Schizophrenia Research, 8 (1992) 119-123 ‘G 1992 Elsevier Science Publishers B.V. All rights reserved
SCHIZO
119 0920-9964/92/$05.00
00262
Repetitive behaviors in chronically institutionalized patients Daniel
J. Luchinsavb,
Morris
B. Goldmanaqbgc,
Mark
Lieb”
and
Patricia
schizophrenic
Hanrahana,b
“Department of Psychiatry. Pritzker School I$ Medicine, University of Chicago, Chicago, IL, USA, bIllinois State Psychiatric Institule, Chicago, IL, USA, and ‘E&n Mental Health Center, Chicago, IL, USA (Received
27 February
1992; revision
received
17 July 1992; accepted
27 July 1992)
bulimia, hoarding, mannerisms) are frequently Repetitive dysfunctional behaviors (e.g., polydipsia, observed in chronically institutionalized schizophrenics, cause significant morbidity and are readily reproduced in animal models. The goal of this study was to assess the frequency and severity of these behaviors. Thirty-two chronic schizophrenics on an extended treatment unit were rated on the Elgin Behavioral Rating Scale, which includes eight repetitive behaviors and eight positive and negative symptoms. Fortyseven percent of the patients exhibited at least one severe, or 2 moderate, repetitive behaviors, while 63% exhibited at least one severe or 2 moderate positive or negative symptoms. The mean total score (i SD) on the eight repetitive behaviors (10.3 + 6.1) was about 2/3 that for the eight positive and negative symptoms (15.3k8.9, r=4.l, p= .OOOl). Interrater reliability for the repetitive behaviors was similar to that for the positive and negative symptoms. Repetitive behaviors were positively related to male gender, white race and total length of hospitalization. Repetitive dysfunctional behaviors are frequently observed and can be reliably rated in chronically institutionalized schizophrenics. Kq
words: Repetitive
behaviors;
(Schizophrenia)
INTRODUCTION
During the past decade, investigators have focused on the significance of positive (e.g., delusions, hallucinations, formal thought disorder) and/or negative (e.g., blunted affect, lack of motivation, social withdrawal) symptoms to the pathophysiology and treatment of schizophrenia (Crow, 1980; Andreasen, 1982) and have largely ignored a group of symptoms not easily subserved by either category. Although rather heterogenous, these symptoms can be conceptualized as the dysfunctional repetition of a behavior that under other circumstances is normal. Such behaviors include polydipsia, bulimia, pacing, excessive smoking, Correspondence fo: D.J. Luchins, Department of Psychiatry, University of Chicago, 5841 S. Maryland Ave, Chicago, Illinois 60637, USA.
pica, bizarre grooming, hoarding and mannerisms. Many of these were observed by Bleuler (1950), and later included by Arieti (1974), as part of the ‘terminal’ stages of schizophrenia. Arieti noted that these behaviors appear similar to those described by Kluver and Bucy (1939) in animals with anterior bitemporal lesions (hyperorality, hypersexuality, hypermetamorphosis, and passivity). While most of these behaviors have not been systematically assessed, some have. Polydipsia is the best studied, and occurs in about 25% of inpatient chronic schizophrenics, irrespective of medication use (Sleeper, 1935; Lawson et al., 1985). Smoking has also been shown to be increased in schizophrenics (80%) versus the general population (56%; Masterson and O’Shea, 1984) while repetitive, stereotypic movements occur in over 40% of schizophrenics but not in affective disorder patients (Manschreck et al., 1982).
120
These symptoms cause significant morbidity. Polydipsia is associated with protozoa1 infections, urinary tract dysfunction, pathological fractures, and water intoxication (for review see Goldman, 1991). In many cases, polydipsia and water intoxication are primary reasons a patient cannot be discharged from the hospital. In our clinical experience, bulimia not infrequently leads to death from choking, and pica causes bowel perforation. The sequelae of smoking are well-known. Repetitive behaviors may also be of interest for theoretical reasons. In animal experiments the tendency to develop repetitive behaviors is increased by hippocampal lesions (Davenport et al.. 1981). The hippocampus is frequently noted to be abnormal in brain imaging and neuropathological studies of schizophrenics particularly in those with repetitive behaviors such as polydipsia (Suddath et al., 1989). On the basis of such observations, we had previously hypothesized (Luchins. 1990) that hippocampal dysfunction might be the neurobiological substrate for the development of repetitive behaviors in schizophrenics. As a step toward better understanding of repetitive behaviors in schizophrenia, we undertook a study of their prevalence and severity.
(social withdrawal, blunted affect, motor retardation and depressive mood) drawn from the Psychiatric Symptoms Assessment Scale (PSAS; Bigelow and Berthot, 1989). These positive and negative symptom items were chosen to allow us to compare the severity of repetitive behaviors and the more commonly described schizophrenic symptoms. Items were scored using anchor points on a 7-point scale with 0 = none, l-2 = mild, 334 = moderate, and S-6 = severe symptoms. Patients were assessed using the Elgin Scale by nine different mental health technicians working on the day shift. Each was paid a small additional stipend for participating. The raters were trained over four sessions in which consensus was established on the basis of simultaneous group ratings. Each patient was rated by a mean of 2.2 raters for a one week period. Raters assessed patients three times weekly at the end of the shift for symptoms shown during that day. and again at the end of the week to generate an overall rating of symptoms seen during the week. Mean weekly ratings are reported here. Interrater reliability was assessed by calculating percentage agreement (mild, moderate or severe) for all ten instances when two different raters carried out their weekly assessment on the same patient during the same week.
METHODS RESULTS Subjects were 32 chronic schizophrenics residing in a 70 bed extended-treatment unit at Elgin Mental Health Center. This protocol was approved by the facility’s Institutional Review Board. Diagnosis was made by their consulting psychiatrist (MBG) using DSM-IIIR criteria. To assess repetitive behaviors and contrast them to other schizophrenic symptoms the ‘Elgin Behavioral Rating Scale’ was developed. After reviewing Bleuler (1950) and Arieti (1974) we included eight repetitive behaviors (bizarre grooming, bulimia, hoarding. nicotine associated behaviors, pacing, pica and polydipsia). In addition, hypersexuality was added to test Arieti’s hypothesis that some patients’ behavior was analogous to monkeys with temporal lobectomies. The instrument also includes four positive symptoms (hallucinating behavior, suspiciousness, unusual ideas and disorganized speech) and four negative symptoms
The 32 patients (56% female, 59% black) had a mean age of 39 (SD= 19) years, a mean of 10.7 ( f I .6) years of education and had spent a mean total of 16.7 (+ 6.7) years in hospital. Their mean antipsychotic dosage in chlorpromazine equivalents was 538 (i418) mg (Davis, 1964). The mean (i SD) severity of symptoms is presented in Fig. I. The mean total score on all eight repetitive behaviors (10.3 +6.l) was less than that for the eight positive or negative symptoms (15.3+8.9 t=4.1, 1,=0.0001). Fifteen of the 32 (47%) patients had at least one severe or two moderate repetitive behaviors while 20 (63%) met this criterion for the positive or negative symptoms. Eleven of the fifteen (73%) who met this criteria for repetitive behaviors also did so for positive and negative symptoms. To test the hypothesis that these behaviors are
121
seven most reliably rated repetitive behaviors. Using a backward multiple regression, gender. with a preponderance of symptoms in males, was the strongest correlate (Beta = 0.43, p = 0.02); next was a positive relationship to total length of hospitalization (Beta = 0.38, p = 0.03); and the last significant variable was race, with a preponderance of symptoms amongst white patients, (Beta = 0.38, p = 0.03). Neither age, education nor antipsychotic dose were significantly related. A comparable analysis for the three reliable positive symptoms revealed no significant relationships to the demographic and clinical variables. A similar analysis using the three reliable negative symptoms revealed one significant relationship, that with gender (male preponderance, Beta = 0.40, p = 0.04).
AVERAGE GLOBAL RATINGS (f. STANDARD DEVIATION) Negative Symptoms Motor Retardation Blunted Affect Depression Social Withdrawal Positive Symptoms Unusual ideas Suspiciousness Hallucinations Disorganized Thoughts Repetitive
Behaviors Pica Polydipsia Hoarding Bulimia Grooming Hypersexuality Pacing Nicotine Mannerisms 0
0.5
1 Mean
1.5 Scores
2
2.5
Fig. I. Mean (k SD) gobal ratings for 32 chronically hospitalized schizophrenics on the Elgin Behavioral Rating Scale.
DISCUSSION
part of a Kluver-Bucy syndrome, we examined the correlation of hypersexuality to oral symptoms. Hypersexuality was significantly correlated only with bulimia (r= 0.45, p= 0.009) but not with smoking (r = - 0.05, p = 0.78), pica (r= - 0.005, p = 0.98) or polydipsia (r = 0.10, p = 0.60). The mean percentage of interrater agreement for the eight repetitive behaviors was 85%, while it was 74% for the eight positive or negative symptoms. Only one of the eight repetitive behaviors (mannerisms), one of the four positive (disorganized speech), and one of the four negative symptoms (social withdrawal) had a percentage of interrater agreement of less than 70%. The seven most reliably rated repetitive behaviors tended to be intercorrelated with the standardized item alpha=0.71. To examine the relationship of repetitive behaviors with negative and positive symptoms we correlated the scores of the seven most reliably rated repetitive behaviors with those of the three most reliably rated positive and the three most reliably rated negative symptoms for all 32 patients. The total score for these repetitive behaviors was significantly correlated with that of the positive (r = 0.50, p = 0.004) but not of the negative symptoms (r = 0.27, p = 0.1). We computed the relationship of the patients’ demographic and clinical characteristics to the
We believe this is the first study to quantify the prevalence and severity of repetitive behaviors in chronically hospitalized schizophrenics. Because neither acutely hospitalized schizophrenics nor other diagnostic groups were studied, the results are relevant only to this specific population, in which such behaviors appear to be widespread. Although comparison of the severity of different symptoms is problematic, the eight repetitive symptoms appeared to be about two thirds as prominent as the eight positive or negative symptoms. That 73% of the patients having one severe or two moderate repetitive behaviors, also met this criteria for positive and negative symptoms suggests that, within the chronically hospitalized population, patients with one form of psychopathology generally have the other. The percentage interrater agreement of the repetitive items on Elgin Behavioral Rating Scale was comparable to that of the negative or positive symptoms drawn from a scale previously shown to be reliable (Bigelow and Berthot, 1989). Since our raters were mental health technicians with little professional training and only four training sessions, it also suggests that a more skilled, better trained group of raters might obtain higher interrater reliabilities. Little support was obtained for Arieti’s view that these behaviors are similar to those seen in
122
animals with bilateral, anterior temporal lobe lesions, since hypersexuality was not correlated with most of the ‘oral’ behaviors (i.e. smoking, pica, or polydipsia). Mean total scores on repetitive behaviors were significantly correlated with ratings of positive but not of negative symptoms. This seems counterintuitive, since repetitive behaviors are related to length of hospitalization (see below), a factor associated with poor outcome and negative symptoms (Crow, 1980). That repetitive behaviors are not closely related to negative symptoms supports the view expressed in the Introduction that they are not easily subserved under the rubric of positive and negative symptoms. Repetitive behaviors were significantly correlated to two demographic factors, white race and male gender. The meaning of these findings is unclear, although in schizophrenia less severe psychopathology has often been associated with being female (Seeman, 1988). Repetitive behaviors were also related to increased total length of hospitalization. This is consistent with the view of Arieti (1974) that these symptoms occur in the later stages of schizophrenia and suggests that much lower rates of repetitive behaviors might be found in more acute settings. Since repetitive behaviors, but neither positive nor negative symptoms, were related to total length of hospitalization, it raises issues about the etiology of repetitive behaviors. Are they due to institutionalization, medication, nicotine, caffeine. or to a progression of the schizophrenic process? We believe these behaviors, like others, represent an interaction of biological determinants (including possibly the neurobiology of schizophrenia) and the environment (chronic hospitalization) and that greater understanding of these determinants might point towards ways to reduce the morbidity associated with them. If repetitive behaviors are as widespread and severe in chronic settings as our results suggest, then more effort should be directed towards their management and control. For example, teaching staff the Heimlich maneuver to reduce deaths from choking due to bulimia, and the targeted weight program to prevent water intoxication (Goldman, 1991). Obviously, the value of pharmacologic interventions requires assessment. WC found no relaantipsychotic dosage and tionship between repetitive behaviors but this was only a correla-
tional approach. Whether dosage adjustment would effect symptoms remains unknown. Again, in the case of polydipsia, which has been more extensively studied, dosage reduction generally leads to an exacerbation of water drinking (Goldman and Janecek, 1989). Further research is necessary to determine just how specific repetitive behaviors are to chronic schizophrenia, the course of their development and their response to other treatments besides psychotropic agents. Furthermore, the neurobiological substrate for these behaviors, including both possible neuroanatomical and neurochemical disturbances (see Luchins, 1990) warrant study.
REFERENCES
Andrcasen, N.C. (1982) Negative symptoms in Schizophrenia Arch. Gcn. Psychiatry 39, 7X4-788. Arirti, S. (1974) Interpretation of Schizophrenia Second Edition. Basic Books. New York. pp. 415.-422. Bigelow. L.B. and Berthot. B.D. (1989) The psychiatric Symptom Assessment Scale (PSAS) Psychopharm Bull. 25. 16X-179. Bleulcr. E. (I 950)Dcmcntia Precox or the Group ofSchizophrenias. International Universities Press. New York. Crow, T.J. (I 980) Molecular pathology of schizophrenia: More than one disease process. Brat. Med. J. 280. l-9. Davenport, L.D.. Davenport. J.A. and Halloway. F.A. (19X1) Reward induced stereotyples: Modulation by the hippocanpus. Science 212, 128X-1289. Davis, J.M. (1974) Dose equivalence of the antlpsychotic druss. J. Psychiatry Res. 2, 65-69. Goldman. M.B. (1991) A rational approach to polydipsia. hyponatremio and water intoxication. Hosp. Comm. Psychi;,try 42, 4XX494. Goldman. M.B. and Janicak. H.M. (1989) Neuroleptics do not worsen hyponatrcmia in hyponatremic psychotics. Schlr. Res. I. 171 I. Kluver. H. and Bucy. P.C. (1939) Preliminary analysis of the temporal lobes in monkeys. Arch. Ncurol. Psychiatry 42. 979- 1000. Lawson. W.B. and Karson. C.N.. and Bigelow. L.B. (19X5) Increased urine volume in chronic schizophrenic patxnts. Psychiatry Res. 14. 323-331. Luchins, D.J. (1990) A possible role of hippocampal dysfunctlon in schizophrenic symptomatology. Biol. Psychiatry. 2X. X7-91. Manschreck. T.C.. Mahcr. B.A., Rucklos. M.E. and Vcreen. D.R. (1982) Disturbed voluntary motor activity in schirophrenic disorder. Psych Med. 12, 73-84. Masterson. E.. and O’Shea. B. (1984) Smoking and malignancy in schizophrenia. Br. J. Psychutry 145, 429-432. Seeman. M.V. (198X) Schizophrenia in women and mtn. In:
123 Treating Chronically Mentally III Women. Edited by Bachrach, L.L. and Nadelson, C.C. Washington, DC: American Psychiatric Press. Sleeper, F.H. (1935) Investigation of polyuria in schizophrenia. Am. J. Psychiatry 91, 1019-1031.
Suddath, R.L., Foote, M.. Godelski. L., et al. (1989) MRI of polydipsia hyponatremia. Presented at 142th Annual Meeting of American Psychiatric Association, San Francisco, CA.
SCHIZO
119 0920-9964/92/$05.00
00262
Repetitive behaviors in chronically institutionalized patients Daniel
J. Luchinsavb,
Morris
B. Goldmanaqbgc,
Mark
Lieb”
and
Patricia
schizophrenic
Hanrahana,b
“Department of Psychiatry. Pritzker School I$ Medicine, University of Chicago, Chicago, IL, USA, bIllinois State Psychiatric Institule, Chicago, IL, USA, and ‘E&n Mental Health Center, Chicago, IL, USA (Received
27 February
1992; revision
received
17 July 1992; accepted
27 July 1992)
bulimia, hoarding, mannerisms) are frequently Repetitive dysfunctional behaviors (e.g., polydipsia, observed in chronically institutionalized schizophrenics, cause significant morbidity and are readily reproduced in animal models. The goal of this study was to assess the frequency and severity of these behaviors. Thirty-two chronic schizophrenics on an extended treatment unit were rated on the Elgin Behavioral Rating Scale, which includes eight repetitive behaviors and eight positive and negative symptoms. Fortyseven percent of the patients exhibited at least one severe, or 2 moderate, repetitive behaviors, while 63% exhibited at least one severe or 2 moderate positive or negative symptoms. The mean total score (i SD) on the eight repetitive behaviors (10.3 + 6.1) was about 2/3 that for the eight positive and negative symptoms (15.3k8.9, r=4.l, p= .OOOl). Interrater reliability for the repetitive behaviors was similar to that for the positive and negative symptoms. Repetitive behaviors were positively related to male gender, white race and total length of hospitalization. Repetitive dysfunctional behaviors are frequently observed and can be reliably rated in chronically institutionalized schizophrenics. Kq
words: Repetitive
behaviors;
(Schizophrenia)
INTRODUCTION
During the past decade, investigators have focused on the significance of positive (e.g., delusions, hallucinations, formal thought disorder) and/or negative (e.g., blunted affect, lack of motivation, social withdrawal) symptoms to the pathophysiology and treatment of schizophrenia (Crow, 1980; Andreasen, 1982) and have largely ignored a group of symptoms not easily subserved by either category. Although rather heterogenous, these symptoms can be conceptualized as the dysfunctional repetition of a behavior that under other circumstances is normal. Such behaviors include polydipsia, bulimia, pacing, excessive smoking, Correspondence fo: D.J. Luchins, Department of Psychiatry, University of Chicago, 5841 S. Maryland Ave, Chicago, Illinois 60637, USA.
pica, bizarre grooming, hoarding and mannerisms. Many of these were observed by Bleuler (1950), and later included by Arieti (1974), as part of the ‘terminal’ stages of schizophrenia. Arieti noted that these behaviors appear similar to those described by Kluver and Bucy (1939) in animals with anterior bitemporal lesions (hyperorality, hypersexuality, hypermetamorphosis, and passivity). While most of these behaviors have not been systematically assessed, some have. Polydipsia is the best studied, and occurs in about 25% of inpatient chronic schizophrenics, irrespective of medication use (Sleeper, 1935; Lawson et al., 1985). Smoking has also been shown to be increased in schizophrenics (80%) versus the general population (56%; Masterson and O’Shea, 1984) while repetitive, stereotypic movements occur in over 40% of schizophrenics but not in affective disorder patients (Manschreck et al., 1982).
120
These symptoms cause significant morbidity. Polydipsia is associated with protozoa1 infections, urinary tract dysfunction, pathological fractures, and water intoxication (for review see Goldman, 1991). In many cases, polydipsia and water intoxication are primary reasons a patient cannot be discharged from the hospital. In our clinical experience, bulimia not infrequently leads to death from choking, and pica causes bowel perforation. The sequelae of smoking are well-known. Repetitive behaviors may also be of interest for theoretical reasons. In animal experiments the tendency to develop repetitive behaviors is increased by hippocampal lesions (Davenport et al.. 1981). The hippocampus is frequently noted to be abnormal in brain imaging and neuropathological studies of schizophrenics particularly in those with repetitive behaviors such as polydipsia (Suddath et al., 1989). On the basis of such observations, we had previously hypothesized (Luchins. 1990) that hippocampal dysfunction might be the neurobiological substrate for the development of repetitive behaviors in schizophrenics. As a step toward better understanding of repetitive behaviors in schizophrenia, we undertook a study of their prevalence and severity.
(social withdrawal, blunted affect, motor retardation and depressive mood) drawn from the Psychiatric Symptoms Assessment Scale (PSAS; Bigelow and Berthot, 1989). These positive and negative symptom items were chosen to allow us to compare the severity of repetitive behaviors and the more commonly described schizophrenic symptoms. Items were scored using anchor points on a 7-point scale with 0 = none, l-2 = mild, 334 = moderate, and S-6 = severe symptoms. Patients were assessed using the Elgin Scale by nine different mental health technicians working on the day shift. Each was paid a small additional stipend for participating. The raters were trained over four sessions in which consensus was established on the basis of simultaneous group ratings. Each patient was rated by a mean of 2.2 raters for a one week period. Raters assessed patients three times weekly at the end of the shift for symptoms shown during that day. and again at the end of the week to generate an overall rating of symptoms seen during the week. Mean weekly ratings are reported here. Interrater reliability was assessed by calculating percentage agreement (mild, moderate or severe) for all ten instances when two different raters carried out their weekly assessment on the same patient during the same week.
METHODS RESULTS Subjects were 32 chronic schizophrenics residing in a 70 bed extended-treatment unit at Elgin Mental Health Center. This protocol was approved by the facility’s Institutional Review Board. Diagnosis was made by their consulting psychiatrist (MBG) using DSM-IIIR criteria. To assess repetitive behaviors and contrast them to other schizophrenic symptoms the ‘Elgin Behavioral Rating Scale’ was developed. After reviewing Bleuler (1950) and Arieti (1974) we included eight repetitive behaviors (bizarre grooming, bulimia, hoarding. nicotine associated behaviors, pacing, pica and polydipsia). In addition, hypersexuality was added to test Arieti’s hypothesis that some patients’ behavior was analogous to monkeys with temporal lobectomies. The instrument also includes four positive symptoms (hallucinating behavior, suspiciousness, unusual ideas and disorganized speech) and four negative symptoms
The 32 patients (56% female, 59% black) had a mean age of 39 (SD= 19) years, a mean of 10.7 ( f I .6) years of education and had spent a mean total of 16.7 (+ 6.7) years in hospital. Their mean antipsychotic dosage in chlorpromazine equivalents was 538 (i418) mg (Davis, 1964). The mean (i SD) severity of symptoms is presented in Fig. I. The mean total score on all eight repetitive behaviors (10.3 +6.l) was less than that for the eight positive or negative symptoms (15.3+8.9 t=4.1, 1,=0.0001). Fifteen of the 32 (47%) patients had at least one severe or two moderate repetitive behaviors while 20 (63%) met this criterion for the positive or negative symptoms. Eleven of the fifteen (73%) who met this criteria for repetitive behaviors also did so for positive and negative symptoms. To test the hypothesis that these behaviors are
121
seven most reliably rated repetitive behaviors. Using a backward multiple regression, gender. with a preponderance of symptoms in males, was the strongest correlate (Beta = 0.43, p = 0.02); next was a positive relationship to total length of hospitalization (Beta = 0.38, p = 0.03); and the last significant variable was race, with a preponderance of symptoms amongst white patients, (Beta = 0.38, p = 0.03). Neither age, education nor antipsychotic dose were significantly related. A comparable analysis for the three reliable positive symptoms revealed no significant relationships to the demographic and clinical variables. A similar analysis using the three reliable negative symptoms revealed one significant relationship, that with gender (male preponderance, Beta = 0.40, p = 0.04).
AVERAGE GLOBAL RATINGS (f. STANDARD DEVIATION) Negative Symptoms Motor Retardation Blunted Affect Depression Social Withdrawal Positive Symptoms Unusual ideas Suspiciousness Hallucinations Disorganized Thoughts Repetitive
Behaviors Pica Polydipsia Hoarding Bulimia Grooming Hypersexuality Pacing Nicotine Mannerisms 0
0.5
1 Mean
1.5 Scores
2
2.5
Fig. I. Mean (k SD) gobal ratings for 32 chronically hospitalized schizophrenics on the Elgin Behavioral Rating Scale.
DISCUSSION
part of a Kluver-Bucy syndrome, we examined the correlation of hypersexuality to oral symptoms. Hypersexuality was significantly correlated only with bulimia (r= 0.45, p= 0.009) but not with smoking (r = - 0.05, p = 0.78), pica (r= - 0.005, p = 0.98) or polydipsia (r = 0.10, p = 0.60). The mean percentage of interrater agreement for the eight repetitive behaviors was 85%, while it was 74% for the eight positive or negative symptoms. Only one of the eight repetitive behaviors (mannerisms), one of the four positive (disorganized speech), and one of the four negative symptoms (social withdrawal) had a percentage of interrater agreement of less than 70%. The seven most reliably rated repetitive behaviors tended to be intercorrelated with the standardized item alpha=0.71. To examine the relationship of repetitive behaviors with negative and positive symptoms we correlated the scores of the seven most reliably rated repetitive behaviors with those of the three most reliably rated positive and the three most reliably rated negative symptoms for all 32 patients. The total score for these repetitive behaviors was significantly correlated with that of the positive (r = 0.50, p = 0.004) but not of the negative symptoms (r = 0.27, p = 0.1). We computed the relationship of the patients’ demographic and clinical characteristics to the
We believe this is the first study to quantify the prevalence and severity of repetitive behaviors in chronically hospitalized schizophrenics. Because neither acutely hospitalized schizophrenics nor other diagnostic groups were studied, the results are relevant only to this specific population, in which such behaviors appear to be widespread. Although comparison of the severity of different symptoms is problematic, the eight repetitive symptoms appeared to be about two thirds as prominent as the eight positive or negative symptoms. That 73% of the patients having one severe or two moderate repetitive behaviors, also met this criteria for positive and negative symptoms suggests that, within the chronically hospitalized population, patients with one form of psychopathology generally have the other. The percentage interrater agreement of the repetitive items on Elgin Behavioral Rating Scale was comparable to that of the negative or positive symptoms drawn from a scale previously shown to be reliable (Bigelow and Berthot, 1989). Since our raters were mental health technicians with little professional training and only four training sessions, it also suggests that a more skilled, better trained group of raters might obtain higher interrater reliabilities. Little support was obtained for Arieti’s view that these behaviors are similar to those seen in
122
animals with bilateral, anterior temporal lobe lesions, since hypersexuality was not correlated with most of the ‘oral’ behaviors (i.e. smoking, pica, or polydipsia). Mean total scores on repetitive behaviors were significantly correlated with ratings of positive but not of negative symptoms. This seems counterintuitive, since repetitive behaviors are related to length of hospitalization (see below), a factor associated with poor outcome and negative symptoms (Crow, 1980). That repetitive behaviors are not closely related to negative symptoms supports the view expressed in the Introduction that they are not easily subserved under the rubric of positive and negative symptoms. Repetitive behaviors were significantly correlated to two demographic factors, white race and male gender. The meaning of these findings is unclear, although in schizophrenia less severe psychopathology has often been associated with being female (Seeman, 1988). Repetitive behaviors were also related to increased total length of hospitalization. This is consistent with the view of Arieti (1974) that these symptoms occur in the later stages of schizophrenia and suggests that much lower rates of repetitive behaviors might be found in more acute settings. Since repetitive behaviors, but neither positive nor negative symptoms, were related to total length of hospitalization, it raises issues about the etiology of repetitive behaviors. Are they due to institutionalization, medication, nicotine, caffeine. or to a progression of the schizophrenic process? We believe these behaviors, like others, represent an interaction of biological determinants (including possibly the neurobiology of schizophrenia) and the environment (chronic hospitalization) and that greater understanding of these determinants might point towards ways to reduce the morbidity associated with them. If repetitive behaviors are as widespread and severe in chronic settings as our results suggest, then more effort should be directed towards their management and control. For example, teaching staff the Heimlich maneuver to reduce deaths from choking due to bulimia, and the targeted weight program to prevent water intoxication (Goldman, 1991). Obviously, the value of pharmacologic interventions requires assessment. WC found no relaantipsychotic dosage and tionship between repetitive behaviors but this was only a correla-
tional approach. Whether dosage adjustment would effect symptoms remains unknown. Again, in the case of polydipsia, which has been more extensively studied, dosage reduction generally leads to an exacerbation of water drinking (Goldman and Janecek, 1989). Further research is necessary to determine just how specific repetitive behaviors are to chronic schizophrenia, the course of their development and their response to other treatments besides psychotropic agents. Furthermore, the neurobiological substrate for these behaviors, including both possible neuroanatomical and neurochemical disturbances (see Luchins, 1990) warrant study.
REFERENCES
Andrcasen, N.C. (1982) Negative symptoms in Schizophrenia Arch. Gcn. Psychiatry 39, 7X4-788. Arirti, S. (1974) Interpretation of Schizophrenia Second Edition. Basic Books. New York. pp. 415.-422. Bigelow. L.B. and Berthot. B.D. (1989) The psychiatric Symptom Assessment Scale (PSAS) Psychopharm Bull. 25. 16X-179. Bleulcr. E. (I 950)Dcmcntia Precox or the Group ofSchizophrenias. International Universities Press. New York. Crow, T.J. (I 980) Molecular pathology of schizophrenia: More than one disease process. Brat. Med. J. 280. l-9. Davenport, L.D.. Davenport. J.A. and Halloway. F.A. (19X1) Reward induced stereotyples: Modulation by the hippocanpus. Science 212, 128X-1289. Davis, J.M. (1974) Dose equivalence of the antlpsychotic druss. J. Psychiatry Res. 2, 65-69. Goldman. M.B. (1991) A rational approach to polydipsia. hyponatremio and water intoxication. Hosp. Comm. Psychi;,try 42, 4XX494. Goldman. M.B. and Janicak. H.M. (1989) Neuroleptics do not worsen hyponatrcmia in hyponatremic psychotics. Schlr. Res. I. 171 I. Kluver. H. and Bucy. P.C. (1939) Preliminary analysis of the temporal lobes in monkeys. Arch. Ncurol. Psychiatry 42. 979- 1000. Lawson. W.B. and Karson. C.N.. and Bigelow. L.B. (19X5) Increased urine volume in chronic schizophrenic patxnts. Psychiatry Res. 14. 323-331. Luchins, D.J. (1990) A possible role of hippocampal dysfunctlon in schizophrenic symptomatology. Biol. Psychiatry. 2X. X7-91. Manschreck. T.C.. Mahcr. B.A., Rucklos. M.E. and Vcreen. D.R. (1982) Disturbed voluntary motor activity in schirophrenic disorder. Psych Med. 12, 73-84. Masterson. E.. and O’Shea. B. (1984) Smoking and malignancy in schizophrenia. Br. J. Psychutry 145, 429-432. Seeman. M.V. (198X) Schizophrenia in women and mtn. In:
123 Treating Chronically Mentally III Women. Edited by Bachrach, L.L. and Nadelson, C.C. Washington, DC: American Psychiatric Press. Sleeper, F.H. (1935) Investigation of polyuria in schizophrenia. Am. J. Psychiatry 91, 1019-1031.
Suddath, R.L., Foote, M.. Godelski. L., et al. (1989) MRI of polydipsia hyponatremia. Presented at 142th Annual Meeting of American Psychiatric Association, San Francisco, CA.
