DIMENSIONS OF PSYCHOPATHOLOGY: A REVIEW O F FACTOR ANALYTIC STUDIES*

BRIAN BOLTON

University of Arkansas

PROBLEM A large number of factor analytic studies are reported in the psychological

literature each year. This profusion of research can be viewed as (1) a seemingly endless sequence of unrelated and relatively meaningless statistical analyses, or (2) a series of independent replications that provide an empirical basis for the identification of major dimensions of defined behavioral domains. The present study adopted the second point of view and attempted to ascertain the major dimensions of variation for hospitalized psychiatric patients.

METHOD Eighteen studies were selected from the clinical literature that met three

criteria: (1) The Ss were hospitalized psychiatric patients; (2) the variables were symptom ratings made by observers; and (3) the method was factor analysis of the symptom intercorrelation matrix. Thus, studies that employed outpatient or mixed subject samples, self-report or psychological test variables, or obverse factor analysis were excluded from consideration. Despite these restrictive criteria, it is evident from the brief summaries presented in Table 1 that the 18 studies differed with respect to subject samples and symptom rating scales. Furthermore, the professional status of the raters ranged from psychiatrist to psychiatric aide, and statistical methodology varied considerably. Methodological differences included procedures for scoring the rating scales, type of correlation coefficient employed, method of factor extraction, and factor rotation procedure. This diversity among the 18 studies strengthens the argument on which the current report is based and thus en- hances the validity of the factor identifications. Two preliminary investigations in the development of the Psychiatric Status Schedule are conspicuous by their ab- sence from Table 1. Although the studies by Bostian, Smith, Lasky, Hover and Ging (1) and Spitzer, Fleiss, Endicott and Cohen(19) failed to satisfy the criteria out- lined above, the available data suggest that they support the conclusions of this study.

SeveraI authors(2* 6 , 6* 9 , have summarized factor analytic studies in the general personality domain. Lorr, Klett and McNair (12) presented a confirmatory synthesis of 13 factor analytic studies of psychiatric symptoms. The present study differs from Lorr, et al. (12) in that no a priori conceptual scheme was utilized. Each of the 135 first-order factors (syndromes) identified in the 18 selected studies was recorded on a 5 by 8 notecard with the defining symptoms listed in order of the magnitude of the factor loadings. The 135 notecards then were sorted by the author into clusters of similar factors.'

RESULTS The procedure described above produced twelve primary dimensions of psycho-

pathology. Three representative defining symptoms further define the syndromes : I. Paranoid DeIusions (feels systematically persecuted ; believes others influence him; believes people talk about him), 11. Thinking Disorganization (irrelevant

*This project was su ported by R & D Grant No. 16-P-56812 to the Arkansas Rehabilitation Research and Training d n t e r from the Social and Rehabilitation Service. The assistance of Fini Heynen and James Thompson in conducting the initial literature review is acknowledged gratefully.

'Due to the judgmental nature of the sorting task, the results of the study may be viewed with skepticism by some readers. Therefore, a list of the 135 factors and their defining symptom ratings (Supplementary Table 3) will be provided upon request to the author.

B.

Witt

enbo

rn a

nd

Hol

zber

g (1

951)

C.

Witt

enbo

rn,

et a

l. (1

951s

) D

. W

itten

born

, et

al.

(195

1 b)

E.

Lor

r, et

al.

(195

1)

F.

Deg

an (

1952

)

G.

Gue

rtin

(19

52)

H.

Lor

r, e

t al.

(195

5)

I.

Lorr

(19

57)

J.

Lorr

, et a

l. (1

957)

K.

Gue

rtin

and

K

rugm

an (

1959

)

TA

BL

E

1. F

AC

TO

R

AN

ALY

TIC

S

TU

DIE

S OF P

SY

CH

IAT

RIC

SYM

PTOM

S

Stud

y Ss

and

Var

iabl

es

Fact

ors

A.

Witt

enbo

rn (

1951

) 14

0 m

ale

patie

nts

1. H

ebep

hren

ic s

chiz

ophr

enic

2.

Man

ic-d

epre

ssiv

e 50

sym

ptom

ratin

gs

3. C

onve

rsio

n hy

ster

ia 4

. C

atat

onic

exc

item

ent

5. A

nxie

ty a

nd d

epre

ssio

n 6.

Par

anoi

d sc

hizo

phre

nia

7. P

aran

oid

cond

ition

1.

Par

anoi

d sc

hizo

phre

nia

2. E

xcite

men

t 3.

Man

ic-d

epre

ssiv

e 4.

Anx

iety

5.

Hys

teri

cal

6. P

aran

oid

cond

ition

7.

Phob

ic-c

ompu

lsiv

e

1. A

nxie

ty 2

. E

xcite

men

tdet

erio

rate

d 3.

Man

ic-d

epre

ssiv

e 4.

Par

anoi

d sc

hizo

phre

nic

5. C

onve

rsio

n hy

ster

ia

1. A

nxie

ty 2

. M

anic

-exc

item

ent 3

. Pa

rano

id s

chiz

ophr

enic

4.

Men

tal d

eter

iora

tion

1. S

chiz

oid

with

draw

al 2

. Sc

hizo

phre

nic

real

ity d

isto

rtio

n 3.

Per

sona

lity

rigi

dity

or

inad

apta

bilit

y 1.

Hyp

er-p

roje

ctio

n 2.

Dep

ress

ion

3. M

anic

hyp

er-e

xcita

bilit

y 4.

Cat

aton

ia 5

. Sc

hizo

phre

nic

diss

ocia

tion

6. T

raum

atic

hys

teri

a 7.

Hyp

er-i

rrita

bilit

y 8.

Det

erio

ratio

n 9.

Neu

rast

heni

a 1.

Exc

item

ent-h

ostil

ity

2. P

sych

omot

or r

etar

datio

n an

d w

ithdr

awal

3.

Gui

lt-co

nflic

t. 4.

Con

fuse

d-w

ithdr

awal

5.

Pers

ecut

ed-s

uspi

ciou

s 6.

Per

sona

lity

diso

rgan

izat

ion

1. D

epre

ssio

n us

. ex

cite

men

t 2.

Res

istiv

enes

s 3.

Par

anoi

d pa

tter

n 4.

A

ctiv

ity le

vel 5

. Mel

anch

oly

agita

tion

6. P

erce

ptua

l dis

tort

ion

7. M

otor

di

stur

banc

e 8.

Su

bmis

sive

vs.

belli

gere

nce

9.

With

draw

al p

roce

ss

10. G

rand

iose

exp

ansi

vene

ss 1

1. C

once

ptua

l dis

orga

niza

tion

1. P

aran

oid

schi

zoph

reni

a 2.

Thi

nkin

g di

sorg

aniz

atio

n 3.

Exc

item

ent

with

hos

tile

belli

gere

nce

4. A

nxie

ty 5

. C

onve

rsio

n-hy

ster

ia 6

. Ex

cite

- m

ent w

ith e

xpan

sive

ness

7. P

hobi

c-co

mpu

lsiv

e re

actio

n 1.

Dep

ress

ion

us. e

xcite

men

t 2. R

esis

tive

3. P

aran

oid

proj

ectio

n 4.

Mel

anch

oly

agita

tion

5. P

erce

ptua

l di

stor

tion

6. M

otor

dis

turb

ance

7.

Soc

ial w

ithdr

awal

8. D

epre

ciat

ion

us. e

xpan

sive

ness

9. T

hink

ing

dis-

or

gani

zatio

n 10

. Pho

bic

com

puls

ive

1. D

eter

iora

ted

beha

vior

2. I

nter

pers

onal

tens

ions

3.

Em

otio

nal c

ontr

ols

4. R

esis

tive

isol

atio

n 5.

Reg

ress

ive

agita

tion

6. R

ealit

y co

ncer

n

250

patie

nts

51 s

ympt

om ra

tings

83 y

oung

pat

ient

s 20

sym

ptom

ratin

gs

120

elde

rly

orga

nic

patie

nts

20 s

ympt

om ra

tings

20

0 ps

ycho

tic p

atie

nts

17 s

ympt

om ra

tings

36

7 ps

ycho

tic p

atie

nts

32 s

ympt

om ra

tings

100

schi

zoph

reni

c pa

tient

s 52

sym

ptom

ratin

gs

423

mal

e ps

ycho

tic p

atie

nts

55 s

ympt

om ra

tings

reac

tion

(Obl

ique

rota

tion

of W

itten

born

an

d H

olzb

erg

data

)

116

psyc

hotic

pat

ient

s 52

sym

ptom

ratin

gs

100

mal

e pa

tient

s 55

sym

ptom

ratin

gs

8 f ;3

X

0 P ..

w

w

0

TA

BL

E

1. F

AC

TO

R

AN

ALY

TIC

ST

UD

IES OF P

SYC

HIA

TR

IC

SYM

PTO

MS-

cont

inue

d

Stud

y Ss

and

Var

iabl

es

Fact

ors

L.

Witt

enbo

rn (

1962

)

M.

Lor

r and

O’C

onno

r (1

962)

N.

Lor

r, et

al.

(196

2)

0.

Lorr

, et a

l. (1

963)

P.

Lorr

, et a

l. (1

964

Q.

Nut

tala

nd

Solo

man

(19

65)

R.

Coh

en, e

t at.

(196

6)

150

mal

e pa

tien

ts

98 s

ympt

om r

atin

gs

500

mal

e ps

ycho

tic p

atie

nts

85 b

ehav

iora

l ra

tings

296

patie

nts

77 s

ympt

om ra

tings

566

patie

nts

65 s

ympt

om ra

tings

1185

mal

e ps

ycho

tic p

atie

nts

85 b

ehav

iora

l rat

ings

291

mal

e sc

hizo

phre

nic

patie

nts

28 s

ympt

om ra

tings

1274

mal

e ps

ycho

tic p

atie

nts

20 s

ympt

om ra

tings

1. S

chiz

ophr

enic

exc

item

ent

2. D

epre

ssiv

e re

tard

atio

n us

. m

anic

sta

te

3. P

aran

oid

schi

zoph

reni

a 4.

Psy

chot

ic b

ellig

eren

ce 5

. Int

elle

ctua

l im

- pa

irm

ent

6. C

onve

rsio

n hy

ster

ia 7

. Heb

ephr

enic

neg

ativ

ism

8. H

omo-

se

xual

dom

inan

ce 9

. Pho

bic

com

puls

ive

10. A

nxie

ty

1. T

hink

ing

diso

rgan

izat

ion

2. P

aran

oid

proj

ectio

n 3.

Hos

tile

belli

ger-

en

ce 4

. R

esis

tiven

ess

5. D

omin

ance

6.

Ove

ract

ivity

7.

Agi

tate

d de

- pr

essi

on 8

. W

ithdr

awal

1.

Exc

item

ent 2

. Par

anoi

d pr

ojec

tion

3. H

ostil

e be

llige

renc

e 4.

Agi

tate

d de

pres

sion

5.

With

draw

al w

ith r

etar

datio

n 6.

Per

cept

ual

dist

ortio

ns 7

. Gra

ndio

se e

xpan

sive

ness

8.

Mot

or d

istu

rban

ces

9. C

on-

cept

ual

diso

rgan

izat

ion

1. E

xcite

men

t 2.

Par

anoi

d pr

ojec

tion

3. H

ostil

e be

llige

nenc

e 4.

Per

cept

ual d

isto

rtio

n 5.

Anx

ious

intr

opun

itive

ness

6. R

etar

datio

n an

d m

ap

athy

7. M

otor

dis

turb

ance

s 8.

Con

cept

ual

diso

rgan

izat

ion

9. D

isor

ient

atio

n 10

. Gra

ndio

se e

xpan

sive

ness

Z

m

1. P

aran

oid

proj

ectio

n 2.

Hos

tile

belli

ere

nce

3. R

esis

tiven

ess

4. D

omin

ance

5. A

nxio

us d

epre

ssio

n 8. S

eclu

sive

ness

7. R

etar

datio

n o

8. A

path

y 9.

Con

cept

ual d

isor

gani

zatio

n 10

. Per

cept

ual d

isto

rtio

n 11

. Mot

or d

istu

rban

ces

0

Z 1.

Soc

ial w

ithdr

awal

2. I

nade

quat

e he

tero

sexu

al r

elat

ions

hips

3 S

ocia

lly

unde

sira

ble

beha

vior

4. A

path

y us

. em

otio

nalit

y 5.

Insi

diou

s on

set

6. S

tubb

orn

11s. s

ensi

tive

7. C

hron

ic p

oor

heal

th.

1. U

ncoo

pera

tive

2. D

epre

ssio

n-an

xiet

y 3.

Par

anoi

d ho

stili

ty

4. D

eter

iora

ted

thin

king

5.

Unm

otiv

ated

P s

DIMENSIONS OF PSYCHOPATHOLOGY: A REVIEW OF FACTOR ANALYTIC STUDIES 331

speech; disoriented; emotional disharmony), 111. Anxiety-Depression (doubts he can be helped; feelings of impending doom; unrealistic self-blame), IV. Excitement- Hostility (initiates physical assaults; destructive; obscene), V. Excitement-Depres- sion (shouts, sings, and talks loudly; irritable; temper tantrums), VI. Withdrawal- Retardation (speech is slowed or deliberate; shut-in personality; lacks motivation), VII. Perceptual Distortions (visual hallucinations; auditcry hallucinations; tactual hallucinations), VIII. Phobic-Compulsive Reaction (behavior disrupted by phobias; compulsive acts occur daily; obsessional thinking), IX. Paranoid (grandiose con- victions; dramatically attention-demanding; voices praise or extol him), X. Motor Disturbances (manneristic movements; giggling; assumes bizarre postures), XI. De- terioration (incontinent because of own negligence; foreign objects in mouth; un- aware of the feelings of others), and XII. Conversion Hysteria (no organic basis for complaints; organic pathology with emotional basis; use made of physical disease symptoms).

The similarity between several of the dimensions and traditional psychiatric diagnostic terminology is apparent. The important distinction between a set of dimensions of psychopathology and the psychiatric classification model is recognized as the classical dichotomy of trait versus type approaches to the study of personality. When psychiatric syndromes are conceptualized as profiles of traits rather than mutually exclusive categories, the problems of heterogeneity of diagnostic categories and unreliability of classification may be substantially reduced (Zigler and Phillips, 1961). Syndrome status profiles are clearly preferable to diagnostic labels for clinical evaluation as well as research purposes.

SUMMARY Eighteen factor analytic studies of symptom ratings for hospitalized psychiatric

patients provided the basic data for this study. Twelve major dimensions of psycho- pathology were identified by a judgmental clustering procedure. The use of syn- drome status profiles for clinical and research purposes was suggested.

REFERENCES 1. BOSTIAN, D. W., SMITH, P. A., LASKY, J. J., HOVER, G. L. and Ging, R. J. Empirical observa- tions on mental status examination. Arch. Ben. Psychiat., 1959, 1, 253-262.

2 CATTELL, R. B. Description and Measurement of Personality. Yonkers-on-Hudson, N. Y.: World Book, 1946.

3. COHEN, J., GUREL, L. and STUMPF, J. C. Dimensions of psychiatric symptom ratings determined a t thirteen timepoints from hospital admission. J . consult. Psychol., 1966, 30, 39-44.

4. DEGAN, J. W. Dimensions of Functional Psychosis. (Psychometric Monograph No. 6) Chicago: University of Chicago Press, 1952.

5. EYSENCK, H. J. Thestructure of Human Personality. London: Methuen, 1953. 6. FRENCH, J. W. The Description of Personality Measurements in Terms of Rotated Factors. Prince- ton, N. J.: Educational Testing Service, 1953.

7. GUERTIN, W. H. A factor analytic study of schizophrenic symptoms. J . consult. Psychol., 1952, 16, 308-312.

8. GUERTIN, W. H. and KRUQMAN A. D. A factor analytically derived scale for rating activities of psychiatric patients. J . clin. psycxol., 1959, 16, 32-36.

9. GUILFORD, J. P. Personalzty. New York: McGraw-Hill, 1959. 10. LORR. M. The Wittenborn psvchatric syndromes: an obliaue rotation. J . consult. Psuchol.. - - - ,

1957, $1; 439-444.

behavior of hospitalized psychotics. J . abn. SOC. Psychol., 1955, 60, 78-86. 11.

12.

LORR, M., JENKINS, R. L. and O'CONNOR, J. P. Factors descriptive of psychopathology and

LORR, M., KLETT, C. J. and MCNAIR, D. M. Syndromes of Psychosis. New York: Macmillan, 1462

13.

14.

15.

16.

LORR, M., KLETT, C. J. and MCNAIR, D. M. Ward-observable psychotic behavior syndromes.

LORR, M., MCNAIR, D. M., KLETT, C. J. and LASKY, J. J. Evidence of ten psychotic syndromes.

LORR, M. and CONNO NOR, J. P. Psychotic symptom patterns in a behavior inventory. Educ.

LORR M , CONNO NOR, J P. and Stafford, J. W. Confirmation of nine psychotic symptom pat-

Educ. Psychol Meas., 1964, 9.4, 291-300.

J . consult. Psychol. 1962, 26, 185-189.

Psychol. Meas. 1962, I%, 139-146.

terns. j. clin. Psychol., 1957, 13, 252-257.

332 BEIAN BOLTON

17. LORR, M., WITTMAN, P. and SCHANBERQER, W. An analysis of the Elgin prognostic scale.

18. NUTTALL, R. L. and SOLOMON, L. F. Factorial structure and prognostic significance of pre-

19. SPITZER, R. L., FLEISS, J. L., ENDICOTT, J. and COHEN, 3. Mental status schedule. Arch.

20. WITTENBORN, J. R. Symptom patterns in a group of mental hospital patients J . consult.

21. WITTENBORN, J. R., BELL, E. G. and LESSER, G. S. Symptom patterns among organic patients

22. WITTENBORN, J. R. and HOLZBERG, J. D. The generality of psychiatric syndromes. J . consult.

23. WITTENBORN, J . R., MANDLER, G. and WATERHOUSE, I. K. Symptom patterns in youthful

24. ZIQLER, E. and PHILLIPS, L. Psychiatric diagnosis and symptomatology. J . abn soc. Psychol.,

J . din. Psychol., 1951, 7, 260-263.

morbid adjustment in schizophrenia. J . consult. Psychol., 1965, 69, 362-372.

gen. Psychiat., 1967, 16, 479-493.

Psychol., 1951,16,290-302.

of advanced age. J . d in . Psychol., 1951, 7 , 328-331.

Psychol., 1951, 16, 372380.

mental hospital patients. J . clin. Psychol., 1951, 7 , 323-327.

1961, 63, 69-75.

CLINICAL JUDGMENT VS. MULTIVARIATE FORMULAE I N ASSIGNMENT OF PSYCHOTROPIC DRUGS

RICHARD C. EVENSON HAROLD ALTMAN IVAN W. SLETTEN AND DONG WON CHO

Missouri Institute of Psychiatry, 6400 Arsenal St., St. Louis

INTRODUCTION Since 1966, the Missouri Division of Mental Health has been building a state-

wide computer network called the Missouri Standard System of Psychiatry (SSOP). This system has, been described elsewhere(’# 9 , and provides for coding clinical in- formation from checklist forms by a computer center a t the Missouri Institute of Psychiatry that is connected by leased telephone lines to the Division’s ten major mental health facilities. Data are automatically processed, stored and retrieved via this teleprocessing system.

Since psychotropic drug treatment is based, at least in part, on mental status findings, we are attempting to develop a system !n which the computer can use a set of statistical equations to assign a drug to a patient based on the patient’s mental status findings.

In an earlier study@), clinicians in the Missouri Division were asked to indicate those items on a chelklist mental status form for which each of 10 psychotropic drugs was thought to be particularly useful. The 10 drugs selected were 5 major tranquilizers: chlorpromazine, trifluoperazine, thioridazine, fluphenazine, haloper- idol; 3 minor tranquilizers : chlordiazepoxide, diazepam, hydroxyzine; and 2 anti- depressants: imipramine HCl, and amitriptyline HCI. Although agreement be- tween clinicians was low for individual drugs, multivariate formulae were developed on this prototype (P) data in which the derivation sample was in 95% agreement with clinical assignment to one of three major drug groups and in 84% agreement on a, cross-validation sample.

The aim of this study was to validate, on videotaped interviews, the drug- prediction equations derived from the earlier prototype study and to compare the ‘IP” multivariate equation with one generated from videotape (V) data.

METHOD Twenty mental status interviews with patients from St. Louis State Hospital

were videotaped. Subsequently, staff and resident psychiatrists throughout the Division viewed sets of these videotaped interviews and filled out the usual mental status checklist (*) and diagnosis for each interview. In addition, the clinician was