VOL. 13, NO. 2,1967 The Positive and Negative Syndrome ... · VOL. 13, NO. 2,1967 The Positive and Negative Syndrome Scale (PANSS) for Schizophrenia by Stanley R. Kay, Abraham Flszbeln,

VOL. 13, NO. 2,1967 The Positive and NegativeSyndrome Scale (PANSS)for Schizophrenia

by Stanley R. Kay, AbrahamFlszbeln, and Lewis A. QpJer

Abstract

The variable results of positive-negative research with schizo-phrenics underscore the importanceof well-characterized, standardizedmeasurement techniques. We reporton the development and initialstandardization of the Positive andNegative Syndrome Scale (PANSS)for typological and dimensional as-sessment. Based on two establishedpsychiatric rating systems, the 30-item PANSS was conceived as anoperationalized, drug-sensitive in-strument that provides balancedrepresentation of positive and nega-tive symptoms and gauges their re-lationship to one another and toglobal psychopathology. It thusconstitutes four scales measuringpositive and negative syndromes,their differential, and general sever-ity of illness. Study of 101 schizo-phrenics found the four scales to benormally distributed and supportedtheir reliability and stability. Posi-tive and negative scores were in-versely correlated once theircommon association with generalpsychopathology was extracted,suggesting that they represent mu-tually exclusive constructs. Reviewof five studies involving thePANSS provided evidence of its cri-terion-related validity with anteced-ent, genealogical, and concurrentmeasures, its predictive validity, itsdrug sensitivity, and its utility forboth typological and dimensionalassessment.

Schizophrenia has long been re-garded as a heterogeneous entity,and over the decades researchershave sought consistent subpattemsthat might explain different aspectsof this complex disorder. Most re-cently, Crow (1980a, 1980b) and An-dreasen (1982; Andreasen and Olsen1982) have proposed that two dis-

tinct syndromes in schizophreniacan be discerned from the phe-nomenological profiles. The Type I,or positive, syndrome is composedof florid symptoms, such as delu-sions, hallucinations, and disor-ganized thinking, which aresuperimposed on the mental status.The Type II, or negative, syndromeis characterized by deficits in cogni-tive, affective, and social functions,including blunting of affect and pas-sive withdrawal.

It has been speculated that thesesyndromes in schizophrenia bearetiological, pharmacological, andprognostic import. Thus, Crow(1980a) conceived of the positivesymptoms as an aspect of hyper-dopaminergia (hence, a neuroleptic-responsive disorder) in contrast to astructural brain deficit that wasthought to underlie the negativesymptoms. The research to date hasprovided some indirect support forthis model (e.g., Johnstone et al.1976, 1978a, 19786; Andreasen andOlsen 1982), but the diversity of re-sults has defied clear-cut interpreta-tions. For example, Angrist,Rotrosen, and Gershon (1980) notedthat one of the three negative symp-toms assessed improved with neu-roleptics, and Andreasen et al.(1982) found none of five negativesymptoms to be associated withventricular size as assessed by com-puted tomography of schizophrenicpatients. The distinctiveness of thesyndromes and their stability overdifferent phases of illness also havebeen questioned. Whereas An-dreasen and Olsen (1982) contendedthat positive and negative syn-dromes are "at opposite ends of acontinuum," Pogue-Geile and Har-

Reprint requests should be sent to Dr.Stanley R. Kay, Research and Assess-ment Unit, Bronx Psychiatric Center,1500 Waters PI., Bronx, NY 10461.

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262 SCHIZOPHRENIA BULLETIN

row (1984) observed a significantinterrelationship during theposthospitalization phase. Linden-mayer, Kay, and Friedman (1986)further demonstrated that the exter-nal correlates of positive and nega-tive syndromes among acuteschizophrenics change over thecourse of 2 years.

Research findings, of course, areat best only as reliable and valid asthe measures on which they arebased. Thus, a fundamental sourceof variability that can account for thedisparate results is the instrumentused for positive-negative assess-ment. Well-characterized and stand-ardized techniques are a clearprerequisite for meaningful study ofthese syndromes, their relationshipto other features of schizophrenia,and their response to medication.Although several carefully con-ceived scales have been devised re-cently (e.g., Andreasen and Olsen1982; Lewine, Fogg, and Meltzer1983; Heinrichs, Hanlon, and Car-penter 1984; lager, Kirch, and Wyatt1985), none have undergone thethorough process of psychometricstandardization that is necessary toaddress fundamental, and as yethighly contested, issues of contentand construct validity (Sommers1985). It has also been a matter ofconcern that to achieve satisfactoryreliability and validity, more rigor isneeded in providing strict opera-tional criteria for eliciting, defining,and measuring symptoms (Zubin1985). Other limitations in some ofthe reported methods include thefollowing: (1) evaluation of the pres-ence but not severity of componentsymptoms, (2) imbalance in thenumber of items representing posi-tive and negative facets, (3) inap-plicability for both typological anddimensional assessment of syn-dromes, (4) no evidence of sen-sitivity for monitoring drug-related

changes, (5) no measurement of therelative preponderance of positiveversus negative symptoms, and (6)no measure of general psycho-pathology and its possible influenceon the severity of positive and nega-tive syndromes.

The purpose of this study was todevelop and standardize a well-de-fined instrument for positive-nega-tive assessment that attends to thesemethodological and psychometricconsiderations. In addition, we rec-ognized the need for a procedurethat can be applied in relatively brieftime (40-50 minutes), with minimalretraining and reorientation for theclinician, and that can be used re-peatedly for longitudinal or psycho-pharmacological assessment. We re-port here on the development andinitial standardization of the Positiveand Negative Syndrome Scale(PANSS) involving 101 schizo-phrenics and review evidence of itsvalidity from five separate studies.

Methods

Subjects and Design. Patients withan unqualified diagnosis of schizo-phrenia were surveyed to assess thedistribution, reliability, construct va-lidity, and criterion-related validityof the PANSS. The medical charts ofinpatients from long-term psychi-atric units in a university-affiliatedurban hospital were screened con-secutively to select those having aformal DSM-III diagnosis of schizo-phrenia (American Psychiatric Asso-ciation 1980). All cases withquestionable diagnosis, knownorganic disorder, or mental retarda-tion were excluded. The remainderwere interviewed on their ownwards by one of two research psy-chiatrists to ascertain independentlywhether patients met DSM-11I crite-ria for schizophrenia. If diagnoseswere thus confirmed, patients un-derwent the semiformalized PANSS

interview (infra) and were then as-sessed on the PANSS scales plus aseries of measures deriving fromclinical interview, cognitive testing,motor assessment, and careful re-view of medical and historical rec-ords. These measures are describedin separate articles that chiefly ad-dress their relationship to positiveand negative syndromes (Kay,Opler, and Fiszbein 1986; Opler,Kay, and Fiszbein 1986).

The assessments were conductedby two research psychiatrists, one ofwhom collected data on 47 patientsand the other on 54. Both psychia-trists first underwent intensive train-ing in the PANSS interview andrating methods until satisfactoryteam concordance was achieved,and subsequently they rated pa-tients individually. The raters heldno a priori assumptions about theoutcome of data and were unawareof results on the PANSS, which wasundertaken before other measuresbut scored only after the conclusionof study.

The final sample consisted of 101subjects of ages 20-68 (mean =36.81, SD = 11.16), including 70males, 31 females, 33 whites, 43blacks, and 25 Hispanics. Twelvepatients were married, 10 divorced,and the remainder single. Meaneducation was 10.09 years (SD =2.92), with the range extending to 4years of college in four cases.Twenty-nine subjects had a first-de-gree relative who was previouslyhospitalized for psychiatric treat-ment; schizophrenia was specifiedin five cases and affective disorder(depressive, manic, or bipolar) in 10cases; alcohol abuse was reported inthe nuclear family of 16 patients;and among 13 subjects there was ev-idence of family sociopathy, asjudged by record of criminal be-havior and prosecution.

On the average, patients were

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VOL 13, NO. 2,1987 263

first hospitalized at age 22.39 years(SD = 8.63) and had since been illfor 14.41 years (SD = 8.95), with amedian of six separate admissions.Over the past year and a half, 67.4percent of the sample experiencedcontinuous hospitalization, while forthe remainder the mean duration ofinpatient stay was 195 days. Allwere receiving neuroleptic medica-tion in standard dose ranges at thetime of study.

Assessment Procedure. The PANSSratings are based on all informationpertaining to a specified period,usually the previous week. The in-formation derives from both clinicalinterview and reports of primarycare staff (if institutionalized) orfamily members. The latter is the es-sential source for assessing socialimpairment, including items of im-pulse control, hostility, passivewithdrawal, and active social avoid-ance. All other ratings accrue from a30- to 40-minute semiformalizedpsychiatric interview that permitsdirect observation of affective, mo-tor, cognitive, perceptual, atten-tional, integrative, and interactivefunctions. The interview may beconceptualized as involving fourphases.1

In the first 10-15 minutes, patientsare encouraged to discuss their his-tory, circumstances surroundingtheir hospitalization, their currentlife situation, and their symptoms.The object of this phase is to estab-lish rapport and allow the patient toexpress areas of concern. Therefore,the interviewer at this point as-sumes a nondirective, unchallenging

•Full text of the PANSS Rating Man-ual, which includes the interview proce-dure, item definitions, anchoring pointdescriptions, and rating form, is avail-able on request from the authors.

posture to observe, as unobtrusivelyas possible, the nature of thoughtprocesses and content, judgmentand insight, communication andrapport, and affective and motor re-sponses.

Deviant material from the firstsegment of the interview is probedduring the second phase, lasting an-other 10-15 minutes, through pro-totypic leading questions thatprogress from unprovocative, non-specific inquiry (e.g., How do youcompare to the average person? Areyou special in some ways?) to moredirect probe of pathological themes(e.g., Do you have special or un-usual powers? Do you consideryourself famous? Are you on a spe-cial mission from God?). The objectnow is to assess productive symp-toms that can be judged from thepatient's report and elaborationsthereof, such as hallucinations, de-lusional ideation, suspiciousness,and grandiosity. For this purpose,the interviewer attempts to establishfirst the presence of symptoms andnext their severity, which is gener-ally weighted according to theprominence of abnormal manifesta-tions, their frequency of occurrence,and their disruptive impact on dailyfunctioning.

The third and most focused phaseof the interview, requiring another5-10 minutes, involves a series ofspecific questions to secure informa-tion on mood state, anxiety, orienta-tion to three spheres, and abstractreasoning ability. The evaluation ofabstract reasoning, for example,consists of a range of questions onconcept formulation (e.g., How area train and bus alike?) and proverbinterpretation, which are varied incontent when using the PANSS forrepeated assessment.

After all the essential rating infor-mation is obtained, the final 5-10minutes of the interview are allo-

cated for more directive and forcefulprobing of areas where the patientappeared defensive, ambivalent, oruncooperative. For example, a pa-tient who avoided forthright ac-knowledgment of having apsychiatric disorder may be chal-lenged for a decisive statement. Inthis last phase, therefore, the patientis subjected to greater stress andtesting of limits, which may be nec-essary to proceed beyond the socialdemand characteristics inherent inthe interview situation and to ex-plore susceptibility to disorganiza-tion.

The interview procedure therebylends itself to observation of physi-cal manifestations (e.g., tension,mannerisms and posturing, excite-ment, and blunting of affect), inter-personal behavior (e.g., poorrapport, uncooperativeness, hos-tility, and impaired attention), cog-nitive-verbal processes (e.g.,conceptual disorganization, stereo-typed thinking, and lack of spon-taneity and flow of conversation),thought content (e.g., grandiosity,somatic concern, guilt feelings, anddelusions), and response to struc-tured questioning (e.g., disorienta-tion, anxiety, depression, anddifficulty in abstract thinking).

Positive and Negative SyndromeScale (PANSS). Data elicited by thisassessment procedure are applied tothe PANSS, a 30-item, 7-point ratinginstrument that has adapted 18items from the Brief Psychiatric Rat-ing Scale (BPRS) (Overall andGorham 1962) and 12 items from thePsychopathology Rating Schedule(PRS) (Singh and Kay 1975a). Eachitem on the PANSS is accompaniedby a complete definition as well asdetailed anchoring criteria for allseven rating points, which representincreasing levels of psychopathol-ogy: 1 = absent, 2 = minimal, 3 =mild, 4 = moderate, 5 = moderate-

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severe, 6 = severe, and 7 = ex-treme. Four sample items from thePANSS appear in the Appendix,and scoring is performed on a sepa-rate rating form in consultation withthe Rating Manual.

In assigning ratings, one first re-fers to the item definition to deter-mine presence of a symptom. Theseverity of an item, if present, isthen judged by using a holistic per-spective in deciding which anchor-ing point best characterizes thepatient's functioning, whether ornot all elements of the descriptionare observed. The highest applicablerating point is always assigned,even if the patient meets criteria forlower ratings as well.

Of the 30 psychiatric parametersassessed on the PANSS, seven werechosen a priori to constitute a Posi-tive Scale, seven a Negative Scale,and the remaining 16 a General Psy-chopathology Scale (see table 3 forthe listing of component items).

The selection of items was guidedby five considerations, in the follow-ing order of importance: (1) Itemsmust be consistent with the hypo-thetical construct, i.e., with the the-oretical concept of positive andnegative psychopathology as repre-senting productive features super-added to the mental status vs.deficit features characterized by lossof functioning (cf. Andreasen andOlsen 1982). (2) As per Carpenter,Heinrichs, and Alphs (1985), itemsshould comprise symptoms whoseclassification as positive or negativeis unambiguous and which, by mostaccounts, are regarded as primaryrather than derivative (as, for exam-ple, impaired attention, disorienta-tion, and preoccupation may besecondary to arousal disorder or hal-lucinations). (3) They should be rep-resentative of different spheres offunctioning (e.g., cognitive, affec-tive, social, and communicative) to

optimize content validity. (4) To theextent possible, they should includesymptoms consensually regarded ascrucial to the definition of the posi-tive syndrome (e.g., hallucinations,delusions, and disorganized think-ing) and negative syndrome (e.g.,blunted affect, emotional with-drawal, and apathetic social with-drawal). (5) For practical andpsychometric reasons, such as facili-tating cross-comparisons and equal-izing reliability potential, thenumbers of items included in thepositive and negative scales shouldbe the same.

Insofar as this approach was de-termined by theoretical and heuristicconsiderations, there was no cer-tainty that all chosen items would beequally well suited or that all suita-ble items had been chosen; the inter-nal validity of the scales' composi-tion was to be determined em-pirically by the data herein assem-bled.

The General PsychopathologyScale was included as an importantadjunct to the positive-negative as-sessment since it provides a separatebut parallel measure of severity ofschizophrenic illness that can serveas a point of reference, or controlmeasure, for interpreting the syn-dromal scores. It was not assumed

that this scale is statistically or con-ceptually distinct from the positive-negative assessment (an issue whichalso was to be determined by thisstudy), but only that it may be usedas a yardstick of collective non-specific symptoms against which tojudge severity of distinct positiveand negative manifestations.

In addition to these three scales, abipolar Composite Scale was con-ceived to express the direction andmagnitude of difference betweenpositive and negative syndromes.This score was considered to reflectthe degree of predominance of onesyndrome over the other, and itsvalence (positive or negative) mayserve for typological characteriza-tion.

The PANSS is scored by summa-tion of ratings across items, suchthat the potential ranges are 7-49 forthe Positive and Negative Scales and16-112 for the General Psycho-pathology Scale. The CompositeScale is arrived at by subtracting thenegative from positive score, thusyielding a bipolar index that rangesfrom -42 to +42.

Results

Distribution of Scores. Table 1 sum-marizes the distribution characteris-tics of the four scales from the

Table 1. Distribution characteristics of the PANSS for 101schizophrenics

Distributioncharacteristics

MeanMedianSDRange (potential)

Range (obtained)SkewnessKurtosis

Positive

18.20186.087 to 49

7 to 32.07

- .97

Negative

21.01206.177 to 49

8 to 38.48.06

PANSS scale

Composite

- 2.69- 2

7.45- 4 2 to +42

- 2 5 to +13- .45

.13

Generalpsychopathology

37.7436

9.4916to11219 to 63

.23- .30

NotB—PANSS = Positive and Negative Syndrome Scale.

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VOL. 13, NO. 2,1987 265

Figure 1. Frequency polygraph of distributions on the 4 scales ofthe Positive and Negative Syndrome Scale (PANSS)

401-

30 ->ozLJJ

oaiOCu. 10 -

20 -

-

i—r i .

COMPOSITEPOSITIVENEGATIVEGENERAL PSYCHOPATHOLOGY

• AJr\ ••••-•••K../-; ,̂x"x-,....

-25 -17 - 9 -1 15 23 31

PANSS SCORE

39 47 55 63

PANSS was examined using coeffi-cient a to analyze its internal consis-tency and the contribution of thecomponent items. As detailed intable 3, each of the items making upthe Positive and Negative Scales cor-related very strongly with the scaletotal (p < .001), and the mean item-total correlations of .62 and .70, re-spectively, far exceeded the cross-correlations of .17 (Positive itemswith Negative Scale) and .18 (Nega-tive items with Positive Scale). The acoefficients with single items re-moved ranged from .64 to .84, andno perceptible gain on either scale

PANSS, and the full spectrum ofscores is illustrated in figure 1. Allfour measures exhibited a roughlynormal distribution pattern, withoutsubstantial skewness or kurtosis.This observation suggested that theconstructs in question represent typ-ical continua and that their measure-ment is amenable to parametricstatistical treatment. The obtainedrange of scores in all cases was con-siderably less than the potentialrange, suggesting that the scaleswere of ample breadth to avoid ceil-ing restrictions. The medians of thePositive and Negative Scales werestrikingly close (18 and 20, respec-tively), and therefore the CompositeScale, representing their differential,exhibited a median of -2, which indi-cated an almost equal contributionby positive and negative items.

On the basis of the normality ofdistribution, it was possible toconvert raw scores for each of thePANSS scales to percentile ranks(table 2). This process enables provi-sional interpretation of individualscores with reference to a medicatedchronic schizophrenic sample.

Internal Consistency and Test-Re-test Reliability. The reliability of the

Table 2. PANSS distribution based on sample of 101schizophrenics: Conversion of raw scores to percentile ranks

Raw score on PANSS scale

Percentilerank

99.999989590858075706560555045403530252015105210.1

Positive

37333129262524232221201918—1716151413121187

——

Negative

40363432292827262524232221—201918171615141187

—

Composite

211513107543210

- 1- 2- 4- 5- 6- 7- 8- 9- 1 1- 1 3- 1 5- 1 8- 2 0- 2 5


676058545048464443424039383635343331302826221816—

Note—PANSS - Positive and Negative Syndrome Scale.

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Table 3. Internal reliability analysis of

Individual scale Hems

Positive ScaleDelusionsConceptual disorganizationHallucinatory behaviorExcitementGrandiositySuspiciousnessHostility

Scale total

Negative ScaleBlunted affectEmotional withdrawalPoor rapportPassive-apathetic social withdrawalDifficulty in abstract thinkingLack of spontaneity & flow of conversationStereotyped thinking

Scale total

General Psychopathology ScaleSomatic concernAnxietyGuilt feelingsTensionMannerisms & posturingDepressionMotor retardationUncooperatJvenessUnusual thought contentDisorientationPoor attentionLack of judgment & insightDisturbance of volitionPoor impulse controlPreoccupationActive social avoidance

Scale total

the PANSS

Mean

3.183.032.502.352.362.702.10

18.20 (

2.943.032.582.783.952.872.90

21.01 (

2.392.43 11.72 12.35 11.54 11.902.09 12.11 13.42 12.09 12.45 13.82 12.10 12.17 12.71 12.48 1

SD

1.52.42.70.24.56.24.14

5.08

.931.081.441.191.34.45.30

5.17

.21

.20

.06

.19

.12

.97

.10

.21

.49

.14

.28

.31

.30

.31

.18

.1837.74 9.49

Item-totalcorrelation

.78

.48

.66

.55

.64

.61

.59(a = .73,p<.001)

.63

.78

.76

.79

.61

.86

.50(a = .83,p<.001)

.48

.60

.23

.70

.33

.24

.27

.51

.51

.42

.65

.35

.66

.66

.60

.43(a = .79,p<.001)

P

<.001<.001<.001<.001<.001<.001<.001

<.001<.001<.OO1<.001<.001<001<.001

<.001<.001<.O2<.001<.001<.O2<.01<.001<.001<.001<.001<.001<.001<.001<.001<.001

a coefficientwith Item deleted

.64

.73

.70

.71

.73

.69

.70

.81

.78

.79

.78

.82

.76

.84

.77

.77

.79

.76

.79

.79

.79

.78

.78

.78

.76

.79

.76

.76

.76

.78

Note.—PANSS = Positive and Negative Syndrome Scale.

could be achieved by discarding anyitem. Overall, the a coefficients forthe Positive and Negative Scaleswere .73 and .83, respectively

(p < .001).As expected, both scales corre-

lated strongly with the CompositeScale, and they yielded coefficients

of similar magnitude (r = .59 and- .61, respectively, p < .001). Thisagain indicated that the two scalescontributed equivalently to the com-

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VOL13.NO 2,1987 267

posite score, which thus representeda reasonable balance between posi-tive and negative features.

The General PsychopathologyScale similarly revealed high internalconsistency, producing an a coeffi-cient of .79 (p < .001). Each of the 16component items contributed ho-mogeneously to the scale (a rangedfrom .76 to .79 with single items re-moved) and correlated significantlywith the total score (table 3).

The internal reliability of the Gen-eral Psychopathology Scale couldfurther be evaluated by the split-halfmethod comparing odd and evenitems. When the Spearman-Brownprophesy formula was used, the re-liability coefficient from the sampleof 101 was .80 (p < .001). This scalecorrelated substantially also with thePositive and Negative Scales (r =.68 and .60, respectively, p < .001),whereas its correlation with theComposite Scale was nonsignificant(r = .07). Accordingly, both positiveand negative symptoms seemed tobe potentiated by severity of globalillness, and in a nondifferentiatingmanner.

From within the full sample it waspossible to study the test-retest sta-bility and reliability of the PANSS 3-6 months later in a cohort of 15 un-remitted patients who remainedhospitalized on a research wardand, by inference, proved refractoryto their ongoing neuroleptic treat-ment. Their initial assessment re-vealed somewhat higher thanaverage scores on the Positive,Negative, and General Psycho-pathology Scales (mean = 21.07,25.60, and 46.67, respectively). De-spite measurable clinical gains dur-ing the intervening phase, asindicated by a small but significantdrop of 4.74 points on the GeneralPsychopathology Scale (correlatedt = 2.59, p < .05), the positive andnegative scores were not noticeably

affected (mean = 21.13 and 26.27,respectively, p > .40). More impor-tantly, the relative ordering ofPANSS scores between baseline andfollowup held fairly constant overthis extended period, despite the in-evitable clinical variations and secu-lar trends. For the Positive,Negative, Composite, and GeneralPsychopathology Scales, respec-tively, the test-retest Pearson cor-relations were .80 (p < .001), .68(p < .01), .66 (p < .01), and .60(p < .02), which corresponded to re-liability indexes ranging from .77 to.89 as estimates of their theoreticallytrue values (Garrett 1964).

Construct Validity. A direct inter-relationship of modest size wasfound between the Positive andNegative Scales (r = .27, p < .01),suggesting that the two syndromesare not independent. However,their common association with gen-eral schizophrenic pathology, as de-scribed above, raised the possibilitythat severity of the disorder medi-ated the covariation between twootherwise distinct scales. This prop-osition was supported by a partialcorrelation which, upon extractingthe shared variance from the Gen-eral Psychopathology Scale, re-vealed a significant inversecorrelation between positive andnegative scores ( r ^ = - .23, tv =2.37, p < .02). Thus, once the influ-ence of severity of illness was re-moved statistically, the Positive andNegative Scales tended to be mutu-ally exclusive. Because of the perva-sive contribution of general severityof psychopathology, of course, thetwo syndromes clinically can be ex-pected to overlap to some degree.

Criterion-Related Validity. The dis-criminant and convergent validity ofthe PANSS was supported by itscorrelations with a series of clinical,

genealogical, psychometric, and his-torical assessments, as reported byKay, Opler, and Fiszbein (1986).These data were analyzed using sec-ond-order partial correlations to ad-just for age and extrapyramidalsyndrome, as measured by the Ab-normal Involuntary Movement Scale(National Institute of Mental Health1974) and Extrapyramidal RatingScale (Alpert et al. 1978), since thesetwo parameters covaried signifi-cantly with the negative pole of theComposite Scale (r = — .25 and- .26, respectively, p < .02). The re-sults indicated that the Positive,Negative, and Composite Scales ofthe PANSS were not influenced byextraneous variables such as race,cultural group, chronicity of illness,depressive symptoms (BPRS) or sadaffective tone (Manifest Affect Rat-ing Scale; Alpert and Rush 1983),verbal intelligence (Quick Test; Am-mons and Ammons 1962), temporalattention (Span of Attention Test;Kay and Singh 1974), and percep-tual-motor development (Pro-gressive Figure Drawing Test; Kay1982).

On the other hand, as sum-marized in table 4, the Positive andNegative Scales produced distinctiveprofiles across the various spheresof assessment, and many of the dif-ferences were substantiated by sig-nificant correlations of dependentvariables with the Composite Scale.Thus, the positive syndrome wasdistinguished by unusual thoughts,anxiety, anger, preoccupation, dis-orientation, labile affect, more fre-quent episodes of hospitalization,and greater likelihood of sociopathyin first-degree relatives. Conversely,the negative syndrome was charac-terized by slowed motorium, deficitson several affective measures,thought impoverishment, lessereducation, and dysfunction on de-velopmentally based cognitive tests.

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Table 4. Relationship of the PANSS to external variables

Variable

Demographic/historicalNumber of hospital admissionsYears of educationMale gender

Family history of illnessSociopathyUnspecified psychosisMajor affective disorderTotal psychiatric illness

Cognitive/psychometricEgocentricity of Thought Test

(CDB)Random number fluencyColor Form Preference Test

(CDB)

Affective (MARS)Angry affective toneAffective labilityTotal affective impairmentDull facial expressionImpoverished thought contentGlobal unrelatednessLack of vocal emphasisSlow response latencyGlobal immobilityLack of expressive gesturesSoft voice levelPoor eye contactIncreased noncommunicative

movements

Clinical (BPRS)Unusual thought contentAnxietyPreoccupationDisorientationMotor retardationSomatic concern

Significant partial correlation (p<.05)

Positive

.20

.21

.46

.31

.73

.38

.28

.26

Negative

-.29.21

.29-.21

-.34-.33

.64

.54

.52

.50

.49

.47

.43

.41

.32

.22

.20

Com-posite

.33

.24

.39

.27

.23

-.41-.40-.49-.42-.40-.36-.43- .37-.30

.50

.33

-.28


.28

.20

.47

.24

.27

.30

.39

.46

.41

——————

Note—Based on study of 101 chronic schizophrenics (Kay, Opter & Rszbein 1986). Shown are thesignificant (p<.05) nonovertapping covartates of the Positive and Negative Scales and the correlatesof the Composite and General Psychopathology Scales, excluding those clinical items that enter Intothe latter scale. Abbreviations.—COB - Cognitive Diagnostic Battery (Kay1982); MARS - ManifestAffect Rating Scale (Alpert and Rush 1983); BPRS - Brief Psychiatric Rating Scale (Overall andGorham 1962); PANSS - Positive and Negative Syndrome Scale.

It prevailed especially among malesfrom families with history of psy-chotic disorder but not affective ill-ness. The positive-negativedistinction on the PANSS, accord-ingly, was sustained along familial,antecedent, and concurrent assess-ments and suggested a more per-nicious disease process for thenegative syndrome, one devolvingfrom genealogical and ontogeneticsources (Kay, Opler, and Fiszbein1985; Opler and Kay 1985; Opler,Kay, and Fiszbein 1986). A com-parison of results with simple vs.partial correlations suggested thatthese findings were not mitigated byneuroleptic-induced side effects(Kay, Opler, and Fiszbein 1986).

Because of the number of correla-tions performed, the reliability of in-dividual coefficients must beinterpreted with due caution. Thefinding of a statistically significantrelationship in a large sample, more-over, does not presuppose substan-tial shared variance betweenmeasures, which may be judged bythe magnitude of the squared coeffi-cients of correlation. What standsout as important for the present pur-poses, however, is the general pat-tern of correlations rather than theindividual values. The extensivenessof significant associations, the con-sistency across different spheres andmethods of assessment, the concep-tual cohesiveness, and the corre-sponding unrelatedness of PANSSscores to extraneous variables maybe regarded as evidence toward con-vergent and discriminant validity.

The General PsychopathologyScale, by comparison, yielded fewerexternal correlations and a non-specific profile that encompassedboth positive and negative charac-teristics (table 4). As a measure ofseverity of illness, the scale was sig-nificantly associated with seven ofthe affective symptoms reflecting

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both a productive syndrome (i.e.,anger and increased noncom-municative movements) and deficits(e.g., dull facial expression, pooreye contact, and emotional unre-latedness). In terms of family psy-chiatric disorder, it correlated withpsychosis as well as prevalence ofany major disturbance among first-degree relatives (i.e., history ofschizophrenia, affective illness, alco-holism, sociopathy, or suicide). Al-ternatively, it bore no significantrelationship with the various controlmeasures such as age, sex, maritalstatus, cultural group, chronicity ofillness, verbal intelligence, or neu-rological soft signs.

In keeping with the impressionfrom the correlational analyses,stepwise multiple regression re-vealed no overlap among the param-eters that best accounted for thePositive and Negative Scales. ThePositive Scale, with 74 percent of itsvariance explained, was contributedto primarily by unusual thoughtcontent (i.e., bizarre quality of idea-tion), family history of sociopathy,angry affective tone, and global psy-chopathology. The Negative Scale,with 81 percent of its variance ex-plained, was accounted for chieflyby general affective impairment onthe Manifest Affect Rating Scale,family history of psychosis, cogni-tive developmental deficit on theEgocentricity of Thought Test (Kay1982), impoverished thought con-tent, lack of insight, and active so-cial withdrawal. For the CompositeScale, which denotes tendency to-ward the positive or negative pole,69 percent of the variance was pre-dicted by unusual thought content,emotional unrelatedness, im-poverished thought content, yearsof education, and conceptual de-velopment on the Color Form Rep-resentation Test (Kay 1982). Themultiple correlation values for the

three scales were .86, .90, and .84,respectively, all highly significant(p < .001).

Pharmacological Validation. Thevalidity and drug sensitivity of thePANSS were examined experimen-tally by assessing differential re-sponse of syndrome scores to drugtreatment.

In a single-subject experimentalstudy, we analyzed changes on thePANSS when the dopamine precur-sor, L-dopa, was used adjunctivelywith neuroleptics (Kay and Opler1985-86). The investigation followeda 27-week double-blind, placebo-controlled, reversal design. After 2weeks of treatment with neurolep-tics alone, a haloperidol + placebocombination was instituted for 13weeks, followed by a haloperidol +L-dopa combination for thenext 8 weeks, and then a return tohaloperidol + placebo in the remain-ing 5 weeks. When the interveningL-dopa phase was compared againstthe preceding and following 4-weekphases, significant improvementwas found on the Negative Scale ofthe PANSS (p < .05) as well as twoof the individual negative items, dif-ficulty in abstract thinking (p < .025)and passive-apathetic social with-drawal (p < .05). By contrast, nei-ther the Positive Scale nor any of itsindividual items showed changeduring the L-dopa challenge(p > .50).

A second investigation consideredthe specificity of adverse clinical re-action to anticholinergic drugs whenused with neuroleptics. This workwas predicated on the findings ofSingh and Kay (1975fl, 1975b, 1979)that antiparkinsonian agents tend toworsen psychiatric symptoms ofneuroleptic-treated schizophrenics,and the more recent qualification byJohnstone et al. (1983) that the phe-nomenon obtains mainly to positive

features of the illness. Thus, Singh,Kay, and Opler (1987) reanalyzedtheir earlier data on 47 well-definedschizophrenics who had received,under double-blind conditions, anti-parkinsonian medication (benz-tropine or trihexyphenidyl) for 2 to 4weeks along the course of neurolep-tic treatment (haloperidol or chlor-promazine). Clinical ratings duringthe antiparkinsonian phase werecontrasted against the precedingand following 2-week periods ofneuroleptic alone, thus controllingfor the time-series factor via anABA' design (Singh and Kay 1978).The PANSS dusters were used toinspect the data, which was possiblesince ratings on both the BPRS andPRS had been conducted originally.Our results indicated that only thePositive Scale was adversely influ-enced by the anticholinergic inter-vention (t = 2.58, p < .02). Thecorrelation between positive andnegative clusters in their directionand magnitude of change provednonsignificant, suggesting that thetwo scales did not covary in their re-sponse to anticholinergics.

Typological Validation. The PANSShas been applied also as a method ofcharacterizing schizophrenic pa-tients with a predominantly positivevs. a predominantly negative syn-drome. We considered patients whoscored "moderate" or higher on atleast three of the seven positiveitems as positive-type schizo-phrenics and those with the reversepattern ("moderate" on at leastthree negative items) as negative-type schizophrenics; patients whoqualified for both groups or neitherwere labeled as mixed type. Thissystem was applied in separatestudies involving 37 acute (< 2 yearsof illness) and 47 chronic schizo-phrenics, all with confirmed DSM-III diagnosis (Lindenmayer, Kay,

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and Opler 1984; Opler et al. 1984).The results supported the validity

of the PANSS for isolating groupsthat differ on both antecedent andconcurrent variables. A significantinverse relationship between posi-tive and negative symptoms was ob-tained in both studies (r = - .62,p < .001, and r = - .55, p < .01, re-spectively). In the acute sample(Lindenmayer, Kay, and Opler1984), patients classified by thePANSS as negative differed from thepositive group in premorbid func-tioning (lesser schooling, p < .02;poorer work adjustment, p < .10),likelihood of nonparanoid subdiag-nosis (p < .02), and various deficitsymptoms that encompassed thecognitive, social, affective, and mo-tor spheres. The chronic study(Opler et al. 1984) also found thenegative type to have achieved lesseducation (p < .02) and, on otherhistorical dimensions, to be charac-terized more by winter birth(p < .02) and early onset of illness(p < .05), as judged by age of initialhospitalization. On objective psy-chometric tests, this group was dis-tinguished by a developmentallymore primitive cognitive style(p < .01) and slower psychomotorpace (p < .05) on the Cognitive Di-agnostic Battery (Kay 1982), despitesimilar scores on tests of intelligenceand visual-motor deficits. In bothstudies, no group differences wereobtained on control variables suchas sex, race, ethnic background,chronicity of illness, and level ofgeneral psychopathology.

Typological comparisons wererendered also in the Singh, Kay, andOpler (1987) study of clinical re-sponse to antiparkinsonian agents.From the baseline drug-free assess-ment with the PANSS, schizo-phrenic patients were prospectivelyclassified as predominantly positive(n = 25) or negative type (n = 22)

according to the valence of theirComposite Scale score (i.e., positiveminus negative value above zerobeing positive and below zero beingnegative). It was found that onlythose classified as positive typeshowed subsequent clinical worsen-ing when antiparkinsonian drugswere introduced (p < .02), while thenegative group was essentially un-affected. Thus, complementing thestudies of Lindenmayer, Kay, andOpler (1984) and Opler et al. (1984),which supported the validity of thePANSS typology in relation to ante-cedent and concurrent measures,the Singh, Kay, and Opler (1987)finding introduced evidence of pre-dictive validity.

Discussion

We have described the developmentand initial standardization of the 30-item PANSS as an instrument formeasuring the prevalence of positiveand negative syndromes in schizo-phrenia. A major impetus of its de-velopment was the need tor a psy-chometrically sound procedure toserve typological and dimensionalassessment. Perhaps its most impor-tant contributions are the provisionof specified interview guidelines andassessment criteria, and the inclu-sion of two additional scales thatconsider positive-negative syn-dromes relative to one another andrelative to general severity ofpsychopathology.

The PANSS method derives fromtwo established psychiatric ratingscales for which interrater agree-ment and treatment sensitivity havebeen demonstrated. As such, it pro-ceeds from reliable techniques thatare familiar to clinicians and re-searchers, requiring relatively littleadditional training. For the purposeof the PANSS, however, precise op-

erational definitions were intro-duced for all items at every ratinglevel. These guidelines, by enhanc-ing the objectivity and replicabilityof observations, are expected toaugment concordance among raters.Although this aspect of reliabilitycould not be measured in the pres-ent study,2 the various other indica-tors of reliability, stability, andvalidity from a sample of 101 schizo-phrenic patients suggested that thegoal of developing objective andreplicable scales was met.

The PANSS scales, as already dis-cussed, were assembled mainly onthe basis of theoretical and psycho-metric considerations (e.g., defini-tion of construct, content sampling,and balancing of items). The presentempirical analyses indicated that theitems selected were appropriate tothe constructs and were internallycoherent, yet it also emerged thatother clinical variables could wellhave been included. Specifically, ac-cording to correlational and multipleregression analyses, a positive syn-drome was strongly associated withunusual thought content and anx-iety, while a negative syndromeseemed to encompass motor retar-dation, lack of judgment and in-sight, and active social avoidance.

As based on the initial item selec-tion, however, the validation proc-ess supported the use of thisinstrument for positive-negative as-sessment. All four scales from thePANSS produced normal Gaussiandistribution curves, which sug-gested amenability to powerful para-metric statistics—hence, reducedrisk of Type II error in clinical re-

this article went to press, wehave reported interrater reliabilities in arange between .83 and .87 for the fourPANSS scales on a sample of 31 acuteschizophrenics (Kay, Opler, and Linden-mayer, in press).

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search. The reliability of the PANSSwas upheld by coefficient a, split-half analysis, and test-retestmethods, which also provided someevidence of stability in a refractorychronic schizophrenic cohort. Its va-lidity was considered on the basis offive separate studies in which itserved typological and/or dimen-sional assessment of schizophrenics.The studies supported its constructand criterion-related validity withrespect to both antecedent and con-current variables that involved his-torical, genealogical, clinical, andpsychometric assessments.

The reliance on individual ratherthan team ratings raises the questionof whether the outcomes may havebeen influenced by an individual'spreconceptions. Such a possibilitywas mitigated by several safeguardsin the design: the participation oftwo independent psychiatrists, eachgathering data on approximatelyhalf the sample; their lack of knowl-edge of PANSS scores when collect-ing other data; their perception ofthe research as exploratory ratherthan hypothesis testing; the use ofmultiple external criteria, includingsuch measures as psychometric testsand historical records that are objec-tive and derive from separate andindependent sources; and, above all,the convergence of several differentstudies, involving different ratersand designs, which supportedvarious aspects of validation.

The pattern of findings also ac-corded with the results of otherstudies, employing different inves-tigative tools, which have similarlyimplicated lesser education, premor-bid impairments, poor cognitive per-formance, and genealogicalpredisposition in the characteriza-tion of a negative schizophrenic syn-drome (Andreasen and Olsen 1982;Andreasen et al. 1982; Dworkin andLenzenweger 1984; Pogue-Geile and

Harrow 1984). In these respects,there is some evidence of cross-val-idation. In addition, predictive va-lidity and sensitivity to change wereindicated by the significance of thePositive and Negative Scales for an-ticipating and reflecting differentialresponse to medication. The PANSSresearch, therefore, was undertakenas a sequential programmatic seriesof studies that included multi-method and experimental ap-proaches and, as such, heeded themethodological requisites discussedby Sommers (1985) and Zubin (1985)for validation of relatively unchartedconstructs.

The premise of our work was thatsome of the disparities in the re-search on positive-negative distinc-tions may reflect the application ofimprecise instruments, which pro-motes Type II error by reducing thechance of observing true variance,and may be due also to the very di-versity among studies in methods ofassessment.

There has been considerable dis-agreement, for example, surround-ing the issue of content validity, i.e.,what symptoms, how many, andeven which spheres of functioningbest represent positive and negativesyndromes (Sommers 1985). Thus,Angrist, Rotrosen, and Gershon(1980) have measured these twosyndromes by using clusters of 10and 3 symptoms, respectively, whileAndreasen and Olsen (1982) de-scribed instead 4 and 5 symptomsand Lewine, Fogg, and Meltzer(1983) incorporated a compilation of22 and 11 symptoms. WhereasOwens and Johnstone (1980) orig-inally conceived of the negative syn-drome as entailing flat affect andimpoverished speech, Crow (1980a)expanded the concept to includeavolition, and Andreasen (1982)modified it by excluding poverty ofspeech and introducing alogia,

anhedonia-asociality, and atten-tional impairment. Elsewhere wehave proposed that attentional dys-function in schizophrenia is multi-determined and at least partly afunction of arousal disorder (Kay1981; Kay and Singh 1974), andstudies by our group and othershave since confuted its specificity toeither the negative or positive syn-drome (Opler et al. 1984; Bilder et al.1985; Cornblatt et al. 1985; Kay,Opler, and Fiszbein 1986). By con-trast to other descriptions of thenegative syndrome, the PANSS ex-cludes attentional impairment butembraces deficits along five majorspheres of functioning: the cogni-tive, affective, social, interpersonal,and communicational.

Aside from variation in content ofscales, there has been little studyand much disagreement about theconstruct validity of positive andnegative syndromes (Zubin 1985).Researchers have differed in theiropinion of whether these syndromesare independent of one another—hence, distinct constructs—and gen-erally have ignored their relation-ship to overall psychopathology.Andreasen and Olsen (1982), for ex-ample, have argued that the positiveand negative aspects represent op-posite poles of a continuum,whereas Pogue-Geile and Harrow(1984) have concluded that they areoverlapping features of schizo-phrenia. Our analysis of the PANSSnot only supported the cohesivenessof the separate positive and negativeclusters via coefficient a, butprovided evidence of their dis-tinctiveness from one another by re-vealing low, nonsignificant item-total cross-correlations (means of .17and .18) and nonoverlap of determi-nants identified through multiple re-gression analysis. However, therelationship between positive andnegative dimensions was observed

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to be strongly mediated by theirshared association with level of psy-chopathology. Thus, a significant di-rect correlation was initially foundbetween the Positive and NegativeScales, but when their correlationswith the General PsychopathologyScale were statistically extracted,they bore a significant inverse cor-relation. This disclosure of the mu-tually exclusive nature of thePositive and Negative Scales notonly supports their conceptual sepa-rateness, i.e., construct validity, butprovides a compelling rationale forpursuing typological study based onthis distinction.

In view of the pattern of PANSScorrelations with historical, cogni-tive developmental, and genealogi-cal variables, we have proposed thatthe negative syndrome is dis-tinguished by a familial predisposi-tion for psychosis and earlyontogenetic failures, particularly inthe cognitive realm, which fore-shadow premorbid adaptational dif-ficulties and, eventually, enduringmultimodal deficits (Kay, Opler, andFiszbein 1985, 1986; Opler, Kay, andFiszbein 1986). The results and inter-pretations are congruent with thepivotal role ascribed to developmen-tal dysfunction in the pathogenesisof certain expressions of schizo-phrenia (cf. Walker and Emory 1983;Aylward, Walker, and Bettes 1984;Pogue-Geile and Harrow 1984) andwith our dual-process model thatposits separate developmental(neuroleptic-resistant) and arousal-related, disorganizational (neurolep-tic-responsive) components to theschizophrenic cognitive abnormality(Kay and Singh 1979).

Clearly, a systematic program ofstudy will be needed to pursue thisemerging model. Further researchon the PANSS also is necessary, in-cluding drug-free assessments andexpansion of the data base for estab-

lishing norms. The latter objectiveentails comparisons of scores amongschizophrenic subtypes, such asclassified by subdiagnosis andchronicity of illness, as well as in re-lation to nonschizophrenic groups.

It should be cautioned that gener-alization of results depends on therepresentativeness of the sample,which in the present case was achronic group in whom neuroleptictreatment could not be withdrawn.With regard to chronicity, however,our analyses indicated no significantcorrelation between years since ini-tial hospitalization and positive syn-drome (r = - .03), negativesyndrome (r = - .09), or the com-posite index (r = .04) (Kay, Opler,and Fiszbein 1986). Evidence fromour typological comparisons also re-vealed no covariation betweenlength of illness and the positive-negative dimension as observedwithin an acute (lindenmayer, Kay,and Opler 1984) or chronic schizo-phrenic population (Opler et al.1984). In addition, we recently con-cluded two studies which furthersuggest that positive and negativesyndromes prevail to a similar ex-tent across various stages of schizo-phrenia. A 2-year followup of 19acute schizophrenics (Lindenmayer,Kay, and Friedman 1986) revealednegligible change (p > .20) in posi-tive score (17.26 to 18.37), negativescore (22.05 to 21.16), composite in-dex (-4.29 to -2.79), or generalpsychopathology (39.04 to 38.56). Bycontrast to the present report of sta-bility among refractory patients dur-ing the chronic phase, the correlateswere low and nonsignificant whenscores were tracked from the acuteinto the subacute phase, i.e., beforethe more established course of ill-ness (cf. Brown 1960). Thus, somepatients evidently improvedclinically, some worsened, and somewere unchanged. In a cross-sec-

tional investigation of 134 schizo-phrenics (Kay et al. 1986), whichpooled data from an acute sample(Lindenmayer, Kay, and Opler 1984)with the present group, we com-pared PANSS scores in the acute (0-2 years), chronic (3-10 years), andlong-term chronic stages of illness(> 10 years). Analysis of variance re-vealed nonsignificant differences(F =£ 1) of means among these re-spective groups on all scales: Posi-tive (18.76, 19.71, 17.98), Negative(21.42, 21.21, 21.27), Composite(-2.66, -1.50, -3.29), and GeneralPsychopathology (39.58, 37.40,38.13).

The assessment of neuroleptic-treated patients poses an interpreta-tional problem for this as for otherpublished studies on the positive-negative dimension. Particularly inevaluating the negative syndrome, ithas been proposed that neurolepticsmay produce a seeming indifferenceto the environment, and their sideeffects can be misconstrued as mo-tor, affective, verbal, or motivationaldeficits (Rifkin, Quitkin, and Klein1975; Van Putten and May 1978). Toguard against systematic rating er-rors attributable to extrapyramidalreaction, we separately assessedthese symptoms on two side effectsscales and statistically partialed outtheir influence on PANSS scores. Itwas seen that the criterion-relatedvalidity was not diminished as a re-sult (Kay, Opler, and Fiszbein 1986).The general impact of medicationand dose, however, could not bestatistically adjusted due to in-complete and unreliable informationin many cases. In our typologicalstudies, where this information wasavailable, neuroleptic dose was un-related to the positive-negative dis-tinction in acute schizophrenics(Lindenmayer, Kay, and Opler 1984)and, contrary to the proposed direc-tion of confound, was only half as

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high for those with a preponderanceof negative features in a chronicsample (Opler et al. 1984).

We are presently examining theinfluence of neuroleptic treatmentand withdrawal on positive andnegative scores, their variations overthe course of illness, their prognos-tic implications, and their relation-ship to neurological status. Inproceeding with our study of the re-liability and validity of the PANSS,we also have begun to collect simul-taneous ratings from paired ob-servers using this instrument as wellas corresponding assessment withAndreasen's (1982) method, whichwill permit analysis of interjudgeconcordance and cross-comparisonof scales (Kay, Opler, and Linden-mayer, in press). Should the validityof the PANSS be upheld by futurestudies and independent investiga-tors, its use might be expected topromote uniformity and reliability inresearch findings.

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Van Putten, T., and May, P.R.A."Akinetic depression" in schizo-phrenia. Archives of General Psychia-try, 35:1101-1107, 1978.

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Walker, E., and Emory, E. Infants atrisk for psychopathology: Offspringof schizophrenic parents. Child De-velopment, 54:1269-1285, 1983.

Zubin, J. Negative symptoms: Arethey indigenous to schizophrenia?Schizophrenia Bulletin, 11:461-470,1985.

Acknowledgment

We thank Dr. Jean Endicott, Dr.Joseph Zubin, and the editorial re-viewers of Schizophrenia Bulletin fortheir constructive comments on anearlier draft of this article. A debt ofgratitude is owed also to Dr. Man

Mohan Singh, whose conceptualiza-tion of schizophrenic phenomena in-fluenced the definitions of manyscale items.

The Authors

Stanley R. Kay, Ph.D., is AssistantClinical Professor, Department ofPsychiatry, Albert Einstein Collegeof Medicine/Montefiore MedicalCenter, and Co-Director, ResearchUnit, Bronx Psychiatric Center,Bronx, NY. Abraham Fiszbein,M.D., is Resident in Psychiatry,

Albert Einstein College of Medicine/Montefiore Medical Center andBronx Psychiatric Center, Bronx,NY. Lewis A. Opler, M.D., Ph.D., isAssociate Clinical Professor, Depart-ment of Psychiatry, Albert EinsteinCollege of Medicine/MontefioreMedical Center, and Clinical Direc-tor, Bronx Psychiatric Center, Bronx,NY. Dr. Opler has recently accepteda position as Director of Schizo-phrenia Research, Department ofPsychiatry, Presbyterian Hospital,and Associate Professor of Psychia-try, College of Physicians and Sur-geons, Columbia University, NewYork, NY.

Appendix Sample Items From the Positiveand Negative Syndrome Scale

PI. Delusions. Beliefs which are un-founded, unrealistic, and idio-syncratic. Basis for rating: thoughtcontent expressed in the inteviewand its influence on behavior.

1. Absent—Definition does not ap-ply.

2. Minimal—Questionable pathol-ogy; may be at the upper extreme ofnormal limits.3. Mild—Presence of one or two de-lusions that are vague, un-crystallized, and not tenaciouslyheld. Delusions do not interferewith thinking, social relations, or be-havior.

4. Moderate—Presence of either a ka-leidoscopic array of poorly formed,unstable delusions or of a few well-formed delusions that occasionally

interfere with thinking, social rela-tions, or behavior.5. Moderate-severe—Presence of nu-merous well-formed delusions thatare tenaciously held and occasion-ally interfere with thinking, socialrelations, or behavior.

6. Severe—Presence of a stable set ofdelusions that are crystallized, pos-sibly systematized, tenaciously held,and clearly interfere with thinking,social relations, and behavior. Pa-tient at times acts inappropriatelyand irresponsibly on the basis of un-realistic beliefs.

7. Extreme—Presence of a stable setof delusions that are either highlysystematized or very numerous, anddominate major facets of the pa-tient's life. This frequently results ininappropriate and irresponsible ac-tion, which may even jeopardize thesafety of the patient or others.

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SCHIZOPHRENIA BULLETIN

P2. Conceptual disorganization.Disorganized process of thinkingcharacterized by disruption of goal-directed sequencing, e.g., circum-stantiality, tangentiality, loose asso-ciations, non sequiturs, grossillogicality, or thought blocking.Basis for rating: cognitive-verbalprocesses observed during thecourse of interview.

1. Absent—Definition does not ap-ply.2. Minimal—Questionable pathol-ogy; may be at the upper extreme ofnormal limits.3. Mild—Thinking is circumstantial,tangential, or paralogical. There issome difficulty in directing thoughtstoward a goal, and some looseningof associations may be evidencedunder pressure.

4. Moderate—Able to focus thoughtswhen communications are brief andstructured, but becomes loose or ir-relevant when dealing with morecomplex communications or whenunder minimal pressure.

5. Moderate-severe—Generally hasdifficulty organizing thoughts, asevidenced by frequent irrelevancies,disconnectedness, or loosening ofassociations even when not underpressure.

6. Severe—Thinking is seriously de-railed and internally inconsistent,resulting in gross irrelevancies anddisruptions of thought processes,which occur almost constantly.

7. Extreme—Thoughts are disruptedto the point where the patient is in-coherent. There is marked looseningof associations, which results in total

failure of communication, e.g.,"word salad" or mutism.

Nl. Blunted affect. Diminishedemotional responsiveness as charac-terized by a reduction in facial ex-pression, modulation of feelings,and communicative gestures. Basisfor rating: observation of physicalmanifestations of affective tone andemotional responsiveness duringthe course of interview.

1. Absent—Definition does not ap-ply.2. Minimal—Questionable pathol-ogy; may be at the upper extreme ofnormal limits.3. Mild—Changes in facial expres-sion and communicative gesturesseem stilted, forced, artificial, orlacking in modulation.

4. Moderate—Reduced range of facialexpression and few expressive ges-tures.

5. Moderate-severe—Affect generallyappears "flat," with few changes infacial expression and a paucity ofcommunicative gestures.

6. Severe—Marked flatness and defi-ciency of emotions exhibited most ofthe time. There may be unmodu-lated extreme affective discharges,such as excitement, rage, or inap-propriate uncontrolled laughter.

7. Extreme—Changes in facial ex-pression and evidence of commu-nicative gestures are virtuallyabsent. Patient seems constantly toshow a barren or "wooden" expres-sion.

N6. Lack of spontaneity and flow ofconversation. Decrease in the nor-

mal flow of communication associ-ated with apathy, avolition,defensiveness, or cognitive impair-ment. This is manifested by dimin-ished fluidity and productivity ofthe verbal-interactional process.Basis for rating: cognitive-verbalprocesses observed during thecourse of interview.

1. Absent—Definition does not ap-ply.

2. Minimal—Questionable pathol-ogy; may be at the upper extreme ofnormal limits.

3. Mild—Conversation shows littleinitiative. Patienf s answers tend tobe brief and unembellished, requir-ing direct and leading questions bythe interviewer.

4. Moderate—Conversation lacks freeflow and appears uneven or halting.Leading questions are frequentlyneeded to elicit adequate responsesand proceed with conversation.

5. Moderate-severe—Patient shows amarked lack of spontaneity andopenness, replying to the inter-viewer's questions with only one ortwo brief sentences.

6. Severe—Patient's responses arelimited mainly to a few words orshort phrases intended to avoid orcurtail communication (e.g., "I don'tknow," "I'm not at liberty to say").Conversation is seriously impairedas a result, and the interview ishighly unproductive.

7. Extreme—Verbal output isrestricted to, at most, an occasionalutterance, making conversation notpossible.

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