psychotic symptoms in schizophrenia after the acute phase*

608 SCHIZOPHRENIA BULLETIN psychotic symptoms in schizophrenia after the acute phase* Martin Harrow and Marshall L. Silverstein Concepts about the nature of schizophrenia and psychosis have been challenged by a number of new findings in the area. One of the central ideas associated with a diagnosis of schizophrenia has been the anticipation of an extremely negative outcome, and a negative symptomatic outcome in particular. This belief has been sharply questioned in recent years, in regard to relatively young, acute schizophrenics, by the work of Strauss and Carpenter and others, who found evidence suggesting relatively small differences in functioning between schizophrenics and nonschizophrenics some years after hospitalization (Strauss and Carpenter 1972 and Hawk, Carpenter, and Strauss 1975). In an earlier phase of our own work, using a young, acute sample, we found smaller differences between schizophrenic and nonschizophrenic psychiatric patients than once would have been expected, although the overall indices of functioning still showed significant differences (Harrow, Bromet, and Quinlan 1974). Another of our recent studies using young schizophrenic patients has shown considerable differences in overall outcome between schizophrenic and nonschizophrenic patients (p<.001), although again the differences are not so large as reports many years ago would have suggested (Harrow et al. 19776). The recent results in this area, especially those indicating very small differences, bring into question traditional concepts of schizophrenia based on ideas of a downhill clinical course and persistent psychosis. While there has been some questioning of traditional ideas about schizophrenia, the diagnosis has usually *Reprint requests should be addressed to the senior author at the Psychosomatic and Psychiatric Institute, Michael Reese Hospital and Medical Center, 29th St. and Ellis Ave., Chicago, IL 60616. been closely linked to the presence of psychotic symptoms. It would thus seem logical that interest in the distinction between schizophrenic and nonschizophrenic disorders, both during the acute phase and afterwards, should center on psychotic symptoms as the key aspect of schizophrenia. Surprisingly, however, there have been relatively few systematic studies of outcome focusing on this aspect of schizophrenia. A recent study by Astrachan et al. (1974) did reveal a large percentage of schizophrenics with both neurotic and psychotic symptoms during the followup phase of their disorder. However, this study employed an older, more chronic schizophrenic sample, and did not include a comparative sample of nonschizophrenics to assess ways in which schizophrenics might differ from other disordered patients. Thus, an assessment of the type and extent of psychotic symptoms in relatively young schizophrenic and nonschizophrenic patients during the postacute and recovery stages could provide valuable information concerning schizophrenia as a disorder distinct from other pathological states. Whether psychotic symptoms are present or absent in schizophrenics during the postacute period after hospital discharge is an important question that might shed light on what features of schizophrenia are essential to the disorder. A number of outcome studies have focused on the postpsychotic functioning of schizophrenic patients in terms of their work and social functioning (Freeman and Simmons 1963, Hawk, Carpenter, and Strauss 1975, and Stephens 1970). Although these data are of value, many of the most crucial questions about schizophrenia revolve around psychotic symptoms their nature, extent, and persistence, and how they relate to other aspects of functioning. The presence, during the postacute period, of Kurt Schneider's (1959) first rank symptoms of schizophrenia

VOL. 3, NO. 4, 1977 609 (based on 11 psychotic features) is also an important subject for investigation. Since many clinicians, especially in Europe, regard these symptoms as pathognomonic of schizophrenia, their presence during the posthospital period could provide further information about which psychotic features are essential characteristics of schizophrenia. In an attempt to resolve some of the questions discussed above, the present study addressed the following issues: Are psychotic symptoms a prominent characteristic of some or all schizophrenic patients after the acute phase? For relatively young patients, does the presence of psychotic symptoms distinguish schizophrenic from nonschizophrenic patients during the posthospital period? For which subtypes of schizophrenia (e.g., acute schizophrenics, chronic schizophrenics, paranoid schizophrenics) are psychotic symptoms most prominent during the posthospital phase? Which of the various types of psychotic symptoms (e.g., delusions, hallucinations, other sensory aberrations, and strange experiences) persist for schizophrenic patients? Are Schneiderian first rank symptoms a prominent feature of schizophrenia during the postacute phase, and do these symptoms distinguish schizophrenics from nonschizophrenics? Method Patient Sample Ninety-four young psychiatric patients from Michael Reese Medical Center who ranged in age from 17 to 35 (mean age 22.6 years) were studied at the time of hospitalization and later during the posthospital period. The followup assessment took place an average of 2.94 years after the patients' discharge from acute psychiatric hospitalization (71 percent of the schizophrenic sample was evaluated for posthospital psychosis at least 3 years after discharge). The patients who were almost entirely from Hollingshead-Redlich social classes 1, 2, and 3 were part of an ongoing multidisciplinary schizophrenia project being conducted since 1970 at Michael Reese Hospital and the University of Chicago (Grinker and Holzman 1973, Harrow et al. 1977<7, and Holzman and Grinker 1974). The total sample consisted of two major subgroups: 60 schizophrenic and 34 nonschizophrenic patients. Diagnoses were determined at the time of the index hospitalization by consensus of two senior clinicians using standard diagnostic criteria (DSM II) and were based upon an extensive clinical interview, detailed knowledge of previous history, initial hospital behavior, and presenting clinical picture. The schizophrenic population (mean age 22.4 years) included a subsample of 10 acute schizophrenics, 16 paranoid schizophrenics, 1 and 19 relatively young chronic schizophrenics. Fifty-six percent of the schizophrenics were males and 44 percent were females. The nonschizophrenic sample (mean age 22.8 years) comprised 20 depressive disorders, 8 severe personality disorders, and 6 patients with other diagnoses. Thirtyeight percent were males and 62 percent were females. There were no significant differences between the schizophrenic and nonschizophrenic patient samples in age, education, intellectual level, or length of time since hospitalization. At the time of the followup assessment, 52 percent of the schizophrenics were taking phenothiazines. Data Collection and Psychotic Symptoms The major assessment interview used was the Silverstein-Harrow revision of the current form of the Wing Present State Examination (Wing, Cooper, and Sartorius 1974), which had been modified by Strauss and Carpenter (see World Health Organization 1973). This structured interview, which we have labeled the Psychotic Symptoms Inventory (PSI), was designed to provide information on the presence and severity of psychotic symptomatology during the posthospital period. The interview covered 17 types of psychotic signs and symptoms, including: (1) delusions (thought control, thought dissemination, ideas of control, reference, persecution, depressive delusions, nihilistic delusions, gran- 1 AII but a few of these paranoid patients had some chronic or long-term features, and thus the group could also be labeled as chronic-paranoid schizophrenics.

610 SCHIZOPHRENIA BULLETIN deur, religious delusions, etc.); (2) hallucinations (in all sensory modalities); and (3) nonhallucinatory sensory aberrations and strange experiences, including severe depersonalization and derealization. Items covering all of Schneider's 11 first rank symptoms of schizophrenia were included in the interview, and a composite score for first rank symptoms was obtained. The ratings of the 17 signs and symptoms were combined into composite scores on 3-point scales (1 = feature absent; 2 = an intermediate rating for weak or infrequent features, psychotic symptoms that were probable but not absolutely certain, or where very good perspective was shown by the patient; and 3 = feature present). The composite ratings covered the following three areas: Delusions the presence of at least one type of delusional phenomenon. Hallucinations-auditory, visual, tactile, gustatory, or olfactory. Other sensory aberrations or strange experiences the presence of somatic aberrations, severe depersonalization or derealization, and related strange or bizarre phenomena. This category was typically reserved for aberrations that were psychotic in nature but were not classical hallucinatory or delusional phenomena. A summary labeled "Overall Psychotic Symptoms" and combining ratings for psychosis was also scored, based on the presence of at least one of the above three types of symptoms. Results Table 1 presents results for schizophrenics, for the major diagnostic subtypes of schizophrenia, and for nonschizophrenics on the overall index of psychotic symptoms observed during the posthospital period. 2 An overall weighted estimate of the rate of psychosis among the combined acute and chronic schizophrenics is also presented in table 1. Table 2 presents the results on the major types of psychotic symptoms. Several major features can be seen in tables 1 and 2: A large number of schizophrenics showed psychotic activity during the posthospital phase, although the features were sometimes weak and often were not disruptive to functioning. On the overall index of psychotic symptoms, 47 percent of the combined sample of schizophrenics showed clear psychotic features, and another 22 percent weak or sporadic psychotic features (see table 1). Since a very high rate of delusions was found among paranoid schizophrenics, the overall percentage of schizophrenics with psychotic symptoms in the current sample was disproportionately increased. Therefore, posthospital psychosis among nonparanoid schizophrenics was also assessed by looking only at the acute and the chronic schizophrenics (most had some paranoid features, but were not primarily paranoid). In this analysis, 38.5 percent of the nonparanoid schizophrenics showed clear signs of psychosis, 20.5 percent doubtful or weak signs, and 41 percent no psychotic features at all (see table 1). 3 Using the overall index of psychotic symptoms, schizophrenic patients were significantly higher than nonschizophrenics (p <.01) at the followup period. The most common types of psychotic symptoms occurring during the posthospital period were delusions (table 2), which were significantly more frequent among the schizophrenic patients (p<.01). Hallucinations and other strange experiences were not extremely common in the postacute phase among these relatively young schizophrenics (less than 20 percent of the schizophrenics received a score of "3"). As a result, the schizophrenics did not score significantly higher on these two features, although there was a tendency for these two phenomena to occur more frequently among the schizophrenics than among the nonschizophrenics. Severe (psychotic-like) depersonalization and derealization were not frequent in any type of patient. Comparisons among the four major schizophrenic subgroups did not show any significant differences in level of psychotic symptoms during the posthospital period. More symptoms were observed among the paranoid schizophrenics (predominantly a young chronic sample) and to a lesser extent among the chronic schizophrenics, but this tendency was not statistically significant. 2 Since this report focuses primarily on psychotic activity most clearly associated with schizophrenia, depressive delusions are excluded from the data presented. The addition of this material would not have changed any of the major comparisons between schizophrenics and nonschizophrenics, but would have shifted the number of schizophrenics and nonschizophrenics with delusional and psychotic activity up a few percentage points. 3 The 38.5-percent figure estimate was based on an equal sample size for the acute and chronic groups, so that the particular local sample distribution, which contains more young chronic schizophrenics, would not dominate the results.

VOL. 3, NO. 4, 1977 611 Table 1. Psychotic symptoms in major schizophrenic subtypes at followup Overall psychosis index Diagnostic groups Absent Intermediate Present Nonschizophrenic patients (n = 34) 17 (50%) 12 (35%) 5 (15%) All schizophrenics 1 (n = 60) 19 (31%) 13 (22%) 28 (47%) Acute schizophrenics (n = W) 5 (50%) 2 (20%) 3 (30%) Acute-chronic schizophrenics (n = 7) 3 (43%) 1 (14%) 3 (43%) Chronic schizophrenics (/7=19) 6 (32%) 4 (21%) 9 (47%) Paranoid schizophrenics (n=16) 3 (19%) 3 (19%) 10 (62%) Other schizophrenics (n = 8) 2 (25%) 3 (38%) 3 (38%) Acute and chronic schizophrenics 2 (weighted estimate) (41%) (21%) (39%) All schizophrenics vs. nonschizophrenics: Chi square - 9.73, p <.01. Major composite estimate of psychosis derived from an equal weighting of acute and chronic schizophrenic subgroups (the two major subtypes who are not primarily paranoid). Psychotic features were seen in a surprising number of nonschizophrenics: even with depressive delusions excluded, 15 percent of the nonschizophrenics showed evidence of clear psychotic features, and another 35 percent showed weak or sporadic signs of psychotic-like activity. These weak signs were usually based on psychotic features patients could recognize as unusual or unrealistic, and thus seemed to exert a less disruptive influence on their overall functioning. No significant differences were found among major subdiagnostic types within the nonschizophrenic sample on any of the indices of psychotic symptoms, although there was a weak tendency for depressives to exhibit more psychotic symptoms at the post-acute stage than other nonschizophrenics. Schneider's first rank symptoms were significantly more frequent in schizophrenics than in nonschizophrenics, with the difference just reaching the.05

612 SCHIZOPHRENIA BULLETIN Table 2. Specific types of psychotic symptoms at followup Delusions Hallucinations Absent Intermediate Present Absent Intermediate Present Schizophrenics 25 (42%) 9 (15%) 26 (43%) 45 (75%) 6 (10%) 9 (15%) Nonschizophrenic patients 22 (67%) 7 (21%) 4 (12%) 31 (91%) 2 (6%) 1 (3%) Schizophrenics vs. nonschizophrenics Chi square = 9.54 (p <.01) Schizophrenics vs. nonschizophrenics Chi square = 4.10 (NS) Other strange experiences/ sensory aberrations First rank symptoms Absent Intermediate Present None present At least one present Schizophrenics 40 (67%) 12 (20%) 8 (13%) 43 (72%) 17 (28%) Nonschizophrenic patients 28 (82%) 5 (15%) 1 (3%) 31 (91%) 3 (9%) Schizophrenics vs. nonschizophrenics Chi square = 3.52 (NS) Schizophrenics vs. nonschizophrenics Chi square = 4.35 (p <.05) level of significance. Schneiderian symptoms were not extremely frequent during the posthospital period; they were present in less than 30 percent of these relatively young schizophrenics (see table 2). Discussion Are Schizophrenics Psychotic During the Posthospital Phase? At followup assessment, a sizable percentage of these young schizophrenics showed some evidence of psychotic features usually in the form of delusions, the most common and severe type of psychotic symptom. A key question arises from these findings: If a moderate to high percentage of schizophrenics show some psychotic features during the posthospital period, how does this stage differ from the acute phase of hospitalization? While many schizophrenics showed signs of psychosis during the posthospital period, these features usually differed in quality, intensity, and relevance for the patient from those present during the more acute or active stages. Support for this observation was found in data indicating that a sizable proportion (nearly one-fourth) of these young schizophrenics received intermediate ratings (a score of "2") on the various psychotic symptoms.

VOL. 3, NO. 4, 1977 613 The patient with a score of "2" frequently realized that his experiences were not grounded in reality, and had more insight, perspective, or recognition that his problem had its source within himself, not in the world around him. The psychotic symptoms of many of these patients were weak in intensity or sporadic in frequency. Even among the schizophrenics with definite psychotic features present (47 percent of the total sample and 38.5 percent of the weighted estimate of nonparanoid schizophrenics), most were less disturbed than during the height of the acute period. The difference seemed to be that the psychotic features were not sufficiently salient or compelling to cause complete inability to function or to necessitate rehospitalization. (Only 18 percent of the schizophrenics were hospitalized at followup, although 62 percent had been in the hospital at some point since the index episode.) Thus, although a large percentage of patients showed some psychotic features, these psychotic ideas occupied less of their attention and were less upsetting than during the index episode, allowing them some degree of comfort in the world. These data show some, but not complete, agreement with standard conceptions about schizophrenia, particularly the idea that a schizophrenic who has once shown psychosis can be expected to show psychotic symptoms either all or most of the time in the future. The suggestion that the psychotic aspect of schizophrenia is not usually just a temporary state is supported by data from many patients in the current study. At followup, psychotic symptoms (mostly delusions) were significantly more common in schizophrenic than in nonschizophrenic patients. However, while many schizophrenics showed psychotic features during the posthospital period, there was also a moderate percentage of posthospital schizophrenics who did not show such psychotic features. Three patterns of outcome emerged in regard to psychosis: (1) persistence of psychosis (in 47 percent of the total sample of schizophrenics and 38.5 percent of the weighted estimate of nonparanoid schizophrenics); (2) complete absence of these types of psychotic symptoms (in another 31 percent of the total sample of former schizophrenics and 41 percent of the weighted estimate of nonparanoid schizophrenics); and (3) an apparent persistence of some abnormal psychotic-like experiences, which had a minimally disruptive influence on overall functioning in the remaining schizophrenics. Psychosis During the Posthospital Phase: Other Factors It could be questioned whether those schizophrenics who manifested psychotic symptoms at followup had been more disturbed at the acute phase of index hospitalization than the rest of the schizophrenic sample. It might be expected that key characteristics of chronicity would differentiate psychotic from nonpsychotic schizophrenics at the followup stage. In order to examine this possibility, the schizophrenic sample was subdivided according to followup PSI ratings on overall psychosis (absent, intermediate, and present) and then compared on the following major variables obtained at the time of index hospitalization: (1) length of index hospital admission; and (2) number of hospitalizations before the index hospitalization. The results of these analyses indicate that schizophrenics with psychotic features at followup did not differ significantly from those without such features on these two key characteristics of previous psychiatric history. Similarly, there were no significant differences among the nonschizophrenic patients when they were categorized in this way. Apparently, for young psychiatric patients, the number of previous hospitalizations does not distinguish those who continue to show psychotic features during the posthospital phase. Recently, investigators have seriously questioned whether a diagnosis of schizophrenia always implies poor outcome and whether schizophrenics differ appreciably from nonschizophrenics in posthospital outcome (Strauss and Carpenter 1972 and 1977 and Hawk, Carpenter, and Strauss 1975). The present results, however, suggest that with regard to psychotic symptoms (an essential area closely associated with the concept of schizophrenia) there are relatively clear differences between postacute schizophrenic and nonschizophrenic patients. These differences were found despite the use of phenothiazines and other modern treatment techniques, since about half of the schizophrenic sample (52 percent) were on phenothiazines at followup. Interestingly, the schizophrenics receiving phenothiazines had more psychotic features {p <.01) during the postacute period than those who were not on phenothiazines. In a number of instances, however, the greater degree of psychotic symptoms may have been the reason the phenothiazines were being administered.

614 SCHIZOPHRENIA BULLETIN In the area of treatment, there was no significant difference between schizophrenics with and those without psychotic symptoms at the postacute stage in terms of the number of patients in each group receiving some form of posthospital therapy. The absence of a significant difference here applied at the time of followup assessment as well as for the previous 12 months. During the total period of time since the index hospitalization, a significantly greater number of schizophrenics with psychotic symptoms at followup had been in individual psychotherapy at some point (p <.02). In many instances, however, the increased treatment for the schizophrenics with psychotic symptoms may have been due to their poorer clinical condition. Thus, as in most cases in which patients are not randomly assigned to treatment and nontreatment groups, interpretation of these data must be approached with caution. Within the limits of this restriction, the present data do not provide positive evidence that certain forms of treatment completely offset other factors that might lead to increased psychosis and poorer functioning. If schizophrenia is looked at as a basic syndrome consisting of a set of psychotic symptoms and disordered thinking, accompanied by possible trait (or long-term) features centering around personal and subjective inadequacies and lower levels of competency, it is not surprising that one of the basic features of the disorderpsychotic symptoms should continue to be a discriminator between schizophrenics and nonschizophrenics after the acute phase. It should be noted, however, that the psychotic symptoms which differentiated the groups did not show signs of persistence in all schizophrenics. Overall, the answer to one of the major questions posed is that the diagnosis of schizophrenia carries generally clear, predictable diagnostic implications, and that a schizophrenic state at the time of acute hospitalization suggests a moderate to high probability of subsequent psychotic symptoms. Psychotic Features in Nonschizophrenic Patients Another question of theoretical interest is why a subgroup of nonschizophrenics shows psychotic features. Data indicating that a certain percentage of nonschizophrenics have psychotic features are not unique to the present research. Recently, others have reported some peculiarities of thinking and psychotic-like features in many manic patients (Andreasen and Powers 1975 and Carlson and Goodwin 1973), in families of schizophrenics (Singer and Wynne 1965 and Wild et al. 1965), and in people who are not usually considered psychotic. Even Astrup and Noreik (1966) found at least 12 percent of nonschizophrenics with some or much schizophreniclike deterioration in a large-scale followup study. Recent analysis of our data on another sample has revealed a surprising degree of at least mild levels of thought pathology in many nonschizophrenics (Harrow and Quinlan 1977). The current nonschizophrenics were neither grossly psychotic nor totally disrupted in their functioning. Whereas most or almost all of the schizophrenics had at one point (during a previous acute phase) been so grossly psychotic that they could not function and were totally preoccupied by their delusional ideas, the nonschizophrenics had never shown any such extreme disruption in functioning. Thus, although a surprising number of nonschizophrenics displayed psychotic symptoms, the great majority received an intermediate rating of "2" rather than the stronger rating of "3." This finding indicates that about two-thirds of the nonschizophrenics with some psychotic-like features showed better perspective about the unrealistic nature of these symptoms. Of the schizophrenics with psychotic symptoms, on the other hand, a smaller percentage sensed the unrealistic nature of the experiences they reported. Subdiagnosis of Schizophrenia and Posthospital Psychosis The data presented here and in other reports clearly indicate that some, rather than all, schizophrenics will show psychotic features, in varying degrees, during the postacute phase. The question which then arises is, Which types of subgroups of schizophrenics later show psychotic features and which do not? Our initial findings suggest that distinctions among schizophrenic subtypes provide only a partial answer to this question. Psychotic features during the posthospital period were observed in all subdiagnostic groups, although they showed a nonsignificant tendency to occur more frequently in the chronic paranoid patients and, to

VOL. 3, NO. 4, 1977 615 a lesser extent, in the chronic nonparanoid patients. Nevertheless, a certain number of acute schizophrenics also showed psychotic symptoms in the posthospital phase. These data suggest that in young schizophrenic patients, diagnosis by major clinical subtypes contains some, but not clear-cut, prognostic information about the long-term symptomatic course of the schizophrenic disorder. The uncertainty is perhaps greatest for acute patients; however, the fact that a patient during the psychotic episode and hospitalization is a chronic or chronic paranoid schizophrenic, even in the case of relatively young schizophrenics, indicates with some greater measure of confidence that psychotic features are more likely than not to be relatively permanent characteristics. cantly higher than nonschizophrenic patients on the overall index of psychotic features (p<.01) and on the index of delusions (p<.01). Using a weighted estimate, 38.5 percent of the nonparanoid schizophrenics showed clear evidence of psychotic features, and another 20.5 percent showed some evidence of psychotic features which were weak or sporadic or which the patients seemed able to bring into perspective. Schizophrenic subdiagnosis did not predict later psychotic symptoms, although there was a trend for more psychotic features in paranoid and in chronic schizophrenics. The belief that psychotic symptoms in schizophrenia are not just temporary states was supported. However, conceptions about psychotic symptoms persisting in all schizophrenics were not affirmed. Schneiderian First Rank Symptoms During the Postacute Phase Schneider's first rank symptoms, although more prevalent in schizophrenics than nonschizophrenics, were not very common during the posthospital period. Apparently, among most young schizophrenics, these symptoms are not enduring characteristics of the schizophrenic syndrome. The first rank symptoms are composed of features associated with boundary disturbances, special forms of auditory hallucinations, and delusional interpretations of normal preceptions. One limitation may be that Schneider's first rank symptoms do not include the paranoid-like features that are found in a certain number of schizophrenics. An inference that may be drawn from the results is that first rank symptoms are not so typically associated with schizophrenia as some clinicians have believed. Carpenter, Strauss, and Muleh's (1973) study lends support to this view, as they reported that only 51 percent of their sample of schizophrenics had any first rank symptoms. Their data and ours suggest that first rank symptoms are less frequent in schizophrenia than Schneider reported, and that this pattern continues throughout the posthospital period as well. Summary Sixty schizophrenic and 34 nonschizophrenic patients were assessed 3 years after discharge on 17 types of psychotic symptoms. Schizophrenics were signifi- References Andreasen, N.J.C., and Powers, P.S. Creativity and psychosis: An examination of conceptual style. Archives of General Psychiatry, 32:70-73, 1975. Astrachan, B.M.; Brauer, L.; Harrow, M.; and Schwartz, C. Symptomatic outcome in schizophrenia. Archives of General Psychiatry, 31:155-160, 1974. Astrup, C, and Noreik, K. Functional Psychoses: Diagnostic and Prognostic Models. Springfield, III.: Charles C Thomas, Publisher, 1966. Carlson, G.A., and Goodwin, F.K. The stages of mania: A longitudinal analysis of the manic episode. Archives of General Psychiatry, 28:221-228,1973. Carpenter, W.T., Jr.; Strauss, J.S.; and Muleh, S. Are there pathognomonic symptoms in schizophrenia? An empiric investigation of Schneider's first-rank symptoms. Archives of General Psychiatry, 28:847-852,1973. Freeman, H.E., and Simmons, O.G. 777e Mental Patient Comes Home. New York: John Wiley & Sons, Inc., 1963. Grinker, R.R., Sr., and Holzman, P.S. Schizophrenic pathology in young adults: A clinical study. Archives of General Psychiatry, 28:168-175,1973. Harrow, M.; Bromet, E.; and Quinlan, D. Predictors of posthospital adjustment in schizophrenia: Thought disorders and schizophrenic diagnosis. Journal of Nervous and Mental Disease, 158:25-36, 1974. Harrow, M.; Grinker, R.R., Sr.; Holzman, P.S.; and Kayton, L. Anhedonia and schizophrenia. American Journal of Psychiatry, 134:794-797, 1977a. Harrow, M.; Grinker, R.R., Sr.; Silverstein, M.L.; and Holzman, P.S. "Is Modern-Day Schizophrenic

616 SCHIZOPHRENIA BULLETIN Outcome Still Negative?" Presented at the 130th Annual Meeting of the American Psychiatric Association, Toronto, Canada, May 2-6,1971b. Harrow, M., and Quinlan, D. Is disordered thinking unique to schizophrenia? Archives of General Psychiatry, 34:15-21,1977. Hawk, A.B.; Carpenter, W.T., Jr.; and Strauss, J.S. Diagnostic criteria and five-year outcome in schizophrenia. Archives of General Psychiatry, 32:343-347, 1975. Holzman, P.S., and Grinker, R.R., Sr. Schizophrenia in adolescence. Journal of Youth and Adolescence, 3:267-279,1974. Schneider, K. Clinical Psychopathology. Translated by M.W. Hamilton. New York: Grune <& Stratton, Inc., 1959. Singer, M.T., and Wynne, L.C. Thought disorder and family relations of schizophrenics. Archives of General Psychiatry, 12:201-212, 1965. Stephens, J.H. Long-term course and prognosis in schizophrenia. Seminars in Psychiatry, 2:464-485, 1970. Strauss, J.S., and Carpenter, W.T., Jr. The prediction of outcome in schizophrenia: I. Characteristics of outcome. Archives of General Psychiatry, 27:739-746, 1972. Strauss, J.S., and Carpenter, W.T., Jr. Prediction of outcome in schizophrenia: III. Five-year outcome and its predictors. Archives of General Psychiatry, 34:159-163,1977. Wild, C; Singer, M.; Rosman, B.; Ricci, J.; and Lidz, T. Measuring disordered styles of thinking: Using the object sorting test on parents of schizophrenic patients. Archives of General Psychiatry, 13:471-476,1965. Wing, J.K.; Cooper, J.E.; and Sartorius, N. 777e Measurement and Classification of Psychiatric Symptoms. London: Cambridge University Press, 1974. World Health Organization. The International Pilot Study of Schizophrenia. Vol. 1. Geneva: WHO, 1973. Acknowledgment This research was supported, in part, by Grant Nos. MH-26341 and MH-05519 from the National Institute of Mental Health. The authors are indebted to Roy R. Grinker, Sr., M.D., Philip S. Holzman, Ph.D., and Lawrence Kayton, M.D., for providing information on the current patient sample via interviews and other studies of the patients at an earlier phase of their disorder. Annalee Fjellberg, Kevin Grimes, Stephen Hurt, Roberta Laffey, and Marion Levin aided in the collection and analysis of the data. The Authors Martin Harrow, Ph.D., is Director of Psychology, Michael Reese Hospital and Medical Center, and Associate Professor, Department of Psychiatry, University of Chicago. Marshall L. Silverstein, Ph.D., is Senior Psychologist, Michael Reese Hospital and Medical Center, and Research Associate (Assistant Professor), Department of Psychiatry, University of Chicago, Chicago, III. Scottish rite fellowships The Scottish Rite Schizophrenia Research Program has announced that the deadline for the receipt of applications for Dissertation Research Fellowship Awards or Research Grant Awards is March 15, 1978. The review of applications received will be held early in June 1978. For further information, write the Scottish Rite Schizophrenia Research Program, P.O. Box 519, 33 Marrett Road, Lexington MA 02173.