Download Distress Attributed to Negative Symptoms in Schizophrenia

Distress Attributed to Negative Symptoms
in Schizophrenia
by Jeari'Paul Selten, Durk Wiersma, and Robert J. van den Bosch
Experience of Negative Symptoms (SENS; Selten et al.
1993). Since the 21 SENS items were taken from the Scale
for the Assessment of Negative Symptoms (SANS;
Andreasen 1989), the patient's rating can be compared to
the psychiatrist's rating for the corresponding SANS item,
and discrepancies may provide a measure of the awareness
of negative symptoms. The SENS also attempts to collect
information on attributions for negative symptoms and to
measure the level of distress ascribed to such symptoms.
A previous study using the SENS compared schizophrenia patients to patients with a depressive disorder and
to normal subjects. The schizophrenia patients reported
more impairments than normal subjects and attributed
higher levels of distress to these impairments. However,
they reported fewer negative symptoms than did the
patients with a depressive disorder, attributed these
impairments less often to mental illness, and attributed
lower levels of distress to such impairments. Since the
schizophrenia patients did not assess themselves as the
normal subjects did, it was inferred that they were at least
"somewhat" aware of their negative symptoms. On the
other hand, as their self-assessments were less realistic
than those of patients with a depressive disorder, the
results suggested that schizophrenia patients are less
aware of and concerned about their impairments than are
patients with a depressive disorder (Selten et al. 1998).
The aim of this study was (1) to assess the prevalence
and severity of distress that schizophrenia patients attribute
to negative symptoms and (2) to examine whether the levels
of reported distress are predictable. The predictive performance of a large number of clinical variables was studied.
How some variables that hold an important place in the
symptomatology and treatment of schizophrenia (positive
and negative symptoms, psychiatric disability, depression,
anxiety, legal status of stay, type and dosage of medication)
Abstract
The purpose of the study was to examine (1) to which
negative symptoms schizophrenia patients attribute
distress and (2) whether clinical variables can predict
the levels of reported distress. With the help of a
research assistant, 86 hospitalized patients completed
a self-rating scale for negative symptoms. The 21 items
of the self-rating scale were taken from the Scale for
the Assessment of Negative Symptoms (SANS). A psychiatrist rated the patients on a number of scales,
including the SANS. When patients reported particular symptoms, they were asked whether those symptoms bothered or distressed them. Answers to this
question were highly dependent on the type of symptom involved. Distress was most often attributed to
symptoms in the subscale avolition-apathy. Patients
were also asked how much they were bothered or distressed. Again, high levels of distress were most often
attributed to items in the subscale avolition-apathy. A
summary score was developed for the level of reported
distress: the distress score. Regression analysis showed
that distress scores were not associated with the
observed severity of negative symptoms or with the
level of psychiatric disability. High distress scores were
best predicted by the combination of high scores for
depression and high scores for insight into positive
symptomatology. However, this model explained only a
quarter of the variance in distress scores.
Keywords: Schizophrenia, negative symptoms,
awareness, phenomenology, neuropsychology, rehabilitation.
Schizophrenia Bulletin, 26(3):737-744, 2000.
Several reports have indicated that schizophrenia patients
may be aware of some, but not all, signs of the disorder
(e.g., McEvoy et al. 1993; Amador et al. 1994). To examine
the awareness of negative symptoms, we developed a selfrating scale for negative symptoms, the Subjective
Send reprint requests to Dr. J.-P. Selten, Dept. of Psychiatry,
University Hospital, Reference nr B01.206, P.O. Box 85500, 3508 GA,
Utrecht, The Netherlands; e-mail: [email protected].
737
Schizophrenia Bulletin, Vol. 26, No. 3, 2000
J.-P. Selten et al.
were selected is, we believe, self-explanatory. The reason
for the selection of other variables (length of illness, severity
of illness, age at first admission, length of admission) may
need some clarification. Kraepelin (1971) regarded schizophrenia as an illness with a deteriorating course. It was of
interest, therefore, to assess to what extent the level of
reported distress was influenced by length of illness or
severity of illness ("Kraepelinian type" or not; see below).
Johnstone et al. (1989) reported that age at onset was an
important predictor of cognitive impairments in schizophrenia. Since in many cases reliable information about illness
onset was no longer available, age at first admission was
chosen as a measure of age at onset. Since it has been suggested that long-term hospitalization may lead to emotional
indifference, the variable length of admission was included.
remainder did not. According to the physician responsible,
54 patients fulfilled criteria for Kraepelinian schizophrenia.
This designation was introduced by Keefe et al. (1987) for
severely deteriorated patients who had been either continuously hospitalized for the previous 5 years or who had been
unable to provide themselves with necessities such as food,
shelter, and clothing. The admission was involuntary in 12
patients. After complete description of the study to the subjects, written informed consent was obtained.
The SENS. Self-ratings were elicited in a semistructured
interview. The interviewer gave a standardized explanation of each item in everyday language and asked a first
question (e.g., "How much energy do you have?"). Next,
the interviewer handed the patient a card that listed five
alternative answers: "very little" (1), "little" (2), "average" (3), "a lot" (4), and "very much" (5). It is important
to bear in mind that impairments are reported by low
scores, not by high scores. Questions about frequency
(e.g., "How often do you succeed in making friends?")
were answered with the help of a second card displaying
the response categories "rarely" (1), "not often" (2),
"average" (3), "often" (4), and "very often" (5).
Symptoms were thus reported with a rating of 1 or 2. The
patients had to choose one answer. They were instructed
to compare themselves to people of their age who had not
been admitted to a psychiatric hospital, and they were
reminded of this instruction at four points in the SENS
interview. Having asked the first question for all 21 SENS
items, the interviewer asked two more questions about
items that had elicited a rating of 1 or 2 (i.e., the patient
had indicated the presence of the symptom). The aim of
the second question was to collect information regarding
the patient's attributions. Finally, the interviewer asked
the patients whether they were bothered or distressed by
the symptom (question 3a). If the answer was affirmative,
the patients were asked how much they were bothered or
distressed (question 3b) and were given a third card listing five alternative answers: "very little" (1), "little" (2),
"quite a lot" (3), "much" (4), and "very much" (5).
Methods
Patients. Schizophrenia patients (DSM-Ill-R criteria;
American Psychiatric Association 1987) were recruited
from the medium- and long-stay wards of the Rosenburg
Psychiatric Hospital in The Hague and the Joris
Psychiatric Hospital in Delft, The Netherlands. We
excluded patients who had a physical handicap that
explained their impaired functioning. Other reasons for
exclusion were the presence of mental subnormality
(defined as having failed to complete primary education
or having repeated more than one grade in primary
school), an organic mental disorder (DSM-III—R), recent
or current substance abuse (DSM-IH-R), a current manic
or major depressive episode (DSM-III-R), having a first
language other than Dutch, and incomprehensible speech.
Thirty-one patients refused to take part. They were
patients who had been committed more often than those
who agreed to participate (32.3% versus 13.8%; x 2 = 10.6;
df= 1; p < 0.01) but did not differ significantly from participants with regard to age, sex, level of education, length of
illness, or length of current admission (two-tailed chi-square
tests or t tests). The final sample included 60 men and 26
women. Their mean age was 44.4 years (standard deviation
[SD] = 10.3; range 20-65). The mean age at first admission
was 25.7 years for men (SD = 8.7) and 28.0 years (SD =
9.4) for women. Length of illness was defined as the number of years since first admission. The length of the current
admission was not normally distributed and varied greatly:
less than 1 year in 26 patients and more than 5 years in 35
patients (median: 44.5 months; 25th percentile: 9.8 months;
75th percentile: 132.0 months; range 1—495 months). Five
patients were on clozapine. The mean dosage of classic neuroleptics for the remaining 81 patients, converted into equivalents of haloperidol, was 21.9 mg (SD = 27.3; range 0-171;
van Wielink 1987). Forty patients were on anticholinergics.
Forty-nine patients had at least a tenth-grade education; the
The SENS rating procedure has two important advantages over one in which the interviewer decides to what
extent the patient is aware of the symptom. First, there is
no risk of interpretation bias. Second, SENS ratings are
independent of the amount of the patient's spontaneous
speech. The three questions constitute the three parts of
the SENS (awareness, attribution, and distress). The items
"blocking" and "poverty of content of speech" and the
items measuring attention are not included in the SENS
and in the analysis of the SANS because they do not
appear to belong to the negative syndrome (Miller et al.
1993).
738
Distress Attributed to Negative Symptoms
Schizophrenia Bulletin, Vol. 26, No. 3,2000
in percentages of the number of valid replies to the first
SENS question. A total score for disruption and distress was
obtained by adding all scores for question 3b: This provided
the distress score. SANS summary scores were arrived at by
adding the scores for four SANS subscales (affective flattening, alogia, avolition-apathy, and asociality-anhedonia).
Bivariate and multiple regression analyses were used to
examine the predictability of distress scores. We studied the
predictive qualities of 20 variables, divided into four sets
(table 1). To avoid collinearity, four Manchester scale items
(depression, flat affect, psychomotor retardation, and
poverty of speech) were excluded from the fourth set.
Scores for the depression item correlated strongly with
Procedure. Nurses completed the REHAB (Rehabilitation
Evaluation Hall and Baker), a scale for the assessment of
psychiatric disability (Baker and Hall 1988). They had followed the standard REHAB training program. The aim of
this procedure was to provide the psychiatrist (J.-P.S.) with
detailed information on the patient's daily activities. In addition, the REHAB total general behavior score (REHAB
score) provides a measure of psychiatric disability. Nurses
also provided written information about the patient's "relationships with friends and peers," "abihty to feel intimacy
and closeness," and "sexual interest and activity."
Patients were interviewed twice. In one session they
completed the SENS with the help of a research assistant. In
the other session the psychiatrist assessed all patients using
the SANS, the Montgomery-Asberg Depression Rating
Scale (MADRS; Montgomery and Asberg 1979), the
Manchester scale (Hyde 1989), and a slightly modified version of item 104 ("insight into psychotic condition") of the
Present State Examination (PSE; Wing et al. 1974). The
order of the sessions was random, and the interval was limited to a maximum of a week.
The Manchester scale includes nine key items of
chronic schizophrenia (delusions, hallucinations, incoherence, incongruous affect, depression, anxiety, poverty of
speech, psychomotor retardation, flattened affect). Four
items relate to positive symptoms (delusions, hallucinations,
incoherence, and incongruous affect). The PSE item, which
has been defined as "the subject's ability to recognize that
the psychotic symptoms are anomalies of his own mental
processes" (Wing et al. 1974, p. 177), served as a measure
for insight into positive symptoms. The psychiatrist assessed
this item in patients with psychosis and patients without
psychosis and examined their ability to recognize that their
current or previous psychotic symptoms were anomalies of
their own mental processes. After 2 months, the assessments
were repeated in 80 patients. The times of the first and second measurement will be indicated as time I and time PL
The interrater reliability of the psychiatrist's ratings was
largely sufficient for all instruments (ICC [intraclass correlation coefficient] for SANS summary score = 0.81).
Table 1. Predictors of distress score (bivariate
regression analysis)
Analysis. To calculate the prevalence of negative symptoms according to patients, self-ratings in reply to the first
SENS question were dichotomized. Ratings of 1 or 2 were
taken as scores indicating the presence of the symptom.
Sometimes patients failed to give a "valid" reply to the first
SENS question (i.e., a rating of 1 through 5): They said that
they did not know the answer or refused to answer questions
about sexuality. The prevalence of symptoms, therefore, was
expressed in percentages of the number of valid replies to
the first SENS question.
The prevalence of reports of disruption or distress (as
evidenced by a positive reply to question 3a) was expressed
739
Predictor variable
Timel
beta1
Time II
beta1
Demographic
Age
Sex2
Education3
-0.10
0.12
0.04
-0.07
0.21
-0.20
Clinical
Age on first admission
Length of illness
Length of current admission
Kraepelinian type 4
Forced admission4
-0.10
0.01
-0.20
0.07
0.13
0.17
-0.21
-0.24*
0.05
-0.03
Pharmacological
Equivalents of haloperidol
Use of anticholinergics4
Use of clozapine4
0.05
0.05
-0.22*
0.01
-0.04
-0.08
Psychopathological
Anxiety5
Delusions5
Hallucinations5
Incoherence5
Incongruous affect5
SANS summary score
MADRS score
REHAB score
Insight (item 104 PSE)
0.25*
0.14
0.17
0.05
-0.07
0.04
0.44**
0.01
0.28**
0.19
0.13
0.07
0.13
0.01
-0.11
0.45**
0.01
0.33**
Note.—SANS = Scale for the Assessment of Negative
Symptoms; MADRS score = Montgomery-Asberg Depression
Rating Scale, total score; REHAB score = Rehabilitation
Evaluation Hall and Baker total general behavior score; PSE =
Present State Examination.
1
Standardized regression coefficient.
2
Male = 1, female = 2.
3
At least a tenth-grade education: yes = 1, no = 0.
4
Yes = 1,no = 0.
5
Items of Manchester scale.
'p < 0.05; "p < 0.01
J.-P. Selten et al.
Schizophrenia Bulletin, Vol. 26, No. 3, 2000
were more often negative (341 times) than positive (264
times; table 3). Occasionally (11 times) patients said they
did not know the answer to this question. Remarkably few
patients attributed distress to inability to feel or affective
nonresponsivity. In addition, relatively few patients
seemed to be distressed about the experience of decreased
sexual interest and activity. Distress was attributed most
frequently to items in the SANS avolition-apathy subscale: lack of energy and impersistence. The same applies
to high ratings for the severity of distress (question 3b).
The results obtained at time II were similar (data not
shown). The stability of distress scores across a 2-month
interval was moderate (table 4).
MADRS scores and those for the remaining items with
SANS summary scores. All scores were transformed into z
scores. Use was made of a backward elimination strategy
that starts with all variables in the equation and sequentially
removes them (Kleinbaum et al. 1988). The first step was to
examine the performance of all the variables individually
(bivariate regression analysis). Next, multiple regression
analysis was used to control for covariance among these
variables. First, all variables pertaining to one set were
entered into the regression equation, and then the variables
meeting the criterion for removal (p > 0.15) were eliminated
one by one. Next, all variables selected in one of the foregoing sets of regression were entered into the final regression
analysis (criterion for removal: p > 0.05). All quoted p values are two-sided.
Bivariate Regression Analysis. At both assessments distress scores were found to be associated with MADRS
scores and the PSE item. Distress scores were not associated
with SANS summary scores or REHAB scores (table 1).
Results
The results obtained with the various instruments are
given in table 2. The prevalence of negative symptoms
according to the patients is given in table 3. In a previous
study it was shown that patients underestimate the prevalence of these symptoms (Selten et al. 2000).
Multiple Regression Analysis. First, all variables pertaining to each set were entered into the regression equation (table 5). Next, the selected variables were entered
into the final regression equation. The final model for the
efficient prediction of distress scores at time I included
two variables: the MADRS score and the score for the
PSE item (Multiple R = 0.49). When this procedure was
followed to predict distress scores at time II, the same
variables were selected (Multiple R = 0.52). Thus, the
combination of depression and insight into positive symptoms predicted high distress scores.
Prevalence and Severity of Reported Distress. It is
important to note that the question about disruption or distress (the third SENS question) is asked only about those
symptoms that are present according to the patient (as evidenced by a rating of 1 or 2 in reply to the first SENS
question). Replies to the question about whether they
were bothered or distressed by the symptom (question 3a)
Discussion
Table 2. Results of assessment at time I
Prevalence of Distress. The patients' reports varied
greatly. Some patients made it clear that they suffered a
lot from a particular symptom, but others denied the experience of disruption or distress. A discussion about the
validity of these findings should take into account the
concepts of primary and secondary negative symptoms.
According to Carpenter et al. (1988), primary negative
symptoms should be viewed as the expression of a schizophrenia-specific pathological process, whereas secondary
negative symptoms can be traced back to known causes of
diminished functioning (e.g., long-term hospitalization,
depression, side effects of neuroleptics). Neither the
SANS nor the SENS excludes secondary negative symptoms, and some patients may have complained (or may
have failed to complain) about secondary negative symptoms. It is unlikely, however, that the SENS measures
mainly the experience of impairments that are due to a
long admission. Staff in both hospitals made every effort
to activate the patients and to prepare them for living in
the community or in a sheltered home. A long period of
Prevalence
Variable
%
1
26
22
16
58
41
51
Anxiety
Incongruous affect1
Incoherence1
Delusions1
Hallucinations1
Poor insight2
SANS summary score
MADRS score
REHAB score
n
(22/86)
(19/86)
(14/86)
(50/86) '
(35/86)
(44/86)
Mean
SD
10.1
10.5
47.0
4.4
9.4
23.7
Note.—SD = standard deviation; SANS = Scale for the
Assessment of Negative Symptoms; MADRS score =
Montgomery-Asberg Depression Rating Scale, total score;
REHAB score = Rehabilitation Evaluation Hall and Baker total
general behavior score.
1
1tem of Manchester scale, rating of at least 2 (moderate).
2
Item 104 of Present State Examination, rating of 2 or 3
(pathological).
740
Table 3. Prevalence of negative symptoms according to patient and psychiatrist and prevalence of reported distress (assessment
at time I)
Prevalence of Symptoms
According to patient1
According to psychiatrist2
Negative symptoms
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16a.
16b.
17a.
17b.
18.
19.
20.
21.
1
Unchanging facial expression
Decreased spontaneous movements
Paucity of expressive gestures
Lack of vocal inflections
Affective nonresponsivity
Poor eye contact
Inability to feel
Poverty of speech
Increased latency of response
Absence of thoughts
•
Poor grooming and hygiene
Impersistence
Physical anergia
Lack of motivation
Lack of energy
Decreased recreational interest
Decreased recreational activity
Decreased sexual interest
Decreased sexual activity
Inability to feel intimacy
Few relationships with friends
Asociality
Anhedonia
35 (29/84)
31 (26/83)
57 (48/85)
35 (29/82)
33 (27/82)
20 (17/85)
18(15/84)
45 (38/85)
13(11/85)
26(22/85)
12(10/86)
48(40/84)
45 (38/85)
37 (31 /84)
40(34/84)
41(35/86)
55 (47/86)
59 (47/80)
81(65/80)
44 (37/85)
38(32/84)
26 (22/86)
28 (23/86)
54 (45/84)
40 (33/83)
58 (49/85)
50 (41/82)
63 (52/82)
38 (32/85)
64 (54/84)
45 (38/85)
19(16/85)
44 (37/85)
63 (54/86)
93 (78/84)
88 (75/85)
92 (77/84)
91 (77/85)
78 (67/86)
78 (67/86)
71 (57/80)
71 (57/80)
85 (72/85)
92 (77/84)
91 (78/86)
73 (63/86)
As evidenced by rating of 1 or 2 in reply to first Subjective Experience of Negative Symptoms question.
As evidenced by Scale for the Assessment of Negative Symptoms rating of at least 2.
3
As evidenced by positive reply to Subjective Experience of Negative Symptoms question 3a.
4
As evidenced by rating of 4 or 5 in reply to Subjective Experience of Negative Symptoms question 3b.
2
Prevalence of
reported distress3
Prevalence of high
ratings for severity
of distress4
% (n)
% (n)
5 (4/84)
6 (5/83)
11 (9/85)
13(11/82)
10(8/82)
9 (8/85)
6 (5/84)
15(13/85)
8 (7/85)
11 (9/85)
7 (6/86)
35 (29/84)
21 (18/85)
18(15/84)
32 (27/85)
26 (22/86)
0 (0/84)
1 (1/83)
5 (4/85)
4 (3/82)
5 (4/82)
4 (3/85)
2 (2/84)
7 (6/85)
6 (5/85)
7 (6/85)
5 (4/86)
20(17/84)
13(11/85)
11 (9/84)
22(19/85)
13(11/86)
23(18/80)
9(7/80)
18(15/85)
18(15/84)
7 (6/86)
16(14/86)
6
8
4
9
(5/85)
(7/84)
(3/86)
(8/86)
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Schizophrenia Bulletin, Vol. 26, No. 3, 2000
J.-P. Selten et al.
Table 4. Stability of distress scores (2-month interval)
Timel
Variable
Distress score
Time II
1
Mean
SD
Mean
SD
Correlation, r
11.3
12.8
10.8
11.3
0.53
Note.—SD = standard deviation.
1
Pearson's correlation; p < 0.001.
toms that the professionals have come to consider this
state normal. Our results confirm and extend the findings
of a study in which the interviewer decided to what
extent the patient suffered from negative symptoms:
complaints about affective flattening, alogia, avolitionapathy, and asociality-anhedonia were found to be much
less severe in a group of patients with schizophrenia than
in a group of patients with a major depressive disorder
(Kulhara and Chadda 1987).
A lack of emotional reaction to a given lesion or
impairment has been described in a variety of neuropsychiatric conditions, including tardive dyskinesia
(Alexopoulos 1979; Rosen et al. 1982; Myslobodsky et al.
1985). Babinski (1914) coined the term "anosodiaphoria"
to describe a lack of emotional reaction to left hemiplegia.
According to Babinski, anosodiaphoria, as a rule, followed the stage of "anosognosia," during which the
patient was unaware of the paralysis. In view of the evidence for organic causes of negative symptoms, anosodiaphoria can be regarded as a proper designation for the
lack of concern that some schizophrenia patients display
toward negative symptoms. Perhaps the mechanisms
underlying anosognosia and anosodiaphoria are the same,
in that they prevent the patient from appreciating the full
extent of the severity of the impairments. The nature of
these mechanisms remains unknown.
Table 5. Predictors of distress scores (significant contributors to final regression equation
in multiple regression analysis)
Variable
Timel
Beta1
Time II
Beta1
MADRS score
Insight (item 104 PSE)
0.41*"
0.22*
0.41***
0.26**
Note.—MADRS score = Montgomery-Asberg Depression
Rating Scale, total score; PSE = Present State Examination.
1
Standardized regression coefficient.
*p < 0.05; " p < 0.01; ***p < 0.001
stay was therefore more likely the consequence, not the
cause, of negative symptoms. One might suggest that
information on what constitutes "normal behavior" is no
longer available to patients who have been hospitalized
for a long time, but all patients had ample occasion to
observe the behavior of nurses and therapists, to watch
television, and to read newspapers. Even the few patients
who lived in locked wards were frequently permitted to
leave the hospital. There is also no evidence that the
SENS measures primarily the experience of impairments
that are caused by depression. First, the sum of self-ratings in response to the first SENS question, which measures the level of awareness of negative symptoms, correlated only weakly with MADRS scores (at time I: r =
-0.23; p > 0.05). Second, patients who suffered from a
major depressive episode were excluded from the study. It
follows that the third SENS question (about distress) was
asked to patients with normal mood as well as to (mildly)
depressed patients. In sum, some self-assessments may
have been of secondary negative symptoms, but it is
unlikely that such self-assessments were more frequent
than self-assessments of primary negative symptoms.
The finding of a relative indifference toward negative symptoms agrees with clinical experience. The problem here may be that mental health professionals have
gotten so used to the low frequency and intensity of
schizophrenia patients' complaints about negative symp-
Predictability of Distress. The lack of association
between levels of reported distress and measures of negative symptoms and psychiatric disability was a striking
finding. The final model for the prediction of distress
scores, which included MADRS scores and scores for the
PSE item, suggests that the combination of depression
and insight into positive symptoms determines to some
degree the level of suffering from negative symptoms.
Since patients with greater insight may be expected to
have greater levels of dysphoria, this finding makes good
sense and provides some evidence for the construct validity of the third part of the SENS.
Limitations. Several limitations have already been mentioned. We should point out that the sample was not repre-
742
Schizophrenia Bulletin, Vol. 26, No. 3, 2000
Distress Attributed to Negative Symptoms
sentative of the population of schizophrenia patients as a
whole, in that the patients were more severely impaired
than patients in the community.
Keefe, R.S.E.; Mohs, R.C.; Losonczy, M.F.; Davidson, M.A.;
Silverman, J.; Kendler, K.S.; Horvath, T.B.; Nora, R.; and
Davis, K.L. Characteristics of very poor outcome schizophrenia. American Journal ofPsychiatry, 147:889-895,1987.
Kleinbaum, D.G.; Kupper, L.L.; and Muller, K.E. Applied
Regression Analysis and Other Multivariable Methods.
Boston, MA: PWS-Kent, 1988.
Conclusion
We found that a large number of clinical variables were relatively weak predictors of the degree to which the patients
suffered from the clinical variables. Perhaps one negative
result was the most interesting finding: the level of distress
attributed to negative symptoms was not related to their
observed severity. A clinical implication of our findings is
that mental health professionals should be aware of a broad
spectrum of possible attitudes toward negative symptoms:
from indifference at one end of the spectrum to deep suffering at the other end. Future studies could try to distinguish
between primary and secondary negative symptoms and
examine the experience of each type of symptom.
Kraepelin, E. Dementia Praecox and Paraphrenia. New
York, NY: Krieger, 1971.
Kulhara, P., and Chadda, R. A study of negative symptoms in schizophrenia and depression. Comprehensive
Psychiatry, 28:229-235, 1987.
McEvoy, J.P.; Schooler, N.R.; Friedman, E.; Steingard, S.;
and Allen, M. Use of psychopathology vignettes by patients
with schizophrenia or schizoaffective disorder and by mental health professionals to judge patients' insight. American
Journal of Psychiatry, 150:1649-1653,1993.
Miller, D.; Arndt, S.; and Andreasen, N.C. Alogia, attentional impairment and inappropriate affect: Their status in
the dimensions of schizophrenia.
Comprehensive
Psychiatry, 34:221-226, 1993.
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Acknowledgments
The authors thank Margaret Jones and Hugo
Duivenvoorden for advice.
The Authors
Jean-Paul Selten, M.D., Ph.D., is Associate Professor,
Department of Psychiatry, University of Utrecht, Utrecht,
The Netherlands. Durk Wiersma, Ph.D., is a sociologist
and Associate Professor, Department of Social Psychiatry;
and Robert J. van den Bosch, M.D., Ph.D., is Professor of
Psychiatry, University of Groningen, Groningen, The
Netherlands.
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