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VOL. 13, NO.

2,1967
The Positive and Negative
Syndrome Scale (PANSS)
for Schizophrenia

by Stanley R. Kay, Abraham Abstract tinct syndromes in schizophrenia


Flszbeln, and Lewis A. QpJer can be discerned from the phe-
The variable results of positive- nomenological profiles. The Type I,
negative research with schizo- or positive, syndrome is composed
phrenics underscore the importance of florid symptoms, such as delu-
of well-characterized, standardized sions, hallucinations, and disor-
measurement techniques. We report ganized thinking, which are
on the development and initial superimposed on the mental status.
standardization of the Positive and The Type II, or negative, syndrome
Negative Syndrome Scale (PANSS) is characterized by deficits in cogni-
for typological and dimensional as- tive, affective, and social functions,
sessment. Based on two established including blunting of affect and pas-
psychiatric rating systems, the 30- sive withdrawal.
item PANSS was conceived as an It has been speculated that these
operationalized, drug-sensitive in- syndromes in schizophrenia bear
strument that provides balanced etiological, pharmacological, and
representation of positive and nega- prognostic import. Thus, Crow
tive symptoms and gauges their re- (1980a) conceived of the positive
lationship to one another and to symptoms as an aspect of hyper-
global psychopathology. It thus dopaminergia (hence, a neuroleptic-
constitutes four scales measuring responsive disorder) in contrast to a
positive and negative syndromes, structural brain deficit that was
their differential, and general sever- thought to underlie the negative
ity of illness. Study of 101 schizo- symptoms. The research to date has
phrenics found the four scales to be provided some indirect support for
normally distributed and supported this model (e.g., Johnstone et al.
their reliability and stability. Posi- 1976, 1978a, 19786; Andreasen and
tive and negative scores were in- Olsen 1982), but the diversity of re-
versely correlated once their sults has defied clear-cut interpreta-
common association with general tions. For example, Angrist,
psychopathology was extracted, Rotrosen, and Gershon (1980) noted
suggesting that they represent mu- that one of the three negative symp-
tually exclusive constructs. Review toms assessed improved with neu-
of five studies involving the roleptics, and Andreasen et al.
PANSS provided evidence of its cri- (1982) found none of five negative
terion-related validity with anteced- symptoms to be associated with
ent, genealogical, and concurrent ventricular size as assessed by com-
measures, its predictive validity, its puted tomography of schizophrenic
drug sensitivity, and its utility for patients. The distinctiveness of the
both typological and dimensional syndromes and their stability over
assessment. different phases of illness also have
been questioned. Whereas An-
dreasen and Olsen (1982) contended
Schizophrenia has long been re- that positive and negative syn-
garded as a heterogeneous entity, dromes are "at opposite ends of a
and over the decades researchers continuum," Pogue-Geile and Har-
have sought consistent subpattems
that might explain different aspects
of this complex disorder. Most re-
Reprint requests should be sent to Dr.
cently, Crow (1980a, 1980b) and An- Stanley R. Kay, Research and Assess-
dreasen (1982; Andreasen and Olsen ment Unit, Bronx Psychiatric Center,
1982) have proposed that two dis- 1500 Waters PI., Bronx, NY 10461.
262 SCHIZOPHRENIA BULLETIN

row (1984) observed a significant changes, (5) no measurement of the interview (infra) and were then as-
interrelationship during the relative preponderance of positive sessed on the PANSS scales plus a
posthospitalization phase. Linden- versus negative symptoms, and (6) series of measures deriving from
mayer, Kay, and Friedman (1986) no measure of general psycho- clinical interview, cognitive testing,
further demonstrated that the exter- pathology and its possible influence motor assessment, and careful re-
nal correlates of positive and nega- on the severity of positive and nega- view of medical and historical rec-
tive syndromes among acute tive syndromes. ords. These measures are described
schizophrenics change over the The purpose of this study was to in separate articles that chiefly ad-
course of 2 years. develop and standardize a well-de- dress their relationship to positive
Research findings, of course, are fined instrument for positive-nega- and negative syndromes (Kay,
at best only as reliable and valid as tive assessment that attends to these Opler, and Fiszbein 1986; Opler,
the measures on which they are methodological and psychometric Kay, and Fiszbein 1986).
based. Thus, a fundamental source considerations. In addition, we rec- The assessments were conducted
of variability that can account for the ognized the need for a procedure by two research psychiatrists, one of
disparate results is the instrument that can be applied in relatively brief whom collected data on 47 patients
used for positive-negative assess- time (40-50 minutes), with minimal and the other on 54. Both psychia-
ment. Well-characterized and stand- retraining and reorientation for the trists first underwent intensive train-
ardized techniques are a clear clinician, and that can be used re- ing in the PANSS interview and
prerequisite for meaningful study of peatedly for longitudinal or psycho- rating methods until satisfactory
these syndromes, their relationship pharmacological assessment. We re- team concordance was achieved,
to other features of schizophrenia, port here on the development and and subsequently they rated pa-
and their response to medication. initial standardization of the Positive tients individually. The raters held
Although several carefully con- and Negative Syndrome Scale no a priori assumptions about the
ceived scales have been devised re- (PANSS) involving 101 schizo- outcome of data and were unaware
cently (e.g., Andreasen and Olsen phrenics and review evidence of its of results on the PANSS, which was
1982; Lewine, Fogg, and Meltzer validity from five separate studies. undertaken before other measures
1983; Heinrichs, Hanlon, and Car- but scored only after the conclusion
penter 1984; lager, Kirch, and Wyatt Methods of study.
1985), none have undergone the The final sample consisted of 101
thorough process of psychometric Subjects and Design. Patients with
an unqualified diagnosis of schizo- subjects of ages 20-68 (mean =
standardization that is necessary to 36.81, SD = 11.16), including 70
address fundamental, and as yet phrenia were surveyed to assess the
distribution, reliability, construct va- males, 31 females, 33 whites, 43
highly contested, issues of content blacks, and 25 Hispanics. Twelve
and construct validity (Sommers lidity, and criterion-related validity
of the PANSS. The medical charts of patients were married, 10 divorced,
1985). It has also been a matter of and the remainder single. Mean
concern that to achieve satisfactory inpatients from long-term psychi-
atric units in a university-affiliated education was 10.09 years (SD =
reliability and validity, more rigor is 2.92), with the range extending to 4
needed in providing strict opera- urban hospital were screened con-
secutively to select those having a years of college in four cases.
tional criteria for eliciting, defining, Twenty-nine subjects had a first-de-
and measuring symptoms (Zubin formal DSM-III diagnosis of schizo-
phrenia (American Psychiatric Asso- gree relative who was previously
1985). Other limitations in some of hospitalized for psychiatric treat-
the reported methods include the ciation 1980). All cases with
questionable diagnosis, known ment; schizophrenia was specified
following: (1) evaluation of the pres- in five cases and affective disorder
organic disorder, or mental retarda-
ence but not severity of component (depressive, manic, or bipolar) in 10
tion were excluded. The remainder
symptoms, (2) imbalance in the cases; alcohol abuse was reported in
were interviewed on their own
number of items representing posi- wards by one of two research psy- the nuclear family of 16 patients;
tive and negative facets, (3) inap- chiatrists to ascertain independently and among 13 subjects there was ev-
plicability for both typological and whether patients met DSM-11I crite- idence of family sociopathy, as
dimensional assessment of syn- ria for schizophrenia. If diagnoses judged by record of criminal be-
dromes, (4) no evidence of sen- were thus confirmed, patients un- havior and prosecution.
sitivity for monitoring drug-related derwent the semiformalized PANSS On the average, patients were
VOL 13, NO. 2,1987 263

first hospitalized at age 22.39 years posture to observe, as unobtrusively cated for more directive and forceful
(SD = 8.63) and had since been ill as possible, the nature of thought probing of areas where the patient
for 14.41 years (SD = 8.95), with a processes and content, judgment appeared defensive, ambivalent, or
median of six separate admissions. and insight, communication and uncooperative. For example, a pa-
Over the past year and a half, 67.4 rapport, and affective and motor re- tient who avoided forthright ac-
percent of the sample experienced sponses. knowledgment of having a
continuous hospitalization, while for Deviant material from the first psychiatric disorder may be chal-
the remainder the mean duration of segment of the interview is probed lenged for a decisive statement. In
inpatient stay was 195 days. All during the second phase, lasting an- this last phase, therefore, the patient
were receiving neuroleptic medica- other 10-15 minutes, through pro- is subjected to greater stress and
tion in standard dose ranges at the totypic leading questions that testing of limits, which may be nec-
time of study. progress from unprovocative, non- essary to proceed beyond the social
specific inquiry (e.g., How do you demand characteristics inherent in
Assessment Procedure. The PANSS compare to the average person? Are the interview situation and to ex-
ratings are based on all information you special in some ways?) to more plore susceptibility to disorganiza-
pertaining to a specified period, direct probe of pathological themes tion.
usually the previous week. The in- (e.g., Do you have special or un- The interview procedure thereby
formation derives from both clinical usual powers? Do you consider lends itself to observation of physi-
interview and reports of primary yourself famous? Are you on a spe- cal manifestations (e.g., tension,
care staff (if institutionalized) or cial mission from God?). The object mannerisms and posturing, excite-
family members. The latter is the es- now is to assess productive symp- ment, and blunting of affect), inter-
sential source for assessing social toms that can be judged from the personal behavior (e.g., poor
impairment, including items of im- patient's report and elaborations rapport, uncooperativeness, hos-
pulse control, hostility, passive thereof, such as hallucinations, de- tility, and impaired attention), cog-
withdrawal, and active social avoid- lusional ideation, suspiciousness, nitive-verbal processes (e.g.,
ance. All other ratings accrue from a and grandiosity. For this purpose, conceptual disorganization, stereo-
30- to 40-minute semiformalized the interviewer attempts to establish typed thinking, and lack of spon-
psychiatric interview that permits first the presence of symptoms and taneity and flow of conversation),
direct observation of affective, mo- next their severity, which is gener- thought content (e.g., grandiosity,
tor, cognitive, perceptual, atten- ally weighted according to the somatic concern, guilt feelings, and
prominence of abnormal manifesta- delusions), and response to struc-
tional, integrative, and interactive
tions, their frequency of occurrence, tured questioning (e.g., disorienta-
functions. The interview may be
tion, anxiety, depression, and
conceptualized as involving four and their disruptive impact on daily
difficulty in abstract thinking).
phases.1 functioning.
In the first 10-15 minutes, patients The third and most focused phase Positive and Negative Syndrome
are encouraged to discuss their his- of the interview, requiring another Scale (PANSS). Data elicited by this
tory, circumstances surrounding 5-10 minutes, involves a series of assessment procedure are applied to
their hospitalization, their current specific questions to secure informa- the PANSS, a 30-item, 7-point rating
life situation, and their symptoms. tion on mood state, anxiety, orienta- instrument that has adapted 18
The object of this phase is to estab- tion to three spheres, and abstract items from the Brief Psychiatric Rat-
lish rapport and allow the patient to reasoning ability. The evaluation of ing Scale (BPRS) (Overall and
express areas of concern. Therefore, abstract reasoning, for example, Gorham 1962) and 12 items from the
the interviewer at this point as- consists of a range of questions on Psychopathology Rating Schedule
sumes a nondirective, unchallenging concept formulation (e.g., How are (PRS) (Singh and Kay 1975a). Each
a train and bus alike?) and proverb item on the PANSS is accompanied
interpretation, which are varied in by a complete definition as well as
content when using the PANSS for detailed anchoring criteria for all
•Full text of the PANSS Rating Man-
ual, which includes the interview proce- repeated assessment. seven rating points, which represent
dure, item definitions, anchoring point After all the essential rating infor- increasing levels of psychopathol-
descriptions, and rating form, is avail- mation is obtained, the final 5-10 ogy: 1 = absent, 2 = minimal, 3 =
able on request from the authors. minutes of the interview are allo- mild, 4 = moderate, 5 = moderate-
284 SCHIZOPHRENIA BULLETIN

severe, 6 = severe, and 7 = ex- optimize content validity. (4) To the that this scale is statistically or con-
treme. Four sample items from the extent possible, they should include ceptually distinct from the positive-
PANSS appear in the Appendix, symptoms consensually regarded as negative assessment (an issue which
and scoring is performed on a sepa- crucial to the definition of the posi- also was to be determined by this
rate rating form in consultation with tive syndrome (e.g., hallucinations, study), but only that it may be used
the Rating Manual. delusions, and disorganized think- as a yardstick of collective non-
In assigning ratings, one first re- ing) and negative syndrome (e.g., specific symptoms against which to
fers to the item definition to deter- blunted affect, emotional with- judge severity of distinct positive
mine presence of a symptom. The drawal, and apathetic social with- and negative manifestations.
severity of an item, if present, is drawal). (5) For practical and In addition to these three scales, a
then judged by using a holistic per- psychometric reasons, such as facili- bipolar Composite Scale was con-
spective in deciding which anchor- tating cross-comparisons and equal- ceived to express the direction and
ing point best characterizes the izing reliability potential, the magnitude of difference between
patient's functioning, whether or numbers of items included in the positive and negative syndromes.
not all elements of the description positive and negative scales should This score was considered to reflect
are observed. The highest applicable be the same. the degree of predominance of one
rating point is always assigned, Insofar as this approach was de- syndrome over the other, and its
even if the patient meets criteria for termined by theoretical and heuristic valence (positive or negative) may
lower ratings as well. considerations, there was no cer- serve for typological characteriza-
Of the 30 psychiatric parameters tainty that all chosen items would be tion.
assessed on the PANSS, seven were equally well suited or that all suita- The PANSS is scored by summa-
chosen a priori to constitute a Posi- ble items had been chosen; the inter- tion of ratings across items, such
tive Scale, seven a Negative Scale, nal validity of the scales' composi- that the potential ranges are 7-49 for
and the remaining 16 a General Psy- tion was to be determined em- the Positive and Negative Scales and
chopathology Scale (see table 3 for pirically by the data herein assem- 16-112 for the General Psycho-
the listing of component items). bled. pathology Scale. The Composite
The selection of items was guided The General Psychopathology Scale is arrived at by subtracting the
by five considerations, in the follow- Scale was included as an important negative from positive score, thus
ing order of importance: (1) Items adjunct to the positive-negative as- yielding a bipolar index that ranges
must be consistent with the hypo- sessment since it provides a separate from -42 to +42.
thetical construct, i.e., with the the- but parallel measure of severity of
schizophrenic illness that can serve Results
oretical concept of positive and
negative psychopathology as repre- as a point of reference, or control Distribution of Scores. Table 1 sum-
senting productive features super- measure, for interpreting the syn- marizes the distribution characteris-
added to the mental status vs. dromal scores. It was not assumed tics of the four scales from the
deficit features characterized by loss
of functioning (cf. Andreasen and Table 1. Distribution characteristics of the PANSS for 101
Olsen 1982). (2) As per Carpenter, schizophrenics
Heinrichs, and Alphs (1985), items PANSS scale
should comprise symptoms whose
classification as positive or negative Distribution General
is unambiguous and which, by most characteristics Positive Negative Composite psychopathology
accounts, are regarded as primary Mean 18.20 21.01 - 2.69 37.74
rather than derivative (as, for exam- Median 18 20 - 2 36
ple, impaired attention, disorienta- SD 6.08 6.17 7.45 9.49
tion, and preoccupation may be Range (potential) 7 to 49 7 to 49 - 4 2 to +42 16to112
secondary to arousal disorder or hal- 19 to 63
lucinations). (3) They should be rep- Range (obtained) 7 to 32 8 to 38 - 2 5 to +13
resentative of different spheres of Skewness .07 .48 - .45 .23
functioning (e.g., cognitive, affec- Kurtosis -.97 .06 .13 -.30
tive, social, and communicative) to NotB—PANSS = Positive and Negative Syndrome Scale.
VOL. 13, NO. 2,1987 265

Figure 1. Frequency polygraph of distributions on the 4 scales of PANSS was examined using coeffi-
the Positive and Negative Syndrome Scale (PANSS) cient a to analyze its internal consis-
COMPOSITE
tency and the contribution of the
401- POSITIVE component items. As detailed in
NEGATIVE table 3, each of the items making up
GENERAL PSYCHOPATHOLOGY the Positive and Negative Scales cor-
> 30 -- related very strongly with the scale
o
z
LJJ
•A total (p < .001), and the mean item-
total correlations of .62 and .70, re-
20 -
o
ai
OC
Jr\ ••••-••• spectively, far exceeded the cross-
correlations of .17 (Positive items
with Negative Scale) and .18 (Nega-
u. 10 -
x x tive items with Positive Scale). The a

-25
i—r i .
-17 -9 -1
K../-;^, " -,....
15 23 31 39 47 55 63
coefficients with single items re-
moved ranged from .64 to .84, and
no perceptible gain on either scale
PANSS SCORE

PANSS, and the full spectrum of Table 2. PANSS distribution based on sample of 101
scores is illustrated in figure 1. All schizophrenics: Conversion of raw scores to percentile ranks
four measures exhibited a roughly
normal distribution pattern, without Raw score on PANSS scale
substantial skewness or kurtosis. Percentile General
This observation suggested that the rank Positive Negative Composite psychopathology
constructs in question represent typ- 99.9 37 40 21 67
ical continua and that their measure- 99 33 36 15 60
ment is amenable to parametric 98 31 34 13 58
statistical treatment. The obtained
95 29 32 10 54
range of scores in all cases was con-
90 26 29 7 50
siderably less than the potential
85 25 28 5 48
range, suggesting that the scales
80 24 27 4 46
were of ample breadth to avoid ceil-
75 23 26 3 44
ing restrictions. The medians of the
70 22 25 2 43
Positive and Negative Scales were
65 21 24 1 42
strikingly close (18 and 20, respec-
tively), and therefore the Composite 60 20 23 0 40
Scale, representing their differential, 55 19 22 - 1 39
exhibited a median of -2, which indi- 50 18 21 - 2 38
45 — — - 4 36
cated an almost equal contribution
by positive and negative items. 40 17 20 - 5 35
35 16 19 - 6 34
On the basis of the normality of 30 15 18 - 7 33
distribution, it was possible to 25 14 17 - 8 31
convert raw scores for each of the 20 13 16 - 9 30
PANSS scales to percentile ranks 15 12 15 -11 28
(table 2). This process enables provi- 10 11 14 -13 26
sional interpretation of individual 5 8 11 -15 22
scores with reference to a medicated 2 7 8 -18 18
chronic schizophrenic sample. 1 — 7 -20 16
Internal Consistency and Test-Re- 0.1 — — -25 —
test Reliability. The reliability of the Note—PANSS - Positive and Negative Syndrome Scale.
266 SCHIZOPHRENIA BULLETIN

Table 3. Internal reliability analysis of the PANSS


Item-total a coefficient
Individual scale Hems Mean SD correlation P with Item deleted
Positive Scale
Delusions 3.18 1.52 .78 <.001 .64
Conceptual disorganization 3.03 .42 .48 <.001 .73
Hallucinatory behavior 2.50 .70 .66 <.001 .70
Excitement 2.35 .24 .55 <.001 .71
Grandiosity 2.36 .56 .64 <.001 .73
Suspiciousness 2.70 .24 .61 <.001 .69
Hostility 2.10 .14 .59 <.001 .70
Scale total 18.20 (5.08 (a = .73,
p<.001)

Negative Scale
Blunted affect 2.94 .93 .63 <.001 .81
Emotional withdrawal 3.03 1.08 .78 <.001 .78
Poor rapport 2.58 1.44 .76 <.OO1 .79
Passive-apathetic social withdrawal 2.78 1.19 .79 <.001 .78
Difficulty in abstract thinking 3.95 1.34 .61 <.001 .82
Lack of spontaneity & flow of conversation 2.87 .45 .86 <001 .76
Stereotyped thinking 2.90 .30 .50 <.001 .84
Scale total 21.01 (5.17 (a = .83,
p<.001)

General Psychopathology Scale


Somatic concern 2.39 .21 .48 <.001 .77
Anxiety 2.43 1 .20 .60 <.001 .77
Guilt feelings 1.72 1 .06 .23 <.O2 .79
Tension 2.35 1 .19 .70 <.001 .76
Mannerisms & posturing 1.54 1 .12 .33 <.001 .79
Depression 1.90 .97 .24 <.O2 .79
Motor retardation 2.09 1 .10 .27 <.01 .79
UncooperatJveness 2.11 1 .21 .51 <.001 .78
Unusual thought content 3.42 1 .49 .51 <.001 .78
Disorientation 2.09 1 .14 .42 <.001 .78
Poor attention 2.45 1 .28 .65 <.001 .76
Lack of judgment & insight 3.82 1 .31 .35 <.001 .79
Disturbance of volition 2.10 1 .30 .66 <.001 .76
Poor impulse control 2.17 1 .31 .66 <.001 .76
Preoccupation 2.71 1 .18 .60 <.001 .76
Active social avoidance 2.48 1 .18 .43 <.001 .78
Scale total 37.74 9.49 (a = .79,
p<.001)
Note.—PANSS = Positive and Negative Syndrome Scale.

could be achieved by discarding any (p < .001). of similar magnitude (r = .59 and
item. Overall, the a coefficients for As expected, both scales corre- - .61, respectively, p < .001). This
the Positive and Negative Scales lated strongly with the Composite again indicated that the two scales
were .73 and .83, respectively Scale, and they yielded coefficients contributed equivalently to the com-
VOL13.NO 2,1987 267

posite score, which thus represented affected (mean = 21.13 and 26.27, genealogical, psychometric, and his-
a reasonable balance between posi- respectively, p > .40). More impor- torical assessments, as reported by
tive and negative features. tantly, the relative ordering of Kay, Opler, and Fiszbein (1986).
The General Psychopathology PANSS scores between baseline and These data were analyzed using sec-
Scale similarly revealed high internal followup held fairly constant over ond-order partial correlations to ad-
consistency, producing an a coeffi- this extended period, despite the in- just for age and extrapyramidal
cient of .79 (p < .001). Each of the 16 evitable clinical variations and secu- syndrome, as measured by the Ab-
component items contributed ho- lar trends. For the Positive, normal Involuntary Movement Scale
mogeneously to the scale (a ranged Negative, Composite, and General (National Institute of Mental Health
from .76 to .79 with single items re- Psychopathology Scales, respec- 1974) and Extrapyramidal Rating
moved) and correlated significantly tively, the test-retest Pearson cor- Scale (Alpert et al. 1978), since these
with the total score (table 3). relations were .80 (p < .001), .68 two parameters covaried signifi-
(p < .01), .66 (p < .01), and .60 cantly with the negative pole of the
The internal reliability of the Gen-
(p < .02), which corresponded to re- Composite Scale (r = — .25 and
eral Psychopathology Scale could - .26, respectively, p < .02). The re-
further be evaluated by the split-half liability indexes ranging from .77 to
.89 as estimates of their theoretically sults indicated that the Positive,
method comparing odd and even Negative, and Composite Scales of
items. When the Spearman-Brown true values (Garrett 1964).
the PANSS were not influenced by
prophesy formula was used, the re- extraneous variables such as race,
liability coefficient from the sample Construct Validity. A direct inter- cultural group, chronicity of illness,
of 101 was .80 (p < .001). This scale relationship of modest size was depressive symptoms (BPRS) or sad
correlated substantially also with the found between the Positive and affective tone (Manifest Affect Rat-
Positive and Negative Scales (r = Negative Scales (r = .27, p < .01), ing Scale; Alpert and Rush 1983),
.68 and .60, respectively, p < .001), suggesting that the two syndromes verbal intelligence (Quick Test; Am-
whereas its correlation with the are not independent. However, mons and Ammons 1962), temporal
Composite Scale was nonsignificant their common association with gen- attention (Span of Attention Test;
(r = .07). Accordingly, both positive eral schizophrenic pathology, as de- Kay and Singh 1974), and percep-
and negative symptoms seemed to scribed above, raised the possibility tual-motor development (Pro-
be potentiated by severity of global that severity of the disorder medi- gressive Figure Drawing Test; Kay
illness, and in a nondifferentiating ated the covariation between two 1982).
manner. otherwise distinct scales. This prop-
From within the full sample it was osition was supported by a partial On the other hand, as sum-
possible to study the test-retest sta- correlation which, upon extracting marized in table 4, the Positive and
bility and reliability of the PANSS 3- the shared variance from the Gen- Negative Scales produced distinctive
6 months later in a cohort of 15 un- eral Psychopathology Scale, re- profiles across the various spheres
remitted patients who remained vealed a significant inverse of assessment, and many of the dif-
hospitalized on a research ward correlation between positive and ferences were substantiated by sig-
and, by inference, proved refractory negative scores ( r ^ = - .23, tv = nificant correlations of dependent
to their ongoing neuroleptic treat- 2.37, p < .02). Thus, once the influ- variables with the Composite Scale.
ment. Their initial assessment re- ence of severity of illness was re- Thus, the positive syndrome was
vealed somewhat higher than moved statistically, the Positive and distinguished by unusual thoughts,
average scores on the Positive, Negative Scales tended to be mutu- anxiety, anger, preoccupation, dis-
Negative, and General Psycho- ally exclusive. Because of the perva- orientation, labile affect, more fre-
pathology Scales (mean = 21.07, sive contribution of general severity quent episodes of hospitalization,
25.60, and 46.67, respectively). De- of psychopathology, of course, the and greater likelihood of sociopathy
spite measurable clinical gains dur- two syndromes clinically can be ex- in first-degree relatives. Conversely,
ing the intervening phase, as pected to overlap to some degree. the negative syndrome was charac-
indicated by a small but significant terized by slowed motorium, deficits
drop of 4.74 points on the General Criterion-Related Validity. The dis- on several affective measures,
Psychopathology Scale (correlated criminant and convergent validity of thought impoverishment, lesser
t = 2.59, p < .05), the positive and the PANSS was supported by its education, and dysfunction on de-
negative scores were not noticeably correlations with a series of clinical, velopmentally based cognitive tests.
268
SCHIZOPHRENIA BULLETIN

Table 4. Relationship of the PANSS to external variables It prevailed especially among males
from families with history of psy-
Significant partial correlation (p<.05) chotic disorder but not affective ill-
Com- General ness. The positive-negative
Variable Positive Negative posite psychopathology distinction on the PANSS, accord-
Demographic/historical
ingly, was sustained along familial,
Number of hospital admissions .20
antecedent, and concurrent assess-
Years of education -.29 .33
ments and suggested a more per-
Male gender .21
nicious disease process for the
negative syndrome, one devolving
Family history of illness from genealogical and ontogenetic
Sociopathy .21 sources (Kay, Opler, and Fiszbein
Unspecified psychosis .29 .28 1985; Opler and Kay 1985; Opler,
Major affective disorder -.21 Kay, and Fiszbein 1986). A com-
Total psychiatric illness .20 parison of results with simple vs.
partial correlations suggested that
Cognitive/psychometric these findings were not mitigated by
Egocentricity of Thought Test neuroleptic-induced side effects
(CDB) -.34 .24 (Kay, Opler, and Fiszbein 1986).
Random number fluency -.33 .39 Because of the number of correla-
Color Form Preference Test tions performed, the reliability of in-
(CDB) .27 dividual coefficients must be
interpreted with due caution. The
Affective (MARS) finding of a statistically significant
Angry affective tone .46 .23 .47 relationship in a large sample, more-
Affective lability .31 over, does not presuppose substan-
Total affective impairment .64 -.41 tial shared variance between
Dull facial expression .54 -.40 .24 measures, which may be judged by
Impoverished thought content .52 -.49 the magnitude of the squared coeffi-
Global unrelatedness .50 -.42 .27 cients of correlation. What stands
Lack of vocal emphasis .49 -.40 .30 out as important for the present pur-
Slow response latency .47 -.36 .39 poses, however, is the general pat-
Global immobility .43 -.43 tern of correlations rather than the
Lack of expressive gestures .41 -.37 individual values. The extensiveness
Soft voice level .32 -.30 of significant associations, the con-
Poor eye contact .46 sistency across different spheres and
Increased noncommunicative methods of assessment, the concep-
movements .41 tual cohesiveness, and the corre-
sponding unrelatedness of PANSS
Clinical (BPRS) scores to extraneous variables may
Unusual thought content .73 .50 — be regarded as evidence toward con-
Anxiety .38 .33 — vergent and discriminant validity.
Preoccupation .28 —
Disorientation .26 — The General Psychopathology
Motor retardation .22 -.28 — Scale, by comparison, yielded fewer
Somatic concern .20 —
external correlations and a non-
specific profile that encompassed
Note—Based on study of 101 chronic schizophrenics (Kay, Opter & Rszbein 1986). Shown are the
significant (p<.05) nonovertapping covartates of the Positive and Negative Scales and the correlates
both positive and negative charac-
of the Composite and General Psychopathology Scales, excluding those clinical items that enter Into teristics (table 4). As a measure of
the latter scale. Abbreviations.—COB - Cognitive Diagnostic Battery (Kay1982); MARS - Manifest severity of illness, the scale was sig-
Affect Rating Scale (Alpert and Rush 1983); BPRS - Brief Psychiatric Rating Scale (Overall and nificantly associated with seven of
Gorham 1962); PANSS - Positive and Negative Syndrome Scale. the affective symptoms reflecting
VOL13.NO. 2,1887

both a productive syndrome (i.e., three scales were .86, .90, and .84, features of the illness. Thus, Singh,
anger and increased noncom- respectively, all highly significant Kay, and Opler (1987) reanalyzed
municative movements) and deficits (p < .001). their earlier data on 47 well-defined
(e.g., dull facial expression, poor schizophrenics who had received,
eye contact, and emotional unre- Pharmacological Validation. The under double-blind conditions, anti-
latedness). In terms of family psy- validity and drug sensitivity of the parkinsonian medication (benz-
chiatric disorder, it correlated with PANSS were examined experimen- tropine or trihexyphenidyl) for 2 to 4
psychosis as well as prevalence of tally by assessing differential re- weeks along the course of neurolep-
any major disturbance among first- sponse of syndrome scores to drug tic treatment (haloperidol or chlor-
degree relatives (i.e., history of treatment. promazine). Clinical ratings during
schizophrenia, affective illness, alco- In a single-subject experimental the antiparkinsonian phase were
holism, sociopathy, or suicide). Al- study, we analyzed changes on the contrasted against the preceding
ternatively, it bore no significant PANSS when the dopamine precur- and following 2-week periods of
relationship with the various control sor, L-dopa, was used adjunctively neuroleptic alone, thus controlling
measures such as age, sex, marital with neuroleptics (Kay and Opler for the time-series factor via an
status, cultural group, chronicity of 1985-86). The investigation followed ABA' design (Singh and Kay 1978).
illness, verbal intelligence, or neu- a 27-week double-blind, placebo- The PANSS dusters were used to
rological soft signs. controlled, reversal design. After 2 inspect the data, which was possible
In keeping with the impression weeks of treatment with neurolep- since ratings on both the BPRS and
from the correlational analyses, tics alone, a haloperidol + placebo PRS had been conducted originally.
stepwise multiple regression re- combination was instituted for 13 Our results indicated that only the
vealed no overlap among the param- weeks, followed by a haloperidol + Positive Scale was adversely influ-
eters that best accounted for the L-dopa combination for the enced by the anticholinergic inter-
Positive and Negative Scales. The next 8 weeks, and then a return to vention (t = 2.58, p < .02). The
Positive Scale, with 74 percent of its haloperidol + placebo in the remain- correlation between positive and
variance explained, was contributed ing 5 weeks. When the intervening negative clusters in their direction
to primarily by unusual thought L-dopa phase was compared against and magnitude of change proved
content (i.e., bizarre quality of idea- the preceding and following 4-week nonsignificant, suggesting that the
tion), family history of sociopathy, phases, significant improvement two scales did not covary in their re-
angry affective tone, and global psy- was found on the Negative Scale of sponse to anticholinergics.
chopathology. The Negative Scale, the PANSS (p < .05) as well as two
with 81 percent of its variance ex- of the individual negative items, dif- Typological Validation. The PANSS
plained, was accounted for chiefly ficulty in abstract thinking (p < .025) has been applied also as a method of
by general affective impairment on and passive-apathetic social with- characterizing schizophrenic pa-
the Manifest Affect Rating Scale, drawal (p < .05). By contrast, nei- tients with a predominantly positive
family history of psychosis, cogni- ther the Positive Scale nor any of its vs. a predominantly negative syn-
tive developmental deficit on the individual items showed change drome. We considered patients who
Egocentricity of Thought Test (Kay during the L-dopa challenge
scored "moderate" or higher on at
1982), impoverished thought con- (p > .50).
least three of the seven positive
tent, lack of insight, and active so- A second investigation considered items as positive-type schizo-
cial withdrawal. For the Composite the specificity of adverse clinical re- phrenics and those with the reverse
Scale, which denotes tendency to- action to anticholinergic drugs when pattern ("moderate" on at least
ward the positive or negative pole, used with neuroleptics. This work three negative items) as negative-
69 percent of the variance was pre- was predicated on the findings of type schizophrenics; patients who
dicted by unusual thought content, Singh and Kay (1975fl, 1975b, 1979) qualified for both groups or neither
emotional unrelatedness, im- that antiparkinsonian agents tend to
poverished thought content, years were labeled as mixed type. This
worsen psychiatric symptoms of system was applied in separate
of education, and conceptual de- neuroleptic-treated schizophrenics,
velopment on the Color Form Rep- studies involving 37 acute (< 2 years
and the more recent qualification by of illness) and 47 chronic schizo-
resentation Test (Kay 1982). The Johnstone et al. (1983) that the phe-
multiple correlation values for the phrenics, all with confirmed DSM-
nomenon obtains mainly to positive III diagnosis (Lindenmayer, Kay,
270 SCHIZOPHRENIA BULLETIN

and Opler 1984; Opler et al. 1984). according to the valence of their erational definitions were intro-
The results supported the validity Composite Scale score (i.e., positive duced for all items at every rating
of the PANSS for isolating groups minus negative value above zero level. These guidelines, by enhanc-
that differ on both antecedent and being positive and below zero being ing the objectivity and replicability
concurrent variables. A significant negative). It was found that only of observations, are expected to
inverse relationship between posi- those classified as positive type augment concordance among raters.
tive and negative symptoms was ob- showed subsequent clinical worsen- Although this aspect of reliability
tained in both studies (r = - .62, ing when antiparkinsonian drugs could not be measured in the pres-
p < .001, and r = - .55, p < .01, re- were introduced (p < .02), while the ent study,2 the various other indica-
spectively). In the acute sample negative group was essentially un- tors of reliability, stability, and
(Lindenmayer, Kay, and Opler affected. Thus, complementing the validity from a sample of 101 schizo-
1984), patients classified by the studies of Lindenmayer, Kay, and phrenic patients suggested that the
PANSS as negative differed from the Opler (1984) and Opler et al. (1984), goal of developing objective and
positive group in premorbid func- which supported the validity of the replicable scales was met.
tioning (lesser schooling, p < .02; PANSS typology in relation to ante- The PANSS scales, as already dis-
poorer work adjustment, p < .10), cedent and concurrent measures, cussed, were assembled mainly on
likelihood of nonparanoid subdiag- the Singh, Kay, and Opler (1987) the basis of theoretical and psycho-
nosis (p < .02), and various deficit finding introduced evidence of pre- metric considerations (e.g., defini-
symptoms that encompassed the dictive validity. tion of construct, content sampling,
cognitive, social, affective, and mo- and balancing of items). The present
tor spheres. The chronic study empirical analyses indicated that the
(Opler et al. 1984) also found the items selected were appropriate to
negative type to have achieved less Discussion the constructs and were internally
education (p < .02) and, on other coherent, yet it also emerged that
We have described the development
historical dimensions, to be charac- other clinical variables could well
and initial standardization of the 30-
terized more by winter birth have been included. Specifically, ac-
item PANSS as an instrument for
(p < .02) and early onset of illness cording to correlational and multiple
measuring the prevalence of positive
(p < .05), as judged by age of initial regression analyses, a positive syn-
and negative syndromes in schizo-
hospitalization. On objective psy- drome was strongly associated with
phrenia. A major impetus of its de-
chometric tests, this group was dis- unusual thought content and anx-
velopment was the need tor a psy-
tinguished by a developmentally iety, while a negative syndrome
chometrically sound procedure to
more primitive cognitive style seemed to encompass motor retar-
serve typological and dimensional
(p < .01) and slower psychomotor dation, lack of judgment and in-
assessment. Perhaps its most impor-
pace (p < .05) on the Cognitive Di- sight, and active social avoidance.
tant contributions are the provision
agnostic Battery (Kay 1982), despite
of specified interview guidelines and As based on the initial item selec-
similar scores on tests of intelligence
assessment criteria, and the inclu- tion, however, the validation proc-
and visual-motor deficits. In both
sion of two additional scales that ess supported the use of this
studies, no group differences were
consider positive-negative syn- instrument for positive-negative as-
obtained on control variables such
dromes relative to one another and sessment. All four scales from the
as sex, race, ethnic background,
relative to general severity of PANSS produced normal Gaussian
chronicity of illness, and level of
psychopathology. distribution curves, which sug-
general psychopathology.
The PANSS method derives from gested amenability to powerful para-
Typological comparisons were two established psychiatric rating metric statistics—hence, reduced
rendered also in the Singh, Kay, and scales for which interrater agree- risk of Type II error in clinical re-
Opler (1987) study of clinical re- ment and treatment sensitivity have
sponse to antiparkinsonian agents. been demonstrated. As such, it pro-
this article went to press, we
From the baseline drug-free assess- ceeds from reliable techniques that have reported interrater reliabilities in a
ment with the PANSS, schizo- are familiar to clinicians and re- range between .83 and .87 for the four
phrenic patients were prospectively searchers, requiring relatively little PANSS scales on a sample of 31 acute
classified as predominantly positive additional training. For the purpose schizophrenics (Kay, Opler, and Linden-
(n = 25) or negative type (n = 22) of the PANSS, however, precise op- mayer, in press).
VOL. 13, NO. 2,1987 271

search. The reliability of the PANSS Harrow 1984). In these respects, anhedonia-asociality, and atten-
was upheld by coefficient a, split- there is some evidence of cross-val- tional impairment. Elsewhere we
half analysis, and test-retest idation. In addition, predictive va- have proposed that attentional dys-
methods, which also provided some lidity and sensitivity to change were function in schizophrenia is multi-
evidence of stability in a refractory indicated by the significance of the determined and at least partly a
chronic schizophrenic cohort. Its va- Positive and Negative Scales for an- function of arousal disorder (Kay
lidity was considered on the basis of ticipating and reflecting differential 1981; Kay and Singh 1974), and
five separate studies in which it response to medication. The PANSS studies by our group and others
served typological and/or dimen- research, therefore, was undertaken have since confuted its specificity to
sional assessment of schizophrenics. as a sequential programmatic series either the negative or positive syn-
The studies supported its construct of studies that included multi- drome (Opler et al. 1984; Bilder et al.
and criterion-related validity with method and experimental ap- 1985; Cornblatt et al. 1985; Kay,
respect to both antecedent and con- proaches and, as such, heeded the Opler, and Fiszbein 1986). By con-
current variables that involved his- methodological requisites discussed trast to other descriptions of the
torical, genealogical, clinical, and by Sommers (1985) and Zubin (1985) negative syndrome, the PANSS ex-
psychometric assessments. for validation of relatively uncharted cludes attentional impairment but
The reliance on individual rather constructs. embraces deficits along five major
than team ratings raises the question The premise of our work was that spheres of functioning: the cogni-
of whether the outcomes may have some of the disparities in the re- tive, affective, social, interpersonal,
been influenced by an individual's search on positive-negative distinc- and communicational.
preconceptions. Such a possibility tions may reflect the application of Aside from variation in content of
was mitigated by several safeguards imprecise instruments, which pro- scales, there has been little study
in the design: the participation of motes Type II error by reducing the and much disagreement about the
two independent psychiatrists, each chance of observing true variance, construct validity of positive and
gathering data on approximately and may be due also to the very di- negative syndromes (Zubin 1985).
half the sample; their lack of knowl- versity among studies in methods of Researchers have differed in their
edge of PANSS scores when collect- assessment. opinion of whether these syndromes
ing other data; their perception of There has been considerable dis- are independent of one another—
the research as exploratory rather agreement, for example, surround- hence, distinct constructs—and gen-
than hypothesis testing; the use of ing the issue of content validity, i.e., erally have ignored their relation-
multiple external criteria, including what symptoms, how many, and ship to overall psychopathology.
such measures as psychometric tests even which spheres of functioning Andreasen and Olsen (1982), for ex-
and historical records that are objec- best represent positive and negative ample, have argued that the positive
tive and derive from separate and syndromes (Sommers 1985). Thus, and negative aspects represent op-
independent sources; and, above all, Angrist, Rotrosen, and Gershon posite poles of a continuum,
the convergence of several different (1980) have measured these two whereas Pogue-Geile and Harrow
studies, involving different raters syndromes by using clusters of 10 (1984) have concluded that they are
and designs, which supported overlapping features of schizo-
and 3 symptoms, respectively, while
various aspects of validation. phrenia. Our analysis of the PANSS
Andreasen and Olsen (1982) de-
The pattern of findings also ac- scribed instead 4 and 5 symptoms not only supported the cohesiveness
corded with the results of other and Lewine, Fogg, and Meltzer of the separate positive and negative
studies, employing different inves- (1983) incorporated a compilation of clusters via coefficient a, but
tigative tools, which have similarly 22 and 11 symptoms. Whereas provided evidence of their dis-
implicated lesser education, premor- Owens and Johnstone (1980) orig- tinctiveness from one another by re-
bid impairments, poor cognitive per- vealing low, nonsignificant item-
inally conceived of the negative syn-
formance, and genealogical total cross-correlations (means of .17
drome as entailing flat affect and
predisposition in the characteriza- and .18) and nonoverlap of determi-
impoverished speech, Crow (1980a)
tion of a negative schizophrenic syn- nants identified through multiple re-
expanded the concept to include
drome (Andreasen and Olsen 1982; gression analysis. However, the
avolition, and Andreasen (1982) relationship between positive and
Andreasen et al. 1982; Dworkin and modified it by excluding poverty of
Lenzenweger 1984; Pogue-Geile and negative dimensions was observed
speech and introducing alogia,
272 SCHIZOPHRENIA BULLETIN

to be strongly mediated by their lishing norms. The latter objective tional investigation of 134 schizo-
shared association with level of psy- entails comparisons of scores among phrenics (Kay et al. 1986), which
chopathology. Thus, a significant di- schizophrenic subtypes, such as pooled data from an acute sample
rect correlation was initially found classified by subdiagnosis and (Lindenmayer, Kay, and Opler 1984)
between the Positive and Negative chronicity of illness, as well as in re- with the present group, we com-
Scales, but when their correlations lation to nonschizophrenic groups. pared PANSS scores in the acute (0-
with the General Psychopathology 2 years), chronic (3-10 years), and
It should be cautioned that gener-
Scale were statistically extracted, long-term chronic stages of illness
alization of results depends on the
they bore a significant inverse cor- (> 10 years). Analysis of variance re-
representativeness of the sample,
relation. This disclosure of the mu- vealed nonsignificant differences
which in the present case was a
tually exclusive nature of the (F =£ 1) of means among these re-
chronic group in whom neuroleptic
Positive and Negative Scales not spective groups on all scales: Posi-
treatment could not be withdrawn.
only supports their conceptual sepa- tive (18.76, 19.71, 17.98), Negative
With regard to chronicity, however,
rateness, i.e., construct validity, but (21.42, 21.21, 21.27), Composite
our analyses indicated no significant
provides a compelling rationale for (-2.66, -1.50, -3.29), and General
correlation between years since ini-
pursuing typological study based on Psychopathology (39.58, 37.40,
tial hospitalization and positive syn-
this distinction. 38.13).
drome (r = - .03), negative
In view of the pattern of PANSS syndrome (r = - .09), or the com- The assessment of neuroleptic-
correlations with historical, cogni- posite index (r = .04) (Kay, Opler, treated patients poses an interpreta-
tive developmental, and genealogi- and Fiszbein 1986). Evidence from tional problem for this as for other
cal variables, we have proposed that our typological comparisons also re- published studies on the positive-
the negative syndrome is dis- vealed no covariation between negative dimension. Particularly in
tinguished by a familial predisposi- length of illness and the positive- evaluating the negative syndrome, it
tion for psychosis and early negative dimension as observed has been proposed that neuroleptics
ontogenetic failures, particularly in within an acute (lindenmayer, Kay, may produce a seeming indifference
the cognitive realm, which fore- and Opler 1984) or chronic schizo- to the environment, and their side
shadow premorbid adaptational dif- phrenic population (Opler et al. effects can be misconstrued as mo-
ficulties and, eventually, enduring 1984). In addition, we recently con- tor, affective, verbal, or motivational
multimodal deficits (Kay, Opler, and cluded two studies which further deficits (Rifkin, Quitkin, and Klein
Fiszbein 1985, 1986; Opler, Kay, and suggest that positive and negative 1975; Van Putten and May 1978). To
Fiszbein 1986). The results and inter- syndromes prevail to a similar ex- guard against systematic rating er-
pretations are congruent with the tent across various stages of schizo- rors attributable to extrapyramidal
pivotal role ascribed to developmen- phrenia. A 2-year followup of 19 reaction, we separately assessed
tal dysfunction in the pathogenesis acute schizophrenics (Lindenmayer, these symptoms on two side effects
of certain expressions of schizo- Kay, and Friedman 1986) revealed scales and statistically partialed out
phrenia (cf. Walker and Emory 1983; negligible change (p > .20) in posi- their influence on PANSS scores. It
Aylward, Walker, and Bettes 1984; tive score (17.26 to 18.37), negative was seen that the criterion-related
Pogue-Geile and Harrow 1984) and score (22.05 to 21.16), composite in- validity was not diminished as a re-
with our dual-process model that dex (-4.29 to -2.79), or general sult (Kay, Opler, and Fiszbein 1986).
posits separate developmental psychopathology (39.04 to 38.56). By The general impact of medication
(neuroleptic-resistant) and arousal- contrast to the present report of sta- and dose, however, could not be
related, disorganizational (neurolep- bility among refractory patients dur- statistically adjusted due to in-
tic-responsive) components to the ing the chronic phase, the correlates complete and unreliable information
schizophrenic cognitive abnormality were low and nonsignificant when in many cases. In our typological
(Kay and Singh 1979). scores were tracked from the acute studies, where this information was
into the subacute phase, i.e., before available, neuroleptic dose was un-
Clearly, a systematic program of
the more established course of ill- related to the positive-negative dis-
study will be needed to pursue this
ness (cf. Brown 1960). Thus, some tinction in acute schizophrenics
emerging model. Further research
patients evidently improved (Lindenmayer, Kay, and Opler 1984)
on the PANSS also is necessary, in-
clinically, some worsened, and some and, contrary to the proposed direc-
cluding drug-free assessments and
were unchanged. In a cross-sec- tion of confound, was only half as
expansion of the data base for estab-
VOL 13, NO. 2,1987 273

high for those with a preponderance Andreasen, N.C. Negative symp- ease process? British Medical Journal,
of negative features in a chronic toms in schizophrenia: Definition 280:66-68, 1980a.
sample (Opler et al. 1984). and reliability. Archives of General Crow, T.J. Positive and negative
We are presently examining the Psychiatry, 39:784-788, 1982. schizophrenic symptoms and the
influence of neuroleptic treatment Andreasen, N . C , and Olsen, S. role of dopamine. British Journal of
and withdrawal on positive and Negative v positive schizophrenia: Psychiatry, 137:383-386, 1980b.
negative scores, their variations over Definition and validation. Archives of Dworkin, R.H., and Lenzenweger,
the course of illness, their prognos- General Psychiatry, 39: 789-794, 1982. M.F. Symptoms and the genetics of
tic implications, and their relation-
Andreasen, N . C ; Olsen, S.A.; Den- schizophrenia: Implications for diag-
ship to neurological status. In
nert, J.W.; and Smith, M.R. Ven- nosis. American Journal of Psychiatry,
proceeding with our study of the re-
tricular enlargement in schizo- 141:1541-1546, 1984.
liability and validity of the PANSS,
we also have begun to collect simul- phrenia: Relationship to positive Garrett, H.E. Statistics in Psychology
taneous ratings from paired ob- and negative symptoms. American and Education. New York: David
servers using this instrument as well Journal of Psychiatry, 139:297-302, McKay, 1964. pp. 337-370.
as corresponding assessment with 1982. Heinrichs, D.W.; Hanlon, T.E.; and
Andreasen's (1982) method, which Angrist, B.; Rotrosen, J.; and Carpenter, W.T., Jr. The Quality of
will permit analysis of interjudge Gershon, S. Differential effects of life Scale: An instrument for rating
concordance and cross-comparison amphetamine and neurolepn'cs on the schizophrenic deficit syndrome.
of scales (Kay, Opler, and Linden- negative vs. positive symptoms in Schizophrenia Bulletin, 10:388-398,
mayer, in press). Should the validity schizophrenia. Psychopharmacology, 1984.
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VOL. 13, NO. 2,1987

Walker, E., and Emory, E. Infants at Mohan Singh, whose conceptualiza- Albert Einstein College of Medicine/
risk for psychopathology: Offspring tion of schizophrenic phenomena in- Montefiore Medical Center and
of schizophrenic parents. Child De- fluenced the definitions of many Bronx Psychiatric Center, Bronx,
velopment, 54:1269-1285, 1983. scale items. NY. Lewis A. Opler, M.D., Ph.D., is
Zubin, J. Negative symptoms: Are Associate Clinical Professor, Depart-
they indigenous to schizophrenia? ment of Psychiatry, Albert Einstein
Schizophrenia Bulletin, 11:461-470, College of Medicine/Montefiore
1985. The Authors Medical Center, and Clinical Direc-
tor, Bronx Psychiatric Center, Bronx,
Stanley R. Kay, Ph.D., is Assistant NY. Dr. Opler has recently accepted
Acknowledgment
Clinical Professor, Department of a position as Director of Schizo-
We thank Dr. Jean Endicott, Dr. Psychiatry, Albert Einstein College phrenia Research, Department of
Joseph Zubin, and the editorial re- of Medicine/Montefiore Medical Psychiatry, Presbyterian Hospital,
viewers of Schizophrenia Bulletin for Center, and Co-Director, Research and Associate Professor of Psychia-
their constructive comments on an Unit, Bronx Psychiatric Center, try, College of Physicians and Sur-
earlier draft of this article. A debt of Bronx, NY. Abraham Fiszbein, geons, Columbia University, New
gratitude is owed also to Dr. Man M.D., is Resident in Psychiatry, York, NY.

Sample Items From the Positive interfere with thinking, social rela-
Appendix and Negative Syndrome Scale tions, or behavior.
5. Moderate-severe—Presence of nu-
PI. Delusions. Beliefs which are un-
merous well-formed delusions that
founded, unrealistic, and idio-
are tenaciously held and occasion-
syncratic. Basis for rating: thought
ally interfere with thinking, social
content expressed in the inteview
relations, or behavior.
and its influence on behavior.
6. Severe—Presence of a stable set of
1. Absent—Definition does not ap- delusions that are crystallized, pos-
ply. sibly systematized, tenaciously held,
2. Minimal—Questionable pathol- and clearly interfere with thinking,
ogy; may be at the upper extreme of social relations, and behavior. Pa-
normal limits. tient at times acts inappropriately
3. Mild—Presence of one or two de- and irresponsibly on the basis of un-
lusions that are vague, un- realistic beliefs.
crystallized, and not tenaciously 7. Extreme—Presence of a stable set
held. Delusions do not interfere of delusions that are either highly
with thinking, social relations, or be- systematized or very numerous, and
havior. dominate major facets of the pa-
4. Moderate—Presence of either a ka- tient's life. This frequently results in
leidoscopic array of poorly formed, inappropriate and irresponsible ac-
unstable delusions or of a few well- tion, which may even jeopardize the
formed delusions that occasionally safety of the patient or others.
SCHIZOPHRENIA BULLETIN

P2. Conceptual disorganization. failure of communication, e.g., mal flow of communication associ-
Disorganized process of thinking "word salad" or mutism. ated with apathy, avolition,
characterized by disruption of goal- Nl. Blunted affect. Diminished defensiveness, or cognitive impair-
directed sequencing, e.g., circum- emotional responsiveness as charac- ment. This is manifested by dimin-
stantiality, tangentiality, loose asso- terized by a reduction in facial ex- ished fluidity and productivity of
ciations, non sequiturs, gross pression, modulation of feelings, the verbal-interactional process.
illogicality, or thought blocking. and communicative gestures. Basis Basis for rating: cognitive-verbal
Basis for rating: cognitive-verbal for rating: observation of physical processes observed during the
processes observed during the manifestations of affective tone and course of interview.
course of interview. emotional responsiveness during
the course of interview. 1. Absent—Definition does not ap-
1. Absent—Definition does not ap-
ply.
ply.
1. Absent—Definition does not ap- 2. Minimal—Questionable pathol-
2. Minimal—Questionable pathol-
ply. ogy; may be at the upper extreme of
ogy; may be at the upper extreme of
2. Minimal—Questionable pathol- normal limits.
normal limits.
ogy; may be at the upper extreme of 3. Mild—Conversation shows little
3. Mild—Thinking is circumstantial,
normal limits. initiative. Patienf s answers tend to
tangential, or paralogical. There is
3. Mild—Changes in facial expres- be brief and unembellished, requir-
some difficulty in directing thoughts
sion and communicative gestures ing direct and leading questions by
toward a goal, and some loosening
seem stilted, forced, artificial, or the interviewer.
of associations may be evidenced
under pressure. lacking in modulation. 4. Moderate—Conversation lacks free
4. Moderate—Reduced range of facial flow and appears uneven or halting.
4. Moderate—Able to focus thoughts
expression and few expressive ges- Leading questions are frequently
when communications are brief and
tures. needed to elicit adequate responses
structured, but becomes loose or ir-
and proceed with conversation.
relevant when dealing with more 5. Moderate-severe—Affect generally
complex communications or when appears "flat," with few changes in 5. Moderate-severe—Patient shows a
under minimal pressure. facial expression and a paucity of marked lack of spontaneity and
communicative gestures. openness, replying to the inter-
5. Moderate-severe—Generally has
viewer's questions with only one or
difficulty organizing thoughts, as 6. Severe—Markedflatnessand defi- two brief sentences.
evidenced by frequent irrelevancies, ciency of emotions exhibited most of
disconnectedness, or loosening of the time. There may be unmodu- 6. Severe—Patient's responses are
associations even when not under lated extreme affective discharges, limited mainly to a few words or
pressure. such as excitement, rage, or inap- short phrases intended to avoid or
propriate uncontrolled laughter. curtail communication (e.g., "I don't
6. Severe—Thinking is seriously de- know," "I'm not at liberty to say").
railed and internally inconsistent, 7. Extreme—Changes in facial ex-
Conversation is seriously impaired
resulting in gross irrelevancies and pression and evidence of commu-
as a result, and the interview is
disruptions of thought processes, nicative gestures are virtually
highly unproductive.
which occur almost constantly. absent. Patient seems constantly to
show a barren or "wooden" expres-
7. Extreme—Thoughts are disrupted 7. Extreme—Verbal output is
sion.
to the point where the patient is in- restricted to, at most, an occasional
coherent. There is marked loosening N6. Lack of spontaneity and flow of utterance, making conversation not
of associations, which results in total conversation. Decrease in the nor- possible.