70 SCHIZOPHRENIA BULLETIN

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. . . the diagnosis and understanding of schizophrenia

summary and conclusions

In this series of reports, we have described an their severity, their rank order, or their mere presence.
approach to understanding the relationship between the At present, none of the alternative methods is clearly
symptoms and concept of schizophrenia. Symptoms are superior to the others. Each has very different clinical
used as major criteria by investigators to arrive at a and statistical implications and affects the way data are
diagnosis of schizophrenia. A t the same time, variability translated into conclusions. The choice among the
regarding which symptoms a're considered as diagnostic methods will have to be made on the basis of the ability
criteria has, in the past, made comparisons of patients of their results to relate to the basic clinical factors:
difficult. Using data collected by psychiatrists from nine etiology, response to treatment, and prognosis.
nations in the International Pilot Study of Schizo- The symptoms of schizophrenia also serve to provide
phrenia, it is possible to go beyond previous symptom clues regarding the nature of the underlying pathological
lists of diagnostic criteria from particular centers and, processes involved. A review of findings suggests that the
based on the way the concept of schizophrenia is used, processes underlying these symptoms are less discrete
to describe 12 discriminating symptoms as diagnostic from other disorders and from normal function than was
criteria that apply in many different cultural settings. originally assumed. This review also suggests that the
These symptoms can be readily used by clinicians and manifestations of schizophrenia can usefully be
researchers to define patients who will be widely categorized into the following three groups: positive
considered schizophrenic. symptoms, a group of symptoms including delusions and
Proceeding beyond diagnostic criteria that are based hallucinations that appear to have relatively little
on key symptoms, it is important to describe a broader specific relationship to antecedents or prognosis; nega-
range of the characteristics of patients who have these tive symptoms, including blunted affect, apathy and
symptoms. In the second part of this series, we kinds of formal thought disorder, such as blocking,
presented several alternative methods for describing and which are related in a manner to be determined with
comparing patients with symptoms of schizophrenia and chronicity; and disorder of personal relationships, which
for determining subgroups. These methods differ regard- appears to be a relatively independent continuing
ing three basic principles for determining profiles and process that also has prognostic implications for the
defining diagnostic groups: 1) whether the data them- outcome of positive and negative symptoms. It is
selves will contribute to determining which patients are important to clarify the relationships among these three
considered similar or whether diagnostic groups and types of manifestations and to determine further their
subgroups will be determined primarily from a priori etiologies and responses to treatment.
concepts; 2) whether all symptoms are considered From this series of reports, the relationship between
equally important for diagnosis or whether some are symptoms and schizophrenia emerges as follows: 1)
counted as more important than others; and 3) which Discriminating symptoms for diagnostic purposes can be
aspect of the patient's characteristics is considered described and can form a valuable foundation for
diagnostically most crucial, the pattern of symptoms, research and clinical comparison. 2) Broader profiles,
ISSUE NO. 11, WINTER 1974 71

extending beyond the 12 discriminating symptoms, Babigian, H. M.; Gardner, E. H.; Miles, H. C ; and
provide a more complete picture and a means for Romano, J. Diagnostic consistency and change in a
comparison of the people being studied. Alternative follow-up study of 1215 patients. American Journal of
methods for describing and comparing these profiles Psychiatry, 121:895-901, 1965.
have important relationships to clinical assumptions and Bartko, J. J.; Strauss, J. S.; and Carpenter, W. T. An
the interpretation of findings. 3) The processes under- evaluation of taxonometric techniques for psychiatric
lying schizophrenic symptoms appear to reflect extremes data. The Classification Society Bulletin, 2(3):1-29,

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1971.
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1970. experience obtained during the participation of the
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participating field research centers. (Ed. note: See p. 34
World Health Organization. The International Pilot
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Organization Press, 1973. study.)
Wynne, L. C. The study of intrafamilial alignments The present series of reports represents the results
and splits in exploratory family therapy. In: Ackerman, from data analysis done at the Washington Center; the
N. W., Beatman, F. L , and Sherman, S. N., eds. opinions expressed do not necessarily represent the
Exploring the Base for Family Therapy. New York: viewpoints of the sponsoring agencies nor of other
Family Service Association of America, 1961. pp. investigators of the International Pilot Study of
95-115. Schizophrenia.
Wynne, L. C. Communication disorders and the quest The authors express their profound appreciation to
for relatedness in families of schizophrenics. American
Dr. Lyman C. Wynne for his major role in establishing
Journal of Psychoanalysis, 30:100-114, 1970.
and developing the Washington Center of the Interna-
Wynne, L. C ; Ryckoff, I. M.; Day, J.; and Hirsch, S.
I. Pseudo-mutuality in the family relations of schizo- tional Pilot Study of Schizophrenia. Appreciation is also
phrenics. Psychiatry: Journal for the Study of Inter- expressed to Ruth Boesman Williams, Margaret Toohey,
personal Processes, 21:205-220,1958. Carol Langsner, Lydia S. Castle, Autumn Van Ord,
Wynne, L. C , and Singer, M. T. Thought disorder and Estelle Churgin, and Nancy Ryan for providing technical
family relations of schizophrenics: II. A classification of assistance.

multidisciplinary workshop on schizophrenia

An international workshop will be held September 24-27, 1975, at Capri, Italy, to assess the impact of recent
research advances on the problem of schizophrenia. Held under the auspices of the University of Naples, the workshop
will deal with such topics as: definition, classification, and nomenclature; epidemiology and sociology; genetics and
biochemistry; pharmacology of hallucinogens and drug-induced psychoses; and pharmacological and psychological
approaches. Scheduled speakers include: S. Arieti (New York), A. Carlsson (Goteborg), C. L. Cazzullo (Milan), S. S.
Ke'ty (Boston), T. Lambo (Geneva), I. Matte Blanco (Rome),M. Munkvad (Roskilde), A. Pletscher (Basel), D. Rochter
(London), H. A. Rosenfeld (London), N. Sartorius (Geneva), M. Shepherd (London), J. Shields (London), and R.
Tissot (Geneva). For further information, write: Dr. D. Kemali, Cattedra di Psichiatria, I Facolta di Medicina e
Chirurgia, Universita di Napoli, Piazza Miraglia, 2, 80138 Napoli, Italy.
76 SCHIZOPHRENIA BULLETIN

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Appendix I

Sign or Symptom PSE Question(s) Reliability

Restricted affect Blank, expressionless face .62

Very little or no emotion shown when delusional or normal material that
would usually bring out emotion is discussed .63

Poor insight Overall rating of insight .85

Abnormal explanations When a patient indicates that he has a hallucination or a delusion, he is

asked how he explains the experience and to what it is due. Following
the queries, the interviewer rates explanations as follows:

(Rate the patient's explanation of abnormal experiences)

Scoring:
0 None or no abnormal explanation (specify which)
1 Uncertain, but suspects some abnormal mechanism
2 Firm delusional belief
Mean for total items .76

Persecutory ideas Have you been particularly singled out for persecution? .88
Do you think people want to harm you? .91
Do you think that somebody is following you around, or spying on you? .82
Do you think that some force is trying to harm you? .77
Is there any particular person trying to harm you? .78
Have you recently been suspicious about people's intentions toward you? .89

Suspiciousness Suspicious of the interviewer, questions, procedure, etc. .66

Guarded, wary of revealing information .71
Do people make signs to each other, either in your presence or behind your
back? .89
Do you get the feeling that people are looking at you more than usual in
the streets or in a restaurant? .95
Do they ever seem to laugh at you or talk about you? .91
Do you see any reference to yourself in the newspaper or on television? .90

Widespread delusions How widespread are the patient's delusions? .74

How many areas in the patient's life are interpreted delusionally?

Poor rapport Did the interviewer find it possible to establish good rapport with the
patient during the interview? .86
Other difficulties in rapport .75
ISSUE NO. 11, WINTER 1974 77

Appendix I—Continued

Sign or Symptom PSE Question(s) Reliability

Preoccupied with delusions How much of the time is the patient preoccupied with delusions? .88

Thoughts aloud Do you feel your thoughts are being broadcast, transmitted, so that

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everyone knows what you are thinking? .95
Do you ever seem to hear your thoughts spoken aloud (almost as if someone
standing nearby could hear them)? .74

Auditory hallucinations Rate presence of auditory hallucination .93

Apathy Apathetic and uninterested .67

Voices speak to patient Do the voices speak directly to you? .82

What sorts of things do they say? Single words or syllables or sentences? .79
Do they comment on something you are thinking? .84
Do they sometimes repeat the same sentence many times? .84
Do they repeat something that you have just thought? .89
Do they comment on something you are reading? .76
Do the voices tell you to do things? .77

Depressed facies (-) Facial expression sad, depressed .73

Waking early (-) Have you been waking earlier in the morning and remained awake? .83

Preoccupied, inattentive Preoccupied, or inattentive, or fails to understand questions .77

Thought alienation Do you feel as if your thoughts were being taken away, so that your mind is
a complete .blank? .91
Are thoughts put into your mind that you know are not your own? .89

Apophany Have you felt that people change their appearance in some puzzling way? .82
Have people seemed to be acting a part, as though they were in a play? .89
Do you see people around whom you recognize from earlier in your life, but
who say they could not have seen you before? .90
Do you feel you're being tested in some way? .90
Are there people around who are not what they seem to be, who are perhaps
in disguise? .92
Delusional mood .59

Unreliable information Was the information obtained in this interview credible or not? .73

irrelevance Replies tangentially or irrelevantly to questions .84

Responds without apparent regard to content of question .68

Blocking Sudden and inexplicable interruption of a line of thought, without a

recognizable reason, so that the patient stops in the middle of a
sentence or phrase and cannot recapture the theme .78
Do you feel as if your thoughts were being taken away, so that your mind
is a complete blank? .91
78 SCHIZOPHRENIA BULLETIN

Appendix I—Continued

Sign or Symptom PSE Question(s) Reliability

Vagueness Patient talks so vaguely that information given is of little or no value .58
Patient fails to generalize and describes only constituent details and

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aspects of the situation .62
Circumstantial speech, much unnecessary detail, yet object in view is
ultimately reached .55
Excited speech that loses its aim and wanders off in all kinds of bypaths
(flight of ideas) .79
Patient's description of difficulties unclear or inadequate .78
Remoteness from reality Did patient prefer private modes of thought and behavior and remoteness
from reality? .68
Incomprehensibility Examiner's understanding of what the patient says to him or to other
person .72
Bizarre delusions Are the delusions realistically possible? .69
Thoughts broadcast Do you feel your thoughts are being broadcast, transmitted, so that every-
one knows what you are thinking? .95
Denies delusions though Do you think the patient is denying delusions? .68
present

Lack of affective reaction How do you feel about these experiences? .84
to disordered thoughts
(Rate the patient's affective reaction to abnormal experiences)

Scoring:
0 Strong affective reaction present
1 Mild affective reaction only
2 No affective reaction whatever (indifferent)
N A No subjective experience of disordered thought

Voices arguing Do you ever hear several voices speaking about you among themselves with-
out talking directly to you? .76

Idiosyncratic speech Peculiar or idiosyncratic usage of ordinary words .77

Distorted or idiosyncratic grammatical structure, e.g., "They've all be
going he she first wife." nor
Words are associated together inappropriately by their sound or rhyme; e.g.,
"Where's my Teddy, Freddy? Bed . . . . " .69
Patient makes up words that have no generally accepted meaning (neologisms)
(Do not include ordinary words used with an idiosyncratic meaning) .66
Pedantic manner of speech with many abstract or pseudoscientific phrases
that have unclear meaning or connection to topic; e.g., " I believe
we live in a world in an age where the elements are a force that the
elders professionalism hope not to conquer but to control." ' .57
1
Insufficient variance for intraclass correlation.
ISSUE NO. 11, WINTER 1974 79

Appendix I—Continued

Sign or Symptom PSE Question(s) Reliability

Thought intrusion Are thoughts put into your mind that you know are not your own? .89
Can you tell the difference between your own thoughts and the other

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thoughts that have been put into your mind? .55

Audible thoughts Do they sometimes repeat the same sentence many times? .84
Do they repeat something that you have just thought?- .,.•• .89
Do you ever seem to hear your, thoughts spokenaloud (almost-as if someone
standing nearby could hear them)? ' .74

Stereo typic Frequent repetition of one or more stereotyped phrases; e.g., "I'm not
coming the old Isaacs" or " I t doesn't prove power to any patients."
(Do not include frequent reversion to certain themes or topics) .71

Made feelings Do you feel that you are made to want things that you would not want

yourself? .76
Incoherent speech
Rate free and spontaneous flow in incoherent speech .74
Neologisms
Patient makes up words that have no generally accepted meaning (Do not
include ordinary words used with an idiosyncratic meaning) .66
Thought withdrawal Do you feel as if your thoughts were being taken away, so that your mind
is a complete blank? .91

Frequence of auditory How often do you hear them? .76

hallucinations

Perseveration Clogging persistence in continuing a train of thought or an utterance,

without the capacity to alter the mental set .54

Hallucinated voices speak What sort of things do they say? Single syllables or words or sentences? .79
sentences

Hallucinated voices sound Can you tell the voices from normal voices? .75
human

Nonverbal auditory Do you ever hear other noises for which you cannot account? .87
hallucinations Do you ever hear music when none is being played? .76

Elation (-) Elated, joyous mood .67

Nihilistic delusions Do you feel that your body is decaying, rotting? no r1

Do you feel that some part of your body is missing; e.g., head, brain,
arms? .70
Do you ever have the feeling that you do not exist at all, that you are
dead, dissolved? .71
1
Insufficient variance for intraclass correlation.