Rating scale for the assessment of communication disorders in schizophrenics

Eur Psychiatry 1997;12:352-361

0 Elsevier, Paris

Original article

Rating scale for the assessment of communication disorders in schizophrenics V Olivier l, MC Hardy-Bay16 l, S Lancrenon *, J Fermanian 3, Y Sarfati l, C Passerieux l, JF Chevalier

l

I Dkpartement de Psychiatric, JDkpartement

Hdpital Richaud, I rue Richaud, 78000 Versailles; 2Syliastat, 31 avenue du G&kral L.eclerc, 92340 Bourg-la-Reine; de Biostatistiques, Hapita des Enfants Malades, 151 rue de Svres. 75015 Paris, France

(Received 12 September 1996; accepted 20 June 1997)

Summary

- Taking up the Bleulerian view of a clinical description based on a pathogenic model, we propose a rating scale for the assessment of communication disorders in schizophrenic patients. The scale consists of clinical items that could be the direct expression of the three hypotheses of cognitive dysfunction which have been postulated to explain communication dysfunction in these patients. We assessed the frequency of the 16 items in the scale in a total of 80 subjects (43 schizophrenic subjects, ten manic subjects, 17 depressive subjects and ten normal control subjects). The results of this study showed that this item schedule was specific to schizophrenic patients and, in particular, could statistically significantly discriminate schizophrenic patients from psychotic patients with affective disorder. The methodological qualities of the scale were explored and proved accurate, except for the reliability which is too low for some items and the item-to-total correlation which is too low for one item of the scale. schizophrenia

/ communication

disorders

/ rating scale / cognitive dysfunction

INTRODUCTION Until recently, the schizophrenia diagnostic was based on Bleuler’s ‘associative loosening’ concept (Bleuler, 1993) which defines schizophrenia as a group of disorders with a common pathogeny. This ‘associative loosening’ (spaZtung) was seen as the fundamental, pathognomonic, and organizing disorder which enabled the observed clinical symptoms to be explained (explicative theory). However, as many studies had shown the nonspecificity of this vaguely defined concept (Cooper, 1972; Andreasen, 1979; Harrow et al, 1983, 1986), attempts were made to replace it with more precise diagnostic criteria, notably Schneider’s first rank symptoms (1959). Nevertheless, schizophrenic patients clearly show specific communication disorders and many clinicians in France still use the ‘associative loosening’ syndrome to diagnose schizophrenia.

Belonging to this school, we believe that communication disorder could remain a diagnostic criterion of schizophrenia if it were described more precisely. The difficulty in describing communication disorder in schizophrenic patients could be due to the fact that current descriptions such as the Scale for the Assessment of Thought, Language and Communication Disorders (TLC) (Andreasen, 1979) do not refer to a pathogenic dysfunction model which explains clinical symptoms. In fact, the ‘pragmatic translation’ of the communication disorder in the TLC reduced Bleuler’s concept of ‘associative loosening’ to precise and objective criteria, but distorted the diagnostic value of the concept. Bleuler’s process, on the other hand, would appear more relevant to describe communication disorders, in that pathogenic hypotheses can be used as a guide for re-reading clinical symptoms and suggesting new clinical signs. Having chosen

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this descriptive approach in our clinical work, we then had to formulate new pathogenic hypotheses with reference to a normal psychic function model. Thus, cognitive psychology seemed to us to be the best model to elaborate new pathogenic hypotheses of communication disorders in schizophrenic patients. Adopting this approach, Frith (1992) proposed a clinical re-reading of the fundamental syndromes of schizophrenia using a model of pathogenic dysfunction derived from cognitive neuropsychology. Currently, three cognitive hypotheses of communication dysfunction are suggested in the literature. The first hypothesis concerns the discursive action of schizophrenics, which is an action adjustment disorder due to a deficit in the cognitive operations involved in contextual information processing (Hardy-Baylt, 1994). All studies of language show that, whatever the level tested, be it lexical, syntactic, semantic or pragmatic, schizophrenics have difficulties in taking context into account to adjust their answer. For semantic matching, the classic example is the interpretation of an ambiguous word, for example araignte which has two meanings in French: the prevailing meaning is the insect (spider), and the non-prevailing meaning is the piece of meat. When the word aruignge is inserted into a sentence such as: “I like the aruignte with shallots”, the schizophrenic attributes the ambiguous word with its prevailing meaning, ie, the insect, without taking the context of the sentence into consideration (Chapman et al, 1976). The second cognitive hypothesis postulates a deficit in the mental representation of an action (Harvey, 1987; Frith, 1992). Frith et al gave an example of this deficit, showing that in a task of mistake correction, the schizophrenics were unable to correct their mistakes without external, visual feedback because of the absence of internal control (monitoring) of their action. The third cognitive hypothesis postulates a deficit in the attribution of mental states (Frith, 1992; Sarfati, 1997). Sarfati gave an example of this deficit, pointing out the difficulties for schizophrenics to attribute intention to a protagonist in a short story presented in a strip cartoon. Hardy-Bay16 (1994) has suggested that these three hypotheses are joined together in a pathogenic train, in that the cognitive operation deficit in context planning determines the deficit in the mental representation of an action which in turn determines the deficit in the attribution of mental states. Her hypothesis is that the dysfunctions observed in ‘complex cognitive processes’ are the

outcome of a preliminary deterioration in the more elementary components of information processing which are involved in the adjustment of an action to its context. This failure in ‘contextdependent’ information processing leads, by way of a successive mechanism, to a disorder in the organisation of the action, its representation, and the attribution of intention which the subject makes secondary to the development of the action. This cognitive model proposes to account for the ‘associative loosening’ or disorganization symptoms which characterize schizophrenia. Following on from this, our cognitive hypothesis postulated that these three cognitive abnormalities were interdependent. Developing the clinical approach proposed by Frith (1992), our aim was to elaborate and validate a rating scale of communication disorders in schizophrenics and to define the interview conditions which would elicit the clinical items that could directly express the cognitive hypotheses of dysfunction postulated among these patients. Three clinical hypotheses were tested. First, that the factor analysis of the scale ratings in the schizophrenics’ group would reveal one factor. We hypothesized that, as the three cognitive abnormalities that guided our choice of items were dependent, all these features had to appear together at any one given time in the clinical context. Second, that this clinical items schedule was specific for schizophrenic patients and would allow us to discriminate schizophrenic patients from the other diagnostic groups, in particular psychotic patients with affective disorder. Third, related to the chronicity of schizophrenic disorder, was that these items were present at any time during the course of the illness and would reveal this permanent disorder better than traditional items. In fact, due to the method of identifying the items when elicited during conversational pressure situations and to the finesse of rated communication disorders, the sensitivity of the scale allowed us to detect these abnormalities in patients who, according to the traditional clinic, had few or no symptoms. METHODS Construction

of the rating scale: choice of items

The rating scale consisted of 16 items defined from the three cognitive dysfunction hypotheses. Each item was accompanied by a specific definition and criteria for four rating points which represented increasing levels of psychopathology: 0 = absent, 1 = minimal, 2 = moder-

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ate, and 3 = severe. As the severity rating points definition was based on the frequency of appearance of the abnormality for the majority of the items, each item had to be tested several times throughout the interview. The interview situations used to elicit the items of the scale were particularly well defined as, according to cognitive psychology, behaviour can only be tested if the situation which gives rise to this behaviour is controlled. Consequently, the interview technique included conversational pressures situations which were likely to reveal the communication disorders. Within the scale, four groups of items were distinguished. The first group consisted of the first two items (items 1 and 2) which describe the action adjustment disorder by a cognitive operation deficit in contextual information processing and the mental representation of an action deficit. For example, at the clinical level, these deficits are assessed by asking the subject to summarize a corpus of his/her speech. To do this, the subject must have a clear and coherent mental representation of what he/she just said. The second group consisted of three items (items 3, 4 and 5) to describe the action adjustment disorder by a cognitive operation deficit in contextual information processing. This context information processing deficit is rated, for example, by testing the ability of the subject to process semantic ambiguities inserted by the clinician into the conversation. To recognize the ambiguity, and then choose the correct meaning of the ambiguous word, the subject has to correctly process the contextual information of the conversation. The third group of items described the deficit in the attribution of mental states. This group consisted of five items (items 6,7, 89 and 10). For example, to assess the deficit in attributing intentions to others, the subject was asked to describe the clinician’s intention during the interview: “In your opinion, what did I want to say?” Finally, the fourth group was made up of items from the traditional clinic which, although not described from our hypotheses, would appear to be related. This group included the last six items of the scale (items 11, 12, 13, 14, 15 and 16). The scale is presented in the Appendix. Subjects A total of 80 subjects divided into four groups were evaluated: 43 schizophrenic subjects, ten manic subjects, 17 depressive subjects and ten normal subjects. The answers of the control group were compared to those of the patients. The patients came from four centers: the psychiatric unit of Richaud Hospital in Versailles, the psychiatric unit of the University and Hospital Center of PitieSalpetriere in Paris, the psychiatric unit of Lagny Hospital and the University Center of Georges Heuyer in Paris.

The “Corn&e de protection des PersoMes se p&ant a la recherche biomtdicale” (CCPPRB de Paris-Ouest, Paris) gave a positive opinion for the project of this study. Every voluntary patient received information about the study and had to give oral consent. For inclusion, patients had to satisfy International Classification of Diseases (ICD)-10 criteria (World Health Organisation, 1992) for schizophrenic disorder, manic disorder and depressive disorder, as assessed by an independent, experienced psychiatrist. These criteria were chosen because they are more restrictive than the Diagnostic and Statistical Manual @SM)-III-R (American Psychiatric Association, 1987) for schizophrenic disorder and exclude patients with chronic delusions but without formal thought disorder. Diagnoses were made by the clinician treating the patient who was a psychiatrist independent of the study. Subjects were excluded from the study if they had no current symptoms satisfying ICD-10 criteria for schizophrenic, manic or depressive disorder, were younger than 18 years of age or older than 65 years of age, not French mother tongue or had an organic or toxic disease which could interfere with psychiatric data collection. The normal control group were aged between 18 and 65 years, had French mother tongue and no history of psychiatric illness. Patients were assessed by a non-structured interview, but controlled by clinician’s questions, which covered various areas but not psychiatric symptomatology. The interview lasted approximately 30 min and was videorecorded. These interviews were then evaluated with our scale by two of the group of four blind and experienced raters, in order to assess inter-rater reliability. A first evaluation was made during an acute phase, and a second one as soon as the patient was in a stabilized phase, which we called the remission phase in this study. The treating psychiatrists were asked to score each patient on the following traditional scales: the scale for the assessment of thought, language and communication disorders or TLC (Andreasen, 1979), the scale for the assessment of negative symptoms (SANS) (Andreasen, 1982). the scale for the assessment of positive symptoms (SAPS) (Andmasen, 1983), the positive and negative syndrome scale (PANSS) (Ray et al, 1986) and the clinical global imptessions (CGI) (Van Frenckell, 1976). The SAPS, SANS and PANSS were used to study the association between our items and the three schizophrenic dimensions (positive, negative and disorganization dimensions). The depressive subjects were also scored on the depression scale of Montgomery and Asberg or MADRS (1979). The educational level was evaluated with a six-level French scale: illiterate, primary school, CAP/BEPC, secondary school/general certificate of education (baccalaureat), higher education first stage, higher education second and third stages. All the patients in the study were treated with neuroleptics.

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RESULTS

analysis

To validate the first hypothesis of the unidimensionality of our scale, we performed a principal component analysis on the full range of the 16 items, scored during the acute phase in order to study the factor structure of the scale. The internal consistency of the scale, reflecting the. homogeneity of the items of the scale, was studied using Cronbach’s alpha coefficient. To determine the role of each item on the internal consistency of the scale, this coeficient was re-calculated with one item suppressed each time. If the coefficient increased without the item, there was a poor correlation with the first factor yielded by the principal component analysis, and thus contributed to a decrease in the internal consistency of the scale. This item would then be reconsidered in the scale because either the definition was not precise enough, the rating points were not well defined or another dimension needed to be included. We also studied the characteristics of the scale’s global score (mean, median, standard deviation, minimum, maximum, and distribution) on the schizophrenic group evaluated during the acute phase and the association between the global score and the patients’ age, sex, educational level and duration of illness. Finally, we studied the association between the global score of our scale, the global score of the TLC, as well as each item of the TLC, and items belonging to the third schizophrenic dimension (dizorganisation syndrome) described by many authors (Bilder et al, 1985; Gibbson et al, 1985; Moscarelli et al, 1987; Liddle, 1987; LCpine et al, 1989; Kulhara et al, 1990; Mot-timer et al, 1990; Dollfus et al, 1991; Amdt et al, 1991; Gur et al, 1991; Peralta et al, 1992; Minas et al, 1992). The inter-rater reliability was studied in the acute phase and in the remission phase for each item, using the observed concordance (PO) which represents the percentage of judges agreed on their scores. The generalized kappa coefficient could not be used because only a few patients were studied and the hypothesis of margins homogeneity was not satisfied. To demonstrate the specificity of our scale, we compared the schizophrenics’ global scores to those of the other three patient groups using a one factor analysis of variance (ANOVA) with contrasts study according to Scheffe’s method. Finally, to validate the hypothesis of the chronicity of the disorder, we studied the stability of our items during the course of the illness by assessing patients during an acute phase and then during a remission phase. The analysis was only descriptive because of the small number of schizophrenic subjects assessed in both phases.

in schizophrenics

Group characteristics

A total Among

of 43 schizophrenics were evaluated. these 43 schizophrenics, 11 were evalu-

ated in an acute phase only, 11 in an acute phase and then in a stabilized phase, and 21 during a stabilized phase only. Thus, 22 (11 + 11) patients were evaluated in an acute phase and 32 (11 + 21) in a stabilized phase. Consequently, most of the schizophrenic patients were scored only during a symptomatic stability period, on the occasion of a visit to their psychiatrist. There was no significant difference between the four groups for the educational level (KruskalWallis test: P = 0.35), but there was a significant difference for age (Fisher test: P = 0.0007) and sex. The mean duration of illness was 12 years for the schizophrenic group, 9.4 years for the manic group and 7.8 years for the depressive group. Using ICD-10 criteria, patients in the schizophrenic group were diagnosed as: eight paranoid (18%), two hebephrenic (4.6%). one catatonic (2.3%). 24 undifferentiated (55%), seven residual (16%) and one simple (2.3%). According to Andreasen’s restrictive criteria for subtyping schizophrenia (Andreasen, 1990), 62.8% of the patients were classified as mixed schizophrenia and 37.2% as negative schizophrenia. Results in the schizophrenic an acute phase

group

assessed

in

Item frequency and internal consistency of the scale Twenty-two of the 43 schizophrenic subjects were assessed in an acute phase. Most of the items were scored frequently, with only two items (items 4 and 9) being scored in less than 50% of the patients. Seven items were scored in all patients (items 1, 2, 6, 7, 11, 12, and 13). The other items were relatively frequent: 90.9% for item 3, 72.7% for item 5, 68.2% for item 14, 77.3% for item 8, 90.9% for item 15, 82.4% for item 16, and 68.2% for item 10. As most of our schizophrenic patients scored on the TIC, this was evidence that formal thought disorder was present. The internal consistency of the scale judged by the Cronbach alpha coefficient was alpha = 0.91. On the whole, as these new coefficients were close to the global alpha coefficient, the exclusion of one item from the scale would not have notably improved the internal consistency of the scale.

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The correlation coefficients between the global score and each item were very high for items 1, 2, 3, 4, 7, 8, 10, 11, 12 and 14 (0.67-0.81, P = O.OOl), high for items 5, 6 and 13 (0.55-0.62, P = O.Ol), moderate for items 15 and 16 (0.484.50, P = 0.05) and not significant for item 9 (0.35). Regardless of the too low item-to-total correlation for item 9, this item has not to be taking into account in the final scale. The correlation coefficients between each item and the global score without the item were also calculated. The global score of the scale (sum of all the items, continuous variable from 0 to 48) showed a mean of 29.45, a median of 29.5, a standard deviation of 9.15, a minimum of 15, a maximum of 48 and a range of 33. Principal component analysis Before rotation, the principal component analysis of the patients’ ratings in an acute phase yielded a one factor solution which explained 46.9% of the total variance. Items l-8 and lo-13 had the best saturation coefficients (0.59-0.87); items 14, 15 and 16 were not as high (0.43-0.53) and only item 9 was not correlated to the factor. However, these results had to be omitted at this stage of the study, regardless of the small sample size (only 22 schizophrenics evaluated in an acute phase). The principal component analysis will be performed in the future with a bigger sample. Relationship between global score and clinical variables The results revealed no significant difference between the male and female global scores (Student’s t-test: P = 0.98). However, the global score was correlated to the educational level (ANOVA: P = 0.05) and to the duration of illness (ANOVA: P < 0.0001). The TLC global score was also correlated to the educational level (ANOVA: P = 0.002) and to the duration of illness (ANOVA: P = 0.007). The global score of our scale was also positively correlated to the TLC global score (0.75, P = 0.001). The TLC items which had the highest correlations with our global score were: poverty of content of speech (0.64, P = O.OOl>, tangentiality (0.57, P = O.Ol), derailment (0.72, P = O.OOl), incoherence (0.48, P = 0.05), illogicality (0.62, P = O.OOl), neologisms (0.68, P = O.OOl), loss of goal (0.689, P = O.OOl), perseverance (0.43, P = 0.05), and self-reference (0.57, P = 0.01). Our items were also positively correlated to some items belonging to the third schizophrenic

dimension or Liddle’s disorganization syndrome (Liddle, 1987): tangentiality, derailment, inappropriate affect (0.54, P = O.Ol), strange behaviour (0.53, P = 0.05) and alogia (0.46, P = 0.05). Pressure of speech, distractible speech and attentional impairment were not correlated to our global score. Finally, the global score of our scale was positively correlated to the CGI score. Score comparison acute phase

between

all the groups in the

The mean global scores were: 29.45 for the schizo-

phrenic group, 3.20 for the manic group, 1.52 for the depressive group and 0.30 for the control group. The ANOVA revealed significant differences between the groups; the schizophrenic group was significantly different from the other groups. On the contrary, there was no significant difference between the schizophrenic group and the manic group for the TLC mean global score (23.3/15.7). Likewise, there was no significant difference between the schizophrenic group and the depressive group for the SANS mean global score. Inter-rater

reliability

Fifteen schizophrenic patients (acute phase, n = 8 and stabilized phase, II = 7) were scored by two of the group of four raters. The inter-rater reliability was studied using the observed concordance (PO) for each item of the scale. In the acute phase, eight of the 16 items of the scale (items 2, 3, 6, 7.8, 11, 12 and 15) had a good concordance (PO > 0.75), five items (items 1, 4, 9, 10 and 16) had a moderate concordance (PO = 0.63) and three items (items 5, 13 and 14) had a poor concordance (PO = 0.5). In the stabilized phase, 12 items (items 1, 2, 3, 4, 5, 7, 8, 9, 11, 14, 15 and 16) had a good concordance (PO > 0.70) and four items (items 6, 10, 12 and 13) had a poor concordance (PO = 0.29-0.57). Stability illness

of the items during

the course

of the

Of the 33 schizophrenic patients assessed during remission phase, ten patients had a global score between 2 and 8, four patients had a score between 10 and 12, and 19 patients had a score between 15 and 32. The most frequently scored items were items 1, 2, 3, 6, 7, 8 and 11. Of the 11 patients assessed in both acute and remission phase, seven had a much lower global score during the second evaluation than during the first evaluation. In this

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group, items 1, 2, 3, 6, 7 and 11 were still scored during the remission phase. DISCUSSION The results of our study confirmed the specificity of the items of the scale. In fact, the comparison between the four groups showed that our items schedule was specific to schizophrenic patients. Our scale, shown in the Appendix, was the only one among all the tested scales, and in particular the TLC scale, able to statistically significantly discriminate the schizophrenic patients from the other patients, especially the psychotic patients with affective disorder. Most of the studies of formal thought disorder, as evaluated by the current rating scales of language disorder (TLC, Andreasen, 1979 and TDI, Johnston and Holzman, 1979), have shown that formal thought disorder was not a specific sign of schizophrenia and moreover, could not discriminate schizophrenic patients from other psychotic patients and non-psychotic manic patients (Andreasen, 1979; Harrow and Marengo, 1986; Holzman et al, 1986). Our result could not be explained by treatment differences between the groups because all the psychotic patients were treated with neuroleptics. The most discriminating items were items l-8 and 10, which describe a clinical sign detected during a conversational pressure situation implemented by the clinician during the interview. The results showing that schizophrenic patients had a much higher mean global score than that of the other patients provides evidence of a great specificity of our scale and allows us to envisage the ulterior construction of a qualitative diagnostic tool with binary answers of the type present/absent. Although some manic or depressive psychotic patients were scored on items 11, 12 and 13 of our scale, their scores were much lower than those of the schizophrenics. These items from the traditional clinic, which assess speech coherence, refer more to a speech peculiarity related to the delusions than to a peculiarity related to speech disorganization. In addition, some non-schizophrenic patients were scored on the ‘attribution of intention’ items, but much less than the schizophrenic patients. As all of these patients had a low educational level, the rating of these items seemed to be strongly related to intelligence level. In general, it seems that intelligence level influences the rating of the scales assessing the language, as shown by the correlations between our scale and the TLC (even much stronger correla-

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tion), and the education level. However, this intelligence factor seemed to effect the rating of some items more specifically than others and so did not explain all of the results. The items most strongly correlated to intelligence level need to be identified and redefined so that their rating is less dependent on intelligence quotient. In this study, the main methodological qualities of the scale were explored and were proved correct, except for the reliability which is too low for some items in the remission phase. In fact, the inter-rater reliability assessed by the observed concordance is too low (0.29-0.43) for four items in the remission phase. A generalized kappa analysis, in the schizophrenic and non-schizophrenic groups, needs to be done in a further study with more patients. The Cronbach’s alpha is correct; the item-tototal correlations are also correct, except as concerns item 9. From this result, it is suggested that this item be omitted in the final scale. The question of the chronicity of the communication disorders could not be answered because of the small number of schizophrenic patients assessed in an acute phase and then in a remission phase, and also because the schizophrenic group assessed during a stabilized period was not homogeneous. For these reasons, we could neither explore the data, nor perform a principal component analysis on the scores of these patients. However, as the descriptive analysis of the results obtained during the remission phase showed that some of these patients were scored on our scale and not on the TLC, this would appear to indicate that our scale is more sensitive than the traditional scales. Our interview technique and the finesse of the items allowed us to detect a communication disorder in patients who seemed to have few or no symptoms in the traditional clinic. CONCLUSION The most outstanding result of our study was that the scale was specific to schizophrenic patients. The methodological problems raised by this study were the small size of the samples, the heterogeneity of the group of schizophrenics assessed during remission phase, the imprecise definition of some items and the lack of assessment of the intelligence level which interfered with the rating of some items of our scale, such as the items of the TLC. In addition, the interview technique needs to be refined, by defining more precisely how the interviewer should elicit the items, in order to improve the inter-rater reliability of the scale. A scoring

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manual needs to be created to include these instructions. Furthermore, the scale itself needs to be revised by selecting the most discriminating items and including new items which describe one of the three cognitive abnormalities already postulated. In particular, items other than those pertaining to the speech field, notably those of the behavioural and affective fields, have to be added. In fact, our results demonstrated a correlation between the global score of our scale and the items ‘inappropriate affect’ and ‘peculiar behaviour’ that belong to the disorganization syndrome described by the dimensional clinic. From a theoretical point of view, these items would appear to explain the hypothesis of the discursive action adjustment disorder belonging to a more general action adjustment disorder. The inappropriateness of affect with the context could be a reflection of an action adjustment disorder in the affective field, just as the peculiarity of behaviour is in the behavioural field. Other diagnostic groups need to be included, especially subjects with chronic delusions (chronic psychotic patients without schizophrenic disorder) and subjects with a border-line personality, in order to test the specificity of the scale in a larger sample of patients. Schizoid and schizotypic personalities should also be assessed because some authors (Peralta, 1991) consider that these two personalities are related to schizophrenia. A further study is currently underway to address each of these points. REFERENCES American

Psychiatry

Association.

Diagnosfic

Ment Dis 1985;173:67-73 Holzman PS, Shenton ME, Solovay MR. Quality of thought disorder in differential diagnosis. Schizophren Bull 1986; 12360-71 Hymowitz P, Spohn H. The effect of antipsychotic medication on the linguistic ability of schizophrenics. J Nerv Ment Dis 1980;168:287-96 Johnston MH, Holzman PS. Assessing Schizophrenic Thinking. San Francisco: Jossey Bass, 1979 Kay SR, Fisz-Bein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophren Bull 1987;13:261-74 Kulhara P, Chandiramani K. Positive and negative subtypes of schizophrenia: a follow-up study of India. Schizophr Res 1990;3:107-16 Lepine JP, Piron JJ. Chapotot E. Factor analysis of the PANSS in schizophrenic patients. V/II Congrtis Mondial de Psychiutrie. Athens: Abstract 3232, 1989 Liddle PF. The Symptoms of chronic schizophrenia. A reexamination of the positive-negative dichotomy. Br J Psych&n, 1987a;15 1: 145-51 Liddle PC. Schizophrenic syndromes, cognitive performance and neurological dysfunction. Psychol Med 1987b;l7:49-57 Liddle PF, Barnes TRE, Morris D, Haque S. Three syndromes in chronic schizophrenia. Br J Psychiatry 1989;155(Suppl 7):119-22

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Minas IH, Stuart GW, Jackson HJ, Singh BS, Copolov DL. Positive and negative symptoms in the psychoses: multidimensional scaling of SAPS and SANS items. Schirophr Res 1992;8:143-56 Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979; 134:382-g Mortimer AM, Lund CE. McKenna PJ. The positive-negative dichotomy in schizophrenia. Br J Psychiatry 1990;157: 41-9 Moscarelli M, Maffei L, Cesana BM et al. An international perspective on assessment of positive and negative symptoms in schizophrenia. Am J Psychiatry 1987;144: 1595-8 Organisation Mondiale de la Sante. ClussiJication intern&on& des troubles mentaux et des troubles du comportement. Description Clinique et Directives pour le Diagnostic. CM-lO/ICD-10. Paris: Masson, 1994 Peralta V, De Leon J, Cuesta MJ. A critique of the positive-negative dichotomy. Br J Psychiatry 1992;161: 33543 Sarfati Y, Hardy-Bay16 MC, Nadel J, Chevalier JP, Widlijcher D. Attribution of mental states of others in schizophrenic patients. Cognit Neuropsychiatry 1997;2: l-17 Schneider K. Clinical Psychopathology. [Translation: Hamilton]. New York: Grune 8z Stratton Inc, 1959

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APPENDIX Rating scale for the assessment of communication disorders in schizophrenics

to clarify a speech corpus, ie, to make it more informative, more understandable and clearer, at the clinician’s explicit request, even after having reminded the patient of the question at the root of the corpus. 0. Absence. The patient gives more information which makes the previous speech clearer. 1. Minimal. The patient gives more information which, although related to the previous theme, only partly clarifies the speech. 2. Moderate. The patient gives more information which, although related to the previous theme, does not make the speech clearer. 3. Severe. The patient does not give any information related to the previous theme or gives information unsuited to the theme. 2 / Inability to give a summary of a speech corpus even after being reminded of the question at the root of the corpus. 0. Absence. The patient gives a very suitable summary of his speech. 1. Minimal. The patient gives a moderately suitable summary of his speech. The summary is related to the speech theme but is

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only partly understandable or the patient only literally repeats his words. 2. Moderate. The patient gives a relatively unsuitable summary of his speech. The summary is related to the speech theme but is not very understandable. 3. Severe. The patient gives a summary unsuited to the speech. The summary is not related to the speech theme and is incomprehensible. Inability to process semantic ambiguity, the non-prevailing meaning of the polysemous word being reinforced by the sentence context or the conversational context. 0. Absence. The patient processes all the ambiguities in a suitable way, i.e. always processes the context and chooses the right sense of the word. 1. Minimal. The patient processes the majority of the ambiguities. 2. Moderate. The patient processes only some ambiguities. 3. Severe. The patient never processes the ambiguity. Use of paralogisms or word approximations and inability to specify the sense of these. Absence. No paralogism or presence of paralogisms that the patient can clarify in a way suitable to the sentence context or conversational context. Minimal. Sometimes the patient can clarify the paralogism in a way suitable to the context. Moderate. The patient gives an explanation of the paralogism unsuited to the context. Severe. The patient cannot clarify the paralogism or does not admit that it is a paralogism. Use of reference expressions without previous reference and inability to clarify or specify the ambiguous reference, at the clinician’s explicit request. 0. Absence. No use of reference expressions without previous reference. 1. Minimal. The patient uses ambiguous reference expressions but can always specify them. 2. Moderate. The patient uses ambiguous reference expressions that he can sometimes specify. 3. Severe. The patient uses ambiguous reference expressions that he can never specify. Difficulties in attributing intentions to others:

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360

“What your mother, father, friend, psychiatrist, the nurses (...) think about you, about your difficulties?’ 0. Absence. The patient can attribute an intention to the different protagonists and answers the questions using position modes (I think that, I believe that, I hope that...). Answers are adjusted according to the various protagonists. 1. Minimal. The patient can attribute an intention to the majority of the protagoIliStS.

2. Moderate. The patient can attribute an intention to some of the protagonists. 3. Severe. The patient is unable to answer the question or repeats literally the protagonist’s words or attributes an unsuitable intention to the protagonist, whomever the protagonist. 7 / Difficulties in describing the clinician’s intention during the interview: “In your opinion, what did I want to say?’ 0. Absence. The patient always describes the clinician’s intention in a suitable way. 1. Minimal. The patient sometimes has difficulties describing the clinician’s intention. 2. Moderate. The patient often has difficulties describing the clinician’s intention. 3. Severe. The patient is regularly unable to answer the question or attributes an unsuitable intention to the clinician. 8 / Inability to attribute a false belief to a short story character. Example: “Do you know the Little Red Riding Hood story?’ The clinician reminds the patient of the story up to the arrival of Little Red Riding Hood at the grandmother’s house. Then he asks the patient the following questions: “In your opinion, is she going into the house?’ If the patient answers yes, the clinician asks: “Why did she go into the house even though the wolf is in the grandmother’s bed?” If the patient answers no, the clinician asks: “Why doesn’t she go into the house?* 0. Absence. At once the patient rightly answers and rightly describes the mental state of the character, ie, recognizes the false belief of Little Red Riding Hood. 1. Minimal. Doubts about the recognition of the false belief. 2. Moderate. The patient rightly answers but with the clinician’s help. 3. Severe. The patient is unable to describe the character’s mental state and thus give the correct and well-justified answer.

9 / Inability to recognize a ‘false’ implicit intention suggested by the clinician, ie, an intention which does not come from the patient’s speech. The question asked by the clinician to the patient after suggesting a ‘false’ intention can be: “Is that an accurate summary of your intention?’ 0. Absence. The patient refuses all the suggested intentions which are not his own intentions. 1. Minimal. The patient refuses some of the suggested intentions which are not his own intentions. 2. Moderate. The patient refuses a few of the suggested intentions which are not his own intentions. 3. Severe. The patient accepts all the suggested intentions which are not his own intentions. 10 / Incomprehensibility of the spontaneous speech, in other words, clinician’s inability to elicit the main idea that the patient wants to express, on a theme suggested by the clinician. 0. Absence. The spontaneous speech is always comprehensible. 1. Minimal. The spontaneous speech is sometimes comprehensible. 2. Moderate. The spontaneous speech is often but irregularly comprehensible. 3. Severe. The spontaneous speech is regularly incomprehensible. 1 1 / Answer unsuited to the context of a question about the patient’s mental state. 0. Absence. The patient’s answer is always suitable to the question context. 1. Minimal. The patient’s answer is sometimes unsuited to the question context. 2. Moderate. The patient’s answer is often but irregularly unsuited to the question context. 3. Severe. The patient’s answer is regularly unsuited to the question context. 12 / Answer unsuited to the context of a ‘neutral’ question, ie, a question which is not about the patient’s mental state. 0. Absence. The patient’s answer is always suitable to the question context. 1. Minimal. The patient’s answer is sometimes unsuited to the question context. 2. Moderate. The patient’s answer is often but irregularly unsuited to the question context. 3. Severe. The patient’s answer is regularly unsuited to the question context.

Assessment

of communication

13 / Peculiar, strange, bizarre behaviour defined by behaviour unsuited to the conversational context. NB: If the behavioural peculiarity is associated with a delirium, the item will not be performed. 0. Absence. The behaviour is always suitable to the conversational context. 1. Minimal. The patient sometimes behaves peculiarly or has strange facial expressions which are unsuited to the conversational context. 2. Moderate. The patient often but irregularly behaves peculiarly or has strange facial expressions which are unsuited to the conversational context. 3. Severe. The patient very often or permanently behaves peculiarly or has strange facial expressions which are unsuited to the conversational context. 14/ Delusions of thought reading: the patient believes that other people can read his thoughts. 0. Absence. The patient does not believe that other people can read his thoughts.

disorders

in schizophrenics

361

1. Minimal. The patient believed that other people could read his thoughts but now has doubts and cannot explain the phenomenon. 2. Moderate. The patient has a delirious belief that other people can read his thoughts. He frequently experiences the phenomenon. 3. Severe. The patient has a delirious belief that his thoughts are permanently read by other people. 15 / Thought and act withdrawal: delusions of thought control, thought theft or thought divulgence. 0. Absence. No thought and act withdrawal. 1. Minimal. The patient used to think that his thoughts did not belong to him, but now has doubts. 2. Moderate. The patient often but irregularly thinks that his thoughts do not belong to him. 3. Severe. The patient believes that none of his thoughts belongs to him and he does not attribute any intention.