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The prediction of short term adjustment in psychotic patients Smith, Geoffrey Norman 1983

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THE PREDICTION OF SHORT TERM ADJUSTMENT IN PSYCHOTIC PATIENTS GEOFFREY NORMAN SMITH B.A., University of Victoria, 1981 A THESIS IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF PSYCHOLOGY We accept this degree as conforming to the required standard THEVUNIVERSITY OF^BRITISH COLUMBIA December 1983 ® Geoffrey Norman Smith In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission for extensive copying of t h i s t h e s i s for scholarly purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 :-6 (3/81) - i i -ABSTRACT Progress in schizophrenia research has been hindered by the l i m i t a -tions of contemporary diagnostic c r i t e r i a . A l l widely used diagnostic systems allow considerable v a r i a b i l i t y i n symptoms between schizophre-nics and much s i m i l a r i t y across psychotic disorders. Furthermore, schizophrenics show large differences in response to treatment s t r a t e -gies and in prognosis. These facts have led to a growing consensus that schizophrenia i s not a homogeneous disorder but represents a heteroge-neous c o l l e c t i o n of disorders. In the face of this heterogeneity, most schizophrenia research is conducted by comparing a group of diagnosed schizophrenics with a control group. This approach c a r r i e s with i t the i m p l i c i t assumption that the disorder i s homogeneous. The v a r i a b i l i t y between schizophrenics and s i m i l a r i t i e s across various psychotic d i s -orders i n association with this research strategy probably contributes to the slow progress in schizophrenia research. An a l t e r n a t i v e , three-point research strategy was proposed: 1) A l l psychotic patients, without diagnosed organic disorders, should be included in research studies to compensate for the imprecision i n contemporary diagnostic procedures, 2) multiple measures should be used to i d e n t i f y variables that c l u s t e r within subgroups of patients, and 3) any i d e n t i f i e d sub-category of schizophrenia should be evaluated with regard to how well i t predicts response to treatment and prognosis. In the present study, premorbid adjustment, negative symptoms (e.g., f l a t a f f e c t ) , and smooth pursuit eye movement anomalies were used to predict r e h o s p i t a l i z a t i o n , general l e v e l of adjustment at follow-up, and employment-heterosexual - i i i -period was nine to 18 months. Thirty-seven patients who had recently experienced their first psychotic episode served as subjects. Twenty were diagnosed schizophreniform, nine unipolar depressed, six bipolar, and two paranoid. The results of this study were successful in identi-fying two subgroups of psychotic patients. Disrupted eye-tracking, poor premorbid adjustment and a preponderance of negative symptoms tended to cluster in individuals with poor general and employment-heterosexual adjustment while good eye-tracking, normal premorbid adjustment, and a relative absence of negative symptoms were common in individuals with good adjustment at follow-up. Rehospitalization was not predicted successfully. The results are discussed in terms of their implications for a neuropathological subtype of schizophrenia. Suggestions for further research to extend the present findings are offered. - i v -TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES ' v i ACKNOWLEDGEMENTS v i i i INTRODUCTION 1 Problems i n Schizophrenia Research 1 Limitations of Current Diagnostic Systems 1 The Problem of Overinclusion 1 The Problem of Heterogeneity 4 Summary of Problems i n Schizophrenia Research 6 Objectives of the Present Research 8 Rationale 8 J u s t i f i c a t i o n for Choice of Dependent Measures 11 Premorbid Adjustment 11 Negative Symptoms 13 Eye Movements 14 Smooth Pursuit Eye Movements 15 Saccadic Eye Movements 16 Overview of Current Project and Hypothesis 18 METHOD 20 Subjects 20 Interviews and Apparatus 22 - v -Page Procedure 25 Data Q u a n t i f i c a t i o n 26 Interview Data 26 Eye Movement Data 27 RESULTS 29 R e l i a b i l i t y and Reduction of Measures 31 Interview Data 31 Smooth Pursuit Eye Movements 33 Saccadic Eye Movements 32 Analysis of Results 35 Predictive V a l i d i t y 35 Concurrent V a l i d i t y 39 Exploratory Analyses 44 DISCUSSION 49 Summary of Results 49 Predictors of Outcome 51 Premorbid Adjustment... 51 Negative Symptoms 52 Smooth Pursuit Eye Movements 52 Exploratory Measures 53 Summary of Discussion 54 REFERENCES i 56 APPENDIX A - Screening Schedule 63 APPENDIX B - Follow-up Interview 67 - v i -Page APPENDIX C - Abbreviated Form of P h i l l i p s Premorbid Adjustment Scale 88 APPENDIX D - Negative Symptom Rating 90 APPENDIX E - Employment-Heterosexual Adjustment During the Follow-up Period 94 APPENDIX F - Global Assessment Scale 96 - v i i -LIST OF TABLES Page Table 1 C h a r a c t e r i s t i c s of the Subjects 21 Table 2 Saccadic Eye Movements for Left and Right Eyes over Leftward and Righward Movements 34 Table 3 Predictor and Outcome Variable Correlations 36 Table 4 Good and Poor Adjustment Groups for Each Outcome Variable 38 Table 5 Prediction of Outcome Measures using Discriminant Analysis 40 Table 6 Concurrent and Outcome Variable Correlations 41 Table 7 Concurrent V a l i d i t y of Eye Movement Measures 43 Table 3 Age and Duration of H o s p i t a l i z a t i o n Correlations with Predictor and Outcome Variables 45 Table 9 Diagnostic Categories Compared to Follow-up Adjustment 48 - v i i i -ACKNOWLEDGMENTS I wish to extend special thanks to Dr. W.G. Iacono for his guidance and support throughout this research project. I would l i k e to express ray appreciation to Dr. D. Papageorgis for his help and to Dr. J. Pinel for his timely assistance. I am also most g r a t e f u l to Dr. M. Moreau, to Mike S a t t e r f i e l d , Nancy Mann, and the M.A.P. team for their assistance. 1 INTRODUCTION  Problems In Schizophrenia Research  Limitations of Current Diagnostic Systems The enormous quantity of research that has been devoted to tr y i n g to understand schizophrenia r e s u l t s , i n part, from the i n t r a c t a b l e nature of the problem. However, the l i m i t a t i o n s of contemporary methods i n schizophrenia research have resulted i n less progress than might otherwise have been hoped f o r . These l i m i t a t i o n s a r i s e from two sources: (1) Contemporary diagnostic c r i t e r i a , and (2) the i m p l i c i t assumption that schizophrenia i s a homogeneous disorder. The Problem of Overinclusion Ideally, diagnoses are based on the i n t e r r e l a t i o n s h i p or c l u s t e r i n g among elements within a diagnostic category and the degree of non-rel a t i o n s h i p or independence between elements across categories. Once made, a diagnosis should have implications for treatment decisions and outcome predictions for ind i v i d u a l s who f a l l within a p a r t i c u l a r diag-n o s t i c category (World Health Organization, 1979). With the advent of DSM I I I , the diagnosis of schizophrenia i s more r e l i a b l e than ever before (American P s y c h i a t r i c Association, 1980). The symptom categories that define schizophrenia, under every commonly used diagnostic system, are based on the course and presenting state as defined by the patient's verbal report of subjective experiences and behavioral observations made by others. In addition to the symptom categories that c l u s t e r i n diagnosed schizophrenics, there are c r i t e r i a that are used to define nonrelationships between i n d i v i d u a l s i n other diagnostic categories and schizophrenics. DSM I I I , for example, excludes those i n d i v i d u a l s who develop an a f f e c t i v e syndrome before 2 schizophrenia or who are found to have an organic mental disorder coin-cident with schizophrenic symptoms.. It should be added, however, that DSM III allows the p o s s i b i l i t y of an i n d i v i d u a l who i s diagnosed schizo-phrenic to have a superimposed organic mental disorder (American P s y c h i a t r i c Association, 1980). Any exclusionary diagnosis comprises a set of symptoms which together define an a l t e r n a t i v e symptom complex. For example, an i n d i v i d u a l may present with f l o r i d psychotic symptoms, but, i f , a f t e r medical examination, a number of symptoms congruent with the symptom complex of cerebral trauma are found, then the diagnosis w i l l be cerebral trauma. The psychotic symptoms in this case are a n c i l l a r y . Even with the improved r e l i a b i l i t y introduced by DSM I I I , there remain some serious problems. As was noted above, any diagnosis i s based, i n part, on the i n t e r r e l a t i o n s h i p or c l u s t e r i n g among elements within a diagnostic category. Substantial i n d i v i d u a l differences have been observed over a number of behavioral and b i o l o g i c a l dimensions across diagnosed schizophrenics (for a review of variables putatively related to schizophrenia see B a l d e s s a r i n i , 1977; H a i l e r , 1980;Houlihan, 1977; P e r r i s , Struwe, & Jansson, 1981). These differences, for the most part, are not incorporated into any a l t e r n a t i v e diagnosis. If addi-t i o n a l anomalies that occur with the schizophrenic symptoms do not combine to form an a l t e r n a t i v e diagnosis, then schizophrenia i s diag-nosed and the ad d i t i o n a l anomalies are regarded as a n c i l l a r y . By l i m i t -ing diagnosis to the presently used psychotic symptoms, as reported by the i n d i v i d u a l , and s e l f - c a r e a b i l i t y , as observed by others, researchers may be overlooking numerous p o t e n t i a l l y useful v a r i a b l e s . 3 The additional variables, if they were incorporated into the schizo-phrenia symptom complex, would be useful in defining schizophrenia more precisely and, thus, in helping to better understand the disorder. A more precise (i.e. more inclusive) diagnostic scheme would probably lead to a better defined, more homogeneous population of patients. In addition to the interrelationship or co-occurrence among ele-ments, it was noted above that any diagnosis involves nonrelationship or independence between elements across diagnostic classes. There are numerous disorders that present with psychotic symptoms that are indis-tinguishable from those found in diagnosed schizophrenics. Affective disorders, for example, are defined such that it is frequently difficult to specify whether an individual has schizophrenia or an affective disorder (American Psychiatric Association, 1980). This decision is made on the basis of which symptoms occurred first and/or which symptoms are prominent. Unless a particular patient presents himself at the first sign of any symptoms, the decision as to which symptoms occurred first is frequently difficult to make. The decision regarding which symptoms are prominent is confused by the symptom overlap between the two diagnostic categories and by the prevalence of depression in diag-nosed schizophrenics (American Psychiatric Association, 1980). There are also a number of organic disorders that may present with psychotic symptoms that are indistinguishable from those found in schizophrenia (Davidson & Bagley, 1969). Thus, the symptom overlap between the diag-nosis of schizophrenia and numerous other diagnoses frequently makes it difficult to demonstrate nonrelationship or independence between 4 elements across diagnostic classes. For the purposes of the present discussion, the term psychotic will refer to psychiatric disorders that present with psychotic symptoms (i.e., delusions and hallucinations) but that have no diagnosed organic correlates (e.g., epilepsy, cerebral trauma). The fact that schizophrenia, as it is presently defined, is frequently very difficult to distinguish from some other disorders, indicates that the schizophrenia symptom complex is inadequate. As was noted above, more variables must be incorporated into the symptom complex in order to derive a more inclusive diagnostic scheme and, thus, to define a more homogeneous population of patients. A more precise diagnostic scheme would make it possible to distinguish between dis-orders more consistently than is possible with contemporary diagnostic systems. Finally, it was stated above that a diagnosis should have implica-tions for treatment decisions and outcome predictions for individuals who f a l l within the diagnostic category. There is a great deal of evidence indicating that there are large individual differences between diagnosed schizophrenics both in response to any treatment strategy and in prognosis (for a review, see Clare, 1976; Cryder, 1979; Hailer, 1980; Houlihan, 1977; Neale & Oltraanns, 1980). Considering the variability across diagnosed schizophrenics and the overlap between diagnostic cate-gories that were noted above, it is not surprising that large individual differences are observed in outcome. These diagnostic limitations are central to the second problem in schizophrenia research. The Problem of Heterogeneity By using a prescribed diagnostic method to define a disorder, the 5 diagnostic category is implicitly assumed to describe a population that is homogeneous with regard to the disorder. Research protocol dictates that the effects of one manipulation on a homogeneous c l i n i c a l popula-tion be compared with the effects on a homogeneous control group. Any observed differences on dependent measures support the hypothesis that the populations from which the groups were derived, as determined by the  diagnostic procedure used, are different with regard to the manipulation made. However, i f the diagnostic procedure allows much v a r i a b i l i t y within the disorder, much similarity across disorders, and i s associated with var i a b i l i t y in prognosis, then the only clear relationshp that can be claimed i s between the population of diagnosed patients and the construct that the diagnostic procedure purportedly measures. This i s the case with schizophrenia. Without a more comprehensive definition of this diagnostic class, the individual differences within the disorder and similarities across disorders w i l l continue to hinder research progress. In practice, the vari a b i l i t y that i s observed within the population of diagnosed schizophrenics tends to be minimized in favor of the diagnostic s i m i l a r i t i e s . Thus, while schizophrenics have been shown to vary widely with regard to numerous variables, group differences are hypothesized based on the homogeneity assumption. This research approach persists despite the fact that there is an emerging consensus that schizophrenia may not be a unitary disorder but rather is a hetero-geneous group of disorders with similar presenting symptoms (Baldessarini, 1977; Hailer, 1980; Houlihan, 1977; Jeste, Kleinman, Potkin, Luchins, & Weinberger, 1982; Kety, 1980). Some of the 6 dimensions along which diagnosed schizophrenics have been shown to vary must be incorporated into the diagnostic system i f this heterogenous group i s to be more s p e c i f i c a l l y defined into homogeneous subgroups. In addition to studying i n d i v i d u a l s within the schizophrenic diag-nosis, i n d i v i d u a l s with p s y c h i a t r i c diagnoses that overlap with schizo-phrenia also need to be considered. As was noted above, a number of anomalies are observed both within some schizophrenics and within some nonschizophrenic p s y c h i a t r i c patients. These variables are frequently not incorporated into the schizophrenic symptom complex nor into any alt e r n a t i v e diagnosis. If a number of these variables were systemati-c a l l y studied i n combination over heterogeneous groups of psychotic patients, investigators could define subgroups more s p e c i f i c a l l y using those variables that co-occur within subgroups and show independence between subgroups. The i s o l a t i o n of homogeneous subgroups using a number of variables would be the f i r s t step towards making s p e c i f i c predictions for individuals over such measures as response to treatment or prognosis. This could also lead to the development of more s p e c i f i c treatment s t r a t e g i e s . Summary of Problems i n Schizophrenia Research Progress i n schizophrenia research has been hindered by the l i m i t a -tions of contemporary diagnostic c r i t e r i a . A l l widely used diagnostic systems allow much v a r i a b i l i t y between schizophrenics and much s i m i l a r -i t y across psychotic disorders. Furthermore, large differences are observed i n response to treatment strategies and in prognosis between diagnosed schizophrenics. These facts have led to a growing consensus 7 that schizophrenia i s not a homogeneous disorder but represents a heterogeneous c o l l e c t i o n of disorders. In the face of this heterogene-i t y , most schizophrenia research i s conducted by comparing a group of diagnosed schizophrenics with a control group. This approach carr i e s with i t the i m p l i c i t assumption that the disorder defined by the diag-nostic method is homogeneous. The v a r i a b i l i t y between schizophrenics and s i m i l a r i t i e s across various psychotic disorders, i n asso c i a t i o n with this research strategy probably contributes to the slow progress i n schizophrenia research. A more p r o f i t a b l e approach might be to incor-porate schizophrenic patients and nonschizophrenic psychotic patients (without diagnosed organic brain damage) into a single research strategy aimed at defining this heterogeneous group of disorders more p r e c i s e l y . The psychoses must be defined by a number of variables, i n addition to the presently used c r i t e r i a , i n order to i s o l a t e homogeneous subgroups. This could be the f i r s t step towards making s p e c i f i c predictions for psychotic i n d i v i d u a l s over response to various treatment strategies and for prognosis. 8 Objectives of the Present Research The previous observations can be used to generate three recommenda-tions for schizophrenia research: (1) U n t i l a narrower, more i n c l u s i v e symptom complex i s found, research should include a l l psychotic patients, excluding those with diagnosed organic disorders, regardless of the p s y c h i a t r i c diagnosis made; (2) a multidimensional approach should be used i n order to derive subgroups of in d i v i d u a l s who show i n t e r r e l a t i o n s h i p over a number of variables and to demonstrate indepen-dence between subgroups of psychotic i n d i v i d u a l s , and; (3) the u t i l i t y of any i d e n t i f i e d categories should be evaluated with regard to how well they predict response to treatment strategies and prognosis. Neces-s a r i l y , this research involves numerous studies designed to i s o l a t e groups of variables that can be used to define meaningful subgroups of psychotic patients, to r e p l i c a t e findings, to extend findings to incor-porate more defining variables, and to test the p r e d i c t i v e value of i d e n t i f i e d subgroups of patients by demonstrating a r e l a t i o n s h i p between the subgrouping and outcome variables. This thesis represents an attempt to i s o l a t e a homogeneous subgroup of psychotic patients by using a number of variables and by following the above recommendations. A nine to 18 month follow-up w i l l be used to evaluate the predictive u t i l i t y of any categories that are i s o l a t e d . The s e l e c t i o n of variables has been made so as to provide the basis for further research. Further studies w i l l be conducted based on the results from the present thesis. Rationale The notion that there are d i s t i n c t subtypes within the schizophre-9 nia diagnosis i s not new. Numerous d i s t i n c t i o n s have been made during the history of schizophrenia research ( f or a review see Neale & Oltmanns, 1980). Kraepelin coined the term dementia praecox to define a disorder with early onset and progressive i n t e l l e c t u a l d e t e r i o r a t i o n . This c l a s s i f i c a t i o n contained paranoid, catatonic, hebephrenic, and simple sub-types (Neale & Oltmanns, 1980). A further subtype that pre-sented with acute onset followed by rapid recovery was described by Kasanin (1933). It was termed " s c h i z o a f f e c t i v e " disorder and, as the name implies, includes individuals who present with both schizophrenic and a f f e c t i v e symptoms. More recently a d i s t i n c t i o n was made between process and reactive schizophrenia (Garraezy & Rodnick, 1959). Process schizophrenics are defined by poor premorbid status and poor prognosis. This d i s t i n c t i o n resembles Kraepelin 1s dementia praecox with early onset and d e t e r i o r a t -ing course. Reactive schizophrenics, on the other hand, usually have normal premorbid adjustment, rapid onset, and r e l a t i v e l y good prognosis (Garmezy & Rodnick, 1959). Recent work by Crow (1980, Johnstone,Crow, F r i t h , Carney, & Price , 1978) and Weinberger (Weinberger, Cannon-Spoor, & Potkin, 1980a; Weinberger, D e L i s i , Perman, Targum, & Wyatt, 1982) has stimulated renewed int e r e s t in the process c l a s s i f i c a t i o n . It has been hypothesized that patients with poor prognosis have few f l o r i d psychotic symptoms with r e l a t i v e l y more negative symptoms ( f l a t a f f e c t , poverty of speech and lack of drive; Johnstone et a l . , 1978), poor response to neuroleptics (Weinberger,Bigelow, & Kleinman, 1980b), signs of neuro-pathology (Weinberger et a l . , 1982) and poor premorbid status (Weinberger et a l . , 1980a). Other measures that are putatively related 10 to poor prognosis in schizophrenics include deviant smooth pursuit eye movements (Holzman, Proctor, & Hughes, 1973), poor heterosexual adjust-ment (Kok.es, Strauss, & Klorman, 1977), and low scores on neuropsycho-l o g i c a l tests (Donnelly, Weinberger, Waldman, & Wyatt, 1980). These measures have not been integrated into any contemporary diagnosis of schizophrenia. Measures of premorbid status, negative symptoms, and eye movements w i l l be investigated in the present study. Each of these measures w i l l be discussed further below. Most studies that have investigated poor prognosis in schizophrenia have used groups of c h r o n i c a l l y i l l , often h o s p i t a l i z e d , patients (Neale & Oltraanns, 1980). With this strategy, findings may be influenced by extended periods of h o s p i t a l i z a t i o n , long term medication, or the process of having a disorder for a long period of time. Furthermore, h i s t o r i c a l data are frequently d i f f i c u l t to obtain or are unreliable for these patients (Neale & Oltmanns, 1980). In order to reduce the i n f l u -ence from these sources, only patients who have experienced t h e i r f i r s t psychotic episode up to three months before entering t h i s study were used. F i n a l l y , by using patients who have recently suffered t h e i r f i r s t psychotic episode, the p r o b a b i l i t y of obtaining a group that i s homo-geneous with regard to the s t a r t i n g point of the disorder i s increased. Level of adjustment achieved at the end of the follow up period (deter-mined from the Global Assessment Scale), the number of p s y c h i a t r i c r e h o s p i t a l i z a t i o n s i n the nine months a f t e r the f i r s t psychotic episode, and employment-heterosexual adjustment achieved during the follow-up period were used to assess the short term course of the disorder. 11 In summary, limitations in schizophrenia research were used to generate three recommendations for further research: (1) All psychotic patients who have no diagnosed organic disorder should be selected for study; (2) A multidimensional approach should be used to identify homo-geneous subgroups; (3) Any identified subclassification should be evalu-ated with regard to its predictive utility. This thesis represents the first in a series of studies aimed at isolating homogeneous subgroups and following the recommendations made above. One enduring distinction that has prevailed throughout the history of schizophrenia research is that of poor prognosis (dementing or process) schizophrenia. Numerous variables have been studied in relation to process schizophrenia but are not used in the diagnosis of schizophrenia. Measures of premorbid status, negative symptoms, and eye movement anomalies are among the putative predictors of poor prognosis. These measures will be used in the present study in an attempt to isolate subgroups of patients who show poor outcome nine to 18 months after their first psychotic episode. Justification for Choice of Dependent Measures  Premorbid Adjustment In a review of the literature, Kokes, Strauss, and Klorman (1977) concluded that while much progress has been made, the available measures of premorbid status are inadequate. No single variable adequately defines the essential aspects of prognosis since both premorbid status and prognosis are multidimensional. Also, social variables signific-antly affect outcome. Various premorbid measures that are presently used differentially predict specific types of outcome and are thus, not comparable. Furthermore, studies that use the same measures frequently 12 use d i f f e r e n t cutoff scores to i s o l a t e groups based on good or poor premorbid h i s t o r y . This has resulted in confusing findings that are d i f f i c u l t to interpret and often contradictory (Kokes et a l . , 1977; Klorman, Strauss, & Kokes, 1977). Nevertheless, h i s t o r i c a l information concerning premorbid adjustment has proved to be the most powerful predictor of outcome in schizophrenia (Neale & Oltmanns, 1980). The P h i l l i p s Premorbid History scale (PMH) has been accepted as a r e l i a b l e and v a l i d measure of premorbid adjustment and has widespread use (Kokes et a l . , 1977). A long form of the scale was developed by P h i l i p s (1953). This measure was found to be s i g n i f i c a n t l y related to percent of l i f e t i m e spent in p s y c h i a t r i c hospitals (r = .42 to .45; DeWolfe, 1968) and duration of h o s p i t a l i z a t i o n i n a three year follow-up period (_r = .38; Cancro & Sugerman, 1968). In another study (Schnell, 1964) the PMH was found to be related to social-heterosexual adjustment. The v a l i d i t y of the PMH was questioned by Strauss and Carpenter (1974, 1977) who found no relationship between this measure and duration of h o s p i t a l -i z a t i o n , poor s o c i a l r e l a t i o n s , unemployment, or symptoms at a two year follow-up. Kokes et a l . (1977) suggest that these results indicate that the PMH may have predictive v a l i d i t y only for s p e c i f i c types of out-come. A shortened version of the PMH has been devised by Harris (1975). This scale has been shown to have high r e l i a b i l i t y (_r = mid • 80s to mid .90s) and high concurrent v a l i d i t y with the PMH (r_ = .95 for males and .85 for females; Kokes et a l . , 1977). Because of the r e l a -t i v e l y good properties of this scale, the shortened version of the PMH w i l l be used i n this study as a measure of premorbid adjustment. \ 13 Negative Symptoms A series of studies by Crow and his co-workers have examined nega-t i v e symptoms ( f l a t a f f e c t , poverty of speech, and lack of drive) i n schizophrenics (Crow, 1978; 1980; 1981; Crow, et al.1982). Johnstone et a l . (1978) found a positive relationship between negative symptoms and poor prognosis. Other studies have indicated that negative symptoms may r e f l e c t neurological anomalies (Crow, 1981), decreased dopamine receptor le v e l s (Crow, 1978), poor response to neuroleptics (Owens, Johnstone & F r i t h , 1982), i n t e l l e c t u a l impairment (Crow et a l . , 1981), and temporal d i s o r i e n t a t i o n (Crow et a l . , 1981). Furthermore, while f l o r i d symptoms (hall u c i n a t i o n s and delusions) tend to improve with treatment, negative symptoms tend to be more refractory and ulti m a t e l y more c r i p p l i n g (Andreasen & Olsen, 1982). On the basis of these findings Crow (1980) postulated that the form of schizophrenia characterized by negative symptoms may be related to the dementias. These findings suggest that negative symptoms may be useful i n defining a homogeneous subgroup of psychotic patients that i s associated with poor c l i n i c a l outcome. Andreasen (1982) reviewed the l i t e r a t u r e on positive-negative symptomatology and noted that Bleuler's d i s t i n c t i o n , between core and accessory symptoms, which p a r a l l e l s the positive-negative d i s t i n c t i o n f e l l into disuse because of the d i f f i c u l t y i n r e l i a b l y assessing symptoms l i k e f l a t a f f e c t , loose associations, etc. Andreasen (1982) developed a r e l i a b l e scale to measure the negative symptom complex and used i t to divide a group of schizophrenics into predominantly p o s i t i v e , predominantly negative, or mixed symptoms ( i n d i v i d u a l s who do not meet 14 eith e r p o s i t i v e or negative c r i t e r i a or meet c r i t e r i a for both; Andreasen & Olsen, 1982). i The three groups of patients (positive,n_ = 18, negative,n_ = 16, mixed,n_ = 18) did not d i f f e r s i g n i f i c a n t l y on any demographic variables except education. Patients with predominantly negative symptomatology achieved the least educationally (negative = 11.06 yr, mixed = 12.05 yr, positive = 13.55 y r ) . The results of this study indicate that individuals with predominantly negative symptoms had poor premorbid adjustment, lower i n t e l l e c t u a l functioning, and signs of neuropathology. Individuals with p o s i t i v e symptoms had better premorbid adjustment, better o v e r a l l functioning and cognitive functioning, and showed no signs of neuropathology. The mixed group scored between the pos i t i v e and negative symptom groups on a l l variables (Andreasen & Olsen, 1982). A strong negative c o r r e l a t i o n was found between po s i t i v e and negative symptoms. In Andreasen's preliminary work (1982; Andreasen & Olsen, 1982), she appears to have developed a r e l i a b l e tool for sepa-rating schizophrenics into r e l a t i v e l y homogeneous groups. Andreasen's scale for Assessing Negative Symptoms i s comprised of f i v e subscales: a f f e c t i v e f l a t t e n i n g or blunting, alogia or impoverished thinking, avolition-apathy,anhedonia-asociality and at t e n t i o n . Items taken from the Present State Examination ( a structured diagnostic interview) w i l l be used to complete this scale and w i l l be used as the rating of nega-tive symptoms i n the present study. Eye Movements The measures of oculomotion that have been studied i n schizophre-L5 nics include smooth pursuit eye movements (SPEM) and saccadic eye move-ments . Smooth Pursuit Eye Movements - Smooth pursuit eye movements (SPEM) are voluntary, slow movements that maintain an image on the fovea by matching the v e l o c i t y of the eye with the v e l o c i t y of the target. These movements occur i n the h o r i z o n t a l , v e r t i c a l or diagonal plane. The early work of Holzman and his associates (Holzman, Levy, Uhlenhuth, Proctor & Freeman, 1975; Holzman, et a l . , 1973; Holzman, Proctor, Levy, Y a s i l l o , Meltzer & Hurt, 1974) i d e n t i f i e d deviant SPEM in some schizo-phrenics. This d e f i c i t was found to be worse in chronic schizophrenics than i n recently diagnosed schizophrenics (Holzman et a l . , 1974). This suggests that poor tracking may be associated with a chronic course. A number of methods have been used to quantify SPEM i n t e g r i t y . Of these a root-mean-square (RMS) analysis provides an estimate that i s as s e n s i t i v e or more se n s i t i v e than other methods of analysis (Iacono & Lykken, 1979). This procedure involves determining the tracking error throughout the tracking performance i n terms of the difference, in standard deviation units, between the target s i g n a l and the subject's eye movements. Conceptually, this measure represents the degree of f i t between the target s i g n a l and tracking performance (Iacono & Lykken, 1979). This method correlates highly with q u a l i t a t i v e ratings and shows high t e s t - r e t e s t r e l i a b i l i t y (Iacono & Lykken, 1979; 1981). The RMS method of analysis also provides a good estimate of the extent to which a subject's eyes lag behind the target during tracking. This lag measure i s r e l a t i v e l y r e l i a b l e (Iacono & Lykken, 1981). 16 Schizophrenics appear to have more phase lag than bipolar or unipolar depressives and normal individuals (Iacono & Koenig, 1983; Iacono, Peloquin, Lumry, & Valentine, 1982). The tracking impairment has been i d e n t i f i e d consistently and involves numerous saccadic ( f a s t ) eye movements intruding upon a smooth following movement. This tracking d e f i c i t has been found in remitted schizophrenics (Iacono et a l . , 1982; Salzman, Klei n , & Strauss, 1978), in both young (Kuechenmeister, Linton, & Mueller, 1977) and older schizophrenics (Holzman, Kringlen, Levy, Proctor, & Hakerman, 1978), and sex has not been shown to s i g n i f i c a n t l y influence the d e f i c i t (Iacono & Koenig, 1983; Iacono, Tuason, & Johnson, 1981). Neuroleptic medication also appears not to be a causal factor in the tracking d e f i c i t (Holzman et a l . , 1974; 1975; Mailet & Pichot, 1981; Shagass, Amadeo, & Overton, 1974). F i n a l l y , a t t e n t i o n a l demands of the task probably do not account for the d e f i c i t . Only extremely d i s t r a c t i n g tasks disrupt pursuit move-ments (Lipton, Frost, & Holzman, 1980; Pass, Salzman, Klorman, Kaskey, & K l e i n , 1978), and the d e f i c i t has been found by numerous investigators using various methodologies (see Iacono, 1983, for a review). Saccadic Eye Movements - Saccades involve high v e l o c i t y b a l l i s t i c movement of the eyes. They serve to r e f i x a t e v i s i o n and are apparently i n i t i a t e d v o l u n t a r i l y (Carpenter, 1977). However the time course (amplitude, v e l o c i t y and duration) i s preprogrammed and i s not affected by practice or extra voluntary e f f o r t (Carpenter, 1977). There i s normally very l i t t l e v a r i a b i l i t y In amplitude-velocity-duration 17 r e l a t i o n s h i p s in a variety of stimulus conditions,although v e l o c i t y may be reduced by alcohol, sedatives, or fatigue (Carpenter, 1977). Saccadic latency increases, to some extent, with amplitude although small saccades generally have the same latency regardless of amplitude (Carpenter, 1977). The normal range of saccadic latency i s 150 to 250 msec (Levy-Schoen & Blanc-Garin, 1974). This latency may be reduced by the p r e d i c t a b i l i t y of the target movements. However, i f the number of possible target positions extends beyond two, latency i s not reduced (Carpenter, 1977). A refractory period immediately following any saccadic move can also influence reaction time. A refractory period of 150 msec, during which time a second saccade cannot be generated, follows every saccade (Carpenter, 1977). Thus, the shortest possible time i n which one saccade can follow another i s 150 msec. Saccades are usually accurate i f the amplitude of the eye movement i s less than 20° (Carpenter, 1977). However, some saccades to target movements under 20° appear to systematically undershoot the target p o s i -t i o n by an amount that has an almost l i n e a r r e l a t i o n s h i p to the size of the i n i t i a l saccade. There has been l i t t l e research on saccadic eye movements i n schizo-phrenics. Levin, Jones, Stark, Merrin and Holzraan (1982), using small groups (6 chronic and 3 normal controls) found no difference i n saccadic latency or amplitude-velocity r e l a t i o n s h i p s . In another study with a larger subject sample, Levin, Holzman, Rothenberg and Lipton (1981) used a target that moved over unpredictable, variable amplitudes (2 to 24° i n 1° steps) and with unpredictable variable i n t e r t r i a l i n t e r v a l s (1 to 6 seconds). Measures were taken for the l e f t (target moved centre to 18 l e f t ) and right visual f i e l d s (target moved centre to r i g h t ) . No s i g n i -ficant differences were found between schizophrenics, manic-depressives and normal controls for latency, v e l o c i t y , duration, accuracy, or velocity-amplitude and duration-amplitude functions. However, the EOG was used to monitor eye movements and this recording technique may not be s u f f i c i e n t l y sensitive to i d e n t i f y small (1-2°) inaccuracies in move-ment and subsequent r e f i x a t i o n saccades (Iacono, & Koenig, 1983). Iacono et a l . , (1981) also used unpredictable i n t e r t r i a l i n t e r v a l s and EOG, and found no s i g n i f i c a n t differences i n saccadic latency between schizophrenics and normal controls. However, Cegalis, Sweeney, and Delis (1982) used a more s e n s i t i v e , i n f r a - r e d eye monitoring device and presented a series of target displacements of equal amplitude over equal i n t e r t r i a l i n t e r v a l s . Twenty schizophrenic, 20 nonpsychotic control, and 20 normal controls were used (mean ages were 17.1, 17.4 and 26 years). Schizophrenics were found to be more inaccurate than normal people and p s y c h i a t r i c controls, and they showed lower v e l o c i t i e s and peak v e l o c i t i e s than the normals but not the p s y c h i a t r i c controls. As was noted above, normals can take advantage of predictable target move-ments, and, thus, these findings may represent a learning e f f e c t rather than a index of neuropathology. In order to control for t h i s , Cegalis et a l . (1982) analysed the f i r s t four cycles separately and obtained results comparable to the o v e r a l l r e s u l t s . Overview of Current Project and Hypothesis A strategy aimed at improving present methods in schizophrenia research i s proposed. A l l psychotic patients, without diagnosed organic 19 disorders, should be included to compensate for the imprecision in con-temporary diagnostic procedures; multiple measures should be used to i d e n t i f y variables that c l u s t e r within subgroups and that discriminate between subgroups of psychotic patients. F i n a l l y , any i d e n t i f i e d cate-gory should be evaluated with regard to how well i t predicts response to treatment and prognosis. The aim of the present study was to i s o l a t e a subgroup of psychotic patients who show poor adjustment nine to 18 months af t e r their i n i t i a l psychotic episode. Three variables that are putative predictors of poor prognosis (process or negative) type schizo-phrenia were studied. Poor premorbid status, negative symptoms and eye movement anomalies were used i n the present study to predict rehospita-l i z a t i o n , general l e v e l of adjustment and employment-heterosexual adjustment nine to 18 months af t e r the f i r s t psychotic episode. The s p e c i f i c hypothesis of this study can be stated as follows: the combination of poor premorbid adjustment, numerous negative symptoms, and disrupted smooth pursuit eye tracking w i l l be found in a subgroup that shows poor general adjustment, poor employment-heterosexual adjust-ment, and one or more periods of r e h o s p i t a l i z a t i o n during the follow-up period. This pattern of predictors w i l l be reversed for a second sub-group of patients who show good adjustment and no r e h o s p i t a l i z a t i o n . The study described above, by i t s very nature, represents exploratory research. Further studies w i l l be conducted to r e p l i c a t e and extend the findings from this study. 20 METHOD Subjects Sixty-nine psychiatric patients were recruited for the f i r s t stage of a epidemiological study on psychosocial markers and predictors of psychopathology. An objective of this study was to determine the incidence of f i r s t break psychosis i n the Vancouver metropolitan area during the period extending from February, 1982 to February, 1984. Patients were referred from a l l p s y c h i a t r i c hospitals i n the Vancouver area as well as from a l l community mental health centres and private practice p s y c h i a t r i s t s who agreed to a s s i s t the project. In addition, a random sample of one of every six general p r a c t i t i o n e r s i n the area was s o l i c i t e d to refer patients. A l l participants had experienced t h e i r f i r s t treated psychotic episode within three months of entering this study. Of this i n t i a l group, 51 also p a r t i c i p a t e d i n a psychophysio-l o g i c a l assessment. Thirty-three (64.7%) of the patients that were given the i n i t i a l psychophysiological testing were reassessed 9 to 18 months following the onset of their psychosis. Seventeen of the 31 subjects that were tested i n i t i a l l y were not a v a i l a b l e for or were excluded from follow-up: seven moved out of the Vancouver area, f i v e refused to be retested, one was excluded because of recently diagnosed neuropathology, one because he used street drugs immediately before the experimental session, one committed suicide and two could not be released from h o s p i t a l for the retest. Four subjects who received only the s o c i a l assessment during the i n i t i a l period were also included i n the follow-up. This produced a sample of 37 subjects (see Table 1). Table 1 Cha r a c t e r i s t i c s of the Subjects Number of Subjects Age Diagnosis Male Female Total Medications 1 M SD 1 2 3 4 5 Total* Schizophreniform 17 3 20 14 2 2 7 1 15 20.42 4.18 Major Depression 7 2 9 5 1 1 1 0 5 24.33 5.74 Bipolar 3 3 6 2 0 2 2 1 2 30.66 10.67 Paranoid 1 1 2 1 0 0 0 0 1 41.00 8.48 Psychoactive medication at follow-up: 1 = antipsychotics, 2 = antidepressants, 3 = lithium, 4 = antiparkinsonian, 5 = antianxiety. Number of subjects on one or more medication. 22 At the time of the f i r s t testing 36 of the 37 subjects were psyc h i a t r i c inpatients and one was an outpatient. A l l patients presen-ted with psychotic symptoms (delusions and/or h a l l u c i n a t i o n s ) . I n d i v i -duals with a diagnosed neurological disorder were excluded. Diagnostic decisions were based on DSM III c r i t e r i a and r e f l e c t the consensus of at least two p s y c h i a t r i s t s and two c l i n i c a l psychologists. Twenty patients received a diagnosis of schizophreniform disorder, nine of major depres-sion, six of bipolar disorder-manic, and two of paranoid disorder. A l l the patients with a f f e c t i v e psychoses had mood incongruent delusions and/or h a l l u c i n a t i o n s . A l l p a r t i c i p a n t s were receiving psychotropic medication at the time of the f i r s t evaluation. There were 28 males and nine females between the ages of 16 and 47 (M = 24.37, SD = 8.82). At the time of the second t e s t i n g , four p a r t i c i p a n t s were receiving treatment as inpatients, 23 were treated as on outpatient basis, and ten were receiving no p s y c h i a t r i c treatment. F i f t e e n i n d i v i d u a l s were medi-cation free at follow-up (see Table 1). A l l subjects gave informed consent and were paid $10 for the i r p a r t i c i p a t i o n . Interviews and Apparatus Interviews At the time each subject experienced his or her f i r s t psychotic episode, a screening schedule was completed based on information obtained from the r e f e r r i n g agency ( h o s p i t a l , community care team, private p s y c h i a t r i s t , or general p r a c t i t i o n e r , see Appendix A). This schedule was used to screen out i n d i v i d u a l s with organic mental d i s -orders and to i d e n t i f y those who were p o t e n t i a l l y psychotic. 23 If a subject was deemed appropriate for i n c l u s i o n i n the study and gave informed consent, the Present State Examination was completed and was used as a basis for making diagnostic decisions. A d i f f e r e n t i n t e r -view was completed at follow-up to obtain information regarding l e v e l of adjustment both during and at the time of follow-up (see Appendix 2). The items from this interview that were used to rate the presence of symptoms (Items 6-51) were taken from the Diagnostic Interview Schedule (National I n s t i t u t e of Mental Health, 1981). Items 58, 59 and 63 to 67 from the follow-up interview were used to make a rating of premorbid adjustment on the abbreviated form of the P h i l l i p s Premorbid Adjustment Scale (Harris, 1975, see Appendix C). A rating of the severity of nega-t i v e symptoms was made by summing items 19, 20, 58, 107, 128, 129 and 138 of the Present State Exam (see Appendix D). A rating of employ-ment-heterosexual adjustment was made using questions 63 to 71, and 53c to 53f from the follow-up interview to complete items l a , 3a and 4 of the Prognostic Scale (Strauss & Carpenter, 1974, see Appendix E). F i n a l l y , the Gobal Assessment Scale (GAS) was used to make a rating of adjustment for the month preceding the follow-up testing (see Appendix F). Information from questions 6 to 51, and 53, 54 of the follow-up interview were used to make this r a t i n g . Apparatus A Wavetek D i g i t a l VCG Model 113 sine wave generator was used to drive a target h o r i z o n t a l l y across the screen of a Tektronix Type RM 15 single beam oscilloscope. The target, which simulated the harmonic motion of a swinging pendulum, served as the stimulus for smooth pursuit tracking. The target consisted of a c i r c l e approximately 5 mm in 24 diameter with a dot in the centre. To assess saccadic eye tracking proficiency, a spot of l i g h t c o ntrolled by a random i n t e r v a l random amplitude square wave generator appeared to move h o r i z o n t a l l y across a 30 cm square, semi-transparent p l a s t i c screen. The screen was placed at the rear of a white p l a s t i c box to l i m i t d i s t r a c t i n g s t i m u l i . Red l i g h t - e m i t t i n g diodes placed behind the screen served as the s t i m u l i . When illuminated the diodes appeared as points of red l i g h t , approxi-mately 5 mm in diameter. These l i g h t sources were activated by a paper tape-operated switching system. The time i n t e r v a l s elapsing between the i l l u m i n a t i o n of the diodes were one, two, three, or four seconds and the distances between diodes corresponded to eye movement amplitudes of 12, 14, 16 or 18 degrees of v i s u a l arc. The diodes were arranged such that the target appeared to move from a minimum of 4 > l e f t or right of centre to a maximum of 20* l e f t or right of centre. A chin and forehead rest placed 30 cm i n front of the equipment served to s t a b i l i z e the subject's head for the sinusoidal and square wave tasks. One cm s i l v e r / s i l v e r chloride electrodes were attached to the abraided outer canthi for h o r i z o n t a l EOG recording. A t h i r d electrode placed above the right eye and referenced to the electrode at the right outer canthus, was used to monitor b l i n k s . A ground electrode was attached to the l e f t ear lobe. A Gulf and Western model 200 i n f r a - r e d (IR) eye movement monitor, attached to a pair of lensless eye glasses, was used to monitor movements of the l e f t and right eyes separately. Signals from both the EOG and IR systems were recorded simultaneously on a Beckman RM Dynograph and on a magnetic tape using a Vetter FM Model A 25 tape recorder. Modified type 9806A AC couplers were used for EOG, IR, and target input on the dynograph. The couplers were set to DC for the IR and target signals for both the s i n u s o i d a l and square wave tasks. Time constants of three seconds for the s i n u s o i d a l task and ten seconds for the square wave tasks were used for EOG recording. AC coupling was used for recording the EOG in order to reduce the contribution of base-l i n e s h i f t to the records. A time constant of .1 seconds was used to monitor b l i n k s . Procedure The Present State Examination (PSE) was conducted at the time each subject was recruited by a p s y c h i a t r i s t trained i n the use of this instrument. With appropriate t r a i n i n g , the PSE i s reported to have' a r e l i a b i l i t y of .84 (Shapiro & Jablonsky, 1976). No r e l i a b i l i t y check was done on these interviews i n the present study. This instrument was used to obtain a rating of adjustment for the month preceding the i n t e r -view. The PSE was administered as close as possible to the time of the f i r s t t e s t i n g . A number of psychophysiological measures were also taken at this time. Among these was a measure of .4 Hz smooth pursuit eye movements (SPEM). The procedure used for this i n i t i a l SPEM measurement was the same as that used in the follow-up except for the addition of the i n f r a - r e d eye monitors during the follow-up assessment. At the time of the follow-up, subjects were shown the apparatus and given an explanation of the experimental procedures before the experi-ment began. Subjects sat in front of the oscilloscope while EOG elec-trodes were attached and IR monitors positioned. The subject's head was 26 s t a b i l i z e d i n the chin and forehead r e s t , and the l i g h t s were dimmed. Tape recorded i n s t r u c t i o n s were used to request that the subject r e f r a i n from b l i n k i n g , relax, hold his or her head s t i l l and follow the target c l o s e l y . IR and EOG recordings were cal i b r a t e d at this time. A .4 Hz o s c i l l a t i n g , sinusoidal target was presented for 20 cycles. The subject was then asked to move in front of the p l a s t i c screen and the same procedure was repeated for the square wave task. This task was repeated twice with at least ten seconds between tasks. The follow-up interview was conducted either immediately before or immediately a f t e r the psycho-p h y s i o l o g i c a l t e s t i n g . This interview was conducted by the experimenter or one of three research assi s t a n t s . The t o t a l duration of each session was from two to two and a half hours. Data Q u a n t i f i c a t i o n  Interview Data. The scores on the negative symptom rating ranged from zero to 15. Zero would indicate that no negative symptoms were judged to be present while 15 would be severely incapacitated. The ra t i n g of premorbid adjustment ranged from one (good premorbid adjustment) to 12 (very poor premorbid adjustment). Global adjustment (GAS) ranged from 100 ("superior functioning") to one ("needs constant supervision"). F i n a l l y , employment-heterosexual adjustment scores ranged from zero to eight. A score of zero indicates no employment or heterosexual i n t e r e s t while 8 indicates f u l l - t i m e employment and eit h e r married or dates regularly. Interater r e l i a b i l i t y for the above ratings was assessed by comparing a rating made by the experimenter with one made by a second 27 r a t e r . The second rater was blind to the i d e n t i t y of the subjects. Inconsistencies were resolved through mutual agreement. The follow-up interviews were conducted by the experimenter or one of three research a s s i s t a n t s . Six of 37 interviews were conducted by an interviewer with an observer also present in the interview room. The observer noted the subject's responses but did not p a r t i c i p a t e i n the interviews. These observed interviews were used to check i n t e r r a t e r r e l i a b i l i t y . Eye Movement Data. Taped EOG, IR and target channels from the .4 Hz smooth pursuit eye-tracking task were fed into a D i g i t a l Equipment Corporation LSI 11/23 d i g i t a l computer. The computer was programmed to compute root-mean-square (RMS) error deviation of each data channel (EOG, l e f t eye i n f r a - r e d , and right eye infra-red) from the target channel. The amplitudes of the channels were set equal with respect to t h e i r respective envelopes, and the channels aligned for phase d i f f e r e n -ces. The process of aligni n g the channels produced an estimate of the degree to which an i n d i v i d u a l ' s eyes lag behind the target. These two measures (RMS error and phase lag) were taken from .4 Hz eye tracking performance for EOG at the time of the f i r s t t e s ting and for EOG, l e f t eye Infra-red, and right eye in f r a - r e d at the follow-up t e s t i n g . Taped saccadic eye movement data, recorded only during the follow-up t e s t i n g , was also fed into the computer which was programmed to compute latency, accuracy and mean v e l o c i t y of each eye movemnt for the IR channels. Latency was the i n t e r v a l ( i n msec) between the target 28 movement and the i n i t i a t i o n of an eye movement. Accuracy was divided into overshoot and undershoot ( i n degrees of v i s u a l a r c ) . Overshoot was the difference between eye movements greater than the target movement and the target movement. Undershoot was the difference between eye movements less than the target movement and the target movements. Mean v e l o c i t y was a function of the magnitude and the duration of the sacca-dic movement ( i n degrees of v i s u a l arc per). In order to compute these measures a manual c a l i b r a t i o n value had to be calculated. The c a l i b r a -t i o n value was used to translate voltages from the eye movement channels to amplitudes of eye movement i n degrees of v i s u a l arc. The c a l i b r a t -ion provided a figure i n vo l t s that corresponded to each degree of v i s u a l arc. This value was computed for each subject by measuring the voltage of signals while the subject was f i x a t i n g on points known to be ce r t a i n number of degrees apart. Eight points to the l e f t and eight points to the right of centre were used for th i s purpose. The average value associated with eye movements between these points was transformed to volts per degree and was used to set the c a l i b r a t i o n value. Move-ments that occurred at the same time as blinks were deleted. 29 RESULTS This section of the thesis i s divided into several subsections. The f i r s t , e n t i t l e d R e l i a b i l i t y and Reduction of Measures, presents the procedure and rationale followed in reducing the saccadic eye movement data, the interjudge r e l i a b i l i t y c o e f f i c i e n t s for the various rating scales and the t e s t - r e t e s t r e l i a b i l i t y estimates for smooth pursuit and saccadic eye movement data. Also presented are the correlations between simultaneously recorded EOG and IR estimates of smooth pursuit tracking p r o f i c i e n c y . The second subsection deals with the p r e d i c t i v e v a l i d i t y of the eye tracking and rating data. The p r e d i c t i v e variables are smooth pursuit RMS error and phase lag from the f i r s t t e s t i n g , the score on the nega-t i v e symptom scale, and the P h i l l i p s r a ting of premorbid adjustment. The variables that were predicted were GAS score based on adjustment over the month preceding the follow-up interview, employment-hetero-sexual adjustment during the follow-up period, and whether or not the patient was rehospitalized. Two steps were taken In the analysis of the predictive v a l i d i t y . As a f i r s t step, correlations were computed between the four predictor variables and the three outcome measures. (While the term "outcome measure" i s usually reserved for measures of outcome in a treatment study, for convenience of expression the term i s used i n this discus-sion to refer to the l e v e l of adjustment over the follow-up period). Second, each outcome measure was dichotomized to produce one group with poor adjustment and a second with good adjustment. A score of 65 on the 30 GAS (generally functioning with some d i f f i c u l t y , see Appendix F) was used as the cut o f f . For the employment-heterosexual adjustment (see Appendix E), a cut-off of 2 was used since t h i s score most nearly s p l i t the group into halves. The group was also dichotomized according tc whether patients were rehospitalized at least once or never re h o s p i t a l -ized. A discriminant analysis was executed for each of these dichoto-mized variables i n order to i d e n t i f y the best combination of predictor v a r i a b l e s . This s t a t i s t i c a l analysis l i n e a r l y combines the best predic-tors of outcome i n a stepwise procedure. Each measure that accounts for a unique proportion of the variance i s added to the prediction formula. Two groups that are as s t a t i s t i c a l l y d i s t i n c t as possible are produced. The s t a t i s t i c a l s i g n i f i c a n c e of the discriminant function i s determined using a chi square s t a t i s t i c . Four subjects did not complete the eye movement task on the f i r s t t e s t ing and were deleted from discriminant analyses that incorporated eye movement data. If the eye movement variables were not included i n the set of predictor v a r i a b l e s , a l l 37 subjects were used. The t h i r d subsection e n t i t l e d Concurrent V a l i d i t y deals with the a b i l i t y of concurrently recorded eye movement data to i d e n t i f y outcome status at follow-up. The variables used to i d e n t i f y outcome were smooth pursuit RMS error and phase lag, saccadic latency, average v e l o c i t y , average overshoot, and average undershoot. The outcome variables that were used for concurrent v a l i d a t i o n were the same as those used i n assessing predictive v a l i d i t y (GAS score, employment-heterosexual adjustment, and r e h o s p i t a l i z a t i o n ) . The analyses used to assess concur-31 rent v a l i d i t y were also the same as those used i n determining p r e d i c t i v e v a l i d i t y . The fourth subsection e n t i t l e d Exploratory Analyses deals with variables that were used to describe the patients and that were found to have some discriminating value. Correlations were computed between the age of the patients at the time of the i r f i r s t psychotic episode and the predictor and outcome variables. Further c o r r e l a t i o n s were computed between the duration of the f i r s t h o s p i t a l i z a t i o n and the predictor and outcome measures. In order to assess the impact of these variables on the prediction of outcome, a discriminant analysis was executed, adding age and duration of h o s p i t a l i z a t i o n to the l i s t of predictor variables, for each of the outcome measures. F i n a l l y , since the saccadic measures were not obtained at the f i r s t testing, the value of these measures as predictors of outcome could not be assessed. In an exploratory analy-s i s , these saccadic measures were added to the predictor variables and a discriminant analysis computed for each of the outcome measures. R e l i a b i l i t y and Reduction of Measures Interview Data. The interjudge r e l i a b i l i t y of the follow-up i n t e r -view was assessed by comparing a l l recorded responses across the i n t e r -viewer's and observer's interview schedules. There was 100% agreement between interviewer and observer on a l l items of the follow-up interview for the s i x pairs of interviews checked. The interjudge r e l i a b i l i t y of the Abbreviated Scale of Premorbid Sexual Adjustment and the Abbreviated Scale of Premorbid So c i a l Personal Adjustment were high, r = .81, and r = .85, respectively. 32 Item three of the Strauss-Carpenter Prognostic scale was not s u f f i -c i e n t l y s e n s i t i v e to detect v a r i a b i l i t y i n s o c i a l contacts during the follow-up period for this group of patients. This item was dropped from further analyses. The interjudge r e l i a b i l i t y for the ratings of hetero-sexual and employment adjustment during the follow up period were .93, and .92, r e s p e c t i v e l y . The interjudge r e l i a b i l i t y for the ratings of global adjustment ( i . e . , the GAS) during the month before the follow-up intervew was .82. Smooth Pursuit Eye Movements. Consistent with e a r l i e r studies (Iacono & Lykken, 1979; 1931) the log of the median RMS value was used as an index of eye tracking i n t e g r i t y . The l e f t i n f r a - r e d , right i n f r a - r e d and EOG measures of median RMS values were a l l highly c o r r e l a -ted _r = .85 to r_ = .94. In order to be consistent with previous studies, almost a l l of which have used the EOG, and because of the high l e v e l of agreement between the three measures, the EOG was used for smooth pursuit analyses. As with the RMS values, the measures of phase lag during eye tracking correlated highly across the EOG and i n f r a - r e d measures r = .81 to .91. The EOG measure of phase lag was also used for a n a l y s i s . The t e s t - r e t e s t r e l i a b i l i t y between the f i r s t and follow-up t e s t -ings was moderately high for the RMS error _r = .61, p < .01 and low for the measure of phase lag r_ = .32, p_ < .05. There was a moderately high c o r r e l a t i o n between RMS error and phase lag measures at both the f i r s t , r = -.61, p_ < .01, and second r_ = -.64, p_ < .01 t e s t i n g s . Consistent with previous findings of Iacono and colleagues (Iacono & Koenig, 1983; Iacono & Lykken, 1979), these negative c o r r e l a t i o n s indicate that good 33 smooth pursuit eye tracking i s associated with a tendency for the eyes to lag behind the target without producing "catch-up" saccades. Saccadic Eye Movements. The saccadic eye movement task was not completed at the f i r s t testing session. Test-retest r e l i a b i l i t y for this task was, therefore, obtained by comparing performances on two i d e n t i c a l saccadic tasks given at the follow-up testing session. The l e f t and right eye latencies and the latencies for leftward and r i g h t -ward movements were s i m i l a r (see Table 2). These measures were collapsed and one measure of latency was used for further analyses. The te s t - r e t e s t r e l i a b i l i t y of the latency measure was r = .91. Measures of average saccadic v e l o c i t y were obtained for l e f t and righ t eyes, for l e f t and rightward movements over f i v e amplitude ranges (1-5, 6-10, 11-15, 16-20, and over 20 degrees of v i s u a l a r c ) . There were i n s u f f i -cient observations in the 1 to 5, and over 20 degree ranges to compute r e l i a b l e s t a t i s t i c s . These ranges were therefore dropped from the analysis. V e l o c i t y measures over d i r e c t i o n of movement and between l e f t and right eyes were e s s e n t i a l l y i d e n t i c a l . These measures were there-fore collapsed to produce three measures of average saccadic v e l o c i t y . These were for saccadic eye movements from 6 to 10, 11 to 15, and 16 to 20 degrees of v i s u a l arc. The t e s t - r e t e s t r e l i a b i l i t y of these measures was _r = .52, r = .85, and r = .77. As was expected (Carpenter, 1977), there was an increase in v e l o c i t y when the magnitude of the eye movement increased (Mg_io = 1^9 deg/sec, M^.^ = 241 deg/sec, M.16-20 = 290 deg/sec). Since the majority of eye movements f e l l within the 11 to 15 degree range, this measure was used in further analyses (see Table 2). Table 2 Saccadic Eye Movements Leftward and for Left Rightward and Right Movements Eyes over Saccadic Eye Movement Measure Eye and D i r e c t i o n of Movement V e l o c i t y 1 Latency Accuracy 3 M SD M SD M SD Left Eye Leftward 244 36 196 40 2.62 1.40 Left Eye Rightward 246 48 193 31 2.34 0.90 Right Eye Leftward 233 37 197 38 1.30 0.61 Right Eye Rightward 248 43 190 31 2.29 1.11 Ve l o c i t y = the average v e l o c i t y of the eye i n degrees of v i s u a l arc per sec. Latency = the time elapsed ( i n msec) between the onset of target movement and the onset of eye movement. Accuracy = the dif f e r e n c e , i n degrees of v i s u a l arc, between the amplitude of the target movement and the amplitude of the eye movement. 35 Measures of saccadic eye movement accuracy were obtained by sub-tra c t i n g the magnitude of the target movement from the magnitude of the eye movement. These measures were averaged to produce mean measures of overshoot (an eye movement greater than the target movement), undershoot (an eye movement less than the target movement) for the l e f t and right eyes over l e f t - and rightward movements. Accuracies over l e f t and right eyes across leftward and rightward movements were e s s e n t i a l l y the same (see Table 2). These measures were collapsed to give average overshoot and average undershoot and were used for further analyses. The test-retest r e l i a b i l i t y of overshoot was, r = .73, and of undershoot, r = .79. These findings indicate that the various measures of saccadic eye movement are stable. The EOG was not used in the saccadic task because of the imprecision in measuring small saccades that i s associated with this measuring technique (Iacono & Koenig, 1983). Analysis of Results P r e d i c t i v e V a l i d i t y . Pearson c o r r e l a t i o n s were computed for the predictor variables (RMS error and phase lag from the f i r s t t e sting, premorbid adjustment and negative symptoms during the f i r s t psychotic episode), and outcome measures (GAS scores at the time of follow-up and employment-heterosexual adjustment during the nine to 18 month follow-up period). Since r e h o s p i t a l i z a t i o n was a dichotomous variable, point-b i s e r a l correlations were computed for this v a r i a b l e . As can be seen i n Table 3, GAS scores were found to be s i g n i f i c a n t l y related to premorbid adjustment, r_ = -.401, p^  = .007, and phase lag, r_ = .339, p^  = .027. Neither negative symptoms nor RMS error were s i g n i f i c a n t l y related to Table 3 Predictor and Outcome Variable Correlations Predictor Measures Outcome Measures 2 Smooth Pursuit Negative Premorbid *3 E' -H Rehospital RMS Error Phase Lag Symptoms Status GASJ Adjustment i z a t i o n 5 RMS error r = -.642 r = .329 r = .061 r = -.274 r = -.207 r = .003 P = .001 p = .031 P = .369 P = .061 P = .124 P = .581 Phase lag _ - r = -.374 r = -.225 r = .339 r .198 r = .085 - p = .016 P = .104 P = .027 P = .135 P = .307 Negative - r = .079 r = -.252 r = • -.275 r = .029 symptoms — P = .320 P = .066 P .050 P = .451 Premorbid - r = -.401 r = .362 r = .033 Status - P = .007 P = .014 P = .408 GAS3 — r = .662 r = .112 - P = .001 P = .279 h E-H - r = .070 Adjustment - P = .361 Rehos p i t a l i z a t i o n Pearson correlations are used unless otherwise reported. Correlations that are underlined are s t a t i s t i c a l l y s i g n i f i c a n t at the p < .05 l e v e l (two-tailed s i g n i f i c a n c e ) . i Smooth pursuit eye movement task from the f i r s t test session. Global adjustment scale. Employment-heterosexual adjustment. 'Rehospitalization i s a dichotomous variable, correlations in this column are point b i s e r a l . 37 GAS scores. Poor employment-heterosexual adjustment was s i g n i f i c a n t l y related to premorbid adjustment, r_ = .362, p_ = .014, and negative symp-toms, £ = .275, _p = .050. These results indicate that poor premorbid adjustment tended to precede poor adjustment during and at the time of follow-up, while negative symptoms were more l i k e l y to occur i n i n d i v i -duals who l a t e r showed poor employment-heterosexual adjustment. There was also a tendency for in d i v i d u a l s who anticipated a moving target ( i . e . moved their eyes ahead of the target) i n the o r i g i n a l testing to show low GAS scores i n d i c a t i v e of poor adjustment at follow-up. Table 4 shows the means and standard deviations for each of the predictor variables after they had been dichotomized into good and poor adjustment on each of the dependent measures. For both GAS and employ-ment-heterosexual adjustment a l l four predictor measures showed a consistent difference i n the predicted d i r e c t i o n between groups. Poorly adjusted subjects had more negative symptoms, poor premorbid adjustment, numerous eye tracking errors and tended to move th e i r eyes ahead of the moving target. A l l the ' predictor measures were s i m i l a r across the rehospitalized-nonrehospitalized groups. In order to obtain the best combination of predictor variables separate discriminant analyses were computed for GAS scores, employ-ment-heterosexual adjustment, and r e h o s p i t a l i z a t i o n . GAS scores were best predicted by a combination of negative symptoms, and premorbid adjustment, X (2) = 7.39, ri = 37, p. = .025. Together these variables were able to c o r r e c t l y predict 27 (73%) of the 37 subjects. Both RMS error and phase lag were s i g n i f i c a n t l y related to negative symptoms, r = .329, p = .031 and r = -.374, p = .016, and did not account for any Table 4 Good and Poor Adjustment Groups for each Outcome Variable Outcome Measures GAS1 E-H Adjustment Rehospitalization Good Poor Good Poor Good Poor Predictor Measures n=ll n=22 n=15 iv 18 n=23 n=10 RMS1* M 2.025 2.116 2.043 2.121 2.186 2.084 error SD 0.213 0.198 0.178 0.222 0.179 0.264 Phase5 M -1.182 -5.182 -1.400 -5.889 -3.348 -5.000 lag SD 3.995 10.358 3.439 11.375 4.849 14.885 Negative M 3.000 4.364 3.533 4.222 3.826 4.100 Symptoms SD 2.608 1.989 2.446 2.130 2.462 1.853 Premorbid M 2.454 4.273 2.533 4.611 3.652 3.700 Status SD 1.440 2.292 1.356 2.355 2.403 1.767 GAS = Global Assessment Scale: Good adjustment and poor adjustment. E-H Adjustment = Employment-heterosexual adjustment: Good adjustment and poor adjustment. 'Rehospitalization: Good adjustment = not rehospitalized and poor adjustment = rehospitalized one or more times. Log RMS error from smooth pursuit eye tracking at the first testing. Unit of measurement = arbitrary units here. 'Phase lag from smooth pursuit eye tracking at the first testing. Unit of measurement = degrees of sine wave. A negative phase lag signifies that the subject's eye were ahead of the target. 39 add i t i o n a l v a r i a b i l i t y in this prediction formula. As can be seen i n Table 5, 18 (69%) of the 26 subjects who had poor adjustment at follow-up ( i . e . low GAS scores) were c o r r e c t l y predicted from l e v e l of premor-bid adjustment and number of negative symptoms, while nine (82%) of the 11 well adjusted individuals were c o r r e c t l y predicted. Employment-heterosexual adjustment during the follow-up period was successfully predicted by RMS error and l e v e l of premorbid adjustment, X 2(2) = 8.79, n = 33, p_ = .012. Four subjects were deleted from t h i s analysis because of missing eye movement data. It can be seen from Table 5 that 23 (70%) of the 33 subjects used in this analysis were co r r e c t l y i d e n t i f i e d by t h i s combination of predictors. Eleven (61%) of the 18 individuals with poor adjustment during the follow-up period were co r r e c t l y i d e n t i f i e d from t h e i r premorbid adjustment rating and RMS error scores, while 12 (80%) of the 15 well adjusted individuals were co r r e c t l y i d e n t i f i e d from th e i r scores on these vari a b l e s . Of the 18 individuals who were accurately predicted as having low GAS scores (poor adjustment), 11 were also accurately predicted as having poor employ-ment-heterosexual adjustment; i . e . , 11 subjects were poorly adjusted according to the two outcome measures and were accurately predicted as being such. Eight of the nine subjects who had high GAS scores also had high employment adjustment scores. None of the predictor variables were successful in i d e n t i f y i n g r e h o s p i t a l i z a t i o n . Concurrent V a l i d i t y . Table 6 shows the Pearson co r r e l a t i o n s that were computed between the eye movement measures obtained at follow-up (Smooth pursuit RMS error and phase lag and saccadic latency, average Table 5 Pred i c t i o n of Outcome Measures Using Discriminant Analysis Number of Subjects and Percentage Predicted Groups 1 Total Actual Groups 2 N Good Poor Correctly Predicted 37 Good 9 (82%) 2 (18%) 27 (73%) GAS3 Poor 8 (31%) 18 (69%) Good 12 (80%) 3 (20%) 23 (70%) E-H Adjustment 33 Poor 7 (39%) 11 (61%) Predicted group of membership according to a combination of predictor variables. Actual group of membership according to the outcome measures. Global Assessment Scale: Good adjustment and poor adjustment. Predicted by negative symptoms and premorbid adjustment. Employment-heterosexual adjustment: Good adjustment and poor adjustment. Predicted by RMS error and premorbid adjustment. Table 6 Concurrent and Outcome Variable Correlations Concurrent Measures Outcome Measures Smooth Pursuit Saccadic Eye Movements E-H Rehospital-2 3 4 RMS Error Phase Lag Velocity Overshoot Undershoot Latency GAS Adjustment i z a t i o n RMS error r = -.605 r = -.159 r = .334 r = .483 r = .181 r = -.253 r = -.041 r = .235 p = .001 p = .184 P = .031 P = .002 P = .153 P = .072 P = .408 P = .087 Phase lag r = .373 r -.384 r = -.417 r .089 r -.008 r -.239 r .201 p = .015 P = .015 P = .008 P = .307 P = .482 P = .084 P = .131 Saccadic — r .106 r -.322 r .072 r = .147 r .132 r = -.079 v e l o c i t y - P = .279 P = .032 P = .333 P = .200 P = .224 P = .320 Saccadic — r = .508 r = .209 r = .252 r = .072 r = .209 overshoot - P = .001 P = .121 P = .079 P .345 P = .121 Saccadic _ r = .080 r = .038 r = -.024 r = .109 undershoot - P = .326 P = .415 P = .446 P = .267 Saccadic - r = -.203 r = -.064 r = -.038 latency - P = .131 P = .357 P .415 GAS - r .662 r = .112 - P = .001 P = .279 E-H - r = .070 Adjustment - p- = .361 Reho s p i t a l i -zation Pearson correlations are used unless otherwise reported. Correlations that are underlined are s t a t i s t i c a l l y s i g n i f i c a n t at the p < .05 l e v e l . Global Assessment Scale. Employment-heterosexual adjustment. Rehospitalization is a dichotomous variable. Correlation i n this column are point b i s e r a l . 'Smooth pursuit eye movement task from the follow-up session. 42 v e l o c i t y , average overshoot and average undershoot), and the follow-up measures (GAS rating at follow-up and employment-heterosexual adjustment during follow-up). Point b i s e r a l c o r r e l a t i o n s were computed between r e h o s p i t a l i z a t i o n and the eye movement measures obtained at follow-up (see Table 6). It can be seen from Table 6 that there were no s i g n i f i -cant relationships between any of the follow-up eye-movement measures and the three measures of adjustment at follow-up. Discriminant analyses were computed for each of the three dichoto-mized outcome measures over the eye-movement measures obtained at follow-up. Although two of the three discriminant analyses f a i l e d to produce s i g n i f i c a n t results at the .05 l e v e l , given the exploratory nature of this project the results of the two analyses which attained borderline s i g n i f i c a n c e are presented here. Whether or not the r e l a -tionships indicated by these analyses are important ones must, of course be determined with r e p l i c a t i o n . The combination of RMS error, and average saccadic overshoot approached s i g n i f i c a n c e i n i d e n t i f y i n g GAS scores at follow-up, _X (2) = 5.66, _n = 32, p = .059. Together these variables c o r r e c t l y i d e n t i f i e d 24 (75%) of the 32 subjects used in t h i s a n a l y s i s . Five subjects were deleted from this analysis because of missing eye movement data. Eighteen (78%) of the 23 i n d i v i d u a l s who scored low on the GAS were c o r r e c t l y predicted from RMS error and average saccadic overshoot (see Table 7). Both phase lag and average saccadic undershoot were s i g n i f i c a n t l y related to RMS error, £ = -.654, £ < .001 and £ = .555, j> < .001, and did not account for any a d d i t i o n a l v a r i a b i l i t y i n the prediction of GAS scores. Employment-heterosexual adjustment during the follow-up period was Table 7 Concurrent V a l i d i t y of Eye Movement Measures Number of Subjects and Percentage Actual Group^ Predicted Groups 1 Good Poor Total Correctly Predicted GAS' E-H Adjustment 32 34 Rehos p i t a l i z a t i o n 32 Good 6 (67%) 3 (33%) 26 (75%) Poor 5 (22%) 18 (78%) Good 8 (57%) 6 (43%) 24 (71%) Poor 4 (20%) 16 (80%) Good 18 (78%) 5 (22%) 25 (78%) Poor 2 (22%) 7 (78%) I d e n t i f i e d group of membership according to a combination of concurrently assessed va r i a b l e s . Actual group of membership according to the outcome measure. 3Global Assessment Scale: Good adjustment and poor adjustment. Predicted by RMS error and saccadic overshoot. ^Employment-heterosexual adjustment: Good adjustment and poor adjustment. Predicted by RMS error, phase lag, and saccadic average v e l o c i t y . ^Rehospitalization: Good = not rehospitalized during follow-up, poor = rehospitalized one or more times. Predicted by RMS error and overshoot. 44 related to the combination of RMS error, phase lag, and saccadic average 2 v e l o c i t y . This combination approached s t a t i s t i c a l s i g n i f i c a n c e , X_ (3) = 7.32, n = 34, p = .061. Together these variables i d e n t i f i e d 24 (71%) of the 34 subjects used i n this a n a l y sis. Three subjects were deleted because of missing eye movement data. Sixteen (80%) of the 20 i n d i v i -duals who scored low on employment-heterosexual adjustment were c o r r e c t l y predicted while eight (51%) of the 14 well adjusted subjects were c o r r e c t l y predicted (see Table 7). Reho s p i t a l i z a t i o n during the follow-up period was associated with 2 greater RMS error and less mean saccadic overshoot, X (2) = 6.09, n_ = 32, _p = .047. Twenty-five (78%) of the 32 subjects included i n this analysis were co r r e c t l y c l a s s i f i e d (see Table 7). Seven (78 %) of the nine subjects who were rehospitalized were c o r r e c t l y predicted from t h e i r RMS error and saccadic overshoot values while 18 (78%) of the non-rehospitalized group were accurately predicted. Phase lag and average saccadic undershoot were both s i g n i f i c a n t l y related to RMS error, r = -.644 and _r = .538, and did not contribute any addit i o n a l variance to the prediction formula. Exploratory Analyses. From Table 8 i t can be seen that the dura-tion of h o s p i t a l i z a t i o n at the time of the f i r s t psychotic episode was found to be s i g n i f i c a n t l y related to GAS score at follow-up, r = -.513, p_ < .001, and to l e v e l of employment-heterosexual adjustment during follow-up r = .324, _p = .025. These r e l a t i o n s h i p s indicate a trend towards poorer adjustment during follow-up i n i n d i v i d u a l s who i n i t i a l l y spend extended periods of time i n h o s p i t a l . Duration of h o s p i t a l i z a t i o n Table 8 Age and Duration of H o s p i t a l i z a t i o n Correlations with Predictor and Outcome Variables. 1 Predictor Measures Outcome Measures Smooth P u r s u i t 2 Negative Premorbid RMS Error Phase Lag Symptoms Status E-H Rehospital-Adjustment i z a t i o n GAS; Age 6 r = -.124 r = .335 r = -.386 r = -.318 r = .417 r = .384 r = .103 p = .245 p = .028 p = .009 p = .028 p = .005 p = .009 p = .242 Duration of r = .132 r = -.190 r = .093 r = .201 r = -.513 r = .324 r = .133 H o s p i t a l i z a t i o n p = .232 p = .145 p = .292 p = .116 p = .001 p = .025 p = .223 ^Pearson correlations are used unless otherwise reported. Correlations that are underlined are s t a t i s t i c a l l y s i g n i f i c a n t at the p<.05 l e v e l (two-tailed s i g n i f i c a n c e ) . Smooth pursuit eye movement task from the f i r s t test session. 3 Global adjustment scale. ^Employment-heterosexual adjustment. 5 R e h o s p i t a l i z a t i o n i s a dichotomous variable, correlations with this variable are point b i s e r a l . 6Age at the time of the f i r s t p s y c h i a t r i c h o s p i t a l i z a t i o n or age at r e f e r r a l to this study i f the patient was not ho s p i t a l z e d . 46 was not s i g n i f i c a n t l y related to RMS error, r = .473, or phase lag from the f i r s t t e s t i n g . Table 8 summarizes the relationships between age and the predictor and outcome measures. The age of the subjects at the time of their f i r s t psychotic episode was found to be s i g n i f i c a n t l y related to nega-tiv e symptoms, r_ = -.386, p_ = .009, premorbid adjustment, v_ = -.318, £ = .028, GAS scores, _r = .417, £ = .005, and phase lag, _r = .335, £ = .028. These re l a t i o n s indicate a tendency for older subjects i n this sample to have fewer negative symptoms, better premorbid adjustment, better adjustment at follow-up and more phase lag during eye tracking than did younger subjects. In order to assess the impact of these variables on the p r e d i c t i o n of outcome, discriminant analyses were computed using the -predictor variables (RMS error, phase lag, premorbid adjustment and negative symptoms) plus age and duration of h o s p i t a l i z a t i o n over the three out-come measures (GAS, employment-heterosexual adjustment, and r e h o s p i t a l i -z a t i o n ) . With these variables added to the p r e d i c t i o n formula, GAS 2 scores were best predicted by age and premorbid status X (2) = 8.46, n = 37, £ = .014. Of the 37 subjects used i n this analysis 28 (76%) were c o r r e c t l y predicted. This is a s l i g h t improvement on the 27 (73%) that were c o r r e c t l y predicted when negative symptoms and premorbid status were used in the prediction formula (see Table 5). Negative symptoms were s i g n i f i c a n t l y related to age, _r = -.386, £ = .028 and did not account for any a d d i t i o n a l v a r i a b i l i t y in the prediction formula. Re h o s p i t a l i z a t i o n was not successfully predicted using this combination of predictor v a r i a b l e s . The best predictors for employ-ment-heterosexual adjustment during follow-up were premorbid status and 47 age, X 2(2) = 9.75, n = 37, p = .008. With this combination, 25 (78%) of the 37 subjects were c o r r e c t l y c l a s s i f i e d . This i s an improvement over the prediction formula of premorbid status and RMS error (see Table 5). Saccadic measures were not recorded during the f i r s t testing and, thus, the predictive v a l i d i t y of these measures could not be assessed. Given the exploratory nature of this thesis, a further discriminant analysis was computed using the predictor variables and the saccadic measures to ascertain whether the saccadic measures could p o t e n t i a l l y add anything to the prediction of the outcome. The magnitude of saccadic overshoot was found to improve the prediction of GAS scores at follow-up. The prediction formula included premorbid adjustment, nega-tive symptoms and saccadic overshoot, X_ (3) = 15.77, n_ = 37, p = .002. Using these combined predictors 30 (81%) of the 37 subjects were co r r e c t l y c l a s s i f i e d . This compares favorably to the 27 (73%) that were predicted by negative symptoms and premorbid adjustment alone. The saccadic measures were not incorporated into the p r e d i c t i o n of rehos-p i t a l i z a t i o n or employment-heterosexual adjustment. Table 9 shows the overlap between diagnosis and the good-poor adjustment dichotomy for each of the outcome measures. Individuals who received a diagnosis of schizophreniform disorder were more l i k e l y to have poor adjustment than they were to have good adjustment during follow-up. There were, however, only one t h i r d who were r e h o s p i t a l i -zed. Most in d i v i d u a l s in the major depression group were poorly adjusted during and at the time of follow-up and were l i k e l y to be re h o s p i t a l i z e d . Bipolar disorder patients were generally better adjusted during follow-up, as were paranoid patients. Table 9 Diagnostic Categories Compared to Follow-up Adjustment Number of Patients Diagnosis Outcome Measures Schizophreniform Bipolar Major Depression Paranoid GAS1 Good 4 3 2 2 Poor 16 3 7 0 Good 6 5 3 2 2 E-H Adjustment Poor 14 1 6 0 Good 13 4 5 2 R e h o s p i t a l i z a t i o n 3 Poor 7 2 4 0 Global Assessment Scale: Good and poor adjustment. i Employment-heterosexual adjustment: Good and poor adjustment. Re h o s p i t a l i z a t i o n : Good = not rehospitalized during the follow-up period, poor = re h o s p i t a l i z e d one or more times. 49 DISCUSSION Summary of Results The results from this study indicate that the interview data were r e l i a b l y c o l l e c t e d and the ratings that were based on interview data were r e l i a b l y made. The measure of smooth pursuit eye tracking i n t e -g r i t y (RMS error) was r e l a t i v e l y stable across nine to 18 months although the measure of phase lag was less r e l i a b l e than expected. The eye tracking results were e s s e n t i a l l y the same whether the in f r a - r e d or EOG method of measurement was used. Each of the saccadic eye movement measures (latency, v e l o c i t y , and accuracy) produced very s i m i l a r values across l e f t and right eyes, and leftward and rightward movements. These measures were collapsed to produce four measures of saccadic i n t e g r i t y (latency, average v e l o c i t y , average undershoot, and average overshoot). These measures were r e l a t i v e l y stable over the short t e s t - r e t e s t period that was used i n this assessment. The a b i l i t y of RMS error, phase lag, negative symptoms, and premor-bid adjustment to predict GAS scores, employment-heterosexual adjust-ment, and r e h o s p i t a l i z a t i o n was determined. GAS scores were s i g n i f i -cantly related to premorbid adjustment and phase lag. However, premor-bid adjustment and negative symptoms combined to produce the best predictions of GAS scores. Employment-heterosexual adjustment during the follow up period was s i g n i f i c a n t l y r e l a t e d to premorbid adjustment and negative symptoms. The best combination of predictors for this outcome measure was premorbid adjustment and RMS error . None of the predictor variables were able to predict r e h o s p i t a l i z a t i o n . 50 The degree to which RMS error and phase lag from the SPEM task, and latency, average v e l o c i t y , average undershoot and average overshoot from the saccadic task could be used to predict concurrently assessed GAS scores, employment-heterosexual adjustment and r e h o s p i t a l i z a t i o n was also determined. There were no s i g n i f i c a n t relationships between the eye movement measures and the outcome measures. The combination of RMS error and saccadic overshoot approached s i g n i f i c a n c e i n i d e n t i f y i n g GAS scores. RMS error, phase lag, and saccadic average v e l o c i t y combined to i d e n t i f y employment-heterosexual adjustment. This combination approached but f a i l e d to reach s i g n i f i c a n c e . A s i g n i f i c a n t r e l a t i o n s h i p was found between r e h o s p i t a l i z a t i o n and the combination of RMS error and saccadic overshoot. Duration of the f i r s t h o s p i t a l i z a t i o n was s i g n i f i c a n t l y related to RMS error and phase lag from the f i r s t t e s t i n g , GAS scores and employment-heterosexual adjustment. The age of the patients at the time of t h e i r f i r s t h o s p i t a l i z a t i o n was s i g n i f i c a n t l y related to negative symptoms, premorbid adjustment, GAS scores, and phase lag from the f i r s t t e s t i n g . Age, combined with premorbid adjustment, proved to be a r e l a t i v e l y powerful predictor of GAS and employment-heterosexual adjust-ment. The saccadic measures were included i n the prediction analysis to determine i f these measures could p o t e n t i a l l y predict outcome. The prediction of GAS scores was enhanced by adding saccadic overshoot to the combination of premorbid status and negative symptoms. There was considerable overlap between the diagnosed disorders for each of the outcome measures used. Schizophrenics tended to be poorly adjusted as 51 did depressed patients. Bipolar and paranoid patients were likely to be better adjusted. Predictors of Outcome The results from this study were successful in identifying two subgroups of psychotic patients. These groups were identified by the level of adjustment attained nine to 18 months after their first psycho-tic episode. Poor premorbid adjustment, negative symptoms and deviant smooth pursuit eye-tracking tended to occur in subjects who had poor adjustment during the follow-up period. These patients were likely to be young and to have longer than average hospitalization periods. Well adjusted patients were generally older, with shorter periods of hospitalization, better premorbid adjustment, fewer negative symptoms and better smooth pursuit eye tracking. The association between age at the first hospitalization, longer duration of hospitalization, a preponderance of negative symptoms and slow recovery has been reported in other studies (see Seidraan, 1983, for a review). These aspects of psychosis, together with poor premorbid adjustment, have been associated with neurological impairment (Seidman, 1983) and may reflect a subgroup with neurological involvement within the present patient sample. This hypothesis needs to be investigated further using a measure of neuropathology. Premorbid Adjustment. The strongest single predictor of adjustment after a psychotic episode was level of premorbid adjustment. The find-ings from this study concur with those of Schnell (1964) in finding a positive relationship between the Phillips Premorbid Adjustment Scale 52 (PPAS) and l a t e r employment-heterosexual adjustment. The PPAS was also found to be related to GAS score for the month of the follow-up i n t e r -view. However, duration of h o s p i t a l i z a t i o n and subsequent h o s p i t a l i -zation were not related to PPAS scores. This finding was in agreement with that of Strauss and Carpenter (1977). Negative Symptoms. S i g n i f i c a n t r e l a t i o n s h i p s between negative symptoms and l a t e r employment-heterosexual adjustment indi c a t e that negative symptoms are p o t e n t i a l l y useful in predicting adjustment. The a b i l i t y of negative symptoms together with premorbid adjustment to predict poor outcome supports this position and i s in agreement with the findings of Andreasen and Olsen (1982). It i s also i n t e r e s t i n g to note that negative symptoms tended to occur i n younger rather than older patients. Together the findings regarding negative symptoms support the position of Crow (1980) who argued that negative symptoms tended to be associated with early onset, poor premorbid status and chronic course. The s i g n i f i c a n t r e l a t i o n s h i p between negative symptoms and RMS error (whether estimated from the f i r s t or follow-up testing) further attests to the s t a b i l i t y of the eye-tracking measure and suggests that negative symptoms and disrupted eye-tracking may r e f l e c t a common, stable under-l y i n g phenomenon. To my knowledge this r e l a t i o n s h i p between RMS error and negative symptoms has not been previously reported and therefore needs to be re p l i c a t e d . Smooth Pursuit Eye Movements. RMS error, at the time of the f i r s t t e s t ing, combined with premorbid status to predict GAS scores at follow-up. This finding suggests that disrupted smooth pursuit eye-53 tracking may be a useful adjunct in the prediction of future adjustment in psychotic patients. Phase lag, too, appears to account for some v a r i a b i l i t y i n the p r e d i c t i o n of adjustment in psychotic patients. However, phase lag was highly related to RMS error and appears not to explain any unique variance i n the p r e d i c t i o n of the outcome measures used i n this study. The moderately high t e s t - r e t e s t r e l i a b i l i t y of eye-tracking performance (RMS error) r e p l i c a t e s the finding of Iacono and Lykken (1979, 1981) and indicates that t h i s measure i s stable. Exploratory Measures. Since the saccadic measures were taken con-currently with the outcome measures, t h e i r predictive value could not be assessed d i r e c t l y . The i n c l u s i o n of saccadic overshoot in the predic-t i o n of GAS scores indicates that overshoot may be useful in the predic-t i o n of adjustment. This finding needs to be r e p l i c a t e d . Duration of the f i r s t h o s p i t a l i z a t i o n was found to be s i g n i f i c a n t l y r e l a t e d to a number of predictor and outcome measures, but did not account for any variance over that of the predictor variables in the discriminant analyses. Nevertheless, duration of h o s p i t a l i z a t i o n i s strongly related to GAS scores and employment-heterosexual adjustment. One explanation that cannot be ruled out with the present evidence derives from the fact that s o c i a l factors may play a role in the d e c i -sions to admit or release an i n d i v i d u a l from h o s p i t a l . Further research i s needed to assess t h i s variable. The predictors, i n t h i s study, were successful i n d i s t i n g u i s h i n g two groups that d i f f e r e d with regard to outcome (GAS scores and employ-ment-heterosexual adjustment at follow-up). These outcomes are, 54 however, limited i n scope. As Kok.es et a l (1977) noted, prognosis i s multidimensional and a number of dimensions must be taken into account i f p r ediction of outcome i s to be accurate. Thus, while the present findings look promising, further outcome measures must be incorporated to extend the present research. R e h o s p i t a l i z a t i o n was not useful i n d i s t i n g u i s h i n g two subgroups that were independent on the predictor measures used. Further research i s needed to i s o l a t e the factors that can be used to predict r e h o s p i t a l i z a t i o n . Recent research on expressed emotion i n families of schizophrenics (Miklowitz, Goldstein & Falloon, 1983) indicated that the family environment may be s i g n i f i c a n t i n occur-rence of r e h o s p i t a l i z a t i o n . This factor needs to be investigated further in the present sample. Summary of Discussion In summary, the present study has achieved some success in defining subgroups that are based on the i n t e r r e l a t i o n s h i p or c l u s t e r i n g among variables within a subgroup and a degree of nonrelatioship or indepen-dence between subgroups. The subgroups appear to have implications for short-term adjustment. Necessarily, this study was, to some extent, exploratory. The findings must be repl i c a t e d before confident conclu-sions can be made. Nevertheless, this d i a g n o s t i c a l l y heterogeneous group of patients appears to form at least two r e l a t i v e l y d i s t i n c t groups. These groups do not coincide with any of the diagnostic catego-ries used. One group i s generally younger and i s distinguished by a tendency towards poor premorbid adjustment, negative symptoms, deviant smooth pursuit eye-tracking, and longer h o s p i t a l i z a t i o n . The second 55 group i s more l i k e l y to have good premorbid adjustment, few negative symptoms, good smooth pursuit eye-tracking, shorter periods of hospita-l i z a t i o n and i s more usual in older patients. Individuals in this group were l i k e l y to be well adjusted nine to 18 months aft e r t h e i r f i r s t psychotic episode. Individuals i n the f i r s t group were l i k e l y to have poor adjustment af t e r t h e i r f i r s t psychotic episode. This subgroup appears to correspond to the process d i s t i n c t i o n (Crow, 1980, Garraezy & Rodnick, 19659, Weinberger et a l . , 1982; Seidman, 1983) with poor premorbid status, poor heterosexual adjustment and poor prognosis. Further research i s needed to determine whether this subgroup i s also associated with neuropathology as was reported by Crow (1980) and Weinberger (1982), and to obtain measures of adjustment af t e r longer follow-up periods. 56 REFERENCES American P s y c h i a t r i c Association. (1980). 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New York: John Wiley and Sons. 63 APPENDIX A SCREENING SCHEDULE WHO COLLABORATIVE STUDY ON DETERMINANTS OF OUTCOME OF SEVERE MENTAL DISORDER Name of F a c i l i t y : Person who made this assessment: Name: Po s i t i o n : Patient's research number (to be completed by research team) Date when this form was f i l l e d i n : Sex of patient (1 = male; 2 = female) A. 1) Is this patient's age below 15 or above 54? 2) Does this patient at present l i v e outside the catchment area defined for the study? Ring as Appropriate No No Yes Yes B. Is there evidence that this patient has any of the following problems: (see guidelines) 1) C l i n i c a l l y manifest organic cerebral disorder (e.g. i n f e c t i o u s , p a r a s i t i c , t o x i c , cerebrovascular; e p i l i p s y ; brain i n j u r y , etc.) 2) Severe mental retardation ( i . e . IQ less than 50, or c l i n i c a l l y manifest as such) No Yes No Yes 3) Severe alcohol dependence manifest i n : Presence of marked withdrawal symptoms No Yes 64 Presence of alcohol encephalopathy or Korsakov's psychosis No Yes History of acute alcohol psychosis (d e l i r i u m tremens or h a l l u c i n o s i s ) within the l a s t year No Yes 4) Demonstrable dependence on ei t h e r : i ) opium or de r i v a t i v e s ; or i i ) barbiturates No Yes C. During the past one year has the patient presented any of the following? 1) Hallucinations or pseudohallucinations i n any modality No Yes 2) Delusions No Yes 3) Marked thought and speech disorder (e.g. incoherence, irrelevance, thought blocking, neologisms, incomprehensibility of speech) other than simple retardation or a c c e l e r a t i o n No Yes 4) Marked psychomotor disorder (e.g. negativism, mutism or stupor; catatonic excitement; constrained attitudes or unnatural postures maintained for long periods) other than simple retardation or acceleration No Yes 5) Emergence or marked exacerbation of bizarre and grossly inappropriate behavior (e.g. t a l k i n g or giggling to s e l f , acts incomprehensible to others, loss of s o c i a l constraints, etc.) No Yes D. During the past one year, has the patient presented a d e f i n i t e change of personality and behaviour manifested in any of the following? 1) Marked reduction or loss of i n t e r e s t s , i n i t i a t i v e and drive, leading to serious d e t e r i o r a t i o n of the performance of usual a c t i v i t i e s and tasks No Yes 2) Emergence of marked exacerbation of s o c i a l withdrawal (active avoidance of communication with other people) No Yes 3) Severe excitement, purposeless destructiveness or aggression No Yes 65 4) Episodic or persistent states of overwhelming fear or severe anxiety No Yes 5) Gross and persistent s e l f - n e g l e c t No Yes E. Has this patient been admitted to any h o s p i t a l , or otherwise diagnosed or treated for psychotic disorder, s i m i l a r to, or continous with the present i l l n e s s , at any time before the current contact or s p e l l of treatment for p s y c h i a t r i c disorder? (Do not consider contacts for minor problems long ago, l i k e attendance of a c h i l d guidance c l i n i c for conduct or emotional disorder, etc.) No Yes F. Diagnoses of patient made at the f a c i l i t y . G. Conditions for i n c l u s i o n in the study: 1) A l l r e p l i e s to questions i n sections A, Bl , and B2 and E must be "no" and there should be at least one "yes" i n section C or two "yes" in section D OR 2) If the patient does not meet the c r i t e r i a s p e c i f i e d under 1) the patient may s t i l l be included i f the rater has other reasons to believe that he/she may be s u f f e r i n g from a schizophrenic disorder. Such reasons should be s p e c i f i e d below: Other reasons for i n c l u s i o n TO BE COMPLETED BY RESEARCH TEAM: INCLUDED CONCLUSION: This patient i s ( r i n g as appropriate) EXCLUDED 66 Guidelines for Use of the Screening Schedule General The Screening Schedule should be f i l l e d i n by a p s y c h i a t r i s t or by another investigator with relevant experience' q u a l i f y i n g him to apply r e l i a b l y the screening c r i t e r i a . Any user of the scedule, whether a member of the project team or not, should be given b r i e f , but adequate t r a i n i n g i n the use of the instrument. The chief investigator should check the adequacy of such t r a i n i n g by discussion and by a j o i n t screen-ing exercise on a few cases. The Screening Schedule w i l l be f i l l e d i n on the basis of information from: ( i ) a b r i e f interview with the patient, ( i i ) a b r i e f interview with an informant, ( i i i ) admission or outpatient notes, ( i v ) any combin-ation of these. Considering the l i m i t e d access to some kinds of information at the screening stage, the investigator should preferably e r r on the overinclusive side and not exclude cases which raise doubts or cannot be adequately assessed with the screening c r i t e r i a . Such patients can be excluded, i f necessary, a f t e r a more detailed assessment with the PSE and the P s y c h i a t r i c History Schedule. Organic cerebral disorder i s considered to be present i f there i s c l e a r evidence at the time of examination or i n the l a s t three months of any of the following: ( i ) marked disturbances of memory, ( i i ) episodes of clouding of consciousness or confusion manifested i n impaired orientation i n place and/or time, ( i i i ) f o c a l symptoms l i k e aphasia. Organic cerebral disorder i s also considered present i f in the l a s t one  year there was: ( i ) a history of head injury followed by coma l a s t i n g for eight hours or more, or by post-traumatic amnesia l a s t i n g for 72 hours or more, ( i i ) two or more e p i l e p t i c f i t s , or evidence that the patient has been on anti-convulsant medication for more than six months. Severe alcohol dependence i s presumed to be present i f with regard to the l a s t 12 months there i s evidence of excessive alcohol intake and any of the following: ( i ) withdrawal symptoms (tremor, sweating, p a l p i t a t i o n s , insomnia, i r r i t a b i l i t y ) on cessation of drinking, ( i i ) h i s t o r y of alcohol psychosis i n last year, ( i i i ) symptoms of alcohol encephalopathy or p o l y n e u r i t i s . Caution should be exercised in cases of suspected alcohol h a l l u c i n o s i s accompanied by clear consciousness: such patients should be p r o v i s i o n a l l y included. The diagnosis to be entered i s the one made at the f a c i l i t y p r i o r to the assessment of the patient by the project team. The project diagno-sis made aft e r the assessment should be recorded on the Present State Examination (PSE). APPENDIX B FOLLOW-UP QUESTIONNAIRE 67 Background Data Patient's ID Number: Date signed consent form. Month: Day: Year: Date discharged from f i r s t - b r e a k h o s p i t a l i z a t i o n : Month: Day: Year:_ Number of months on which follow-up interview questions are based: Date from which follow up i s based: Month: Day: Year: Note: This is the beginning follow-up date, and should be same as the date the person was released from h o s p i t a l . If the person was not hospitalzed, this date should be the same as the date the person signed the consent form. Date s o c i a l data c o l l e c t i o n completed. Mon th: Day: Year: Follow-Up Interview Data Date: Time Started:__ Time Ended: . Primary Interviewer: Secondary Interviewer: Introduction As I guess you know, we're seeing you again to find out how things have been going with you, and what kinds of things have been happening. So I ' l l be asking you some questions about how you've been f e e l i n g , and how you're spending your time. The main reason for this study i s so that we can help people l i k e yourself i n the future. A l l the information you give me w i l l be c o n f i d e n t i a l . 1. Are you r e c e i v i n g treatment at the present time? Yes [FILL OUT HEALTH SUMMARY TABLE BELOW] No [GO TO QUESTION 2] A. Current treatment 1. Agency or type of health p r o f e s s i o n a l : 2. Location: 3. Treatment from to . Length: 4. Reasons: 5. Nature of treatment: 68 6. Medications. [COMPLETE TABLE BELOW OR CHECK TO SEE IF THERE HAVE BEEN ANY CHANGES SINCE TELEPHONE CONTACT. IF NO MEDICATION, RECORD LENGTH OF DRUG-FREE PERIOD.] a) Current Medications: Name Dose Frequency Date began prescription b) Medications terminated during the l a s t month: Name Dose Frequency Date began-Date ended c) People have d i f f e r e n t attitudes toward taking medication. In the last month, what percentage of the time have you taken the medications as pres cribed ? Percentage of time: 2. Since (beginning follow-up date) have you been h o s p i t a l i z e d or seen a doctor or any other health professional for emotional problems (other than those you have just described)? Yes [FILL OUT HEALTH-TREATMENT SUMMARY TABLE BELOW] No [GO TO QUESTION B] A. Prior treatments i ) Treatment One: 1. Agency or type of health p r o f e s s i o n a l : 2. Location: 3. Treatment from t o . Length: 4. Reasons: 5. Nature of treatment: i i ) Treatment Two 1. Agency or type of health p r o f e s s i o n a l : 69 2. Location: 3. Treatment from to . Length: 4. Reasons: . . _ . i i i ) Treatment Three 1. Agency or therapist: 2. Location: 3. Treatment from ..... to . Length: 4. Reasons: 5. Nature of treatment: B. Have you ever received electroconvulsive therapy? Yes When? C. Involvement i n Social Programs 1. Since (beginning follow-up date), have you pa r t i c i p a t e d in any groups for s o c i a l purposes such as one run by a community care teams? Yes [IF YES, COMPLETE ACTIVITIES SUMMARY TABLE] No 2. Since (beginning follow-up date), have you taken any job t r a i n i n g courses or l i f e s k i l l s classes? For example, assertiveness t r a i n i n g , stress management, parenting c l a s s e s , yoga. Yes [IF YES, COMPLETE ACTIVITIES SUMMARY TABLE] No 3. Since (beginning follow-up date), have your family taken any counselling or joined any mental health associations? Yes [IF YES, COMPLETE ACTIVITIES SUMMARY TABLE] No i ) A c t i v i t y One 1. Agency or type of health p r o f e s s i o n a l : 2. Location: . 3. Treatment from to Length: 70 Reasons: 5. Nature of program: ... . . .. .... i i ) A c t i v i t y Two 1. Agency or type of health p r o f e s s i o n a l : . . 2. Loca tion: . . . . . 3. Treatment from . to Length: 4. Reasons: ... . _ . . . . 5. Nature of program: . . • . . . . i i i ) A c t i v i t y Three L. Agency or type of health profess i o n a l : . 2. Location: 3. Treatment from ^ to ... • Length: 4. Reasons: . . . . 5. Nature of program: . . . . , iv) A c t i v i t y Four 1. Agency or type of health professional: . . .... 2. Location: 3. Treatment from to . Length: 4. Reasons: 71 5. Nature of program: 3. What have your drinking habits been l i k e since we la s t saw you? [NOTE FREQUENCY AND QUANTITY). 4. How much have you been drinking in an average week over the l a s t month? Type Quantity Frequency Date of Last Use 5. A. During the last month, have you taken anything on your own for sleeping, or your mood, or to get high -- l i k e Dexedrine, Seconal or some other barb i t u r a te. B. How about marijuana, n a r c o t i c s , LSD or things l i k e that? C. Have you used anything else to get high, lose weight, or stay awake? Type Quantity Frequency Date of Last Use DEPRESSION I would l i k e to get an idea of any things that might have been bothering you during the past month. 6. During the l a s t month have you f e l t sad, blue, depressed or lost a l l i n t e r e s t and pleasure in things that you usually cared about or enjoyed? Yes [ASK a & b] 5 No 1 a. For how long did this depressed [OR Ss EQUIVALENT] f e e l i n g l a s t ? b. Are you f e e l i n g depressed now? Yes No 7. During the l a s t month, has there been a time when you lo s t your appeti te ? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 5 No a. For how long did this appetite loss las t? b. Have you had an appetite for the la s t 2 or 3 days? Yes No 72 8. Have you lost any weight without trying to within the last month? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 No \ a. How much weight did you lose? _ _ _ _ _ _ _ _ _ b. Are you s t i l l losing weight? Yes No 9. Has you eating increased so much that you have gained weight in the past month? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 5 No a. How much weight have you gained? b. Are you s t i l l gaining weight? Yes No 10. Have you had any trouble f a l l i n g asleep, staying asleep or waking up too early in the past month? Yes, [ASK a & b AND PROBE QUESTIONS] 1 3 4 5 No a. For how long did you have trouble f a l l i n g asleep las t? b. Are you s t i l l having trouble f a l l i n g asleep? Yes No 11. Have vou been sleeping too much during the past month? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 ! No a. For how long were you sleeping too much? b. Are you s t i l l sleeping too much? Yes No_ 12. Has there been a period during the past month when you f e l t t i r e d out a l l the time ? I Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 ! No _ a. For how long did you feel t i r e d out a l l the time? b. Are you s t i l l f e e l i n g t i r e d out? Yes No_ 13. Has there been a period during the past month when you talked or moved more s1 owly than is normal for you? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 ! No a. For how long did you move more slowly? b. Are you s t i l l moving more slowly than is normal for you? Yes No 14. Has there been a period during the past month when you had to be moving a l l the time — that i s , you couldn't s i t s t i l l and paced up and down? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 5 No 73 a. For how long did you fee l that you had to be moving a l l the time? b. Do you s t i l l f e e l i n g that you have to keep moving? Yes_ No 15. Has there been a period during the past month when your in t e r e s t in sex was a lot less than usual? Yes [ASK a & b AND PROBE USING "decreased i n t e r e s t in sex"l 1 2 3 4 5 6 No a. How long did this decreased i n t e r e s t in sex last? b. Do you s t i l l have less i n t e r e s t in sex than usual? Yes No 16. Has there been a period during the past month when you f e l t worthless, s i n f u l or g u i l t y ? Yes [ASK a & b] 5 No 1 a. How long did this f e e l i n g of worthlessness las t ? b. Are you s t i l l f e e l i n g worthless? Yes No 17. Has there been a period during the past month when you had a lot more trouble  concen tra ting than i s normal for you? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 ! No a. For how long did you have trouble concentrating? b. Are you s t i l l having trouble concentrating? Yes No_i  18. Has there been a period during the past month when your thoughts came much slower than usual or seemed mixed up? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 4 No a. For how long did your thoughts come slower than usual? b. Are your thoughts s t i l l coming slower than usual? Yes Noi  19. Has there been a period, during the past month, when you thought a lot about death — either your own, someone else ' s , or death in general? Yes [ASK a & b] 5 No 1 a. How long did these thoughts about death last? b. Are you s t i l l having these thoughts about death? Yes No 20. Has there been a period, during the past month, when you f e l t l i k e you wan ted  to die? Yes [ASK a 6. b] 5 No 1 a. How long did you feel l i k e you wanted to die? . b. Are you s t i l l f e e l i n g l i k e you want to die? Yes No 74 21. Has there been a period in the past month when you f e l t so low you thought of committing suicide ? Yes [ASK a i b] 5 No 1 a. For how long did you think of commiting suicide b. Are you s t i l l thinking of commiting suicide? Yes No 22. Have you attempted suicide in the past month? Yes 5 No 1 llz.. (ASK A. IF DEPRESSION IS DENIED AND SOME OF THE DEPRESSION ITEMS ARE ANSWERED IN THE POSITIVE) A. When you were having some of these problems (LIST Sx CODED 5 IN QUESTIONS 7-22), at the same time were you f e e l i n g okay, or were you f e e l i n g low, gloomy, blue, or uninterested in everything? Okay Gloomy, low, etc. (CODE ITEM 6, 5 AND ASK 6a AND 6b) ANXIETY 23. During the past month, has there been a period of a day or more when you f e l t nervous or were trembling, j i t t e r y , shaky, r e s t l e s s , tense, or uptight most of the time? Yes [ASK a. & b. AND PROBE QUESTIONS] 1 3 4 5 No Ale/Med a. How long did you feel nervous [OR Ss EQUIVALENT]? b. Are you s t i l l f e e l i n g nervous? Yes No 24. During the past month, has there been a period of a day or more when you worried much of the time about things that might happen? Yes [ASK a. & b. AND PROBE QUESTIONS] 1 3 4 No Ale/Med a. For how long did you worry much of the time? . b. Are you s t i l l worrying much of the time? Yes No 25. During the past month, has there been a period when you were bothered by sweating, dizziness, shortness of breath or pounding heart? Yes [ASK a. & b. AND PROBE QUESTIONS] 1 3 4 No Ale/Med a. How long did [ L i s t Sx REPORTED] last? b. Are you s t i l l experiencing [Sx]? Yes No 75 26. During the past month, has there been a period of a day or more when you f e l t  on edge, i r r i t a b l e or impatient much of the time? Yes [ASK a. & b. AND PROBE QUESTIONS] 1 3 4 5 No Alc/Med a. How long did [List Sx REPORTED] last? b. Are vou s t i l l f e e l i n g [Sx] way? Yes No MANIA 27. Has there been a period, during the past month, when you were so happy or excited, or high that you got into trouble, or your family or friends worried about i t , or a doctor said you were manic? Yes, [ASK a & b AND PROBE QUESTIONS] 1 3 5 No Alc/Med a. For how long did you feel happy and excited? b. Are you f e e l i n g happy and excited? Yes No 28. Has there been a period in the past month when you were so much more active than usual that you or your family or friends were concerned about i t ? Yes_ [ASK a & b AND PROBE QUESTIONS] 1 3 5 No 1 Alc/Med a. For how long were you more ac t i v e than usua1? b. Are you s t i l l more active than usual? Yes No 29. Has there been a period in the past month when you went on spending sprees --spending so much money that i t caused you or your family some f i n a n c i a l trouble? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 5 No Alc/Med a. For how long did this spending spree last?_ b. Have you been going on spending sprees in the last few days? Yes__ No 30. Has there been a period in the past month when your i n t e r e s t in sex was so much s tronger than is t y p i c a l for you that you wanted to have sex a lot more frequently than is,normal for you or with people you wouldn't normally be interested in? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 5 No Alc/Med a. For how long did you have an increased i n t e r e s t in sex? b. Do you have an increased i n t e r e s t in sex at the present time? Yes No_ 31. Has there been a period in the past month when you talked so fas t that people said they couldn't understand you? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 5 No Alc/Med .... 76 For how long did this fast t a l k i n g last?_ b. Have you been talking fast i n the l a s t day or two? Yes No 32. Has there been a period in the la s t month when your thoughts raced through your head so fast that you couldn't keep track of them? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 5 No Alc/Med _ _ _ _ _ _ ? a. For how long did your thoughts race? b. Have your thoughts raced in the l a s t day or two? Yes No 33. Has there been a period in the past month when you f e l t you had a specia l g i f t or special powers to do things others couldn't do, or that you were a s p e c i a l l y important person? (Refers to supernatural powers) Yes ASK FOR AN EXAMPLE BEFORE PROBING? [ASK a 6, b AND PROBE QUESTIONS] No 1 Alc/Med How long did you feel that you had a sp e c i a l g i f t or specia l b. Do you feel that you have s p e c i a l g i f t s or powers now? Yes No 34. Has there been a period in the past month when you hardly slept but s t i l l didn't feel t i r e d or sleepy? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 5 No Alc/Med a. For how long did you sleep very l i t t l e ? b. Do you s t i l l sleep very l i t t l e ? Yes No 35. Has there been a period in the past month when you were e a s i l y d i s t r a c t e d so that any l i t t l e i nterruption could get you o f f the track? Yes [ASK a & b AND PROBE QUESTIONS] 1 3 5 No Alc/Med a. For how long were you e a s i l y d i s t r a c t e d ? b. Are you s t i l l e a s i l y distracted? Yes No^ SCHIZOPHRENIA CODE: 1 = no 4 = med. exp. 2 = below c r i t . 5 = yes 3 = drugs or a l e . INTERVIEWER: FOR QUESTIONS 38-45 ASK FOR AN EXAMPLE BEFORE PROBING. *D0 NOT USE EXAMPLES IN PROBING. DO USE UNDERLINED WORDS. 77 36. Now I want to ask about some ideas you might have had about other people. During the past month, did you believe people were watching you or spying on  you? [IF YES ASK a. AND PROBE QUESTIONS] Ex: _ . * 1 2 3 4 5 MD: SELF: IF QUALIFIES AS 5, BUT PLAUSIBLE OR JUST SELF-CONSCIOUS, CODE 6. a. Do you s t i l l feel people are watching you? Yes No 37. During the past month was there a time when you believed people were following ,rou? [IF YES ASK a. AND PROBE QUESTIONS] Ex: * 1 2 3 4 5 MD: SELF: IF QUALIFIES AS 5, BUT PLAUSIBLE CODE 6. a. Do you s t i l l feel people are following you? Yes No 38. During the past month did you feel that someone was p l o t t i n g against you or  try i n g to hurt you or poison you? [IF YES ASK a. AND PROBE QUESTIONS] Ex: * 1 2 3 4 5 6 MD: SELF: _______ IF QUALIFIES AS 5, BUT PLAUSIBLE, CODE 6. a. Do you s t i l l f e e l someone is p l o t t i n g against you or t r y i n g to hurt you? Yes No 39. During the past month did you feel that someone was reading your mind? INTERVIEWER: IF NO, CODE 1. ALL OTHERS ASK A. A. Did they a c t u a l l y know what you thought or were they just guessing from the look on your face or from knowing you for a long time? [IF "KNOW" ASK a. AND PROBE QUESTIONS] INTERVIEWER: IF "JUST GUESS", CODE 1. OTHERS ASK FOR AN EXAMPLE AND BEGIN PROBING. Ex: * 1 2 3 4 5 MD: SELF: a. Do you s t i l l feel someone is reading your mind? Yes No 78 40. During the past month have you f e l t that you could a c t u a l l y hear what another person was thinking, even though he was not speaking, or believed that others could hear your thoughts? [IF YES ASK a. AND PROBE QUESTIONS] Ex:_ * 1 2 3 4 5 MD: SELF: . a. Do you s t i l l feel that you can hear that others are thinking or that others can hear your thoughts? Yes No 41. During the past month, did you think that others were c o n t r o l l i n g how you moved  or what you thought, against, your, w i l l ? [IF YES ASK a. AND PROBE QUESTIONS] Ex: , * 1 2 3 4 5 MD: SELF: a. Do you s t i l l think others are c o n t r o l l i n g how you move or what you think? Yes No 42. During the past month did you feel that someone, or something could put strange  thoughts d i r e c t l y into your mind or could take or s t e a l your thoughts out of  your mind? [IF YES ASK a. AND PROBE QUESTIONS] Ex: * 1 2 3 4 5 MD: SELF: a. Do you s t i l l feel that others can put in or remove strange thoughts from your mind? Yes No 43. During the past month have you f e l t that you were being, sent special messages  through, t e l e v i s i o n or the radio? [IF YES ASK a. AND PROBE QUESTIONS] Ex: * 1 2 3 4 5 MD: SELF: a. Do you s t i l l feel that you are being sent speci a l messages through the televions or radio? Yes No 44. INTERVIEWER: RECORD ANY VOLUNTEERED DELUSIONS NOT CODEABLE IN 0. 39-46. DO NOT ASK. [IF ANY VOLUNTEERED ASK a. AND PROBE QUESTIONS] IF NONE, CODE 1. IF ANY, DESCRIBE. 1 2 3 4 5 MD: SELF: a. Do you s t i l l feel [Sx] is the case? Yes No 79 45. During the past month have you had the experience of seeing something or someone that others who, were present could not s e e — t h a t i s , had a v i s i o n when you were completely awake? [IF YES ASK a., b., AND PROBE QUESTIONS] a. What did you see? RECORD BELOW AND THEN BEGIN PROBING. * 1 2 3 4 5 MD: SELF: b. Have you had the experience of seeing something or someone that others who were present could not see in the last day or two? Yes No . . 46. During the past month have you more than once had the experience of hearing  things other people couldn't hear, such as a voice? [IF YES ASK a. AND PROBE QUESTIONS] a. What did you hear? RECORD BELOW AND THEN BEGIN PROBING. 1 2 3 4 5 MD: SELF: IF CODED 2-5: ASK b, c AND d b. Did you hear voices commenting on what you were doing or thinking? No 1 Yes 5 c. Did you hear two or more voices t a l k i n g to each other? No 1 Yes 5 d. Have you heard these things in the past day or two? Yes ____ No _____ 47. During the past month have you been bothered by strange smells around you that  nobody else seemed to be able to smell, perhaps even odors coming from your own body? [IF YES ASK a. & b. AND PROBE QUESTIONS] a. What did you smell? RECORD BELOW AND THEN BEGIN PROBING. 1 2 3 4 5 MD: SELF: Have you noticed these smells in the past day or two? Yes No 80 48. During the past month have you had unusual feelings inside or on your b o d y — l i k e being touched when nothing was there or f e e l i n g something moving inside your body? [IF YES ASK a & b AND PROBE QUESTIONS] INTERVIEWER: IF NO: .CODE 1. ALL OTHERS ASK A a. What did you feel? RECORD BELOW AND THEN BEGIN PROBING. * 1 2 3 4 MD: SELF: b. Have you had unusual feelings inside or on your body in the l a s t day or two": Yes No INTERVIEWER: ASK 49-51 IF ANY 5s ARE RECORDED IN Qs 36-48. 49. At the time you had these b e l i e f s or experiences [LIST Sx. CODED 5 IN Qs. 36-48] were you your normal s e l f , or were you f e e l i n g nervous, upset, unable to work, unable to go places or unable to enjoy yourself? Normal s e l f 1 Not normal [ASK a] 5 a. For how long did you feel nervous, upset, unable to work or unable to enjoy yourself? . b. Are you f e e l i n g nervous, upset, unable to work or enjoy yourself now? Yes No [IF YES SKIP TO 52, IF NO ASK 50-51.] 50. After you had these b e l i e f s or experiences, did you find that you were less able to do your work well? No e f f e c t 1 Less able 5 51. After you had these b e l i e f s or experiences (LIST Sx CODED 5 IN Qs 36-48), were you less able to enjoy s o c i a l r e l a t i o n s h i p s with other people? No 1 Yes 5 INTERVIEWER: CODE Q52 WITHOUT ASKING 52. Blunted a f f e c t (expressionless face and voice, uniform blunting whatever the topic of conversation, indifference to d i s t r e s s i n g t o p i c s , whether delusional or normal. No blunted a f f e c t 0 Blunting not uniform, e.g., at times responds a f f e c t i v e l y but at other times is markedly f l a t ; or responds with some evidence of a f f e c t , but d e f i n i t e l y less than expected 1 Severe and uniform blunting 2 81 53a. During the last month have you been working (including working as a housewife) or going to school? Yes _ [COMPLETE TABLE BELOW, BE SPECIFICl No [SKIP TO QUESTION 53C] nature of job/school % of f u l l time date began date ended why ended B. Would you say your (work/school performance) during the l a s t month has been above average, average, or below average compared to others who (have the same job/follow the same course of study)? above average average _____ below average C. For how many of the __ months since (beginning follow-up date) were you not working and not in school? mon ths D. For how much of that time were you looking for work but were not able to find a job ? mon ths Is that the s i t u a t i o n now? yes no . E. For how much of that time wer^ you not looking for work because of emotional or mental problems or because of problems with drugs and alcohol? mon ths Is that the s i t u a t i o n now? yes no F. How much time (besides that) were you just not interested in working? months Is that the s i t u a t i o n now? yes no _____ 54A. How many hours in an average week during the l a s t month did you spend s o c i a l i z i n g with other people? By s o c i a l i z i n g , I mean t a l k i n g with them, phoning them, or doing something together. This means more than just s i t t i n g in the same room. hours 82 B. In an average week during the l a s t month, how many d i f f e r e n t times did you s o c i a l i z e with other people? By s o c i a l i z e , I mean ta l k i n g with other people, phoning them, or doing something together. number of times C. How many d i f f e r e n t people do you s o c i a l i z e with in an average week? By s o c i a l i z e , I mean t a l k i n g with other people, phoning them, or doing something together. number of people D. Is there a TV a v a i l a b l e for you to watch? Yes, [ASK QUESTION i BELOW] No i ) In an average day during the l a s t month, how many hours did you spend watching TV? hours E. During the l a s t month, how many hours in an average week did you spend doing leisure time a c t i v i t i e s or hobbies by yourself? Don't include time you spent watching TV. Do include things l i k e going on walks, jogging, c y c l i n g , reading, swimming or working on a hobby or project. hours 55. With whom are you l i v i n g now? [FOR EACH PERSON, INQUIRE ABOUT AGE, SEX, RELATIONSHIP TO PATIENT.] Relationship Sex Age Length of l i v i n g arrangement 1. 2. 3. . U. t _ 5. , If l i v i n g alone, indicate for how long: 56. In the _____ months since (beginning follow-up date), have any of the events on this l i s t happen to you. What e f f e c t did (event) have on you? [GIVE ATTACHED SCALE TO INTERVIEWEE AND OBTAIN A RATING FOR EACH EVENT CHOSEN] 57. For many people, s t r e s s f u l events can cause emotional problems. I would l i k e to see i f any of the things on this l i s t happened to you in the year before you were hospitalized/came to . What e f f e c t did (event) have on you? [OBTAIN A RATING FOR EACH ITEM CHOSEN] LIFE EXPERIENCES Marriage _ . En ga gemen t | Divorce . . . . . ... Arr es ted Physical i l l n e s s or injury to yourself Death of r e l a t i v e or friend Serious i l l n e s s or injury of r e l a t i v e or fr i e n d Problems with r e l a t i v e s or friends Foreclosure on mortgage or loan Outstanding personal ach ievement Pregnancy or w i f e - g i r l f r i e n d pregnant Gaining a new family member Major change in eating or sleeping habits Sexual problems Abortion or w i f e - g i r l f r i e n d had abortion New job or change in work s i t u a t i o n Problems at work . . . . Change in spouse's or b o y f r i e n d / g i r l f r i e n d ' s job Change in f i n a n c i a l status Change of residence Change in recreational a c t i v i t y Change in church a c t i v i t i e s Separation from spouse or b o y / g i r I f r i e n d Getting back together with spouse or b o y / g i r l f r i e n d Borrowing money . . . Laid o f f , f i r e d , or quit job Completed or dropped out of school Son or daughter leaving home 84 Ending of formal schooling ' . . . . Leaving home for f i r s t time Other experiences that have had an e f f e c t on your 1i fe . . LIFE HISTORY 58. Now I would l i k e to ask you about your l i f e as a teenager. Did you belong to any groups, clubs, organizations, or a t h l e t i c teams, including school organizations, while you were a teenager? Yes, [ask i] No ____ [ask iv] i ) What type of organization or group did you belong to? How long were you a member? Did you hold an o f f i c e or p o s i t i o n of leadership i n (any of) the group(s)? Yes [ask i i ] No _____ [ask i i i ] i i ) What po s i t i o n ( s ) did you hold? How long did you hold this/these p o s i t i o n ( s ) ? [IF SUBJECT HELD A LEADERSHIP POSITION, CODE "A" AND GO TO QUESTION 59] i i i ) Would you describe yourself as an ac t i v e and interested member or were you not very a c t i v e in (this/any of these) organization(s)? A c t i v e / i n t e r e s t e d . Not active . i v . While you were a teenager, did you belong to a group of friends who did things together? Yes [ASK v] No [ASK v i ] v) Would you describe yourself as an active and interested member? Yes No 85 v i ) Did you have any close friends while you were a teenager? [ALLOW SUBJECTS TO USE THEIR OWN DEFINITION OF CLOSE FRIEND] Yes [ask v i i ] No _____ [ask v i i i ] v i i ) When you were a teenager, how many close friends did you have? How many of these people were friends you could r e a l l y t r u s t or count on? v i i i ) Would you describe yourself as generally prefering to be by yourself during your teenage years or did you prefer to be with other people? With others Alone ix ) Did you prefer to be alone in the years before your teens? Yes No C i r c l e correct code l e t t e r (A) A leader or o f f i c e r in formally designated groups, clubs, organizations, or a t h l e t i c teams in senior high school, vocational school, college, or in young adulthood. (B) An active and interested p a r t i c i p a n t , but did not play a leading role in groups of friends, clubs, organizations, or a t h l e t i c teams in senior high school, vocational school, col lege, or in young adulthood. (C) A nominal member, but had no involvement i n , or commitment to, groups of fri e n d s , clubs, organizations, or a t h l e t i c teams in senior high school, vocational school, college, or in young adulthood. (D) From adolescence through e a r l y adulthood, had only a few casual or close fr iends. (E) From adolescence through early adulthood, had no real friends, only a few s u p e r f i c i a l r e l a t i o n s h i p s or attachments to others. (F) From adolescence through early adulthood ( i . e . , a f t e r childhood) quiet, s e c l u s i v e , preferred to be by s e l f ; minimal e f f o r t s to maintain any contact at a l l with others. (G) No desire to be with playmates, peers, or others, from e a r l y childhood. Either a s o c i a l or a n t i s o c i a l . 5 9 . Did you date as a teenager? Yes [ask A] No [ ask B] A. How old were you when you started dating? [GO TO QUESTION C] B. Have you dated since then? Yes [ask A] No 86 C. When you were most a c t i v e l y dating, how many times did you date in an average month? D. How old were you then? 60. Have you ever held a fu l l - t i m e job, in c l u d i n g a summer job, that lasted 3 months or more? Yes [Ask A] No [GO TO QUESTION 62] A. How old were you when you held your f i r s t f u l l - t i m e job? 61. What was the longest period of time you were employed? This time may include d i f f e r e n t jobs, as long as there i s no break in between. [IF TIME SPAN COVERS MORE THAN ONE JOB, SUBJECT MUST HAVE HAD THE SECOND JOB BEFORE QUITTING THE FIRST] mon ths 62. In the year before we f i r s t saw vou (date) were you working or going to school at least h a l f time? Yes [Ask A] No [GO TO QUESTION 66] A. For how many months were you a) in school: b) work ing: 63. Are you presently married or are you widowed, separated, divorced, or have you never been married? married _____ [ask A & B] widowed ______ (ask A] When did your husband/wife die ? separated ______ [ask A] When did you and your husband/wife separate? divorced ______ (ask A) When did you and your husband/wife separate ?_ never married ______ [skip to 69] A. When were you married? . . . . B. Are you presently l i v i n g with your husband/wife? 64. How many times have you been l e g a l l y married? 65. (So you've never been/ How many times have you been) divorced? number of times 66. Have you ever l i v e d with someone for at l e a s t a year as though you were married? Yes No 87 67. [IF NOT MARRIED] Are you l i v i n g with someone now as though you were married? Yes ^ ^ ^ ^ For how long? No 68. [ASK IF NOT PRESENTLY LIVING WITH SPOUSE OR SPOUSE-LIKE PERSON.] Since (beginning follow-up date), have you been dating? Yes [Ask A & B] No [GO TO QUESTION 72] A. How many times a mon th? B. How many di f f e r e n t people have you been dating? . -69. How many children have you had, not counting any who are yours by adoption or who were born dead? How old are they? [LIST AGES] Do you have any adopted children? Yes How old are they? ... No 70. Were you adopted or raised by someone other than your natural parents? Own parents Someone else [ASK A AND B] A) Who? [DESCRIBE NATURE OF RELATED PERSON] . . '  B) From what age? 88 APPENDIX C Abbreviated Form of P h i l l i p s Premorbid Adjustment Scale (Harris 1975) A. Abbreviated Scale of Premorbid Sexual Adjustment I. Married, presently or formerly (1) Married, only one marriage (or remarried only one time as a consequence of death of spouse), l i v i n g as a unit. (2) Married, more than one time, maintained a home i n one marriage for at least 5 years. (3) Married and apparently permanently separated or divorced without remarriage, but maintained a home i n one marriage for at least 5 years. (4) Same as (3), but maintained a home i n one marriage for less than 5 years. I I . Single (30 years or over) (3) Has been engaged one or more times or has had a long-term r e l a t i o n s h i p (at least 2 years) involving heterosexual r e l a -tions or apparent evidence for a "love a f f a i r " with one person, but unable to achieve marriage. (4) Brief or short-term heterosexual or s o c i a l dating experiences with one or more partners, but no lo n g - l a s t i n g sexual experiences with a single partner. (5) Sexual and/or s o c i a l r e l a t i o n s h i p s primarily with the same sex, but may have had occasional heterosexual contaccts or dating experiences. (6) Minimal sexual or s o c i a l i n t e r e s t i n either men or women. I I I . Single (under 30 years) (1) Has had at least one long-term "love a f f a i r " (minimum of 6 months to 1 year) or engagement, even though r e l i g i o u s or other prohibitions or i n h i b i t i o n s may have prevented actual sexual union (a) If ever actually engaged (b) Otherwise (2) Brief or short-terra heterosexual or s o c i a l dating experien-ces, "love a f f a i r s " , with one or more partners, but no long-l a s t i n g sexual experiences with a sing l e partner. 89 (3) Casual sexual or s o c i a l r e l a t i o n s h i p s with persons of eitner sex, with no deep emotional meaning. (4) Sexual and/or s o c i a l r e l a t i o n s h ips primarily with the same sex, but may have had occasional heterosexual contacts or dating experiences. (5) Minimal sexual or s o c i a l interest i n either men or women. Abbreviated Scale of Premorbid Social-Personal Adjustment A leader or o f f i c e r in formally designated groups, clubs, organi-zations, or a t h l e t i c teams i n senior high school, vocational school, college, or i n young adulthood. An active and interested p a r t i c i p a n t , but did not play a leading role i n groups of friends, clubs, organizations, or a t h l e t i c teams i n senior high school, vocational school, college, or in young adulthood. A nominal member, but had no involvement i n , or commitment to, groups of friends, clubs, organizations, or a t h l e t i c teams i n senior high school, vocational school, college, or i n young adult-hood. From adolescence through early adulthood, had only a few casual or close friends. From adolescence through early adulthood, had no re a l f r i e n d s , only a few s u p e r f i c i a l r e l a t i o n s h i p s or attachments to others. From adolescence through early adulthood ( i . e . , a f t e r childhood) quite, seclusive, preferred to be by s e l f ; minimal e f f o r t s to maintain any contact at a l l with others. No desire to be with playmates, peers, or others, from early childhood. E i t h e r a s o c i a l or a n t i s o c i a l . 90 APPENDIX D Negative Symptom Ratings PSE items 19, 20, 58, 107, 128 and 129 Thinking and Concentration 19. Can you think c l e a r l y or i s there any interference with your thoughts? Do your thoughts tend to be muddled or slow? (Can you make up your mind about simple things quite e a s i l y ? ) (Make decisions about everyday matters?) RATE SUBJECTIVELY INEFFICIENT THINKING ( i f due to i n t r u s i o n of al i e n thoughts, rate 9). 1 = Symptom d e f i n i t e l y present during the past month, but of moderate c l i n i c a l i n t e n s i t y , or intense less than 50% of the time. 2 = Symptom c l i n i c a l l y intense more than 50% of the past month. 20. What has your concentration been l i k e recently? (Can you read an a r t i c l e i n the paper or watch a TV programme right through?) (Do you thoughts d r i f t off so that you don't take things in?) RATE POOR CONCENTRATIONS. 1 = Only moderate form of symptom present during the past month (e.g. can read a short a r t i c l e , can concentrate i f t r i e s hard); or intense less than 50% of the time. 2 = Symptom c l i n i c a l l y intense (cannot attempt to read or con-centrate) more than 50% of the past month. 91 Thought Block 58. Do you ever experience your thoughts stopping quite unexpectedly so that there are none l e f t in your mind, even when your thoughts were flowing freely before? (What i s that l i k e ? ) (How often does i t occur? What i s i s due to?) Do your thoughts ever seem to be taken out of your head, as though some external person or force were removing them? (Can you give an example?) (How do you explain i t ? ) RATE THOUGHT BLOCK OR WITHDRAWAL. 1 = Thought block. Do not include i f due to anxiety or lack of concentration; only i f i t occurs t o t a l l y unexpectedly when thoughts are flowing f r e e l y . One single occasion i s not s u f f i -cient for rating. Be very c r i t i c a l i n r a t i n g t h i s symptom. 2 = Delusional explanation that thoughts are withdrawn. S o c i a l Impairment 107. Of a l l the problems you have told me about, which one a f f e c t s you most? How much does i t i n t e r f e r e with your work or your r e l a t i o n -ships with other people? (Have you act u a l l y been out of work, or been unable to do the housework, or go shopping, t r a v e l l i n g , etc., during the past month?) (Have the symptoms impaired your e f f i c i e n c y i n any other way?) 92 RATE SOCIAL IMPAIRMENT DUE TO PSYCHOTIC CONDITION. 0 = No neurotic or psychotic symptoms present. 1 = Psychotic symptoms present but l i t t l e diminution of subject's e f f i c i e n c y or intereference with everyday a c t i v i t i e s . 2 = Psychotic symptoms i n t e r f e r e with subject's e f f i c i e n c y to a moderate extent but are not inc a p a c i t a t i n g , e.g. subject neg-l e c t s housework or can't enjoy l e i s u r e a c t i v i t i e s or s o c i a l r e l a t i o n s h i p s , or finds work-efficiency reduced. Subject does not, however, stop work altogether or completely neglect house-hold. 3 = Subject severely incapacitated by psychotic symptoms: had to have at least a week off work during past month; was housebound for a week or more; was a c t i v e l y withdrawn from a l l s o c i a l r e l a t i o n s h i p s , etc. The subject does not have to be t o t a l l y incapacitated for the whole month for this rating to be made, but Impairment has to be very severe. 8 = Examiner unsure. 9 = Neurotic condition, and no psychotic condition, present. Blunted A f f e c t 128. Blunted a f f e c t (expressionless face and voice, uniform blunting whatever the topic of converstion, indifference to d i s t r e s s i n g t o p i c s , whether delusional or normal). 1 = Blunting not uniform, e.g. at times responds a f f e c t i v e l y but at other times i s markedly f l a t ; or responds with some evidence of a f f e c t , but d e f i n i t e l y less than expected. 2 = Severe and uniform blunting. 93 Incongruity of Affect 129. Incongruity of affect (emotion i s shown, but not congruent with topic) RATINGS 0 = Symptom absent. 1 = Present in f a i r l y severe degree, or very severe but intermit-tent during interview. 2 = Presenting in very severe degree and almost continous during interview. 8 = Examiner not sure. 9 = Subject not examined, or examination not appropriate. N.B. If in doubt, rate (0). A rating of (1) means there Is no doubt about the symptom being present i n f a i r l y severe form. 138. Poverty of content of speech. The subject talks f r e e l y but so vaguely that l i t t l e information i s given i n spite of the number of words used: rambles on without coming to a point; may wander f a r from o r i g i n a l theme. Exclude incoherence or f l i g h t of ideas. Rate only i f severe and always give written example. RATINGS 0 = Symptom absent. 1 = Present in f a i r l y severe degree, or very severe but intermit-tent during interview. 2 = Presenting in very severe degree and almost continous during interview. 8 = Examiner not sure. 9 = Subject not examined, or examination not appropriate. N.B. If in doubt, rate (0). A ra t i n g of (1) means there i s no doubt about the symptom being present i n f a i r l y severe form. 94 APPENDIX E Employment-Heterosexual Adjustment During the Following Period Prognostic Scale items l a , 3a, and 4 (Strauss & Carpenter, 1974) IA Quantity of useful work in past year. (Include as job: paid work, student, housewife. Exlude time i n h o s p i t a l . Any hosptalization i n past year would not contribute to lower score. Working as a student for a f u l l academic year would be rated "4"). "Employed" f u l l time continously 4 "Employed" for about 3/4 of the year's working hours (e.g., f u l l time work for 9 months) 3 "Employed" for about 1/2 of the year's working hours (e.g. employed half time continously or f u l l time for 6 months 2 "Employed" for about 1/4 of the year's working hours (e.g., half time work for 6 months) 1 No useful work 0 3A Number of s o c i a l relations most usual i n past year. (Meets with friends or does things with s o c i a l groups, bowling, meetings, etc. EXCLUDE dates with opposite sex or s o c i a l a c t i v i t i e s only with spouse.) Meets with friends on average of at least once a week 4 Meets with friends about once every 2 weeks 3 Meets with friends about once a month 2 95 Include a l l acquaintances Does not meet with friends, except "over the back fence" or at work or school 1 Does not meet with friends at a l l under any conditions 0 4. Heterosexual relations most usual in past year Married without divorce or separation, or dates r e g u l a r l y . . . . 4 Married with c o n f l i c t s causing b r i e f separation(s), or dates sometimes 3 Unmarried or separated, dates frequently 2 Unmarried or separated, r a r e l y dates 1 Unmarried or separated, never dates 0 96 APPENDIX F  GLOBAL ASSESSMENT SCALE Rate the subject's lowest l e v e l of functioning i n the last week by sel e c t i n g the lowest range which describes his functioning on a hypothetical continuum of mental h e a l t h - i l l n e s s . For example, a subject whose "behavior i s considerably influenced by delusions" (range 21-30), should be given a ra t i n g i n that range even though he has "major impairment i n several areas" (range 31-40). Use intermediary l e v e l s  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. 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 problems never seem to get out of hand, i s sought out by others because of his warmth and i n t e g r i t y . 90 Transient symptoms may occur, but good functioning i n a l l areas, | interested and involved i n a wide range of a c t i v i t i e s , s o c i a l l y 81 e f f e c t i v e , generally s a t i s f i e d with l i f e , "everyday" worries that only occasionally get out of hand. 80 Minimal symptoms may be present but no more than s l i g h t j impairment i n functioning, varying degrees of "everyday" worries 71 and problems that sometimes get out of hand. 97 70 Some mild symptoms (e.g., depressive mood and mild insomnia) OR | some d i f f i c u l t y i n several areas of functioning, but generally 61 functioning pretty well, has some meaningful interpersonal r e l a -tionships and most untrained people would not consider him "si c k " . 60 Moderate symptoms OR generally functioning with some d i f f i c u l t y | (e.g., few friends and f l a t a f f e c t , depressed mood and pathologi-c a l self-doubt, euphoric mood and pressure of speech, moderately severe a n t i s o c i a l behavior). 50 Any serious symptomatology or impairment in functioning that most | c l i n i c i a n s would think obviously requires treatment or attention 41 (e.g., s u i c i d a l preoccupation or gesture, severe obsessional r i t u a l s , frequent anxiety attacks, serious a n t i s o c i a l behavior, compulsive drinking.) 40 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 31 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 suicide attempt. 98 Unable to function In almost a l l areas (e.g. , stays in bed a l l day) OR behavior i s considerably influenced by either delusions or hallucinations OR serious impairment in communication (e.g., sometimes incoherent or unreponsive) or judgment (e.g., acts grossly inappropriately). Needs some supervision to prevent hurting s e l f 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 incoherent or mute). 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 intensive care unit with s p e c i a l observation by s t a f f ) . 

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