Schizophrenia Research 133 (2011) 172–181

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Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

Review

Impaired cognitive inhibition in schizophrenia: A meta-analysis of the Stroop

interference effect
René Westerhausen a, b,⁎, Kristiina Kompus a, Kenneth Hugdahl a, b
a
Department of Biological and Medical Psychology, University of Bergen, Jonas Lies vei 91, N-5009 Bergen, Norway
b
Division of Psychiatry, Haukeland University Hospital, N-5009 Bergen, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Schizophrenia has been consistently shown to be associated with impairment in executive functioning. How-
Received 27 April 2011 ever, although frequently treated as such, the term executive functioning does not refer to a unitary cognitive
Received in revised form 9 August 2011 function; it rather represents a set of basic, lower-level cognitive sub-components, e.g. updating, shifting, and
Accepted 29 August 2011
cognitive inhibition. This specification into sub-components allows for a further differentiation of the execu-
Available online 19 September 2011
tive deficits found in schizophrenia. Focusing on the sub-component of cognitive inhibition, we here present
Keywords:
a meta-analysis of interference effect as assessed with the Stroop Color-Word Interference paradigm. Includ-
Schizophrenia ing the results of 36 studies with 1081 schizophrenia patients and 1026 healthy control subjects, it was
Stroop paradigm shown that schizophrenia patients exhibit an increased Stroop interference effect both in response time
Inhibition (mean effect size: M(g) = 0.43; 95% confidence interval, CI95%: 0.35–0.52) and accuracy (M(g) = 0.62;
Interference CI95%: 0.47–0.77) measures of interference. However, a meta-regression analysis revealed that the size of
Meta-analysis the effect varies depending on the version of the Stroop paradigm used. Regarding the response time mea-
Executive functions sures of interference, studies using the classical card version of the paradigm showed a significantly larger
effect size than studies using a single-trial computerized version of the paradigm (M(g) = 0.60 vs.
M(g) = 0.19). Despite of the dissociation between the two versions of the paradigm, the results of the present
meta-analysis indicate that the reported global deficits in executive functioning found to be associated with
schizophrenia are at least partly due to a reduced ability of cognitive inhibition.
© 2011 Published by Elsevier B.V.

1. Introduction meta-analyses have revealed that executive functions are affected in

Cognitive impairment can be considered a primary symptom asso-
ciated with schizophrenia (Kerns et al., 2008; Simpson et al., 2010)
and is likely to constitute the basis for the reduced abilities of schizo-
phrenia patients to organize their lives with respect to vocational and
interpersonal relations, or self-care activities (Aubin et al., 2009).
Furthermore, the level of cognitive functioning has been shown to
be an important predictor for the recovery from the illness and the
functional outcome (Harvey et al., 1998; Green et al., 2000), underlin-
ing the importance of achieving a better understanding of the nature
of cognitive deficits associated with schizophrenia in order to opti-
mize rehabilitation and intervention programs. The cognitive func-
tions which enable individuals to interact with their environment in
a purposeful and meaningful way are usually summarized in the
term “executive functions” (Jurado and Rosselli, 2007), and previous
⁎ Corresponding author at: Department of Biological and Medical Psychology, University
of Bergen, Jonas Lies vei 91, N-5009 Bergen, Norway. Tel.: +47 5586640.
E-mail address: rene.westerhausen@psybp.uib.no (R. Westerhausen).
schizophrenia (Green et al., 2000; Johnson-Selfridge and Zalewski,
2001; Fioravanti et al., 2005). However, although frequently treated
as such, the term executive functions does not refer to a unitary cog-
nitive faculty; it rather summarizes a set of basic sub-components
which together constitute executive functioning (Miyake et al.,
2000; Jurado and Rosselli, 2007). Thus, also the analysis of the execu-
tive impairments associated with schizophrenia will likely benefit
from an analysis on the level of specific subcomponents as opposed
to an approach on the global level of executive functioning (Kerns
et al., 2008).
According to an influential model proposed by Miyake et al.
(2000), a central sub-component of executive functioning is the abil-
ity to utilize weaker sources of information or select less likely behav-
ior in the presence of a competing, stronger sources or behavioral
tendencies (Miller and Cohen, 2001; Posner and Rothbart, 2007).
Usually referred to as “inhibition” or “cognitive inhibition” (Nigg,
2000; Friedman and Miyake, 2004; MacLeod, 2007) this process has
been defined as “the stopping or overriding of a mental process, in
whole or in part, with or without intention” (see MacLeod, 2007,
p.5). A frequently applied paradigm which is considered to assess
cognitive inhibition (Miyake et al., 2000; Nigg, 2000) is the Stroop
Color-Word Interference Test or, for short, the Stroop paradigm

0920-9964/$ – see front matter © 2011 Published by Elsevier B.V.

doi:10.1016/j.schres.2011.08.025
 R. Westerhausen et al. / Schizophrenia Research 133 (2011) 172–181
(Stroop, 1935; MacLeod, 1991). In this paradigm cognitive inhibition
is tested by asking the participants to name the ink color in which a
series of color words is printed, whereas the ink color does not corre-
spond to the semantic meaning of the color word (e.g., the word
“blue” printed in the color red). Confronted with such stimuli the
dominant process is to read the word (i.e., answering with “blue”)
and in order to successfully follow the requirements of the task, the
reading process has to be inhibited in favor of the naming of the ink
color (here: “red”; c.f. Cohen et al., 1990; Friedman and Miyake,
2004). Although frequently applied and interpreted alone, this so-
called incongruent condition has to be related to a “neutral”, color
naming condition in order to quantify the extent to which the incon-
gruency interferes with the color naming performance (MacLeod,
1991). An appropriate neutral condition contains stimuli, such as
“X's” or colored patches, of which the ink color has to be determined
by the participant. The response time or accuracy difference between
incongruent and neutral condition provides an interference (INT)
score and can be seen as an inverse indicator of inhibition subcompo-
nent of executive functioning. Thus, deficits in inhibition should re-
sult in an increased INT.
The use of the Stroop paradigm has a long tradition in schizophrenia
research and dates back to a study by Wapner and Krus published in,
1960 (Wapner and Krus, 1960), who were the first to show that pa-
tients with schizophrenia needed over-proportionally more time in
the interference condition than controls. Since these early studies, the
Stroop paradigm has been frequently applied providing largely incon-
sistent results (for review see Henik and Salo, 2004) and preventing a
general conclusion about the cognitive inhibition abilities associated
with schizophrenia. Thus, the aim of the present meta-analysis was to
systematically analyze and statistically summarize the studies available.
Since the inconsistency has been attributed to the large variety of para-
digm versions that have been employed (Hepp et al., 1996; Perlstein et
al., 1998; Henik and Salo, 2004), the present meta-analysis focuses on
the methodological aspects of the paradigm. More specifically, we
focus on the distinction between card and computerized versions of
the Stroop paradigm, which – although both are supposed to assess
the same cognitive processes – show substantial methodological differ-
ences that might especially interfere with the performance of schizo-
phrenia patients. The traditional card versions of the paradigm usually
consists of a series of multiple-stimuli cards, with each card represent-
ing only one condition (e.g., one card for the neutral and one for the in-
congruent condition). In contrast, in the computerized version the
participant is presented with one stimulus at a time and stimuli of dif-
ferent conditions are usually intermixed.
2. Material and methods
2.1. Study characteristics and selection
The studies were selected using Pubmed (ncbi.nlm.nih.gov/
pubmed), ISI Web of Knowledge (apps.isiknowledge.com), and PsycInfo
(apa.org/pubs/databases/psycinfo) databases using combined search
terms related to the Stroop paradigm (Stroop, color-word test, interfer-
ence) and to schizophrenia (schizophrenia, psychosis). Furthermore, the
reference lists of published articles were used to locate additional stud-
ies. The search was performed in the end of December 2010 and the
meta-analysis thus covers all studies published or published online
ahead of print at this time point. After screening the abstracts of the ini-
tial search results for relevance, 141 studies were identified. These stud-
ies were analyzed deeper and the following inclusion criteria were
applied: (a) inclusion of a healthy, non-clinical control group in addition
to the schizophrenia group; (b) application of a standard version of the
paradigm, i.e. excluding emotional, lateralized, or phonemic variants of
the Stroop paradigm; (c) calculation of effect size measure for a group
comparison regarding INT possible, i.e. studies not including a neutral
“color-naming” condition were excluded (see below); (d) the Stroop
173
paradigm had to be described in enough detail to be able to extract all
information necessary to perform the analysis; (e) the results had to
be independent, i.e. had not been (in total or partly) published in anoth-
er included report; and (f) the language of the publication was
English, French, or German.
The application of the above criteria reduced the number of stud-
ies to 36, published between 1984 and 2011. Of these, 23 used the
DSM-IV, 7 the DSM-III-R, and 3 the ICD-10 to diagnose the patients.
For the remaining three of the studies the diagnosis criteria were
not explicitly stated. An overview of the included studies can be
found in Table 1 and Appendix A.
2.2. Variables of interest
The INT in the Stroop paradigm is usually defined as the perfor-
mance in a neutral, color naming condition (NEU) subtracted from the
performance in the incongruent (INC) condition (MacLeod, 1991). The
performance can be measured as time to perform the task or the num-
ber of errors committed while performing the task. Hence, INT as an in-
crease in the response time (INT_T) or an increase in the number of
errors (INT_E) served as dependant variables in the present meta-
analysis. Regarding the INT_T parameter, the included studies reported
the response time in three different ways: (a) as the mean single-trial
response time differences per stimulus; (b) the time to name the colors
of the stimuli present on each card, or (c) the number of stimuli correct-
ly identified in a given time period. However, all three measures could
be expressed as items processed per time unit and are thus treated as
equivalent in the present analysis. Furthermore, three of the studies in-
cluded in the meta-analysis (cf. Table 1) used a method suggested by
Golden (1978) to determine INT instead of a simple difference score.
This method utilizes a combination of a neutral color naming and a
word reading condition (reading color words written in black ink) to
predict the time for the INC condition. The predicted time subtracted
from the observed time is considered a measure of INT. In order to
make use of as much data as possible in our meta-analysis, these
three studies were included. However, a separate analysis removing
these studies did not substantially change the results or their
interpretation.
2.3. Calculation of study effect size
The aim of the analysis was the difference between healthy con-
trols and schizophrenia patients in the dependant variables INT_T
and INT_E, whereby the difference was expressed as the effect size
Hedges' g serving as an unbiased estimate of the population effect.
Hedges' g represents the standardized mean difference (also known
as Cohen's d) corrected for the sample bias (Hedges and Olkin, 1985).
In the attempt to calculate the effect sizes for the included studies,
three different situations were encountered. First, both mean and
standard deviation for the respective INT parameter were available
so that g could be directly computed. Second, only the test statistics
(F-/t-values) for the group comparison were reported in the original
study and the effect size had to be calculated using formulas convert-
ing these test-statistics to effect size measures (Cohen, 1988). Third,
only the raw mean and standard deviations of the experimental con-
ditions (incongruent, neutral) were reported. In this case, following
the approach taken by van Mourik et al. (2005), mean and standard
deviation of the INT score were calculated for each group before the
effect size measures were determined. To achieve this, however,
also the standard deviation of the interference score has to be esti-
mated which is only possible knowing the intercorrelation of the per-
formance in the NEU and the INC conditions. As suggested by van
Mourik et al. (2005), this correlation was set to r = 0.70 what closely
matches the correlation reported by other studies (Abramczyk et al.,
1983). In two studies (Boucart et al., 1999; Chen et al., 2001) the
raw RT or error means (and SD) were only available in graphs, and
174 R. Westerhausen et al. / Schizophrenia Research 133 (2011) 172–181

Table 1
Characteristics of studies included in meta-analysis.

StudyID Schizophrenia patients Controls Stroop paradigm Comment on data usage

n m/all age Diagnosis n m/all Age Version Interference Stimulus Response

criterium calculation presentation modality

Barch 1999a 40 0.50 39.4 DSM-IV 20 0.45 36.1 CPT Difference Intermixed Verbal Effect is mean of two conditions
using color patches and animal
names, respectively, as neutral
stimuli
Barch 1999b 56 0.57 28.3 DSM-IV 25 0.52 35.2 CPT Difference Intermixed Verbal
Barch 2004 29 0.55 35.4 DSM-IV 29 0.62 36.2 CPT Difference Intermixed Verbal
Barch 2005 10 0.67 40.3 DSM-IV 22 0.55 36.6 CPT Difference Intermixed Verbal Data from placebo condition
Barr 2008 28 0.57 47.0 DSM-IV 32 0.53 40.0 Card Golden Blocked Verbal Data as average of pre-nicotine
and pre-placebo condition
Boucart 1999 12 0.75 30.9 n.a. 12 0.75 n.a. CPT Difference Both Verbal Average of block and intermixed
task version
Brebion 1996 32 0.66 35.6 DSM-IV 32 0.69 37.1 Card Difference Blocked Verbal
Breton 2011 52 0.69 32.7 DSM-IV 53 0.36 43.8 Card Difference Blocked Verbal
Buchanan 1994 39 n.a. n.a. DSM-III-R 30 0.67 34.2 Card Golden Blocked Verbal Patient data as average of both
groups
Carter 1993 23 0.83 32.1 DSM-III-R 14 0.71 31.3 CPT Difference Intermixed Verbal Patient data pooled over both
patient groups; Sample is
extension of Carter et al. (1992)
Carter 1997 14 0.57 35.7 DSM-IV 15 0.47 34.3 CPT Difference Intermixed Verbal
Chen 2001 56 0.45 32.8 DSM-IV 64 0.41 34.4 CPT Difference Intermixed Manual Patient data as average of both
measuring points
Dollfus 2002 17 0.70 29.8 DSM-IV 17 0.70 28.1 Card Difference Blocked Verbal
George 2002 25 n.a. n.a. DSM-IV 35 n.a. n.a. CPT Difference Intermixed Manual Mean of smoker and non-
smokers at baseline
Golden 1976 35 n.a. n.a. n.a. 37 n.a. n.a. Card Difference Blocked Verbal
Haker 2009 43 0.74 34 ICD-10 45 0.73 35 Card Difference Blocked Verbal Original study used quotient
to express INT_T; difference
values kindly provided by
authors
Henik 2002 11 0.82 32.1 DSM-III-R 16 0.81 31.7 CPT Difference Intermixed Verbal Data as average of the three
employed experimental
conditions
Hepp 1996 44 0.55 36.0 ICD-10 50 0.58 36.9 CPT Difference Intermixed Verbal Also provides Card data for
subsample of 9 patients and
31 controls.
Jaquet 1997 42 0.60 37.7 DSM-IV 19 n.a. n.a. Card Difference Blocked Verbal
Killian 1984 34 0.50 24.3 Others 26 0.50 28.8 Card Difference Blocked Verbal Patient data as average of both
measuring points
Markela-Lerenc 2009 15 0.60 27.4 DSM-IV 15 0.47 27.7 CPT Difference Intermixed Manual
Matsuzawa 2008 20 0.60 30.7 DSM-IV 16 0.75 30.0 Card Difference Blocked Verbal
McGowan 2004 16 n.a. 37.4 DSM-IV 12 n.a. 38.3 Card Difference Blocked Verbal
McNeely 2003 13 0.62 31.6 DSM-IV 13 0.54 28.7 CPT Difference Intermixed Manual
Moritz 2002 25 0.56 34.7 DSM-IV 70 1.33 33.1 Card Difference Blocked N.a.
Mulet 2007 46 0.70 31.5 DSM-IV 39 0.21 21.6 Card Golden Blocked Verbal
Nordahl 2001 9 0.78 37.6 DSM-III-R 10 0.80 32.3 CPT Difference Intermixed Verbal
Perlstein 1998 55 0.54 38.5 DSM-IV 24 0.56 35.5 Both Difference Both Verbal Average of CPT and card version
for main analysis
Rizzo 1996 33 0.64 32.8 DSM-III-R 33 0.64 31.3 Card Difference Blocked Verbal
Sacco 2006 14 0.43 41.9 DSM-IV 15 0.67 38.3 CPT Difference N.a. N.a.
Salo 1997 24 n.a. n.a. DSM-III-R 16 0.56 40.8 CPT Difference Intermixed Verbal Patient data as average of both
groups
Salo 2002 23 n.a. n.a. DSM-IV 16 0.63 36.4 CPT Difference Intermixed Verbal Patient data as average of both
groups;
Scholes 2010 49 0.88 37.8 ICD-10 35 0.77 34.2 Card Difference Blocked Verbal Data of non-cannabis groups
Szoke 2009 54 0.72 33.8 DSM-IV 42 0.52 41.5 Card Difference Blocked Verbal
Takei 2009 31 0.39 33.8 DSM-IV 65 0.37 34.7 CPT Difference Intermixed Verbal
Taylor 1996 12 0.67 39.2 DSM-III-R 12 0.67 37.9 CPT Difference Intermixed Verbal

Notes: The StudyID (first column) refers to the list provided in Appendix A; n = number of subjects; m/all = proportion of males in the respective sample; CPT = computerized
version of the Stroop paradigm; Card = card version of the Stroop paradigm; n.a. = respective information not available.

thus were read out using a ruler. This procedure was conducted twice
and the average of both read-outs was taken to calculate the INT
scores. Finally, whenever more than one effect size estimate was
available for a study the average of the different effects was taken
(for details see Table 1).
2.4. Statistical analysis
A meta-analysis was conducted testing for differences between
patients with schizophrenia and healthy controls in the interference
effect. The effect size obtained for INT_T and INT_E, respectively,
served as dependant variables. Regarding the analysis of INT_T, first
an “analytic” meta-analysis was performed using a fixed-effects
model to estimate the weighted mean effect (M(g)) over all studies
and test whether it deviates from zero. A fixed-effect approach was
a priori chosen with the assumption that all included studies measure
the same population effect.
Since the first analysis step indicated significant inhomogeneity in
the INT_T effect sizes, a second, explorative meta-analysis step was
conducted aiming to identify reasons for this variance. Following
 R. Westerhausen et al. / Schizophrenia Research 133 (2011) 172–181
the procedure described by Hedges and Olkin (1985), the meta-
regression analysis was performed using a weighted-least square ap-
proach with the inverse of each study's weight (i.e., one divided by
the estimated variance of g) employed as weights. Suggested to be
an important influencing factor (Hepp et al., 1996; Perlstein et al.,
1998; Henik and Salo, 2004) the meta-regression analysis was
applied contrasting the results of studies which used a card version
of the paradigm with the results of those studies that used single-
trial computerized version.
The threshold of statistical significance for the mean effect size
analysis as well as for the meta-regression were set to α = 0.05. The
significant threshold for inhomogeneity testing was set to α = 0.10
to increase statistical power (Deeks et al., 2008) and the inhomogene-
ity was expressed using the I 2 index, which quantifies the percentage
of the variability in the effect size estimates due to inhomogeneity of
the studies. The presence of a publication bias was assessed using fun-
nel plots and Egger's regression procedure (Egger et al., 1997), and for
significant effects Rosenberg's fail safe N was calculated to estimate
the number of unpublished studies (showing no effect) which
would nullify a present effect in the published studies (Rosenberg,
2005). Power analyses were conducted using GPower 3.0 software
(http://www.psycho.uni-duesseldorf.de/abteilungen/aap/gpower3/).
3. Results
3.1. Interference as increase in response time
The analytic meta-analysis included k = 36 studies summarizing
the data of 1081 schizophrenia patients and 1026 healthy
control subjects. The analysis revealed a mean weighted effect size
of M(g) = 0.43 (95% confidence interval, CI95%: 0.35–0.52), signifi-
cantly deviating from zero (Z = 9.62, p b 0.0001), and indicating that
the patients with schizophrenia show a pronounced INT_T. The Fail
Safe N was high (Nfs = 828) and a non-significant intercept in the
Egger's regression analysis (a = −1.35; t(35) = −0.98; p = 0.33)
indicates that a report bias is unlikely. However, a significant test
for inhomogeneity (Q(35) = 118.47, p b 0.0001) together with an
I 2 = 70.5% indicated a substantial inter-study variability in the latent
population effect sizes (Deeks et al., 2008).
To further explore reasons for the inhomogeneity we conducted a
meta-regression analysis contrasting the results of studies which
used a card or computerized version of the test. One study (Perlstein
et al., 1998), providing data for both test versions, was excluded from
the regression analysis in order to guarantee independence of the
data points included for both test versions. The analysis revealed a
significant prediction of the study effect size by test version (b =
−0.44; t(32) = − 2.88, p = 0.007, see Fig. 1) indicating a significantly
larger effect in the card as compared to the computerized version of
the Stroop paradigm. The weighted mean effect size of the 16 includ-
ed studies (including 565 patients and 538 controls) using the card
version was M(g) = 0.68 (CI95%: 0.55–0.80). The weighted mean ef-
fect of the 19 studies (461 patients, 464 controls) using the comput-
erized version was M(g) = 0.22 (CI95%: 0.09–0.35). Although
different in magnitude, the mean effects of both versions also deviat-
ed significantly from zero (card version: Z = 10.71, p b 0.0001,
Nfs = 459; computerized version: Z = 3.26; p = 0.001; Nfs = 31).
Adding the data from Perlstein et al.(1998), as well as the results of
the card version provided by Hepp et al.(1996), the weighted mean effect
size of the card version increased slightly to M(g)=0.60 (CI95%: 0.48–
0.71; 18 studies; 629 patients, 593 controls; see Fig. 2a) and remained sig-
nificant (Z=9.90; pb 0.0001; Nfs=438). Adding the results of Perlstein
et al. (1998) to the analysis of computerized version slightly reduced
the mean effect size to M(g)=0.19 (CI95%: 0.06–0.32; 20 studies; 516
patients, 488 controls; Z=2.97; p=0.003; Nfs=23; see Fig. 2b). Inter-
estingly, although significant for both the card (Q(17)=78.85,
pb 0.0001) and the computerized version (Q(19)=28.70, p=0.07), the
175
inhomogeneity remained with I2 =78.4% high for the card version, but
was low (I2 =33.8%) in the computerized version.
3.2. Interference as increase in errors
The meta-analysis of the INT_E consisted of k = 12 studies including
424 patients and 343 control subjects (cf. Fig. 3). The fixed effect estima-
tion revealed a significant weighted mean effect size of M(g) = 0.62
(CI95%: 0.47–0.77; Z = 8.22; p b 0.0001) indicating a stronger interfer-
ence effect in the patient group. A significant intercept of the Egger's re-
gression analysis (a= 3.21; t(11) = −2.46; p = 0.034) can be taken to
indicate a significant report bias in the data, which might lead to an
overestimation of the population effect size. However, an Nfs = 196 in-
dicates that the number of unpublished studies (showing no effect)
would have to be rather large to nullify the present effect in the pub-
lished studies. Homogeneity of the included study effects can be as-
sumed (Q(11)= 16.07, p = .139; I2 = 31.6%).
4. Discussion
The present meta-analysis indicates that patients with schizo-
phrenia show a significant increased interference effect when com-
pared with healthy controls. The interference effect was present
both regarding the response time (INT_T) and the errors (INT_E) in
the Stroop paradigm. Patients with schizophrenia not only appear to
be over-proportionally slower than controls, but also produce rela-
tively more errors in a task in which inhibitory control processes
are required. Thus, the present analysis supports the notion that
schizophrenia is associated with a reduction in the ability of cognitive
inhibition. Beyond this overall effect, the present data also confirms a
dissociation between the INT_T results obtained with the card and
computerized version of the Stroop paradigm, i.e. although both ver-
sions are supposed to measure the same cognitive construct, the two
versions provide inconsistent results when applied in schizophrenia
research. The level of performance in the two test versions seems to
be influenced not only by the ability of cognitive inhibition, but also
by additional aspects of the testing procedure. Apparently, these as-
pects differentially affect schizophrenia patients and controls so that
a closer examination of possible reasons for this dissociation is likely
to shed additional light on the cognitive impairments associated with
schizophrenia. In the following sections, we thus examine in more de-
tail the methodological differences between the card and the comput-
erized version which might have contributed to the differences in the
group comparison effect size revealed for the two test versions.
Fig. 1. Meta-regression analysis indicating a significant difference (b = − 0.44; t(32) =
− 2.88, p = 0.007) between the results obtained in the card and computerized version
of the Stroop paradigm. Each circle represents the effect size of a single study. The size
of the circle codes the weight with which of each effect size was entered in the meta-
regression analysis (weighted-least square approach). The solid horizontal lines indi-
cate the mean effect for both test versions, and the gray area marks the 95%-confidence
interval of the mean effects.
176 R. Westerhausen et al. / Schizophrenia Research 133 (2011) 172–181

Fig. 2. Forest plot of the study effect size (squares) and 95%-confidence interval (horizontal line) of the difference between schizophrenia patients and controls in the Stroop inter-
ference effect measured as increase in response time (INT_T): (a) and (b) summarize the studies utilizing the card and the computerized version, respectively. The size of the square
indicates the weight of the study in the calculation of the mean effect over all studies (bottom row; gray diamond). Open squares indicate those studies which were not part of the
meta-regression analysis (for details see Result section). The numbers at the right margin represent the individual study effect size; the numbers in parentheses give the lower and
upper boundaries of its confidence interval.
 R. Westerhausen et al. / Schizophrenia Research 133 (2011) 172–181 177

Fig. 3. Forest plot of the study effect size (squares) and 95%-confidence interval (horizontal line) of the difference between schizophrenia patients and controls in the Stroop inter-
ference effect measured as increase in response errors (INT_E). The size of the square indicates the weight of the study. The open squares represent studies which used the card
version of the paradigm, while the black squares are studies using a computerized version. Like in Fig. 2, numbers at the right margin represent the individual study effect size
and the boundaries of the confidence interval.

4.1. Dissociation between card and computerized Stroop version
The Stroop paradigm versions which have been used to study
schizophrenia patients can be grouped in two major categories
(Henik and Salo, 2004): traditional multiple-stimuli card versions
and single-trial computerized versions. The card version consists of
a series of cards – one for each condition – on which multiple stimuli
are presented, and the total time to name the color of all items of a
card (or number of correctly named stimuli in a given time) is
taken as measure of performance. In the computerized version one
stimulus is presented at a time, whereby stimuli of different condi-
tions are usually intermixed. Regarding the response time derived
measures (INT_R), the present meta-analysis indicates that the tradi-
tional multiple-stimuli card versions yielded, with M(g) = 0.60 to
0.68, a mean effect size which can be classified to be moderate to
large (Cohen, 1988). On the other hand, studies using the computer-
ized version yielded only a small mean effect size (M(g) = 0.19 to
0.22). This dissociation fits well to the observation presented in a
review by Henik and Salo (2004), that only the use of the card version
consistently reveals a difference between schizophrenia patients and
controls. The here indicated smaller population effect size of the
computerized version requires a substantially larger sample size to
guarantee sufficiently high statistical power (see Supplementary
Table 1). Thus, assuming comparable sample sizes, studies using the
card version should more frequently and consistently yield significant
group comparisons than studies using the computerized version. The
claim of a dissociation between the two versions of the paradigm is
further supported by the studies on healthy subjects, reporting no
or only moderate correlations of INT assessed with the computerized
and the card version (Hepp et al., 1996; Kindt et al., 1996; Perlstein et
al., 1998).
Possible reasons for this dissociation might be found in (a) the
context of stimulus presentation, (b) the mode of stimulus
presentation, (c) the response modality, and (d) the way errors are
accounted in the data analysis (Henik and Salo, 2004). Regarding
the context of stimulus presentation, the computerized version pre-
sents only one stimulus at a time (the target stimulus), while the
card version additionally confronts the subjects – depending on the
position of the target stimulus on the card – with two or more flank-
ing stimuli which can be present below, above, and to either side of
the target stimulus. Thus, the card version might be seen as a “dual
task”, which not only requires inhibiting the prepotent process of
reading in favor of the color naming (Cohen et al., 1990), but also de-
mands resistance to interference from adjacent non-target stimuli
(Friedman and Miyake, 2004). As a result, the card version might be
experienced as more demanding than the computerized version,
what especially would affect the performance of schizophrenia pa-
tients. In accordance with this notion, Boucart et al. (1999) report
an increase in the interference effect in schizophrenia patients in a
computerized Stroop version with additionally presented flanking
color words relative to the performance in the regular single-item
version of the task. Furthermore, only in the task with flanking non-
target words, the interference effect was stronger in schizophrenia
patients than in healthy controls, who in general appear to be little af-
fected by the presence of distractor stimuli (MacLeod and Hodder,
1998; MacLeod and Bors, 2002). Although these findings indicate a
higher susceptibility to distracting stimuli in patients, evidence from
studies directly assessing the patients' resistance to interference, e.g.
by using various versions of the Flanker task (Friedman and Miyake,
2004), appears to be inconsistent. While some studies find an in-
creased distractor interference in schizophrenia (Wang et al., 2005;
Urbanek et al., 2009; Breton et al., 2011) others do not find any signif-
icant differences to control groups (Kopp et al., 1994; Nestor et al.,
2007). However, assuming that the presence of flanking stimuli
would indeed be the basis for the dissociation between card and com-
puterized version, it is not clear if this is due to the presence of non-
178 R. Westerhausen et al. / Schizophrenia Research 133 (2011) 172–181
target stimuli per se or to the fact that the dual-task situation over-
strains the patients' limited cognitive resources. In any case, it
would appear that as long as the patients are confronted with only
one stimulus or task at a time, their performance is little affected.
With increasing cognitive load, however, the deficits become more
obvious.
A second methodological difference between the two Stroop par-
adigm versions can be found in the mode of stimulus presentation,
i.e. whether the different conditions (neutral, incongruent, etc.) are
presented in separate blocks or in an intermixed, randomized fashion.
The mode of presentation is tightly linked to the Stroop version: all
studies included in the present meta-analysis which used the card
version also used a blocked presentation with the stimulus cards con-
taining stimuli of only one condition. Of the 20 studies using comput-
erized version, all but one study used intermixed presentation only,
whereas the exception, Boucart et al. (1999), additionally used a
blocked version of the single-trial version. However, basic experi-
mental research on the Stroop interference effect in healthy subjects
has repeatedly shown that intermixing incongruent trials with neu-
tral or congruent trial increases the response time to the incongruent
trials and, in turn, also the interference effect (Lowe and Mitterer,
1982; Tzelgov et al., 1992). This effect appears to be linear, i.e. the in-
terference effect gets stronger the less frequent the incongruent trials
are (Tzelgov et al., 1992). Interestingly, however, a study by Henik et
al. (2002) showed that the interference effect is less affected by the
intermixing of congruent and neutral trials in schizophrenia patients
than in control subjects. Manipulating the proportion of incongruent
stimuli in three steps (37.5%, 25%, and 12.5%) did not significantly
alter the interference effect in the schizophrenia group, but stepwise
increased the interference effect in the control group (Henik et al.,
2002). As a result the group difference, expressed as effect size, chan-
ged from g = 0.62, i.e. lower interference in controls, to g = − 0.39
and −0.55, respectively, indicating lower interference in patient
group. Interpolating from these findings it could be predicted that a
blocked presentation mode, like the card version (with blocks of
100% incongruent trials), would show the largest differences between
the two groups. On the other hand, standard intermixed presentation
modes, employing between 25 and 50% incongruent stimuli (cf.
Carter et al., 1992; Takei et al., 2009), should produce smaller effect
sizes. These predictions would well fit to the results of the present
meta-analysis showing that the difference between schizophrenia pa-
tients and controls in INT_T is smaller in the intermixed computer-
ized than in the blocked card version. However, the only study
comparing blocked and intermixed presentation mode in the same
subjects by Boucart et al. (1999) did not reveal any significant effect
on the group difference in INT_T. Regarding the cognitive processes
that might underlie the described phenomenon, it has been argued
that a blocked presentation (or high proportion of incongruent stim-
uli) allows healthy subjects to establish a task set or cognitive task
representation which leaves the subject prepared to inhibit the
word reading (Tzelgov et al., 1992). The task set is, however, weaker
when only a low proportion of incongruent stimuli is presented mak-
ing it more difficult for the subject to exert inhibitory processes, and
increasing the response times. In schizophrenia patients the task set
might be in general be weaker than in healthy controls, and changes
in the proportions of incongruent stimuli might less affect the quality
of the already weak task set, so that the response time stay on stable,
low level.
Third, it has been suggested that differences in the response mo-
dality might also contribute to the differences between the card and
computerized version (Henik and Salo, 2004). In the present meta-
analysis, all studies based on the card version used an oral response,
while this was only the case in 15 out of the 20 studies using a com-
puterized version. Four of the remaining five studies used a manual
response, i.e. a keypress, as response mode and in one study the rele-
vant information was not reported. Previous studies on healthy
subjects have shown that the Stroop interference effect is reduced
when the response modality is switched from oral to manual re-
sponse (Redding and Gerjets, 1977; Ikeda et al., 2010). This effect
was explained referring to stimulus–response compatibility, i.e. in
the oral response modality the pre-dominant, but incorrect response
of reading the word maps onto the same (oral) response modality as
the required response to name the color. In the manual response mo-
dality, however, the correct and incorrect answer map on to different
responses, apparently reducing the interference effect (MacLeod,
1991). Applied on the present case, the use of the manual response
modality in some of the computerized studies should result in a smal-
ler average (across studies) interference effect compared with card
versions of the paradigm. However, it should only have an effect on
the observed difference regarding the group effect sizes, if it would
be assumed that the manual response reduces the interference effect
stronger in schizophrenia patients than controls. Recalculating the
meta-analysis of the computerized studies after removing the five
single-trial studies which did not employ verbal responses, the
mean effect dropped from the original M(g) = 0.19 with 20 studies
to M(g) = 0.13 (CI95%: −0.02–0.27; Z = 1.66; p = 0.096). Thus, rath-
er than bringing the effect size of computerized and card version clos-
er together it increased the distance between them, so that it seems
unlikely that the response modality can explain the effect size differ-
ences found between both versions of the test.
Fourth, the difference in effect sizes might be due to the different
ways in which the two test versions deal with errors committed dur-
ing testing. Regarding the computerized version, error trials are usu-
ally removed from the analysis and the mean reaction time is
calculated considering only the correct color naming responses
(Carter et al., 1992; Chen et al., 2001; Takei et al., 2009). However,
in the majority of studies using the card version it is not explicitly
stated how errors were treated. Perlstein et al. (1998) explicitly re-
port that erroneous responses were pointed out to the subjects with
the instruction to correct the response (see also Stroop's original pro-
cedure; Stroop, 1935). However, even when not pointed out by the
examiner, participants might notice their errors and spontaneously
correct themselves (van der Elst et al., 2006). Thus, the mean time
measured in the incongruent but also in the neutral condition of the
card version, not only summarizes correct responses (like in the
single-trial version) but also includes the time for erroneous
responses and their corrections. Furthermore, the present meta-
analysis showed a significant higher INT_E in schizophrenia patients
(M(g) = 0.62–0.64) as compared to controls, also indicating an
over-proportionally increased number of errors in the incongruent
condition in schizophrenia patients. Consequently, the inclusion of in-
correct and corrected answers in the time measures obtained for the
card version substantially biases the time measures of the card ver-
sion in disfavor of the patients, resulting in an accentuation of the in-
terference effect (when expressed as INT_T). The increased effect size
of the INT_T found in the card as opposed to the computerized ver-
sion might thus at least partly reflect the inclusion of errors than indi-
cate the involvement of divergent cognitive processes in the two test
versions.
4.2. Limitations and perspective
The present meta-analysis focused on the methodological aspects
of the Stroop paradigm and how these aspects influence the perfor-
mance of schizophrenia patients relative to healthy controls. An alter-
native approach would be to focus on patient variables, i.e. how
different symptoms or subgroups affect the performance. Indeed,
some studies have addressed the questions how patients with posi-
tive vs. negative symptoms (e.g., Buchanan et al., 1994), or first-
episode patients initially vs. after stabilization (e.g., Chen et al.,
2001) perform in the Stroop paradigm. Other studies were interested
in the effects medication has on the performance (e.g., Killian et al.,
 R. Westerhausen et al. / Schizophrenia Research 133 (2011) 172–181
1984). It appears likely that these and other patient variables have
substantial impact on the level of performance. Thus, a systematic
analysis of the effect of these variables would provide valuable infor-
mation about how much the here revealed impairment in cognitive
inhibition can be considered a primary symptoms of schizophrenia
or is just secondary to medication or other symptoms. However, at
the present time point the few available studies examining the effect
of these specific patient variables do not allow a meta-analytic
summary.
The separate analyses of studies using the computerized and the
card versions of the Stroop paradigm did not only reveal difference
in effect size, but also indicated difference in the homogeneity of
the individual study results: the effect sizes from studies using the
computerized version were homogenous, while those of the card ver-
sion still showed considerable inhomogeneity. Thus, other – here not
considered patient or methodological variables – might substantially
influence the performance in the card version of the paradigm, and
increase the variance of the results. The nature of these factors re-
mains to be determined.
4.3. Conclusion
The present meta-analysis indicates that schizophrenia patients
show an increased Stroop interference effect which is present both
in time and accuracy measures of interference. This finding supports
the notion that the reported deficits in global executive functioning
(Green et al., 2000; Fioravanti et al., 2005) are at least partly attribut-
able to an impairment in the sub-component of cognitive inhibition.
It remains to be analyzed if these deficits can also be measured in
other paradigms, e.g. Stop signal paradigms, which are also assumed
to measure cognitive inhibition (Friedman and Miyake, 2004). Since
cognitive inhibition only represents one of several sub-components
of executive functions (Miyake et al., 2000; Kerns et al., 2008), it
also remains to be systematically analyzed if and to what degree
other sub-components, like shifting or updating (Miyake et al.,
2000), are affected. Such necessary extensions would ultimately
lead to a profile of executive deficits in schizophrenia, which might
prove helpful to evaluate treatment effects, support remediation or
training approaches, and guide future research.
Supplementary materials related to this article can be found on-
line at doi:10.1016/j.schres.2011.08.025.
Role of funding source
Funding for this study was provided by European Research Council (ERC, Advanced
Grant to Kenneth Hugdahl); the ERC had no further role in study design; in the collec-
tion, analysis and interpretation of data; in the writing of the report; and in the deci-
sion to submit the paper for publication.
Contributors
RW designed the study, managed the literature search and statistical analyses. RW,
KK, and KH wrote the manuscript. All authors contributed to and have approved the
final manuscript.
Conflict of interest
None.
Acknowledgment
None.
Appendix A. Study ID and studies included in the meta-analysis
Barch 2005: Barch, D. M., Carter, C. S., 2005. Amphetamine
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179
Barch 1999a: Barch, D. M., Carter, C. S., Hachten, P. C., Usher, M.,
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25(4) 749–762.
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Cohen, J. D., Schooler, N., 1999. Increased Stroop facilitation
effects in schizophrenia are not due to increased automatic spreading
activation. Schizophr. Res. 39(1) 51–64.
Barr 2008: Barr, R. S., Culhane, M. A., Jubelt, L. E., Mufti, R. S., Dyer,
M. A., Weiss, A. P., et al., 2008. The effects of transdermal nicotine on
cognition in nonsmokers with schizophrenia and nonpsychiatric
controls. Neuropsychopharmacology 33(3) 480–490.
Boucart 1999: Boucart, M., Mobarek, N., Cuervo, C., Danion, J. M.,
1999. What is the nature of increased Stroop interference in schizo-
phrenia? Acta Psychol., 101(1). 3–25.
Brebion 1996: Brebion, G., Smith, M. J., Gorman, J. M., Amador, X.,
1996. Reality monitoring failure in schizophrenia: the role of selective
attention. Schizophr. Res. 22(2) 173–180.
Breton 2011: Breton, F., Plante, A., Legauffre, C., Morel, N., Ades, J.,
Gorwood, P., et al., 2011. The executive control of attention differen-
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healthy controls. Neuropsychologia 49 203–208.
Buchanan 1994: Buchanan, R. W., Strauss, M. E., Kirkpatrick, B.,
Holstein, C., Breier, A., Carpenter, W. T., Jr., 1994. Neuropsychological
impairments in deficit vs nondeficit forms of schizophrenia. Arch
Gen Psychiatry 51(10) 804–811.
Carter 1997: Carter, C. S., Mintun, M., Nichols, T., Cohen, J. D., 1997.
Anterior cingulate gyrus dysfunction and selective attention deficits
in schizophrenia: O-15 H2O PET study during single-trial Stroop
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Carter 1993: Carter, C. S., Robertson, L. C., Nordahl, T. E., O'Shora-
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Chen 2001: Chen, E. Y. H., Wong, A. W. S., Chen, R. Y. L., Au, J. W. Y.,
2001. Stroop interference and facilitation effects in first-episode
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George 2002: George, T. P., Vessicchio, J. C., Termine, A., Sahady,
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