SCHIZOPHRENIA

RESEARCH
SchizophreniaResearch 17 ( 1995) 257-265

ELSEVIER

Memory and vigilance training to improve social perception in

schizophrenia
Patrick W. Corrigan *, Joyce Nugent Hirschbeck, Michelle Wolfe
Llniversity of Chicago Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, IL 60477. USA
Received 28 November 1994; revision received 23 January 1995; accepted 30 January 1995

Abstract

Previous research has suggested that social cue recognition in schizophrenia may be significantly associated with
visual vigilance and verbal memory. Therefore, we predicted that subjects who participated in a cognitive rehabilitation
program that incorporated vigilance and memory training strategies would show significantly better social cue
recognition than subjects participating in vigilance training alone. Forty subjects with a DSM-III-R diagnosis of
schizophrenia or schizoaffective disorder were randomly assigned to either a vigilance-alone or a vigilance-plusmemory training condition. Results showed that subjects in the vigilance-plus-memory condition were able to identify
social cues in the videotaped training materials significantly better than subjects in the vigilance-alone condition. This
difference was evident in an independent measure of social cue recognition and was present at a 48 h follow-up.
Implications for future development of cognitive rehabilitation for schizophrenia were discussed.
Keywords: Social cue recognition; Memory training; Vigilance training; (Schizophrenia)

1. Introduction

Clinical research has consistently shown that, in

concerl with careful titration of neuroleptic medication, behavioral rehabilitation strategies, like
social skills training, effectively reverse the downhill trend in the deteriorating interpersonal skills
of some schizophrenia patients. Patients participating in social skills training programs have been
found to increase their range of prosocial behaviors, to diminish their psychotic symptoms, and
to decrease their time in the hospital (Bellack
et al., 1984; Hogarty et al., 1986, 1991; Wallace
* Corresponding author.
0920-9964/95/$09.50 1995ElsevierScienceB.V. All rights reserved
SSD1 0920-9964(95)00008-9

and Liberman, 1985). These effects seem to be

limited, however; many patients who demonstrate
significant cognitive deficits seem to be refractory
to traditional skills training strategies (Liberman
et al., 1985; Massel et al., 1991). Therefore, development of cognitive rehabilitation strategies may
facilitate social skill learning and may improve
overall interpersonal functioning.
In order to meet this goal, research teams have
attempted to conceptualize interpersonal functioning and social skills training in terms of information processing functions (Bellack et al., 1989;
Corrigan, Schade and Liberman, 1992). Recent
studies have evaluated the relationships between
two information processing functions - visual

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P. W. Corrigan et al./Schizophrenia Research 17 (1995) 257-265

vigilance and verbal recall 1 - and domains of social

cognitive functioning including psychosocial skill
learning and social cue recognition. In terms of
psychosocial skill learning, studies have found
significant relationships between skill acquisition
and measures of visual vigilance (Bowen et al.,
1994; Kern et al., 1992) and short term, verbal
recall (Corrigan et al., 1994; Kern, Green and
Satz, 1992; Mueser et al., 1991).
A similar pattern was found with social cue
recognition. Social cue recognition has been distinguished from other information processing tasks
by the content of these tasks which are believed
to be more ecologically valid (Ostrom, 1984; Penn
et al., 1994). The foci of social cue recognition
tasks are concerned with relatively molar information, focus on behavioral and individual differences, tend to be labile, act as their own causal
agent, and interact with the perceiver. One study
examined the relationship between social cognition
and information processing measures. Results
showed social cue recognition to be significantly
associated with both recall memory and visual
vigilance (Corrigan et al., 1994). Therefore,
improving deficits in social cue recognition seemed
like a logical first step in remediating cognitive
dysfunctions that interfere with social skill learning
and interpersonal competence, and therefore was
the target of the cognitive interventions discussed
in this paper.
Findings from the above literature on descriptive
psychopathology suggest that cognitive rehabilitation strategies which attempt to improve recognition of interpersonal cues might be more successful
when incorporating interventions that address
deficits in vigilance and recall memory. Reviews of
the literature on cognitive rehabilitation of schizophrenia have showed, however, that most studies
have used various 'vigilance' strategies alone as
the basis of their rehabilitative approach (Corrigan
1 Information processing is a complex construct that has been
explained by various models including serial processing
(Sternberg, 1966, 1967), cognitive capacity (Kahneman, 1973),
and parallel distributed processing (McLeUand et al., 1986).
Description of these models exceeds the scope of this paper.
The two processes targeted in this paper were selected because
they have been widely studied in laboratory-based research of
cognition in schizophrenia (Nuechterlein and Dawson, 1984).

and Storzbach, 1993; Green, 1993). Investigators

conducting vigilance enhancement studies assumed
that primary deficits in vigilance accounted for
subsequent deficits in memory; therefore, remediation of vigilance deficits should clear memory
dysfunctions (McGhie and Chapman, 1961;
Silverman, 1964; Venables, 1964). Despite this
assumption, few studies of cognitive rehabilitation
have actually examined the effects of remediated
vigilance on more complex memory and encoding
studies. One well-controlled study failed to find an
association between improvements in vigilance
processes and subsequent increments in encoding
and memory (Wagner, 1968). If this dissociation
is supported in future studies, then significant
improvement of social perception may not be
addressed sufficiently by 'vigilance' interventions
alone. Much of this research has been completed
on laboratory-based stimuli; interventions targeting social cognitive deficits have been lacking.
The purpose of this study was to compare the
effects of two cognitive rehabilitation approaches
on the social cue perception of patients with schizophrenia. Vigilance training alone was contrasted
to a training package that combined vigilance
enhancement and semantic encoding; the latter
intervention had been shown to remediate
recall memory deficits in schizophrenia (Koh
et al., 1976). Vigilance-plus-memory training was
expected to yield superior effects on social cue
recognition than vigilance-alone.

2. M e ~ o ~

2.1. Subjects
Forty-six individuals who were either inpatients
at Tinley Park Mental Health Center (n---18) or
outpatients at the University of Chicago Partial
Hospitalization Program (n= 28) were asked to
participate in this study. Patients who agreed to
participate were initially included if they had: a
DSM-III-R chart diagnosis of schizophrenia or
schizoaffective disorder, were between the age of
18 and 55 years, had no chart history of substance
abuse in the past six months nor any history of
tolerance or withdrawal during their lifetime, had

P. W. Corriganet al./Schizophrenia Research 17 (1995) 257 265

corrected vision of at least 20/30 as measured on

the Snellen Eye Chart, exceeded a third grade
reading level as measured on the Wide Range
Achievement Test-Revised (Jastak and Wilkinson,
1984), and had no chart history of neurological
disorder or developmental disability. DSM-III-R
diagnoses were validated by completion of the
Mood and Psychotic Symptoms Modules of the
Structured Clinical Interview for DSM-III-R
(SCID: Spitzer et al., 1990). In addition, the
Psychoactive Substance Use Disorders Module
from the SCID was administered to assess history
of recent drug dependence or abuse. The SCID
was administered by individuals trained to a kappa
of at least 0.60 with consensus criteria from our
lab.
Fort) subjects participated in the study; six
declined to participate. The sample had a mean
age of 35.3 years (SD= 10.1) and had completed
12.6 (SD=2.1) years of education on average.
Subjects were 55% female, 57.5% African
American and 42.5% white. Seventy-five percent
of the sample was single, 10% was married, and
15% was divorced or widowed. On average, the
sample had spent 60.7 (SD =73.6) of the previous
180 days in the hospital; 35.0% of the sample were
inpatients at the time of the study. Thirty-eight of
the patients received antipsychotic medication;
mean dose in chlorpromazine equivalents equaled
711 mgs (SD=522). Seventeen patients received
benztropine for side effects; mean dose equaled
3.5 rags (SD=3.6).
2.2. Predictor measures

Patients selected to participate in the study

completed two measures that have been shown to
be significantly associated with performance on
the social cue recognition tasks: verbal recall/
recognition and psychiatric symptomatology
(Corrigan et al., 1994).
2.3. Rev auditory verbal learning task (RAVLT)

Ability to recognize and recall word lists was

measured by administering the RAVLT (Rey,
1964). Subjects were instructed to listen to a list
of 15 common words read by the examiner. When

259

the examiner finished the list, subjects repeated

aloud as many of the words as they could remember. The examiner then repeated the entire list two
more times with subjects recalling words at the
end of recitation. The recall score equaled total
number of correctly identified words for the three
trials. After a fifteen minute interference task,
subjects were instructed to read a paragraph and
circle words that were included in the stimulus list.
Number of correctly circled words represented the
recognition score.
2.4. Brief psychiatric rating scale (BPRS)

Subjects were administered the expanded version

of the BPRS to measure psychiatric symptoms
(Lukoff et al., 1986). Raters conducting BPRS
interviews were previously trained to a minimum
intraclass correlation coefficient (ICC( 1,1 ): Shrout
and Fleiss, 1979) of 0.80 according to criterion
ratings established at our lab. Two summary
scores, identified in a factor analysis by Overall
et al. (1967) were determined: a Thinking
Disturbance Factor (conceptual disorganization +
hallucinations + unusual thought content) and a
Withdrawal/Retardation Factor (blunted affect +
emotional withdrawal + motor retardation).
2.5. Training conditions

After completing the predictor variables,

patients were randomly assigned to either vigilance-alone or vigilance-plus-memory training. To
diminish variables that might confound training
effects, the stimulus materials, training environment, and length of training sessions were similar
across conditions. The stimulus material for both
training conditions was eight videotaped vignettes
from the Social Cue Recognition Test (SCRT:
Corrigan and Green, 1993). SCRT vignettes are
30 to 45 s long and include two or three actors
engaged in either low emotion (e.g., two friends
assembling a puzzle) or high emotion (e.g., a
husband and wife fighting about their children)
situations. All training sessions were conducted in
the cognition laboratory at the University of
Chicago Center for Psychiatric Rehabilitation.

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P. W. Corrigan et al./Schizophrenia Research 17 (1995) 257-265

Training in both conditions was completed in one

60-minute session.
Vigilance training comprised three strategies self-instruction, salient cues, and repeated practice
that had been shown to improve the vigilance of
schizophrenia subjects on information processing
tasks (Meichenbaum, 1969; Meiselman, 1973).
During a typical training session, subjects were
seated in front of the video monitor on which
SCRT vignettes were presented and asked whether
they were 'ready to attend to the task' prior to
presenting the vignette. They were then given a
card with a self-instructional message prior to each
vignette which they were told to say aloud (e.g.,
'The scene is going to flash on the screen soon. I
should watch with my eyes and listen with my
ears.'). Subjects were then shown the videotaped
vignettes twice to facilitate repeated practice.
Training per se requires patients to 'learn something' as a result of the intervention. In vigilance
training, patients learned to self-instruct a message
about attending to the stimulus array.
Vigilance-plus-memory training combined the
three strategies discussed above with semantic elaboration, a neuropsychological training strategy
that has been shown to remediate memory deficits
(Gouvier et al., 1986; Koh et al., 1981; Koh et al.,
1976). When participating in semantic elaboration,
subjects were instructed, prior to viewing the
vignette, to put the gist of the story in their own
words. The self-instructional message was, 'I
should try to put the story into my own words'.
After viewing the vignette, subjects in the vigilance-plus-memory condition were asked to say
aloud what happened in the story. Subjects who
were not able to report key aspects of the situation,
as outlined in the training manual, were asked
questions by the examiner that facilitated encoding
of the situation: 'What did the actors say in this
situation? What did they do in this situation? Why
did they say (or do) that? How do you think
they felt in this situation? What do you think
may happen next?'. Subjects were urged to put
responses in their own words rather than repeat
the actors' lines. Subjects were also provided a list
of 'feeling words', divided into 'good' and 'bad'
feelings, to help them choose responses to the
question about how actors felt in the situation.
-

2.6. Training fidelity

Trainers conducting the sessions (JNH and
MW) had met competency criteria on each condition during two pilot sessions prior to working
with patients. Actual training sessions were also
videotaped and subsequently rated by two
independent raters on a measure of fidelity that
summarized the competency criteria. The fidelity
instrument contained 137 training behaviors which
trainers were supposed to demonstrate during the
sixty minute session; trainers were expected to
show 63 behaviors when engaged in vigilance
training and 74 behaviors for vigilance-plusmemory.
Sixteen of the forty training sessions were randomly selected and rated by two independent
raters on the fidelity checklist; raters were blind to
hypotheses of the study and patient's training
condition. The occurrence agreement (Hartmann,
1982) representing their interrater reliability was
0.92. The mean percent of training behaviors
observed for each of the training strategies was
95.1% for vigilance alone and 94.2% (SD = 5.1 and
6.8) vigilance-plus-memory.
2. 7. Dependent measures
Immediately after completing training exercises
on each of the SCRT vignettes, subjects answered
36 true-false questions about that vignette. Hence,
the sixty minute training session included the time
necessary to conduct the vigilance-plus-memory or
vigilance-alone training and the time to answer the
36 true-false questions for each of the vignettes. A
sample question was 'True or false. At the end of
the scene, Carl sat down at the table'. Previous
research on the SCRT showed these questions to
be reliable and valid measures of the social
cue recognition of severely mentally ill adults
(Corrigan et al., 1990; Corrigan and Green, 1993).
Social cue recognition was also assessed on an
independent measure of cue recognition - the Cue
Recognition Test (CRT: Corrigan et al., 1992) after the sixty minute training session was completed. The CRT consists of eight videotaped
vignettes depicting persons involved in interpersonal problems. Subjects answer eighteen true-

261

P. 14~ Corrigan et al./Schizophrenia Research 17 (1995) 257-265

false questions after each vignette; e.g., 'True or

false. Barbara is standing at the front of the line'.
The CRT has been shown to be reliable and
correlates highly with SCRT performance
(Corrigan et al., 1992).
The tests of social cue recognition (the SCRT
and the CRT) each yielded two outcome measures:
correct identification rate (percent of true items
reported as true) and false alarm rate (percent of
false items reported as true). These indices may be
biased, however, by the perceived payoffs for correct identifications and perceived penalties for
incorrect attributions (Davies and Parasuraman,
1982). For example, subjects participating in a
study where they are reimbursed $5.00 for correct
identifications are more likely to say false items
are true than subjects who are fined $5.00 for false
alarms. Therefore, a nonbiased measure of cue
sensitivity (A') was determined from correct identification and false alarm rates for the SCRT and
CRTZ; this has been shown to be a valid index of
memory in general (Snodgrass and Corwin, 1988),
and of social cue recognition in particular
(Corrigan and Green, 1993).
To assess maintenance of training effects, the
SCRT and CRT were re-administered at a 48 hour
follow-up.

3. Results

The mean and standard deviations of demographic and predictor variables for the vigilanceplus-memory and vigilance-alone training conditions were summarized in Table 1. The two groups
participating in each condition were not found to
differ significantly on gender, marital status, age,
education, or days hospitalized during the previous
six months (p > 0.20). The two groups were shown
to differ in terms of ethnicity, with more African
Americans being randomly assigned to the vigilance-alone training condition (Xz = 5.01, p < 0.05 ).
None of the demographic variables in Table 1 were

1 (CI-FA)(I+CI-FA)
2A' = 9 q4CI(1 - F A )
where CI=correct identification and FA=false alarm rate.

Table 1
Means and standard deviations of demographic and predictor
variables for the vigilance-plus-memory and vigilance-alone
training conditions
Vigilance-plus-memory Vigilance-alone
training
training
(n=20)
(n=20)
Gender
Ethnicity
Marital status

Age
Education
Antipsychotic dose
Benztropine dose
Days hospitalized
BPRS Think Disturb
BPRS With/Retard
Rey Recall
Rey Recognition

55.0% female
60.0% white
40.0% afr amer
75.0% single
5.0% married
20.0% wid/div
35.9 _+10.9
12.6 +_2.2
705 + 513
3.8 +_3.7
59.9 +_74.1
7.8_+3.2
4.5_+2.2
19.7 + 6.2
9.9 +4.0

55.0% female
25.0% white
75.0% afr amer
75.0% single
15.0% married
10.0% wid/div
34.7 _+9,5
12.6 +_2.0
717 + 531
3.3 _+3.6
61.6 +__75.1
7.4+3.4
5.2_+2.5
17.8 _+4.4
10.3 _+3.9

BPRS: Brief Psychiatric Rating Scale

found to covary significantly with A' on the SCRT

or CRT (p>0.15).
No significant differences were found in predictor variables (i.e., RAVLT and BPRS) across
groups (p >0.20). The correlations between these
variables and the social cue recognition outcome
measures are summarized in Table 2. Results seem
to support earlier research which showed a significant association between verbal memory and social
cue recognition (Corrigan et al., 1994). In particuTable 2
Pearson product moment correlations between predictor measures and measures of cue sensitivity (SCRT A' and CRT A'I
at post-test and follow-up
SCRT A'

CRT A'

Post-test Follow-up Post-test Follow-up

BPRS Think Disturb - 0 . 2 2
-0.15
-0.11
-0.12
BPRS With/Retard -0.27
-0.37
-0.19
-0.20
Rey Recall
0.43**
0.41"*
0.36*
0.26
Rey Recognition
0.42**
0.50***
0.48** 0.37*
* p<0.05. ** p<0.01. *** p<0.001
Correlation coefficients in italics met the Bonferroni Criterion
for significance.

262

P. W. Corrigan et al./Schizophrenia Research 17 (1995) 257 265

lar, seven of the eight correlation coefficients representing associations between social cue recognition
and verbal memory were significant; two of these
associations met the Bonferroni criterion for significance. Contrast this pattern to the associations
between psychiatric symptoms and social cue
recognition. Only one correlation coefficient was
significant, the association between Withdrawal/
Retardation on the BPRS and the SCRT sensitivity
score at follow-up. No significant associations were
found between Thinking Disturbance and any of
the measures of social cue recognition. Despite
this pattern, results of a statistical test for differences between correlations showed only one pair
of correlation coefficients - the coefficient representing the association of Thinking Disturbance
and post-test CRT A' versus the coefficient representing the association of Rey Recognition with
follow-up SCRT A' - to be significantly different

(p<0.05).
3.1. Differences in vigilance-plus-memory versus
vigilance-alone training conditions
Means and standard deviations for the sensitivity (A') of SCRT and CRT scores at post-test and
follow-up are summarized in Table 3. Results of a
2 x 2 MANOVA (condition by trial) with SCRT
and CRT A's as the dependent measure showed a
significant main effect for condition (F(1,38)=
5.65, p < 0 . 0 5 ) but not for trial (F(1,38)=0.02,
n.s.) or the interaction (F(1,38) = 0.02, n.s.).
Table 3
Scores on the Social Cue Recognition Test (SCRT) and the
Cue Recognition Test (CRT) for subjects in the vigilance-plusmemory and vigilance-alone conditions after training and at
48 h follow-up

SCRT A r
CRT A'

Vigilance-plusmemory training
(n=20)

Vigilance-alone
training
(n=20)

Post-test

Follow-up

Post-test

Follow-up

0.89
(0.04)
0.93
(0.05)

0.89
(0.05)
0.93
(0.04)

0.83
(0.09)
0.88
(0.07)

0.84
(0.10)
0.88
(0.11)

Standard deviations included parenthetically.

A subsequent 2 x 2 ANOVA with SCRT A' as

the dependent variable showed a significant effect
for condition (F(1,38) = 5.53, p < 0.05). The trial
effect and interaction were non-significant
(F(1,38)=0.04 and F(1,38)=0.29 respectively).
Post hoc oneway ANOVAs showed that SCRT A'
was significantly higher for subjects in the vigilance-plus-memory training condition, compared
to individuals in the vigilance-alone condition, at
post-test (F(1,38)=6.43, p<0.05) and at followup (F(1,38) =4.30, p<0.05).
A 2 x 2 ANOVA was also conducted with CRT
A' as the dependent variable; it showed a significant effect for condition (F(1,38)=4.68, p <0.05)
but not trial (F(1,38)=0.00) or the interaction
(F(1,38)= 0.23). Post hoc oneway ANOVAs also
showed that CRT A' was significantly higher for
subjects in the vigilance-plus-memory training condition, compared to vigilance-alone at post-test
(F(1,38) = 5.43, p < 0.05). Nonsignificant trends
suggested a between group CRT A' difference at
follow-up (F(1,38) = 3.63, p = 0.06).

4. Discussion
Subjects in a vigilance-plus-memory enhancement condition were better able to recognize social
cues presented in videotaped vignettes than subjects participating in a vigilance-alone, control
condition. This effect was shown on both the
stimulus materials on which training was conducted, as well as on an independent measure of
social cue recognition. Therefore, the combination
of semantic elaboration and self-instruction seems
to yield greater cue recognition scores than vigilance strategies alone.
The post hoc analysis illustrates one of the short
falls in this study; namely, the size of the vigilanceplus-memory effect was not determined directly by
collecting SCRT scores prior to conducting the
rehabilitation intervention. A repeated measures
design would allow the reader to determine the
extent of change from baseline. The SCRT could
not be administered at pretest in this study, however, because vignettes from the measure were used
as training materials in the study. This problem

P. I,E Corrigan et al./Schizophrenia Research 17 (1995) 257-265

could be obviated in future research by using

training materials from other videotaped vignettes.
Findings from this study showed that significant
differences in the effects of vigilance-plus-memory
versus vigilance-alone were present 48 hours later.
Maintenance of therapeutic effects is an important
finding, especially if it is replicated in subsequent
research in which longer follow-ups are used. It is
unclear from this study, however, whether maintenance of treatment effects is due to change in the
theoretical mechanism that accounts for social cue
recognition (e.g., improved social recall memory
per se) or to learning a cognitive prosthetic (i.e.,
the self-instructional message) that, when used in
the future, will help subjects perceive social situations better. Future research can resolve this question by randomly assigning subjects to semantic
elaboration plus self-instruction versus semantic
elaboration alone. Some researchers argue that
clinicians need to strategically incorporate interventions into a treatment protocol which will
maintain a treatment effect over time rather than
assume that improvement will naturally endure
(Stokes and Baer, 1977). Therefore, we expect that
self-instruction will be the essential component for
maintaining the treatment effect in this study.
We attributed the significant vigilance-plusmemory effect to improvement of the recognition
and recall memory of participating subjects. This
finding is consistent with earlier research which
showed that word and facial recognition improved
significantly in patients who participated in semantic elaboration (Koh et al., 1981; Koh et al., 1976).
However, neither the studies conducted by Koh
and his colleagues nor the research described in
this paper has shown that this effect is specifically
due to improved recall or recognition. Future
research would need to include independent evidence of improvement in recall or recognition after
training to assert the specificity of our finding.
Alternatively, perhaps the combination of selfinstruction and semantic elaboration therapeutically improves an earlier stage in the information
processing series (e.g., vigilance) which subsequently enhances memory. Attempts to isolate the
effects of cognitive interventions vis-a-vis specific
information processes are difficult because of the
serial nature of cognition. Nevertheless, the effort

263

is important for practical reasons. Demonstrating

that the vigilance-plus-memory procedure used to
improve social cue recognition in fact enhanced
recall memory suggests that other memory
enhancement procedures (e.g., guided imagery, use
of mnemonics) may also be helpful for schizophrenia patients (Corrigan and Yudofsky, in press).
Morrison and Bellack (1981) have argued that
patients who perceive and understand social cues
may demonstrate relatively better social functioning. Therefore, improvement of interpersonal cue
recognition is likely to correspond with a concomitant gain in social learning and social skill.
However, increments in social cue recognition
alone are probably not sufficient to improve social
functioning. The macro construct of social functioning comprises several other social cognitive
components - comprehension of the rules that
define a social situation, development of a response
to the demands of a situation given these rules,
retrieval of various actions that may be appropriate to the response - which may be deficient in
schizophrenia subjects. Change in these functions
may yield clinically meaningful changes in prominent symptoms like paranoia and social anxiety.
Future research and development efforts must also
address social cognitive functions like these to
ameliorate the range of deficits that impede the
social functioning of schizophrenia patients.

Acknowledgements
This study was made possible in part by a grant
from the Illinois Department of Mental Health
and Developmental Disabilities. The authors wish
to thank Drs. David Penn and Stanley McCracken
for their comments about earlier versions of the
manuscript.

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