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FIRST-RANK SYMPTOMS: FIRST-RANK SYMPTOMS: CURRENT STATUS CURRENT STATUS Presenter: Ravi Philip Rajkumar Presenter: Ravi Philip Rajkumar Chairperson: Dr. G. Chairperson: Dr. G. Venkatasubramanian Venkatasubramanian

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FIRST-RANK SYMPTOMS: FIRST-RANK SYMPTOMS: CURRENT STATUSCURRENT STATUS

Presenter: Ravi Philip RajkumarPresenter: Ravi Philip Rajkumar

Chairperson: Dr. G. VenkatasubramanianChairperson: Dr. G. Venkatasubramanian

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Mr. S, aged 35, with a family history of psychiatric Mr. S, aged 35, with a family history of psychiatric illness and suicide in his father, presents with illness and suicide in his father, presents with two years’ episodic illness with complete two years’ episodic illness with complete recovery on treatment. He has had two past recovery on treatment. He has had two past episodes, each lasting 4-6 months. The current episodes, each lasting 4-6 months. The current episode has lasted 3 months so far. Each episode has lasted 3 months so far. Each episode is characterized by pervasive low episode is characterized by pervasive low mood, low energy, crying spells, decreased mood, low energy, crying spells, decreased interest in activities, reduced social and interest in activities, reduced social and occupational functioning, death wishes, suicidal occupational functioning, death wishes, suicidal ideation, terminal insomnia, reduced appetite, ideation, terminal insomnia, reduced appetite, and weight loss of 5 kilograms. He also reports and weight loss of 5 kilograms. He also reports suspicions that his wife is unfaithful to him, suspicions that his wife is unfaithful to him, beliefs that his relatives are poisoning his food beliefs that his relatives are poisoning his food and practicing black magic to harm him, and and practicing black magic to harm him, and hearing the voices of his relatives speaking ill of hearing the voices of his relatives speaking ill of him when alone, which are not related to any him when alone, which are not related to any preoccupation with guilt.preoccupation with guilt.

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His physical examination and laboratory His physical examination and laboratory investigations are within normal limits. investigations are within normal limits. There is no history of substance use. On There is no history of substance use. On mental status examination he reports feeling mental status examination he reports feeling that his thoughts become known to others that his thoughts become known to others even as he thinks, which he is sure of; when even as he thinks, which he is sure of; when asked how this is possible, he says it may be asked how this is possible, he says it may be due to black magic. His mood is depressed, due to black magic. His mood is depressed, with reduced range and reactivity. He with reduced range and reactivity. He reports death wishes and hopelessness. He reports death wishes and hopelessness. He has delusions of persecution and infidelity. has delusions of persecution and infidelity. He reports third person auditory He reports third person auditory hallucinations consisting of his relatives hallucinations consisting of his relatives arguing among themselves and discussing arguing among themselves and discussing him. His insight is poor and he denies that him. His insight is poor and he denies that the “voices” or suspicions may be due to a the “voices” or suspicions may be due to a mental illness, but is willing to be treated for mental illness, but is willing to be treated for his sad mood.his sad mood.

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INTRODUCTIONINTRODUCTION

The definition of schizophrenia – The definition of schizophrenia – concept, clinical syndrome, group of concept, clinical syndrome, group of syndromes or illness?syndromes or illness?

Boundaries between schizophrenia Boundaries between schizophrenia and other disorders – nosology and and other disorders – nosology and otherwiseotherwise

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INTRODUCTIONINTRODUCTION

Earliest definition of Earliest definition of dementia dementia praecox praecox (Kraepelin) based on course (Kraepelin) based on course and outcomeand outcome

Later definition of Later definition of schizophreniaschizophrenia was was conceptual (Bleuler’s 4 A’s – actually conceptual (Bleuler’s 4 A’s – actually 6!) and led to difficulties in clinical 6!) and led to difficulties in clinical and research workand research work

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INTRODUCTIONINTRODUCTION

FIRST-RANK SYMPTOMSFIRST-RANK SYMPTOMS First proposed by Kurt Schneider First proposed by Kurt Schneider

(1939)(1939) Based on his study of the Based on his study of the Schwabing Schwabing

cohortcohort of over 3000 patients of over 3000 patients Based primarily on clinical Based primarily on clinical

experienceexperience

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DEFINITIONDEFINITION

““When we say, for example, that When we say, for example, that thought withdrawal is a first rank thought withdrawal is a first rank symptom, we mean the following. If symptom, we mean the following. If this symptom is present in a non-this symptom is present in a non-organic psychosis, then we call that organic psychosis, then we call that psychosis psychosis schizophreniaschizophrenia, as opposed , as opposed to to cyclothymic psychosiscyclothymic psychosis, or , or reactive reactive psychosis psychosis in an abnormal personality”in an abnormal personality”

- Kurt Schneider, “Clinical Psychopathology” - Kurt Schneider, “Clinical Psychopathology” (1958)(1958)

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In other words….In other words….

First-rank symptoms (FRS) are a First-rank symptoms (FRS) are a group of delusional and hallucinatory group of delusional and hallucinatory experiences that, in Schneider’s experiences that, in Schneider’s experience with the Schwabing experience with the Schwabing cohort, reliably distinguished cohort, reliably distinguished “schizophrenic” from “affective” “schizophrenic” from “affective” psychosis. psychosis.

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What are they?What are they?1.Hallucinatory voices – voices commenting,

voices discussing2.Somatic passivity phenomena3.Delusions of alien control – made feelings,

made impulses, made volitional acts4.Thought alienation phenomena – thought

insertion, thought broadcast, thought withdrawal

5.Thought echo (echo des pensees or Gedankenlautwerden)

6.Delusional perception

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What was their basis?What was their basis?

Essentially atheoreticalEssentially atheoretical Influenced by the phenomenological Influenced by the phenomenological

school, founded by Husserl and school, founded by Husserl and adapted to psychopathology by adapted to psychopathology by JaspersJaspers

However some of the phenomena However some of the phenomena (thought alienation, passivity and (thought alienation, passivity and control) were thought to represent a control) were thought to represent a “loss of ego boundaries”“loss of ego boundaries”

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Rise of the FRSRise of the FRS Readily lent themselves to elicitation Readily lent themselves to elicitation

by a structured interview by a structured interview Had high inter-rater reliability (was Had high inter-rater reliability (was

confirmed in later studies) and confirmed in later studies) and replicabilityreplicability

Could be easily used in designing Could be easily used in designing diagnostic criteriadiagnostic criteria

Schneider’s own reputationSchneider’s own reputation Heuristically useful in clinical work Heuristically useful in clinical work

and researchand research

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Rise of the FRSRise of the FRS

Incorporation into diagnostic criteria: Incorporation into diagnostic criteria: RDC (Spitzer RDC (Spitzer et al., et al., 1978), ICD-9 and 1978), ICD-9 and 10, DSM-III-R, DSM-IV10, DSM-III-R, DSM-IV

Incorporation into diagnostic tools: Incorporation into diagnostic tools: SADS (Spitzer and Endicott, 1978) SADS (Spitzer and Endicott, 1978) and PSE (Wing and PSE (Wing et al.et al., 1974), 1974)

Use in the International Pilot Study of Use in the International Pilot Study of SchizophreniaSchizophrenia

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Theories behind FRSTheories behind FRS Phenomenological: Phenomenological: defect in the defect in the

integration of the self, leading to a “loss integration of the self, leading to a “loss of ego boundaries”of ego boundaries”

Local dysfunction: Local dysfunction: Trimble (1990) Trimble (1990) suggested FRS indicate temporal lobe suggested FRS indicate temporal lobe dysfunctiondysfunction

Genetics: Genetics: initial studies (initial studies (low low nn) ) suggested heritability of zero, later suggested heritability of zero, later authors (McGuffin et al., 2002) found authors (McGuffin et al., 2002) found 26.5% concordance in MZ twins, 0.3% in 26.5% concordance in MZ twins, 0.3% in DZ twins.DZ twins.

““What exactly is inherited?” (Crow, 1996)What exactly is inherited?” (Crow, 1996)

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Current theories behind FRSCurrent theories behind FRS Tim Crow (1998)Tim Crow (1998) – schizophrenia – schizophrenia

as the price paid for the evolution as the price paid for the evolution of language?of language?

Defects in Defects in interhemispheric interhemispheric connectivityconnectivity

Inadequate damping of non-Inadequate damping of non-dominant hemisphere activity – dominant hemisphere activity – thought alienation phenomenathought alienation phenomena

Abnormal feedback from dominant Abnormal feedback from dominant frontal lobe to Wernicke’s area – frontal lobe to Wernicke’s area – voices commenting?voices commenting?

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Current theories behind FRSCurrent theories behind FRS Neuropsychological:Neuropsychological: currently currently

has the most evidencehas the most evidence Mainly based on the work of Mainly based on the work of

Christopher Frith (1992)Christopher Frith (1992) Divided the symptoms of Divided the symptoms of

schizophrenia into three broad schizophrenia into three broad groupsgroups

1. disorders of willed action 1. disorders of willed action 2. disorders of self-monitoring2. disorders of self-monitoring 3. disorders in monitoring the3. disorders in monitoring the intentions of others. intentions of others.

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Current theories behind FRSCurrent theories behind FRS

According to this theory, deficits in self-According to this theory, deficits in self-monitoring lead to a loss of the sense ofmonitoring lead to a loss of the sense of

* * agencyagency (leading to made phenomena) (leading to made phenomena)

* * ownershipownership (leading to thought alienation (leading to thought alienation phenomena)phenomena)

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Origins of Delusion of Control

Motor Instruction

Comparator Or Self Monitoring System

Motor Act Proprioceptive Input

Reference Copy

Re-afference CopyOwnership

Agency

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Evidence from imagingEvidence from imaging Spence et al. (1997) – passivity Spence et al. (1997) – passivity

hyperactivation of right inferior hyperactivation of right inferior parietal lobule and cingulate gyrus parietal lobule and cingulate gyrus (replicated in an fMRI study in 2005)(replicated in an fMRI study in 2005)

Andreasen et al. (2002) – FRS scoreAndreasen et al. (2002) – FRS score correlated with increased blood flow correlated with increased blood flow in the right parietal area and reduced in the right parietal area and reduced flow in the left posterior cingulate flow in the left posterior cingulate and lingual gyriand lingual gyri

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In conclusionIn conclusion

Dysfunction of brain areas involved Dysfunction of brain areas involved in space and body representation in space and body representation implicatedimplicated

Correlate with the cognitive modelCorrelate with the cognitive model

May involve prefrontal-parietal and May involve prefrontal-parietal and prefrontal-temporal networksprefrontal-temporal networks

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Clinical correlates of FRSClinical correlates of FRS1. Variations in occurrence of FRS1. Variations in occurrence of FRS• Mellor (1970) – Mellor (1970) – thought broadcast commonest thought broadcast commonest

(21.4%), followed by thought echo, 3(21.4%), followed by thought echo, 3rdrd person person AH, thought insertion and passivity. Made AH, thought insertion and passivity. Made impulse least common (2.9%)impulse least common (2.9%)

• Radhakrishnan et al. (1983) - Radhakrishnan et al. (1983) - 33rdrd person AH, person AH, thought broadcast and passivity commonestthought broadcast and passivity commonest

• Coffey et al. (1993) –Coffey et al. (1993) – somatic passivity somatic passivity commonest (36.8%)commonest (36.8%)

• Peralta and Cuesta (1999) – Peralta and Cuesta (1999) – thought broadcast thought broadcast commonest (43.8%) followed by 3commonest (43.8%) followed by 3rdrd person AH, person AH, thought insertion and passivity (over 30%)thought insertion and passivity (over 30%)

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Clinical correlates of FRSClinical correlates of FRS2. Correlations between FRS2. Correlations between FRS• Authors such as Schneider (1942) and Conrad Authors such as Schneider (1942) and Conrad

(1958) proposed subgroups on theoretical (1958) proposed subgroups on theoretical groundsgrounds

• Mellor (1970) found correlations between 3Mellor (1970) found correlations between 3rdrd person AH commenting and arguing, and person AH commenting and arguing, and between thought insertion and withdrawalbetween thought insertion and withdrawal

• Gureje Gureje et al. et al. (1987) found correlations between (1987) found correlations between thought broadcast/withdrawal, made affect/made thought broadcast/withdrawal, made affect/made act, and passivity/made affect/made impulseact, and passivity/made affect/made impulse

• Coffey Coffey et al. et al. (1993) found correlations between (1993) found correlations between thought insertion/broadcast and thought thought insertion/broadcast and thought insertion/passivityinsertion/passivity

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Clinical correlates of FRSClinical correlates of FRS3. Correlates with other symptoms 3. Correlates with other symptoms • No correlation with schizophrenia subtype across No correlation with schizophrenia subtype across

studies (paranoid / hebephrenic / catatonic)studies (paranoid / hebephrenic / catatonic)

• Mellor (1970) found associations between Mellor (1970) found associations between made made phenomenaphenomena and respective domains and respective domains (motor, (motor, thought thought and and affectiveaffective symptoms), and between symptoms), and between passivitypassivity and and olfactory hallucinationsolfactory hallucinations

• Crow Crow et alet al. (2003) found correlations between . (2003) found correlations between formal thought disorder (measured by formal thought disorder (measured by CLANG)CLANG) and first-rank symptomsand first-rank symptoms

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Clinical correlates of FRSClinical correlates of FRS

4. Correlates with patient and 4. Correlates with patient and illness variablesillness variables

• Mellor (1970) found an inverse relation between Mellor (1970) found an inverse relation between the presence of FRS and the presence of FRS and duration of illness duration of illness and and number of admissionsnumber of admissions

• Gureje et al. (1987) found a positive association Gureje et al. (1987) found a positive association between between ageage and two FRS: and two FRS: voices commentingvoices commenting and and somatic passivitysomatic passivity

• Mortensen et al. (1989) found that FRS early in Mortensen et al. (1989) found that FRS early in the illness predicted FRS later on.the illness predicted FRS later on.

• Coffey et al. (1993) found FRS and non-FRS Coffey et al. (1993) found FRS and non-FRS hallucinationshallucinations to correlate in various ethnic to correlate in various ethnic groups.groups.

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Clinical correlates of FRSClinical correlates of FRS

5. Ethnic and cultural variations5. Ethnic and cultural variations• The The IPSSIPSS found that FRS were found across all found that FRS were found across all

cultures and were most reliable in diagnosiscultures and were most reliable in diagnosis• Chandrasena et al. (Chandrasena et al. (1983)1983) replicated this, but felt replicated this, but felt

FRS were less reliable in FRS were less reliable in immigrants to the Westimmigrants to the West, , and that and that subcultural beliefssubcultural beliefs could cause could cause confusion. Also noted that confusion. Also noted that voices commenting voices commenting were less common in ethnic minorities.were less common in ethnic minorities.

• Coffey et al. (1993) found FRS more common in Coffey et al. (1993) found FRS more common in UK-bornUK-born patients (73.3%) and less in patients (73.3%) and less in Greek-bornGreek-born patients in Australia (40.8%)patients in Australia (40.8%)

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Clinical correlates of FRSClinical correlates of FRS

6. Incidence in schizophrenia6. Incidence in schizophrenia• Mellor (1970) found a 75% incidence of FRS in Mellor (1970) found a 75% incidence of FRS in

schizophreniaschizophrenia• Later authors have given figures from 35.2% Later authors have given figures from 35.2%

(Radhakrishan et al., 1983) to 70% (Tanenberg-(Radhakrishan et al., 1983) to 70% (Tanenberg-Karant et al., 1995)Karant et al., 1995)

• The largest study gave an incidence of 57% The largest study gave an incidence of 57% (Carpenter et al., 1975), replicated by recent (Carpenter et al., 1975), replicated by recent studies (60.3%, Tandon et al., 1987; 68.5%, studies (60.3%, Tandon et al., 1987; 68.5%, Peralta and Cuesta, 1999) Peralta and Cuesta, 1999)

• Lower in prolonged illness (37.5%, 13-year follow-Lower in prolonged illness (37.5%, 13-year follow-up, Mortensen et al., 1989)up, Mortensen et al., 1989)

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Clinical correlates of FRSClinical correlates of FRS

7. Incidence in affective illness7. Incidence in affective illness• Rates from 6 to 23% were found in mania (Taylor Rates from 6 to 23% were found in mania (Taylor

and Abrams, 1973; Wing and Nixon, 1975; and Abrams, 1973; Wing and Nixon, 1975; Brockington et al., 1978) Brockington et al., 1978)

• Initially contradicted (Tandon and Greden, 1987)Initially contradicted (Tandon and Greden, 1987)• Later studies replicated this: (43.4% of patients Later studies replicated this: (43.4% of patients

with affective psychosis had FRS; Peralta and with affective psychosis had FRS; Peralta and Cuesta, 1999; 29% of patients with mania with Cuesta, 1999; 29% of patients with mania with psychotic symptoms and 18% of patients with psychotic symptoms and 18% of patients with psychotic depression; Tanenberg-Karant et al., psychotic depression; Tanenberg-Karant et al., 1995). 1995).

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Clinical correlates of FRSClinical correlates of FRS

8. In non-schizophrenic illness8. In non-schizophrenic illness

• Abrams and Taylor (1981) – no difference on any Abrams and Taylor (1981) – no difference on any variables between variables between manic manic patients with or without patients with or without FRSFRS

• Tanenberg-Karant Tanenberg-Karant et al.et al. (1995) – greater interval (1995) – greater interval between onset and hospitalization in manic between onset and hospitalization in manic patients with FRS, and higher SAPS scores.patients with FRS, and higher SAPS scores.

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Criticism of the FRSCriticism of the FRS Mellor (1970) pointed three failings Mellor (1970) pointed three failings

of FRS:of FRS:

1. they make no contribution to our 1. they make no contribution to our understanding of schizophreniaunderstanding of schizophrenia

2. they are not first-rank even in 2. they are not first-rank even in Schneider’s senseSchneider’s sense

3. the method by which they are 3. the method by which they are elicited is unreliable.elicited is unreliable.

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Criticism of the FRSCriticism of the FRS

Further criticism can be divided into Further criticism can be divided into four broad categories:four broad categories:

1.1. Unreliability of assessmentUnreliability of assessment

2.2. Lack of diagnostic utilityLack of diagnostic utility

3.3. Flaws in Schneider’s original workFlaws in Schneider’s original work

4.4. Diverting attention from other Diverting attention from other “core” symptoms“core” symptoms

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Unreliability of assessmentUnreliability of assessment

Whose definitions are used? Are they Whose definitions are used? Are they ambiguous?ambiguous?

Phenomenological versus structured Phenomenological versus structured interviewinterview

Inter-rater reliability (Inter-rater reliability (has generally has generally proved to be highproved to be high))

A case in point: Kluft (AJP 1987)’s A case in point: Kluft (AJP 1987)’s claim that claim that FRS are found in FRS are found in dissociative identity disorderdissociative identity disorder

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Lack of diagnostic utilityLack of diagnostic utility

Increased recognition of psychotic Increased recognition of psychotic mood disorders and their treatmentmood disorders and their treatment

Low sensitivity (65-71%, Peralta and Low sensitivity (65-71%, Peralta and Cuesta, 1999; 73.3%, Tanenberg-Cuesta, 1999; 73.3%, Tanenberg-Karant et al., 1995) and specificity Karant et al., 1995) and specificity (39-59%, Peralta and Cuesta, 1999)(39-59%, Peralta and Cuesta, 1999)

Reflection in the DSM-IV and DSM-IV-Reflection in the DSM-IV and DSM-IV-TR criteriaTR criteria

But overall, still But overall, still commoner commoner in “non-in “non-affective” psychosis.affective” psychosis.

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Flaws in Schneider’s original workFlaws in Schneider’s original work

Crichton (1996) points out that Crichton (1996) points out that Schneider’s 11 symptoms were Schneider’s 11 symptoms were derived from clinical experiencederived from clinical experience

No statistical data presentedNo statistical data presented Would not meet contemporary Would not meet contemporary

standards for publication?standards for publication? However, much evidence suggests However, much evidence suggests

that they do form a meaningful that they do form a meaningful cluster.cluster.

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Diverting attention from other “core” Diverting attention from other “core” symptomssymptoms

Other symptoms may be more Other symptoms may be more essentially schizophrenic, such as essentially schizophrenic, such as negative symptomsnegative symptoms (Crichton 1996) (Crichton 1996) and and thought disorderthought disorder (Carpenter (Carpenter et et al.al. 1993, Crow 1993, Crow et al. et al. 2003)2003)

Affective flattening Affective flattening and and social uneasesocial unease (Mortensen et al., 1989) are more (Mortensen et al., 1989) are more stable predictors of a diagnosis of stable predictors of a diagnosis of schizophreniaschizophrenia

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Current status: ICD-10Current status: ICD-10 Criteria (a) through (c) for schizophrenia (F20.-) Criteria (a) through (c) for schizophrenia (F20.-)

correspond to the FRS:correspond to the FRS:

(a) thought echo, thought insertion or withdrawal, and (a) thought echo, thought insertion or withdrawal, and thought broadcasting;thought broadcasting;

(b) delusions of control, influence, or passivity, clearly (b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;thoughts, actions, or sensations; delusional perception;

(c) hallucinatory voices giving a running commentary on (c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory among themselves, or other types of hallucinatory voices coming from some part of the bodyvoices coming from some part of the body

If these symptoms are present concurrently with an If these symptoms are present concurrently with an affective (manic or depressive) episode, a diagnosis of affective (manic or depressive) episode, a diagnosis of schizoaffective disorder (F25.-) is made.schizoaffective disorder (F25.-) is made.

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APPROACH TO DIAGNOSIS OF PSYCHOSIS – ICD-10Psychotic illness

First-rank symptoms

Affective symptoms

Duration > 1 month

Polymorphic picture

ACUTE SCHIZOPHRENIA-

LIKE PSYCHOSIS

SCHIZOPHRENIA

ACUTE POLYMORPHIC

PSYCHOSIS WITH SZ

YES

SCHIZOAFFECTIVE DISORDER

NOYES

YESNO

YES

To page 2

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APPROACH TO DIAGNOSIS OF PSYCHOSIS – ICD-10Psychotic illness without first-rank symptoms

Affective symptomsYES

MOOD DISORDER WITH PSYCHOTIC SYMPTOMS

NO

Other schizophrenic symptomsYES

Duration > 1 monthNO YES

SCHIZOPHRENIA Polymorphic

picture

NO

YES NO

ACUTE PSYCHOSIS

(OTHER)ACUTE

POLYMORPHIC

PSYCHOSIS

Single persistent delusion

YES

Duration

> 3 months

NO

Other persistent

delusions ± hallucinations

Lasts > 1 monthNO

YES

NO

PSYCHOSIS NOS

NO YES

F23.3 DELUSIONAL

DISORDER

YES

F22.8

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Current status: DSM-IV-TRCurrent status: DSM-IV-TR Under DSM-IV-TR, Criterion A for schizophrenia (295.-) Under DSM-IV-TR, Criterion A for schizophrenia (295.-)

requires any two of the following five symptoms for at requires any two of the following five symptoms for at least one month, with 6 months of impairment, least one month, with 6 months of impairment, provided mood disorder, substance use and general provided mood disorder, substance use and general medical conditions are excludedmedical conditions are excluded::

1. delusions1. delusions2. hallucinations2. hallucinations3. disorganized thought3. disorganized thought4. grossly disorganized or catatonic behaviour4. grossly disorganized or catatonic behaviour5. negative symptoms5. negative symptoms

butbut states that only one symptom is sufficient states that only one symptom is sufficient ifif hallucinations are third-person commenting or arguing, hallucinations are third-person commenting or arguing, or if delusions are bizarre – including delusions of or if delusions are bizarre – including delusions of influence and thought alienation phenomena. influence and thought alienation phenomena.

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APPROACH TO DIAGNOSING PSYCHOSIS (DSM-IV)Psychotic illness

Affective symptoms Interim periods with only psychosis?

SCHIZOAFFECTIVE

DISORDER

MOOD DISORDER WITH PSYCHOTIC SYMPTOMSCriterion A for

schizophrenia met? Total duration > 6 months

Total duration > 1 month SCHIZOPHRENIA

SCHIZOPHRENIFORM

DISORDER

Single persistent

delusion?

Total duration

> 1 month

Total duration

> 1 month

PSYCHOSIS NOS BRIEF PSYCHOTIC DISORDER

YES

YES

YES

YESYES

YES

NONO

NO

NONO

NO

NO DEL. DISORDER

YES

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Current status: ImplicationsCurrent status: Implications In schizophreniaIn schizophrenia• No correlation between FRS and neuroleptic responseNo correlation between FRS and neuroleptic response• FRS negatively predicted ECT response in one study FRS negatively predicted ECT response in one study

(Koehler and Sauer, 1983)(Koehler and Sauer, 1983)• Brockington et al. (1978) and Huber et al. (1980) Brockington et al. (1978) and Huber et al. (1980)

found that FRS indicated a poorer prognosis.found that FRS indicated a poorer prognosis.• Bland et al. (1980) found FRS could account for only Bland et al. (1980) found FRS could account for only

17-26% of variation in outcome17-26% of variation in outcome• Radhakrishnan et al. (1983) found a lower outcome Radhakrishnan et al. (1983) found a lower outcome

score with FRS, but not reaching significancescore with FRS, but not reaching significance• Mortensen et al. (1989) found severe impairment to Mortensen et al. (1989) found severe impairment to

be associated with FRS, but not significantlybe associated with FRS, but not significantly• Gureje et al. (1987) found delusional perception to be Gureje et al. (1987) found delusional perception to be

positively associated with severity, and thought positively associated with severity, and thought insertion negativelyinsertion negatively

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Current status: ImplicationsCurrent status: Implications

In affective illness: In affective illness: • Early studies suggested poorer outcome in mania Early studies suggested poorer outcome in mania

with FRS (Tohen et al., 1992) and depression with with FRS (Tohen et al., 1992) and depression with FRS or mood-incongruent psychotic symptoms FRS or mood-incongruent psychotic symptoms (Brockington et al., 1980). (Brockington et al., 1980).

• Abrams and Taylor (1981) found no differences in Abrams and Taylor (1981) found no differences in social, occupational or academic functioning as social, occupational or academic functioning as well as residual symptoms between manic well as residual symptoms between manic patients and “schizoaffective” patients patients and “schizoaffective” patients

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Current status: ImplicationsCurrent status: Implications In affective illness: In affective illness: • The Zurich study (Angst The Zurich study (Angst et alet al., 1978) found ., 1978) found

higher residual symptoms in this group (57%, higher residual symptoms in this group (57%, as against 24% for “pure” affective illness.) as against 24% for “pure” affective illness.)

• Mania with schizophrenic symptoms may Mania with schizophrenic symptoms may have poorer course and outcome (Marneros have poorer course and outcome (Marneros et al., 1990) and greater severity (Tsuang et et al., 1990) and greater severity (Tsuang et al., 1979)al., 1979)

• Tanenberg-Karant et al. (1995) found no Tanenberg-Karant et al. (1995) found no association between FRS and illness severity association between FRS and illness severity in psychotic mania or depression, but noted in psychotic mania or depression, but noted that this area required further study. that this area required further study.

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Current status: SummaryCurrent status: Summary

Have lost their primacy in the Have lost their primacy in the diagnosis of schizophreniadiagnosis of schizophrenia

Considered a cluster of “core Considered a cluster of “core psychotic symptoms”psychotic symptoms”

Still a part of diagnostic systemsStill a part of diagnostic systems Share certain “interesting properties” Share certain “interesting properties”

(Crow, 1996)(Crow, 1996) Have been extremely useful in Have been extremely useful in

formulating and testing formulating and testing pathophysiological theoriespathophysiological theories

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ConclusionConclusion

Have played a central role in the Have played a central role in the study of psychosisstudy of psychosis

Have led to areas of study such as Have led to areas of study such as neurophenomenology and neurophenomenology and neurobiology of psychotic symptomsneurobiology of psychotic symptoms

Despite controversies, still importantDespite controversies, still important Implications and associations still Implications and associations still

need elucidationneed elucidation

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Perhaps Mellor summed it up best in Perhaps Mellor summed it up best in 1982 when he observed that 1982 when he observed that “Schneider’s claims about first-rank “Schneider’s claims about first-rank symptoms find only limited support symptoms find only limited support from the more recent literature”from the more recent literature”, but , but goes on to add that goes on to add that “those who find “those who find first-rank symptoms of clinical value first-rank symptoms of clinical value need not yet abandon them.”need not yet abandon them.”

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THANK YOU!THANK YOU!