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lIBRARY
Michigan State
University

This is to certify that the

dissertation entitled

Premorbid Adjustment as a
Predictor of Symptom Presentation
in First-Episode Schizophrenia

presented by
Fiona P. Gallacher

has been accepted towards fulfillment
of the requirements for

PhD degreein Clinical Psychology

/7 ,. ”7/ . {

Major professor ’

 

Date Dec 5, 2001

 

MSUiJ an Affirmative Action/Equal Opportunity Institution 0-12771

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
To AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE

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6/01 cJCIRC/DateDuepGS—p. 15

 

PREMORBID ADJUSTMENT AS A
PREDICTOR OF SYMPTOM PRESENTATION
IN FIRST-EPISODE SCHIZOPHRENIA
By

Fiona P. Gallacher

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

2001

ABSTRACT
PREMORBID ADJUSTMENT AS A
PREDICTOR OF SYMPTOM PRESENTATION
IN FIRST-EPISODE SCHIZOPHRENIA
By

Fiona P. Gallacher

The present study sought to fiirther our current knowledge of the clinical course
of schizophrenia by providing additional evidence for the existence of phenomenological
subtypes, and integrating comprehensive data fiom two illness epochs that have received
considerable attention in recent years, namely, the period before illness onset (premorbid
adjustment) and the period during illness onset (first-episode psychosis). Specifically,
this study examined the relationships between three patterns of premorbid adjustment
(deteriorating, stable-good, stable-poor) and the presence of specific schizophrenic
symptomatology (negative symptoms, hallucinations, Schneiderian first-rank symptoms
[FRS], thought disorder, bizarre behavior, and paranoia) during first-episode psychosis in
order to delineate specific etiologies or developmental pathways of schizophrenia.

An Exploratory Factor Analysis of SANS, SAPS, and BPRS items confirmed the
presence of four symptom factors: a negative factor, a “disinhibition” factor (thought
disorder and bizarre behavior), a positive factor (hallucinations and Schneiderian FRS),
and a paranoid factor. In addition, a Cluster Analysis confirmed the presence of three
clusters of patients: a cluster one group with predominantly negative symptoms, a cluster

two group with predominantly disinhibition symptoms (thought disorder and bizarre

\i

 

behavior) and paranoid symptoms, and a cluster three group with predominantly positive
symptoms (hallucinations and Schneiderian FRS).

There were significant associations between the deteriorating PMA group and
cluster one (negative symptoms); the stable-good PMA group and cluster two
(disinhibition and paranoid symptoms) and the stable-poor PMA group and cluster three
(positive symptoms). With respect to specific symptomatology the deteriorating PMA
group had significantly more negative symptoms than the stable-poor or stable-good
group. The stable-good group had more severe paranoid delusions, bizarre behavior, and
thought disorder than the deteriorating or stable-poor group, although these differences
were not statistically significant. And, the stable-poor group had more severe
hallucinations and Schneiderian FRS than the deteriorating or stable-good group,
although this difference was not statistically significant.

Overall, these findings provide support for the existence of three developmental
pathways of schizophrenia. It appears that patterns in early development are associated
with the types of psychotic symptoms one manifests in first-episode psychosis. This
information can help to guide us in early detection, prevention, and treatment of first-

episode schizophrenia.

To my parents, with love and gratitude.
Patricia Gallacher (193 8-1999)

Thomas Gallacher (1936-1984)

iv

ACKNOWLEDGMENTS

I extend my deepest gratitude to Dr. Bert Karon for his encouragement,
acceptance, and words of wisdom. Many thanks as well to Dr. Gersh Kaufman, Dr.
Ralph Levine, and Dr. Joel Nigg for their guidance. I would also like to thank Dr. Raquel
Gur for the generous use of data from The University of Pennsylvania. Finally, thank

you to my husband, Brenden Readett, for his endless love and support.

TABLE OF CONTENTS

LIST OF TABLES .......................................................................... viii
LIST OF FIGURES. . . .' ..................................................................... ix
INTRODUCTION AND RATIONALE FOR THE STUDY ......................... 1
LITERATURE REVIEW .................................................................. 6
Premorbid Adjustment in Schizophrenia ............................... 6
Definition of Premorbid Adjustment .......................... 6
Common Premorbid Traits .....................................
Theories of Premorbid Adjustment ........................... 11
Premorbid Adjustment in Schizophrenia versus Normal
Controls and Other Disorders ........................ 13
Premorbid Adjustment and Demographic Variables ...... 13
Premorbid Adjustment and Biological Markers ........... 14
Premorbid Adjustment and Subtypes ....................... 15
Premorbid Adjustment and Negative Symptoms ......... 16
Premorbid Adjustment and Treatment Outcome .......... 17
Patterns of Premorbid Adjustment .................................... 18
Patterns of Clinical Symptoms ......................................... 20
Benefits of F irst-Episode Populations ................................ 24
THE PRESENT STUDY ................................................................. 26
Overview ................................................................ 26
Research Hypotheses .................................................... 28
METHODOLOGY ........................................................................ 30
Subjects .................................................................... 30
Clinical Assessment ...................................................... 30
Measures .................................................................. 32
Premorbid Adjustment Scale .................................. 32

vi

 

 

 

 

 

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Scale for the Assessment of Negative Symptoms ......... 35

Scale for the Assessment of Positive Symptoms ........... 37
Brief Psychiatric Rating Scale ................................ 39
Data Analysis ............................................................ 40
RESULTS ................................................................................. 42
Demographics .......................................................... 42
Exploratory Factor Analysis .......................................... 46
Cluster Analysis of Patients .......................................... 51
Patterns of Premorbid Adjustment (PMA) ........................ 55
Chi Square Test ....................................................... 58
Planned Comparisons ................................................. 60
DISCUSSION ........................................................................... 65
APPENDICES ........................................................................... 77
A: Table 1: Prodromal Features in F irst-Episode Psychosis ....... 78
B: Table 2: Psychosocial Indicators of Vulnerability to
Schizophrenia ........................................ 79
C: The Premorbid Adjustment Scale ................................... 80
D: The Scale for the Assessment of Negative Symptoms ........... 88
E: The Scale for the Assessment of Positive Symptoms ............ 92
F: The Brief Psychiatric Rating Scale ................................. 97
G: Consent Form ......................................................... 100
REFERENCES .......................................................................... 106

vii

LIST OF TABLES

Table Page
1: Prodromal Features in F irst-Episode Schizophrenia ........................... 76

2: Psychosocial Indicators of Vulnerability to Schizophrenia .................... 77

3: Means and Standard Deviations of Demographic Information ............... 44

4: Frequencies and Percentages of Demographic Information ................... 45

5: SANS, SAPS, BPRS Factor Analysis ............................................. 48-50
6: Cluster Centers of Four Symptom Factors ....................................... 52

7: Demographic Information for PMA Groups ..................................... 57

8: Chi-Square Contingency Table of Cell Frequencies and Percentages ........ 59

viii

LIST OF FIGURES

Figure Page
1: Cluster Profiles on Four Factors ................................................. 53
2: Cluster Group Membership ........................................................ 54
3: Premorbid Adjustment Group Membership ..................................... 56
4: Means of Factor 1 by PMA Group ................................................ 61
5: Means of Factor 2 by PMA Group ................................................ 62
6. Means of Factor 4 by PMA Group ................................................ 63
7. Means of Factor 3 by PMA Group ................................................ 64

ix

 

 

 

 

 

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INTRODUCTION AND RATIONALE FOR THE STUDY

Clinical phenomenology has been an area of long-standing interest in the study of
schizophrenia. Descriptions of course and outcome in schizophrenia can be found as
early as the 1800’s when Kraepelin characterized “dementia praecox” as an illness with
an early onset, cognitive impairment, and progressive deterioration (Kraepelin,
1896/1987). Later, Bleuler (1911/1950) introduced the term schizophrenia and identified
a number of significant clinical features including problems with attention, ambivalence,
and affective blunting. Bleuler further proposed that fragmented thinking processes or
“associative loosening” constituted a pathognomonic sign of schizophrenia. Psychotic
symptoms including hallucinations and delusions have also been characterized as
pathognomonic signs of schizophrenia, however, as with thought disorder, have been
found in individuals with other illnesses such as bipolar disorder or personality disorders.
In a review of the clinical phenomenology of schizophrenia, Andreasen and colleagues
(1988) state, “No single symptom can be considered pathognomonic of this disorder.
Rather, it is characterized by a polythetic cluster of symptoms, usually expressed in a
particular course or pattern” (p. 350). The ability to accurately describe the course or
pattern of schizophrenia is essential if predictions regarding etiology and treatment are to
be valid.

Crow’s (1980, 1985) two-dimensional model has been widely used to describe the
clinical course of schizophrenia in the past two decades. This model suggests that there
are two syndromes of schizophrenia, namely Type I and Type 11. Similarly, Carpenter

and colleagues (1988) describe a deficit/non-deficit typology that distinguishes between

proposed “trait” versus “state” characteristics. Many researchers have adopted these two-
dimensional models and categorized patients with schizophrenia as either positive or
negative based on a number of factors. As outlined by Andreasen and colleagues (1988)
positive, Type I, or non-deficit schizophrenia includes factors such as good premorbid
adjustment, acute onset, predominant positive symptoms, favorable response to
neuroleptic treatment, and neurochemical abnormalities such as hyperdopaminergic
transmission. In contrast, negative, Type II, or deficit schizophrenia includes factors such
as poor premorbid adjustment, insidious onset, predominant negative symptoms, poor
response to neuroleptic treatment, cognitive impairment, and structural brain
abnormalities such as ventricular enlargement.

While the advent of factor and cluster analyses firrther confirmed the positive and
negative dimensions of schizophrenia, they also suggested a more complex picture.
Specifically, numerous researchers began to describe the presence of a third factor. For
example, Strauss, Carpenter, & Bartko (1974) suggested that positive symptoms, negative
symptoms, and premorbid social functioning were all independent pathological
processes. Other researchers have described a third dimension of schizophrenia called
“disorganization.” The disorganization or disinhibition factor is primarily characterized
by thought disorder, inappropriate affect and bizarre behavior (Amdt, Alliger, &
Andreasen, 1991; Gur et al., 1991; Miller, Amdt, & Andreasen, 1993: Peralta, DeLeon,
& Cuestra, 1992; Shtasel, Gur, Gallacher, Heimberg, Cannon, & Gur, 1992b; Thompson
& Meltzer, 1993). In addition, more complex factor and cluster analyses results have
suggested the existence of fourth and fifth factors of schizophrenia (He & Zhang, 2000;

Lenzenweger & Dworkin, 1996; Lykouras, Oulis, Daskalopoulou, Psarraos, &

Christodoulou, 2001; Peralta et al., 1992; Shtasel et al., 1992b).

Controversy remains about the existence of “pure” dimensions or developmental
and clinical subtypes in schizophrenia. Some researchers have emphasized the
heterogeneity of the disorder in their descriptions of the overlap between positive and
negative symptoms (Andreasen, Flaum, Swayze, Tyrrell, & Amdt, 1990; Kay, 1991).
For emple, authors of a review of treatment, services and environmental factors in
schizophrenia describe, “Most investigators assume that at least several disease entities
will be defined within the schizophrenic syndrome; and that a more definitive nosology
for schizophrenia and schizophrenia like psychoses will emerge from further scientific
study” (Carpenter et al., 1988, p. 427).

In recent years researchers have attempted to provide a more definitive nosology
and comprehensive description of the clinical course of schizophrenia by studying a
number of “illness epochs.” These illness epochs include all areas of the lifespan, from
prenatal and genetics studies (Gottesman, Shields, & Hanson, 1982; Mednick & Cannon,
1991) to post-mortem brain studies (Arnold et al., 1995a). Similarly, some researchers
have focused on childhood-onset schizophrenia (Eggers & Bunk, 1997) and others on
late-onset schiZOphrenia or psychosis in geriatric populations (Arnold et al., 1995b;
Copeland et al., 1998). Many focus on identifying individuals at high risk for developing
schizophrenia (Mednick, Pamas, & Schulsinger, 1987; Olin & Mednick, 1996), while
others are concerned with long-term treatment outcome of chronic patients (Szymanski,
Cannon, Gallacher, Erwin, & Gur, 1996). Although extensive research exists on discreet
illness epochs in the course of schizophrenia, limited attention has been given to

systematic integration of this information. Synthesis of comprehensive data across the

lifespan can help provide invaluable information regarding etiology, course, and outcome
in schizophrenia.

The present study attempted to further our current knowledge of the clinical
course of schizophrenia by integrating comprehensive data fi'om two illness epochs that
have received considerable attention in recent years, namely, the period before illness
onset (i.e., premorbid adjustment) and the period during illness onset (i.e., first-episode
psychosis). Interest in the early course of the disorder continues to grow due to its
predictive potential. Specifically, the identification of childhood precursors of adult
schizophrenia has expanded our understanding of the etiology of the disorder (Mednick et
al., 1987). Similarly, the study of good versus bad premorbid adjustment has begun to
provide critical information about possible developmental subtypes of schizophrenia
(Andreasen et al., 1988; Crow, 1980) although to date, the data in this area are limited.
Most studies that have looked at patterns of premorbid adjustment have divided
adjustment into only two categories (i.e., good versus bad) (Harrow, Westermeyer,
Silverstein, Strauss, & Cohler, 1986). Similarly, most studies that have attempted to
investigate the relationships between patterns of premorbid adjustment and clinical
symptomatology have divided symptoms into only two categories (i.e., positive versus
negative) (Andreasen et al., 1990). This study aimed to provide a richer, more detailed
description of the relationships between patterns of premorbid adjustment and first-
episode symptomatology than is currently present in the literature. The identification and
description of these relationships sought to provide additional information about specific

developmental pathways in the course of the illness.

In addition, focus on early detection and intervention in schizophrenia can lead to
less psychological and social disruption and more positive treatment outcomes (F alloon,
1992; Loebel et al., 1992; McGlashan & Johannessen, 1996). As suggested by Harry
Stack Sullivan (1953), “many incipient cases might be arrested before the efficient
contact with reality is completely suspended” (p. 106) if early detection is prioritized.
Therefore, continued investigation of the premorbid and onset phases of schizophrenia
appears to be a critical area for further research.

In summary, the proposed research investigated the relationships between specific
patterns of adjustment found during the years prior to illness onset (i.e., childhood, early
adolescence, late adolescence, and adulthood) and initial symptom presentation during
first-episode psychosis. Specifically, this study examined the relationships between three
patterns of premorbid adjustment (i.e., deteriorating, stable-good, stable-poor) and the
presence of specific schizophrenic symptomatology (i.e., negative symptoms,
hallucinations, Schneiderian first-ranked delusions, thought disorder, bizarre behavior,
and paranoia/grandiosity) during first-episode psychosis in an attempt to delineate

specific developmental pathways of schizophrenia.

 

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LITERATURE REVIEW

Premorbid Adjustment in Schizophrenia

The literature on premorbid adjustment in schizophrenia is vast. The following
review will begin with a discussion of the definition of premorbid adjustment, including
the time parameters and areas of firnctioning referred to by the term. It will then provide
an overview of common premorbid personality traits found in preschizophrenic
individuals. Next, a review of competing theories of premorbid adjustment will be
presented. Lastly, an overview of the most contemporary and influential studies to date
with respect to premorbid adjustment in schizophrenia in a variety of areas will be
provided. These areas include premorbid adjustment in schizophrenia as compared to
those with other disorders; correlates of premorbid adjustment in schizophrenia such as
demographic variables and biological markers; and premorbid adjustment in
schizophrenia and its relationship to subtypes of schizophrenia, clinical symptomatology,

treatment outcome and first-episode psychosis.

Definition of Premorbid Adjustment

The term “premorbid adjustment” in relation to schizophrenia refers to the level
of adjustment or firnctioning attained by an individual before the onset of schizophrenia
or schizophreniforrn disorder. Confusion has existed in the literature regarding the
precise time period referred to by the term premorbid adjustment. To date it is generally

accepted that this period refers to the level of firnctioning attained at various

 

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developmental stages up to a period of six months before first psychiatric contact or
hospitalization. In addition, most definitions of the premorbid adjustment period also
state that if psychotic symptoms were present for some time before first psychiatric
contact, then ratings should be made of the time period “six months before evidence of
characteristic florid psychotic symptomatology including delusions, hallucinations,
thought disorder, inappropriate or bizarre behavior, or gross psychomotor behavior in
which the symptoms are not apparently due to organic causes” (Cannon-Spoor, Potkin, &
Wyatt, 1982, p. 471). Strauss and colleagues (1977) describe premorbid adjustment as
“personal firnctioning measured along various dimensions at specific temporal points” (p.
240). The authors claim that the most important dimensions include functioning in the
area of social relations and school or work. Most measures of premorbid adjustment in
the literature today assess four areas of firnctioning. These four areas include sociability-
withdrawal, peer relationships including social-sexual relationships, adaptation and
performance at work or school, and establishment of independence outside the nuclear
family (Cannon-Spoor et al., 1982; Harris, 1975).

Some researchers have distinguished the “prodromal period” from the “premorbid
period” in the early course of schizophrenia. Specifically, prodromal symptoms refer to
“the early symptoms and signs of an illness that precede the characteristic manifestations
of the acute, firlly developed illness” (Yung & McGorry, 1996, p. 353). Many
investigators describe prodromal symptoms as the first unusual or noticeable behaviors
before the development of overt psychotic symptoms (Loebel et al., 1992; Beiser,
Erickson, Fleming, & Iacono, 1993). In a comprehensive review of the literature on the

prodromal phase of first-episode psychosis, Yung and McGorry (1996) outline the most

commonly described prodromal signs in first-episode studies. These features are shown
in Table 1 (see Appendix A). The DSM-III-R (American Psychiatric Association, 1987)
included a list of prodromal features of schizophrenia, however, concerns about the
reliability and validity of these features led to the list being dropped fiom DSM-IV
(American Psychiatric Association, 1994). According to Keith and Matthew (1991),
prodromal symptoms are not included in the ICD-lO (World Health Organization, 1992)
because they are too nonspecific and cannot be reliably measured. The risks of confusing
“premorbid” and “postmorbid” features in schizophrenia have been discussed repeatedly
(Deister & Marneros, 1993; Marneros & Tsuang, 1991; Marneros, Deister, Rohde,
Steinmeyer, & Junemann, 1989). Despite continued controversy about the exact
characteristics of premorbid and prodromal symptoms in schizophrenia, there does exist
general consensus among those who choose to differentiate between premorbid and
prodromal phases of schizophrenia regarding the definitions of these chronological
periods (McGlashan & Johannessen, 1996). Specifically, the premorbid phase of
schizophrenia refers to the time period between birth and first signs of illness. In
contrast, the prodromal phase of schizophrenia refers to the time period between the first
signs of illness and the onset of psychosis. For the purposes of this study, the premorbid
period will refer to the period between birth and six months before first psychiatric
contact or hospitalization. Therefore individuals with an insidious onset will likely
evidence prodromal features for a significant portion of the premorbid period. In
contrast, individuals with a rapid onset will likely not evidence prodromal features at all,

or only for a short time during the premorbid period.

 

 

 

 

 

 

 

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Common Premorbid Traits

Although not always the case, observations which date back to Kraepelin
(1989/1987) and Bleuler (1911/1950) indicate that some adults with schizophrenia
demonstrate unusual behaviors in childhood. Hartmann et al. (1984) report that some
studies, “strongly suggest that schizophrenia does not in most cases ‘break out’ suddenly
at the age of twenty years in someone who has had a normal childhood and adolescence”
(p. 1055). In contrast, other researchers state, “many individuals who develop
schizophrenia have normal childhoods and are not identifiable in their early years”
(Torrey, 1995, p. 95).

Despite differences in the presence of premorbid traits in individuals who later
develop schizophrenia, there does exist some consensus regarding which traits are most
commonly found. For example, Watt and colleagues (1970, 1972, 1978) examined
school records of individuals who later developed schizophrenia and found that, in
comparison to controls, preschizophrenic boys tended to demonstrate internal conflict,
over-inhibition, unsocialized aggression, disagreeable behavior, and emotional
depression. In addition, preschizophrenic girls were described as introverted, passive,
and emotionally unstable. These authors conclude that between one-third and one-half of
preschizophrenic children manifested some type of maladjustment at least a decade
before their first hospitalization. A review by Cutting (1985) reported that approximately
half of adult schizophrenic subjects evidenced abnormal personality traits in childhood.
Examples of these traits include blunted affect, suspiciousness, rigidity, eccentricity,
unusual speech, and solitariness (F oerster, Lewis, Owen, & Murray, 1991; Kretschmer,

1921). In a study that retrospectively recalled social firnctioning in individuals with

schizophrenia and their nonschizophrenic siblings, and normal controls and their well
siblings, it was found that the pre-onset childhood and adolescent social functioning of
the individuals with schizophrenia was significantly poorer than that of the other three
subject groups (Stempel, 1998). In recent years, a number of high risk, longitudinal
studies (Erlenmeyer-Kimling, Comblatt, & Golden, 1983; Goldstein, 1987; Mednick et
al., 1987; Tienari et al., 1987) have been developed to look at premorbid behavioral
predictors of adult schizophrenia. Many of these studies have demonstrated that
individuals who later develop schizophrenia are often withdrawn, anxious, emotionally
labile, and at times disruptive (Hans, Marcus, Henson, Auerback, & Mirsky, 1992; John,
Mednick, & Schulsinger, 1982; Olin, John, & Mednick, 1995). A similar study that
looked at childhood precursors of schizotypal personality disorder (Olin et al., 1997),
suggested that those who later developed schizotypal personality disorder were sensitive
to criticism, passive, and unengaged in childhood compared to the nonschizophrenic
groups. Evidence of behavioral difl’erences between children who later developed
schizophrenia and their siblings who did not were found by Walker and Lewine (1990) in
a prospective study of children’s home movies. Specifically, analysis of these movies
demonstrated that the children who later developed schizophrenia were overall less
responsive and had poorer fine and gross motor coordination, poorer eye contact, and less
positive affect than their siblings who did not develop the disorder. In a prospective,
longitudinal study of the children of individuals with schizophrenia, psychiatric controls,
and normal controls findings suggest the presence of social impairment and withdrawal in
the children of individuals with schizophrenia (Powell, 2000). A study by Hartmann et

al. (1984) provides a comprehensive list of psychosocial indicators of vulnerability to

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schizophrenia as listed in Table 2 (see Appendix B).

Theories of Premorbid Adjustment

Controversy exists about how early traits or premorbid patterns of adjustment
rrright relate to later symptoms of schizophrenia. Some researchers describe deficiencies
in premorbid adjustment as signs of vulnerability to schizophrenia. That is, difficulties in
childhood functioning represent early signs of maladjustment, which if not remedied may
continue to manifest and worsen over time. Therefore, early traits are the beginnings of a
longitudinal process. Researchers have postulated both interpersonal and biological
explanations regarding the origins of these early traits. For example, early
psychoanalytically oriented theorists emphasized the interpersonal nature of the disorder
and suggested that oral dynamics and maternal transference (Bychowski, 193 0; F romm-
Reichmann, 1947), poor ego boundaries (F edem, 1943 ), and poor object relations
(Fairbairn, 1954; Freud, 1964; Guntrip, 1969) predispose individuals to the relationship
problems indicative of schizophrenia. Melanie Klein (1930, 1948, 1975) furthered the
development of a psychoanalytic theory of schizophrenic symptomatology in her work
with psychotic patients around early oral dynamics and internalized object relations. In
general, Kleinian analysts understand the symptoms of schizophrenia as defenses against
terrifying persecutory and annihilation anxieties (Bion, 1967; Rosenfeld, 1969; Sega],
1973). Similarly, Kretschmer (1921) viewed psychotic symptoms as reactions to stress
in particularly vulnerable individuals. Sullivan (1953) and Winnicott (1965) also
emphasized the interpersonal nature of the disorder, and the influence of environmental

deficiencies in the maturational processes of early childhood in individuals who later

11

develop schizophrenia. Several contemporary psychoanalytically oriented researchers
also agree that the symptoms of schizophrenia represent attempts to cope with
overwhelming feelings of terror due to traumatic life histories (Karon, 1992; Karon &
Teixeira, 1995; Karon & VandenBos, 1981; Teixeira, 1984). In addition, many of the
early symptoms present in children who later develop schizophrenia are seen in children
who later develop other disorders (e.g. bipolar affective disorder, personality disorders),
therefore these traits are seen as not specific to schizophrenia, but instead constitute
symptoms on a continuunr, with schizophrenia being the most severe (Teixeira, 1998).

In contrast, other researchers would agree with Kraepelin’s (1989/ 1987) view that
abnormal personality traits in childhood constitute the early stages or precursors of a
longitudinal disease process of abnormal perceptions and relations. Advocates of this
viewpoint stress the neurobiological underpinnings of schizophrenia, and therefore see
early traits and poor premorbid adjustment as the beginning signs of brain dysfunction or
aberrant neurological development (Torrey, 1995; Weinberger, 1995).

Still other researchers focus on describing the deficiencies in premorbid
adjustment as leading to increased difficulty in recovering from schizophrenia when it
hits. For example, numerous studies stress that poor premorbid firnctioning, especially
social firnctioning, lead to poor outcome in schizophrenia (Kokes, Strauss & Klonnan,
1977; Bailer, Brauer & Rey, 1996). These researchers emphasize that particular
premorbid characteristics are not necessarily early signs of schizophrenia, but instead
may make it more difficult for the individual who later develops the disorder to cope with

the subsequent symptoms.

12

Premorbid Adjustment in Schizophrenia versus Normal Controls and Other Disorders
Numerous studies have demonstrated that individuals with schizophrenia
consistently show poorer premorbid adjustment than normal controls (Cannon-Spoor et
al., 1982; Lewine, Watt, Prentky, & Fryer, 1980; Watt, Stolorow, Ludensky, &
McClelland, 1970). Krauss and colleagues (1998) found that individuals with
schizophrenia or schizoaffective disorder and normal controls differed significantly on
every item of the Premorbid Adjustment Scale (PAS; Cannon-Spoor et al., 1982). Many
researchers have also shown that individuals with schizophrenia show poorer premorbid
adjustment than those with affective disorders (Bromet et al., 1996; Dalkin, Murphy,
Glasebrook, Medley & Harrison, 1994; Gureji, Aderibigbe, Olley, & Bamidele, 1994;
Maneros et al., 1989; Van Os et al., 1995; Vocisano, Klein, Keefe, Dienst, & Kincaid,
1996). For example, a recent study by Cannon and colleagues (1997) demonstrated that
individuals with schizophrenia were impaired in childhood and adolescence both socially
and scholastically in comparison to normal controls and individuals with bipolar disorder.
In addition, the children who later developed bipolar disorder functioned well
scholastically, and were socially impaired only in adolescence, but to a lesser degree than
the children who later developed schizophrenia. Of note, the researchers controlled for

confounding factors such as sex, social class, ethnicity, and premorbid IQ.

Premorbid Adjustment and Demographic Variables
It has been well established that poor premorbid adjustment in schizophrenia is
associated with demographic variables such as male gender and earlier onset of the

disorder (Goldstein, Tsuang, & Faraone, 1989; Klorman, Strauss, & Kokes, 1977;

13

Lewine, 1981; Loranger, 1984; Shtasel, Gur, Gallacher, Heimberg, & Gut, 1992a;
Westermeyer & Harrow, 1984). Larsen and colleagues (1996b) found that gender
differences during the onset of schizophrenia can be striking, with males evidencing
poorer premorbid adjustment than females. The authors firrther described males’
tendency to deteriorate faster than females, especially close to onset of the disorder.
Some researchers suggest that these differences may be due to males’ higher incidence of
brain insult in childhood (Nasrallah & Wilcox, 1989) or brain morphology (Lewine,
Gulley, Risch, Jewart, & Houpt, 1990). It has also been suggested that womens’ later
onset and less severe course may be due to the “protective effect” of estrogen (Hafirer et
al., 1998; Seeman & Lang, 1990; Woolley & McEwen, 1994). Others have hypothesized
that differences in the expression of schizophrenia may be a result of cultural and social

factors (Loranger, 1984), such as sex differences in depth of affect (Shtasel et al., 1992a).

Premorbid Adjustment and Biological Markers

Studies examining the relationship between poor premorbid adjustment and
biological markers suggest that difficult premorbid firnctioning is associated with
neurological impairment (Guy, Liaboe, & Wallace, 1986; Lilliston, 1970), minor physical
anomalies which have been hypothesized to originate fiom first trimester trauma (Guy,
Majovski, Wallace, & Guy, 1983), impaired N2 auditory event-related potential (Levitt,
O’Donnell, McCarley, Nestor, & Shenton, 1996), CT scan abnormalities (Weinberger,
Cannon-Spoor, Potkin & Wyatt, 1980), enlarged ventricles (Levitt, Shenton, McCarley,
Faux, & Ludwig, 1994; Weinberger et al., 1980), and temporal lobe impairment (Saykin

et al., 1991). Poor premorbid adjustment has also been associated with

14

neuropsychological deficits including impaired performance on the visual memory span
task of the Wechsler Memory Scale and more perseverative errors on the Vlfrsconsin Card

Sorting Test (Levitt et al., 1996).

Premorbid Adjustment and Subtypes

Interest in investigating the temporal features of onset in schizophrenia has been
generated by a desire to identify both developmental and clinical subtypes of the disorder
(Bleuler, 1978; Ciompi, 1980). To this end, numerous investigations of the relationship
between premorbid adjustment and the various subtypes of schizophrenia have been
conducted. Many researchers in the area of premorbid adjustment have emphasized the
paranoid versus non-paranoid subtype distinction. Despite some evidence which
supports no differences (Eisenthal et al., 1972; Sanes & Zigler, 1971), it is now generally
accepted that individuals who have paranoid schizophrenia have a better premorbid
adjustment than those who have disorganized or undifl'erentiated types of schizophrenia
(Deister & Marneros, 1993; Magaro, 1981; Zigler, Levine, & Zigler, 1977). Deister and
Marneros (1993) reported that significantly more patients with paranoid initial episodes
had a stable social-sexual partnership before onset than patients with residual, negative or
catatonic subtypes. Similarly, the lowest rates of social isolation were found among the
patients with paranoid in comparison to disorganized subtypes. Lastly, a study of
premorbid firnctioning in a sample of state hospital patients found that paranoids had

higher levels of social competence than non-paranoids (Zigler & Levine, 197 3).

15

 

 

.....

 

 

 

 

Premorbid Adjustment and Negative Symptoms

Considerable evidence indicates a relationship between poor premorbid
adjustment and negative symptomatology (Andreasen & Olsen, 1982; Andreasen et al.,
1990; Dworkin et al., 1987; Kay & Lindenmayer, 1987; Pogue-Geile & Harrow, 1984).
Specifically, McGlashan and F enton (1992) reported that poor premorbid firnctioning in
the areas of social relationships, educational attainment, and work performance are all
associated with the development of the negative symptoms of schizophrenia (i.e.,
affective flattening or blunting, alogia, avolition-apathy, anhedonia—asociality and
attention). Peralta and colleagues (1991) investigated the relationship between negative
symptoms and presence of premorbid personality disorders and reported that affective
flattening and alogia were more fi'equently present and severe in schizophrenics who met
criteria for schizoid or schizotypal personality disorder before onset of schizophrenia than
those who did not. In addition, some studies have demonstrated that the relationship
between poor premorbid adjustment and negative symptoms is stronger in men than
women (Ring et al., 1991, Shtasel et al., 1992a). Studies examining first-episode
populations have filrther demonstrated that the relationship between poor premorbid
adjustment and negative symptomatology holds across a wide range of methodologies
and age ranges (Dalkin et al., 1994; Haas & Sweeney, 1992; Larsen, McGlashan, & Moe,
1996a; Larsen, McGlashan, J ohannessen, & Vibe-Hansen, 1996b; Larsen, Moe, Vibe-

Hansen, & Johannessen, 2000; Peralta, Cuestra, & DeLeon, 1991; Shtasel et al., 1992b).

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Premorbid Adjustment and Treatment Outcome

There is substantial evidence to indicate that poor premorbid adjustment is also
associated with unfavorable treatment outcomes in schizophrenia (F enton & McGlashan,
1987; Kay & Lindenmayer, 1987; Larsen et al., 2000; McGlashan, 1986; Prudo & Blum,
1987 ; Strauss & Carpenter, 1974). Numerous studies have demonstrated that poor
premorbid adjustment is associated with slower remission of symptoms and less
improvement in community adjustment over time (Bromet et al., 1996; Gittelman-Klein
& Klein, 1969; Strauss & Carpenter, 1977). Poor premorbid adjustment has also been
associated with poor response to neuroleptic medication (Goldstein, 1970; Stem et al.,
1993; Sternberg, van Kammen, Lerner & Bunney, 1982). A retrospective case study by
Amminger and Mutschlenchner (1995) demonstrated that patients who showed complete
remission after eight weeks of neuroleptic medication had significantly higher social
functioning ratings during childhood than patients who showed only a partial remission
or no response. Wieselgren and Lindstroms’ (1996) data suggest that schizophrenics who
evidence deviant premorbid behavior, such as problems in school with fiiends or teachers
are more likely to have a poor outcome than those who show no deviant behavior.
Overall, various researchers have indicated that when looking at a number of potential
predictive variables in schizophrenia, premorbid adjustment is the strongest overall
predictor of outcome (Bailer, Brauer, & Rey, 1996; Bromet et al., 1996; Strauss &

Carpenter, 1977).

17

Patterns of Premorbid Adjustment

The majority of early studies of premorbid adjustment in schizophrenia used a
simple, two-dimensional design and categorized individuals as having either good or poor
premorbid adjustment. This two-dimensional model was expanded (Bromet, Harrow, &
Kasl, 1974; Chapman et al., 1961; Vaillant, 1964) when good premorbid adjustment was
associated with a reactive-type psychosis and poor premorbid adjustment was associated
with a process-type psychosis. As outlined by Heilbrun, Blum, & Goldreyer (1985),
“Reactive schizophrenics, by definition, are more responsive to their social environment
than process schizophrenics. The major factors in the better premorbid adjustment of the
reactive are greater commitment to, and success in, social relationships and greater
commitment to attainment of socially recognized goals” (p. 105). One of the most widely
used measures of premorbid adjustment, namely the Phillips Scale (Phillips, 1953), has
often been used to classify individuals with schizophrenia as process or reactive based on
their ratings of premorbid social and sexual adjustment. According to Harrow and
colleagues (1986, p. 195), “Literally thousands of studies have been based on the process-
reactive dimension and on good versus poor premorbid social adjustmen -- two related
but not necessarily identical concepts” (Bromet et al., 1974; Chapman & Chapman, 1973;
Putterman & Pollak, 1976; Strauss & Carpenter, 1974; Quitkin, Riflcin & Klein, 1976).

The methodological flaws inherent in classifying subjects into dichotonries such
as good versus bad premorbid adjustment have been outlined (Sorensen, Paul, &
Mariotto, 1988). Zigler, Levine and Zigler (1977) suggest that such dichotorrries

artificially constrict the true variance that exists in premorbid firnctioning. Instead they

18

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suggest that better characterization of premorbid adjustment can be achieved by
measuring multiple levels of functioning. Examining the mode of onset (i.e. gradual
versus sudden) may increase understanding of the course of schizophrenia (Carpenter &
Kirkpatrick, 1988; McGlashan, 1988). For example, recent studies have characterized
premorbid functioning based on three subtypes: stable-poor, deteriorating, and stable-
good (Haas & Sweeney, 1992; Larsen et al., 1996b). Specifically, the stable-poor group
refers to individuals who show consistently low levels of functioning from childhood
through adolescence and adulthood. The deteriorating group refers to individuals who
evidence a pattern of progressive or insidious decline in firnctioning from childhood
through adolescence and adulthood. And the stable-good group refers to individuals who
show consistently adequate to good levels of firnctioning from childhood until the onset
of first psychotic symptoms.

Results of these studies indicate that individuals with a deteriorating course of
premorbid functioning evidence more severe negative symptoms (i.e., anhedorria and
social withdrawal) than both the stable-good and the stable-poor groups (Haas &
Sweeney, 1992; Larsen et al., 1996b). In addition, the stable-good group showed both a
later age of symptom onset as well as a later age of first psychiatric contact. This finding
is consistent with previous data which suggest that later age of onset and good premorbid
firnctioning are associated with a more benign course of illness (World Health

Organization, 1979; Burack & Zigler, 1989).

19

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Patterns of Clinical Symptoms

A number of standardized clinical rating scales have been developed in the past
two decades to assess the presence and severity of symptomatology in schizophrenia.
Hughlings-Jackson was the first to use the terms positive and negative with respect to
symptomatology in the context of a model of brain function (Hughlings-Jackson, 1931).
Negative symptoms involved a loss of function through damage to some area of the
brain, whereas positive symptoms involved a release of firnction by damage to the higher
cortical area that worked to inhibit the firnction. Hughlings-Jackson later described
positive and negative psychiatric symptoms. He concluded that affective flattening or
alogia were caused by loss of function, and therefore negative symptoms and
hallucinations and delusions were caused by a release of function and therefore positive
symptoms. Crow (1980) and Andreasen and Olson (1982) extended the ideas of
Hughlings-Jackson and further differentiate between the ‘positive’ and ‘negative’
symptoms of schizophrenia. As outlined by Carpenter et al. (1988), “While the positive
symptoms represent an exaggeration or distortion of normal function (i.e., hearing voices
when none are there), negative symptoms represent a diminution or loss of normal
firnctioning” (p. 350). This differentiation lead to the creation of standardized rating
scales such as the Scale for the Assessment of Positive Symptoms (SAPS) and the Scale
for the Assessment of Negative Symptoms (SANS) (Andreasen, 1982, 1983, 1984). The
Scale for the Assessment of Positive Symptoms (SAPS) includes ratings of the most
striking psychotic symptoms of schizophrenia such as auditory and visual hallucinations,

paranoid and grandiose delusions, positive formal thought disorder and bizarre behavior.

20

In contrast, the Scale for the Assessment of Negative Symptoms (SANS) includes ratings
of affective flattening or blunting, alogia, avolition-apathy, anhedonia-asociality and
attention. Another clinical rating scale that has held broad appeal in the research
community is the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962). This
scale includes a broad range of symptoms and assesses many of the symptoms of
schizophrenia in a general way. For example, the BPRS includes a global rating of
hallucinatory behavior, as opposed to detailed ratings of auditory, somatic, olfactory and
visual hallucinations found on the SAPS.

It has been suggested that about one-third of patients with schizophrenia have
predominantly positive symptoms, one-third have primarily negative symptoms, and one
third have a mixed symptom presentation of both positive and negative symptoms
(Andreasen & Olsen, 1982). Factor analysis of the SAPS and SANS has confirmed the
positive-negative dimensions of schizophrenia and suggested the presence of a third
“disorganization” factor (Amt et al., 1991; Miller et al., 1993; Peralta et al., 1992). This
disorganization or disinhibition factor consists primarily of symptoms of thought
disorder, as well as extravagant, bizarre or inappropriate behavior and affect. Factor
analysis of the BPRS has indicated five factors, namely anxiety-depression, anergia,
thought disorder, activity, and hostility (Guy, Cleary & Bonota, 197 5). Gur, Resnick and
Our (1989) repeated this factor analysis of BPRS items, but divided them into symptoms
specific to schizophrenia (e.g., suspiciousness, hallucinatory behavior, unusual thought
content) and those non-specific to schizophrenia (e. g., anxiety, guilt feelings, depressive
mood). The results of this analysis suggested that patients with schizophrenia scored

higher on specific symptoms than depressed patients and that there was a correlation

21

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between severity of specific symptoms and regional cerebral blood flow and glucose
metabolism.

In another study of the relations among clinical scales Gur and colleagues (1991)
compared specific and nonspecific ratings on the BPRS, global ratings on the SAPS and
SANS, and deficit/non-deficit ratings (Carpenter, Heinrichs, & Wagrnan, 1988) in a
sample of patients with schizophrenia. Because the BPRS includes psychiatric symptoms
that are both specific to schizophrenia (e.g., conceptual disorganization, hallucinatory
behavior, unusual thought content, blunted afi‘ect) and nonspecific to schizophrenia (e.g.,
anxiety, guilt feelings, depressive mood, uncooperativeness) it makes clinical sense to
divide the items in this way. Carpenter developed the deficit/non—deficit scale to
distinguish between long-standing negative symptoms of schizophrenia (deficit) and
transitory negative symptoms that might be caused by secondary factors (non-deficit).
Gur et al. (1991) reported that deficit patients had more specific symptoms, fewer
nonspecific symptoms, and more negative symptoms. In addition, results of a cluster
analysis suggested three clusters of patients. The first cluster consisted of primarily non-
deficit patients who had high specific symptoms and low nonspecific symptoms. The
second cluster consisted of primarily deficit patients with high scores on specific
symptoms, positive and negative symptoms. And the third cluster consisted of primarily
deficit patients with low scores on specific symptoms, and high scores on positive and
negative symptoms.

A similar study by Shtasel and colleagues (1992b) compared first-episode with
non first-episode patients and extended their factor analysis to include all items on the

SAPS, SANS, and BPRS. Results fiom this analysis yielded a four-factor solution. The

22

 

 

 

first factor included symptoms associated with the negative or deficit syndrome. The
second factor included disorganization or disinhibition symptoms such as positive formal
thought disorder and bizarre behavior. The third factor included hallucinations and
Schneiderian first-rank symptoms (FRS) (e. g., mind reading, thought insertion and
withdrawal) (Schneider, 1959). The fourth factor included paranoia and grandiosity. A
cluster analysis was then done on the four factors (i.e., negative symptoms, thought
disorder/bizarre behavior, hallucination and Schneiderian FRS, and paranoia/grandiosity).
This analysis produced three clusters of patients. The first cluster represented a group of
patients with severe negative symptoms and moderate thought disorder, delusions and
hallucinations. The second cluster represented a group of patients with predominantly
thought disorder/bizarre behavior, and paranoia/grandiosity. And the third cluster of
patients included those with severe hallucinations and Schneiderian FRS. One of the
most notable findings in this study was the lack of difference between first-episode and
non first-episode patients in overall severity of symptoms. Some difi‘erences were found
on specific symptoms. For example, first-episode patients had less severe ratings with
respect to thought disorder and more severe ratings with respect to delusions and
hostility. The two groups did not differ in negative symptomatology. Further analysis
suggested that poor premorbid and current firnctioning are associated with negative

symptoms in both first-episode and non-first-episode groups.

23

Benefits of First-Episode Populations

The benefits of studying first-episode populations have been described by
numerous researchers (Keshavan & Schooler, 1992; Lieberman, Matthews, & Kirch,
1992; Shtasel et al., 1992b). Some emphasize that a detailed analysis of the time period
surrounding first-episode psychosis is critical for an accurate picture of schizophrenia
because the majority of clinical changes occur early on in the disorder (Bilder et al.,
1992; Lieberman et al., 1992). Haas and Sweeney (1992) indicate, “One of the chief
advantages is that the clinical symptomatology and behavior observed during the first
episode are less affected by the confounding influences of medical treatments, secondary
social difficulties, and disease progression” (p. 374). The presence of confounding ,
variables such as the use of neuroleptic medication, stigma, long-term treatment in the
community, and repeated hospitalizations are likely with a chronic schizophrenic
population. Issues regarding increased reliability of data are also an important benefit of
studying first-episode populations. Specifically, the relatively short time span between
the onset of symptoms and clinical documentation enhances accuracy of recall for both
the patient and any third-party reporters such as family members (Haas & Sweeney,
1992)

Issues regarding the definition of first-episode schizophrenia have been discussed
at length in the literature. Flaum and colleagues (1992) point out the often elusive nature
of schizophrenia onset. They discuss the importance of an operationalized definition of
first-episode because “patients who experience a chronic and unremitting course could be

said to be in their first episode for most of their lives” (p. 482). For the purpose of this

24

study first-episode was defined as the first time psychiatric treatment was sought and
accepted by neuroleptic naive patients who receive a diagnosis of schizophrenifonn

disorder or schizophrenia.

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THE PRESENT STUDY

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Schizophrenia is seen as the most severe form of mental illness because those
who suffer from it have broken ties with reality. This break with reality can manifest
itself in various ways and to various degrees. In general, it makes sense that the longer
an individual has been engaged in breaking ties with reality, the more severe his or her
psychotic symptoms. From this theoretical perspective, we are not seeing differential
disease processes in the various manifestations of schizophrenia, but instead one disease
process that falls on a continuum of severity. For example, negative symptoms can be
seen as a less severe form of psychosis, because the individual has simply withdrawn
from reality, not created alternative realities in the form of hallucinations and delusions.
Similarly, thought disorder and paranoia can be seen as less severe forms of psychosis in
comparison to hallucinations and delusions because of their interpersonal nature. That is,
the individual with thought disorder has developed faulty communication patterns and the
paranoid individual has developed a faulty connection with others. Overall, this
theoretical perspective points to the existence of complex relationships between patterns
of premorbid fimctioning and the development of various types of schizophrenic
symptomatology.

The current study aimed to extend the work on premorbid firnctioning and
symptomatology in schizophrenia by attempting to firrther determine the relationship

between patterns of premorbid adjustment and specific symptom presentation in first-

26

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episode schizophrenia. Specifically, the aim of the current research was to firrther assess
the association between patterns of premorbid adjustment based on Haas and Sweeney’s
(1992) subtypes (i.e., stable-poor, deteriorating, and stable-good) and the four symptom
factors (i.e., negative, disinhibition, positive, paranoia) and three patient clusters (i.e., a
predominantly “negative” group with moderate delusions, hallucinations and thought
disorder; a predominantly “disinhibited” group with moderate thought disorder, bizarre
behavior, and paranoia; and a predominantly “positive” group with severe hallucinations
and Schneiderian FRS) described by Shtasel et al. (1992b).

First, previous research suggests that the deteriorating premorbid group will
evidence more negative symptomatology than the stable-good and stable-poor groups
(Haas & Sweeney, 1992; Larsen et al., 1996b). Next, it is indicated that paranoid
schizophrenia is directly related to good premorbid adjustment (Ritzler, 1981; Zigler &
Levine, 1973 ), therefore, it is expected that the stable-good group will evidence more
paranoid and grandiose symptomatology than the stable-poor or deteriorating group.
Lastly, a recent study by Bailer and colleagues (1996) suggested that the highest
proportion of positive symptoms (e.g. hallucinations, delusions) was found in the poor
premorbid adjustment group as compared to the good, therefore it is expected that the
stable-poor group will evidence more hallucinations and Schneiderian first-ranked

symptoms than the stable—good or deteriorating group.

27

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Research Hypotheses

The present study addressed the following hypotheses:

1. It was predicted that an Exploratory Factor Analysis of all SANS, SAPS, and
BPRS items would evidence the same four-symptom factor solution as previously
determined in the Shtasel et al. (1992b) study. Specifically, it was predicted that the four
factors would include, 1) a negative factor, 2) a thought disorder/bizarre behavior factor,

3) a hallucinations/Schneiderian FRS factor, and 4) a paranoid/grandiose factor.

2. It was predicated that a Cluster Analysis of the four symptom factors would
produce three clusters of patients as previously deternrined in the Shtasel et al. (1992b)

study. Specifically, it was predicted that:

a) Cluster 1 would represent a group of patients with prominent negative
symptoms.
b) Cluster 2 would represent a group of patients with prominent

paranoia/grandiosity and thought disorder/bizarre behavior.
c) Cluster 3 would represent a group of patients with prominent

hallucinations and Schneiderian FRS.

3. It was predicated that the three clusters of patients would evidence significantly
different patterns of premorbid adjustment. It was firrther predicated that:

a) Cluster 1 would evidence a deteriorating pattern of premorbid adjustment.

28

b) Cluster 2 would evidence a stable-good pattern of premorbid adjustment.

c) Cluster 3 would evidence a stable-poor pattern of premorbid adjustment.

With respect to specific symptomatology it was predicted that:

a) The deteriorating group would evidence the most severe negative
symptoms, in comparison to the stable-poor or stable-good group.

b) The stable-good group would evidence the most severe paranoid
delusions, bizarre behavior and thought disorder in comparison to the
deteriorating or stable-poor group.

c) The stable-poor group would evidence the most severe hallucinations and

Schneiderian FRS in comparison to the deteriorating or stable-good group.

29

 

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METHODOLOGY

Subjects

Subjects included eighty-six adults with a diagnosis of first-episode
schizophrenia, schizoatfective disorder, or schizophreniforrn disorder. Subjects were
categorized as first-episode because they were experiencing psychotic symptoms for the
first time, had not accepted psychiatric treatment in the past, and were neuroleptic na'r've.
Subjects were recruited by the University of Pennsylvania’s Neurobehavioral Study of
Schizophrenia research team and were selected from an ongoing longitudinal study
investigating brain firnction in schizophrenia. Subjects were referred from private
practitioners, community mental health centers, emergency rooms, state hospitals, and the
inpatient unit of the Hospital of the University of Pennsylvania. Subjects were excluded
from the study if they had: 1) a concomitant axis I or II psychiatric disorder; 2) past or
present substance abuse or dependence; 3) a history of a medical illness that might effect
brain function (e. g., cardiac, endocrine, pulmonary, or renal disease); 4) a history of a
neurological disorder (e.g.,. epilepsy, migraines, head trauma with loss of consciousness);

5) current pregnancy.

Clinical Assessment

Afier informed consent was obtained, subjects underwent a comprehensive intake

evaluation as part of enrollment into the University of Pennsylvania’s Neurobehavioral

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Study of Schizophrenia. Intake evaluations were conducted by members of the research
team and included both medical and psychiatric components. The medical component
included a history, physical examination, and routine laboratory tests. None of the
medical data were used in the present study. The psychiatric component included a
standard clinical interview (SCID-P; Spitzer, Williams, Gibbon, & First, 1989, 1994) and
personality questionnaires. Diagnoses were based on information gained fiom the
standard clinical interview, chart review, and discussions with family members and other
professionals (e.g. inpatient unit or emergency room stafi). After an interview, the
interviewer completed numerous clinical rating scales that characterized premorbid
adjustment, symptom presentation, and social and occupational functioning. The
following clinical rating scales were used in the present study: the Premorbid Adjustment
Scale (PAS; Cannon-Spoor et al., 1982), the Scale for the Assessment of Negative
Symptoms (SANS; Andreasen, 1982, 1983), the Scale for the Assessment of Positive
Symptoms (SAPS; Andreasen, 1984), and the Brief Psychiatric Rating Scale (BPRS;
Overall & Gorham, 1962). Other rating scales and personality questionnaires were
completed but were not used in the present study. Psychiatric interviews and rating
scales were completed by members of the research team trained to a criterion reliability
of a minimum of 0.90 intraclass correlation on each instrument. Intake evaluations were
performed at the Hospital of the University of Pennsylvania. All subjects were
interviewed while off neuroleptic medications and clinical rating scales were completed

within 5 days of study entry.

31

Measures

The Premorbid Adjustment Scale

Most rating scales used to measure premorbid adjustment in schizophrenia were
developed thirty years ago. Examples of these scales include the Elgin Prognostic Scale
(Wittman, 1941), the Phillips Scale (Phillips, 1953), and The Premorbid Asocial
Adjustment Scale (Gittelman-Klein & Klein, 1969). Cannon-Spoor and colleagues
(1982) developed the Premorbid Adjustment Scale (PAS) in an attempt to remedy some
of the limitations of using outdated instruments. For example, many of the anchor points
on the old scales no longer reflected cultural norms. Also, none of the old scales
evaluated premorbid adjustment systematically at several developmental time points.

The authors reported that the PAS, “1) was usefirl for research purposes, 2)
conceptualized successfirl premorbid adjustment in terms of the attainment of certain
developmental goals that were viewed as necessary milestones for healthy functioning,
and 3) considered attainment of these goals as specific age-related tasks” (p. 471).

The PAS is designed to evaluate level of firnctioning in four major areas. These
areas include social accessibility-isolation, peer relationships, ability to function outside
the nuclear family, and capacity to form intimate social-sexual ties. Items that evaluate
age-appropriate fimctioning in each of these areas are included for Childhood (birth up to
age 11), Early Adolescence (age 12-15), Late Adolescence (age 16-18), and Adulthood
(19 years and beyond). The final section is labeled General, and contains items to assess
the highest level of functioning attained before the individual became ill, the time span

and characteristics of illness onset, and general information including education and

32

 

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establishment of independence. There are a total of 23 items on the PAS.

Ratings were based on interviews with patients and as many sources of
corroborating information as possible. Family member reports, school and hospital
records, and information from other professionals such as teachers or physicians often
augment the information provided in a personal interview. Each item was rated based on
a 0-6 Likert type scale, with 0 representing the healthiest end of the adjustment range,
and 6 representing the least healthy. All items included descriptive anchor points to
increase reliability and validity.

Cannon-Spoor and colleagues (1982) describe two studies of PAS interrater
reliability. In the first study, two raters who were familiar with the PAS rated 11 patients.
Both raters reviewed chart notes and in some cases interviewed patients simultaneously.
Each rater completed the PAS independently. The intraclass correlation coeficient was
r = .85 (p = .0001). In the second study, ratings of three Veteran’s Administration
hospital (VA) clinicians and two National Institute of Mental Health (NIMH) clinicians
unfamiliar with the PAS were compared. All five clinicians reviewed chart notes only.
The average intraclass correlation coefficient was r = .74 (p = .0001).

Cannon-Spoor et al. (1982) have addressed issues of validity by comparing the
PAS ratings of subjects with schizophrenia to normal populations, and outpatients to
chronically hospitalized patients. In a study that compared 76 normal controls and 86
patients with schizophrenia, the normal group was significantly different (p < .01 , two-
tailed t test) on every subscale as well as on overall average score than the schizophrenic
group. Similarly, when the PAS scores of current outpatients were compared to those of

patients who had been continuously hospitalized for the past seven years, significant

33

differences were found between the groups. These discriminations were found on all
subscales except Childhood (Early Adolescence, p = .02; Late Adolescence, p = 009;
Adulthood, p = .02; and Average score, p = .002; one-way analysis of variance).

Krauss and colleagues’ (1998) report on the reliability and validity of the PAS in
a study of 86 German patients with schizophrenia and schizoafi‘ective disorder and 38
normal controls. In this sample, the estimation of the reliability coefficients showed high
positive values of Cronbach’s alpha between .80 and .93. In addition, the researchers
reported that patients and normal controls significantly difi‘ered on all items of the PAS.

For the purposes of the current study, premorbid functioning was classified based
on PAS scores, into one of three patterns of premorbid adjustment, as identified by Haas
& Sweeney (1992): 1) deteriorating or insidious premorbid functioning before onset of
first psychotic symptoms; 2) stable-good premorbid adjustment, identified by consistently
adequate-to—good levels of premorbid firnctioning from childhood until onset of first
psychotic symptoms; and 3) stable-poor premorbid adjustment, identified by consistency
low levels of firnctioning from childhood until time of onset of first psychotic symptoms.
For the purpose of consistency, the definitions and cut-ofi‘s used by Haas & Sweeney
(1992) and Larsen et al. (1996) were implemented. The deteriorating group was defined
with a pattern of worsening scores fiom childhood throughout the various developmental
periods and “the equivalent of a two-point change over four premorbid stages (childhood,
early adolescence, late adolescence, and adulthood) or a proportionate decline for cases in
which illness onset was before late adolescence or adulthood” (Haas & Sweeney, 1992, p.
376). In other words, the average score for each developmental period was calculated,

and an individual was categorized as deteriorating if their scores dropped by two points,

34

between childhood and adulthood. In contrast to the deteriorating group, the good and
poor groups were defined with a stable pattern of adjustment across premorbid periods.
All subjects who did not meet criteria for the deteriorating group were placed in the
stable-good or stable-poor group based on their overall mean PAS score. The overall
mean PAS score was used as a cut-off point to divide the cases into stable-good or stable-

poor

The Scale for the Assessment of Negative Symptoms

In recent years the importance of distinguishing between positive and negative
symptoms in schizophrenia has been widely accepted (Crow, 1980; Strauss et al., 1974).
Andreasen (1982, 1983) was the first to develop a standardized method to define and rate
negative symptoms in schizophrenia with the creation of the Scale for the Assessment of
Negative Symptoms (SANS). The SANS contains items for rating 24 negative
symptoms, including 5 global symptoms. Andreasen included the following global
symptoms (i.e., alogia, affective flattening, avolition-apathy, anhedonia-asociality, and
attentional impairments) which “were chosen empirically, based on [her] 12 years
experience evaluating, treating, and following many schizophrenic patients in a single
setting” (p. 785). Each of the five global areas is broken down into observable behavioral
components that are rated on a 6-point Likert scale ranging from (0) None to (5) Severe.
For example, the global symptom of avolition-apathy refers to an overall lack of energy,
drive, and interest. The patient is rated globally, as well as on the specific items of
grooming and hygiene, irnpersistence at work or school, and physical anergia. A total

score of all items is calculated to give the rater a sense of overall severity of pathology.

3S

35
all

 

an

511

M

im

the

her

Andreasen (1982) originally reported the reliability of the SANS using only an
interrater reliability design. This approach was chosen over a test-retest design because
the primary goal was to determine how well two independent raters would agree on
ratings of various patient behaviors. Also the use of the test-retest design introduces an
additional source of variance (i.e., changes in the patient’s behavior over time).
Andreasen (1982) reported intraclass reliability scores that include both individual items
as well as global scores. The global intraclass reliability scores are as follows:
anhedonia, r = 0.81; affective blunting, r = 0.80; avolition, r = 0.86; alogia, r = 0.66; and
attention, r = 0.67. Consistently high reliability scores have been reported in a number of
studies fiom Japan, Spain, and Italy (Humbert, Salvador, Segui, Obiols, & Obiols, 1986;
Moscarelli, Maffei, & Cesana, 1987; Ohta, Okazaki, & Anzai, 1984). Examples of these
intraclass reliabilities include ranges of r = 0.75 to r = 0.86 for affective flattening and r =
0.73 to r = 0.86 for anhedonia-asociality.

Later, Andreasen (1990) added to her work by reporting SANS test-retest
reliability scores. For this study, two clinicians simultaneously evaluated a patient on
two consecutive days in order to ensure minimal change in symptoms over time. Test-
retest reliability scores were somewhat poorer than interrater reliability scores, but most
global ratings continued to be in the acceptable range. Global test-retest reliability scores
include the following: anhedonia, r = 0.71; afi‘ective blunting, 0.76; avolition, 0.67;
alogia, 0.38; attention, 0.46.

Andreasen (1990) reported the reliability coefficient of each global symptom on
the SANS using Cronbach’s alpha. This coefficient measures the extent to which all

items in a given subscale measure the same symptom complex. Cronbach’s alpha is

36

 

 

 

 

 

dt

5y

Tl

pa:
C0.“
half

56‘1

 

We}

 

adequate for all 5 global symptoms: affective flattening (0.83), alogia (0.63), attentional
impairment (0.75), avolition-apathy (0.74), and anhedonia-asociality (0.77). Cronbach’s
alpha was also determined for the composite score (the sum of all items) as 0.89. As
described by Andreasen (1990), the high scores suggest that the items on the negative

symptom scale are highly integrated to one another.

The Scale for the Assessment of Positive Symptoms

Shortly after the development of the SANS to rate negative symptoms of
schizophrenia, Andreasen (1984) decided to create a similar standardized method to
define and rate positive symptoms of schizophrenia. This instrument is called The Scale
for the Assessment of Positive Symptoms (SAPS). The SAPS contains items for rating
34 positive symptoms, including 4 global symptoms. Andreasen included the following
global symptoms (i.e., hallucinations, delusions, bizarre behavior, and positive formal
thought disorder). As with the SANS, each of the global areas is broken down into
observable behavioral components that are rated on a 6 point Likert scale ranging fi'om
(0) None to (5) Severe. For example, the global symptom of hallucinations is based on
the duration and severity of the hallucinations and their effects on the patient’s life. The
patient is rated globally, as well as on the specific items of auditory hallucinations, voices
commenting, voices conversing, somatic or tactile hallucinations, and visual
hallucinations. A total score of all items is calculated to give the rater a sense of overall
severity of pathology.

Andreasen (1990) reported SAPS intraclass reliabilities for individual items as

well as the global scores. The global intraclass reliabilities are as follows: hallucinations,

37

r = .0.93; delusions, r = 0.76; bizarre behavior, r = 0.62; and, positive formal thought
disorder, r = 0.79. As with the SANS, the interrater reliabilties of the SAPS are
consistently high across a wide range of cultural settings. Studies which compared
multiple raters in Italy, Spain, and Japan reported global ratings of hallucinations ranging
from intraclass r = 0.84 to r = 0.93. Similarly, global ratings of positive formal thought
disorder were reported ranging from intraclass r = 0.82 to r = 0.99. According to
Andreasen (1990), such high interrater reliabilities suggest “the soundness of the basic
strategy of using observational rather than subjective evaluation” (p. 80).

Later, Andreasen (1990) added to her work by reporting SAPS test-retest
reliability scores. For this study, two clinicians simultaneously evaluated a patient on
two consecutive days in order to ensure minimal change in symptoms over time. Test-
retest reliability scores were somewhat poorer than interrater reliability scores, but most
global ratings continued to be acceptable. Global test-retest reliability scores include the
following: hallucinations, r = 0.65; delusions, r = 0.71; bizarre behavior, 0.50; positive
formal thought disorder, r = 0.62. As outlined by Andreasen (1990), test-retest reliability
includes components of both rater variance (differences in raters over time) as well as
occasion variance (differences in clinical symptoms over time) therefore it is expected to
be lower than interrater reliability.

Andreasen (1990) also reported the reliability coefficient of each global symptom
on the SAPS using Cronbach’s alpha. Cronbach’s alpha is acceptable for all 4 global
symptoms: hallucinations (0.75), delusions (0.66), positive formal thought disorder
(0.74), and bizarre behavior (0.79). Cronbach’s alpha was also determined for the

composite score (the sum of all items) as 0.48. Andreasen and colleagues (1990)

38

conclude that this score suggests that positive symptoms are less highly correlated than

negative symptoms.

The Brief Psychiatric Rating Scale

The Brief Psychiatric Rating Scale was developed to provide a quick and eficient
and assessment tool for the evaluation of symptom change in psychiatric patients (Overall
& Gorham, 1962). It has been widely used in psychiatric research not only because it is
a rapid assessment tool, but also because it provides a comprehensive description of the
major psychiatric symptoms. It has been recommended for use where efliciency, speed,
and economy are important considerations. It has been determined that raters who are
familiar with the rating scale can make the required judgments and complete the
instrument in less than five nrinutes following a clinical interview.

The Brief Psychiatric Rating Scale has gone through several revisions during the
course of its development (Gorham & Overall, 1960, 1961). The current scale consists of
16 symptom constructs that resulted from factor analyses of two larger sets of items,
namely Lorr’s Multidimensional Scale for Rating Psychiatric Patients (MSRPP) (Lorr,
Jenkins, & Holsopple, 1953) and Inpatient Multidimensional Psychiatric Scale (IMPS)
(Lorr, McNair, Klett, & Lasky, 1960). Examples of the 16 items include somatic
concern, anxiety, emotional withdrawal, suspiciousness, hallucinatory behavior, and
uncooperativeness. According to the authors, it is important that raters become familiar
with the definitions and delineations of each symptom area as outlined by them. Ratings
of some items (i.e., tension, mannerisms and posturing, motor retardation) can be made

on the basis of observation alone. Whereas other items (i.e., guilt feelings, grandiosity,

39

 

 

 

 

Bi

0L

S_Vr

Per

011‘.

Pa:

 

unusual thought content) must be rated based on more directive interview questions and
the verbal report of the patient. Each item is rated on a 7-point Likert scale ranging fiom
(1) not present to (7) extremely severe. Each individual score provides a sense of the
“degree of pathology” (p. 807) in each of the 16 symptom areas. The authors suggest
using a “total pathology” score, which is the simple sum of ratings on all 16 items.
Overall & Gorham (1962) provide BPRS interrater reliability scores based on
ratings by two independent clinicians on 83 “newly admitted schizophrenic patients” (p.
811). Examples of the interrater reliability scores on each of the 16 BPRS items include
the following: somatic concern, r = .81; anxiety, r = .86; guilt feelings, r = .87; depressive
mood, r = .76; uncooperativeness, r = .68, and unusual thought content, r = .83. No
information concerning test-retest reliability or internal consistency has been provided for

this instrument.

Data Analysis

An Exploratory Factor Analysis (EFA) of the items in the SANS, SAPS and
BPRS was performed to determine the presence of specific symptom “factors.” As
outlined in the Research Hypotheses section, it was predicted that the same four-
symptom factor solution would be found as in the Shtasel et al. (1992b) study.

A Cluster Analysis of specific patients and their four symptom factors scores was
performed to determine the presence of specific subtypes or “clusters” of patients. As
outlined in the Research Hypotheses section, it was predicted that three clusters of

patients would be produced as in the Shtasel et al. (1992b) study.

40

A Chi-Square Analysis was performed to determine if there was an association
between cluster group and premorbid adjustment group, and an interpretation of cell
frequencies was carried out to determine which cells were associated.

Lastly, planned comparisons were performed to test the specific predictions
outlined in the Research Hypotheses section conceming differences between the three
premorbid groups (deteriorating, stable-good, stable-poor) and clinical symptomatology.
Four planned comparisons were done to determine differences in negative symptoms,
thought disorder/bizarre behavior, hallucinations/Schneiderian first-ranked symptoms,
and paranoia between the groups. Specifically, one planned comparison tested the
hypothesis that the deteriorating group would evidence the most severe negative
symptoms, compared to the stable-good or stable-poor groups. Two planned
comparisons tested the hypothesis that the stable-good group would evidence the most
severe thought disorder/bizarre behavior and paranoia compared to the deteriorating or
stable-poor groups. One planned comparison tested the hypothesis that the stable-poor
group would evidence the most severe hallucinations/Schneiderian first-rank symptoms

compared to the deteriorating or stable-good group.

41

RESULTS

Demographics

A total of 86 subjects ranged in age fi'om 18-48 years (mean = 26.44 years, sd =
7.14). Sixty-six percent of the subjects were male (n = 57) and 34% percent were female
(11 = 29). The majority of the subjects were African-American (n = 52), with the next
largest group being Caucasian (n = 30). The remaining four subjects were Asian-
American. Level of educational attainment ranged from 8-22 years (mean = 12.98 years,
sd = 2.69). Although subjects were enrolled in the study and defined as first-episode
because they were experiencing psychotic symptoms for the first time, had not accepted
psychiatric treatment in the past, and were neuroleptic naive, more extensive chart review
revealed that some subjects did not meet all three of these criteria. Specifically, it was
discovered that ten subjects had been taken to psychiatric emergency rooms in the past
(i.e., before study entry) and nine of them had been given neuroleptic medication. None
of these subjects remained on medication; therefore, all were free of neuroleptics at time
of study participation. It was for this reason, as well is issues of sample size, that a
decision was made to include these subjects in the current study. Therefore, at study
entry 90% of subjects were neuroleptic naive (n = 77) and 10% of subjects had been
exposed to short duration neuroleptics in the past (n = 9). The average age psychotic
symptoms first appeared ranged from 15-48 years (mean = 24.7, sd = 6.87). At study
entry, 55% of subjects had a diagnosis of schizophrenia (n = 47), 44% had a diagnosis of
schizophreniform disorder (i.e., evidence of psychotic symptoms for less than six

months) (n = 38), and 1 % had a diagnosis of schizoaffective disorder (n = 1). Group

42

means and standard deviations for demographic information are summarized in Table 3.
Group frequencies and percentages for demographic information are summarized in

Table 4.

43

Table 3

Means and Standard Devfitions of Demographic Informaction

 

Yams

Age

Age of Onset
Education
Father’s Education

Mother’s Education

Minimum

18

15

Maximum

48

48

22

21

21

Mean

26.44

24.70

12.98

13.19

12.81

Marti Deviation
7.14
6.87
2.69
3.39

2.80

 

44

Table 4

Frequencies 311d Percentages of Demographic Information

 

Variable

Sex
Male
Female

Race
Afiican-American
Caucasian
Asian-American

Medication Status

Neuroleptic Naive
Not Neuroleptic Naive

Intake Diagnosis

Schizophrenia
Schizophreniform Disorder
Schizoaffective Disorder

F regueng

57
29

52
3O

47
38

Percentage

66%
34%

60%
35%
5%

90%
10%

55%
44%
1%

 

45

Exploratory Factor Analys’s

The SANS, SAPS, and BPRS items were subjected to a principal components
Exploratory Factor Analysis (EF A) followed by an orthogonal (i.e., varimax) rotation of
the factor pattern. The rotation converged in six iterations. Examination of the scree plot
suggested a four-factor solution. Specifically, there was a clear separation between the
eigenvalues of the first four factors (13.8, 7.2, 5.7, and 3.6 respectively) and those of the
remainder. The most salient loadings of the SANS, SAPS, and BPRS items on the four
symptom factors are shown in Table 5. These four factors accounted for 21.3, 11.1, 8.7,
and 5.5 percent of the variance in the symptom ratings, respectively. As shown in Table
5, the four factors are easily interpretable.

The first factor (the negative factor) represents the negative symptoms of
schizophrenia, otherwise known as the deficit syndrome. Significant loadings on this
factor include all but two of the SANS items, the SAPS repetitive or stereotyped behavior
item, and the BPRS blunted affect, emotional withdrawal, motor retardation, and
mannerisms and posturing items. The second factor (the disinhibition factor) represents
symptoms including positive formal thought disorder and bizarre behavior. Significant
loadings on this factor include the SAPS thought disorder and bizarre behavior items, the
SANS inappropriate affect and grooming and hygiene items, and the BPRS conceptual
disorganization, excitement, hostility and uncooperativeness items. The third factor (the
positive factor) represents the positive symptoms of schizophrenia, otherwise known as
the non-deficit syndrome. Significant loadings on this factor include the hallucinations,

delusions, and Schneiderian FRS items on the SAPS, the hallucinatory behavior item on

46

the BRPS, and no SANS items. The fourth factor (the paranoid factor) represents the
paranoid symptoms of schizophrenia. Significant loadings on this factor include the
SAPS persecutory delusions, global rating of delusions, delusions of guilt and sin and
aggressive and agitated behavior items, the BPRS anxiety, guilt, depression,
suspiciousness and tension items, and no items on the SANS. As predicted, all four
factors were consistent with the original Exploratory Factor Analysis done by Shtasel et
al. (1992) with the exception of factor four. Specifically, Shtasel et al. (1992) described
factor four as a paranoia/grandiosity factor. In the present study, the grandiosity items
did not load significantly on factor four, but instead evidenced weak loadings on factor
two.

The reliability coefficient for each factor was calculated using Cronbach’s alpha.
Cronbach’s alpha was high for all 4 factors: factor 1 —- negative (0.95); factor 2 —

disinhibition (.87); factor 3 — positive (.86); factor 4 — paranoid (.75).

47

Table 5

SAN S. SAPS. BPRS Raptor Analysis

 

Scales

 

Factor 1 — The Negative Factor (Negative Symptoms)

SANS

Global Rating of Affective Flattening
Lack of Vocal Inflections

Poverty of Speech

Global Rating of Alogia

Paucity of Expressive Gestures
Unchanging Facial Expression
Decreased Spontaneous Movements
Increased Latency of Response
Social Inattentiveness

Affective Nonresponsivity

Poor Eye Contact

Global Rating of Attention

Physical Anergia

Poverty of Content of Speech
Blocking

Recreational Interests

Relationships with Friends

Global Rating of Anhedonia/Asociality
Global Rating of Avolition/Apathy
Ability to Feel Intimacy
Inattentiveness during Mini-Mental Status Exam
Irnpersistence at Work/School
Sexual Activity

SAPS
Repetitive or Stereotyped Behavior

BPRS

Blunted Affect

Emotional VVIthdrawal
Motor Retardation
Mannerisms and Posturing
Disorientation

48

Salient Factor Loading

.82
.81
.78
.78
.78
.76
.76
.73
.72
.67
.66
.65
.65

.60
.56
.56
.55
.53
.52
.45
.42
.34

.40

.89
.75
.58
.37
.28

Table 5 (cont’d)

 

Pita 2 — The Disinhibition Factor (Thought Disorder/Bizarre Behavior)

SANS

Inappropriate Affect .62
Grooming and Hygiene .42
SAPS

Global Rating of Thought Disorder .84
Derailment .72
Illogicality .72
Tangentiality .71
Incoherence .61
Circumstantiality .55
Pressure of Speech .49
Clanging .43
Distractible Speech .42
Global Rating of Bizarre Behavior .42
Somatic Delusions .32
Somatic or Tactile Hallucinations .30
Clothing and Appearance .30
Grandiose Delusions .29
Social and Sexual Behavior .27
BPRS

Conceptual Disorganization .77
Excitement .62
Hostility .46
Uncooperativeness .41
Grandiosity .34

F_actor 3 — The Positive FactcLfliflucinaftiog/Schneidefian FRS)

SANS

No items

SAPS

Auditory Hallucinations .81
Global Rating of Hallucinations .81
Thought Insertion .70
Delusions of Mind Reading .68
Thought Broadcasting .62
Voices Conversing .59

49

Table 5 (cont’d)

 

Voices Commenting

Thought Withdrawal
Delusions of Being Controlled
Delusions of Reference

Visual Hallucinations
Olfactory Hallucinations

BPRS
Hallucinatory Behavior
Unusual Thought Content

Factor 4 — The Paranoid Factor

SANS
No items

SAPS

Persecutory Delusions

Global Rating of Delusions
Delusions of Guilt or Sin
Aggressive and Agitated Behavior

BPRS

Anxiety

Guilt Feelings
Depressed Mood
Suspiciousness
Tension

Somatic Concern

.56
.54
.49
.37
.36
.32

.82
.32

.58
.56
.55
.53

.79
.58
.46
.43
.41
.35

 

50

Cluster Analysis of Patients

The Exploratory Factor Analysis (EFA) generated a regression factor score (with
a mean of zero) for every subject on each of the four symptom factors. The four factor
scores for each subject were then subjected to a K-means Cluster Analysis to determine
whether they could differentiate subgroups of patients. The factor scores were used as
the basis for clustering subjects (i.e., as opposed to the original symptom items) to ensure
that the clusters of patients difi‘ered on symptoms that represent independent dimensions
of the illness. This method is consistent with Shtasel et al. (1992). The Cluster Analysis
of the four symptom factor scores (i.e., negative, disinhibition, positive, paranoid)
produced three clusters of patients. The solution required five iterations. Values of the
cluster centers (i.e., mean regression factor score) for each of the four symptom factors
are shown in Table 6.

As shown in Figure 1, each cluster evidenced a difi‘erent factor profile.
Specifically, cluster one represents a group of patients with predominantly negative
symptoms. Cluster two represents a group of patients with predominantly disinhibition
symptoms (i.e., thought disorder and bizarre behavior) and paranoid symptoms. Cluster
three represents a group of patients with predominantly positive symptoms (i.e.,
hallucinations and Schneiderian FRS). As predicted, all three clusters were consistent
with the original Cluster Analysis done by Shtasel et a1 (1992).

As shown in Figure 2, 29 subjects (34%) were in cluster one (negative), 18
subjects (21%) were in cluster two (disinhibition/paranoia), and 39 (45%) were in cluster

three ansitive).

51

Table 6

Cluster Centers of Four Symptom Factors

 

Cluster 1 Cluster 2 Cluster 3
Factor 1 (negative) .84 -.29 -.49
Factor 2 (disinhibition) -.16 1.04 -.36
Factor 3 (positive) -.53 -.54 .64
Factor 4 (paranoid) -.53 .87 -.01

 

52

Figure 1

Cluster Profiles on Four Factors

 

Cluster Profiles on Four Factors

 

Severity

 

 

 

 

Clinical Factors

 

 

L—e— Cluster 1 —a— Cluster 2 + Cluster 3

 

 

Factor 1 - negative symptoms
Factor 2 - disinhibition symptoms (thought disorder/bizarre behavior)
Factor 3 - positive symptoms (hallucinations and Schneiderian FRS)
Factor 4 - paranoid symptoms

Cluster 1 - prominent negative symptoms
Cluster 2 - prominent disinhibition and paranoid symptoms
Cluster 3 - prominent positive symptoms

53

Figure 2

Cluster Group Membership

Cluster Group

45%

 

21%

 

E3 neg ldisin/para :1 pos

 

 

 

Cluster 1: 34% prominent negative symptoms (11 = 29)
Cluster 2: 21% prominent disinhibition/paranoid symptoms (n = 18)

Cluster 3: 45% prominent positive symptoms (n = 39)

54

Patterns of Premorbid Adjustment (PMA)

As outlined in the Methods section, subjects were classified into three patterns of
premorbid adjustment: deteriorating, stable-good, and stable-poor. Subjects were
classified as deteriorating if they had a pattern of worsening scores over the premorbid
periods that totaled a two-point change. All other subjects were classified as stable, and
the mean PMA score (2.0) was used as a cutoff point to divide subjects into the stable-
good or stable-poor group. As shown in Figure 3, 15 subjects (17%) had a deteriorating
pattern of premorbid adjustment, 44 subjects (52%) had a stable-good pattern, and 27
subjects (31%) had a stable-poor pattern. Demographic information for the PMA groups

is presented in Table 7.

55

Figure 3

Premorbid Adjustment Group Membersaip

PMA Group

 

 

[stable-poor deteriorating c] stable-good

 

 

 

Stable-poor: 31% (n = 27)
Deteriorating: 17% (n = 15)

Stable-good: 52% (n = 44)

56

Table 7

Demogarphic Infomaation for PMA Groups

 

Statue-fiat

Sex (frequency/percentage)

Male 18 (67 %)
Female 9 (33 %)

Race (frequency/percentage)

Afiican-American 18 (67 %)

Caucasian 7 (26 %)
Asian-American 2 (7 %)
Education (mean/3d) 13.11 (3.08)

Deteriorating

14 (93 %)
1 (7 %)

8 (53 %)
6 (4o %)
1 (7 %)

11.87 (2.07)

MOO—0d

25 (57 %)
19 (43 %)

26 (59 %)
17 (39 %)
1 (2 %)

13.27 (2.57)

 

57

Chi-Square Test

A Pearson’s Chi-Square Test of Independence was performed to determine if
there was an association between cluster group (i.e., cluster 1-negative, cluster 2-
disinhibition/paranoia, cluster 3-positive) and premorbid adjustment group (i.e.,
deteriorating, stable-good, stable—poor). The number of subjects in each cluster group
differed as a function of PMA group. The overall difference in proportions was
significant, chi-square (4, 86) = 31.9, p 5 .0001. A contingency table that outlines cell
frequencies and percentages is provided in Table 8. Further interpretation of cell
frequencies suggested a significant relationship between the deteriorating group and
cluster l-negative (expected count 5, count 13), the stable-good group and cluster 2-
disinhibition/paranoia (expected count 9, count 16), and the stable-poor group and cluster

3-positive (expected count 12, count 18).

58

Table 8

Chi-Square Contingengy Table of Cell Frguencies amt Percentagg

 

PMA Group

Deteriorating Stable-Good Stable-Poor

 

Cluster Group

Negative Count 13 9 7
Expected Count 5 15 9
Percentage 45 % 31 % 24 %

Disinhibition/ Count 0 16 2

Paranoia Expected Count 3 9 6
Percentage 0 % 89 % 11 %

Positive Count 2 19 18
Expected Count 7 20 12
Percentage 5 % 49 % 46 %

 

Planned Comparisons

Lastly, four planned comparisons were performed to test the specific predictions
outlined in the Research Hypotheses section concerning difl‘erences between the three
premorbid groups (i.e., deteriorating, stable-good, stable-poor) and clinical
symptomatology. Specifically, one planned comparison confirmed the hypothesis that
the deteriorating group had the most severe negative symptoms, compared to the stable-
good or stable-poor groups (t = -3.4, p 5 .001) (std. error = .535), (d = -.97) (see Figure
4). Two planned comparisons suggested that the stable-good group had the most severe
disinhibition symptoms and paranoid symptoms, compared to the deteriorating or stable-
poor groups, although these differences were not statistically significant (t = -1.5, p 5
.136) (std. error = .438), (d = -.32); (t = -1.7, p 5 .084) (std. error = .437), (d = -.37)
respectively (see Figure 5 and Figure 6). And, one planned comparison confirmed the
hypothesis that the stable-poor group had the most severe hallucinations/Schneiderian
first-ranked delusions compared to the deteriorating or stable-good groups (t = -2.89, p s

.005) (std. error = .469), (d = -.67) (see Figure 7).

6O

Figure 4

Means of Factor 1M PMA gpoup

 

1.0

 

 

 

 

Mean of Factor 1 - Negative st

 

PMA group

PMA group 1 = deteriorating
PMA group 2 = stable-good

PMA group 3 = stable-poor

61

Figure 5

Means of Factor} by PMA Group

 

 

 

Mean of Factor 2 - Disinhibition st

 

 

PMA group

PMA group 1 = deteriorating
PMA group 2 = stable-good

PMA group 3 = stable-poor

62

Figure 6

_Me_ans of Factor 4 by PMA Group

 

 

 

Mean of Factor 4 - Paranoia

 

 

PMA group

PMA group 1 = deteriorating
PMA group 2 = stable-good

PMA group 3 = stable-poor

63

Figure 7

Me_ans of Feator 3 by PMA Group

 

 

 

Mean of Factor 3 - Positive st

 

 

Mr
(A)

1'

PMA group

PMA group 1 = deteriorating
PMA group 2 = stable-good

PMA group 3 = stable-poor

64

DISCUSSION

The goals of the present study were twofold. First, it attempted to strengthen the
existing literature on clinical phenomenology of schizophrenia by providing additional
evidence for the presence of phenomenological subtypes. Second, it attempted to firrther
our knowledge of the clinical course of schizophrenia by integrating data fi'om the period
before illness onset (i.e., premorbid adjustment) and the period during illness onset (i.e.,
first-episode psychosis). Specifically, it examined the relationships between three
patterns of premorbid adjustment (i.e., deteriorating, stable-good, stable-poor) and the
presence of specific schizophrenic symptomatology (i.e., negative symptoms,
hallucinations, Schneiderian FRS, thought disorder, bizarre behavior, and paranoia)
during first-episode psychosis in an attempt to delineate specific etiologies or
developmental pathways of schizophrenia. The results of the present study achieved both
of the aforementioned goals. Despite these encouraging findings, issues of postulating
specific etiologies or developmental pathways of schizophrenia is a complex endeavor
and therefore warrants carefirl consideration and discussion.

With respect to the clinical phenomenology of schizophrenia, this study provides
additional support for the presence of phenomenological subtypes. With the growing
sophistication of both symptom rating scales and statistical procedures over the years,
researchers have been able to abandon the simple positive/negative (Andreasen & Olson,
1982; Hughlings-Jackson, 1931) Type I/Type 11 (Crow, 1980, 1985), and deficit/non-
deficit (Carpenter et al., 1988) dichotonries and investigate more complex patterns of

symptom presentation. The discovery of several symptom factors (Liddle, 1987, Bilder

65

et al. 1985, Gur et al 1991) has guided researchers away from the notion that positive and
negative symptoms of schizophrenia are in someway bipolar, like depression and mania
(Shtasel et a], 1992). Instead positive and negative symptoms of schizophrenia are now
thought to be distinct processes, which may occur simultaneously in some individuals.
This realization has fireled the development of more complex symptom characterization
in schizophrenia. To that end, the factor analysis carried out in the present study
confirmed the presence of four symptom factors. As predicted, these factors were similar
to those found by Shtasel et al (1992) and included: a negative factor, a “disinhibition”
factor (thought disorder, bizarre behavior), a positive factor (hallucinations/Schneiderian
FRS) and a paranoid factor.

The only difference between the factor analysis results in the present study and
those in the Shtasel et al. (1992) study is that Shtasel and her colleagues’ fourth factor
included significant loadings on both paranoia and grandiosity items; however, in the
current analysis the two grandiosity items had insignificant loadings on factor two.
Further investigation of this suggests that differences in the sample may responsible.
That is, 65% of the subjects in the Shtasel et al. (1992) study were not first-episode,
instead having had schizophrenia for an average of approximately 10 years. It is possible
that individuals who have had schizophrenia longer may be more likely to develop
grandiose delusions as a defense against the feelings of powerlessness and inadequacy
that may arise as a result of living with schizophrenia long-term. In other words,
development of an exaggerated self-opinion or conviction of special powers or abilities
may develop secondarily, to help the individual with schizophrenia cope with and find

some meaning (albeit delusional) in their psychotic symptoms. In addition, when

symptoms of paranoia and grandiosity are present, it makes sense that they would load on
the same factor, as they both constitute a narcissistic world-view.

The cluster analysis carried out in the present study confirmed the presence of
three groups of patients. As predicted, these clusters were similar to those found by
Shtasel et. al (1992) and included: a cluster one group with predominantly negative
symptoms; a cluster two group with predominantly disinhibition symptoms (thought
disorder and bizarre behavior) and paranoid symptoms; and a cluster three group with
predominantly positive symptoms (hallucinations and Schneiderian FRS). Several issues
warrant discussion.

First, despite the inclusion of only first-episode, 90% neuroleptic naive patients,
there was a group with predominantly negative symptoms. This provides evidence for
the fact that negative symptoms can manifest early in the illness and are therefore not
always a result of medication effects, institutionalization, stigma, or chronicity.

Second, prominent disinhibition and paranoid symptoms were both displayed in
cluster two. It may be that symptoms of disinhibition or disorganization such as thought
disorder and bizarre behavior exacerbate paranoia. That is, both the inability to
communicate one’s thoughts clearly and the presence of bizarre behaviors are overt,
easily noticeable symptoms and there presence may cause the person with schizophrenia
to have trouble interacting with others in the world. Stated more specifically, when
individuals with schizophrenia attempt to communicate in a bizarre or unclear way, they
may receive negative reactions from others that fuel feelings of paranoia.

Next, with respect to comparing the individuals in each cluster in the two studies

there exist several differences. Most notable is the fact that in the Shtasel et al. (1992)

67

study, the largest number of patients were in cluster one (45%), whereas in the present
study the largest number of patients were in cluster three (45%). It may be that the
Shtasel et al (1992) study evidenced more cluster one patients than the present study
(45% versus 34%) because, as mentioned earlier, the majority of its’ subjects were
individuals with chronic schizophrenia. And, as can be the case in chronic patients,
negative symptoms may develop as a result of long-term use of neuroleptic medication,
effects of chronicity of illness, stigma, institutionalization, and a general withdrawal and
sense of hopelessness over time. Furthermore, it may be that most patients were in
cluster three in the present study because of their first-episode status. That is, individuals
who are experiencing the positive symptoms of schizophrenia such as auditory, tactile,
olfactory or visual hallucinations and delusions of reference, mind reading, or thought
broadcasting may be more likely to be referred for inpatient treatment by family
members, the legal system, or other health professionals. In contrast, individuals with a
more benign form of the illness may be able to remain unnoticed by family members or
be maintained on an outpatient basis and therefore would be less likely to be represented
in the present study.

Lastly, the aforementioned factor analysis of symptoms provides statistical
support for the existence of clinical subtypes in schizophrenia. However, for the
clinician, the results of a cluster analysis provides even more compelling evidence for the
existence of clinical subtypes given the fact that it yields distinct subgroups of
individuals. Overall, these results support the notion that schizophrenia can manifest
itselfin a number of ways. There is no doubt that the patient in cluster one would look

very different than the patient in clusters two or three. The remaining statistical

68

procedures in this study were designed to understand the role of premorbid adjustment in
helping to explain why two people with a diagnosis of schizophrenia can look so very
different.

Subjects were classified into three patterns of premorbid adjustment based on
their levels of functioning in several areas (e.g., scholastic performance and adaptation,
peer and social-sexual relationships) across childhood (0-11 years), early adolescence
(12-15 years), late adolescence (16-18 years) and adulthood (19 years and beyond). The
present study found that 17 % of the subjects had a deteriorating pattern of premorbid
adjustment. That is, they evidenced a slow, insidious decline in firnctioning over time.

F ifiy—two percent of subjects had a stable-good pattern of premorbid adjustment
identified by consistently adequate-good levels of functioning from childhood until onset
of first psychotic symptoms. Finally, 31% of subjects had a stable-poor pattern of
premorbid adjustment identified by consistently low levels of firnctioning from childhood
until onset of first psychotic symptoms.

There were significantly more males than females in both the deteriorating (14
males, 1 female) and stable-poor (18 males, 9 females) groups in comparison to the
stable-good group. These findings are consistent with numerous studies that suggest that
males evidence poorer premorbid adjustment than females (Klorman et al., 1977; Lewine,
1981; Loranger, 1984; Shtasel et al., 1992a; Larsen 1996). Possible explanations for this
include males’ greater incidence of brain insult and morphology in childhood (N asrallah
& Wilcox, 1989, Lewine et al., 1990) and differences in social factors such as depth of
afi‘ect (Loranger, 1984; Shtasel et al., 1992). Gender stereotyping may make it more

difficult for boys to discuss their difiiculties and the feelings surrounding them than girls,

69

which may have a cumulative effect and result in even greater problems with functioning.

In addition, there were significantly more Afiican-American individuals than
those of other races in the stable-poor group compared to the other premorbid adjustment
groups. It is suggested that these racial differences may be a result of socio-economic
issues including greater poverty, less access to resources such as adequate health care and
childcare, poor schooling, and issues of racial prejudice experienced by the Afiican-
American community in West Philadelphia.

Another notable difi’erence between the premorbid adjustment groups included
average level of educational attainment. The deteriorating group evidenced a lower
average of educational attainment than the other two premorbid groups (deteriorating =
11.9 years, stable-good = 13.3 years, stable-poor = 13.1 years). This suggests that
individuals in the deteriorating group were less likely to have finished high school than
those in the other two groups. This inability to finish high school may be a result of the
deteriorating groups’ difficulty adjusting to their insidious decline in functioning. In
contrast, the stable-poor group, who are accustomed to experiencing difficulties, may be
better able to complete high school (even though their level of achievement is low) as a
result of longer-term adjustment to poor levels of firnctioning.

A chi-square test was then performed to determine if there was an association
between premorbid adjustment group and cluster group. In other words, if an individual
was in a particular premorbid group were they likely to also be in a particular cluster
group. As predicted, the results of the present study suggested several significant

relationships.

70

First, there was an association between the deteriorating group and cluster one
(negative). This suggests that individuals who experienced a slow, insidious decline in
functioning over time are also likely to evidence prominent negative symptoms during
first-episode psychosis. A planned comparison provided firrther evidence for this finding
by confirming the hypothesis that the deteriorating group had the most severe negative
symptoms, compared to the stable-good or stable-poor groups. These results are
consistent with findings by both Haas and Sweeney (1992) and Larsen et al. (1996b,
1998) that those with an insidious decline in firnctioning had a trend for more severe
anhedonia and social withdrawal than those in other premorbid groups. The relationship
between poor premorbid adjustment and negative symptomatology has been repeatedly
demonstrated in both chronic (Andreasen & Olsen, 1982; Andreasen et al., 1990;
Dworkin et al., 1987; Kay & Lindenmayer, 1987; McGlashan & F enton, 1992; Pogue-
Geile & Harrow, 1984) and first-episode schizophrenia (Dalkin et al., 1994; Larsen et al.,
1996a; Peralta et al., 1991, 1992). Given this body of knowledge one might expect to
find a relationship between cluster one (negative) and the stable-poor group instead of the
deteriorating group. Instead there was an association between the stable-poor group and
cluster three (positive). A planned comparison confirmed the hypothesis that the stable-
poor group had the most severe hallucinations and Schneiderian FRS compared to the
deteriorating or stable-good groups.

The results of the present study suggest that the relationship between premorbid
adjustment and clinical symptomatology is more complex than was originally proposed
in research designs that employed a simple good versus bad premorbid adjustment

dichotomy. In more sophisticated designs, where poor-premorbid adjustment has been

71

further broken down into deteriorating versus stable-poor one finds difl‘erences between
the two groups. The major difference is that those in the deteriorating group were
functioning adequately in childhood or early adolescence, with a decline in firnctioning
not occurring until late adolescence or adulthood. In contrast, the stable-poor group did
not have a period of adequate functioning in early life, and instead were always
functioning poorly. From a developmental perspective, a period of adequate firnctioning
in childhood may provide a protective mechanism against the development of severe
psychotic symptoms such as hallucinations and Schneiderian FRS. That is, individuals
who have always been withdrawn and struggling with issues of competence and
adaptation in school and with peers may be more likely to escape into psychosis and
create delusional realities. In comparison, children who did not develop a decline in
functioning until later in life may be better able to remain in touch with reality and
therefore negative symptoms such as blunted affect and social withdrawal are more likely
than symptoms of overt psychosis. Also, if one conceptualizes the symptoms of
schizophrenia along a severity continuum, with negative symptoms as less severe (with
respect to a break from reality) than positive symptoms, then it makes sense that those
who have been sicker longer (stable-poor) would be more likely to develop severe
positive symptoms. Larsen and colleagues (1998) provide support for this notion in their
report that individuals with a long duration of untreated symptoms appear to be more
likely to develop bizarre hallucinations and delusions than those with a short duration of
untreated symptoms. Overall, this suggests that the stable versus unstable dichotomy is

more predictive than the simple good versus bad.

72

There was also an association between the stable-good group and cluster two
(disinhibition/paranoia). Two-planned comparisons suggested a trend that the stable-
good group had the most severe disinhibition symptoms and paranoid symptoms,
compared to the deteriorating or stable-poor groups, although these results were not
statistically significant. Traditional analyses of significance, such as those used in the
present study, may have contributed to the probability of making a type 11 error (i.e., the
hypotheses were in fact true, despite insignificant results). In any event, these trends are
consistent with previous studies that suggest individuals with paranoid schizophrenia
have better premorbid adjustment than those with other subtypes of schizophrenia
(Deister & Marneros, 1993; Magaro, 1981; Zigler, Levine, & Zigler, 1977). Additional
studies have reported that individuals with paranoid schizophrenia are more likely to have
had higher levels of social competence and a stable socio-sexual partner before onset of
illness than non-paranoids (Deister & Marneros, 1993, Zigler & Levine, 1983). This
relationship between good premorbid adjustment and disorganized and paranoid
symptoms may exist because of their interpersonal nature. That is, individuals with good
premorbid adjustment were involved in social relationships and active in social
institutions such as school or work. They likely had more opportunity to interact with
others than those in the deteriorating or stable-poor groups and as a result, manifest the
more interpersonal symptoms of schizophrenia such as thought disorder (i.e., difficulty
communicating with others) and paranoia (i.e., fear that other people are out to harm
them).

Overall, these findings provide support for the existence of three developmental

pathways of schizophrenia. It appears that patterns in early development are associated

73

with the types of psychotic symptoms one manifests in first-episode psychosis. More
specifically, the results of the present study provide evidence for a “continuum of
severity” model of schizophrenia. That is, at first-episode the sickest premorbid group
(stable-poor) evidenced the most severe symptoms (positive); the moderate premorbid
group (deteriorating) evidenced moderate symptoms (negative); and the healthiest
premorbid group (stable-good) evidenced the mildest symptoms (thought
disorder/paranoia).

This information can help to guide us in early detection, prevention, and treatment
of first-episode schizophrenia. Clinicians have begun to target the period before the onset
of frank psychotic symptoms as an important time for intervention. Early intervention in
psychosis has been deemed important from several perspectives. First, from a biological
perspective, the brain is seen as retaining some measure of plasticity early in the illness,
therefore early intervention may help to prevent both structural and firnctional
deterioration (McGlashan, 1998). Second, with respect to treatment, a number of
researchers have found that the earlier intervention takes place, the more successful the
outcome (Edwards et al., 1998; Inoue et al., 1986; Loebel et al., 1992; McGlashan, 1996;
McGlashan & Johannessen, 1996;McGor1y et al., 1996; Wyatt, 1991). Similarly,
numerous studies have found significant inverse correlations between the duration of
untreated psychosis and better outcome (Crow et al. 1986; Lo & Lo, 1977; Moscareli,
1994; Rabiner et al., 1986). And from a purely humane perspective, as articulated by
McGlashan and Johannessen (1996) “ Bringing treatment more rapidly to a person who
has been psychotic is in itself enough to justify early detection efforts” (p. 201). In

general, Birchwood, Todd and Jackson (1998) define the early phase of psychosis

74

(including the period of untreated psychosis) as the ‘critical period’ because it is at this
time that psychological, psychosocial, and biological influences are developing and are at
their maximum plasticity.

In one of the first programs of its kind, Falloon and colleagues in England
(F alloon, 1992; F alloon et al., 1996) used prodromal symptom indicators to identify
individuals at risk for psychosis. Early intervention with this population resulted in a
reduction of florid schizophrenia. McGorry and colleagues have recently developed the
Early Psychosis Prevention and Intervention Center (EPPIC) in Australia, which is
pioneering the treatment of individuals in the prodromal stage of schizophrenia (McGorry
et al., 1996; Yung & McGorry, 1996; Yung et al., 1996). EPPIC has successfully
decreased the duration of untreated psychosis and improved one-year outcome measures
in their study participants in comparison to a similar group of individuals with first-
episode psychosis who received treatment before the early detection program was
instituted. As stated by McGorry et al. (1998) “Psychotic symptoms occur on a
continuum with normal states of mind” (p. 15). This points to the development of a new
ideology in the treatment of psychosis, which suggests that sub-threshold symptoms can
be detected, and have some predictive value for the subsequent development of psychosis
(Allen et al. 1987; Chapman & Chapman, 1980).

Despite the encouraging findings in the present study, several methodological
issues warrant discussion. First, an increase in sample size would provide more robust
statistical evidence. Second, because of the retrospective nature of gathering premorbid
adjustment data, issues regarding accuracy of recall are raised. As discussed by Fava and

Kellner (1991), a long-delay between the first noticeable changes in behavior and the

75

onset of psychotic symptoms can negatively affect recall. Several researchers describe
the influence of “effort after meaning” which refers to the tendency of patients and
families to identify one event that marked the change in behavior and dating their
histories from that event (Hirsch et al 1992; Tennant, 1985). Yung and McGorry (1996)
report other factors that may influence what is reported including family guilt at not
noticing changes sooner, and denial of difficulties in an attempt to cope with the onset of
psychosis.

Schizophrenia is one of society’s most severe and costly medical conditions
(McGlashan, 1996). Further research is needed to identify those at risk for developing
psychotic disorders and provide treatment in the early phases of the illness. Both large-
scale meta-analytic studies and long-term, high-risk models can help to further identify
causal links between early development and first-episode psychotic symptoms. Finally,
attention to the integration of data from various developmental periods can help us better
understand that psychotic symptoms may not be random biological mechanisms, but
instead may have meaning in the context of a developmental history. Continued attempts
must be made to formulate an integrated conceptualization of the developmental

processes underlying psychotic symptomatology.

76

APPENDICES

77

sq...) ‘,-~

APPENDIX A

Table l

Prodromal Features in First Episode Psychosis (Yung & McGorry, 1996)

 

 

1. Reduced concentration, attention
2. Reduced drive and motivation, anergia

3. Depressed mood

4. Sleep disturbance

5. Anxiety

6. Social withdrawal

7. Suspiciousness

8. Deterioration in role firnctioning
9. Irritability

 

78

Table 2

APPENDIX B

Psychosocial Indicators of Vulnerability to Schizophreng (Hartmann et al., 1984)

 

10.

11.

12.

UNUSUAL ANXIETY: inconsolable baby; world perceived as scary;
frequent nightmares; continuing anxiety in school

NEOPHOBIA: fear of new things; reacting to familiar as if new; failure
to enter familiar situations with decreased apprehension

LACK OF HISTORICITY: lack of sense of self continuing over time;
poor goal-directed behavior; lack of ambition

INAPPROPRIATE AGGRESSION: random aggression; cruelty;
unusually aggressive fantasies

INAPPROPRIATE ANGER: self-directed anger; denial of anger when
appears angry to others; inexplicable bursts of anger

FLAT AFFECT: affective disturbance in direction of flat of inappropriate
affect

ANHEDONIA: inability to enjoy anything; lack of hobbies; lack of
pleasure in play

LACK OF OBJECT CONSTANCY: lack of ability to relate; difliculty in
shifting away fi'om family to fiiends; overclinging or defensive
overindependence

DIFFICULTY IN INTERPERSONAL RELATIONSHIPS: parents find it
hard to “reach” child; considered undependable; no or little peer group
relations

PERMEABLE BOUNDARIES: easily distracted; excessive daydreaming;
tendency to tangential thinking; poorly integrated body image

LACK OF COMPETENCY: delays in developmental milestones; poor
schoolwork; poor sense of competence

CHEMICAL OR NEUROLOGIC ABNORMALITIES: disturbed sleep;
disturbed gait; neurologic soft signs; unusual reactions to drugs or alcohol

79

 

APPENDIX C:

THE PREMORBID ADJUSTMENT SCALE

(Cannon-Spoor, Potkins, & Wyatt, 1982)

80

CHILDHOOD

THE PREMORBID ADJUSTMENT SCALE (PMA)

 

THROUGH AGE 11

1. Sociability and Withdrawal

0
l
2

3
4

5
6

Not withdrawn, actively and frequently seeks out social contacts.

Mild withdrawal, enjoys socialization when involved, occasionally seeks
opportunities to socialize.

Moderately withdrawn, given to daydreaming and excessive fantasy, may
passively allow self to be drawn into contact with others but does not seek
it.

Unrelated to others, withdrawn and isolated, avoid contact.

2. Peer Relationships

0
1
2

3
4

5
6

Many fiiends, close relationships with several.

Close relationships with a few fiiends (one or two), casual fiiendships
with others.

Deviant fiiendship patterns — fiiendly with children younger or older
only, or relatives only, or casual relationships only.

Social isolate, no friends, not even superficial relationships.

3. Scholastic Performance

GUI-IBWN—‘O

Excellent student.
Good student.
Fair student.

Failing all classes.

4. Adaptation to School

0

1
2

b.)

Good adaptation, enjoys school, no or rare discipline problems, has fiiends
at school, likes most teachers.

Fair adaptation, occasional discipline problems, not very interested in
school but no/or rare truancy, has fiiends in school but does not often take
part in extracurricular activities.

Poor adaptation, dislikes school, frequent discipline problem.

81

 

(II

Refirses to have anything to do with school - delinquency or vandalism
directed against school.

ADOLESCENCE (EARLY, AGES 12-15)

1. Sociability and Withdrawal

0
1
2

3
4

5
6

Not withdrawn, actively and fi'equently seeks out social contacts.

Mild withdrawal, enjoys socialization when involved, occasionally seeks
opportunities to socialize.

Moderately withdrawn, given to daydreaming and excessive fantasy, may
passively allow self to be drawn into contact with others but does not seek
it.

Unrelated to others, withdrawn and isolated, avoid contact.

2. Peer Relationships

0
1
2

3
4

5
6

Many fiiends, close relationships with several.

Close relationships with a few fiiends (one or two), casual fiiendships
with others.

Deviant fiiendship patterns - fiiendly with children younger or older
only, or relatives only, or casual relationships only.

Social isolate, no fiiends, not even superficial relationships.

3. Scholastic Performance

0

1
2
3
4
5
6

Excellent student.
Good student.
Fair student.

Failing all classes.

4. Adaptation to School

0

1

Good adaptation, enjoys school, no or rare discipline problems, has fiiends
at school, likes most teachers.

Fair adaptation, occasional discipline problems, not very interested in

school but no/or rare truancy, has fiiends in school but does not often take
part in extracurricular activities.

82

 

kit

6

Poor adaptation, dislikes school, frequent discipline problem.

Refirses to have anything to do with school - delinquency or vandalism
directed against school.

5. Social-Sexual Aspects of Life During Early Adolescence

O

1

(It

Started dating, showed a “healthy interest” in the opposite sex, may have
gone “steady,” may include some sexual activity.

Attachment and interest in others - may be same sex attachments, may be
a member of a group, interested in the opposite sex although may not have
close emotional relationship with someone of the opposite sex, “crushes”
and flirtations.

Consistent deep interest in same sex attachments with restricted or no
interest in the opposite sex.

Casual same-sex attachments with inadequate attempts at relationships
with the opposite sex, casual contacts with both sexes.

Casual contacts with the same sex, no interest in the opposite sex.

A loner, no or rare contacts with either boys or girls.

Antisocial, avoids and avoided by peers (differs fi'om above in that an
active avoidance of others rather than passive withdrawal is implied).

ADOLESCENCE (LATE. 16-18)

1. Sociability and Withdrawal

0
1
2

3
4

5
6

Not withdrawn, actively and frequently seeks out social contacts.

Mild withdrawal, enjoys socialization when involved, occasionally seeks
opportunities to socialize.

Moderately withdrawn, given to daydreaming and excessive fantasy, may
passively allow self to be drawn into contact with others but does not seek
it.

Unrelated to others, withdrawn and isolated, avoid contact.

2. Peer Relationships

0
1
2

3
4

£11

Many fiiends, close relationships with several.

Close relationships with a few fiiends (one or two), casual friendships
with others.

Deviant fiiendship patterns — fi'iendly with children younger or older
only, or relatives only, or casual relationships only.

Social isolate, no fiiends, not even superficial relationships.

83

3. Scholastic Performance

OUIQWN—‘O

Excellent student.
Good student.
F air student.

Failing all classes.

4. Adaptation to School

0

1

OLA-bl»)

Good adaptation, enjoys school, no or rare discipline problems, has fiiends
at school, likes most teachers.

Fair adaptation, occasional discipline problems, not very interested in
school but no/or rare truancy, has fiiends in school but does not often take
part in extracurricular activities.

Poor adaptation, dislikes school, fi'equent discipline problem.

Refirses to have anything to do with school — delinquency or vandalism
directed against school.

5. Social Aspects of Sexual Life During Adolescence and Immediately Beyond

0

1

5

6

Always showed a “healthy interest” in the opposite sex, dating, has gone
“steady,” engaged in some sexual activity (not necessarily intercourse).
Dated regularly, had only one fiiend of the opposite sex with whom the
patient went “steady” for a long time (includes sexual aspects of a
relationship, although not necessarily intercourse, implies a twosome
pairing ofi‘ into couples, as distinguished from above).

Always mixed closely with boys and girls (involves membership in a
crowd, interest in and attachment to others, no couples).

Consistent deep interest in same-sex attachments with restricted of no
interest in the opposite sex.

Casual same-sex attachments with inadequate attempts at adjustment to
going out with the opposite sex, casual contacts with boys and girls.
Casual contacts with same sex with lack of interest in opposite sex,
occasional contacts with the opposite sex.

No desire to be with boys and girls, never went out with the opposite sex.

ADULTHOOD (AGE 19 AND ABOVE)

l. Sociability and Withdrawal

O
1
2

Not withdrawn, actively and frequently seeks out social contacts.

Mild withdrawal, enjoys socialization when involved, occasionally seeks
opportunities to socialize.

84

b.)

kit

Moderately withdrawn, given to daydreaming and excessive fantasy, may
passively allow self to be drawn into contact with others but does not seek
it.

Unrelated to others, withdrawn and isolated, avoid contact.

2. Peer Relationships

1

3

4

5
6

Many fiiends, close relationships with several.

Close relationships with a few fiiends (one or two), casual fiiendships
with others.

Deviant fiiendship patterns — fiiendly with children younger or older
only, or relatives only, or casual relationships only.

Social isolate, no fiiends, not even superficial relationships.

3. Aspects of Adult Social-Sexual Life

a. Married, presently or formerly

O

l

1

2

3

Married, only one marriage (or remarried as a result of death of spouse),
living as a unit, adequate sexual relations.

Currently married with a history of low sexual drive, periods of difficult
sexual relations or extramarital affair.

Married, more than one time, currently remarried, adequate sexual
relations during at least one marriage.

Married, and apparently permanently separated or divorced without
remarriage, but maintained a home in one marriage for at least three years.
Same as above, but divorce occurred over 3 years ago and while married
maintained a home for less than 3 years.

b. Never married, over 30

2

{It

Has been engaged one or more times or has had a long-term relationship
(at least 2 years) involving heterosexual or homosexual relations, or
apparent evidence of a love affair with one person but unable to achieve

a long-term commitment such as marriage.

Long-term heterosexual or homosexual relationships lasting over 6 months
but less than 2 years (if stable, long-lasting homosexual relationship, over
2 years, score as 3).

Brief, or short-term dating experiences (heterosexual or homosexual) with
One or more partners but no long-lasting sexual experience with a single
Partner.

Sexual and/or social relationships rare or infrequent.

Minimal sexual or social interest in either men or women, isolated.

85

0. Never married, age 20-29

0

4

5
6

GENERAL

1. Education
0

1

OU’IAWN

Has had at least one long-term love afl‘air (minimum of 6 months) or
engagement even though religious or other prohibitions or inhibitions may
have prevented actual sexual union, may have lived together.

Has dated actively, had several “boyfiiends” or “girlfiiends,” some
relationships have lasted a few months, but no long-term relationships,
relationships may have been “serious” but a long-term commitment such
as marriage was not understood to be an eventuality.

Brief, short-term dating experiences or “affairs” with one or more
partners, but no long-lasting sexual experiences with a single partner.
Casual sexual or social relationships with persons of either sex with no
deep emotional bonds.

Sexual and/or social relationships rare or infi'equent.

Minimal sexual or social interests in either men or women, isolated.

Completed college and/or graduate school or professional school (i.e.
Law).

Completed high school and some college or vocational training school

or business school (such as secretarial or computer programming school).
Completed high school.

Completed eighth grade.

Did not get beyond fifth grade.

2. During a period of 3 years up to 6 months before first hospitalization or onset of first
episode, patient was employed for pay or fimctioning in school

GUI-th—‘O

All of the time.
Half of the time.
Briefly, about 25 percent of the time.

Never.

3. Within a period of a year up to 6 months before first hospitalization or first episode
change in work or school performance occurred

MAWNf—‘O

Abruptly.
Within 3 months.

Within 6 months.

86

6 Irnperceptibly, difficult or not possible to determine onset of deterioration.

4. During a period of 3 years up to 6 months before first hospitalization or first episode,
frequency of job change, if working, or interruption of school attendance

0 Same job held, or remained in school.

2 Job change or school interruption occurred two to three times.

4 Kept the same job more than 8 months but less than a year, or remained
continuously in school for the same period.

6 Less than 2 weeks at a job or in school.

5. Establishment of Independence
0 Successfully established residence away from family home, financially
independent of parents.

2 Made unsuccessfirl attempts to establish independent residence, lives in
parents home but pays parents room and board, otherwise financially
independent.

4 Lives in parents’ home, receiving allowance from parents which patient
budgets to pay for entertainment, clothes, etc.

6 Made no attempt to leave home or be financially independent.

6. Global assessment of highest level of firnctioning achieved in patient’s life
0 Fully able to function successfully in and take pleasure fi'om 1) school or
job, 2) fiiends, 3) intimate sexual relationships, 4) church, hobbies, etc.;
enjoys life and copes with it well.
2 Able to function well in and enjoys some spheres of life but has a definite
lack of success in at least one area.
Minimum success and pleasure in three areas of life.
Unable to function in or enjoy any aspects of life.

ON-h

87

 

APPENDIX D:
THE SCALE FOR THE ASSESSMENT
OF NEGATIVE SYMPTOMS

(Andreasen, 1984)

88

SCALE FOR THE ASSESSMENT OF NEGATIVE SYMPTOMS (SANS)

 

0=None 1=Questionable 2=Mild 3=Moderate 4=Marked 5=Severe
AFFECTIVE FLATTENING OR BLUNTING

1. Unchanging Facial Expression
The patient’s face appears wooden — changes less than expected 0 1 2 3 4
as emotional content of discourse changes.

2. Decreased Spontaneous Movements
The patient shows few or no spontaneous movements, does not 0 1 2 3 4
Shift positions, move extremities, etc.

3. Paucity of Expressive Gestures
The patient does not use hand gestures, body position, etc., as O l 2 3 4
an aid in expressing his ideas.

4. Poor Eye Contact
The patient avoids eye contact or “stares through” interviewer 0 1 2 3 4
even when speaking.

5. Afi‘ective Nonresponsivity
The patient fails to laugh or smile when prompted. 0 1 2 3 4

6. Inappropriate Affect
The patient’s affect is inappropriate or incongruous, not simply 0 l 2 3 4
flat or blunted.

7. Lack of Vocal Inflections
The patient fails to Show normal vocal emphasis patterns, is 0 l 2 3 4
often monotonic.

8. Global Rating of Affective Flattening

This rating should focus on overall severity of symptoms, 0 1 2 3 4
especially unresponsiveness, eye contact, facial expression

and vocal inflections.

ALOGIA
9. Poverty of Speech

The patient’s replies to questions are restricted in amount, 0 1 2 3 4
tend to be brief, concrete, unelaborated.

89

10. Poverty of Content of Speech

The patient’s replies are adequate in amount but tend to be
vague, overconcrete or overgeneralized, and convey little
information.

11. Blocking
The patient indicates, either spontaneously or with prompting,
that his train of thought was interrupted.

12. Increased Latency of Response
The patient takes a long time to reply to questions; prompting
indicates the patient is aware of the question.

13. Global Rating of Alogia
The core features of alogia are poverty of speech and poverty
of content.

AVOLITION -- APATHY

l4. Grooming and Hygiene
The patient’s clothes may be sloppy or soiled, and he may have
greasy hair, body odor, etc.

15. Irnpersistence at Work or School

The patient has difficulty seeking or maintaining employment,
completing school work, keeping house, etc. Ifan inpatient,
cannot persist at ward activities, such as OT, playing cards, etc.

16. Physical Anergia
The patient tends to be physically inert. He may sit for hours
and not initiate spontaneous activity.

17. Global Rating of Avolition - Apathy
Strong weight may be given to one or two prominent symptoms
if particularly striking.

ANHEDONIA -- ASOCIALITY

18. Recreational Interests and Activities

The patient may have few or no interests. Both the quality and
quantity of interests should be taken into account.

19. Sexual Activity

The patient may Show decrease in sexual interest and activity,
or enjoyment when active.

90

 

20. Ability to Feel Intimacy and Closeness
The patient may display an inability to form close or intimate 0 1 2 3 4 5
relationships, especially with opposite sex and family.

21. Relationships with Friends and Peers
The patient may have few or no friends and may prefer to spend 0 1 2 3 4 5
all his time isolated.

22. Global Rating of Anhedonia - Asociality
This rating should reflect overall severity, taking into account 0 1 2 3 4 5
the patient’s age, family status, etc.

ATTENTION

23. Social Inattentiveness
The patient appears uninvolved or unengaged. He may seem O 1 2 3 4 5
“spacey.”

24. Inattentiveness during Mental Status Testing
Tests of “serial 7’s” (at least 5 subtractions) and spelling 0 1 2 3 4 5
“world” backwards.

(score 2 = 1 error, score 3 = 2 errors, score 4 = 3 errors)

25. Global Rating of Attention
This rating should assess the patient’s overall concentration, 0 1 2 3 4 5
clinically and on tests.

Copyright:
Nancy C. Andreasen, M.D., Dept. of Psychiatry, Univ. of Iowa, Iowa City, IA (1984)

91

 

APPENDIX E:
THE SCALE FOR THE ASSESSMENT
OF POSITIVE SYMPTOMS

(Andreasen, 1984)

92

SCALE FOR THE ASSESSMENT OF POSITIVE SYMPTOMS (SAPS)

 

0=None 1=Questionable 2=Mild 3=Moderate 4=Marked 5=Severe
HALLUCINATIONS

l. Auditory Hallucinations
The patient reports voices, noises, or other sounds that no one 0 l 2 3 4
else hears

2. Voices Commenting
The patient reports a voice which makes a running commentary 0 1 2 3 4
on his behavior or thoughts.

3. Voices Conversing
The patient reports hearing two or more voices conversing. 0 l 2 3 4

4. Somatic or Tactile Hallucinations

The patient reports experiencing peculiar physical sensations in 0 1 2 3 4
the body.

5. Olfactory Hallucinations
The patient reports experiencing unusual smells which no one 0 l 2 3 4
else notices.

6. Visual Hallucinations
The patient sees shapes or people that are not actually present. 0 1 2 3 4

7. Global Rating of Hallucinations
This rating should be based on the duration and severity of the 0 1 2 3 4
hallucinations and their effect on the patient’s life.

DELUSIONS

8. Persecutory Delusions
The patient believes he is being conspired against or persecuted 0 1 2 3 4
in some way.

9. Delusions of Jealousy
The patient believes his spouse is having an affair with someone. 0 1 2 3 4

10. Delusions of Guilt or Sin
The patient believes that he has committed some terrible sin or 0 1 2 3 4
done something unforgiveable.

93

l 1. Grandiose Delusions
The patient believes he has Special powers or abilities.

12. Religious Delusions
The patient is preoccupied with false beliefs of a religious nature.

13. Somatic Delusions
The patient believes that somehow his body is diseased, abnormal,
or changed.

14. Delusions of Reference
The patient believes that insignificant remarks or events refer to
him or have special meaning.

15. Delusions of Being Controlled
The patient feels that his feelings or actions are controlled by
some outside force.

16. Delusions of Mind Reading
The patient feels that people can read his mind or know his
thoughts.

l7. Thought Broadcasting
The patient believes that his thoughts are broadcast so that he
himself or others can hear them.

18. Thought Insertion
The patient believes that thoughts that are not his own have been
inserted into his mind.

19. Thought Withdrawal
The patient believes that thoughts have been taken away from
his mind.

20. Global Rating of Delusions
This rating should be based on the duration and persistence of
the delusions and their effect on the patient’s life.

BIZARRE BEHAVIOR

21. Clothing and Appearance
The patient dresses in an unusual manner or does other strange
things to alter his appearance.

22. Social and Sexual Behavior
The patient may do things considered inappropriate according to
usual social norms (e. g., masturbating in public).

94

O

23. Aggressive and Agitated
The patient may behave in an aggressive, agitated manner, often
unpredictable.

24. Repetitive or Stereotyped Behavior
The patient develops a set of repetitive actions or rituals that he
must perform over and over.

25. Global Rating of Bizarre Behavior
This rating should reflect the type of behavior and the extent to
which it deviates fiom social norms.

POSITIVE FORMAL THOUGHT DISORDER

26. Derailment
A pattern of speech in which ideas slip off track onto ideas
obliquely related or unrelated.

27. Tangentiality
Replying to a question in an oblique or irrelevant manner.

28. Incoherence
A pattern of speech which is essentially incomprehensible
at times.

29. Illogicality
A pattern of speech in which conclusions are reached which
do not follow logically.

30. Circumstantiality
A pattern of speech which is very indirect and delayed in
reaching its goal idea.

31. Pressure of Speech

The patient’s speech is rapid and difficult to interrupt; the
amount of speech produced is greater than that considered
normal.

32. Distractible Speech
The patient is distracted by nearby stimuli which interrupt
his flow of speech.

33. Clanging

A pattern of speech in which sounds rather than meaningfirl
relationships govern word choices.

95

34. Global Rating of Positive Formal Thought Disorder

This rating should reflect the frequency of abnormality and 0 1 2 3 4 5
degree to which it effects the patient’s ability to

communicate.

Copyright:
Nancy C. Andreasen, M.D., Dept. of Psychiatry, Univ. of Iowa, Iowa City, IA. (1984)

96

 

APPENDIX F:
THE BRIEF PSYCHIATRIC RATING SCALE

(Overall & Gorhanr, 1962)

97

THE BRIEF PSYCHIATRIC RATING SCALE

 

1 2 3 4 5 6 7
not very mild moderate moderately severe extremely
present mild severe severe

1. SOMATIC CONCERN
Degree of concern over present bodily health. Rate the degree to which physical health is
perceived as a problem by the patient, whether complaints have realistic basis or not.

2. ANXIETY

Worry, fear, or over-concern for present or future. Rate solely on the basis of verbal
report of patient’s own subjective experiences. Do not infer anxiety fi'om physical signs
or fiom neurotic defense mechanisms.

3. EMOTIONAL WITHDRAWAL

Deficiency in relating to the interviewer and to the interview situation. Rate only the
degree to which the patient gives the impression of failing to be in emotional contact with
other people in the interview situation.

4. CONCEPTUAL DISORGANIZATION

Degree to which the thought processes are confused, disconnected or disorganized. Rate
on the basis of integration of the verbal products of the patient. Do not rate on the basis
of patient’s subjective impression of his own level of functioning.

5. GUILT FEELINGS

Over-concem or remorse for past behavior. Rate on the basis of the patient’s subjective
experiences of guilt as evidenced by verbal report with appropriate afl‘ect. Do not infer
guilt feelings fi'om depression, anxiety of neurotic defenses.

6. TENSION

Physical and motor manifestations of tension, “nervousness,” and heightened activation
level. Tension should be rated solely on the basis of physical signs and motor behavior
and not on the basis of subjective experiences of tension reported by the patient.

7. MANNERISMS AND POSTURING

Unusual and unnatural motor behavior, the type of motor behavior which causes certain
mental patients to stand out in a crowd of normal people. Rate only abnormality of
movements. Do not rate simple heightened motor activity here.

8. GRANDIOSITY

Exaggerated self-opinion, conviction of unusual ability or powers. Rate only on the basis
of patient’s statements about himself, or self in relation to others, not on the basis of his
demeanor in the interview situation.

98

9. DEPRESSIVE MOOD

Despondency in mood, sadness. Rate only degree of despondency. Do not rate on the
basis of inferences concerning depression based upon general retardation and somatic
complaints.

10. HOSTILITY

Animosity, contempt, belligerence, disdain for other people outside the interview
situation. Rate solely on the basis of the verbal report of feelings and actions of the
patient toward others. Do not infer hostility fiom neurotic defenses, anxiety nor somatic
complaints. (Rate attitude toward interviewer under “uncooperativeness.”)

11. SUSPICIOUSNESS

Belief (delusional or otherwise) that: others have now, or have in the past, malicious or
discriminatory intent toward the patient. On the basis of verbal report, rate only those
suspicions which are currently held whether they concern past or present circumstances.

12. HALLUCINATORY BEHAVIOR

Perceptions without normal external stimulus correspondence. Rate only those
experiences which are reported to have occurred within the last week and which are
described as distinctly different from the thought and imagery processes of normal
people.

13. MOTOR RETARDATION

Reduction in energy level evidenced in slowed movements. Rate on the basis of
observed behavior of the patient only. Do not rate on the basis of patient’s subjective
impression of own energy level.

14. UNCOOPERATIVENESS

Evidence of resistance. Unfiiendliness, resentment, and lack of readiness to cooperate
with interviewer. Rate only on the basis of the patient’s attitude and responses to the
interviewer and the interview situation. Do not rate on basis of reported resentment or
uncooperativeness outside the interview situation.

15. UNUSUAL THOUGHT CONTENT
Unusual, odd, strange, or bizarre thought content. Rate here the degree of unusualness,
not the degree of disorganization of thought processes.

16. BLUNTED AFFECT
Reduced emotional tone, apparent lack of normal feeling or involvement.

17. EXCITEMENT
Heightened emotional tone, agitation, increased reactivity.

18. DISORIENTATION
Confusion or lack of proper association for person, place or time.

99

APPENDIX G:

CONSENT FORM

100

University of Pennsylvania
A Neurobehavioral Study of Schizophrenia: Protocol #782-0
Initial Evaluation and Follow-up Evaluation Consent Form
Neuropsychiatry

Dr. Raquel Our (215) 662-2826

Dr. Christian Kohler (215) 662-7388
Dr. Bruce Turetsky (215) 662-6094
Dr. Stephen Kanes (215) 662-73 88
Dr. Steven Siegel (215)662-7388
24-hour Emergency (215) 662-6059
(ask for Psychiatry Resident on call)

CONSENT FORM
IN ITIAL/FOLLOW-UP EVALUATION

SELECTION OF SUBJECTS

Our research center is dedicated to the study of brain function in healthy people and
people with brain disorders. We evaluate individuals and their family members in order
to get comprehensive information

You were selected because you are:

a healthy control subject

a family member subject

a subject with a brain disorder

a healthy pregnant woman

a pregnant woman with a brain disorder

and you are willing to participate in research on brain processes and behavior and you
have met other inclusion criteria. These inclusion criteria are based on medical and
design requirements, and do not discriminate on the basis of sex or ethnic background.

PURPOSE

The purpose of conducting these research studies is to learn about how the brain works.
This is done by studying patients with brain disorders and their relatives and comparing
these results with healthy people and their relatives who do not. In addition, the
relationship between brain abnormalities in the patients and the risk for psychiatric
disorder in their relatives is being assessed. This may help to learn more about genetic
factors that are important in brain firnction and disease. Before participating in any
specific study we need to evaluate your health status.

101

University of Pennsylvania
A Neurobehavioral Study of Schizophrenia: Protocol #782-0
Initial Evaluation and Follow-up Evaluation Consent Form
Neuropsychiatry

PROCEDURE

Initial Evaluation

The first step is a standard clinical interview followed by personality questionnaires. You
will be given a medical evaluation which includes a history, physical examination, and
routine laboratory tests. The tests consist of urine and blood tests. For the blood tests,
approximately 40ml (about 2.5 tablespoons) of your blood will be needed. Ifyou are a
female, an additional 20ml of blood may be drawn at the same time to examine hormone
levels.

«I

You agree to have a sample of blood taken for genetic studies. The blood cells will be
transformed to allow them to be stored permanently or grown in culture for long periods.
Transformation allows many genetic measures to be rrrade on a very small sample of
blood. The amount of blood obtained will be approximately 40ml (about 2.5
tablespoons). The procedure involves placing a needle in a vein in your arm to take
blood.

 

If you are a female, you may be asked to keep track of your menstrual cycle for
approximately 3 months using a diary or a calendar. We may contact you by phone
periodically to remind you about the diary. Your medical evaluation which includes a
health history will place special emphasis on menstruation.

Ifyou are pregnant we will ask you questions about the pregnancy and how you are doing
and will work with the doctors in the obstetric clinic to get information about your health
and the development of the baby.

Follow-Up Evaluation

We have a particular interest in the changes which occur in brain function over time and
we shall contact you again in the firture to ask if we can repeat some of the investigations.
At follow-up, you will be asked questions about how things have been going for you
since your initial evaluation and you may be asked to repeat studies or to participate in
new studies.

Ifyou are a female, you may be asked to keep track of your menstrual cycle for
approximately 3 months using a diary or a calendar. We may contact you by phone
periodically to remind you about the diary. Your medical evaluation which includes a
health history will place special emphasis on menstruation.

102

University of Pennsylvania
A Neurobehavioral Study of Schizophrenia: Protocol #782-0
Initial Evaluation and F ollow-up Evaluation Consent Form
Neuropsychiatry

If you are pregnant, we would like to see you when you come for your obstetrical visit

about once a month. We will check how you are doing and get information from your

doctors in the obstetric clinic about your health and the development of the baby. This

will continue during the pregnancy. At the time of delivery we will check how you are

doing and how the baby is doing and again will like to get information fiom the doctors
who take care of you and the baby.

RISKS

Occasionally there are minor complications, and you may experience bruising, swelling
and/or black and blue marks at the site. Should you develop any complications, you
should call Dr. Raquel Gur at her office (662-2826 or 662-2915) or by pager (452-4745)
or one of the other doctors listed on this consent form. Should you be unable to reach Dr.
Gur or any other physician associated with the study, you Should go to the emergency
room of the Hospital of the University of Pennsylvania. You will receive a copy of this
consent form, which contains the procedures to be followed in case any complications
occur.

BENEFITS

Although the results of this evaluation may not benefit you directly, they can easily be
made available to your physician upon request.

ALTERNATIVES

The alternative to this study is not to participate.
COMPENSATION

You will be reimbursed for your travel and parking expenses.
CONFIDENTIALITY

Data collected during this evaluation will be confidential, except as may be required by
law and any publication resulting from the research will not personally identify you.

103

University of Pennsylvania
A Neurobehavioral Study of Schizophrenia: Protocol #782-0
Initial Evaluation and Follow-up Evaluation Consent Form
Neuropsychiatry

DISCLAIMER/WITHDRAWAL

You understand that you are free to decide whether or not to participate and to withdraw
from the study at any time. You are assured that if you withdraw from this project this
will not influence standards of care or services provided to you by the participating
facilities.

INJURY/COMPLICATIONS

You understand that in the event of injury resulting fi'om the research procedures,
medical treatment in excess of that covered by third party payors will be provided
without cost to you, but financial compensation for injury is not available.

SUBJECT RIGHTS

You understand that if you wish firrther information regarding your rights as a research
subject, you may contact the Director in the Office of Regulatory Affairs at the
University of Pennsylvania by telephoning (215) 898-2614. You also understand that if
you have any questions pertaining to your participation in this research study you may
contact the physician by calling the telephone number(s) listed at the top of page one.
You have been given the opportunity to ask questions and have had them answered to
your satisfaction.

CONCLUSION
You have read and received a copy of this consent form and have been given the
opportunity to ask questions. You realize this consent is voluntary and may be

withdrawn at any time without prejudicing your care.

You agree to participate in this study voluntarily.

 

 

Subject’s Signature Date

 

Subject’s Name (print)

104

University of Pennsylvania
A Neurobehavioral Study of Schizophrenia: Protocol #7 82-0
lrritial Evaluation and F ollow-up Evaluation Consent Form

 

 

 

 

 

 

Neuropsychiatry
Signature of Witness Date 'f
Name of Witness (print) H
g -
Signature of Investigator Date

105

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