Original Research Relevance of Schneider’s first-rank symptoms in Zulu patients with paranoid schizophrenia 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 delusion, 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 delusions. “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 SA Fam Pract 2005;47(3) 55 Original Research 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 hallucinations 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, thought insertion 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 hallucination, 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. Schizoaffective disorder 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