EMOTIONAL BLUNTING AND SOCIAL ISOLATION IN SCHIZOPHRENICS AND PSYCHOSIS-PRONE COLLEGE STUDENTS. by MARTIN EDWARD LEMON, B.S. A DISSERTATION PSYCHOLOGY

Transcription

1 EMOTIONAL BLUNTING AND SOCIAL ISOLATION IN SCHIZOPHRENICS AND PSYCHOSIS-PRONE COLLEGE STUDENTS by MARTIN EDWARD LEMON, B.S. A DISSERTATION IN PSYCHOLOGY Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY Approved December, 1992 ^v

2 1 ^ f\ c ' Copyright Martin Edward Lemon All Rights Reserved ^ \

3 ACKNOWLEDGEMENTS I would like to express my deep gratitude to Bonnie Spring, Kenneth Ketner, and Kenneth Lawrence. I am grateful for the ways that each has influenced my thinking and my person. The confluence of what I have learned from and discovered with them formed many of the core ideas for this dissertation. Without all of the generous help from the staff of Lubbock Regional Mental Health/Mental Retardation Center, this project would not have been possible. I am especially indebted to Rebeca Wallace, Sue Han/vell, and Cathy Pope for all of their guidance, assistance and support, and to each of the Case Managers who invested so much time and effort in this project. I would also like to thank Paula O'Donnell for her many hours of assistance In data collection and tabulation. I wish Paula much success in her own graduate career. Finally. I wish to thank my wonderful family whose love and continual encouragement of my academic work (through twenty-four years, for the record) has seen me through. II

4 TABLE OF CONTENTS ACKNOWLEDGEMENTS LISTOFTABLES LIST OF FIGURES ii v vi CHAPTER I. INTRODUCTION 1 Social Network Research in Schizophrenia 2 Positive and Negative Symptoms in Schizophrenia 4 Symptom-Based Research in Schizophrenia 5 Emotional Blunting and Social Isolation 9 Use of the Chapman Scales 11 II. METHODS 16 Subjects 16 Measures 21 III. STATISTICAL ANALYSES 26 Demographic Characteristics of the Sample 26 Analyses Regarding Social Network Variables 34 Positive and Negative Symptom Scales 48 IV. DISCUSSION AND CONCLUSIONS 54 Toward Identifying Pathological Processess 68 REFERENCES 74 ^

5 ^ - ^ APPENDICES A. SOCIAL NETWORKS 80 B. SOCIAL NETWORK RESEARCH IN SCHIZOPHRENIA 94 C. POSITIVE AND NEGATIVE SYMTPOMS IN SCHIZOPHRENIA D. THE ASSESSMENT OF PSYCHOSIS-PRONENESS 108

6 LIST OF TABLES 1. Means and Standard Deviations for the Revised Physical Anhedonia, Magical Ideation and Perceptual Aberration scales Demographic Characteristics of the Sample Mean Network Size, Multiplexity. and Reciprocity of Minority College Students in Comparison to White Students History of Psychiatric Treatment Mean Network Size, Multiplexity. and Reciprocity of Minority Schizophrenic Subjects in Comparison to White Schizophrenic Subjects Past Psychiatric Hospitalizations and Current Medication Dosages of Schizophrenic Subjects Correlations Among the Dependent Variables in the Five Groups Correlations for Physical Anhedonia, Magical Ideation, Perceptual Aberration Scores and SAPS, SANS Variables for Schizophrenic Anhedonics and Schizophrenic Per-Mags 50 ^

7 LIST OF FIGURES 1. Group Means for Networt< Size Group Means for Number of Multiplex Relationships Group Means for Number of Reciprocal Relationships Illustration of the Distribution of Network Size Data within the Three College Student Groups Illustration of the Distribution of Network Size Data within the Two Schizophrenia Groups Illustration of the Distribution of Multiplex Relationships Data within the Three College Student Groups Illustration of the Distribution of Multiplex Relatonships Data within the Two Schizophrenia Groups Illustration of the Distribution of Reciprocal Relationships Data within the Three College Student Groups Illustration of the Distribution of Reciprocal Relationships Data within the Two Schizophrenia Groups Illustration of the Connections within a Social Network Illustration of Two Social Networks Which Differ in Terms of the Degree to Which Network Members Know Each Other 87 VI " ^

8 CHAPTER I INTRODUCTION Psychopathologists dating back to Kraepelin (1919/1971), Bleuler (1911/ 1950), and Hoch (1910) have often noted that many schizophrenics seemed to have been socially isolated prior to the onset of their disorder. These early theorists tended to view preschizophrenic isolation as a concomitant of certain premorbid personality characteristics (e.g., seduslveness), however, later sociologically oriented theorists hypothesized that social isolation might play an etiological role (Paris, 1934; Paris & Dunham, 1939). Various forms of the hypothesis that social isolation was involved in the etiology of schizophrenia received considerable attention as well as some empirical support (e.g., Jaco, 1954) up until the 1950's when a landmark study by Kohn and Clausen (1955) found that only about one-third of a sample of hospitalized, first-admission schizophrenics reported having been socially isolated during adolescence. Kohn and Clausen concluded that social isolation should not be considered a "crucial element" in the genesis of schizophrenia since a pattern of isolation during adolescence did not seem to characterize even a majority of the cases they studied. During the decade following this refutation of the "Isolation hypothesis," the focus of schizophrenia research shifted away from aspects of social interaction (Lipton, Cohen, Fischer, & Katz, 1981). Schizophrenia research 1

9 on social isolation reappeared in the 1970's, however, when a new methodology developed by anthropologists and sociologists was employed. Social network methodology was developed to investigate the structure and functions of the web of social connections which comprise an individual's social environment. (An extended discussion of social network research methods appears in Appendix A.) Social Network Research in Schizophrenia Commenting on the nature of social networks, Tolsdorf (1976) emphasized that an individual and his or her network are in constant interaction, influencing and being influenced by each other. Social network data, thus, represents a snapshot of a dynamic social process. For psychopathologists, social network research has become a valuable tool for investigating the social processes that accompany particular psychological symptoms or disorders. When research shows that particular social network features tend to occur in conjunction with particular syndromes or symptoms, this information provides clues which can be used to understand how the symptomatic individual and others in his or her social environment are Influencing each other. The information may also provide clues as to the nature of the psychosocial process(es) that is (are) contributing to the emergence of symptoms. With regard to schizophrenia, several social network studies have provided evidence that, as a group, schizophrenics tend to be socially

10 isolated. In particular, studies have reported that schizophrenics have smaller social networks, fewer multiplex relationships (wherein, the focal individual and the network member engage in multiple types of activities) and fewer reciprocal relationships (wherein, emotional support is both provided and received) in comparison to nonpsychiatric controls (Pattison, DeFrancisco, Wood, Frazier & Cowder, 1975; Tolsdorf, 1976; Sokolovsky, Cohen. Berger & Geiger, 1978; Cohen & Sokolovsky, 1978; Garrison. 1978; Westermeyer & Pattison, 1981). However, while it has been demonstrated that many schizophrenics tend to be isolated after they have developed the disorder, it has remained unclear whether isolation plays any etiological role either for all schizophrenics or for a particular subgroup. Moreover, the nature of the process(es) which contribute(s) to the social isolation of many schizophrenics has remained unclear. (For a comprehensive review of research concerning schizophrenics' social networks, see Appendix B.) Interestingly, a recent study by Hamilton, Ponzoha, Cutler and Weigel (1989) indicated that schizophrenics' level of social Isolation correlated only with the severity of negative symptoms, and not with the severity of positive symptoms. By linking specific social network characteristics to negative symptoms, this study raised the possibility that a process of social isolation might be contributing to and/or resulting from negative symptoms, while it is

11 Irrelevant for positive symptoms. (For a discussion of negative and positive symptoms In schizophrenia, see Appendix C.) Positive and Neoative Svmptoms in Schizophrenia In terms of their Impact on other persons. It is important to point out that positive and negative symptoms tend to produce different consequences. Positive symptoms such as hallucinations and delusions may force themselves upon an observer's attention, and are in effect, somewhat like sending up a flare or distress signal. Negative symptoms, in contrast, such as emotional blunting, apathy or anhedonia, are more like becoming profoundly listless or "dead In the water." Either type of symptom may attract attention, but in different ways. An Individual with only positive symptoms (both positive and negative symptoms may, in fact, be exhibited simultaneously) is more likely to say or do things which may surprise or even startle others. These types of behaviors are likely to arouse concern even among people who may not know the schizophrenic Individual personally, such as the police. The behavior of a person with only negative symptoms, in contrast, is more likely to be conspicuous in terms of the lack of Its Impact on others. When negative symptoms are chronic (e.g., a chronic absence of any emotional expression), they may in fact go unnoticed even by personal acquaintances because the symptom behaviors are seen as typical of the symptomatic individual. Considering how the social impact of

12 negative symptoms contrasts with that of positive symptoms, it is perhaps not surprising that Hamilton et al.'s (1989) findings would suggest that different social processes might be linked to negative as opposed to positive symptoms. In light of the previous research on the social networks of schizophrenics, and particularly Hamilton et al.'s (1989) findings, the present study sought to refine this avenue of inquiry in two ways: (1) by investigating whether social isolation might be linked to a single specific negative symptom known as emotional blunting, and (2) by investigating whether this linkage might exist premorbidly, at a time when isolation could be impacting the development of emotional blunting. There were a number of reasons for selecting a single schizophrenic symptom for study, and for selecting emotional blunting. In particular. Symptom-Based Research in Schizophrenia Ideally, research on the etiology of any psychiatric disorder would involve investigation of the various processes that are operative prior to the appearance of clinical symptoms. Obtaining access to such premorbid processes, however, Is difficult because it necessitates identifying persons who do not currently exhibit clinical symptoms but will manifest them at some time In the future. One approach to dealing with the problems that are inherent to etiological research has been developed by Chapman and Chapman (1987).

13 who during the past two decades have attempted to identify subclinical symptoms that precede the onset of schizophrenia. The Chapmans' research was inspired by the work of Meehl (1962) whose clinical and research inquiries led him to propose that four "schizophrenia indicators" -namely cognitive slippage, interpersonal aversiveness. anhedonia and ambivalencewere premorbidly discernible and were the phenotypic manifestations of an underlying genetically transmitted "integrative neural defect" he termed "schizotaxia." Meehl hypothesized that schizotaxia was the biological flaw which, unless environmental conditions were exceptionally favorable, would result In a schizotypic personality organization. In order to study the possibility of a genetically transmitted schizotaxia, Meehl sought to investigate the inheritance of schizotypic characteristics which, according to his hypotheses, should frequently be observable among schizophrenics' relatives. To facilitate this type of research, he called for the development of psychometric measures to assess schizotypic symptoms. Although the Chapmans' research was not conceived as a means of investigating genetic hypotheses, it has involved attempting to identify persons who have attenuated, premorbid forms of schizophrenic symptoms. The Chapmans have developed questionnaires for this purpose and have screened large numbers of college students in an attempt to identify those who exhibit such symptoms. In all, the Chapmans and their colleagues have developed five scales-two of which are often combined-to assess symptoms

14 which have been hypothesized precursors of schizophrenia. (For a review of research on the Chapmans' psychosis-proneness scales, see Appendix D.) One of the major goals of the Chapmans' research has been to identify symptoms that may characterize diverse pathways to schizophrenia. The most notable problem Involved in studying individual premorbid symptoms is that individual symptoms may be identified that, in fact, predispose persons to several disorders, or to psychopathology In general rather than to schizophrenia specifically. Some investigators have argued that while it may be worthwhile to demonstrate that, say. a certain cognitive process predisposes an individual toward developing a variety of disorders, understanding this process may tell us little or nothing about the nature of schizophrenia. In response to this argument. Persons (1986) has offered several compelling reasons why studying symptoms that schizophrenia has in common with other disorders may be just as fruitful as trying to ascertain what is unique about schizophrenia. First, Persons has pointed out that the study of symptoms facilitates theoretical development In that it allows for tighter, more direct explanatory links between hypothesized psychological or social processes and overt phenomena. She cites Maher's (1974) theory of delusions as an example. Maher's theory posited that delusions result from a cognitive attempt to account for aberrant sensory experiences such as when a person who is hard of hearing concludes that others are concealing things from him or her.

15 Thus, Maher's theory attempted to forge a direct link between a psychological process (sensory deficits) and overt symptoms (delusions). In contrast, focusing on diagnostic categories. Persons argues, has tended to result in theories that do not account for any of the particular symptoms observed in schizophrenic patients. For instance, Nuechterlein and Dawson's (1984) "heuristic vulnerabilitystress model" of schizophrenia, which emerged from diagnostic category research, does not attempt to account for why one individual may exhibit persecutory delusions while another exhibits auditory hallucinations. Instead, the model lumps all such symptoms into the category of "psychotic disturbances" and attempts to outline what factors predispose persons toward psychosis in general, thereby avoiding the task of accounting for specific symptom phenomena. Second. Persons argues that if researchers can learn something about the pathological processes underlying a symptom or set of symptoms, they may choose to redefine a particular diagnostic category In terms of this process, in this regard. Persons cites Harvey and Neale's (1983) conclusion that the attempt to locate the central cognitive deficit in schizophrenia has failed. It is quite possible. Persons notes, that there is no central cognitive deficit in schizophrenia as It is currently defined. Studying the processes associated with particular symptoms, therefore, might be more profitable than searching for processes which underlie an entire diagnostic category. 8

16 Third, perhaps Person's most compelling argument concerns the advantages of Isolating single elements of pathology for study. Here she cites the Chapmans' research in pointing out that the study of specific symptoms in a premorbid sample increases the likelihood that the phenomena of interest will not be obscured by other powerful coexistent processes including other symptoms and the effects of medication and hospitalization. This point provided much of the logical basis for the present study. This study attempted to focus upon the relationship between emotional blunting and social network deficits while controling for the influence of such "third variables" as (1) the social stigmatization of mental patients, (2) medication effects, and (3) the effects of repeatedly removing an individual from his/her ordinary social environment to be hospitalized. To accomplish this, the social networks of college students with essentially no psychiatric history were studied in addition to the social networks of schizophrenics. In other words, college student data was collected because it was expected that college students' social lives - unlike the social lives of schizophrenics - would be relatively unaffected by extraneous factors such as the effects of antipsychotic medication or being stigmatized as a "mental patient."

17 Emotional Blunting and Social Isolation Emotional blunting, a marked reduction in the intensity of emotional expression, was focused upon here for two reasons. First, prior research had demonstrated a strong link between this symptom and social network deficits. Hamilton et al. (1989) reported a strong negative correlation between deficits In "expressive relatedness" and social network size. Expressive relatedness deficits were defined as "decreased verbal rate and paucity of nonverbal expression in an interview." Emotional blunting has been similarly defined as "a characteristic impoverishment of emotional expression, reactivity, and feeling" (Andreasen, 1982). Second, theoretical assumptions concerning emotional blunting, positive symptoms and social isolation provided the organizing impetus of this study. These assumptions had to do with (1) the nature of the link between emotional blunting and isolation, and (2) why persons who have exhibited positive symptoms but have not exhibited emotional blunting may participate in~and. In fact, facilitate-a non-isolative psychosocial process, despite their occasional bizarre behavior. In the present study, emotional blunting was assumed to contribute to the dissolution of relationships in at least two ways. It might result in a lack of motivation to seek out and maintain relationships because they are not gratifying, and equally important, it might engender frustration and ultimately despair and surrender In others because they are unable to engage or make 10

18 any sort of emotional connection with the emotionally blunted individual. Moreover, through the steady loss of emotionally significant relationships, the person may further lose the capacity to experience and differentiate his or her emotions such that blunting is exacerbated in a pathologically reciprocal cycle. This cycle might account for why the social networks of emotionally blunted schizophrenics often deteriorate to the point that only a few relationships remain which typically involve network members providing support to the schizophrenic (nonreciprocal. nonmulitplex relationships). In contrast, schizophrenics with positive symptoms (including attenuated, premorbid positive symptoms or postmorbid residual positive symptoms) but without significant emotional blunting were assumed here to have retained their ability to experience emotions, and thus, would likely continue to be motivated to seek out and maintain relationships with others. Even though they occasionally express bizarre ideas or behaviors, they were expected to be capable of seeking out individuals or groups that could tolerate such behavior. Thus, by maintaining some basic emotional capacities, schizophrenics with positive symptoms may be able to avoid a reciprocal cycle of isolation and blunting. Use of the Chapman Scales Two of the most thoroughly researched Chapman scales, the Perceptual Aberration-Magical Ideation Scale and the Revised Physical Anhedonia Scale 11

19 were utilized In the present study. The Perceptual Aberration Scale (Chapman, Chapman & Raulin, 1978) was designed as a measure of distortion in the perception of one's own body and of other objects. This scale has been shown to correlate strongly with the Magical Ideation Scale (Eckblad & Chapman, 1983), which was developed as a measure of the tendency to accept forms of causality that are viewed as invalid in Western culture. Following the precedent of prior research (Chapman & Chapman, 1987), in the present study the two scales were combined. Both appear to measure the types of experiences, beliefs and thoughts that characterize positive symptoms. In contrast, the Revised Physical Anhedonia Scale (Chapman, Chapman & Raulin, 1976) was designed as a measure of a deficient capacity to experience pleasure from physical experiences. This scale appears to measure an inability to experience one's own emotions in general, and this type of emotional disengagement was assumed here to be at the root of the objectively observable behaviors that constitute emotional blunting. High scorers on the combined Perceptual Aberration-Magical Ideation (Per- Mag) Scale and the Revised Physical Anhedonia Scale appear to exhibit definite, yet distinct predispositions toward severe psychopathology (Chapman & Chapman. 1987). For instance. In standardized interviews, college students who scored high on the Per-Mag Scale reported significantly more thoughtbroadcasting experiences, unusual auditory experiences, aberrant beliefs, and schizotypal experiences than did control students who scored near the scale's 12

20 mean (Eckblad & Chapman, 1983). On the other hand, students who scored high on the Revised Physical Anhedonia Scale did not differ from controls in terms of reported "psychotic-like" experiences (Chapman. Edell & Chapman, 1980). Moreover. Bernstein and Riedel (1987) reported that the performance of college student high scorers on the Revised Physical Anhedonia Scale on tests measuring psychophysiological response patterns (orienting response) resembled the performance of schizophrenics. They reported that the performance of high scorers on the Per-Mag Scale, in contrast, did not assume a "schizophrenic-like" pattern. Bernstein and Riedel noted that orienting response deficits are more closely associated with negative symptoms and went on to suggest that the Revised Physical Anhedonia Scale may identify Individuals at risk for developing negative symptoms. The present study was conducted to investigate a possible direct link between premorbid, subclinical emotional blunting (as assessed by the Revised Physical Anhedonia Scale) and social Isolation. For the sake of comparison, the relationship between particular premorbid, subclinical positive symptoms (as assessed by the Per-Mag Scale) and social involvements was also investigated. With the above mentioned theoretical assumptions providing a framework for inquiry, the proposed study involved comparisons of the social networks of (1) college students who were high scorers on the Revised Physical Anhedonia Scale but not on the Per-Mag Scale, (2) college 13

21 students who were high scorers on the Per- Mag Scale but not on the Revised Physical Anhedonia Scale. (3) college student controls who scored high on neither scale, (4) outpatient schizophrenics who were high scorers on the Revised Physical Anhedonia Scale but not on the Per-Mag Scale, and (5) outpatient schizophrenics who were high scorers on the Per-Mag Scale but not on the Revised Physical Anhedonia Scale. Four specific predictions were tested. First, the same pattern of social network peculiarities (small size, few multiplex or reciprocal relationships) was expected to be evident in the social network data of college student high scorers and schizophrenic high scorers on the Revised Physical Anhedonia Scale. The most powerful determinant of social isolation, emotional blunting, was expected to lead to the same degree of isolation in a premorbid sample of college students as In a sample of schizophrenics with similar emotional blunting. (The same cutoff scores on each of the Chapman scales were used for all college student and schizophrenia groups.) Second, college students who were high scorers on the Revised Physical Anhedonia Scale were expected to have significantly smaller social networks with fewer multiplex and fewer reciprocal relationships than (1) the college students who were high scorers on the Per-Mag. (2) the schizophrenics who were high scorers on the Per-Mag, or (3) the college student controls who scored high on neither scale. Again, emotional blunting was expected to be 14

22 the primary determinant of social isolation even when it was present in a premorbid sample. Third, the schizophrenics who were high scorers on the Revised Physical Anhedonia Scale were expected to have significantly smaller social networks with fewer multiplex and fewer reciprocal relationships than the schizophrenics who were high scorers on the Per-Mag Scale. This prediction reflected the expectation that emotional blunting would be a primary factor in leading to isolation in a postmorbid sample as well. Fourth, the social network size, multiplexity. and reciprocity of the college students who were high scorers on the Per-Mag Scale was expected to be essentially the same as the social network characteristics of the college student controls. Without significant emotional blunting, most network features of the Per-Mag college students were expected to mirror those of the college student controls. 15

23 CHAPTER II METHODS Subjects Thirty clinical outpatients who had been diagnosed schizophrenic and 45 college students were chosen for interviews based on questionnaire scores. Provided that they scored below predetermined cutoff scores on the Gough Dissimulation Scale (Gough, 1957) and an Infrequency Scale designed by the Chapmans to accompany their psychosis-proneness scales, all persons (students or schizophrenics) who scored at least two standard deviations above the mean on the Physical Anhedonia (PA) scale but no more than.5 standard deviations above the mean on the Perceptual Aberration Scale or the Magical Ideation Scale were invited for a social network interview, until 15 students and 15 schizophrenics had been interviewed. These subjects comprised the College Anhedonic and Schizophrenic Anhedonic groups. Also, persons who scored at least two standard deviations above the mean on either the Perceptual Aberration Scale or the Magical Ideation Scale or above 1.5 standard deviations on both of the scales, but no more than.5 standard deviations above the mean on the PA scale were contacted, until 15 more schizophrenics and 15 more students had been interviewed. These subjects formed the College Per-Mag and the Schizophrenic Per-Mag groups. Finally, college students who scored no more than.5 standard deviations above the 16

24 mean on either the PA scale or the Per-Mag scale were contacted and interviewed until 15 persons completed the College Control group. Cutoff scores were determined according to norms (means, standard deviations) established through administration of the Magical Ideation, Perceptual Aberration and Revised Physical Anhedonia scales to a sample of 750 college students in previous research conducted at Texas Tech University (Weinsteln-Rlchardson, 1989/1991). Means and standard deviations reported by Weinsteln-Rlchardson and those for all college students and schizophrenics screened in the present study are reported in Table 1. The process of screening for college student subjects and inviting them to participate in an interview was as follows: A total of 982 college students (415 males and 567 females) were screened over a four-month period (during two consecutive semesters) using a questionnaire which included a combination of items from the two validity scales, the Revised Physical Anhedonia Scale (PA), and the combined Perceptual Aberration-Magical Ideation Scale (Per-Mag). Students whose scores met the criteria for either the College Anhedonic or the College Per-Mag group were contacted by telephone as soon as possible after they completed the questionnaire and it had been scored (usually within one week). Thus, they were contacted roughly in an order corresponding to the order in which they voluntarily chose to complete the questionnaire. In 17

25 Table 1: Means and Standard Deviations for the Revised Physical Anhedonia, Magical ideation and Perceptual Aberration scales Weinstein-Richardson - college subjects (n = 750) Mean Standard Deviation Lemon - college subjects (n= 982) Mean Standard Deviation nnale female nnale female male female nnale female Revised Physical Anhedonia Magical Ideation Perceptual Aberration Lemon - schizophrenic subjects (n=58) Mean Standard Deviation male female male female Revised Physical Anhedonia Magical Ideation Perceptual Aberration return for their participation in completing the questionnaire, students were given credit toward fulfilling a requirement for their introductory psychology course. The students were offered additional credit toward the requirement for the time required to complete the social network interview. Two of the students whose scores qualified for the College Anhedonic group and one student whose scores met the criteria for the College Per-Mag group declined to participate in the interview. Each of these students said they declined the 18

26 interview because by completing the questionnaire, they had already earned all of the experimental credits they needed for their course. The gender distribution of the College Anhedonic group (eight males, seven females) was due entirely to chance. In the case of the College Per- Mags, in order to match the gender makeup of the College Anhedonics, one male Per-Mag qualifier was not invited for an interview. Instead of contacting him, screening continued until another Per-Mag was identified, and this student happened to be female. For the College Controls, eight males were chosen at random from the pool of males with appropriate scores, and likewise, seven females were chosen from the pool of females with appropriate scores. One male with qualifying Control scores declined to participate because he already had all of the credits he needed. Another male was invited to participate in his place. The process of inviting the schizophrenic subjects to participate involved first asking case managers at Lubbock Regional Mental Health/Mental Retardation Center to suggest persons on their caseload who were diagnosed schizophrenic. Next, these persons' medical records were reviewed to confirm the diagnosis of schizophrenia according to the Research Diagnostic Criteria (RDC) (Spitzer, Endlcott & Robins, 1978). To be eligible, the clinical subjects had to (1) have a diagnosis of schizophrenia documented for at least two years, (2) be between the ages of 18 and 55, (3) be a native English speaker, (4) not currently carry an additional diagnosis of alcohol or drug abuse or 19

27 dependence, and (5) never have been diagnosed with an organic mental disorder or mental retardation. The same Chapman Scale and validity scale norms used as cutoff scores for the college student subjects were used with the schizophrenics. The caseworkers were then asked to (1) contact persons whose diagnoses had been verified and who met the other criteria for participation, (2) briefly describe the study to them, and (3) ask them whether they were interested in participating. If a given individual was interested, his/her casemanager contacted the investigator to inform him of the potential participant's name and how he/she wished to be contacted (e.g., by telephone at a certain time of day). Seventy-one schizophrenics agreed to be contacted by the investigator and all were invited to participate in the study. When contacted, eleven said they had changed their minds and they declined to participate. Two others began filling out the questionnaire but elected not to complete it; both stated that It seemed too long. Of the remaining 58 schizophrenics, 26 were female and 32 were male. Subjects were not selected with regard to any demographic characteristic other than those used as exclusion criteria (e.g., no person over age 55 was invited to participate). Thus, for example, the composition of the Schizophrenic Anhedonic and Schizophrenic Per- Mag groups in terms of gender was not influenced by any effort to balance the numbers of males and females. 20

28 The schizophrenic subjects received $2 for participating in the questionnaire phase of the study, and $5 for participating in the interview. All schizophrenic subjects were Informed both verbally and on their consent forms that receiving this remuneration would not be conditional upon completing the questionnaire or completing the Interview. None of the college student subjects or the schizophrenic subjects chose to terminate the interview prior to its completion. Measures Each of the student and schizophrenic subjects completed: (1) the Per- Mag scale, (2) the PA scale, (3) an infrequency scale designed by the Chapmans as a means of Identifying inappropriate test-taking attitudes or strategies, and (4) the Gough Dissimulation scale (Gough, 1957), a Minnesota Multiphasic Personality Inventory (MMPI) subscale designed to identify persons who are either simulating or exaggerating psychopathology. In addition, they were Interviewed with a standardized social network Interview (Mueller, 1980). Finally, to assess the validity of the Per-Mag and PA scales as measures of positive symptoms and emotional blunting respectively, Andreasen's (1979a, 1979b, 1984) scales for assessing positive and negative symptoms were used to make ratings of interview behaviors. These various assessment instruments are described below: 21

29 (1) Magical Ideation Scale - (Eckblad & Chapman. 1983). This 30-item true-false scale was developed as a measure of the tendency to accept forms of causality that are viewed as Invalid In western culture. It assesses beliefs in a number of magical Influences including thought transmission, psychokinetic effects, precognition, spirit influences, reincarnation, and transfer of physical energies between people. Eckblad and Chapman (1983) reported a coefficient alpha for the scale of.85 for males and.83 for females. Examples of items and deviant responses include: "I have noticed sounds on my records that are not there at other times" (true); "I have sometimes felt that strangers were reading my mind" (true); "It is not possible to harm others merely by thinking bad thoughts about them" (false). (2) Perceptual Aberration Scale - (Chapman. Chapman & Raulin. 1978). This scale consists of 35 items and was designed as a measure of distortion In the perception of one's own body and of other objects. Chapman, Chapman and Raulin (1978) reported a coefficient alpha estimate of reliability for the scale of.91 for females and.89 for males. Examples of the items and responses scored as deviant Include: "Sometimes I have felt that I could not distinguish my body from other objects around me" (true); "My hands or feet have never seemed far away" (false); and "Sometimes when I look at things like tables and chairs they seem strange" (true). (3) Revised Phvsical Anhedonia Scale - (Chapman. Chapman & Raulin. 1976). This is a 61-item scale designed as a measure of a deficient capacity to 22

30 experience pleasure from physical experiences. Chapman, Chapman and Raulin (1976) reported coefficient alpha of.82 for males and.78 for females for large samples of college undergraduates. Examples of items and deviant responses include: "The taste of food has always been Important to me" (false); "I have had very little fun from physical activities like walking, swimming, or sports" (true); "I have always loved having my back massaged" (false). (4) Infrequency Scale. This is a 10-item scale designed by the Chapmans to be used as an adjunct to their psychosis-proneness scales as a means of detecting persons who were responding either carelessly or in a deliberately bogus manner. Examples of scale items and responses scored as deviant include: "Driving from New York to San Francisco is generally faster than flying between these cities" (true); "There have been times when I have dialed a telephone number only to find that the line was busy" (false). No subject with an Infrequency Scale score greater than two was included in the sample. (5) Gough Dissimulation Scale - (Gouoh. 1957). A 40-item subscale of the MMPI, the Gough Dissimulation Scale was designed as a way of Identifying persons who were overreporting psychopathology. In several studies, It has successfully differentiated persons with well-documented psychopathology from persons-including professional psychologists~who were instructed to simulate psychopathology in their responses (e.g., Gough, 1954; Anthony, 1971). Its Items pertain to commonly held yet erroneous 23

31 stereotypes about psychopathology. Examples of scale items and responses scored as deviant include: "No one seems to understand me" (true); "I usually expect to succeed in things I do" (false). Subjects were excluded if their Gough scores exceeded a cutoff corresponding to an MMPI T-score of 80. Accordingly, males who scored above 19 and females who scored above 21 were excluded (Greene, 1980). (6) Social Network Interview - (Mueller. 1980). This Is a structured interview that elicits a variety of information about the subject's social network including: first names of persons In the network, their gender, ages, relationship to the subject (e.g., neighbor), how far they live from the subject, duration of the relationship, frequency of contact, mode of contact (e.g., in person, by telephone), date of most recent contact, the "plexity" of each relationship (i.e., number of activities they do together and number of settings in which they meet), and emotional support received and provided. At the outset of this interview, subjects were asked to talk about how they typically spent their time. This enabled the investigator to note the various social spheres and activities reported by the subject. It was then explained that the first task of the Interview was to build a list of the first names of only those persons (whether friends, relatives, co-workers, etc.) with whom the subject had had some significant conversation at least four times within the past year. Subjects were told to think of a "significant conversation" as "something more than just saying 'hello,' but not necessarily a conversation about personal 24

32 matters." While building the list of names, the investigator encouraged thesubject to concentrate, one at a time, on each social sphere he or she had mentioned. For instance, the investigator began by saying: "Let's start with the people you know through your tx)wling league. Which of these people have you talked with at least four times during the past year?" (7) Scale for the Assessment of Positive Svmptoms (SAPS) -- (Andreasen. 1984). This is a 34-ltem scale designed to facilitate interviewer ratings of positive symptoms Including various types of hallucinations (e.g., voices conversing) and delusions, bizarre behavior (e.g., inappropriate social or sexual behavior), and positive formal thought disorder (e.g., loose associations). Each rating is made on a scale ranging from 0 (no evidence of this symptom) to 5 (severe). (8) Scale for the Assessment of Negative Svmptoms (SANS) -- (Andreasen. 1979a. 1979b). This 30-ltem scale is used to rate five specific negative symptoms: affective flattening, alogla (poverty of speech and thought), avolltion, anhedonia, and attentional impairment. As with the SAPS, each item on the SANS is rated on a five-point scale ranging from 0 (no evidence of this symptom) to 5 (severe). Andreasen (1982) reported an interrater reliability of for the SANS. 25

33 CHAPTER III STATISTICAL ANALYSES Demographic Characteristics of the Sample The three college student groups were generally similar to one another In terms of the numbers of persons classified in various demographic categories (see Table 2). There was one noteworthy exception, however. The College Anhedonic group had considerably more minority students than the other two groups. Sixty percent of the College Anhedonics were minority students while only 13% of the College Controls and only 27% of the College Per-Mags were minority students. Factors such as racial discrimination might affect the makeup of minority students' social networks. Therefore, within each of the three student groups, data was sorted into ethnic subgroups and means were calculated for (1) network size, (2) number of multiplex relationships, and (3) number of reciprocal relationships. Table 3 lists these means. Note that among the College Anhedonics, the average network size for Blacks, HIspanics and Asians was actually larger than the average network size of white students. On the other hand, minority student averages for number of multiplex and reciprocal relationships were somewhat lower than the corresponding averages for white students. Note further that among College Per-Mags, minority students often exceeded white students in average 26

34 Table 2: Demographic Characteristics of the Sample Average Age (range) Av. yrs. educ. completed Male Female College Controls 19.8 (18-25) College Per-Maas 19.5 (18-23) 12.7 Number of persons in < College Anheds 19.3 (18-26) Schiz Anheds 37.1 (22-51) 11.7 sach category: 10 5 Schiz Per-Maas 37.8 (23-51) White Black Hispanic Asian Married Divorced Separated Widowed Single (engaged) Single (not engaged) Living in family of origin home 2 on campus 8 in private house/apt. 5 in coop. apt. (staffed) Living alone 2 with family of origin 2 with same sex rmmt.(s) 9 with opp. sex rmmt.(s) 1 with spouse and/or children Unemployed Empolyed part time: Unskilled Skilled Self-emp. Employed full time (>30 hrsvwk) Unskilled Skilled Receiving public assist. no income <$3500 $ $5000 $ $9000 $ $20,

35 Table 3: Mean Network Size, Multiplexity, and Reciprocity of Minority College Students In Comparison to White Students College College College Controls Anhedonics Per-Mags White Hispanic White Black Hispanic Asian White Black Hispanic Asian Network Size Number of Multiplex Relshps Number of Reciprocal Relshps network size, average number of multiplex relationships, and average number of reciprocal relationships. To test whether these differences were statistically significant, univariate analyses of variance were performed. Network size, number of multiplex relationships and number of reciprocal relationships served as dependent variables. The ANOVAs indicated no significant differences between minority and white students within any of the three college student groups, with one exception. Black College Per-Mags reported significantly more reciprocal relationships than white College Per-Mags (F (1,10) = 20.24, p <.0001). It should be noted, however, that due to small ethnic group sample sizes (there were only two black College Per-Mags) and in light of the number of analyses performed, the difference between black and white College Per-Mags and the 28

36 lack of significant differences regarding the other ethnic groups should be interpreted cautiously. Multivariate analyses of variance were also performed to test for any effects attributable to gender. Separate MANOVAs for each of the college student groups with network size, number of multiplex and number of reciprocal relationships as the dependent variables indicated no significant differences when subjects were grouped according to gender. As mentioned above, the college student groups were generally composed uniformly with regard to the remaining demographic characteristics. The average age for each group was 19, and the average years of education completed was 12. Moreover, at the time of the interview, all of the students were attending college on a full-time basis (i.e., enrolled for at least 12 credit hours), the vast majority (84%) were employed half time or less, and only four of the 45 students had earned more than $9,000 in the past year. Almost all (93%) were single, and approximately half of each group resided on campus and had one, same sex roommate. College student data was collected for this study, in part, because It was assumed that college students' social lives-unlike the social lives of schizophrenics-would be relatively unaffected by extraneous factors such as the effects of antipsychotic medication or being stigmatized as a "mental patient." Data regarding the actual psychological/psychiatric treatment histories of the college students who participated in the study are summarized 29

37 Table 4: History of Psychiatric Treatment College College College Schiz Schiz Controls Anheds Per-Mags Anheds Per-Mags Number of persons in each group who received various types of treatment: Previous outpatient psychiatric treatment Currently receiving outpatient psychiatric treatment Currently taking psychiatric medication 1 o Previous Inpatient psychiatric treatment Previous outpatient substance abuse treatment Previous inpatient substance abuse treatment in Table 4, alongside the same data for the schizophrenic subjects. A total of eight of the college students reported having received some form of emotional/psychological treatment in the past, although only one, reported currently receiving treatment. The treatment experiences reported by the college students are briefly summarized here. In the College Control group, one person reported having been in Individual psychotherapy about a year ago for around eight weeks to address conflicts with a parent. Another College Control group member reported having been diagnosed with Attention Deficit Disorder by a psychiatrist several months ago and was now taking Ritalin (monthly medication checkups constituted the only treatment this subject was receiving 30

38 other than taking the medication itself). This was the only college student in any group who (1) reported currently receiving treatment, and (2) reported having taken any psychiatric medication at any time, past or present. Two College Anhedonics said they had previously participated in family therapy; one at age 16, and the other just prior to leaving for college this year. Four College Per-Mags said they had received some form of treatment. The most extensive Involved two years of weekly Individual psychotherapy for depression. The subject who reported this history stated the depression had been precipitated by a high school friend's suicide, and that the therapy - which had been beneficial ~ was terminated about one year before he entered college with no recurrence of the symptoms. Two other College Per-Mags reported brief therapy experiences (less than six sessions): crisis therapy following a car accident, and premarital couple's counseling. The fourth College Per-Mag reported having been referred by parents at around age 15 to see a psychiatrist for Inhalant (glue and halrspray) abuse. The treatment lasted approximately ten sessions. None of the college students in any group reported ever having been hospitalized for psychiatric or substance abuse treatment. The two schizophrenic groups were more balanced than the college student groups In terms of ethnic composition (see Table 2). Forty percent of the Schizophrenic Anhedonics and 53% of the Schizophrenic Per-Mags belonged to ethnic minorities. As shown in Table 5, the schizophrenics' social 31

39 Table 5: Mean Network Size, Multiplexity, and Reciprocity of Minority Schizophrenic Subjects in Comparison to White Schizophrenic Subjects Network Size White 23.6 Schizophrenia Anhedonics Black Hispanic White 34.6 Schizophrenia Per-Maas Black 41.8 Hispanic 29.3 Number of Multiplex Relshps Number of Reciprocal Relshps network data were similar to the college students' data when sorted according to ethnicity. In general, among Schizophrenic Anhedonics, mean network size, number of multiplex and number of reciprocal relationships for minority subjects were somewhat lower than for whites. In contrast, In most of these categories, minority Schizophrenic Per-Mags reported a higher mean number of relationships than did white Schizophrenic Per-Mags. Just as with the college student groups, ANOVAs comparing white and minority schizophrenics on social network variables were not significant. Again, this finding must be interpreted in light of the fact that sample sizes were small, thus serving to diminish the statistical capacity or power to demonstrate group differences. Also, there were no significant differences for either Schizophrenic Anhedonics or Schizophrenic Per-Mags in social network MANOVAs with subjects grouped according to gender. 32

40 Marital status (47% of both groups had never married) and living arrangements (73% of both groups either lived alone or with their families of origin) were generally consistent across the two groups. Another similarity was that fourteen of the fifteen persons In each schizophrenia group were unemployed. All but three of the schizophrenics received some sort of monthly public assistance income (these three were in the process of applying). Certain aspects of the schizophrenics' prior and current psychiatric treatment were of particular relevance to the questions addressed In this study. Table 6 presents data related to the past psychiatric hospitalizations and current medications of the schizophrenic subjects. A series of ANOVAs were performed to test for differences between the Schizophrenic Anhedonia and Table 6: Past Psychiatric Hospitalizations and Current Medication Dosages of Schizophrenic Subjects Average age at first psychiatric hospitalization Average number of psychiatric hospitalizations Average total days spent in a psychiatric hospital Average current daily dosage of antipsychotic medication (expressed in terms of chlorpromazine equivalent) (range) Schizophrenia Anhedonics mg (0 to 2000) Schizophrenia Per-Mags F(1.28) = p < F(1.28) = p < F(1.28) = p < mg F (1.28) = (100 to 2000) p <

41 Schizophrenic Per-Mag groups with regard to each of the four variables listed in Table 6, and the results are presented in the column on the far right. As presented in the table, the results of the ANOVAs indicated there were no significant differences between the schizophrenia groups with regard to age at first hospitalization, number of psychiatric hospitalizations, number of days spent In a psychiatric hospital, or current dosage of antipsychotic medication. Additional ANOVAs indicated there were no significant differences among the schizophrenia groups in terms of age (F (1,28) < 1, p <.9999) or years of education (F (1,28) < 1, p <.6789). Analyses Reoardina Social Network Variables As shown In Table 7, correlation matrices for each of the five groups did not indicate multicollinearlty or singularity among the dependent variables. None of the correlations exceeded a correlation of.9 which might have indicated multicollinearlty (Tabachnick & Fidell, 1989). An inspection of the distribution of the data within each group also indicated there were no outliers that might have affected the analyses. A series of one-way MANOVA planned comparisons was performed to determine whether three social network variables (network size, number of multiplex relationships, and number of reciprocal relationships) could be optimally weighted to maximize differences between the five subject groups. 34

42 Table 7: Correlations Among the Dependent Variables in the Five Groups College Controls Network Size Multiplexity Multiplexity.21 Reciprocity College Anhedonics Network Size Multiplexity Multiplexity.11 Reciprocity College Per-Mags Network Size Multiplexity Multiplexity.63 Reciprocity Schizophrenic Anhedonics Network Size Multiplexity Multiplexity.76 Reciprocity Schizophrenic Per-Mags Network Size Multiplexity Multiplexity.54 Reciprocity These planned comparisons served as the initial step In the statistical Inquiry of each of the major hypotheses addressed in this study. As a point of reference to accompany the results of these MANOVAs, Figures 1, 2 and 3 are graphs of the means for each of the five subject groups in terms of network size, number of multiplex relationships and number of 35

43 60 -T ~ ~ Coll Cntris Coll Anheds Coll Per- Mags Sz Anheds Sz Per- Mags (27-83) (21-58) (25-84) (10-50) (14-62) Figure 1 Group Means for Network Size (ranges are listed below) 36