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The development of a self-reported scale for measuring functionality in patients with schizophrenia—Self-reported version of the graphic Personal and Social Performance (SRG-PSP) scale
Schizophrenia Research 159 (2014) 546–551
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The development of a self-reported scale for measuring functionality in patients with schizophrenia—Self-reported version of the graphic Personal and Social Performance (SRG-PSP) scale Ya Mei Bai a,b, Chih Yin Hsiao c,d, Kao Chin Chen c,d,e, Kai-Lin Huang a,b, I. Hui Lee c,d, Ju-Wei Hsu a,b, Po See Chen c,d, Yen Kuang Yang c,d,⁎ a
Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan Department of Psychiatry, College of Medicine, National Yang-Ming University, Taipei, Taiwan c Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan d Addiction Research Center, National Cheng Kung University, Tainan, Taiwan e Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan b
a r t i c l e
i n f o
Article history: Received 5 May 2014 Received in revised form 11 August 2014 Accepted 15 August 2014 Available online 23 September 2014 Keywords: Schizophrenia Functionality PSP scale Self-rating scale
a b s t r a c t Background: The Personal and Social Performance (PSP) scale is used for the assessment of patient function by mental health professionals. This study aimed to evaluate the internal reliability and validity of a self-reported graphic version of the PSP (SRG-PSP) scale and its correlations with psychiatric symptoms, daily life ability and quality of life. Methods: The SRG-PSP scale was developed following the four PSP domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior. In total, 108 patients with schizophrenia were enrolled. All participants completed the SRG-PSP, the Activities of Daily Living Rating Scale II (ADLRS-II), and the World Health Organization Quality of Life-BREF (WHOQOL). They were also assessed using the PSP and the Positive and Negative Syndrome Scale (PANSS). Spearman's ρ was used to examine the correlations between SRG-PSP scores and other variables. Results: The results of the SRG-PSP were significantly correlated to those of their corresponding criteria on the PSP. The global score of the SRG-PSP and the scores of three domains, socially useful activities, personal and social relationships, and self-care, were positively correlated with most sub items of the ADLRS-II and WHOQOL, and were negatively correlated with the PANSS scores. The disturbing and aggressive behavior domain of the SRGPSP was negatively correlated with most sub items of the ADLRS-II and WHOQOL (ρ = − 0.19 to − 0.36, all p b 0.05) and positively correlated with the PANSS (ρ = 0.24–0.30, all p b 0.05), with the exception of negative symptoms (ρ = 0.09, p = 0.40). Conclusion: The SRG-PSP is a valid self-reported scale for the assessment of functionality in patients with schizophrenia. © 2014 Elsevier B.V. All rights reserved.
1. Introduction In addition to improving psychopathologies, improvement in social functionality has been defined as an important goal of treatment in patients with schizophrenia (Cohen et al., 2006; Matza et al., 2006; Bellack et al., 2007; San et al., 2007). Deficits in social functioning have been established as a defining characteristic of mental illness (Dickerson et al., 1999; Dickinson et al., 2007). It is well known that social functioning is highly correlated with individuals' ⁎ Corresponding author at: Department of Psychiatry, National Cheng Kung University Hospital, 138 Sheng Li Road, North Dist., Tainan 70403, Taiwan. Tel.: + 886 6 2353535x5213; fax: +886 6 2759259. E-mail address: [email protected] (Y.K. Yang).
http://dx.doi.org/10.1016/j.schres.2014.08.024 0920-9964/© 2014 Elsevier B.V. All rights reserved.
neurocognitive function (Addington and Addington, 1999, 2000; Xiang et al., 2010; Schaub et al., 2011), social cognition (Vauth et al., 2004; Cohen et al., 2006; Addington et al., 2010; Bae et al., 2010), severity of psychopathology (especially negative symptoms) (Milev et al., 2005; Bora et al., 2006; Lysaker et al., 2009; Rocca et al., 2009; Weinberg et al., 2009; Xiang et al., 2010; Hunter and Barry, 2011), life quality (Tasiemski et al., 2009; Woon et al., 2010), occupational function (Weinberg et al., 2009; Ucok et al., 2011), suicide risk (Tarrier et al., 2004), depression (Bowie et al., 2006), and risk of relapse (Nicholl et al., 2010). For the evaluation of functioning in general, the Global Assessment of Function (GAF) is a simple instrument. However, the disadvantage of this scale lies in its incorporation of psychopathological aspects; confusing them with psychosocial factors. Upon this criticism, the Social and
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Occupational Functioning Assessment Scale (SOFAS) was developed; however this includes no clear operational instructions on how to rate the severity of disability (Juckel and Morosini, 2008). There are other complex instruments available to measure psychosocial functioning, such as the Activities of Daily Living Rating Scale (ADLRS) (Dinnerstein et al., 1965) and the Social Adjustment Scale (Aumack, 1962); however, these measures are detailed, complex, and require a profound knowledge of the patient and his/her actual circumstances or an extended interview (up to 30 min). There is the need to train the rater before using these instruments. Because of their complexity, these instruments are not satisfactory for use in clinical practice. Against this background, Morosini et al. (2000) developed the Personal and Social Performance (PSP) scale in a rehabilitation center for patients with schizophrenia. The PSP scale offers several advantages. Without mixing psychopathological with psychosocial aspects, the PSP is a more specific operationalization of the occupational, social, and personal functioning. In addition, the rater can assess one global score as well as subscores of the four domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behaviors, to be a more specific rating scale for functioning in comparison to the GAF scale and SOFAS. The reliability and validity of the PSP scale have been investigated in several studies, which have confirmed its high test–retest reliability, good inter-rater reliability validity (Morosini et al., 2000; Srisurapanont et al., 2008; Schaub and Juckel, 2011; Brissos et al., 2012), and high correlations with the GAF scale, SOFAS, MiniInternational Classification of Functioning-Rating for Mental Disorders (Mini-ICF-P), and Positive and Negative Syndrome Scale (PANSS) (Nasrallah et al., 2008; Apiquian et al., 2009; Patrick et al., 2009; Garcia-Portilla et al., 2011; Nafees et al., 2012; Wu et al., 2013). The PSP scale offers an efficient method of monitoring both psychosocial functioning in the acute phase and continuing treatment of schizophrenia (Kawata and Revicki, 2008; Nasrallah et al., 2008; Patrick et al., 2009), and has been translated into different languages, including German (Juckel et al., 2008), Spanish (Apiquian et al., 2009), Portuguese (Brissos et al., 2012), Thai (Srisurapanont et al., 2008), Chinese (Tianmei et al., 2011), and Taiwanese Mandarin (Hsieh et al., 2011; Wu et al., 2013). The Taiwanese Mandarin version of the PSP scale was authorized by the original authors and is of proven validity and reliability (Hsieh et al., 2011; Wu et al., 2013). The PSP scale was designed to be administered by mental health professionals after a short training period (Morosini et al., 2000). However, a previous study showed that the most frequent reasons for psychiatrists not using scales to monitor outcomes were lack of time and lack of training (Zimmerman and McGlinchey, 2008). Therefore, a self-reported scale for measuring functionality would be invaluable in clinical practice. Many studies have shown that patients with schizophrenia have greater impairment in processing speed and verbal memory than visual spatial-perception memory (Chen et al., 2005; Kravariti et al., 2009; Kalkstein et al., 2010). A graphic selfreported rating scale is more applicable in patients with schizophrenia than narrative rating scales, and could be a convenient and useful measurement for functionality assessment; not only for research, but also for everyday clinical practice. In the present study, a self-reported graphic version of the PSP (SRG-PSP) scale was developed. The aims of this study were to evaluate the internal reliability and validity of the SRG-PSP scale and to analyze the correlations between the SRG-PSP, psychiatric symptoms and the daily life ability among patients with schizophrenia. 2. Methods 2.1. Participants In total, 108 patients with schizophrenia, including 56 (51.9%) females, of an average age of 40.2 ± 9.7 years, were recruited from daycare wards, community rehabilitation centers and outpatient clinics of the Departments of Psychiatry in two medical centers in Taiwan
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Table 1 Demographic data and characteristics of the participants. Mean
SD
Range
Age (years) Education (yrs) Duration of illness (yrs) Gender, male (%)
40.2 12.8 16.2 52
9.7 2.9 9.2 48.1
21–60 3–19 0.1–38.8
SRG-PSPa Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
13.6 9.6 16.5 6.0 33.6
3.0 2.9 2.2 1.7 7.0
7–18 5–15 8–18 5–13 13–46
PSPb Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
4.3 4.3 5.1 5.6 63.2
0.8 0.8 0.7 0.6 9.6
3–6 2–6 3–6 4–6 40–82
ADLRS-II Part A score Part B score Total score
32.5 36.5 68.9
7.2 7.8 12.1
14–48 13–49 37–93
WHOQOL Overall Physical health Psychology Social relationships Environment Total score
6.0 20.5 16.4 12.7 29.3 84.8
1.7 5.0 4.6 3.0 5.8 17.8
2–10 7–33 7–29 4–20 12–45 34–137
PANSS Positive symptoms Negative symptoms General symptoms Total score
13.9 17.8 30.7 62.4
4.5 5.3 8.4 15.7
7–26 8–34 18–55 36–105
SRG-PSP: Self-reported version of the graphic Personal and Social Performance scale. PSP: Personal and Social Performance scale. ADLRS-II: Activities of Daily Living Rating Scale II. WHOQOL: World Health Organization Quality of Life-BREF. PANSS: Positive and Negative Syndrome Scale. a For the SRG-PSP sub domains, the scores ranged from 0 to 18; higher scores representing better functioning in socially useful activities, personal and social relationships, and self-care, but worse disturbing and aggressive behavior. The global score summed up the first three domains and then subtracted the disturbing and aggressive behavior score; a higher global score meant better personal and social function. b For the PSP sub domains, the score ranged from 1 to 7; higher scores representing less severe functional impairment. The global score provided a single, overall rating from 1 to 100, where a higher score represented better personal and social function.
(Table 1). The inclusion criteria included: a) meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for schizophrenia; b) age between 20 and 60 years; c) not currently hospitalized 24 h a day (and had lived in the community for one month). Patients who met any of the following criteria were excluded: a) a severe and unstable major medical disease or a history of neurological disease; b) a history of alcohol or substance dependence or abuse, except nicotine dependence; c) a history of head injury; d) previous electroconvulsive therapy within 6 months; e) intelligence quotient b70; f) severe vision deficiency, e.g. color blindness or any corrected visual acuity b0.5; and g) illiteracy or disability and unable to read traditional Chinese characters. The participants' demographic data, physical history and psychiatric history were collected. The participants were assessed using the PSP scale and the PANSS by a psychiatrist in each hospital. All participants also completed the SRG-PSP scale and the Activities of Daily Living Rating Scale II (ADLRS-II). The Ethical Committees for Human Research at Taipei Veterans General Hospital and National Cheng Kung University Hospital approved the study protocol, and all participants signed a written informed consent form. Those who joined the study received 3.5USD per hour as compensation.
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2.2. Self-reported version of the graphic PSP (SRG-PSP) First, the SRG-PSP scale was developed following the four PSP domains, including the sub-items of socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior. The items of this self-rating scale were developed as cartoon-like pictures that the participant could easily understand and were based on the narrative text of the PSP scale. The cartoon-like pictures were created by a professional cartoonist with a background in creating advertisements. Both male and female versions of the cartoons were developed. The graphic items are shown in the supplementary material. In the initial development stage, there were 12 items for each single domain; creating a total of 48 items. After the scale had been reviewed by 10 senior psychiatrists in terms of its content validity, the final version contained 22 items in total. The Cronbach's alpha coefficient of the patients' scores was 0.79. In this calculation, the patients' data were used to measure the internal consistency of the SRG-PSP scale, not the inter-rater reliability of the psychiatrists who reviewed the scale. Simplifying the choice for each item is very important due to the possible cognitive deficit in patients with schizophrenia. All the items were rated from 1 (seldom) to 3 (always), and the domain score was summed. Higher scores represented better function in socially useful activities, personal and social relationships, and self-care, but worse disturbing and aggressive behavior. To generate the global score, the scores from the socially useful activities, personal and social relationships, and self-care domains were summed, and then subtracted with the disturbing and aggressive behavior score. A higher global score indicated better personal and social functioning. 2.3. Other measurements 2.3.1. The Personal and Social Performance (PSP) scale The PSP scale was administered by psychiatrists. It was developed from the Social and Occupational Functioning Assessment Scale (SOFAS) and measures psychosocial functioning within four domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior. The final global score is defined according to a summary instruction table (Morosini et al., 2000). This scale also provides a single, overall rating from 1 to 100, where a higher score represents better personal and social function. This global scale for functionality was validated by our previous study and was found to be highly correlated with objective instrument measurements such as cognitive function or the ADLRS-II (Hsieh et al., 2011; Wu et al., 2013). 2.3.2. Positive and Negative Syndrome Scale (PANSS) The Traditional Chinese version of the PANSS consists of 30 items and offers three rationally derived categories: positive, negative and general symptoms (Cheng et al., 1996). Psychotic symptoms occurring during the week prior to the interview are rated from 1 to 7. The higher the PANSS score is, the more severe the psychopathology of the patient. 2.3.3. Activities of Daily Living Rating Scale II (ADLRS-II) The ADLRS-II was developed to assess activities of daily living (ADL), and is performed by experienced occupational therapists. Its reliability and validity have been established in previous studies (Hsieh et al., 2011). The part A score (PAS) represents basic ADL functioning and is calculated as the sum of items 1 to 5, whereas the part B score (PBS) measures instrumental ADL functioning and is calculated as the sum of items 6 to 10. The total score of the ADLRS-II is calculated as PAS + PBS. 2.3.4. World Health Organization Quality of Life-BREF (WHOQOL) The Taiwanese version of the WHOQOL was used to assess the overall and the specific quality of life (QOL) of the participants (Yao et al., 2002; Yao and Wu, 2005). This instrument contains one overall score and four subdomains: physiology, psychology, social interpersonal relationships, and environment. Higher scores represent a better QOL. The
WHOQOL has been used in previous studies of the QOL of patients with schizophrenia (Chan et al., 2003; Sim et al., 2004; Alptekin et al., 2005). 2.4. Statistical analysis The data were analyzed using SPSS software version 17.0. Cronbach's alpha coefficient was used to test the internal consistency reliability, and Spearman's ρ was used to examine the correlation between the SRG-PSP and other scales to confirm the criterion-related validity of the SRG-PSP scale. The threshold for statistical significance was 0.05. 3. Results Detailed demographic and other characteristics are presented in Table 1. The correlation between the results of the SRG-PSP and PSP scales suggests that the criteria validities of SRG-PSP scale are valid (socially useful activities, personal and social relationships, self-care, disturbing and aggressive behavior, and global score: ρ = 0.30, 0.32, 0.24, and −0.21, and 0.42, respectively, all p b 0.05). The global score of the SRG-PSP scale was significantly correlated with each individual domain (ρ = −0.38, p b 0.01 for disturbing and aggressive behavior; ρ = 0.68–0.83, p b 0.01 for the other three domains). Individual domains were also significantly positively correlated with one another (ρ = 0.38–0.60, all p b 0.01), with the exception of disturbing and aggressive behavior. The self-care domain was the only domain significantly negatively correlated with disturbing and aggressive behavior (ρ = −0.29, p b 0.01). Most correlations between the SRG-PSP and ADLRS-II scales were statistically significant (ρ = −0.32 to −0.37, all p b 0.01 for disturbing and aggressive behavior; ρ = 0.29–0.65, all p b 0.01 for the other three domains and global score), with the exception of the correlation between the personal and social relationship domain of the SRG-PSP scale and the PBS (ρ = 0.17, p = 0.08) and the correlation between the disturbing and aggressive behavior domain of the SRG-PSP scale and the PBS (ρ = −0.17, p = 0.09), which were marginally significant. This means that a higher personal and social function score was associated with a higher ADLRS-II score. Most correlations between the SRG-PSP scale and the WHOQOL were statistically significant (ρ = − 0.19 to − 0.36, all p b 0.05 for disturbing and aggressive behavior; ρ = 0.20–0.44, all p b 0.05 for the other three domains and global score), with the exception of the correlation between the personal and social relationship domain of the SRGPSP scale and the overall WHOQOL, which was marginally significant (ρ = 0.18, p = 0.07). Most correlations with the PANSS were statistically significant (ρ = 0.24–0.30, all p b 0.05 for disturbing and aggressive behavior; ρ = − 0.21 to − 0.50, all p b 0.05 for the other three domains and global score), with the exception of the correlation between the disturbing and aggressive behavior domain of the SRG-PSP scale and the negative symptoms of the PANSS (ρ = 0.09, p = 0.40). The details are shown in Table 2. 4. Discussion Our results show that the criterion-related validities between the SRG-PSP and the PSP scales were all significantly correlated with their counterparts. The SRG-PSP global score and three domains (socially useful activities, personal and social relationships, and self-care) were positively correlated with the ADLRS-II and the WHOQOL, and were negatively correlated with the PANSS. The SRG-PSP disturbing and aggressive behavior score was negatively correlated with the ADLRS-II and the WHOQOL scores, and was positively correlated with the PANSS positive and general symptoms. These results suggest that the SRG-PSP scale is a reliable and valid instrument for assessing the
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Table 2 Spearman's ρ correlations between the SRG-PSP scale results and other outcome measures. SRG-PSP
Socially useful activities
Personal and social relationships
Self-care
Disturbing and aggressive behavior
Global score
SRG-PSP Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
1.00 0.60⁎⁎ 0.44⁎⁎ −0.14 0.83⁎⁎
0.60⁎⁎ 1.00 0.38⁎⁎ −0.18 0.82⁎⁎
0.44⁎⁎ 0.38⁎⁎ 1.000 −0.29⁎⁎ 0.68⁎⁎
−0.14 −0.18 −0.29⁎⁎ 1.00 −0.38⁎⁎
0.83⁎⁎ 0.82⁎⁎ 0.68⁎⁎ −0.38⁎⁎ 1.00
PSP Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
0.30⁎⁎ 0.28⁎⁎ 0.27⁎⁎ 0.22⁎ 0.40⁎⁎
0.19⁎ 0.32⁎⁎ 0.11 0.17 0.26⁎⁎
0.26⁎⁎ 0.29⁎⁎ 0.24⁎ 0.29⁎⁎ 0.28⁎⁎
−0.29⁎⁎ −0.15 −0.08 −0.21⁎ −0.27⁎⁎
0.35⁎⁎ 0.39⁎⁎ 0.22⁎ 0.26⁎⁎ 0.42⁎⁎
ADLRS-II Part A score Part B score Total score
0.57⁎⁎ 0.32⁎⁎ 0.53⁎⁎
0.45⁎⁎ 0.17 0.35⁎⁎
0.61⁎⁎ 0.29⁎⁎ 0.52⁎⁎
−0.37⁎⁎ −0.17 −0.32⁎⁎
0.65⁎⁎ 0.34⁎⁎ 0.57⁎⁎
WHOQOL Overall Physical health Psychology Social relationships Environment Total score
0.28⁎⁎ 0.37⁎⁎ 0.35⁎⁎ 0.25⁎⁎ 0.32⁎⁎ 0.38⁎⁎
0.18 0.26⁎⁎ 0.20⁎ 0.28⁎⁎ 0.27⁎⁎ 0.28⁎⁎
0.26⁎⁎ 0.42⁎⁎ 0.38⁎⁎ 0.34⁎⁎ 0.37⁎⁎ 0.42⁎⁎
−0.27⁎⁎ −0.36⁎⁎ −0.20⁎ −0.24⁎ −0.19⁎ −0.27⁎⁎
0.35⁎⁎ 0.44⁎⁎ 0.39⁎⁎ 0.37⁎⁎ 0.39⁎⁎ 0.45⁎⁎
PANSS Positive symptoms Negative symptoms General symptoms Total score
−0.25⁎⁎ −0.36⁎⁎ −0.40⁎⁎ −0.41⁎⁎
−0.21⁎ −0.29⁎⁎ −0.38⁎⁎ −0.35⁎⁎
−0.24⁎ −0.28⁎⁎ −0.33⁎⁎ −0.33⁎⁎
0.30⁎⁎ 0.09 0.25⁎ 0.24⁎
−0.31⁎⁎ −0.39⁎⁎ −0.50⁎⁎ −0.49⁎⁎
SRG-PSP: Self-reported version of the graphic Personal and Social Performance scale. PSP: The Personal and Social Performance scale. ADLRS-II: Activities of Daily Living Rating Scale II. WHOQOL: The World Health Organization Quality of Life-BREF. PANSS: Positive and Negative Syndrome Scale. ⁎ p b 0.05. ⁎⁎ p b 0.01.
psychosocial functioning of patients with schizophrenia. Since the most important barriers to the use of scales by psychiatrists in clinical practice are lack of time and the requirement for training (Zimmerman and McGlinchey, 2008), this self-reported graphic functionality rating scale could be a convenient and useful measurement for functionality assessment; not only for research, but also for everyday clinical practice. However, in this study, we found that, in comparison with the other three domains, the disturbing and aggressive behavior domain showed relatively lower correlations with the other three domains of the SRGPSP, PSP, ADLRS-II, and WHOQOL scales. Furthermore, as seen in previous reports (Swanson et al., 1990; Ekinci and Ekinci, 2013), our results show that the disturbing and aggressive behavior domain was correlated most significantly with the positive symptoms of the PANSS, but was not correlated with the negative symptoms. Many studies have shown that the negative symptoms of schizophrenia have a greater impact on social functioning than positive symptomatology (Villalta-Gil et al., 2006; Corcoran et al., 2011; Lincoln et al., 2011; Shamsi et al., 2011; Fulford et al., 2013; Strauss et al., 2013). Previous validation studies of the PSP scale also found that the disturbing and aggressive behavior domain was relatively dispensable to the PSP scale score or the assessment of psychosocial functioning (Juckel et al., 2008; Tianmei et al., 2011). Furthermore, patients with poor insight may deny that they have these disturbing behaviors. Further studies are required to investigate the influence of disturbing and aggressive behavior on the social functioning of patients with schizophrenia. The present study had several limitations. First, the study was conducted on patients from day-care wards, community rehabilitation centers and outpatient clinics; therefore, generalization of these results should be performed cautiously. Second, the sample size was relatively small, and further studies with more subjects are thus needed to
confirm the findings of this work in different disease phases, such as patients with acute exacerbated conditions or in those with poor insight. Third, function disability is a complex phenomenon as an interaction between the patient and the features of the overall context in which the patient lives. This self-reported graphic functionality scale could be a simple and convenient tool, but while we strived for simplicity in the design of an instrument for clinical use, the issue of its reductionistic and possibly stigmatizing nature still needs consideration. Role of funding source The study was supported by grants V103C-018 from Taipei Veterans General Hospital and NCKUH-10202055 from National Cheng Kung University Hospital. This research also received funding (D102-35001 and D103-35A09) from the Headquarters of University Advancement at the National Cheng Kung University, which is sponsored by the Ministry of Education, Taiwan, ROC.
Contributors Yen Kuang Yang designed the study and wrote the protocol. Chih Yin Hsiao helped to design the study. Chih Yin Hsiao and Po See Chen contributed to the statistical analyses. Ya Mei Bai wrote the first draft of the manuscript. Kao Chin Chen, Kai-Lin Huang, I Hui Lee, and Ju-Wei Hsu managed the data collection. All authors interpreted the results and helped to revise the manuscript.
Conflict of interest All authors declare that they have no competing interests. The funding institutions of this study had no further role in the study design, the collection, analysis, and interpretation of data, the writing of this paper, or the decision to submit it for publication.
Acknowledgments The authors are indebted to the research participants, Ms. Tsai Hua Chang, Mr. Chien Ting Lin from National Cheng Kung University Hospital, and Janssen Taiwan Limited for their administrative support.
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Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
The development of a self-reported scale for measuring functionality in patients with schizophrenia—Self-reported version of the graphic Personal and Social Performance (SRG-PSP) scale Ya Mei Bai a,b, Chih Yin Hsiao c,d, Kao Chin Chen c,d,e, Kai-Lin Huang a,b, I. Hui Lee c,d, Ju-Wei Hsu a,b, Po See Chen c,d, Yen Kuang Yang c,d,⁎ a
Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan Department of Psychiatry, College of Medicine, National Yang-Ming University, Taipei, Taiwan c Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan d Addiction Research Center, National Cheng Kung University, Tainan, Taiwan e Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan b
a r t i c l e
i n f o
Article history: Received 5 May 2014 Received in revised form 11 August 2014 Accepted 15 August 2014 Available online 23 September 2014 Keywords: Schizophrenia Functionality PSP scale Self-rating scale
a b s t r a c t Background: The Personal and Social Performance (PSP) scale is used for the assessment of patient function by mental health professionals. This study aimed to evaluate the internal reliability and validity of a self-reported graphic version of the PSP (SRG-PSP) scale and its correlations with psychiatric symptoms, daily life ability and quality of life. Methods: The SRG-PSP scale was developed following the four PSP domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior. In total, 108 patients with schizophrenia were enrolled. All participants completed the SRG-PSP, the Activities of Daily Living Rating Scale II (ADLRS-II), and the World Health Organization Quality of Life-BREF (WHOQOL). They were also assessed using the PSP and the Positive and Negative Syndrome Scale (PANSS). Spearman's ρ was used to examine the correlations between SRG-PSP scores and other variables. Results: The results of the SRG-PSP were significantly correlated to those of their corresponding criteria on the PSP. The global score of the SRG-PSP and the scores of three domains, socially useful activities, personal and social relationships, and self-care, were positively correlated with most sub items of the ADLRS-II and WHOQOL, and were negatively correlated with the PANSS scores. The disturbing and aggressive behavior domain of the SRGPSP was negatively correlated with most sub items of the ADLRS-II and WHOQOL (ρ = − 0.19 to − 0.36, all p b 0.05) and positively correlated with the PANSS (ρ = 0.24–0.30, all p b 0.05), with the exception of negative symptoms (ρ = 0.09, p = 0.40). Conclusion: The SRG-PSP is a valid self-reported scale for the assessment of functionality in patients with schizophrenia. © 2014 Elsevier B.V. All rights reserved.
1. Introduction In addition to improving psychopathologies, improvement in social functionality has been defined as an important goal of treatment in patients with schizophrenia (Cohen et al., 2006; Matza et al., 2006; Bellack et al., 2007; San et al., 2007). Deficits in social functioning have been established as a defining characteristic of mental illness (Dickerson et al., 1999; Dickinson et al., 2007). It is well known that social functioning is highly correlated with individuals' ⁎ Corresponding author at: Department of Psychiatry, National Cheng Kung University Hospital, 138 Sheng Li Road, North Dist., Tainan 70403, Taiwan. Tel.: + 886 6 2353535x5213; fax: +886 6 2759259. E-mail address: [email protected] (Y.K. Yang).
http://dx.doi.org/10.1016/j.schres.2014.08.024 0920-9964/© 2014 Elsevier B.V. All rights reserved.
neurocognitive function (Addington and Addington, 1999, 2000; Xiang et al., 2010; Schaub et al., 2011), social cognition (Vauth et al., 2004; Cohen et al., 2006; Addington et al., 2010; Bae et al., 2010), severity of psychopathology (especially negative symptoms) (Milev et al., 2005; Bora et al., 2006; Lysaker et al., 2009; Rocca et al., 2009; Weinberg et al., 2009; Xiang et al., 2010; Hunter and Barry, 2011), life quality (Tasiemski et al., 2009; Woon et al., 2010), occupational function (Weinberg et al., 2009; Ucok et al., 2011), suicide risk (Tarrier et al., 2004), depression (Bowie et al., 2006), and risk of relapse (Nicholl et al., 2010). For the evaluation of functioning in general, the Global Assessment of Function (GAF) is a simple instrument. However, the disadvantage of this scale lies in its incorporation of psychopathological aspects; confusing them with psychosocial factors. Upon this criticism, the Social and
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Occupational Functioning Assessment Scale (SOFAS) was developed; however this includes no clear operational instructions on how to rate the severity of disability (Juckel and Morosini, 2008). There are other complex instruments available to measure psychosocial functioning, such as the Activities of Daily Living Rating Scale (ADLRS) (Dinnerstein et al., 1965) and the Social Adjustment Scale (Aumack, 1962); however, these measures are detailed, complex, and require a profound knowledge of the patient and his/her actual circumstances or an extended interview (up to 30 min). There is the need to train the rater before using these instruments. Because of their complexity, these instruments are not satisfactory for use in clinical practice. Against this background, Morosini et al. (2000) developed the Personal and Social Performance (PSP) scale in a rehabilitation center for patients with schizophrenia. The PSP scale offers several advantages. Without mixing psychopathological with psychosocial aspects, the PSP is a more specific operationalization of the occupational, social, and personal functioning. In addition, the rater can assess one global score as well as subscores of the four domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behaviors, to be a more specific rating scale for functioning in comparison to the GAF scale and SOFAS. The reliability and validity of the PSP scale have been investigated in several studies, which have confirmed its high test–retest reliability, good inter-rater reliability validity (Morosini et al., 2000; Srisurapanont et al., 2008; Schaub and Juckel, 2011; Brissos et al., 2012), and high correlations with the GAF scale, SOFAS, MiniInternational Classification of Functioning-Rating for Mental Disorders (Mini-ICF-P), and Positive and Negative Syndrome Scale (PANSS) (Nasrallah et al., 2008; Apiquian et al., 2009; Patrick et al., 2009; Garcia-Portilla et al., 2011; Nafees et al., 2012; Wu et al., 2013). The PSP scale offers an efficient method of monitoring both psychosocial functioning in the acute phase and continuing treatment of schizophrenia (Kawata and Revicki, 2008; Nasrallah et al., 2008; Patrick et al., 2009), and has been translated into different languages, including German (Juckel et al., 2008), Spanish (Apiquian et al., 2009), Portuguese (Brissos et al., 2012), Thai (Srisurapanont et al., 2008), Chinese (Tianmei et al., 2011), and Taiwanese Mandarin (Hsieh et al., 2011; Wu et al., 2013). The Taiwanese Mandarin version of the PSP scale was authorized by the original authors and is of proven validity and reliability (Hsieh et al., 2011; Wu et al., 2013). The PSP scale was designed to be administered by mental health professionals after a short training period (Morosini et al., 2000). However, a previous study showed that the most frequent reasons for psychiatrists not using scales to monitor outcomes were lack of time and lack of training (Zimmerman and McGlinchey, 2008). Therefore, a self-reported scale for measuring functionality would be invaluable in clinical practice. Many studies have shown that patients with schizophrenia have greater impairment in processing speed and verbal memory than visual spatial-perception memory (Chen et al., 2005; Kravariti et al., 2009; Kalkstein et al., 2010). A graphic selfreported rating scale is more applicable in patients with schizophrenia than narrative rating scales, and could be a convenient and useful measurement for functionality assessment; not only for research, but also for everyday clinical practice. In the present study, a self-reported graphic version of the PSP (SRG-PSP) scale was developed. The aims of this study were to evaluate the internal reliability and validity of the SRG-PSP scale and to analyze the correlations between the SRG-PSP, psychiatric symptoms and the daily life ability among patients with schizophrenia. 2. Methods 2.1. Participants In total, 108 patients with schizophrenia, including 56 (51.9%) females, of an average age of 40.2 ± 9.7 years, were recruited from daycare wards, community rehabilitation centers and outpatient clinics of the Departments of Psychiatry in two medical centers in Taiwan
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Table 1 Demographic data and characteristics of the participants. Mean
SD
Range
Age (years) Education (yrs) Duration of illness (yrs) Gender, male (%)
40.2 12.8 16.2 52
9.7 2.9 9.2 48.1
21–60 3–19 0.1–38.8
SRG-PSPa Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
13.6 9.6 16.5 6.0 33.6
3.0 2.9 2.2 1.7 7.0
7–18 5–15 8–18 5–13 13–46
PSPb Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
4.3 4.3 5.1 5.6 63.2
0.8 0.8 0.7 0.6 9.6
3–6 2–6 3–6 4–6 40–82
ADLRS-II Part A score Part B score Total score
32.5 36.5 68.9
7.2 7.8 12.1
14–48 13–49 37–93
WHOQOL Overall Physical health Psychology Social relationships Environment Total score
6.0 20.5 16.4 12.7 29.3 84.8
1.7 5.0 4.6 3.0 5.8 17.8
2–10 7–33 7–29 4–20 12–45 34–137
PANSS Positive symptoms Negative symptoms General symptoms Total score
13.9 17.8 30.7 62.4
4.5 5.3 8.4 15.7
7–26 8–34 18–55 36–105
SRG-PSP: Self-reported version of the graphic Personal and Social Performance scale. PSP: Personal and Social Performance scale. ADLRS-II: Activities of Daily Living Rating Scale II. WHOQOL: World Health Organization Quality of Life-BREF. PANSS: Positive and Negative Syndrome Scale. a For the SRG-PSP sub domains, the scores ranged from 0 to 18; higher scores representing better functioning in socially useful activities, personal and social relationships, and self-care, but worse disturbing and aggressive behavior. The global score summed up the first three domains and then subtracted the disturbing and aggressive behavior score; a higher global score meant better personal and social function. b For the PSP sub domains, the score ranged from 1 to 7; higher scores representing less severe functional impairment. The global score provided a single, overall rating from 1 to 100, where a higher score represented better personal and social function.
(Table 1). The inclusion criteria included: a) meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for schizophrenia; b) age between 20 and 60 years; c) not currently hospitalized 24 h a day (and had lived in the community for one month). Patients who met any of the following criteria were excluded: a) a severe and unstable major medical disease or a history of neurological disease; b) a history of alcohol or substance dependence or abuse, except nicotine dependence; c) a history of head injury; d) previous electroconvulsive therapy within 6 months; e) intelligence quotient b70; f) severe vision deficiency, e.g. color blindness or any corrected visual acuity b0.5; and g) illiteracy or disability and unable to read traditional Chinese characters. The participants' demographic data, physical history and psychiatric history were collected. The participants were assessed using the PSP scale and the PANSS by a psychiatrist in each hospital. All participants also completed the SRG-PSP scale and the Activities of Daily Living Rating Scale II (ADLRS-II). The Ethical Committees for Human Research at Taipei Veterans General Hospital and National Cheng Kung University Hospital approved the study protocol, and all participants signed a written informed consent form. Those who joined the study received 3.5USD per hour as compensation.
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2.2. Self-reported version of the graphic PSP (SRG-PSP) First, the SRG-PSP scale was developed following the four PSP domains, including the sub-items of socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior. The items of this self-rating scale were developed as cartoon-like pictures that the participant could easily understand and were based on the narrative text of the PSP scale. The cartoon-like pictures were created by a professional cartoonist with a background in creating advertisements. Both male and female versions of the cartoons were developed. The graphic items are shown in the supplementary material. In the initial development stage, there were 12 items for each single domain; creating a total of 48 items. After the scale had been reviewed by 10 senior psychiatrists in terms of its content validity, the final version contained 22 items in total. The Cronbach's alpha coefficient of the patients' scores was 0.79. In this calculation, the patients' data were used to measure the internal consistency of the SRG-PSP scale, not the inter-rater reliability of the psychiatrists who reviewed the scale. Simplifying the choice for each item is very important due to the possible cognitive deficit in patients with schizophrenia. All the items were rated from 1 (seldom) to 3 (always), and the domain score was summed. Higher scores represented better function in socially useful activities, personal and social relationships, and self-care, but worse disturbing and aggressive behavior. To generate the global score, the scores from the socially useful activities, personal and social relationships, and self-care domains were summed, and then subtracted with the disturbing and aggressive behavior score. A higher global score indicated better personal and social functioning. 2.3. Other measurements 2.3.1. The Personal and Social Performance (PSP) scale The PSP scale was administered by psychiatrists. It was developed from the Social and Occupational Functioning Assessment Scale (SOFAS) and measures psychosocial functioning within four domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior. The final global score is defined according to a summary instruction table (Morosini et al., 2000). This scale also provides a single, overall rating from 1 to 100, where a higher score represents better personal and social function. This global scale for functionality was validated by our previous study and was found to be highly correlated with objective instrument measurements such as cognitive function or the ADLRS-II (Hsieh et al., 2011; Wu et al., 2013). 2.3.2. Positive and Negative Syndrome Scale (PANSS) The Traditional Chinese version of the PANSS consists of 30 items and offers three rationally derived categories: positive, negative and general symptoms (Cheng et al., 1996). Psychotic symptoms occurring during the week prior to the interview are rated from 1 to 7. The higher the PANSS score is, the more severe the psychopathology of the patient. 2.3.3. Activities of Daily Living Rating Scale II (ADLRS-II) The ADLRS-II was developed to assess activities of daily living (ADL), and is performed by experienced occupational therapists. Its reliability and validity have been established in previous studies (Hsieh et al., 2011). The part A score (PAS) represents basic ADL functioning and is calculated as the sum of items 1 to 5, whereas the part B score (PBS) measures instrumental ADL functioning and is calculated as the sum of items 6 to 10. The total score of the ADLRS-II is calculated as PAS + PBS. 2.3.4. World Health Organization Quality of Life-BREF (WHOQOL) The Taiwanese version of the WHOQOL was used to assess the overall and the specific quality of life (QOL) of the participants (Yao et al., 2002; Yao and Wu, 2005). This instrument contains one overall score and four subdomains: physiology, psychology, social interpersonal relationships, and environment. Higher scores represent a better QOL. The
WHOQOL has been used in previous studies of the QOL of patients with schizophrenia (Chan et al., 2003; Sim et al., 2004; Alptekin et al., 2005). 2.4. Statistical analysis The data were analyzed using SPSS software version 17.0. Cronbach's alpha coefficient was used to test the internal consistency reliability, and Spearman's ρ was used to examine the correlation between the SRG-PSP and other scales to confirm the criterion-related validity of the SRG-PSP scale. The threshold for statistical significance was 0.05. 3. Results Detailed demographic and other characteristics are presented in Table 1. The correlation between the results of the SRG-PSP and PSP scales suggests that the criteria validities of SRG-PSP scale are valid (socially useful activities, personal and social relationships, self-care, disturbing and aggressive behavior, and global score: ρ = 0.30, 0.32, 0.24, and −0.21, and 0.42, respectively, all p b 0.05). The global score of the SRG-PSP scale was significantly correlated with each individual domain (ρ = −0.38, p b 0.01 for disturbing and aggressive behavior; ρ = 0.68–0.83, p b 0.01 for the other three domains). Individual domains were also significantly positively correlated with one another (ρ = 0.38–0.60, all p b 0.01), with the exception of disturbing and aggressive behavior. The self-care domain was the only domain significantly negatively correlated with disturbing and aggressive behavior (ρ = −0.29, p b 0.01). Most correlations between the SRG-PSP and ADLRS-II scales were statistically significant (ρ = −0.32 to −0.37, all p b 0.01 for disturbing and aggressive behavior; ρ = 0.29–0.65, all p b 0.01 for the other three domains and global score), with the exception of the correlation between the personal and social relationship domain of the SRG-PSP scale and the PBS (ρ = 0.17, p = 0.08) and the correlation between the disturbing and aggressive behavior domain of the SRG-PSP scale and the PBS (ρ = −0.17, p = 0.09), which were marginally significant. This means that a higher personal and social function score was associated with a higher ADLRS-II score. Most correlations between the SRG-PSP scale and the WHOQOL were statistically significant (ρ = − 0.19 to − 0.36, all p b 0.05 for disturbing and aggressive behavior; ρ = 0.20–0.44, all p b 0.05 for the other three domains and global score), with the exception of the correlation between the personal and social relationship domain of the SRGPSP scale and the overall WHOQOL, which was marginally significant (ρ = 0.18, p = 0.07). Most correlations with the PANSS were statistically significant (ρ = 0.24–0.30, all p b 0.05 for disturbing and aggressive behavior; ρ = − 0.21 to − 0.50, all p b 0.05 for the other three domains and global score), with the exception of the correlation between the disturbing and aggressive behavior domain of the SRG-PSP scale and the negative symptoms of the PANSS (ρ = 0.09, p = 0.40). The details are shown in Table 2. 4. Discussion Our results show that the criterion-related validities between the SRG-PSP and the PSP scales were all significantly correlated with their counterparts. The SRG-PSP global score and three domains (socially useful activities, personal and social relationships, and self-care) were positively correlated with the ADLRS-II and the WHOQOL, and were negatively correlated with the PANSS. The SRG-PSP disturbing and aggressive behavior score was negatively correlated with the ADLRS-II and the WHOQOL scores, and was positively correlated with the PANSS positive and general symptoms. These results suggest that the SRG-PSP scale is a reliable and valid instrument for assessing the
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Table 2 Spearman's ρ correlations between the SRG-PSP scale results and other outcome measures. SRG-PSP
Socially useful activities
Personal and social relationships
Self-care
Disturbing and aggressive behavior
Global score
SRG-PSP Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
1.00 0.60⁎⁎ 0.44⁎⁎ −0.14 0.83⁎⁎
0.60⁎⁎ 1.00 0.38⁎⁎ −0.18 0.82⁎⁎
0.44⁎⁎ 0.38⁎⁎ 1.000 −0.29⁎⁎ 0.68⁎⁎
−0.14 −0.18 −0.29⁎⁎ 1.00 −0.38⁎⁎
0.83⁎⁎ 0.82⁎⁎ 0.68⁎⁎ −0.38⁎⁎ 1.00
PSP Socially useful activities Personal and social relationships Self-care Disturbing and aggressive behavior Global score
0.30⁎⁎ 0.28⁎⁎ 0.27⁎⁎ 0.22⁎ 0.40⁎⁎
0.19⁎ 0.32⁎⁎ 0.11 0.17 0.26⁎⁎
0.26⁎⁎ 0.29⁎⁎ 0.24⁎ 0.29⁎⁎ 0.28⁎⁎
−0.29⁎⁎ −0.15 −0.08 −0.21⁎ −0.27⁎⁎
0.35⁎⁎ 0.39⁎⁎ 0.22⁎ 0.26⁎⁎ 0.42⁎⁎
ADLRS-II Part A score Part B score Total score
0.57⁎⁎ 0.32⁎⁎ 0.53⁎⁎
0.45⁎⁎ 0.17 0.35⁎⁎
0.61⁎⁎ 0.29⁎⁎ 0.52⁎⁎
−0.37⁎⁎ −0.17 −0.32⁎⁎
0.65⁎⁎ 0.34⁎⁎ 0.57⁎⁎
WHOQOL Overall Physical health Psychology Social relationships Environment Total score
0.28⁎⁎ 0.37⁎⁎ 0.35⁎⁎ 0.25⁎⁎ 0.32⁎⁎ 0.38⁎⁎
0.18 0.26⁎⁎ 0.20⁎ 0.28⁎⁎ 0.27⁎⁎ 0.28⁎⁎
0.26⁎⁎ 0.42⁎⁎ 0.38⁎⁎ 0.34⁎⁎ 0.37⁎⁎ 0.42⁎⁎
−0.27⁎⁎ −0.36⁎⁎ −0.20⁎ −0.24⁎ −0.19⁎ −0.27⁎⁎
0.35⁎⁎ 0.44⁎⁎ 0.39⁎⁎ 0.37⁎⁎ 0.39⁎⁎ 0.45⁎⁎
PANSS Positive symptoms Negative symptoms General symptoms Total score
−0.25⁎⁎ −0.36⁎⁎ −0.40⁎⁎ −0.41⁎⁎
−0.21⁎ −0.29⁎⁎ −0.38⁎⁎ −0.35⁎⁎
−0.24⁎ −0.28⁎⁎ −0.33⁎⁎ −0.33⁎⁎
0.30⁎⁎ 0.09 0.25⁎ 0.24⁎
−0.31⁎⁎ −0.39⁎⁎ −0.50⁎⁎ −0.49⁎⁎
SRG-PSP: Self-reported version of the graphic Personal and Social Performance scale. PSP: The Personal and Social Performance scale. ADLRS-II: Activities of Daily Living Rating Scale II. WHOQOL: The World Health Organization Quality of Life-BREF. PANSS: Positive and Negative Syndrome Scale. ⁎ p b 0.05. ⁎⁎ p b 0.01.
psychosocial functioning of patients with schizophrenia. Since the most important barriers to the use of scales by psychiatrists in clinical practice are lack of time and the requirement for training (Zimmerman and McGlinchey, 2008), this self-reported graphic functionality rating scale could be a convenient and useful measurement for functionality assessment; not only for research, but also for everyday clinical practice. However, in this study, we found that, in comparison with the other three domains, the disturbing and aggressive behavior domain showed relatively lower correlations with the other three domains of the SRGPSP, PSP, ADLRS-II, and WHOQOL scales. Furthermore, as seen in previous reports (Swanson et al., 1990; Ekinci and Ekinci, 2013), our results show that the disturbing and aggressive behavior domain was correlated most significantly with the positive symptoms of the PANSS, but was not correlated with the negative symptoms. Many studies have shown that the negative symptoms of schizophrenia have a greater impact on social functioning than positive symptomatology (Villalta-Gil et al., 2006; Corcoran et al., 2011; Lincoln et al., 2011; Shamsi et al., 2011; Fulford et al., 2013; Strauss et al., 2013). Previous validation studies of the PSP scale also found that the disturbing and aggressive behavior domain was relatively dispensable to the PSP scale score or the assessment of psychosocial functioning (Juckel et al., 2008; Tianmei et al., 2011). Furthermore, patients with poor insight may deny that they have these disturbing behaviors. Further studies are required to investigate the influence of disturbing and aggressive behavior on the social functioning of patients with schizophrenia. The present study had several limitations. First, the study was conducted on patients from day-care wards, community rehabilitation centers and outpatient clinics; therefore, generalization of these results should be performed cautiously. Second, the sample size was relatively small, and further studies with more subjects are thus needed to
confirm the findings of this work in different disease phases, such as patients with acute exacerbated conditions or in those with poor insight. Third, function disability is a complex phenomenon as an interaction between the patient and the features of the overall context in which the patient lives. This self-reported graphic functionality scale could be a simple and convenient tool, but while we strived for simplicity in the design of an instrument for clinical use, the issue of its reductionistic and possibly stigmatizing nature still needs consideration. Role of funding source The study was supported by grants V103C-018 from Taipei Veterans General Hospital and NCKUH-10202055 from National Cheng Kung University Hospital. This research also received funding (D102-35001 and D103-35A09) from the Headquarters of University Advancement at the National Cheng Kung University, which is sponsored by the Ministry of Education, Taiwan, ROC.
Contributors Yen Kuang Yang designed the study and wrote the protocol. Chih Yin Hsiao helped to design the study. Chih Yin Hsiao and Po See Chen contributed to the statistical analyses. Ya Mei Bai wrote the first draft of the manuscript. Kao Chin Chen, Kai-Lin Huang, I Hui Lee, and Ju-Wei Hsu managed the data collection. All authors interpreted the results and helped to revise the manuscript.
Conflict of interest All authors declare that they have no competing interests. The funding institutions of this study had no further role in the study design, the collection, analysis, and interpretation of data, the writing of this paper, or the decision to submit it for publication.
Acknowledgments The authors are indebted to the research participants, Ms. Tsai Hua Chang, Mr. Chien Ting Lin from National Cheng Kung University Hospital, and Janssen Taiwan Limited for their administrative support.
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