2004 - Ego-pathology And Common Symptom

Brur R-eponts

nomcnology in schizophrenia.Explicitly refening to the conceplof schizophreniaas severeego-disorderand dra* ing from Jaspers'(1920) descriptionof formal characteristicsol Scharfetier(1981) operationallydefined ego-conscrousncss. Frank Ri)hrit ht, MD, MRCPs\,.h,* 6ve basic dimensbns ofthe empirical-ego;he developedand und Stefa Pliebe.MD, FRCP.'r.hf validated a conespondingpsychopathometrictool with filr Abstact: The phenonenological constructof egopathologyin ego-parhology symptom fac&'s. lhe Ego-Pathology Inven\.hlzophreniahas beensidely refefiedto in psychopathologEal tory (EPl; Scharfelter,1995a. 1995b).Unlike the symptoni leilbooksbut was syslemically ase$ed nr very ies cnpirrcat of ego-disorderclassified as Schneidenanfirst-ranl srmpstudies. This studyinvestigated the a$ocrationbclsccncgo-pathol- r o m s .m e r . a ( r o r . c a p r L - eb r . i . q l a l r ' e ' o I e g o - c o n . c r o r l ogy (E8oPathology INentory)md comnronsymptonfacto's(Pos ness,and its conespondingpalhology can be summarizeda. iiive and Ncg.iile SymptomScale)in paranoidschizothrenia !albllo\\,s. Ego-litalilv dcscribcsthe self-experienceof being tjcntsslthin I day\ alteradnnslonandaiter2 weeksofreahent. present as a living bcing. Ego-activiiy is tunctioning as a for shon'rem ftalmenl Tne predictile value of ego-parhology self-directing unily. self'goveming. and inteniionaily direcrA factoranallsisofall subscale scores outcomc$as alsoassessed. , , n g o n e o $ n h i n k i n g .i e e l i 1 r .a n , ir c r i n g .f p o * o . ] s i q e D c \ , e \ e r l < J i". r u - t u . r ' r . r , ' n n o i r . e " ) n p r o - . .n e g r i e . ) - p , , o e f i n e d d . r h eq , u l r D a r d c " h . ' . n c c ^ l s e l f - e x p e r c n cae. tohs. and r$d dislin.t ego-padologyfaclors,i..., generalard "activit!' loadedon idemily.Allhough$e ego-palhology subscale structured and organized. Ego demarcadon relates to bounG the posiriveslnptom factor. the otherlbur subscalcslbrncd lhc t$o ariesand the differentiatioDbctwcenego and nonegospheGs ego paiholoSyfacloB wilh !o high loadingson othcr tactoB. Hieh Ego-identio refers to the prcrcffcxilely giv€n cenain$ of scoreson egodemecationar ldmjssioDprcdiclcdpoor lreatmcnt one's own definite selfhood. outcome after 2 weeks The lindings suggcslthat cgo-palhology Other aurlors (Loftus et al., 2000; Soyka. 1990) idennlghl be used to catlure addillonaldd dinically meanngtul ' r l i ( J r d r { n . 1c g ^ - p a r l o l o g }l d c r o r b a . e d on,)mpromrrerrl. slnplom dlnensionsin schizophienia (main\ as Schneiderian tust-ranL symptoms classificd Key Words: fsychopalhology. ego.syhpron lactors. passivity thoughr bro3dcasting, and pherhoughl insertion, , u E . r . r i n g \ a l i d i $ p o renh e ' e b ) d d . J g r o q i c o r nomeral. genedc *Unnfor Socialandconnuni!_Psychialry, and signiticance of ego-psychoNewham Cenllefor ltlenlal iially an etiological pathology. Although the litenture on schizopbrenia HeahhEastLondon andTheCr]-MentllHelhhTrusr;$d TBansDd theLondon School ofMedicinc, QuemMary\, Unilersn)of London. throughout the last ccntury th€refore frequenily refers ro London. LnnedK,ngdonr schizophreniaas an ego disorder. the associationbet\eer Sdndrepiinriequensr. Dr Fiant Riiltri.hrEa$ Londo.andThc Cit! NlcdalHcaldTn(, Ncslan Cenaefor Menralttealth.GlenRoad, common symptom facbrs and ego-pathologyand their cliF ical significancchas nol been systematicallyinvestigated)er London !l:l 8SP.Ldled Kingdon. q 200.1by L,ppincot W,lllans & Wrlkrs T h L t r ( . e n r . r L d \ d n e d r o 1 s . e . se g o - D d r h o l o !.)\ . r e m a c . Copynght DOI l0.l09lr0lnnd.0000ll0ll36217037 cally in paients with acute schiTophreniaand explore whelher ego-pathologyscores overlap with or arc disdtrct from cornmon psychopathology,l.€.. general,positive. and dir\.' !m,,,edcui((pr ol \hrl^phrerra $I\ Inc a. T\( . ) m p r o m , l i m e n . i o r t . . . ncgalilc s),mptomhc|ors. Additionally. rhe predictive \alue | . J m p t i o n . tr $ o r a i r J i ' i r J I , of cgo-pathoiogy scor€s lbr shon-term treatmenl outcom. a positive and a negative symptom factor, has received was invcstigalcd, frequentcritjcism (Andreasenet a1.,I995; Amdt ei al., I991: Grube et al., 1998), and il has been suggesledthat tufher METHODS meaningtulsymptomfaclors shouldbe g€nerated(Toomey et Patients Nith a clinical diagnosis of acul€ paranoid al., 1997). The concept of ego pathology mighl provide a model to assesssuch addirional symptom dimensions.Egoschizophreniaaccordnlgto ICD-10 (,\ = 60) rere assessed experience or selt'-experienceand the coffesponding ego$ithin I days after admission for treatment inlo aD acure pathology have repeatedlybeen described in textbooks as psychiatric catchmenl arca ho\pital. The decision ro t_o.!: importanr symptom djmensions in schizophrenia (Sims. only on this subtwe was made 10assessa reiatively homos1995). The conceprhas been refered to from phenomenoenized sanple with high lev€ls of llorid psychotic or fiL!:r' logical (Rithricht and Pricbc. 2002: Scharfcftcr.1981). psy rank symptoms.Basedon a struciuredclinical inlervre$- rrF chological (K€rnberg, 2000), and neurobiological (VollenEPI (Scharfetter, 1995b) and the Positive and ).Jegati\e \,!eiderer al.. 1997) perspectives. Slmptom Scal€(PAN SS: Kay et al.. I 987 ) were administered Empincaliy. cgo patholo$/ has moslly been assesscd by an indep€ndent research€rto obtain rating scores on cgo-psychoparholog]' and comrnon psychopathology.So.ic undcr thc umbrclla rcrms €8o fundioning. ego strength, sell. d'|arcness,or ego delbksene.hanisns. These conceptsrrc dcmogaphic (age. sex, mantal status,educatlonstatus)a.d nor rcgardcd as mcaningful for th€ psychopathologicalphcclinical charactenslics(dunlion of illness, number of pre\r-

Ego-Pathology and Common Factors in Schizophrenia Symptom

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Theloumolof NeNousdndMentalDkease. Volume192,Number6, June20O.

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Ego pothology ond Synpton Fdctots

oushospitalizations. chlorpronazine-equivalents of antipsychoricm€dicattun) $ere alsorecordedafteradmission. Comqas reass€ssed mon psychopathology on thc PANSSby the sameresenrcher after 2 \eeks (N = 43): this periodwas chosenbecauseacuteslmpiomatologycan be expectedto havesubstaniallyimpro\edin mostpatjemsby thistime.and themajorityofparienrs$ould srill b€ treatedin thehospital. BnefPsychiatncRarngScale(BPRST Overailandcorham. 1962) subscalcscoressere also calculatedbasedon thc identicalPANSS irem rarmgs1()enhancerhe variely of symptomllcto^ tbr anal)sis

y€ars.SD. 1l.l; meanl€ngthof illness.6.0 years.SD,6.3; frequency of hospitalizations. 3.8,SD, 3.3;mantalstatus.1,1 marricd with partner.SS singl€. 8 dilorcedr educational status,3 no desree,l4 GCSE.23 A-level).Alter admission, meantotalscoreswere72.3on PANSS{SD, 16.2).and 12.5 on EPI (SD, 6.8). Thc meanchlorpromzz ine-equilalentof antipsychotic medicationwas487 mg (SD.157). Forty-lbreepatjcntswere reassessed after 2 weeksof inpatlcnttreatment.Of ihe 17 palicntswho could not be reassessed, l1 withdrcwfrom assessment, and six rverealreadydischarged. Comparing demographic andclinicalbaselinc characteristics betwe€nthc 60 initially includedpatients 5tatisticalAnalysis and the 4l r€maining forfollow-up,no signilicantdiffcrcnces SPSSPC. \.Non 10.1. sralistical soft$'are sas used *cre detected. The mean PANSStotalscoreai iollow-upwas for data anal)sii. Ali :ubscales of PANSS and EPI were (SD. 59.1 14.9). the difTerence betweenadnissionscoreand subjectedto a pnn.+3j .omponent facror analysiswith varifollow-up score was saistically significant(pairedsamples max rotation Io t.jr rhe aso.iation of ego-psychopathology : < r-test, / 6.6; ll. 12) p .000),. and the mean changc jn and common ps! cht1adrolog). Pearsoncorelalion coeffi, (SD. PANSS total score was 13.2 13.1). crcnts we.e calcularedro assessfurther lhe associ.rtionbeTableI summarizes theresultsofthe factoramlysis01' lwcen symptom la(-rLrl\ psychopathology (PAN-SS subscales and EPI) at baseline. For predlcting!.ul.ome. changesofPANSS totalscor€s The analvsisrcvealsa foxr-factorsolutionexplaining betwe€nmirial d*:m.nr and:+eek ibllolr-up were raken 76% of the total variancc.The solutionshowsa positive as outcomecnreria.Ihi .hnge icorc was enteredas depen s]'rnplom faclor and a negatives]'rnptonrfactor in line with dent variable in a lmear r+reijion analysis (m€ihod stcp the established two-djncnsionalmodelof commonpsychowise). Independent\a:rabl.: $ere demographiclsex; agci mantal stntus. mar.ied siih panne. versus single/divorccd: pathology.Howevef,rt additionallyidentificst*'o drstincl egopalhologyfactors,x'hichmay bc called€go-gerefaland < d J c a t r o ng. c n e l a lj . r u n j a t e u l , | J r J d r d e o u c d l . o n\ e . , u . advancedlelcl) and cLln]r3l .hancteristics (number ol prc ego-derli'_r-. Althoughthe EPI subscale activilyloadson ftc positivesymptomhctor. ego-idendtyfoms a lactor on its vious hospitaliz-allonr. d@ron of illness from tust hospital, ization, legal statusar adnristoD. medicarion)including psy own, and the threercmainingFiPl subscales demarcation. chopathology5coresar baielme consislency. ,nd vitality all loadon a generalcgo-pathology facbr. Eachsubscale hasloadingsofmore than 50 on only RESULTS one lactor.ln additjonto the infomation gatheredrhrough qrri Faramidxhrzophrcnra Sixtypauents werentacloranalysis,thc calculation of Pearson coirelalioncoeffi cludedin the srud\rj6 ii'male.:1 male:meanage,35.9 cjcnN indicatespositiveassocjatjonbcNeen Efl subscale

TABLI 1. Factoranalysis(varimaxrotation) on all psychoparhologysubscales' t Positive

2 f,go-g€nerrl

P.{\SS gtueEl pi\choparhology P.{\SS n.sanie smptoms PA\SS Bx,n\. s\Tptoms EPldentitr

EPI riralilv % Explainedvariance

3 4 Negative Egcidcrtirr_ .922 .9t6

.8i2 ..109 t.7 20.7%

.737 .8I .t0l .510

24.4"n

.106

t5 19,1%

t.2 I5.,19i,

rlr8cnyrlue >'l Md nem loadinas>0l0 ar shosn Tokl cumulatircvananceexth,ned:75.9%.

a: 2041 LhPincon ,fi ion! & witkins

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ego-jdentity and BPRS subscalethought disturbance(/ = .51i p < .001) and betwccn EPI subscaleego-activit-!and BPRS subscalehostilelsusfic usness(. : .56; p < .001). The linearregressionidentificdthreepredictorsfor shon-tenn lrearrnenr response defined as reduction in PANSS total scores benveen baseline and finlow-up: EPl-demarcalion 'gcra. t,ll. do.ageot rr'rp.\\h,iiJ' 'n r\lorp'Jnri1
.461.

DISCUSSION A factor amlysis ofego psychopalholog)and common s),mptom factors in acute pafanoid schizophreniayielded a four-lactor solution.Each scal€had k)adingsol rnorethnn.50 on only one laclor. and the amounrol exphined lanance was 'lhus. the analysisprolided a comrelatively high at 769n. paratively cleaf model. In line wr|h pre\ious studies (And r e a s e ne r a 1 . .1 9 9 5 ;A m d t c t a l . . 1 9 9 1 ;G r u b ee i a l . , 1 9 9 8 ) , { p d r d r e p o s r r i \ ed n d n e r d r i \ . J m t t . m d , n e n s : o n . $ e r e $tablished, which may indicaie a faciuiil !,lidity of fie psychopalhohg) ratings in this study. t-iieraturecommonly describcsa third or tburth factor (Lidd1e,1987;Peraltaet al.. 1992). usually refening to the consL.uctsof disorganization and bizane beha\ior. ln thls study, subscale scofes werc enteredinto the factor an,rlysis,thusnot allowing detectionof other common symptdn lactors. Nevenheless.two disiinct ego-pathologyfactorswerc identified, t d., one factor mainly determined by the scorc of the subscale ego-idenntj and another factor with signilicanl loadings of three of the five subscalesof thc EPI. thus called ego-gene|al.Taking the posililc as$cirlion belween the subscalesego identily and thoughl disrurbance(including the hem .onccptu!] disorganiralion) into accoxnt. one may coDlidcr lhis factor representingr third common (disorganizalion)factor. Thc fourth facnn in this srudy, however. suggeststhat ego-palhology indeedrcprcscnNone or more additional and distinct dimcn sions of psychopathologyin schizophftnia. I hc cgo rctivity subscaleloadedon the posjt've symp' lom factor and *as also posltively coffelatedwith rhe UPRS Ego-activityscorcsreflecta subscalehostility/suspiciousness. lack of one's own ability and power lbr s€lidetermr,red aclion the association appearsplauandthoughls.Phenomenologically. sib1e,and the expenencc of passivty also retered to as /osr oI Meinhaliisk h (my nessFhas been suggested as a corc phenomcnon of llrid psycho[c qmptoms. Thc findings of1h1sstudy may be seen.to so'ne exlent. as revnlidatng Scharfetter's(1981) onginal conccprofegopttrhologl. Yet, the loadingsofthe subscalesarc split among threc facrors.which might be taken as a reasonto speciryand amcnd thc conccprin the light oflhese and further empirical findings. Ego'pathology as assessedin this study. applying ihe .onccpt of Scharfetter'sfive basic dimensions (1981).

44lJ

caplures a variety of distind symptoms. xnd therr overlap $,ith Schneid€n3nslmptoms remainsunclcar rnd should be assesscdin lurure studi€s.Given the findings of thls study. one mighl consider ego-psychopalhologyto bc lbllowing Bleulels (1911) onginal conceptualization a fundamenlal symptom dime.sion a1fie core ofschizoptuenia.thus representing specific signs of thc disorder ralher than underlyirg personality.ln line uith fie ]aller notion- some psychiatnsts have continued to refcr b schi2ophrenia as a r€f€/c €go d,rordef since Heinroth (1818) phrasedthe term. The predidion ofshon-terrn outcomein this study had various methodologicalshortcomings.suchas the naturalistic approachwith the lack ofstandardizedlreatmentcondiiions. Nevenheless,a multivariatcanal),sisconside.inga numberof variablesas polential prcdictors found allered ego-demarcation to predict poor trcatmcnt rcspons€independentlyofthe influenceof oiher lariablcs. This mlghlcaunously beenlaken as a sign ofsome prcdictivc ulldily olthe construct.Disturbancesof ego-demarcarionwere first describedby fedem (1952) and later empnically undc{rinned by Fisher (1986). r h e I n " u i e U r b u u n d a n e a. . . t c c m S r r r ' .r l q v s l c u g g e . r e d mon dcnominator lbr first-rank symptoms and cmphasized that thc senseof invasion of oneselfappearstundrmcntal ro the naturc of schizophrenia.Theretbre, poor treatment response in parients wllh wdkened ego-demarcationmight indicate that thc concepl is closely linked with ihe core sympbmatology of the disorder. Systematic studies in bigg€r samplesacrossthe specL.um of subq?es of sclrizophrenix will be needed to ad'ance the concept of ego prthology and specily its associalion ! iih other slmptomatology. The olenll findings ofthis study lcnd support n) rhe concepl of scbrzophreniaas severeego disordcr.

REFERENCES MillerD.FUunNl(1995)Slmtroms df A nascnNC.AndlS.AlLigerR. Vethod!.n.an,ng rnd mc.hanismtt.h Gd ],lihn .l schizophrenir: Amdr s. Alligcr RJ.lndrcascnNC (lL)91)The disnrdin ol losihe and n c g x l v cs y n p r o n Nr /.J / 5 r r r d n . 1 5 8 : 3 1 7 : 1 2 : Blculer| (r9l r. tlrms 1952b! NS Klrne)Dezenrn,Pt11t.d.r !h! G.u? al S.ht:olhrdia\ \eR Y.rk: lm.marionalUmveNtresPres. FedcmP (1952)Es, P.\'rr,/,S dhd th. Ps\rhas.sI ondon:Imago. Frhei S (1986)D.f./.)p,?,7 drd Snr.trr. afth( B.Ar InuK \trtr I nd 2 Hilhdalc.Nl Larcnce-Erlhum A$ocrlres cnbe BS, Bilder Rltl, aroldnanRs (1993) \'lelaanxllns of tnprom facro^ in suhvothrflia s.hi.?/r,R6. ll l13 120. H€,nrolhICA (l8l3l r.rrlr., iet Stbtut4, i.\ S.'tltnlthen!otb dcr S..l.niiiruha.h Ml thr. B.hdd'zg A.hang 1825 Lcipzlg vogcl K ll920l ,llke-r,,! Pj-[r4,/rol,st ts.din: Sp.nger JasDers Kdy SR.FszbcinA. OplcrLA (l9lJr) Theporlve andn€gdiveslndrome SLhtT)phr Bull. \l26], 216. scaleIPANSS)for schiTothrenix Kembe'sOF (2000)Pslch.rnalysis:Frcuds rheoriesandtheircontenrporary develotn.d lr: Mc ccldcf. lL Lopezlbor,NC Andrease.(Eds.r. t?\1 otbr.1 Tenh.rk rf Plrh]drry rpp ll1 l4ll Nes Yorr Oxford a E-exanimtion LiddleFI (1!8rtThe lymfbmi .l .hroni. s.hizophrcni.: l5l l15 l5l. ofthe posni!€negrt!. dl.horomy.A.JPrr.ridt' L.ltus J. Delisi LE. Crow ll (20001Factorstlcrure and l:mnulity of e 201)t t ltrtnnl

tt tlltan\ [

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lirst{a.k synplomsi. siblng pairsrith schrophJfliaand \chizoaJlec dh lrr:t! t9. l y c d N o r d c,rr / P \ k rating\calc t9"r/ o*,"ti rs. Cotru. on tlqri, lhc briel psvchiatric ll.r l0 7q9 812 Peralav. d.Leonl. Cuesra\ll Lq!:) Arc lheF nore thunNo slndromes nl lli ll ,n {hruoh(nk B, / P ,.ncc dbe" l ' D I '\eL'roF{\ R r i n r i - In r P re t ' r\ ' j t chdacr.rize! "uberoupr \=.hrropbFnra'"1'r'Prl"rdt l'dtd l05l :16 llJt. SchartnerC (l98li Fge$l.hrFadolog-v lhe concefland its enft'cal evalualDn.Psr.,i,ll/.r : I I llt(J. of \chuoplEnici r^"reiz S.hadeterC (1995a'lte -'jn jeLaexpenencc ?: ,:jJ t.16:200:06 Arch!\.urol\a\\;t af SLhi:ophreni" Envni'al Schrlifter a rlga:b :.. -':'L.l,.na..

C 2001 LiPt)in.ox Ailhotns & llrjlkjns

shklrs rl th. FEolsallin S.hrnPhrcntuB'r'larlin' DnnL6 anll De , ' . \ t r t h a r h P ' r J t cP r b l i ( r i o l t"i t t t r' t' th:' .';. r, *. 1P , t ' h 0 a t h . l ' ! t L ' n d o nS: r u n d e F '' sorr,r",oo"i .,frr' ir.rl n r'Ln '|'r''l JlJldrl ! / / l n . r i d t S . , , / 8 1 : 2 5 51 5 9 ,^".. n *..'. \\' s'np-r ' \'T ' A \Pdr 'li lr'r'\lr L1 e i n'\rl i - i " . . . ' . r - , v r , i o - R c \- r ' o r l e r ' " rp " n J' e J r r ' e " p o r " \ ' o ( 1 c l o ' ' l " t ' ' d 5 " g ' r { ' ' E ln I P Llrot^ l\a 1-l i" .r ^',tt"-' ot"*' Kr, ScLTret.r C Antodni A, Mas!trc Nt\\mcr \ olh;;ei&. F\. !a.d$ l. Anlsi J i I99r) Mctbolic h!'lt.Fonuliri" andpsvchQatholog!in rhekcbn h'o8,, +,dr ; ; . 4 . " . , . , " . ,+ s F . ' o , - , o , -o -4 r"+"4 " "r" ' l t r " i / ' J d li'lnor.J.'

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