Negative Symptom Assessment of Chronic

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Negative Symptom Assessment of Chronic Schizophrenia Patients

by Allen Raskin, Rodney Pelchat, Raman Sood, Larry D. Alphs, and Jerome Levlne

Abstract

Negative symptoms of schizophrenia include blunted affect, social isolation, loss of motivation, and deficits in cognitive functioning (Crow 1980a, 1980b). More florid symptoms such as delusions, hallucinations, and disorganized thinking are characterized as positive symptoms. Crow (1980a), Andreasen (1982), and Carpenter et al. (1985) believe that studies of negative and positive symptoms will reduce the heterogeneity of schizophrenia and add to our understanding of the causes, treatment, and course of the illness. Crow (1980a), for example, believed that negative symptoms reflected structural brain changes and were therefore not likely to respond to typical neuroleptics.

Interest in this classification has spawned the development of rating scales designed specifically to measure negative symptoms (Andreasen and Olsen 1982; lager et al. 1985; Kay et al. 1987). Alphs and associates (1989) recently published a report on a new instrument to assess negative symptoms, the Negative Symptom Assessment (NSA). The NSA has several desirable features, including a wide range of negative symptoms, welldefined items, anchor points for rating symptom severity, a semistructured interview for eliciting information for making ratings, and sensitivity to changes over brief periods such as weeks (Alphs et al. 1989). The study presented here had a number of related aims. Primary among them was an interest in the psychometric properties of the NSA when administered to chronic schizophrenia inpatients. Specifically, the study looked at the following questions: Is the factor structure stable? Are the scale items essentially unidimensional or multidimensional? Is there good interrater reliability? Finally, is there good agreement (concurrent validity) between NSA factors and comparable negative symptom items on the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham 1962)? Stability of the NSA's factor structure will be assessed by comparing results of the inpatient schizophrenia sample in this study with results of an earlier study (Alphs et al. 1989),

Reprint requests should be sent to Dr. A. Raskin, University of Maryland School of Medicine, 645 West Redwood St., Rm. PMF18, Baltimore, MD 21201.

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A new scale for assessing negative symptoms in schizophrenia, the Negative Symptom Assessment (NSA), was administered to 101 male chronic, inpatient schizophrenia patients. Factor analysis of the NSA yielded seven factors, but most of the explained variance resided in Factor 1, Restricted Affect/ Emotion. The factors that emerged from this study closely resembled NSA factors derived from an earlier study of outpatient schizophrenia patients, which indicates the factor structure of the NSA is robust. A constellation of variables reflecting long-term or chronic illness were significantly related to six of the seven factors. These results suggest that "institutionalism" may play a role in the evolution of some negative symptoms.

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Method Subjects. The study sample consisted of 101 male veterans who were inpatients at the Perry Point Veterans Affairs Medical Center (VAMC). All patients admitted to the study had a DSM-IH-R (American Psychiatric Association 1987) diagnosis of schizophrenia or schizoaffecrive disorder. Diagnosis was based on information obtained from a structured interview, the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L; Spitzer and Endicott 1977). Background information on these patients is outlined in table 1. Patients were excluded from the study if they had a history of severe head injury, had received electroconvulsive therapy (ECT) within the past 3 months, had undergone psychosurgery, or had a severe, debilitating medical illness. Evaluations. A brief social and psychiatric history form was completed for each patient. Identifying psychiatric history variables such as age, age at onset of illness, age

Table 1. Age and psychiatric history of study sample (n = 101) Variable Age (yrs) Total length of hospitalization (mos) Length of current stay (mos) Number of prior admissions Age at first admission to psychiatric hospital

Mean

SD

Range

49 155 68 7

14 144 112 8

26-74 8-540 0-540 1-80

24

5

17-48

Note.—SD = standard deviation.

at first psychiatric hospitalization, total months of psychiatric hospitalization, and current length of hospitalization were included. The patients' medication records revealed that 98 percent were taking one or more neuroleptics and 74 percent were on moderate to high doses of a neurolepric. Because of the limited variance and skewed nature of these distributions, it was not possible to use these variables in the study. However, only 39 percent of the patients were taking an antiparkinson drug. Hence, it was possible to examine the relationship of this variable to the NSA factors. Ratings were performed on two scales, the NSA and the BPRS. The version of the NSA used in this study had 30 items plus an additional item to assess the overall severity of negative symptoms. The NSA includes six rational or a priori categories of negative symptoms, that is, difficulties in communicating, lack of emotion/ flattened affect, social inactivity, loss of interest/motivation, cognitive difficulties, and psychomotor retardation (see table 2). Ratings of symptom severity are made on a 6-point scale from absent to severe. A semistrucrured interview was developed for use

with the NSA and descriptors or scale anchor points are used to rate the presence and level of symptom severity on each of the 30 items. The 18-item BPRS was used in this study. Three items on the BPRS—Emotional Withdrawal, Motor Retardation, and Blunted Affect—reflect negative symptoms, and five items have been characterized as reflecting positive symptoms of schizophrenia— Grandiosity, Suspiciousness, Hallucinatory Behavior, Excitement, and Hostility (Kay et al. 1987). Guelfi et al. (1989) also included Mannerisms and Posturing as a negative symptom. Whether to include Conceptual Disorganization is somewhat controversial; some authors regard this item as a positive symptom and others see it as a negative symptom. In a recent factor analytic shady (liddle and Barnes 1990), a separate disorganization factor emerged that was distinct from a psychomotor poverty and reality distortion factor. Raters. Three psychiatrists who were enrolled in a geropsychiatry fellowship program acted as raters in the study. Training sessions were held with these raters and their supervisors (including L.D.


which primarily sampled outpatients. Secondary aims of this study are related to some of the controversy surrounding the meaning of negative symptomatology. For example, some authors have maintained that these behaviors are related to the akinetic effects of neuroleptics (Zubin 1985) or, in the case of chronic schizophrenia patients, to institutionalism (Wing 1962; Pfohl and Winokur 1982; Thiemann et al. 1987). We therefore examined the relationship of the NSA factors to months of hospitalization and to the use of antiparkinson medication.

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Table 2.

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Negative Symptom Assessment1 items

27. Concrete 28. Poor memory 29. Temporal disorientation F. Psychomotor Activity 30. Slowed movements 1

Negative Symptom Assessment (Alpha et al. 1989).

Alphs, who developed the NSA) to ensure comparability in understanding the meaning of the NSA items. To test interrater reliability, the three raters independently rated interviews with another 10 patients. The intraclass correlation (Ebel 1951; Bartko 1966) of these ratings was 0.80 for an individual

rater and 0.89 for pooled or averaged ratings by the three raters. Similarly, high inrraclass reliability coefficients were obtained for the BPRS. Procedure. Patients who met inclusion criteria were assigned to one of five age groups: 26-35, 36-

Statistical Analyses. Factor analysis. A principal components factor analysis with normal varimax rotation was performed on the 30 NSA items for 101 subjects. The rotation was performed on factors with eigenvalues of ^ 1. Exact factor scores were then obtained for each subject on each factor. This scoring approach maintained the orthogonality or independence of the factors. Regression analysis. Stepwise multivariate regression analyses (Hays 1963) were performed with five background variables serving as the independent variables and the factor scores serving as the dependent variables. These analyses were done separately for each factor. A similar analysis was performed with the 18 BPRS items entered as independent variables. The internal consistency of the NSA items was also examined by correlating the individual NSA items with a total NSA summation score and by running a Cronbach alpha. Results Factor Analysis. The factor analysis of the NSA yielded seven factors with eigenvalues of s* 1. The key items on each factor, that is, items with loadings of 2= 0.60 on the factor and no loading of


A. Difficulties In Communicating 1. Long lapses before replies 2. Restricted speech quantity 3. Impoverished speech content 4. Fails to answer 5. Speech slowed 6. Speech blocked 7. Monotonous voice 8. Low voice, difficult to hear 9. Mumbled, garbled speech 10. Reduced expressive gestures B. Lack of Emotion/Flattened Affect 11. Blank, expressionless face 12. Emotion: Reduced range 13. Emotion: Reduced experience 14. Affect: Reduced range 15. Affect: Reduced use 16. Affect: Reduced perception (visual) 17. Affect: Reduced perception (auditory) C. Social Inactivity 18. Reduced social drive 19. Poor rapport with interviewer 20. Avoids looking at interviewer 21. Reduced sexual interest D. Loss of Interest / Motivation 22. Poor grooming and hygiene 23. Reduced sense of purpose 24. Reduced interest 25. Reduced daily activity E. Cognitive Difficulties 26. Little awareness of recent events

45, 46-55, 56-65, and 66-75. This was done to obtain equal numbers of subjects within these age decades. Within each age decade patients were randomly assigned numbers admitting them to the study. Assignment to each rater was also randomized within age decades so that each rater saw equal numbers of patients within the various groups.


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Table 3. Key Negative Symptom Assessment1 Items on each factor Item No.

Description

Loading

Factor 1: Restricted Affect/Behavior (58% of variance) 2 Restricted speech 5 Slowed speech 7 Monotonous voice 10 Reduced gestures 11 Blank face 13 Reduced emotional expression 15 Affect: Reduced use 30 Slowed movements

0.62 0.75 0.70 0.74 0.79 0.64 0.65 0.65

Factor 2: Emotion Perception Deficits (11% of variance) 16 Affect: Visual perception 17 Affect: Auditory perception 27 Concreteness

0.62 0.72 0.85

Factor 3: Speech Retardation (8% of variance) 1 Long lapses to reply 4 Fails to answer 6 Speech blocked

0.76 0.72 0.77

Factor 4: Poor Speech Quality (7% of variance) 8 Speaks in a low voice 9 Mumbled speech

0.72 0.77

Factor 5: Poor Grooming/Hygiene (5% of variance) 22 Poor grooming/hygiene

0.77

Factor 6: Temporal Dlsorientatlon (5% of variance) 29 Temporal disorientation

0.81

Factor 7: Reduced Social/Sexual Interest (5% of variance) 18 Reduced social drive 21 Reduced sexual interest 23 Reduced sense of purpose

0.65 0.68 0.61

'Negative Symptom Assessment (Alphs et at. 1989).

to understand or comprehend what is said rather than long lapses or delays in speaking. Factor 5, Poor Grooming/ Hygiene, has only one key item, referring to patient self-care. Factor 6, Temporal Disorientation, is another single-item factor. Most patients who received ratings on this item scored in the questionable range, which was defined as missing the date by 1 or 2

days. Factor 7, Reduced Social/Sexual Interest, contains three items related to interpersonal skills and behavior: "reduced sexual interest," "reduced social drive," and "reduced sense of purpose." Relationship of Factors to Demographic Variables. Five demographic variables were entered as predictors in the multivariate step-


2= 0.60 on another factor, are listed in table 3. Although this is a fairly stringent criterion for item inclusion on a factor, 21 of the 30 NSA items met this criterion. Factor 1, labeled Restricted Affect/Behavior, is composed of eight key items. This was the largest factor, accounting for 58 percent of the explained variance. Factor 1 had a correlation of r = 0.65 with an independent 6-point global rating of negative symptom severity. It emphasized the restricted affect and retardation component of the negative symptom syndrome. Examples include "blank face," "slowed speech," "reduced emotional expression," and "slowed movements." Factor 2, Emotion Perception Deficits, contained three key items, auditory perception of affect, visual perception of affect, and concreteness. Visual perception of affect was assessed by presenting patients with a series of facial photographs of professional actors displaying a variety of emotions and asking the patients to correctly identify the emotion portrayed. Auditory perception of affect was assessed by playing transcribed passages from a variety of sources that permitted actors to express different emotions. Again, patients were asked to identify the verbally expressed emotions. Factor 3, Speech Retardation, consists of three items that intuitively go together: "fails to answer," "long lapses, to reply," and "speech blocked." Blocking refers to speech delays in midsentence, whereas long lapses are long pauses before speech is begun. Factor 4, Poor Speech Quality, contains two items: "speaks in a low voice" and "mumbled speech." These items reflect an inability by the listener or examiner

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Table 4. Significant partial correlations of demographic variables and Brief Psychiatric Rating Scale (BPRS) items with Negative Symptom Assessment factors Partial correlation Factor 1: Restricted Affect/Behavior Demographic variable Total stay in hospitals BPRS items Blunted Affect Motor Retardation Hostility Factor 2: Emotion Perception Deficits Demographic variable Current stay in hospital BPRS items Conceptual Disorganization Grandiosity Excitement Factor 3: Speech Retardation Demographic variable None BPRS items Emotional Withdrawal Suspiciousness Factor 4: Poor Speech Quality Demographic variable Total stay in hospitals BPRS items Emotional Withdrawal Excitement Mannerisms and Posturing Blunted Affect Factor 5: Poor Grooming/Hygiene Demographic variable Age BPRS items Mannerisms and Posturing Motor Retardation Blunted Affect Somatic Concern Factor 6: Temporal Dlsorlentation Demographic variable Total stay in hospitals BPRS item Disorientation

0.21 1 0.342 0.261 -0.23 2

0.282 0.362 -0.30 2 -0.28 2

0.282 0.201

0.352

0.472 -0.29 2 0.242 0.232

0.472

0.462 0.282 0.252 0.21 2

0.291 0.772


wise regression analysis. The demographic variables were age, current stay in hospital (months), number of prior admissions to a mental hospital, age at first admission to a mental hospital, and total time in mental hospitals (months). Table 4 lists the demographic variables that have significant partial correlations with the factor scores. These are the variables that contributed significant independent or unique variance to the regression equation when their correlations with the other demographic variables were controlled. Because these independent variables have significant correlations with each other (see below), this approach has the advantage of determining whether they share some unique variance with the factor scores that is not accounted for by their relationships to the other background variables (Hays 1963). A cautionary note is in order when interpreting these results. One must recognize that the demographic variables are not independent of each other. For example, age, the most reliable measure, is significantly correlated with current length of stay (r = 0.42, p < 0.01) and total time in hospitals (r = 0.38; p < 0.01). Current stay in a hospital and total stay are also significantly correlated (r = 0.74; p < 0.01), reflecting the chronic nature of the population sampled. The above results indicate that the constellation of variables reflecting long-term or chronic mental illness (current stay in a mental hospital, total stay in mental hospitals, and age) is the key element in the relationship of the demographic variables to the factor scores. As age and stay in one or more mental hospitals increase, so do the presence and severity of

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Table 4. Significant partial correlations of demographic variables and Brief Psychiatric Rating Scale (BPRS) items with Negative Symptom Assessment factors—Continued Partial correlation

0.252 0.252 0.252 0.21 2

Note.—Brief Psychiatric Rating Scale (Overall and Gotham (1962); Negative Symptom Assessment (Alphs et a). 1989). 1 2

p < 0.05 (two-tailed). p < 0.01 (two-tailed).

negative symptoms as measured by six of the seven factors. Relationship of Medication Variable to Factor Scores. We noted earlier that 98 percent of study patients were taking one or more neuroleptics and 74 percent were on a moderately high or high dose of a neuroleptdc. On the other hand, only 39 percent were taking an antiparkinson drug. Although there was sufficient variance on this latter variable to relate it to the NSA factors, taking or not taking an antiparkinson drug was not significantly related to any of the NSA factor scores. Relationship of BPRS Items to NSA Factors. In general, there was good correspondence between the NSA factors and relevant items on the BPRS. For example, BPRS Blunted Affect and Motor Retardation are positively correlated with Factor 1, Restricted Affect/ Behavior. BPRS Hostility is negatively correlated with this factor

(see table 4). Two NSA factors— Factor 2, Emotion Perception Deficits and Factor 7, Reduced Social/ Sexual Interest—appear to tap behaviors that are not significantly associated with the negative symptom items on the BPRS: Blunted Affect, Emotional Withdrawal, and Motor Retardation. Patients who did poorly on Factor 2 displayed concreteness in thinking and an inability to identify different emotions. In many cases they would perseverate so that all the faces were viewed as happy or sad. In this sense the significant relationship between this factor and BPRS Conceptual Disorganization makes sense. Factor 7 also taps behaviors that are generally not regarded as "core" negative symptoms, namely, reduced social drive, reduced sexual interest, and reduced sense of purpose. It is not difficult to make the case that patients who are uncooperative, display mannerisms and posturing, and have thinking disturbances (the BPRS items correlating with this factor) would score high on this factor.

Factors reflecting speech retardation, poor speech quality, reduced social drive, and poor grooming also emerged in both studies. The Temporal Disorientation factor and Emotion Perception Deficits factor were unique to the current study. However, the Emotion Perception Deficits factor is understandable because the two key terms measuring auditory and visual perception of affect were not included in the factor analysis in the Alphs et al. (1989) study. Further, in an effort to simplify the administration of the NSA, Alphs (personal communication, 1992) has since eliminated these two items from a recent revision of the NSA. Internal Consistency. Productmoment correlations of the individual NSA items with a total score derived by summing across all items ranged from a low of 0.33 to a high of 0.80, and the majority of item correlations were above 0.50. Further, a statistical test of the internal consistency of


Factor 7: Reduced Social/Sexual Interest Demographic variable Age BPRS items Uncooperative Conceptual Disorganization Mannerisms and Posturing

Relationship to Prior Factor Analysis. Both the current inpatient study and the prior outpatient study by Alphs et al. (1989) performed a principal components factor analysis and normal varimax rotation to extract independent or orthogonal factors from the NSA. Seven factors emerged in both studies. There was considerable similarity in the item content and key items in both studies. This similarity is best illustrated by the key item comparison of Factor 1 (see table 5). In both studies Factor 1 was the major factor to emerge, accounting for over half of the explained variance. Restricted range and expression of emotion and behavior were represented in key items in Factor 1 in both studies.

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Table 5.

633

Key items in Factor 1 across studies Rotated factor loadings

Item No.

Restricted speech quantity Monotone voice Low voice, difficult to hear Reduced gestures Blank face Emotion: Reduced range Emotion: Reduced depth Affect: Reduced depth

Current study

Alphs1

0.62 0.70 0.41 0.74 0.79 0.46 0.64 0.65

0.64 0.77 0.60 0.66 0.75 0.64 0.76 0.74

'Adapted from Alphs et al. 1989.

the NSA yielded a Cronbach alpha of 0.86. Discussion Study results indicated that the NSA has a number of psychometric properties to recommend it for use in assessing negative symptoms of schizophrenia. The factor structure was stable and replicated well in both inpatient and outpatient samples of schizophrenia patients, despite the relatively small sample sizes for a factor analysis in both studies. Interrater reliability was high, which speaks well for the use of the semistructured interview and anchor points for rating psychopathology. These two features are unique to the NSA and in this sense give it an edge over other scales for rating negative symptoms. Concurrent validity, as assessed by comparing the relationships among comparable BPRS items and NSA factors, was good, especially for the large first factor of the NSA, Restricted Affect/ Retardation. In at least one respect the NSA did not wholly meet expectations. Alphs et al. (1989) sought to incor-

porate six a priori or rational categories of negative symptoms in the NSA. However, the NSA appears to have a strong unidimensional component. Factor 1 accounted for 58 percent of the explained variance, and individual NSA item correlations with each other were generally high, as were their correlations with a total NSA summation score. The Cronbach alpha, a measure of internal consistency, was also high. Hence these findings would support the use of a total NSA summation score in treatment assessment studies. This does not necessarily mean that the negative symptom syndrome itself is unidimensional. In fact, this issue is currently under debate (Lewine et al. 1983; Gibbons et al. 1985; Grau and Mueser 1986; Lewine 1986). It is essentially a conceptual issue that depends on how broadly one defines the concept of negative symptoms (Sommers 1985). Factor analytic results of this study suggest it may be possible to expand the dimensional domain of the NSA. A number of the independent factors that emerged contained only one or two items. Additional items tapping behaviors similar to those in

Despite the fact that our sample was composed of older chronic schizophrenia patients with long hospital stays and long-term use of neuroleptics, two-thirds had total NSA summation scores in the mild to moderate range. Alphs (personal communication, 1992) obtained similar results in his sample of 100 schizophrenia patients who were primarily outpatients. These results run counter to prior find-


2 7 8 10 11 12 13 15

Description

these smaller factors should expand the size of these factors and increase their proportion of explained variance. This step plus the possible pairing of items reflecting flattened affect and retardation should result in a more broadly based instrument. In this study of chronic schizophrenia patients, a significant relationship emerged between length of hospitalization and negative symptomatology. What is unclear is whether institutionalism played a role in this finding. Wing (1962) has described the avolitional, compliant, and withdrawn behavior that one often sees in patients after long periods in a mental hospital, which he attributed to the effects of insriturionalization. In this context, Thiemann et al. (1987) have suggested that some of the negative symptoms of schizophrenia may be caused by abnormal brain neurochemistry, while others may be the result of insriturionalization. These authors note that a drug that altered brain neurochemistry might improve flattening of affect without altering the degree of avolirion or apathy. Conversely, it may be possible to reduce or reverse negative symptoms associated with institutionalism by behavioral approaches such as providing patients a more active and stimulating ward and hospital environment.


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References Alphs, L.D.; Summerfelt, A.; Lann, H.; and Muller, R.J. The Negative Symptom Assessment: A new instrument to assess negative symptoms of schizophrenia. Psychopharmacology Bulletin, 25:159-163, 1989. American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: The Association, 1987. Andreasen, N.C. Negative symptoms in schizophrenia: Definition and reliability. Archives of General Psychiatry, 39:784-788, 1982. Andreasen, N.C, and Flaum, M. Schizophrenia: The characteristic symptoms. Schizophrenia Bulletin, 17:27-49, 1991. Andreasen, N.C, and Olsen, S. Negative v. positive schizophrenia: Definition and validation. Archives of General Psychiatry, 39:789-794, 1982. Bartko, J.J. The intraclass correlation coefficient as a measure of reliability. Psychological Reports, 19:311, 1966. Carpenter, W.T., Jr.; Heinrichs, D.W.; and Alphs, L.D. Treatment of negative symptoms. Schizophrenia Bulletin, 11:440-452, 1985. Crow, TJ. Positive and negative schizophrenic symptoms and the

role of dopamine. British Journal of Psychiatry, 137:383-386, 1980a. Crow, TJ. Molecular pathology of schizophrenia: More than one disease process? British Medical Journal, 280:1-9, 1980b. Ebel, R.L. Estimation of the reliability of ratings. Psychometrika, 16:407-424, 1951. Gibbons, R.D.; Lewine, R.R.J.; Davis, J.M.; Schooler, N.R.; and Cole, J.O. An empirical test of a Kraepelinian vs. a Bleulerian view of negative symptoms. Schizophrenia Bulletin, 11:390-396, 1985. Grau, B.W., and Mueser, K.T. Measurement of negative symptoms. Schizophrenia Bulletin, 12:7-8, 1986. Guelfi, G.P.; Faustman, W.O.; and Csernansky, J.G. Independence of positive and negative symptoms in a population of schizophrenic patients. Journal of Nervous and Mental Disease, 177:285-290, 1989. Hays, W.L. Statistics for Psychologists. New York, NY: Holt, Rinehart and Winston, 1963. lager, A.-C; Kirch, D.G.; and Wyatt, R.J. A negative symptom rating scale. Psychiatry Research, 16:27-36, 1985. Kay, S.R.; Fiszbein, A.; and Opler, L.A. The Positive and Negative Syndrome Scale (PANSS) for Schizophrenia. Schizophrenia Bulletin, 13:261-276, 1987. Lewine, R.R.J. Reply to Grau and Mueser. Schizophrenia Bulletin, 12:9-11, 1986. Lewine, R.R.J.; Foggs, L.; and Meltzer, H.Y. Assessment of negative and positive symptoms in schizophrenia. Schizophrenia Bulletin, 9:368-376, 1983. Liddle, P.F., and Barnes, T.R.E. Syndromes of chronic schizo-

phrenia. British Journal of Psychiatry, 157:558-561, 1990. Overall, J.E., and Gorham, D.R. The Brief Psychiatric Rating Scale. Psychological Reports, 10:799-805, 1962. Pfohl, B., and Winokur, G. The evolution of symptoms in institutionalized hebephrenic/catatonic schizophrenics. British Journal of Psychiatry, 141:567-572, 1982. Sommers, A.A. "Negative symptoms": Conceptual and methodological problems. Schizophrenia Bulletin, 11:364-379, 1985. Spitzer, R.L., and Endicott, J. Schedule for Affective Disorders and Schizophrenia—Lifetime Version (SADS-L). New York, NY: New York State Psychiatric Institute, 1977. Thiemann, S.; Csemansky, J.G.; and Berger, P.A. Rating scales in research: The case of negative symptoms. Psychiatric Research, 20:47-55, 1987. Wing, J.K. Institutionalism in mental hospitals. British Journal of Social and Clinical Psychology, 1:38-51, 1962. Zubin, J. Negative symptoms: Are they indigenous to schizophrenia? Schizophrenia Bulletin, 11:461-470, 1985. Acknowledgments The authors acknowledge the efforts of Dr. Harini Balu, who served as one of the interviewers and raters. A note of thanks is also extended to Dr. Byron Wittlin, former Director of Psychiatry, and Dr. John Lipkin, Medical Director, at the Veterans Affairs Medical Center at Perry Point, Maryland, who provided consultation and support for this study. We also thank Dr. Paul Ruskin, Director of the Geriatric Psychiatry Division at


ings that the severity of negative symptoms should be higher in more severe chronic inpatients than in less severe outpatients (Andreasen and Flaum 1991). One possible explanation for our results may be that we were required to get written informed consent from our patients or their relatives, which eliminated many of the more severely retarded and uncommunicative patients.

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the University of Maryland, for his encouragement and support. The Authors

An Invitation to Readers

School of Medicine, Baltimore, MD; Rodney Pelchat, M.D., is Assistant Professor, Department of Psychiatry, Thomas Jefferson University, Philadelphia, PA; Raman Sood, M.D., is in private practice, Aberdeen, MD; Larry D. Alphs, M.D.,

is Associate Professor, Department of Psychiatry, Wayne State University, Detroit, MI; and Jerome Levine, M.D., is Research Professor, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD.

Providing a forum for a lively exchange of ideas ranks high among the Schizophrenia Bulletin's objectives. In the section At Issue, readers are asked to comment on specific controversial subjects that merit wide discussion. But remarks need not be confined to the issues we have identified. At Issue is open to any schizophrenia-related topic that needs airing. It is a place for readers to discuss articles that appear in the Bulletin or elsewhere in the professional literature, to report informally on

experiences in the clinic, laboratory, or commmunity, and to share ideas—including those that might seem to be radical notions. We welcome all comments.—The Editors. Send your remarks to: At Issue Research Projects and Publications Branch National Institute of Mental Health 5600 Fishers Lane, Rm. 18C-06 Rockville, MD 20857


Allen Raskin, Ph.D., is Research Professor, University of Maryland

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