A major flaw in the diagnosis of schizophrenia: what happened to the Schneider's first rank symptoms

Revisiting Rorschach test and Minnesota Multiphasic Personality Inventory-II patterns in Kraepelinian vs. DSM-wise Schizophrenia: How They Differ and What It Means for Diagnosis

OBJECTIVE

This retrospective chart review study aimed to investigate the differences in the Rorschach test and Minnesota Multiphasic Personality Inventory (MMPI)-II profiles among patients with Kraepelinian schizophrenia, those with DSM-wise schizophrenia, and controls. Kraepelinian schizophrenia is characterised by a chronic, deteriorative disease course and a predominance of negative symptoms.

METHODS

Patients with Kraepelinian schizophrenia were selected based on medical record reviews. We then compared their Rorschach test and MMPI-II results with those of the DSM-wise schizophrenia group and the control group.

RESULTS

The Rorschach test revealed a significant increase in DV2 score and a decrease in D score in patients with Kraepelinian schizophrenia compared to those with DSM-wise schizophrenia. In the MMPI-II profiles, patients with Kraepelinian schizophrenia exhibited an elevated L relative to those with DSM-wise schizophrenia.

CONCLUSION

Our results suggested the value of revisiting psychological tests in clinically delineated subgroups, such as Kraepelinian schizophrenia. Although patients fall under the same diagnostic category of schizophrenia, considering different phenotypes is important when interpreting psychological test outcomes. Additionally, our study indicated that both schizophrenia groups did not show as many abnormalities as expected compared to controls. This highlights the potential value of revisiting established profiles of certain psychological tests and calls for further research on other psychological tests.

Longitudinal assessment of ventricular volume trajectories in early-stage schizophrenia: evidence of both enlargement and shrinkage

BACKGROUND

Lateral ventricular enlargement represents a canonical morphometric finding in chronic patients with schizophrenia; however, longitudinal studies elucidating complex dynamic trajectories of ventricular volume change during critical early disease stages are sparse.

METHODS

We measured lateral ventricular volumes in 113 first-episode schizophrenia patients (FES) at baseline visit (11.7 months after illness onset, SD = 12.3) and 128 age- and sex-matched healthy controls (HC) using 3T MRI. MRI was then repeated in both FES and HC one year later.

RESULTS

Compared to controls, ventricular enlargement was identified in 18.6% of patients with FES (14.1% annual ventricular volume (VV) increase; 95%CI: 5.4; 33.1). The ventricular expansion correlated with the severity of PANSS-negative symptoms at one-year follow-up (p = 0.0078). Nevertheless, 16.8% of FES showed an opposite pattern of statistically significant ventricular shrinkage during ≈ one-year follow-up (-9.5% annual VV decrease; 95%CI: -23.7; -2.4). There were no differences in sex, illness duration, age of onset, duration of untreated psychosis, body mass index, the incidence of Schneiderian symptoms, or cumulative antipsychotic dose among the patient groups exhibiting ventricular enlargement, shrinkage, or no change in VV.

CONCLUSION

Both enlargement and ventricular shrinkage are equally present in the early stages of schizophrenia. The newly discovered early reduction of VV in a subgroup of patients emphasizes the need for further research to understand its mechanisms.

Schneider's first-rank symptoms have neither diagnostic value for schizophrenia nor higher clinical validity than other delusions and hallucinations in psychotic disorders

The validity of studies on the diagnostic significance of first-rank symptoms (FRS) for schizophrenia has been put in doubt because of a poor compliance with Schneider's criterion for their definition and the lack of use of the phenomenological method for their assessment. In this study, using a rigorously phenomenological approach to elicit FRS, we examined (a) the degree to which unequivocally present FRS differentiated schizophrenia (n=513) from other psychotic disorders (n=633), and (b) the comparative validity between FRS and other reality-distortion symptoms against 16 external validators in the whole sample of psychotic disorders (n=1146). Diagnostic performance indices (with 95% CIs) of FRS for diagnosing schizophrenia were as follows: sensitivity=0.58 (0.54-0.61), specificity=0.65 (0.62-0.67), positive predictive value=0.57 (0.54-0.60) and negative predictive value=0.65 (0.63-0.68). While the overall association pattern of FRS and non-FRS scores with the validators was rather similar, three validators (premorbid social adjustment, number of hospitalizations and global assessment of functioning) were significantly related to non-FRS scores (p < 0.006) but not to FRS scores (p > 0.05). Furthermore, no validator was significantly related to FRS scores and unrelated to non-FRS scores, all of which indicates an overall better predictive validity for non-FRS delusions and hallucinations. These findings suggest that FRS do not have diagnostic value for diagnosing schizophrenia and that they do not meaningfully add to the external validity showed by other delusions and hallucinations. We believe that much of the misunderstanding about the diagnostic and clinical validity of FRS for schizophrenia is rooted in Schneider's confusing concept of the disorder.

Delusional Perception Revisited

Delusional perception designates a sudden, idiosyncratic, and often self-referential delusion triggered by a neutral perceptual content. In classical psychopathology, delusional perception was considered almost pathognomonic for schizophrenia. Since delusional perception has been erased from ICD-11 and always been absent in DSM, it risks slipping out of clinical awareness. In this article, we explore the clinical roots of delusional perception, elucidate the psychopathological phenomenon, and discuss its two predominant conceptualizations, i.e., Schneider's well-known two-link model and Matussek's lesser known one-link model. The two-link model posits that delusional perception amounts to an abnormal interpretation of an intact perception, whereas the one-link model posits that the delusional meaning is contained within a changed perception. Despite their differences, both models stress that delusional perception is a primary delusion that takes place within an altered experiential framework that is characteristic of the psychopathological Gestalt of schizophrenia. We discuss the role of delusional perception in future psychopathological and diagnostic assessment and argue that such assessments must be conducted in comprehensive manner, eliciting the psychopathological context within which symptoms and signs are embedded. Finally, we discuss the compatibility of the two models of delusional perception with contemporary cognitive models on delusion and cognitive psychotherapeutic approaches.

Prospective, observational, single-centre cohort study with an independent control group matched for age and sex aimed at investigating the significance of cholinergic activity in patients with schizophrenia: study protocol of the CLASH-study

INTRODUCTION

Alterations in the cholinergic metabolism may cause various clinical symptoms of schizophrenia. In addition to the 'monoamine hypothesis,' neuroinflammation is also discussed as a cause of schizophrenia. To date, there has been no evidence of alterations in the central cholinergic transmitter balance in patients with schizophrenia under clinical conditions. By contrast, studies in critically ill patients have established the measurement of acetylcholinesterase activity as a suitable surrogate parameter of central cholinergic transmitter balance/possible pathophysiological changes. Butyrylcholinesterase activity has been established as a parameter indicating possible (neuro)inflammatory processes. Both parameters can now be measured using a point-of-care approach. Therefore, the primary objective of this study is to investigate whether acetylcholinesterase and butyrylcholinesterase activity differs in patients with various forms of schizophrenia. Secondary objectives address the possible association between acetylcholinesterase and butyrylcholinesterase activity and (1) schizophrenic symptoms using the Positive and Negative Syndrome Scale, (2) the quantity of antipsychotics taken and (3) the duration of illness.

METHODS AND ANALYSIS

The study is designed as a prospective, observational cohort study with one independent control group. It is being carried out at the Department of Psychiatry and Psychotherapy III, Ulm University Hospital, Germany. Patient enrolment started in October 2020, and the anticipated end of the study is in January 2022. The enrolment period was set from October 2020 to December 2021 (extension required due to SARS-CoV-2 pandemic). The sample size is calculated at 50 patients in each group. Esterase activity is measured on hospital admission (acute symptomatology) and after referral to a postacute ward over a period of three consecutive days. The matched control group will be created after reaching 50 patients with schizophrenia. This will be followed by a comprehensive statistical analysis of the data set.

ETHICS AND DISSEMINATION

The study was registered prospectively in the German Clinical Trials Register (DRKS-ID: DRKS00023143,URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023143) after approval by the ethics committee of the University of Ulm, Germany Trial Code No. 280/20.

TRIAL REGISTRATION NUMBER

DRKS00023143; Pre-results.