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B rit is h Jou rnal o f P sych ia tr y 1987 , 151 , 145— 151

The Sym ptom s of Chronic Schizophrenia

A Re-exam ination of the Positive-Negative D ichotomy

PETERF. L IDDLE

The relat ionsh ips between symptoms in 40 schizophren ic patien ts , se lec ted for pers is tence

o f s ymp toms, were e xam ined . The s ymp toms seg rega te d in to th re e s yndromes : p sy cho

mo to r poverty poverty o f s peech, la ck o f s ponta neous movemen t and vario us a spec ts o f

b lun ting o f a ffec t) ; d isorgan isa tion inappropriate a ffec t, pover ty o f conten t o f speech,and

d is tu rb an ce s o f th e fo rm o f th ough t); a nd reality d is to rtio n partic ula r ty pe s o f d elu sio ns

and ha ll uc ina tions) . Bo th the psychomotor pove rty and d isor gan isati on synd romes were

a ss oc ia te d w ith s ocia l a nd o cc up atio na l im pa irm en t; in p artic ula r, th e p syc homo to r

p ov erty s yn drome w as a ss ocia te d w ith im pa irm en t o f p ers on al re la tio ns hip s, a nd th e

d isorgan isa tion syndrome wi th poor se lf -care and impersistenceat work .

T he c lin ic al d iv ersity o fsch izo ph re nia h as p ro mp ted

m any attem pts to define subtypes of the illness.

Several recent attempts have been based on the

distin ctio n b etw een p ositive a nd n ega tiv e sy mp tom s

 Crow, 1980a,b;Andreasen Olsen, 1982;Lewine

et al 1983 . N egative sym ptom s reflect deficiency

of a m ental function which is norm ally present, for

example blunting of affect and poverty of speech.

Positive sym ptom s, such as delusions and halluci

n ati on s, r ef le ct a be rra nt m en ta l a ct iv ity .

R ecent attem pts to m easure negative sym ptom s

stem from the work of Venables (1957) and W ing

(1961). They found that “¿wi thd rawa ln ch ron ic

schizophrenic patients is a unidim ensional variable

w hich can be reliably m easured. It is defined by such

item s as: underactivity, slow ness, lack of conver

sation, lack of friends, avoidance of others, poor

personal hygeine, carelessness about appearance,

and lack of interests― (V enables W ing, 1962).

E lectrophysiological evidence that w ithdraw al w as

associated w ith high arousal led V enables and W ing

to suggest that withdrawal might be a protective

m echanism adopted to cope w ith a decreased ability

to filter sensory input. H ow ever, em phasis shifted to

the role of social factors in the genesis of negative

symptom s, after the demonstration by W ing

B row n (1970) that these sym ptom s are com mon in an

u ns tim ulatin g en viro nm ent, an d fu rth erm ore a re les s

s ev er e a fte r a n â €œ ¿ n cr ea sen the richness of the social

e nv ir on m en tâ €• ( W in g, 1 97 8) .

Subsequently, the evidence that schizophrenic

patients with negative symptoms are more likely

to have abnorm alities such as cerebral ventricular

enlargem ent and intellectual im pairm ent (H uber,

1957; Johnstone et al, 1978; Andreasen Olsen,

145

1982) has regenerated interest in the role of organic

factors. C row (1980a) proposed tw o types of schizo

p hr en ia : ty pe I i s c ha ra ct er is ed b y p os it iv e s ym pt om s,

usually in the setting ofan acute illness, w hile type II

is characterised by negative sym ptom s and indices

of cerebral dam age, and is usually chronic. Crow

did not regard the tw o types as m utually exckisive,

but as independent dim ensions reflecting different

u nd erlyin g p ath olo gic al p ro ce sse s (C ro w, 1 98 0b ).

A ndre as en O lsen (1 98 2) a dop ted a d iffe ren t v ie w

of the relationship between positive and negative

sym ptom s, regarding them as characteristic of tw o

different types of illness. In a sam ple consisting of

consecutive hospital adm issions satisfying m odi

f le d D SM â €” II I c rit eri a f or s ch iz op hr en ia ( Am er ic an

P sychiatric A ssociation, 1980), they dem onstrated a

negative correlation betw een the occurrence of posi

tive and negative sym ptom s. T hey w ere able to assign

about one-third of their cases to each of the positive

an d n eg ativ e ca te go ries. T he se tw o g ro ups of p atien ts

d iffere d in m any re sp ec ts, in clud in g c ours e of illn ess,

evidence of cerebral ventricular enlargem ent, and

e vi de nc e o f c og ni ti ve i mp air me nt .

It is p ossib le tha t th e n eg ativ e co rrelation b etw een

positive and negative symptom s demonstrated by

A ndreasen O lsen (1982) arises from a difficulty in

eliciting positive sym ptom s in the presence of nega

tiv e sy mp to ms. A noth er p ossib ility is th at the p attern

o fc orre la tio ns w as in flu en ced b y th e m ix tu re o f a cu te

and chronic cases in their sam ple. U nless subjects are

hom ogeneous w ith regard to chronicity, in the sense

of having sym ptom s of com parable persistence over

tim e, there w ill be a tendency for sym ptom s to segre

gate into groups on the basis of their tendency to

persist. Although segregation of symptoms on the

This On•

1@fl1fli@IIIflIUllihII@I

RRR BAT RAHW

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146

L ID D LE

basis o f per si stence i so f i tsel f importan t, t he quest ion

of w het her per si stent posi ti ve sy mpt om s segr egate

f rom persi stent negati ve sy mptoms i n a separate

i ssue. I t i s r el ev ant to t he f ur ther quest ion of w het her

sy mptom ty pe per se, rather than the persi stence

of sy mpt om s, di sti ngui shes bet ween di f fer ent t ypes

of schi zophreni a. T here are al so unresol ved i ssues

concer ni ng t he assi gnm ent of sy mpt om s to t he nega

ti ve symptom group. A ndreasen (1982) i ncl uded

inappropriate af fect in the negative group, w i th

ack now ledged m isgi vi ngs, w hereas Crow (1980a)

regarded i t as a posi ti ve sy mptom . A ndreasen al so

i ncl uded l ack of v ol iti on and anhedoni a i n the group

o f negat i ve symptoms, and assessed these unobser v

abl e attri butes of the m ental state by rati ng i mpai r

ment of sel f-care, occupati onal perf orm ance, and

soci al f unct ion. Si nce m any di f fer ent att ri butes of t he

mental state mi ght i n pri nci pl e contri bute to these

obser vabl e i mpai rm ents, t he v al i di ty of t hi s m eans of

assessmen t r emains to be estab li shed , and migh t w el l

be l i mi ted to par ti cul ar sam pl es of pat ients. Fi nal l y,

w hi le A ndreasen and Crow agree that di sorders of

the f orm of thought such as derai lm ent and i ncoher

ence are positi ve symptoms, L ew ine et a (1983)

assi gn such symptoms to the negati ve symptom

group.

T hi s st udy at tem pt ed t o del i neate t he segr egati on

of sy mptom s i n a sampl e of schi zophreni c pati ents

selected in a manner intended to discriminate in

f av our of cases w ith persi stent sy mptom s. N o pri or

assumptions about which symptoms should be

regarded as positive or negati ve w ere made. The

st udy al so i ncl uded an assessm ent of cogni ti v e f unc

ti on and of neurol ogi cal abnorm al iti es, w hi ch w il l be

reported separately.

 e t ho

T he f ol l ow i ng cr iter ia w er e adopt ed, w i th t he obj ect of

selecting a sample of schizophrenic pat ients in a manner

w hi ch di scr im inated i n f av our of t hose w i th per si stent

symptoms.

(a) The pat ient must have sat isf ied DSM — I I Icri ter ia for

the diagnosis of schizophrenia at some point in the

cour se of the i l lness, and at the t im e of i nterv i ew

exhibi t at l east one symptom f r om sec ti on A or C o f

those criteria.

(b) The t ime since onset of i l lness must be 3—18ears.

The low er l im it of t hr ee year s w as chosen because

Huber et al ( l975) found that the pat tern of i l lness is

general ly estab l ished by this stage. Cases wi th an

ext remely long durat ion of i l lness were excluded so

as to decrease thel ikelihood that any observed segre

gat ion of symptoms would merely ref lect the ef fects

of prol onged i ll ness; a 15-y ear range of i ll ness

du rat ion w as the minimum per mi t ti ng the r ec rui t

ment of an adequate num ber of cases f rom the

population available.

(c) The pat ients must beunder regular psychiat ric care,

but have had no increase in neuro leptic medicat ion

or readmission to hospital within the preceeding six

months.

( d) A g e m ust be l ess than 55 y ear s, so as to m ini mi se

t he i nf l uence of the ef f ect s of agi ng on cogni ti ve

function.

 

From all of thepatients receiving in-patient, day-patient,

o r r egular ou t- pat ient car e f r om one o f the seven c li ni cal

teams at Warneford Hospital , Oxford, Lit t lemore Hospital ,

Oxford, and Fai r Mi le Hospi tal , Wall ingford, or receiv ing

day o r out -pat ien t car e at t he E ldon R oad D ay H osp it al ,

R eading , 47 pat ien ts sat isf y i ng the above c ri ter i a w er e

identi f ied. Of these, 7 did not reply or refused to part icipate

in thestudy. The remaining 40comprised 12in-pat ients, 12

day-pat ients and 16out-pat ients; there were 31males and 9

females. The mean dur at ion o f i l l ness w as 10 .5 year s, and ,.

the mean age was35 years (range 21—54ears).

A asemmentof schizophrenic symptoms

Symptoms w er e r ated accor ding to sect ion I I o f t he C om

prehensive Assessment of Symptoms and History (CASH)

(Andreasen, 1983),and sections 13—20f the Present State

Examinat ion (PSE) (Wing eta , 1974).Two separate rat ing

scales were employed because the scope of the def in i tion

o f each symptom, and the r ange o f symptoms assessed ,

in f luence the detectab le pat tern of cor relat ions between

symptoms, and it istherefore valuable to beable to compare

the results obtained using different rating scales.

CASH was used because i t isdesigned to prov ide a com

prehensive rat ing of schizophrenic symptoms. I t incorpor

ates the Scale of t he A ssessmen t o f N egat ive Symptoms

(SAN S), which consists of five sub-scales: affective flatten

i ng, al ogi a, l ack of v ol iti on, anhedoni a, and attenti on I

impai rment. In addi t ion, CASH includes comprehensive

rat ings of disorders of theform of thought, and of delusions

and hal lucinat ions. Most of the i temsin CASH are rated on

a scale of 0—5,eflecting grades of severity.

A number of SANS i tems demand a detai led knowledge

of the pat ient' s l i festy le. Andreasen (1983) recommends

that w her e possible thi s i nfor mat ion be obtained f rom a

t hi rd par ty , such as nur si ng st af f . I n thi s st udy , w i th i n

pat ients in theminor i ty, this was not alwayspossible, How

ever, several interviews with each pat ient were required to

al l ow the admini st rat i on o f t he cogn it ive test bat ter y in a

manner that avoided pr olonged per iods o f t est ing, and

these in terv iews were st ructured so as to al low a substan

t ial t ime for i nfor mal conver sat ion, i nc luding standar d

questions about the patients' activities and relationships.

The PSE was employed because i t has been standardised . t

and because its glossary provides precise def ini t ions of the

i tems to berated. To avoid pro longed formal examinat ion

o f t he pat ien ts, t he ful l PSE w as not admini ster ed . Q ues

t ions f rom sections 13—15ere used to el ic it ev idence of

delusions and hal lucinat ions, and scores were assigned to

all syndromes concerned with delusions or hallucinations in

Selection of patients

 

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147

YM PTOMSOF CHRONIC SCHIZOPHRENIA

the PSE syndrome checkl ist . Sections 18—20f the PSE,

w hi ch i nv ol v e obser vati ons of behav i our , af f ect, and

speech, were also completed.

Data analysis

The symptom r at ings w er e subjected to fac to r anal ysi s

using the program FACTORrom the Stat ist ical Package for

t he Soc ial Sciences ( N ie ci a , 1975 ). I ni ti al f actor s w er e

extracted by themethod ofpr incipal factors, and subjected

to obl ique rotat ion. CASH and PSE rat ings wereanalysed

separately.

I n t he case of C A SH rat ing si ngl e i tem s, r at her than

sub-scale scores, were employed as uni ts of analysis, to

av oi d hav ing t o m ak e any i ni ti al assum pt ions about t he

relat ionsh ips between i tems. Since major d ispar i ty in the

frequency of occurrence of symptoms necessar i ly restr icts

the upper bound o f the r ange o f the co rr elat ion betw een

i tem s, onl y those i tem s rated as def ini tel y present i n

mor e than 10% of the pat ien t sample w er e inc luded. O ne

consequence of this l imi tat ion was the exc lusion of some

specific types ofdelusions and hallucinations, most notably

Schneiderian fi rst-rank symptoms, because thesei temsw ere

individual ly quite rare in thissample.

Since i t was not assumed that the i tems of an indiv idual

sub-scale could be taken asmeasures of the singleconstruct

embodied in that sub-scale, a problem arose in the case of

the symptoms lack of vol i t ion, anhedonia, and attentional

impairment. As these symptoms are represented by SANS

sub-scales consist ing of i tems measuring self-care, occu

pat ion, and social f unct ion, w hich might be r egar ded as

measures o f per for mance in dai l y l i f e r ather than symp

toms, the relat ionship between these items and symptoms

wasexamined separately by determining the Pearson corre

lation coeffi cientsbetween these itemsand symptom factor

scores.

In the case ofthe PSE rat ings, the units ofanalysis repre

senting sections 18—20onsisted ofsingle items. These items

record rat ings of behaviour, af fect, and speech observed

at in terv iew. The relat ively f ined ist inctions between mdi

v idual i tems in sect ions 13— 15f t he PSE , w hich r ecor d

delusions and hal lucinat ions, made it necessary to employ

syndrome scores embracing these itemsas units of analysis.

I n gener al , PSE sy ndr om es cont ai n a sm al l num ber of

sy mptom s w hi ch are j udged on cl ini cal grounds to be

si mi l ar . T hese use of PSE sy ndr om e scor es as uni ts of

anal ysi s has been just if i ed stat ist ical l y using data f r om

the US-UK Diagnost ic Project and the Internat ional Pi lo t

Study ofSchizophrenia (Wing et a , 1974)which conf irmed

that PSE symptoms have a satisfactory degree of statistical

associat i on w i th the synd romes to w hich they have been

allocated.

In compar ing the resu l ts of the factor analysis of the two

setsof symptom rat ings, i t isnecessary to bear in mind that

the prior ex istence of stat ist ical ly just i f ied syndromes in

the case of t he PSE per mi t s analysi s o f t he r elat ionsh ips

between delusions and hal lucinat ions at a d i f ferent level

f rom t hat f or the CA SH r ati ngs. A l so, di f ferences i n t he

scopeof the def in it ions of i tems in d i f ferent rat ing scales is

inev i table, and i s the r eason w hy tw o r at ing scales w er e

employed in the f irst place.

Results

Factor analysis ofCASH rat ings

The factor analysis ofCASH rat ings revealed three factors,

each having high loadings in a separate group of symptoms

(Table I) . The f irst factor loads heavi ly in poverty of speech,

decreased spontaneous movement, and four i tems which

m ight be regarded as m easures of bl unti ng of af fect:

unchanging facial expression, paucity ofexpressive gesture,

affect ivenon-responsivi ty and lack ofvocal inf lection. This

gr oup of si x sy mpt om s i s desi gnat ed the psy chom ot or

poverty syndrome.

The second factor has heavy loadings in inappropriate

af fect, pover ty of content of speech, and four i tems which

are recogni sed di sturbances of the f orm of thought:

tangentiality, derailment, pressure of speech, and distract

i bi li ty . T hi s group of si x sy mptom s i s desi gnated the

disorganisation syndrome.

The thi rd factor has heavy loadings in audi tory hal luci

nat ions of v oi ces speak ing t o the pati ent , del usi ons of

per secut ion and del usi ons of r ef erence. T hi s gr oup of

symptoms is designated the reality distortion syndrome.

In this sample of pat ients, the three syndromes are not

st rongly cor related. There is a weak negat ive cor relat ion

 r = â € ” ¿.2 2) b e tw e e n th e fa c to rs a s s o c ia te d w it h th e p s yc h o

m ot or pov ert y sy ndr om e and t he di sor gani sati on sy n

drom e, and the other correl ati ons are near zero. T he

syndromes are thus not mutual ly exclusive. For example,

the probabi l it y that a pat ient has symptoms of the psycho

motor pover ty syndrome is independent of whether hehas

symptoms of the real i ty distort ion syndrome.

Factor analysisofPSE rat ings

T he f actor anal ysi s of PSE rati ngs (T abl e I I) rev eal s a

pattern ofsegregat ion ofsymptoms similar to that obtained

for t he C A SH r at ings. The f i rst f ac to r l oads heav i l y i n the

incongruous affect, poverty of content of speech, incoher

ence o f speech, d ist ract ib il i ty , and sel f -neg lec t. These

symptoms ar e sim il ar i n char acter t o the symptoms o f the

disorganisation syndrome. The second factor loads heavily

i n r est ri ct ed quan ti ty of speech , slow ness, and b lunted

af fect, symptoms which are simi lar in character to those of

the psychomotor poverty syndrome.

T here i s ev idence of a sub-di vi si on w ith regard to

delusions and hal lucinat ions. A third factorhas heavy load

ings in the PSE nuclear syndrome (which consists main ly

o f Schneider i an f i rst r ank symptoms) and in sexual and

fantast ic delusions. This group of symptoms is designated

the d isinteg rat i ve r eal i ty d istor ti on synd rome. A fou rth

factor has substantial loadings in delusions of persecut ion,

delusions of reference, and grandiose delusions; this group

is designated the in tegrat ive real i ty d istor tion syndrome.

However, delusions of reference and persecution also have

a moder ate dependence on the thi rd factor , and hal l uci

nat ions o f voi ces speak ing to the pat ien t depend, albei t

weakly , on both factors. Fur thermore, the thi rd and four th

factor s have a moder ate posi t ive co rr elat ion ( r = 0.29) in

this sample ofpatients. There is therefore somejustification

for consider ing delusions and hal lucinat ions as a group of

related symptoms, irrespective of content.

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SymptomsFactor 1Factor

2FactorPsychomotor

povertyyndrome high

loadings onactor] Poverty

ofpeech0.80—0.01—0.03Decreased

spontaneousovement0.95—0.04—0.03Unchanging

facialxpression0.85—0.010.05Paucity

o f ex pr e ss i v ee s t u r e 9 7 2 †” 4 Af f e c t i v e

non-responsivity0.820.02—0.00Lack

o f voca lnflection0.90—0.20—0.05Disorganisation

syndrome high

loadings onfactor I nappropriate

affect0.190.840.09Poverty

o f c on te nt o fpeech—0.080.570.01Tangentiality—0.050.940.03Derailment—0.050.940.04Pressure

ofpeech—0.100.610.08Distractibility—0.000.810.01Reality

distortionyndrome high

load ing onfactor Voices

s pe ak t oatient0.04—0.070.67Delusions

ofersecution—0.190.060.51Delusions

ofeference0.130.040.84Somatic

delusions—0.03—0.030.03

14 8

LIDDLE

T AB LE I

Fact or l oadi ng s obt ai ned by f act or anal ysi s of CASH symptom rat ings

 

I

Self-care , occupation and social function

T h e c or re la ti on s b et we en t he i te m s o f t he l ac k o f v ol it io n,

anhedon ia and a tten t ional impai rmen t sub-sca le s o f S ANS ,

w h ic h a re r at in gs o f s el f- ca re , o cc up at io n a nd s oc ia l f un c

t io n, a nd t he f ac to r s co re s d er iv ed f ro m t he f ac to r a na ly si s

o f C A S H r at in gs a re s ho w n i n T a b le I II . I f t h e f ac to r s co re s

a re r eg ar de d a s m e as ur es o f t he c or re sp on di ng s yn dr om e s,

i t i s a p pa re nt t ha t i n t h is s am p le o f p a ti en ts b ot h t he p sy ch o

m o to r p ov er ty a nd d is or ga ni sa ti on s yn dr om e s a re a ss oc i

a te d w it h i m pa ir m en t o f s el f- ca re , o cc up at io n, a nd s oc ia l

f un ct io n. H ow ev er , t he s yn dr om es d if fe r in t he p at te rn o f

thei r a ssociat ion wi th these impai rmen ts .

T he m o st w id es pr ea d a nd s ev er e d is tu rb an ce is a ss oc i

a ted w ith th e d iso rga nis atio n sy ndro me . In p artic ula r,

s elf-c are a nd pe rsiste nce a t w ork a re p oo r. T he p sy cho

m oto r p ov erty sy nd ro me is a sso cia te d w ith relativ ely

g re at er i m pa ir m en t o f r ec re at io na l i nt er es ts a nd a bi li ty t o

m a ke f ri en ds hi ps . T h er e w e re n o s ig ni fi ca nt c or re la ti on s

betw een factor scores and age, duration of illness, or

du ra tion o f hosp ital in-pat ien t ca re .

Assoclatioas betweensyndromes and medication

T h e r ea li ty d is to rt io n s yn dr om e w a s c or re la te d t o c ur re nt

d os e o fn eu ro le pt ic dr ug s( r= 0. 3l , P < 0. 10 ), c ur re nt u se o f

a nt ic ho li ne rg ic d ru gs ( r= 0 .5 3, P < 0. 01 ), a nd c ur re nt u se o f

b en zo di az ep in es ( r= 0 .3 5, P < 0. 05 ). T h e d is or ga ni sa ti on

syndrom e w as related to total duration of neuroleptic

trea tm en t o nly (r= 0.3 l, P < 0.1 0), a nd the p sy cho moto r

pove rty synd rome isno t a ssociated wi th any o f the va riab les

rela ted to medication.

D iscussion

The segregation of symptoms in this sample of

patients provides som e support for the previously

p ostu la te d po sitiv e-n ega tiv e dic ho to my . F irstly , th e

sym ptoms belonging to the Psychomotor Poverty

syndrom e (blunting of affect, poverty of speech and

decreased spontaneous movem ent) are sim ilar in

c ha r a c t e r o t h es y mp t o ms t h at a r e c ommo n t o t h e

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SymptomFactor IFactor 2Factor 3FactorDisorganisation

syndrome high

loadingonfactorIncoherenceofspeech0.93—0.140.01—0.00Poverty

ofcontentfspeech0.68—0.060.20—0.34Distractibility0.74—0.160.03—0.01Incongruous

affect0.72—0.000.05—0.00Self-neglect0.800.24—0.160.30Psychomotor

povertyyndrome high

loadingonfactor Restricted

quantityfspeech0.010.840.06—0.01Slowness—0.040.95—0.01—0.05Blunted

affect—0.080.79—0.06—0.08Disintegrative

reality distortionyndrome high

loadingonfactor PSE

nuclearsyndrome10.05—0.090.540.10Sexual

  fantasticelusions—0.00—0.040.93—0.17Voices

t o t heatient0.040.170.270.23Integrative

reality distortionyndrome high

loadingonfactor Delusions

ofreference—0.030.040.390.49Delusions

ofpersecution—0.04—0.170.280.33Grandiose

delusions0.04—0.10—0.050.64

Factor1

 psychom otorpoverty Factor

2

 disorganisation Factor

3

 realityistortion Poor

grooming andygiene0.130.56****0.15Impersistence

atork0.060.380.18Physical

anergia0.52—0.280.16Recreational

in terests andctivities0.290.23—0.07Sexual

in terest andctivity0.21—0.21—0.14Ability

fo rntimacy0.030.3l—0.04Relationships

wi th f riends andeers0.350.190.06Social

inattentiveness0.090.39'0.01

SYM PTOM SOF CHRONIC SCHIZOPHRENIA 149

TABLEI

Factor loadingsder ivedbyfactoranalysisof PSE rat ings

I C onsi st s of passi vi ty exper iences al ienat ion of t hought pr im ar y del usi ons and t hi rd per son audi tor y

hallucinations.

TABLEII I

Correlat ionsbetweenfactorscoresobtainedbyfactor analysisofCASH symptomrat ings andm easuresofself-care, work

per fo rmance andso cia lf un ct io nf rom the l ack o fvol it io n. a nhedon ia and a tt en tio na l impai rment sub -s ca le so f SANS

 P <0 10; P <0 05; @ <0 01; P <0 001

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L IDDLE

negative symptom groups def ined by W ing & Brown

(1970), Crow (1980a,b), A ndreason (1982) and

L ew ine et a (1983). Secondl y, i n accord w ith pre

v ious studies, t hi s study demonst rates that delusions

and hal lucinati ons bel ong to a group w hi ch can be

separated f rom the psy chom otor pov erty group of

symptoms.

T he evidence provided by the f actor analysi s of

PSE rati ngs that there i s a di vi si on betw een ty pes of

del usi ons and hal luci nati ons i s sl ender, but gi ves

parti al support to the v iew that f irst rank sy mptom s

shou ld bed ist ingu ished f r om other t ypes o f delusions

and hal luci nati ons. N onethel ess, i t i s i mportant to

bear in mind that the factors associated wi th the

di si ntegrati ve real ity di storti on sy ndrom e and the

i ntegrati ve real ity di storti on sy ndrom e w ere posi

ti vel y correl ated i n thi s sampl e, suggesti ng that al l

hal luci nati ons and del usi ons consti tute a rel ated

g roup of symptoms.

T he m aj or di ff erence betw een the f indi ngs of thi s

study and other recent i nvestigati ons of posi ti ve

and negati ve sy mptom s i s the i denti fi cati on of the

di sor gani sati on sy ndr om e as a separ ate sy ndr om e. I t

consi st s of sy mpt om s w hi ch ot her i nv est igator s hav e

v ar iousl y assi gned to ei ther t he posi ti ve or negat iv e

sy mptom groups. D isorders of the f orm of thought

consti tute a major part of this syndrome. B leuler

(1911) considered i t l ikely that disturbances of

associat ion ar e p rimar y symptoms of schi zophr en ia,

and subsequentl y many cl ini ci ans hav e accorded

them a central pl ace among schi zophrenic symp

toms. Harrow et a (1983) attempted to assess

w hether di sordered f orm of thought i denti fi es a sub

group of schi zophr eni c pati ent s w i th poor outcom e.

T hey f ound that thought di sorder persi sti ng af ter

di scharge f rom hospi tal i denti fi ed a subgroup w ith

poor outcom e, but som e pati ents w ithout thought

di sorder al so had a poor outcom e. T hey concl uded

that “¿severehought disorder is one of several

major features of schizophrenia―. The present study

suppor ts thei r conclusion.

The r elat ionsh ips betw een the thr ee synd romes has

i mpor tant i mpl i cati ons f or pr edi ct ed r el at ionshi ps

betw een sy mptom s i n di f fer ent pat ient sam pl es, and

al so f or hy potheses concerni ng pathol ogi cal pro

cesses i n schi zophreni a. I n thi s sam pl e the psy cho

m otor pov erty and real ity di storti on sy ndrom es are

not m utual ly excl usi ve; som e pati ents hav e sy mp

toms from both syndromes. T his suggests that i n a

pati ent sample i ncl udi ng a substanti al number of

cases w i thout any schi zophreni c sy mpt om s, cor rel a

t ions bet ween sy mptom s f rom t hese t wo sy ndr om es

w oul d be positi ve. On the other hand, in a pati ent

sample selected in a manner that favours cases

having a single pure syndrome, the correl ations

betw een sy mptom s f rom the psy chom otor pov erty

and the real i ty distortion syndromes would be

expected to be negat ive.

For example, the f indi ngs of this study predi ct

a negati ve correl ati on betw een the psy chom otor

poverty syndrome and the real ity di stortion syn

dr om e i n a sam pl e such as t hat st udi ed by A n dr easen

& Ol sen (1982). T hei r sampl e i ncl uded som e acute

cases, l i kel y t o hav e r eal i ty di st ort ion sy mpt om s onl y

( or per haps di sor gani sat ion sy mptom s as w el l ), and

other cases l ikel y to have psychomotor poverty

symptoms only, because D SM — II I cri teri a w ere

m odi fi ed to accept sev ere pov erty of speech i n pl ace

of posi ti ve sy mptom s i n the mandatory sym ptoms

section.

Furthermore, Pogue-Gei le & Harrow (1984)

r ecen tl y studied sch izoph ren ic symptoms r eco rded 18

m ont hs af ter t he pat ients' di schar ge f rom hospi tal . I t

i s l ik el y that thei r sam pl e of pati ents w as si mi lar to

the patients assessed i n this study w ith regard to

per si st ence of sy mpt om s. I n cont rast t o A n dr easen &

Ol sen, they f ound a negl igi bl e correl ati on betw een

posi ti v e and negat iv e sy mpt om s, consi st ent w i th t he

f i ndi ngs of the cur rent st udy .

T he obser vat ion that a pat ient can hav e sy mptom s

f rom more than one syndrome suggests that the

sy ndr om es do not r epresent di st inct t ypes of schi zo

phreni a, but i nstead ref lect di screte pathol ogi cal

processes occurri ng w ithi n a si ngl e di sease. T hi s

suggests that there i s a f undam ental abnorm al ity i n

schi zophreni a, w hi ch i n any i ndi vi dual case m ight

be associated with one or more of three distinct

pathol ogi cal pr ocesses, dependi ng on t he pat ient 's

consti tut ion and cur rent env i ronm ent . I n pr inci pl e,

t he putati v e pat hol ogi cal pr ocesses m ight be ei ther

a cause or a consequence of the fundamental

abnormality.

The existence of patients who currently have

symptoms of only the psychomotor poverty syn

drome, despi te selection cri teria w hich demand

symptoms f rom ei ther the real ity di stortion or di s

or gam sat ion sy ndrom es at som e stage i n t he i l lness,

dem onstrates that the sy ndrom es detectabl e at any

one time can change during the course of the i l l

ness. The absence o f sign if i cant cor relat ion betw een

syndrome scores and durati on of i ll ness makes i t

unl i kel y that the syndromes f ol low each other i n a

specif ic sequence.

 

k now l e dg emen t s

This work was car ri ed out wh il e the au thor was suppor ted by the

Well comeTrust.am gratefultoD rT. K olakowska,ProfessorM .0.

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151

G el der , D r D . C lar k, D r 1. R . E. B ar nes, D r N . C . A ndr easen and t o st udy pat ient s un der t hei r car e, t o M r s A . Sl ev i n f or i nt roduci ng

Mrs F. E . B .L idd le fo r suggest i onsand cri t ic ism, to theconsu ltan ts me to pat i en ts at E ldon Road Day Hosp ital , and to the pat i en ts

of the L i t t lemore, Warneford and Fai r Mi le Hospi tals forpermission themselves.

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10.1192/bjp.151.2.145Access the most recent version at DOI:1987, 151:145-151.BJPP F Liddle

positive-negative dichotomy.The symptoms of chronic schizophrenia. A re-examination of the

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