Research reportSchneiderian first rank symptoms predict poor outcome within first episode manic psychosis
Introduction
Psychotic symptoms often occur during a manic episode. Goodwin and Jamison (1990) found that close to 60% of the patients with a bipolar disorder had a lifetime history of at least one psychotic symptom. More recent publications in first episode mania suggest even higher prevalence, ranging between 63% and 88% of the cases Tohen et al., 1990, McElroy et al., 1997, Strakowski et al., 2000a, Strakowski et al., 2000b. It has also been reported that manic patients may manifest any type of psychotic symptoms, which contributes to misdiagnosis with schizophrenia and can therefore delay the introduction of appropriate mood stabilizing treatment (Gonzales-Pinto et al., 1998).
The DSM-III classification (American Psychiatric Association, 1980) introduced a subcategory among psychotic affective episodes according to the presence or absence of mood-incongruent psychotic symptoms (MIPS) (delusions or hallucinations that do not involve typical manic or depressive themes). The prevalence of such symptoms in bipolar disorders has not been frequently assessed but has been reported to range between 8% and 84% Goodwin and Jamison, 1990, Rosenthal et al., 1980, Tohen et al., 1992, Toni et al., 2001. Their predictive usefulness for outcome and therefore the validity of such a categorization is still debated. Kendler (1991) found evidence in the literature for a modestly worse outcome in affective illness with MIPS. Similarly, Tohen et al. (1992) found that patients with MIPS during the index manic episode had a significantly shorter time in remission during the four following years. In contrast, Keck et al. (1998) did not find any correlation between MIPS and any of the outcome variables assessed. Fennig et al. (1996a) literature review reveals that this categorization appears neither to identify sub-groups with distinct demographic and onset characteristics nor to predict course and outcome.
Few authors have explored the question in first episode (FE) subjects. The study of FE populations offers various advantages and avoids important confounding variables known to impact on outcome, such as the number of relapses. In a cohort of 49 FE bipolar subjects, Fennig et al. (1996b) found a significant association between MIPS and both higher BPRS score at 6 months and lower GAF at 24-month follow-up. They considered nevertheless that MIPS are weak predictors of outcome. Recently, Strakowski et al., 2000a, Strakowski et al., 2000b reported a poorer GAF at eight months follow-up in FE manic subjects with MIPS at baseline compared to subjects without MIPS. They suggested this worse outcome could be related to a longer persistence of psychotic symptoms over the follow-up period. However, in a previous publication (Strakowski et al., 1998), the same group found no association between the presence of MIPS and level of recovery.
These discrepancies might be partly explained by important variations in the criteria used to categorize patients as having MIPS or not. One of the main difficulties relates to the fact that a significant number of patients present with both mood congruent and incongruent features. Many authors include those patients into one or the other category according to loose and imprecise criteria . Others are more explicit, but there is no consistency in the rules applied. Tsuang and Coryell (1993) described, relying on very inclusive criterion, all such cases in the mood-incongruent group. Others are more restrictive and have classified patients according to the predominant type of symptoms (Tohen et al., 1992), or the more severe type of symptoms as measured by SAPS Keck et al., 1998, Strakowski et al., 2000a, Strakowski et al., 2000b. Such discrepancies led Fennig et al. (1996a) to suggest this sub-classification should be abandoned until more precise criteria were proposed.
However, the early identification of patients at risk of poorer outcome after a first manic episode would be very useful for preventive purposes through more intensive recovery oriented interventions, In the absence of reliable biological markers, clinical predictors may play an important role in this endeavour. In addition to MIPS, other symptom groups might prove to be candidates as clinical predictor. For example, Tohen et al. (1992) showed that FE manic patients with first rank Schneiderian symptoms (FRSS) during the index episode had poorer residential status 4 years later. More research is therefore needed, particularly in first episode cohorts, to clarify these issues.
Section snippets
Objectives
The aims of the study are:
- (1)
to assess the prevalence of various types of psychotic symptoms during a first manic episode with psychotic features;
- (2)
to assess whether the presence of MIPS during a first manic episode with psychotic features identifies a sub-group of patients with poorer outcome at 12 months;
- (3)
to assess whether the presence of FRSS during a first manic episode with psychotic features identifies a sub-group of patients with poorer outcome at 12 months.
Subjects
Subjects for this study were recruited among all the patients who experienced a first psychotic episode in the EPPIC catchment area (western metropolitan region of Melbourne, population of 900 000) during the study period (1989–1997) and who consented to assessments throughout the course of their first episode and the 12-month follow-up period after their recovery or stabilization (565 subjects). No significant differences were found when a sub-sample (from a specifically defined study period)
Baseline demographic data and clinical variables
Demographic data and clinical variables for the total sample and the MIPS and FRSS groups are detailed in Table 1.
Prevalence of the various psychotic symptoms
A wide variety of psychotic symptoms were present at T1 (see Table 2). Grandiose delusions were the most common (90.6% of the subjects). MIPS were observed in 78.7% of the patients, persecutory delusions in 72.5%, and FRSS in 63%. Only seven (6.5%) subjects presented exclusively with MIPS while 72.2% presented with both mood congruent and mood incongruent symptoms.
Impact of the presence of mood incongruent psychotic symptoms
Eighty-five
Discussion
Bleuler and especially Kurt Schneider considered that certain psychotic symptoms are specific to schizophrenia and others of mania. It has however been shown since then that any type of psychotic symptoms can occur during a manic episode Goodwin and Jamison, 1990, McElroy et al., 1996, Gonzales-Pinto et al., 1998. Our data confirm these results in a first manic episode sample. The subjects included in our cohort displayed a wide variety of psychotic symptoms, including MIPS in 78.7% of cases
Acknowledgements
This study was supported by scholarships to Dr Conus from the Société Académique Vaudoise, the Fondation du 450ème Anniversaire de l'Université, the Service des Affaires Universitaires and the Departement Universitaire de Psychiatrie Adulte of Lausanne, Switzerland.
References (30)
- et al.
The confusion between bipolar disorder and schizophrenia in youth: where does it stand in the 1990s?
J. Am. Acad. Child Adolesc. Psych.
(1994) - et al.
Mood-congruent versus mood-incongruent psychotic symptoms in first-admission patients with affective disorder
J. Affect. Disord.
(1996) - et al.
The development, use and reliability of the Brief Psychiatric Rating Scale (Nursing modification)—an assesment procedure for the nursing team in clinical and research settings
Compr. Psychiatry
(1988) - et al.
Eight-month functional outcome from mania following a first psychiatric hospitalisation
J. Psychiatr. Res.
(2000) - et al.
Is impaired outcome following a first manic episode due to mood-incongruent psychosis?
J. Affect. Disord.
(2000) - et al.
Four-year follow-up of twenty-four first-episode manic patients
J. Affect. Disord.
(1990) DSM-III: Diagnostic and Statistical Manual of Mental Disorders
(1980)DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders,
(1987)The Scale for the Assessment of Negative Symptoms (SANS)
(1983)- et al.
Screening depressed patients in family practice. A rapid technique
Postgrad. Med.
(1972)
First-episode mania: a neglected priority for early intervention
Aust. N. Z. J. Psychiatry
Mood-congruent versus mood-incongruent psychotic symptoms in affective psychotic disorders
Isr. J. Psychiatry Relat. Sci.
First episode in bipolar disorder: misdiagnosis and psychotic symptoms
J. Affect. Disord.
Manic-Depressive Illness
The Quality of Life Scale: an instrument for rating the schizophrenia deficit syndrome
Schizophr. Bull.
Cited by (35)
Interactions between mood and paranoid symptoms affect suicidality in first-episode affective psychoses
2023, Schizophrenia ResearchAuditory verbal hallucinations (AVHs) and related psychotic phenomena in mood disorders: analysis of the 2010 Survey of High Impact Psychosis (SHIP) data
2016, Psychiatry ResearchCitation Excerpt :Yet empirical studies of hallucinations have focused on BD or combined affective psychosis (Kumari et al., 2013; Okulate and Jones, 2003), with a paucity of reports for DP (Toh et al., 2015). Understanding whether these types of AVHs arise in DP as well as BD may have prognostic value, as FRS in first-episode mania have been associated with earlier onset, severe negative symptoms, and poorer psychosocial outcomes (Conus et al., 2004; Jorgensen and Aagaard, 1988). There has been scant research on negative voices per se, but several studies have reported negative content as less characteristic of SCZ relative to affective (Kumari et al., 2013) and other disorders (Slotema et al., 2012; Wearne and Genetti, 2015).
Social functioning in patients with a psychotic disorder and first rank symptoms
2016, Psychiatry ResearchCitation Excerpt :Another explanation for the trait effect of FRD on social functioning may be that patients with self-disturbance related symptoms, represent a group with a more severe form of psychotic illness, and consequently experience more lasting impairments on social functioning. Indeed, earlier studies suggested that patients with FRD had worse outcome, higher PANSS scores and were hospitalized more often compared with patients without FRD (Schimansky et al., 2012; Conus et al., 2004). Finally, Whitford et al. (2010) pointed out that FRS might be explained by abnormal myelination in frontal brain fasciculi.
Grandiose delusions: A review and theoretical integration of cognitive and affective perspectives
2011, Clinical Psychology ReviewDiagnostic and prognostic significance of Schneiderian first-rank symptoms: A 20-year longitudinal study of schizophrenia and bipolar disorder
2011, Comprehensive PsychiatryCitation Excerpt :Regarding the prognostic validity of FRS, the International Pilot Study of Schizophrenia, prospective research sponsored by the World Health Organization, and other studies have suggested that the presence of FRS does not predict poor outcome [10-13]. However, some studies have found that FRS predict poor outcome in individuals with psychotic illnesses other than schizophrenia, even while failing to predict poor outcome for schizophrenia [14]. A number of studies have suggested that schizophrenia and affective disorders are not discrete entities but rather constitute a continuum of psychotic symptoms that cross diagnostic boundaries [15-17].