multiplied by the FC,

followed by the P of the second most significant

result, which is multiplied by the FC�1 and so on

until this product remains inferior to 0.05 (Darling-

ton, 1990). Statistical analysis were computed using

SYSTAT (1992).

3. Results

The first set of analyses aimed at selecting the

neuropsychological variables and AIPSS constructs

that differentiated patients from healthy controls. In

the second set, we looked at the relationships between

A. Zanello et al. / Psychiatry Research 142 (2006) 67–78 73

these significant variables in the two groups of sub-

jects. In the third set, we calculated whether signifi-

cant relationships were larger in one group than in the

other. In the fourth set, we examined, independently,

the specific relationship between demographic vari-

ables, neuropsychological variables and BPRS symp-

toms and AIPSS constructs in the patients. Finally, in

the last set, we re-examined the data performing step-

wise multiple linear regression analysis (general linear

model procedure).

3.1. Group comparisons

As presented in Table 2, subjects with schizophre-

nia performed worse than healthy control subjects on

all neuropsychological measures. Differences between

the two groups were analyzed separately for each

AIPSS construct. Patients scored significantly lower

than healthy subjects on all constructs. All neuropsy-

chological tests and AIPSS constructs were included

in the correlation analysis, as they met the Bonferroni

layering method criteria.

Table 3

Correlations between AIPSS constructs and neuropsychological scores

AIPSS constructs Schizophrenic patients (n =20)

Receiving Processing

Visual organization

RF copy 0.17 0.16

Visual memory

RF immediate recall 0.07 0.16

RF delayed recall 0.15 0.14

Verbal memory

RAVLT learning 0.12 0.27

RAVLT delayed recall 0.21 0.28

Attention

d2 0.16 0.58*

Executive functioning

VF 0.04 0.35

DF 0.43 0.45*

WCST (perseverative errors) �0.39 �0.27

Global intellectual ability

SPM 0.40 0.39

RAVLT: Rey Auditory Verbal Learning Test, RF: Rey-Osterrieth Complex F

Card Sorting Test, SPM: Standard Progressive Matrices 1938, AIPSS: As

*P b0.05, without correction for multiple comparison.

3.2. Correlation analysis in both groups

As shown in Table 3, in the patients, attention (d2)

was associated with Processing and Sending skills,

VF with Sending skills, DF with Processing skills and

the SPM with Sending. None of these associations

met the Bonferroni correction criteria. In the healthy

control group, none of the interrelationships were

statistically significant.

3.3. Between-group comparisons of the significant

correlations

Coefficients of correlation representing the signifi-

cant associations between d2, VF, DF and SPM and

Processing and Sending skills performance were

transformed in z using Fisher transformation before

comparison between the two groups using the formula

z= zr1� zr2 /0.5 (1 /n1�3)+ (1 /n2�3) (Table 4).

The relationships between DF and Processing

(P=0.008) as well as between SPM and Sending

skills (P=0.005) were significantly different between

Healthy subjects (n =20)

Sending Receiving Processing Sending

0.29 �0.19 �0.22 �0.21

0.20 �0.24 �0.15 �0.140.36 �0.19 0.10 �0.10

0.34 0.33 0.30 0.24

0.38 0.06 0.42 0.20

0.48* 0.24 0.00 0.21

0.44* �0.06 0.05 �0.040.39 0.11 �0.39 �0.42�0.42 �0.14 �0.07 0.00

0.60* �0.13 �0.13 �0.26igure, DF: Design Fluency, d2 encumbrance test, WSCT: Wisconsin

sessment of Interpersonal Problem-Solving Skills.

Table 4

Group comparison of the significant coefficients of correlation

Neurocognitive and

AIPSS associations

Schizophrenic

patients (n =20)

Healthy

patients

(n =20)

z2 P

zr1 zr2

d2 and Processing 0.66 0 3.73 0.052

and Sending 0.53 0.21 0.81 0.33

VF and Sending 0.47 �0.04 2.23 0.13

DF and Processing 0.49 �0.41 6.83 0.008*

SPM and Sending 0.69 �0.27 7.82 0.005*

AIPSS: Assessment of Interpersonal Problem-Solving Skills, zr1:

Fisher transformation r to z in the patients group, zr2: Fisher

transformation r to z in the healthy control group, d2 encumbrance

test, VF: Verbal Fluency, DF: Design Fluency, SPM 38: Standard

Progressive Matrices 1938.

*P b0.05 with Bonferroni layering method correction.

Table 5

BPRS scores and correlations with AIPSS constructs in the patients

BPRS Mean S.D. Schizophrenic patients (n =20)

AIPSS constructs

Receiving Processing Sending

- Negative 6.6 (2.9) �0.61** �0.47* �0.63**- Positive 5.4 (2.9) �0.51* �0.20 �0.28S.D.: standard deviation, AIPSS: Assessment of Interpersonal Pro-

blem-Solving Skills, BPRS: Brief Psychiatric Rating Scale negative

symptoms (or withdrawal/retardation factor) and positive symptoms

(or thinking disturbance factor).

*P b0.05, without correction for multiple comparison, **significant

value after Bonferroni layering method correction.

A. Zanello et al. / Psychiatry Research 142 (2006) 67–7874

the two groups, whilst the associations between d2

and Processing were not significant. After correction

for multiple comparisons, the differences found in the

two groups remained significant.

3.4. Correlations between demographic, neuropsy-

chological, symptoms variables and AIPSS constructs

in the patients

No significant correlation was found between

demographic variables (age, illness duration, antipsy-

chotic dosage), neuropsychological measures and

AIPSS constructs. The highest correlation found was

between illness duration and AIPSS Processing skills

(r=�0.36, P=0.12). However, as shown in Table 5,

the BPRS negative symptoms score was related to the

three constructs, whilst the BPRS positive symptoms

score was only associated with the Receiving scores.

The association between negative symptoms and

Receiving skills and Sending skills met the Bonferroni

criteria. Negative symptoms were not significantly

related to performance on any of the neuropsychologi-

cal tests. The highest correlation was found for WSCT

perseveration responses (r=0.37, P=0.10). The posi-

tive score was related to DF (r =�0.51, P=0.02), butthis correlation did not met the Bonferroni criterion.

3.5. Multiple regression analyses

The significant difference between groups on glo-

bal intellectual ability led us to reanalyze AIPSS

constructs as a function of diagnostic group (patients

and healthy controls) and neuropsychological mea-

sures, after controlling for socio-demographic vari-

ables (age, gender and educational level) and taking

into account SPM score.

After adjusting for age, gender and education, SPM

displayed a significant association with all three

AIPSS constructs. It contributed to increase the frac-

tion of explained variation (R2) by 26% for the

Receiving skill score (F1,35=13.1, P b0.001), with a

0.52 partial correlation coefficient. For the Processing

skill score, R2 increased by 17% (F1,35=9.5, P b0.01)

and the partial correlation coefficient was 0.46. For

the Sending skill score, SPM contributed to a 43% R2

increase (F1,35=38.0, P b0.001) and the partial cor-

relation was 0.72. After taking SPM into account,

neither diagnostic group nor any of the cognitive

measures made a significant additional contribution

for Receiving and Sending skills. However, d2 dis-

played a significant 0.37 partial correlation with Pro-

cessing skills (F1,34=5.3, P b0.05).

4. Discussion

In the present study, we compared the relationships

between chronic schizophrenic outpatients’ cognitive

functioning and their interpersonal problem-solving

skills with those of healthy control subjects, the two

groups being statistically comparable for age, gender

and educational level. The aim was to examine which

cognitive processes are critical determinants of social

competence. Another issue was to analyze the rela-

A. Zanello et al. / Psychiatry Research 142 (2006) 67–78 75

tions between demographic variables, psychiatric

symptoms and social skills in chronic schizophrenia.

Schizophrenic patients performed worse than

healthy controls in all cognitive domains that we

considered. These findings are in agreement with the

studies reporting that chronic schizophrenic patients

have a diffuse and general cognitive impairment

(Kolb and Whishaw, 1983; Braff et al., 1991; Heaton

et al., 1994). However, we found that the neuropsy-

chological performance of the patients was not related

to demographic variables or BPRS factors, which it is

in agreement with some studies (Heaton et al., 1994;

Corrigan and Toomey, 1995) but not with others that

found an association between psychiatric symptoms

or illness duration and cognitive disturbances (e.g.,

Cuesta et al., 1998; Basso et al., 1998; Addington and

Addington, 1999, 2000).

Schizophrenic patients were less competent than

healthy subjects on the AIPSS Receiving, Processing

and Sending constructs. These results replicate find-

ings of previous AIPSS studies comparing inpatients

or outpatients with healthy controls (Donahoe et al.,

1990; Bowen et al., 1994). According to other authors

(Bowen et al., 1994; Corrigan and Toomey, 1995;

Ikebuchi et al., 1996), none of the variables examined

(age, illness duration, antipsychotic dosage) were

associated with SPS constructs. Whereas BPRS posi-

tive symptoms were only significantly related to

Receiving skills, BPRS negative symptoms were sig-

nificantly associated with all AIPSS constructs. The

relationships between BPRS negative symptoms and

Receiving and Sending skills were fairly robust as

both associations met the Bonferroni criteria. Thus,

it appears that patients with high negative symptoms

exhibit more SPS impairments. These findings are

consistent with those reported in other studies

(Addington and Addington, 1999, 2000), whereas

others suggest a lack of relation between psychiatric

symptoms and SPS skills (Bellack et al., 1994; Corri-

gan and Toomey, 1995; Ikebuchi et al., 1996). Such

discrepancy may reflect the heterogeneity of the scales

used to measure symptoms among studies.

The association between cognitive performances

and AIPSS constructs was calculated in both groups.

In the patients group, cognitive performances were

particularly associated with late and more complex

stages of the SPS process, i.e., Processing and Send-

ing skills. DF and VF correlated, respectively, with

Processing and Sending skills, suggesting that at least

some executive functions are related to SPS. Sus-

tained attention, as reflected by the d2 encumbrance

test, was positively correlated to Processing and Send-

ing skills. Intellectual global functioning (SPM) was

positively related to Sending skills, indicating that

poor general intellectual abilities determine low social

competence. Such an association could not be attrib-

uted to mental retardation as our patients performed

on the SPM in the normal range when compared with

larger samples (Thuillard and Assal, 1991). Such

results are in accordance with some research relating

SPS to executive functioning (Addington et al., 1998),

vigilance (Bowen et al., 1994; Penn et al., 1995;

Ikebuchi et al., 1999; Addington and Addington,

2000) and IQ measures (Donahoe et al., 1990; Bellack

et al., 1994; Ikebuchi et al., 1996; Addington et al.,

1998; Addington and Addington, 1999, 2000). None-

theless, no significant relationships were found

between verbal, visual memory or visual organization

and AIPSS constructs, as was reported by Addington

et al. (1998). These results are quite surprising, as one

would expect memory impairment to impede main-

taining initial received information and thus interferes

with Processing and Sending skills required to gen-

erate social solutions. Discrepancies with previous

reports (Bellack et al., 1994; Mueser et al., 1995;

Corrigan and Toomey, 1995; Addington and Adding-

ton, 1999, 2000) that demonstrated an association

between memory performances and SPS could be

explained either by variables like sample composition

(i.e., inpatients or outpatients, gender or age differ-

ences among samples), dose of antipsychotic medica-

tions or use of different cognitive assessments and

measures. Cognitive flexibility (WCST perseverative

errors) was not associated with SPS even though

patients presented significantly higher scores of per-

severation than nonpatients. This result is in accor-

dance with previous findings (Penn et al., 1995;

Corrigan and Toomey, 1995; Addington et al.,

1998). For healthy subjects, cognitive performances

were not associated with any SPS skills. A similar

result was reported previously by Penn et al. (1993). It

was interpreted as the expression of a relative inde-

pendence of the cognitive and social domains, as well

as a consequence of the btwisted pearQ phenomenon,

that is, a test predicts deviant more functioning effi-

ciently than normative functioning, e.g., as the AIPSS

A. Zanello et al. / Psychiatry Research 142 (2006) 67–7876

elicits interpersonal situations where outpatients have

difficulties but not healthy subjects; for the latter, a

possible ceiling effect in the AIPSS could be sus-

pected. It could also be hypothesized that factors

diminishing the cognitive and social performances

of schizophrenic patients do not affect (or only

slightly affect) those of healthy control subjects. For

example, the role-play of social measures in standar-

dized laboratory conditions could induce less social

anxiety and performance anxiety in control subjects

than in schizophrenic patients. Also, SPS tasks, such

as those in the AIPSS, rely on btheory of mindQ(ToM). ToM (or in others words bmetarepresentationQ,Q, that is, an awareness of one’s own and others’ goals,intentions, emotions and beliefs) is a domain that is

altered at least in some schizophrenic patients as

reported in experimental studies (Corcoran et al.,

1995; Frith and Corcoran, 1996), in clinical remedia-

tion therapy (Hodel and Brenner, 2002) and in cogni-

tive psychotherapy (Carcione and Falcone, 1999).

From this perspective, impairments on SPS may be

viewed as a consequence of patients’ difficulties in

inferring other peopleTs state of mind and translating

their own intentions into adaptive social acts. Recent

findings give some support to this hypothesis (e.g.,

Roncone et al., 2002).

We also examined whether the significant coeffi-

cients of correlation representing the association

between DF, VF, d2 or SPM and AIPSS scores

found in the patients were significantly different

from those of the healthy subjects group. DF-Proces-

sing and SPM-Sending associations differentiated the

two groups. Thus, this result supports the hypothesis

that low general intellectual functioning and some

aspects of executive functioning are two potential

determinants of SPS skills in schizophrenic patients.

However, multiple regression analyses suggest that

social skills were unrelated to diagnostic group (schi-

zophrenic versus control subjects) or cognitive mea-

sures, except the attention variable (d2), after

intellectual general competence, gender, age and edu-

cation level were taken into account.

Several potential shortcomings may limit the gen-

eralization of our findings. Firstly, our data were

derived from a relatively small sample that may

only partially represent the schizophrenic or nonpati-

ent populations. Secondly, we did not include a psy-

chiatric group as comparison. This may tend to

attribute cognitive or SPS deficits to schizophrenia,

although these deficits may also be shared by other

diagnostic groups. For example, cognitive or social

alterations are also found in patients with bipolar,

depressive, anxiety and borderline personality disor-

ders (e.g., Bellack et al., 1994; Penn et al., 1995;

O’Leary, 2000; Zubieta et al., 2001). Thirdly, the

association found herein between BPRS symptom

severity and other variables must be considered with

caution, as the BPRS summary scores do not provide

an extensive view of negative and positive symptoms

as do such other instruments as the Positive and

Negative Syndrome Scale (PANSS, Kay et al.,

1987) or the Scales for the Assessment of Positive

(SAPS) and Negative Symptoms (SANS) (Andreasen,

1982; Andreasen and Olsen, 1982). SPS ratings by

trained professionals may be negatively influenced by

the knowledge of patients’ individual psychiatric his-

tories, which may bring indirect stigmatization.

Further research should consider such factors by mea-

suring interpersonal problem-solving skills in real life

situations and rated by bnaive ratersQ with notably

larger samples and different psychiatric groups con-

trolling for mental illness representation.

Controversial accumulated evidence suggesting

heterogeneous relationships between cognitive and

SPS impairments in schizophrenia and the lack of

association found in healthy controls could be ex-

plained by the hierarchical model of the organization

of deficient behavior in schizophrenia (Brenner, 1987,

1989). This model assumes that cognitive impairments

b. . .which operate at the interface of biological

abnormalities have pervasive effects on both microso-

cial and macrosocial functioning . . . Some of these

disturbing influences may operate independently,

whereas others may do so only by mutual accumula-

tion or interaction, or with environmental and organis-

mic variablesQ (Brenner, 1989, p. 75). Thus, cognitiveimpairment may reduce social skills and impede learn-

ing of interpersonal social skills needed to meet every-

day life situations. These latter deficits expose patients

to greater stress than felt by healthy control subjects.

As a consequence of heightened emotional arousal,

patientsT cognitive deficits worsen. This vicious circleperpetuates cognitive and behavioral impairments. The

clinical implications of our results fit with the proposi-

tions of this model, i.e., the combination of cognitive

training with social skills training, as Integrated Psy-

A. Zanello et al. / Psychiatry Research 142 (2006) 67–78 77

chological Treatment (Brenner et al., 1994) or Cogni-

tive Enhancement Therapy (Hogarty and Flesher,

1999) does in social rehabilitation for chronic schizo-

phrenic outpatients or inpatients exhibiting cognitive

and SPS skills abnormalities.

Acknowledgments

We would like to thank Marianne Gex-Fabry for

her help in statistical analysis; Annabel McQuillan

Newlands and Irene Schlenker for reading this

manuscript; Corinne Degoumois, Michel Godbillon

and Catherine Bernier for AIPSS assessment; and

the Editor and the Anonymous Reviewers for their

advice.

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