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.

"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.

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.

Well-Being and Self-Disorders in Schizotypal Disorder and Asperger Syndrome/Autism Spectrum Disorder.

We explored subjective well-being in two groups of young adult participants diagnosed with either schizotypal disorder (Sd) (n = 29) or Asperger syndrome/autism spectrum disorder (As/ASD) (n = 22). Well-being was impaired in both groups and was lower in the Sd group than in the As/ASD group. Furthermore, there was a negative correlation between well-being and the presence of self-disorders. The negative effect of self-disorders on well-being was still significant when adjusted for diagnosis, age and gender, and level of function. The present findings point toward clinically important disorder-specific differences in the nature of impaired well-being between the Sd group and the As/ASD group, as there seems to be a self-disorder-driven additional contribution to impaired subjective well-being within the schizophrenia spectrum. These findings further nuance the understanding of fundamental and clinically important qualitative differences between the schizophrenia spectrum and the autism spectrum.

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.

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.

Self-experience in the early phases of schizophrenia: 5-year follow-up of the Copenhagen Prodromal Study.

Despite the avalanche of empirical data on prodromal/"at risk" conditions, the essential aspects of the vulnerability to the schizophrenia spectrum remain largely unaddressed. We report here the results of the Copenhagen Schizophrenia Prodromal Study, a prospective, observational study of first admission patients in putative state of beginning psychosis (N=151) with a follow-up length of 60 months. At follow-up, the rate of conversion to schizophrenia spectrum diagnosis was 37%, whereas the conversion rate from schizotypal disorder to schizophrenia was 25%. High levels of perplexity and self-disorders baseline scores yielded the best prediction of the subsequent development of schizophrenia spectrum disorders. Escalating transitions within the spectrum (i.e., from schizotypal disorder to schizophrenia) were not associated to any candidate psychopathological predictor.

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.

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.

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.

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.

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.

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.

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.