درمان خاص توهمات شنوایی درجه اول و هذیان های عجیب در تشخیص اسکیزوفرنی

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.

In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the diagnosis of schizophrenia can be made with just one criterion A symptom if that symptom is auditory hallucinations characterized by running commentary (RC) or voices conversing (VC), or bizarre delusions (BD) (APA, 2000). RC and VC are first-rank symptoms (FRS), proposed to distinguish schizophrenia from other psychoses (Schneider, 1959), and we will use the term first-rank auditory hallucinations (FRAH) to refer to these. BD, according to the DSM-IV-TR, are delusions that are “clearly implausible and not understandable and not derived from ordinary life experiences.” Some BD involve the delusion of control by others, including the control of the person's thought (thought insertion, thought withdrawal, and thought broadcasting). These delusions are also referred to as alien control or passivity phenomena. FRAH and BD were thought to be particularly characteristic of schizophrenia and were thus accorded special diagnostic significance in the DSM, beginning with the DSM-III-R (APA, 1987). There are problems, however, with rating FRAH and BD. The inter-rater reliability for BD is variable, with kappa coefficients ranging from 0.28 to 0.92 (Kendler et al., 1983, Flaum et al., 1991, Goldman et al., 1992, Spitzer et al., 1993, Mojtabai and Nicholson, 1995, Tanenberg-Karant et al., 1995 and Nakaya et al., 2002). The definition of BD is ambiguous, particularly regarding whether emphasis should be placed on form vs. content, and the validity of BD as currently operationalized in the DSM has been questioned (Mullen, 2003 and Cermolacce et al., 2010). Inter-rater reliability for FRAH is higher: Peralta and Cuesta (1999) report kappa values of 0.63 for RC and 0.70 for VC; Carpenter and Strauss (1974) report r = 0.76 for RC and for VC; and in the International Pilot Study of Schizophrenia (IPSS), the mean reliability for examiners within a study center was high (r = 0.87) for VC (Wing and Nixon, 1975). However, reliability between study centers was still highly variable (r = 0.37 to 0.95) (Wing and Nixon, 1975). Determining the prevalence of FRAH in schizophrenia has also been problematic, with estimates ranging from 10 to 40% for RC, 0 to 34% for VC, and 22 to 48% for cases with at least one FRAH (Mellor, 1970, Carpenter and Strauss, 1974, Zarrouk, 1978, Chandrasena and Rodrigo, 1979, Bland and Orn, 1980, Lewine et al., 1982, Ahmed and Naeem, 1984, Marneros, 1984, Gureje and Bamgboye, 1987, Malik et al., 1990, Salleh, 1992, Peralta and Cuesta, 1999, Thorup et al., 2007 and Shinn et al., 2012). The variations in FRAH estimates may reflect different clinical and cultural contexts (Chandrasena, 1987), and may be due to the variable use of narrow or wide interpretations of FRAH (Koehler, 1979 and O'Grady, 1990), as well as the use of different diagnostic criteria for schizophrenia when determining FRAH base rates (Nordgaard et al., 2008). Furthermore, neither FRAH (Shinn et al., 2012) nor BD (Carpenter et al., 1973 and Goldman et al., 1992) are pathognomonic of schizophrenia. Finally, FRS and BD hold little prognostic value (Strauss and Carpenter, 1972, Carpenter et al., 1973, Hawk et al., 1975, Brockington et al., 1978, Kendell et al., 1979, Stephens et al., 1982, Goldman et al., 1992, Thorup et al., 2007 and Nordgaard et al., 2008). The DSM-5 Psychotic Disorders Work Group has proposed to remove the special status of FRAH and BD from the diagnostic criteria for schizophrenia (Tandon, 2012 and Tandon and Carpenter, 2012). This prompted us to ask whether this affects the “caseness” of schizophrenia. Specifically, how many cases would no longer be diagnosed with schizophrenia if special treatment of FRAH or BD was eliminated? Two studies previously answered this question in relation to BD using the DSM-III-R. Goldman et al. (1992) studied 214 consecutively admitted inpatients with psychosis and found that of the 152 broad-spectrum schizophrenia cases (schizophrenia, schizoaffective disorder, and schizophreniform disorder), 4.6% were diagnosed on the basis of BD alone. Tanenberg-Karant et al. (1995) studied 196 first-admission patients with psychosis and found that of the 96 cases with schizophrenia spectrum disorders, 7.5% were due to the sufficiency of BD. These rates have not been estimated using subsequent versions of the DSM, and the prevalence of cases diagnosed solely on the basis of FRAH has never been examined. Here, we investigated the prevalence of cases diagnosed with FRAH or BD as the solitary psychotic symptom using the DSM-IV-TR.

FRS, which reflect experiences of disturbed self-demarcation, and BD, as originally conceptualized (Jaspers, 1963), are common and represent important phenomenological features pertaining to self-disturbances in schizophrenia. However, as our data show, cases diagnosed on the basis of either FRAH or BD alone are exceedingly rare. We provide evidence of this from two independent datasets. The majority of patients with schizophrenia spectrum disorders have 2–3 criterion A symptoms. The vast majority of patients with FRAH have other criterion A symptoms, especially delusions and negative symptoms. Similarly, almost all patients with BD also have hallucinations, and up to a half have negative symptoms. These findings are also consistent with our previous report, which showed strong associations between auditory hallucinations and BD as well as several other schizophrenia criterion A symptoms (Shinn et al., 2012). One of the biometric principles guiding the selection of items for inclusion in diagnostic criteria is an adequate base rate (Andreasen and Flaum, 1991). Given the exceptionally low base rate of schizophrenia cases diagnosed on the sole presence of FRAH or BD, the utility of their special weighting in the diagnostic criteria for schizophrenia is questionable. Our case estimates are lower than those reported by Goldman et al. (1992) and Tanenberg-Karant et al. (1995) (Table 1). This may be related, in part, to differences in the patient samples studied. Our study included a broad range of patients—both in- and outpatients, and chronic as well as early-stage patients. Goldman et al. (1992) included only inpatients, and Tanenberg-Karant et al. (1995), who studied only first-admission patients, found the highest prevalence. It may be more common to find patients who present with a single criterion A symptom earlier in the course of illness, and that as the disease unfolds more symptoms emerge and/or are detected. The discrepancy in estimates may also reflect changes in the definition of BD from the DSM-III-R (APA, 1987)—“involving a phenomenon that the person's culture would regard as totally implausible”—to the DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000)—“clearly implausible and not understandable and not derived from ordinary life experiences.” While both definitions require subjective judgment, the latter DSM-IV/DSM-IV-TR definition is narrower, requiring that a delusion be un-understandable and not derived from ordinary life experiences in addition to being implausible in order to qualify as bizarre. The ambiguous definition of BD is further complicated by the design of the SCID, which lists specific types of BD (i.e., DC, TI, TW, and TB) and then separately asks whether any delusions are bizarre (SCID item B15). In both the McLean and Vanderbilt datasets, we found that item B15 did not always reflect the presence of DC, TI, TW, or TB, even though the DSM-IV-TR gives these as examples of BD. Therefore we determined BD prevalence in our sample with item B15 only, as well as all forms of BD in the SCID. An additional problem with SCID item B15 [which prompts the rater to assess, “IF DELUSIONAL: How do you explain (CONTENT OF DELUSION)?”] is that it takes into account only the content of BD, or what the belief is about, and ignores the form of BD, which relates to the way a belief is experienced. In the case of the latter, a delusion can be bizarre if a belief represents a significant departure from what is known about an individual's history, values, and beliefs, even if that belief is not objectively or culturally bizarre (Mullen, 2003). The concept of bizarreness stems in large part from Jaspers' notion of un-understandability (Jaspers, 1963). As described by Cermolacce et al. (2010), Jaspers contrasted true delusions, which lack a sense of intersubjective reality in being “non-understandable from our normal empathic stance,” from delusion-like ideas, which are often seen in mood disorders and can more readily be understood as originating from experiences or affects existing prior to the delusional manifestation. The DSM-IV's emphasis on bizarreness of content over form has been criticized as conceptually invalid ( Mullen, 2003 and Cermolacce et al., 2010). Since both the McLean and Vanderbilt datasets were collected using the SCID for the DSM-IV, the form of BD was not specifically examined, and this is a limitation of the current study. Another potential limitation of this study is that we did not examine systematically each of Schneider's eleven FRS. We made the a priori decision to analyze only those FRS that have achieved special status in DSM. Running commentary and voices conversing are FRS that are explicitly given special weight in criterion A of DSM-IV and DSM-IV-TR; thus we included these two FRS in our analyses. How bizarre delusions relate to FRS in the DSM is less straightforward. While bizarre delusions are not FRS per se, bizarre delusions and most FRS have in common abnormal self experiences (especially relating to loss of ego-boundaries), un-understandability, and physical impossibility (Cermolacce et al., 2010), and the FRS of delusions of control, thought insertion, thought withdrawal, and thought broadcasting are given as examples of bizarre delusions in the DSM. Yet another issue is that Schneider's FRS do not map easily onto individual items in the SCID. While “delusions of control” was not among Schneider's eleven FRS, this symptom as operationalized in the DSM (“feelings, impulses, thoughts, or actions are experienced as being under the control of some external force”) is presented as an aggregate of Schneider's concepts of somatic passivity, ‘made’ feelings, ‘made’ impulses, and ‘made’ volitional acts (Mellor, 1970). As such, we did not assess somatic passivity and each of the ‘made’ phenomena individually. Lastly, we did not address the FRS of audible thoughts and delusional perception in this study. Since these two FRS are not included either explicitly or implicitly in criterion A for schizophrenia and are not explored sufficiently during a SCID interview, we did not include them in our analysis. The objective of the study, however, was not to examine all FRS. In spite of the limitations of the SCID, we were able to answer a very specific question—whether eliminating special treatment of FRAH and BD in the DSM affects the caseness of schizophrenia. In conclusion, our data suggest that while FRAH and BD are common in schizophrenia, patients diagnosed on the basis of solitary FRAH or BD are rare. These symptoms have variable reliability, inconsistent frequency, lack of specificity, and poor prognostic value. In addition, the rarity of schizophrenia cases diagnosed due to RC, VC, and/or BD alone suggests that the elimination of the special Criterion A provision for these symptoms in the DSM-5 would not significantly alter the practice of diagnosing schizophrenia.