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ognitive deficits in schizophrenia include impaired attention (Franke et al., 1994; Nuechterlein and Asarnow,
1989) and executive functions (Rund and Borg, 1999), particularly cognitive flexibility and forward planning (Morice
and Delahunty, 1996); and motor abnormalities (Wolff and
ODriscoll, 1999), including fine motor skills (Griffith et al.,
1994; Vrtunski et al., 1989). Cognitive abnormalities may be
present long before illness onset in individuals who develop
schizophrenia (Cuesta et al., 2001).
Altered personality is another consistent feature of
schizophrenia (Gurrera et al., 2000; Solano and De Chavez,
2000) and is often evident before the clinical disorder
manifests itself. Patients with schizophrenia are less extraverted and have higher neuroticism and lower conscientiousness and agreeableness scores than healthy controls (see
Gurrera et al., 2000, for concise review). High neuroticism
and low extraversion (Berenbaum and Fujita, 1994) and
cluster A personality disorder traits (Cuesta et al., 1999) are
most commonly found in individuals who later develop
schizophrenia, but the prevalence of all personality disorder
types is increased in schizophrenia (Lyons and Jerskey, 2002;
Solano and De Chavez, 2000).
Severity and quality of personality deviance affect
long-term outcome in schizophrenia (Gross and Huber, 1993;
Smith et al., 1996; Solano and De Chavez, 2000). Even
so-called normal personality traits contribute to variability
in clinical presentation and treatment response (Smith et al.,
1995) and predict workplace performance (Lysaker et al.,
1998). Poorer workplace function, particularly in the area of
social skills, is also predicted by deficits in cognitive function
(Lysaker et al., 1998). Verbal memory, attention, and card
sorting predict community and social functioning, but positive symptoms do not (Green, 1996).
Despite pari passu premorbid emergence and overlapping effects on illness outcome, little research has been done
to determine whether personality abnormalities and cognitive
deficits in schizophrenia are related or independent domains
(Cuesta et al., 2001). Abnormal cognition is generally attributed to altered brain function caused by the disorder, but there
is no consensus regarding the source of the personality
differences. Whether premorbid personality is an independent
risk factor for developing schizophrenia (van Os and Jones,
2001) or a manifestation of a common, underlying neuropathological process remains an open question.
The Journal of Nervous and Mental Disease Volume 193, Number 11, November 2005
The Journal of Nervous and Mental Disease Volume 193, Number 11, November 2005
Several recent studies have begun to address this question. In recently admitted inpatients with psychosis, more
severe negative, positive, and disorganization symptoms were
associated with more extreme personality disorder traits
(Cuesta et al., 1999). Sociopathy was positively correlated
with disorganization, whereas schizoid features were correlated only with positive and negative symptom dimensions. In
another study of patients with psychosis (Cuesta et al., 2001),
passive-dependent and schizoid traits, but not anankastic or
sociopathic traits, correlated with measures of memory, attention, and executive function. Moreover, personality and
cognitive measures each accounted for substantial amounts of
the others variance (Cuesta et al., 2001).
Personality and cognitive ability are correlated in the
general population (Harris et al., 1998), and the former can
affect the latter. For example, some individual differences in
task performance have been attributed to temperamentally
based speed-related personality attributes (Brebner and
Stough, 1995). Introverts may perform relatively better on
tasks emphasizing accuracy or involving associative learning
ability (e.g., verbal tasks), while extraverts may be comparatively advantaged on tasks that emphasize speed or require
the acquisition of automatic motor sequences (i.e., performance tasks; Zeidner, 1995). In a community sample selected
on the basis of self-reported schizophrenia spectrum symptoms, variation in several personality dimensions predicted
Wisconsin Card Sort Test (WCST) performance (Tien et al.,
1992). Thus, personality may also influence cognition in
individuals prone to schizophrenia.
Neurocognitive deficits can impact the acquisition of
social skills in schizophrenia (Addington et al., 1998; Green,
1996), so it seems plausible that schizophrenia could impact
cognitive operations essential to healthy personality functioning, thus contributing to premorbid and comorbid personality
features of schizophrenia. In multiple sclerosis, a progressive
demyelinating disorder commonly associated with cognitive
disturbance, frontal lobe function correlates with personality
traits (Benedict et al., 2001). In healthy volunteers, smaller
frontal brain volume is associated with more pathologic
MMPI scores (Matsui et al., 2000), suggesting that even
subclinical reductions in functional brain capacity may produce personality changes.
Considerable evidence indicates that five major trait
dimensions account for most personality variance in normal
and psychiatrically ill populations (John and Srivastava,
1999; Stone, 1993). The NEO Personality Inventory (NEO-PI;
Costa and McCrae, 1992), widely used to assess these five
factors, measures neuroticism, extraversion, openness, agreeableness, and conscientiousness. High neuroticism individuals are tense, irritable, discontented, shy, and moody, and lack
self-confidence. Extraverted individuals are sociable, assertive, energetic, adventurous, enthusiastic, and outgoing. Open
individuals are curious, imaginative, unconventional, artistic,
and excitable, and have wide interests. Agreeable individuals
are forgiving, warm, sympathetic, and modest, and not demanding or stubborn. Conscientious individuals are selfdisciplined, efficient, thorough, dutiful (not careless), deliberate (not impulsive), and organized.
2005 Lippincott Williams & Wilkins
METHODS
Design and Procedure
Data collection was cross-sectional and consisted of
formal neuropsychological assessment and a self-administered personality measure.
Subjects
Medicated outpatients with clinically stable DSM-IV
schizophrenia (N 30) and healthy subjects (N 45)
recruited from the community participated in this study,
which was approved by the Human Studies Subcommittee of
the VA Boston Healthcare System. Subjects were age 18 to
55 years and spoke English as a first language. Community
volunteers were recruited through advertisements placed in
local newspapers. Callers were screened for the following
exclusion criteria: any history of ECT, neurological disorder,
head injury, mental retardation, or loss of consciousness; and
current treatment with medications that might affect cognitive
function. Potential subjects were subsequently evaluated with
the Clinicians Version of the Structured Clinical Interview
for DSM-IV Axis I disorders, which was conducted by
doctorate-level psychologists who had been trained and qualified in performing this assessment. Those with DSM-IV
alcohol or drug dependence (ever) or DSM-IV alcohol or
drug abuse within the past year were excluded. After a
complete description of the study was provided to the subjects, written informed consent was obtained.
Patients had significantly lower mean (SD) educational
achievement (12.0 1.9 vs. 14.8 2.2 grades; t 5.70; p
0.001) and socioeconomic status (SES; Hollingshead, 1965)
than controls (4.13 .63 vs. 2.33 1.04; t 9.30; p
0.001), but mean (SD) parental SES (PSES) was similar for
both groups (2.57 1.29 vs. 2.69 1.00; t .439; p 0.646).
Subject groups did not differ with respect to gender (male/
female ratio, 38/7 vs. 24/6; Fisher exact test, p 0.757) or
mean (SD) age (39.7 8.9 vs. 39.2 9.7 years; t .247;
p 0.806). Patients had mean (SD) illness duration of 17.7
(9.7) years (range, 134 years). Clinical stability was defined
operationally as the ability to complete an extensive battery
of neuropsychological tests.
Symptom Measures
Schizophrenia symptom data, measured with the SANS
and SAPS (Andreasen, 1984a, 1984b), were available in 22
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Gurrera et al.
The Journal of Nervous and Mental Disease Volume 193, Number 11, November 2005
Medication
Twenty-four patients were receiving antipsychotic
monotherapy, and six patients were treated with two different
antipsychotic medications, in the following frequencies: olanzapine (eight), fluphenazine (six), risperidone (six), haloperidol (four), clozapine (four), loxapine (three), quetiapine
(two), chlorpromazine (two), and ziprasidone (one). Chlorpromazine-equivalent dosages (Stoll, 1998) were used in
analyses. Antipsychotic medication dosage data were available for 27 patients: mean (SD) dosage was 533 (475)
chlorpromazine-equivalent milligrams.
Neuropsychological Variables
A neuropsychological battery was administered to subjects as part of a multidisciplinary, longitudinal study of
schizophrenia. The battery included measures of motor speed,
visual attention, and executive functions, assessed respectively by Finger Tapping, Trail Making, and Wisconsin Card
Sort (Lezak, 1995). These variables were selected because of
their previous associations with personality function (see
introduction), and because they were available for all study
subjects. Finger tapping performance was measured by the
number of taps accomplished within 10 seconds (average of
three trials). Performance on Trails A and B of the HalsteadReitan Battery was defined as time (seconds) to task completion. WCST performance was measured by counting categories
completed, perseverative responses, and errors (perseverative
and nonperseverative). Wechsler Memory Scale, Third Edition,
measures of immediate and delayed auditory and visual memory
and working memory (Wechsler, 1997) were available for a
subset (N 21) of patients.
Personality Measures
The NEO Five Factor Inventory (NEO-FFI), Form S
(Costa and McCrae, 1992), is a self-administered questionnaire consisting of 60 items rated on a 5-point response scale
(strongly disagree to strongly agree); it is a shortened
version of the NEO-PI, which has 180 items. Both instruments measure the dimensions of neuroticism, extraversion,
openness, agreeableness, and conscientiousness. Correlations
between the FFI and PI versions range from .77 to .92, and
coefficients for FFI scales range from .68 to .86 (Costa and
McCrae, 1992). Although originally developed for nonpsychiatric populations, the NEO-PI appears valid for patients
with schizophrenia (Kentros et al., 1997), and the FFI has
also been used to assess individuals with schizophrenia (Gurrera et al., 2000).
Statistical Analyses
Personality dimensions and profiles in each group were
compared by MANOVA before and after extracting personality
variance shared with neuropsychological task performance. For
the latter comparison, multiple linear regression was used to
compute residual scores for each NEO scale. Product moment
correlations between personality and neuropsychological variables, by group, supplemented this analysis.
716
RESULTS
Neuropsychological Measures
Mean neuropsychological test scores differed significantly
between groups (MANOVA multivariate F8,66 8.94; p
0.001; all univariate F1,73 7.06; p 0.010). As expected,
patients performed significantly worse than controls on all measures. Medication dosage was not correlated with neuropsychological components (r .084; p 0.677).
Personality Measures
Personality scores differed significantly between subject groups (multivariate F5,69 4.29; p 0.002). Patients
scored higher on neuroticism (53.08 vs. 44.35; univariate
2005 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease Volume 193, Number 11, November 2005
df
Mean
Square
Neuroticism
1 Regression
Residual
2 Regression
Residual
940.84
5769.95
1428.03
5282.76
2
72
3
71
3 Regression
Residual
2272.26
4438.53
Agreeableness
1 Regression
Residual
2 Regression
Residual
R2
R2
Variable
470.42
80.14
476.01
74.40
5.870
0.004
.374
.140
.140
6.398
0.001
.461
.213
.073
6
68
378.71
65.27
5.802
0.000
.582
.339
.126
Educ/SES
Age/PSES
Educ/SES
Age/PSES
Diagnosis
Educ/SES
Age/PSES
Diagnosis
WCST
Finger Tapping
Trail Making
.374*
.021
.125
.014
.367*
.021
.152
.064
.244*
.202
.434*
0.001*
0.845
0.384
0.895
0.013*
0.880
0.160
0.691
0.041*
0.073
0.001*
1447.55
10363.30
1448.43
10362.42
2
72
3
71
723.78
143.94
482.81
145.95
5.029
0.009
.350
.123
.123
3.308
0.025
.350
.123
.000
3 Regression
Residual
2444.21
9366.64
6
68
407.37
137.74
2.957
0.013
.455
.207
.084
Educ/SES
Age/PSES
Educ/SES
Age/PSES
Diagnosis
Educ/SES
Age/PSES
Diagnosis
WCST
Finger Tapping
Trail Making
.338*
.090
.330*
.090
.012
.257
.191
.229
.133
.163
.369*
0.003*
0.416
0.032*
0.421
0.938
0.094
0.108
0.195
0.302
0.186
0.011*
Conscientiousness
1 Regression
Residual
2 Regression
Residual
431.17
6367.70
515.37
6283.49
2
72
3
71
215.58
88.44
171.79
88.50
2.438
0.095
.252
.063
.063
1.941
0.131
.275
.076
.012
3 Regression
Residual
1089.86
5709.01
6
68
181.64
83.96
2.164
0.057
.400
.160
.084
Educ/SES
Age/PSES
Educ/SES
Age/PSES
Diagnosis
Educ/SES
Age/PSES
Diagnosis
WCST
Finger Tapping
Trail Making
.168
.188
.065
.185
.151
.010
.288*
.042
.288*
.238
.133
0.146
0.104
0.676
0.110
0.333
0.948
0.020*
0.815
0.032*
0.062
0.362
Model
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Gurrera et al.
The Journal of Nervous and Mental Disease Volume 193, Number 11, November 2005
718
.189 .440*
.023
.355* .185
.196 .398*
.324 .159
.047
.140
.271
.241
.224
.087 .029
.197
.049
.204
.250 .252 .039 .117 .098
.304* .115
.059 .234 .319*
.340* .235
.289* .197
.307*
.259 .333* .203 .345* .167
.322* .151 .184 .384* .245
.277 .288* .175 .312* .189
The Journal of Nervous and Mental Disease Volume 193, Number 11, November 2005
DISCUSSION
The finding that patients with clinically stable schizophrenia have significantly altered personality profiles
higher neuroticism and lower scores on other NEO scalesis
consistent with prior studies using healthy comparison groups
or normative data (Gurrera et al., 2000). A principal finding
of the present study is that group personality differences
disappear when the variance shared with neuropsychological
task performance is statistically controlled, indicating that
personality differences may be related to abnormal cognition
associated with schizophrenia.
A second major finding of the present study is that
diagnosis, in itself, uniquely accounted for very little personality variance. Neuroticism was the only dimension to which
diagnosis made a statistically significant contribution, but
after neuropsychological variables were added to the regression model, diagnosis was no longer significantly associated
even with this dimension. Since patients with more severe
illness will also tend to have more extreme personality
deviations and more impaired cognition, one of the risks of a
cross-sectional study is that simultaneous variation within
these domains will be misinterpreted as being causally related
when it is not. A major strength of the multiple linear
regression technique, supplemented by analysis of partial and
semipartial correlation coefficients, is that this collinearity
can be statistically controlled so that unique independentdependent variable relationships can be measured. If diagnosis had been the principal source of variance for both personality and task performance in this study (i.e., patients had
schizophrenia-related altered personality and also schizophrenia-related impaired cognition), diagnosis would have been
related consistently to personality across all regression models. In addition, its semipartial correlation coefficients would
have been similar in magnitude to its first-order correlation
coefficients and substantially larger than the semipartial correlation coefficients for task performance. However, the opposite pattern was found, suggesting that neuropsychological
task performance is, at least quantitatively, a much more
important source of personality variance than is diagnosis.
The observation that neuropsychological task performance variables and personality dimensions were correlated
more frequently in the control group supports the interpretation that diagnosis per se is not the principal source of
personality variance in schizophrenia. Rather, these data
seem more consistent with the view that neuropsychological
function contributes to personality variation, regardless of
diagnosis. Correlations were modest in size across groups, the
pattern of associations between tasks and personality dimensions showed similarities and differences between groups,
and most of the total personality variance in this sample was
not explained by the independent variables included in this
2005 Lippincott Williams & Wilkins
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Gurrera et al.
The Journal of Nervous and Mental Disease Volume 193, Number 11, November 2005
CONCLUSION
These data provide preliminary evidence that neuropsychological performance deficits associated with schizophrenia may contribute to personality alterations that also characterize this disorder. Individuals personal background and
educational experience also appear to contribute significantly
to other personality features, such that individual differences
in personal background and neuropsychological function dis-
720
tinctly affect personality dimensions. These results also suggest that the relationships between neuropsychological function and personality may be independent of diagnosis.
REFERENCES
Addington J, McCleary L, Munroe-Blum H (1998) Relationship between
cognitive and social dysfunction in schizophrenia. Schizophr Res. 34:
59 66.
Andreasen NC (1984a) Scale for the Assessment of Negative Symptoms
(SANS). University of Iowa: Iowa City.
Andreasen NC (1984b) Scale for the Assessment of Positive Symptoms
(SAPS). University of Iowa: Iowa City.
Benedict RH, Priore RL, Miller C, Munschauer F, Jacobs L (2001) Personality disorder in multiple sclerosis correlates with cognitive impairment.
J Neuropsychiatry Clin Neurosci. 13:70 76.
Berenbaum H, Fujita F (1994) Schizophrenia and personality: Exploring the
boundaries and connections between vulnerability and outcome. J Abnorm
Psychol. 103:148 158.
Brebner J, Stough C (1995) Theoretical and empirical relationships between
personality and intelligence. In DH Saklofske, M Zeidner (Eds), International Handbook of Personality and Intelligence (Chapter 16, pp 321
347). New York: Plenum Press.
Cohen J, Cohen P (1983) Applied Multiple Regression/Correlation Analysis
for the Behavioral Sciences (pp 79 132). Hillsdale, New Jersey: Lawrence
Erlbaum Associates.
Costa PT Jr, McCrae RR (1992) NEO PI-R: Professional Manual (Revised
NEO Personality Inventory (NEO PI-R) and NEO Five-Factor Inventory
(NEO-FFI)). Odessa (FL): Psychological Assessment Resources, Inc.
Cuesta MJ, Peralta V, Caro F (1999) Premorbid personality in psychoses.
Schizophr Bull. 25:801 811.
Cuesta MJ, Peralta V, Zarzuela A (2001) Are personality traits associated
with cognitive disturbance in psychosis? Schizophr Res. 51:109 117.
Franke P, Maier W, Hardt J, Hain C, Cornblatt BA (1994) Attentional
abilities and measures of schizotypy: Their variation and covariation in
schizophrenic patients, their siblings and normal control subjects. Psychiatry Res. 54:259 272.
Golden CJ, Kushner T, Lee B, McMorrow MA (1998) Searching for the
meaning of the Category Test and the Wisconsin Cart Sort Test: A
comparative analysis. Int J Neurosci. 93:141150.
Goode DJ, Manning AA, Middleton JF, Williams B (1981) Fine motor
performance before and after treatment in schizophrenic and schizoaffective patients. Psychiatry Res. 5:247255.
Green MF (1996) What are the functional consequences of neurocognitive
deficits in schizophrenia? Am J Psychiatry. 153:321330.
Griffith JM, Adler LE, Freedman R (1994) Fine motor performance in
schizophrenia. Neuropsychobiology. 29:179 184.
Gross G, Huber G (1993) Premorbid personality in schizophrenia: The
contribution of European long-term studies. Neurol Psychiatry Brain Res.
2:14 20.
Gurrera RJ, Nestor PG, ODonnell BF (2000) Personality traits in schizophrenia: Comparison with a community sample. J Nerv Ment Dis. 188:
3135.
Harris JA, Vernon PA, Jang KL (1998) A multivariate genetic analysis of
correlations between intelligence and personality. Dev Neuropsychol.
14:127142.
Hollingshead AB (1965) Two Factor Index of Social Position. New Haven
(CT): Yale University Press.
John OP, Srivastava S (1999) The Big Five trait taxonomy: History, measurement and theoretical perspectives. In LA Pervin, OP John (Eds),
Handbook of Personality: Theory and Research (2nd ed, Chapter 4, pp
102138). New York: Guilford Press.
Kentros M, Smith TE, Hull J, McKee M, Terkelsen K, Capalbo C (1997)
Stability of personality traits in schizophrenia and schizoaffective disorder: A pilot project. J Nerv Ment Dis. 185:549 555.
Lezak MD (1995). Neuropsychological Assessment (3rd ed). New York:
Oxford University Press.
Lyons MJ, Jerskey BA (2002) Personality disorders: Epidemiological findings, methods and concepts. In MT Tsuang, M Tohen (Eds), Textbook in
Psychiatric Epidemiology (2nd ed, Chapter 21, pp 563599). New York:
Wiley-Liss, Inc.
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