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Hospitalized and released schizophrenic and nonpsychiatric subjects’ performance on measures of thought… Klinka, Jan 1981

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HOSPITALIZED AND RELEASED SCHIZOPHRENIC AND NONPSYCHIATRIC SUBJECTS' PERFORMANCE ON MEASURES OF THOUGHT DISORDER by JAN A. KLINKA Charles University, Prague, 1964-1969 M.A.., The University of B r i t i s h Columbia, 1975 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA February 19 81 © Jan A. Klinka, 1981 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of Brit ish Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department nf Psychology  The University of Brit ish Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 D a t e A p r i l 10, 1981 ABSTRACT An attempt was made to separate the effects of length of i l l n e s s from the effects of length of h o s p i t a l -i z a t i o n on the vocabulary and concept formation performance of chronic schizophrenic and chronic nonpsychiatric patients. Groups of these patients approximately matched for length of i l l n e s s , but which d i f f e r e d i n terms of t o t a l time spent i n i n s t i t u t i o n s (several years vs. a few months) were compared on the Rattan and Chapman vocabulary test that includes associative d i s t r a c t o r s and on several concept formation measures derived by Harrow et a l . from the Object Sorting Test. The schizophrenic inpatients and outpatients ( a l l under antipsychotic medication) were further subdivided into paranoid and nonparanoid subgroups and equated on severity of current disturbance. A t o t a l of 90 patients served as subjects. The results indicated that nonparanoid schizophrenics show the most d e f i c i t s on the measures used i n the study ( p a r t i c u l a r l y associative intrusions and i d i o s y n c r a t i c thinking), while paranoid schizophrenics performed at levels that were comparable to the performance of the chronic nonpsychiatric patients. I t was also found that associative intrusions and i d i o s y n c r a t i c thinking were the measures that provided the best discrimination between patients with prolonged as opposed to short i n s t i t u t i o n a l i z a t i o n . I t was concluded that neither length of i l l n e s s nor length of i n s t i t u t i o n a l i z a t i o n by i t s e l f accounts for the cognitive d e f i c i t s found i n t h i s study. Rather, such effects depend on the p a r t i c u l a r subtypes of schizophrenic patients, the p a r t i c u l a r indices of thought d e f i c i t s , and the p a r t i c u l a r measuring instruments. i v TABLE OF CONTENTS Page Abstract i i Table of Contents , • iv L i s t of Tables yi Acknowledgements v i i i Chapter 1 STATEMENT OF THE PROBLEM 1 Introduction 1 Key Variables 2 Dependent Variable Measures 5 Hypotheses Formulation 7 2 REVIEW OF RELEVANT LITERATURE 9 Disordered Thought in Schizophrenia .... 9 Issues Related to Chronicity and H o s p i t a l i z a t i o n 11 Thought Disorder and Object Sorting Tasks 15 Associative Interference 28 Psychometric Considerations 43 Psychopharmacological Issues 47 3 METHOD 51 Subjects. 51 P s y c h i a t r i c (Schizophrenic) Subjects .... 53 Nonpsychiatric Subj ects 58 C h a r a c t e r i s t i c s of the Six Experimental Subgroups . 58 Materials 61 Procedure 6 5 4 RESULTS 70 Differences in C h a r a c t e r i s t i c s of the Experimental Subgroups 70 Main Analyses 80 V Chapter Page Combined Vocabulary and Object Sorting Test Performance 80 Object Sorting Test Performance .... 81 Vocabulary Performance 89 Other Analyses 104 5 DISCUSSION 106 Group Comparability 106 Main Results 109 Comparison to Findings of E a r l i e r Studies H5 A b i l i t y of the Various Measures to Discriminate Between Groups 117 Influence of Psychoactive Medication . 121 Nature of Control Subjects 122 P r a c t i c a l Implications 125 6 SUMMARY AND CONCLUSION 129 Directions for Further Research 151 BIBLIOGRAPHY 134 APPENDICES - 1 ' 147 2 150 3 152 4 155 5 157 6 159 7 161 8 166 9 (9.1, 9.2, 9.3) 169 10 181 11 (11.1, 11.2, 11.3) 183 12 187 v i LIST OF TABLES Table Page 1 Diagnostic Category, Length and Severity of Il l n e s s , Length of Hospi t a l i z a t i o n , and Demographic Variables For A l l 90 Subjects ... 59 2 Correlation C o e f f i c i e n t s Between Age, Chroni-c i t y , and Education and the Dependent Variable Measures 72 3.1 Summary of Analysis of Variance df the Chronicity Variable 74 3.2 Tukey's Pairwise Contrasts Among Means on the Chronicity Variable 76 4 Tukey's Pairwise Contrasts Among Means on the Education Variable 77 5 Summary of the Multivariate Analysis of Covariance for A l l Dependent Measures (Covariates: Accuracy Scores on the Sub-test Without Distractors and Chronicity of Illness) 82 6 Summary of the Multivariate Analysis of Co-variance of the Object Sorting Test Measures (Covariate: Chronicity) 83 7 Covariance-adjusted Means and Standard Deviations on the Object Sorting Test Measures for A l l Subject Subgroups 85 8 Summary of Analyses of Covariance for the Object Sorting Test Meausres (Covariate: Chronicity) 87 9 Tukey's Pairwise Contrasts Among Sample Means for Idiosyncratic Thinking 88 10 Accuracy Means and Standard Deviations on the Vocabulary Subtests; Means and Standard Deviations for Distractor Choices and Correctly Answered F i l l e r Items for A l l Subject Groups 9 0 v i i Table Page 11 Correlation C o e f f i c i e n t s Between the Accuracy Scores on the Vocabulary Subtest With and Without Distractors for A l l Six Subject Groups 9 2 12 Summary of Analysis of Variance for the Vocabulary Subtest Without Distractor Scores 93 13 Summary of Analysis of Covariance for the Vocabulary Subtest With Distractor Scores (Covariates: Vocabulary Subtest Without Distractor Scores and Chronicity) 95 14 Covariance-adjusted Accuracy Means and Standard Deviations for the Vocabulary Sub-test With Distractors for A l l Subject Groups 9 6 15 Tukey 1s Pairwise Contrasts Among Sample Means for Scores on the Vocabulary Subtest .. 97 16 Summary of Analysis of Covariance of the Distractor Choices on the Vocabulary Subtest With Distractors (Covariate: Accuracy Scores on the Vocabulary Subtest With Distractors) . 98 17 Covariance-adjusted Means for Distractor Alternatives on the Vocabulary Subtest With Distractors for A l l Subject Subgroups .. 99 18 Summary of Analysis of Variance for the Vocabulary Test F i l l e r Item Accuracy Scores . 101 19 Tukey's Pairwise Contrasts Among Sample Means for Accuracy Scores on F i l l e r Items ... 103 20 Accuracy and Distractor Mean Scores on Long-term Hospitalized Schizophrenic Patients on the Multiple-choice Vocabulary Test 116 21 Mean Rating Scores on Long-term Hospitalized Schizophrenic Patients on Some Concept Formation Measures 118 ACKNOWLEDGEMENTS I am grateful to Dr. Demetrios Papageorgis for his support and encouragement as my thesis supervisor and departmental advisor. My special thanks go to Drs. P. Davidson and R. Hakstian of the Psychology Department, University of B r i t i s h Columbia, to Dr. D. Crockett of the Psychiatry Department, University of B r i t i s h Columbia and to Dr. A. Clark of Riverview Hospital for t h e i r con-tributions as members of my thesis committee. Further thanks go to Drs. M.W. Hislop, W. Goresky, members of the Research and Ethics Committee and s t a f f of Riverview Hospital; to Mr. J.W. Seager, Mr. R.W. Lakes, members of the Research Committee of Greater Vancouver Mental Health Services, and to i t s Strathcona Community Care Team s t a f f ; to Dr. M. Seraglia, Mr. W.E. Gueho, Mr. B. Brown, Mrs. M. Brockett of Pearson Hospital; to Dr. J.M. Houston, Mrs. C. Martin, Mrs. M. Vulpe of Gorge Road Hospital, and to Mrs. J . McNamara of Vancouver Island MS Society for their invaluable assistance i n maki available t h e i r f a c i l i t i e s and experimental subjects. I am also indebted to Dr. L.J. Chapman of the University of Wisconsin and to Dr. M. Harrow of Michael Reese Hospital, Chicago for test materials. i x Mrs. V. Green of the University of B r i t i s h Columbia deserves my warm thanks for help with analyzing the data and Ms. J . Pitcher for typing the manuscript. Chapter 1 Statement of the Problem Introduction This chapter presents the basic rationale of the study. A more detailed review of the relevant l i t e r a t u r e w i l l be provided i n Chapter 2. The study i t s e l f w i l l be presented i n d e t a i l and discussed i n the remaining chapters. The present study deals primarily with the effects of length of i l l n e s s and length of h o s p i t a l i z a t i o n on thought processes of chronic schizophrenic patients. The main question i s whether disordered thought i n chronic schizo-phrenics i s best viewed as a r e s u l t of a long-term i l l n e s s process or of prolonged and continuous h o s p i t a l i z a t i o n . In the l i g h t of this objective, chronic schizophrenic patients with lengthy and continuous h o s p i t a l i z a t i o n were compared to chronic schizophrenic patients with a r e l a t i v e l y short stay i n hospital and to comparable groups of non-psychiatric chronically i l l patients. Additional questions concern possible differences between paranoid and non-paranoid chronic schizophrenics, and the r e l a t i v e u t i l i t y of several indices of thought disorder i n schizophrenia. - 1 -2 The p a r t i c u l a r aspects of thought disorder that were investigated were associative intrusions i n vocabulary performance and certain indices of disordered concept formation. Key Variables Chronicity of i l l n e s s i s considered to be a continuous variable i n a time dimension and i s defined as length of i l l n e s s (either mental or physical) i n years since the time when the disorder i n question was f i r s t recognized and recorded by a professional. Length of h o s p i t a l i z a t i o n i s defined as length of continuous hospital" stay in,-years since•beginning of current admission. The major i n i t i a l problem faced by the investigator involves the separation of chronicity of the disorder from length of h o s p i t a l i z a t i o n . U n t i l recently, public p o l i c i e s had p r a c t i c a l l y guaranteed that most chronic schizophrenic patients would remain ho s p i t a l i z e d . As a r e s u l t , research had to s e t t l e for conditions that kept the variables of length of i l l n e s s and length of h o s p i t a l i z a t i o n hopelessly confounded. Thus, deficits"'" i n performance observed i n most "'"It i s recognized that the term ' d e f i c i t ' may contain unwarranted evaluative connotations i n addition to i t s de-scriptive status. " D e f i c i t , " as i t i s used throughout the present study, i n no way implies judgements of i n f e r i o r i t y , d i s a b i l i t y , etc. I t refers simply to d i f f e r e n t i a l performance (decrement), and i t s use i s dictated by a long established t r a d i t i o n i n studies of schizophrenia. 3 c h r o n i c s c h i z o p h r e n i c samples c o u l d be i n t e r p r e t e d as r e s u l t s of a c h r o n i c i l l n e s s process or of lengthy i n s t i t u t i o n a l -i z a t i o n or of some unknown combination of the two ( c f . Wing, 1962). P s y c h i a t r i c management of the c h r o n i c a l l y i l l s c h i z o p h r e n i c p a t i e n t s has r e c e n t l y s h i f t e d away from lengthy and continuous i n p a t i e n t h o s p i t a l i z a t i o n and has, to a c o n s i d e r a b l e extent, been r e p l a c e d by b r i e f h o s p i t a l -i z a t i o n s f o r r e c u r r e n t episodes of p s y c h o s i s . Improved treatment techniques seem to have less e n e d the need f o r l a r g e i n s t i t u t i o n s and have made i t p o s s i b l e to d e a l with a s u b s t a n t i a l number of the m e n t a l l y d i s o r d e r e d through s e r v i c e s developed w i t h i n l o c a l communities (e.g., Bigelow & B e i s e r , 1977; T e s t & S t e i n , 1978). The changing p o l i c i e s r e g a r d i n g h o s p i t a l i z a t i o n have p r o v i d e d c l i n i c a l i n v e s t i -g a t o r s w i t h o p p o r t u n i t i e s to o b t a i n samples of c h r o n i c a l l y i l l i n p a t i e n t s and o u t p a t i e n t s . A c c o r d i n g l y , the p r e s e n t study seeks to determine the e f f e c t s of c h r o n i c i t y on thought d i s o r d e r by t e s t i n g e q u a l l y c h r o n i c and e q u a l l y d i s t u r b e d s c h i z o p h r e n i c p a t i e n t s who were e i t h e r r e l e a s e d from h o s p i t a l a f t e r a r e l a t i v e l y b r i e f s tay or who were r e -t a i n e d i n h o s p i t a l f o r a lengthy p e r i o d of time. As a c o n t r o l group, e q u a l l y c h r o n i c p h y s i c a l l y i l l h o s p i t a l i z e d and n o n h o s p i t a l i z e d p a t i e n t s were a l s o t e s t e d . E f f o r t s were made to ensure t h a t a l l i n p a t i e n t s had comparable lengths of h o s p i t a l s t a y . 4 Another major problem t h a t c o n f r o n t s the contemporary i n v e s t i g a t o r of s c h i z o p h r e n i c f u n c t i o n i n g concerns the a p p r o p r i a t e procedure f o r a s s i g n i n g p a t i e n t s to t h i s d i a g -n o s t i c category. The use of the Research D i a g n o s t i c C r i t e r i a of S p i t z e r , E n d i c o t t , and Robins (1975; 1978) perm i t t e d a more o b j e c t i v e and r e p l i c a b l e method of a s s i g n -ment than broad d e f i n i t i o n s of s c h i z o p h r e n i a p r o v i d e d i n the D i a g n o s t i c and S t a t i s t i c a l Manual of Mental D i s o r d e r s , Second E d i t i o n (DSM-II) c l a s s i f i c a t i o n (American P s y c h i a t r i c A s s o c i a t i o n , 1968), and avoided p o s s i b l e f a l s e p o s i t i v e 2 i d e n t i f i c a t i o n . H eterogeneity was f u r t h e r reduced by s u b d i v i d i n g the s c h i z o p h r e n i c s u b j e c t s i n t o paranoid and nonparanoid subgroups on the b a s i s of the presence of d e l u s i o n a l i d e a t i o n ( c f . G o l d s t e i n , 1978; Ralph & McCarthy, 1968; R i t z i e r & Smith, 1976). There i s c o n s i d e r a b l e evidence f o r the v a l i d i t y of the paranoid-nonparanoid d i s t i n c t i o n (e.g., Chapman & Chapman, 1973b; Lang & Buss, 1965; Shakow, 1962; S t r a u s s , 1973), w i t h paranoids o f t e n per-forming i n a manner more s i m i l a r to t h a t of normal c o n t r o l s u b j e c t s than to other subgroups of c h r o n i c s c h i z o p h r e n i c s . In view of the numerous methodological problems i n v o l v e d i n c r o s s - s e c t i o n a l s t u d i e s of i n s t i t u t i o n a l e f f e c t s At the time t h a t the study was conceived and s t a r t e d , the DSM-III (1980) c l a s s i f i c a t i o n was not y e t a v a i l a b l e . 5 (Chapman & Chapman, 1973b; 1977; Mednick & McNeil, 1968; Strauss, 1973; Wynne, 1963), p a r t i c u l a r care was necessary i n forming subject groups and ensuring t h e i r r e l a t i v e comparability on p o t e n t i a l l y influencing variables. While removing schizophrenic subjects from psychoactive drugs was not feasible i n the context of the present study, the variables of premorbid adjustment, paranoid dimension, and current o v e r a l l severity of i l l n e s s were a l l taken into account, as were age and education. Dependent Variable Measures The vast majority of e a r l i e r investigations concerned with demonstration and measurement of various performance d e f i c i t s i n schizophrenia may have been lacking i n parsimony because hypothesized s p e c i f i c performance d e f i c i t s were not c l e a r l y separated from generalized across-the-board performance d e f i c i t (Chapman & Chapman, 1973a; 1973b). As schizophrenics, for the most part, perform less well in almost every behavior requiring a voluntary response, the mere demonstration of i n f e r i o r performance on a p a r t i c u l a r task selected by the investigator may r e f l e c t no more than the fact that schizophrenics exhibit i n f e r i o r performance on t h i s task and on a variety of other related (or possibly even unrelated) tasks. Furthermore, spurious d e f i c i t s ' may be- inferred- as" schizophrenic when-experimental 6 task performance i s compared to performance on control tasks, but the tasks i n question are not comparable i n terms of cert a i n psychometric requirements. Chapman and Chapman (1973a; 1973b) have s p e c i f i c a l l y suggested that tasks designed to measure d i f f e r e n t i a l schizophrenic d e f i c i t should be matched i n advance (with normal subjects) i n terms of r e l i a b i l i t y and item d i f f i c u l t y . Only then the tasks are considered to be matched on discriminating power (the extent to which the scores d i f f e r e n t i a t e the more able from the less able subjects), and thus permit the assess-ment of hypothesized d i f f e r e n t i a l performance d e f i c i t s i n schizophrenic and other deviant samples. The Rattan and Chapman (1973) test of associative interference i n vocabulary performance meets the above requirements; for t h i s reason and because of i t s demon-strated u t i l i t y i n previous investigations with schizo-phrenic samples (Klinka & Papageorgis, 1976; Rattan & Chapman, 1973), the test was included as one of the dependent measures of the present study. In addition, the Goldstein and Scheerer (1941) Object Sorting Test, which i s designed to assess p e c u l i a r i t i e s of concept formation, has played an important h i s t o r i c a l role i n investigations of schizophrenic thought processes; the version adopted i n t h i s study i s the modification of the Object Sorting Test by Harrow, Himmelhoch, Tucker, Hersh, and Quinlan 7 (1972) which has been shown to be quite powerful i n several recent studies by Harrow and his associates. At the same time, i t must be emphasized that the dependent measures of the present investigation c l e a r l y do not exhaust the domain of thought disorder i n schizophrenia. Hypotheses Formulation The present study compared the performance of hospi-talized and nonhospitalized chronic schizophrenic and nonpsychiatric patients on measures of associative interference i n vocabulary performance and of concept formation. No d i f f e r e n t i a l predictions were made concerning performance on vocabulary and concept attainment tasks. Sim i l a r l y , no s p e c i f i c d i f f e r e n t i a l predictions were made with regard to the various d i f f e r e n t measures of concept formation, though i t was expected that c e r t a i n of these measures (e.g., i d i o s y n c r a t i c thinking) would provide a better means of discriminating between schizophrenic and nonpsychiatric patients than others (e.g., behavioral overinclusion). The following s p e c i f i c hypotheses were made: (1) Hospitalized patients, regardless of diagnosis, w i l l show greater d e f i c i t i n (a) vocabulary performance ( i . e . , greater s u s c e p t i b i l i t y to associative i n t r u -sions) , and (b) concept formation performance than 8 w i l l nonhospitalized patients, again regardless of diagnosis. (2) Nonparanoid schizophrenic patients w i l l show greater d e f i c i t i n (a) vocabulary performance ( i . e . , greater s u s c e p t i b i l i t y to associative intrusions), and (b) concept formation performance, regardless of hos-p i t a l i z a t i o n status, and nonpsychiatric patients w i l l show the least corresponding d e f i c i t s , again regardless of h o s p i t a l i z a t i o n status. Paranoid schizophrenics are expected to perform at a l e v e l that w i l l be lower but s t i l l more similar to that of nonpsychiatric patients. No interactions between h o s p i t a l i z a t i o n status and diagnosis on the various measures were predicted. 9 Chapter 2 Review of Relevant L i t e r a t u r e This chapter i s divided into six sections. The f i r s t section b r i e f l y discusses the concept of schizophrenic thought disorder. The second section touches upon issues related to chronicity of i l l n e s s and length of h o s p i t a l -i z a t i o n . Since the results obtained i n many investigations concerning cognitive (schizophrenic) d e f i c i t s depend, to a large extent, on the p a r t i c u l a r test used (Payne, 19 73), the t h i r d section deals with the u t i l i t y and evolution of methodologically improved investigative instruments of concept formation processes (Goldstein & Scheerer, 1941; Vigotsky, 1962) . The fourth and f i f t h sections deal i n turn with theory and measurement of associative i n t e r -ference and cognitive d i f f e r e n t i a l d e f i c i t s i n general. A f i n a l b r i e f section concerns the effects of psychoactive medication on the cognitive performance of schizophrenic patients. Disordered Thought in Schizophrenia Since i t s o r i g i n a l modern conceptualizations by Kraepelin (1919; o r i g i n a l l y 1913) and Eugen Bleuler (1950; o r i g i n a l l y 1911), disordered thinking has been considered a 10 c e n t r a l f e a t u r e of the s c h i z o p h r e n i c psychoses. Even though many e a r l i e r c l aims f o r s p e c i f i c aspects of d i s o r d e r e d thought probably r e s t on shaky methodological grounds (e.g., Chapman & Chapman, 19 7 3b) and even though the extent to which d i s o r d e r e d thought uniquely c h a r a c t e r i z e s s c h i z o p h r e n i c p a t i e n t s has been probably overestimated (e.g., Harrow & Quinlan, 1977), the overwhelming body of both c l i n i c a l and r e s e a r c h o b s e r v a t i o n s continues to support the important r o l e of d i s o r d e r e d thought i n s c h i z o p h r e n i a and the need to s p e c i f y i t s nature. For example, B l e u l e r (1950) l i s t e d d i s t u r b e d thought a s s o c i a t i o n s among the fundamental symptoms of s c h i z o -p h r e n i a . In f a c t , he c o n s i d e r e d these d i s t u r b a n c e s to be of primary s i g n i f i c a n c e . As he e x p l a i n e d i t , i n s c h i z o -phrenic psychoses the a s s o c i a t i v e threads t h a t c h a r a c t e r i z e and d i r e c t normal thought processes break up ( s p l i t ) -. p a r t l y or completely. The p r o g r e s s i o n of s c h i z o p h r e n i c thought thus seems only p a r t i a l l y determined by a s p e c i f i c g u i d i n g i d e a . Since words of the same, s i m i l a r , or even opp o s i t e meaning, as w e l l as i r r e l e v a n t or seemingly n o n s e n s i c a l a s s o c i a t e s f i n d t h e i r way i n t o the broken a s s o c i a t i v e pathways of the p a t i e n t s , much of the s c h i z o -p h r e n i c s 1 i d e a t i o n and v e r b a l i z a t i o n gets beyond the normal l i s t e n e r ' s e x p e c t a t i o n and comprehension. Utterances of s c h i z o p h r e n i c i n d i v i d u a l s are then o f t e n judged to be 11 fragmentary, i l l o g i c a l , or simply b i z a r r e . P a r t i a l l y as a r e s u l t of Bleuler's influence, every ensuing major conceptualization of schizophrenia has included disordered thought as either a core or very prominent feature of the psychosis (for one of the few exceptions, see Knight, Roff, Barnett, & Moss, 1979) . Several of the viewpoints about the nature and origins of thought disorder i n schizo-phrenia are actually variants of a hypothesis that attributes the thought disorder (as well as other forms of performance d e f i c i t ) to the interference of competing s t i m u l i , often of an associated nature (Buss & Lang, 1965; Lang & Buss, 1965). Despite a voluminous l i t e r a t u r e on d e f i c i t i n schizophrenic cognition, methodological inadequacies (Buss & Lang, 1965; Chapman & Chapman, 1973b), misunderstanding of t h e o r e t i c a l formulations, or faulty assessment of the data (Wright, 1975) preelude?:any unequivocal conclusions •at- t h i s time. Issues Related to Chronicity and H o s p i t a l i z a t i o n The controversy over the relationship between length of i l l n e s s (chronicity) and severity of disordered thought derives i n a l l l i k e l i h o o d from Kraepelin's observation that dementia praecox patients became progressively more disorganized i n the i r cognition the longer they remained in h o s p i t a l . I t would seem too easy to contend that long 12 i l l n e s s with concomitant stay i n the generally-impover-ished environments of i n s t i t u t i o n s may bring about an impairment of most mental a b i l i t i e s i n p s y c h i a t r i c or even nonpsychiatric populations. The persuasive arguments of numerous authors often stemming from first-hand obser-vation of l i f e conditions of residents i n large i n s t i t u -t i o n s (e.g., Barton, 1959; Belknap, 1956; Goffman, 1961; Ludwig & F a r r e l l y , 1966) give additional weight to the data drawing on empirical evidence (e.g., Braginsky & Braginsky, 1967; Goldstein & Halperin, 1977; Gordon & Groth, 1961; Klinka & Papageorgis, 1976; McKinney, 1973; Ullmann, 1967; Wing, 1962). Findings of abnormalities in behavior and cognition have also been reported i n studies dealing with i n s t i t u t i o n a l i z e d children (Bettel-heim & Sylvester, 1948; Haggerty, 1959; Yarrow, 1961), prison inmates (Silverman, Berg, & Kantor, 1966), and prisoners of war (Bettelheim, 19 43; Klonoff, McDougall, Clark, Kramer, & Horgan, 1976; Shein, 1957). The study of Silverman et a l . (1966) i n p a r t i c u l a r , i n which s i g n i f i c a n t differences i n perceptual and con-ceptual performance were found between short-term and 13 long-term nonpsychiatric prison inmates, approximating the difference found previously between short-and long-term schizophrenics (Silverman, 1964), i s widely c i t e d i n support of an i n s t i t u t i o n a l i z a t i o n - d e t e r i o r a t i o n hypothesis. However, even seemingly convincing data do not allow for firm conclusions i f the e f f e c t s of i n s t i t u t i o n a l i z a t i o n are investigated by means of cross-sectional designs i n which the hospitalized long-term schizophrenic subjects cannot be presumed to be representative of the t o t a l long-term schizophrenic population. Strauss (1973), for instance, pointed out that the s i g n i f i c a n t differences between Silverman's (1964) acute and chronic schizophrenics were obtained post hoc, and were applicable to paranoid schizophrenic subjects only. In another context, Best (1968), c i t e d i n Strauss (1973), reported differences i n reaction time and some conceptual tasks between short- and long-term schizophrenic patients, but not between matched prisoner controls. Johannsen and O'Connel (1965) also presented disappointing findings on re-examination of an e a r l i e r study (Johannsen, Friedman, & Liccione, 1964), i n which a number of visual-perceptual measures were found to be related to c h r o n i c i t y . When schizophrenic patients were subsequently divided into groups i n terms of proportion of time spent i n h o s p i t a l , the perceptual performance of short-term and long-term 14 s u b j e c t s was, with a s i n g l e e x c e p t i o n , comparable. Almost an equal number of i n v e s t i g a t i o n s can be found t h a t e i t h e r f a v o r or oppose the n o t i o n t h a t c o g n i t i v e changes (decrement) d u r i n g the course of s c h i z o p h r e n i a should be a s c r i b e d to h o s p i t a l i z a t i o n e f f e c t s alone. Among s t u d i e s i n f a v o r of the n o t i o n are those by Blaney (1974), Harrow, Tucker, Himmelhoch, and Putnam (1972), K l i n k a and Papageorgis (1976), Silverman, Berg, and Kantor (1965) and Wynne (1963). Examples of s t u d i e s t h a t r e j e c t the above n o t i o n i n c l u d e those by Foulds, Hope, McPherson, and Mayo (1967), Moran, Gorham, and Holtzman (1960) and Smith (1964). D i f f e r e n c e s i n these f i n d i n g s and c o n c l u s i o n s may be e x p l a i n e d i n terms of i n c o n s i s t e n c i e s i n the use of the c h r o n i c i t y c o n s t r u c t , centered around the c o n f u s i o n or coalescence of c h r o n i c i t y w i t h l e n g t h of h o s p i t a l i z a t i o n . In a d d i t i o n , c r i t e r i a f o r s e p a r a t i n g l o n g - and short-term p a t i e n t s are o f t e n a r b i t r a r y . Both of these problems r e s u l t i n i n c o n s i s t e n t and sometimes b i a s e d sampling p r a c t i c e s . Admittedly, l o n g i t u d i n a l i n v e s t i g a t i o n s , r a t h e r than c r o s s - s e c t i o n a l comparisons, are p r e f e r a b l e ( c f . Pokorny, Thornby, Kaplan, & B a l l , 1976) although a b i a s e d s e l e c t i o n of s u b j e c t s cannot be r u l e d out i n t h i s case e i t h e r mainly because an unknown number of improved sub-j e c t s may no longer be p a r t of the o r i g i n a l sample. Furthermore, groups of equal c h r o n i c i t y but w i t h d i f f e r e n t 15 length of h o s p i t a l i z a t i o n are l i k e l y to d i f f e r with respect to demographic and symptom-related variables the s i g n i f i -cance of which i s largely unknown. I t i s prudent to keep i n mind and act upon Strauss' (19 73) concluding remarks regarding research designs i n schizophrenic chronicity studies: . . . comparisons of hospitalized early-term and long-term subjects . . . are comparisons of d i f f e r e n t l y heterogeneous groups: paranoid and nonparanoid, good and poor premorbid, drug responsive and nonresponsive subjects are compared with primarily nonparanoid, primarily poor premorbid, drug responsive, and non-responsive subjects. Early-term-long-term differences are also affected by the selec t i v e retention, and readmission of schizophrenics associated with s o c i a l , psychological and psychopharmacological variables. (Strauss, 1973, p. 277) Thought Disorder and Object Sorting Tasks E s s e n t i a l l y , concept formation has to do with the thought process that enables a person to bring disparate stimuli together i n some orderly fashion which i s meaningful to himself and to others. Within the context of object sorting tasks, the objects of the environment can be grouped according to various p r i n c i p l e s ( l e v e l s ) , notably physical dimension, functional relationship, and abstract re l a t i o n s h i p . An abstract concept thus refers to a certa i n general class of objects which share many common properties simultaneously (e.g., animals, f r u i t , f u r n i t u r e ) , or put 16 d i f f e r e n t l y i t i s defined by a grouping of objects based on a single common a t t r i b u t e . D i f f i c u l t i e s i n forming abstract concepts or i n abstract thinking experienced by brain-damaged and schizophrenic patients when asked to perform on sorting tasks were explained as an impairment i n the patients' 'abstract attitude' (Goldstein, 1944) or 'complexes' (Vigotsky, 1934). Cameron (e.g., 1938) described several major con-ceptual components of schizophrenic thinking p e c u l i a r i t i e s , including asyndetic thinking, metonymic d i s t o r t i o n , and interpenetfation (subsumed l a t e r under the term "over-inclusion")''", and inspired a great many research studies and test developments, including sorting tasks (Payne, 1962) . The Object Sorting Test, as o r i g i n a l l y developed by Gelb, Goldstein, Weigl, and Scheerer (Goldstein & Scheerer, 1941), has proved to be p a r t i c u l a r l y r i c h i n providing data about conceptual l e v e l and breadth. The Object Sorting Test comprises a variety of r e a l and toy objects, including tools, eating u t e n s i l s , food items, smoking material, and playthings. The objects lend them-Nowadays usually defined as a conceptual disorder i n which boundaries of concepts become overly broad and blur-red, making the schizophrenic ideation imprecise, vague, and often incomprehensible. 17 selves to numerous groupings by substance (e.g., wood, metal, rubber, pla s t i c ) or by use (e.g., to make things with, to eat with, to play with). As such, the stimuli of the Object Sorting Test embrace v i r t u a l l y a l l the dimensions that can be involved i n developing concepts: substance (material), color, shape, use, class, and any combinations of these. The o r i g i n a l version of the Object Sorting Test had been nonquantitative, at best only p a r t i a l l y standardized, and provided no data on r e l i a b i l i t y or group norms. Accordingly, findings of early studies using the Object Sorting Test (e.g., Bolles & Goldstein, 1938; Goldstein & Scheerer, 1941), although of great exploratory value, should be viewed with caution, even more so i n view of the lack of control over subject variables such as age, educational or i n t e l l e c t u a l l e v e l s , and length of i l l n e s s and h o s p i t a l i z a t i o n . The p o t e n t i a l i t i e s of the Object Sorting Test as a diagnostic and research instrument have been recognized along with i t s shortcomings (e.g., Lovibond, 1954; McGaughran & Moran, 1956; Rappaport, G i l l , & Schafer, 1945; Tutko & Spence, 196 2; Wild, Singer, Rosman, R i c c i , & Lidz, 1965), and this has led to test q u a n t i f i c a t i o n and procedural simplication. A p a r t i c u l a r l y thoughtful application of the Object Sorting Test was that of McGaughran and Moran (1956) . 18 This investigation tested whether schizophrenic thought r e f l e c t s an impairment i n the a b i l i t y to conceptualize at an abstract l e v e l or whether i t can be viewed as an impairment of s k i l l s i n s o c i a l communication. Sorting performance, including both 'active' and 'compliant' sorting phases, was scored i n terms of two conceptual levels (abstract vs. concrete) and four conceptual areas derived from dichotomous variables of publicness-privateness and openess-closedness. In the active (handing over) phase, the subject's task i s to group objects that belong with a pa r t i c u l a r object selected by the examiner, while the passive (compliant) phase consists of tasks requiring the subject to i d e n t i f y the basis for grouping of a number of objects arranged by the examiner. While no s i g n i f i c a n t l y d i f f e r e n t performance i n abstracting a b i l i t y was found between schizophrenic and nonpsychiatric patients, schizo-prenics, i n addition to scoring s i g n i f i c a n t l y higher on an ' a u t i s t i c ' index than nonpsychiatric controls, employed fewer closed-public and more open-private concepts than the i r nonpsychiatric counterparts. Furthermore, education and i n t e l l i g e n c e were found to be related to conceptual performance on some measures, esp e c i a l l y to the public-private dimension i n schizophrenics. The importance of the open-private dimension, suggestive of tendencies toward autism (McGaughran, 1954), w i l l become apparent i n further 19 Object Sorting Test refinements described below. Despite limited g e n e r a l i z a b i l i t y of the McGaughran and Moran study (the schizophrenic sample was composed only of chronic paranoid males), i t s outcome b a s i c a l l y supported deductions from Sullivan's (1944) and Cameron's (1938; 1944) positions concerning defective s o c i a l communication i n schizophrenia, and f a i l e d to support the s p e c i f i c notions of Goldstein (1944) and Vigotsky (Kasanin & Hanfmann, 1938). Further meaningful d i s t i n c t i o n within the construct of concreteness has come from Tutko and Spence (1962) who distinguished two types of nonabstract response: r e s t r i c t i v e ( r e f l e c t i n g d i f f i c u l t i e s to specify a basis for the sorting), and expansive ( r e f l e c t i n g tendencies to give loose, i d i o s y n c r a t i c s o rtings). These i n v e s t i -g a t o r s employed the compliant portion of the Object Sorting Test to compare groups of physically i l l , brain-injured, and process and reactive schizophrenic patients (unfortunately unmatched on length of i l l n e s s or hospi-talization), i n terms of the two v a r i e t i e s of response. While the process schizophrenics resembled the brain-injured patients as to t h e i r r e l a t i v e proportions of r e s t r i c t i v e and expansive errors, they d i f f e r e d from reactive schizophrenic and tubercular patients. The re-active schizophrenics were, comparable to nonpsychiatric controls on r e s t r i c t i v e errors but exceeded them on 20 expansive errors. Since the process schizophrenics gave predominantly r e s t r i c t i v e errors, i n contrast to the reactive schizophrenics who erred i n roughly the opposite d i r e c t i o n , both schizophrenic groups d i f f e r e d from the non-psychiatric subjects by vir t u e of manifesting d i f f e r e n t kinds of concrete errors. Among the predominant studies conducted on the topic of overinclusion over the l a s t two decades have been those of Payne and his co-workers. I n i t i a l l y , Payne, Matussek, and George (19 59) compared schizophrenic and neurotic patients on several measures of overinclusion including t h e i r own Object C l a s s i f i c a t i o n Test (Payne, 1962), the Benjamin Proverbs Test (Benjamin, 1944), and the 'handing over' score of the Goldstein-Scheerer Object Sorting Test. As predicted, scores on these and other tests d i f f e r e n t i a t e d acute schizophrenics from neurotics (e.g., Payne & Hewlett, 1960). Payne et a l . (1959) reasoned that overinclusive individuals would l i k e l y select more objects i n t h e i r sortings i n response to the s t a r t i n g object. This resulted i n the creation of a quantitative index of overinclusion, l a t e r l a b e l l e d 'behavioral over-i n c l u s i o n ' by Harrow, Himmelhoch, Tucker, Hersh, and Quinlan (1972). Thus, the researcher who follows Payne's procedure asks the subject to select the f i r s t object from the set ('object of departure" or 'starting point') 21 and then to hand over a l l objects that might be grouped with i t ; the procedure i s repeated three more times, but the 'points of departure 1 that' follow, that i s , the red plate, the box of matches, and the bicycle b e l l are selected by the examiner. The (behavioral) overinclusion score i s the average number of objects chosen over the four sortings, excluding the four s t a r t i n g objects. Payne and Friedlander (1962) proposed a single com-posite overinclusion score obtained by combining measures of the proverb count, the sum of the objects sorted on the Object Sorting Test, and the sum of unusual solutions i n the Object C l a s s i f i c a t i o n Test. Using t h i s approach, Payne, Ancevich, and Laverty (1963) reported that af t e r schizophrenic patients began to recover from t h e i r psychoses, overinclusion scores declined. S i m i l a r l y , Payne, Friedlander, Laverty, .and Haden (1963) found that long-term chronic schizophrenics gave, i n comparison to acute schizophrenics tested previously, lower over-inclusion scores, and suggested that chronic patients may not be as overinclusive as those patients who do not progress to the chronic stage. The idea that over-in c l u s i v e schizophrenics may have a better prognosis was further pursued by Payne (1968) . His newly-admitted psychiatric patients, most of whom were l a t e r diagnosed as schizophrenic, were more overinclusive and showed 22 b e t t e r adjustment i n a 3-year f o l l o w up i n terms of a number of outcome c r i t e r i a , i n c l u d i n g l e n g t h of continuous stay i n h o s p i t a l , f u l l - t i m e employment with no r e l a p s e , and so on. The c o r r e l a t i o n between o v e r i n c l u s i o n composite index and outcome c r i t e r i a (x=-33) was s t a t i s t i c a l l y s i g n i f i c a n t . These f i n d i n g s i n d i c a t e d t h a t o v e r i n c l u s i v e -ness may be c o n s i d e r e d as a p o s s i b l e good p r o g n o s t i c s i g n f o r those p a t i e n t s who m anifest i t ( c o n t r a r y to one popular assumption t h a t s c h i z o p h r e n i c s with pronounced thought d i s o r d e r should have a poorer'prognosis) , or as a p o s s i b l e p r e d i c t o r of c h r o n i c i t y f o r those who do not show i t ( c f . Payne, Hawks, F r i e d l a n d e r , & Hart, 1972). An a l t e r -n a t i v e e x p l a n a t i o n t h a t . . . o v e r i n c l u s i o n i s somewhat e l i m i n a t e d by the apathy t h a t develops w i t h i n s t i t u t i o n a l -i z a t i o n , and thus i t s disappearance may be, i n e f f e c t , h o s p i t a l - i n d u c e d . . . (Maher, 1966, p. 416) a l s o seems p l a u s i b l e . Subsequent s t u d i e s , however, f a i l e d to c o n f i r m the Payne e t a l . f i n d i n g s . Bromet and Harrow (1973), f o r i n s t a n c e , found n o n s i g n i f i c a n t c o r r e l a t i o n s between the o v e r i n c l u s i o n measure (de r i v e d from Payne's m o d i f i c a t i o n of the Object S o r t i n g T e s t and d e f i n e d as the t o t a l number of o b j e c t s s o r t e d on the Object S o r t i n g T e s t , u s i n g seven d i f f e r e n t ' s t a r t i n g p o i n t ' o b jects) at the acute stage and the 8-month p o s t - h o s p i t a l i z a t i o n adjustment of mixed s c h i z o p h r e n i c and nonschizophrenic 23 patients. S t i l l another alternative, 'the sample com-position-change hypothesis,' states that differences between short-and long-term patients on overinclusion . . . could r e f l e c t the loss of overinclusive subjects from long-term groups rather than any cognitive change. (Strauss, 1973, p. 275) S i m i l a r l y , Harrow, Bromet, and Quinlan (1974) obtained rather equivocal results about the prognostic u t i l i t y of thought disorder as measured by several Rorschach and Object Sorting Test indices with emphasis on reasoning involved i n the sorting s e l e c t i o n . Harrow and his colleagues (Harrow, Himmelhoch, Tucker, Hersh, & Quinlan, 1972) distinguished three types of overinclusiveness: (a) behavioral overinclusion, based, as already mentioned, on quantitative aspects of the subject's behavior; (b) conceptual overinclusion, depending on both the number of objects sorted and the quality of the subjects' reasoning processes; and (c) stimulus overinclusion, r e f l e c t i n g d i f f i c u l t y i n attending s e l e c t i v e l y to stimuli considered relevant i n a given context and a tendency to be distracted by i r r e l e v a n t s t i m u l i . As stimulus overinclusion appeared to be primarily a disorder of attention rather than of concept formation 24 (Harrow, Tucker, & Shield, 1972) , the group focused on the d i s t i n c t i o n between behavioral and conceptual v a r i e t i e s of overinclusion. The authors also raised the question whether or not other features of schizophrenic thinking, such as the presence of r i c h associations ( o r i g i n a l , creative, or uncommon) or id i o s y n c r a t i c ideas (bizarre or a u t i s t i c ) contribute to scores on overinclusion t e s t s . As a r e s u l t , other measures, la b e l l e d 'richness of association' and 'idiosyncratic thinking,' were objectively defined and added to the l i s t of conceptual indices. Since McGaughran1s open-private dimension and Cameron's interpenetration tendency referred i n essence to similar phenomena, that i s , to intrusion of fantasy and thoughts of a personal nature i n ongoing schizophrenic verbal discourse, both of these c h a r a c t e r i s t i c s may be regarded as conceptual precursors of the id i o s y n c r a t i c thinking measure. Harrow et a l . (1972) found conceptual overinclusion and i d i o -syncratic thinking to d i f f e r e n t i a t e between recently hospitalized schizophrenic and nonschizophrenic patients; such thinking was also more frequent i n delusional patients regardless of diagnosis. On the behavioral overinclusion variable, schizophrenics were generally more overinclusive, but so were many acutely disturbed nonschizophrenics. The investigators concluded that the behavioral overinclusion index probably r e f l e c t s excessive 25 b e h a v i o r a l output r a t h e r than a p a r t i c u l a r q u a l i t y of t h i n k i n g ( c f . Gathercole, 1965). The l o n g i t u d i n a l aspect of s c h i z o p h r e n i c thought d i s -order has been examined i n s t u d i e s by Harrow, Tucker, Himmelhoch, and Putnam (19 7 2 ) , Harrow, Harkavy, Bromet, and Tucker (1973) , and by Harrow and Quinlan (1977) . In the f i r s t p a r t of the Harrow e t a l . (1972) i n v e s t i g a t i o n , the performance of acute s c h i z o p h r e n i c p a t i e n t s d u r i n g t h e i r f i r s t 10 days of h o s p i t a l i z a t i o n was compared to t h e i r performance 7 weeks l a t e r . Contrary to nonschizo-p h r e n i c s , whose conceptual o v e r i n c l u s i o n and i d i o s y n c r a t i c t h i n k i n g scores remained v i r t u a l l y unchanged over time, the s c h i z o p h r e n i c s d i s p l a y e d r e d u c t i o n i n thought pathology as they became l e s s p s y c h o t i c . The second p a r t of the study i n v o l v e d comparisons of acute, mostly female s c h i z o -p h r e n i c s and n o n s c h i z o p h r e n i c s , and c h r o n i c female s c h i z o -p h r e n i c s who were, on the average, h o s p i t a l i z e d f o r almost 10 y e a r s . The r e s u l t s i n d i c a t e d t h a t the c h r o n i c s c h i z o -phrenic p a t i e n t s scored s i g n i f i c a n t l y lower on r i c h n e s s of a s s o c i a t i o n and b e h a v i o r a l , o v e r i n c l u s i o n than e i t h e r the acute s c h i z o p h r e n i c or nonschizophrenic p a t i e n t s . The acute s c h i z o p h r e n i c s scored h i g h e r on i d i o s y n c r a t i c t h i n k i n g and conceptual o v e r i n c l u s i o n than other p a t i e n t s , but c h r o n i c s a l s o gave r e l a t i v e l y high scores on these i n d i c a t o r s of d i s t u r b e d t h i n k i n g . The authors' comment 26 about chronic patients' test functioning seems worthy of quote because i t has a d i r e c t bearing on the f i r s t of the two major hypotheses of the present investigation: . . . key factors that may help explain why the chronic schizophrenics scored r e l a t i v e l y high on measures of disturbed thinking (such as i d i o s y n c r a t i c thinking and conceptual overinclusion) but low on behavioral over-inclu s i o n are t h e i r absence of r i c h asso-ciations, t h e i r low motivational and energy l e v e l , and possibly other factors associated with chronic i n s t i t u t i o n a l i z a t i o n and de-s o c i a l i z a t i o n . (Harrow et a l . , 1972, p. 825) S i m i l a r l y , i n the Harrow et a l . (1973) study, schizo-phrenic and nonschizophrenic patients were tested at admission to the hospital and again 11 months l a t e r . The schizophrenic patients s i g n i f i c a n t l y reduced t h e i r con-ceptual overinclusion scores during the posthospital phase of the disorder, while t h e i r i d i o s y n c r a t i c thinking scores declined only marginally. The investigators suggested that conceptual overinclusion rather than bizarre thinking characterizes the acute stage of schizophrenia; idiosyn-c r a t i c thinking, on the other hand, may be seen as a permanent c h a r a c t e r i s t i c of thinking for a subgroup of schizophrenics. (Nonschizophrenic patients, i n contrast, although i n i t i a l l y less overinclusive and i d i o s y n c r a t i c than schizophrenics, scored higher on conceptual over-inclusion and s l i g h t l y higher even on i d i o s y n c r a t i c thinking at follow-up than they did i n the acute phase of hospitalization.) 27 Harrow and Quinlan (19 77) assessed thought disorder i n short-term schizophrenic and nonschizophrenic patients using the Comprehension subtest of the Wechsler Adult Intelligence Scale, the Benjamin Proverbs test, the Object Sorting Test, and the Rorschach test (to evaluate lev e l s of disordered thinking, mild vs. severe) at admission and after 7-8 weeks of h o s p i t a l i z a t i o n . B r i e f l y , the scores on a l l indices of thought pathology dropped (except for the nonschizophrenics 1 performance on conceptual over-inclusion) as the patients went into remission. These findings thus appear consistent with those reported e a r l i e r (Harrow et a l . , 1972; Harrow et a l . , 1973). Thus, there i s considerable support for the u t i l i t y of the Object Sorting Test i n investigations of the d e t a i l s of schizophrenic thought disorder and t h i s j u s t i f i e s i t s adoption i n the present investigation. Measures of behavioral overinclusion, conceptual over-inclusion, and id i o s y n c r a t i c thinking were derived from the Object Sorting Test. Two more p o t e n t i a l l y important indices of thought disorder, concrete thinking and under-in c l u s i v e thinking, for which quantifiable d e f i n i t i o n s are available (Himmelhoch, Harrow, Tucker, & Hersh, 1973) , were also included. Other thought disorder measures mentioned i n the review, such as stimulus overinclusion or richness of association were, however, excluded. The 28 stimulus overinclusion variable i s probably more suitable for measuring attentional d e f i c i t s rather than concept attainment disorder, and the richness of association variable appears unsuited for chronic schizophrenic patients i n view of the r e l a t i v e lack of r i c h associations that they manifest (e.g., Harrow, Tucker, Himmelhoch, & Putnam, 1972). Also the use of other instruments u t i l i z e d previously for assessment of disordered thinking, e.g., the Rorschach test and the Benjamin Proverbs test, were deemed unnecessary given the objectives, constraints, and possible psychometric superiority of the measures adopted i n the present study. While a detailed description of the Object Sorting Test's scoring system with examples and inter-judge r e l i a b i l i t i e s i s provided i n the manual developed by Himmelhoch et a l . (1973), a b r i e f review of the test c r i t e r i a for the f i v e thought disorder measures u t i l i z e d i n this study i s presented i n Appendix 1, and the complete l i s t of 38 objects of t h i s Object Sorting Test version i s i n Appendix 2. Associative Interference Performance decrement i n schizophrenic, r e l a t i v e to normal subjects, may depend almost e n t i r e l y on how the schizophrenics attend to s p e c i f i c s t i muli and how they i n h i b i t or exclude responses not c a l l e d for on a given task 29 (Lang & Buss, 1965). A general interference theory of schizophrenic d e f i c i t assumes that . . . when a schizophrenic i s faced with a task, he cannot attend properly or i n a sustained fashion, maintain a set, or change the set quickly when necessary. His ongoing response tendencies suffer interference from ir r e l e v a n t , external cues and from 'internal' s timuli which consist of deviant thoughts and associations. These i r r e l e v a n t , d i s -t r a c t i n g , mediated stimuli prevent him from maintaining a clear focus on the task at hand, and the r e s u l t i s psychological d e f i c i t . (Buss & Lang, 1965, p. 20) Esp e c i a l l y noteworthy i n terms of i t s empirical support i s the associative interference hypothesis of Chapman and associates (Chapman & Chapman, 1965; Chapman, Chapman, & M i l l e r , 1964). The hypothesis states that the schizo-phrenic thought disorder stems from an excessive y i e l d i n g to normal response biases ("response bias" being defined as a predisposition toward making a p a r t i c u l a r one of the various possible kinds., of responses that may be made to a given stimulus). Having recognized the tendency to-ward certa i n kinds of verbal errors i n normal people under exceptional conditions such as lack of sleep, fatigue, sensory deprivation, hallucinogenic drugs, and the l i k e , Chapman et a l . (1964, see below) contended that mani-festations of disordered thought i n normals closely resemble those found i n most schizophrenic patients. In other words, schizophrenic subjects make the same kind of 30 errors that normal subjects do, but schizophrenics make more of them more often. A t y p i c a l example of a response bias i s the response on a sorting or vocabulary task that contains strong associations to the stimulus at hand. For instance, the schizophrenic, when confronted with a multi-meaning word on a vocabulary test, follows a response bias that tends to favor the commonly preferred meaning of that word regardless of the context which may c l e a r l y require the use of a less preferred word meaning (Chapman et a l . , 1964; Chapman & Chapman, 1965) . Response biases are mediated, according to the authors, by denotative 2 meaning responses, and the r e l a t i v e strength of these meaning responses can be obtained from normal judges. The Chapman hypothesis i s supported by a series of experiments using words with multiple meanings. Such words have been shown to produce errors i n t h e i r interpretations by drug-free, chronic schizophrenics. In one experiment (Chapman et al.,1964), normal nonhospitalized subjects and long-term schizophrenics were presented with vocabulary items (homographs) i n which the context determined the correct meaning response. In some A meaning response refers to a "hypothetical i n t e r n a l event which mediates a person's overt behavioral response to a word" (Chapman et a l . , 1964,, p. 52) . 31 i n s t a n c e s the c o r r e c t response c a l l e d f o r by the context i n v o l v e d the s t r o n g e r (or p r e f e r r e d ) meaning of the word, while i n other i n s t a n c e s , the c o r r e c t response c a l l e d f o r the word's weaker (or l e s s p r e f e r r e d ) meaning. As pre-d i c t e d , the s c h i z o p h r e n i c s approximated the performance of normal s u b j e c t s when the c o r r e c t response depended on the s t r o n g e r meaning of the word, but made s i g n i f i c a n t l y more e r r o r s when the c o r r e c t response r e q u i r e d use of i t s weaker meaning. An example of an item where s c h i z o p h r e n i c s performed as w e l l as normals was: The p r o f e s s o r loaned h i s pen to Barbara. T h i s means (a) He loaned her a pick-up t r u c k (b) He loaned her a w r i t i n g implement (c) He loaned her a fenced e n c l o s u r e In t h i s context, the c o r r e c t response (b) i n v o l v e s the commonly p r e f e r r e d d e n o t a t i v e meaning of "pen." On the other hand, s c h i z o p h r e n i c p a t i e n t s made more e r r o r s than normals by responding to the st r o n g e r but c o n t e x t u a l l y i n c o r r e c t meaning when presented by the f o l l o w i n g item: When the farmer bought a herd of c a t t l e he needed a new pen. T h i s means (a) He needed a new w r i t i n g implement (b) He needed a new fenced e n c l o s u r e (c) He needed a new pick-up t r u c k Here, the c o r r e c t answer i s a l t e r n a t i v e (b) which i n v o l v e s the weaker d e n o t a t i v e meaning of "pen." A l t e r n a t i v e ( a), which i n v o l v e s the s t r o n g e r meaning of the word i s i n c o r r e c t 32 i n t h i s context and may be seen as an associative d i s -t r a c t o r . F i n a l l y , alternative (c) i s both incorrect and i r r e l e v a n t and i s included for control purposes. The schizophrenic errors of misinterpretation were presumably mediated by a response bias toward the stronger meaning of words even though strong meaning responses were wrong. The schizophrenic patients, as opposed to normals, were either i n s e n s i t i v e to contextual cues indicating appropriateness of the weaker meaning response or they were unable to i n h i b i t the stronger meaning response regardless of whether or not i t was recognized, as appropriate. Another Chapman et a l . (1964) experiment dealt with errors of exclusion from common concepts. Schizophrenics, by re l y i n g on the stronger common meaning responses to a conceptual class name (and at the same time ignoring the weaker meaning responses), were expected to make more errors than normals when required to sort out cards into conceptual categories having more than one meaning. In the experimental task, the subjects were given cards con-taining names of animate, inanimate, and i r r e l e v a n t objects and were asked to sort the cards into four categories marked as "Things that have (a) head, (b) legs, (c) teeth, and (d) skin." The animate items included words l i k e "rat," "dog," "cow," " l i o n , " "horse," and "man," whereas the inanimate items consisted of words such as "pin," " n a i l , " 33 and "match" for the concept 'Things that have a head;' "chair," "bed," and "table" for the concept 'Things that have legs;' "saw," "rake," and "comb" for the concept 'Things that have teeth;' and f i n a l l y "prune'/ "potato," and "banana" for the concept 'Things that have skin.' E a r l i e r , a group of student judges had interpreted the four concepts primarily i n terms of animate meaning; accordingly, i t was predicted that schizophrenics, more than normals, would select items with animate class names at the expense of inanimate names. The findings supported the hypothesis: there were s i g n i f i c a n t l y more exclusions of inanimate examples from the conceptual classes i n the schizophrenic sample, while exclusions of animate items were about equal for both normal and schizophrenic subjects. A t h i r d study i n the Chapman et a l . (19 64) series showed that strong contextual cues can help schizophrenics make responses that are mediated by the weaker meanings of words, and consequently, to reduce t h e i r error rate to the l e v e l of normal subjects. Schizophrenics were matched with normals on vocabulary (Stanford-Binet), and were given a multiple-choice vocabulary test for words of double meaning. The subjects were asked to choose the correct meaning (strong or weak) under conditions where the other meaning did not appear i n the same context. In the two examples that 34 follow, there i s only one correct response available which i s either the weak or the strong meaning: The word BEAR may mean The word BEAR may mean (a) to carry (a) a sharp end (b) to command (b) an animal (c) neither of the (c) neither of the above above (d) I don't know (d) I don't know There were minimal differences between error rates of schizophrenics and normals (both groups appeared less accurate on the weaker meaning responses), the implication being that schizophrenic patients can respond to weaker meanings i n situations where the stronger meaning i s absent, and thus cannot intrude. Chapman and Chapman (19 65) presented further supportive evidence for the notion that schizophrenics r e l y on the stronger (more preferred) normal meaning responses i n the i r interpretation and use of words. The investigators obtained a measure of the degree of s i m i l a r i t y between pairs of words from college students, and administered these word pairs, varying from high to low s i m i l a r i t y to schizo-phrenic and normal i n d i v i d u a l s . Schizophrenics considered word pairs that shared preferred meaning to be synonymous to a greater extent than they did word pairs that shared nonpreferred meaning: for example, the words "pig" and "dog," which share preferred meaning ("animal"), were more l i k e l y to be accepted as synonymous than the words "news-35 paper" and "magazine" which have no n p r e f e r r e d meaning i n common ( t h e i r r e s p e c t i v e p r e f e r r e d meanings are "inform-a t i v e " and "reading m a t e r i a l " ) . Normal s u b j e c t s d i d not e x h i b i t t h i s tendency. A c c e n t u a t i o n of normal response b i a s e s i n s c h i z o -p h r e n i c p a t i e n t s had been noted even i n e a r l i e r s t u d i e s . Thus, Chapman and T a y l o r (1957) and Chapman (1961) r e p o r t e d on s c h i z o p h r e n i c s ' tendency to regard words (names of common concepts) of s i m i l a r meaning as synonymous. The s c h i z o p h r e n i c s , f o r example, broadened t h e i r c o n c e p t u a l -i z a t i o n of the " f r u i t " category by i n c l u d i n g i n c o r r e c t , though s i m i l a r , names of v e g e t a b l e s . S i m i l a r l y , Moran (1953) found t h a t paranoid s c h i z o p h r e n i c p a t i e n t s gave a l a r g e r number of imprecise synonyms to a word than d i d n o n p s y c h i a t r i c p a t i e n t s . B u r s t e i n (1961) and Blumberg and G i l l e r (1965) found s c h i z o p h r e n i c p a t i e n t s c o n f u s i n g antonyms and homonyms (both regarded as a s s o c i a t e s ) w i t h synonyms. I t i s worthy of note t h a t i n h i s reviews on c o g n i t i v e a b n o r m a l i t i e s , Payne (1970, 1973) while d i s c u s s i n g the Chapman and Chapman (19 65) f i n d i n g s , p o i n t e d out t h a t s c h i z o p h r e n i c s 1 r e l i a n c e on . . . the s t r o n g e s t meaning i n a h i e r a r c h y of p o s s i b l e meanings may w e l l be the essence of v e r b a l concreteness . . . (Payne, 1960, p. 64; c f . W i l l n e r , 1965) 36 Likewise, Chapman et a l . (1964) suggested that the abstract-concrete dimension lends i t s e l f to interpretation i n terms of t h e i r theory. The schizophrenics' sortings, the authors asserted, should be mediated by the strongest normal meaning responses to the objects regardless of whether or not the responses may be considered abstract or concrete. At least two studies have focused on c l a r i f y i n g con-tr a s t i n g predictions derived from the Chapmans1 response bias theory and the 'response-interference' theory of Broen and Storms (1967) . Boland and Chapman (1971) showed that nonmedicated chronic schizoprehnics, but not normal subjects, displayed a heightened intrusion of associates on a multiple-choice vocabulary test i n which the available incorrect alternative included a strong associate to the stimulus word. In a study designed to compare the per-formance of male schizophrenic inpatients and alcoholic outpatients, Roberts and Schuham (1974) modified the Chapmans' (1958) card sorting test (by adding a medium-associative d i s t r a c t o r to the low and high d i s t r a c t i o n conditions), and found that the schizophrenics made more errors than the alcoholics on a l l levels of d i s t r a c t i o n . In addition, the schizophrenics' associative error scores closely approximated a straight l i n e function which was seen as supporting the hypothetical h i e r a r c h i c a l responding central to the response bias notion. 37 More recently, Mourer (1973) tested predictions derived from Chapman's theory regarding the conditions under which schizophrenic patients show excessive errors i n semantic generalization. Drug-free chronic male schizo-phrenics and psychiatric aides were presented with a l i s t of words on a memory drum and asked to press a button marked 'yes' or 'no' depending on whether the words appeared i n a previously presented l i s t . Generalized errors were defined as incorrect inclusions of words not i n i t i a l l y shown. The word pairs were equated i n terms of strength of shared meaning responses as either weak or strong, and also equated on rated s i m i l a r i t y into moderate and low status. As predicted, the schizophrenics, unlike the normal subjects, erred more on test words sharing strong meaning responses with t r a i n i n g l i s t words than on words sharing weak meaning responses. M i l l e r (1974) provided further, although q u a l i f i e d , experimental support for what he c a l l e d 'primacy response bias,' i . e . , an i n c l i n a t i o n to select the primary (strongest or preferred) meanings of multiple-meaning words. The study used a 24-noun homograph test (cf. Benjamin & Watt, 1969) that could be scored for errors i n terms of primary-secondary and concrete-abstract meanings, and controlled for two levels of ambiguity. Since the t o t a l errors of acute and chronic schizophrenic male inpatients 38 were comparable over a l l four main error categories, these two groups were combined and compared with hospital employees matched for vocabulary, educational l e v e l , and parental s o c i a l c l a s s . M i l l e r found that the schizophrenics and normals responded s i m i l a r l y to highly ambiguous items; on items of low ambiguity, the schizophrenics had higher o v e r a l l error scores. Furthermore, the schizophrenics tended to choose an abstract interpretation on items where a concrete interpretation would be more appropriate: they made, i n contrast to normals, s i g n i f i c a n t l y more abstract than concrete errors which may represent, accord-ing to M i l l e r , a u t i s t i c or i d i o s y n c r a t i c thinking. Other relevant data on language related behavior within the normal response bias frame of reference were obtained by Blaney (19 74) . In addition to Chapman's semantic (lexical) ambiguity strongest meaning test (Chapman et a l . , 1964), Blaney administered his own newly devised test i n which semantically ambiguous statements were replaced by statements of d i f f e r e n t s y n t a c t i c a l structures to groups of male schizophrenic, nonschizophrenic psy-c h i a t r i c , and hospital s t a f f subjects. Overall, no s i g -nificant differences among any groups were found on either instrument. Dividing the schizophrenic group on the basis of length of h o s p i t a l i z a t i o n , Blaney observed that patients hospitalized more than 5 years showed s i g n i f i c a n t l y greater 39 stronger meaning bias on l e x i c a l ambiguity tasks than did patients h o s p i t a l i z e d 2 years or l e s s . These short-term schizophrenics, on the other hand, made more errors than long-term schizophrenics on the s t r u c t u r a l ambiguity t e s t . Higher error scores on Chapman's l e x i c a l ambiguity test were also found i n disorganized schizophrenic patients, while the r e l a t i v e l y nonpsychotic schizophrenics had s i g n i f i c a n t l y higher error rates on Blaney's s t r u c t u r a l ambiguity t e s t . The above findings suggest, as the author put i t , that the semantic/lexical stronger meaning bias . . . i s largely a function of schizophrenics' chronicity/disorganization rather than of schizophrenia or schizotypy regardless of state. (Blaney, 1974, p. 29) Rattan and Chapman's (19 73) demonstration that chronic schizophrenics were susceptible to the effects of associative d i s t r a c t o r s i n t h e i r vocabulary (word definition) performance was achieved by means of two experimental tasks matched i n terms of discriminating power. As . the development of tasks matched on discriminating power introduced i n the Rattan and Chapman study sig n a l l e d an important methodological advance i n the measurement of d i f f e r e n t i a l cognitive d e f i c i t s , i t s rationale as well as findings of some studies that have u t i l i z e d the above p r i n c i p l e are presented i n greater d e t a i l i n the next section. Only one investigation that gave an impetus for the present inquiry i s described at t h i s point. 40 Using Rattan and Chapman's matched m u l t i p l e - c h o i c e vocabulary s u b t e s t s , K l i n k a and Papageorgis (19 76) addressed themselves to the q u e s t i o n of whether s u s c e p t i b i l i t y to d i s t r a c t o r s i s p e c u l i a r t o s c h i z o p h r e n i c d i s o r d e r or can be a l s o found i n other d i s o r d e r s . They s e l e c t e d samples of s h o r t - and long-term s c h i z o p h r e n i c , nonschizophrenic, and n o n p s y c h i a t r i c p a t i e n t s and de t e c t e d heightened suscep-t i b i l i t y to a s s o c i a t i v e i n t r u s i o n s i n a l l groups of l o n g -term p a t i e n t s r e g a r d l e s s o f d i a g n o s i s . Short-term p a t i e n t s , with the p o s s i b l e e x c e p t i o n of s c h i z o p h r e n i c s , d i d not show such a tendency. A prolonged h o s p i t a l . s t a y and/or c h r o n i c i t y of i l l n e s s thus appeared to be i m p l i c a t e d i n a t l e a s t t h i s form of d i s o r d e r e d t h i n k i n g which a p p a r e n t l y i s not unique to s c h i z o p h r e n i a . (Other s t u d i e s , e.g., Hamsher and A r n o l d (1976) and Harrow and Quinlan (1977) have a l s o r e p o r t e d f i n d i n g s t h a t ' s c h i z o p h r e n i c ' d e f i c i t s are not unique to s c h i z o p h r e n i c psychoses, and M i l l e r ' s (1975) review has s i m i l a r l y i n d i c a t e d c o g n i t i v e d e f i c i t s i n a f f e c t i v e d i s o r d e r s . ) Thus i t appears t h a t the weight of e m p i r i c a l evidence g e n e r a l l y f a v o r s the Chapman's theory although not unequi-v o c a l l y so. Deckner and Blanton (1969), f o r i n s t a n c e , t e s t e d the hypothesis t h a t s c h i z o p h r e n i c s are unable to use weak c o n t e x t u a l cues t o the same degree as normal s u b j e c t s . The i n v e s t i g a t o r s used a c l o z e procedure i n 41 which every f i f t h , eighth, or tenth word was deleted from three passages of f i r s t and t h i r d grade d i f f i c u l t y . Male schizophrenic (good and poor premorbid) and male general medical patients were asked to determine an appropriate word to replace the one omitted. They hypothesized that schizophrenics should be unaffected by changes i n context, whereas the medical patients should be better able to guess the appropriate word with more words between deletions. Despite the finding that schizophrenic patients performed poorly at every l e v e l of context, there was no i n t e r a c t i o n between groups and context. Thus, the experiment did not provide support for the notion that schizophrenics are less influenced by context than non-schizophrenics . S i m i l a r l y , Neuringer and associates (Neuringer, Fiske, & Goldstein, 1969; Neuringer, Fiske, Schmidt, & Goldstein, 1972) f a i l e d to r e p l i c a t e the Chapman et a l . (1964) findings of strong meaning vocabulary biases i n schizophrenics. In two separate investigations using chronic male medicated schizophrenics and nonpsychotic psychiatric patient controls, the schizophrenics' biases toward strong-meaning d e f i n i t i o n s were not s i g n i f i c a n t . In addition, Neuringer et a l . (1972) also developed a S i m i l a r i t i e s Test which allowed choices between the strong mea.ning associate alone and the strong and weak meaning associates together. 42 For example: BAT may be l i k e A. MITT B. MITT and MOCKINGBIRD C. None of the above S c h i z o p h r e n i c s d i d not d i s p l a y a tendency to choose the s t r o n g meaning a s s o c i a t e presented by i t s e l f ( i . e . , a l t e r n a t i v e "A" i n the example). Other i n v e s t i g a t o r s have suggested t h a t the observed e f f e c t s based on the Chapman theory are probably a p p l i c a b l e only to c e r t a i n s c h i z o p h r e n i c subtypes or may not be n e c e s s a r i l y unique to s c h i z o p h r e n i c psychoses (e.g., Broen, 1968; Hamsher & Ar n o l d , 1976; K l i n k a & Papageorgis, 1976; Rice, 1970) . S t i l l o thers have added s i g n i f i c a n t q u a l i f i -c a t i o n s to the theory (e.g., Blaney, 1974; Davis & Blaney, 1976; M i l l e r , 1974), or have ob j e c t e d t o the m u l t i p l e -choice format of the tasks and t h e i r r e l a t i v e l a c k of safeguards a g a i n s t responses based on guessing and p a r t i a l knowledge (Schwartz, 1978), or have argued from the p s y c h o l i n g u i s t i c p o s i t i o n and have p o i n t e d out the theory's l i m i t a t i o n s i n terms of g e n e r a l i z a b i l i t y (e.g., M i l l e r , 1965; Pavy, 1968). 43 • Psychometric Considerations As touched upon i n ' c h a p t e r 1, Chapman and Chapman's (19 73a, b; 1978) p e n e t r a t i n g c r i t i q u e of methodology i n measurement of c o g n i t i v e d e f i c i t s and t h e i r suggestions about how to a v o i d a r t i f a c t u a l f i n d i n g s i n s t u d i e s of hypothesized s p e c i f i c d i f f e r e n t i a l d e f i c i t s , have made a c o n s i d e r a b l e impact on every s e r i o u s i n v e s t i g a t o r of d i s o r d e r e d thought i n s c h i z o p h r e n i a . In essence, t h e i r argument r e s t s on the f a c t t h a t demonstration of poorer performance by s c h i z o p h r e n i c s , r e l a t i v e to normal s u b j e c t s , on any p a r t i c u l a r task i s of l i t t l e v a lue because s c h i z o -p h r e n i c s u b j e c t s are known to be d e f i c i e n t on v i r t u a l l y a l l tasks r e q u i r i n g a v o l u n t a r y response. In o t h e r words, the s c h i z o p h r e n i c s s u f f e r from a g e n e r a l i z e d o v e r a l l d e f i c i t i n c o g n i t i v e f u n c t i o n i n g or performance. Meaning-f u l measurement of a s p e c i f i c h y pothesized c o g n i t i v e d e f i c i t t h e r e f o r e r e q u i r e s the use of a t l e a s t two measures, one of which deals w i t h the s p e c i f i c d e f i c i t i n q u e s t i o n . The hypothesized d e f i c i t would be confirmed only i f the d i s c r e p a n c y of the s c h i z o p h r e n i c s ' performance on the two tasks exceeds the d i s c r e p a n c y shown by c o n t r o l s u b j e c t s . The extent to which scores of s c h i z o p h r e n i c s u b j e c t s d i f f e r from those of c o n t r o l s u b j e c t s on a p a r t i c u l a r experimental t a s k , the argument proceeds, depends on 44 the discriminating power of the instrument ( i . e . , power to d i f f e r e n t i a t e the more able from the less able subjects, or power to distinguish two groups that d i f f e r i n the a b i l i t y measured by the t e s t ) . Since the discriminating power of a test i s b a s i c a l l y a function of item d i f f i c u l t y and r e l i a b i l i t y , experimental and control tasks have to be equated, using normal individuals of varying a b i l i t i e s 3 as a standardization group, on c o e f f i c i e n t alpha, mean item d i f f i c u l t y , variance and shape of d i s t r i b u t i o n of item d i f f i c u l t y , and shape of the d i s t r i b u t i o n of task scores. Only with such a match, that i s , with tests of i d e n t i c a l discriminating power, can s p e c i f i c d i f f e r e n t i a l d e f i c i t be genuinely separated from generalized d e f i c i t of the schizophrenic subjects, and/or a r t i f a c t u a l d e f i c i t s , mis-takenly inferred, avoided. Moreover, the use of equivalent tasks makes unnecessary a matching of groups on c e r t a i n variables, such as education and premorbid or current i n t e l l i g e n c e because the matching of tasks rules out generalized cognitive d e f i c i t as a source of s p e c i f i c d i f f e r e n t i a l performance d e f i c i t . Most recently, Chapman and Chapman (19 78) pointed out that matching on 'true-score' variance obviates the need The c o e f f i c i e n t alpha i s the average value of a l l possible s p l i t - h a l f r e l i a b i l i t y c o e f f i c i e n t s , representing an i n t e r n a l consistency index of r e l i a b i l i t y . 4 5 for separate matching on r e l i a b i l i t y and item d i f f i c u l t y . The 'true-score' refers to the portion of the score which i s r e p l i c a b l e ( r e l i a b l e ) , not to the a b i l i t y which the subject t r u l y possesses. Matching on a l l the test variables, the authors state, can be achieved for most pairs of tests by giving large, and preferably equal, numbers of items of the two types to normal subjects of d i f f e r i n g a b i l i t y l evels and selecting pairs of items of the same d i f f i c u l t y and item-scale c o r r e l a t i o n . Rattan and Chapman's (1973) test for associative intrusions exemplifies, the above psychometric requirements (for a b r i e f test description with item examples, see Chapter 3, 'Method'). In t h e i r study, the investigators administered two cl o s e l y matched multiple-choice vocabulary subtests, standardized on normal groups of firemen and prison inmates, to chronic schizophrenic patients withdrawn from drug therapy. One of the subtests contained d i s -tractor items associated with the word to be defined among the alternatives, whereas the other subtest had no such d i s t r a c t o r s . I t was found that schizophrenics not only made more errors than normals on both subtests, but more importantly, they erred more on the with-associates subtest than on the subtest without associates. As general d e f i c i t was controlled by matching the subtests on d i s -criminating power, the schizophrenics' less accurate per-46 formance on the subtest with d i s t r a c t o r s could be attributed to a s p e c i f i c d i f f e r e n t i a l d e f i c i t , namely, to a greater s u s c e p t i b i l i t y to associative intrusions. In studies that followed, other presumed schizophrenic d e f i c i t s were either confirmed or refuted by means of tasks equated on discriminating power. Thus schizophrenic response to a f f e c t i v e , as opposed to neutral s t i m u l i , was shown to have been spurious as both newly-admitted and long-term schizophrenic patients' performance on matched vocabulary tests yielded comparable scores (Chapman, Chapman, & Daut, 1974). S i m i l a r l y , no differences were found when affect-laden analogies were compared to a f f e c t i v e l y neutral ones (Chapman & Chapman, 1975a). Other studies using the same methodology include Chapman and Chapman (19 75b), Chapman, Chapman, and Daut (19 76), Raulin and Chapman (19 76), Oltmans and Neale (1976), and Davis and Blaney (1976). Undoubtedly, the introduction of psychometrically sophisticated instruments to the study of schizophrenic performance d e f i c i t s represents a s i g n i f i c a n t methodological advance i n t h i s area of research which i s being responded to by an increasing number of investigators. Both new and revised studies could, i n turn, lead toward a clearer understanding and reassessment of psychological d e f i c i t s i n schizophrenia over the entire range of the phenomena of thought disorder. 47 Psychopharmacologioal Issues Evaluation of cognitive performance i n schizophrenic subjects who are receiving psychoactive medication may pose serious methodological drawbacks (Chapman & Chapman, 1973b; Chapman, 1977; Lang & Buss, 1965; Spohn, 1973) . E s s e n t i a l l y , differences on test scores between drug-free subjects and those receiving some form of chemotherapy may be attributable to the drug e f f e c t s . Drug-free schizophrenics, on the other hand, are unrepresentative of the schizophrenic population usually seen i n i n s t i t u t i o n s . A large portion of schizophrenic patients, when withdrawn from psychoactive drugs, worsen i n t h e i r psychotic symptomatology (Chapman, 196 3), and may no longer be capable of performing adequately on cognitive tasks. Denial of medication to such patients would, moreover, be unethical. Further, patients who can be removed from psychoactive drugs without noticeable change i n t h e i r mental status are probably r e l a t i v e l y undisturbed to begin with. Consequently, caution i n interpreting findings based on studies involving medicated patients i s c a l l e d for, as the results are, s t r i c t l y speaking, generalizable only to those schizophrenic patients who are under sim i l a r antipsychotic medication. 48 The previous statement remains v a l i d even though some e a r l i e r work, already described (e.g., Klinka & Papageorgis, 1976), suggests that psychoactive drugs do not necessarily a f f e c t some of the measures used; comparable vocabulary interference performance scores have been obtained from chronic drug-free (Rattan & Chapman, 1973) and chronic medicated (Klinka & Papageorgis, 1976) schizophrenic inpatients. I t may also be noted that investigations on the effects of antipsychotic drugs on disordered thought of schizophrenics (or other psychotic patients) have been so far inconclusive. Chapman and Knowles (1964), for instance, tested chronic schizophrenics on a conceptual breadth card-sorting test and found that phenothiazine treatment s i g n i f i c a n t l y reduced errors of overinclusion but increased propensity for random errors. Spohn, Lacoursiere, Thompson, and Coyne (1977), however, f a i l e d to r e p l i c a t e the results on a s i m i l a r sample of chronic schizophrenics using an alternative measure of conceptual breadth, although they demonstrated posi t i v e phenothiazine effects on psychophysiological responses and attention-perception measures. Further, Goldstein, Judd, Scored for three types of errors: overinclusion errors, r e f l e c t i n g a tendency to sort class items by overly broad concepts; exclusion errors, representing excessively narrow sorting concepts; and random errors, i n d i c a t i n g i n d i f f e r e n c e to tasks and o v e r a l l decline i n i n t e l l e c t u a l e f f i c i e n c y . 49 Rodnick, and LaPolla (1969) have found poor premorbid schizophrenics to improve (but c f . Payne, 19 7 2) and good premorbid schizophrenics not to improve or to get worse on selected psychophysiological and behavioral measures i n response to phenothiazine drugs. Studies by Goldberg and associates (Goldberg, Klerman, & Cole, 1965; Goldberg, Schooler, & Mattson, 1967) and by the Goldstein team (Goldstein, Judd, Rodnick, & LaPolla, 1969; Judd, Gold-st e i n , Rodnick, & Jackson, 1973) have documented, i n addition, the value of separating paranoid from nonparanoid schizophrenics i n evaluating psychoactive medication e f f e c t s . The above investigators reported a d i f f e r e n t rate of change on a variety of behavioral, perceptual, and cognitive measures following phenothiazine drug admin-., istration for patients divided according to paranoid/non-paranoid status. Such d i f f e r e n t i a l responding to drug treatment allows for speculation that process and reactive as well as paranoid and nonparanoid schizophrenics may suffer from d i s t i n c t types of schizophrenia. Thus, i t appears that neuroleptic therapy i s not b e n e f i c i a l to a l l schizophrenic patients. Those schizo-phrenics who p r o f i t from phenothiazine treatment may d i f f e r not only i n terms of making fewer errors, but also i n making q u a l i t a t i v e l y d i f f e r e n t errors on a given cognitive task . In situations where drug withdrawal cannot be 50 achieved (notwithstanding the p o s s i b i l i t y of forming a biased subpopulation of schizophrenics), or where the investigator i s not i n charge of assigning patients to medicated/nonmedicated status (with medicated status l i k e l y involving assignment of d i f f e r e n t dosages) on a random basis, i t i s necessary to record the patients' present pharmacological regimen i n f u l l (Spohn, 1973) . 51 Chapter S Method As stated i n Chapter 1, the present investigation was designed to compare the performance of chronic schizo-phrenic and nonpsychiatric inpatients and outpatients on certain measures of concept formation and vocabulary performance. I t was predicted that chronic patients with prolonged i n s t i t u t i o n a l i z a t i o n would manifest a greater propensity to disordered thought than would com-parably chronic patients with r e l a t i v e l y b r i e f inpatient experience. Further, i t was predicted that nonparanoid schizophrenics would exhibit greater performance d e f i c i t s than paranoid schizophrenics. The present chapter deals with a detailed description of the subjects and the way that they were selected, the measuring instruments, and the procedures. Subjects The subject sample of the present study consisted of a t o t a l of 9 0 male and female psychiatric or medical inpatients or outpatients residing i n the greater Vancouver or greater V i c t o r i a areas of B r i t i s h Columbia, Canada. With four exceptions (the exceptions consisted of two 52 native-Indian females, and one black and one A s i a t i c male), a l l these subjects were Caucasians of European ancestry. S p e c i f i c a l l y , hospitalized psychiatric patients were obtained from Riverview Hospital, Port Coquitlam, B r i t i s h Columbia, which i s the largest psychiatric hospital i n the Vancouver region. Psychiatric outpatients were c l i e n t s of the Strathcona Community Care Team, which i s part of the Greater Vancouver Mental Health Services. Nonpsychiatric inpatients were from Gorge Road Hospital i n V i c t o r i a and from Pearson Hospital i n Vancouver. F i n a l l y , nonhospitalized nonpsychiatric subjects were a l l residents of V i c t o r i a . The age range of the subjects was 20-60 years (two female subjects i n the nonpsychiatric nonhospitalized group, however, were 63 and 66 years o l d ) . There were no r e s t r i c -tions concerning the subjects' marital and socio-economic status. On the other hand, to be e l i g i b l e for p a r t i c i p a t i o n i n the study, subjects had to be native speakers of English and to have had at least six years of formal school attendance. A l l individuals with a known history of alcohol or other drug abuse or with a suspected organic brain syndrome or. mental retardation were excluded from the study. A l l subject subgroups were also subdivided according to the i r present h o s p i t a l i z a t i o n status into h o s p i t a l i z e d groups (with at least 2 years of continuous stay i n an i n s t i t u t i o n since t h e i r l a s t admission) and nonhospitalized groups (with previous single or multiple 53 hospital stays that did not exceed a t o t a l of 6 months). P s y c h i a t r i c (Schizophrenic) Subj ects A l l psychiatric subjects i n the sample had o f f i c i a l diagnoses of schizophrenia, both i n i t i a l l y and on a l l subsequent assessment occasions. In terms of t r a d i t i o n a l subtypes of schizophrenia, "paranoid," and "chronic undifferentiated" were the most common i n both the inpatient and outpatient groups. In order to ensure a certain l e v e l of r e p l i c a b i l i t y and homogeneity i n the study sample, a l l schizophrenic subjects were further screened by means of the Research Diagnostic C r i t e r i a of Spitzer, Endicott, and Robins (1975, 1978; see the Behavioral Checklist, Appendix 3). Only those subjects who met the Research Diagnostic C r i t e r i a requirements for d e f i n i t e or probable schizophrenia were retained i n the study. S p e c i f i c a l l y , 49 (82%) schizophrenic subjects met the Research Diagnostic C r i t e r i a requirements for " d e f i n i t e " schizophrenia at the time of t h e i r p a r t i c i p a t i o n i n the study; the remaining 11 schizophrenic subjects (of whom 6 were hospitalized and 5 nonhospitalized) met the same c r i t e r i a for "probable" schizophrenia at the time of t h e i r p a r t i c i p a t i o n i n the study, but were s t i l l c l a s s i f i e d as simple or residual schizophrenics and had manifested c l e a r l y schizotypal"'" c h a r a c t e r i s t i c s for at least 5 years. In e f f e c t , a l l 54 s c h i z o p h r e n i c s u b j e c t s belonged to the ehronio category: " c h r o n i c " s c h i z o p h r e n i a , a c c o r d i n g to the Research Diag-n o s t i c C r i t e r i a subtyping based on the course of the i l l n e s s , r e f e r s to the more or l e s s continuous presence of the core symptoms over more than two years, whereas the acute stage i s d e f i n e d by c l e a r - c u t episodes of s c h i z o -p h r e n i a with symptom r e m i s s i o n in-between a t t a c k s . A d d i t i o n a l l y , the s c h i z o p h r e n i c s u b j e c t s were f u r t h e r s u b c l a s s i f i e d i n t o paranoid and nonparanoid subgroups. The paranoid subgroup was composed of those i n d i v i d u a l s who (a) had an o f f i c i a l h o s p i t a l d i a g n o s i s o f pa r a n o i d subtype, and who (b) met the Research D i a g n o s t i c C r i t e r i a requirements f o r paranoid subtype, and who (c) were assigned a t o t a l o f a t l e a s t 6 p o i n t s (out of a p o s s i b l e 20) from the f o u r 5-point s c a l e items d e a l i n g with d e l u s i o n s of the Venables and O'Connor (1959) s h o r t s c a l e f o r r a t i n g paranoid s c h i z o p h r e n i a (see the B e l i e f Rating Sheet, Appendix 4 ) . The nonparanoid subgroup i n c l u d e d s u b j e c t s who d i d not meet a l l three of the above c r i t e r i a . Thus, the assignment of s u b j e c t s i n t o the paranoid and nonparanoid subgroups r e s u l t e d i n a s t r i n g e n t l y d e f i n e d paranoid sub-"Schizotypy" r e f e r s to e c c e n t r i c behavior, marked s o c i a l withdrawal, b l u n t e d o r i n a p p r o p r i a t e a f f e c t , m i l d i n d i c e s o f formal thought d i s o r d e r , and unusual thoughts or p e r c e p t u a l e x p e r i e n c e s . 55 group and i n a less stringently defined nonparanoid sub-group. In other words, the nonparanoid subjects included some who either q u a l i f i e d for paranoid diagnosis only i n terms of the Research Diagnostic C r i t e r i a or who could be considered "paranoid" by virtue of scoring over 6 points on the Venables and O'Connor scale. Comparison summaries between c l e a r l y nonparanoid subjects (n=23) and 'nonparanoid' subjects with evidence of some paranoid features (n=7) are presented i n Appendix 5. I t s u f f i c e s here to report that the performance of the less stringently defined non-paranoids on the dependent measures was not s i g n i f i c a n t l y d i f f e r e n t from the performance of the more stringently defined nonparanoids. Likewise nonsignificant differences (Appendix 6) were found i n performance comparisons within the paranoid subgroup, i . e . , between subjects with lower and higher degree of paranoid symptomatology i n terms of th e i r scores on the Venables and O'Connor scale. Eighteen paranoid schizophrenic subjects who scored between 6 and 8 points on the Venables and O'Connor scale constituted the less stringently defined paranoids, whereas the remaining 12 subjects with scores i n excess of 8 scale points were viewed as "exemplary" paranoids. In any event, i t should be noted that the analyses of paranoid-nonparanoid differences reported i n the next chapter are based on a conservative d e f i n i t i o n of the variable. 56 The schizophrenic subjects' premorbid socio-sexual adjustment was determined with reference to the Harris (1975) scale of premorbid adjustment, which i s an abbre-viated version of the widely used P h i l l i p s (1953) scale of premorbid adjustment (see parts B-E of the Background Information Sheet, Appendix 7). R e l i a b i l i t y of these assessments was evaluated by having 16 randomly selected patients (equally representative of the various h o s p i t a l -i z a t i o n and diagnosis subgroups) rated independently by the investigator and a second rater. Pearson product-moment cor r e l a t i o n c o e f f i c i e n t s between the ratings of the two raters on premorbid sexual adjustment, premorbid social-personal adjustment, and th e i r composite, o v e r a l l premorbid adjustment, were a l l i n excess of .90. The raters' agreement within one scale point was found to be i n the 62.5—87.5% range. Assignment of a subject to the "good" premorbid category required scores of 0, 1, or 2 on both subscales (maximum 4 for the t o t a l scale), while assignment to the "poor" premorbid category required scores of 4, 5, or 6 on either subscale (minimum 6 for the t o t a l s c a l e ) . Subjects with a score of 3 on either subscale or with a t o t a l scale score of 5 were considered as "borderline" cases. With these procedures, the t o t a l sample of schizophrenic subjects was found to consist of 41 (68%) "poor" premorbids, 13 (22%) "borderline" cases, and 57 6 (10%) "good" premorbids. Interestingly, 4 of the non-hospitalized paranoid subjects were good premorbids, while no good premorbid subjects were i d e n t i f i e d among the hospitalized nonparanoid subjects. The schizophrenic subjects were also rated for t h e i r current o v e r a l l severity of disturbance l e v e l by means of the 100-point Global Assessment Scale (Endicott, Spitzer, F l e i s s , & Cohen, 1976; see Appendix 8). The rating of each subject was the average of two ratings assigned by two independent raters. One of these raters was the subject's primary therapist ( i . e . , a p s y c h i a t r i s t , nurse, or s o c i a l worker); the other rater was also a member of the therapeutic team. Thus, each given pair of ratings on the Global Assessment Scale usually involved a d i f f e r -ent pair of raters. Consequently, a one-way analysis of variance was used to determine the i n t r a c l a s s c o r r e l a t i o n c o e f f i c i e n t (Shrout & F l e i s s , 1979) . The c o e f f i c i e n t was .68. The four schizophrenic subgroups (hospitalized and nonhospitalized, paranoid and nonparanoid) did not d i f f e r i n terms of the o v e r a l l severity of current d i s -turbance (F(3,56)=2.13,n.s.). The schizophrenics' o v e r a l l mean was 52.46, and the four subgroup means were dispersed only over two of the ten descriptive inte r v a l s of the Global Assessment Scale. (Even so, following planned orthogonal comparisons among means, i t was found that the 58 mean Global Assessment Scale ratings of the nonhospitalized paranoid schizophrenics was higher and d i f f e r e d s i g n i f i c a n t l y (p<.05) from the combined mean of the other three schizo-phrenic subgroups.) Nonpsychiatric Subjects The 30 nonpsychiatric subjects were physically d i s -abled individuals suffering for the most part from multiple s c l e r o s i s (14 subjects, or 47%) and i r r e v e r s i b l e damage to the spinal cord that resulted i n paraplegic or quadriplegic conditions (10 subjects, or 33%). The remaining 6 subjects had been diagnosed as advanced rheumatoid a r t h r i t i s (2 cases), Friedreich's ataxia (2 cases, 1 with diabetes), osteogenesis imperfecta (1 case, permanently i n s t i t u t i o n -alized) , and amputated leg (1 case). A l l subjects showed generally adequate s o c i a l functioning, within the l i m i t s imposed by th e i r physical handicap, and were judged to be free of central nervous system impairment that would be s u f f i c i e n t to i n t e r f e r e with cognitive performance. C h a r a c t e r i s t i c s of. the Six Experimental Subgroups Table 1 shows the breakdown of the six experimental subgroups (paranoid schizophrenic; nonparanoid schizo-phrenic, nonpsychiatric; each either h o s p i t a l i z e d or nonhospitalized) i n terms of mean age i n years, mean years Table 1 Diagnostic Category, Length and Severity of I l l n e s s , Length of Hos p i t a l i z a t i o n , and Demographic Variables For A l l 90 Subjects Diagnostic Currently Mean Years Mean Years Mean R i t a i Category H o s p i t a l i zed(H) Hospital- Length of Severity of Or Not (Nil) i z a t i o n I l l n e s s Current n=15 per group Disturbance Mean Age Mean Gender Marital Status Premorbid Adjustment (Years) Hducation (Years) Male Female Single Married Other Good Borderline Poor Paranoid Schizophrenia 15.30 (7.75) 21 .86 (8.43) 15.06 (5.19) 51 .30 (14.79) 59.13 (12.98) 43.06 (9.26) 38.20 (7.16) 10.06 (1.58) 9.53 (2.11) 1.3 12 12 11 13. (9. ,88 .98) 23. (7 .46 .28) 47.60 (12.57) 43.46 (8.81) 9.46 (1.76) 10 5 14 0 1 0 1 14 Nonparanoid Schizophrenia Nil 16 (6 .06 .80) 51 .85 (10.48) 38.13 (9.76) 8.93 (1.80) 8 7 11 1 3 1 5 9 H 14, (7 , 10 .92) 18 (y .20 .55) - 41.26 (12.52) 9.66 (2.86) 6 9 9 3 3 - - -Nonpsychiatric Subj ects Nil 13 (8 .06. .66) 37.86 (15.19) 13.73 (2.20) 6 9 7 7 1 a Standard deviations i n parentheses, b Number of subjects per category. 6 0 of formal schooling (education), gender, and marital status. Table 1 also shows mean t o t a l length of i l l n e s s i n years, and where appropriate, mean length of current h o s p i t a l -i z a t i o n i n years, mean ratings of severity of current condition (Global Assessment Scale), and premorbid status. I t w i l l be noted that the various groups are not uniformly equivalent i n terms of some of the above variables. Analyses of these subject c h a r a c t e r i s t i c s and s t a t i s t i c a l treatments of the dependent measures that were suggested by these analyses are reported i n the Results chapter. An attempt was also made to determine the subjects' socio-economic status by means of the Blishen Occupational Class Scale (Blishen, 1958) . Unfortunately, i n too many instances, subjects had either never held a job or the i r employment history could not be determined. The available but incomplete data suggest that psychiatric subjects had been predominantly semi-skilled and unsk i l l e d workers (roughly corresponding to Blishen's class 6 or 7), while nonpsychiatric subjects, and espe c i a l l y those l i v i n g outside i n s t i t u t i o n s occupied a variety of positions (classes 1 through 7). F i n a l l y , most of the schizophrenic subjects were receiving various types of psychoactive medication, espe-ci a l l y phenothiazine compounds. As to the duration of drug treatment, the schizophrenic patients had been under 61 moderate to heavy psychotropic treatment intermittently throughout the course of t h e i r i l l n e s s . Hospitalized nonpsychiatric patients were invariably on minor tran-q u i l i z e r s . Drug intake between-group comparisons as well as relationships between the drug regimen and l e v e l of performance on the dependent variable measures are presented i n the Results and i n Appendices 9.2 and 9.3. The detailed drug status of the subjects i n terms of the presence or absence of antipsychotic (or other) medication, type of medication, and d a i l y dosage l e v e l , including chlorpromazine equivalence estimates, i s given i n Appendix 9.1. Materials The two instruments that provided the dependent variable measures of the study were the Rattan and Chapman (1973) associative interference vocabulary test, and the Goldstein and Scheerer (1941) Object Sorting Test as modified by Harrow, Himmelhoch, Tucker, Hersh, and Quinlan (1972). The associative interference vocabulary test con-s i s t s of 140 randomly ordered multiple-choice vocabulary d e f i n i t i o n items. I t requires subjects to choose and c i r c l e the alternative which i s closest i n meaning to the stimulus word. Included are two subtests, with 60 items i n each. One of the subtests (D), includes one 62 a l t e r n a t i v e which p r o v i d e s the c o r r e c t answer (a synonym), and another a l t e r n a t i v e which serves as an a s s o c i a t i v e d i s t r a c t o r . The other two a l t e r n a t i v e s are i n c o r r e c t . For example, POOL means the same as: A. PUDDLE ( c o r r e c t answer); B. COLD ( i n c o r r e c t and i r r e l e v a n t ) ; C. SWIM ( i n c o r r e c t and a s s o c i a t i v e d i s t r a c t o r ) ; D. NONE OF THE ABOVE. The other s u b t e s t (ND) c o n t a i n s no a s s o c i a t i v e d i s t r a c t o r s among the a l t e r n a t i v e s . For example: SCALE means the same as: A. PIN ( i n c o r r e c t and i r r e l e v a n t ) ; B. YELL ( i n c o r r e c t and i r r e l e v a n t ) ; C. CLIMB ( c o r r e c t answer); D. NONE OF THE ABOVE. The s u b j e c t s ' accuracy scores ( t o t a l number c o r r e c t out of 60) on the D s u b t e s t are compared t o t h e i r accuracy s c o r e s on the ND s u b t e s t . A lower accuracy score on the D s u b t e s t i s assumed to r e f l e c t s u s c e p t i b i l i t y to a s s o c i a t i v e i n t r u s i o n s . The two sub t e s t s were c o n s t r u c t e d by Rattan and Chapman so t h a t they are c l o s e l y matched, i n terms of the performance of normal s u b j e c t s , on d i s t r i b u t i o n of scores and of item d i f f i c u l t y , on means and standard d e v i a t i o n s of scor e s , on standard d e v i a t i o n of item d i f f i c u l t y , and on r e l i a b i l i t y . Thus, the D and ND su b t e s t s have been deemed to be e q u i v a l e n t i n d i s c r i m i n a t i n g power, a f e a t u r e which i s e s s e n t i a l f o r the assessment of any hypothesized s p e c i f i c c o g n i t i v e d e f i c i t i n p s y c h i a t r i c p a t i e n t s (Chapman & Chapman, 1973a, 1973b). D e t a i l s about the 63 construction and psychometric properties of the two sub-tests of the associative interference vocabulary test have been given by Rattan and Chapman (1973). The remaining 20 items of the test are f i l l e r s , designed to provide a check on random response tendencies by the subjects. The alternatives are neither correct answers nor associative d i s t r a c t o r s , and the only "correct" choice i s "None of the above." The word 'HORIZON,1 for example, i s obviously unrelated to i t s three other alternatives CARD, SILO, and MILDEW. The Object Sorting Test (Harrow et a l . , 1972) involves the successive presentation to the subject of seven "starting objects" (e.g., a metal fork, a red rubber ball) from a set of 38 objects of similar common use (for the complete l i s t , see the Object Sorting Test Scoring Sheet, Appendix 1). The subject i s asked to sort out a l l the other objects from the set that belong with the s t a r t -ing object. Upon the completion of each sorting, the subject i s asked to give reasons for the selections. As described i n the previous chapter, f i v e performance measures based on the Object Sorting Test sortings were used i n t h i s study. These were behavioral overinclusion, conceptual overinclusion, i d i o s y n c r a t i c or bizarre think-ing, concrete thinking, and underinclusive thinking. For the most part, these measures are not independent of 6 4 each o t h e r . In a d d i t i o n , these measures (except f o r b e h a v i o r a l o v e r i n c l u s i o n which r e p r e s e n t s the t o t a l number of o b j e c t s s o r t e d w i t h a l l seven s t a r t i n g objects) are o b tained by means of r a t i n g s . F i r s t , each s o r t i n g i s r a t e d on a 1-5 s c a l e f o r each of the f o u r types of thought d i s o r d e r . Then the a c t u a l score f o r each type i s obtained i n terms of a composite r a t i n g of the t o t a l performance by each s u b j e c t d u r i n g a l l seven s o r t i n g s ( c f . Himmelhoch, Harrow, Tucker, and Hersh, 1973) . To assess the r e l i a b i l i t y of these composite r a t i n g s , the p r o t o c o l s from 42 s u b j e c t s (about 47% of the t o t a l sample and about e q u a l l y r e p r e s e n t a t i v e of each subsample) were independently scored by a second r a t e r , t r a i n e d i n the use of the s c o r i n g c r i t e r i a , who was unaware of the subgroup i n which each s u b j e c t belonged. T h i s procedure y i e l d e d a c c e p t a b l e l e v e l s of i n t e r r a t e r r e l i a b i l i t i e s i n terms of product-moment c o r r e l a t i o n c o e f f i c i e n t s : conceptual o v e r i n c l u s i o n , _r=-87; i d i o s y n c r a t i c t h i n k i n g , r_=.78; concre t e t h i n k i n g , _r=.75; and u n d e r i n c l u s i v e t h i n k i n g , r = . 9 l . A l t e r n a t i v e l y , the r a t e r s ' disagreements beyond one s c a l e p o i n t were 0% f o r c onceptual o v e r i n c l u s i o n , 9.6% f o r i d i o s y n c r a t i c t h i n k i n g , 2.4% f o r c o n c r e t e t h i n k i n g , and 4.8% f o r u n d e r i n c l u s i v e t h i n k i n g . 65 Procedure After securing the approval of the subjects' thera-p i s t s , a l l subjects who had met the selection c r i t e r i a and who had tentatively agreed to parti c i p a t e i n the study were approached i n d i v i d u a l l y at the i r respective institu-r tions, community care centre, or i n the i r homes or places of gathering. The investigator b r i e f l y informed each subject about the nature of the study, which was des-cribed as a "study on the use or misuse of the English language and of the a b i l i t y to sort some objects of common use." E f f o r t s were made to establish rapport and to answer any questions about the tes t i n g . The Informed Consent Form (see Appendix 10) was presented, explained, and subjects were asked to sign i t . (Nonhospitalized psychiatric patients and their.primary therapists were requested to sign an additional, "Authorization for Release of Information," form). Eleven (12% of the o r i g i n a l sample) po t e n t i a l subjects refused to take part i n the experiment at thi s time; they would have been di s t r i b u t e d about equally among the various experimental subgroups. Upon obtaining the subjects' consent to par t i c i p a t e i n the study, the associative interference vocabulary test and the Object Sorting Test were administered, i n counter-balanced order, with about half the subjects responding to 66 the vocabulary test f i r s t and the other half of the subjects responding f i r s t to the Object Sorting Test. As a rule, a single session was s u f f i c i e n t for the admin-istration of both tests; i n a few cases, however, two testing sessions were necessary because of the subject's expressed fatigue or because either the subject or the investigator had other engagements (6 subjects, i . e . , approximately 7%, participated i n two testing sessions). The associative interference vocabulary test items were mimeographed i n e a s i l y readable form, i n c a p i t a l l e t t e r s and with only 8 items to a page. The subject was asked to " c i r c l e the word which i s closest i n meaning to the f i r s t word given" for each item. T y p i c a l l y , the i n v e s t i -g a t o r read the instructions to the subject while the l a t t e r followed the same instructions as they appeared on the cover sheet of the test booklet. The subject then practiced on a sample item. Further questions were s o l i c i t e d and explanations were given whenever necessary. The subject then proceeded with the test, which i s not timed. After the f i r s t 8 items were completed, the inves-tigator checked the responses to make sure that the instructions were f u l l y comprehended by the subject; i f necessary, the instructions were repeated and c l a r i f i e d . The subjects were allowed, but not encouraged, to take b r i e f rest periods during the tes t i n g . Testing time 67 ranged between 20-140 minutes, the average being j u s t s l i g h t l y under one hour. The s c o r i n g was done by the i n v e s t i g a t o r . The Object S o r t i n g T e s t was i n t r o d u c e d by s e t t i n g out o b j e c t s before the s u b j e c t s and a s k i n g them whether there were any o b j e c t s t h a t they c o u l d not r e c o g n i z e . Of the 38 o b j e c t s , the s i n k stopper, r e d c i r c l e , c l a p p e r , and b l o c k w i t h n a i l were s p e c i f i c a l l y p o i n t e d out. A f t e r answering any ques t i o n s brought up by the s u b j e c t , the i n s t r u c t i o n s continued as f o l l o w s : "Now I'm going to take the s i n k stopper and p l a c e i t i n the box. What I want you to do i s to choose from among these o b j e c t s those you f e e l go with the si n k stopper and p l a c e them i n the box. Then I ' l l ask you why you have chosen them." Upon p u t t i n g the si n k s t o p p e r — f i r s t of the seven s t a r t i n g o b j e c t s — i n the box, the i n v e s t i g a t o r recorded the s u b j e c t ' s s o r t i n g behavior and wrote down a l l v e r b a l i z a t i o n s d u r i n g both the s o r t i n g and the sub-sequent i n q u i r y . When the s u b j e c t had i n d i c a t e d t h a t the s o r t i n g was complete, the i n v e s t i g a t o r asked: "Why do these o b j e c t s go wit h the s i n k stopper (or f o r k , or pip e , e t c . ) ? " , or "Why do a l l these belong t o g e t h e r ? " For the second s t a r t i n g o b j e c t ( f o r k ) , the i n v e s -tigator p l a c e d i t i n the box and then asked: "Now, what goes wi t h the f o r k ? " The remaining s t a r t i n g o b j e c t s , 68 however, were not named. The investigator placed each i n the box and then stated simply: "What goes with t h i s ? " or "Now, do the same for th i s one." Some subjects appeared to hesitate before sorting with the f i r s t or with the f i r s t two st a r t i n g objects. In such cases, a l l the instructions were repeated together with additional questions such as "What might go with the sink stopper (fork)?", or "What could belong with the sink stopper (fork)?" If the subject continued to appear unable to f i n d any object to sort with the s t a r t i n g object, further encouragement was given, and the following question(s) were asked i n order as necessary: "What i s i t you are looking for to go with the sink stopper (fork)?"; "Is there anything here that could go with i t ? " ; "Well, i f you had to pick something here, what might you pick to go with i t ? " It should be noted that only twice (2 subjects were involved with one instance each) did i t become necessary to force the issue i n this manner, and these instances were scored as underinclusiveness. Refusals to sort with s t a r t i n g objects 3-7 were accepted as such. The investigator responded by saying: "That's a l l r i g h t . A l o t of people can't see anything for that one. Let's try t h i s one" (holding up the next s t a r t i n g object). Inquiry about the reasons for each sorting was kept at a minimum. Requests for a b r i e f explanation or simple 69 d i r e c t questions were asked only i f the subjects' verbal-i z a t i o n was too d i f f i c u l t to hear, understand, or appeared to be vague. Also, a l l questions by subjects about how they should make the i r selections were answered non-committally: "It's up to you. Just put i n what you f e e l goes with i t . " The average sorting time for a l l seven sortings was about 15 minutes. The investigator obtained the behavioral overinclusion scores by counting the t o t a l number of objects sorted with a l l seven s t a r t i n g objects. The remaining indices were obtained by ratings on a 9-point scale (1-5 with half steps, i . e . , 1, 1.5, 2, 2.5, e t c . ) . R e l i a b i l i t y was established i n the manner indicated previously under 'Materials.' S l i g h t departures from the standard testing procedure described above took place i n those instances where the subject's v i s i o n and/or motor coordination were impaired. In such cases, the investigator read aloud each vocabulary item along with the subject and c i r c l e d the alternative indicated by the subject. In the case of the Object Sorting Test, the investigator picked and placed i n the box the objects indicated by the subject. 70 Chapter 4 Results The main dependent variables of the study were (1) the number of correct answers given by the subjects on the two vocabulary subtests and (2) the ratings on the f i v e object sorting performance measures. Because, however, the subjects i n the various diagnostic subgroups were not as closely matched as would have been desirable (see Table 1, page 5 9 ) , differences were analyzed, and the analyses of the dependent measures were modified accordingly. This chapter begins with analyses of subject c h a r a c t e r i s t i c s . Wherever i t was deemed necessary, relationships between subject c h a r a c t e r i s t i c s and dependent variable measures were established. The second part of the chapter presents the re s u l t s of the main analyses. Differences in C h a r a c t e r i s t i c s of the Experimental Subgroups In terms of age, the o v e r a l l mean of the sample was 40.32 years (N=90). A two-way analysis of variance (diagnostic category by h o s p i t a l i z a t i o n status) yielded one s i g n i f i c a n t main e f f e c t (F(1,84)=3.99, p<.05) for h o s p i t a l i z a t i o n status, while the other main e f f e c t and the int e r a c t i o n were nonsignificant. Inspection of 71 group means (Table 1, page 59) showed that patients i n the nonhospitalized samples were younger than th e i r i n s t i t u -tionalized counterparts (the means were 38.06 and 42.86 years, r e s p e c t i v e l y ) . With a single exception, none of the correlations between age and the measures of thought d i s -order reached s t a t i s t i c a l s ignificance (Table 2). Thought disorder indices included difference scores on the associative interference vocabulary test (number correct on the subtest without d i s t r a c t o r s minus number correct on the subtest with distractors"*") , and the ratings on the f i v e object sorting measures. Since only one s i g n i f i c a n t correlation(r=-.233, p<.05) was found (between age and underinclusive thinking), the evidence for a r e l a t i o n s h i p between age and magnitude of disordered thought was judged to be meager. The t o t a l group of subjects consisted of 50 males and 40 females. As shown i n Table 1, males and females were about equally divided within the subgroups, except for the fact that the nonhospitalized paranoid sample was pre-2 dominantly male =4.3, p<.05). Where score on the subtest with d i s t r a c t o r s exceeds the score on the subtest without d i s t r a c t o r s , the resultant difference score i s considered to be zero.. 7 2 Table 2 C o r r e l a t i o n C o e f f i c i e n t s Between Age, C h r o n i c i t y , and Education and the Dependent V a r i a b l e Measures (N=90) Age C h r o n i c i t y Education Vocabulary D i f f e r e n t i a l Score .098 .050 -.270* Behavioral O v e r i n c l u s i o n .145 .155 .157 Conceptual O v e r i n c l u s i o n .005 ,058 .023 I d i o s y n c r a t i c Thinking .021 ,170 -.020 Concrete Thinking .012 .074 ,191 Unde r i n c l u s i v e Thinking -.233* .050 .217" *p_<.05 73 Mean d i f f e r e n c e s i n l e n g t h of c u r r e n t i n s t i t u t i o n a l -i z a t i o n ( d e f i n e d as continuous stay i n h o s p i t a l s i n c e l a s t admission) f o r the three h o s p i t a l i z e d groups were not s t a t i s t i c a l l y s i g n i f i c a n t (F(2,42)=.24,n.s.). The o v e r a l l mean f o r these three groups was 14.62 years (N=90). T o t a l l e n g t h of i l l n e s s or c h r o n i c i t y ( d e f i n e d as l e n g t h of i l l n e s s i n years s i n c e the time when the d i s o r d e r i n q u e s t i o n was f i r s t r e c o g n i z e d and recorded by a pro-f e s s i o n a l ) has c o n s i d e r a b l e b e a r i n g on the analyses and i n t e r p r e t a t i o n of the r e s u l t s of the present study. The o v e r a l l mean was 17.95 years (N=90), c l e a r l y i n d i c a t i n g t h a t the study s u b j e c t s were indeed " c h r o n i c . " Table 1, however, shows t h a t the experimental groups, though i n every case c h r o n i c by any p r a c t i c a l c r i t e r i a , were not very c l o s e l y matched i n terms of years of l e n g t h of i l l n e s s s i n c e onset. A two-way a n a l y s i s of v a r i a n c e ( d i a g n o s t i c category by h o s p i t a l i z a t i o n status) r e s u l t e d i n a s i g n i f i c a n t main e f f e c t (F(1,84)=15.46, p<.0002) f o r h o s p i t a l i z a t i o n s t a t u s . N o n s i g n i f i c a n t e f f e c t s were found f o r d i a g n o s t i c category (F(2,84)=2.21,n.s.) and f o r the i n t e r a c t i o n (F(2,84)=.17,n.s., Table 3.1). The s i g n i f i c a n t h o s p i t a l -i z a t i o n main e f f e c t i s the r e s u l t of s h o r t e r l e n g t h of i l l n e s s i n the n o n h o s p i t a l i z e d as opposed to the c u r r e n t l y h o s p i t a l i z e d s u b j e c t s (the means are 14.72 and 21.17 years, r e s p e c t i v e l y ) . In a d d i t i o n , post.hoc comparisons 74 Table 3.1 Summary of Analysis of Variance of the Chronicity Variable Source of V a r i a t i o n SS df MS F Diagnostic Groups 268.02 2 134.01 2.21 .1130 (DG) H o s p i t a l i z a t i o n 934.44 1 934.44 15.46 .0002 Status (HOSP) DG x HOSP 20.68 2 10.34 .17 .841* Error 5076.66 84 60.43 75 among means (Table 3.2) showed that nonhospitalized non-psychiatric subjects had been i l l for a shorter period of time than the two groups (paranoid and nonparanoid) of ho s p i t a l i z e d psychiatric patients (p_<.05 or beyond; the respective means are 13.06 vs. 21.86 and 23.46 years). The comparisons further showed that nonhospitalized paranoid schizophrenic patients had been i l l for a shorter period of time compared to t h e i r h ospitalized nonparanoid counterparts (p<.05; the respective means are 15.06 and 23.46) . Despite the inequality of the subgroups i n terms of length of i l l n e s s , none of the correlations between length of i l l n e s s and the indices of thought disorder reached s t a t i s t i c a l s ignificance (Table 2), and thus indicated that the magnitude of thought disorder varies rather independently from chronicity of i l l n e s s . In terms of education (defined as number of years com-pleted i n school, including, where applicable, post-secondary education), the o v e r a l l mean was 10.22 years (N=90). In a two-way analysis of variance both main effects and the int e r a c t i o n were found to be s i g n i f i c a n t : diagnostic groups (F(2,84)=11.87, p<.0000); h o s p i t a l i z a t i o n status (F(l,84) = 5.22, p_<.0235); and diagnostic groups by h o s p i t a l i z a t i o n status (F(2,84)=12.28, p_<.0000). Subsequent pairwise contrasts (Table 4), however, indicated that only the nonhospitalized nonpsychiatric group (mean of 13.73 years) Table 3.2 Tukey's Pairwise Contrasts Among Means on the Chronicity Variable (n=15 per c e l l ) ^6 ^5 Nonhospitalized Nonpsychiatric M =13.06 —6 2.00 3.00 5.14 8.80* 10.40* Nonhospitalized M=15.06 Paranoid ~~ 1.00 3.14 6.80 8.40* Nonhospitalized M^=16.06 Nonparanoid 2.14 5.80 7.40 Hos p i t a l i z e d M =18.20 Nonpsychiatric — 3.66 5.26 Hospi t a l i z e d M=21.86 Paranoid — 1.60 Hos p i t a l i z e d M3=23.46 Nonparanoid HSD=8.28 * (£<.05) 9.90 ** (p_<.01) Table 4 Tukey's Pairwise Contrasts Among Means on the Education Variable (n=15 per c e l l ) M4 M2 ^5 ^6 Nonhospitalized Nonparano i d =8.9 3 .53 .60 .73 1.13 4.80 Ho s p i t a l i z e d Nonparanoid M3=9.46 .07 .20 .60 4.27 Nonhospitalized Paranoid ^=9.53 Hosp i t a l i z e d Nonpsychiatric M^=9.66 ,13 ,76 .46 4.20 4.07 H o s p i t a l i z e d Paranoid M =10.06 Nonhospitalized Nonpsychiatric M^=13.73 3.67 HSD= ' 2.64 **(p_<.01) 78 was s i g n i f i c a n t l y d i f f e r e n t (p<.01) from each of the other study groups. I t i s noteworthy that t h i s group contained 10 individuals (67%) who had attended college or univer-s i t y ; 4 of these 10 had college degrees. The only other individuals who attended college were 2 hospitalized nonpsychiatric subjects and 1 nonhospitalized paranoid schizophrenic subject; none of these three had received a degree. Thus, with the exception of the nonhospitalized nonpsychiatric subjects who were more educated, the remaining f i v e subgroups were quite comparable i n terms of educational l e v e l . This may be also taken to mean that the subgroups are reasonably matched on a rough index of premorbid i n t e l l i g e n c e (Chapman & Chapman, 1973a), par-ticularly i n view of the fact that t h e i r ages were f a i r l y comparable. Of the six correlations between education and the dependent variables (Table 2), two yielded s t a t i s -t i c a l l y s i g n i f i c a n t c o e f f i c i e n t s : Underinclusive thinking, r=-.217 (p<.05), and vocabulary d i f f e r e n t i a l score, r=-.270 (p_<;05). The remaining correlations between educational l e v e l and object sorting measures were non-s i g n i f i c a n t . Incidentally, Chapman and Chapman (1977) reported a nonsignficant c o r r e l a t i o n of .03 between education and vocabulary d i f f e r e n t i a l d e f i c i t score. Thus, there i s only marginal evidence for a negative r e l a t i o n -ship between educational l e v e l and magnitude of disordered thought. 79 A d d i t i o n a l l y , the present study yielded two s t a t i s t i c a l l y s i g n i f i c a n t correlations between thought disorder measures and the variables of premorbid adjustment and current o v e r a l l severity of disturbance. F i r s t , a s i g n i f i c a n t c o r r e l a t i o n (r=.30, p_<.05) between vocabulary difference score and score on the premorbid socio-sexual adjustment scale indicated, as i t may have been expected, that poor premorbid schizophrenics showed more associative interference than schizophrenics with better premorbid functioning. Second, a s i g n i f i c a n t c o r r e l a t i o n (r=-.37, p_<.01) between id i o s y n c r a t i c thinking scores and ratings on the Global Assessment Scale indicated that schizophrenic patients who were rated as more d i s -turbed were more i d i o s y n c r a t i c (bizarre) i n t h e i r thinking than globally less impaired schizophrenics. Medication intake of the psychiatric patients was recorded i n approximate d a i l y chlorpromazine equivalents (e.g., H o l l i s t e r , 1970) i n milligrams (Appendix 9.1). Although these d a i l y chlorpromazine or chlorpromazine-equivalent levels were considerably higher i n the h o s p i t a l -ized than i n the released schizophrenics, the means for the h o s p i t a l i z e d groups (700.66 for the paranoid schizo-phrenic inpatients and 664.66 for the nonparanoid schizo-phrenic inpatients) did not d i f f e r s i g n i f i c a n t l y (t(28)= .25, p>.05). Likewise nonsignificant (t(28)=1.48, p>.05) 80 was the mean d i f f e r e n c e between the paranoid and non-paranoid s c h i z o p h r e n i c o u t p a t i e n t s ' i n t a k e , 156.00 and 230.66 mgs., r e s p e c t i v e l y . T w o - t a i l e d t - t e s t s o f independ-ent means were used i n the above analyses (Appendix 9.2). No meaningful comparison c o u l d be made concerning the drug i n t a k e of the n o n p s y c h i a t r i c p a t i e n t s because they were t a k i n g too many d i f f e r e n t medications, but no chlorpromazine or other major p s y c h o a c t i v e drug. As none of the c o r r e l a t i o n s between measures of d i s o r d e r e d thought and the s c h i z o p h r e n i c s ' d a i l y i n t a k e o f p s y c h o a c t i v e medications i n chlorpromazine e q u i v a l e n t s reached s t a -t i s t i c a l s i g n i f i c a n c e (Appendix 9.3), i t may be concluded t h a t the amount of a n t i p s y c h o t i c medication does not seem to have a n y _ s i z a b l e • d i f f e r e n t i a l impact on the- v a r i a b l e s under i n v e s t i g a t i o n ^ . . i . Main Analyses Combined Vocabulary and Object Sorting Test Performance I n i t i a l l y , a 3 x 2 f i x e d - e f f e c t s m u l t i v a r i a t e a n a l y s i s of c o v a r i a n c e was c a r r i e d out to assess the e f f e c t s of d i a g n o s t i c groups and h o s p i t a l i z a t i o n s t a t u s on a l l vocabu-l a r y and concept formation measures. Two c o v a r i a t e s , c h r o n i c i t y of i l l n e s s and accuracy scores on the vocabulary s u b t e s t without d i s t r a c t o r s , were chosen i n view of the 81 subgroup differences on these variables (Tables 3.2 and 12). Wilks 1 lambda c r i t e r i a (Bock, 1975) were employed for a l l multivariate significance t e s t s . In th i s i n i t i a l analysis, both main effects and the inte r a c t i o n were found to be s i g n i f i c a n t : diagnostic groups (F(2,82)=10.40, p_<.0000); h o s p i t a l i z a t i o n status (F(1,82)-4.22, p<.0010); and diagnostic groups by h o s p i t a l i z a t i o n status (F(2, 82) = 1.97, p<.0302). Table 5 summarizes these r e s u l t s . To examine which of the dependent variables contributed most to the r e j e c t i o n of the o v e r a l l multivariate n u l l hypothesis, another multivariate analysis of covariance of the f i v e object sorting measures alone was performed. This was followed with a series of univariate analyses of co-variance which included the object sorting and vocabulary indices. Object Sorting Test Performance In order to assess the t e n a b i l i t y of the o v e r a l l multi-variate n u l l hypothesis, a 3 x 2 fixed-effects multivariate analysis of covariance of the f i v e object sorting ratings was carr i e d out. The covariate was length of i l l n e s s ( c h r o n i c i t y ) . This analysis resulted i n s i g n i f i c a n t main effects and i n a nonsignificant i n t e r a c t i o n (Table 6). The s i g n i f i c a n t diagnostic group main e f f e c t (F(2,83) = 2.496, p<.008) indicated marked differences between some 82 Table 5 Summary of the Mu l t i v a r i a t e Analysis of Covariance f o r A l l Dependent Measures (Covariates: Accuracy Scores on the Subtest Without Distractors and Chronicity of Ill n e s s J Wilks' Approximate Source of V a r i a t i o n Lambda* ^ - s t a t i s t i c * P r o b a b i l i t y Diagnostic Groups .30312 10.4082 .0000 (DG) (6,2,82) (12,153) H o s p i t a l i z a t i o n .75242 4.2228 .0010 (HOSP) Status (6,1,82) (6,77) DG x HOSP .75002 1.9722 .0302 (6,2,82) (12,153) *Degrees of freedom i n parentheses. 83 Table 6 Summary of the Multivariate Analysis of Covariance of the Object Sorting Test Measures (Covariate: Chronicity) Source of Va r i a t i o n Wilks» Lambda* Approximate F - s t a t i s t i c * P r o b a b i l i t y Diagnostic Groups (DG) .74571 (5,2,83) 2.4967 (10,158) .0083 H o s p i t a l i z a t i o n (HOSP) Status .85430 (5,1,83) 2.6947 (5,79) .0267 DG x HOSP .88330 (5,2,83) 1.0114 (10,158) .4362 *Degrees of freedom i n parentheses. 8 4 of the diagnostic subgroups, and the s i g n i f i c a n t h o s p i t a l -i z a t i o n status main e f f e c t (F (1, 83) =2 . 694 , p_<.026) r e f l e c t e d lower (worse) performance levels of inpatients as opposed to outpatients. The o v e r a l l sample means were 20.31 for behavioral overinclusion, 1 . 8 7 for conceptual over-inclu s i o n , 1.39 for i d i o s y n c r a t i c thinking, 1.91 for con-crete thinking, and 2.22 for underinclusive thinking (N=90). Table 7 shows the covariance-adjusted means for the various subgroups. Next, for each source row of the multivariate analysis of covariance tables that yielded r e j e c t i o n of the o v e r a l l multivariate n u l l hypothesis, univariate analyses of covariance were conducted to determine which s p e c i f i c concept formation measures were involved. The f i v e sub-sequent 2 x 3 f a c t o r i a l analyses of covariance (using chronicity as the covariate) indicated that diagnostic grouping was not s i g n i f i c a n t l y related to behavioral over-inclu s i o n performance (F(2,83)=.455,n.s.) or to concrete thinking performance ( F ( 2 , 8 3 ) = 1 . 6 8 3 , n . s . ) , but was s i g n i f i -cantly associated with the subjects' performance on the indices of conceptual overinclusion (F(2,83)=3.491, p_<.034), underinclusive thinking (F (2 , 83) =4 . 520 , p<.013), and especially i d i o s y n c r a t i c thinking (F(2,83)=5.604, p<.0053). Ho s p i t a l i z a t i o n status was found to be s i g n i f i c a n t l y associated with scores on concrete thinking Table 7 Covariance-adjusted Means* and Standard Deviations** of Scores on the Object Sorting Test Measures f or A l l Subject Subgroups (n=15 per c e l l ) Behavioral Overinclusion Paranoid 17.30 (7.75J H o s p i t a l i z e d Nonparanoid Nonpsychiatric 20.68 (6.40) 20.56 (7.30) Nonhospitalized  Paranoid Nonparanoid Nonpsychiatric 21.74 (13.74) 18.92 (8.41) 22.66 (8.37) Conceptual 1.98 2.11 Overinclusion (.58) (.76) 1.70 (.49) 2.03 (.99) 1.93 (.68) 1.49 (.46) Idiosyncratic 1.50 2.04 Thinking (.71) (1.01) 1.17 (.31) 1.27 (.65) 1.30 (.49) 1.06 (.18) Concrete Thinking 2.15 (.44) 2.12 (.47) 1.90 (.57) 1.72 (.50) 1.92 (.56) 1.64 (.59) Underinclusive 2.44 2.38 Thinking (.96) (.79) 1.97 (.44) 2.12 (.90) 2.59 (.66) 1.81 (.67) For c h r o n i c i t y . In parentheses. 86 performance (F(1,83)=6.20, p<.015) and i d i o s y n c r a t i c think-ing performance (F(1,83)=6.316, p<.013). None of the interactions reached s t a t i s t i c a l s i g n i f i c a n c e . The summaries of the above analyses are shown i n Table 8. Furthermore, planned orthogonal comparisons among subgroup means showed that ratings on both conceptual overinclusion and underinclusive thinking measures were s i g n i f i c a n t l y higher (p<.05) for psychiatric (schizophrenic) patients than for nonpsychiatric patients regardless of h o s p i t a l i z a t i o n . On the i d i o s y n c r a t i c thinking measure, however, the nonparanoid schizophrenics d i f f e r e d s i g n i f i -cantly (p<.05) from the combined groups of paranoid and nonpsychiatric subjects. S i g n i f i c a n t differences between inpatients and outpatients i n terms of concrete and i d i o -syncratic thinking could be attributed to the r e l a t i v e l y low scores of the nonpsychiatric subjects. A p o s t e r i o r i pairwise comparisons among means adjusted for chronicity on the i d i o s y n c r a t i c thinking variable (Table 9) revealed that the hospitalized nonparanoid schizophrenic patients scored s i g n i f i c a n t l y higher (p<.05 or beyond) than did subjects i n a l l but one other subgroup. Only the hospitalized paranoid schizophrenics performed s i m i l a r l y to t h e i r nonparanoid counterparts. A p o s t e r i o r i pairwise contrasts among means of the concrete thinking, underinclusive thinking, and conceptual overinclusion 87 Table 8 Summary of Analyses of Covariance for the Object Sorting Test Measures (Covariate: Chronicity) Source of Variation df Behavioral Overinclusion Diagnostic Groups (DC) Hos p i t a l i z a t i o n (HOSP) Status DG x HOSP Error 36.858 48.295 73.446 80.899 .455 .597 .907 n. s. n. s. Conceptual Overinclusion Diagnostic Groups (DG) Hos p i t a l i z a t i o n (HOSP) Status DG x HOSP Error 1.656 2 .251 1 .156 2 .474 83 5.491 .530 .329 .0342 Idiosyncratic Thinking Diagnostic Groups (DG) Hos p i t a l i z a t i o n (HOSP) Status DG x HOSP Error 2.182 2 2.460 1 .836 2 .389 83 5.604 6.316 2.148 .0053 .0134 n. s. Concrete Thinking Diagnostic Groups (DG) Hosp i t a l i z a t i o n (HOSP) Status DG x HOSP Error .466 2 1.670 1 .108 2 .277 S3 1.683 6.020 .590 n. s. .0155 Underinclusive Thinking Diagnostic Groups (DG) Hosp i t a l i z a t i o n (HOSP) Status DG x HOSP Error .615 .142 .551 .578 4.520 .246 .952 .0136 Table 9 cl Tukey's Pairwise Contrasts Among Sample Means For Idiosyncratic Thinking (n=15 per c e l l ) H o spitalized Nonparanoid M^=2.04 h % % M. M, -4 —1 ^3 Nonhospitalized Nonpsychiatric M^=1.06 11 .21 .24 .44 .98" Hosp i t a l i z e d Nonpsychiatric NL__ = 1.17 .10 .13 .33 .87* Nonhospitalized Paranoid M_2=1.27 .03 ,23 .77* Nonhospitalized Nonparanoid M^=1.30 .20 .74* Hosp i t a l i z e d Paranoid M =1.50 .54 HSD=.67 * (p_<.05) .79 ** (p_<.01) Covariance--adjusted f o r c h r o n i c i t y . 8 9 indices were found to be s t a t i s t i c a l l y nonsignificant. In addition to the covariance analyses just reported, the object sorting results were also analyzed by means of multivariate and univariate analyses of variance. The outcomes (in terms of s t a t i s t i c a l significance for the main effects and interactions) of these analyses were the same as those obtained with the covariance analyses. Appendices 11.1 and 11.2 summarize the variance analyses and Appendix 11.3 shows the o r i g i n a l unadjusted means for the object sorting measures. Vocabulary Performance The obtained means and standard deviations for the D subtest (with distractors) and the ND subtest (without distractors) accuracy scores on the Rattan and Chapman vocabulary test are shown i n Table 10 for a l l six experi-mental subgroups. This table also presents the means and standard deviations of actual d i s t r a c t o r choices on the D subtest, and corresponding data for corr e c t l y answered f i l l e r items. I t i s apparent from these results that the ND accuracy means are higher than the D accuracy means for a l l subject groups and that some of these differences are considerable. The o v e r a l l means of the sample were 33.91 for the items without d i s t r a c t o r s , and 28.56 for the items with d i s t r a c t o r s (N=90). Table 10 Accuracy Means and Standard Deviations* on the for D i s t r a c t o r Choices and Correctly (n=15 Diagnosis . H o s p i t a l i z a t i o n Status Vocabulary Subtests; Means and Standard Deviations* Answered F i l l e r Items for A l l Subject Groups per c e l l ) a a ND D Subtest Subtest Distractors F i l l e r s Paranoid Schizophrenics H o s p i t a l i z e d Nonhospitalized 29.13 (10.80) 33.06 (13.35) 27.86 (9.67) 30.53 (13.43) 14.86 (11.49) 12.26 (13.22) .15.13 (5.44) 18.20 (2.04) Nonparanoid Schizophrenics H o s p i t a l i z e d Nonhospitalized 31.13 (9.45). 32.80 (9.02) 17.60 (4.10) 24.53 (12.49) 30.53 (9.20) 22.26 (14.41) 11.86 (6.81) 16.40 (4.01) Nonpsychiatric Subjects H o s p i t a l i z e d Nonhospitalized 35.26 (11.42) 42.06• (13.53) 30.40 (10.86) 40.46 (10.78) 16.80 (12.63) 7.80 (9.29) 17.46 (2.46) 18.73 (2.86) In parentheses, ND: Subtest without d i s t r a c t o r s ; D: Subtest with d i s t r a c t o r s . 91 Relative strengths of association between accuracy scores on the D and ND subtests for a l l subgroups are given i n terms of Pearson product-moment co r r e l a t i o n c o e f f i c i e n t s (Table 11) . I t can be seen that a l l " c o e f f i -cients are s i g n i f i c a n t at or beyond the .05 l e v e l and that the degree of association i s quite high. This i s not surprising given that the D and ND subtests are i n fact p a r a l l e l , with lower accuracy on the D subtest r e f l e c t i n g associative interference. Since the vocabulary performance accuracy data were to be assessed i n terms of the subjects 1 d i f f e r e n t i a l performance involving both the ND and D scores, the ND accuracy scores were i n i t i a l l y subjected to an analysis of variance (Table 12) to determine the significance of the subgroup differences on t h i s variable. This two-way f a c t o r i a l analysis of variance (Diagnostic Category by H o s p i t a l i z a t i o n Status) yielded a s i g n i f i c a n t main ef f e c t (F(2,84)=3.962, p_<.022) for diagnostic groups, whereas the other main e f f e c t and the in t e r a c t i o n were nonsignificant. In view of the s i g n i f i c a n t diagnostic group differences, the D accuracy scores were analyzed by means of analysis of covariance using the ND scores as one covariate and, given the substantial subgroup d i f f e r -ences on length of i l l n e s s discussed e a r l i e r , chronicity 9 2 Table 11 Corr e l a t i o n C o e f f i c i e n t s Between the Accuracy Scores on the Vocabulary Subtest With and Without Distractors f o r A l l Six Subject Groups (n=15 per c e l l ) Paranoid Schizophrenics Nonparanoid Schizophrenics Nonpsychiatric Subj ects Hospitalized .836** .593* .858** Nonhospitalized .956** .775** .916** * p_<.05 ** £ <.01 93 Table 12 Summary of Analysis of Variance f o r the Vocabulary Subtest Without Distra c t o r Scores Source of Va r i a t i o n SS df MS Diagnostic Groups (DG) 1028.95 514.47 3.9624 .0223 H o s p i t a l i z a t i o n (HOSP) Status 384.40 384.39 2.9605 .0851 DG x HOSP 99.26 49.63 3823 .6887 Error 10906.66 84 129.84 94 as a second covariate.^ The results of the 3 x 2 (Diag-nostic Groups by Hospitalization Status) fixed-effects analysis of covariance are summarized i n Table 13, with corresponding covariance-adjusted means i n Table 14 for a l l six experimental subgroups. The s i g n i f i c a n t diagnostic group main e f f e c t (F(2,82)=23.01, p<.0000) indicated that the average number of correct choices on the vocabulary subtest with d i s t r a c t o r s made by the subjects d i f f e r e d markedly depending on t h e i r diagnostic membership. Si m i l a r l y , the s i g n i f i c a n t h o s p i t a l i z a t i o n status main e f f e c t (F(l,82)= 7.37, p<.0079) showed, as expected, that i n s t i t u t i o n a l i z e d subjects were less accurate on the subtest with d i s t r a c t o r s than t h e i r released counterparts. A p o s t e r i o r i pairwise comparisons among subgroups on the D subtest accuracy performance (Table 15) showed that the hospitalized nonparanoid schizophrenics d i f f e r e d s i g n i f i c a n t l y (p<.01) from every other subgroup except from t h e i r nonhospitalized counterparts; and that the nonhospitalized nonparanoid schizophrenic patients' per-formance was s i g n i f i c a n t l y (p<.01) lower than that of the nonhospitalized nonpsychiatric subjects. An alternative covariance analysis with only one co-variate (ND score) was also c a r r i e d out. Significance levels were the same, as those obtained with the two-covar-iate analysis reported above (Appendix 12). 95 Table 13 Summary of Analysis of Covariance f o r the Vocabulary Subtest With Distra c t o r Scores (Covariates: Vocabulary Subtest Without Distractor- Scores and Chronicity) Source of V a r i a t i o n SS Diagnostic Groups 1597.20 (DG) H o s p i t a l i z a t i o n 255.79 1 255.79 7.37 .0079 (HOSP) Status DG x HOSP 158.61 2 79.30 2.28 .1059 df MS F p 2 798.60 23.01 .0000 Error 2844.91 82 34.69 96 Table 14 Covariance-adjusted Accuracy Means* and Standard Deviations** for the Vocabulary Subtest With Distractors f o r A l l Subject Groups (n=15 per c e l l ) H o s p i t a l i z e d Nonhospitalized Paranoid Schizophrenics 31.32 31.37 (9.67) (13.43) Nonparanoid Schizophrenics 19.40 25.51 (4.10) (12.49) Nonpsychiatric Subjects 29.33 34.45 (10.86) (10.78) * For two covariates: accuracy scores on the vocabulary subtest without d i s t r a c t o r s and c h r o n i c i t y ** In parentheses. Table 15 Tukey's Pairwise Contrasts Among Sample Means* for Scores on the Vocabulary Subtest With Distractors (n=15 per c e l l ) M4 M: M2 Hospitalized Nonparanoid M3=19.40 6.11 9.93** 11.92** 12.97** .15.05** Nonhospitalized Nonparanoid M =25.51 -A 3.82 5.81 5.86 8.94** Hospitalized Nonpsychiatric M =29.33 —5 1.99 2.04 5.12 Hospi t a l i z e d Paranoid M =31.32 .05 3.13 Nonhospitalized Paranoid M2=31.37 3.08 Nonhospitalized Nonpsychiatric M^=34.45 HSD=7.52 ** p<.01 * Covariance-adjusted f o r accuracy scores on the vocabulary subtest without d i s t r a c t o r s and c h r o n i c i t y . 98 Table 16 Summary of Analysis of Covariance of the Distr a c t o r Choices on the Vocabulary Subtest With Distractors (Covariate: Accuracy Scores on the Vocabulary Subtest With Distractors) Source of V a r i a t i o n SS Diagnostic Groups 841.84 (DG) H o s p i t a l i z a t i o n 139.24 Status (HOSP) DG x HOSP 35.26 Error 8255.07 df MS F_ p_ 2 420.92 4.232 .0175 1 139.24 1.400 .2384 2 17.63 .177 .8370 83 99.45 99 Table 17 Covariance-adjusted Means* for Distr a c t o r A l t e r n a t i v e s on the Vocabulary Subtest With Dis t r a c t o r s f o r A l l Subject Subgroups (n=15 per c e l l ) H ospitalized Nonhospitalized Paranoid Schizophrenics 14.44 13.47 Nonparanoid Schizophrenics 23.82 19.80 Nonpsychiatric Subjects 17.92 15.08 * For accuracy scores on the vocabulary subtest with d i s t r a c t o r s . 100 F u r t h e r i n s p e c t i o n of Table 10 r e v e a l e d c o n s i d e r a b l e d i f f e r e n c e s among subgroups i n terms of the a c t u a l l y chosen d i s t r a c t o r a l t e r n a t i v e means (the o v e r a l l mean was 17.60). I t i s apparent t h a t the means of d i s t r a c t o r c h o i c e s are, to a s i z a b l e extent, i n v e r s e l y r e l a t e d to the accuracy means on the D s u b t e s t . S p e c i f i c a l l y , the product-moment c o r r e l a t i o n c o e f f i c i e n t between number of d i s t r a c t o r c hoices and c o r r e c t scores on the D su b t e s t was found to be -.67 (p_<.01). A 3 x 2 f a c t o r i a l a n a l y s i s of co v a r i a n c e , with the D accuracy scores as the c o v a r i a t e , r e s u l t e d i n a s i g n i f i c a n t main e f f e c t (F(2,83)=4.23, p<.017) f o r d i a g -n o s t i c groups (Table 16). The main e f f e c t of h o s p i t a l i z a t i o n s t a t u s and the i n t e r a c t i o n were not s i g n i f i c a n t . The co-v a r i a n c e - a d j u s t e d means of the d i s t r a c t o r c h o i c e s f o r a l l s i x s u b j e c t subgroups are g i v e n i n Table 17. Based on the s i g n i f i c a n t (p_<.01) orthogonal comparison d i f f e r e n c e s between the nonparanoid s c h i z o p h r e n i c s ' performance and t h a t o f the combined groups of paranoid and n o n p s y c h i a t r i c p a t i e n t s , i t appears t h a t the nonparanoid s c h i z o p h r e n i c s , as opposed to the paranoid or n o n p s y c h i a t r i c s u b j e c t s , are more l i k e l y t o choose d i s t r a c t o r a l t e r n a t i v e s than c o r r e c t or i n c o r r e c t but n o n d i s t r a c t o r a l t e r n a t i v e s . F i n a l l y , d i f f e r e n c e s among subgroups i n terms of f i l l e r item accuracy scores were analyzed i n a two-way a n a l y s i s of v a r i a n c e (Table 18). T h i s a n a l y s i s y i e l d e d 101 Table 18 Summary of Analysis of Variance f o r the Vocabulary Test F i l l e r Item Accuracy Scores Source of V a r i a t i o n SS df MS Diagnostic Groups 235.26 2 127.63 6.96 .01 (DG) H o s p i t a l i z a t i o n 205.50 1 205.50 11.21 .01 Status (HOSP) DG x HOSP 45.08 2 22.54 1.22 n.s. Error 1539.76 84 18.33 102 s i g n i f i c a n t main effects for diagnostic groups (F(2,84) = 6.96, p<.01) and h o s p i t a l i z a t i o n status (F(1,84)=11.21, £<.01) and a nonsignificant i n t e r a c t i o n . Subsequent p a i r -wise comparisons among f i l l e r item accuracy means (Table 19) showed that the hospitalized nonparanoid schizophrenics d i f f e r e d s i g n i f i c a n t l y (p_<.05 or beyond) from a l l other subgroups except from the hospitalized paranoid schizo-phrenic patients. I t may be reasoned that i n s t i t u t i o n a l i z e d nonparanoid schizophrenics tend to respond at random not only on the f i l l e r items, but also on the other and more c r i t i c a l vocabulary items. Taken together, the analyses of associative i n t e r -ference vocabulary performance suggest that the nonparanoid schizophrenics, especially i f i n s t i t u t i o n a l i z e d , perform less well on the vocabulary test indices. Unlike the paranoid schizophrenics, who performed s i m i l a r l y to the physically i l l subjects, the nonparanoid schizophrenics, by virtue of making d i s t r a c t o r errors, gave fewer correct responses on the subtest with d i s t r a c t o r s than on the sub-test without d i s t r a c t o r s . A prolonged hospital stay, hypothesized to be implicated i n heightened responsiveness to associative di s t r a c t o r s i n a l l i n s t i t u t i o n a l i z e d groups, appears to be s p e c i f i c a l l y related to the d i f f e r e n t i a l performance of the nonparanoid schizophrenic patients. The relationship of prolonged h o s p i t a l i z a t i o n to heightened Table 19 Tukey's Pairwise Contrasts Among Sample Means for Accuracy Scores on F i l l e r Items (n=15 per c e l l ) ^3 M . ^4 ^5 M„ Hosp i t a l i z e d Nonparanoid Ho s p i t a l i z e d Paranoid Nonhospitalized Nonparanoid M =11.66 M =15.13 1^=16.40 Hospit a l i z e d Nonpsychiatric M^=17.46 3.47 4.74* 5.80** 6.54** 7.07** 1.27 2.33 1.06 3.07 1.80 .74 3.60 2.33 1.27 M2=18.20 Nonhospitalized Paranoid Nonhospitalized Nonpsychiatric M^=18.73 .53 HSD=4.57 *p_<.05 5.46 **p_<.01 o 104 s u s c e p t i b i l i t y to d i s t r a c t o r s i n paranoid and n o n p s y c h i a t r i c p a t i e n t s , on the other hand, i s much weaker. Other Analyses The r e s u l t s thus f a r have d e a l t with mean d i f f e r e n c e s between p a t i e n t groups. In order t o determine the a c t u a l number (percentage) of s u b j e c t s i n the v a r i o u s subgroups who e x h i b i t e d a r a t h e r pronounced s u s c e p t i b i l i t y to a s s o c i a t i v e i n t r u s i o n s , a combined c r i t e r i o n of the ND minus D accuracy score >^  9 and p r o p o r t i o n of a c t u a l d i s -t r a c t o r c h o i c e s to t o t a l D s u b t e s t e r r o r s ( D i s t r a c t o r s ) X 60-D ' >_• .5 was adopted. T h i s c r i t e r i o n was s e l e c t e d i n accord" w i t h the post hoc o b s e r v a t i o n that" none of the n o n h o s p i t a l i z e d n o n p s y c h i a t r i c s u b j e c t s produced a ND - D d i f f e r e n c e g r e a t e r than 9 p o i n t s and chose twice as many d i s t r a c t o r s than c o r r e c t a l t e r n a t i v e s on the su b t e s t with d i s t r a c t o r s . On the b a s i s of t h i s double c r i t e r i o n , 9 (60 per cent) of the h o s p i t a l i z e d nonparanoid s c h i z o -p h r e n i c s and 6 (40 per cent) of the n o n h o s p i t a l i z e d nonparanoid s c h i z o p h r e n i c s c o u l d be c l a s s i f i e d as e s p e c i a l l y prone to a s s o c i a t i v e d i s t r a c t o r s ; the number of su b j e c t s who c o u l d be thus c l a s s i f i e d i n the remaining f o u r subgroups ranged between 1 - 3 ( 6 . 6 - 2 0 per c e n t ) . Thus, d i f f e r e n t i a l vocabulary performance and, by i m p l i -c a t i o n , d i f f e r e n t i a l s u s c e p t i b i l i t y t o a s s o c i a t i v e d i s -105 tractors, appears to discriminate e f f e c t i v e l y between the 2 paranoid and nonparanoid schizophrenic groups =11.42, p<.001) as well as between the i n s t i t u t i o n a l i z e d paranoid 2 and nonparanoid schizophrenic groups =7.03, p<.01). A s i m i l a r procedure was used with the index of id i o s y n c r a t i c thinking from the object sorting measures with an ar b i t r a r y optional cut-off point of 2.5. This d i f f e r e n t i a t e d between the hospi t a l i z e d and released 2 patient groups =5.07, p_<.05) and between the hospitalized 2 and released schizophrenic groups =5.45, p<.05). The above c r i t e r i o n also successfully d i f f e r e n t i a t e d the paranoid from the nonparanoid.schizophrenic groups within the i n s t i t u t i o n a l i z e d subsample: 2 (13.3 per cent) of the paranoid inpatients and 7 (46.6 per cent) of the nonparanoid inpatients exhibited more frequent and/or more severe 2 instances of bizarre thinking (^  =3.96, p<.05). Thus, both associative intrusions and i d i o s y n c r a t i c thinking appear once again able to discriminate between diagnostic subgroups. These results reinforce the con-clusions from the main analyses, although i t must be stressed that the cut-off points used were selected for optimal discrimination between groups and require cross-v a l i d a t i o n before they can be of any p r a c t i c a l use. 106 Chapter 5 Discussion This chapter begins with a b r i e f appraisal of the degree to which the present study did control p o t e n t i a l l y influencing variables that otherwise could have invalidated or at least seriously compromised the interpretation of the findings. The second section presents the main results as these r e l a t e to the major hypotheses of the study. Further sections deal with a comparison of present findings to findings of e a r l i e r studies, and with the a b i l i t y of the various measures used i n t h i s investigation to discriminate between subject groups. The remaining sections touch upon the influence of psychoactive medi-cation and the nature of control subjects as possible l i m i t i n g factors of the study. F i n a l l y , some p r a c t i c a l implications are brought forward. Group Comparability Considerable e f f o r t was made to match the experimental subgroups i n terms of several possibly i n f l u e n t i a l back-ground c h a r a c t e r i s t i c s . In the f i r s t place, i t may be noted that the subgroups were adequately matched on length of h o s p i t a l i z a t i o n (for i n s t i t u t i o n a l i z e d subgroups), and 107 that they also approached equivalence as to t h e i r gender representation, age, education, and socio-economic status, although the l a s t was not precisely determined for lack of information. In e f f e c t , however, one of the subgroups (the nonhospitalized paranoid schizophrenics) contained more males than females, and the nonhospitalized non-psychiatric subjects were more educated than subjects i n other subgroups. Additionally, the h o s p i t a l i z e d subjects were older than th e i r nonhospitalized counterparts. None of these variables, however, was deemed to have had any appreciable effects on the dependent measures under investigation (see the correlations reported i n the previous chapter). Premorbid adjustment indices revealed the predominance of "poor" premorbids (41 cases) among the schizophrenic patients, with only 6 subjects rated as "good" premorbids, and the remaining 13 subjects categorized as "borderline" cases. This i s hardly surprising given the chronic status of a l l subjects, but i t did make comparisons i n terms of premorbid adjustment within the schizophrenic sample impractical. The schizophrenic subgroups were, however, matched on the o v e r a l l severity of current disturbance, except for the released paranoid schizophrenics who were rated as s i g n i f i c a n t l y less disturbed. I t i s also note-worthy that 9 of these 15 nonhospitalized paranoid 108 schizophrenics belonged to either the "good" or the "border-l i n e " premorbid adjustment category. The problem of diagnostic accuracy regarding schizo-phrenia and i t s paranoid/nonparanoid subtypes was largely avoided by the use of conservative inclusion c r i t e r i a (Research Diagnostic C r i t e r i a and Venables & O'Connor Scale) i n conjunction with hospital diagnoses. Thus, 49 subjects were judged to have a d e f i n i t e diagnosis of schizophrenia and the remaining 11 subjects met the requirements for probable schizophrenia according to the Research Diagnostic C r i t e r i a . S t i l l , some possible sampling problems may have arisen as a r e s u l t of possible disappearance of paranoid symptoms with chronicity (Depue & Woodburn, 1975; Strauss, 1973), or perhaps as a r e s u l t of amelioration i n severity of symptoms with length of i l l n e s s and/or i n s t i t u t i o n a l -i z a t i o n (cf. Bleuler, 1973; Weiner, 1966). I t should also be kept i n mind that the present d e f i n i t i o n of paranoid schizophrenia was quite stringent. Given the objectives of the present investigation, the c r u c i a l variable, length of i l l n e s s (chronicity), unfortunately could not, within the constraints of subject selection, be held constant. Inequalities between some of the subgroups, especially between the released paranoid schizophrenic and the h o s p i t a l i z e d nonparanoid schizo-phrenic patients, suggested the use of covariance techniques 109 i n the analyses of the dependent variable measures. How-ever, i n view of the minimal e f f e c t s exerted by chronicity on both vocabulary and concept formation scores, i t may be concluded that t h i s important variable was controlled (compare the analyses of covariance presented i n the pre-vious chapter to the analyses of variance i n Appendices 11.1 and 11.2, and Appendix 12). Once again, i t must be stressed that the subjects p a r t i c i p a t i n g i n the study were i n absolute terms chronic, i . e . , i l l for almost 18 years on the average with a range of 5 - 36 years, and that within this l i m i t , chronicity differences were r e l a t i v e l y small. Thus, matching of the subjects i n the various subgroups for p o t e n t i a l l y influencing variables was success-f u l i n certa i n respects and not quite successful i n others. These l a t t e r instances, and esp e c i a l l y those where sta-t i s t i c a l control could not be applied, suggest some caution concerning the interpretation of the data. Main Results With regard to the general guiding hypotheses, as they were proposed i n Chapter 1, the results of the present study provide q u a l i f i e d support for a l l hypotheses. Hypothesis l a had predicted greater s u s c e p t i b i l i t y to associative intrusions i n vocabulary performance for hospitalized patients, regardless of diagnosis. Support for 110 t h i s hypothesis was found i n the case of i n s t i t u t i o n a l i z e d nonparanoid schizophrenics who were indeed more susceptible to d i s t r a c t o r s than t h e i r noninstitutionalized counterparts. On the other hand, there were no s i g n i f i c a n t differences between hosp i t a l i z e d and released paranoid schizophrenics, and between hospitalized and released nonpsychiatric patients i n vocabulary performance (Table 15). Hypothesis lb had predicted a s i m i l a r difference between hosp i t a l i z e d and nonhospitalized patients i n terms of concept formation performance. The hypothesis received support for measures of i d i o s y n c r a t i c thinking and concrete thinking, but was not supported for the remaining indices of concept formation ( i . e . , behavioral overinclusion, conceptual overinclusion, and underinclusive thinking). Pairwise comparisons showed that the s i g n i f i c a n t differences involved higher levels of i d i o s y n c r a t i c thinking (Table 9) i n h ospitalized nonparanoid schizophrenics when these subjects were compared to a l l other subject subgroups with the exception of the h o s p i t a l i z e d paranoid patients. No s i g n i f i c a n t contrast relevant to t h i s hypothesis was found i n the case of the concrete thinking index. Thus, hypo-thesis lb was supported primarily i n terms of the d i f f e r -e n t i a l performance of the i n s t i t u t i o n a l i z e d nonparanoid schizophrenic patients i n t h e i r i d i o s y n c r a t i c thinking tendencies. I l l Hypothesis 2a had p r e d i c t e d g r e a t e r s u s c e p t i b i l i t y to a s s o c i a t i v e vocabulary i n t r u s i o n s f o r nonparanoid s c h i z o p h r e n i c s r e l a t i v e t o the paranoid s c h i z o p h r e n i c s and the n o n p s y c h i a t r i c p a t i e n t s , again r e g a r d l e s s of h o s p i t a l -i z a t i o n s t a t u s . T h i s hypothesis was supported to some extent. The nonparanoid s c h i z o p h r e n i c s were more suscep-t i b l e to d i s t r a c t o r s than the other two d i a g n o s t i c groups. A l s o , as had been a n t i c i p a t e d , the performance of the paranoid s c h i z o p h r e n i c s was q u i t e s i m i l a r t o t h a t of the n o n p s y c h i a t r i c p a t i e n t s who i n f a c t d i d show the l e a s t s u s c e p t i b i l i t y to a s s o c i a t i v e d i s t r a c t o r s . P a i r w i s e c o n t r a c t s (Table 15) i n d i c a t e d t h a t the h o s p i t a l i z e d non-paranoid s c h i z o p h r e n i c s were more s u s c e p t i b l e to d i s -t r a c t o r s than e i t h e r h o s p i t a l i z e d or n o n h o s p i t a l i z e d paranoid s c h i z o p h r e n i c s . Both h o s p i t a l i z e d and r e l e a s e d paranoid s c h i z o p h r e n i c p a t i e n t s outperformed t h e i r h o s p i -t a l i z e d nonparanoid c o u n t e r p a r t s , but the d i f f e r e n c e between e i t h e r paranoid subgroup and the r e l e a s e d non-paranoid s c h i z o p h r e n i c s f e l l s h o r t of s t a t i s t i c a l s i g n i f i c a n c e . Hypothesis 2b had p r e d i c t e d a g r e a t e r d e f i c i t i n concept formation f o r nonparanoid s c h i z o p h r e n i c p a t i e n t s . T h i s hypothesis r e c e i v e d support only i n terms of the i d i o s y n c r a t i c t h i n k i n g index. Whereas the nonparanoid s c h i z o p h r e n i c i n p a t i e n t s were s i g n i f i c a n t l y more b i z a r r e 112 in t h e i r thinking than were the paranoid schizophrenic inpatients (Table 9 ) , the performance of the l a t t e r subgroup was s i m i l a r to that of the nonpsychiatric inpatients. Other comparisons relevant to t h i s hypothesis f a i l e d to reach s t a t i s t i c a l s i g n i f i c a n c e . Although no interactions between diagnostic categories and h o s p i t a l i z a t i o n status were predicted, one s i g n i f i c a n t i n t e r a c t i o n was obtained i n the multivariate analysis of covariance that included a l l six dependent variable measures (Table 5 ) . However, no interactions were found i n the univariate covariance analyses involving vocabulary scores alone, concept formation ratings alone, and i n the multivariate analysis of covariance of concept f o r -•mation measures. I t may be that the one obtained i n t e r -action resulted from contributions of a l l dependent measures and t h e i r cumulative e f f e c t s . Thus, summarizing the discussion up to t h i s point, the present data do not allow unequivocal conclusions as to the major question whether disordered thought i n chronic schizophrenic patients i s the r e s u l t of a long-term i l l = ness or of prolonged and continuous stay i n h o s p i t a l . In the l i g h t of the above findings i t appears that neither of these propositions can provide an e n t i r e l y s a t i s f a c t o r y answer, even though both length of i l l n e s s and length of h o s p i t a l i z a t i o n variables are related to cognitive functioning 113 of i n s t i t u t i o n a l i z e d schizophrenic patients. Apparently, the answer would require reformulation of the experimental question i n terms of p a r t i c u l a r subtypes of schizophrenics, p a r t i c u l a r indices of thought disorder, and p a r t i c u l a r measuring instruments. Accordingly, i t can be stated that the long-term nonparanoid schizophrenic inpatients (more than outpatients) are prone to associative interference as measured by the Chapman vocabulary test and exhibit i d i o s y n c r a t i c thinking as determined by object sorting tasks. These patients are also more l i k e l y to resort to guessing on vocabulary items. The hospitalized paranoid schizophrenics, on the other hand, are r e l a t i v e l y free of associative intrusions, and experience s i g n i f i c a n t l y less bizarre ideation than the nonparanoid schizophrenics. In other words, the a b i l i t y of the h o s p i t a l i z e d nonparanoid schizophrenia patients to withstand interference from associative d i s t r a c t o r s on a forced-choice vocabulary task and to ward-off forming concepts i n a personally peculiar manner or for i l l o g i c a l or s o c i a l l y unshared reasons may be adversely affected by prolonged h o s p i t a l i z a t i o n . D i f f e r e n t i a l performance scores on the vocabulary subtests and the idi o s y n c r a t i c index of the Object Sorting Test therefore appear to be better suited for the appraisal of long-term cognitive d e f i c i t than other (e.g., the remaining Object Sorting 114 T e s t measures) i n d i c e s , e s p e c i a l l y i n s c h i z o p h r e n i c s who are not paranoid. While d i f f e r e n c e s i n performance between long-term paranoid and nonparanoid s c h i z o p h r e n i c s e v i d e n t l y do e x i s t , the extent to which thought pathology i s unique to s c h i z o -p h r e n i a a l s o r e q u i r e s some d i s c u s s i o n . Previous data (e.g., Harrow & Quinlan, 1977; K l i n k a & Papageorgis, 1976; M i l l e r , 1975) have i n d i c a t e d the presence of c o g n i t i v e d e f i c i t s i n nonschizophrenic samples. A d d i t i o n a l l y , Harrow and Quinlan p o i n t e d out t h a t acute d i s t u r b a n c e a f f e c t s the l e v e l of thought pathology i n a l l p s y c h i a t r i c , and not only s c h i z o p h r e n i c , p a t i e n t s . The d i s t i n c t i o n between m i l d and severe l e v e l s of d i s o r d e r e d thought was a l s o c o n s i d e r e d important s i n c e the more severe thought d i s o r d e r was found more o f t e n i n s c h i z o p h r e n i c s whereas m i l d e r l e v e l s c h a r a c t e r -i z e d both nonschizophrenic and some a c u t e l y d i s t u r b e d s c h i z o p h r e n i c p a t i e n t s . The present data suggest t h a t i n s t i t u t i o n a l i z e d nonparanoid s c h i z o p h r e n i c s perform a t s i g n i f i c a n t l y e l e v a t e d l e v e l s on c e r t a i n measures of thought d i s o r d e r . The remaining groups of paranoid and p h y s i c a l l y i l l p a t i e n t s are more or l e s s comparable to each o t h e r . Depending on one's d e f i n i t i o n of "thought d i s o r d e r , " i t i s e i t h e r l i m i t e d to a subgroup of these c h r o n i c s c h i z o -p h r e n i c s or i t i s to be found i n s c h i z o p h r e n i c and non-p s y c h i a t r i c p a t i e n t s , a l b e i t with g r e a t e r s e v e r i t y among some s c h i z o p h r e n i c s . 115 Comparison to Findings of E a r l i e r Studies The obtained support for hypotheses l a and 2a suggests that the present findings i n e f f e c t r e p l i c a t e vocabulary performance results previously reported with comparable samples of schizophrenic patients (Klinka & Papageorgis, 1976; Rattan & Chapman, 1973) . Furthermore (Table 20), the vocabulary subtest means from the present study are similar to means reported i n the e a r l i e r investigations. Table 20 compares data from the present sample of long-term hospitalized schizophrenic patients to data from chronic schizophrenics reported previously. I t can be seen that mean accuracy scores on the two subtests (with the exception of the paranoid patients) are reasonably si m i l a r and that the d i f f e r e n t i a l accuracy between the two subtests i s consistently obtained i n a l l investigations. In addi-tion, actual d i s t r a c t o r choice means are proportionally and inversely related to the accuracy means of the subtest with associative d i s t r a c t o r s . Thus, the decreased accuracy on t h i s subtest appears to be mainly the r e s u l t of subjects' actually choosing the associative d i s t r a c t o r a l t ernatives. I t i s also noteworthy that the means between investigations are comparable despite the nonmedicated status of the Rattan and Chapman sample. The findings further suggest that paranoid schizophrenics should be Table 20 Accuracy and Distr a c t o r Mean Scores of Long-term Hospitalized Schizophrenic Patients on the Multiple-choice Vocabulary Test Paranoid Schizophrenics (n=15) Klinka, 1980 Nonparanoid Schizophrenics (n=15) Paranoid and Nonparanoid Schizophrenics combined (N=30) Klinka and Papageorgis, 1976 Medicated (mixed) Schizophrenics (N=14) Rattan and Chapman, 1973 Nonmedicated (mixed) Schizophrenics (N=42) ND subtest D a subtest Distractors 29.13 27.86 14.86 31.13 17.60 30.53 30.13 22.73 22.69 23.92 17.78 27.94 28.00 22.43 21.79 ND: Subtest without d i s t r a c t o r s ; D: Subtest with d i s t r a c t o r s . 117 viewed as a d i s t i n c t group from other schizophrenic patients. With regard to Object Sorting Test indices, the most appropriate data available for comparison with the present data are means on behavioral overinclusion, conceptual overinclusion, and idi o s y n c r a t i c thinking obtained by Harrow, Tucker, Himmelhoch, and Putnam (1972) . Table 21 shows data relevant to this comparison. It should be noted that the Harrow et a l . sample was composed of female schizophrenics with an average length of current h o s p i t a l -i z a t i o n of 9.8 years. Despite the differences between the two samples, the means for idi o s y n c r a t i c thinking and conceptual overinclusion are quite s i m i l a r , and are p a r t i c u l a r l y so i n the case of the nonparanoid schizo-phrenic patients. Again, the paranoid schizophrenic patients appear to represent a group that i s d i s t i n c t from other schizophrenic patients. A b i l i t y of the Various Measures to Discriminate Between Groups There seems to be l i t t l e reason to doubt the u t i l i t y of the Rattan and Chapman vocabulary subtests for studies that evaluate cognitive d e f i c i t s . The mean differences between the hospitalized nonparanoid schizophrenics and a l l other groups were, with only one exception, s i g n i f i c a n t (Table 15), as were the relevant cfoi-square comparisons Table 21 Mean Rating Scores on Long-term Hospitalized Schizophrenic Patients on Some Concept Formation Measures Klinka, 1980 Harrow et a l . , 1972 Behavioral Overinclusion Paranoid Schizophrenics (n=15) 16.86 Nonparanoid Schizophrenics (n=15) 20.06 Paranoid and Nonparanoid Schizophrenics combined (N=30) 18.46 Female (mixed) Schizophrenics (N=31) 30.61 Conceptual Overinclusion 1.96 2.10 2.03 2.45 Idiosyncratic Thinking 1.50 2.03 1.76 2.19 oo 119 reported i n the l a s t section of the previous chapter. The measure of behavioral overinclusion, i n contrast, f a i l e d to d i f f e r e n t i a t e between groups: mean scores were quite s i m i l a r and r e l a t i v e l y low. I t seems that this index, i f elevated, may indeed measure patients' excessive behavioral output rather than the quality of (schizophrenic) thinking. Low scores obtained on behavioral overinclusion then can be plausibly explained, i n l i n e with Harrow, Tucker, Himmelhoch, and Putnam (1972), i n terms of the subjects' reduced mental and motor a c t i v i t i e s . Character-i s t i c s of apathy and withdrawal, frequently observed i n patients with prolonged h o s p i t a l i z a t i o n , are c e r t a i n l y not inconsistent with the above suggestion. Likewise, lowered motivational and energy levels are, speculatively speaking, major reasons behind comparatively low behavioral overinclusion scores of nonhospitalized yet s t i l l c h ronically i l l subjects. Conceptual overinclusiveness was found to be elevated for both paranoid and nonparanoid schizophrenics regard-less of t h e i r h o s p i t a l i z a t i o n status, and s l i g h t l y elevated for hospitalized physically i l l patients. Thus, this index may be useful for evaluating certain aspects of disturbed thinking i n schizophrenic patients (Harrow, Harkavy, Bromet, & Tucker, 1973), but does not appear to be p a r t i c u l a r l y suitable for comparison of h o s p i t a l i z a t i o n 120 effects i n long-term schizophrenic patients. The index of id i o s y n c r a t i c thinking, on the other hand, was he l p f u l i n d i f f e r e n t i a t i n g among various sub-groups. The mean differences between the hospitalized nonparanoid schizophrenics and a l l other subgroups were, again with only one exception, s i g n i f i c a n t (Table 9). Also s i g n i f i c a n t were the relevant chi-square contrasts presented e a r l i e r . Comparison of the present findings to related post-hospital data of acutely hospitalized schizophrenics by Harrow et a l . (1973) lend further, though q u a l i f i e d , support to the Harrow team's contention concerning con-sistency of selected thought disorder indices over time. It i s probable that conceptual overinclusiveness, besides being a function of acute pathology, i s a permanent c h a r a c t e r i s t i c of disturbed thinking for a subgroup of acute schizophrenics. Idiosyncratic components, however, have a greater chance of continuing to characterize the cognitive a c t i v i t y of acutely disturbed schizophrenics, but only when these patients bear primarily a nonparanoid diagnosis and remain i n s t i t u t i o n a l i z e d . F i n a l l y , based on the present r e s u l t s , the measures of concrete and underinclusive thinking appear to be of rather limited u t i l i t y . Although the a b i l i t y to generate abstract categories on object sorting tasks seemed better preserved 121 in nonhospitalized than i n hospitalized subjects, the sub-group differences were nonsignificant. Further refinement of the concrete thinking index i s therefore needed before i t may prove i t s usefulness i n discriminating between various modes of cognitive functioning. As to the schizo-phrenic subgroups' mean scores on the underinclusive thinking measure, they were higher r e l a t i v e to scores on the conceptual overinclusion measure. If the two measures are viewed as extremes of a dimension measuring " i n c l u s i v e -ness," then i t may be argued, i n accord with Andreasen and Powers (1976), that schizophrenic patients tend to be disturbed i n the d i r e c t i o n of underinclusiveness more than i n terms of conceptual overinclusion. This matter cer-t a i n l y warrants further investigation. Influence of- Psychoactive Medication With the exception of 5 nonpsychiatric patients who were completely drug-free at the time of testing, the present study dealt with medicated subjects. A l l psychi-a t r i c (schizophrenic) patients were on either a single type or on various combinations of phenothiazines or s i m i l a r l y - a c t i n g compounds, frequently supplemented with medication against s i d e - e f f e c t s . Nonpsychiatric patients were taking small dosages of minor t r a n q u i l i z e r s , pre-dominantly as muscle relaxants, and/or s p e c i f i c drugs on 122 an i n d i v i d u a l basis, such as analgesics, sedatives, a n t i -hypertensives, and antibiotics , multivitamins , etc. (Appendix 9.1). As stated previously, d a i l y drug intake of schizo-phrenic inpatients was s i g n i f i c a n t l y (p<.05) higher than that of schizophrenic outpatients, but there were no s i g n i f i c a n t differences within the h o s p i t a l i z e d and within the outpatient subgroups. In view of the low and nonsignificant relationships obtained between the d a i l y amounts of psychoactive medication and the subjects' performance on a l l dependent measures, i t seems that psycho-active drugs probably, have a n e g l i g i b l e d i f f e r e n t i a l e f f e c t on the thought disorder indices employed i n t h i s study. The present findings, however, may be generalized only to schizophrenic patients under s i m i l a r antipsychotic drug regimens. Nature of Control Subjects The control nonpsychiatric subjects i n the present investigation included cases of multiple s c l e r o s i s (14 sub-jects) , and Friedreich's ataxia (2 subjects). The inclusion of such cases and perhaps even of patients with permanent spinal i n j u r i e s may be questioned i n l i g h t of one of the c r i t e r i a set up for subject selection, i . e . , the exclusion of subjects with past or present signs of organicity. 123 While e a r l i e r s t u d i e s (e.g., Parsons, Stewart, & Arenberg, 1957; Jambor, 1969) d i d r e p o r t evidence suggestive of impairment of conceptual t h i n k i n g and/or i n t e l l e c t u a l e f f i c i e n c y , R eitan, Reed, and Dyken (1971) found t h a t m u l t i p l e s c l e r o s i s p a t i e n t s , i n c o n t r a s t t o matched medical p a t i e n t s , showed d e f i c i e n c y on a number of t e s t s demanding p r e c i s e motor f u n c t i o n i n g , but were r e l a t i v e l y m i l d l y impaired i n tasks r e q u i r i n g a b s t r a c t reasoning and l o g i c a l a n a l y s i s ( c f . Ionik, 1978; Karagan, 1979). I n c o n s i s t e n c i e s i n r e s e a r c h f i n d i n g s w i t h regard to estimates of i n t e l l e c -tual decrement i n the m u l t i p l e s c l e r o s i s s u b j e c t s may, to a l a r g e extent, depend on the p a r t i c u l a r t e s t s used; and a l s o to some extent on s e l e c t i o n c r i t e r i a f o r c o n t r o l groups, and h o s p i t a l i z a t i o n s t a t u s . Furthermore, the i n s i d i o u s onset of the m u l t i p l e s c l e r o s i s symptoms, i n a d d i t i o n to impeding d i a g n o s i s , precludes proper d e t e r -m i n a tion of the commencement of the d i s e a s e and, t h e r e -f o r e , of l e n g t h of i l l n e s s . F i n a l l y , as the p h y s i c a l symptoms c h a r a c t e r i s t i c a l l y f o l l o w d i f f e r e n t courses and f l u c t u a t e with time, or i n s e v e r i t y i n some cases, so may c o g n i t i v e f u n c t i o n i n g . In any case, i t has been shown t h a t p h y s i c a l l y i l l p a t i e n t s (with the m u l t i p l e s c l e r o s i s p a t i e n t s about e q u a l l y d i s t r i b u t e d among h o s p i t a l i z e d and n o n h o s p i t a l i z e d groups) i n the present i n v e s t i g a t i o n were c l e a r l y l e s s 124 l i k e l y to display cognitive impairment than schizophrenic patients. The performance of nonpsychiatric nonhospitalized. patients most l i k e l y resembles that of healthy normal con-t r o l subjects. The possible d i s t o r t i o n i n the data through the inclu s i o n of the multiple s c l e r o s i s patients thus may be dismissed i n view of the obtained performance levels of both nonpsychiatric samples which indicated minimal i n t e l l e c t u a l deterioration and/or disordered thought. The decision to include such patients was also dictated by p r a c t i c a l considerations: there simply were not enough control candidates elsewhere suited for matching with long-term schizophrenic patients. S t i l l , only those individuals suffering from demyelinating disease or i r r e v e r -s i b l e spinal cord damage who were judged by hospital s t a f f to be s o c i a l l y adjusted and i n t e l l e c t u a l l y i n t a c t — w i t h i n the l i m i t s imposed by t h e i r c ondition—served as non-psychiatric controls i n thi s i nvestigation. (These same c r i t e r i a were also c r i t i c a l for the selection of other nonpsychiatric control subjects). Thus, even though some noticeable capriciousness and i r r i t a b i l i t y were seen i n some of the control subjects, no subject presented evidence of personality disturbance beyond what could be c l e a r l y understood as a s t r a i g h t f o r -ward consequence of e f f o r t s to adjust to a d e b i l i t a t i n g physical i l l n e s s . 1 2 5 P r a c t i c a l Implications Bearing i n mind that the present investigation has dealt only with a few selected aspects of thought disorder i n schizophrenia and that, s i g n i f i c a n t as these aspects may be, they c l e a r l y represent a very limited area of thi s disorder, i t i s s t i l l possible to venture a few tentative conclusions which contain some p r a c t i c a l implications. In the f i r s t place, as the findings from the nonparanoid schizophrenics make clear, disordered thinking i s a character-i s t i c of some long-term schizophrenics even when th e i r hos-p i t a l stay has been quite b r i e f , r e l a t i v e l y speaking. Thus, disordered thought, as defined by the measures used i n the present investigation, cannot be e n t i r e l y attributed to the e f f e c t s of prolonged h o s p i t a l i z a t i o n . At the same time, however, disordered thinking i s more pronounced i n those nonparanoid schizophrenics who have spent many years i n ho s p i t a l . One possible i n t e r p r e t a t i o n would be that lengthy h o s p i t a l i z a t i o n aggravates an already ex i s t i n g c h a r a c t e r i s t i c i n nonparanoid schizophrenics who may be for some reason p a r t i c u l a r l y vulnerable to h o s p i t a l i z a t i o n effects or at least lack the i n v u l n e r a b i l i t y that may characterize paranoid schizophrenics (see below). In any event, from the p r a c t i c a l standpoint, i t would appear especially important to attempt to keep h o s p i t a l i z a t i o n 126 of nonparanoid schizophrenics to a minimum consistent with the requirements of treatment and other broader s o c i e t a l considerations. Secondly, the picture that emerges concerning paranoid schizophrenics i s quite d i f f e r e n t . Again bearing i n mind the li m i t a t i o n s of the variables examined i n the present study, chronic paranoid schizophrenics appear to be only minimally affected by certain forms of disordered thought and i n t h i s sense are quite d i f f e r e n t from nonparanoid schizophrenics. Morover, paranoid schizophrenic patients do not seem to be adversely affected by prolonged h o s p i t a l -i z a t i o n . The reasons for t h i s are unclear, however,- i t may be simply that no i l l n e s s process s p e c i f i c to the aspects of thought disorder under consideration exists i n these patients to begin with and, hence, there i s l i t t l e l i k e l i h o o d of aggravation of what may have never existed or did ex i s t only temporarily during an early, acute phase of the psychosis. A l t e r n a t i v e l y , the paranoid schizo-phrenics may be p a r t i c u l a r l y able to r e s i s t the adverse effects of prolonged i n s t i t u t i o n a l i z a t i o n by means of th e i r greater alertness, suspiciousness, lack of cooperation, and delusional b e l i e f s . In any event, once more the p r a c t i c a l implication i s that adverse effects of i n s t i t u - . tionalization should be of less r e l a t i v e concern i n the case of paranoid schizophrenic patients. 127 The findings of the present study have also provided evidence that some aspects of thought disorder (suscep-t i b i l i t y to associative intrusions, tendencies toward id i o s y n c r a t i c or bizarre concept formation) are more ch a r a c t e r i s t i c of long-term schizophrenic psychoses than are other aspects (e.g., behavioral overinclusion). Both associative d i s t r a c t o r s u s c e p t i b i l i t y and i d i o s y n c r a t i c thinking can cause considerable departures from consensually defined perceptions of r e a l i t y and s o c i a l l y expected patterns of interpersonal communication. Therapeutic e f f o r t s directed at these s p e c i f i c d e f i c i t s would be most useful especially i n the case of nonparanoid schizophrenic patients regardless of h o s p i t a l i z a t i o n status. For instance, communication to such patients should probably emphasize brevity and unequivocality while avoiding vague-ness, equivocality, and metaphorical language. In a more general vein, the importance of keeping meaningful communi-cation channels between patients and t h e i r immediate s o c i a l environments open, as a part of r e s o c i a l i z a t i o n e f f o r t s (Paul, 1968), appears quite obvious. F i n a l l y , an obvious but s t i l l necessary further note of caution must be added. A l l the differences i n vocabulary and conceptual performance that were obtained i n the present study are c l e a r l y differences between groups of patients. They do not necessarily apply to single individuals within 128 any of these groups, and, hence, by themselves have probably l i t t l e u t i l i t y for i n d i v i d u a l diagnostic assignments. 129 Chapter 6 Summary and Conclusions The present study was designed to investigate suscep-t i b i l i t y to interference from associative d i s t r a c t o r s and certai n concept formation p e c u l i a r i t i e s i n samples of long-term schizophrenic and nonpsychiatric patients that consisted of hospitalized and nonhospitalized subjects. Ninety patients i n the three basic groups, i . e . , paranoid schizophrenic, nonparanoid schizophrenic, and non-psychiatric patients were selected according to t h e i r h o s p i t a l i z a t i o n status (inpatients with minimally 2 years of continuous stay i n ho s p i t a l , and outpatients with single or multiple hospital admissions not exceeding 6 months) so that s i x subgroups were formed each containing an equal number of subjects (n=15). Since the subgroups were comparable on some but not quite equivalent on other variables of potential influence (current severity of i l l n e s s , c h r o n i c i t y ) , s t a t i s t i c a l controls were introduced i n the analyses, and the data were interpreted with certain s p e c i f i e d reservations. Main objectives of the study included separation of chronicity (length of i l l n e s s ) from length of h o s p i t a l -i z a t i o n , s p e c i f i c a t i o n of d i f f e r e n t i a l task performance i n 130 r e l a t i o n to diagnosis, and the assessment of effects of i n s t i t u t i o n a l i z a t i o n on the above cognitive performance measures. A l l subjects were i n d i v i d u a l l y tested with the multiple-choice vocabulary test of associative interference and with the Object Sorting Test. As had been hypothesized, the nonparanoid hospitalized schizophrenics were found to be far more susceptible to vocabulary associative i n t e r -ference than the hospitalized paranoid schizophrenics or the h o s p i t a l i z e d nonpsychiatric patients. Even among nonhospitalized patients, the nonparanoid schizophrenics showed greater s u s c e p t i b i l i t y to associative d i s t r a c t o r s than the other two groups. In terms of concept formation indices derived from the Object Sorting Test, the non-paranoid schizophrenic inpatients showed instances of i d i o s y n c r a t i c thinking s i g n i f i c a n t l y more often than patients i n every other subgroup. Thus, the results of the present investigation indicated that: (a) certain measures of thought disorder (vocabulary associative interference and i d i o s y n c r a t i c thinking) are better suited for the assessment of long-term cognitive d e f i c i t s than other measures (e.g., overinclusion); (b) prolonged i n s t i t u t i o n a l stay has an adverse but quite s p e c i f i c r elationship to the cognitive perform-131 ance of some chronic patients; s p e c i f i c a l l y , t h i s adverse relationship characterizes nonparanoid schizophrenics, while there i s only minimal evidence for i t s presence among stringently defined paranoid schizophrenic patients. Directions for Further Research While the present investigation generally confirmed the u t i l i t y of some of the measures used, i t also raises questions about the s u i t a b i l i t y of others and/or t h e i r inherent l i m i t a t i o n s . Thus, a reasonable f i r s t step for future research should involve the development of additional indices of thought processes or conceptual styles that are suitable for use with both normal and p s y c h i a t r i c a l l y disturbed i n d i v i d u a l s . Categories of disordered verbalization, based on free speech samples, as described by Siegel, Harrow, R e i l l y , and Tucker (1976), are one example of such measures. In cases where new test devices are contemplated, careful consideration should probably be given to the structure of natural language rather than focusing on single, i s o l a t e d words as i s c l e a r l y the case with the vocabulary used i n the present study. Pavy (1968) r i g h t l y argued that placing an emphasis on misinterpreta-tion of ambiguous words, mediated by response bias, l i m i t s 132 the g e n e r a l i z a b i l i t y of findings. Following M i l l e r ' s (1965) argument, Pavy went on to state that . . . the meaning of an utterance i s not the l i n e a r sum of the meanings of the words that comprise i t . This implies that studies which r e s t r i c t themselves to the meaning of i s o l a t e d words are dealing with a quite unnatural s i t u a t i o n and are probably of very limited value . . . the pen i n 'fountain pen' and the pen i n 'cattle pen' are very d i f f e r e n t pens. (Pavy, 1968, p. 172). In t h i s perspective, newly developed psychometric i n s t r u -ments should seriously consider issues of transformational grammar, c o l l o q u i a l phrasing (cf. M i l l e r , 1974) and perhaps of further separation of the. morphemic and/or s y n t a c t i c a l (cf. Blaney, 1974) from l e x i c a l c h a r a c t e r i s t i c s of language. Combined e f f o r t s of experimental psychopathologists and psycholinguists interested i n verbal behavior thus appear necessary i n future research of what i s known as "formal thought disorder." Further improvement i n subject selection, p a r t i c u l a r l y i f investigations are to be conducted by means of a cross-sectional design, i s also needed. In view of the complex-i t i e s of i n s t i t u t i o n a l i z a t i o n variables, the i n c l u s i o n of other chronic groups i s c a l l e d for; s i m i l a r l y , t i g h t e r control of already recognized variables of importance such as patients' cooperativeness (capability and w i l l i n g -ness to l e t themselves be tested), current severity of i l l n e s s , premorbid adjustment, drug status, and diagnostic subtype i s recommended. 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Impairment i n a b s t r a c t c o n c e p t u a l i z a t i o n i n s c h i z o p h r e n i a . Psychological Bulletin, 1975, 82, 120-12,7 . Wynne, R.D. The i n f l u e n c e of h o s p i t a l i z a t i o n on the v e r b a l behavior o f c h r o n i c s c h i z o p h r e n i c s . British Journal of Psychiatry, 1963, 109, 380-389. Yarrow, L . J . Maternal d e p r i v a t i o n : Toward an e m p i r i c a l and c o n c e p t u a l r e e v a l u a t i o n . Psychological Bulletin, 1961, 58, 459-490. APPENDIX 1 Object Sorting Test C r i t e r i a 148 Object Sorting Test C r i t e r i a Behavioral Overinclusion. This i s the t o t a l number of objects sorted with a l l seven s t a r t i n g objects, ir r e s p e c t i v e of the quality of thinking. Conceptual Overinclusion. A score of 1 represents normal, l o g i c a l sortings whereas a score of 5 indicates maximal overinclusiveness. Sorting behavior leading to high ratings includes i n a b i l i t y to form or maintain a category, the use of vague or unrelated concepts to arrange groups, a r b i t r a r i l y changing s t a r t i n g objects, and " f o r c e - f i t t i n g " objects into a category into which they do not belong. I d i o s y n c r a t i c Thinking. A score of 1 i s assigned for no bizarre responses i n sortings and a score of 5 for extremely bizarre responding, such as engaging i n strange, inappropriate behavior toward the investigator or test, using the s t a r t i n g object i n reference to per-sonal experience, or using i t as a cue understandable only to the subject. Concrete Thinking. This type of behavior receives a score of 1 i f no concreteness i s noted and a score of 5 for extreme concreteness. Concrete thinking i s manifested by the subjects' i n a b i l i t y to extract an abstract dimension from the s t a r t i n g object, by tendencies to change the name 149 of the s t a r t i n g object, and by stimulus-bound responding ("chaining") i n which the f i n a l selection of objects has no relationship to the s t a r t i n g object. Underinclusive Thinking. A score of 1 represents no underinclusiveness whereas a score of 5 represents maximal evidence of underinclusive thinking. High scores for this measure are assigned to subjects who are unable to sort at a l l i n response to some of the s t a r t i n g objects, who do not complete sortings, and who repeatedly use the same categorizing p r i n c i p l e . APPENDIX 2 Scoring Sheet of the Object Sorting Test 151 Scoring Sheet of the Object Sorting Teat Patient 0 Date Conceptual overinclusion Idiosyncratic thinking Concrete thinking Underinclusive thinking Total // objects Objects starting points verbalization - sets - behavior. 1|2 3 4 5 6 7 1. Sink Stopper 1. Fork I | "2. Knife 3. Spoon 4. Toy Fork —1 1 5. Toy Knife i —1 , — 6. Toy Spoon i i 1 7. Red Rubber Bail 2. Fork H. Red Wax Apple 9. Red Paper Circle j 1U. Red Saucer j i — - 11. Red Poker Chip 1 j 12. Vellow Poker Chip i • 1 " — ! I J . ioy cnina uog ! 14. Toy Clapper 3. Pipe 1" 15. Bicycle Bell j - lb. Toy Screwdriver — j — j . — j 1/. Toy saw !—IB7~~T6y F i l e 19. Toy Hammer zu. acrewariver —TT.—Pliers ! 22. Block with Nail 1 — r — - \ -4. Bicycle Bell j 23. Sink Stopper j "74.' PadlocF ! '^jTTadlock with 2 Keys l.\ 1 1-i —26:—Rubber Cigar ')"} Ruhhle Gum Clear 1 — i — — 28. Candy Cigarettes 29. Cigarette 5. Red Paper Circle 30. Cigar "31. Pipe " ~ ._ ..... .-. .-32. Matchbox 33. Red Candle 34T White Candle "35". Sugar Cube 36. Sugar Cube i 6. Pliers 37. Cork 1 j a _ 38. Eraser _ _ j j - . i Totals 7. Red Rubber Ball Comments I i APPENDIX 3 Behavior Checklist 153 Patient # N a m e o f^ Rater: Date: Behaviour Checklist  Part I A, Duration of present i l l n e s s : weeks ( i f duration or anticipated duration i s less than 2 weeks, do MOT continue), B. Symptoms present (in a l l cases c i r c l e either "yes" or "no"): (definition numbers refer to the RDC C r i t i c a l Terms: please consult). l a . Thought Broadcasting (Definition #2) Yes No lb . Thought Insertion (Definition #3) Yes No l c . Thought Withdrawal (Definition #4) Yes No 2a. Delusions of Control (Definition 05) Yes No 2b. Other Bizarre Delusions (Definition 96) Yes No 2c. Multiple Delusions (Definition 07) Yes No 3. Delusions other than Persecutory or Jealousy lasting at least one week Yes No 4. Delusions of any type IF accompanied by hallucinations of any type for at least one week Yes No 5. Auditory Hallucinations i n which Either a voice keeps up a running commentary on the subject's behaviours ox thoughts as >they occur, OR two or more voices converse with each other Yes No 6. Non-Affective Verbal Hallucinations spoken to the Subject (Definition 910). Yes No 7a. Hallucinationo of Any Type throughout the day for several days. Yes No 7b. Hallucinations of any type intermittently for at least a month. Yes No 8. Definite instances of formal thought disorder (Definition 91) as follows: a. Incoherence Yes No b. Loosening of associations Yes No c. I l l o g i c a l thinking Yes No d. Poverty of content of speech Yes No e. Delusions involving the Von Domarus -Principle Yes No 9. Obvious Catatonic Motor Behaviour (Definition #9) Yes No (Note; If a l l Section B ratings have been "No", do not continue^ with the experiment). C. Patient exhibits signif icant mood disturbances that are a prominent part of the i l lness * Refers to d i s t i n c t periods of either dysphoric (depressed, hopeless, saa, etc. 5 or elevaterj—or i r r i t a t e d mood APPENDIX 4 B e l i e f Rating Sheet BELIEF RATING SHEET 156 A. Throughout the active period of the il l n e s s , the c l i n i c a l picture i s dominated by the relative! persistence of or preoccupation with one or more of the following: 1. Persecutory delusions: Yes No 2. Grandiose delusions: Yes No 3. Delusions of jealousy: Yes No 4. Hallucinations with a persecutory or grandiose content: Yes No B. 1. Does patient tend to suspect or to believe on slight evidence or without good reason that people and external forces are trying to or now do influence his/her behavior and control his/her thinking? no unjustified suspicions Will admit suspicion when pressed Easily admits suspicion Openly states others are trying to control Has firm conviction that i s i n -fluenced or controlled. 2. Does patient tend to suspect or to believe on slight evidence or without good reason that some people talk about, refer to, or watch him/her? No unjustified suspicions Will admit suspicion Easily admits uuspicion Openly states that i s being watched Has firm conviction of being watched 3 . Does patient tend to suspect or to believe on slight evidence or without good reason that some people are against him/her (persecuting, conspiring, cheating, depriving, punishing) in various ways? no unjustified suspicions expressed when pressed expressed belief that i s conspired against Frequently inclined to suspect frank i n c l i n -ation to believe in persecution strongly ex-pressed con-viction of persecution 4. Does patient have an exaggeratedly high opinion of self or an unjustified belief or conviction of having unusual a b i l i t y , knowledge, power, wealth or status? no expressed high opinion of self when pressed ex-presses a high opinion of self frequently ex-presses a high opinion of self open con-viction of un-usual power, wealth, etc. strongly ex-pressed con-viction of grandiose or fantastic power,wealth, etc. 157 APPENDIX 5 Comparison of Dependent Variable Measure Means Between the Two Nonparanoid Schizophrenic Subsamples Appendix 5 Comparison of Dependent Variable Measure Means Between the Two Nonparanoid Schizophrenic Subsamples Group (n=23) " c l e a r l y non-paranoid" Group (n=7) "nonparanoid with mild paranoid signs" two-tailed t - t e s t s for inde-pendent means Vocabulary Difference Score Behavioral Overinclusion Conceptual Overinclusion Idiosyncratic Thinking M = 11.69 M = 20.39 M = 2.10 M = 8.28 s =66.58 2 *1 s =35.01 -M s =.497 M = 1.76 17.00 o 1.71 M = 1.35 t(28)=.97 t (28) =1.33 t(28)=1.29 t(28)=1.10 s =.742 Concrete Thinking M = 2.10 M = 1.78 s =.246 t(28)=1.51 Underinclusive Thinking M = 2.47 s =.544 2.50 t(28) = .09 , ... For df=28, a t=2.048 i s required for s i g n i -ficance at the .05 l e v e l , APPENDIX 6 Comparison of Dependent Variable Measure Means Between the Two Paranoid Schizophrenia Subsamples Appendix 6 Comparison of Dependent Variable Measure Means Between the Two Paranoid Schizophrenic Subsamples Group (n=18) "paranoids" Group (n=12) "exemplary paranoid" two-tailed t - t e s t s f o r independent means Vocabulary Difference Score Behavioral Overinclusion M = 2.77 M = 3.41 s =14.71 M = 21.11 M = 17.00 s =127.35 t(28)=.45 t(28)=.98 Conceptual Overinclusion M = 2.16 M = 1.75 s =.616 t (28-) =1.40 Idiosyncratic Thinking M = 1.36 M = 1.41 s =.476 t(28) = .20 Concrete Thinking M = 2.00 M = 1.83 s =.256 t(28)=.90 w Underinclusive Thinking M = 2.19 M = 2.41 s =.874 t(28)=.63 For df=28, a t=2.048 i s required f o r s i g n i f i c a n c e at the .05 l e v e l . APPENDIX 7 Background Information Sheet 162 BACKGROUND INFORMATION SHEET PART A. 1. Patient #: • Native language English Yes No (circle) 2. Sex (circl e ) : M F 3. Age (years): (date of birth): 4. Education ( c i r c l e ) : last grade completed 6 7 8 9 10 11 12 college, vocational school, etc. 1 2 3 4 degree: 5. Psychiatric history in family: ____________________ _ 6. Father's occupation: 7. Patient's occupation prior to f i r s t hospitalization: 7a. Average income: 8. Present marital state ( c i r c l e ) : married separated divorced (details to be completed i n single widowed Parts B,C,D and E that follow). 9. Psychiatric f i r s t admission? ( c i r c l e ) : YES NO If "Yes", (a) admission date: Diagnosis: (b) date seen for testing: 10. Psychiatric Re-admission? ( c i r c l e ) : YES NO If "Yes", (a) admission date: Diagnosis: (b) date seen for testing: (c) date of f i r s t psychiatric admission: • diagnosis: (d) how many previous psychiatric hospitalizations?: diagnoses: _____________ 163 10. Psychiatric Re-admission? (cont'd): (e) estimated total time spent as psychiatric inpatient i ) during past three years: months i i ) since f i r s t hospital izat ion: months. 11. Present therapy: 12. Drug regimen? YES NO. (c i rc le ) . If "Yes", a) medication b) amount in Mg per day c) Chlorpromazine equivalent d) started date e) e) discontinued date PART B. 1. Married now and l iv ing with spouse? YES NO (circle) Note: If "YES", continue on items 2 or 3 of Part B, then complete Part E; If "NO", complete item 4 of Part B or Part C or D, whichever i s appropriate, then complete Part E. 2. Married only once (or remarried only one time as a consequence of death of spouse) and l i v ing as a unit? YES NO If "NO", go to item 3. If "YES", adequate heterosexual relations achieved? YES NO. If "NO", a) low sexual drive? (either partner) YES NO. b) d i f f i c u l t sexual relations? (either partner) YES NO c) extramarital affairs? (either partner) YES NO 3. Married more than once but maintained a home in one marriage for at least 5 years? YES NO. If "NO", go to item 4. If "YES", adequate sexual relations achieved during at least one marriage? YES NO. If "NO", sexual l i f e chronically inadequate? YES NO. 4a. Married but apparently permanently separated divorced , . , x (c i rc le one). widowed without remarriage? 4b. A home with (any) spouse was maintained during a marriage for a period: less than 5 years. at least 5 years, ( c i rc le ) . 164 PART C. 1. Single (i.e., never married), age 20-29 years? YES NO. Note; If "NO", go to Part D and E; If "YES", complete this Part (C) to an applicable degree, then complete Part E. 2. Has or has had at least one long-term (minimum: 6 months) "love a f f a i r " or engagement? YES NO. If "NO" go to item 3; If "YES", engaged now or at any time in the past? YES NO. 3. Has or has had short-term heterosexual or social dating experience with one or more partners? YES NO If "NO" go to the next item 4. Has or has had casual sexual or social relationships with persons of either sex, with no deep emotional meaning? NO If "NO" go to the next item 5. Has or has had sexual and/or social relationships primarily with the same sex but has or may have had occasional heterosexual contacts or dating experiences? Y E g N Q > If "NO" go to the next item 6. Has or has had minimal sexual or social interest in either men or women? YES NO PART D. 1. Single (i.e., never married), age 30 or over? YES NO. If "YES" complete this Part (D) to an applicable degree, then complete Part E. 2. Engaged now or at any time in the past or has or has had a long-term (at least 2 years) relationship with one person of the opposite sex ("love affair")? YES NO. If "NO" go to the next item. 3. Has or has had short-term heterosexual or social dating experience with one or more partners? YES NO. If "NO" go to the next item. 4. Has or has had sexual and/or social relationships primarily with the same sex bat has or may have had occasional heterosexual contacts or dating experiences? YES NO. 165 PART D (cont'd): 5. Has or has had minimal sexual or social interest in either men or women? YES NO. PART E. 1. The f i r s t three items concern formally designated groups, clubs, organizations, or athletic teams i n senior high school, vocational school, college, or in young adulthood: a) Is or was a leader or officer? YES b) Is or was an active and interested participant? YES c) Is or was a nominal member only? YES 2. The next three items refer to the period from adolescence through early adulthood (i.e., after childhood): a) Had only a few casual or close friends? b) Had no real friends, only a few superficial relationships or attachments to others? c) Was quiet, seclusive; preferred to be alone; showed minimal efforts to maintain any contacts at a l l with others? 3. From early childhood no desire to be with playmates, peers or others? NO NO NO YES NO YES NO YES NO YES NO APPENDIX 8 Global Assessment Scale (GAS) 167 Global Assessment Scale (GAS) Robert L. Spitzer.M.D., Miriam Gibbon,M.S.W., Jean Endicott,Ph.D. Rate the subject's lowest level of functioning in the last week by selecting the lowest range which describes his functioning on a hypothetical continuum of mental health-illness. For example, a subject whose "behavior i s considerably influenced by delusions" (range 21-30), should be given a rating in that range even though he has "major impairment in several areas" (range 31-40). Use intermediary levels  when appropriate (e.g., 35,58.62). Rate actual functioning independent of whether or not subject i s receiving and may be helped by medication or some other form of treatment. GAS Rating: 100 No symptoms, superior functioning i n a wide range of a c t i v i t i e s , l i f e ' s 1 problems never seem to get out of hand, i s sought out by others because 91 of his warmth and integrity. 90 Transient symptoms may occur, but good functioning a l l areas, interested and I involved in a wide range of a c t i v i t i e s , socially effective, generally satisfied 81 with l i f e , "everyday" worries that only occasionally get out of hand. 80 Minimal symptoms may be present but no more than slight Impairment in function-I ing, varying degrees of "everyday" worries and problems that sometimes get out 71 of hand. 70 Some mild symptoms (e.g., depressive mood or mild insomnia) OR some d i f f i c u l t y in several areas of functioning, but generally functioning pretty well, has some meaningful interpersonal relationships and most untrained people would 61 not consider him "sick". 60 Moderate symptoms OR generally functioning with some d i f f i c u l t y (e.g., few J friends and f l a t affect, depressed mood and pathological self-doubt, euphoric 1 mood and pressure of speech, moderately severe antisocial behavior). 50 Any serious symptomatology or impairment in functioning that most clinicians would think obviously requires treatment or attention (e.g., suicidal pre-occupation or gesture, severe obsessional r i t u a l s , frequent anxiety attacks, 41 serious antisocial behavior, compulsive drinking). Patient # Admission Date Date of Rating Rater .continued 168 - 2 -AO Major Impairment i n several areas, such as work, family r e l a t i o n s , judgment, thinking or mood (e.g., depressed woman avoids friends, neglects family, unable to do housework), OR some impairment i n r e a l i t y testing or communication (e.g., speech i s at times obscure, i l l o g i c a l or i r r e l e v a n t ) , OR single serious 31 suicide attempt. 30 Unable to function i n almost a l l areas (e.g., stays i n bed a l l day), OR behavior i s considerably influenced by either delusions or hallucinations, OR serious impairment i n communication (e.g., sometimes incoherent or unresponsive) 21 or judgment (e.g., acts grossly inappropriately). 20 Needs some supervision to prevent hurting self or others, or to maintain minimal personal hygiene (e.g., repeated suicide attempts, frequently v i o l e n t , manic excitement, smears feces), OR gross impairment i n communication (e.g, largely 11 incoherent or mute). 10 Needs constant supervision for several days to prevent hurting s e l f or others, | or makes no attempt to maintain minimal personal hygiene (e.g., requires an 1 intensive care unit with special observation by s t a f f ) . 169 APPENDIX 9 Appendix 9.1 Drug Status of Subjects: Paranoid Hospitalized (n=15) Subj ect Medication Daily Amount (mg) Weekly or Bi-weekly Amount (mg) Daily Chlorpromazine Equivalent (mg) Note 1 Methotrimeprazine Benzhexol Fluphenazine Decanoate 150 5 50 q 2 weeks 375 2 Chlorpromazine 850 850 3 Chlorpromazine Fluphenazine Decanoate (Chlorpromazine) 800 37.5 q 2 weeks 930 100 prn 4 Haloperidol Methotrimeprazine (Chlorpromazine ) (Benztropine Mesylate) 30 50 675 100 prn 2 prn 5 Haloperidol Benztropine Mesylate Fluphenazine Decanoate 40 2 50 q 2 weeks 975 6 Methotrimeprazine 50 65 7 Chlorpromazine Haloperidol (Benztropine Mesylate) Fluphenazine Enanthate (Chlorpromazine) 600 45 2 25 q 2 weeks 1585 100 prn Estimates of equivalent doses are based on Hollister',s (1970) conversion table f o r major antipsychotic drugs and t h e i r r e l a t i v e potency/sedative e f f e c t s . For example, 5 Mg of Tr i f l u o p e r a z i n e (Stelazine) i s as potent as 100 Mg of Chlorpromazine (Thorazine). Drug Status of Subjects: Paranoid Hospitalized (n=15) (Continued) Subject Medication Daily Amount Weekly or Bi-weekly Daily Chlorpromazine Note (mg) Amount (mg) Equivalent (mg) 8 Chlorpromazine Benztropine Mesylate Fluphenazine Enanthate Ferrous Gluconate F o l i c Acid 600 2 900 15 12.5 q 1 week 685 9 Trifluoperazine 15 300 10 Fluphenazine Thioridazine 10 300 800 11 Haloperidol Benztropine Mesylate Fluphenazine Decanoate (Chlorpromazine) 10 2 37.5 q 2 weeks ^ ® 12 Methotrimeprazine Orphenadrine Trifluoperazine 200 100 15 565 13 Chlorpromazine Haloperidol Benztropine Mesylate 400 15 2 1150 14 Thioridazine (Benztropine Mesylate) Fluphenazine Decanoate 300 2 475 50 q 2 weeks' 15 Haloperidol Benztropine Mesylate Diazepam 9 2 20 450 Drug Status of Subjects: Paranoid Nonhospitalized (n=15) Subject Medication Daily Amount Weekly or Bi-weekly Daily Chlorpromazine Note (mg) Amount (mg) Equivalent (mg) 1 Thioridazine Methotrimeprazine 200 100 335 2 F l u s p i r i l e n e 5 q 1 week 35 3 Fluphenazine Decanoate 25 q 4 weeks 45 4 Thioridazine 100 100 5 Chlorpromazine Imipramine 50 75 50 6 Pimozide 4 200 7 Fluphenazine Decanoate 12.5 q 4 weeks 25 8 Trifluoperazine 15 300 9 Trifluoperazine Benztropine Mesylate 15 2 300 10 Methotrimeprazine 50 65 11 Mesoridazine Benztropine Mesylate Fluphenazine Decanoate 40 2 140 25 q 2 weeks 12 Thioridazine Flurazepam 75 30 75 Drug Status of Subjects: Paranoid Nonhospitalized (n=15) (Continued) Subj ect Medication Daily Amount (mg) Weekly or Bi-weekly Amount (mg) Daily Chlorpromazine Equivalent (mg) Note 13 14 15 Chlorpromazine Benztropine Mesylate Fluphenazine Decanoate Trifluoperazine (Benztropine Mesylate) Fluphenazine Decanoate 300 2 10 25 q 2 weeks 25 q 2 weeks 385 200 2 prn Drug Status of Subjects: Nonparanoid Hospitalized (n=15) Subj ect Medication Daily Amount (mg) Weekly or Bi-weekly Amount (mg) Daily Chlorpromazine Equivalent (mg) Note Methotrimeprazine Fluphenazine Decanoate Chlorpromazine Methotrimeprazine Procyclidine HC1 Fluphenazine Decanoate Chlorpromazine Benztropine Mesylate Haloperidol Haloperidol Benztropine Mesylate Fluphenazine Decanoate (Chlorpromazine) Methotrimeprazine Benztropine Mesylate Haloperidol Fluphenazine Decanoate Chlorpromazine (Benztropine Mesylate) (Chlorpromazine) Chlorpromazine Procyclidine HC1 Fluphenazine Decanoate (Chlorpromazine) 150 800 150 5 700 2 10 10 4 100 2 10 1000 600 10 50 q 3 weeks 50 q 2 weeks 37.5 q 2 weeks 37.5 q 2 weeks 25 q 2 weeks 220 800 375 1200 630 100 prn 1000 685 2 prn 75 prn 100 prn Drug Status of Subjects: Nonparanoid Hospitalized (n=15) (Continued) Subj ect Medication Daily Amount (mg) Weekly or Bi-weekly Amount (mg) Dail y Chlorpromazine Equivalent (mg) Note 10 11 12 13 14 Chlorpromazine Fluphenazine Enanthate Benztropine Mesylate Lithium C i t r a t e (Haloperidol) Methotrimeprazine Benztropine Mesylate Fluphenazine Enanthate (Chlorpromazine) Trifluoperazine Procyclidine HC1 Haloperidol Benztropine Mesylate Fluphenazine Decanoate Methotrimeprazine Haloperidol Procyclidine HC1 Diazepam (Benztropine Mesylate 400 2 2250 50 2 / 10 5 20 4 100 60 20 30 25 q 2 weeks 25 q 2 weeks 25 q 2 weeks 400 85 160 200 1085 .1275 5 prn 75 prn 2 prn 15 Chlorpromazine 1100 1100 Drug Status of Subjects: Nonparanoid Nonhospitalized (n=15) Subject Medication Daily Amount Weekly or Bi-weekly Daily Chlorpromazine Note (mg) Amount (mg) Equivalent (mg) 1 Fluphenazine Decanoate 25 q 4 weeks 45 2 Fluphenazine Decanoate (Benztropine Mesylate) 37.5 q 3 weeks 85 3 Haloperidol 3 150 4 Chlorpromazine Fluphenazine Decanoate 100 25 q 2 weeks 185 5 Methotrimeprazine Haloperidol 50 10 565 6 Thioridazine 150 150 7 8 Haloperidol F l u s p i r i l e n e Benztropine Mesylate Chlorpromazine 7 400 8 q 1 week 400 9 Chlorpromazine 150 10 Haloperidol Flurazepam Lithium Carbonate 6 60 1200 300 11 Chlorpromazine 300 300 12 Fluphenazine Decanoate 25 q 2 weeks 85 Drug Status of Subjects: Nonparanoid Nonhospitalized (n=15) Subject Medication Daily Amount Weekly or Bi-weekly Daily Chlorpromazine Note (mg) Amount (mg) Equivalent (mg) Thioridazine 300 13 Benztropine Mesylate 4 385 Fluphenazine Decanoate 25 q 2 weeks j4 Trifluoperazine 10 245 Fluphenazine Decanoate 12.5 q 2 weeks 15 F l u s p i r i l e n e 2 q 1 week 15 Drug Status of Nonpsychiatric Subjects Subj ect Hospitalized (n=15) Medication Nonhospitalized (n=15) Daily Amount (mg) Subj ect Medication Daily Amount (mg) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Diazepam 10 (Chloral Hydrate) .5 g prn (Secobarbital Sodium) 500 prn Lactulose syrup 20 g (Diazepam) 5 prn Diazepam 5 C l o x a c i l l i n Sodium 750 (Chloral Hydrate) 1 g prn Diazepam 5 (Chloral Hydrate) .5 g prn Propoxyphene Napsylate 300 C l a z a c i l l i n Sodium 750 Diazepam 5 Multivitamins Metorpolol Tartrate Insulin 1QQ 2 3 4 5 6 7 10 11 12 13 14 15 Bethanechol Chloride 30 (Diazepam) Multivitamins Multivitamins Dexamethasone 2 Chlordiazepoxide 15 (Diazepam) (Diazepam) Naproxen 500 Tolmetin Sodium 600 Diazepam 40 Diazepam 10 Dantrolene Sodium 150 (Diazepam) 5 prn 10 prn 5 prn 5 prn Appendix 9.2 Comparison of Daily Chlorpromazine Equivalent Means* Between Schizophrenic Subsamples Paranoid Nonparanoid two-tailed t>tests for independent means Hospitalized M = 700.66 M = 664.66 t(28)=.25 (n=30) 2 - s =152743.45 Nonhospitalized M = 156.00 M = 230.66 t_(28)=1.48 (n=30) . - 2 s =19867.84 For df=28, a t_=2.048 i s required for s i g n i f i c a n c e at the .05 l e v e l . Amounts i n mg 180 Appendix 9.3 Corr e l a t i o n C o e f f i c i e n t s Between D a i l y Chlorpromazine Equivalents and Dependent Variable Measures (N=60) Daily Chlorpromazine Equivalents i n mg Vocabulary Difference Score -.047 Behavioral Overinclusion -.144 Conceptual Overinclusion -.022 Idiosyncratic Thinking .101 Concrete Thinking .243 Underinclusive Thinking .102 Note: A l l r's are s t a t i s t i c a l l y n onsignificant. A P P E N D I X 10 Consent Form 182 THE UNIVERSITY OF BRITISH COLUMBIA Department of Psychology Consent I, , do hereby give my consent to the administration of a vocabulary test and an object s o r t i n g test that are c a l l e d f o r in the study on the use/misuse of the English language and on the a b i l i t y to sort some objects of common use. I understand a) that p a r t i c i p a t i o n i n the study involves no r i s k s or discomforts; b) that my p a r t i c i p a t i o n i s voluntary and that I may withdraw at any time; c) that r e f u s a l to p a r t i c i p a t e i n the study or withdrawal from the study w i l l i n no way i n t e r f e r e with the treatment which I w i l l receive, and d) that a l l information personally i d e n t i f y i n g me as a p a r t i c i p a n t i n t h i s study w i l l remain s t r i c t l y c o n f i d e n t i a l . Signed: C l i e n t Signed: Date: Primary Therapist 183 APPENDIX 11 184 Appendix 11.1 Summary of the M u l t i v a r i a t e A n a l y s i s of Variance of the Object S o r t i n g Test Measures Source of V a r i a t i o n W i l k s 1 Lambda* Approximate F - s t a t i s t i c * P r o b a b i l i t y Diagnostic Groups (DG) .74008 (5,2,84) 2.5986 (10,160) .0060 H o s p i t a l i z a t i o n Status (HOSP) .84938 (5,1,84) 2.8372 (5,80) .0207 DG x HOSP .88348 (5,2,84) 1.0225 (10,160) .4269 * Degrees of freedom i n parentheses. 185 Appendix 11.2 Summary of Analyses of Variance for Che Object Sorting Test Measures Source'of Variation MS df Behavioral Over-inclusion Diagnostic Groups (DG) Hospi t a l i z a t i o n (HOSP) Status DG x HOSP Error 54.577 120.177 71.244 80.684 .676 1.489 84 Conceptual Overinclusion Diagnostic Groups (DG Hos p i t a l i z a t i o n (HOSP) Status DG x HOSP Error 1.669 .225 .158 .469 1 2 84 3.559 .479 .337 .0321 Idiosyncratic Thinking Diagnostic Groups (DG) Hospi t a l i z a t i o n (HOSP) Status DG x HOSP Error 2.269 2.844 .836 .384 1 2 84 5.895 .0042 .0078 2.172 n.s. Concrete Thinking Diagnostic Groups (DG) Hospitalization (HOSP) Status DG x HOSP Error 1 . 5 9 9 1 .108 2.75 2 84 1.523 n.s. 5.809 .0173 .393 n.s. Under-inclusive Thinking Diagnostic Groups (DG) Hospi t a l i z a t i o n (HOSP) Status DG x HOSP Error 2 .636 .099 .558 .572 1 2 84 4.606 .0126 .174 n.s. .975 n.s. Appendix 11.3 Means and Standard Deviations* of Scores on the Object Sorting Test Measures f or A l l Subject Subgroups (n=15 per c e l l ) Behavioral Overinclusion Hospitalized Paranoid Nonparanoid Nonpsychiatric 16.87 (7.75) 20.07 (6.40) 20.53 (7.30) Nonhospitalized Paranoid Nonparanoid Nonpsychiatric 22.07 (13.74) 19.13 (8.41) 23.20 (8.37) Conceptual Overinclusion 1.97 (.58) 2.10 (.76) 1.70 (.49) 2.03 (.99) 1.93 (.68) 1.50 (.46) Idiosyncratic Thinking 1.50 (.71) 2.03 (1.01) 1.17 (.31) 1.27 (.65) 1.30 (.49) 1.07 (.18) Concrete Thinking 2.13 (.44) 2.10 (.47) 1.90 (.57) 1.73 (.50) 1.93 (.56) 1.67 (.59) Underinclusive Thinking 2.43 (.96) 2.37 (.79) 1.97 (.44) 2.13 (.90) 2.60 (.66) 1.83 (.67) *In parentheses. APPENDIX 12 Summary of Analysis of Covariance for the Vocabulary Subtest With D i s t r a c t o r Scores 188 Appendix 12 Summary of Analysis of Covariance f o r the Vocabulary Subtest With Di s t r a c t o r Scores (Covariate: The Vocabulary Subtest Without Distractors Scores) Source of Va r i a t i o n SS df MS F Diagnostic Groups 1584.41 2 792.20 22.94 .0000 (DG) H o s p i t a l i z a t i o n (HOSP) 240.14 1 240.14 6.95 .0097 Status DG x HOSP 159.63 2 79.81 2.31 .1033 Error 2865.49 83 34.52 

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