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Characterization of Psychotic Conditions: Use of the Domains Of ORIGINAL ARTICLE Characterization of Psychotic Conditions Use of the Domains of Psychopathology Model Santhi Ratakonda, MD; Jack M. Gorman, MD; Scott A. Yale, MSW; Xavier F. Amador, PhD Background: Previous factor analytic studies of patients of positive, negative, and disorganization domains for pa- with schizophrenia have consistently demonstrated the pres- tients with schizophrenia as well as other diagnoses. Dif- ence of 3 psychopathological domains labeled positive, nega- ferential associations found between individual do- tive, and disorganized. This study examined whether simi- mains and clinical variables (premorbid functioning and lar domains can be seen in disorders other than negative domain; absence of remissions and disorgani- schizophrenia, and the degree to which such domains are zation domain) were similar in both schizophrenia and independent of diagnostic categorization. nonschizophrenia groups. Methods: Data from the Diagnostic and Statistical Manual Conclusions: The 3 psychopathological domains pre- of Mental Disorders, Fourth Edition (DSM-IV) field trial in- viously described in schizophrenia are not specific for that volving 221 patients with schizophrenia and 189 patients diagnosis. Differential associations found between indi- with nonschizophrenia diagnoses were factor analyzed to vidual domains and clinical variables were not limited study the nature of psychopathological domains in the 2 by diagnostic categorization. The results suggest that these groups. Differential associations between each domain and domains are not unique to schizophrenia and may each selected clinical variables were assessed. correspond to a discrete pathophysiologic condition. Results: Factor analysis yielded a similar 3-factor model Arch Gen Psychiatry. 1998;55:75-81 T IS GENERALLY accepted that pa- empirical level, identification of such psy- tients grouped under the category chopathological domains can be at- of schizophrenia vary widely in tempted through factor analysis, which their clinical presentation, course, groups symptoms on the basis of the cor- and response to treatment. Much relations among their relative severities. Ieffort has been made to subtype schizophre- Changes in the severity of an underlying dis- nia into groups that are clinically more order would be reflected in corresponding homogeneous. However, relatively little at- changes in the severity of symptoms pro- tention has been paid to psychotic condi- duced by it, while symptoms produced by tions grouped under categories other than other pathologic processes would show no schizophrenia. The degree to which such correlation. Under this model, a group of categories are distinct from schizophrenia symptoms that show a consistent correla- has not been adequately assessed. The tion in their degrees of severity can be as- DSM-IV uses a categorical-hierarchical sumed to arise from the same underlying model for subtyping schizophrenia.1 An al- disorder. ternative approach to subtyping schizo- Studies that factor analyzed ratings of phrenia, which has received recent atten- patients with schizophrenia by means of tion, is the domains of psychopathology the Scale for Assessment of Negative Symp- model. In this article, we report on the ap- toms (SANS)2 and the Scale for Assess- 3 From the Division of Diagnosis plicability and validity of this model for psy- ment of Positive Symptoms (SAPS) have and Evaluation, Department of chotic patients classified under diagnoses consistently demonstrated the existence of Clinical Psychobiology, New other than schizophrenia. symptom groups corresponding to 3 in- York State Psychiatric Institute In recent years, there has been grow- dependent underlying factors.4-8 These 3 (Drs Ratakonda, Gorman, and ing interest in examining the possibility that symptom groups have been generally re- Amador and Mr Yale), and specific groups of symptoms (domains of ferred to as positive, negative, and disor- Department of Psychiatry, psychopathology) within the category of ganization domains. It has been shown that Columbia University College of schizophrenia may arise from indepen- symptoms in each domain may be differ- Physicians and Surgeons (Drs Ratakonda, Gorman, and dent disorders. It has been postulated that entially associated with specific biologi- Amador), New York, NY, and co-occurrence of such independent do- cal, neuropsychological, course, and treat- 9-16 Schizophrenia Research Unit, mains in different combinations in differ- ment response variables. These data, Creedmoor Psychiatric Center, ent patients may explain the observed clini- together with the consistent replicability Queens, NY (Dr Ratakonda). cal heterogeneity of schizophrenia. At the of the 3 domains in different schizophre- ARCH GEN PSYCHIATRY/ VOL 55, JAN 1998 75 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 SUBJECTS AND METHODS a scale of 0 to 5, with a score of 0 indicating absence of the symptom, 1 indicating questionable presence, and scores from 2 to 5 indicating progressively increasing levels of se- SAMPLE SELECTION AND SUBJECT RECRUITMENT verity. There were a total of 10 global items: affective flat- tening or blunting, alogia, avolition/apathy, asociality/ The sample consisted of 412 patients from the DSM-IV Field anhedonia, catatonia, delusions, hallucinations, disorganized Trial for Schizophrenia and Related Psychotic Disorders. speech (positive formal thought disorder), disorganized be- Patients were recruited from 8 sites: 7 sites in the United havior, and inappropriate affect. Of these, catatonia was ex- States and 1 in Mexico. At each site, a recruitment coordi- cluded because of a low base rate of prevalence (8%) rela- nator reviewed consecutive admissions to the inpatient tive to the other variables. The remaining 9 items were and/or outpatient service participating in the field trial. All retained for analysis. patients gave informed consent to participate in the study. Information on some clinical variables other than At least 1 of the following positive or negative symptoms those used for factor analysis was also available. The fol- had to be currently present to at least a mild degree for a lowing variables were studied to see whether they subject to be included in the study: delusions, hallucina- showed an association with individual domains, and tions, disorganized speech, flat affect, poverty of speech, whether such associations were independent of diagnos- and passive, apathetic social withdrawal. Information was tic groupings: age at first psychiatric symptom; history obtained from subject interviews, current and past medi- of remissions; number of hospitalizations; frequency of cal records, and informant interviews. hospitalizations (duration of illness/number of hospital- All patients were assessed with the field trial instru- izations); fraction of total illness duration spent in the ment, which was composed of several scales, including the hospital (duration of hospitalization/duration of illness); SAPS and the SANS. More than 90% of the patients in the current, past year, and past 5 years Global Assessment sample were also in either interrater reliability or test- Scale scores; presence of tardive dyskinesia; and premor- retest reliability studies. The reliability for diagnoses and bid level of functioning. The majority of these variables symptom ratings ranged from good to excellent. Although relate to severity of illness and course and thus were of diagnoses were made by several criteria, only diagnoses from interest as validators of the domain model. In addition, the Diagnostic and Statistical Manual of Mental Disorders, we were interested in examining the relationship Third Edition, Revised (DSM-IIIR) are reported herein.20 The between tardive dyskinesia and the 3 domains, as previ- sample included 221 patients with a DSM-IIIR diagnosis ous reports indicate an association with the negative of schizophrenia, 189 patients with DSM-IIIR diagnoses other domain.21 than schizophrenia, and 2 patients with missing diag- Premorbid functioning was rated on 7 subscales with noses. Table 1 presents descriptive data on the sample. scores ranging from 0 (good function) to 2 (poor func- tion). For this analysis, scores on the 7 subscales were PSYCHIATRIC MEASURES summed to form 1 composite item with a score range of 0 to 14. In the field trial, history of remissions was scored as The global subscale scores from SAPS and SANS were used either present or absent. For testing its association with in- for analysis in the present study. Each item was scored on dividual domains, we excluded patients whose total nia populations, support the hypothesis that each do- In this study, we analyzed data obtained for the main arises from an independent pathologic process. DSM-IV Field Trial for Schizophrenia and Related Psy- Given the significant symptom overlap among differ- chotic Disorders,19 to answer the following questions: (1) ent psychiatric diagnoses, we believed it would be valu- Will the 3 psychopathological domains identified in able to study whether these 3 psychopathological do- schizophrenia also be seen in patients grouped under other mains demonstrated in schizophrenia can also be seen in diagnostic categories? (2) Do the individual domains show other diagnoses. Optimally, such a study would use the SAPS a differential association with relevant clinical vari- and SANS to rate patients, as these are the instruments most ables? And if they do, are such associations indepen-
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