Symptom dimensions in recent-onset schizophrenia and mania: a principal components analysis of the 24-item Brief Psychiatric Rating Scale
Introduction
The Brief Psychiatric Rating Scale (BPRS; Overall and Gorham, 1962) was initially developed as a rapid method to assess symptom change in psychiatric inpatients of various diagnoses and has become one of the most widely used semi-structured instruments in psychiatric research. The original 16-item BPRS was expanded to 18 items (Overall and Klett, 1972). The 18-item version was expanded to 24 items through the addition of six symptom items — bizarre behavior, self-neglect, suicidality, elevated mood, distractibility, and motor hyperactivity — to increase sensitivity to a broader range of psychotic and affective symptoms (Lukoff et al., 1986). The latest version of the expanded 24-item BPRS provides detailed anchor points and probe questions for each item (Ventura et al., 1993). Studies have shown the expanded 24-item BPRS to be a sensitive and effective measure of psychiatric symptoms with good interrater reliability that can be maintained over time (Ventura Green et al., 1993, Roncone et al., 1999).
Psychiatric symptom data gathered with the BPRS have been factor analyzed to identify symptom dimensions in psychiatric disorders. However, most of the factor analyses have used the 16- or 18-item BPRS and were performed on schizophrenia patients who were chronically ill (Guy, 1976, Overall and Beller, 1984, Malla et al., 1993, Mueser et al., 1997, Long and Brekke, 1999). To our knowledge, there are only three published factor analyses of the 24-item BPRS (van der Does et al., 1993, Dingemans et al., 1995, Burger et al., 1997). Van der Does et al. (1993) reported a four-factor solution with a sample of recent-onset schizophrenia patients and Dingemans et al. (1995) a five-factor solution with a diverse sample of psychiatric inpatients. The items of Motor Hyperactivity, Distractibility, and Elevated Mood, which were added to the 18-item version, help to form for van der Does et al. a ‘disorganization’ factor and for Dingemans et al. a ‘mania’ factor. Burger et al. (1997) reported a five-factor solution for the 24-item BPRS with a sample of homeless, chronically mentally ill patients, including factors for positive symptoms, negative symptoms, anxious–depressive symptoms, hostile–suspiciousness, and ‘activity.’ Thus far, it appears that the composition of factors for the 24-item BPRS varies across samples. Furthermore, it is unclear whether a meaningful and replicable fifth factor is present.
In an attempt to replicate previous research, the present study examined the factor structure of symptom ratings on the expanded 24-item BPRS in a sample of recent-onset schizophrenia patients and bipolar manic patients, most of whom also represented recent-onset disorders. The patients were participating in studies at the research center that developed the 24-item version of the BPRS.
Section snippets
Subjects
The sample comprised 141 psychotic patients, 101 (72%) of whom were male with a mean age at study entry of 23.7 years (S.D.=4.8) and mean education of 12.9 years (S.D.=1.9). The ethnic/racial distribution was 70% Caucasian, 8% Latino, 8% African American, 6% Asian, and 6% Other. On the Hollingshead Two-Factor Scale (Hollingshead, 1957) of social class, these patients represented the full range with a mean in the middle class (Mean=3.05, S.D.=1.1). By DSM-III-R criteria (1987), entry diagnoses
Principal components analysis of the 18-item BPRS
First, we conducted a principal components analysis of the 18-item version of the BPRS. Using a principal components analysis, we extracted and examined the four- and five-factor solutions. The five-factor solution resulted in a fifth factor with loadings ≥0.40 from only two BPRS items, uncooperativeness (0.67) and emotional withdrawal (0.68). This fifth factor accounted for only 12% of the variance and was not conceptually coherent. The post-rotated eigenvalues for the first four factors were
Discussion
In the present study a mania factor was formed, indicating a clear advantage for the 24-item BPRS as compared to the 18-item BPRS and the Positive and Negative Syndrome Scale (PANSS). Items that had traditionally loaded on the Hostile–Suspiciousness factor on the 18-item BPRS loaded on a mania factor in the 24-item BPRS. This suggests that affective symptoms which appeared partially as hostility and uncooperativeness may actually be associated with a mania dimension. Furthermore, high loadings
Acknowledgements
The authors wish to thank George Bartzokis, M.D., Craig Childress, M.A., Rosemary Collier, M.S., Rhonda Daily, B.A., David Fogelson, M.D., Sally Friedlob, M.S.W., Debbie Gioia-Hasick, M.S.W., Michael Gitlin, M.D., Sandy Rappe, M.S.W., Margie Stratton, M.A., and the patients of the Aftercare Research Program for their contributions to this project. This research was supported by Research Grants MH37705 (P.I.: Keith H. Nuechterlein, Ph.D.) and MH30911 (P.I.: Robert P. Liberman, M.D.) from the
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