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

THANK YOU