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This article was downloaded by: [Universidad Autonoma deBarcelona]On: 28 October 2014, At: 07:03Publisher: RoutledgeInforma Ltd Registered in England and Wales RegisteredNumber: 1072954 Registered office: Mortimer House, 37-41Mortimer Street, London W1T 3JH, UK
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Cognitive functioningand social problem-solving skills inschizophreniaMichi Hatashita-Wong , Thomas E.Smith , Steven M. Silverstein , JamesW. Hull & Deborah F. WillsonPublished online: 09 Sep 2010.
To cite this article: Michi Hatashita-Wong , Thomas E. Smith ,Steven M. Silverstein , James W. Hull & Deborah F. Willson(2002) Cognitive functioning and social problem-solving skillsin schizophrenia, Cognitive Neuropsychiatry, 7:2, 81-95, DOI:10.1080/13546800143000168
To link to this article: http://dx.doi.org/10.1080/13546800143000168
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Cognitive functioning and social problem-solvingskills in schizophrenia
Michi Hatashita-Wong, Thomas E. Smith, Steven M. Silverstein,James W. Hull, and Deborah F. Willson
Weill Medical College of Cornell University/ New York Presbyterian Hospital,New York, USA
Introduction . This study examined the relationships between symptoms, cognitivefunctioning, and social skill deficits in schizophrenia. Few studies haveincorporated measures of cognitive functioning and symptoms in predictivemodels for social problem solving. Method. For our study, 44 participants wererecruited from consecutive outpatient admissions. Neuropsychological tests weregiven to assess cognitive function, and social problem solving was assessed usingstructured vignettes designed to evoke the participant’s ability to generate,evaluate, and apply solutions to social problems. A sequential model-fittingmethod of analysis was used to incorporate social problem solving, symptompresentation, and cognitive impairment into linear regression models. Predictorvariables were drawn from demographic, cognitive, and symptom domains.Because this method of analysis was exploratory and not intended as hierarchicalmodelling, no a priori hypotheses were proposed. Results. Participants with higherscores on tests of cognitive flexibility were better able to generate accurate,appropriate, and relevant responses to the social problem-solving vignettes.Conclusions. The results suggest that cognitive flexibility is a potentially importantmediating factor in social problem-solving competence. While other factors arerelated to social problem-solving skill, this study supports the importance ofcognition and understanding how it relates to the complex and multifaceted natureof social functioning.
INTRODUCTION
This study examined the relationships between symptoms, cognitive function-ing, and social skill deficits in schizophrenia after an acute psychoticexacerbation. Poor social adjustment in schizophrenia has long been acknowl-edged as persistent and detrimental to many aspects of daily living. Social skill
Correspondence should be addressed to Michi H. Wong, Coordinator, Cognitive Rehabilitation,Center for Psychosocial Rehabilitation, Hawaii State Hospital, 45–710 Keaahala Road, Cooke Bldg.,Kaneohe, Hawaii 96744, USA. Email: [email protected] s
# 2002 Psychology Press Ltdhttp://www.tandf.co.uk/journals/pp/13546805.html DOI:10.1080/13546800143000168
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impairments are strongly associated with increased stress, poor quality of life,and difficulties in psychosocial and occupational functioning (Bellack,Morrison, Mueser, Wade, & Sayers, 1990; Bellack, Sayers, Mueser, & Bennett,1994). While the deleterious impact of social dysfunction in schizophrenia isundeniable, further efforts are needed to delineate how illness symptoms andneurocognitive impairments differentially contribute to psychosocial andfunctional outcomes including response to rehabilitative or remediativeintervention (Brenner, Hodel, Roder, & Corrigan, 1992).
Investigators have increasingly focused their research on the relationshipbetween cognitive impairments and social outcomes, in large part becauseresearch has shown that psychotic symptoms do not account for a significantamount of the variation in social adjustment (Green, 1996). Recent studies havefound only modest associations between positive and negative symptoms andoverall social adjustment (Anthony, Rogers, Cohen, & Davies, 1995; Jacobs,Wissusik, Collier, Stackman, & Burkeman, 1992; Van der Does, Dingemans,Linszen, Nugter, & Scholte, 1996). However, other data indicate thatdisorganised symptoms may have some predictive value in treatment outcomessuch as social behaviour and community functioning (Norman et al., 1999;Smith et al., 1999).
In contrast, research that specifically examines the role of cognitive variablesas mediating factors in social functioning has revealed significant relationshipsbetween cognition and social problem solving. For example, verbal memory(Addington & Addington, 1999; Bellack et al., 1994; Corrigan, Green, &Toomy, 1994), vigilance (Bowen et al., 1994), early visual processing (Asarnow& Nuechterlein, 1992; Corrigan, Wallace, Schade, & Green, 1994; Penn,Mueser, Spaulding, Hope, & Reed, 1995; Penn et al., 1993), and cognitiveflexibility (Addington & Addington, 1999) have been found to be significantlyassociated with social problem solving in inpatients with schizophrenia. In areview of the literature, Green (1996) noted that research has consistentlydemonstrated significant relationships between impaired executive functioningand social skills, social problem solving, and adjustment outcomes incommunity living. In addition, comorbid presentation of both cognitive deficitand impaired social functioning can be found prior to illness onset in many cases(Cornblatt, Obuchowski, Andreasen, & Smith, 1998), and cognitive deficits arerelated to poorer premorbid social functioning in schizophrenia (Knight &Silverstein, 1998). The research cited indicates a significant relationshipbetween cognitive deficits and social functioning. However, it is only recentlythat researchers have attempted to develop theoretical models to account forthese relationships (Green & Nuechterlein, 1999; Silverstein, 1997; Silverstein& Schenkel, 1997).
Researchers have just begun to critically examine the interrelationshipbetween symptoms, cognition, and adaptive outcomes (Velligan et al., 1997). Todate, there are few studies that have incorporated measures of cognitive
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functioning and symptoms in predictive models for social problem solving. Thisstudy addressed these issues by using a sequential model-fitting method ofstatistical analysis, and by incorporating the three domains, social problem-solving ability, core symptom presentation, and cognitive impairment, intolinear regression models. Predictor variables were drawn from both the cognitiveand symptom domains. A neuropsychological test battery was selected to assesscognitive functions that have been shown to be significant predictors ofoutcomes involving social skills. Clinical symptoms of schizophrenia, demo-graphic factors, and chronicity variables were also included to furtherencompass the different aspects of the illness.
A methodological problem addressed by this study concerns the measurementof social skill functioning. Researchers have applied various definitions andmeasures of functional outcomes leading to difficulty in interpretation of dataand generalisability of the results (Green, 1996; Silverstein, Schenkel, Valone,& Nuernberger, 1998). Although patients with schizophrenia are known toexperience difficulties in social perception, social behaviour, and socialinteraction, delineating which aspects of complex social processes are the mostcritical has remained a challenge. Others who have studied the relationshipbetween cognitive function and schizophrenia symptoms, including socialfunctioning, suggest that the relative lack of significant findings may be due inpart to the need for more precise, and less global, measures of functionaloutcomes (Green, 1996; Heaton & Pendleton, 1981; Palmer et al., 1997).Therefore, consistent with efforts to more effectively define and operationalisethe construct of social skill functioning, this research utilised a theoreticallybased and empirically developed measure, the Social Problem-SolvingAssessment Battery, SPSA (Sayers, Bellack, Wade, Bennett, & Fong, 1995).The SPSA was designed to target the multiple aspects of social problem-solvingbehaviour and therefore provides a more rigorous method with which toexamine social problem solving as a functional outcome.
METHOD
Subjects
Participants were recruited from consecutive admissions to an outpatienttreatment programme. Inclusion criteria included: (a) age 18–50 years; (b)diagnosis of schizophrenia or schizoaffective disorder; and (c) inpatienthospitalisation for treatment of an acute psychotic exacerbation within 30 daysof initial assessment for this study. Exclusion criteria included: (a) comorbiddiagnosis of substance or alcohol dependence; (b) estimated IQ less than 70 (IQscores were extrapolated from WAIS-IIIR subtests; Information, Vocabulary,and Block Design); and (c) any history of serious traumatic brain injury (e.g.,any head injury resulting in seizure activity, loss of consciousness, or requiring
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hospitalisation of more than 24 hours). No attempts were made to control forspecific medication or nonpsychopharmacological treatments.
A total sample of 44 research participants was obtained. The diagnosticcomposition of the sample comprised 28 (60%) patients with a diagnosis ofschizophrenia, and 17 (40%) with diagnosis of schizoaffective disorder.Diagnostic subtypes of schizophrenia were represented by 12 (27%) patientswith paranoid type, 10 (22%) with undifferentiated, and 4 (9%) withdisorganised type schizophrenia. Primary Axis I clinical diagnosis wasconfirmed in 43 of the subjects using the Structured Clinical Interview forDSM-IV. Only one patient’s primary Axis I diagnosis was determined by usingthe admitting diagnosis at last hospitalisation.
Of the participants 23 (51%) were male, 80% were Caucasian, 7 (16%) wereAfrican-American, and 2 (4%) identified themselves as Other with respect torace or ethnicity. The mean age of the cohort was 36 years (SD, 9.8 years), themean age of illness onset was 18 years (SD, 6.7 years), and patients had anaverage of 6.7 prior hospitalisations (SD, 3.7). The study procedures were fullyexplained to all potential subjects. Participation was voluntary and full writtenconsent was obtained from all participants.
Assessments
All assessments were completed within 14 days after the participant gaveinformed consent. Positive and negative symptom dimension scores weregenerated for each participant using the Scale for the Assessment of PositiveSymptoms (SAPS; Andreasen, 1984b), and the Scale for the Assessment ofNegative Symptoms (SANS; Andreasen, 1984a). Global ratings for positivesymptoms, negative symptoms, and formal thought disorder (FTD) were used asdefined and validated by Andreasen, Arndt, Allinger, Miller, and Faum (1995).The FTD subscale was used instead of the disorganised symptom dimension(Andreasen et al., 1995) because FTD was normally distributed in this sample.Depression was assessed using the Brief Psychiatric Rating Scale (BPRS;Ventura, Lukoff, Nuechterlein, Green, & Shaner, 1993). Three trained graduate-level research associates conducted assessment and ratings of participantresponses to the symptom measures. Inter-rater reliability was achieved on allsymptom measures (r = .89 to r = .92).
The selection of neuropsychological tests was based on two criteria: (1)measures that had predicted outcome in previous research studies (Kern, Green,& Satz, 1992); and (2) measures of cognitive function that are believed to beassociated with social skill acquisition (Silverstein et al., 1998), but had not beenused in past studies. Psychomotor speed was assessed using the Finger Tappingtest (Halstead, 1947; Reitan & Wolfson, 1993), and verbal fluency wasmeasured using the Controlled Oral Word Association Test (COWAT, FAS)(Benton & Hamsher, 1976). Visual information processing was assessed using
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the UCLA Degraded Stimulus Continuous Performance Task (DSCPT)(Nuechterlein et al., 1992). The Digit Span Distraction Test (DSDT) (Oltmanns& Neale, 1975) was used as a measure of immediate memory span. Memory wasassessed using the California Verbal Learning Test (CVLT) (Delis, Kramer,Kaplan, & Ober, 1987). Two measures of executive functioning were used,namely, the Wisconsin Card Sorting Test (WCST) (Berg, 1948; Grant & Berg,1948) and Trail Making Test (TMT) (Armitage, 1946).
Social skill was measured with the SPSA (Sayers et al., 1995). Based ontheoretical models, the SPSA was specifically designed to be used with chronicpsychiatric populations. Bellack et al. (1994) argued that social problem solving,as a multi-step process, represented a feasible way to operationalise and evaluatethe higher-order cognitive processes purportedly involved in social behaviour.These researchers developed the SPSA to measure social problem solving acrossseveral domains; (1) general orientation or development of a cognitive ‘‘set’’;(2) problem definition; (3) generation of alternatives; (4) decision making; and(5) verification. In a prior study examining performance on tests of socialproblem-solving skills, patients with schizophrenia and patients with bipolardisorder were equally impaired on the SPSA when compared to normal controls(Bellack et al., 1994). In addition they found that cognitive impairment wassignificantly associated with impaired social problem-solving skill in patientswith schizophrenia, but not in patients with bipolar disorder (Bellack et al.,1994).
Only the Response Generation Test (RGT) subtask of the SPSA was given.The RGT uses video-taped structured vignettes that were designed to evoke theparticipant’s ability to generate, evaluate, and apply solutions to socialproblems. The participants’ responses were rated across five categories ofsolution criteria: (1) Correctness, the accuracy and relevance of the solutioninformation given by the patient to address the problem; (2) Appropriateness,the degree to which the given solution fits the social problem at hand; (3)Elaboration, the degree to which clarification and detail of the solution areprovided by the respondent; (4) Implementability, the likelihood that the plancan be put into effect and implemented; and (5) Limitations (‘‘Wrong’’),whether the patient can identify and anticipate realistic problems, limitations, oradverse consequences of a given solution.
The assessments and ratings of participant responses to the RGT wereconducted by the three research associates mentioned earlier, all trainedgraduate students. Inter-rater reliability on assessments and ratings was achieved(r = .92).
Data analysis
A correlational matrix was created to explore the underlying associationsbetween the measures of social skill ability, psychiatric symptoms, and cognitive
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factors. A sequential model-fitting strategy using stepwise linear regression wasthen used to identify the predictor variables most strongly associated withperformance on the SPSA. For each rating category of the SPSA, three separateregression models were initially created, one for each predictor domain. Thesymptom predictors included the positive, negative, and formal thought disordervariables. The cognitive predictors included seven variables: DSDT (proportionof correct responses in the nondistraction condition); DCPT A’; WCST(Conceptual Level Responses and Categories); CVLT (sum of trials 1–5, andshort delayed free recall); and Finger Tapping (mean score for right and lefthand over five trials). The cognitive variables dropped from the regressionanalysis due to low correlation with the SPSA included the Trail Making Testand fluency test, FAS. The third predictor domain to be included compriseddemographic predictor variables. These included gender, age, race, education,marital status, age of first treatment, and first psychiatric hospitalisation. Finalregression models were created using only those predictors found to besignificant in the three initial predictor domains. Note that this method ofanalysis was exploratory and not intended as hierarchical modelling, thereforeour analyses were limited to the variables found to be significant in the initialcorrelational matrix.
RESULTS
Table 1 lists the correlation coefficients between the categories of socialproblem-solving skills, psychiatric symptoms, and cognitive variables. Nosignificant correlations were found between psychiatric symptoms (positivesymptoms, negative symptoms, or the presence of formal thought disorder) andany of the social problem-solving skill domains. Higher experimenter ratings ofpatients’ responses across all domains of the social problem-solving skill taskwere significantly correlated with better performance on cognitive measures.Correlation coefficients also indicated significant associations between socialproblem-solving skill dimensions and patient demographic and illness chronicityvariables. Cognitive variables, FAS, Trails A, and Trails B, and demographicvariables, gender, race, education, and marital status were dropped from theregression analyses due to low correlations with the SPSA outcome variables.
Because previous research has suggested that the association betweencognitive functioning and social functioning differs for males compared tofemales (Mueser, Bellack, Douglas, & Wade, 1991; Penn, Spaulding, Reed, &Sullivan, 1996), a multivariate analysis of variance (MANOVA) was conducted.However, no between-group differences by gender were found for any of theSPSA social problem-solving categories, F(5, 39) = .263, p < .93.
A specific model for each rating category of the SPSA was developed usingthe stepwise linear regression model-fitting strategy. To reiterate, the final
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regression models (Table 2) were created using only those predictors found to besignificant in the three initial domain models (see Table 1).
In the Correctness category, predictor variables from the demographicdomain included First Hospitalisation and Onset of Illness, however, the Onsetof Illness variable was dropped due to correlation with the First Hospitalisationvariable. From the cognitive domain, WCST-CLR, CVLT, Short Delayed FreeRecall, and Finger Tapping were entered as predictor variables. In the finalregression model for Correctness category, the cognition domain model wassignificant when variables were entered as predictors, F = 2.86; df = 4, 35; p <
TABLE 1Pearson correlation coefficients between social problem-solving skill measures, core
symptoms, and neurocognitive variables
SPSA-reponse generation taskCorrectness Appropriateness Elaboration Implementability Limitations
Symptom domainPositive symptoms 7.18 7.07 7.25 7.14 7.16Negative symptoms 7.15 7.05 7.11 7.14 7.26Formal thoughtdisorder
7.06 .14 .10 7.20 7.17
Demographic domainGender 7.05 7.11 7.15 .04 7.00Age 7.02 7.11 7.25 .07 7.09Race .09 .11 .23 .19 .12Education .09 7.15 .14 .24 .21Marital status .08 7.04 .08 .08 .18Onset of illness .33* .38* .36* .23 7.37*First hospitalisation .33* .14 .21 .01 .19
Cognitive domainIQ .23 .20 .31 .25 7.14WAIS-III, information .17 .33* .36* .17 7.05CVLT,
Sum of Trials 1–5 .24 .25 .47** 7.04 .02Short delay freerecall
.34* .27 .39** 7.07 .18
DCPT-A1 .12 .24 .36* .10 .13DSDT, Nondistractiontask
.22 .23 .15 .51** .15
Finger tapping .37* .09 .19 .08 .15FAS .22 .17 .27 .01 .02Trails B 7.11 7.18 7.16 7.15 7.07WCST
Conceptual level .32* .31* .43** .07 .24WCST, Categories .19 .15 .38* 7.004 .30*
*p < .05, 2-tailed, **p < .01, 2-tailed.
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.040; psychomotor speed (b = .389, p < .025) was a significant predictor;however, cognitive flexibility (WCST-CLR) and verbal memory (CVLT, ShortDelayed Free Recall) were not significant predictors. The demographic variabledomain was also not a significant predictor. The final model (see Table 2)accounted for 27% of the variance in ratings of Correctness.
The regression model for the Appropriateness category was significant, F =2.94; df = 3, 35; p < .048, and accounted for 22% of the variance. Aftercorrelations for each predictor domain were analysed, one significant variablefrom the demographic predictor domain and two from the cognitive predictordomain were identified. The final regression model for Appropriatenesscategory that was tested used the cognitive flexibility variable, (WCST-CLR),a general knowledge variable (WAIS-R, Information), and a chronicity of illnessdemographic variable (Onset of Illness). None of the variables entered into thefinal regression model was a significant predictor.
When the model-fitting strategy was applied to the Elaboration category,cognitive flexibility was a significant predictor in the final regression model.Significant predictor variables for final analysis included; from the demographicdomain, Onset of Illness; and from the cognitive domain, WCST-CLR, CVLT
TABLE 2Stepwise linear regression models for social problem-solving skill domains with core
psychiatric symptoms, and neurocognitive variables as predictors
Domains of socialproblem-solving skill F-value df
Modelp < r2 Predictors
Betapredictor p <
Correctness 2.86 4 .040 .17 WCST Conceptuallevel response
7.258 .119
Finger tapping .389 .025CVLT Short delayfree recall
.225 .184
First hospitalisation 7.193 .258
Appropriateness 2.94 3 .048 .14 WCST Conceptuallevel response
.263 .110
WAIS-IIIInformation
.285 .092
Illness onset 7.118 .470
Elaboration 5.37 3 .004 .26 WCST Conceptuallevel response
.323 .038
CVLT 1–5 .301 .060Illness onset .147 .330
Implementability Not applicable
Limitations 5.94 2 .006 .21 WCST categories .375 .019Illness onset .248 .112
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Trials 1–5, WAIS-IQ, and CVLT, Short Delay Free Recall. These predictorvariables were significantly correlated to the RGT Elaboration category from theinitial correlational matrix. The DCPT-A’, WAIS- IQ, and CVLT Short DelayFree Recall were dropped from the regression model for the Elaboration Scorebecause of covariance with the CVLT Trials 1–5. The WCST Category scorewas dropped because of covariance with WCST-CLR. When the remainingvariables were entered into the final regression model, the ability to attain,maintain and shift cognitive set emerged as a significant cognitive predictorvariable (WCST-CLR, b = .323, p < .038). The other cognitive predictor variableentered, immediate verbal memory, approached significance (CVLT-Trials 1–5,b = .301, p < .060). The illness onset demographic variable included was not asignificant predictor variable (illness onset, b = .147, p < .330) in the finalregression analysis. The final model for Elaboration (F = 5.42; df = 3, 37;p < .004) accounted for 32% of the variance in the patients’ ability to give detailsand elaborate possible solutions to social problem situations.
One cognition domain variable that was significant in the initial model forImplementability was immediate memory span (DSDT-Nondistraction condi-tion, b = .565, p < .000). Regression analysis of symptom domain variables anddemographic domain variables were not significant, therefore no additionalpredictor variables were included. Due to the lack of additional domainvariables, no final regression model was done for Implementability.
Lastly, the model-fitting strategy was applied to the Limitations category.One demographic variable (illness onset, b = .248, p < .112), and one cognitionvariable (WSCT-Categories, b = .375, p < .019) were included in the finalregression model. When entered into the last regression analysis, cognitiveflexibility (the ability to attain, maintain, and shift cognitive set) was significant(F = 5.94; df = 2, 35; p < .006) and the final model accounted for 25% of thevariation in ratings on the Limitations category.
DISCUSSION
To date, relatively few studies have been designed to incorporate the threedistinct illness dimensions of schizophrenia that were examined here, namelypsychiatric symptoms, cognitive performance, and social problem-solving skillcompetence. Overall, there were no significant relationships found betweenpositive, negative, and disorganised symptoms and social problem-solvingability. However, the results presented here are consistent with recent researchsuggesting that cognitive deficits in schizophrenia are significant predictors ofgeneral adaptive outcomes including social functioning (Bellack et al., 1994;Corrigan et al., 1994; Penn et al., 1995; Silverstein et al., 1998; Velligan et al.,1997). How cognitive ability is linked to social perception and social cognitionis important to understanding the underpinnings of adaptive social functioning,
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and these results confirmed that cognitive functioning and social problem-solving skill are not unrelated.
More specifically, the results of our study indicated significant relationshipsbetween cognitive flexibility, verbal memory, immediate memory span, and themulti-step process of social problem solving. Our finding of the relationshipbetween immediate verbal memory and social cognition is consistent with theliterature that shows these variables to be predictors of skill acquisition.However, the role of verbal memory and immediate memory span in real-worldsocial skill behaviors remains somewhat unclear because of the limitations ofstatistical power in past studies and inconsistent replication of these findings(Green, 1996). Given the inconsistencies in research thus far, the specificity andimplications of these findings should be interpreted with caution.
Of notable interest here, significant relationships between performance ontests of ability to demonstrate cognitive flexibility and the functional outcome ofsocial problem-solving skill were found in two of the five designated SPSAdomains. Higher scores on tests of abstraction ability were associated withgreater ability to clarify and provide further detail-oriented alternatives to theoriginal solutions given as solutions to social problems. In addition, judgementregarding the incorrectness and limitations of a given social problem solutionwas associated with the ability to maintain and shift conceptual sets. The resultsof our study thus support the idea that cognitive flexibility may potentially be animportant mediating factor in influencing social problem-solving competence.
The relationship between symptom dimensions and social problem-solvingabilities was not significant in this study. However, the lack of significant resultswas not entirely unanticipated, because this absence of association between thetwo constructs is consistent with recent research suggesting that psychoticsymptoms are not strongly related to various aspects of social functioning(Anthony et al., 1995; Jacobs et al., 1992; Van der Does et al., 1996). Whereasother studies suggest that disorganised symptoms may be more stronglyassociated with social behaviour and community functioning outcomes thanpositive or negative symptoms (Norman et al., 1999; Smith et al., 1999), furtherinvestigation is needed to ascertain whether changes in symptoms orneurocognitive abilities are precursors to impaired social function. Otherresearchers have called attention to how method of assessment contributes to theproblem of learning more about the influence of symptom presence; lack ofagreement about symptom differentiation leads to methodological inconsistency,resulting in poor standard symptom categorisation across studies (Norman et al.,1999). For example, some studies apply the positive versus negative symptomdistinction rather than using a multidimensional categorisation that includes thedisorganised symptom spectrum, making it difficult to assess the relativecontribution of symptom domains to social problem solving and other aspects ofsocial functioning. Clearly, future studies that incorporate multidimensionalcategorisation of schizophrenia symptoms, and research designs using long-
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itudinal assessments, will be useful in clarifying whether these findings reflectchange in symptom presence after acute episode, and how social problem-solving abilities change as symptoms and cognitive functions change.
Aside from methodological issues, these results support the utility of socialproblem solving tasks as valid clinical outcome measures. These measures canbe used as a longitudinal follow-up measure to track the stability of socialfunctioning, or the response to psychosocial interventions. In our study, therecent acute hospitalisation of the patients in our sample probably contributed tothe lack of significant findings between illness symptoms and social skilloutcomes. The recent discharge from an inpatient stay most likely indicates thatthe participants here were a relatively stable group given the recency of targetedpsychopharmacological intervention. Again, tracking changes over time in thistriad of illness domains may reveal whether the relationships between cognitivevariables and social behaviours vary with changes in severity of psychoticsymptoms.
Utilising outcome measures such as the SPSA is important in other respects.Finding empirically valid and ecologically useful measures of social behaviourshas also been a formidable challenge for researchers. Only modest associationshad been found between cognitive function and social functioning inschizophrenia, and in response to this limitation, researchers have called for:(1) the use of cognitive measures that assess processes with theoretical links tofactors involved in social functioning (Silverstein, 1997); and (2) less globalmeasures of social functioning that allow investigators to conduct more preciseexaminations of the complex functional outcomes such as social skills and theirunderlying mechanisms (Green, 1996; Heaton & Pendleton, 1981; Palmer et al.,1997). In assessing social problem-solving skill, our study was limited becausemeasure of social functioning relied on response to videotaped vignettes, and didnot incorporate more real-world exercises and performance-based measures suchas role playing. In addition, while social problem-solving models have high facevalidity, the external validity of these measures has not been demonstrated and isnot known (Bellack et al., 1994; Liberman et al., 1986).
Clarifying which aspects of social problem solving are related to outcome canguide the development of targeted interventions. For example, if substantialevidence was found to implicate proficiency in cognitive flexibility as a ‘‘rate-limiting’’ factor, then this would suggest the need to remediate abstract thinkingskills as part of social skills training. This approach has been used by Brennerand his colleagues (Brenner et al., 1992; Spaulding, et al., 1999a; Spaulding,Reed, Sullivan, Richardson, & Weiler, 1999b). However, the specificcontribution of executive functioning including the cognitive differentiationand flexibility (abstraction) module to the overall effectiveness of the treatmentof which it forms a part, Integrated Psychological Therapy, has not beendetermined (Bellack, Gold, & Buchanan, 1999; Silverstein, Menditto, & Stuve,2001). Therefore, future studies are necessary to examine not only the multiple
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aspects of problem solving, but also how to directly address attention, memory,and executive functioning deficits, and other ‘‘rate-limiting’’ cognitive factors,and the degree to which these interventions improve outcomes.
To date, studies of rehabilitation approaches are not conclusive, and the fieldis in relatively early stages of development. Many rehabilitation expertsconcentrate their work on remediation of key cognitive deficits. However, otherswork on the rebalancing of impairments by utilising relative strengths, and therehabilitative focus here might be to use data to link certain types of cognitivedeficits to specific types of skill training. In this way, data, such as the linkagebetween levels of cognitive functioning and social problem solving, can be usedto develop interventions that help compensate for specific and targeted deficits.Therefore, whereas data may shape interventions by leading psychiatricrehabilitation specialists to focus on remediation of specific areas of cognitivedeficit, information about the relationship between cognitive variables andillness outcomes is also used to develop strategies and interventions aimed atbuilding compensatory skills (Flesher, 1990). For example, the limitations posedby impairments in cognitive processing may not be sufficiently addressed ifpsychiatric rehabilitation interventions primarily focus on community re-entryskills training without attending to the potential rate-limiting effects of cognitivedeficits. In addition, it may not be sufficient to address deficits at the level ofcognitive remediation when further intermediary or targeted skills training isneeded before entering more complex or more cognitively challenging levels ofskills training. In conducting research studies, the multifaceted nature ofoutcome in schizophrenia must be appreciated, as it is likely that differentcombinations of variables (e.g., attention, memory, abstraction) are related todifferent outcomes (e.g., skills training, social functioning, symptom reduction)as preliminary evidence already suggests is the case (Silverstein et al., 1998).Recent research indicates that cognitive remediation, using both computer-assisted and non-computer-assisted generic problem-solving strategies, pro-motes beneficial social outcomes such as improved social cognition (Spauldinget al., 1999a,b) and decrease in socially inappropriate behaviours (Wykes,Reeder, Corner, Williams, & Everitt, 1999).
In summary, we conducted a study that examined the relationship betweensymptoms, cognitive functioning, and social skill deficits in schizophrenia. Ourresults showed that cognitive function, specifically cognitive flexibility andverbal learning memory, are important mediating factors in the process ofencoding information and effectively evaluating alternative social responses.Whereas symptoms were not indicated as predictors of adaptive social problem-solving skills, cognitive deficits were shown to contribute to problems in theseaspects of social functioning in schizophrenia. These data have implicationswith respect to: (1) the need for longitudinal research to clarify theinterrelationship between symptoms, cognition, and social functioning; (2) thevalue of utilising real-world approximations of social abilities and integrating
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neuropsychological assessments to determine functional level; and (3) utilisingcomprehensive evaluations to develop targeted cognitive interventions orcompensatory strategies designed to maximise social skill training in psychiatricrehabilitation.
Manuscript received 4 December 2000Revised manuscript received 7 September 2001
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