Basic symptoms of schizophrenia

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Symptoms in Schizophrenia, a 1938 silent film.

Basic symptoms of schizophrenia are subjective symptoms, described as experienced from a person's perspective, which show evidence of underlying psychopathology. Basic symptoms have generally been applied to the assessment of people who may be at risk to develop psychosis. Though basic symptoms are often disturbing for the person, problems generally do not become evident to others until the person is no longer able to cope with their basic symptoms. Basic symptoms are more specific to identifying people who exhibit signs of prodromal psychosis (prodrome) and are more likely to develop schizophrenia over other disorders related to psychosis. [1] Schizophrenia is a psychotic disorder, but is not synonymous with psychosis. [1] In the prodrome to psychosis, uncharacteristic basic symptoms develop first, followed by more characteristic basic symptoms and brief and self-limited psychotic-like symptoms, and finally the onset of psychosis. [2] People who were assessed to be high risk according to the basic symptoms criteria have a 48.5% likelihood of progressing to psychosis. [3] In 2015, the European Psychiatric Association issued guidance recommending the use of a subscale of basic symptoms, called the Cognitive Disturbances scale (COGDIS), in the assessment of psychosis risk in help-seeking psychiatric patients; in a meta-analysis, COGDIS was shown to be as predictive of transition to psychosis as the Ultra High Risk (UHR) criteria up to 2 years after assessment, and significantly more predictive thereafter. [4] The basic symptoms measured by COGDIS, as well as those measured by another subscale, the Cognitive-Perceptive basic symptoms scale (COPER), are predictive of transition to schizophrenia. [5]

Contents

Course

There are several factors that interact prior to the development of basic symptoms, including predisposed vulnerability, environmental stressors, and support systems. [6] Recent work in the field of neural oscillation has demonstrated that defective excitatory and inhibitory signalling in the brain during development plays an important role in the formation of basic symptoms. [7] These signalling disturbances can lead to cognitive deficits that result in the future appearance of more complicated symptoms of the disorder. [7] The interaction of these factors increases the risk for development of basic symptoms of schizophrenia. [6] It is important to identify when a person is exposed to these factors to prevent, modify or delay the onset of basic symptoms through early intervention. [6] The recognition of these basic symptoms in the prodromal phase can lead to early intervention in psychosis that aids in the delay or prevention of schizophrenia. [8] Such early interventions include cognitive behavioural therapy (CBT) or the use of antipsychotic drugs. [8]

Basic symptoms are subjective and can be subtle. It may be difficult for the person to realize that something is wrong and tell someone else, especially without being asked directly. Often, the person will try to adapt and cope with the symptoms. Functioning becomes impaired when people reach their adaptive capacity. [9] In the period leading up to the first episode of schizophrenia, uncharacteristic basic symptoms first appear and are followed by the onset of more characteristic basic symptoms and, finally, psychosis. [9]

Basic symptoms often appear several years before the onset of psychosis, but are often preceded by the onset of self-disorders. [10] They may sometimes appear and then disappear before appearing again much later, where they occur as part of an outpost syndrome. At one point, uncharacteristic basic symptoms will appear, which comprise various disturbances of mood, emotions, drive, thought, and attention that can occur in many other disorders, followed by the characteristic basic symptoms, which comprise disturbances of thought, perception, and attention, along with minor reality distortion, that are associated with schizophrenia in particular. Afterward, attenuated symptoms of psychosis or brief periods of psychosis will appear, before culminating in the emergence of full-blown psychosis. At any stage before psychosis, the person will attempt to cope with the basic symptoms, which might conceal the problems from others; once the person reaches the limit of their ability to compensate, however, the problems will become evident to others and cause impairment. [5] Poorer long-term outcomes such as increases in relapses, increases in hospitalizations, and poorer social/occupational functioning are associated with the age of onset of these symptoms, suggesting the importance of early intervention. [11]

After the resolution of psychosis, basic symptoms may follow one of 3 courses: Psychosis and the basic symptoms may resolve completely allowing the restoration of normal functioning; they may remit but remain at an uncharacteristic level, with relapses of psychosis; or the characteristic basic symptoms may remain creating a deficit syndrome dominated by negative symptoms. [5]

Evaluation

Basic symptoms are generally evaluated using the Schizophrenia Proneness Instrument (SPI), of which there are both a child and youth version (SPI-CY) and an adult version (SPI-A); [10] this instrument assesses basic symptoms, both those that are uncharacteristic and those characteristic of psychosis. Out of the items evaluated on the SPI-CY and the SPI-A, there can be derived 2 scales to evaluate specifically the characteristic basic symptoms: the Cognitive Disturbances scale (COGDIS) and the Cognitive-Perceptual Basic Symptoms scale (COPER). [5]

COGDIS criteria are met when at least 2 of the symptoms on the scale (see table below) are present with at least weekly occurrence in the last 3 months, and which were not present during the pre-morbid phase of the illness and do not result from drug use. The European Psychiatric Association (EPA) recommends the use of this scale, along with attenuated psychotic symptoms and brief transient psychosis, to detect at-risk mental states in help-seeking people. [4]

COPER criteria are met when at least 1 of the symptoms on the scale (see table below) is present with at least weekly occurrence in the last 3 months, and the first occurrence of symptoms was more than 12 months prior to evaluation. [5]

Below are the basic symptoms associated with psychosis, along with whether they appear on COGDIS, COPER, or both: [2] [4] [5]

SymptomCOGDISCOPERDescription
Thought interferenceYesYesInterference of unimportant, irrelevant thoughts that hinders thinking and concentration.
Thought perseverationNoYesRepetition of thoughts that have little or no salience.
Thought pressureYesYesMany thoughts with no common theme pop up uncontrollably.
Thought blockagesYesYesSudden loss of train of thought that may be accompanied by the intrusion of a new thought.
Disturbance of receptive languageYesYesLack of immediate comprehension of speech or text in one's native language.
Disturbance of expressive languageYesNoDifficulty producing speech or text that is appropriate to one's message in one's native language.
Disturbances of abstract thinkingYesNoDifficulty comprehending idioms and metaphors.
Inability to divide attentionYesNoDifficulty doing something with one sense (such as vision) while simultaneously using another sense for something else (such as hearing).
Captivation of attention by details of the visual fieldYesNoAttention is drawn to unimportant details as if one were "spellbound".
Decreased ability to discriminate between perception and ideas, true memories and fantasiesNoYesDifficulty discriminating between what one has observed and what one has imagined.
Unstable ideas of reference with insightYesYesSub-psychotic referential ideation that is thereafter immediately corrected by the person.
DerealizationNoYesSense of disconnect or unreality in one's environment.
Visual or acoustic perceptual disturbances with insightNoYesDisturbances of the perception of brightness or loudness, color or sound quality, or distortions in one's perceptions that are recognized by the person as false.

The Examination of Anomalous Self-Experience (EASE) is another scale used to evaluate subjective symptoms of schizophrenia. [12] [13] This is a semi-structured interview scheme that was designed to specifically assess anomalous self-experience. [12]

See also

Related Research Articles

Psychosis is a condition of the mind that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.

<span class="mw-page-title-main">Schizophrenia</span> Mental disorder with psychotic symptoms

Schizophrenia is a mental disorder characterized by reoccurring episodes of psychosis that are correlated with a general misperception of reality. Other common signs include hallucinations, delusions, disorganized thinking, social withdrawal, and flat affect. Symptoms develop gradually and typically begin during young adulthood and are never resolved. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months or one month. Many people with schizophrenia have other mental disorders, especially substance use disorders, depressive disorders, anxiety disorders, and obsessive–compulsive disorder.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.

<span class="mw-page-title-main">Anhedonia</span> Inability to feel pleasure

Anhedonia is a diverse array of deficits in hedonic function, including reduced motivation or ability to experience pleasure. While earlier definitions emphasized the inability to experience pleasure, anhedonia is currently used by researchers to refer to reduced motivation, reduced anticipatory pleasure (wanting), reduced consummatory pleasure (liking), and deficits in reinforcement learning. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), anhedonia is a component of depressive disorders, substance-related disorders, psychotic disorders, and personality disorders, where it is defined by either a reduced ability to experience pleasure, or a diminished interest in engaging in previously pleasurable activities. While the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) does not explicitly mention anhedonia, the depressive symptom analogous to anhedonia as described in the DSM-5 is a loss of interest or pleasure.

<span class="mw-page-title-main">Thought disorder</span> Disorder of thought form, content or stream

A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."

Schizotypal personality disorder, also known as schizotypal disorder, is a cluster A personality disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM) classification describes the disorder specifically as a personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, derealization, transient psychosis, and unconventional beliefs. People with this disorder feel pronounced discomfort in forming and maintaining social connections with other people, primarily due to the belief that other people harbor negative thoughts and views about them. Peculiar speech mannerisms and socially unexpected modes of dress are also characteristic. Schizotypal people may react oddly in conversations, not respond, or talk to themselves. They frequently interpret situations as being strange or having unusual meanings for them; paranormal and superstitious beliefs are common. Schizotypal people usually disagree with the suggestion that their thoughts and behaviors are a 'disorder' and seek medical attention for depression or anxiety instead. Schizotypal personality disorder occurs in approximately 3% of the general population and is more commonly diagnosed in males.

In psychology, schizotypy is a theoretical concept that posits a continuum of personality characteristics and experiences, ranging from normal dissociative, imaginative states to extreme states of mind related to psychosis, especially schizophrenia. The continuum of personality proposed in schizotypy is in contrast to a categorical view of psychosis, wherein psychosis is considered a particular state of mind, which the person either has or does not have.

Schizophrenia is a neurodevelopmental disorder with no precise or single cause. Schizophrenia is thought to arise from multiple mechanisms and complex gene–environment interactions with vulnerability factors. Risk factors of schizophrenia have been identified and include genetic factors, environmental factors such as experiences in life and exposures in a person's environment, and also the function of a person's brain at it develops. The interactions of these risk factors are intricate, as numerous and diverse medical insults from conception to adulthood can be involved. Many theories have been proposed including the combination of genetic and environmental factors may lead to deficits in the neural circuits that affect sensory input and cognitive functions.

In medicine, a prodrome is an early sign or symptom that often indicates the onset of a disease before more diagnostically specific signs and symptoms develop. It is derived from the Greek word prodromos, meaning "running before". Prodromes may be non-specific symptoms or, in a few instances, may clearly indicate a particular disease, such as the prodromal migraine aura.

<span class="mw-page-title-main">Grandiose delusions</span> Subtype of delusion

Grandiose delusions (GDs), also known as delusions of grandeur or expansive delusions, are a subtype of delusion characterized by extraordinary belief that one is famous, omnipotent, wealthy, or otherwise very powerful. Grandiose delusions often have a religious, science fictional, or supernatural theme. Examples include the extraordinary belief that one is a deity or celebrity, or that one possesses extraordinary talents, accomplishments, or superpowers.

Brief psychotic disorder—according to the classifications of mental disorders DSM-IV-TR and DSM-5—is a psychotic condition involving the sudden onset of at least one psychotic symptom lasting 1 day to 1 month, often accompanied by emotional turmoil. Remission of all symptoms is complete with patients returning to the previous level of functioning. It may follow a period of extreme stress including the loss of a loved one. Most patients with this condition under DSM-5 would be classified as having acute and transient psychotic disorders under ICD-10. Prior to DSM-IV, this condition was called "brief reactive psychosis." This condition may or may not be recurrent, and it should not be caused by another condition.

Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of a new prevention paradigm for psychiatry and is leading to reform of mental health services, especially in the United Kingdom and Australia.

Barbara A. Cornblatt is Professor of Psychiatry and Molecular Medicine at Hofstra Northwell School of Medicine. She is known for her research on serious mental disorders, with a specific focus on psychosis and schizophrenia. Her efforts to find treatments to help youth with mental illness led to the development of the Recognition and Prevention Program, which she founded in 1998.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

<span class="mw-page-title-main">Prognosis of schizophrenia</span>

The prognosis of schizophrenia is varied at the individual level. In general it has great human and economics costs. It results in a decreased life expectancy of 12–15 years primarily due to its association with obesity, little exercise, and smoking, while an increased rate of suicide plays a lesser role. These differences in life expectancy increased between the 1970s and 1990s, and between the 1990s and 2000s. This difference has not substantially changed in Finland for example – where there is a health system with open access to care.

The diagnosis of schizophrenia, a psychotic disorder, is based on criteria in either the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or the World Health Organization's International Classification of Diseases (ICD). Clinical assessment of schizophrenia is carried out by a mental health professional based on observed behavior, reported experiences, and reports of others familiar with the person. Diagnosis is usually made by a psychiatrist. Associated symptoms occur along a continuum in the population and must reach a certain severity and level of impairment before a diagnosis is made. Schizophrenia has a prevalence rate of 0.3-0.7% in the United States.

At risk mental state is the clinical presentation of those considered at risk of developing psychosis or schizophrenia. Such states were formerly considered treated as prodromes, emerging symptoms of psychosis, but this view is no longer prevalent as a prodromal period can not be confirmed unless the emergence of the condition has occurred.

<span class="mw-page-title-main">Imprinted brain hypothesis</span> Conjecture on the causes of autism and psychosis

The imprinted brain hypothesis is an unsubstantiated hypothesis in evolutionary psychology regarding the causes of autism spectrum and schizophrenia spectrum disorders, first presented by Bernard Crespi and Christopher Badcock in 2008. It claims that certain autistic and schizotypal traits are opposites, and that this implies the etiology of the two conditions must be at odds.

Sex differences in schizophrenia are widely reported. Men and women exhibit different rates of incidence and prevalence, age at onset, symptom expression, course of illness, and response to treatment. Reviews of the literature suggest that understanding the implications of sex differences on schizophrenia may help inform individualized treatment and positively affect outcomes.

A self-disorder, also called ipseity disturbance, is a psychological phenomenon of disruption or diminishing of a person's minimal self – the fundamental sense that one's experiences are truly one's own. People with self-disorder feel that their internal experiences are actually external; for example, they may experience their own thoughts as coming from outside themselves, whether in the form of true auditory hallucinations or merely as a vague sense that their thoughts do not belong to them.

References

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  3. ↑ Fusar-Poli, P; Bonoldi, I; Yung, AR; Borgwardt, S; Kempton, MJ; Valmaggia, L; Barale, F; Caverzasi, E; McGuire, P (March 2012). "Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk". Archives of General Psychiatry. 69 (3): 220–9. doi: 10.1001/archgenpsychiatry.2011.1472 . PMID   22393215.
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  9. 1 2 Frauke Schultze-Lutter (January 2009). "Subjective symptoms of schizophrenia in research and the clinic: the basic symptom concept". Schizophrenia Bulletin . 35 (1): 5–8. doi:10.1093/schbul/sbn139. PMC   2643966 . PMID   19074497.
  10. 1 2 Schultze-Lutter et al. 2016, Supplementary material.
  11. ↑ Immonen, J; Jääskeläinen, E; Korpela, H; Miettunen, J (27 April 2017). "Age at onset and the outcomes of schizophrenia: A systematic review and meta-analysis". Early Intervention in Psychiatry. 11 (6): 453–460. doi:10.1111/eip.12412. PMC   5724698 . PMID   28449199.
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  13. ↑ Parnas, Josef; Møller, Paul; Kircher, Tilo; Thalbitzer, Jørgen; Jansson, Lennart; Handest, Peter; Zahavi, Dan (September 2005). "EASE: Examination of Anomalous Self-Experience". Psychopathology. 38 (5): 236–258. doi:10.1159/000088441. ISSN   0254-4962. PMID   16179811. S2CID   28066244.
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