Original Article
It is generally accepted that patients with schizophrenia have unusual behavioral characteristics during premorbid periods. In Korea, the "Record of School Life", which is a record of school students kept by the teachers who are directly in charge of them, can be used as a convenient tool for surveying and evaluating school functioning in psychiatric patients. We performed this study in order to determine whether there were any differences in the school function in the Record of School Life between patients with schizophrenia and patients with neurotic disorders. Using the Records of School Life of patients with schizophrenia and neurotic disorders, we examined the differences in the descriptions made by teachers of these two categories of subjects during their school years. Since the subjects with schizophrenia had more check marks than those with neurotic disorders in three of the eight negative items, their teachers regarded them as having more negative traits. Herein, we report that male subjects with schizophrenia with early onset show more eccentric features than subjects with neurotic disorders, using a relatively standardized and simple tool, the Record of School Life.
Correspondence: Won-Myong Bahk, MD, Department of Psychiatry, St. Mary's Hospital, The Catholic University of Korea, 62 Yoido-dong, Youngdeungpo-gu, Seoul 150-713, Korea
Tel: +82-2-3779-1250, Fax: +82-2-780-6577, E-mail: wmbahk@catholic.ac.kr
It is generally accepted that patients with schizophrenia have unusual
behavioral characteristics during premorbid periods1. However, Hanson et al.2
suggested that there were no specific abnormalities in the pregnancy or delivery
variables, neurologic examinations, physical growth measures or psychological
tests in premorbid schizophrenic patients. Even today, there is still some
controversy surrounding the premorbid behavioral characteristics of patients
with schizophrenia.
In Korea, where national defense duty is compulsory for all young men, the
psychiatrists at the Office of the Military Manpower Administration or the Armed
Forces General Hospitals who performed the physical examinations prior to
conscription, often request "the Record of School Life" of the
candidates, in order to evaluate their premorbid school functioning. The Record
of School Life is an objective record kept by the teacher who is directly in
charge of the student during every term throughout the student's primary, middle
and high school periods, and contains information about his or her demographic
background, school attendance, psychological tests including intelligence
quotient and aptitude tests, physical growth variables, behavioral
characteristics, scholastic achievements, extracurricular activities and general
comments. Since the items contained in the Record of School Life are the same,
regardless of which school the student attended and in which province it is
situated, this record can provide a convenient tool for surveying and assessing
school functioning in psychiatric patients.
We performed this study in order to determine if there were any differences in
school function contained in the Record of School Life between patients with
schizophrenia who were exempted from military service and patients with neurotic
disorders who were regarded as being able to serve in the army, in spite of
their having psychiatric morbidity by the regulation of Ministry of National
Defense.
Materials and Methods
Subjects
All of the subjects were drawn from the examinees of the secondary close
examination unit for military draft of the psychiatric department at the Capital
Armed Forces General Hospital in Seoul, Korea. They were referred to this unit
from three Local Offices of the Military Manpower Administration near Seoul for
further evaluation of their psychiatric morbidity.
The exclusion criteria were psychotic disorders other than schizophrenia, mental
disorders due to known organic factors, a history of injury or possible injury
to the central nervous system, mental retardation and acute psychiatric
disorders that could not be confirmed as definite entities. To homogenize the
sample, only those subjects whose official education extended beyond the high
school level were selected. Subjects having had prior psychiatric treatment were
asked to bring their medical certificate for military examination, and their
medical records were also reviewed. With these data, all of the subjects were
assessed by two psychiatrists (JHC, WMB) and classified according to the
DSM-III-R3 diagnostic criteria. After excluding those subjects whose Record of
School Life was incomplete, ninety schizophrenic patients and forty-five
patients with neurotic disorders were retained in the final study population.
Measures
With the Record of School Life for the primary, middle and high schools, we
examined the differences between the schizophrenic patients and the patients
with neurotic disorders. Student's t-test was used to analyze the continuous
variables, such as the subject's age, the number of days on which he was absent
from school, the number of days on which he either left early or arrived late,
the total number of days for which he missed classes (calculated as the sum of
the previous two items for all school periods), the relative standing calculated
by dividing the average academic ranking by the total number of students for
each school, and the IQ recorded in the middle and high schools and their
average value.
X2 analyses were used to compare both groups based on non-continuous measures,
such as the frequency of entering college and the degree of schooling of the
subject's parents.
The correlation coefficients of Spearman's rho were obtained, in order to
analyze the relationship between the degree of schooling of the index subject's
parents and the school attendance for all school periods, the relative academic
standings and the IQ recorded in the middle and high schools.
A total of 78 kinds of individual description were made by the teachers, which
we simplified and reclassified into 22 items. We attempted to reclassify these
22 items into three categories, after referring to a prior study4. The first
category was made up of eight positive items, including
"good-naturedness"(well-rounded, having good interpersonal
relationships, affable), "courtesy"(polite, well-mannered),
"law-abidance"(obeying the regulations),
"neatness"(manifesting care and orderliness),
"diligence"(diligent, hard-working), "honesty"(honest,
frank), "responsibility"(sincere, fulfilling one's responsibility) and
"excellence"(excellent, superior, winning honor prizes). The second
category consisted of six neutral items, which could not be classified as either
good or bad and which had different merit depending on one's point of view.
These included "gentleness"(gentle, obedient compliant),
"brightness"(cheerful, lighthearted), "positiveness"(active,
constructive), "calmness"(calm, silent),
"passiveness"(passive, introverted) and
"stubbornness"(stubborn, obstinate). Thirdly, eight items including
"unlawfulness"(selfish, acting illegally, not obeying public
regulations), "psychological problems"(needing to be helped by
psychological professionals, anxious, having psychological problems),
"anergy"(anergic, lazy, having few facial expressions),
"inattention"(inattentive, easily distractible), "poor
understanding"(limited scholastic aptitude, understanding poorly),
"irresponsibility"(irresponsible, having poor willpower, being
inconsistent), "isolation"(isolated, solitary, having no friends), and
"childish"(immature, greedy) were classified into the negative
category. Then we analyzed the general comments made by the teachers in the
Record of School Life corresponding to the above items, regardless of whether
these indications overlapped with each other. Using Chi square analysis with
Yates'correction, we examined the differences in the frequencies of these items
between the two groups for each school. The Mann-Whitney U test was used to
determine the differences in the sums of the positive, neutral and negative
categories of both groups as a function of the school.
All p values reported
represented two-tailed comparisons and the significance level alpha was taken to
be less than 0.05.
Results
The demographic data of the subjects with schizophrenia and the subjects with
neurotic disorders, including the diagnostic classification according to
DSM-III-R3 for the subjects with neurotic disorders, are listed in Table 1.
There was no significant difference in age between the subjects with
schizophrenia and those with neurotic disorders.
The number of days of leaving early or arriving late at school during the middle
school period was significantly higher in the neurotic disorders group, but
there were no differences in the number of days of absence or days of leaving
early or arriving late at school between the two groups during the other periods
(Table 2). There were no differences in the relative academic standings of the
two groups at any of the grades during the middle or high school periods (Table 3). The IQs during the high school period and the mean IQs of the middle and
high school periods were significantly lower in the schizophrenic group than in
the neurotic disorders group (Table 4). The frequency of entering college was
significantly higher in the subjects with neurotic disorders (Table 5). The
parents of the schizophrenic group had a significantly lower level of formal
education (Table 6). The educational level of the subjects' fathers was
significantly correlated with the subjects'scholastic achievement during the
middle school periods, with the mean value of the grades they obtained during
the middle and high school periods and with their IQ during the middle and high
school periods (Table 7). Table 8 summarizes all of the data regarding the
general comments made by the teachers. The diligence item of the positive
category was check-marked significantly more often for the subjects with
schizophrenia than for those with neurotic disorders during all school periods.
The good-naturedness item was significantly more checked in the schizophrenic
group during the middle school period. For the neurotic group, the
responsibility item was significantly more checked during the middle school
period. In the neutral category, the gentleness item was significantly more
checked for the neurotic subjects than for the schizophrenia subjects during the
high school period. The calmness item was significantly more checked for the
neurotic subjects during the primary and high school periods, but was
significantly more checked for the schizophrenic subjects during the middle
school period. The stubbornness item was significantly more checked for the
schizophrenic group during the high school period. With regard to the negative
category, the anergy item was significantly more checked for the subjects with
schizophrenia during the middle and high school period and the irresponsibility
item was significantly more checked for these subjects during the primary school
period. The psychological problems item was significantly more checked for those
subjects with neurotic disorders during the middle school period and the
isolation item was significantly more checked for these subjects during the
primary and high school periods. In summary, for all school periods, those
subjects with schizophrenia had significantly more check marks in the anergy,
irresponsibility and childish items. In contrast, the isolation item was
significantly more checked in those subjects with neurotic disorders. Finally,
the total number of negative items was significantly higher in those subjects
with schizophrenia than in those subjects with neurotic disorders.
Discussion
Many traditional studies have suggested that premorbid schizophrenic children
have behavioral peculiarities and disturbances in their interpersonal
relationships in the primary school period1. Kretschmer considered that unique
disturbances in emotional contact, that is a "schizoid personality",
were present in premorbid schizophrenic patients5. A longitudinal study of the
high-risk offspring of schizophrenic mothers suggested that the presence of
peculiar premorbid behaviors could predict subsequent schizophrenia or
schizotypy, and that these peculiarities and eccentricities might represent a
biological marker of the schizophrenic genotype6. However, given that another
report claimed that premorbid schizophrenic subjects had extroverted or
multidimensional personalities rather than introverted personalities, the
findings of these previous studies concerning the premorbid behavioral patterns
of schizophrenic subjects have remained controversial1.
After Offord7 suggested that the school performance of male schizophrenic
patients was inferior to that of female schizophrenic patients, and that male
probands but not female probands performed more poorly in school than their aged
matched controls, there have been many observations that females with
schizophrenia tend to exhibit better premorbid functioning than males8. Thus, it
is important to control factors such as age, sex, intelligence, socioeconomic
status, and homogeneity of sampling areas, and to use reliable methods of
surveying premorbid function or social competence. In this regard, the entrance
examination for the military draft provides a good opportunity of selecting
relatively homogeneous samples for the purpose of studying premorbid function,
because the examinees are all young men in similar circumstances. At the same
time, since the Record of School Life is often presented as a co-information
source which is used in conjunction with entrance examinations for colleges or
job applications, it has a limitation in that the teachers have a tendency to be
generous in their appraisal of the students, and thus to give them higher marks
than they really deserve, except for those items dealing with scholastic
achievement. Nevertheless, it is the only official record of school function
completed by the teacher directly responsible for the subject using a
standardized format across the nation at the same time, and can therefore be a
good tool to evaluate the subject's school function.
This study demonstrated that certain behavioral patterns on the Record of School
Life between the subjects with schizophrenia and those with neurotic disorders
were different. The schizophrenic group tended to be more anergic, hypoactive,
irresponsible, lacking in willpower and consistency (irresponsibility), immature
and greedy (childish) even though they were classified as being more diligent
(diligence). In contrast, the neurotic subjects were reported to be more
isolated (isolation). Three out of the total of eight negative items were more
frequently checked for those subjects with schizophrenia and, in the overall
negative category, those subjects with schizophrenia were regarded as having
more negative traits by their teachers. However, the result that the neurotic
patients were more likely to be isolated suggested that they experienced more
difficulties in making friends than the schizophrenic subjects. This observation
contradicts a previous finding9 that adolescents at risk of developing
schizophrenia had poorer peer relationships than those at risk of developing
affective disorders. In a future study, it would be highly desirable to include
all types of major psychiatric disorders, including schizophrenia, affective
disorders and neurotic disorders.
Also, the item pertaining to psychological problems during the middle school
period was checked more often in the neurotic patients. We hypothesized that
this corresponded to a behavioral pattern wherein neurotic patients at puberty
were more likely to be seen as "having psychological problems" than
schizophrenic patients, because the symptoms of premorbid subjects in the
neurotic group were more apparent to observers such as teachers. Among the items
belonging to the positive category, the responsibility item was checked more
often in the neurotic group during the middle school period. In contrast, the
schizophrenic group had more check marks for the diligence item during all
school periods. Since these items might share some common characteristics, it
was considered that our results showed conflicting data. To resolve this
problem, it will be necessary to perform a factor analysis of the
teachers'appraisals in future studies, in order to further specify and
reclassify the behavioral patterns. With regard to the neutral category, since
the calmness item was checked more often for the schizophrenic subjects during
the middle school period, whereas it was checked more often for the neurotic
group during the primary and high school periods, this item could not be used to
differentiate between these two groups. The stubbornness item was checked more
often for the schizophrenic subjects during the high school period. This finding
suggested that it was likely for the behavioral patterns of the schizophrenics,
whose illness was close to manifesting itself, to be regarded as being
"stubborn" or "obstinate".
In a series of studies using school records in Japan, where the educational
situation is similar to that in Korea, schizophrenics had more check marks in
the five negative items, in contrast to their siblings who had more check marks
in the eleven positive items4. The schizophrenic group had less check marks in
the positive items, such as "taking responsibility", and more check
marks in the negative items, such as "difficulty releasing tension",
than the affective disorders group10. Also, the schizophrenics had
characteristics such as "having excessive tension",
"isolation", "lack of self-confidence", "lack of
responsibility, leadership and activeness" and "poor ability of verbal
expression" in comparison with the normal control group11. However, all of
these studies had shortcomings such as a small study population or the failure
to control the gender and other socioeconomic variables that might affect the
behavioral patterns. Our data, which at least partially overcame these
shortcomings, showed that there were more negative characteristics in the
schizophrenic subjects than in the neurotic subjects and supported some aspects
of the previous Japanese studies.
In terms of scholastic achievement, it has often been reported that
schizophrenics show more school retardation and failure, including a higher rate
of examination failure1. Some studies based on classroom observations reported
that high risk schizophrenic children showed lower levels of arithmetic
proficiency, perceptual motor functioning, several specific language or thought
patterns and more forms of withdrawal behavior12,13. However, our study did not
show any differences in scholastic achievement, as regards the relative
standings in school between the schizophrenics and neurotic subjects. This
result might be associated with the previous finding that school failure was not
able to distinguish preschizophrenics from controls14. It should be noted that
we used neurotic subjects as the comparison group, and that these subjects were
perhaps less capable of scholastic accomplishment than the normal controls. Our
data demonstrated that the scholastic performances of both groups during the
high school period were poorer than those during the middle school period. We
believe the most likely interpretation of the above result to be that mental
disorders are most likely to begin or become aggravated during the adolescent
period ranging from middle school to high school and that this might deteriorate
the school performances of those children who are affected by these disorders.
The IQs during the high school period and the mean IQs of the middle and high
school periods of the subjects with schizophrenia were significantly lower than
those of the neurotic groups. These data supported the notion that schizophrenic
patients score lower on standardized measures of intelligence than might be
expected and, indeed, their premorbid IQ tended to be lower than the scores of
their siblings and peers of a similar social class15.
This study showed that the parents of schizophrenic subjects were more likely to
have a lower educational level than those of the neurotic subjects, and this
result might be related to the results of many studies, which confirmed the
inverse relationship of social class status with the risk of developing
schizophrenia15. Considering that the schooling of the patient's father was
correlated with the patient's scholastic achievement
during the middle school period and with his or her IQ during all periods, it is
necessary to control the parent's schooling as a covariate. Also, we did not use
normal subjects as a comparison group. Therefore, in order to obtain more
definite information about the school function of schizophrenics, studies should
be performed using normal persons as the control group. In addition to this, we
consider that this result cannot be generalized to all mental disorders, because
our results were based on subjects with psychiatric disorders having a
relatively early onset, who already had disorders at the time of examination for
conscription. Offord et al.1 suggested that schizophrenic patients should be
divided into two groups, namely those who have a lower IQ, greater scholastic
difficulty, poorer peer group adjustment, and for whom there is some evidence of
minimal brain damage at an early age, and those who do not have any of these
indications, on the other hand. Following this hypothesis, there have been many
studies that reported that some male schizophrenic patients had
neurodevelopmental disturbances. Weinberger et al.16's study showed that chronic
schizophrenic patients with brain atrophy had worse premorbid adjustment, and
this neuropathological process occurred from early in their development. Thus,
it seems likely that there is a subgroup in schizophrenia which has
developmental disturbances and that the subjects of this subgroup may have
eccentric behavioral features starting from school age. Herein, we reported that
male subjects with early onset schizophrenia showed more eccentric features than
subjects with neurotic disorders using a relatively standardized and simple
tool, namely the Record of School Life and these results supported the above
hypotheses.
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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. revised, Washington DC. 1987.
Harata S, Okasaki Y, Masui K, Takakuwa M, Kano Y: Premorbid behavioral characteristics of schizophrenic patients: a comparison of the school records of patients and their sibling. Seishinigaku 1987; 29, 705-715.
Pfohl B, Winokur G: The micropsychopathology of hebephrenic/catatonic schizophrenia. J Nerv Ment Dis 1983; 171, 296-300.
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