Exploring Heterogeneity on the Wisconsin Card Sorting Test in Schizophrenia Spectrum Disorders: A Cluster Analytical Investigation

J Int Neuropsychol Soc. 2019 Aug;25(7):750-760. doi: 10.1017/S1355617719000420.


Objectives: The Wisconsin Card Sorting Test (WCST) is a complex measure of executive function that is frequently employed to investigate the schizophrenia spectrum. The successful completion of the task requires the interaction of multiple intact executive processes, including attention, inhibition, cognitive flexibility, and concept formation. Considerable cognitive heterogeneity exists among the schizophrenia spectrum population, with substantive evidence to support the existence of distinct cognitive phenotypes. The within-group performance heterogeneity of individuals with schizophrenia spectrum disorder (SSD) on the WCST has yet to be investigated. A data-driven cluster analysis was performed to characterise WCST performance heterogeneity.

Methods: Hierarchical cluster analysis with k-means optimisation was employed to identify homogenous subgroups in a sample of 210 schizophrenia spectrum participants. Emergent clusters were then compared to each other and a group of 194 healthy controls (HC) on WCST performance and demographic/clinical variables.

Results: Three clusters emerged and were validated via altered design iterations. Clusters were deemed to reflect a relatively intact patient subgroup, a moderately impaired patient subgroup, and a severely impaired patient subgroup.

Conclusions: Considerable within-group heterogeneity exists on the WCST. Identification of subgroups of patients who exhibit homogenous performance on measures of executive functioning may assist in optimising cognitive interventions. Previous associations found using the WCST among schizophrenia spectrum participants should be reappraised. (JINS, 2019, 25, 750-760).

Keywords: Cognitive flexibility; Cognitive subgroup; Concept formation; Executive function; Psychosis; Schizophrenia spectrum and other psychotic disorders.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cluster Analysis
  • Cognitive Dysfunction / classification
  • Cognitive Dysfunction / etiology
  • Cognitive Dysfunction / physiopathology*
  • Executive Function / physiology*
  • Female
  • Humans
  • Male
  • Phenotype
  • Schizophrenia / complications
  • Schizophrenia / physiopathology*
  • Severity of Illness Index
  • Task Performance and Analysis*
  • Wisconsin Card Sorting Test*
  • Young Adult