FIRST RANK SYMPTOMS OF SCHIZOPHRENIA

C/P DR.ARUNA PRESENTER DR.DAVIN 27/09/2011

INTRODUCTION
Experiences 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

DEFINITION
A group of delusional and hallucinatory experiences that, in Schneiders experience reliably distinguished schizophrenic from affective psychosis. Schneider claimed that in absence of somatic (organic) illness, first rank symptoms are pathognomonic of schizophrenia.

CONCEPT EVOLUTION
EMIL KRAEPELIN (1856 to 1926) 2 major patterns of primary insanity(1893)

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 EVOLUTION
EUGEN BLEULER (1857 to 1959) Schizophrenia 1911- splitting of psychic functions Primary and secondary symptoms Primary 4 As

Abnormal associations Autistic behaviour and thinking Abnormal affect Ambivalence

CONCEPT EVOLUTION
Hallmark - loss of association between thought processes and thought, emotion, and behavior. Secondary manifestations

Hallucinations Delusions Social withdrawal Diminished drive

Continuum with normal behavior Contoversial concept for decades

CONCEPT EVOLUTION
KURT

SCHNEIDER(1887 to 1967):

German psychiatrist Translation of Kurt Schneider's Clinical Psychopathology (CP) 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 EVOLUTION
Based 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 FRS
1)

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.

2)

3)

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 (diffusion of thought)

FIRST RANK SYMPTOM PRESENT STATE EXAMINATION EQUIVALENT PASSIVITY EXPERIENCES : DELUSION OF Delusions of control CONTROL 8.Passivity of Delusions of control affect(made feelings) 9.Passivity of impulse Delusions of control (made drives) 10.Passivity of volition (made volitional acts) Delusions of alien 11.Somatic passivity penetration (influence playing on the

Type of Primary delusion(PSE) Perception that has a unique and idiosyncratic meaning for a person, which leads to an immediate delusional interpretation. New meaning cannot be understood as arising from prevailing affective state or previous attitudes [Perceived object subjects perception of the object] [new significance of this perception]

1.DELUSIONAL PERCEPTION

1.DELUSIONAL PERCEPTION

Eg: On seeing a salt shaker being pushed towards him , one patient suddenly believed it was a sign that the Pope was calling him to Rome

2.AUDIBLE THOUGHTS
Gedankenlautwerden Bumke (1948) , Leonhard(1948) Fish( 1962) Echo de pensees French Auditory hallucinations of a person's voice being spoken aloud Patient experiences the voices & almost immediately has the experience that the content of hallucination is his thought ( Conrad)

2.AUDIBLE THOUGHTS
Patient may hear people- Repeating his thoughts out loud after he has thought them Answering his thoughts Talking about them having said them audibly Saying aloud what he is about to think (his thoughts repeat the voices) Thought echo Often very upset gross intrusion of

2.AUDIBLE THOUGHTS

Eg. 35 year old painter heard a quiet voice, which could be heard equally well in both ears. The voice would say I cant stand that man, the way he holds the brush he looks like a poof . He immediately experienced whatever the voice was saying as his own thoughts, with exclusion of all other thoughts

3.VOICES ARGUING/DISCUSSING
Auditory hallucinations of two or more voices arguing or discussing, usually about the person experiencing the hallucination Patient usually features as 3rd person in content of the voices Unlikely to be volunteered spontaneously

3.VOICES ARGUING/DISCUSSING

Eg. 24 year old male patient reported hearing voices coming from nurses office . One voice , deep in pitch , roughly spoken , repeatedly said, G.T. is a bloody paradox, and another in higher pitch said. He is that,he should be locked up.

4.VOICES COMMENTING ON PATIENTS ACTIONS

Auditory hallucinations commenting on a person's behaviours Time sequence just before , during or after patients activities Experienced as perceptions which are coming from outside the self Inferred through patients complaints against his voices

4.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 WITHDRAWAL
Sensation 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 (alien).

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 INSERTION
Thoughts 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
Sense that a person's thoughts are experienced as real phenomena by others Thoughts are made audible, or may be experienced by others through telepathy Content of the patients mind is no longer private How-depends on background culture,predominant interests Usually a secondary delusional explanation

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

Feelings that are not a person's own are imposed on that person by an external agent Pt believes he has been MADE to feel it by an external source Eg. : A 23 yr old female patient reported, I cry, tears roll down my cheeks and I look unhappy, but inside I have a cold anger because they are using me in this way, and it is not me who is unhappy, but they are projecting unhappiness onto my brain.

9.PASSIVITY OF IMPULSE
An impulse for action is imposed on a person by some external agent Usually ovecomes the patient to which he almost invariably gives way Impuse may be experienced without subject carrying out the act If carried out, action is admitted to be patients own , not the impulse Differentiates from compulsive phenomenon of OCD

9.PASSIVITY OF IMPULSE

Eg. : A 26 yr old engineer emptied the contents of a urine bottle over the ward dinner trolley. He said, The sudden impulse came over me and I must do it. It was not my feeling, it came into me from the X-ray dept, that was why I was sent there for implants yesterday. It was nothing to do with me,they wanted it done.So I picked up the bottle and poured it in.It seemed all I could do.

10.PASSIVITY OF VOLITION
Person's actions are from and are controlled by an external agent The person is a passive participant in the action The movements are initiated and directed through out by the controlling influence , and the patient feels he is an automation, the passive observer of his own actions.

10.PASSIVITY OF VOLITION

Eg. A 29 yr old shorthand typist described her actions as follows, When I reach my hand for the comb, it is my hand and arm which move and my fingers pick up the pen, but I dont control them I sit there watching them move and they are quite independent, what they do is nothing to do with me I am just a puppet who is manipulated by cosmic strings . When the strings are pulled, my body moves and I cant prevent it.

11.SOMATIC PASSIVITY
Tactile or visceral hallucinations that are imposed by some external agent. Can be combinations of different somatic hallucinations Kinaesthetic,haptic,thermic. Delusional belief-Body influenced from outside the self. May also occur in association with a normal percept.

11.SOMATIC PASSIVITY

Eg. A 38 yr old man had jumped from a bedroom window , injuring his right knee which was very painful . He described his physical experience as, The sun-rays are directed by U.S. army satellites in an intense beam which I can feel entering the centre of my knee and then radiating outwards causing the pain.

ASSESSMENT PROBLEMS
Requires considerable clinical experience Must know the First Rank Symptoms first. Must know how this person from this social and racial background is likely to describe any particular first rank symptom. Must ask appropriate direct questions skillfully

CLINICAL IMPLICATIONS
FRS incorporated in important diagnostic sysytems as criteria for schizophrenia. ICD 9

the most intimate thoughts, feelings and acts are often felt to be known to or shared by others thought broadcast, thought withdrawal, thought insertion and made acts hallucinations esp. of hearing may comment on the pt. or address him voices commenting and voices discussing

CLINICAL IMPLICATIONS
ICD 10 F20 Criteria (a) ,(b) and (c) correspond:a) thought echo, thought insertion or withdrawal, and thought broadcasting b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception

CLINICAL IMPLICATIONS
c)

hallucinatory voices giving a running commentary on the patients behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body If present concurrently with affective symptoms (manic or depressive),diagnosis of schizoaffective disorder(F25.-) is made.

CLINICAL IMPLICATIONS
DSM IV TR (295.-) Criterion A - 2 or more of the following,each present for a significant portion of time during 1 month period(/less if successfully treated), with 6 months of impairment, provided mood disorder, substance use and general medical conditions are excluded: 1) Delusions 2) Hallucinations 3) Disorganized speech 4) Grossly disorganized/catatonic behavior 5) Negative symptoms

CLINICAL IMPLICATIONS
Note Only 1 Criterion A symptom is required if delusions are bizarre or hallucinations consist of

a voice keeping up a running commentary on the persons behavior or thoughts, or 2 or more voices conversing with each other

CLINICAL IMPLICATIONS

Also used in other diagnostic criteria Research diagnostic criteria(RDS) Feighner diagnostic criteria New Haven schizophrenia Index St. Louis criteria Present State Examination(Wing et al) in IPSS Study

CLINICAL IMPLICATIONS
PRESENT DAY STATUS Presence or absence of FRS does not alter the specificity in the diagnosis of schizophrenia Characteristic and discriminatory Not pathognomonic No diagnostic significance Does not indicate severity of schizophrenia No prognostic significance

FRS PREVALENCE
AUTHOR (YEAR OF STUDY) 1.Mellor (1970) 2.Guraji.O and Bamgbeye (1987) 3. Nedetei and Singh (1983) 4.Zarruk(1978)
5.Chandrasenna and Rodrego(1979) 6.Radhakrishnen et al(1983) 7.Koehler(1977)

COUNTRY
Britain Nigeria Kenya

PREVALENCE
72% 73% 73%

Saudi Arabia Sri Lanka

India India

58%
25% 35% 35%

8.Ahmad & Nadeem

Pakistan

52.5%

AUTHOR (YEAR OF STUDY)

COUNTRY

PREVALENCE 67% 70% 26.7% 24% 24% 30% 79%

9.Malik et al(1990) Pakistan 10.Chopra and Gunter(1987) 11.Salleh(1992) 12.Marshall & Silverstein(1978) 13.Silverstein & Harrow(1978) 14.Carpenter & Strauss(1974) 15.Carpenter & Strauss(1974) Australia Malay USA Britain USSR Taiwan

THEORIES FOR 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 Genetics: initial studies (low n) suggested heritability of zero, later authors (McGuffin et al., 2002) found 26.5% concordance in MZ twins, 0.3% in DZ twins. What exactly is inherited? (Crow, 1996)

THEORIES FOR FRS

Tim Crow (1998) schizophrenia as the price paid for the evolution of language? Defects in interhemispheric connectivity Inadequate damping of non-dominant hemisphere activity thought alienation phenomena Abnormal feedback from dominant frontal lobe to Wernickes area voices commenting?

THEORIES FOR FRS

Neuropsychological: currently has the most evidence Mainly based on the work of Christopher Frith (1992) Divided the symptoms of schizophrenia into three broad groups 1. disorders of willed action 2. disorders of self-monitoring 3. disorders in monitoring the intentions of others.

THEORIES FOR FRS

According to this theory, deficits in selfmonitoring lead to a loss of the sense of

* agency (leading to made phenomena)

* ownership (leading to thought alienation phenomena)

IMAGING STUDIES

Spence et al. (1997) passivity :hyperactivation of right inferior parietal lobule and cingulate gyrus (replicated in an fMRI study in 2005) Andreasen et al. (2002) FRS score correlated with increased blood flow in the right parietal area and reduced flow in the left posterior cingulate and lingual gyri

IMAGING STUDIES

Dysfunction of brain areas involved in space and body representation implicated

Correlate with the cognitive model

May involve prefrontal-parietal and prefrontal-temporal networks

IMAGING RESEARCH
Vijay Danivas et al(2009) NIMHANS 3 Tesla MRI Study Results : FRS + patients showed significant volume deficit in right Inferior Parietal Lobule in comparison with healthy controls Right IPL volume deficit in FRS+patients adds further support to the Frith's model of FRS in schizophrenia.

RESEARCH IN FRS
C.S.Mellor(1970) Manchester 1st detailed pioneering study Clearly defined characteristics with examples of the 11 FRS Interviewed pts directly 72% - Diagnosis of schizophrenia by FRS Remaining 28%-no 1st hand FRS symptoms

RESEARCH IN FRS
Carpenter & Strauss(1974)-FRS in 51% pts Koehler(1979)-FRS in 33% pts

Used in very narrow and very wide sense Distinguished thought alienation and influence

John C . OGrady (1990)

73% - schizophrenics,14%- affective disorders

VARIATIONS IN FRS OCCURRENCE

Mellor (1970)
Thought broadcast commonest (21.4%) > thought echo, 3rd person AH, thought insertion and passivity. Made impulse least common (2.9%) correlations b/w 3rd PAH commenting and arguing, and between thought insertion and withdrawal

Radhakrishnan et al. (1983) - 3rd person AH, thought broadcast and passivity commonest Coffey et al. (1993) somatic passivity(36.8%) Peralta and Cuesta (1999)
Thought broadcast (43.8%) > 3rd PAH,

ETHNIC,CULTURAL VARIATIONS

IPSS - FRS were found across all cultures and were most reliable in diagnosis Chandrasena et al. (1983) :
FRS were less reliable in immigrants to the West subcultural beliefs could cause confusion voices commenting - less common in ethnic minorities.

Coffey et al. (1993) - FRS more common in UK-born patients (73.3%) and less in Greek-born patients in Australia (40.8%)

PREVALENCE IN SCHIZOPHRENIA

Mellor (1970) - 75% prevalence of FRS in schizophrenia Figures vary from 35.2% (Radhakrishan et al., 1983) to 70% (Tanenberg-Karant et al., 1995) The largest study gave an prevalence of 57% (Carpenter et al., 1975), replicated by recent studies (60.3%, Tandon et al., 1987; 68.5%, Peralta and Cuesta, 1999) Lower in prolonged illness (37.5%, 13year follow-up, Mortensen et al., 1989)

PREVALENCE IN AFFECTIVE ILLNESS

6 - 23% found in mania (Taylor and Abrams, 1973; Wing and Nixon, 1975; Brockington et al., 1978) Initially contradicted (Tandon and Greden, 1987) Later studies replicated this:
FRS in 43.4% of patients with affective psychosis (Peralta and Cuesta, 1999) FRS in 29% of patients with mania with psychotic symptoms , 18% of patients with psychotic depression (Tanenberg-Karant et al., 1995).

PREVALENCE IN NONSCHIZOPHRENIC ILLNESS

Abrams & Taylor (1981) no difference on any variables between manic patients with or without FRS Tanenberg-Karant et al. (1995) greater interval between onset and hospitalization in manic patients with FRS, and higher SAPS scores.

INDIAN RESEARCH
Raguram & Kapoor(1985): NIMHANS 53.3%-schizophrenia 33.3%- mood disorders 23.3%- reactive psychosis Strong co relation between the occurrence of FRS in the pt. population and those who had a family history of schizophrenia

INDIAN RESEARCH
Radhakrishnan et al (1983)(Vellore): 35.2% - schizophrenia 3%- affective psychosis 21%- hysterical psychosis 15%- mania Mohan Raj & Raguram(1995): 74% diagnosed solely on the presence of FRS Voices arguing (85%) commonest 66.6% - both FRS and non-FRS

INDIAN RESEARCH
Dr. Rajesh Raman & Dr. John Mathai (1998): FMIMER Schizophrenia- 76.6% Mood disorder- 56.6% Substance use disorder-60% Common FRS in all three groups were voices arguing and voices commenting

CRITICISM
1.

Unreliability of assessment:
Definitions?;Inter-rater reliability?

2.

Flaws in Schneiders original work:

No statistical data by Schneider

3.

Diverting attention from other core symptoms:

Negative symptoms(Crichton 1996) Affective flattening,social unease (Mortensen et al., 1989) stable predictors of prognosis.

CONCLUSION
Special value for diagnosis of schizophrenia in most of the international diagnostic criteria Characteristic and discriminatory but not diagnostic or pathognomonic No significance for prognosis and do not indicate severity Extremely useful in formulating and testing pathophysiological theories Despite controversies, still important

Mellor in 1982 said those who find first-rank symptoms of clinical value need not yet abandon them

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