Paul H. Lysaker

Five-component model of schizophrenia: assessing the factorial invariance of the positive and negative syndrome scale.

A five-component model of schizophrenia has been presented by Kay and Sevy based upon an analysis of the Positive and Negative Syndrome Scale. Kay and Sevy found factorial validity for negative and positive syndromes, and they identified excitement, depressive, and cognitive components as well. They suggested that subtypes and syndromes can be mapped along dimensions presented in their model. The present study compares the five-component solution for a new sample of 146 subjects to a reanalysis of the Kay and Sevy data. Despite divergent demographic characteristics, the two samples produce similar dimensions. Correlations of component loadings and subject scores as well as confirmatory factor analysis are presented. Discussion focuses on points of agreement and important differences in the symptoms assigned to each component. How the dimensions relate to rationally derived models of positive and negative syndromes is reviewed, and implications for subtyping and other methods of examining the heterogeneity of schizophrenia are considered.

Metacognition amidst narratives of self and illness in schizophrenia : associations with neurocognition, symptoms, insight and quality of life

Objective:  Impairments in laboratory tasks of metacognition appear to be associated with symptoms, functioning, and neurocognition in schizophrenia. We sought to replicate these results in a study of metacognition within personal narratives of self and illness.

Pathways Between Internalized Stigma and Outcomes Related to Recovery in Schizophrenia Spectrum Disorders

OBJECTIVE The mechanisms by which internalized stigma affects outcomes related to recovery among people with severe mental illness have yet to be explicitly studied. This study empirically evaluated a model for how internalized stigma affects important outcomes related to recovery. METHODS A total of 102 persons with schizophrenia spectrum disorders completed measures of internalized stigma, awareness of mental illness, psychiatric symptoms, self-esteem, hopefulness, and coping. Path analyses tested a predicted model and an alternative model for the relationships between the variables. RESULTS Results from model 1 supported the view that internalized stigma increases avoidant coping, active social avoidance, and depressive symptoms and that these relationships are mediated by the impact of internalized stigma on hope and self-esteem. Results from model 2 replicated significant relationships from model 1 but also supported the hypothesis that positive symptoms may influence hope and self-esteem. CONCLUSIONS Findings from two models supported the hypothesis that internalized stigma affects hope and self-esteem, leading to negative outcomes related to recovery. It is recommended that interventions be developed and tested to address the important effects of internalized stigma on recovery.

Insight and Personal Narratives of Illness in Schizophrenia

Abstract Insight in schizophrenia tends to be assessed as the degree to which one possesses specific knowledge. It therefore often fails to account for the fact that awareness of illness is an inextricable part of a personal narrative and may be incoherent or incomplete for many different narrative reasons. Accordingly, we have developed a means of eliciting narratives of illness: the Indiana Psychiatric Illness Interview, and a method for rating the coherence of those narratives: the Narrative Coherence Rating Scale. In this article we describe these methods and present data on their reliability and validity in a study of the illness narratives of 33 outpatients with schizophrenia or schizoaffective disorder. Results suggest our measures possess sufficient internal consistency and good to excellent interrater reliability. Additionally, as predicted, our measures of narrative coherence were significantly correlated with traditional measures of insight and with measures of cognitive impairment and hopelessness gathered earlier.

Positive and negative affect recognition in schizophrenia: a comparison with substance abuse and normal control subjects

This study had three aims: to compare a schizophrenia sample (n = 50) with a substance abuse (n = 25) and normal sample (n = 81) on affect recognition; to compare differences in their performance between positive and negative affect recognition; and to introduce a new videotape method of stimulus presentation. Subjects were asked to identify the predominant affect depicted in 21 5-10-s vignettes containing three trials of seven affect states. Results demonstrate significant group differences: normal subjects scored in the normal or mild range, substance abuse (s/a) subjects scored in the mild and moderate ranges, and the schizophrenia sample scored predominantly in the moderate to severe ranges. Accuracies were 92.3% for the normal sample, 77.2 for the s/a sample and 64.8 for the schizophrenia sample. Response dispersions were 97.6% for the schizophrenia group, 69% for the s/a sample and 38% in the normal sample. A repeated measures ANOVA revealed a group by type of affect interaction with schizophrenia subjects showing far greater differential impairment on negative affect recognition. Difficulty of item did not contribute to this difference. Test-retest reliability at 5 months for this new method was r = 0.76, and stability of categorization was very high over 5 months (weighted kappa = 0.93). These affect recognition deficits in schizophrenia are discussed as they relate to lateralization of brain function, high EE families, social skills impairment and implications for rehabilitation services.

The positive and negative syndrome scale and the brief psychiatric rating scale : reliability, comparability, and predictive validity

In a psychiatric rehabilitation study, 154 concurrent ratings were performed using the 30-item Positive and Negative Syndrome Scale (PANSS) and the 18-item Brief Psychiatric Rating Scale (BPRS). Although both instruments had excellent interrater reliability, the PANSS was consistently better: on the 18 symptom items the two instruments share, the PANSS had higher intraclass rs on 14; for the syndromes, the PANSS was higher than the BPRS on positive, negative, and total. Weighted Kappas comparing shared items revealed that most were not interchangeable, with only three coefficients in the excellent range. However, syndrome scale scores were very highly correlated and resulted in similar classification for negative schizophrenia. Ten of the 12 items of the PANSS not included in the BPRS had low zero-order correlations with BPRS items, which suggests that they measure symptoms distinct from those measured by the BPRS and should add to clinical predictive power. This proved true in our study of rehabilitation of patients with schizophrenia PANSS symptom ratings explained up to 55% of the variance on seven measures of work performance, whereas the BPRS had lower predictive power on six of the seven measures. We concluded that the PANSS may be superior to the BPRS in clinical research on schizophrenia and that most BPRS items are not interchangeable with identically named PANSS items.

Metacognition and schizophrenia: The capacity for self-reflectivity as a predictor for prospective assessments of work performance over six months

Research has indicated that many with schizophrenia experience deficits in metacognitive capacity, defined as impairments in the ability to think about thinking. These difficulties are related to, but not reducible to symptoms and have been hypothesized to function as an independent impediment to psychosocial function. To explore the possibility that deficits in one domain of metacognition, self-reflectivity, are a barrier to effective work function, 56 participants with schizophrenia were categorized into three groups according to their capacity for self reflection based on an interview conducted prior to accepting a job placement. Blind ratings of work performance of these three groups over the next six months were then compared. Results of repeated measures ANOVA revealed that the group rated as having the highest level of metacognition, that is, able to see that their conclusions are subjective and fallible, had higher ratings of work performance over time than groups with medium and low levels of self reflectivity. These findings were found to persist even when impairment on a test of executive function was controlled for statistically. Results are interpreted as consistent with emerging models that deficits in metacognition may be key features of severe mental illness which affect function. Clinical and theoretic implications are discussed.

Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: Associations across 6 months

Research suggests stigma is a barrier to self-esteem and the attainment of resources in schizophrenia. Less clear is the association of stigma experiences with symptoms and social function both concurrently and prospectively. To assess this, symptoms were measured using the Positive and Negative Syndrome Scale, social function was measured using the Quality of Life Scale and stigma experience was assessed using the Internalized Stigma of Mental Illness Scale among 36 persons with schizophrenia at two points, 6 months apart. Correlations found stigma was associated with concurrent levels of positive and emotional discomfort symptoms and degree of social contact. When initial stigma levels were controlled for, stigma at 6 months was predicted by baseline levels of positive symptoms. Greater initial stigma predicted greater emotional discomfort at follow-up. Results suggest internalized stigma is linked with social function and symptoms. Positive symptoms may make some persons with schizophrenia more vulnerable to ongoing stigma experience.

Cognitive and clinical predictors of success in vocational rehabilitation in schizophrenia

Cognitive impairments in schizophrenia appear to be associated with social problem solving, social and vocational functioning, and psychosocial skill acquisition. The present study examined the relationship of cognitive functioning, as well as clinical symptoms, to vocational outcomes among individuals with schizophrenia. One hundred and twelve participants with DSM-IV schizophrenia spectrum diagnoses underwent a comprehensive neuropsychiatric evaluation after enrolling in one of several employment programs. The neuropsychological evaluation examined verbal learning and memory, attention, speed of information processing, and executive functioning. Clinical symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS). Vocational outcomes were assessed 4 months after baseline assessment and included both measures of employment outcome (e.g., earnings) and of work performance as assessed by the Work Behavior Inventory (WBI). Negative symptoms, learning and memory performance, processing speed, and executive functioning were related to hours, weeks, and wages earned on the job. Stepwise multiple regression analyses found that among baseline clinical and cognitive predictors, only verbal learning and memory and cognitive disorganization symptoms were significant predictors of work behaviors 4 months later. Learning and memory were the only significant predictors of integrated employment at 4 months. These results suggest specific aspects of cognition may be modestly predictive of vocational outcomes.

Wisconsin Card Sorting Test and work performance in schizophrenia.

Patients with schizophrenia have long been observed to perform poorly on the Wisconsin Card Sorting Test (WCST). Although numerous studies have established links between WCST performance and specific and diffuse structural brain abnormalities, little is known about its relationship to occupational functioning. The present study has investigated the relationship between behavior at a vocational work placement and performance on the WCST test for 89 subjects with schizophrenia or schizoaffective disorder. Multiple regression analyses that examined select WCST raw scores and that covaried out IQ and Digit Symbol Subtest scores found that Task Orientation at work was significantly related to WCST Trials to the First Category and Total Number Correct. Multiple regression analyses that examined standard scores, corrected for age and education, revealed that Task Orientation was related to Percent Conceptual Level and that Social Skills were related to Total Errors and Percent Conceptual Level. Results support the criterion-related validity of the WCST and have implications for understanding impairments in work function.