BRIEF REPORTS Ego-Pathology and Common Symptom Factors in Schizophrenia Frank Ro ¨hricht, MD, MRCPsych,* and Stefan Priebe, MD, FRCPsych† Abstract: The phenomenological construct of ego-pathology in schizophrenia has been widely referred to in psychopathological textbooks but was systematically assessed in very few empirical studies. This study investigated the association between ego-pathol- ogy (Ego-Pathology Inventory) and common symptom factors (Pos- itive and Negative Symptom Scale) in paranoid schizophrenia pa- tients within 3 days after admission and after 2 weeks of treatment. The predictive value of ego-pathology for short-term treatment outcome was also assessed. A factor analysis of all subscale scores revealed a four-factor solution: positive symptoms, negative symp- toms, and two distinct ego-pathology factors, i.e., general and identity. Although the ego-pathology subscale “activity” loaded on the positive symptom factor, the other four subscales formed the two ego-pathology factors with no high loadings on other factors. High scores on ego-demarcation at admission predicted poor treatment outcome after 2 weeks. The findings suggest that ego-pathology might be used to capture additional and clinically meaningful symptom dimensions in schizophrenia. Key Words: Psychopathology, ego, symptom factors, schizophrenia. *Unit for Social and Community Psychiatry, Newham Centre for Mental Health East London and The City Mental Health Trust; and †Barts and the London School of Medicine, Queen Mary’s, University of London, London, United Kingdom. Send reprint requests to Dr. Frank Ro ¨hricht, East London and The City Mental Health Trust, Newham Centre for Mental Health, Glen Road, London E13 8SP, United Kingdom. Copyright © 2004 by Lippincott Williams & Wilkins DOI: 10.1097/01.nmd.0000130138.62770.87 T he dichotomized concept of schizophrenia with the as- sumption of two main distinct symptom dimensions, i.e., a positive and a negative symptom factor, has received frequent criticism (Andreasen et al., 1995; Arndt et al., 1991; Grube et al., 1998), and it has been suggested that further meaningful symptom factors should be generated (Toomey et al., 1997). The concept of ego-pathology might provide a model to assess such additional symptom dimensions. Ego- experience or self-experience and the corresponding ego- pathology have repeatedly been described in textbooks as important symptom dimensions in schizophrenia (Sims, 1995). The concept has been referred to from phenomeno- logical (Ro ¨hricht and Priebe, 2002; Scharfetter, 1981), psy- chological (Kernberg, 2000), and neurobiological (Vollen- weider et al., 1997) perspectives. Empirically, ego-pathology has mostly been assessed under the umbrella terms ego-functioning, ego-strength, self- awareness, or ego defense mechanisms. These concepts are not regarded as meaningful for the psychopathological phe- nomenology in schizophrenia. Explicitly referring to the concept of schizophrenia as severe ego-disorder and drawing from Jaspers’ (1920) description of formal characteristics of ego-consciousness, Scharfetter (1981) operationally defined five basic dimensions of the empirical-ego; he developed and validated a corresponding psychopathometric tool with five ego-pathology symptom factors, the Ego-Pathology Inven- tory (EPI; Scharfetter, 1995a, 1995b). Unlike the symptoms of ego-disorder classified as Schneiderian first-rank symp- toms, these factors capture basic qualities of ego-conscious- ness, and its corresponding pathology can be summarized as follows. Ego-vitality describes the self-experience of being present as a living being. Ego-activity is functioning as a self-directing unity, self-governing, and intentionally direct- ing one’s own thinking, feeling, and acting. Ego-consistency is defined as the quality and coherence of self-experience as structured and organized. Ego-demarcation relates to bound- aries and the differentiation between ego and nonego spheres. Ego-identity refers to the prereflexively given certainty of one’s own definite selfhood. Other authors (Loftus et al., 2000; Soyka, 1990) iden- tified a distinct ego-pathology factor based on symptom-items classified as Schneiderian first-rank symptoms (mainly thought insertion, thought broadcasting, and passivity phe- nomena), thereby suggesting a diagnostic validity or poten- tially an etiological and genetic significance of ego-psycho- pathology. Although the literature on schizophrenia throughout the last century therefore frequently refers to schizophrenia as an ego-disorder, the association between common symptom factors and ego-pathology and their clin- ical significance has not been systematically investigated yet. The present study aimed to assess ego-pathology systemati- cally in patients with acute schizophrenia and explore whether ego-pathology scores overlap with or are distinct from common psychopathology, i.e., general, positive, and negative symptom factors. Additionally, the predictive value of ego-pathology scores for short-term treatment outcome was investigated. METHODS Patients with a clinical diagnosis of acute paranoid schizophrenia according to ICD-10 (N = 60) were assessed within 3 days after admission for treatment into an acute psychiatric catchment area hospital. The decision to focus only on this subtype was made to assess a relatively homog- enized sample with high levels of florid psychotic or first- rank symptoms. Based on a structured clinical interview, the EPI (Scharfetter, 1995b) and the Positive and Negative Symptom Scale (PANSS; Kay et al., 1987) were administered by an independent researcher to obtain rating scores on ego-psychopathology and common psychopathology. Socio- demographic (age, sex, marital status, education status) and clinical characteristics (duration of illness, number of previ- The Journal of Nervous and Mental Disease • Volume 192, Number 6, June 2004 446