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An analysis of the cognitive deficit of schizophrenia based on the Piaget

developmental theory

Article  in  Comprehensive Psychiatry · July 2007

DOI: 10.1016/j.comppsych.2006.12.006 · Source: PubMed

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 Comprehensive Psychiatry 48 (2007) 376 – 379
www.elsevier.com/locate/comppsych

An analysis of the cognitive deficit of schizophrenia based on

the Piaget developmental theory
Alejandro Torresa, Jose M. Olivaresb, Angel Rodrigueza,
Antonio Vaamondec, German E. Berriosd,4
a
Department of Psychiatry, Hospital Nicolas Peña, Complejo Hospitalario Universitario de Vigo, 36200 Spain
b
Department of Psychiatry, Hospital Meixoeiro, Complejo Hospitalario Universitario de Vigo, 36200 Spain
c
Department of Statistics. University of Vigo, 36200 Spain
d
Department of Psychiatry, University of Cambridge, UK, CB2 2QQ

Abstract

Objective: The objective of the study was to evaluate from the perspective of the Piaget developmental model the cognitive functioning of a
sample of patients diagnosed with schizophrenia.
Method: Fifty patients with schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and 40 healthy matched
controls were evaluated by means of the Longeot Logical Thought Evaluation Scale.
Results: Only 6% of the subjects with schizophrenia reached the bformal period,Q and 70% remained at the bconcrete operationsQ stage. The
corresponding figures for the control sample were 25% and 15%, respectively. These differences were statistically significant. The samples
were specifically differentiable on the permutation, probabilities, and pendulum tests of the scale.
Conclusions: The Longeot Logical Thought Evaluation Scale can discriminate between subjects with schizophrenia and healthy controls.
D 2007 Elsevier Inc. All rights reserved.

1. Introduction reported in schizophrenia may underlie its cognitive

deficits [8]. Whether global or specific, the latter
The cognitive deficit in schizophrenia has been exten-
are considered to reflect a failure of central nervous
sively studied during the past decades [1]. Patients with
system integration.
schizophrenia perform worse than healthy subjects at
In this study, cognitive functioning will be assessed by
most cognitive tasks, particularly those involving attention,
means of an instrument based on Jean Piaget’s ideas [9].
memory, and executive functions [2]. Executive function,
According to this author, cognition develops in 4 stages:
defined as the capacity to plan strategies, follow rules,
first, there is a sensorimotor stage (0-2 years) governed by
and organize resources, is conventionally assessed (inter
sensorial experience; a preoperational stage (2-7 years); a
alia) by means of the Wisconsin Card Sorting Test [3].
concrete operational stage (7-11 years) during which
It is the current view that such deficits reflect a front-
children develop skills to think logically about concrete
temporal dysfunction [4]. It remains a moot point
events; and the formal operational stage (starting from
whether such deficits are specific particularly because they
11 years) characterized by the acquisition of abstract
have also been reported in bipolar disorder [5]. Likewise,
reasoning [10]. Age ranges are not rigid, and the fourth
it has been claimed that the general drop in IQ [6,7]
stage is not reached by everyone. Bereft of any represen-
tations of reality at the beginning of development (concrete
period) (sensorimotor stage), the child remains dependent
4 Corresponding author. University of Cambridge, Cambridge, UK,
upon raw experiential reality. At the other end of what is,
CB2 2QQ. Tel.: +44 1223 336965; fax: +44 1223 336968. in fact, a unilinear process of development (period of
E-mail address: geb11@cam.ac.uk (G.E. Berrios). formal operations), the child is in principle able to acquire
0010-440X/$ – see front matter D 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2006.12.006

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 A. Torres et al. / Comprehensive Psychiatry 48 (2007) 376 – 379 377

Table 1
Demographic variables of the samples
Characteristics Experimental group (n = 50) Control group (n = 40) Statistical significance
n (%) Mean (SD) n (%) Mean (SD)
Sex
Male 45 (90%) – 36 (80%) – NS
Female 5 (10) 4 (20%)
Age (y) 36.04 (8.34) 42.11 (8.31) NS
Education
No education 3 (6%) 1 (2.5%) NS
Primary 28 (56%) 23 (57%)
Secondary 18 (36%) 15 (37.5%)
Superior 1 (2%) 1 (2.5%)
Age at diagnosis (y)
1-10 16 (32%)
11-30 34 (68%)
NS indicates not significant.

the ability to carry out the following [11]: (1) probabilistic Some of the cognitive processes of subjects with
reasoning (to reason after the experience itself); (2) schizophrenia and of controls were mapped in this study
problem reasoning (to develop hypothetical solutions); by means of the Spanish version of the Longeot Logical
(3) combinatorial reasoning (to see the world in terms of Thought Evaluation Scale (EPL) [19]. First published in
possibilities more than absolute); and (4) relational French in 1974 and standardized in children between 9 and
reasoning (to recognize the relations between conducts— 16 years of age, this instrument adapted a suite of tests first
behaviors—and their consequences). According to Piaget, developed by Piaget and Inhelder [20]. A nonverbal
brain maturation is an important condition for develop- psychometric instrument, the EPL comprises 5 logical
mental progression. subtests each pertaining to one of the following concepts:
Inasmuch as schizophrenia is currently considered to be a conservation of volume, permutation, quantification of
neurodevelopmental disorder [12-14], it can be hypothe- probabilities, mechanical curves, and pendulum. A global
sized that its onset coincides with an arrest of, or change of score is obtained by totting up the 5 individual task scores
pace in, brain development that would be expressed in a and a modal stage score for the total of tasks. Subjects can
slowing down of developmental cognitive acquisitions. It be classified by the EPL into 5 categories: concrete A,
can be further hypothesized that, because of the typical age concrete B, preformal, formal A, and formal B. The EPL has
of onset [15], schizophrenia is more likely to affect the also been used to evaluate disintegration of cognitive
fourth stage, that is, the stage of formal operations [16-18]. function occurring in old age [21].
It seemed reasonable to test this hypothesis by means of a
test grounded on one of the most important European
2. Materials and methods
developmental theories.
Fifty patients meeting the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition criteria for
Table 2
The EPL results for each sample
Evolution stage Experimental Control group Original group from
group (n = 50) (n = 40) Piaget-Longeot sample
(15 years old)
(n = 30)
n (%) n (%) n (%)
Concrete A 10 (20%)4 0 (0%) 0 (0%)
(0-4 points)
Concrete B 25 (50%)4 6 (15%) 3 (10%)
(5-10 points)
Preformal 12 (24%)4 22 (55%) 16 (53%)
(11-17 points)
Formal A 3 (6%)4 10 (25%) 8 (27%)
(18-23 points)
Formal B 0 (0%)4 2 (5%) 3 (10%)
(24-28 points)
4 P N .0001 (Jonckheere-Terpstra test). Fig. 1. Classification according to stage for each sample.

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378 A. Torres et al. / Comprehensive Psychiatry 48 (2007) 376 – 379
Fig. 2. Comparison between scorings from EPS subtest depending on
sample (experimental and control) (Mann-Whitney test). *P b .05, **P b
.001, ***P b .0001.
schizophrenia and clinically stable at the time of the study
were recruited. The control group included 40 healthy
subjects matched to the patients in terms of the variables
shown in Table 1. Both groups were assessed by means of
the EPL [19]. The protocol was approved by the hospital
research ethics committee.
3. Results
There were no differences on EPL scores between the
control sample included in the present study and the original
Longeot standardization data (Table 2 and Fig. 1).
Six percent of the subjects with schizophrenia and
25% of the controls reached formal period A. No patient
and 5% of the controls reached formal period B. Seven-
ty percent of the patients were classified as operating in
the concrete period (20% in concrete A and 50% in concrete
B). Only 15% of the control sample were placed in the
concrete B period. All the differences (except those
pertaining to the pendulum test) were statistically significant
(Fig. 2). There was no correlation (Pearson) between EPL
scores and duration of illness (ranging between 1 and 30
years), suggesting that time per se does not worsen EPS
scores (Table 3).
Table 3
Pearson correlations between years from diagnosis and EPL subtests
Weight Volume
Years from diagnosis (rank: 1-30) 0.134 0.165
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4. Discussion
Subjects with schizophrenia performed in the EPL at a
significantly lower level than controls. About 70% were
placed at the bconcrete thoughtQ stage, none reached the last
period (formal B), and only 6% reached formal A. Inasmuch
as the control sample included in the present study did not
differ from that standardized by Longeot, it can be
concluded that these results are valid and significant.
Given that schizophrenia is considered to be a relative-
ly stable neurodevelopmental disorder characterized by
cognitive deficits [22-24], our results support the hypoth-
esis that patients affected by this condition do not
seem to have developed the necessary functions to
undertake logical-formal thought. This may result from
the fact that the prodromal phase of schizophrenia does
occur at a time when logical-formal thought has not yet
become organized.
A link between the global intellectual deficit and the
beginning of the disease in patients with schizophrenia has
been established by Hijman et al [25]. These authors also
found that the deficits (as identified by 4 subtests of the
Wechsler Adult Intelligence Scale) were independent from
age of onset and duration of disease. However, because the
EPL is an instrument designed to measure development and
is less dependent upon verbal elements, it is likely to
perform better than instruments used in the assessment of
executive function, such as the Wisconsin, which are unduly
sensitive to low IQ and to intellectual and other types of
deficits. It remains unclear whether the executive functions
are more affected in schizophrenia. Intelligence quotient
tests are notoriously difficult to apply in patients with
schizophrenia because of their slowness, cognitive disorga-
nization, and lack of cooperation. The instrument used in
this study is not timed and independent of verbal factors.
For all these reasons, we believe that the EPL has some
advantages and should be added to the panoply of instru-
ments already used in Anglo-Saxon psychiatry.
Among the limitations of this study, the following should
be mentioned. This study was carried out in patients already
diagnosed with schizophrenia and on medication (to have
suspended this for the study would not have been ethical).
Despite the fact that duration of disease and magnitude of
treatment did not correlate with EPL results, the ideal
paradigm to test our hypotheses would have been to follow
up a cohort of healthy adolescents so that it would have
been determined prospectively whether those who develop
schizophrenia did not reach the formal period and those who
had reached it lost this achievement as the disease
developed. This remains a subject for future research.
Dissoc weight-volume Permutations Probabilities Pendulum Curves
0.149 0,014 0.117 0.129 0.106
 A. Torres et al. / Comprehensive Psychiatry 48 (2007) 376 – 379
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