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Problèmes méthodologiques posés par la classification des formes de schizophrénie: recherche de corrélations ou de relations d'appartenance?

Published online by Cambridge University Press:  28 April 2020

Monique de Bonis
Affiliation:
C.N.R.S., Université de PARIS XI, UFR Kremlin-Bicêtre
Paul de Boeck
Affiliation:
Université Catholique de Louvain
Marie-Odile Lebeaux
Affiliation:
I.R.E.S.C.O. - C.N.R.S.
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Résumé

Le présent travail comporte une critique de la méthodologie employée pour définir une typologie des schizophrènes et une étude empirique de la distinction entre forme productive et forme déficitaire.

Après avoir souligné que les études factorielles visant l’identification de deux types de schizophrènes reposaient sur des choix méthodologiques discutables: recherche de corrélations entre variables, alors qu’il s’agit de découvrir des corrélations entre sujets; préférence pour des relations symétriques, alors que les liaisons sont probablement d’ordre asymétrique, les auteurs présentent deux études empiriques.

La première réalisée sur un échantillon de 99 schizophrènes s’appuie sur la factorisation des estimations de la symptomatologie (BPRS* á 42 items) à l’aide de la méthode factorielle en plan Q et d’une analyse des correspondances. La seconde a porté sur un sous-échantillon de 52 schizophrènes à l’aide d’une nouvelle méthode d’analyse hiérarchique (HICLAS). Les résultats de ces analyses aboutissent aux conclusions suivantes. Les résultats des analyses factorielles montrent: • qu’il existe plus de deux formes de schizophrènie et qu’à l’intérieur des classes formées par les individus l’opposition déficitaire -productif est stable quelle que soit la métrique utilisée; • que cette opposition repose principalement, pour ce qui est de la forme déficitaire sur 3 symptômes: l’émoussement affectif, le retrait affectif et le ralentissement, et pour ce qui est de la forme productive sur l’humeur expansive, l’attitude manipulatoire, l’excitation, la dramatisation et la labilit émotionnelle; • que contrairement aux travaux antérieurs ni les hallucinations ni la désorganisation conceptuelle ne permettent d’établir la différence entre les deux groupes de malades sans doute parce qu’elles sont communes à tous les schizophrènes; • qu’il n’y a pas de correspondance entre les diagnostics cliniques et les formes décrites; et, • que les malades les plus déficitaires (situés aux extrêmités du pole factoriel) se différencient des malades productifs essentiellement par des variables liées au sexe (plus d’hommes que de femmes dans le premier cas), un statut marital de célibat plus fréquent, et des antécédents psychiatriques plus importants. Les résultats des analyses factorielles soulignent d’une part que les types mixtes sont plus fréquents que les types purs et, d’autre part qu’il suffit de moins de 10 symptômes pour réaliser une opposition satisfaisante entre forme productive et forme déficitaire (Tableau 3, figure 1).

Toutes ces conclusions sont valables aussi pour l’analyse hiérarchique. Mais de plus, cette méthode permet d’individualiser un groupe de malades “purs” dans la forme déficitaire seulement, groupe disjoint des autres individus sur la base d’un très petit nombre de symptômes. A côté de ces types purs figurent des types mixtes, qui possédent à la fois des symptômes déficitaires et des symptômes productifs suivant des combinaisons hiérarchiques précises, c’est-à-dire avec une dominance de l’une ou de l’autre forme. Il existe aussi des formes résiduelles dans lesquelles aucune hiérarchie ne peut être mise au jour (Tableau 4).

En conclusion on a insisté, outre les problèmes méthodologiques négligés dans les précédentes recherches, sur l’existence d’une dissymétrie entre la forme déficitaire et la forme productive, dans la mesure où c’est seulement la forme déficitaire qui présente une grande singularité et sur l’importance des symptômes liés à la vie affective et à son appauvrissement qui ont un pouvoir discriminatif plus élevé que les symptômes productifs.

*BPRS = Brief Psychiatric Rating Scale

Summary

Summary

This article presents a criticism of the methodology traditionally used in subtyping schizophrenic patients, together with two empirical studies devised to test the validity of the distinction between positive versus negative schizophrenia.

The focus of the critical approach is twofold: typologies are generally based on correlations between symptoms, whereas correlations between patients are required; symmetric relationships are analyzed, whereas asymmetric relations (e.g. those of inclusion) seem to prevail in symptoms organization.

The experimental approach consists of a presentation of two studies. The first, carried out in 99 schizophrenic patients, provides a subject-centered principal component analysis of the 42 items of the Brief Psychiatric Rating Scale, together with a factorial correspondence analysis which gives a dual plotting of subjects and variables. In the second study, a new hierarchical classification method (HICLAS), based on the search for asymmetric relationships, is processed in a subsample of 52 schizophrenic patients rated on a dichotomous version of the BPRS.

Results of the factorial analysis show that there are more than two types of schizophrenia, and that within these types, the distinction between negative and positive symptoms is clearcut and stable, regardless of the classification method adopted. This distinction holds well for three symptoms as regards the negative form: blunted affect, affective withdrawal and retardation; as regards the positive form, it is valid for grandiosity, elevated mood, manipulativeness, excitement, dramatization and emotional lability (table 3, fig 1).

In contrast to previous studies, neither hallucinatory behavior nor conceptual disorganization allows this distinction to be drawn between the positive and negative forms, probably because these symptoms are common to all types of schizophrenia. No relationship was found between the traditional clinical diagnosis and the statistical subtypes. The most negative patients, that is, those with the highest loadings on the factorial axis, differed from the most positive patients mainly in terms of variables related to sex, marital status and psychiatric antecedents (the former, predominantly male patient group presented a higher incidence of celibacy and more marked psychiatric antecedents).

The results of factorial analysis emphasize the higher frequency of mixed as compared with pure types, and show that less than 10 items are necessary to realize a satisfactory differentiation between positive and negative symptomatology.

All these conclusions are likewise valid for the hierarchical analysis. Furthermore, the present method allows better identification of the “pure” negative form patients, characterized by a very limited number of symptoms. Alongside these pure types are the mixed types in which positive and negative symptoms are hierarchically combined, that is, in which the negative or positive aspects are prominent. There are also patients belonging to residual forms with no identifiable hierarchy (table 4).

In conclusion, this study draws attention to the methodological problems neglected in previous attempts to determine a dissymmetry between the negative and the positive forms, in that only the negative form displays an important singularity. Moreover, the conclusions stress the fact that affective-related symptoms, particularly a reduction in affective life, seem to be more discriminative than the positive symptoms.

Type
Research Article
Copyright
Copyright © European Psychiatric Association 1987

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Problèmes méthodologiques posés par la classification des formes de schizophrénie: recherche de corrélations ou de relations d'appartenance?
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