Slow cortical potentials (SCPS) in schizophrenic patients during performance of the Wisconsin card-sorting test (WCST)

A Predictive Processing Account of Card Sorting: Fast Proactive and Reactive Frontoparietal Cortical Dynamics during Inference and Learning of Perceptual Categories

For decades, a common assumption in cognitive neuroscience has been that prefrontal executive control is mainly engaged during target detection [Posner, M. I., & Petersen, S. E. The attention system of the human brain. Annual Review of Neuroscience, 13, 25-42, 1990]. More recently, predictive processing theories of frontal function under the Bayesian brain hypothesis emphasize a key role of proactive control for anticipatory action selection (i.e., planning as active inference). Here, we review evidence of fast and widespread EEG and magnetoencephalographic fronto-temporo-parietal cortical activations elicited by feedback cues and target cards in the Wisconsin Card Sorting Test. This evidence is best interpreted when considering negative and positive feedback as predictive cues (i.e., sensory outcomes) for proactively updating beliefs about unknown perceptual categories. Such predictive cues inform posterior beliefs about high-level hidden categories governing subsequent response selection at target onset. Quite remarkably, these new views concur with Don Stuss' early findings concerning two broad classes of P300 cortical responses evoked by feedback cues and target cards in a computerized Wisconsin Card Sorting Test analogue. Stuss' discussion of those P300 responses-in terms of the resolution of uncertainty about response (policy) selection as well as the participants' expectancies for future perceptual or motor activities and their timing-was prescient of current predictive processing and active (Bayesian) inference theories. From these new premises, a domain-general frontoparietal cortical network is rapidly engaged during two temporarily distinct stages of inference and learning of perceptual categories that underwrite goal-directed card sorting behavior, and they each engage prefrontal executive functions in fundamentally distinct ways.

Cognitive flexibility in neurological disorders: Cognitive components and event-related potentials

Performance deficits on the Wisconsin Card Sorting Test (WCST) in patients with prefrontal cortex (PFC) lesions are traditionally interpreted as evidence for a role of the PFC in cognitive flexibility. However, WCST deficits do not occur exclusively after PFC lesions, but also in various neurological and psychiatric disorders. We propose a multi-component approach that can accommodate this pattern of omnipresent WCST deficits: the WCST is not a pure test of cognitive flexibility, but relies on the effective functioning of multiple dissociable cognitive components. Our review of recent efforts to decompose WCST performance deficits supports this view by revealing that WCST deficits in different neurological disorders can be attributed to alterations in different components. Frontoparietal changes underlying impaired set shifting seem to give rise to WCST deficits in patients with amyotrophic lateral sclerosis, whereas the WCST deficits associated with primary dystonia and Parkinson's disease are rather related to frontostriatal changes underlying deficient rule inference. Clinical implications of these findings and of a multi-component view of WCST performance are discussed.

Cognitive flexibility and its electrophysiological correlates in Gilles de la Tourette syndrome

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Gilles de la Tourette syndrome (GTS) may involve cognitive inflexibility.

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A meta-analysis reveals GTS-related deficits on the Wisconsin Card Sorting Test.

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Card-sorting deficits are larger in children than in adults with GTS.

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Adults with GTS show electrophysiological signs of enhanced cognitive control.

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This change may underlie the normalization of cognitive flexibility in adult GTS.

Motor symptoms in Gilles de la Tourette syndrome (GTS) have been related to changes in frontostriatal brain networks. These changes may also give rise to alterations in cognitive flexibility. However, conclusive evidence for altered cognitive flexibility in patients with GTS is still lacking. Here, we meta-analyzed data from 20 neuropsychological studies that investigated cognitive flexibility in GTS using the Wisconsin Card Sorting Test (WCST). Results revealed medium-sized GTS-related performance deficits, which were significantly modulated by age: Whilst being substantial in children and adolescents with GTS, WCST deficits seem to dissolve in adult patients with GTS. This age-related normalization of WCST performance might result from the compensatory recruitment of cognitive control in adult patients with GTS. We addressed this possibility by examining neural correlates of proactive and reactive cognitive control in an event-related potential (ERP) study. We analyzed cue- and target-locked ERPs from 23 adult patients with GTS and 26 matched controls who completed a computerized version of the WCST. Compared to controls, patients with GTS showed a marked increase in parietal cue-locked P3 activity, indicating enhanced proactive cognitive control. We conclude that the additional recruitment of proactive cognitive control might ensure flexible cognitive functioning in adult patients with GTS.

Attentional Set-Shifting Across Species

Attentional set-shifting, as a measure of executive flexibility, has been a staple of investigations into human cognition for over six decades. Mediated by the frontal cortex in mammals, the cognitive processes involved in forming, maintaining and shifting an attentional set are vulnerable to dysfunction arising from a number of human neurodegenerative diseases (such as Alzheimer's, Parkinson's and Huntington's diseases) and other neurological disorders (such as schizophrenia, depression, and attention deficit/hyperactivity disorder). Our understanding of these diseases and disorders, and the cognitive impairments induced by them, continues to advance, in tandem with an increasing number of tools at our disposal. In this chapter, we review and compare commonly used attentional set-shifting tasks (the Wisconsin Card Sorting Task and Intradimensional/Extradimensional tasks) and their applicability across species. In addition to humans, attentional set-shifting has been observed in a number of other animals, with a substantial body of literature describing performance in monkeys and rodents. We consider the task designs used to investigate attentional set-shifting in these species and the methods used to model human diseases and disorders, and ultimately the comparisons and differences between species-specific tasks, and between performance across species.

Declarative memory and WCST-64 performance in subjects with schizophrenia and healthy controls

The Wisconsin Card Sorting Test (WCST) is a set-switching task used extensively to study impaired executive functioning in schizophrenia. Declarative memory deficits have also been associated with schizophrenia and may affect WCST performance because continued correct responding depends on remembering the outcome of previous responses. This study examined whether performance in visual and verbal declarative memory tasks were associated with WCST performance. Subjects comprised 30 patients with schizophrenia or schizoaffective disorder (SCZ) and 30 demographically matched healthy controls (CON) who were tested on the WCST, the Benton Visual Retention Test (BVRT), the California Verbal Learning Test (CVLT), and the Continuous Performance Test (CPT). SCZ subjects showed significant correlations between visual and verbal declarative memory and performance on the WCST-64 that were in the hypothesized direction such that worse memory performance was associated with worse performance on the WCST. CON subjects did not show a significant relationship between visual or verbal memory and WCST-64 performance. Fisher's r to z transformations indicated that the associations between declarative memory and WCST-64 performance in the SCZ subjects differed significantly from those of CON subjects. The findings suggest that interpretations of WCST-64 scores for subjects with schizophrenia should be considered in light of their declarative memory functioning.

Right frontal event related EEG coherence (ERCoh) differentiates good from bad performers of the Wisconsin Card Sorting Test (WCST)

AIM

To investigate changes in Event-Related Coherence (ERCoh) associated to good and bad resolution of the Wisconsin Card Sorting Test (WCST).

METHODS

Event-Related Potentials (ERPs) were recorded from a sample of 30 university students while they performed a computerized version of the WCST. ERCoh was calculated for frontal and parietal electrodes for two specific moments: immediately before the response and after the feedback cues.

RESULTS

Bad performers presented significantly reduced ERCoh at the right frontal region (in alpha, beta-1 and beta-2 bands), while no consistent group differences emerged for parietal ERCoh. Furthermore, the strength of functional coupling (ERCoh) between midfrontal and right-frontal electrodes was a good predictor of WCST behavioural parameters, such as the percentage of perseverative errors or the number of categories achieved.

CONCLUSIONS

The results suggest that the right prefrontal cortex is specifically involved in executive functions, such as planning and foresight, tapped by the WCST. Although the specificity of the WCST to explore frontal lesions has been recently questioned, the present findings support that prefrontal areas are specifically involved in the successful resolution of the test by healthy subjects.

Do schizophrenia patients make more perseverative than non-perseverative errors on the Wisconsin Card Sorting Test? A meta-analytic study

The Wisconsin Card Sorting Test (WCST) is widely used to explore executive functions in patients with schizophrenia. Among other findings, a higher number of perseverative errors has been suggested to implicate a deficit in task switching and inhibitory functions in schizophrenia. Many studies of patients with schizophrenia have focused on perseverative errors as the primary performance index in the WCST. However, do schizophrenia patients characteristically make more perseverative than non-perseverative errors compared with healthy controls? We reviewed the literature where schizophrenia patients were engaged in the WCST irrespective of the primary goal of the study. The results showed that while both schizophrenia patients and healthy participants made more perseverative than non-perseverative errors, the contrast between perseverative and non-perseverative errors is higher in schizophrenia patients only at a marginal level of significance. This result suggests that schizophrenia patients do make a comparable number of non-perseverative errors and cautions against simplistic interpretation of poor performance of schizophrenia patients in WCST as entirely resulting from impairment in set-shifting or inhibitory functions.

The Madrid card sorting test (MCST): a task switching paradigm to study executive attention with event-related potentials

Event-related potentials (ERPs) provide valuable information about the fast brain dynamics subserving cognitive functions such as attention and working memory. Most ERP studies employ cognitive paradigms with a fixed task-set (i.e., press a button to coloured targets), but few have measured ERPs time-locked to shifts in set using a task-switching paradigm. The Madrid card sorting test (MCST) is a dual task protocol in which feedback cues signal unpredictable shifts in set (i.e., from 'sort cards by colour' to 'sort cards by shape'). This protocol allows for an integrated analysis of ERPs to both feedback cues and target card events, providing separate ERP features for the shifting, updating, and rehearsal of attention sets in working memory. Two of these ERP indices are the frontal and posterior aspects of the P300 response. Feedback cues that direct a shift in set also elicit a frontally distributed P3a potential (300-400 ms). Instead, target card events evoke increasingly larger posterior P3b (350-600 ms) activity as the new task set becomes gradually rehearsed. The observed modulations in the frontal and posterior aspects of the P300 response system are interpreted from current models of prefrontal cortex function in the executive control of attention.

Think differently: a brain orienting response to task novelty

Cognitive flexibility hinges on a readiness to direct attention to novel events, and on an ability to change one's mental set to find new solutions for old problems. Human event-related potential (ERP) studies have described a brain 'orienting' response to discrete novel events, marked by a frontally distributed positive potential peaking 300-400 ms post-stimulus (P3a). This brain potential has been typically related to bottom-up processing of novel non-targets under a fixed task-set (i.e., press a button to coloured targets), but had never been related to top-down attention control in dual-task paradigms. In this study, 27 subjects had their ERPs measured while they performed a version of the Wisconsin card sorting test (WCST), a dual-task paradigm where the same feedback cue signalled unpredictable shifts to a new task set (i.e., from 'sort by colour' to 'sort by shape'). Feedback cues that directed a shift in the subject's mental set to a new task-set elicited frontally distributed P3a activity, thus suggesting a role of the P3a response system in task-set shifting. Feedback cues also evoked a longer latency positive potential (350-600 ms; P3b), that was larger the more task rules were held in memory. In line with current models of prefrontal function in the executive control of attention, this P3a/P3b response system appears to reflect the co-ordinated action of prefrontal and posterior association cortices during the switching and updating of task sets in working memory.

Cerebral signs of altered adaptability in females with acute psychosis

In psychosis, behavior is not guided by sensory cues from surroundings. Novel, meaningful behaviors require intact integrative functions such as short-term memory and motor planning, as well as an optimized level of arousal. In this study, we monitored markers of automatic auditory processing in 15 female never-medicated psychotic patients. Fifty-eight channels of EEG were recorded simultaneously with sympathetic skin responses while arousing auditory stimuli were delivered. Neuropsychological tests concentrating on frontal lobe functions were also performed. Prominent neurophysiological and behavioral signs of increased cortical activation were observed in psychotic patients. This widespread disinhibition may attempt to compensate for the impairment of neuronal processing of sensory input from surroundings in the earliest stages of a psychotic illness.

Does the Wisconsin Card Sorting Test measure prefontral function?

This review describes a research program aimed at evaluating the validity and specificity of the Wisconsin Card Sorting Test (WCST), one of the most widely used tests of prefrontal function in clinical and experimental neuropsychology. In spite of its extensive use, voices of caution have arisen against the use of WCST scores as direct markers of prefrontal damage or dysfunction. Adopting a cognitive neuroscience approach, the present research program integrates behavioral, physiological, and anatomical information to investigate the cognitive and neural mechanisms behind WCST performance. The results show that WCST performance evokes conspicuous physiological changes over frontal as well as posterior brain regions. Moreover, WCST scores confound very heterogeneous cognitive and neural processes. This confounding effect may have led many authors to overlook the relative importance of certain dysfunctional states such as those indexed by random errors. These findings strongly suggest that WCST scores cannot be regarded as valid nor specific markers of prefrontal lobe function. However, they do provide some relevant clues to update our current knowledge about prefrontal function. In the long run, the integrative approach of cognitive neuroscience may help us design and develop more valid and sensitive tools for neuropsychological assessment.

Attentional set shifting modulates the target P3b response in the Wisconsin card sorting test

For years the Wisconsin card sorting test (WCST) has been used as a test of frontal lobe function. Recent event-related potential (ERP) research has shown large differences in the amplitude of P3b responses evoked by early and late trials within each WCST series ([8]: Barceló F., Sanz M., Molina V., Rubia FJ. The Wisconsin Card Sorting Test and the assessment of frontal function: A validation study with event-related potentials. Neuropsychologia 1997;35:399-408). In this study, 16 normal subjects performed a WCST adaptation to investigate the role of attentional set shifting in these WCST P3b effects. Two control tasks were designed to examine whether early-late WCST P3b changes reflect category selection (attention) or category storage (memory) operations. Results suggest both a sharp P3b attenuation during shift WCST trials, followed by a gradual P3b build-up during post-shift trials. This P3b modulation could not be attributed to selection or storage of simple sensory stimulus dimensions, nor was it observed when the new rule was externally prompted by the first card in the WCST series. Instead, WCST P3b changes seem related to the endogenously generated shift in the perceptual rule used to sort the cards (i.e., the shift in set). The gradual build-up in P3b amplitude paralleled a progressive improvement in sorting efficiency over several post-shift WCST trials. A model based on formal theories of visual attention and attentional set shifting is proposed to account for these effects. The model offers firm grounds for prediction and bridges the gap between related clinical and experimental evidence.

Slow EEG potentials (contingent negative variation and post-imperative negative variation) in schizophrenia: their association to the present state and to Parkinsonian medication effects

Between warning signal (S1) and imperative signal (S2), the EEG shifts negatively (contingent negative variation, CNV) reflecting preparation and expectancy. Reduced CNV and continued negativity after S2 (post-imperative negative variation, PINV) have been repeatedly found in schizophrenic patients and have been interpreted as a deficit in attentional processes (CNV) and as uncertainty about the correctness of one's own response to the S2 (PINV). Recent studies obtained a CNV reduction specifically at central sites but not at frontal ones. The present study investigated whether these alterations of slow negative potentials depend on present state of symptoms, on the particular task used, and on neuroleptic medication. Therefore, out-patients and in-patients were studied, two different S1-S2 tasks were used, and the control groups were healthy subjects and patients with Parkinson's disease. The central CNV reduction was stable across tasks and across in-patients and outpatients. Frontal CNV was reduced in in-patients but in only one of the two tasks in outpatients. The schizophrenic patients' enhanced PINV was larger contralaterally than ipsilaterally to the responding hand, correlated with medication, and occurred in similar way in patients with Parkinson's disease. Thus, the PINV increase might reflect the Parkinsonian side effects of the anti-psychotic medication. In contrast, the central CNV reduction appears as a stable marker of schizophrenia, the frontal CNV reduction as a state-dependent effect. The central CNV reduction might reflect impairment in forming stable stimulus-response associations, the relative frontal enhancement might reflect the out-patients' attempt at compensating that impairment.

A meta-analytic review of Wisconsin Card Sort studies in schizophrenia: general intellectual deficit in disguise?

A majority of studies show that schizophrenics perform poorly on so-called tests of executive or frontal lobe function--the paradigmatic case being the Wisconsin Card Sort Test (WCST). Nevertheless, the specific character of this deficit in schizophrenia remains underspecified. In particular, it seems premature to assume that schizophrenia is characterised by an executive dysfunction and/or a disorder of frontal lobe function before determining whether any deficit is: selective; disproportionate to the general level of intellectual functioning; or qualitatively comparable with that of frontal lobe patients. A meta-analysis was conducted on 29 studies comparing the performance of schizophrenics and normal controls on the WCST. This showed that the mean weighted effect size was large for categories achieved (d = 0.91), medium for absolute level of perseveration (d = 0.53), but only small for the proportion of perseverative errors (d = 0.18). By contrast, the effect size for Wechsler Adult Intelligence Scale Intelligence Quotient (WAIS IQ) in a subset of these studies (d = 1.23) was significantly larger than for any WCST measures. This pattern of findings challenges notions that schizophrenia is characterised by an executive dysfunction that is: selective; disproportionate to IQ level; and analogous to that found in frontal lobe patients. Rather, the poor WCST performance of schizophrenics appears to reflect a generalised intellectual deficit.

Cognitive deficits associated with frontal-lobe infarction in children with sickle cell disease

This study examined the cognitive manifestations of frontal-lobe infarction in a population of children with sickle cell disease (SCD). Forty-one patients with SCD underwent MRI. Five patients with stroke symptoms had large infarcts encroaching on the tissue of the frontal lobes. Four patients without symptoms had smaller frontal-lobe infarcts. The patients with stroke were significantly impaired on measures of intelligence, memory, and frontal-lobe function (Wisconsin Card Sorting Test, WCST) compared with both the patients with normal MRI scans (N=30) and a group of sibling controls (N=15), who did not differ from each other. Patients with covert infarction obtained scores on the intelligence tests and the WCST that fell in between those of the stroke patients and the other two groups. This trend toward impairment suggests that patients with covert infarction are at similar risk for cognitive deficits to those with stroke.

The Wisconsin Card Sorting Test and the assessment of frontal function: a validation study with event-related potentials

The Wisconsin Card Sorting Test (WCST) is generally regarded as the prototype of abstract reasoning task and has been routinely used to assess frontal lobe function in a variety of clinical and research contexts. However, there are growing concerns that the WCST fails to discriminate frontal patients from those with lesions in other brain regions or from normals. Event-related potentials (ERP) from frontal, fronto-temporal, temporal, parietal and occipital areas were recorded during the performance of a computerized version of the WCST in order to explore frontal versus non-frontal ERP indexes during WCST activation. The task protocol was contrived to focus on the differences between early and late trials of each WCST series. Cognitive processes underlying these two task conditions have been described as extradimensional and intradimensional shifts in attention, respectively. Differences between early and late WCST trials appeared as soon as 120 msec poststimulus and were associated with a negative field potential centred at the fronto-temporal region of the left hemisphere. Significantly larger amplitudes of the posterior P3b wave for late as compared with early WCST trials also lent support to claims of a strong involvement of working memory mechanisms during WCST performance. Results are discussed in terms of the implications for the utility of ERP measures in clinical neuropsychology.

Contingent negative variation (CNV) and determinants of the post-imperative negative variation (PINV) in schizophrenic patients and healthy controls

A slowly rising cortical potential shift with negative polarity following the imperative stimulus of a forewarned reaction time task, the 'post-imperative negative variation' (PINV), is regularly observed in schizophrenic patients but not in controls. The topography of the PINV suggests that it may originate in frontal cortical regions. We used a task designed to test two putative prefrontal cortical functions: working memory and processing of ambiguity. Nineteen patients with a chronic schizophrenic disorder and 19 control subjects matched for age, sex, and education participated in two experimental sessions. The EEG was recorded from frontal, central, temporal, and parietal leads over both hemispheres using a DC amplifier. PINV amplitudes were generally larger in patients than in controls. If the result of comparing physical features of the two successively presented stimuli (warning and imperative stimulus) was ambiguous rather than clear, an augmentation of the PINV amplitudes was seen in both groups. If this comparison required high rather than low involvement of working memory functions, PINV amplitudes were augmented in schizophrenic patients only. Scalp distribution of the PINV indicated a left-hemisphere fronto-central PINV maximum in patients, and a right-hemisphere predominance in controls, which was larger following ambiguous stimulus comparisons. These results suggest that ambiguity during the comparison of physical features of successively presented stimuli may be a general factor of the PINV in schizophrenic patients and healthy controls. Augmented involvement of working memory functions, presumably subserved by the prefrontal cortex, specifically affected the fronto-centrally predominant PINV in schizophrenic patients. This result is compatible with the hypothesis of prefrontal cortical dysfunctions in schizophrenia.

Reduced emotional response of schizophrenic patients in remission during social interaction

Inappropriate emotional response during social interaction is a prominent feature of schizophrenia during the acute stage of illness. This study evaluates the course of reduced facial activity in schizophrenic patients in remission and compares it with healthy controls. The experimental conditions included watching two films, one inducing happy and the other sad emotional states. Each is followed by an interview eliciting happy and sad feelings. The facial actions were recorded (1) by a computer-based analysis of recordings of the skin movement and (2) by electromyography of the corrugator and zygomaticus muscles. Twenty schizophrenic patients in remission and 20 normal controls participated in the study. In contrast to previously studied acute patients, there was no overall reduction of facial expression in the upper face of schizophrenic patients in remission. Patients showed fewer movements (automatic analysis) of the lower face during the happy interview and more movements during the sad interview compared with controls. Furthermore, schizophrenic patients showed reduced zygomaticus activity (EMG) during both the happy film and the interview, suggesting a reduced ability of schizophrenic patients to express happy facial expressions, such as smiling, in the lower face. This may indicate a reduced variability in emotional response in schizophrenia.

Steady-state visually evoked potential topography during the Wisconsin card sorting test

This paper describes, for the first time, changes in steady-state visually evoked potential (SSVEP) topography associated with the performance of a computerised version of the Wisconsin card sort test (WCS). The SSVEP was recorded from 64 scalp sites and was elicited by a 13 Hz spatially uniform visual flicker presented continuously while 16 subjects performed the WCS. in the WCS, the sort criterion was automatically changed after subjects had sorted 10 cards correctly. Feedback on the 11th card always constituted a cue for a change in the sort criterion. It was found that in the 1-2 sec interval after the occurrence of the cue to change sort criterion, the prefrontal, central and right parieto-temporal regions showed a pronounced attenuation in SSVEP amplitude and an increase in phase lag. These changes, interpreted as an increase in regional cortical activity, are not apparent in the equivalent portions of the WCS when the sort criterion does not need to be changed. These results indicate that the levels of prefrontal and right parieto-temporal activity varied during the performance of the WCS, peaking at the times a change in sort criterion was required.

SPECT analysis of regional cerebral blood flow changes in patients with schizophrenia during the Wisconsin Card Sorting Test

Single photon emission computed tomography (SPECT) images were obtained in 10 right-handed neuroleptic-treated schizophrenic patients and 10 healthy volunteers using Tc-99m-hexamethyl-propylenamine oxime (Tc99m-HMPAO) during performance of the Wisconsin Card Sorting Test (WCST) and at rest. None of the patients showed severe impairment on the WCST. The patient group showed a statistically insignificant trend to incur more unique errors. In both the patient and control groups, the left lateral prefrontal blood flow significantly increased during the WCST, as compared to during resting conditions. Only during the WCST, the patient group showed a significant regional cerebral blood flow (rCBF) decline in the left medial prefrontal cortex, as well as in the right side under both the test and resting conditions. This left medial prefrontal rCBF during the WCST correlated positively with the number of unique errors, although this correlation was statistically insignificant. The right fronto-parietal rCBF was significantly increased in the patient group under both the test and resting conditions. Moreover, in the left hippocampal region, the patient group showed a significant rCBF increase under resting conditions.

Frontal lobology--psychiatry's new pseudoscience

The frontal lobes are the most evolutionarily advanced organ of the body. Here lies the seat of the highest human functions of thought, intellect, creativity, self-control and social interaction (Milner & Petrides, 1984; Lishman, 1987; Russell & Roxanas, 1990; Kolb & Wishaw, 1990). As one recent reviewer notes (Reading, 1991), it is hard to avoid ‘sounding metaphysical’ when going through such a list. It seems that, in accordance with psychiatry's own late phylogenesis, the frontal lobes have only just been discovered.