Stability of Personality Traits in Schizophrenia and Schizoaffective Disorder: A

Pilot Project
[Articles]
KENTROS, MARY M.D.1; SMITH, THOMAS E. M.D.1; HULL, JAMES PH.D.1;
MCKEE, MICHAEL PH.D.1; TERKELSEN, KENNETH M.D.1; CAPALBO,
CHRISTINE M.S.W.2
1
Department of Psychiatry, Cornell University Medical College, The New York
Hospital-Cornell Medical Center Westchester Division, 21 Bloomingdale Road, White
Plains, New York; 10605.
2
MACC Center, Sun City Center, Florida.
Send reprint requests to Dr. Kentros.
Abstract
This study was performed in an effort to begin characterization of personality traits in
schizophrenia. Specific concerns included personality profiles relative to normal
adults, personality profile stability over time, and trait-state issues. The authors
administered the NEO Personality Inventory as well as symptom ratings at two time
points to 21 patients. Patients were all stabilized outpatients attending an adult
continuing day treatment program and diagnosed with either schizophrenia or
schizoaffective disorder. Personality profiles were determined for all patients.
Compared with a normal adult sample, this sample's scores on three out of five of the
personality domains assessed were not distinguishable from normal adults. Test-retest
correlations were highly significant over an average 28.2-week time interval. In
general, the presence of positive symptoms did not appear related to NEO-PI stability,
while negative symptoms did show a relationship to the stability of personality
profiles. These data suggest that personality profiles can be looked at in schizophrenia,
that these profiles do appear stable over time, and that negative symptoms have a
strong influence on profile stability and appear to be trait-like.
By definition, personality represents stable and enduring cognitive, behavioral, and
psychological patterns both intrapsychically and in relation to one's environment.
Modern psychiatry, specifically the current nosology based on DSM-IV, places
personality on a separate diagnostic axis from other psychiatric syndromes (American
Psychiatric Association, 1994). There continues to be a great deal of interest, however,
in the relationship between personality and psychiatric symptoms related to
conditions diagnosed on Axis I. Many fundamental questions remain unanswered and
are the focus for research. For example, can one diagnose a personality disorder or trait
in a reliable and valid way when an Axis I disorder is present? In fact, what constitutes
personality, and where does one draw a distinction between personality (or trait
factors) and syndrome (state factors)? How does personality affect the
manifestations of an illness? Or, put another way, do personality traits endure and
remain stable in the face of an Axis I disorder and when symptoms of this disorder
have resolved? These state-trait interactions are important issues in our current
understanding and treatment of psychiatric patients.

Despite the theoretical and methodological difficulties inherent in sorting out trait from
state, research suggests that personality factors can influence the course and treatment
response of a variety of Axis I disorders. Reich and Green (1991) reviewed 21 studies
showing that in the treatment of major depression, alcoholism, panic disorder, and
obsessive compulsive disorder, increased levels of personality pathology were
associated with poorer treatment outcome. Ricciardi et al. (1992) reported on 17
patients with obsessive-compulsive disorder (OCD) plus a comorbid DSM-III-R
diagnosable personality disorder. After 4 months of treatment for OCD, 10 of 17
patients responded to treatment for OCD, and 9 of these 10 no longer met criteria for a
personality disorder. In contrast, other researchers have found that personality traits
and disorders can be assessed and appear to endure beyond treatment of an affective
episode. In his 1991 study of trait-state artifacts and the diagnosis of personality
disorders, Loranger et al. (1991) examined 84 patients using a semistructured interview
administered both during an affective episode and following recovery. Notably, he
found that with use of a sensitive diagnostic instrument (the Personality Disorder
Examination) by experienced clinicians, no evidence emerged that a patient's morbid
mental state had affected the diagnosis of personality disorder (p. 726), using either a
categorical or dimensional approach to diagnosis of personality disorders. This finding
is especially important because other studies using different diagnostic instruments
have been unable to sort out these trait-state interactions. Loranger's study suggests
that personality traits remain stable in the face of an affective illness. Also, these
findings are compatible with the concept that personality by definition, is stable and
enduring.
What about personality in schizophrenia? DSM-IV cautions against making a
personality disorder diagnosis in schizophrenic patients due to the effect of the illness
on personality (American Psychiatric Association, 1994). However, clinicians who
work with schizophrenic patients often note characteristics that might be
conceptualized as personality, and clinical wisdom suggests that schizophrenic patients
have a variety of personality styles (Oldham and Skodol, 1991; Smith et al., 1995).
Some research is beginning to emerge to support clinical impressions that personality
traits, and likely fully diagnosable personality disorders, can be found in individuals
with schizophrenia. Hogg et al. found that between 57.5% to 70.3% of recent-onset
schizophrenics were diagnosable as having a DSM-III personality disorder using two
different diagnostic instruments, the SIDP (Structured Interview for DSM-III
Personality Disorders) and the MMCI-I (Millon Multiaxial Clinical Inventory; pp. 198199; Hogg et al., 1990). Donat et al. (1992) reported that they were able to empirically
derive five personality subtypes that were distributed equally between schizophrenics
and patients with mood or psychotic disorders. In a 4-year study of prevalence of
personality disorder diagnoses in hospital inpatients, Smith et al. (1996) found that
11% of schizophrenics and 28.6% of schizoaffective patients were given personality
disorder diagnoses by experienced clinicians and that the comorbid personality
disorder diagnosis was associated with a twofold longer length of stay. Tien et al.
(1992) were able to measure distinct personality features in a sample of persons with
schizophrenia spectrum traits, finding elevated neuroticism and low openness.
This study aims to extend the previous research on the role of personality in
schizophrenia. As outlined by Smith et al. (1995), for personality to be meaningful in
this population it should be demonstrated that a) specific traits are stable over time; b)
traits are independent of characteristic psychotic symptoms; and c) traits have clinical

relevance, e.g., they are associated with factors such as functional ability or treatment
response. To collect preliminary data exploring these areas, we conducted a
prospective analysis of a small cohort of stable schizophrenic phrenic patients.
Personality was assessed using a measure of normal personality traits to diminish
confusion regarding the boundary between schizophrenic psychopathology and
pathological personality traits.
Methods
Twenty-one patients from The New York Hospital, Westchester division Adult
Continuing Day Treatment Program participated in the study. All patients who were not
currently experiencing an acute psychotic exacerbation were eligible to participate on a
voluntary basis. Informed consent was obtained from each patient after explanation of
the proposed research. The patients represented a convenience sample in that they
were those who volunteered to participate in the project as opposed to consecutive
admission. Because only volunteered to participate in the project as opposed to
consecutive admission. Because only volunteers were recruited on an ongoing basis,
the number of patients excluded from the study or who did not consent is not known.
In general, the sample represented a population of chronically ill young adults (mean
age [ SD] = 33.91 7.80 years), predominantly single white men (men = 71.4%) who
had been ill over 10 years (mean age at onset of symptoms = 18.81 5.16 years).
Patients had been hospitalized as inpatients a mean of 5.86 4.62 times. On average,
patients were taking 497 315 mg of chlorpromazine-equivalents neuroleptic dose.
Data on side effects of medication were not collected, as it was initially not felt that
this was an area relevant to the present investigation.
All subjects were diagnosed with schizophrenia or schizoaffective disorder according
to Research Diagnostic Criteria (Spitzer and Endicott, 1977) by a member of the
research team trained in using the Schedule for Affective Disorders and Schizophrenia
(SADS; Endicott and Spitzer, 1978). Only patients with SADS diagnosed
schizophrenia or schizoaffective disorder were included in the study. Of the sample,
71.4% were diangosed with schizoaffective disorder; 28.6% were diagnosed with
schizophrenia. This two-to-one ratio of schizoaffective to schizophrenia diagnoses
was characteristic of the diagnoses of all patients attending this day treatment program.
The high percentage of schizoaffectives is probably a reflection of the fact that the
program had an intensive rehabilitation focus and selected only those persons with
chronic psychotic disorders who had the potential for rehabilitation. In this case, this
program tended to select patients with a more favorable prognosis who were more
likely to be schizoaffective, as opposed to schizophrenic patients with predominantly
negative symptoms.
Patients with low-morbid organic brain pathology or low intelligence were excluded
from this study. IQ estimates were taken from patient records, as all clinicians are
required to estimate intellectual functioning in this program.
Procedure
Patients were assessed at two points in time, separated by approximately 6 months
(mean = 28.2 14.4 weeks). At each assessment point, the patient was assessed for
symptoms using the Brief Psychiatric Rating Scale (BPRS; Lukoff et al., 1986) and the
Scale for the Assessment of Negative Symptoms (SANS; Andreason, 1983). The Beck
Depression Inventory (BDI; Beck, 1978) was used to assess depressive symptoms. An

outcome assessment was performed at the second time point, using the Level of
Function (LOF) scales (Hawk et al., 1975). These assessments were used to determine
both level of symptomatology and functioning.
At both time points, the patients were given the NEO Personality Inventory to assess
personality profiles. The NEO-PI is a self-report questionnaire consisting of 181
questions designed to assess traits dimensionally in the five domains of neuroticism
(N), extroversion (E), openness to experience (O), agreeableness (A), and
conscientiousness (C; Conoley and Kramer, 1989). Within each of these five domains,
there are six facets that attempt to measure a broad range of relevant thoughts,
feelings, and actions (Costa and McCrae, 1985). Each domain represents a spectrum
along which an individual can be assessed as having more or less of a particular trait.
Patients were instructed in the completion of NEO-PI and specifically directed to rate
items based on their current state. Subjects who had difficulty filling out the NEO
questionnaires were assisted by a member of the research team, e.g., for several
patients, team members read each item and assisted with filling out forms.
Data Analysis
NEO profiles were constructed for all patients in the sample. Subjects' scores were
converted to t-scores based on the normal adult standardization sample (Costa and
McCrae, 1988). Only domain scores were used because of the small sample size and
number of variables to be analyzed. This made possible the construction of a
scizophrenic profile, showing how the present sample compared with a normal
population. The distribution of subjects' scores on each NEO scale was examined to
identify possible floor and ceilling effects, whereby subjects would obtain scores
so extreme that significant variability within the sample would be obscured. For this
purpose, extreme scores were defined as subjects obtaining t-scores >75 or >25.
The temporal stability of NEO scores was examined through calculation of test-retest
correlations from Time 1 to Time 2. For purposes of comparison, test-retest
correlations also were calculated for positive and negative symptoms. Correlations
between NEO scores and symptom scores were used to determine the degree of
overlap or convergence between these two domains. Finally, the relationship of
subjects' NEO scores to the LOF scale (Hawk et al., 1975) was investigated, again
through correlational analysis.
Results
Personality Profiles
The mean NEO t-scores and standard deviations are summarized in Table 1. Compared
with a normal adult sample, neuroticism scores are elevated, while conscientiousness
scores are low. Also notable is that taken as a group, this samples' scores on E, O, and
A are not distinguishable from those found in a normal adult sample.

TABLE 1 Mean NEO-PI Domain T-Scoresa and TestRetest Correlationsb

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An analysis was performed to determine the number of subjects having extreme scores
at either Time 1 or Time 2 (t score <25 or >75). Extreme scores were a concern
primarily in the N domain (33%), particularly in the subscales of vulnerability (52%),
depression (29%), and self-consciousness (24%). The remainder of the domains had
few scores that fell outside the normal range: E, 10%; O, 5%; A, 5%; and C, 14%.
Temporal Stability and Validity of Personality Measures
Test-retest correlations are also included in Table 1. Time span between Time 1 and 2
assessments was variable, with a mean of 28.2 weeks. Test-retest correlations are high
for N, E, O, and C scales. These correlations remained significant even when analysis
was performed controlling for the variable time interval between assessments. All 23
subscale correlations were significantly positive, with 17 of them at the p < 0.001
level.
Test-retest correlations for symptoms were performed. High test-retest correlations
between ratings at Time 1 and Time 2 are observed with the BDI (r =.61, p <.01), the
SANS (r =.89, p <.001), and the BPRS subscales of anxiety/depression (r =.77, p
<.001) and negative symptoms (r =.61, p <.05). Correlations were not found between
measures of positive symptoms including global BPRS score and BPRS subscales
assessing positive symptoms, activation, and hostility. In addition, no correlations
between NEO domain scores and medication dose were found.
One of the other issues raised in this study concerns the differing patterns of positive
and negative symptoms and their varying influences on the NEO-PI. Although positive
symptoms varied over time, negative and depressive symptoms remained stable. When
a correlation was performed between symptoms at Time 1 and NEO domains, the BDI
and SANS were significantly inversely correlated with the domains of E, O, and A
(Table 2). There were no correlations found between BPRS-Positive Symptoms
measures and any of the NEO-PI domains.

TABLE 2 Relationship of NEO-PI to Symptom

Measures and Level of Functioning Scales
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Predictive Validity
To assess whether the NEO-PI offers any information relevant to clinical functioning in
this population, an analysis of the NEO-PI's relationship to the LOF Scale was
performed. The LOF offered an independent assessment of behavior and functioning in
the areas of time spent out of hospital (NH), social contacts (SOC), and employment
over the last year (EMP; 16). Higher LOF scores represent higher levels of
functioning.

The five major NEO-PI domains were compared with the LOF Scale, and results are
summarized in Table 2. As can be seen, SOC was correlated with all NEO-PI domains
except conscientiousness. Higher Neuroticism scores are associated with a paucity of
social contacts and lower levels of employment.
Discussion
The results of this study suggest that personality profiles can be looked at in
schizophrenia. Considering the relatively small percentage of extreme scores, the NEO
does appear to be a valid instrument for use in this population. With the exception of
the N domain, the NEO scores fell within the usual range for normal adults.
Our data also suggest that personality traits in schizophrenic patients are stable over
time. In this study, NEO test-retest correlations after an average 6-month time interval
showed significant stability, particularly in the domains of N, E, O, and C. These
correlations were stable despite the finding that symptom profiles, especially positive
symptoms, were not. This would appear to suggest that positive symptoms do not
interfere with the NEO's ability to measure traits that are stable over time in a
schizophrenic population.
In normal adult populations, the NEO has been shown to have a high retest stability
over time. In a 6-year study of over 900 persons, retest stability for the N, E, and O
scales was 0.83, 0.82, and 0.83, respectively (Costa and McCrae, 1988). In this study,
test-retest correlations for N, E, and O were strikingly similar: 0.84, 0.90, and 0.84,
respectively. These data strongly suggest that in stabilized schizophrenic and
schizoaffective outpatients, one can begin to define personality traits that are stable
over time.
Our data suggest that personality profiles in schizophrenics are independent of
positive, psychotic symptoms. In this study, positive symptoms appeared to have little
influence on profile stability. It should again be noted that although patients studied
were stabilized outpatients, they continued to experience significant symptoms
(average BPRS score at time 1, mean = 51.41 10.9; BPRS subscale for positive
symptoms at time 1, mean = 16.7 4.4). Despite ongoing positive symptoms, the
NEO-PI data remained stable. In contrast, there were correlations between the
personality domains and negative symptoms, which some researchers consider to be
trait-like (Arndt et al., 1995). This group of patients suffered from significant chronic
anxiety and depression, which is seen in elevated mean scores on BPRS, the BDI, and
the N domain of the NEO.
The most compelling area of study here was the issue of the clinical relevance of
personality profiles in such patients. There were significant correlations between social
functioning and the N, E, O, and A domains. In particular, higher levels of N were
associated with poorer social and vocational functioning, while higher levels of E, O,
and A were associated with greater social functioning. The data suggest that NEO-PI
profiles in this population may have some meaning clinically in differentiating
populations with varying levels of functioning. In addition, the NEO-PI's stability over
time and its association with stable negative and depressive symptoms points to the
significance of clearly identifying these symptoms. As seen in this study, such
symptoms are associated with poorer social functioning. Further studies looking at how
these negative symptoms affect quality-of-life outcomes might be warranted. In
addition, the question arises as to whether psychopharmacologic and rehabilitative

treatments aimed at negative, anxious, and depressive symptoms improve quality-oflife measures.
One threat to the validity of this study is the possibility that NEO scores are primarily
reflective of symptoms, especially negative symptoms. According to this hypothesis,
stability or change in the NEO would be determined by patterns of stability or change
in negative symptoms, such that the NEO would not provide significant independent
information, above and beyond that provided by negative symptom ratings. Because of
the small size of our sample it was not possible for us to test this directly, but we were
able to perform a post hoc analysis that suggested that NEO contributes independent
information, at least in some cases. We carried out a series of linear regression analyses
with the Social Contacts scale (Hawk et al., 1975) as the dependent measure.
Predictors included the SANS and the NEO domains, with a separate analysis carried
out for each domain. We found that N (p <.03) and O (p <.05) made significant
independent contributions to the prediction of Socialization, above and beyond
negative symptoms as measured by the SANS. By contrast, E, A, and C did not make
independent contributions to the prediction of SOC. We recognize the limitations of
repeated regression analyses with such a small sample, but these findings provide a
preliminary suggestion that some domains of the NEO are independent of symptom
constructs such as negative symptoms.
The results of this study support the clinical impression that interactions between
state and trait are important to understanding schizophrenic patients. As novel
antipsychotic drugs allow better symptom control and rehabilitative approaches
become a focus of concern, issues of personality traits and styles among
schizophrenics are likely to become more of a relevant clinical concern. Personality
traits and disorders are also likely to have important implications for treatment
outcome.
Despite the clinical wisdom that personality issues are relevant in studying and treating
schizophrenia, it remains difficult to gain a full understanding of the nature and
prevalence of personality disorders in schizophrenics. Gathering data for diagnosis of
personality disorders in schizophrenia may be complicated by psychotic symptoms
(state issues) as well as by those factors that complicate all personality diagnoses, e.g.,
the validity of the self-report instruments versus interviews and the assignment of
categorical versus dimensional personality diagnoses. Furthermore, measurement of
premorbid personality may be compromised by distorted or faulty memory on the part
of patients or informants. Premorbid functioning may be important prognostically but
remains difficult to accurately assess (Werry, 1992). Thus, some clinicians have begun
to rely on the construct of current personality in chronic schizophrenia (Terkelsen et
al., 1991).
One of the clinically relevant purposes of an assessment of current personality traits
in such patients would be in the development of differential therapeutics. In this regard,
the categorical approach of DSM-IV may not be as useful as a descriptive assessment
of a patient's personality traits and their strengths and vulnerabilities. As Terkelsen et
al. (1991) note, current personality, which is presumably influenced by premorbid
personality and by traits acquired in response to schizophrenia and treatment, may be
more accessible to investigation and more relevant to treating clinicians than
premorbid personality (p.538). In the patients studied, current personality appears to
represent a composite of premorbid personality features interwoven with the
experience of a psychotic condition present for an average of a decade. With 10 years

of history of having a psychotic condition, disentangling trait from state, particularly

regarding negative symptoms, may represent a difficult, if not impossible, task.
However, this study suggests the NEO-PI may add to our ability to describe patients
and perhaps enhance our ability to match patients with treatments.
This study has several weaknesses that may have influenced results. The samples size
in this pilot project (N = 21) was small and may limit generalizations to a broader
population. The small sample size may also limit inferences derived from the statistical
analyses that were performed. In addition, patients were primarily diagnosed with
schizoaffective disorder; profiles in purely schizophrenic patients may exhibit fewer
affective features, so that issues of depression and anxiety may be different. Another
weakness in this study is that interrater reliability was not established before
undertaking assessments of patients.
Another issue in this study is the use of the NEO-PI in a sample of patients with
varying degrees of psychosis. As with any self-report questionnaire, the reliability and
validity of the NEO must be considered. The NEO is subject to test-retest and practice
biases. However, when used in cross-sectional studies of normal adults of different
ages, these effects were not found to affect the general stability of personality traits
over time as measured in the NEO (McCrae and Costa, 1990, p. 70). Other concerns
about self-report instruments in general include self-misrepresentation. Subjects may
lie or distort information about themselves for a variety of reasons. One of the ways
results from self-report questionnaires can be validated is comparing self-ratings with
ratings of the subject done by others. The NEO has been studied in this manner, with
significant correlations found between self-rating and those of a spouse and peer
(McCrae and Costa, 1990, p. 38). This study differs from that of Loranger et al. (1991)
in that his instrument was used by trained raters and that psychosis was excluded from
his study. He found that state factors exerted little effect on traits. Although we do not
know that the state factors exerting effect holds for self-report inventories on
psychosis, data from this study suggest it might be the case.
Overall, the NEO is a widely accepted instrument to measure personality traits
consistent with the 5-factor model of personality. This questionnaire has been
extensively used to study stability of personality traits over time in normal adults. The
developers of the NEO, McCrae and Costa, have used this instrument to argue
persuasively that personality remains stable in adulthood (McCrae and Costa, 1990).
The use of the NEO in a schizophrenic population to measure personality traits has not
been validated. Nevertheless, data from this study begin to provide preliminary
evidence regarding the construct and predictive validity of the NEO-PI to predict
depressive and negative symptoms and to predict independent ratings of the social
contacts portion of the LOF Scale.
Nonetheless, the data are consistent with the clinical observation that there are two
types of symptom patterns in schizophrenics: positive and negative. This study appears
to support the theory that psychotic symptoms vary over time and represent state
issues while negative and depressive symptoms are more like traits. This study also
suggests that these traits may impact on LOF. Further research will be necessary to
clarify relationships between negative symptoms and depression and to assess the
utility of the NEO in the schizophrenic population.
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Journal of Nervous & Mental Disease. 185(9):549-555, September 1997.