symptomatology and the prediction of social skills acquisition in schizophrenia

Schizophrenia Research, 8 (1992) 59-68

0 1992 Elsevier Science Publishers B.V. All rights reserved 0920-9964/92/$05.00

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SCHIZO 00252

Symptomatology and the prediction of social skills acquisition in schizophrenia

Kim T. Mueser, Mary H. Kosmidis and Margaret D. Sayers Department qf Psychiatr_v, Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute. Philadelphia, PA, USA

(Received 17 January 1992, revised received 27 April 1992, accepted 1 I May 1992)

The relationship between patient symptomatology and the acquisition of social skills during an inpatient social skills training program, and the maintenance of skills at a one-month followup, were examined in a sample of recently hospitalized schizophrenic and schizoaffective disorder patients. Subtypes of patients with enduring Thought Disorder (vs. no enduring Thought Disorder) or enduring Anergia (vs. no enduring Anergia) on the BPRS during the treatment period were compared in their response to the social skills training intervention. Patients with enduring Thought Disorder acquired skills at the same rate as patients without Thought Disorder, but were unable to retain their skills at followup, in contrast to their counter- parts. Enduring Anergia was not related to either the acquisition or maintenance of social skills. The results were unaffected when memory was statistically controlled. The findings suggest that patient symptomatology may be an important factor mediating the efficacy of social skills training interventions.

Key words: Schizoaffective disorder; Social skills training; Symptomatology; Thought disorder: (Schizophrenia)

INTRODUCTION

Social skills training has emerged in recent years as one of the most widely practiced psychosocial interventions for schizophrenia (Donahoe and Driesenga, 1988; Benton and Schroeder, 1990). As the popularity of this treatment approach has grown, more researchers have addressed the effects of social skills training on the course and outcome of schizophrenia. Several controlled studies have provided support for the efficacy of skills training for schizophrenic patients (Bellack et al., 1984; Hogarty et al., 1986, 1987, 1991; Liberman et al., 1986). While these studies have their methodologi- cal limitations (Bellack and Mueser, 1990) they suggest that social skills training is a promising intervention for schizophrenia.

Although there is some evidence supporting the

Correspondence to: K.T. Mueser, Medical College of Pennsyl- vania at EPPI, 3200 Henry Ave., Philadelphia, PA 19129, USA.

clinical utility of social skills training, not all patients appear to benefit from this treatment. For example, Hogarty et al, (1987) reported that 42% of their patients who received social skills training over a 2-year period relapsed, compared to the

67% relapse rate for patients who received antipsy- chotic medication only. Similar cumulative 2-year relapse rates were reported by Liberman et al. (1986) for their patients who received social skills training. Thus far, research on social skills training has not addressed the characteristics of patients who respond to skills training compared to non- responsive patients. The identification of predictors

of response to social learning interventions has important implications for both referring patients to effective psychosocial interventions and refining existing treatment strategies. Furthermore, under- standing patient characteristics related to treatment response may provide clues regarding factors that influence the course of illness and mechanisms responsible for the effects of the treatment.

The current study was conducted in order to

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explore the relationship between individual patient characteristics and the acquisition of social skills during a brief inpatient social skills training intervention and at a one-month followup assessment. In previous reports from this project we have examined the prediction of improvement in social skills during training from patient demographic variables and history of the illness (Douglas and Mueser, 1990) as well as memory and pretreatment symptomatology (Mueser et al., 1991 b). The general pattern of results indicated that the social skills training group resulted in improvements in social skill independent of either demographic or chronicity variables. Patients with poor memory tended to have more pronounced skill deficits and acquired social skills at a slower rate, but maintained improvements in skill at the followup assessment (Mueser et al., 1991b). Pretreat- ment symptomatology, on the other hand, was not related to changes in skill.

The lack of a relationship between symptoms and response to social skills training may be due, in part, to the use of a single assessment of psychopathology, which may be a poor reflection of a patient’s symptomatology over time. The episodic, erratic course of symptoms in schizophrenia suggests that cross-sectional assessments of symptomatology may be of limited use in predic- ting outcome or response to treatment. For example, Carpenter has suggested that more meaningful subgroups of schizophrenia can be identified on the basis of longitudinal assessments of negative symptoms (i.e. the deficit syndrome; Carpenter et al., 1988). In line with this hypothesis, in a previous study we found stronger clinical correlates when schizophrenic patients were subgrouped based on enduring negative or positive symptoms than when a single assessment was used for sub- typing (Mueser et al., 1991~).

Therefore, the present analysis was conducted in order to examine the relationship between subgroups of patients with enduring symptoms and response to social skills training. Specifically, we evaluated whether patients whose negative or positive symptoms endured over the training period acquired or maintained skills at a different rate than patients who did not have enduring symptoms. We chose to focus on the relationship of two symptom clusters on the Brief Psychiatric Rating Scale (Overall and Gorham, 1962) Anergia

and Thought Disorder, because these symptoms represent common negative and positive symptoms of schizophrenia that have been the focus of extensive research over the past decade (Fenton and McGlashan, 1991; McGlashan and Fenton, 1992). Change in Thought Disorder on the BPRS, such as the emergence or worsening of hallucinations or delusions, has frequently been used as an outcome measure in studies examining the effect of interventions on the course of schizophrenia (e.g., Liberman, Mueser, and Wallace, 1986). The Anergia subscale on the BPRS, including symptoms such as blunted affect and motor retardation, has been found to be highly correlated with the Scale for the Assessment of Negative Symptoms (Andreasen, 1982) in a mixed sample of schizophrenic in/outpatients (Thiemann, Csernansky, and Berger, 1987) and is elevated in patients with enduring ‘primary’ negative symptoms (i.e. the deficit syndrome; Carpenter, Heinrichs, and Wagman, 1988). For these reasons, patients with high levels of Thought Disorder or Anergia are described in the present study as having prominent positive or negative symptoms.

METHODS

The subjects were 33 schizophrenic and 21 schizoaffective disorder inpatients who had recently been admitted to Eastern Pennsylvania Psychiatric Insti- tute for the treatment of an acute symptom exacerbation. Patients were recruited from an inpatient social skills training program. Patients included in the study were between the ages of 18 and 59, had no known organic impairment, and were not alcohol or substance dependent upon admission to the hospital. Psychiatric diagnoses for 58% of the patients were based on the Struc- tured Clinical Interview for DSM-IIIR (Spitzer et al., 1990). For the remaining patients the dis- charge diagnosis was used; these diagnoses were established by the attending psychiatrist and resi- dent using DSM-IIIR criteria. All patients were treated with psychotropic medications, mainly antipsychotics, anticholinergics, lithium, and anti- depressants. Patients provided informed consent and were paid for participating in the assessment procedures, which were conducted prior to social

skills training, at posttreatment, and at a one- month followup.

Of 54 patients enrolled in the treatment and assessment protocol, 18 (33%) were either dis- charged from the hospital before they were able to participate in at least two treatment sessions or were unavailable for the posttreatment assessment. These 18 patients did not differ from the study completers on demographic, diagnostic, or clinical characteristics, as determined by r-tests and chi- square tests. The characteristics of the final study sample of 36 patients are summarized in Table 1.

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Social skills training All patients were referred by their inpatient treatment teams to the social skills training group based on the presence of social skill deficits and problems with interpersonal conflicts. Patients began to participate in the group when their acute symptoms had been partially stabilized pharmacologically, an average of two weeks following admission to the hospital. Most patients continued to be symptom- atic throughout the two-week skills training period.

The social skills training group was conducted by two leaders, a clinical psychology intern and

TABLE 1

Demographic and clinical characteristics of study sample

Variables Enduring symptom subgroups”

Total group (n = 36)

No TDb TDb No A A (n= 13) (n = 22) (n = 26) (n = IO)

Age

Years of education

Prior hospitalizations

Length of current hospitalization

(Days) Days in hospital before first group

Number of training sessions attended

Wechsler scale memory

WQ) Gender

Female

Male Race

Black

Caucasian

Asian Marital status

Never married

Married/Previously married Legal staus

Voluntary admission Involuntary admission

Diagnosis

Schizophrenia

Schizoaffective disorder

34.08 37.15 32.91 33.81 34.80

(9.89) (5.81) (10.85) (9.11) (11.30)

11.24 11.42 11.21 11.86 9.63

(3.86) (3.94) (3.21) (2.13) (5.63)

5.47 6.46 4.82 5.81 4.60

(1.83) (1.56) (2.01) (1.83) (2.22)

43.45 44.77 43.00 38.35 56.70

(19.32) (22.50) (20.41) (16.14) (25.73)

15.16 11.62 14.05 14.38 17.20

(10.01) (9.83) (10.59) (8.42) (14.30)

5.00 5.08 4.90 4.92 5.22

(0.93) (1.12) (0.83) (1.02) (0.67)

86.90 92.75 83.68 86.68 87.60 (18.78) (16.09) (19.51) (19.63) (15.72)

16 8 8 15 1 20 5 14 II 9

18 7 11 13 5

17 6 10 12 5

1 0 1 1 0

27 5 18 17 7

9 8 3 9 2

22 7 16 17 6 14 6 6 9 3

21 7 13 14 7

15 6 9 12 3

“TD = Thought Disorder; A = Anergia.

“One patient was dropped from the Thought Disorder-No Thought Disorder Comparison because of a missing BPRS rating on Conceptual Disorganization at the 2-week post-treatment assessment.

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another professional (nurse, occupational thera- pist, research assistant, psychologist, or psychiatrist), and included five to ten patients. Group sessions lasted one hour and were conducted three times per week, with patients remaining in the group for a two-week period. Prior research conducted in our clinic has indicated that schizophrenics often lack interpersonal skills for managing conflict situations (Bellack et al., 1990b). There- fore, the group focused on teaching two skills for resolving conflicts: ‘expressing negative feelings’ and ‘compromise and negotiation.’ Three consecu- tive sessions during one week were spent teaching one skill, followed by three more sessions the next week teaching the other skill. Patients could begin participating in the group only at the beginning of either week, regardless of which of the two skills was being taught.

Social skills training was conducted following the principles outlined by Bellack et al. (1984) and Liberman et al. (1989). To facilitate teaching of the two skills, each was divided into several component steps. For ‘expressing negative feelings’ these steps included: speak with a firm voice tone; tell the person what they did that upset you; tell the person how it made you feel; and tell how this could be prevented from happening in the future. For ‘compromise and negotiation’ components included: explain your viewpoint; listen to the other person’s viewpoint and repeat back what you heard; and suggest a compromise. Posters were used to display the steps of the skill being taught. The social skills training procedures employed in the conflict resolution group are described in greater detail elsewhere (Douglas and

Mueser, 1990).

Sociul skills assessment Social skills were assessed using a role play test which was conducted prior to the first treatment session, after the two week social skills training intervention, and at a one month followup, at which point patients were again living in the community. Performance of psychiatric patients on role play tests has been found to correlate significantly with social skill during more naturalis- tic social interactions (e.g. videotaped family prob- lem solving discussions; Bellack et al., 1990a) and is sensitive to the effects of social skills training (Bellack, 1983).

Patients participated in a total of eight role play situations: two practice situations, three situations

to assess ability to express negative feelings and

three situations to assess ability to compromise with another person. Each scenario began with the

research assistant reading to the patient a brief description of the situation. Following the descrip-

tion of the scenario, the research assistant initiated

the role play, which was then followed by three exchanges between the research assistant and the patient. Responses by the research assistant were scripted in advance based on pilot work. Patients

received no training in these specific situations

during the social skills training groups. Role plays

were audiotaped and later rated in randomized

order.

Ratings qf social skill

The two skills taught in the social skills training

groups, expressing negative feelings and compromise and negotiation, can be subsumed under the broad class of assertive behaviors since they both

involve expressing oneself in direct, honest, and appropriate ways and serve as a means toward assuring one’s personal rights (Lange and Jaku-

bowski, 1976). Therefore, a global rating of assertiveness was made, as well as ratings of the verbal components of each skill. Assertiveness was rated

on a 5-point likert scale ranging from 1 (very unassertive) to 5 (very assertive). Binary ratings

(absent/present) were made for each of the components taught (see Social skills training section), except for two components (‘repeat back what you heard’ and ‘tell the person how it made you feel’), which were rated on a three-point scale (absent/

partly present/present). These ratings were summed for each role play to obtain a total score of number of components performed in the role play. Assertiveness and component ratings were averaged across the six role plays to form two measures of social skill for each assessment. Three research assistants who were unfamiliar with the patients made the social skill ratings, with 20% of the assessments (drawn randomly over the project)

rated by a second rater. Pearson correlation coefficients between different pairs of raters were moderate to high, ranging from 0.65 to 0.89, indicating satisfactory interrater reliability.

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Memory assessment Memory was assessed at pretreatment using the Wechsler Memory Scale (WMS; Wechsler, 1945) a widely used measure of memory in both clinical and non-clinical populations. The Wechsler Mem- ory Quotient was used as an index of overall memory in the present study.

Symptomatology assessment

Symptoms were assessed at pretreatment, posttreatment, and at the one month followup by interviewers using the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham, 1963). The BPRS consists of five subscales, including Anxiety- Depression (Somatic Concern, Anxiety, Guilt Feelings, Depressive Mood), Thought Disorder (Conceptual Disorganization, Grandiosity, Hallu- cinatory Behavior, Unusual Thought Content), Anergia (Emotional Withdrawal, Motor Retard- ation, Blunted Affect, Disorientation), Activation (Tension, Mannerisms and Posturing, Excitement), and Hostility (Hostility, Suspiciousness, Uncoop- erativeness). Interrater reliabilities were satisfactory for all the BPRS subscales, with Pearson correlation coefficients ranging from 0.69 to 0.92.

RESULTS

Enduring positive and negative symptom subgroups In order to identify patients with enduring positive and negative symptoms, we used pretreatment and posttreatment ratings on the items of the BPRS subscales for Thought Disorder and Anergia. We chose to examine patients with enduring symptoms from pretreatment to posttreatment, rather than from pretreatment to followup, because we were interested in the relationship between patient symptomatology during social skills training and response to this intervention. Since previous research in our clinic on both inpatients and outpatients has indicated that severe negative and positive symptoms frequently co-exist (Mueser et al., in press), two subgroups of patients were formed using the Thought Disorder items (positive symptom group vs no positive symptoms group) and two subgroups were formed independently using the Anergia items (negative symptom group vs no negative symptoms group).

Patients were subtyped as having enduring posi-

tive symptoms if they had at least one Thought Disorder symptom of moderate or greater severity at both the pretreatment and posttreatment assessments (the same symptom did not have to be present at both assessments). The same criteria were applied to subtype patients into enduring negative symptom subgroups based on the Anergia subscale items. These criteria yielded 22 patients in the enduring positive symptom subgroup (and 13 patients in the non-positive subgroup) and 10 patients in the enduring negative symptom subgroup (and 26 patients in the non-negative subgroup). One patient was dropped from the positive symptom subgroup because of missing BPRS data. Repeated measures ANOVAs comparing patients with and without enduring positive symptoms on Thought Disorder at baseline and posttreatment, and comparing patients with and without enduring negative symptoms on Anergia at baseline and post-treatment were both highly significant (ps < 0.005). A chi-square test on the negative and positive symptom subtypes was not significant (chi- square( 1) = 0.00, n.s.), indicating no relationship between the two sets of subtypes.

To evaluate whether the subgroups of patients differed in demographic characteristics or history of the illness, t-tests (for continuous variables) and chi-square tests (for categorical variables) were calculated comparing the positive to the non-positive groups, and the negative to the non-negative groups. Only one comparison was significant: patients who had enduring positive

symptoms were less likely to have been married than patients without enduring positive symptoms (chi-square( 1) = 6.17, p < 0.02). See Table 1 for descriptive information for patients in the different subgroups.

Improvement in social skills To determine whether social skills improved over the two-week training period and at the one-month followup, we performed a repeated measures multivariate analyses of variance (MANOVA) on the Global Assertiveness and Component Social Skill ratings. The multivariate time effect was significant (F(2,35) = 4.00, p < 0.03). The univariate time effects were significant for both Assertiveness and Component ratings (Fs(2,72) = 3.19,3.68, ps < 0.05, 0.03) indicating improvements in skill over the

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training and followup period. Trend analyses indicated that improvements over time were linear.

D@erences in social skill acquisition

Repeated measures MANOVAs were also conducted to evaluate whether patients with enduring positive or negative symptoms differed in their acquisition or maintanence of social skills. Because l-month followup data were available on only 26 of the 36 patients, separate MANOVAs were performed comparing pretreatment social skill with posttreatment skill to assess differences in social skill acquisition, and posttreatment skill with followup skill to assess differences in social skill maintenance. Two MANOVAs were performed comparing the Thought Disorder and No Thought Disorder groups, and two MANOVAs comparing the Anergia and No Anergia groups. For each MANOVA, we examined the main effects for time and group and the group by time interaction. The interaction is a test of whether the two groups differ in their rate of skill change over time.

The MANOVA comparing the Thought Disor- der groups at pretreatment and posttreatment resulted in a significant time effect (F(2,29) = 3.45, p < 0.05) indicating improvement. Neither the main effect for group (F(2,29) = 0.14, ns.), nor the group by time interaction (F(2,29)=0.33, n.s.) were significant. Thus, all patients improved in social skill from pretreatment to posttreatment, with enduring thought disorder patients improving at a similar rate to non-thought disorder patients. The MANOVA comparing the Thought Disorder groups at posttreatment and followup revealed a significant group by time interaction (F(2,21)= 4.10, p < 0.04) but not a main effect for time (F(2,210=0.23, n.s.) or group (F(2,21)=0.51, ns.). The group by time interaction was significant for both social skill component ratings and overall assertiveness (Fs(1,31)= 11.61, 4.95, ps=O.O02, 0.04). Patients with enduring thought disorder had similar levels of social skill after the 2-week social skills training group to patients without enduring thought disorder. However, at the l-month followup the thought disordered patients had deteriorated to pretreatment skill levels, whereas the other patients had retained their skill gains. The social skills ratings at pretreatment, posttreatment, and at followup for the Thought Disorder groups are displayed in Table 2.

Similar MANOVAs comparing the social skill acquisition and maintenance of patients with and without enduring Anergia were not significant. The main group effect for Anergia was not significant for either the MANOVA on social skill at pretreatment and posttreatment (F(2,44)= 1.84, n.s.), or the MANOVA on skill at posttreatment and followup (F(2,30) = 1.69, n.s.), nor were the group by time interactions significant for either MANOVA (F(2,44)=0.42, F(2,30)=0.50, n.s.). Thus, high levels of enduring Anergia were not related to either overall differences in social skill or to differential rates of skill acquisition or maintenance. The skill ratings for patients with and without enduring Anergia are displayed in Table 3.

Because we found that pretreatment memory was related to pretreatment social skill and rate of skill acquisition in our previous analysis of these data (Mueser et al., 1991b), we conducted additional analyses controlling for memory. Pretreat- ment memory was statistically controlled by regressing the Wechsler Memory Quotient on the assertiveness and social skill component ratings at each of the three assessments, and using the residual skill ratings as dependent variables in the subsequent analyses. Thus, the residual social skill scores reflected skill after statistically adjusting for pretreatment memory. Four MANOVAs were performed, as described above, comparing the Thought Disorder and No Thought Disorder groups, and the Anergia and No Anergia groups at pretreatment and posttreatment, and at posttreatment and followup. Consistent with the MANOVAs that did not control for memory, none of these four MANOVAs yielded a significant main effect for group. Also similar to the previous analyses, the multivariate effect for the group by time interaction comparing the Thought Disorder and No Thought Disorder groups at posttreatment and followup was significant (F(2,20)= 3.79, p= 0.04). The ANOVA on social skill components was highly significant (F(l,30) = 9.28, p = 0.005) but not for assertiveness (F(1,30)= 2.53, n.s.). As before, patients with enduring Thought Disorder deteriorated in the components of social skill from posttreatment to followup, whereas the other patients retained their improvements in social skill. The group by time interaction was not significant for the MANOVA on Thought Disorder groups at pretreatment and posttreatment, nor were inter-

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TABLE 2

Meun (and SD) of social skill ratings by Enduring Thoughi Disorder subgroup

Global assertivenessa

Pretreatment

Post-treatment

Followup

Social skills componentsb Pretreatment

Post-treatment

Followup

No Thought Disorder

2.61 (0.99)

3.15 (1.10)

3.59 (0.99)

1.74 (0.59)

2.02 (0.67)

2.41 (0.61)

Enduring Thought Disorder

2.89 (1.11)

3.22 (1.09)

3.03 (1.07)

1.87 (0.52)

2.16 (0.65)

1.85 (0.61)

“High scores denote superior skill. Possible range: l-5.

‘High scores denote superior skill. Possible range: O-3.5.

TABLE 3 DISCUSSION Mean (and SD) of social skill ratings by enduring anergia

subgroups

No anergia Anergia

Global assertivenes?

Pretreatment 2.88 (1.14) 2.73 (1.10)

Post-treatment 3.13 (1.08) 3.46 (1.05)

Followup 3.24 (1.01) 3.21 (1.20)

Social skills componentsb

Pretreatment 1.90 (0.61) 1.69 (0.51)

Post-treatment 2.14 (0.67) 2.04 (0.61)

Followup 2.09 (0.66) 2.03 (0.67)

“High scores denote superior skill. Possible range: l-5.

‘High scores denote superior skill. Possible range: O-3.5.

actions significant for either of the MANOVAs on the Anergia groups.

Last, to compare the symptoms of patients with enduring Thought Disorder to patients without enduring Thought Disorder, we performed a repeated measures MANOVA on the other four subscales of the BPRS (Anxiety-Depression, Aner- gia, Activation, Hostility) with pretreatment, posttreatment, and followup scores as the repeated measures. The multivariate effects were nonsigni- ficant for group (F(4,17) = 2.00, n.s.) and the group by time interaction (F(8,13) = 1.07, n.s.), although the time effect approached significance (F(8,13) = 2.48, p = 0.07). There was a tendency for symptoms to improve over the three assessments. The mean symptom rating for both groups are displayed in Table 4.

A clear pattern of results emerged from the analyses examining the acquisition and maintenance of social skills as a function of the enduring positive and negative symptom subtypes. Neither enduring positive nor negative symptoms were related to the rate of social skill acquisition from the pretreatment assessment to posttreatment. Patients with enduring positive symptoms during training, however, failed to retain their skill improvements at the one-month followup, whereas patients without these symptoms had maintained their gains. Sim- ilar to the patients without enduring positive symp-

toms, both patients with and patients without enduring negative symptoms also retained their

skills at followup. When pretreatment memory was

statistically controlled, an identical pattern of results was obtained.

The differential responsiveness of patients with enduring positive symptoms may have important implications for the provision of social skills train-

ing to schizophrenics. The relatively brief duration of the social skills training program (2 weeks) may have resulted in insufficient learning for those

patients with enduring thought disorder. These patients might clinically benefit from a more extensive training program provided over a longer period of time. Whether patients with enduring

psychotic symptoms are capable of retaining social skills after a long-term intervention is an unre- solved question. It is possible that some patients

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TABLE 4

Means (und SD) of hrkf psychiairic rating scale (BPRS) suhscule .scmw hy Enduring Thought Disorder

Thought disorder

Anxiety-Depression

Anergia

Activation

Hostility

No Thought Disorder

Prr Post

8.18 8.09

(2.86) (4.1 I) 7.91 9.36

(2.02) (3.61) 7.18 5.64

(3.95) (1.80)

4.64 3.73

(2.50) (1.42) 8.00 6.59

(2.93) (2.78)

Followup

5.09

(4.35) 9.88

(3.18) 4.88

(0.99)

2.45

(1.69) 5.56

(1.68)

Thought Disorder

Pw PO.Sf

13.05 12.67

(3.97) (3.58) 13.10 Il.10

(4.56) (4.58) 7.71 6.14

(3.57) (2.73)

4.95 5.38

(1.94) (2.04) 7.00 8.00

(2.86) (3.55)

Follonup

6.00

(6.99)

8.82

(3.66)

7.64

(3.47)

3.05

(3.58) 6.64

(4.03)

with these chronic symptoms may require ongoing, rather than time-limited social learning treatment. The purpose of such ongoing treatment would be to prompt the patient to use the targeted skills in order to compensate for problems with skill retention.

It should be noted here that the term “enduring” to describe symptoms that were present at two assessments conducted over a 2-week period does not imply that these symptoms are necessarily long-standing in these patients. Studies of enduring negative or deficit symptoms have usually assessed patients over a longer period of time, such as one year or more (Carpenter, Heinrichs, and Wagman, 1988; Mueser et al., 1991c). However, the use of two, rather than one assessment of symptoms in the present study appears to be fruitful in obtaining a more stable index of patients’ symptomatology over the course of the social skills training intervention.

The finding that schizophrenic patients with enduring thought disorder were unable to retain their skills at followup, unlike other groups of schizophrenic patients, suggests that psychotic symptoms may interfere with cognitive processes related to skill retention. This interference does not appear to be due to problems in memory, since we obtained the same results when we controlled for memory in the analyses. Indeed, patients who experience chronic positive symptoms frequently report a wide range of problems, including dis- tractability, as well as negative affective states such as anxiety, depression, and anger (Carr, 1988;

Falloon and Talbot, 1981) any of which could interfere with the retention of social skills. If this is the case, these patients may require training in strategies to help them cope with their positive symptoms first (Piatkowska and Farnill, 1992; Tarrier, 1992). The development of such coping techniques may facilitate their response to social skills training.

All groups in this study improved on the targeted social skills within the two-week intervention. A comparison of groups on BPRS subscales (Anxi- ety-Depression, Anergia, Activation, and Hostil- ity) at pretreatment, posttreatment, and followup assessments yielded no significant differences on symptoms between the enduring and non-enduring Thought Disorder groups. Since both groups showed only a non-significant trend towards improvement in symptoms over time, improvements in social skills could not be explained on the basis of symptom change alone. In addition, previous research conducted in our clinic has docu- mented that in the absence of skills training, social skills are relatively stable over time, even in the year following a symptom exacerbation (Mueser et al., 1991a).

Several limitations of the current study need to be acknowledged. The duration of the social skills intervention was relatively brief and addressed a narrow range of skills, although some learning appeared to take place. Also, a no-treatment control group was not available, because the intervention was provided as a clinical service to all eligible patients. However, as discussed above, the

improvements in social skills appear to rellect learning, rather than changes in symptomatology. Two additional limitations concern the measures we employed. Structured clinical interviews for diagnosis were available for only 58% of the sample, raising some questions as to the accuracy of the diagnoses made by patients’ treatment teams. Last, standardized assessments of social functioning, such as the Social Adjustment Scale- II (Schooler et al., 1979) were not available. Future research needs to evaluate the relationship between symptomatology and clinical response to social skills training provided on a longer-term outpatient basis and with a longer followup period. The present study makes a step towards under- standing which patients may benefit most from social skills training and suggests that subtypes of patients with enduring psychotic symptoms may be less capable of retaining targeted social skills.

ACKNOWLEDGEMENTS

This research was supported by a grant from National Alliance for Research in Schizophrenia

and Depression (NARSAD) and NIMH grants MH-38636, MH-39998, and MH-41577. Apprecia- tion is extended to Ruthanne Vendy for manuscript preparation and the following persons for their help in the project: Julie Agresta, M.A., Jill Belchic, B.A., Alan Bellack, Ph.D., Melanie Bennett, B.A., Howard Berenbaum, Ph.D., Jack Blanchard, Ph.D., Erika Brady, B.A., Guila Glosser, Ph.D., Elkhonon Goldberg, Ph.D., Kate Hamblin, R.N., Debra Hope, Ph.D., Kimmy Kee, B.A., Nancy McGuire, B.A., Abby Michelski, B.A., Ken Podell, Ph.D., Dan Ragland, Ph.D., Vivian Rowan, Ph.D., Seven Sayers, Ph.D. Eileen Wade, Ph.D.

Edward Shearin, Ph.D., and

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