Schneiderian Symptoms

[peiyueng]

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Hey guys: about to start fellowship, so I figured I'd shore up on the Kaplan and Saddock.

In regards to Schneiderian first rank symptoms . . .

what is somatic passivity experiences?

What is volition made affects?

What is volition made impulses?

Anyone know the answers? Thx!

cheers.

 

[FrasierMD]

My understanding is that these are delusions of some external force controlling behavior, affect , etc. I have heard somatic passivity described as believing that one is a puppet and actions are not his or her own.

What are fellowship are you starting?

 

[deleted452516]

abbreviated from Mellor, C. S. (January 01, 1970). First rank symptoms of schizophrenia. I. The frequnncy in schizophrenics on admission to hospital. II. Differences between individual first rank symptoms. The British Journal of Psychiatry : the Journal of Mental Science,117, 536, 15-23.

somatic passivity experience: the experience of influences playing on the body. The patient is a passive and invariably a reluctant recipient of bodily sensations imposed upon him by some external agency. According to Jaspers the perception is simultaneously experienced as being both a bodily change and externally controlled. It is a single experience and not simply the delusional interpretation of an abnormal bodily sensation. These somatic perceptions may be due to haptic, thermic or kinaesthetic hallucinations. Sometimes there may be an admixture of different hallucinations.

made volitional act (edit: corrected thanks to Splik, see below): acts that are experienced by the patient as the work or influence of others. The patient experiences his actions as being completely under the control of an external influence. The movements are initiated and directed throughout by the controlling influence, and the patient feels he is an automaton, the passive observer of his own actions.

 

[splik]

there is no such a thing as a volition made impulse. there are 'made' volitional acts, and 'made' impulses

Schneider describes 11 symptoms that he believed to cardinal to schizophrenia, which are known as the 'first-rank symptoms' with other symptoms that support the diagnosis known as second rank symptoms.

The 11 first rank symptoms are:

1. though echo
2. voices giving a running commentary
3. voices heard arguing
4. delusions of thought insertion
5. delusions of thought withdrawal
6. delusions of thought broadcast
7. passivity of affect
8. passivity of volition
9. passivity of impulse
10. somatic passivity
11. delusional perception

In DSM-IV these symptoms were given special weighting such that any symptom alone was sufficient for the diagnosis of schizophrenia without the need for a 2nd symptom which was otherwise the case. This is no longer true in DSM-5. Although these symptoms occur in organic states, mood disorder, and substance induced conditions, they tell us something about the underlying deficits in the patient's theory of mind, and also correlate with poorer response to treatment and prognosis. You should inquire about these symptoms in every case of a psychotic patient IMHO.

It is a shame that people aren't learning this. If descriptive psychopathology is a deficiency in your training you should seek to remedy it. Buying an old edition of Symptoms in the Mind: a introduction to descriptive psychopathology by Andrew Sims, or Fish's Clinical Psychopathology (Max Hamilton's 2nd edition, don't bother with the recent edition, though the older one is out of print) would be an excellent place to start.

Passivity phenonomena are not very common today, but I still see it described.

 

[Salpingo]

It is a shame that people aren't learning this. If descriptive psychopathology is a deficiency in your training you should seek to remedy it. Buying an old edition of Symptoms in the Mind: a introduction to descriptive psychopathology by Andrew Sims, or Fish's Clinical Psychopathology (Max Hamilton's 2nd edition, don't bother with the recent edition, though the older one is out of print) would be an excellent place to start.

Passivity phenonomena are not very common today, but I still see it described.

The closest to somatic passivity I encountered was on the consult service, when a nice, elderly woman politely requested discharge AMA, complaining of the electricity constantly being shot into her body. When I asked who exactly was doing this, she just gave me a knowing, incredulous stare, as if I didn't know exactly who was perpetrating it. At the time, I figured it was some psychotic interpretation of neuropathic pain, but as noted above, it was actually a complex interplay across multiple delusional systems (somatic, persecutory, paranoid). In popular culture, I think its equitable to making tinfoil hats to keep the rays from beaming into your head.

In regards to DSM-IV, wanted to point out that it was the running commentary/conversing voices (or bizarre delusions) symptom that automatically provided a "Criteria A" point. My understanding was that Schneiderian schizophrenia had become "paranoid schizophrenia", where as Bleuler's model (with a focus on negative symptoms) became the hebephrenic/disorganized type. That was one of the more dissapointing elements of DSM-5 for me. Instead of moving towards a recognition that schizophrenia is likely multiple syndromes that should be studied individually, there was a collective shrugging of shoulders, and everything was collapsed into one category. Very unsatisfying.

Anyway, I'm also interested in hearing about this fellowship.

 

[splik]

Bleuler's schizophrenia had nothing to do with negative symptoms. In fact he didn't mention negative symptoms at all. DSM-IV schizophrenia has nothing to do with Bleuler's conception of schizophrenia whatsoever. In fact his influence was completed expunged with DSM-III. The DSM-II/IV conception of schizophrenia is Neo-Kraepelinian. Kraepelin described three subtypes of schizophrenia - paranoia, hebephrenic, and catatonic. Kraepelin believed that cognitive impairment (i.e. the 'dementia' of dementia praecox and the deteriorating course is what separated the illness from manic-depressive insanity [which includes recurrent depressive illness and not just bipolar disorder]) whereas Bleuler believed that loosening of associations was the sine qua non of schizophrenia, and that delusions, disorganized thinking, hallucinations, bizarre behavior were all explained by this fundamental deficit. As Kraepelin's concept was too negative for American Psychiatrists, it was the Bleulerian concept of schizophrenia that held sway for 50 years and let to a very fluid of the illness that encompassed everything from bipolar disorder, to hysterical and borderline personalities.

The removal of the subtype specifiers in DSM-5 reflects a positive move as there was no evidence these were distinct syndromes, or had any prognostic significance, and the manifestation of illness can change overtime. There is no evidence supporting the idea that people with the paranoid form would stay faithful to that throughout the course of illness. So this was actually a positive change supported by the evidence.

I think this thread only serves to highlight how poor/non-existent the teaching of descriptive psychopathology is in US psychiatry residency given the errors in every post. whether this matters on not (some people would argue it is irrelevant) is another question altogether.

 

[Salpingo]

I think this thread only serves to highlight how poor/non-existent the teaching of descriptive psychopathology is in US psychiatry residency given the errors in every post. whether this matters on not (some people would argue it is irrelevant) is another question altogether.

Thanks for the constructive critique of American education. I hold that Bleuler's work was ESSENTIAL to our understanding and identification of negative symptoms. Of course, loosening of associations was the primary deficit identified by Bleuler, and was a central part of his early writings, but his work didn't stop there. Phenomenologically, he recognized the role of dysregulated affect, ambivalence and internal preoccupation, which I would argue are all inherently negative features of schizophrenia (my argument should of course be taken with a grain of salt given my limited American education). His de-emphasis of sensory symptoms is more suggestive of the DSM-IV description of disorganized subtype, but again, what do I know.

As for schizophrenia not being distinct syndromes, I'll leave it to personal opinion. I would guess anyone who has walked onto an inpatient unit and seen the breadth of patient carrying the diagnosis of schizophrenia would disagree. IMHO, the lack of clinical utility is more due to the poor diagnostic standards and inter-rater reliability.

 

[shan564]

Thanks for the constructive critique of American education. I hold that Bleuler's work was ESSENTIAL to our understanding and identification of negative symptoms. Of course, loosening of associations was the primary deficit identified by Bleuler, and was a central part of his early writings, but his work didn't stop there. Phenomenologically, he recognized the role of dysregulated affect, ambivalence and internal preoccupation, which I would argue are all inherently negative features of schizophrenia (my argument should of course be taken with a grain of salt given my limited American education). His de-emphasis of sensory symptoms is more suggestive of the DSM-IV description of disorganized subtype, but again, what do I know.

Yeah, and Kraepelin. Kraepelin is required reading at my program now.

As for schizophrenia not being distinct syndromes, I'll leave it to personal opinion. I would guess anyone who has walked onto an inpatient unit and seen the breadth of patient carrying the diagnosis of schizophrenia would disagree. IMHO, the lack of clinical utility is more due to the poor diagnostic standards and inter-rater reliability.

I think most of us would agree that there are likely some distinct syndromes present, but I think splik's point is that the DSM-IV didn't characterize these syndromes correctly. If you walk into an inpatient unit, you'd get a distorted perspective because you're looking at a cross-sectional view of each patient. The "poor diagnostic standards and inter-rater reliability," as you describe, is what the DSM-5 was trying to eliminate by removing the subtypes of schizophrenia... we don't know enough to effectively characterize the subtypes, and the DSM-IV subtypes were just an attempt to do something that we didn't have the ability to do.