Schizophrenia Research 153 (2014) 220–224
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Measuring community functioning in schizophrenia with the Social Behaviour Schedule Matteo Cella a,⁎, Paolo Stratta a,b, Kamel Chahal c, Vyv Huddy d, Clare Reeder a, Til Wykes a a
Institute of Psychiatry, King's College London, UK Department of Mental Health, ASL 1, L'Aquila, Italy South London and Maudsley NHS Foundation Trust, London, UK d Research Department of Clinical, Educational and Health Psychology, University College London, UK b c
a r t i c l e
i n f o
Article history: Received 15 September 2013 Received in revised form 28 November 2013 Accepted 27 December 2013 Available online 22 January 2014 Keywords: Schizophrenia Psychosis Functioning Social behaviour Assessment
a b s t r a c t Background: Current emphasis on community integration requires reliable and valid measures of social behaviour; existing assessments largely overlap with symptoms or provide little detail on functioning. This study aims to re-assess the Social Behaviour Schedule (SBS) to fulfil this measurement role. Methods: Internal consistency, construct validity and test–retest reliability were investigated in 421 community out-patients with schizophrenia. Concurrent validity was assessed against the Life Skill Profile (LSP), in 143 additional patients. Results: A 17-item SBS supported the construct validity of four factors: Antisocial Behaviour, Depressed Behaviour, Social Withdrawal and Thought Disturbance. It showed good test–retest reliability and rated significant social behaviour in a community sample. Weak correlations were observed with positive and negative symptoms. With the exception of Depressed Behaviour, the SBS factors showed strong correlations with the LSP. Conclusion: SBS-17 is a valid measure assessing relevant community social functioning factors with relatively few items. The SBS could be useful both in research and in clinical settings. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Schizophrenia is a severe mental disorder characterised by a complex array of symptoms and cognitive impairments. However, the only attribute which applies invariably to all individual cases is a marked deterioration in social functioning. Now that the majority of people suffering from schizophrenia reside in the community, the measurement of social functioning has become a crucial indicator not only of their social functioning but also of their well being. Caregivers are increasingly directed by the mental health services to a goal of functional community participation. This goal appears to be of importance not only for services but also, and crucially, for service users (Crawford et al., 2011; Hampson et al., 2011). Such a goal, in order to be assessed and evaluated, must be translated into specific measures first and then carefully tested, refined and validated. The evaluation of social behaviour and social integration is a significant topic in psychiatric research and for the evaluation of rehabilitation programmes (Bromley and Brekke, 2010; Lin et al., 2013). A good measure of social functioning should be parsimonious, require a short administration time but also have robust psychometric properties resulting from extensive testing in different settings and with different ⁎ Corresponding author at: Department of Psychology, Institute of Psychiatry, King's College London, De Crespigny Park, SE5 8AF London, UK. Tel.: + 44 20 7848 5001; fax: + 44 20 7848 0334. 0920-9964/$ – see front matter © 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.schres.2013.12.016
populations. The Social Behaviour Schedule (SBS) (Wykes and Sturt, 1986) is one such measure. The assessment is administered as a semistructured interview with an informant therefore removing bias from self-report. It focuses on the patient's functioning in the past month. Compared to other available measures, the SBS was rated by an expert panel as amongst the best measures of real-world social functioning (Leifker et al., 2011). The scale is available in several languages including Spanish, Italian and Portuguese (Ballantini et al., 1989; Salvador-Carulla et al., 1998; Lima et al., 2006). The factorial structure of the SBS has been reported in several studies. Two of these studies (Harvey et al., 1996; Curson et al., 1999) identified the same four factors: ‘Thought disturbance’, ‘Social withdrawal’, ‘Depressed behaviour’ and ‘Anti-social behaviour’. In the same studies the factors were shown to distinguish between long-stay acute and community patients and differently correlate with symptoms and social functioning variables. Lima et al. (2006), in a study of long-stay patients, also reported four factors extracted from the SBS that largely overlap with previous factor analytic studies including ‘Social withdrawal’, ‘Embarrassing social behaviour’, ‘Restless behaviour’, and ‘Hostility and violence’. Although the SBS was developed to assess problems which prevented movement from inpatient settings to the community (Wykes, 1982; Wykes and Sturt, 1986), it has also been tested in supported accommodation (Hewett et al., 1975; Ryan and Wing, 1979) and community care settings (e.g. Wykes, 1982). After more than two decades of clinical use and
M. Cella et al. / Schizophrenia Research 153 (2014) 220–224
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nearly 30 years after the initial validation study (Wykes and Sturt, 1986) the time has come for ‘field’ verification. Expectations of social behaviour are governed by the social norms of the time and therefore the measure may now need adaptation for the next era of psychiatric care. The aim of the studies presented in this paper is to test the SBS reliability and explore its factor structure and validity in community settings. In particular we anticipate the SBS scores to fulfil some expected psychometric standards by showing not only good internal consistency and test–retest reliability but also the expected associations with indicators of illness chronicity, employment and socio-economic status. Further, we expect high levels of associations with a measure of functioning and modest/ moderate correlations with symptoms.
those with a PANSS total score change below 10% between the two assessment points. The two assessments were conducted by the same informant. Test–retest was evaluated using intraclass correlation (ICC).
2. Methods
2.2.1. Measure Life Skills Profile (LSP) (Rosen et al., 1989) is a 39-item scale each scored on a 4-point ordinal rating. High scores indicate high levels of life skills and social functioning. The scale has 5 factors: self-care (10 items), non-turbulence (12 items), social contact (6 items), communication (6 items) and responsibility (5 items). The SBS was collected in addition.
2.1. Study 1 2.1.1. Participants Participants were 421 out-patients with schizophrenia, diagnosed using Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in a range of community mental health services in South London. Details of each participant's psychiatric history and antipsychotic medication were collected from the clinical notes. Antipsychotic dosage was converted to chlorpromazine equivalents using well-known methods (Woods, 2003). 2.1.2. Measures Social behaviour was measured with the 21-item SBS (Wykes and Sturt, 1986). The assessment was completed through an interview with the patient's care coordinator who, depending on the setting, was a community psychiatric nurse, a social worker, a psychiatrist or a clinical psychologist. All items are rated on a 5-point anchored scale (i.e. from 0 to 4), with a higher score representing lower levels of functioning. The SBS total score is the sum of all item scores. The SBS problem score represents the number of items endorsed at anchor points 3 or 4. Scale completion takes approximately 15 min. Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987) by trained evaluators. All evaluators achieved high reliability with each other (i.e. Kappa N .80 for individual symptom ratings) before evaluating participants included in this study. PANSS positive, negative, general psychopathology subscales and total score were used in the analysis. Basic demographic and clinical details were also collected. 2.1.3. Data analysis Descriptive statistics and Cronbach's alpha for all SBS items were computed. SBS dimensionality was explored using a principal components analysis with oblimin rotation using Kaiser's criterion for factor retention (i.e., eigenvalue N 1) (Kaiser, 1960). In line with previous reports finding relationships between social functioning, clinical, and demographic variables and medication levels (Rosen et al., 1989; Patterson et al., 2001; Ventura et al., 2009; Guo et al., 2010), we used bivariate correlations between the SBS dimensions, sociodemographic factors, antipsychotic medication levels and the PANSS scores. Discriminant validity was tested using variance analysis (ANOVA) with Tukey's HSD test. P-Values were determined, and significance was assessed by conducting Benjamini–Hochberg correction for multiple testing to control for type I error (Benjamini and Hochberg, 1995). 2.1.4. Test–retest reliability The SBS was rated twice on 62 clinically stable patients with a three month interval. This time interval was chosen because in a community population behaviour is expected to be more stable. The longer time interval may prevent raters from relying solely on their initial assessment once asked to complete the retest. Stable patients were defined as
2.2. Study 2 The aim of Study 2 was to investigate the concurrent validity of the SBS with a similar assessment tool measuring life skills and social functioning. Participants were 143 out-patients with schizophrenia fulfilling the same criteria of individuals recruited for Study 1.
3. Results Participant characteristics for both studies are shown in Table 1.
3.1. Study 1 3.1.1. Internal consistency and construct validity The SBS-21 showed very high skewness (i.e. N3) and kurtosis (N 10) values for four items: acting out of bizarre ideas, posturing and mannerism, violent threatening or destructive behaviour, and inappropriate sexual behaviour. These items reported higher than 90% endorsement of ‘0’ level and 95% when considered ‘0’ and ‘1’ together, showing a significant lack of variability. Due to this violation of multivariate normality these items were excluded from the subsequent analysis (Fabrigar et al., 1999). Cronbach's alpha on the remaining 17 items was .81 with no items whose exclusion increased the overall reliability value (Table 2). An exploratory factor analysis, performed on the 17 remaining items, retrieved 4 factors, (Kaiser–Meyer–Olkin value of .81 and a Bartlett's Test of Sphericity of 1869.03, p b .0005) and explained 54.2% of the total variance (Table 3). The obliquely rotated pattern matrix of the four factors solution is presented in Table 2. The factors were labelled: Antisocial Behaviour (AB), Depressed Behaviour (DB), Social Withdrawal (SW) and Thought Disturbance (TD). Cronbach's alpha for the four factors was .69, .61, .74 and .67 respectively. Table 1 Demographic characteristic of participants in Study 1 and Study 2.
Male — N (%) Age — mean (SD) Education level yrs First contact with psychiatric services (yrs) PANSS positive PANSS negative PANSS general Medication (Mg–chlorpromazine equivalents) SBS total score SBS antisocial behaviour SBS depressed behaviour SBS social withdrawal SBS thought disturbance SBS problem score
Study 1 (N = 421)
Study 2 (N = 143)
232 (55) 36.4 (11.7) 12.8 (2.5) 3.1 (7.8) 12.8 (4.9) 14.04 (6.5) 29.2 (7.8) 211.5 (315.9) 9.1 (7.6) 2.9 (3.6) 2.0 (2.3) 2.8 (2.6) 1.3 (2.1) 1.1 (1.6)
93 (65) 43.8 (9.6) n/a 3.7 (0.6) n/a n/a n/a n/a 8.7 (5.9) 2.4 (2.6) 2.2 (1.9) 3 (2.3) 1.2 (2.1) 1.0 (1.4)
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Table 2 SBS items descriptive statistics for Study 1 participants (n = 421).
1 Taking the initiative 2 Coherence of conversation 3 Oddity/Inappropriateness of conversation 4 Ability to make appropriate social contacts 5 Hostility/friendliness 6 Attention-seeking behaviour 7 Suicidal ideas and self harm 8 Panic attacks and phobias 9 Overactivity and restlessness 10 Laughing and talking to self 13 Socially unacceptable manners or habits 15 Depression 17 Personal appearance and hygiene 18 Slowness 19 Underactivity 20 Concentration 21 Other behaviours that impede progress Total score
Mean
SD
Cronbach's alpha if item deleted
.63 .37 .57 .36 .23 .23 .24 .79 .44 .52 .30 .55 .60 .54 .94 .74 1.05 9.10
.86 .87 .96 .76 .51 .62 .69 .98 .90 1.14 .72 .82 1.01 .84 1.03 .70 1.43 7.68
.80 .81 .79 .80 .81 .80 .81 .80 .80 .79 .80 .81 .79 .80 .79 .79 .80
Table 3 Principal component exploratory factor analysis, rotation method oblimin with Kaiser normalization, of the SBS (421 subjects): extraction factors with eigenvalue N 1.
Item n°
Factors 1
21
13
17
6
10 5 15 7 8 9
Other behaviours that impede progress Socially unacceptable manners or habits Personal appearance and hygiene Attention–seeking behaviour
20
Concentration
2
Coherence of conversation
4
Ability to make appropriate social contact Oddity/ inappropriateness of conversation % variance explained Cronbach’s alphas
3
4
.644
3.1.3. Discriminant validity As expected, married participants (10%) have better social behaviour scores compared to single and divorced individuals, F(2, 402) = 3.3, p = 0.002. Those who have had limited experience of paid employment (i.e. never had a paid job for more than 3 months) have poorer social behaviour: total SBS, F(4, 398) = 4.1, p b 0.001; SBS Antisocial, F(4, 398) = 4.8, p b 0.001; SBS Withdrawal, F(4, 398) = 6.3, p b 0.001; SBS Problem score, F(4, 398) = 3.4, p = 0.005, compared to those who have experienced more employment (78.6%). SBS total score, SBS Antisocial, SBS Withdrawal and SBS Thought disturbance significantly discriminate between individuals living independently (including with a partner or sharing) compared to those living in supported accommodation (e.g. hostel or lodging with some services provided); with participants living in supported accommodation scoring roughly twice the score of those in who lived in independent accommodation (all p b .001). 3.1.4. Test–retest reliability Table 4 shows the time 1 and 2 means of the subscales of SBS-17 items, and the intraclass correlations between the two assessments. The reliability was high, with percent agreement ranging from 76% to 91%; all the coefficients reached statistical significance.
.679
–.315
.555
3.2. Study 2
.548 .508
Depression Suicidal ideas and self harm Panic attacks and phobia Overactivity and restlessness Slowness Underactivity Taking the initiative
3
.715
Laughing and talking to self Hostility/friendliness
18 19 1
2
3.1.2. Correlations with sociodemographic and clinical variables After Benjamini–Hochberg correction, significant, negative correlations between SW and time since first contact with psychiatric services (r = − 0.19, p b 0.01) and with age (r = − 0.15, p b 0.01) were observed. AB negatively correlated with educational level (r = − 0.15, p b 0.01). There were no significant correlations between medication and SBS constructs but PANSS positive symptoms significantly correlated with AB, TD and SBS total score (r = 0.18, p b 0.01; r = 0.17, p b 0.01 and r = 0.14, p b 0.05). There was a significant positive association between the negative subscale and SW (r = 0.24, p b 0.01) and SBS total score (r = 0.14, p b 0.05). PANSS general psychopathology correlated with all SBS factors (r between 0.17 and 0.31, all p b 0.01). The PANSS total score also was significantly correlated with all the SBS factors (r between 0.16 and 0.44, all p b 0.01).
.780 .713 .608 .513
.331 –.795
3.2.1. Concurrent validity As expected, three SBS factors (i.e. AB, SW and TD) and the total SBS score show strong negative correlations with the LSP scales. Correlations with AB ranged between − 0.48 for Social Contact and −0.8 for Self-care. Correlations with SW ranged between −0.37 for Responsibility and −0.7 for Social Contact. Correlations with TD ranged between −0.33 for Responsibility and −0.63 for Communication. The SBS total and the LSP total had a high negative correlation (r = −0.86). All correlations were significant at p b 0.0001 level. 4. Discussion
–.775 –.700 .364
–.411 .831
.613
In this study we assess the psychometric properties of the SBS in two large samples of community outpatients with a diagnosis of schizophrenia. The analyses conducted in the two studies contributed to a redefinition of the 21-item version of the SBS into a 17-item version more Table 4 Comparison of SBS factors and total score between time 1 and time 2 (n = 62). Time 1
.573
27.00
Loadings less than .30 have been omitted.
.687
11.01 .612
9.39 .738
6.81 .668
Antisocial behaviour Depressed behaviour Social withdrawal Thought disturbance Total score Problem score
2.95 2.21 3.55 1.26 9.97 1.1
± ± ± ± ± ±
Time 2 3.18 1.99 2.91 1.85 6.50 (1.6)
2.47 2.04 3.00 1.19 8.71 0.98
± ± ± ± ± ±
ICC 2.63 1.93 2.35 2.13 5.93 (1.4)
.76 .76 .81 .82 .91 .90
M. Cella et al. / Schizophrenia Research 153 (2014) 220–224
suitable for community patients (see Appendix A for full version). The 17-item version of the scale assesses important domains of social functioning and shows modest association with symptom assessment and high association with a functional measure. Both discriminant and concurrent validity and test re-test reliability are acceptable. Three previous studies report factor analyses of the SBS; however, these were different in their aims and populations (Harvey et al., 1996; Curson et al., 1999; Lima et al., 2006). Two studies defined the characteristic patterns of problem behaviours related to symptomatic subtypes of schizophrenia (Harvey et al., 1996; Curson et al., 1999) and Lima et al. (2006) performed a construct validation in a long-stay population. The results from the current study confirm the factor structure from two studies (Harvey et al., 1996; Curson et al., 1999) with similar explained variance and item loadings, suggesting the use of the same factor labels. We observed no significant correlations between the SBS factors and medication levels and only weak correlations between positive symptoms and AB, TD and SBS total score. This finding is consistent with previous reports suggesting that impairment in social functioning in schizophrenia is unlikely to be associated with psychotic symptoms and medications (Heinssen et al., 2000; Bellack et al., 2004). All the correlations between the SBS and PANSS were weak (b 0.3) replicating findings of previous studies in the field of social behaviour. Exceptions are the Social Function Scale (SFS) (Birchwood et al., 1990) and the WHO Disability Assessment Schedule (WHODAS-II) (McKibbin et al., 2004) which correlated significantly with symptoms making these assessments less independent of symptoms than the SBS. The weak observed correlation is compatible with the different perspectives of the psychopathological and social evaluations with only partial overlap amongst the constructs that interact dynamically with each other (Harvey et al., 1996). We found that several items, thought important to good community maintenance, were rarely endorsed and had very limited variability suggesting exclusion from the analysis. These items are nevertheless important as they assess behaviours that may constitute a barrier to independent living (e.g. violence, inappropriate sexual behaviours). In consideration of their importance, despite the low endorsement frequencies, these behaviours can be recorded under the last item of the SBS-17 called “other behaviour” and will be mentioned in the guidance. This will prevent these important behaviours from being missed. Not surprisingly the SBS Antisocial Behaviour showed strong negative correlations with the LSP factors non-turbulence, self-care and communication; while the SBS Social Withdrawal factor showed strong negative association with the LSP factors self-care and social contact. Thought Disturbance showed relevant although moderate negative correlations (−.30 b r b −.70) with all the LSP factors. The SBS therefore seems to be able to provide comprehensive information on patient's community experience with a smaller number of items compared to the LSP. The discriminant validity results also corroborate the constructs measured by the SBS. In particular all the SBS scales show lower scores (i.e. less problems) in those individuals with a considerable employment history. This is an important finding confirming the close association between vocational and functional capacities in people with schizophrenia (Tsang et al., 2010). The field of functional outcome measurement in psychosis is a challenging one. A number of large collaborations are attempting to devise new measures that would overcome the limits of indirect assessments, reduce the assessor time commitment and would be prognostic and have better and clearer links to interventions (Harvey et al., 2011). Good measures in this field are clearly crucial; however, sound validation processes and field use cannot be replaced. The introduction of new measures would inevitably require a long preparation and validation time; therefore it seems wise not only to innovate but also to capitalise on the history of long standing measures in this field. The new
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version of the SBS has these characteristics and the potential to enrich this field. Two limitations need to be noted in considering the results of this study. It would have been desirable to assess the agreement across different categories of informants, in particular between a family member and a health care professional. Recent research, however, suggests that these two informants tend to have converging ratings (Harvey et al., 2013). A second limitation is not having assessed the SBS against a global measure of recovery encompassing other more holistic outcomes such as quality of life and illness perception. On the basis of its good psychometric properties the 17-item SBS can be recommended as useful instrument for measuring behaviours of patients living in the community. The schedule may also be relevant to identify strengths and weaknesses in social areas in need of more specific attention as well as in research settings where a variety of different dimensions need to be assessed with parsimony. Role of the funding source None specific to this project. Contributors PS and MC did the analyses. MC, PS and TW wrote the first draft of the paper. All authors contributed to the final version and have approved the final manuscript. Conflict of interest None. Acknowledgements Til Wykes would like to acknowledge the support of the NIHR Biomedical Sciences Centre in Mental Health at the South London and Maudsley Foundation Trust and the Institute of Psychiatry, King's College London as well as her NIHR Senior Investigator Award.
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Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Measuring community functioning in schizophrenia with the Social Behaviour Schedule Matteo Cella a,⁎, Paolo Stratta a,b, Kamel Chahal c, Vyv Huddy d, Clare Reeder a, Til Wykes a a
Institute of Psychiatry, King's College London, UK Department of Mental Health, ASL 1, L'Aquila, Italy South London and Maudsley NHS Foundation Trust, London, UK d Research Department of Clinical, Educational and Health Psychology, University College London, UK b c
a r t i c l e
i n f o
Article history: Received 15 September 2013 Received in revised form 28 November 2013 Accepted 27 December 2013 Available online 22 January 2014 Keywords: Schizophrenia Psychosis Functioning Social behaviour Assessment
a b s t r a c t Background: Current emphasis on community integration requires reliable and valid measures of social behaviour; existing assessments largely overlap with symptoms or provide little detail on functioning. This study aims to re-assess the Social Behaviour Schedule (SBS) to fulfil this measurement role. Methods: Internal consistency, construct validity and test–retest reliability were investigated in 421 community out-patients with schizophrenia. Concurrent validity was assessed against the Life Skill Profile (LSP), in 143 additional patients. Results: A 17-item SBS supported the construct validity of four factors: Antisocial Behaviour, Depressed Behaviour, Social Withdrawal and Thought Disturbance. It showed good test–retest reliability and rated significant social behaviour in a community sample. Weak correlations were observed with positive and negative symptoms. With the exception of Depressed Behaviour, the SBS factors showed strong correlations with the LSP. Conclusion: SBS-17 is a valid measure assessing relevant community social functioning factors with relatively few items. The SBS could be useful both in research and in clinical settings. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Schizophrenia is a severe mental disorder characterised by a complex array of symptoms and cognitive impairments. However, the only attribute which applies invariably to all individual cases is a marked deterioration in social functioning. Now that the majority of people suffering from schizophrenia reside in the community, the measurement of social functioning has become a crucial indicator not only of their social functioning but also of their well being. Caregivers are increasingly directed by the mental health services to a goal of functional community participation. This goal appears to be of importance not only for services but also, and crucially, for service users (Crawford et al., 2011; Hampson et al., 2011). Such a goal, in order to be assessed and evaluated, must be translated into specific measures first and then carefully tested, refined and validated. The evaluation of social behaviour and social integration is a significant topic in psychiatric research and for the evaluation of rehabilitation programmes (Bromley and Brekke, 2010; Lin et al., 2013). A good measure of social functioning should be parsimonious, require a short administration time but also have robust psychometric properties resulting from extensive testing in different settings and with different ⁎ Corresponding author at: Department of Psychology, Institute of Psychiatry, King's College London, De Crespigny Park, SE5 8AF London, UK. Tel.: + 44 20 7848 5001; fax: + 44 20 7848 0334. 0920-9964/$ – see front matter © 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.schres.2013.12.016
populations. The Social Behaviour Schedule (SBS) (Wykes and Sturt, 1986) is one such measure. The assessment is administered as a semistructured interview with an informant therefore removing bias from self-report. It focuses on the patient's functioning in the past month. Compared to other available measures, the SBS was rated by an expert panel as amongst the best measures of real-world social functioning (Leifker et al., 2011). The scale is available in several languages including Spanish, Italian and Portuguese (Ballantini et al., 1989; Salvador-Carulla et al., 1998; Lima et al., 2006). The factorial structure of the SBS has been reported in several studies. Two of these studies (Harvey et al., 1996; Curson et al., 1999) identified the same four factors: ‘Thought disturbance’, ‘Social withdrawal’, ‘Depressed behaviour’ and ‘Anti-social behaviour’. In the same studies the factors were shown to distinguish between long-stay acute and community patients and differently correlate with symptoms and social functioning variables. Lima et al. (2006), in a study of long-stay patients, also reported four factors extracted from the SBS that largely overlap with previous factor analytic studies including ‘Social withdrawal’, ‘Embarrassing social behaviour’, ‘Restless behaviour’, and ‘Hostility and violence’. Although the SBS was developed to assess problems which prevented movement from inpatient settings to the community (Wykes, 1982; Wykes and Sturt, 1986), it has also been tested in supported accommodation (Hewett et al., 1975; Ryan and Wing, 1979) and community care settings (e.g. Wykes, 1982). After more than two decades of clinical use and
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nearly 30 years after the initial validation study (Wykes and Sturt, 1986) the time has come for ‘field’ verification. Expectations of social behaviour are governed by the social norms of the time and therefore the measure may now need adaptation for the next era of psychiatric care. The aim of the studies presented in this paper is to test the SBS reliability and explore its factor structure and validity in community settings. In particular we anticipate the SBS scores to fulfil some expected psychometric standards by showing not only good internal consistency and test–retest reliability but also the expected associations with indicators of illness chronicity, employment and socio-economic status. Further, we expect high levels of associations with a measure of functioning and modest/ moderate correlations with symptoms.
those with a PANSS total score change below 10% between the two assessment points. The two assessments were conducted by the same informant. Test–retest was evaluated using intraclass correlation (ICC).
2. Methods
2.2.1. Measure Life Skills Profile (LSP) (Rosen et al., 1989) is a 39-item scale each scored on a 4-point ordinal rating. High scores indicate high levels of life skills and social functioning. The scale has 5 factors: self-care (10 items), non-turbulence (12 items), social contact (6 items), communication (6 items) and responsibility (5 items). The SBS was collected in addition.
2.1. Study 1 2.1.1. Participants Participants were 421 out-patients with schizophrenia, diagnosed using Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in a range of community mental health services in South London. Details of each participant's psychiatric history and antipsychotic medication were collected from the clinical notes. Antipsychotic dosage was converted to chlorpromazine equivalents using well-known methods (Woods, 2003). 2.1.2. Measures Social behaviour was measured with the 21-item SBS (Wykes and Sturt, 1986). The assessment was completed through an interview with the patient's care coordinator who, depending on the setting, was a community psychiatric nurse, a social worker, a psychiatrist or a clinical psychologist. All items are rated on a 5-point anchored scale (i.e. from 0 to 4), with a higher score representing lower levels of functioning. The SBS total score is the sum of all item scores. The SBS problem score represents the number of items endorsed at anchor points 3 or 4. Scale completion takes approximately 15 min. Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987) by trained evaluators. All evaluators achieved high reliability with each other (i.e. Kappa N .80 for individual symptom ratings) before evaluating participants included in this study. PANSS positive, negative, general psychopathology subscales and total score were used in the analysis. Basic demographic and clinical details were also collected. 2.1.3. Data analysis Descriptive statistics and Cronbach's alpha for all SBS items were computed. SBS dimensionality was explored using a principal components analysis with oblimin rotation using Kaiser's criterion for factor retention (i.e., eigenvalue N 1) (Kaiser, 1960). In line with previous reports finding relationships between social functioning, clinical, and demographic variables and medication levels (Rosen et al., 1989; Patterson et al., 2001; Ventura et al., 2009; Guo et al., 2010), we used bivariate correlations between the SBS dimensions, sociodemographic factors, antipsychotic medication levels and the PANSS scores. Discriminant validity was tested using variance analysis (ANOVA) with Tukey's HSD test. P-Values were determined, and significance was assessed by conducting Benjamini–Hochberg correction for multiple testing to control for type I error (Benjamini and Hochberg, 1995). 2.1.4. Test–retest reliability The SBS was rated twice on 62 clinically stable patients with a three month interval. This time interval was chosen because in a community population behaviour is expected to be more stable. The longer time interval may prevent raters from relying solely on their initial assessment once asked to complete the retest. Stable patients were defined as
2.2. Study 2 The aim of Study 2 was to investigate the concurrent validity of the SBS with a similar assessment tool measuring life skills and social functioning. Participants were 143 out-patients with schizophrenia fulfilling the same criteria of individuals recruited for Study 1.
3. Results Participant characteristics for both studies are shown in Table 1.
3.1. Study 1 3.1.1. Internal consistency and construct validity The SBS-21 showed very high skewness (i.e. N3) and kurtosis (N 10) values for four items: acting out of bizarre ideas, posturing and mannerism, violent threatening or destructive behaviour, and inappropriate sexual behaviour. These items reported higher than 90% endorsement of ‘0’ level and 95% when considered ‘0’ and ‘1’ together, showing a significant lack of variability. Due to this violation of multivariate normality these items were excluded from the subsequent analysis (Fabrigar et al., 1999). Cronbach's alpha on the remaining 17 items was .81 with no items whose exclusion increased the overall reliability value (Table 2). An exploratory factor analysis, performed on the 17 remaining items, retrieved 4 factors, (Kaiser–Meyer–Olkin value of .81 and a Bartlett's Test of Sphericity of 1869.03, p b .0005) and explained 54.2% of the total variance (Table 3). The obliquely rotated pattern matrix of the four factors solution is presented in Table 2. The factors were labelled: Antisocial Behaviour (AB), Depressed Behaviour (DB), Social Withdrawal (SW) and Thought Disturbance (TD). Cronbach's alpha for the four factors was .69, .61, .74 and .67 respectively. Table 1 Demographic characteristic of participants in Study 1 and Study 2.
Male — N (%) Age — mean (SD) Education level yrs First contact with psychiatric services (yrs) PANSS positive PANSS negative PANSS general Medication (Mg–chlorpromazine equivalents) SBS total score SBS antisocial behaviour SBS depressed behaviour SBS social withdrawal SBS thought disturbance SBS problem score
Study 1 (N = 421)
Study 2 (N = 143)
232 (55) 36.4 (11.7) 12.8 (2.5) 3.1 (7.8) 12.8 (4.9) 14.04 (6.5) 29.2 (7.8) 211.5 (315.9) 9.1 (7.6) 2.9 (3.6) 2.0 (2.3) 2.8 (2.6) 1.3 (2.1) 1.1 (1.6)
93 (65) 43.8 (9.6) n/a 3.7 (0.6) n/a n/a n/a n/a 8.7 (5.9) 2.4 (2.6) 2.2 (1.9) 3 (2.3) 1.2 (2.1) 1.0 (1.4)
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Table 2 SBS items descriptive statistics for Study 1 participants (n = 421).
1 Taking the initiative 2 Coherence of conversation 3 Oddity/Inappropriateness of conversation 4 Ability to make appropriate social contacts 5 Hostility/friendliness 6 Attention-seeking behaviour 7 Suicidal ideas and self harm 8 Panic attacks and phobias 9 Overactivity and restlessness 10 Laughing and talking to self 13 Socially unacceptable manners or habits 15 Depression 17 Personal appearance and hygiene 18 Slowness 19 Underactivity 20 Concentration 21 Other behaviours that impede progress Total score
Mean
SD
Cronbach's alpha if item deleted
.63 .37 .57 .36 .23 .23 .24 .79 .44 .52 .30 .55 .60 .54 .94 .74 1.05 9.10
.86 .87 .96 .76 .51 .62 .69 .98 .90 1.14 .72 .82 1.01 .84 1.03 .70 1.43 7.68
.80 .81 .79 .80 .81 .80 .81 .80 .80 .79 .80 .81 .79 .80 .79 .79 .80
Table 3 Principal component exploratory factor analysis, rotation method oblimin with Kaiser normalization, of the SBS (421 subjects): extraction factors with eigenvalue N 1.
Item n°
Factors 1
21
13
17
6
10 5 15 7 8 9
Other behaviours that impede progress Socially unacceptable manners or habits Personal appearance and hygiene Attention–seeking behaviour
20
Concentration
2
Coherence of conversation
4
Ability to make appropriate social contact Oddity/ inappropriateness of conversation % variance explained Cronbach’s alphas
3
4
.644
3.1.3. Discriminant validity As expected, married participants (10%) have better social behaviour scores compared to single and divorced individuals, F(2, 402) = 3.3, p = 0.002. Those who have had limited experience of paid employment (i.e. never had a paid job for more than 3 months) have poorer social behaviour: total SBS, F(4, 398) = 4.1, p b 0.001; SBS Antisocial, F(4, 398) = 4.8, p b 0.001; SBS Withdrawal, F(4, 398) = 6.3, p b 0.001; SBS Problem score, F(4, 398) = 3.4, p = 0.005, compared to those who have experienced more employment (78.6%). SBS total score, SBS Antisocial, SBS Withdrawal and SBS Thought disturbance significantly discriminate between individuals living independently (including with a partner or sharing) compared to those living in supported accommodation (e.g. hostel or lodging with some services provided); with participants living in supported accommodation scoring roughly twice the score of those in who lived in independent accommodation (all p b .001). 3.1.4. Test–retest reliability Table 4 shows the time 1 and 2 means of the subscales of SBS-17 items, and the intraclass correlations between the two assessments. The reliability was high, with percent agreement ranging from 76% to 91%; all the coefficients reached statistical significance.
.679
–.315
.555
3.2. Study 2
.548 .508
Depression Suicidal ideas and self harm Panic attacks and phobia Overactivity and restlessness Slowness Underactivity Taking the initiative
3
.715
Laughing and talking to self Hostility/friendliness
18 19 1
2
3.1.2. Correlations with sociodemographic and clinical variables After Benjamini–Hochberg correction, significant, negative correlations between SW and time since first contact with psychiatric services (r = − 0.19, p b 0.01) and with age (r = − 0.15, p b 0.01) were observed. AB negatively correlated with educational level (r = − 0.15, p b 0.01). There were no significant correlations between medication and SBS constructs but PANSS positive symptoms significantly correlated with AB, TD and SBS total score (r = 0.18, p b 0.01; r = 0.17, p b 0.01 and r = 0.14, p b 0.05). There was a significant positive association between the negative subscale and SW (r = 0.24, p b 0.01) and SBS total score (r = 0.14, p b 0.05). PANSS general psychopathology correlated with all SBS factors (r between 0.17 and 0.31, all p b 0.01). The PANSS total score also was significantly correlated with all the SBS factors (r between 0.16 and 0.44, all p b 0.01).
.780 .713 .608 .513
.331 –.795
3.2.1. Concurrent validity As expected, three SBS factors (i.e. AB, SW and TD) and the total SBS score show strong negative correlations with the LSP scales. Correlations with AB ranged between − 0.48 for Social Contact and −0.8 for Self-care. Correlations with SW ranged between −0.37 for Responsibility and −0.7 for Social Contact. Correlations with TD ranged between −0.33 for Responsibility and −0.63 for Communication. The SBS total and the LSP total had a high negative correlation (r = −0.86). All correlations were significant at p b 0.0001 level. 4. Discussion
–.775 –.700 .364
–.411 .831
.613
In this study we assess the psychometric properties of the SBS in two large samples of community outpatients with a diagnosis of schizophrenia. The analyses conducted in the two studies contributed to a redefinition of the 21-item version of the SBS into a 17-item version more Table 4 Comparison of SBS factors and total score between time 1 and time 2 (n = 62). Time 1
.573
27.00
Loadings less than .30 have been omitted.
.687
11.01 .612
9.39 .738
6.81 .668
Antisocial behaviour Depressed behaviour Social withdrawal Thought disturbance Total score Problem score
2.95 2.21 3.55 1.26 9.97 1.1
± ± ± ± ± ±
Time 2 3.18 1.99 2.91 1.85 6.50 (1.6)
2.47 2.04 3.00 1.19 8.71 0.98
± ± ± ± ± ±
ICC 2.63 1.93 2.35 2.13 5.93 (1.4)
.76 .76 .81 .82 .91 .90
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suitable for community patients (see Appendix A for full version). The 17-item version of the scale assesses important domains of social functioning and shows modest association with symptom assessment and high association with a functional measure. Both discriminant and concurrent validity and test re-test reliability are acceptable. Three previous studies report factor analyses of the SBS; however, these were different in their aims and populations (Harvey et al., 1996; Curson et al., 1999; Lima et al., 2006). Two studies defined the characteristic patterns of problem behaviours related to symptomatic subtypes of schizophrenia (Harvey et al., 1996; Curson et al., 1999) and Lima et al. (2006) performed a construct validation in a long-stay population. The results from the current study confirm the factor structure from two studies (Harvey et al., 1996; Curson et al., 1999) with similar explained variance and item loadings, suggesting the use of the same factor labels. We observed no significant correlations between the SBS factors and medication levels and only weak correlations between positive symptoms and AB, TD and SBS total score. This finding is consistent with previous reports suggesting that impairment in social functioning in schizophrenia is unlikely to be associated with psychotic symptoms and medications (Heinssen et al., 2000; Bellack et al., 2004). All the correlations between the SBS and PANSS were weak (b 0.3) replicating findings of previous studies in the field of social behaviour. Exceptions are the Social Function Scale (SFS) (Birchwood et al., 1990) and the WHO Disability Assessment Schedule (WHODAS-II) (McKibbin et al., 2004) which correlated significantly with symptoms making these assessments less independent of symptoms than the SBS. The weak observed correlation is compatible with the different perspectives of the psychopathological and social evaluations with only partial overlap amongst the constructs that interact dynamically with each other (Harvey et al., 1996). We found that several items, thought important to good community maintenance, were rarely endorsed and had very limited variability suggesting exclusion from the analysis. These items are nevertheless important as they assess behaviours that may constitute a barrier to independent living (e.g. violence, inappropriate sexual behaviours). In consideration of their importance, despite the low endorsement frequencies, these behaviours can be recorded under the last item of the SBS-17 called “other behaviour” and will be mentioned in the guidance. This will prevent these important behaviours from being missed. Not surprisingly the SBS Antisocial Behaviour showed strong negative correlations with the LSP factors non-turbulence, self-care and communication; while the SBS Social Withdrawal factor showed strong negative association with the LSP factors self-care and social contact. Thought Disturbance showed relevant although moderate negative correlations (−.30 b r b −.70) with all the LSP factors. The SBS therefore seems to be able to provide comprehensive information on patient's community experience with a smaller number of items compared to the LSP. The discriminant validity results also corroborate the constructs measured by the SBS. In particular all the SBS scales show lower scores (i.e. less problems) in those individuals with a considerable employment history. This is an important finding confirming the close association between vocational and functional capacities in people with schizophrenia (Tsang et al., 2010). The field of functional outcome measurement in psychosis is a challenging one. A number of large collaborations are attempting to devise new measures that would overcome the limits of indirect assessments, reduce the assessor time commitment and would be prognostic and have better and clearer links to interventions (Harvey et al., 2011). Good measures in this field are clearly crucial; however, sound validation processes and field use cannot be replaced. The introduction of new measures would inevitably require a long preparation and validation time; therefore it seems wise not only to innovate but also to capitalise on the history of long standing measures in this field. The new
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version of the SBS has these characteristics and the potential to enrich this field. Two limitations need to be noted in considering the results of this study. It would have been desirable to assess the agreement across different categories of informants, in particular between a family member and a health care professional. Recent research, however, suggests that these two informants tend to have converging ratings (Harvey et al., 2013). A second limitation is not having assessed the SBS against a global measure of recovery encompassing other more holistic outcomes such as quality of life and illness perception. On the basis of its good psychometric properties the 17-item SBS can be recommended as useful instrument for measuring behaviours of patients living in the community. The schedule may also be relevant to identify strengths and weaknesses in social areas in need of more specific attention as well as in research settings where a variety of different dimensions need to be assessed with parsimony. Role of the funding source None specific to this project. Contributors PS and MC did the analyses. MC, PS and TW wrote the first draft of the paper. All authors contributed to the final version and have approved the final manuscript. Conflict of interest None. Acknowledgements Til Wykes would like to acknowledge the support of the NIHR Biomedical Sciences Centre in Mental Health at the South London and Maudsley Foundation Trust and the Institute of Psychiatry, King's College London as well as her NIHR Senior Investigator Award.
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