understanding processing speed—its subcomponents and their relationship to characteristics of...

16
This article was downloaded by: [Gazi University] On: 16 August 2014, At: 18:22 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Cognitive Neuropsychiatry Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/pcnp20 Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia Matteo Cella a & Til Wykes a a Department of Psychology, Institute of Psychiatry, King's College London, London, UK Published online: 19 Oct 2012. To cite this article: Matteo Cella & Til Wykes (2013) Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia, Cognitive Neuropsychiatry, 18:5, 437-451, DOI: 10.1080/13546805.2012.730038 To link to this article: http://dx.doi.org/10.1080/13546805.2012.730038 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/ terms-and-conditions

Upload: til

Post on 03-Feb-2017

212 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

This article was downloaded by: [Gazi University]On: 16 August 2014, At: 18:22Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Cognitive NeuropsychiatryPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/pcnp20

Understanding processing speed—itssubcomponents and their relationshipto characteristics of people withschizophreniaMatteo Cellaa & Til Wykesa

a Department of Psychology, Institute of Psychiatry, King'sCollege London, London, UKPublished online: 19 Oct 2012.

To cite this article: Matteo Cella & Til Wykes (2013) Understanding processing speed—itssubcomponents and their relationship to characteristics of people with schizophrenia, CognitiveNeuropsychiatry, 18:5, 437-451, DOI: 10.1080/13546805.2012.730038

To link to this article: http://dx.doi.org/10.1080/13546805.2012.730038

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to orarising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms& Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Page 2: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

Understanding processing speed*its subcomponents and

their relationship to characteristics of people with

schizophrenia

Matteo Cella and Til Wykes

Department of Psychology, Institute of Psychiatry, King’s College

London, London, UK

Introduction. Processing speed has been advanced as one of the core cognitivedeficits of schizophrenia. Several methods were developed to assess this domain;however, most tasks, despite indexing several cognitive and motor components,tend to characterise processing speed as a unitary construct. This study explorespotential subcomponents of processing speed in schizophrenia and their relation-ship with demographic, clinical, and neuropsychological characteristics.Methods. One hundred and sixty participants with a diagnosis of schizophreniawere assessed on neuropsychological tasks measuring processing speed, executivefunction, and memory. Demographics and clinical characteristics were alsorecorded. Three independent measures were extracted to account for subcompo-nents of processing speed: behavioural execution, response processing, andaccuracy.Results. The identified components of processing speed were differently predictedby demographic characteristics, clinical characteristics, and overall intelligenceestimates. Age and symptom severity were important predictors for behaviouralexecution; intelligence and social withdrawal predicted response processing; andaccuracy was predicted by illness duration. Correlations showed executive functionand memory to be associated with response processing and accuracy but not withbehavioural execution.Conclusions. Distinct characteristics of schizophrenia seem to predict processingspeed subcomponents. Distinguishing between behavioural, processing, andaccuracy may be a useful way forward to refine our understanding of processingspeed impairment in schizophrenia.

Keywords: Cognition; Cognitive deficit; Neuropsychology; Processing speed;

Psychomotor; Schizophrenia.

Correspondence should be addressed to Matteo Cella, Department of Psychology, Institute

of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Email:

[email protected]

Cognitive Neuropsychiatry, 2013

Vol. 18, No. 5, 437�451, http://dx.doi.org/10.1080/13546805.2012.730038

# 2013 Taylor & Francis

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 3: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

INTRODUCTION

A large number of studies have now shown that cognitive impairment is a

reliable feature associated with the diagnosis of schizophrenia. Several

cognitive domains including memory, attention, and executive function

accumulated compelling evidence, supported by meta-analysis, in favour of

their critical role in schizophrenia (Aleman, Hijman, de Haan, & Kahn,

1999; Bokat & Goldberg, 2003; Johnson-Selfridge & Zalewski, 2001). More

recently, research has emphasised the role of processing speed as a possible

critical factor underlying deficits in different cognitive domains and a

significant mediator of functional capacity (Ojeda, Pena, Sanchez,

Elizagarate, & Ezcurra, 2008; Wykes, Reeder, & Corner, 2000). Two large

meta-analyses have characterised the extent of the processing speed deficit in

schizophrenia with effect sizes comprised between �1.3 and �1.5

(Dickinson, Ramsey, & Gold, 2007; Knowles et al., 2010). In the more

recent of these studies, Knowles, David, and Reichenberg (2010) found that

the processing speed deficit was moderated by IQ difference between

comparison subject and schizophrenia patients, study vintage and chlorpro-

mazine equivalent daily dosage.

A number of caveats, however, may be relevant in considering these

results and might warrant a closer look. Processing speed, as originally

defined, refers to the execution speed of a task (Salthouse, 1996). Processing

speed tasks traditionally measure behaviour as their dependent variables;

this is, as for most neuropsychological tasks, the time taken to complete the

mental operation and implement the response behaviour. Most processing

speed tasks therefore assess processing speed by coupling together the

mental processing and the behavioural execution. The widely used digit

symbol coding task, for instance, requires participants to substitute symbols

and digits using a key under time conditions (Weschler, 1997). In this way

the task measures processing speed by assessing both the time in which the

mental operation (i.e., substitution) is performed and the time necessary to

execute the behaviour (i.e., writing the symbol). Both the cognitive and the

behavioural part of the task require time; however, which process is affected

in schizophrenia is still unclear. A task that may be able to disentangle these

two components could characterise effectively what is impaired. Further,

the moderating effect of antipsychotic medication on processing speed

found by Knowles et al. (2010) could, speculatively, be dependent on a

selective effect of the medication on one of these processing speed

components.

A second caveat relates to the construct validity of processing speed. The

concept of processing speed, as mentioned earlier, refers to the velocity with

which a task is accomplished. This definition, however, gives little emphasis

to errors, their potential interference effect, and influence on the cognitive

438 CELLA AND WYKES

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 4: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

system. When assessing processing speed with the digit symbol coding task,

assessors infer processing speed from the number of correct responses given

in a specified time frame. Errors, however, are part of the information

processing accomplished and may interact significantly with performance

(Hester, Madeley, Murphy, & Mattingley, 2009). In the context of

schizophrenia this may signify that the lower processing speed performance

consistently found with the digit symbol coding task could result from

either an excessive number of errors, a lower speed of information

processing, or a combination of these two variables. Research has shown

that schizophrenia is associated with various difficulties in error monitoring

and that these difficulties may mediate performance in a number of

neuropsychological tasks (Huang & Chan, 2007; Mathalon et al., 2002;

Silver & Goodman, 2007). It appears important therefore to investigate

errors in the context of the processing speed deficit observed in

schizophrenia.

Tasks assessing processing speed are often used in studies investigating the

relationship between cognitive characteristics and clinical features of schizo-

phrenia (Fuller & Jahanshahi, 1999; Holthausen, Wiersma, Knegtering, &

Van den Bosch, 1999; Hong et al., 2002; Morrens, Hulstijn, Van Hecke,

Peuskens, & Sabbe, 2006; Van Hoof, Jogems-Kosterman, Sabbe, Zitman, &

Hulstijn, 1998). Further, some longitudinal studies have suggested schizo-

phrenia’s poor prognosis may be associated with reduced processing speed

performance at intake (Gold, Arndt, Nopoulos, O’Leary, & Andreasen, 1999;

Wykes et al., 2000). However, these findings carry a substantial degree of

variability in their results. This variability has been hypothesised to be

dependent on the different tasks used to assess processing speed but also to

the differential relationship that subcomponents of processing speed may

have with schizophrenia clinical features (Morrens, Hulstijn, & Sabbe,

2007).In the current study, we aim to explore three subcomponents of

processing speed, namely: Behavioural Execution (BE), Response Proces-

sing (RP), and Accuracy (AC). A first aim of this study is to assess the

validity of these subcomponents against a traditional measure of processing

speed, the Trail Making test, Part A (Gaudino, Geisler, & Squires, 1995). A

second aim is to investigate how variables with a known effect on

processing speed differentially predict each processing speed subcomponent.

To this end, we explored the role that patients’ characteristics, symptom

severity, medication, and IQ levels may have in predicting different

processing speed components. A third aim of this study is to assess the

association that processing speed components may have with other

impaired neuropsychological domains in schizophrenia: executive function

and memory.

PROCESSING SPEED SUBCOMPONENTS 439

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 5: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

METHOD

Participants

A total of 160 participants were recruited from local community mental

health teams in the South London and Maudsley National Health ServiceFoundation Trust. Participants were included if they had been in contact

with the services for at least 1 year, were at least 17 years old, had a diagnosis

of schizophrenia based on DSM-IV (American Psychiatric Association,

1994), presented no evidence of organic brain disease, no primary diagnosis

of substance abuse, and have not changed medication in the last month. The

majority of eligible participants were treated as outpatients, but a few were in

residential rehabilitation programmes in psychiatric hospitals. All partici-

pants recruited were medicated with antipsychotic medication. Medicationdosage at assessment is reported in mg of Chlorpromazine equivalent

according to Woods (2003).

Measures

Processing speed

Response Processing Task (RPT). The RPT was developed by Wickens(1974) and then tested and adapted to psychiatric settings by Wykes, Katz,

Sturt, and Hemsley (1992). Briefly, the task comprises three conditions where

different types of response are required: an initial simple reaction time

condition, with one light and one button, where participants are asked to

press the button when the light flashes; a second condition, with four lights

and four buttons, where participants are asked to press the button next to the

flashing light; and a final condition, also with four lights and four buttons,

where participants are asked to press the first button clockwise to the lightthat has flashed. Both Conditions 1 and 2 have 40 trials, and Condition 3 has

80 trials. In all the conditions response time is recorded. Condition 1 indexes

a simple motor response (i.e., one button), Condition 2 indexes motor

response with a degree of uncertainty (i.e., four buttons), and Condition 3

indexes the aforementioned processes in addition to the mental time

necessary to adapt an acquired response to contingent information. The

additional time necessary to perform in Condition 3 is therefore indicative of

the ability to inhibit a high-frequency, potent response in favour of thecorrect response. The additional time necessary to perform this operation is

indicative of the speed of inhibition and consequent programming of the

correct response.

Hayling sentence completion test. This task was developed by Burgess

and Shallice (1997) to assess executive function and response speed.

440 CELLA AND WYKES

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 6: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

Specifically, this task is thought to assess both initiation speed and response

suppression (Bielak, Mansueti, Strauss, & Dixon, 2006). It consists of two

parts each comprising 15 sentences missing the last word. Participants are

read each sentence and asked to complete with a word. In Part 1,

participants are asked to complete the sentence with an appropriate word;

in Part 2, they are asked to complete the sentence with an unrelated word.

Response reaction time is recorded for each part of the task and number of

mistakes is recorded for the second part of the task.

Three processing speed components were considered in the analysis:

Behavioural Execution (BE), Response Processing (RP), and Accuracy (AC).

We considered the simple reaction time mean of the Response Processing Task

to Index BE, the difference in mean reaction times between Condition 3 and 2

of the Response Processing Task to Index RP, and the total number of mistakes

in the Hayling Part 2 to Index AC. We preferred to use the Hayling instead of

the Stroop errors because the Stroop errors occurred infrequently in our

sample (i.e., 60% did not have an error on the Stoop against 9% on the

Hayling). In addition to the three subcomponents mentioned we also evaluated

a classical measure of processing speed as a way of measuring the construct

validity of the proposed subcomponents. For this purpose the time to complete

Trail A of the Trail Making test (Gaudino et al., 1995) was chosen.

Neuropsychological measures of memory and executive function

Participants were assessed with widely used neuropsychological tests

assessing memory and executive functions. These were the Digit Span

(Wechsler, 1997), the Stroop Test (Golden, 1978), the Wisconsin Card

Sorting (Heaton, Chelune, Talley, Kay, & Curtiss, 1993), and the Trail

Making test (Gaudino et al., 1995). All tests were administered in computer-

based format. Premorbid intelligence levels were assessed with the National

Adult Reading Test (NART; Russell et al., 2000).

Symptom severity

Symptom severity was measured with the PANSS (Kay, Fizbein, & Opler,

1987) and the BPRS (Overall & Gorham, 1962). The inconsistency between

these measures is due to a modification of the routine symptoms assessment

tools adopted by the recruiting centres, initially using the BPRS and more

recently changed to the PANSS. Due to incomplete overlapping between the

measures, the scales scores were transformed in Clinical Global Impression

(CGI) equivalent levels using Leucht et al. (2006) recommendations. The

Social Behaviour Schedule (Wykes & Sturt, 1986) was used to assess

problematic behaviour and functional levels.

PROCESSING SPEED SUBCOMPONENTS 441

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 7: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

Analysis

Normality distribution was assessed with examination of skew and kurtosis

values and of P-P plots and inferential tests of normality (i.e., the

Kolmorogov-Smirnov test; Orr, Sackett, & DuBois, 1991). Distributions

with significant skew were normalised with logarithmic transformation.

Hierarchical regression models were used to explore the contribution of

patient’s characteristics and IQ to different components of processing speed.

Predictors shown to have an influence on processing speed were entered in

the first level (e.g., medication), whereas predictors with a less clear

contribution were entered at subsequent stages. The same hierarchical

structure was applied to each subcomponent of processing speed (i.e., BE,

RP, and AC). Pearson product momentum correlation was used to assess the

association between processing speed components, memory, and executive

function. Analysis of variance was used to assess between groups differences.

RESULTS

The patients’ general characteristics and neuropsychological measures are

reported in Table 1. Processing speed components did not differ between

patients recruited from different settings (e.g., outpatient units and

residential care settings).

Processing speed

Average processing speed subcomponents with standard deviation are

presented in Table 1. BE significantly correlates with AC, r�.27, p B

.0001, and RP also correlates with AC, r�.24, p B.01. Scores on the Trail

Making Part A positively correlates with BE, r�.41, p B.0001, RP, r�.46,

p B.0001, and AC, r�.25, p B.0001.

Predictors of processing speed

Hierarchical regression models were performed to evaluate the contribution

patients’ characteristics to the three components of processing speed. In the

first level predictors with a known influence on processing speed were

entered. These are age, education, illness length, symptom severity, and

medication. Overall estimate intelligence levels were entered at Level 2.

Model summaries for each of the processing speed components are

presented in the Table 2.

442 CELLA AND WYKES

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 8: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

Processing speed, memory, and executive function

Correlations were performed to explore the relationship between processing

speed, memory, and executive function. BE significantly correlates with Trail

Making A. RP significantly correlates with memory, Stroop number of

words, and Trail Making B � A time. Similarly AC significantly correlates

with memory, Stroop number of words, Trail Making B � A time, but had

also a significant association with the WCST number of preservative errors.

Errors and processing speed

To further explore the relevance that errors may have on processing speed

and its components we divided the entire sample in four quartiles based on

number of errors on Hayling B (i.e., AC score). The bottom quartile

comprises 41 participants with a mean number of errors of 0.93 (SD�0.18),

the top quartile comprises 36 participants with a mean number of errors of

13.06 (SD�3.1); the mean number of errors differed significantly between

TABLE 1Participants’ demographics, clinical characteristics, and neuropsychological mea-

sure scores

Mean (SD)

Age (years) 28 (12.4)

Female n (%) 45 (28.1)

Years of education 11.6 (2)

Illness duration (years) 2.9 (1.1)

Chlorpromazine equivalent (mg) 464.5 (401.3)

CGI equivalent 3.7 (1)

SBS total 12.5 (9.3)

SBS Social Withdrawal 3.2 (2.1)

SBS Thought Disorder 2.4 (2)

IQ (NART) 94.6 (16.2)

BE (RPT simple reaction time; ms) 510.3 (416.6)

RP (RPT processing speed; ms) 513.5 (541.6)

AC (Accuracy) 6 (4.6)

WAIS-II Digit span 14.6 (3.9)

WCST*Preservative errors 47 (34.5)

WCST*Categories achieved 2.3 (2.1)

Stroop n words in 120 s (colour word) 71.9 (25.5)

Stroop time (colour word task � colour task; second) 106.7 (62.7)

Trail Making time A (second) 53.8 (48.2)

Trail Making time B � A (second) 86.8 (99.1)

CGI�Clinical Global Impression; SBS�Social Behaviour Schedule; NART�National Adult

Reading Test.

PROCESSING SPEED SUBCOMPONENTS 443

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 9: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

the groups, F(1, 79)�654.8, pB.0001. When compared these two groups

showed significant differences in BE, F(1, 79)�6.36, p�.01, and RP,

F(1, 79)�8.1, p�.006, but also on a traditional measure of processing

speed, the Trail Making Part A, F(1, 79)�5.7, p�.02.

Processing speed components and positive and negativesymptoms

As the global CGI score may fail to characterise the clinical complexity of

schizophrenia symptoms, a further analysis was conducted to assess the

association of processing speed subcomponents with positive and negative

symptoms as measured by the PANSS in a subset of patients (n�82) that

completed this assessment instrument (see Table 4).

TABLE 2Stepwise regression

Unstandardised beta Standard error Standardised beta

Behavioural execution

Step 1

Age 0.005 0.001 0.33***

Symptoms severity (CGI) 0.033 0.013 0.22**

Social withdrawal (SBS) 0.01 0.005 0.18*

Step 2

Age 0.005 0.001 0.36***

Symptoms severity (CGI) 0.034 0.012 0.23**

IQ (NART) �0.002 0.001 �0.182*

Response processing

Step 1

Education �0.044 0.017 �0.224**

Social withdrawal (SBS) 0.029 0.011 0.24*

Step 2

Social withdrawal (SBS) 0.025 0.011 0.2*

IQ (NART) 0.009 0.002 �0.33***

Accuracy

Step 1

Duration of illness 0.323 0.116 0.274**

Step 2

Duration of illness 0.376 0.120 0.320**

Variables entered in Step 1: Age, education, SBS total, SBS social withdrawal, SBS thought

disorder, Chlorpromazine equivalent (mg), CGI equivalent score derived from BPRS or PANSS,

illness length. Variables entered in Step 2: NART estimated premorbid IQ. For behavioural

execution, R2�.22*** for Step 1; ^R2�.03*** for Step 2. *pB.05; **pB.01; ***pB.001. For

response processing, R2�.14* for Step 1; ^R2�.1*** for Step 2. *pB.05; **pB.01; ***pB.001.

For accuracy, R2�.14* for Step 1; ^R2�.02** for Step 2. *pB.05; **pB.01; ***pB.001.

444 CELLA AND WYKES

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 10: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

DISCUSSION

A wealth of converging literature suggests that deficits in processing speed

are one of the key cognitive problems associated with schizophrenia

(Bachman et al., 2010; Dickinson et al., 2004; Sanchez et al., 2009).

However, the definition and the traditional assessment of processing speed

encompass a number of subcomponents that may be differentially affected

by psychotic symptoms, medications, demographic characteristics, and

schizophrenia illness course. In this paper, we have attempted to study

TABLE 4Person correlation of procession speed subcomponents and positive and negative

factors from the PANSS

PANSS positive PANSS negative

AC (no. of errors) .13 .19

BE (time in s) �.01 .28**

RP (time in s) .19 .42**

Trail Making A (time in s) �.03 .43**

**p B .0001.

TABLE 3Correlation between processing speed subcomponents, premorbid intelligence,

memory, executive function, and processing speed measures

Behavioural

execution

Response

processing Accuracy

Premorbid intelligence

�.11* �.41** .19*

Memory

WAIS-II Digit span �.19 �.28** �.32**

Executive function

WCST*Preservative errors �.156 .207 �.322***

WCST*Categories achieved �.05 �.26* �.37**

Stroop time colour word task � colour

task

�.16 �.28* .05

Trail Making time B � A .036 .385*** .09

Processing speed

Trail Making time A .414*** .460*** .245**

Stroop n words in 120 s (colour word) �.242 �.647** �.28**

*p B .05; **p B.01; ***p B .001.

PROCESSING SPEED SUBCOMPONENTS 445

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 11: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

how subcomponents of processing speed may be differentially affected by

patients’ characteristics and to explore their relationship with other known

impaired neuropsychological domains such as memory and executive

function. To do this we identified three subcomponents of processing speed:

BE (indexing the time necessary to execute the response behaviour), RP(indexing the time necessary to mentally compute and plan the response),

and AC (indexing the number of errors made).

We found that global symptom severity and age were the most significant

predictors of BE. This result is in line with the literature on psychomotor

slowing in the general population in regards to age, and also for

schizophrenia where higher symptom severity was found to be associated

with psychomotor slowness (Morrens et al., 2007; Morrens, Hulstijn, &

Sabbe, 2008). In line with previous research, further analysis conducted on asubsample indicated that negative symptoms may be the dimension

prevalently associated with BE problems. However, BE was not associated

with memory and most of the executive function measures employed with

the exception of Trail Making Part A. This association was expected and

indeed supports the validity of BE as the motor-behavioural part of

processing speed tasks. The lack of correlation with most executive function

tests employed may, on the other hand, indicate that the behavioural

component of processing speed could be detached from cognitivecomponents.

Social withdrawal and intelligence were found to be important predictors

of the RP component of processing speed. Social withdrawal, as indexed by

the SBS, measures behaviours considered part of the negative symptoms of

schizophrenia. The relevance of negative symptoms to processing speed is a

consistent finding in the literature (e.g., McDowd, Tang, Tsai, Wang, & Su,

2011); however, our results suggest that the negative symptoms may be more

relevant for the RP rather than affecting equally all processing speedcomponents.

Overall intelligence levels estimates were found to be relevant in predicting

both the BE and the RP. This is perhaps unsurprising as processing speed is

considered one of the core cognitive domains for estimating intelligence. Our

findings, in particular, support the relevance of intelligence for the RP

component. RP represents perhaps the most ‘‘cognitive’’ component of

processing speed and, similarly to computational power for computers, it can

be applied to a number of different tasks but only with the assistance ofother cognitive domains.

We found RP to correlate with various executive function tests. A

particularly strong association was found between RP and the number of

correct coloured words in the Stroop test. This association suggests that the

response processing indexed by the response processing task may draw

considerably on response inhibition. Recent work conducted in the general

446 CELLA AND WYKES

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 12: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

population suggests that response inhibition is an important, although

distinct, component of processing speed (McAuley & White, 2011). In our

view the task used here to index RP features clear elements of response

inhibition that may be difficult to disentangle. Indeed if RP can be defined as

the time necessary to complete the mental operations required to accomplisha task, this time is clearly dependent on the amount and relevance of the

information that the cognitive system requires to use but also inhibit.

The result of the regression analysis suggested illness duration as a

significant predictor of AC. This is an interesting and in part unexpected

finding. Some research has speculatively suggested that error monitoring and

insensitivity to errors may be a characteristic associated with various features

of schizophrenia including symptoms severity, illness chronicity, and

prognosis (Huang & Chan, 2007; Silver & Goodman, 2007; Silver et al.,2006). Our results partially support this claim and advance the role of illness

length as a better predictor compared to previously suggested features such

as global symptom severity. Research on factors affecting error monitoring

and accuracy in schizophrenia suggest a general decline associated with the

illness course; however, additional research is required to reach more

conclusive findings (Johnson-Selfridge & Zalewski, 2001).

AC was also found to inversely correlate with memory and the WCST.

The association with the WCST number of category achieved suggests thatAC may require substantial support from the attentional shifting component

traditionally indexed by this measure and consistently found impaired in

schizophrenia (Koren et al., 1998). Tasks indexing processing speed through

the exclusive measure of correct behaviour (e.g., digit coding) do not require

attentional shift to monitor errors. Our findings suggest, in line with

previous research, that attentional shifting may be important for error

monitoring, has a general impact on executive function, and may have a

specific relevance for some components of processing speed (Kim et al.,2006).

Although a less conventional component of processing speed, AC

influenced traditional components such as BE and RP. The results of the

sensitivity analysis showed that participants with higher number of errors on

the Hayling B also had higher behavioural and processing response time as

well as higher overall processing speed time on the Trail Making Part A. This

suggests that processing speed can be influenced by errors made during the

task.A second sensitivity analysis conducted on a subset of participants

assessed with the PANSS confirmed the association of processing speed

components with negative symptoms with the exception of AC. The lack of

association between errors and negative symptoms may be due to the

oversensitivity to negative feedback observed in negative affect (Cella,

Dymond, & Cooper, 2010; Martin-Soelch, 2009).

PROCESSING SPEED SUBCOMPONENTS 447

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 13: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

None of the processing speed components examined was predicted by

chlorpromazine equivalent dose. This finding adds to the controversial

literature on the effects of antipsychotic medication on processing speed.

Early studies suggested that neuroleptic medications were strongly associated

with, if not the cause of, slow psychomotor behaviour observed in

schizophrenia (King, 1990). More recent studies, however, suggest that

atypical antipsychotic treatment is associated with improvement in psycho-

motor performance (Bilder et al., 2002; Purdon et al., 2000). The incon-

clusive findings warrant further research focusing on the role of different

medication on processing speed.The current paper also reintroduces the use of the Response Processing

Task to measure processing speed (Wykes at al., 1992). This task carries

considerable advantages compared to the traditional digit symbol coding

task. A first advantage is the possibility to disentangle behavioural execution

from information processing. The second advantage is that the response

required is simple (i.e., press a button) and does not involve more advanced

motor planning such as copying symbols. The task also carries the limitation

of not recording errors and therefore biasing participants towards correct

rather than faster performance, although the task can be adapted.

A further limitation to our findings is the absence of a healthy control

group with which compare the findings of our clinical group. In the absence

of a control group, it is difficult to say with certainty whether the pattern of

association evidenced from the current data might differ in a group of

individuals not affected by schizophrenia.

Although processing speed deficit in schizophrenia is widely reported in

the literature very little research has tried to explore in details what might

contribute to the behavioural response considered by processing speed tasks.

In this study we have attempted to identify relevant subcomponents of

processing speed and assess how neuropsychological and clinical features

could influence this process. Our results support the notion that the

behavioural response to tasks indexing processing speed consists of different

subcomponents differently affected by schizophrenia characteristics.

Manuscript received 11 January 2012

Revised manuscript received 5 July 2012

First published online 19 October 2012

REFERENCES

Aleman, A., Hijman, R., de Haan, E. H., & Kahn, R. S. (1999). Memory impairment in

schizophrenia: A meta-analysis. American Journal of Psychiatry, 156, 1358�1366.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th

ed.). Washington, DC: Author.

448 CELLA AND WYKES

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 14: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

Bachman, P., Reichenberg, A., Rice, P., Woolsey, M., Chaves, O., Martinez, D., et al. (2010).

Deconstructing processing speed deficits in schizophrenia: Application of a parametric digit

symbol coding test. Schizophrenia Research, 118(1�3), 6�11.

Bielak, A. A., Mansueti, L., Strauss, E., & Dixon, R. A. (2006). Performance on the Hayling and

Brixton tests in older adults: Norms and correlates. Archive of Clinical Neuropsychology, 21,

141�149.

Bilder, R. M., Goldman, R. S., Volavka, J., Czobor, P., Hoptman, M., Sheitman, B., et al. (2002).

Neurocognitive effects of clozapine, olanzapine, risperidone, and haloperidol in patients with

chronic schizophrenia or schizoaffective disorder. American Journal of Psychiatry, 159, 1018�1028.

Bokat, C. E., & Goldberg, T. E. (2003). Letter and category fluency in schizophrenic patients: A

meta-analysis. Schizophrenia Research, 64, 73�78.

Burgess, P. W., & Shallice, T. (1997). The Hayling and Brixton Tests. Thurston, UK: Thames Valley

Test Company.

Cella, M., Dymond, S., & Cooper, A. (2010). Impaired flexible decision-making in Major

Depressive Disorder. Journal of Affective Disorders, 124(1�2), 207�210.

Dickinson, D., Iannone, V. N., Wilk, C. M., & Gold, J. M (2004). General and specific cognitive

deficits in schizophrenia. Biological Psychiatry, 55, 826�833.

Dickinson, D., Ramsey, M. E., & Gold, J. M. (2007). Overlooking the obvious: A meta-analytic

comparison of digit symbol coding tasks and other cognitive measures in schizophrenia.

Archive of General Psychiatry, 64, 532�542.

Fuller, R., & Jahanshahi, M. (1999). Concurrent performance of motor tasks and processing

capacity in patients with schizophrenia. Journal of Neurology, Neurosurgery, and Psychiatry, 66,

668�671.

Gaudino, E. A., Geisler, M. W., & Squires, N. K. (1995). Construct validity in the Trail Making

Test: What makes Part B harder? Journal of Clinical and Experimental Neuropsychology, 17,

529�535.

Gold, S., Arndt, S., Nopoulos, P., O’Leary, D. S., & Andreasen, N. C. (1999). Longitudinal study of

cognitive function in first-episode and recent-onset schizophrenia. American Journal of

Psychiatry, 156, 1342�1348.

Golden, C. J. (1978). Stroop Color and Word Test: A manual for clinical and experimental uses.

Chicago, IL: Skoelting.

Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G. (1993). Wisconsin Card Sorting

Test manual: Revised and expanded. Odessa, FL: Psychological Assessment Resources.

Hester, R., Madeley, J., Murphy, K., & Mattingley, J. B. (2009). Learning from errors: Error-related

neural activity predicts improvements in future inhibitory control performance. Journal of

Neuroscience, 29, 7158�7165.

Holthausen, E. A., Wiersma, D., Knegtering, R. H., & Van den Bosch, R. J. (1999).

Psychopathology and cognition in schizophrenia spectrum disorders: The role of depressive

symptoms. Schizophrenia Research, 39, 65�71.

Hong, K. S., Kim, J. G., Koh, H. J., Koo, M. S., Kim, J. H., Lee, D., & Kim, E. (2002). Effects of

risperidone on information processing and attention in first-episode schizophrenia. Schizo-

phrenia Research, 53, 7�16.

Huang, A. J., & Chan, R. C. (2007). Error monitoring is associated with the clinical state of

schizophrenia. Australian and New Zealand Journal of Psychiatry, 41, 773�774.

Johnson-Selfridge, M., & Zalewski, C. (2001). Moderator variables of executive functioning in

schizophrenia: Meta-analytic findings. Schizophrenia Bulletin, 27, 305�316.

Kay, S. R., Fizbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS)

for schizophrenia. Schizophrenia Bulletin, 13, 261�276.

Kim, M. S., Kang, S. S., Shin, K. S., Yoo, S. Y., Kim, Y. Y., & Kwon, J. S. (2006).

Neuropsychological correlates of error negativity and positivity in schizophrenia patients.

Psychiatry and Clinical Neurosciences, 60, 303�311.

PROCESSING SPEED SUBCOMPONENTS 449

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 15: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

King, D. J. (1990). The effect of neuroleptics on cognitive and psychomotor function. British

Journal of Psychiatry, 157, 799�811.

Knowles, E. E., David, A. S., & Reichenberg, A. (2010). Processing speed deficits in schizophrenia:

Reexamining the evidence. American Journal of Psychiatry, 167, 828�835.

Koren, D., Seidman, L. J., Harrison, R. H., Lyons, M. J., Kremen, W. S., Caplan, B., et al. (1998).

Factor structure of the Wisconsin Card Sorting Test: Dimensions of deficit in schizophrenia.

Neuropsychology, 12, 289�302.

Leucht, S., Kane, J. M., Etschel, E., Kissling, W., Hamann, J., & Engel, R. R. (2006). Linking

the PANSS, BPRS, and CGI: Clinical implications. Neuropsychopharmacology, 31, 2318�2325.

Martin-Soelch, C. (2009). Is depression associated with dysfunction of the central reward system?

Biochemical Society Transactions, 37, 313�317.

Mathalon, D. H., Fedor, M., Faustman, W. O., Gray, M., Askari, N., & Ford, J. M. (2002).

Response monitoring dysfunction in schizophrenia: An event-related brain potential study.

Journal of Abnormal Psychology, 111, 22�41.

McAuley, T., & White, D. A. (2011). A latent variables examination of processing speed, response

inhibition, and working memory during typical development. Journal of Experimental Child

Psychology, 108, 453�468.

McDowd, J., Tang, T. C., Tsai, P. C., Wang, S. Y., & Su, C. Y. (2011). The association between

verbal memory, processing speed, negative symptoms and functional capacity in schizophrenia.

Psychiatry Research, 187, 329�334.

Morrens, M., Hulstijn, W., & Sabbe, B. (2007). Psychomotor slowing in schizophrenia.

Schizophrenia Bulletin, 33, 1038�1053.

Morrens, M., Hulstijn, W., & Sabbe, B. (2008). The effects of atypical and conventional

antipsychotics on reduced processing speed and psychomotor slowing in schizophrenia: A

cross-sectional exploratory study. Clinical Therapy, 30, 684�692.

Morrens, M., Hulstijn, W., Van Hecke, J., Peuskens, J., & Sabbe, B. G. (2006). Sensorimotor and

cognitive slowing in schizophrenia as measured by the Symbol Digit Substitution Test. Journal

of Psychiatry Research, 40, 200�206.

Ojeda, N., Pena, J., Sanchez, P., Elizagarate, E., & Ezcurra, J. (2008). Processing speed mediates the

relationship between verbal memory, verbal fluency, and functional outcome in chronic

schizophrenia. Schizophrenia Research, 101(1�3), 225�233.

Orr, J. M., Sackett, P. R., & DuBois, C. L. Z. (1991). Outlier detection and treatment in I/O

psychology: A survey of researcher beliefs and an empirical illustration. Personnel Psychology,

44, 473�486.

Overall, J. E., & Gorham, D. R. (1962). The Brief Psychiatric Rating Scale. Psychological Reports,

10, 799�812.

Purdon, S. E., Jones, B. D., Stip, E., Labelle, A., Addington, D., David, S. R., et al. (2000).

Neuropsychological change in early phase schizophrenia during 12 months of treatment with

olanzapine, risperidone, or haloperidol: The Canadian Collaborative Group for research in

schizophrenia. Archives of General Psychiatry, 57, 249�258.

Russell, A. J., Munro, J., Jones, P. B., Hayward, P., Hemsley, D. R., & Murray, R. M. (2000). The

National Adult Reading Test as a measure of premorbid IQ in schizophrenia. British Journal of

Clinical Psychology, 39, 297�305.

Salthouse, T. A. (1996). The processing-speed theory of adult age differences in cognition.

Psychological Review, 103, 403�428.

Silver, H., & Goodman, C. (2007). Impairment in error monitoring predicts poor executive

function in schizophrenia patients. Schizophrenia Research, 94(1�3), 156�163.

Silver, H., Goodman, C., Bilker, W., Gur, R. C., Isakov, V., Knoll, G., & Feldman, P. (2006).

Impaired error monitoring contributes to face recognition deficit in schizophrenia patients.

Schizophrenia Research, 85, 151�161.

450 CELLA AND WYKES

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014

Page 16: Understanding processing speed—its subcomponents and their relationship to characteristics of people with schizophrenia

Sanchez, P., Ojeda, N., Pena, J., Elizagarate, E., Yoller, A. B., Gutierrez, M., & Ezcurra, J. (2009).

Predictors of longitudinal changes in schizophrenia: The role of processing speed. Journal of

Clinical Psychiatry, 70, 888�896.

Van Hoof, J. J., Jogems-Kosterman, B. J., Sabbe, B. G., Zitman, F. G., & Hulstijn, W. (1998).

Differentiation of cognitive and motor slowing in the Digit Symbol Test (DST): Differences

between depression and schizophrenia. Journal of Psychiatry Research, 32, 99�103.

Wechsler, D. (1997). The Wechsler Adult Intelligence Scale (3rd ed.). San Antonio, TX:

Psychological Corporation.

Wickens, C. (1974). Temporal limits of human information processing: A developmental study.

Psychological Bulletin, 81, 739�755.

Woods, S. W. (2003). Chlorpromazine equivalent doses for the newer atypical antipsychotics.

Journal of Clinical Psychiatry, 64, 663�667.

Wykes, T., Katz, R., Sturt, E., & Hemsley, D. (1992). Abnormalities of response processing in a

chronic psychiatric group: A possible predictor of failure in rehabilitation programmes? British

Journal of Psychiatry, 160, 244�252.

Wykes, T., Reeder, C., & Corner, J. (2000). The prevalence and stability of an executive processing

deficit, response inhibition, in people with chronic schizophrenia. Schizophrenia Research,

46(2�3), 241�253.

Wykes, T., & Sturt, E. (1986). The measurement of social behaviour in psychiatric patients: An

assessment of the reliability and validity of the SBS schedule. British Journal of Psychiatry, 148,

1�11.

PROCESSING SPEED SUBCOMPONENTS 451

Dow

nloa

ded

by [

Gaz

i Uni

vers

ity]

at 1

8:22

16

Aug

ust 2

014