Beha\ Re\. & Therap!.
CASE
1976. Vol
14. pp 361).372. Perpaman Press Prmted I” Great Bntam.
HISTORIES
AND
SHORTER
COMMUNICATIONS
The Eysenck personality scales: stability and change after therapy (Receired
22 Murch
1976)
Eysenck has linked personality theory with the aetiology and treatment of abnormal behaviour (Eyscnck. 1970). At least four levels of explanation link hypothetical nemophysiological mechanisms to self-report measures of personality. laboratory task performance and observed social habits and attitudes (Eyscnck. 1960). The phenomena of neurotic breakdown and recovery provide one natural test of predictions from personality theory with respect to neuroticism (A’) and extraversion (El. Takmg phobias as an example. it is predicted that persons with a high score on IX’(a low threshold for emotional activation) develop phobic reactions more readily. and the more introverted the person. the more quickly and strongly are the phobic reactions acquired and lastingly maintained (Eysenck and Rachman. 1965. p. 36). In a prospective study of univjersity students. Kelvin et ul. (1965) were unable to find a relationship to between Initial N score and psychological distress up to 2.5 years later. Rather. the IV scale appeared reHect current mental status. increasing when distress was reported. E scores also dropped in a group of students who happened to be referred to a psychiatrist. Similarly. in a 3-year follow-up of patients who had attended a psychiatrist. Ingham (1966) found that change in climcal status was reHected in a change of A’. with the score of the improved group returning to the population mean. Initial personahty did not predict change in clinical status. It was also found in a number of analyses that improvjement was related to an increase in extrav,ersion. The present study was designed to replicate Ingham’s experiment on a more homogeneous group of neurotic patients-all phobic-who had received fantasy or iri rim exposure treatment (Marks. 1974). This treatment can be compared to an extinction procedure. i.e. the non-reinforced presentation of the CS. and should therefore provide a good testing ground of personality theory. Eysenck’s theory predicts that the speed and success of treatment will be related to initial E and N scores. In particular. the speed of extinction of the neurotic fear should be related to extraversion; the more extraverted the patient the more rapidly should the fear extinguish. MFTHOD
The subjects were 49 patients (18 men. 31 women) referred for behavioural treatment of their irrational fears. Twenty-two had specific phobias, 14 social phobias. and 13 agoraphobia. Mean length of treatment was 11 sessions or 20 hr. Ss were outpatients. mean age 31. of average educational attainment and most were from social class 2 and 3. Ss filled in the personality questionnaire (Eysenck and Eysenck. 1975) on two occasions. once after the initial psychiatric assessment and then 6 or 12 months after discharge. The majority were tested at 6months. Outcome was measured on a O-8. fear and avoidance scale with high Inter-rater and patient-rater agreement. Details can be found in Marks et al. (1972). Rating was carried out without knowledge of personality scores. Forty per cent of the assessor ratings were made by an independent assessor. the remainder by the patient’s own therapist. The 49 patients represented 52 per cent of a consecutive series of 95 phobics treated by five different therapists. The remainder either did not appear at follow-up (IX). or were not due for follow-up (I I). or for other reasons such as insufficient time the test was not admmistered (17). The untested patients differed from the follow-up group in having higher initial X scores (17.2 vs. 14.9. 11< 0.05) but they did not diflcr on E. P or I.. Post-treatment ratings averaged betvvecn patient and assessor, were used to categorize patients into outcome groups. This rating indicated the degree to which the patient feared and avoided a selected phobic target. e.g. eating in a restaurant. crossing a road. a large live spider. etc. This target was the main fear for which he had received therapy. Four outcome categories were chosen dividmg the Ss according to the degree of fear remaining, i.e. ‘almost complete extinction*. scale pomts O- 1.5. II = 1I : ‘uneasiness. no avoidance’, scale point 2.0. )i = 12: ‘slight fear. tendency to avoid‘. scale points 2.54.5. II = 14: ‘definite fear. usually or always avoids’. scale points 5-8. II = 12. The sex ratio in each group was approximately equal, Mean score before therapy was 7.1. Personality at first assessment, and also change in personality score. were accordingly related to fear status at follow-up. Change scores on the phobia rating scales were not employed as measures of outcome as they were more difficult to interpret. Of primary interest was the question whether the phobia had or had not extinguished. regardless of initial rating on the scale. However. as there was a small but significant correlation between the initial and follow-up target ratings. it was necessary to check that initial personality scores were not correlated with initial target ratings. thereby producing a spurious association between personality and outcome. These correlations were. N (0.12). E (0.03). P (-0.15). and L (0.20). none of which were significant at the 5 per cent level. The data were then examined for the existence of a trend in mean personality score (and change score) across the four outcome groups, in order of increasing fear status. The mid-point values of the outcome categories (0.75. 2.0. 3.5. 6.5) were used as the metric for the independent variable. This trend might not be linear if. for example. only one outcome group was demonstrably different from the other three groups. The above analysis related personality to treatment success. The number of hours of exposure to the phobic stimulus required to reach this level of success wa\ also available for analysis, In time-limited therapy 369
370
CASE HISTORIES
Table
1. Success
of therapy
AND SHORTER
m relation
to initial
iv
COMh:UNICATIONS
(I) and follow-up
(FIJI personality
E
P
scores L
Outcome
it
I
FU
I
FU
I
FU
I
FU
Very good (O-1.5) Good (2.0) Intermediate (L54.5) Poor (5.G-R.O) Mean Norm (men and women)
I1
I h.1
14.7
7.8
1 I.5
4.4
3.9
7.5
5.9
12
14.5
12.2
11.3
12.X
10
2.9
7.5
6.X
14
l-l.6
1.3.3
9.4
9.6
4.1
-1.1
79
91
12
14.7
17.4
9.9
8.4
4.5
57
s.3
S.-l
14.4
9.6
10.6
4.0
4.0
7.x
* The scoring
14.9 11.2
system
13.0
3.4+
7.6 7.6
of the P scale has since been modified.
success and duration are confounded. but in the present study treatment was contmued as long as the patient showed some signs of improving. The figures do not include any self-initiated exposure undertaken between sessions. Ss were divided into four groups of approximately equal hi. comprising (a) l-6 hr exposure. ii = I1 (b) 7-10 hr. n = 15: (c) 1 l-15 hr. II = 12: (d) > I7 hr. ri = 1 I. Interestingly. speed and success of treatment were not significantly correlated.
:
RESI’LTS
Stabiliry of scales. Personality scores should be reasonably stable if they are assumed to reflect enduring. heritable traits. The test-retest product moment correlations were: N. 0.58; E, 0.78: P. 0.72; and L. 0.65. Previous studies of test-retest reliability have found correlations of comparable magnitude. (Ingham. 1966). N and E were correlated on both test occasions (-0.46. -0.50) as were P and L (-0.60. -0.30). As Table 1 shows. the phobic patients are introverted neurotics when compared to Eysenck’s normative data. This conforms with his prediction that neurotic mtroverts are more likely to develop dysthymic disorders. Ourcome qf trratmrnr cmd per.w~o/ir~~. The four outcome groups did not differ on any of the four personality dimensions at initial testing (Table I). If anything the most improved group was more dysthymic than the other three groups. Initial personality did not therefore predict success of treatment. Change in personality was. however, related to outcome status (Fig. I). The more complete the extinction of the phobic reaction the greater the mcrease in extraversion (linear trend. p < 0.005). The fall in R; score was also a function of the ultimate level of fear and avoidance (linear trend. p < 0.01). No other trends attained signihcance. Ss were then separately reclassified according to self-rated outcome and assessor-rated outcome and the analyses repeated. The same trends with approximately the same significance levels were preserved. These results replicate Ingham’s. !v and E alter as a function of clinical status but do not predict change in clinical status. Speed qJ‘rr_rtrtwr~t md pcwomrlir~~. The analysis of personality scores at initial assessment gave slight support for the hypothesis that the more introverted the patient the slower the course of therapy (linear trend for
-3’ 0 75
20
35
YC
G
I
OUTCOME
65 P
STATUS
Fig. 1. Relation between change in personality score after therapy and outcome status (extinction of phobia). VG = very good outcome. G = good, I = intermediate, P = poor.
371
CASE HISTORIESAND SHORTERCOMMUNlCATlONS
Table
2. Initial
personality
score and speed of therapq
Hours of exposure
,1
A‘
E*
P
L
l-6 7-10 11-18 17
II 15 12 11
13.5 15.2 13.7 17.4
11.8 9.5 9.x 7.3
4.2 3.1 4.3 4.7
7.0 8.8 7.8 7.3
* Linear
trend
for E. p < 0.08.
E. p i 0.08. Table 2). The difference between the means of the two extreme groups (very past slow) was significant when a one-tailed r-test was applied. (r = 1.93. p < 0.05). Neuroticism was not related to speed of therapy. Psychoricism and social desirahilirx. The L scale. a measure of social desirability. correlated negatively with P and not at all with N or E. An analysis of variance of the P scores of the treatment outcome groups was therefore performed. covarying the L score. Initial P scores adjusted in this way were unrelated to speed or success of treatment. However, adjusted P scores at follow-up were slightly related to clinical status. The very good/good outcome categories combined had lower P scores than the intermediate/bad outcome groups. @ < 0.10). DISCL’SSION
The application of personality theory to an understanding of the aetiolog> of abnormal behaviour and the effects of attempts to modify it, depend on an assumption of stability in the underlying personality traits. Fairly high test-retest correlations were observed in this study despite intervening therapy. However, the changes that did occur in N, E. and to some extent P. could be largely accounted for by the patient’s response to therapy. Ingham’s results were essentially replicated. N increased or decreased a 0.5-standard deviation according to outcome and E increased up to 0.75 of a standard deviation. This suggests that discrepancies between the personality scores of psychiatric groups and normal groups may be a consequence of the psychiatric disorder. and inferences about the aetiology of a person’s abnormality based on his observed personality scores are therefore of doubtful validity. If, on the other hand, personality predicts the likelihood and type of later abnormality then the Eysenckian hypotheses concerning underlying biological dimensions may be supported or rejected. More prospective studies are required to test out these hypotheses. The present study found no relationship between N. E and P and the outcome of flooding or desensitization, but it should be noted that the range of personality scores in this outpatient sample was probably smaller than might be expected in a mixed inpatient population. This reservation applies particularly to the P scale. One prediction from personality theory was partially confirmed: the hypothesis that the phobic reactions of extraverts would undergo extinction more rapidly was weakly supported. Further evidence is required to establish that E is related to length of exposure for the reasons suggested by the theory. Extreme introversion may be a sign of generalized psychological disturbance which prolongs the length of therapy. Thus. an increase in extraversion is found after recovery from depression. (Shaw rt al., 197S), and after leucotomy (Levinson and Meyer, 1965). suggesting that there is an association between mental ill-health of various kinds and introversion. The poorer prognosis of introverted phobic patients treated by behavloural methods has been reported elsewhere (e.g. Gelder et al., 1967; Mathews. t’t ctl.. 1974). Mathews cr nl. conclude that “extraversion and traits (16 P.F.) apparently related to it are the only variables consistently distinguishing between improvement groups”. Results of the present study suggest that introverts have a poorer prognosis in time-limited therapy because they take longer to treat: no association between introversion and success per sr was found. The fact that successful therapy increases the phobic patient‘s E score raises the possibility that introversion m this population is a behavioural deficit which retards the speed of therapy. In a larger series of mixed phobics (unpublished data), E was significantly correlated (r- = 0.69. p < 0.01) with a social fears factor score derived from a factor analysis of a fears survey schedule. Measurement of E in the phobic population is therefore likely to be highly influenced by neurotic avoidance of social situations. thus limiting the extent to which inferences from personality theory can be applied on the basis of observed personality scores. Deparrment of Pswhology, Nor?/1 Eusr Londotl Pol~rrclmic, Abbe!, Lane, London, E. 15, Ellylunri
EYSENCK H. .I. (1960) Levels of personality. approach. fnt. J. sot. Psyclriar. 6, 12-24.
R. S. HALLAM
constitutional
factors
and
social
influences:
an experimental
system of psychodiagnostics. In: NW Approaches to Personality Class#cation (Ed. A. R. MAHRER). Columbia University Press, New York. EYSENCK H. J. and EYSENCK S. B. G. (1975) Mtrrluul of t/w E~wnck Personality Questionnaire (Adult and Junior). University of London Press, London (in press). EYSENCK H. J. and RACHMAN S. (1966) T/w Causes and Cures of Nwrosk Routledge & Kegan Paul, London,
EYSENCK H. 1. (1970) A dimensional
372
CASE HISTORIESAND SHORTER COMhlUNlCATlONS
and psychotherapy in the treatment GILDER M. G.. MARKS I. M. and WOLFF H. H. (1967) Desensitisation of phobic states: a controlled inquiry. Br. J. P.sj,c/iitrr 113. 53-73. INGHAM J. G. (1966) Change in MPI scores in neurotic patients: a three year follow-up. Br. .1. P.si~c/ruir 112, 931-939. between personality. mental health and KELVIN R. P.. LLICAS C. J. and OJHA A. B (1965) The relation academic performance in university students. Br. J. sec. c/in. Psrcliol. 4. ?44-25?. LE~IN~ON F. and MEYER V. (1965) Personality changes in relation to psychiatric status following orbital cortex undercutting. Br. J. P\i&iot. 11 I. 2077118. MATHFWS A. M.. JOHXTON D. Qj.. SHAWP. M. and G~LIXR M. G. (1974) Process variables and the pi-cdiitmn of outcome in behaviour therapy. Br. J. Ps~hiar. 125. 256264. MARKS I. M. (19741 Research in neurosis: a selective review. 1. Treatment. J. p.\j,ciir~/. .\fc[/. 4. 89 109. MARKS I. M. CONNOLLY J. and HALLAM R. S. (1973) Psychiatric nurse as therapist. Br. jnc[1. J. 3, Ii6 160. SHAM. D. M.. MACSWEFNEY D. A.. JOHNSON A. L. and MERRY J. (1975) Personality characteristics of alcoholic and depressed patients. Br. J. Psvrhicrr. 126. 5659.
Beha\. Res 61Therap!. lY7h. Vol I?.pp.372~ 373.PerpamonPress. Prm!rd,nCrea,Br,,am
Token economy: who responds how?* (Received
9 February
1976)
Token economy programs (TEPI ~.rn successfully modify a variety of specific and generalized behaviors m clinical populations (Gripp and Sl.igaro. 1974). but this general success is offset by the frequent occurrence of individual nonresponsiveness (Kazdin. 1973). Two solutions to the problem of nonresponsiveness have been proposed. One proposal regards the nonresponder as needing intensified training with behavioral methods while the other suggests that the operant paradigm may be inappropriate or inefficient with such patients. In either case, it would be helpful to identify potential nonresponders before or shortly after their introduction to a TEP in order that alternative treatments or pretraining might be developed to suit them while reserving the TEP for those who could derive maximum benefit from it. However. little consistent relationship between individual responsiveness and other patient-related characteristics has been found upon which to base such judgements. The present research examined the changes in response to treatment ov’er time of a TEP population and its component diagnostic groups with the hypothesis that distinct and umque patterns of response would be associated with the diagnostic groups and that the patterns would be dilferent from that shown by the total group.
METHOD Subjrcts.Twenty-nine
female and 31 male patients on a TEP ward in a state hospital served as subjects. Their ages ranged from 16 to 65 years with a mean of 35, and their total previous hospitalization ranged from 2 to 367 months with a mean of 36. Hospital staff diagnoses of the patients included 15 nonpsychotic. I6 paranoid schizophrenic, and 29 nonparanoid schizophrenic. Each had been hospitalized at least once previously and for approximately 30 days on the current admission. Ward. No more than 24 patients at a time participated in the TEP which was similar in most procedural respects to many published accounts and which was described in detail by Deering (1974). Chemotherapy was adjunctively used in several cases. Procedures. For the first three days after transfer to the TEP ward, each patient was given noncontmgent tokens and allowed to function ud lib. while the staff made behavioral observations and completed the inttial ratings using the NOSIE scale (Honigfeld and Klett. 1965). Contingencies were implemented on the fourth day and subsequent NOSIE ratings were completed every seventh day thereafter for 8 weeks by the same raters. The Total Assets scores of the Initial and eight subsequent NOSIE ratings were combined across individuals who were grouped according to various diagnostic criteria. The grouping criteria used were: (1) All patients, (2) Nonpsychotic. (3) Psychotic. (4) Paranoid schizophrenic. and (5) Nonparanoid schizophrenic. In an expanded analysis. all psychotic patients were grouped according to chronicity of previous hospitalization (chrome = more than one year; acute = one year or less) or adequacy of premorbid adjustment (good = currently or previously married: poor = never married), but the obtained response profiles of the two groups in each dimension essentially paralleled each other and the total group reference profile. thus failing to show differential respondmg. The profiles are not considered further here. but the summary data describing the chronicity and premorbidity groups are included for general reference.
RESULTS
The mean initial and eighth week Total Assets scores of the group are shown in Table I. All groups showed an increase in score after 8 weeks of TEP participation, but only the total group, psychotics. and paranoids attained statistically significant difference scores. *This research was supported in part by United States Public Health Service grant No. MH 19490-01 to the Bangor Mental Health Institute. Reprints may be obtained from Robert F. Gripp, Bangor Mental Health Institute. Bangor. Maine 04401.
CASE
1976. Vol
14. pp 361).372. Perpaman Press Prmted I” Great Bntam.
HISTORIES
AND
SHORTER
COMMUNICATIONS
The Eysenck personality scales: stability and change after therapy (Receired
22 Murch
1976)
Eysenck has linked personality theory with the aetiology and treatment of abnormal behaviour (Eyscnck. 1970). At least four levels of explanation link hypothetical nemophysiological mechanisms to self-report measures of personality. laboratory task performance and observed social habits and attitudes (Eyscnck. 1960). The phenomena of neurotic breakdown and recovery provide one natural test of predictions from personality theory with respect to neuroticism (A’) and extraversion (El. Takmg phobias as an example. it is predicted that persons with a high score on IX’(a low threshold for emotional activation) develop phobic reactions more readily. and the more introverted the person. the more quickly and strongly are the phobic reactions acquired and lastingly maintained (Eysenck and Rachman. 1965. p. 36). In a prospective study of univjersity students. Kelvin et ul. (1965) were unable to find a relationship to between Initial N score and psychological distress up to 2.5 years later. Rather. the IV scale appeared reHect current mental status. increasing when distress was reported. E scores also dropped in a group of students who happened to be referred to a psychiatrist. Similarly. in a 3-year follow-up of patients who had attended a psychiatrist. Ingham (1966) found that change in climcal status was reHected in a change of A’. with the score of the improved group returning to the population mean. Initial personahty did not predict change in clinical status. It was also found in a number of analyses that improvjement was related to an increase in extrav,ersion. The present study was designed to replicate Ingham’s experiment on a more homogeneous group of neurotic patients-all phobic-who had received fantasy or iri rim exposure treatment (Marks. 1974). This treatment can be compared to an extinction procedure. i.e. the non-reinforced presentation of the CS. and should therefore provide a good testing ground of personality theory. Eysenck’s theory predicts that the speed and success of treatment will be related to initial E and N scores. In particular. the speed of extinction of the neurotic fear should be related to extraversion; the more extraverted the patient the more rapidly should the fear extinguish. MFTHOD
The subjects were 49 patients (18 men. 31 women) referred for behavioural treatment of their irrational fears. Twenty-two had specific phobias, 14 social phobias. and 13 agoraphobia. Mean length of treatment was 11 sessions or 20 hr. Ss were outpatients. mean age 31. of average educational attainment and most were from social class 2 and 3. Ss filled in the personality questionnaire (Eysenck and Eysenck. 1975) on two occasions. once after the initial psychiatric assessment and then 6 or 12 months after discharge. The majority were tested at 6months. Outcome was measured on a O-8. fear and avoidance scale with high Inter-rater and patient-rater agreement. Details can be found in Marks et al. (1972). Rating was carried out without knowledge of personality scores. Forty per cent of the assessor ratings were made by an independent assessor. the remainder by the patient’s own therapist. The 49 patients represented 52 per cent of a consecutive series of 95 phobics treated by five different therapists. The remainder either did not appear at follow-up (IX). or were not due for follow-up (I I). or for other reasons such as insufficient time the test was not admmistered (17). The untested patients differed from the follow-up group in having higher initial X scores (17.2 vs. 14.9. 11< 0.05) but they did not diflcr on E. P or I.. Post-treatment ratings averaged betvvecn patient and assessor, were used to categorize patients into outcome groups. This rating indicated the degree to which the patient feared and avoided a selected phobic target. e.g. eating in a restaurant. crossing a road. a large live spider. etc. This target was the main fear for which he had received therapy. Four outcome categories were chosen dividmg the Ss according to the degree of fear remaining, i.e. ‘almost complete extinction*. scale pomts O- 1.5. II = 1I : ‘uneasiness. no avoidance’, scale point 2.0. )i = 12: ‘slight fear. tendency to avoid‘. scale points 2.54.5. II = 14: ‘definite fear. usually or always avoids’. scale points 5-8. II = 12. The sex ratio in each group was approximately equal, Mean score before therapy was 7.1. Personality at first assessment, and also change in personality score. were accordingly related to fear status at follow-up. Change scores on the phobia rating scales were not employed as measures of outcome as they were more difficult to interpret. Of primary interest was the question whether the phobia had or had not extinguished. regardless of initial rating on the scale. However. as there was a small but significant correlation between the initial and follow-up target ratings. it was necessary to check that initial personality scores were not correlated with initial target ratings. thereby producing a spurious association between personality and outcome. These correlations were. N (0.12). E (0.03). P (-0.15). and L (0.20). none of which were significant at the 5 per cent level. The data were then examined for the existence of a trend in mean personality score (and change score) across the four outcome groups, in order of increasing fear status. The mid-point values of the outcome categories (0.75. 2.0. 3.5. 6.5) were used as the metric for the independent variable. This trend might not be linear if. for example. only one outcome group was demonstrably different from the other three groups. The above analysis related personality to treatment success. The number of hours of exposure to the phobic stimulus required to reach this level of success wa\ also available for analysis, In time-limited therapy 369
370
CASE HISTORIES
Table
1. Success
of therapy
AND SHORTER
m relation
to initial
iv
COMh:UNICATIONS
(I) and follow-up
(FIJI personality
E
P
scores L
Outcome
it
I
FU
I
FU
I
FU
I
FU
Very good (O-1.5) Good (2.0) Intermediate (L54.5) Poor (5.G-R.O) Mean Norm (men and women)
I1
I h.1
14.7
7.8
1 I.5
4.4
3.9
7.5
5.9
12
14.5
12.2
11.3
12.X
10
2.9
7.5
6.X
14
l-l.6
1.3.3
9.4
9.6
4.1
-1.1
79
91
12
14.7
17.4
9.9
8.4
4.5
57
s.3
S.-l
14.4
9.6
10.6
4.0
4.0
7.x
* The scoring
14.9 11.2
system
13.0
3.4+
7.6 7.6
of the P scale has since been modified.
success and duration are confounded. but in the present study treatment was contmued as long as the patient showed some signs of improving. The figures do not include any self-initiated exposure undertaken between sessions. Ss were divided into four groups of approximately equal hi. comprising (a) l-6 hr exposure. ii = I1 (b) 7-10 hr. n = 15: (c) 1 l-15 hr. II = 12: (d) > I7 hr. ri = 1 I. Interestingly. speed and success of treatment were not significantly correlated.
:
RESI’LTS
Stabiliry of scales. Personality scores should be reasonably stable if they are assumed to reflect enduring. heritable traits. The test-retest product moment correlations were: N. 0.58; E, 0.78: P. 0.72; and L. 0.65. Previous studies of test-retest reliability have found correlations of comparable magnitude. (Ingham. 1966). N and E were correlated on both test occasions (-0.46. -0.50) as were P and L (-0.60. -0.30). As Table 1 shows. the phobic patients are introverted neurotics when compared to Eysenck’s normative data. This conforms with his prediction that neurotic mtroverts are more likely to develop dysthymic disorders. Ourcome qf trratmrnr cmd per.w~o/ir~~. The four outcome groups did not differ on any of the four personality dimensions at initial testing (Table I). If anything the most improved group was more dysthymic than the other three groups. Initial personality did not therefore predict success of treatment. Change in personality was. however, related to outcome status (Fig. I). The more complete the extinction of the phobic reaction the greater the mcrease in extraversion (linear trend. p < 0.005). The fall in R; score was also a function of the ultimate level of fear and avoidance (linear trend. p < 0.01). No other trends attained signihcance. Ss were then separately reclassified according to self-rated outcome and assessor-rated outcome and the analyses repeated. The same trends with approximately the same significance levels were preserved. These results replicate Ingham’s. !v and E alter as a function of clinical status but do not predict change in clinical status. Speed qJ‘rr_rtrtwr~t md pcwomrlir~~. The analysis of personality scores at initial assessment gave slight support for the hypothesis that the more introverted the patient the slower the course of therapy (linear trend for
-3’ 0 75
20
35
YC
G
I
OUTCOME
65 P
STATUS
Fig. 1. Relation between change in personality score after therapy and outcome status (extinction of phobia). VG = very good outcome. G = good, I = intermediate, P = poor.
371
CASE HISTORIESAND SHORTERCOMMUNlCATlONS
Table
2. Initial
personality
score and speed of therapq
Hours of exposure
,1
A‘
E*
P
L
l-6 7-10 11-18 17
II 15 12 11
13.5 15.2 13.7 17.4
11.8 9.5 9.x 7.3
4.2 3.1 4.3 4.7
7.0 8.8 7.8 7.3
* Linear
trend
for E. p < 0.08.
E. p i 0.08. Table 2). The difference between the means of the two extreme groups (very past slow) was significant when a one-tailed r-test was applied. (r = 1.93. p < 0.05). Neuroticism was not related to speed of therapy. Psychoricism and social desirahilirx. The L scale. a measure of social desirability. correlated negatively with P and not at all with N or E. An analysis of variance of the P scores of the treatment outcome groups was therefore performed. covarying the L score. Initial P scores adjusted in this way were unrelated to speed or success of treatment. However, adjusted P scores at follow-up were slightly related to clinical status. The very good/good outcome categories combined had lower P scores than the intermediate/bad outcome groups. @ < 0.10). DISCL’SSION
The application of personality theory to an understanding of the aetiolog> of abnormal behaviour and the effects of attempts to modify it, depend on an assumption of stability in the underlying personality traits. Fairly high test-retest correlations were observed in this study despite intervening therapy. However, the changes that did occur in N, E. and to some extent P. could be largely accounted for by the patient’s response to therapy. Ingham’s results were essentially replicated. N increased or decreased a 0.5-standard deviation according to outcome and E increased up to 0.75 of a standard deviation. This suggests that discrepancies between the personality scores of psychiatric groups and normal groups may be a consequence of the psychiatric disorder. and inferences about the aetiology of a person’s abnormality based on his observed personality scores are therefore of doubtful validity. If, on the other hand, personality predicts the likelihood and type of later abnormality then the Eysenckian hypotheses concerning underlying biological dimensions may be supported or rejected. More prospective studies are required to test out these hypotheses. The present study found no relationship between N. E and P and the outcome of flooding or desensitization, but it should be noted that the range of personality scores in this outpatient sample was probably smaller than might be expected in a mixed inpatient population. This reservation applies particularly to the P scale. One prediction from personality theory was partially confirmed: the hypothesis that the phobic reactions of extraverts would undergo extinction more rapidly was weakly supported. Further evidence is required to establish that E is related to length of exposure for the reasons suggested by the theory. Extreme introversion may be a sign of generalized psychological disturbance which prolongs the length of therapy. Thus. an increase in extraversion is found after recovery from depression. (Shaw rt al., 197S), and after leucotomy (Levinson and Meyer, 1965). suggesting that there is an association between mental ill-health of various kinds and introversion. The poorer prognosis of introverted phobic patients treated by behavloural methods has been reported elsewhere (e.g. Gelder et al., 1967; Mathews. t’t ctl.. 1974). Mathews cr nl. conclude that “extraversion and traits (16 P.F.) apparently related to it are the only variables consistently distinguishing between improvement groups”. Results of the present study suggest that introverts have a poorer prognosis in time-limited therapy because they take longer to treat: no association between introversion and success per sr was found. The fact that successful therapy increases the phobic patient‘s E score raises the possibility that introversion m this population is a behavioural deficit which retards the speed of therapy. In a larger series of mixed phobics (unpublished data), E was significantly correlated (r- = 0.69. p < 0.01) with a social fears factor score derived from a factor analysis of a fears survey schedule. Measurement of E in the phobic population is therefore likely to be highly influenced by neurotic avoidance of social situations. thus limiting the extent to which inferences from personality theory can be applied on the basis of observed personality scores. Deparrment of Pswhology, Nor?/1 Eusr Londotl Pol~rrclmic, Abbe!, Lane, London, E. 15, Ellylunri
EYSENCK H. .I. (1960) Levels of personality. approach. fnt. J. sot. Psyclriar. 6, 12-24.
R. S. HALLAM
constitutional
factors
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social
influences:
an experimental
system of psychodiagnostics. In: NW Approaches to Personality Class#cation (Ed. A. R. MAHRER). Columbia University Press, New York. EYSENCK H. J. and EYSENCK S. B. G. (1975) Mtrrluul of t/w E~wnck Personality Questionnaire (Adult and Junior). University of London Press, London (in press). EYSENCK H. J. and RACHMAN S. (1966) T/w Causes and Cures of Nwrosk Routledge & Kegan Paul, London,
EYSENCK H. 1. (1970) A dimensional
372
CASE HISTORIESAND SHORTER COMhlUNlCATlONS
and psychotherapy in the treatment GILDER M. G.. MARKS I. M. and WOLFF H. H. (1967) Desensitisation of phobic states: a controlled inquiry. Br. J. P.sj,c/iitrr 113. 53-73. INGHAM J. G. (1966) Change in MPI scores in neurotic patients: a three year follow-up. Br. .1. P.si~c/ruir 112, 931-939. between personality. mental health and KELVIN R. P.. LLICAS C. J. and OJHA A. B (1965) The relation academic performance in university students. Br. J. sec. c/in. Psrcliol. 4. ?44-25?. LE~IN~ON F. and MEYER V. (1965) Personality changes in relation to psychiatric status following orbital cortex undercutting. Br. J. P\i&iot. 11 I. 2077118. MATHFWS A. M.. JOHXTON D. Qj.. SHAWP. M. and G~LIXR M. G. (1974) Process variables and the pi-cdiitmn of outcome in behaviour therapy. Br. J. Ps~hiar. 125. 256264. MARKS I. M. (19741 Research in neurosis: a selective review. 1. Treatment. J. p.\j,ciir~/. .\fc[/. 4. 89 109. MARKS I. M. CONNOLLY J. and HALLAM R. S. (1973) Psychiatric nurse as therapist. Br. jnc[1. J. 3, Ii6 160. SHAM. D. M.. MACSWEFNEY D. A.. JOHNSON A. L. and MERRY J. (1975) Personality characteristics of alcoholic and depressed patients. Br. J. Psvrhicrr. 126. 5659.
Beha\. Res 61Therap!. lY7h. Vol I?.pp.372~ 373.PerpamonPress. Prm!rd,nCrea,Br,,am
Token economy: who responds how?* (Received
9 February
1976)
Token economy programs (TEPI ~.rn successfully modify a variety of specific and generalized behaviors m clinical populations (Gripp and Sl.igaro. 1974). but this general success is offset by the frequent occurrence of individual nonresponsiveness (Kazdin. 1973). Two solutions to the problem of nonresponsiveness have been proposed. One proposal regards the nonresponder as needing intensified training with behavioral methods while the other suggests that the operant paradigm may be inappropriate or inefficient with such patients. In either case, it would be helpful to identify potential nonresponders before or shortly after their introduction to a TEP in order that alternative treatments or pretraining might be developed to suit them while reserving the TEP for those who could derive maximum benefit from it. However. little consistent relationship between individual responsiveness and other patient-related characteristics has been found upon which to base such judgements. The present research examined the changes in response to treatment ov’er time of a TEP population and its component diagnostic groups with the hypothesis that distinct and umque patterns of response would be associated with the diagnostic groups and that the patterns would be dilferent from that shown by the total group.
METHOD Subjrcts.Twenty-nine
female and 31 male patients on a TEP ward in a state hospital served as subjects. Their ages ranged from 16 to 65 years with a mean of 35, and their total previous hospitalization ranged from 2 to 367 months with a mean of 36. Hospital staff diagnoses of the patients included 15 nonpsychotic. I6 paranoid schizophrenic, and 29 nonparanoid schizophrenic. Each had been hospitalized at least once previously and for approximately 30 days on the current admission. Ward. No more than 24 patients at a time participated in the TEP which was similar in most procedural respects to many published accounts and which was described in detail by Deering (1974). Chemotherapy was adjunctively used in several cases. Procedures. For the first three days after transfer to the TEP ward, each patient was given noncontmgent tokens and allowed to function ud lib. while the staff made behavioral observations and completed the inttial ratings using the NOSIE scale (Honigfeld and Klett. 1965). Contingencies were implemented on the fourth day and subsequent NOSIE ratings were completed every seventh day thereafter for 8 weeks by the same raters. The Total Assets scores of the Initial and eight subsequent NOSIE ratings were combined across individuals who were grouped according to various diagnostic criteria. The grouping criteria used were: (1) All patients, (2) Nonpsychotic. (3) Psychotic. (4) Paranoid schizophrenic. and (5) Nonparanoid schizophrenic. In an expanded analysis. all psychotic patients were grouped according to chronicity of previous hospitalization (chrome = more than one year; acute = one year or less) or adequacy of premorbid adjustment (good = currently or previously married: poor = never married), but the obtained response profiles of the two groups in each dimension essentially paralleled each other and the total group reference profile. thus failing to show differential respondmg. The profiles are not considered further here. but the summary data describing the chronicity and premorbidity groups are included for general reference.
RESULTS
The mean initial and eighth week Total Assets scores of the group are shown in Table I. All groups showed an increase in score after 8 weeks of TEP participation, but only the total group, psychotics. and paranoids attained statistically significant difference scores. *This research was supported in part by United States Public Health Service grant No. MH 19490-01 to the Bangor Mental Health Institute. Reprints may be obtained from Robert F. Gripp, Bangor Mental Health Institute. Bangor. Maine 04401.
