First rank symptoms %80%a0%a0%92%b6 seminar

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First rank symptoms %80%a0%a0%92%b6 seminar

  1. 1. FIRST-RANK SYMPTOMS: CURRENT STATUS Presenter: Ravi Philip Rajkumar Chairperson: Dr. G. Venkatasubramanian
  2. 2. <ul><li>Mr. S, aged 35, with a family history of psychiatric illness and suicide in his father, presents with two years’ episodic illness with complete recovery on treatment. He has had two past episodes, each lasting 4-6 months. The current episode has lasted 3 months so far. Each episode is characterized by pervasive low mood, low energy, crying spells, decreased interest in activities, reduced social and occupational functioning, death wishes, suicidal ideation, terminal insomnia, reduced appetite, and weight loss of 5 kilograms. He also reports suspicions that his wife is unfaithful to him, beliefs that his relatives are poisoning his food and practicing black magic to harm him, and hearing the voices of his relatives speaking ill of him when alone, which are not related to any preoccupation with guilt. </li></ul>
  3. 3. <ul><li>His physical examination and laboratory investigations are within normal limits. There is no history of substance use. On mental status examination he reports feeling that his thoughts become known to others even as he thinks, which he is sure of; when asked how this is possible, he says it may be due to black magic. His mood is depressed, with reduced range and reactivity. He reports death wishes and hopelessness. He has delusions of persecution and infidelity. He reports third person auditory hallucinations consisting of his relatives arguing among themselves and discussing him. His insight is poor and he denies that the “voices” or suspicions may be due to a mental illness, but is willing to be treated for his sad mood. </li></ul>
  4. 4. INTRODUCTION <ul><li>The definition of schizophrenia – concept, clinical syndrome, group of syndromes or illness? </li></ul><ul><li>Boundaries between schizophrenia and other disorders – nosology and otherwise </li></ul>
  5. 5. INTRODUCTION <ul><li>Earliest definition of dementia praecox (Kraepelin) based on course and outcome </li></ul><ul><li>Later definition of schizophrenia was conceptual (Bleuler’s 4 A’s – actually 6!) and led to difficulties in clinical and research work </li></ul>
  6. 6. INTRODUCTION <ul><li>FIRST-RANK SYMPTOMS </li></ul><ul><li>First proposed by Kurt Schneider (1939) </li></ul><ul><li>Based on his study of the Schwabing cohort of over 3000 patients </li></ul><ul><li>Based primarily on clinical experience </li></ul>
  7. 7. DEFINITION <ul><li>“ 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” </li></ul><ul><li>- Kurt Schneider, “Clinical Psychopathology” (1958) </li></ul>
  8. 8. In other words…. <ul><li>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. </li></ul>
  9. 9. What are they? <ul><li>Hallucinatory voices – voices commenting, voices discussing </li></ul><ul><li>Somatic passivity phenomena </li></ul><ul><li>Delusions of alien control – made feelings, made impulses, made volitional acts </li></ul><ul><li>Thought alienation phenomena – thought insertion, thought broadcast, thought withdrawal </li></ul><ul><li>Thought echo ( echo des pensees or Gedankenlautwerden) </li></ul><ul><li>Delusional perception </li></ul>
  10. 10. What was their basis? <ul><li>Essentially atheoretical </li></ul><ul><li>Influenced by the phenomenological school, founded by Husserl and adapted to psychopathology by Jaspers </li></ul><ul><li>However some of the phenomena (thought alienation, passivity and control) were thought to represent a “loss of ego boundaries” </li></ul>
  11. 11. Rise of the FRS <ul><li>Readily lent themselves to elicitation by a structured interview </li></ul><ul><li>Had high inter-rater reliability (was confirmed in later studies) and replicability </li></ul><ul><li>Could be easily used in designing diagnostic criteria </li></ul><ul><li>Schneider’s own reputation </li></ul><ul><li>Heuristically useful in clinical work and research </li></ul>
  12. 12. Rise of the FRS <ul><li>Incorporation into diagnostic criteria: RDC (Spitzer et al., 1978), ICD-9 and 10, DSM-III-R, DSM-IV </li></ul><ul><li>Incorporation into diagnostic tools: SADS (Spitzer and Endicott, 1978) and PSE (Wing et al. , 1974) </li></ul><ul><li>Use in the International Pilot Study of Schizophrenia </li></ul>
  13. 13. Theories behind FRS <ul><li>Phenomenological: defect in the integration of the self, leading to a “loss of ego boundaries” </li></ul><ul><li>Local dysfunction: Trimble (1990) suggested FRS indicate temporal lobe dysfunction </li></ul><ul><li>Genetics: initial studies ( low n ) suggested heritability of zero, later authors (McGuffin et al., 2002) found 26.5% concordance in MZ twins, 0.3% in DZ twins. </li></ul><ul><li>“ What exactly is inherited?” (Crow, 1996) </li></ul>
  14. 14. Current theories behind FRS <ul><li>Tim Crow (1998) – schizophrenia as the price paid for the evolution of language? </li></ul><ul><li>Defects in interhemispheric connectivity </li></ul><ul><li>Inadequate damping of non-dominant hemisphere activity – thought alienation phenomena </li></ul><ul><li>Abnormal feedback from dominant frontal lobe to Wernicke’s area – voices commenting? </li></ul>
  15. 15. Current theories behind FRS <ul><li>Neuropsychological: currently has the most evidence </li></ul><ul><li>Mainly based on the work of Christopher Frith (1992) </li></ul><ul><li>Divided the symptoms of schizophrenia into three broad groups </li></ul><ul><li>1. disorders of willed action </li></ul><ul><li>2. disorders of self-monitoring </li></ul><ul><li>3. disorders in monitoring the </li></ul><ul><li>intentions of others. </li></ul>
  16. 16. Current theories behind FRS <ul><li>According to this theory, deficits in self-monitoring lead to a loss of the sense of </li></ul><ul><li>* agency (leading to made phenomena) </li></ul><ul><li>* ownership (leading to thought alienation phenomena) </li></ul>
  17. 17. Origins of Delusion of Control Motor Instruction Comparator Or Self Monitoring System Motor Act Proprioceptive Input Reference Copy Re-afference Copy Ownership Agency
  18. 18. Evidence from imaging <ul><li>Spence et al. (1997) – passivity hyperactivation of right inferior parietal lobule and cingulate gyrus (replicated in an fMRI study in 2005) </li></ul><ul><li>Andreasen et al. (2002) – FRS score correlated with increased blood flow in the right parietal area and reduced flow in the left posterior cingulate and lingual gyri </li></ul>
  19. 20. In conclusion <ul><li>Dysfunction of brain areas involved in space and body representation implicated </li></ul><ul><li>Correlate with the cognitive model </li></ul><ul><li>May involve prefrontal-parietal and prefrontal-temporal networks </li></ul>
  20. 21. Clinical correlates of FRS <ul><li>1. Variations in occurrence of FRS </li></ul><ul><li>Mellor (1970) – thought broadcast commonest (21.4%), followed by thought echo, 3 rd person AH, thought insertion and passivity. Made impulse least common (2.9%) </li></ul><ul><li>Radhakrishnan et al. (1983) - 3 rd person AH, thought broadcast and passivity commonest </li></ul><ul><li>Coffey et al. (1993) – somatic passivity commonest (36.8%) </li></ul><ul><li>Peralta and Cuesta (1999) – thought broadcast commonest (43.8%) followed by 3 rd person AH, thought insertion and passivity (over 30%) </li></ul>
  21. 22. Clinical correlates of FRS <ul><li>2. Correlations between FRS </li></ul><ul><li>Authors such as Schneider (1942) and Conrad (1958) proposed subgroups on theoretical grounds </li></ul><ul><li>Mellor (1970) found correlations between 3 rd person AH commenting and arguing, and between thought insertion and withdrawal </li></ul><ul><li>Gureje et al. (1987) found correlations between thought broadcast/withdrawal, made affect/made act, and passivity/made affect/made impulse </li></ul><ul><li>Coffey et al. (1993) found correlations between thought insertion/broadcast and thought insertion/passivity </li></ul>
  22. 23. Clinical correlates of FRS <ul><li>3. Correlates with other symptoms </li></ul><ul><li>No correlation with schizophrenia subtype across studies (paranoid / hebephrenic / catatonic) </li></ul><ul><li>Mellor (1970) found associations between made phenomena and respective domains (motor, thought and affective symptoms), and between passivity and olfactory hallucinations </li></ul><ul><li>Crow et al . (2003) found correlations between formal thought disorder (measured by CLANG) and first-rank symptoms </li></ul>
  23. 24. Clinical correlates of FRS <ul><li>4. Correlates with patient and illness variables </li></ul><ul><li>Mellor (1970) found an inverse relation between the presence of FRS and duration of illness and number of admissions </li></ul><ul><li>Gureje et al. (1987) found a positive association between age and two FRS: voices commenting and somatic passivity </li></ul><ul><li>Mortensen et al. (1989) found that FRS early in the illness predicted FRS later on. </li></ul><ul><li>Coffey et al. (1993) found FRS and non-FRS hallucinations to correlate in various ethnic groups. </li></ul>
  24. 25. Clinical correlates of FRS <ul><li>5. Ethnic and cultural variations </li></ul><ul><li>The IPSS found that FRS were found across all cultures and were most reliable in diagnosis </li></ul><ul><li>Chandrasena et al. ( 1983) replicated this, but felt FRS were less reliable in immigrants to the West , and that subcultural beliefs could cause confusion. Also noted that voices commenting were less common in ethnic minorities. </li></ul><ul><li>Coffey et al. (1993) found FRS more common in UK-born patients (73.3%) and less in Greek-born patients in Australia (40.8%) </li></ul>
  25. 26. Clinical correlates of FRS <ul><li>6. Incidence in schizophrenia </li></ul><ul><li>Mellor (1970) found a 75% incidence of FRS in schizophrenia </li></ul><ul><li>Later authors have given figures from 35.2% (Radhakrishan et al., 1983) to 70% (Tanenberg-Karant et al., 1995) </li></ul><ul><li>The largest study gave an incidence of 57% (Carpenter et al., 1975), replicated by recent studies (60.3%, Tandon et al., 1987; 68.5%, Peralta and Cuesta, 1999) </li></ul><ul><li>Lower in prolonged illness (37.5%, 13-year follow-up, Mortensen et al., 1989) </li></ul>
  26. 27. Clinical correlates of FRS <ul><li>7. Incidence in affective illness </li></ul><ul><li>Rates from 6 to 23% were found in mania (Taylor and Abrams, 1973; Wing and Nixon, 1975; Brockington et al., 1978) </li></ul><ul><li>Initially contradicted (Tandon and Greden, 1987) </li></ul><ul><li>Later studies replicated this: (43.4% of patients with affective psychosis had FRS; Peralta and Cuesta, 1999; 29% of patients with mania with psychotic symptoms and 18% of patients with psychotic depression; Tanenberg-Karant et al., 1995). </li></ul>
  27. 28. Clinical correlates of FRS <ul><li>8. In non-schizophrenic illness </li></ul><ul><li>Abrams and Taylor (1981) – no difference on any variables between manic patients with or without FRS </li></ul><ul><li>Tanenberg-Karant et al. (1995) – greater interval between onset and hospitalization in manic patients with FRS, and higher SAPS scores. </li></ul>
  28. 29. Criticism of the FRS <ul><li>Mellor (1970) pointed three failings of FRS: </li></ul><ul><li>1. they make no contribution to our understanding of schizophrenia </li></ul><ul><li>2. they are not first-rank even in Schneider’s sense </li></ul><ul><li>3. the method by which they are elicited is unreliable. </li></ul>
  29. 30. Criticism of the FRS <ul><li>Further criticism can be divided into four broad categories: </li></ul><ul><li>Unreliability of assessment </li></ul><ul><li>Lack of diagnostic utility </li></ul><ul><li>Flaws in Schneider’s original work </li></ul><ul><li>Diverting attention from other “core” symptoms </li></ul>
  30. 31. Unreliability of assessment <ul><li>Whose definitions are used? Are they ambiguous? </li></ul><ul><li>Phenomenological versus structured interview </li></ul><ul><li>Inter-rater reliability ( has generally proved to be high ) </li></ul><ul><li>A case in point: Kluft (AJP 1987)’s claim that FRS are found in dissociative identity disorder </li></ul>
  31. 32. Lack of diagnostic utility <ul><li>Increased recognition of psychotic mood disorders and their treatment </li></ul><ul><li>Low sensitivity (65-71%, Peralta and Cuesta, 1999; 73.3%, Tanenberg-Karant et al., 1995) and specificity (39-59%, Peralta and Cuesta, 1999) </li></ul><ul><li>Reflection in the DSM-IV and DSM-IV-TR criteria </li></ul><ul><li>But overall, still commoner in “non-affective” psychosis. </li></ul>
  32. 33. Flaws in Schneider’s original work <ul><li>Crichton (1996) points out that Schneider’s 11 symptoms were derived from clinical experience </li></ul><ul><li>No statistical data presented </li></ul><ul><li>Would not meet contemporary standards for publication? </li></ul><ul><li>However, much evidence suggests that they do form a meaningful cluster. </li></ul>
  33. 34. Diverting attention from other “core” symptoms <ul><li>Other symptoms may be more essentially schizophrenic, such as negative symptoms (Crichton 1996) and thought disorder (Carpenter et al. 1993, Crow et al. 2003) </li></ul><ul><li>Affective flattening and social unease (Mortensen et al., 1989) are more stable predictors of a diagnosis of schizophrenia </li></ul>
  34. 35. Current status: ICD-10 <ul><li>Criteria (a) through (c) for schizophrenia (F20.-) correspond to the FRS: </li></ul><ul><li>(a) thought echo, thought insertion or withdrawal, and thought broadcasting; </li></ul><ul><li>(b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception; </li></ul><ul><li>(c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body </li></ul><ul><li>If these symptoms are present concurrently with an affective (manic or depressive) episode, a diagnosis of schizoaffective disorder (F25.-) is made. </li></ul>
  35. 36. APPROACH TO DIAGNOSIS OF PSYCHOSIS – ICD-10 Psychotic illness First-rank symptoms Affective symptoms Duration > 1 month Polymorphic picture ACUTE SCHIZOPHRENIA- LIKE PSYCHOSIS SCHIZOPHRENIA ACUTE POLYMORPHIC PSYCHOSIS WITH SZ YES SCHIZOAFFECTIVE DISORDER NO YES YES NO YES To page 2
  36. 37. APPROACH TO DIAGNOSIS OF PSYCHOSIS – ICD-10 Psychotic illness without first-rank symptoms Affective symptoms YES MOOD DISORDER WITH PSYCHOTIC SYMPTOMS NO Other schizophrenic symptoms YES Duration > 1 month NO 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 month NO YES NO PSYCHOSIS NOS NO YES F23.3 DELUSIONAL DISORDER YES F22.8
  37. 38. Current status: DSM-IV-TR <ul><li>Under DSM-IV-TR, Criterion A for schizophrenia (295.-) requires any two of the following five symptoms for at least one month, with 6 months of impairment, provided mood disorder, substance use and general medical conditions are excluded : </li></ul><ul><li>1. delusions </li></ul><ul><li>2. hallucinations </li></ul><ul><li>3. disorganized thought </li></ul><ul><li>4. grossly disorganized or catatonic behaviour </li></ul><ul><li>5. negative symptoms </li></ul><ul><li>but states that only one symptom is sufficient if hallucinations are third-person commenting or arguing, or if delusions are bizarre – including delusions of influence and thought alienation phenomena. </li></ul>
  38. 39. APPROACH TO DIAGNOSING PSYCHOSIS (DSM-IV) Psychotic illness Affective symptoms Interim periods with only psychosis? SCHIZOAFFECTIVE DISORDER MOOD DISORDER WITH PSYCHOTIC SYMPTOMS Criterion 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 YES YES YES NO NO NO NO NO NO NO DEL. DISORDER YES
  39. 40. Current status: Implications <ul><li>In schizophrenia </li></ul><ul><li>No correlation between FRS and neuroleptic response </li></ul><ul><li>FRS negatively predicted ECT response in one study (Koehler and Sauer, 1983) </li></ul><ul><li>Brockington et al. (1978) and Huber et al. (1980) found that FRS indicated a poorer prognosis. </li></ul><ul><li>Bland et al. (1980) found FRS could account for only 17-26% of variation in outcome </li></ul><ul><li>Radhakrishnan et al. (1983) found a lower outcome score with FRS, but not reaching significance </li></ul><ul><li>Mortensen et al. (1989) found severe impairment to be associated with FRS, but not significantly </li></ul><ul><li>Gureje et al. (1987) found delusional perception to be positively associated with severity, and thought insertion negatively </li></ul>
  40. 41. Current status: Implications <ul><li>In affective illness: </li></ul><ul><li>Early studies suggested poorer outcome in mania with FRS (Tohen et al., 1992) and depression with FRS or mood-incongruent psychotic symptoms (Brockington et al., 1980). </li></ul><ul><li>Abrams and Taylor (1981) found no differences in social, occupational or academic functioning as well as residual symptoms between manic patients and “schizoaffective” patients </li></ul>
  41. 42. Current status: Implications <ul><li>In affective illness: </li></ul><ul><li>The Zurich study (Angst et al ., 1978) found higher residual symptoms in this group (57%, as against 24% for “pure” affective illness.) </li></ul><ul><li>Mania with schizophrenic symptoms may have poorer course and outcome (Marneros et al., 1990) and greater severity (Tsuang et al., 1979) </li></ul><ul><li>Tanenberg-Karant et al. (1995) found no association between FRS and illness severity in psychotic mania or depression, but noted that this area required further study. </li></ul>
  42. 43. Current status: Summary <ul><li>Have lost their primacy in the diagnosis of schizophrenia </li></ul><ul><li>Considered a cluster of “core psychotic symptoms” </li></ul><ul><li>Still a part of diagnostic systems </li></ul><ul><li>Share certain “interesting properties” (Crow, 1996) </li></ul><ul><li>Have been extremely useful in formulating and testing pathophysiological theories </li></ul>
  43. 44. Conclusion <ul><li>Have played a central role in the study of psychosis </li></ul><ul><li>Have led to areas of study such as neurophenomenology and neurobiology of psychotic symptoms </li></ul><ul><li>Despite controversies, still important </li></ul><ul><li>Implications and associations still need elucidation </li></ul>
  44. 45. <ul><li>Perhaps Mellor summed it up best in 1982 when he observed that “Schneider’s claims about first-rank symptoms find only limited support from the more recent literature” , but goes on to add that “those who find first-rank symptoms of clinical value need not yet abandon them.” </li></ul>
  45. 46. <ul><li>THANK YOU! </li></ul>

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