Knowledge of the clinical outcome of schizophrenia has increased because of follow-up studies covering periods of several years or even much longer (Bleuler, 1972 ; Ciompi & MUller, 1976; Huber eta!, 1979; Serban, 1980; Strauss & Carpenter, 1972, 1974 and 1977; WHO, 1979). On the other hand, social outcome in term of the ways in which patients are functioning in everyday life after comparable periods of time, has so far hardly been described, despite the availability of many instruments to assess social behaviour (Weissman, 1975; Weissman ct a!, 1981). The existing rating schedules used to describe social disability or maladjustment lack a conceptual framework by which disabilities can be classified (Cooper, 1980). Therefore, most schedules are “¿ simply reasonable lists of items, chosen for their practical importance, but not related to each other by any particular set of classificatory ideas or rules.―To fill this theoretical gap, Cooper proposes a general and comprehensive classification, based on a hierarchy,which consistsof eightlevels, differ ing from each other with respect to the complexity of normal human behaviour. Although this hierarchy was meant as a classifica tion, its meaning may be more far-reaching: actual human behaviour might also be structured along hierarchical lines, whether or not derived from the notion of a differentiation in complexity (Clark, 1968; Ruesch & Brodsky, 1968; Glazer et a!, 1980). It is the purpose of this paper to explore the possible existence of such a hierarchy, using data from a cohort of schizophrenic patients. It will be shown that an unidimensional rating-scale can be con structed, which can be considered to be an empirical corroboration of the existence of the hypothetical hierarchy, and the scale is used to describe the course of social disability in the cohort.

Most of the existing instruments for the assessment of social dysfunctioning of psychiatric patients are merely lists of precoded items, leaving little or no room for posing supplementary questions. In this article a new, semi-structured questionnaire--the Groningen Social Disabilities Schedule (GSDS)--is described, in which this shortcoming is met. The development of the GSDS is based on social role theory and on the existence of a hierarchy in social disabilities, demonstrated in an earlier World Health Organization study. Compatibility was sought with the International Classification of Impairments, Disabilities and Handicaps (ICIDH), a trial-classification of the World Health Organization, to be used in research on the consequences of illness. It is concluded that the inter-rater reliability of the GSDS is good. To a large extent the hierarchy proved to hold true for this instrument. Some implications for future research and for the ICIDH are discussed.

Rating scales used in psychiatric research are often based on factor analysis. In practice, the resulting factors or dimensions will generally be empirically derived rather than based on theoretical considerations. In addition, it often proves difficult to determine their validity. It is argued that the use of an hierarchical scale may be a partial answer to these problems. This is illustrated by the analysis of data from two interview schedules, using Mokken's model for stochastic, cumulative scaling. Data were derived from a follow-up study of patients with a first life-time episode of non-affective, functional psychosis. Two scales for the assessment of psychopathology and social dysfunctioning were constructed. Scale statistics proved to be satisfactory, while the order of items in the scales corresponded to a priori theoretical expectations.

In the recurring discussion of the relationship between social class and mental disorder in psychiatric epidemiology, the significance of the former in terms of its inherent stresses for the individual is more often implied than made explicit. Yet a mental disorder such as schizophrenia is considered not as a class phenomenon, but as an individual hazard encountered somewhat more often — but by no means only — in the lower social strata. Unfortunately, one of the originators of the concept of social class as a moving force, Karl Marx, has not left us with much theory to build on. Dahrendorf (1959) wrote: “Marx postponed the systematic presentation of his theory of class until death took the pen from his hand”. By systematically ordering a number of quotations and connecting them to a coherent text, Dahrendorf undertook to complete Marx’s chapter on “The Classes” from the last volume of Das Kapital. Central themes in this unfinished theory of social class appear the more or less direct “conflict or antagonism” between collectivities (labour, the owners of capital and landowners), and people’s growing awareness of one controlling the other through its authority over society’s resources. Social classes are assumed to gain identity because of this awareness, which produces a sense of belonging to either the collectivity of the haves or that of the have-nots. This is a far cry from the artificially defined socioeconomic stratification current in psychiatric epidemiology, of which the lowest and most morbidly affected one is supposed to be characterized by anomy and alienation rather than a sense of belonging; while the other strata differ only marginally or very gradually with respect to mastery or control over a society’s resources.

The relationship between symptomatology and social functioning was investigated. Data were derived from a Dutch cohort of 82 patients with a first life-time episode of non-affective, functional psychosis, who participated in the WHO Collaborative Study on the Assessment and Reduction of Psychiatric Disability. Correlations between scores on two unidimensional, hierarchical rating scales in the 3 years after onset of illness were examined and a comparison was made between course of symptomatology and social disability. The relationship was found to be rather weak, a conclusion that is somewhat in variance with earlier studies. It is conjectured that this may partly be explained by the fact that different study methods were used.

To gain more insight into the social (as opposed to clinical) outcome of schizophrenia, a unidimensional, hierarchical scale was constructed. Items were selected from the Disability Assessment Schedule (DAS)–a new instrument, used in the WHO Collaborative Study on the Assessment and Reduction of Psychiatric Disability. Data were derived from the Dutch cohort participating in this study, which consisted of patients with a first life-time episode of a non-affective, functional psychosis. Patients were followed-up during the first three years of their illness, and analyses of the stability and reliability of the scale proved to be satisfactory. It was subsequently used to characterise the course of social disability.

Synopsis In order to evaluate Foulds' hierarchical model of psychiatric illness, a study was carried out using data from a 3-year follow-up of patients suffering from functional non-affective psychoses. Of the 177 Present State Examinations carried out 86% yielded symptom patterns compatible with the model. It was shown that failures to fit the hierarchy can be explained either by measurement error or by the masking of major symptoms by the simultaneous presence of minor ones. A one-dimensional scale to measure the severity of psychiatric illness was constructed. Patients' scores were compared with ratings on the Index of Definition and the diagnosis of current mental state. The results of these comparisons were considered to be supportive validatory evidence. Some of the implications of the model and the data are discussed.

Synopsis Recent data from a 2-year follow-up of functional non-affective psychosis, and particularly schizophrenia, favoured social selection rather than social causation theory. Data concerning the cohort were compared with inter- and intra-generational mobility in a random Dutch sample. The results indicate that the educational and occupational mobility of patients, relative to their fathers, was greater than expected. Although patients were better educated than the random sample, they fared less well occupationally. An analysis of patterns of occupational mobility before and after the onset of psychosis also showed that social selection played a major role in achieving social status. The outcome of patients' occupational career at follow-up was poor, and only a minority succeeded in obtaining or keeping a regular job.