A meta-cognitive Wisconsin Card Sorting Test in people with schizophrenia and bipolar disorder: Self-assessment of sorting performance

People with serious mental illness have challenged self-awareness, including momentary monitoring of performance. A core feature of this challenge is in the domain of using external information to guide behavior, an ability that is measured very well by certain problem-solving tasks such as the Wisconsin Card Sorting Test (WCST) . We used a modified WCST to examine correct sorts and accuracy decisions regarding the correctness of sort. Participants with schizophrenia (n = 99) or bipolar disorder (n = 76) sorted 64 cards and then made judgments regarding correctness of each sort prior to feedback. Time series analyses examined the course of correct sorts and correct accuracy decisions by examining the momentary correlation and lagged correlation on the next sort. People with schizophrenia had fewer correct sorts, fewer categories, and fewer correct accuracy decisions (all p<.001). Positive response biases were seen in both groups. After an incorrect sort or accuracy decision, the groups were equally likely to be incorrect on the next sort or accuracy decision. Following correct accuracy decisions, participants with bipolar disorder were significantly (p=.003) more likely to produce a correct sort or accuracy decision. These data are consistent with previous studies implicating failures to consider external feedback for decision making. Interventions aimed at increasing consideration of external information during decision making have been developed and interventions targeting use of feedback during cognitive test performance are in development.