VOL. 12, NO. 3, 1986 Evaluating Bizarre-Idiosyncratic Thinking: AComprehensive Index ofPositive Thought Disorder

497

by Joanne T. Marengo,Martin Harrow,//on© LanlnKetterlng,and Arnold Wilson

Abstract

A summary of our method ofassessing positive thought disorder,or bizarre-idiosyncratic thinking,from two short verbal tests ispresented. This measure provides forstandardized thought disorder assess-ments of: (1) the overall presenceand severity of thought disorder, and(2) the type of disordered thinkingshown. A definition and examples ofbizarre-idiosyncratic thinking areprovided, along with information onthe reliability and validity of thescoring system. A method ofestablishing subject groups based onthe severity of positive thoughtdisorder also is presented—rangingfrom no thought disorder, toabnormal thinking, to severe formalthought disorder. This measure hasbeen used to assess longitudinalchanges in thought disordersymptoms over time and to evaluaterelationships between thoughtdisorder, other aspects of psycho-pathology (such as delusions), andadjustment in other areas offunctioning across diagnostic groups.

Investigators have attempted toassess disordered thinking from anumber of different viewpoints (Bussand Lang 1965; Maher, McKean, andMcLaughlin 1966; Gottschalk andGleser 1969; Payne 1970; Maher1972; Chapman and Chapman 1973;Andreasen 1979a, 1979b; Chapman1979; Johnston and Holzman 1979).Much of our own approach tostudying positive thought disorderhas revolved around the construct ofbizarre-idiosyncratic speech andthinking (Harrow and Quinlan 1985;Marengo and Harrow 1985). Acomprehensive assessment of bizarre-idiosyncratic thinking involves anevaluation of most of the majortypes of phenomena usually includedunder the term "formal positive

thought disorder" (Fish 1962;Andreasen and Olsen 1982).

Since the concept of positivethought disorder deals with a poten-tially important symptom of distur-bance, we have focused on thisfeature as one major aspect of along-term, multidisciplinary researchproject studying the course ofpsychosis and adjustment in schizo-phrenia (Chicago Followup Study,Michael Reese Hospital and MedicalCenter, Chicago, Illinois). In thiscontext, our studies of positivethought disorder have been primarilydirected toward answering thefollowing research questions: (1) Isthought disorder characteristic onlyof schizophrenia, or do otherpsychotic and nonpsychotic popula-tions also demonstrate this behavior7(2) What changes in positive thoughtdisorder occur over the course of theschizophrenic disorder? (3) Is thedegree of disordered speech andthinking during posthospital orpostacute stages of schizophrenia anindex of the severity of disturbance?(4) What is the longitudinalrelationship between disturbedlanguage and thought and otheraspects of psychiatric adjustment(e.g., work and social functioning,delusions and hallucinations)?

This manual represents a portion of alarger and more detailed manual by thesame authors: The assessment of bizarre-idiosyncratic thinking: A manual forscoring responses to verbal tests.In: Harrow, M., and Quinlan, D., eds.Disordered Thinking and SchizophrenicPsychopathology. New York: GardnerPress, Copyright ©1985. This shorter andslightly modified version of the manualhas been adapted for the current purposewith the kind permission of GardnerPress.

Reprint requests should be sent toDr. J.T. Marengo, Dept. of Psychiatry,Michael Reese Hospital and MedicalCenter, 29th & Ellis Ave., Chicago, 1L60616.

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The thought disorder measurepresented here focuses on assessingthe frequency and severity of positivethought disorder. While more quali-tative typologies exist, it is assumedthat measuring the degree of severityof thought disorder, which relates tohypotheses regarding a continuum ofdisturbance, will provide fruitfulresults.

The following system outlines thescoring of bizarre-idiosyncraticverbalizations from two short verbaltests. The complete scoring manualand further examples can be found inHarrow and Quinlan (1985). Thissystem represents an extension ofprior research efforts in the area.Some of the material from thecurrent procedure incorporatescriteria developed by D. Adler thathave been used successfully inprevious research (Harrow, Tucker,and Adler 1972; Adler and Harrow1973, 1974; Harrow and Quinlan1977, 1985). However, more specificcriteria are now included forevaluating bizarre-idiosyncraticresponses, and characteristicexamples of such responses areoffered as an aid to assessment.Analyses of disturbed speech andthinking, drawn from a variety ofpatient populations in varioussettings and contexts, have provideda framework for the current work.

Definition of Bizarre-Idiosyncratic Thinking

We have defined bizarre-idiosyncraticspeech and behavior as that whichis: (1) unique to the particularsubject; (2) deviant with respect toconventional social norms; and (3)frequently hard to understand, or toempathize with, in the context fromwhich the response arose. Whilethese three features are central to theconcept, other less frequent charac-teristics are verbalizations that: (4)

may appear confused, contradictory,or illogical; (5) may involve suddenor unexpected contrasts; and(6) are usually inappropriate orunresourceful in relation to the taskat hand

The first two of the above featuresare directly linked to social norms,though they are viewed fromdifferent vantage points: that of theindividual and that of society. Thelast three characteristics listed in thedefinition may also appear asfeatures of bizarre-idiosyncraticthinking, but they are features thatare present some of the time, insteadof being invariant. It is surprisinglyeasy to spot bizarre-idiosyncraticstatements, since the manner ofpresentation or the ideas themselvesimpress the rater (including a naiverater) as unusual, strange, odd, orinappropriate.

The above definition provides uswith a broad conceptualization ofwhat are usually considered idiosyn-cratic statements. It is important toemphasize that bizarre or idiosyn-cratic qualities may be found inabstract and concrete as well ascorrect and incorrect responses, butthey are analyzed and scored as adimension separate from these otheraspects of response behavior.

To illustrate, suppose the examinerpresents the proverb:

Strike while the iron is hot.

And the subject responds with:

It could mean (pause) Hercules!(Could you say more?) I saw themovie Hercules. (Yes . . .) and itmeans don't iron over your handsand don't strike anybody beforeyou cast the first stone.

Although a response may bescored for positive thought disorderwithout meeting all of the abovecriteria, this particular responsemeets many of the criteria forbizarre-idiosyncratic thinking noted

above. It represents an explicitexample of disordered thinking. Theevaluator first wonders, "Hercules?What is the relation of the responseto the original proverb? " Theresponse deviates in an idiosyncraticway from consensual norms foranswering this question. Uponreflection, one sees some of thepossible reasons for the subject'sinterpretation in the suggestion ofstriking and violent action, with thisleading to a response involvingHercules. In both this and othercomponents of the response, it isdifficult for the scorer to empathizewith or understand the context fromwhich the answer arose. In addition,the idea of ironing one's hands isunexpected with respect to what haspreceded it, and unusual on its ownaccount. The entire statementappears confused, and the line ofthinking that has led to the responsehas resulted in an idiosyncraticanswer to the question.

Procedure

The procedure includes: (1) assessingsubjects with two short verbal tests;and (2) assigning an overall score forthe severity of thought disorder toeach of the subject's responses. Thisprocedure is outlined below. Inaddition, scoring criteria have beendeveloped to characterize thesubtypes of disordered thinkingfound in each response. Fivecategories and 11 subcategories ofbizarre-idiosyncratic thinking havebeen defined and will be summarizedin this article. More complete scoringcriteria for these categories can befound in Harrow and Quinlan(1985). A protocol representing arange of overall and category scoresfor bizarre-idiosyncratic thinking isprovided in Appendix I. This scoredprotocol may be used as a basis forpractice and scoring comparisons.

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Instruments and Administration ofTests. During the course of pilotwork, it became clear that testmaterials vary in their potential foreliciting idiosyncratic verbalbehavior. Even for those subjectswhose speech would be labeled asodd by many, some types of verbalmaterials and tests do not readilyelicit idiosyncratic responses. Wehave found that more open-endedprocedures better lend themselves toeliciting this response behavior inthose subjects with a potential forthought-disordered speech. Othertests prove cumbersome orunreliable. However, two verbaltests, the Gorham Proverbs Test(Gorham 1956) and the Compre-hension Subtest of the WechslerAdult Intelligence Scale (WAIS)(Wechsler 1955, 1981), are relativelyshort and easy to administer andwere found to be satisfactory toolsfor evoking idiosyncratic verbalresponses in those individuals with apotential for disordered thought.

The Proverbs Test. The GorhamProverbs Test (clinical, free-answerset) consists of three parallel forms,each containing 12 proverbs. In ourresearch, the multiple forms havebeen useful in the collection of longi-tudinal data over time from the samesubject.

For purposes of standardizingsubject assessment, directions for thetest are read as follows:

I am going to read you somesayings. For example, the saying,"Large oaks from little acornsgrow" could mean that great thingsmay have small beginnings. Now,please tell me what each sayingmeans instead of just telling memore about it. Try to answer everyone.

WAIS Comprehension Subtest.The Comprehension Subtest of theWAIS (Wechsler 1955) or WAIS-R(Wechsler 1981) consists of questions

relating to social comprehension andjudgment (e.g., Why does land in thecity cost more than land in thecountry?). Twelve of these questionsprovide the materials for ourevaluation of bizarre-idiosyncraticthinking (questions 3-14).

The Comprehension subtest isintroduced to the subject asinstructed in the WAIS manual.Encouragement toward responding issometimes needed in this test, as wellas in the proverbs test, and is appro-priate to use in the manner stand-ardized by the Wechsler manual.

Recording the data. It is essentialthat the verbalizations of the subject,as well as those of the examiner, bewritten down verbatim. The protocolalso should include notations withreference to the behavior or affectstimulated by the test material orexpressed during the course oftesting. If it is impossible to recordthe verbalizations of an acutelydisturbed patient, a transcribed taperecording may result in the mostaccurate test protocol. The examinershould inquire about all unclear orodd words or responses in a curiousbut nonintrusive manner, and theseinquiries should be noted in paren-theses. Since the object of these tasksis to obtain enough information toassess various aspects of speech andthinking that contribute to idiosyn-cratic responses, examiners mustexercise judgment based on their ownunderstanding of what has been saidas the criteria for initiating inquiry.

Other verbal tests. Othercomparable proverbs tests have beenused in previous research (Benjamin1944). Recently, we also have used averbal test (Lanin-Berndt Communi-cations Interview) with a series ofstandard questions designed to tapseveral important dimensions ofverbal behavior (Berndt 1981; Laninet al. 1981). Our efforts to derive ascoring system for tests of this

general type led to the developmentof the current manual.

The Rorschach Test and free-verbalization situations have alsobeen useful in our assessments ofbizarre-idiosyncratic thought(Quinlan et al. 1972; Quinlan andHarrow 1974; Reilly et al. 1975).Both of these techniques show manyvaluable features. However, theRorschach Test takes longer toadminister and to transcribe. Thefree-verbalization technique, whilesensitive to eliciting bizarre-idiosyn-cratic behavior, also presented someproblems in its standardization andtranscription.

Scoring

Overall score for bizarre-idiosyncratic responses. An overallscore for bizarre-idiosyncraticthinking is assigned to each response.It assesses each response for its fitwith the current verbal context andwhat is generally considered appro-priate and understandable in oursociety. The extent to which aresponse as a whole is bizarre, aswell as the extent to which it meetsthe criteria of any or all of thespecific types of bizarre-idiosyncraticthinking, varies greatly. In thepresent scoring system, we evaluatedegrees of thought disorder byassigning scores of 0, .5, 1, or 3,ranging from absent to severethought disorder. Several examplesof responses at each level of bizarre-idiosyncratic speech are providedhere. Other examples with the appro-priate overall score for bizarre-idiosyncratic thinking are presentedin Harrow and Quinlan (1985).

Overall score values

0 «• Idiosyncratic verbalizationsare absent.

.5 = Mild cognitive slips. Verbal-izations that contain some mildly

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idiosyncratic material. The responseis slightly odd, but in a socialsituation the verbalization is notunusual enough to draw considerableattention. Two examples of responsesscored .5 are presented below:

Q: What should you do if while inthe movies you were the firstperson to see smoke and fire?A: Go out and tell the messenger.(Q) Did I say that7 1 meantmanager.

Q: Why should people pay taxes?A: Taxes are necessary. Obsessivefakes help the government. I couldgive a whole thesis on it.

1 = A definite idiosyncratic orbizarre response. This type ofresponse is noticeably unusual orstrange, but usually still under-standable. Most responses with clearbizarre or idiosyncratic aspectsreceive this rating. These responseswould definitely be noticeable fortheir strangeness in a social situation.Two examples are presented below:

Q: Why should we keep awayfrom bad company?A: They produce an aura of ill-effect. (Q) They're not—youshouldn't be "subseeded" ordeceited by people who are bad.They're just no good.

Q: Rome was not built in a day.

A: It's love, I think of it as love. Ihave to work towards love andlove has to work towards me. Andthis has to gradually come.

3 = A very severe bizarreresponse. Such responses reflect avery serious deviation fromconsensual statements, may containconsiderable confusion, and are verysocially atypical. It is often hard tounderstand why such a response wasgiven to the particular questioninvolved. This type of response isvery rarely found in the normalpopulation. Two examples arepresented below:

Q: When the cat's away, the micewill play.A: Yeah. On the earth, up at thetop, in the middle. XYZ. The end,the beginning of the end of thebeginning.Q: One swallow doesn't make asummer.A: Boy, that's greedy as hell, man,that's real greedy. That's likepulling my actual backwards.

Summed overall scores for theproverbs and comprehension testsrange from 0 to 36. In assigning theoverall score for potential bizarre-idiosyncratic thinking to eachresponse, the rater is essentiallyassessing how strange or deviant theresponse is in relation to moreconventional answers. Evenresponses that one can understand orempathize with will at times bescored, since they may show oddfeatures or deviate from socialconvention in an unusual orunexpected manner. However,responses that deviate from theconventional answer and that arealso difficult to understand areassigned more severe thoughtdisorder ratings.

As outlined above, an overallscore of 0 is assigned whenthe response is not bizarre oridiosyncratic in any way. An overallscore of .5 is assigned when theresponse is slightly off, or containscognitive slips that are not grosslydeviant. In a social situation, suchresponses would not really startlepeople or raise major questions. Thisscore is meant to capture slightdeviations, some of which areexpected to be found in normalrecords as well. An overall score of 1is assigned to a response that isclearly idiosyncratic or bizarre. Anoverall score of 3 is assigned only toextremely unusual or very bizarrestatements.

Note that in scoring bizarre-idiosyncratic responses, incorrect

answers are not penalized, since lackof knowledge does not representstrangeness or bizarreness. However,incorrect answers in which it isdifficult to understand why theparticular incorrect answer wasgiven, and incorrect answers thathave no relationship at all to thequestion, are usually consideredbizarre or idiosyncratic and scored assuch.

The overall score has emerged inour research as the most accurateestimate of the severity of disorderedthinking. It involves a judgment ofpositive thought disorder in theresponse as a whole and is based onthe scorer's understanding of thedefinition of bizarre-idiosyncraticthinking as well as on the coherenceand appropriateness of the response.The overall score is an assessment ofthe degree of idiosyncracy reflectedin a response.

Establishing Subject Groups Based onthe Severity of Bizarre-IdiosyncraticThinking

Continuum model. Responsesreflecting thought disorder can beplaced on a continuum extendingfrom very severe bizarre-idiosyncratic thinking to normal,socially consensual thinking, withconsiderably heavier weightings forvery severe bizarre responses, asopposed to mild cognitive slips. Italso can be useful to have somesystem available to facilitate placingsubjects into rough categoriesaccording to whether they showsevere thought pathology, moderatelevels of thought pathology, or nothought pathology. Accordingly, weassign subjects' total summed overallscores from the Proverbs andComprehension tests to categories orlevels reflecting various degrees ofbizarre-idiosyncratic thinking.

In this system, subjects' totaloverall scores have been categorized

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into a continuum of positive thoughtdisorder. The five specific categoriesincluded in the current systemare: (1) no thought disorder;(2) minimal to mild bizarre-idiosyncratic thinking; (3) signs ofabnormal thinking or definitethought disorder; (4) severe thoughtdisorder; and (5) very severe thoughtdisorder. The conversion levelspresented in table 1 are used.

Levels 1 and 2 of the ThoughtDisorder Scale are representative oflittle or no pathological thinking andlie well within the normal range.Level 3 (moderate level) reflectsdefinite evidence of thoughtpathology or abnormal thinking. Thenumber of patients at levels 4 and 5provides an estimate of severelythought-disordered patients. Thecombined number of patients atlevels 3, 4, and 5 gives thepercentage with definite signs ofpositive thought disorder orabnormal thinking.

Composite index of bizarre-idiosyncratic thinking. A compositeindex of bizarre-idiosyncraticthinking also can be computed fromboth verbal tests, the Proverbs andthe Comprehension tests, using thefive levels of bizarre-idiosyncraticthinking described above. In thiscomposite index, each subject isassigned to the highest (most severe)level into which he or she fits oneither of the two tests. Thiscomposite index classifies subjectsaccording to whether they show anysigns of bizarre-idiosyncraticthinking, given opportunities on twoseparate tests to show such behavior.

In our research we also obtainmeasures of thought disorder fromthe Object Sorting Test (Goldsteinand Scheerer 1941; Goldstein 1944)and have categorized the scores fromthe Object Sorting Test into the samefive levels of bizarre-idiosyncraticthinking (Harrow et al. 1985). We

have combined the category scores orlevels from the Object Sorting Testwith the parallel category scores orlevels from the Proverbs andComprehension tests to obtain ourmajor composite index of bizarre-idiosyncratic thinking (table 1).

This composite index is based onscores from the three separatemeasures of thought disorder. Forthis composite index, each patient isassigned to one of the five categoriesor levels ranging from no abnormalthinking (level 1) to very severethought disorder (level 5) accordingto the most severe level attained onany of the three tests. This classi-fication system categorizes patientsaccording to whether they show anypositive thought disorder, given threeseparate opportunities to do so. Thecomposite score encompasses a broadsample of behavior and is morecomprehensive than indexes thatinclude only one or two tests.

Relation of this System of EvaluatingBizarre-Idiosyncratic Thinking toOther Systems of Thought DisorderAssessment

Rapaport, Gill, and Schafer (1968)system. Note that in several ways theconceptual framework we employ toassess bizarre-idiosyncratic thinkingis different from that used byRapaport in his research studyingdisordered thinking, although thetwo systems are comparable inseveral respects. Our conceptualframework is closely tied to implicitconceptual norms that people haveacquired over time about what isappropriate and what is deviant in aparticular response situation. Theframework used by Rapaport isbased, in part, on assessing patho-logical verbalizations by whetherthey involve too much distance or aloss of distance from the originalstimuli, with such judgments being

based on implicit social norms(Rapaport, Gill, and Schafer 1968).However, while there is somedifference in the conceptual basis ofthe systems, there is much similarityin the actual practice of scoringdisordered verbalizations. The systemwe use involves assessingconsensually deviant responses andbehavior along dimensions ofthought disorder that Rapaport mighthave labeled as "too much distance"or a "loss of distance" from theoriginal stimuli.

Johnston-Holzman ThoughtDisorder Index (1979). Our constructof bizarre-idiosyncratic thinking andJohnston and Holzman's ThoughtDisorder Index also show similarity.In both systems, bizarre, strange,and deviant responses are assignedscores, and in both systems moreseverely deviant responses are givenheavier or more pathologicalweighting. Johnston and Holzman'sThought Disorder Index is used withthe WAIS Comprehension Subtestand with other WAIS subtests, aswell as with the Rorschach Test.

Our Proverbs test measures ofbizarre-idiosyncratic thinking showedsignificant correlations (r =• .61) withthought disorder as measured onJohnston and Holzman's (1979)Thought Disorder Index in a sampleof young schizophrenic subjectsstudied during postacute phases ofdisturbance. We have found thissystem valuable. We tend, however,to favor the current verbal tests andsystem of assessment since they areless time consuming.

Andreasen's Scale for theAssessment of Thought, Language,and Communication (TLC).Andreasen's (1979a, 1979b) TLCScale defines different languagebehaviors as subtypes of thoughtdisorder. Ratings for the severity ofthought disorder are included and arebased on a standardized means of

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Table 1. Derivation of thought disorder groups and the Thought Disorder Scale from 3psychological tests

Thought disordergroup

ThoughtDisorder

Scale

Thoughtdisorder

continuum

Proverb orComprehension

Test totalscore

ObjectSorting

Test totalscore

No abnormalthinking

Abnormal thinking

Severe thoughtdisorder

AbsentMild

Definite

SevereVery severe

0-.51-2.5

3-6.5

7-11 512-36

3-67-21

assessment. In general, the types ofstrange and bizarre thinking tappedin our measure of positive thoughtdisorder are also assessed inAndreasen's composite index ofpositive thought disorder derivedfrom the TLC. For instance, thevarious types of thought disorderassessed by Andreasen (e.g., tangen-tiality, incoherence, and loss of goal)are also scored for bizarre-idiosyncratic thinking when theyappear in the verbal tests we admin-ister to assess positive thoughtdisorder.

RDC and DSM-III criteria ofthought disorder. The key compo-nents of bizarre-idiosyncraticthinking in the current system alsocan be helpful in assessing whether apatient has the type of formalthought disorder listed in majordiagnostic systems such as theResearch Diagnostic Criteria (RDC)and DSM-III (Spitzer and Endicott1968; American Psychiatric Associ-ation 1980). Four of the five types ofpathological speech and thinkingoutlined in the RDC as constitutingformal thought disorder (impairedunderstandability of speech,loosening of association orderailment, illogical thinking, andneologisms) are viewed in the presentsystem as components of bizarre-idiosyncratic thinking.

Similarly, although DSM-III is alittle less optimistic about the conceptof formal thought disorder, three ofthe specific types of thought disorderwhich, in effect, are substituted inDSM-III for formal thought disorder(incoherence, marked loosening ofassociations, and markedly illogicalthinking) are included in the presentsystem. Note that these types ofthought pathology are included assymptoms that can be used inDSM-III as partial criteria for adiagnosis of schizophrenia.

Reliability and Validity. Evaluationsof both reliability and validity of thecurrent system of assessment havebeen based on normal subjects andon outpatient and inpatient psychi-atric groups. These assessments havetaken place in a variety of settingsand have included chronic and acute,psychotic and nonpsychotic, andmedicated and unmedicated patientsamples.

Reliability. Interrater reliability hasbeen obtained for: (1) the overallscores of bizarre-idiosyncraticthinking using Proverbs and Compre-hension tests; and (2) for the subcate-gories of bizarre-idiosyncraticthinking presented in the followingsection Interrater reliability estimatesalways have been high for theoverall scores and moderate to high

for scoring the specific categoriesFour separate assessments of 20patient records produced interraterreliabilities of r = .93, r = .88,r =-= .67, and r = .91 for totaloverall scores on the Proverbs andComprehension tests. Interrater relia-bilities for each category of idiosyn-cratic thinking were as follows:

Category Range of rI. Linguistic form and structure

.82-.99II. Content of statement: Ideas

expressed .84-.99III. Intermingling .75-.85IV. Relationship between response

and question .73-.99V. Behavior .47-.98

In addition to interrater reliability,internal consistencies for theProverbs test using Cronbach's oproduced a reliability of .85 for allpossible combinations of item-by-item scores. Subjects were also testedon two parallel forms of theProverbs test administered succes-sively in the same test session.Gorham's (1956) Proverbs Set 1 andProverbs Set 3 were used. The corre-lation of subnets' overall scores forbizarre-idiosyncratic thinkingbetween these two sets of proverbswas r = .79 (Harrow and Miller1980).

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The total overall scores ofProverbs and Comprehension testsfor the same subjects have also beencompared to determine whether asubject with more pathological scoreson one of these tests is likely to havemore pathological scores on the othertest. In a sample of 18 unmedicatedState hospital inpatients assessedwith both tests during the first weekof hospitalization, the reliabilitycoefficient was r = .74 betweenProverbs and Comprehension totalscores. A second sample of 104medicated patients (63 schizophrenicand 41 nonschizophrenic subjects)from a private and State hospitalsetting provided a reliability coeffi-cient of r — .53 between Proverbsand Comprehension total scores.Significant correlations between thetests emerged for: (1) the totalnumber of thought-disorderedresponses, r = .57; (2) the number ofmoderate and severe bizarreresponses, r — .55; and (3) thefrequency of severely bizarreresponses, r = .47. This indicatesthat the bizarre-idiosyncratic thinkingfound is not peculiar to a specifictest.

However, a significant differenceemerged between the total scoresderived from the two tests, r — 2.69,df = 102, p < .01. The Proverbs testelicited more severely bizarreresponses than the Comprehensionsubtest when administered at theacute phase of patients' disorders.The Proverbs test appears to be moresensitive to eliciting thought-disordered responses in acute patientswho have a tendency toward bizarrethinking (Marengo 1983). Thisappears to be a function of differ-ences in test stimuli and demandcharacteristics. The Proverbs testpresents less familiar material to thepatient and demands moreabstraction and more complexthinking. The subject cannot rely as

much on previous experience andsocially stereotyped responses whenresponding to many of the proverbs.

Validity. We have conducted aseries of investigations which bear onthe construct validity of this systemfor assessing positive thoughtdisorder. A number of these studiesare based on our longitudinalresearch assessing (1) the relationshipbetween bizarre-idiosyncratic speechand other aspects of psychopath-ology, and (2) the level of bizarre-idiosyncratic thinking across differentstages of patients' disorders. Earlyresults on various patient and normalsamples have supported the validityof the construct of bizarre-idiosyn-cratic thinking.

Our research on bizarre-idiosyncratic thinking with theProverbs and Comprehension testshas indicated the following:

• Bizarre-idiosyncratic thinkingwas positively correlated withlinguistic errors on a structuredcommunication task (Lanin-Kettering1983). Thought disorder as measuredon the Proverbs Test showed asignificant association with anoverall index of contextual coordi-nation, r = .48, p < .001, and wasalso correlated with severalcomponent measures, including theability to maintain topic, r = .29,p < .03, and to produce sentence-to-sentence coherence, r = .43,p < .003. Assessment included aseparate sample of psychiatric andnormal subjects.

• Schizophrenic and nonschizo-phrenic patients (n = 85) with adisturbance of associative processeson a word association test alsomanifested significantly more severeidiosyncratic thinking on theComprehension Subtest of the WAIS(Silverstein, Harrow, and Marengo1980).

• Correlations of the Proverbs andComprehension test total scores with

the Object Sorting Test measure ofbizarre-idiosyncratic thinking werer = .60 and r = .50, respectively, in50 psychiatric subjects assessed at theacute inpatient phase.

• We have assessed the relation-ships between earlier versions of ourindexes of bizarre-idiosyncraticthinking and a measure of commu-nication deviance employed by sometheorists on schizophrenic families(Wild et al. 1965; Wild 1972), usingthe Object Sorting Test. In a study of40 schizophrenic and nonschizo-phrenic patients, these relationshipswere significant. Wild and Lidz'smeasure of transactional thinkingwas significantly related to ourearlier measures of bizarre-idiosyn-cratic thinking assessing WAISComprehension Subtest responses

(r = .45), and to our similar measureassessing Object Sorting Testresponses (r = .67) (Quinlan et al.1978). These results suggest a signif-icant relationship between measuresof bizarre-idiosyncratic thinking orpositive thought disorder andmeasures of communicative deviancefrom family studies.

In a series of studies using thecomposite index of positive thoughtdisorder (including the three thoughtdisorder measures), the systemdescribed above has proved useful.

• At the acute phase ofdisturbance, early schizophrenicpatients showed significantly moresevere bizarre-idiosyncratic thinkingthan other psychotic and nonpsy-chotic patient groups (with theexception of manic subjects),indicating the index's sensitivity todiagnostic factors (Marengo andHarrow 1985).

• Differences exist in the severityof bizarre-idiosyncratic thinking overdifferent stages of psychiatricdisturbance. A decline in the severity

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of bizarre-idiosyncratic thinking isevident between acute-phaseassessment and the stage of partialrecovery (7 weeks after acute-phaseassessment). This reduction is signif-icantly associated with improvementin other aspects of patients' clinicalconditions (Harrow et al. 1982;Harrow, Marengo, and Lanin-Kettering 1983).

• In a longitudinal study wefound significant schizophrenic-nonschizophrenic differences indisordered thinking at the acutephase, and considerably smallerdifferences at 1.5-year followup, apostacute period (Harrow, Marengo,and McDonald 1986).

• We have found significantassociations between the ThoughtDisorder Scale (based on thecomposite index) and other majorpsychopathology, such as delusions(Harrow, Silverstein, and Marengo1983; Marengo and Harrow 1985;Harrow and Marengo, this issue;Harrow, Marengo, and McDonald1986). In addition, we have foundsignificant relationships between theThought Disorder Index and thedegree of dysfunction in current andsubsequent overall adjustment shownby schizophrenic and other psychi-atric groups (Harrow, Silverstein,and Marengo 1983; Marengo 1983;Harrow and Marengo, this issue;Harrow, Marengo, and McDonald1986).

While we view the points of thethought disorder scale as lying on acontinuum, the specific cutoff pointsthat establish the thought disordergroups have proved valuable. Whenpatients are categorized according towhether they have severe thoughtdisorder, as opposed to signs ofabnormal thinking, as opposed tolittle or no thought disorder on ourcomposite index, significant differ-ences among groups in various types

of major psychopathology emerge(Harrow and Marengo, this issue).This has occurred in comparisonsamong schizophrenic patients withno or only mild thought disorder(Thought Disorder Scale levels 1 and2), others showing signs of abnormalthinking (Thought Disorder Scalelevel 3), and those exhibiting severeor very severe thought disorder(Thought Disorder Scale levels 4 and5). Thought disorder group differ-ences have been found in concurrentassessments of work functioning,overall psychotic activity, andrehospitalization rates duringposthospital phases of schizophreniaand major depressive disorders(Marengo 1983). These data indicatesome degree of validity for the cutoffpoints established and listed above.

In other phases of our research, theThought Disorder Scale and thethought disorder groups (using thecomposite index) were predictive ofthe future functioning of patientswhen thought disorder was assessedat an early, posthospital phase ofdisorder. The presence of severethought disorder (Thought DisorderScale level 4 or 5) is a goodprognostic indicator of futuresustained functioning impairments inboth schizophrenic and nonschizo-phrenic disorders (Harrow andMarengo, this issue). By contrast,non-thought-disordered patients andthose showing abnormal thinking(but not severe thought disorder)evidence a more benign or remittingsubsequent course of psychosis thando severely thought-disorderedpatients over the longitudinal courseof disturbance (Marengo 1983).

In these early studies, the resultsfrom the Thought Disorder Indexhave generally fit in with commonclinical observations and theoriesabout bizarre-idiosyncratic thinkingand positive thought disorder.

Note that in our assessments of

nonpatient control samples, somenormal subjects have manifestedsigns of abnormal thinking (Marengoand Harrow 1985). Normal subjectshave also demonstrated signs ofsevere positive thought disorder.From 10 to 15 percent of normalsubjects showed level 4 or 5 on theComprehension or Proverbs testwhen one of these tests was usedalone, and 10 percent showedseverely disordered thinking on thecomposite index (Marengo andHarrow 1985). The finding of somecontrol subjects with severe levels ofthought disorder should not besurprising, in view of variousfindings over the years of certainlevels of psychopathology, and evensevere psychopathology, in some"normals. "

We should also point out thatthought-disordered individuals showa great deal of normal speech. Thisattests to the phasic nature ofthought disorder, in some subjects,even during periods of acute upset.Our measures assess the behavioralpotential for bizarre-idiosyncraticthinking in spontaneous, open-endedspeech situations.

Specific Categories andSubcategories of Bizarre-Idiosyncratic Thinking

In addition to the overall scores forthought disorder severity, we haveoutlined a system for evaluations ofeach response focusing on criteriaconstructed to delineate theanomalies of positive thoughtdisorder. Five categories and 11subcategories of bizarre-idiosyncraticthinking provide the criteria forevaluating components of bizarre-idiosyncratic verbalizations in greaterdetail. These major categories andsubcategories represent various typesof abnormal ideas, behavior, andlanguage. They also provide one way

VOL. 12, NO. 3, 1986 505

of categorizing some of the differenttypes of disordered thinking that canbe seen in response to specific tasks,as well as in people's day-to-daybehavior.

The presence of these componentsof disordered thinking can beindependently studied in light ofdifferent theoretical predictions,developments at different points inthe unfolding of, or recovery from, aparticular disorder, and in under-standing differences among clinicalpopulations. With bizarre-idiosyncratic thinking as a moregeneral construct, these categoricalevaluations provide the opportunityto study particular kinds of thoughtdisorder.

We have found these subtypes ofbizarre-idiosyncratic verbalizationsand behavior useful, and we do scorethem in our own research. We shouldemphasize, however, that scoring orattending to these specific criteria isnot absolutely necessary for attainingthe overall score for bizarre-idiosyncratic thinking. One can usethe overall system of assessment ofthought disorder severity on the basisof the criteria outlined in theprevious pages without the detailedand specific subcategories noted inthe following pages. If the followingsubcategories are used, the initialoverall rating of bizarre-idiosyncraticthinking should be made first, beforescoring these individualsubcategories.

We have used five basic categoriesto study both the subject's linguisticform (i.e., the manner in which ideasare communicated) and the contentof the responses (i.e., the ideasthemselves). Detailed examples ofspecific responses and how theyshould be scored within the 5categories and 11 subcategories ofbizarre-idiosyncratic responses areprovided in Harrow and Quinlan(1985). These categories are not

exclusive, and many responses arescored for several types ofcomponent problems, particularlysince problems in form and problemsin content are often difficult to teaseapart.

Five Categories of Bizarre-Idiosyncratic Thinking

I. Linguistic form and structure.Here, the structure of languagewithin the response is under scrutiny.A problem in this area implies that itis difficult to understand the subject'sstatement owing to distortions inword use, grammatical form, or thelinkage of words and phrases. Aresponse also may be communicatedpoorly. Questions are raised aboutpeculiarities in the individual's verbalstyle, the linguistic structure of theresponse, or gaps in communicationthat may interfere with the clearcommunication of meaning.

II. Content of the statement: Theideas expressed. Under primaryconsideration are the ideas presentedwithin the response. This categorypertains to peculiarities within aresponse such as idiosyncraticreasoning, asocial attitudes, anddisorganized or confused ideas. Theideas or attitudes the subject presentsare evaluated from the perspective ofconventional attitudes, logicalthought, or cogent explanations.

III. What is intermixed into theresponse. In this category, the focusis on whether the response movesaway from a consensual answerowing to a shift to loosely associatedideas or the subject's personalpreoccupations. The twofoldemphasis of this category is on:(1) the mixing or blending into theresponse of personal material fromthe subject's past or currentexperience, and (2) the extensiveelaboration of a theme or idea,which does not fit neatly into the

structure of the response, making itappear somewhat unusual. Thequestion raised is: Are there anypersonal associations or tangentialideas that the subject is expressing aspart of his response that are idiosyn-cratic or bizarre!

IV. Relationship between questionand response. Here, the focus ofevaluation is on how the ideas thesubject presents relate to the questionasked. Is the subject able to addressthe task of interpretation, or answera question? Is the subject inappro-priately, or totally, focused onprivate, autistic associations orthoughts?

V. Behavior. Behavior is assessedusing conventional norms forconduct in a testing situation,including physical, affective, andverbal behavior. Is the subject'sbehavior deviant either in its extremeexpression or in its incongruity andimpropriety within the testingcontext?

Suggested Step-by-Step Procedure forEvaluating the Individual Categoriesof Bizarre-Idiosyncratic Thinking.The assignment of scores within thesecategories is determined using thecriteria listed below. The extent towhich a response meets each (ornone) of the relevant categorycriteria is evaluated and the responseis assigned a score of 0, .5, 1, or 3for each category.

In assigning category andsubcategory scores, it helps to:

• Consider how the subjectexpresses ideas. Is the responsepoorly structured, composed ofvague elements, or obscured byidiosyncratic terminology? What isthe subject's choice of words? Is thereany unusual word usage or use ofartificial, pedantic, or stiltedlanguage? Does the subjectcommunicate ideas in a reasonablefashion, or are there unexplained

506 SCHIZOPHRENIA BULLETIN

gaps or missing referents that make itvery difficult to understand? If yes,then evaluate the response in termsof subcategory indicators and assigna score reflecting the degree ofthought disorder in Category I.

• Consider next the ideaspresented. Does the subject'sstatement make any sense at all? Ifthe response makes no sense, score a3 in Category II. Does the reasoningdeviate from rules of logic or socialconvention? Does the statementinvolve an odd meaning or outlook?If yes, then evaluate the extent andassign an appropriate score inCategory II and in its appropriatesubcategories.

• Then evaluate intermingling inthe response. At times a subject'sanswer shows intermingling ofpersonal material from the verybeginning of a response. At othertimes, after a smooth beginning (inwhich the initial thrust of theresponse is partially or completelycorrect), does the subject's responsethen wander onto tangential orirrelevant topics7 Does the responsereflect intermingled personalmaterial? If yes, then evaluate theextent to which this additionalmaterial causes the response toappear odd and assign scores to theappropriate subcategories and toCategory III.

• Now consider the relation of theresponses to the question or proverb.Does the content of the response (atleast initially) refer to the questionasked (irrespective of whether it iscorrect or incorrect, concrete orabstract, and despite other aspects ofbizarreness)? Is there any discernibleassociation between the words orconcepts of the question or proverbon the one hand, and the subject'sstatement on the other? Assign ascore reflecting the distance of theresponse from the question orproverb in Category IV.

• Finally, consider whether thesubject's physical, affective, or verbalbehavior deviates from conventionalnorms during the test situation. If itdoes, then evaluate the degree andassign a score of 0, .5, 1, or 3 inCategory V.

Each of the five categories isscored on the scoring sheet. Thescoring of the above five categories isbased primarily on the following 11subcategories of disturbed languageand thinking. These indicators haveproved useful in orienting raters tothe behavioral foundations of the fivedescriptive categories of idiosyncraticthinking. In addition, some of thesesubcategories may be related tospecific mechanisms involved inbizarre-idiosyncratic thinking. Somebizarre-idiosyncratic responses maybe influenced by, or in part be aconsequence of, confusion-disorganization, a tendency to inter-mingle personal concerns whenthinking about neutral material, adisorder in logical reasoning, orattending to part rather than all of aquestion. However, while these 11subtypes of bizarre-idiosyncraticthinking may be important, they donot represent an exhaustive list of allpossible types of bizarre behaviorand ideas, or all the possible dimen-sions with which one can look atthese phenomena. There are a vastnumber of ways responses can bestrange and bizarre, and a vastnumber of ways that responses candeviate from social convention in anidiosyncratic manner.

Category I: Linguistic Form andStructure

1. Strange verbalizations.

a. Single words used in an unusualor peculiar manner (which are, in therater's best judgment, not attrib-utable to intellectual or culturaldeficits).

b. Mild or moderate cognitiveslippage in sentence structure, theexpression of ideas, or theconstruction of new words (the newword is close in form to the correctword).

c. Neologisms (a new word withprivate meaning). Real neologisms(involving a private meaning) arevery unusual, and are scored "3" toreflect their very severe idiosyncraticquality.

d. Artificial, pedantic, or stiltedlanguage, inappropriate to the levelof discourse in the testing situation.

2. Lack of shared communication.

a. Responses that are not explicitlystated.

b. Small gaps in communication,in which words are not explained orreferents are unclear.

c. Larger gaps in communication,in which phrases are not explained.Elements of private language may beapparent with unshared orunexplained concepts or ideas.

d. Disorganized or poor linkagebetween consecutive words, phrases,or sentences within the response.

Category II: Content of theStatement

3. Responses involving coherent butodd ideas.4. Responses that are deviant withrespect to social convention.

5. Peculiar or idiosyncratic reasoningor logic.

a. Responses that are incorrect andillogical in terms of commonknowledge about people, events, orthe environment.

b. Responses violating a logicalparadigm, such as predicate logic.

c. Self-contradictory responses orresponses with confused logic.

d. Responses with peculiar,autistic logic.

VOL 12, NO. 3, 1986 507

6. Confused or disorganized ideas.

a. Combinations of words puttogether in a manner that only dimlymakes sense.

b. Grammatically correct sentencesthat do not hold a logical thought.

Category III: Intermixing

7. Overelaborated response.

a. Irrelevant wandering within apartially correct or correct answer.

b. Elaboration that is far tooextensive, to the point where theoriginal question is almost lost fromsight.

8. Intermingling of personal concernsor associations into the response.

Category IV: Relationship BetweenQuestion and Response

9. Attending to a part of rather thanthe whole question: associations orinterpretations of a word or phrasethat suggest the subject's response isnot based on the question as aconceptual whole, and also make theresponse appear strange or idiosyn-cratic.10. Lack of a relationship betweenthe subject's statement and thequestion asked—almost as if adifferent question is being asked.

Category V: Behavior

11. Strange behavior—includingphysical and affective behavior.

In scoring a response according tothe list of major categories andsubcategories outlined above, thescorer first analyzes the subject'sresponse and scores it according toeach of the 11 subcategories. Thescorer then assigns scores on the fivemajor categories. The presence ofone type of subcategory of bizarre-idiosyncratic thinking in a response(e.g., lack of shared communication)

does not exclude the simultaneouspresence of another type orsubcategory from that same response(e.g., intermingling or an overelab-orated response).

The categories were constructed tofocus on the distinct properties of aresponse that may contribute to anoverall impression of unusual or oddverbal behavior. However, at times,although a category score is indicated(i.e., something unusual occurs inlinguistic style, or in how a responseis stated), the idiosyncracy is notattributable to any specificsubcategory or behavioral indicator.In such instances, a category scorefor bizarre-idiosyncratic thinking isstill justified in that particular area,while the individual behavioraldescriptors are left blank.

The categories and the subcate-gories that they comprise are not anexhaustive list of all possible aspectsof idiosyncratic thought andlanguage. The overall response scoreis a general barometer of bizarre-idiosyncracy, and the categories andtheir foci are probes for the compo-nents of such verbal behavior. Anyone response may be scored foroverall bizarreness but may not fitneatly into any of the outlinedcategories or subcategories, with allof the categories and subcategoriesconsequently rated as 0.

On the other hand, if a score of 1is assigned for any of the fivecategories, an overall score of at least1 is logically indicated, as the overallresponse or part of it is clearlybizarre or idiosyncratic. Althoughthe overall score should be at least asgreat as that given in any individualcategory, the accumulation ofcategory scores may, and often does,add up to more than the overallscore. (The overall score for aresponse can only equal 0, .5, 1, or 3and is not the summation of categoryscores.)

As we have indicated, manyresponses are scored in more thanone category or subcategory. In asample of hospitalized schizophrenicpatients, for example, we found thatof those responses scored for bizarre-idiosyncratic language and thought,approximately 50 percent werescored in one subcategory, 30 percentin two subcategories, and 20 percentin three or more subcategories. Thisratio, however, may differ withvarying populations.

Conclusion

In this article, we have summarizedour method of assessing positivethought disorder in two verbal tests.This has included information onsome of our conceptualizations aboutbizarre-idiosyncratic thinking andpositive thought disorder, as well asthe reliability and validity of ourscoring system. While we haveconveyed the essential aspects of ourscoring system here, more thoroughand detailed scoring procedures forthe categories of bizarre-idiosyncraticthinking and additional scoringexamples are presented in Harrowand Quinlan (1985).

References

Adler, D., and Harrow, M. Manualfor Assessing Components ofIdiosyncratic or Bizarre Responses.(AS1S/NAPS #02191) NewYork: Microfiche Publication, 1973.

Adler, D., and Harrow, M. Idiosyn-cratic thinking and personally overin-volved thinking in schizophrenicpatients during partial recovery.Comprehensive Psychiatry, 15:57-67,1974.

American Psychiatric Association.DSM-I11: Diagnostic and StatisticalManual of Mental Disorders. 3rd ed.

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Washington, DC: The Association,1980Andreasen, N.C. The clinicalassessment of thought, language andcommunication disorders. Archivesof General Psychiatry, 36:1315-1321,1979a.

Andreasen, N.C. The diagnosticsignificance of disorders in thought,language and communicationdisorders. Archives of GeneralPsychiatry, 36:1325-1330, 1979b.Andreasen, N.C, and Olsen, S.Negative v. positive schizophrenia.Archives of General Psychiatry,39:789-794, 1982.

Benjamin, J.D. A method for distin-guishing and evaluating formalthinking disorders in schizophrenia.In: Kasanin, J.S., ed. Language andThought in Schizophrenia.Berkeley: University of CaliforniaPress, 1944. pp. 65-90.Berndt, D.J. "The Course of ThoughtDisorder at Acute and Posthospital-ization Phases With an Emphasis onthe Roles of Energy Level andAffective Disturbance." Ph.D. thesis,Loyola University, Chicago, IL,1981.Buss, A.H. and Lang, P.J. Psycho-logical deficit in schizophrenia: I.Affect, reinforcement, and conceptattainment. Journal of AbnormalPsychology, 70:2-24, 1965.Chapman, L.J Recent advances inthe study of schizophrenic cognition.Schizophrenia Bulletin, 5:568-580,1979.

Chapman, L.J., and Chapman, J.P.Disordered Thought in Schizo-phrenia New York: AppletonCentury Crofts, 1973.

Fish, F.J. Schizophrenia.Baltimore: William & Wilkins Co.,1962.

Goldstein, K. A methodologicalapproach to the study of schizo-

phrenic thought disorder.In. Kasanin, J.S., ed. Language andThought in Schizophrenia.Berkeley: University of CaliforniaPress, 1944. pp. 17-40.

Goldstein, K., and Scheerer, M.Abstract and concrete behavior. Anexperimental study with special tests.Psychological Monographs, 53: No.2, 1941.

Gorham, D.R. A proverbs test forclinical and experimental use.Psychological Reports, 1:1-12, 1956.

Gottschalk, L.A., and Gleser, G.C.The Measurement of PsychologicalStates Through the Content Analysisof Verbal Behavior. Berkeley and LosAngeles' University of CaliforniaPress, 1969.

Harrow, M.; Grossman, D.; Silver-stein, M.L.; and Meltzer, H. Thoughtpathology in manic and schizo-phrenic patients: At hospitaladmission and seven weeks later.Archives of General Psychiatry,39:665-671, 1982.Harrow, M.; King, G.; Marengo, J.;Rattenbury, F.; and Silverstein, M.L."A Manual to Assess PositiveThought Disorder, Using the ObjectSorting Test." Unpublished manual,1985.

Harrow, M., and Marengo, J.Schizophrenic thought disorder atfollowup: Its persistence andprognostic significance. Schizo-phrenia Bulletin, 12.373-393, 1986.

Harrow, M.; Marengo, J.; andLanin-Kettering, I. "LongitudinalTrends in Positive Thought Disorderin Schizophrenia and Psychosis."Presented at the Annual Meeting ofthe American PsychologicalAssociation, Anaheim, CA, August,1983

Harrow, M.; Marengo, J., andMcDonald, C. The early course ofschizophrenic thought disorder.

Schizophrenia Bulletin, 12:208-224,1986.Harrow, M., and Miller, J.G. Schizo-phrenic thought disorders andimpaired perspective. Journal ofAbnormal Psychology, 89:717-727,1980.

Harrow, M., and Quinlan, D. Isdisordered thinking unique to schizo-phrenia? Archives of GeneralPsychiatry, 34:15-21, 1977.

Harrow, M., and Quinlan, D.Disordered Thinking and Schizo-phrenic Psychopathology. NewYork: Gardner Press, 1985.Harrow, M.; Silverstein, M.L.; andMarengo, J. Disorderedthinking: Does it identify nuclearschizophrenia? Archives of GeneralPsychiatry, 40:765-771, 1983.

Harrow, M.; Tucker, G.; and Adler,D. Concrete and idiosyncraticthinking in acute schizophrenicpatients. Archives of GeneralPsychiatry, 26:433-439, 1972.Johnston, M.H., and Holzman, P.S.Assessing Schizophrenic Thinking.San Francisco: Jossey-Bass, 1979.Lanin, I.B.; Berndt, D.; Harrow, M ;and Neiditz, J. "The Many Levels ofCohesive Speech Behavior: AnEmpirical Examination." Presented atthe Parasession on Language andBehavior of the Chicago LinguisticSociety, Chicago, IL, May 1981.

Lanin-Kettering, I. "Towards aCommunicative Model of DiscourseCohesion." Ph.D. thesis, Universityof Chicago, Chicago, IL 1983.

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Marengo, J. 'The Prognosis ofThought Disordered Schizo-phrenics: A Followup Study." Ph.D.thesis, Northwestern University,Evanston, IL, 1983.

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G.J.; and Carlson, K. Varieties of"disordered" thinking on theRorschach: Findings in schizophrenicand non-schizophrenic patients.Journal of Abnormal Psychology,79:47-53, 1972.Rapaport, D.; Gill, M.; and Schafer,R. Diagnostic Psychological Testing.Edited by R. Holt. New York:International Universities Press,1968.

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Acknowledgment

This work was supported in part byGrant No. MH-26341 from theNational Institute of Mental Health,and by research grants from the JohnD. and Catherine T. MacArthurFoundation and the Irving B. HarrisFoundation.

The Authors

Joanne T. Marengo, Ph.D., is SeniorPsychologist, Department ofPsychiatry, Michael Reese Hospitaland Medical Center, and ResearchAssociate (Assistant Professor),Department of Psychiatry, TheUniversity of Chicago. Martin M.Harrow, Ph.D., is Director ofPsychology, Michael Reese Hospitaland Medical Center, Chicago, IL,and Professor, Department ofPsychiatry and Behavioral Sciences,The University of Chicago. IleneLanin-Kettering, Ph.D., is SeniorAccount Executive, KapulerMarketing Research, Inc., ArlingtonHeights, IL. Arnold Wilson, Ph.D.,is Assistant Professor, Department ofPsychology, New School for SocialResearch, New York, NY.

510 SCHIZOPHRENIA BULLETIN

Appendix 1:Scored Protocol

1. Where there's a will, there's away.

Destiny is always truth.

2. Rome was not built in a day.

You'd have to ask my brotherthat. He's an architect. In theKoran, my brother is Moses, sohe's the best to answer thatquestion. I'm studying theRomans in the Bible now. I'mstudying their mental attitudestoward life. I'm in schoolnow—University of Mozam-bique. It's through the mind I'mlearning.1

3. When the cat's away, the micewill play.

It refers to supervision-children get aggressive andselfish when their parents aren'tthere. Behavior is mischievouswhen there is no supervision.

4. Barking dogs seldom bite.

Intimidation. (Q) A barkingdog is trying to frighten orintimidate you.

5. A stream cannot rise higher thanits source.

Water doesn't run up hill.

6. Don't swap (trade) horses whencrossing a stream.

•Subject has never attended a foreignuniversity.

It is negative, a pyramid overwater. Others out theredisagree with me.

7. The used key is always bright.

I don't know what that meansin frontal knowledge, but not inlateral.

8. Gold goes in at any gate exceptheaven's.

Heaven has a gate of gold. Youcan't buy heaven.

9. One swallow (bird) doesn't makea summer.

Teaches patience.

10. The wife is the key to the house.

She's the protective image ofthe household. She's the leaderbehind closed doors.

11. Riches serve a wise man butcommand a fool.

That's true. (Enc.) It's thedifference between sitting yogaand traveling or putting onyour clothes and usingtransportation. (Q) It'stranscendental sound.

12. Don't cast pearls before swine(pigs).

Swine are only intended to eatground or soil but not pearlswhich are the epitome ofeternity.

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