Original Research

Relevance of Schneider’s first-rank symptoms in Zulu patients with paranoid Schiopu B, MFamMed Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein Nel M, MMedSc Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein Hiemstra LA, MPraxMed Department of Family Medicine. Faculty of Health Sciences, University of the Free State, Bloemfontein Latecki B, DipMed.Med.Lodz Independent practice, Empangeni

Correspondence: Ms M Nel, Department of Biostatistics, Faculty of Health Sciences, University of the Free State, PO Box 339 (G31), Bloemfontein, 9300, Tel: (051) 401 3116, Fax: (051) 401 2939, Email: [email protected]

Keywords: Schneider’s first-rank symptoms; paranoid schizophrenia

Abstract

Background: The aim of this study was to examine the prevalence of Schneider’s first-rank symptoms (FRS) in Zulu patients diagnosed with paranoid schizophrenia and to ascertain the diagnostic and prognostic significance of Schneider’s FRS in this group.

Methods: This descriptive study was done on 75 psychiatric Zulu in- and outpatients diagnosed with paranoid schizophrenia. A questionnaire was completed and included sociodemographic data, Schneider’s FRS and a functional assessment.

Results: Fifty-three percent of the patients heard voices at some or other time. Most patients (90.7%) confirmed having experienced at least one of the five related symptoms of thought disturbances and 80% of the patients confirmed the presence of passivity phenomena. Most patients (87%) indicated that they had presented at least one type of primary , at the time of the interview. Regarding functional assessment, some (12%) patients were still entirely productive (“no problems”), 28% rated “mild problems”, 45% “moderate problems” and 15% “severe problems”. With regard to social functioning, 8% of the patients scored “no problems”, 25% “mild problems”, 50% “moderate problems” and 17% “severe problems”.

Conclusions: The prevalence of Schneider’s FRS in these patients is 100%, with a 95% confidence interval [95.2%; 100%]. Even though extremely sensitive for paranoid schizophrenia, the specificity of Schneider’s FRS merits further study. (SA Fam Pract 2005;47(3): 55-60)

The concept of schizophrenia slow social decline, with apathy and In 1908, Eugen Bleuler, rejecting Schizophrenia is a class of psychiatric withdrawal rather than florid psychotic Kraepelin’s emphasis, established that disorders that constitutes perhaps the symptoms. Paranoid dementia there was no global dementing ultimate in psychological breakdown praecox involved fear and vaguely process and introduced the term and strikes at the very heart of what systematised persecutory . “schizophrenia”. For Bleuler, we consider the essence of the The hebephrenic type was “silly” and schizophrenia was a group of person. According to Lempérière et facetious. Catatonic patients were disorders including mild and severe al1 schizophrenia has been described those with predominant motor cases, those with a favourable as “folie circulaire” (Falvet, 1851), symptoms (increased muscle tone, outcome and those with a deteriorating “hebephrenia” (Hecker, 1871), and preservation of posture, waxy flexibility course, as well as the acute and “catatonia” and “paranoia” (Kahlbaum, and fear). For Kraepelin, the early age chronic presentations. He defined four 1874). In 1878, Kraepelin consolidated of onset was the defining criterion for characteristics of schizophrenia, now the various concepts and called the schizophrenia, with a deteriorating known as “the four A’s”: autism disease “dementia praecox”. course an additional defining (preoccupation with internal stimuli, a Depending on the clinical presentation, characteristic. Even though Kraepelin’s retreat into an inner world four types were identified: simple, definition incorporated observable incomprehensible to the outsider); paranoid, hebephrenic and catatonic. symptoms, his approach was fairly blunted or inappropriate affect; Simple dementia praecox involved a narrow.1 loosening of associations (illogical

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or fragmented thought processes); (Note: Only one criterion A condition. and ambivalence (simultaneous, symptom is required if delusions F. Relationship to a pervasive contradictory thinking). The notion of are bizarre or consist developmental disorder. If there is schizophrenia as a disease category of a voice keeping up a running a history of autistic disorder or was cemented in Bleuler’s claim that commentary on the person’s another pervasive developmental a fundamental abnormality underlay behaviour or thoughts, or two or disorder, the additional diagnosis its symptomatology. He identified the more voices conversing with each of schizophrenia is made only if loosening of associations as the core other.) prominent delusions or psychological feature that unified this B. Social/occupational dysfunction. hallucinations are also present for group of disorders. This approach was For a significant portion of the time at least a month (or less if followed in the United States for much since the onset of the disturbance, successfully treated). of the sixth decade of the 20th century, one or more areas of functioning, when Bleuler’s definition was such as work, interpersonal The ICD-10 (International Classification broadened to include various other relations or self-care are markedly of Diseases) manual places a further inferred mental processes.1 below the level achieved prior to emphasis on the presence of In Europe, there was a tendency the onset (or when the onset is in Schneider’s FRS.5 Although no strictly to narrow the meaning of childhood or adolescence, failure pathogenomic symptoms can be schizophrenia away from the broad to achieve the expected level of identified, there are groups that have Bleulerian conceptions. In 1959, the interpersonal, academic or special importance for the diagnosis German psychiatrist Kurt Schneider occupational achievement). and that often occur together. A list of proposed a list of first-rank symptoms C. Duration. Continuous signs of the diagnostic criteria follows (Schneider’s (FRS), which he regarded as disturbance persist for at least six FRS have been placed in italics): diagnostic of the disorder. The months. This six-month period must A. Thought echo, or emphasis was on identifying include at least one month of withdrawal, and thought observable symptoms that would symptoms (or less if successfully broadcasting. indicate the presence of disease, and treated) that meet Criterion A (i.e. B. Delusions of control, influence, or avoiding inferred processes: third- active-phase symptoms) and may passivity, clearly referred to body person auditory , thought include periods of prodromal or or limb movements or specific disturbances, passivity phenomena residual symptoms. During these thoughts, actions or sensations; and delusional perceptions.2 prodromal or residual symptoms, delusional perception. Schneider offered the FRS and said the signs of the disturbance may C. Hallucinatory voices giving a that they “are not theoretical be manifested by only negative running commentary on the possibilities, but are intended only for symptoms or by two or more patient’s behaviour, or discussing pragmatic diagnostic use”.2 It was symptoms listed in Criterion A the patient among themselves, or agreed that these symptoms provided present in an attenuated form (e.g. other types of hallucinatory voices a boundary that could be defined. odd beliefs, unusual perceptual coming from some part of the body. experiences). D. Persistent delusions of other kinds Current understanding of D. Schizoaffective or mood disorder that are inappropriate and schizophrenia exclusion. completely impossible, such as The present version of DSM-IV favours or mood disorder with psychotic religious or political identity, or a much more restrictive approach and features has been ruled out superhuman powers and abilities does not rely solely on Schneider’s because either no major (e.g. being able to control the FRS.3 Identifying features of depressive, manic or mixed weather, or being in communication schizophrenia are: episodes have occurred with aliens from another world). A. Characteristic symptoms. Two (or concurrently with the active-phase E. Persistent hallucinations in any more) of the following, each present symptoms3; or if mood episodes modality, when accompanied either for a significant portion of time have occurred during active-phase by fleeting of half-formed delusions during a one-month period (or less symptoms, their total duration has without clear affective content, or if successfully treated): delusions, been brief relative to the duration by persistent over-valued ideas, or hallucinations, disorganised of the active and residual periods.4 when occurring every day for speech (e.g. frequent derailment E. Substance/general medical weeks or months on end. of incoherence), grossly condition exclusion. The F. Breaks or interpolations in the train disorganised or catatonic disturbance is not due to the direct of thought, resulting in incoherence behaviour, or negative symptoms physiological effects of a or irrelevant speech, or neologisms. (i.e. affective flattening, alogia or substance (e.g. drug abuse, a G. Catatonic behaviour, such as avolition). medication) or a general medical excitement, posturing or waxy

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flexibility, negativism, mutism and reference, exalted birth, special their assessment. Staff at Ngwelezana stupor. mission, bodily change or jealousy. Hospital routinely use the DSM-IV H. “Negative” symptoms, such as B. Hallucinatory voices that threaten criteria to diagnose schizophrenic marked apathy, paucity of speech, the patient or give commands, or patients. These criteria were therefore and blunting or incongruity of auditory hallucinations without used to identify patients to be emotional responses, usually verbal form, such as whistling, included in the study. Males and resulting in social withdrawal and humming or laughing. females older than 16 years with no lowering of social performance. It C. Hallucinations of smell or taste, or set upper age limit were included in must be clear that these are not of sexual or other bodily sensations; the study. Even though priority was due to depression or to neuroleptic visual hallucinations might occur, given to patients with an active medication. but are rarely predominant. psychotic episode, stable patients I. A significant and consistent with inter-episode residual symptoms change in the overall quality of Thought disorder may be obvious in or with no inter-episode residual some aspects of personal acute states, but if so, it does not symptoms were also permitted to behaviour, manifested as loss of prevent the typical delusions or participate. When feasible, patients interest, aimlessness, idleness, a hallucinations from being described presenting a form of paranoid self-absorbed attitude and social clearly. Affect is usually less blunted schizophrenia with prominent withdrawal. than in other varieties of schizophrenia. negative symptoms were approached. The following exclusion The normal requirement for a diagnosis Ubiquity of first-rank symptoms criteria were used: primary language of schizophrenia is that a minimum of The World Health Organization Ten- not Zulu; Mini Mental State one very clear symptom (and usually Country Study of Incidence concluded Examination (MMSE) less than 24; two or more if less clear-cut) belonging that schizophrenic illnesses are any ongoing substance abuse to any one of the groups listed as A ubiquitous, appear with similar precipitating the active episode, or to D above, or symptoms from at least incidence in different cultures and any previous admission for a two of the groups referred to as E to have features that are more remarkable substance-induced psychotic H, should have been clearly present by their similarity across cultures than disorder or acute confusional for most of the time during a period of by their difference. These conclusions episode. one month or more. Because of the were drawn on the basis of a definition Each patient was selected difficulty in timing the onset, the one- of schizophrenia that depended according to the biographical and month duration criterion applies only critically upon the use of FRS.6 clinical data available in their files at to the specific symptoms listed above The ICD-10 makes special the time of the consultation. In the and not to any prodromal non- reference of the fact that persecutory case of acutely ill patients, when there psychotic phase. delusions might carry little diagnostic was not enough information about the The diagnosis of schizophrenia is weight in people from certain ethno- circumstances surrounding the present not to be made in the presence of cultural backgrounds. episode, a general physical extensive depressive or manic The aim of this study was to examination was performed and, when symptoms, unless it is clear that the examine the prevalence Schneider’s feasible, they also underwent an schizophrenic symptoms antedate the FRS in a group of Zulu patients MMSE in an attempt to exclude any affective disturbance. If both diagnosed with paranoid cognitive impairment. After being schizophrenic and affective symptoms schizophrenia and to ascertain the ascertained suitable for the study, the develop together and are evenly diagnostic and prognostic significance patients were presented with the Zulu balanced, the diagnosis of of Schneider’s FRS in this group. version of Schneider’s FRS schizoaffective disorder should be Assessment Questionnaire. Illiterate made, even if the schizophrenic Methods patients and those needing further symptoms by themselves would have This was a descriptive study that explanations were helped by the justified the diagnosis of included 75 consecutive psychiatric attending nursing staff, who were schizophrenia. Schizophrenia should Zulu in- and outpatients diagnosed specially instructed for this purpose not be diagnosed in the presence of with paranoid schizophrenia according prior to the commencement of the overt brain disease or during states to DSM-IV. A systematic sample was project. The questionnaire included of drug intoxication or withdrawal. taken because the first author only three sections: Schneider’s FRS find a clear had two months available for data Section One: Sociodemographic expression in the paranoid type of collection. The patients were either data – to establish gender, age, schizophrenia. Examples of the most admitted to the psychiatric ward or marital status, highest qualification common paranoid symptoms are: were attending the psychiatric clinics and employment status; A. Delusions of persecution, at Ngwelezana Hospital at the time of Section Two: Schneider’s FRS

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Table I: Percentage of patients experiencing Schneider’s FRS FRS group n Total % Group % Third person auditory hallucinations: Actions 27 36 67.5 Thoughts 27 36 67.5 Behaviour 23 31 57.5 Total 40 53 Thought disturbances: Audible 49 65 72 Echo 44 59 65 Insertion 34 45 50 Withdrawal 32 43 47 Broadcasting 40 53 59 Total 68 90.7 Passivity phenomena: Imposed actions 47 63 78 Imposed emotions 42 56 70 Imposed will/impulses 40 53 67 Total 60 80 Primary delusions: Total 65 87

– enquired into the presence of Table II: Percentage distribution according to the patients’ number of positive schizophrenic core symptoms as answers to any one FRS described in the first chapter of Number of FRS presented Percentage this study; 1 5.3 Section Three: Functional 2 2.7 assessment – was completed by 3 9.3 the researcher, who assessed each 4 8 patient’s occupational and social 5 10.7 functioning as a result of the overall 6 17.3 evolution of his or her illness. This 7 9.3 was done by compiling information 8 13.3 from the clinical notes, as well as 9 9.3 by interviewing the patients and 10 8 their attending relatives. 11 4 Occupational functioning was 12 2.7 coded into four degrees of Table III: Distribution of FRS in total sample increasing severity affecting aspects of day-to-day productive Distribution Percentage living and encompassing a time Primary delusions 87 from adolescence to maturity. Due Audible thoughts 65 to early school interruption and a Imposed actions 63 Thoughts echo 59 lack of marketable skills, the focus Imposed emotions 56 was on the occupational Imposed will/impulses 53 functioning within the extended Thought broadcasting 53 family in rural and semi-rural areas. Thought insertion 45 The answers were rated as “no Thought withdrawal 43 problems” or “mild problems” when Commentaries on actions 36 the patient was able to carry on Commentaries on thoughts 36 with his/her activities of daily living Commentaries on behaviour 31 at a level as close as possible to what was socially acceptable and “Moderate” and “severe problems” dependent on the family and/or necessary in his/her environment, were scored when that decline was social assistance. and when there was no permanent obvious (e.g. job loss, school decline from a previous level of dropout) and permanent, and the When the age could not be functioning due to the illness. patient had become increasingly determined, recourse was made to

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estimations. The degree of psychotic residual symptoms detected during syndrome of mental automatism”.1 All activity in each patient (active the interview were essentially the other FRS are mentioned in a rather psychotic episode, paranoid components of Schneider’s FRS. narrative manner in the first two sub- schizophrenia with no inter-episode All patients were medicated with categories of this syndrome: 1) the residual symptoms, paranoid anti-psychotics, prior to or after the minor mental automatism (“le petit schizophrenia with inter-episode interview. Benzodiazepines were automatisme mental”) and 2) the residual symptoms, paranoid added PRN to the inpatients’ treatment phenomena of mechanical split of schizophrenia with prominent negative schedule as an adjuvant to be used thinking – thought, reading and gesture symptoms) was also noted. only in the case of agitation and echo (“les phénoménes de The questionnaire presented was aggressiveness. An attempt to rule dédoublement méchanique de la anonymous and all information out any possible interference of pensée – écho de la pensée, de la collected was kept confidential. After substance abuse was done through lecture et des actes”). When asked the study was fully explained to the obtaining a proper history from the about passivity phenomena, 80% of patients in Zulu by the attending patient and his/her relatives. the patients confirmed their presence nursing staff, informed written consent at one time or another during the was obtained. The patients were Schneider’s FRS course of their illness. allowed to withdraw from the study at A characterisation of the patients’ The presence of primary delusions any time and were allowed access to psychotic experiences (auditory was determined by means of eight the results of the study if they so hallucinations, thought disturbances, questions. Even though one positive wished. The study was approved by passivity phenomena and primary answer only would have been enough the Manager of Ngwelezana Hospital. delusions) is given in Table I. to confirm the occurrence of this core Descriptive statistics, namely Fifty-three percent of the patients symptom, all types of primary frequencies and percentages for heard voices at some or other time. delusions (i.e. reference, persecutory, categorical data and percentiles for The question did not probe the grandiose, somatic, religious, continuous data, were calculated. The presence of non-vocal stimuli, but erotomanic, jealousy and guilt) were prevalence of Schneider’s FRS is centred on what the patient could enumerated in order to increase described by means of 95% understand when the hallucinations sensitivity and give the topic a more confidence intervals (CI). were verbal. On the basis of these concrete character. It is this last core answers, the following three questions symptom that displays as the most Results inquired into the presence of a first prominent FRS in the psychotic Sociodemographic data defining group of Schneider’s FRS, experience of the patients who Seventy-five patients completed the namely a voice/voices keeping up a participated in the study, with 87% questionnaire (52 men and 23 women). running commentary on the person’s indicating that they had presented at Their ages ranged from 16 to 60.6 actions, thoughts or behaviour. Of the least one type of primary delusion, years, with a median of 33 years. Most patients who reported voices or whether criticised or not, at the time (73.9%) patients were unmarried conversations, only one denied the of the interview. (n=73). occurrence of any of the three above- This study inquired into the The patients (n=74) had received mentioned FRS, while still admitting presence, active or retrospective, of varied schooling, with only 4.1% to the presence of auditory twelve first-rank symptoms, divided having matriculated and none with a hallucinations. into four main categories: hallucinatory higher degree. Only a few patients Most patients (90.7%, n=68) experience, thought disturbances, (4.5%) were still attending school. Most confirmed having experienced at least passivity phenomena and primary (84%, n=65) patients were one of the five related symptoms of delusions. Interestingly enough, all the unemployed, 46 of whom were thought disturbances at some time patients, even those with a prominently unskilled labourers/subsistence during the course of their illness. negative form of schizophrenia, farmers. The category of passivity identified at least one FRS to match Almost half the patients (46.7%) phenomena, with its three defining features from their past or present were diagnosed with paranoid symptoms (imposed actions, emotions psychotic activity. Approximately 17% schizophrenia/an acute psychotic and will/impulses), is actually a (n=13) patients gave a positive answer episode, 34.7% presented in the refinement of the older concept of to six FRS, followed by 13% (n=10) remission phase with no residual triple motor, ideo and ideo-verbal who endorsed eight FRS, and 11% symptoms, 14.7% in the remission automatism (“le triple automatisme (n=8) with five FRS. The percentage phase with inter-episode residual moteur, idéique et idéo-verbal”), first distribution according to the patients’ symptoms, while 4% were diagnosed described by the French psychiatrist number of positive answers to any one with paranoid schizophrenia with Guy de Clérambault as part of a larger FRS is given in Table II. prominent negative symptoms. All the psychopathologic entity called “the Auditory hallucinations are among

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the most prominent and distressing percent of the patients scored “no clinician in making a more focused symptoms of a psychotic episode. The problems”, 25% “mild problems”, 50% and earlier diagnosis in future cases. form and content of hallucinatory “moderate problems” and 17% “severe The findings of the study are limited, experiences have been used as problems”. however, to this group of patients. significant clinical signs with diagnostic The distribution of Schneider’s FRS The study also tried to ascertain the implications. In this study, however, and FRS categories in both types of existence of a correlation between the symptom category of third-person assessment followed the trends specific Schneider’s FRS (or groups verbal auditory hallucinations ranked emerging from the functional of FRS) and the long-term functional the last (53%), preceded by thought assessment. A remarkable feature in prognosis of this group of patients. disturbances (91%), primary delusions both evaluations was the overall Therefore, it looked for an indication (87%) and passivity phenomena predominance of moderate and severe of those cases where a more (80%). Individual FRS displayed a dysfunctional patterns, amounting to aggressive course of treatment might more scattered distribution (Table III), 60% of the patients for the have become warranted in order to the most being primary delusions occupational and 67% for the social preserve function or prevent further (87%), followed by audible thoughts assessments. Were it only for these social decline. (65%) and imposed actions (63%). estimates, they would have been in A positive answer to only one of line with the results of those studies References the questions from this section meant where the FRS were associated with 1. Lempérière T, Féline A, Gutmann A, Adès J, Pilate C. Psychiatrie de l'adulte. 13th that at least one FRS was present in a trend for poorer prognostic features edition. Paris: Edition Masson; 1994. a specific patient, thus being, in the schizophrenic sample.7 However, 2. Schneider K. Klinische Psychopathologie. according to Schneider, diagnostic of numerous potential confounding 13th ed. Stuttgart: Georg Thieme Verlag; 1987. schizophrenia. Therefore, the factors overshadow the relevance of 3. American Psychiatric Association. prevalence of Schneider’s FRS is these findings. A bad prognosis of Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington, 100%, with a 95% CI [95.2%; 100%]. schizophrenia is not only the result of DC: American Psychiatric Press; 1994. However, even though extremely certain disease features, such as 4. Berner P. Conceptualization of sensitive for paranoid schizophrenia, insidious onset, long duration of first schizophrenia: the symptom-oriented approach. Psychopathology 1997;30:251- the specificity of Schneider’s FRS episode, emotional blunting, etc., but 6. merits further study. is also dependent on the availability 5. Organisation Mondiale de la Santé. of family and appropriate social Classification internationale des troubles mentauz et des troubles du comportement Functional assessment support. Much more needs to be done (CIM-10/ICD-10). 10th edition. Paris: Edition Some patients (12%) were still entirely concerning this latter aspect, and the Masson; 1993. 6. Mason P, Harrison G, Croudace T, productive (“no problems”), 28% challenges are great. Glazebrook C, Medley I. The predictive reported “mild problems”, 45% validity of a diagnosis of schizophrenia. A “moderate problems” and 15% “severe Implementation of findings report from the International Study of Schizophrenia (ISoS) coordinated by the problems”. This study aimed at obtaining a better World Health Organization and the Social functioning received a insight into the presence of Department of Psychiatry, University of similar type of rating, spanning a schizophrenic core symptoms in a Nottingham. Br J Psychiatry 1997;170:321- 7. continuum of deterioration from the group of Zulu patients already 7. Tanenberg-Karant M, Fennig S, Ram R, initial point of normalcy to states of diagnosed with this disease. Its Krishna J, Jandorf L, Bromet EJ. Bizarre delusions and first-rank symptoms in a first- increasing social and familial findings try to point out those FRS with admission sample: a preliminary analysis disinsertion, amotivation and a higher prevalence in this ethno- of prevalence and correlates. Compr auto/hetero-aggressiveness. Eight cultural group, thus helping the Psychiatry 1995;36:428-34.

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