First Rank Symptoms For Schizophrenia
It is important for patients with psychosis to be correctly diagnosed as soon as possible. The earlier schizophrenia is diagnosed the better the treatment outcome. However, other diseases sometimes have similar psychotic symptoms as schizophrenia, for example bipolar disorder. This review looks at how accurate First Rank Symptoms are at diagnosing schizophrenia. FRS are symptoms that people with psychosis may experience, for example hallucinations, hearing voices and thinking that other people can hear their thoughts. We found 21 studies, with 6253 participants, that looked at how good FRS are at diagnosing schizophrenia when compared to a diagnosis made by a psychiatrist. These studies showed that for people who actually have schizophrenia, FRS would only correctly diagnose just over half of them as schizophrenic. For people who do not have schizophrenia, almost 20% would be incorrectly diagnosed with schizophrenia. Therefore, if a person is experiencing a FRS, schizophrenia is a possible diagnosis, but there is also a chance that it is another mental health disorder. We do not recommend that FRS alone can be used to diagnose schizophrenia. However, FRS could be useful to triage patients who need to be assessed by a psychiatrist.
We conducted searches in MEDLINE, EMBASE, and PsycInfo using OvidSP in April, June, July 2011 and December 2012. We also searched MEDION in December 2013.
Family History And Genetics
Patients are more likely to develop schizophrenia if there is a family history of the illness. For example, the monozygotic twin of a person with schizophrenia has a 50% chance of developing schizophrenia, while a dizygotic twin has a 15% chance.
An adopted child still has a 12% chance of developing schizophrenia if their birth parent was a sufferer.4 The chance is 48% for a child where both parents are affected.6
There is also some increased risk with advanced paternal age, where the father was aged over 55.7
Ological Quality Of Included Studies
See also risk of bias and applicability concerns in , , and for an overview of the assessment of risk of bias and applicability concerns for each of the 21 studies included in the review.
Risk of bias and applicability concerns graph: review authors’ judgements about each domain presented as percentages across included studies
1. Patient Selection
Twelve studies used a consecutive or random sample of patients; one study selected participants from a previous study and in the remainder the method of selection of participants was unclear. Twelve studies did not use a casecontrol design and nine studies either used a casecontrol design or it was unclear whether this was the design. Eight studies avoided inappropriate exclusions and it was unclear how exclusions were managed in the remaining studies. As a result, 17 studies were considered as having an unclear risk of bias and four were low risk. In terms of applicability, we judged 10 included studies to be of low concern, four to be of high concern and the remaining to be of unclear applicability concerns.
2. Index test
3. Reference standard
4. Flow and timing
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Disturbance Of Intentionality: A Phenomenological Study Of Body
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Affiliations Section Phenomenological Psychopathology and Psychotherapy, Department of General Psychiatry, Center of Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany, Structural Neuroimaging Group, Department of General Psychiatry, Center of Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
- Thiemo Breyer ,
Contributed equally to this work with: Dusan Hirjak, Thiemo Breyer
Affiliation Section Phenomenological Psychopathology and Psychotherapy, Department of General Psychiatry, Center of Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
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Affiliation Structural Neuroimaging Group, Department of General Psychiatry, Center of Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
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Affiliation Section Phenomenological Psychopathology and Psychotherapy, Department of General Psychiatry, Center of Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
Putting It All Together: The Two Faces Of Frs
On the one hand, FRS represent profoundly anomalous experiences that can be properly identified and evaluated only by using a phenomenological approach that focuses on their experiential dimension rather than concentrating exclusively on their propositional aspects . In this perspective, FRS are not considered as ontologically independent atomic entities that can be known from a third-person perspective, but are seen as strange and bizarre experiences involving a profound change in the structure of consciousness that can only be adequately understood from a first-person perspective focusing on experience and subjectivity and from a second-person perspective grounded in notions of engagement, resonance, and responsiveness . Concerning the latter, it should be highlighted that Schneider himself, predating the introduction of the concept of Praecox-Gefühl by Rümke , emphasised the importance of the doctor-patient relationship for making the diagnosis of schizophrenia:
This is in workaday psychiatry usually the method of diagnosis. It concerns what is referred to as rapport or contact. Here the relevant fact is that schizophrenics seem to occupy another, alien space that one cannot simply relate to them as to a healthy individual or to a psychopath or to a cyclothymic depressive. It is difficult to express this other than in images and it is impossible to articulate this method as a concept .
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Voices Commenting On Patients Actions
Eg. A 41 year old lady heard a voice coming from house across the road which went on incessantly in a flat monotone,describing everything she was doing,with critical comments, She is peeling potatoes, got hold of the peeler, she does not want that potato ,she is putting it back, because she has a dirty mind , now she is washing them
5.THOUGHT WITHDRAWALSensation of thoughts being actively removed from a person’s mind Patient has feeling of loss as a result As thoughts cease, pt. simultaneously experiences them being withdrawn by some external force against his will .
5.THOUGHT WITHDRAWAL
Eg. 22 year old woman said , I am thinking about my mother & suddenly my thoughts are sucked out of my mind by a vacuum extractor and there is nothing in my mind , it is empty
6.THOUGHT INSERTIONThoughts inserted into a person’s mind by some external agent Thoughts are unfamiliar , results in self image disturbance and affects boundary in between whats self and whats not self.
6.THOUGHT INSERTION
Eg. A 29 yrs old lady said, I look out of the window and I think the garden looks nice and grass looks cool, but the thoughts of Andrews comes into my mind. There are no other thoughts there,only his. He treats my mind like a screen.
7.THOUGHT BROADCASTING
Eg. : A 21 yr old student said, As I think ,my thoughts leave my head on a type of mental ticker tape. Everyone around has only to pass the tape through their mind and they know my thoughts.
8.PASSIVITY OF AFFECT
9.PASSIVITY OF IMPULSE
COUNTRY
Likelihood Ratios As An Alternative Measure Of Diagnostic Accuracy For Frs
While the properties of a diagnostic test are often described using sensitivity and specificity, they are not the only statistics for summarising diagnostic accuracy and do not answer all the questions a clinician is interested in. Importantly, they do not give hints about how a particular test result predicts the risk of the disease of interest. This is an important issue, as the decision to obtain a given test is usually made on the assumption that its results will significantly change the pre-test probability that a specific disease is present, that is, the probability of disease that exists before the testing is done . If a diagnostic test did not substantially increase the clinicians confidence in making or excluding a diagnosis, it would be useless.
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Results Of The Search
We screened 32,755 potentially relevant references for inclusion. We excluded 32,127 references through title and abstract screening. An initial first round full text assessment of the remaining 628 references resulted in 507 references being excluded mainly because they were not diagnostic studies or FRSs were not being assessed. Following a second round of full text screening, a further 99 references were excluded . We included 21 studies , and an additional study in German is awaiting assessment. See for an overview of the selection process.
Included studies
1. Study Design
Seventeen studies were prospective and three studies were retrospective ; included both a prospective sample and a retrospective sample of participants. Twelve studies consecutively enrolled participants, three randomly selected participants ; randomly selected participants from a previous study; also selected participants from a previous study, but did not report whether this was random;and four studies did not report how participants were enrolled .
2. Setting
Sixteen studies were undertaken in inpatient settings, two in both inpatient and outpatient departments , one in an outpatient setting ; two studies did not report on setting .
Studies were conducted from 1974 to 2011. Only four studies were conducted after 2000 . Three studies were conducted in the 1970’s , eight in the 1980’s and six in the 1990’s .
3. Participants
4. Index test
5. Reference standard
6. Target condition
Excluded studies
Manic Depressive Psychosis Dementia Praecox
Based on long term prognosis and course of illness Dementia praecox – loss of the inner unity of the activities of intellect, emotion, and volition. Deteriorating ,irreversible
CONCEPT EVOLUTIONEUGEN BLEULER Schizophrenia 1911- splitting of psychic functions Primary and secondary symptoms Primary 4 As
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INTRODUCTIONExperiences whereby thoughts and actions are perceived to be under the control or influence of an external agent OR Loss of clear boundaries between the sense of self and others Considered a core of schizophrenia psychopathology
DEFINITIONA group of delusional and hallucinatory experiences that, in Schneiders experience reliably distinguished schizophrenic from affective psychosis. Schneider claimed that in absence of somatic illness, first rank symptoms are pathognomonic of schizophrenia.
CONCEPT EVOLUTIONEMIL KRAEPELIN 2 major patterns of primary insanity
Intentionality And The Sense Of Agency
Husserl further describes the passive synthesis of gestalt formation based on the fact that all directed bodily experiences and movements are constituted as consciously performed intentional acts . These are dynamic self-organizing processes connected within the framework of activity and founded in a passive synthesis: all activity essentially presupposes a foundation of passivity as well as an objectlike formation that is already pre-constituted in it. . As Husserl further writes: the whole of conscious life is unified synthetically . Consequently, the passive synthesis of gestalt formation in bodily acts is a dynamic constitution of multiple aspects of mind and body unified in a meaningful way. For example, if I want to pick up a cup, the decision and intentional effort to do so is conjoined with the kinaesthetic experience of moving my arm and hand, and with the visual perception of cup, arm and hand. At the same time, the perception, decision and intentional effort guarantee the directed bodily movement to be experienced as a coherent gestalt .
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Strengths And Weaknesses Of The Review
The search strategy that we used was very wide and meant that we had over 35,000 references to screen. On the one hand, this meant that we feel certain that all possible studies were included, but on the other hand, the sheer volume of screening may have meant that some relevant studies may have been erroneously excluded. We have one article in German that is yet to be translated. There was some disagreement in selecting papers, as most of the eventually included studies were not specifically designed as diagnostic test accuracy studies, or included all admissions to the psychiatric ward as opposed to those with psychotic symptoms only, and therefore most of the final decisions to include studies took some discussion between review authors. We also found that the completion of QUADAS2 also involved discussion between review authors, mostly because the studies were again not designed as diagnostic test accuracy studies and many of the signalling questions were rated unclear due to lack of reporting of relevant details, which also made it difficult to judge the risk of bias of the QUADAS2 domains.
Previous research
We know of no other reviews evaluating the diagnostic accuracy of FRSs.
The Conceptualisation Of Frs As A Diagnostic Test
On the one hand, the formal examination by meta-analysis of the operating characteristics of FRS as a diagnostic test deserves much credit both for its methodological rigor and for having sparked renewed interest in a concept, such as FRS, of enormous psychopathological importance. On the other hand, it should be noted that the meta-analytic estimation of the diagnostic accuracy of FRS puts them in a particular conceptual framework concerning their significance, nature, and assessment. Such an approach treats FRS strictly as a diagnostic test whose performance can be conventionally measured in terms of sensitivity and specificity, basically a sort of screening test as they have been described as a simple, quick clinical indicator , though not useful to detect schizophrenia due to their low sensitivity .
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Continuum With Normal Behavior Contoversial Concept For Decades
CONCEPT EVOLUTION KURT
SCHNEIDER:
German psychiatrist Translation of Kurt Schneider’s Clinical Psychopathology 1939-Identified a group of symptoms most characteristic of the illness FRS Changes in affect,volition,motor activity not included not comprehensive list Based on own reading and clinical experience Not related to any theoretical concepts of psychological mechanism
CONCEPT EVOLUTIONBased on his study of the cohort of over 3000 patients admitted to the Psychiatric Research Institute in Munich Used term FRS in place of primary Diagnosis appropriate if patient experienced just one first-rank symptom Second rank symptoms not specific
Paranoia Affective extremes Apathy or absence of emotions Any other hallucinatory experience
CHARACTERISTICS OF A FRS1)
Must occur with reasonable frequency in schizophrenia Must generally not occur in conditions other than schizophrenia Must not be too difficult to decide if the symptom is or is not present.
FIRST RANK SYMPTOM PRESENT STATE EXAMINATION EQUIVALENT DELUSION 1.Delusional Percept Primary Delusion
AUDITORY HALLUCINATIONS 2.Audible thoughts 3.Voices arguing or discussing 4.Voices commenting on the patients action
Thought echo or commentary Voices about the patient Voices about the patient
FIRST RANK SYMPTOM PRESENT STATE EXAMINATION EQUIVALENT THOUGHT DISORDER :PASSIVITY OF THOUGHT Thought block or withdrawal 5.Thought withdrawal Thought insertion 6.Thought insertion Thought broadcast or 7.Thought broadcasting thought sharing
Specificity And Sensitivity Of The Studies
Early studies were quick to question the specificity of first-rank symptoms when comparing a clinical diagnosis of schizophrenia with that of illnesses such as bipolar disorder . First-rank symptoms are also very common in individuals at high risk of psychosis, but they may or may not predict conversion to a full episode . Thus, it is relevant to consider that the application of a test or tool is dependent not just on the main diagnosis in question but also on the comparator condition. For example, schizophrenia v. aged-matched healthy controls might be relevant to a community field survey. Schizophrenia v. other non-psychotic mental disorder could be useful in primary care or psychiatric practice. Ideally, a test should also be evaluated in all of these situations. Unfortunately, a significant limitation of Soares-Weiser et als review is that the authors excluded casecontrol studies that involved healthy controls.
The prevalence of first-rank symptoms in schizophrenia is one indicator of the value of these symptoms as a diagnostic test for the disorder, because such a test should usually be positive in those with the condition. Generally, the prevalence of first-rank symptoms in schizophrenia is reported to range between 25 and 88%, and in this review it was 57%.
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First Rank Symptoms And Neurological Soft Signs In Schizophrenia
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Specifically; auditory hallucinations, thought broadcast, thought insertion, thought withdrawal, and delusional perception. Relative to other symptoms of psychosis, the presence of a single FRS is considered sufficient to reach a diagnosis of schizophrenia, hence the special treatment traditionally afforded to FRS within diagnostic manuals Shinn et al. In lieu of more in-depth assessments or highly-trained clinicians, FRS may serve as a quick, efficient diagnostic tool. On the other hand, there is much empirical uncertainty regarding the diagnostic specificity and sensitivity of FRS despite its ubiquity Shinn et al.
Psychiatry Journal
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Absence Of A Real Gold Standard
An even more serious issue is that there is no real reference standard or gold standard test against which FRS can be compared. A gold standard test is a diagnostic test that is usually regarded as definitive. In principle, it should have 100% sensitivity and 100% specificity and thus would never make a classification error. In many areas of medicine, however, that may not be the case, and the gold standard is simply regarded as the best available test . As far as schizophrenia is concerned, the situation is even worse because the gold standard is akin to a moving target, given the ever-changing conceptualisation of schizophrenia and its many competing diagnostic definitions. Therefore, bias through misclassification of the true disease status due to an imperfect gold standard almost by definition affects studies of the diagnostic accuracy of FRS to some degree. Given the lack of validating criteria, any operational definition of schizophrenia and, hence, any gold standard is to some extent arbitrary . Indeed, Schneider himself had alluded to this issue: Rarely there are truly intermediary cases which could be assigned with equal justification to either type One should really no longer argue about such cases: this is a cyclothymia, no, this is a schizophrenia. One can argue like this about an uncertain general paralysis of the insane versus a cerebral tumour. Here the is can be verified .
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