Using the Scale for the Assessment of

Transcription

1 Thought, Laguage, ad Commuicatio i Schizophreia: Diagosis ad Progosis by Nacy C. Adrease ad William M. Grove Abstract Usig the Scale for the Assessmet of Thought, Laguage, ad Commuicatio (TLC), we examied the frequecy of "thought disorder" i 9 ormal voluteers ad psychiatric patiets ( each sufferig from maic disorder, schizoaffective disorder, schizophreic disorder, disorgaized type, ad schizophreic disorder, paraoid type). We observed the maics to have a substatial amout of thought disorder ad the ormals to have a modest amout, suggestig that thought disorder is probably ot pathogomoic of schizophreia. The patiets with affective illess did, however, show a somewhat differet patter of abormality. I particular, patiets with affective psychosis have more promiet positive thought disorder, while the schizophreic patiets ted to have more egative thought disorder. Evaluatio of the patiets moths later idicated that most types of thought disorder remit i the maics, while they persist i the schizophreics; patiets with schizoaffective disorder also ted to improve substatially. The strogest predictor of outcome was the presece of egative thought disorder. Ever sice the cocept of thought disorder was give preemiece i Bleuler's (9) coceptualizatio of schizophreia, the study of this importat symptom (or sig) has bee plagued by the absece of a commo groud of agreemet cocerig its defiitio or the best methods for assessig it. Bleuler's descriptio of associative looseig is relatively vague, ad util the recet eo-kraepeliia revival, Kraepehs (99) early descriptios of thought ad laguage abormalities were rarely cosulted. The Scale for the Assessmet of Thought, Laguage, ad Commuicatio (TLC) was origially developed i order to remedy this problem ad to provide a cosistet set of defiitios that could be used cliically ad that would have high reliability (Adrease 9, 99a, 99b). Because these defiitios were desiged for use i a cliical settig, they rely heavily o the aturalistic observatio of laguage behavior. While it is also possible to obtai idices of cogitive performace or "thought" usig formal tests to elicit disordered thikig, such as proverb iterpretatio or projective tests (Gorham 9; Shimkuas, Gyther, ad Smith 9; Adrease, Tsuag, ad Cater 9; Johsto ad Holzma 99), i a cliical settig we usually ifer a perso's thoughts directly from his speech. Cosequetly, the set of defiitios i the TLC emphasizes the observatio of laguage behavior as a way of evaluatig thought disorder. I our early work with these defiitios, we studied a sample of patiets sufferig from maia, depressio, ad schizophreia (Adrease 99a, 99b). We observed that the traditioal cocept of thought disorder, which empha- sizes the importace of associative looseig, was ot useful diagostically, sice may patiets sufferig from maia also exhibited associative looseig. O the other had, we observed some differeces betwee maic ad schizophreic patiets i their overall patter of subtypes of thought disorder. I particular, a distictio betwee positive ad egative formal thought disorder seemed to be useful, sice patiets Rept requests should be set to Dr N C Adrease, Dept of Psychiatry, Uiversity of Iowa, Iowa City, IA Dowloaded from by guest o November,

2 VOL., NO., 9 9 sufferig from schizophreia teded to have promiet poverty of speech ad poverty of cotet while maic patiets did ot. We cocluded that "thought disorder" is probably ot pathogomoic of schizophreia, as Bleuler origially suggested, although some patiets with schizophreia may show a type of thought disorder that is characterized by itellectual impoverishmet ad that is somewhat more characteristic of schizophreia. Sice our origial developmet of the TLC, a umber of other ivestigators have explored its usefuless (Harvey 9; Harvey, Earle-Boyer, ad Wielgus 9; Berebaum, Oltmas, ad Gottesma 9; Simpso ad Davis 9; Davis et al., i press). They have foud it to be highly reliable i a variety of differet settigs ad have supported the distictio betwee positive ad egative formal thought disorder. I our ow work o thought ad laguage i schizophreia, we felt it was importat to amplify our origial studies of thought, laguage, ad commuicatio i several differet ways. I particular, we were iterested i observig the extet to which ormal idividuals exhibit the types of TLC abormality observed i schizophreic patiets. Further, we were iterested i examiig the frequecy of thought, laguage, ad commuicatio abormalities i a trasitioal diagostic group, patiets with schizoaffective disorder, ad i subtypes of schizophreia. Fially, we were iterested i explorig whether either severity or type of thought disorder is predictive of outcome whe patiets are followed logitudially. Methods The patiets i this study were stratified ito four diagostic groups: each sufferig from maic disorder; schizoaffective disorder; schizophreic disorder, disorgaized or hebephreic subtype; ad schizophreic disorder, paraoid subtype. Patiets for each of these groups were recruited from cosecutive admissios to the Uiversity of Iowa Psychiatric Hospital. All diagoses were made usig the Research Diagostic Criteria (RDC) (Spitzer, Edicott, ad Robis 9). RDC diagoses were made based o data collected usig the Schedule for Affective Disorders ad Schizophreia (SADS) (Edicott ad Spitzer 9). A compariso or cotrol group cosisted of 9 ormal idividuals recruited from Iowa City ad earby commuities. Recruits were obtaied through advertisig i a local ewspaper. I order to match the cotrols to the patiets as closely as possible, ormal idividuals were icluded oly if they were uder age ad had less tha years' college educatio. The ormals were screeed for past history of major psychiatric illess (limited to those diagoses defied by the RDC), ad voluteers who had a curret or past history of these illesses were excluded. All subjects i the study were evaluated usig the Scale for the Assessmet of Thought, Laguage, ad Commuicatio (TLC) (Adrease 9). This istrumet cotais defiitios of subtypes of "thought disorder" ad has bee foud to have good iterrater reliability. The scale cotais both the defiitios ad istructios for ratig severity o a - or - scale (depedig o the item). To esure good reliability, defiitios are relatively specific, ad judgmet as to severity for each of the idividual items usually depeds o the frequecy with which a particular pheomeo has bee observed. Sice such frequecies may vary with the legth of the iterview, we have used a stadard -miute iterview. All subjects were evaluated with a stadardized iterview desiged to avoid a discussio of the patiet's psychopathology (available from N.C.A. o request). This iterview begis by havig each subject talk about himself for as log as possible (for at least miutes) without iterruptio, i respose to the prompt, "Could you tell me a little bit about what you're like, such as where you're from, what you're iterested i, ad thigs like that?" If the patiet had difficulty i elaboratig his respose, ospecific prompts such as "Could you tell me a little more about that" were used. After the iitial moologue, additioal prespecified questios i the iterview covered a variety of topics, such as politics, religious beliefs, ad family life. Ratigs of thought, laguage, ad commuicatio were doe "live," ad score sheets were filled out immediately after the iterview, ad after the patiet had left the room. Because it defies types of thought disorder, the TLC is a complicated scale; cosequetly, raters usually make otes durig the iterview about the frequecy of idividual pheomea ad complete the score sheet immediately after the iterview. Iterviews were coducted either by oe of the authors (W.M.G.) or by a research assistat with a bachelor's degree i psychology who had bee traied i the use of the scale by oe of the authors. All iterviews were also tape-recorded ad trascribed for later aalysis, but all the data i this article are based o the live iterviews. The stadardized iterview coverig eutral topics was used i order to keep the iterviewer as blid Dowloaded from by guest o November,

3 SCHIZOPHRENIA BULLETIN to the patiet's diagosis as possible. Discussio of the patiet's psychopathology was avoided. Nevertheless, i a "live" situatio, some clues are ievitably provided. Quite simply, maics ted to talk more ad more rapidly, ad ormals ted to appear relatively ormal ad umedicated. Thus, the use of live ratigs does itroduce some potetial bias which could be avoided by usig either tapes or trascribed samples. For the preset ivestigatio, however, our primary goal was to obtai the most accurate ratigs of thought disorder that would be possible, ad we felt this goal was best achieved through the use of live iterviews. We have ot as yet completed ratigs of thought disorder usig live versus taped versus trascribed samples, but we aticipate that estimated severity is likely to icrease as oe becomes more removed from the live situatio, sice itoatios, gestures, ad iterpersoal iteractio ted to make speech appear more comprehesible. Thus, i this ivestigatio, we used all possible safeguards to maximize blidess, but we recogize that blidess is probably ot complete. Evaluatio of trascripts might provide the most rigorous test of the frequecy of abormalities i ormals versus various groups of patiets, although with the possible hazard of overestimatig the degree of abormality i all groups. To give some idicatio of geeral itelligece, all ormals ad patiets were also evaluated with the Shipley Istitute of Livig Scale. Patiets were evaluated durig the first week after admissio, usually i the first days. Nearly all were receivig medicatio at the time of evaluatio, sice medicatios are usually prescribed at Iowa Psychiatric Hospital withi the first day or two after admissio to reduce legth of stay. Despite this, all were still severely symptomatic ad maifested a full ad typical maic, schizophreic, or schizoaffective sydrome. I a few istaces, patiets who were admitted cosecutively ad met iclusio diagostic criteria had respoded to medicatio so quickly that they o loger maifested the full maic sydrome durig the first week; these patiets were therefore ot iterviewed with the TLC ad ot icluded i the study. We coducted a followup evaluatio with the patiets moths after the idex evaluatio. At followup, all available patiets were examied with a abridged versio of the SADS (SADS-C) ad with the Global Assessmet Scale (GAS) (Edicott et al. 9) ad the TLC. We were able to obtai followup evaluatios o approximately percet of the origial sample. These were divided evely across the various diagostic cells. No sigificat differeces i diagosis, sex ratio, age, or severity of illess were observed betwee those patiets whom we were successful i followig up ad those who could ot be iterviewed at the followup evaluatio. Results Demographic ad other characteristics of the subjects are summarized i table. I geeral, all subjects are relatively similar i age, educatioal status, sex ratio, ad itelligece (as assessed by the Shipley). As might be expected, the patiets do differ substatially from oe aother i duratio of the curret episode ad total amout of time spet i the hospital durig previous episodes. I particular, the two schizophreic groups had cosid- Dowloaded from by guest o November, Table. Demographic ad other characteristics of subjects Normals ( = : 9) Maics ( = ) Schizoaffectives ( = ) Hebephreics ( = ) Paraoids ( = ) Mea SD Mea SD Mea SD Mea SD Mea SD Age () female Educatio, years Shipley-Hartford Duratio of episode, weeks Time i hospital, total weeks (9) () () () ()

4 VOL., NO, 9 erably greater chroicity, while the maics had the least chroicity. Table idicates the frequecies with which the various types of thought, laguage, ad commuicatio abormalities were observed i the ormal idividuals ad the four patiet groups. It is iterestig to ote that some TLC "abormalities" occur i the speech of ormal idividuals; i particular, the ormals showed a relatively large amout of derailmet ad loss of goal. The patiet groups differ sigificatly from oe aother o early all types of laguage abormality that occur with ay frequecy. Maic speech teds to be fluet ad disorgaized, as maifested by a high rate of pressure of speech, derailmet, loss of goal, circumstatiality, icoherece, ad illogicality. The schizoaffectives show a less severe but similar type of abormality, with a somewhat greater frequecy of poverty of speech ad a lesser frequecy of pressure of speech. Hebephreic speech teds to be empty (high ratigs o poverty of speech ad poverty of cotet), but also very disorgaized (high frequecy of derailmet, icoherece, ad illogicality). The paraoid patiets show a similar but less severe patter, particularly with less poverty of cotet ad icoherece. Followig are illustrative examples of some of the abormalities observed i these various groups: Normal I: Tell me about your work. What do you like about it the most, ad why P: Oh, it's easy work for the pay. I guess that's what I like about it the best. It has good beefits. Uh, my hours are pretty good, except whe I have to work -hour days. Sometimes I get stuck with the to shift. That's kid of a drag. Ur, it's mostly older people that come ito the grocery store, sice it's up i the Polish eighborhood, I guess, of Iowa City. I thik they come there mostly for somebody to talk to. They do't have aythig else to do, most of them are retired. Uh, I like to sew. I wet ad got a ew sewig machie this week, ad I pla o makig a dress for Noelle for Christmas. like to swim, I have't had the chace sice I was pregat Table. Frequecies of thought, laguage, ad commuicatio abormalities ' amog groups Poverty of speech Poverty of cotet Pressure of speech Distractible speech Tagetiallty Derailmet Icoherece Illogicality Clagig Neologisms Word approximatios Circumstatiality Loss of goal Perseveratio Echolalia Blockig Stilted speech Self-referece Normals Maics 9 Paraoids 9 Schizoaffectives Hebephrelcs Chisquare* P Dowloaded from by guest o November, Global ratig 9.. 'Criterio: Ratig >. 'Betwee patiet groups, ormals excluded.

5 SCHIZOPHRENIA BULLETIN ad I have't goe back yet I like little kids. I hope I'll have some more, but I do't kow whether I'll be able to afford it Um, let me thik. I voted today. Maic I: So, to begi with, could you tell me a little bit about yourself, thigs like where you're from P: I'm from Cedar Rapids, ad I live with my parets. My parets are the holy family, part of it. My brother lives i Omaha, ad he's part of the holy family He's Jesus I'm the daughter of God, ad my sister's pregat ad she has a part i the holy family ad God kows what I'm goa do ext. God has preplaed, has plaed my life, ad I'm ot afraid to speak for the, for the ufortuate as for the fortuate, ad for the stars ad for Stella ad for, ad for, ad for myself. I'm a big star I just have't grow eough, um, God ad the Holy Spirit help me. Ad without, without my frieds I would be othig. Without my music I'm a vegetable. Without my, my urses which have, heroes, the wome are the heroes, the me are the heroes, but there's a champio that, that's bee sufferig. That all ow? Schizophreic I: Why do't you tell me a little bit about what you thik about curret political issues, like the eergy crisis, for example. P: They're destroyig too may cattle ad oil ]ust to make soap. If we eed soap whe you ca ump ito a pool of water ad the whe you go to buy your gasolie, m-my folks always thought they should, get pop but the best thig to get, is motor oil, ad moey. May as well go there ad trade i some, pop caps ad, uh, tires, ad tractors to grup, car garages, so they ca pull cars away from wrecks, is what I believed i To obtai a perspective o how patiets' speech differs from ormal speech i its descriptive characteristics, we compared the mea scores for each of the patiet groups to that of the ormals. Because of the large umber of comparisos, we used a somewhat coservative. sigificace level, rather tha the more customary. level. At this level, the maics showed sigificat differeces o pressure of speech, distractibility, derailmet, icoherece, illogicality, circumstatiality, loss of goal, ad perseveratio. The schizoaffectives showed fewer differeces, havig oly more pressured speech, derailmet, ad illogicality. The hebephreic patiets had sigificatly higher ratigs o poverty of speech, poverty of cotet, tagetiality, derailmet, icoherece, illogicality, word approximatios, ad perseveratio. The paraoids had sigificatly higher ratigs o poverty of speech, poverty of cotet, derailmet, icoherece, ad illogicality. Tables - explore our ability to replicate our previous work. Oe major aspect was the divisio of TLC abormalities ito positive versus egative thought disorder. I our previous study, this cocept was more useful i distiguishig maics from schizophreics tha was a descriptio ivolvig loose associatios. Table shows the mea scale scores of the four diagostic groups for positive versus egative formal thought disorder ad loose associatios. The score for positive versus egative formal thought disorder was developed by subtractig two idices of egative formal thought disorder (poverty of speech ad poverty of cotet) from the sum of pressure of speech, tagetiality, derailmet, icoherece, ad illogicality. The score for loose associatios cosists of a sum of five types of thought disorder ofte cosidered to be maifestatios of loose associatios: tagetiality, derailmet, icoherece, illogicality, ad clagig. Table also shows a aalysis of variace (ANOVA) for positive versus egative formal thought disorder. The four groups differ sigificatly o this variable at the. level. Followup tests idicate that the sigificace is due to differeces betwee maics ad other patiets, maics ad schizoaffectives, ad maics ad schizophreics. Thus, the results of this secod study cofirm the usefuless of the positive versus egative distictio i discrimiatig betwee maic formal thought disorder ad various types of schizophreic formal thought disorder. Table also shows the ANOVA for loose associatios. This ANOVA is also sigificat, although to a somewhat lesser degree. The followup tests idicate that this costruct may be more useful i discrimiatig betwee various traditioal subtypes of schizophreia. The followup tests idicate sigificat cotrasts betwee the schizoaffectives ad the schizophreics, ad betwee the hebephreics ad the paraoids. I our 99 article (Adrease 99a, 99b), we did ot fid sigificat differeces betwee maics ad schizophreics whe we used a similar measure of "loose associatios. We did ot, however, stratify by schizophreic subtype or iclude schizoaffectives i the sample; therefore, we could ot make subtype comparisos. Table compares the discrimiat fuctio weights geerated from our earlier work ad from the preset ivestigatio. The weights developed from the two samples are somewhat differet. I our first sample, poverty of speech ad derailmet were somewhat more importat as discrimiators tha they are i the Dowloaded from by guest o November,

6 VOL., NO., 9 Table. Compariso of diagostic groups o formal thought disorder ratigs Variable Positive-egative formal thought disorder' Loose associatios Source Groups Error Total Cotrasts Maic vs. other patiets Schlzoaffective vs. schizophreic Hebephreic vs. paraoid Affective symptoms vs. oaffectlve Maic vs. schizoaffective Maic vs. schizophreic df Maics ( = ) df Mea 9..9 SD. 9. Schlzoaffectives ( = ) Mea..99 ANOVA for positive-egative formal thought disorder Sums of squares Mea square F P. t P SO.. df 9 99 df Hebephrelcs ( = ) Mea Paraoids ( = ) SD Mea SD ANOVA for loose associatios Sum of Mea squares square F t 'Idividual ratigs were trasformed to have a mea of ad a stadard deviatio of. 'Sum of pressure of speech, tagetlality, derailmet, Icoherece, ad Illogicality, less sum of poverty of speech ad poverty of cotet. 'Sum of tagetlality, derailmet, icoherece, Illogicality, ad clagig. preset sample, while i the curret sample, illogicality has bee icluded with a egative weightig. However, the 99 discrimiat fuctio performed very successfully i classifyig the secod replicatio sample. Usig the 99 fuctio o the 99 sample, we correctly classified percet of maics ad schizophreics. Whe applied to the preset sample for class crossvalidatio, this fuctio correctly classifies percet of the cases. We also used jackkife procedures i order to apply the ew fuctio derived from the curret sample ad foud that it correctly classified percet of that sample. These results provide a relatively strog cofirmatio of our earlier work, suggestig that examiig various subtypes of TLC abormality may be quite useful i distiguishig maics from schizophreics o the basis of their laguage behavior. Tables ad compare the frequecy of TLC abormalities i the 99 ad the curret sample i order to explore what might be called replicability. The ratigs o the curret sample were completed by differet iterviewers from those who collected the 99 sample. The patiets were, of course, completely P. P differet, although the size of the diagostic cells for maia ad schizophreia is quite similar. The frequecy of ratigs shows surprisig stability from oe study to aother. The oly sigificat differeces betwee the two studies are the global ratig for schizophreics ad the ratig of tagetiality for maics. Table cotais a orthogoal factor aalysis of the TLC variables. The results of this aalysis yielded three factors from Cattell's scree test. After rotatio to simple structure by ormalized Varimax rotatio, the first factor might be termed a "fluet disorgaizatio" factor, with high Dowloaded from by guest o November,

7 SCHIZOPHRENIA BULLETIN Table. Compariso of discrimiat fuctios betwee maics ad schizophreics Stadardized discrimiat weight Fuctio from Fuctio from replicatio 99 sample sample Variable ( = ) ( = ) Poverty of speech Poverty of cotet Pressure of speech Distractible speech Derailmet Illogicality Loss of goal Correctly classified 'Cross-validatio performace Estimated performace by Jackkife ' Table. Compariso of thought, laguage, ad commuicatio abormalities for schizophreics: 99 vs. replicatio sample Variable Poverty of speech Poverty of cotet Pressure of speech Distractible speech Tagetiality Derailmet Icoherece Illogicality Clagig Neologisms Word approximatios Circumstatiality Loss of goal Perseveratio Echolalia Blockig Stilted speech Self-referece 99 ( sample = ) 9 Replicatio sample ( = ) positive loadigs o pressure of speech, derailmet, icoherece, illogicality, loss of goal, ad perseveratio, ad a high egative loadig o poverty of speech. Factor appears to be a "emptiess" factor, with high positive loadigs o poverty of speech, poverty of cotet, ad tagetiality ad a egative loadig o pressure of speech ad circumstatiality. Factor might be cosidered to be a "liguistic cotrol" factor, with high positive loadigs o stilted speech ad persistet self-referece ad egative loadigs o clagig ad eologisms. The compoets i this third factor occur so ifrequetly, Chi-square P' Dowloaded from by guest o November, Global ratig 9.. 'Criterio ratig > 'Where o statistic is reported, Fisher's exact test was used

8 VOL., NO., 9 Table. Compariso of thought, laguage, ad commuicatio abormalities for maics: 99 vs. replicatio sample Variable Poverty of speech Poverty of cotet Pressure of speech Distractible speech Tagetiality Derailmet Icoherece Illogicality Clagig Neologisms Word approximatios Circumstatiality Loss of goal Perseveratio Echolalia Blockig Stilted speech Self-referece Global ratig 99 ( sample = ) 'Criterio: ratig >. Where o statistic is reported, Fisher's exact test was used. however, that it caot be cosidered to be a very importat oe. Table shows the frequecy of TLC abormalities i the various diagostic groups at the time of followup. We did ot follow up the ormal idividuals, but their rates at the idex evaluatio are icluded i table for compariso. As table 9 idicates, the maic patiets have remitted sigificatly at followup, as have the schizoaffectives. The speech of the maics has essetially ormalized. So, too, has that of the schizoaffectives, although they cotiue to have a somewhat high rate of poverty of speech. O the other had, the schizophreic patiets cotiue to have relatively Replicatio sample ( = ) persistet disorgaizatio. Whe mea ratigs betwee idex evaluatio ad followup evaluatio are compared, the hebephreics show a sigificat chage oly i pressure of speech ad icoherece (i the directio of improvemet), while the paraoids show o sigificat differeces. Thus, the laguage abormalities i the schizophreics ted to persist at followup. We were iterested i determiig whether the type ad amout of thought disorder show by these patiets was i ay sese predictive of the severity of their sydrome at followup. Therefore, we examied the correlatio betwee outcome, as measured by the Global Assessmet - Chl-square* P Scale, ad positive versus egative thought disorder (as previously defied). Table 9 shows that egative formal thought disorder is moderately correlated with outcome, as idicated by absolute GAS rarig ad by the degree of chage i the GAS from idex evaluatio to followup. Thus, the presece of egative formal thought at idex evaluatio predicts a poor outcome at followup. O the other had, positive formal thought disorder has little progostic sigificace whe used to predict outcome amog psychotic patiets i geeral. The lack of correlatio appears to occur because maic patiets, who have a relatively high rate of positive formal Dowloaded from by guest o November,

9 SCHIZOPHRENIA BULLETIN Table. Factor aalysis of thought, laguage, ad commuicatio variables amog patiets Loadig o factor Variable Poverty of speech Poverty of cotet Pressure of speech Distractible speech Tagetiality Derailmet Icoherece Illogicality Clagig Neologisms Word approximatios Circumstatiality Loss of goal Perseveratio Echolalia Blockig Stilted speech Self-referece Fluet disorgaizatio of variace. Cumulative of variace. thought disorder, have a good outcome, but its predictive power washes out whe maic patiets are pooled with schizophreic patiets (who may have a high rate of positive formal thought disorder ad a relatively poor outcome). Discussio This larger ad more extesive study of thought, laguage, ad commuicatio i schizophreia, schizoaffective disorder, ad maia has replicated a umber of our previous fidigs ad has elaborated them further. Take together with our previous work, the curret study suggests that the global cocept of "thought disorder" should ot be cosidered to be pathogomoic of schizophreia Emptiess or diagostic of it. The preset study idicates that mild abormalities i laguage behavior eve occur i ormal idividuals. Derailmet, the closest sigle equivalet to Bleuler's "associative looseig," is the most commo type of "abormality" observed. Further, patiets with maia ad schizoaffective disorder also display promiet abormalities i thought, laguage, ad commuicatio. If aythig, the abormalities are more proouced i patiets with maia tha i those with schizophreia. The preset study provides additioal support for the utility of subdividig the global cocept of thought disorder ito a variety of subtypes. The TLC distiguishes betwee differet subtypes. Some of these, however, are relatively Liguistic cotrol Commoality ucommo; some types of thought disorder that have frequetly bee widely described ad discussed i the past are amog those that are relatively ucommo, such as blockig or eologisms. Whe the rate of the various subtypes of thought disorder is observed across four diagostic groups, iterestig differeces i quality ad severity of formal thought disorder are observed. The abormalities see i maia appear to be qualitatively differet from those observed i schizophreia. I particular, patiets with maia have a more promiet positive thought disorder, while patiets with schizophreia have a more promiet egative formal thought disorder. The distictio betwee positive ad egative formal thought disorder Dowloaded from by guest o November,

10 VOL., NO., 9 Table. Frequecies of thought, laguage, ad commuicatio abormalities amog diagostic groups at followup Variable Poverty of speech Poverty of cotet Pressure of speech Distractible speech Tagetiality Derailmet Icoherece Illogicality Clagig Neologisms Word approximatios Circumstatiality Loss of goal Perseveratio Echolalla Blockig Stilted speech Self-referece Global ratig Normal ( = : 9) 'Criterio: Ratig >. Betwee patiet groups, ormals excluded. may have more cliical utility tha the traditioal cocept of associative looseig. Both approaches to coceptualizig thought disorder were examied i the four diagostic groups. The distictio betwee positive versus egative thought disorder was useful i separatig maics from all other patiets, from Maic ( = : ) Schlzoaffective ( = 9) Hebephrelc ( * = ) 9 schizoaffectives, ad from schizophreics. O the other had, associative looseig is sigificatly more severe i schizophreics tha i schizoaffectives, ad withi the schizophreic group more severe i the hebephreics tha i the paraoids. These results suggest that, withi the schizophreia spectrum, Table 9. Correlatio betwee idex formal thought disorder ad outcome as measured by Global Assessmet Scale Positive FTD Negative FTD GAS.9. Chage i GAS ' P Note.GAS = Global Assessmet Scale; FTD = formal thought disorder Paraoid ( = ) Chl-square P the degree of disorgaizatio (as maifested by associative looseig) may be useful i idetifyig more severe illesses (i.e., pure schizophreia versus schizoaffective disorder or hebephreic versus paraoid schizophreia). O the other had, withi the broad spectrum of psychosis, the fluecy ad productivity of laguage behavior may be more importat for distiguishig betwee affective psychosis ad "core" schizophreia. Whe laguage behavior is observed logitudially i psychotic patiets, the patiets appear to differ substatially i course ad outcome. Patiets sufferig from maia ted to improve markedly ad to have esse- Dowloaded from by guest o November,

11 SCHIZOPHRENIA BULLETIN tially reversible abormalities. O the other had, the schizophreic patiets ted to have relatively persistet abormalities. Patiets with schizoaffective disorder resemble the maics ad improve, but to a somewhat lesser degree. This fidig is iterestig sice, at idex evaluatio, the schizoaffectives are more similar to the schizophreics; at outcome, however, they more closely resemble the maics. This fidig is probably idicative of some heterogeeity withi the schizoaffective group, but it may also idicate that schizoaffective disorder is a trasitioal diagosis ad (as defied by the RDC) represets a illess that resembles schizophreia pheomeologically but which has a relatively better outcome. The overall good outcome i patiets with pure maic pheomeology or some ticture of maic pheomeology suggests that the laguage disorgaizatio i maia is probably due to a differet mechaism tha that occurrig i schizophreia. The type of thought disorder observed iitially may provide some progostic idicatio. Patiets who maifest a promiet egative thought disorder are less likely to have global improvemet or remissio, as idicated by the Global Assessmet Scale. Thus, egative thought disorder, whe preset, may be predictive of a poor outcome. O the other had, positive thought disorder is ot a useful progostic idicator. Some patiets with positive thought disorder will remit or improve, while others will ot Based o these observatios, the Scale for the Assessmet of Thought, Laguage, ad Commuicatio (TLC) appears to be a useful tool for the cliical assessmet of laguage behavior i the major psychoses. The results show good cosistecy from oe study to aother, with relatively stable rates of the various TLC abormalities across two differet samples ad good cross-validatio of a discrimiat fuctio. Thus, the defiitios that it cotais appear to have utility both i the real world of the cliic ad as a research tool. Refereces Adrease, N.C. The Scale for the Assessmet of Thought, Laguage, ad Commuicatio (TLC). Iowa City: The Uiversity of Iowa, 9. Adrease, N.C. Thought, laguage, ad commuicatio disorders: I. Cliical assessmet, defiitio of terms, ad evaluatio of their reliability. Archives of Geeral Psychiatry, :-, 99a. Adrease, N.C. Thought, laguage, ad commuicatio disorders: II Diagostic sigificace. Archives of Geeral Psychiatry, :-, 99b. Adrease, N.C, Tsuag, M.T.; ad Cater, A. The sigificace of thought disorder i diagostic evaluatio. Comprehesive Psychiatry, :-, 9. Berebaum, H.; Oltmas, T.F., ad Gottesma, I.I. Formal thought disorder i schizophreics ad their twis. Joural of Abormal Psychology, 9:-, 9. Bleuler, E. Demetia Praecox, or the Group of Schizophreias. (9) Traslated by J. Ziki. New York: Iteratioal Uiversities Press, 9. Davis, G.C.; Simpso, D.M.; Foster, D.; Ariso, Z.; ad Post, M. Reliability of Adrease's Thought, Laguage, ad Commuicatio Scale. Joural of Cliical Psychiatry, i press. Edicott, J., ad Spitzer, R.L. A diagostic iterview: The Schedule for Affective Disorders ad Schizophreia (SADS). Archives of Geeral Psychiatry, :-, 9. Edicott, J.; Spitzer, R.L.; Fleiss, J.; ad Cohe, J. The Global Assessmet Scale: A procedure for measurig overall severity of psychiatric illess. Archives of Geeral Psychiatry,.-, 9. Gorham, D.R. Use of the proverbs test for differetiatig schizophreics from ormals. Joural of Cosultig Psychology, :-, 9. Johsto, M.H., ad Holzma, P.S. Assessig Schizophreic Thikig. Sa Fracisco: Jossey-Bass, Publishers, 99. Kraepeli, E. Demetia Praecox ad Paraphreia. Traslated by R.M. Barclay. Ediburgh: E. & S. Livigstoe, 99. Harvey, P.D. Speech competece i maic ad schizophreic psychoses: The associatio betwee cliically rated thought disorder ad cohesio ad referece performace. Joural of Abormal Psychology, 9:-, 9. Harvey, P.D.; Earle-Boyer, E.A.; ad Wielgus, M.S. The cosistecy of thought disorder i maia ad schizophreia: A assessmet of acute psychotics. Joural of Nervous ad Metal Disease, :-, 9. Shimkuas, A.M.; Gyther, M.D.; ad Smith, K Schizophreic resposes to the proverbs test: Abstract, cocrete, or autistic? Joural of Abormal Psychology, :-, 9. Simpso, D.M., ad Davis, G.C. Measurig thought disorder with cliical ratig scales i schizophreic ad oschizophreic patiets. Psychiatry Research, :-, 9. Dowloaded from by guest o November,

12 VOL., NO., 9 9 Spitzer, R.L.; Edicott, J.; ad Robis, E. Research Diagostic Criteria: Ratioale ad reliability. Archives of Geeral Psychiatry, :-, 9. Ackowledgmet The research reported was supported i part by Natioal Istitute of Audio Tapes o Schizophreia Available Metal Health, Grat MH-9; a Scottish Rite Schizophreia Research Grat; the Nelle Ball Foudatio; ad Grat RR9 from the Geeral Cliical Research Ceters Program, Divisio of Research Resources, Natioal Istitutes of Health. Guilford Publicatios aouces Schizophreia: Iterview Strategies for Detectig Characteristic Symptoms, a traiig model by BMA Audio Cassettes. Developed at the UCLA Neuropsychiatric Istitute by Dr. Ia Falloo ad Dr. David Lukoff, the package icludes two cassette tapes ad a useful maual with istructive iformatio desiged for researchers, psychiatric residets, ad psychology iters. The program focuses o perceptual, thought, ad commuicatio dysfuctios specific to schizophreia. Drs. Falloo ad Lukoff use a experietial, iteractive approach to demostrate how to elicit ad evaluate distictive qualities of a patiet's experiece ad to relate this iformatio to today's complex diagostic stadards. The program addresses the assessmet of thought iterferece, halluciatios, delusios, ad speech ad behavioral disturbaces. Clear defiitios of symptoms, dramatized iterviews, ad critical commetary ecourage listeers to develop their ability to The Authors Nacy C. Adrease, M.D., Ph.D., is Professor of Psychiatry, ad William M. Grove, Ph.D., is Research Associate, Departmet of Psychiatry, Uiversity of Iowa, Iowa City, LA. detect characteristic idicators of schizophreia, as they compare their ow coclusios with those of the authors. BMA also offers The Iitial Iterview: Evaluatio Strategies for DSM-III Diagosis, by Robert Spitzer, M.D., ad Jaet Williams, D.S.W., A.C.S.W. This set of tapes presets iterviewig strategies which ca be applied across the full rage of DSM-III, while focusig o four represetative symptom types (axiety, depressio, crisis adjustmet, ad psychosis). The program demostrates the Structured Cliical Iterviews for DSM-III (SCID) method which Drs. Spitzer ad Williams pioeered to gather more reliable iformatio from cofused or relatively iarticulate patiets ad to establish procedural guidelies for iterviewig. For more iformatio or to order, write to BMA Audio Cassettes, Park Aveue South, New York, NY or call toll-free --9 (i New York State ad Caada, call --9). Dowloaded from by guest o November,