Brit.J. Psychiat.

(1979), 135,438443

The Hierarchy Model of Psychiatric Symptomatology: An

Investigation Based on Present State Examination Ratings
By P. G. SURTEES

and R. E. KENDELL

SUMMARY
Psychiatric
diagnoses are arranged in a rough hierarchy,
generally regarded as a convention to enable patients with a wide range
of symptoms
to be allocated to single diagnostic
categories.
Foulds,
on the basis of self-report
questionnaire
responses,
claimed
that
patients
may but

with symptoms
characteristically

at the higher
levels of this hierarchy
do exhibit
symptoms
at all lower

not only
levels
as

well. Foulds' hierarchy model was tested here, using PSE ratings from
two large series of in-patients;
at least 75 per cent fulfilled the require
ments of the model, but up to 50 per cent of schizophrenic
and manic
patients failed to do so. Almost two-thirds of all patients with psychotic
symptoms
establishing
them in one of the upper two classes of the
hierarchy did not exhibit the neurotic symptoms
they required lower
in the hierarchy.
symptoms
are classified as schizophrenics.
On
the other hand, neurotic symptoms of any kind
may be present without disturbing
the diagnosis,
for neurotic illness comes below manic-depressive
in the hierarchy.
In general, any given diagnosis
excludes the symptoms
of all higher members
of
the hierarchy
and embrace3 the symptoms
of
all lower members.
It is therefore
no accident
that the order in which psychiatric
diagnoses
have been listed in the last three revisions of the
International
Classification
of Disease and the
flow charts of computer
programs
for deriving
diagnoses from clinical ratings (e.g. Spitzer and
Endicott,
1968; Wing et al, 1974) are based on
the same sequence.

Although they may not be aware of doing so,

most psychiatrists
use diagnostic categories as if
the major
psychotic
and neurotic
disorders
were arranged
in a hierarchy.
Uppermost
in
this hierarchy
come the organic psychoses.
If
there is evidence of brain disease like epilepsy or
severe cognitive
impairment,
that determines
the diagnosis almost regardless
of which other
psychotic
or neurotic
symptoms
are present.
Next comes schizophrenia.
By tradition,
certain
symptoms
are regarded
as diagnostic
of schizo
phrenia
no matter what other symptoms
may
also be present, provided only that there is no
question of cerebral disease. The symptomsof
the first rank which Schneider (1959) regarded
as pathognomonic
of schizophrenia
exceptin
the presence
of coarse brain disease are an
explicit statement
of this convention,
and in
practice
other
clinicians
attach
a similar
significance to thought disorder.
The next tier down is occupied
by manic
depressive
illness.
Even if its characteristic
features are present,
organic or schizophrenic
psychoses take precedence
so that, for instance,
patients with both schizophrenic
and affective

J aspers(1959),whowasthe firstto recognise

the existence of this hierarchy,
assumed that it
was simply a convention,
adopted
to enable
psychiatrists
to attribute
a single diagnosis to
each
patient,
even
though
many
patients
exhibited the characteristic
symptoms of several
different
diagnostic
categories.
More recently,
Foulds claimed
that psychiatric
patients
not
only may but almost invariably
do possess the
symptoms
438

of

disorders

lower

down

the

hier

439

P. G. SURTEES AND R. E. KENDELL

archy

(Foulds,

1965

ignores organic

and

1976).

His

states and arranges

disorders
into four distinct
classes, with each
class representing
a different
level of psycho
pathology.
The classes are as follows :
Class 4

Delusions
of
(DD)delusions
autochthonous

(the highest)

Disintegration
of control,
delusions
and

hallucinations.
Class 3

Integrated
delusions

Delusions
of persecution,

(ID)
gran

deur and contrition.

Class 2

Neurotic
Symptoms
(NS)
obsessional, phobic and hysteri
cal symptoms.

Class 1
(the lowest)

Dysthymic States (DS)states

of anxiety,
depression
and
elation.

In order to test this model, Foulds developed

a self-report inventory, the Delusions-Symptoms
States Inventory (DSSI) which consists of 84
items, each scored on a four-point scale, covering
the groups of symptoms represented
in this
hierarchy. He then demonstrated
that 93 per
cent of 480 psychiatric patients (a mixture of in
and out-patients
from English, Scottish and
Canadian hospitals) obtained scores on the R
(recent) form of the inventory which fulfilled
the requirements
of his model (Foulds and
Bedford,

1975).

threshold

score of 4 on DD reached the thresh

holds

for ID,

Patients

NS and

who

achieved

DS as well;

those

the
who

achieved the threshold score for ID, also did so

for NS and DS; and those who reached the
threshold

for NS also did so for DS.

So far, this finding has not attracted

interest

as it deserves,

perhaps

because

Method

schema

functional

as much
of the

idiosyncratic
terminology
Foulds used. If it
could be confirmed by other workers for other
patient populations, however, the implications
would be far reaching, not just for psychiatric
nosologies but also for theories of aetiology and
therapeutics.
The present study was designed to find out
whether ratings made by psychiatrists using
structured interviews fulfilled the requirements
of Foulds' hierarchy as well as the self-report
questionnaire responses he himself described.

Between

US/UK

1966

and

Diagnostic

1968,

the

staff

Project

(J.

E.

of the

Cooper,

J. R. M. Copeland, R. E. Kendell and N.

Sartorius)

examined

two large consecutive

series

of admissions to English mental hospitals250

patients admitted
to Netherne
Hospital in
Surrey

and 174 from a representative

sample

of

9 of the 22 mental hospitals serving Greater

London. All patients were between the ages of
20 and 59 and each was interviewed

within

a few

days of admission, using the Present State

Examination (Wing ci al, 1974). Full details of
the patients, interviewing methods and diag
nostic criteria employed are given elsewhere
(Cooper et a!, 1972). The present study was
based on the PSE ratings of these Netherne'
and
London'series. Partly because the Netherne
patients had been given the 480 item 7th edition
of the PSE and the London patients the 442 item
8th edition, and partly to condense the inform
ation into more useful units, both sets of data
were converted
by stage 1 of the Catego
programme
(Wing et a!, 1974) into the 145
symptoms'of the 9th edition. Prior to data
analysis, these 145 PSE symptoms, or com
binations of them, were then equated as closely
as possible with the 84 items of the DSSI.
Seventeen PSE items were assigned to Foulds'
Dysthymic States, ten to Neurotic Symptoms,
seven

to

Integrated

Delusions

and

ten

to

Delusions of Disintegration.
It was harder to
decide what the threshold score should be for
each level of the hierarchy and eventually two
alternative sets were useda low threshold set
(Method 1) in which a score of one on any PSE
item assigned to that class of the hierarchy was
accepted, and a high threshold set (Method 2)
which used the thresholds for each PSE item
suggested by Wing ci al (1974). (Details of which
PSE items were equated with which DSSI items
and of these threshold scores are available from
the authors on request.)
Results
Sixteen patients were excluded
original

PSE

interviews

had

because their
been

rated

as

incomplete, and eleven others because they had

project diagnoses of organic illness. This reduced
the Netherne series to 235 patients and the

440

THE HIERARCHY
TABLE

MODEL OF PSYCHIATRIC

centages
of patients
groupings
fitting the
Table II.

Overall conformity to the hierarchy model

Patients

modelNNetherne

fitting

the

hierarchy

80.9Method2206
1190

N87.7London
=235Method
69.Method1112
2117

commoner
81 .4

London
series
to 162. The
proportion
of
patients
in each series fitting
Foulds'
hier
archy model was then examined,
first with
Method
1 and then with Method 2. The results
are shown in Table I.
A somewhat higher proportion
of the Netherne
patients than of the London patients fitted the
model, and Method 2 (high threshold) produced
patients

Whichever

method

It is clear from this that some of the eleven

possible
non-conforming
patterns
are much

and
76.Method 1302
London
N = 397Method
2323

non-conforming

The results are clear-cut.

Table III.

patients

fewer

from these four broad

hierarchy
are shown in

of analysis is used, over 90 per cent of the

Depression
and Other Diagnoses groups fit the
requirements
of the hierarchy,
but for Schizo
phrenia
and Mania
the percentage
is much
lower, varying from 48 per cent to 70 per cent.
Finally,
all non-conforming
patients
were
examined
separately.
The results are shown in

patients

72.2Netherne
N = 162Method

SYMPTOMATOLOGY

in both.

Overall,

however, at least 75 per cent of patients fitted the

model.
For the next stage of the analysis, the Netherne
and London patients were combined
to form a
single population
of 397 patients and different
diagnostic categories were examined separately.
These diagnoses
had originally
been made by
the project psychiatrist
after a detailed history
had
been
obtained
and
the mental
state
examination
carried out. They were based on
the nomenclature
of the 8th (1965) revision of
the lCD and the descriptions
in the British
glossary (Registrar
General,
1968). Four broad
diagnostic
groupings
were examined:
Depres
sion, consisting of lCD categories
296.0, 296.2,
296.3, 296.9, 298.0 and 300.4; Mania,
con

sisting of lCD category 296.1 and a single case

of reactive
excitation
(298.1);
Schizophrenia,
consisting
of lCD
category
295 plus five
patients with paranoid
states (297); and Other
Diagnoses,
consisting mainly of neuroses (other
than depressive),
personality
disorders,
alco
holism and combinations
of these. The per

than

others

and

that,

as

Foulds

found himself, the majority of failures to meet

the requirements
of the model (72 per cent with
Method 1 and 47 per cent with Method 2) are
due to an absence of neurotic symptoms
(NS)
in patients with either integrated
delusions (ID)
or delusions of disintegration
(DD).

Discussion
This
arbitrary
valence

study
required
a large
number
of
decisions concerning
both the equi
of PSE and DSSI
items and the

appropriate
classes
of

threshold
scores for each of the four
Foulds'
hierarchy.
It is possible,

therefore, that different choices at either

stages would have produced
different

We doubt, however, whether

of these
results.

they would have

been sufficiently
different
to change the main
conclusions.
It is likely that if the threshold
scores had been set even higher than they were
in our Method
2, the overall percentage
of
patients
fitting the model would have been
somewhat
higher. This would, however,
have
been at the expense of reducing even further the
number
of patients
reaching
the two higher
classes (DD and ID) of the hierarchy,
and as it
was, the thresholds
of our Method
2 only
allowed 67 of 121 schizophrenics
(55 per cent)
to qualify.
The most important
cause of failure to fulfil
the requirements
of the hierarchy model was an
apparent
absence
of neurotic
symptoms
in
patients
with Delusions
of Disintegration
or
Integrated
Delusions. This could, of course, have
been due simply to an inadequate
coverage of
neurotic symptoms in the PSE, or to the failure

441

P. 0. SURTEES AND R. E. KENDELL

T@isr.zII
Percentageof patientsfalling to eachof thefive hierarchypatterns
A.

Method 1
classesOther
0011

Diagnostic groupGroup
PTDepressiveillness1683.05.4

Fit1111
DD0111
sizeHierarchy

ID

0001

NS

45.21.29.590.5Mania2010.00

DS0000

patterns%

35.7

40.05.045.055.0Schizophrenia12114.16.6

.652.147.9Other

10.7

14.91

.18.092.0Total3976.04.3
conditions8800

43.2

47.71

36.31.523.976.1B.
28.0
2Diagnostic

Method
classesOther

PTDepressive groupGroup

sizeHierarchy
DD0111 ID
Fit1111

illness16802.4
.84.895.2Mania2005.0
60.05.030.070.0Schizophrenia1215.05.0

0011
NS

0001
DS0000

29.1

61 .91

patterns%

24.810.744.655.4Other

9.9

conditions8800
58.03.46.893.2Total3971.52.8

31 .8
22.4

49.65.118.681.4

Membership of each class of the hierarchy is denoted by 1 and non-membership by 0. The letters associated
with each pattern (DD, ID, NS, DS, PT) indicate the highest class included in that pattern. PT, to use Foulds'
notation,

indicates the absence of personal

illness' i.e. symptoms where present do not reach the threshold

for any of the four classes.

of the Diagnostic Project psychiatrists to go
systematically
through
this section of the
interview in patients who were clearly psychotic.
In fact, the PSE covers phobic and obsessional
symptoms

editions

very

thoroughly.

used here, however,

The

7th

and

8th

did not include

items for either conversion

symptoms
or dis
sociative states, and had they done so it is likely

that a few more patients would have scored on

Neurotic

Symptoms.

We do not think,

though,

that the inclusion of these items would have

altered our findings very much. Hysterical
symptoms are less common than phobic or
obsessional

symptoms,

particularly

in psychotic

patients. It can be calculated from the data in

Tables II and III that only 49 of 135 patients
(36 per cent) by Method 1, or 24 of 90 patients
(27 per cent) by Method 2, who scored on
Delusions of Disintegration or Integrated Delu
sions also scored on Neurotic Symptoms and the
addition of a few hysterical symptoms would not
be likely to increase these low percentages very
much.
Nor do we think that a failure

by the original

interviewers
to elicit neurotic symptoms in
psychotic patients is a plausible explanation of
these findings. In most cases, even in patients
who were obviously hallucinated or deluded, the

442

THEHIERARCHY
MODEL
OFPSYCHIATRIC
SYMPTOMATOLOGY
T@.sLzIII
Non-conforming patients

A.

Method 1

Symptom pattern

DD

ID

NS

DS

Depressive
illness

Mania

Schizophrenia

Other
conditions

Total

33

41

10

10

15

27

B. Method 2
Symptom

pattern

DD

ID

NS

DS

Depressive
illness

Mania

Schizophrenia

Other
conditions

Total

18

19

12

21

10

16

443

P. 0. SURTEES AND R. E. KENDELL

interviewers worked systematically through the

interview from beginning to end, and in all
editions of the PSE neurotic symptoms precede
psychotic ones. Moreover, in any patient in
whom

any substantial

section

of the interview

mania are almost incompatible

and that if
patients with lifelong phobic or obsessional
symptoms

ever

become

schedule was not completed, a rating of in

complete interview' was made and the sixteen
patients to whom this applied were not included
in the analysis.
In conclusion,

therefore,

our findings

at least 75 per cent of patients

and

52 per

cent

of patients

and by over 90 per

with

manic

and

schizophrenic illnesses do not fulfil its require

ments and, more damaging still, at least 64 per
cent of all patients with Delusions of Dis
integration

or

Integrated

possess

the

required

to have.

Neurotic
Perhaps

Delusions

Symptoms

do

not

they

are

this is not surprising.

It is common clinical experience that although

schizophrenics
frequently have mood distur
bances
(usually
depression
but sometimes
anxiety

or elation)

L., CoPEw@,J.

do not

cent of those with depressive illnesses, neurotic

illnesses and personality
disorders. The in
compatible findings are that between 30 per cent

as well as their hallucinations

and delusions, it is less common for them to have

hysterical, phobic or obsessional symptoms. It is
also well known that neurotic symptoms and

their

neurotic

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P. G. Surtees, B.5c.,M.Sc..Ph.D., Medical Research Council Unit for Epidemiological Studies in Psychiatey,
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(Received 24 April 1979)

The hierarchy model of psychiatric symptomatology: an

investigation based on present state examination ratings.
P G Surtees and R E Kendell
BJP 1979, 135:438-443.
Access the most recent version at DOI: 10.1192/bjp.135.5.438

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