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The Current State of ProcessReactive Schizophrenia William G. Herron
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St. John's University , USA Published online: 02 Jul 2010.
To cite this article: William G. Herron (1979) The Current State of Process-Reactive Schizophrenia, The Journal of Psychology: Interdisciplinary and Applied, 101:2, 157-168, DOI: 10.1080/00223980.1979.9915067 To link to this article: http://dx.doi.org/10.1080/00223980.1979.9915067
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Published as a separate and in Thp Journal of Psychology, 1979, 101, 157-168.
T H E CURRENT STATE OF PROCESS-REACTIVE SCHIZOPHRENIA*’ S;
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WILLIAMG . HERRON SUMMARY Current developments in the process-reactive classification of schizophrenia are examined in the light of diagnosis, paranoid-nonparanoid status, premorbid adjustment, demographic factors, and outcome. Recent studies are reviewed as suggestive of a present focus, and theoretical possibilities are explored. Recommendations are made to include a broader, more complex view of the process-reactive conception, methodological improvements, further theoretical development, and increased research into a variety of promising areas utilizing this framework and facilitating its useful growth as an approach to understanding the totality of schizophrenia. A.
INTRODUCTION
The utility of reducing the heterogeneity of schizophrenia to homogeneous subgroupings has resulted in the three major dimensions of symptoms, duration, and prognosis. The most prominent of the symptom groups is paranoid-nonparanoid, while chronic-acute is the major temporal classification. Prognosis is most often illustrated by the process-reactive distinction. While the three dimensions often appear interrelated, processreactive is the most popular. The initial review of the process-reactive classification of schizophrenia in 1962 (11) suggested the potential value of the concept. In subsequent reviews and discussions (6, 13, 14, 15, 17, 24, 25) the growing complexity of this approach and necessary reservations along with its probable continuing value have all been manifest. Higgins (14) criticized the existing body of research because of the use of
* Received in the Editorial Office oil November 2 2 , 1978, and published immediately at Provincetown, Massachusetts. Copyright by The Journal Press. I Portions of this paper were presented in the visiting lecturer series on schizophrenia at Manhattan Psychiatric Institute, New York, in May, 1978. 157
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samples that were too small and underrepresented extremes, as well as for inappropriate selection of dependent variables and contamination from such factors as chronicity and sociocultural status. But, he confirmed the use of the process-reactive classification to reduce heterogeneity. His review appears to have been the last to cover thoroughly the spectrum of processreactive studies: namely classification criteria, personality, arousal, conceptual and language studies, performance and learning, perception, and family relationships. Subsequently, there has been a proliferation of studies using this classification. For example, Herron’s (12) selective review of 20 studies on schizophrenics during the first six months of 1975 showed half employing the process-reactive distinction. With this increase in the amount of research, detailed comprehensive reviews become more difficult to both synthesize and analyze, especially when particular issues are unresolved and so can reflect seriously upon the interpretation of results. Consequently, in recent years reviews have become focused more on specific issues in the process-reactive conception. For example, there has been consideration of the evidence for a developmental view of a process-reactive continuum with the aim of deriving implications for differential treatment (26). Also, there has been a series of studies discussing the most frequent operational process-reactive measure, premorbid adjustment (19, 20, 21, 32). The current paper, in turn, attempts to select the significant trends that have emerged and propose new directions for exploration using the process-reactive framework. B.
DIAGNOSIS
A constant problem in most types of schizophrenia research has been the lack of a reliable, quantifiable diagnosis. The answer to who was indeed schizophrenic has been, whoever was diagnosed that way. Such a procedure limited comparability of process-reactive studies as well. However, recent studies have accomplished a great deal to mitigate the basic problem. There are now systematic structured interviews using operational criteria which result in reliable designations of schizophrenia as a syndrome across cultures and environments (37). However, as Stoller (30) has pointed out, what we have is the first piece of a diagnosis: namely, the syndrome, a constellation of signs common to a group and apparent to an observer. For example, there are the 12 discriminating signs and symptoms delineated by Carpenter, Strauss, and Bartko (3) which include the presence of restricted affect, poor insight, thoughts aloud, poor rapport, widespread delusions,
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incoherent speech, unreliable information, bizarre delusions, and nihilistic delusions, as well as the absence of waking early, depressed facies, and elation. This is what might be termed a gross yet reliable description which does not say anything about the psychoanalytic conception of underlying dynamics or pathogenesis, nor about etiology, the possible source of origin for the dynamics. However, if these symptoms have meaning, then causality might be discovered. The process-reactive conception has been linked to the possible meaning of symptoms, most prominently in the work of Phillips ( 2 5 ) . This classified symptoms according to the most dominant sphere of expression, as thought, affect, and action symptoms, and according to role orientation, as turning against the self, turning against others, and avoidance of others. The contention was of a relationship between turning against the self, thought dominance, and the reactive designation (defined as social competence). This was contrasted to a constellation of turning against or avoiding others, action dominance, and the process designation. The evidence for these constellations was suggestive, and although others have used the symptom designation as a way to differentiate groups then called process and reactive, little has actually been reported to support the totality of these constellations. However, the tendency for symptoms to have meaning beyond classification remains appealing. There has been the suggestion (31) of positive symptoms, such as hallucinations and delusions, negative symptoms, as apathy and blunting of affect, and a third category, disorders in relating to others. The three tangential clusters are conceived as having possible differential antecedents and prognostic implications-so the possible link to the process-reactive approach. Again, the evidence is only suggestive, offering clues about etiology and prognosis, rather than answers. Inherent in a process-reactive symptom schema would certainly be relationships between symptoms and both antecedents and prognosis. In this regard, the diagnostic division of paranoid and nonparanoid groups has been the most utilized, but recently that has been called into some question. The details are examined in the next section.
C. PARANOID-NONPARANOID The process-reactive distinction has been most frequently operationalized in terms of some scale of premorbid adjustment, while the paranoidnonparanoid distinction is usually based on psychiatric diagnosis. In par-
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ticular, premorbid social competence has been construed as related to paranoid-non paranoid status. Paranoids were more likely to have good premorbid social competence, and a certain equation grew between reactives and paranoids, while process patients were equated with nonparanoids. Actually, the evidence is inconsistent (35). One possibility is the effect of type of setting on the relationship, which seems to occur most frequently in populations characterized by a broader range of prernorbid social competence scores. Then. other methodological possibilities complicate comparison of studies. These are the use of different measures of pre morbid competence, failure to utilize the range of scores, and the possible heterogeneity of the paranoid-non paranoid designations in regard to such variables as symptom intensity, diagnostic reliability, length of illness, and duration of hospitalization. For example, RitzIer and Smith (27) surveyed reports on research in paranoid schizophrenia between 1970-1975 and concluded that the majority contained insufficient specification of diagnostic (paranoid) criteria. Houlihan (16), in a selective review of heterogeneity among schizophrenics, concluded that a question appears to exist as to the magnitude and character of the interaction between paranoid status and the paranoid designation. In a recent attempt to resol ve some of the conflicting findings, Goldstein (8) divided schizophrenics into five levels of premorbid adjustment on the UCLA Social Attainment Scale and into three levels of paranoid symptomatology using the Venables and O'Connor criteria (27). There was a definite increment in both quantity and quality of paranoid symptoms from lower to higher levels of psychosocial adjustment. The one exception to the linear trend was at the highest level of premorbid adjustment. Goldstein's study indicates the potential value of refining the classification and using the entire range of scores on the scales of premorbid adjustment and paranoid symptomatology. Now, other possible implicated sources of variance in sample characteristics, as well as various other premorbid competence measures, could be explored with this approach. In this study the subjects were primarily acute and white, suggesting a particular sample that is not characteristic of at least some of the previous explorations of the paranoid-pre morbid relationship. Actually, a similar question appears in regard to the relationship of these variables to chronicity (33). The possibility arises that the dimensions of symptomatology, including its duration, and premorbid adjustment, account for only a portion of the process-reactive conceptualization. It may
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be that the interaction of these dimensions, while prevalent, is not consistent because of the influence of other variables such as affective symptoms and/or demographic, genetic, and biological factors.
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D. PREMORBID ADJUSTMENT The process-reactive equation with various scales of premorbid adjustment refers to behavioral characteristics reported to be present prior to flagrant schizophrenic symptoms. These behaviors are usually interpersonal and occupational and have customarily been validated as prognostic indicators through some improvement criteria. The major scales have been the Elgin Prognostic Scale (EPS), with the most recent revision by Steffy and Becker (29); the Phillips Scale of Premorbid Social and Sexual Adjustment (1, 9); and those described in a recent review by Kokes, Strauss, and Klorman (2 l)-namely, the Zigler and Phillips Social Competence Scale, the Ullmann-Giovannoni Self-Report Process-Reactive Questionnaire, the Premorbid Asocial Adjustment Scale (PAAS), as well as the develop mentally oriented Kantor Scales, Rorschach Indices of Premorbid Adjustment, the Prognostic Scales of Vaillant, Stephens, and Astrup, the Strauss-Carpenter Prognostic Scale, and the Goldstein Premorbid Adjustment Scale. The list does not stop there. Levinson and Campus (22) compared the Bromet-Harrow modification of the Phillips Scale with the Phillips-Zigler Social Competence Index, PAAS, and the UCLA Premorbid Adjustment Scale. They concluded the Phillips has the most general applicability. A comparison of the ability of 12 process-reactive measures to predict symptom removal at 3 and 6 month intervals by Schultz and Herron (28) again gave highest marks to the Phillips Scale. The last study points out an important consideration in regard to the relationship between premorbid adjustment and prognosis. In this case, the specific criterion was symptom removal, and the Phillips Scale predicted that quite well. Such a specific indicator of improvement suggests that prognosis is a generic term whose components may have differential predictors. It appears that there are different ways of being better, and recovery on one dimension does not automatically encompass a similar recovery in other areas. In fact, improvement has been viewed as involving the semiindependent areas of social relationships, work, personal care, and symptoms (21). Thus, both prognosis and premorbid adjustment begin to appear as complex, multidimensional concepts, with different scales predicting specific types of outcome more successfully than other scales. As a result,
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the prognostic identification of the process-reactixre conception in turn becomes multidimensional. Also a t issue is the relationship between prognosis and demographic and diagnostic variables, such as age, symptom course, and social class. The focus of the different scales suggests such investigation. For example, the Phillips Scale of Premorbid Sexual Adjustment emphasizes marital status with some reference to age. The PAAS stresses social relationships in preadolescence, adolescence, and up to age 20. where the Phillips begins. The Strauss and Carpenter Prognostic Scale is concerned with work, social class, and social relations to some extent, but emphasizes onset, severity, type, and duration of symptoms.
E.
DEMOGRAPHIC FACTORS
Klorman, Strauss. and Kokes (19) find support for a relationship between marital status and prognosis, with marriage a favorable factor. But, it is apparently more of a factor for males than females, and its power diminishes with more varied and complete outcome criteria. Also, with contemporary changes in sexual conventions the married-unmarried dichotomy may be too simplistic and need to be replaced by various categories of interpersonal relationships more appropriately reflective of socialsexual competence. In addition, a number of premorbid adjustment scales contain sex differences, with males more often obtaining poorer scores than females. Findings in regard to socioeconomic status, rural-urban residence, race, and culture are a t the moment uncertain, with relationships to prognostic status appearing sometimes without discernible patterns. Strauss, Kokes, Klorman, and Sacksteder (32) suggest the inclusion of psychosocial, biological. and demographic measures in conceptualizing premorbid adjustment. They consider it as personal functioning estimated on a number of apparently significant dimensions at different points in time and within varying environments.
F. OUTCOME While the complexity and multiform nature of prognosis is certainly more apparent, so is the difficulty in determining the reasons for the particular relationships that have been found. For example, does being married reflect a higher level of social competence to start with, or an emotional support system to return to? Also, why is marriage a seemingly more important factor for males than females in a culture where women are alleged to have more interest in being married than men?
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On a more global level three main explanatory hypotheses have been proposed for the relationship between premorbid processes and outcomes (32). The first is that premorbid adjustment is indicative of vulnerability to schizophrenia, or even shows early stages of schizophrenic symptoms, particularly in regard to relationship problems. Then, there is the possibility that premorbid adjustment reflects the degree of recovery that can be had from schizophrenia. This is the most customary explanation. The third possibility, suggested by Zubin and Spring (36), is that premorbid competence is not related to outcome, but just looks as if it is. Thus poor premorbids never functioned well, and the fact that they do not get better simply means they stayed where they already were before the obvious appearance of their schizophrenic symptoms. Strauss, Kokes, Klorman, and Sacksteder (32) try to agree with all three possibilities by suggesting that premorbid competence is a continual process determining vulnerability to symptoms and recoverability. This really does not explain the contention by Zubin and Spring (36) of independence between premorbid competence and vulnerability, though their model appears to be based on selective supporting evidence. Nonetheless, it is provocative, arguing for still further re-examination of the role of premorbid adjustment factors as well as an explanation open to more testable scrutiny than constitutional vulnerability as the key to schizophrenia. For the moment, tho evidence remains on the side of links between premorbid adjustment, symptoms, and outcomes.
G . RECENT STUDIES Houlihan’s (16) review of selected literature through 1975 suggests the value of considering the length of illness as an influential variable, as well the greater presence of affective symptoms in reactives, differential treatment plans, and varying genetic contributions. He also suggests not equating the process-reactive dimension with premorbid adjustment. Processreactive is pictured as a broader conceptualization involving the development and course of schizophrenia. Premorbid adjustment is a part only, though certainly a major one. The thrust of his paper is the revival of a process-reactive distinction based on physiological measures. He concludes that psychological dimensions are accounting for only a portion of variance, and that there are promising developments in terms of differentiations based on autonomic arousal measures, such as skin conductance and heart rate, as well as central nervous system measures. This conclusion suggests further search-
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ing i n the area of biological etiology and another look a t an etiological process-reactive distinction rather than the more prevalent prognostic one. Rlorman, Straws, and Rokes (20) consider the research on particular biological characteristics of specific premorbid groups to have produced inconsistent results. So, they are less optimistic than Houlihan (16), yet admit that the findings of pharmacologic differences, such as response to phenothiazines, support probable biological distinctions. The specifics of the schizophrenic thought disorder have continued to be an interesting area of investigation, with the probable hope of moving from certain distinct types of thinking to antecedents and causes of these types. For example, Carpenter ( 2 ) tested acute good and poor premorbids classified on the P'4A.S ( 7 ) as well as two control groups. When recall due to syntactic structure was considered as part of total recall, the groups were not significantly different. Schizophrenics showed poor overall recall, but both goods and poors werc sensitive to syntactic structure. Then the delusions of process-reactive patients, divided by the Ullmann-Giovannoni scale, were examined ( 10). The delusions of reactives were more extensive, varied, integrated, inductive, environmentally oriented, and less autistic. Thus, in this case, where there were broader possibilities for finding differences, they appeared. However, neither of these two studies took into account all the possible modifying dimensions described in the present paper. A more sophisticated attempt appears in the work of Watson (34) who considered the relationship of the process-reactive dimension, the paranoid-nonparanoid dimension, length of illness, and length of hospitalization, to abstract thinking, While the study can be faulted for using the Ullmann-Giovannoni rather than the Phillips Scale, and for using the MMPI Paranoia score, it attempts to account for three significant dimensions: namely, premorbid adjustment, symptoms, and chronicity. Length of illness and the symptom dimension appeared to be of little value, though this may be due to the measures used, but the process-reactive and length of hospitalization indicators suggested differences. Watson suggests support for a two-factor thought disorder in schizophrenia connected to the process-reactive distinction. The possibility of an emerging process-reactive theory appears and will be examined next.
H.
THEORETICAL POSSIBILITIES
DeWolfe ( 5 ) has elaborated upon a process-reactive theory of cognitive functioning which starts from the position that schizophrenics have a
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different conceptual organization than normals, and that further differentiation in such thinking processes appears in the use of the processreactive dimension. The distinction is primarily qualitative, allowing for thc possibility of the same numerical scores on a task. However, process patients will display idiosyncratic thought due to poor cognitive development, lack of involvement, and underresponsiveness. In contrast, the reactive thought disorder will appear as fragmented thinking from overresponsiveness and excessive task involvement. Tying this distinction in with premorbid status, DeWolfe suggests process patients have their particular thinking problems as a concomitant of early, continuing social withdrawal. Reactives, not subject to this, when not under stress or in an acute episode, will think more like normals. However, when disturbed, they will demonstrate a fragmentation of their thought processes, a t times severe. This may be due to response interference from excessive reaction to irrelevant external stimuli, while the process disturbance arises from interference by internal stimuli. The chronicity dimension is also considered, with the chronic process patient expected to show consistently low cognitive performance. The reactives would be more variable, with poor performance when acutely disturbed, but later improvement. This approach is consistent with other views suggesting different dimensions of schizophrenia correlated with premorbid adjustment, as the activity-withdrawal dimension (4) and locus of control (23). Extending the conception further, Putterman and Pollack (26) suggest that process and reactive schizophrenics are a t a different level of maturation in many areas of functioning, such as conceptual, verbal, perceptual, social, and possibly biochemical processes. Regression, or fixation, by process patients in turn limits their prognosis and the types of treatment to which they are amenable. Particular aspects of functioning still need caicful examination, however, for DeWolfe points out the necessity of viewing one dimension such a5 cognition in terms of perceptual, motivational, and cognitive components. Considerable specificity of performance, at least in regard to thought disorders, is not uncommon and may be due to idiosyncratic processes as well as methodological imperfections (1 1). Such specificity increases the difficulty of establishing a generalized process-reactive theory.
I. RECOMMENDATIONS I . The process-reactive conception will be most accurately viewed as a broad, complex picture of the course and essence of schizophrenia from
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probable etiology to probable prognosis. Equating process-reactive with any one variable, such as premorbid adjustment, will therefore account for partial variance, but other variables merit inclusion, though their present power is not known. 2 . In this vein, standzrd measures, such as the paranoid-nonparanoid and acute-chronic distinctions. indeed appear influential, but how and in what degree remains to be settled. These questions highlight the many methodological errors that have beset studies concerned with the reduction of heterogeneity through subtyping. Certainly current research is making more of an attempt to deal with these problems, including basics such as a measurable definition of schizophrenia. These efforts must continue to be refined. 3 . Moreover, the process-reactive conception bears recognition as having become elaborated into more than a way to achieve relatively homogeneous groupings. The process-reactive view appears to have the potential for unlocking some secrets, such as the specifics of the schizophrenic thought disorder, the genetic loading, the biochemical substrait, the paths of prognosis, and differential treatments linked to these variables as well as to social-sexual developmental patterns. 4. In addition to the vital task of improving methodology, theoretical developments deserve more concern. They in turn require research into such a r e a as language and associative disturbances, judgment and concept formation, vulnerability and stress tolerance, longitudinal effects of onset and length of hospitalization, psychomotor activity, affectibity and other symptom patterns, possible psychodynamic formulations, and genetic and neurophysiological correlates. 5 . This list of possibilities to be explored is meant to be suggestive rather than exhaustive. It also indicates, along with the large number of processreactive studies appearing consistently in the literature, that the processreactive classification which had its formal introduction as a research concept by Kantor, Wallner, and Winder in 1953 (18) is not only still alive but, in cadence with its developmental suggestions, needs to keep growing. REFERENCES I
2.
HROMIT. F...HAKKOW. M.. & KASL.S. Premorbid iunctioning and outcome in srhizophrc.nic.> and nonschizophrenics. . 4 w / i . G ? r ! ‘ . \ w / i i ~ i ~ . , 1974. 30. 203.207. CAKPENTEK. hl. D. Sensitivity to syntactic strurture. Good versus poor premorbid . J . 4 6 t 1 . P s ~ ~ - / I o1976. / . , 85, 41-SO. T.. JR.. S T R A ~ SJ. S . S . . & BARTKO.J. J. Flexible system for the
WILLIAM G. HERRON
4. 5.
Downloaded by [Carnegie Mellon University] at 00:48 14 January 2015
6.
7. 8. 9. 10. 11. 12.
167
diagnosis of schizophrenia: Report from the W H O International Pilot Study of Schizophrenia. Science, 1973, 182, 1275-1278. DEPUE,R. A. An activity-withdrawal distinction in schizophrenia: Behavioral, clinical, brain damage and neurophysiological correlates. J. A h . Psychol., 1976, 85, 174-185. DEWOLFE, A. S. Are there two kinds of thinking in process and reactive schizophrenics? J . Abn. Psychol., 1974, 83, 285-290. GARMEZY, N . Process and reactive schizophrenia: Some conceptions and issues. Schiz. Bull., 1970, 2, 30-74. GITTLEMAN-KLEIN, R., & KLEIN,D. F. Premorbid asocial adjustment and prognosis in schizophrenia. J. Psychiat. R P ~ . 1969, , 7, 35-53. GOLDSTEIN, M. J. Further data concerning the relation between premorbid adjustment and paranoid symptomatology. Srhiz. Bull., 1978, 4, 236-243. HARRIS.J. G . , JR. An abbreviated form of the Phillips Rating Scale of Premorbid Adjustment in schizophrenia. J. Abn. Psychol., 1975, 84, 129-137. HEILBRUN, A. B . , J R . . & HEILBRUN, K. S. Content analysis of delusions in reactive and process schizophrenics. J. Abn. Psychol., 1977, 86, 597-608. HERRON, W. G . The process-reactive classification of schizophrenia. Psychol. Bull., 1962, 59, 329-343. . Necessary and sufficient conditions for schizophrenia research. Psychol. R e p . , 1977, 41, 891-923.
13. 14.
HIGGINS,J. The concept of process-reactive schizophrenia: Criteria and related research. J. Nmr. & Ment. Dis., 1964, 138, 9-25. . Process-reactive schizophrenia: Recent developments. J. N e w . 6. Ment. D i s . , 1969, 149, 450-472.
IS. HIGGINS,J., & PETERSON, J. C. Concept of process-reactive schizophrenia: A critique. Psyrhol. Bull., 1966, 66, 201-206. J. P. Heterogeneity among schizophrenic patients: Selective review of recent 16. HOULIHAN, findings (1970-1975). Srhiz. Bitll., 1977, 3, 246-253. R. E . , & HERRON,W. G. Reactive and Process Schizophrenia. Palo Alto, 17. UNTOR, Calif.: Science & Behavior Books, 1966. 18. KANTOR, R. E., WALLNER, J , , & WINDER,C. L. Process and reactive schizophrenia. J. Consult. Psychol., 1953, 17, 157-163. 19. KLORMAN, R., STRAUSS, J. S., & KOKES,R. F. Premorbid adjustment in schizophrenia: Concepts, measures and implications: Part 111. The relationship of demographic and diagnostic features to measures of premorbid adjustment in schizophrenia. Schiz. Bull., 1977, 3 , 214-225. 20. . Premorbid adjustment in schizophrenia: Concepts, measures and implications: Part IV. Some biological approaches to research on premorbid functioning in schizophrenia. S r h i z . Bull., 1977, 3, 226-239. 2 1 . KOKES,R. F., STRAUSS, J. S . , & KLORMAN,R. Premorbid adjustment in schizophrenia: Concepts, measures and implications: Part 11. Measuring premorbid adjustment: The instruments and their development. Schiz. Bull., 1977, 3, 186-2 13. 22. LEVINSON,P., & CAMPUS,N. A comparison of four scales that assess premorbid competence. J . N P ~ G. Ment. Dis., 1978. 166, 204-208. 23. LOTTMAN, T. J.. & DEWOLFE,A. S. Internal versus external control in reactive and process schizophrenia. J. Consult. & Clin. Psyrhol., 1972, 39, 344. 24. PHILLIPS, L. Social competence, the process-reactive distinction. and the nature of mental disorder. In P. H. Hoch, & J. Zubin (Eds.), Psychopathology of Schkophrenia. New York: Grune & Stratton, 1966. Pp. 471-481. 25. . Human Adaptation and Its Failures. New York: Academic Press, 1968. 26. PUTTERMAN, A. H.. & POLLACK,H. B. The developmental approach and processreactive schizophrenia: A review. S c h t . Bull., 1976, 2, 198-208.
168 27.
28. 29.
Downloaded by [Carnegie Mellon University] at 00:48 14 January 2015
30. 31.
32.
33.
34.
35.
36. 37.
JOURNAL OF PSYCHOLOGY
RITZLER.B. A . & SMITH, M . Th e problem of diagnostic criteria in the study of the paranoid subclassification of schizophrenia. S r h i z . Bt!ll., 1976. 2, 209-2 1;. SCHULTZ.C. L . . & HERRON,W . G . A comparison of process-reactive measures in schizophrenia. J. C l i n . Psyrhol.. in press. STEFFY,R. A . . & BECKER,W. C. Measurement of the seventy of the disorder in schizophrenia by means of the Holtzman Inkblot Test. J . C ~ J 7 l S l d t .Psyrhol.. 1961, 25. 555. STOLLER,R. J . Psychoanalytic diagnosis. In V. M. RAKDFI.', H . C. STANCER,& H. B . (Eds.1. Psychintrir Didgnosis. New York: Brunner/Mazel, 1977. Pp. 25-41, KEDWARD STRACSS. J. S.. CARPENTER.W . T.. J R . .& BARTKO,J . J. An approach to the diagnosis and understanding of schizophrenia: Part 111. Speculations on the processes that underlie schizophrenic symptoms and signs S c h i z . B u l l . . 1974, 11. 61-6Y. S T M U S S . J. S.. KOKES. R. F . , KLORMAN.R . . & SACKSTEDER, J. L. Premorbid adjustment in schizophrenia: Concepts, measures. and implications: Part 1 'The concept of premorbid adjustment. S i h i t . Bull.. 1977, 3. 182-185. STRAWS.M . E. Behavioral differences between acute and chronic schizophrenics: Course of psvchoss, effects of institutionalization, or sampling biases? Psyc I d . Bull., 1973, 79. 271-279 WATSON.C . C . The relationship of the processireactive. paranoidnonparanoid, length of illness. and length of hospitalization dimensions to schizophrenic abstract thinking deficits. J . Nun'.Ci M e n f . D i s . , 1976, 163, 334-340. ZIGLER.E.. LEVINE,J.. & ZIGLEW,B . The relation betwern premorbid competence and paranoid-nonparanoid status in schizophrenia: A methodological and theoretical critique. Psxf-hol. Bttll., 1976. 83. 303-313. ZUBIN,J . , & SPRING,B. Vulnerability-A new view of schizophrcnia. J. ..lbn. P.ryrkol., 1977, 85, 103-126. Z U B I N J. . , SALZINGER. S . , FLEISS,J. L., GARLAND, B . . SPITZER, R. L . . ENDICOTT,J . , & SUTTON. S. Biometric approach to psychopathology: Abnormal and clinical psychology-Statistical. epidemiological. and diagnostic approaches. Ann. Rrzn. P S ~ C h l . .1975. 26, 621-671.
Depavtmvnt of Psychology S t . John's Univevsity Jamail-a, N e w Yovk 11J.39
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The Current State of ProcessReactive Schizophrenia William G. Herron
a
a
St. John's University , USA Published online: 02 Jul 2010.
To cite this article: William G. Herron (1979) The Current State of Process-Reactive Schizophrenia, The Journal of Psychology: Interdisciplinary and Applied, 101:2, 157-168, DOI: 10.1080/00223980.1979.9915067 To link to this article: http://dx.doi.org/10.1080/00223980.1979.9915067
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Published as a separate and in Thp Journal of Psychology, 1979, 101, 157-168.
T H E CURRENT STATE OF PROCESS-REACTIVE SCHIZOPHRENIA*’ S;
Johil’~\ L ,‘ti’t’i>lly
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WILLIAMG . HERRON SUMMARY Current developments in the process-reactive classification of schizophrenia are examined in the light of diagnosis, paranoid-nonparanoid status, premorbid adjustment, demographic factors, and outcome. Recent studies are reviewed as suggestive of a present focus, and theoretical possibilities are explored. Recommendations are made to include a broader, more complex view of the process-reactive conception, methodological improvements, further theoretical development, and increased research into a variety of promising areas utilizing this framework and facilitating its useful growth as an approach to understanding the totality of schizophrenia. A.
INTRODUCTION
The utility of reducing the heterogeneity of schizophrenia to homogeneous subgroupings has resulted in the three major dimensions of symptoms, duration, and prognosis. The most prominent of the symptom groups is paranoid-nonparanoid, while chronic-acute is the major temporal classification. Prognosis is most often illustrated by the process-reactive distinction. While the three dimensions often appear interrelated, processreactive is the most popular. The initial review of the process-reactive classification of schizophrenia in 1962 (11) suggested the potential value of the concept. In subsequent reviews and discussions (6, 13, 14, 15, 17, 24, 25) the growing complexity of this approach and necessary reservations along with its probable continuing value have all been manifest. Higgins (14) criticized the existing body of research because of the use of
* Received in the Editorial Office oil November 2 2 , 1978, and published immediately at Provincetown, Massachusetts. Copyright by The Journal Press. I Portions of this paper were presented in the visiting lecturer series on schizophrenia at Manhattan Psychiatric Institute, New York, in May, 1978. 157
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samples that were too small and underrepresented extremes, as well as for inappropriate selection of dependent variables and contamination from such factors as chronicity and sociocultural status. But, he confirmed the use of the process-reactive classification to reduce heterogeneity. His review appears to have been the last to cover thoroughly the spectrum of processreactive studies: namely classification criteria, personality, arousal, conceptual and language studies, performance and learning, perception, and family relationships. Subsequently, there has been a proliferation of studies using this classification. For example, Herron’s (12) selective review of 20 studies on schizophrenics during the first six months of 1975 showed half employing the process-reactive distinction. With this increase in the amount of research, detailed comprehensive reviews become more difficult to both synthesize and analyze, especially when particular issues are unresolved and so can reflect seriously upon the interpretation of results. Consequently, in recent years reviews have become focused more on specific issues in the process-reactive conception. For example, there has been consideration of the evidence for a developmental view of a process-reactive continuum with the aim of deriving implications for differential treatment (26). Also, there has been a series of studies discussing the most frequent operational process-reactive measure, premorbid adjustment (19, 20, 21, 32). The current paper, in turn, attempts to select the significant trends that have emerged and propose new directions for exploration using the process-reactive framework. B.
DIAGNOSIS
A constant problem in most types of schizophrenia research has been the lack of a reliable, quantifiable diagnosis. The answer to who was indeed schizophrenic has been, whoever was diagnosed that way. Such a procedure limited comparability of process-reactive studies as well. However, recent studies have accomplished a great deal to mitigate the basic problem. There are now systematic structured interviews using operational criteria which result in reliable designations of schizophrenia as a syndrome across cultures and environments (37). However, as Stoller (30) has pointed out, what we have is the first piece of a diagnosis: namely, the syndrome, a constellation of signs common to a group and apparent to an observer. For example, there are the 12 discriminating signs and symptoms delineated by Carpenter, Strauss, and Bartko (3) which include the presence of restricted affect, poor insight, thoughts aloud, poor rapport, widespread delusions,
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incoherent speech, unreliable information, bizarre delusions, and nihilistic delusions, as well as the absence of waking early, depressed facies, and elation. This is what might be termed a gross yet reliable description which does not say anything about the psychoanalytic conception of underlying dynamics or pathogenesis, nor about etiology, the possible source of origin for the dynamics. However, if these symptoms have meaning, then causality might be discovered. The process-reactive conception has been linked to the possible meaning of symptoms, most prominently in the work of Phillips ( 2 5 ) . This classified symptoms according to the most dominant sphere of expression, as thought, affect, and action symptoms, and according to role orientation, as turning against the self, turning against others, and avoidance of others. The contention was of a relationship between turning against the self, thought dominance, and the reactive designation (defined as social competence). This was contrasted to a constellation of turning against or avoiding others, action dominance, and the process designation. The evidence for these constellations was suggestive, and although others have used the symptom designation as a way to differentiate groups then called process and reactive, little has actually been reported to support the totality of these constellations. However, the tendency for symptoms to have meaning beyond classification remains appealing. There has been the suggestion (31) of positive symptoms, such as hallucinations and delusions, negative symptoms, as apathy and blunting of affect, and a third category, disorders in relating to others. The three tangential clusters are conceived as having possible differential antecedents and prognostic implications-so the possible link to the process-reactive approach. Again, the evidence is only suggestive, offering clues about etiology and prognosis, rather than answers. Inherent in a process-reactive symptom schema would certainly be relationships between symptoms and both antecedents and prognosis. In this regard, the diagnostic division of paranoid and nonparanoid groups has been the most utilized, but recently that has been called into some question. The details are examined in the next section.
C. PARANOID-NONPARANOID The process-reactive distinction has been most frequently operationalized in terms of some scale of premorbid adjustment, while the paranoidnonparanoid distinction is usually based on psychiatric diagnosis. In par-
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ticular, premorbid social competence has been construed as related to paranoid-non paranoid status. Paranoids were more likely to have good premorbid social competence, and a certain equation grew between reactives and paranoids, while process patients were equated with nonparanoids. Actually, the evidence is inconsistent (35). One possibility is the effect of type of setting on the relationship, which seems to occur most frequently in populations characterized by a broader range of prernorbid social competence scores. Then. other methodological possibilities complicate comparison of studies. These are the use of different measures of pre morbid competence, failure to utilize the range of scores, and the possible heterogeneity of the paranoid-non paranoid designations in regard to such variables as symptom intensity, diagnostic reliability, length of illness, and duration of hospitalization. For example, RitzIer and Smith (27) surveyed reports on research in paranoid schizophrenia between 1970-1975 and concluded that the majority contained insufficient specification of diagnostic (paranoid) criteria. Houlihan (16), in a selective review of heterogeneity among schizophrenics, concluded that a question appears to exist as to the magnitude and character of the interaction between paranoid status and the paranoid designation. In a recent attempt to resol ve some of the conflicting findings, Goldstein (8) divided schizophrenics into five levels of premorbid adjustment on the UCLA Social Attainment Scale and into three levels of paranoid symptomatology using the Venables and O'Connor criteria (27). There was a definite increment in both quantity and quality of paranoid symptoms from lower to higher levels of psychosocial adjustment. The one exception to the linear trend was at the highest level of premorbid adjustment. Goldstein's study indicates the potential value of refining the classification and using the entire range of scores on the scales of premorbid adjustment and paranoid symptomatology. Now, other possible implicated sources of variance in sample characteristics, as well as various other premorbid competence measures, could be explored with this approach. In this study the subjects were primarily acute and white, suggesting a particular sample that is not characteristic of at least some of the previous explorations of the paranoid-pre morbid relationship. Actually, a similar question appears in regard to the relationship of these variables to chronicity (33). The possibility arises that the dimensions of symptomatology, including its duration, and premorbid adjustment, account for only a portion of the process-reactive conceptualization. It may
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be that the interaction of these dimensions, while prevalent, is not consistent because of the influence of other variables such as affective symptoms and/or demographic, genetic, and biological factors.
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D. PREMORBID ADJUSTMENT The process-reactive equation with various scales of premorbid adjustment refers to behavioral characteristics reported to be present prior to flagrant schizophrenic symptoms. These behaviors are usually interpersonal and occupational and have customarily been validated as prognostic indicators through some improvement criteria. The major scales have been the Elgin Prognostic Scale (EPS), with the most recent revision by Steffy and Becker (29); the Phillips Scale of Premorbid Social and Sexual Adjustment (1, 9); and those described in a recent review by Kokes, Strauss, and Klorman (2 l)-namely, the Zigler and Phillips Social Competence Scale, the Ullmann-Giovannoni Self-Report Process-Reactive Questionnaire, the Premorbid Asocial Adjustment Scale (PAAS), as well as the develop mentally oriented Kantor Scales, Rorschach Indices of Premorbid Adjustment, the Prognostic Scales of Vaillant, Stephens, and Astrup, the Strauss-Carpenter Prognostic Scale, and the Goldstein Premorbid Adjustment Scale. The list does not stop there. Levinson and Campus (22) compared the Bromet-Harrow modification of the Phillips Scale with the Phillips-Zigler Social Competence Index, PAAS, and the UCLA Premorbid Adjustment Scale. They concluded the Phillips has the most general applicability. A comparison of the ability of 12 process-reactive measures to predict symptom removal at 3 and 6 month intervals by Schultz and Herron (28) again gave highest marks to the Phillips Scale. The last study points out an important consideration in regard to the relationship between premorbid adjustment and prognosis. In this case, the specific criterion was symptom removal, and the Phillips Scale predicted that quite well. Such a specific indicator of improvement suggests that prognosis is a generic term whose components may have differential predictors. It appears that there are different ways of being better, and recovery on one dimension does not automatically encompass a similar recovery in other areas. In fact, improvement has been viewed as involving the semiindependent areas of social relationships, work, personal care, and symptoms (21). Thus, both prognosis and premorbid adjustment begin to appear as complex, multidimensional concepts, with different scales predicting specific types of outcome more successfully than other scales. As a result,
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the prognostic identification of the process-reactixre conception in turn becomes multidimensional. Also a t issue is the relationship between prognosis and demographic and diagnostic variables, such as age, symptom course, and social class. The focus of the different scales suggests such investigation. For example, the Phillips Scale of Premorbid Sexual Adjustment emphasizes marital status with some reference to age. The PAAS stresses social relationships in preadolescence, adolescence, and up to age 20. where the Phillips begins. The Strauss and Carpenter Prognostic Scale is concerned with work, social class, and social relations to some extent, but emphasizes onset, severity, type, and duration of symptoms.
E.
DEMOGRAPHIC FACTORS
Klorman, Strauss. and Kokes (19) find support for a relationship between marital status and prognosis, with marriage a favorable factor. But, it is apparently more of a factor for males than females, and its power diminishes with more varied and complete outcome criteria. Also, with contemporary changes in sexual conventions the married-unmarried dichotomy may be too simplistic and need to be replaced by various categories of interpersonal relationships more appropriately reflective of socialsexual competence. In addition, a number of premorbid adjustment scales contain sex differences, with males more often obtaining poorer scores than females. Findings in regard to socioeconomic status, rural-urban residence, race, and culture are a t the moment uncertain, with relationships to prognostic status appearing sometimes without discernible patterns. Strauss, Kokes, Klorman, and Sacksteder (32) suggest the inclusion of psychosocial, biological. and demographic measures in conceptualizing premorbid adjustment. They consider it as personal functioning estimated on a number of apparently significant dimensions at different points in time and within varying environments.
F. OUTCOME While the complexity and multiform nature of prognosis is certainly more apparent, so is the difficulty in determining the reasons for the particular relationships that have been found. For example, does being married reflect a higher level of social competence to start with, or an emotional support system to return to? Also, why is marriage a seemingly more important factor for males than females in a culture where women are alleged to have more interest in being married than men?
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On a more global level three main explanatory hypotheses have been proposed for the relationship between premorbid processes and outcomes (32). The first is that premorbid adjustment is indicative of vulnerability to schizophrenia, or even shows early stages of schizophrenic symptoms, particularly in regard to relationship problems. Then, there is the possibility that premorbid adjustment reflects the degree of recovery that can be had from schizophrenia. This is the most customary explanation. The third possibility, suggested by Zubin and Spring (36), is that premorbid competence is not related to outcome, but just looks as if it is. Thus poor premorbids never functioned well, and the fact that they do not get better simply means they stayed where they already were before the obvious appearance of their schizophrenic symptoms. Strauss, Kokes, Klorman, and Sacksteder (32) try to agree with all three possibilities by suggesting that premorbid competence is a continual process determining vulnerability to symptoms and recoverability. This really does not explain the contention by Zubin and Spring (36) of independence between premorbid competence and vulnerability, though their model appears to be based on selective supporting evidence. Nonetheless, it is provocative, arguing for still further re-examination of the role of premorbid adjustment factors as well as an explanation open to more testable scrutiny than constitutional vulnerability as the key to schizophrenia. For the moment, tho evidence remains on the side of links between premorbid adjustment, symptoms, and outcomes.
G . RECENT STUDIES Houlihan’s (16) review of selected literature through 1975 suggests the value of considering the length of illness as an influential variable, as well the greater presence of affective symptoms in reactives, differential treatment plans, and varying genetic contributions. He also suggests not equating the process-reactive dimension with premorbid adjustment. Processreactive is pictured as a broader conceptualization involving the development and course of schizophrenia. Premorbid adjustment is a part only, though certainly a major one. The thrust of his paper is the revival of a process-reactive distinction based on physiological measures. He concludes that psychological dimensions are accounting for only a portion of variance, and that there are promising developments in terms of differentiations based on autonomic arousal measures, such as skin conductance and heart rate, as well as central nervous system measures. This conclusion suggests further search-
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ing i n the area of biological etiology and another look a t an etiological process-reactive distinction rather than the more prevalent prognostic one. Rlorman, Straws, and Rokes (20) consider the research on particular biological characteristics of specific premorbid groups to have produced inconsistent results. So, they are less optimistic than Houlihan (16), yet admit that the findings of pharmacologic differences, such as response to phenothiazines, support probable biological distinctions. The specifics of the schizophrenic thought disorder have continued to be an interesting area of investigation, with the probable hope of moving from certain distinct types of thinking to antecedents and causes of these types. For example, Carpenter ( 2 ) tested acute good and poor premorbids classified on the P'4A.S ( 7 ) as well as two control groups. When recall due to syntactic structure was considered as part of total recall, the groups were not significantly different. Schizophrenics showed poor overall recall, but both goods and poors werc sensitive to syntactic structure. Then the delusions of process-reactive patients, divided by the Ullmann-Giovannoni scale, were examined ( 10). The delusions of reactives were more extensive, varied, integrated, inductive, environmentally oriented, and less autistic. Thus, in this case, where there were broader possibilities for finding differences, they appeared. However, neither of these two studies took into account all the possible modifying dimensions described in the present paper. A more sophisticated attempt appears in the work of Watson (34) who considered the relationship of the process-reactive dimension, the paranoid-nonparanoid dimension, length of illness, and length of hospitalization, to abstract thinking, While the study can be faulted for using the Ullmann-Giovannoni rather than the Phillips Scale, and for using the MMPI Paranoia score, it attempts to account for three significant dimensions: namely, premorbid adjustment, symptoms, and chronicity. Length of illness and the symptom dimension appeared to be of little value, though this may be due to the measures used, but the process-reactive and length of hospitalization indicators suggested differences. Watson suggests support for a two-factor thought disorder in schizophrenia connected to the process-reactive distinction. The possibility of an emerging process-reactive theory appears and will be examined next.
H.
THEORETICAL POSSIBILITIES
DeWolfe ( 5 ) has elaborated upon a process-reactive theory of cognitive functioning which starts from the position that schizophrenics have a
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different conceptual organization than normals, and that further differentiation in such thinking processes appears in the use of the processreactive dimension. The distinction is primarily qualitative, allowing for thc possibility of the same numerical scores on a task. However, process patients will display idiosyncratic thought due to poor cognitive development, lack of involvement, and underresponsiveness. In contrast, the reactive thought disorder will appear as fragmented thinking from overresponsiveness and excessive task involvement. Tying this distinction in with premorbid status, DeWolfe suggests process patients have their particular thinking problems as a concomitant of early, continuing social withdrawal. Reactives, not subject to this, when not under stress or in an acute episode, will think more like normals. However, when disturbed, they will demonstrate a fragmentation of their thought processes, a t times severe. This may be due to response interference from excessive reaction to irrelevant external stimuli, while the process disturbance arises from interference by internal stimuli. The chronicity dimension is also considered, with the chronic process patient expected to show consistently low cognitive performance. The reactives would be more variable, with poor performance when acutely disturbed, but later improvement. This approach is consistent with other views suggesting different dimensions of schizophrenia correlated with premorbid adjustment, as the activity-withdrawal dimension (4) and locus of control (23). Extending the conception further, Putterman and Pollack (26) suggest that process and reactive schizophrenics are a t a different level of maturation in many areas of functioning, such as conceptual, verbal, perceptual, social, and possibly biochemical processes. Regression, or fixation, by process patients in turn limits their prognosis and the types of treatment to which they are amenable. Particular aspects of functioning still need caicful examination, however, for DeWolfe points out the necessity of viewing one dimension such a5 cognition in terms of perceptual, motivational, and cognitive components. Considerable specificity of performance, at least in regard to thought disorders, is not uncommon and may be due to idiosyncratic processes as well as methodological imperfections (1 1). Such specificity increases the difficulty of establishing a generalized process-reactive theory.
I. RECOMMENDATIONS I . The process-reactive conception will be most accurately viewed as a broad, complex picture of the course and essence of schizophrenia from
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probable etiology to probable prognosis. Equating process-reactive with any one variable, such as premorbid adjustment, will therefore account for partial variance, but other variables merit inclusion, though their present power is not known. 2 . In this vein, standzrd measures, such as the paranoid-nonparanoid and acute-chronic distinctions. indeed appear influential, but how and in what degree remains to be settled. These questions highlight the many methodological errors that have beset studies concerned with the reduction of heterogeneity through subtyping. Certainly current research is making more of an attempt to deal with these problems, including basics such as a measurable definition of schizophrenia. These efforts must continue to be refined. 3 . Moreover, the process-reactive conception bears recognition as having become elaborated into more than a way to achieve relatively homogeneous groupings. The process-reactive view appears to have the potential for unlocking some secrets, such as the specifics of the schizophrenic thought disorder, the genetic loading, the biochemical substrait, the paths of prognosis, and differential treatments linked to these variables as well as to social-sexual developmental patterns. 4. In addition to the vital task of improving methodology, theoretical developments deserve more concern. They in turn require research into such a r e a as language and associative disturbances, judgment and concept formation, vulnerability and stress tolerance, longitudinal effects of onset and length of hospitalization, psychomotor activity, affectibity and other symptom patterns, possible psychodynamic formulations, and genetic and neurophysiological correlates. 5 . This list of possibilities to be explored is meant to be suggestive rather than exhaustive. It also indicates, along with the large number of processreactive studies appearing consistently in the literature, that the processreactive classification which had its formal introduction as a research concept by Kantor, Wallner, and Winder in 1953 (18) is not only still alive but, in cadence with its developmental suggestions, needs to keep growing. REFERENCES I
2.
HROMIT. F...HAKKOW. M.. & KASL.S. Premorbid iunctioning and outcome in srhizophrc.nic.> and nonschizophrenics. . 4 w / i . G ? r ! ‘ . \ w / i i ~ i ~ . , 1974. 30. 203.207. CAKPENTEK. hl. D. Sensitivity to syntactic strurture. Good versus poor premorbid . J . 4 6 t 1 . P s ~ ~ - / I o1976. / . , 85, 41-SO. T.. JR.. S T R A ~ SJ. S . S . . & BARTKO.J. J. Flexible system for the
WILLIAM G. HERRON
4. 5.
Downloaded by [Carnegie Mellon University] at 00:48 14 January 2015
6.
7. 8. 9. 10. 11. 12.
167
diagnosis of schizophrenia: Report from the W H O International Pilot Study of Schizophrenia. Science, 1973, 182, 1275-1278. DEPUE,R. A. An activity-withdrawal distinction in schizophrenia: Behavioral, clinical, brain damage and neurophysiological correlates. J. A h . Psychol., 1976, 85, 174-185. DEWOLFE, A. S. Are there two kinds of thinking in process and reactive schizophrenics? J . Abn. Psychol., 1974, 83, 285-290. GARMEZY, N . Process and reactive schizophrenia: Some conceptions and issues. Schiz. Bull., 1970, 2, 30-74. GITTLEMAN-KLEIN, R., & KLEIN,D. F. Premorbid asocial adjustment and prognosis in schizophrenia. J. Psychiat. R P ~ . 1969, , 7, 35-53. GOLDSTEIN, M. J. Further data concerning the relation between premorbid adjustment and paranoid symptomatology. Srhiz. Bull., 1978, 4, 236-243. HARRIS.J. G . , JR. An abbreviated form of the Phillips Rating Scale of Premorbid Adjustment in schizophrenia. J. Abn. Psychol., 1975, 84, 129-137. HEILBRUN, A. B . , J R . . & HEILBRUN, K. S. Content analysis of delusions in reactive and process schizophrenics. J. Abn. Psychol., 1977, 86, 597-608. HERRON, W. G . The process-reactive classification of schizophrenia. Psychol. Bull., 1962, 59, 329-343. . Necessary and sufficient conditions for schizophrenia research. Psychol. R e p . , 1977, 41, 891-923.
13. 14.
HIGGINS,J. The concept of process-reactive schizophrenia: Criteria and related research. J. Nmr. & Ment. Dis., 1964, 138, 9-25. . Process-reactive schizophrenia: Recent developments. J. N e w . 6. Ment. D i s . , 1969, 149, 450-472.
IS. HIGGINS,J., & PETERSON, J. C. Concept of process-reactive schizophrenia: A critique. Psyrhol. Bull., 1966, 66, 201-206. J. P. Heterogeneity among schizophrenic patients: Selective review of recent 16. HOULIHAN, findings (1970-1975). Srhiz. Bitll., 1977, 3, 246-253. R. E . , & HERRON,W. G. Reactive and Process Schizophrenia. Palo Alto, 17. UNTOR, Calif.: Science & Behavior Books, 1966. 18. KANTOR, R. E., WALLNER, J , , & WINDER,C. L. Process and reactive schizophrenia. J. Consult. Psychol., 1953, 17, 157-163. 19. KLORMAN, R., STRAUSS, J. S., & KOKES,R. F. Premorbid adjustment in schizophrenia: Concepts, measures and implications: Part 111. The relationship of demographic and diagnostic features to measures of premorbid adjustment in schizophrenia. Schiz. Bull., 1977, 3 , 214-225. 20. . Premorbid adjustment in schizophrenia: Concepts, measures and implications: Part IV. Some biological approaches to research on premorbid functioning in schizophrenia. S r h i z . Bull., 1977, 3, 226-239. 2 1 . KOKES,R. F., STRAUSS, J. S . , & KLORMAN,R. Premorbid adjustment in schizophrenia: Concepts, measures and implications: Part 11. Measuring premorbid adjustment: The instruments and their development. Schiz. Bull., 1977, 3, 186-2 13. 22. LEVINSON,P., & CAMPUS,N. A comparison of four scales that assess premorbid competence. J . N P ~ G. Ment. Dis., 1978. 166, 204-208. 23. LOTTMAN, T. J.. & DEWOLFE,A. S. Internal versus external control in reactive and process schizophrenia. J. Consult. & Clin. Psyrhol., 1972, 39, 344. 24. PHILLIPS, L. Social competence, the process-reactive distinction. and the nature of mental disorder. In P. H. Hoch, & J. Zubin (Eds.), Psychopathology of Schkophrenia. New York: Grune & Stratton, 1966. Pp. 471-481. 25. . Human Adaptation and Its Failures. New York: Academic Press, 1968. 26. PUTTERMAN, A. H.. & POLLACK,H. B. The developmental approach and processreactive schizophrenia: A review. S c h t . Bull., 1976, 2, 198-208.
168 27.
28. 29.
Downloaded by [Carnegie Mellon University] at 00:48 14 January 2015
30. 31.
32.
33.
34.
35.
36. 37.
JOURNAL OF PSYCHOLOGY
RITZLER.B. A . & SMITH, M . Th e problem of diagnostic criteria in the study of the paranoid subclassification of schizophrenia. S r h i z . Bt!ll., 1976. 2, 209-2 1;. SCHULTZ.C. L . . & HERRON,W . G . A comparison of process-reactive measures in schizophrenia. J. C l i n . Psyrhol.. in press. STEFFY,R. A . . & BECKER,W. C. Measurement of the seventy of the disorder in schizophrenia by means of the Holtzman Inkblot Test. J . C ~ J 7 l S l d t .Psyrhol.. 1961, 25. 555. STOLLER,R. J . Psychoanalytic diagnosis. In V. M. RAKDFI.', H . C. STANCER,& H. B . (Eds.1. Psychintrir Didgnosis. New York: Brunner/Mazel, 1977. Pp. 25-41, KEDWARD STRACSS. J. S.. CARPENTER.W . T.. J R . .& BARTKO,J . J. An approach to the diagnosis and understanding of schizophrenia: Part 111. Speculations on the processes that underlie schizophrenic symptoms and signs S c h i z . B u l l . . 1974, 11. 61-6Y. S T M U S S . J. S.. KOKES. R. F . , KLORMAN.R . . & SACKSTEDER, J. L. Premorbid adjustment in schizophrenia: Concepts, measures. and implications: Part 1 'The concept of premorbid adjustment. S i h i t . Bull.. 1977, 3. 182-185. STRAWS.M . E. Behavioral differences between acute and chronic schizophrenics: Course of psvchoss, effects of institutionalization, or sampling biases? Psyc I d . Bull., 1973, 79. 271-279 WATSON.C . C . The relationship of the processireactive. paranoidnonparanoid, length of illness. and length of hospitalization dimensions to schizophrenic abstract thinking deficits. J . Nun'.Ci M e n f . D i s . , 1976, 163, 334-340. ZIGLER.E.. LEVINE,J.. & ZIGLEW,B . The relation betwern premorbid competence and paranoid-nonparanoid status in schizophrenia: A methodological and theoretical critique. Psxf-hol. Bttll., 1976. 83. 303-313. ZUBIN,J . , & SPRING,B. Vulnerability-A new view of schizophrcnia. J. ..lbn. P.ryrkol., 1977, 85, 103-126. Z U B I N J. . , SALZINGER. S . , FLEISS,J. L., GARLAND, B . . SPITZER, R. L . . ENDICOTT,J . , & SUTTON. S. Biometric approach to psychopathology: Abnormal and clinical psychology-Statistical. epidemiological. and diagnostic approaches. Ann. Rrzn. P S ~ C h l . .1975. 26, 621-671.
Depavtmvnt of Psychology S t . John's Univevsity Jamail-a, N e w Yovk 11J.39
