Journal of Abnormal Psychology 1977, Vol. 86, No. 5, 492-500

Relation of Psychopathology and Bilingualism to Kinesic Aspects of Interview Behavior in Schizophrenia Stanley Grand, Luis R. Marcos, Norbert Freedman, and Felix Barroso Clinical Behavior Research Unit, State University of New York, Downstate Medical Center, Brooklyn, New York Ten bilingual schizophrenic patients were interviewed in both their native and second languages. Hand-movement behavior observed during the videotaped interviews was scored and related to ratings of psychopathology derived from the Brief Psychiatric Rating Scale. Discrete symptom clusters were found to be meaningfully related to various types of hand-movement behavior during the nondominant-language interview. These patterns of correlations provide support for the assumption that kinesic behavior is related to cognitive processing dysfunctions and language encoding stress in our patient population. The findings are discussed in terms of the function of kinesic behavior in modulating such stresses. This article focuses on kinesic attributes of communication behavior in bilingual schizophrenic patients interviewed in both their native and second languages. The study is part of an ongoing research program addressed to the investigation of the role of hand-movement behavior during speech. A basic assumption of this work is that apart from their intrinsic communicative value for a listener, hand movements that accompany speech serve an important regulatory and supportive function in the encoding of thought for the speaker himself. Conditions that heighten encoding stress in particular ways should therefore enable us to articulate the role of hand-movement behavior in relation to these stresses. This research was supported in part by Grants MH-14383, MH-1983, and MH-5090 awarded by the National Institute of Mental Health, United States Public Health Service. We wish to express our appreciation to Wilma Bucci and Reuben Margolis for their helpful comments about various aspects of this article and to Lois Lazarus and Philip Faulty for their help in the analysis of the data. Luis R. Marcos is now at the Department of Psychiatry, New York University Medical School, New York, New York. Requests for reprints should be sent to Stanley Grand, Clinical Behavior Research Unit, Department of Psychiatry, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York 11203.

A comparative study of bilingual schizophrenic patients' interviews in both their native and second languages provides a way of highlighting distinctive cognitive-load conditions known to increase encoding stress in very specific ways. For example, whatever may be the underlying mechanism of the schizophrenic process, it is well known that problems with focal attention are prominent in this disorder (Shakow, 1963). Indeed, the schizophrenic disorder appears to entail a high degree of stress associated with vulnerability to distraction, and such stress has been related to qualities of linguistic organization (Grand, Steingart, Freedman, & Buchwald, 197S), conceptual and associational disorganization (Depue, Dubicki, & McCarthy, 1975), and incoherence in speech production (Venables & Wing, 1962). Thus, one form of cognitive-load condition represented in our sample involves patients' vulnerability to distraction, a form of stress that interferes with attentional processes necessary for focused intentional communication. A second kind of cognitive-load condition is provided by bilingualism. Speaking a subordinate language entails a linguistic stress over and above that ordinarily encountered in one's native tongue (Tonaka, Oyama, & Osgood, 1963). Indeed, the stress of communicating in a nondominant language has been shown to increase speech disturbances (Ervin & Osgood, 19S4; 492

INTERVIEW BEHAVIOR IN SCHIZOPHRENIA

Marcos, Urcuyo, Kesselman, Si Alpert, 1973), speech delays (Kolers, 1973), and other indicators of interference with encoding associated with lexical, syntactic, and articulatory difficulties (Marcos, 1976). Therefore, a second sort of cognitive-load condition in our patient sample involves the bilingual patient's difficulty with the process of transforming thoughts into speech, a form of stress most directly related to the verbal encoding process. Two main issues stand out with respect to hand-movement behavior that accompanies speech. The first concerns the role of such behavior as an index of communicative stress, and the second concerns the function of this behavior in regard to such stress. With respect to the first issue, the study of bilingual patients communicating in their native and second languages provides an opportunity to distinguish motoric manifestations of encoding stress associated with psychopathology from those motor manifestations that are associated with the stresses of verbal encoding difficulty. With respect to the second issue, the nature of the relations observed may provide information about the role of such behavior in facilitating the process of articulating ideas in communicative speech. Two classes of hand-movement behavior and their relation to specific cognitive processes have been denned (Freedman, O'Hanlon, Oilman, & Witkin, 1972). One class of movement is termed object focused; these movements, through their empirical relation to the coding of meanings, have been considered to play their role in the representational process. Subcategories of this class of movements have been related to the organization, complexity, rhythm, and meaning of the speech product and are considered to support the chunking and representation of thought (Freedman, Blass, Rifkin, & Quitkin, 1973; Freedman et al., 1972). A second class of movement is termed body focused; these movements, through their empirical relation to tension states, have been considered to play their role in the process of attention regulation. Subcategories of this class of movement have been related to the focusing of attention and

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the regulation of distraction and interference from stimulus field properties (Freedman, in press; Grand, in press; Grand, Freedman, Steingart, & Buchwald, 1975; Barroso, Freedman, Grand, & van Meel, Note 1). The immediate background for the present study is our most recent findings, which showed distinct kinds of hand movements in two different types of chronic schizophrenic patients (Grand, Freedman, Steingart, & Buchwald, 197S). In that study, we contrasted hand-movement behavior in relatively undifferentiated and chronically isolated schizophrenic patients and more highly differentiated and linguistically more articulate chronic belligerent patients. Our findings in that study indicated that one form of body touching, characterized by its amorphous and bilateral form (i.e., finger on hand), was significantly more prevalent in our group of undifferentiated isolated patients; whereas a second form of body touching, characterized by its more discrete, unilateral, and instrumental form (i.e., discrete body touching), was significantly more prevalent in our group of relatively differentiated belligerent patients. Language organization differences were also observed in these two groups of patients, suggesting a more simple "narrative" type of linguistic organization in our undifferentiated patients and a more complex "conditional" type of linguistic organization in our relatively more differentiated patients. Thus, linguistic and kinesic indices reflecting different levels of communicative organization were found to be related to different levels of cognitive organization in schizophrenic patients. However, that study could not address itself directly to the role of kinesics in verbal encoding difficulties in schizophrenia, since both language and kinetic measures were inextricably intertwined with pathology. That is, the relation between kinesics and cognitive organization was confounded by pathological state differences in our patient groups. The present study represents an effort to disentangle this confounding by holding subjects constant while language encoding stress is varied, using a subjects-as-their-own-control design.

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Method Subjects All patients were part of an ongoing research project initiated to explore the effects of interview language on the evaluation of psychopathology in Spanish-American schizophrenic patients (Marcos, Alpert, Urcuyo, & Kesselman, 1973; Marcos, Urcuyo, Kesselman, & Alpert, 1973). The 10 patients included in this study were all recent admissions to the adult services at Bellevue Psychiatric Hospital in New York City. Criteria for admission to the research project were (a) diagnosis of schizophrenia made independently by two psychiatrists, (b) no evidence of organic brain disorder, (c) Spanish as the native language, (d) fluency in English sufficient to participate in English psychiatric interviews, and (e) willingness to volunteer for the study. The final sample of subjects included six males and four females, who were between the ages of 21 and 42 years, ranged in years of education from S to 12 years, and had lived in this country from 3 to 39 years. Raw scores on the Vocabulary subscale of the Wechsler Adult Intelligence Scale (WAIS) given in Spanish ranged from 18 to. 68; in English, the scores ranged from 9 to 60. Differential competence reflected in the WAIS Vocabulary subscale scores ranged from 2 to 32 points, with a mean value of 17.3 points and a modal value of 19 points. However, since WAIS Vocabulary scores in Spanish and in English were uncorrelated with ratings of psychopathology or with any of the hand-movement categories, it is unlikely that this measure is related to the sorts of stress studied in this report. Six of the patients were given a diagnosis of chronic undifferentiated schizophrenia; the remaining four patients were given the diagnosis of schizophrenia with paranoid trends. All patients were receiving medication in the form of phenothiazines, and their dosage level ranged from 30 mg to 400 mg. Extra-pyramidal symptoms were not observable in any of the patients.

Procedure Closed-circuit television recordings were made of standard psychiatric interviews in English and Spanish. The order of interviews was counterbalanced so that half of the patients participated in the English interview first and the Spanish interview second and vice versa for the remaining half of the sample. The two interviews were spaced no more than 24 hours and no less than 20 hours apart. During this period, no change was made in the patient's medication. An English-speaking or Spanish-speaking clinician was present during the interview; however, his participation was minimal because the interview questions had been prerecorded on audiotape in both English and Spanish, and this tape was used as the method of questioning the patient. The English and Spanish questions, which were identical, were presented in the same order. Following the completion of both interviews, the English and Spanish versions of the WAIS were administered to the patients.

Assessment Procedures Brief Psychiatric Rating Scale (BPRS). The Overall and Gorham BPRS has been described elsewhere (Overall & Gorham, 1962). Briefly, this scale permits the clinical evaluation of 18 relatively independent symptom areas on seven-point scales of intensity. In the present study, four psychiatrists who were experienced in the use of the BPRS viewed the interview videotapes and contributed independent ratings on each of the 18 symptom areas. Two of the clinical raters had Spanish as their mother tongue and two were English speaking. Raters were blind to the purpose of the study and to the admission criteria as well. Interrater reliability in the use of the BPRS was established prior to rating the videotapes of the current study and was high (r = .85, p < .01) for ratings of total pathology in a sample of 10 English-speaking schizophrenic patients. Pathology scores for each of the 18 symptom dimensions were obtained separately for the English and Spanish interviews by averaging the ratings of the two Spanish-speaking psychiatrists and the ratings of the two English-speaking psychiatrists. Kinesic behavior. A detailed method for coding the levels of object-focused and body-focused activity and the reliabilities for scoring such activity have been presented elsewhere (Freedman et al., 1972). Briefly, three levels of object-focused activity have been delineated: (a) speech primacy movements, which are qualifying and punctuating motions subordinate to the rhythm of speech and lacking representational quality; (b) representational movements, which are a supplement to the verbal utterance and in which some referent—an object, an idea, or feeling state—is given physical and visible representation; and (c) nonrepresentational movements, consisting of groping and pointing gestures where the primary mode of expression is in the motor realm and is relatively autonomous from the verbal flow. These categories of movement suggest a progression in the level of integration of speech and movement behavior from subordination to supplementation to substitution of movement for the flow of speech. Two-judge percentage agreement for the identification of an object-focused movement was 86%, and category-assignment agreement as to type of objectfocused act was 70%. Three levels of body-focused activity have been delineated that are distinguishable in terms of the relative degree of organization of the movements themselves. Discrete body touching consists of brief (under 3 sec) instrumental acts of body stimulation or the touching of a body adornment such as a tie. Continuous body touching consists of continuous stimulation by the hand of some body part (other than the hands) or of a body adornment. Continuous finger-to-hand activity consists of repetitive and unpatterned continuous stimulation of the fingers and/ or hands. These categories suggest a progression from relatively circumscribed and integrated movement to relatively diffuse an unpatterned movements. Reliabilities for scoring the amount of time

INTERVIEW BEHAVIOR IN SCHIZOPHRENIA spent in each type of body-focused movement ranged from .99 for discrete and continuous body touching to .91 for finger-to-hand movement. All movement behavior is scored by viewing the videotapes on a monitor and by playing back any segment of the tape as many times as the coder may need for a satisfactory location and identification of a particular hand movement. Object-focused movements are scored in relation to speech and, therefore, are computed in terms of rates that take account of the subject's total word output (i.e., Frequency of Object-Focused Movements X 100/Total Words). Such rates are determined separately for total objectfocused movements and their subcategories. Total continuous body-focused movement, as well as the subcategories of these movements, are expressed as time scores and refer to the number of seconds spent in a particular type of activity per interview segment. The distribution of scores is then normalized using a ( X + . S ) ' transformation, where X — number of seconds of movement. Discrete body touching is counted as a single act, and the incidence of such acts is determined for the interview segment. In the present study, 5 minutes of parallel portions of the English and Spanish interviews were coded for analysis.

Results and Discussion Reliability studies (Marcos, Alpert, Urcuyo, & Kesselman, 1973) already established that the BPRS ratings by the two Spanish clinician raters and the two English clinician raters were highly reliable (r — .91 between both sets of raters), and the total pathology score on the BPRS obtained from the English interview was significantly correlated with the score obtained from the Spanish interview (r = .64, p < .OS). It was also established that the magnitude of rated psychopathology increased significantly for all patients under the English-language interview condition regardless of order of interviewing, suggesting that this condition invoked additional stress presumably associated with second-language encoding. To determine the patterning of hand movements and psychopathology in the two languages, we correlated the pathology ratings for the English and Spanish interviews with each of our hand-movement categories obtained from the English and Spanish interviews. Again, order of interviewing was unrelated to the amount of hand movements. This analysis generated two 18 X 12 correlation matrices revealing significant correlations

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for 13 of the 18 BPRS categories. These 13 symptom dimensions were then reviewed, and on the basis of Overall and Gorham's (1962) descriptions, we organized the symptom dimensions according to whether judges' ratings were based primarily on the patient's nonverbal behavior during the interview or on his verbal descriptions of his feelings or experiences. It was felt that distinguishing those symptom ratings that disregard the verbal content of what the patient says would enable us to make inferences about the intensity of psychopathological stress relatively free of linguistic encoding factors. Similarly, those symptoms rated on the basis of the patient's verbal expressions would enable us to make inferences about the role of linguistic encoding stress in the expression of psychopathology. Six of the 13 symptoms were most meaningfully located in a category that we term motor discharge (i.e., tension, motor retardation, withdrawal, excitement, mannerisms, and uncooperativeness); two were considered to be affect-representational (anxiety and depression) ; and five were categorized as ideational-representational (i.e., conceptual disorganization, unusual thoughts, hallucinations, disorientation, and somatic delusions). We then looked at the patterning of the relations between our hand-movement categories and these three symptom clusters.1 1 The Bellevue studies indicated that the total pathology scores on the BPRS for the English and Spanish interviews were highly reliable. However, since our interest in the present research focused on distinct symptom clusters, we undertook studies to estimate the separate reliabilities for each component scale of the BPRS during the two language interviews. As expected, the reliabilities for the separate symptom dimensions were lower than for the total pathology score. The average reliability for the 18 scales during the English-language interview was .67 (p < .05) ; for the Spanish-language interview, it was ,78 ( / > < . 0 0 5 ) . Considering this fact, our interest was limited to clusters of symptom-handmovement relations that were internally consistent with our theoretical expectations. The lower reliabilities for the separate pathology dimensions caution against interpretation of the individual correlations between a particular symptom dimension and handmovement category. Where such individual correlations are discussed in the text, the reliability for rating that symptom dimension was above .79 (P < .005).

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Relation Between Hand Movement and Patterns oj Psychopathology

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Relation of psychopathology and bilingualism to kinesic aspects of interview behavior in schizophrenia.

Journal of Abnormal Psychology 1977, Vol. 86, No. 5, 492-500 Relation of Psychopathology and Bilingualism to Kinesic Aspects of Interview Behavior in...
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