role of first rank symptoms in diagnosis of psychiatric disorders
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ROLE OF FIRST RANK SYMPTOMS IN DIAGNOSIS
OF PSYCHIATRIC DISORDERS
PRESENTER : PRAVEEN DAS
CHAIRPERSON : DR ASHOK MV
Emil Kraepelin
First delineated separate psychotic conditions
Two major patterns of primary insanity
Based on long term prognosis and course of illness
- Manic Depressive Psychosis
- Dementia praecox
1856-1926
Eugen Bleuler Introduced the term
Schizophrenia in 1911 Primary symptoms 4As-
abnormal associations, autistic behavior and thinking, abnormal affect and ambivalence
Secondary- hallucinations, delusions, social withdrawal and diminished drive 1857-1959
Kurt Schneider First Rank Symptoms Clinical Psychopathology Based on his study of the
Schwabing cohort
Identified a group of symptoms characteristic to schizophrenia
Based on clinical experience
1887-1967
Definition
“When we say, for example, that thought withdrawal is a first rank
symptom, we mean the following. If this symptom is present in a non-
organic psychosis, then we call that psychosis schizophrenia, as
opposed to cyclothymic psychosis, or reactive psychosis in an
abnormal personality” Kurt Schneider, “Clinical
Psychopathology” (1958)
In other words…
First-rank symptoms (FRS) are a group of delusional and hallucinatory
experiences that, in Schneider’s experience with the Schwabing cohort, reliably distinguished “schizophrenic”
from “affective” psychosis.
They are…
Auditory Hallucinations 1. Audible thoughts 2. Voices heard arguing 3. Voices heard commenting on one’s
action
Thought disorder: Passivity of thought 4. Thought withdrawal 5. Thought Insertion 6. Thought Broadcasting
Passivity experiences: delusion of control
7. “Made” affect 8. “Made” impulse 9. “ Made” volition 10. Somatic passivity
Delusion: 11. Delusional perception
FRS- A separate cluster within positive symptoms
Principal axis factor analysis (PAF) at baseline (n = 857) and a confirmative factor analysis (CFA) at three-year follow-up (n = 414) on (FRS) symptom score
A two-factor structure of first rank symptoms, i.e. FRS-delusional self experience and FRS-auditory hallucinations, with a moderate to large internal coherence within each factor and relative stability over time
(Heering HD et al.,2013)
Basis for FRS
Schneider considered these symptoms based on a diagnostic sense
Empirical rather than thoeretical
Influenced by the phenomenological school of psychopathology (Husserl, Jaspers)
Some represent a disruption of ego boundaries
Reasons for wide acceptance
Easy to elicit High inter-rater reliability and replicability Schneider’s reputation Heuristically useful in clinical work &
research Incorporated into diagnostic criteria ICD-9,
10 & DSM III, IV Incorporated in diagnostic tools like PSE Use in IPSS
FRS in ICD 10
Criteria for diagnosis of Schizophrenia a to d
First rank symptomsPersistent delusions that are culturally
inappropriate and completely impossible
Should be present for most of the time during a period of one month
FRS in DSM IV
Criterion A Voices conversing with each other,
running commentary Bizarre delusions – clearly implausible
and not understandableIncludes thought insertion, withdrawal,
broadcast, delusion of control Continuous signs of disturbance for at
least six months with symptoms for most of one month period
Explaining FRS…
Phenomenological: defect in the integration of the self, leading to a “loss of ego boundaries”
Local dysfunction: Trimble (1990) suggested FRS indicate temporal lobe dysfunctionRight inferior parietal lobule implicated in FRS (Frith’s Model)Morphological abnormalities in the limbic-paralimbic regions such as the cingulate gyrus and parahippocampal gyrus
(Suzuki M.,2005)
Explaining FRS…
Genetics: initial studies (low n) suggested heritability of zero, later authors (Mc Guffin et al., 2002) found 26.5% concordance in MZ twins, 0.3% in DZ twins
The nuclear symptoms of schizophrenia can be understood as a failure to establish dominance for a key component – the phonological sequence – of language in one hemisphere
(TJ Crow)
Current theories for FRS
Neuropsychological: currently has the most evidence
Mainly based on the work of Christopher Frith (1992)
Symptoms of schizophrenia arising from a defect in self monitoring
Deficits in self monitoring leads to a loss of sense of AgencyOwnership
Deficits of self monitoring due to a dysfunction in the internal forward model system
Current theories for FRS
According to this theory, deficits in self-monitoring lead to a loss of the sense
of
agency (leading to made phenomena)
ownership (leading to thought alienation phenomena)
Motor command
Comparator / Self Monitoring System
Motor Act Proprioceptive Input
Efference Copy/ corollarydischarge
Re-afference Copy
Ownership
Agency
The forward model system
The subjective experience of schizophrenia patients with body-affecting FRS (made impulses and made acts) is rooted in the disturbance of intentionality and diminished sense of agency
(Thomas Fuchs et al., 2010)
Evidence for FRS - ImagingAuditory Hallucinations Increased blood oxygen level dependent (BOLD) signal
in Heschl Gyrus in the dominant hemisphere (Thomas Dierks et al., 1999)
Smaller superior temporal lobe volume is associated with auditory hallucinations in schizophrenia (Barta et al 1990)
Persistence of auditory hallucinations over 5 years of care was associated with smaller temporal lobe volumes bilaterally
(Milev et al., 2003)
Frontotemporal functional dysconnectivity in schizophrenia and may be associated with auditory hallucinations
(C Frith et al.,)
Evidence for FRS - Imaging
Passivity phenomenon Involvement of right parietal cortex using
PET scan. Schizophrenic patients with passivity showed hyperactivation of parietal and cingulate cortices. This hyperactivation remitted in those subjects in whom passivity decreased over time (Spence et al.,1997)
A significant positive correlation between Schneiderian scores and rCBF was observed in two regions of right parietal cortex
(Nancy C Andreason et al.,2002)
Schizophrenia patients with FRS (antipsychotic naïve) had significantly larger deficit in right IPL volume in comparison with healthy controls
(G Venkatsubramanian et al.,2009)
Reduced cortical volume was observed in parietal and frontal association cortices in the passivity group
(C Pantelis et al)
Those with FRS had larger splenium than those without FRS and were closer to controls and probably have adequate connectivity through splenium regions; this would support the hyperconnectivity hypothesis
(Venkatsubramanian G et al.,2011)
Auditory hallucinations and passivity experiences are associated with an abnormality in the self-monitoring mechanism that normally allows us to distinguish self-produced from externally produced sensations
(Frith C, Blakemore)
Facial emotion recognition deficits (FERD) have been consistently demonstrated in schizophrenia. However the relation between psychopathology and FERD remains inconclusive. First Rank Symptoms (FRS) of schizophrenia is associated with heightened sense of paranoia and rapid processing of threatful emotional stimuli. FRS+ group made significantly greater errors in Over-identification as compared to the FRS- group. This study supports that FERD is one of the important deficits in schizophrenia
(Venkatsubramanian G et al.,2011)
Brain derived Neurotrophic factor (BDNF) and FRS
Schizophrenia patients had low BDNF than controls
FRS(+) patients to have significant deficit in plasma BDNF level in comparison with healthy controls (p = 0.002); however, FRS(−) patients did not differ from healthy controls (p = 0.38)
(Sunil Vasu Kalmadi et al .,2013)
Prevalence of FRSinvestigator method No of
patients FRS %
Huber et al 1967 Chart review 195 72
Mellor 1970 interview 166 72
Carpenter et al 1974 interview 811 57
Wing et al 1975 interview 810 51
Koehler et al 1977 Chart review 210 33
Bland et al Chart review 50 88
Chandrasena & Rodrigo 1979
interview 169 25.4
Raguram 1980 interview 30 53.3
Ndetei DM & Singh interview 80 73
Radhakrishnan et al 1983 interview 88 35
Tannenberg-karant et al 1995
interview 94 72
Botros MM et al interview 42 67
Idrees et al 2010 interview 100 34
Prevalence of Individual FRSInvestigator Highest (%) Lowest (%)
Mellor (1970)UK
Thought broadcast (31%)
Made impulse (4.2%)
Koehler (1977)Germany
Delusional perception (55%)
Made impulse (0%)
Ona (1982)Nigeria
Somatic passivity (80.9%)
Audible thoughts (6.4%)
Idrees (2010)Pakistan
Voices commenting (41.2%)
Delusional perception (0%)
Raguram (1980)India
Thought broadcast(62.5%)Insertion (56%)Withdrawal (56%)
Delusional perception (12.5%)Made phenomena (each 12.5%)
Are they seen in other disorders also ?
How specific are they ..???
Several findings indicated that FRS were not more effective than non- Schneiderian psychotic symptoms in delineating central characteristics of the schizophrenic syndrome; they may identify a subgroup of schizophrenics with a more chronic course, but they do not appear to have the unique importance or diagnostic specificity that has been accorded to them
(Silverstein ML. Harrow M.,1981)
Investigators Diagnosis (N) FRS %
Taylor, 1972 Mania (7) Depression (8)Neuroses & PD(18)
000
Carpenter et al, 1973 Affective. Psychoses (39) Neuroses(23)
239
Abrams et al, 1974 Mania (43) 9
Taylor et al, 1973 Mania (52) 11.5
Carpenter et al, 1974 Mania (66)Depression(119)Neuroses & PD(123)
231612.7
Wing et al, 1975 Mania (79)Depression (176)PD/Neuroses (53)
1657.2
Marsha et al (1995) BPAD (62) 32
Radhakrishnan et al (1983)
Affective Disorders (46)Hysterical Psychosis (39)Paranoid State (6)
172
O'Grady (1990) Affective disorders (34) 14
Prevalence in other mental illness Affective disorders
Prevalence 33.3% Most common: voices commenting and made
acts (31% each)**
Reactive psychosis Prevalence: 23.3% Most common: voices commenting, thought
insertion & withdrawal (57%)** ( Raguram, 1980)
**% of those who had FRS
In an analysis the case records of 83 first admissions of FRS+ schizophrenics, hospitalized in a strongly Schneider-oriented German University Clinic during the period 1962-1971. Research diagnosable "schizo-affective" disorder was thus found in 27.7% (23 cases) of these patients; 12 of the 23 satisfied "full" affective research criteria for depression or mania, whereas 11 fulfilled "adjusted" affective criteria geared to cover more "labile" mixed mood states. Moreover, 48.2% (40 cases) and 25.3% (21 cases) of the sample were research-positive for "schizophreniform" illness and "atypical schizophrenia" respectively (Koehler K.,1979)
A high rate of FRSs in manic and mixed patients was found with a higher frequency in men (31%) than in women (14%; P=0.038)
A monotonic increase in the association between FRSs and younger age was apparent
These results confirm previous findings that FRSs are not specific to schizophrenia
(Gonzalez Pinto A et al.,2003)
FRS has also been described in dissociative disorders
(Laddis A, Dell PF., 2012; Kluft RP.,1987; Shibayama M.,2011)
Also described in BZD withdrawal (Roberts K 1986)
One study shows high specificity to schizophrenia
(Tandon et al., 1987)
Most of the other studies: occur frequently but not exclusively in schizophrenia
FRS are not pathognomonic but very strong indicators of schizophrenia
FRS which are considered pathognomonic of schizophrenia occur in one fourth of the cohort of manic-depressive patients. Therefore, Schneider's system for identifying schizophrenia, while highly discriminating, leads to significant diagnostic errors if FRSs are regarded as pathognomonic
(Carpenter et al.,1973)
FRS and outcome
Most of the studies No correlation between FRS and outcome FRSs did not have a postdictive or predictive
function, as no relationship could be established between FRSs and duration or outcome of illness
(Carpenter et al.,1973)
Number of FRS in an individual patient does not predict outcome (Julie Norgaard 2007)
A few studiesFRS & poor prognostic signs identify the same
patients (Taylor 1972 )
FRS in the acute stage and at 2 years predicted lack of recovery during 20 year follow
(Rosen et al., 2011)
First-rank symptoms are not exclusive to schizophrenia; they also occur in some bipolar patients. However, they are more frequent and more severe in patients with schizophrenia than bipolar disorder
Schizophrenia patients with FRS during the acute phase are more likely to have poorer long-term outcome than schizophrenia patients who do not have FRS during the acute phase
(Rosen C, Grossman LS.,2011)
FRS Criticism
Mellor, 1970
Pointed out three criticisms of FRS
They make no contribution to our understanding of Schizophrenia
They are not first rank even in Schneider’s sense
The method by which they are elicited is unreliable
Few other criticisms
Various definitions Unreliability of assessment Not specific Does not predict the outcome Other symptoms may be more specific
(negative symptoms, thought disorder) Represent only one dimension (core
psychotic symptoms?)
DSM 5- Schizophrenia Two or more of the following present for a
significant duration during a 1 month period. Atleast one must be 1, 2 or 3
1. Delusions 2. Hallucinations 3. Disorganized speech ( frequent
derailment or incoherence)4. Grossly disorganized or catatonic
behaviour5. Negative symptoms ( diminished
emotional expression or avolition)
This change should have little impact on prevalence because fewer than 5% individuals receive a diagnosis of schizophrenia based on a single bizzare delusion or hallucination
(PCNA sept 2012 Vol 35 No 3)
FRAH was common in two DSM IV schizophrenia datasets (42.2% and 55.2%) and BD was present in the majority of patients (62.5% and 69.7%). However, FRAH and BD rarely determined the diagnosis. In database 1, we found only seven cases among 325 patients (2.1%) and in the second database we found only one case among 201 patients (0.5%) who were diagnosed based on FRAH or BD alone.
Among patients with FRAH, 96% had delusions, 14-42% had negative symptoms, 15-21% had disorganized or catatonic behavior, and 20-23% had disorganized speech.
Among patients with BD, 88-99% had hallucinations, 17-49% had negative symptoms, 20-27% had disorganized or catatonic behavior, and 21-25% had disorganized speech.
FRAH and BD are common features of schizophrenia spectrum disorders, typically occur in the context of other psychotic symptoms, and very rarely constitute the sole symptom criterion for a DSM-IV-TR diagnosis of schizophrenia
(Shinn AK, Heckers S.,2013)
Although bizarre delusions and/or Schneiderian hallucinations were present in 124 (n=221) patients (56.1%), they were singly determinative of diagnosis in only one patient (0.46%). Additionally, only three of the 221 patients (1.4%) with DSM-IV schizophrenia did not have a delusion, hallucination, or disorganized speech
DSM-5 changes in criteria A should have a negligible effect on the prevalence of schizophrenia, with over 98% of individuals with DSM-IV schizophrenia continuing to receive a DSM-5 diagnosis of schizophrenia in this dataset (Tandon R, Bruijnzeel D, Rankupalli B.,2013)
Issues in FRS research
Diagnosis of psychiatric illness, schizophreniaLack of a solid lab testDiagnosis is based on conventions
Unclear definitions of FRS Difficulty in differentiating
schizophrenia and mood disorders To be understood in the context of
patient’s total illness picture
As long as the diagnosis of
Schizophrenia depends on FRS, it is
logically impossible to assess the
diagnostic specificity of FRS
Nordgaard et al., 2008
Conclusions Schneider’s work on delineating these
symptoms in his cohort and being able to consistently describe them is unparalleled
Has served to initiate and propel research on Schizophrenia, both phenomenological and neurobiological
Has influenced current diagnostic systems Has shown to be indicative of severity of
illness in a few studies As long as hallucinations and delusions
remain as symptoms of psychosis, FRS of Schneider will influence its diagnosis
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