Pseudoneurotic Symptoms in the Schizophrenia Spectrum: A Longitudinal Study of Their Relation to Psychopathology and Clinical Outcomes

BACKGROUND AND HYPOTHESIS

Nonpsychotic symptoms (depression, anxiety, obsessions, etc.) are frequent in schizophrenia-spectrum disorders and are usually conceptualized as comorbidity or transdiagnostic symptoms. However, in twentieth century foundational psychopathological literature, many nonpsychotic symptoms with specific phenomenology (here termed pseudoneurotic symptoms) were considered relatively typical of schizophrenia. In this prospective study, we investigated potential associations of pseudoneurotic symptoms with diagnostic status, functional outcome as well as psychopathological dimensions of schizophrenia.

STUDY DESIGN

First-admitted patients (N = 121) diagnosed with non-affective psychosis, schizotypal disorder, or other mental illness were examined at initial hospitalization and 5 years later with a comprehensive assessment of psychopathology. Informed by the literature, we constructed scales targeting pseudoneurotic symptoms and other, more general, nonpsychotic symptoms.

STUDY RESULTS

Pseudoneurotic symptoms aggregated in schizophrenia-spectrum groups compared to other mental illnesses and occurred at similar levels at baseline and follow-up. They longitudinally predicted poorer social and occupational functioning in schizophrenia-spectrum patients over a 5-year-period but not transition to schizophrenia-spectrum disorders from other mental illnesses. Finally, the level of pseudoneurotic symptoms correlated with disorder of basic self at both assessments and with positive and negative symptoms at follow-up. The scale targeting general nonpsychotic symptoms did not show this pattern of associations.

CONCLUSIONS

The study supports that a group of nonpsychotic symptoms, ie, pseudoneurotic symptoms, are associated with schizophrenia-spectrum disorders and linked with temporally stable psychopathology, particularly disorder of the basic self. Their prospective association with social and occupational functioning needs replication.

Disordered Selfhood in Schizophrenia and the Examination of Anomalous Self-Experience: Accumulated Evidence and Experience

Disordered selfhood in schizophrenia was rediscovered at the turn of the millennium. In 2005, Psychopathology published the psychometric instrument, the Examination of Anomalous Self-Experience (EASE). In this article, we summarize the historical background of the creation of the EASE, explicate the notion of the disorder of basic or minimal self with the help of phenomenological philosophy, and provide a brief description of clinical manifestations targeted by the EASE. We also present our personal experience using and teaching the EASE and summarize the empirical evidence obtained so far. We conclude that the basic self-disorder represents a crucial phenotype of schizophrenia spectrum disorders and that this phenotype offers a potential avenue to empirical pathogenetic research and psychotherapeutic treatment.

"Transition" to Schizophrenia or Fluctuations within the Same Disorder?

BACKGROUND

To prevent or delay the onset of psychotic disorders or ameliorate their course, prodromal research has strived to identify and treat individuals at risk of developing psychosis. While this approach is laudable, it is, however, not entirely unproblematic from clinical and conceptual perspectives. For example, it remains unclear how we are to understand the development from a nonpsychotic, distressing condition such as schizotypal disorder to a psychotic disorder such as schizophrenia? The current terminology on the subject implies either a nonlinear jump ("conversion") or a more linear progression ("transition") from one disorder to another. To enrich our understanding of such diagnostic shifts, we examined the psychopathological pictures of patients who "transitioned" from schizotypal disorder to schizophrenia.

METHODS

From a larger study on psychopathology, we examined 40 patients who were diagnosed with schizotypal disorder at baseline. At 5-year follow-up, 30 patients maintained the diagnosis of schizotypal disorder, while 10 were re-diagnosed with schizophrenia. We examined detailed descriptions of the 10 patients who progressed to schizophrenia, comparing psychopathology and level of functioning.

RESULTS

The level of functioning decreased slightly from baseline to follow-up in 9 out of 10 patients. Eight patients had previously had micro-psychotic or psychotic experiences. All patients had self-disorders at baseline, and several patients had perceptual disorders. Nine patients had formal thought disorders at baseline. The progression is illustrated by 2 cases.

CONCLUSION

In this small study, we did not find any striking changes in any of the patients, neither in terms of psychopathological manifestations nor in terms of their level of functioning. Thus, rather than witnessing a genuine "conversion" or "transition" from schizotypal disorder to schizophrenia, we observed dimensional fluctuations within the same condition.

Self-Disorders in Asperger Syndrome Compared to Schizotypal Disorder: A Clinical Study

OBJECTIVE

There are historical and theoretical indications of a difference in subjective experience between autism spectrum disorder (ASD) and the schizophrenia spectrum. However, this difference has not been empirically explored. Therefore, to explore potential differences in subjective experience between the 2 spectra, we examined the presence/absence of self-disorders in Asperger syndrome/autism spectrum disorder (As/ASD) compared to schizotypal disorder (Sd). Self-disorders represent changes in basic self-awareness which have been found to accumulate within the schizophrenia spectrum.

METHODS

All participants were recruited from clinical units and interviewed with a focus on the exploration of presence/absence of self-disorders, with the Examination of Anomalous Self-Experience (EASE) scale, and a general assessment of present psychopathology, with Schedules for Clinical Assessment in Neuropsychiatry (SCAN).

RESULTS

A total of 51 participants (As/ASD, n = 22; Sd, n = 29) were included in the statistical analyses. When controlling for age, gender, years of education, mental problems before the age of 16, and special needs school attendance, there was a clear difference in presence/absence of self-disorders between the 2 groups, with significantly higher levels in the Sd group. Further, there was an overlap in SCAN-rated symptoms between the 2 groups.

CONCLUSION

Our results indicate a significant difference between As/ASD and Sd at the level of the basic self, which, in turn, indicates that an exploration of anomalous self-experience is a valuable supplement in the clinical differentiation between As/ASD and Sd.

Arguments for a Phenomenologically Informed Clinical Approach to Autism Spectrum Disorder

OBJECTIVE

The aim of this paper is to provide arguments for a phenomenologically informed clinical approach to autism spectrum disorder (ASD), including a plea for clinical attention to the self in ASD.

METHODS

Central concepts of continental phenomenology, phenomenological psychopathology, and the phenomenological interview are presented, with an emphasis on the potential unifying qualities of an approach which includes the exploration of subjective and intersubjective experience. These phenomenological concepts and methods are contrasted with the current conceptualization of ASD, where the first-person perspective is not in focus.

RESULTS

Contemporary phenomenological papers on ASD address key concepts like intersubjectivity, intercorporeality, and intentionality. However, insights from this theoretical field have not been followed up in clinical research and practice. Consequently, there is (to our knowledge) still a lack of phenomenologically informed clinical explorations of experience of self, others, and the world in ASD.

CONCLUSION

A phenomenologically informed focus on the form and structure of subjective experience, including a focus on self-experience in ASD, can lead to new and important insights in relation to clinical differentiation between ASD and schizophrenia spectrum disorder.

A Sensitive Solid-Phase Immunosorbent Assay for Tissue-Type Plasminogen Activator Activity in Plasma Using Trinitrobenzoylated Poly-D-Lysine as a Stimulator for Plasminogen Activation

A sensitive, specific and precise immunosorbent assay for tissue-type plasminogen activator (t-PA) activity in plasma was developed. It measured the single-chain and the two-chain forms of t-PA with equal sensitivity. The assay involved (I) coating of wells in microtiter plates with a monoclonal antibody directed towards an epitope on t-PA apart from the catalytic active site, (II) binding of t-PA to the solid-phase antibody, (III) activation of plasminogen by antibody-bound t-PA in the presence of a new potent stimulator, trinitrobenzyl alkylated poly-D-lysine (TNB-poly-D-Lysine) and measurement of plasmin activity with D-Val-Leu-Lys-pNA. Plasma samples were acid-treated and diluted 80 times in order to minimize the inhibitory effect of plasma on the assays. The assay could be performed within one working day with precoated microtiter plates.

The sensitivity of the assay for t-PA in plasma was 1 pM (~70 ng/1). The recoveries of single-chain and two-chain t-PA added to plasma was 97-104%. The intraassay coefficient of variation was 3.4-5.1% and the interassay coefficient of variation was 7.8-18%. Resting values of t-PA in plasma for 42 healthy subjects ranged between 0 and 30 pM (median: 4.1 pM). The values after 10 min venous occlusion ranged between 1.2 and 520 pM (median: 100 pM). The t-PA concentrations determined by the immunosorbent assay correlated well with euglobulin clot lysis time measurements (r = 0.940).

EASE: Examination of Anomalous Self-Experience

Skala EASE jest listą objawów do częściowo ustrukturalizowanego fenomenologicznego badania subiektywnych lub empirycznych nieprawidłowości (anomalii), które można uznać za zaburzenia podstawowej, „minimalnej” samoświadomości. EASE opracowana została na podstawie samoopisów otrzymanych od pacjentów chorujących na zaburzenia ze spektrum schizofrenii. Skala ma duże znaczenie dla opisu, diagnozy oraz diagnozy różnicowej zaburzeń ze spektrum schizofrenii. Prezentowana wersja zawiera istotne szczegółowe kwestie dotyczące zbierania wywiadu oraz opisy objawów psychopatologicznych (Podręcznik), arkusz wyników (Aneks A), listę pozostałych pozycji Skali stosowanych w czasie wywiadu (Aneks B) oraz porównawczą listę pozycji EASE/BSABS (Bonner Skala für die Beurteilung von Basissymptomen, Bońska Skala do Oceny Objawów Podstawowych) (Aneks C).

Temporal persistence of anomalous self-experience: A 5years follow-up

BACKGROUND

The concept of self-disorders in schizophrenia has gained substantial interest and it has now been established empirically that self-disorders aggregate in schizophrenia-spectrum disorders but not in other mental disorders or in healthy controls. Yet, the issue of temporal persistence has not been addressed.

AIM

The aim of this study is to examine the temporal persistence of self-disorders.

METHODS

96 first admission patients were thoroughly assessed for psychopathology including SD at baseline and again 5years later. We created a 25-item self-disorder scale which was used both at baseline and follow-up to assess self-disorders. The scale was a pre-cursor of the later published EASE-scale. Additionally, we examined the development of positive and negative syndromes and of the Global Assessment of Functioning (GAF).

RESULTS

There was a high correlation between self-disorders at baseline and at follow-up, and the majority of the items in self-disorders scale showed equal proportions between baseline and follow-up.

CONCLUSION

Self-disturbances showed a high level of persistence at 5-year follow-up.

Schizophrenia symptoms and functioning in patients receiving long-term treatment with olanzapine long-acting injection formulation: a pooled analysis

BACKGROUND

This analysis of pooled data evaluates treatment outcomes of patients with schizophrenia receiving maintenance treatment with olanzapine long-acting injection (OLAI) by means of a categorical approach addressing the symptomatic and functional status of patients at different times.

METHODS

Patients were grouped into 5 categories at baseline, 6 months, and 12 months. Shifts between categories were assessed for individual patients and factors associated with improvement were analyzed. 1182 patients from 3 clinical trials were included in the current analysis.

RESULTS

At baseline, 434 (36.8%) patients had minimal Positive and Negative Syndrome Scale (PANSS) symptoms but seriously impaired Heinrich Carpenter's Quality of Life Scale (QLS) functioning; 303 (25.6%) had moderate to severe symptoms and seriously impaired function; 208 (17.6%) had mild to moderate symptoms but good functioning, and 162 (13.7%) had minimal symptoms and good functioning. Baseline category was significantly associated with Clinical Global Impression--Severity (CGI-S), extrapyramidal symptoms, working status, age, and number of previous episodes. The majority of all patients starting OLAI treatment maintained or improved (62% at 6 months and 52% at 12 months) their symptom and functioning levels on OLAI maintenance treatment. Less than 8% of the patients showed worsening of symptoms or functioning. An improvement in category was associated with high PANSS positive and low CGI-S scores at baseline.

CONCLUSIONS

We present evidence that a composite assessment of schizophrenic patients including symptom severity and functioning is helpful in the evaluation of maintenance treatment outcomes. This approach could also be useful for the assessment of treatment options in clinical practice.The trials from which data are reported here were registered on clinicaltrials.gov as NCT00088491, NCT00088465, and NCT00320489.

Improvement in patient symptoms and functioning during long-term treatment with olanzapine long-acting injection (OLAI)

Introduction, objectives and aims

To evaluate the outcome of patients with schizophrenia during maintenance treatment with OLAI.

Methods

Data from three studies with OLAI were pooled and patients classified according to a cluster analysis [Lipkovich, Psychiatry Res, 2009] into five categories according severity of psychiatric symptoms (sx) and functional impairment (imp):A

Improvement was defined as a change from B or C to A, or from D or E to A, B or C. Changes between the categories in the 6 months were analyzed. Stepwise logistic regression modeling was done to determine factors associated with improvement.

Results

1182 patients were classified. Patients who remained in the studies at 6 months had lower baseline CGI-S (3.04 vs 3.28, p < 0.001), lower PANSS (61.38 vs 64.05, p = 0.012) and higher QLS (1.76 vs 1.39, p = 0.001). (Table 1) As patients in category A couldn’t improve and in category D&E couldn’t worsen, 261(39%) patients from categories B, C, D and E improved and only 55(10%) from categories A, B and C got worse during 6 months. Baseline factors associated with improvement were: baseline category (p < 0.001), CGI-S score (p = 0.022), and PANSS positive (p = 0.003)

Conclusions

Majority of patients with schizophrenia who stay on 6 months treatment with OLAI improve or maintain their symptoms and functioning level. The strongest factor associated with a higher chance of improvement was poor baseline category.

The diagnostic status of first-rank symptoms

OBJECTIVE

In the International Statistical Classification of Diseases, Tenth Revision(ICD-10) and Diagnostic and Statistical Manual of Mental Disorder, Third and Fourth Edition(DSM-III-IV), the presence of one of Schneider "first-rank symptoms" (FRS) is symptomatically sufficient for the schizophrenia diagnosis. Yet, it has been claimed that FRS may also be found in the nonschizophrenic conditions, and therefore, they are not specific or diagnostic for schizophrenia. This review was made to clarify the issue of diagnostic specificity.

METHODS

(1) A critical review of FRS studies published in English between 1970 and 2005. (2) A highlight of the 5 most frequently cited studies identified in the Web of Science. (3) Theoretical implications of the epistemological issues of FRS.

RESULTS

The reviewed studies do not allow for either a reconfirmation or a rejection of Schneider's claims about FRS. The sources of disagreement between the studies are (1) including or excluding acute patients with potential degradation of consciousness; (2) assessing or not the phenomenological context; (3) assessing patients in different stages of their illness evolution; and (4) differential emphasis on mood symptoms and history of psychiatric symptoms.

CONCLUSION

Both DSM-IV and ICD-10 emphasize FRS to a degree that is not supported by the empirical evidence. Until the status of FRS is clarified in depth, we suggest that the FRS, as these are currently defined, should be de-emphasized in the next revisions of our diagnostic systems. Future studies aiming at validation of FRS as diagnostic features need to apply a phenomenological perspective and include a homogenous group of patients across a wide spectrum of diagnoses.

Premorbid IQ varies across different definitions of schizophrenia

The nature of the association between IQ and schizophrenia is still unclear. So far no study addressed this issue in relation to the breadth or scope of the very concept of schizophrenia. We examined the premorbid IQ in a polydiagnostic study with four classifications of schizophrenia: ICD-8/9, ICD-10, St. Louis and Flexible System-Wide. Only the ICD-10 schizophrenia patients exhibited a significantly lower premorbid IQ. There were suggestive differences between the four examined systems as well as between the ICD-10 paranoid and non-paranoid subtypes. Exploration of crucial diagnostic features of schizophrenia in relation to IQ revealed associations between low premorbid IQ and hallucinations as well as negative symptoms. It is concluded that premorbid IQ varies across different definitions of schizophrenia.

Reliability of measuring anomalous experience: the Bonn Scale for the Assessment of Basic Symptoms

BACKGROUND

Studying subjective experience, apart from preformed self-rating questionnaires, has nearly vanished in psychiatry, partly due to reliability concerns. Recent research in early detection of schizophrenia has entailed an increasing interest in the subtle experiential anomalies that may assist in identifying the patients at risk of psychosis. Some of these anomalies are described in the Bonn Scale for the Assessment of Basic Symptoms (BSABS). We examined the reliability of this instrument.

SAMPLING AND METHOD

18 hospitalised patients accepted to participate in a psychopathological interview assessing BSABS items, affective and psychotic symptoms.

RESULTS

Out of the total 79 BSABSitems examined,we found an interrater reliability kappa >0.60 in 68 items (86%).

CONCLUSION

Good reliability can be achieved using BSABS.

Clinical characteristics of first-admitted patients with ICD-10 schizotypal disorder

BACKGROUND

The clinical picture of schizotypal disorders is rarely comprehensively described.

AIMS

To describe psychopathological profiles of patients with ICD-10 schizotypal disorder.

METHOD

A total of 151 first-admitted patients (with affective and somatic disorders excluded) were given a comprehensive psychopathological evaluation, including the Bonn Scale for the Assessment of Basic Symptoms. Patients with schizotypal disorder (n=50) were compared with those with psychosis (n=51) and those outside the schizophrenia spectrum (other diagnoses, n=50) on a number of psychopathological scales.

RESULTS

Patients with schizotypal disorder scored intermediately between patients with psychosis and other diagnoses on scales related to positive and negative symptoms, disorders of emotional contact and formal thought disorder, but had the same scores as patients with schizophrenia for subtle aberrations of subjective experience. Schizotypal criteria were not normally distributed with an excess of patients between 2 and 6 criteria. Family history of schizophrenia was equally elevated among those with schizotypal disorder and those with psychosis.

CONCLUSIONS

ICD-10 schizotypy represents a milder, less psychotic, variant of schizophrenia but there is no clear-cut division between the two disorders.

Anomalous subjective experience among first-admitted schizophrenia spectrum patients: empirical investigation

Our research group has for several years conducted philosophically informed, phenomenological-empirical studies of morbid alterations of conscious experience (subjectivity) in schizophrenia (Sz) and its spectrum of disorders. Some of these experiential alterations constitute, in our view, the vulnerability markers to Sz--indicators that are intrinsic to this disorder and which were historically considered as constituting the phenotypic anchor of the very concept and the diagnostic validity of Sz spectrum disorders. In a more pragmatic clinical context, these indicators, considered here as symptoms, may be potentially effective for early differential diagnosis. In this study, 151 consecutive first-admitted patients (with bipolar, melancholic and organic patients excluded) diagnosed according to the ICD-10, were evaluated on a number of expressive and experiential psychopathological dimensions, with special emphasis on the experiences of perplexity, disorders of self-awareness, perceptual disorders and anomalous bodily experiences. The a priori scales derived from the item pool of a slightly modified OPCRIT and BSABS were used for analyses. Sz and schizotypal disorder scored equally on the subjective dimensions, suggesting a basic phenomenological affinity of these disorders. In contrast, anomalies of subjective experience were clearly more pronounced among the patients within, as compared to those outside the Sz spectrum.

Thinking within the spectrum: schizophrenic thought disorder in six Danish pedigrees

Formal thought disorder (FTD), a major symptom of schizophrenia, is known to aggregate in families. Our aim was to examine the specificity of FTD in the schizophrenia spectrum disorders and the hypothesized linear aggregation of FTD within pedigrees. Six individuals with a diagnosis of schizophrenia were identified in the Copenhagen High-Risk study and each pedigree was centered on one of the six original schizophrenic probands' nuclear families. The 329 pedigree members in the study were considered at risk for schizophrenia spectrum disorders because most were genetically related to the originating schizophrenic probands. The participants were administered the Copenhagen Interview of Functional Illness to determine diagnoses and the Thought Disorder Index (TDI) was used to assess FTD. Individuals with a schizophrenia diagnosis had higher global levels of FTD, exhibited more severe types of FTD, and had a qualitatively different type of FTD than did participants with other diagnoses or no mental illness. Individuals with Cluster A diagnoses exhibited more FTD and FTD similar in quality to participants with schizophrenia. These results support the construct of a spectrum of schizophrenia conditions. There was a generally high level of FTD in the pedigrees, in part due to assortative mating in this sample. However, there was no apparent pattern of linear aggregation of FTD within the families.

Anomalies of subjective experience in schizophrenia and psychotic bipolar illness

OBJECTIVE

Contemporary psychopathology, as a result of behaviourally dominated epistemological stance, downplays anomalies of the patient's subjectivity. This neglect has probably deleterious consequences for research in the causes and the boundaries of the schizophrenia spectrum conditions. The purpose of this study is to explore frequency of qualitative, not-yet-psychotic, anomalies of subjective experience in patients with residual schizophrenia and psychotic bipolar illness in remission.

METHOD

The patients were examined with the Danish version of the Bonn Scale for the Assessment of Basic Symptoms (BSABS). Anomalies of experience were condensed into rational scales with good internal consistencies.

RESULTS

Diagnosis of schizophrenia was associated with elevated scores on the scales measuring perplexity (loss of immediate meaning), disorders of perception, disorders of self-awareness, and marginally so, disorders of cognition.

CONCLUSION

These findings, in conjunction with those from other, methodologically similar studies, suggest that certain anomalies of subjective experience aggregate significantly in schizophrenia. These experiential anomalies appear to be relevant for early differential diagnosis and therefore potentially useful in the preonset detection of the schizophrenia spectrum illness.

Phenomenology of anomalous self-experience in early schizophrenia

Disorders of self-experience were emphasized in classic literature and in phenomenological psychiatry as essential clinical features of the schizophrenia spectrum disorders, but are neglected in the contemporary psychopathology due to epistemologically motivated distrust of studying anomalies of subjectivity. Based on our own and other empirical studies, we present here detailed clinical phenomenological descriptions of nonpsychotic anomalies of self-experience that may be observable in the prodromal phases of schizophrenia and in the schizotypal disorders. Anomalies of self-experience are grouped according the experiential domain that appears to be affected and are illustrated by short vignettes or verbatim quotes from the patients. It is suggested that disorders of the self deserve further systematic empirical investigations, also from an etiological perspective. Self-disorders may turn out to be potentially useful as a psychopathological organizer of the schizophrenia spectrum disorders. Psychopathological emphasis on these disorders may also help to integrate the search for the neurodevelopmental mechanisms in schizophrenia with developmental-psychological research on the ontogenesis of the self.

[Aspiration pneumonia caused by an alternative drug]

A case of aspiration pneumonia caused by an alternative drug in a 86-year old women is presented. Complications in the form of acute myocardial infarction with pulmonary oedema and left bundle branch block led to the death of the patient.

A sensitive solid-phase immunosorbent assay for tissue-type plasminogen activator activity in plasma using trinitrobenzoylated poly-D-lysine as a stimulator for plasminogen activation

A sensitive, specific and precise immunosorbent assay for tissue-type plasminogen activator (t-PA) activity in plasma was developed. It measured the single-chain and the two-chain forms of t-PA with equal sensitivity. The assay involved (I) coating of wells in microtiter plates with a monoclonal antibody directed towards an epitope on t-PA apart from the catalytic active site, (II) binding of t-PA to the solid-phase antibody, (III) activation of plasminogen by antibody-bound t-PA in the presence of a new potent stimulator, trinitrobenzyl alkylated poly-D-lysine (TNB-poly-D-lysine) and measurement of plasmin activity with D-Val-Leu-Lys-pNA. Plasma samples were acid-treated and diluted 80 times in order to minimize the inhibitory effect of plasma on the assays. The assay could be performed within one working day with precoated microtiter plates. The sensitivity of the assay for t-PA in plasma was 1 pM (approximately 70 ng/l). The recoveries of single-chain and two-chain t-PA added to plasma was 97-104%. The intraassay coefficient of variation was 3.4-5.1% and the interassay coefficient of variation was 7.8-18%. Resting values of t-PA in plasma for 42 healthy subjects ranged between 0 and 30 pM (median: 4.1 pM). The values after 10 min venous occlusion ranged between 1.2 and 520 pM (median: 100 pM). The t-PA concentrations determined by the immunosorbent assay correlated well with euglobulin clot lysis time measurements (r = 0.940).