Scale for the evaluation of communication disorders in patients with schizophrenia: A validation study

Schizophrenia Research 77 (2005) 75 – 84 www.elsevier.com/locate/schres

Scale for the evaluation of communication disorders in patients with schizophrenia: A validation study Nadine Bazina,T, Yves Sarfatia,b, Fre´de´ric Lefre`rea, Christine Passerieuxa, Marie-Christine Hardy-Bayle´a,b a

Department of Psychiatry, Centre Hospitalier de Versailles, Le Chesnay, France b University of Versailles-Saint Quentin, Versailles, France Received 18 January 2005; accepted 30 January 2005 Available online 2 April 2005

Abstract Objective: A scale for the evaluation of communication disorders in patients with schizophrenia (Schizophrenia Communication Disorder Scale-SCD) is proposed based on studies showing that cognitive disorders specific to the disorganization seen in schizophrenia consist of context processing deficits and problems in the attribution of mental states. Thus the focus of this scale is on the cognitive difficulties revealed in conversation during a structured interview. Method: Fifty-six patients with schizophrenia, depression or mania were evaluated. Results and conclusion: Significantly elevated scores on the SCD were present in patients with schizophrenia compared to all other groups. Thus, this scale adds to the tools available for evaluating the language of patients with schizophrenia and helps focus on characteristics that are specific to this psychotic diagnosis. D 2005 Elsevier B.V. All rights reserved. Keywords: Schizophrenia; Disorganization; Language evaluation scale; Communication disorders

1. Introduction As currently defined on the basis of the available tools, and even though great progress has been made in the attempt to arrive at a totally objective

T Corresponding author. Service de Psychiatrie, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150 Le Chesnay, France. Tel.: +33 1 39 63 93 80; fax: +33 1 39 63 95 34. E-mail address: [email protected] (N. Bazin). 0920-9964/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2005.01.020

description, the assessment of communication disorders in patients with schizophrenia continues to raise as yet unanswered questions. First, although factor analyses reveal an item overlap for the components associated with communication disorders, a number of different item groupings have been proposed without it as yet being possible to provide a clear definition (Bell et al., 1994; Bryson et al., 1999). Second, there is a consistent body of evidence that items reflecting communication disorders are particularly unstable (Peralta and Cuesta, 2001). Third, they are not

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specific to schizophrenia: the communication disorders reported as the direct expression of schizophrenic disorganization, that is to say tangentiality, derailment, incoherence and illogicality, occur with almost equal frequency in patients with schizophrenia and mania (Harvey, 1984; Andreasen and Grove, 1986). Current definitions of communication disorder-related issues derived from the dimensional approach do not refer to any cognitive theory and abstract away from the underlying mechanisms (Andreasen, 1999). Therefore, many authors currently stress the fact that it is necessary to explain clinical symptoms if we are to explore the pathophysiological mechanisms. Consequently, the search for a psychometrically and clinically relevant symptom-based method for measuring the communication disorders associated with schizophrenia continues to be of great importance (Bryson et al., 1999; Docherty et al., 2000; Peralta and Cuesta, 2001). Elsewhere (Hardy-Bayle et al., 2003), we have presented in detail a cognitive model that provides an explanation of schizophrenic communication disorders on the basis of two pathophysiological mechanisms: (1) a deficit in the integration of contextual information; (2) a theory of mind deficit. We have also provided a volume of experimental evidence suggesting the involvement and the specificity of these two cognitive abnormalities in schizophrenic communication disorders (Besche et al., 1997; Passerieux et al., 1997, 1998; 2000a,b; Sarfati et al., 1997a,b, 1999, 2000; Sarfati and Hardy-Bayle´, 1999; Brunet et al., 2000, 2001). These cognitive abnormalities also formed the starting point for our desire to re-evaluate clinical symptoms and identify new clinical signs which we think represent the clinical expression of the two cognitive deficits. In the same way that Bleuler described thinking disturbance on the basis of an underlying theory of bSpaltungQ (Bleuler, 1950), our objective was to find a neo-bleulerian way of describing schizophrenic communication disorders which reflect either (1) the deficit in the integration of contextual information or (2) a theory of mind deficit. We have constructed new, fine-grained, pathophysiologically-based clinical items which we believe can identify specific communication disorders elicited under constrained conversational situations. We have already proposed a first version of a Schizophrenic Communication Disorders scale

(SCD) (Olivier et al., 1997) which showed that this approach was promising but that much more was needed. Now that the pathophysiology of schizophrenic communication disorders is more precisely characterized, we can present a revised clinical instrument that specifically permits the evaluation of these two cognitive deficits using a semi-structured interview, and which can be implemented in clinical practice.

2. Methods 2.1. Material The present Schizophrenic Communication Disorder Scale (SCD) consists of 7 items, which are presented in Appendix A: three items relate to difficulties in the integration of contextual information, while the other four items evaluate difficulties in attributing mental states to others. This is a revised version of our original (already published) 15-item scale (Olivier et al., 1997). The original scale has been improved in three ways. Firstly, in the light of a factor analysis of our initial proposal, we have removed all items that are more closely associated with general symptomatology than with specific cognitive deficits. Secondly, we have improved the interjudge agreement by proposing a specific definition with precise instructions concerning the conversational constraints necessary for the correct rating of every item in the scale. Thirdly, we have fine-tuned the clinical items to ensure that they reflect the cognitive deficits as directly as possible. To illustrate the approach that has enabled us to create clinical items on the basis of cognitive data, we shall detail the logic applied to the construction of two of them. One of the items thought to reflect a deficit in the integration of contextual information is the binability to clarify a speech corpusQ: patients are unable to make their speech clearer, more understandable, more informative when requested to do so by the clinician. The clinician’s request constitutes a conversational constraint which is thought to aggravate conversational difficulty: as soon as a patient’s speech becomes vague, unclear or incomprehensible, the clinician asks for clarification: bWhat do you mean by that? Can you explain what your answer means? Can you tell me what you are

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trying to say? etc.Q. In effect, in order to clarify what has just been said, it is necessary to integrate the contextual information which has just been evoked in the conversational exchange. Normal subjects, who have no deficit in the integration of contextual information should be able to clarify their speech, to adapt it within the conversation by using the elements of the conversational context, and to add information which makes what they have just said clearer (Harrow et al., 2000). Patients who suffer from a deficit in the integration of contextual information should not be able to provide any information relating to the previous topic of conversation and should therefore not be able to clarify their speech. The second example is taken from the items which are thought to reflect a theory of mind deficit: it is the binability to attribute an intention to another personQ. In this case, the patient has an impaired perspective (Harrow et al., 2000) and is unable to describe or recognize the intentions of relatives. Once again, we should stress that the pathogenetic logic requires the patient to be placed in a constrained conversational situation which is necessarily artificial since it needs, to the greatest possible extent, to call on the cognitive functions which are thought to be defective in the patient. The clinician assesses the patient’s ability to attribute intentions to others by asking him or her, during the interview, to describe the intentions of various familiar people: bIn your opinion, what does your father, mother, friend, doctor, team, neighbor think about you, your problems?Q In effect, to reply to such a question, patients must possess a theory of mind, i.e. a personal representation of the mental states of others, otherwise they will not be able to provide their own view of other people’s opinions together with all the accompanying doubts.

during the interview. As far as the rating of item 3 is concerned, three short texts involving a semantic ambiguity are proposed in Appendix A. 2.3. Subjects Thirty-four patients, all native speakers of French and exhibiting symptoms satisfying the DSM-IV criteria for schizophrenia (APA, 1994), participated in the study. The majority of them were recruited from various psychiatric centers. The subjects were either in an acute or post-acute phase of the illness, and all were receiving antipsychotic medication. All of the patients were evaluated by two experienced psychiatrists, trained in the use of the Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987) the Scale for Thought, Language and Communication Disorders (TLC) (Andreasen, 1979a,b), and the SCD. Verbal IQ was estimated using the Binois and Pichot vocabulary scale (Binois and Pichot, 1947). Twelve of the initial 34 patients (9 men and 3 women, mean age 31.3 (7.3) years) were re-evaluated 6 months later. Twenty-two patients, whose symptoms satisfied the DSM-IV criteria for major depressive episode (N = 12) and mania (N = 10), respectively, were also assessed in order to compare patients with schizophrenia with other psychiatric groups. All three groups were matched for age, sex, educational level, IQ and period of illness (Table 1). The patients with depression were all hospitalized and receiving antidepressant treatment at the time of the evaluation. They were severely depressed with a mean MADRS

Table 1 Sociodemographic and clinical data for the three groups

2.2. Procedure The interview takes about 1/2 h. A variety of topics should be raised while avoiding any discussion of symptoms or illness. Instead, the questions should tend to refer to the subject’s everyday life (tastes, hobbies, family relations, friends, television viewing, etc.). Items 3 and 7 have to be rated at the end of the interview. Intensity is rated on a 3-point scale: 0=absent, 1=slight, 2=moderate and 3=severe depending on the frequency with which the difficulty appears

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Group with Group with schizophrenia depression

Group with mania

Mean M 22 F 12 Age 33.4 Education (years) 11.6 Binois–Pichot 21.5 Period of illness 12.3 (years) TLC scores 17.0 SCD scores 9.9

SD

Mean SD

Mean SD

9.5 1.9 2.7 10.1

7 5 47.2 12.2 27.5 11.5

4 6 38.6 13.3 27.4 12.0

15.0 2.6 4.2 10.3

9.2 4.7

5.6 1.7

4.6 17.1 1.2 2.5

5.4 2.4

Sex

15.4 2.9 4.5 10.0

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of 41.9 (4.6) (from 39 to 47). The patients with mania were all hospitalized and receiving antimania treatment (mood stabilizer +/- antipsychotic) at the time of the evaluation. The evaluation of the severity of the mania at the time of the evaluation using the MAS scale (Bech et al., 1978) revealed a mean score of 24.9 (7.1) (from 16 to 38).

3. Results The factor analysis into principal components before rotation for the population of 34 patients with schizophrenia indicates that this scale has a good level of internal consistency (see Table 2). The first factor explains 47% of the total variance. All the items had a weight greater than 0.6 within the first-order factor (from 0.6 to 0.83) with the exception of item 3 (processing of a semantic ambiguity) which had a much smaller weight within the first-order factor (0.32) and alone accounted for the second-order factor (weight 0.77). The sensitivity was good: in the group of patients with schizophrenia, each item of the SCD ranged from 0 to 3 and the range of total scores varied from 1 to 21 (mean and sd for each item in Table 3). Sensitivity to change was tested in a population of 12 patients with schizophrenia taken from the 34 patients who took part in the study. These patients were tested again 6 months after initial evaluation. The mean SCD score for these 12 patients on initial testing was 11.7 (sd 4.5). Six months later, this SCD score had fallen considerably to 7.5 (sd 6.7) ( p b 0.01) as had the TLC score (from 20.8 to 14.4). Table 2 Principal-component factor analysis before rotation Factor 1 SCD SCD SCD SCD SCD SCD SCD

1 2 3 4 5 6 7

0.79 0.6 0.32 0.7 0.8 0.83 0.61

Factor 2 0.33 0.41 0.77 0.35 0.14 0.3 0.26

Table 3 Mean scores on the different items Mean Std. dev. Max Min SCD 1 Clarify speech SCD 2 Summarize speech SCD 3 Process an ambiguity SCD 4 Attribute an intention SCD 5 Describe clinician’s intention SCD 6 Attribute an intention to one’s own speech SCD 7 Attribute a false belief Total SCD score

1.56 1.68 0.91 2.24 1.71 1.26

0.8 1.04 0.93 0.99 1.17 0.9

3 3 3 3 3 3

0 0 0 0 0 0

0.65 9.91

1.07 4.71

3 21

0 0

The total SCD score was highly correlated with the total TLC score in our population of patients with schizophrenia (Pearson’s r = 0.66, p b 0.01) whereas the SCD was only poorly correlated with the PANSS (r = 0.32, NS) and the TLC was also poorly correlated with the PANSS (r = 0.20, NS). The coefficient of correlation between SCD and TLC remained very high for the 12 patients who were tested again after 6 months of treatment: r = 0.73, p b 0.01 on initial testing pour these 12 patients and r = 0.91, p b 0.01 after six months. Disorganization as indicated by the TLC factor analysis is interpreted differently depending on the author and the type of factor analysis used: according to Andreasen and Grove (1986), this dimension comprises the following TLC items: Pressure of speech, Derailment, Incoherence, Illogicality, Loss of goal and Perseveration ; according to Peralta et al. (1992): Tangentiality, Derailment, Incoherence, Illogicality, Circumstantiality and Loss of goal; for the purposes of the disconnection factor proposed by Harvey et al. (1992): Poverty of content of speech, Tangentiality, Derailment, Incoherence, Circumstantiality and Loss of goal; according to Bazin et al. (2002): Poverty of content of speech, Tangentiality, Derailment, Incoherence, Illogicality, Loss of goal and Perseveration. Whatever the dimension considered, the total SCD score is significantly correlated with all the measures of disorganization (respectively, r = 0.51, 0.54, 0.59 and 0.66, p b 0.01). The data obtained from the intergroup comparison for the scale were submitted to an analysis of variance (one-way ANOVA) (see Table 1). As far as the SCD is concerned, we observed a highly significant group

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effect: F(2,53) = 28.50, p b 0.0001. Using a planned comparison, we observed a significantly higher score in the patients with schizophrenia (M = 9.9, sd 4.7) than in those with mania (M = 2.5 sd 2.41; F(1.53) = 29.19, p b 0.0001) or depression (M = 1.66 sd 1.23; F(1.53) = 41.36, p b 0.0001), and noted no significant difference between the patients with depression and those with mania ( F b 1). In the case of the TLC, we again found a highly significant group effect: F(2.53) = 9.86 p = 0.0002. Using a planned comparison, we found no significant difference between the patients with schizophrenia (M = 17.0 sd 9.2) and those with mania (M = 17.1 sd 5.38; F b 1), whereas we observed a significant difference between the patients with schizophrenia and those with depression (M = 5.58 sd 4.66; F(1.53) = 18.5, p b 0.0001) and between the patients with mania and those with depression ( F(1.53) = 11.51, p = 0.0013). To summarize: – in the patients with depression, the scores were low on both the TLC and the SCD – in the patients with schizophrenia, the scores were high on both the TLC and the SCD – in the patients with mania, the scores were high on the TLC and low on the SCD.

4. Discussion and conclusion Many authors have recently stressed the fact that it is a very challenging undertaking to try to measure the communication disorders associated with schizophrenia. They agree that one of the best ways currently available to us is to start with the pathophysiological mechanisms of communication disorder and then to proceed to a cognitively based method of symptom description (Bryson et al., 1999; Docherty et al., 2000; Peralta and Cuesta, 2001). In this article, we propose a new way of designing a communications disorder scale in which clinical items reflect two well-known cognitive deficits which play a key role in the disruption of communication (Hardy-Bayle et al., 2003). The 7-item scale presented here is the fruit of the revision of an earlier 15-item version (Olivier et al., 1997). The

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results of the associated validation study confirm several positive aspects of the pathophysiological approach. First, our scale reveals a one-dimensional structure in the principal-component factor analysis before rotation, thus making it possible to calculate the global score. This result is normal given that the items were designed to directly reflect two cognitive anomalies that occur together (Pickup and Frith, 2001; Hardy-Bayle et al., 2003). Only item 3 seems to be somewhat isolated from the others. This is doubtlessly due to the rating conditions for this item which are highly specific and different from the conditions used to rate the other items. In effect, the item consists in presenting the subject with three short stories, and asking him or her a number of questions; it is presented at the end of the interview and departs from the conversational rules used to rate the other items. Second, the scale has good psychometric validity. It exhibits: ! a high level of sensitivity with a spread of scores on each item, a spread of total scores and a Gaussian distribution. ! good concurrent validity: The total SCD score was correlated with the total TLC score (the scale still currently considered to be the best able to reflect communication disorders) and the various dimensions of disorganization resulting from the TLC factor analyses published in the literature (Andreasen and Grove, 1986; Peralta et al., 1992; Harvey et al., 1992; Bazin et al., 2002). ! good sensitivity to change with a total score which fell by 25% in 6 months, paralleled by a clinical improvement in formal thought and language disorders as measured using the TLC. ! a good specificity since the scores of the patients with depression, and in particular those of the disorganized patients with mania, were significantly lower and different from those of the patients with schizophrenia. It should be noted that interjudge reliability was not reassessed for this study since the preceding study had already revealed a high level of interjudge reliability for the majority of the 16

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items and, in particular, for those selected for the current version (Olivier et al., 1997). Third, this new version of the SCD is not only shorter than the earlier version. The items it contains are all specific to the cognitive difficulties observed in schizophrenia. We therefore think that it should be sufficiently accurate to merit widespread use. Furthermore, the revised version, presented in Appendix A, is easier to use, contains precise guidelines for conducting the interview and introduces conversational constraints which reveal the shortcomings of schizophrenic speech. Future studies will need to consider the permanent or intermittent nature of these communication disorders and their level of sensitivity in patients who exhibit few or no symptoms. Since the experimental data suggest that the two cognitive anomalies involved in disorganization have state character, it is conceivable that the resulting communication anomalies may be normalized following an acute episode in patients experiencing a period of symptomatic remission. Studies designed to address these various points are currently underway. Clinical approaches that attempt to define a more specific clinical view of schizophrenia on the basis of a pathogenetic approach and which have their roots in the European tradition are largely unrepresented in the literature. It is first necessary to prove their ability to explain, as here, a specific dimension of the illness before claiming to be able to account for a large proportion, if not all, of the semiology of schizophrenia. We hope that our research has illustrated the value of such an approach.

Appendix A. Scale for the evaluation of communication disorders in patients with schizophrenia A.1. Schizophrenic Communication Disorders Scale (SCD) A.1.1. Instructions The items described in this scale are, at the level of clinical practice, the reflection of

cognitive anomalies that are not immediately visible to the clinician. They explore communications abilities that clinicians are not used to investigating or to which they pay insufficient attention. However, these formal communication anomalies are highly specific to the speech of patients with schizophrenia. That is why the context for their evaluation has been designed as a semi-structured interview in which clinicians can concentrate on detecting and recording 7 specific communication abnormalities. To this end, we have developed an interview technique involving conversational constraints which can reveal the specific signs of schizophrenic communication disorders. Within the interview context, the patients are naturally led to hide their communication difficulties by means of various coping strategies which differ from subject to subject (silence; laconic or, on the contrary, profuse responses; opposition; aggression humor; etc. . .). During the 30 min that the interview lasts, the clinician must not forget that his or her task is to reveal precisely those conversational difficulties that the patient is trying to avoid. Overall, the interview must therefore appear like a conversation, with the clinician nevertheless insisting on questions that make it possible to rate the seven formal difficulties in the patient. The thrust of the interview, and this is a rare departure from established custom, is therefore to create difficulties for the patients and to observe their ability to extricate themselves from the formal difficulties caused by the questions posed to them. Each of the seven items is accompanied by a specific definition. Three items are thought to indicate the unsuitability of action in its context, while the other four relate to the deficit in attributing mental states to others. The evaluation is quantitative, with each item being associated with criteria which correspond to four levels of severity (0. Absent/1. Slight/2. Moderate/3. Severe). The subject matter touched on during the interview must be varied (family, professional and other activities, hobbies, psychological difficulties, current affairs, etc.) but the interview conditions must regularly include thematic con-

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straints given that the speech of certain patients without schizophrenia can become disorganized when they are asked about their own psychological difficulties, even though their speech remains appropriate to the context when discussing other topics. The evaluation of the items which test the appropriateness of action to the context must therefore be based solely on the speech corpus produced in response to questions which do not relate to the patients’ psychological difficulties. The interview takes approximately 30 min to complete. It is preferable to rate item 3 at the end of the interview given that it differs very much in style from the pattern of spontaneous conversation. A.1.2. The scale A.1.2.1. Inability to clarify a speech corpus. Patient’s inability to make his/her speech clearer, more comprehensible, more informative when explicitly asked to do so by the clinician. Conversational constraint. As soon as the patient’s speech becomes vague, ask for clarification: bWhat do you mean by that? Can you explain your reply? Can you tell me what you mean? etcQ. If asked to do so by the patient, the clinician may repeat the question giving rise to the corpus. 0. Absent: The patient clarifies his speech, reorganizes it, repositions himself within the conversation on the basis of the conversational context and supplies information which makes it possible to clarify the preceding speech. 1. Slight: The patient supplies information which is related to the preceding topic but which only partially clarifies his speech. 2. Moderate: The patient supplies information which is related to the preceding topic but which does not clarify his speech. 3. Severe: The patient does not supply any information related to the preceding topic or supplies information which is irrelevant to the subject in question. A.1.2.2. Inability to summarize a speech corpus. Patient’s inability to summarize a part of his/her

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own speech when explicitly asked to do so by the clinician. Conversational constraint. Ask the patient to summarize the speech produced in response to subject matter proposed by the clinician: bCan you summarize what you’ve just told me? Can you sum up your ideas on the question of ... Can you tell me in just a few words what you’ve just said?Q 0. Absent: The patient is always able to summarize his/her speech. 1. Slight: The patient summarizes his speech moderately well. The proposed summary is related to the topic in question but is only partially comprehensible or the patient simply repeats what he has said word for word. 2. Moderate: The patient summarizes his speech in a somewhat inappropriate way. The proposed summary is unrelated to the topic of speech and is incomprehensible. 3. Severe: The patient summarizes his speech in an inappropriate way. The proposed summary is unrelated to the topic of speech and is incomprehensible. A.1.2.3. Inability to process a semantic ambiguity. Patient’s inability to choose the appropriate meaning of an ambiguous polysemic word on the basis of the context provided by the sentence or the conversation. Conversational constraint. The clinician informs the patient that he is going to present him with a short text and then ask several questions to which the patient must respond quickly by saying the first idea that comes into his head. The clinician reads three ambiguous interviews (see below) containing a polysemic word. The text activates the non-dominant meaning of the ambiguous word (e.g: pump—shoe). An initial question makes it possible to ensure that the context has been activated (here, the dance class and the dancing pumps). An interfering mental arithmetic task consisting of three simple sums precedes the ambiguous question. This only weakly activates the dominant meaning of the word (e.g.: pump—mechanical device).

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AMBIGUOUS INTERVIEW No. 1: bRoger’s sister was ill so Roger had to look after her. He thought this was something of a tie. Every day he cooked for her and made sure she was all right. But sometimes he could have some time to himself.Q Question 1: bHow was Roger’s sister?Q Interfering task (calculation: 3 operations, e.g. 3 + 11, 36 12, 54 / 2) Question 2: bWhat was Roger’s tie like?Q Question 3 (optional) If the subject’s response is incomplete, it is possible to ask for more precise details: bWhat do you mean by that?Q AMBIGUOUS INTERVIEW No. 2: bMr. Jones wanted to learn to dance and the instructor told him he would need to buy some pumps. Even though Mr. Jones went to all the shops in the town where he lived, he couldn’t find any pumps anywhere. He feared he would have to abandon the idea.Q Question 1: bWhat did Mr. Jones want to do?Q Interfering task (calculation: 3 operations) Question 2: bWhat do you think Mr. Jones would do with his pumps?Q Question 3 (optional) If the subject’s response is incomplete, it is possible to ask for more precise details: bWhat do you mean by that?Q AMBIGUOUS INTERVIEW No. 3 : bThe students at the university wanted to organize a rag. They hoped it would raise money for one of the local charities. The one they chose was devoted to cancer research because one of their friends was suffering from cancer.Q Question 1: bWhy did the students want to raise money?Q Interfering task (calculation: 3 operations) Question 2: bHow could a rag help them?Q Question 3 (optional) If the subject’s response is incomplete, it is possible to ask for more precise details: bWhat do you mean by that?Q

0. Absent: The patient processes the three semantic ambiguities. 1. Slight: The patient processes two semantic ambiguities. 2. Moderate: The patient processes one semantic ambiguity. 3. Severe: The patient does not process any of the semantic ambiguities. A.1.2.4. Difficulties in attributing intentions to others. The patient is not able to describe or recognize other people’s intentions. Conversational constraint. The clinician evaluates the patient’s ability to attribute intentions to others by asking him/her to describe the intentions of various people he knows: bWhat do you think your father, your mother, your doctor, the team, your neighbor ... think of you, of your difficulties?Q 0. Absent: The patient is able to attribute intentions to the various people he knows. 1. Slight: The patient recognizes the intentions of most of the people. 2. Moderate: The patient recognizes the intentions of some of the people. 3. Severe: The patient is regularly unable to answer the question or repeats word-for-word what the various people have said or attributes incorrect intentions to others. A.1.2.5. Difficulties in describing the clinician’s intention during the interview. The patient is unable to describe the clinician’s intention during the interview. Conversational constraint. The clinician evaluates the patient’s ability to attribute an intention to his/her speech by asking at various points during the interview: bWhat do you think I meant by that?Q. 0. Absent: The patient is always able to describe the clinician’s intention. 1. Slight: The patient sometimes has difficulties in describing the clinician’s intention. 2. Moderate: The patient has frequent difficulties in describing the clinician’s intention. 3. Severe: The patient is regularly unable to answer the question or attribute an intention to the clinician correctly.

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A.1.2.6. Difficulties in attributing an intention to one’s own speech. The patient is unable to describe his own intentions, attribute a meaning to his own speech. Conversational constraint. To ask the subject to describe his implicit intention, to extract his intention from his speech is to ask him to attribute a meaning to his speech: bWhat were you trying to tell me by saying that? What did you want to say to me? Why did you tell me that? Can you tell me what you’re trying to say?Q 0. Absent: The patient is always able to attribute a meaning/intention to his speech. 1. Slight: The patient sometimes has difficulties in attributing a clear meaning/intention to his speech. 2. Moderate: The patient regularly has difficulties in attributing a meaning/intention to his speech. 3. Severe: The patient is always unable to attribute a meaning/intention to his speech. A.1.2.7. Inability to attribute an erroneous belief to a character in a short story. The selected story is that of Little Red Riding Hood. The patient is unable to recognize Little Red Riding Hood’s erroneous belief that her grandmother is in her bed at the time she arrives at her house, this belief being at odds with reality and the knowledge of the patient who is aware that the wolf is in grandmother’s bed. Conversational constraint. bDo you know the story of Little Red Riding Hood?Q The clinician reminds the patient of the story or tells it up to the point at which Little Red Riding Hood arrives at the door of her grandmother’s house, and then asks the following question: bDo you think she’s going to go into the house or not?Q If the patient says yes then the following question is asked: bWhy did she go in when the wolf was in her grandmother’s bed and she might have been eaten?Q If the answer is negative, ask the patient why Little Red Riding Hood did not go in. 0. Absent: The patient immediately recognizes the erroneous belief and describes the character’s mental state correctly. 1. Slight: Doubt concerning the recognition of an erroneous belief (the patient gives the correct response but does not describe the character’s mental state).

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2. Moderate: The patient is able to describe the character’s mental state when helped by the clinician (bIn your opinion, what is Little Red Riding Hood thinking when she arrives at her grandmother’s house? Who does she think she’s going to find at her grandmother’s houseQ). 3. Severe: The patient is unable to describe the character’s mental state and therefore to provide a properly justified correct response.

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