Tag: SANS: Scale for the Assessment of Negative Symptoms

Who is Nancy Coover Andreasen?

Published on by Andrew Marshall2 Comments

Introduction

Nancy Coover Andreasen (born 11 November 1938) is an American neuroscientist and neuropsychiatrist.

She currently holds the Andrew H. Woods Chair of Psychiatry at the Roy J. and Lucille A. Carver College of Medicine at the University of Iowa.

Early Life

Andreasen was born in Lincoln, Nebraska. She received her undergraduate degree from the University of Nebraska with majors in English, History, and Philosophy. She received a Ph.D. in English literature. She was a Professor of Renaissance Literature in the Department of English at the University of Iowa for 5 years. She published scholarly articles on John Donne and her first book in the field of Renaissance English literature: John Donne: Conservative Revolutionary

Clinical

A serious illness after the birth of her first daughter piqued Andreasen’s interest in medicine and biomedical research, and she decided to change careers to study medicine. She attended medical school at the University of Iowa College of Medicine, graduated in 1970 and completed her psychiatry residency in 1973. In 1974, she conducted the first modern empirical study of creativity that recognised some association between creativity and manic-depressive illness.

Early in her career she recognised that negative symptoms and associated cognitive impairments had more debilitating effects than psychotic symptoms, like delusions and hallucinations. While psychotic symptoms represent an exaggeration of normal brain/mind functions, negative symptoms represent a loss of normal functions, for example, alogia the loss of the ability to think and speak fluently, affective blunting the loss of the ability to express emotions, avolition, loss of the ability to initiate goal-directed activity, and anhedonia, loss of the ability to experience emotions. The papers describing these concepts have become citation classics, as determined by the Science Citation Index produced by the Institute for Scientific Information. Andreasen is largely responsible for development of the concept of negative symptoms in schizophrenia, having created the first widely used scales for rating the positive and negative symptoms of schizophrenia. She became one of the world’s foremost authorities on schizophrenia. She contributed to nosology and phenomenology by serving on the DSM III and DSM IV Task Forces, chairing the Schizophrenia Work Group for DSM IV.

Andreasen pioneered the application of neuroimaging techniques in major mental illnesses, and published the first quantitative study of magnetic resonance imaging (MRI) of brain abnormalities in schizophrenia. Andreasen became director of the Iowa Mental Health Clinical Research Centre and the Psychiatric Iowa Neuroimaging Consortium. She leads a multidisciplinary team working on three-dimensional image analysis techniques to integrate multi-modality imaging and on developing automated analysis of structural and functional imaging techniques. Software developed by this team is known as BRAINS (Brain Research: Analysis of Images, Networks, and Systems).

She resumed research about the neuroscience of creativity in the 2000s.

Honours

In 2000 President Clinton awarded her the National Medal of Science, America’s highest award for scientific achievement. This award was given for:

her pivotal contributions to the social and behavioral sciences, through the integrative study of mind, brain, and behavior, by joining behavioral science with the technologies of neuroscience and neuroimaging in order to understand mental processes such as memory and creativity, and mental illnesses such as schizophrenia.

She has received numerous other awards, including the Interbrew-Baillet-Latour Prize from the Belgian Academy of Science, the Lieber Schizophrenia Research Prize, and many awards from the American Psychiatric Association, including its Research Prize, the Judd Marmor Award, and the Distinguished Service Award. She was elected a Fellow of the American Academy of Arts and Sciences in 2002. She is a member of the National Academy of Medicine (formerly the Institute of Medicine of the National Academy of Sciences. She was elected to serve two terms on the governing council of the latter organisation. She chaired two Institute of Medicine/National Academy of Sciences Committees that published influential reports. She served as Editor-in-Chief of the American Journal of Psychiatry for 13 years. She is past president of the American Psychopathological Association and the Psychiatric Research Society. She was the founding Chair of the Neuroscience Section of the American Association for the Advancement of Science. She is a member of the Society for Neuroscience and on the Honorary International Editorial Advisory Board of the Mens Sana Monographs.

Experience of Sexism

She has spoken about her experiences of sexism. Early in her career she found that her articles were more likely to be accepted for publication when she used her initials instead of her first name.

Personal Life

She is the mother of two daughters. Suz Andreasen, who was a jewellry designer who lived in New York City, died from ovarian cancer on 10 November 2010. Robin Andreasen is a professor of Cognitive Science at the University of Delaware. She is married to Captain Terry Gwinn, a retired military officer who flew helicopter gunships for 3.5 tours during the Vietnam War.

Selected Bibliography

She has written three books for the general public:

  • “The Broken Brain: The Biological Revolution in Psychiatry” (1983).
  • “Brave New Brain: Conquering Mental Illness in the Era of the Genome” (2001).
  • “The Creating Brain: The Neuroscience of Genius”.

She authored, co-authored, or edited twelve other scholarly books and over 600 articles.

  • John Donne: Conservative Revolutionary. 1967.
  • Introductory Textbook of Psychiatry, Fourth Edition by Nancy C. Andreasen and Donald W. Black.
  • Understanding mental illness: A layman’s guide (Religion and medicine series).
  • Schizophrenia: From Mind to Molecule (American Psychopathological Association).
  • Brain Imaging: Applications in Psychiatry.

What is the Scale for the Assessment of Positive Symptoms?

Published on by Andrew Marshall2 Comments

Introduction

Within psychological testing, the Scale for the Assessment of Positive Symptoms (SAPS) is a rating scale to measure positive symptoms in schizophrenia.

The scale was developed by Nancy Andreasen and was first published in 1984. SAPS is split into 4 domains, and within each domain separate symptoms are rated from 0 (absent) to 5 (severe). The scale is closely linked to the Scale for the Assessment of Negative Symptoms (SANS) which was published a few years earlier.

Items

  • Hallucinations:
    • Auditory Hallucinations.
    • Voices Commenting.
    • Voices Conversing.
    • Somatic or Tactile Hallucinations.
    • Olfactory Hallucinations.
    • Visual Hallucinations.
    • Global Rating of Severity of Hallucinations.
  • Delusions:
    • Persecutory Delusions.
    • Delusions of Jealousy.
    • Delusions of Sin or Guilt.
    • Grandiose Delusions.
    • Religious Delusions.
    • Somatic Delusions.
    • Ideas and Delusions of Reference.
    • Delusions of Being Controlled.
    • Delusions of Mind Reading.
    • Thought Broadcasting.
    • Thought Insertion.
    • Thought Withdrawal.
    • Global Rating of Severity of Delusions.
  • Bizarre Behaviour:
    • Clothing and Appearance.
    • Social and Sexual Behaviour.
    • Aggressive and Agitated Behaviour.
    • Repetitive or Stereotyped Behaviour.
    • Global Rating of Severity of Bizarre Behaviour.
  • Positive Formal Thought Disorder:
    • Derailment (loose associations).
    • Tangentiality.
    • Incoherence (Word salad, Schizophasia).
    • Illogicality.
    • Circumstantiality.
    • Pressure of speech.
    • Distractible speech.
    • Clanging.
    • Global Rating of Positive Formal Thought Disorder.

What is the Scale for the Assessment of Negative Symptoms?

Published on by Andrew Marshall3 Comments

Introduction

The Scale for the Assessment of Negative Symptoms (SANS) is a rating scale that mental health professionals use to measure negative symptoms in schizophrenia.

Negative symptoms are those conspicuous by their absence – lack of concern for one’s appearance, and lack of language and communication skills, for example. Nancy Andreasen developed the scale and first published it in 1984. SANS splits assessment into five domains. Within each domain it rates separate symptoms from 0 (absent) to 5 (severe). The scale is closely linked to the Scale for the Assessment of Positive Symptoms (SAPS), which was published a few years later. These tools are available for clinicians and for research.

Background

Schizophrenia is a severe mental illness characterised by a range of behaviours, including hallucinations and delusions. Hallucinations refer to disorders involving the sensory systems, and are most often manifested as seeing or hearing things (e.g. voices) that do not exist. Delusions include odd or unusual beliefs such as grandiosity or paranoia. Both hallucinations and delusions are inconsistent with reality. Other symptoms of schizophrenia include bizarre behaviour, odd posture or movements, facial grimacing, loss of, or indifference to self-help skills (grooming, washing, toileting, feeding, etc.). Schizophrenia may also be marked by a host of social and communication deficits, such as social withdrawal, odd use of language, including excessive use of made up words (neologisms), incomprehensible combinations of words (word salad) or overall poverty of speech. The symptoms are often classified into two broad categories: positive and negative symptoms. Positive symptoms refer to those behaviours or condition that are present in schizophrenia but that are not present under typical conditions (hallucinations, delusions). Negative symptoms refer to those behaviours that are conspicuous because of their absence (grooming, language, communication). Several measures or rating scales have been developed to assess the positive and negative aspects of schizophrenia.

Items

  • Affective Flattening or Blunting:
    • Unchanging Facial Expression.
    • Decreased Spontaneous Movements.
    • Paucity of Expressive Gestures.
    • Poor Eye Contact.
    • Affective Non-responsivity.
    • Lack of Vocal Inflections.
    • Global Rating of Affective Flattening.
    • Inappropriate Affect.
  • Alogia:
    • Poverty of Speech.
    • Poverty of Content of Speech.
    • Blocking.
    • Increased Latency of Response.
    • Global Rating of Alogia.
  • Avolition – Apathy:
    • Grooming and Hygiene.
    • Impersistence at Work or School.
    • Physical Anergia.
    • Global Rating of Avolition – Apathy.
  • Anhedonia – Asociality:
    • Recreational Interests and Activities.
    • Sexual Interest and Activity.
    • Ability to Feel Intimacy and Closeness.
    • Relationships with Friends and Peers.
    • Global Rating of Anhedonia-Asociality.
  • Attention:
    • Social Inattentiveness.
    • Inattentiveness During Mental Status Testing.
    • Global Rating of Attention.
    • Scale for the Assessment of Positive Symptoms (SAPS).

What is Alogia?

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Introduction

In psychology, alogia (from Greek ἀ-, “without”, and λόγος, “speech” + New Latin -ia) is poor thinking inferred from speech and language usage.

There may be a general lack of additional, unprompted content seen in normal speech, so replies to questions may be brief and concrete, with less spontaneous speech. This is termed poverty of speech or laconic speech. The amount of speech may be normal but conveys little information because it is vague, empty, stereotyped, overconcrete, overabstract, or repetitive. This is termed poverty of content or poverty of content of speech. Under Scale for the Assessment of Negative Symptoms (SANS) used in clinical research, thought blocking is considered a part of alogia, and so is increased latency in response.

This condition is associated with schizophrenia, dementia, severe depression, and autism. As a symptom, it is commonly seen in patients suffering from schizophrenia and schizotypal personality disorder, and is traditionally considered a negative symptom. It can complicate psychotherapy severely because of the considerable difficulty in holding a fluent conversation.

The alternative meaning of alogia is inability to speak because of dysfunction in the central nervous system, found in mental deficiency and dementia. In this sense, the word is synonymous with aphasia, and in less severe form, it is sometimes called dyslogia.

Characteristics

Alogia may be on a continuum with normal behaviours. People without mental illness may have it occasionally including when fatigued or disinhibited, when writers use language creatively, when people in certain disciplines – such as politicians, administrators, philosophers, ministers, and scientists – use language pedantically, or in people with intelligence or little education. Hence, deciding if an individual has alogia depends on contextual clues. Is the person in control? Can the person moderate the effect if asked to be specific or concise? Is it better with another topic? Are there other significant symptoms?

Alogia is characterised by a lack of speech, often caused by a disruption in the thought process. Usually, an injury to the left side of the brain may cause alogia to appear in an individual. While in conversation, alogic patients will reply very sparsely and their answers to questions will lack spontaneous content; sometimes, they will even fail to answer at all. Their responses will be brief, generally only appearing as a response to a question or prompt.

Apart from the lack of content in a reply, the manner in which the person delivers the reply is affected as well. Patients affected by alogia will often slur their responses, and not pronounce the consonants as clearly as usual. The few words spoken usually trail off into a whisper, or are just ended by the second syllable. Studies have shown a correlation between alogic ratings in individuals and the amount and duration of pauses in their speech when responding to a series of questions posed by the researcher. The inability to speak stems from a deeper mental inability that causes alogic patients to have difficulty grasping the right words mentally, as well as formulating their thoughts. A study investigating alogiacs and their results on the category fluency task showed that people with schizophrenia who exhibit alogia display a more disorganised semantic memory than controls. While both groups produced the same number of words, the words produced by people with schizophrenia were much more disorderly and the results of cluster analysis revealed bizarre coherence in the alogiac group.

If the condition is assessed using a language other than the individual’s primary language, the medical professional needs to make sure that the problem is not from language barriers.

This condition is associated with schizophrenia, dementia, and severe depression.

Example

The following table shows an example of “poverty of speech” which shows replies to questions that are brief and concrete, with a reduction in spontaneous speech:

Poverty of SpeechNormal Speech
Q: Do you have any children?
A: Yes.		Q: Do you have any children?
A: Yes, a boy and a girl.
Q: How many?
A: Two.		Q: How old are they?
A: Edmond is sixteen and Alice is six.
Q: How old are they?
A: Six and sixteen.
Q: Are they boys or girls?
A: One of each.
Q: Who is the sixteen-year-old?
A: The boy.
Q: What is his name?
A: Edmond.
Q: And the girl’s?
A: Alice.

The following example of “poverty of content of speech” is a response from a patient when asked why he was in a hospital. Speech is vague, conveys little information, but is not grossly incoherent and the amount of speech is not reduced. “I often contemplate—it is a general stance of the world—it is a tendency which varies from time to time—it defines things more than others—it is in the nature of habit—this is what I would like to say to explain everything.”

Causes

Alogia can be brought on by frontostriatal dysfunction which causes degradation of the semantic store, the centre located in the temporal lobe that processes meaning in language. A subgroup of chronic schizophrenia patients in a word generation experiment generated fewer words than the unaffected subjects and had limited lexicons, evidence of the weakening of the semantic store. Another study found that when given the task of naming items in a category, schizophrenia patients displayed a great struggle but improved significantly when experimenters employed a second stimulus to guide behaviour unconsciously. This conclusion was similar to results produced from patients with Huntington’s and Parkinson’s disease, ailments which also involve frontostriatal dysfunction.

Treatment

Medical studies conclude that certain adjunctive drugs effectively palliate the negative symptoms of schizophrenia, mainly alogia. In one study, Maprotiline produced the greatest reduction in alogia symptoms with severity reduction in 50% of patients (out of 10). Of the negative symptoms of schizophrenia, alogia had the second best responsiveness to the drugs, surpassed only by attention deficiency. D-amphetamine is another drug that has been tested on people with schizophrenia and found success in alleviating negative symptoms. This treatment, however, has not been developed greatly as it seems to have adverse effects on other aspects of schizophrenia such as increasing the severity of positive symptoms.

Relation to Schizophrenia

Although alogia is found as a symptom in a variety of health disorders, it is most commonly found as a negative symptom of schizophrenia.

Previous studies and analyses conclude that at least three factors are needed to cover both the positive and negative symptoms of schizophrenia; the three are: psychotic, disorganization, and negative symptom factors. Studies suggest that an inappropriate affect is strongly associated with bizarre behaviour and positive formal thought disorder on a disorganisation factor; attention impairment correlates significantly with psychotic, disorganization, and negative symptom factors. Alogia contains both positive and negative symptoms, with the poverty of content of speech as the disorganization factor, and poverty of speech, response latency, and thought blocking as the negative symptom factors.

Alogia is a major diagnostic sign of schizophrenia, when organic mental disorders have been excluded.

In schizophrenia, negative symptoms including flattening of affect, avolition, and alogia are responsible for the considerable morbidity of the disease compared with other psychotic disorders. Negative symptoms are common in the prodromal and residual phases of the disease and can be severe. During the first year, negative symptoms can progress, especially alogia, which may start off from a relatively low rate. Within 2 years, up to 25% of patients will have significant negative symptoms. Psychotic symptoms tend to diminish as the individuals age, but negative symptoms tend to persist. Prominent negative symptoms at disease onset, including alogia, are good predictors of worse outcomes.

Negative symptoms can arise in the presence of other psychiatric symptoms. Positive symptoms are a common cause of apathy, social withdrawal, and alogia. Secondary causes of negative symptoms, such as depression and demoralisation, often remit within a year, which helps distinguishing them from primary negative symptoms. Symptoms that don’t diminish over a year with medications should be reconsidered as possible primary negative symptoms.