symptom monitoring in the rehabilitation of schizophrenic patients€¦ · 578 symptom monitoring...

578 Symptom Monitoring in theRehabilitation ofSchizophrenic Patients

by David Lukoff, Robert PaulLiberman, and Keith H.Nuechterleln

Abstract

Although precise laboratory methodsfor measuring psychopathology arenot available, interviewer-ratedinstruments developed to assesssymptomatology can be used tomonitor schizophrenic patientsundergoing rehabilitation. Byregularly assessing patients, rehabil-itation staff can improve the effec-tiveness of their interventions.Patients can be screened for highlevels of symptomatology whichmight preclude assignment to rehabil-itation programs with high levels ofsocial stimulation. Monitoring theprodromal symptoms of relapse cansometimes prevent florid relapses andsustain a rehabilitative trajectory.Standardized instruments formeasuring positive symptoms (e.g.,hallucinations, delusions, andconceptual disorganization) andnegative symptoms (e.g., affectiveblunting, amotivation, andasodality) are available. Monitoringtarget symptoms may be particularlycost effective in the rehabilitationmilieu. Use of suggested operationalcriteria for defining clinical statessuch as relapse would improveoutcome studies on rehabilitationinterventions.

The careful and reliable elicitationand rating of psychopathology in theformulation of a DSM-II1 Axis Idiagnosis (American PsychiatricAssociation 1980) is preparatory torehabilitation efforts with thementally ill. In the lexicon of therehabilitation practitioner, the arrayof characteristic symptoms of psychi-atric disorder and the syndromaldiagnosis represent the impairmentsof the patient. Given the primeimportance of diagnosis in deter-mining phase-specific drug andpsychosocial treatments, the role ofpsychopathology assessment in

rehabilitation planning cannot beoverstated.

Beyond diagnosis, the repeated orongoing monitoring of psycho-pathology is a valuable adjunct tothe rehabilitation of individuals withschizophrenic or other major mentaldisorders. While other medicalspecialties can monitor the progressof patients through laboratory,radiological, and other quantitativeassessments, psychiatric practitionersmust rely on regular ratings ofpsychopathology to determinetreatment and rehabilitationdecisions. A thorough initialassessment of psychopathology andregular monitoring of symptoms inpatients undergoing rehabilitationcan improve the quality of treatmentdecisions in several areas.

1. The selection of an appropriaterehabilitation program is related totype and intensity of symptoms.Goldberg et al. (1977) found thatpatients assigned to an intensiverehabilitation program varied in theirresponse depending on their initiallevel of symptomatology. Patientswho entered the program with lowlevels of psychopathology generallybenefited from treatment. However,symptomatic patients had high ratesof relapse, which suggests thatassignment of patients to demandingand socially stimulating programsshould be preceded by an assessmentof their symptoms. In that way,entry of symptomatic patients couldbe postponed until their symptomshave receded or stabilized.

The assessment of both positiveand negative symptoms, as part ofthe rehabilitation planning process,can help patients and their caregivers

Reprint requests should be sent toDr D Lukoff. San Francisco VA MedicalCenter, 116D, 4150 Clement St., SanFrancisco, CA 94121.

VOL. 12, NO. 4, 1986 579

avoid programs that might beoverstimulating or understimulating.Understimulating social andvocational environments can leadpatients to social withdrawal andoften foster passivity, anergia,anhedonia, and loss of interest andinitiative. On the other hand,placement of the patient in a "totalpush rehabilitation program" canproduce overstimulation withattendant increased risk of exacer-bation of florid symptoms ofpsychosis (Bennett 1978). The patientwith schizophrenia, therefore, isoften walking a tightrope betweenexposure to understimulating oroverstimulating environments; themeans for balance can come fromperiodic monitoring of symptom-atology—including prodromalsymptoms. The benefits of symptommonitoring can be amplified bysharing the results of the check-upwith the patient and the patient'scaregivers, thereby involving themactively in the planning of continuedtreatment and rehabilitation.

2. The effectiveness of rehabil-itation efforts can be evaluated bychanges in ratings. For example, bymonitoring symptoms regularly, thetherapist can determine whethersocial skills training is reducing thepatient's anxiety at work. Inaddition, exacerbations of symptom-atology in response to rehabilitationcan be closely monitored andmedications, changes in the program,additional therapy, or temporarysuspension of the rehabilitation canbe implemented to prevent furtherexacerbation of symptoms.

3. The need for and impact ofmedication changes can be system-atically evaluated. Most medicationappointments are brief, with 5 or 10minutes being the norm. By using arating scale, a psychiatrist involvedin rehabilitation can more accurately,yet efficiently determine whether

symptoms are improving or exacer-bating. Because they observe patientsover a longer time, rehabilitationpersonnel who are trained to monitorsymptoms can provide valuableinformation to the prescribingpsychiatrist about a patient'smedication needs.

4. Patients can be taught tomonitor their own symptoms and torecognize "warning signs." Patientswho are trained to assess symptomsaccurately are more capable ofparticipating actively in theirtreatment decisions. In addition, theycan initiate stress-reduction activitieswhen they become sensitive toprodromal symptoms or find thattheir residual symptoms are exacer-bating.

5. Research on rehabilitationwould be enhanced by the use ofinstruments and procedures thataccurately assess symptoms and thestandardization of criteria for clinicalconditions such as relapse. Compara-bility of psychopathology measuresacross studies is currently very lowand hampers the contributions thatresearch is capable of making torehabilitation efforts. Accurateassessment of symptoms involvestwo distinct processes: Symptomsmust first be elicited from the patientthrough interviewing and obser-vation. Then, symptoms need to becategorized and rated for intensity.

Instruments for RatingPsychopathology

Researchers, concerned about thevalidity and reliability of theirinstruments, have developed severalhigh quality instruments which canbe incorporated into clinical rehabil-itation programs with little or nomodification. The three differentinstruments described below illustratethe options available for practitioners

who are interested in assessingpsychopathology.

Brief Psychiatric Rating Scale(BPRS). The BPRS (Overall andGorham 1962) originally contained16 symptom categories and was laterexpanded to 18 items (Guy 1976).The items are rated on a 1- to 7-point scale of increasing severity.Included in these scales are thepsychotic symptoms of greatestimportance for assessing the clinicalcondition of schizophrenic patients,i.e., hallucinations, unusual thoughtcontent (including delusions), andconceptual disorganization (includingincoherence). The BPRS was designedoriginally for use by clinicalobservers of inpatient psychiatricpopulations in psychopharma-cological outcome studies. For astudy of schizophrenic outpatients atthe UCLA Clinical Research Centerfor Schizophrenia and PsychiatricRehabilitation, we found it necessaryto devise a brief interview andanchor points applicable to anoutpatient population. In addition, areview of the literature on theprodromata of relapse and hospital-ization in schizophrenia (Wing 1978;Herz and Melville 1980) led to theaddition of three new scales to assessbehaviors which might signal adeterioration in an outpatient schizo-phrenic patient's condition: bizarrebehavior, self-neglect, andsuiddality. Three scales which assesssymptoms of particular importancein the manic phase of bipolar andschizoaffective (manic type) illnesswere also added (Bigelow andMurphy 1978). The manual, whichincludes a semistructured interviewand anchor points, is presented asAppendix A. Administration of theinterview and rating of symptomstakes 10-40 minutes depending uponthe interviewer's familiarity with thepatient, the number of symptoms

580 SCHIZOPHRENIA BULLETIN

present, and the patient's capacity todescribe symptoms. The symptomscan be readily graphed so thatchanges in baseline levels of one ormore symptoms can be quicklydetected and intervention mountedBoth nonpsychotic, prodromalsymptoms and psychotic symptomscan be thus followed

Schedule for the Assessment ofNegative Symptoms (SANS). InBleuler's (1911/1950) formulation ofschizophrenia as a separate diseaseentity, negative symptoms were heldto be a primary feature of schizo-phrenia. Although the symptomsconsidered to be in the groupingdiffer somewhat across authors(Andreasen 1982, Crowe 1985),negative symptoms usually includedeficiencies in psychological andbehavioral functions such asmotivation (amotivation), ability toexperience enjoyment (anhedonia),need for social contact (asociality),flow of thought (alogia), andaffective expressiveness andexperience (blunted affect). While thepositive symptoms of schizophrenia(hallucinations, delusions, andincoherence) have been the primaryfocus of clinicians and theorists,negative symptoms have againattracted attention and are nowconsidered a significant componentof the symptom picture of schizo-phrenia. In approximately one thirdof schizophrenic patients, thenegative symptoms show greaterclinical prominence than the positivesymptoms (Andreasen and Olsen1982).

Negative symptoms can be asincapacitating as positive symptomsand, in one study, patients whoseclinical picture was dominated bynegative symptoms had a pooreroutcome than patients with predomi-nantly positive symptoms (Andreasenand Olsen 1982). In rehabilitation,

amotivation often presents a greaterobstacle to effective treatment thanhallucinations. The SANS(Andreasen 1982) was developed toassess 20 of the negative symptomsdivided into five areas: affectiveflattening, alogia, avolition/apathy,anhedonia/asociality, and attention.Symptoms are rated on a 0- to 5-point scale of increasing severity. Abrief interview covering the previousmonth requires 10-30 minutesdepending upon the interviewer'sfamiliarity with the patient, thenumber of symptoms present, andthe patient's capacity to describesymptoms.

Target Symptoms. The rating oftarget symptoms makes use of thefinding that patients tend to haveexacerbations of the same symptomsacross different episodes of relapse(Leff and Wing 1971). Therefore, it ispossible and efficient to monitor thespecific symptoms that most sensi-tively reflect a given patient's clinicalcondition. Battle et al. (1966) firstused this approach to monitorprogress on target complaints inpsychotherapy research. An Idiosyn-cratic Target Symptom Scale,comprising 100 points for rating oneor more symptoms or signs ofpsychosis, has been used fortreatment studies in schizophrenia(May 1980). This, as well as othertarget symptom scales, can be readilyused by clinicians of various stripes,and it correlates well with multi-dimensional scales of patients'psychopathology (Mintz 1985).

Falloon, Boyd, and McGill (1984)adapted this methodology to monitorthe psychopathology of schizophrenicpatients who were participating in a2-year study of family, individual,and drug therapy. For each patient inthe study, they selected twosymptoms that had recurred inprevious exacerbations. Care was

taken to specify each symptomexactly as it was manifested in thatpatient and to avoid behavioraldisturbances that might occur in thepresence of a nonschizophrenicepisode (e.g., social withdrawalduring a depressive episode). Thesetarget symptoms were monitoredmonthly and rated on a 1- to 7-pointscale of increasing severity similar tothe BPRS. The target symptom scalewas sensitive to episodes of relapseand better distinguished thetreatment conditions than did theBPRS. It is likely that targetsymptom scales, because theyhighlight symptoms that are key foreach patient, reflect individual differ-ences and are more sensitive tochanges in clinical state than multi-dimensional, more comprehensiveinstruments.

Methods and Definitions forSymptomatic Outcome andClinical States

Although symptoms vary on acontinuum, for some purposes it isadvantageous to demarcate categoriesof clinical status such as relapse.While studying the effects of amedication washout, Docherty et al.(1978) identified a sequentialunfolding of states with uniformsymptom configuration. Otherstudies have identified the charac-teristic prodromal symptoms thatprecede relapse (Herz and Melville1980). Although the concept ofrelapse is more problematic to definefor schizophrenic disorder than formost other diseases, operationaldefinitions of this state have alsobeen developed in the course ofresearch projects. Relapse may beuseful to recognize as a clinical stateby rehabilitation practitionersbecause its frequency and intensitymay militate against the referral and

VOL. 12, NO. 4, 1986 581

involvement of patient in a rehabil-itation program. Symptoms of highintensity that qualify for thedefinition of "relapse" are generallybelieved to interfere with productiveinvolvement and progress in rehabil-itation (Liberman and Foy 1983;Anderson, Reiss, and Hogarty 1986).Similarly, recognizing the prodromalstages of relapse may equip rehabil-itation personnel with the capabilityof intervening with patients toprevent deterioration of function andcognitive status (Herz, Szymanski,and Simon 1982). Below are listedsome definitions of relapse whichcould be transplanted to rehabil-itation settings for clinical decision-making.

Operational Relapse. The definitionof relapse in schizophrenic disordersis characterized by both method-ological and conceptual disarray. Ina recent survey of 15 treatmentoutcome studies conducted during the1970s, Falloon (1984) found that notwo studies used the same criteria todefine relapse. The designation ofrelapse was tied to a host of differingvariables.

Admission to a psychiatric hospitalunit, increase of medication,worsening of florid symptoms ofschizophrenia, worsening of anypsychiatric symptoms, andthreatened clinical exacerbationshave all been variables consideredunder the rubric of relapse.[Falloon 1984, p. 295]

In addition, none of these definitionsreported interrater reliabilityagreement coefficients. The lack ofcomparable relapse definitions usedin various rehabilitation programscontributes to the difficulty in deter-mining and disseminating effectivetreatments for schizophrenic patients.

Because of its variable symptompresentation and course, schizo-phrenia presents a unique challenge

to the operationalization of theconcept of relapse. Classically, thenotion of relapse refers to thereemergence of a florid episode ofillness in a person previously in astate of stable remission. Thisconcept is appropriate for illnessessuch as tuberculosis and peptic ulcer,which are characterized by periods offull remission alternating withperiods of symptomatology.However, longitudinal studies havefound that perhaps 50 percent ofschizophrenic patients do not attain astable clinical remission (Bleuler1974; Ciompi 1980). By the tradi-tional concept of relapse, manyschizophrenic patients are in acontinuous state of partial or fullrelapse. The issue of persistingsymptoms has been one of the majormethodological obstacles to thedevelopment of reliable and validdefinitions of relapse.

Relapse has been used to refer to alongitudinal outcome and also across-sectional clinical state. Intreatment studies, relapse typicallyrefers to an outcome: that is, ameasure of the trajectory of changein clinical condition from thebeginning to the end of a study.Although the clinical condition ofpatients defined as relapsed by thismethod shows signs of severedecompensation, the range ofintensity can vary widely dependingon the preexisting baseline level ofsymptomatology. Patients in fullremission at the beginning of theevaluation period may relapse at alower point of severity. When usedto designate a specific clinical staterather than a relative exacerbation,the definition adheres more closely tothe classical concept of relapse.Patients defined as relapsed by thismethod would be in a narrowerrange of severity symptoms.

It is important that both outcomeand clinical state definitions be keyed

to the psychotic symptoms that arecharacteristic of schizophrenicdisorder. Many of the definitionsused in the past have confoundedrelapse with social factors such asbehavioral disturbance and hospi-talization. Behavioral disturbancesare differentially tolerated by familiesof different ethnic backgrounds, anda wide variety of social factors thatare not related to symptoms affectthe likelihood that a given patientwill be hospitalized (Wing 1968).Therefore, for relapse to serve as anindicator of the schizophrenic diseaseprocess, the definition must be basedon the core psychotic symptoms thatspecifically characterize schizophreniaunconfounded by social variables ormore peripherally experiencednonpsychotic symptoms.

Moreover, the mere presence ofpsychotic symptoms does not alwaysrepresent a condition that warrantsthe designation of relapse. Even whenthe symptoms are diagnosticallysignificant (e.g., mood-incongruentthird person auditory hallucinations),they may not be at a level of severityassociated with the term "relapse" inusual clinical practice. For example, aschizophrenic patient who hears avoice a couple of times a week oroccasionally believes songs on theradio give him messages would notusually create much concern amongtreatment personnel. It is only whenthe patient's symptoms reach acertain level of frequency andintensity (e.g., auditory hallucina-tions throughout the day) and thepatient's functioning is impaired(e.g., the messages from the radiotell the patient not to eat or go to hisjob) that the appellation "relapsed"would usually be applied bytreatment personnel. Therefore, thedefinitions presented below incor-porate both specific symptom,frequency, and intensity criteria, aswell as the degree to which


symptoms interfere with socialfunctioning.

The level of seventy that is set todefine relapse will affect the findingsof a study. For example, Kane et al.(1983) reported a relapse rate of 56percent for schizophrenic patientstreated with low-dose medication,whereas Hogarty (1984) found that asimilar low dose of medicationyielded only a 23 percent incidence ofrelapse. A parsimonious explanationis that these two sets of investigatorsused different criterion intensities ofsymptomatology to define relapses.

Outcome definitions require acareful initial assessment of thepatient's level of symptomatology toset the baseline from which relapse isdetermined. The first study to use adefinition of relapse that took intoaccount the level of preexistingsymptoms was conducted by Brown,Birley, and Wing (1972). They foundthat 29 percent of their sample ofschizophrenic patients weredischarged from the hospital withpersisting symptoms as elicited by astructured Present State Examination(PSE) interview (Wing, Cooper, andSartorius 1974). Brown, Birley, andWing (1972) distinguished two typesof relapse: Type I involved a changefrom a normal or nonschizophrenicstate to a state of schizophrenia asdefined by the PSE Catego diagnosticsystem (Wing, Cooper, and Sartorius1974). Type II relapse involved amarked exacerbation of psychoticsymptoms from the patient's baselinelevel assessed at discharge from thehospital.

The definitions of relapse used instudies at our UCLA ClinicalResearch Center have been morequantitatively operationalized thanprevious definitions because we felt itwas essential to achieve high degreesof interrater reliability. Moreover,even when a particular patient'sclinical state is being monitored for

treatment planning, quantitativeratings are helpful because theyenable more sensitive distinctions tobe made and permit the practitionerto graph the changes in psychopath-ology over time. Our colleagues inmedicine have monitored illnessfactors in quantitative fashion forgenerations (e.g., fever charts, bloodcounts, and other laboratory values);thus, as psychiatric practice developsa biomedical data base, quantitativemonitoring of symptoms shouldbecome routine.

The first definition (Nuechterlein etal. 1985) was developed for a studyin which schizophrenic patients weregiven BPRS assessments during theirregular clinic visits every 2 weeks. Atthe end of a 1-year period, theresearchers wanted to assignoutcomes to the patients based on thecourse of symptoms over a 1-yearperiod. Figure 1 schematically illus-trates the criteria and decision-making process used in this outcomedefinition of relapse. Actually, nineoutcome possibilities were opera-tionally defined and then groupedinto relapse/no relapse/unchangedcategories.

The second set of criteria forrelapse as an outcome measure wasdeveloped by Drs. Robert P.Liberman, Ian Falloon, and SimonJones for a study in which it was notpossible to assess the patients duringregularly scheduled visits to a clinic.The patients were recruited while stillhospitalized, for a study of familyfactors in relapse (Vaughn et al.1984). The research called for ascer-taining which of them relapsedduring the 9 months followingdischarge. Certain family variables,particularly high "expressed emotion "(Brown, Birley, and Wing 1972;Vaughn and Leff 1976), werepredicted to be associated withhigher likelihood of relapse.

Patients were administered the PSE

and the Psychiatric Assessment Scale(PAS) (Krawiecka, Goldberg, andVaughan 1977) at admission to anddischarge from the psychiatrichospital. The PAS is a standardizedrating scale that was designedspecifically to reflect severity ofsymptoms among chronic psychiatricpatients. It consists of eight itemsrated on a 0-4 scale of increasingseverity.

In the Vaughn et al. (1984) study,the researchers contacted the patientor the patient's family by telephoneeach month and inquired whetherthere were any signs of symptomaticexacerbation, deterioration infunctioning, or change in medicationdosage. The information from thetelephone calls was transcribed andretained. A psychiatrist andpsychologist trained in the PSE andPAS monitored these reports andmade immediate arrangements toconduct a PSE and PAS with anypatient for whom the telephone callrevealed indications of a possiblerelapse. All patients who did nothave an evaluation triggered by thismethod were reassessed at the 9-month postdischarge point.

The relapse criteria developed forthis study made use of three datasources: PAS, PSE, and anecdotalreports of the patient's clinical andsocial status. The results from thePAS were reviewed first. Criteria forrelapse from a previous study(Wallace 1982) were applied (table1). A psychoticism score was createdfrom the PSE-elicited symptoms bysumming the items that refer to thecharacteristic symptoms of schizo-phrenia (table 2). A determination ofrelapse was made based on thecomparison of the dischargepsychoticism score versus thefollowup score. If both the PAS andPSE produced the same outcome, thepatient was rated accordingly.However, if they produced differing

VOL 12, NO. 4, 1986 583

outcomes or if high levels ofsymptoms present at dischargepersisted to the followup evaluation,the anecdotal information (with allidentifying features removed) wasreviewed. In some cases thisadditional information allowed thepatient to be assigned to the relapsedor nonrelapsed outcome category.Even with these three sources of

symptom data, 22 percent of thepatients had such high persisting andunremitting symptoms for the full 9-month followup period that theycould not be assigned into therelapsed or nonrelapsed category.Agreement between two psychiatristsacross 76 cases was 92 percent.

For an ongoing longitudinalfollow-through study of schizo-

Figure 1. Flow chart for determining relapse outcome after 1 yearbased on Brief Psychiatric Rating Scale (BPRS)

Acrt0ve romlMton orm o d « » •ymptomMcttato (4 tor 3 months)

phrenic patients, "DevelopmentalProcesses in Schizophrenic Disorders"(Principal Investigator: Keith H.Nuechterlein, Ph.D.), an operationaldefinition for relapse as a clinicalstate has been derived from the BPRSby Drs. Lukoff and Nuechterlein.This study aims to determinepredictors of schizophrenic relapseand remission as well as vulner-ability-linked versus symptom-linkedmarkers of disorder. The inves-tigators developed a definition thatenables patients whose psychoticsymptoms have exacerbated to a highlevel of intensity to be identifiedimmediately. Patients are assessedbiweekly, and extensive cognitiveand psychophysiological tests areadministered to patients who arefound to be in a state of relapse.

Operational criteria for twocategories of relapse were developed:(1) psychotic relapse, which is basedon the core BPRS psychotic symptomscales of hallucinations, unusual

Table 1. Relapse criteria basedon the Psychiatric AssessmentScale

Type I. If a change from dischargerating occurs on only 1 of the 3scales, a 2-point increase is desig-nated as a relapse, providing that amaximum severity score of 4 onthat scale occurs. Thus, score in-creases from 0 to 2 or from 1 to 3would not be considered a re-lapse, but an increase from 2 to 4would be a relapse.

Type II. A total increase of 3points on 1 or more of the 3 scalesis designated a relapse, with thecaveat that single point changesfrom 0 to 1 are not counted (0 =symptoms absent; 1 = symptomsnot clearly pathological).

Tab

le 2

. R

elap

se r

atin

g f

orm

fro

m V

aug

hn

et

al. (

1984

)

Cas

e N

o.

Psy

chia

tric

Ass

essm

ent

Sca

le S

core

sD

elus

ions

Hal

luci

natio

nsIn

cohe

renc

eD

ecis

ion

(circ

le o

ne)

Pre

sen

t S

tate

Exa

min

atio

n (P

SE

) ite

m s

core

sT

houg

ht d

isor

der

sym

ptom

s (S

core

"1"

if

rate

d "1

" or

"2

" on

PSE

)T

houg

ht i

nser

tion

Tho

ught

bro

adca

stin

gT

houg

ht e

cho/

com

men

tary

Tho

ught

blo

ck/w

ithdr

awal

Del

usio

n of

tho

ught

s re

ad:

(Sco

re "

1"

if ra

ted

"2"

on P

SE

)H

allu

cina

tions

(S

core

"1"

if

rate

d "1

" or

"2

" on

PSE

)N

onve

rbal

aud

itory

Voi

ce c

omm

enta

ry/3

rd p

erso

nsV

oice

s to

sub

ject

Vis

ual

Olfa

ctor

yO

ther

Del

usio

n of

odo

rs(S

core

"1"

if

rate

d "2

" on

PSE

)D

elus

ions

(Sco

re "

1" o

nly

if fu

ll de

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ons

are

rate

d "2

" on

PSE

)C

ontr

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Mis

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alou

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ancy

Sex

ual

Fan

tast

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App

eara

nce

Init

ial

55 56 57 58 59 60 62 63 66 68 70 69 71 72 73 74 75 76 77 78 79 80 81 82 84 85 86 87 88 89

Dis

char

ge

Fo

llow

up

Rel

apse

N

o re

laps

e

o I I 33 m CD c

Dep

erso

naliz

atio

n 90

Hyp

ocho

ndria

cal

91C

atas

trop

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92S

corin

g

PSE

ratin

g

95P

reoc

cupa

tion

0 =

0-

21

= 3

2 4

3 5

Insi

ght

1=

2 10

42

3In

terv

iew

beh

avio

r S

corin

g

PSE

rat

ing

1 =

22

= 2

Initi

al

Dis

char

ge

Foiio

wup

Dis

trac

tibili

ty

114

Man

neris

ms

& p

ostu

ring

116

Beh

aves

as

if ha

lluci

nate

d 11

8C

atat

onic

mov

emen

ts

119

Sus

pici

on

125

Per

plex

ity

126

Inco

ngru

ity o

f affe

ct

129

Mut

enes

s 13

3N

eolo

gism

s 13

5In

cohe

renc

e 13

6T

otal

PS

E p

sych

otic

ism

sco

reD

ecis

ion

(circ

le o

ne)

Rel

apse

N

o re

laps

eG

loba

l R

atin

gs o

f se

verit

y of

sym

ptom

s an

d ac

ting

out

sym

p-to

ms

base

d on

tele

phon

e an

d ot

her

foiio

wup

sou

rces

Dec

isio

n (c

ircle

one

) R

elap

se

No

rela

pse

Ove

rall

judg

men

t us

ing

all

data

sou

rces

R

elap

se

No

rela

pse

Com

men

ts

o r o


thought content, and conceptualdisorganization; and (2) other typesof relapse, which signal gross impair-ments in the patient's functioning or

thinking, but which are not clearlyrelated to schizophrenic psychoticprocesses, i.e., depression, suici-dality, self-neglect, bizarre behavior,

hostility. (See table 3.) A rating of 6(severe) or 7 (extremely severe) onany of the key symptom itemssignifies a relapse The intraclass

Table 3. Brief Psychiatric Rating Scale and behavioral anchors used to define types of relapse in the"Developmental Processes in Schizophrenic Disorders Project"

Scale itemUnusual

thoughtcontent

Hallucinations

Conceptualdisorgani-zation

Rating6 Severe

7 Extremelysevere

6 Severe

7 Extremelysevere

6 Severe

7 Extremelysevere

Psychotic relapse

Definition

Full delusion(s) present with much preoccupation or manyareas of functioning are disrupted by delusional thinkingFull delusion(s) present with almost total preoccupation ormost areas of functioning are disrupted by delusional thinking

Several times a day or many areas of functioning are disruptedby hallucinationsPersistent throughout the day or most areas of functioning aredisrupted by hallucinations

Speech is incomprehensible due to severe impairments mostof the timeSpeech is incomprehensible throughout interview

Reliabilitycoefficient1

.93

.97

.73

Other types of relapsesDepression 6 Severe Deeply depressed most of the time or many areas of function- .90

ing are disrupted by depression7 Extremely Deeply depressed constantly or most areas of functioning are

severe disrupted by depressive thinking

Suicidallty 6 Severe Wants to kill self Searches for appropriate means and time orsuicide attempt that is a potentially serious threat to life withpatient knowledge of possible rescue

7 Extremely Specific suicidal plan and intent (e.g., "as soon as , Isevere will kill myself by doing X") or suicide attempt characterized by

plan that the patient thought was lethal or an attempt in se-cluded environment

.97

Self-neglect

Bizarrebehavior

6 Severe

7 Extremelysevere

6 Severe

7 Extremelysevere

Hygiene and eating potentially life-threatening (e.g., eatsand/or bathes only when prompted)Hygiene and eating life-threatening (eg , does not eat or en-gage in hygiene)

Unusual petty crimes (e.g , directing traffic, public nudity, con-tacting authorities about imaginary crimes)Unusual serious crimes (e g., setting fires, asocial theft, kid-napping committed in bizarre fashion or for bizarre reasons)

.78

.84

Hostility 6 Severe Has assaulted others but with no harm likely (e.g., slapped or .89pushed others or destroyed property, knocked over furniture,broken windows)

7 Extremely Has attacked others with definite possibility of harming themsevere or with actual harm (e.g., assault with hammer or weapon)

'Median ICC among the 7 Developmental Processes BPRS raters

VOL 12, NO. 4, 1988 587

correlation coefficient among sevenraters across 17 cases was .81.

Detecting Prodromal Symptoms.Several recent studies have pointed tothe existence of identifiable interme-diate states between remission andrelapse in schizophrenic illness. WhenHere and Melville (1980) retro-spectively interviewed schizophrenicpatients and their relatives about theperiod preceding a relapse, mostwere able to report a distinctprodromal period. The symptomsmentioned most frequently bypatients and their relatives werenonpsychotic:

symptoms of dysphoria thatnonpsychotic individualsexperience under stress, such aseating less, having trouble concen-trating, having trouble sleeping,depression, and seeing friends less.(Herz and Melville 1980, p. 803]

In a prospective study of schizo-phrenic outpatients, Marder et al.(1984) also found evidence for aprodromal period by noting changesin ratings on quantitative scales justbefore relapse. The interpersonalsensitivity, depression, anxiety,paranoid ideation, and psychoticismscales of the Symptom Checklist-90(Derogatis, Lipman, and Covi 1973)and the thought disorder, depression,and paranoia factors on the BPRSwere significantly elevated fromprevious administrations during the1- to 3-month period before asignificant exacerbation or return ofpatients' characteristic psychoticsymptoms.

From the viewpoint of specificityin the prediction of relapse, it isunfortunate that both of theseresearch teams reported thatprodromal symptoms did not alwayssignal an impending relapse. Theteam led by Marder developed apredictive model but found that there

was a distinct trade-off betweensensitivity and specificity. When thepredictive equation was adjusted forhigh sensitivity, it identified 92percent of the patients who subse-quently relapsed, but was mediocrein specificity, predicting relapsesincorrectly for 51 percent of thepatients who did not relapse.Conversely, when specificity was setlow to avoid false positives inpredicting relapses, false positivescould be reduced to 2 percent.However, only 42 percent of actualrelapses were identified.

Of course, one would not expectevery instance of raised psychopath-ology to herald a relapse sinceprotective factors in the individualand his social network wouldoccasionally buffer and interdict thestress-linked relapse process.Clinicians who use such criteria toassess impending relapse need tojudge the costs versus the benefits offalse positives versus false negativesin deciding the level of prodromalsymptoms to consider noteworthy.High sensitivity and only modestspecificity in predicting actualprodromata would serve animportant function in continuing careand rehabilitation programs,permitting clinicians to intervenepreventively by increasing the doseof medication or psychosocialtherapies. Providing additionaltreatment even on occasions thatwould not have led to relapse, fromthis vantage point, would hardlyconstitute wasted resources.

Clearly, it would be desirable to beable to identify impending relapsesduring their formative prodromalstage. Preventive medication andpsychosocial treatment strategiescould be used in tandem with identi-fication of prodromata. The devel-opment of intermittant medicationstrategies (Herz, Szymanski, andSimon 1982; Carpenter and Heinrichs

1983), a promising innovation inpsychopharmacological treatment,requires the ability to recognize theearly signs of relapse that signal thereintroduction of medication. Bybecoming familiar with theprodromal signs of relapse, rehabili-tation staff who interact withpatients on a regular basis may oftenbe in a position to recognize andforestall patient relapses.

With increased awareness andunderstanding of the prodromal stageof relapse, schizophrenic patients,who are usually relegated to apassive role regarding their illness,can become more actively involvedwith their treatment. Mendel (1976)developed a program where schizo-phrenic patients in the communitywere trained to recognize their own"warning signs." Each patient carrieda list of his or her own idiosyncraticsymptoms, ranging from "thinking alot about past hospitalizations" to"trouble sleeping," along with aphone number to call if thesewarning signs developed.

In the Herz and Melville (1980)study, the symptom configurationreported by the patients and relativesseemed to show a high degree ofintraindividual specificity andstability across incidents of relapse.Yet there was much variability in thetypes of symptoms present during theprodromal period and also in thetime period over which thesymptoms developed. Only a smallpercentage of patients (8 percent)reported that the period betweenonset of prodromata and frankrelapse was less than 1 day.However, 50 percent of patientsreported that they noticed symptomsfor less than 1 week before floridreturn of psychosis. Thus, it wouldseem that a rating of targetsymptoms would be most appro-priate for monitoring prodromalsymptoms since the symptoms being


monitored would be mostly nonpsy-chotic and idiosyncratic. A detailedphenomenological interview coveringprevious relapse periods would benecessary to determine the specificsymptoms to be monitored. Checkingwith the patient's relatives andtreating professionals would alsocontribute to a clearer picture of thepatient's prodromal periods. Whileprodromal symptoms should bemonitored on at least a weekly basis,the rating of target symptoms, bypatient and responsible clinician,would not be time-consuming.

Training schizophrenic patients inthe use of stress-reduction techniquescould also play a role in preventingthe onset of prodromal symptomsand the exacerbation of prodromalsymptoms into relapses. Therelationship between stressors such aslife events (Brown and Birley 1968)and familial tension (Vaughn et al.1984) has been established in severalstudies (for review, see Lukoff et al.1984). Herz and Melville (1980)found that the most commonprodromal symptom that appearedbefore hospitalization of schizo-phrenic patients was feeling tense andnervous—reported by 80 percent ofthe patients. Many of the otherprodromal symptoms uncovered intheir study are also thought to berelated to stress, e.g., troublesleeping and restlessness.

Lukoff et al (1986) at the UCLAClinical Research Center for theStudy of Schizophrenia developed a10-week inpatient program thatincorporated aerobic exercise,meditation, and educational sessionson stress. While the schizophrenicpatients were in the hospital, theyparticipated actively in the programand showed substantial decreases inpsychopathology. Upon discharge,however, they discontinuedpracticing the stress-reductiontechniques. Given the relationship

between stress and schizophrenicrelapse, the regular use of stress-reduction techniques might actprophylactically. A program incor-porating techniques such as exercise,relaxation, and stress-monitoringwould need to use behavioralprinciples and procedures (e.g.,reinforcement and modeling) in thetraining phase and for maintenanceof the stress-reduction activities.

Clinical Vignettes ThatIllustrate Symptom Monitoring

The following examples (withfictitious names) are compilationsdrawn from the UCLA AftercareClinic, where patients are monitoredevery 2 weeks with the BPRS. Foreach patient, a psychotic indexconsisting of the sum of the ratingson the hallucinations, unusualthought content, and conceptualdisorganization scales from the BPRSis graphed. These data provide thecase managers with a longitudinalperspective that shows previouslevels of psychopathology againstwhich the current levels can becompared. By regular monitoring ofpsychopathology and computation ofthe psychotic index, the casemanagers can evaluate the signif-icance of fluctuations in clinicalstatus and readily mount effectivetreatment interventions.

Case 1. Bill, a patient at theAftercare Clinic, requested that thesocial worker help him move froma small board-and-care facilitywhere he had been living for thepast 2 years to a board-and-carefacility closer to his parents. Thesocial worker arranged a transferto a much larger facility in theneighborhood where his parentslived. One month after the move,the social worker had a sessionwith the patient and asked himhow he was doing. Bill replied thathe enjoyed being able to spend

some evenings and weekends withhis parents. If she had stopped theinterview at that point, everythingwould have seemed fine. However,when the social worker proceededto ask questions from the BPRS,she uncovered the patient's beliefthat others at the board-and-carefacility were staring at him andtalking about him, an increasefrom very mild (2) to mild (3) onthe unusual thought content item.She also noted the presence of mildconceptual disorganization for thefirst time. These prodromalsymptoms were of concern to thesocial worker because they repre-sented a definite exacerbation fromthe level of symptomatologypresent before the patient's move(see figure 2) even though thesesymptoms were not at fullpsychotic levels. Additionalquestioning revealed that Bill feltoverwhelmed at the new largerplacement and had not made evenany casual friendships. However,he did not want to move furtheraway from his parents. The socialworker immediately scheduled anappointment that afternoon withhis psychiatrist to determine if anincrease in medication waswarranted. With the patient'sconsent, she notified the board-and-care manager and suggestedthat he pay special attention to thepatient. Then she contacted otherboard-and-care facilities in the areato locate one which housed asmaller number of residents.Medication dose was notincreased, but Bill's visits to hissocial worker therapist weretemporarily increased. Three weekslater, a more suitable placementwas found and Bill's symptomssoon thereafter returned to theirprevious level. Through the socialworker's careful monitoring of thepatient's symptomatology and herefforts to alter the stressfulsituation, a potential relapse wasaverted.

Case 2. John told his psychologistthat he both wanted to and wasvery worried about starting to takecollege courses again. One yearbefore, he had a psychotic relapsewhich resulted in hospitalization 2weeks after starting a new

VOL. 12, NO. 4, 1986 589

semester. John had completed sixsemesters of college and stated thathe wanted to finish college but saidthat his parents were worried thattaking college courses would makehim iD again. Dr. Smith arrangedfor a family session. After allowingtime for John's parents to discusstheir concerns, she encouraged the

family to develop a "game plan"that would allow John to tacklecollege again. John's family madethe suggestion that John shoulddrop down from his usual load ofthree or four courses to twocourses. John's mother also agreedto support John by making himbreakfast and bag lunches on his

Figure 2. Graph of psychotic index for "Bill"

BPRS

Unutij*ttmushl

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Ottw symptom

P»yctx*c nd«<

D r u p l dOM

Dm* 2/1

7

8

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4

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6

5

4

3

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7

6

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I S

15

14

13

12

11

10

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M

3/1

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M

M

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-

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I

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7/2

H I

H I

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H I

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1

BPRS = Brief Psychiatric Rating Scale.

school days. John's father, whoinitially argued that John shoulddefer one more semester, agreed totake a "wait-and-see" attitude. Dr.Smith said that she would arrangea time when John would call hertwice-a-week during the first 2weeks. In addition. Dr. Smith saidthat she would be monitoringJohn's clinical condition veryclosely using a standardized ratingscale that would reveal any trendstoward relapse. As figure 3 shows,the first week of classes didproduce a mild exacerbation. Dr.Smith consulted the aftercare clinicpsychiatrist who managed John'smedications and arranged for atemporary increase in dosage. Bythe fourth week, John had accli-mated to the demands of schooland reported that he was doingfine in his courses and enjoyingbeing active again. His dose ofantipsychotic drug was subse-quently reduced when thepsychotic index returned to itsbaseline level.

Case 3. When Joan was first seenin the hospital, she was admin-istered the BPRS by one of theaftercare clinic psychologists. Theunusual thought content item wasrated a 7, the highest possiblerating, due to Joan's almost totalpreoccupation with messages fromTV, radio, and computers. Shealso reported hallucinations severaltimes a day, thereby warranting a6 on that item. She was takingoral Prolixin, 20 mg daily. Byhospital discharge, her halluci-nations had remitted totally. Whenshe came to the aftercare clinic forthe first time 2 days after herdischarge from the hospital, Joantold her case manager that she stillwas getting messages but onlyfrom the radio. She did not thinkabout them and they did notinterfere with her functioning,which warrants a rating of 4 onthe BPRS Unusual ThoughtContent item. After she had beenseen for 4 weeks as an outpatient,the case manager was concernedabout the persistence of Joan'sdelusions of reference aboutmessages from the radio eventhough they were at a low level ofintensity. The finding of persisting


delusional thinking was discussedwith one of the aftercare clinicpsychiatrists and a decision wasreached to increase Joan's dailyProlixin dosage to 30 me. Sixweeks later, another BPRSrevealed no change in her ratings.With the patient's agreement, shewas switched to biweekly 20 mgi.m. Prolixin to rule out

compliance as a factor in herpersisting symptomatology. WhenJoan came in for her injection, sheannounced she would not take hershot. She stated that the injectionswere embarrassing to her and thatshe wanted pills. After reviewingthe BPRS ratings and finding noadditional therapeutic impact fromthe increased dosage or from i.m.

Figure 3. Graph of psychotic index for "John"

Pircftollc M a i

BPRS = Brief Psychiatric Rating Scale

administration, the case managerand psychiatrist agreed to placeher back on oral Prolixin at theoriginal postdischarge dosage. (Seefigure 4.)

Conclusion

In treatment studies, psycho-pathology has often been the soleoutcome variable used to evaluateeffectiveness. In particular, relapsehas been overused as the solecriterion for evaluating treatmentprogram. Psychopathology offersonly a limited view of the overallfunctioning of schizophrenic patients.In a study of outcome, Strauss andCarpenter (1974) followed 85 schizo-phrenic patients for 2 years after ahospitalization. They found that

outcome is not a singularphenomenon but that thereare several areas of outcomefunction—interrelated but alsopartly independent of each other,[p. 37]

They included social relations andemployment status in their multidi-mensional approach to evaluatingoutcome. A full spectrum offunctional behaviors needs to beassessed by rehabilitation workersthroughout the patient's participationin a program (see Wallace, thisissue). Rehabilitation staff membersmay view their responsibilities andefforts as more directed towardimproving social functioning thansymptom reduction. However, theyare interrelated. Exacerbations ofschizophrenic symptomatology havebeen clearly related to a host ofsocial variables (Lukoff et al. 1984).Rehabilitation is one source of socialstimulation that may improve clinicalstatus or, at times, exacerbatesymptoms.

Psychopathology assessmentinstruments can be used to improvethe rehabilitation of schizophrenic

VOL. 12, NO. 4, 1986 591

patients. When psychopathology ismonitored through structured inter-views developed originally forresearch, highly symptomaticpatients can be diverted fromintensive rehabilitation programs,

negative reactions to rehabilitationefforts can be identified, andprodromal signs of impending relapsedetected. Similarly, individual andprogram-wide benefits from rehabil-itation can also be accurately and

Figure 4. Graph of psychotic Index for "Joan"

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BPRS = Brief Psychiatric Rating Scale.

convincingly documented.

References

American Psychiatric Association.DSM-lll: Diagnostic and StatisticalManual of Mental Disorders. 3rd ed.Washington, DC: The Association,1980.Anderson, C; Reiss, D.; andHogarty, G. Schizophrenia and theFamily. New York: Guilford Press,1986.Andreasen, N. Negative symptoms inschizophrenia: Definition and relia-bility. Archives of GeneralPsychiatry, 39:784-788, 1982.

Andreasen, N., and Olsen, S.Negative u. positive schizo-phrenia: Definition and validation.Archives of General Psychiatry,39:789-794, 1982.Battle, C ; Imber, S.; Hoehn-Saric,R.; Stone, A.; Nash, E.; and Frank,J. Target complaints as criteria ofimprovement. American Journal ofPsychotherapy, 20:184-192, 1966.Bennett, D. Social forms of psychi-atric treatment. In: Wing, J.K., ed.Schizophrenia: Towards a NewSynthesis. New York: Grune &Stratton, Inc., 1978. pp. 211-232.

Bigelow, L., and Murphy, D.L."Guidelines and Anchor Points forModified BPRS." Unpublishedmanuscript, NIMH IntramuralResearch Program, Saint ElizabethsHospital, 1978.Bleuler, E. Dementia Praecox or theGroup of Schizophrenias. (1911)Translated by J. Zinkin. New York:International University Press, 1950.

Bleuler, M. The long-term course ofthe schizophrenic psychoses. Psycho-logical Medicine, 4:244-254, 1974.Brown, G., and Birley, J. Crises andlife changes and the onset of schizo-phrenia. Journal of Health and SocialBehavior, 9:203-214, 1968.


Brown, G.; Birley, J.; and Wing, ].Influence of family life on the courseof schizophrenic disorders: A repli-cation. British Journal of Psychiatry,121:241-258, 1972.Carpenter, W.T, Jr., and Heinrichs,D. Early intervention, time-limited,targeted pharmacotherapy of schizo-phrenia. Schizophrenia Bulletin,9:533-542, 1983.

Ciompi, L. Catamnestic long-termstudy on the course of life and agingof schizophrenics. SchizophreniaBulletin, 6:606-618, 1980.Crow, T. The two-syndromeconcept: Origins and current status.Schizophrenia Bulletin, 11:471-485,1985.

Derogatis, L.; Lipman, R.; and Covi,L. SCL-90: An outpatient psychiatricrating scale—Preliminary report.Psychopharmacology Bulletin,9:13-17, 1973.

Docherty, J.; van Kammen, D.; Siris,S.; and Marder, S. Stages of onset ofschizophrenic psychosis. Americanjournal of Psychiatry, 136:420-426,1978.

Falloon, I. Relapse: A reappraisal ofassessment of outcome in schizo-phrenia. Schizophrenia Bulletin,10:293-299, 1984.

Falloon, I.; Boyd, ].; and McGill, C.Family Care of Schizophrenia: AProblem-Solving Approach to theTreatment of Mental Illness. NewYork: Guilford Press, 1984.

Goldberg, S.; Schooler, N.; Hogarty,G.; and Roper, M. Prediction ofrelapse in schizophrenic outpatientstreated by drug and sociotherapy.Archives of General Psychiatry,34:171-184, 1977.

Guy, W. ECDEU Assessment Manualfor Psychopharmacology. DHEWPub. No. (ADM) 76-338. Rockville,MD: National Institute of MentalHealth, 1976.

Herz, M., and Melville, C. Relapsein schizophrenia. American Journalof Psychiatry, 137:801-805, 1980.

Herz, M.; Szymanski, H.; andSimon, J. Intermittent medication forstable schizophrenic outpatients.American Journal of Psychiatry,139:918-922, 1982.

Hogarty, G. Depot neuroleptics: Therelevance of psychosocial factors.Journal of Clinical Psychiatry,45:36-42, 1984.

Kane, J.; Rifkin, A.; Woerner, M.;Reardon, G.; Sarantakos, S.;Schiebel, D.; and Ramos-Lorenzi, J.Low-dose neuroleptic treatment ofoutpatient schizophrenics: I. Prelim-inary results for relapse rates.Archives of General Psychiatry,40:893-896, 1983.

Krawiecka, M.; Goldberg, D.; andVaughan, M. A standardized psychi-atric assessment scale for ratingchronic psychotic patients. AdaPsychiatnca Scandinavica,55:299-308, 1977.

Leff, J., and Wing, J. Trial of mainte-nance therapy in schizophrenia.British Medical Journal, 3:599-604,1971.

Liberman, R., and Foy, D. Psychi-atric rehabilitation of chronic mentalpatients. Psychiatric Annals,13:539-545, 1983.

Lukoff, D.; Snyder, K.; Ventura, J.;and Nuechterlein, K. Life events,familial stress, and coping in thedevelopmental course of schizo-phrenia. Schizophrenia Bulletin,10:258-292, 1984.

Lukoff, D.; Wallace, C; Liberman,R.; and Burke, K. A holistic programfor chronic schizophrenic patients.Schizophrenia Bulletin, 12:274-282,1986.

Marder, S.; Van Putten, T.; Mintz,J.; Labell, M.; McKenzie, J.; andFaltico, G. Maintenance therapy in

schizophrenia: New findings.In: Kane, J., ed. Drug MaintenanceStrategies in Schizophrenia.Washington, DC: AmericanPsychiatric Press, 1984. pp. 31-49.

May, P.R.A. Strategies for appliedresearchers in chronic schizo-phrenia: Choosing the righttreatment and measuring outcome.In: Baxter, C , and Melnechuck, T.,eds. Perspectives in SchizophreniaResearch. New York: Raven Press,1980. pp. 317-328.

Mendel, W. Schizophrenia: TheExperience and Its Treatment. SanFrancisco: Jossey-Bass, 1976.

Mintz, J.; Luborsky, L.; andChristoph, P. Measuring theoutcomes of psychotherapy: Findingsof the Penn psychotherapy project.Journal of Consulting and ClinicalPsychology, 47:319-334, 1979.

Nuechterlein, K.; MikJowitz, D.;Ventura, J.; Stoddard, M.; andLukoff, D. "Manual for AssessingOutcome in Schizophrenic andBipolar-Manic Patients." Unpublishedmanuscript, 1985.

Overall, J., and Gorham, D. TheBrief Psychiatric Rating Scale.Psychological Reports, 10:799-812,1962.Strauss, J.S., and Carpenter, W.T.,Jr. The prediction of outcome inschizophrenia: II. Relationshipsbetween predictor and outcomevariables. Archives of GeneralPsychiatry, 31:37-42, 1974.

Vaughn, C, and Leff, J. Theinfluence of family and social factorson the course of psychiatricillness: A comparison of schizo-phrenic and depressed neuroticpatients. British Journal ofPsychiatry, 129:125-137, 1976.

Vaughn, C : Snyder, K.; Jones, S.;Freeman, W.; and Falloon, I. Familyfactors in schizophrenic relapse: A

VOL 12, NO. 4, 1986 593

California replication of the Britishresearch on expressed emotion.Archives of General Psychiatry,41:1169-1177, 1984.Wallace, C. The social skills trainingproject of the Mental Health ClinicalResearch Center for the Study ofSchizophrenia. In: Curran, ]., andMonti, P., eds. Social SkilbTraining: A Practical Handbook forAssessment and Treatment. NewYork: Guilford Press, 1982. pp.57-89.Wing, J. Social treatments of mentalillness. In: Shepherd, M., andDavies, D., eds. Studies of

Psychiatry. London: OxfordUniversity Press, 1968.Wing, J. Social influences on thecourse of schizophrenia. In: Wynne,L; Cromwell, R.; and Matthysse, S.,eds. The Nature of Schizophrenia:New Approaches to Research andTreatment. New York: John Wiley &Sons, 1978. pp. 599-616.

Wing, J.; Cooper, J.; and Sartorius,N. The Description and Classificationof Psychiatric Symptoms: AnInstruction Manual for PSE andCatego System. London: CambridgeUniversity Press, 1974.

The Authors

David Lukoff, Ph.D., is Psycholo-gist, San Francisco VA Medical DayTreatment Program, San Francisco,CA. Robert Paul Liberman, M.D., isDirector, Clinical Research Centerfor Schizophrenia and PsychiatricRehabilitation, UCLA Department ofPsychiatry, Brentwood VA MedicalCenter, and Camarillo StateHospital, Los Angeles, CA. Keith H.Nuechterlein, Ph.D., is AssociateProfessor in the Department ofPsychiatry and BiobehavioralSciences, University of California,Los Angeles, CA.

594 Appendix A. Manual for ExpandedBrief Psychiatric Rating Scale (BPRS)

Developed by David Lukoff,Keith H. Nuechterlein, andJoseph Ventura

The following guidelines are designedfor use with an outpatient psychiatricpopulation. This manual contains aninterview schedule, symptom defini-tions, and specific anchor points forrating symptoms. The ratings foritems 1-10 and 19-22 are based onthe patient's answers to the inter-viewer's questions. The time framefor these items is the past 2 weeks.Items 11-18, 23, and 24 are based onthe patient's behavior during theinterview and the time frame coveredis the interview period only. Whenpsychotic symptoms (e.g., hallucina-tions and unusual thought content)have had a period of exacerbationlasting at least 1 day, the ratingshould reflect mainly the peak

period. When the anchor pointdefinitions contain an "or," thepatient is assigned the highest ratingthat applies, e.g., if a patient hashallucinations persistently throughoutthe day (a rating of 7) but the hallu-cinations only interfere withfunctioning to a limited extent (arating of 5), a rating of 7 is given.An additional guideline which isoften helpful involves the distinctionbetween pathological and nonpatho-logical intensities of symptoms.Ratings of 2-3 indicate a nonpatho-logical intensity of a symptomwhereas ratings of 4-7 indicate apathological intensity of thatsymptom.

Rate items 1-10 on the basis of patient's self-report

1. Somatic concern: Degree of concern over present bodily health. Rate the degree to which physical health isperceived as a problem by the patient, whether complaints have realistic bases or not

2-3

4-5

6-7

MildModerate

Severe

Occasional complaint or expression of concernFrequent expressions of concern or exaggerations of existing ills. Some preoccu-pation. Not delusional

Preoccupied with physical complaints or somatic delusions

Have you been concerned about your physical health?Have you had any physical illness or seen a medical doctor?

Anxiety: Reported apprehension, tension, fear, panic or worry. Rate only patient's statements—not observedanxiety which is rated under tension.

Reports feeling worried more than usual or some discomfort due to worryWorried frequently but can turn attention to other thingsWorried most of the time and cannot turn attention to other things easily butno impairment in functioning or occasional anxiety with automatic accompa-niment but no impairment in functioning

Frequent periods of anxiety with autonomic accompaniment or some areas offunctioning are disrupted by anxiety or constant worryAnxiety with autonomic accompaniment most of the time or many areas offunctioning are disrupted by anxiety or constant worryConstantly anxious with autonomic accompaniment or most areas offunctioning are disrupted by anxiety or constant worry

Have you felt worried or anxious7Do unpleasant thoughts constantly go round and round in your mind7

2

3

4

5

6

7

Very mildMildModerate

ModeratelysevereSevere

Extremelysevere

VOL. 12, NO. 4, 1986 595

2

3

4

5

6

7

Very mildMildModerate


Extremelysevere

Did your heart beat fast (or sweating, trembling, choking)?Has it interfered with your ability to perform your usual activities/work?

Depression: Include mood—sadness, unhappiness, anhedonia; and cognitions—preoccupation with depressingtopics (can't switch attention to TV, conversations), hopelessness, loss of self-esteem (dissatisfied or disgusted withself). Do not include vegetative symptoms, e.g., motor retardation, early waking

Reports feeling sad/unhappy/depressed more than usualSame as 2, but can't snap out of it easilyFrequent periods of feeling very sad, unhappy, moderately depressed, but ableto function with extra effortFrequent periods of deep depression or some areas of functioning are disruptedby depressionDeeply depressed most of the time or many areas of functioning are disruptedby depressionConstantly deeply depressed or most areas of functioning are disrupted bydelusional thinking

Have you felt unhappy or depressed?How much of the time7Are you able to switch your attention to more pleasant topics when you want to?Have your interests in work, hobbies, social or recreational activities changed?Has it interfered with your ability to perform your usual activities/work?

4. Guilt: Overconcern or remorse for past behavior. Rate only patient's statements—do not infer guilt feelings fromdepression, anxiety, or neurotic defenses

2-3 Mild Worries about having failed someone or at something. Wishes to have donethings differently

4-5 Moderate Preoccupied about having done wrong or injured others by doing or failing todo something

6-7 Severe Delusional guilt or obviously unreasonable self-reproach

Have you been thinking about past problems?Do you tend to blame yourself for things that have happened?Have you done anything you're still ashamed of?

5. Hostility: Animosity, contempt, belligerence, threats, arguments, tantrums, property destruction, fights, and anyother expression of hostile attitudes or actions. Do not infer hostility from neurotic defenses, anxiety, or somaticcomplaints. Do not include isolated appropriate anger

Irritable, grumpy

Argumentative, sarcastic, or feels angryOvertly angry on several occasions or yelled at othersHas threatened, slammed about or thrown things

Has assaulted others but with no harm likely, e.g., slapped, pushed, ordestroyed property (knocked over furniture, broken windows)Has attacked others with definite possibility of harming them or with actualharm, e.g., assault with hammer or weapon

2

3

4

5

6

7

Very mildMild

ModerateModeratelysevereSevere

Extremelysevere


How have you been getting along with people (family, board-and-care residents, co-workers)?Have you been irritable or grumpy lately?Have you been involved in any arguments or fights?

6. Suspiciousness: Expressed or apparent belief that other persons have acted maliciously or with discriminatoryintent Include persecution by supernatural or other nonhuman agencies (e.g., the devil)

2-3 Mild Seems on guard. Unresponsive to "personal" questions. Describes incidentswhere other persons have harmed or wanted to harm him/her that soundplausible. Patient feels as if others are laughing at or criticizing him/her inpublic

4-5 Moderate Says other persons are talking about him/her maliciously or says others intendto harm him/her. Beyond likelihood of plausibility but not delusional

6-7 Severe Delusional. Speaks of Mafia plots, the FBI, or others poisoning food

Do you ever feel uncomfortable as if people are watching you?Is anyone trying to harm or interfere with you in any way?Are you concerned about anybody's intentions toward you?Have you felt that any people are out to get you?

7. Unusual thought content: Unusual, odd, strange, or bizarre thought content. Rate the degree of unusualness, notthe degree of disorganization of speech. Delusions are patently absurd, clearly false, or bizarre ideas verballyexpressed. Include thought insertion, withdrawal, and broadcasting. Include grandiose, somatic, and persecutorydelusions even if rated elsewhere

2 Very mild Ideas of reference (people stare/laugh at him/her). Ideas of persecution (peoplemistreat him/her). Unusual beliefs in psychic powers, spirits, UFO's. Notstrongly held. Some doubtSame as 2 with full conviction but not delusionalDelusion present but not strongly held—functioning not disrupted; or encapsu-lated delusion with full conviction—functioning not disrupted

Full delusion(s) present with some preoccupational or some areas of functioningdisrupted by delusional thinkingFull delusion(s) present with much preoccupation or many areas of functioningdisrupted by delusional thinkingFull delusion(s) present with almost total preoccupation or most areas offunctioning disrupted by delusional thinking

Have things or events had special meanings for you?Did you see any references to yourself on TV or in the newspapers?Do you have a special relationship with God?How do you explain the things that have been happening (specify)?Have you felt that you were under the control of another person or force?

8. Grandiosity: Exaggerated self-opinion, self-enhancing conviction of special abilities, powers, or identity as someonerich or famous. Rate only patient's statements about self, not demeanor

2 Very mild Feels great and denies obvious problems3 Mild Exaggerated self-opinion beyond abilities and training4 Moderate Inappropriate boastfulness, claims to be "brilliant, " understands how every-

thing works

3

4

5

6

7

MildModerate


Extremelysevere

VOL. 12, NO. 4, 1986 597

5 Moderately Claims to be great musician who will soon make recordings or will soon makesevere patentable inventions—but not delusional

6 Severe Delusional—claims to have special powers like ESP, to have millions of dollars,made movies, invented new machines, worked at jobs when it is known that hewas never employed in these capacities

7 Extremely Delusional—claims to have been appointed by God to run the world, controlssevere the future of the world, is Jesus Christ, or President of the U.S.

Is there a special purpose or mission to your life?Do you have any special powers or abilities?Have you thought that you might be somebody rich or famous?

9. Hallucinations: Reports of perceptual experiences in the absence of external stimuli. When rating degree to whichfunctioning is disrupted by hallucinations, do not include preoccupation with the content of the hallucinations.Consider only disruption due to the hallucinatory experience. Include thoughts aloud-gedankenlautwerten

2 Very mild While resting or going to sleep, sees visions, hears voices, sounds, or whispersin absence of external stimulation, but no impairment in functioning

3 Mild While in a clear state of consciousness, hears nonverbal auditory hallucinations(e.g., sounds or whispers) or sees illusions (e.g., faces in shadows) on no morethan two occasions and with no impairment in functioning

Occasional verbal, visual, olfactory, tactile, or gustatory hallucinations (1-3times) but no impairment in functioning or frequent nonverbal hallucina-tions/visual illusions

Daily or some areas of functioning are disrupted by hallucinations

Several times a day or many areas of functioning are disrupted by halluci-nationsPersistent throughout the day or most areas of functioning are disrupted byhallucinations

Have you heard any sounds or people talking to you or about you when there has been nobody around7Have you seen any visions or smelled any smells others don't seem to notice7Have these experiences interfered with your ability to perform your usual activities/work?

10. Disorientation: Does not comprehend situations or communications. Confusion regarding person, place, or time

2-3 Mild Occasionally seems muddled, bewildered, or mildly confused

4-5 Moderate Seems confused regarding person, place, or time. Has difficulty rememberingfacts—e.g., where born—or recognizing people. Mildly disoriented as to timeor place

6-7 Severe Grossly disoriented as to person, place, or time

May I ask you one or two standard questions we ask everybody?How old are you?What is the date?What is this place called7

Rate items 11-18 on the basis of observed behavior and speech

4

5

6

7

Moderate


Extremelysevere


2

3

4

5

6

7

Very mildMild

Moderate


Extremely

11. Conceptual disorganization: Degree to which speech is confused, disconnected, or disorganized. Rate tangentiality,circumstantiality, sudden topic shifts, incoherence, derailment, blocking, neologisms, and other speech disorders.Do not rate content of speech. Consider the first 15 minutes of the interview

Peculiar use of words, rambling but speech is comprehensible

Speech a bit hard to understand or make sense of due to tangentiality, circum-stantiality, or sudden topic shifts

Speech difficult to understand due to tangentiality, circumstantiality, or topicshifts on many occasions or 1-2 instances of severe impairment, e.g.,incoherence, derailment, neologisms, blockingSpeech difficult to understand due to circumstantiality, tangentiality, or topicshifts most of the time or 3-5 instances of severe impairment

Speech is incomprehensible due to severe impairments most of the timeSpeech is incomprehensible throughout interview

severe

12. Excitement: Heightened emotional tone, increased reactivity, impulsivity

2-3 Mild Increased emotionality. Seems keyed up, alert4-5 Moderate Reacts to most stimuli whether relevant or not with considerable intensity.

Short attention span. Pressured speech

6-7 Severe Marked overreaction to all stimuli with inappropriate intensity, restlessness,impulsiveness. Cannot settle down or stay on task

13. Motor retardation: Reduction in energy level evidenced in slowed movements and speech, reduced body tone,decreased number of spontaneous body movements. Rate on the basis of observed behavior of the patient only. Donot rate on the basis of patient's subjective impression of his/her own energy level. Rate regardless of medicationeffects

Noticeably slowed or reduced movements or speech compared to most peopleLarge reduction or slowness in movements or speechSeldom moves or speaks spontaneously or very mechanical stiff movements

Does not move or speak unless prodded or urgedFrozen, catatonic

severe

14. Blunted affect: Restricted range in emotional expressiveness of face, voice, and gestures. Marked indifference orflatness even when discussing distressing topics

Some loss of normal emotional responsivenessEmotional expression very diminished, e.g., doesn't laugh, smile, or react withemotion to distressing topics except on 2 or 3 occasions during interviewEmotional expression extremely diminished, e.g., doesn't laugh, smile, or reactwith emotions to distressing topics except for a maximum of 1 time duringinterview

Mechanical in speech, gestures, and expressionFrozen expression and flat speech. Shows no feeling

severe

2-3

4

5

6

7

MildModerateModeratelysevereSevereExtremely

2-3

4

5

6

7

MildModerate

Moderatelysevere

SevereExtremely

VOL. 12, NO. 4, 1986 599

15. Tension: Observable physical and motor manifestations of tension, nervousness, and agitation. Self-reportedexperiences of tension should be rated under the item on anxiety

2-3 Mild Seems tense. Tense posture, nervous mannerisms some of the time4-5 Moderate Seems anxious. Fearful expression, trembling, restless

6-7 Severe Continually agitated, pacing, hand wringing

16. Mannerisms and posturing: Unusual and bizarre behavior, stylized movements, or acts, or any postures which areclearly uncomfortable or inappropriate. Exclude obvious manifestations of medication side effects

2-3 Mild Eccentric or odd mannerisms or activity that ordinary persons would havedifficulty explaining, e.g., grimacing, picking

4-5 Moderate Mannerisms or posturing maintained for 5 seconds or more that would makethe patient stand out in a crowd as weird or crazy

6-7 Severe Posturing, smearing, intense rocking, fetal positioning, strange rituals thatdominate patient's attention and behavior

17. Uncooperativeness: Resistance, unfriendliness, resentment, or lack of willingness to cooperate with the interview.Rate only uncooperative behavior observed during interview, not uncooperativeness with relatives2-3 Mild Gripes or tries to avoid complying but goes ahead without argument

4-5 Moderate Verbally resists, or negativistic but eventually complies. Some informationwithheld

6-7 Severe Refuses to cooperate. Physically resistant

18. Emotional withdrawal: Deficiency in patient's ability to relate emotionally during interview situation. Use yourown feeling as to the presence of an "invisible barrier" between patient and interviewer

2-3 Mild Tends not to show emotional involvement with interviewer but responds whenapproached

4-5 Moderate Emotional contact not present most of the interview. Responds only withminimal affect

6-7 Severe Actively avoids emotional participation. Unresponsive or yes/no answers. Mayleave when spoken to or just not respond at all

19. Suiddality: Expressed desire, intent, or actual actions to harm or kill self

2 Very mild Occasional feelings of being tired of living. No overt suicidal thoughts

3 Mild Occasional suicidal thoughts without intent or specific plan. Or feels he wouldbe better off dead

4 Moderate Suicidal thoughts frequent, without intent or plan

5 Moderately Many fantasies of suicide by various methods. May seriously consider makingsevere specific attempt with specific time or worked out plan. Or impulsive suicide

attempt using nonlethal method or in full view of potential saviors.

6 Severe Wants to kill self. Searches for appropriate means and time. Or potentiallymedically serious suicide attempt with patient knowledge of possible rescue

7 Extremely Specific suicidal plan and intent (e.g., "as soon as , I will do it bysevere doing X"). Or suicide attempt characterized by plan patient thought was lethal

or attempt in secluded environment


Have you felt that life wasn't worth Iiving7Have you thought about harming or killing yourself?Do you have a specific plan?

20. Self-neglect: Hygiene, appearance, or eating behavior below usual expectations, below socially acceptablestandards, or life threatening.2 Very mild Hygiene/appearance somewhat below usual standards, e.g., shirt out of pants,

buttons unbuttoned

3 Mild Hygiene/appearance much below usual standards, e.g., clothing disheveled andstained, hair uncombed

4 Moderate Hygiene/appearance below socially acceptable standards, e.g., large holes inclothing, bad breath, hair uncombed, oily, eating irregular and poor

5 Moderately Hygiene highly erratic and poor, e.g., extreme body odor, eating very irregularsevere and poor, e.g., eating only potato chips

6 Severe Hygiene and eating potentially life threatening, e.g., eats and/or bathes only whenprompted

7 Extremely Hygiene and eating life threatening, e.g., does not eat or engage in hygienesevere

How often do you take showers; change your clothes?Has anyone (parents/staff) complained about your grooming or dress?Do you eat regular meals?

21. Bizarre behavior: Reports of behaviors that are odd, unusual, or psychotically criminal. Not limited to interviewperiod. Exclude mannerisms and posturing, verbalizations with bizarre content

Slightly odd behavior, e.g., hoarding food in private, wears gloves indoorsPeculiar behavior, e.g., talking loudly in public, fails to make appropriate eyecontact when talking with othersModerately unusual, e.g., bizarre dress or makeup, "preaching" to strangers,fixated staring into space while in public, collecting garbageHighly unusual, e.g., wandering streets aimlessly, eating nonfoods, fixatedstaring in a socially disruptive wayUnusual petty crimes, e.g., directing traffic, public nudity, contacting author-ities about imaginary crimesUnusual serious crimes, e.g., setting fires, asocial theft, kidnapping committedin a bizarre fashion or for bizarre reasons

Have you done anything that has attracted the attention of others7Have you done anything that could have gotten you into trouble with the police?Have you done anything that seemed unusual or disturbing to others?

22. Elevated mood: A pervasive, sustained, and exaggerated feeling of well-being, cheerfulness, euphoria (implying apathological mood), optimism that is out of proportion to the circumstances. Do not infer elation from increasedactivity or from grandiose statements alone2 Very mild Seems to be unusually happy, cheerful without much reason3 Mild Some unaccountable feelings of well-being

4 Moderate Reports excessive or unrealistic feelings of well-being, cheerfulness, confidence,or optimism inappropriate to circumstances, some of the time. May frequentlyjoke, smile, be giddy, or overly enthusiastic or few instances of markedelevated mood with euphoria

2

3

4

5

6

7

Very mildMild

Moderate


Extremelysevere

VOL. 12, NO. 4, 1986 601

5 Moderately Reports excessive or unrealistic feelings of well-being, confidence or optimismsevere inappropriate to circumstances much of the time. May describe feeling "on top

of the world," "like everything is falling in place," or "better than ever before,"or several instances of marked elevated mood with euphoria

6 Severe Mood definitely elevated almost constantly throughout interview and inappro-priate to content, or many instances of marked elevated mood with euphoria

7 Extremely Seems almost intoxicated, laughing, joking, giggling, constantly euphoric,severe feeling invulnerable, all inappropriate to immediate circumstances

Have you been feeling cheerful and on top of the world without any reason7How long does that last?Have you felt so good or high that other people make comments to you about it?

23. Motor hyperactivlty: Increase in energy level evidenced in more frequent movement and/or rapid speech. (Note: Inmaking this rating, consider the 15-minute period of most severe symptomatology)2 Very mild Some restlessness, difficulty sitting still, lively facial expressions, or somewhat

talkative3 Mild Occasionally very restless, definite increase in motor activity, lively gestures,

1-3 brief instances of pressured speech

4 Moderate Very restless, fidgety, excessive facial expressions, or nonproductive and repeti-tious motor movements. Much pressured speech, up to one-third of interview

5 Moderately Frequently restless, fidgety. Many instances of excessive nonproductive andsevere repetitious motor movements. On the move most of the time. Frequent

pressured speech, difficult to interrupt. Rises on 1-2 occasions to pace6 Severe Excessive motor activity, restlessness, fidgety, loud tapping, noisy, etc.,

throughout most of the interview. Constant pressured speech with only fewpauses. Speech can only be interrupted with much effort. Rises on 3-4occasions to pace

7 Extremely Constant excessive motor activity throughout entire interview, e.g., constantsevere pacing, constant pressured speech with no pauses, interviewee can only be

interrupted briefly and only small amounts of relevant information can beobtained

24. Distractibillty: Degree to which observed sequences of speech and actions are interrupted by minimal externalstimuli. Include distractibility due to intrusions of visual or auditory hallucinations. Interviewee's attention may bedrawn to noise in adjoining room, books on a shelf, interviewer's clothing, etc. Do not include preoccupation dueto delusions or other thoughts.

2 Very mild Generally can focus on interviewer's questions with only 1 distraction orinappropriate shift of attention of brief duration due to minimal externalstimuli

3 Mild Same as above but occurs 2 times

4 Moderate Responsive to irrelevant stimuli in the room or in the environment much of thetime

5 Moderately Same as above, but now interferes with comprehensibility of speechsevere

6 Severe Extremely difficult to conduct interview or pursue a subject due to preoccu-pation with unimportant and irrelevant stimuli or almost totally incomprehen-sible because attention shifts rapidly between various irrelevant external stimuliand interviewer's questions


Extremely Impossible to conduct interview due to preoccupation with unimportant andsevere irrelevant external stimuli

Brief Psychiatric Rating ScalePatient's name Date Interviewer's name_Hospital Ward Date of admission

Instructions: This form consists of 24 symptom constructs, each to be rated on a 7-polnt scale of severityranging from "not present" to "extremely severe." If a specific symptom is not rated, mark "NA" (notassessed). Circle the number headed by the term that best describes the patient's present condition

NANot assessed

1.2.3.4.

in

6.7.8.9.

10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.

1 2 3Not present Very mild Mild

Somatic concernAnxietyDepressionGuiltHostilitySusplciousnessUnusual thought contentGrandiosityHallucinationsDisorientationConceptual disorganizationExcitementMotor retardationBlunted affectTensionMannerisms and posturingUncooperativenessEmotional withdrawalSuicidalitySelf-neglectBizarre behaviorElated moodMotor hyperactivityDistractibility

4Moderate

5Moderatelysevere

NANANANANANANANANANANANANANANANANANANANANANANANA

111111111111111111111111

222222222222222222222222

6Severe

333333333333333333333333

444444444444444444444444

555555555555555555555555

7Extremelysevere

666666666666666666666666

777777777777777777777777

VOL. 12, NO. 4, 1986 603

Maryland's largest community support program for thedeinstitutionalized mentally ill, established in collaboration with

the Department of Psychiatry of Sinai Hospital.

l i \ I I ( ) \ \ K I ) II . s i \ \ l . l . \

PEP seeks your assistance in collecting exceptional works of art, painting,sculpture, and craft by persons who have, or have had mental illness. It is ourintention to establish a dynamic, national museum center for the exhibition offine works which express the complexity, power, and beauty of the humanspirit.

The art work of many talented individuals with histories of mental illnesshas too often failed to gain the support and recognition it merits. In addition toevolving a large, quality, nonsaleable permanent museum collection throughdonations, PEP needs help in identifying especially talented artists whose workswarrant exhibition in the gallery component. The greater percentage of galleryart sales will go directly to the artist and the rest to help us assist other artistswith mental illness to continue their craft.

Initial inquiry should be made by sending photographs of specific pieces. Allwork will be juried by the PEP Art Advisory Committee for possible inclusioninto the museum and/or gallery. Please provide brief biographical informationon the artist when possible. Confidentiality wishes will be respected.

PEP Art Museum/GalleryAdvisory Committee:

Robert P. Bergman, Director,The Walters Art Gallery

Leroy Hoffberger, Art CollectorJohn B. Imboden, M.D.,

Chief of Psyc\iiatry, Sinai HospitalSamuel Keith, M.D., Chief.

Schizophrenia Research Branch,NIMH

Fred Lazarus, President,Maryland Institute College of Art

Karl Metzler, Art TherapistAmalie Rothschild, Artist

Direct all photographs andquestions to:

Rebecca Alban Puharich,Development Director

People Encouraging People, Inc.The Northwest Plaza5708 Wabash AvenueBaltimore, MD 21215Phone: (301) 764-8560 ext. 25

or (301) 764-1063

PEP, Inc., is a nonprofit charitable organization. All contributions are taxdeductible.

symptom monitoring in the rehabilitation of schizophrenic patients€¦ · 578 symptom monitoring...

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