Research report
Schneiderian first rank symptoms predict poor outcome within first episode manic psychosis

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Abstract

Background: The validity of a sub-classification of affective psychosis according to the mood congruence of psychotic features has been questioned in the literature. While some authors have found a correlation between such symptoms and outcome, their predictive value was rather limited in these studies. Method: Prospective study of 108 subjects presenting with a first DSM-III-R manic episode with psychotic features to determine the frequency of different types of psychotic symptoms and to measure the predictive utility of mood incongruent psychotic symptoms (MIPS) and first-rank Schneiderian symptoms (FRSS) during the first episode for a 12-month outcome. Outcome was measured by the level of positive, negative, depressive symptoms, and psychosocial functioning. Duration of affective and psychotic symptoms was also assessed. Results: Patients presented with a wide variety of psychotic symptoms. The presence of MIPS at baseline was significantly correlated with a longer persistence of psychotic symptoms, but not with poorer outcome at 12 months. By contrast, the presence of FRSS at baseline was significantly associated with earlier onset of psychosis as well as increased severity of negative symptoms and poorer psychosocial functioning after 12 months. Conclusion: The presence of FRSS during a first manic episode with psychotic features identifies a sub-group of patients with more severe presentation and poorer short-term outcome. These results question the prognostic utility of MIPS. Limitations: Despite the relatively large number of subjects compared with other studies, the statistical power to detect all but large effect sizes is limited by the sample size.

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.

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