Barry A. Ritzler

Do Psychiatric Patients Fit Their Diagnoses? Patterns of Symptomatology as Described with the Biplot

Systems of psychiatric diagnosis have been regularly criticized for their low reliability and their inability to fit accurately the kinds of patients coming for treatment. To explore the reasons for these problems, this study utilizes a new method, the biplot, for defining groups of similar patients and the relationships of these groups to key symptom clusters. Using this technique to analyze data from a representative sample of first admissions for psychiatric disorder, results showed: a) symptom clusters representing the classical diagnostic categories, mania, schizophrenia, neurotic depression, and psychotic depression, were readily identified; b) however, only a few patients were clustered near these traditional syndromes. These findings suggest that although syndromes do exist that fit traditional diagnostic categories, the vast majority of patients fall between these syndromes, having characteristics from several of them. For most patients, forcing the diagnostician to choose among the categories requires an arbitrary decision that may contribute to dissatisfaction in the diagnostician who recognizes how misleading the diagnosis can be.

Patterns of disorder in first admission psychiatric patients.

Are there patterns of characteristics in psychiatric patients, different from traditional diagnostic considerations, that could provide important information for understanding, treatment, and research? To pursue this question, this report describes an investigation of clinical and demographic characteristics in a representative sample of first admissions for functional psychiatric disorder. Analyzing the patterns of these characteristics showed that social class had a particularly key role relating to a larger number of characteristics than did symptom and functioning measures. Symptoms when analyzed together revealed replicated factors not corresponding to diagnostic types. The implications of these and other findings for considering a broad perspective in conceptualizing, studying, and treating psychiatric disorder are discussed.

The effect of inquiry on the Exner comprehensive system

The effect of inquiry on the Comprehensive System was tested by scoring 130 protocols of patients and normals with and without inquiry. The absence of inquiry significantly reduced the means for Developmental Quality-vague (DQv), Form Quality-unusual (FQu), the sum of color responses (SumC), the sum of shading responses (Sum Shading), and the weighted thought disorder measure (W Sum6 SP SC), but significantly increased pure form (F). The effect for W Sum6 SP SC was strongest for schizophrenic protocols. Liberalized scoring rules were established in an attempt to restore the interpretative validity of the scoring categories distorted by the lack of inquiry. The new rules significantly improved the accuracy of color and shading categories, but did not improve the special scores measure of thought disorder.

How diagnostic concepts of schizophrenia differ.

How do various diagnostic definitions of schizophrenia compare? As part of a larger study of diagnosis and prognosis, nine different systems used for diagnosing schizophrenia were applied to a sample of patients (N=272) from two geographical catchment areas who had been hospitalized for the first time in their lives for functional psychiatric illness. The size and composition of the groups diagnosed schizophrenic by each set of criteria were then compared with respect to five clinical variables hypothesized to be important for differentiating the diagnostic systems. All data were collected with structured interviews of demonstrated reliability. Results showed that several of the variables tested distinguished schizophrenics diagnosed by some systems from those considered schizophrenic by other systems and from those patients in the sample not considered schizophrenic by any system. High levels of delusions of passivity characterized the patients classified as schizophrenic by three systems: Schneider, Langfeldt, and the Flexible System. High psychosis scores characterized the patients considered schizophrenic by the New Haven Schizophrenia Index. Increased chronicity and low levels of affective symptoms characterized the patients considered schizophrenic by the Feighner criteria. Poor work and social function characterized the patients considered schizophrenic by the hospital physician using DSM-II guidelines. These and other findings reported indicate that the various systems for diagnosing schizophrenia have both characteristic differences and overlap. Considering these can help to delineate the extent to which research findings or clinical experience based on the system can be generalized to findings based upon another.

The therapeutic community inpatient ward: does it really work?

Abstract This study compared ward atmosphere, member satisfaction, and treatment effectiveness on community-oriented and medical model psychiatric inpatient wards. The method used for comparison was the Community Oriented Program Environment Scale (COPES) developed by Moos. The results showed that the community-oriented ward has greater patient autonomy, interpersonal involvement, and practical orientation than the medical model ward, whereas the medical model ward shows more order and organization. These results suggest that a community orientation sacrifices the appearance of an orderly ward for increased patient activity and involvement. In addition, the members of the community-oriented ward showed significantly greater satisfaction than the members of the medical model ward, suggesting that the community approach is more effective at creating a helpful level of morale and confidence in the treatment approach. A check of hospital records revealed that neurotics treated on the community-oriented ward were readmitted twice as frequently as neurotics on the medical model ward. Also, character disorder patients left the hospital against medical advice more frequently on the community-oriented ward.

Convergent and concurrent validation of four measures of assertion

This study examined the relationship among the College Self-Expression Scale (CSES), the Dominance Scale of the California Psychological Inventory (Do), role-play assessment, and peer ratings of assertion. Peer ratings served as the criterion measure. Fifty-three members of a college sorority completed the CSES and the Do Scale, role played eight scenes requiring an assertive response, and rated each other on a five-point scale of assertion. Peer ratings were significantly correlated with the Do Scale and the CSES. A significant correlation was also obtained between the CSES and the Do. Role-play ratings were not significantly related to any measure. Results are discussed in terms of convergent and concurrent validity for the Do and CSES as measures of assertion. A precautionary note is presented regarding the use of role-play assessment for measuring assertion and as a behavioral validation procedure.

Bilateral transfer of inhibition in the motor learning of schizophrenics and normals.

Bilateral transfer of the effects of massed practice in motor learning was evaluated for an adjusted sample of 36 chronic undifferentiated schizophrenics and 36 normal controls. Ss were trained and tested on a rotary pursuit task under two bilateral transfer conditions-Rest and No-Rest- and one non-transfer Control condition. Normal Ss demonstrated positive reminiscence scores in the Rest condition and significant transfer of inhibitory effects in the No-Rest condition. Schizophrenics, on the other hand, showed no significant transfer of inhibition. The results were discussed as supporting the hypothesis of a proprioceptive deficit in schizophrenia involving central integrating mechanisms. Such findings also suggested that a proprioceptive deficit might be a significant underlying factor in the cognitive dysfunction and body image disturbances of schizophrenia, processes which also can be explained by impairment in central integrating mechanisms.

Social class and psychiatric disorder. The examination of an extreme.

Relationships between social status and various aspects of mental disorder have been of long-standing interest to both clinicians and researchers, and a large body of literature exists attesting to the importance of social status in understanding psychiatric illness and disability. Reports examining social status and schizophrenia suggest that relationships between socioeconomic status and psychiatric illness may rest heavily upon differences between the lowest socioeconomic stratum and the remainder of society. To investigate the extent to which relationships between socioeconomic status and psychiatric illness and disability reflect differences between a deviant lowest socioeconomic stratum and the remainder of society, data from 217 patients hospitalized for psychiatric disorder and reassessed at a 2-year follow-up were examined. At initial assessment, 17 patient characteristics were found to be associated with socioeconomic status; for seven of these 17 characteristics, the largest difference between classes was found between the lowest and the adjacent (nextlowest) social class. At follow-up, for five of 15 characteristics found to be related to social class, the greatest interclass difference occurred between the lowest and the adjacent social class. Both initially and at follow-up, significant associations between patient characteristics and social class remained when the lowest social class patients were excluded from the analyses.

Comment on “Addressing Issues in the Development and Use of the Composite International Reference Values as Rorschach Norms for Adults” (Meyer, Shaffer, Erdberg, & Horn, 2015)

Exner established norms for using the Rorschach with the Comprehensive System in 1986 (Exner, 1986). Those norms (and the related coding variables) underwent changes for a number of years. With Exner’s death in 2006, there was confusion about whether the CS could (or should) be changed. Exner often stated that the CS would continue to change as research clarified findings, societal changes occurred, and technology advanced. Norms serve best, however, when they are collected in a standardized manner with adequately trained and experienced examiners, under similar testing conditions, and with clear inclusion and exclusion criteria. Recently, Meyer, Shaffer, Erdberg, and Horn (2015) recommended the use of the Composite International Reference Values (CIRV) on the adult Rorschach reference norms as opposed to the norms established by Exner in the Comprehensive System (CS; Exner, 2003). Those reference values were derived from the studies published in the Journal of Personality Assessment’s special issue, “International Reference Samples for the Rorschach Comprehensive System” (Shaffer, Erdberg, & Haroian, 2007). It is important to keep in mind, however, that the studies in the special issue were originally intended as reports from various countries with the expressed motivation to provide a compendium of country-specific or locale-specific norms. There was no study design prior to the collection of data that would lead to an integrated international norm set. In effect, there were a number of uncoordinated studies that lacked a specific data-gathering protocol or any overall coordination of the research parameters. As a result, there are a number of concerns that should call into question the use of the CIRV, because of this lack of coordinated research. Ritzler and Sciara (2009) presented a number of “cautionary notes” regarding the integrity of many of the studies used to develop the CIRV and expressed concerns about the appropriateness of combining those data to make a “composite” international reference value. The concerns raised questions regarding the methods of data collection and generalizability to nonpatient samples. In particular, these concerns focused on (a) the use of inexperienced examiners; (b) the ways sampling might affect generalizability (i.e., questionable selection procedures, insufficient exclusion criteria, inadequate sample size); and (c) the use of less than ideal administration procedures, including the lack of a warmup phase as part of the administration process and possible translation issues regarding administration and inquiry procedures. The article by Meyer et al. (2015) that is the focus of this comment addressed only one of the “cautionary notes” put forth by Ritzler and Sciara. The cautionary note identified in the article was in relation to the simplistic protocols, which we suspect were due to the reliance on insufficiently experienced examiners, that have led to poorer quality protocols. The article identifies highand low-quality protocols for which the authors found no differences. Ritzler and Sciara (2009) expressed concern that all the protocols in the CIRV and not just “low-quality” protocols should be evaluated for appropriateness. It should furthermore be noted that Meyer et al. had some difficulty separating the samples according to quality, yet the absence of significant differences can be due to a number of reasons—not just that the samples do not differ because they are of equal quality. In the second study, the authors reported that the international norms are significantly lower than the CS norms for many variables, indicating that the CS norms are likely to identify many “normal” individuals as being pathological. If an individual provides a Rorschach that is below the mean level of adequate psychological functioning, it does not mean that the individual is “pathological.” Pathological pertains an individual who has a diagnosable psychological disorder. The CS identifies such individuals and contrasts them with others functioning below an adequate level. Additionally, nowhere in the report of the study or anywhere else in the article did the authors mention that there was not a coordinated sampling procedure in the international norms. The sampling procedures used were different compared to those involved in the collection of the CS norms. When Exner established the CS norms (Exner, 2003), he attempted to identify a mean level of adequate psychological functioning by obtaining protocols from individuals who were meaningfully involved in activities outside the home. The international samples, on the other hand, selected individuals with varying backgrounds and with varying strategies for inclusion and exclusion. As an example, the U.S. normative sample (Shaffer et al., 2007) obtained protocols from individuals in a blood donor clinic—a much different sampling procedure than that used by Exner (2003). This is a problem because individuals in a blood donor clinic are