FIRST RANK SYMPTOMS IN THE DIAGNOSIS OF SCHIZOPHRENIA

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1 ORIGINAL ARTICLE FIRST RANK SYMPTOMS IN THE DIAGNOSIS OF SCHIZOPHRENIA Mohammad Idrees, Imran Khan, Muhammad Irfan, Robina Sarwar Department of Psychiatry, Khyber Teaching Hospital & Lady Reading Hospital Peshawar - Pakistan ABSTRACT Objectives: To determine the usefulness of Schneider's first rank symptoms of schizophrenia. Methodology: Patients suffering from schizophrenia, admitted to the Psychiatry Ward Khyber Teaching Hospital, Peshawar during the year 2009 were selected by non probability purposive sampling. It was a descriptive study and the diagnosis was made according to DSM-IV criteria. Patients were interviewed by using a semi structured questionnaire based on Present State Examination and first rank symptoms were assessed. Results: Out of 0 patients suffering from schizophrenia, there were 5 males and 42 females. Thirty four (34%) (22 male & 12 females) reported having one or more first rank symptoms while Sixty six (66%) patients although diagnosed with schizophrenia on DSM IV criteria did not show first rank symptoms. The most often found individual first rank symptoms in these 34 patients were voices commenting (n=14, %), made impulses (n=12, %), and voices arguing (n=12, %). None reported delusional perception. Conclusions: The reliability of the presence of first rank symptoms in Schizophrenia should be taken cautiously as only one third of the patients diagnosed with schizophrenia as per the DSM IV criteria showed any first rank symptom. Key words: Schizophrenia, First Rank Symptoms (FRS), Present State Examination (PSE). INTRODUCTION diagnostic value in both major diagnostic systems Schizophrenia is a major mental illness 4, 5 i.e. ICD- & DSM-IV, especially in the former. with prevalence of about 1% equally found in This diagnostic status is under continuous 1 different cultures and both genders. Since its criticism for several phenomenological and introduction by Kraeplin & Eugen Bleuler, no methodological reasons leading to recommenconclusive model could be agreed upon regarding dations that their status be de-emphasized in next its aetiology, diagnosis or treatment. editions of diagnostic systems till their value is In 1959 Kurt Schneider, a German clarified. Besides the facts that many patients with 6 Psychiatrist introduced certain symptoms which he schizophrenia do not exhibit FRS and that FRS 7 claimed to be diagnostic of schizophrenia, called are found in several non-schizophrenic entities, 2 as first-rank symptoms (FRS). He proposed that in methodology adopted by Schneider has never absence of organic brain disease, presence of any satisfied a large majority of critics. All these of these FRS is sufficient to make the diagnosis of factors have raised several yet un-answered schizophrenia. Contrary to his claim however, questions regarding the usefulness of FRS in there is a parallel on-going debate about their making a confident diagnosis of schizophrenia. It diagnostic value as they may be encountered in has been increasingly argued and agreed that FRS 3 several other non-schizophrenic conditions also. neither characteristic nor pathognomonic of FRS are given enormous significance and schizophrenia. 323

2 With this background, this study was according to DSM-IV criteria. Patients were planned to determine the usefulness of Schneider's i n t e r v i e w e d b y u s i n g a s e m i s t r u c t u r e d FRS of schizophrenia. questionnaire based on Present State Examination METHODOLOGY (PSE). The FRS were elicited according to Mellor's definitions (Table 1). This descriptive study was conducted on the patients suffering from schizophrenia admitted to the Psychiatry Ward Khyber Teaching Hospital, Peshawar during the year 2009 were selected by convenient sampling. Diagnosis was made RESULTS Out of 0 patients suffering from schizophrenia, there were 5 males and 42 females (Figure 1). The mean age of the sample was Table 1: First Rank Symptoms according to Mellor s definitions (1970) Figure 1: Gender Distribution of the sample (n=0) Males First Rank Symptoms 1. Audible thoughts 2. Voices arguing 3. Voice commenting 4. Somatic passivity 5. Thought withdrawal 6. Thought insertion 7. Thought broad cost. Made affect 9. Made impulse. Made volition 11. Delusional percept Females Figure 2: Presence of First Rank Symptoms (n=0) Without FRS With FRS With FRS Without FRS 324

3 Figure 3: Individual First Rank Symptoms (n=34) Delusional percept 0 Made volition Made impulse 12 Made affect Thought broadcast Thought insertion Thought withdrawal 6 Somatic passivity Voice commenting 14 Voices arguing 12 Audible thoughts Note: Maximum FRS in an individual patient were five years. The mean age for male patients schizophrenia. FRS, it has now been advocated, w as years and for females, may be found in a wide variety of mental illnesses, years. Out of 0 patients, 34 (22 ranging from personality disorder through drug male & 12 females) reported having one or more w i t h d r a w a l s y n d r o m e t o s y m p t o m a t i c FRS (Figure 2). Sixty six patients although schizophrenia. diagnosed with schizophrenia on DSM IV criteria Ross et al and Kluft reported that did not show FRS. In fact, non-first rank Schneider's FRS are more characteristic of multiple symptoms e.g. incoherent talk, disorganized,11 behaviour, self neglect, postural abnormalities and personality disorder than of schizophrenia. changes in eating, sleeping and social behaviour For the first time FRS were also found in were more frequently reported as major or only benzodiazepine withdrawal syndrome and 12,13 symptoms. erotomania. Beckman et al reported that FRS Among the 34 exhibiting FRS, the most 14 were a frequent finding in cycloid psychosis. often found individual FRS were (n=14), made Huber and Marneros investigated the impulses (n=12), and voices arguing (n=12). Not a frequency of FRS in symptomatic schizophrenia single patient reported delusional perception. 15,16 and organic mental disorders respectively. Both Maximum FRS in an individual patient were five reported that FRS were as frequently encountered (Figure 3). as were other schizophrenic symptoms. Marneros DISCUSSION further observed that depending upon level of consciousness and etiology of the disorder the frequency of FRS could be exactly equal to that Schneider's claim that in the absence of an 17 seen in schizophrenia. organic illness, FRS are pathognomomic of schizophrenia gained un-opposed importance In a Danish study, Munk-Jorgensen et al initially but gradually came under considerable reported that FRS were poorly correlated with 9 1 criticism later. It has been argued on the basis of diagnosis of schizophrenia. They reported that data from different sources that these symptoms instead, more emphasis was placed on the are neither characteristic nor specific for chronicity of course and flattening of affect: two 325

4 important features of Danish concept of various countries selected in UK, the phenomenoschizophrenia. Based on data from IPSS, Tsirkin logy was influenced more by cultural reasons Slu found that no differences in the rate of rather than social environment and racial status in morbidity from different countries was evident 31 the host country. Having studied patients in three when narrow diagnostic criteria of schizophrenia different countries, Chandrasena concluded that were used indicating poor correlations between ethnicity and nationality were significant variables, cultural factors and development of schizophrenia 2 1 associated with lower prevalence of FRS. 19 with FRS. Berner et al compared six different However, he believes that universally FRS have operational diagnostic systems and concluded that 21 good discriminatory value. Bleular's basic symptoms were obviously Chopra and Gunter suggested that FRS are considered by all of them to be more significant much more common among schizophrenias and for attribution to schizophrenia than Schneider's could be relied upon for the diagnosis. FRS. Contrary to taking extreme positions, few Few other studies have pointed out the researchers have adopted neither this nor that potential effects of cultural beliefs on reporting of posture. Kulhara et al evaluated four diagnostic FRS and agree that some of the FRS may never be systems of schizophrenia for usefulness, comprereported to psychiatrists because they are 33 21, 22 hensiveness and concordance. One of them was considered normal by the community members. Scheniderian system. He found that all the Marneros et al observed that even is diagnostic systems had good agreement with the Schneider oriented university clinics; the majority index diagnosis. In a similar fashion, Fenton et al of diagnosis schizophrenia was based on non-first believed that no diagnostic system is preferable rank symptoms. FRS have inherent weaknesses, he over others on the basis of data they are all concludes. arbitrary. Hafner et al found that in 70% cases In summary, irrespective of arguments and schizophrenia started solely with negative counter arguments regarding usefulness of FRS in 23 symptoms. Since Schneider's symptoms are the diagnosis of schizophrenia, an undeniable fact traditionally positive symptoms, there usefulness in is that continued acceptance and influence of these the early stages of schizophrenia is doubtful. In symptoms in different diagnostic systems. There is contrast to above mentioned findings Brockington thus need for psychiatrists to remain familiar and et al appreciate FRS as diagnostic tool for their well versed not only with the definitions of FRS 24 higher inter rater reliability. Malik et al described but more significantly with the precise method of 25 them as simple to use. In the absence of organic eliciting the same. They also need to appreciate the brain dysfunction, Salleh found that the influence of culture and religious beliefs on the specification of FRS for schizophrenia was 7.% tendency to report FRS. and argued that although FRS are not pathognomonic for schizophrenia, their presence should CONCLUSIONS 26 strongly suggest the diagnosis of schizophrenia. The reliability of the presence of first rank David and Appleby followed the same suit and symptoms in Schizophrenia should be taken stated that FRS are common as well as reliable, 2 7 cautiously as only one third of the patients therefore highly useful. They wrote that diagnosed with schizophrenia as per the DSM IV Although not specific to schizophrenia, FRS show criteria showed any first rank symptom. good discriminability. No other types of symptoms or investigation method can make such claims to usefulness. Wu Y reported that the specificity of REFERENCES FRS for schizophrenia as apposed to manic depressive psychosis was 93% and the sensitivity 2 of FRS for schizophrenia was 72.9%. O'Grady reported that FRS are not specific to schizophrenia but this can be increased if narrow rather than 29 wide definition is employed. Al-Ansari et al although admitted the special importance of FRS in the diagnosis of schizophrenia but warns that caution is necessary in detecting these symptoms in societies where socio-culturally shared beliefs bear a resemblance 30 to FRS. Ndetie found that in immigrants from 1. Meueser KT, Mc Gurk SR. Schizophrenia. Lancet 2004;363: S c h n e i d e r K. P r i m a r e u n d s e k u n d a r e symptome bei der Schizophrenie. Fortschr Neurol Psychiatr1957;25: Koehler K, Seminario I. Research diagnosable schizo-affective disorder in Schneiderian first rank schizophrenia. Acta Psychiatr Scand 1979;60: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th 326

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