East Asian Arch Psychiatry 2018;28:75-9


Premorbid Adjustment in Predicting Symptom Severity and Social Cognitive Deficits in SchizophreniaCME
RL Dewangan, P Singh

Roshan Lal Dewangan, PhD, School of Studies in Psychology, Pt Ravishankar Shukla University, Raipur (C.G.), India
Promila Singh, PhD, School of Studies in Psychology, Pt Ravishankar Shukla University, Raipur (C.G.), India

Address for correspondence: Dr Roshan Lal Dewangan, Department of Applied Psychology, Kazi Nazrul University, Asansol (W.B.), 713340, India Email: devanganroshan@gmail.com

Submitted: 11 August 2017; Accepted: 9 March 2018

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Objective: Schizophrenia patients have deficits in premorbid adjustment (PMA) and social cognition (SC); both deficits are associated with symptom severity, neuro-cognitive deficits, and prognosis. This study aimed to determine symptom severity and two domains of SC deficit by assessing specific areas of PMA in schizophrenia patients.

Methods: This cross-sectional study included 60 male and 60 female patients with paranoid schizophrenia aged 20 to 35 years from two psychiatric inpatient departments of Chhattisgarh state of India. They were assessed using the Scale for Assessment of Positive Symptoms, Scale for Assessment of Negative Symptoms, Premorbid Adjustment Scale, Recognition of Facial Expression Task, and Picture Arrangement Test.

Results: Deficits in premorbid sociability and in scholastic performance were the best predictors of severity of positive symptoms, social knowledge, and negative emotion recognition deficit in schizophrenia patients.

Conclusion: Given the important role of SC and PMA, assessing premorbid functioning can help in deciding early and appropriate intervention for schizophrenia.

Key words: Affective symptoms, Schizophrenia, paranoid; Social adjustment


Premorbid adjustment (PMA) is defined as a combination of peer and social relationships, school adaptation, job functioning, and satisfactory opposite sex relationship prior to the development of schizophrenia.1 It is associated with the onset, symptomatology, cognitive functioning, and prognosis of schizophrenia.2-4 In both chronic5-7 and first-episode3,8 cases of schizophrenia, disturbances in several areas of functioning have been observed prior to the onset of diagnosable illness. PMA studies that compare schizophrenia disorder, bipolar disorder,9 and mania10 have reported larger deterioration in functioning in schizophrenia cases. Schizophrenia can be considered a neurodevelopmental disorder,11 and its manifestation affects several areas of general and cognitive functioning.12 PMA studies may enable early detection of the illness.

PMA is associated with negative schizophrenia symptoms.3-5 In a study of 41 schizophrenia patients, poor PMA was associated with a poor Positive and Negative Syndrome Scale score that was in turn associated with progressive deterioration from childhood to adulthood, poor peer relationships, and poor scholastic performance.13 In a follow-up study of the PMA Scale in 87 schizophrenia patients, three patterns of premorbid deterioration (stable-good, stable-poor, and continuous deterioration) were identified in 36.8%, 35.6%, and 27.6% of patients, respectively.3 Patients with stable-poor PMA had significantly more severe negative symptoms in their second- and third-year course than patients with stable- good PMA, whereas patients with good PMA had fewer negative symptoms even in their third year of follow-up.

Social cognition (SC) is defined as a cognitive process to make sense of the social world and its utilisation to facilitate social interactions.14,15 Five domains of SC have been identified by the Measurement and Treatment Research to Improve Cognition in Schizophrenia working group: emotion processing, theory of mind, social perception, social knowledge, and attributional bias.16 Schizophrenia patients consistently have cognitive deficits,17,18 which are targets for intervention.19,20 In first-degree relatives and first- episode schizophrenia patients, cognitive deficits in verbal memory and executive function are commonly reported and thus schizophrenia is considered a neurodevelopmental disorder.21 These deficits can exist in childhood, long before the development of schizophrenia.22 They are caused by abnormal brain development that hinders the patient’s ability to acquire appropriate cognitive abilities. PMA is also associated with clinical and gender issues.23-25 Nonetheless, studies of association between PMA and SC are lacking. This study aimed to predict symptom severity and two domains of SC deficit through specific areas of PMA in schizophrenia patients.


This study was approved by the Institutional Ethical Committee for Human Research, Pt. Ravishankr Shukla University Raipur, Chhattisgarh, India (reference No. 038/ IEC/PRSU/2014). Written informed consent was obtained from each patient and/or adult caregiver. A total of 60 males and 60 females diagnosed with paranoid schizophrenia as per ICD-10 Classification26 were recruited through purposive sampling from the in-patient department of two psychiatric hospitals in Chhattisgarh state of India. Inclusion criteria were: age 20-35 years (so as to match the principal age of onset of schizophrenia in Indian and other populations,27,28 to indirectly control illness duration to ensure accurate memory of premorbid functioning, and to ensure age-wise homogeneity of participants for better generalisation), minimum education of 10 years (to fulfil the minimum requirement for outcome measures), and absence of any history of neurological or severe physical illness or comorbidity of other psychiatric illness. Patients with any other comorbidity were excluded to ensure that social cognitive deterioration was due to schizophrenia only.

Severity of positive symptoms (hallucinations, delusions, bizarre behaviour, and positive formal thought disorder) and negative symptoms (affect disturbances, alogia, avolition, anhedonia, and attention) of schizophrenia was assessed using the Scale for Assessment of Positive Symptoms (SAPS)29 and Scale for Assessment of Negative Symptoms (SANS).30 Both were a 6-point Likert scale (0-5); a higher score indicated more severity. The SAPS comprised 34 items, with a possible score of 0 to 170. The SANS comprised 25 items, with a possible score of 0 to 125. Both scales have been used in Indian samples.31,32

The PMA Scale1 was used to assess the degree of sociability and peer interactions, scholastic performance(0-11 years), early adolescence (12-15 years), late adolescence (16-18 years), and adulthood (≥19 years) by interviewing close informers (parents, siblings, and patients). Performance in different domains of the PMA scale one year before schizophrenia onset was obtained. Higher score indicated poorer adjustment.

Two domains of SC were assessed: recognition of facial expression task33 and social knowledge.15 Eight standardised photographs (four male and four female) depicting seven facial expressions (neutral, aggression, surprise, happiness, disgust, fear, and sad) were shown one-by-one on a computer screen. Patients were asked to recognise them from a list of six random affects. Neutral affect was used only for trial purposes and was not included in analysis. These photographs were dichotomised into positive emotions (happy and surprise) and negative emotions (aggression, disgust, fear, and sad). One point was assigned for each correct recognition and zero point for wrong recognition. Social knowledge was assessed using the Indian version Picture Arrangement test,34 a subtest of the Wechsler Adult Intelligence Scale.35 The Picture Arrangement test is a time-bound test and consists of nine sets of pictures depicting nine themes. Patients were asked to arrange a given set of pictures aain a way that described the correct sequence of theme. Higher score indicated better social knowledge (range, 0-42).

Stepwise regression analyses were conducted by entering age, sex, and education level as independent variables in the first step and then entering all PMA scale domains to determine the predictors. Domains that significantly predicted the criterion were retained; the regression model did not predict SANS and positive emotion (criterions) and hence these were not reported. A p value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS (version 21.0; IBM Corp, Armonk [NY], USA).

75 T1


A total of 60 males and 60 females with schizophrenia (mean age, 25.34 ± 3.06 years) were included (Table 1). Most had education up to an intermediate level (45.8%) or graduation (42.5%). Severity of positive symptoms of schizophrenia was positively associated with premorbid sociability (β = 0.226, p = 0.015) and scholastic performance (β = 0.20, p = 0.036) [Table 2]. Education level was positively associated with social knowledge (β = 0.23, p = 0.014). After controlling for education level and other demographic variables, premorbid poor scholastic performance remained predictive of poor social knowledge (β = –0.259, p = 0.006). Females scored better for recognition of negative emotions (β = 0.194, p = 0.029). Premorbid deficit in sociability also predicted poor recognition of negative emotions (β = –0.315, p = 0.001).

75 T2


PMA significantly predicted symptom severity along with SC deficits in schizophrenia. Severity of negative symptoms has been reported to be associated with poor sociability and poor prognosis of schizophrenia.3,36,37 Cognitive deficits have been reported to be associated with scholastic performance and thus both poor sociability and scholastic performance are associated with negative symptoms.3 In our study, none of the PMA domains was associated with severity of negative symptoms, but poor premorbid sociability and scholastic performance were predictive of the severity of positive symptoms. About 88% of participants had at least 12 years of education, but they may have had several failures during this period as suggested by PAS. Higher education attainment was positively associated with better social knowledge. Thus, we found no association of PMA with negative symptoms. In addition, the PMA deficit score in our participants was less severe than that reported in other studies.3,37 Further study is required to explore the association of symptom severity and PMA with different demographics.

Social knowledge as a domain of SC has been less studied, probably because of the lack of proper assessment tools. In our study, the Picture Arrangement test was used to determine social knowledge, as described by other studies.35,38 Poor social knowledge was affected by poor premorbid scholastic performance; better scholastic performance predicted better social knowledge. Picture Arrangement score has been shown to increase with increasing education.39

Schizophrenia patients have a deficit in recognition of negative emotions (i.e. sad, disgust, fear, and anger).40-42 In our study, poor premorbid sociability was the best predictor of this deficit, and female sex was a protective factor. Fitness threat suggests that by evolution, females have had to recognise negative emotions of infants in order to take protective measures.43 Accurate recognition of facial expression is important in social interaction. Deficit in this component may result in ineffective or disturbed social functioning. Poor PMA and deficits in facial expression recognition have been reported to be associated with the presence of neuro-cognitive deficits.7,44


There are limitations to our study. Only two dimensions of SC were used; other dimensions of SC should have been explored. This is a cross-sectional study; a longitudinal study is required to understand the association between PMA and SC and generalisation of results. PAS has not been validated in an Indian population. Indian standardisation is required, because (1) despite scholastic disturbances a large number of participants had high educational attainment, therefore norms required to establish disturbed pattern; (2) some items from the socio-sexual domain of PAS were not suitable, as sex relationship (especially premarital) is unreported by most Indian families.45,46 Nonetheless, certain domains of PMA can be used to predict symptomatology and SC deficits, and can help in planning early intervention and predicting prognosis in schizophrenia. Advances in schizophrenia treatment have facilitated control of florid symptoms; management has shifted from being institutional to community-based. Early detection of a propensity to develop illness and possible skill deficits may help in management through skill training, stress management, and neuroleptic medication to control symptoms and episodes and support better community living.47


Premorbid sociability and scholastic performance were predictive of the severity of positive symptoms, social knowledge, and negative emotion recognition deficit in schizophrenia. Given the important role of SC and PMA, assessing premorbid functioning can help in deciding early and appropriate intervention for schizophrenia.


  1. Cannon-Spoor HE, Potkin SG, Wyatt RJ. Measurement of premorbid adjustment in chronic schizophrenia. Schizophr Bull 1982;8:470-84. cross ref
  2. Brill N, Levine SZ, Reichenberg A, Lubin G, Weiser M, Rabinowitz J. Pathways to functional outcomes in schizophrenia: the role of premorbid functioning, negative symptoms and intelligence. Schizophr Res 2009;110:40-6. cross ref
  3. Chang WC, Tang JY, Hui CL, Wong GH, Chan SK, Lee EH, et al. The relationship of early premorbid adjustment with negative symptoms and cognitive functions in first-episode schizophrenia: a prospective three-year follow-up study. Psychiatry Res 2013;209:353-60. cross ref
  4. McGlashan TH. Premorbid adjustment, onset types, and prognostic scaling: still informative? Schizophr Bull 2008;34:801-5. cross ref
  5. Gupta S, Rajaprabhakaran R, Arndt S, Flaum M, Andreasen NC. Premorbid adjustment as a predictor of phenomenological and neurobiological indices in schizophrenia. Schizophr Res 1995;16:189-97. cross ref
  6. Schmael C, Georgi A, Krumm B, Buerger C, Deschner M, Nöthen MM, et al. Premorbid adjustment in schizophrenia: an important aspect of phenotype definition. Schizophr Res 2007;92:50-62. cross ref
  7. Strauss GP, Allen DN, Miski P, Buchanan RW, Kirkpatrick B, Carpenter WT Jr. Differential patterns of premorbid social and academic deterioration in deficit and nondeficit schizophrenia. Schizophr Res 2012;135:134-8. cross ref
  8. Monte RC, Goulding SM, Compton MT. Premorbid functioning of patients with first-episode nonaffective psychosis: a comparison of deterioration in academic and social performance, and clinical correlates of Premorbid Adjustment Scale scores. Schizophr Res 2008;104:206-13. cross ref
  9. Kutcher S, Robertson HA, Bird D. Premorbid functioning in adolescent onset bipolar I disorder: a preliminary report from an ongoing study. J Affect Disord 1998;51:137-44. cross ref
  10. Koenen KC, Moffitt TE, Roberts AL, Martin LT, Kubzansky L, Harrington H, et al. Childhood IQ and adult mental disorders: a test of the cognitive reserve hypothesis. Am J Psychiatry 2009;166:50-7. cross ref
  11. 1 Weinberger DR. From neuropathology to neurodevelopment. Lancet 1995;346:552-7. cross ref
  12. Niemi LT, Suvisaari JM, Tuulio-Henriksson A, Lönnqvist JK. Childhood developmental abnormalities in schizophrenia: evidence from high-risk studies. Schizophr Res 2003;60:239-58. cross ref
  13. Saracco-Alvarez R, Rodríguez-Verdugo S, García-Anaya M, Fresán A. Premorbid adjustment in schizophrenia and schizoaffective disorder. Psychiatry Res 2009;165:234-40. cross ref
  14. Green MF, Olivier B, Crawley JN, Penn DL, Silverstein S. Social cognition in schizophrenia: recommendations from the measurement and treatment research to improve cognition in schizophrenia new approaches conference. Schizophr Bull 2005;31:882-7. cross ref
  15. Derntl B, Habel U. Deficits in social cognition: a marker for psychiatric disorders? Eur Arch Psychiatry Clin Neurosci 2011;261(Suppl 2):S145-9. cross ref
  16. Green MF, Penn DL, Bentall R, Carpenter WT, Gaebel W, Gur RC, et al. Social cognition in schizophrenia: an NIMH workshop on definitions, assessment, and research opportunities. Schizophr Bull 2008;34:1211-20. cross ref
  17. Savla GN, Vella L, Armstrong CC, Penn DL, Twamley EW. Deficits in domains of social cognition in schizophrenia: a meta-analysis of the empirical evidence. Schizophr Bull 2013;39:979-92. cross ref
  18. Ventura J, Wood RC, Hellemann GS. Symptom domains and neurocognitive functioning can help differentiate social cognitive processes in schizophrenia: a meta-analysis. Schizophr Bull 2013;39:102-11. cross ref
  19. Pinkham AE. Social cognition in schizophrenia. J Clin Psychiatry 2014;75(Suppl 2):14-9. cross ref
  20. 20. Sterea R. The relationship between social cognition and functional out- comes in schizophrenia. Procedia Soc Behav Sci 2015;187:256-60. cross ref
  21. Bora E, Yücel M, Pantelis C. Cognitive impairment in schizophrenia and affective psychoses: implications for DSM-V criteria and beyond. Schizophr Bull 2010;36:36-42. cross ref
  22. Reichenberg A, Caspi A, Harrington H, Houts R, Keefe RS, Murray RM, et al. Static and dynamic cognitive deficits in childhood preceding adult schizophrenia: a 30-year study. Am J Psychiatry 2010;167:160-9. cross ref
  23. Allen DN, Strauss GP, Barchard KA, Vertinski M, Carpenter WT, Buchanan RW. Differences in developmental changes in academic and social premorbid adjustment between males and females with schizophrenia. Schizophr Res 2013;146:132-7. cross ref
  24. Cotton SM, Lambert M, Schimmelmann BG, Foley DL, Morley KI, McGorry PD, et al. Gender differences in premorbid, entry, treatment, and outcome characteristics in a treated epidemiological sample of 661 patients with first episode psychosis. Schizophr Res 2009;114:17-24. cross ref
  25. Fett AK, Maat A; GROUP Investigators. Social cognitive impairments and psychotic symptoms: what is the nature of their association? Schizophr Bull 2013;39:77-85. cross ref
  26. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: World Health Organization; 1992.
  27. Häfner H. Gender differences in schizophrenia. Psychoneuroendocrinology 2003;28(Suppl 2):17-54. cross ref
  28. Venkatesh BK, Thirthalli J, Naveen MN, Kishorekumar KV, Arunachala U, Venkatasubramanian G, et al. Sex difference in age of onset of schizophrenia: findings from a community-based study in India. World Psychiatry 2008;7:173-6. cross ref
  29. Andreasen N. Scale for the Assessment of Positive Symptoms (SAPS). Iowa City: University of Iowa; 1984.
  30. Andreasen NC. Scale for the Assessment of Negative Symptoms (SANS). Iowa City: University of Iowa; 1983.
  31. Rao NP, Kalmady S, Arasappa R, Venkatasubramanian G. Clinical correlates of thalamus volume deficits in anti-psychotic-naïve schizophrenia patients: a 3-Tesla MRI study. Indian J Psychiatry 2010;52:229-35. cross ref
  32. Siddharatha, Lal N, Tewari SC, Dalal PK, Kohli N, Srivastava S. A computed tomographic study of schizophrenia. Indian J Psychiatry 1997;39:115-21.
  33. Saha G. Dimension of Emotion: An Experimental Study. Kolkata: University of Calcutta (WB); 1968.
  34. Ramlingaswami P. Indian Adaptation of WAIS: Performance Scale. 2nd ed. New Delhi: Manasayan; 1974.
  35. Wechsler D. Manual for the Wechsler Adult Intelligence Scale. New York: Psychological Corp; 1955.
  36. Bailer J, Bräuer W, Rey ER. Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study. Acta Psychiatr Scand 1996;93:368-77. cross ref
  37. Larsen TK, Friis S, Haahr U, Johannessen JO, Melle I, Opjordsmoen S, et al. Premorbid adjustment in first-episode non-affective psychosis: distinct patterns of pre-onset course. Br J Psychiatry 2004;185:108-15. cross ref
  38. Campbell JM, McCord DM. The WAIS-R Comprehension and Picture Arrangement subtests as measures of social intelligence: testing traditional interpretations. J Psychoeduc Assess 1996;14:240-9. cross ref
  39. Colom R, Abad FJ, García LF, Juan-Espinosa M. Education, Wechsler’s Full Scale IQ, and g. Intelligence 2002;30:449-62. cross ref
  40. Bediou B, Franck N, Saoud M, Baudouin JY, Tiberghien G, Daléry J, et al. Effects of emotion and identity on facial affect processing in schizophrenia. Psychiatry Res 2005;133:149-57. cross ref
  41. Edwards J, Jackson HJ, Pattison PE. Emotion recognition via facial expression and affective prosody in schizophrenia: a methodological review. Clin Psychol Rev 2002;22:789-832. cross ref
  42. Leppänen JM, Niehaus DJ, Koen L, Du Toit E, Schoeman R, Emsley R. Emotional face processing deficit in schizophrenia: a replication study in a South African Xhosa population. Schizophr Res 2006;84:323-30. cross ref
  43. Hampson E, van Anders SM, Mullin LI. A female advantage in the recognition of emotional facial expressions: test of an evolutionary hypothesis. Evol Hum Behav 2006;27:401-16. cross ref
  44. Schmidt SJ, Mueller DR, Roder V. Social cognition as a mediator variable between neurocognition and functional outcome in schizophrenia: empirical review and new results by structural equation modeling. Schizophr Bull 2011;37(Suppl 2):S41-54. cross ref
  45. Bawa JS. 63% want to marry virgins, but majority approve of premarital sex. Hindustan Times. Available at: http://www.hindustantimes.com/india/63-want-to-marry-virgins-but-majority-approve-of-premarital-sex/story-A79JdagFgmswYwwFIxyEkO.html. Accessed 7 August 2017.
  46. Dhawan H, Kurupl S. Pre-marital sex: girls like to keep mum. The Times of India. Available at: http://timesofindia.indiatimes.com/india/Pre-marital-sex-Girls-like-to-keep-mum/articleshow/2236263.cms. Accessed 7 August 2017.
  47. Falloon IR, Kydd RR, Coverdale JH, Laidlaw TM. Early detection and intervention for initial episodes of schizophrenia. Schizophr Bull 1996;22:271-82. cross ref
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