Followup of Psychotic Outpatients: Dimensions of Delusions and Work Functioning in Schizophrenia

Followup of Psychotic Outpatients: Dimensions of Delusions and Work Functioning in Schizophrenia by Martin Harrow, Ellen S. Herbener, Anne Shanldin, Thomas H. Jobe, Francine Rattenbury, and FJalman J. Kaplan Abstract We studied three characteristics or dimensions of delusions in schizophrenia patients living hi the community, including their influence on work and community functioning. The 149-patient sample included 57 delusional schizophrenia and nonschizophrenia outpatients, 50 nondelusional outpatient controls, and 42 delusional inpatient controls. The data indicated the strength and prominence of acute-phase psychopathology on characteristics of delusions, with large significant differences hi intensity of delusions between the acute inpatient phase and the postacute inpatient and outpatient phases. Contrary to some views, the data indicate that the overall presence of any delusions hi general, and the various dimensions of delusions, both influence work performance and community functioning, with the greater part of the variance due to the presence of delusions in general. Despite their outpatient status, delusional outpatients showed surprisingly poor self-monitoring about whether others would regard their delusional ideation as unrealistic. Schizophrenia and affectively disordered patients with high emotional commitment to their delusions showed significantly poorer work functioning and were significantly more likely to be rehospitalized (p < 0.05), indicating the important impact on functioning of patients' feelings of immediacy and urgency about their unrealistic beliefs. Keywords: Schizophrenia, work, dimensions, emotions, self-monitoring, psychosis, delusions, longitudinal. Schizophrenia Bulletin, 30(1): 147-161,2004. Delusions are regarded by many as a central characteristic of schizophrenia and schizoaffective disorders. Yet, despite their centrality, there are still gaps in our knowledge about the nature of delusions and their major characteristics, and even the criteria for delusions are open to debate (Bowers 1974; Moor and Tucker 1979; Winters and Neale 1983; Oltmanns and Maher 1988; Butler and Braff 1991; Garety and Hemsley 1994). While delusions and major dimensions of delusions have frequently been studied in hospitalized patients, many psychotic patients who have been hospitalized are treated and then discharged from the hospital with some level of delusions still remaining. There are relatively few studies of dimensions or characteristics of delusions in formerly hospitalized patients living in the community. The current research was designed to advance knowledge about three important characteristics of delusions. The plan involved studying these key dimensions of delusional behavior in formerly hospitalized schizophrenia and other psychotic individuals who are living outside of a hospital setting and functioning with varying degrees of success in the community. The three dimensions are as follows: 1. Hospitalized and nonhospitalized psychiatric patients' strength or extent of belief-certainty (BC) in their delusions. 2. Psychotic patients' self-monitoring (SM), editing, or perspective about their delusions. Are they able to recognize whether others regard their false ideas as strange? 3. Hospitalized and nonhospitalized delusional patients' emotional commitment (EC) to their delusions. Emotional commitment involves the immediacy, importance, or urgency that the patient attaches to his or her delusions. Emotional factors can shape and provide urgency to the delusions. EC can involve high and frequent preoccupation with delusions, and great impact of delusions on behavior. Send reprint requests to Dr. M. Harrow, Department of Psychiatry (M/C 912), University of Illinois, College of Medicine, 1601 W. Taylor Street, Chicago, IL 60612; e-mail: mharrow@psych.uic.edu. 147

Schizophrenia Bulletin, Vol. 30, No. 1, 2004 M. Harrow et al. One of the goals of the current investigation was to advance knowledge about these three major characteristics of delusions because our previous research on them had found promising results. This includes a relationship between EC and length of hospitalization (Stoll et al. 1987; Harrow et al. 1988). It also includes a possible link between impairment in select aspects of SM in schizophrenia and both thought disorder (Harrow and Miller 1980; Harrow et al. 1989) and delusions (Harrow et al. 1988). In addition, the research compares the strength of these major dimensions or aspects of delusional behavior for these delusional outpatients with those for delusional inpatients. An issue of key importance in the field concerns disability in schizophrenia, factors that influence it, and whether the overall presence of any delusions, and the strength of major dimensions of these delusions, interfere with community functioning and adjustment. There has been recent controversy concerning whether certain types of neurocognitive impairments, psychotic symptoms, and other types of pathology influence psychosocial and work functioning (Green, 1996; Green et al. 2000; Racenstein et al. 2002) and what the economic impact of psychosis in schizophrenia is. Other promising empirical and theoretical research on factors involved in delusions has been undertaken by major investigators, such as Garety, Hemsley, and Freeman (Garety and Hemsley 1987, 1994; Hemsley 1987, 1996; Garety et al. 2001); Bentall, Kinderman, and Kaney (Bentall et al. 1994, 1998, 2001); Frith and colleagues (Frith 1994; Frith and Corcoran 1996); Beck and colleagues (Beck and Rector 2000; Rector and Beck 2001; Morrison et al. 2002); and Maher (Maher and Ross 1984; Maher 1988). Most of this work focuses on cognition, with some including views about impaired reasoning processes, jumping to conclusions, attributional bias, theory of mind, and cognitive-behavioral therapy (CBT). Theoretical reports by investigators such as Brockington (1991), Spitzer (1999), Freeman et al. (2002), and others also have discussed different factors involved in delusion formation versus delusion maintenance. In regard to research on dimensions of delusions, while we have focused on three dimensions, other important dimensions or characteristics of delusions also have become the subject of research and analysis (Hole et al. 1979; Rudden et al. 1982; Kendler et al. 1983; Garety and Hemsley 1994; Appelbaum et al. 1999). Some of these other dimensions include extension (Hole et al. 1979; Kendler et al. 1983; Brockington 1991; Appelbaum et al. 1999), fixity of ideas (Eisen et al. 1998), negative affect (Appelbaum et al. 1999), mood-congruent versus -incongruent delusions (Coryell and Tsuang 1985; Tohen et al. 1992; Harrow et al. 20006), and interference (Garety and Hemsley 1987). The study of various dimensions of delusions has shown promise toward advancing knowledge on delusions. Data from this type of research bear on views about "double awareness." In this state, the patient partly believes and partly does not believe the delusions and "is no longer totally immersed" in them (Sacks et al. 1974). The study of major dimensions also bears on issues about the potential multidimensional nature of delusions (Kendler et al. 1983; Appelbaum et al. 1999) and about which components of delusions are most strongly associated with hospitalization (Harrow et al. 1988). The current investigation analyzes the above three dimensions of delusions (BC, SM, and EC) to further our understanding of psychosis. The following questions were studied: 1. Does the degree or intensity of BC, SM, or EC differ when (1) delusional schizophrenia and other psychotic outpatients who are living in the community are compared to (2) delusional schizophrenia and other psychotic inpatients] 2. Are there diagnostic differences? Do delusional schizophrenia outpatients differ from other types of psychotic outpatients in the extent of their BC, SM, and EC? 3. Among schizophrenia and nonschizophrenia outpatients, does (1) the presence of delusions, and (2) major dimensions of their delusions, influence the probability of rehospitalization and the adequacy of their psychosocial adjustment (i.e., work and social adjustment)? 4. Is the presence of any delusion a more important influence on rehospitalization and community functioning than the strength of specific dimensions of the delusion? Method Subjects. The 149-patient sample consisted of (1) 57 currently delusional outpatients, (2) 50 nondelusional outpatient controls, and (3) 42 delusional inpatient controls. The 107 outpatients are participants in the Chicago Followup Study, which involves a large sample of patients who were studied prospectively as inpatients and have been followed up to evaluate, on a longitudinal basis, delusional thinking (Harrow et al. 1985, 1995; Sands and Harrow 1994), other positive and negative symptoms (Pogue-Geile and Harrow 1985; Harrow and Marengo 1986; Marengo and Harrow 1987; Marengo et al. 2000; Herbener and Harrow 2001), and course and outcome in schizophrenia and major affective disorders (Harrow et al. 1990, 1997, 20006). 148

Delusions and Work Functioning in the Psychotic Outpatient Schizophrenia Bulletin, Vol. 30, No. 1, 2004 All 107 outpatients were studied prospectively and given research diagnoses as inpatients and then followed up systematically after index hospital discharge, a mean of 11.53 years later (11.14 years later for the delusional patients, and 11.98 years later for the nondelusional controls). When the Research Diagnostic Criteria (Spitzer et al. 1978) were used, index hospitalization diagnosis for the delusional outpatient sample was as follows: 26 schizophrenia patients, 10 schizoaffective patients, 7 bipolar manic patients, 5 other nonschizophrenia patients who were psychotic at hospitalization, and 9 patients who at the acute phase of hospitalization were not psychotic but who were delusional at followup. The nonpsychotic outpatient comparison or control group included 50 patients from the same research program who also had been studied prospectively as inpatients and then were followed up. None of these 50 patients were delusional or psychotic at the current followup. The 50 nonpsychotic outpatient controls were selected to match the delusional outpatients in terms of diagnosis and time since index hospitalization; as controls, they were also selected for absence of current psychosis. Their selection was blind with regard to such variables as clinical course, posthospital functioning, and potential rehospitalization. Index inpatient diagnosis for this group of nondelusional outpatients was 23 schizophrenia patients, 9 schizoaffective patients, 6 bipolar manic patients, 5 other patients who were psychotic at index hospitalization, and 7 other patients who were not psychotic at index. Demographically, the mean age of the delusional outpatient sample was 34.88 years and of the nondelusional control sample 34.12 years. The educational level of the delusional outpatients was 13.56 years and of the nondelusional outpatients 14.44 years. Exactly 43.9 percent of the delusional outpatients and 48.0 percent of the nondelusional outpatients were female. There were no significant differences between the delusional and nondelusional outpatient samples in diagnostic distribution, age, education, or sex ratio (p > 0.30). While the main focus of this report is on the extent and influence of dimensions of delusions in psychotic patients living in the community, we also studied a comparison sample of delusional inpatients, to explore differences between outpatients and inpatients. This inpatient sample included 42 patients, with the following diagnostic distribution at index hospitalization: 18 schizophrenia patients, 14 schizoaffective patients, and 10 other types of psychotic patients. There was no overlap between the 107 outpatients and the 42 inpatients. The delusional inpatient control sample did not differ significantly from the delusional outpatient sample in education or sex ratios. Their mean age (24.45 years) differed significantly from that of the delusional outpatient sample (t = 9.42, 97 df, p < 0.001). However, within the delusional inpatient and also within the delusional outpatient samples, the patients' scores on the three dimensions of delusions studied was not related significantly to age (p > 0.30). Procedures. Subjects were interviewed using the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer 1978). They also were interviewed using the Personal Ideation Inventory (PU), a semistructured interview designed to assess major dimensions and components of delusions (Rattenbury et al. 1984). The term dimensions of delusions is not being used here in the statistical sense of a factor analytic study. Rather, the term is used in the sense that some have called characteristics of delusions (e.g., Garety and Hemsley 1987) and others, including Kendler et al. (1983), Appelbaum et al. (1999), Bentall et al. (2001), and our own group (Harrow et al. 1988), have labeled dimensions of delusions. Thus, dimensions is used to describe a potentially important axis of delusions that may help to further understanding about important aspects of delusions and possibly about the nature of delusions. The present research studies the 3 PII measures of BC, SM, and EC. Based on a series of structured questions, BC is rated on a 3-point scale, with a score of 1 assigned for no belief (the nonpsychotic outpatient controls received this score), 2 for partial belief in the delusion, and 3 for full BC. On the SM scale, a score of 1 was assigned for good SM, 2 for partial SM, and 3 for poor SM. One question assessing whether a patient viewed his or her delusional beliefs as atypical versus acceptable to other people and to society was, "What do you think other people feel concerning your idea that? Is it possible that other people share your view of T' The measure of EC to the delusion, based on a series of queries, ranges from a score of 1 for none to 5 for very high. To facilitate the analysis, this variable was grouped into a 3-point scale. One question assessing EC included evaluation of the extent of the patient's preoccupation with the delusional idea: "How often these past 2 weeks have you thought about the idea that?" Other questions included assessment of the extent to which the patient's behavior was influenced by delusional thinking: "In the past 2 weeks how much has the thought that influenced your daily activities or daily decisions?" Satisfactory interrater reliability has been obtained for these measures in previous research (Harrow et al. 1988) and was achieved again in a recent evaluation using intraclass correlations as a measure that corrects for chance. Thus, employing intraclass correlations to obtain interrater reliability on the seven main probes used to assess the three dimensions of delusions, we recently 149

Schizophrenia Bulletin, Vol. 30, No. 1, 2004 M. Harrow et al. obtained correlations ranging from 0.73 to 0.95 (p < 0.0001) with a mean of 0.88. The delusion of each patient selected for study was the patient's most prominent delusion found on the SADS. PII inquiry for each delusion focused on the status of the delusion during the past 2 weeks. In the inpatient sample, PII inquiry focused on the status of the delusion both (1) at the height of the delusion (the early acute inpatient phase) and (2) at a PII interview 4 to 5 weeks after hospitalization (the postacute inpatient phase). Data collection on 8 of the 42 inpatients included assessments at the postacute inpatient phase but not at the acute inpatient phase, and while data were collected on all three dimensions (BC, SM, and EC) at the postacute inpatient phase, at the acute inpatient phase complete data were available on only BC and EC, not SM. In addition to the use of the SADS for all outpatients, functioning for the 107 outpatients was assessed using a structured interview (the Harrow Functioning Interview) to assess work and social functioning, quality of life, rehospitalization, and other major areas. Both the SADS and the functioning interview were administered by trained interviewers bund to the patients' diagnosis, with these interviews having been used successfully by the present research team in a series of longitudinal studies (e.g., Harrow et al. 1990, 1997; Sands and Harrow 1994; Herbener and Harrow 2001). Specific questions from the functioning interview were used to score three specific outcome scales (the S-C scales) developed by Strauss and Carpenter (1972). These scales were used to assess the degtee of adjustment in social and instrumental work functioning, and rehospitalization during the past year. Examples of questions from the functioning interview on employment included, "Are you employed at present?" "What jobs have you held?" "How long have you been unemployed?" These and similar questions were used to score the S-C scale on work functioning. Previous research, by others and by our own group, using these scales has obtained adequate interrater reliability (Strauss and Carpenter 1972; Harrow et al. 1997, 2000fc). In addition, in a recent reassessment using a reliability measure that corrects for chance we obtained intraclass correlations ranging from r = 0.85 to r = 1.00 for rehospitalization (assessment of variables such as recent rehospitalization are often very easy to make from direct questions in the interview). The S-C scales have been used successfully by our research team and others, with previous research indicating that they show a relationship to other clinical variables, including diagnosis and thought disorder (Strauss and Carpenter 1972; Grinker and Harrow 1987; Harrow et al. 1990; Harrow et al. 1997; Racenstein et al. 1999). Parametric statistics (e.g., F tests, t tests, product moment correlations) were used for most of the data analysis. However, in select instances (e.g., data involving 2-point scales), we used nonparametric statistics, such as the Kruskal-Wallis 1-way analysis of variance (ANOVA) and x 2 (Siegel 1956). Medications. For the outpatient delusional sample, at the time of assessment 80.6 percent of the schizophrenia and schizoaffective patients were on neuroleptics and another 5.6 percent were on other medications but not neuroleptics. Exactly 13.9 percent of the schizophrenia and schizoaffective patients were not on any medications; 47.6 percent of the other delusional outpatients were on neuroleptics, and another 23.8 percent were on other medications but not neuroleptics; and 28.6 percent of the other psychotic patients were not on any medications. There were no significant differences in extent of BC, SM, or EC between the schizophrenia and schizoaffective outpatients on neuroleptics versus those not on neuroleptics (p > 0.30). Similarly, there were no significant differences in extent of BC, SM, or EC between the delusional outpatients who did not have a schizophrenia or schizoaffective disorder when those nonschizophrenia patients on neuroleptics were compared to the nonschizophrenia patients not on neuroleptics (p > 0.30) (table 1). Results Dimensions of Delusions at Three Phases of Illness. Table 1 reports the data on the delusional outpatient sample, on the inpatient sample during the most acute phase, and on the delusional inpatients during the postacute phase. With a focus on the outpatient sample, the following results emerged. BC. The data in table 1 indicated that half of the delusional outpatients fully believed in the validity of their false beliefs (BQ. However, the other half were only partially convinced. In contrast, at the acute inpatient phase over 80 percent of the patients showed full belief in their delusions. At the acute phase, patients showed a significantly greater degree of BC than did those who were assessed as outpatients (x 2 = 7.79, 1 df, p < 0.01). The inpatients also showed significantly more BC at the acute phase than at the postacute phase of hospitalization (McNemar Test, p < 0.01). There were no differences in extent of BC between the outpatient sample and the postacute inpatients (x 2 = 0.11, 1 df, p > 0.50). SM. Most of the delusional outpatients (78%) showed some impaired SM, impaired self-editing, or loss of perspective. They did not completely recognize that others would view their delusions as strange or unrealistic. Twenty-one percent of the delusional outpatients had good SM (i.e., were fully aware that others would view their beliefs as atypical). They showed significantly better 150

Delusions and Work Functioning in the Psychotic Outpatient Schizophrenia Bulletin, Vol. 30, No. 1, 2004 Table 1. Relationship between dimensions of delusions and clinical status Belief-certainty Partial belief Full belief Self-monitoring 2 Good self-monitoring Moderate self-monitoring Poor self-monitoring Emotional commitment Low emotional commitment Moderate emotional commitment High emotional commitment Note. Percentages may not total exactly 100 owing to rounding. Inpatients acute phase (n = 34),% 17.6 82.4 5.9 11.8 82.4 Inpatients postacute 1 47.4 52.6 5.3 65.8 28.9 18.5 26.3 55.2 1 Four Inpatients who were no longer delusional at the postacute inpatient phase are not included In these analyses, acute-phase data in this area were incomplete. Delusional outpatients (n = 57),% 50.9 49.1 21.4 58.9 19.3 32.7 25.5 41.8 SM than the postacute inpatients (r = 2.00, 92 df, p < 0.05). EC. Only 42 percent of the delusional outpatients showed behaviors or cognitive preoccupations indicating high or very high levels of EC to their delusional beliefs. In contrast, 82 percent of the acute inpatients had high or very high levels of EC to their delusions. The delusional outpatients had significantly less EC to their delusions than patients at the acute inpatient phase (r = 5.29, 87 df, p < 0.001) and a nonsignificant tendency toward less EC than patients at the postacute inpatient phase (t = 1.89, 91 df, p = 0.06). The very high level of EC to their delusions by the inpatients at the acute phase had declined significantly during the postacute phase of hospitalization (t = 4.54, 33 df, p < 0.001). Diagnosis. To analyze potential diagnostic differences, F tests were conducted for the delusional outpatients, and for the inpatients, comparing the delusional schizophrenia with the delusional schizoaffective with the other delusional patients on each dimension. A Kruskal-Wallis test comparing the three groups of outpatients (schizophrenia vs. schizoaffective vs. other patients) on extent of BC about their delusions was not significant (x 2 = 0.42, 2 df, p > 0.50). Similarly, a Kruskal-Wallis test for diagnosis for the inpatients on BC at the postacute phase was not significant (x 2 = 1.58, 2 df, p > 0.40). The F test comparing the three diagnostic groups of outpatients on SM was not significant (F = 0.72, df= 2,52, p > 0.40). The F test for diagnosis for the inpatients on SM at the postacute phase also was not significant. The F test on the extent of EC to their delusions for the three diagnostic groups of outpatients was not significant (F = 1.56, df =2,51, p> 0.20), and the F test for diagnosis for the postacute inpatient phase was not either (F = 0.27, df = 2,35, p> 0.50). Relationship Between the Three Dimensions of Delusions. Analysis of the relationship between the three dimensions of delusions indicated the following: 1. The relationship between BC and EC was significant for both the inpatient sample (r = 0.53, 40 df, p < 0.001) and the outpatient sample (r = 0.26, 53 df, p = 0.05). 2. The relationship between BC and SM was significant for the inpatient sample (r = 0.77, 40 df, p < 0.001) but not for the outpatient sample (r = 0.19, 54 dfp = 0.15). 3. The relationship between EC and SM was significant for the inpatient sample (r = 0.59, 40 df, p < 0.001) but not for the outpatient sample (r = 0.18, 53 df, p< 0.20). Relationship Between Presence of Any Delusions and Posthospital Adjustment, and Between Dimensions of Delusions and Posthospital Adjustment. Table 2 presents a 2 X 2 ANOVA for the outpatient sample ([1] delusional vs. nondelusional patients, and [2] schizophrenia vs. nonschizophrenia patients) analyzing the relationship between the presence of any delusions and functioning in various areas. The delusional patients showed significantly poorer work (p < 0.001) and social functioning (p < 0.05) and significantly more hallucinations (p < 0.001). There were fewer schizophrenia versus nonschizophrenia 151

Schizophrenia Bulletin, Vol. 30, No. 1, 2004 M. Harrow et al. Table 2. Relationship between presence of any delusions, diagnosis, and posthospltal adjustment 2 x 2 ANOVAs: Presence of Delusions x Diagnosis Posthospltal fuctlonlng Work functioning Social functioning Rehospitalization Hallucinations Delusions (Del) Present-Absent 25.20 4.04 1.70 64.64 < 0.001 <0.05 <0.20 < 0.001 4.67 2.46 0.09 0.14 Diagnosis (DX) SZ-NSZ Note. ANOVA «analysis of variance; NSZ = nonschizophrenia; SZ» schizophrenia <0.05 <0.12 >0.30 >0.30 0.33 2.072 0.71 0.14 Interaction (Del x DX) >0.30 <0.16 >0.30 >0.30 differences than what one usually finds because to serve as controls for schizophrenia patients the selection criteria required relatively pathological nonschizophrenia outpatients (slightly over half of the nonschizophrenia outpatients were delusional). However, despite the selection of pathological nonschizophrenia outpatients, the schizophrenia patients still had significantly poorer work functioning than the nonschizophrenia patients (p < 0.05). The 2X3 ANOVAs (2 diagnostic groups: schizophrenia vs. nonschizophrenia, and 3 levels of each dimension of delusions) assessed the relationship between each dimension and work functioning, social functioning, hallucinations, and rehospitalization for the outpatients. BC About One's Delusions 1. For the overall outpatient sample (combined delusional and nondelusional patients), the ANOVAs on the BC data were significant for work functioning (F = 11.816, df = 2,101, p< 0.001), for social functioning (F = 4.324, df= 2,101, p < 0.02), and for hallucinations (F = 36.453, df= 2,101, p < 0.001). 2. Much of the variance could be accounted for by the poorer functioning of the delusional outpatient groups versus the nondelusional outpatients, who, in general, showed better functioning. To control for this, we also analyzed the data separately for only the delusional outpatients. When we compared those delusional outpatients with severe BC scores versus those patients with lower BC scores, the differences in each area of functioning (e.g., work functioning, rehospitalization) were not significant (p > 0.10). 3. The data on hallucinations indicated that the majority of delusional schizophrenia outpatients with severe BC showed hallucinations (73%) and the majority of delusional nonschizophrenia outpatients with severe BC also showed hallucinations (58%). However, they did not differ significantly in extent of hallucinations from the outpatients with only moderate BC about their delusions, with over half of these schizophrenia outpatients (56%) and nonschizophrenia outpatients (62%) also showing hallucinations. In contrast to these two groups, none of the 50 schizophrenia and nonschizophrenia outpatients who were not delusional showed hallucinations. SM of One's Delusions 1. For the overall outpatient sample, the ANOVAs on SM of one's delusions were significant for work functioning (F = 11.438, df= 2,100, p < 0.001), for social functioning (F = 6.574, df= 2,100, p < 0.002), and for hallucinations (F = 34.777, df= 2,100, p < 0.001). 2. When separate analysis of only the delusional outpatients was conducted, the results indicated poorer social functioning among the delusional schizophrenia patients with poorer SM of their delusions, as compared to the delusional schizophrenia patients with better SM (/ = 2.98, 14.73 df, p < 0.01). The results comparing the delusional outpatients with poorer versus better SM showed no significant differences on work functioning, hallucinations, or rehospitalization (p > 0.10). 3. Figure 1, on the relationship between poor SM of their delusions and social functioning, indicates that all the delusional schizophrenia outpatients with poor SM showed poor social functioning. Only 40 percent of the delusional schizophrenia outpatients with better SM showed poor social functioning (p < 0.05). EC to One's Delusions 1. For the overall outpatient sample, the ANOVAs on the EC data were significant on work functioning (F = 12.461, df = 2,99, p < 0.001), on social functioning (F = 3.796, df= 2,99, p < 0.05), and on hallucinations (F = 33.637, df= 2,99, p < 0.001) and showed a nonsignificant trend on rehospitalization (F = 2.414. df = 2,98, p< 0.10) (figure 2). 152

Delusions and Work Functioning in the Psychotic Outpatient Schizophrenia Bulletin, Vol. 30, No. 1, 2004 Figure 1. The relationship between poor self-monitoring and social functioning 100% " 100% 75% 1 SZ Patients B Non-SZ Patients 50%- 25%" NonDelusional Partial SelfMonitoring Poor SelfMonitoring Note. SZ = schizophrenia. The y-axis indicates the percentage of patients with poor social fuctioning. 2. When only the delusional outpatients were analyzed separately, the delusional outpatients with high EC to their delusions were significantly more likely to be rehospitalized (t = 2.35, 39 df, p < 0.05). Figure 2 indicates that among delusional patients with low levels of EC, only 25 percent of the schizophrenia patients and 10 percent of the nonschizophrenia patients were rehospitalized. In contrast, at least 45 percent of the schizophrenia and nonschizophrenia patients with high EC to their delusions were rehospitalized during the year. 3. Figure 3, on the relationship between EC and good work functioning (working over half-time), indicates that slightly over half of the nondelusional schizophrenia patients (57%) were working more than halftime during the followup year. However, delusional schizophrenia patients with both low and high levels of EC were less likely to show adequate work functioning (25% with low EC and only 9% with high EC). A number of delusional nonschizophrenia patients with low EC were able to work (40%), as contrasted with only a small percentage (17%) with high EC. The delusional outpatients with low EC to their delusions were significantly more likely to show good work functioning than those with high EC (t = 2.10, 39 df, p< 0.05). Discussion The present research was designed to advance knowledge about delusions in schizophrenia patients and other psychotic outpatients living in the community, with a particular focus on three major dimensions or aspects of delusions. There has been a paucity of published research on dimensions or aspects of delusions in relation to whether they influence patients' community function as outpatients. The major questions that the research attempts to answer include (1) whether the delusions of schizophrenia and other types of psychotic outpatients differ from those of schizophrenia and other psychotic inpatients, (2) whether there are diagnostic differences, and (3) whether the presence of delusions, or specific dimensions of delusions, are associated with impaired work functioning and/or rehospitalization. 1S3

M. Harrow et al. Schizophrenia Bulletin, Vol. 30, No. 1, 2004 Figure 2. The relationship between high emotional commitment and rehospitalization sz Patients M Non-SZ Patients NonDelusional Low EC High EC Note. EC = emotional commitment; SZ = schizophrenia. The y-axis indicates the percentage of patients who were re-hospitalized. Andreasen 1995) and with our group (Harrow et al. 1974; Harrow and Quinlan 1977; Harrow et al. 1982, 1988), contrasting early acute phases to later phases of psychopathology. Looked at in one way, the increased psychopathology at the acute phase should be obvious. It could be asserted that the severity of psychotic symptoms is one major factor in defining the acute phase of schizophrenia. However, looked at another way, most of the time this large difference has not been emphasized or focused on in terms of its theoretical implications about what factors are involved in psychopathology. We have proposed that affective overexcitement, heightened cognitive arousal, or increased activation or overactivation of nodes often plays a role in such acute psychopathology, with this acute psychopathology including various types of positive symptoms, such as strange thinking (Harrow et al. 1989, 2000a) and delusions (Harrow et al. 1988; Jobe and Harrow 2000). Delusional Inpatients Versus Delusional Outpatients: Influence of the Acute Phase. One of the issues studied is whether there is a difference between the delusional ideation and behavior of inpatients and the ideation of patients who are also delusional but are living (with varying degrees of success) as outpatients in the community. The data in table 1 indicate that the biggest differences in both strength or level of BC about their delusions, and strength of EC to their delusions, is between the more severe scores during the acute inpatient phase and the less severe scores during the other two phases (the postacute inpatient phase and the outpatient phase). The differences between the postacute inpatient phase and the outpatient phase were much smaller. The data indicating very large differences (p < 0.001) between the strength of major dimensions of delusions during the acute phase, as contrasted to the other two phases of disorder studied, highlight the strength and prominence of acute-phase psychopathology. These data are in accord with data from a number of other groups (Andreasen and Grove 1986; Ragin and Oltmanns 1987; Harvey et al. 1990; Arndt and Presence of Delusions, Dimensions of Delusions, and Other Factors as Influences on Work and Community Functioning in Schizophrenia. The question of whether 154

Delusions and Work Functioning in the Psychotic Outpatient Schizophrenia Bulletin, Vol. 30, No. 1, 2004 Figure 3. The relationship between high emotional commitment and work functioning 80% n 60%Non-SZ Patients SZ Patients 40%- 20% Non-Delusional Low EC High EC Note. EC = emotional commitment; SZ = schizophrenia. The y-axis indicates the percentage of patients with good (over half the time) work functioning. abstraction and impaired work functioning and a very strong relationship between processing speed and impaired work functioning. Overall, our longitudinal data and the results of other investigators would support a multifactor model of work dysfunction in schizophrenia. In regard to the overall presence of any delusions and the various dimensions of delusions, our data indicate that both influence community functioning, at times in an interactive fashion. The greater part of the variance in the relationship between positive symptoms and functioning can be linked to the overall presence of any delusions, rather than to specific dimensions of delusions. Thus, the ANOVAs, which included both delusional and nondelusional patients, were significant for most major aspects of functioning studied. While the data indicate that the presence of any delusion in outpatients is a more important influence on functioning, certain dimensions of delusions also are related to aspects of functioning and provide clues to factors that may lessen the impact of psychosis on community func- the presence of positive symptoms, and delusions in particular, is an important influence on outpatient work and social functioning is a subject of controversy (Green 1996; Racenstein et al. 1999, 2002; Green et al. 2000; McGurk et al. 2000). This issue touches on the economic impact of schizophrenia in the United States. Results in this area are controversial. Data from some programs suggest that neuropsychological impairment is important and that psychosis may not be an important influence on work dysfunction (Green 1996; Green et al. 2000). The current research and other longitudinal data suggest that there is an impact on work functioning by psychosis and other positive symptoms (Harrow and Marengo 1986; Racenstein et al. 1999, 2002), by negative symptoms (Herbener and Harrow 2001), and by depressive syndromes (Sands and Harrow 1999). Other results of ours, in agreement with the consensus, indicate that neuropsychological impairment and cognitive deficits also are important influences on work functioning (Reed et al. 2002), with a strong relationship between deficits in 155

Schizophrenia Bulletin, Vol. 30, No. 1, 2004 M. Harrow et al. tioning. Delusional schizophrenia patients living in the community with poor SM about their delusions showed considerably more difficulty in social functioning than schizophrenia patients with better SM about their delusions. It is possible that patients' poor SM concerning societies' views on their unrealistic beliefs and patients' being immersed in their own unrealistic ideas could also be related to a lack of sensitivity about their impact on other people. When patients express beliefs to others that seem strange and socially inappropriate, acquaintances can become apprehensive and reluctant to make contact with them. These factors may contribute to patients' poor social functioning. Rehospitalization and Different Dimensions of Delusions. The data on EC to one's delusions help further our understanding of why some delusional patients are rehospitalized and others are not. Psychotic patients both inside and outside of the hospital exhibited similar levels of BC about their delusions, suggesting that they would be considered equally "delusional" by some conventional assessment procedures. However, in SM and EC, hospitalized and nonhospitalized delusional patients differed. In delusional patients, the presence of some SM ability, and the absence of strong EC to their delusions, may have acted as protective factors, decreasing the pathology associated with delusions such that delusional patients were more likely to be able to remain in the community. Those outpatients with high EC, impinging on their behavior and involving more preoccupation about their delusions, were rehospitalized more frequently. In support of the data in figure 2 on the role of EC in rehospitalization for outpatients, in previous research focusing on dimensions of delusions in inpatients, the strength of patients' EC to their delusions was related, significantly, to their being kept in the hospital for a longer period (Harrow et al. 1988). BC and Double Awareness. Sacks et al. (1974) have presented observations about states in many delusional patients of double awareness, when patients have partial or wavering beliefs about their delusions. In this state, patients either question them or "simultaneously accept and reject them" (Sacks et al. 1974, p. 119). These observations highlight the complex interrelation of delusional ideation and reality testing that occurs in many patients after the most acute phase. The current BC data show a number of patients with partial beliefs about their delusions, especially in the postacute inpatient phase (47.4%) and during the outpatient phase (50.9%). These data fit with data from other major groups (Strauss 1969; Sacks et al. 1974; McGlashan et al. 1975; Chapman and Chapman 1980) and from our own group (Harrow et al. 1988, 1995) supporting formulations about delusions as points on a continuum that can extend from normal beliefs to very unrealistic beliefs. While the data on BC support views about delusions as points on a continuum, they also indicate that both patients with full BC and those with only partial BC had increased difficulty functioning. The biggest difference was between (1) nondelusional patients and (2) those with partial and those with complete BC about their delusions (p < 0.05). Thus, for schizophrenia patients a state of double awareness involving only partial belief rather than full belief did not automatically confer a large advantage in functioning. However, others' research indicates that patients become increasingly able to work successfully with professionals and show other advantages when they emerge from full psychosis into states of double awareness (Sacks et al. 1974). Diagnosis. The absence of diagnostic differences for the three dimensions studied indicates that the observed patterns of relationships show at least some similarity for both schizophrenia and nonschizophrenia patients. Other research has suggested other similarities across diagnosis in that both schizophrenia patients who are psychotic at the acute phase and nonschizophrenia patients who are psychotic at the acute phase have a traitlike vulnerability to recurrent or future episodes of delusions (Harrow et al. 1995; Jobe and Harrow 2000). This lack of diagnostic specificity in several different areas suggests that delusional ideation involves the presence of at least some common underlying factors that cut across diagnosis. While there were similarities across diagnosis, other investigators have found data indicating that a schizophrenia diagnosis does make a difference in regard to some dimensions of delusions (e.g., Appelbaum et al. 1999). In addition, once a patient becomes delusional, other features associated with delusions among schizophrenia versus other diagnostic groups do show diagnostic differences. This includes greater vulnerability of schizophrenia patients to having their delusions persist for a longer period and to the delusions' recurring more frequently. Fitting in with this, schizophrenia patients also show slower rates of recovery from their delusional episodes (Harrow et al. 1995), slower rates of recovery of functioning in other areas, and poorer ability to adapt to new circumstances (Harrow et al. 1997), with the possibility that this lack of resiliency and slower recoverability may be an important characteristic of schizophrenia. Impaired SM as a Factor in Delusional Thinking. The data on impaired SM support the view that impaired recognition of how unacceptable one's delusional beliefs are to other people and to society in general often is an important part of the delusional picture. It is possible that, 156

Delusions and Work Functioning in the Psychotic Outpatient Schizophrenia Bulletin, Vol. 30, No. 1, 2004 as part of an overall picture, (1) patients with more adequate SM might be less likely to reveal their delusions to other people, and (2) as noted earlier, this type of better SM could facilitate and lead to better social functioning. In regard to the role of SM, our group and other investigators have proposed that impaired SM, impaired self-editing, or impaired perspective about one's strange or unrealistic thinking is an important factor in positive symptoms such as thought disorder and delusions (Harrow et al. 1988, 1989; Benson and Stuss 1990; McGrath 1991; Frith 1995; Frith and Done 1998). Research in this area has provided empirical evidence linking impaired SM to thought disorder (Harrow and Miller 1980; Harrow et al. 1989) and to delusional thinking (Harrow et al. 1988). Our evidence has suggested that the impaired SM is not a general factor that cuts across all aspects of a patient's thinking. Rather, it is content-specific, with psychotic patients being better able to monitor the appropriateness of their thinking in other content areas and better able to monitor other patients' ideas than their own ideas (Harrow et al. 1989). Delusions and thought disorder are not just due to impaired SM, but it is one important factor, and this impairment is almost necessary for full psychosis to occur. This raises issues as to what criteria the field should set to define a delusion. Our data indicate that over 70 percent of the delusional inpatients and outpatients manifested some impairment in SM about their delusional ideas, although other samples may differ. Is some lack of self-awareness concerning how unrealistic their delusions sound to other people necessary to label a patient as being fully psychotic or fully delusional? It is probably not necessary, although there is not uniformity in the field about how to view people who have "delusional" ideas but who are aware that these beliefs sound unreal to other people. Adequate SM of one's ideas, thinking, and behavior is linked, in part, to effective and usually routine accessing, or effective use, of stored knowledge or long-term memory, concerning standards of social appropriateness (Harrow et al. 1989). Under normal circumstances, this would help to keep one's ideas and beliefs "on track" and consonant with socially accepted standards. The current data indicating problems with SM in select areas concerning the acceptance of their unrealistic beliefs by the delusional outpatients and inpatients could fit with a view that the patients' guiding motives and preoccupations, which are emotionally based, lead to strong biases in the accessing of stored knowledge or long-term memory involved in SM (Harrow et al. 2000a; Jobe and Harrow 2000). The data on SM indicate that, in the content area involving their specific delusions, these psychotic patients' judgments were impaired about what types of ideas and beliefs of theirs meet standards of appropriateness and about what types of beliefs of theirs seem strange to other people. Possibly this type of impairment could be influenced by reduced frontal activity or insufficient frontal control during acute phases of disorder (Benson and Stuss 1990) EC and the Role of Emotions in Delusional Ideation. While delusions should be viewed as complex events involving multiple factors, the current data point to the importance of EC, especially in its relationship to rehospitalization and work functioning, and they could point to the importance of emotional life in delusions and in belief systems in general. Emotions can play a role in delusions, in terms of (1) the role of emotions as an activating and energizing, and if too high, disorganizing factor (Le Doux 19%), and (2) emotions as a directional factor in terms of influencing emotional content in the form of fantasy life and memories, which can enter into and contribute to the direction of ideas and of thinking (Harrow et al. 1988). In previous reports we have proposed that delusions are emotionally driven, emphasizing the role of emotions and emotional memory in the formation of delusions (Jobe and Harrow 2000). One outlook toward delusions would be that a person's interpretation or perception of the environment is influenced by his or her background motives/goals/plans and associated concerns and needs (Lazarus 1991). The ideas-beliefs that result are generated with the background motive/goals and associated emotions as one of the guiding forces for interpretation, and occasionally misinterpretation, of events occurring in the world. We have emphasized that at the acute phase, under heightened cognitive arousal, there is often cognitive disruption. The emphasis on heightened cognitive arousal and our data on EC could fit in with recent research and theoretical formulations on dopamine dysregulation by Kapur (2003) and with the work of others (Berridge and Robinson 1998; Bnmdege and Williams 2002) and older views by Matthysse (1978). This line of research on dopamine and particularly Kapur's formulation could suggest that heightened cognitive arousal and heightened activation in schizophrenia may be associated with increased salience of stimuli linked to dopamine (DA) dysregulation, possibly in the nucleus accumbens/mesolimbic DA system. With such heightened cognitive arousal and cognitive disruption, memories from the patient's affective past, and wishes and preoccupations from current affective life, could thrust themselves into and intermingle with the patient's ongoing thinking (Harrow et al. 1983). This can lead to unrealistic ideas and delusions in vulnerable people (Harrow et al. 1988; Jobe and Harrow 2000). The data indicating the strongest level of BC and of EC at the acute phase would fit this view. The data on impaired SM in specific content 157

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