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PSYCHIATRIC SYMPTOMS AND CHANGES

IN HOSTILITY STRUCTURE

By: NIKIFOROS ANGELOPOULOS

Submitted to the Faculty of Medicine in fulfilment of the requirements for the degree of Doctor of Philosophy in the St. Mary's Medical School, University of-London, 19S2

2

1 . ABSTRACT

The relationship between the changes of the phenomena (symptoms) of

mental illness on the one hand and changes in hostility patterns

on the other has been examined in this study. The purpose was to

investigate whether there is any interaction between these symptomatic

phenomena and the hostility patterns with the lapse of time in

psychiatric patients.

The directional hypothesis was that there would be a positive

association between changes in symptoms frequencies and changes in

hostility.

Symptoms fluctuate according to the severity of the illness;

hostility patterns are commonly regarded as reflecting more enduring

features of the personality but there is evidence to suggest that they

are not so permanent and unchanging as character traits.

A sample of seventy three patients, allocated to a relatively wide range

of diagnostic categories was examined. The patients completed a pair

of questionnaires - the Hostility and Direction of Hostility

Questionnaire (HDHQ) and the Delusions Symptoms States Inventory

(DSSI/R) - at intervals from the time of admission until their discharge.

The relationships between the changes of certain symptomatological entities

(expressed in the form of DSSI/R score changes) and certain hostility

patterns (expressed in the form of HDHQ subscale score changes) have

been examined in the light of the data obtained.

3

It was found that certain features of hostility are significantly

related to the changes in measure of symptomatology. The implications

of this finding are discussed with respect to the characterization

of hostility as a measure of symptomatology or as a manifestation

of more enduring personality features.

4

p. TABLE OF CONTENTS

Title page. Page

1. Abstract 2

2. Table of contents 4

3. Introduction 8

4. A survey of the literature 11

'•.1. Personality and psychopathology H

4.1.1. The concept of trait and personality type 14

4.1.2. The concepts of symptom, sign, state and syndrome 15

4.1.3. The concept of attitude -j -

4.1.4. Distinction between personality and psychopathology variables 1;7

4.2. Psychiatric symptomatology jg

4.2.1. Personal relationships and psychopathology 20

4.2.2. The hierarchical nature of mental illness 21

4.2.3* The classes of personal illness 2.3

4.2.4. Testing the hierarchy model 26.

4.3. Hostility 29

4.3.1. Hostility and psychopathology 32

4.3.2. Hostility and anxiety t 35

4.3.3. Hostility and depression 38

4.3.4. Hostility and mania 4 6

4.3.5. Hostility and conversion-dissociative phenomena , 4 8

4.3.6. Hostility and phobic symptoms 52

4.3.7. Hostility and obssessive-compulsive neurosis 54

4.3.8. Hostility and paranoid disorder 56

4.3.9. Hostility and schizophrenia 58

4.4. Summary 60 »

5

TABLE OF CONTENTS (CONT) Page

5. Methods 62^

5-1. Population and selection of the sample £2

5-2. Measuring instruments used and their administration 641

5-3» Data processing and analysis

5.4. Summary . 7

6. Results 73

6.1. Study-point I 77(

6.2. Study-point II g .-

6 . 3 . Study-point III Qy.'

6A. Study-point IV , 93"

6 . 5 . Comparisons across the study-points gQr

6.5.1. Relationships between the score changes of state of anxiety (sA) and HDHQ subscales 100

6.5*2. Relationships between the score changes of state of depression (sD) and HDHQ subscales 103

6.5.3. Relationships between the score changes of state of elation (sE) and HDHQ subscales -jQg

6.5.^. Relationships between the score changes of conversion symptoms (PS) and HDHQ subscales 108

6.5.5. Relationships between the score changes of dissociative symptoms (DS) and HDHQ subscales 110

6.5.6. Relationships between the score changes of phobic symptoms (FS) and HDHQ subscales 113

6.5.7* Relationships between the score changes of compulsive symptoms (CS) and HDHQ subscales '116

6.5.8. Relationships between the score changes of ruminative symptoms (RS) and HDHQ subscales -j g

6.5.9. Relationships between the score changes of delusions of grandeur (dG) and HDHQ subscales 122

6.5-10. Relationships between the score changes of delusions of persecution (dP) and HDHQ subscales 125

6.5.11. Relationships between the score changes of delusions of contrition (dC) and HDHQ subscales 128

TABLES OF CONTENTS (CONT) Page

6.5*12. Relationships between the score-changes of

delusions of disintegration (DD) and HDHQ subscales .13-1.

6.5. 13 Summary 134

7. Discussion 135

7.1. Self-rating scales 139

7.2. Hostility and Direction of Hostility Questionnaire

(HDHQ) 145

7.3. Delusions Symptoms States Inventory (DSSl) 151

7.4. A note on the descriptive status of the data 155

7-5. Anxiety and hostility 159

7.6. Depression and hostility 162

7.7. Mania and hostility 169

7.8. Conversion-dissociative phenomena and hostility 171

7.9. Phobic symptoms and hostility 174

7.10. Obsessive-compulsive symptoms and hostility 176

7.11. Delusions of persecution and hostility 179

7.12. Delusions of disintegration and hostility 1 82

7.13. General comments 184

7.14. Summary 191

8. References 192

9. Acknowledgements 207

10. Tables and Figures 209

11. Appendices 285

Appendix As Presentation of the Hostility and Direction of Hostility Questionnaire (HDHQ) 286 Appendix B: Presentation of the Delusions Symptoms States Inventory (DSSl/R) 290 Appendix C: Correlation coefficients with probability values 296

Appendix D: Key to the coding of information used in the data forms, punched cards and computer's 316 listing

TABLE OF CONTENTS (CONT)

Appendix E: Index of abbreviations and symbols

Appendix F: Listing of the data

8

3. INTRODUCTION

The aim of this study was the examination of the.relationships

between psychiatric symptoms and hostility as they are seen through

the changes of those two variables with the lapse of time in

psychiatric patients.

If aggression and hostility are considered to have any significant

role at all in psychiatric illnesses, it would be reasonable to

expect some change to occur in their status and expression between

the time the patients are manifesting acute psychiatric symptomatology

and the later time when changes of their psychiatric clinical

picture have taken place.

The problems of the relationship between hostility and psychiatric

illness have not only theoretical interest but also direct implications

in every-day psychiatric practice and they have been a matter of

earlier study by a number of investigators.

There has been a widespread discussion regarding the various patterns

of hostility, their meaning, their function and their relationship

to psychiatric illness, a discussion initiated by the psychoanalytic

school. The most interesting views about this relationship are

presented later (see the survey of the literature section).

The great number of studies about the relationship between hostility

and psychiatric illness, and the large range of often conflicting

views, relfects not only the importance of this matter but also

the existing confusion which is caused by the difficulties in

9

definition and measurement in particular of hostility "but also of

certain symptomatological entities. Difficulties in definition and

measuring could also "be regarded as the main obstacles in the application

of an efficient methodology to the study of this relationship.

It seems that studies of changes during the development and remission

of psychiatric illness are needed, as well as investigations of specific

relationships between hostility features and the various psychiatric

categories.

Hostility has been regarded as an attitude and being in an intermediate

positon - as far as stability, universality and the cause of distress

are concerned - between personality traits (regarded as stable,

universal and not causing distress to the individual) and psychiatric

illnesses (regarded as transient, sporadically found in the general

population and causing distress to the individual). In the field of

psychopathology, personality disorder is manifested through deviant

character traits whereas mental illness is expressed through symptoms

and signs (Poulds, 1965b; Priest and Steinert, 1977).

This study tries to examine some important aspects associated with the

problem of the relationship between hostility and psychiatric illnessi

1. To what extent hostility is related to the course of psychiatric

illness, or, more specifically, which measures of hostility parallel

the course of. certain psychopathological entities; 2. How stable or

how changeable are the components of hostility during the course

of a certain psychiatric symptom.

10

This work consists of ten sections; among them are included:

a survey of the literature, in which the important theories and

views about the relationships "between psychiatric illnesses and

hostility are adumbrated; a chapter devoted to methodology, in

which subject selection and participation in the study as v/ell as the

questionnaires used and the statistical analysis of the obtained data

are presented and discussed; a chapter with a presentation of the

results of the statistical analysis of the data collected; and a

chapter in which the findings are discussed in the light of the

established views and findings of previous authors.

11

4. A SURVEY OF THE LITERATURE

Personality and Psychopathology

Among the numerous theories about personality those of Kelly and

Eysenck are currently influential and may be contrasted with the

ideas of Foulds.

Kelly never makes explicit his definition of the term "personality"

but he implies that it is a way of construing and experimenting with

one's personal world. What he does do is to provide "design specif i-i

cations" for a theory of personality. According to his "personal

construct theory" (Kelly 1955) all human beings are concerned with

the prediction and control of their environment. In the process

of adapting to the environment, each individual develops his own

unique pattern of personal constructs, described as the indivi-

duality corollary. Human processes, according to the theory's

fundamental postulate, are "psychologically channelized by the ways

in which the (person) anticipates events" (Kelly, 1955). The antici-

pation of events is accomplished by "construing their replication"

(construction corollary). Constructs are bipolar structures-

(dichotomy corollary). Their poles may be emergent (immediately

perceived) or submerged. Each person chooses the pole of a construct

which "seems to him more suitable for extention and clarification

of his system (choice corollary). Constructs are "based on simul-

taneous awareness of likeness and differences" (Kelly, 1955) among

the objects or events that are evaluated and that are called elements.

Constructs have a limited range of elements to which they can be

12

applied (range corollary), and they are organized into a network

of interrelationships forming the person1s construct system

(organization corollary). This system is continuously modified

in the course of the successive replication of events (experience

corollary). However, the modifications of a person's construct

system are limited by the capability^of his constructs to admit

newly perceived elements (modulation corollary). A variety of

apparently incompatible constructs subsystems may be employed by

a person to evaluate similar sets of elements (fragmentation corollary).

While personal constructs and construct systems are unique for each

person, there are similarities between the systems and constructs

of different persons (commonality corollary). An individual may

partially construe the construction processes of another person and

in that way, play a role in the social processes involving the other

person (sociality corollary).

According to Kelly(1955), events and objects can be appreciated

and appear real and meaningful only when an individual's construct

system allows him to assimilate or interpret.them. Each construct

has a"range of convenience" that is"all those things to which the user

would find, its application useful". Some constructs-are represented by

words and others are not (preverbal constructs). The subject may

have a high or low "level of cognitive awareness1' for the constructs

that are used in his patterns of construction. Some constructs are

more important than others and they may include other constructs as

elements in their range of convenience (superordinate constructs)«

Thus the distinction between elements and constructs may seem to be

artificial. Constructs may become elements and vice versa. According

to Kelly's theory hostility is, regarded as the continued effort to

obtain evidence in support of an already failed social prediction.

13

Eysneck (1970) regards personality as consisting of two major

dimensions: introversion - extraversion and neuroticism -

psychoticisra. The neurotic dimension is closely related to the

inherited degree of lability of the autonomic nervous system while

extraversion is closely related to the degree of excitation and

inhibition prevalent in the central nervous system. According to

Eysenck this balance too is largely inherited and may be mediated

by the ascending reticular formation.

Eysenck (1967) suggests that individual differences in extraversion

introversion reflect variations in tie nature of ascending reticular

activating system of the brain, while neuroticism is related to

characteristics of visceral brain (i.e., hippocambal structures,

amygdala, cingulum, septum and hypothalamus).

There are at least three main schools of ihought with reference to

the nature of the relationship between psychiatric symptoms and personality.

The first adopts the thesis that psychopathology may be regarded as

synonymous with the personality of the patient, giving emphasis to the

underlying weakness of the personal . integration which produces both

symptoms and traits. The second considers psychopathology as an

intrusion into personality in the sense that symptoms are, in various

ways and degrees, dependent on tie traits. The traits precede symptoms

and are more enduring; but when symptoms do develop they could be regarded

as an exacerbation of the pre-existing traits and this is a sufficient

explanation of the form the symptoms take. The third school maintains

that psychopathology is independent of the personality and that there

is no absolutely necessary connection between symptoms and personality traits.

u

It was argued by Foulds (1976) and Foulds and Bedford (1977 d) that

if the personality scores were a consequence of particular forms of

illness it would be expected for them to covary with changes in illness

status, something they did not observe in their studies. It was

suggested by these authors that it is difficult to arrive at final

conclusions on the question of whether particularly extreme personality

scores predispose an individual to particular types of illness or whether

the extreme scores seen during medical care are at least in part determined

by the type of illness. These authors advised closer study of this matter

with long follow-up periods. They nevertheless tended to accept the

view that both tendencies may be operative and the latter may assume

greater importance as one moves from the neurotic disorders to the

psychotic illnesses.

The three possibilities regarding this relationship and the confusion

in the diagnostic work which is created from the differences of these

schools have been discussed extensively (Foulds, 1965a ; 1965b ;

Zubin, 1965 ; 1967).

1.1. The concepts of Personality Trait and Personality Type

Concerning personality structure, the trait-attitude concepts were

introduced to describe certain aspects of the economy of the organism

which imply personal continuity. They serve, as Foulds (1965b)stressed,

to classify the relative generality, consistency and continuity of

responses i> somewhat similar situations. 1

The term trait implies a constellation of expressive behavioural charac-

teristics and denotes a special kind of style in behaving. It is more

15

constitutional than attitude, though it too may be a result of

early learning.

A personality type (Foulds, 1961) is an observable constellation of traits

which can be distinguished from other such constellations. As Foulds (1965 b)

notes, despite the emphasis on the possible constitutional aspects of

trait development by many authors, social pressures which vary according

to cultural and social conditions have a considerable effect on the expression

or inhibition of certain reaction patterns.

Despite the fact that some of the critics of the trait approach have objected i that each personality is totally unique and therefore classification in

this area is misleading or impossible, the trait approach seems to be a

convenient model for research purposes.

4«1.2. The Concepts of Symptom. Sign. State and 8yndrome

Symptoms signs and states represent structural components of the mental

illness (just as traits and attitudes represent structures of the personality).

All three represent a change from a previous habitual condition. Their

presence is an indication that the normal consistency and continuity of

behaviour have been interrupted.

In the case of symptoms the change is most probably a qualitative one ;

symptoms are found only sporadically in any random sample of the general

population and they are causes of complaint either by the subject or by

others because, for various reasons, they are distressful to them. Foulds

(1965b) however, pointed out that despite being distressful symptoms

do not constitute a logically sufficient condition for the diagnosis o£

16

mental illness and that some "breakdown" or "unmanageability" concept

was needed in addition. According to Caine and Smail (1969), symptoms

are experienced as stressful, they inhibit adjustment, disrupt the normal

continuity of behaviour, are experienced as alien to the personality

and are relatively transient in nature and may be idiosyncratic.

A state (Foulds, 1965 b) may be conceived as a persistent but not

immutable mood which endures at least for weeks rather than days.

Moods may be shift upwards as in elation or downwards as in depression.

The change is most probable a quantitative one since such emotions are

experienced by everyone in some degree at some time and for some duration.

Whenever symptoms exist they are likely to be accompanied by states.

While it is probably true to say that all who manifest symptoms also

manifest states/ the converse almost certainly does not hold. From

this description it is obvious that symptoms are rarer than states.

A sign is a change in bodily or mental functioning which is not reported

as a distressing complaint but which the skilled observer recognises as

indicative of such maladaptation and which may have caused danger or

distress to'others or to the patient himself. This is similar to

its use in other branches of medicine when a symptom (complained of by

the patient) is contrasted with a sign (observed by the doctor).

A symdrome is a constellation or cluster of symptoms and signs which

tend to occur together rather commonly and which is distinguishable

from other such clusters of agns and symptoms. Syndroms per se

must be, as Foulds stressed (1965 b), mutually exclusive.

17

The Concept of Attitude

According to Caine and Smail (1969) traits facilitate adjustment,

are actually "how" we behave, they are dispositional may be consti-

tutionally determined and are relatively persistent in nature having

general application. Attitudes on the other hand, fall somewhere

between symptoms and traits and are not like symptoms which are experienced

as alien t> the personality. They do not represent a break in the normal

continuity of the behaviour. They are not the "how" of the behaviour

but are motivational, they may be learned rather than constitutionally

determined and they have been described as enduring organisations of

motivational, emotional, perceptual and cognitive,processes.

Possibly the most important distinguishing features of attitudes are that.

they are evaluative or affective. Certain types of beliefs may also be

constituents of attitudes.

The prevalence of different degrees of an attitude usually shows a con-

tinuous frequency distribution in the general population (Foulds, 1965 b)

and attitudes are more enduring conditions than signs, symptoms or states.

If an attitude changes at all, it does so over an extended period of time.

Distinction Between Personality and Psychopathology Variables

The first necessary step towards the understanding of the interaction

between personality and psychopathology is the distinction of iieir structural

components.

It was suggested by Foulds (196-4, 1965 b, 1971) that the presence of symptoms

18

and signs of mental illness is an indication of a disruption of the

normal continuity of personality, arising from the failure of defence

mechanisms a) to reorganise retreating forces, b) to maintain sufficient

integration of the self-concept and c) to enable the individual to continue

to be in satisfying relations with other persons. It was thought (Foulds

19655 Priest and Steinert, 1977) that symptoms and signs could usefully

be distinguished from traits and attitudes by means of three criteria runiversality

transitoriness and the cause of distress : traits and attitudes are universal

in the sense that they apply to the total population under observation

without exception, relatively enduring and relatively ego-syntonic. Symptoms

and signs are on the opposite side being rare, transient and distressful

(Table I).

19

Psychiatric Symptomatology

According to Foulds1 views (1965 b) an individual can be characterised

as personally ill if he becomes impaired - at least partially - in those

functions which are responsible for his maturity as far as his feelings,

thoughts, behaviour and relations with other persons are concerned and

when this impairement is considerably distressful either to him or to

others acting on his behalf. The term personal illness is preferred

to the more customary psychiatric term of functional mental illness

to indicate severe disturbance in the form of personal relationships

or " realm of the person " rather than merely in tie type of the brain

disfunction.

Mc Murray (1957, 1961), who gave a philosophical base to Foulds1

formulations sees the concept of a person as inclusive of the concept

of an "organism" and the concept of an organism as inclusive of that of

a "material body". The concept of an organism is derived from the

concept of a person by excluding from attention those characteristics

which belong to the person category alone. Similarly the concept of a

material body can be derived from the concept of an organism by excluding

from attention those characteristics which belong to the organism category

alone. Thus, in logical terms, all persons are organisms but not all,

organisms are persons. The person is inclusive of tie organism and tie

organism is therefore necessary but subordinate to the person. All

organisms - which includes all persons - are material bodies but not

all material bodies are organisms. The term personal illness in this context

is intended t> convey that there is disturbance of the person and not merely

of the organism. Foulds (1965 b) differentiated the purely personally ill

20

from those who are not only personally ill (i.e. psychosomatic,

somatopsychological, organic cases and those who are altogether

free from ill health) and those who are not ill at all by means of three

criteria : 1) the patient's experiences of difficulty in maintaining

or establishing mutual personal relationships ; 2) the difficulty is

so distressful to the individual that he seeks outside help in order to

alleviate the symptoms which have been thrown up to defend himself against

facing this basic problem. The symptoms could be distressful not to

the patient himself but to his closer associates so rtfiat they seek

help on his "behalf for the same purpose ; 3) in the cases of those

who are not only personally ill, the organic concomitants are such

that, in the absence of personal illness they would necessitate medical

or surgical interference.

4-.2.1. Personal Relationships and Psychopathology

The ability and opportunity to express highly personal positive or

negative self-attitudes in interpersonal situations has been recognised

as important by numerous theoretical writers (e.g. Cameron, 1963; Rogers,

1965).

Some authors (Jourard and Lasakow, 1958; Jourard, 1959, 1961; Newcomb,

1961) have emphasised that self-disclosure - i.e., the amount of personal

information that one person is willing to disclose to another - and

social reinforcement are essential in tie development of .adequate mutual

relationships. Jourard (1959) showed that liking, self-disclosure, ac-

ceptance of tie other's self-disclosure, knowing the other and being

known, are interrelated.

21

Many suggest an association between neurotic illness and low self-disclosure;

Mayo, (1968) showed that neurotics would report lower self-disclosure

than normals and he stressed that high or low disclosure by one person

encourages the same behaviour in tie other person.

Analogous is Fould's (1965 b) thesis : The more that individuals are

able to empathise with others the more sucessful they are likely to be

in establishing mutual relationships and the less likely they are even

in times of stress to resort to blaming themselves or others. The

inability to share experience, because of symptoms and abnormal traits,

hampers the capacity to enter into mutual relationships. The normal in-

dividual knowing who he is, can risk putting himself in a state of vul-

nerability by revealing himself and thus allowing himself to become capable

of entering into mutual personal relationships. The disturbed individual

fearing the possibility of rejection, cannot allow himself to become

vulnerable. By protecting himself by his resistance to reveal himself

he hinders the possibility of being known by others or knowing others.

He thus finds it more difficult to enter into mutual relationships.

4*2.2. The Hierarchical Nature of Mental Illness

Foulds1 concept of all psychiatric illness as "illness of the person"

focuses on processes which occur in the mentally ill and that interfere

with the satisfactory establishment and relative endurance of adequate

personal relationships. These interferring processes were regarded as

barriers t> achieving "personhood" and a continuum was proposed of the

major classes of personal illness, arranged by increasing degrees of

failure to maintain or establish mutual personal relationships in the

sense that through accumulating conflicts and frustrations the already

22

established set of defence mechanisms is invalidated and as a result

a deeper mental disorder develops. Schizophrenics are considered to

exhibit the most extreme degree of such failure. Mild neurotics could

be considered as among those with the least impoverished personal

relationships. The more severe the personal illness the less the individual

is able to intend his own actions and thoughts,the more he ceases to be

a person and the more be becomes an organism.

A final consequence of personal illness is the alienation from other

individuals.; The personally ill diminish themselves or are diminished

as persons by withdrawal from or by rejection by others or, most commonly

by both of these processes.

Foulds' theory of mental illness (Foulds, 1964, 1965 a, 1965 b, 1971, 1976;

Foulds and Bedford, 1975; Foulds, Bedford and Gsapo, 1975; Bedford and

Foulds, 1978 a) posits that the continuum of the classes of personal

illness is of hierarchial nature, ranging from dysthymic states (the least

severe, at the bottom of the hierarchy) through neurotic symptoms and

-integrated delusions to delusions of disintegration (the most severe,

at the top of the hierarchy).

The relationship between the classes is logically inclusive and non-reflexive

which means that when a patient's membership to a class is established he

will necessarily also be a member of all classes lower in the hierarchy.

The king Lear principle (Foulds, 1964.; 1965 b) " where the greater

malady is fixed, the lesser is scarse felt "- implies that the "greater

malady" may mask, confuse, override or direct attention away from the

"lesser". In this sense all members of the disintegrated delusions class

have some symptoms of the lower classes of integrated delusions, neurotic symptoms

and dysthymic states. All members of the integrated delusions class,

2 3

have some symptoms of the lower classes of neurotic symptoms and dusthymic states

All members of the neurotic symptoms class have some symptoms od the lower class

of dysthymic states.

4*2.3 The Classes of Personal Illness. Here follows a description as brief as possible of the classes of

personal illness.

I Class 0. Non-personally ill : In Class 0 could be allocated all

those who do not manifest symptoms or signs of personal illness.

Class 1. Dysthymic States: It is formed from three groups : state

of anxiety (sA) representing what in clinical practice is called

anxiety state or anxiety neurosis, state of depression (sD) representing

neurotic depression and state of elation (sE) representing hypomania.

All these states refer to changes of affect (Foulds, 1971, 1976). An

individual falling into any of these states might be said to be disturbed

emotionally stirred up, altered in tiis respect from his normal self.

Such states are common to almost all psychiatric paiients and as a

class, therefore, have little or no differentiating power. They are

more "understandable" than the symptoms of the other classes, they are

perhaps more related to prevailing circumstances and experienced by

most of us at some time and with some intensity.

Traditionally the states of anxiety and depression are included within

the neurotic class. Foulds and Bedford (1976; 1976 a) using the self-

report Delusions, Symptoms, States, Inventory (DSSI), (Bedford and

2A

Foulds, 1978 a), found that the states of anxiety and depression have

a relationship to phobic, conversion, dissociative, compulsive or

ruminative symptoms, different from that which is obtained between

all pairs of these five neurotic symptoms groups. The former is an

inclusive non-reflexive relationship; the latter is an either/or

relationship. For this reason states of anxiety and depression were

removed to a lower class in the hierarchy, which took the name dysthymic

states and includes also state of elation (more controversially). State

of elation has different implications for normals and patients. Those

who experience such a state alone, without delusions of grandeur or i extreme hyperactivity, only rarely presentAas patients.

Class 2. Neurotic Symptoms (NS). The subject belonging to this

class is in a state of dissonance in that he views a part of his

behaviour and experience as alien to his normal self. This class is

made up of five groups, conversion symptoms (PS) - called for a period

by Foulds "pithiatic symptoms", dissociative symptoms (DS) these first

two making up what in clinical practice is called hysteria, phobic

symptoms (FS) - called for a period by Foulds " fear symptoms " -

compulsive symptoms (CS) and ruminative symptoms ; the last two groups

make up what in clinical practice is called obsessive-compulsive neurosis.

Class 3. Integrated Delusions (ID). This class refers to persons whose

self-concept have become distorted, warped or exaggerated. The presence

of delusions implying a distorted self-schema (grandeur, persecution,

unworthiness) is the necessary and sufficient condition for alloting

a person to this class, which is composed of three groups : delusions

of persecution (dP) representing the clinical category of paranoid disorder

delusions of grandeur (dG) representing mania and delusions of contrition (dC) representing psychotic depression.

25

Class Delusions of Disintegration (DP)or non-integrated delusions.

The implication here is that the patient has been disintegrated t> a very

considerable extent as a person, in that he has lost his concept of himself

as the agent of his own actions. Disintegration is manifested by feelings

of passivity, incongruity (including flattening) of affect and disorders

of thought process. Delusions of disintegration are characteristic of

the clinical diagnosis of schizophrenia.

As the patient moves from dysthymic states and neurotic symptoms through

integrated delusions to delusions of disintegration we say that he moves

higher to the hierarchy. If the opposite process takes place, we can

say that the patient is moving down the hierarchy.

Foulds and Bedford (1975) suggested that patients, during the recovery

from their personal illness, move from one class to another in a way .

conforming the hierarchical model. Evidence is provided (Foulds, Bedford

and Csapo, 1975; Foulds and Bedford, 1976 b; 1977 d) supporting the thesis

that the hierarchy is maintained after a period of one month, even though

there has been a considerable reduction in the symptoms of the group as

a whole. The conclusion was that symptoms higher in the hierarchy (i.e.,

the most severe symptoms) appeared to remit before those lower in the hierarchy.

This concept about hierarchial arrangement of psychiatric symptoms is

not universally recognised in the ordinary mainstream of the current

psychiatric ideas on the nature of mental illness. Additional difficulties

to the understanding of this approach have been emerged by Foulds' use

of a rather idiosyncratic terminology. But even if it is accepted that

the proposed model is not applicable in all circumstances, the central

26

concept that there is a structural relationship between certain

psychiatric symptoms in the sense that a symptom A may be incorporated

by a symptom B and not being clearly manifested unless the symptom

B is removed, is an interesting one not only from theoretical bvit

also from clinical point of view.

4#2.4* Testing the Hierarchy Model.

In an attempt to trace the roots of his thesis about the hierarchy model,

Foulds (1976) referred to the ideas and formulations of numerous authors

who had contributed to this view, such as Ernst von Feuchtersbelen (1845))

Eugene Bleuler (1950), Berrington et al (1956), Clark and Mallet (1963),

Chapman (1966), Gittleson (1966), Maxwell (1972, 1973), Priest et al

(1973), Wing et al (1974).

.Using the DSSI, Foulds and Bedford (1975) found that 93,3 percent of

480 patients they studied had symptom patterns conforming to the model.

Mc Pherson et al (1977), testing the hierarchical model by administering

the DSSI to 100 patients, produced data supporting Foulds' thesis. Bagshaw

(1977) employing the same inventory with 78 depressive patients found

that over 90 percent had patterns of states and symptoms compatible

with the model. Foulds and Bedford (1977 c), using other than self-report

techniques, (e.g., psychomotor tasks such as speed measure and the scatter

of tapping measure) found significant relationship between illness class .

and psychomotor speed and what they called expansive-constricted movement,

Bagshaw and Mc Pherson (1978) testing a group of 30 manic and hypomanic

patients, found that the relationship between delusions of gradeur and

state of elation was inclusive and non-reflexive.

2 7

Surtees and Kendel (1979) using the Present State Examination (PSE)

which is a systematic form 0f the psychiatrist's mental examination

procedure., in a large series of patients found that a high percentage

of schizophrenic and manic patients failed to fulfill the requirements

of the model, since although they had symptoms which would establish

them in the classes" of integrated delusions or delusions of disintegration

they did not exhibit the neurotic symptoms that they required lower in

the hierarchy. Generally, in this work, the hierarchy requirements

were fulfilled by 75 percent of the patients and by over 90 percent of

those with depressive illness, neurotic illness and personality disorders.

There are however methodological peculiarities in the approach of these

authors which may explain this result; in the two samples of Surtees and

Kendel study the 7th and 8th edition of PSE were given. Both sets of data

were converted into 145 symptoms of the 9th edition of PSE and prior to

data analysis these 145 symptoms were equated to the 84 DSSl/R items.

These authors admit that they made a large number of arbitrary decisions

concerning both the equivalence of PSE to DSSI items and the appropriate

scoring.

DYS NS ID Dt)

PSE items 17 10 7 10

DSSI items 21 35 21 7

Table a. Equation of PSE and DSSI items by Surtees and Kendel (1979).

' It is obvious from Table a. that there are important differences in the

coverage of the four symptomatological groups. The neurotic symptoms (NS)

are represented in the PSE by only ten items instead of the 35 DSSI items.

On the other side the schizophrenic group (DD) is represented by ten items

instead of the seven DSSI items. This inadequate coverage of neurotic

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symptoms i s due to the l a c k o f i n c l u s i o n i n the PSE o f the c o n v e r s i o n

and d i s s o c i a t i v e symptoms on the b a s i s t h a t , a c c o r d i n g to S u r t ee s and

Kende l , t he se symptoms a re l e s s common than phob ic o r o b s e s s i o n a l

symptoms i n p s y c h o t i c p a t i e n t s .

T h i s i s n o t an e s t a b l i s h e d f a c t a t l e a s t so f a r a s the sample o f the

p r e s e n t s t udy i s concerned. Of the p s y c h o t i c p a t i e n t s p a r t i c i p a t i n g i n

i n the p r e s e n t s t udy who r e p o r t e d n e u r o t i c symptoms i n the DSS l/R

e i gh teen r e p o r t e d c o n v e r s i o n o r d i s s o c i a t i v e symptoms,.n ineteen r e p o r t e d

compul s i ve o r r u m i n a t i v e symptoms and t h i r t e e n r epo r t ed phob ic symptoms.

What seems t o be the case f rom the se r e s u l t s i s t h a t h y s t e r i c a l symptoms

i n p s y c h o t i c p a t i e n t s a re r e p o r t e d a s f r e q u e n t l y a s o b s e s s i o n a l symptoms

and t h i s f i n d i n g c o u l d s u g g e s t t h a t the om i s s i on o f these n e u r o t i c symptoms

by S u r t e e s and Kende l may have c o n t r i b u t e d s i g n i f i c a n t l y t o t h e i r r e s u l t s .

I t c ou l d t h e r e f o r e be s ugge s ted t h a t a d i f f e r e n t cho ice by these a u t h o r s

r e g a r d i n g the s e l e c t i o n o f P S E i t e m s cou l d have produced d i f f e r e n t r e s u l t s .

Furthermore i t c ou l d be h y p o t h e s i z e d t h a t there i s another e x p l a n a t i o n

o f S u r t e e s and Kendel r e s u l t s : a l t h o u g h n e u r o t i c symptoms have a d i s t r e s s i n g

c ha r a c t e r and t h u s can be e l i c i t e d i n a s e l f - r e p o r t q u e s t i o n a i r e f rom

a s c h i z o p h r e n i c p a t i e n t who a t the same time p re fe r s ? f o r v a r i o u s r e a s o n s ,

t o d i m i n i s h the we igh t o f h i s p s y c h o t i c symptoms, these n e u r o t i c symptoms

cou l d be o ve r l ooked by the o b s e r v e r who i s much more a t t r a c t e d by the

p s y c h o t i c f e a t u r e s o f h i s s c h i z o p h r e n i c p a t i e n t .

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4 . 3 . H o s t i l i t y

There i s a wide range o f f e a t u r e s a t t r i b u t e d t o h o s t i l i t y . I t may be

p h y s i c a l , v e r b a l o r n o n - v e r b a l , i t i s d i r e c t e d • outwards o r i nwa rd s ,

i t i s c o n s c i o u s o r u n c o n s c i o u s , i t i s open o r d i s g u i s e d . Because o f

t h i s wide range o f i t s m a n i f e s t a t i o n s , i n c o n s i s t e n c i e s i n t h e d e f i n i t i o n

and measurement o f h o s t i l i t y abound. D i f f e r e n c e s i n meaning between

ange r , h o s t i l i t y , a g g r e s s i o n , r a g e , ha te and v i o l e n c e have been d e s c r i b e d

by a l a r g e number o f a u t h o r s e s p o u s i n g v a r i o u s s c h o o l s o f t hough t .

Fo r some a u t h o r s a g g r e s s i o n i s i d e n t i f i e d w i t h a g g r e s s i v e behav i ou r i n

the form o f unprovoked a t t a c k s . O the r s (DdL la rd e t a l . 1 939 ) , i n c l u d e

i n t h e i r d e f i n i t i o n s p e c i f i c a l l y the i n t e n t i o n to harm and the e x i s t e n c e

o f a t a r g e t . Anger w i t h i t s concomi tant ; p s y c h o p h y s i o l o g i c a l m a n i f e s t a t i o n s

i s r ega rded a s the most d i s t i n c t i v e f e a t u r e o f a g g r e s s i v e behav i ou r

(Magargee and Hokanson, 1970 ; S c h l e s s e t a l . 197-4)• Other s argue t h a t

the h o s t i l e behav i ou r h a s to be add re s sed t o a l i v i n g t a r g e t and have a

" s u b j e c t i v e p r o b a b i l i t y " o f r e a c h i n g the t a r g e t i n o rde r to be c l a s s i f i e d

a s a g g r e s s i v e ' ( K a u f m a n , 1 9 7 0 ) . Some a u t h o r s r e g a r d the f a n t a s y o f an

a g g r e s s i v e a c t a s f u l f i l l i n g t h e i r d e f i n i t i o n s o f a g g r e s s i o n even i f the

o v e r t behav i ou r neve r t a k e s p l a c e (Feshbach, 1955; M i l l e r , 1941 ) * The .

p o s s i b i l i t y t h a t a g g r e s s i o n may be exp re s sed i n d i s q u i s e d fo rms - r e d i r e c t i o n

o f the a t t a c k o r s u b s t i t u t e r e s p o n s e s - i s a l s o c on s i de red (Hokanson, Burges

and. Cohen, 1963; L o r en z , 1 9 6 6 ) .

I t seems t h a t a common denominator u n d e r l i e s t he se v i e w s about a g g r e s s i o n

which i s b e i n g exp re s sed o r e xpe r i enced a s a tendency or urge to commit

an a g g r e s s i v e a c t ; t h i s i s p r o b a b l y an e s s e n t i a l f e a t u r e o f a g g r e s s i o n .

The term h o s t i l i t y i s u sed by many a u t h o r s f o r the d e s c r i p t i o n o f t h i s

30

p o t e n t i a l i t y f o r a g g r e s s i o n (Feshbach, 1961; Kaufman, 1 9 7 0 ) .

The importance o f a g g r e s s i o n a s a m o t i v a t i n g f o r c e i n human behav i ou r

ha s been l o n g acknowledged. F r eud (1920, 1933) c o n s i d e r e d i t a s one

o f the b a s i c i n s t i c t u . a l f o r c e s i n man and he r e c o g n i s e d i t s importance

i n t h e p e r s o n a l i t y development. I n h i s e a r l y f o r m u l a t i o n s about n e u r o s i s ,

he c on s i de r ed a g g r e s s i o n to r e s u l t f rom the i n h i b i t i o n o f l i b i d i n a l

f o r c e s , i n an e f f o r t to i n t e r p r e t the s e l f - d e s t r u c t i v e phenomena observed

i n d e p r e s s i o n and masochism, F r eud ( 1 9 2 2 ) , l a t e r mod i f i ed h i s v i e w s ,

p r o p o s i n g the ^existence o f a d e s t r u c t i v e i n s t i c t t h a t he c a l l e d " t h a n a t o s " .

I n accordance w i t h p s y c h o a n a l y t i c t h e o r y , a g g r e s s i o n i n i t s o r i g i n a l form

i s c on s i de r ed to be a " p r i m a r y p r o c e s s " phenomenon, i n s t i n c t i v e o r i m p u l s i v e

i n n a t u r e , n o t governed by the demands o f r e a l i t y and u l t i m a t e l y d e s t r u c t i v e

i n q u a l i t y . The concept o f a g g r e s s i o n a s an i n s t i c t ha s been a l s o suppor ted

by the b i o l o g i c o - e t h o l o g i c a l t h e o r i e s (T inbergen , 1951; L o r enz , 1966;

A rd rey , 1966; M o r r i s , 1 9 6 7 ) . O the r s have^p re fe r r ed t o i i h i n k o f i t i n

terms o f a r e spon se t o f r u s t r a t i o n ( E b l l a r d e t a l . 1939; S e a r s e t a l . 1957;

Feshbach, 1 9 6 1 ) . Bandura e t a l (1961) and Bandura (1973) s t r e s s e d the view

t h a t a g g r e s s i v e n e s s i s a p r o d u c t o f s o c i a l l e a r n i n g e i t h e r t h rough i m i t a t i o n

o r t h rough r e i n f o r cemen t o f the a g g r e s s i v e r e s p o n s e s .

B u s s (1961) v iewed h o s t i l i t y a s an " a t t i t u d i n a l r e sponse t h a t endures :

an i m p l i c i t v e r b a l r e spon se i n v o l v i n g nega t i v e f e e l i n g s and n e g a t i v e

e v a l u a t i o n s o f peop le and e v e n t s " , d i f f e r e n t i a t i n g i t f rom anger wh ich

was c h a r a c t e r i s e d a s an emot i ona l r e a c t i o n and a g g r e s s i o n he c h a r a c t e r i s e d

a s i n s t r u m e n t a l r e s p o n s e . T h i s d e f i n i t i o n exc ludes s e l f - p u n i t i v e f e e l i n g ;

wh ich B u s s r ega rded a s b e i n g an " i n h i b i t i n g i n f l u e n c e " t o the e x p r e s s i o n

o f h o s t i l i t y .

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B u s s , Durkee and Baer (1956) and Bu s s and Durkee (1957) have po i n ted

out t h a t the term h o s t i l i t y c o v e r s many d i v e r s e behav iou r and a t t i t u d e s

t h a t r e q u i r e separa te a s se s sment and have d e s c r i b e d s u b s c a l e s o f h o s t i l i t y

t y p i c a l l y man i fe s ted i n every c l i n i c a l s i t u a t i o n s , such a s a s s a u l t ( p h y s i c a l

v i o l e n c e a g a i n s t o t h e r s ) , i n d i r e c t h o s t i l i t y ( roundabout and i n d i r e c t

a g g r e s s i o n ) , i r r i t a b i l i t y ( r e a d i n e s s t> explode w i t h n e g a t i v e a f f e c t

a t the s l i g h t e s t p r o v o c a t i o n ) , n e g a t i v i s m ( o p p o s i t i o n behav i ou r , u s u a l l y

d i r e c t e d a g a i n s t a u t h o r i t y ) , re sentment ( j e a l o u s y and ha t r ed o f o t h e r s ,

which r e f e r s to a f e e l i n g o f anger a t the wor ld ove r r e a l o r f a n t a s i s e d

m a l t r e a t m e n t , ) s u s p i c i o n ( p r o j e c t i o n o f h o s t i l i t y onto o t he r s ) and v e r b a l

h o s t i l i t y ( nega t i v e a f f e c t e xp re s s ed i n bo th the s t y l e and the con ten t

o f s peech . ) .

G o t t s c h a l k e t a l ( 1 9 6 3 ) , c o n s i d e r e d t h a t the concept o f h o s t i l i t y

i n c l u d e d : a ) a b e h a v i o u r a l a c t , p h y s i c a l o r v e r b a l , w h i c h i s i n t e r p r e t e d

a s h a v i n g a d e s t r u c t i v e f u n c t i o n by an o u t s i d e ob se rve r ; they termed

t h i s " a g g r e s s i o n " , b) a t t i t u d e s o f d i s l i k e , resentment and s u s p i c i o n ,

c a l l e d " h o s t i l i t y " , c) a s u b j e c t i v e exper ience o f an a f f e c t w i t h p h y s i o -

l o g i c a l concomi tant s u s u a l l y c a l l e d " a n g e r " , d) a d i s p o s i t i o n t o be aroused

t o hehave i n a h o s t i l e o r a g g r e s s i v e manner. They thought t h a t h o s t i l i t y

d i r e c t e d towards the s e l f s hou l d be d i s t i n g u i s h e d from h o s t i l i t y

d i r e c t e d towards o t h e r s . They a l s o s ugge s ted t h a t the l e v e l o f awareness

o f the h o s t i l i t y , r a n g i n g f rom c o n s c i o u s to uncon s c i ou s , i s another d imens ion

which can be i n v o l v e d i n the t h e o r e t i c a l c o n s t r u c t o f h o s t i l i t y w i t hou t a lways

be i n g made e x p l i c i t .

J u n g ! s (1917, 1923) c oncep t i on o f E x t r a v e r s i o n - I n t r o v e r s i o n i s one o f

d i r e c t i o n o f mental energy , l i b i d o o r i n t e r e s t . I t was i n a b a s i s o f

t h i s concept i on t h a t Rozenzwd-g(1934) d e s c r i b e d the th ree t ypes o f r e a c t i o n

' t o f r u s t r a t i o n which he c a l l e d e x t r a p u n i t i v e , i n t r o p u n i t i v e and impun i t i v e :

32

e x t r a p u n i t i v e n e s s i s the b l am ing o f o t h e r s i n the sense t h a t the i n d i v i d u a l

a f r a i d t o blame h i m s e l f , g a i n s s e c u r i t y by b laming "the e x t e r n a l wo r l d ;

he r e a c t s w i t h anger and h o s t i l i t y and defends h i m s e l f p h y c h o l o g i c a l l y

w i t h the mechanism o f p r o j e c t i o n . I n t r o p u n i t i v e n e s s was con s i de red t o be

the b laming o f the s e l f i n the sense t h a t the i n d i v i d u a l a f r a i d to blame

o t h e r s , g a i n s s e c u r i t y by the tendency t o blame h i m s e l f ; he r e a c t s w i t h

f e e l i n g s o f remorse and g u i l t and employs the mechanisms o f d i sp l acement

i s o l a t i o n and undo ing . I m p u n i t i v e n e s s was con s i de red a s i n v o l v i n g the

s u p p r e s s i o n (o r r e p r e s s i o n ) o f any awareness o f f r u s t r a t i o n .

F o u l d s (1976) sugge s ted t h a t i t m ight be more app rop r i a t e t o t h i n k i n te rns

o f tro d imens i on s , i n t r o p u n i t i v e - i m p u n i t i v e and e x t r a p u n i t i v e - i m p u n i t i v e .

On the e x t r a p u n i t i v e s i d e would be tho se who r a t h e r h a b i t u a l l y r e a c t ed to

f r u s t r a t i o n by b l am ing o t h e r s . On the i n t r o p u n i t i v e s i d e would be those

who r a t h e r h a b i t u a l l y s upp re s s ed (o r r e p r e s s e d ) any tendency to blame

otherSo I n the i n t e rmed i a te ( i m p u n i t i v e n e s s ) would be tho se who sometimes

re spond i n one o f tho se two ways o r "who sought some more p o s i t i v e r e s o l u t i o n

to tie c o n f l i c t s i t u a t i on©

4 . 3 . 1 . H o s t i l i t y and P s y c h o p a t h o l o g y .

I t was sugge s ted by F o u l d s (1964) t h a t , i n v iew o f t h e emphas is on f a i l u r e

i n mutual p e r s o n a l r e l a t i o n s h i p s , the g ene r a l p u n i t i v e measure, wh i ch r e p r e s e n t s

t he agg rega te o f the f e a t u r e s o f h o s t i l i t y d i r e c t e d outward and i nward , i s

pe rhaps o f p a r t i c u l a r i n t e r e s t , b e i n g a r ea sonab le e s t imate o f such f a i l u r e .

Conce rn ing p s y c h i a t r i c p a t i e n t s i t i s w e l l - e s t a b l i s h e d (Watson e t a l . 1955;

F o u l d s , Ca ine and C r e a s y , 1960; Ca i ne , 1960; F o u l d s , 1956 b; 1966; Ca ine

F o u l d s and Hope, 1967; F o u l d s and Mayo, 1967; F o u l d s and Bed fo rd , 1977 b ;

Ha fne r , 1977 a ) t h a t t hey expe r i ence o r e xp re s s h i g h l e v e l s o f h o s t i l i t y .

33

I t h a s been found t h a t n o n - i n t e g r a t e d p s y c h o t i c s are more g e n e r a l l y

p u n i t i v e than i n t e g r a t e d p s y c h o t i c s who a re more g e n e r a l l y p u n i t i v e than

n e u r o t i c s and t h a t n e u r o t i c s a r e more g e n e r a l l y p u n i t i v e than no rma l s .

Mayo (1969) u s i n g the HDHQ ( H o s t i l i t y and D i r e c t i o n o f H o s t i l i t y Q u e s t i o n n a i r e ) ,

(Ca ine e t a l 1967) found t h a t normal pe r s on s w i t hou t symptoms scored

s i g n i f i c a n t l y l ower i n g ene r a l h o s t i l i t y than d i d e i t h e r normal p e r s o n s wi-fch

symptoms who d i d n o t s u f f e r a break-down o r n e u r o t i c p a t i e n t s . T h i s

f i n d i n g was conf i rmed by F o u l d s and Bed fo rd (1977 b ) . P a t i e n t s w i t h

p s y c h o p a t h i c p e r s o n a l i t y d i s o r d e r a l s o man i fe s t h i g h l e v e l s o f h o s t i l i t y ( F o u l d s

Ca ine and C rea s y , 1960; Ca ine F o u l d s and Hope, 1967; F o u l d s , 1967, 1968 ;

Gossop and Roy, 1977; Crawford, ' 1 9 7 7 ) .

A t tempt ing t o g i v e an e x p l a n a t i o n to t h i s phenomenon, F o u l d s (1965 b)

p o s t u l a t e s t h a t the re i s some k i n d o f n e g a t i v e c o r r e l a t i o n between symptoms

and gene ra l h o s t i l i t y . Symptoms a r e o f t e n defences a g a i n s t becoming f u l l y

aware o f o n e f s h o s t i l i t y to o t h e r s o r to o n e s e l f ; t h e i r presence seems to

i n h i b i t the e x p r e s s i o n o f h o s t i l i t y a t t i t u d e s , and symptoms r a t h e r t h a n s i g n s

predominate i n n e u r o s i s and do so d e c r e a s i n g l y i n i n t e g r a t e d p s y c h o s i s , non-

i n t e g r a t e d p s y c h o s i s and by d e f i n i t i o n to p sychopath s . T h i s t h e s i s i s

i n d i r e c t l y suppor ted by a number o f a u t h o r s (Tob in and Lew i s , 1960;

L i o n , 1967; I t i l a n d Wadud, 1975 ; Gossop and Roy, 1976; Gardos e t a l . 1968;

D i Masc io e t a l 1969) who ob t a i ned ev idence s u g g e s t i n g t h a t b a r b i t u r a t e s and

o the r c e r t a i n t r a n g u i l l i s i n g d r u g s - a p p a r e n t l y taken f o r the a l l e v i a t i o n

o f c e r t a i n p s y c h i a t r i c symptoms - have a d i s i n h i b i t i n g e f f e c t on a g g r e s s i v e

behav i ou r .

Rega rd i n g the u s e f u l n e s s , o f a g e n e r a l h o s t i l i t y measure i t seems t h a t the

s tudy o f i t s s t r u c t u r e and d i r e c t i o n g i v e s v a l u a b l e i n f o r m a t i o n about the

way p a t i e n t s w i t h v a r i o u s p s y c h i a t r i c problems exper ience o r e xp re s s t h e i r

34

h o s t i l i t y f e e l i n g s . S i e g e l ( 1956 a) sugges ted t h a t i n d i v i d u a l s may v a r y

more i n t he manner and d i r e c t i o n i n which they e x p r e s s h o s t i l i t y than

i n the amount o f h o s t i l i t y t h e y p o s s e s s . G u i l f o r d ( 1934 ) , s u r v e y i n g the

l i t e r a t u r e , found t h a t a c o n s i d e r a b l e number o f a u t h o r s tended t o a s s o c i a t e

i n t r o v e r s i o n w i t h n e u r o t i c t e n d e n c i e s . I n 1938 Rosenzweig, s ugge s ted

t h a t e x t r a p u n i t i v e n e s s was r e l a t e d t o pa rano i a , i n t r o p u n i t i v e n e s s t o

o b s e s s i o n a l i l l n e s s and i m p u n i t i v e n e s s t o h y s t e r i a . F o u l d s and B e d f o r d

(1977 b) suppor ted the f u r t h e r t h e s i s t h a t h i g h s c o r e s on e x t r a p u n i t i v e n e s s

decrease t h e l i k e l i h o o d o f d e v e l o p i n g symptoms whereas h i g h i n t r o p u n i t i v e n e s s

s c o r e s i n c r e a s e the l i k e l i h o o d o f d e v e l o p i n g symptoms.

The r e l a t i o n s h i p between c e r t a i n p s y c h i a t r i c symptoms and the v a r i o u s d imens i on s

o f g ene ra l h o s t i l i t y w i t h the pa s s age o f t ime needs t o be s t u d i e d f o r t h e o r e t i c a l

and c l i n i c a l r e a s o n s . The l i t e r a t u r e r e g a r d i n g t h i s a s s o c i a t i o n i s r a t he r

p o o r , l a c k i n g c o n v i n c i n g ev idence and l a r g e l y p r o v i d i n g c o n f l i c t i n g f i n d i n g s .

.These r e l a t i o n s h i p s shou ld be s t u d i e d d u r i n g the cou r se o f the changes i n

symptomatology i n d i f f e r e n t p s y c h i a t r i c p o p u l a t i o n s under d i f f e r e n t t r e a t i e n t

and mi l i ew c o n d i t i o n s and f o r extended p e r i o d s o f t ime.

35

4»3«2. H o s t i l i t y and A n x i e t y .

On t h e o r e t i c a l g rounds a r e l a t i o n s h i p between a n x i e t y and h o s t i l i t y

i s t o be expected. The F r e u d i a n v iew i s t h a t the re i s a c o n f l i c t

between i d f o r c e s (one o f them b e i n g the death i n s t i c t ) and ego and

superego f o r c e s . A s t r o n g superego i n h i b i t s e x p r e s s i o n o f the a g g r e s s i v e

i m p u l s e s o f the i d , r e s u l t i n g i n a c o n f l i c t between these two f o r c e s t h a t i n

t u r n p roduces a n x i e t y .

A c c o r d i n g to C a t t e l (1964) a n x i e t y i s c on s i de red t o be a d i s o r g a n i s i n g

f o r c e o r symptom o f d i s o r g a n i s a t i o n r a t h e r than a d r i v e o r motivating.-,

f o r c e . He d e s c r i b e d the a n x i o u s pe r s on a s showing on the one hand i r r i -

t a b i l i t y , s u s p i c i o n o f o t h e r s and t e n s i o n and on the o ther hand l a c k

o f con f i dence , dependency and a sense o f g u i l t and unwor th i ne s s .

I t i s r a t h e r d i f f i c u l t t o at tempt an o v e r a l a s se s sment o f the f i n d i n g s

o f v a r i o u s s t u d i e s c a r r i e d ou t on the r e l a t i o n s h i p between a n x i e t y

and t y p e s o f h o s t i l i t y . T h i s i s because v a r i o u s a u t h o r s g i v e a s p e c i a l

o r even an i d i o s y n c r a t i c meaning n o t o n l y to h o s t i l i t y bu t a l s o to

a n x i e t y . Consequent l y the measurement o f both i s based ' on c o n s i d e r a b l y

d i f f e r e n t and n o t e a s i l y comparable methods.

There i s t h e r e f o r e a spectrum o f o p i n i o n s r e g a r d i n g the r e l a t i o n s h i p between

h o s t i l i t y and a n x i e t y the m a j o r i t y o f them based on s i n g l e - o c c a s i o n s t u d i e s .

A number o f a u t h o r s suppo r t the v iew t h a t a n x i e t y i s p o s i t i v e l y a s s o c i a t e d

w i t h g e n e r a l h o s t i l i t y and i n t r o p u n i t i v e n e s s . F o u l d s (1965 b) f ound that

the s t a t e o f a n x i e t y i s p o s i t i v e l y a s s o c i a t e d w i t h g ene r a l h o s t i l i t y ,

36

c r i t i c i s m o f o t h e r s and s e l f - c r i t i c i s m . Fernardo (1977) examin ing the r e -

l a t i o n s h i p between h o s t i l i t y and n e u r o t i c symptoms i n a s i n g l e measurement

found t h a t f r e e f l o a t i n g a n x i e t y and t o a l e s s e r degree phob ic a n x i e t y tended

to be a s s o c i a t e d w i t h g u i l t i n dep re s s ed p a t i e n t s . L i a k o s e t a l (1977)

i n v e s t i g a t e d the r e l a t i o n s h i p between a n x i e t y and h o s t i l i t y i n n e u r o t i c

p a t i e n t s and found s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s between the s t a t e

o f a n x i e t y and s e l f - c r i t i c i s m , g u i l t , i n t r o p u n i v e n e s s and gene ra l h o s t i l i t y a s

measured by the HDHQ. Bu t i n the same i n v e s t i g a t i o n , a n x i e t y was n e g a t i v e l y

r e l a t e d to i n t r o p u n i t i v e r e s p o n s e s a s measured by Ro senzwe i g ! s P i c t u r e F r u s t r a t i o n

t e s t . I t was s ugge s ted t h a t t he se i n s t r u m e n t s a s s e s s two d i f f e r e n t t y p e s

o f h o s t i l i t y . I n a s i n g l e measurement L i a k o s (1977) s t ud i ed 22 p s y c h o t i c a l l y

dep re s sed p a t i e n t s and found t h a t a n x i e t y was s t r o n g l y r e l a t e d to i n t r o v e r t e d

h o s t i l i t y , p a r t i c u l a r l y to i:he s e l f - c r i t i c i s m component. P h i l i p (1971)

s t u d i e d two r a t h e r s m a l l g r o u p s o f p a t i e n t s w i t h d e p r e s s i o n be fo re and a f t e r

the rapy u s i n g the HDHQ and the N e u r o t i c i s m Sca le Que s t i onna i r e ( S c h e i e r and

C a t t e l , 1961) and found a s i g n i f i c a n t d rop i n bo th i n t r o p u n i t i v e n e s s and

a n x i e t y , a f i n d i n g s u g g e s t i n g a p o s i t i v e a s s o c i a t i o n between i n t r o p u n i -

t i v e n e s s and a n x i e t y .

I n s e v e r a l t h e o r i e s o f a g g r e s s i o n the e x p r e s s i o n o f h o s t i l i t y i s r e ga rded as

a n x i e t y r e d u c i n g . The F r e u d i a n s c h o o l supported the wel l -known y iew t h a t

c a s t r a t i o n a n x i e t y , genera ted by i n c e s t u o u s w i she s towards mother d u r i n g the

o e d i p a l phase , may be r e l i e v e d by i d e n t i f i c a t i o n w i t h the a g g r e s s o r t h a t

i s the f a t h e r . Lo renz (1966) suppor ted the v iew t h a t the energy o f the

a g g r e s s i v e i n s t i c t , i f n o t e xp re s s ed , may accumulate w i t h i n the i n d i v i -

d u a l , r a i s i n g the l e v e l o f p h y s i o l o g i c a l a c t i v i t y and p roduc i ng a c o n d i t i o n

s i m i l a r t o the a r o u s a l o f a n x i e t y . Bandura (1973) i n h i s s o c i a l l e a r n i n g

t heo r y o f a g g r e s s i o n assumes t h a t i m i t a t i n g the a g g r e s s i o n o f a model f i g u r e

37

may be t e n s i o n r e d u c i n g .

However these f r e u d i a n , e t h o l o g i c a l and s o c i a l l e a r n i n g t h e o r e t i c a l

v i ews are v e r y d i f f i c u l t t o examine w i t h s t r i c t methods o f i n v e s t i g a t i o n .

I n a s e r i e s o f expe r imenta l s t u d i e s (Hokanson and Bu rge s , 1962; Hokanson,

B u r g e s , and Cohen, 1963; Hokanson and S h e l t e r , 1 961 ) , p s y c h o p h y s i o l o g i c a l

ev idence was p r o v i ded t o s u g g e s t t h a t the e x p r e s s i o n o f a g g r e s s i o n may

be t e n s i o n r e d u c i n g . I t h a s been found t h a t the decrease o f a n x i e t y

b r ough t about by the u s e o f c h l o r d i a z e p o x i d e i n c r e a s e s t o a l a r g e e x ten t

the h o s t i l e t endenc i e s o f i n d i v i d u a l s w i t h h i g h l e v e l s o f a n x i e t y (Gardos e t a l

1968; D i Masc io e t a l 1 9 6 9 ) . On t h i s matter Gardos and h i s c o l l e a g u e s

showed t h a t i t i s the s p e c i f i c a c t i o n o f c h l o r d i a zepox i de t h a t i s c r u c i a l

r a t h e r than the concomitant o f a n x i e t y r e d u c t i o n s i n ce oxazepan, w h i l e

e x h i b i t i n g the same a n t i - a n x i e t y e f f e c t , d i d n o t produced i n c r e a s e d

• h o s t i l i t y . R i c k e l s and Dowing (1974) adm in i s t e red c h l o r d i a z e p o x i d e to n e u r o t i c

p a t i e n t s bu t f a i l e d to demonstrate any i n c r e a s e o f h o s t i l i t y , f i n d i n g

o n l y a weak p o s i t i v e r e l a t i o n s h i p between a n x i e t y and h o s t i l i t y .

I t c ou l d be conc luded t h a t t he complex r e l a t i o n s h i p between a n x i e t y

and the v a r i o u s d imen s i on s o f h o s t i l i t y may be e l u c i d a t e d i f these

- v a r i a b l e s were s t u d i e d w i t h r e c u r r e n t measurements d u r i n g the cou r se o f

a n x i e t y i n v a r i o u s g roup s o f p a t i e n t s under d i f f e r e n t t reatment and

m i l l i e w c o n d i t i o n s .

38

4 . 3 . 3 » H o s t i l i t y and D e p r e s s i o n .

The d i s p u t e c once rn i n g the d i s t i n c t i o n between the d i f f e r e n t t y p e s

o f d e p r e s s i o n , p a r t i c u l a r l y t h a t between p s y c h o t i c and n e u r o t i c

d e p r e s s i o n , h a s been e x t e n s i v e l y d i s c u s s e d ( K e n d e l l , 1 976 ) .

The d i f f i c u l t y i n making t h i s d i s t i n c t i o n l i e s i n the l a c k o f p r e c i s e

d e f i n i t i o n s n o t o n l y o f these two t y p e s , bu t a l s o o f the meaning o f

d e p r e s s i o n a s a more g e n e r a l p s y c h o l o g i c a l phenomenon. I t ha s been

p o i n t e d out ( P r i e s t and S t e i n e r t , 1977; P r i e s t , Beaumont and Rap topou l o s , 1 9 8 0 )

t h a t the word d e p r e s s i o n i s u s e d a t l e a s t i n f o u r ways : 1 . a s an emotion,

when d e p r e s s i o n i s the d i s t r e s s i n g mood o r a f f e c t t h a t f o l l o w s a l o s s o r d i s -

appointment; 2 . a s a symptom, when the d e p r e s s i o n i s out o f p r o p o r t i o n to

the p r e c i p i t a t i n g event and when i t i s e x c e s s i v e i n c U r a t i o n o r deg ree ;

3• a s a syndrome, c h a r a c t e r i z e d by a combinat ion o f l o s s o f i n t e r e s t ,

l o s s o f p h y s i c a l and mental ene r gy , l o s s o f appe t i t e and l o s s o f s l e e p .

The l o s s o f i n t e r e s t i n the env i ronment ha s been regarded a s c r u c i a l i n t h i s

c o l l e c t i o n o f symptoms ; a s an i l l n e s s . I n t h i s l a s t case n o t only

i s the p resence o f the d e p r e s s i v e symdrome nece s s a r y f o r the e s tab l i s hment

o f t he d i a g n o s i s o f d e p r e s s i v e i l l n e s s , bu t a l s o the e x c l u s i o n o f another

u n d e r l y i n g cause ( such a s s c h i z o p h r e n i c i l l n e s s o r o r g an i c b r a i n d i s e a s e )

i s r e q u i r e d .

F reud (1917) s ugge s ted a s the d i f f e r e n t i a t i n g f e a t u r e s o f me l ancho l i a ,

" a p r o f o u n d l y p a i n f u l d e j e c t i o n , c e s s a t i o n o f i n t e r e s t i n the o u t s i d e

wo r l d , l o s s o f c a p a c i t y t o l o v e , i n h i b i t i o n o f a l l a c t i v i t y and a l ower i ng o f -

the s e l f - r e g a r d i n g f e e l i n g s t o a degree t h a t f i n d s u t te rance i n s e l f - r e p r o a c h e s

-and s e l f r e v i l i n g s and c u l m i n a t e s i n a d e l u s i o n a l e xpec t a t i on o f pun i shment " .

On the q u e s t i o n o f whether n e u r o t i c and p s y c h o t i c d e p r e s s i o n are two d i s t i n c t

i l l n e s s e s o r m a n i f e s t a t i o n s o f the same i l l n e s s o r p o l e s o f on-e

39

o r two c on t i nua , i t was s u g ge s t ed ( F o u l d s and Hope, 1969; F o u l d s , 1973;

F o u l d s and Bed fo rd , 1976 b; Bagshaw, 1977) t ha t the r e l a t i o n s h i p ± s i n

f a c t an i n c l u s i v e n o n - r e f l e x i v e one such t ha t a l l those w i th " p s y c h o t i c d e p r e s -

s i v e " symptoms have " n e u r o t i c d e p r e s s i v e " symptoms, whereas no t a l l

those w i t h n e u r o t i c d e p r e s s i v e symptoms have p s y c h o t i c d e p r e s s i v e symptoms.

A c c o r d i n g t o F o u l d s , the n e c e s s a r y and s u f f i c i e n t c o n d i t i o n f o r making a

d i a g n o s i s o f p s y c h o t i c d e p r e s s i o n i s the presence o f i n t r o p u n i t i v e

d e l u s i o n s .

I n t r o p u n i t i v e a t t i t u d e s e x p r e s s e d a s f e e l i n g s o f g i i l t , s e l f - b l ame and wo r t h -

l e s s n e s s a re impor tan t a s p e c t s o f t h e c l i n i c a l p i c t u r e o f d e p r e s s i v e i l l n e s s

wh ich , n o t i n f r e q u e n t l y , a re a l s o accompanied by e x t r a p u n i t i v e a t t i t u d e s

such a s ange r , re sentment , i r r i t a b i l i t y and demanding behav i ou r .

The i d e a t h a t d e p r e s s i v e i l l n e s s i s a s s o c i a t e d w i t h a s p e c i a l k i n d o f

h o s t i l i t y was f i r s t e xp re s s ed by the p s y c h o a n a l y t i c s c h o o l , Abraham

(1911, 1924) s u gge s t ed t h a t the g u i l t o f the man i c -dep re s s i ve p a t i e n t ,

when i n the phase o f d e p r e s s i o n , r e s u l t e d from t h e r e p r e s s i o n o f v i o l e n t

and s a d i s t i c i m p u l s e s , f o l l o w i n g the f r u s t r a t i o n o f o r a l s t r i v i n g s .

F reud (1917) i n h i s compar i son o f me l ancho l i a and g r i e f a rgued t h a t the

i n w a r d - d i r e c t e d h o s t i l i t y o f the me lancho l i c stemmed from the a c t u a l ,

th reatened o r s ymbo l i c l o s s o f an impor tan t l o v e d ob jec t . L o s s ha s

been r ega rded a s a n e c e s s a r y bu t no t s u f f i c i e n t c o n d i t i o n f o r p a t h o l o g i c a l

g r i e f . The a d d i t i o n a l c au se s were t o be found i n the ambiva lent and n a r c i s -

s i s t i c n a t u r e o f the i n d i v i d u a l ' s r e l a t i o n s h i p s w i t h the l o s t o b j e c t .

Through i d e n t i f i c a t i o n the h o s t i l i t y o r i g i n a l l y f e l t towards the l o s t

ob j e c t was tu rned a g a i n s t the s e l f .

Me lan ie K l e i n ' s o b j e c t r e l a t i o n s t h e o r y (1934) gave emphasis to deve -

AO

lopmental i s s u e s . I n e a r l y i n f a n c y the c h i l d f a i l s to perce ive h i s

mother a s a whole ob jec t and he r n good " and " bad " a spec t s are r e -

presented to him a s separate e n t i t i e s , a r o u s i n g f e e l i n g s o f l o ve and hate

r e s p e c t i v e l y . L a t e r on, the c h i l d acknowledges tha t h i s a g g r e s s i v e

impu l se s towards the " bad " ob jec t have been, and a re , d i r e c t e d a l s o a g a i n s t the

" g ood " . The p o s s i b i l i t y t h a t h i s h o s t i l i t y might de s t r oy t he . ob jec t he' most

l o v e s r e s u l t s i n the exper ience o f dep re s s i v e anx i e t y . Nego t i a t i on '

o f the " dep re s s i v e p o s i t i o n " depends on the r e l a t i v e s t r eng t h o f h i s

l o ve and h o s t i l i t y . When the ba lance f a vou r s the "bad" ob jec t , the

" good " becomes vu l ne r ab l e and the c h i l d ' s a g g r e s s i o n i s p o t e n t i a l l y

d e s t r u c t i v e . T h i s s i t u a t i o n , a cco rd i ng to K l e i n , u n d e r l i e s d e p r e s s i v e

i l l n e s s .

Another h ypo the s i s about the pa thogene s i s o f dep re s s i on and i t s r e l a t i o n -

s h i p s to h o s t i l i t y i s supported by K e n d e l l (1970) and Lyons ( 1972 ) . Th i s

h y p o t h e s i s p o s i t s t h a t d e p r e s s i o n i s a s s o c i a t e d w i t h an i n h i b i t i o n o f

a g g r e s s i v e re sponse s and i s based on the a n a l y s i s o f ep i dem io l o g i c a l ,

s o c i o l o g i c a l , c u l t u r a l and o the r m a t e r i a l .

B i b r i n g (1953) mainta ined t h a t d e p r e s s i o n i s a mood s ta te a r i s i n g out

o f a r e c o g n i t i o n o f o n e ' s own h e l p l e s s n e s s i n r e l a t i o n to l o s s exper ience,

and i t i s no t i n v a r i a b l y a consequence o f i n n e r - d i r e c t e d h o s t i l i t y , a l though

i n some i n d i v i d u a l s t h i s p s y c h o l o g i c a l p roce s s p l a y s an important pa r t i n

d e c i d i n g the type o f the d e p r e s s i v e syndrome t ha t r e s u l t s . He d i s t i n g u i s h e d

between dep re s s i v e s t a t e s which r ep re sen t a ' the ego k i l l i n g . , i t s e l f " arid depress iv -

s t a t e s which r ep re sen t " t he ego l e t t i n g i t s e l f d i e " and he cons ide red that o n l y

i n the f i r s t type o f case i s the problem o f the e x p r e s s i o n o f a g g r e s s i o n

i n v o l v e d a s a c e n t r a l dete rmin ing f a c t o r o f the development o f

Al

d e p r e s s i o n . He ma in ta ined t h a t the form which the a g g r e s s i v e i m p u l s e s

take i s secondary to the exper ience o f the break-down o f s e l f - esteem and

to the e g o r s awareness o f i t s h e l p l e s s n e s s when con f ron ted w i th an i n s o l u b l e

s i t u a t i o n .

Psychodynamic f o r m u l a t i o n s a r e n o t r e a d i l y subjected to e m p i r i c a l o b j e c t i v e

v a l i d a t i o n . Cochrane (1975) attempted to do so by u s i n g an i n s t r u m e n t

d e v i s e d on the b a s i s o f K l e i n ' s t h e o r e t i c a l f o r m u l a t i o n s and he con f i rmed

o n l y some o f the K l e i n i a n v i e w s and the i n h i b i t i o n o f a g g r e s s i o n t h e o r y .

S t u d i e s aimed a t c l a r i f y i n g the l i n k between h o s t i l i t y and d e p r e s s i o n have

i n d i c a t e d t h a t d e p r e s s i o n i s n o t a s s o c i a t e d w i t h any one c h a r a c t e r i s t i c

s t y l e o f e x p e r i e n c i n g o r e x p r e s s i n g h o s t i l i t y . There are a u t h o r s s uppo r t i n g

the t h e s i s t h a t h o s t i l i t y i n d e p r e s s i o n t a ke s a p redominant ly i nward

d i r e c t i o n . The o p p o s i t e v iew t h a t h o s t i l i t y t a ke s a p redominant ly outward

d i r e c t i o n a l s o f i n d s i t s a dhe ren t s .

I t was observed w i t h the u se o f s t a n d a r d i s e d p e r s o n a l i t y and symptom measures

( F o u l d s , 1956; Ca i ne , F o u l d s and Hope, 1967) t h a t d e p r e s s i o n i s a s s o c i a t e d

w i t h h o s t i l i t y d i r e c t e d i n t r o p u n i t i v e l y . Salmon (1964-) found e x t r a p u n i t i v e n e s s

and d e p r e s s i o n to be n e g a t i v e l y c o r r e l a t e d . V inoda (1966) s t u d i e d a group

o f attempted s u i c i d e s and f ound t h a t they had more gene ra l h o s t i l i t y and

more i n t r o p u n i t i v e n e s s than the p s y c h i a t r i c c o n t r o l s . Bu l a t ao (1961)

s t u d i e d a sample o f h o s p i t a l i z e d dep re s sed women, u s i n g the Rosenzwe ig

P i c t u r e F r u s t r a t i o n Te s t . There was a lower f requency o f e x t r a p u n i t i v e j e s p o n s e s

i n d e p r e s s i o n and a h i g h e r f r equency o f i n t r o p u n i t i v e r e s p o n s e s . Two s t ud i e s

u s i n g reco rded spontaneous t a l k a s a means o f d e t e c t i n g h o s t i l i t y (Go t t s cha l k

e t a l 1963; Gershon e t a l 1968) f ound t h a t " h o s t i l i t y - i n " c o r r e l a t e d p o s i t i v e l y

42-

with the degree o f d e p r e s s i o n bu t t ha t the c o r r e l a t i o n between " h o s t i l i t y - o u t "

and d e p r e s s i o n r a t i n g s was c l o s e to ze ro . There was one group o f p a t i e n t s

however, i n G o t t s c h a l k ' s s tudy i n whom the c o r r e l a t i o n w i th h o s t i l i t y - o u t

was s i g n i f i c a n t l y p o s i t i v e .

Regard ing the r e l a t i o n s h i p between dep re s s i on and HDHQ sub sca l e s , F o u l d s ,

Caine and Creasy (1960) found t h a t self-Griticism was s i g n i f i c a n t l y r e l a ted

t o the degree o f me lancho l i a . F o u l d s (1965 b) conf irmed t h i s f i n d i n g and

noted t ha t s e l f - c r i t i c i s m i s c o r r e l a t e d w i th the melancho l ic s ca le o f the

Symptom-Sign I n v e n t o r y ( S S I ) ( F ou l d s and Hope, 1968) to such a degree that

s e l f - c r i t i c i s m behaves a s a d i a g n o s t i c measure; he a l s o noted t ha t the more

severe the d e p r e s s i v e i l l n e s s the more the h o s t i l i t y i s d i r e c t e d i n t r o -

p u n i t i v e l y . F o u l d s , Ca ine and C rea sy (1960) observed tha t male melancho l ie s

gave h i g h s co re s on pa rano id . h o s t i l i t y and Fou l d s (1965 b) r epo r ted t h a t

a c t i n g - o u t h o s t i l i t y measure c o r r e l a t e d " a lmos t s i g n i f i c a n t l y " w i th the

melancho l i c s ca l e o f the S S I i n a g roup o f predominant ly a g i t a t e d depressed

women. P r i e s t and Ne t te r (1975) r epo r ted t h a t among depressed p a t i e n t s

the b e s t outcome a f t e r a t reatment w i t h a n t i d e p r e s s a n t s was found among

those whose i n i t i a l s c o r e s on s e l f - c r i t i c i s m , c r i t i c i s m o f o the r s and projected

h o s t i l i t y were low.

There i s a sma l l number o f s t u d i e s which have examined the r e l a t i o n s h i p

between h o s t i l i t y and d e p r e s s i o n no t i n s i n g l e o c ca s i on s but t a k i n g i n t o

account the passage o f time : i t i s r epo r ted (Mayo, 1967 ; P h i l i p , 1971 ;

B l ackburn , 1974 J L y k e t s o s e t a l 1978) t ha t depressed p a t i e n t s , a s t h e i r

p s y c h i a t r i c s ta te improves show a r e d u c t i o n o f genera l h o s t i l i t y and a

decrease i n i t s i n t r o p u n i t i v e d i r e c t i o n . Mayo (1967) found t h a t bo th

43

s e l f - c r i t i c i s m and g u i l t showed app re c i ab l e f a l l s a s h i s 24 me l ancho l i c

p a t i e n t s improved. D e l u s i o n a l g u i l t was a l s o found by Adams and F o u l d s

(1962, 1963) to be s i g n i f i c a n t l y a s s o c i a t e d w i th p s y c h o t i c d e p r e s s i o n and s hoved

a s i g n i f i c a n t decrease i n improved p a t i e n t s . P h i l i p (1971) observed no change

on e x t r a p u n i t i v e n e s s i n h i s dep re s s ed p a t i e n t s a f t e r t h e i r improvement.

Mayo (1967) and B l a c k b u r n (1974 ) f ound t h a t a n o n - s i g n i f i c a n t d rop o f

e x t r a p u n i t i v e n e s s occured i n t h e improved depres sed p a t i e n t s they s t u d i e d .

Copper and Me tca l f e (1965) f o u n d t h a t d u r i n g improvement, p s y c h o t i c d e p r e s s i v e s

become s i g n i f i c a n t l y more e x t r a v e r t e d than the o the r g roups o f dep re s sed

p a t i e n t s they s t u d i e d ; t h i s i s an i n d i c a t i o n , a s they sugges ted , t h a t the

i l l n e s s i n f l u e n c e s the p e r s o n a l i t y s c o r e s to a g r e a t e r degree thai i doe s

n e u r o t i c d e p r e s s i o n . F o u l d s (1965 b) and L y k e t s o s e t a l (1978) f ound rthai;

p s y c h o t i c d e p r e s s i v e s become more e x t r a p u n i t i v e w i t h c l i n i c a l improvement.

There i s ano the r g roup o f a u t h o r s who do n o t suppor t the v iew t h a t h o s t i l i t y

i n d e p r e s s e d p a t i e n t s t a k e s a p redominan t l y i n t r o p u n i t i v e d i r e c t i o n .

P i l o w s k i and Spence (1975) i n v e s t i g a t e d s e l f - r e p o r t e d anger i n p s y c h o t i c and

n o n - p s y c h o t i c depre s sed p a t i e n t s . They found t h a t the h i g h e r the p s y c h o t i c i s m

sco re the more' l i k e l y the p a t i e n t was to r e p o r t ange r . T h i s f i n d i n g s u g g e s t s

a r e l a t i o n s h i p between d e p r e s s i o n and e x t e r n a l 1 y d i r e c t e d h o s t i l i t y .

S c h l e s s and h i s a s s o c i a t e s (1974) examined the r e l a t i o n s h i p between dep re s -

s i o n and h o s t i l i t y i n 37 p a t i e n t s . F o r the measurement o f h o s t i l i t y they

u sed s e l f - a d m i n i s t e r i n g s c a l e s d e r i v e d from the MMPI and the Bu s s -Du rkee

H o s t i l i t y S c a l e . I n a f a c t o r a n a l y t i c s tudy they f ound t h a t app rox ima te l y

h a l f o f the depre s sed p a t i e n t s showed a predominance o f outward ly d i r e c t e d

h o s t i l i t y and the o the r h a l f a predominance o f im/a rd l y - d i r e c t e d h o s t i l i t y ;

p a t i e n t s who were the most s e v e r e l y dep re s sed had an i n c r e a s e o f bo th i n w a r d l y

and outward ly d i r e c t e d h o s t i l i t y . Furthermore, Weissman e t a l (1971) found

t h a t dep re s sed p a t i e n t s d i r e c t e d t h e i r d e p r e s s i o n inwards when seen by

a p s y c h i a t r i s t , bu t d i r e c t e d i t outwards when they i n t e r a c t e d w i t h t h e i r

r e l a t i v e s .

Wessman, R i c k s and T y l (1960) s t u d i e d mood f l u c t u a t i o n s i n woman s t uden t s i n

a c o l l e g e do rm i t o r y d u r i n g a s i x - w e e k s p e r i o d u s i n g the P i c t u r e F r u s t r a t i o n

Te s t (Rosenzweig , 194-8). The f r equency o f e x t r a p u n i t i v e r e s pon se s was

s i g n i f i c a n t l y h i g h e r i n d e p r e s s i o n a n d the f requency o f i m t r o p u n i t i v e

r e s pon se s was n o t i n c r e a s e d s i g n i f i c a n t l y .

Gershon e t a l (1968) examined the r e l a t i o n s h i p between h o s t i l i t y and dep re s -

s i o n d u r i n g the cour se o f the i l l n e s s i n a v e r y sma l l sample o f o n l y s i x

p a t i e n t s . They u sed a D e p r e s s i v e Symptom Sca l e deve loped f rom the Hami l ton

r a t i n g s c a l e f o r d e p r e s s i o n and the method o f G o t t s c h a l k et a l (1963) f o r

the a s se s sment o f h o s t i l i t y . They ob ta i ned mixed r e s u l t s ; they f ound tha t

i n women w i t h h y s t e r i c a l p e r s o n a l i t i e s , h o s t i l i t y - o u t i n c r e a s e d w i t h deepening

d e p r e s s i o n and s ub s i ded w i t h improvement whereas i n women w i t h many o b s e s s i v e

f e a t u r e s , the ' r e l a t i o s h i p was r e v e r s e d o r n o t p r e s e n t .

Klerman and Gershon (1970) f ound t h a t measures o f h o s t i l i t y i n t h e i r sample

o f d e p r e s s i v e p a t i e n t s had no r e l a t i o n s h i p a t a l l to symptomatic improvement.

The q u e s t i o n whether o r n o t h o s t i l i t y i s a' consequence o f d e p r e s s i o n o r

whether d e p r e s s i o n i s a consequence o f i n n e r - d i r e c t e d h o s t i l i t y c o u l d be

rega rded a s a p a r t o f the more g e n e r a l problem o f the c au s a t i v e r e l a t i o n s h i p

45

between h o s t i l i t y and p s y c h i a t r i c symptomatology.

The m a j o r i t y o f the mentioned s t u d i e s were conducted i n one-measur ing

s e t t i n g s . However the more s u b t l e r e l a t i o n s h i p s between h o s t i l i t y and depre s

s i o n cannot be demonstrated u n l e s s the se s t u d i e s take i n t o account the cou r se

o f the i l l n e s s i n v a r i o u s g r oup s o f p a t i e n t s under d i f f e r e n t the rapy

c o n d i t i o n s .

46

4 . 3 . 4 * H o s t i l i t y and Mania

I t i s b r o a d l y accepted t h a t p a t i e n t s b e l o n g i n g to the m a j o r i t y o f p s y c h i -

a t r i c d i a g n o s t i c • c a t e g o r i e s channe l t h e i r h o s t i l i t y a s measured by

the HDHQ, i n t r o p u n i t i v e l y on ba l ance . I t seems, however, t h a t i n a t l e a s t two

g r oup s , p a r ano i d s and man ic s , the d i r e c t i o n o f h o s t i l i t y i s towards e x t r a -

p u n i t i v e n e s s . A c c o r d i n g t o Ca ine e t a l (1967) on l y manics and " se lec ted 1 1

pa rano i d s - i . e . , p a r a n o i d s w i t h no h i s t o r y o f d ep re s s i v e ep i s ode s - a re

p redominant l y e x t r a p u n i t i v e . Salmon (1964) found a p o s i t i v e c o r r e l a t i o n

between hypomania and e x t r a p u n i t i v e n e s s . I

N e v e r t h e l e s s , t h i s f i n d i n g does n o t a lway s emerge so c l e a r l y . F ou l d s

and Bed fo rd (1976 c) s t u d i e d e x t r a p u n i t i v e n e s s , i n t r o p u n i t i v e n e s s and dominance

i n a group o f 13 e l a t e d p a t i e n t s . There i s no i n f o r m a t i o n about the

c l i n i c a l d i a g n o s i s g i v e n to tho se p a t i e n t s . A s measur ing i n s t r u m e n t s

the DSS l/R and PDS ( P e r s o n a l i t y Dev iance S ca l e s ) ( Fou ld s and Bed fo rd

1978b) were u sed . I t was f ound t ha t these p a t i e n t s d i f f e r e d s i g n i f i c a n t l y

from norma l s i n b e i n g bo th l e s s e x t r a p u n i t i v e ' and l e s s i n t r o p u n i t i v e .

Among e l a t e d p a t i e n t s the re was a l s o a h i g h p r o p o r t i o n o f p a t i e n t s w i t h

v e r y low s c o r e s on a l l th ree measures b u t p a r t i c u l a r l y on e x t r a p u n i t i v e n e s s .

B l a c kbu rn (1974) examined g r o u p s o f p a t i e n t s s u f f e r i n g from u n i p o l a r and b i p o l a r

d e p r e s s i o n and c l a s s i f i e d them a s improved o r no t improved. The HDHQ was

u sed f o r the measurement o f h o s t i l i t y . The compar i sons were c r o s s - s e c t i o n a l

r a t h e r than . l o n g i t u d i n a l d i f f e r e n t p a t i e n t s be i n g i n c l u d e d i n the i l l and

recove red g roups . The mean i n t r o p u n i t i v e score i n manic p a t i e n t s was i n

the normal r ange . Recovered manic p a t i e n t s had s i g n i f i c a n t l y lower s co re s

on e x t r a p u n i t i v e n e s s than the a c t i v e manic p a t i e n t s . The d i f fe rence between

these g roups on i n t r o p u n i t i v e n e s s was n o t s i g n i f i c a n t . T h i s f i n d i n g suppor t s

47

the t h e s i s t h a t e x t r a p u n i t i v e n e s s i s c l o s e l y a s s o c i a t e d w i th changes o f

the c l i n i c a l p i c t u r e i n mania, r e v e r t i n g t o normal a s the manic symptoms

* r e m i t . A s B l a c k b u r n c l a i m s , manics a re the o n l y group i n which i t h a s

been shown t h a t such s h i f t s i n e x t r a p u n i t i v e n e s s occu r r e l i a b l y

w i t h r e c o v e r y .

More r e l i a b l e answers t o tie q u e s t i o n o f the r e l a t i o n s h i p between manic

symptomatology and h o s t i l i t y c ou l d be g i v e n i f the v a r i a t i o n o f the

cour se o f t h i s i l l n e s s w i t h t he pa s sage o f time cou l d be c o n s i d e r e d .

48

4«3*5* H o s t i l i t y and C o n v e r s i o n . - D i s s o c i a t i v e Phenomena.

Two impor tan t d i s t i n c t i o n s s h o u l d be made conce rn ing h y s t e r i a . The

f i r s t i s between h y s t e r i a a s a p e r s o n a l i t y t r a i t and h y s t e r i a a s an

i l l n e s s and the second i s between c o n v e r s i o n h y s t e r i a and d i s s o c i a t i v e h y s -

t e r i a .

*

H y s t e r i a a s an i l l n e s s i s c h a r a c t e r i s e d by the presence o f symptoms

s u g g e s t i n g the d i s t u r b a n c e o f f u n c t i o n and the absence o f p h y s i c a l s i g n s

o r any ev idence o f p h y s i c a l p a t h o l o g y . The behav iou r o f the p a t i e n t s ! s u g g e s t s t h a t the symptoms f u l f i l some p s y c h o l o g i c a l need.

When the term i s u s ed to r e f e r to the p e r s o n a l i t y i t connotes the h i s t r i o n i c

q u a l i t y o f the b e h a v i o u r . .

.Conve r s i on h y s t e r i a c o r r e s p o n d s t o the t r a d i t i o n a l concept o f h y s t e r i a

and i t r e f e r s t o the p r o c e s s by wh i ch a mental c o n f l i c t i s t r an s fo rmed to p h y -

s i c a l symptoms such a s p a r a l y s i s .

D i s s o c i a t i v e h y s t e r i a c o u l d be r e g a r d e d a s the p s y c h o p a t h o l o g i c a l s t a t e in

wh ich two o r more mental p r o c e s s e s c o e x i s t w i thout becoming connected o r

i n t e g r a t e d r e s u l t i n g i n such symptoms a s amnesia o r s t u p o r .

I t i s w i de l y accepted t h a t among ne>*roses, none ha s been more d e f i n i t e l y

and c l e a r l y a s s o c i a t e d w i t h the o p e r a t i o n o f a s p e c i f i c defence mechanism

t h a t h a s h y s t e r i a w i t h r e p r e s s i o n . H y s t e r i a i s con s i de red by many

p s y c h o a n a l y t i c a l l y o r i e n t e d a u t h o r s t o be a defence a g a i n s t a p a r t i c u l a r

range o f a n x i e t i e s a r i s i n g from u n r e s o l v e d o e d i p a l o r p r e - o e p i d a l c o n f l i c t s ,

wh ich r e f e r more s p e c i f i c a l l y t o the r e l a t i o n s h i p w i t h the pa ren t o f the

49

same sex , a g a i n s t whom h o s t i l i t y i s d i r e c t e d because o f the p a t i e n t 1 3

r i v a l r y w i t h the o the r p a r e n t . Concern ing c o n v e r s i o n h y s t e r i a , Cameron (1963)

s t a t e d t h a t the d i s t u r b e d f u n c t i o n may exp re s s f o r b i d d e n impu l s e s , the

defences a g a i n s t them and a l s o s e l f - pun i s hmen t f o r h a v i n g such i m p u l s e s .

Another i n t e r p r e t a t i o n o f h y s t e r i c a l symptomatology i s t h a t o f l e a r n e d

behav i ou r ; the p a t i e n t i s rewarded w i t h sympathy when he adop t s the s i c k

r o l e , m a n i p u l a t i n g o t h e r s v i a symptoms and a t the same time a v o i d i n g those

demands o f l i f e which a re p a r t i c u l a r l y t roublesome t o h im.

The ev idence t h a t h y s t e r i c a l ' symptoms a lways a r i s e i n p a t i e n t s w i t h

h y s t e r i c a l p e r s o n a l i t y i s n o t v e r y s t r o n g ; t r a i t s l i k e e g o c e n t r i c i t y ,

e x h i b i t i o n i s m , e m o t i o n a l i t y , dependency, p r o v o c a t i v e n e s s , s u g g e s t i b i l i t y

and f e a r o f s e x u a l i t y , wh ich i l l u s t r a t e the h y s t e r i c a l p e r s o n a l i t y f e a t u r e s ,

a r e n o t a lway s f ound i n p a t i e n t s w i t h h y s t e r i c a l symptoms ( La sa re and Klerman

1968 ) . Ingham and Rob i n s on (1964 ) took agroup o f p a t i e n t s d i a g n o s e d non-

s p e c i f i c a l l y a s " h y s t e r i c s " and s u b d i v i d e d them i n t o p a t i e n t s w i t h

c o n v e r s i o n h y s t e r i a and t ho se w i t h h y s t e r i c a l p e r s o n a l i t y . The mean e x t i a -

v e r s i o n s co re f o r t he c o n v e r s i o n h y s t e r i c s was s i m i l a r to t h a t o f dy s thym ic s

( i . e . p a t i e n t s w i t h a n x i e t y and/or n e u r o t i c d e p r e s s i o n ) wh i l e the h y s t e r i c a l

p e r s o n a l i t i e s ob ta i ned a more e x t r a v e r t e d s co r e . As Ca ine and Hope(196^)

conc luded, h y s t e r i c s a re more e x t r a v e r t e d than dy s thym ic s i n the sense that ' a

h y s t e r i c i s more l i k e l y than a dy s thymic to have a h y s t e r o i d p e r s o n a l i t y ,

Ey senck (1962) s t u d i e d v a r i o u s c a t e g o r i e s o f n e u r o t i c s w i t h the MP I and

found t h a t h y s t e r i c s were the most e x t r a v e r t e d g roup a f t e r p s y chopa th s .

Ca ine and Hope (1964) u s i n g the same s c a l e i n f i f t y n e u r o t i c p a t i e n t s

found h y s t e r i c s a s the most e x t r a v e r t e d bu t the d i f f e r e n c e from o the r

d i a g n o s t i c g roup s was n o t s i g n i f i c a n t . S i n ce i t h a s been found ( F o u l d s

1965 b) t h a t e x t r a v e r s i o n i s p o s i t i v e l y a s s o c i a t e d w i t h e x t r a p u n i t i v e n e s s

50

these f i n d i n g s have some impor tance r e g a r d i n g the r e l a t i o n s h i p between ho s -

t i l i t y and h y s t e r i c a l symptomatology.

On t h i s matter P h i l i d a Salmon (1964) when examining seventy- two MMPI r e co rd s

observed no c o r r e l a t i o n between h y s t e r i a and e x t r a p u n i t i v e n e s s and Fernardo

(1977) noted t h a t h y s t e r i c a l t e n d e n c i e s i n depres sed p a t i e n t s a re l i k e l y

t o i n c r e a s e r a t h e r than dec rea se i n t r o p u n i t i v e n e s s . Rosenzweig (1938)

c on s i de r ed h y s t e r i c s a s i m p u n i t i v e s . F o u l d s (1965 b) showed t h a t they

produce r a t h e r low s c o r e s on i n t r o p u n i t i v e n e s s compared w i t h p a t i e n t s

w i t h phob i c , compu l s i ve o r r u m i n a t i v e symptoms and he i n t e r p r e t e d t h i s i I

a s a r e s u l t o f t h e i r , a t l e a s t p a r t i a l , r e p r e s s i o n - o r d i s s o c i a t i o n - o f .

p a i n f u l a f f e c t .

I t seems t h a t h y s t e r i c s g e n e r a l l y , and p a t i e n t s v i th c o n v e r s i o n symptoms

p a r t i c u l a r l y , be l ong t o the most " s o m a t i c " group i n p s ychopa tho l ogy .

F o u l d s (1966) demonstrated t h a t , when p s y c h i a t r i c p a t i e n t s were c l a s s e d a s

" P s y c h i c s " and " S o m a t i c s " on t he b a s i s o f the k i n d o f symptomatology they

man i fe s ted ( i . e . on the one hand symptoms r e l a t e d to p a t i e n t ' s f e e l i n g s and

on the o the r symptoms r e l a t e d t o h i s p h y s i c a l f u n c t i o n s ) , " s o m a t i c " p a t i e n t s

o f a lmos t a l l d i a g n o s t i c g r oup s s c o r ed lower on gene ra l h o s t i l i t y and were

l e s s i n t r o p u n i t i v e than " p s y c h i c " p a t i e n t s . He sugges ted t h a t s o m a t i z a t i o n

o f symptoms cou l d be a s u b s t i t u t e f o r i n t r o p u n i t i v e n e s s . F e r n a r d o ( 1 9 7 7 ) ,

however, p o i n t e d ou t i n h i s s t u d y o f d e p r e s s i v e p a t i e n t s t h a t i t was no t

c l e a r whether somat ic m a n i f e s t a t i o n s and g u i l t f e e l i n g s were n e c e s s a r i l y

i n v e r s e l y r e l a t e d i n the way F o u l d s sugge s ted . I t ha s been c la imed

(Woodruff e t a l 1974; Watson and Buraven, 1 979 ) t ha t p a r a l y s i s , b l i n d n e s s ,

dea f ne s s , h y s t e r i c a l f i t s , e t c . , d e s c r i b e d i n c l a s s i c a l tex tbooks a s the most

common c o n v e r s i o n symptoms, a r e no t c u r r e n t l y so common a s i n the p a s t p o s s i b l y

because i n everyday p s y c h i a t r i c p r a c t i c e these symptoms have 'been-. rep laced by

51

o the r symptoms a s d i z z i n e s s , headache, o ther p a i n s , p a r a e s t h s i a ,

pseudo - h e a r t a t t a c k s e t c . T h i s phenomenon cou ld p robab l y be

a t t r i b u t e d t o the i n c r e a s e d s o p h i s t i c a t i o n o f the d i a g n o s i s and o the r

soc io -economic and c u l t u r a l f a c t o r s . However, the common denominator o f

both the c l a s s i c a l and minor convers ion. symptoms i s t h e i r " somat ic "

c h a r a c t e r .

On the o the r hand d i s s o c i a t i v e symptoms, whether exp re s sed a s amnes ia ,

fugue s t a t e , Ganser syndrome o r m u l t i p l e p e r s o n a l i t y , wh i l e i m p l y i n g a

d i s t u r b a n c e o f f u n c t i o n , t h e y have a more c l e a r p s y c h o l o g i c a l c ha r a c t e r

than c o n v e r s i o n symptoms. I t ha s been sugges ted ( F o u l d s , 1976) t h a t i t

i s more l i k e l y f o r p a t i e n t s w i t h d i s s o c i a t i v e symptoms to move towards

the e x p r e s s i o n o f d e l u s i o n a l i d e a s t han the p a t i e n t s m a n i f e s t i n g o the r

n e u r o t i c symptoms.

. I t would be expected t h e r e f o r e t h a t p a t i e n t s w i t h d i s s o c i a t i v e symptoms

might s co re h i g h e r on g ene r a l h o s t i l i t y and i n t r o p u n i t i v e n e s s than p a t i e n t s

w i t h c o n v e r s i o n symptoms.

I t i s e v i d e n t from t h i s r e v i ew t h a t i n r e s p e c t o f t h e r e l a t i o n s h i p s between

h o s t i l i t y and h y s t e r i c a l symptomatology the l i t e r a t u r e i s v e r y poor indeed.

Furthermore no s tudy h a s been conducted w i t h the purpose o f i n v e s t i g a t i n g

these r e l a t i o n s h i p s i n a l o n g i t u d i n a l framework.

52

H o s t i l i t y and Phob ic Symptoms

Phob i a s can be rega rded a s abnormal and d i s a b l i n g f e a r s o f c e r t a i n ob jec t s

o r s i t u a t i o n s . They gee a s s o c i a t e d w i t h a l a r g e number o f p s y c h i a t r i c d i a g -

gnoses bu t a re most o f t e n a s s o c i a t e d w i t h a n x i e t y s t a t e s and o b s e s s i o n a l n e u r o s i s

The morbid f e a r i s , a c c o r d i n g to p s y c h o a n a l y t i c s c h o o l , based on the

d i s p l a cement o f ano the r o r i g i n a l f e a r ; f o r example, " the agoraphob ic

b e i n g a f r a i d o f a g g r e s s i v e , d e s t r u c t i v e impu l se s a g a i n s t o t h e r s , d e v e l o p s

h i s phob ic symptoms i n o rde r t o p r even t h i m s e l f f rom a c t i n g out h i s a g g r e s s i v e

i m p u l s e s . A d i f f e r e n t v i e w p o i n t a t t r i b u t e d on l e a r n i n g theory p r i n c i p l e s ;

the source o f p h o b i a s o f s p e c i f i c o b j e c t s o r s i t u a t i o n s ( i . e . , . s u r g e r y p h o b i a ) '

may be r e l a t e d t o c o n d i t i o n i n g p r o c e s s e s i n the p a s t .

.The r e l a t i o n s h i p between phob i c symptomatology and h o s t i l i t y a t t i t u d e s i n

• v a r i o u s d i a g n o s t i c g roups o f p s y c h i a t r i c p a t i e n t s h a s no t been adequate l y

s t u d i e d .

I t was sugges ted by F o u l d s (1976) t h a t p a t i e n t s w i t h phob ic symptoms would

man i f e s t h i g h l e v e l s o f i n t r o p u n i t i v e a t t i t u d e s and Feraardo(1977) r epo r ted

t h a t i n d e p r e s s i v e p a t i e n t s phob i c m a n i f e s t a t i o n s were p o s i t i v e l y c o r r e l a t e d

w i t h an i n t r o p u n i t i v e d i r e c t i o n o f h o s t i l i t y and f e e l i n g o f g u i l t .

Ha fne r (1977 a ) , s t u d y i n g t h i r t y ago raphob i c women i n three measurement p o i n t s

d u r i n g a p e r i o d o f twelve months w i t h the HDHQ and the MHQ, ob se rved that

they man i fe s ted h i g h l e v e l s o f h o s t i l i t y w i t h e x t r a p u n i t i v e d i r e c t i o n ;

agoraphob ic women w i t h h i g h l e v e l s o f t o t a l h o s t i l i t y had a r e l a t i v e l y h i gh

i n c i dence o f g e n e r a l phob ic and n e u r o t i c symptoms, whereas i n agoraphob ic

women w i th lower l e v e l s o f t o t a l h o s t i l i t y , ago raphob i c symptoms e x i s t e d i n

53

r e l a t i v e i s o l a t i o n . A y e a r a f t e r an i n t e n s i v e therapy procedure, these

women ( b e l o n g i n g to bo th g r o u p s ) were s i g n i f i c a n t l y l e s s h o s t i l e and more

e x t r a p u n i t i v e (Ha fne r , 1977 b ) .

Rega rd i ng the problem o f the r e l a t i o n s h i p between phob ic symptoms and

h o s t i l i t y w i t h the pa s sage o f t ime the l i t e r a t u r e i s a g a i n v e r y poo r .

The s t u d i e s o f F o u l d s and Fe rna rdo a r e based on da t a obta ined from s i n g l e

o c c a s i o n s . The s tudy o f Ha fne r i s l i m i t e d on l y to agoraphob ic p a t i e n t s .

S t u d i e s c o v e r i n g the w ider a r e a o f phob ic symptomatology and i t s r e l a t i o n s h i p s

w i t h h o s t i l i t y w i t h t h e l a p s e o f t ime a re l a c k i n g .

54

4 . 3 * 7 . H o s t i l i t y and O b s e s s i v e - Compuls ive N e u r o s i s

Ob se s s i v e - compu l s i v e n e u r o s i s i s b r o a d l y rega rded a s a p s y c h o p a t h o l o g i c a l

c o n d i t i o n c h a r a c t e r i z e d by o b s e s s i o n a l t hough t s and compu l s i on s .

O b s e s s i o n a l t hough t s are e xpe r i enced by the p a t i e n t a s d i s t r a c t i n g and r e p e t i -

t i v e ; they a re ab su rd , b i z a r r e , i r r e l e v a n t or obscene. Compul s ions are

t hough t s or a c t i o n s wh ich the s ub j e c t f e e l s compel led to t h i n k or c a r r y

out i n a r e p e t i t i v e s t e r e o t y p e d and r i t u a l i s t i c way and which he cannot p r e v e n t .

Ob se s s i v e - compu l s i v e phenomena have been c la imed t o be more o f t e n

a s s o c i a t e d w i t h c e r t a i n t y p e s o f c u l t u r a l p r a c t i c e s (Akhta r e t a l 1975;.

C h a k r a b o r t i and B a n e r j i , 1975 ) bu t o t he r s t u d i e s (Dawson, 1977) have

g i v e n no suppor t to t h i s t h e s i s .

Rega rd i n g the r e l a t i o n s h i p between h o s t i l i t y and o b s e s s i v e - c o m p u l s i v e

phenomena there i s a wide r ange o f t h e o r e t i c a l v i ews ' a v a i l a b l e .

Lo renz (1966) f rom h i s e t h o l o g i c a l p o s i t i o n e spouses the v iew t h a t there i s a.

p h y l o g e n e t i c p r o c e s s o f r i t u a l i z a t i o n which c r e a t e s a new autonomous i n s t i n c t ;

t h i s i n s t i n c t i n t e r f e r e s a s a n independent f o r c e w i t h the p r imary f unc t i on o f

p r e v e n t i n g the ha rmfu l e f f e c t s o f a g g r e s s i o n by i n d u c i n g mutual unde r s t and i ng

between the members o f s p e c i e s . He does n o t exc lude man fl-om t h i s p roces s .

One t h e r e f o r e c ou l d assume t h a t p r o d u c i n g compuls ive symptoms under s t r e s s -

f u l s i t u a t i o n s , c o u l d be a way o f d e c r e a s i n g h i g h l e v e l s o f h o s t i l i t y d i r e c t e d

outwards .

The r o l e o f f e e l i n g s o f h o s t i l i t y a s impor tant de te rminant s o f o b s e s s i v e

compuls ive n e u r o s i s h a s been d i s c u s s e d by numerous au tho r s ( i . e . , Fen i che l

1945; Cameron, 1 963 ) . F reud (1924) p o s t u l a t e d t h a t there was a c l o s e

55

a s s o c i a t i o n between h o s t i l i t y and a n a l e r o t i c i s m i n the development

o f t h i s d i s o r d e r . D a l b i e z ( 1 9 4 1 ) , emphas i z ing the r o l e o f g u i l t i n o b s e s -

s i v e - c o m p u l s i v e n e u r o s i s , c a l l e d i t a g u i l t n e u r o s i s .

Dawson (1977) s t u d y i n g 4 1 o b s e s s i v e - c o m p u l s i v e p a t i e n t s found t h a t

1) 12 pe r cen t of them had a f e a r o f c a u s i n g harm to s e l f and o t h e r s

2) seven percent had an u rge to cause p h y s i c a l harm to s e l f and o t h e r s

3 ) 3 2 pe r cen t had t hough t s o f d e s t r u c t i o n , v i o l e n c e , death o r i n j u r y (symptoms

1 and 2 exc l uded ) . B u t i t h a s been sugge s ted (Akhta r e t a l 1975) t h a t the

a g g r e s s i v e content o f o b s e s s i o n s i s n o t n e c e s s a r i l y connected w i th the !

p a t i e n t 1 s u n d e r l y i n g h o s t i l i t y c o n s i d e r e d a s a p e r s o n a l i t y f e a t u r e .

F o u l d s e t a l (1960) s u gge s t ed t h a t o b s e s s i o n a l p a t i e n t s might show a

p r e d i l e c t i o n f o r i n t r o p u n i t i v e r e s p o n s e s .

Manchanta e t a l (1979) i n v e s t i g a t e d 30 c a s e s o f o b s e s s i v e - c o m p u l s i v e

n e u r o s i s w i t h the HDHQ and the Thematic Appercept i on Te s t (Mur ray , 1943)

u s i n g a s c o n t r o l s an equa l number o f d e p r e s s i v e s . They found the a c t i n g - o u t

h o s t i l i t y score to be s i g n i f i c a n t l y h i g h e r i n the. exper imenta l g roup w i t h

no s i g n i f i c a n t d i f f e r e n c e on g u i l t s c o r e s .

I t c ou l d be come a s a g e n e r a l c o n c l u s i o n from t h i s rev iew o f the l i t e r a t u r e

t h a t the i d e a s r e g a r d i n g the r e l a t i o n s h i p s between h o s t i l i t y and o b s e s s i v e

compuls ive symptoms a re mos t l y t h e o r e t i c a l . There are v e r y few s t u d i e s

based on o b j e c t i v e methods.

S i n ce i t c ou l d be h y p o t h e s i s e d t h a t o b s e s s i o n s have a d i f f e r e n t k i n d

o f r e l a t i o n s h i p to h o s t i l i t y than compu l s t i on s , the s tudy o f the whole

problem r e q u e s t s a more d e t a i l e d examinat ion based on repeated measurements

d u r i n g the cour se o f t h e symptomatology.

56

4 * 3 * 8 . H o s t i l i t y and P a r a n o i d D i s o r d e r

The l i t e r a t u r e r e g a r d i n g the r e l a t i o n s h i p s between pa rano i d d i s o r d e r and

h o s t i l i t y i s v e r y poor wh ich i s s u r p r i s i n g f o r a p s y c h i a t r i c e n t i t y a s

w i d e l y d i s c u s s e d a s t h i s d i s o r d e r .

I t ha s been sugge s ted (Rosenzwe ig , 1 9 3 8 ) , t h a t p a t i e n t s m a n i f e s t i n g

symptoms o f a p a r a n o i d s t a t e e x p r e s s t h e i r h i g h l e v e l s o f h o s t i l i t y i n an

e x t r a p u n i t i v e way and i t ha s been shown ( Fou l d s e t a l 1960; Salmon 1964 ;

Ca ine e t a l 1967) "that tho se p a t i e n t s - e s p e c i a l l y p a r ano i d s w i thou t a h i s t o r y I

o f d e p r e s s i v e e p i s o d e s - b e l o n g to the v e r y few p s y c h i a t r i c g roups tfiich man i f e s t

a predominance o f e x t r a p u n i t i v e n e s s over i n t r o p u n i t i v e n e s s .

On the HDHQ p a r a n o i d p a t i e n t s may be expected t o channe l t h e i r e x t r a -

p u n i t i v e n e s s t h rough p a r a n o i d ( p r o j ec ted ) h o s t i l i t y and c r i t i c i s m o f o t h e r s .

A c t i n g - o u t h o s t i l i t y may be den i ed by them because i t i s p r o j e c t e d to others

and the s e l f - c r i t i c i s m sco re i s p r o b a b l y low because these p a t i e n t s f ea r

b laming themse lves a s Rosenzwe ig c l a i m s . F o u l d s e t a l (1960) s t u d y i n g

p a t i e n t s a l l o c a t e d t o s i x d i f f e r e n t d i a g n o s t i c g r oup s , found t h a t pa rano id

p a t i e n t s s co red h i g h e s t o f a l l g r oup s on pa r ano i d h o s t i l i t y .

Ca ine (1960) s t u d i e d 17 m e l a n c h o l i c p a t i e n t s and 14 p a t i e n t s w i t h a pa rano id

s t a t e u s i n g three h o s t i l i t y s c a l e s ( a c t i n g - o u t h o s t i l i t y , p r o j e c t e d h o s t i l i t y

and s 6 l f - c r i t i c i s m / g u i l t ) s p e c i a l l y d e r i v e d from the M innesota M u l t i p h a s i c

P e r s o n a l i t y I n v e n t o r y (Hathaway and Mc K i n l e y , 1 951 )• He. found t h a t the

p a r a n o i d g roup had s i g n i f i c a n t l y l ower s co re s on the s e l f - c r i t i c i s m / g u i l t

s c a l e . T h i s i s i n accordance w i t h t h e f i n d i n g o f Adams and F o u l d s (1963)

t h a t p a r a n o i d s were more d e l u s i o n a l l y ex t rapun i t i ve . . and m e l a n c h o l i e s more

d e l u s i o n a l l y i n t r o p u n i t i v e .

57

A l t hough a l l theso s t u d i e s examine s p e c i f i c a l l y t h e r e l a t i o n s h i p between

h o s t i l i t y and pa rano id d e l u s i o n s they f a i l t o g i v e answers r e g a r d i n g the

more s u b t l e i n t e r a c t i o n s between these v a r i a b l e s . The l a t t e r would be

p o s s i b l e t h r ough l o n g i t u d i n a l s t u d i e s o f d i f f e r e n t d i a g n o s t i c groups

m a n i f e s t i n g such d i s o r d e r s unde r v a r i o u s t reatment c o n d i t i o n s .

58

4«3*9« H o s t i l i t y and S ch i z oph ren i a

The number o f the s t u d i e s r e g a r d i n g the r e l a t i o n s h i p between h o s t i l i t y

and s ch i zoph ren i c symptoms i s r a t h e r sma l l ; those t ha t e x i s t are based

main ly on measurements o f these v a r i a b l e s on s i n g l e o c ca s i on s .

Non - i n teg ra ted p s y c h o t i c s have been cons ide red (Fou lds , 1965 b; Ca ine

e t a l 1967) to be the most g e n e r a l l y p u n i t i v e group o f a l l mental i l l n e s s e s .

Concern ing the d i r e c t i o n o f t h e i r h o s t i l i t y , Fou ld s (1965 b) noted t ha t

there i s a tendency f o r s c h i z o p h r e n i c s to score predominant ly i n the

e x t r a p u n i t i v e d i r e c t i o n . I t seems, however, t ha t the d i r e c t i o n o f h o s t i l i t y

depends on the k i n d o f d e l u s i o n a l ideas the s ch i zophren i c p a t i e n t h a s . I t.

i s p robab le (Lucas , S a i n s b u r y a n d C o l l i n s , 1962) t ha t the g rea t m a j o r i t y

o f s c h i z oph ren i c s have d e l u s i o n a l i d e a s o f some k i n d . The " n o n - i n t e g r a t e d "

p s y c h o t i c , i t i s c l e a r , may r e p o r t a p a t t e r n o f h o s t i l i t y depending on h i s

i n t e g r a t e d d e l u s i o n s . F o u l d s and Bedfo rd (1977 d) found t ha t s ch i zoph ren i c

p a t i e n t s w i t h d e l u s i o n s o f c o n t r i t i o n s co red , a s one cou ld expect, much h i g he r

on i n t r o p u n i t i v e n e s s than t h o s e . w i t h d e l u s i o n s o f pe r s ecu t i on o r d e l u s i o n s

o f g randeur.

It would n e v e r t h e l e s s be o f importance, i f i t were p o s s i b l e , to examine the

l e v e l and d i r e c t i o n o f h o s t i l i t y i n the m i n o r i t y o f s c h i z oph ren i c s without

i n t e g r a t e d d e l u s i o n s . The more " p u r e " symptoms o f a n on - i n t e g r a t ed p sychot i c

may be regarded a s i m p l y i n g a breakdown o f the boundary between the s e l f

and the o the r s and a d i s t u r bance o f the p a t i e n t f s awareness o f h i m s e l f as

agent; a u d i t o r y h a l l u c i n a t i o n s , d e l u s i o n s o f thought i n s e r t i o n and o f "thought

broadcasting and d e l u s i o n s o f d i s i n t e g r a t i o n , f l a t t e n i n g and i n c o n g r u i t y o f

a f f e c t and thought d i s o r d e r cou ld a l s o be regarded a s symptoms manifested

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by n o n - i n t e g r a t e d p s y c h o t i c s .

P r i e s t (1969) h y p o t h e s i z e d t h a t thought d i s o r d e r i n n o n - i n t e g r a t e d p s y c h o t i c s

would be a s s o c i a t e d w i t h h i g h l e v e l s o f h o s t i l i t y ; c h r on i c s c h i z o p h r e n i c s

tend to u se t h e i r t hough t d i s o r d e r t o a v o i d communication. I n t h i s way they

a re ab l e to a v o i d i n d i c a t i n g t h e i r d i s t r u s t and h o s t i l i t y . These p a t i e n t s

become i n t r o p u n i t i v e a f t e r the removal o f t h i s symptom d u r i n g the t reatment .

More p o s i t i v e answers t o the problem o f the v a r i o u s i n t e r a c t i o n s between h o s -

t i l i t y and s c h i z o p h r e n i c symptoms c o u l d be g i v e n i f the r e l a t i o n s h i p s of

these v a r i a b l e s would be s t u d i e d i n d i f f e r e n t s e t t i n g s w i t h o b j e c t i v e methods

d u r i n g the cour se o f t reatment o f t h e s c h i z o p h r e n i c symptomatology.

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4 . 4 . S U M M A R Y

The v iews o f a number o f a u t h o r s r e l a t i n g t o v a r i o u s a s pec t s o f t h i s study-

a re p re sen ted i n t h i s s e c t i o n .

The t h e o r e t i c a l p o s i t i o n s r e g a r d i n g the r e l a t i o n s h i p between p e r s o n a l i t y

and p s y c h i a t r i c symptomatology a re p u t fo rward and the d i s t i n g u i s h i n g

f e a t u r e s between p e r s o n a l i t y t r a i t s and mental i l l n e s s a re po i n ted ou t .

The concepts o f t r a i t and p e r s o n a l i t y type and the concepts o f symptom r-

s i g n , s t a t e and syndrome are d i s c u s s e d . The th ree c r i t e r i a o f s t a b i l i t y

over t ime, u n i v e r s a l i t y i n the p o p u l a t i o n and the e x p e r i e n c i n g o f d i s t r e s s

a s d i s c r i m i n a t i n g f a c t o r s between p e r s o n a l i t y t r a i t s and symptomatology

have been o u t l i n e d . F u r t h e r ment ion ha s been g i v e n t o the concept o f a t t i t u d e

a s a f a c t o r c o n c e p t u a l l y somewhere between these concep t s .

Fou ld s 1 t heo r y on the h i e r a r c h i a l n a t u r e o f mental i l l n e s s and a b r i e f

d e s c r i p t i o n o f h i s c l a s s e s o f p e r s o n a l i l l n e s s have been p re sen ted . *

The v i ews o f v a r i o u s s c h o o l s o f t hough t about the na tu re o f h o s t i l i t y

(which i s r e ga rded a s an a t t i t u d e r a t h e r than a s p e r s o n a l i t y t r a i t ) and

i t s r e l a t i o n s h i p s w i t h a wide range o f p s y c h i a t r i c c o n d i t i o n s were

con s i de red . These p s y c h i a t r i c c o n d i t i o n s are : a n x i e t y , d e p r e s s i o n , mania,

ob se s s i v e - c ompu l s i v e , i l l n e s s , h y s t e r i a , pa rano id p s y c h o s i s and s c h i z o p h r e n i a .

I t seems t h a t -there i s no u n i v e r s a l agreement r e g a r d i n g the r e l a t i o n s h i p o f

the h o s t i l i t y to the m a j o r i t y o f p s y c h i a t r i c d i s t u r b a n c e s , except i n the

case o f mania and pa r ano i d s t a t e s f o r both o f wh ich i t i s accepted t h a t

outward ly d i r e c t e d h o s t i l i t y i s a c o n s i s t e n t accompaniment. The d i a g n o s t i c

61

c r i t e r i a and t h e me thodo l o g i c a l approach cou ld be rega rded a s the

main r e a s o n s u n d e r l y i n g these d i s ag reement s .

A s p e c i a l r ev iew t o the l i t e r a t u r e c o n s i d e r i n g the r e l a t i o n s h i p s

between h o s t i l i t y and p s y c h i a t r i c symptoms w i th the l a p s e o f t ime

(which i s the theme o f t h i s s t udy ) was g i v e n . I t i s observed t h a t t h i s mat te r

h a s been r a t h e r p o o r l y i n v e s t i g a t e d .

62

5 . METHODS

5 . 1 . P o p u l a t i o n and S e l e c t i o n o f the Sample

The p re sen t s tudy was c a r r i e d out i n the P s y c h i a t r i c Department o f

S t , M a r y ' s H o s p i t a l , Harrov/ Road, London.

S t . M a r y ' s H o s p i t a l h a s a catchment a rea which l a r g e l y c o i n c i d e s w i th

Westminster S o c i a l S e r v i c e s A rea which i s s ou th o f the Grand Un ion

C a n a l , west o f Edgware Road and n o r t h o f the P a r k s (Bayswater Road ) .

T h i s i s e s t imated to cove r a m u l t i c u l t u r e p o p u l a t i o n o f *f0 - 5 0 , 0 00 .

The P s y c h i a t r i c Department c ompr i s e s $0 h o s p i t a l p l a c e s o f which 50

a re u sed by i n - p a t i e n t s and 30 are a v a i l a b l e to n o n - r e s i d e n t s . Ou t -

p a t i e n t and d a y - p a t i e n t f a c i l i t i e s are a v a i l a b l e w i t h i n the u n i t .

The U n i t i s made up o f f ou r f i r m s . I t s medica l s t a f f i s compr i sed

o f the P r o f e s s o r and a s e n i o r l e c t u r e r (both honora ry c o n s u l t a n t s ) ,

a l e c t u r e r , two NHS c o n s u l t a n t p s y c h i a t r i s t s , two c o n s u l t a n t

p s y c h o t h e r a p i s t s , two s e n i o r r e g i s t r a r s , three r e g i s t r a r s and t h ree

s e n i o r house o f f i c e r s ( S H O ' s ) . There are a l s o p s y c h o l o g i s t s , s o c i a l

wo r ke r s , o c c u p a t i o n a l and a r t t h e r a p i s t s , n u r s i n g and a u x i l i a r y s t a f f

a v a i l a b l e .

T h i s i s a g e n e r a l p s y c h i a t r i c u n i t o f a d i s t r i c t g e n e r a l h o s p i t a l

o p e r a t i n g a l s o a s a " t h e r a p e u t i c m i l i e u " under the g u i d e l i n e s o f

t h e r a p e u t i c community p r i n c i p l e s , i n a ve ry broad and e c l e c t i c s e n s e .

63

P h y s i c a l methods o f t reatment a s w e l l a s behav iour therapy and

psychodyr.amic p s ycho the rapy i n an i n d i v i d u a l or g roup b a s i s

a re p r o v i d e d .

Community meet ings a re h e l d week l y . Groups f o r each o f the four

c o n s u l t a n t f i r m s , p r e - d i s c h a r g e g r o u p s , o c c u p a t i o n a l and a r t t he rapy

s e s s i o n s a re a l s o i n o p e r a t i o n .

Community n u r s i n g ca re i s a l s o a v a i l a b l e w i th the purpose o f c o n t i n u i n g

the h o s p i t a l based t r ea tment , and to a s s i s t the assessment o f p a t i e n t s

i n t h e i r own env i ronment .

A l l the s u b j e c t s who p a r t i c i p a t e d i n the s tudy were p a t i e n t s o f

S t . M a r y ' s H o s p i t a l , P s y c h i a t r i c Department, most o f them from

the P r o f e s s o r i a l U n i t .

Because o f d i f f i c u l t i e s i n o b t a i n i n g s u f f i c i e n t number o f p a t i e n t s

from the P r o f e s s o r i a l U n i t , the c o n s u l t a n t s o f the o the r f i r m s were

approached and w i t h t h e i r c o - o p e r a t i o n p a t i e n t s from t h e i r f i r m s

p a r t i b i p a t e d i n the s t u d y .

The p a t i e n t s were s e l e c t e d a s c o n s e c u t i v e s e r i e s o f those admi t ted .

I t was i n tended tha t a l l the c a s e s s hou l d be newly admitted though not

n e c e s s a r i l y f i r s t p s y c h i a t r i c a d m i s s i o n s o n l y . Each p a t i e n t was f u l l y

in formed about the pu rpo se s o f t h i s work.

C r i t e r i a f o r i n c l u s i o n to the s t u d y were age . between 16 and 70 y e a r s

and a b i l i t y to co -ope ra te i n the t e s t i n g p rocedure . I l l i t e r a t e s and

64 '

p a t i e n t s w i t h l a n g u a g e p r o b l e m s were e x c l u d e d f r o m t h e s t u d y . P a t i e n t s

w i t h o r g a n i c b r a i n d i s e a s e a n d menta l d e f i c i e n c y were a l s o e x c l u d e d .

D i a g n o s e s were d e c i d e d i n t h e ward r o u n d s , a t t e n d e d b y the

c o n s u l t a n t p s y c h i a t r i s t i n c h a r g e o f t h e f i r m , t h e s e n i o r r e g i s t r a r ,

r e g i s t r a r o r t h e SHO, t h e s o c i a l w o r k e r , t he o c c u p a t i o n a l t h e r a p i s t and

t h e n u r s e s . The c l i n i c a l d i a g n o s e s o f a l l t he p a r t i c i p a t i n g p a t i e n t s

were g i v e n i n t h i r t y s i x d i f f e r e n t t e r m i n o l o g i c a l f o r m s ( T a b l e 2 )

but i t was d e c i d e d , f o r p r a c t i c a l r e a s o n s , t o merge t h e s e l a b e l s i n t o

t w e l v e d i a g n o s t i c c a t e g o r i e s .

; ! 5 . 2 . M e a s u r i n g I n s t r u m e n t s U s e d and t h e i r A d m i n i s t r a t i o n

The p s y c h o m e t r i c i n s t r u m e n t s u s e d were t h e H o s t i l i t y and D i r e c t i o n o f

H o s t i l i t y Q u e s t i o n n a i r e (HDHQ), ( C a i n e et a l . 1 967 ) and the D e l u s i o n s

Symptoms S t a t e s I n v e n t o r y ( D S S l / R ) , ( B e d f o r d and F o u l d s , 1 9 7 8 a ) .

/

The HDHQ c o n s i s t s o f 5 2 i t e m s p r e s e n t e d i n f i v e s u b s c a l e s . T h r e e

s u b s c a l e s , a c t i n g - o u t h o s t i l i t y ( A H ) , c r i t i c i s m o f o t h e r s (CO) and

p a r a n o i d h o s t i l i t y ( PH ) a r e mea su re s o f e s r f c r apun i t i vene s s . Two s c a l e s ,

s e l f - c r i t i c i s m ( S C ) and d e l u s i o n a l g u i l t ( g ) measure i n t r o p u n i t i v e n e s s .

T o t a l h o s t i l i t y i s t h e sum o f a l l t h e f i v e s u b s c a l e s .

The DSS l / l t c o n t a i n s 84 i t e m s , d i v i d e d i n t o t w e l v e s e t s o f s e v e n i t e m s

each . T h e s e s e t s a r e : d e l u s i o n s o f d i s i n t e g r a t i o n ( D D ) , d e l u s i o n s of

p e r s e c u t i o n ( d P ) , d e l u s i o n s o f g r a n d e u r ( d G ) , d e l u s i o n s o f c o n t r i t i o n

( d C ) , c o n v e r s i o n symptoms ( P S ) , d i s s o c i a t i v e symptoms ( D S ) , p h o b i c

65

symptoms (FS), c o m p u l s i v e symptoms (cs), r u m i n a t i v e symptoms (RS),

s t a t e o f a n x i e t y ( s A ) , s t a t e o f d e p r e s s i o n ( s D ) , s t a t e o f e l a t i o n ( s E ) ,

The q u e s t i o n n a i r e s were a d m i n i s t e r e d d u r i n g the f i r s t week o f a d m i s s i o n

and t h e p l a n was f o r them t o "be comp le ted e v e r y f i v e weeks , u n t i l

t h e d i s c h a r g e o f t h e p a t i e n t .

S i n c e a l l t h e c a s e s were t e s t e d w i t h i n a week o r so a f t e r a d m i s s i o n

t h e y were v i r t u a l l y u nde r no t r e a t m e n t , except i n so f a r a s some migh t

have been o n m e d i c a t i o n a s o u t - p a t i e n t s . No EOT was a d m i n i s t e r e d

b e f o r e t h e c o m p l e t i o n o f the- f i r s t q u e s t i o n n a i r e s .

The s c o r i n g o f t h e HDHQ was c a r r i e d ou t r e g u l a r l y d u r i n g t h e s t a y o f

t h e p a t i e n t i n t h e D e p a r t m e n t . The D S S l / R , a l t h o u g h a d m i n i s t e r e d

t o t h e p a t i e n t a t t h e same t i m e w i t h t h e HDHQ, was no t s c o r e d u n t i l

a f t e r t h e d i s c h a r g e o f t h e p a t i e n t and t h e e s t a b l i s h m e n t o f t h e

c l i n i c a l d i a g n o s i s , i n o r d e r t o a v o i d c o n t a m i n a t i o n o f t h e c l i n i c a l

d i a g n o s i s .

0

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5 . 3 . D a t a P r o c e s s i n g and A n a l y s i s

I n o r d e r t o examine t h e e x t e n t t o w h i c h change s o f c e r t a i n D S S l / R

s e t s a r e a s s o c i a t e d w i t h c h a n g e s o f c e r t a i n HDHQ s u b s c a l e s , we had :

1 . t o c a l c u l a t e t h e d i f f e r e n c e s o f t h e s c o r e s o f t h e p a r t i c u l a r

HDHQ s u b s c a l e s and D S S l / R s e t s ( e . g . t h e a c t i n g - o u t h o s t i l i t y s c o r e

o f a p r e c e d i n g , m inus t h e a c t i n g - o u t h o s t i l i t y s c o r e o f a f o l l o w i n g

q u e s t i o n n a i r e ) a nd 2 . t o c a l c u l a t e t h e c o r r e l a t i o n c o e f f i c i e n t s

between t h e s c o r e d i f f e r e n c e s o f t h e HDHQ s u b s c a l e s and t h e D S S l / R

s e t s .

The s c o r e s were e n t e r e d onto ' d a t a s h e e t s and f r o m them t r a n s f e r r e d t o

c o d i n g f o r m s . P rom t h e c o d i n g f o r m s t h e d a t a were encoded o n 80 -

co lumn punched c a r d s w h i c h c a n be r e a d b y t he computer p e r i p h e r a l s

d i r e c t l y . A doub l e m a s t e r deck o f c a r d s was p r e p a r e d t o m i n i m i z e t h e

e f f e c t s o f a n y l o s s o r damage o f t h e o p e r a t i o n a l deck o f c a r d s .

E a c h p e r s o n t h a t p a r t i c i p a t e d i n t h e p r o j e c t was a l l o t t e d a u n i q u e

i d e n t i f i c a t i o n number. Numbers were a l s o a l l o c a t e d t o each a n s w e r ,

f o r t h e p u r p o s e o f d a t a p r o c e s s i n g . F o r i n s t a n c e , male s e x was

r e c o r d e d a s 1 and f e m a l e s e x a s 2. O t h e r a l l o c a t i o n s were a l s o

a r b i t r a r y ( e . g . o u t - p a t i e n t a s 1 , d a y - p a t i e n t a s 2 , i n - p a t i e n t a s

3 ) bu t some were more l o g i c a l ( e . g . a g e , i n y e a r s , c a l c u l a t e d f r o m

da te o f b i r t h ) . The d a t a t o o k t h e f o r m o f p o s i t i v e i n t e g e r s , e x c e p t

f o r t h e d i r e c t i o n o f h o s t i l i t y s c o r e s , where n e g a t i v e i n t e g e r s c o u l d

be f o u n d . I n A p p e n d i x D , t h e k e y t o t h e c o d i n g o f i n f o r m a t i o n u s e d

i n t h e d a t a t a b l e s i s f u l l y p r e s e n t e d , w i t h t he mean ing o f a l l t h e

a b b r e v i a t i o n s u s e d .

67

Repeated checks o f accuracy, were made u n t i l the data l i s t s were

rega rded a s " c l e a n " . The f i n a l s t a g e s o f t h i s p r o ce s s i n c l u d e d the

p r e p a r a t i o n o f f requency d i s t r i b u t i o n t a b l e s , measures o f c e n t r a l

t endenc i e s and r a n g e s . The c l e a n data were then a v a i l a b l e f o r the

s t a t i s t i c a l a n a l y s i s wh ich i n v o l v e d d e s c r i p t i o n o f the raw da ta ,

p r e p a r a t i o n o f f u r t h e r d e s c r i p t i v e s t a t i s t i c s , con t i ngency t a b l e s

and i n f e r e n t i a l s t a t i s t i c s .

A b a t t e r y o f program s c a l l e d S t a t i s t i c a l Package f o r the S o c i a l

S c i e n c e s ( S P S S ) , (N ie et a l . 1975) i s a v a i l a b l e on the U n i v e r s i t y

o f London Computer, S t . M a r y ' s H o s p i t a l Med i ca l S choo l p e r i p h e r a l ,

which took the data on the 80 -co lumn punched c a r d s , p repared

d e s c r i p t i v e s t a t i s t i c s , c o n t i n g e n c y t a b l e s and i n f e r e n t i a l

s t a t i s t i c s and p r i n t e d out the a s s o c i a t e d p r o b a b i l i t y v a l u e s .

I n c o n s i d e r i n g the a p p r o p r i a t e methods f o r a n a l y s i s o f the da ta ,

i t i s impor tant to r e c o g n i s e t h a t t he re a re few a s sumpt ions tha t can

be made about the p o p u l a t i o n from wh ich t h i s sample was drawn. I n

p a r t i c u l a r few i f any o f the v a r i a b l e s recorded can be assumed to

come from a no rma l l y d i s t r i b u t e d p o p u l a t i o n .

I t i s r a r e to f i n d tha t the r e s u l t s a re so s t r i k i n g that one can

a v o i d u s i n g i n f e r e n t i a l s t a t i s t i c s to a s s e s s the r e su l t s * . I f they a re

t ha t s t r i k i n g , then the s t a t i s t i c a l i n f e r e n c e s a re s t i l l p re sent but

a re i m p l i c i t r a t h e r than e x p l i c i t . One i s u s u a l l y faced w i t h

o b s e r v a t i o n s c a t e g o r i s e d a s above and the t a s k o f s e l e c t i n g an

a p p r o p r i a t e a n a l y s i s f o r the da ta .

68

The data take s e v e r a l fo rms r a n g i n g from measurements on an equal

i n t e r v a l s c a l e ( e . g . a g e , l e n g t h o f e l ap sed t ime) th rough rank

o rdered c a t e g o r i e s a s i n the d e r i v e d s c o r e s , down to d i cho t cm ie s

( e . g . male or f ema le ) . T h u s , a d i f f e r e n t type o f s t a t i s t i c a l

a n a l y s i s r e q u i r e d f o r each . Rank o rde red c a t e g o r i e s r ep re sen t the

o r d i n a l l e v e l o f measurement. With a r a t i n g s c a l e which goes from

1 to 3 ( e . g . on D S S I / R ) one assumes tha t a per son i n ca tego r y 3 i s

worse than i n ca tego ry 1. One i s not j u s t i f i e d i n a s suming , however,

that a pe r son i n c a t e g o r y 2 i s tw ice a s bad ly o f f a s one i n c a t e go r y

1. Some data a re mere l y nom ina l .

S t r i c t l y s p e a k i n g , p a r ame t r i c s t a t i s t i c s , u s i n g mfeans, s t anda rd

d e v i a t i o n s e t c , ( e . g . a n a l y s i s o f v a r i a n c e , s t uden t s Jfc and P e a r s o n ' s

c o r r e l a t i o n c o e f f i c i e n t ) are on l y a p p l i c a b l e to the f i r s t type o f

measurement - equa l i n t e r v a l s c a l e s - such a s l e n g t h o f t ime and

age . Even then they make a s s umpt i on s about the u n d e r l y i n g d i s t r i b u t i o n s

o f these v a r i a b l e s t h a t may w i l l no t be j u s t i f i e d i n the i n d i v i d u a l

s t u d y .

A s i n most s i m i l a r t e s t s , the s c o r e s s h o u l d be c on s i de r ed as ranked

ca tego r i e s , r a t h e r than equa l i n t e r v a l s c a l e s and f o r the a n a l y s i s a.

non -pa ramet r i c s t a t i s t i c i s t h e r e f o r e r e q u i r e d ( S i e g e l , 1956b) .

On the whole i t i s more a p p r o p r i a t e to use non -pa ramet r i c s t a t i s t i c s .

T h e i r t i t l e emphas izes t h a t they do not depend f o r t h e i r accu racy

on a s sumpt ion s about the behav iou r o f the parameters o f the u n d e r l y i n g

p o p u l a t i o n . Fo r i n s t a n c e they do no t r e q u i r e t h a t the sample be

drawn from a p o p u l a t i o n whose v a r i a b l e s might be expected to be normal ly

d i s t r i b u t e d .

69

The commonest non -pa ramet r i c t e s t o f s i g n i f i c a n c e used f o r d e a l i n g

w i t h d a t a . i n d i s c r e t e c a t e g o r i e s i s p robab l y the c h i - s q u a r e t e s t .

T h i s e s t i m a t e s the l i k e l i h o o d o f a g i v e n combinat ion o f ca se s

entered i n the c e l l s o f a c on t i n gency t a b l e . However, when the

number o f deg rees o f freedom i s more than one, c h i - s q u a r e t e s t s

s u f f e r from the de fec t t h a t they a re i n s e n s i t i v e to the e f f e c t o f

o rde r ( S i e g e l , 1956b) .

A more power fu l i n s t r ument f o r the e s t i m a t i o n o f the s t r e n g t h o f

a s s o c i a t i o n betv/een two v a r i a b l e s , would be a rank o rde r c o r r e l a t i o n

u s i n g Spea rman ' s rho o r K e n d a l l ' s tau f o r t i e d r ank s ( K e n d a l l , 1 962 ) .

These rank o r de r c o r r e l a t i o n methods, make no assumption about the

f requency d i s t r i b u t i o n o f the p p u l a t i o n from which the s c o r e s were

drawn, a re a p p r o p r i a t e f o r the o r d i n a l l e v e l o f measurement and i n

a d d i t i o n , w i l l g i v e a measure o f the degree o f a s s o c i a t i o n o r c o r r e l a t i o n

between the two s e t s o f r a n k s . The main d i f f e r e n c e s between

Spea rman ' s r ho and K e n d a l l ' s t au seem to be t ha t the K e n d a l l ' s

c o e f f i c i e n t s a re somewhat more mean ing fu l when the data c o n t a i n a

l a r g e number o f t i e d r a n k s .

The t e s t u sed i n t h i s s t udy was K e n d a l l ' s t au f o r t i e d r ank s

( K e n d a l l , 1962; S i e g e l , 1 956b ) . The case f o r u s i n g t h i s w i t h

p sychomet r i c data h a s been a r gued be fo re (Ro s s and F r i e s t , 1970; P r i e s t

1969b, 1971, 1976 ) . B r i e f l y i t i s a c o e f f i c i e n t o f a s s o c i a t i o n

tha t makes no a s sumpt i on s about the n o r m a l i t y o f the u n d e r l y i n g

d i s t r i b u t i o n o f the data ( o t he r t h a n tha t can be seen a s c a t e g o r i e s

ranked i n o r d e r ) i t i s a p p r o p r i a t e f o r the o r d i n a l l e v e l o f

measurement ( e . g . rank on one to t h r ee on a r a t i n g s c a l e ) i t does not

70

g i v e undue va l ue to o u t l y i n g scorer;, g i v e s c o e f f i c i e n t s o f r a n k -

ordered c o r r e l a t i o n s and a l e v e l o f s t a t i s t i c a l s i g n i f i c a n c e and a l l o w s

a p a r t i a l c o r r e l a t i o n c o e f f i c i e n t to be c a l c u l a t e d i f n e c e s s a r y . I t

ha s the advantage over S p e a r m a n ' s rho o f h a v i n g a c a l c u l a t e d s amp l i ng

d i s t r i b u t i o n which i s p r a c t i c a l l y i n d i s t i n g u i s h a b l e from normal

d i s t r i b u t i o n f o r sample s i z e s a s s m a l l a s 9» S i n c e the sampl ing

d i s t r i b u t i o n o f K e n d a l l ' s t a u f o r samples above that number approx imates

very c l o s e l y to the normal d i s t r i b u t i o n the s t a t i s t i c a l s i g n i f i c a n c e '

o f a f i n d i n g may be determined from t a b l e s . F o r each cont ingency t a b l e

then, one ha s a c o r r e l a t i o n c o e f f i c i e n t and a l e v e l o f p r o b a b i l i t y .

K e n d a l l ' s tau then may be u sed to t e s t the n u l l h y p o t h e s i s tha t the tv/o

v a r i a b l e s under c o n s i d e r a t i o n are u n r e l a t e d i n the p o p u l a t i o n .

Apar t from K e n d a l l ' s t a u , S p e a r m a n ' s rho and P e a r s o n ' s r c o r r e l a t i o n

c o e f f i c i e n t s have a l s o been produced, and a l l those r e s u l t s are

p resented f o r i n f o r m a t i o n i n Appendix C. Cur c o n s i d e r a t i o n s and

c o n c l u s i o n s , however, a re based on K e n d a l l ' s t au c o r r e l a t i o n

c o e f f i c i e n t s .

The data a re d i s p l a y e d i n t a b l e s . D e s c r i p t i v e s t a t i s t i c s ( e . g . mean,

s t anda rd d e v i a t i o n ) are a p p l i e d a c c o r d i n g to the l e v e l o f measurement.

Fo r i n f e r e n t i a l s t a t i s t i c s K e n d a l l ' s tau and Spea rman ' s rho w i l l be

d i s p l a y e d f o r the c o r r e s p o n d i n g v a r i a b l e s w i th the l e v e l o f

s i g n i f i c a n c e g i v e n i n te rms o f e q u a l i t y ( e . g . P = 0 . 0 0 1 ) .

One problem to be c o n s i d e r e d i s i n which form the data cou ld be

p re sented . On the one hand maximum i n f o r m a t i o n i s p re se rved by

l e a v i n g data i n t h e i r o r i g i n a l form. T h i s cou ld r e s u l t i n a g r ea t

71

a m p l i f i c a t i o n o f t h e vo lume o f t h i s t h e s i s and i t seemed t h a t

i t was n e c e s s a r y t o c o n d e n s e t h e r e s u l t s t o some e x t e n t . T h e r e f o r e ,

where t h e r e s u l t s a p p r o a c h s t a t i s t i c a l s i g n i f i c a n c e t h i s i s

m e n t i o n e d and t h e v a l u e o f t a u and t h e l e v e l o f s i g n i f i c a n c e

i s g i v e n . The who le o f t h e d a t a i s g i v e n at t h e end o f t h e

t h e s i s i n A p p e n d i x F$ i n A p p e n d i x C a l l t h e o b t a i n e d c o r r e l a t i o n

c o e f f i c i e n t s w i t h t h e p r o b a b i l i t y v a l u e s a re d i s p l a y e d . O n l y

t a b l e s o f p a r t i c u l a r i n t e r e s t a r e r e p r o d u c e d .

A l t h o u g h o f t e n P » 0 . 0 0 5 i s r e g a r d e d a s s t a t i s t i c a l l y " s i g n i f i c a n t "

i

and P as 0 . 0 1 a s " v e r y s i g n i f i c a n t " i n - t h i s s t u d y t h e r e a re very-

l a r g e number o f s i g n i f i c a n t r e s u l t s and t h e P v a l u e s a r e v e r y

t i n y i n d e e d . I t was t h e r e f o r e deemed n e c e s s a r y t o t r y t o

d i s c r i m i n a t e be tween t h e s e r a t h e r t h a n lump e v e r y t h i n g be l ow

0 . 0 1 t o g e t h e r .

F o r t h e above r e a s o n s we d e s c r i b e , f o r t h i s s t u d y , c o r r e l a t i o n s

o f P = 0 . 0 0 1 a s b e i n g o f h i g h s t a t i s t i c a l s i g n i f i c a n c e ( * * * * * ) .

Where P = 0 . 0 0 2 - 0 . 0 0 5 i t i s d e s c r i b e d a s h a v i n g a moderate

( * * * * ) s t a t i s t i c a l s i g n i f i c a n c e . Where P «= 0 . 0 0 6 - 0 . 0 0 9

t h e c o r r e l a t i o n i s r e g a r d e d a s h a v i n g l ow ( * * * ) s t a t i s t i c a l

s i g n i f i c a n c e . Where P = Q01O - 0 . 0 2 0 we t a l k about v e r y l ow

( * * ) s t a t i s t i c a l s i g n i f i c a n c e . C o r r e l a t i o n c o e f f i c i e n t s w i t h

P = 0 . 0 2 1 - 0 . 0 5 0 a r e r e g a r d e d a s b o r d e r i n g o n t he a c c e p t e d

l e v e l o f s t a t i s t i c a l s i g n i f i c a n c e ( * ) .

T h i s a l l o c a t i o n w o u l d a p p e a r t o make d e s c r i p t i v e s e n s e o f

t h e r a n g e o f p r o b a b i l i t i e s f o u n d w i t h t h e i n f e v e n t i a l s t a t i s t i c s

f o r t h e d a t a i n t h i s s t u d y .

72

SUMMARY

T h i s s tudy was c a r r i e d out i n the P s y c h i a t r i c Department o f

S t . M a r y ' s H o s p i t a l , London, W.9.

The s e l e c t i o n o f s u b j e c t s and t h e i r p a r t i c i p a t i o n i n the s tudy

are de s c r i bed .

A b r i e f account o f the H o s t i l i t y and D i r e c t i o n of H o s t i l i t y

Que s t i onna i r e (HDHQ) and the D e l u s i o n s Symptoms S t a t e s I n ven t o r y

(DSS I/R ) and t h e i r a d m i n i s t r a t i o n to the p a t i e n t s i s g i v e n .

'' I I

A l s o , b r i e f l y , the s t a t i s t i c a l approach to the data obta ined i s

d i s c u s s e d .

73

6 . RESULTS

T h e r e were f o u r p o i n t s o f e x a m i n a t i o n o f t h e r e l a t i o n s between t h e

s c o r e c h a n g e s o f t h e HDHQ s u b s c a l e s and t h e D S S l / R s e t s , and t h e y

have been named a s s t u d y - p o i n t I , s t u d y - p o i n t I I , s t u d y - p o i n t I I I

and s t u d y - p o i n t I V ,

I n s t u d y - p o i n t I t h e r e i s a g r o u p o f 73 p a t i e n t s who comp le ted a f i r s t

and s e c o n d b a t t e r y o f q u e s t i o n n a i r e s ; t h e g r o u p o f 35 p a t i e n t s who

c o m p l e t e d a s e c o n d and a t h i r d b a t t e r y o f q u e s t i o n n a i r s i s named

a s s t u d y - p o i n t I I ; t h e g r o u p o f 17 p a t i e n t s who comp le ted a t h i r d and

a f o u r t h q u e s t i o n n a i r e i s r e g a r d e d a s s t u d y - p o i n t I I I and t h e g r o u p

o f 1 1 p a t i e n t s who c o m p l e t e d a f o u r t h and a f i f t h b a t t e r y o f q u e s t i o n n a i r e s

i s r e g a r d e d a s s t u d y - p o i n t I V ,

T h u s , i n s t u d y - p o i n t I t h e p a r t i c i p a t i n g p a t i e n t s comp le ted two

b a t t e r i e s o f q u e s t i o n n a i r e s . I n s t u d y - p o i n t I I t h e y comp le ted t h r e e

b a t t e r i e s o f q u e s t i o n n a i r e s . I n s t u d y - p o i n t I I I t h e y comp le ted f o u r

b a t t e r i e s o f q u e s t i o n n a i r e s a n d i n s t u d y - p o i n t I V t h e y comp le ted f i v e

b a t t e r i e s o f q u e s t i o n n a i r e s . I t i s e v i d e n t t h a t t h e e x a m i n a t i o n o f

t h e r e l a t i o n s between t h e s c o r e c h a n g e s o f t h e HDHQ s u b s c a l e s and t he

D S S l / R s e t s t o o k p l a c e , i n e a c h s t u d y - p o i n t , between t h e l a s t two

b a t t e r i e s o f q u e s t i o n n a i r e s .

A n o t h e r way t o examine t h e r e l a t i o n between s c o r e change s o f HDHQ

s u b s c a l e s and D S S l / R s e t s w o u l d be t o s t u d y t h e s c o r e d i f f e r e n c e s

between t h e f i r s t and t h e l a s t q u e s t i o n n a i r e s , r e g a r d l e s s o f t h e

t ime i n t e r v a l s . T h i s i s an i n t e r e s t i n g way o f a p p r o a c h i n g t he

p rob l em but we h a d t o a v o i d i n c o r p o r a t i n g s u ch an e x a m i n a t i o n i n t o

74

t h i s s tudy because i t v/ould i n v o l v e l a r g e amounts o f data w i t h

s t a t i s t i c a l and o the r m a t e r i a l and would i n c r e a s e the l e n g t h o f

t h i s t h e s i s to an unaccep tab le degree .

One hundred and f i f t y one p a t i e n t s completed the two q u e s t i o n n a i r e s

f o r the f i r s t t ime. 73 p a t i e n t s ( ^8 percent ) completed the q u e s t i o n n a i r e s

f o r a second t ime. 35 (23 pe r cen t ) f o r a t h i r d t ime. 17 p a t i e n t s

( 1 1 . 25 pe r cen t ) f o r a f o u r t h and 11 ( 7 - 30 pe rcen t ) completed the

q u e s t i o n n a i r e s f o r a f i f t h t ime (Tab le 3 )«

S e v e n t y - e i g h t p a t i e n t s v/ere exc luded from the s t udy because they

f a i l e d to complete the second s e r i e s o f the q u e s t i o n n a i r e s . From

those p a t i e n t s , 3& were d i s c h a r g e d be fo re the e l ap se o f f ou r weeks;

another g roup o f 3$ p a t i e n t s d i d not complete one o r both o f the

q u e s t i o n n a i r e s f o r the second time e i t h e r because they were p revented

to do so by t h e i r p s y c h i a t r i c c o n d i t i o n o r because they r e f u s e d ,

i n v a r i o u s v/ays, to c o n t i n u e t h e i r c o - o p e r a t i o n . One p a t i e n t was

exc luded because he s u f f e r e d from an a l c o h o l i c p s y c h o s i s and another

one because o f h i s menta l d e f i c i e n c y .

The sample o f the p a t i e n t s who con t i nued t h e i r p a r t i c i p a t i o n c o n s i s t e d

then o f 73 c a s e s . However, two o f the p a t i e n t s were d i s c ha r ged a f t e r

comple t ing the t h i r d b a t t e r y o f q u e s t i o n n a i r e s and about s i x months

l a t e r they were readmi t ted and each o f thern completed another two

b a t t e r i e s o f q u e s t i o n n a i r e s . I t was decided f o r each o f those

p a t i e n t s to be rega rded a s p a r t i c i p a t e d i n two d i f f e r e n t s e r i e s o f

measurements. Thus , a l t h o u g h the number o f ca se s i s 73 i the

a c t u a l number o f the p a t i e n t s p a r t i c i p a t i n g i n t h i s s t udy i s 71•

75

As f a r a s the c l i n i c a l s t a t u s o f the p a t i e n t s i s concerned, the

f i r s t two q u e s t i o n n a i r e s were completed by 52 i n - p a t i e n t s , 17 day -

p a t i e n t s and fou r f o l l o w - u p p a t i e n t s . The second b a t t e r y was

completed by 47 i n - p a t i e n t s , 19 d a y - p a t i e n t s and seven o u t - p a t i e n t s .

The t h i r d was completed by 19 i n - p a t i e n t s , 12 d a y - p a t i e n t s and f o u r

o u t - p a t i e n t s . The f o u r t h by seven i n - p a t i e n t s and e i g h t d a y - p a t i e n t s

and two o u t - p a t i e n t s . The f i f t h q u e s t i o n n a i r e s were completed by

f ou r i n - p a t i e n t s and s even d a y - p a t i e n t s (Tab le 4 ) .

The time tha t e l ap sed between the f i l l i n g o f the q u e s t i o n n a i r e s was,

i n ve ry few c a s e s , r a t h e r l o n g (more than 100 days ) o r qu i t e s m a l l

( l e s s than 20 d a y s ) ; i n s t u d y - p o i n t I i n three c a s e s ( 4 . 1 pe r cen t )

the time i n t e r v a l between the comp le t i on o f the q u e s t i o n n a i r e s was

l e s s than 20 days and i n f i v e c a s e s ( 6 . 5 pe rcent ) was more than

100 d a y s . We dec ided , however, not to r e j e c t those p a t i e n t s from

the s tudy because t h e i r number i s r e l a t i v e l y s m a l l . G e n e r a l l y , most

o f the p a t i e n t s completed t h e i r q u e s t i o n n a i r e s a t a t ime o f about

40 days a f t e r the p r e v i o u s one. More s p e c i f i c a l l y the second

q u e s t i o n n a i r e s were completed a f t e r a mean time o f 42 .4 ( s . d . 2 4 . 1 )

day s , a f t e r the comple t ion o f the f i r s t ; the t h i r d a f t e r a mean

time o f 3 5 - 5 ( s . d . 16 . 9 ) from the complet ion o f the second; the

f o u r t h , a f t e r a mean t ime o f ( s . d . 15 -4 ) days from the comp le t i on

o f the t h i r d and the f i f t h a f t e r a mean o f 47 .6 ( s . d . 33 -3 ) days

from the complet ion o f the f o u r t h (Tab le s 5 and 6 ) .

A s f a r a s the time o f s t a y i n the h o s p i t a l i s concerned, ^rom the

time o f a d m i s s i o n to the t ime o f d i s c h a r g e , i f we exc lude the 3,Q'

pa t ien t s , who f o r v a r i o u s r e a s o n s were not a v a i l a b l e f o r p a r t i c i p a t i o n

76

i n the s t udy and f o r whom v/e do not have the nece s s a r y ev idence ,

the r ema in i ng 111 p a t i e n t s ( t h o s e who completed even o n l y one

b a t t e r y o f q u e s t i o n n a i r e s i n c l u d e d ) remained i n the h o s p i t a l a s

f o l l o w s : p a t i e n t s f o r l e s s than k weeks; 21 p a t i e n t s f o r a time

between - 6 weeks; 17 p a t i e n t s f o r 7 - 9 weeks; 1 0 , f o r 10 - 12

weeks; s i x , f o r 13 - 13 weeks; e i g h t , f o r 16 - 18 v/eeks and f i v e ,

f o r 19 - 21 weeks. T h i s makes up the 97 -3^ o f the p a t i e n t s . Four

p a t i e n t s (2 .7/0 remained i n the h o s p i t a l f o r a time from 22 to

50 weeks. ( F i g u r e 1 ) .

77

6 . 1 . S t u d y - p o i n t I

The c o r r e l a t i o n c wh ich were ob se r ved between the s co re changes o f

HDHQ s u b s c a l e s and DS S I /R s e t s i n the g roup o f p a t i e n t s who completed

a f i r s t and a second b a t t e r y o f q u e s t i o n n a i r e s a re examined a t t h i s

s t u d y - p o i n t .

S e v e n t y - t h r e e p a t i e n t s p a r t i c i p a t e d at t h i s s t u d y - p o i n t , 32 males

and M females and they were a l l o c a t e d to 12 c l i n i c a l d i a g n o s t i c c a t e g o r i e s

a c c o r d i n g to the d i a g n o s e s they r e c e i v e d on d i s c ha r ge (Tab le ? ) • The

d i a g n o s i s o f n e u r o t i c d e p r e s s i o n w i t h or w i thout p e r s o n a l i t y d i s o r d e r

i s g i v e n to 29 p a t i e n t s ( 3 S . 8 p e r c e n t ) ; three d i a g n o s t i c c a t e g o r i e s

b e l o n g i n g to the s c h i z o p h r e n i c framework ( pa r ano i d s c h i z o p h r e n i a ,

s c h i z o a f f e c t i v e d i s o r d e r , s c h i z o p h r e n i a ) c o n s t i t u t e a g roup o f 29

p a t i e n t s ( 3 8 * 8 p e r c e n t ) . The r ema i n i n g 13 p a t i e n t s are a l l o c a t e d t o

the o the r seven d i a g n o s t i c c a t e g o r i e s .

The ages o f these p a t i e n t s ranged from 17 to 68 w i th a mean age o f

35 * 2 ( s . d . 1 2 . 2 ) . The most f r equent age ca tego ry was 17 - 29

y e a r s (Tab le 9 ) .

Most o f them completed the f i r s t q u e s t i o n n a i r e s a s i n - p a t i e n t s . The

change o f t h e i r c l i n i c a l s t a t u s on the complet ion o f the second

q u e s t i o n n a i r e s does not seem to be i m p r e s s i v e ; on l y a sma l l number

moved from the i n - p a t i e n t towards the day and o u t - p a t i e n t s t a t u s

(Tab le 8 ) .

78

The mean o f the e l ap sed t ime between the complet ion o f the

q u e s t i o n n a i r e s i s 42 .4 ( s . d . 2 4 . 1 ) d a y s . F i f t y - f i v e o f the

p a t i e n t s ( 7 5 * 3 pe r cen t ) completed the second q u e s t i o n n a i r e betv/een

21 and 49 days (Tab le 1 0 ) . The r e a s o n some p a t i e n t s completed the

second q u e s t i o n n a i r e s e a r l i e r i s t ha t these p a t i e n t s were about to

be d i s c h a r g e d .

A c c o r d i n g to t h e i r D S S I / R c l a s s a l l o c a t i o n s c o r e s , 37 p a t i e n t s

( 5 0 . 7 pe r cen t ) d i d not change c l a s s i n the second q u e s t i o n n a i r e ;

10 p a t i e n t s ( 13 -6 p e r c e n t ) moved from a lower to a h i g h e r c l a s s ,

i n d i c a t i n g an impa i rment; t w e n t y - s i x p a t i e n t s ( 3 6 . 6 pe rcent ) improved : I

by moving from h i g h e r c l a s s e s to l ower ones . The c l a s s a l l o c a t i o n

w i t h the c o r r e s p o n d i n g c l i n i c a l d i a g n o s e s and the c l a s s changes v/ith

the numbers o f the i n v o l v e d p a t i e n t s are p resented i n Tab le 11.

Three p a t i e n t s ( 4 . 1 p e r c e n t ) were a l l o c a t e d to C l a s s 0 ( n o n - p e r s o n a l l y

i l l ) a c c o r d i n g to the s c o r e s they ob ta ined i n the f i r s t D S S I / R . Two

were d i a gno sed a s s c h i z o p h r e n i c s and one was d iagnosed a s

n e u r o t i c a l l y dep re s sed . Two o f t h e s e p a t i e n t s changed c l a s s towards

C l a s s 1 (Dysthymic s t a t e s ) and C l a s s 2 (Neu ro t i c symptoms).

Ten p a t i e n t s ( 13 *6 p e r c e n t ) be longed to C l a s s 1 i n i t i a l l y . Four o f

them r e c e i v e d a c l i n i c a l d i a g n o s i s from the g roup o f s c h i z o p h r e n i a s ,

th ree were d i agno sed a s n e u r o t i c s and three r e c e i v e d o the r d i a g n o s e s .

S i x remained unchanged, th ree moved downwards and one moved upwards

i n the c l a s s h i e r a r c h y .

79

T w e n t y - f i v e p a t i e n t s ( 3 4 . 2 p e r c e n t ) were a l l o c a t e d t o C l a s s 2 .

F i f t e e n r e c e i v e d a d i a g n o s i s f r o m t h e n e u r o s e s , f i v e a d i a g n o s i s

f r o m t h e s c h i z o p h r e n i a s a n d f i v e r e c e i v e d o t h e r d i a g n o s e s . R e g a r d i n g

t h e i r c l a s s c h a n g e , 13 r e m a i n e d unchanged , s even moved down and f i v e

moved up t h e h i e r a r c h y .

E i g h t e e n p a t i e n t s ( 2 4 . 6 p e r c e n t ) were a l l o c a t e d t o C l a s s 3

( i n t e g r a t e d d e l u s i o n s ) . F i v e h a d a d i a g n o s i s o f s c h i z o p h r e n i a ,

t w e l v e a d i a g n o s i s o f n e u r o t i c d e p r e s s i o n w i t h o r w i t h o u t p e r s o n a l i t y

d i s o r d e r and one p e r s o n a l i t y d i s o r d e r . S e ven r e m a i n e d i n t he same

c l a s s , n i n e moved t o a l o w e r and two t o a h i g h e r c l a s s . i

j

S e v e n t e e n p a t i e n t s ( 2 3 . 3 p e r c e n t ) were a l l o c a t e d t o C l a s s 4

( d e l u s i o n s o f d i s i n t e g r a t i o n ) . T h i r t e e n o f them r e c e i v e d a

c l i n i c a l d i a g n o s i s f r o m t h e s c h i z o p h r e n i a s . F o r t h e o t h e r f o u r

t h e r e were t h e d i a g n o s e s : n e u r o t i c d e p r e s s i o n , m a n i c - d e p r e s s i v e

p s y c h o s i s (man i c p h a s e ) , n e u r o t i c a n x i e t y - p e r s o n a l i t y d i s o r d e r and

p e r s o n a l i t y d i s o r d e r . T e n o f t h o s e p a t i e n t s r ema i ned unchanged and

s e v e n moved t o a c l a s s l o w e r i n t h e h i e r a r c h y .

A l t h o u g h i t i s n o t c e n t r a l t o t h e p u r p o s e o f t h i s t h e s i s , i t i s o f

impo r t ance t o n o t e t h a t t h e r e i s a c o n s i d e r a b l e deg ree o f d i s a g r eemen t

between t h e c l i n i c a l d i a g n o s e s g i v e n b y t h e p s y c h i a t r i s t s a nd t h e DSSl/R

c l a s s a l l o c a t i o n s w h i c h r e s u l t e d f r o m t h e D S S l ( R ) s c o r e s o b t a i n e d by

t h e s e p a t i e n t s . F o r examp le , ( T a b l e 12 ) f r o m t h e 13 p a t i e n t s who

r e c e i v e d t h e c l i n i c a l d i a g n o s i s o f s c h i z o p h r e n i a o n l y f i v e have been

a l l o c a t e d t o C l a s s 4 a n d s i x r e p o r t e d no symptoms o r . s ymptoms o n l y

enough t o a l l o c a t e them t o c l a s s e s 1 and 2 . On t h e o t h e r hand f r o m

t h e 14 p a t i e n t s who r e c e i v e d t h e c l i n i c a l d i a g n o s i s o f n e u r o t i c

80

d e p r e s s i o n , none r e p o r t e d symptoms b e l o n g i n g m e r e l y t o C l a s s 1

but s i x r e p o r t e d symptoms b e l o n g i n g t o C l a s s 2 and s i x r e p o r t e d

symptoms s u f f i c i e n t t o a l l o c a t e them t o C l a s s 3 ; one r e p o r t e d no

symptoms and one was a l l o c a t e d t o C l a s s 4 . S i m i l a r d i s c r e p a n c i e s

have been o b s e r v e d i n p a t i e n t s who r e c e i v e d t h e d i a g n o s e s o f p a r a n o i d

s c h i z o p h r e n i a and n e u r o t i c d e p r e s s i o n - p e r s o n a l i t y d i s o r d e r .

The mean s c o r e s w h i c h were o b t a i n e d i n t h e HDHQ s u b s c a l e s and D S S l / R

s e t s o f t h e s e c o n d q u e s t i o n n a i r e s , compared w i t h t h o s e o f t h e f i r s t ,

i n d i c a t e a d r o p i n a l l t h e p u n i t i v e n e s s s c o r e s , except a c t i n g - o u t

h o s t i l i t y w h i c h i n c r e a s e d s l i g h t l y , and a d r op i n a l l symptom

s c o r e s ( T a b l e 1 3 ) .

The c h a n g e s o f t h e s t a t e o f a n x i e t y s c o r e s a r e f o u n d t o be c o r r e l a t e d

t o a h i g h l e v e l o f s i g n i f i c a n c e w i t h t h e change s o f t o t a l h o s t i l i t y

s c o r e s . C o r r e l a t i o n s o f a moderate l e v e l o f s i g n i f i c a n c e a r e

d e t e c t e d w i t h t h e c h a n g e s o f s e l f - c r i t i c i s m and t o t a l e x t r a p u n i t i v e n e s s

s c o r e s . C o r r e l a t i o n s w i t h c h a n g e s o f t o t a l i n t r o p u n i t i v e n e s s a n d

p a r a n o i d h o s t i l i t y , r e a c h e d a v e r y l ow l e v e l o f s i g n i f i c a n c e . A

c l o s e t o s i g n i f i c a n c e c o r r e l a t i o n w i t h a c t i n g - o u t h o s t i l i t y was a l s o

d e t e c t e d ( T a b l e 1 4 ) .

Change s o f t h e s t a t e o f d e p r e s s i o n s c o r e s a re c o r r e l a t e d t o a h i g h

l e v e l o f s i g n i f i c a n c e w i t h c h a n g e s o f a c t i n g - o u t h o s t i l i t y s c o r e s

and t o a moderate l e v e l o f s i g n i f i c a n e w i t h c hange s i n s e l f - c r i t i c i s m ,

t o t a l h o s t i l i t y and t o t a l i n t r o p u n i t i v e n e s s . The c o r r e l a t i o n w i t h

c h a n g e s i n t h e t o t a l e x t r a p u n i t i v e n e s s s c o r e s , r e a c h e d a v e r y l ow

l e v e l o f s t a t i s t i c a l s i g n i f i c a n c e ( T a b l e 1 5 ) .

81

Changes o f s t a t e o f e l a t i o n s co re s are c o r r e l a t ed to a h i g h l e v e l

o f s i g n i f i c a n c e w i th changes i n the s co re s o f parano id h o s t i l i t y ,

t o t a l h o s t i l i t y and t o t a l e x t r a p u n i t i v e n e s s . C o r r e l a t i o n s o f a

moderate l e v e l o f s i g n i f i c a n c e w i t h c r i t i c i s m o f o the r s score

changes and a n e g a t i v e ^ l o s e to s i g n i f i c a n c e , c o r r e l a t i o n w i th

d i r e c t i o n o f h o s t i l i t y were a l s o observed (Table 16 ) .

No correlations of statistical significance between score changes

of conversion symptoms (PS) and HDHQ subscales were observed.

D i s s o c i a t i v e symptoms s co re changes are c o r r e l a t ed to h i g h l e v e l s

o f s i g n i f i c a n c e w i th s c o r e changes on a c t i n g - ou t h o s t i l i t y , pa rano id

h o s t i l i t y , t o t a l h o s t i l i t y , t o t a l e x t r a p u n i t i v e n e s s and d i r e c t i o n

o f h o s t i l i t y , the l a s t c o r r e l a t i o n be ing nega t i ve . A c l o s e to

s i g n i f i c a n c e c o r r e l a t i o n w i t h c r i t i c i s m o f o the r s was a l s o

detected (Table 1 ? ) .

Changes o f phobic symptoms (FS ) s c o r e s are found to be c o r r e l a t e d

at a moderate l e v e l o f s i g n i f i c a n c e w i th changes o f t o t a l h o s t i l i t y

and t o t a l e x t r a p u n i t i v e n e s s s c o r e s and at a low l e v e l o f s i g n i f i c a n c e

w i th a c t i n g - o u t h o s t i l i t y . A c l o s e to s i g n i f i c a n c e c o r r e l a t i o n w i th

t o t a l i n t r o p u n i t i v e n e s s was a l s o detected(Table 18 ) .

Changes i n the s c o r e s o f compuls ive symptoms (CS) are found to be

c o r r e l a t e d to a h i g h l e v e l o f s i g n i f i c a n c e w i th changes i n the s c o r e s

on pa rano id h o s t i l i t y , t o t a l h o s t i l i t y and t o t a l e x t r a p u n i t i v e n e s s .

There i s a c o r r e l a t i o n o f moderate s i g n i f i c a n c e w i th changes i n

82

a c t i n g - o u t h o s t i l i t y s c o r e s . C o r r e l a t i o n s w i th changes o f g u i l t

and t o t a l e x t r a p u n i t i v e n e s s S c o r e s reach a very low l e v e l o f .

s i g n i f i c a n c e (Tab le 19)•

Changes o f r um ina t i v e symptoms s c o r e s are c o r r e l a t e d w i t h changes

o f p a r a n o i d h o s t i l i t y s c o r e s to a h i g h l e v e l of s i g n i f i c a n c e , w i t h

changes o f t o t a l h o s t i l i t y s c o r e s to a moderate l e v e l o f s i g n i f i c a n c e

and w i th changes o f t o t a l e x t r a p u n i t i v e n s s and a c t i n g - o u t h o s t i l i t y

s c o r e s to a v e r y low l e v e l o f s i g n i f i c a n c e . A c l o s e to s i g n i f i c a n c e

c o r r e l a t i o n w i t h g u i l t i s a l s o de tec ted (Table 2 0 ) .

D e l u s i o n s o f g randeur s c o r e changes a re c o r r e l a t e d w i t h t o t a l

e x t r a p u n i t i v e n e s s and d i r e c t i o n o f h o s t i l i t y s co re changes to a

v e r y low l e v e l o f s i g n i f i c a n c e , the second c o r r e l a t i o n b e i n g

n e g a t i v e . There i s a l s o a c l o s e t o s i g n i f i c a n c e c o r r e l a t i o n w i t h

pa rano id h o s t i l i t y (Tab le 2 1 ) .

Changes o f d e l u s i o n s o f p e r s e c u t i o n s c o r e s are c o r r e l a t e d to a

h i g h l e v e l o f s i g n i f i c a n c e w i t h changes i n pa rano id h o s t i l i t y s c o r e s .

A c l o s e to s i g n i f i c a n c e c o r r e l a t i o n w i t h a c t i n g - o u t h o s t i l i t y i s

a l s o ob se rved (Tab le 2 2 ) .

Changes o f d e l u s i o n s o f c o n t r i t i o n s c o r e s are found t o be c o r r e l a t e d to

moderate l e v e l s o f s i g n i f i c a n c e w i t h pa rano id h o s t i l i t y and g u i l t

s c o r e changes . A c l o s e to s i g n i f i c a n c e c o r r e l a t i o n w i t h t o t a l

i n t r o p u n i t i v e n e s s i s a l s o de tec ted (Table 2 3 ) .

Changes o f d e l u s i o n s o f d i s i n t e g r a t i o n s c o r e s are found to be

c o r r e l a t e d to a moderate l e v e l o f s i g n i f i c a n c e w i t h changes i n

pa r ano i d h o s t i l i t y s c o r e s . A n e g a t i v e c o r r e l a t i o n o f moderate

s i g n i f i c a n c e w i t h changes o f g u i l t s c o r e s , a c l o s e to s i g n i f i c a n c e

c o r r e l a t i o n w i t h t o t a l e x t r a p u n i t i v e n e s s and a n e g a t i v e c l o s e to

s i g n i f i c a n c e c o r r e l a t i o n w i t h d i r e c t i o n o f h o s t i l i t y a re a l s o

obse rved (Tab le 2b).

6 . 2 . S t u d y - p o i n t I I

84

T h i r t y - f i v e p a t i e n t s , 16 males and 19 females , c o n s t i t u t e d the g roup

o f s t u d y - p o i n t I I h a v i n g completed a second and a t h i r d b a t t e r y o f

q u e s t i o n n a i r e s .

The most f requent age c a t e g o r i e s were 19 - 29 and 40 - 49 w i t h

a range from minimum 17 y e a r s to maximum 65 y e a r s and a mean age

o f 3 4 . 6 ( s . d . 15 .5 ) y e a r s ( Tab le 2 5 ) .

A c c o r d i n g to the c l i n i c a l d i a g n o s e s they r e c e i v e d , they were

a l l o c a t e d to n i ne d i a g n o s t i c c a t e g o r i e s (Tab le 2 6 ) . Ten ( 25 . 6

pe r cen t ) r e c e i v e d on d i s c h a r g e the c l i n i c a l d i a g n o s i s o f n e u r o t i c

d e p r e s s i o n w i t h o r w i t hou t p e r s o n a l i t y d i s o r d e r . E i g h t e e n o f them

(51 .4 pe rcen t ) r e c e i v e d a d i a g n o s i s a t tached t o the three d i a g n o s t i c

c a t e g o r i e s r e l a t e d to s c h i z o p h r e n i a . The rema in ing seven p a t i e n t s

were a l l o c a t e d to the o t he r f i v e d i a g n o s t i c c a t e g o r i e s .

T h e i r c l i n i c a l s t a t u s was mo s t l y t h a t o f i n - p a t i e n t w i thout

s i g n i f i c a n t change when they completed the t h i r d q u e s t i o n n a i r e s ,

(Tab le 27 ) a l t h o u g h the re i s an o b v i o u s p r o g r e s s i o n from the i n -

p a t i e n t towards the day - and o u t - p a t i e n t s t a t u s .

The time e l ap s ed between the comp le t i on o f the second and t h i r d

q u e s t i o n n a i r e s ha s a mean v a l u e o f 3 5 * 5 days ( s . d . 1 9 - 6 ) . The

m a j o r i t y o f the p a t i e n t s ( 8 5 . 7 pe r cen t ) completed the . t h i r d

q u e s t i o n n a i r e between 21 and 49 days a f t e r the second (Table 2 8 ) .

85

R e g a r d i n g t h o D S S l / R c l a s s a l l o c a t i o n , 19 p a t i e n t s ( 5 4 * 3 p e r c e n t )

d i d no t change t h e i r c l a s s i n t h e p e r s o n a l i l l n e s s h i e r a r c h y at

t h e c o m p l e t i o n o f t h e t h i r d q u e s t i o n n a i r e . E l e v e n p a t i e n t s ( 3 1 . 4

p e r c e n t ) moved f r o m a h i g h e r t o a l owe r c l a s s and f i v e ( 1 4 . 3

p e r c e n t ) f r o m a l o w e r t o a h i g h e r c l a s s ( T a b l e 2 9 ) . Two p a t i e n t s

( 5 . 7 p e r c e n t ) were a l l o c a t e d t o C l a s s 0 a f t e r t h e c o m p l e t i o n o f t he

s e c o n d D S S l / R . One d i d n o t change c l a s s and t h e o t h e r moved t o

C l a s s 1 , b y t h e c o m p l e t i o n o f t h e t h i r d q u e s t i o n n a i r e . S e v e n p a t i e n t s

( 2 0 . 0 p e r c e n t ) b e l o n g e d t o C l a s s 1 o n t h e s e cond q u e s t i o n n a i r e , YJhen

t h e y comp le ted t h e t h i r d o n e , t h r e e o f them r ema i ned i n t h e same

c l a s s , two moved t o C l a s s 0 , and two moved t o C l a s s 2 . T w e l v e

p a t i e n t s ( 3 4 . 3 p e r c e n t ) b e l o n g e d t o C l a s s 2 o n t h e s e cond q u e s t i o n n a i r e .

On t h e t h i r d q u e s t i o n n a i r e , f i v e o f them r ema i ned i n t h e same

c l a s s , f i v e moved t o " a l o w e r c l a s s and two moved t o a h i g h e r c l a s s .

F i v e p a t i e n t s ( l 4 « 3 p e r c e n t ) b e l o n g e d t o C l a s s 3 on t h e s e c o n d

q u e s t i o n n a i r e . A t t h e t h i r d q u e s t i o n n a i r e t h r e e o f them r e m a i n e d

i n t h e same c l a s s and two moved t o C l a s s 2 , N i n e p a t i e n t s ( 2 5 , 7

p e r c e n t ) were a l l o c a t e d t o C l a s s 4 a f t e r c o m p l e t i n g t h e s e c o n d

q u e s t i o n n a i r e . On t h e t h i r d q u e s t i o n n a i r e , s e v e n o f them r e m a i n e d

unchanged and two moved t o a l o w e r c l a s s ( T a b l e 2 9 ) .

The s c o r e s w h i c h were a l l o c a t e d i n d i c a t e a d rop i n most o f t h e

h o s t i l i t y s u b g r o u p s e x cep t s e l f - c r i t i c i s m s c o r e s w h i c h i n c r e a s e d

s l i g h t l y i n f l u e n c i n g , a s a r e s u l t , t h e s c o r e s o f t h e t o t a l

i n t r o p u n i t i v e n e s s and d i r e c t i o n o f h o s t i l i t y . C o n c e r n i n g t h e

D S S l / R s c o r e s , a d r op i n a l l s u b g r o u p s i s o b s e r v e d ( T a b l e 3 0 ) ,

86

The c o r r e l a t i o n s between HDHQ and DSS I /R s co re changes found i n

t h i s g roup o f p a t i e n t s a re now c o n s i d e r e d .

Changes o f s t a t e o f a n x i e t y s c o r e s are found to be c o r r e l a t e d w i t h

p a r a n o i d h o s t i l i t y s c o r e changes t o a h i g h l e v e l o f s i g n i f i c a n c e

and w i t h t o t a l h o s t i l i t y and t o t a l e x t r a p u n i t i v e n e s s to a moderate

l e v e l . A c o r r e l a t i o n w i t h g u i l t t o a v e r y low l e v e l o f s i g n i f i c a n c e

and c o r r e l a t i o n s w i t h c r i t i c i s m o f o t h e r s and t o t a l i n t r o p u n i t i v e n e s s

c l o s e to s t a t i s t i c a l s i g n i f i c a n c e were a l s o found (Tab le 3 " 0 -

S t a t e o f d e p r e s s i o n s c o r e changes a re c o r r e l a t e d to a h i g h l e v e l o f I

s i g n i f i c a n c e w i th s c o r e changes o f a c t i n g - o u t h o s t i l i t y , g u i l t , t o t a l

h o s t i l i t y and t o t a l i n t r o p u n i t i v e n e s s ; to a moderate l e v e l o f

s i g n i f i c a n c e w i t h t o t a l i n t r o p u n i t i v e n e s s and to a low l e v e l o f

s i g n i f i c a n c e w i th p a r a n o i d h o s t i l i t y s co re changes . C o r r e l a t i o n s

near to s i g n i f i c a n c e , w i t h s e l f - c r i t i c i s m and c r i t i c i s m o f o t h e r s

a re a l s o detected ( Tab l e 3 2 ) .

No c o r r e l a t i o n s o f an a c c e p t a b l e l e v e l o f s i g n i f i c a n c e between the

s co re changes o f s t a t e o f e l a t i o n and changes o f the HDHQ s u b s c a l e s

were ob se r ved .

C o n v e r s i o n symptoms ( P S ) s c o r e changes v/ere found to be c o r r e l a t e d

w i t h t o t a l h o s t i l i t y s c o r e changes to a v e r y low l e v e l o f s i g n i f i c a n c e .

C o r r e l a t i o n s near to s t a t i s t i c a l s i g n i f i c a n c e w i t h a c t i n g - o u t

h o s t i l i t y , pa r ano i d h o s t i l i t y and t o t a l e x t r a p u n i t i v e n e s s were a l s o

ob se r ved (Tab le 33 )•

87

Changes of dissociative symptoms scores are found to be correlated

to a high level of significance with acting-out hostility, paranoid

hostility, total hostility and total extrapunitiveness score changes.

Close to significance correlations with criticism of others, self-

criticism guilt and total intropunitiveness are also observed

(Table 3*0.

Phobic symptoms (FS) score changes are correlated with total hostility

and total extrapunitiveness score changes to a high level of

significance. The correlations with acting-out hostility, paranoid

hostility, guilt and total intropunitiveness are found to be of

a moderate statistical significance. Correlations close to

statistical significance with criticism of others and self-criticism

are also detected (Table 35)-

Changes of compulsive symptoms (CS) scores are found not to be

correlated with hostility score changes to acceptable levels of

statistical significance.

Ruminative symptoms score changes are correlated to high levels of

statistical significance with acting-out hostility, guilt, total

hostility and total extrapunitiveness score changes; there is also

a correlation v/ith total intropunitiveness score changes to a

moderate level of statistical significance. Correlations with

criticism of others and self-criticism close to statistical

significance are also observed (Table 36).

Correlations of high statistical significance are observed

between score changes of delusions of persecution and acting-out

88

h o s t i l i t y and g u i l t . T h e r e i s a c o r r e l a t i o n o f l ow s i g n i f i c a n c e

w i t h t o t a l h o s t i l i t y s c o r e c h a n g e s . C o r r e l a t i o n s t o a v e r y l o w

l e v e l o f s i g n i f i c a n c e w i t h p a r a n o i d h o s t i l i t y and t o t a l

i n t r o p u n i t i v e n e s s and a c o r r e l a t i o n c l o s e t o s t a t i s t i c a l s i g n i f i c a n c e

w i t h t o t a l e x t r a p u n i t i v e n e s s a r e a l s o o b s e r v e d ( T a b l e 3 7 ) .

D e l u s i o n s o f g r a n d e u r s c o r e c h a n g e s a re f o u n d t o be c o r r e l a t e d

w i t h p a r a n o i d h o s t i l i t y s c o r e c h a n g e s t o a v e r y low l e v e l o f

s i g n i f i c a n c e ( T a b l e 3 8 ) .

•

D e l u s i o n s o f c o n t r i t i o n s c o r e c h a n g e s a r e c o r r e l a t e d w i t h t o t a l

h o s t i l i t y s c o r e c h a n g e s t o a moderate l e v e l and w i t h a c t i n g - o u t

h o s t i l i t y and g u i l t t o a l ow l e v e l o f s i g n i f i c a n c e . The re i s a l s o

a c o r r e l a t i o n a t a v e r y l o w l e v e l o f s i g n i f i c a n c e w i t h t o t a l

i n t r o p u n i t i v e n e s s s c o r e c h a n g e s ; c l o s e t o s i g n i f i c a n c e c o r r e l a t i o n s

w i t h p a r a n o i d h o s t i l i t y a n d t o t a l e x t r a p u n i t i v e n e s s s c o r e c h a n g e s

a r e a l s o d e t e c t e d ( T a b l e 3 9 ) .

D e l u s t i o n s o f d i s i n t e g r a t i o n s c o r e change s a r e f o u n d t o be

c o r r e l a t e d w i t h p a r a n o i d h o s t i l i t y s c o r e change s a t a low l e v e l

o f s t a t i s t i c a l s i g n i f i c a n c e ( T a b l e 4 0 > .

i

89

6 . 3 . S t u d y - p o i n t I I I

The c o r r e l a t i o n s w h i c h a r c o b s e r v e d between t h e s c o r e c hange s o f

HDHQ s u b s c a l e o a n d D S S l / R s e t s i n t h e g r o u p o f p a t i e n t s who c o m p l e t e d

a t h i r d and a f o u r t h b a t t e r y o f q u e s t i o n n a i r e s a r e examined a t t h i s

s t u d y - p o i n t .

S e v e n t e e n p a t i e n t s , e i g h t ma l e s and n i n e f e m a l e s , c o n s t i t u t e t h e

sample w h i c h p a r t i c i p a t e d a t s t u d y - p o i n t I I I .

The mean age o f t h e p a t i e n t s was 3 5 * 2 ( s . d . 1 4 . 6 ) w i t h a r a n g e f r om

a minimum o f 19 y e a r s t o a maximum o f 65 y e a r s . E i g h t p a t i e n t s

( 4 7 . 0 p e r c e n t ) b e l o n g e d t o t h e age g r o u p 1 9 - 2 9 y e a r s ( T a b l e 4 l ) .

The t ime t h a t e l a p s e d be tween t h e c o m p l e t i o n o f t h o s e two b a t t e r i e s

o f q u e s t i o n n a i r e s h a d a mean v a l u e o f 3 8 . 0 d a y s ( s . d . 1 5 . 4 ) . Most

o f t h e p a t i e n t s ( 8 8 . 2 p e r c e n t ) . c o m p l e t e d t h e f o u r t h q u e s t i o n n a i r e s

between 2 1 and 4 9 d a y s a f t e r t h e t h i r d ( T a b l e 4 2 ) .

A c c o r d i n g t o t h e d i a g n o s e s t h e y r e c e i v e d on d i s c h a r g e , t h e y were

a l l o c a t e d t o s e v e n d i a g n o s t i c c a t e g o r i e s ( T a b l e 4 3 ) . F o u r o f t h e s e

p a t i e n t s ( 2 3 . 5 p e r c e n t ) r e c e i v e d t h e d i a g n o s i s o f n e u r o t i c d e p r e s s i o n

w i t h o r w i t h o u t p e r s o n a l i t y d i s o r d e r . E l e v e n ( 6 4 . 7 p e r c e n t ) r e c e i v e d

a d i a g n o s i s b e l o n g i n g t o t h e t h r e e d i a g n o s t i c c a t e g o r i e s r e l a t e d to

s c h i z o p h r e n i a . The r e m a i n i n g two p a t i e n t s r e c e i v e d t h e d i a g n o s e s o f

m a n i c - d e p r e s s i v e p s y c h o s i s ( d e p r e s s i v e p h a s e ) a n d a n x i e t y s t a t e .

T h e i r c l i n i c a l s t a t u s o n c o m p l e t i n g t h e t h i r d q u e s t i o n n a i r e was m a i n l y

t h a t o f i n - p a t i e n t - 10 p a t i e n t s , 5 8 . 8 p e r c e n t - v/ith s i x d a y - p a t i e n t s

( 3 5 . 3 p e r c e n t ) and one o u t - p a t i e n t . On c o m p l e t i n g t h e f o u r t h

q u e s t i o n n a i r e , s e v e n were i n - p a t i e n t s ( 4 1 . 2 p e r c e n t ) , e i g h t

.90

day-patients (47*0 percent) and two out-patients (Table 44).

The means of the scores obtained in these two series of

questionnaires (Table 45) indicate thati 1. there is a drop in

most of the scores of the hostility subgroups except guilt and

direction of hostility which increased and 2. that in eight out

of twelve DSSl/R sets there is an increase of the mean score, in three

a decrease and there is no change in one (ruminative symptoms).

According to the DSSl/R class allocation scores, nine patients

(52.9 percent) did not change their class in the.personal illness

hierarchy after the completion of the fourth questionnaire. Five

(29.4 percent) moved from a higher to a lower class and three

patients (17.6 percent) moved from a lower to a higher class

(Table 46).

Three patients (17.6 percent) were allocated to Class 0 on

completing the third questionnaire. On the fourth questionnaire

those patients all remained in the same class. Two patients (ll.8

percent) belonged to Class 1 on the third questionnaire; on the fourth

questionnaire one moved to Class 2 and the other remained in the same

class. Six patients (35.3 percent) belonged to Class 2 on the

third; on the fourth questionnaire three remained in the same

class, two moved to a lower and one to a higher class. Two

patients (ll.8 percent) belonged to Class 3 on the third questionnaire;

on completing the fourth, one moved to Class 2 and the other to

Class 4. Fpur patients (23.5 percent) belonged to Class 4 on the

third questionnaire; on the fourth, two of them remained in the

.91

same class, one moved to Class 3 and the other to Class 0

(Table 46).

Concerning the relationships between the score changes of HDHQ

subscales and DSSI/R sets, the following is observed.

Changes of state of anxiety scores were correlated with total

hostility and total intropunitiveness score changes to a moderate

level of significance and with criticism of others to a low level

of significance. Correlations of a very low statistical significance

with self-criticism and total extrapunitiveness and a correlation

close to significance with guilt score changes were also detected

(Table 47).

A correlation of state of depression with acting-out hostility score

changes of a very low statistical significance and correlations

close to significance with total extrapunitireness and direction

of hostility(the latter being negative) were observed (Table 48).

A correlation of phobic symptoms (FS) score changes with total

hostility of a very low level of significance and'correlations

close to significance with criticism of others, total intropunitiveness

and total extrapunitiveness were observed (Table 49)

Changes of compulsive symptoms scores are correlated with paranoid

hostility score changes to a moderate level of significance

(Table 50).

Changes of ruminative symptoms scores are correlated to a moderate

.92

level of significance with total hostility and a low level of

significance v/ith total intropunitiveness and total extrapunitive-

ness score changes. Correlations of a very low level of significance

are observed with criticism of others, paranoid hostility and self-

criticism score changes (Table 5l)»

Changes of dissociative symptoms scores are observed to be correlated

with acting-out hostility score changes to a near to significance

level (Kendall1s tau, 0.3057 P = 0.044, Spearman's rho, 0.3814

P = 0.066).

Changes of delusions of persecution scores are related to a high

level of significance with paranoid hostility changes and to a

moderate level of significance v/ith guilt, total extrapunitiveness

and (negatively) with direction of hostility. A correlation of very

low statistical significance with acting-out hostility and another

close to significance with total hostility score changes are

observed (Table 52).

Changes of delusions of grandeur are correlated with paranoid

hostility score changes to a low level of significance; there is

also a close to significance correlation with guilt (Table 53).

No correlations of statistical significance between the score changes

of delusions of disintegration and HDHQ subscales are observed,

apart from a close to significance correlation with paranoid

hostility (Kendall»s taus 0.3012, P = 0.046, Spearman*s rho:

0.3087, P » 0.114).

•93

6.4. Study-point IV

Eleven patients, six males and five females, constitute the sample

that participated in the study-point IV.

In this study-point the relationships are examined "between the score

changes of the HDHQ subscales and DSSl/R sets of the patients who

completed the .fourth and fifth battery of the t-wo questionnaires.

The mean age of these patients is 36.9 years (s.d. 15*9) with a

range from a minimum of 20 to a maximum of 65 years. (Table 54).

The time that elapsed between the completion of the questionnaires had a

mean value of 47-64 days (s.d. 33.68). Most of the patients (81.8

percent) completed the fifth questionnaires within a period of time

of between 21 and 49 days after the fourth ones (Table 55).

Regarding their clinical status on completing the fourth

questionnaires, four were in-pat ien"ts (36.4 percent), six were

day-patients (54.5 percent) and one was an out-patient. On

completing the fifth questionnaires, four were in-patients (36.4

percent) and seven (63.6 percent) day-patients (Table 56).

According to the diagnoses they received on discharge, they were

allocated to five diagnostic categories (Table 57). Three of those

patients received the diagnosis of neurotic depression with or without

personality disorder. One was diagnosed as suffering from an anxiety

state and seven (63.6 percent) received the diagnosis of

schizophrenia or paranoid schizophrenia.

According to the DSSl/R scores they obtained, seven patients

(63,6 percent) did not change their class in the personal illness

hierarchy after the completion of the fifth questionaire. Three

(27,3 percent) moved from a higher to a lower class. One moved from

a lower to a higher class (Table 5&). Pour patients (36,4 percent) were

allocated to Class 0, on completion of the fourth questionnaire. On the

fifth questionnaire the three remained in the same class and one moved

to Class 2, Two patients belonged to Class 1 on the fourth question-

naire, On the fifth, one remained in the same class and the other moved »

to Class 0. I Of three patients of Class 2, two remained in the same

class and one moved to Class 0; of the two patients allocated to

Class 4, one remained in this class and the other moved to Class 0

(Table 58).

The changes of the means of the scores which were obtained in the two

series of the questionnaires indicate that, regarding the HDHQ subscales,

there is an increase in criticism of others, self-criticism, total

hostility, total intropunitiveness, total extrapunitiveness, and

direction of hostility and a decrease in acting-out hostility, guilt

and paranoid hostility scores. Regarding the DSSl/R sets, there is an

increase in state of anxiety, state of depression, dissociative

symptoms, compulsive symptoms,, delusions of persecution and delusions

of disintegration and a decrease in state of elation, conversion

symptoms (PS), phobic symptoms (PS), ruminative symptoms, delusions of

grandeur (dG) and delusions of contrition (dC) scores, (Table 59).

As far as the correlations between the score changes of HDHQ subscales

and the DSSl/R sets are concerned, the following were observed.

.95

Changes of state of anxiety scores are correlated with changes

of total extrapunitiveness scores to a low level of significance.

There is a correlation of very low significance with total hostility

and correlations close to significance with guilt and total

intropunitiveness (Table 60).

Changes of state of depression scores are correlated with guilt score

changes tb a very low level of significance; there are also correlations

near to significance with paranoid hostility and total extrapunitiveness

(Table 61).

A close to significance correlation between state of elation and

self-criticism was observed (Kendall's tau = 0.3963* P = 0.045,

Spearman's rho 0.4495, P = O.O83).

•Close to significance correlations between the score changes of

' compulsive symptoms and total hostility (Kendall's tau, 0.3873,

P = 0.049, Spearman's rho, O.5167, P = O.O52), total extrapunitiveness

(Kendall's tau, 0.4793, P = 0.021, Spearman's rho, 0.5925, P = 0.028),

total intropunitiveness (Kendall's tau, 0.473^1 P = 0.022, Spearman's

rho O.5515, P = 0.040), paranoid hostility (Kendall's tau, 0.4529,

P =0.027, Spearman's rho,0.5577, P = O.O38) and guilt (Kendall's tau,

0.4108, P = 0.040, Spearman's rho, 0.4755, P = 0.070), were observed.

Changes of conversion symptoms (PS) scores are correlated with total

extrapunitiveness to a high level of significance and with criticism

of others to a moderate level. A correlation~to a very low level of

significance with paranoid hostility and correlations close to

.96

significance with total hostility and direction of hostility

' (negative) are also detected (Table 62).

Changes of dissociative symptoms scores are correlated to a high level

of significance v/ith total extrapunitiveness and paranoid hostility

and to a moderate level of significance v/ith criticism of others and

total hostility; a correlation close to statistical significance with

acting-out hostility is also observed (Table 63).

Changes of phobic symptoms (FS) scores are found to be correlated with

total extrapunitiveness score changes to a low level of significance.

There is also a correlation with criticism of others score changes

to a very low level of significance (Table 6*0.

Changes of ruminative symptoms and paranoid hostility scores are found

to be correlated to a high level of significance. Moderate levels of

significance are detected in the correlations with total extrapunitiveness

and total hostility score changes. Correlations close to statistical

significance with criticism of others, guilt and total intropunitiveness

are also observed (Table 65),

Delusions of persecution and paranoid hostility score changes are

correlated to a high level of significance; correlations of moderate

significance with total hostility, total intropunitveness and total

extrapunitiveness, a correlation of low significance with guilt and

correlations close to significance v/ith criticism of others and self-

criticism are also observed (Table 66).

Changes of delusions of grandeur scores are correlated to a moderate

.97

level of significance with paranoid hostility score changes and to

a low level with total extrapunitiveness; there are also correlations

of very low significance with self-criticism and total intropunitive-

ness and close to significance correlations with guilt and total

hostility score changes, (Table 67),

Correlations of delusions of contrition with paranoid hostility and

total extrapunitiveness score changes to a high level of significance

are detected; there is also a correlation of moderate significance wiih

total hostility and another to a low level of significance with

criticism of others (Table 68),

Changes of delusions of disintegration scores are found to be related

to paranoid hostility score changes at a high level of significance.

Correlations of moderate significance with total extrapunitiveness,

total hostility, total intropunitiveness, of low significance with guilt

and near to significance with criticism of others and self-criticism

are also observed (Table 69),

.98

6.5« Comparisons Across the Study-points

In the following pages the data will be approached in a way more relevant

to the basic question of this study which is the relationship between

the changes of certain symptomatological entities and hostility patterns.

Thus, in this section, the relationships between the score changes

of each DSSI/R set with the HDHQ subscales will be examined.

In a series of tables (70 to 81) the statistically significant correlations

between each DSSI/R set and the HDHQ subscales in all the study-points

are presented.

Evaluations of the degrees of closeness of the relationships between the

changes of the scores of HDHQ subscales and DSSI/R sets are made,

based on the frequency of the statistically significant correlations

observed in the four study-points. These evaluations are illustrated

as a series of Tables numbered from 82 to 90.

The•expression "very strong association" suggests, that statistically

significant correlations between the score changes of a certain HDHQ

subscale and a certain DSSI/R set, were observed in all four study-

points. "Strong association" suggests that significant correlations

were observed in three study-points. "Moderate association" means that

significant correlations were detected in two study-points. "Weak

association" suggests that only one statistically significant correlation

was observed in one study-point.

99

Close to significance correlations are not regarded as enough for

the allocation of an association to one of these levels but they

will not be ignored in the discussion section.

.100

6.5-1- Relationships Between the Score Chanpes of State of Anxiety (sA)

and HDHQ Subscales

Correlations of statistical significance between state of anxiety score

changes and one or more HDHQ subscales have been observed at all the

study-points (Table 70).

Correlations between state of anxiety and total hostility score changes,

having a statistical significance, were observed at all the study-

points, which suggests a very strong association. This DSSI/R set

could be regarded as one of the sets that are most closely associated

with total hostility, ruminative symptoms sharing a similar position

(Table 82).

Correlations of significance with total extrapunitiveness (Table 83)

are also observed at all the study-points. According to these results,

state of anxiety could be regarded as very strongly associated with

total extrapunitiveness. It could be regarded, with ruminative symptoms

sharing again the same position, as the DSSI/R set most closely associated

with total extrapunitiveness.

Apart from.a close to significance correlation of study-point I,

(Table 14), no correlations of acceptable significance between state

of anxiety score changes and those of acting-out hostility were detected

at the four study-points.

One correlation of low significance with criticism of others was observed

at study-point III (Table 4?) and another close to significance at

study-point II (Table 31). State of anxiety score changes appear to

be loosely associated with criticism of others score changes as do

.101

the majority of the DSSI/R sets (Table 85).

Paranoid hostility score changes seem to be moderately associated

with state of anxiety score changes; two significant correlations

were observed at the study-point I (Table 1*0 and study-point II

(Table 31). Compared with the other DSSI/R sets (Table 86) state of

anxiety has an association with paranoid hostility of similar closeness

as compulsive symptoms and delusions of contrition have, below

delusions of persecution (dP), ruminative symptoms (RS), dissociative

symptoms (DS), delusions of grandeur (dG) and delusions of disintegration

(DD).

Regarding the relationship with total intropunitiveness, two correlations

of significance were observed at the study-points I (Table 1*0 and

III (Table *f7)« It should also be mentioned that two near to

significance correlations were detected at the study-points II (Table 31)

and IV (Table 60). This could be regarded as a moderate association.

Compared v/ith the other DSSI/R sets (Table 87), state of anxiety appears

to be at a similar position as state of depression, ruminative symptoms

and delusions of persecution, which are the DSSI/R sets most closely

related to .total intropunitiveness.

It can be seen (Table 88) that for the majority of DSSI/R sets there

are not correlations of significance with self-criticism except state

of depression, ruminative symptoms and delusions of grandeur which have

a weak overall association and state of anxiety score changes

associated v/ith self-criticism to a moderate level giving statistically

significant correlations at study-points I (Table 1*0 and III (Table V?);

.102

state of anxiety therefore could he regarded as the set most closely

associated v/ith self-criticism, compared with the other DSSl/R sets.

A correlation of very low statistical significance with guilt is

observed at study-point II (Table 31) suggesting a weak overall

association; two close to significance correlations at the study-

points III (Table 47) and IV (Table 60) should be mentioned.

Compared with the other DSSl/R sets, state of anxiety takes its

place among the many sets that are loosely associated with guilt

(Table 89).

No correlation of acceptable significance was detected between the

score changes of state of anxiety and direction of hostility, as

in the case with the majority of the DSSl/R sets (Table 90)*

According to these data it appears that state of anxiety scores on

changing are to a high degree closely associated with general

hostility, extrapunitive and to a lesser degree intropunitive responses.

The extrapunitive responses are expressed mainly as paranoid

hostility and in a less degree as criticism of others. The

intropunitive responses are expressed as self-criticism and.guilt.

.103

6.5.2. Relationships Between the Score Changes of State of

Depression (nD) and the HDHQ Subscales.

Statistically significant correlations between the score changes of

state of depression and one or more HDHQ subscales were observed at

each of the four study-points (Table J1).

Correlations of significance with total hostility were found at the study-

point I and II (Table 15 and 32). This association could be regarded

as a moderate one. Compared with the other DSSl/R sets (Table 82)

state of depression correlations take up a similar place to delusions

of persecution and delusions of contrition, below state of anxiety,

but appear to be more closely associated with total hostility than do

state of elation, conversion symptoms (PS), compulsive symptoms (CS),

delusions of grandeur (dG) and delusions of disintegration (DD).

Correlations of significance with total extramtnitiveness were also

found at the same study-points (Table 15 and 32); additionally, two

correlations near to statistical significance were observed at the

study-points III (Table 48) and IV (Table 6l). This is a moderate

association. Compared with the other DSSl/R sets (Table 83)» state

of depression takes a similar position to delusions of grandeur and

delusions of persecution, below dissociative symptoms and phobic

symptoms.

The relationship to acting-out hostility score changes appears to be

closer; correlations of significance were observed at the study-

points I (Table 15), II (Table 32) and III (Table 48). This

' 104

association is a strong one, and viG-a-vis the other DSSI/R subgroups,

state of depression is placed in the highest level, with dissociative

symptoms, phobic symptoms (FS), ruminative symptoms and delusions of

persecution taking a lesser place (Table 8*4).

Apart from one close to significance correlation at the study-point II

(Table 32) no correlations of an acceptable significance with

criticism of others were observed.

One correlation of low statistical significance at study-point II

(Table 32) and another close to significance at study-point IV

(Table 61) with paranoid hostility were observed. This is a weak

overall association, and vis-a-vis the other DSSI/R sets, state of

depression shares the weakest position (Table 86) with state of

elation, conversion symptoms (PS) and phobic symptoms (FS).

Correlations of significance with total intropunitiveness are

observed at the study-points I (Table 15) and II (Table 32); this

could be regarded as a moderate overall association. Compared with the

other DSSI/R sets (Table 87) state of depression takes a similar

place to state of anxiety, ruminative symptoms and delusions of

persecution which are the DSSI/R sets most closely associated with

total intropunitiveness.

It can be seen (Table 88) that there is a weak overall association

between the score changes of state of depression and self-criticism;

one correlation of significance at study-point I (Table 15) and

another close to significance at study-point II (Table 32) were

detected. The majority of the cDSSI/R sets do not seem to be

.105

associatod v/ith self-criticism; state of depression is in. a similar

place to ruminative symptoms and delusions of grandeur, below state of

anxiety which is the DSSl/R set most closely related to self-criticism.

Concerning the score changes of guilt, statistically significant

correlations were observed at the study-points II (Table 32) and

IV (Table 6l). This could be regarded as a moderate association; vis-

a-vis the other DSSl/R subgroups, state of depression is similar to

delusions of contrition, being in a lesser place after delusions of

persecution (Table 89),

Direction of hostility score changes do not seem to be associated v/ith

DSSl/R score changes; as with most of the DSSl/R sets (Table 90),

no correlations of an acceptable statistical significance v/ith state

of depression score changes were detected, apart from a close to

significance negative correlation observed at study-point IV

(Table 6l).

According to these data it appears to be that state of depression,

(like state of anxiety), is related with both extrapunitive and

intropunitive responses, but in the case of state of depression

intropunitiveness is mobilized in an almost equal degree to

extrapunitiveness. The extrapunitive responses are expressed

predominantly as acting-out hostility and to a lesser degree as

paranoid hostility whereas the intropunitive ones mainly as guilt

and to a lesser degree as self-criticism.

.106

6.5»3« Relationships Between the Score Changes of State of Elation

(sE) and the HDHQ Subscales.

Correlations to an acceptable level of statistical significance

between the score changes of state of elation and HDHQ subscales

were detected only at the study-point I (Table 72).

One correlation of high statistical significance with total hostility

was detected (Table 16), suggesting a weak association. Compared

with the other DSSI/R subgroups, state of elation, (Table 82), takes

a position among the sets most loosely associated with total hostility

such as delusions of disintegration, compulsive symptoms (CS) and

conversion symptoms (PS).

Regarding its association with total extrapunitiveness, one correlation

of significance was observed (Table 16), suggesting again a weak

association.

Examining the correlation between state of elation and the three

extrapunitive subscales it can be seen that there is a weak

association with criticism of others, i.e. one significant correlation

at study-point I (Table 16); a negative non-significant correlation

was found at study-point II. With paranoid hostility there is again

a loose association, with a statistically significant correlation at

study-point I (Table 16); a negative non-significant correlation at

study-point III was also observed. It seems from Table 86 that the

majority of the DSSI/R sets are more closely associated with paranoid

hostility than state of elation, except phobic symptoms (FS), state

of depression and conversion symptoms which are/^similar place as state

of elation. No correlations of acceptable significance with acting-

.107

out hostility were found, state of elation being in similar position

as delusions of grandeur, delusions of disintegration, state of

anxiety and conversion symptoms (PS) which have no relations with acting-

out hostility (Table 5*0; it should be noted that a negative non-

significant correlation v/ith acting-out hostility v/as observed at

study-point IV.

No correlations of statistical significance between the score changes

of state of elation and total intropunitiveness, self-criticism and

guilt was detected although a near to significance correlation with

self-criticism was observed at study-point IV; a negative non-significant

correlation with guilt was found at study-point II.

As far as direction of hostility is concerned, a negative close to

significance correlation at study-point I (Table 16) v/as observed.

These results suggest that there is a loose association between the

score changes of state of elation and total hostility and that state

of elation is associated exclusively - although in a low level -

with extrapunitive responses mobilized predominantly as criticism of

others and paranoid hostility.

.108 *

6.5-4. Relationships Between the Score Changes of Conversion

Symptoms (PS) and the HDHQ Subscales

Correlations of an acceptable significance between the score changes

of conversion symptoms (PS) and the HDHQ subscales v/ere detected at

study-points II and IV (Table 75).

Conversion symptoms (PS) were found to be correlated to a very low

level of significance v/ith total hostility at study-point II

(Table 33); at study-point IV (Table 62) a close to significance

correlation was also detected. This implies a weak overall relation

between conversion symptoms and total hostility and, compared with the

other DSSl/R sets, conversion symptoms take a similar place with state of

elation, compulsive symptoms and delusions of disintegration which also

have a weak association with total hostility (Table 82).

The same applies to total extrapunitiveness. Only at study-point

IV (Table 62) was a significant correlation found; in study-

point II (Table 33) there was also a very close to significance

correlation. Vis-a-vis the other DSSI/R subgroups (Table 83),

conversion symptoms are placed at the lowest level, with delusions

of disintegration, compulsive symptoms, state of elation and delusions

of contrition.

Conversion symptoms like the majority of DSSI/R sets have a weak

association v/ith criticism of others (Table 85). Only one correlation

of significance was found at study-point IV (Table 62).

.109

With paranoid hostility a significant at study-point IV (Table 62)

and a close to significance correlation at study-point II (Table 33)

were detected, putting this relation in the lowest position if it is

compared with other DSSI/R subgroups (Table 86).

No correlation of an acceptable significance with acting-out

hostility was detected although a correlation very close to

statistical significance was detected at the study-point II (Table 33)•

Conversion symptoms appear to be unrelated to total intropunitiveness,

self-criticism and guilt. i j

As far as direction of hostility is concerned a negative close to

significance correlation at study-point IV (Table 62) and a negative

non-significant correlation at study-point II (Appendix C) were found.

Concluding it would appear that changes of conversion symptoms (PS)

are associated with general hostility responses to a low level. These

responses are manifested exclusively in an extrapunitive-way, having

the form of criticism of others and paranoid hostility.

. 1 1 0

6.5-5- Relationships Between the Scorc Changes of Dissociative

Symptoms (PS) and the HDHQ subscales.

Statistically significant correlations between dissociative symptoms

and HDHQ score changes were observed at the study-points I, II and

IV (Table 76).

Correlations of statistical significance with total hostility were

detected at the study-points I (Table 17), II (Table J>k) and IV

(Table 63). Dissociative symptoms are associated with total

hostility to a much greater degree than conversion symptoms, being

in a position just below ruminative symptoms and state of anxiety I I

which are the DSSI/R sets most closely associated with total

hostility (Table 82).

Significant correlations with total extrapunitiveness were detected

at the same study-points. The association v/ith total extrapunitiveness

could therefore be regarded as strong. Compared v/ith the other DSSI/R

subgroups, dissociative symptoms take a similar place to phobic

symptoms (FS) below state of anxiety and ruminative symptoms which

could be regarded as the sets most closely related with total

extrapunitiveness (Table 83).

Regarding the relationships with acting-out hostility highly

significant correlations were detected at study-points I (Table 17)

and II (Table and close to significance correlations at study-

points III (Appendix D) and IV (Table 63)- This relation could thus

be regarded as a moderate one. Compared with the other DSSI/R sets

dissociative symptoms take a similar place to phobic symptoms (FS),

.111

ruminative symptoms (RS) and delusions of persecution (dP) below state

of depression which is the DSSI/R set most closely associated with

acting-out hostility (Table 84)-

Significant correlations with paranoid hostility were detected at

study-points I (Table 17), II (Table 34) and IV (Table 63); this

implies a strong overall relation. Compared with the other DSSI/R

subgroups, dissociative symptoms take a position below the dehsions

of persecution which have the closest association with paranoid

hostility (Table <°6). : I

I

The relation with criticism of others is a weak one, just as in most

DSSI/R subgroups (Table 85); only one correlation was detected at

study-point IV (Table 63), but two correlations close to significance

at study-points I (Table 17) and II (Table 34) were also observed.

No correlations with total intropunitiveness and its two intropunitive

subscales, self-criticism and guilt were detected; we should, however,

mention that regarding total intropunitiveness a negative non-

significant and a positive close to significance correlation at

study-points I (Appendix D) and II (Table were detected; the same

observation holds for self-criticism. As far as guilt is concerned,

a close to significance correlation at study-point II (Table 34)

and a negative non-significant correlation at study-point IV

(Appendix C) were detected.

A highly significant negative correlation with direction of hostility

was detected at study-point I (Table 17); negative non-significant

correlations were also found at the study-points II, III and IV

.112

(Appendix C). Compared with the other DSSI/R subgroups, dissociative

symptoms could be regarded as the most extrapunitive DSSI/R set

(Table 90) although this relation is itself a weak one.

It could be concluded that changes of dissociative symptoms are very

closely related with changes of general hostility and exclusively

v/ith changes of extrapunitive responses. All of the three

extrapunitive attitudes are mobilized, predominantly paranoid

hostility, acting-out hostility and, to a considerably lower degree,

criticism of others.

.113

6.5-6. Relationships Botv/oen t.ho Score Changes of Phobic Symptoms (PS)

and HDH'J subscalcr..

Statistically significant correlations between hanges of the scores

of phobic symptoms and one or more of the HDHQ subscales were observed

at all the study-points (Table 77)•

Phobic symptoms appear to be associated with total hostility in a

strong degree being in a similar place as dissociative symptoms above

state of depression and below state of anxiety and ruminative symptoms

(Table 82). Correlations of statistical significance were detected

at study-points I (Table ifi), II (Table 35) and III (Table *+9).

The association v/ith total extrapunitiveness could again be regarded

as strong, phobic symptoms being (Table 83) in a similar position to

dissociative symptoms, more closely associated to total extrapunitiveness

than state of depression, delusions of grandeur and delusions of

persecution and less closely than state of anxiety and ruminative

symptoms. Statistically significant correlations v/ere detected at the

study-points I (Table 1P), II (Table 35) and IV (Table 6*0,and a close

to significance correlation at study-point III (Table *+9)«

Regarding the relations v/ith acting-out hostility, significant

correlations were detected at study-points I (Table 18) and II (Table 35) •

This is a moderate overall association; compared v/ith other DSSI/R

sets phobic symptoms appear to be in a similar place as dissociative

symptoms, ruminative symptoms and delusions of persecution below state

of depression (Table 8*0. »

One correlation of significance with criticism of others was observed at

study-point IV (Table 6*0; close to significance correlations were

.14

observed at the study-points II (Table 35) and III (Table 49). As

with most of the DSSI/R sets, phobic symptoms are related to a v/eak

degree with criticism of others (Table 85).

Almost the same applies for paranoid hostility. One correlation of

significance was found at study-point II (Table 35); the relationships

between phobic symptoms and paranoid hostility are among the weakest

compared with the rest of DSSI/R subgroups (Table 86).

The association with total intropunitiveness seems to be a v/eak one.

One correlation of significance was detected at study-point II

(Table 35); close to significance correlations were found at the

study-points I (Table 18) and III (Table 49).

No correlation of significance between self-criticism and phobic

symptoms score changes was detected, but a close to significance

correlation was noticed at study-point II (Table 35)-

There is a significant correlation v/ith guilt at study-point II

(Table 35) implying a weak association. Compared with the other

DSSI/R sets, phobic symptoms appear to be placed among the least

associated v/ith guilt (Table 89).

No correlation of significance between the score changes of direction

of hostility and phobic symptoms was observed: negative non-significant

correlations were noticed at the study-points I, II and IV

(Appendix C).

.115

To conclude, it could be said that changes of phobic symptoms

are associated very closely v/ith general hostility responses. They

are also associated v/ith extrapunitive and intropunitive attitudes, but

with a considerable predominance of the extrapunitive ones. As far

as the HDHQ subscales are concerned, the extrapunitive attitudes are

manifested predominantly through acting out and to a lower degree v/ith

criticism of others and paranoid hostility, whereas the intropunitive

ones are expressed as feeLings of guilt.

.116

6.5-7- Relationship:', Between the Score Changes of Compulsive

Symptoms (CS) and HDHQ Subscales.

Correlations between compulsive symptoms and HDHQ score changes were

observed at the study-points I and III (Table 73)*

One correlation of high statistical significance with total hostility

was detected at study-point I (Table 19) and another close to

significance at study-point IV (Appendix C). Compared with the other i

DSSI/R sets, compulsive symptoms seem to be loosely associated with

total hostility (Table 82), taking a similar position as delusions j

of disintegration, state of elation and conversion symptoms (PS).

As far as their relationship v/ith total extrapunitiveness is concerned,

one correlation of significance was observed at study-point I (Table 19)

and another close to significance at the study-point IV (Appendix C).

Compared v/ith the other DSSI/R sets, compulsive symptoms take their

place with those less associated with total extrapunitiveness

(Table 83).

V/ith acting-out hostility a moderately significant correlation was

detected at study-point I (Table 19)» It appears that compulsive

symptoms are loosely associated with acting-cut hostility (Table 8*+).

No correlation of an acceptable statistical significance v/ith

criticism of others was detected, although there is a close to

significance correlation at study-point II (Appendix C).

.117

Two statistically significant correlations with paranoid hostility

at study-points I (Table 19) and III (Table 50) and another close

to significance at study-point IV (Appendix C) were observed. This

suggests a relation of a moderate overall degree. Compared with the

other DSSI/R sets, compulsive symptoms, v/ith state of anxiety and

delusions of contrition are placed between a majority of DSSI/R

sets having a relatively strong association and a minority having a

weak association with paranoid hostility (Table 86).

A correlation of significance with total intropunitiveness was

observed at study-point I (Table 19)- Also a close to significance I i

correlation at study-point IV and a negative non-significant at

study-point II were observed (Appendix C). This is a weak and

variable overall association and if compared v/ith the .other DSSI/R

sets, compulsive symptoms take a place among phobic symptoms (FS),

delusions of grandeur, delusions of contrition and delusions of

disintegration (Table 87).

No significant correlation with self-criticism was observed although

a close to significance one was detected at study-point IV (Appendix C).

As in the.majority of DSSI/R sets, compulsive symptoms do not seem to

have an association v/ith self-criticism (Table 88).

A significant correlation v/ith guilt at study-point I (Table 19) and

another close to significance at study-point IV (Appendix C) were

observed. This is regarded as a weak overall level of association

and compulsive symptoms could be placed among the majority of DSSI/R

sets having this sort of association with guilt (Table 89).

.118

No significant correlation v/ith direction of hostility was found

although nori-significant negative correlations could he detected

at all the four study-points (Appendix C).

Concluding it would seem that patients reporting changes of their

compulsive symptoms do not seem to mobilize high levels of general

hostility. It appears, however, that they are more likely to

manifest their hostility in an extrapunitive direction, predominantly

with paranoid hostility responses and in a less degree with acting-i i

out hostility. Intropunitive responses, having the form of guilt,

are reported to a lesser degree.

.119

6.5«8. Relationships Between the Score Changes of Ruminative r

Symptoms (RS) and HDHQ Subscales.

Statistically significant correlations between ruminative symptoms and

one or more HDHQ subscales score changes were detected at all the study-

ponts (Table 7*0.

There is a very strong overall association between ruminative symptoms

and total hostility; at all the study-points (Tables 20, 3&» 51, 65)

significant correlations were observed. Compared with the other

DSSI/R subgroups, ruminative symptoms appear to achieve the highest

affinity with total hostility, with state of anxiety in a similar I position (Table 82).

V/ith total extrapunitiveness the relationship is again very strong.

Correlations of significance were observed at all the study-points.

When compared with the other DSSI/R subgroups, ruminative symptoms -

with state of anxiety - could be regarded as one of the sets most

closely associated with total extrapunitiveness (Table 83).

Regarding the relationship with acting-out hostilitysignificant

correlations were detected at study-points I (Table 20) and II

(Table 3 T h i s is a moderate overall association. Compared with

the other DSSI/R sets, ruminative symptoms could be placed, with

dissociative symptoms, phobic symptoms (FS) and delusions of

persecution, below state of depression which is one of the sets

most closely associated with acting-out hostility (Table 8*f).

.120

One correlation of very lov; statistical significance with

criticism of others was observed

at study-point III (Table 51);

but close to significance correlations were observed at study-points

II (Table 36) and IV (Table 65). As with the majority of other

DSSI/R subgroups, ruminative symptoms appear to be related with

criticism of others to a weak degree (Table 85).

Three correlations of statistical significance v/ith paranoid

hostility were detected at study-points I (Table 20), III (Table 36)

and IV (Table 65). This appears to be a strong relationship. Compared

with the other DSSI/R subgroups, ruminative symptoms take a similar

place to delusions of disintegration, dissociative symptoms and

delusions of grandeur just below delusions of persecution v/hich has

the most close association with paranoid hostility (Table 86).

Correlations of significance with total intropunitiveness were

observed at study-points II (Table 36) and III (Table 51). A close

to significance correlation at study-point IV (Table 65) was also

detected. These data suggest a moderate association. Compared with

the other DSSI/R subgroups, ruminative symptoms take a place among

state of anxiety, state of depression and delusions of persecution

which appear to have the closest association with intropunitiveness

(Table 87).

One correlation of significance with self-criticism was detected at

study-point III (Table 51)? there is also a near to significance 4 correlation at study-point II (Table 36). This result suggests a

weak overall association between ruminative symptoms and self-

.121

criticism. Compared v/ith the other DSSI/R sets, ruminative

symptoms take a place between a minority group moderately associated

and a majority group v/ith no association with self-criticism

(Table 88).

Concering the relationships with guilt, one correlation of high

significance was observed at study-point II (Table 36) and two near

to significance correlations at study-points I (Table 20) and IV

(Table 65)• Vis-a-vis the other DSSI/R subgroups ruminative symptoms

take a similar position to compulsive symptoms (Table 89).

No correlation of significance v/ith direction of hostility was

detected, although two non-significant negative correlations were

detected at study-points III and IV (Appendix C).

Concluding it would appear that ruminative symptoms on changing

appear to be related very strongly to general hostility responses;

they are also related to both extrapunitiveness and intropunitiveness,

the association being closer with the former. The extrapunitive

responses are expressed mostly with paranoid hostility and to a

lower degree with acting-out hostility and criticism of others. The

intropunitive responses are expressed mainly as guilt and to a lesser

degree as self-critical attitudes.

.122

6.5-9- Relationships Between the Score Changes of Delusions of

Grandeur (dG) and the HDHQ Subscales

Correlations of statistical significance between the score changes

of delusions of grandeur and one or more HDHQ subscales we re observed

at all the study-points (Table 78).

No correlation of acceptable significance betv/een delusions of

grandeur and total hostility was observed; a near to significance

correlation was found at study-point IV (Table 67)- Delusions of

grandeur is the only DSSI/R set manifesting no overall association

with total hostility (Table 82).

Correlations of statistical significance v/ith total extrapunitiveness

were detected at study-points I (Table 21) and IV (Table 67)

suggesting a moderate association. Compared with the other DSSI/R

subgroups delusions of grandeur take a sinilar position v/ith state of

depression and delusions of persecution below dissociative symptoms

and phobic symptoms (Table 83).

No correlations of acceptable statistical significance v/ith acting-

out hostility and criticism of others were detected; negative non-

significant correlations v/ith acting-out hostility at study-point

III and v/ith criticism of others at study-point II were found

(Appendix C).

Correlations of significance with paranoid hostility at study-

points II (Table 38)» H I (Table 53), IV (Table 67) and a near to

significance at study-point I (Table 21) were detected. This implies

a strong association. Compared v/ith the other DSSI/R subgroups, delusions

.123

of grandeur chare a similar position with ruminative symptoms,

dissociative symptoms and delusions of disintegration bfelow

delusions of persecution which is the DSSI/R set most closely

associated with paranoid hostility (Table 86).

One significant correlation with total intropunitiveness at

study-point IV (Table 67) and two negative non-significant

correlations at study-points I and II (Appendix C) were observed.

This is seen as a weak overall level of association. Compared with

the other DSSI/R sets, delusions of grandeur could be regarded as one

of the sets that are most loosely related to total intropunitivcnose

(Table 87).

One significant correlation with self-criticism at study-point IV

(Table 67) and two negative non-significant correlations at study-

points I and II (Appendix C) were observed, suggesting a weak

overall relation. Vis-a-vis the other DSSI/R subgroups, delusions

of grandeur take a place among the less strongly related subgroups

(Table 88).

No correlation of significance v/ith guilt was detected; two near to

significance positive correlations at study-points III (Table 53)

and IV (Table 67) and two non-significant negative correlations at \

study-points I and II (Appendix C) v/ere observed. .

A statistically significant negative correlation with direction of

hostility at study-point I (Table 21) and two non-significant

negative correlations at study-points II and III (Appendix C) were

found; this is regarded as a weak overall level of negative

.124

interrelationship suggesting that delusions of grandeur gravitate in

an extrapunitive direction.. Compared v/ith the other DSSI/R

subgroups, the delusions of grandeur set is v/ith dissociative

symptoms and delusions of persecution among the few DSSI/R

subgroups having a relationship v/ith direction of hostility

(Table 90).

It v/ould appear that the association between the score changes of

delusions of grandeur and punitive responses is weak and although

this .DSSI/R set has links with both general extrapunitive and to some

extent general intropunitivie attitudes it seems that is is centered

more on extrapunitive, predominantly paranoid hostility, responses.

.125

6.5-10. Relationships Between the Score Changes of Delusions of

Persecution (dP) and HDHQ Subscales.

Correlations of statistical significance between the score changes

of delusions of persecution and one or more HDHQ subscales v/ere

detected at all the study-points (Table 79)-

Two correlations of significance with total hostility at the

study-points II (Table 37) and IV (Table 66) and another near to

significance at study-point III (Table 52) were found. This could

be regarded as a moderate overall level of association. Compared

with the other DSSI/R subgroups, delusions of persecution take a

similar position to delusions of contrition and state of depression

coming below dissociative symptoms and phobic symptoms (FS)

(Table 82).

Almost the same applies to total extrapunitiveness; two correlations

of significance at study-points III (Table 52) and IV (Table 66) and

another near to significance at study-point II (Table 37) were

observed. The overall association with total extrapunitiveness could

therefore be regarded as a moderate one. Compared with the other

DSSI/R subgroups, delusions of persecution take a similar place to

delusions of grandeur and state of depression coming below dissociative

symptoms and phobic symptoms (FS) (Table 83). \

Acting-out hostility seems to have a moderate association with

delusions of persecution as well; two correlations of statistical

significance were observed at study-points II (Table 37) and

III (Table 52) and another near to significance at study-point I

.126

(Table 22). Compared with the other DSSI/R subgroups, it takes a

place below state of depression which is the set most closely

associated v/ith acting-out hostility (Table 84).

No correlation of significance between delusions of persecution and

criticism of others was detected. We should, however, mention the

two negative non-significant correlations observed at the study-

points I and II (Appendix C) and a near to significance correlation

observed at study-point IV (Table 66).

The relationship with paranoid hostility is very strong. Correlations

of statistical significance were observed at all the study-points.

Vis-a-Vis the other DSSI/R subgroups, delusions of persecution could

be regarded as the set most closely related to paranoid hostility

(Table 86).

The association v/ith total intropunitiveness seems to be a moderate one

with two correlations of significance at the study-points II (Table 37)

and IV (Table 66). Compared with the other DSSI/R sets, it could be

regarded as one of the sets that are most closely related to total

intropunitiveness (Table 87)•

No correlation of acceptable statistical significance with self-

criticism was detected; but we should mention two negative

non-significant correlations observed at the study-points I and III

(Appendix C) and a near to significance correlation, observed at

study-point IV (Table 66).

.127

A strong overall association with guilt is observed; correlations

of statistical significance at study-points II (Table 37), H I

(Table 52) and IV (Table 66) were found. These findings put the

link between delusions of persecution and guilt in the first position

compared with the other DSSI/R subgroups, state of depression and

delusions of contrition being in a second place (Table 89).

A significant negative correlation at study-point III (Table 52)

and another non-significant negative at study-point IV (Appendix C)

with direction of hostility were observed indicating a weak overall

level of association. But, despite this loose relationship, delusions

of persecution belongs to the small number of DSSI/R sets having a very

close relationship with direction of hostility, the other sets being

in the non-relationship position \Table 90).

It could be concluded that reports of delusions of persecution, are not

related strongly to general hostility reports. They are related mainly

to extrapunitive responses, predominantly those of paranoid hostility

and acting-out hostility. General intropunitiveness is moderately

mobilized, slightly less than extrapunitiveness; there is also a fairly

close relationship with the score changes of guilt.

i

. 1 2 8

6.5»11« Relationships Between the Score Chanson of Delusions of

Contrition (dC) and HDHQ Subscales.

Correlations of significance between the score changes of delusions

of contrition and HDHQ subscales were observed at the study-points

I, II and IV (Table 80).

Correlations of statistical significance with total hostility were

found at the study-points II (Table 39) and IV (Table 68) the overall

association being a moderate one (Table 82).

As far as the relationships with total extrapunitiveness are concerned, I

one correlation of significance at the study-point IV (Table 68)

and another close to significance at study-point II (Table 39) were

detected. Compared with the other DSSI/R subgroups,delusions of

contrition take a similar place as the subgroups less closely associated

with total extrapunitiveness (Table 83).

One correlation of low significance with acting-out hostility in

study-point II (Table 39) was observed. This is regarded as a weak

overall association. Compared with the other DSSI/R subgroups, delusions

of contrition are placed among those associated -less closely with act-

ing hostility (Table 8*+).

A correlation of low significance with criticism of others was observed

.at study-point IV (Table 68). As with the majority of the DSSI/R

subgroups, delusions of contrition have a weak overall association

with criticism of others (Table 85)* It should be mentioned that

non-significant negative correlations with criticism of others

were detected at study-points I and II (Appendix C).

.129

Correlations of statistical significance with paranoid hostility

were detected at the study-points I (Table 23) and IV (Table 68);

one close to significance correlation at study-point II (Table 39)

and a negative non-significant correlation at study-point III

(Appendix C) v/ere also detected. This is seen as a moderate overall

relation. Compared with the other DSSI/R sets, delusions of

contrition have a similar place with state of anxiety and compulsive

symptoms; this association is closer than the association with state

of depression (Table 86).

A correlation of very low significance with total intropunitiveness

at study-point II (Table 39) and another close to significance at

study-jpoint I (Table 23) were observed. This suggests a weak overall

association; delusions of contrition have a more remote relationships

v/ith total intropunitiveness than state of depression, state of

anxiety, ruminative symptoms and delusions of persecution (Table 87)•

No correlation of significance between delusions of contrition and

self-criticism was detected.

As far as .relationships v/ith guilt are concerned, statistically

significant correlations were observed at study-points I (Table 23) i 1

and II (Table 39); a non-significant negative correlation v/as also

detected at study-point III (Appendix C). This could be regarded as

a moderate overall association. Compared with the other DSSI/R

sets, delusions of contrition take a similar position as state of

depression being below delusions of persecution (Table 89).

.130

No correlations of significance between delusions of contrition and

direction of hostility were found but two negative non-significant

correlations were detected at the study-points III and IV (Appendix C)

Concluding it could be said that there is a loose association between

the score changes of delusions of contrition and general hostility

responses. Extrapunitive responses could be regarded as slightly

more closely related to delusions of contrition than intropunitive

ones. Theextrapunitive responses are expressed predominantly as

paranoid hostility and to a lesser degree as acting-out hostility

and criticism of others. The intropunitive responses are manifested J as guilt.1,

.131

6.5«12. Relationships Between the Score Changes of Delusions of

Disintegration (DP) and HDIIQ Subscales'.

Correlations of significance between the score changes of delusions

of disintegration and the HDHQ subscales were observed at the study-

points I, II and IV (Table 82).

One correlation of moderate significance with total hostility was

detected at the study-point IV (Table 69) and a negative non-

significant correlation at study-point II (Appendix C). This is seen

as a weak overall association. If compared with the other DSSI/R

•subgroups, delusions of disintegration are in a similar position

as conversion symptoms (PS)-, compulsive symptoms (CS), and state of

elation, only above delusions of grandeur (Table 82).

The same applies to total extrapunitiveness; only one correlation of

moderate significance at study-point IV (Table 69) was found; a close

to significance correlation at study-point I (Table Zk) was also

detected. Compared with the other DSSI/R sets, delusions of

disintegration, take a similar position as the sets less closely

associated with total extrapunitiveness (Table 83).

No correlations of significance between delusions of disintegration

and acting-out hostility score changes were detected; a non-significant

negative correlation at study-point II was found (Appendix C).

No correlations .of significance v/ith criticism of others was

detected either; a close to significance correlation at study-point

IV was found (Table 69).

.132

Three significant correlations v/ith paranoid hostility at the

study-points I (Table 24), II (Table 40) and IV (Table 69) and one

close to significance at study-point III (Appendix C) were found.

The overall relationship between delusions of disintegration and

paranoid hostility thus appears to be a strong one. Compared v/ith the

other DSSI/R subgroups, delusions of disintegration take a

place below delusions of persecution which is the subgroup most

closely associated with paranoid hostility (Table 86).

One significant correlation with total intropunitiveness at study-

point IV (Table 69) and two negative non-significant correlations

at the study-points I and II (Appendix C) were observed. This is

regarcfed as a weak overall association. Vis-avis the other DSSI/R

subgroups, delusions of disintegration take a place among the subgroups

less closely associated with total intropunitiveness (Table 87),

No correlation of significance between delusions of disintegration

and self-criticism was observed; one positive close to significance

finding at study-point IV (Table 69) and two negative non-significant

correlations at the study-points I and II (Appendix C) were observed.

As far as guilt is concerned, conflicting results have been obtained.

A negative statistically significant correlation at study-point I

(Table 24) and a negative non-significant correlation at study-point

II (Appendix C) were detected. A positive statistically significant

correlation was found at study-point IV (Table 69). Cqmpared with the

other DSSI/R subgroups, delusions of disintegration have a unique

position having two different characteristics; first, they are the

.133

only DSSl/R set having a negative although weak relationship with

guilt and second they are placed among the subgroups positively

associated with guilt (Table 89).

No correlation of statistical significance with direction of hostility

was observed; negative correlations, one close to significance at

study-point I (Table' 24) and another non-significant at study-point

II (Appendix C) were observed.

It could "be concluded that changes of delusions of disintegration

scores are not associated with general hostility, total intropunitive

and total extrapunitive responses in a considerable degree; as far

as general hostility and general intropunitiveness are concerned,

negative tendencies have also been noticed. There is, however, a

strong association with paranoid hostility and there are complex

relationships with guilt.

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6.5.13. SUMMARY

The results are viewed and presented from two angles: 1. The

associations "between the score changes of DSSl/R sets and HDHQ

subscales in each study-point separately. 2. The overall

associations between each DSSl/R set and the HDHQ subscales talcing

the study-points together. The general characteristics of the

population (age, clinical status, DSSl/R class allocation, clinical

diagnoses) for the sample as a whole and for those remaining at

each study-point are described.

.135

7. D I S C U S S I O N

It is not easy to determine in what ways the results of this study

have been influenced by the sampling technique, the size of the

sample, the general-. characteristics of the population, the way the

questionnaires were administered, the diagnoses of the patients who

participated or the therapeutic environment. It is clear however,

that generalizations and final conclusions based on such a small

sample as this could not be expressed with absolute confidence.

Some patients exceeded the five weeks time interval between the

completion of the questionnaires; in other patients the lapse of

time was much shorter than five weeks.

The psychiatric patient is commonly expected to stay in the hospital

for a duration of about six to eight weeks. Priest, Raptopoulos and Chan

(1979) showed that in the psychiatric unit of St. Mary's Hospital,

London W.9, during the period 1977 - 1979, when a frequency diagram was

made up of numbers of we6ks of in-patient stay, a duration of stay

for a time up to one week was the commonest. The frequencies then fell

week by week (with a median of two weeks) and 90 percent of the patients

had been discharged before the lapse of 13 weeks.

The time of stay in the hospital of the patients that participated

in the present study gives some idea of the difficulties encountered

in trying to collect a large number of participants. Between the

first and the second study-point there was a drop-out of about 50

percent. This is because of the very high discharge rate; the majority

.136

of the patients remained in tie hospital for. a period less than eight

weeks and the commonest duration of stay was less than 4- weeks (Figure 1).

This is an explanation of the small size of the sample and particularly

for the very small numbers of the patients who participated in the

study-points III and IV,

On the other hand, the main reason that the time that elapsed between

successive completions of the questionnaires extended beyond the five

weeks time limit was the reluctance on the part of the participants to

complete their questionnaires or their grudging delay in doing so. In

some cases it was very difficult to persuade a patient to complete his

questionnaire, although he had originally agreed to participate in the

study. This was the case for patients who had completed two or three

batteries of questionnaires and then became tired of the procedure.

As a consequence it could be hypothesized that the results of this study

have been distorted to an unknown extend as a result of this attribution.

In the following pages I shall discuss the relationships between HDHQ

subscales and DSSl/R sets and I shall try to compare our findings with

those of other investigators whenever this is possible. I have to point out

that what I studied in this work are relationships between score changes

of certain subscales with the passage of time; this is a different approach

than that used in other studies. In the large majority of the studies re-

viewed in the survey of the literature, the relationships between hostility

and psychiatric symptoms were studied in single occasions. In very few

studies repeated measurements were carried-out during the course of the

psychiatric illness.

.137

Other factors which may influence the attempt to compare the results

of this study with those of other studies are other methological differences

such as the alternative definitions or meanings given to tie various

concepts and the different instruments that were used. Thus, although

the common denominator between these studies and the present study is the

examination of relationships between hostility and psychiatric symptoma-

tology, the differences in method may, to some extend, explain the dis-

crepancies in the conclusions.

How could ttie selection of the sample affect the results ?

The mixture of the diagnostic categories of tie patients who participated

in the study may be regarded as a factor influencing the results, but

this influence is difficult to assess.

The relationships between the score changes of HDHQ subscales and DSSl/R

. sets may be expected to reflect to some extent the relationships between

symptomatological processes and hostility that take place during the course

of a psychiatric illness ; these instruments, however, have their limitations

known and unknown - and the conditions under which they have been used in

this study-may put further limitations on their validity, reliability

and sensitivity.

It is important to Jteep in mind that even if the study were carried out

under perfect conditions, the correlations between the measures employed

would reflect only the degree of convariance under the particular

conditions of the study, and they may be found to go in quite different

directions under different circumstances.

138

It is appropriate, before begining the discussion of the findings,

to describe the instruments used, the advantages and disadvantages of

choosing such instruments and the background from which they emerged.

.139

7.1. Self-rating Scales

The difficulties inherent in arriving at consistent and adequate clinical

diagnostic categories for the purposes of research and therapy in psychiatric

patients have been pointed out by a number of authors.

Ward et al (1962) found in an experimental investigation nine basic

sources of disagreement in psychiatric diagnosis. They attributed these

to : a) the inconsistent behaviour of the diagnostician 32,5% J b)

inadequacy of tie nosological system, 62,5% ; c) the inconsistent behaviour

of the patient, 5%. These inconsistencies could be mostly attributed to

the lack of specific definitions of the various symptomatological

categories and to the various degrees of subjective biases resulting

from the unavoidable personal approach of the interviewer.

Pasamanic et al (1959) viewed the low inter-clinical agreement on diagnosis

as an indictment of the present state of psychiatry and called for the

development of verifiable criteria for classification, based not on personal

considerations but on behavioural and other objectively measurable mani-

festations. . Foulds (1965 b) pointed out that the lack of valid measuring

instruments is one of the great difficulties in arriving at a fuller

understanding of the nature of personality-trait and symptom complexes.

Attempts by a considerable number of investigators to submit clinical

observations and judgements to objective measurement have resulted in

a wide variety of psychiatric observer-rating scales, self-rating scales

and inventories.

However, there are criticisms regarding the efficacy of objective

.140

psychometric tests, reflecting various points of view.

Zubin (1967) pointed out that the primary advantage of the diagnostic

interview over its derivatives lies in the fact that the chief purpose

of interviewing in psychopathology is not to obtain factual information

but to cbtermine attitudes and feelings, and the only means the inter-

viewer has available for eliciting attitudes and feelings is the

utilization of verbal and non-verbal behaviour e.g. reinforcement,

surprise, change of tempo, silence etc.

Horn (1950) challenges the assumption that the items of an inventory

convey the same or similar meaning to everyone who takes the test. He

argues that a personality self-rating questionnaire is in the nature of a

projective test : each item serves as an ambiguous stimulus whose

interpretation is affected by the subject's needs, wishes, fears and

so on. This verdict would remove from consideration the self-rating

inventory as an accurate self-evaluation.

Jackson and Messick (1957) emphasize;the intrusion of tendencies such as

acquiescence, overgeneralization and the giving of socially desirable

responses..' Regarding the socially desirable responses which seem to be

an important uncontrolled variable, it was suggested (Edwards, 1953 J

Rosen, 1956 ; Fordyse, 1956) that responses to inventory items are at least

in part determined by the respondent's desire to place himself in a favour-

able position. This tendency assumes considerable inportance in a hostility

inventory which deals with behaviours that are generally regarded as

socially unacceptable. It would be objected at this point, however,

.141

that whereas with variables such as intelligence and neuroticism there

is considerable agreement as to which end of tiie scale is desirable, an

individual's own position in relation to an attitude (such as hostility )

is by definition perceived as good if it is ego-syntonic.

Other authors point out that some questionnaires described as personality

inventories are in fact a mixture of items covering symptoms and traits

and the results produced are confusing and difficult to interpret.

The lack of validation against an outside criterion (Mailer, 1944),

the inadequate preparation of the testing instruments and inadequate theories

of personality are blamed for iais deficiency (Cronbach, 1949)*

According to Foulds (1965 b), the first step in .the development of an

adequate measuring instrument should be the logical separation of the two

concepts of trait and symptom, involving the distinction of the more

general from the more specific, the more permanent from the more transient

and the promoters from the inhibitors.

Since the purpose of the assessment is to differentiate amongst individuals

it is important that the tests are reliable, in the sense that they always

differentiate in the same way, valid in that they should differentiate in

the way they are intended to, and — in the case if questionnaires examining

psychiatric symptoms - sensitive in that they should reflect changes in the

symptomatology with the passage of time.

Both observer ratings and self-ratings have their merits. Self-rating scales

pose problems when dealing with psychotic patients. Perhaps a more serious

.142

problem is that of compliance. Not all patients are able or prepaired to

complete a questionnaire containing a systematic enquiry about their symptoms.

Guy and his colleagues (1967) have discussed the influence of the observer

on assessment results. As Eysenck (1970)points out "rating cannot be

taken strictly as a description of the person rated ; it is always quite

inevitably an interaction between rater and ratee. Some raters tend to be

over-generous, giving ratings toward.; the favourable end of the scale

to nearly everybody". The term "halo-effect" refers to the tendency for ratings

of an individual on specific traits to be influenced by the overall im-

pression that he gives. Kellner (1972) reviewing the literature regarding

the use of psychometric instruments in research he found no difference

between self-ratings and observer1s ratings but he was able to compare

only two rating scales.

The ability of self-rating techniques to approximate to or confirm

clinical judgements through means other than the clinical interview offers

a number of advantages in their use for research purposes: They meet

the problem of the variability of clinical judgement about nosological

entities and provide standardised, consistent measures which are not

vulnerable to the theoretical orientation or idiosyncracies of the indivi-

duals who administer them, minimising, thus, the biases of the assessors.

Since they provide numerical scores, they facilitate comparison with

other quantitative data. Since they reflect changes of symptomatology

with the lapse of time, they provide measures for judging improvement

resulting from various forms of therapy (Kellner, 1971> 1972; Shapiro, 1961)#

They also are useful for screening the mentally disturbed in the general

population (Goldberg, 1972; Wing, Cooper, Sartorious, 1974; Bedford, Foulds,

Sheffield, 1976).

.143

A variety of psychometric techniques have been devised for measuring specific

personality traits or psychiatric symptoms. Many of them are standardised

with normative data provided and with known validity and reliability.

Regarding the personality questionnaires, Eysenck's personality Inventory

E.P.I. (Eysenck and Eysenck, 1964-) is a U.K. based questionnaire measuring

neuroticism and extraversion and widely used. Kelly's repertory grid tech-

nique (Kelly, 1955) has become popular as a personality test in clinical asses-

sment. It is a method of empirically determining the structure of an indivi-

dual' s perceptions and it enables the construct systems of individuals to be

analysed and described quantitavely. A repertory grid is produced when

a person is asked to classify a set of elements by his personal-repertory of

constructs. Kelly's repertory grid is not standardized but is flexible so that

the person being tested rates people and objects. This is a very individual-

istic method of assessment and it is difficult to study populations with

it.

'As far as the psychometric intruments dealing with psychiatric symptoms

are concerned, examples of successful questionnaires could be mentioned here

such as the Crown and Crisp Middles sex Hospital Questionnaire - MHQ .(Crown and

Crisp, 1966; Crown and Crisp, 1970; Crown et al 1970; Crisp and Priest, 1971).

The MHQ is confined to neurotic as opposed to psychotic disorders and measures

six neurotic categories : anxiety, phobic symptoms, obsessional symptoms,

somatic symptoms of anxiety, depressive symptoms and hysterical features«

Present State Examination - PSE is a special type of observer rated diagnostic

inventory which is a standardised clinical interview (Wing et al 1974-)• There

are also inventories that concentrate on a specific category of symptoms such

as anxiety (Taylor, 1953; Hamilton, 1959) or depression (Hamilton, 1960;

Beck et al 1961; Zung, 1965) • More recently attention has been directed to-

wards a-more precise measurement of changes in psychiatric symptomatology during

the course of the

.144

illness. Montgomery and Asberg (1978) constructed a depression rating scale particularly sensitive to changes due to treatment. This scale consists of 10 items selected from the Comprehensive Psychopathological Rating Scale or CPRS (Asberg et al 1978) which covers a wide range

of psychopatholbgical variables and it is used for the measurement of

the change of psychiatric symptoms and signs during the course of time.

In this study preference was given to two self-report instruments, the

Hostility and Direction of Hostility Questionnaire - HDHQ (Caine et al

1967) and the Delusions Symptoms State Inventory - DSSl/R (Bedford and

Foulds, 1978 a).

.145

7.2. Hostility and Direction of Hostility Questionnaire (HDHQ.)

The techniques for tie measurement of hostility have ranged from those

designed to assess personality characteristics with one or more hostility

components, to those concerned with hostility per se or aspects of it.

They have included observer and self-ratings, inventories, questionnaires

and check-lists. Most of them have tended to be global devices, some of them

projective techniques and some derived from the Minesota Multiphasic

Personality Inventory (MMPI),. (Hathaway and Mc Kinley, 1951; Welsh and

Dahlstrom, 1956). The MMPI was originally developed as an aid to diagnostis | of psychiatric disorders. Its authors began with a set of several hundred

statements covering psychiatric symptoms, physical health, general habits

domestic, occupational and social affairs. Score keys were then developed

according to the power of each item to discriminate various criterion groups,

regardless of the content or apparent meaning of the statement. This is a

reliable instrument but distinguishes poorly between character traits and

symptoms.

The Rosenzweig's Picture- Frustration test (1948) is a projective technique

which devides direction of hostility into extrapunitive, intropunitive

and impunitive categories.

A detailed review of -Rorschach and Thematic Apperception Test (TAT) hostility

scales has been written by Hafner and Kaplan (1960).

Siegel (1956 a) has developed a hostility scale from the MMPI, the Manifest

Hostility Scale (MHS), reflecting the degree to which the individual is

willing'to express hostility. With the MHS, Siegel attempted to study hostility

in what he referred to as authoritarian and non-authoritarian groups.

.146

Buss and Durkee (1957) deviced an inventory for the assessment of various

aspects of hostility. The items of this inventory were selected mostly

from the MMPI but they underwent some degree of modification. It

consists from 75 items which represent eight aspects of hostility;

assault, indirect hostility, irritability, negativism, resentment,

suspicion, verbal hostility and guilt. Factor analysis of the items of this

inventory, revealed an attitudinal component of hostility (resentment

and suspicion) and a "motor" component (assault, indirect hostility, ir-

ritability and verbal hostility).

i

Gottschallk et al (1963) applied a method of hostility assessment, based

on verbal speech analysis of their subjects. Three scales are obtained

from the verbal material : hostility-out scale, hostility-in scale and

an ambivalent hostility scale. The hostility-out scores positively for .

critical and destructive impulses aimed at objects outside the self.

The hostility-in scale scores positively for self-critical statements and

expressions of depressed affect and injured narcisism. The ambivalent

hostility scale, though derived from verbal communications suggesting

destructive and critical thoughts or actions of others to tie self, measures

not only some aspects of hostility directed inward but at the same time

some features of hostility directed outwards.

The hostility and Direction of Hostility Questionnaire - HDHQ

(Foulds, Caine and Creasy, 1960; Caine at al 1967)

was devised as an attitudinal measure and is designed to measure a wide,

though not exhaustive, range of possible manifestations of aggression,

hostility or punitiveness. Two broad dimensions underlie hostility as

measured by the HDHQ. These may be conceptualised (Blackburn, 1974-) as the

.147

readiness to respond with aggressive behaviour and the tendency to

evaluate persons, including the self, in negative and unfavourable

terms. Five scales totalling 52 items have been selected on face vali-

dity from the MMPI of which three, acting-out hostility (AH), criticism

of others (CO) and paranoid hostility (PH) are measures of extrapunitiveness,

while the remaining two self-criticism (SC) and delusional guilt (G) measure

intropunitiveness.

Paranoid hostility implies a feeling of direct personal receipt of hostility,

a belief in an act of open enmity about which the question of delusional

thinking might be raised. The scale of guilt covers delusional guilt,

more realistic feelings of guilt and low self-esteem. . . The .self-criticism

scale consists of items of one's own ability and adequacy in particular

areas, or on a tendency to belittle one's own achievements. The Criticism

of others scale consists of items implying negative evaluations about

persons other than the self. Acting-out hostility consists of items

implying readiness to manifest physical aggressive behaviour.

Every subscale appears t> be measuring something different (to some degree)

from every other one and to justify its separate existence. Foulds, Caine

and Creasy (1960) found that all the correlations between the subscales

ere positive allowing the postulation of a factor of general punitivenss.

But when the size and pattern of the correlations were considered it was

clear that the extrapunitive » scores together were to some extend

measuring something different from the intropunitive scores. Hope (1963)

and Philip (1968) tested these assumptions about the unitary nature of

hostility and its direction inward or outward by calculating the principal

components of a number of subtest correlation matrices on normal and neurotic

samples. Their results showed a similar component structure both for normals

.148

and neurotics, the first component (total hostility) being unipolar

with all five subtests represented, while the second component

(direction of hostility) contrasted the intropunitive scales SC and G

with AH,CO and PH, the extrapunitive measures. An exception to the predic-

ted finding was that in the normal sample acting - out hostility had

a very small loading on the second component, in the light of which

finding Hope(1963) reinterpreted this scale as an "urge" to act-out hostility

which implies a readiness to manifest physical aggressiveness.

In the HDHQ we can distinguish delusional blame scales (PH, G) and non-

delusional blame scales (AH,C0,SC); the non-delusional blame is a measure

of rather more habitual attitudes whereas the delusional blame reflects

a somewhat transient and exaggerated deviation from, or even reaction

against, the patient's usual attitudes (Foulds, 1965 b); however, the

delusional scales do not necessarily represent full delusions in the

clinical sense.

Punitiveness as measured by HDHQ is mainly an attitudinal facet of per-

sonality with very little implication of actual assault or aggressive

behaviour physically expressed. Somatisation of aggression (e.g.,

psychosomatic disorder) is also excluded from the questionnaire (Caine et al

1967). An analysis of its item content (Philip, 1973) shows that only

6 of the 52 items carry connotations of physical aggressiveness. Most

of the extrapunitive items deal with verbal anger and impatience (6),

cynical views about people's motives (6), resentment of others (9),

and delusions of persecution (5)* Five of the intropunitive items are

concerned with delusions of guilt; the remainder are self-critical in

content, five being specifically concerned with under-rating one's

ability to perform tasks. It can be seen from-this breakdown that extra-

. 1 4 9

punitiveness on the HDHQ will be characterised by resentment, anger and

synicism while intropunitiveness will be manifested with expressions of

guilt, self-doubt and self-criticism.

For calculating scores Hope (1963) set out formulae which would appro-

ximate to full component scores. For general punitiveness the formula is

AH+CO+PH+SC+G ; for direction of punitiveness the formula is (2SC + G) -

(AH + CO + PH), positive scores indicating a balance in the direction of

intropunitiveness.

Other studies (Mayo, 1967; Philip, 1969, 1973) pointed out that experience i

with the,' questionnaire indicated that the two intropunitive measures

SC and G varied over time than the three extrapunitive measures. For these

reasons, Philp suggested that it might be profitable to measure extrapunitive-

ness and intropunitiveness independently rather than considering them in a

direction of hostility score. His proposal was accepted by other authors

(Warder, 1969; Mayo and Bell, 1971; Blackburn, 1974)• This additional

scoring is included in the present study i.e., AH + CO + PH summing to give

the extrapunitive score and the simple sum of SC + G giving the intropunitive

score.

A modified version of the method of criterion groups was used in the

validation of the questionnaire. This method was applied both to the

individual tests of the HDHQ and to the second principal component of the

questionnaire . The reliability of the questionnaire was estimated by the

calculation of test-restest correlations. "The questionnaire was administered'

to a sample of thirty normal persons and-.the subjects were retested one

year later (Caine et al 1967).

Normative data on the HDHQ have been provided by several authors (Hope, 1963 ;

Philip, 1968; Mayo and Bell,- 1971). Philip (1968) detected some variation

. 1 5 0

in the scores of normal populations from different areas of U.K. and

suggested the need of caution in the use of normative data since local

norms may vary considerably.

The HDHQ has been used for measuring hostility in alcoholics (Walton, 1968;

Foulds and Hassel, 1969; Ritson, 1971) in drug trials (Ross and Priest, 1970)

in attempted suicide cases (Vinoda, 1966), prisoners (Caine et al 1967;

Foulds, 1968; Philip, 1968; Crawford, 1977; Blackburn, 1968), in d?ug

dependence (Anymonye,^1970; Gossop and Roy, 1976), in psychopaths (Foulds,1967)

to differentiate between neurotic/patients who seek treatment and those

who do not 1(Foulds and Mayo, 1967), to differentiate between patients with

"psychic" and "somatic" symptoms (Foulds, 1966) and in other clinical

situations (Caine and Smail, 1969). It was also administered to different

cultural and ethnic groups (Fernardo, 1966,1969; Giel 5-972).

.More recently the HDHQ's limitations , which include its forced answer

' format (false-true) and the problems created by symtom-like subscales

(PH and G) have been under closer examination (Foulds, 1976; Philip, 1969).

As a result the PDS (Personality Deviance Scale) has been devised (Bedford

and Foulds, 1978 b) which is to a considerable 'degree a successor to the

'HDHQ.

The HDHQ is fully presented in Appendix A.

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7.3. Delusions-Symptoms-States Inventory (DSSI)

The Delusions-Symptom-States-Inventory (DSSI) (Bedford and Foulds, 1978 a)

is a self-report scale developed by Foulds and Bedford (1975)* Its prede-

cessor, symptom-sign-Inventory (SSI) (Foulds and Hope, 1968) was designed

as an aid to the diagnostic procedure rather than to describe characteristics

of symptomatology ; the SSI was an observer scale and was presented orally.

The DSSI differ s from the SSI in that it is more descriptive than diagnostic.

Although psychiatric diagnosis has been formally abandoned as an outside

criterion for the allocation of items to traditional syndromes, the items

were intended to be representative of the salient features of particular

clinical conditions. It has no specific relevance to mental subnormality,

to symptomatology resulting specifically from organic brain disease nor to

traits of personality disorder. The DSSI was explicitly designed to

detect symptoms and states-evidence of discription of normal continuity of

the personality, distressful to tie patient - as opposed to the personality

variables of traits that are universal, relatively ego syntonic and of long

duration.

Although the DSSI is used as a self- report checklist, this does not

preclude' its eventual use in semi structured situations (Foulds, 1976;

Bedford and Foulds, 1978 a). There are two temporal versions, "most of my

life" (ML) and "recently" (R). In this study the R form is usedin which

all items begin with tie word "Recently". DSSl/R is composed of twelve

sets which represent the four classes of personal illness. These sets are :

. 1 5 2

C l a s s 4 . D e l u s i o n s o f d i s i n t e g r a t i o n (DD), r e p r e s e n t i n g the c l i n i c a l

d i a g n o s i s o f s c h i z o p h r e n i a . I n t h i s s e t though d i s o r d e r and i n c o n g r u i t y

o f a f f e c t a re no t r e p r e s e n t e d , bu t many o f the i tems a re concerned w i t h l o s s

o f awareness o f the s e l f a s a g e n t , l o s s o f the bounda r i e s o f s e l f concept ,

a u d i t o r y and v i s u a l h a l l u c i n a t i o n s .

C l a s s 3 . I n t e g r a t e d d e l u s i o n s ( I D ) , T h i s i s made up o f three s e t s :

d e l u s i o n s o f p e r s e c u t i o n (dP) r e p r e s e n t i n g pa rano id d i s o r d e r , d e l u s i o n s

o f g randeur (dG) r e p r e s e n t i n g mania, and d e l u s i o n s o f c o n t r i t i o n (dC)

r e p r e s e n t i n g p s y c h o t i c d e p r e s s i o n .

C l a s s 2. N e u r o t i c symptoms ( N S ) . T h i s i s composed o f f i v e s e t s :

conver s ion ' symptoms c o r r e s p o n d i n g t o the c l i n i c a l syndrome o f c o n v e r s i o n

h y s t e r i a ; f o r t h i s s e t F o u l d s ( 1976 ) used the term p i t h i a t i c symptoms

( P S ) . D i s s o c i a t i v e symptoms (DS) r e p r e s e n t i n g d i s s o c i a t i v e h y s t e r i a ;

phob ic symptoms r e p r e s e n t i n g p h o b i c d i s o r d e r ; f o r t h i s s e t F o u l d s (1976)

u sed the term f e a r symptoms ( F S ) . Compuls ive symptoms (CS) r e p r e s e n t i n g

o b s e s s i v e d i s o r d e r when t a k i n g the form o f r i t u a l s and rum ina t i ve symptoms

(RS) r e p r e s e n t i n g o b s e s s i v e d i s o r d e r when t a k i n g the form o f r um ina t i on s .

C l a s s 1 . Dysthymic s t a t e s (DYS ) . T h i s c l a s s i s composed o f th ree s e t s :

s t a t e o f a n x i e t y ( sA ) r e p r e s e n t i n g a n x i e t y s t a t e , s t a t e o f dep re s s i o n ( sD )

r e p r e s e n t i n g n e u r o t i c d e p r e s s i o n and s t a t e o f e l a t i o n ( s E ) r e p r e s e n t i n g

hypomania.

The 84 i tems from wh ich DSS l /R i s composed, a l t h o u g h n o t e x h a u s t i v e ,

encompass a l a r g e p a r t o f the r a n g e o f phenomena r epo r t ed by p a t i e n t s and

e x t e n s i v e l y d e s c r i b e d i n p s y c h i a t r i c l i t e r a t u r e . F o u l d s and Bed fo rd (1975)

t r i e d , i n c o n s t r u c t i n g the i n v e n t o r y , to c on f i ne themselves to t ho se f ea tu re s

. 1 5 3

wi thou t which the p s y c h o p a t h o l o g i c a l c o n d i t i o n cou l d n o t be con s i de red .

They emphasize the p o i n t t h a t f a i l u r e to do t h i s has o f t e n r e s u l t e d

i n t h e unnece s sa r y l e n g t h e n i n g o f i n v e n t o r i e s and weakened them i n

the sense t h a t i t ems a r e i n t r o d u c e d which a re common to many syndromes

and t h u s c rea te u n d e s i r a b l e o v e r l a p between syndromes, e s p e c i a l l y

when i t ems are n o t r e s t r i c t e d t o symptoms and s i g n s bu t i n c l u d e p r e c i -

p i t a t i n g e ven t s , age and p e r s o n a l i t y c h a r a c t e r i s t i c s .

I t ems answered " f a l s e " s co re 0 . I n n e a r l y a l l i n s t a n c e s i n the e i g h t

s e t s c o m p r i s i n g the dy s thymic s t a t e s and n e u r o t i c symptoms c l a s s e s ,

i f the pe r son a f f i r m e d the q u e s t i o n , he h a s a d d i t i o n a l l y to

i n d i c a t e the extend t o wh ich i t u p s e t s him, f o r example ; a b i t ,

a l o t o r unbea rab l y . • O c c a s i o n a l l y , p a r t i c u l a r l y f o r the s t a t e o f

e l a t i o n , the f requency o f occurance i s a s ked , f o r example : seldom

o f t e n o r n e a r l y a lway s . S c o r e s 1 , 2 , o r 3 are g i v e n to the d i r e c t i o n

o f i n c r e a s i n g d i s t r e s s o r f r equency . A pe r s on a f f i r m i n g any o f tie

d e l u s i o n a l i tems h a s to i n d i c a t e the degree o f h i s c o n v i c t i o n , f o r

example : n o t v e r y s u r e , f a i r l y s u r e , o r c e r t a i n . These a re

l i k e w i s e scored ' 1 , 2 o r 3 . Those who s co re 4- o r more on any s e t - which

r e q u i r e s the endorsement o f a t l e a s t two i tems - are a l l o c a t e d to t h a t

s e t .

Bed fo rd and F o u l d s (1977) p r e s e n t e d t h ree s t u d i e s a s s uppo r t i v e

ev idence f o r the v a l i d i t y o f D S S I . I n the. f i r s t , s e n i o r p s y c h o l o g i s t s

and p s y c h i a t r i s t s were a sked to a l l o c a t e the 84 i tems to c l i n i c a l s y n -

dromes. I n the second, f u r t h e r r e f e r e e s had to put 17 D S S I i t ems -

f o r wh ich the p s y c h o l o g i s t s ' and t he p s y c h i a t r i s t s ' a s s i gnment d i d no t

co r r e spond to t h a t o f the a u t h o r s o f the i n v e n t o r y - i n t o the D S S I s e t s .

. 1 5 4

T h i s was done a s p r e d i c t e d i n a l l b u t two i tems . I n the t h i r d s tudy

c l i n i c i a n s o f v a r i e d exper ience were a sked to r a t e t h e i r p a t i e n t s

a c c o r d i n g to the p resence o f D S S I syndromes. These r a t i n g s b r oad l y

agreed w i t h the p a t i e n t s ' s c o r e s on the D S S I s e t and f o r n i ne o f the

twelve D S S I s e t s the a s s o c i a t i o n was s t a t i s t i c a l l y s i g n i f i c a n t .

I n p r e v i o u s s t u d i e s and i n A f f e r e n t s e t t i n g s the two aforement ioned

i n t r ument s ( D S S I and HDHQ) were u sed i n combinat ion ( F o u l d s and

Bed fo rd , 1 976 ) . Be fo re the development o f the DSS l/R i t s p r e d e c e s s o r s

Runwel l Symptoms S i g n s I n v e n t o r y o r R S S I ( F o u l d s , 1962) and the S S I

were used w i t h HDHQ. The R S S I and the HDHQ have been u sed by Adams

and F o u l d s ( 1962 ; 1963 ) . The S S I and HDHQ have been used by F o u l d s

( 1964 ; 1965 ; 1966 ; 1967 ; 1968 ) , F o u l d s and Mayo ( 1967 ) , Mayo ( 1967 ) , V i noda

( 1966 ) , Walton (1968) and Warder ( 1 9 6 9 ) . 'The P e r s o n a l Deviance S c a l e s

(Bedford and F o u l d s , 1978 b) (wh ich i s the s u cce s s o r o f the HDHQ) have beer,

u sed w i t h DSS l/R i n v a r i o u s r e s e a r c h p r o j e c t s ( Fou ld s and Bedfo rd ,

1976 c; 1977 a ) .

. 1 5 5

7 . 4 * A note on the d e s c r i p t i v e s t a t u s o f the da ta .

Rega rd i ng the s c o r e s o f the HDHQ s u b s c a l e s and the DSS l/R s e t s t h a t

ob t a i ned a t the- f o u r s t u d y - p o i n t s the d e s c r i p t i v e data (mean, s . d ,

v a r i a n c e ) a re d i s p l a y e d i n n u m e r i c a l form i n the t a b l e s 13 , 30 , 45

and 59 • These r e s u l t s a re a l s o d i s p l a y e d i n a d i f f e r e n t form i n

f i g u r e s numbered from 2 to 8 .

The means o f the s c o r e s o f t o t a l h o s t i l i t y - TH, t o t a l e x t r a p u n i t v e n e s s

TE and t o t a l i n t r o p u n i t i v e n e s s - T I . which are obta ined i n the f o u r

s t u d y - p o i n t s a re p re sen ted i n F i g . 2 . I t can be seen t h a t there i s

a tendency towards r e d u c t i o n w i t h the excep t i on o f s t u d y - p o i n t I V

where there i s an i n c r e a s e o f the means of the s co re s o f these HDHQ

s u b s c a l e s . I t i s apparent t h a t t he means o f t o t a l h o s t i l i t y - and

t o t a l e x t r a p u n i t i v e n e s s a re h i g h e r t han those ob ta ined from t o t a l

i n t r o p u n i t i v e n e s s . I t can a l s o be seen tha t t o t a l h o s t i l i t y and t o t a l

e x t r a p u n i t i v e n e s s change to a g r e a t e r degree than t o t a l i n t r o p u n i t i v e n e s s

d u r i n g the cou r se o f p s y c h i a t r i c symptoms* The same p a t t e r n o f dec rea s i ng

s c o r e s a l ong the f i r s t t h r ee s t u d y - p o i n t s and i n c r e a s i n g s co re s i n t h e

f o u r t h s t u d y - p o i n t h o l d s t r ue f o r c r i t i c i s m o f o t h e r s - CO whereas f o r

p a r a n o i d h o s t i l i t y - PH the re i s a con t i nuou s decrease o f the mean

s c o r e s i n the f o u r s t u d y - p o i n t s . F o r a c t i n g - o u t h o s t i l i t y - AH the re

i s an i n c r e a s e o f s c o r e s i n s t u d y - p o i n t I f o l l o w e d by a decrease i n

the r e s t th ree s t u d y - p o i n t s ( F i g . 3 ) « Decrease o f the mean v a l u e s o f

the s c o r e s o f g u i l t - G i s o b s e r v e d i n a l l the s t u d y - p o i n t s except

s t u d y - p o i n t I I I i n which an i n c r e a s e i s observed; s e l f - c r i t i c i s m - SC

mean s c o r e s show a f l u c t u a t i n g c o u r s e a l ong the f o u r s t u d y - p o i n t s ( F i g . 4 ) .

/

I t i s n o t an unexpected f i n d i n g t h a t gene ra l h o s t i l i t y dec rea se s w i t h

. 1 5 6

the pas sage o f t ime i n p s y c h i a t r i c p a t i e n t s . T h i s v iew i s suppor ted by

a l l the a u t h o r s i n v o l v e d i n the s t udy o f h o s t i l i t y a s i t i s r e l a t e d to

p s y c h i a t r i c symptomatology. Bu t a l t h o u g h the f i n d i n g s o f the p r e s e n t

s tudy show a c oncu r r en t dec rea se o f both e x t r a p u n i t i v e n e s s and i n t r o -

p u n i t i v e n e s s the d rop o f the f i r s t i s more pronounced than t h a t o f the

second. T h i s i s i n c o n t r a s t w i t h the b r o a d l y accepted v iew t h a t p s y c h i -

a t r i c p a t i e n t s , w i t h the p a s s a g e o f t ime, become more e x t r a p u n i t i v e and

l e s s i n t r o p u n i t i v e . There i s no t a s a t i s f a c t o r y e x p l a n a t i o n a v a i l a b l e f o r

t h i s phenomenon. P o s s i b l y an u n c o n t r o l l e d f a c t o r r e l a t e d to the

t h e r a p e u t i c env i ronment p l a y e d a r o l e . The i n c r e a s e o f the s c o r e s o f

these h o s t i l i t y f e a t u r e s o b s e r v e d i n s t u d y - p o i n t I V cou ld be r e l a t e d to

the f a c t t h a t the p a t i e n t s ' p a r t i c i p a t e d i n t h i s s t u d y - p o i n t a re r a t h e r

c h r o n i c p a t i e n t s . I n c h r o n i c p a t i e n t s a f t e r an i n i t i a l drop o f the s co re s

o f h o s t i l i t y to the l o w e s t p o s s i b l e l e v e l , a f l u c t u a t i o n o f the l e v e l of

h o s t i l i t y c ou l d s t a r t wh ich i s p r o b a b l y r e l a t e d to the s p e c i a l t h e r a p e u t i c

c i r cums tance s o f tie p a t i e n t s .

A s f a r a s the DSS l/R s e t s a r e concerned i t i s worth ment ion ing t h a t

the h i g h e s t v a l u e s were r e c o r d e d f o r state- o f d e p r e s s i o n - $ D and

s t a t e o f a n x i e t y - sA ( F i g . 5)# These v a l u e s tend to decrease i n the

f i r s t two s t u d y - p o i n t s but t h i s t r e n d i s r e v e r s e d - i n the s t u d y - p o i n t s

I I I and I V . D i s s o c i a t i v e symptoms - DS ( F i g . 7 ) and d e l u s i o n s o f d i s i n t e -

g r a t i o n - DD ( F i g . 8) show a s i m i l a r p a t t e r n bu t t h e i r s c o r e s a r e much l o w e r

f a l l i n g i n l i n e w i t h tie r e s t o f D S S l /R s e t s . I n r um ina t i ve symptoms - R S

( F i g . 7) the re i s a dec rea se o f t h e mean s c o r e s i n the s t u d y - p o i n t s I and

I I and an i n c r e a s e i n s t u d y - p o i n t I V , bu t they show no change i n s tudy-

p o i n t I I I . There c o u l d be two d i f f e r e n t e x p l a n a t i o n s o f t h i s p i c t u r e :

a c c o r d i n g to the f i r s t , t h i s p a t t e r n r e f l e c t s i n i t i a l degrees o f improvement t

which a f t e r a p e r i o d o f time are s u s t a i n e d and then r e v e r s e d because of

r e l a p s e s o f these symptoms; a c c o r d i n g to t h e second, i n the f i r s t tiro

. 1 5 7

s t u d y - p o i n t s more acute p a t i e n t s p a r t i c i p a t e d and t h e i r r a p i d improvement

i s r e f l e c t e d i n tie d rop o f t he s c o r e s ; i n the f o l l o w i n g two s t u d y - p o i n t s

more c h r o n i c p a t i e n t s p a r t i c i p a t e d and t h e i r p e r s i s t e n d symptomatology i s

r e f l e c t e d a l s o i n the s c o r e s .

S t a t e o f e l a t i o n - s E s c o r e s dec rea se c o n t i n u o u s l y a l ong a l l the s t u d y -

p o i n t s ( F i g . 5 ) * I t would be h y p o t h e s i z e d t h a t p s y c h i a t r i c p a t i e n t s r e p o r t i n g

a s t a t e o f e l a t i o n a re i n a s e r i o u s s i t u a t i o n indeed and the decrease o f the

s c o r e s i n t h i s s e t r e f l e c t t h e i r improvement and the r e g a i n i n g o f some o f

i n s i g h t which i n h i b i t s them f rom b e i n g i n c o n g r u o u s l y happy.

The p a t t e r n f o l l o w e d i n c o n v e r s i o n symptoms - PS s co re s i s s i m i l a r to

t h a t o f s t a t e o f e l a t i o n .

F o r the phob ic symptoms - F S ( F i g . 6) there i s a tendency towards a r e -

d u c t i o n o f the s c o r e s w i t h t he e x c e p t i o n o f s t u d y - p o i n t I I I i n wh ich there

i s an i n c r e a s e e D e l u s i o n s o f g randeur - dG ( F i g . 8) show a l s o the same

p a t t e r n o f mean s c o r e s .

I n d e l u s i o n s o f p e r s e c u t i o n - dP t h e r e i s a decrease o f the mean sco re

i n t ie f i r s t th ree s t u d y - p o i n t s and a s ha rp i n c r e a s e i n s t u d y - p o i n t I V

( F i g . 8 ) . T h i s p o s s i b l y r e f l e c t s t he f a c t t h a t a s we proceed from s t u d y - p o i n t

I t o d iudy -po in t I V the sample becomes more " p s y c h o t i c " w i t h the departure

o f the more n e u r o t i c p a t i e n t s ; p r o b a b l y r e l a p s e s o f the i l l n e s s i n members

o f a v e r y sma l l g roup o f p a t i e n t s a r e r e s p o n s i b l e f o r t h i s s ha rp i nc rease

o f the means o f the s c o r e s *

I t c ou l d g e n e r a l l y be assumed th&t a l l the DSS l/R s c o r e s show a (fecrease of

the mean s c o r e s i n t he f i r s t two s t u d y - p o i n t s and the m a j o r i t y o f them show >

an i n c r e a s e i n the l a s t two s t u d y - p o i n t s . I t i s e v i den t from t h e s co re s

ob t a i ned by the two p sychomet r i c i n s t r u m e n t s t h a t there i s a decrease for

. 1 5 8

the m a j o r i t y o f both.- HDHQ and DSS l /R s ub se t s a s expres sed by the means of

t h e i r s c o r e s i n s t u d y p o i n t s I and I I and an i n c r e a s e i n s t u d y - p o i n t I I I

which becomes even more pronounced i n ' s t u d y - p o i n t I V .

T h i s p i c t u r e r e f l e c t s i n a c l e a r way the p a r a l l e l cou r se s o f p s y c h i a t r i c

symptoms and h o s t i l i t y f e a t u r e s w i t h the l a p s e o f t ime.

. 1 5 9

7*5* Anxiety and H o s t i l i t y

The most impor tant o b s e r v a t i o n i n the p r e s e n t s tudy r e g a r d i n g

the r e l a t i o n s h i p s between s t a t e o f a n x i e t y and HDHQ measures i s t h a t

there i s a v e r y s t r o n g a s s o c i a t i o n between the sco re changes o f

s t a t e o f a n x i e t y and t o t a l h o s t i l i t y and a l s o t o t a l e x t r a p u n i t i v e

r e s p o n s e s . From the twelve D S S l / R s e t s t h a t were examined, o n l y

r um ina t i v e symptoms have a s c l o s e a r e l a t i o n s h i p w i t h HDHQ measures.

I t c o u l d be assumed t h a t p s y c h i a t r i c p a t i e n t s r e p o r t i n g e l eva ted

s t a t e o f a n x i e t y e x p r e s s a l s o h i g h s c o r e s on gene ra l h o s t i l i t y . ,

d i r e c t e d ma in l y e x t r a p u n i t i v e l y wh ich change i n p a r a l l e l w i th the

changes i n s t a t e o f a n x i e t y . F o u l d s (1965 b) t h e s i s , t h a t s t a t e

o f a n x i e t y i s p o s i t i v e l y a s s o c i a t e d w i t h gene ra l h o s t i l i t y , c r i t i c i s m

o f o t h e r s and s e l f - c r i t i c i s m , i s i n accordance w i t h t he r e s u l t s

ob ta i ned i n the p r e s e n t s t u d y p a r t i c u l a r l y a s f a r a s changes o f

g e n e r a l h o s t i l i t y a re concerned; r e g a r d i n g the changes o f c r i t i c i s m

o f o t h e r s and s e l f - c r i t i c i s m the d a t a o f the p r e sen t s tudy s u g g e s t

a much l e s s c l o s e a s s o c i a t i o n ( T a b l e s 1 4 , 3 1 , 4 7 , 6 0 , 7 0 ) .

Another impo r tan t o b s e r v a t i o n i s t h a t the e x t r a p u n i t i v e r e spon se s

c e r t a i n l y w i t h respect to t o t a l e x t r a p u n i t i v e n e s s and pa rano id h o s t i l i t y

but t o a l e s s e r degree f o r c r i t i c i s m o f o t h e r s , p r e v a i l over the

i n t r o p u n i t i v e ones man i f e s ted a s s e l f - c r i t i c i s m and g u i l t . The f i n d i n g s

o f some a u t h o r s based on s i ng le -measurement s t u d i e s ( L i a k o s e t a l ,

1977; P h i l i p , 1971) t h a t a n x i e t y i s p o s i t i v e l y c o r r e l a t e d w i t h

g e n e r a l h o s t i l i t y , t o t a l i n t r o p u n i t i v e n e s s , g u i l t and s e l f - c r i t i c i s m

do n o t c o n t r a d i c t w i t h the da ta o f the p re sen t s t udy . However i t i s

impor tant to s t r e s s t ha t the a s s o c i a t i o n between the changes o f

s t a t e o f a n x i e t y and t o t a l e x t r a p u n i t i v e n e s s i s s t r o n g e r than t h a t

. 1 6 0

w i t h t o t a l i n t r o p u n i t i v e n e s s .

The v iew ( C a t t e l , 1964; F e r n a r d o , 1977) t h a t a n x i e t y i s accompanied

by g u i l t i s a l s o i n accordance w i th the data o f the p re sen t s tudy but

t h i s a s s o c i a t i o n does n o t seem to be v e r y s t r o n g .

The p s y c h i a t r i c p a t i e n t who r e p o r t s a n x i e t y cou l d be t he re f o r e expected to

become l e s s g e n e r a l l y h o s t i l e and l e s s e x t r a p u n i t i v e w i t h the improvement

o f h i s a n x i e t y o r more h o s t i l e d i r e c t i n g h i s h o s t i l i t y outward ly a s

h i s a n x i e t y g e t s worse . T h i s i s n o t i n accordance w i th the t h e s i s t h a t

e x p r e s s i o n o f h o s t i l i t y i n an outward d i r e c t i o n i s a s s o c i a t e d w i t h isduced

l e v e l s o f a n x i e t y (Gardos e t a l 1968; D i Masc io e t a l 1969; L o r en z , 1966

Bandura e t a l 1973 ) * No such n e g a t i v e c o r r e l a t i o n between s t a t e o f anx ie t y

and any HDHQ s u b s c a l e was ob se r ved i n the p r e sen t s tudy . What a c t u a l l y

happened was t h a t s t a t e o f a n x i e t y , t o t a l h o s t i l i t y and t o t a l e x t r a p u n i -

t i v e n e s s had p a r a l l e l c o u r s e s . The l a c k o f a s s o c i a t i o n between s t a t e o f

a n x i e t y and a c t i n g - o u t h o s t i l i t y s c o r e changes , however cou ld be rega rded

. a s an i n t e r e s t i n g f i n d i n g . A c t i n g - o u t h o s t i l i t y re semb le s , more t han any

o the r HDHQ s u b s c a l e , what the above a u t h o r s regarded a s h o s t i l i t y o r

a g g r e s s i v e n e s s ; the re i s n o t , o f c o u r s e , a nega t i v e r e l a t i o n s h i p i n the

p r e s e n t s tudy but n e i t h e r i s t he re a m a t e r i a l p o s i t i v e one. I t s hou l d

be a l s o po i n t ed out t h a t t he se a u t h o r s r epo r t ed nega t i ve r e l a t i o n s h i p s

between a n x i e t y and h o s t i l i t y bu t t hey d e f i n e d and measured them i n

v a r i o u s ways under d i f f e r e n t s i t u a t i o n s and w i th d i f f e r e n t samples.

G e n e r a l l y i t c ou l d be s a i d t h a t the r e s u l t s o f t h i s s tudy are i n

accordance w i th C a t t e l ' s (1964) d e s c r i p t i o n o f the anx i ou s pe r son a s

s u s p i c i o u s , l a c k i n g con f i dence and h a v i n f f e e l i n g s o f unwor th i ne s s ; f rom

the r e s u l t s ob ta ined from the p r e s e n t s tudy i t c ou l d , f u r the rmore , be assumed

t h a t these c h a r a c t e r i s t i c s a re no t u n a l t e r a b l e b u t , on

. 1 6 1

the c o n t r a r y , f o l l o w the changes o f a n x i e t y w i th the pas sage o f t ime.

P a r ano i d h o s t i l i t y and s e l f - c r i t i c i s m are the main channe l s th rough

which p a t i e n t s r e p o r t i n g a n x i e t y e x p r e s s t h e i r h o s t i l i t y i n t h i s

s t udy . T h i s ' r a t h e r c o n t r a d i c t o r y f i n d i n g might be a t t r i b u t e d

to .the f a c t t h a t s c h i z o p h r e n i c p a t i e n t s (expected to r e p o r t d e l u s i o n s

o f p e r s e c u t i o n ) and dep re s sed p a t i e n t s (expected t o r e p o r t f e e l i n g s

o f s e l f - b l a m e ) a re i n c l u d e d i n r e l a t i v e l y h i g h p r o p o r t i o n s i n the

sample t h a t p a r t i c i p a t e d i n t h i s s t u d y .

. 1 6 2

7 . 6 . D e p r e s s i o n and H o s t i l i t y

The r e l a t i o n s h i p s between changes o f h o s t i l i t y and two d i a g n o s t i c

c a t e g o r i e s o f d e p r e s s i o n have been con s i de red i n t h i s s tudy .

S t a t e o f d e p r e s s i o n r e p r e s e n t s n e u r o t i c d e p r e s s i o n and d e l u s i o n s

o f c o n t r i t i o n r e p r e s e n t s p s y c h o t i c d e p r e s s i o n .

Changes o f s t a t e o f d e p r e s s i o n measures^were no t found to be c l o s e l y

a s s o c i a t e d w i t h changes o f t o t a l h o s t i l i t y s c o r e s i n the p re sen t s t udy .

Other DSS l /R s e t s , such a s r u m i n a t i v e symptoms and s t a te o f a n x i e t y ,

have a much c l o s e r r e l a t i o n s h i p w i t h gene ra l h o s t i l i t y . The same

a p p l i e s to i n t r o p u n i t i v e r e s p o n s e s ; the r e l a t i o n s h i p appears to be

l e s s c l o s e than i t would p r o b a b l y be expected f o r d e p r e s s i o n wh ich

i s w i d e l y rega rded a s c l o s e l y r e l a t e d to i n t r o p u n i t i v e a t t i t u d e s .

I n t h i s case however, i t i s t r ue t h a t no o the r DSS l/R s e t t ake s

precedence over s t a t e o f d e p r e s s i o n and , f rom t h i s p o i n t o f v i ew,

s t a t e o f d e p r e s s i o n c o u l d be r e g a r d e d a s one o f the DSS l/R s e t s t h a t

a re most c l o s e l y a s s o c i a t e d w i t h i n t r o p u n i t i v e r e s p o n s e s .

A l t h o u g h the a l r e a d y weak a s s o c i a t i o n between the changes o f s e l f - c r i t i c i s m

and s t a t e o f d e p r e s s i o n i s s uppo r t ed by a c l o s e to s i g n i f i c a n c e c o r r e l a t i o n ,

we a re n e v e r t h e l e s s f a r f rom a c c e p t i n g the v iew ( F o u l d s , 1965 b)

t h a t s e l f - c r i t i c i s m i s behav i n g a s a d i a g n o s t i c measure f o r d e p r e s s i o n .

I t would be acceptab le f o r an HDHQ s ub s ca l e to be rega rded a s behav i n g

a s a d i a g n o s t i c measure i f i t were c l o s e l y r e l a t e d to the symptom

changes d u r i n g the cou r s e o f the i l l n e s s , a f e a t u r e which h a s no t

been observed so f a r a s s e l f - c r i t i c i s m i s concerned* G u i l t was

m o b i l i z e d somewhat more f r e q u e n t l y than s e l f - c r i t i c i s m i n r e l a t i o n

to s t a t e o f d e p r e s s i o n changes . T h i s i s t o some ex ten t an unexpected

f i n d i n g s i n c e g u i l t , a s i t i s r e f l e c t e d i n the HDHQ, h a s a d e l u s i o n a l

. 1 6 3

q u a l i t y \h ich i s no t a c h a r a c t e r i s t i c o f neu ro t i c dep re s s i on . T h i s

predominance o f g u i l t over s e l f - c r i t i c i s m i s p o s s i b l y r e l a t e d to

the .fact t h a t p s y cho t i c p a t i e n t s r e p o r t i n g s t a te of dep re s s i on p a r t i c i p a t e d

i n t h i s s t udy .

As f a r a s the r e l a t i o n s h i p o f dep re s s i on w i th e x t r apun i t i v ene s s i s

concerned t h i s appears t o be o f the same degree as t ha t noted w i t h genera l

h o s t i l i t y and genera l i n t r o p u n i t i v e n e s s , a l though the a s s o c i a t i o n between

the score changes o f these two v a r i a b l e s cou ld be regarded a s somewhat

c l o s e r , i f we take i n t o account the c l o se to s i g n i f i c a n c e c o r r e l a t i o n s

observed i n the s t u d y - p o i n t s III and IV. ! I

The a s s o c i a t i o n o f s t a t e o f d e p r e s s i o n score changes w i th t iose o f

a c t i n g - o u t h o s t i l i t y i s the c l o s e s t observed among a l l the DSSl/R s e t s . . The

l e s s depres sed a p a t i e n t becomes . the l e s s he has an urge to a c t - o u t h o s t i -

l i t y . T h i s i s a v e r y impor tant f i n d i n g w i th p o t e n t i a l l y s i g n i f i c a n t c l i n i c a l

i m p l i c a t i o n s . Adams and F o u l d s (1963) repo r ted a p o s i t i v e r e l a t i o n s h i p

between a c t i n g - o u t h o s t i l i t y and a melancho l ic s ca le i n a s i n g l e measurement

and they exp la i ned t h i s r e l a t i o n s h i p as be ing caused by the h i g h p r o p o r t i o n

o f a g i t a t e d p a t i e n t s p a r t i c i p a t e d to t i e i r s tudy . Another e xp l ana t i o n

however cou ld be t ha t a c t i n g - o u t h o s t i l i t y i s an i n d i c a t o r o f the s e v e r i t y

o f d e p r e s s i o n and thu s i t s e f f i c a c y , a s a h o s t i l i t y . subsca le

in detecting f o r , e x a m p l e , s u i c i d a l p a t i e n t s cou ld be o f i n t e r e s t . With

the passage o f time and the i n f l u e n c e o f t he rapy , i n the r e l a t i v e l y safe

and f r i e n d l y environment o f the h o s p i t a l and f a r fbom the per sons and s i t u -

a t i o n s towards whom they have most-problems w i th t h e i r h o s t i l e tendenc ie s ,

p a t i e n t s r e p o r t i n g d e p r e s s i v e symptoms might f e e l i t l e s s n e c e s s a r y to

exp re s s t h i s k i n d o f h o s t i l i t y . The wel l -known view tha t an . ' i nc reas ing

e x p r e s s i o n o f a g g r e s s i o n r e l i e v e s dep re s s i on does no t seem to be i n

accordance w i th tie r e s u l t s o f t h i s study s i n ce there i s not a nega t i ve r e l a -

t i o n s h i p between changes o f tiese v a r i a b l e s .

1 6 4 .

Pa rano i d h o s t i l i t y was found t o be c l o s e l y r e l a t e d to changes o f s t a t e

o f d e p r e s s i o n ; c r i t i c i s m o f o t h e r s was found to be no t r e l a t e d w i t h

s t a t e o f d e p r e s s i o n to an a p p r e c i a b l e degree. N e v e r t h e l e s s the number o f

c o r r e l a t i o n s obse rved i s p r o b a b l y enough evidence to c a s t doubt on the view

t h a t the depre s sed p e r s o n b e i n g a f r a i d o f b laming o t h e r s (PH,C0) , g a i n s s e -

c u r i t y by b laming h i m s e l f i n s t e a d (SC and G) . Thus, the i n f e r ence r e s u l t i n g

from t h i s v i ew, t h a t when c e a s i n g t o blame o t h e r s , b laming the s e l f i s the

o n l y r ema in i ng a l t e r n a t i v e , does n o t seem to ge t enough suppo r t f rom the

r e s u l t s t h a t a re ob t a i ned i n the p r e s e n t s tudy .

As f a r a s the r e l a t i o n s h i p between p s y c h o t i c d e p r e s s i o n ( d e l u s i o n s o f c o n t r i -

t i o n ) and h o s t i l i t y i s concer ned t h e da ta ob ta ined from tie p re sen t s tudy i i

produce a sence o f s u r p r i s e .

The a s s o c i a t i o n obse rved between d e l u s i o n s o f c o n t r i t i o n and t o t a l h o s t i l i t y

i s a t the same l e v e l a s t h a t w i t h s t a t e o f d e p r e s s i o n ;and t o t a l h o s t i l i t y .

A c c o r d i n g to F o u l d ' s v i e w s , t he h i g h e r the p e r s o n a l i l l n e s s c l a s s a p a t i e n t

i s a l l o c a t e d t o , the h i g h e r the amount o f g ene ra l h o s t i l i t y he e x p r e s s e s ;

Mayo (1967) admi t ted t h a t w i t h a p s y c h o t i c a l l y dep re s sed pe r son , the i l l n e s s

i n t r u d e s i n t o the p e r s o n a l i t y i n a raeasureable degree, s u g g e s t i n g a c l o s e r

r e l a t i o n s h i p between p s y c h o t i c d e p r e s s i o n and h o s t i l i t y than between n e u r o t i c

d e p r e s s i o n and h o s t i l i t y . The ^ r e su l t s o f the p r e s e n t s tudy based on the

compar i son between changes i n s c o r e s r a t h e r than on compar i sons between t o t a l

s c o r e s i n s i n g l e s t u d i e s , a re no t i n accordance w i t h these v i e w s .

D e l u s i o n s o f c o n t r i t i o n s co re change s , appear t o be a s s o c i a t e d i n t he same

weak degree w i t h bo th t o t a l i n t r o p u n i t i v e n e s s and t o t a l e x t r a p u n i t i v e n e s s ;

the meaning o f t h i s f i n d i n g c o u l d be t h a t the more dp re s sed p a t i e n t s r e p o r t '

an improvement o f t h e i r symptoms t he l e s s i n t r o p u n i t i v e they become; t h i s i s

t o be exprec ted . The unexpected a s p e c t o f t h i s f i n d i n g i s . t h a t t hey become l e s s

e x t r a p u n i t i v e a s w e l l . The r e a s o n o f t h i s equ i va l ence , hypo the t i c a l l y , cou ld be

t h a t p a t i e n t s r e p o r t i n g d e l u s i o n s o f c o n t r i t i o n were c l i n i c a l l y

. 1 6 5

i n a s t a te o f a g i t a t i o n .

Concern ing the e x t r a p u n i t i v e s ub s ca l e s i t seems t ha t parano id h o s t i l i t y

i s the main channel th rough which these low l e v e l s o f h o s t i l i t y a re e x -

p r e s s ed by p a t i e n t s r e p o r t i n g changes o f t h e i r d e l u s i o n s o f c o n t r i t i o n .

I f we take i n t o account one c l o s e t o s i g n i f i c a n c e c o r r e l a t i o n detected i n

s t u d y - p o i n t I I pa rano id h o s t i l i t y cou ld be regarded as even more c l o s e l y r e l a t e

to d e l u s i o n s o f c o n t r i t i o n than i s g u i l t . Th i s f i n d i n g cou ld be a t t r i b u t e d

to the f a c t t h a t melancholic p a t i e n t s have a r ead i ne s s towards d e l u s i o n a l

a t t i t u d e s . F ou l d s e t a l (1960) f o und tha t male melancho l ies gave h i g h s c o r e s

on pa rano id h o s t i l i t y . S chzophren i c p a t i e n t s with d e l u s i o n s o f p e r s e c u t i o n

repo r ted a l s o d e l u s i o n s o f c o n t r i t i o n and one cou ld expect them to connect

these symptoms w i t h p r o j ec ted h o s t i l i t y .

The a s s o c i a t i o n between the sco re changes o f a c t i n g - o u t h o s t i l i t y and d e l u -

s i o n s o f c o n t r i t i o n i s a weak one and the same takes p lace v/ith c r i t i c i s m o f

o t h e r s .

The a s s o c i a t i o n between g u i l t melancho l ia has u s u a l l y been regarded a s

a s i g n i f i c a n t one (Fou ld s e t a l 1960 ; Adams and F o u l d s , 1962; F o u l d s , I965).

Accord ing to the r e s u l t s o f the p r e s e n t s tudy the r e l a t i o n between the s c o r e

changes o f g u i l t and d e l u s i o n s o f c o n t r i t i o n might be regarded a s o n l y

a moderate one. However, i f we compare t h i s r e l a t i o n s h i p with those of t he

other BSS l/R s e t s , we can see, t h a t , w i th the except ion o f d e l u s i o n s of

p e r s e c u t i o n and s t a t e o f d e p r e s s i o n , a l l the o ther s e t s are a s soc i a ted w i t h

g u i l t l e s s c l o s e l y than d e l u s i o n s o f c o n t r i t i o n .

Adams and Fou l d s (1963) r epo r ted s i g n i f i c a n t c o r r e l a t i o n s between s e l f - c r i t i -

c i sm and the melancho l i c s c a l e o f R S S I ( Fou l d s , 1962 ) . They d i d no t

expect t h i s s i n ce i n a p r e v i o u s s t udy (Fou lds and Ca ine , 1959) such

. 1 6 6

d i f f e r e n c e between melancho l i ' c s and n e u r o t i c ..depress ives had not been found*-

Th i s f i n d i n g p o s s i b l y i m p l i e s t ha t p a t i e n t s r e p o r t i n g symptoms o f p s y cho t i c

dep re s s i o n have no t the a b i l i t y to l o o k a t themselves because t h e i r s e l f - concep t

ha s become d i s t o r t e d and they are nea r to d i s i n t e g r a t i o n o f t h e i r personhood.

S c h i z o p h r e n i s are mos t l y the p a t i e n t s repor ted d e l u s i o n s o f c o n t r i t i o n i n t h i s

s tudy .

I f changes i n s t a t e o f d e p r e s s i o n and d e l u s i o n s o f c o n t r i t i o n are compared

r e g a r d i n g t h e i r r e l a t i o n s to the changes o f h o s t i l i t y measures (Table 91 ) , i t

cou ld be seen t h a t both have the same, moderate, a s s o c i a t i o n w i th genera l h o s -

t i l i t y r e spon se s . Both are r e l a t e d to mixed extrapunit ive: -and i n t r o p u n i t i v e

r e spon se s ; d e l u s i o n s o f c o n t r i t i o n , however, are r e l a t e d to both ex t r apun i t i v ene

and i n t r o p u n i t i v e n e s s . a t a lower l e v e l and s ta te o f dep re s s i on has a s l i g h t l y

more c l o s e a s s o c i a t i o n w i th e x t r a p u n i t i v e n e s s . I t i s obv ious tha t the t h e s i s

t h a t the genera l h o s t i l i t y measure i s so s e n s i t i v e t ha t i t cou ld be used a s an

i n d i c a t o r o f the s e v e r i t y o f t h e d e p r e s s i o n (Mayo, 1967) i s c o n s i s t e n t with t he

r e s u l t s o f the p r e sen t s t udy , i n wh i ch changes between these v a r i a b l e s are

examined.

P i l o w s k i and S p e n c e ' s (1975) v iew, s u g ge s t i n g a p o s i t i v e r e l a t i o n s h i p between

d e p r e s s i o n and e x t r a v e r s i o n , i s i n accordance w i th a 3.arge p a r t o f the f i n d i n g s

o f the p re sent s tudy p a r t i c u l a r l y a s f a r a s the r e l a t i o n s h i p between the s c o r e

changes o f s t a t e o f d e p r e s s i o n and e x t r a p u n i t i v e n e s s - i n t r o p u n i t i v e n e s s s ub s ca l e s

i s concerned, p r ov i ded t h a t e x t r a v e r s i o n and e x t r apun i t i v ene s s are s u b s t a n t i a l l y

a s s o c i a t e d as i t ha s been shown by Fou ld s (1965b). Others (Salmon, 1964;

Coppen and Metca l fe , 1965; L y k e t s o s e t a l 1978) s ugge s t an i n v e r s e r e l a t i o n -

s h i p between d e p r e s s i o n and e x t r a p u n i t i v e n e s s , which was not observed i n t h i s

s tudy . Wessman e t a l (1960). and G r i n ge r e t a l (1972) s ugge s t i n g t h a t p a t i e n t s

w i t h h i g h l e v e l s o f h o s t i l i t y - o u t are l e s s depressed than the c l a s s i c a l p a t i e n t s

w i t h h i g h h o s t i l i t y - i n . T h i s a g a i n i m p l i e s an i n v e r s e r e l a t i o n s h i p between

e x t r a p u n i t i v e n e s s and dep re s s i o n .

.167

Concern ing the HDHQ s u b s c a l e s , on the e x t r a p u n i t i v e s i de s t a te o f

dep re s s i on score changes are a s s o c i a t e d predominant ly with a c t i n g - o u t

h o s t i l i t y and to a much l e s s e r degree with pa rano id h o s t i l i t y . On the

o ther hand d e l u s i o n s o f c o n t r i t i o n are r e l a t e d predominant ly w i th p a r a -

n o i d h o s t i l i t y and to a l e s s e r degree w i th c r i t i c i s m o f o the r s and a c t i n g - o u t

h o s t i l i t y . N e u r o t i c a l l y depres sed p a t i e n t s on improv ing cou ld be expected t o

show lower l e v e l s o f a c t i n g - o u t h o s t i l i t y and p s y c h o t i c a l l y depres sed p a t i e n t s

might be expected to . 'manifest .lower ..scores on pa rano id h o s t i X i t y . ' Th i s

d i f f e r e n c e i s a l s o r e f l e c t i n g the d e l u s i o n a l symptomatology which

d i f f e r e n t i a t e s between n e u r o t i c and p s y c h o t i c dep re s s i on .

On the i n t r o p u n i t i v e s i d e , the a s s o c i a t i o n w i th g u i l t changes i s a t the

same l e v e l i n both s t a t e o f dep re s s i on and d e l u s i o n s o f c o n t r i t i o n

changes; bu t s t a te o f d e p r e s s i o n changes are a s s o c i a t e d w i th changes

i n s e l f c r i t i c a l a t t i t u d e s which i s no t observed i n the case o f d e l u s i o n s

on c o n t r i t i o n changes.

C l e a r l y some h o s t i l i t y measures have p a r a l l e l e d the course o f dep re s s i ve

symptomatology to a c o n s i d e r a b l e degree ( such a s a c t i n g - o u t h o s t i l i t y

i n s t a te o f dep re s s i on ) and some have not ( such as s e l f - c r i t i c i s m i n d e l u s i o n s

o f c o n t r i t i o n ) . The most c h a r a c t e r i s t i c d i f f e r e n c e s between those two

p s y chopa tho l o g i c a l e n t i t i e s cou ld be t ha t s t a t e o f dep re s s i on changes are

more c l o s e l y a s s o c i a t e d w i t h e x t r apun i t i v e i i s s and w i th n o n - d e l u s i o n a l

blame (AH,C0,SC) whereas d e l u s i o n s o f c o n t r i t i o n score changes are l e s s

c l o s e l y a s s o c i a t e d w i t h e x t r a p u n i t i v e n e s s and more c l o s e l y a s s o c i a t e d

w i t h d e l u s i o n a l blame (PH,G).

The predominance o f e x t r a p u n i t i v e n e s s over i n t r o p u n i t i v e n e s s , observed in

both s t a te o f dep re s s i on and d e l u s i o n s o f c o n t r i t i o n , may be r e l a t e d to c e r t a i n

g roups o f p a t i e n t s t ha t p a r t i c i p a t e d i n the s tudy . I t has been suggested

(Gershon e t a l 1968; Pa yke l 1971; Lazare and Klerman I968) t h a t p a t i e n t s

. 1 6 8

wi th v a r i o u s k i n d s o f p e r s o n a l i t y d i s o r d e r s who s u f f e r from d e p r e s s i o n

c o u l d d i r e c t t h e i r h o s t i l i t y ou twa rd s . P robab l y the c l o s e r e l a t i o n s h i p

between s t a t e o f d e p r e s s i o n and a c t i n g - o u t h o s t i l i t y found i n t h i s s tudy i

cause d by the r e l a t i v e l y h i g h p r o p o r t i o n s o f depre s sed p a t i e n t s who a l s o

had p e r s o n a l i t y d i s o r d e r s .

G e n e r a l l y i t c ou l d be s a i d t h a t the r e s u l t s wh ich were ob ta ined i n t h i s

s t udy a re c o n s i s t e n t w i t h tie v i ew t h a t r a t h e r than the c l a s s i c f o r m u l a t i o n

i m p l y i n g a n e g a t i v e - r e l a t i o n s h i p between e x t r a p u n i t i v e n e s s and d e p r e s s i o n

we can see an a l t e r n a t i v e p a t t e r n i n wh ich e x t e r i o r i s e d h o s t i l i t y and d e -

p r e s s i o n G o - e x i s t and i n wh i ch t h e r e s p e c t i v e changes w i t h t ime are

no t n e g a t i v e l y c o r r e l a t e d .

. 1 6 9

7 . 7 . Mania and H o s t i l i t y

On examin ing the r e l a t i o n s h i p s ' b e t w e e n the changes o f manic sympto-

matology ( i n the forms o f s t a t e o f e l a t i o n and d e l u s i o n s o f

g randeur ) and h o s t i l i t y , i n the fo rm o f HDHQ s u b s c a l e s (Tab le 9 2 ) ,

i t i s impor tan t to bear i n mind a s was s t r e s s e d by F o u l d s and

Bed fo rd ( 1 975 ) , t h a t the s t a t e o f e l a t i o n s e t might be un ique

among the s e t s o f D S S I i n h a v i n g a d i f f e r e n t s i g n i f i c a n c e f o r

norma l s than f o r p s y c h i a t r i c p a t i e n t s .

I n normals, 'a s t a t e o f e l a t i o n may r e f l e c t a r e a l i t y o f l i f e whereas

i n a p a t i e n t w i t h p s y c h i a t r i c p rob l ems i t may imp ly a p a t h o l o g i c a l

l a c k o f judgment; a l l the p e r s o n s i n v o l v e d i n t h i s s tudy had

p s y c h i a t r i c problems c a u s i n g d i s t r e s s to them o r to t h e i r a s s o c i a t e s .

Of the 28 p a t i e n t s r e p o r t e d s c o r e s a l l o c a t i n g them to the s t a te o f

e l a t i o n 25 were d i a gno sed a s s c h i z o p h r e n i c s .

We shou ld a l s o bear i n mind t h a t t he r e l a t i o n s h i p between s ta te

o f e l a t i o n and d e l u s i o n s o f g r a n d e u r i s i n c l u s i v e and non r e f l e x i v e

a s Bagshaw and Mc Phe r son (1978) showed. T h i s r e l a t i o n s h i p

i m p l i e s t h a t those r e p o r t i n g d e l u s i o n s o f g randeur r e p o r t a l s o s t a t e

o f e l a t i o n but the oppo s i t e does n o t take p l a c e .

I t i s o f i n t e r e s t to note how weak i s the a s s o c i a t i o n t h a t was

observed i n the p r e s e n t s t udy between score changes o f s t a t e o f

e l a t i o n and the h o s t i l i t y a i b s c a l e s . F o u l d s and Bed fo rd (1976 c)

found t h a t p a t i e n t s w i t h s t a t e o f e l a t i o n are low s c o r e r s i n

h o s t i l i t y measures. On ly e x t r a p u n i t i v e r e s pon se s have been detec ted

to have a s s o c i a t i o n s w i t h s t a t e o f e l a t i o n changes, i n p a r t i c u l a r

t o t a l e x t r a p u n i t i v e n e s s , p a r a n o i d h o s t i l i t y and c r i t i c i s m o f o t h e r s .

. 1 7 0

As f a r a s the score changes o f d e l u s i o n s o f grandeur are con -

cerned the a s s o c i a t i o n w i t h g e n e r a l h o s t i l i t y changes i s even

weaker than t h a t w i th s t a t e o f e l a t i o n ; from the twelve DSS l /R

s e t s examined, o n l y d e l u s i o n s o f g randeur score changes f a i l e d

to have any s a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n w i t h t o t a l

h o s t i l i t y score changes V/ith d e l u s i o n s o f g randeur , a l t hough the

d i r e c t i o n i s a g a i n e s p e c i a l l y towards the e x t r a p u n i t i v e s i d e ,

and the re i s e x c l u s i v e l y and s t r o n g l y expre s sed a s pa rano id h o s t i l i t y ,

i n t r o p u n i t i v e r e s p o n s e s have been de tec ted a s w e l l i n the form o f

weak a s s o c i a t i o n s w i t h t o t a l i n t r o p u n i t i v e n e s s and s e l f - c r i t i c i s m .

Thus , the r e s u l t s o f the p r e s e n t s t u d y seem to be i n accordance w i t h

S a l m o n ' s (19&4-) f i n d i n g o f a p o s i t i v e c o r r e l a t i o n between hypomania

and e x t r a p u n i t i v e n e s s and C a i n e ' s e t a l (1967) v iew t h a t manics

are p redominant l y e x t r a p u n i t i v e . Fu r the rmore , a l t hough no t c o n f l i c t i n g

w i t h B l a c k b u r n ' s (1974) paper i n wh i ch she c l a ims t h a t change o f

manic symptomatology towards improvement i s s t r o n g l y a s s o c i a t e d w i t h

a d?op i n e x t r a p u n i t i v e n e s s , ou r v i ew would be l e s s c a t e g o r i c a l

because the a s s o c i a t i o n w i t h e x t r a p u n i t i v e r e spon se s t h a t were observed

i n t h i s s tudy was a weak one. N e v e r t h e l e s s i t cou ld be s a i d t h a t the euphonic

hypomanic p a t i e n t does n o t u s u a l l y f e e l i t nece s s a r y to blame; but when he does

need t o do t h a t , he a v o i d s b l aming h i m s e l f and p r e f e r s t o p r o j e c t h i s h o s t i l i t y

pn t o o t h e r s . I n the p s y c h i a t r i c l i t e r a t u r e the i d e a o f p a r ano i d a t t i t u d e i s

f r e q u e n t l y l i n k e d w i t h t h a t o f mania and g r a n d i o s i t y and v i c e v e r s a .

. 1 7 1

7 . 8 . Conve r s i o n - D i s s o c i a t i v e Phenomena and H o s t i l i t y

From the f i n d i n g s o f the p r e s e n t s t udy i t comes as a g ene ra l c on -

c l u s i o n , i n r e s p e c t o f the r e l a t i o n s between changes i n h o s t i l i t y

and c o n v e r s i o n and d i s s o c i a t i v e phenomena, t h a t these two DSS l/R s e t s

c o u l d be con s i de red a s r e l a t e d ma i n l y t o e x t r a p u n i t i v e r e s p o n s e s .

A l t hough t h i s s tudy i s c o n s i d e r e d w i t h t h e changes o f s co re s w i t h

the pas sage o f t ime i t s f i n d i n g s r e f l e c t the v i ews (based on s i n g l e

measurement) exp re s sed by numerous a u t h o r s (Caine and Hope, 1964.;

Ey sneck , 1962; F o u l d s , 1976) abou t t he e x t r a v e r s i o n o r e x t r a p u n i t i v e n e s s

o f p a t i e n t s m a n i f e s t i n g h y s t e r i c a l symptomatology.

R o s e n z w e i g ' s (1938) t h e s i s on the i m p u n i t i v e n e s s o f the h y s t e r i c s ,

S a l m o n ' s (1964) f i n d i n g o f no c o r r e l a t i o n between h y s t e r i a and

e x t r a p u n i t i v e n e s s and F e r n a r d o ' s (1977) p o s i t i o n t h a t h y s t e r i c a l

m a n i f e s t a t i o n s a re p o s i t i v e l y c o r r e l a t e d w i t h g u i l t , a re n o t i n accordance

w i t h the r e s u l t s o f t h i s s t u d y . M e t h o d o l o g i c a l d i f f e r e n c e s cou ld be

rega rded a s r e s p o n s i b l e f o r t he se r e s u l t s . Rosenzweig u sed h i s

P i c t u r e F r u s t r a t i o n T e s t f o r the measurement o f h o s t i l i t y ; there i s

a t l e a s t one s u g g e s t i o n ( L i a k o s , 1977) t h a t t h i s i n s t r ument measures

a k i n d o f h o s t i l i t y o t he r t han t h a t de tec ted by the HDHQ. S a l m o n ' s

s tudy was based on r e t r o s p e c t i v e d a t a , emerged from a few hundred

o f MMPI r e c o r d s measur ing p s y c h i a t r i c symptoms and h o s t i l i t y and

F e r n a r d o ' s s t udy was based on a sample o f depres sed p a t i e n t s .

I t s hou ld be p o i n t e d ou t a g a i n t h a t s t u d y i n g the r e l a t i o n s h i p s between

h o s t i l i t y and p s y c h i a t r i c symptoms on s i n g l e o c c a s i o n s , a s happens

w i t h these s t u d i e s , might l e a d to d i f f e r e n t i n f e r e n c e s than from s t u d y i n g

the se r e l a t i o n s h i p s i n a framework t a k i n g i n t o account the time f a c t o r .

The i u d i e s o f the second k i n d , however, are r a t h e r r a r e i n the l i t e r a t u r e

. 1 7 2

and one i s f o r ced to make compar i sons w i th the f i r s t type o f s t udy .

A l though the d i s advan tage s o f aich compar i sons are obv ious they

n e v e r t h e l e s s g i ve a c l ue about the r e l a t i o h s i p s o f these v a r i a b l e s .

A p o s s i b l e e xp l ana t i on o f the p a r a l l e l changes o f e x t r a p u n i t i v e n e s s

and c o n v e r s i o n or d i s s o c i a t i v e symptoms may be t h a t somat i za t i on

o f ^mptoms cou ld be regarded a s a s u b s t i t u t e f o r i n t r o p u n i t i v e n e s s .

I t i s b r oad l y accepted t ha t d i s s o c i a t i v e and conve r s i on symptoms,

e x p e c i a l l y the l a t t e r , are the most " s omat i c " groups i n p sychopatho logy .

I n t h i s way, a s Fou ld s (1966) put i t , s omat i za t i on o f symptoms cou ld

be regarded a s an a l t e r n a t i v e o u t l e t f o r i n t r o p u n i t i v e n e s s a t a more

cove r t l e v e l . Cameron (1963) sugge s ted t h a t the d i s t u r b e d p h y s i c a l

f u n c t i o n , wh i ch i s the b a s i s o f c o n v e r s i o n h y s t e r i a , i s a t the same

time the e x p r e s s i o n o f f o r b i d d e n i m p u l s e s , the defences a g a i n s t them

•and the se l f - pun i shment o f h a v i n g such impu l se s . T h i s v iew g i v e s

the b a s i s o f another i n t e r p r e t a t i o n o f the l a c k o f a s s o c i a t i o n between

conve r s i on symptoms and the th ree i n t r o p u n i t i v e s ub s ca l e s : a p a t i e n t

f e e l i n g tha t he i s a l r e ady pun i s hed , may not f e e l the urge to p u n i s h

h i m s e l f a d d i t i o n a l l y .

As f a r a s the r e l a t i o n s h i p s o f d i s s o c i a t i v e and conve r s i on symptoms

score changes w i th the p a r t i c u l a r HDHQ s ub sca le s are concerned, a p a r t

form the s i m i l a r i t i e s between these two p s y chopa tho l o g i c a l i n t i t i e s ,

e s p e c i a l l y w i t h r e spec t to the a s s o c i a t i o n w i th e x c l u s i v e l y e x t r a -

p u n i t i v e r e spon se s , some i n t e r e s t i n g q u a n t i t a t i v e and q u a l i t a t i v e

d i f f e r e n c e s between them cou ld be n o t i c e d (Table 94-)*

D i s s o c i a t i v e symptoms are v e r y c l o s e l y f o l l owed by genera l h o s t i l i t y

and t o t a l e x t r a p u n i t i v e n e s s , pa r ano i d h o s t i l i t y changes be ing the

HDHQ s ub s ca l e most c l o s e l y r e l a t e d t o t h e i r scpre changes.

. 1 7 3

On the o the r hand c o n v e r s i o n symptoms a re no t so c l o s e l y a s s o c i a t e d

w i t h g e n e r a l h o s t i l i t y and i t s e x t r a p u n i t i v e s u b s c a l e s . A p o s s i b l e

e x p l a n a t i o n o f t h i s d i f f e r e n c e c o u l d be t h a t d i s s o c i a t i v e symptoms

imp l y a d i s t u r b e d f u n c t i o n wh ich i s n o t p h y s i c a l . A l l the DS i tems

o f the DSS l /R imp l y a d i s t u r b a n c e o f c o g n i t i v e e t c . f u n c t i o n s . Thus

DS c o u l d be rega rded a s b e i n g i n the " p s y c h o l o g i c a l " po le o f the spectrum

o f the h y s t e r i c a l symptomatology whereas c o n v e r s i o n symptoms be long

t o the " s o m a t i c " po l e o f t h i s spectrum.

Rega rd i n g the r e l a t i o n s h i p s w i t h the i n t r o p u n i t i v e measures no conv i n c i n g

o v e r a l l a s s o c i a t i o n i s f ound , a s we have seen., and t h i s f a c t c o n t r i b u t e s

fu r thermore to the d e c i s i v e o r i e n t a t i o n - o f p a t i e n t s r e p o r t i n g h y s t e r i c a l

symptomato logy-towards e x t r a p u n i t i v e r e s p o n s e s .

.Attempt ing t o summarise the way t h a t h o s t i l i t y i s r e l a t e d to c o n v e r s i o n

• and d i s s o c i a t i v e symptom changes , i t c o u l d be s a i d t ha t d i s s o c i a t i v e

symptom changes a re s t r o n g l y r e l a t e d t o the changes o f p r o j e c ted

h o s t i l i t y and to a l e s s e r degree w i t h a c t i n g - o u t h o s t i l i t y and

c r i t i c i s m o f o t h e r s , c o n v e r s i o n symptom changes are r e l a t e d , a t a 1 l ow

l e v e l , t o p r o j e c t e d h o s t i l i t y and c r i t i c i s m o f o t h e r s . N e i t h e r are

r e l a t e d to changes o f i n t r o p u n i t i v e n e s s .

. 1 7 4

7 . 9 * Phob ic Symptoms and H o s t i l i t y

I t s hou l d ne emphas ised t h a t changes o f phob ic symptoms tend to

be a s s o c i a t e d v e r y c l o s e l y w i t h changes o f g e n e r a l h o s t i l i t y .

The changes o f e x t r a p u n i t i v e r e s p o n s e s are c o n s i d e r a b l y more c l o s e l y

r e l a t e d to the changes o f t he se symptoms than tho se o f the i n t r o -

p u n i t i v e ones wh ich, a c c o r d i n g t o the data o f the p r e s e n t s t udy ,

have weak a s s o c i a t i o n s w i t h phob i c symptoms changes .

Changes o f phob i c symptoms, t end to be v e r y c l o s e l y r e l a t e d t o

t o t a l e x t r a p u n i t i v e n e s s changes and phob i c symptoms cou ld be

rega rded a s one o f the few D S S l / R s e t s h a v i n g such a c l o s e a s s o c i a t i o n

w i t h t o t a l e x t r a p u n i t i v e n e s s . A c t i n g - o u t h o s t i l i t y i s the main

channe l t h r ough which t h i s p s y c h o p a t h o l o g i c a l e n t i t y m o b i l i z e s

e x t r a p u n i t i v e a t t i t u d e s , c r i t i c i s m o f o t he r s and pa rano id h o s t i l i t y

be ing r e l a t e d l e s s c l o s e l y to phob i c symptoms changes . Acco rd i ng

to these r e s u l t s p a t i e n t s r e p o r t i n g phob ic symptoms cou ld be expected

to become i n the cour se o f t ime l e s s g e n e r a l l y h o s t i l e and l e s s e x t r a -

p u n i t i v e , e x p r e s s i n g i n a l e s s e r degree the u rge to a c t - o u t h o s t i l i t y

a s t h e i r symptomatology improve s .

Thus the vievr exp re s sed d i r e c t l y b y F o u l d s (1976) and Fe rna rdo ,

(1977) o r i n d i r e c t l y by H a f f n e r (1977 b) t h a t phob ic symptoms a re

r e l a t e d p o s i t i v e l y to i n t r o p u n i t i v e a t t i t u d e s , i s i n accordance

w i t h the r e s u l t o f the p r e s e n t s t u d y ; the f i n d i n g s t h a t ob ta ined ,

however, g i v e emphas i s t o the f a c t t h a t e x t r a p u n i t i v e n e s s p r e v a i l s

over i n t r o p u n i t i v e n e s s to a c o n s i d e r a b l e degree,

Ha f f ne r (1977 b) found t h a t h i s a l r e a d y p redominant l y e x t r a p u n i t i v e

agoraphob ic women^ a f t e r a y e a r o f t reatment become more e x t r a p u n i t i v e

. 1 7 5

a l t h o u g h l e s s h o s t i l e . The meaning o f t h i s f i n d i n g i s p robab l y

t h a t i n the improved a go r aphob i c i n t r o p u n i t i v e n e s s i s no t a s s t r o n g

a s i t was p r e v i o u s l y i n b a l a n c i n g e x t r a p u n i t i v e r e spon se s . T h i s c o u l d

s u g g e s t a n e g a t i v e r e l a t i o n s h i p between agoraphob ic symptoms and

e x t r a p u n i t i v e n e s s . I n the p r e s e n t s tudy no nega t i v e c o r r e l a t i o n

between the changes o f phob i c symptoms and changes o f any o f the

h o s t i l i t y s u b s c a l e s were o b s e r v e d .

. 1 7 6

7 . 1 0 . Ob se s s i v e - Compul s i ve Symptoms and H o s t i l i t y

A l t hough o b s e s s i v e compu l s i ve n e u r o s i s i s g e n e r a l l y regarded a s a

s i n g l e p s y c h o p a t h o l o g i c a l e n t i t y , i t seems from the p re sen t

s t udy t h a t the re are c o n s i d e r a b l e d i f f e r e n c e s between o b s e s s i v e and

compuls ive symptoms w i t h r e s p e c t to t h e i r r e l a t i o n s h i p s to h o s t i l i t y .

Changes o f r um ina t i v e symptoms, a c c o r d i n g to the r e s u l t s o f t h i s

s t u d y , tend to be a s s o c i a t e d v e r y s t r o n g l y v/ith gene ra l h o s t i l i t y

r e s p o n s e s whereas compu l s i ve symptoms changes are a s s o c i a t e d w i th

g ene r a l h o s t i l i t y to a much l ower degree (Table 93 )•

Both these p s y c h o p a t h o l o g i c a l e n t i t i e s go w i t h e x t r a p u n i t i v e

r e s pon se s to a g r e a t e r extend than i n t r o p u n i t i v e ones , a f i n d i n g

which i s i n c o n t r a s t w i t h the v iew t h a t o b s e s s i o n a l p a t i e n t s .p re fer

to d i r e c t t h e i r h o s t i l i t y p r edom inan t l y i nwards (Fen iche l , 194-5;

- D a l b i e z -1941; Cameron, 1963; F o u l d s e t a l 1960; F o u l d s , 1976;

F o u l d s and Bed fo rd , 1977 a ; F e r n a r d o , 1 9 7 7 ) . None o f these a u t h o r s

ha s r e f e r r e d to the r e l a t i o n s h i p s between changes o f those v a r i a b l e s ,

and the d e f i n i t i o n s o f both o b s e s s i v e - c o m p u l s i v e phenomena and

h o s t i l i t y accepted by them d i f f e r f r om each o t he r .

These p s y c h o p a t h o l o g i c a l e n t i t i e s d i f f e r i n the degree t h a t they

vary w i t h the h o s t i l i t y s ub s ca l e s f o r compul s i ve symptoms the a s s o c i a t i o n s

w i t h e x t r a p u n i t i v e n e s s o r i n t r o p u n i t i v e n e s s are much weaker than

f o r r um ina t i ve symptoms (Table 93 ) *

F o u l d s and Ca ine (1959) found t h a t a s f a r a s e x t r a p u n i t i v e n e s s was

concerned o b s e s s i v e n e u r o t i c women were more e x t r a p u n i t i v e than o the r

. 1 7 7

n e u r o t i c s . A l t hough the sample o f the p r e s e n t s tudy c o n s i s t e d o f

bo th sexes and the way o f examin ing the r e l a t i o n s between h o s t i l i t y and

o b s e s s i o n - c o m p u l s i v e symptoms i s d i f f e r e n t , another p i c t u r e emerges :

changes o f r um ina t i v e symptoms are s t r o n g l y a s s o c i a t e d v/ith e x t r a p u n i t i v e -

n e s s whereas changes o f compu l s i ve symptoms have the weakest a s s o c i a t i o n

w i t h the e x t r a p u n i t i v e n e s s i n compar i son w i t h the o the r DSS l/R s e t s .

F o u l d s and Ca ine do n o t s p e c i f y to what ex ten t t h e i r p a t i e n t s r epo r t ed

r u m i n a t i o n s and compu l s i on s .

The d i f f e r e n c e between i ie se g r oup s o f symptoms r e g a r d i n g .their r e l a t i o n s h i p

to e x t r a p u n i t i v e n e s s w i t h the p a s s a g e o f time i s q u a n t i t a t i v e r a t h e r

than q u a l i t a t i v e because i n b o t h the e x t r a p u n i t i v e s u b s c a l e s are mani fested

ma in l y a s p r o j e c t e d h o s t i l i t y and s e c o n d l y a s a c t i n g - o u t h o s t i l i t y and c r i -

t i c i s m o f o t h e r s ; a g a i n r u m i n a t i v e symptoms are more c l o s e l y r e l a t e d to these

h o s t i l i t y s u b s c a l e s than compu l s i ve symptoms.

I n t r o p u n i t i v e r e s p o n s e s a re e x p r e s s e d e s p e c i a l l y a s t o t a l i n t r o p u n i t i v e n e s s

and t o a l e s s e r degree a s g u i l t and s e l f - c r i t i c i s m i n bo th rumina t i ve and

compul s i ve symptoms* A g a i n , compu l s i ve symptoms are c h a r a c t e r i s t i c a l l y l e s s

s t r o n g l y a s s o c i a t e d w i t h these s c a l e s than rumina t i ve symptoms. D e s p i t e the

g e n e r a l l y accepted v iew t h a t s e l f - c r i t i c i s m i s a t y p i c a l i n t r o p u n i t i v e a t t i -

tude o f p a t i e n t s m a n i f e s t i n g o b s e s s i o n - c o m p u l s i v E symptoms, i n the p resent

s tudy g u i l t i s more c l o s e l y a s s o c i a t e d v/ith 'them; than' s e l f - c r i t i c i s m .

The o b s e r v a t i o n o f Manchanta e t a l (1969) t ha t o b s e s s i v e - c o m p u l s i v e p a t i e n t s

g i v e h i g h e r s c o r e s on a c t i n g - o u t h o s t i l i t y and r a t h e r s i m i l a r s c o r e s on

g u i l t t o n e u r o t i c a l l y dep re s sed p a t i e n t s does no t seem to be matched by the

r e s u l t s o f the p r e s e n t s tudy i n wh i ch rum ina t i ve and compuls ive.symptoms are

f o l l o w e d by g u i l t and a c t i n g - o u t h o s t i l i t y l e s s c l o s e l y than i n the s t a t e o f

d e p r e s s i o n . There i s , however, an i n t e r e s t i n g f i n d i n g i n the p r e sen t s t udy .

D e l u s i o n s o f c o n t r i t i o n

.178

( r e p r e s i n t i n g p s y c h o t i c d e p r e s s i o n ) a re l e s s c l o s e l y r e l a t e d to All than ru-

m ina t i ve symptoms whereas compu l s i v e symptoms a re r e l a t e d to AH to the

same degree a s d e l u s i o n s o f c o n t r i t i o n . Presumably, Manchanta ' s n e u r o t i -

c a l l y dep re s sed p a t i e n t s r e p o r t h o s t i l i t y a t t i t u d e s r e semb l i ng those of

the p s y c h o t i c a l l y dep re s sed p a t i e n t s o f the p r e s e n t s tudy . C u l t u r a l

and e t h n i c c h a r a c t e r i s t i c s o f the samples u sed may be regarded a s r e s -

p o n s i b l e f o r t he se d i f f e r e n c e s ,

•Although the p a t t e r n s o f h o s t i l i t y a s s o c i a t e d w i t h score changes i n these

two DSS l/R s e t s seem to have many s i m i l a r i t i e s , i t i s obv iou s t h a t

r um ina t i v e , symptoms c o r r e l a t e w i t h h o s t i l i t y r e s pon se s to a much h i g h e r I i

degree than compu l s i ve symptoms,

Akh ta r (1975) s ugge s ted a p r o g n o s i s r e l a t e d , h i e r a r c h i c a l continuum o f

o b s e s s i v e - c o m p u l s i v e phenomena and Dawson (1977) s t r e s s e d t ha t compu l s i ve

behav i ou r i s the e x p r e s s i o n o f a s s o c i a t e d t hough t s so that' any compuls ion

f,must occur i n c o n j u n c t i o n w i t h a t l e a s t one o b s e s s i o n a l symptom.

The q u a n t i t a t i v e r a t h e r than q u a l i t a t i v e d i f f e r e n c e s between these p s y -

c h o p a t h o l o g i c a l e n t i t i e s , a s f a r a s t h e i r r e l a t i o n to h o s t i l i t y i s

concerned, c o u l d be unde r s t ood i f the motor a c t i v i t y imp l i ed i n

compul s i ve .phenomena were a h o s t i l i t y r educ i ng f a c t o r .

. 1 7 9

7 . 1 1 . D e l u s i o n s o f P e r s e c u t i o n and H o s t i l i t y

From the r e s u l t s which were o b t a i n e d i n t h i s s tudy , i t i s e v i d e n t

t h a t changes i n the s c o r e s o f d e l u s i o n s o f p e r s e c u t i o n tend to be

a s s o c i a t e d t o a moderate degree w i t h gene ra l h o s t i l i t y and g e n e r a l

e x t r a p u n i t i v e r e s p o n s e s ; the ba lance between i n t r o p u n i t i v e n e s s and

e x t r a p u n i t i v e n e s s f a v o u r s the e x t r a p u n i t i v e s i d e , a f i n d i n g be ing i n accordance

w i th the w ide l y accepted v i ew t h a t pa r ano i d s are e x t r a p u n i t i v e . The

da ta , however, s u g g e s t i n g o n l y a s l i g h t d i f f e r e n c e between t o t a l

i n t r o p u n i t i v e n e s s and t o t a l e x t r a p u n i t i v e n e s s , do no t pe rmi t a s p e c i a l

emphasis on t h i s v i ew.

A l s o i n accordance w i t h the da ta o f the p r e s e n t s tudy i s the b r o a d l y

accepted t h e s i s t h a t the most p rominent way these p a t i e n t s m o b i l i z e

t h e i r h o s t i l i t y r e spon se s i s i n p r o j e c t i n g h o s t i l i t y onto o t h e r s ;

there i s a v e r y c l o s e p a r a l l e l between the course o f d e l u s i o n s o f

p e r s e c u t i o n and t h a t o f p a r a n o i d h o s t i l i t y score changes which i n d i -

ca te s t h a t the l a t t e r c ou l d be u sed a s a gu ide to the changes o f the

fo rmer .

But i n t h i s s t udy , the p a t i e n t s who repo r ted changes i n t h e i r d e l u s i o n s

o f p e r s e c u t i o n have a l s o r e p o r t e d r a t h e r f r e q u e n t l y , v i s - a - v i s the ma jo r i t y

o f the DSS l/R s e t s , a p a r a l l e l change i n t h e i r urge to a c t - o u t h o s t i l i t y

a r e p o r t supposed to be den ied by pa r ano i d p a t i e n t s ( F ou l d s et a l . 1960).

The c o - e x i s t e n c e o f p a r a n o i d h o s t i l i t y and a c t i n g - o u t h o s t i l i t y i n

p a t i e n t s r e p o r t i n g d e l u s i o n s o f p e r s e c u t i o n cou ld be i n t e r p r e t e d a s

s u g g e s t i n g t h a t a c t i n g - o u t h o s t i l i t y i s a f i r s t s tage o f a coun te r - a t t a ck

p r o c e s s .

D e s p i t e the e x p e c t a t i o n s , no r e l a t i o n s h i p between the score changes

o f d e l u s i o n s o f p e r s e c u t i o n and c r i t i c i s m o f o t he r s ha s been n o t i c e d

. 1 8 0

i n t h i s s t udy . I t i s an i n t e r e s t i n g o b s e r v a t i o n tha t (Table 85)

a p a r t from p a t i e n t s r e p o r t i n g d e l u s i o n s o f c o n t r i t i o n who mob i l i z e

c r i t i c i s m o f o t h e r s i n a weak deg ree , p a t i e n t s r e p o r t i n g d e l u s i o n s o f

p e r s e c u t i o n , d e l u s i o n s o f g r andeu r and d e l u s i o n s o f d i s i n t e g r a t i o n

( i . e . , p a t i e n t s b e l o n g i n g t o the p s y c h o t i c c l a s s e s , which i m p l i e s

d i s t o r t e d s e l f - c o n c e p t and d i s i n t e g r a t i o n o f the personhood)do no t v a r y

the changes o f t h e i r symptoms i n p a r a l l e l w i t h changes i n the a t t i t u d e

o f c r i t i c i s i n g o t h e r s .

I t i s somewhat s u r p r i s i n g t h a t d e l u s i o n s o f p e r s e c u t i o n , regarded a s

be i n g r e l a t e d c l o s e l y to e x t r a p u n i t i v e r e s p o n s e s , are found i n t h i s

s tudy to be a s s o c i a t e d w i t h changes o f t o t a l i n t r o p u n i t i v e n e s s s c o r e s

to such a r e l a t i v e l y h i g h deg ree . B u t more s u r p r i s i n g i s the f a c t t h a t

changes o f d e l u s i o n a l g u i l t - s c o r e s a r e found to be a s s o c i a t e d w i t h

d e l u s i o n s o f p e r s e c u t i o n s co re changes more s t r o n g l y even than they a re

w i t h s t a t e o f d e p r e s s i o n o r d e l u s i o n s o f c o n t r i t i o n .

The l a c k o f r e l a t i o n s h i p s between d e l u s i o n s o f p e r s e c u t i o n and s e l f -

c r i t i c i s m i s n o t an unexpected f i n d i n g s i n ce the pa r ano i d p a t i e n t s

have n o t on l y a f e a r o f b l am ing t hemse l ve s , a s Rosenzweig (1938)

c l a ims bu t have a l s o l o s t t h e i r s e l f - c o n c e p t to a c on s i de r ab l e deg ree .

I n s t e a d o f c r i t i c i s i n g o t h e r s o r themse lves they p r e f e r to p r o j e c t

h o s t i l i t y o r d e v e l o p i n g d e l u s i o n a l means o f a t t a c k i n g themse lves .

T h i s i s unde r s tandab le s i n c e p s y c h o t i c p a t i e n t s a re expected to

employ d e l u s i o n a l ways on d e a l i n g w i t h r e a l i t y .

I n C a i n e ' s s tudy (1960) a p a r a n o i d g roup , i n contras t t o a me lancho l i c

group was found to have s i g n i f i c a n t l y h i g h e r s c o r e s on pa rano id h o s t i l i t y

and s i g n i f i c a n t l y lower s c o r e s on a s e l f - c r i t i c i s m / g u i l t s c a l e . V/e attempted

a somewhat s i m i l a r compar i son, between the score changes o f d e l u s i o n s

. 1 8 1

o f c o n t r i t i o n and d e l u s i o n s o f p e r s e c u t i o n ; a c co rd i n g to our

f i n d i n g s , changes i n d e l u s i o n s o f p e r s e c u t i o n were a s s o c i a t e d v e r y

c l o s e l y w i t h p a r a n o i d h o s t i l i t y (Tab le 8 6 ) , more s t r o n g l y than tho se

w i t h d e l u s i o n s o f c o n t r i t i o n ; b u t the r e l a t i o n s h i p o f p a r ano i d symptoms

to g u i l t (Tab le 89) was f ound to be c l o s e r than t h a t w i t h d e l u s i o n s o f

c o n t r i t i o n s ; no r e l a t i o n t o s e l f - c r i t i c i s m (Table 88) i n s t a t i s t i c a l l y

s i g n i f i c a n t l e v e l s was f ound on e i t h e r d e l u s i o n s o f c o n t r i t i o n

o r d e l u s i o n s o f p e r s e c u t i o n . I t may, t h e r e f o r e , be concluded t h a t p a t i e n t s

w i t h d e l u s i o n s o f p e r s e c u t i o n were more d e l u s i o n a l l y e x t r a p u n i t i v e than

p a t i e n t s r e p o r t i n g d e l u s i o n s o f c o n t r i t i o n , b u t n o t t h a t the p a t i e n t s v i t h

d e l u s i o n s o f c o n t r i t i o n were more d e l u s i o n a l l y i n t r o p u n i t i v e than p a t i e n t s I

w i t h d e l u s i o n s o f p e r s e c u t i o n , i

I n c l i n i c a l terms t h i s c l o s e r e l a t i o n s h i p between g u i l t and d e l u s i o n s of

p e r s e c u t i o n cou l d mean t h a t the l e s s a p a t i e n t r e p o r t s i n t r o p u n i t i v e

a t t i t u d e s ( e s p e c i a l l y f e e l i n g s o f g u i l t ) the l e s s c ou l d be expected to

m a n i f e s t d e l u s i o n s o f p e r s e c u t i o n . Th i s i s a r a t h e r s t r ange f i n d i n g s i n ce

one would n o t expect a p a r a n o i d p a t i e n t to f e e l g u i l t y . T h i s c o u l d

be a t t r i b u t e d to the f a c t t h a t w i t h s c h i z o p h r e n i c p a t i e n t s a combinat ion

o f d e l u s i o n s o f p e r s e c u t i o n and d e l u s i o n s o f c o n t r i t i o n i s the most common

f i n d i n g ( Fou l d s and B e d f o r d , 1977 d) and such a group p o s s i b l y , i n f l u e n c e d

the r e s u l t s .

. 1 8 2

7 . 1 2 . D e l u s i o n s o f D i s i n t e g r a t i o n and H o s t i l i t y

D e l u s i o n s o f d i s i n t e g r a t i o n tend to v a r y w i t h changes o f g ene ra l

h o s t i l i t y a t t i t u d e s o n l y t o a weak deg ree . One n i g h t have

expected a c l o s e r r e l a t i o n s h i p between these v a r i a b l e s w i t h the pas sage

o f t ime s i n c e i t ha s been f ound by F o u l d s (196$) and Ca ine e t a l (1967)

t h a t p a t i e n t s w i th d e l u s i o n s o f d i s i n t e g r a t i o n are the most g e n e r a l l y

p u n i t i v e p a t i e n t s .

I t seems t h a t e x t r a p u n i t i v e r e s p o n s e s are a s soc i a ted to a s l i g h t l y

h i g h e r degree than the i n t r o p u n i t i v e ones w i t h changes o f d e l u s i o n s

o f d i s i n t e g r a t i o n , a f i n d i n g s i m i l a r t o t h a t r epo r ted by F o u l d s (1965 b ) .

Changes o f p a r ano i d h o s t i l i t y c l o s e l y . f o l l ow the changes o f d e l u s i o n s

o f d i s i n t e g r a t i o n ; t h i s a s s o c i a t i o n i n d i c a t e s t h a t pa r ano i d h o s t i l i t y

i s the main channe l t h rough which e x t r a p u n i t i v e a t t i t u d e s a re man i fe s ted

by p a t i e n t s r e p o r t i n g d e l u s i o n s o f d i s i n t e g r a t i o n . The r e l a t i o n s h i p s

o f d e l u s i o n s o f d i s i n t e g r a t i o n to a c t i n g - o u t h o s t i l i t y and c r i t i c i s m

o f o t h e r s c ou l d be r ega rded a s n e g l i g i b l e .

An e x p l a n a t i o n o f the f i n d i n g t h a t d e l u s i o n s o f d i s i n t e g r a t i o n a re

r e l a t e d t o a r a t h e r weak degree w i t h gene ra l h o s t i l i t y and the

e x t r a p u n i t i v e s u b s c a l e s , except p a r a n o i d h o s t i l i t y , c ou l d be t h a t

the p a t i e n t s p a r t i c i p a t i n g i n t h i s s tudy d i s s o c i a t e d t h e i r p s y c h i a t r i c

symptomatology f rom t h e i r h o s t i l i t y a t t i t u d e s because they d i d n o t

w i sh to g i v e the i m p r e s s i o n o f b e i n g a g g r e s s i v e and, con sequen t l y ,

dangerous which i s the commonest s t i gma o f s c h i z o p h r e n i c p a t i e n t s .

I n s t e a d o f g i v i n g the i m p r e s s i o n t h a t they were i n a p r o ce s s o f a t t ack i ng

o the r peop le they p r e f e r ed to p r o j e c t t h e i r h o s t i l i t y on to o t h e r s .

.The above mechanisms may be c o n s c i o u s o r un con s c i ou s . Another exp l ana t i on

. 1 8 3

cou l d be t h a t s c h i z o p h r e n i c s have become d i s i n t e g r a t e d a s pe r son s

which i m p l i e s a l s o d i s t o r t i o n o f t h e i r s e l f - c o n c e p t and the concept

o f o t h e r s ; t h i s c o u l d be the r e a s o n o f t h e i r avo idance o f r e l a t i n g

t h e i r symptoms t o the rion-delusional k i n d o f h o s t i l i t y .

As f a r a s i n t r o p u n i t i v e n e s s i s concerned, the r e l a t i o n s h i p cou ld

be rega rded a s a weak one and i s man i f e s ted a s a s s o c i a t i o n w i th

t o t a l i n t r o p u n i t i v e n e s s and g u i l t a t a low l e v e l . Changes o f

d e l u s i o n s o f d i s i n t e g r a t i o n a re r e l a t e d to g u i l t changes n e g a t i v e l y

i n s t u d y - p o i n t I and p o s i t i v e l y i n s t u d y I V . On ly i n p a t i e n t s r e p o r t i n g

d e l u s i o n s o f d i s i n t e g r a t i o n i s t h i s phenomenon o f c o n t r a d i c t i n g r e l a t i o n s

observed a t a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l . I t s i n t e r p r e t a t i o n

cou ld be a s f o l l o w s . D u r i n g the e a r l y phases o f s c h i z oph ren i a the

p a t i e n t does no t have i n s i g h t so f a r a s h i s p s y c h o p a t h o l o g i c a l c o n d i t i o n

i s concerned; a t t h i s s t age he p redominan t l y man i f e s t s e x t r a p u n i t i v e

a t t i t u d e s w i t h an a d d i t i o n a l d e n i a l o f i n t r o p u n i t i v e n e s s . V/ith the

p r o g r e s s o f t reatment the p a t i e n t r e g a i n s i n s i g h t which mod i f i e s h i s

a t t i t u d e towards h i m s e l f ; now he t u r n s h i s h o s t i l i t y towards h i m s e l f

and he e xp re s s e s f e e l i n g s o f g u i l t and, to a l e s s e r degree, s e l f -

c r i t i c i s m . I t . c o u l d be p o s t u l a t e d t h a t d u r i n g f u r t h e r improvement

the p a t i e n t becomes more s e l f - c r i t i c a l and l e s s g u i l t y i . e . , h i s

d e l u s i o n a l i n t r o p u n i t i v e n e s s may be r e p l a c e d by a n o n - d e l u s i o n a l

i n t r o p u n i t i v e n e s s .

.184

7 . 13 Genera l Comments

I t i s n o t o n l y o f importance to know the l e v e l o f h o s t i l i t y and

i t s s t r u c t u r e a s i t i s man i f e s t ed i n p a t i e n t s r e p o r t i n g c e r t a i n

p s y c h i a t r i c symptoms but a l s o i t i s o f i n t e r e s t to know i t s move-

ment d u r i n g the cou r se o f the symptomatology w i t h the pa s sage o f t ime.

I t s h o u l d be s t r e s s e d , t h e r e f o r e , t h a t the s t udy o f tie r e l a t i o n s h i p s

between h o s t i l i t y and p s y c h i a t r i c symptoms d u r i n g the cour se of the

p s y c h i a t r i c i l l n e s s c ou l d r e v e a l more s u b t l e types o f r e l a t i o n s h i p s

between h o s t i l i t y and p s y c h i a t r i c symptoms. The m a j o r i t y o f the i

s t u d i e s rev iewed r e g a r d i n g the r e l a t i o n s h i p s between h o s t i l i t y and

p s y c h i a t r i c symptoms have been c a r r i e d out i n s i n g l e o c c a s i o n s . S t u d i e s

t a k i n g i n t o account the cou r se o f the p s y c h i a t r i c symptomatology are

o f a v e r y l i m i t e d number ma in l y concen t r a ted on the r e l a t i o n s h i p s

between h o s t i l i t y and d e p r e s s i o n o r a n x i e t y . Consequent l y , the t h e o -

r e t i c a l and c l i n i c a l i m p l i c a t i o n s o f t he f i n d l i n g s o f the p r e sen t s t u d y

cou l d be n o t i c e a b l e ; f o r example, i t would be expected d u r i n g the cour se

o f a p s y c h i a t r i c i l l n e s s f o r c e r t a i n h o s t i l i t y f e a t u r e s to c o n t r i b u t e

to i t s p r o g n o s i s o r to the a s se s sment o f the degree o f i t s s e v e r i t y .

I t i s r a t h e r r i s k y to compare the f i n d i n g s o f t h i s work w i t h those o f

o ther au t ho r s s i n c e there a re d i f f e r e n c e s i n methodo log i ca l approach.

The most o u t s t a n d i n g o f them i s t h a t the m a j o r i t y o f the r e l a t e d s t u d i e s

r e f e r r e d to the rev iew o f the l i t e r a t u r e , have been c a r r i e d out i n

s i n g l e o c c a s i o n s whereas the p r e s e n t was c a r r i e d out i n s t u d y - p o i n t s

w i t h time i n t e r v a l s . The d i f f e r e n c e s r e g a r d i n g the c r i t e r i a f o r i n c l u s i o n

the d e f i n i t i o n o f h o s t i l i t y and symptomatology e n t i t i e s and the i n s t rument s

used must have s i g n i f i c a n t i n f l u e n c e i n the f r e q u e n t l y encountered

c o n t r a d i c t o r y f i n d i n g s . These s t u d i e s , however, are the on l y b a s i s f o r

compar i son and t h e i r c o n s i d e r a t i o n i n the d i s c u s s i o n was necce s s a r y .

. 1 8 5

R e g a r d i n g gene ra l h o s t i l i t y Adams and Fou l d s (1963) sugges ted t h a t i t

d i s t i n g u i s h e s between n e u r o t i c s . a n d p s y c h o t i c s , p s y c h o t i c s be i ng more

g e n e r a l l y p u n i t i v e than n e u r o t i c s . F o u l d s (1976) expres sed the v iew t h a t

the h i g h e r the p e r s o n a l i l l n e s s c l a s s a p e t i e n t i s a l l o c a t e d t o , the h igher

the amount o f gene ra l h o s t i l i t y ' h e expresses ; , n o n - i n t e g r a t e d p s y c h o t i c s

are more g e n e r a l l y p u n i t i v e t han i n t e g r a t e d p s y c h o t i c s who i n t u r n a re

more g e n e r a l l y p u n i t i v e than n e u r o t i c s and n e u r o t i c s more g e n e r a l l y p u n i t i v e

than dysthymic^* T h i s c o n t r a s t s w i th ,the r e l a t i o n s h i p between the changes of

f o s t i l i t y s u b s c a l e s and changes i n p s y c h i a t r i c symptoms a s they a re observed

i n t h i s s t udy . There a re n o n - p s y c h o t i c DSS l/R s e t s such a s s t a t e o f anx ie ty

and r um ina t i v e symptoms wh ich a r e v e r y c l o s e l y r e l a t e d to t o t a l h o s t i l i t y

s co re changes , whereas g roup s f rom the p s y c h o t i c c l a s s e s , such a s d e l u s i o n s

o f g randeur score changes have no s u b s t a n t i a l a s s o c i a t i o n w i t h t o t a l h o s t i -

l i t y changes . These d i f f e r e n t f i n d i n g s do n o t , n e c e s s a r i l y , c o n t r a d i c t each

o the r i n c l i n i c a l terms; a p a t i e n t c o u l d p robab l y r e p o r t h i g h l e v e l s of

h o s t i l i t y bu t the change o f h i s symptomatology may no t be c o r r e l a t e d w i t h

the change i n h i s h o s t i l i t y .

I t i s d i f f i c u l t to g i v e an answer r e g a r d i n g the meaning o f t h i s f i n d i n g

and i t s c l i n i c a l i m p l i c a t i o n s . . P o s s i b l y , n e u r o t i c p a t i e n t s have no reasons

t o concea l t h e i r f e e l i n g s o f h o s t i l i t y s i n ce t h e i r e x i s t ence i s an a d d i -

t i o n a l ev idence o f t h e i r i l l n e s s f o r which they seek t reatment. On the

o the r hand p s y c h o t i c p a t i e n t s b e i n g i n f i g h t to persuade people t h a t they

a re n o t dangerous i n t h e i r i l l n e s s , d i s s o c i a t e t h e i r symptomatology

from t h e i r f e e l i n g s o f g e n e r a l h o s t i l i t y by deny ing a c t i n g - o u t h o s t i l i t y

and c r i t i c i s m o f o t he r s and p r e f e r i n g t o p r o j e c t t h e i r h o s t i l i t y on t o

o t h e r s . T h i s cou ld s u g ge s t t h a t the s tudy o f b e h a v i o u r a l m a n i f e s t a t i o n s

rniight be a more r e l i a b l e method f o r a s s e s s i n g h o s t i l i t y i n p s y c h o t i c

p a t i e n t s than s e l f - r e p o r t t e c h n i q u e s .

. 1 8 6

Acco rd ing to the r e s u l t s o f t h i s s t u d y , score changes o f a l l the

DSS l/R s e t s appear t o be r e l a t e d predominant ly w i th changes i n

e x t r a p u n i t i v e n e s s and i n some c a s e s - e x c l u s i v e l y w i th e x t r a p u n i t i v e n e s s ;

• t h i s w a s n ° t a n t i c i p a t e d from the f i n d i n g s o f other au tho r s : i t has

been suggested by Fou l d s e t a l (1960) and Salrnon(1964) t h a t p a t i e n t s

be l ong i ng to the ma jo r i t y o f p s y c h i a t r i c d i a g n o s t i c c a t e g o r i e s ,

channel t h e i r h o s t i l i t y i n t r o p u n i t i v e l y and Caine e t a l (1967) po in ted

out t h a t from a l l the p s y c h o p a t h o l o g i c a l e n t i t i e s they examined, o n l y

manics and " s e l e c t e d " p a r a n o i d s were predominant ly e x t r a p u n i t i v e . I t

i s o f i n t e r e s t to note here t h a t a c co rd i n g to the r e s u l t s o f the p re sen t

s tudy , symptoms thought o f a s h a v i n g a somatic o r motor charac te r are

connected more c l o s e l y to e x t r a p u n i t i v e n e s s than symptoms imp ly ing a

more p s y c h o l o g i c a l d i s o r d e r .

There i s a tendency (Table 83) f o r DSS l /R s e t s be long ing to the n e u r o t i c

c l a s s e s to be more c l o s e l y r e l a t e d t o t o t a l e x t r apun i t i v ene s s whereas

there i s a tendency o f DSS l /R s e t s b e l o n g i n g to i n t e g r a t ed d e l u s i o n s

and d e l u s i o n s o f d i s i n t e g r a t i o n c l a s s e s to be l e s s c l o s e l y a s s o c i a t e d

w i th t o t a l e x t r a p u n i t i v e n e s s . I t would there fo re be expected t ha t

d u r i n g the improvement o f the m a j o r i t y o f p s y c h i a t r i c symptoms

e x t r a p u n i t i v e l y d i r e c t e d h o s t i l i t y becomes l e s s pronounced whereas i n t r o -

p u n i t i v e l y d i r e c t e d h o s t i l i t y e i t h e r i s no t r e l a t e d to the course o f

i l l n e s s o r i s r e l a t e d to a l e s s e r degree. The meaning o f t h i s i s t h a t

p a t i e n t s hav i ng these symptoms become less h o s t i l e and i n some ca se s

l e s s i n t r o p u n i t i v e but d e f i n i t e l y and c l e a r l y l e s s e x t r a p u n i t i v e . Th i s

cou ld be regarded a s an i n d i r e c t change o f the p a t i e n t ' s b laming a t t i t u d e s

towards h i m s e l f : an improv ing p a t i e n t abandons h i s b laming a t t i t u d e

towards the ou t s i de wor ld and becomes more competent to see h i m s e l f w i th

a c r i t i c a l eye.

. 1 8 7

No one DSSl/R set has been found to be related predominantly to

total intropunitiveness score changes. Nevertheless it is interesting

to see the levels of proximity that were observed; the score changes

in state of anxiety, state of depression, ruminative symptoms and

delusions of persecution were more closely related to those of total

inrtopunitiveness than score changes of delusions of contrition, phobic

symptoms, compulsive symptoms, delusions of disintegration and delusions

of grandeur. Changes in conversion symptoms, dissociative symptoms

and state of elation showed no substantial association with changes of

intropunitiveness scores.

The score changes of some hostility subscales were found to be related

to certain DSSl/R score changes to such a close degree, with significant

correlations in all the study-points, which suggests that these were parellel

courses for these particular DSSl/R sets : total hostility and total

extrapunitiveness have parallel courses with state of anxiety and

ruminative symptoms arid paranoid hostility follows delusions of persecution ,

It is understandable for paranoid patients to manifest less projected

hostility after "the" improvement of their symptoms but, regarding patients

reporting anxiety or ruminative symptoms it is not easily accepted that

they report feelings of general extrapunitiveness at a lower level

as their symptoms improve. This finding is possibly related to the

nosological status of the participating patients. No patients suffering

exclusively from anxiety or obsessive neurosis participated in this study.

These symptoms were reported from patients manifesting psychiatric

symptomatology of a different kind, mainly from depression and schizophrenia.

On the other hand, there are DSSl/R sets which, on changing, were not

found to be related to certain hostility patterns : delusions of grandeur

.188

are not related to total hostility ; state of elation, state of

anxiety, delusions of grandeur, delusions of disintegration and

conversion symptoms are not related to acting-out hostility;

state of elation, conversion symptoms and dissociative symptoms

are not related to total intropunitiveness ; state of depression,

compulsive symptoms, delusions of grandeur, delusions of persecution

and delusions of disintegration are not related to criticism of others:

state of elation, conversion symptoms, dissociative symptoms and

delusions of grandeur are not related to guilt ; no DSSl/R sets

except state of anxiety, state of depression, ruminative symptoms l

and delusions of grandeur are related to self-criticism.

It is evident from the descriptive data that the general course of the

changes of both HDHQ subscales and DSSl/R sets have a trend towards

a decrease of their scores in the first two study-points. This is

more pronounced in the. scores of general hostility, extrapunitiveness

and intropunitiveness of the HDHQ and state of anxiety, state of depression, >

dissociative symptoms, compulsive symptoms and delusions of disintegration

of the DSSl/R. From the inferential statistics it is clear that changes

in general hostility and general extrapunitiveness -follow symptomatology

more closely than intropunitiveness.

Therefore, in clinical situations it is more probable that the clinician

will have to deal with psychiatric patients manifesting mixed forms of

hostility. The patient's level of general hostility and its subscales

of extrapunitiveness and to alesser degree of intropunitiveness could be

valuable indicators of the severity of the majority of psychiatric

states. It seems also that the evaluation of acting-out hostility

is of importance in assessing severity of depression in psychiatric

. 1 8 9

patients.

Symptoms fluctuate according to the severity of illness; hostility

patterns are commonly regarded as reflecting more enduring feature's

of the personality but the findings of the present study suggest

that since hostility's status and expression changes follow the

course of the majority of the symptoms that are examined it could be

regarded as reflecting symptomatology to a considerable degree. There

is an'interaction between symptoms and hostility patterns during the

course of psychiatric illness in the form of positive associations.

It could be assumed then that hostility is a significant feature of

psychiatric illness. Trying to answer -the very important theoretical

and clinical question on whether hostility changes influence the course

of the psychiatirc symptoms or changes of the psychiatric symptoms in-

fluence the levels of the patterns of hostility, it could probably be

• postulated that both processes are in operation during the course

of psychiatric illness and ther'e is a constant interaction between

hostility features and psychiatric symptoms. However the problem is

still open and more work is necessary for its elucidation.

To attempt the development of psychometric instruments that measure

hostility and at the same time are not influenced by psychiatric symptoms

is probably unrewarding. However in the case of the HDHQ some scales

such as paranoid hostilityand to a lesser degree guilt seem particularly

related to symptoms as well which could influence the interpretation of

the scores obtained - mainly i n paranoid and depressed patients.

What is needed for the study of the complex relationships between

personality traits and attitudes on the one hand and psychiatric phenomena

on the other is further study and more accumulation of the experience on

. 1 9 0

tho p sychomet r i c methods f o r use i n c l i n i c a l and r e s e a r c h

s i t u a t i o n s . Many r a t i n g s c a l e s have been deve loped over the p a s t

t h i r t y o r f o r t y y e a r s but the g e n e r a l s tudy o f t h e i r s t r e n g t h s and weak-

n e s s e s i s poo r and f ragmented. What i s n e c e s s a r y apa r t from the d e -

velopment o f new o b j e c t i v e p s y c h o m e t r i c i n s t r u m e n t s i s the c o n t i n u a t i o n

o f the a p p l i c a t i o n o f t ho se a l r e a d y b e i n g i n use and i n t e g r a t i o n o f the

exper ience so ob ta i ned .

i

1 9 1

7 . 1 4 . SUMMARY

General characteristics of the population, the time intervals betv/een

the completion of the questionnaires and the length of stay of the

patients in the hospital are presented and discussed, in this section.

The scope and limitations of the instruments used, are discussed within

the framework of a survey of the literature related to the rating

scales generally and to the HDHQ and DSSI/R in particular.

The relationships between the changes of each of the twelve DSSI/R

sets and the HDHQ subscales are discussed in the light of data

obtained and of the views and findings of other investigators.

A general conclusion would be that changes of state of elation,

conversion symptoms and dissociative symptoms are related only to

extrapunitive attitudes whereas changes on the other nine DSSI/R sets

are associated with mixed intropunitive and extrapunitive attitude

changes.

No intropunitive responses were detected to be associated exclusively

with the changes of any of the studied DSSI/R sets or to prevail

over extrapunitive responses.

. 1 9 2

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(1917) C o l l e c t e d Papers on A n a l y t i c a l P sycho logy . London: B a i l l i e r e , T i n d a l and Cox 2nd Ed.

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(1970) R e l a t i o n s h i p Between Agg r e s s i o n and Dep re s s i on . E p i d e m i o l o g i c a l I m p l i c a t i o n s o f a Hypo the s i s . A r c h . Gen. P s y c h i a t . 22, 308 - 318.

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. 2 0 7

9 . ACKNOWLEDGEMENTS

T h e r e a r e no adequate w o r d s t o e x p r e s s t h e d e p t h o f my g r a t i t u d e t o

P r o f e s s o r R . G. P r i e s t , who s u p e r v i s e d my s t u d y , f o r h i s i n v a l u a b l e

h e l p i n e v e r y way d u r i n g t h e c o u r s e o f t h i s wo rk , I am s u r e t h a t

w i t h o u t h i s c o n t i n u o u s s u p p o r t I c o u l d n e v e r have been a b l e t o

comp le te t h i s wo rk .

The e n t i r e m a n u s c r i p t h a s b e n e f i t e d f r o m a number o f v a l u a b l e comments

I

and c r i t i c i s m s b y D r . P . R a p t o p o u l o s . To h im I am a l s o i n d e b t e d f o r

h i s s e a r c h f o r v a l u a b l e p a p e r s . A s p e c i a l wo rd s o f t h a n k s i s due t o

D r . T o n k s and D r . G r a n v i l l e - G r o s s m a n f o r t h e i r h e l p i n p r o v i d i n g

p a t i e n t s f r o m t h e i r f i r m s .

I am e s p e c i a l l y g r a t e f u l t o my w i f e , A l e x a n d r a , f o r h e r s u p p o r t

t h r o u g h o u t t h e p r e p a r a t i o n o f t h i s w o r k .

I am i n d e b t e d t o M r . N i c h o l a s B o y a r s k y f o r h i s comments o n t h e

m a n u s c r i p t .

I n p a r t i c u l a r I w o u l d l i k e t o m e n t i o n t h e Greek F e l l o w s h i p F o u n d a t i o n

f o r i t s f i n a n c i a l s u p p o r t ; O n a s s i s F o u n d a t i o n a l s o d e s e r v e s my t h a n k s

f o r i t s u s e f u l f i n a n c i a l a i d .

I w i s h t o e x p r e s s my deep t h a n k s t o t h e p a t i e n t s who p a r t i c i p a t e d , f o r

t h e i r w i l l i n g n e s s t o c o - o p e r a t e i n t h i s s t u d y and t o the s t a f f o f

2CB

the Department o f P s y c h i a t r y , S t . M a r y ' s H o s p i t a l , f o r t h e i r h e l p

i n a d m i n i s t e r i n g the q u e s t i o n n a i r e s .

I would l i k e to e x p r e s s my s i n c e r e t hank s to Deborah Young fo r

her pa t i ence i n t y p i n g t h i s t h e s i s .

2 0 9 .

TABLES AND FIGURES

. 2 1 0

Number of

p a t i e n t s

Weeks

F i g u r e 1. Leng th o f s t a y i n h o s p i t a l .

2 1 1 .

TRAITS SYMPTOMS

U n i v e r s a l S p o r a d i c

Endu r i ng T r a n s i e n t

E g o - s y n t o n i c D i s t r e s s i n g

Tab le 1 D i s t i n c t i v e f e a t u r e s between p e r s o n a l i t y t r a i t s

and mental i l l n e s s symptoms

A d a p t e d f r o m F o u l d s G.A. (1965b).

. 2 1 2

NEUROTIC DEPRESSION -PERSONALITY DISORDER

S e v e r e c h r o n i c d e p r e s s i o n - P e r s o n a l i t y d i s o r d e r

D e p r e s s i v e n e u r o s i s - P e r s o n a l i t y d i s o r d e r

D e p r e s s i v e r e a c t i o n - H y s t e r i c a l p e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n - Inadequate p e r s o n a l i t y

D e p r e s s i o n - P e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n - A l c o h o l i s m

R e a c t i v e d e p r e s s i o n - Drug abuse

N e u r o t i c d e p r e s s i o n - P e r s o n a l i t y d i s o r d e r

NEUROTIC DEPRESSION N e u r o t i c d e p r e s s i o n

D e p r e s s i o n

D e p r e s s i v e n e u r o s i s

D e p r e s s i v e r e a c t i o n

Abnormal g r i e f r e a c t i o n

R e a c t i v e d e p r e s s i o n

D e p r e s s i o n - P sychosomat ic problems

N e u r o t i c d e p r e s s i o n - A n x i e t y s t a t e

ANOREXIA NERVOSA A n o r e x i a ne r vo sa

ANXIETY STATE Ago r aphob i a - A n x i e t y s t a t e

ANXIETY NEUROSIS -PERSONALITY DISORDER

A n x i e t y n e u r o s i s - P e r s o n a l i t y d i s o r d e r

PERSONALITY DISORDER P e r s o n a l i t y d i s o r d e r

H y s t e r i c a l p e r s o n a l i t y d i s o r d e r

SCHIZOAFFECTIVE DISORDER

D e l u s i o n a l i d e a s o f p e r s e c u t i o n - Dep re s s i on

P a r a n o i d p s y c h o s i s w i t h marked a f f e c t i v e component

S c h i z o a f f e c t i v e d i s o r d e r

PSYCHOTIC DEPRESSION P s y c h o t i c d e p r e s s i o n

R e a c t i v e d e p r e s s i v e p s y c h o s i s

MANIC-DEPRESS IVE M a n i c - D e p r e s s i v e p s y c h o s i s (Manic phase ) PSYCHOSIS (MANIC PHASE)

. 2 1 3

(CONTINUED FROM OVER PAGE)

10. MANIC-DEPRESS IVE M a n i c - D e p r e s s i v e p s y c h o s i s ( Dep re s s i v e pha PSYCHOSIS (DEPRESS IVE PHASE)

11. PARANOID SCHIZOPHRENIA P a r a n o i d s c h i z o p h r e n i a

Acute pa rano id s c h i z o p h r e n i a

12. SCHIZOPHRENIA S c h i z o p h r e n i a

Acute s c h i z o p h r e n i c ep i sode

C h r o n i c s c h i z p h r e n i a

S imp l e s c h i z o p h r e n i a

B o r d e r l i n e s c h i z o p h r e n i a

Monosymptomatic h ypochond r i a ca l p s y c h o s i s

Tab le 2 D i a g n o s t i c c a t e g o r i e s ( i n b l o c k l e t t e r s ) chosen to r e p r e s e n t

the v a r i o u s d i a g n o s t i c terms used a s c l i n i c a l d i a g n o s e s .

Number o f

p a t i e n t s Percentage

F i r s t Q u e s t i o n n a i r e s 151 100

Second ' » 73 '

T h i r d " 3 5 23

F o u r t h 11 17 11 .25

F i f t h " 11 7 - 3 0

Tab le 3 Number o f p a t i e n t s , w i t h pe r cen tage s , who completed

each o f the f i v e b a t t e r i e s o f q u e s t i o n n a i r e s .

. 2 1 4

C l i n i c a l s t a t u s

B a t t e r i e s o f Q u e s t i o n n a i r e s I n - p a t i e n t s D a y - p a t i e n t s O u t - p a t i e n t s

1 s t 5 2 17 b

2nd k t ' 1 9 7

3 r d 19 12

4 t h 7 8 2

5 t h ^ 7 0

Tab le k The c l i n i c a l s t a t u s o f the p a t i e n t s who p a r t i c i p a t e d i n

the s t udy i n r e l a t i o n to the b a t t e r i e s o f q u e s t i o n n a i r e s

they completed

Q u e s t i o n n a i r e s Time e lapsed i n days

mean s . d .

1 s t - 2nd 2 ^ . 1

2nd - 3 r d 3 5 - 8 16 .9

3 r d - kth 3 8 . 0 15.4

kth - 5 t h ^ 7 . 6 3 5 . 3

Tab le 5 Time e l ap sed between the complet ion o f the q u e s t i o n n a i r e s

- means a s t a n d a r d d e v i a t i o n s ,

Q u e s t i o n n a i r e s E l a p s e d t ime, i n days

1 - 2 0 2 1 - ^ 9 50 - 99 >100

1 s t - 2nd 3 5 5 10 5

2nd - 3 rd 3 3 0 2 0

3 r d - kth 0 15 2 0

bth - 5 t h 0 9 1 0

Tab le 6 Time e lapsed between the complet ion o f the q u e s t i o n n a i r e s - f r e q u e n c y d i s t r i b u t i o n t a b l e .

. 2 1 5

C l i n i c a l D i a g n o s e s

Ma le s Females T o t a l

1 . P a r a n o i d s c h i z o p h r e n i a 9 2 11

2 . S c h i z o p h r e n i a 9 ^ 13

3 . S c h i z o a f f e c t i v e d i s o r d e r 1 k 5

Man ic d e p r e s s i v e p s y c h o s i s

( D e p r e s s i v e phase) 0 2 2

5 . Manic d e p r e s s i v e p s y c h o s i s

(Man ic phase) 1 1 2

6 . P s y c h o t i c d e p r e s s i o n 2 0 2

7 . A n o r e x i a ne r vo sa 1 1 2

8 . A n x i e t y s t a t e 0 1 1

9 - N e u r o t i c a n x i e t y - P e r s o n a l i t y

D i s o r d e r 0 1 1

10. N e u r o t i c d e p r e s s i o n 2 12 14

11. N e u r o t i c d e p r e s s i o n - P e r s o n a l i t y D i s o r d e r 5 10 15

12. P e r s o n a l i t y d i s o r d e r 2 3 5

32 41 73

Tab le 7 C l i n i c a l d i a g n o s e s g i v e n t o the p a t i e n t s who p a r t i c i p a t e d

i n s t u d y - p o i n t I , w i t h the numbers o f p a t i e n t s a l l o c a t e d to

each d i a g n o s t i c c a t e g o r y .

CL IN ICAL STATUS

I n - p a t i e n t s D a y - p a t i e n t s O u t - p a t i e n t s

F i r s t 5 2 ( 7 1 . 2 3 $ ) 17 (23 .29%) 4 (5.47/tO

Q u e s t i o n n a i r e s

Second ^7 (64 .38% ) 19(26.02?<0 7 ( 9 - 58% )

Q u e s t i o n n a i r e s

Tab le 8 C l i n i c a l s t a t u s o f the p a t i e n t s who p a r t i c i p a t e d i n s t u d y - p o i n t I

. 2 1 6

Age ( i n y e a r s ) mean: 3 5 - 2 s . d . : 12.2 min. 17 max. 68

Age ( i n y e a r s ) Number o f p a t i e n t s

1 7 - 2 9 30

30 - 39 14

40 - 49 19

50 - 68 10

73

Tab le 9 Age o f the p a t i e n t s who p a r t i c i p a t e d i n s t u d y - p o i n t I

Time e l ap sed ( i n d a y s ) mean: 4 2 . 3 6 s . d . : 24 .12

Days Number o f p a t i e n t s

< 2 0 3

21 - 49 55

5 0 - 9 9 10

> 100 5

73

Tab le 10 Time e l ap sed between the complet ion o f the f i r s t and the

second b a t t e r i e s o f q u e s t i o n n a i r e s .

. 2 1 7

F i r s t Second Questionnaire Questionnaire

CLASS 0 0

1 2

CL IN ICAL DIAGNOSIS

S c h i z o p h r e n i a

P a r a n o i d s c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n

Number o f P a t i e n t s

1 1 1

CLASS 1 P a r a n o i d s c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

A n o r e x i a ne r vo sa

S c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

P e r s o n a l i t y d i s o r d e r

P s y c h o t i c d e p r e s s i o n

M a n i c - D e p r e s s i v e P s y c h o s i s ( D e p r e s s i v e phase)

S c h i z o p h r e n i a

CLASS 2 0

0

1

1 1

1 2

2

2

2

2

M a n i c - D e p r e s s i v e p s y c h o s i s (Man ic phase)

N e u r o t i c d e p r e s s i o n

N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n

P e r s o n a l i t y d i s o r d e r

S c h i z o a f f e c t i v e d i s o r d e r

P a r a n o i d s c h i z p h r e n i a

P e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n

S c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

1

2

1

1

1

1

1

2

3

k

P s y c h o t i c d e p r e s s i o n

First Second Questionnaire Questionnaire

2

2

. 2 1 8

CLINICAL DIAGNOSIS

Psychotic depression

Manic-Depressive psychosis (Depressive phase)

Neurotic depression -Personality disorder

Neurotic depression

Anorexia nervosa

Anxiety state

Neurotic depression

Number of patients

CLASS 3 Schizoaffective disorder

Neurotic depression -Personality disorder

Schizoaffective disorder

Personality disorder

Neurotic depression -Personality disorder

Neurotic depression

Paranoid schizophrenia

Neurotic depression -Personality disorder

Neurotic depression

Schizophrenia

Neurotic depression

Schizophrenia

2

1

3

3

1

1

1

CLASS k Schizophrenia

Paranoid schizophrenia

Paranoid schizophrenia

Schizophrenia

. 2 1 9

F i r s t Second C L I N I C A L DIAGNOSIS Number Q u e s t i o n n a i r e Q u e s t i o n n a i r e o f p a t i e n t s

1 ' S c h i z o a f f e c t i v e d i s o r d e r 1

2 N e u r o t i c a n x i e t y - 1 P e r s o n a l i t y d i s o r d e r

2 Man i c d e p r e s s i v e p s y c h o s i s 1 (manic phase)

4 S c h i z o a f f e c t i v e d i s o r d e r 1

k S c h i z o p h r e n i a 3

4 P e r s o n a l i t y d i s o r d e r 1

k P a r a n o i d s c h i z o p h r e n i a k

h N e u r o t i c d e p r e s s i o n 1

73

Tab le 11 C l a s s a l l o c a t i o n on D S S I ( R ) , c l a s s change and c l i n i c a l

d i a g n o s e s o f the p a t i e n t s who completed a f i r s t and a

second b a t t e r i e s o f q u e s t i o n n a i r e s .

. 2 2 0

C l a s s 0 C l a s s 1 C l a s s 2 C l a s s 3 C l a s s 4 T o t a l

S c h i z o p h r e n i a 1

P a r a n o i d S c h i z o p h r e n i a 1

N e u r o t i c D e p r e s s i o n 1

N e u r o t i c D e p r e s s i o n - 0 P e r s o n a l i t y D i s o r d e r

2

2

0

2

13

11

14

15

Tab le 12 S t u d y - p o i n t I . C l a s s a l l o c a t i o n on D S S I ( R ) o f p a t i e n t s

a l l o c a t e d to f o u r c l i n i c a l d i a g n o s t i c c a t e g o r i e s

F I R ST QUESTIONNAIRE SECOND QUESTIONNAIRE

mean Va r i ance s . d mean Var i ance s . d . P a t t e r n change

AH 5 - 3 1 6 .02 2 . 4 5 5 . 4 4 7 .05 2 . 6 6 +

CO 5.18 5 . 9 8 2 . 4 5 *+.92 8 .05 2 . 8 4 -

PH 2 . 4 4 5 . 0 3 2 . 4 2 2 . 0 5 4 . 61 2 . 1 5 -

SC 7 . 0 1 6 . 3 5 2 . 5 2 6 . 8 9 6 . 93 2 . 6 3 -

G 3 . 7 5 3 . 8 0 1 .95 3 . 3 6 3 .87 1 .97 -

TH 23 . 70 5 3 . 7 1 7 . 3 3 2 2 . 6 6 67 .81 8 . 2 3 -

T . I . 10 .77 15 .13 3 . 8 9 1 0 . 2 5 16.22 4 . 0 3 -

T . E . 12 .93 2 8 . 0 1 5 . 2 9 1 2 . 4 1 34 .19 5 . 8 5 -

D i 4 . 6 6 5 2 . 8 1 7 . 27 4 . 2 9 53 .71 7 . 3 3 -

sA 7 . 0 0 21 .72 4 . 66 5 . 4 2 21 .80 4 . 67 -

sD 9 . 5 5 33 . 70 5 . 8 0 7 . 3 6 37 .20 6 . 1 0 -

s E 2 . 4 9 7 .67 2 . 7 7 1 . 8 1 5 . 46 2 . 3 4 -

PS 2 . 6 7 12 .25 3 . 5 0 1 . 7 0 5 .27 2 . 2 9 -

DS 1 . 9 6 6 .37 2 . 52 1 . 48 4 .89 2 . 2 1 -

FS 3 . 4 1 10.36 3 . 2 2 2 . 9 4 11.86 3 . 4 4 —

. 2 2 1

F I R S T QUESTIONNAIRE SECOND QUESTIONNAIRE

mean Va r i ance s . d . mean Var iance s . d . P a t t e r n o f Change

CS 2 . 3 6 8 . 09 2 . 8 4 1 . 6 4 7 .45 2 . 7 3

RS 3 . 8 6 16.84 4 . 1 0 2 . 8 5 13.96 9 .74

DG 1 .34 9 . 8 1 3 . 1 3 0 . 4 4 1 .30 1 .14

DP 1 .96 16 .35 4 . 0 4 1 . 4 4 17.97 4 . 24

DC 2 . 4 1 9 . 24 3 . 0 4 1 . 4 5 5 . 78 2 . 4 0

DD 2 . 2 3 15.38 3 - 9 2 1 . 6 4 9 .09 3 . 0 1

Tab le 13 Mean, v a r i a n c e and s t a n d a r d d e v i a t i o n s o f the s c o r e s

ob ta i ned i n the f i r s t and second b a t t e r i e s o f q u e s t i o n n a i r e s

( + i n c r e a s e o f the mean - decrease o f the mean )

S t a t e o f a n x i e t y ( s A )

K e n d a l l ' s t a u P Spea rman ' s rho P

SC 0 . 2173 0 . 0 0 4 0 .2976 0 .006

T .H. 0 .2765 0 . 0 0 1 0 . 3671 ' 0 . 0 01

T . I . 0 .1667 0 . 0 1 9 0 .2278 0 .027

T . E . 0 .2210 0 . 0 0 3 0 .2867 0 . 007

AH 0 .1636 0 . 0 2 1 0 . 2241 0 . 029

PH 0 . 1851 0 . 0 1 1 0 .2420 0 . 020

Tab le 14 S t u d y - p o i n t I . A s s o c a t i o n between the changes i n s t a t e of

a n x i e t y ( s A ) and the changes i n HDHQ s u b s c a l e s .

. 2 2 2

S t a t e o f d e p r e s s i o n ( s D )

K e n d a l l ' s t a u P Spea rman ' s rho P

AH 0 . 2 6 5 5 0 . 0 0 1 0 . 35S7 0 . 001

SC 0 .2391 0 . 0 02 0 .3284 0 . 0 0 3

T .H. 0 .2138 0 . 0 0 4 0 .3122 0 .004

T . I . 0 . 2069 0 . 0 0 5 0 .2885 0 . 007

T . E . 0 .1677 0 . 0 1 8 0 .2356 0 . 0 23

Tab le 15 S t u d y - p o i n t I . A s s o c i a t i o n between the changes i n s t a t e

o f d e p r e s s i o n ( s D ) and HDHQ s u b s c a l e s .

S t a t e o f e l a t i o n ( s E )

K e n d a l l ' s t a u P Spea rman ' s rho P

co 0 .2269 0 . 0 0 3 0 .2975 0 .006

PH 0 .2599 0 . 0 0 1 0 .3247 0 . 0 0 3

TH 0 .2902 0 . 0 0 1 0 . ^ 7 5 0 . 0 0 1

TE 0 .2753 0 . 0 0 1 0 .3666 0 . 0 01

D i - 0 . 1 3 4 0 0 . 0 4 0 - 0 . 1 8 5 3 0 . 0 59

Tab le 16 S t u d y - p o i n t I . A s s o c i a t i o n between the changes

e l a t i o n ( s E ) and the changes i n HDHQ s u b s c a l e s .

i n s t a t e o f

. 2 2 3

Dissociative symptoms (DS)

K e n d a l l ' s t a u P Spea rman ' s rho P

AH •0.2583 0 . 0 0 1 0 .3183 0 . 001

PH 0 .4068 0 . 0 0 1 0 .4843 0 . 0 01

TH 0 .2564 0 . 0 0 1 0 .3367 0 . 002

TE 0 .5302 0 . 0 0 1 0 . 4210 0 . 0 0 1

Di - 0 . 2 9 0 8 0 . 0 0 1 - 0 . 3 7 5 2 0 . 0 01

CO 0 .1405 0 . 0 4 0 0 .1800 0 .064

Tab le 17 S t u d y - p o i n t I . A s s o c i a t i o n between the changes o f

d i s s o c i a t i v e symptoms (DS ) and the changes i n HDHQ s u b s c a l e s .

Phobic symptoms (FS)

K e n d a l l ' s t a u P Spea rman ' s rho P

AH 0 .1922 0 . 0 0 9 0 . 2411 0 . 0 20

TH 0 .2158 0 . 0 0 4 0 .2934 0 .006

T I 0 . 1371 0 . 0 4 4 0 .1924 0 .052

TE 0 . 2100 0 . 0 0 5 0 .2749 0 . 0 10

Table 18 Study-point I, Association between the changes of phobic

symptoms (FS) and the changes in HDHQ subscales.

. 2 2 4

Compul s i ve symptoms (CS )

K e n d a l l ' s ta»: P Spea rman ' s rho P

AH 0 .2371 0 . 0 0 2 0 . 2951 0 .006

PH 0 . 3051 0 . 0 0 1 0 . 3711 0 . 0 01

G 0 .1790 0 . 0 1 3 0 . 2 2 2 6 0 . 030

TH 0 .2775 0 . 0 0 1 0 .3623 o . o o i

T I 0 . 1871 0 . 0 1 0 0 .2530 0 . 016

TE 0 . 2545 0 . 0 0 1 0 .3379 0 .002

Tab le 19 S t u d y - p o i n t I . A s s o c i a t i o n between the changes o f compu l s i ve j

: symptoms (CS ) and the changes i n HDHQ s u b s c a l e s .

Ruminat i ve symptoms (RS )

K e n d a l l ' s t a u P Spea rman ' s rho P

PH, 0 .2674 0 . 0 0 1 0 .3322 0 . 0 0 3

G 0 .1426 O.O38 O.1856 0 .058

TH 0 .2116 0 . 0 0 5 0 .2890 0 .007

TE 0 .1844 0 . 0 1 1 0 . 2561 0 . 015

AH 0 .1677 0 . 0 1 8 0 .2177 0 . 0 33

Tab le 20 S t u d y - p o i n t I . A s s o c i a t i o n between the changes o f

r u m i n a t i v e symptoms ( R S ) and the changes i n HDHQ s u b s c a l e s .

. 2 2 5

D e l u s i o n s o f g randeur (dG)

K e n d a l l ' s t au P Spea rman ' s rho P

TE 0 .1668 0 . 0 1 9 0 .2046 0 . 042

D i - O . I 6 5 2 0 . 0 2 0 - 0 . 2 0 8 4 0 . 039

PH 0 .1479 0 . 0 3 3 0 .1769 0 . 068

Tab le 21 S t u d y - p o i n t I . A s s o c i a t i o n between the changes o f d e l u s i o n s

o f g randeur (dG) and the changes i n hDHQ s u b s c a l e s .

D e l u s i o n s o f p e r s e c u t i o n ( d P )

K e n d a l l ' s t a u P Spearman ' s r ho P

PH 0 .2754 0 . 0 0 1 0 .3165 a .oo4

AH 0 .1514 O.O3O 0 .1557 0 . 0 69

Tab le 22 S t u d y - p o i n t I . A s s o c i a t i o n between the changes o f d e l u s i o n s

o f p e r s e c u t i o n ( dP ) and the changes i n HDHQ s u b s c a l e s .

D e l u s i o n s o f c o n t r i t i o n (dC)

K e n d a l l ' s t a u P Spea rman ' s r ho P

0 . 2059 0 . 0 0 5 0 .2582 0 .014

0 .2439 0 . 0 0 2 0 .3036 0 . 0 0 5

0 . 1469 0 . 0 3 3 0 .1896 0 . 055

PH

G

TI

Tab le 23 S t u d y - p o i n t I . A s s o c i a t i o n between the changes o f d e l u s i o n s

o f c o n t r i t i o n (dC) and the changes i n HDHQ s u b s c a l e s .

. 2 2 6

D e l u s i o n s o f d i s i n t e g r a t i o n (DD)

K e n d a l l ' s tan P Spea rman ' s rho P

PH 0 .2456 0 .002 0 .2910 0 .007

G - 0 . 2 3 0 6 0 . 002 - 0 . 2 7 5 7 0 .010

TE 0 .1622 0 . 022 0 .2090 0 .038

D i - 0 . 1 5 6 9 0 . 0 2 5 - 0 . 1 9 2 5 0 .046

Tab le 24 S t u d y - p o i n t I . A s s o c i a t i o n between changes o f d e l u s i o n s o f

d i s i n t e g r a t i o n (DD) and the changes i n HDHQ s u b s c a l e s .

Age ( i n y e a r s )

mean = 3 4 . 6 , s . d . = 15 .8 min . 19 max. 65

Age c a t e g o r i e s No

19 - 29 14

3 0 - 3 9 3

40 - 49 12

5 0 - 6 5 6

T o t a l 35

Tab le 25 Age o f the p a t i e n t s who p a r t i c i p a t e d i n - s t u d y - p o i n t I I .

. 2 2 7

C l i n i c a l D i a g n o s e s

Ma les Females T o t a l

1 . P a r ano i d S c h i z o p h r e n i a 4 2 6

2 . S c h i z o p h r e n i a 7 3 10

3* S c h i z o a f f e c t i v e d i s o r d e r ' 2 2

4 . Manic D e p r e s s i v e P s y c h o s i s 2 2

( D e p r e s s i v e Pha se )

P s y c h o t i c D e p r e s s i o n 2 2

6 . A n x i e t y S t a t e 1 1

7« N e u r o t i c D e p r e s s i o n 1 4 5

8 . N e u r o t i c D e p r e s s i o n and 1 4 5

P e r s o n a l i t y D i s o r d e r

9 . P e r s o n a l i t y D i s o r d e r 1 1 2

16 19 35

Tab le 26 C l i n i c a l d i a g n o s e s g i v e n to the p a t i e n t s who p a r t i c i p a t e d

i n s t u d y - p o i n t I I w i t h the numbers of p a t i e n t s a l l o c a t e d to

each d i a g n o s t i c c a t e g o r y .

CL IN ICAL STATUS

I n - p a t i e n t s D a y - p a t i e n t s O u t - p a t i e n t s

Second 23 ( 6 5 . 7 ^ ) 10 ( 28 .5 ?0 2 ( 5 - 7% )

Q u e s t i o n n a i r e

T h i r d 19 ( 5 4 . 2 k ) 12 (34.2?.) 4 ( 1 1 . 4# )

Q u e s t i o n n a i r e

Tab le 27 C l i n i c a l s t a t u s o f the p a t i e n t s who completed a second and

a t h i r d b a t t e r y o f q u e s t i o n n a i r e s

. 2 2 8

Time e l ap sed ( i n d a y s ) mean: 3 5 * 8 s . d . : 19-6

Days Number o f p a t i e n t s

< 2 0 3

21 - 49 3 0

5 0 - 9 9 2

y 100

35

Tab le 28 Time e l ap sed between the complet ion o f the second and the

t h i r d b a t t e r i e s o f q u e s t i o n n a i r e s

. 2 2 9

Second

Q u e s t i o n n a i r e

CLASS 0

Third_

Q u e s t i o n n a i r e

0

1

CL IN ICAL DIAGNOSIS

S c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

Number o f F a t i o n t n

1 1

CLASS 1 0

0

1 1

1 2

2

S c h i z o p h r e n i a 1

M a n i c - d e p r e s s i v e P s y c h o s i s 1 ( d e p r e s s i v e phase)

P e r s o n a l i t y d i s o r d e r 1

P s y c h o t i c d e p r e s s i o n 1

P a r a n o i d s c h i z p h r e n i a 1

S c h i z o a f f e c t i v e d i s o r d e r 1

P a r a n o i d s c h i z o p h r e n i a 1

CLASS 2 P a r a n o i d s c h i z o p h r e n i a 1

N e u r o t i c d e p r e s s i o n 1

S c h i z o p h r e n i a 3

N e u r o t i c d e p r e s s i o n - 1 P e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n 2

M a n i c - d e p r e s s i v e p s y c h o s i s 1 ( R e p r e s s i v e phase)

P s y c h o t i c d e p r e s s i o n 1

N e u r o t i c d e p r e s s i o n - 1 P e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n - 1 P e r s o n a l i t y d i s o r d e r

. 2 3 0

Socond Q u e s t i o n n a i r e

CLASS 3

CLASS 4

T M r d Q u e s t i o n n a i r e

2

2

3

3

3

2

3

4

4

4

4

C L I N I C A L DIAGNOSIS

N e u r o t i c d e p r e s s i o n

S c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n

A n x i e t y s t a t e

P a r a n o i d s c h i z o p h r e n i a

S c h i z o p h r e n i a

P a r a n o i d s c h i z o p h r e n i a

S c h i z o p h r e n i a

S c h i z o a f f e c t i v e d i s o r d e r

P e r s o n a l i t y d i s o r d e r

Number o f P a t i e n t s

2

3

1

1 33

Tab le 29 D S S I / R C l a s s a l l o c a t i o n and c l a s s change, w i t h the

c l i n i c a l d i a g n o s e s o f the p a t i e n t s v/ho p a r t i c i p a t e d

i n s t u d y - p o i n t I I .

. 2 3 1

SECOND QUESTIONNAIRE

mean Variance s.d.

AH 5.57 6.72 2.59

CO 4.37 7.37 2.71

PH 2.14 5.83 2.41

SC 7.20 6.22 2.49

G 3.40 4.07 2.02

TH 22.87 64.93 8.06

TI 10.60 14.66 3.83

TE 12.29 33.36 5.96

Di 3.17 51.15 7.15

sA 4.97 14.79 3.85

sD 7.71 37.80 6.15

sE 1.23 2.24 1.50

PS 1.87 6.60 2.57

DS 1.71 6 . 0 9 2.47

FS 3-06 8.94 2.99

CS 1.26 4.49 2.12

RS 2.74 10.08 3.17

dG O . 6 3 1.53 1.24

dP 1.86 26.54 5.15

dC 1.87 8.28 2 . 8 8

DD 2.43 14.60 3.82

THIRD QUESTIONNAIRE

mean Variance s.d. Pattern of change

4.73 6.73 2.59 -

4.40 8.31 2.88 -

2.11 4.57 2.14 -

7.34 9.29 3.05 +

3.29 3.68 1.92 -

21.89 77.57 8.61 -

10.63 20.12 4.49 +

11.26 31.08 5.57 N,

6.45 50.14 7.08 +

4.17 12.97 3.60 -

6.43 30.55 5.53

0.94 2.29 1.51 -

1.69 8 .10 2 . 8 5 -

1.31 4.46 2.11 -

2.40 11.31 3.36

1.03 2 . 56 1.60

2.14 8.48 2.91 -

0.29 1.03 1.02

1c00 13-41 3.66

1.74 8.96 2.99 -

1.11 3.57 1.89 —

Table 30 Mean, variance and standard deviation of the scores of

the second and third batteries of questionnaires

( + increase of the mean - decrease of the mean )

2 3 2

S t a t e t o f a n x i e t y ( sA )

K e n d a l l ' s t a u P Spea rman ' s rho P

CO 0 . 2321 0 . 0 2 5 0 .2876 0 . 053

PH 0 . 3913 0 . 0 0 1 0 .4650 0 . 003

G 0 .2469 0 . 0 1 9 0 .3281 0 .028

TH 0 . 3645 0 . 0 0 2 0 .4944 0 . 002

T I 0 . 2325 0 . 0 2 5 0 .3136 0 .034

TE 0 .3582 0 . 0 0 2 0 .4790 0 .002

Tab le 31 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f st£

o f a n x i e t y ( s A ) and the changes i n HDHQ s u b s c a l e s .

S t a t e o f d e p r e s s i o n ( sD )

K e n d a l l ' s t a u P Spea rman ' s rho P

AH 0 .4822 0 . 0 0 1 0 . 6293 0 . 001

CO 0 .2121 0 . 0 3 7 0 . 2941 0 .044

PH 0 .3043 0 . 0 0 6 0 .4052 0 .008

SC 0 .2374 0 . 0 2 3 0 . 3300 0 .027

G O.3663 0 . 0 0 1 0 .4758 0 .002

TH 0 .5137 0 . 0 0 1 0 .6854 0 . 001

T I 0 . 3431 0 . 0 0 2 0 .4647 0 . 003

TE 0 .5005 0 . 0 0 1 0 .6838 0 . 0 0 1

Tab le 32 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f s t a t e

o f d e p r e s s i o n ( s D ) and the changes i n HDHQ s u b s c a l e s

. 2 3 3

C o n v e r s i o n symptoms (PS )

K e n d a l l ' s t a u P Spea rman ' s rho P

AH 0 . 2340 0 . 0 2 3 0 .2926 0 .039

PH 0 .2103 0 . 0 3 8 0 .2569 0 . 069

TH 0 .2675 0 . 0 1 2 0 .2974 0 . 042

TE 0 . 2308 0 . 0 2 6 0 .2655 0 .062

Tab le 33 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f

c o n v e r s i o n symptoms (PS ) and the changes i n HDHQ s u b s c a l e s .

D i s s o c i a t i v e symptoms (DS)

K e n d a l l ' s t a u P Spea rman ' s rho P

AH 0 .3732 0 . 0 0 1 0 .4632 0 . 003

CO 0 .2387 0 . 0 2 2 0.2847 0 .049

PH 0 .4652 0 . 0 0 1 0 .5722 0 . 0 01

SC 0 .2050 0 . 0 4 2 0 .2778 0 .054

G 0 . 2401 0 . 0 2 2 O.3030 0 . 039

TH 0 .4658 0 . 0 0 1 O.5825 0 . 0 01

T l 0 . 2241 0 . 0 3 0 0 .3333 0 .026

TE 0 .4987 0 . 0 0 1 0 .6092 0 . 001

Tab le 34 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f

d i s s o c i a t i v e symptoms (DS ) and the changes i n HDHQ

s u b s c a l e s .

. 2 3 4

Phob ic symptoms (FS )

K e n d a l l ' s t a u P Spearman ' s rho P

AH 0.3582 0 . 002 0 .4553 0 .003

CO 0.2228 0 . 030 0 .2900 0.046

PH 0.3288 0 . 0 0 3 0.3978 0 .009

SC 0.2317 0 . 026 0 .315^ 0 .033

G 0.33^2 0 . 0 0 3 0.4258 0.006

TH 0.4821 0 . 0 0 1 0 .6275 0 .001

TI 0.3456 0 . 002 0 .4613 0 .003

TE 0.4698 0 . 0 0 1 0.^978 0 .001

Table 35 S t udy - po i n t I I . A s s o c i a t i o n betv/een the changes o f phob ic

symptoms ( F S ) and the changes i n HDHQ s u b s c a l e s .

Ruminat ive symptoms (RS )

K e n d a l l ' s t a u P Spearman ' s rho P

AH 0.3914 0 . 001 0.4814 0.002

CO 0 .2233 0 . 0 3 0 0 .2769 0.054

SC 0.1967 0 . 0 4 9 0 .2911 0 .045

G 0.4572 0 . 0 0 1 0.5508 ' 0 .001

TH 0.4622 0 . 0 0 1 0 .5843 0 .001

n 0.3562 0 .002 0 .4941 0.C02

TE 0.3894 0 . 001 0 .4883 0.002

Table 56 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f ruminat ive

symptoms (RS) and the changes i n HDHQ s ub s ca l e s

. 2 3 5

D e l u s i o n s o f p e r s e c u t i o n (dP )

K e n d a l l ' s tau. P Spea rman ' s rho P

AH 0 .4124 0 . 0 0 1 0 .4620 0 . 003

PH •0.2602 0 . 0 1 4 0 .2972 0 .042

G 0.3928- 0 . 0 0 1 0 . 4511 0 .004

TH 0 .2988 0 . 0 0 6 0 .3537 0 . 019

T I 0 .2799 0 . 0 1 0 O.3389 0 .024

TE 0 .2118 0 . 0 3 7 0 .2535 0 . 071

Tab le 57 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f

d e l u s i o n s o f p e r s e c u t i o n (dP) and the changes i n HDHQ

s u b s c a l e s .

D e l u s i o n s o f g randeur (dG)

K e n d a l l ' s t a u P Spearman ' s rho P

PH 0 .2702 0 . 0 1 2 0 .3196 0 . 031

Tab le 38 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f d e l u s i o n s

o f g randeur (dG) and the changes i n HDHQ s u b s c a l e s .

. 2 3 6

D e l u s i o n s o f c o n t r i t i o n (dC)

K e n d a l l ' s t au P Spea rman ' s rho P

AH 0 .2884 0 . 0 0 8 0 .3349 0 . 025

PH 0 .2150 0 . 0 3 5 0 . 2640 0 . 0 6 3

G 0 .2846 0 . 0 0 9 0 .3428 0 .022

TH 0 .3338 0 . 0 0 3 0 . 4001 0 . 009

T I 0 . 2680 0 . 0 12 0 .3306 0 .027

TE 0 .2028 0 . 044 0 . 2379 O.O85

Tab le 59 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f

d e l u s i o n s o f c o n t r i t i o n (dC) and the changes i n HDHQ

s u b s c a l e s .

D e l u s i o n s o f d i s i n t e g r a t i o n (DD)

K e n d a l l ' s tau P Spea rman ' s rho P

. PH 0 .2851 0 . 0 0 8 0 . 3^83 0 . 021

Tab le 40 S t u d y - p o i n t I I . A s s o c i a t i o n between the changes o f de l uaon s

o f d i s i n t e g r a t i o n (DD) and the changes i n HDHQ s u b s c a l e s .

. 2 3 7

Ago ( i n y e a r s ) mean: 3 5 - 2 s . d . : 14.6 min: 19 max: 63

Age c a t e g o r i e s ( i n y e a r s ) Number o f p a t i e n t s

1 9 - 2 9 8

3 0 - 3 9 2

4 0 - 4 9 3

5 0 - 6 5

17

Tab le 41 Age o f the p a t i e n t s who p a r t i c i p a t e d i n s t u d y - p o i n t I I I

Time e l ap sed ( i n d a y s ) mean: 38 . 0 s . d . : 15.4

Days Number o f p a t i e n t s

< 2 0

2 1 - 4 9 15

5 0 - 9 9 2 .

y 100

17

Tab le 42 Time e l ap sed between the complet ion o f the t h i r d and

f o u r t h b a t t e r i e s o f q u e s t i o n n a i r e s .

2 3 8

C l i n i c a l D i a g n o s e s

1. Paranoid schizophrenia

2 . S c h i z o p h r e n i a

3» S c h i z o a f f e c t i v e d i s o r d e r

4 . M a n i c - D e p r e s s i v e P s y c h o s i s

( D e p r e s s i v e phase )

5 . A n x i e t y s t a t e

6 . N e u r o t i c d e p r e s s i o n

7 . N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

Ma les Females T o t a l

3

7

1 1

1 2

2

17

Tab le 45 C l i n i c a l d i a g n o s e s g i v e n t o the p a t i e n t s who p a r t i c i p a t e d

i n s t u d y - p o i n t I I I , w i t h the number o f p a t i e n t s a l l o c a t e d

t o each d i a g n o s t i c c a t e g o r y .

CL IN ICAL STATUS

I n - p a t i e n t s

T h i r d 10 ( 58 .8/0 Q u e s t i o n n a i r e

F o u r t h 7 (41.2%-) Q u e s t i o n n a i r e

D a y - p a t i e n t s

6 (33.3% ')

8 ( 4 7 . ( # )

O u t - p a t i e n t s

1 ( 3 . 8 k )

2 ( 11 . 7% )

Tab le 44 C l i n i c a l s t a t u s o f the p a t i e n t s who completed a t h i r d

and a f o u r t h b a t t e r i e s o f q u e s t i o n n a i r e s .

. 2 3 9

THIRD QUESTIONNAIRE FOURTH QUESTIONNAIRE

mean V a r i a n c e s . d . mean Va r i ance s . d . P a t t e r n change

AH 4 .94 3 - 5 6 1 . 89 4 . 4 7 6 .14 2 . 4 8 -

CO 4 . 7 1 8 . 3 5 2 . 8 9 2 . 9 ^ 8 0 I 8 2 . 8 6 -

PH 1.76 4 . 1 9 2 . 0 5 1 . 2 9 5 .22 2 . 2 8 -

SC 7 .12 12 .73 3 . 5 7 7 . 0 0 12.12

CO

-d-• -

G 3 . 4 1 4 . 0 1 2 . 0 0 3 . 5 3 5 . ^ 9 2 . 3 4 +

TH 21 . 7 7 . ^3 8 . 8 0 1 9 . 0 6 106.43 10.32 -

T I 10 .33 25 . 14 5 . 0 1 1 0 . 3 5 27.44 5 . 2 7 -

TE 11 .41 2 5 . 88 5 . 0 9 8 . 7 1 36 .85 6 . 07 -

D i I

6 . 2 9 5 8 . 3 5 7 . 64 8 . 5 9 44 .51 6 . 67 +

sA 4 . 18 13 .40 3 . 6 6 4 . 5 3 18.64 4 . 32 +

sD 5 . 82 34 . 65 5 . 8 9 6 . 8 8 39 .98 6 . 32 +

s E 0 . 9 ^ 1 .68 1 .30 0 . 7 6 1.82 1 .35 -

PS 2 . 4 1 13 .63 3 . 6 9 1 . 9 4 5 . ^ 3 2 . 3 3 -

DS 2 . 0 0 6 . 62 2 . 5 7 2 . 1 2 5 .98 2 . 4 5 +

FS 3 . 1 8 18 .03 4 . 2 5 3 . 7 1 16.60 4 . 07 +

CS 1 .12 2 . 1 1 1 .45 1 . 2 9 4 .85 2 . 2 0 +

RS 2 . 8 8 12 .98 3 . 6 0 2 . 8 8 18.48 4 ; 30 0

dG 0 . 2 9 1 .47 1 . 21 0 . 7 1 4 .47 2 . 1 1 +

dP 0 . 9 ^ 7 . 18 2 . 6 8 0 . 7 1 2 .60 1 . 61 -

dC 1 .47 9 . 89 3 . 14 2 . 1 2 14.23 3 . 77 +

DD 1 .41 4 . 5 1 2 . 1 2 1 . 7 6 7 . 56 2 . 7 5 +

Tab le 45 Mean, v a r i a n c e and s t a n d a r d d e v i a t i o n o f the s c o r e s

ob ta ined i n the t h i r d and f o u r t h b a t t e r i e s o f q u e s t i o n n a i r e s

( + i n c r e a s e o f the mean - decrease o f the mean )

0 - no change o f mean

. 2 4 0

T h i r d

Q u e s t i o n n a i r e

CLASS 0

F o u r t h CL IN ICAL DIAGNOSIS Q u e s t i o n n a i r e

0 P a r a n o i d s c h i z o p h r e n i a

0 S c h i z o p h r e n i a

CLASS 1 1

2

CLASS 2 0

1 2

i i i i

i 2

2 4

CLASS 3 2

4

CLASS 4 0

3

4

4

S c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n

N e u r o t i c d e p r e s s i o n

P a r a n o i d s c h i z o p h r e n i a

M a n i c - D e p r e s s i v e p s y c h o s i s ( D e p r e s s i v e phase)

S c h i z o a f f e c t i v e d i s o r d e r

N e u r o t i c d e p r e s s i o n

S c h i z o p h r e n i a

A n x i e t y s t a t e

S c h i z o p h r e n i a

S c h i z o p h r e n i a

N e u r o t i c D e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

P a r a n o i d s c h i z o p h r e n i a

S c h i z o p h r e n i a

Number o f P a t i e n t s

1

2

Tab le 46 D S S I /R C l a s s a l l o c a t i o n and c l a s s change w i t h the c l i n i c a l

d i a g n o s e s o f the p a t i e n t s who p a r t i c p a t e d i n s t u d y - p o i n t I I I .

.241

S t a t e o f a n x i e t y ( s A )

K e n d a l l ' s tau . P Spea rman ' s rho P

CO 0 .4484 0 . 0 0 6 0 .6035 0 .006

s c 0 .4100 0 . 0 1 1 0 .5372 0 .014

G 0 .3366 0 . 0 3 0 0 .4391 0 .039

TH 0 .5256 0 . 0 0 2 0 .6919 0 .002

T I 0 . 4960 0 . 0 0 3 O.638O 0 .003

TE 0 .4080 0 . 0 1 2 0 .5347 0 .014

Tab le 47 S t u d y - p o i n t I I I . A s s o c i a t i o n between the changes o f s t a t e

o f a n x i e t y ( s A ) and the changes i n HDHQ s u b s c a l e s .

S t a t e o f d e p r e s s i o n ( s D )

K e n d a l l ' s ta.f.\ P Spea rman ' s rho P

AH 0 .3793 0 . 0 1 7 0 . 5013 0 . 021

. TE 0 . 3253 0 . 0 3 5 0 .4578 0 . 033

* D i - 0 . 2 9 5 6 0 . 0 4 9 - 0 . 4 3 9 3 0 .039

Tab le 48 S t u d y - p o i n t I I I . A s s o c i a t i o n between the changes o f s t a t e

o f d e p r e s s i o n ( s D ) and t h e changes i n HDHQ s u b s c a l e s .

. 2 4 2

Phob i c symptoms ( FS )

K e n d a l l ' s ta.u P Spea rman ' s rho P

CO 0 .3434 0 , 0 2 8 0 ,4417 0 .038

TH 0 ,4135 0 , 0 1 1 O.5623 0 ,010

T I 0 ,2977 0 , 0 4 8 0 ,4198 0 ,047

TE 0 ,3556 0 . 024 0 , 4245 0 ,045

Tab le 49 S t u d y - p o i n t I I I , A s s o c i a t i o n between the changes o f

phob ic symptoms ( F S ) and the changes i n HDHQ s u b s c a l e s .

Compuls ive symptoms (CS )

K e n d a l l ' s t a u P Spea rman ' s rho P

PH 0 ,4602 0 , 0 0 5 0 .5802 0 ,008

Tab le 50 S t u d y - p o i n t I I I . A s s o c i a t i o n between the changes o f compul s ive

symptoms (CS ) and the changes i n HDHQ s u b s c a l e s .

Ruminat i ve symptoms (RS )

K e n d a l l ' s t a u P Spea rman ' s rho P

CO Oo4l63 0 . 0 1 1 0 , 5235 0 ,016

PH O.38OI 0 . 0 1 7 0 . 4599 0 .032

SC 0 .3811 0 . 0 1 7 0 . 5143 0 ,018

TH 0 .5304 0 . 0 0 2 O.6658 0 . 002

T I 0 .4479 0 . 0 0 7 0 , 5785 0 . 008

TE 0 .4310 0 . 0 0 8 0 ,5352 0 .014

Tab le 51 S t u d y - p o i n t I I I . A s s o c i a t i o n between the changes o f

r um ina t i v e symptoms (RS ) and the changes i n HDHQ s u b s c a l e s

. 2 4 3

D e l u s i o n s o f p e r s e c u t i o n ( dP )

K e n d a l l ' s tau P Spearman ' s rho P

AH 0 .3721 0 . 0 1 9 0 .4456 0 .037

PH 0 .5854 0 . 0 0 1 0 .6353 o.oo4

G 0 .4908 0 . 0 0 3 0 .5558 0 . 0 11

TH 0 .3269 0 . 0 3 4 O.3867 0 . 0 63

TE 0 . 4800 0 . 0 0 4 0 .5406 0 . 0 13

D i - 0 . 4 8 5 6 0 . 0 0 4 - 0 . 5 7 5 6 0 . 009

Tab le 52 S t u d y - p o i n t I I I . A s s o c i a t i o n between the changes o f d e l u s i o n

o f p e r s e c u t i o n (dP ) and the changes i n HDHQ s u b s c a l e s .

D e l u s i o n s o f g randeur (dG)

K e n d a l l ' s t a u P Spearman ' s rho P

PH 0 .4426 0 . 0 0 7 0 .4913 0 . 023

G 0 .3225 0 . 0 3 6 O.3687 0 . 073

Tab le 53 S t u d y - p o i n t I I I . A s s o c i a t i o n between the changes o f d e l u s i o n s

o f g randeur (dG) and the changes i n HDHQ s u b s c a l e s .

. 2 4 4

mean: 3 6 . 9 s . d . : 15 - 9 min: 20 max: 65 Age ( i n year

Age c a t e g o r i e s ( i n y e a r s ) Number o f P a t i e n t s

20 - 29 • 3

3 0 - 3 9 1

40 - 49 ' 2

3 0 - 6 3 3

11

Tab le 54 Age o f p a t i e n t s who p a r t i c i p a t e d i n s t u d y - p o i n t I V

mean: 47 .64 s . d . : 3 3 * 6 8 Time e l a p s e d ( i n day s )

Days Number o f P a t i e n t s

20

2 1 - 4 9 9

5 0 - 9 9 1

100 1

11

Tab le 55 Time e l ap sed between the complet ion o f the f o u r t h and

f i f t h b a t t e r i e s o f q u e s t i o n n a i r e s .

. 2 4 5

CL IN ICAL STATUS

I n - p a t i e n t 3 D a y - p a t i e n t s O u t - p a t i e n t s

Fou r th h ( 36A 0 / ) 6 (54.5/) 1 (9.0fc) Que s t i o nna i r e s

F i f t h 4 ( 3 6 . W 7 (63 .6^ ) Que s t i onna i r e s

Table 56 C l i n i c a l s t a t u s o f the p a t i e n t s who completed a f ou r th and

a f i f t h b a t t e r i e s o f q u e s t i o n n a i r e s .

C l i n i c a l D i a g n o s e s • ' Male Female To t a l I

1. Pa rano id s c h i z o p h r e n i a 1 0 1

2 . S c h i z oph ren i a 5 . 1 6

3 - Anx ie ty s t a t e 0 1 1

4 . Neu ro t i c d e p r e s s i o n 0 2 2

5 . Neu ro t i c d e p r e s s i o n - 0 1 1 P e r s o n a l i t y d i s o r d e r

11

Table 57 C l i n i c a l d i a g n o s e s g i v e n to the p a t i e n t s who p a r t i c i p a t e d

" i n study-.point I V , w i th the numbers o f p a t i e n t s a l l o c a t e d

to each d i a g n o s t i c c a t e g o r y .

. 2 4 6

F o u r t h

Q u e s t i o n n a i r e

CLASS 0

F i f t h

Q u e s t i o n n a i r e

0

0

C L I N I C A L DIAGNOSIS

S c h i z o p h r e n i a

N e u r o t i c d e p r e s s i o n -P e r s o n a l i t y d i s o r d e r

N e u r o t i c d e p r e s s i o n

Number of P a t i e n t s

2 1

CLASS 1

CLASS 2

CLASS 3

0

1

0

2

2

0

k

S c h i z o p h r e n i a

P a r a n o i d s c h i z o p h r e n i a '

S c h i z o p h r e n i a

A n x i e t y s t a t e

N e u r o t i c d e p r e s s i o n

S c h i z o p h r e n i a

S c h i z o p h r e n i a

11

Tab le 58 D S S I /R C l a s s a l l o c a t i o n and c l a s s change w i t h the

c l i n i c a l d i a g n o s e s o f the p a t i e n t s who p a r t i c i p a t e d

i n s t u d y - p o i n t I V .

FOURTH QUESTIONNAIRE

mean v a r i a n c e s . d .

F I FTH QUESTIONNAIRE

mean Va r i ance s . d . P a t t e r n o f change

AH 4 . 1 8 4 . 96 2 . 2 3 4 . 0 0 6 . 0 0 2 . 4 5 -

CO 2 . 6 4 10 .85 3 . 2 9 3 - 8 2 7 .56 2 . 7 5 +

PH 1 .36 7 . 2 5 2 . 6 9 1 . 1 8 3 . 96 1 . 99 -

SC 6 . 2 ? 11.02 3 . 3 2 7 . 0 9 9.09 3 . 0 1 +

G 3 . 0 9 4 . 89 2 . 2 1 2 . 8 2 2 .16 1 .47 -

TH 17.54 134.07 11 .58 1 8 . 9 1 65 .69 8 . 10 +

T I 9 . 36 2 4 . 6 5 4 . 9 6 9 . 9 1 16.69 4 . 0 8 +

TE 8 . 1 8 55 .56 7 . 4 5 9 . 0 0 29 .20 5 . 4 0 +

D i 7 . 36 37 . 25 6 . 1 0 • 8 . 0 0 51 .00 7 . 14 +

sA 3 . 64 13.85 3 . 7 2 4 . 5 4 32 .67 5 . 72 +

sD 5 . 0 9 25 .29 5 . 0 3 5 . ^ 5 39 .87 6 . 3 1 +

s E 0 . 5 5 1.07 1 .04 0 . 5 4 1.07 1 .04 -

PS 2 . 0 0 6 . 0 0 2 . 4 5 1 . 5 ^ 5 . 87 2 . 42 -

DS 1 . 5^ 6 .47 2 . 5 4 1 . 8 2 7 .96 2 . 8 2 +

FS 3 . 1 8 15.56 3 . 94 2 . 6 3 6 . 45 2 . 54 -

CS 1 . 00 4 . 60 2 . 1 4 1 . 6 3 9 . 05 3 . 0 1 +

RS 2 . 2 7 23 .22 4 . 8 2 2 . 3 6 14.25 3 - 7 8 +

dG 0 . 7 3 5 . 82 2 . 4 1 - O .36 0 . 85 0 . 92 -

dP 0 . 7 3 2 . 82 1 .68 3 . 3 6 56 . 05 7 . 4 9 +

dC 1 .45 15.07 3 . 8 8 1 . 0 9 7 . 29 2 . 7 0 -

DD 1 .27 8 .82 2 . 9 7 1 . 9 1 16.29 4 . 04 +

Table 59 Mean, v a r i a n c e and s t a n d a r d d e v i a t i o n v a l u e s o f the

s c o r e s o f the f o u r t h and f i f t h b a t t e r i e s o f q u e s t i o n n a i r e

( + i n c r e a s e o f the mean - decrease o f the mean )

2 4 8

Str.te o f a n x i e t y ( s A )

Kendall's tau P Spearman's rho P

G 0 .4203 0 . 0 3 6 0 .5468 0 . 0 41

TH 0 o 4907 0 . 0 1 8 0 .5734 . 0 . 033

T I 0 .4152 O.O38 0 .4358 0 . 091

TE 0 .6005 0 . 006 0 . 7419 0 . 005

Tab le 60 S t u d y - p o i n t I V . A s s o c i a t i o n between the changes o f s t a t e

o f anx i e t y ( s A ) and the changes i n HDHQ s u b s c a l e s .

S t a t e o f d e p r e s s i o n ( s D )

K e n d a l l ' s t au P Spea rman ' s rho P

0 .3934 0 . 0 4 7 0 . 5233 0 . 050

0 .5155 0 . 014 0 . 6201 0 . 0 21

0 .4362 0 . 0 3 1 0 . 5833 0 . 030

Tab le 61 S t u d y - p o i n t I V . A s s o c i a t i o n between the changes o f s t a t e

o f d e p r e s s i o n ( s D ) and the changes i n HDHQ s u b s c a l e s .

. 2 4 9

C o n v e r s i o n symptoms ( P S )

K e n d a l l ' s taxi P Spea rman ' s rho P

CO 0 .6162 0 . 0 0 5 0 . 7180 0 .007

PH 0 .5058 0 . 0 1 6 0 . 5965 0 .027

TH 0 .4773 0 . 0 2 1 0 . 5495 0.040

TE 0.7264 0 . 0 0 1 O.7896 0 . 005

D i - 0 . 4 7 2 9 0 . 0 22 - 0 . 5 6 7 3 0 . 073

Tab le 62 S t u d y - p o i n t I V . A s s o c i a t i o n between the changes o f

conversion symptoms (PS) and the changes in HDHQ subscales.

Dissociative symptoms (DS)

K e n d a l l ' s t a u P Spea rman ' s rho P

AH 0 .3862 0 . 0 5 0 0 . 4295 0 .096

CO 0 . 6240 0.004- 0 . 7131 0 . 007

PH 0 .7483 0 . 0 0 1 0 .8152 0.C02

TH 0 .6755 0 . 0 0 2 0 .7672 0 . 0 0 3

TE 0 . 8321 0 . 0 0 1 0 .8847 0 . 0 01

Table 63 Study-point IV. Association between the'changes of

dissociative symptoms (DS) and the changes in

HDHQ subscales.

. 2 5 0

Phobic symptoms (FS)

Kendall's ta u P Spearman's rho P

CO 0 . 4899 0 .018 0.6188 0 .022

TE 0.5715 0 .008 0.6762 0 .012

Table 64 Study-point IV. Association between the changes of

phobic symptoms (FS) and the changes in HDHQ subscales

Ruminative symptoms (RS)

Kendall's tau P Spearman's rho P

CO 0.4743 0 . 022 0.5867 0 .029

PH 0 .7538 0 . 001 0.8609 0 .001

G 0 .4124 0 . 0 3 9 0 .5321 0 .047

TH 0 . 6221 0 . 004 0.7484 0 .005

TI O .3888 0 . 0 4 8 0.5106 0 .055

TE 0 .7217 0 . 0 0 2 0.8234 0 . 001

Table 65 Study-point IV. Association betv/een the changes

symptoms (RS) and the changes in HDHQ subscales.

of ruminative

. 2 5 1

D e l u s i o n s o f p e r s e c u t i o n (dP)

K e n d a l l •s t a u P Spearman ' s rho P

CO 0 .4444 0 . 0 2 9 O.5283 0 ,048

PH 0 . 75^3 0 . 0 0 1 0 .8206 0 . 001

SC 0 .4722 0 . 022 0 .5338 0 .046

G 0 .5556 0 . 0 0 9 0 .6375 0 .018

TH 0 .6024 0 . 0 0 5 0 .7243 0 .006

TE 0 .6944 0 . 002 0 .7948 0 .002

T I 0 .6024 0 . 0 0 5 0 .6837 0 . 011

Tab le 66 S t u d y - p o i n t I V . A s s o c i a t i o n between the changes o f

d e l u s i o n s o f p e r s e c u t i o n (dP) and the changes i n HDHQ

s u b s c a l e s .

D e l u s i o n s o f g randeur (dG)

K e n d a l l ' s tau P Spea rman ' s rho P

PH 0 . 6225 0 . 004 0 .6734 0 .012

SC 0 .5298 0 . 012 0 .5880 0 .029

G 0 .3984 0 . 0 4 5 0 .4475 0 .084

TH 0 . 4683 0 . 0 2 3 0 .5406 ' 0 . 043

T I 0 . 5307 0 . 0 12 0 .6082 0 .024

TE 0 . 5629 0 . 0 0 8 0 .6225 0 . 021

Tab le 67 S t u d y - p o i n t I V . A s s o c i a t i o n between the changes o f

d e l u s i o n s o f g randeur (dG) and the changes i n HDHQ r .ubsca les .

2 5 2

Delusions of contrition (dC)

Kendall's tan P Spearman's rho P

CO 0 .5778 0 . 0 0 7 0.6928 0 . 010

PH 0 .7242 0 . 0 0 1 0 .7917 0 .002

TH 0 .6319 0 . 0 0 4 0 .7423 0 . 005

TE O.7858 0 . 0 0 1 0 .8643 0 . 001

Tab le 68 S t u d y - p o i n t I V . A s s o c i a t i o n betv/een the change: s o f

d e l u s i o n s o f c o n t r i t i o n (dC) and the changes i n HDHQ

-e u b s c a l e s .

D e l u s i o n s o f d i s i n t e g r a t i o n (DD)

K e n d a l l ' s tau P Spea rman ' s rho P

CO 0 .4444 0 . 0 2 9 0 .5283 0 .048

PH 0 .75^3 0 . 0 0 1 0 .8206 0 . 001

SC 0 .4722 0 . 0 2 2 . 0 .5338 0 .046

G 0 .5556 0 . 0 0 9 0 .6375 0 .018

TH 0 .6024 0 . 0 0 5 0 .7243 0 .006

T I 0 .6024 0 . 0 0 5 0 .6737 0 . 0 11

TE 0 .6944 0 . 002 0 .79^8 0 . 002

Table 69 Study-point IV. Association between the changes of delusions

of disintegration (DD) and the changes in HDHQ subscales.

. 2 53

S t a t e o f a n x i e t y ( s A )

S t u d y - p o i n t S t u d y - p o i n t S tudy -po in f ; S t u d y - p o i n t

I II III IV

TH * * * * * * * * * * * * * * •

g * * * * * * * * * » • • •

AH •

CO * * * *

pjj * • * * * * *

fpj * * # * * * * *

SC * * * * * •

G * *

D i

Tab le 70 L e v e l s o f s i g n i f i c a n c e o f c o r r e l a t i o n s between the s co re

changes o f s t a t e o f a n x i e t y ( sA ) and HDHQ s u b s c a l e s

P = 0 . 0 01 * • * * •

P = 0 .002 - 0 . 005 * * * *

P = 0 .006 - 0 . 009 * * * i

P = 0 . 010 - 0 . 020 * *

P = 0 . 0 21 - 0 . 050 *

2 5 4

S t a t e o f d e p r e s s i o n ( s D )

Study-point Study-point Study-point Study-point

I I I I I I I V

TH • * * *

TE •• * * * • # • «

y jj * * * * * * * * * * * *

CO •

PH *

Q1J * * * * •*••

SC *

Q * * * * * * *

D i * ( - )

Tab le 71 L e v e l s o f s i g n i f i c a n c e o f c o r r e l a t i o n s between the s c o r e

changes o f s t a t e o f d e p r e s s i o n ( sD ) and HDHQ s u b s c a l e s .

P = 0 . 0 01 * * * * *

P = 0 .002 - 0 . 005 * * * *

P = 0 .006 - 0 . 009 * * * i

P = 0 . 0 1 0 - 0 . 020 * *

P = 0 . 0 21 - 0 . 050 *

( - ) : n e g a t i v e c o r r e l a t i o n

. 2 5 5

S t a t e o f e l a t i o n ( s E )

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I I I I I I I V

TH •*••»

ijE * • * * •

AH

CO * • * * pjj * * * * *

T I

SC *

G

D i • ( - )

Tab le 72 L e v e l s o f s i g n i f i c a n c e o f c o r r e l a t i o n s between the changes

o f s t a t e o f e l a t i o n ( s E ) and HDHQ s u b s c a l e s .

P * 0 . 0 01 * * * * *

P « 0 .002 - 0 . 005 * * * *

P 0 . 006 - 0 . 0 0 9 * * *

p = 0.010 - o.ceo **

P = 0 . 0 21 - 0 . 050 *

( - ) : nega t i v e c o r r e l a t i o n

2 5 6

Compul s i ve symptoms (CS )

Study-point Study-point Study-point Study-point

I I I I I I I V

TH * * * * * •

TE * * * * * *

AH

CO * pjj * * * * * *

T I * * *

SC

G * *

D i

Tab le 73 L e v e l s o f s i g n i f i c a n c e o f c o r r e l a t i o n s between the s co re

changes o f compu l s i ve symptoms (CS) and HDHQ s u b s c a l e s .

P = 0 . 001

P = 0 .002 - 0.005

P = 0 .006 - 0 . 0 09 * * *

P = 0 . 010 - 0 . 0 20 * *

P = 0 . 021 - 0 . 0 5 0 *

. 2 5 7

Ruminat i ve symptoms (RS )

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

* II III IV

TH * * * * * * * * * * * * * * * * *

y g •* * * * * * * * * * * * *

AH * * * * * * *

CO * * * *

pjj * * * * * * * * * * * *

rpj * * * *

SC I * **

G

D i

Tab le 7k L e v e l s o f s i g n i f i c a n c e , o f c o r r e l a t i o n s betv/een the s c o r e

changes o f r u m i n a t i v e symptoms (RS) and HDHQ s u b s c a l e s .

P = 0 . 001 * * * * *

P = 0 .002 - 0 . 005 * * * *

P = 0 .006 - 0 . 009 * * *

P = 0 . 0 1 0 - 0 . 020 * *

P = 0 . 021 - 0 . 050 *

. 2 5 8

Conversion symptoms (PS)

Study-point Study-point Study-point Study-point I II III IV

TH ** *

TE * • * » * *

AH *

CO *•**

PH * ••

TI

SC

G

Di • (-)

Table 75 Levels of significance, of correlations between the score

changes of conversions symptoms (PS) and HDHQ subscales.

P = 0.001 *****

P = 0.002 - 0.005 ****

P = 0.006 - 0.009 ***

P = 0.Q10 - 0.020

P = 0.021 - 0.050 *

negative correlation

. 2 5 9

P i B s o c i a t i v e symptoms (DS )

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I • I I I I I I V

TH * * * * *

TE * * * * *

AH * * * * *

CO *

PH * * * * *

T I

SC

G

D i * * * * * ( - )

• »**

Tab le 76 L e v e l s o f s i g n i f i c a n c e , o f c o r r e l a t i o n s between the s c o r e

changes o f d i s s o c i a t i v e symptoms (DS) and HDHQ s u b s c a l e s .

P = 0 . 0 0 1 * * * * *

P = 0 . 002 - 0 . 005 * * * *

P = 0 . 006 - 0 . 009 * * *

P = 0 . 0 1 0 - 0 .020 * *

P = 0 . 0 2 1 - 0 . 050 *

( - ) : n e g a t i v e c o r r e l a t i o n

2 6 0

Phob i c symptoms ( F S )

Study-point Study-point Study-point Study-point I • II III IV

T H * * * * « * * * • * *

* • * * • * * * *

AH * * * * * • *

CO * * * •

PH * * * *

rpj • * * • * *

SC *

G • * * *

D i

Tab le 77 L e v e l s o f s i g n i f i c a n c e , o f c o r r e l a t i o n s between the s c o r e

changes o f phob i c symptoms ( F S ) and HDHQ s u b s c a l e s

P = 0 . 0 01 * * * * *

P = 0 . 002 - 0 . 005 * * * *

P = 0 . 006 - 0 . 009 * * *

P = 0 . 010 - 0 . 020 * *

P = 0 . 0 2 1 - 0 . 050 *

. 2 6 1

Delusions of grandeur (dG)

Study-point Study-point Study-point Study-point

I II III IV

TH # *

TE * * . * * *

AH

CO pjj * * * * * * * * * *

TI **

SC ) ** i

G * *

Di ** (-)

Table 78 Levels of significance, of correlations between the score

changes of delusions of grandeur (dG) and HDHQ subscales.

P = 0.001 *****

P = 0.002 - 0.005 ****

P = 0.006 - 0.009 ***

P = 0.010 - 0.020 **

P = 0.021 - 0.050 *

(-): negative'correlation

. 2 6 2

D e l u s i o n s o f p e r s e c u t i o n (dP )

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I I I I I I I V .

TH ••• * *•••

TE * • * » *

AH * * * * * * * *

CO *

P J J * * * * * * * * * * * * * * * * *

T j * • * * * *

SC *

Q ***** **** ***

D i * * * * ( - )

Tab le 79 L e v e l s o f s i g n i f i c a n c e , o f c o r r e l a t i o n s betv/een the s c o r e

changes o f d e l u s i o n s o f p e r s e c u t i o n (dP) and HDHQ s u b s c a l e s .

P = 0 . 001 * * * * *

P = 0 .002 - 0 . 005 * * * *

P = 0 .006 - 0 .009 * * *

P = 0 . 010 - 0 . 020 * *

P = 0 . 021 - 0 . 050 *

( - ) : nega t i v e c o r r e l a t i o n

. 2 6 3

Delusions of contrition (dC)

TH

TE

AH

CO

PH

TI

SC

G

Di

Study-point Study-point Study-point Study-point

II III IV * * * *

* * *

Table 80 Levels of significance, of correlations between the score

changes of delusions of contrition (dC) and HDHQ subscales.

P'= 0.001

P = 0.002 - 0.003 ****

P = 0.0C6 - 0.009 ***

P = 0.010- 0.020 **

P = 0.021 - 0.050 *

. 2 6 4

Delusions of disintegration (DD)

Study-point Study-point Study-point Study-point

1 ' II III IV

TH ****

TE * # «* • *

AH

CO * p jj * # • * * » * * * * * * *

TI

SC *

G (-) *•*

Di • (-)

Table i>1 Levels of significance, of correlations between the score

changes of delusions of disintegration (DD) and HDHQ

subscales.

P = 0.001 ***••

P = 0.002 - 0.005 ****

P = 0.006 - 0.009 ***

P.= 0.010 - 0.020 **

P = 0.021 - 0.050 *

(-).: negative correlation

. 2 6 5

T o t a l H o s t i l i t y (TH)

A . P r o b a b i l i t i e s

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I I I I I I I V

sA

sD

s E

PS

DS

FS • * • *

CS

RS * * * *

dG

dP

dC

DD

* # *

• * » *

* * * »

* * * *

* * * *

* • * * * + # *

B . Summary

Very s t r o n g A s s o c i a t i o n sA RS

S t r o n g A s s o c i a t i o n

Moderate A s s o c i a t i o n

V/eak A s s o c i a t i o n

sD

s E

FS

DS

PS

CS

dC

dP

DD

No A s s o c i a t i o n dG

Tab le 82 Degrees o f A s s o c i a t i o n Between T o t a l H o s t i l i t y (TH) and

the DSS I/R S e t s .

Very S t r o n g A s s o c i a t i o n : S t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n s found i n f ou r s t u d y - p o i n t s .

S t r o n g A s s o c i a t i o n : " " " " i n th ree s t u d y - p o i n t s .

Moderate A s s o c i a t i o n : " fl " " i n two s t u d y - p o i n t s .

V/eak A s s o c i a t i o n : 11 " " " one s t u d y - p o i n t .

p = o.ooi *****; p = 0.002 - 0.005 ****; p = 0.006 - 0.009 *** p = 0 . 0 1 0 - 0 . 2 0 * * ; P = 0 . 0 2 1 - 0 . 0 5 0 *

. 2 6 6

Total Extrapunitiveness (TE) A. P r o b a b i l i t i e s

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I I I I I I I V

* * * * * * * * * • « • * * i

sA

sD

s E

PS

DS

FS

CS

RS

dG

dP

dC

DD

B . Summary

Ve ry S t r o n g A s s o c i a t i o n sA RS

S t r o n g A s s o c i a t i o n DS

Moderate A s s o c i a t i o n sD

FS

PS

• * * * * * * • • • *

dG

dP

Weak A s s o c i a t i o n s E ^ dC DD

No A s s o c i a t i o n .

Tab le 83 Degrees o f A s s o c i a t i o n Between T o t a l E x t r a p u n i t i v e n e s s (TE)

-and the DS S I /R S e t s .

(See Tab le 82 f o r the meaning o f the d e f i n i t i o n s used i n summary t a b l e )

. 2 6 7

* * * • * • * » * * *

Ac t i n g - ou t H o s t i l i t y (AH)

A . P r o b a b i l i t i e s

S t udy - po i n t S t u d y - p o i n t S t udy -po i n t S t udy -po i n t

I I I I I I I V

sA sD ***** ' ***** ** sE PS

DS ***** *****

FS

CS

RS

dG

dP * * * * * * *

dC * * *

DD

B. Summary

Very S t r o n g A s s o c i a t i o n

S t r o n g A s s o c i a t i o n sD Moderate A s s o c i a t i o n RS dP

FS

Weak A s s o c i a t i o n ^ CS dC

» *

No A s s o c i a t i o n sE PS dG DD

Table 84. Degrees o f A s s o c i a t i o n Be/tween Ac t i n g - ou t H o s t i l i t y (AH)

and the DSS I /R s e t s .

(See Table 82 f o r the meaning o f d e f i n i t i o n s used i n summary t a b l e ) .

. 2 6 8

C r i t i c i s m o f O the r s (CO)

A. P r o b a b i l i t i e s

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I II ill : IV

sA * * *

sD

s E

PS

DS

FS

CS

RS * *

dG

dP

dC

DD

* * * *

B. Summary

Very S t r o n g A s s o c i a t i o n

S t r o n g A s s o c i a t i o n

Moderate A s s o c i a t i o n

V/eak A s s o c i a t i o n

No A s s o c i a t i o n

s E

sA

sD

RS PS DS FS

CS

dC

dG

dP DD

Tab le 85 Degrees o f A s s o c i a t i o n Between C r i t i c i s m o f O the r s (CO) and

the DSS I /R s e t s .

(See Tab le 82 f o r the meaning o f d e f i n i t i o n s UBed i n summary t a b l e )

. 2 6 9

Pa rano i d H o s t i l i t y (PH)

A . P r o b a b i l i t i e s

S t u d y - p o i n t S t u d y - p o i n t

I I I

sA * * * * * * *

sD * * *

s E * * * * *

PS

DS * * * * * * * * * *

FS * * * *

CS * * * * *

RS * * * * *

dG *•

dP * * * * * ••

dC * * * *

DD * * * *

B . Summary

Ve ry S t r o n g A s s o c i a t i o n

S t r o n g A s s o c i a t i o n

Moderate A s s o c i a t i o n

Weak A s s o c i a t i o n

No A s s o c i a t i o n .

S t u d y - p o i n t S t u d y - p o i n t

I I I I V

* * * *

* *

* * *

* * * * *

» * * * *

sA sD s E

RS DS

CS PS FS

dP dG

dC

DD

Tab le 86 Degrees o f A s s o c i a t i o n Between Pa rano i d H o s t i l i t y (PH)

and the DSS I /R s e t s .

(See Tab le 82 f o r the meaning o f the d e f i n i t i o n s used i n summary t a b l e )

. 2 7 0

Total Intropunitivcnoss (TI) A. Probabilities

Study-point Study-point Study-point Study-point I II III IV

sA sD sE PS DS FS CS RS dG dP dC DD

* * • *

* * * *

* *

B. Summary Very Strong Association Strong Association Moderate Association

V/eak Association

No Association sE

sA RS dP sD

CS dG FS dC DD PS DS

Table #7 Degrees of Association Between Total Intropunitiveness (TI) and the DSSI/R sets.

(See Table 62 for the meaning of the definitions used in summary table)

. 2 7 1

Solf-Criticism (SC) A. Probabilities

Study-point Study-point Study-point Study-point I ' II III IV * * * * * * sA

sD sE PS DS FS CS RS dG dP dC DD

* * * *

B. Summary Very Strong Association Strong Association Moderate Association sA Weak Association sD No Association sE

Table 88 Degrees of Association the DSSI/R sets.

(See Table 82 for the meaning of

RS dG PS dP DS FS dC CS

Betv/een Self-Criticism (SC) and

the definitions used in summary table)

. 2 7 2

G u i l t (G)

A . P r o b a b i l i t i e s

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I II III IV

sA

sD

s E

PS

DS

FS

CS

RS » • * * *

dG

dP

dC * * * *

DD * • * • ( - )

• *

B . Summary

Very S t r o n g A s s o c i a t i o n

S t r o n g A s s o c i a t i o n dP

Moderate A s s o c i a t i o n sD dC FS -DD

V/eak A s s o c i a t i o n sA ^

PS No A s s o c i a t i o n s E dG

FS DD PS DS

Tab le 89 Degrees o f A s s o c i a t i o n Between G u i l t (G) and the

DSS I /R s e t s .

(See Tab le 82 f o r the meaning o f the d e f i n i t i o n s used i n summary t a b l e )

. 2 7 3

D i r e c t i o n o f Ho t i l i t y ( D i )

A. P r o b a b i l i t i e s

S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t S t u d y - p o i n t

I I I I I I I V

sA

sD

s E

PS

DS • * • * • ( - )

FS

CS

RS

dG • • ( - )

dP * * • * ( - )

dC

DD

B . Summary

Very S t r o n g A s s o c i a t i o n

S t r o n g A s s o c i a t i o n

Moderate A s s o c i a t i o n

V/eak A s s o c i a t i o n - D S

No A s s o c i a t i o n

- d P -dG

sA PS sD FS s E CS dC DD

RS

Tab le 90 Degrees o f A s s o c i a t i o n Between D i r e c t i o n o f H o s t i l i t y ( D i )

and the D S S I / R s e t s .

(See Tab le 82 f o r the mean ings o f the d e f i n i t i o n s used i n summary t ab l e )

2 7 4

S t a t e o f den re sn i on ( sD )

TH TE AH CO PII TI SC G j * * * * * * * * * * * * * * * * * * *

j j * * * * * * * * * * * * * * * * * * * * * * * * * <

I I I * * *

IV * * **

D e l u s i o n s o f c o n t r i t i o n (dC)

SC G

* * * *

» * *

Tab le 91 Compar i son o f the p a t t e r n s o f r e l a t i o n s h i p s to h o s t i l i t y -

changes , between s t a t e o f d e p r e s s i o n ( sD ) and d e l u s i o n s o f

c o n t r i t i o n (dC) s c o r e changes .

P = 0 . 001 * * * * *

P = 0.002 - 0.005 »***

P = 0 .006 - 0 . 009 * * *

P = 0 . 010 - 0 . 020 * * •

P = 0 . 021 - 0 .050 *

( - ) : n e g a t i v e n o n - s i g n i f i c a n t c o r r e l a t i o n

I

I I

I I I

I V

iTH TE

* * * * *

AH CO

( - )

( - )

PH T I

• # * * *

2 7 5

State of elation (sE)

TH TE AH CO PII TI SC G j * * * * * * * * * * * * * * * * * * *

I I ( - ) ( - )

I I I ( - )

I V ( - )

Delusions of grandeur (dG)

TH TE AH CO PH TI SC G

I ( - ) ( - )

I I ( - ) * * ( - ) ( - )

I I I ( - )

jy * »»• * * * * * * ** *

Table 92 Comparison of the patterns of relationships to hostility

changes, between state of elation (sE) and delusions of

grandeur (dG) score changes.

P = 0.001 *****

P = 0.002 - 0.005 ****

P = 0.006 - 0.009 ***

P = 0.010 - 0.020

P = 0.021 - 0.050 *

(-): negative correlation

2 7 6

C o m p u l s i v e symptoms (CS)

TH TE AH CO PII TI SC G j * * * * * * * * * * * * * * * * * * * * *

I I * ( - )

I I I * * *

I V * • * * *

Ruminative symptoms (RS)

TH TE AH CO PH TI SC j * * * * ** * * * * * * *

22 * * * * * * * * * * * * * * * * * * * * *

2 2 1 * * * * * * * # * * * * * * * *

2v * * • * * * * * # * * * * * *

Table 93 Comparisons of the patterns of relationships to hostility

changes between compulsive symptoms (CS) and ruminative

symptoms (RS) score changes.

P = 0.001 *****

P = 0.002 - 0.003 ****

P •= 0.006 - 0.009 ***

P = 0.010 - 0.020 **

P = 0.021 - 0.050 *

negative correlation

. 2 7 7

C o n v e r s i o n symptoms (PS)

TH TE AH CO PH TI SC G

I ( - )

II •• • * *

III j y • * * * * * * * * * * *

Dissociative symptoms (DS)

TH TE AH CO PH TI SC G j * * * * * * * * * * * * * * * * * * * * *

II * * * * * * * * * * * * * * * *

III * (-) I V * » • * * * * * * * * * * * * * * * *

Table Comparisons of the patterns of relationships to hostility

changes between conversion symptoms (FS) and dissociative

symptoms (DS) score changes.

P = 0.001 ' *****

P = 0.002 - 0.005 ****

P = 0.006 - 0.009 ***

P = 0.010 - 0.020 **

P = 0.021 - 0.050 *

(-): negative correlation

2 7 8

•'.Mm: i i . ..i.jjj:

^TutW-PoiNIj i - ^ - m i t r h ti

Figure 2. Means of scores of Total Hostility (TH), Total Extrapunitiveness (TE) and Total Intropunitiveness (Tl) along the four study-points.

2 7 9

uLLi.Iti:!:.:.|:!".(:tt r ; w l — — ~

Figure 3. Means of scores of acting-out hostility (All), criticism of others (CO) and paranoid hostility (PH) along the four study-points.

2 8 0

F i g u r e 4 . Means of scores of self-criticism (SC) and guilt (G) along the four study-points.

2 8 1

F i g u r e Means of scores of state of depression (SD) state of anxiety (SA) and state of elation (SE) along the four study-points.

282

(>0 i HT| f-tMf PovNXLTZil^UTU Pe i WT i J Q ^ t x i i t f c

a-H_L| 4- fj-i-UJTE —i- i—r-t-r—i"T r-K-f-t-H 44-r i i

F i g u r e 4. Means of scores"of phobic symptoms (FS), conversion symptoms (PS) and dissociative symptoms (DS) along the four study-points.

2 8 3

' i—-1—• J—i I—L—i J_4_-U_L~T1T

F i g u r e 4. M e a n s o f s c o r e s o f r u m i n a t i v e symptoms ( R S ) ,

c o m p u l s i v e symptoms ( C S ) a n d d e l u s i o n s o f

g r a n d e u r ( d G ) a l o n g t h e f o u r s t u d y - p o i n t s .

2 8 4

F i f ru re 8 . Means o f s c o r e s o f d e l u s i o n s o f c o n t r i t i o n ( d C ) ,

d e l u s i o n s o f p e r s e c u t i o n ( d P ) and d e l u s i o n s o f

d i s i n t e g r a t i o n (DD) a l o n g t he f o u r s t u d y - p o i n t s .

2 8 5

APPENDICES

2 8 6

APPENDIX A

HOST IL ITY AND D IRECT ION OF HOST IL ITY QUESTIONNAIRE (HDHQ)

The i tem numbers r e f e r t o t h e i r p o s i t i o n i n the q u e s t i o n n a i r e

ACTING-OUT H O S T I L I T Y ( A H )

7 . I d o n ' t blame anyone f o r t r y i n g to g r a b e v e r y t h i n g he can g e t

i n t h i s w o r l d .

15 . I can e a s i l y make o t h e r peop l e a f r a i d o f me, and somet imes do

f o r the f un o f i t .

17 . I n s c h o o l I was somet imes s e n t to the P r i n c i p a l f o r m i s b e h a v i n g .

2 0 . Somet imes I e n j o y h u r t i n g p e r s o n s I l o v e .

2 2 . Somet imes I f e e l a s i f I must i n j u r e e i t h e r m y s e l f o r someone

e l s e .

2 4 . I sometimes t e a s e a n i m a l s .

2 5 . I ge t ang r y s omet imes .

39 - At t imes I have a s t r o n g u r g e to do someth ing h a r m f u l o r s h o c k i n g .

4 0 . I am e a s i l y downed i n an a r gument .

4 2 . I e a s i l y become i m p a t i e n t w i t h p e o p l e .

4 5 . I ge t ang r y e a s i l y and then g e t ove r i t s o o n .

4 6 . A t t ime s I f e e l l i k e s m a s h i n g t h i n g s .

4 9 . A t t ime s I f e e l l i k e p i c k i n g a f i s t f i g h t w i t h somepne.

Each s ta tement f i l e d a s " t r u e " i s s c o r e d 1, except the s ta tement 40 where

" f a l s e " s c o r e s 1 .

C R I T I C I S M OF OTHERS (CO)

1 . Mos t peop le make f r i e n d s because f r i e n d s a r e l i k e l y to be u s e f u l

t o them.

2 8 7

2 . I do not blame a p e r s o n f o r t a k i n g advantage o f someone who

l a y s h i m s e l f open to i t .

6 . I t h i n k n e a r l y anyone would t e l l a l i k e to keep out o f t r o u b l e .

10. Some people a re s o b o s s y t h a t I f e e l l i k e do ing the o p p o s i t e of

what they r e q u e s t , even though I know they a re r i g h t .

11. Some o f my f a m i l y have h a b i t s tha t bother and annoy me v e r y

much.

13. I have ve r y few q u a r r e l s w i t h members o f my f a m i l y .

18. I have at t imes s t o o d i n the way o f people who were t r y i n g to

do someth ing , not because i t amounted to much but because o f

the p r i n c i p l e o f the t h i n g .

19« Most people a re hone s t c h i e f l y th rough f ea r o f be ing caugh t .

29- 1 t h i n k most people would l i k e to get ahead.

32 . I have o f t e n found peop le j e a l o u s o f my good ideas, j u s t

because they had not thought o f them f i r s t .

36 . When someone does me a wrong I f e e l I s h o u l d pay him back

i f I can, j u s t f o r the p r i n c i p l e o f the t h i n g .

41 . I t i s s a f e r t o t r u s t nobody.

Each statement f i l e d a s " t r u e " i s s co red 1, except the statement 13

where " f a l s e " s c o r e s 1 .

PARANOID HOSTIL ITY (PH)

I have no enemies who r e a l l y w i sh to harm me.

9 . I know who, apa r t from m y s e l f , i s r e s p o n s i b l e f o r most o f

my t r o u b l e s .

31 . I f people had not had i t i n f o r me I would have been much

more s u c c e s s f u l .

3 5 . Someone ha s i t i n f o r me.

2 8 8

37- I am cure I got a raw dea l from l i f e .

38 . I b e l i e v e I am be ing f o l l o w e d .

k k . I commonly wonder what h i dden reason another pe r son may have

f o r do i ng someth ing n i c e f o r me.

47 . I b e l i e v e I am p l o t t e d a g a i n s t .

50 . Someone ha s been t r y i n g to r o b me.

Each statement f i l e d a s " t r u e " i s s c o r e d 1, except the statement

v/here " f a l s e " s c o r e s 1.

S E L F - C R I T I C I S M (SC)

3 . I u s u a l l y expect to succeed i n t h i n g s I do.

8 . My h a r d e s t b a t t l e s a re w i t h m y s e l f .

14. I have o f t e n l o s t out on t h i n g s because I c o u l d n ' t make up

ray mind soon enough..

23* I seem to be about a s capab le and c l e v e r a s most o t he r s a round

me.

26 . I am e n t i r e l y s e l f - c o n f i d e n t .

27« O f t en I c a n ' t unde r s t and why I have been so c r o s s and g r ouchy .

28 . I s h r i n k from f a c i n g a c r i s i s o r d i f f i c u l t y .

30 . I have sometimes f e l t t h a t d i f f i c u l t i e s were p i l i n g up so

h i g h t ha t -I c ou l d not overcome them.

34 . I have sometimes g i v e n up do i ng a t h i n g because I thought

too l i t t l e o f my a b i l i t y .

40 . I am e a s i l y downed i n an argument.

51 . I am c e r t a i n l y l a c k i n g i n s e l f - c o n f i d e n c e .

Each statement f i l e d a s " t r u e " i s s co red 1 except i n the s ta tements

3 i 23 and 40 where " f a l s e " s c o r e s 1.

I

2 8 9

DELUSIONAL GUILT (G)

5 . I w i s h I c o u l d g e t o v e r w o r r y i n g about t h i n g s I have s a i d

t h a t may have i n j u r e d o t h e r p e o p l e ' s f e e l i n g s .

12 . I b e l i e v e my s i n s a r e u n p a r d o n a b l e .

I b e l i e v e I am a condemned p e r s o n .

2 1 . I have not l i v e d the r i g h t k i n d o f l i f e .

3 3 . Much o f the t ime I f e e l a s i f I have done someth ing wrong o r

e v i l .

4 3 . A t t i m e s I t h i n k I am no good a t a l l .

4 8 . I c e r t a i n l y f e e l u s e l e s s a t t i m e s .

E a c h s t a t e m e n t f i l e d a s t r u e i s s c o r e d 1 .

I

2 9 0

APPENDIX D

Items of the DSSI by set.

The i t em numbers r e f e r t o t h e i r p o s i t i o n i n the i n v e n t o r y .

A l l i t e m s s t a r t w i t h t h e word " R e c e n t l y " .

S t a t e o f a n x i e t y ( s A )

1 . I have been b r e a t h l e s s o r had a pound ing o f my h e a r t .

13- F o r no good r e a s o n , I have had f e e l i n g s o f p a n i c .

2 5 - I have been so " w o r k e d u p " t h a t I c o u l d n ' t s i t s t i l l .

3 7 . I have had a p a i n o r t e n s e f e e l i n g i n my neck o r head .

4 9 . I have w o r r i e d about e v e r y l i t t l e t h i n g .

6 1 . Y/orry ing h a s k e p t me awake a t n i g h t .

73 - I have been s o a n x i o u s t h a t I c o u l d n ' t make my mind up about

the s i m p l e s t t h i n g .

S t a t e o f d e p r e s s i o n ( s D )

7 . The f u t u r e h a s seemed h o p e l e s s .

19 . I have l o s t i n t e r e s t i n j u s t about e v e r y t h i n g .

3 1 . I have been so d e p r e s s e d t h a t I have t hough t o f d o i n g away

w i t h m y s e l f .

4 3 . I have been so m i s e r a b l e t h a t I have had d i f f i c u l t y w i t h my s l e e p .

55• I have been s o low i n s p i r i t s ' t h a t I have s a t f o r a ge s d o i n g

a b s o l u t e l y n o t h i n g .

67• I have been d e p r e s s e d w i t h o u t knowing why.

79* I have gone to bed n o t c a r i n g i f I n e ve r woke up.

/

2 9 1

S t a t e o f e l a t i o n ( s E )

4 . I have been ve r y e x c i t e d l y happy f o r no p a r t i c u l a r r ea son .

16. I j u s t h a v e n ' t been a b l e to s t o p l a u g h i n g and j o k i n g w i t h

everyone*.

28 . New i d e a s and schemes have been r u s h i n g th rough my head one

a f t e r ano the r .

40 . I have had so much pep and energy tha t I c ou l d h a r d l y s t o p

do i n g t h i n g s .

52 . I have been a b s o l u t e l y " o n top o f the w o r l d " .

64 . I have been so c h e e r f u l I have wanted to decorate my se l f w i t h

much b r i g h t e r , more c o l o u r f u l t h i n g s , than I i s u a l l y do.

76 . T h i n g s cou ld not have been b e t t e r i n any way.

C o n v e r s i o n symptoms (PS)

2 . I have l o s t the u se o f one o f my arms o r l e g s f o r a t ime.

14. I l o s t my s i g h t o r h e a r i n g f o r a wh i l e and then i t came back .

26 . I have had p a i n s wh i ch moved about to d i f f e r e n t p a r t s o f my

body.

38 . I have o f t e n had d i f f i c u l t y i n keep ing my ba l ance .

5 0 . I have been unab le to c o n t r o l my v i o l e n t s h a k i n g .

62 . I have had f i t s .

74 . I have had b u r n i n g o r t i n g l i n g s e n s a t i o n s under my s k i n wh ich

were much worse than " p i n s and n e e d l e s " .

2 9 2

D i s s o c i a t i v e symptoms (DS )

12. I have been s l e e p w a l k i n g .

2 4 . I have l o s t my memory and f o r g o t t e n who I was, o r where I l i v e d .

3 6 . A l l my behav iou r became l i k e t h a t o f a young c h i l d f o r q u i t e

some t ime.

48 . People around me have seemed s t r a n g e , u n f a m i l i a r , or d i f f e r e n t .

49 . T h i n g s around me have seemed odd, u n f a m i l i a r or changed.

72 . I have l o s t c o n s c i o u s n e s s f o r a few seconds w i thout a c t u a l l y

f a l l i n g .

84 . I have found m y s e l f i n some p lace w i thout knowing why I was

there o r how I got t h e r e .

Phob ic symptoms ( F S )

8 . I have been a f r a i d o f h e i g h t s .

20 . I have had a f e a r o f some h a r m l e s s an imal or i n s e c t .

32 . I have been a f r a i d o f h a n d l i n g some weapon or s ha rp o b j e c t .

44 . I have had an un rea sonab l e f e a r o f germs.

56 . I have had a f e a r o f e n c l o s e d s pace s .

68 . I have been f r i g h t e n e d o f g o i n g i n t o crowds o r s o c i a l g a t h e r i n g s .

80 . I have been q u i t e unab le t o b r i n g myse l f to go out a l one .

Compul s i ve symptoms (CS )

5 . I have been u n n e c e s s a r i l y c a r e f u l about c a r r y i n g out even s imp l e

everyday t a s k s .

17- I have been unab le to s t o p my se l f from c o u n t i n g , o r t app i ng

t h i r g s or u t t e r i n g p h r a s e s q u i t e p o i n t l e s s l y .

29- I have had to keep check i n g t h i n g s a g a i n and a g a i n q u i t e

u n n e c e s s a r i l y .

2 9 3

I have kept h a v i n g to wash a g a i n and a g a i n .

I have f e l t compel led t o do t h i n g s i n a c e r t a i n o r d e r , or a

c e r t a i n number o f t i m e s , to guard a g a i n s t something go i ng

wrong.

I have had to wash t h i n g s a g a i n and a g a i n to make a b s o l u t e l y

c e r t a i n that they v/ere s a f e .

I have f e l t compel led to keep t ouch i n g t h i n g s .

Ruminat i ve symptoms ( R S )

I have had n a g g i n g doubt s about n e a r l y e v e r y t h i n g that I have

done.

I have been a f r a i d o f the thought that I might make a p h y s i c a l

a t t a c k on someone.

I have had an un rea sonab l e f e a r that I might f o r g e t to do

something and then someth ing r e a l l y awfu l might happen.

I have had n a g g i n g f e a r s t h a t someone c l o s e to me might be

k i l l e d or s e r i o u s l y i n j u r e d .

Na s t y t hough t s or words have kept r unn i n g th rough my mind a g a i n s t

my w i l l .

I have been w o r r i e d by the thought that c e r t a i n t h i n g s might

have been l e f t l y i n g a round.

I have had p e r s i s t e n t f e e l i n g s o f h a v i n g l e f t something

u n f i n i s h e d w i thou t knowing what.

2 9 4

D e l u s i o n s o f p e r s e c u t i o n (dP)

3 . I have f e l t t ha t an o r g a n i s a t i o n or g roup has been p l a n n i n g

my d o w n f a l l .

15* There have been peop le t r y i n g to po i s on me or do me ve ry g r e a t

harm.

27 . Someone ha s d e l i b e r a t e l y t r i e d to make me i l l .

39* People have been s e c r e t l y p l o t t i n g to r u i n me.

51 . Someone ha s had e v i l d e s i g n s a g a i n s t me.

63 . I have thought t ha t I was be i n g fo l l owed f o r a s p e c i a l r e a s o n .

75. Peop le have been t r y i n g to d r i v e me i n s a n e .

D e l u s i o n s o f g randeur (dG)

9 . I have con s i de red m y s e l f s u p e r i o r to everyone.

21 . I have f e l t t ha t I am a v e r y much g r ea t e r per son than most

people t h i n k .

3 3 . I have f e l t tha t I have been sent to save the wo r l d .

45 . I have f e l t I must t e l l the whole wor ld o f my b r i l l i a n t i d e a s .

57 . I have f e l t t h a t I have a m i s s i o n to c a r r y out o f g r ea t

importance to the wo r l d .

69* I have thought t ha t I am the r i c h e s t person i n the wor ld .

81 . I have f e l t t h a t I have s p e c i a l , F.lmost mag i c a l , powers.

D e l u s i o n s o f c o n t r i t i o n (dC)

11. I have harmed people because I am unc lean or e v i l .

23» People have been t a l k i n g about me because o f my wicked

deeds.

35- I have thought t ha t the w o r l d i s such an e v i l p lace tha t I ,

and those nea re s t to me, would be be t te r out o f i t .

2 9 5

47- I have f e l t t h a t I am condemned f o r e v e r .

59 . I have f e l t t h ' t I have committed the u n f o r g i v a b l e s i n .

71 . I have f e l t t h a t I am the v i l e s t , most wicked per son a l i v e .

83 . I have f e l t t hn t my i n s i d e s are a l l r o t t e n .

D e l u s i o n s o f d i s i n t e g r a t i o n (DD)

6 . I have seen v i s i o n s o f s t r a n g e t h i n g s which no-one e l s e c o u l d

see .

18. I have f e l t t ha t I have been i n t e r f e r e d v/ith s e x u a l l y o r

e l e c t r i c a l l y .

30 . I have wondered whether I am male or female.

42 . Someone e l s e ha s been do ing the t h i n k i n g that goes on i n my

head.

54 . V o i c e s have spoken to me when no-one was there at a l l .

66 . I have f e l t t he re was a s p e c i a l meaning i n one s i d e o f my

body be ing d i f f e r e n t from the o t h e r .

78 . My f e e l i n g s have been taken over by someone.

2 9 6

APPENDIX C

Correlation coefficients .v/ith probability values.

Study-point I

Correlation coefficients.

Pearson 's r Kendall' 's ta.u Spearman1 s rho

AH - sA .3678 .001 .1636 .021 .2241 .029

AH - sD .4541 .000 .2653 .001 .3587 .001

AH - sE .2016 .044 .1252 .059 .1594 .090

AH - PS .IP30 .061 .0638 .213 0.868 .233

AH - DS .3492 .001 .2583 .001 .3183 .004

AH - FS .3043 .004 .1922 .009 .2411 .020

AH - CS .000 .2371 .002 .2951 .006

AH - RS .3399 .001 .1677 .018 .2177 .033

AH - dG .0311 .397 .1132 .079 .1336 .127

AH - dP .3617 .001 .1514 .030 •1757 .069

AH - dC .1930 .049 .0429 .296 .0602 .307

AH - DD .2103 . 037 .1057 .094 .1307 .136

CO - sA .0433 .357 . 0 963 .114 .1157 .165

CO - sD - . 0 2 9 0 .404 .0371 .322 .0463 •349

CO - sE .3147 .003 .2269 .003 .2975 .006

CO - PS - . 1 5 6 0 .094 -.0902 .130 " - . 1 1 6 8 .163

CO - DS .1944 . 030 .1405 .040 . 1800 .064

CO - FS .1379 .122 .1020 .101 .1313 .135

CO - CS .0926 .218 . 1075 .090 .1431 .114

CO - RS .1100 .177 .0434 .285 .0535 .327

CO - dG .1017 .196 . 1 133 .079 .1364 .125

CO - dP .0802 .250 - . 0 8 1 0 .156 -.0957 .211

CO _ dC - . 1 0 3 1 .193 - . 0 6 1 0 .223 - . 0 9 2 8 .218

2 9 7

Study-point I

C o r r e l a t i o n c o e f f i c i e n t s .

P e a r s o n ' s r

CO - DD .1197 .199

PH - sA .3331 .002

PH - sD .1825 .061

PH - sE .3243 .003

PH - PS .1687 .077

PH - DS .5119 .000

PH - FS .2671 .011

PH - CS .5048 .000

PH - RS .4252 .000

PH - dG .2786 .009

EH - dP .5193 .000

PH - dC .4241 .000

PH - DD .5385 .000

SC - sA .2420 .020

SC - sD .3331 .002

SC - sE .0632 .298

SC - PS .1026 .194

SC - DS -.1616 .086

SC - FS .1244 .147

SC - CS .2075 .039

SC - RS .1293 .138

SC - dG -.1231 .190

SC - dP .1677 .078

SC dC -.0080 .473

K e n d a l l ' s tau

.0062 .470

.1851 .011

.1001 .106

.2599 .001

.0323 .343

.4068 .001

.1160 .074

.3051 .001

.2674 .001

.1479 .033

.2734 .001

.2039 .003

.2456 .002

.2173 .004

.2391 .002

.0775 .166

.0333 .339

.1042 .097

.0605 .225

.1236 .061

.0859 .142

.0798 .139

.0380 .318

.0249 .378

Spea rman ' s r ho

.0037 .488

.2420 .020

.1394 .120

.3247 .003

.0449 .354

.4843 .001

.1531

.3711 .001

.3322 .003

.1769 .068

.3165 .004

.2582 .014

.2910 .007

.2976 .006

.3284 .003

.1150 .167

.0460 ^390

- . 1 2 8 5 .140

.0732 .270

.1657 . 081

.1263 .144

-.0993 .202

- . 0 4 1 1 . 363

.0302 . 401

2 9 8

S t u d y - p o i n t II

C o r r e l a t i o n c o e f f i c i e n t s -

P e a r s o n ' s r

SC -- DD -.031? .396

G - sA .1239 .148

G - sD .1772 .067

G - sE .1391 . 089

G - PS .1411 .117

G - DS .1804 . 0 63

G - FS .2459 .018

G - CS .3487 .001

G - RS .2736 .010

G - dG .0575 .314

G - dP .3260 .002

G - dC .2903 .006

G - DD -.1465 . 108

TH -• sA .3470 .001

TH -• sD .3461 .001

TH -• sE .3395 .002

TH - PS .1245 .147

TH -• DS .3367 .002

TH - FS .3341 .002

TH - CS .4698 .000

TH - RS .3993 .000

TH - dG .1076 .182

TH - dP .4434 .000

TH - dC . 2287 .026

TH - DD .2286 .026

K e n d a l l ' s t a n

•.0520 .258

.0062 .470

. 0321 .345

.1033 .099

.0420 .300

.0540 .250

.1311 .051

.1790 .013

.1426 .038

-.0435 .294

.0558 .243

.2439 .002

. 2306 .002

.2765 . 001

. 2138 .004

. 2902 . 001

.0399 .309

.2564 . 001

.2158 .004

.2775 . 001

. 2116 . 005

. 0906 .129

. 0 6 6 9 .202

. 1 065 .092

.1041 .097

Spearman1 s rho

-.0613 .304

.0098 .468

.0380 .375

.1319 .134

.0533 . 3 2 8

.0682 .284

.1644 . 0 8 3

.2226 . 0 3 0

.1856 . 0 5 8

- . 0 5 2 0 .332

.0722 .273

.3036 . 0 0 3

-.2757 . 0 1 0

.3671 .001

.3122 .004

.3875 . 0 0 1

.0515 •333

.3367 . 002

.2934 . 0 0 6

.3623 . 0 0 1

. 2890 . 007

. 1138 . 1 6 9

.0916 . 2 2 1

.1445 . 1 1 2

.1287 .139

S t u d y - p o i n t I

C o r r e l a t i o n c o e f f i c i e n t s

P e a r s o n ' s r

TI - sA .2422 .019

TI - sD .3392 .002

TI - sE .1362 .125

TI - PS .1537 .097

TI - DS -.0102 .466

TI - FS .2294 .025

TI - CS .3473 .001

TI - RS .2488 .017

TI - dG I -.0338 .326

TI - dP .3061 . co4

TI - dC .1615 .056

TI - DD -.1066 . 1 8 5

TE - sA .3243 . 003

TE - sD .2654 .012

TE - sE .3789 . 000

TE - PS .0798 . 262

TE - DS .4635 . 000

TE - FS .3^5 . 003

TE - CS .4273 . 000

TE - RS .3913 . 000

TE - dG .1788 . 065

TE - dP .4164 . 0 0 0

TE - dC .2126 .036

TE - DD .3751 . 001

Di _ sA - . 0 0 8 2 .473

Kendall 's ta

.1667 .019

.2069 .005

.1060 .093

.0573 .237

-.0577 .236

.1371 .044

.1871 .010

.1267 .057

-.1113 .082

.0186 .408

.1469 .033

-.1217 .064

.2210 .003

.1677 .018

.2753 .001

.0530 .254

.3302 .001

.2100 .005

.2545 .001

.1844 .011

.1668 .019

. 0 9 2 0 .125

. 0766 .169

.1622 .022

.0180 .411

Spearman' s rho

.2278 .027

.2885 .007

.1511 .101

.0687 .282

..0813 .248

.1924 .052

.2530 .016

.1789 .066

-.1312 .135

.0250 .417

.1896 .055

.1577 .092

.2867 .007

.2356 .023

.3666 .001

.0691 .281

.4210 .001

.2749 .010

.3379 .002

. 2 5 6 1 .015

.2046 .042

. 1206 .155

.0977 .206

.2090 .038

.0154 .449

3 0 0

S t u d y - p o i n t II

C o r r e l a t i o n c o e f f i c i e n t s -

P e a r s o n ' s r

D i - sD .1282 . 140

D i - s E - . 2 3 9 6 . 013

D i - PS . 1791 . 063

D i - DS - . 4 2 0 9 . 000

D i - FS . 0300 . 400

D i - CS - . 0 2 3 8 .414

D i - RS - . 0 5 0 3 .336

D i - dG - . 2 0 0 9 j

. 044

D i - dP - . 0 2 9 7 .402

D i - dC . 0563 .318

D i _ DD - . 2 1 1 8 .036

Kendall's tau

. 0653 .207

- .1399 .040

. 0023 .218

•.2908 .001

•.0030 .483

. 0237 -384

. 0 023 .488

. 1 6 3 2 . 020

. 0094 .454

. 0647 .210

. 1569 .023

S p e a r m a n ' s r h o

.0909 . 2 23

- . 1 8 5 3 • . 0 59

. 0713 . 275

- . 3 7 3 2 . 001

- . 0 0 5 1 . 484

- . 0 3 8 1 . 375

. 0035 . 4 89

- . 2 0 8 4 . 0 3 9

.0153 . 449

.1021 .195

- . 1 9 9 3 .046

3 0 1

S t u d y - p o i n t I I

C o r r e l a t i o n c o e f f i c i e n t s -

P e a r s o n ' s r

AH - sA .2921 .044

AH - sD .4879 .001

AH - sE .0688 .3^7

AH - PS .1761 .156

AH - DS .2379 .084

AH - FS .4407 .004

AH - CS .1507 .194

AH - RS .4991 i .001

AH - dG I .0626 .361

AH - dP .3646 .016

AH - dC . 1829 .147

AH - DD .0923 .299

CO - sA . 2581 .067

CO - sD .3773 .013

CO - sE -.0123 .472

CO - PS . 0560 .375

CO - DS . 3060 .037

CO - FS .4309 .005

CO - CS .1190 .248

CO - RS . 4309 .005

CO - dG - . 0 7 6 0 .332

CO - dP .0243 .445

CO - dC -.1024 .270

CO _ DD -.0489 .390

K e n d a l l ' s t a u

. 1763 .068

.4822 .001

.1202 .155

. 2340 . 025

.3732 . 001

.3582 .002

.0557 . 319

.3914 .001

. 0645 - 294

.4124 . 001

.2884 .008

. 0 273 .^09

. 2 3 2 1 .025

. 2121 .037

. 0360 .381

. 0918 .219

.2387 .022

.2228 .030 *

. 2 005 .046

. 2 233 .030

.0577 . 313

.0422 . 361

. 0214 . 429

. 0223 .426

S p e a r m a n ' s r h o

.2156 .107

. 6293 . 0 0 1

.1474 . 1 9 9

. 2696 . 0 5 9

.4632 . 0 0 3

. 4553 . 0 0 3

. 0653 . 3 5 5

.4814 . 0 02

.0808 . 3 2 3

.4620 . 0 0 3

.3349 . 0 2 5

- . 0 4 2 1 . 4 0 6

.2786 . 0 5 3

. 2941 . 0 4 4

- . 0 3 4 9 . 4 22

.1097 . 2 6 6

.2847 . 0 4 9

•2900 . 0 4 6

.2397 . 0 8 3

.2769 . 0 5 4

- . 0 6 9 0 . 347

- . 0 4 9 5 . 3 8 9

- . 0 2 7 9 . 437

C . 0 ? 9 2 . 4 3 4

3 0 2

S t u d y - p o i n t III

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson's r

PH - sA .4074 .005

PH - sD . 3678 .015

FH - sE .0207 .433

PH - PS .2967 .042

PH - DS .5887 .000

PH - FS .4448 .004

PH - CS .2070 .116

PH - RS .3810 .012

PH - dG .3149 .033

PH - dP .4679 .002

PH - dC . 5286 . 0 01

PH - DD .3411 .022

SC - sA . 1956 .130

SC - sD .2693 .062

SC - sE .0300 .432

SC - PS .1147 .256

SC - DS .2348 .087

SC - FS .3312 .026

SC - CS -.0083 .480

SC - RS .2729 .056

SC - dG - . 0 3 8 9 .412

SC - dP .OO83 .481

SC - dC - .OO85 .481

SC - DD -.1371 .216

Kendall 's tau Spearman' s rho

.3913 .001 .4650 .003

.3043 .006 .4052 .008

.0547 .323 . 0636 • 359

.2103 .038 .2569 .069

.4652 .001 .5722 . 0 0 1

. 3288 . 003 .3978 .009

.0759 . 261 .0803 .324

.1905 .054 .2535 .071

.2702 .012 .3196 .031

. 2602 .014 .2972 .042

. 2 1 5 0 .035 .2640 .063

. 2 851 .008 .3483 . 0 2 1

. 1322 .132 . 2 103 .113

.2374 .023 . 3300 .027

.0135 .455 .0246 .445

.1175 .161 .1596 .180

. 2050 .042 . 2778 .054

.2317 .026 - .3154 .033

.0293 .403 .0428 .404

.1967 .049 .2911 .045

- . 0 1 8 6 .438 -.0222 .450

.0102 .466 .0100 .478

.1345 .128 .1758 .157

-.0647 .293 -.0854 .313

3 0 3

S t u d y - p o i n t I I

C o r r e l a t i o n c o e f f i c i e n t s -

P e a r s o n ' s r

G - sA .3116 .034

G - sD .4477 . 0 03

G - sE . 0150 .465

G - PS .2^32 . 0 80

G - DS .1770 .155

G - FS .4596 . 0 03

G - CS .1225 .242

G - RS . 5686 . 0 00

G - dG -.0633 .359

G - dP .4630 .003

G - dC .3^7 . 0 2 1

G - DD .2213 . 1 0 1

TH - sA .4334 .005

TH - sD .5780 .000

TH - sE .0374 .416

TH - PS .2592 .066

TH - DS .4605 .003

TH - FS . 6265 .000

TH - CS .1726 .161

TH - RS .6362 .000

TH - dG .0576 . 3 71

TH - dP .3812 .012

TH - dc .2666 .061

TH - DD . 1263 .235

Kendall ' s tau Spearman' s rho

.2469 .019 .3281 .028

. 3 663 .001 .^738 .002

-.0281 .407 -.0239 •435

.1727 .073 .2042 .120

.2401 .022 .3032 .039

.33^2 .003 .4258 .006

-.0143 • 53 .0337 .424

.4572 .001 .5508 .001

-.0857 .235 -.0860 .312

.3928 .001 .4511 .004

.2846 .009 .3428 .022

-.1213 . 153 -.1323 .225

.3645 .002 .4944 .002

.5137 .001 .6854 .001

.0773 .257 .135 .220

.2675 .012 .297^ .042

.4658 .001 .5825 .001

.4821 .001 .6275 .001

.0611 .303 .0910 .302

.4622 . .001 .5843 .001

.0571 . 315 .0687 • 348

. 2 988 .006 •3537 .019

.3338 .003 .4001 .009

. 0169 .444 -.0081 .482

304

S t u d y - p o i n t III

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson1 s r Kendall ' s tau Spearman' s rho

TI - sA .3023 .039 .2325 .025 .3136 .034

TI - sD .4240 .006 .3431 .002 .4647 .003

TI - sE .0286 .435 .0208 .431 . 0 605 .365

TI - PS .2104 .112 .1475 .107 . 1850 .144

TI - DS .2548 .070 .2241 .030 .3333 .026

TI - FS .4747 .002 .3456 .002 .4613 .003

TI - CS .0613 .363 -.0133 .449 - . 0 0 3 8 .492

TI - RS .4993 .001 .3562 .002 .4941 .002

TI - dG -.0608 .364 - . 0 3 6 5 .380 - . 0 3 8 7 .413

TI - dP .2596 .066 .2799 .010 .3389 .024

TI - dC .1833 .146 .2680 .012 .3306 .027

TI - DD .0293 .434 - . 0 6 9 8 .278 - . 0 8 1 9 .321

TE - sA .4556 .003 .3582 .002 .4790 .002

TE - sD .5917 .000 .5005 .001 .6838 .001

TE - sE .0374 .416 .1088 .179 .1372 .217

TE - PS .2497 .074 .2308 .026 .2655 .062

TE - DS .5351 .000 .4987 .001 .6092 .001

TE - FS .6297 .000 .4698 .001 .5978 .001

TE - CS .2267 . 095 . 1858 .059 .2090 .115

TE - RS .6293 .000 .3894 .001 .4882 .002

TE - dG . 1380 . 215 .1839 .061 .2230 .099

TE - dP .4055 .008 . .2118 .037 .2535 .071

TE - dC . 2823 . 0 50 .2028 .044 .2379 ',085.

TE _ DD .1779 . 1 53 .0790 .253 .0956 .293

3 0 5

S t u d y - p o i n t I I

C o r r e l a t i o n c o e f f i c i e n t s -

P e a r s o n ' s r

Di - sA -.0717 .3^1

Di - cD -.0677 -350

Di - sE .1117 .262

Di - PS -.0647 -356

Di - DS -.1270 .234

Di - FS .0120 -973

Di - CS -.2393 . 083

Di - RS -.0325 .427

Di - dG -.1771 .154

Di - dP -.0183 .458

Di - dC -.0147 .467

Di _ DD - . 0 3 8 6 .413

Kendall •s tau Spearman' s rho

•.0072 .476 .0096 -479

.0089 .471 .0425 .405

.0985 .203 .1483 .198

.0662 .288 -.0767 .381

•.0077 -475 .0012 .498

.0546 .323 .093*+ .297

.1823 .062 -.2485 .076

.033^ .389 .0613 .364

-1173 .161 -.1445 .204

.0500 -337 .0619 .362

.0894 .225 .1312 .227

.0783 -255 -.1267 -235

306

S t u d y - p o i n t I I I

C o r r e l a t i o n c o e f f i c i e n t s .

Pearsons's r

AH - sA .1045 .345

AH - sD . 3909 . 060

AH - sE . 1952 .226

AH - PS - . 0 2 0 7 . 469

AH - DS . 3172 .107

AH - FS . 0766 . 385

AH - CS . 1577 . 2 73

AH - RS . 1694 .258 I

AH - dG - . 1 4 3 9 . 2 91

AH - dP . 3124 . 111

AH - dC . 0 5 0 1 .424

AH - DD . 1491 .246

CO - sA . 5205 .016

CO - sD . 1 0 7 1 . 341

CO - s E . 3 479 . 086

CO - PS . 1038 .346

CO - DS . 4 040 . 054

CO - FS . 3 720 . 071

co - cs .2822 .136

CO - RS . 4897 . 023

CO - dG .3868 .063

CO - dP . 3593 .078

CO - dC . 4247 .045

CO - DD . 2821 .136

Kendall 's tau Spearman' s rho

. 2067 .124 .2744 . 1 4 4

. 3793 .017 . 5013 .021

. 0974 .293 . 1151 . 3 3 0

. 0 253 .444 . 0313 . 4 5 3

.3057 .044 . 3814 . 0 6 6

. 1 1 1 1 .267 . 1693 . 2 5 8

.1813 .155 . 2209 . 198

. 1048 .279 . 1389 . 2 9 8

.1103 .269 - . 1 4 6 3 . 2 8 8

. 3 7 2 1 . 019 . 4456 . 0 3 7

.0292 . 435 .0619 . 4 0 7

.0388 .415 .0534 . 4 2 0

. 4484 .006 .6035 . 0 0 6

. 0 433 .405 .0459 . 4 3 1

. 2134 .116 .2698 ' . 1 4 8

. 1 4 4 1 . 210 .1682 . 2 6 0

.2632 . 0 71 .3277 . 1 0 0

. 3434 .028 . .4417 .038

.0819 .324 . 0973 .355

. 4 123 .011 .5235 .016

. 2076 .123 .2410 .176

. 2076 .123 .2458 .171

.1174 .256 . 1331 .306

.1752 .164 .2020 .219

3 0 7

S t u d y - p o i n t I I I

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson' 's r Kendall ' s tau Spearman1 s rho

PH - sA .3661 .074 .2399 .090 .3247 .102

PH - sD .2008 .220 .2858 .055 . .3725 .071

PH - sE .1710 .256 -.2018 .130 -.2674 .213

PH - PS .2903 .129 .0699 eo • . 0883 .369

PH - DS .5968 .006 .0453 .400 .0928 .362

PH - FS .2361 .181 .0808 .346 .0759 .387

PH - CS .73^6 .000 .1602 . 005 .5802 .008

PH - RS ,.6332 i .003 . 3 8 0 1 .017 .4599 .032

PH - dG '.7384 .000 .4426 .007 .4913 .023

PH - dP .8179 .000 .5854 . 001 .6353 .004

PH - dC . 6387 .002 -.1111 .267 -.1244 .318

PH - DD .3577 .079 .3012 .046 .3087 .114

SC - sA .3746 .069 .4100 .011 .5372 .014

SC - sD .0746 .388 .0171 .462 .0173 .474

SC - sE .9^82 .011 .1405 .216 .1768 .249

SC - FS .1719 . 2 55 .1590 .187 .2113 .208

SC - DS .2010 .220 .2425 .088 .3297 .099

SC - FS ..3^27 .089 .2797 .059 ' .3781 .068

SC - CS .0046 .493 .1348 .22 6 .1666 .262

SC - RS .3034 .118 .3811 .017 .51^3 .018

SC - dG . 1013 .3^9 .1913 .142 .2289 . 1 8 9

SC - dP -.0395 .440 -.0137 .470 -.0056 .492

SC - dC . 1363 .301 . 0 870 .314 .1272 .31^

SC - DD .3402 .091 . 1826 .154 .2277 .190

G - sA .3350 .094 .3366 .030 .4398 .039

G - sD .0947 .359 . 2281 .101 .3062 .116

3 0 8

S t u d y - p o i n t I I I

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson' s r Kendall 's tou Spearman" ' c rho

G - sE .2131 .200 .0270 .440 .0406 .439

G - PS .0245 .463 0 .500 .0090 .487

G - DS .1173 .327 -.0356 .422 -^0607 .409

G - FS .0039 .486 . 1218 .248 .1019 .349

G - CS . 3638 .076 . 2 8 6 0 .055 .3617 .077

G - RS . 2650 .152 .2400 .090 . 2683 .149

G - dG • 3939 .059 .3225 .036 .3687 .073

G - dP .4868 .024 .4908 .003 .5558 .011

G - dC .1750 .251 -.1884 .146 -.2142 .205

G - DD .3786 .067 . 1 874 .147 .2196 .199

TH - sA .4968 .021 .5256 .002 .6919 .002

TH - sD .2236 .194 .2699 .066 .3952 .059

TH - sE .4339 .041 . 1 008 .287 .1423 .293

TH - PS .1753 .250 .2802 .059 .3467 .087

TH - DS .4744 .027 . 2818 .058 .3482 .086

TH - FS .3347 .095 .4133 .011 .5623 .010

TH - CS .4091 .051 .2494 .082 .3410 .091

TH - RS .5407 .013 .5304 .002 - . 6658 .002

TH - dG .4190 .048 .2353 .094 .2933 .127

TH - dP . 5020 .025 .3269 .034 .3867 .063

TH - dC .4286 .043 .1572 .190 .1848 .259

TH - DD .4178 .048 .2574 .075 . 2921 . 128

TI - sA . 4 363 .040 .4960 .003 .6380 . 0 03

TI - sD . 0985 .354 . 0667 .355 .1195 .324

TI - sE .5276 .015 .1713 .169 .2242 .194

3 0 9

S t u d y - p o i n t I I I

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson' s r Kendall 's tau Spearrr.an' s rho

TI - PS .1^76 .286 .1715 .169 .2107 .209

TI - DS .2087 .211 .2113 .119 .2837 .134

TI - FS .2779 .140 .2977 .048 .4198 .047

TI - CS .1519 .180 .1666 .176 .2018 .219

TI - RS .3567 .084 .4479 .007 •3785 .008

TI - dG .2413 .173 .2667 .068 .3096 .114

TI - dP .1667 .261 .1467 .206 . 1636 .266

TI - dC .18O4 .244 .0660 .356 .0956 .358

TI - DD .4265 .044 . 1 781 .160 .2146 .205

TE - sA .4602 . 032 .4080 .012 .5347 .014

TE - sD .2632 .15^ .3253 .035 .^578 .033

TE - sE .3179 .107 .0257 .443 .0231 .465

TE - PS .1660 .262 .1878 .147 .1687 .259

TE - DS .5385 .010 .2874 .034 .3^50 .0 88

TE - FS .3192 .106 .3556 .024 .4245 .045

TE - CS .4977 .021 .2894 .053 .3796 .067

TE - RS .5719 .008 .4310 .008 .5352 .014

TE - dG .4590 .032 .1733 .166 . .1972 .224

TE - dP .6220 .004 .4800 .004 .5406 . 0 1 3

TE - dC .5092 . 018 .0849 .318 .1019 .3^9

TE - DD .3527 . 082 .2344 .095 .2695 .148

Di - sA -.0333 .419 -.0472 .396 -.0715 .393

Di - sD - . 1 6 7 6 .260 -.2936 .049 -.^393 .039

Di _ sE .2407 .176 .1318" .198 .1926 . 2 30

310

S t u d y - p o i n t I I I

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson's r Kendall's tau Spearman's rho

Di - PS -.0102 .484 .0563 .377 . 0570 .414

Di - DS -.3^33 . 0 £7 -.1747 .164 - . 2 2 0 1 .199

Di - FS -.0026 .496 -.0651 .358 - . 0 7 6 5 . 386

Di - CS -.^255 .044 -.1986 .133 -.2533 .164

Di - RS -.2272 .190 -.1082 .273 -.1414 .293

Di - dG -.2792 .139 -.0131 .471 -.0296 . 456

Di - dP -.5644 .009 -.4856 .004 -.5706 .009

Di - dC -.3^12 . 0 9 0 -.0464 .398 - . 0 6 3 5 .405

Di - DD .0522 .421 .1292 .235 .1449 .290

311

S t u d y - p o i n t III

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson's r

AH - sA .4225 . 098

AH - sD .3820 .123

AH - sE -.1452 .335

AH - PS .19 22 .286

AH - DS .4314 .093

AH - FS .2299 .248

AH - CS .2532 .226

AH - RS ,.2063 I .271

AH - dG -.1118 .372

AH - dP .5125 .053

AH - dC .0243 .471

AH - DD .2221 . 256

CO - sA .3553 .142

CO - sD .3124 .175

CO - sE 0 .500

CO - PS .5800 . 0 3 1

CO - DS • 6259 .020

CO - FS ..4432 .086

CO - CS .3920 .117

CO - RS .4842 .066

CO - dG .2955 .189

CO - dP .4729 .071

CO - dC .3671 .133

CO — DD .183

Kendall's tau

.3763 .054

.2692 .125

-.2661 .128

.2759 .119

.3862 . 050

.2558 • 137

.1907 .208

• 3230 .084

0 . 500

.2321 . 161

.3380 .074

. 2 3 2 1 . 161

. 3803 .052

. 1586 .249

.0849 .359

. 6 163 .005

.6240 .004

.4899 .018

.3651 .059

.4743 .022

.3311 .079

.4444 .029

.5778 .007

.4444 .029

Spearman' s rho

.4981 .060

.3649 .135

.3264 .164

.3158 .173

.4259 . 096

. 2 835 .200

.2710 .211

.3913 .117

0 .500

.3161 .172

.3919 .117

.3161 .172

.5468 .041

.2844 .199

.0770 .411

. 7180 .007

.7131 .007

.6188 .022

.4530 .081

.5867 .029

.3786 .126

. 5283 .048

.6928 .010

.5283 .048

3 1 2

S t u d y - p o i n t III

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson*a r

PH - sA .5773 . 0 3 1

PH - sD .5950 .027

PH - sE .4839 . 0 6 3

PH - PS .9328 . OCO

PH - DS .8641 . 0 00

PH - FS . 6 201 . 0 21

PH - CS .8618 . 0 00

PH - RS .9607 .OCO

PH - dG .8874 . 000

PH - dP . 7821 .002

PH - dC .9032 . 000

PH - DD . 7801 .002

SC - sA .4842 .066

sc - sD .4069 .107

SC - sE .5306 .047

SC - PS .3384 .134

SC - DS .3840 .122

SC - FS . 3686 .132

SC - CS .5716 .033

SC - RS .5019 .048

SC - dG .5071 .056

SC - dP .4742 .070

SC - dC .5352 .045

SC DD .5929 .027

K e n d a l l 1 c t a u Spearman ' 'G rho

. 3 763 .034 . 4475 .084

.393** .047 . 5233 . 050

. 2 6 6 1 .128 .2776 . 205

. 3058 .016 . 5965 .027

- 7 ^ 8 3 .001 .8132 .002

. 3 ^ 1 1 . 073 . 3998 .112

. 4 5 2 9 .027 •5577 .038

. 7538 . 001 . 8609 . 0 01

. 6 2 2 5 . 001 . 673^ .012

. 7 5 4 3 . 001 .8206 . 001

. 7242 . 001 . 7917 .002

. 7 5 4 3 .001 .8206 . 0 0 1

. 3 002 .100 . 3263 .164

. 2776 .118 . 2 834 . 2 00

. 3 9 6 3 . 043 . 4 495 . 0 83

. 1 1 0 1 .319 . 1467 . 3 3^

. 3005 .100 . 3^93 . 147

. 1 633 . 243 • . 2 199 . 258

. 3 8 8 0 .049 .4577 . 0 7 9

. 2887 .109 . 3^61 . 1 4 9

. 5 298 .012 .5880 . 0 2 9

. 4 722 .022 . 5338 . 046

. 3236 .083 .3697 . 1 3 2

. 4 722 .022 .5338 . 046

3 1 3

S t u d y - p o i n t III

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson's r

G - sA .6261 .020

G - sD .6445 .016

G - sE .2491 .230

G - PS .4023 .110

G - DS .4991 .059

G - FS .3015 .184

G - CS .3857 .029

G - RS .5086 . 0 5 5

G - dG .3221 .137

G - dP .7137 . 0 07

G - dC .3940 .115

G - DD .5776 . 0 31

TH - sA .6774 .011

TH - sD .6419 . 017

TH - sE .3645 . 135

TH - PS .7424 .004

TH - DS .8123 .001

TH - FS ..583^ . 030

TH - CS .7797 .002

TH - RS .7983 .002

TH - dG .6157 .022

TH - dP .8212 .001

TH - dC .6936 .009

TH - DD .7211 .006

Kendall 's ta.u

.4203 .036

.5155 .014

.0849 .359

. 0 880 .35^

. 3698 .057

.2245 .169

.4108 .040

.4124 .039

.3974 .045

.5556 .009

.3^67 .069

.5556 .009

.4907 .018

.3365 .075

.1601 .247

.4773 .021

.6755 .002

.3657 .059

.3873 .049

.6951 .004

.4683 .023

.6024 .005

.6319 .004

.6024' .005

Spearman' s rho

.5^68 .041

.6201 .021

.0918 .395

.1558 .324

.4415 .087

.2518 .228

.4758 .070

.5321 .047

.4495 .084

.6375 .018

.4086 .107

.6375 .018

.573^ .033

.4851 .066

.1512 .329

.5^95 .040

.7672 .003

.4850 .066

.5167 .052

.7484 .005

.5406 .043

• 7243 .006

.7423 .005

.7243 .006

S t u d y - p o i n t I V

C o r r e l a t i o n c o e f f i c i e n t s .

Pearson's r

TI - sA .028

TI - sD .5^23 .042

TI - sE .4687 .073

TI - PS .3971 .113

TI - DS .4678 .073

TI - FS .3774 .126

TI - CS .6329 .018

TI - RS .5334 .039

TI - dG .4818 .067

TI - dP .6177 .021

TI - dC .3303 .047

TI - DD .6441 .016

TE - sA .3985 .026

TE - sD .5773 .031

TE - sE .2215 . 236

TE - PS .8200 .001

TE - DS .8753 .000

TE - FS -.6012 .025

TE - CS .7184 .006

TE - RS .7981 .002

TE - dG .3792 .031

TE - dP . 7890 .002

TE - dC .6607 .013

TE - DD .6655 .020

3 H

Kendall 's tau. Spearman' 's rho

.4132 .038 .4358 .091

.3738 .033 .4668 .074

.2669 .127 .3199 .169

.1038 .329 .2007 .278

.3704 .057 .4733 .071

-1732 .230 .2448 .235

.4734 .022 .3315 .040

. 3888 .048 .3106 .033

.5307 .012 .6082 .024

.6024 .005 .6837 .011

.3704 .057 .4633 . 0 7 6

.6024 .005 .6837 .011

. 6 0 0 5 .oc6 .7419 .005

. 4362 . 0 31 .5833 . 0 3 0

. 2 265 .167 .2143 .264

.7264 . 001 .7826 .003

. 8 3 2 1 . 001 .8847 . 0 0 1

.5715 .008 .6762 . 012

.4793 . 0 21 .3925 .028

.7217 .002 .8234 . 0 0 1

.5629 .008 .6223 . 0 2 1

.6944 .002 .7948 . 002

. 7858 .001 .8643 . 0 0 1

.6944 .002 .7948 . 0 02

315

S t u d y - p o i n t III

C o r r e l a t i o n c o e f f i c i e n t s .

Pea r son " ' s r K e n d a l l * s tau Spearman ' ' s r h o

Di - sA - . 0 0 5 1 .484 - . 1 8 7 0 .212 - . 2 6 0 9 . 220

Di - sD - . 0 4 4 9 .448 - . 0 9 2 6 .346 - . 1 0 9 6 . 375

Di - s E . 2993 .186 . 2119 . 1 83 . 2 ? 2 7 . 209

Di - PS - . 2 6 5 1 . 1 35 - . 4 7 2 9 .022 - . 5 6 7 3 . 035

Di - DS - . 3 5 2 1 .144 - . 2 8 0 7 .115 - . 3 4 7 9 .148

Di - FS - . 1 7 3 ^ . 305 - . 1 5 2 6 .257 - . 2 5 3 5 . 226

Di - CS - . 0 3 6 2 .438 - . 0 8 3 3 .358 - . 0 6 9 4 . 4 20

Di - RS - . 1 8 1 6 .297 - . 0 1 7 3 4 .229 . 2466 . 2 33

Di - dG - . 0 2 9 5 .474 . 0 3 0 9 .448 . 0674 . 422

Di - dP - . 1 5 1 9 .328 - . 1 2 9 7 . 290 - . 1 2 1 4 . 362

Di - dC - . 0 3 6 5 .434 . 155 - . 3 0 3 2 . 1 8 3

Di - DD .0624 . 428 . 1297 .290 - . 1 2 1 4 . 3 62

3 1 6

APPENDIX D

Key to the coding of information entered into the data forms,

punched cards and computer listing.

COLUMN

2 , 3

4

5

6 , 7

8

INFORMATION

The patients belongs to the group that completed two batteries of questionnaires.

The patient belongs to the group that completed three batteries of questionnaires.

The patient belongs to the group that completed four batteries of questionnaires.

The patient belongs to the group that completed five batteries of questionnaires.

Identification number of patient

Number of batteries of questionnaires completed.

Age (in years)

Sex Male Female

Clinical status Gut-patient Day-patient In-patient

10

11,12,13 Time e l a p s e d ( i n d a y s ) s i n c e the complet ion o f the p r e v i o u s q u e s t i o n n a i r e s

14

15,16

17,18

19

20

21, 22

2 3

Acting-out Hostility - AH

Criticism of Others - CO

Paranoid Hostility - PH

Self-criticism - SC

Guilt

CODE

3

4

5

01 - 58

1 - 5

317

COLUMN INFORMATION

24

25 ,26 T o t a l h o s t i l i t y - TH

27

28 ,29 T o t a l i n t r o p u n i t i v e n e s s - T I

30

31,32 T o t a l e x t r a p u n i t i v e n e s s - TE

33

34 ,35 ,36 D i r e c t i o n o f h o s t i l i t y - D i

37

38 ,39 S t a t e o f a n x i e t y - sA

40 ,41 S t a t e o f dep re s s i o n - sD

42 ,43 S t a t e o f e l a t i o n - sE

44

45,46 C o n v e r s i o n symptoms - PS

47,48 D i s s o c i a t i v e symptoms - DS

49 ,50 Phob ic symptoms - FS

51,52 Compuls ive symptoms - CS

53,54 Ruminat ive symptoms - RS

55

56,57 D e l u s i o n s o f grandeur - dG

58,59 D e l u s i o n s o f pe r s e cu t i on - dP

60 ,61 D e l u s i o n s o f c o n t r i t i o n - dC

62,63 D e l u s i o n s o f d i s i n t e g r a t i o n - DD

64

65,66 Dysthymic s t a t e s - DYS

67,68 Neu ro t i c symptoms - NS

69 ,70 I n t e g r a t e d d e l u s i o n s - I D

318

COLUMN INFORMATION CODE

71»72 N o n - i n t e g r a t e d d e l u s i o n s - N ID

7 3 , 7 4 , 7 5 T o t a l D S S I / R s c o r e - SCOR

76

77 C l a s s a l l o c a t i o n - CLASS N o n - p e r s o n a l l y i l l 0 Dy s thymic s t a t e s 1 N e u r o t i c symptoms 2 I n t e g r a t e d d e l u s i o n s 3 D e l u s i o n s o f d i s i n t e g r a t i o n 4

78

79 ,80 C l i n i c a l d i a g n o s i s - DIAGN S c h i z o p h r e n i a 11 P a r a n o i d s c h i z o p h r e n i a 12 S c h i z o a f f e c t i v e d i s o r d e r 13 M a n i c - d e p r e s s i v e p s y c h o s i s 15

(Manic phase) M a n i c - d e p r e s s i v e p s y c h o s i s 16

( D e p r e s s i v e phase) P s y c h o t i c d e p r e s s i o n 17 P e r s o n a l i t y d i s o r d e r 20 N e u r o t i c d e p r e s s i o n 31 A n x i e t y s t a t e 32 N e u r o t i c d e p r e s s i o n - P e r s o n a l i t y 41

d i s o r d e r N e u r o t i c a n x i e t y - P e r s o n a l i t y 42

d i s o r d e r A n o r e x i a n e r v o s a 50

319

ATPENDIX E

I ndex o f tho A b b r e v i a t i o n s and Symbols

DSS I/R D e l u s i o n s Symptoms S t a t e s I n v e n t o r y / R e c e n t l y

DYS Dysthymic S t a t e s

sA S t a t e o f A n x i e t y

sD S t a t e o f D e p r e s s i o n

s E S t a t e o f E l a t i o n

NS Neu ro t i c Symptoms

PS C o n v e r s i o n Symptoms ( o r i g i n a l l y the term " p i t h i a t i c symptoms" was u s e d by F o u l d s ) .

DS D i s s o c i a t i v e Symptoms

FS Phob ic Symptoms ( o r i g i n a l l y the term " f e a r symptoms" was used by F o u l d s ) .

CS Compuls ive Symptoms

RS Ruminat ive Symptoms

I D I n t e g r a t e d D e l u s i o n s

dP D e l u s i o n s o f P e r s e c u t i o n

dG D e l u s i o n s o f Grandeur

dC D e l u s i o n s o f C o n t r i t i o n

DD D e l u s i o n s o f D i s i n t e g r a t i o n (o r n o n - i n t e g r a t e d d e l u s i o n s )

C l a s s 0 N o n - p e r s o n a l l y 1 1 1

C l a s s 1 Dysthymic S t a t e s

C l a s s 2 Neu ro t i c Symptoms

C l a s s 3 I n t e g r a t e d D e l u s i o n s

C l a s s k D e l u s i o n s o f D i s i n t e g r a t i o n (o r n o n - i n t e g r a t e d d e l u s i o n s )

HDHQ H o s t i l i t y and D i r e c t i o n o f H o s t i l i t y Q u e s t i o n n a i r e

AH A c t i n g - o u t H o s t i l i t y

CO C r i t i c i s m o f O t h e r s

PH Pa r ano i d H o s t i l i t y

3 2 0

SC S e l f - c r i t i c i s m

G Guilt

TH Total Hostility

TE Total Extrapunitiveness

TI Total Intropunitiveness

Di Direction of Hostility

P = 0.001

**** P = 0 . 0 0 2 - 0 . 0 0 5

P = 0.006 - 0.009

** | P = 0.010 - 0.020

* I P = 0.021 - 0.050

(-) Negative correlation.

( _ ) A l o n e - n e g a t i v e "but n o n - s i g n i f i c a n t c o r r e l a t i o n

( - ) * - ( — ) * * * * * - r e s p e c t i v e s i g n i f i c a n t n e g a t i v e c o r r e l a t i o n s

321

A p p e n d i x F : L i s t i n g o f t h e d a t a .

C A R D NllMBKR

] 2 3 ^ 4 5 6 7 8 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 I 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 f t 9 0 1 2 1 4 5 6 78 90

1 . 5 0 1 t 2 6 2 3 0 6 0 4 1 0 9 4 "2 1 13 1 1 + 11 0 6 1 4 0 0 0 0 0 0 0 2 0 2 0 3 0 0 0 3 0 8 0 0

2 . 5 0 1 2 2 6 2 3 0 3 9 0 5 0 4 0 07 4 2 0 11 0 9 + 0 9 0 3 0 2 0 0 0 0 0 0 0 3 0 2 0 2 0 0 0 0 0 1 0 0

3 . 5 0 1 3 2 6 2 3 o9R 0 5 0 10 0 9 5 2 3 14 0 9 + 15 0 2 0 8 0 0 0 0 0 1 0 2 0 1 0 3 0 0 0 0 0 2 0 0

4 . 5 0 1 4 2 b 2 1 0 8 2 0 4 0 2 0 0 8 5 19 13 06 + 15 0 3 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0

5 . 5 0 1 5 2t>2 3 128 0 40 10 0 9 4 2 1 13 08 + 14 0 5 0 9 0 0 0 0 0 2 0 3 0 1 0 2 o o o o o i o o

6 . 5 0 2 1 4 5 1 3 0 3 0 7 4 0 3 2 19 05 14 - 0 6 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 o o o o o o o o

7 . 5 0 2 2 4 5 1 3 0 2 8 0 1 0 7 1 0 4 2 17 06 11 - 0 1 o o o o o o 0 0 0 0 0 0 0 1 0 0 o o o o o o o o

B~. 5 0 2 3 4 5 1 3 0 3 0 0 3 0 8 1 0 2 2 16 04 12 - 0 6 OOOOOO o i o o o o o o o o o o o o o o c o

9 . " 5 0 2 4 4 5 1 2 n5 4 0 2 0 0 0 0 2 3 07 05 02 + 05 OOOOOO o o o o o o o o o o o o o o o o o o

1 0 . 5 0 2 5 4 5 1 2 o i l 0 2 0 6 U 0 1 2 11 0 3 0 8 - 0 4 0 1 0 0 0 0 o o o o o o o o o o o o o o o o o o

11 . 5 0 3 1 3 0 1 3 0 2 0 6 1 0 5 1 15 0 6 0 9 + 02 0 2 0 0 0 2 o o o o o o o o o o o o o o o o o o

1 2 . 5 0 3 2 3 0 1 3 0 2 3 1 1 0 7 1 0 3 6 33 14 19 + 03 0 6 1 2 0 0 0 4 0 2 0 5 0 2 0 5 o o o o o i o o

1 3 . 5 0 3 3 3 0 1 3 0 3 4 0 3 0 1 0 0 5 2 1 1 0 7 04 + 0H 0 3 0 2 0 0 o o o o o i o o o o o o o o o o o o

1 4 . 5 0 3 4 3 0 1 3 0 2 9 0 6 0 5 0 0 7 4 22 11 11 + 07 0 5 0 6 0 0 0 0 0 0 0 2 0 0 0 0 o o o o o o o o

1 5 . 5 0 3 5 3 0 J 3 0 3 3 0 2 0 4 0 0 3 1 10 0 4 0 6 + 01 o o o o o o OOOOOOOOOO o o o o o o o o

1 6 . 5 0 4 1 5 3 2 2 0 5 0 6 4 0 74 2 6 11 15 + 03 1 4 0 9 0 4 04 0 1 0 R 0 2 1 0 0 1 O 0 0 2 0 0

1 7 . 5 0 4 2 5 3 22 o i l 0 6 0 7 0 0 5 1 19 0 6 13 - 0 2 0 8 1 0 0 1 0 3 0 1 0 8 0 1 0 2 0 4 0 0 0 0 0 0

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