The concept of clinical state in psychiatry: A review

The Concept of Clinical State in Psychiatry: A Review Vaughan Carr

T

HE STATE-TRAIT distinction has had a useful application in psychiatry but is not without controversy. The field has been particularly beset by various problems in the definition and measurement of each set of phenomena. Traits, enduring characteristics or qualities that describe interindividual differences, lend themselves readily to retesting in the assessment of instrument reliability and construct validity. This single factor has been important in facilitating the development of conceptual formulations upon which hypotheses can be proposed and tested as has been done in the area of personality theory, for example. Since states are, by definition, transitory characteristics or qualities that describe intraindividual differences, they tend to be less reliable’ and do not lend themselves so readily to retesting in this way. The validity of repeated measures in these cases should require some independent measure of whether or not a particular state has recurred. The lack of such independent measures can lead to the circular process of measuring states in terms of one instrument that, in turn, is validated against yet another similar instrument designed to measure the same state. This problem is one that has acted to retard the development of adequate definition and conceptual formulation with regard to the state concept. This paper reviews and critically examines the state concept in relation to clinical psychiatry. No attempt is made to review the use of the state concept in the field of psychology, in particular, the psychometric tradition. This would require a separate paper in order to do justice to the size and complexity of the subject. Instead, the focus has been narrowed to include predominantly the clinical literature, incorporating fields most relevant to psychopathology as it presents to the clinician. The term “state” derives from the Latin status, meaning manner of standing or condition. The Oxford English Dictionary2 gives the following definitions of the noun, state, under the broad heading of “condition, manner of existing.” 1) A combination of circumstances or attributes belonging for the time being to a person or thing: a particular manner or way of existing, as defined by the presence of certain circumstances or attributes; 2) A condition (of mind or feeling); the mental or emotional condition in which a person finds him or herself at a particular time.

From the Department oj’Psychiatq, Uni\vrsity oj’Adelaide. Royal Adelaide Hospital, Adelaide. South Australia. Vaughan Carr, M.B., B.S., F.R.C.P. CC.), F.R.A.N.Z.C.P.: Department of Psychiatry. Unitersity of Adelaide. Royal Adelaide Hospital. Address reprint requests to Dr. Vaughan Carr. Department of Psychiatry. Unik,ersity oj Adelaide, Adeiaide. South Australia. 5000. @ 1983 by Grune & Stratton. Inc. 0010-440X/83/2404-0009$2.00/0

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OVERVIEW

The observation of changes in mental state, disposition, or “frame of mind” has always been a commonplace daily occurrence in the course of human relationships. In comparison to this, a scientific study of states has a very much shorter history, but it is difficult to pinpoint exactly when the concept was introduced to clinical psychiatry. There, the concept of psychopathologic state seems to have antedated the phenomenologic grouping of symptoms and signs into discrete diagnostic entities that are relatively recent inventions. The use of the state concept as a technical term to categorize the properties of matter in the physical sciences preceded its incorporation into the technical language of psychology. When the latter occurred it seems that the use of the term represented a de facto transfer from the common vocabulary rather than a considered attempt to imitate the empirical methods of the physical sciences. In reference to the act of introspection, William James’ wrote, “Everyone agrees that we there discover states of consciousness,“ and ‘*the existence of such states has never been doubted. . . .” He then discussed what best to call them--“mental state,” “state of consciousness.” “subjective condition,” “affection of the soul” and so forth. However. he neglected to define the concept in general terms. Nor did he explicitly set down criteria by which states were to be recognized. In the eighteenth and nineteenth centuries the striking nature of the hypnotic state drew widespread attention in Europe?’ The use of hypnosis in the deliberate induction of different behavioral states became a popular demonstration in the nineteenth century, and different states or stages in the hypnotic process itself were identified. ‘,’ This work reached its zenith in the demonstrations of Charcot’ which Freud incorporated with his own observations in formulating the notion of “hypnoid states.” Breuer and he“ then used this concept to explain the pathogenesis of hysteria. They differentiated these states from hypnosis by defining them as a spontaneous “emergence” of intense ideas cut off from associative communication with the rest of the content of consciousness.” In postulating that these ” hypnoid states” were present, that is. unconscious, before the onset of manifest illness, they laid the groundwork for later psychoanalytic investigators who claimed that childhood ego states continued to exist in the unconscious of adults and were regressively reactivated in psychopathology generally, not only in hysteria.“,” Meanwhile, no doubt owing to their dramatic qualities, the phenomena of multiple personalities and other dissociative states (somnambulism, fugues, twilights, etc.) attracted much attention, and many descriptions of the states that comprise these conditions were published.‘,“,” From this point two major paths in psychiatry were followed. The psychoanalytic movement concentrated on formulating metapsychologic theories based on their observations of the changing states of patients in psychoanalysis. Descriptive psychiatrists focused on grouping states into defined syndromes in accordance with a disease process model of psychopathology. Although implicitly relying heavily on the state concept, neither of these groups turned to a systematic examination of the concept in its own right. In psychoanalysis it was the collective work of

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Fedem, published in 1952,” which helped to bring the concept of “ego state” to wider attention, and this thread was later picked up by Berne14-18 and reformulated in his transactional analysis theories. Comparatively few psychoanalysts explicitly investigated the concept in the 1950s and 1960~.‘~.‘~.~~ By this time, in the distinctly separate field of infant research, Wolff2’*22 among others23 found significant variations in observed phenomena occurring in a given infant depending on the time at which the infant was studied. They accounted for these differences on the basis of differential patterns of activity and responsivity (i.e., states) occurring over time. Failure to take the state of the infant into consideration led to important errors in the results of their research.24 Subsequent investigations in this field had to account for these states either by circumvention, control, or representative inclusion.24,25 Others studied the states in their own right. 24.26 In either case, operational definitions of state were required and several were formulated.*’ However, in the field of behaviorist psychology the state concept was met with severe criticism. Skinner28 avoided the concept and instead described behavior in terms of stimulus and response. Skinner did not explicitly deny the existence of mental states; rather, he asserted that they were not relevant to the principal object of psychology as he saw it, namely, the prediction of behavior. Criticism also came from social learning theorists. Mische129 argued that state and trait were misleading terms that were based on empirically unjustified assumptions. Bandura and Walters3’ favored a dimensional rather than a state approach in their studies of social behavior. Further attacks on the “mythical”3’ state concept in relation to specific phenomena such as hypnosis, hallucinations, schizophrenia, and anxiety came from others.3”3 In contrast to these views of the learning theorists, the field of psychology was further divided into two areas that did use and explore the concept of state. One was the discipline of psychometrics which has contributed much to the empirical and theoretical literature on the subject of trait and state (e.g., Cattell). The other covered the movements of existentialism and humanistic psychology which made extensive use of the concept and explored individual states in the areas of creativity, consciousness expansion, drug experiments, psychedelic experiences, Eastern religion, and meditation,35m4’ as well as in psychopathology *42 Hilgard ,43 who also reviewed this subject, argued against the extreme positions taken by both the behaviorist and humanist psychology camps. He defended the concept of state with respect to the waking condition, sleep, and hypnosis, taking up a position he termed “modern functionalism.” He claimed that states represented a classification of phenomena that simplified complex data for purposes of study, that operational criteria could be used for state definition, and, finally, that states represented useful categories without necessarily implying causal relationships. Ever since Cannon’s” exploration of the physiologic accompaniments of certain states, other biologically oriented investigators have searched for changes in physical parameters that are specific to individual states. This search met with little success until Aserinsky and Kleitman4’ published their findings in which electroencephalogram (EEG) and eye-movement criteria were found to define particular states within sleep. Since then this kind of

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approach has flourished, not only in relation to studies of the sleep-wakefulness cycle46,47 but also more generally in psychophysiology.a-50 Biologic investigations have often focused on the influence of exogenous and endogenous chemical compounds on state,” particularly those of ‘*fight” or “flight.“” However. the work of Schachter and Singe? in which adrenalin injections were given to subjects under varying conditions demonstrated that there was no simple one-to-one relationship between a bioactive substance and state but that the resulting emotional effect was a function of physiologic, cognitive. and social factors. Studies of the effects of drugs in inducing altered states in humans4 .5J ?Xand behavioral states in animalss’-65 have relied on the state concept defined by behavioral criteria and, in the case of human studies, self-report scales as well. The effect of a wide variety of drugs in altering psychologic state subsequently spawned investigations of what has since been called state-dependent learning.&-‘” Returning to the field of clinical psychiatry, a recent application of the state concept is seen in the work of Horowitz which centers around the concept of state as applied to the stress-response syndrome” and neurotic patients in psychotherapy.7’m72 Similarly, other contemporary investigators” X0have described stages or sequential states in the development of and recovery from schizophrenia. Since the state concept is widely employed in psychiatry, although not always explicitly acknowledged, it would seem important to review the use of the term as a step toward more careful definition and use of the concept in the future. At the very least, any refinement in the concept that may result could assist in managing the continual problem of heterogeneity in psychiatric research and practice.” USE OF THE STATE CONCEPT IN SPECIFIC AREAS Psychodynamic

Psychiatry

Federn” formulated his ideas about “ego states” within the context of the psychoanalytic movement. He used the term in relation to normative phenomena (waking, sleep, dreams), narcissism, schizophrenic phenomena, and other conditions such as depersonalization and fainting. He did not describe these states in detail but formulated a general theory in metapsychologic terms. He held that within an individual’s “ego boundaries” particular “ego contents” determined the ego state but that changes in ego boundaries also correlated with different ego states. He believed that psychologic development involved a seriesof successive ego states and that these early ego states were repressed (“unconscious ego states”) or fixated during development. For him schizophrenia represented, in part, a defensive regression to earlier ego states, and he also described similar infantile ego states among the complex of symptoms in neurotic adults. Bibring” attempted to explain the phenomena he observed in treating depressed patients by postulating four basic ego states. Described by using his combination of phenomenologic and metapsychologic terms, they are:

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1) The state of balanced narcissism (normal self-esteem), the secure and self-assured ego; 2) The state of excited or exhilarated self-esteem, the triumphant or elated ego; 3) The state of threatened narcissism, the anxious ego; 4) The state of broken down self-regard, the inhibited or paralyzed, the depressed ego. Bibring gave extensive descriptions of the fourth ego state together with theoretical propositions as to its pathogenesis. He appears to have resorted to this state model in order to organize his observations of psychopathology upon which his theory of depression was built. This author also adhered to a view analogous to that of Federn,” namely, that during development, fixation of an ego state (e.g., helplessness) could occur and become regressively reactivated as a state of depression in later life. Pious” described a series of “behavioral states” in a particular patient in psychotherapy. He described them as being “a recurrent series of changes in the patient’s behavior which followed each other in sequence over a period of time.” These states, he wrote, were “sufficiently delineated” and had their own “characteristic combinations of gestures, affects, intonations and verbaliorganization of sations.” He felt that each state had its own “characteristic perception and therefore its own state of consciousness.” He propounded a theory of the structure of levels of organization in this patient’s behavior from most to least archaic developmentally and believed that each behavioral state that he described was organized at one or another of these particular levels. He further described the process of symptomatic recovery in terms of the patient’s movement from one state to the next that he believed to represent a developmental “progression.” A similar mode1 was put forward by VolkanzO who described a series of states in a schizophrenic patient with an unusually heightened facility for labeling her “frames of mind.” As with other psychoanalysts, he commented on the nature of schizophrenia in terms of a regression to “primitive ego states” and discussed the defensive use of changes of state. Eric Berne,14-18 formulated a psychologic theory and therapeutic technique (transactional analysis) based on the notion of ego states. His work represents an elaboration and extension of that of Federn. ‘I From his study of intuition and “primal images” grew the idea of ego state as a “cohesive system of feelings and thoughts with a related set of behavioral patterns.” He defined three broad categories of state, each supposedly coexisting within a given individual: the child, based on personal images and judgments; the adult, using logical and rational behavior; and the parent, dealing with morals, values, and prejudices. He claimed that each had its source in early development and that each determined behavior, including pathologic ego states. More recently, Horowitz ” has used the state concept to describe the stress response syndrome in which he has postulated the four broad state categories of outcry, denial-numbness, intrusiveness, and working through. In subsequent work72 he has used the state concept in the study of neurotic patients in psychotherapy in which he defines state as a “recurrent pattern of experience

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and of behaviour that is both verbal and non-verbal (and which represents) a configuration of information in multiple systems. ” In this work he describes the sequence of changes, cycles, and intervening events that are observed by using his method of “configurational analysis” of the psychotherapeutic process. On a more abstract plane, Gedo and Goldberg’* described a model for psychopathology in which they postulate five “modes” of functional organization that correspond to five developmental phases. These are more or less analogous to the ego states referred to in the developmental framework throughout the psychoanalytic literature. Their model is formulated in metapsychologic terms, and they pay no attention to phenomenologic definitions of their five “modes,” providing only case examples. In summary (see Table l), the only general definitions of state or ego state in the psychoanalytic literature are provided by Berne.‘“- Ix Horowitz,“.” and Pious.” Specific state descriptions are without systematic application of descriptive criteria and tend to be loosely defined or illustrated through case examples. Methods of investigation are confined to the psychoanalytic and psychotherapeutic situations and, with the exception of Horowitz,“.” systematic efforts at validation are lacking. There is no shortage of theoretical formulations, however, and most investigators use a developmental model of ego states. A further review of the state concept in the field of psychoanalysis is provided by Allen.H3 Descriptive

Psychiatry

Parallel with the continuing refinement of nosologic methods,XJ attention has also been paid to state categorization and reliable methods of defining and rating psychologic parameters according to a state or stage model. Although this model is not incompatible with the disease process model, some ambiguity arises in this literature when the model being used is not made explicit or when conceptualization switches between one model and another without acknowledgment. The measurement techniques that have been developed to categorize psychopathologic data include interview ratings, naturalistic observations, and self-report scales. Each of these has been used variously in studies of psychopathologic states such as mania,*5m.‘M depression,y’my3 anxiety,” ” and stages in the decompensation and recovery from schizophrenic disorders.‘J X0 The numerous studies that have used these techniques of which the above are merely a few representative examples, employ multiple raters making repeated observations or tests of many subjects. They depend for their validity on statistical techniques for testing internal consistency, correlations with independent measures, both psychologic and biologic, as well as measures of predictive validity. Although such studies, at least implicitly, are measuring psychopathologic states, this fact is usually taken for granted or overlooked in favor of a disease process model of psychopathology. One important exception to this generalization can be found in the clinically important work of Spielberger who took pains to clarify the conceptual ambiguity arising from the failure to distinguish between state anxiety and trait anxiety.” This work aside, no significant

None. Ego states defined by example

None. Ego state defined by example.

“Behavioral state” is a characteristic combination of gestures movements, affects, intonations, and verbalization. A series of changes in behavior that occur in sequence.

Bibring 1953

Pious 1961

Definition

Fecisrn 1952

General

As above. Various descriptions (specific for one patient).

As above. 1. Secure, self-assured state. 2. Elated, exhilarated state. 3. Anxious. threatened state. 4. Depressed state, composed of felt emotion low self-esteem inhibitron of function.

Based on combinations of symptoms, behavior, and self-reports, No operational criteria. Various descriptions.

of

Psychoanalytic psychotherapy patient.

of one

Meticd

of

Evaluation

Single rater with repeated observations of one patient.

Single rater with repeated observations of several patients.

Single rater with repeated observations of several patients.

States

of and other

Psychoanalytic psychotherapy of depressed patients

Psychoanalytic psychotherapy schizophrenic patients.

Investigation

Method

Psychoanalytic-Psychodynamic

Operational

Definition

Specitrc

Table 1.

Characteristic organization of perception. Developmentally based theory of levels of psychologic organrzation. An individual state corresponds to a particular level in the developmental hierarchy.

Developmental fixation of ego states that are regressively reactivated in psychopathology.

Ego contents and ego boundaries both determine the ego state. Developmental succession of ego states repressed or fixated. Ego states regressively reactivated in psychopathology.

Explanation

None Ego states defined by example

A cohesive system of feelings and thoughts with a related set of behavroral patterns.

A recurrent pattern of experience and behavtor that is verbal and nonverbal. A configuration of information in multiple systems.

Volkan 1964

Berne 1955-1964

Horowitz 1976, 1979

above. Child Adult Parent

E.g., a. The stress response syndrome (1976) 1. Outcry 2. Denial-numbness 3. Intrusiveness 4 Working through b. Neurotic patients in psychotherapy ( 1979). Various descrtptions that are patient speciftc

More clearly defined criteria

As 1. 2. 3.

As above. Various descriptions (specific for one patient). of one

b. Psychoanalytic psychotherapy with neurotic patients

a. Crisis intervention with pattents following stress.

Psychotherapy (TA) with various patients.

Psychoanalyttc psychotherapy patient

No general explanation given. Method is largely descriptive

Developmental origin of ego states. Several ego states coexist within an individual and determine behavior.

Smgle rater with repeated observations of numerous patients.

Multiple raters with repeated observations of numerous patients.

Developmental origin of ego states. Regression to primitive ego states in psychopathology.

Single rater with repeated observations of one patient.

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systematic attempts appear to have been made to define the state concept in the descriptive psychiatry literature and, consequently, no generally acceptable definition or conceptualization of state has emerged for universal application. Criteria for defining the particular states under investigation are most often expressed in terms of scores on the measuring instruments, but usually scant attention is paid to the theoretical basis of the state being measured or states in general. Thus the strength in method and relative neglect of theoretical conceptualization is quite the opposite of the case that applies to the psychoanalytic work. Biologic Psychiatry The first extensive investigations of the relationship between psychologic states and physiologic events were carried out in the 1920s by Cannon.44 Since then numerous parameters such as EEG data, electrodermal activity, evoked responses, and other physiologic parameters such as blood pressure, heart rate, blood flow, respirations, and so forth have been investigated in relation to state and state change. Neurochemical work has focused on the measurement of certain metabolites by using human subjects and animal models, the latter having the added advantage of opportunity for tissue studies. Most of the biologic measurement techniques have demonstrated acceptable levels of reliability and the methods of applying them have been carefully standardized. In the investigation of drug-induced state changes, the state being examined was generally defined in terms of subjective reports of the experience and/or observations of behavior during the time of intoxication. In research on state-dependent learning, the state being examined was usually defined in terms of the pharmacologic manipulation that produced it98 and specific characteristics of the induced state were not systematically described as a rule. One of the limitations of the latter approach lies in the organismic variability between and within individuals as a consequence of which subtle but important differences almost certainly would have been missed. Another limitation is the circularity of reasoning implied in defining a particular state solely in terms of the drug that produced it. Generally, systematic efforts to define the psychopathologic state under investigation in both neurochemical and psychophysiologic studies have employed mostly the techniques of naturalistic observations and self-report scales, with animal studies requiring a careful record of alterations in behavioral parameters. The aim of such investigations being to find a correlation between biologic parameters and psychopathologic states, it is crucial to define the states with at least as much reliability as biologic measures possess. Barchas et al stated the problem well when they wrote: “Choice of a specific behaviour requires application of criteria of reliability and validity in the context of the species-specific repertoire of the animal. BehaviouraI states and processes need as careful delineation and articulation as do neurochemical events.“59 Whether state changes are spontaneous or induced as they have been by drugs, hormones, and somatic, psychologic, social, or environmental manipulation, measures of psychologic and/or behavioral change continue to rely almost exclusively on naturalistic observations and self-report scales. Although many of these measures are reliable, further conceptual refinement of the state under

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investigation is necessary in order to specify the essential characteristics of the particular state so that satisfactory replication can be facilitated and general conclusions drawn. Some of the inconsistencies found in this field may be related to the absence of a generally accepted definition of state. Little attention is paid explicitly to what is understood by the concept of state in biologic psychiatry and often particular states are merely referred to in terms of scores on the scales of their psychologic and/or behavioral components without reference to an underlying unified conceptualization. The many conflicting neurochemical reports may also be related to the fact that most often a disease process model is adhered to rather than a state model of psychopathology so that variations over time are not taken into account. As in the descriptive psychiatry literature, an alternative explanation may lie with the tendency to make conceptual switches from a state model to a disease process model and vice versa without acknowledgment of the switch or of the difference between the two models. Nevertheless, some neurochemical studies have demonstrated alterations in biologic parameters accompanying some psychopathologic states. Examples include 3-methoxy-4-hydroxyphenyl-glycol (MHPG),“- lo2 corticosteroids,‘03 and dexamethasone nonsuppression’@’ in some depressive states; monoamine oxidase (MAO),‘0s-‘07 catecholamines.“‘” and corticosteroids79~80~‘Win various states of the schizophrenic disorder. Animal studies have also demonstrated changes in neurochemical metabolites in association with various behavioral states.“‘-” Implicit in both the human and animal work is the search for biochemical parameters that may be used as valid and reliable criteria for determining particular states. Should this eventuate then the assumption that underlies many of these investigations, namely, that neurochemical changes reflect a relationship between a given neuroregulator and the state being investigated, is likely to be verified and a causal relationship between the neurochemical change and psychopathologic state established. Psychophysiologic studies have similarly attempted to test the hypothesis that certain measured psychophysiologic parameters are specific for a particular state implying a causal connection between the two. In this field, however. this hypothesis has met with less success in verification than in the neurochemical work. Both in her own research and in a review of the literature, Johnson”” concluded that not only do certain psychophysiologic parameters vary within a given state but that such parameters often remain unchanged from one state to another. Although this may be a problem of inadequate state conceptualization and definition, she nevertheless supports Cannon’s similar conclusion of four decades earlier.44,“’ A more recent report by Morrow and Labrum in relation to anxiety is also consistent with this view.‘12 As far as psychophysiologic investigations are concerned, at our current level of knowledge, no reliable physiologic criteria exist that can be applied to state definition with the exception of combined EEG and EOG (electroculogram) data in determining the REM state. This is not to say, however, that important physiologic parameters are not concommitants of particular states. It is merely that they cannot yet be used as the sole criteria for state definition. It is still possible that this may also be the case for neurochemical parame-

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ters, in which case the earlier work of Schachter and Singer may well be taken as a caveat.53 It is also possible that a confounding factor in the general area of biologic research may be a variant of the principle of neurologic equipotentiality. In other words, any of a range of psychopathologic states or processes may be served by a variety of neurophysiologic processes.

Neonatal Research Since the discovery in the 1950s that patterns of activity and responsivity within and between infants varied from time to time under test conditions, neonatal researchers have endeavored to find, account for, and explain such variability. The term state was employed in conceputalizing these differences, although, for some time, there was no agreed upon general definition of state in infant research. In some cases conceputalization went no further than referring to state as a convenient classification of behaviors in the neonate.21,1’3 Often quoted in this body of literature is the definition given by the systems theorist Ashby, who wrote, “By state of a system is meant any well, defined condition or property that can be recognised if it occurs again.“‘14 In arguing for the state concept he used the example of Tinbergen’s description of a sequence (trajectory) of discrete clusters of behavioral units in the courtship and mating behavior of the spitted stickleback. He described states in terms of vectors defined as compound entities having a specific number of components. An example given of such a vector was barometric pressure, temperature, humidity, and degree of cloudiness in describing the state of the weather. Ashby’s conceptualization was later reflected in the investigations of Prechtl and his coworkers in their studies of infant states which are discussed below.“*“5,“6 In this field the term state unfortunately became used in two conflicting ways, which led to confusion and misunderstanding of research reports. This problem has been reviewed by Ashton who clearly articulated both views of the subject.27 One was to regard states as distinct levels or patterns of functional organization that are arranged on a continuum of central nervous system arousal and characterized in part by varying capacities of the infant to respond to stimulation. l” The view of state as level of arousal, excitation, activation, or position on a sleep-awake continuum was an attempt at explanation and was held mostly in the field of psychophysiology.“x*‘19 It contrasted with the conceptualization of other observers of infant behavior, particularly those with a neurologic orientation who regarded state in purely descriptive terms as a convenient categorization of infant behavioral parameters.“3”‘7 Some investigators have acknowledged both views.2’.22 The former conceptualization has been refuted by Prechtl on the basis of the circularity of reasoning involved in using arousal as an explanatory concept.26 Also, the elusiveness of the phenomenon of arousal when conceptualized solely in terms of a continuum and the fact that dividing a continuum measure into state categories is largely an arbitrary process have caused this formulation to be set aside for the present. State is now more cautiously viewed as a convenient classification of behaviors of the neonate. Attempts at explanation have not been abandoned altogether, however. For instance, Prechtl postulates that states are distinct functional conditions, each having its specific properties and reflecting “particular modes of nervous function.“26

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Wolffz’,** was the first to design a descriptive rating scale for infant states and others soon followed.“3.‘20 These are reviewed and summarized by Ashton.” As might be expected, the criteria for defining specific states is different from one investigator to another. However, Prechtl’s criteria seem to be a model applicable to psychiatric research.23,26.“6 He defined five states in the newborn by using strict operational criteria which he derived from empirical observation. These states are based on eyelid position (open vs closed), head and limb mobility, vocalization, and regularity of respiration. These parameters are organized in five particular combinations which do not overlap with each other (see Table 2). Prechtl characterized the five states as vectors occupying discrete “vector spaces.“‘6 They have been validated by himself and other investigators by means of neurologic tests and the measurement of accompanying physiologic parameters. These states, he says, are “purely descriptive . mutually exclusive and qualitatively different constellations.” Superimposed transitory events such as the startle response or drowsiness are not considered by him to be sufficient to warrant state categorization. and he has chosen 3 min as the minimum time period acceptable for state assignments. The methods of investigation and validation described in Prechtl’s work above, to which might be added the naturalistic technique of examining state sequences observed in rhythmic circardian variations, represent the best of the typical methods employed in the field of infant research.“’ RESULTS

Table 3 summarizes the use of the state concept in each of the areas reviewed and organizes this literature into five categories. Of these, “General Definition” refers to the broad conceptual formulation of the term and “Specific Operational Definition” refers to the particular operational criteria used to specify individual states. “Methods of Investigation” summarizes the techniques used for exploring these phenomena while “Methods of Evaluation” refers to the means of validating the existence of particular states. Finally, the category of “Explanation” outlines hypotheses as to the causes or organizing principles ot the proposed states in each area of investigation. Overall it was found that general definitions of the state concept are hard to find. A few psychoanalytic-psychodynamic investigators give the most articulated defnitions but most other fields do not address the problem adequately. Some neonatal researchers have attended to Ashby’s”” definition but others Table 2.

Eyes Open State State State State State ~_ Code:

-1 -1 +1 +1 0

1 2 3 4 5 -1 = true .- 1 = false 0 = true or false

*From Prechtl (1974).%

Vectors of Behavioral States’ Resplratlon Regular +1 1 +1 1 1

Gross Movements -1 -1 1 t1 -1

VOCEdl2EdlO~

1 1 1

1

+l

Often none given. Most conform with: Transient combinations of psychologic and/or behavioral parameters observed, reported, and/or inferred. Better articulated definitions given by Pious, Berne. & Horowitz.

Usually undefined. Implied is: Transient combinations of psychologic and/or behavioral parameters observed and/or reported. A broad unitary response pattern that recurs in the same form regardless of the stimuli that provoke it (Cattell).

Psychodynamic psychiatry

Descriptive psychiatry

General Definition

Combinations of symptoms and behaviors with variable, usually firm operational criteria. Specific descrtptions given in terms of scores on rating scales.

Combinations of symptoms and behaviors with variable, usually loose defining criteria (except for Horowitz). Specific descriptions applicable across individuals given by some authors (e.g., Bibring, Berne, 8 Horowitz).

Specific Operational Definition

Multiple raters making repeated observations on many subjects, Statistical tests of internal consistency. Correlations with independent measures (biologic and psychologic). Prediction,

Single rater, usually making repeated observations on one (Pious, Volkan) or several (Federn, Bibring, 8 Berne) subjects. Rarelv multiple raters repeatedly observing several subjects (Horowitz).

Psychoanalysis. Psychotherapy. Crisis intervention. “Configurational analysis” of psychotherapy material (Horowitz)

Standardized interviews. Standard ratings of naturalistic observations. Self-report scales.

Methods of EValtIatan

Summary Methods of Investigation

Table 3.

None or disease model

Metapsychologic theories. Developmental models. Descriptive model facilitating psychodynamic formulations (Horowitz).

Explanatiins

Undefined. Implied is: Transient combinations of psychologic and/or behavioral parameters observed and/or reported.

Several but none agreed upon. 1. Convenient classification of behaviors. 2. Any well-defined condition or property that can be recognized if it occurs again (Ashby).

Biologic investigations

Neonatal research

---

Specific clusters of behaviors defined by means of strict operational criteria. Several systems developed (Wolff, Prechtl).

Combmatrons of symptoms and behaviors with variable, usually firm operational criteria. Speck descriptions given on rating scales.

Standard ratings of naturalistic observations Physical manipulation: response to stimulation. Polygraph recordings of physiologic processes.

Measurement of metabolites. Polygraph recordings of physiologic processes. External/internal manipulations (drugs, hormones, psychologic. somatic, social).

Repeated measures on many subjects by different investigators under standardized or controlled conditions. Statistical correlations among and between behavioral and biologic parameters. Neurologic testing. Rhythmic circadian sequences.

Repeated measures on many subjects by different investigators under standardized or controlled conditions. Statistical correlations among and between psychosocial and biologic parameters. Animal studies.

Continuum of arousal. Particular modes of nervous function.

processes.

neurochemical

events and/or neurophysiologic

Hypothesized

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have simply referred to state as a convenient classification of behaviors. Specific operational definitions of state are absent in the psychoanalyticpsychodynamic literature and descriptive criteria are either absent or loosely defined at best, usually by means of case examples. The more systematic work of Horowitz is a significant exception in attempting to employ more clearly defined state criteria.‘l*‘* Descriptive psychiatry and biologic investigations delineate specific states usually in terms of rating scale scores, and although they generally do not directly address the problem of conceptual formulation, their operational criteria, when defined, and their rating instruments at least attempt to reach acceptable levels of reliability. Neonatal researchers have also gone far in developing strict operational criteria that can be used with a high degree of reliability. Methods of investigation for each field differ widely and these are summarized in Table 3. Methods of evaluation are weakest in the psychoanalytic-psychodynamic literature, although recent attempts by Horowitz are exceptional in laying the necessary groundwork to tackle this problem more systematically.‘* The other fields rely on multiple raters making repeated observations of many subjects, together with statistical tests of internal consistency, correlations with independent measures, tests of predictive validity, and examination of rhythmic phase sequences in their efforts at establishing validity. Psychoanalytic-psychodynamic theorists tend to be the most adventurous with respect to explanatory conceptualizations, and most of those reviewed rely on a developmental model of causation. Descriptive psychiatric and biologic investigators seek explanation in terms of a disease model of neurochemical-neurophysiologic processes but all formulations in this area are considered tentative (e.g., that catecholamine hypothesis). Neonatal researchers have tried to explain state on the basis of the arousal continuum model, but this has been set aside for the moment in favor of a more cautious nonspecific approach in postulating that particular modes of nervous functioning may underlie a particular functional state. DISCUSSION Medicine has long made use of the concept of stage in approaching the investigation of pathologic phenomena. A glance at the history of pathology reveals references to the stages of inflammation (e.g., the triple reaction), thrombosis, healing, tubercular lesions, lobar pneumonia, and so forth. Similarly, clinicians have identified stages of malignant disease (e.g., Hodgkin’s lymphoma), unconsciousness, and labor to name but a few. The term stage implies a point in a process, a temporal progression in a definable direction or evolution, etc.). It is, toward some arbitrary “end” (as in development, therefore, well suited to the phenomena of disease processes that progress in time from onset through their course to an outcome. Although, as strictly defined, the general term state does not necessarily encompass a temporal dimension (it is conceivable that the state of an object can remain invariant for the duration of the existence of that object), it has come to be used in the clinical sciences with the temporal axis implied, but not necessarily with a specified direction or “end” as implied in the concept of stage. Indeed, states are generally identified clinically by means of the intraindividual differences

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that occur over time. Cattell has used statistical techniques to locate and define states based on this principle of covariation in a number of variables within the same individual over time.34 It would be absurd to propose that states are in any way absolutes or that they have, in themselves, irreducible intrinsic value. Rather, their importance lies in their heuristic value which appears to be twofold. As with other areas of medical research, the concept provides a means of organizing complex data for the purpose of investigating underlying processes. Just as the basically arbitrary stages of inflammation provided a preliminary framework within which to investigate the underlying processes of blood flow change. capillary permeability, chemotaxis, and so forth, so the use of psychopathologic states provides a descriptive framework within which to investigate underlying electrophysiologic, neurochemical, psychodynamic. or other processes relevant to the psychiatric disorder in question. Secondly, the concept provides a pragmatic means of characterizing clinical phenomena for the purposes of prediction. The stages of labor, for example, have been useful to the obstetrician in predicting the nature of uterine contractions, possible complications, the behavior and experience of the mother, and the need for analgesia or other treatments. as well as the probable outcomes of certain therapeutic or other interventions. Similarly, a model of the stages of psychiatric illness can be used to predict behavioral and experiential changes and to guide the timing and choice of a variety of therapeutic interventions, both biologic and psychosocial.“’ When we come to ask what a (mental or psychopathologic) state actually is. we are posing an ontologic question of “essence” which places an excessive demand on the concept and threatens to empty it of any sense in real terms. If. instead, we put the question differently and ask what may we regard a (mental or psychopathologic) state to be, we are more likely to get an intelligible answer, although the actual formulation will depend on the philosophical position taken. The strict physicalist view is that mental state is identical with the state of the central nervous system, whereas the behaviorist position in that mental state is a disposition to behave. Armstrong has combined and extended these two viewpoints in a materialist theory which holds that a mental state is a state of the person, which is apt to bring about a certain sort of behavior.“’ The notion of causality in this proposition can be further elaborated and emphasized as in the materialist formulation of Lewis that a mental state is a state of the person apt for being caused by certain stimuli and apt for causing certain behavior.“3 Functionalism can be considered to be a variant of the materialist position because it does not represent a refutation of the fundamental propositions of materialism but, rather, complements them. A functional explanation is one that involves a “decomposition of a system into its component parts: it explains the working of the system in terms of the capacities of the parts and the way the parts are integrated with one another.““4 The key concept ot functionalism is that of the info~mution-pr-occ,.r.sing role of physiologic mechanisms rather than the physiologic mechanisms themselves. Thus, the functionalist definition of a mental state is an c.uplrrtrrrto~~ or c~rrrrsrrlone that asserts that a mental (or functional) state is a manifestation of particular

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physiologically mediated “configurations of information-processing systems,” or internal programs within the body of the organism.lz5 The strict application of this theory would involve a specification of the range of functional states that the organism possesses and the set of rules governing the probabilities of particular outcomes, given a particular (physical or informational) input while the organism is in a given functional state. The functionalist position may, at least, provide a satisfactory nonreductionistic framework within which to approach the issue of clinical state. Indeed, a functionalist approach to the state concept is implicit in the work of investigators quoted earlier whose subjects are as widely separated as Precht126 and Horowitz.72 One task of psychiatric research, then, would be to use the state concept as a frame of reference in working from the observed clinical phenomena (i.e., range of states) and inputs to the underlying “configurations of information-processing systems” and the relationships between such systems by measuring outcomes within the context of psychiatric illness. Psychopathologic states have not yet been defined in terms of their underlying functional properties. Therefore, at the practical level of working from the “outside-in” as it were, both the clinician, whose interest is likely to be in the clinical predictive role of states, and the research worker will require a general descriptive definition of state. One such definition could be as follows: The concept of state denotes a recarrent stable property of an open system defined by a cluster of specific behavioral andlor experiential components that covary over time. The existence together of these components defines a qualitatively distinct group exclusive of all others that may occur in the system over time. In order to have general clinical and research value, individual states must be operationally defined in terms of a set of specific properties that yield unambiguous categories. Although certain states may have particular biologic concomitants, in most cases they cannot yet be used as sufficient differentiating criteria in themselves to define particular states. A more cautious approach would be to use biologic parameters where appropriate as one or more components of the set of operational criteria for delineating the state. It is believed that a careful approach to state detinition would have heuristic value in delineating particular psychopathologic profiles within generally accepted nosologic categories. Systems of diagnostic classification tend to reinforce a static picture of psychopathology that is at variance with clinical experience where temporal changes in psychopathologic symptoms are observed to occur within minutes to days. State specification, then, is one way of characterizing psychopathology within the diagnostic framework. At the very least, this should serve to decrease the level of heterogeneity of patient groups so that biologic, psychologic, and social research may be facilitated and different state-specitic treatment strategies investigated or applied in clinical practice. ACKNOWLEDGMENT The author gratefully acknowledges the assistance John Docherty in the preparation of this paper.

provided

by Professor

I. Pilowsky

and Dr.

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