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University
Micrdrilms
International
300 N. Zeeb Road
Ann Arbor, Ml 48106
8521953

D o n o h u e , M a ry V e ro n ic a

A STUDY OF THE RELATIONSHIP BETWEEN AGE OF ONSET OF


PARANOID AND NON-PARANOID SCHIZOPHRENIA AND BI-POLAR
AFFECTIVE DISORDERS, AND THE SOCIAL COMPETENCE OF ADULT
FEMALE PSYCHIATRIC PATIENTS

N e w York U ni ver s i t y Ph.D. 1985

University
Microfilms
International 3 0 0 N. Zeeb Road, Ann Arbor, Ml 48106

Copyright 1985
by
Donohue, Mary Veronica
All Rights Reserved
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University
Microfilms
International
D is s e rta tio n Committee: Professor Deborah R. L ab o vitz, Chairperson
Professor Carol Mil Isom
Professor Rosalie J . M i l l e r

A STUDY OF THE RELATIONSHIP BETWEEN AGE OF ONSET OF PARANOID

AND NON-PARANOID SCHIZOPHRENIA AND BI-POLAR AFFECTIVE DISORDERS,

AND THE SOCIAL COMPETENCE OF ADULT FEMALE PSYCHIATRIC PATIENTS

Mary V. Donohue

Submitted in P a r t i a l F u l f il lm e n t
of the Requirements f o r the Degree of
Doctor of Philosophy in the School
of Education, H ealth, Nursing and A rts Professions
New York U n iv e rs ity
February, 1985
Mary V. Donohue 1985
I hereby guarantee th a t no p a r t o f the d is s e r t a t io n which I have submitted
f o r p u b lic a tio n has been hereto fo re published and (o r ) copyrighted in the
United States o f America, except in the case o f passages quoted from
other published sources; t h a t I am the sole author and p r o p r ie to r o f said
d i s s e r t a t io n ; t h a t the d is s e r t a t io n contains no m atter which, i f published
w i l l be lib e lo u s or otherwise i n ju r i o u s , or i n f r i n g e in any way the copy­
r i g h t o f any other p a rty ; and th a t I w i l l defend, indemnify and hold harm­
less New York U n iv e rs ity ag ainst a l l s u its and proceedings which may be
brought and against a l l claims which may be made against New York U n iver­
s i t y by reason o f the p u b lic a tio n o f said d is s e r t a t io n .
r

February ?2, 1985

Dr. Gorn:

The C a li f o r n ia Psychological Inventory ( CPI) booklet and the copies


o f the p r o f i l e sheets o f the CPI (pp. 123 and 124) are not be be sub­
m itted f o r p u b lic a t io n , and w i l l be removed before submission fo r p u b l i ­
catio n and the page numbers changed in the appendix and t a b le o f contents.
D is s e r ta tio n Committee: Professor Deborah R. Lab ovitz, Chairperson
Professor Carol Millsom
Professor Rosalie J. M i l l e r

An Abstract of:

A STUDY OF THE RELATIONSHIP BETWEEN AGE OF ONSET OF PARANOID

AND NON-PARANOID SCHIZOPHRENIA AND BI-POLAR AFFECTIVE DISORDERS,

AND THE SOCIAL COMPETENCE OF ADULT FEMALE PSYCHIATRIC PATIENTS

Mary V. Donohue, M .A ., OTR

A D e s c rip tiv e D is s e r ta tio n in P a r t i a l F u l f i l l m e n t


of the Requirements f o r the Degree of
Doctor of Philosophy in the School
o f Education, H e a lth , Nursing and A rts Professions
New York U n iv e rs ity
February, 1985
ABSTRACT

Although social s k ill le v e ls among p s y c h ia tr ic p a tie n ts have been

previously examined in conjunction with diagnosis and age of onset

of psychosis, most studies analyzed only r e la te d socio-economic f a c to r s .

I t was the in te n tio n of t h is study to expand t h is focus by analyzing

the in d iv id u a l components of social competence. The problem under i n ­

v e s tig a tio n is the i d e n t i f i c a t i o n of the level o f social competency f o r

the three social s k i l l s of s o c i a b i l i t y , social presence and s o c ia l i z a t i o n

among female p s y c h ia tr ic p a tie n ts of three diagnoses: non-paranoid

schizophrenia, paranoid schizophrenia and b i - p o l a r disorders.

The C a li f o r n ia Psychological Inventory ( C P I, Gough, 1956) was

administered to 90 female p s y c h ia tr ic p a t ie n t s . This group consisted

of three sub-groups, comprised of 30 p a tie n ts from each o f the above

three diagnostic groupings.

Discrim inant an alysis supported the expectations t h a t the r e l a t i o n ­

ship o f age of onset of psychosis and le v e l of social competence would

be located in the pred icted p o s itio n and d ir e c t io n f o r each diagnostic

grouping.

Non-paranoid schizophrenic subjects had the lowest average age of

onset of psychosis and lowest scores of s o c i a b i l i t y and social presence.

Paranoid schizophrenic subjects had moderate age of onset of psychosis

and moderate scores of s o c i a b i l i t y and social presence. B i- p o la r a f f e c ­

t i v e disorder subjects had l a t e s t age of onset of psychosis and highest

scores of s o c i a b i l i t y and social presence. Paranoid schizophrenic sub­

je c t s had lowest scores on the s o c ia l i z a t i o n s ca le, with non-paranoid


schizophrenic subjects a t ta in in g somewhat higher scores, in t h is un­

expected r e s u l t .

I t was p o s s ib le , using the age of onset of psychosis and le v e ls

of scores of s o c i a b i l i t y , social presence and s o c ia l i z a t i o n through

a d isc rim in a n t an alysis to p r e d ic t 51% o f the subjects expected group

membership, though the s t a t i s t i c o f the p r i o r p r o b a b ilit y was merely

33%.

Although r e s u lts of the study cannot be generalized because of

small sample s ize and environmental c o n s tr a in ts , the analysis of com­

ponents of social competence fo r p s y c h ia tr ic p a tie n ts has treatm ent

ap p lic a tio n s f o r occupational therapy and o th er r e h a b i l i t a t i o n pro­

fe s s io n a ls .
ACKNOWLEDGEMENTS

My f i r s t expression of appreciation is f o r my committee: to Deborah

R. L ab o vitz, P h .D ., OTR, fo r her c r e a t i v i t y , in c is iv e comments and en­

couragement; to Carol M illsom , P h .D ., fo r her experience, wisdom, c l a r i t y

o f thought, and devotion over the years; to Rosalie J . M i l l e r , P h .D .,

OTR, fo r her professional perspectives during the l a t t e r stages of the

study; to Brena G. Manoly, P h .D ., OTR, f o r providing a bridge to carry

on; to Anne Cronin Mosey, P h .D ., OTR, fo r i n i t i a l l y launching t h is under­

takin g . I wish to thank them f o r t h e i r knowledgeable and tim ely c r itiq u e s

of t h is work, as w ell as f o r t h e i r perseverance through eons of conside” -

ations and d e lib e r a tio n s .

I am g r a te fu l fo E s t e l l e Douglas, M .A ., CRC, D ir e c to r of R e h a b ilit a ­

tio n A c t i v i t i e s Department of Long Island Jewish H i l l s i d e Medical Center,

fo r her generosity and assistance in providing the tim e, space and place

to enable t h i s research to develop. I thank the s t a f f a t H i l l s i d e Hospi­

t a l f o r t h e i r support in r e f e r r in g p a tie n ts to the study, the l i b r a r i a n s

fo r t h e i r b ib lio g r a p h ic e x p lo ra tio n s , and the medical records s t a f f f o r

t h e i r charting exp ed itio n s. My thanks, too, are extended to Beth Landa,

P h .D ., fo r her s t a t i s t i c a l advisement and research e x p e rtis e .

At New York U n iv e r s it y , Robert Mulgady, P h .D ., deserves acknowledge­

ment f o r his s t a t i s t i c a l guidance, as does George Sharrod, P h .D ., fo r his

computer con su ltatio n s both in person and by phone to EDMVD.

This volume is dedicated to Jorge Ramos-Lorenzi, M .D ., D ire c to r

of A f t e r Care Services a t H i l l s i d e H o s p ita l, f o r his scholarship and


spa rk ling humor, keen i n t e l l e c t and a b i l i t y to in s p ir e confidence.

I wish to express my appreciation to the p a tie n ts who were

subjects in t h is study f o r t h e i r cooperation and forebearance in re s ­

ponding to 480 questions.

I would l i k e to convey my g r a titu d e to Harvey Lieberman, Ph .D .,

American Psychological Association Gold Medal Award winner of 1984 f o r

his o f f e r to e d i t t h is f i n a l d r a f t .

F in a lly , I would l i k e to thank my t y p is ts and word processors,

Sharon G io z a lis and Karen Fecina. Special thanks go to S a lly Small

f o r her much appreciated a tte n tio n to d e t a i l throughout careful

e d i t o r i a l re v is io n s .
TABLE OF CONTENTS

Acknowledgments ............................................................................................................. iii

L i s t of Tables ...................................................................................................................v i i

L i s t of F i g u r e s ................................................................................................................ v i i i

CHAPTER

1. The Problem and I t s Background.................................................................. 1

Statement of the Problem ........................................................................... 2


D e fin itio n s ..................................................................................................... 3
Assumptions ..................................................................................................... 6
L im ita tio n s ..................................................................................................... 7
S ig n ific a n c e ..................................................................................................... 7
Th e o retical Framework ............................................................................... 9
H y p o t h e s is ......................................................................................................... 14

2. Related L i t e r a t u r e ............................................................................................ 16

Social Competence in P s y c h ia tric P a tie n ts .................................. 17


Age o f Onset of Psychosis and Social Competence ...................... 25
Diagnosis, Social Competence and Age of Onset of Psychosis . 27

3. M e t h o d o l o g y ......................................................................................................... 38

Selection of Subjects ............................................................................... 38


Instrum entation: C a li f o r n ia Psychological Inventory . . . . 41
R e l i a b i l i t y ................................................................................................ 43
V a l i d i t y ......................................................................................................... 44
S o c i a b i l i t y .......................................................................................* • 45
S o c ia liz a t io n ........................................................................................ 47
Social Presence ................................................................................... 50
Data C o lle c tio n Procedures ...................................................................... 52
A d m in istra tio n and Scoring o f the C P I ........................................ 53

4. Research Findings, In t e r p r e t a t i o n and Discussion ........................... 55

Basic Assumptions f o r D iscrim ina nt Analysis ............................... 55


Test o f the H y p o t h e s i s ............................................................................... 58
D isc rim in a n t Function Analysis ......................................................... 62
Tests of A d ditional D a t a ...................................................................... 68
Summary of R e s u l t s ........................................................................................ 68
Discussion o f Results ............................................................................... 73

v
5. Summary and Recommendations ............................................................................ 85

Summary.......................................................................................................................85
Recommendations ................................................................................................ 88

References and Selected Bibliography .................................................................. 90

Appendices
A. Human Subjects Review Board ............................................................................ 107
A p p l i c a t i o n ............................................................................................................ 108
L e t t e r of Approval ...........................................................................................119
B. C a li f o r n ia Psychological Inventory .......................................................... 120
Test Booklet ....................................................................................................
D escription of Scales ...................................................................................
P r o f i l e Sheet ....................................................................................................
Correspondence ....................................................................................................
From Harrison Gough, Ph.D........................................................................... 121
From David Rogers, Ph.D................................................................................123
C. Covariance M a tric e s , Histograms and Scattergram . . . ................... 124

P u b lic a tio n Manual o f the American Psychological A s s o c ia tio n . E d itio n


Three. Washington: American Psychological A ssociation, In c. 1983 and
S ty le Guide f o r Doctoral D is s e r ta tio n s , SEHNAP. 1984.
LIST OF TABLES

1. Pooled C o rr e la tio n M a trix w ith in Groups .................................................. 56

2. Measures of Central Tendency f o r Four


Discrim inant V a riab les ....................................................................................... 59

3. Means of Diagnostic Groups f o r Age of Onset


and Social S k i l l Variables ............................................................................... 61

4. Canonical D iscrim inant Functions f o r the


In te r a c tio n of Age of Onset of Psychosis
and Three Social S k i l l s ................................................................................... 62

5. C la s s if ic a t i o n of Actual and Predicted


Hypothesized Diagnostic Groupings ............................................................. 65

vi i
LIST OF FIGURES

1. Schematic diagram o f major t h e o r e tic a l


propositions and h y p o t h e s i s .......................................................... 16, 36 & 73

2. Expanded schematic diagram o f th e o r e tic a l


propositions and hypothesis .......................................................................... 37

3. Venn diagram of the i n te r a c tio n o f the three


diagnostic groupings i l l u s t r a t i n g the
d isc rim in a n t analysis of diagnoses, social
s k i l l s and ages of onset of p s y c h o s i s ........................................................70

4. Schematic diagram o f operational hypothesis


based on s t a t i s t i c a l in te r a c tio n .................................................................. 74

5. Expanded schematic diagram i l l u s t r a t i n g


the ass o ciatio n a l r e la tio n s h ip among the
t h e o r e t ic a l and p r a c t ic a l v a ria b le s ..................................................... 74

vi i i
CHAPTER 1

THE PROBLEM AND ITS BACKGROUND

This study was proposed to examine the theory of social competence

f o r p s y c h ia tric p a tie n ts as conceived by P h i l l i p s (1953 ); Z i g l e r and

P h i l l i p s (19 6 1 ); G oldstein, Held and Cromwell (1968) and as r e la te d

to aspects of treatm ent fo r p a tie n ts in occupational therapy. This

theory is concerned with the manner in which diagnosis and age of onset

of psychosis are associated w ith le v e ls of social competence. The ex­

tension of t h is theory w ith in the present study examined the s u b -s k ills

of social competence as re le v a n t f o r groups o f people presenting them­

selves f o r r e h a b i l i t a t i o n through occupational therapy.

Three major diagnoses with psychotic components were studied: non­

paranoid and paranoid schizophrenia and b i - p o l a r a f f e c t i v e disorders. It

was the th esis of the previously named in v e s tig a to rs th a t e a r l i e r age of

onset of psychosis coincides with non-paranoid schizophrenia, t h a t mid­

range age of onset of psychosis coincides with paranoid schizophrenia

and th a t b i - p o la r a f f e c t i v e disorders coincide with l a t e s t age o f onset

of psychosis. I t was also the contention of these researchers th a t age

o f onset of psychosis influenced the level of social s k i l l development.

In itia lly , in examining fa c to rs r e la te d to social competence r e ­

covery le v e ls and diagnosis, Z i g l e r and P h i l l i p s (1961, 1964) s c r u tin iz e d

c o r r e la tio n s of age, education, m a rita l s ta tu s , employment, and length

and number of h o s p it a liz a t io n s in an e f f o r t to expand on p re d ic ta b le

determinants of prognosis. However, t h is l i t e r a t u r e does not include the

1
examination of how various aspects of social competence survive a psy­

chotic episode. Nor, to date, has research been d ire c te d to the com­

ponent parts of social competence, defined f o r purposes of t h is study as:

s o c ia b ility , social presence and s o c ia l i z a t i o n . The way in which these

social s u b -s k ills i n t e r a c t with age of onset and types of diagnoses is

c u rre n tly unknown and needs to be examined, both f o r a b e t t e r under­

standing of the theory, and to a s s is t occupational therapy as a pro­

fession d ire c te d toward t r e a t i n g problems in social competence.

Statement of the Problem

Peripheral demographic data and developmental th e o rie s r e la te d to

social competence f o r p s y c h ia tr ic p a tie n ts have been looked a t w ithout

examination of the social s k i l l le v e ls fo r s p e c ific subdivisions of

social competence. This study, t h e r e fo r e , focused on the problem of how

s p e c if ic s u b - s k il ls of social competence survive a schizophrenic or b i ­

p o lar psychotic episode, since i t was not known whether a l l aspects of

social competence are c o r r e la te d with diagnosis and age of onset of i l l ­

ness to the same degree, or in the same manner. In sum, the o b je c tiv e of

t h is study was to a s c e rta in how age of onset of psychosis and diagnosis

r e l a t e to p a r t i c u l a r social competencies: s o c ia b ility , social presence

and s o c ia l i z a t i o n le v e ls in female a d u lt p s y c h ia tric p a t ie n t s .

Sub-Problems

(a) Would the non-paranoid schizophrenic group of p a tie n ts show

e a rly age of onset of psychosis and lowest scores on the scales of so c i­

a b i l i t y , social presence and s o c ia liz a tio n ?

(b) Would the paranoid schizophrenic group of p a tie n ts show mid-


3

range of age of onset of psychosis and m id-level scores on the scales of

s o c i a b i l i t y , social presence and s o c ia liz a tio n ?

(c) Would the b i - p o la r a f f e c t i v e group of p a tie n ts show the l a t e s t

age of onset of psychosis and the highest scores of s o c i a b i l i t y , social

presence and s o c ia liz a tio n ?

D e fin itio n s

Social Competence

Social competence is the a b i l i t y to r e l a t e to others in a manner

which manifests a relaxed and comfortable exchange of verbal and non­

verbal i n t e r a c t i o n , as well as the w illin g n e ss to assume adequate and

ju d ic io u s r e s p o n s i b il it y fo r the c u ltu r a l expectations of in d iv id u al

and group interpersonal life . Social competence was defined f o r the

purposes of t h is study, as consisting o f measures of s o c i a b i l i t y , social

presence and s o c i a l i z a t i o n as measured by the C a li f o r n ia Psychological

In ven to ry. (C P I, Gough, 1956)

The C a l i f o r n i a Psychological Inventory is a m u lti-s c a le inventory

developed by Harrison Gough in 1948 which assesses p e rs o n a lity and social

i n t e r a c t io n . The aim o f the t e s t is to fo recas t what people w i l l say

and do in various interpersonal s itu a tio n s .

S o c i a b i l i t y is the personal preference and cap acity to be outgoing,

comfortable with people, of p a r t i c i p a t i v e temperament, to seek out and

enjoy social encounter. M anifestations of s o c i a b i l i t y include f r i e n d ­

l in e s s , agreeableness, and a relaxed a f f a b i l i t y . Average s o c i a b i l i t y was

o p e ra tio n a lly defined as measured by the C P I, co n sis ting of a level of


4

standard scores ranging w it h in the span of the f i r s t standard d e v ia tio n .

(Gough, 1956)

Social presence is the capacity to i n t e r a c t with others in a s t y le

which includes poise, spontaneity, enthusiasm, s e lf-c o n fid e n c e , with

the a b i l i t y to enjoy j o c u l a r i t y and/or f l i r t a t i o u s n e s s . Average social

presence was o p e r a tio n a lly defined as measured by the C P I, co n sisting

o f a le v e l o f standard scores ranging w ith in the span of the f i r s t stan­

dard d e v ia tio n . (Gough, 1956)

S o c ia liz a t io n is the degree of m a t u r it y , i n t e g r i t y , r e c t it u d e ,

prudence, circumspection, and responsiveness to the o b lig a tio n s o f i n t e r ­

personal l i f e , common needs and customs of one's social and work groups.

Average s o c ia l i z a t i o n was o p e ra tio n a lly defined as measured by the CP I,

c o n sis tin g of a level of standard scores ranging w ith in the span of the

f i r s t standard d e v ia tio n . (Gough 1956)

Diagnoses

Schizophrenia, non-paranoid type, is a disorder m anifesting evidence

o f delusions, h a llu c in a tio n s , incoherence, loosening o f a s s o c ia tio n s , i l ­

lo g ic a l th in k in g or poverty o f content of speech, causing a d e t e r io r a tio n

from a previous level of fu n ctio n in g in areas of work, social r e l a t i o n s

and s e lf - c a r e ; y e t w ith o u t paranoid symptomotology. Continuous signs of

i l l n e s s are in evidence f o r a t l e a s t s ix months ( D S M - II I, 1980, pp. 188-

193 ). The diagnosis of non-paranoid schizophrenia, f o r t h is study, was

defined o p e ra tio n a lly as co n sis ting of those disorders documented in the

hospital chart as residual schizophrenia and u n d if f e r e n t ia t e d schizo­

phrenia ( D S M - II I, 295.6 and 2 9 5 .9 , r e s p e c t iv e ly ) .


5

Schizophrenia, paranoid ty p e , includes the above d e s c rip tio n of

schizophrenic diso rd ers, but is dominated by one o f the fo llo w in g :

persecutory delusions, grandiose delusions, delusional je a lo u s y , or

h a llu c in a tio n s with persecutory or grandiose content ( D S M - II I, 1980,

pp. 1 88 -1 93). The diagnosis o f schizophrenia, paranoid type, f o r t h is

study, was defined o p e r a tio n a lly as consisting of those disorders so

documented in the h ospital ch a rt ( D S M - III, 2 9 5 .3 ) .

B i- p o la r a f f e c t i v e disorders are c h a ra cterized by the m an ife sta tio n

of manic-depressive symptoms. The manic period of the disorder is char­

a c te r iz e d by a predominantly e le v a te d , expansive, or i r r i t a b l e mood,

with a duration of one week, or of any du ratio n , i f h o s p it a l iz a t i o n is

required, and is marked by increase in a c t i v i t y , physical restle ssn e ss,

increased t a lk a tiv e n e s s , pressured speech, f l i g h t of ideas, racing

thoughts, i n f l a t e d s e lf-e s te e m , decreased need f o r sleep, d i s t r a c t i b i l i t y

or excessive involvement in a c t i v i t i e s having a high p r o b a b il it y of p ain ­

fu l consequences, g e n e ra lly denied by the i n d iv id u a l. The depressive

period of the disorder is c h a ra c te rize d by a dysphoric mood or loss of

i n t e r e s t or pleasure in almost a l l a c t i v i t i e s , accompanied by sad, blue,

hopeless, and i r r i t a b l e states. Both manic and depressive s tates mani­

f e s t diminished a b i l i t y to concentrate and/or re c u rre n t thoughts of death

or suicide ( D S M - II I, 1980, pp. 188-193; 208 -2 15).

S c h iz o a ffe c tiv e disorders must include evidence of b i - p o l a r a f f e c ­

t i v e disorder and most c lo s e ly resemble a f f e c t i v e d iso rd ers, according to

DS M -III (p. 202) and the fin d in g s of Pope, L ip in s k i , Cohen and Axelrod

(1980) as well as those of Tsuang, Dempsey and Rauscher (1976) and were,

th e r e fo r e , f o r the purposes of th is study, defined as a sub-category of


6

b i - p o l a r a f f e c t i v e diso rd ers. F urther discussion of these fin d in g s w i l l

be presented in the review o f the r e la te d research l i t e r a t u r e . B i-p o la r

a f f e c t i v e disorders were defined o p e r a t i o n a l ly , f o r t h is study, as con­

s is t in g of those disorders so documented in the hospital ch a rt ( D S M - III,

2 9 5 .7 , 2 9 6 .4 , 296.5 and 2 9 6 .6 ) .

The admission diagnosis is th a t diagnosis which is assigned upon

admission to the h o s p ita l.

The discharge diagnosis is t h a t diagnosis which is given as a sum­

mary o f the on-going assessment during treatm ent, and is acknowledged as

the established diagnosis upon discharge.

Age o f onset of psychosis is t h a t age a t which a f i r s t episode oc­

curs i n t e r f e r i n g with general functions of mental co n cen tratio n , r e a l i t y -

t e s t in g , decision-making and good judgment. Since t h is can be o b je c tiv e ly

documented by the f i r s t h o s p it a l iz a t i o n of a p a t i e n t , the age of onset

v a r ia b le was defined o p e r a tio n a lly as the age of the f i r s t h o s p i t a l i z ­

a tio n . This age of f i r s t h o s p it a l iz a t i o n is found in the hospital charts

under the section e n t i t l e d H isto ry o f Previous I l l n e s s .

Assumptions

I t was assumed t h a t the hospital records were accurate as to the age

of onset o f psychosis and the diagnoses given.

I t was also assumed t h a t the p a tie n ts selected by t h e i r counsellors

as subjects were able to concentrate on the t e s t f o r the time period

necessary to complete the C a li f o r n ia Psychological In v e n to r y , because

in d iv id u a l counsellors are be^t able to evaluate readiness to concentrate

on an a c t i v i t y . Thus, i t was assumed t h a t the re s u lts of the tes ts taken


7

by these p a tie n t-s u b je c ts were v a l i d since they had recovered s u f f i c i e n t l y

to comprehend and complete the C P I.

Lim itatio n s

The sample was lim ite d to female p s y c h ia tric p a tie n ts from an o uter-

c i t y hospital who had one of three diagnoses: non-paranoid schizophrenia,

paranoid schizophrenia and b i - p o la r a f f e c t i v e disorders. I t was f u r t h e r

l im it e d to females 18 years and o ld e r.

The subjects of th is study consisted o f a purposive or f o r tu it o u s

sample of voluntary p a r t ic ip a n t s , so th a t g e n e ra liz a tio n s about the

find ings were l im it e d to populations s im ila r to t h a t described above.

Because the data was taken from a s e l f - e v a lu a t i o n type scale, in ­

accuracies due to the s u b je c t's s e lf-p e rc e p tio n could f u r t h e r l i m i t the

find ings or g e n e r a l i z a b i l i t y of t h is study.

Sig n ific a n c e

The t h e o r e t ic a l s ig n ific a n c e of th is study is t h a t i t con tributes

new concepts both to the body of knowledge of general social competence

theory, and to the social s k i l l theory of occupational therapy fo r

p s y c h ia tr ic p a t ie n t s . This research intends to provide a more in-depth

examination of aspects of social competence previously not explored:

s o c i a b i l i t y , social presence and s o c ia l i z a t i o n . I t contains data r e l a t i n g

the social competence theory of P h i l l i p s (1953); Z i g l e r and P h i l l i p s

(1961, 1964); and G oldstein, Held and Cromwell (1968) concerning three

major diagnoses and age of onset of psychosis as they r e l a t e to these

three s u b -s k ills or s p e c if ic social competencies. I t was thus designed


8

to expand upon c u r r e n tly e x is t in g social competence theory in order to

provide a broader base of understanding of social s k ill le v e ls fo llo w in g

psychosis.

The t h e o r e t ic a l value of t h is study to the profession of occupational

therapy is i t s c o n trib u tio n of introducing new concepts in to t h is f i e l d

through the social competence theory. These concepts are taxonomic sub-

s k i l l s of social competence which are new to th e o r e tic ia n s of social

competence as well as to th e o r e tic ia n s o f occupational therapy. Although

Eleanor Clark Slagle discussed the need f o r social r e h a b i l i t a t i o n of

p s y c h ia tric p a tie n ts on back wards o f p s y c h ia tr ic ho s p ita ls in the 192 0's ,

(G ille tte , in W illa r d & Spackman, 1971) to date general social s k ills

have not been analyzed in terms of t h e i r components f o r purposes of psy­

c h i a t r i c occupational therapy treatm ent. Analysis o f a c t i v i t i e s , and

separating them in to t h e i r various component p a r ts , is a d is tin g u is h in g

c h a r a c t e r is t i c o f occupational therapy assessment and treatm ent.

This study has p r a c t ic a l s ig n ific a n c e because of i t s c o n tr ib u tio n to

the domain of p r a c tic e of occupational therapy. Treatment goals in oc­

cupational therapy can be more c l e a r l y formulated, and more e f f e c t i v e l y

implemented, i f p r a c t i t i o n e r s can a n t i c ip a t e p o te n tia l le v e ls of social

s k i l l s from knowledge of diagnosis and ages o f onset of psychoses. This

inform ation about the association among these fa c to rs would be of value

in assessing the degree of focus on social s k i l l s in the a c t i v i t i e s tre a t­

ment of in d iv id u a l p a t ie n t s . The r e s u lts of t h is study can then be of as­

sistance in planning social s k ill treatm ent goals in l e is u r e , l i v i n g - s k i l l

developmental and p re-v o c a tio n a l a c t i v i t y groups where p a tie n ts are ex­

pected to work on r e l a t i n g to others around the a c t i v i t y or task involved.


9

Theoreti cal Framework

The social competence theory f o r p s y c h ia tr ic p a tie n ts set fo r th by

P h illip s , (19 5 3 ); Z i g l e r and P h i l l i p s , (1961 ); and G oldstein, Held and

Cromwell, (1968) states th a t both diagnostic and non-diagnostic c r i t e r i a

are r e la te d to a p a t i e n t 's le v e l of social s k i l l performance and, th e r e ­

f o r e , to o ve ra ll prognosis. This is an evolving theory, spanning a period

o f more than t h i r t y years of continuous development. The theory as tested

here, is a c o lle c t io n of postulates dealing w ith the r e la tio n s h ip between

social competence and two major v a ria b le s of diagnosis and age of onset of

psychosis. The two independent v a ria b le s of diagnoses and age of onset of

psychosis are examined f i r s t , followed by the dependent v a ria b le s of social

competence s k i l l s .

Diagnosis is the f i r s t independent v a r ia b le discussed. According to

the social competence th eo ry, the major diagnostic c a te g o riz a tio n s of

psychosis can be in d ic a to rs o f expected le v e ls of social competence of

groups of p a tie n ts p re c is e ly because the diagnoses are associated with

varying le v e ls o f social s k i l l achievement. The three major diagnostic

groupings which can be considered to be associated with given le v e ls of

post-psychotic social competence f o r p a t i e n t groups are (1) non-paranoid

schizophrenia; (2 ) paranoid schizophrenia; and (3) b i - p o l a r a f f e c t i v e

disorders. These are l i s t e d in the order of the expected degree of

s e v e r ity of residual symptoms of psychosis. Such symptoms i n t e r f e r e with

normal c o g n itiv e fu n ctio n al a b i l i t i e s , such as the a b i l i t y to con centrate,

to communicate c o h e re n tly , to perceive r e a l i t y as most others do, to make

judgments in accordance with cause and e f f e c t reasoning, to plan and


10

organize tasks. The three diagnoses l i s t e d above are expected to m anifest

severe, moderate, and mild residual symptoms, r e s p e c tiv e ly , due to the

nature of the s p e c ific disorders. Though not ap p licab le to each p a t i e n t ,

these trends have been noted by c l in i c i a n s in t h e i r general observations

of groups of p a tie n ts over the yea rs. These observations, t h e r e f o r e , have

t h e i r conceptual source in a base providing an e ss en tial face v a l i d i t y .

Non-paranoid schizophrenic p a tie n ts are noticeably the most s o c ia lly

withdrawn of these three groupings, with a gen erally very f l a t a f f e c t

fo llo w in g a psychotic episode. They have the g re a te s t number and degree

of residual psychotic symptoms (G o ld s te in , Held & Cromwell, 1968). Be­

cause they have the le a s t successful recovery o f social competencies,

t h e i r social s k i l l s have been described as "poor" (Pope, L i p in s k i , Cohen

& Axelrod, 1980, p. 926 ).

Paranoid schizophrenic p a tie n ts usually m anifest a g r e a te r capacity

f o r demonstration o f a f f e c t , and attempt to in t e r a c t s o c i a l l y . There

is less evidence in number and degree of residual psychotic symptoms

(G o ld stein , Held & Cromwell, 1968). The exten t of recovery of social

competencies in paranoid schizophrenia has been described as " f a i r " , in ­

d ic a tin g a le s s e r degree of s e v e r ity of fu n ctio n al loss than in non­

paranoid schizophrenia (Pope, L i p in s k i , Cohen & Axelrod, 1980, p. 926 ).

P a tien ts w ith b i - p o l a r a f f e c t i v e disorders most ofte n give in d ic a ­

tio n s of a s t i l l g r e a te r a b i l i t y to r e l a t e to others w ith more app ro priate

a f f e c t , tending to be less defensive s o c ia lly than both catego ries of

schizophrenic p a t ie n t s . They are sometimes capable of social in t e r a c t io n

t h a t would be considered " w ith in normal l i m i t s " , despite t h e i r previous

psychotic episode (L evin e, Watt & F re y e r, 1978). The degree of recovery


of social competencies of p a tie n ts with b i- p o la r a f f e c t i v e disorders

a f t e r a psychotic episode has been described as "moderately good" or

"good," in d ic a tin g the le a s t degree of s e v e rity of fu n ctio n al loss among

these three categories (Pope, L i p in s k i , Cohen & Axelrod, 1 9 8 0 , p . 9 2 6 ) .

The term b i - p o la r a f f e c t i v e disorders excludes major depressive disorders

which are u n i- p o la r , non-psychotic and non-manic in nature ( D S M - III,

1980, pp. 205-218; RDC, 1978, pp. 9 - 1 6 ) .

The second major independent v a r ia b le of t h is study is age of onset

of psychosis. The social competence theory proposes th a t non-diagnostic

c rite ria , such as age of onset of psychosis, are r e la te d to o ve ra ll

general prognosis. The g re a te r the basis of social s k i l l s p r i o r to a

psychotic disturbance, the g re a te r the p o te n tia l f o r r e s to r a tio n of social

competencies during the r e h a b i l i t a t i o n period ( Z i g l e r & P h i l l i p s , 1961,

1964). Higher le v e ls of social s k i l l s are achieved p r i o r to psychosis

when i t s onset is l a t e r in l i f e (Z ig le r & P h i l l i p s , 1961, 1964). There­

fo r e , higher le v e ls of social fu n ctio n in g are possible when the age of

onset of psychosis is l a t e r .

I t is documented t h a t c e r ta in ages o f onset are associated w ith

s p e c if ic diagnoses. The Diagnostic and S t a t i s t i c a l Manual o f Mental

Pi sorders-111 (1980) s tates th a t age o f onset fo r the schizophrenic

disorders is usu ally during adolescence or e a rly adulthood (p. 184 ),

with non-paranoid schizophrenia m anifesting e a r l i e r than paranoid schizo­

phrenia. The Manual observes t h a t the f i r s t manic episode of b i - p o la r

a f f e c t i v e diso rd er t y p i c a l l y occurs before age 30 (p . 2 1 5 ).

There is then a general r e la tio n s h ip between given diagnoses and

ages of onset of these disorders. These fac to rs are inseparable and


12

i n t e r a c t with functio nal achievement, e s p e c ia lly with social competen­

c ie s . S p e c ific diagnoses and ages of onset are expected to occur in

conjunction as they r e l a t e to s p e c ific le v e ls of social competence.

The social competence theory as j u s t described can be conceptualized

in four summary propositions:

Proposition One: Both diagnostic and non-diagnostic c r i t e r i a are

r e la te d to social competence le v e ls and general prognosis in p s y c h ia tric

p a tie n ts .

Proposition Two: Levels of social competence can be r e la te d to

diagnosis by examination of pre- and post-psychotic le v e ls o f the three

groups of major diagnostic c a te g o rie s , moving from low to high social

competence, as follow s:

a. Non-paranoid schizophrenia

b. Paranoid schizophrenia

c. B i- p o la r a f f e c t i v e disorders.

Proposition Three: Age of onset of psychosis is r e la te d to le v e ls

of social competence achieved by p s y c h ia tric p a tie n ts .

Proposition Four: The three groups of major diagnostic categories

are s p e c i f i c a l l y associated w ith c e r t a in ages of onset of psychosis:

a. Non-paranoid schizophrenia - adolescence and e a rly young

adulthood (20-23)

b. Paranoid schizophrenia - mid-young adulthood (23-26)

c. B i- p o la r a f f e c t i v e disorders - l a t e young adulthood (26-30)

The v a ria b le s emerging from these propositions which were included

in t h is study co n sist of the two independent v a ria b le s of diagnosis and

age of onset of psychosis.


13

The dependent v a r ia b le o f social competence was subdivided in to the

social scale behaviors presented by Gough (1956) in his C a li f o r n ia Psycho­

lo g ic a l In v e n to ry . Social competencies were broken down in to component

parts as presented by Gough f o r the dependent v a r ia b le so t h a t the nature

of social s k i l l s among p s y c h ia tr ic p a tie n ts can be expanded and c l a r i f i e d .

Gough's three social scale behavioral competencies are s o c i a b i l i t y , social

presence and s o c i a l i z a t i o n . The r e la tio n s h ip of the independent to the

dependent v a r ia b le s is proposed in the th e o r e t ic a l hypothesis presented

below.

For the purposes of t h is study, pre-psychotic le v e ls of social s k i l l

competencies were not examined, but merely post-psychotic le v e l s , which

according to the social competence th eo ry, are not expected to r is e

above pre-psychotic le v e ls ( P h i l l i p s , 1953; Z i g l e r & P h i l l i p s , 1961,

1964).

As mentioned in the problem statement, studies t e s t in g various

aspects of the social competence theory of Z i g l e r and P h i l l i p s (1961)

and G olds te in, Held and Cromwell (1968) have not examined the various

s u b - s k ills of social competence (Pope, L i p in s k i , Cohen & Axelrod, 1980;

Tsuang & Winokur, 1975; Tsuang, Dempsey & Rauscher, 1976). An examina­

tio n of the social competencies of s o c i a b i l i t y , social presence and

s o c ia l i z a t i o n are o f value in analyzing which social s k i l l s need develop­

ment so t h a t a c t i v i t i e s may be designed to a s s is t in the recovery of

p s y c h ia tr ic p a t ie n t s . A lack of standardized norms a t present f o r such

treatm ent planning e s ta b lis h e s the need f o r a study which examines the

major v a ria b le s of the social competence theory, diagnosis and age of

onset of psychosis, in order to c l a r i f y the assessment o f social a c t i v i t y


14

components f o r r e h a b i l i t a t i o n .

In summary, i t is noted t h a t f o r c l i n i c a l / p r a c t i c a l reasons the

theory of social competence considers the diagnoses most fre q u e n tly found

in most p s y c h ia tric h o s p ita ls : non-paranoid schizophrenia, paranoid

schizophrenia, and b i - p o l a r a f f e c t i v e disorders. These same diagnoses

are the subject of the studies which examine the theory o f social com­

petence (Tsuang & Winokur, 1975; Tsuang, Dempsey &Rauscher, 1976; Pope,

L ip in s k i, Cohen <5 Axelrod, 1980).

I t is also f o r p r a c t ic a l reasons t h a t the age of the f i r s t h o s p it a l­

iz a t io n is the best c l e a r l y documented age fo r the onset of psychosis be­

cause parents, frie n d s and f a m ilie s are gen erally unable a t t h a t time to

care f o r a psychotic person unassisted. I t is th e r e fo r e assumed t h a t the

f i r s t h o s p it a liz a t io n coincides w ith the age of onset of psychosis. It

is also expected t h a t the age of onset of psychosis marks a developmental

c u t - o f f age f o r the normal growth o f social competencies ( P h i l l i p s , 1953;

G oldstein, Held & Cromwell, 1968, 1974; G ittle m a n -K le in & K le in , 1969;

Z i g l e r , Levine & Z i g l e r , 197 7). I t is f o r th is reason t h a t these r e ­

searchers consider i t ess en tial to examine age of onset of psychosis in

eva lu a tin g social prognosis, as le v e ls of social s k i l l s are based on

pre-morbid s k i l l s .

Hypothesi s

I t was with the foregoing t h e o r e t ic a l propositions and considerations

in mind t h a t the fo llo w in g hypothesis was developed:

The three diagnoses would be p re d ic ta b le through consideration of a

given age of onset of psychosis and given scores of s o c i a b i l i t y , social


presence and s o c ia l i z a t i o n :

a. The non-paranoid schizophrenic group of p a tie n ts is expected

to be associated w ith e a rly age of onset of psychosis and lowest scores

on the scales of s o c i a b i l i t y , social presence and s o c i a l i z a t i o n .

b. The paranoid schizophrenic group of p a tie n ts is expected to

be associated w ith a m id -le v e l age of onset of psychosis and m id -level

scores on the scales of s o c i a b i l i t y , social presence and s o c i a l i z a t i o n .

c. The b i - p o l a r a f f e c t i v e group of p a tie n ts is expected to be

associated with l a t e s t age of onset o f psychosis and highest scores

of s o c i a b i l i t y , social presence and s o c i a l i z a t i o n .

In the a p p lic a tio n of the r e s u lts of t h is study, i t should be noted


th a t caution must be exercised in moving from a s e l f - e v a l u a t i v e
p e rs o n a lity p r o f i l e , which is l im i t e d by the p a t i e n t 's s u b jec tive
response, to the realm of the behavioral world.
CHAPTER 2

RELATED LITERATURE

The l i t e r a t u r e r e la te d to the theory of social competence has three

major sub -divisio ns which c o n sis t of: (1 ) social competence in psychia­

t r i c p a tie n ts as demonstrated by t h e i r le v e l of social s k i l l s ; (2) the

age of onset of psychosis; and (3) three major p s y c h ia tr ic diagnoses:

non-paranoid schizophrenia, paranoid schizophrenia and manic-depressive

illn e s s . This theory o f social competence explains how these three areas

i n t e r r e l a t e , whereby age of onset of psychosis and diagnosis r e l a t e

j o i n t l y to in flu e n c e the le v e l o f social s k i l l s in p s y c h ia tr ic p a tie n ts .

This can be i l l u s t r a t e d by Figure 1, which shows the in t e r a c t io n of the

t h e o r e t ic a l propositions and the major hypothesis as presented in the

r e la te d l i t e r a t u r e .

Age of Onset
of Psychosis

Level of
Social S k i l l s

Diagnosis

Figure 1. Schematic diagram o f major t h e o r e t ic a l propositions and


hypothesis.

L a te r , t h is diagram w i l l be expanded to demonstrate the f u l l e r

unfolding of t h is t h e o r e t ic a l model.

16
17

Social Competence in P s y c h ia tric P a tients

Within the body of l i t e r a t u r e regarding social competence in psy­

c h i a t r i c p a tie n ts , th e o r e tic ia n s addressed both pre-morbid and recovered

or post-discharge social competence. Authors of the theory and research

o f pre-morbid and post-recovery showed a r e la tio n s h ip between le v e ls of

social competence in both these periods since immediate recovery le v e ls of

social s k i l l s cannot exceed pre-morbid social development. As presented

in the fo llo w in g th ree sections, t h is r e la tio n s h ip between pre- and post-

psychotic le v e ls of social competence was discussed and v e r i f i e d in the

work of P h i l l i p s ( 1 9 5 3 ), Farina and Webb (1 9 5 6 ), P h i l l i p s and Z i g l e r

(1 9 6 2 ), G ittle m a n -K le in and K lein (1 9 6 9 ), Sanes and Z i g l e r (1 9 7 1 ), Z i g l e r

and Levine (1973) and Lewine, Watt and Freyer (1 9 7 8 ).

I t was the plan of t h is study to examine the le v e ls of social com­

petence s t a t i s t i c a l l y in the recovery or post-discharge period. The

r e la te d l i t e r a t u r e o f pre-morbid social competence was reviewed because

i t is both t h e o r e t i c a l l y and s t a t i s t i c a l l y interwoven w ith t h a t of re ­

covered social competence as a prognostic v a r ia b le of post-discharge

social competence. I t is because pre-morbid le v e ls of social competence

are shown to be c o r r e la te d to the le v e ls of recovered social competence

t h a t they are inseparable in the l i t e r a t u r e .

In the e a r ly 1 9 5 0 's , L e s lie P h i l l i p s (1953) opened t h e o r e t ic a l

discussion and a s e rie s of r e tro s p e c tiv e studies of pre-morbid adjustment

of p a tie n ts diagnosed as schizophrenic, observing t h a t m atu rity in the

pre-morbid p erio d , s p e c i f i c a l l y , the work record and social and sexual

adequacy, appeared to be r e la te d to good prognostic p o te n tia l (p . 515).


18

P h i l l i p s f u r t h e r explained th a t the presence of s o c i a l / a f f e c t i v e respon­

siveness in manic-depressive i l l n e s s , in c o n trast to the t y p ic a l fla tn e s s

of social a f f e c t in non-paranoid schizophrenia, seemed to be a major

in d ic a t o r of p o te n tia l f o r improvement in post-discharge le v e ls of social

competence (p. 5 1 5 ). To t e s t th is observational hypothesis, he developed

the P h il li p s Pre-Morbid Adjustment Scale (1953) c o n sis tin g of f i v e parts:

(1) recent sexual adjustment; (2) social aspects o f sexual l i f e during

adolescence; (3) social aspects of recent sexual l i f e ; (4 ) interp ersonal

r e la tio n s h ip s during e a r ly youth; and (5) recent pre-morbid adjustment in

interpersonal r e la tio n s h ip s . The degree to which a p a t ie n t was able to

form and maintain personal r e la tio n s with others p r i o r to i l l n e s s seemed

r e la te d to the outcome of le v e ls of social competence a f t e r a psychotic

episode, according to P h i l l i p s ' r e s u lts (p. 517). P h i l l i p s also noted

t h a t the more m a tu rity displayed in pre-morbid l i f e , the more r e a l i s t i c

and mature would be the nature of the disturbance which caused the break­

down (p. 5 2 0 ). At t h is p o in t P h i l l i p ' s work was merely observational and

th e o r e tic a l and lacked s t a t i s t i c a l v e rific a tio n .

In the m id -19 50's, Farina and Webb (1956) continued the discussion

and study of the pre-morbid adjustment of schizophrenic p a t ie n t s , noting

t h a t the post-morbid period r e f le c t e d the lev e l o f pre-morbid social and

sexual adjustment, in d ic a t in g , t h e r e f o r e , th a t the pre-morbid period had

good p r e d ic t iv e value c l i n i c a l l y . They c r i t i c i z e d the P h i l l i p s ' r a t in g

scale f o r i t s heavy emphasis on the social aspects of sexual l i f e . Not­

withstanding t h is drawback, Farina and Webb found th a t the scale revealed

a strong connection between pre-morbid social competence and success in

staying out of the hospital when the period of fo u r and ten years post-
19

h o s p it a liz a t io n was examined. The strength of the Farina and Webb study

la y in i t s lo n g itu d in a l nature.

The fo llo w in g y e a r , Rodnick and Garmezy (1957) also examined schizo­

phrenic p a t ie n t s , d iv id in g them in to two categories of good and poor p re-

morbid adjustment. The poor pre-morbid schizophrenic subjects were more

s e n s itiv e to social censure, more s o c ia l l y withdrawn, and much harder to

re h a b ilita te . The poor pre-morbid group was gen e ra lly designated as

chronic by type. One weakness of these e a rly studies was t h e i r lack of a

"normal" comparison group. Another weakness was the s i m p li s t ic d iv is io n

o f the p a tie n ts in to only two catego ries or le v e ls of social competence.

Thus f a r in the development of t h is theory, researchers, in t h e i r

s ta tis tic a l in q u iry focused narrowly on one diagnosis, schizophrenia, as

a general category. Proposition One o f t h is study proposed t h a t both

diagnostic and non-diagnostic c r i t e r i a are r e la te d to social recovery and

general prognosis in p s y c h ia tr ic p a tie n ts ; y e t the e a rly major developers

of the theory o f pre-morbid and post-recovery social competence i n i t i a l l y

postulated th a t outcome could not be c o n s is te n tly associated w ith any

given diagnosis ( Z i g l e r & Levine, 1962, p. 2 1 6 ). T h e ir bias was r e f le c t e d

in t h e i r regard o f the diagnostic system as a r e l a t i v e l y " s t e r i l e " one

(p. 2 2 ). Z i g l e r and Levine (1962) recommended expanding the study of

pre-morbid social competence to include dimensions of psychopathology

o th er than schizophrenia. They contended th a t the developmental aspects

o f achieved le v e l of social m a tu r ity , which they defined as pre-morbid

social competence (p. 2 1 6 ), were not unique to schizophrenia, but cut

across a l l diagnostic l i n e s , includin g the three major diagnoses of non­

paranoid schizophrenia, paranoid schizophrenia, and manic-depressive


20

illn e s s . They th e re fo re expanded the work of t h e i r predecessors to i n ­

clude a spectrum o f diagnoses, w hile focusing p r im a r ily on non-diagnostic

c o r r e la te s o f social competence. In t h is 1962 study, Z i g l e r and Levine

became absorbed in a perip h eral examination of process and r e a c tiv e

schizophrenia, a popular non-diagnostic c a te g o riz a tio n commonly respected

a t t h a t time which has since f a l l e n in to d is fa v o r.

In 1960 and 1961, Z i g l e r worked w ith P h i l l i p s to construct a Social

Competence Scale ( SCS, 1961) based on t h e i r developmental theory of pre-

morbid and post-recovery social competence, as well as on em pirical

fin d in g s . The c en tral t h e o r e t ic a l assumption in t h is developmental f o r ­

mulation was t h a t a p a t i e n t 's psychological r e s i li e n c y and adaptive

p o te n tia l in responding to environmental stress and in recovering from

breakdown depended on his e a r l i e r a b i l i t y in coping w ith the so c ie ta l

tasks associated w ith successive developmental stages (Sanes & Z i g l e r ,

1971, pp. 140, 142 ). Z i g l e r and P h i l l i p s ' contention was t h a t the

f a r t h e r along a p a t i e n t was on the continuum of developmental tasks p r io r

to breakdown, the g r e a te r would be his p o te n tia l f o r adaptation and sub­

sequent recovery ( P h i l l i p s , 1953; P h i l l i p s & Rabinovitch, 1958; Z i g l e r &

Levine, 1960, 1961). In the construction of t h e i r s c a le , the SCS, they

focused on six non-diagnostic in d ic a to r s of age, i n t e l l i g e n c e , education,

occupation, employment h is to ry and m a rita l status as t h e i r c r i t e r i a fo r

c a l i b r a t i n g social competence. T h e ir s ca le, designed to r a t e p a tie n ts

e x c lu s iv e ly on the basis of case h i s t o r i e s , th e r e f o r e , had the weakness

of being r e tro s p e c tiv e in focus.

In itia l attempts at v a lid a t in g t h is scale were inadequate because

there was no control f o r diagnosis. In l a t e r s tu d ie s , researchers made


21

a stronger case f o r the p r e d ic t iv e v a l i d i t y of the P h i l l i p s / Z i g l e r Social

Competence Scale by the in clu sio n o f d i f f e r e n t i a l data across several

diagnoses. Strauss, Kokes, Klorman and Sacksteder (1977) c r i t i q u e d the

s c a le 's v a lid a t io n te s ts fo r not c o n tr o llin g f o r the age f a c t o r . S till,

Strauss found s i g n i f i c a n t c o r r e la tio n s between the SCS ra tin g s and m u l t i ­

dimensional outcome c r i t e r i a in both schizophrenic and non-schizophrenic

samples, thus in d ic a t in g the s c a le 's a p p l i c a b i l i t y to several diagnostic

c a teg o ries. In 1978, Levinson and Campus compared fo u r scales purported

to assess social competence. They rated the P h i l l i p s Scale as having the

best r e l a t i v e accuracy and c l i n i c a l a p p l i c a b i l i t y (p. 2 0 4 ). The con­

tinuous and repeated use of t h is scale by subsequent in v e s tig a to r s

(Schwartz, 1967; Sanes & Z i g l e r , 1971; Strauss and C arpenter, 1972;

G oldstein, Held & Cromwell, 1968; McCreary, 1974), as well as i t s modified

use by others (Rodnick & G oldstein, 1974) r e f le c t e d i t s p o p u la r ity . How­

ever, opponents of t h is measure (Sarbin & Mancuso, 1980) c r i t i c i z e d i t

f o r i t s focus on socioeconomic status fa c to rs r a th e r than on social p e r­

s o n a lity t r a i t s .

For a time, Z i g l e r and P h i l l i p s continued to examine other non­

diagnostic c r i t e r i a of social competence, such as the p ro ce ss-reactiv e

dimension of onset of symptomatology, previously discussed, as well as

t u r n in g - a g a in s t - t h e - s e l f versus tu rn in g -a g a in s t-o th e rs (1961, 1962) which

proved to be another i n v e s t i g a t iv e impass. They were adamant in t h e i r

p o s itio n t h a t the diagnostic system was a s t e r i l e one, as a prognostic

in d ic a t o r o f social recovery (1962, pp. 220, 2 2 1 ). In t h e i r stu d ies,

P h illip s et a l. ignored the possible value of diagnostic an a lys is even

as a control v a r i a b l e . I t can be acknowledged, however, th a t a t t h is


22

period o f tim e, diagnostic d e lin e a tio n s l e f t much to be d esired, often

adding more confusion than c l a r i f i c a t i o n by t h e i r in clu sio n in p s y c h ia tric

stu d ies. Z i g l e r and P h i l l i p s found th a t the p ro ce ss-reactiv e d i s t in c t i o n ,

though s i g n i f i c a n t , was reduc ible to the social competence dimension

its e lf. They thus e lim in a te d i t as a separate v a r ia b le from fu tu re

stu d ies.

By 1971 Z i g l e r was working w ith Sanes, and continued to focus on

non-nosological aspects of social adjustment in d ic a t o r s , such as tu rn in g -

a g a in s t - t h e - s e lf and tu r n in g -a g a in s t- o t h e r s , but they continued to ignore

the place of diagnosis in p re d ic tio n s of recovery outcome. They did

f i n d , however, t h a t the t u r n i n g - a g a in s t - t h e - s e l f response was found

in p a tie n ts with higher le v e ls of social competence. In a study in

1973, Z i g l e r and Levine focused on the same v a ria b le s as the 1971 study,

expressing a continuing caution regarding the use of diagnostic d is ­

t in c t i o n s (p. 190).

While looking f o r in te rv en in g v a ria b le s between pre-morbid social

competence and social recovery le v e ls a f t e r a psychotic episode, Z i g le r

and his c o lla b o ra to rs continued to accumulate evidence f o r the c o r r e l a ­

t io n of these two major fa c t o r s . I t was c o n s is te n tly confirmed t h a t the

higher the pre-morbid le v e ls of social development p r i o r to a psychotic

episode, the higher the le v e ls of post-psychotic recovery would be in the

r e h a b i l i t a t i o n period ( P h i l l i p s & Z i g l e r , 1961; Z i g l e r & P h i l l i p s , 1962;

Sanes & Z i g l e r , 1971; Z i g l e r & Levine, 1973; Levine, Watt & F ry e r, 1978).

Sarbine and Mancuso (1980) c r i t i c i z e d these studies f o r espousing what

they considered to be a t a c i t id e o lo g ic a l premise, th a t the acceptance by

a p a t ie n t of the dominant social norms of the middle class give such


23

p a tie n ts a b e t t e r social competence r a tin g (p. 56, 5 7 ). I t was t h e i r

contention t h a t social class membership was a hidden v a r ia b le in the

schizophrenia research of the Phi 11i p s / Z i g l e r group. I t was t h e i r obser­

vation t h a t too great weight was placed on m arital status in t h is s ca le,

in such a way as to equate social m aturity with a successful marriage.

In 1968, another in v e s t i g a t iv e group emerged to carry on research

in social competence w ith a new focus. G oldstein, Held and Cromwell

published t h e i r r e s u lt s j o i n t l y in 1968, though they conducted separate

studies. They also looked a t good versus poor social competence in

schizophrenic p a t ie n t s , using p a r t of the P h i l l i p s Prognostic Scale ( PPS)

of 1953 to eva lu a te perso n al-so cia l adequacy and le v e ls of adjustment

a f t e r h o s p it a l iz a t i o n . The G oldstein group added the f a c t o r of diagnosis

to t h e i r research, thus coming c lo s e r to the co n cep tu a liza tio n of Proposi­

tio n One (Chapter One) in looking a t both diagnostic and non-diagnostic

c r i t e r i a , thus, moving beyond the e a r l i e r viewpoint of the P h i l l i p s and

Z i g l e r group in t h e i r opposition to nosological f a c to r s .

G ittle m a n -K le in and K lein in 1969 also focused on social adjustment

and prognosis in schizophrenia. They developed the Pre-Morbid Asocial

Adjustment Scale (1969) which was lim ite d to aspects of a s h u t- in , sc h i­

zo id , withdrawn, a s o c ia l, pre-morbid p e rs o n a lity which they expected would

p r e d ic t the l i m i t a t i o n s o f post-psychotic recovery. Through t h is scale

they were able to reveal a bi-modal d is t in c t io n between "good" and "poor"

social competence l e v e l s . However the scale has been c r i t i c i z e d because

of i t s dependence on i n t e r r a t e r r e l i a b i l i t y and judgment in assignment of

scale le v e ls on a seven-point s ca le. Nevertheless, they confirmed e a r l i e r

fin d in g s t h a t the g r e a te r the degree of pre-morbid a s o c ia l, withdrawn


24

p e rs o n a lity c h a r a c t e r is t i c s , the less the lik e lih o o d of recovery from

a schizophrenic episode and of m aintaining oneself adequately in the

community (1968, p. 4 2 ) . Through t h e i r data they made the f u r t h e r

d i s t in c t i o n t h a t w hile high pre-morbid schizoid c h a r a c t e r is t ic s i n ­

v a r ia b ly predicted a narrow range of p ost-hosp ital adjustments, p atie n ts

with r e l a t i v e l y few pre-morbid asocial t r a i t s could have a wide range of

outcomes (p. 4 4 ). Because the data were p a r t i a l l y re tro s p e c tiv e r a tin g s ,

these re s u lts needed to be r e p lic a te d w ith in p r e d ic t iv e in v e s t ig a t io n s .

In 1972, Strauss and Carpenter developed t h e i r own p re d ic to rs fo r

outcome in schizophrenia. In so doing, they were c lo s e r to acceptance

of the th e o r e tic a l stance of Proposition One, wherein both diagnostic and

non-diagnostic c r i t e r i a are ess en tial v a ria b le s of prognosis. These

in v e s tig a to rs developed the Strauss-Carpenter Prognostic Scale (1 9 7 4 ),

with four v a ria b le s as c r i t e r i a f o r outcome of dysfunction: (1) p e r ­

centage of time employed; (2 ) s e v e r ity of symptomatology; (3) frequency

of social contacts; and (4) time spent out of the h o s p it a l. Social com­

petence was j u s t one v a r ia b le focused on as a p r e d ic to r f o r good recovery.

T h e ir re s u lts c o n f l ic t e d w ith those of the G oldstein group, showing th a t

non-diagnostic fa c to rs were the strongest p red ic to rs of outcome, although

t h e i r c o r r e la tio n s revealed only moderate le v e ls of association o f non­

diagnostic fa c to rs with outcome/prognosis. Strauss-Carpenter confirmed

the prognostic value of pre-morbid social re la tio n s h ip s as c o r r e la te s of

s p e c ific social recovery l e v e l s . The Prognostic S c ale 's v a l i d i t y has been

proven by these fin d in g s a t a tw o-year, and subsequently, a t a f i v e - y e a r

fo llo w -u p .

By 1977, the r e la tio n s h ip between pre-morbid and post-discharge


25

social competence was so well established t h a t i t engendered l i t t l e

f u r t h e r discussion. In l a t e r s tu d ies, researchers s h if te d t h e i r focus

to the in te rv e n in g v a ria b le s of age and diagnosis.

Age of Onset of Psychosis and Social Competence

In Proposition Three (Chapter One), the re la tio n s h ip of age of

onset of psychosis to le v e ls of social competence achieved by p s y c h ia tric

p a t ie n t s , was discussed, touching on both pre-morbid adjustment and o u t­

come in r e h a b i l i t a t i o n . While c o lla b o ra tin g with Held and Cromwell,

Goldstein (1968) found t h a t "good pre-morbid schizophrenic p a tie n ts "

were s i g n i f i c a n t l y o ld er than "poor pre-morbid schizophrenic p a tie n ts "

(p. 384 ). In 1974, w hile working w ith Rodnick, Goldstein discovered a

c le a r c o r r e la t io n between the age of onset of psychosis and pre-morbid

adjustment w h ile examining the recovery of the mothering fu n ctio n in

acute schizophrenic women (p. 6 2 3 ). With these r e s u l t s , Goldstein e t a l .

in d ic a te d t h a t the age of onset was seven years l a t e r f o r "good pre-

morbid mothers" than f o r the "poor pre-morbid mothers" (p. 6 2 5 ). By

means of t h is data they supported the proposition t h a t the o ld e r p a t i e n t ,

having had the b e n e fit of a longer period of normal social development

before onset of psychosis, would m anifest a higher lev e l of subsequent

social fu n c tio n in g . There were strong in d ic a to rs t h a t the poor pre-

morbid group was a p a th e tic and i n d i f f e r e n t to t h e i r c h ild re n in the 30

days p r io r to admission, whereas t h is was not tru e of the good pre-morbid

groups (p. 6 2 6 ). The strength of t h is study lay in the f a c t t h a t obser­

vational data on the subjects was c o lle c te d f o r one year fo llo w in g d i s ­

charge.
26

The K leins (1969) looked a t early childhood p e rs o n a lity c h a ra c te r­

i s t i c s of schizoid and schizophrenic sub jects, fin d in g t h a t a t a very

e a r ly age they e x h ib ite d a q u ie t , shy and r e t i r i n g d is p o s it io n , made no

frien d s and liv e d only f o r themselves (p. 3 5 ). They found t h a t such p re -

morbid schizoid or asocial functio ning was p o s it iv e ly r e la te d to poor

p o s t-h o sp ital adjustment; and t h a t , furtherm ore, the g re a te r the degree

of pre-morbid asocial w ith d raw al, the less l i k e l y the recovery from a

schizophrenic episode (p . 4 2 ). A g re a te r degree of asocial fu nctio ning

in the post-psychotic a d u lt p a tie n ts was associated w ith a g re a te r degree

o f schizoid c h a r a c t e r is t ic s during pre-adolescence (p. 4 1 ). Thus, the

Kleins v e r i f i e d a r e la tio n s h ip between e a rly age of emergence of social

incompetence and poor recovery le v e ls of social s k i l l s a f t e r a psychotic

episode. Strauss e t a l . (1977) commended the Kleins f o r t h e i r focus on

age of onset of psychosis as a r e l i a b l e p re d ic tio n of recovery of social

competence, e s p e c ia lly in c o n tra s t with other less e a s ily defined v a r i ­

ables used in many of these studies.

While reviewing the re la tio n s h ip between pre-morbid social compe­

tence and age of onset of female schizophrenic p a t ie n t s , i t was noted

by Z i g l e r , Levine and Z i g l e r (1977) in one of t h e i r l a t e r studies th a t

a higher developmental le v e l and b e t t e r pre-morbid and post-discharge

social status were associated w ith s i g n i f i c a n t l y higher ages of onset

of psychosis (p. 3 35 ).

Lewine, Watt and F reyer (1978) found the average age of onset of

psychosis f o r p s y c h ia tr ic p a tie n ts to be of various ascending ages in

keeping w ith a r e la te d in creasing degree of pre-morbid and post-psychotic

social competence. Those with the g re a te s t social competence had t h e i r


27

f i r s t psychotic breakdown a t a l a t e r age (p. 2 9 4 ). Lewine e t a l . used

school records of teachers' w r i t t e n a d - l i b comments of students from

kindergarten to t w e lf t h grade which c o r r e la te d well with scores on the

Phil 1i p s / Z i g l e r Social Competence Scale (1 9 6 1 ). The u t i l i z a t i o n of a six

y ea r follow -up period l e n t strength to the ra tin g s in social competence,

and presented average ages of f i r s t admission as 2 2 .9 , 24.4 and 2 5 .1 ,

re s p e c tiv e ly f o r non-paranoid schizophrenia, paranoid schizophrenia

and s c h iz o - a f fe c tiv e d iso rd er.

Most r e c e n tly , the authors o f the Diagnostic and S t a t i s t i c a l Manual

of Mental Disorders - I I I (1980) r e i t e r a t e d these observations, and t ie d

them to diagnostic c a te g o rie s , by way of summarizing observations from

in te r n a tio n a l s tu d ie s . T h e ir fin d in g s in d ic a te d t h a t the age of onset

f o r the schizophrenic disorders was usually during adolescence or e a rly

adulthood (p. 1 8 4 ), w ith non-paranoid schizophrenia m anifesting e a r l i e r

than paranoid schizophrenia. The w r it e r s o f D S M -III also stated t h a t the

f i r s t manic episode of b i - p o l a r a f f e c t i v e diso rd er t y p i c a l l y occurred

before age 30 (p . 215 ).

Diagnosis, Social Competence and Age of Onset o f Psychosis

In 1968, G oldstein of UCLA and Held and Cromwell of the V a n d e rb ilt

School o f Medicine sep arately but simultaneously decided to examine the

paranoid versus non-paranoid spectrum of schizophrenia. They then agreed

to c o lla b o ra te on t h is a n a ly s is . They found t h a t the paran oid /non -para­

noid dichotomy did not provide a simple bi-modal d i s t r i b u t io n between

good and poor social competence groups. However, they did f in d w ith in

the poor social competence group, strong rep res en tatio n o f non-paranoid
28

symptomatology (p. 3 8 4 ). The group of good social competence p atie n ts

was then found to be both paranoid and non-paranoid, so t h a t three

groupings were seen to emerge: "Paranoid-Goods," "Non-Paranoid Goods,"

and "Non-Paranoid Poors" (p. 3 8 5 ). There were no "Paranoid-P oors."

For t h is study, G o ld s te in , Held and Cromwell used P a rt I o f the

P h i l l i p s Prognostic Scale (1 9 5 3 ). Because diagnosis was such a contro­

v e r s ia l issue, the in v e s tig a to r s looked beyond the i n i t i a l and past diag­

noses of the p a t ie n t to a r r iv e a t a f i n a l agreed-upon diagnosis (p. 383 ).

A weakness of t h is study was t h a t the authors did not address the demo­

graphic d iffe re n c e s among p a tie n ts in the two s t a t e ho s p ita ls studied in

Los Angeles and N a s h v ille . Among the strengths of t h is study was a change

in analysis from a tw o -d iv is io n to a t h r e e - d iv is io n c a te g o riz a tio n of the

find ings regarding diagnosis.

When Strauss and Carpenter (1972) began to p r e d ic t the outcome of

schizophrenia, they took a d i f f e r e n t approach from t h e i r colleagues by

developing t h e i r own scale which they published in 1974, the Strauss-

Carpenter Prognostic S c a le . They found t h a t in comparing schizophrenic

p a tie n ts w ith non-schizophrenic p a t ie n t s , the non-schizophrenic p a tie n ts

had scores in d ic a tin g no dysfunction by way of lack of employment, length

of h o s p it a l iz a t i o n , and s e v e r ity of symptoms (p. 7 4 2 ). They revealed th a t

schizophrenic p a tie n ts had s i g n i f i c a n t l y lower t o t a l outcome scores i n i t ­

i a l l y , but a f t e r ten years the d iffe r e n c e between schizophrenic and non­

schizophrenic p a tie n ts lessened (p. 7 4 5 ). This fin d in g is a t variance

w ith those of other in v e s t ig a t o r s .

The work of G o ld s te in , Held and Cromwell (1968) on the paranoid/non­

paranoid question e v e n tu a lly e l i c i t e d a response from the Phil 1i p s / Z i g l e r


29

group. In 1971, Sanes and Z i g l e r , and in 1973, Z i g le r and Levine examined

both diagnostic and non-diagnostic fa c to rs in r e la tio n s h ip to social

competence fa c t o r s . They, l i k e the Goldstein group, found t h a t p a tie n ts

with a paranoid diagnosis were more common in the VA hospital in the study,

and r a r e r in the s ta te hospital (p. 193). At the same time they observed

th a t p a tie n ts in the VA hospital had higher social competence scores than

those a t the s ta te h o s p it a l, so t h a t the paranoid diagnosis tended to be

associated w ith g r e a te r social competence. Sarbin and Mancuso (1980)

c r i t i c i z e d t h is f in d in g as evidence of a socioeconomic status bias in the

social e v a lu a tio n of p s y c h ia tr ic p a tie n ts because p a tie n ts in s ta te hos­

p i t a l s were g e n e ra lly of lower socioeconomic background and values. Like

the Goldstein group, in t h e i r p a r a l l e l study, the Z i g l e r group found t h a t

the groups could be categorized as "Poor Non-Paranoids," "Good Paranoids,"

and "Good Non-Paranoids," thus strengthening the v a l i d i t y of both sets of

fin d in g s by r e p l ic a t i o n of r e s u lt s . Once again, there were no "Paranoid-

Poors."

Because the Sanes, Z i g l e r and Levine studies of 1971 and 1973 had the

l i m i t a t i o n o f only having examined males, in 1974, Rodnick and G oldstein

looked a t the groups of "Good Paranoid," "Good Non-Paranoid," and "Poor

Non-Paranoid" p a tie n ts among female p s y c h ia tric p a t ie n t s , using t h e i r

own UCLA Social Attainment Scale (1974, p. 6 2 5 ). They v e r i f i e d the

e a r l i e r re s u lts based on male samples, whereby paranoid symptoms were

found l a r g e ly in p a tie n ts w ith good social competence h i s t o r ie s (p . 6 2 5 ).

The r e p l ic a t i o n of t h is fin d in g also provided a measure of v a l i d i t y fo r

the instruments used by the two groups: the SCS measure used by the

Z i g l e r group, and the UCLA Scale employed by Goldstein and his associates.
30

The UCLA scale was composed o f f iv e of the items of the K le in s '

Scale: (1 ) same-sex peer r e la tio n s h ip s ; (2) leadership in same-sex peer

re la tio n s h ip s ; (3 ) opposite sex r e la tio n s h ip s ; (4 ) dating h is to r y ; and

(5) sexual experience. The UCLA Social Attainment Scale (1974) added

the two items of (6) outside social a c t i v i t i e s ; and (7) p a r t i c i p a t i o n in

o rg an izatio n s. A f i v e - p o i n t L i k e r t scale was used in ra tin g s of these

seven items. The face v a l i d i t y of t h is scale was improved beyond th a t

of e a r l i e r measures of social competence by the in clu sio n of social

in te r a c tio n in the community. The p r e d ic t iv e v a l i d i t y o f t h is scale was

strong on a p re lim in a ry t e s t f o r v a l i d i t y c ite d by Strauss e t a l . (1 9 7 7 ).

Subsequently the Phil 1i p s / Z i g l e r group in v e s tig a te d the question of

diagnostic d iv is io n s among females. Using t h e i r Social Competence Scale

(1 9 6 1 ), Z i g l e r , Levine and Z i g l e r in 1977 undertook a study of 300 female

schizophrenic p a tie n ts diagnosed as paranoid or non-paranoid. Using a

t e s t of analysis of variance between diagnostic groups, Z i g l e r e t a l . i n d i ­

cated t h a t paranoid female p a tie n ts received higher scores fo r social com­

petence than non-paranoid p a tie n ts (p . 3 3 5 ). This e f f e c t was strongest

f o r the f i r s t and second admission. The higher le v e ls of social com­

petence scores reported f o r females in con trast to males emphasized the

necessity of c o n t r o l li n g t h is v a r ia b le (p . 3 3 8 ).

Enlarging h is s c ru tin y of paranoid symptomatology, as r e la te d to

pre-and post-psychotic social competence, and using his own UCLA Social

Attainment Scale ( 1 9 7 4 ), G oldstein (1978) found a s t r i k i n g l i n e a r r e ­

la tio n s h ip between p r e - and p o s t-so cial competence le v e ls on a r a t in g

scale of one to f i v e in a t e s t of 112 subjects (p . 2 3 8 ). This was an

improvement over previous studies which had merely used dichotomous


31

r a tin g s , "good" and "poor." At the lowest lev e l of social adjustment,

there were noticeably fewer cases of c l e a r - c u t paranoid symptomatology

observed. The data then in d ic a te d a gradual s h i f t to d e f i n i t e paranoid

symptomatology w ith increasing social competence (p. 2 3 8 ). At the very

highest le v e ls of social competence, the paranoid symptomatology was much

less p re v a le n t. Upon examination of these sub jects, Goldstein proposed

t h a t they could be s c h iz o - a f f e c t iv e p a tie n ts . This was the f i r s t mention

in t h is l i t e r a t u r e of the p o s s i b i l i t y th a t some of the p a tie n ts in these

studies may be s c h iz o - a f f e c t iv e by diagnosis (p . 2 3 6 ). P r io r to t h is

tim e, t h is diagnostic category was omitted or ignored.

In 1978, the same y e a r in which Goldstein focused on the schizo­

a f f e c t i v e diagnosis, a new group of in v e s tig a to r s , Lewine, Watt and

F ry e r, published a study expanding previous research on a d u lt p a tie n ts by

including childhood social competence in three "schizophrenic" subtypes:

s c h iz o - a f f e c t i v e , paranoid and non-paranoid. This study was c r i t i c i z e d

f o r the in clu sio n of s c h iz o - a f f e c t iv e i l l n e s s as schizophrenic r a th e r

than as an a f f e c t i v e i l l n e s s . In 1978, Lewine e t a l . u t i l i z e d the P h i l l i p s '

SCS index of social competence to p r e d ic t outcome a f t e r psychosis. These

new in v e s tig a to rs found t h a t the s c h iz o - a f f e c t iv e p a tie n ts had the "best"

outcome and non-paranoid schizophrenic p a tie n ts the "worst" outcome

(p. 3 0 0 ). Paranoid p a tie n ts occupied an inte rm ed iate p o s itio n . By con­

t r a s t , female s c h iz o - a f f e c t i v e p a tie n ts had the l e a s t favo rab le outcome.

Lewine e t a l . admitted the need f o r f u r t h e r in v e s tig a tio n of these d i f ­

ferences to exp lain the d i s p a r i t y between the sexes.

As r e fe r r e d to e a r l i e r in the discussion concerning age of onset of

psychosis, c e r t a in average ages of f i r s t admission were c o r r e la te d w ith


32

the three diagnoses under s c ru tin y . Lewine e t a l . found t h a t the average

ages of f i r s t admission fo r non-paranoid schizophrenic, paranoid schizo­

phrenic, and s c h iz o - a f f e c t iv e p a tie n ts were 2 2 .9 , 24.4 and 2 5 .1 , respec­

t i v e l y , thus again spe cifyin g a variance of fa c to rs among the diagnoses

since the d iffe re n c e s reached adequate le v e ls of s ig n ific a n c e . Ages of

onset f o r these th re e diagnoses were corroborated by the d e lin e a tio n s

concerning age reported in D S M -III (1 9 8 0 ).

I t was w ith the ad d itio n of the Goldstein (1978) and Lewine (1978)

studies th a t the theory of social competence among p s y c h ia tr ic p a tie n ts

was broadened in scope to present the r e la tio n s h ip s of fa c to rs in Proposi­

tio n s Two and Four, regarding the association of age and diagnosis with

c e r t a in social competence le v e l s . Lewine e t a l . then undertook a f u r t h e r

study of diagnostic groupings in 1980, with the a d d itio n of a control

group of normal su b jec ts. The lack of normal con trols in e a r l i e r studies

was one o f the major c r itic is m s of Sarbin and Mancuso (1980) of these

studies.

Lewine, Watt, Prentky and F ryer (1980) looked a t childhood social

competence in 59 schizophrenic, 14 psychotic depressive, 28 n e u ro tic , 40

p e rs o n a lity disordered p a tie n ts and 141 normal sub jects. A strength of

t h is study was t h a t the diagnostic c l a s s i f i c a t i o n used was based on the

diagnosis most fre q u e n tly recorded in the hospital c h a rt a t formal e v a lu ­

ations (p. 1 3 4 ). The childhood social competence measures were based

on a d - l i b teachers' comments recorded in school records, spanning k in d e r ­

garten through t w e lf th grade. The r a tin g system consisted of 23 binary

dimensions. The i n t e r r a t e r r e l i a b i l i t y , according to a Spearman rank

c o r r e l a t io n , f o r a random sample of 24 records, had a median of .8 1 .


33

In t h is study, schizophrenic p a tie n ts were found to have s i g n i f i ­

ca n tly lower scores than a l l the other groups mentioned (p . 1 3 5 ). F u rth e r­

more, pre-schizophrenic c h ild re n scored lower on the childhood measure of

social competence than did e i t h e r normals or those c h ild re n eve n tu a lly

h o s p ita liz e d f o r other psychotic disorders (p. 1 36 ). Lewine reported

t h a t the evidence f o r poor interp ersonal s k i l l s among pre-schizophrenics

was e s p e c ia lly s t r ik i n g long before the onset of p s y c h ia tr ic symptoms

(p. 137 ). Lewine also in d ic a te d a weakness in his own fin d in g s , which

i s , t h a t only prospective studies can demonstrate whether childhood social

competence has p r e d ic t iv e v a l i d i t y . He th e re fo re stressed the need fo r

such f u r t h e r stu d ies.

In t h e i r most recent in v e s tig a tio n of what was being measured in

social competence, Z i g l e r and Levine (1981) in d ic a te d t h a t a f u r t h e r

refinement f o r t h e i r m ulti-dim ensional scale f o r social competence would

be to include items t h a t assess social p a r t ic ip a t i o n in frie n d s h ip s and

social a c t i v i t i e s (p. 103 ).

Other researchers noted th a t p a tie n ts with b i - p o l a r a f f e c t i v e d i s ­

orders were often capable o f social in te r a c tio n t h a t was " w ith in normal

l i m i t s , " d es pite a previous psychotic episode. Lewine, W att, Prentky and

Fryer (1980) presented evidence t h a t the capacity to i n t e r a c t a t very

high le v e ls of social exchange was present already in childhood in

p a tie n ts who have a f f e c t i v e disorders. Pope, L i p in s k i , Cohen and Axelrod

(1980) described the recovery of persons with a f f e c t i v e disorders as

"moderately good" or "good." Consensus has been achieved by those

involved w ith t h is area of in q u iry regarding the social s k i l l a b ilitie s

of p a tie n ts with a f f e c t i v e disorders as nearing average le v e l s .


34

Both w ith in the frameworks of the P h i l l i p s , Z i g l e r and Goldstein

groups, as well as outside t h a t framework, inform ation has been ac­

cumulated piece by piece, study by study, in a n a t u r a lly incremental

fashion, as each in te rn a l c r i t i c i s m , omission or a d d itio n a l question

arose, b u ild in g toward the postulates mentioned in Chapter One. The

th e o r e tic a l community-consensus has been achieved slowly over t h i r t y

yea rs, p r im a rily because of disagreements concerning the importance of

diagnosis as a v a r ia b le to be examined or a t l e a s t c o n tr o lle d .

While these studies established the c o r r e la t io n between pre-morbid

and recovered social competence, and also looked a t the c o n trib u tio n of

the in te rv en in g v a ria b le s of age and diagnosis, a weakness of a l l of them

was t h e i r f a i l u r e to examine social p e rs o n a lity t r a i t s in measuring pre-

morbid or recovered social competence. I t was the aim of t h is study to

analyze the degree to which age and diagnosis intervene d i f f e r e n t i a l l y

to e f f e c t s p e c ific social p e rs o n a lity t r a i t s : s o c ia b ility , social p re­

sence and s o c i a l i z a t i o n . By avoiding the outlook of the a lle g e d ly s ta tu s -

focused socioeconomic scale of Z i g l e r and P h i l l i p s , the i n t e n t was to

provide a new focus to the l i t e r a t u r e of social competence in p s y c h ia tr ic

p a tie n ts examining social p e rs o n a lity t r a i t s d i r e c t l y , r a th e r than through

the value-laden scale of Z i g l e r and P h i l l i p s

In summary, the p o s td a te s b a s ic a lly agreed upon by these psycho­

social s c ie n t is t s and t h e o r e t ic ia n s regarding social competence fo llo w in g

psychosis can be presented as follow s:

1. Both d iagnostic and non-diagnostic c r i t e r i a are r e la te d to

social recovery and general prognosis in p s y c h ia tr ic p a t ie n t s .

2. Levels of social competence can be r e la te d to diagnosis by


35

examination of p re- and post-psychotic le v e ls of the three groups of

major diagnostic c a te g o rie s , moving from low to high social competence,

as follow s: (a ) non-paranoid schizophrenia; (b) paranoid schizophrenia;

and (c) b i - p o l a r a f f e c t i v e disorders.

3. Age of onset of psychosis is r e la te d to le v e ls of social com­

petence achieved by p s y c h ia tr ic p a tie n ts both before and a f t e r a psychotic

episode.

4. The three groups o f major diagnostic categories are s p e c i f i c a l l y

associated w ith c e r t a in ages of onset of psychosis:

a. Non-paranoid schizophrenia - adolescence and e a r ly young a d u lt ­

hood ( 2 0 - 2 8 ) .

b. Paranoid schizophrenia - mid-young adulthood ( 2 3 - 2 6 ) .

c. B i- p o la r a f f e c t i v e disorders - l a t e young adulthood ( 2 6 - 3 0 ) .

Expanding on the schematic diagram presented e a r l i e r regarding the

t h e o r e t ic a l propositions and the major hypothesis, the above summary of

the l i t e r a t u r e can be i l l u s t r a t e d again as presented in Figure 1.

This expanded diagram, or e la b o ra tio n model summarizes the t h e o r e t ic a l

propositions and hypotheses as presented in the l i t e r a t u r e by specifying

ages and in d iv id u a l diagnoses which in d ic a te the in t e r a c t io n w ith graded

le v e ls of scores of social s k i l l s in the fo llo w in g manner: (1) l a t e

adolescent and e a rly twenties age of onset o f psychosis and non-paranoid

schizophrenia diagnosis are expected to be associated w ith the lowest

scores of s o c i a b i l i t y , social presence and s o c ia l i z a t i o n f o r p s y c h ia tr ic

p a t ie n t s ; (2 ) m id-tw enties age of onset of psychosis and paranoid schizo­

phrenic diagnosis are expected to be associated w ith moderate scores of

s o c i a b i l i t y , social presence and s o c ia l i z a t i o n f o r p s y c h ia tr ic p a tie n ts ;


36

(3) l a t e twenties age of onset of psychosis and b i - p o la r (manic-depres­

sive) disorders are expected to be associated with the highest scores of

s o c ia b ility , social presence and s o c ia liz a t io n fo r p s y c h ia tric p a tie n ts .

The three path analyses are arranged in three r is in g t i e r s in th is e la b ­

o ra tio n model, in Figure 2, to in d ic a te th a t as the age of onset of psy­

chosis increases along the imaginary "X" a x is , the scores of social s k ills

are expected to in crease, moving toward the r ig h t along the imaginary "Y"

a x is , on th is simulated scattergram i l l u s t r a t i o n .

Age o f Onset
o f Psychosis

Level o f
Social S k i l l s

Diagnosis

Figure 1. Schematic diagram of major t h e o r e t ic a l propositions and


hypothesis.
37

Lat e 20' s Sod abi 1 i t y


jo
Soci al Presence

i - P o l a r Di sor der s Soci a l i z a t i on

AGE
OF Mid-20 ' s
ONSET
s o c i al mesence
OF Paranoi d
Schi zophr eni a
PSYCHOSIS

Lat e Adolescence
E a r l y 20' s
z a
S o c i a l Presence

Soci al i z a t i on

P re -A d ult M a tu rity Averaye


A dult M a tu r ity

SOCIAL DEVELOPMENTAL AXIS

Figure 2: Expanded schematic diagram o f t h e o r e tic a l propositions and


hypothesis.
38

CHAPTER 3

METHODOLOGY

The research problem of t h is study was to t e s t an hypothesis derived

from the research of P h i l l i p s , Z i g l e r , Goldstein and Lewine presented in

the r e la te d l i t e r a t u r e . For the so lu tio n of t h is problem, three groups

of p a tie n ts of three diagnostic groupings were studied according to

the fo llo w in g procedures.

S e lec tio n o f Subjects

The s e le c tio n of the sample consisted o f a purposive sampling of

female p s y c h ia tr ic p a tie n ts of three diagnoses judged to be capable of

p a r t ic ip a t i n g in a r e h a b i l i t a t i o n a c t i v i t y program of a p s y c h ia tr ic

hospital in an o u t e r - c i t y area. A purposive or judgmental sampling is a

n o n -p r o b a b ility -ty p e sampling in which the subjects are selected on the

basis of knowledge of the subdivisions of the pop ulation, the t h e o r e t ic a l

elements to be considered, as well as the nature of the research aims

(Bakkie, 1973, p. 1 0 6 ). In t h i s instance, the th e o r e tic a l and research

framework addressed th re e diagnostic d iv is io n s so t h a t an eq u ally divid ed ,

but non-random, sampling of 30 non-paranoid schizophrenic p a t i e n t s , 30

paranoid schizophrenic p a tie n ts and 30 b i - p o l a r a f fe c tiv e -d is o r d e r e d

p a tie n ts were included. An ongoing or continuous sampling of p a tie n ts

s u f f i c i e n t l y recovered f o r inclusio n in the a c t i v i t y program, and w e l l -

enough r e c o n s titu te d to take a pencil and paper t e s t , made up the sample.

They were te s te d as they entered the program during the one-year data

c o lle c t io n period.
39

The c r i t e r i a f o r admission to the study consisted of gender, age

and diagnosis. The subjects were of female gender, 18 years or o ld e r ,

whose diagnosis was (1 ) non-paranoid schizophrenia; (2) paranoid schizo­

phrenia; or (3) b i - p o l a r a f f e c t i v e disorder. These were the three diag­

noses considered in the theory of social competence.

The admission diagnosis was employed f o r the s e le c tio n of subjects

f o r t e s t in g , and subsequently was compared with the discharge diagnosis.

The discharge diagnosis was considered more accurate, because i t was

based on a g re a te r knowledge of the p a t ie n t a f t e r weeks of observation

and treatm ent. Only those subjects whose admission and discharge diag­

nosis were co n sis ten t were included in the study. This procedure i n ­

creased the v a l i d i t y of the diagnostic c a te g o riz a tio n s .

This study was l im i t e d to the examination of females. Norms given

in the C a li f o r n ia Psychological Inventory Manual by Gough (1957) were

divided by gender f o r males and females. The w r it e r s of psychosocial

theory and l i t e r a t u r e in d ic a te d an expected soc ial-sexu a l d iffe r e n c e be­

tween males and females in the competence of social development ( K e l ly ,

1962; C a t t e l l , 1957; Erikson, 1968; Megargee, 1972; Lips and C o l w i l l ,

1978; Lewine, Watt & F reye r, 1978). A second study, examining males, was

undertaken in which data were c o lle c te d f o r subsequent analysis o f expected

sex ual-so cia l d iffe r e n c e s .

The s ig n ific a n c e le v e l f o r t h is study was set in advance a t .05.

Tw enty-five subjects was considered to be the sm allest number f o r a group

of s u f f i c i e n t s ize to obtain adequate power ratin g s (>41) to provide an

acceptable s ig n ific a n c e le v e l when ( .0 5 ) was used f o r a regression analysis

t e s t (Cohen, 1962, p. 1 5 2 ). Three groups with 25 in each of the three


40

d iagnostic groupings would have met the minimum s t a t i s t i c a l requirements.

However, because 30 subjects would provide a superior d i s t r i b u t i o n , 5

subjects were added to each group, r e s u lt in g in a t o t a l of 90 subjects.

Because the CPI was included in the established assessment program,

i t was not necessary to obtain w r i t t e n consent from the p a t ie n t s , ac­

cording to the p o lic y o f the h o s p it a l's Human Subjects Review Board.

This group gave i t s permission f o r th is research as a non-risk study

(See Appendix A ). I t was explained to the p a tie n ts t h a t p a r t ic ip a t i o n

in the study was anonymous. Assurances of the c o n f i d e n t i a l i t y of the

inform ation c o lle c te d were given, and the p o s s i b i l i t y f o r p a r t ic ip a n ts

to withdraw from the study was explained.

The t e s t was administered as one o f three te s ts in the usual b a tte ry

of p e rs o n a lity and vocational te s ts o ffe re d in a r e h a b i l i t a t i o n a c t i v i t i e s

department. R e h a b ilit a t io n counselors administered and scored the t e s t

on a ro u tin e basis twice weekly. I t was given to a l l p a tie n ts entering

the c e n tra l r e h a b i l i t a t i o n a c t i v i t i e s program when they were considered

by t h e i r r e h a b i l i t a t i o n counselors as ready to move from a unit-based

a c t i v i t y program to the c en tral a c t i v i t i e s program. The r e h a b i l i t a t i o n

counselors decided when t h is change was a p p ro p riate and scheduled the

p a t ie n t f o r the p e r s o n a lity and vocational assessment. The p a t ie n t was

expected to complete t h is te s t in g in the f i r s t few weeks of entry in to

the c e n tra l a c t i v i t y program, but only a f t e r he/she was adequately r e ­

c o n s titu te d , being capable of composed behavior and concentration f o r

reading. As a base l i n e , the le v e ls of recovery f o r the p a tie n ts taking

t h is p e rs o n a lity assessment consisted of those capable of adequate con­

c e n tr a tio n f o r o n e -h a lf hour t e s t in g periods and able to t o l e r a t e the


41

presence o f others in the t e s t in g group. Although these p a tie n ts had

diagnoses of a serious p s y c h ia tr ic nature, i t had been the experience of

the s t a f f over the past twelve years t h a t the population a t t h is o u te r-

c i t y hospital was, in general, able to read and understand psychological

p e rs o n a lity t e s t s , such as the C a li f o r n ia Psychological Inventory ( CPI) .

During the preceding twelve y e a rs , both the C a t t e l l S ix te e n -P e rs o n a lity

Factors and the Edwards' P e rs o n a lity Preference Schedule had been admin-

is te r e d w ith r e s u lts demonstrating t h a t p a tie n ts were capable of taking

these t e s t s . The face v a l i d i t y of the r e s u lts of both these te s ts was

observed by the occupational and r e h a b i l i t a t i o n th e r a p is ts in t h e i r an­

a ly s is of outcome with in d iv id u a l p a t ie n t s . Discussion of t e s t re s u lts

with the p a tie n ts concerning outcome r e f le c t e d s a t i s f a c t io n on the p a rt

o f both p a r tie s regarding t h e i r mutual impressions of the p a t i e n t 's per­

s o n a lity t r a i t s as having v a l i d i t y .

I t was assumed t h a t t h is population of p s y c h ia tr ic p a tie n ts produced

a sample homogeneous in gender, and in socioeconomic le v e l o f e l i g i b i l i t y

f o r pub lic ass istanc e, as well as with a common previous experience of

a p s y c h ia tr ic h o s p i t a l i z a t i o n . This homogeneity was expected to reduce

sampling e r r o r . (Babbie, 1973, p. 94)

Instru m e nta tion: C a li f o r n ia Psychological Inventory

The C a li f o r n ia Psychological Inventory is a m u lti-s c a le inventory

assessing p e r s o n a lity and social in t e r a c t io n scales developed by Harrison

Gough over a span of years s tre tc h in g from 1948 to 1957 co n sis ting of 18

scales and 480 questions. In the Foreward to Megargee's Handbook of the

C a li f o r n ia Psychological Inventory, Gough described the aim of the t e s t


42

as one designed to fo re c a s t what people w i l l say and do in defined con­

t e x t s , and to f o r e t e l l what others w i l l say about them. The inventory

consists of scales composed o f statements Gough c a lls " fo lk concepts",

d e s c r ip tiv e notions concerning behavior and p e rs o n a lity outlook and d is ­

p o s itio n t h a t people tend to use n a t u r a lly in t h e i r d a ily i n te r a c tio n

w ith one another (Megargee, 1972, p. i x ) . Each scale consisted of tru e

and f a ls e questions presented as statements regarding t y p ic a l behavior

p atterns and customary f e e lin g s , opinions and a t t i t u d e s about s o c ia l,

e t h ic a l and fam ily matters (Megargee, p. 5 ) . The fo llo w in g are samples

o f statements included in the In v e n to ry :

1. In most ways the poor man is b e t t e r o f f than the ric h man.

2. I always l i k e to keep my things neat and t id y and in good

order.

3. C leve r, s a rc a s tic people make me fe e l very uncomfortable.

(See Appendix B, Test Booklet)

I t was the in te n tio n of Gough to develop statements t h a t would transcend

s p e c if ic time periods and s o c ie t ie s . T ran s latio n s with adaptations of

these sca les , as w ell as v a lid a t io n studies in a v a r i e t y of c o u n trie s ,

in cludin g c u ltu re s as d isp arate as those w ith European, O rie n ta l and

P a c if i c Is la n d backgrounds tended to confirm the accuracy of these s t a t e ­

ments as " fo lk concepts" t h a t people o f s i m il a r p e rs o n a lity dis p o s itio n s

tend to respond to in s i m il a r ways, despite t h e i r varying c u lt u r a l back­

grounds (Megargee, 1972, p. 4 & 6 , p. 6 5 ) .

Gough was p e r s is t e n t in his e f f o r t s to r e f i n e , c o rre c t and improve

the CP I, by c o lle c t in g p e r t in e n t t e s t r e s u lts from among various c r i t e r i o n

groups, as well as by his responsiveness to c r i t i c i s m of colleagues.


Normative data were a v a ila b le on 31 groups t o t a l i n g 15,294, as of 1972

(Megargee, p. 7 ) .

The three scales used in t h is study are s o c i a b i l i t y , social p re­

sence and s o c i a l i z a t i o n . The s o c i a b i l i t y scale consists of 36 items;

the social presence scale of 53 items and the s o c ia l i z a t i o n scale of 54

items. The s o c i a b i l i t y and social presence scales had 8 questions in

common, w hile the s o c ia l i z a t i o n and social presence scales had only 3

questions in common. The s o c i a b i l i t y and s o c ia l i z a t i o n scales had no

questions in common. Though these three scales have some questions in

common, they are scored independently and do not impinge on each other

in terms of strength of r e s u l t s . In other words, they do not include

forced-choice questions, nor does the response to one scale force the

s u b je c t's r a t in g on o th er scales to r is e or f a l l . These scales may

th e re fo re be described as being independent in scoring, though not in

content.

Rel i abi 1 i ty

Two types of r e l i a b i l i t y te s ts were used to analyze the consistency

of the C P I1s scales, t e s t / r e - t e s t r e l i a b i l i t y and Kuder-Richardson r e l i ­

a b ility (KR formula 2 1 ).

In his Manual, Gough (1975) presented a r e l i a b i l i t y t e s t of the te s t/

r e - t e s t method f o r three samples of subjects: female high school subjects

(n=125), male high school subjects (n=101) and male prisoners (n=200).

The high school subjects took the t e s t in j u n i o r and senior y e a r, one y ea r

a p a rt. Maturation possibly accounted f o r the more modest c o r r e la t io n

c o e f f ic ie n t s among the students, thus confirming the r e l i a b i l i t y o f the


44

CPI. The prisoners were r e - te s te d from 7 to 21 days a f t e r the f i r s t

t e s t in g . T e s t / r e - t e s t c o r r e la tio n s f o r s o c i a b i l i t y , social presence and

s o c ia l i z a t i o n were r e l a t i v e l y high f o r the three groups Gough examined:

high school females, .7 1 , .63 and .6 9 ; high school males, .6 8 , .60 and

.65; and, male priso n ers, .8 4 , .80 and .8 0 , re s p e c tiv e ly (1975, p. 1 9 ).

( In g en eral, high school students scored lower than a d u l t s . ) This con­

sistency of measurement was high enough to perm it use of the scales in

both group and in d iv id u a l t e s t in g (Gough, 1975, p. 1 9 ).

Hase and Goldberg (1971) c it e d t h e i r t e s t / r e - t e s t and Kuder-Richardson

c o r r e la tio n s computed from double a d m in is tra tio n of the CPI to 179 Univer­

s i t y of Oregon freshman women. The re s u lts indicated high Pearson c o rre ­

l a t i o n a l le v e ls w ith the t e s t / r e - t e s t r e l i a b i l i t y method: s o c ia b ility ,

.90; social presence, .89; and, s o c i a l i z a t i o n , .8 8 , as well as with the

Kuder-Richardson r e l i a b i l i t y method (K-R 2 0 ): s o c ia b ility , .80; social

presence, .78; and, s o c i a l i z a t i o n , .78 (Hase & Goldberg, 1965 in Goodstein

& Lanyon, 1971, p. 2 8 9 ).

The su b sta n tial number of items in each of the three scales to be

employed in t h is study also c o n trib u ted to a higher le v e l of r e l i a b i l i t y ,

because one of the methods of increasing r e l i a b i l i t y is to increase the

number of items in a scale ( S e l l t i z , Jahoda, Deutsch & Cook, 1959, p. 182).

Val i d i t y

The Manual f o r the C a li f o r n ia Psychological Invento ry (1975) by Gough

presented the methods of development of the CPI scales and t h e i r inventory

statements. His explanation was developmental and progressive. However,

a more succinct and c l e a r e r presentation was made by Hase and Goldberg


45

(1 9 7 1 ), c o in c id e n ta lly developed, because these authors selected the

CPI as the most re p re s e n ta tiv e instrument f o r te s t in g the v a l i d i t y of

the various methods of general scale development. The four major

s tra te g ie s of t e s t construction analyzed by and with the CPI common

item pool were: (1 ) in te r n a l (fa c to r a n a ly tic ); (2 ) e x t e r n a l / p r a c t i c a l /

em pirical (group d is c r i m i n a t i v e ) ; (3 ) in tu it iv e /c o n c e p t u a l (th e o re tic a l);

and (4) i n t u i t i v e / conceptual (ra tio n a l).

V a l i d i t y as i t app lied to the three s p e c ific scales used as the

measures of social s k i l l development are discussed s e p a ra te ly .

S o c ia b ility . An em pirical group d is c r im in a tiv e strate gy consisting

o f the u t i l i z a t i o n of c r i t e r i o n groups by means of nominations or s e le c ­

t io n by peers or a u t h o r it ie s composed of sample subjects of very high or

very low ratin g s in a given c r i t e r i a is what is r e fe r r e d to as "known

group" v a l i d i t y . These c r i t e r i o n groups were u t i l i z e d in developing the

s o c i a b i l i t y scale. S o c i a b i l i t y inventory statements e l i c i t i n g responses

of a psycho-social nature r e la te d to s o c i a b i l i t y were developed. These

questions were administered to the c r i t e r i o n groups of so ciab le/non­

sociable and s o c ia liz e d /n o n - s o c ia liz e d in d iv id u a ls . Then items were

analyzed to discover which questions t r u l y d elin eated the two extremes in

each c r i t e r i o n group in order to provide in te rn a l v a l i d i t y . Regarding

s o c i a b i l i t y items, Gough comments t h a t some psychologists would a n t ic ip a t e

an aspect of shallowness and s u p e r f i c i a l i t y in any measure of s o c i a b i l i t y ,

but t h a t , to the c o n tra ry , s o c i a b i l i t y seemed to derive from a h ea lth y,

ene rg etic i n t e r e s t in l i f e and from a degree of resourcefulness and con­

fidence s u f f i c i e n t to sustain a high le v e l of interpersonal a c t i v i t y

(Gough, 1968, p. 8 ) .
46

In v a lid a t in g the s o c i a b i l i t y scale, Gough once again u t i l i z e d the

process of the em pirical-group d is c r im in a tiv e or "known group" s tr a te g y ,

described above. In t h is instance, he cont „ e d f i v e high school classes

where the p r in c ip a ls were asked to nominate the "most" and " le a s t" p ar­

t i c i p a t i v e students. The s o c i a b i l i t y scale re s u lts f o r the samples ob­

ta in e d in d ic a te d t h a t among the high school students, s o c ia lly activ e

males had a mean of 25.4 whereas s o c ia lly in a c tiv e males had a mean

of 2 0 .9 6 . S o c ia lly a c tiv e females had a mean of 25.43 w h ile s o c ia lly

in a c t iv e females had a mean of 17.86 (Gough, 1968, p. 2 1 ) . The d i f f e r ­

ences were s t a t i s t i c a l l y s i g n i f i c a n t a t the .01 l e v e l .

Another em pirical method used to examine v a l i d i t y o f in d iv id u a l

items was employed whereby the number of e x t r a - c u r r i c u l a r a c t i v i t i e s t h a t

students engaged in was c a lc u la te d . One hundred selected c r i t e r i a items

were administered to three samples of high school seniors t o t a l i n g 450

subjects, from whose ranks the top and bottom quarters of the class in

terms of p a r t i c i p a t i o n were then extracted to obtain scores i n d ic a t iv e of

a m an ife sta tio n of or lack of t h is t r a i t of s o c i a b i l i t y . T h irty -s ix

items were then selected f o r the present e d itio n o f the scale. V a lid a tio n

studies subsequently administered evidenced the d i s t in c t i o n of t h is scale

in d i f f e r e n t i a t i n g s o c i a b i l i t y t r a i t s from those of other social scales,

thus providing f u r t h e r proof of group d iscrim in an t v a l i d i t y , as mentioned

by Hase and Goldberg (1971) in describing e x t e r n a l/ p r a c t ic a l/ e m p i r ic a l

v a lid ity .

In a study u t i l i z i n g the C P I, Vingoe (1968) employed a sample of 66

freshmen women and found moderately s i g n i f i c a n t c o r r e la t io n s ( . 6 8 ) between

t h e i r s o c i a b i l i t y scores and s e l f - r a t i n g s on another s o c i a b i l i t y scale.


47

Gough's CPI Manual (p. 32) presented standardized scores f o r a l l

scales based on larg e samples. T h e ir means in d ic ated face v a l i d i t y f o r

the r e s u lt s . Among service r e la te d occupations such as policemen (n=88),

dental students (n=251), physicians (n=312), p s y c h ia tr ic residents (n=262),

medical students (n=621), social work students (n=187) and psychology

graduate students (n=572), mean s o c i a b i l i t y scores ranged from 28.0 to

2 6 .3 . Mean s o c i a b i l i t y scores f o r occupations demanding less social

i n t e r a c t i o n , such as machine operators (n=105) and a r c h it e c t s (n=124),

averaged 2 4 .4 , whereas scores f o r prison inmates (n=194), p s y c h ia tric

c l i n i c p a tie n ts (n = 100), high school d i s c i p li n a r y problems (n= 91), and

young delinquents (n=142) were lowest, with averages of 22.8 to 2 1 .2 .

Though these d iffe re n c e s may not appear to be g re a t, i t must be noted

t h a t these were standardized T-scores, not p e r c e n tile s ; thus, a l l scores

had a g re a te r concentration near the mean than in instruments u t i l i z i n g

p e r c e n tile s . In other words, with the C P I, average scores tended to

c l u s t e r w ith in the f i r s t and second standard d e v ia tio n and the deviant

scores tended to be very extreme. Greater weight than usual was also

provided by these scores since the numbers in the samples were so la rg e .

Socia l i z a t io n . The s o c ia l i z a t i o n scale consists of f i f t y - f o u r items

which were o r i g i n a l l y developed by em pirical-group d is c r im in a tiv e s tra te g y .

The d e f i n i t i o n of s o c ia l i z a t i o n as presented by Gough is r e la te d to the

g e n e ra lly accepted s o c io lo g ic a l d e f i n i t i o n of s o c ia l i z a t i o n : the degree

o f m a t u r it y , i n t e g r i t y , r e c t it u d e , prudence and responsiveness to the

o b lig a tio n s of interp ersonal l i f e , as well as to the common needs and

customs o f one's social and work groups. This concept as defined here is

the a n t it h e s is of sociopathy. I t is f o r t h is reason, t h a t in the process


48

o f v a lid a t io n of t h is scale, Gough included studies of sociopaths, to

determine the low range of the scale. Subsequent research in d ic a te d also

t h a t the scale r e f le c te d not j u s t delinquency, but a f u l l range of s o c ia l­

iz a tio n .

The s o c ia l i z a t i o n scale was o r i g i n a l l y constructed by external c r i ­

t e r i a analyses comparing the responses of delinquents and non-delinquents.

Empirical group d is c r im in a tiv e strate g y was employed f o r t h is process of

v a lid a t io n using groups of adolescents con sisting of delinquents and

non-delinquents, Army r e c r u its and stockade prisoners, males and females.

An item pool focused on r o le appropriateness and sociopathy, and the

subsequent empirical item analyses of the control and delinquent groups

showed 64-item s of response groupings with "good d i f f e r e n t i a t i n g power."

I t was noted t h a t not only was there a d iv is io n between delinquents and

non-delinquents, but th a t r e c i d i v i s t s among the delinquents had the most

serious scores (Megargee, 1972, p. 6 0 ) .

The eventual 54-item scale was submitted to c lu s t e r a n a lys is by

S te in , Gough and Sorbin in 1966, w ith the r e s u lt t h a t three major compo­

nents emerged as aspects of th is s ca le, in a breakdown o f sociopathy vs.

s o c ia liz a tio n . I t was found th a t t h is s o c ia l i z a t i o n scale consisted of

three subdivisions: (a ) a s tab le home and fam ily adjustment versus way­

wardness and d i s s a t i s f a c t i o n with fa m ily ; (b) optimism and t r u s t in

others versus dysphoria, d i s t r u s t , a lie n a t io n ; and (c) observance of con­

vention versus asocial d isp o s itio n s and a t t it u d e s (Gough, 1968, p. 1 2 ).

Another method t h a t was used to document the v a l i d i t y of the s o c ia l ­

i z a t i o n scale was to l i s t in rank order a l l of the samples f o r which

s o c ia l i z a t i o n scores were a v a ila b le --m o re than 18,000 sub jects. A


49

continuum o f scores of subjects ranging from high to low was presented by

Gough to demonstrate a concurrent v a lid a t io n of the range o f acceptance of

s o c i a l - r o l e o b lig a tio n s by these su b jec ts, because i t c o n s titu te d a socio­

lo g ic a l continuum, or more s p e c i f i c a l l y a s o c i a l i z a t i o n - a s o c i a l i z a t i o n

continuum of jobs with high social r e s p o n s i b il it y ranging down to groups

o f delinquents and prisoners (Gough, 1975, p. 2 2 ). This s c a le , then, was

able to c l a s s i f y people along a continuum o f s o c ia l i z a t i o n proceeding

from hig h ly s o c ia liz e d and ru le -r e s p e c tin g a t t it u d e s a t one end to highly

asocial and crim inal d isp o s itio n s a t the o th er. Means of s o c ia l i z a t i o n

f o r physicians (n=312), salesmen (n = 85), medical students (n=621), dental

students (n=251), a r c h it e c t s (n=124), bank managers (n=185), psychology

graduate students (n=572), and business executives (n=223) ranged from

41.9 to 3 6 .6 , w hile means of s o c ia l i z a t i o n f o r high school d i s c i p li n a r y

problems (n = 91), young delinquents (n=142) and prison inmates (n=194)

averaged 31.3 to 2 7 .5 . Given the nature of the f in e c a l i b r a t i o n of the

CPI scales, as well as the larg e sample s iz e s , apparently small d i f ­

ferences between high and low groups were both s ta b le and im portant.

Megargee (1972) presented f u r t h e r evidence of d isc rim in a n t v a l i d i t y

developed by Hagan, Mankin, Conway and Fox in 1970, where an incremental

c o r r e la t io n was found between scores on the s o c ia l i z a t i o n scale and a rank

ordering o f (1) fre q u en t marijuana users; (2 ) occasional users; (3 ) non­

users; (4 ) avowed non-users. Megargee (1972) also c ite d Vincent (1961)

who found t h a t unwed mothers had lower scores than single g i r l s who were

never pregnant. Moreover, among unwed mothers, s o c ia l i z a t i o n decreased as

the number of i l l e g i t i m a t e pregnancies increased (Megargee, 1972, p. 6 5 ).


50

F urther evidence of v a l i d i t y was obtained when the scale was admin­

is te r e d to delinquents in 12 fo reig n c o u n trie s . In nations tested up to

1972, s i g n i f i c a n t d iffe re n c e s were found (p . c .0 0 1 ) . Moreover, the mean

raw scores were remarkably s i m il a r from one country to the next (Megargee,

1972, p. 6 2 ).

Construct v a l i d i t y has been manifested by studies in v e s tig a tin g the

f a m i l i a l m ilie u and social background o f co lle g e subjects representing

various points on the s o c ia liz a t io n scale ( H i l l , 1967 Megargee, Parker

and Levine, 1971).

"An impressive array of data have accumulated demonstrating the

concurrent, p r e d ic t iv e and co n struct v a l i d i t y of the CPI s o c ia l i z a t i o n

scale in the United States and elsewhere" (Megargee, 1972, p. 6 5 ).

Social Presence. In c o n tra s t to the two previous scales, which

were b u i l t by the em pirical group d is c r im in a tiv e processes, the social

presence scale was constructed by the r a t io n a l/c o n c e p t u a l/t h e o r e t ic a l

method. This was done by a process of in te rn a l consistency analyses.

E i g h t y - f i v e items were f i r s t i d e n t i f i e d th a t appeared to embody diag­

nostic im p lic a tio n s f o r social poise, v i t a l i t y , spontaneity and w i t .

From these, 56 items were selected as having the highest v a l i d i t y based

on scores in several samples of males and females of no p a r t i c u l a r known

d e s c rip tio n or p e r s o n a lity t r a i t d i s t i n c t i o n . The sh o rter scale was

evaluated a g a in s t external c r i t e r i a .

In one such subsequent t e s t f o r v a l i d i t y , a panel o f psychologists

rated 70 app lican ts o f the U n iv e rs ity of C a l i f o r n i a ' s School of Medicine

f o r evidence of social presence. These ratin g s were c o rre la te d w ith the

ra tin g s from in te rv ie w s and o th e r inte rp ersonal s itu a tio n s in order to


51

s e le c t the most s u ita b le items (Gough, 1968, p. 8 ) .

F urther v e r i f i c a t i o n of t h is scale was in evidence on scores of

social presence f o r 104 high school boys and 102 high school g i r l s in

c o r r e la t io n w ith nominations by p r in c ip a ls in f i v e high schools fo r

students highest and lowest in social presence. For those boys rated

h ig h es t, the average social presence score was 35.5 versus an average of

30.1 f o r those rated lowest. The d iffe r e n c e between the means was s i g n i ­

f i c a n t well beyond the .01 le v e l o f p r o b a b il it y (Gough, 1968, p. 9 ) .

The means f o r the g i r l s were s im ila r : 3 4 . 7 : 3 0 . 1 , in a r a t i o of high to

low. Though the social presence scale was o r i g i n a l l y constructed on a

t h e o r e t ic a l bas is, i t s subsequent v a lid a t io n procedures brought i t in to

the em pirical area. A look a t the means of the CPI's standardized scores

f o r social presence in d ic a te d t h a t research s c i e n t i s t s (n=45) and psy­

chology graduate students (n=572) had the highest averages of 4 1.0 and

41.9 r e s p e c t iv e ly , as might be expected on a scale assessing im agination,

spo ntaneity, and cleverness. Occupations re q u irin g the making of a good

social impression came next with salesmen (n=85) and policemen (n=88)

scoring an average of 3 8 .2 . Young delinquents (n= 142), prison inmates

(n=194) and high school d is c i p li n a r y problems (n=91) were found to have

average means of 34.0 to 3 1 .8 .

S o c ia b ility , social presence and s o c ia l i z a t i o n are defined as of

average le v e l by the CPI i f f a l l i n g in the 40 to 60 range of standardized

scores or T-scores, which is the span of the f i r s t standard d e v ia tio n .

High le v e ls of s o c i a b i l i t y , social presence and s o c i a l i z a t i o n range near

70, and low le v e ls range near 30. This is the range of the second stan­

dard d e v ia tio n .
52

Data C o lle c tio n Procedures

The sampling method consisted of the purposive s e le c tio n of 90

female p s y c h ia tr ic p a t ie n t s , equ ally divided according to the three

d iagnos tic catego ries mentioned above. The C a li f o r n ia Psychological

Inventory was included in an assessment b a tte ry administered con­

s e c u tiv e ly f o r approximately one y e a r , u n t i l the desired number of

subjects was obtained.

The diagnosis was obtained from the p a t i e n t 's c h a rt. These

diagnoses were determined on each of the h o s p it a l 's u n its by a cen tral

diagnostic p s y c h i a t r i s t working in conjunction with a team o f pro­

fe s s io n a ls : the u n i t p s y c h i a t r i s t , psychologists, social workers, occu­

p ational t h e r a p is t s , r e h a b i l i t a t i o n counselors and p s y c h ia tr ic nurses.

The diagnosing p s y c h i a t r i s t a r r iv e d a t his diagnosis by examination of

the p a t i e n t in a d e t a ile d in te r v ie w , and in c o lla b o r a tio n w ith the s t a f f

mentioned, to gather t h e i r impressions and observations. Subsequent

reac tions to medication and ongoing behavioral assessment by the team

were taken in to c o n sid eratio n , if in d ic a te d , to make changes in the pre­

lim in a r y diagnosis. Continuous re -e v a lu a tio n as a ro u tin e process was

summarized in a f i n a l "discharge diagnosis", which was considered to be

as accurate as p o s sib le. The f i n a l s e le c tio n of subjects f o r t h is study

consisted of those w ith a discharge diagnosis in the medical records

c h a rt o f non-paranoid schizophrenia, paranoid schizophrenia and b i - p o l a r

a f f e c t i v e disorders who also had the same diagnosis upon admission.


53

A d m inistration and Scoring o f the CPI

"The CPI is l a r g e ly s e l f - a d m i n i s t e r in g . " (Gough, Manual, 1975,

p. 6 . ) Gough mentions th a t the te s t in g time is usually about 45 to 60

minutes, however, no time l i m i t is imposed. In the a d m in is tra tio n of the

CPI to the 90 female p a t ie n t s , most needed an hour or more to complete

the t e s t . As Gough mentions in the Manual (1975, p. 6 ) :

No rigorous conditions need to be established in order to achieve


v a lid and useful t e s t r e s u lt s . The inventory has been t r i e d under
nearly every conceivable condition - formal te s tin g sessions,
informal sessions, take-home plans, m a il-o u t/m a il-b a c k , and so on.
In so f a r as could be determined from the accuracy of the p r o f i l e s
obtained and from the in d ic a to r s in the t e s t of r e l i a b i l i t y and
d e p e n d a b ility , s a t is f a c t o r y r e s u lts were the ru le under every
co n d itio n . (See Appendix B.!

In order to a s c e rta in the author's opinion of the divided adminis­

t r a t i o n of t h is t e s t to p s y c h ia tr ic p a t ie n t s , he was contacted again by

m a il. As in d ic a te d by his l e t t e r of March 19, 1984 (Appendix B ), he

saw numerous p a tie n ts take the MMPI successfully under such circumstances.

He explained t h a t a t times as many as seven to ten days elapsed during

the course of the a d m in is tr a tio n . Gough believed t h a t re s u lts were v a l i d

despite in te rr u p te d t e s t - t a k i n g sessions.

Gough f u r t h e r recommended th a t the te s ts be scanned to d etect random

answering or faking good or bad. This was done r o u t in e ly . Results from

p a tie n ts whose c u ttin g p o in t scores were unacceptable were excluded.

I t was noted by C a t t e l l in The S c i e n t i f i c Analysis o f P e rs o n ality

(1957, 1967) t h a t in the ad m in is tra tio n of lengthy p e rs o n a lity tests


54

co n sis tin g o f a m u l t i v a r i a t e fa c to r in g o f t r a i t s , more than one s i t t i n g

provided g re a te r r e l i a b i l i t y across moods (1967, p. 2 2 ).

I t would appear t h a t Gough, as a psychologist, a n tic ip a te d some of

the suggestions o f the e d ito rs of A b i l i t y Testing f o r Handicapped People

(1982, p. 9 6 ). Sherman and Robinson recommended t h a t t e s t developers and

users (1) modify te s ts and t e s t a d m in istratio n procedures f o r use with

handicapped people; and (2) con struct and adm inister te s ts so t h a t they

r e f l e c t s k i l l s independent of d i s a b i l i t i e s . Gough's l e t t e r was in d ic a t iv e

o f his b e l i e f t h a t the CPI f u l f i l l s both requirements.

The in ve n to rie s of the p a tie n ts included in t h i s study were scored

by hand using the templates provided f o r each scale.


CHAPTER 4

RESEARCH FINDINGS, INTERPRETATION AND DISCUSSION

This chapter presents the r e s u lts of the s t a t i s t i c a l te s ts of the

data c o lle c te d in t h is study. In itia lly , the fin d in g s are set f o r t h ,

accompanied by t h e i r app ro priate i n t e r p r e t a t i o n . The discussion of

the re s u lts concludes the chapter.

The hypothesis of t h is study states th a t: The diagnoses of

(1) non-paranoid schizophrenia, (2) paranoid schizophrenia, and

(3) b i - p o l a r a f f e c t i v e disorder are p re d ic ta b le through a d iscrim in an t

function equation using age of onset of psychosis and scores of so c i­

a b ility , social presence and s o c i a l i z a t i o n . The study examined 90

sub jects, 30 o f each diagnosis.

A t e s t of d is c rim in a n t a n a ly s is , a type of m u ltip le regression

a n a ly s is , was u t i l i z e d to examine whether the diagnostic groupings f a l l

in to c en tro id c lu s te r s across the axes of age of onset o f psychosis and

the three social competence scale scores.

Basic Assumptions f o r D iscrim inant Analysis

P r io r to an a lys is of the data c o lle c t e d , the seven p r e - r e q u i s i t e

s t ip u la tio n s f o r u t i l i z a t i o n of d iscrim in an t an alysis were reviewed.

This study c l e a r l y met the basic assumptions or mathematical requirements

underlying t h is s t a t i s t i c a l t e s t : the presence o f (1) two or more groups,

(2) each with a t l e a s t 2 cases per group, and (3) no more v a ria b le s than

55
56

the t o t a l number of cases less two (Klecka, 1980, pp. 8 - 1 1 ) . A fourth

assumption t h a t the d is c rim in a tin g v a ria b le s must be measured by in te rv a l

or r a t i o scales was also met: age of onset of psychosis is a r a t i o scale,

and the standardized scores ( t- s c o r e s ) o f the C a l i f o r n i a Psychological

Inventory (C P I) c o n s tit u te an in te r v a l scale.

The three l a s t mathematical assumptions were met by the proofs

of the s t a t i s t i c a l a n a ly s is . According to the f i f t h assumption, no two

d is c rim in a tin g v a ria b le s could be in l i n e a r combination w ith other d i s ­

c rim in a tin g v a ria b le s (Klecka, 1980, p. 1 1 ). The highest c o r r e la t io n

among the d is c rim in a tin g v a ria b le s in t h is study was between s o c i a b i l i t y

and social presence, a t .615 according to the pooled w ithin-groups c o r­

r e l a t i o n m a trix , a moderate-level c o r r e l a t io n . Other c o r r e la tio n s are

presented below.

Table 1

Pooled C o rre la tio n M atrix w ith in Groups

Social S k i l l s Onset S o c ia b il it y Social Presence

Soci abi 1 i ty -0.07817

Social Presence -0.02755 0.61586

S o c ia liz a t io n 0.10661 0.02757 0.17331


57

A s ix th assumption states t h a t the covariance matrices f o r each

group must be approximately equal (Klecka, 1980, p. 1 1 ). As can be

seen in the t a b le in Appendix C, the log determinants of the group

covariance matrices were highly s i m il a r , and t h e i r ranks were equal.

A seventh mathematical requirement is t h a t the groups must be

m utually ex c lu s iv e . No one subject in any diagnostic grouping was found

in another diagnostic grouping, because a l l questionable diagnostic cases

were dropped from the study.

The f i n a l basic s t a t i s t i c a l requirement is t h a t each group must be

drawn from a population w ith a m u l t i v a r i a t e normal d i s t r i b u t io n of the

d is c rim in a tin g v a ria b le s (Klecka, 1980, p. 1 1 ). The histograms of the

four v a r ia b le s showed a r e l a t i v e l y normal d i s t r i b u t i o n f o r s o c i a b i l i t y

and social presence, with almost no skewedness, w h ile age of onset of

psychosis manifested a somewhat skewed d i s t r i b u t io n curve, and s o c ia l ­

iz a t i o n a s l i g h t l y skewed curve. The histograms given in Appendix C

were included to i l l u s t r a t e the d is t r ib u t io n s f o r each of the four d i s ­

crim in an t f a c t o r s . Although m u l t i v a r i a t e norm ality im plies u n iv a r ia t e

n o rm a lity , the reverse is not necessarily tr u e . Nevertheless, t h is was

a minimal check on the t e n a b i l i t y of t h is assumption.

Because d iscrim in an t a n a lys is is a r a th e r robust technique which

can t o l e r a t e some d e v ia tio n from the basic assumptions (Klecka, 1980,

p. 6 1 ) , i t was decided th a t the p re s c rip tio n s f o r the t e s t had been

adequately met, and the s t a t i s t i c a l c a lc u la tio n s could proceed.


58

Test o f the Hypothesis

The sub sidiary sections of the hypothesis of t h is study stated

the expectation th a t:

a. The non-paranoid schizophrenic group o f p a tie n ts was expected

to be associated w ith e a r ly age of onset of psychosis and the lowest

scores among the social v a r ia b le s ,

b. The paranoid schizophrenic group of p a tie n ts was expected to

be associated w ith average age of onset of psychosis and average scores

among the social v a r ia b le s ,

c. The b i - p o l a r a f f e c t i v e group of p a tie n ts was expected to be

associated w ith the l a t e s t age o f onset of psychosis and highest scores

among the social v a r ia b le s .

Before examining the in te r a c tio n of the four v a r ia b le s and the

diagnoses, measures of c e n tra l tendency were examined. The histograms

in Appendix C have already been mentioned. Means, standard d ev ia tio n s ,

modes, medians, skewedness, F-scores and s ig n ific a n c e le v e ls are pre­

sented in Table 2. A t e s t of the analysis of variance of the means of

the th ree groups across the four v a ria b le s showed a strong d iffe r e n c e

among the means of the three groups f o r s o c i a b i l i t y and social presence

a t highly s i g n i f i c a n t l e v e l s , .002 and .0213, r e s p e c t iv e ly ; whereas, the

means of the group scores f o r age of onset of psychosis and s o c ia liz a t io n

were more s i m i l a r , as is in d ic ated in Table 2.


59

Table 2

Measures of Central Tendency f o r Four D iscrim inant Variables

Means, Standard D e v ia tio n s , Modes, Medians, Skewedness,


F-Scores and S ig n ific a n c e Levels

V a riab les M SD Mode Medi an Skewedness F

Age of Onset
of Psychosis 22.7 5.9 21.0 21.7 2.007 1.636 0.2008

S o c ia b ility 42.0 12.3 34.0 43.0 0.039 6.400 0.0020

Social Presence 40.3 11.1 39.0 39.3 0.075 4.025 0.0213

S o c ia liz a t io n 34.6 9.4 43.0 34.5 0.149 2.154 0.1222

A strong in d ic a t o r of a r e l a t i v e l y normal d i s t r i b u t io n of the scores

of the fo u r d isc rim in a n t v a ria b le s was the s i m i l a r i t y of the means and

medians, as shown in Table 2.

The standard d ev iatio n of the three diagnostic groups across the

social s k i l l v a ria b le s was in the range of the SD o f the C a li f o r n ia

Psychological In v e n to r y , which is 10 in standardized scores. The CPI

had an SD of 10 and a mean of 50, and the standard dev iatio n s of t h is

study showed SD r e s u lt s f o r each of the three social s k i l l v a ria b le s

hovering around 10: s o c i a b i l i t y = 1 2 .3 ; social presence = 1 1 .1 ; and

s o c ia l i z a t i o n = 9 . 4 . The means f o r s o c i a b i l i t y (4 2 .0 ) and social

presence (4 0 .3 ) were a t the low range of the f i r s t standard d e v ia tio n


60

of the CP I. The mean fo r s o c ia l i z a t i o n (3 4 .6 ) was a t the low range

of the second standard dev iatio n (See Table 2 ) , in d ic a tin g t h a t the

group as a whole bordered on the frin g e s of extreme scores in the area

o f s o c ia l i z a t i o n .

With one exception, the re s u lts of the p redictio ns o f the hypo­

th e s is were as expected across the data gathered. Across age of onset

o f psychosis, s o c i a b i l i t y and social presence, there was an increment

from lowest means, to moderate, to highest among the non-paranoid

schizophrenic cases, paranoid schizophrenic cases, and b i - p o l a r a f ­

f e c t iv e cases, r e s p e c tiv e ly (See Table 2 ) . Age of onset of psychosis

scores rose from 2 1 .4 6 , to 22.60 to 2 4.20, f o r non-paranoid schizo­

phrenic, paranoid schizophrenic, and b i - p o la r a f f e c t i v e disorder

p a t ie n t s , r e s p e c t iv e ly , moving in the expected d ir e c t io n . Likewise,

s o c i a b i l i t y scores increased from 3 7 .5 0 , to 40.53 to 4 7 .9 6 , fo r these

three d iagnos tic groupings in the order mentioned p re v io u s ly , again

progressing in the expected d ir e c t io n . In a d d itio n , social presence

scores ascend from 3 6 .9 6 , to 39.36 to 4 4 .7 0 , f o r the th ree diagnosic

groupings in the order c ite d above, moving upward in the expected

d i r e c t io n . Only the s o c ia l i z a t i o n scores deviated from t h is p a tte r n .

In the area of s o c i a l i z a t i o n , the paranoid schizophrenic group ranked

low est, followed by the non-paranoid schizophrenic group. The b i - p o l a r

a f f e c t i v e group achieved the highest average of scores in s o c i a l i z a t i o n .

These fin d in g s are presented in Table 3.


61

Table 3

Means o f Diagnostic Groups f o r Age of Onset and Social S k i l l V ariables

Age of Onset Social


Diagnostic Groups of Psychosis S o c ia b ility Presence S o c ia liz a t io n

Non-Paranoi d
Schizophrenic 21.46 37.50 36.96 34.33

Paranoid
Schizophrenic 22.60 40.53 39.36 32.30

B i-P o la r
A f f e c t iv e 24.20 47.96 44.70 37.26

= .2008 = .0020 = .0213 = .1222

Examination of the means o f the fo u r v a r ia b le s in d ic ated t h a t , in

a l l areas except one, the trend p red icted by the hypothesis was as ex­

pected across the standardized scores f o r the th ree diagnostic groupings.

The mean of the s o c ia l i z a t i o n scores fo r the paranoid schizophrenic group

fe ll below t h a t of the non-paranoid group, with a r e s u l t t h a t was not in

keeping w ith the expected progression of low to moderate to high re s u lts

f o r non-paranoid schizophrenic, paranoid schizophrenic, and b i - p o la r

a f f e c t i v e disorder groupings, r e s p e c tiv e ly . On the basis of these t e s t

r e s u lt s whereby the means of the th re e diagnostic groupings f e l l in to the

pro jected p o s itio n s r e l a t i v e to each other across the four v a r ia b le s , the

hypothesis o f th is study can be accepted, except in the instance of the

s o c i a l i z a t i o n score among paranoid schizophrenic p a t ie n t s .


62

The strength of the general trend o f social v a r ia b le scores occurring

in the expected d ir e c t io n was then tested by the process of d iscrim inan t

function a n a ly s is .

D iscrim inant Function Analysis

D iscrim inant functio n analysis consists of two major s t a t i s t i c a l

a c tiv itie s : (1) a n a ly s is , i n t e r p r e t a t i o n or separation and (2) c l a s s i ­

f i c a t i o n (Klecka, 1980, p. 8; SPSS, 1975, p. 435 and Huberty, 1984,

p. 156 ). The s t a t i s t i c a l re s u lts in Table 4 were based on the f i r s t

discrim in an t a n a ly s is , c a r r ie d out by the " d ir e c t method" of computation.

These canonical d isc rim in a n t function scores were developed through the

analysis or i n t e r p r e t a t i o n a c t i v i t i e s of a d iscrim in an t a n a ly s is .

Table 4

Canonical Discrim inant Functions f o r the In t e r a c t io n of


Age of Onset of Psychosis and Three Social S k i l l s

Eigen % of Cumula- Canonical W ilks' C h i- S ig n ifi-


Function Value Variance t i v e % C o rre la tio n Lambda Squared DF cance

1 .20451 89.18 89.18 .412 .810 18.006 8 p = .0212

2 .02482 10.82 100.00 .155 .975 2.096 3 p = .5526

Only the f i r s t d is c rim in a n t function was of use in d i f f e r e n t i a t i n g between

groups. T herefore, a l l f u r t h e r references to i n te r p r e ta t io n s of stan­

dardized d is c rim in a n t function c o e f f ic ie n t s r e f e r to data from Function 1,

as given above.
63

In u t i l i z i n g the d i r e c t method, a l l the independent v a r ia b le s ,

age o f onset of psychosis, as well as s o c i a b i l i t y , social presence and

s o c i a l i z a t i o n were entered in to the an alysis c o n cu rren tly. The discrim ­

in a n t functions were created d i r e c t l y from the e n t i r e set of independent

v a r ia b le s , regardless of the d is c rim in a tin g power of each v a r ia b le ( SPSS,

1975, p. 4 4 6 ). Age of onset o f psychosis and s o c ia l i z a t i o n had less

meaningful le v e ls of s ig n ific a n c e in the a n a lys is of variance of d i f f e r ­

ences between means, as well as some degree of skewedness in the curve of

t h e i r d i s t r i b u t io n s f o r the three diagnostic groupings; however, a l l four

v a r ia b le s passed the tole ra nce t e s t f o r employment of the d i r e c t method,

and were, th e r e f o r e , entered in the a n a lys is (See Table 2 ) . In the

f i r s t anaysis or i n t e r p r e t a t i o n , the focus was on the f i r s t d iscrim in an t

functio n or axis which separated the groups as much as possible (See

Table 4 ) . The maximum number of d isc rim in a n t functions which t h is study

can y i e l d is 2, or one less than the number of groups ( SPSS, 1975,

p. 4 4 2 ). With two d isc rim in a n t fu n c tio n s , two eigenvalue scores are pro­

duced. The Eigenvalue of function one, .20451, was approximately 10 times

l a r g e r than t h a t o f function two, .02482. Thus the f i r s t function had a

much la r g e r magnitude and percentage of the t o t a l d is c rim in a tin g power

(See Table 4 ) . The second function had such a small proportion of the

to ta l d is c r im in a tin g power t h a t i t was u n lik e ly to c o n tr ib u te to an under­

standing o f group d iffe r e n c e s , and lacked research u t i l i t y (Klecka, 1980,

p. 3 6 ) . The canonical c o r r e l a t io n , .412, in d ic a te d t h a t the association

of the f i r s t d is c rim in a n t functio n to the three groups was a moderate

one (SPSS, 1975, pp. 440 & 4 4 2 ).

The Lambda value of the f i r s t d iscrim in an t fu n c tio n , .8 1 0 , was


64

associated w ith a Chi-Square t e s t with corresponding le v e ls of s i g n i ­

fica n ce in d ic a te d . A f t e r the Lambda o f .810 was converted to a Chi-Square

(x ) o f 18.006, i t was found, on a ta b le of C r i t i c a l Values of C h i-

Square, to be outside the r e je c t io n region of 15.51 a t a s ig n ific a n c e

le v e l o f .0212 (Klecka, 1980, pp. 3 8 -4 1 ). The Lambda value of the second

d iscrim in an t fu n c tio n , .975, was so large t h a t i t was s t a t i s t i c a l l y use­

le s s , thus f u r t h e r v e r i f y in g the decision to e lim in a te the second d is ­

crim inan t fu n c tio n .

On the basis of t h is p a rt of the d iscrim in an t a n a ly s is , the i n t e r ­

p r e t a t io n , an alysis or separation fu n c tio n , the hypothesis of d i f f e r ­

e n t i a t i o n of means of groups was accepted a t the r e l a t i v e l y high C h i-


2
Squared (x ) r e s u l t of 18.006 , with a s ig n ific a n c e le v e l of .0212

(See Table 4 ) .

The second a c t i v i t y o f d iscrim in an t a n a ly s is , the process of c l a s s i ­

f i c a t i o n , was then undertaken to i d e n t i f y the l i k e l y group membership of

each of the 90 diagnostic cases ( SPSS, 1975, p. 4 4 5 ). This process was

u t i l i z e d to make a decision f o r each s p e c if ic case as to the p a r t i c u l a r

group the case "belonged to" or "most clo sely resembled." C l a s s if ic a t i o n

w ith in the d ir e c t method was based on a l i n e a r combination of the discrim ­

in a tin g v a r ia b le s , which thus maximized group d iffe re n c e s w h ile minimizing

v a r i a t io n w ith in the groups (K lecka, 1980, p. 4 3 ) . In t h is study, age of

onset o f psychosis, s o c i a b i l i t y , social presence and s o c ia l i z a t i o n were

examined in conjunction, by the d ir e c t method to measure the "distance"

between each case and i t s "group c e n tr o id ," w ith each case being

c l a s s i f i e d in to the "closest" group. The re s u lts of the c l a s s i f i c a t i o n

process are presented in Table 5.


65

Table 5 i l l u s t r a t e s th a t the m a jo rity of cases were located in the

expected category. These data in d ic a te t h a t the in t e r a c t i o n of the four

v a r ia b le s of age of onset o f psychosis, s o c i a b i l i t y , social presence and

s o c ia l i z a t i o n provides more r e l i a b l e c r i t e r i a than chance alone, in t h is

case, .3 3 , f o r placement of cases in c o r r e c t diagnostic groupings. The

highest le v e l of p r e d i c t a b i l i t y , .6 0 , occurred in Group 3, among b i - p o la r

a f f e c t i v e cases. Group 1, the non-paranoid schizophrenic group, had a .50

chance of c o rre c t c l a s s i f i c a t i o n . The paranoid schizophrenic group cases

had a heavier d i s t r i b u t io n in Group 3, than in Group 1, thus tending to be

lo cated higher than expected, a t a r a te of 36.7% f o r t h is study.

Table 5

C l a s s i f i c a t i o n of Actual and Predicted Hypothesized Diagnostic Groupings

Predicted Group Membership

Actual Number
Diagnostic Group of Cases Group 1 Group 2 Group 3

Group 1:
Non-Paranoi d 15 7 8
Schizophrenic Cases 30 50.0% 23.3% 26.7%

Group 2:
Paranoid 6 13 11
Schizophrenic Cases 30 20.0% 43.3% 36.7%

Group 3:
B i- P o la r 7 5 18
A f f e c t iv e Cases 30 23.3% 16.7% 60.0%

P r io r p r o b a b il it y f o r each group = 33%.


Percent of "grouped" cases c o r r e c tly c l a s s i f i e d = 51.11%.
66

Three other methods of d isc rim in a n t c l a s s i f i c a t i o n analysis using

step-wise s e le c tio n procedures were also employed: (1 ) W ilks' sm allest

Lambda, e q u iv a le n t to the la r g e s t o v e ra ll m u l t i v a r i a t e F; (2) la r g e s t

Mahalanobis distance between two groups, fo r the two c lo ses t groups on

the v a r ia b le ; (3 ) maximum/minimum F, f o r the l a r g e s t pairw ise m u l t i ­

v a r i a t e F f o r the two groups w ith the sm alle st F on t h a t v a r ia b le ( SPSS,

1975, p. 4 5 3 ). A ll three of these procedures reduced the number of v a r i ­

ables from four to three in the process of step-wise s e le c tio n . This

was done on the supposition t h a t a la r g e set of independent varia b le s

contains excess inform ation ( SPSS, 1975, p. 4 4 7 ). In a l l three step-wise

procedures employed in t h is study, social presence was dropped as being

"redund ant.11 I t w i l l be remembered t h a t social presence c o r r e la te d with

s o c i a b i l i t y a t a le v e l of r = .615. These processes were based on the

assumption t h a t c e r t a in v a r ia b le s are not as valu ab le or necessary as

others in the d is c rim in a tio n o f groupings (Klecka, 1980, p. 5 2 ) . In t h is

instance, the v a r ia b le of social presence did not share the same d iscrim ­

in a t in g info rm ation as s o c i a b i l i t y , because in a l l three step-wise c l a s s i ­

f i c a t i o n s , the percent of "grouped" cases c o r r e c tly c l a s s i f i e d w ith three

v a ria b le s was 46.67%. This step-w ise combination of three v a ria b le s can

be compared to the d i r e c t method w ith four v a r ia b le s , includin g social

presence, w ith in which 51.11% o f the cases were c o r r e c tly c l a s s i f i e d .

A ll the above procedures were repeated w ith a varimax r o t a tio n

of the d is c rim in a n t functions to determine whether an improved le v e l

o f p r e d i c t a b i l i t y f o r hypothesized groupings would emerge. However,

t h is did not occur. No d iffe re n c e s were observable in the r e s u ltin g

s ta tis tic s .
67

In view of the f a c t t h a t the v a r ia b le s o c i a l i z a t i o n was the only

one whose group means were not in the expected order (Table 3 ) , a question

arose concerning the p o s s i b i l i t y of obtaining a stronger p re d ic ta b le

combination by o m ittin g t h a t v a r ia b le . Subsequent d iscrim in an t analyses

were then repeated, givin g canonical i n t e r p r e t a t i o n s , as well as c l a s s i f i ­

c a tio n s , f o r the remaining three v a ria b le s of age of onset o f psychosis,

s o c i a b i l i t y and social presence. The percentage of group cases accurately

c l a s s i f i e d dropped to 44.44% when u t i l i z i n g only these three v a r ia b le s .

S i m i l a r l y , a r e p e t i t i o n o f d isc rim in a n t analyses procedures was

again conducted, t h is time dropping the v a r ia b le of age of onset of

psychosis on the basis o f i t s somewhat skewed d i s t r i b u t i o n curve. Here

again, the percent of group cases c o r r e c tly c l a s s i f i e d was lower than

w ith a l l fo u r v a r ia b le s : 46.67% with three v a r ia b le s , as contrasted with

51.11% w ith four v a r ia b le s .

F i n a l l y , s o c i a b i l i t y and social presence were c l a s s i f i e d to g eth er,

separated from the other two v a r ia b le s , because t h e i r averages had reached

the highest le v e l o f s ig n ific a n c e . The percent of group cases c o r r e c tly

c l a s s i f i e d then dropped to 43.33%.

C l a s s i f i c a t i o n procedures were also i l l u s t r a t e d by the use of s c a tt e r -

p lo ts in which a l l cases from Groups 1, 2 , and 3 were located a t the

mathematical in te r s e c t io n of values derived from the four d iscrim inan t

v a r ia b le s , which had been analyzed by means of Canonical D iscrim inant

Function 1 on the x a x is , and Canonical D iscrim inant Function 2 on

the y a x is . Group centroids were in d ic ated by a s te ris k s f o r each o f

the three d iagnos tic groups (Group 1, non-paranoid schizophrenic group;

Group 2, paranoid schizophrenic group; and Group 3, b i - p o l a r a f f e c t i v e


68

group), lo c a tin g the mean d iscrim inan t scores f o r each group. As can

be seen by the i l l u s t r a t i o n in Appendix C, there was considerable

overlap among these three groups. They were not w idely separated even

though the d is c rim in a n t analysis is s t a t i s t i c a l l y s i g n i f i c a n t .

Tests of Additional Data

Although the t h e o r is t s of social competence focused on age of onset

of psychosis, data were also gathered to examine cu rren t age o f the psy­

c h i a t r i c p a t ie n t s . An examination of the cu rre n t age of the 90 female

subjects, across the three diagnostic groups, was employed also u t i l i z i n g

a d iscrim in an t a n a ly s is . This in te r a c tio n resu lted in 46.6% o f the group

cases being c o r r e c t l y c l a s s i f i e d . When age of onset of psychosis and

cu rre n t age were analyzed together with the three social s k ill v a r ia b le s ,

the combination of 5 v a r ia b le s raised the le v e l o f c l a s s i f i c a t i o n of cases

to 51.11%. The r e s u l t of the Chi-Squared t e s t f o r the simultaneous sub­

mission o f the f i v e v a ria b le s to analysis was high, 2 7 .5 , w ith a s i g n i ­

ficance le v e l of .0021.

Summary o f Results

Using a d isc rim in a n t a n a ly s is , a s in g le hypothesis, with three sub­

d iv is io n s was tested in t h i s study. The expectations posited were sup­

ported, with one p a r t i a l exception. B i- p o la r a f f e c t i v e subjects had

highest scores f o r average ages of onset of psychosis and highest scores

of s o c i a b i l i t y , social presence and s o c i a l i z a t i o n . Paranoid schizophrenic

subjects had mid-range averages of age of onset of psychosis, and mid­

le v e l scores of s o c i a b i l i t y , and social presence, as expected. However,


69

the average of t h e i r s o c ia l i z a t i o n scores was below t h a t of the non­

paranoid schizophrenic p a tie n ts . Non-paranoid schizophrenic subjects

had the lowest average ages of onset o f psychosis and lowest scores of

s o c i a b i l i t y and social presence. T h e ir average score f o r s o c ia l i z a t i o n

was lower than t h a t of the b i - p o l a r group, but higher than t h a t of the

paranoid schizophrenic group. The simultaneous an alysis of the four

d is c rim in a n t v a r ia b le s of age of onset of psychosis, s o c i a b i l i t y , social

presence and s o c i a l i z a t i o n in te ra c te d j o i n t l y increasing the c o r r e la t io n

to a moderate le v e l (.4 1 2 ) f o r the three diagnostic groups. The d i f f e r ­

ences among the means of the three diagnostic groups was s i g n i f i c a n t ,

according to the Chi-Squared t e s t , e s p e c ia lly f o r s o c i a b i l i t y and social

presence, as in d ic a te d by t h e i r F d i s t r i b u t i o n s . The strongest discrim ­

in an t an alysis occurred in the combination of a l l fo u r v a r ia b le s of age

o f onset of psychosis, s o c i a b i l i t y , social presence and s o c ia l i z a t i o n .

The hypothesis stated t h a t the three diagnoses would be p re d ic ta b le

through a d is c rim in a n t functio n equation using age of onset of psychosis.

I t was found t h a t , o v e r a l l , th ere was a 51.11% chance of c o r r e c tly c l a s s i ­

fy in g cases by diagnoses by examining the age of onset of psychosis in con­

ju n c tio n with the th ree social s k i l l s of s o c i a b i l i t y , social presence and

s o c ia liz a tio n . Although three other combinations of v a ria b le s and four

other methods of c a lc u la t io n of d is c rim in a n t a n a ly s is , the combination of

the fo u r v a r ia b le s simultaneously entered, as p re d ic te d , along w ith the

d i r e c t method of c a lc u la t io n of d is c rim in a n t a n a ly s is , y ie ld e d the highest

percentage of cases c o r r e c tly c l a s s i f i e d in to d iagnostic groupings.

Although 51% i s a moderate l e v e l , i t is considerably higher than the

p r i o r p r o b a b il it y f o r cases occurring in each group by chance, .333.


70

The re s u lts of t h is study in d ic a te d t h a t a moderate ass ociation ex­

is te d between c e r ta in le v e ls of social s k i l l competence and each s p e c if ic

diagnosis. The s c a t t e r p lo t r e f e r r e d to in Appendix C i l l u s t r a t e d the

re s u lts of the d iscrim in an t analyses, as i t was u t i l i z e d to in d ic a te the

proportions of separation and i n t e r a c t i o n of each diagnostic group. This

was f u r th e r demonstrated by a r e -c o n c e p tu a liz a tio n of the s c a t t e r p lo t

which would in d ic a te the degree of overlap of each group. The fo llo w in g

Venn diagram s im p lif ie d and summarized the exten t to which each group was

d i s t i n c t from the other two in i t s le v e l of social s k i l l s on the CPI.

(XI

c
o
• r—
+2
u
c: Non-
3
U-
Paranoid
C +1
CO
c Polar
*r—
£
o 0
l/>

-1
f o
o Paranoid
c
o
c:
ro
O
-2 -1 0 +1 +2

Canonical D iscrim in a n t Function 1

Figure 3: Venn diagram o f the in t e r a c t i o n of the three diagnostic


groupings i l l u s t r a t i n g the d is c rim in a n t an alysis of diagnosis, social
s k i l l s and ages of onset of psychosis.
71

This diagram c l a r i f i e d the degree to which the s t a t i s t i c a l analysis cor­

r e c t l y c l a s s i f i e d the cases by examining each i n d iv id u a l's age of onset

o f psychosis and scores of s o c i a b i l i t y , social presence and s o c ia l i z a t i o n .

The scattergram i l l u s t r a t i o n of the analysis in d ic a te d a 51% p r o b a b ilit y

o f p re d ic tio n o f cases, given the data of age of onset of psychosis and

le v e l of social s k i l l s . F o rty -n in e percent of the cases among the three

groups could be " c o r r e c tly c l a s s i f ie d " by the r e s u lts of these data, and

were i l l u s t r a t e d by the portio n of the c i r c le s not overlapping one another.

The paranoid group f e l l somewhat below the h o rizo n ta l axis due to i t s

scores in s o c i a l i z a t i o n .

There were two s t a t i s t i c a l re s u lts occurring in these data in d ic a tin g

t h a t the hypothesis could be accepted. The d isc rim in a n t an alysis was set

up to use the two functions of separation of groups and c l a s s i f i c a t i o n of

groups to examine d iffe re n c e s among groups. The d i f f e r e n t i a t i o n of means

o f groups in d ic a te d a high Chi-Squared r e s u l t of 18.006 , w ith a s i g n i f i ­

cance le v e l of .0212 (See Table 4 ) , and the c l a s s i f i c a t i o n o f in d iv id u a ls

in to c o r r e c t diagnostic groups rose to a moderate le v e l of .51 above a

p r o b a b il it y le v e l of .33 (See Table 5 ) . Examining Table 5 from another

p ersp ective , i t can be noted th a t the la r g e s t group of non-paranoid

schizophrenic p a tie n ts f e l l in to the predicted hypoth etical Group 1 (50%),

where they were expected to be found, with sm aller numbers f a l l i n g in to

hypoth etical Groups 2 and 3. The la r g e s t group of paranoid schizophrenic

p a tie n ts f e l l in to the p re d ic te d , hypothetical Group 2 (43.3% ), where

they were expected to be found, with sm aller numbers f a l l i n g in to hypo­

t h e t ic a l Groups 1 and 3. F i n a l l y , the la r g e s t group of b i - p o l a r a f f e c t i v e

p a tie n ts f e l l in to the p re d ic te d , hypothetical Group 3 (60.0% ), where they


72

were expected to be found w ith sm aller numbers f a l l i n g in to hypothetical

Groups 1 and 2.

Table 3 shows t h a t there was a t e n -p o in t span between non-paranoid

schizophrenic p a t ie n t s , the group expected to be low est, and b i - p o la r

a f f e c t i v e disordered p a t ie n t s , the group expected to be highest in social

s k i l l s scores. This span was eq u iv a le n t to one standard d ev iatio n on the

C P I. The le v e l of s ig n ific a n c e f o r s o c i a b i l i t y was the highest among the

th ree concepts, .002. Social presence has an 8 -p o in t span between the

lowest and highest scores, between non-paranoid schizophrenic p a tie n ts and

b i - p o l a r a f f e c t i v e disordered p a t ie n t s , r e s p e c t iv e ly , as expected. This

was almost as wide a range as the 1 0 -p o in t standard d e v ia tio n of the CPI.

In t h is instance, the p r o b a b il it y le v e l was also strong, .021. F in a lly ,

s o c ia l i z a t i o n showed the l e a s t d iffe r e n c e among the means o f the three

diagnostic groups, w ith only a 3 -p o in t span between the expected lowest

and highest group. In a d d itio n , the expected trend of the hypothesis

did not occur f o r t h is t r a i t as the paranoid schizophrenic group had the

lowest scores.

Across a l l three t r a i t s , the non-paranoid schizophrenic group o f

p a tie n ts averaged 15 points lower than average, or about 1 and 1/2 stan­

dard d ev ia tio n s below average norms. The range of the b i - p o l a r a f f e c t i v e

group was near the average f o r s o c i a b i l i t y and social presence, w ith in

the f i r s t standard d e v ia tio n below the average norm. A ll three diagnostic

groups f e l l in to the second standard d e v ia tio n on s o c i a l i z a t i o n scores.

In the te s t s of a d d itio n a l data, in which c u rre n t age of the female

p s y c h ia tr ic subjects was included along w ith the age of onset of psy­

chosis and the three social s k i l l s , the simultaneous an a lys is of the f iv e


73

ables was the same as the c l a s s i f i c a t i o n level of p r o b a b il it y o f the four

v a ria b le s mentioned above, .5 1 , but with an even higher level of s i g n i ­

fic a n c e , .0021, due to the Chi-Squared t e s t r e s u l t of 2 7 .5 .

Discussion of Results

This discussion w i l l examine (1) suggested a dd ition s to the theory

of social competence; (2) c u rre n t age and the o r i g in o f the study; (3)

diagnostic influences on le v e ls of social s k i l l s ; and (4) the th e o r e tic a l

and c l i n i c a l a p p lic a tio n s f o r occupational therapy.

In the o r ig in a l theory of social competence as set f o r th in Chapter

Two, the v a r ia b le s , age of onset of psychosis and diagnoses were expected

to p r e d ic t the le v e l of social s k i l l s . This was i l l u s t r a t e d diagram-

m a t ic a lly in Figure 1, implying a causal r e la tio n s h ip between the two

v a ria b le s and the level of social s k i l l s .

Age of Onset
of Psychosis

. Level of
Social S k i l l s

Diagnosis

Figure 1. Schematic diagram of major th e o r e tic a l propositions and


hypothesis.

S t a t i s t i c a l l y , because diagnosis cannot be c a lib r a t e d , i t was necessary

to set up the ju x ta p o s itio n of the v a ria b le s with age and social s k ill

scores on the c a lib r a te d x and y axes. As a r e s u l t , the operational


74

hypothesis c a lle d f o r a d i f f e r e n t s t a t i s t i c a l i n t e r a c t i o n , which can be

i l l u s t r a t e d as follow s:

Age of Onset
of Psychosis

— ^Diagnosi:
Level of
Social S k i l l s

Figure 4: Schematic diagram o f operational hypothesis based on


s ta tis tic a l in te ra c tio n .

The one-way arrows in these diagrams imply causal r e la tio n s h ip s .

A diagram r e f l e c t i n g the ass ociationa l r e la tio n s h ip among v a ria b le s

in t h is study is presented below. I t incorporated the r e s u lts of the

te s ts of a d d itio n a l data outside the hypothesis.

Age of Onset
of Psychosis S o cia b i1i t y

Current Aqe \ \ associated X ' / Social Presence


^ - •
Diagnosis / \S o c ia liz a tio n

Figure 5: Expanded schematic diagram i l l u s t r a t i n g the ass o ciatio n a l


r e la tio n s h ip among the t h e o r e t ic a l and p r a c t ic a l v a r ia b le s .

The a s s o ciatio n a l re la tio n s h ip s among s o c i a b i l i t y , social presence

and s o c ia l i z a t i o n are meaningful because these three fa c to rs were outside


75

the theory of social competence, as i t had been previously presented in

i t s extensive body o f th e o r e tic a l and em pirical l i t e r a t u r e , beginning

w ith Z i g l e r and P h i l l i p s , (1953, 1961) and G olds te in, Held and Cromwell,

(1 9 6 8 ). Without f a m i l i a r i t y with t h is body of knowledge, the present

study might s u p e r f i c i a l l y be c r i t i c i z e d on the grounds t h a t the number of

fa c to r s examined in association with social s k i l l le v e ls of p s y c h ia tric

p a tie n ts was not comprehensive enough, and could th e re fo re be described

as l im i t e d in scope. This l i m i t a t i o n was i n t e n t i o n a l . Knowledge of

e a r l i e r studies revealed t h a t extensive examination of a wide number of

associated v a ria b le s had already taken place. Knowledge of e a r l i e r

studies also in d ic a te d the re tro s p e c tiv e nature of the scales employed

in those in v e s t ig a t io n s .

I t was the in te n tio n of t h is study to extend the parameters o f social

competence theory by s c r u t in iz in g sub sidiary v a r ia b le s , in c o n tra s t to

associated v a r ia b le s , which can most n a t u r a lly be c l a s s i f i e d as sub­

d iv is io n s of social competence in a taxonomy of social s k i l l s . I t was

also the in te n tio n of t h is study to u t i l i z e a n o n -re tro s p e c tiv e s ca le,

r a t h e r than a r e tro s p e c tiv e scale.

The studies done by Z i g l e r , P h i l l i p s , Sanes, Rabinovitch and Lewine

in 1953, 1958, 1961, 1962, 1964, 1971 and 1973 focused on symtomatic fa c ­

to rs associated w ith schizophrenia, such as f la tn e s s of a f f e c t , behaviors

o f turnin g a g a in s t the s e l f or oth ers, process versus r e a c tiv e types of

recovery p a tte r n s , adolescent and recent s e x u a l/s o c ia l maladjustment and

poor in te rp erso n al re la tio n s h ip s in childhood and immediately p r i o r to

h o s p it a l iz a t i o n by u t i l i z i n g the P h i l l i p s ' Pre-Morbid Adjustment Scale

( 1 9 5 3 ). This s c a le , however, was l i m i t e d by i t s examination of case


76

h is t o r ie s in a r e tro s p e c tiv e manner. Farina and Webb (1956) also used

the P h i l l i p s ' Scale in t h e i r in v e s tig a tio n s of these same symptomatic

fa c to rs in conjunction with r e h o s p it a liz a tio n patterns f o r a d u lt schizo­

phrenic p a t ie n t s . Rodnick and Garmezy (1957) looked a t social competence

in a g en erally d e s c r ip tiv e manner, c a te g o rizin g schizophrenic pre-morbid

social adjustment in a s i m p l i s t i c , d iv is io n of "good" or "poor," w ithout

b e n e fit of comparison w ith "normals."

P h i l l i p s and Z i g l e r , with t h e i r revised Social Competence Scale ( SCS,

1961) expanded t h e i r in v e s t ig a t io n of r e la te d ass ociationa l fa c to rs by i n ­

cluding such demographic and socioeconomic in d ic a t o r s , as age, i n t e l l i ­

gence, education, occupation, employment h is to ry and m a rita l s ta tu s . These

r e la te d but i n d ir e c t v a ria b le s came under severe c r i t i c i s m by Sarbin and

Mancuso (1980) who a lle g e d t h a t s o c i o - p o l i t i c a l premises had provided the

basis fo r e s ta b lis h in g social competence norms in schizophrenic p a t ie n t s .

Even in t h e i r u t i l i z a t i o n of the revised Social Competence Scale (1 9 6 1 ),

the P h i l l i p s and Z i g l e r group could be c r i t i c i z e d f o r i t s continued u t i l ­

iz a t i o n of case h i s t o r ie s which merely provided r e tro s p e c tiv e info rm ation.

The G o ld s te in , Held and Cromwell group published a study examining

diagnostic aspects and recovery prospects f o r "good" and "poor" le v e ls of

social competence among paranoid, non-paranoid schizophrenic and schizo­

a f f e c t i v e p a tie n ts in Veterans Adm inistration and s t a t e h o s p ita ls . In

studies in 1968, 1974 and 1978, they u t i l i z e d t h e i r UCLA Social Attainment

Scale to analyze data regarding same-and-opposite-sex r e la tio n s h ip s ,

leadership experience, dating h is t o r y , sexual experience, outside social

a c t i v i t i e s and o rg a n iza tio n a l p a r t i c i p a t i o n , also w ith a re tro s p e c tiv e

focus.
77

The Kleins (1968) looked a t social competence in s c h izo id -ty p e

D a tien ts with t h e i r Pre-Morbid Asocial Adjustment S c a le . Strauss and

Carpenter in 1974 used t h e i r Prognostic Scale f o r r e h o s p it a liz a t io n to

examine percentage of time employed, s e v e rity of symptomatology, frequency

o f social contacts and time spent out of the h o s p it a l. Both scales ex­

amine data r e t r o s p e c t i v e l y .

Lewine, Watt, Prentky and Freyer (1978 & 1980) published re s u lts

from studies in which they s c ru tin iz e d age of onset of psychosis with

paranoid and non-paranoid schizophrenia, s c h iz o - a f f e c t i v e diso rd er, de­

p ress ive , n eu ro tic and p e rs o n a lity disordered and normal in d iv id u a ls . It

was t h is l a s t group of in v e s tig a to rs whose studies were most advanced in

looking a t a spectrum of diagnostic catego ries and the developmental

m ilestone of age of onset of psychosis. For t h is reason, i t formed the

springboard f o r t h is study.

None of these w r it e r s u t i l i z e d a p e rs o n a lity scale to observe per­

sonal social competence components. This was a d e fic ie n c y in social

competence theory. I t was time to develop the theory f u r t h e r by the

taxonomic expansion of fa c to rs having the p o te n tia l to be sub-divisions

of social competence, in co n tra s t to the re tro s p e c tiv e examination of

associated socio-economic v a r ia b le s . I t was also considered tim ely to

use a n o n -re tro s p e c tiv e viewpoint in r a t in g these fa c to rs by employing

a p e rs o n a lity t e s t which r e la te d to c u rre n t eva lu a tio n of p a tie n ts .

For some tim e, tests o f p e rs o n a lity t r a i t s have not been held in as

high regard as fu n ctio n al and behavioral scales by some psychologists.

(McReynolds, 1975; Jones, Reid, & P atterson, 197 5). In a recent p r i ­

vate conference, Harvey Lieberman, P h .D ., (1984 American Psychological


78

Association Gold Medal Award winner, and acknowledged a u th o r ity in be­

havioral p s y c h ia tr y ) , explained t h a t there usually are l i m i t a t i o n s to

t r a i t te s ts in id e n t if y i n g and d i f f e r e n t i a t i n g behavioral c h a r a c t e r is t i c s .

However, a f t e r a c a re fu l review of the r e s u lts of t h is study, he noted

t h a t t h is t r a i t t e s t might be as valuable as a fu n ctio n al scale, despite

the usual r is k s in u t i l i z i n g such an instrument. He f u r t h e r explained

th a t the usual l i m i t a t i o n s of t r a i t te s ts did not appear to i n t e r f e r e

with the re s u lts of t h is t e s t which were able to d e lin e a te d is t in c tio n s

among diagnostic groups. Apparently the CPI is s e n s itiv e enough to iden­

t i f y diagnostic c a te g o ric a l d iffe re n c e s (Lieberman, Harvey, In d iv id u a l

Conference, January 4 , 1985). As a r e s u l t , the employment of t h is t e s t

and the recog nition of these social s k i l l concepts appear to be a c o n t r i ­

bution which the r e s u lt s of t h is research make to the theory of social

competence.

The expected t h e o r e t ic a l developmental trend in the age of onset

of psychosis was revealed by the data of t h is present study, confirming

the fin d in g s of Lewine, Watt, Prentky and Freyer (1978 & 1980), t h a t ages

of f i r s t admission increased from t h a t of non-paranoid schizophrenia to

paranoid schizophrenia to b i - p o la r i l l n e s . I t sub sta n tiated the re s u lts

of previous studies of the three diagnostic groupings regarding associated

fa c to rs examined over the ye a rs . This in d ic ated t h a t Sarbin and Mancuso's

condemnation of the analysis and association of s o -c a lle d socio-economic

fa c to rs in e a r l i e r studies of social competence, though aimed a t a flaw

in social competence theory, was not t o t a l l y warranted. The confirm ation

of social competence theory by t h is study strengthened both the o r ig in a l


79

th e o ry , and t h is study, with i t s aim of extension o f the t h e o r e t ic a l

v a ria b le s of social competence.

This study o r ig in a te d in the observation by t h i s in v e s t ig a t o r of

the d iffe r e n c e in social s k i l l performance and i n t e r a c t i o n among two age

groups of women in young (20 to 29) and a d u lt (30 to 55) women's groups.

The o ld e r group was m an ife stly capable of higher le v e ls of social communi­

c a tio n s k i l l s . This observation was confirmed by other group th e ra p is ts

acting as s u b s titu te leaders in the group. I t was at f i r s t speculated

t h a t t h is was both a c l i n i c a l d iffe r e n c e associated with changes due to

group and in d iv id u a l therapy and a developmental d iff e r e n c e r e la te d to

progress through growth of p e rs o n a lity and l i f e experience. Upon searching

the l i t e r a t u r e f o r a t h e o r e t ic a l r a t io n a le and f o r em pirical evidence con­

cerning the observed behavioral d i s t in c t i o n s , i t was found t h a t th eo ries

of social competence were based on the conviction t h a t p a tie n ts o f d i f ­

f e r in g diagnostic catego ries were capable of social in te r a c tio n o f varying

degrees of development. I t was also f e l t t h a t the age a t which the onset

of psychosis occurred would cre a te a demarcation le v e l a t which natural

social development would be a r r e s te d . In other words, i t was specu­

la t e d t h a t the age a t which the f i r s t psychotic break occurred would prove

to be a p o in t of d e lin e a tio n beyond which the p a t ie n t would not develop

s o c ia lly . While the contention of the social competence t h e o r is ts made

some degree of lo g ic a l sense, i t was also expected by t h is in v e s tig a to r

t h a t cu rre n t age would be associated w ith developmental, c l i n i c a l and

e x p e r ie n tia l growth. The manner in which the in t e r a c t i o n of v a ria b le s was

strengthened by the a d d itio n of cu rre n t age to the d iscrim in an t analysis

v a lid a te s the association of increased cu rre n t age with higher le v e ls o f


80

social competence, p a r t i c u l a r l y in the areas of s o c i a b i l i t y and social

presence.

Diagnostic influ en c es on the le v e l o f social competence were most

c l e a r l y v a lid a t e d in t h is study by i t s examination of the ranges of norms

of s o c i a b i l i t y and social presence.

F i r s t , by d e f i n i t i o n , these two v a r ia b le s are more p re c is e ly sub­

ca teg o ries of social competence because s o c i a l i z a t i o n r e la te s to r o l e ­

fu l f i l l m e n t and r o l e - o b li g a t io n s .

Second, i t was not s u rp ris in g to f in d non-paranoid schizophrenic

p a tie n ts in the lowest ranges of s o c i a b i l i t y and social presence because

they are t y p i c a l l y more withdrawn s o c i a l l y , and are th e r e fo r e more

l i k e l y to be c h r o n ic a lly in t h is c o n d itio n . I t was also not su rp risin g

to f in d b i - p o l a r p a tie n ts emerging with ra tin g s close in rank to normals

on the CPI scales which are based on normals. When b i - p o l a r p a tie n ts are

in m id-cycle between t h e i r high and low a f f e c t i v e periods, they m anifest

normalcy t h a t could not be d i f f e r e n t i a t e d from the behavior and a t t i t u d e

of normal i n d iv id u a ls . Paranoid persons are observed by most p s y c h ia tric

c l i n i c i a n s to f a l l somewhere in between these two groups in t h e i r a b i l i t y

to i n t e r a c t s o c i a l l y . While o fte n not withdrawn, paranoid schizophrenic

p a tie n ts tend to i s o l a t e themselves out of f e a r and h y p e r -v ig ila n c e .

The graduated r e s u lts of average ages of onset of psychosis from

low, to moderately low, to average f o r non-paranoid schizophrenics, para­

noid schizophrenics and b i - p o l a r disordered p a t i e n t s , r e s p e c t iv e ly , in

t h i s study corroborates a time-honored c l i n i c a l observation t h a t p a tie n ts

who become i l l younger tend to have less developed social s k i l l s .

The r e s u lts of t h is study have t h e o r e t ic a l and c l i n i c a l r a m ific a tio n s


81

f o r occupational therapy. As was mentioned in Chapter One, in the discus­

sion of the s ig n ific a n c e of t h is study, occupational therapy th e o re tic ia n s

and p r a c t i t i o n e r s have not divided social s k i l l s taxonomically through

speculation or research. An an alysis of Llorens' (1984) recent review of

the co n cep tu aliza tio n s of occupational therapy theory from 1960 to 1982

was c a r r ie d out to examine concepts most c lo s e ly r e la te d to social com­

petence. F i d l e r (1963 & 1978) discussed general interp ersonal r e l a t i o n ­

ships, Mosey (1968 & 1974) presented the psychosocial model and Llorens

(1970) reviewed global interp ersonal i n t e r a c t i o n . These three w rite r s

did not present subdivisional aspects of social competence in t h e i r con­

s id e r a tio n of social s k l l s . In 1983, B a r r is , K ie lh o fn e r and Watts r e ­

f e r r e d to s o c i a l i z a t i o n , by i t s e l f , w ithout d is tin g u is h in g i t from other

social components, such as s o c i a b i l i t y and social presence. A study

demonstrating the separate nature o f these t r a i t s f o r p s y c h ia tric p atie n ts

was much needed.

This study o f female p s y c h ia tric p a tie n ts of three diagnostic

groupings has now provided data which have been analyzed to reveal the

separate nature of the social concepts of s o c i a b i l i t y , social presence

and s o c ia l i z a t i o n to a degree s u f f i c i e n t to e s ta b lis h these as s u b -s k ills

o f social competence. Thus, the varying r e s u lt s of the s t a t i s t i c s on each

o f the three social s k ill scales supported the v a l i d i t y of the concepts

as separate e n t i t i e s . This conclusion was drawn because among the three

scales of s o c i a b i l i t y , social presence and s o c i a l i z a t i o n , the range of

the scores, the average of the scores, the p r o b a b il it y of the scores, and

the trend o f the p o s itio n of the averages v a rie d from s k i l l to s k i l l .

As a r e s u l t , t h is study can a s s is t in bringin g these concepts of social


82

competence in to the f i e l d o f occupational therapy. A c lo s e r examination

in d ic a te s t h a t they are i n t r i n s i c a l l y r e la te d to the domain of occupational

therapy.

S o c ia b il it y is a concept which ought to be included in occupational

therapy l i t e r a t u r e , since many p s y c h ia tric " A c t i v i t i e s Therapy" groups

are designed to achieve the goal of enabling is o la te d and withdrawn

p a tie n ts to re la x in the presence of other people, and thus to enjoy

simply being w ith people. This can be achieved through r e la x a tio n tech ­

niques, group dynamics, e xe rcis es, sports, movement, dance, and music.

Social presence is another concept which belongs in occupational

therapy theory since the a b i l i t y to reach out to others with one's own

in d iv id u a l s t y le needs to be re in fo rc e d or learned by p a tie n ts who have

experienced a psychotic episode with i t s subsequent breakdown in social

s e lf-c o n fid e n c e and communication s k i l l s . Occupational th e ra p is ts

fre q u e n tly concentrate on t h is s k i l l in p s y c h ia tr ic a c t i v i t i e s therapy

groups u t i l i z i n g r o le playing o f one's s e lf -p r e s e n t a t io n by means of

assertiveness t r a i n i n g . A c l e a r d e f i n i t i o n o f t h is concept has been

lacking w ith in occupational therapy theory and p r a c tic e .

F in a lly , s o c i a l i z a t i o n , as the a b i l i t y to assume one's roles in

life , can be developed in p s y c h ia tr ic a c t i v i t i e s therapy groups through

social a c t i v i t i e s of d a ily l i v i n g so t h a t p a tie n ts may le a rn to assume

roles such as grown son or daughter, f r i e n d , spouse, employee, v o lu n te e r,

t r a in e e , student, member of a day -ce n te r, apartment r e n t e r , and roommate.

A c t i v i t i e s of d a i l y l i v i n g such as budgeting, housekeeping, and p a r t i c i ­

pating in preparations f o r c e le b r a tio n s , can be reviewed in independent

l i v i n g s k i l l s groups. Work r o le s , r e la tio n s h ip s and d a ily amenities of


83

the workplace can be p rac tic e d in task-focused r e h a b i l i t a t i o n groups.

The confirm ation of the s u b - s k ills of s o c i a b i l i t y , social presence

and s o c ia l i z a t i o n as d e f i n i t i v e and separate c l i n i c a l e n t i t i e s w i l l be

useful in planning treatm ent in occupational therapy a c t i v i t y groups

f o r p s y c h ia tr ic p a tie n ts o f the three major diagnostic groupings examined

in t h i s study. The C a li f o r n ia Psychological Inventory can be included

in the occupational therapy assessment process o f evaluation of social

s u b - s k il ls in need of treatm ent, based on the a d d itio n a l inform ation

now a v a ila b le from the re s u lts o f t h is research. Subsequent r e f e r r a l s

to s p e c if ic social a c t i v i t y treatm ent groups designed f o r r e h a b i l i t a t i o n

of various le v e ls of social fu n ctio n in g w i l l now be possib le. These

r e f e r r a l s can be based both on the le v e l o f ratin g s of the C P I1s scales

f o r the three social s k i l l components, as well as upon the ju d ic io u s and

d is c r e te a p p lic a tio n of knowledge of the expected le v e ls of functio ning

associated w ith a given age of onset of psychosis and a s p e c ific diagnosis.

As was seen in the review o f the l i t e r a t u r e in Chapter Two, the

value placed upon diagnostic d i s t in c t io n s has changed throughout the

y e a rs , o fte n being dependent upon trends t h a t are c u r r e n tly in vogue.

W ithin the l a s t few y e a rs , diagnostic d e lin e a tio n s assumed g re a te r im­

portance because of t h e i r im p lic a tio n f o r fe d e ra l funding. National

m e d ic a l/p s y c h ia tr ic reimbursement schedules vary according to d i f f e r e n t

diagnoses. T h e re fo re, c u r r e n t l y , in some p s y c h ia tr ic h o s p it a ls , there

is a retu rn to homogeneous, diagnostic treatm ent groupings on d ia g n o s tic -

s p e c if ic u n it s . The hospital where t h is study took place re c e n tly r e ­

turned to t h is approach a f t e r u t i l i z i n g heterogeneous u n its f o r the past

twenty yea rs. For t h i s reason, the r e s u lts of t h is study also have f is c a l
84

r a m ific a tio n s a p p lic a b le to a d m in is tra tiv e decision-making around u n i t -

centered treatm ent planning f o r each diagnosis.

Because the issue of homogeneous versus heterogeneous treatment has

become a controversy which has s t i r r e d debate and has been examined by

c l i n i c i a n s , t h i r d party-payers and the p u b lic f o r some period of tim e,

the c le a r i d e n t i f i c a t i o n of d ia g n o s tic - r e la te d groups, and t h e i r asso­

c ia te d v a r ia b le s and t r a i t s w i l l become in c re a s in g ly important in q u a lity

assurance stu d ies. The use of the _CPI in i d e n t i f y i n g le v e ls of im p air­

ment in s p e c if ic social s k i l l s , as well as an understanding of associated

needs w ith in varying diagnostic groups, c u rre n t age and age of onset of

psychosis, can make a c o n trib u tio n t h a t can c l a r i f y treatm ent o b jectives

f o r p s y c h ia tr ic p a t ie n t s .

An understanding of the separateness o f the social s k i l l s concept,

and the v a l i d a t io n of c l i n i c a l observations regarding the le v e ls of social

development of p s y c h ia tr ic p a t ie n t s , along w ith the s t a t i s t i c a l analysis

o f them as r e la te d to diagnostic and a g e -r e la te d fa c to r s are the major

t h e o r e t ic a l and c l i n i c a l c o n trib u tio n s of t h is study to the theory of

social competence and to the f i e l d of occupational therapy.


CHAPTER V

SUMMARY AND RECOMMENDATIONS

Summary

The purpose of t h is study was to determine the exten t to which i t

would be possible to p r e d ic t diagnosis f o r a given p s y c h ia tr ic case when

inform ation was provided f o r the age of onset of psychosis, as well as

fo r the scores of social competence s k i l l s , s o c i a b i l i t y , social presence,

and s o c i a l i z a t i o n . The study was concerned w ith the ass ociation of the

le v e ls of age of onset of psychosis with the le v e ls of scores of socia­

b ility , social presence and s o c i a l i z a t i o n . This study has been an attempt

to answer the questions:

1. W ill non-paranoid schizophrenic p a tie n ts m anifest e a r l i e s t

age of onset of psychosis and lowest scores on the social s k i l l scales?

2. W ill paranoid schizophrenic p a tie n ts m anifest a mid-range of age

of onset of psychosis and m id -le v e l scores on the social s k i l l scales?

3. W ill b i - p o l a r a f f e c t i v e p a tie n ts m anifest the highest age of

onset of psychosis and highest scores on the social s k ill scales?

The t h e o r e t ic a l r a t io n a le f o r t h is study was based on the theory of

social competence f o r p s y c h ia tr ic p a tie n ts as conceived by P h i l l i p s and

Z i g l e r (1961) and G olds te in, Held and Cromwell (1 9 6 8 ). According to

t h is t h e o r e t ic a l framework, the expected responses to the above questions

would be p o s it iv e .

Diagnostic determ inations a t the hospital where the study was done

85
86

were made by a p s y c h i a t r i s t a t admission through a formal mental status

examination. On-going r e - e v a lu a t io n , by the p s y c h ia tr ic team, formed

the basis f o r the discharge diagnosis. Cases were included only when

admission and discharge diagnoses were con sis ten t.

The C a l i f o r n i a Psychological Inventory ( CPI) was used to determine

the le v e l o f social s k i l l competence by examining the scores of the

p a tie n ts on three scales: s o c i a b i l i t y , social presence and s o c ia l i z a t i o n .

A d isc rim in a n t function an alysis was employed to examine the r e l a t i o n ­

ships among age of onset of psychosis and the scores o f s o c i a b i l i t y , social

presence and s o c ia l i z a t i o n f o r 90 female p s y c h ia tr ic p a tie n ts of three

p s y c h ia tr ic diagnoses.

The th ree diagnoses were, to a moderate degree, p re d ic ta b le through

the d iscrim in an t an alysis of age of onset o f psychosis and s o c i a b i l i t y ,

social presence and s o c i a l i z a t i o n . Despite s i g n i f i c a n t d iffe re n c e s in

the means of the diagnostic groupings, only a moderate accuracy of c l a s s i ­

f i c a t i o n of cases by diagnosis was in d ic ated by the data through use of

t h is combination of v a r ia b le s in a d iscrim in an t a n a ly s is . This combination

increased the p r o b a b il it y of accurate c l a s s i f i c a t i o n from the chance level

of 1 out of 3, to 1 out of 2. The means of the th re e diagnostic groups,

across the three social s k i l l s , in d ic a te d a trend in the expected d i r e c t io n .

Thus, the hypothesis can be accepted f o r the fo llo w in g reasons:

1. The means of the diagnostic groups in d ic a te d a trend whereby they

are located in p o s itio n s r e l a t i v e to each other as expected occurring in

a p a tte rn in the p red icted d i r e c t io n , with only one out of twelve v a ria b le s

f a l l i n g in to an unexpected placement.

2. The Chi-Squared t e s t of separation w ith in the d iscrim in an t


87

an alysis in d ic a te d t h is trend to be a t a s i g n i f i c a n t l e v e l .

3. The c l a s s i f i c a t i o n of in d iv id u a ls in to groups by d iscrim in an t

analysis rose from a .33 r a te by p r o b a b ilit y to a .51 through the assess­

ment by the CP I.

Social competence theory has been under development f o r about t h i r t y

yea rs. This study was an attempt to provide a more d i r e c t measurement of

phenomena t h a t have been observed c l i n i c a l l y , i n t u i t i v e l y understood by

p r a c t i t i o n e r s , and i n d i r e c t l y measured by researchers. The use of a t r a i t

instrument designed to assess social s k i l l t r a i t s and c h a r a c t e r is t ic s

perm itted the le v e l of social competence to be d i r e c t l y measured. I t was

the contention of t h is i n v e s t ig a t o r , as a r a t io n a le f o r using the C P I,

th a t a p e r s o n a l i t y - t r a i t assessment would be the best measure of social

s k i l l behaviors.

The conclusion may be drawn from t h is study t h a t there was a moder­

a t e ly strong association of increment of age of onset of psychosis,

cu rre n t age, and le v e ls of s o c i a b i l i t y , social presence, and s o c ia l i z a t i o n

with non-paranoid schizophrenia, paranoid schizophrenia and b i - p o l a r

a f f e c t i v e disorders in the predicted d ir e c t io n .

The strengths of t h is study included i t s use of a n o n -retro sp ec tive

instrument f o r measurement of new taxonomic s u b -s k ill components of social

competence, comparing p s y c h ia tr ic p a tie n ts of three diagnoses with norms

based on r e s u lt s from thousands of normal subjects. This study made the

f u r t h e r c o n tr ib u tio n of expanding the c l i n i c a l assessment and treatm ent

planning in occupational therapy to include s o c i a b i l i t y , social presence

and s o c i a l i z a t i o n . In a d d itio n , the r e s u lts of t h is study provided a

review of the in h eren t em pirical and research-based r e la tio n s h ip between


88

diagnosis, a g e -r e la te d f a c t o r s , and social competence, enabling these

v a ria b le s to be c a r e f u l l y examined in conjunction with the expected,

associated le v e ls of social s u b - s k il ls . F i n a l l y , the r e s u lts of th is

study, with i t s diagnostic in fo rm a tio n , have f i s c a l im p lic a tio n s fo r

treatm ent planning a t the a d m in is tra tiv e le v e l in p s y c h ia tr ic h o s p itals

where diagnostic re g u la to ry groupings are mandated f o r reimbursement

purposes.

I t is hoped t h a t t h is study has provided a stimulus f o r revived

i n t e r e s t in the theory of social competence.

Recommendations

Because of expected s e x u a l/s o c ia l d iffe re n c e s in norms of standard­

ized t e s t s , such as the C P I, only females were studied. I t is now recom­

mended t h a t male p s y c h ia tr ic p a tie n ts be assessed by the CP I, and the

re s u lts examined s e p a r a te ly , as well as j o i n t l y , with the females' scores

in order to determine whether the expected s e x u a l/s o c ia l d iffe re n c e s are

actual d iffe r e n c e s .

Because there are other scales on the CPI which r e l a t e to social

competence, and because the number of such r e la te d fa c to rs appears to

increase the power o f the d isc rim in a n t an alysis when there was a r e l a t i o n ­

ship, t r a i t s , such as cap acity f o r s ta tu s , dominance, r e s p o n s i b i l i t y ,

s e l f - c o n t r o l , t o le ra n c e , good impression and communality could also be

analyzed to determine which combination best p re d ic ts diagnosis and c o r ­

r e la te s most highly w ith the d iscrim in an t social fa c to rs already examined.

F i n a l l y , because the sample u t i l i z e d was r e l a t i v e l y sm all, with


89

an n of 30 f o r each of the three diagnostic groups, i t is recommended

t h a t the s iz e of the sample be enlarged to increase the s t a b i l i t y of

the r e s u lt s .

In a d d itio n to the above recommendations f o r research, i t is highly

recommended t h a t the C a li f o r n ia Psychological Inventory be included in

the occupational therapy assessment b a tte ry f o r p s y c h ia tr ic p atie n ts to

determine the le v e l of s u b -s k ills of s o c i a b i l i t y , social presence and

s o c ia liz a tio n . These d ata, in conjunction w ith the cautious and c a r e f u l ly

considered a p p lic a tio n of knowledge regarding age of onset of psychosis

and p s y c h ia tr ic diagnoses, are suggested f o r u t i l i z a t i o n in r e f e r r a l to

s p e c if ic social a c t i v i t y treatm ent groups.

The most d e s ira b le improvement f o r fu tu re studies of t h is theory

would be the examination of c h a r a c t e r is t ic s of s o c i a b i l i t y , social

presence and s o c ia l i z a t i o n using behavioral measurements. A n o n -s e lf-

e v a lu a tiv e tool might provide stronger t e s t re s u lts among the diagnostic

groupings.
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APPENDIX A

A p p lic a tio n f o r Approval o f a Research P r o je c t


Human Subjects Review Board
Long Isla n d J e w is h -H ills id e Medical Center

and

L e t t e r of Approval f o r a No-Risk Study

107
A l'l'llf- A I iO N H i l l AITIUJVAI III A HI SI AHPH I’HOJI CT 108

I U H M f ln it n u h itM .il li t vii'kV Bu<*rr1 I I H I l l Im j | j f |*rrm r»«*>n o 1 N un.an S u b jr rls f'a m c ip a iin g in H r t f a i d

In s i m t nuns lu Pis. C o m p le t e Se c tio n I and II Co mp lete cither A , U. or C as appropriate to y uu i piujBCt Investigators art
r efe rr ed l u l l i t Research M a n u a l w l ii c li cunlai ns ii istilutiuu al policies lo r the pr ote ct ion ul hu ma n subjects participating in
icscdii h 1 lie Office ot G i a n t s M a na ge m e n t wi ll he pleased tn provide any assistance

I investii.uini M a ry U o rto h u e, OIK, MA Dept, or Addiess


Co Investigator..... Teleph one Extension: 4 5 2 5 / 4 3 7 8

l i th of Protocol. A S t u d y _ of th.fi R e l a t i o n s h i p b e t w e e n Ag e a n d S o c i a l De v e l o p m t•
- " ■• ■ " ‘ ‘ ^ Major D i a g n o s e s ___________

Ili'P t. I h a d A|ipi|iv,ll J j-

(IlliKi Dept Involved: Yes Other Institution Involved: Yes U L No ...

Department of Occup a t io n a l Therr

t I A I I I SI A R C H P R ! Sf N E I N G P Q S S I B l E R IS K 1 U S U B J E C T S e g drug and medical device trials, surgical and


ulhe t invasive pro cedur es, studies iiiviilving la n i lr u n i .a t iu n , placcbu contiols, etc. Please submit:

1 Nine (y) copies ot t he com pl e te p i o t o c u l ,

Ninr. (!l) m p i e s ul a lay Mii iii na iy 11! l l .i j. 1.:j i t t ie an exp lan at ion ol the study in non m ed ic a l
It:linDiiloyy.
'i Ntt it (9) i opies of <» prop erl y f x e i u i r r i ni nsu ni f n m i Nutt: Invrs iiga ior must iw r l p the app io pf *a ie cost
M .M f iiM 'U l (H I p . f i l l 1 /

! J B H I SI A R C H I ’ H I S I N 1 I N G M IN IM A L R ISK III SUBJECTS: In oiriei lo t your study to be categorized as a


' m in i m a l risk" p i o j p r ! it must fall in to one m inuie nt the 10 1iowing areas Please indicate the category:

1 )1 Collection of ha il a nd nail d i p p i n g , e xc ic ta and external secretions, uncannulated saliva, placenta r em ov ed at


dehveiy, a m n io t i c f lu id at the t i m e of r u p t u ie of the membra ne , deciduous teeth, and pe im a ne nt t e a t h if
patient caie indicates a need f u i e xt r a c t io n Collection ot dental plaque and calculus done in a noninvasive
iu,niiiei p e i f o i i n e d a n Hiding to st and aid prop hyl act ic techniques.

1.1 2 Collection o f h l n n d samples by venip ur icl tii e, in amo unt s not exceeding 4 5 0 m ill ili le is in an B week pe ii od ,
and no n i o ip o f t e n Il ia n t w ic e a w « e k , h u m subjects over 18 years ol age, in good health, and not pre gnant

I d3 Ret oi dm g o f da ta f r o m subjects 18 yp.us ur older using noninvasive procedures rout in ely em ployed in clinical
practice (e.g. w e ig h in g , testing sensory acuity, electrocardiography, electroencephalography, t he rm o gr ap hy -
N O ! X R A Y S OR M IC R O W A V E S ).

I I 4 Moderate e x e n ise by h e a lth y volunteers.

I. J 5 Vuice reco id m gs m ad e f m research purposes

I ) 6 Research o n be ha v io r: ( Id p e t r c p t i u n studies, I j cognition; l_ ) game the ory; D test dev elopment, w h e i e


the investigator dues not m a n ip u la te subjects' behavior and the research will npl involve sliess to subjects

\ i t . i c l i one ( 1 ) i upy id the 1 n i n | i k tc pi own ul and a • on unary m non medical tei mi oology which wi ll be given tn the subject

( /H I M J R NO R ISK R E S l A M L H - Set N rx t Pagi

11 11 11 ‘.1 1 1• iv 11 ur; m > i pa nr


109

[» C H I SI A n r . H r H I S E N l I N G N O H I S K 1 0 S U B J f C TS In m d r r (or your research lo he considered a f t f ’N o Risl


s lu d y . n must (all in to one or m o i e o l (he lo llu w m g categories (‘lease indicate which a i f j ( s ) apply:

I 1 1. Use o l e duc at ion al tests lor w h ic h there is no subject iden tif y in g data

L I 2. Research in volving col lec tio n or s tu dy of charts, spcuineris. or medical records I or wh ich there wi ll be n
subject id e n t if y in g data

(x 1 3. Heseaich involving questionnaires, suiveys, interviews Subjects cannot be id en tif ied fr o m data; subject
responses, if k n o w n , w il l no t place the m at risk; reseaich dues not deal with sensitive aspects of subject
behavior (e.g. illegal c on d uc t, drug or alcohol use, sexual behavior). A l l o t th e c o n d itio n s m u s t b e m et

A tt a c h one ( 1 ) co py of the p i o t u c n l and, if applic able , a summary ot the pruject in non medical t e rm in ol o gy wh ic h will b
p io v n t e d to the subject

II. A l I IN V I S I I G A 1 0 H S M U S I S I G N T H E F O L L O W I N G S I A l l M E N T 0 1 A S S U R A N C E .

Th e p r op os ed investigation involves the use of human subjects I am s ubm itting this for m w i t h a description o l my
pi o je c t , p i e p a i e d in accordance w i t h in st it u t io n a l policy for the pr ot e c tio n ol human subjects par tic ipat ing in research
I nuclei stand the Medic al Cen tal's po lic y conc er ning research involving hu ma n subjects and I agree:

1. l o ob tai n in f o r m e d consent of subjects w h o are to participate in this project;

2. t o rep ort 1 0 t he H u m a n Subjects R ev ie w C om m it te e any unan ticipa ted effects on subjects wh ic h become
a p p a ie n t du rin g the couise or as a result of e x p e r im e nt a tio n and the actions taken as a result;

3. to coo perate w i t h m ein bei s o f the C o m m i t t e e chaiged w i t h the co ntinuing review of this project;

4 to ob tain p r io r a pj u uv al f r o m the C o m m i t t e e before amending or altering the scope of the project or


i m p l e m e n ti n g changes m the a ppr ove d consent t u i m ,

b to m ai nt a in d o c u m e n t a t io n of consent f o u n t anil juugiess reports as required by insti tut io nal policy.

S i. m .i li iie ..v i t ± . . l (%!. D a t e . __ I. L i t r b * ‘ id **- » / , / f f i r

/
Mule l/iv e s n y a jo /i are referred U> lb * H ese jirb Mamml lo r in m p lrte statement o l institutio n a l policy and procedures regarding research
w ith human subjects

III EOH C U M P I L T IO N BY 1 H I O f l ' I C L 01 GRANTS MANAGEMENT

Dis po s iti on of the P r o t o c o l . _ .................................... . _ Date of C o m m i t t e e Meeting

S u b c o m m i t t e e -----------------------

J In accord anc e w i t h in st it ut io na l jr o li r y , this p i o t u c n l was j|ij<ioved via the procedures for e x p e di te d review.

CoMimtuee Cfirfirnsan/
Suite iKM'Tiii ire Cr**«i»fr>an

C o n t i n u i n g Flrview Sc heduled lor


110

October 30, 1983

Human Subjects Review Board:

The attached papers are submitted to t h is Board to present the

nature and scope of the research p r o je c t being proposed in p a r t i a l

f u l f i l l m e n t of the requirements f o r a doctoral degree in Education

w ith a major in Occupational Therapy a t New York U n iv e rs ity . Included

are:

1) A p p licatio n fo r Approval of a Research P ro je c t

2) O u tlin e of the Protocol

3) A copy o f the t e s t instrument: The C a li f o r n ia Psychological

In v e n to r y , with an answer form p r o f i l e sheet

4) The curriculum v i t a e of the in v e s t ig a t o r

The te s ts w i l l be adm inistered by Brad Broeder, CRC, who is the

usual a d m in is tra to r in the Vocational Assessment Group in the R e h a b ili­

t a t i o n A c t i v i t i e s Department. The t e s t is one o f three custom arily given

as p a r t of the vocational b a ttery. The length of the t e s t - t a k i n g time is

45 t o 60 minutes on the average.

E s te lle Douglas, CRC, D ir e c to r of the Department of R e h a b ilit a tio n

A c tiv itie s , has given her approval of the study.


I ll

I f there is any f u r t h e r m ateria l or inform ation needed, please

contact me a t 470-4378/4525.

Thank you f o r your review of t h is m a t e r ia l.

S in c e re ly , ? ^
' 7 ] ’- H x f U ' ^ l C-
Mary V. Donohue, OTR, MA
Supervisor, A f t e r Care A c t i v i t i e s
112

A STUDY OF THE RELATIONSHIP BETWEEN AGE AND SOCIAL DEVELOPMENT

AMONG FEMALE PSYCHIATRIC PATIENTS

WITH THREE MAJOR DIAGNOSES

INTRODUCTION

Eight years ago in the R e h a b ilit a tio n Therapy Department a t the

H i l l s i d e D iv is io n two social reference groups were established to enable

men and women to re la x in a l e is u r e and social a c t i v i t y group c a lle d

reference groups. The goal o f the Men's and Women's Groups is to a s s is t

the recovering p a t ie n t in engaging in attempts a t re s to rin g in t e r a c t io n

with others in a relaxed environment.

The women's group was so popular t h a t i t was soon divided in to two

age groups, 21 to 30 and 31 to 50, f o r the sake of addressing the d i f f e r ­

ent problems of the two age groups in cohort groups. Cohort groups

con sist of those people who have experienced s i m il a r l i f e - e v e n t s because

of being born in to the same decade or era.

Although the d iv is io n in to two age groups had i t s m e r its , i t was not

long before i t became apparent t h a t the o ld e r group had g r e a te r a b i l i t y

to i n t e r a c t s o c ia l l y and developed a cohesive s p i r i t more e a s il y .

C u rio s ity then arose around the fa c to rs which might c o r r e la t e with

the social d iffe re n c e s observed in the two age groups of females: age-

development, diagnoses, cohort group experience, or the number of

h o s p it a liz a t io n s . Hypotheses have been developed to s ta te how these

fa c to rs of age-development, diagnoses, cohort groups and the number of

h o s p it a liz a t io n s might have been responsible f o r the observed d iffe r e n c e

in the two groups.


113

The study w i l l examine the scores of three social scales on the

C a li f o r n ia Psychological Inventory (CPI) f o r female p s y c h ia tric p a tie n ts

of the two age groups 21 to 30 and 31 to 50, and how they in t e r a c t with

the other possible i n f l u e n t i a l fa c to r s : diagnosis, cohort groups, and

number of h o s p it a l iz a t i o n s .

I t is hoped t h a t the study w i l l enable r e h a b i l i t a t i o n a c t i v i t y

s t a f f to b e t t e r understand what fa c to rs are in flu e n c in g social s k i l l

development in order to take these in to consideration when assessing

p a tie n ts f o r s o c i a l - i d e n t i f i c a t i o n group assignment, as well as to design

and s e le c t the most s u ita b le plans f o r a c t i v i t i e s - t r e a t m e n t .

A more d e ta ile d o u t lin e of the protocol of the study is attached.


114

OUTLINE OF PROTOCOL

THE PROBLEM AND ITS BACKGROUND

The subject of t h is study is the observed d iffe r e n c e in social

s k ill development in two age groups of female p s y c h ia tric p a tie n ts in

the R e h a b ilit a tio n A c t i v i t i e s Department of the H i l l s i d e D iv is io n of

the Medical Center. Questions arose as to whether the source of the

d iffe r e n c e might be a t t r i b u t e d to social age-development, or to diag­

nosis, cohort group or number of h o s p it a l iz a t i o n s .

STATEMENT OF THE PROBLEM

What is the r e la tio n s h ip among the fa c to rs of age, diagnosis, cohort

group, the number of h o s p it a liz a t io n s among female p s y c h ia tr ic p a t ie n t s ,

and t h e i r development of the social s k i l l s of s o c i a b i l i t y , social pres­

ence and s o c ia liz a tio n ?

HYPOTHESES

1) The o ld er group of female p s y c h ia tr ic p a tie n ts w i l l demonstrate

an increase in s o c i a b i l i t y , social presence and s o c ia l i z a t i o n over the

younger group.

2) The increasing age of the cohort groups w i l l c o r r e l a t e with

increasing social s k i l l development among the female p s y c h ia tr ic p a t ie n t s .

3) N either a g re a te r nor a le s s e r number of h o s p it a liz a t io n s w i l l

vary c o n s is te n tly w ith higher or lower scores in social s k i l l s among the

female p s y c h ia tr ic p a t ie n t s .

4) The female p s y c h ia tr ic p a tie n ts with a f f e c t i v e disorders w i l l

demonstrate g re a te r s o c i a b i l i t y , social presence and s o c ia l i z a t i o n than

those w ith a schizophrenic diagnosis.


115

DELIMITATIONS

The d e lim ita tio n s of t h is study have been determined as:

1) Three diagnoses

2) Female sex

3) Two age groups: 21 to 30; 31 to 50

4) Average socioeconomic and educational le v e ls of average

H i l l s i d e p a tie n ts

THEORETICAL FRAMEWORK

The th e o r e tic a l framework consists of the fo llo w in g areas discussed

around the th eo ries of the authors c ite d :

1) A g e-related developmental theory: Erikson, Mosey, Douglas,

Cohan and P e tr o lin o , Sheehy, Levinson, Gould, Goldman, Brim and

Kagan, Block

2) Theories of p s y c h ia tr ic disorders: P in e l, K ra e p lin , B le u le r ,

Mednick, Meissner, K le in , Lewinsohn

3) Theory of sex d iffe re n c e s : K e ll y , Megargee, Becker

4) Cohort group theory: Goulet and B a lte s , W oh lw ill, Kuhlen and

Thompson, Strauss and Carpenter, Coe, White

5) Theory of e f f e c t s of h o s p it a liz a t io n s : Strauss and Carpenter,

Coe, White

6) Theory of social s k ill development in p s y c h ia tric p a tie n ts :

Mosey, F i d l e r and F i d l e r , Donohue, S u lliv a n , Meissner

SIGNIFICANCE OF THE STUDY

Greater understanding of the biopsychosocial aspects of social s k ill

development in p s y c h ia tr ic p a tie n ts would help to c l a r i f y expectations of


116

r e h a b i l i t a t i o n t h e r a p is ts in working w ith p a tie n ts in social a c t i v i t y

groups.

Cancro, Cromwell, S u lliv a n , Meissner, Becker, Strauss, Luchins.

RELATED RESEARCH LITERATURE

An extensive study o f the r e la te d research l i t e r a t u r e has focused on

the fo llo w in g areas with discussion from authors l i s t e d :

1) Pre-morbid social competence and outcome f o r p s y c h ia tr ic

p a tie n ts : Zubin, Farina and Webb, Z i g l e r and P h i l l i p s ,

G ittle m a n -K le in and K le in , Strauss and Carpenter, Beck,

L a n g fe ld t, Kanter, G o ld s te in , Cromwell, Sanes, Vaughn and L e f f ,

R ounsaville, Klerman and Weissman, Kane, R i f k in , Q u itk in , Nayak

and Ramos-Lorenzi

2) Age, sex and cohorts: Block, Costa and McGrae, Brim and Kagan,

K e lly , C a t t e l l

3) Social s k i l l s , S o c i a b i l i t y , s o c ia l i z a t i o n and social presence:

Grupp, Ramseyer and Richardson, H i r t and Cook, Shaie, Gough

4) Diagnostic d e lin e a tio n s and groupings: L e f f and Wing, C a ffe y ,

and K l e t t , K le in , Tsuang and Winoker, Tsuang, Dempsey and

Rauscher, Pope, L ip in s k i and Cohen, Kane, R i f k in , Q u itk in ,

Nayak and Ramos-Lorenzi, Kovacs, Rush, Beck, Hal Ion, Brown,

Johnston and M a y fie ld , Brown and Shuey

RESEARCH DESIGN AND METHODOLOGY

This proposal's design is t h a t of a basic cross -s ectio n a l survey,

with data c o lle c te d over several months, by examination of each subject

a t one p o in t in tim e. In i t s scope, i t is a psychosocial i n v e s t ig a t io n ,

which is assessed by the R e h a b i li t a t i o n A c t i v i t i e s Department to be


117

research presenting no ris k to su b jec ts. The subjects w i l l not be

i d e n t i f i e d from data presented in the f i n a l re p o r t.

S e le c tio n of the Sample and Sampling Method

The s e le c tio n of the sample w i l l c o n sis t of voluntary p s y c h ia tric

p a tie n ts of the two age groups and s t r a t i f i e d by the three diagnoses: (1)

Schizophrenic, residual and u n d if f e r e n t i a t e d types; (2) Schizophrenic,

paranoid type; (3) Major a f f e c t i v e diso rd ers. The sampling method w i l l

be a f o r t u it o u s s e le c tio n of 150 female p s y c h ia tr ic p a t ie n t s , c o lle c t in g

48 subjects in each of the three diagnostic categories w ith 24 subjects

o f each of the two ages in each diagnostic groupings.

Data C o lle c tio n Procedures

The data w i l l be c o lle c te d by adm inistering the C a l i f o r nia Psycho­

lo g ic a l Inventory (CPI) to p a tie n ts s u f f i c i e n t l y re c o n s titu te d to enter

the A c t i v i t y Therapy Program, which custom arily begins with a b a tte ry of

vocational te s t s . Thus, the research involves the manipulation of an

e s ta b lis h e d process of vocational e v a lu a tio n in a conventional and

accepted manner so as not to place the subject a t r is k . There is no

randomization involved.

For the purposes of determining diagnoses and number of h o s p it a l ­

iz a tio n s , i t w i l l be necessary to e x t r a c t inform ation from the medical

c h a rts , however, the an alysis and re p o rtin g of data w i l l be by way of

looking a t groups, not in d iv id u a ls . Three of the 18 CPI scales w i l l be

analyzed: s o c i a b i l i t y , social presence and s o c ia l i z a t i o n .

I t is understood by t h is in v e s t ig a t o r t h a t a n o -ris k protocol does

not necessarily o bv iate the need f o r a consent form; nevertheless, i t is

hoped t h a t t h is study with a t y p ic a l p e r s o n a lity t e s t embedded in an


118

accepted b a tte ry of vocational te s ts may be considered in the category

which does not require a consent form since the adm inistering of such

vocational assessments is a ro u tin e p r a c tic e in the R e h a b ilit a tio n

A c t i v i t i e s Department.

• The checking of charts f o r diagnoses and number of h o s p it a liz a t io n s

w ill be of a r e tro s p e c tiv e nature.

Treatment o f Data

The s t a t i s t i c a l procedures f o r analyzing the data w i l l con sist of

tab les based on analysis of variance or t - t e s t s or F - t e s t s , as well as

Pearson's ' r ' and Spearman c o r r e la tio n s (K e n d a ll's r - t e s t s ) .


119

LO N G ISLAND JEW ISH - HILLSIDE MEDICAL CENTER

MEM ORANDUM

To M s . Mary Donohue November 29, 19d2


^ D a te 1
r

From Mrs. Judith Sloan Subject


Coordinator - HSRC

We are pleased to inform you that the Human Subjects


Review Committe has approved your project entitled

A Study of the Relationship between Age and Social Development


Among Female Psychiatric Patients with Three major Diagnoses

as a no risk study.

Kindly notify the Research Grants Office when you


have completed the project.

Thank you for your cooperation.


APPENDIX B

C a l i f o r n i a Psychological Inventory
(CPI) by Harrison Gough, Ph.D.

1) Test Booklet
May be obtained
2) D escription of Scales from Consulting
Psychologists
3) P r o f i l e Sheet Press

4) Correspondence from Harrison Gough, Ph.D.

5) Correspondence from David Rogers, Ph.D.

120
U N IV E R S IT Y OF C A L IF O R N IA , BERKELEY 121

l l L H K L l. K Y • D A V IS • I K Y i S b • I.O S A N L F L K S • H I Y L H S I D i: • S A N D IK C O • SAN FH AN C TS C O S A N T A H A IU IA K A * S A N T A C IU .’ Z

IN S T IT U T E O F P E R S O N A L IT Y A S S E S S M E N T 3657 T O l.M A N H A L L
A N D RESEA R C H B E R K E L E Y . C A L IF O R N IA 94720

March 19, 198h

Mary V. Donohue
60-25 Marathon Parkway
Little Neck, Ne w York H 362

Dear Ms. Donohue:

Very often the CPI, and other long self-report tests, is given in a bat­
tery that may require two or more hours to finish. In these circumstances,
an inventory may he partly finished at one setting, then completed at another.
I have seen this occur hundreds if not thousands of times with the MMPI, when
patients had the test booklet and answer sheet in their possession for a day
or more at a time. In our work with non-patients here at IPAR \.e frequently
mail an envelope of tests to a client, and ask that the forms be completed
over a period of seven to 10 days. In one of the Cali'ornia correctional
centers, the CPI is administered by means of a tape, during a week of intake
activities. If the tape is unfinished and lunchtime occurs, the wards simply
stop where they are on the inventory and return to it after eating.

In other words, the conditions of testing in this realm arevery diverse,


and the model of all persons completing the full test, under supervision, in
a single sitting seldom obtains. It is my own opinion that results are as
valid in the take-home, interrupted, and auditory modes as they are in the
ordinary one of a single session.

One way to mol* sure that nothing untoward has occurred is to scan the
test profiles for evidence of faking or invalidity. Random answering on the
CPI is easily detected by unusually low scores on Cm. Fake good and fake bad
protocols are also fairly easy to spotted by noting scores on Gi and Wb. These
three scales are sensitive indicators of non-modality in responding to the
test. For more precise identification of unreliable protocols, falee-detecting
formulas have been developed. For visual inspection, I suggest these cutting
points as indicative of possible invalidity: VTb scale, scores less than 19:
Gi, scores greater than 31; aBi Cm, scores less than 15. These numbers all
refer to raw scores.

Let me know if you need or want anything else from me. I think your plan
to allow two b-5-minute periods to complete the CPI is a good one, and it should
give reliable data.

Sincerely

Harrison G. Gough
U N IV E R S ITY O F C A LIFO R N IA , BERKELEY 122

H L H K L l.L Y • DAVIS • 1HVINK • M IS A M . I M S • 11 I VL HMI IF '. • S AN ’ D I M . O • SAN FH A N C 1M O S A N T A IIAllh \H A ■ S A N T A I III Z

IN S T IT U T E O F P E R S O N A L IT Y A S S E S S M E N T 36S7 T O I.M A N IIA L L


A N D RESEA R C H B E R K E L E Y , C A L IF O R N IA 94720

September 14, 1982

Mary V. Donahue, OTR, MA


60-25 Marathon Parkway
Little Neck, New York 11362

Dear Ms. Donahue:

Thank you for letting me know about your thesis on social skills of
psychiatric patients. It sounds like an interesting project.

The psychiatric samples reported in the manual came from routine testing
at the Cleveland Clinic in Ohio. David Rodgers, Ph.D., chief of the psychology
service there, has developed a standard testing battery that includes both the
CPI and the MMPI. Because of this, CPI profiles are available for a large
number of patients, and he was kind enough to send me the descriptive statistics
reported in the manual.

It is quite a task to keep up with studies using the CPI or making references
to CPI findings. I find that the Psychological Abstracts misses at least half of
the studies, even many that are summarized in the volumes themselves. This is
because the test is often used without being cited in the references, which means
a search of citations will miss the paper, and because in non-APA journals the
test Is often referred to as the CPI, an abbreviation not officially recognized
by the APA and hence overlooked in its PASAR computer sweeps.

I make a trip to the library about twice a month, and try to find references
for inclusion in my comprehensive bibliography, but I miss many studies too.
Every now and then I read a paper using CPI data, and find in the references for
that paper two or three studies with the CPI that are entirely new to me. I
mention all of this because on a special topic such as the effect on CPI scores
of neuroleptics and anti-depressants is one on which there may well be studies
unknown to me.

On the attached sheet I have listed some references of general relevance to


problems in psychiatry, psychotherapy, etc. I am also enclosing several "mini­
bibliographies" that I have prepared and in stock for reply to inquiries about
frequently recurring issues such as drug abuse. You may find studies of interest
tn these minibibliographies. I hope these things will be of help to you. If
you need or want anything else from me please let me know.

Harrison G. Gough
Director

Enclosure
12.3

T he C l e v e l a n d C l in ic F o u n d a t io n
U500 Kuclkl Avenue Cleveland, Ohio I'.S.A.

David A. Kodtfers, Ph.D.


Head. Section of Psychology
2 1 (> /4 4 4 -f)8 l4
October 22, 1982

Mary V. Donohue, M.A, O.T.R.


60-25 Marathon Parkway
Little Neck, NY 11362
Dear Ms. Donohue:
We use the CPI routinely in our clinical work with both psychia­
tric and general medical patients at the Cleveland Clinic. How­
ever, we do not have separate norms for these patients. Nor
could I easily pull together norms of any representative sort.
Hence, I am afraid I cannot be of much help to you in providing
comparison norms for your patient sample.
Most of our patients seem to be individuals that I would find
difficulty categorizing into normative groups anyway. Perhaps
this is one reason that I have never developed norms.

Sincerely yours,

David A. Rodgers, Ph.D.

DAR:ki
APPENDIX C

Covariance Matrices
Hi stograms
Scattergram

124
125
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A N A L Y S I S OF 3 O I AG N U S E S , UNSET A G E , J S O CI AL SKILLS 10/

r o t a t e d st a n u a h o i z t o j i s c r i m i n a n i f u n c t i o n c c e f f i l i e n i s
VARI ABLES ABE CRt EHEO BY ThL FUNCTI ON W I T h LARGEST C O E F F I C I E N T A NO THE MAGNI TUDE OF THA
FLNC I FUNC 2
SY 0 . 9 2662 * -0.04673
ONSEI 0.53027* - 0 . 1 j 392
SCC - 0 .20699 1.0172E*

UNST AN U A K O I 2 E 0 CANONI CAL DISCRIMINANT FUNCTI ON COEFFICIENTS


FUNC I FuNC 2
ONSET 0.54580040-C l -0.26169550-01
SY 0 .7 9 4 7 0 9 7 0 -C l - U .40076 2 9 L-02
SOC - 0 . 22.2125JU-C1 0.1C91656
(CONSTANT) -4.720708 -3.C16S45

CA N O N I C A L DISCRIMINANT F U N C T I CN S EVALUATED AT GROUP BEANS (GROUP CENTBOI CS)

GBCUP FLNC 1 FUNC 2


- C . 4 72 8 6 0.01901
- C . 0 7944 ■ 0. 2. 447 J
0 .5 5 2 3 0 0 . 2 25 76

TEST OF E O J A L I I Y U F GROUP COVARI ANCE MAT RI CE S LSINo BOA' S M


THE RANKS A N t NATURAL LCGARUF. MS OF DE T E R M I N A N T S PRlNTEc ARt 1FUSL
OF THE GROUP COVARI ANCE M A I B I C L S .

GROUP LABEL RANK LOG OE TERM I NANT

1 3 12.287298
2 J 11. 8 5 3 5 6 5
3 i 13.352151
POOLEU n 1 I h l N - G R O L P S
COVARI ANCE M A T R I X 12. 6 16704

BOX' S M APPROXI MATE DEGREES OF FREECOM SIGNIFICANCE


26.595 2.1052 12. J666C .5 0.0136

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