role of first rank symptoms in diagnosis of psychiatric disorders
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role of first rank symptoms in diagnosis of psychiatric disorders

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  • He also added paranoia, catatonia, hebephrenia within dementia praecox, included them as the original subtypes of schizophrenia and later also added the simple type
  • Schneiderian symptoms may be associated with morphological abnormalities in the limbic-paralimbic regions such as the cingulategyrus and parahippocampalgyrus, which possibly serve the self-monitoring function and the coherent storage and reactivation of information
  • parietal cortical association area is involvedin perception of space and has been shown to be activeduring both execution and observation of graspingmovements. Our result strengthens the idea thatSchneiderian symptoms are associated with an impairment in the mechanisms underlying the recognition oforiginators of actions.
  • Various lines of studies support the role of IPL in processing endogenous sensory data; optimal processing of these endogenous sensory data is critical in differentiating self versus non-self. Hence IPL deficits can potentially lead to aberrations in mis-attributing self-generated movements to an external agent.In healthy individuals, the interactions between the anterior frontal areas and the posterior parietal areas are reciprocal in the sense that high activity in the frontal region goes with reduced activity in the posterior regions. Normally, signals arising in prefrontal cortex, where actions are initiated, inhibit activity in posterior regions, where the sensory consequences of actions are received. This relationship is not observed in patients with schizophrenia, leading to abnormal independent activities in the frontal and the parietal regions suggesting lack of connectivity. Some of the striking FRS might be associated with deficits in IPL. It is noteworthy that parietal cortical aberrations are given increasing importanceInferior parietal lobule has been involved in the perception of emotions in facial stimuli,[3] and interpretation of sensory information. The Inferior parietal lobule is concerned with language, mathematical operations, and body image, particularly the supramarginalgyrus and the angular gyruswhen normal controls wereled to believe that another person was controlling theiractions, there was activation of the inferior parietal lobule.
  • Methods. Responses to tactile stimulation were assessed in three groups of subjects: schizophrenic patients; patients with bipolar affective disorder or depression; and normal control subjects. Within the psychiatric groups subjects were divided on the basis of the presence or absence of auditory hallucinations and/or passivity experiences. The subjects were asked to rate the perception of a tactile sensation on the palm of their left hand. The tactile stimulation was either self-produced by movement of the subject's right hand or externally produced by the experimenter.Results. Normal control subjects and those psychiatric patients with neither auditory hallucinations nor passivity phenomena experienced self-produced stimuli as less intense, tickly and pleasant than identical, externally produced tactile stimuli. In contrast, psychiatric patients with these symptoms did not show a decrease in their perceptual ratings for tactile stimuli produced by themselves as compared with those produced by the experimenter. This failure to show a difference in perception between self-produced and externally produced stimuli appears to relate to the presence of auditory hallucinations and/or passivity experiences rather than to the diagnosis of schizophrenia
  • We studied differences in patterns of FERD between homogenous sub-groups of antipsychotic naïve schizophrenia patients (n=63); namely those experiencing FRS (FRS+ group n=26) and those who did not (FRS- group n=37), in comparison to age-, sex-, education matched healthy controls (n=45). FERD was assessed using TRENDS - (Tool for Recognition of Emotions in Neuropsychiatric DisorderS), a culturally sensitive and ecologically valid (consisting of both static and dynamic emotional stimuli) tool. The total number of images of non threatful emotions (sad, happy, neutral) which were identified as any of the threatful emotions (fear, anger, disgust) and vice versa were calculated and termed TRENDS Over-identification and Under-identification score respectively
  • BDNF in neuroplasticity and neuronal development esp in hippocampus also known to cause excitotoxicity in hippocampus and thereby bringing about behavioural changes
  • 103 consecutive inpatients who met DSM IV criteria for bipolar disorder, manic or mixed
  • Distinctly characterstic of a particular disease= pathognomonic
  • Diagnostic and prognostic significance of Schneiderian first-rank symptoms: a 20-year longitudinal study of schizophrenia and bipolar disorder

role of first rank symptoms in diagnosis of psychiatric disorders role of first rank symptoms in diagnosis of psychiatric disorders Presentation Transcript

  • 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 threeyear 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 symptoms  Persistent 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 understandable  Includes 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 dysfunction Right 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   Agency  Ownership  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)
  • The forward model system Comparator / Self Monitoring System Agency Efference Copy/ corollarydischarge Re-afference Copy Motor command Ownership Motor Act Proprioceptive Input
  •  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 - Imaging Auditory 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 FRS investigator 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 FRS Investigator Highest (%) Lowest (%) Mellor (1970) UK Thought broadcast (31%) Made impulse (4.2%) Koehler (1977) Germany Ona (1982) Nigeria Idrees (2010) Pakistan Raguram (1980) India Delusional perception (55%) Somatic passivity (80.9%) Voices commenting (41.2%) Thought broadcast (62.5%) Insertion (56%) Withdrawal (56%) Made impulse (0%) Audible thoughts (6.4%) Delusional perception (0%) 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) 0 0 0 Carpenter et al, 1973 Affective. Psychoses (39) Neuroses(23) 23 9 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) 23 16 12.7 Wing et al, 1975 Mania (79) Depression (176) PD/Neuroses (53) 16 5 7.2 Marsha et al (1995) BPAD (62) 32 Radhakrishnan et al (1983) Affective Disorders (46) Hysterical Psychosis (39) Paranoid State (6) 1 7 2 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 studies  FRS & 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 behaviour 5. 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, 1442% 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-IVTR 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, schizophrenia  Lack of a solid lab test  Diagnosis 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 
  • THANK YOU