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Flattening of affect and personal constructs
Article in The British Journal of Psychiatry February 1970
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Brit. 3 . Psychiat. 1970 , ii6, 3943
Flattening of Affect and Personal Constructs
By F. M . M cPH ERSON, VALERIE BARDEN, A. JOAN HAY, D. W . JOH NSTONE and
A. W . KUSHNER
Affective flattening is a disorder of em otional
expression, of which a good definition is a
gross lack of emotional response to the given
situation' (Fish, 1962). It is a clinical sign
whose assessment depends upon the clinician's
intepretation of the patient's facial expression,
tone of voice and content of talk (Harris
M etcalfe, 1956). Although these are subtle cues,
it has been shown that experienced clinicians
can assess the severity of affective flattening
with a high level of inter-rater agreement
(M iller et al., 1953; Harris M etcaife, 1956;
W ing, 1961; D ixon, 1968). The disorder is
usually associated with a diagnosis of schizo
phrenia, although it m ay occur in other
conditions, such as the organic psychoses
(B ullocketal., ig@ i).
There have been very few investigations of
a ff ec ti ve f la tt en in g H er ro n K an to r, 1 96 8) .
M ost authors have suggested that the disorder is
m erely one aspect of a m ore widespread deficit
such as intellectual slowness (Harris
M etcalfe, ig@ 6) or a generally reduced rate of
responding (Salzinger Portnoy, @ 64).
Recently, however, Dixon (i 968) has found
a m ore specific abnorm ality associated w ith
flattening of affect. She investigated the personal
construct system s (Kelly, 1955; Bannister,
1965; Bannister M air, 1968) of schizophrenic
patients with affective flattening. W hereas
m ost previous studies of the construct systems of
schizophrenics have been of the structure of
their system s e.g. the relationships am ong
constructs (Bannister, i96o, 1962; Bannister
Fransella, 1966), D ixon was concerned
w ith the content of their system s i.e. w ith the
types of constructs which they use w hen differ
entiating between or among other people. Her
method of eliciting constructs required the
subject (5) to give what he considered to be the
m ain differences between the people in pairs
of photographs. In a very carefully controlled
study of 37 schizophrenics, Dixon showed that
those with affective flattening, when construing
other people, m ade relatively little use of con
structs descriptive of personality charac
teristics or current em otional state, whereas
they used other types of construct as frequently
a s th e o th er s ub je cts.
The present study aim s to confirm D ixon's
findings. In schizophrenia research, because of
difficulties associated with the selection of
sam ples and with the reliability of diagnosis and
assessm ent, it is im portant for replication
studies to be conducted.
M ETHOD
Patients. i8 Ss were studied. Equal numbers of
male and female, and paranoid and non-paranoid
patients were selected randomly from am ong those
in two wards who satisfied the following criteria:
that they had had an unchanged diagnosis of schizo
phrenia for at least tw o years; that they w ere show ing
active, psychotic signs or sym ptom s (not necessarily
flattening of affect); and that they w ere aged 1760,
inclusive.
The selected sam ple had the following charac
teristics:
Age: mean 3I@2 years, S.D. 8@8 years, range
1862years.
L en gth o f illne ss: m ea n tim e fro m first a dm issio n
5@8years , S .D. 2@4yearS,range 215ears .
linic l ssessment
Raters: The rating of flattening was m ade by two
p sy ch iatrists, bo th o f w hom w ere ex perien ced in the
assessment of schizophrenic patients, and knew the
Ss w ell. They independently interview ed each S,
and rated the am ount of flattening show n. T he ratings
of each S were m ade within one day of each other.
Rating: The raters were instructed to use the term
affective flattening' as they norm ally did: it was
emphasized that it was a ffe ct'ath er th an mood',
and la tt ening'a th er th an n co ng ru ity ',hat was
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F LA TT EN IN G O F A FFE CT A ND PE RSO NA L C ON ST RU CT S
to be rated. The assessment was recorded by the
rater placing a m ark at any point on a line go m m .
long and labelled N ola tte nin g a t o ne e nd a nd
Veryonsiderable f la tten ing a t the o the r .
Inter-rater agreement: Over the :8 Ss, the rank order
correlation coefficient (Kendall s tau) between the
two raters w as +0 .@ (p< @ OO5, one-tailed test).
Because of this high inter-rater agreem ent, in sub
sequ en t calc ulatio ns the m ean o f the tw o ratin gs w as
u se d a s th e c rite rio n o f t he a mo un t o f f la tte nin g sh ow n
by each S .
Analysis of constructs
Erperi m ental task: The procedure for eliciting
constructs was that used, and described in detail,
by D ixon (1968). The m aterial com prised five
pairs of photographs; each was of one or two adults
or children w ho w ere engaged in activities such as
carrying objects, fighting or reading. The people in
each pair were usually similar in age, sex and
apparent social and ethnic background, although
these factors varied considerably betw een pairs. S
w as instructed to give the m ain differences betw een
the people in each of the pairs; three m inutes w ere
allow ed per pair. The instructions w ere repeated
b efo re e ac h p air. T he re sp on se s w ere ta pe -re co rd ed
a nd tr an sc ri be d. T h e p sy ch olo gis t w h o a dm i ni ste re d
the procedure had no knowledge of the clinical
ratings. Testing took place within a day of the
clinical ratings being m ade.
Content analysis: From each S, a series of bi-polar
de sc rip tiv e te rm s c on stru cts h ad th us b ee n e lic i
ted. Analysis of the content of these gives som e
indication of the characteristics to w hich S had
attached greatest im portance when differentiating
among the people in the photographs. The use
m ade of each of the following i 2 categories of
c on st ru ct w a s a na ly se d:
Activ4y : constructs which differentiated be
tw een or am ong the people according to w hat
th ey w ere d oin g, e.g. heom an in th is p ho to
is carrying som ething, but the one in the other
phot oisnot
Stance :constructs which referred to the stance
or posture of the people, e.g. standingsitting ,
armsa is ed a rm s b y s id e .
Physique :hese described the physical charac
teristics or condition of the people, e.g. all
s ho rt , hungry-lookingwell-fed .
P er so na l4 yn d e m ot io na l s ta te : t he se d es cr ib ed
th e fe elin gs, e mo tio na l sta te o r m o re p erm an en t
personality traits of the people e.g. happy
s ad , o ok sn gr y lo ok s p ea ce fu l , apprehen
siveangry , n te ll igent- looking-stupid-look
i ng , kindcruel .
Agereferences to the age of the people in the
p ho to gra ph , e .g . olderyounger ,abo ut5
about so .
X ation al4y re fe re nc es to th eir n atio na lity ,
r ac ia l o r e th ni c c ha ra ct er is ti cs .
Occupationconstructs which referred to their
occupation, social class or status e.g. sh es
p oo r sh e i s b et te r o ff .
Clothes :eferences to what the people were
wearing.
rrelevance : occasionally, a patient would
differentiate between the people in terms of
constructs based on his own preoccupations or
d el us io n al s ys te m, e .g . h eo uld try to ha rm m c
s hew o ul d l ik e m e .
Background :om etim es S ignored the people
(and the instructions) entirely and referred
to the background of the photograph or to its
non-hum an features, e.g. t sunny in this one
but dull in that one or here s book here but
notthere
Photography :ometimes all aspects of the con
te nt w e re ig no re d a nd S d es cr ib ed th e p ho to gr ap h
i ts el f, e .g . over-exposedunder-exposed .
Denial :his was scored when S said spon
taneously that he could observe no (further)
differences.
D etailed criteria are given in D ixon (1968).
Scorers: The content analysis of the transcribed
descriptions was performed by two psychologists
w ho w orked independently and had no know ledge
o f th e c lin ic al r ati ng s.
Scoring: The description of each pair of photographs
b y e ac h S w as s co re d s ep ara te ly . T o sim p lify s co rin g,
an d to im pro ve in ter-scorer reliability , the scorers
d ecid ed m ere ly w heth er e ach c ateg ory o f co nstru ct
had or had not been used by S. Each category was
assigned a score of o (not used) or i (used). Over
the five pairs, each category thus had a score ranging
from 0 to 5. The score obtained in this way from
each of the i 2 categories was expressed as a per
centage of the total category score obtained by sum
m ing the i 2 individual scores. T hese percentage scores
indicated the relative frequency w ith w hich S had
used each category of construct. Percentage scores
w ere used in order to control the effects of inter-S
d iff er en ce s in th e to ta l n um b er o f c on str uc ts e li cite d.
Inter-scorer agreement: For each 5, 6o scoring
decisions had to be m ade, i.e. whether or not each
of 1 2 c ateg orie s h ad b een u sed o n each o f occ asio ns.
Therefore over the i 8 Ss i o8o scoring decisions
were made The two scorers disagreed on only three
o f th ese . B ec au se o f th is v ery h ig h in te r-sc ore r a gre e
m entw hich had also been found by D ixonthe
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Category of
constructCategory
of
tauonstructtauActivity
02 Occupation + .6Stance'+
@26Clothes'+
22Physique'.
o 8 r re le va nc e +2Personality
andemotional
state'
.47* Background +
32Age'+
@02Photography'+o8Nationality'+@
1 5 Denial '
@24
BY F. M . M CPHERSON ET AL.
m ean o f th e tw o sco res w as u sed as th e m easure o f t he
frequency w ith w hich each S had used each category.
Compa ri so no f c on st ru ct u se and rat ed f la tt en in g. Rank
o rd er co rrelatio n co efficien ts (K end all's tau) w ere
calculated over the 18 Ss between each of the 12
in di vid ua l c ate go ry p er ce nta ge s co re s a nd th e c li ni ca l
ratings.
RES ULTS
T he tw elve correlation coefficients are show n
in Table I.
TArn..EI
Correlations between ratings of affective flattening and
r el ati ve ) u se o f 1 2 c ate go rie s of c on str uc t
Positive correlations show that the category of
constru ctas usedmor eoftenby Ssw ithhighamounts
of rated flattening; negative correlations show that the
category w as used less often by Ss w ith high ratings of
flattening. N = :8.
The use of the p e rs o na li ty an d e mo ti on al
state' category was not related to the length of
time for which the patient had been in hospital,
nor to drug dosage. There was no difference
in the scores of m ale and fem ale patients.
Differences related to sub-diagnosis will be
con sid ered in a later article.
DISCUSSION
The present results have confirm ed those of
Dixon (1968) in showing that schizophrenic
patients with flattening of affect are character
ized by an abnorm ality in the content of their
personal construct system s. W hen construing
other people (or at any rate people in photo
graphs), they m ake relatively little use of
constructs referring to their personality traits
or to their current em otional state. The fre
quency of use of other categories of construct,
e.g. those describing other people's activities,
physicalcharacteristicsr dress is not signifi
cantly related to affective flattening.
It m ight be argued that an explanation of
these results is that constructs in the personality
and em otional state' category are m ore diffi
cult' than other constructs and that their less
frequent use by the m ore flattened schizo
phrenics m ay m erely reflect the lower vocabu
lary level of these patients. H ow ever, this is not
so. In a study of 47 schizophrenics, M cPherson
Buckley (1969) found a non-significant
correlation betw een the use of these constructs
and scores on the M ill Hill Synonym Selection
test. M oreover, H arris M etcalfe (1956)
found no difference in the W echsler vocabulary
scores of three groups of schizophrenics, clinic
ally rated as showing gross',m o de ra te ' a nd
n o a ff ec ti ve f la tt en in g.
The correlations between the percentage use
m ade of personality and em otional state'
constructs and the ratings of each of the
clinicians considered separately were +0 .@
and +o@ 53, whereas that between the two
ratings was +0 44.The present procedure
can thus provide an estim ate of the severity of
a p atien t s affective flattening w hich agrees w ith
the rating of an experienced rater at least as
well as, and possibly better than, experienced
raters agree w ith on e an oth er.
However, failure to use personality and
p
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FLATTENING OF AFFECT AND PERSONAL CONSTRUCTS
42
em otional state constructs is not what leads
clinicians to regard a patient as being affectively
flattened. Rather it is because the patient does
use constructs of this type, but w ithout con
com itant affect, i.e. expression of emotion.
The explanation of this apparent paradox is
probably that there is an im portant difference
between the norm al clinical interview, which a
clinician uses to assess whether affective flat
tening is present, and the method of eliciting
constructs described in this study. In the latter
situation the patient is free to attend to and
em phasize, and conversely to ignore, any
features of the people in the photographs:
e.g. he can talk about their em otional state or
he can choose not to. The procedure therefore
assesses the patient s spontaneous use of con
structs of different sorts. In the clinical inter
view situation, on the other hand, it is the
clinician who usually determines what m ust
be discussed. The patient will therefore often
be required to refer to em otional topics and hence
to use constructs in the p er so n al it ya nd e m o
tional state category. W hether or not he
expresses appropriate em otion when using them
will determine whether he is assessed as showing
affective flattening. The present results show
that there is a close relationship betw een these
abnorm alities in the two situations, i.e. that it
is those patients who spontaneously tend not
to em ploy pe rso na lity a nd em otio nal state
constructs who also, in an interview situation,
use them without the concom itant expression
of em otion, and are therefore assessed as show ing
flatte nin g o f affec t.
Two points should be m ade regarding the
m ethod of content analysis used in the study.
The first is that the personal ityand emotiona l
state category is obviously a very broad one,
including as it does both constructs describing
current emotional state, e.g. happysad ,
a pp re he ns iv e ca lm a nd t ho se d es cr ib in g m or e
permanent personality traits, e.g. honestdis
honest , k indc rue l , c leverstup id . How
ever, the category could not be defined more
narrowly sinceinspectionof the resultsof the
content analysis show ed that affectively flattened
patientsfailedto use eithertype of construct
Secondly, as described above, in the scoring
m ethod em ployed in this study and Dixon s,
only the first use of each category of construct
was scored for each pair of photographs. How
ever, sim ilar results would have been obtained
even if the m ore time-consuming m ethod had
been used of counting every use m ade of each
category during each three-m inute period. In
a sam ple of i8 schizophrenics, Buckley (1969)
found a correlation of +0 8 o betw een the tw o
estim ates of the percentage frequency of use of
the p erso nality a nd e mo tio nal sta te ca te go ry .
The present findings, along with those of
Dixon, have im plications both for personal
construct theory and for theories of flattening
of affect. For exam ple, by dem onstrating the
existence of an abnorm ality confined to one
aspect of the construct system, they do not
support those theories w hich account for affec
tive flattening in terms of som e generalized
deficit such as retardation or a general reduction
in activity. On the other hand, they appear to
be com patible with an explanation in term s
of personal construct theory. These topics w ill
be discussed in detail in subsequent articles.
S UMMARY
A content analysis of the constructs used by
i8 schizophrenics to differentiate people in
photographs confirm ed D ixon s (@ 68) finding
that affective flattening, as rated clinically, is
significantly associated with a relative failure to
use constructs descriptive of personality and
em otional state. The use of other types of
construct is not related to the severity of affec
t ive f la tt ening.
AcxuowLp.noaienwrs
W e are grateful to D r. P . M . D ixon for assistance at all
stages of the investigation and to Dr. A . D. Forrest for per
m ission to see the patients. F. M . M . is supported by the
M ental Health Research Fund, whose help he gladly
acknowledges.
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