Schneiderian First-rank Symptoms Research Articles

Towards the DSM-6: Results of a Survey of Experts on the Reintroduction of First-Rank Symptoms as Core Criteria of Schizophrenia and on Redefining Hallucinations.

Diagnostic criteria for mental disorders are subject to change. This is particularly true for schizophrenia, whose diagnostic criteria in the current DSM-5 bear little resemblance to what Kraepelin once named "dementia praecox" and Bleuler termed "the schizophrenias." The present study reports results from a survey of experts on two core topics of schizophrenia: (a) whether subsequent editions of the DSM should once again give the Schneiderian first-rank symptoms (FRS; eg, thought broadcasting) the prominent role they had in the DSM-IV and (b) whether the currently quite narrow definition of hallucinations in the DSM-5 requiring them to be vivid and clear and have the full force and impact of normal perceptions should be broadened to incorporate perceptual-like phenomena that the individual can differentiate from proper perceptions but still perceives as real and externally generated. The aim of the survey was to learn about experts' opinions with no clear hypotheses. International experts on schizophrenia were recruited via various sourcesand invited to participate in a short online survey. The final sample comprised 136 experts with a subgroup of 53 experts with verified identity and at least 6 years of clinical and/or research experience. Slightly more experts voted in favor (49.3%) of returning FRS to the prominent role they had in earlier versions of the DSM than against (34.6%). Approximately four out of five experts agreed that the definition of hallucinations in the DSM should be expanded. According to the results, alongside internal symptoms that are phenomenologically indistinguishable from true perceptions, sensory intrusions that the holder is convinced were inserted from another source (ie, not self-generated) should be included in the definition. While a large majority of experts recommend a change in the definition of hallucinations, the experts' opinions on FRS are more mixed. We hope that this article will stimulate future studies targeting the diagnostic relevance of these symptoms and encourage discussion about the definition of core psychotic symptoms and the diagnostic criteria for the upcoming edition of the DSM.

Psychotic experiences in trauma-related disorders and borderline personality disorder

In the case of trauma and psychotic experiences, such as hearing voices or experiencing delusions, the primary question for the practising psychiatrist in terms of diagnosis is whether to diagnose psychotic disorder, trauma-related disorder, or borderline personality disorder. Although the ICD-11 de-emphasises the role of Schneiderian first-rank symptoms, such as hearing voices, in schizophrenia, it still lacks clarity in the classification of psychotic experiences in disorders specifically associated with stress.

Symptômes psychotiques dans l’épisode maniaque. Un regard de psychiatre libéral

Private practice requires particular vigilance with regard to signs of mood instability in patients with bipolar disorders, in particular the manic aspect, because of the risk of disruption in care. Between the episodes, psychotic symptoms can be sequels or prodroms and, if so, often stereotyped from one episode to the next. During the manic episode, mood-congruent symptoms (grandiosity, possessing superpowers, having a special relationship with God or with celebrities) are most common, but mood-incongruent symptoms (delusions of persecution, auditory hallucinations, first-rank Schneiderian symptoms) are not uncommon. In the absence of delusions or hallucinations, the clinician must be alert to a decline in insight, or when the patient shows symptoms of formal thought disturbances. For certain classical authors, mania was, by itself, a psychotic experience. The relationship between the severity of mania and the existence of psychotic symptoms is strong, but not exclusive. Some patients that have not completely stopped their treatment can have moderate symptoms of mania, albeit with some psychotic symptoms. Congruent and non-congruent psychotic symptoms may persist beyond the manic episode, raising the question of schizoaffective (SA) disorder when elements of a diagnostic criteria for schizophrenia are met. SA is a disputed diagnostic category, whose stability over time is unsatisfactory. The management of psychotic symptoms with mania is difficult in private practice: a clinical case of a female bipolar patient with erotomania before and during manic episodes illustrates the difficulties of management when the patient's insight fluctuates. The side-effects of treatments, a hypomanic switch, induced by an antidepressant despite two mood stabilizers (lithium, valproate), followed by a period of mood instability and a lack of medical coordination had contributed to an interruption in care. Statistical multivariate analyses and the grouping of symptoms and patients together with factor and network analyses suggest a partial independence of psychotic symptoms from other manic symptoms and, in cluster analyses, the likelihood of a subgroup of manic patients with psychotic symptoms.

Dissociative, Schneiderian and borderline personality symptoms in a non-clinical sample in Hong Kong: A preliminary report

IntroductionDissociative symptoms are common in people with trauma-related disorders and often co-occur with other psychiatric conditions. In particular, the relationships between dissociative symptoms, Schneiderian first-rank symptoms and borderline personality symptoms are still contentious, poorly understood and require more attention. ObjectivesThis preliminary study investigated these three symptom clusters in a non-clinical Chinese sample in Hong Kong. MethodsA total of 190 college students in Hong Kong completed the Dissociative Experiences Scale-Taxon (DES-T), the 5-item Somatoform Dissociation Questionnaire (SDQ-5) and some sections of the Dissociative Disorders Interview Schedule (DDIS). ResultsAbout one-fourth of the participants (24.7%) screened positive for one symptom cluster, 12.1% were positive for two symptom clusters; and 5.26% were positive for all three symptom clusters. Preliminary analysis showed that the three symptom clusters were associated with distress/impairment. ConclusionDissociative, Schneiderian and borderline personality symptoms as measured in this study are not uncommon in this non-clinical Chinese sample. The data indicate that these three symptom clusters are highly related but are not the same constructs of psychopathology; the co-occurrence of these symptoms may require additional attention. The findings have significant implications for research and practice. Further studies are needed.

M42 - Using Polygenic Scores Based on Schneiderian First Rank Symptoms To Characterize Disease Trajectories In Severe Mental Illnesses

Background Mental illnesses such as bipolar disorder (BD), schizoaffective disorder (SA) and schizophrenia (SZ) have a huge impact on people’s lives and due to expensive treatments also on our health systems. Despite our advances in genetic and clinical research, it is still unknown what determines the highly variable courses of illness. Recent studies have focused on determining phenotypes more suitable for genetic analyses. Most analyses use diagnostic criteria based on DSM or ICD, however, the question arises whether it may be useful to classify subgroups of patients based on domains of psychopathology across diagnostic classification systems. To date, few studies exist that examine phenotypes based on such domains. We examined the presence/absence of Schneiderian first-rank symptoms (FRS) as a potential phenotype in a genome-wide association study (GWAS) analysis. The results of this analysis were used to calculate polygenic risk scores in an independent sample in which longitudinal clusters of psychopathology have been defined. We aim to explore the association of cluster membership with the individual load on first-rank polygenic risk scores (FR-PRS). Methods Discovery sample: Individuals with SZ, SA and BD (n=1621) were selected from a large multi-site study (BoMA) in Germany and phenotyped using a comprehensive inventory for phenotype characterization (IPGS), including the SCID-I, the OPCRIT and the GAF. Presence/ absence of FRS served to identify diagnostically heterogeneous subgroups. GWAS was carried out with PLINK 1.07 using as covariates: age, age of onset, mode of onset, poor premorbid social adjustment, gender, course of illness and 4 population structure PCs. Test sample: A subsample of individuals (n=198) with SZ, SA and BD from a longitudinal, multi-site cohort study (www.kfo241.de; www.PsyCourse.de) comprehensively phenotyped at 4 time points over 18 months. DNA samples were genotyped and imputed using the 1KG Phase3. 67 longitudinally measured variables derived from clinical symptom scales entered the cluster analyses. FAMD was applied to compute abstract data dimensions, which were used to derive longitudinal trajectories. Based on these trajectories, k-mean clustering for longitudinal data yielded 2 distinct subgroups. Identified clusters served as predictors for FR-PRS at 11 thresholds. Results Two clusters of longitudinal trajectories were identified: i) consistently low psychopathology scores and ii) consistently high psychopathology scores. Cluster membership was not significantly associated with the FR-PRS in either cluster. Discussion Although the results are preliminary and thus need to be interpreted with caution, the approach of longitudinal clustering to identify cross-diagnostic homogeneous subgroups of individuals appears feasible. The fact that more severe psychopathological features were not associated with increased genetic risk burden should be explored further. One possible explanation is a lack of power, another is that maybe psychopathology may be more influenced to a larger degree by other factors than genetics that may be easier to modify for future treatment options.

First-Rank Symptoms in Methamphetamine Psychosis and Schizophrenia

Background: Methamphetamine psychosis (MAP) symptomatology has been described as indistinguishable from that of schizophrenia (SZ), yet research comparing these two disorders on specific psychotic symptoms such as schneiderian first-rank symptoms (FRS) is lacking. We aimed to determine and compare the occurrence and associations of FRS in patients diagnosed with MAP and with SZ. Sampling and Method: Data from SCID-I interviews performed on patients with either a diagnosis of SZ or MAP were compared. We calculated the prevalence of different FRS between MAP and SZ patients and used logistic regression to assess the association between FRS and diagnosis. Results: 102 patients were included in the study (MAP = 33, SZ = 69). Thought broadcasting occurred significantly more often in SZ (42%) than in MAP (24.2%) patients (adjusted OR = 3.02; 95% CI: 1.12-8.15; p = 0.028), while auditory hallucinations (voices conversing) were significantly higher in MAP (48.5%) than in SZ (20.3%) patients (adjusted OR = 0.27; 95% CI: 0.10-0.66; p = 0.004). However, there was no significant difference in the occurrence of one or more FRS in MAP and SZ, with most FRS showing overlap. Conclusions: We found that first-rank auditory hallucinations were more prevalent in MAP, whereas first-rank delusions of thought broadcasting were more prevalent in SZ. However, there was a substantial overlap in MAP and SZ for most FRS. This is consistent with the finding that FRS may have limited diagnostic specificity and that there is significant overlap in the symptoms of MAP and SZ. Future research into the neurobiology of delusions and hallucinations needs to take FRS into account.

What is the future for Schneiderian first-rank symptoms, in the Diagnostic and Statistical Manual of Mental Disorders and otherwise?

What is the future for Schneiderian first-rank symptoms, in the Diagnostic and Statistical Manual of Mental Disorders and otherwise?

The relationship between catatonia and dissociation: A preliminary investigation

ABSTRACTUnlike the relationship between dissociation and Schneiderian first-rank symptoms, the relationship between dissociation and catatonia has not been investigated empirically. In order to gather some initial data about catatonia, dissociation, and childhood adverse experiences, we administered the Bush-Francis Catatonia Scale (BFCS), the Dissociative Experiences Scale (DES), the Adverse Childhood Experiences Questionnaire, and the Dissociative Disorders Interview Schedule to 100 inpatients in a hospital trauma program. The average DES score was 44.1 (SD = 22.4), and 86 participants were in the DES-Taxon. The average score on the BFCS was 7.7 (SD = 10.3); 81 participants scored 2 or higher, and 67 scored 5 or higher. The results showed that, in this sample, catatonic symptoms are frequent and related to adverse childhood experiences but seem to be a separate symptom category from both dissociation and psychosis.

Childhood traumatic events and types of auditory verbal hallucinations in first-episode schizophrenia patients

ObjectiveEvidence is accumulating that childhood trauma might be associated with higher severity of positive symptoms in patients with psychosis and higher incidence of psychotic experiences in non-clinical populations. However, it remains unknown whether the history of childhood trauma might be associated with particular types of auditory verbal hallucinations (AVH). MethodWe assessed childhood trauma using the Early Trauma Inventory Self-Report — Short Form (ETISR-SF) in 94 first-episode schizophrenia (FES) patients. Lifetime psychopathology was evaluated using the Operational Criteria for Psychotic Illness (OPCRIT) checklist, while symptoms on the day of assessment were examined using the Positive and Negative Syndrome Scale (PANSS). Based on ETISR-SF, patients were divided into those with and without the history of childhood trauma: FES(+) and FES(−) patients. ResultsFES(+) patients had significantly higher total number of AVH types and Schneiderian first-rank AVH as well as significantly higher PANSS P3 item score (hallucinatory behavior) in comparison with FES(−) patients. They experienced significantly more frequently third person AVH and abusive/accusatory/persecutory voices. These differences remained significant after controlling for education, PANSS depression factor score and chlorpromazine equivalent. Linear regression analysis revealed that the total number of AVH types was predicted by sexual abuse score after controlling for above mentioned confounders. This effect was significant only in females. ConclusionOur results indicate that the history of childhood trauma, especially sexual abuse, is associated with higher number AVH in females but not in males. Third person AVH and abusive/accusatory/persecutory voices, representing Schneiderian first-rank symptoms, might be particularly related to childhood traumatic events.

Mixed depression: a farewell to differential diagnosis?

J Clin Psychiatry 2015;76(3):e378–e380 (doi:10.4088/JCP.14com09578). © Copyright 2015 Physicians Postgraduate Press, Inc. I this issue of the Journal, Perugi and colleagues1 delve into the murky and controversial diagnostic boundaries between unipolar and bipolar mood disorders. As the authors intimate, the decision by DSM-5’s crafters to loosen the operational definition of mixed episodes adds to ongoing debate over the beleaguered document’s various symptom tweaks and diagnostic reshufflings. DSM-5 rightly acknowledged that many depressed bipolar patients experience subthreshold mania symptoms while depressed and that simultaneous symptoms of both poles can and often do coexist in bipolar II as well as bipolar I mood states. DSM-5 also took notice of empirical findings that high energy states robustly differentiate bipolar from unipolar disorder,2 underscoring the principle that bipolar illness is as much a disorder of energy and psychomotor functioning as mood. But the shortcomings of DSM-5’s revisions involving “mixedness” are important and risk dwarfing these nosologic advances. DSM-5’s decision to apply the “mixed features” specifier to both unipolar and bipolar depressive episodes when subsyndromal mania symptoms also exist harkens to Kraepelin’s view that polarity was not an all-or-none phenomenon and was less important than other characteristics (such as excitation-agitation, or high recurrence) in his original conception of manic-depressive illness. In practice, though, efforts to articulate valid operational criteria for “mixedness” create their own problems—particularly when asking diagnosticians to cherry-pick only some “possible” mania symptoms, side-stepping those that could also reflect depression. Researchers who conduct criteria-based diagnostic interviews may thus agonize all the more over ambiguous cases, while time-pressured everyday clinicians will probably ignore such nuanced distinctions altogether and potentially make “mixed features” (never mind polarity) a wastebasket descriptor for any and all forms of irritable moody people. Throughout its editions and revisions, the DSM has included as its final criterion for virtually every described entity the proviso that observed symptoms should not be attributed to a particular disorder if they can be better accounted for by another condition. This caveat becomes especially difficult when evaluating diagnostically nonspecific symptoms such as irritability or mood instability (or other such broad mental phenomena as “inattentiveness” or “apathy”). When considering depressive mixed states, Perugi et al1 (and other authors3) confront us with the challenge of how best to classify an important nosologic entity without “double counting” symptoms, or conflating 2 or more disease states that share common elements. The BRIDGE data1 invite us to consider whether depressed patients with such diagnostically nonspecific symptoms as irritability, mood instability, distractibility, agitation, and anxiety belong to the bipolar spectrum, or whether they may be better accounted for by other nonbipolar comorbidities. In doing so, they draw our attention to the DSM-5 conundrum of whether to include or exclude transdiagnostic symptoms when characterizing a distinct clinical entity. (By analogy, should a newly recognized inflammatory disease exclude fever as part of its core symptom constellation in order to avoid conflation with a comorbid infectious process? Or, while dyspnea and chest pain do not help to differentiate angina from pneumonia, can those symptoms really be ignored when considering either diagnosis?) If phenomenology studies in psychiatry have taught us anything over the past century, it is that no psychiatric symptom is pathognomonic of any one disorder. Bizarre thought content no longer figures so prominently as it once did in considering a diagnosis of schizophrenia. Nor does catatonia, paranoia, or even Schneiderian first-rank symptoms. In the case of mood disorders, while “mixedness” is no doubt a real phenomenon, its “truest” definition remains messy. Prominent irritability, for example, was found in almost half of unipolar depressed patients in the National Institute of Mental Health (NIMH) Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, and was more closely related to anxiety and depression severity than to occult “bipolar spectrum” features.4 Similarly, in the NIMH Collaborative Depression Study, irritability and anger were evident in over half of unipolar depressed patients, and were in turn linked to an array of complex illness characteristics, including more anxiety and substance misuse, greater depression severity and chronicity, and personality disorders.5 While some authors feel that irritable depression is practically synonymous with “bipolarity,”6 it may simply be an indicator of overall severity and complex psychopathology. “Affective instability” also poses a quandary for differential diagnosis. No edition of the DSM has ever identified affective instability as a criterion for mania or hypomania, although popular perception sometimes leads both patients and practitioners to assume that moment-to-moment “mood swings” are a defining element of bipolar disorder. Our own group found that community practitioners often diagnose bipolar disorder based mainly on the presence of mood lability—yet, when compared alongside individual DSM-IV symptom criteria for mania or hypomania, “affective See article by Perugi et al

Ziprasidone Associated Sexual Hyperarousal: a Case Report

Background Sexual dysfunction is a common condition in patients taking antipsychotic medication, with a reported prevalence of 45-80% in males, and 30-80% in females (1). Ziprasidone induced spontaneous orgasm (2) and priapism (3) were reported in the literature. Here, we report a case of increased sexual arousal after ziprasidone treatment. Case A twenty-three-year old, single, female patient was admitted to our clinic with reference and persecutory delusions, auditory and visual hallucinations. Her complaints had been persisting for about one month. Her mental status examination revealed the following: attention and concentration were diminished, speech was slow, delusions of reference and other Schneiderian first-rank symptoms, and hallucinations were present, reality testing was impaired, judgment and abstract thinking skills partially preserved. The patient was not able to tolerate her treatment due to side effects. Therefore, it was changed to ziprasidone 40 mg/day and the dosage was increased gradually. After increasing the ziprasidone dose to 60 mg/day, she complained about increased sexual arousal. No other symptoms suggestive of a manic episode were present, and no other medical causes were detected. The patient also said that she never had a similar period in her life previously. Ziprasidone was tapered slowly, and quetiapine 300 mg/day was started. She indicated that increased sexual arousal disappeared after the cessation of ziprasidone. Discussion Ziprasidone has been reported to cause sexual dysfunction at a much lower rate than other antipsychotics. To the best of our knowledge, this is the first case report of increased sexual arousal with ziprasidone.

Revisions and refinements of the diagnosis of schizophrenia in DSM‐5.

The DSM-5 changes to the diagnostic criteria for schizophrenia reflect modest incremental changes. The two most substantial changes, the elimination of subtypes and de-emphasis of Schneiderian First-Rank Symptoms, are a significant departure from long-standing approaches to conceptualizing and defining schizophrenia, but are unlikely to have an appreciable impact on caseness or clinical management. Several minor modifications to the diagnosis are generally useful additions that will likely enhance diagnostic precision. The two most controversial changes that were considered, the addition of dimensional ratings and attenuated psychosis syndrome, were ultimately placed in the third section of DSM-5 for further research and consideration. In sum, the changes demonstrate increased precision of diagnosis, with minimal changes in caseness.

Schizophrenia and Other Psychotic Disorders in Diagnostic and Statistical Manual of Mental Disorders (DSM)-5: Clinical Implications of Revisions from DSM-IV.

Byline: Rajiv. Tandon Our current systems of classifying psychiatric disorders (Diagnostic and Statistical Manual of Mental Disorders [DSM] and International Classification of Diseases [ICD]) have evolved over the past 60 years from the first edition of the DSM (DSM-1) [sup][1] to the current DSM-5 [sup][2] and from the sixth revision of the ICD (ICD-6) [sup][3] to the current ICD-10. [sup][4] Each revision has sought to incorporate new knowledge about various psychiatric disorders, improve reliability and validity, provide diagnostic clarity and enhance clinical utility. In addition, DSM-5 sought to address limitations in the DSM-IV definitions of various disorders; with regard to psychotic disorders, these included: [sup][5] (i) Unclear boundary between schizoaffective disorder and schizophrenia; (ii) variable definitions and discrepant treatment of catatonia across DSM-IV manual; (iii) poor description of clinical heterogeneity of schizophrenia and other psychotic disorders; (iv) spurious comorbidity of delusional disorder and obsessive-compulsive disorder; (v) poor reliability and low diagnostic stability of the diagnosis of schizoaffective disorder; and (vi) inappropriate treatment of first-rank (bizarre delusions or special hallucinations) in the definition of schizophrenia. Revisions in DSM-5 sought to address these limitations, while incorporating new information about various psychotic disorders generated since the publication of DSM-IV in 1994. In addition, revisions were intended to enhance clinical utility by reducing unnecessary complexity and improving coherence across this group of disorders. The major revisions in the definition of schizophrenia and other psychotic disorders from DSM-IV to DSM-5 are summarized along with the implications of these changes for clinical practice. Schizophrenia In view of its fair validity and clinical utility, changes in the diagnostic criteria of schizophrenia are relatively modest, and broad continuity with DSM-IV is maintained. The significant heterogeneity of the schizophrenias is, however, poorly explained by DSM-IV and consequently, major changes in this regard were made in DSM-5. The treatment of bizarre delusions and other first-rank in criterion A (active phase symptoms) is eliminated because these have not been found to be specific for schizophrenia and the distinction between bizarre versus nonbizarre delusions has been found to have poor reliability. [sup][6] These lack any significance in the context of schizophrenia. In DSM-5, Schneiderian first-rank symptoms are treated like any other symptom with regard to their diagnostic implication : t0 wo criterion A will be required even if one of them is a bizarre delusion. The impact of this change on clinical practice will be limited because A second change is the addition of a requirement that at least one of the two required to meet criterion A be delusions, hallucinations, or disorganized thinking. These are core positive symptoms and should be necessary for a reliable diagnosis of schizophrenia. [sup][8] Again, this change will have negligible impact on clinical practice as One major change in DSM-5 will be the elimination of the classic subtypes of schizophrenia. These subtypes have limited diagnostic stability, low reliability, poor validity, and little clinical utility. …

Schneiderian first rank symptoms and gamma oscillatory activity in neuroleptic naïve first episode schizophrenia: a 192 channel EEG study.

ObjectiveSchneiderian first-rank symptoms (FRS) and abnormal EEG gamma activity in schizophrenia have been reported independently to have a neurodevelopmental basis. We aimed to investigate spontaneous gamma power in two groups of first episode schizophrenia patients (those who experience FRS and those who do not).MethodsA comparative hospital based study having 37neuroleptic naïve male patients with schizophrenia divided into two groups-FRS(+) and FRS(-) groups based on the presence of FRS. Thirty age, sex, education and handedness matched individuals served as controls (N). All participants underwent a 192-channel resting Electroencephalography (EEG) recording. Gamma spectral power was calculated for low- (30-50 Hz) and high-gamma 1 & 2 (51-70 and 71-100 Hz) bands. Spectral power was compared between three groups using MANOVA and supplementary one-way ANOVA with Bonferroni test controlling for multiple comparisons. Linear regression was used to identifying predictor variables for FRS. Pearson correlation coefficient was computed between spectral power parameters and various clinical variables.ResultsSignificantly higher high gamma band-1 power was observed over right frontal (p<0.05), parietal (p<0.05) and temporal (p<0.05) regions in FRS(+) than FRS(-) group and normal controls. Right parietal high gamma-1 power and paranoid cluster on PANSS significantly predicted number of FRS in total schizophrenia patients; paranoid cluster on PANSS showed significant correlation with number of FRS in FRS(+) group.ConclusionFindings of our study add to the evidence that areas contained within the hetero modal association cortex are associated with FRS. The study findings also strengthen the neurodevelopmental basis of FRS in schizophrenia.

The Psychoses in DSM-5 and in the Near Future

The Psychoses in DSM-5 and in the Near Future

Predicting Diagnostic Change Among Patients Diagnosed With First-EpisodeDSM-IV-TRMajor Depressive Disorder With Psychotic Features

Longitudinal studies beginning from onset of major depressive disorder (MDD) with psychotic features in young adults are rare; therefore, in this study, subjects across a wide age range were included. Since psychotic MDD may be unstable diagnostically, we systematically evaluated such patients prospectively from first episode to ascertain predictors of later diagnostic change. In this prospective naturalistic study, we recruited patients with DSM-IV-TR psychotic MDD from 1989 through 2003 at psychiatric inpatient units in Massachusetts and Italy and followed them from first hospitalization to compare demographic, antecedent, and first-episode clinical characteristics for associations with later changes of diagnosis based on interviews using the Structured Clinical Interview for DSM-III-R, Patient Version. Within a mean (SD) of 4.0 (2.7) years, diagnoses among 107 subjects aged 34.6 (16.2) years (range, 10-82 years) who were experiencing a first lifetime DSM-IV-TR psychotic MDD episode changed in 29.9% to DSM-IV-TR bipolar disorder (18.7%) or schizoaffective disorder (11.2%). Factors associated with stable diagnoses of psychotic MDD included ontological anguish (χ(2) = 13.8, P < .0001), nihilistic delusions (χ(2) = 4.47, P = .034), and weight loss (χ(2) = 4.69, P = .030) at initial syndromal presentation. Factors preceding diagnoses of bipolar disorder included antecedent impulsivity (χ(2) = 9.10, P = .003), ICD-10 mixed states at intake (χ(2) = 19.4, P < .0001), and previous hypomanic symptoms (χ(2) = 13.7, P = .002). Factors predicting later schizoaffective diagnoses included mood-incongruent delusions (χ(2) = 9.17, P = .002) and somatosensory hallucinations (χ(2) = 9.53, P = .033) at intake, previous functional decline (χ(2) = 8.13, P = .008), initial Schneiderian first-rank symptoms (χ(2) = 10.6, P = .005), and meeting criteria for ICD-10 schizoaffective disorder at intake (χ(2) = 24.9, P < .0001). Among patients who initially met DSM-IV-TR criteria for first-episode psychotic MDD, early indications of features typically associated with bipolar disorder or with nonaffective psychoses, respectively, strongly predicted later diagnostic change to bipolar disorder or schizoaffective disorders. The findings support the value of psychopathological details in improving diagnostic and prognostic criteria for complex illnesses.

Does change in definition of psychotic symptoms in diagnosis of schizophrenia in DSM-5 affect caseness?

Psychotic symptoms are a central element in the diagnosis of schizophrenia, although their precise definition has varied through the multiple iterations of DSM and the ICD. Schneiderian first-rank symptoms (FRS) have received a particularly prominent position in the diagnostic criteria of schizophrenia since ICD-9 and DSM-III. In the current iteration of DSM (DSM-IV-TR), whereas two characteristic symptoms are ordinarily required to meet criterion A, only a single symptom is necessary if the psychotic symptom happens to be a FRS, notably a bizarre delusion or auditory hallucination of a running commentary or ‘conversing voices’. Because of limited data in support of the special treatment of FRS, DSM-5 has made changes to criterion A, requiring that at least two psychotic symptoms be present in all cases with at least one of these symptoms being a delusion, hallucination, or disorganized speech. To assess the impact of these changes on the prevalence of schizophrenia, we examined a research dataset of 221 individuals with DSM-IV schizophrenia to study the prevalence and co-occurrence of various criterion A symptoms. Although bizarre delusions and/or Schneiderian hallucinations were present in 124 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.

DSM-5 Status of Psychotic Disorders: 1 Year Prepublication

DSM-5 Status of Psychotic Disorders: 1 Year Prepublication

At the edge of the bipolar spectrum: primacy of affective over psychotic symptoms or vice versa?

Strakowski et al should be congratulated upon this very comprehensive and well balanced essay of pros and cons about a broadening of diagnostic criteria for bipolar disorder. They very well point out potential benefits for otherwise insufficiently treated patients, but also that, given our lack of a full understanding of the biological basis, such a broadening might be premature in treatment research. So far, we still have a long way to go if we want to define groups of mental disorder by shared genetic underpinnings or biological markers, and thus we rely on phenomenology and derived categorizations when we conduct treatment research. And, in my opinion, these categorizations still need to be strict, reliable and largely unaltered over time, until we find better (and tested) definitions. With rising placebo response rates in randomized clinical trials and subsequent narrowing of drug-placebo differences, it becomes increasingly difficult to identify specific benefits of a drug, e.g. against core manic symptoms. Allowing, for example, patients into trials whose “mania” manifests itself just by agitation and irritability may give rise to large numbers of subjects with maniform features which are in fact related to substance use or personality. As a consequence, we would not expect a drug to differentiate from placebo unless it probably has a strong sedative component, but would we consider this as a true and specific antimanic agent? Strakowski et al also make it quite clear that bipolar disorder has a huge overlap of symptoms and features with other major mental disorders. Besides the grey zone that does (or does not) divide bipolar disorder from other affective, or more generalized, emotional states, a fascinating question is the relationship of bipolar disorder and schizophrenia. As Strakowski et al point out, a future trend might be, “based on risk factor and clinical history considerations, that bipolar disorder may be better classified with schizophrenia in a psychotic cluster than with unipolar depression in an emotional cluster”. But, how valid is the clinical observation of psychotic symptoms to serve as a basis of categorical clustering, and are they not more likely subsidiary to emotional processes? Looking back, for many decades bipolar disorder has been an orphan of psychiatry, whereas schizophrenia was considered the most important challenge. At the beginning of last century, it was still well accepted that all psychotic symptoms arise from mood dysregulation 1. In the post-Kraepelinian area, diagnostic habits continuously shifted towards schizophrenia, putting much more weight on psychotic than affective symptoms. Kraepelin’s successor Schneider reports that the ratio of patients diagnosed with schizophrenia vs. cyclothymia at the Munich hospital between 1934 and 1936 was greater than 5:1, while in the same department 35 years earlier Kraepelin had stated that 10-15% of hospital admissions were suffering from manic-depressive illness 2. Whereas it was hard to neglect the obvious existence of (unipolar) depression, bipolar disorder was almost cut down to clinical (and research) insignificance. This tendency of overdiagnosing schizophrenia at the expense of bipolar disorder continued well into the 1970s 3. Now the pendulum seems to swing back the other way. Lake and Hurwitz 4 questioned the validity of the diagnosis of schizophrenia, postulating that a single disease, a mood disorder with a broad spectrum of severity, accounts for functional psychoses. Compared to schizophrenia, and despite all limitations, diagnostic criteria for bipolar disorder may still have a better validity 5. Schneiderian first-rank symptoms (FRS) are not exclusive to schizophrenia; they also occur in some bipolar patients 6, although they may be 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 those who do not have these symptoms. However, the same is true also for bipolar patients exhibiting FRS 7. But what really matters in end is how we can improve our bipolar patient’s life. Strakowski et al make it clear that the categorical vs. spectrum discussion is not a academic one in an ivory tower, but has clinical significance: “People with bipolar disorder are identified from the general population in order to assign therapies that will alleviate their suffering (i.e., symptoms), ideally through evidence-based treatment guidelines developed from past studies of similar individuals”.

PL12 Defining Schizophrenia: From Kraepelin to ICD-11 and DSM-5

Psychotic symptoms are a central element in the diagnosis of schizophrenia, although their precise definition has varied through the multiple iterations of DSM and the ICD. Schneiderian first-rank symptoms (FRS) have received a particularly prominent position in the diagnostic criteria of schizophrenia since ICD-9 and DSM-III. In the current iteration of DSM (DSM-IV-TR), whereas two characteristic symptoms are ordinarily required to meet criterion A, only a single symptom is necessary if the psychotic symptom happens to be a FRS, notably a bizarre delusion or auditory hallucination of a running commentary or ‘conversing voices’. Because of limited data in support of the special treatment of FRS, DSM-5 has made changes to criterion A, requiring that at least two psychotic symptoms be present in all cases with at least one of these symptoms being a delusion, hallucination, or disorganized speech. To assess the impact of these changes on the prevalence of schizophrenia, we examined a research dataset of 221 individuals with DSM-IV schizophrenia to study the prevalence and co-occurrence of various criterion A symptoms. Although bizarre delusions and/or Schneiderian hallucinations were present in 124 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.