Schizophrenia Research: Cognition 1 (2014) e35–e39

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Schizophrenia Research: Cognition

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Qualitative analysis of interviews of future non-affective psychoticdisorder patients and non-psychiatric controls: preliminary results

Katya Rubinstein a,⁎, Rivka Tuval-Mashiach b, Ortal Bhuknik-Atzil b,c, Suzanne Fund d,Abraham Reichenberg e,f, Eyal Fruchter g, Mark Weiser a,c,g

a Department of Psychiatry, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israelb Bar-Ilan University, Department of Psychology, Ramat-Gan, Israelc Sheba Medical Center, Psychiatry Unit, Ramat-Gan, Israeld Center for Behavioral Sciences, Israeli Defense Forces, Ramat-Gan, Israele Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USAf Department of Preventive Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, USAg Mental Health Department, Israeli Defense Forces, Ramat-Gan, Israel

⁎ Corresponding author.E-mail address: rubins.katya@gmail.com (K. Rubinst

2215-0013/$ – see front matter © 2014 Elsevier Inc. Allhttp://dx.doi.org/10.1016/j.scog.2014.02.002

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 5 January 2014Received in revised form 31 January 2014Accepted 4 February 2014Available online 20 March 2014

Keywords:Psychotic disordersSchizophreniaQualitative analysisPremorbid functioning

Background: Previous research has shown that people with psychotic disorders have impaired functioningprior to the onset of the illness. The goal of this study is to obtain a detailed, in depth, analysis of the charac-teristics of premorbid impairment.Methods: In this study we examined summaries of interviews with 20 male adolescents who were later diag-nosed with non-affective psychotic disorders and compared them to interviews conducted with 20 matchedcontrols without psychiatric disorders. The current study applied a qualitative analysis, performed in the fol-lowing stages: each interview was read thoroughly by two blinded raters with no a-priori hypothesis, andthen key themes and statements were identified and organized into meaningful domains. Afterwards, thefrequency of each item was calculated and comparisons between the groups were performed.Results: Future non-affective psychotic disorder patients were more likely to be described as strange or dif-

ferent, be involved in violent behavior, experience difficulties in educational functioning and peer integra-tion, deal with problems in everyday functioning and have an avoidant interpersonal conflict resolutionstyle in comparison with matched controls without psychiatric disorders. In addition, future patients experi-enced more stressful life events and dealt with these stressors more poorly in comparison with controls.Conclusions: The findings of this unique historical-prospective qualitative analysis of interviews performedbefore the onset of psychosis, confirmed previous findings of premorbid abnormality of future non-affective psychosis patients. Using qualitative analysis enabled obtaining a more in-depth understanding ofthe real-life experience of the premorbid period among patients with non-affective psychotic disorders.

© 2014 Elsevier Inc. All rights reserved.

1. Introduction

Psychotic disorders, in general, and schizophrenia, in particular,are debilitating mental illnesses that affect various domains ofhuman behavior. It is well known that impairments in premorbidfunctioning in schizophrenia are present before the onset of theillness, consistent with neuro-developmental models of the disor-der (Davidson et al., 1999; Murray et al., 1992; Weinberger andLipska, 1995).

The premorbid period in schizophrenia is typically defined as be-ginning after birth and lasting until the initial appearance of behav-ioral disturbances or psychotic symptoms (McGlashan andJohannessen, 1996). Medical and psychiatric histories recorded by

ein).

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mental health professionals during their first contact with psychoticpatients often reveal subtle or flagrant motor, cognitive, emotional,and behavioral deviations during childhood, social withdrawal andpersonality changes during adolescence, as well as attenuated psy-chotic symptoms months to years before the first treatment contactand the diagnosis of psychosis (Harvey, 2002).

Previous studies investigating pre-morbid functioning in schizo-phrenia obtained medical histories from patients shortly after theonset of the illness (Andreasen et al., 1990) but were based on chartreview and retrospective patient recall, hence prone to recall bias(Brill et al., 2007).

To overcome these difficulties, longitudinal and historical-prospective investigations have examined developmental curves,school records (Jones et al., 1994) or army records (Davidson et al.,1999). These studies were based on summary scores obtained fromarchived data. Recently, there has been a growing acknowledgment

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that qualitative research methods, solely or combined with quantita-tive ones, can be useful in identifying important nuances that enrichthe understanding of underlying reasons and motivations of people'sbehavior and experience (Gunnmo and Bergman, 2011). For this rea-son, the current study applied qualitative analysis focusing on thecontent of pre-induction interviews of future patients, in order to re-veal the subjective experience of people who were later diagnosedwith psychotic disorders (Lieblich et al., 1998). The primary goal ofthe current study was to gain a better understanding of the emotion-al, interpersonal and functional experience of future non-affectivepsychotic disorder patients.

2. Method

According to Israeli law, all adolescents between the ages of 16and 17 are required to undergo a compulsory pre-induction assess-ment to determine their intellectual, medical, and psychiatric eligibil-ity for military service. The draft board assessment includes anunselected population of individuals who are eligible for military ser-vice, as well as those who will be excused from service on the basis ofmedical, psychiatric, or social reasons. The assessment is adminis-tered by college-age individuals who have completed a 4-monthtraining course on the administration of a semi-structured interview,designed to predict success in combat military units.

The interview includes evaluations of social functioning, assessingsocial abilities and desire for interpersonal closeness, as well as per-sonal autonomy, maturity, and self-directed behavior (e.g., indepen-dent functioning vs. reliance on others); organizational ability (e.g.,compliance to timetables, self-mastery and self-care); and physicalactivity, which assesses involvement in extracurricular physical activ-ities. Behaviors are rated on a scale from 1 (lowest) to 5 (highest)on the basis of predetermined reliable and validated instructions(Gal, 1986).

The interview is administrated in a standardized manner placingequal weights on the different topics which the interview covers.Since 2001 narrative summaries of these interviews have been en-tered into a computerized database and are available in the archivesof the Israeli Defense Forces. The reliability and validity of these mea-sures have been tested by the IDF, and population-based norms areavailable for each of the tests (Tubiana, 1982). For more detailed de-scription of the IDF behavioral assessment please see the article byRabinowitz et al. (2000).

2.1. Procedure

After receiving local IRB approval, the following data linkage wasperformed:

1. The details of soldiers, who were hospitalized for their first out-break of a non-affective psychotic illness during military ser-vice, were extracted from the army records.

2. Control subjects, who were not hospitalized for psychiatricdisorders during service, were identified. The controls werematched to future patients by their age, gender, interviewerand interview date.

3. Summaries of the pre-induction interviews of cases and controlswere obtained and analyzed using qualitative research methods.

2.2. Population

The study sample consisted of 40 male adolescents, aged16–17 years old. Twenty of them were hospitalized for their first ep-isode of non-affective psychotic disorder during military service,whereas the twenty control subjects were not diagnosed with psychi-atric disorders or hospitalized during their military service. Caseswere matched to controls by age, gender, interviewer and interview

date (the interviews of each case and control were conducted bythe same interviewer in the same month). In the future patientsgroup, the mean time between the draft board assessment and firsthospitalization was 3.19 years (ranging from 1.76 to 5.56 years).

2.3. Qualitative analysis

The narrative summary of each interview was read by each re-searcher, who was guided by the existing literature on pre-morbidfunctioning in schizophrenia and psychotic disorders. Themes thatemerged from reading the interviews served as the basis for anopen exploratory analysis of more nuanced expressions of specific as-pects or experiences relating to functional difficulties. For example, insubjects describing minimal interactions with peers and a preferencefor solitary activities such as computer games, themes of social with-drawal were extracted.

The narrative summaries were analyzed using categorical contentanalysis, based on the model of narrative analysis proposed byLieblich et al. (1998). According to this model, textual analysis focuseson the dimensions of content and/or structure, and on the unit ofanalysis, with the choice of using the unit of the text as a whole (ho-listic analysis) or parts of the text (categorical analysis). The analysiswas performed by 2 MA level psychologists, who had experience withpsychotic disorders patients and were blinded to the participants'study group.

The analysis was conducted in the following stages:

1. Each narrative summary was read and deconstructed sentenceby sentence, in order to identify key themes and assign a de-scriptive name for each item (for instance, when the interview-er wrote that the person tended to miss school, or had lowgrades, these items were coded as themes).

2. In the second stage, themes were combined and sorted intohigher level categories (for example, descriptions of the subjects'typical behavior in situations of disagreement with peers and/orauthority figures were labeled as “social conflict resolution”).

The content categories included: interviewer's impression (basedon the expressions that the interviewer used in order to describethe subject's personality qualities and behavior. For example, “intelli-gent”, “pleasant conversational partner”, “contributes according topersonal preference”, etc.); background and life history (stressful lifeevents, immigration, personal and family details); educational func-tioning (attitude towards the educational framework, fulfillment ofstudent duties, discipline); social functioning (interactions withpeers, typical behavior in company, friendship concept and attitudestowards friends); interpersonal conflict resolutions (based on FordWood & Bell's (Ford Wood, 2008) classification of interpersonal con-flict resolution styles - collaborating, accommodating, avoiding andcompeting); and everyday problem solving (independence or relianceon others in overcoming everyday difficulties).

3. Afterwards, the presence or absence of each theme in the inter-view summary of a given subject was coded and entered intoan SPSS data file. The frequency at which each theme appearedin each group was calculated (see example for a similar tech-nique in Dinos et al., 2004).

4. After performing the analysis and summarizing the findings,the data were unblinded.

3. Results

3.1. Future psychotic disorder group

a) Interviewer's impression: The members of this group were de-scribed by the interviewers as being open (7 cases, 35% of thegroup), likable (5 cases, 25%), and good kids (6 cases, 30%).

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Some of the adolescents in this group were described as weird(2 cases, 10%), unusual (2, 10%) and passive (3, 15%). Their mo-tivation for military service was described as high in 9 cases(45%) and low in 2 cases (10%).

b) Background and life-history: The members of this group had abackground of stressful life events in 12 cases (60%), such asthe experience of illness among themselves or their familymembers, death of a close person, divorced parents and im-paired relationshipwith parents, financial difficulties, domesticviolence and immigration. All cases of immigration (15%) in-cluded absorption difficulties, such as enuresis at a relativelyold age (14 years), difficulties with peer integration and becom-ing a scapegoat in the eyes of peers. In one case there was a de-scription of good peer integration, along with feelings of beingunable to “put roots down”, unable to trust people in his environ-ment, and see them as a permanent part of his life. Other reac-tions to stressful events that were described, included feelingsof anger and insult, decrease in self-confidence, deterioration ineducational achievements, feelings of distress, social withdrawaland impaired communication. In one case there was an experi-ence of strange thoughts, bad dreams and difficulty falling asleep.Two future patients (10%) sought professional help from a psy-chologist or school counselor. Four cases (20%) included reportsregarding violent behavior and vandalism, sometimes as a resultof the “bad influence” of problematic peers who “dragged” thesubjects into aggressive behavior. In 6 cases (30%) therewere de-scriptions of strong family connections, respect towards parentsand sharing personal issues with family members.

c) Educational functioning: Four future patients (20%) understoodthe importance of the educational framework, while 6 (30%)tended to neglect their education. The educational functioningof future patients was described as impaired in 7 cases (35%),with 3 (15%) reports of educational difficulties and studying inspecial classes. Four cases (20%) included recent deteriorationin educational functioning that was reflected in decreased effortat school, a tendency to neglect school assignments and a dis-continuation of studies.

d) Social functioning: Ten out of 20 future patients (10, 50%) weredescribed as being sociable. Future patient's connections withtheir peer groupwere described as very close (10, 50%), but hedo-nistic (5 cases, 25%) and shallow (6 cases, 30%), based on spendingtime and having fun together (7 cases, 35%) and not on closenessand sharing. A relatively low number of cases (3, 15%) mentionedfeeling that social relationships were important. In 7 cases (35%)there were reports regarding difficulties in peer integration,the reasons for which included poor social abilities, attributinglow importance to social ties, low investment in social relation-ships, difficulty trusting others, difficulty “finding one's place” inthe social environment and being bothered or bullied by peers.

e) Interpersonal conflict resolution and everyday problem solving:Seven (35%) of the future patients described good everydayfunctioning, in most cases with the help of family and friends,while 8 cases (40%) described poor functioning. The reasons forpoor functioning included being spoilt, laziness, dependence onothers, passiveness, expectation of constant help from others,difficulty in making everyday decisions and a lack of demandfor independent functioning at home. Regarding the resolutionof interpersonal conflicts, the members of this group wereprone to express their opinion in situations of argument or dis-agreement, but mostly did not insist on their point of view andtended to “give up” relatively quickly. They were described aspersonswho “donot bother” to confront others, are not stubbornand avoid “insisting on their opinion”.

As part of the pre-induction evaluation, the army interviewers areinstructed to refer future soldiers to a military mental health officer

for further evaluation, when they feel a need to do so. In our sample,6 out of 20 (30%) future patients were referred for further assess-ment, while no one from the control group was referred.

After a first reading of the interviews, the blinded raters, who haveMA degrees in psychology and experience with psychiatric patients,tried to identify the group that each subject belongs to. The accuracyof this prediction was very low (one rater classified correctly 15%cases, while the other one identified 25%).

3.2. Control group

a) Interviewer's impression: The members of this group were de-scribed by interviewers as cooperative, loveable, pleasant con-versational partners, and some were even depicted as beingcharming and charismatic (13 subjects, 65%), sociable (7 sub-jects, 35%), intelligent and interesting, “high-level” (7, 35%).Their motivation for military service was described as beinghigh in 8 subjects (40%) and low in 4 subjects (20%).

b) Background and life-history: Eight members of this group had abackground of stressful life events (40%). These events includedivorced parents, financial problems and domestic violence, thesuicide of a close person and immigration. Among subjects whowere not born in Israel (5, 25%), 4 succeeded to integrate well,despite social and financial difficulties, while 1 subject dealtwith considerable difficulties in social and educational integra-tion. One of the subjects experienced feelings of sorrow, loneli-ness and alienation shortly after his immigration, but overcamethese feelings within one month and since then reported no dif-ficulties in social or educational domains. Nine subjects (45%)reported a recent transition to a new educational facility, mostlydue to aspirations for better education (for instance, transferringto a religious school for subjects that became more religious, ortransferring to a school with a higher educational level in orderto be able to achieve future goals). All of the cases of educationtransitions included descriptions of good and quick integrationin a new facility, with some initial difficulties.

c) Educational functioning: The controls' attitude towards educa-tion was described mostly as serious, while functioning withinthe educational framework differed according to personal pref-erence, including higher investment in “more important” disci-plines and a tendency to be careless or neglectful in lessimportant areas (8 subjects, 40%). In 4 interviews (20%) the ten-dency to “cut corners”was described as a strategy to deal with ademanding school, high work load and long hours.

d) Social functioning: Fifteen (75%) cases were described as sociablepeople with high social desire. Five control subjects (25%) weredescribed as having low social needs and a preference for soli-tary activities, such as playing computer games and studying.Four subjects (20%) were described as being reluctant to sharetheir personal issues with others, while only two (10%) tendedto share personal matters. Two persons (10%) felt that socialties are important, and two others (10%) reported that theytrusted their friends. A quarter of the controls were describedas having shallow and hedonistic relationships, and preferredto spend time and have fun with friends without intimacy andmutual sharing.

e) Interpersonal conflict resolution and everyday problem solving:The members of this group were described mostly (75%) as ca-pable of independent everyday functioning, people who knowhow to cope by themselves in routine activities, and sometimesin unusual situations. Most of them tended to seek advice whenneeded, but couldmake their own decisions and act accordingly.These subjects tended to express their opinion in an argument,sometimes had disagreements with authority figures, but werenot stubborn and would not insist on their point of view, espe-cially when the issue in question was not of great importance

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to them and if they thought they might “get hurt” or bepunished for their actions.

Differences between future psychotic disorder patients andmatched control subjects on key themes are presented in Table 1.

4. Discussion

The current article presented a pilot study, planned to be part ofa large scale research project. The study was performed usinghistorical-prospective design, qualitative analysis and unique pre-morbid data from the Israeli military archives. The primary goalwas to obtain an in-depth understanding of how future non-affective psychotic disorder patients function in the real worldbefore the outbreak of first psychotic symptoms. We believe thatapplying qualitative analysis enabled us to obtain a richer descriptionof future patients, an advantage that is sometimes missing in classicquantitative analyses.

The main findings indicated that future non-affective psychoticdisorder patients were more likely to be described as strange or dif-ferent, and less intelligent than control subjects. They tended to be-have more violently, experienced difficulties in educationalfunctioning and peer integration, dealt with more problems in every-day functioning and had an avoidant interpersonal conflict resolu-tion style, while controls tended to resolve conflicts by negotiatingand cooperating with others. Future patients experienced morestressful life events, such as family disruption and domestic violenceand tended to deal with these stressors more poorly in comparisonwith controls.

These findings are consistent with the results of previous studiesand confirm what is already known about the premorbid phase inpsychotic disorders and schizophrenia. The interviewers' impressionof future patients as being less intelligent matches previous findingsregarding premorbid cognitive deficits in people who are later diag-nosed with schizophrenia. These deficits are apparent in adolescence(Davidson et al., 1999; Tiihonen et al., 2005) and even in early child-hood (Reichenberg et al., 2010). Stressful life events, such as thedeath of a parent or sibling, are associated with increased risk for

Table 1Differences between future psychotic disorder patients and matched controls on key them

Domain Theme description

Background Stressful live eventsImmigration

Violent behavior/vandalismInterviewer's impression Intelligent, high level

Strange, different, passivePositive (open, nice, cooperative,pleasant etc.)

Educational functioning Impaired educational functioningRecent decline in educational functioningChange of educational facility

Serious attitude to education, understandingof significance of educationInvestment at school according topersonal preference

Social functioning Sociable, with social interestHedonistic and superficial social connectionsDifficulties in peer integration

Interpersonal conflictresolution

Avoiding conflict, not expressing an opinion

Cooperating and negotiating to find solution,expressing an opinion

Everyday functioning Independent functioning in everyday lifeImpaired everyday functioning

future psychotic illness (Clarke et al., 2013). The difficulties of futureschizophrenia patients in social and interpersonal domains have alsobeen described in earlier studies (Cannon et al., 1997; Cornblatt et al.,2012; Davidson et al., 1999). In addition, people with schizophreniatend to express more violent behavior in comparison with the generalpopulation (Walsh et al., 2004). Our findings indicate more violentbehavior within the future psychotic disorder group, compared tothe control group, and may suggest a tendency for violent behaviorbefore the onset of psychotic symptoms, which has been also de-scribed in earlier studies (Kooyman et al., 2012).

To the best of our knowledge, this is the first article to report oninterpersonal conflict resolution in adolescents later diagnosed withnon-affective psychotic disorder. The findings suggest that futurepsychotic disorder patients employ less efficient strategies for resolv-ing conflicts with others. Different styles of conflict resolution havebeen associated with different personality characteristics (FordWood, 2008). To date, little is known about interpersonal conflict res-olution among people with psychotic disorders. This topic requiresfurther research and might be a target for interventions.

Regarding the attempt to identify future psychotic disorder pa-tients based on the interviews alone, the current study shows a verylow accuracy of identification (15% and 25%), thus leaving between75%-85% of future patients unidentified. The number of subjectswho were referred to a mental health officer for further evaluationwas slightly higher (30%). These findings indicate that the majorityof future patients appeared to be normative adolescents at the timeof their pre-induction interviews, and nothing about them “rang awarning bell”. These findings emphasize the difficulty of pre-morbidprediction of psychotic disorders.

The main limitation of the current study is the fact that these in-terviews are focused on predicting success in the military serviceand not on predicting psychotic disorders. However, the content anal-ysis shows that the interviews include relevant and useful informa-tion similar to the items of assessments of schizophrenia prodromalstate, such as Structured Interview of Prodromal Syndromes (SIPS)and Scale of Prodromal Symptoms (SOPS), that include questions re-garding social isolation and withdrawal, abolition and deteriorationin role functioning (Miller et al., 1999).

es.

Future psychotic disorder patients Matched control subjects

60% 40%15% (with absorption difficulties:problems with peer integration,turning into a scapegoat in thepeer group)

25% (with some absorptiondifficulties, such as feelings ofsadness or alienation; Eventuallygood social integration)

20% 0%0% 35%35% 0%55.34% 56.14%

35% 0%20% 0%30% (reasons: social and/oreducational difficulties)

45% (reason: aspiration for abetter education)

35% 40%

35% 40%

50% 75%55% 25%35% 0%55% 20%

20% 60%

35% 75%40% 0%

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Another limitation of the current study is the fact that the Israelidraft board conducts these assessments on male adolescents only.Therefore, we were not able to include female adolescents in ourstudy population. However, we have no theoretical reason to hypoth-esize that the distinction between cases and controls would be differ-ent among females. In addition, the study subjects were followed-uponly during the period of their army service. It is possible that some ofthe adolescents, classified as controls based on the fact that they didnot develop psychosis during the service, may have shown psychoticsymptoms after being discharged from the IDF.

In conclusion, this detailed qualitative analysis confirms the pres-ence of premorbid behavioral and cognitive difficulties in non-affective psychotic patients. Difficulties are apparent in a wide rangeof behavioral domains and represent early warning signs in some,but not most, patients.

Role of Funding Source

Nil.

Contributors

Mark Weiser conceived the idea of the study and together with KatyaRubinstein and Rivka Tuval-Mashiach designed the study method.Eyal Fruchter and Suzanne Fund took part in generating andcollecting the data. Katya Rubinstein and Ortal Bhuknik-Atzilperformed the qualitative analysis. Katya Rubinstein wrote the firstdraft of the manuscript. Abraham Reichenberg consulted on thestudy design and data analyses. All authors contributed to and haveapproved the final manuscript.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgments

The present work benefited from the input of LieutenantColonel Shlomi Ron, Head of the MEYTAV computer unit in IDF,who provided valuable assistance to the undertaking of the researchsummarized here.

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