Predictors of Outcome in Schizophrenia: The Process-Reactive Dimension

Transcription

1 VOL. 12, NO 2, 1986 Predictors of Outcome in Schizophrenia: The Process-Reactive Dimension 195 by Martin Harrow, Jerry F. Westermeyer, Marshall Silverstein, Billie S. Strauss, and Bertram J. Cohler Abstract Premorbid social-sexual competence and the process-reactive dimension, as assessed by the, were investigated as predictors of posthospital adjustment in a prospective study of two samples of 141 young, early phase schizophrenics (a private hospital sample and a state hospital sample). The predicted subsequent at significant levels for one of the two samples of DSM-I1 schizophrenics (a "broad" construct of schizophrenia). It did not predict as well for DSM-III schizophrenics (a "narrow" construct of schizophrenia). Mixed results emerged from separate analyses of first-admission schizophrenics only and for male schizophrenics only. The data indicated that marital status accounts for some of the positive relationship between the Phillips Scale and later. A more focused measure of prehospital social adjustment successfully predicted social functioning at followup for both DSM-I1 and DSM-III schizophrenics (p <.05). There were some significant and near-significant relationships, but overall results suggest that when the influence of chronicity and marital status is reduced, the relationship between the and subsequent is less robust than was once thought. Concepts about the role of premorbid social adjustment in schizophrenia have been central to theoretical formulations about this disorder. In particular, the process-reactive dimension, based on distinctions between good and poor premorbid social and sexual adjustment and measured by part I of the Phillips Scale (Phillips 1953), has been among the most important ways of categorizing schizophrenia in the psychological literature. Literally thousands of studies have been based on the process-reactive dimension and on good vs. poor premorbid social adjustment two related, but not necessarily identical, concepts (DeWolfe 1968; Garmezy 1970; Fowles et al. 1970; Higgins 1971; Chapman and Chapman 1973; Evans, Goldstein, and Rodnick 1973; Bromet, Harrow, and Kasl 1974; Strauss and Carpenter 1974; Putterman and Pollack 1976; Quitkin, Rifkin, and Klein 1976). The relationship between the process-reactive dimension and bears directly on theories about the origin of schizophrenia. Formulations about the importance of the process-reactive dimension are based on theories about a very poor clinical course among process schizophrenics. However, evidence on posthospital adjustment supporting the predictive utility of the distinction between good and poor premorbid adjustment using a prospective research design is surprisingly scant in recent studies. The current research was designed to provide new data in this area. There have been only a handful of modern studies finding positive evidence (Gittleman-Klein and Klein 1969) or mixed evidence (Evans, Goldstein, and Rodnick 1973) in support of the process-reactive dimension, and to date none have used the new diagnostic systems (DSM-III; American Psychiatric Association 1980). A number of older investigations have found positive results (Farina and Webb Reprint requests should be sent to Dr. M. Harrow, Director of Psychology, Michael Reese Hospital and Medical Center, 29th and Ellis Avenue, Chicago, 1L

2 196 SCHIZOPHRENIA BULLETIN 1956; Farina et al. 1962; Query and Query 1964; Nuttal and Solomon 1965; Cancro and Sugarman 1968; DeWolfe 1968; Stephens, O'Connor, and Weiner 1969). These investigations used broad concepts of schizophrenia (DSM-II; American Psychiatric Association 1968); and research with modern, narrow concepts of schizophrenia (e.g., DSM-III) is needed as well. A major problem in research on the process-reactive dimension is that the results from some studies may have been influenced by the use of retrospective research designs and/ or the use of chronic, long-term patients who have already demonstrated years of poor. In these cases, significant findings regarding the may, in part, be influenced by characteristics portraying the severity of an already developed illness rather than premorbid adjustment (Strauss and Carpenter 1974). In contrast to older views, recent prospective studies using multiple measures of and less chronic samples of schizophrenics have found less positive results (Bromet, Harrow, and Kasl 1974; Strauss and Carpenter 1974). The current research studied the relationships between the processreactive dimension and subsequent, while reducing the potential confounding effects of previous chronicity, by analyzing young, early phase schizophrenics. Chronic, older schizophrenics with many years of poor functioning, who can contaminate prognostic results, were not included in the current sample. In addition, multiple measures of were used (i.e., social, work, and symptoms) as well as a measure of rehospitalization. It is now widely recognized that various assessments of different types of symptoms and functioning are preferable for a complete, accurate measure (Strauss and Carpenter 1972, 1974). To increase the generalizability of the findings, the current research employed two samples of young, early phase schizophrenics one from a state hospital type of setting and the other from a private hospital setting. The following questions were studied: 1. Does the process-reactive dimension, as defined by Phillips Scale, predict in young, contemporary schizophrenics, including those defined according to both older, broader diagnostic concepts of schizophrenia (DSM-II) and more modern, narrow (DSM-III) concepts of schizophrenia? 2. Does the process-reactive dimension predict for (a) a subsample of only schizophrenic men and (b) a subsample of firstadmission schizophrenics? Method Patient Sample. The present research represents part of the Chicago Followup Study, a larger program studying schizophrenic thought pathology, prognosis, and on a longitudinal basis by examining these features across different phases of the schizophrenic disorder (Westermeyer and Harrow 1984; Harrow, Carone, and Westermeyer 1985; Harrow and Marengo, in press; Pogue-Geile and Harrow 1985) and exploring mechanisms that may be involved in schizophrenic thought pathology and psychosis (Harrow and Miller 1980; Harrow and Quinlan 1985; Lanin-Kettering and Harrow 1985). To assess the predictive utility of the process-reactive dimension using several different concepts of schizophrenia, two patient samples were studied. Each sample consisted of a group of patients meeting a broad concept of schizophrenia (DSM-II) and a group meeting a narrow concept of schizophrenia (DSM-III). Sample 1. The first sample consisted of 95 young, early phase DSM-II schizophrenics from a private hospital, Michael Reese Hospital (MRH). Thirty-four of the 95 patients also fit the DSM-III criteria for schizophrenia (American Psychiatric Association 1980). Sixty-one of the patients who were classified as having schizophrenia using DSM-II did not meet the DSM-III criteria for the disorder. Previous research by the present investigators has suggested that many patients from this type of population are concurrently experiencing affective disturbances (Silverstein et al. 1982). The diagnoses of these 61 patients using DSM-III criteria were as follows: 4 patients had schizophreniform disorders, 4 patients had paranoid or atypical disorders, 9 patients had manic disorders, 28 patients had major depressive disorders, 10 patients had schizoaffective disorders, and 6 other patients had varied diagnoses. The DSM-II diagnoses were assigned during hospitalization, based on a detailed admission interview, extensive hospital records, and an additional semistructured, tape-recorded interview described previously (Grinker and Holzman 1973). The major focus in this report is on the process and reactive schizophrenics using DSM-II criteria, since DSM-II schizophrenics have been the basis of almost all of the processreactive literature, especially previous reports in this area. The DSM-III diagnoses were based on the admission interviews, the taperecorded research interviews, hospital records, and the Schedule for Affective Disorders and Schizophrenia (Endicott and Spitzer 1978).

3 VOL. 12, NO. 2, The 95 schizophrenic patients consisted of 50 men and 45 women. The mean age of this young, early phase sample was 22.7 years; 48 percent were first-admission patients. Using parental social class (Hollingshead and Redlich 1958), more than 75 percent of sample 1 were brought up in upper-middle-class homes. The mean educational level of sample 1 was 13.6 years at hospitalization. Only 13 of these young, early phase schizophrenics (14 percent) had ever married. The 95 schizophrenics in sample 1 included 35 "reactive" schizophrenic patients (Phillips score below 13), 24 schizophrenics with intermediate scores (scores from 13 to 17), and 36 "process" schizophrenics (scores above 17). Sample 2. The second sample consisted of 46 DSM-II schizophrenics from the Illinois State Psychiatric Institute (ISPI). According to specific DSM-III criteria, the total sample of 46 DSM-II schizophrenics included 24 DSM-III schizophenics and 22 patients with other types of DSM-III diagnoses. These latter 22 patients included 7 patients with schizophreniform disorders or paranoid disorders, 8 with manic disorders, 5 with major depressive disorders, and 2 with schizoaffective disorders (American Psychiatric Association 1980). Diagnostic procedures and methods were the same in both hospital settings. The patient group at ISPI also consisted of young, relatively early phase schizophrenics. The mean age at admission of sample 2 (ISPI) was 22.6 years, and the mean educational level was 12.5 years at hospitalization; 32 percent were firstadmission patients. There were 30 men and 16 women. The 46 schizophrenic patients in sample 2 (ISPI) included 15 "reactive" schizophrenics (Phillips score below 13), 16 schizophrenics with intermediate scores (scores from 13 to 17), and 15 "process" schizophrenics (scores above 17). The patients in sample 2 (ISPI) did not significantly differ from patients in sample 1 (MRH) in age, sex, previous hospitalizations, prior social adjustment (SADS scale), or processreactive scores (p >.10). In line with typical differences between private hospital and state hospital populations, sample 2 had fewer years of education than sample 1 (p <.05). In addition, a greater percentage of the state hospital schizophrenics were from parental social class 4 or 5 (using the Hollingshead and Redlich [1958] socioeconomic status system) than was the case for the schizophrenics from the private hospital (60 percent vs. 25 percent). Previous research, however, has suggested that parental social class may not be a strong predictor of overall in similar types of schizophrenic samples (Westermeyer and Harrow 1984). Nevertheless, because of these differences and because the two populations represented samples from different types of institutions, with possibly different prognoses, the relationship between the process-reactive dimension and was analyzed separately for each of the two samples. For both sample 1 (private hospital) and sample 2 (state hospital), there were no significant differences between process and reactive schizophrenics in age, sex, education, or social class. Medication Status. At the time of followup evaluation, 46 percent of the reactive schizophrenics and 52 percent of the process schizophrenics were receiving neuroleptic medications. The reactive schizophrenics receiving neuroleptics at followup had significantly poorer overall s than the reactive schizophrenics not receiving neuroleptics (p <.05). The process schizophrenics receiving neuroleptics at followup showed a nonsignificant trend toward poorer overall s than the process schizophrenics not receiving neuroleptics (p <.06). It is possible that results suggesting less adequate posthospital functioning among patients who were receiving neuroleptics may be a consequence of more negative- schizophrenics being placed on medication because of their poorer clinical condition. Consequently, caution is warranted in interpreting the results comparing different medication groups, because patients were not assigned to their medication groups on a random basis. Assessment of Prehospital Functioning and Outcome. All patients from sample 1 and sample 2 were studied prospectively as inpatients (Harrow et al. 1983; Marengo and Harrow 1985), and later followed up in detail as part of the Chicago Followup Study (Harrow et al. 1978; Harrow, Silverstein, and Marengo 1983; Harrow, Marengo, and McDonald 1986). Procedures for assessing predictors and were the same in both hospital settings (sample 1 and sample 2). Following traditional instrumentation in this area, part I of the of Premorbid Social- Sexual Adjustment was used as the major predictor instrument of the process-reactive dimension (Phillips 1953). This scale has been modified slightly to make it more applicable to patients under 30 years of age and to women (Bromet, Harrow, and Kasl 1974). Scoring of the was based on prospective administration of a modified version of the General Information Questionnaire, developed by DeWolfe to rate the

4 198 SCHIZOPHRENIA BULLETIN (DeWolfe 1968) on extensive case history material and on the taped interview. In addition, a 7-point scale assessing premorbid social relations was taken directly from the Schedule for Affective Disorders and Schizophrenia, a widely used and standardized schedule (Endicott and Spitzer 1978). Although most of the literature in this area has not reported evidence on interrater reliability, we assessed this factor on our major measures of premorbid adjustment. The results showed satisfactory interrater reliability for these measures (r.81 for, and r =.72 for the SADS Premorbid Social Adjustment Scale). Outcome assessments were made an average of 2.4 years after hospital discharge. Posthospital adjustment was assessed in a structured interview. The followup schedule involved detailed evaluation of the following: (1) social, work, and family functioning; (2) patients' use of medication, psychotherapy, and other possible treatment; (3) neurotic, depressive, and psychotic symptomatology; and (4) rehospitalization. Two scales of overall adjustment were used. The first was an overall scale (the LKP Scale) developed and used by Klein and associates (Levenstein, Klein, and Pollack 1966) that has also been used by our research team and others (Harrow et al. 1978; Summers, Harrow, and Westermeyer 1983; Pogue-Geile and Harrow 1985). This scale is based on work functioning, life disruptions, selfsupport, symptomatology, potential suicide, relapses, and rehospitalizations. The second scale was an overall measure, based on four separate scales, developed by Strauss and Carpenter (1972, 1974) in their investigations of posthospital functioning. Results are also reported on the four separate scales that measure posthospital work functioning, social functioning, rehospitalization, and symptoms. Results Results for Private Hospital Schizophrenics (Sample 1). Table 1 and table 2 present the results for the private hospital (sample 1) and the state hospital (sample 2) schizophrenics. These tables present the correlations between the two major prediction measures (the Phillips Scale and the SADS Scale of Prehospital Social Adjustment) and the various measures of for the full sample of schizophrenics. Separate statistical analyses for the are also presented for (1) schizophrenic men only, (2) firstadmission schizophrenics only, and (3) the sample of DSM-lll schizophrenics. The following results emerged for sample 1: The data for the total sample of schizophrenics in table 1 indicate that the did not have a close relationship with any measure of at followup (p >.10). For DSM-II schizophrenics from a private hospital (sample 1), process schizophrenics as defined by the did not have a significantly poorer than reactive schizophrenics. A more focused measure of prehospital social adjustment, the scale from the SADS, did predict good social functioning at followup (p <.05) for both the total sample of DSM-II schizophrenics and the more narrowly defined sample of DSM-lll schizophrenics (see table 1). Some researchers have suggested the process-reactive dimension may be a better predictor of among men than among women. Analyses using only DSM-II schizophrenic men in sample 1 failed to show a significant association between the and subsequent. Similar nonsignificant relationships were found when schizophrenic women were analyzed separately. Analyses of the subsample of first-admission schizophrenics in sample 1 did show a significant relationship between the Phillips Scale and the LKP Scale of overall (p <.05). This indicates some limited prognostic utility for the process-reactive dimension, even with young, early phase samples. The was also studied for the subgroup of patients from sample 1 who met the DSM-lll criteria for schizophrenia. It did not predict at significant levels within this sample of DSM-lll schizophrenics. The SADS measure of prehospital social adjustment did predict posthospital social functioning for the DSM-lll schizophrenics (p <.05). Table 3A presents a more detailed breakdown of the data for process and reactive schizophrenics in sample 1 if one looks separately (1) at both the first- and multipleadmission schizophrenics, and (2) at both the DSM-lll schizophrenics and only the DSM-II schizophrenics who did not meet the DSM-lll criteria for schizophrenia. A three-way ANOVA was conducted for sample 1 (processreactive dimension, first-admissionmultiple-admission schizophrenics, DSM-lll schizophrenics-dsm-/// nonschizophrenics). The overall F for the process-reactive comparison in this early phase, young schizophrenic sample was not significant for these patients in a private hospital (F (1, 87) =1.8 ns). This analysis is in accord with the earlier analyses presented. It suggests that, within the

5 VOL 12, NO. 2, private hospital sample, the differences in between process and reactive schizophrenics are not significant, although there is a trend toward poorer among the process schizophrenics. Table 4 presents detailed data on the and the LKP Scale of overall for the total sample of schizophrenics in sample 1. The data indicate that a large percent of the process schizophrenics (51 percent) showed very poor s. Among the reactive schizophrenic patients, however, 37 percent also showed very poor. Overall, a smaller percent of the reactive than of the process schizophrenics in sample 1 showed very poor, but group differences were not significant. Results for State Hospital Schizophrenics (Sample 2). The results in table 2, which reports the correlations between and both the and the Scale of Prehospital Social Adjustment for the state hospital sample (sample 2), were as follows: The data in table 2 indicate that the predicted, at statistically significant levels, several key aspects of among the full sample of 46 state hospital schizophrenics. Thus, the successfully predicted both measures of overall (p <.05), rehospitalization (p <.05), and social adjustment (p <.05) at followup among the 46 DSM-II schizophrenics in sample 2. The Prehospital Social Functioning Scale from the SADS successfully predicted social adjustment at followup (without predicting overall ) for the 46 DSM-U schizophrenics and the 24 Table 1. Correlations of with for different types of schizophrenics at private hospital (sample 1) Sample assessed Total sample of DSM-II schizophrenics (n = 95) First-admlsslon schizophrenics (n = 46) Male schizophrenics only (n = 50) DSM-III schizophrenics (n = 34) Overall < at followup Overall : (LKP Scale) ' Overall : (Strauss- Carpenter Scale) ' Specific areas of functioning Rehospitalization Posthospital social functioning.08.24'.22.30' ' Posthospltal work functioning Posthospital symptoms p <.05. Note. Full range of Phillips scores used for all r"s. A positive correlation Indicates that the relationship Is In the direction hypothesized.

6 200 SCHIZOPHRENIA BULLETIN DSM-II1 schizophrenics in sample 2 (p <.05). These positive results were similar to those for the private hospital (sample 1) DSM-ll and DSM-III schizophrenics. The successfully predicted three of the six measures among DSM-II schizophrenic men in sample 2 (p <.05). The did not predict any of the six variables for schizophrenic women at statistically significant levels, although it did show a nonsignificant trend toward predicting symptom for schizophrenic women (p <.10). Analyses of the subsample of first-admission schizophrenics in sample 2 revealed that the Phillips Scale and the SADS Scale failed to predict any aspect of at followup. Nine of the 12 correlations studied for the first-admission schizophrenics were r =.20 or higher, and 4 were r =.30 or higher; but because of the small sample size, these correlations were not significant. Table 3B also presents a detailed breakdown of the data for process and reactive schizophrenics in sample 2 if one looks separately (1) at the first- and multipleadmission schizophrenics and (2) at both the DSM-lll schizophrenics and the DSM-ll schizophrenics who were DSM-III nonschizophrenics. The F for the main effect involving the process-reactive comparison in this young, early phase schizophrenic sample was significant (F (1,38) = 6.0, p <.05). The results support the Table 2. Correlations of with for different types of schizophrenics at state hospital (sample 2) Overall < at followup Specific areas of functioning Sample assessed Total sample of DSM-ll schizophrenics (n = 46) First-admission schizophrenics (n = 15) Male schizophrenics only (n = 30) DSM-III schizophrenics (n = 24) Overall : (LKP Scale).29' Overall : (Strauss- Carpenter Scale).41 J '.15.40'.35.31' ' Rehospltallzatlon Posthospital social functioning.33'.32' '.26.57'.46' Posthospital work functioning ' Posthospital symptoms 'p <.05. 'p<.01. Note. Full range of Phillips scores used for all r's. A positive correlation Indicates that the relationship Is In the direction hypothesized

7 VOL. 12, NO 2, earlier analysis and suggest poorer for process schizophrenics than for reactive schizophrenics from the state hospital setting. Table 5 presents detailed data on the of overall for the total sample of state hospital schizophrenics. As can be seen from this table, a significantly larger percent of the process schizophrenics (60 percent) showed a poor than was the case for the reactive schizophrenics. However, one-third of the reactive schizophrenics also showed a poor. For both sample 1 and sample 2, only a relatively small number of both reactive and process schizophrenics showed a very favorable. Of the reactive schizophrenics in sample 2, however, five (24 percent) showed a very favorable while none of the DSM-Il process schizophrenics in sample 2 showed a very favorable at followup. Marriage and Sex as Influences on the Efficacy of the as a Predictor of Outcome. A separate analysis was conducted to determine whether marriage was an influence on the posthospital results that emerged for the as a predictor of for the state hospital schizophrenics. Table 6 presents detailed data comparing ever married with never married state hospital schizophrenics according to their overall at followup. The data in table 6 indicate marital status was a successful predictor of overall among state hospital (sample 2) schizophrenics. All five remitting schizophrenics in sample 2 were previously married. The never married state hospital schizophrenics had significantly poorer s than the once married schizophrenics (t = 2.83, p <.01). In addition, all five previously married remitting schizophrenics in sample 2 were reactive schizophrenics. Thus, the predictive power of the was strongly associated with marital status for the state hospital schizophrenics. Table 3. Outcome first-admission vs. i 3A. Mean scores for private hospital patients (sample 1) for process and multiadmission reactive schizophrenics, patients DSM-III schizophrenics First-admission Multiadmission n Mean SD n Mean SD according to DSM-III diagnosis and DSM-III nonschlzophrenics First-admission Multiadmission n Mean SD n Mean SD Reactive schizophrenics (1-14) Process schizophrenics (15-30) 3B. Mean scores for state hospital patients (sample 2)' DSM-III schizophrenics DSM-III nonschizophrenlcs First-admission Multiadmission First-admission Multiadmission n Mean SD n Mean SD n Mean SD n Mean SD Reactive schizophrenics (1-14) Process schizophrenics (15-30) 'Higher scores Indicate poorer, using the LKP Scale

8 202 SCHIZOPHRENIA BULLETIN Table 4. Overall at followup for process and reactive schizophrenics from private hospital (sample 1) 1 Reactive schizophrenics (0-14) Process schizophrenics (15-30) Good (1,2) 8(17%) 6(12%) Overall Equivocal (3-6) 21 (46%) 18(37%) Poor (7,8) 17(37%) 25(51%) V =.13, NS. (Full range of Phillips scores used for correlation, rather than category scores.) When the ever married schizophrenics alone were considered, the correlation between the scores and overall for the state hospital patients was r.25 (NS). The similar correlation for the never married state hospital schizophrenics considered alone was r =.02 (NS). Thus, when the influence of marital status was controlled by analyzing once married and never married patients separately, the 's power to predict was reduced. Marital status failed to predict the LKP Scale of overall for the private hospital schizophrenic sample (sample 1), in contrast to sample 2. It is not altogether clear why marital status was not a good predictor for this sample, although one possible influence may be the smaller percentage of married patients in the private hospital sample (only 14 percent). Sex (males vs. females) had a minor influence on the relationship between process-reactive schizophrenics and. There was a trend for more male schizophrenics to fit into the process group and more female schizophrenics to fit into the reactive group. This trend was most pronounced among the DSM-ll schizophrenics and was not prominent for the DSM-Ul schizophrenics. The male process schizophrenics tended to show poorer s than the female process schizophrenics. Among the reactive schizophrenics, the male-female differences in were negligible. Paranoid vs. Nonparanoid Status. Evans, Goldstein, and Rodnick (1973) have looked at data on in process and reactive schizophrenics in terms of whether the process and reactive schizophrenics were paranoid or nonparanoid. We analyzed our data using this two-dimensional scheme, dividing the combined sample from both hospital groups according to whether the patients were (1) good premorbid paranoids, (2) poor premorbid paranoids, (3) good premorbid nonparanoids, or (4) poor premorbid nonparanoids. The results, using the total DSM-II sample of 141 patients, showed a trend similar to that found by Evans, Goldstein, and Rodnick (1973). The good premorbid nonparanoid patients showed the most favorable s, and the poor premorbid paranoid patients showed the poorest overall s. The only overall differences that reached statistical significance, however, involved the more negative s of the poor premorbid paranoid schizophrenics. This group of poor premorbid patients showed significantly poorer s than the poor premorbid nonparanoids (p <.05) and the good premorbid nonparanoid groups (p <.05), and it tended to show poorer s than the good premorbid paranoid group (p <.10). Analyses of the data for the smaller DSM-Ul sample (n = 58) produced similar results. The good premorbid nonparanoid patients had the best overall, and poor premorbid paranoid patients showed the poorest overall, Table 5. Overall at followup for process and reactive schizophrenics from state hospital (sample 2)' Reactive schizophrenics (0-14) Process schizophrenics (15-30) Good (1,2) 5 (24%) 0 Overall Equivocal (3-6) 9 (43%) 10(40%) Poor (7,8) 7 (33%) 15(60%) V =.29, p <.05. (Full range of Phillips scores used for correlation, rather than category scores.)

9 VOL. 12, NO 2, Table 6. Overall at followup for ever married and never married schizophrenics (sample 2) 1 Marital status Ever married Never married 't = 2.83, p< 01. although none of the group differences were close to significant. The lack of significant differences occurred partly because the different types of groups were more homogeneous in, in part because some good- DSM-1I schizophrenics, no longer viewed as "schizophrenic" using DSM-11I criteria (Pawelski, Harrow, and Grossman, in press), were eliminated. This two-dimensional system of categorizing schizophrenics, which has showed some initial promise, will be looked at more closely in subsequent followups, as the followup period lengthens. Discussion From a theoretical standpoint, the most important finding was a suggestion of some relationship between prehospital social-sexual adjustment and later ; it seems not a very strong one, however either just barely significant or nonsignificant. The Phillips Scale was a strong predictor of several aspects of for state hospital DSM-II schizophrenics, but it failed to predict all aspects of. These data are in general agreement with our recent results and those of others (Bromet, Harrow, and Kasl 1974; Strauss and Carpenter 1974). For both these other samples, as with the present two samples, the Qood (1,2) 5 (42%) 0 Overall Equivocal (3-6) 4 (33%) 15(44%) Poor (7,8) 3 (25%) 19 (56%) showed nonsignificant or just significant correlations with overall. Thus, the processreactive dimension may have only limited predictive validity, or it may have prognostic significance only for specific types of and/ or particular groups of patients. One factor that may play a role in the failure of the to predict a very high percentage of the variance in modern studies is better control of key factors such as chronic duration of prior schizophrenic illness. When such factors are better controlled, the predictive utility previously reported for this major index of the process-reactive dimension may be markedly reduced. The hypothesis here is that some previously reported positive findings regarding the, based on older, more chronic samples, may have been influenced by characteristics of the schizophrenics at hospital admission that are a function of the severity of an already developed illness rather than of premorbid adjustment. Strauss and Carpenter (1974, 1977) and Carpenter et al. (1978) also note this possibility and cite the powerful effects of chronicity, or prior length of illness, in predicting. Thus, it is possible that in some previous research the patients showing less adequate premorbid social adjustment were partially deteriorated, chronic schizophrenics. The seemingly poorer adolescent social functioning may not have been an accurate measure of premorbid competence. Rather, it may have been a measure of an early morbid phase, representing deficits from early stages of illness. The current research design also included multiple aspects of rather than relying on a single, global rating or a measure of rehospitalization. It is harder for a prognostic index to predict multiple aspects of and adjustment, some of which demand different skills and abilities. It is of some importance that there was a significant relationship between the measure of prehospital social functioning and social adjustment at followup for all groups of privately hospitalized and state hospitalized DSM-II and DSM-III schizophrenics. Thus, although the SADS Scale of Prehospital Social Functioning (a 7-point continuous scale) does not predict overall adjustment for these schizophrenic groups, it does show significant correlation with the measure of social relations at followup for DSM-II and DSM-III schizophrenics at both institutions. These findings are consistent with those of Strauss and Carpenter (1974), who show that prehospital social relations were the most powerful predictors of social adjustment at followup. Strauss and Carpenter's suggestion, supported by the present data, is that one factor with predictive power is the ability of prehospital competence or adjustment in a particular area to predict hospital functioning in the same area of adjustment. One could propose that the already present skills and competence developed previously in some area should help a patient show some level of adequacy in that same area after hospital discharge.

10 204 SCHIZOPHRENIA BULLETIN The current study is the first prospective research effort (using a variety of measures) to explore the predictive utility of the process-reactive dimension in patient groups using modern, narrow concepts of schizophrenia. It is possible that the may have less predictive utility in narrowly defined DSM-III schizophrenics than in more broadly defined DSM-I1 schizophrenics. Other research by the present investigators has shown DSM-111 schizophrenics to be a more homogeneous group of patients with a poor prognosis in comparison with DSM-II schizophrenics and has indicated that the predictive power of various factors may shift in each group (Westermeyer and Harrow 1984). The predictive utility of the varied by private versus state hospital samples. Differences were explored in terms of marital status. A larger percentage of the state hospital patients were married, with much of the significant relationship being influenced by the more positive of the married, reactive schizophrenics. It is possible that marriage is an important factor that accounts for some positive results previously reported in other studies regarding the process-reactive dimension, since married patients automatically attain better scores than unmarried patients on the. Two of the five Phillips subscales are heavily weighted by marital status, and several researchers have reported a very high correlation between marital status and the total Phillips score (Farina et al. 1962; Cancro and Sugarman 1968; McCreary 1974). Consequently, marital status may be one important determinant of prior findings, both with the and the process-reactive dimension and (Klorman, Strauss, and Kokes 1977). Sample 1 was predominantly an upper-middle-class sample. An upper-middle-class sample is relatively rare in the literature in this area, and especially so in research relating the process-reactive dimension to. Thus, although upper-middle-class patients are one important type of sample, they have been relatively neglected in much of the empirical literature on schizophrenia and o.i major psychotic disorders. Although social class and marital status may play some role in the predictive utility of the, predictive differences for the processreactive dimension among various groups cannot be explained adequately by these factors alone. A host of factors that influence later may also be confounded with institution and diagnostic categories. One of the difficulties in predicting posthospital adjustment is that premorbid personality is only one of the factors that may influence later posthospital adjustment. Other variables that may be important in are the patients' social network, type of family, type of ecological milieu, types of treatment they receive, chance events in their lives, and other unknown factors. We should note that although the showed a moderate relationship to, other types of measures of prehospital competence, such as that of Zigler and Phillips (1961) and of Zigler, Glick, and Marsh (1979), could be better predictors of. The present investigators, using this approach of Zigler and associates, have found evidence that it is a better predictor of for schizophrenics (Westermeyer and Harrow, in press). The process-reactive dimension does seem to provide a useful classification system in studies of schizophrenic performance on psychomotor tests, in studies on perceptual and cognitive processes, and in several other areas. Because of these positive results, which are based on a number of research reports from a variety of settings, the process-reactive dimension would still appear to have considerable utility in reducing heterogeneity in schizophrenic samples. In addition, the positive findings in other areas suggest that the process-reactive dimension could be linked to theory in important ways. It has often been overlooked, however, that there has never been strong empirical evidence to support the underlying assumptions about the positive clinical course of adjustment expected for reactive schizophrenics. Higgins (1971), in an important review article, has begun to express some doubts about the overall importance of this dimension, citing less positive results for process versus reactive schizophrenics in some areas with recent, as opposed to older, research. At the time of Higgins' review, however, he was not able to cite many prospective, long-term studies because of the dearth of empirical research in this area. Current results suggest that there probably is a relationship between the process-reactive dimension and later posthospital but that it is less robust than was once thought. When the potential contaminating effects of an already chronic course of illness are eliminated, it may be more difficult to fit the positive results on the process-reactive dimension concerning performance on various psychological tasks into a larger theoretical network that relates these data to subsequent clinical course and.

11 VOL. 12, NO 2, References American Psychiatric Association. DSM-II: Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: The Association, American Psychiatric Association. DSM-I1I: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: The Association, Bromet, E.; Harrow, M.; and Kasl, S. Premorbid functioning and in schizophrenics and nonschizophrenics. Archives of General Psychiatry, 30: , Cancro, R., and Sugerman, A.A. Classification and in process-reactive schizophrenia. Comprehensive Psychiatry, 9: , Carpenter, W.T.; Bartko, J.J.; Strauss, J.S.; and Hawk, A.B. Signs and symptoms as predictors of : A report from the International Pilot Study of Schizophrenia. American Journal of Psychiatry, 135: , Chapman, L.J., and Chapman, J.P. Disordered Thought in Schizophrenia. New York: Appleton Century Crofts, DeWolfe, A.S. Self-reports and cais histories of schizophrenic patients: Reliability and validity of Phillips Scale ratings. Journal of Clinical Psychology, 24: , Endicott, J., and Spitzer, R. A diagnostic interview: The Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry, 35: , Evans, J.R.; Goldstein, M.J.; and Rodnick, E.H. Premorbid adjustment, paranoid diagnosis, and remission: Acute schizophrenics treated in a community mental health center. Archives of General Psychiatry, 28: , Farina, A.; Garmezy, N.; Zelusky, M.; and Becker, J. Premorbid behavior and prognosis in female schizophrenic patients. Journal of Consulting Psychology, 26:56-60, Farina, A., and Webb, W.W. Premorbid adjustment and subsequent discharge. Journal of Nervous and Mental Disease, 124: , Fowles, D.C.; Watt, N.F.; Maher, B.A.; and Grinspoon, L. Automatic arousal in good and poor premorbid schizophrenics. British Journal of Social and Clinical Psychology, 9: , Garmezy, N. Process and reactive schizophrenia: Some conceptions and issues. Schizophrenia Bulletin, 1 (Experimental Issue No. 2):30-74, Gittleman-Klein, R., and Klein, D. Premorbid asocial adjustment and prognosis in schizophrenia. Journal of Psychiatric Research, 7:35-53, Grinker, R.R., Sr., and Holzman, P.S. Schizophrenic pathology of young adults: A clinical study. Archives of General Psychiatry, 28: , Harrow, M.; Carone, B.J.; and Westermeyer, J.F. The course of psychosis in early phases of schizophrenia. American Journal of Psychiatry, 142: , Harrow, M.; Grinker, R.R.; Silverstein, M.D.; and Holzman, P.S. Is modern-day schizophrenic still negative7 American Journal of Psychiatry, 135: , Harrow, M.; Lanin-Kettering, I.; Prosen, M.; and Miller, J.G. Disordered thinking in schizophrenia: Intermingling and loss of set. Schizophrenia Bulletin, 9: , Harrow, M., and Marengo, J. Schizophrenic thought disorder at followup: Its persistence and prognostic significance. Schizophrenia Bulletin, in press. Harrow, M.; Marengo, J.; and McDonald, C. The early course of schizophrenic thought disorder. Schizophrenia Bulletin, 12: , Harrow, M., and Miller, J.G. Schizophrenic thought disorders and impaired perspective. Journal of Abnormal Psychology, 89: , Harrow, M., and Quinlan, D.M. Disordered Thinking and Schizophrenic Psychopathology. New York: Gardner Press, Harrow, M.; Silverstein, M.; and Marengo, J. Disordered thinking: Does it identify nuclear schizophrenia? Archives of General Psychiatry, 40: , Higgins, J. Process-reactive schizophrenia: Recent developments. In: Cancro, R., ed. The Schizophrenic Syndrome: An Annual Review. New York: Brunner/Mazel, Hollingshead, A.B., and Redlich, R.C. Social Class and Mental Illness. New York: John Wiley & Sons, Klorman, R.; Strauss, J.S.; and Kokes, R.F. Premorbid adjustment in schizophrenia: Concepts, measures, and implications. Part III. The relationship of demographic and diagnostic factors to premorbid adjustment. Schizophrenia Bulletin, 3: , Lanin-Kettering, I., and Harrow, M. The thought behind the words: A view of schizophrenic speech and thinking disorders. Schizophrenia Bulletin, 11:2-7, 1985.

12 206 SCHIZOPHRENIA BULLETIN Levenstein, S.; Klein, D.F.; and Pollack, M. Followup study of formerly hospitalized voluntary psychiatric patients: The first two years. American Journal of Psychiatry, 10: , Marengo, ]., and Harrow, M. Thought disorder: A function of schizophrenia, mania, or psychosis7 Journal of Nervous and Mental Disease, 173:35-41, McCreary, C.P. Comparison of measures of social competency in schizophrenics and the relation of social competency to socioeconomic factors. Journal of Abnormal Psychology, 83: , Nuttal, R.L., and Solomon, L.F. Factorial structure and prognostic significance of premorbid adjustment in schizophrenia. Journal of Consulting Psychology, 29: , Pawelski, T.J.; Harrow, M.; and Grossman, L. The construct of schizophrenia: Should a broad or narrow construct be used? In: Grinker, R.R., Sr., and Harrow, M., eds. Clinical Research in Schizophrenia: A Multidimensional Approach, in press. Phillips, L. Case history data and prognosis in schizophrenia. Journal of Nervous and Mental Disease, 117: , Pogue-Geile, M.F., and Harrow, M. Negative symptoms in schizophrenia: Their longitudinal course and prognostic importance. Schizophrenia Bulletin, 11: , Putterman, A.H., and Pollack, H.B. The developmental approach and process-reactive schizophrenia: A review. Schizophrenia Bulletin, 2: , Query, }., and Query, W. Prognosis and progress: A five-year study of forty-eight schizophrenic men. Journal of Consulting Psychology, 28: , Quitkin, F.; Rifkin, A.; and Klein, D.F. Neurologic soft signs in schizophrenia and character disorders: Organicity in schizophrenia with premorbid asocialiry and emotionally unstable character disorders. Archives of General Psychiatry, 33: , Silverstein, M.L.; Warren, R.A.; Harrow, M.A.; Grinker, R.R.; and Pawelski, T. Changes in diagnosis from DSM II to DSM III. American Journal of Psychiatry, 139: , Stephens, H.J.; O'Connor, G.; and Weiner, G. Long-term prognosis in schizophrenia using the Becker- Wittman Scale and the. American Journal of Psychiatry, 126: , Strauss, J.S., and Carpenter, W.T., Jr. The prediction of in schizophrenia: I. Characteristics of. Archives of General Psychiatry, 27: , Strauss, J.S., and Carpenter, W.T., Jr. The prediction of in schizophrenia: II. Relationships between predictors and variables. Archives of General Psychiatry, 31:37-42, Strauss, J.S., and Carpenter, W.T., Jr. Prediction of in schizophrenia: III. Five year and its predictors. Archives of General Psychiatry, 34: , Summers, F.; Harrow, M.; and Westermeyer, J. Neurotic symptoms in the postacute phase of schizophrenia. Journal of Nervous and Mental Disease, 171: , Westermeyer, J.F., and Harrow, M. "Does the Social Competence Scale Predict Outcome in Schizophrenia?" Paper presented at the 91st Annual Meetings of the American Psychological Association, Predicting in schizophrenics and nonschizophrenics of both sexes. Journal of Abnormal Psychology, in press. Westermeyer, J.F., and Harrow, M. Prognosis and using broad (DSM-II) and narrow (DSM-III) concepts of schizophrenia. Schizophrenia Bulletin, 10: , Zigler, E.; Glick, M.; and Marsh, A. Premorbid social competency and among schizophrenics and nonschizophrenic patients. Journal of Nervous and Mental Disease, 167: , Zigler, E., and Phillips, L. Social competence and in psychiatric disorder. Journal of Abnormal Social Psychology, 63: , Acknowledgments This research was supported, in part, by grant No. MH from the National Institute of Mental Health; and by research grants from the John D. and Catherine T. MacArthur Foundation, the Carnegie Corporation, the University of Illinois at Chicago Campus Research Board, and the Harris Foundation. The Authors Martin Harrow, Ph.D., is Director of Psychology, Michael Reese Hospital and Medical Center, and Professor, Department of Psychiatry and Department of Behavioral Sciences, The University of Chicago, Chicago, IL. Jerry F. Westermeyer, Ph.D., is Research Associate, Department of Psychiatry, Michael Reese Hospital and Medical Center, and Research Associate, Assistant Professor, Department of Psychiatry, the University of Chicago, Chicago, IL.

13 VOL. 12, NO. 2, Marshall Silverstein, Ph.D., is Research Associate, Illinois State Psychiatric Institute, and Associate Professor, Northwestern University, Chicago, IL. Billie S. Strauss, is Associate Professor (Clinical), Department of Psychology, University of Illinois at Chicago, Chicago, IL. Bertram J. Cohler, Ph.D., is Professor, Department of Behavioral Sciences and Department of Psychiatry, The University of Chicago, Chicago, IL. Family Care of Schizophrenia Family Care of Schizophrenia, authored by Ian R.H. Falloon, Jeffrey L. Boyd, and Christine W. McGill, has been recently published by The Guilford Press (200 Park Avenue South, New York, NY 10003). In an ongoing search for the cause (causes) of schizophrenia, the family has often been identified as a prime candidate. Focus on the harmful effects of critical or rejecting family members and deviant communication patterns has obscured the potentially beneficial role of many families in providing support for their schizophrenic members. Though available evidence suggests that intolerance and emotional overinvolvement do heighten the risk of relapse, the authors' thorough review of the literature reveals that only half of the families studied exhibit such attitudes. Family Care of Schizophrenia focuses on a model developed by the authors for the broad-based community treatment of schizophrenia and other severe forms of mental illness that taps this underutilized potential. Based on the hypothesis that environmental stress is a major factor in the onset and severity of schizophrenic episodes, the model incorporates well-established behavioral techniques to enhance the coping mechanisms and problem-solving abilities of the family. The goal of the program is not merely the reduction of stress that can trigger florid episodes, but also the restoration of the patient to a level of effective social functioning that permits employment and socialization with persons outside the family. Following a thoughtful and highly readable discussion of the rationale behind their approach, the authors present a detailed description of their behavioral family model, buttressed by illustrative transcripts from actual therapy sessions. Central to their strategy is the development of problem-solving skills and social supports for the patient and his or her family including education about the illness and the effects of neuroleptics that will enable them to cope not just with potentially threatening behavioral disturbances and other traumatic life events, but also with the stressors of daily life. As the authors persuasively demonstrate, families can, with proper guidance, be taught to modulate the level of intrafamilial stress, regardless of whether it derives from family tensions or external life events. Their careful exposition of the family care model, coupled with case studies and results from a controlled study, reveal the family to be an important resource in the community management of mental illness. A major contribution to the treatment of schizophrenia, this unique synthesis of systems theory and behavioral techniques will be of interest to psychiatrists, who are familiar with the limitations of present treatment strategies, as well as to family and behavior therapists concerned with the problems posed by major mental illness.