Title: Non-verbal behaviour of patients with schizophrenia in medical
consultations – A comparison with depressed patients and association with
symptom levels
Running title: Non-verbal behaviour in consultations
Authors: Sara Dimic¹, Christiane Wildgrube¹ ², Rosemarie McCabe¹, Imren Hassan ¹,
Thomas R. E. Barnes ³, Stefan Priebe¹
¹ Unit for Social and Community Psychiatry, Queen Mary University of London
² North Essex Partnership Foundation Trust
³ Imperial College London
Correspondence: Dr Sara Dimic
Queen Mary University of London
Unit for Social and Community Psychiatry
Newham Centre for Mental Health
London E13 8SP
Tel. 0 (+44) 20 8821 0300
e-mail sara.dimic@eastlondon.nhs.uk
Key words
Non-verbal behaviour, communication, praecox feeling, schizophrenia, medical
consultations
ABSTRACT
Background: The Dutch psychiatrist Rümke introduced the notion that patients with
schizophrenia could be recognised intuitively by an experienced psychiatrist, naming
the process as the 'praecox feeling'. This feeling may reflect aspects of the non-verbal
behaviour of patients as shown in a medical consultation. The aim of this study was to
test whether aspects of the initial non-verbal behaviour of patients with schizophrenia
and depression in medical consultations differ and are associated with symptom levels
in each group.
Sampling and Method: The first two minutes of videotaped outpatient consultations
with 78 patients (39 each with schizophrenia and depression) were analysed by
researchers who were masked to the diagnosis and symptom levels of the patients.
Non-verbal behaviour was assessed using a modified Ethological Coding System for
Interviews (ECSI). Symptom levels were rated by independent researchers on the
Positive and Negative Syndrome Scale (PANSS) and Beck Depression Inventory
(BDI).
Results: The two diagnostic groups showed significant differences on one out of six
aspects of non-verbal communication, with patients with schizophrenia showing more
‘flight’ behaviour, i.e. more looking down or away, crouching and freezing. Within
the group of patients with schizophrenia, more ‘flight’ and less ‘assertion’ were
associated with higher symptom levels.
Conclusion: Initial ‘flight’ behaviour of patients in medical consultations may be
specific for schizophrenia and associated with the symptoms of that illness. Such
behaviour might indicate an avoidance of potentially adverse communication, and
future research should investigate whether it can also be identified in everyday social
interactions other than medical consultations.
BACKGROUND
In 1941 the Dutch psychiatrist Rümke introduced the notion that a patient with
schizophrenia could be recognised intuitively by an experienced psychiatrist, naming
the process as the 'praecox feeling'. According to Rümke [1941] the praecox feeling
of the psychiatrist is based on the facial expression, demeanour, motor behaviour and
changing expressions of patients with schizophrenia, that are characteristic for those
patients and immediately give the condition away. Rümke suggested that the praecox
feeling can be noticed in the “shortest assessment” and is “frequently generated before
any words have been exchanged with the patient” (both quotes Rümke 1941, p. 168,
translation by the authors). He explains that the feeling does not reflect the commonly
assessed clinical symptoms of schizophrenia and rather occurs when the clinician
attempts to establish contact with the patient.
Gaebel [1990] suggested that Rümke intended to base the diagnosis of schizophrenia
largely on specific impressions made on the psychiatrist by the behavioural
characteristics of the patient. Such behavioural aspects may not be captured in the
symptom definitions that determine current diagnostic categories and assessment
instruments. Nevertheless they might be relevant for a better understanding of the
characteristics of the disorder and possibly help explain the frequent difficulties of
patients with schizophrenia in interpersonal communication [Bellack at al., 1990].
Using audio-visual recording, the behaviour of patients can be independently
assessed. Extensive research has assessed some aspects of patients’ non-verbal
behaviour within studies focussing on social cognition and emotional processing
[Feldman-Barret and Salovey, 2002; Gross, 2002; Goldsmith and Davidson, 2004].
Several such studies have found a diminished facial expression of patients with
schizophrenia [Schneider et al., 1990; Berenbaum and Oltmanns, 1992; Blanchard et
al., 1994; Mattes et al., 1995; Geabel and Wolwer, 2005]. Yet, this research has used
experimental settings in laboratories or role plays rather than real-life, everyday
situations to assess patients’ behaviour. For various reasons, it remains unclear to
what extent findings generated in experimental situations help understand patients’
behaviour in real-life situations.
The medical consultation, i.e. the routine meeting between a patient and a psychiatrist,
is an everyday social interaction. The situation is of relevance to the patient since
important decisions about future treatment are negotiated and agreed on [Priebe and
McCabe, 2008]. It is also the context in which the psychiatrist observes the patient’s
behaviour and reaches a diagnosis. It therefore lends itself as a setting in which to
study the patient’s communication behaviour, including its non-verbal aspects, and
test the findings for an association with the clinical diagnosis of the psychiatrist.
However, investigating the medical consultation as a real-life situation has the major
limitation that the methods of recording and documenting the patient’s behaviour
must not change the nature of the consultation and not interfere with the behaviour
normally shown by patients in such situations. This requires a cautious use of
technical equipment (e.g. cameras) in the consultation room and assessment
procedures that accommodate the wide range of behaviour as it occurs in routine
practice.
Over the last 25 years, the techniques of audio-visual recording of human interactions
have been advanced and become widely available. This has facilitated an increasing
body of research on non-verbal behaviour of patients with mental disorders in clinical
consultations. Such ‘naturalistic’ studies have used different theoretical frameworks
and explored various aspects of communicative behaviour in clinical settings without
yet establishing standard procedures and assessment methods.
A review on
professional–patient communication in the treatment of mental illness [Hassan et al.,
2007] found that existing studies used different underlying models. The authors
concluded that there was little methodological consistency and findings were
disparate.
This study used naturally occurring consultations of psychiatrists with patients with
schizophrenia and depression [e.g. McCabe et al., 2002], and assessed patients’ nonverbal behaviour during the first two minutes. This focus on the initial phase of the
interaction was to reflect the assumption of Rümke that the praecox feeling is
immediately noticeable, have a consistent timeframe across all consultations,
investigate behaviour that is less influenced by the actions of the psychiatrist than at
later stages of the consultation, and reduce the likelihood that diagnostically specific
information is revealed in the verbal communication and thus bias the ratings of the
observers. Following Rümke’s notion on the praecox feeling, we tested whether
patients with schizophrenia and depression differed in their non-verbal behaviour. We
also explored whether features of the non-verbal behaviour were associated with
symptom levels in each group.
METHOD
Setting, sample and procedure
The study analysed the outpatient psychiatric consultations of 78 patients with
diagnoses of schizophrenia or depression, who had pre-arranged routine appointments
with a consultant psychiatrist. All consultations took place in East London and in the
normal consultation offices of the consultants, where a digital video-camera was
placed. All aspects of the consultation (including time, length, venue, content and
style) were intended to follow the usual routine and not be influenced by the recording
in any way.
All patients were between 18 and 65 years of age and, prior to the consultation,
provided written informed consent for the session to be videotaped. After the
consultation, patients were interviewed by an independent researcher and structured
questionnaires were administered to capture socio-demographic and clinical
characteristics and symptom levels of the patients.
The first two minutes of the recorded consultations were analysed by two independent
psychiatrists (SD and CW), both of whom were fully qualified with more than 10
years of clinical experience. They were not involved in the patients’ care in any way
and masked towards the clinical diagnosis as well as all other characteristics of the
patient including all assessments made by the researcher after the consultation. Each
of the consultations was assessed by both researchers.
Assessment methods
The diagnosis was the primary clinical diagnosis according to ICD 10, which was
taken from the patients’ records. Each patient’s age, gender, employment, living status
(with partner or not), and length of illness were assessed using a structured
questionnaire.
Symptoms were assessed on the Positive and Negative Syndrome Scale [PANSS:
Kay, Fiszbein and Opler, 1987] in the group of patients with schizophrenia and on the
Beck Depression Inventory [BDI: Beck et al., 1961] in the patients with depression.
The PANSS is a 30-item questionnaire measuring positive, negative and other
symptom dimensions on the basis of a formal semi-structured clinical interview. The
scores for each symptom range from 1=absent to 7=extreme. Of the 30 items, seven
are grouped to form a subscale for positive symptoms, seven form a subscale for
negative symptoms, and the remaining 16 items generate a score for general
psychopathology. The BDI is a self-rating scale with 21 items for measuring the
presence and degree of depression.
For the analysis of the videotaped, non-verbal behaviour of patients during the first
two minutes of the consultation, a modified version of the Ethological Coding System
for Interviews [ECSI: Troisi, 1999] was used. The instrument is based on an
ethological background which aims to integrate an understanding of the individual‘s
interaction with the natural environment into a clinical perspective of mental disorders
(Troisi, 1999). Fourteen behavioural aspects, including facial expression and hand
movements, were used out of an original thirty-seven ECSI patterns. Items were
grouped according to their meaning, comprising ‘prosocial behaviour’ (look at the
interviewer, smile, nod), ‘flight’ (look down, crouch, look away, freezing), ‘assertion’
(lean forward) ‘gesture’ (variable hand and arm movement used during speech),
‘displacement’ (hand–face movements, fumbling) and ‘relaxation’ (fold arm across
chest, laugh, neutral face). The other 23 aspects of the ECSI were not rated because
they were difficult to assess with sufficient accuracy given the limited quality of the
recordings. The quality was compromised as a consequence of attempting to assess
routine consultations with minimal interference from the recording procedures; the
video camera was placed discreetly in a corner of the office, and therefore not all
aspects of non-verbal behaviour could be assessed in sufficient detail, although the
patients’ face, trunk and legs could always be fully seen.
The first two minutes of each videotaped consultation were analysed for the presence
of each of the fourteen behavioural items in four successive 30-second intervals. The
end of each 30s sampling period was marked by a beep. At the end of each 30s period,
the researchers recorded the frequency of each behavioural aspect. A simple threepoint scoring system was used: 0=behaviour not present, 1=behaviour present on only
one occasion, 2=behaviour present more than once. The scoring with three options
rather than two as in other studies was intended to increase the variance of scores
based on only two minutes. Researchers first assessed each tape independently. They
then discussed any differences in ratings and reached an agreement.
Statistical Analysis
The sample size was intended to be more than 30 for each group to achieve a
representative distribution in line with the central limit theorem [Rice, 1995]. The
study aim was to find substantial differences between the diagnostic groups, rather
than identifying small or medium effect sizes. We therefore selected a relatively small
sample in each diagnostic group despite a limited statistical power to detect effects of
small and medium size.
Differences of socio-demographic characteristics between the two groups were tested
using t-tests, Mann-Whitney and Chi square tests. The inter-rater reliability for
assessing the defined aspects of non-verbal behaviour was assessed calculating the
Intraclass Correlation Coefficient. Given the non-normal distribution of the features of
non-verbal behaviour, non-parametric tests were computed to compare the behaviour
in the two groups of patients (Mann-Whitney test) and test the associations with
symptom levels within each group (Spearman-Rho coefficient). The same methods
were used to compare non-verbal behaviour in male and female patients [Troisi,
1999], and in patients in consultations with a clinician of the same or a different
gender [Hall et al 1994; Sandhu et al., 2009]. The analysis was performed using
SPSS for Windows, version 13.0.
RESULTS
The sample consisted of 78 patients, i.e. 39 with the diagnosis of depression and 39
with the diagnosis of schizophrenia. Their characteristics are summarised in Table 1.
Insert table 1 about here
In both groups the mean age of patients was about 44 years, most patients were
without employment and lived alone. The schizophrenia group had significantly more
males (χ2 =8.8, p< 0.05) and a significantly longer mean duration of illness (U=250.5,
p<0.001). There were no other statistically significant differences between the two
groups.
In 67 out of the total of 78 consultations the clinician was male and in 11
consultations female. In 40 consultations clinician and patient were of the same
gender (male clinician + male patient = 37, female clinician + female patient’=3),
while in 38 consultations there was a gender difference (male clinician + female
patient’= 30, female clinician + -male patient’= 8).
The average Intraclass Correlation for the inter-rater reliability for the two researchers
assessing the six aspects of non-verbal behaviour was 0.973 (95% C.I.: 0.968 - 0.975,
using 1092 ratings). The scores on the six aspects of non-verbal behaviour assessed in
the two groups are shown in Table 2.
Insert table 2 about here
Patients with schizophrenia showed significantly more flight behaviour [U = 495.5, p
< 0.05], whilst other differences between the two groups were not statistically
significant.
Across the two groups, there were no statistically significant differences between
male and female patients or between those in consultations with a clinician of the
same or a different gender.
The correlations between the scores of non-verbal behaviour and symptom levels in
each group are shown in Table 3.
Insert table 3 about here
In the group of patients with schizophrenia, higher levels of positive and negative
symptoms and global psychopathology were associated with more flight behaviour
and less assertion, although the correlation failed to reach statistical significance for
the association between positive symptoms and assertion.
In patients with depression, the higher BDI sum scores were correlated significantly
with more displacement and less prosocial behaviour.
DISCUSSION
Main findings
Patients with schizophrenia and depression showed differences in their non-verbal
behaviour during the first two minutes of routine medical consultations. Patients with
schizophrenia displayed more ‘flight’ behaviour, i.e. they more often looked down or
away, crouched, and froze in their movements. Such behaviour is understood as
cutting off social stimuli that are perceived as adverse [Troisi, 1999]. In patients with
schizophrenia more flight behaviour was significantly associated with higher levels of
psychopathological symptoms. Flight behaviour and symptom levels were not
associated in patients with depression, suggesting that flight behaviour is unlikely to
be a non-specific sign of severity of mental illness. Thus, flight behaviour may be
specific for patients with schizophrenia (at least as compared with patients with
depression) and associated with symptom severity. The fact that significant
correlations in schizophrenia patients were found with positive and negative
symptoms as well as global psychopathology may indicate that flight is not
particularly linked with any of the established symptom dimensions, but to aspects
that are captured on all three dimensions.
Strengths and limitations
The study has several methodological strengths. It succeeded in studying patient
behaviour in a real-life situation and analysed routine medical consultations, which
closely reflect the context in which psychiatrists may perceive a praecox feeling. All
consultations were in a similar setting to reduce a potential source of variance. The
analysis took only the first two minutes of the consultation, to minimise any
confounding of the ratings through information revealed later in the consultation or by
patient behaviour influenced by the psychiatrist. The assessment was rigorous and
raters were masked towards the diagnosis and symptom assessments of the patients.
The inter-rater reliability in assessing non-verbal behaviour was very high.
The study also has limitations. Only the first two minutes of each consultation were
analysed. Whilst routine medical consultations are everyday situations, there may still
be specific aspects of the institutional context that influence a patient’s behaviour, and
it is unclear to what extent a patient would show the same behaviour in other everyday
social interactions. The study used wide diagnostic categories based on clinical
diagnoses and did not employ standardised diagnostic interviews. Symptoms were
inconsistently assessed in the two groups, rated by an observer in patients with
schizophrenia and self-rated in patients with depression. Not all aspects of the ECSI
could be rated because of the technical limitations of videotaping real medical
consultations. The analysis was exploratory and not hypothesis driven. It identified a
significant difference between the two groups on only one out of six tested scores,
although the result remains significant after a Bonferroni adjustment for multiple
testing. Patients with schizophrenia were compared only with patients with
depression, and there were no other diagnostic groups and no healthy control sample.
Finally, the two diagnostic groups differed in their gender distribution and mean
length of illness, for which the statistical comparison was not adjusted because of the
small sample size.
Comparison with the literature
Whilst this study identified a difference between patients with schizophrenia and
depression, several ethological studies have shown that patients with schizophrenia
can be distinguished from healthy subjects on the basis of their non-verbal
communication, particularly by their lack of behaviour encouraging ongoing social
interaction during the interview [Brüne et al., 2009]. In an Italian study of young men
with a diagnosis of recent-onset of schizophrenia, nonverbal behavioural patterns
clearly distinguished schizophrenia patients from control subjects, with a global
restriction of non-verbal expressiveness in the patient group [Troisi et al., 1998].
However, our findings of an association of more flight behaviour with a diagnosis of
schizophrenia and higher symptom levels within the group of schizophrenia patients
are inconsistent with a study by Brüne et al. [2008]. They studied a heterogeneous
group of acute adult inpatients with schizophrenia spectrum disorders and reported
less flight behaviour in patients as compared to healthy subjects. In the patient group,
they found more flight behaviour to be correlated with lower scores of negative
symptoms, as well as higher levels of excitement. Whether this inconsistency is due to
differences in patient characteristics between the two studies or the different context
of the behaviour – especially arranged research interviews in the study of Brüne et al.
[2008] and real-life consultations in this study – remains unclear. Yet, clarifying such
inconsistencies appears important for the use of similar assessment methods in future
research.
An association between conventional psychopathology measures and non-verbal
behaviour has also been found in other studies on patients with schizophrenia
[Trémau et al. 2005; Troisi et al. 2007; Brüne et al. 2008]. These studies analysed
videotaped interviews that were specifically arranged for the research and not real-life
situations. The study of Troisi [1998] reported a weak correlation between nonverbal
behaviour and psychiatric symptoms, whilst newer studies found a strong correlation
between less facial expressivity, measured on the ethological prosocial score, and
more negative symptoms, in particular anergia [Trémau et al. 2005; Troisi et al.
2007]. In addition, Brüne et al. [2008] reported multiple associations of
psychopathology, particularly negative symptoms with non verbal behaviour in
patients with schizophrenia spectrum illness. The association between flight and
symptom levels in patients with schizophrenia in this study was moderate, yet found
only in patients with schizophrenia. The combination of the main results of his study,
i.e. the difference in flight between the diagnostic groups and the association between
flight and symptom levels in patients with schizophrenia, suggest that flight behaviour
may indeed be specifically linked with the symptoms of schizophrenia. Flight is a
non-verbal behaviour that can only be identified in the context of interpersonal
communication and involves movements of the whole body. Future research may
investigate whether there is a link between flight behaviour and the diminished facial
expression of patients with schizophrenia that has been documented in social
cognition research [Schneider et al, 1990; Berenbaum and Oltmanns, 1992; Blanchard
et al. 1994; Mattes et al.1995; Geabel and Wolwer, 2005].
The results can be seen as being consistent with Rümke’s notion of the praecox
feeling and the assumption that disturbed communication is an important criterion for
this. Our findings are also similar to those of Grube [2006], who concluded that
psychopathological features including reduced communication skills are associated
with the intensity of 'praecox feeling'. Identifying potential correlates of the praecox
feeling in a real social interactions is of particular interest since Rümke suggested that
the feeling does not reflect “a disturbance of the affect” but “something that concerns
the relationship between people” (Rümke 1941, p 168, translation of the authors).
The patients with depression were analysed only as a comparison group in this study.
We found correlations of aspects of the patients’ non-verbal behaviour, i.e. pro-social
and displacement, with symptom levels within this group [also see Troisi 2002].
Patients with higher symptom levels tended to show less smiling, nodding and
looking at the interviewer, and had more hand-face-movements and fumbling.
Although a previous study [Troisi et al., 1999a] did not find an association between
non-verbal behaviour and severity of depression, the suggestion that more depressed
patients may smile less and fumble more appear clinically plausible.
Conclusion
The study did not aim to validate the concept of the praecox feeling. There are more
precise and reliable methods than the praecox feeling for establishing a diagnosis of
schizophrenia. However, the notion of the praecox feeling guided this study because it
might help develop a better understanding of the particular difficulties of patients with
schizophrenia that prevent them too often from effective interpersonal communication
and good functioning in the community [Priebe, 2007; Priebe et al., 2008a and b]. The
praecox feeling may reflect an interactional problem that hinders patients also in other
areas of life. The ‘flight’ behaviour they exhibit may function to reduce adverse
stimuli in the communication with a psychiatrist and also reduce potentially adverse
contacts with other people. Alternatively, flight behaviour may merely reflect a lack
of expressivity [Mandal et al., 1998; Pinkham et al., 2003] and no intention to avoid
further communication. Such explanation would be consistent with research showing
a disjunction between the expression and experience of emotions in patients with
schizophrenia [Berenbaum and Oltmans, 1992; Earnst and Kring, 1999]
In any case, if flight behaviour occurs throughout the real life of the patients, it might
reduce interpersonal encounters and contribute to social isolation and poor
functioning. More studies in other everyday social situations are required to decide
whether flight behaviour is linked to the problems patients with schizophrenia
encounter in their attempts to function in the community, and whether this may lead to
new therapeutic approaches. Longitudinal studies may establish to what extent flight
behaviour fluctuates along with other symptoms or is relatively stable over time.
Acknowledgements:
The authors would like to thank Mary Laville for her help in the literature search and
data collection.
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Table 1 Characteristics of patients with schizophrenia and depression
Patients with
Patients with
schizophrenia
depression
N=39
N=39
29/10
16/23
Age in years (mean ± SD)
44.1 ± 9.8
44.7 ±10.1
Duration of illness (mean ±
17.0 ±10.2
8.4 ± 6.4
Employed/unemployed
9/30
13/26
Living with partner/living alone
12/27
14/25
Characteristics
Gender male/female
SD)
Table 2 Mean ESCI scores (± SD) of patients with schizophrenia and depression
Patients with
Patients with
Non-verbal
schizophrenia
depression
behaviour
N=39
N=39
Pro-social
8.41 ± 3.34
9.05 ± 2.53
Statistics (MannWhitney test)
U = 654.5, p =
0.287
Flight
4.78 ± 3.32
2.85 ± 3.46
U = 495.5, p =
0.008
Gesture
3.52 ± 2.53
4.32 ± 2.13
U = 615.5, p =
0.146
Assertion
1.01 ± 1.13
1.41 ± 1.73
U = 726.0, p =
0.713
Displacement
4.17 ± 2.68
4.35 ± 3.61
U = 743.0, p =
0.861
Relaxation
8.66 ± 1.77
8.17 ± 1.95
U = 684.5, p =
0.385
Table 3 Correlations of ECSI scores with PANSS scores in patients with
schizophrenia and BDI scores in patients with depression
Patients with schizophrenia
Patients with
N=39
depression
N=39
PANSS
PANSS
PANSS
Non-verbal
positive
negative
global
behaviour
symptoms
symptoms
psychopathology
Pro-social
0.063
0.219
0.053
- 0.345*
Flight
0.447*
0.448*
0.591**
0.007
Gesture
- 0.050
- 0.228
- 0.193
- 0.132
Assertion
- 0.318
- 0.409*
- 0.370 **
0.143
Displacement
0.121
- 0.087
- 0.004
0.399*
Relaxation
0.027
- 0.144
- 0.055
- 0.136
* p<0.05, **p<0.01
BDI