Psychiatry and Clinical Neurosciences (2002), 56, 403–407

Regular Article

Wisconsin Card-Sorting Test performance does notdiscriminate different patterns of premorbid behavioralabnormalities in schizophrenic patients

ALESSANDRO ROSSI,1,2 ROCCO POLLICE,1 PAOLO STRATTA,3 LUCA ARDUINI, md,1

MARIA GRAZIA MARINANGELI, md1 AND ENRICO DANELUZZO, md2

1Dipartimento di Medicina Sperimentale, Clinica Psichiatrica, Università di L’Aquila, 2Unità Operativa diPsicologia Clinica, Casa di cura ‘Villa Serena’ Città Sant’Angelo and 3Dipartimento di Salute Mentale,Azienda Sanitaria Locale L’Aquila, Italy

Abstract It is well documented that premorbid behavior abnormalities precede the onset of schizophreniain a large number of patients. The research findings suggest that there are differences in the typeand severity of these premorbid dysfunctions. Another research field has shown impairment ofpreschizophrenic patients in several cognitive domains. The present study reports retrospectivechildhood and adolescence neurobehavioral assessment in 31 patients with schizophrenia by theChild Behavior Checklist (CBCL) and current Wisconsin Card-Sorting Test (WCST) evaluationin order to investigate whether specific behavioral abnormality (BA) patterns are related toexecutive function as evaluated by the WCST. Cluster analysis was conducted on the childhoodpremorbid behavior ratings for the schizophrenic patients and two subgroups emerged: (i)Cluster I with an initial low level of BA that increased over the years; and (ii) Cluster II with ahigh level of BA that remained relatively stable until early adulthood. Furthermore, Cluster IIshowed more severe current negative and total symptoms, but the two groups did not differ inWCST performance. Our results show that the patterns and severity of CBCL upon retrospec-tive evaluation are not related to WCST performance, which seems to be a feature inherent tothe disease process. Different factors could be responsible for cognitive and behavioral distur-bances in schizophrenia.

Key words behavioral abnormalities, Child Behavior Checklist, neurocognitive impairment, schizophrenia,Wisconsin Card-Sorting Test.

INTRODUCTION

Several lines of evidence suggest that behavioralabnormalities (BA) may precede the onset of schizo-phrenia in a large number of patients.1–8 Studies oninfancy and childhood behavioral precursors in thesepatients show increased adjustment disorders andsigns of cognitive and motor dysfunctions. Otherstudies identified an association between current clinical status and past behavioral abnormalities.9,10

Studies of premorbid neuropsychological test perfor-mance and school achievement reported that individ-uals who later manifest schizophrenia did worse thantheir healthy siblings.11 Reports of no difference havealso appeared.3

Schizophrenic patients perform tests involvingexecutive functions, such as the Wisconsin Card-Sorting Test (WCST), relatively poorly. BecauseWCST performance is believed to be mediated, inpart, by the frontal cortex, particularly the capacity tomaintain and appropriately shift cognitive set,12 theimpairment of schizophrenics on this and similar tasksmay suggest executive dysfunction through frontallobe involvement.13

The aim of the present study was to investigate thepredictive value of retrospective data on childhood

Correspondence address: Professor Alessandro Rossi, Diparti-mento di Medicina Sperimentale, Università de L’Aquila, ViaVetoio, Coppito II, 67100 L’Aquila, Italy. Email: rossi.aq@tin.it

Received 9 July 2001; revised 20 November 2001; accepted 26November 2001.

404 A. Rossi et al.

and adolescence behavior of preschizophrenic chil-dren on the current WCST performance of the samegroup of patients in order to look for a relationshipbetween premorbid signs in childhood and subse-quent cognitive dysfunction.

METHODS

Subjects

Thirty-one schizophrenic subjects (19 males and 12females) were evaluated by a senior psychiatrist (AR)according to the 4th edn of the Diagnostic and Statis-tical Manual of Mental Disorders (DSM IV).14 Diag-nosis was based on direct clinical interview andinformation from the medical history, with particularattention on the illness course. At the time of evalua-tion, all patients were taking typical neurolepticsreported as chlorpromazine-equivalent mean dailydose (Table 1). Anticholinergic medication was ad-ministered to 12 patients. Demographic, clinical andcognitive features of the total sample are shown inTable 1.

All subjects provided written informed consent toparticipate in the study after a complete description

of the study had been given to them, in accordancewith the local university institutional review board.

Measures

All patients were assessed using the Italian version of the Krawiecka Manchester Rating Scale (KM-S):the KM-S consists of a five-point scale (0–4) givingscores of positive (hallucinations, delusions, incoherentspeech), negative (poverty of speech, flat affect,psychomotor retardation) and aspecific symptoms(anxiety and depression) in schizophrenic patients.

We evaluated patient premorbid behavioral symp-toms by using the Baum and Walker7 modifiedversion of the Child Behavior Checklist (CBCL).15

Specifically, the 124 CBCL items were changed to thepast tense. The CBCL items measure a broad range of BA in many situations and allow scores to beobtained for the following behavioral dimensions:social withdrawal, anxious–depressed behavior, socialproblems, attention problems, delinquent and ag-gressive behavior, thought problems. The motherswere the principal informants (mean (±SD) age 46.8 ±9.4 years) about childhood behavior because theywere the primary caretakers of the patients.

Because behavioral ratings were obtained for eachchild at five age periods (birth to 3 years, 4–7 years,8–11 years, 12–15 years, 16–18 years), it was possible tocompute linear slope and intercept variables for thesix behavioral dimensions.

In calculating intercept and slope for each behav-ioral dimension subscale of CBCL, z scores (relativeto the mean ± SD of the control group) relating to thefirst four periods of age have been used. This strategywas chosen according to the previous reports in theliterature.16 Another reason was that the fifth ageperiod (16–18 years) was close to the age of onset of the disorder; therefore, the frankly morbid sub-jects confounded mothers’ memories of premorbid behavior.

The derivation of these indices also provided ameans of data reduction17 so that within-group vari-ability could be explored with Cluster analysis.Next, the slope and intercept variables were used toperform a Cluster analysis. An agglomerative hierar-chical Cluster analysis was performed on data fromthe patient sample using Ward’s18 method for combin-ing cases. Examination of the coefficients revealed thetwo-cluster solution more informative. The two clus-ters we identified were both different in time-courseof subscale scores and initial scores. There was a dif-ference in premorbid features between Cluster I andCluster II patients: Cluster I patients showed a lowscore at the beginning that increased over the years,

Table 1. Demographic, clinical and cognitive features forthe total sample (n = 31)

Variable Mean (± SD)

Age (years) 25.4 ± 2.7Age at onset (years) 20.3 ± 3.67Length of illness (years) 4.33 ± 2.2Chlorpromazine (mg equivalents) 572.46 ± 498.89Child Behavior Checklist

Total 0–3 years 24.13 ± 17.45Total 4–7 years 28.94 ± 18.74Total 8–11 years 32.16 ± 17.82Total 12–15 years 42.84 ± 17.04Total 16–18 years 57.68 ± 24.23

Wisconsin Card-Sorting TestCompleted categories*a 3.72 ± 4.4Perseverative errors*b 14.53 ± 7.49Perseverative errors (%)*c 14.68 ± 5.49Unique errors*d 2.69 ± 4.4Failure to maintain set*e 1.81 ± 1.88

* t-Test results compared with healthy controls (n = 28;nale/female ratio = 16/12) matched for age, sex and educa-tion (selected from patients data reported in Stratta et al.32).

a t = 2.31; P < 0.025.b t = 2.47; P < 0.01.c t = 3.95; P < 0.0005.d t = 2.11; P < 0.05.e t = 3.05; P < 0.005.

whereas Cluster II patients showed a high score thatremained stable over time (for more details see Rossiet al.10).

The WCST was administered to all subjectsenrolled in the study, with the standard instructionsdescribed by Heaton,12 using a computerized versionalso implemented with MEL (Micro ExperimentalLaboratory).19 The test consists of 128 cards, each ofwhich contains geometric figures that may vary alongthree dimensions (color, form, number). Subjects areinstructed to place each card below one of four targetor key cards and to use some principle to guide them.They are not informed of the correct principle, butare told whether they are correct or incorrect aftertheir placement of each card. The initial sorting prin-ciple is to match according to color. Once a criterionof 10 correctly sorted cards is attained, the principle is changed, although the subject is not informed ofthis change. The test proceeds until the subject hascompleted six sorting categories, each consisting of 10 consecutive cards matching the sorting principle inforce, or has placed 64 cards in one category or, other-wise, has sorted all 128 cards.

The computer automatically scored performances,following Heaton’s rules, with the exception that the first unambiguous error repeating the previouslycorrect principle was not scored as perseverationbecause the subject had not received feedback indi-cating that the previously correct principle was incor-rect. This scoring rule resulted in negligible changes in the perseverative error score. The performance on the WCST was based on the number of categoriesachieved, number and percentage of perseverative

errors, failure to maintain set and number and per-centage of unique errors.

RESULTS

Independent t-tests were used to compare Cluster Iand Cluster II schizophrenic patients on demographicfeatures, clinical symptoms and WCST performances(Table 2).

Cluster II patients showed a higher negative KM-Ssubscale score and total score, whereas the aspecificand positive subscale scores did not differ statistically.No differences were found between the two groups as to demographic features, gender differences andWCST either when its indices were analyzed throughMANOVA (Hotellings = 0.26; NS) or independently(Table 2). No differences (two-tailed t-test) were seenfor WCST indices scores between patients whorequired anticholinergic medication and those whodid not. However, the whole patient group had worseWCST performance than matched healthy subjects.No statistically significant correlations betweenWCST indices and CBCL scores were seen withPearson’s analysis.

DISCUSSION

The present study explores the relationship betweenpremorbid behavioral abnormalities and WCST per-formance in schizophrenic patients.

Several authors have demonstrated that premorbidbehavioral, neuromotor and cognitive abnormalitiesprecede the clinical onset of schizophrenia.20–25 Corn-

WCST and CBCL in schizophrenia 405

Table 2. Demographic, clinical and cognitive features of Cluster I and Cluster II schizophrenic patients

Cluster I (n = 16) Cluster II (n = 15) t P

Age (years) 26.6 ± 5.8 23.7 ± 3.7 1.7 NSAge at onset (years) 21.5 ± 3.6 19.5 ± 2.5 1.7 NSLength of illness (years) 5.1 ± 2.9 4.1 ± 1.8 1.1 NSKrawiecka Manchester Rating Scale

Total 13.1 ± 2.6 15.2 ± 2.2 2.4 0.02Positive 5.8 ± 1.7 5.1 ± 1.9 1.1 NSNegative 4.3 ± 2.0 5.9 ± 1.4 2.7 0.01Aspecific 2.9 ± 1.6 3.8 ± 1.3 1.8 NS

Wisconsin Card-Sorting TestCompleted categories 3.2 ± 2.5 4.1 ± 2.5 1.1 NSPerseverative errors 15.0 ± 8.4 14.4 ± 6.8 0.2 NSPerseverative errors (%) 15.0 ± 5.3 14.2 ± 5.9 0.1 NSUnique errors 1.7 ± 2.7 3.9 ± 5.6 1.4 NSFailure to maintain set 2.1 ± 2.1 1.5 ± 1.4 1.0 NS

Data are the mean ± SD.

406 A. Rossi et al.

blatt and Erlenmeyer-Kimling26 and Erlenmeyer-Kimling et al.27 suggested that, in the childhood anam-nesis of adult schizophrenic patients, BA are oftenpresent and may predict the onset of the illness.Examining the premorbid development of individualsdrawn from a stratified random sample of births,Jones et al.2 reported that individuals who developedschizophrenia shared delayed attainment of devel-opmental milestones in infancy, greater social with-drawal in childhood, excessive social anxiety andpoorer educational achievement in comparison withthe rest of the subjects in the birth cohort. Walker etal.,4,9,24 Baum and Walker7 and Neuman et al.16 charac-terized some premorbid neuromotor signs and BA inindividuals who developed schizophrenia, highlightingthat some of these signs were already present in earlydevelopment. As a confirmation that several clinicalsigns in childhood could be specific signs of centralnervous system dysfunction, many studies found thepresence of soft neurological signs in adult schizo-phrenic patients28 and several authors have foundthem in children.2,4,8,29

In the present report we pursued a different per-spective, trying to identify a group of patients withmore severe BA and looking for a possible relation-ship with WCST performance. When Cluster analysiswas applied to the slopes and the intercepts relatingto behavioral problems, two subgroups emerged.Cluster I patients showed the presence of early slightBA that increased progressively over the years.Cluster II patients were characterized by the presenceof more severe BA already during the first years oflife that remained rather stable over time. Moreover,our findings revealed that negative and total KM-Sscores were higher in Cluster II patients than inCluster I patients.

On the basis of previous papers suggesting thatWCST abnormalities in schizophrenia were associ-ated with environmental factors (i.e. birth com-plications)30 and non-familial factors,13 we hadhypothesized that similar factors influencing WCSTperformance could have affected the CBCL rating.However, this was not the case in the present studybecause the two patterns of CBCL (i.e. Cluster I vsCluster II) did not evidence different patterns ofWCST response. We should conclude that WCST isnot influenced by such factors but is more likely afeature inherent to the disease process. Anotherexplanation is that premorbid behavioral and currentcognitive testing, as measured by CBCL and WCST,simply do not overlap, at least in this clinical sample.Within the frame of neurodevelopmental hypothesis,31

CBCL evaluation suggests a possible heterogeneity ofthe disorder at a premorbid level and as to severity of

index episode, whereas the WCST does not. Thispaper suggests the need to better integrate the studyof different psychobiological markers that couldacknowledge different pathophysiological mechanismand meanings (i.e. CBCL vs WCST and their underly-ing neurological substrates).

Some methodological limitations in the presentstudy should be considered. The small sample size, thenumber of statistical tests, the large within-group variance and the use of retrospective reports frommothers make the conclusions suggested in this articletentative. Moreover, the WCST is the only cognitive-dependent measure we evaluated. Although this is themost sensitive test for frontal functions, the impair-ment of which is considered crucial and ubiquitous inschizophrenic patients, it may not exhaustively repre-sent the cognitive profile of schizophrenic patients.Studies using a neuropsychological battery evaluatingother cognitive domains, such as working memory,attentional capacities and other central executivefunctions, are needed.

This research field, however, highlights the rele-vance of premorbid behavioral evaluations in infancy,childhood and adolescence.2,8 Further studies areneeded to investigate whether these BA could followseveral trajectories that could explain part of the het-erogeneity and severity of the clinical syndrome in itsadult presentation.

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