Bizarre delusions and DSM-III-R schizophrenia

Demographic and clinical characteristics associated with a history of bizarre delusions in a cross-diagnostic sample of individuals with psychotic disorders

Bizarre delusions (BizD) are not specific to schizophrenia (SZ) and can be found in other psychotic disorders. However, to date, there are no studies investigating socio-demographic and clinical characteristics associated with BizD across the psychosis spectrum. In this study 819 subjects with a diagnosis of SZ (n = 250), schizoaffective disorder (SZA) (n = 228) and bipolar I disorder (BD) (n = 341) were included. Patients with history of BizD and with no BizD were compared with respect to socidemographic and clinical variables, and predictors of BizD were explored. Patients with BizD were less educated, less likely to be married, had higher Positive and Negative Syndrome Scale (PANSS) negative scores and lower Young Mania Rating Scale scores. Younger age, SZ and SZA diagnoses, higher PANSS positive scores, presence of reference delusions, tactile and olfactory hallucinations were predictors. Our results indicate that BizD are associated with higher illness severity, lower functionality and specific set of symptoms.

Impact of DSM-5 changes on the diagnosis and acute treatment of schizophrenia

OBJECTIVE

To examine the consequences and validity of changes in Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnostic criteria for schizophrenia, eg, omission of subtypes, using a large dataset of double-blind, randomized, placebo-controlled schizophrenia trials.

METHODS

Data from 22 short-term efficacy registration trials of second generation antipsychotics for the treatment of acute psychotic episodes in patients with schizophrenia (N = 5233), submitted to the Dutch regulatory authority were analyzed. We examined whether patients in these pre-DSM-5 trials met the diagnostic criteria for schizophrenia according to DSM-5. Using linear regression, we examined differences in effect size between DSM-IV subtypes and between DSM-5 symptom dimensions.

RESULTS

Over 99.5% of the patients met DSM-5 diagnostic criteria for schizophrenia and no differences in effect size were found between schizophrenia subtypes (P = .65). Symptom dimensions that respond best to treatment with second generation antipsychotics were hallucinations, delusions, disorganized speech, and mania (Hedge's g -0.23 to -0.31).

CONCLUSIONS

Results of clinical trials in patients with pre-DSM-5 schizophrenia also apply to patients diagnosed with DSM-5 schizophrenia. Omission of the classic subtypes is justified as they are not predictive of response to treatment. The DSM-5 C-RDPSS scale adds valuable information to the categorical diagnosis of schizophrenia, which is relevant for antipsychotic response.

Self-Disturbance and the Bizarre: On Incomprehensibility in Schizophrenic Delusions

The notion of 'bizarre delusion' has come into question in contemporary anglophone psychopathology. In DSM-5, it no longer serves as a special criterion for diagnosing schizophrenia nor as an exclusion criterion for delusional disorder. Empirical studies influencing this development have, however, been relatively sparse and subject to methodological criticism. Major reviews have concluded that current conceptualizations of bizarre delusions may require rethinking and refinement. Defining bizarreness entails a return to Jaspers, whose influential views on the supposed incomprehensibility of bizarre delusions and schizophrenic experience are more nuanced than is generally recognized. Jaspers insisted we must 'get behind' three 'external characteristics' (extraordinary conviction, imperviousness, impossible content) in order to acknowledge a 'primary experience traceable to the illness' in the 'delusions proper' of schizophrenia. He also denied that one could empathize with or otherwise 'understand' this basis. Here, we focus on three features of bizarre delusions that Jaspers foregrounded as illustrating schizophrenic incomprehensibility: disturbance of the cogito, certitude combined with inconsequentiality, delusional mood. We link these with the contemporary ipseity disturbance model of schizophrenia, arguing that Jaspers' examples of incomprehensibility can be understood as manifestations of the three complementary aspects of ipseity-disturbance: diminished self-presence, hyperreflexivity and disturbed grip/hold. We follow Jaspers' lead in acknowledging a distinctive strangeness that defies ready comprehension, but we challenge the absolutism of Jaspers' skepticism by offering a phenomenological account that comprehends bizarreness in two ways: rendering it psychologically understandable, and fitting the various instances of bizarreness into a comprehensive explanatory framework.

Psychosis prediction and clinical utility in familial high-risk studies: selective review, synthesis, and implications for early detection and intervention

AIM

Accurate prediction of which high-risk individuals will go on to develop psychosis would assist early intervention and prevention paradigms. We sought to review investigations of prospective psychosis prediction based on markers and variables examined in longitudinal familial high-risk (FHR) studies.

METHODS

We performed literature searches in MedLine, PubMed and PsycINFO for articles assessing performance characteristics of predictive clinical tests in FHR studies of psychosis. Studies were included if they reported on one or more predictive variables in subjects at FHR for psychosis. We complemented this search strategy with references drawn from articles, reviews, book chapters and monographs.

RESULTS

Across generations of FHR projects, predictive studies have investigated behavioural, cognitive, psychometric, clinical, neuroimaging and other markers. Recent analyses have incorporated multivariate and multi-domain approaches to risk ascertainment, with generally modest results.

CONCLUSIONS

Although a broad range of risk factors has been identified, no individual marker or combination of markers can at this time enable accurate prospective prediction of emerging psychosis for individuals at FHR. We outline the complex and multi-level nature of psychotic illness, the myriad of factors influencing its development, and methodological hurdles to accurate and reliable prediction. Prospects and challenges for future generations of FHR studies are discussed in the context of early detection and intervention strategies.

Bizarre delusions: a qualitative study on Indian schizophrenia patients

BACKGROUND

Delusions are an important symptom for the diagnosis of schizophrenia (SZ) in both the commonly used international classificatory systems - the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV - American Psychiatric Association, 2000) and the International Classification of Diseases, X (ICD X - World Health Organization, 1992). Of special significance are "bizarre delusions" the presence of which is alone sufficient for a diagnosis of SZ in DSM IV. In an attempt to find out the frequency, criteria for classification, and other clinical aspects of bizarre delusions and justification of their importance in the diagnostic system, this retrospective study was conducted.

METHODOLOGY

Records of 1952 Indian patients affected with SZ, recruited for various research projects at one center were included in this study. All had a diagnosis of DSM IV SZ; all symptoms of SZ from the Diagnostic Interview for Genetic Studies were asked regardless of the presence of specific symptoms - like bizarre delusions - sufficient for diagnosis.

RESULTS

The prevalence of bizarre delusions was 2.56%. Five themes, identified on analyzing their contents are described. Main themes were unnatural, bodily sensation, change in identity, sexual, and religious.

CONCLUSIONS

These themes were culture based, but definitely out of context, excessive or extremely odd. Moreover, the rarity of bizarre delusions makes it difficult to include them as a sole criterion for diagnosis.

The special treatment of first rank auditory hallucinations and bizarre delusions in the diagnosis of schizophrenia

The presence of a single first-rank auditory hallucination (FRAH) or bizarre delusion (BD) is sufficient to satisfy the symptom criterion for a DSM-IV-TR diagnosis of schizophrenia. We queried two independent databases to investigate how prevalent FRAH and BD are in schizophrenia spectrum disorders and whether the diagnosis depends on them. FRAH was common in both datasets (42.2% and 55.2%) and BD was present in the majority of patients (62.5% and 69.7%). However, FRAH and BD rarely determined the diagnosis. In the first database, we found only seven cases among 325 patients (2.1%) and in the second database we found only one case among 201 patients (0.5%) who were diagnosed based on FRAH or BD alone. Among patients with FRAH, 96% had delusions, 14-42% had negative symptoms, 15-21% had disorganized or catatonic behavior, and 20-23% had disorganized speech. Among patients with BD, 88-99% had hallucinations, 17-49% had negative symptoms, 20-27% had disorganized or catatonic behavior, and 21-25% had disorganized speech. We conclude that FRAH and BD are common features of schizophrenia spectrum disorders, typically occur in the context of other psychotic symptoms, and very rarely constitute the sole symptom criterion for a DSM-IV-TR diagnosis of schizophrenia.

Do we have any solid evidence of clinical utility about the pathophysiology of schizophrenia?

A diagnosis of schizophrenia, as in most of psychiatric practice, is made largely by eliciting symptoms with reference to subjective, albeit operationalized, criteria. This diagnosis then provides some rationale for management. Objective diagnostic and therapeutic tests are much more desirable, provided they are reliably measured and interpreted. Definite advances have been made in our understanding of schizophrenia in recent decades, but there has been little consideration of how this information could be used in clinical practice. We review here the potential utility of the strongest and best replicated risk factors for and manifestations of schizophrenia within clinical, epidemiological, cognitive, blood biomarker and neuroimaging domains. We place particular emphasis on the sensitivity, specificity and predictive power of pathophysiological indices for making a diagnosis, establishing an early diagnosis or predicting treatment response in schizophrenia. We conclude that a number of measures currently available have the potential to increase the rigour of clinical assessments in schizophrenia. We propose that the time has come to more fully evaluate these and other well replicated abnormalities as objective potential diagnostic and prognostic guides, and to steer future clinical, therapeutic and nosological research in this direction.

What is bizarre in bizarre delusions? A critical review

Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) treats the presence of bizarre delusions (BD) as the heaviest-weighted clinical criterion of schizophrenia. Although BD play a major role in contemporary diagnostic systems, only a few empirical studies explore this issue. These studies provide highly heterogenous results because they are based on different experimental paradigms, in terms of definition, clinical sample, and number of raters. Here, we first discuss the psychopathological sources of the concept of BD, which were initially described as either nonsensical or incomprehensible. Then, we provide a critical review of contemporary studies on the reliability of BD and their methodological and conceptual limitations. Current approaches have focused intensely on BD's reliability and have defined BD strictly in terms of delusional content--mainly in terms of the physical impossibility or the cultural or historical incomprehensibility of the delusional claims. These approaches have neglected formal features of experience that underlie BD and the crucial issue of the nature and validity of BD. In the discussion, we argue that clinical diagnosis of BD cannot be limited to delusional contents alone and requires taking into account the subjective side of BD (how altered experience manifests itself) as well as the conditions of intersubjective encounter (how BD are expressed to and experienced by the clinician). The notion of "bizarreness" in schizophrenia is not purely theoretical; it has practical relevance for the therapeutic encounter and implications on further empirical research and on diagnostic approaches.

Inferior parietal lobule volume and schneiderian first-rank symptoms in antipsychotic-naïve schizophrenia: a 3-tesla MRI study

BACKGROUND

As per Frith's neuro-cognitive model, inferior parietal lobule (IPL) is implicated in the pathogenesis of Schneiderian first-rank symptoms (FRS) in schizophrenia. The specific role of IPL structural abnormalities in the pathogenesis of FRS is yet to be ascertained.

MATERIALS AND METHODS

Using 3-tesla MRI scanner, this first-time study examined antipsychotic-naïve schizophrenia patients ( n = 28) (patients with FRS [FRS +]: N = 14, M: F = 7:7; and patients without FRS [FRS-]: N = 14, M: F = 7:7) in comparison with sex-, handedness-, education- and socioeconomic status-matched healthy controls (n = 14, M: F = 7:7). The volume of IPL was measured using a three-dimensional, interactive, semi-automated analysis, with good inter-rater reliability.

RESULTS

FRS + patients showed significant volume deficit in right IPL in comparison with healthy controls (F = 4.0; P=.028) after controlling for the potential confounding effects of age, sex and intracranial volume.

CONCLUSIONS

Right IPL volume deficit in FRS+patients adds further support to the Frith's model of FRS in schizophrenia.

Diagnosing delusions: a review of inter-rater reliability

Although several studies have examined the reliability of diagnosing delusions there is no comprehensive review of the literature. Therefore, the reliability of diagnosing 'delusions in general' and the subcategory of 'bizarre delusions' was reviewed, including both structured interview and standardized instrument methods. The literature suggests that delusions in general can be diagnosed reliably with both structured interview and standardized instruments. However, bizarre delusions are not reliably diagnosed by either, suggesting that this concept may have little clinical validity. Nevertheless, many of the studies reviewed are poorly designed or subject to significant confounds. Criteria are suggested for adequate future studies.

Do different psychotic experiences differentially predict need for care in the general population?

INTRODUCTION

The pathway from subclinical psychotic experiences to need for care may depend on type of psychotic experience, level of associated distress, and previous experience of psychosis.

METHOD

In a general population sample with no previous Diagnostic and Statistical Manual of Mental Disorders , Revised Third Edition , psychotic disorder (n = 4722), 83 subjects displayed at least one psychotic experience. Within the group of 83, subjects with (n = 24) and without need for care (n = 59) were compared. Presence of psychotic experiences at younger ages had been assessed at earlier interviews.

RESULTS

Of 7 different psychotic experiences, only hearing voices, nonverbal hallucinations, and passivity phenomena were significantly associated with need for care. These associations were largely explained by the distress associated with the psychotic experience, but whether individuals had had psychotic experiences at earlier ages did not matter.

CONCLUSIONS

Different psychotic experiences differ in the associated level of need for care and the mediating role of distress. Longer prior exposure to psychosis may not influence the pathway from subclinical to clinical.

Diagnostic significance of Schneider's first-rank symptoms in schizophrenia. Comparative study between schizophrenic and non-schizophrenic psychotic disorders

BACKGROUND

Despite the lack of consistent empirical support, modern diagnostic criteria of schizophrenia give particular emphasis to Schneider's first-rank symptoms (FRSs).

AIMS

To examine the diagnostic significance of FRSs for schizophrenia by trying to overcome the limitations of previous studies.

METHODS

This study examined the diagnostic accuracy of FRSs for schizophrenia in 660 in-patients with the full spectrum of functional psychotic disorders. Schizophrenia was diagnosed according to three criteria: DSM-III-R broad, DSM-III-R narrow and Feighner, the latter being considered as the gold standard because it does not give particular emphasis of FRSs.

RESULTS

FRSs were highly prevalent in both schizophrenia and non-schizophrenic psychoses. The likelihood ratios (and 95% CI) of one or more FRSs for Feighner, DSM-III-R narrow and DSM-III-R broad schizophrenia were 1.06 (0.94-1.20), 1.23 (1.09-1.39) and 1.73 (1.44-2.08), respectively. These data indicate that FRSs do not significantly increase the likelihood of having schizophrenia.

CONCLUSIONS

FRSs are not useful in differentiating schizophrenia from other psychotic disorders. Diagnostic systems for schizophrenia that are heavily based on these symptoms may arise from a tautological definition of the disorder.

Monozygotic twins, folie à deux and heritability: a case report and critical review

A case report of shared delusional disorder, with a primary diagnosis of delusional disorder, is described in identical twins of proven zygosity. A review of literature shows that the primary diagnosis in identical twin pairs, suffering from folie à deux, is delusional disorder. This is in contrast to the reported excess of schizophrenia, as a primary diagnosis, in non-twin cases of folie à deux. Moreover, schizophrenia is poorly related to delusional disorders on the basis of demographic and familial studies. In the light of this paradox, nosological status of this disorder and the sociogenic and genetic factors are critically discussed.

Psychopathology: an edgeless razor?

The declining value of schneiderian first-rank symptoms (FRS) in differentiating between the two major functional psychoses has raised questions as to the utility of psychopathological concepts. In current diagnostic systems such as DSMs, psychopathological criteria and chiefly schneiderian symptoms have been used for nosographical purposes. It must be clear that this nosographically oriented use of psychopathology is only one aspect of the psychopathological enterprise. Indeed, while clinical psychopathology is essentially aimed at the identification of symptoms that are significant in view of nosographical distinctions, the specificendeavor of general psychopathology might be conceived as the organization of internal experiences around a core of meaningfulness, regardless of nosographical attributions. We seek to legitimate the value of psychopathological investigation and concepts as independent from any nosographical concern, and propose the concept of "psychopathological organizers" as synthesizing schemes of comprehension aimed at connecting different pathological experiences into unitary cores of meaningfulness.

Bizarre delusions and first-rank symptoms in a first-admission sample: a preliminary analysis of prevalence and correlates

This report examines the prevalence and correlates of bizarre delusions and Schneider's first-rank symptoms (FRS) in a first-admission sample with psychosis. A total of 196 patients were assessed with the Structured Clinical interview for DSM-III-R (SCID) and given a consensus diagnosis. Project psychiatrists blind to the consensus diagnoses coded each delusion and hallucination in the sample for both FRS and DSM-III-R bizarreness. Interrater reliability of bizarreness was lower than that of FRS (kappa = .681 v 861). The majority of symptoms (72%) were neither bizarre nor FRS, and of the remainder, bizarre delusions that were not also FRS were extremely uncommon. The prevalence of FRS was 70% in schizophrenia, 29% in psychotic bipolar disorder, and 18% in psychotic depression. For seven schizophrenic patients (7.45%), diagnosis of that disorder depended on the presence of a DSM-III-R bizarre delusion to meet criteria. There was a trend for FRS to be associated with poorer prognostic features in the schizophrenic sample. We concluded that although the constructs of bizarre delusions and FRS overlap, FRS were a more important feature in schizophrenia than bizarreness. The rarity of bizarre delusions that were not FRS, combined with the lower reliability of their assessment as compared with that of FRS, raises questions about the continued emphasis on this phenomenon in the definition of schizophrenia.