Stanley R. Kay

Profiles of aggression among psychiatric patients. I. Nature and prevalence.

Based on the Yudofsky scale, a Modified Overt Aggression Scale (MOAS) with upgraded psychometric properties was developed to assess the nature and prevalence of aggression in a psychiatric population. The present report describes the standardization of this scale and the pattern of findings on two cohorts of 114 and 150 inpatients. The results support the discriminative validity of the MOAS and its internal, interrater, and retest reliabilities. Within 1 week some form of aggression was noted in about one fourth of the patient samples, with verbal aggression the most prevalent and autoaggression the least. Chronic patients showed the lowest incidence of physical assault and general aggression, whereas gender differences and daily variations were not significant. Greater stability of aggression was demonstrated for patient groups and for forms of aggression with higher base rates and for the short term (within 1 week) rather than the long course (3 months). The high prevalence of aggression and the consistency of profiles across patient samples suggested that sensitive, multivariable scaling can improve the accuracy of measurement and the depiction of the construct.

A comparative study of haloperidol and chlorpromazine in terms of clinical effects and therapeutic reversal with benztropine in schizophrenia. Theoretical implications for potency differences among neuroleptics

In a double-blind, cross-over study, the comparative therapeutic effects of 6-week courses of two prototypic neuroleptics — haloperidol and chlorpromazine — and the reversal of those effects with benztropine were investigated in a group of 18 schizophrenics. Periodic measurements were made for 32 dimensions of psychopathology, social participation, span of attention, sleeplessness, pulse rate and neurological side effects. The results showed that haloperidol was generally a more effective drug over the period studied. This was particularly apparent in terms of social and emotional responsiveness, communicativeness and cognitive processes. The only superiority of chlorpromazine seemed to be that patients felt less dysphoric on it than they did on haloperidol. Haloperidol also proved to be more rapid in its action. The data failed to support the clinical validity of the distinction often made between “sedative” and “activating” neuroleptics. Consistent with previous reports, benztropine had the effect of diminishing therapeutic response to both neuroleptics. However, haloperidol again proved less susceptible to this effect. The slowness and lesser therapeutic efficiency of chlorpromazine and its greater susceptibility to benztropine reversal were all considered to be due to its built-in anticholinergic properties acting in opposition to its antipsychotic activity. The low potency of chlorpromazine-like drugs was attributed to their inherent anticholinergic characteristics. It was suggested that one of the factors determining potency differences among neuroleptics may be the degree of built-in anticholinergic activity.

Neurological signs and the positive-negative dimension in schizophrenia

Schizophrenic patients have been observed to manifest a variety of abnormal neurological signs, but the nature of their association with differing clinical presentations is less well established. To address this issue, we administered a newly compiled neurological inventory to 28 well-characterized chronic schizophrenic inpatients and separately assessed them on the Positive and Negative Syndrome Scale and on control variables that included measures of global pathology, chronicity of illness, neuropsychological and intellectual integrity, and extrapyramidal dysfunction. We found, first, that our neurological battery provided statistically independent measures of apraxia, fine motor function, and prefrontal, parietal, and nonlocalizing signs. A significant association emerged between negative symptomatology and neurological signs of prefrontal impairment (p less than 0.01), which could not be accounted for by any of the control variables. Positive symptoms were associated with an absence of parietal and nonlocalizing signs; however, these correlations were mediated by higher neuroleptic doses in these patients. There was no association between any neurological sign and age, extrapyramidal symptoms, general neuropsychological integrity, education, IQ, or severity or chronicity of illness. We concluded that the negative syndrome in schizophrenia represents a distinct dimension of psychopathology that is related specifically to prefrontal deficit.

Profiles of aggression among psychiatric patients. II. Covariates and predictors.

An Aggression Risk Profile was developed as an objective multidimensional scale for characterizing aggressive psychiatric patients and predicting verbal, physical, and general manifestations of aggression. Based on earlier studies, the 39-item Aggression Risk Profile incorporated demographic, diagnostic, historical, and clinical parameters. Its reliability, discriminative validity, and predictive validity were supported in its application to a total of 208 inpatients. Aggressive patients were more often found to be men, to be diagnosed with organic mental syndrome or substance abuse disorder, and to be notable in history of aggression. They tended to be angry and excitable but not more floridly ill than control subjects. The contemporaneous covariates of aggression, however, were not the same as the predictors, as determined by 3-month prospective follow-up. Twelve significant predictors were identified, and multiple regression analysis revealed different sets of measures that explain 45.0% to 52.5% of the variance for verbal, physical, and total aggression. The most reliable predictors were younger age, shorter length of illness, hostility, depression, anger, and difficulty in delaying gratification. We concluded that prediction is augmented by the combination of clinical and nonclinical predictors, and we discussed likely sources of disparity in previous research.

SIGNIFICANCE OF COCAINE HISTORY IN SCHIZOPHRENIA

Fifty-one schizophrenic inpatients were divided into two groups, those with and without history of cocaine use, and compared on historical, demographic, cognitive, and psychopathological measures. Patients with a cocaine history were found to be significantly more depressed, less socialized, and more impaired in conceptual encoding and verbal memory, while less disordered in attention. The two groups did not differ in severity of illness or positive and negative syndromes. There were also no differences in control variables such as age, gender, education, intelligence, premorbid adjustment, neuroleptic dose, onset and chronicity of illness, continuity of hospitalization, paranoid subtype, and psychiatric illness in the family. Cocaine history was associated with multiple illicit drug use, but for other substances there was no increased liability for depression or cognitive deficits. The results suggest that the clinical presentation in schizophrenia is significantly associated with prior cocaine experience

The Positive and Negative Syndrome Scale--Spanish adaptation.

The Positive and Negative Syndrome Scale (PANSS) consists of a formalized clinical interview and 30 operationally defined items for psychopathology assessment. We report here on the psychometric equivalence of a Spanish language adaptation (PANSS-S), developed to facilitate minority group, multinational, and cross-cultural studies on schizophrenia. Two bilingual psychiatrists simultaneously rated 57 psychiatric inpatients using the PANSS (N = 20), PANSS-S (N = 20), or both methods (N = 17). The PANSS-S demonstrated sound interrater reliabilities (r = .93 for positive and .74 for negative syndrome, p less than .001), which were similar to those from the current PANSS assessment and original standardization studies. In support of criterion-related validity, the means and variance of the two instruments were comparable, and significant cross-correlations were obtained for the principal scales (r = .92 for positive and .83 for negative syndrome, p less than .0001), component symptoms, and five additional psychopathology clusters. The results suggest that the PANSS-S has psychometric properties resembling those of the PANSS and may be used interchangeably in a Spanish-speaking population.

Positive-negative symptom assessment in schizophrenia: Psychometric issues and scale comparison

The positive-negative distinction has emerged as a meaningful basis for understanding the heterogeneity of schizophrenia and treatment alternatives, but its delineation requires carefully devised, well validated techniques. This article considers the psychometric requisites for such an instrument and describes 30 criteria associated with operationalization, scale construction, and standardization. Six prominent positive-negative scales are compared on these criteria, and most are found deficient in terms of: a formalized interview procedure; detailed definitions for levels of symptom severity; exclusion of “secondary” negative symptoms; comparative scales to assess positive symptoms, depression, and global severity of illness; broad sampling of negative symptoms; large scale standardization studies; and determination of multiple facets of reliability and validity. The Positive and Negative Syndrome Scale (PANSS) is described as an effort to approach these principles of test standardization, and its clinical and research applications are discussed.

Positive and negative syndromes in schizophrenia as a function of chronicity

The construct validity and extended stability of positive and negative syndromes were studied via multidimensional cross‐sectional assessment of 134 schizophrenics in the acute, chronic, and long‐term chronic stages. For all groups the syndromes were internally reliable, not significantly intercorrelated, and of similar severity. The syndromal correlates with clinical, motor, historical, and genealogical dimensions, however, differed as a function of chronicity. In acute schizophrenics, a negative syndrome was associated with clinical and genealogical indicators of good prognosis, whereas the converse obtained for a positive syndrome in the acute stage and a negative syndrome in the chronic stage. The relationship of education, marital status, and attention disorder to the positive‐negative distinction also varied according to length of illness. Its meaning, therefore, appeared phase‐specific and subject to evolution, obviating generalizations across all phases. Implications for theory, prognosis, current research, and future study are presented.

Negative and positive schizophrenic syndromes after the acute phase: a prospective follow-up.

Abstract To study the stability and predictive significance of positive and negative syndromes, we assessed a group of young acute schizophrenics at index admission (N = 37) and upon 2-year follow-up (N = 19). We found these syndromes longitudinally unstable, though equally prevalent in both phases. The baseline negative score was predictive of favorable outcome. The prognostic value of negative symptoms was independent of premorbid ratings, and, in combination these predictors, correlated strongly with follow-up level of functioning. The relationship between negative syndrome and outcome was partly explained by depression, which correlated significantly with baseline negative score. Theoretical and clinical implications of this overlay of a negative syndrome with depression in young acute schizophrenics are presented.

Outcome Predictors in Acute Schizophrenia: Prospective Significance of Background and Clinical Dimensions

In a prospective 2-year follow-up of 37 young acute schizophrenics, we examined the predictive significance and relative contribution of historical, genealogical, course, and clinical dimensions. Patients were evaluated multidimensionally at index admission and after 21 to 33 months, at which time 19 cooperated in follow-up involving clinical, functional, psychometric, and objective outcome measures. Multiple regression analysis found that combinations of 3 to 4 index variables significantly predicted 13 of 14 outcome measures, yielding multiple R values between .63 and .93 (&OV0639;=.78). In total, a set of eight parameters contributed in explaining the outcome variance. The strongest overall predictor of favorable outcome was baseline negative syndrome. Other significant predictors were good premorbid school functioning, favorable prior disposition, sudden onset of illness, nonparanoid subdiagnosis, family history of alcoholism, psychomotor retardation, and depression. Accordingly, a patients premorbid adjustment, course of illness, and presenting clinical profile provided nonoverlapping sources of outcome prediction. Of these three dimensions, it was proposed that the prognostic significance of the clinical profile may be phase specific, carrying different implications when assessed in the acute vs. chronic stage of illness.