Introduction:
Difficulty with abstract thinking, especially maladaptive, concrete thinking, is considered
a primary symptom of schizophrenia, evidenced by previous work done by Bleuler and
Goldstein. Gorham demonstrated a significant drop between controls and patients with
schizophrenia in abstract scores and a rise in concrete scores, indicating severe impairment in
abstract thinking in these patients. Assessing abstract thinking is essential not only in diagnosing
schizophrenia but also in measuring positive responses during treatment.
The positive and Negative Syndrome Scale (PANSS) is the most commonly used method
to assess symptoms of schizophrenia in clinical and research settings. PANSS consists of
Positive Symptoms Scale, which evaluates delusions, hallucinations, and disordered thinking,
and Negative Symptoms Scale, which evaluates apathy and avolition. The Abstract Thinking
subscale (N5) of PANSS consists of 32 items: 16 similarities and 16 proverbs. Similarities and
proverbs are divided into blocks of four. On each administration, the patient is asked four from
each type, one from each block. Scoring is based on responses to similarities and proverb
interpretation and the interviewer's assessment of concrete versus abstract thinking.
Both the interpretation and assessment are subjective and dependent on the interviewers,
depending on their cultural background and the types of similarities and proverbs questions. On
the other hand, interviewees' responses are highly variable, depending on their ability for abstract
thinking, cultural background, and familiarity with the proverbs. The proverbs are highly cultural
and language-specific. Even with translation, it would be hard for non-English speaking patients
from another culture to make sense of them, given the lost-in-translation phenomenon and
cultural specificity. Given the shortcomings of PANSS, we propose to combine it with the five
mood differentiation questions and the pictogram test to assess patients with schizophrenia in a
more culturally universal way.
Dr. Richard Powell developed the five mood differentiation questions to assess abstract
thinking in patients with schizophrenia. "Do you ever take a look at yourself and say, "gee, I
guess I must be hungry/anxious/depressed/angry/afraid? If so, how would you know it must be
hungry/anxious/depressed/angry/afraid, not something else?" In contrast to PANSS, these five
questions inquire about culturally universal feelings. They effectively provide information
regarding the patient's level of ego-organization: normal/neurotic, borderline, or psychotic/ pre-
psychotic, corresponding to well-differentiated, poorly differentiated, and undifferentiated
moods, respectively.
Past research has shown that verbal memory dysfunction happens early in patients with
schizophrenia (Hill, Beers, Kmiec, Keshavan, & Sweeney 2004). Logical memorization is a part
of the ideational component of thinking that addresses how inputs from the environment are
conceptualized (Exner, 1991). Deficient associative memory could cause difficulty organizing
information. The pictogram test delves into association development during mediated
memorization and logical memory organization. It involves mediated memorization of 16
abstract words and phrases for one hour; then, examinees are asked to draw pictograms that will
help them memorize the phrases. Drawings are analyzed, and selection is explained. Birenbaum
noticed that patients with schizophrenia produced concrete drawings with unnecessary details or
overly abstract drawings without connection to the target. Pictogram studies in other cultures
showed similar results in patients with schizophrenia.
Study design:
Our study aims to demonstrate that combining the mood differentiation questions and the
pictogram test with PANSS improves inter-rater reliability in diagnosing patients with
schizophrenia than using PANSS alone. It will consist of two parts, the mood differentiation
study, and the pictogram study.
For part 1, since we had no idea the type of responses we could get from these patients,
we decided to conduct a pilot study first using the five mood differentiation questions in 20
patients with schizophrenia on 4B at Upstate. The writer interviewed 20 patients with
schizophrenia and recorded their responses on paper. Then another researcher, Tommy, rated
those responses based on the scoring guide that tailors the framework of mood differentiation
booklet by Dr. Robert Powell to The New PANSS Scoring Guide for N5 by Dr. Luba Leontieva
as the following.
1: Normal/neurotic, demonstrating well-differentiated mood-
Directly addresses how the patient personally knows when the specific mood is present. May
focus on intra-psychic or physiologic aspects of experiencing the mood.
2-3: Marginal-
Not an utterly perfect response with some inaccuracy in abstraction or otherwise be
idiosyncratic.
4-5: Literal/functional response, demonstrating poorly differentiated mood and significant
problems with abstraction-
-Treatment response: focuses on the action the person takes upon sensing the presence of
mood.
-Concrete response: relates the mood to recent percepts or specific examples/anecdotes.
-Externalization response: relies on outside indicators to sense how they feel.
-Universalization: assumes everyone in the world formulates moods in the same way.
6-7: Incorrect/psychotic response, demonstrating undifferentiated mood-
Unable to address how they know a particular mood is present. Patients may deny
experiencing the mood at all and may otherwise be too distracted or preoccupied with internal
stimuli to answer.
Our results from the pilot study indicate that most of the twenty patients provided normal/
neurotic responses to questions regarding feeling hungry/depressed despite their schizophrenia
diagnoses. However, many of them struggled with questions regarding feeling
anxious/angry/scared. This discrepancy suggests a possible heuristic approach to answering the
more frequently asked questions. Uncommon questions regarding feeling anxious/angry/scared
effectively revealed their concrete thinking.
Our next step is to test the mood differentiation questions in a control group of 20 people
without mental illness. The control group will shed light on the above suspicion of the heuristic
approach on hunger/depression questions in patients with schizophrenia and the differences
between the two groups. A Control group study will be done similarly where the writer will
interview 20 people without mental illness and record their responses on paper. Then Tommy
will rate those responses based on the scoring guide. After this is done, the following step is to
assess inter-rater reliability where we have a second rater with a completely different cultural
background from Tommy, rate the 40 responses, blind to the group assignment, according to the
same scoring guide.
The differences in ratings by the two raters and responses among the two groups will be
analyzed statistically using weighted Cohen's Kappa statistic in Stata, IC. Part 2 pictogram study
will be done in the same manner as part 1 in terms of having one interviewer, two groups of 20
interviewees (patients with schizophrenia vs. standard control), two raters with different cultural
backgrounds, and the Cohen's Kappa statistical test to analyze the group differences & inter-rater
differences. The inter-rater reliability and effectiveness in group differentiation will be elucidated
regarding the mood differentiation questions (part 1) and the pictogram test (part 2) and then
compared with that of PANSS.
References:
1. Bleuler E (1950) Dementia Praecox or the Group of Schizophrenias. New York:
International Universities Press.
2. Goldstein K (1959) Concerning the concreteness in schizophrenia. J Abnormal Social
Psychol 59: 146-148
3. Benjamin JD (1944) A method for distinguishing and evaluating formal thinking
disorders in schizophrenia. In: Kasanin JS (ed.) Language and Thought in schizophrenia,
Berkley, Calif,: University of California Press, pp: 65-90
4. Gorham DR (1956) Use of the Proverbs Test for Differentiating schizophrenics from
Normals. J Consulting Psychol, 20: 435-440.
5. Leontieva L, Dimmock J, Carey K, et al. (2019) Development of a Scoring Guide for the
Positive and Negative Syndrome Scale (PANSS) Abstract Thinking Subscale. Clin
Psychiatry Vol.5 No.1:61
6. Exner JE (1991). The Rorschach: A Comprehensive System: Vol.2: Interpretation (2nd
ed.). New York: Wiley.
7. Hill SK, Beers SR, Kmiec JA, Keshavan MS, & Sweeney JA (2004). Impairment of
verbal memory and learning in antipsychotic-naïve patients with first-episode
schizophrenia. Schizophrenia Research, 68, 127-136.
8. Leontieva L, Rostova J, Tunick R, Golovko S, Harkulich J & Ploutz-Snyder R (2008).
Cross-cultural Diagnostic Applicability of the Pictogram Test. Journal of Personality
Assessment, 90:2, 165-174
