Does change in definition of psychotic symptoms in diagnosis of schizophrenia in DSM-5 affect caseness?

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Abstract

Psychotic symptoms are a central element in the diagnosis of schizophrenia, although their precise definition has varied through the multiple iterations of DSM and the ICD. Schneiderian first-rank symptoms (FRS) have received a particularly prominent position in the diagnostic criteria of schizophrenia since ICD-9 and DSM-III. In the current iteration of DSM (DSM-IV-TR), whereas two characteristic symptoms are ordinarily required to meet criterion A, only a single symptom is necessary if the psychotic symptom happens to be a FRS, notably a bizarre delusion or auditory hallucination of a running commentary or ‘conversing voices’. Because of limited data in support of the special treatment of FRS, DSM-5 has made changes to criterion A, requiring that at least two psychotic symptoms be present in all cases with at least one of these symptoms being a delusion, hallucination, or disorganized speech. To assess the impact of these changes on the prevalence of schizophrenia, we examined a research dataset of 221 individuals with DSM-IV schizophrenia to study the prevalence and co-occurrence of various criterion A symptoms. Although bizarre delusions and/or Schneiderian hallucinations were present in 124 patients (56.1%), they were singly determinative of diagnosis in only one patient (0.46%). Additionally, only three of the 221 patients (1.4%) with DSM-IV schizophrenia did not have a delusion, hallucination, or disorganized speech. DSM-5 changes in criteria A should have a negligible effect on the prevalence of schizophrenia, with over 98% of individuals with DSM-IV schizophrenia continuing to receive a DSM-5 diagnosis of schizophrenia in this dataset.

Introduction

The definition of schizophrenia has evolved through the six editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I, DSM-II, DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR; American Psychiatric Association, 1952, American Psychiatric Association, 1968, American Psychiatric Association, 1980, American Psychiatric Association, 1987, American Psychiatric Association, 1994, American Psychiatric Association, 2000). Since the third edition of the DSM and the ninth edition of the International Classification of Diseases (ICD, World Health Organization, 1978), psychotic symptoms have been mandatory for the diagnosis of schizophrenia and Schneiderian first-rank symptoms (FRS) (Schneider, 1959, Mellor, 1970) have received a special place in its definition (Wing and Nixon, 1975). In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), whereas two characteristic symptoms are necessary to meet criterion A, only one symptom is required if it is either a bizarre delusion or if it is an auditory hallucination with running commentary or conversing voices. The appropriateness of such special treatment of FRS has been questioned because of the absence of data indicating any diagnostic specificity or prognostic significance (Carpenter et al., 1973, Carpenter and Strauss, 1974, Kendell et al., 1979, Crichton, 1996, Peralta and Cuesta, 1999, Jansson and Parnas, 2007, Nordgaard et al., 2008, Tandon and Maj, 2008, Ihara et al., 2009, Tandon, 2012) and the relatively poor reliability in diagnosing bizarreness of delusions (Flaum and Andreasen, 1991, Spitzer et al., 1993, Mojtabai and Nicholson, 1995, Nakaya et al., 2002, Mullen, 2003, Bell et al., 2006, Cermolacce et al., 2010). Because of these concerns, FRS will no longer receive special emphasis in DSM-5 and ICD-11 (Tandon and Carpenter, 2013, Gaebel et al., 2013). The impact of this change on the prevalence of schizophrenia is not known.

Psychotic symptoms have been considered mandatory for a diagnosis of schizophrenia (Bruijnzeel and Tandon, 2011) and the diagnosis of simple schizophrenia has been eliminated from the Diagnostic and Statistical Manual since its third edition (DSM-III). Negative symptoms, that are the defining feature of simple schizophrenia, contribute significantly to the poor outcome associated with schizophrenic illness (Tandon et al., 2009). In an effort to provide appropriate prominence to negative symptoms, they were added as one of five characteristic symptoms in criterion A in DSM-IV (Flaum et al., 1998). This change, however, allowed patients with only negative symptoms and disorganized behavior (akin to simple schizophrenia) to receive a DSM-IV diagnosis of schizophrenia. To address this apparent oversight in DSM-IV, DSM-5 has added a requirement that at least one of the two mandatory characteristic symptoms to meet criterion A be delusions, hallucinations, or disorganized speech. The impact of this change on the prevalence of schizophrenia has not been evaluated.

To assess the impact of these two DSM-5 changes in criterion A on the prevalence of schizophrenia, we examined a research database of 221 individuals with DSM-IV schizophrenia. We studied the prevalence of bizarre delusions and Schneiderian hallucinations and their co-occurrence with other characteristic symptoms. We measured the proportion of individuals who met DSM-IV criterion A solely by virtue of a single Schneiderian FRS. We also evaluated the proportion of individuals with DSM-IV schizophrenia who did not have any delusion, hallucination, or disorganized speech.

Section snippets

Methods

The sample consisted of 221 well-characterized patients with DSM-IV schizophrenia and on whom structured diagnostic data were available. They had all participated in some clinical or pathophysiology research study and had received a Structured Clinical Interview for DSM-IV (SCID, First et al., 1996) and a detailed psychiatric interview as part of their diagnostic assessment (see Tandon et al., 2000 for details).

In coding SCID items for bizarre delusions [B11–B15], running commentary

Results

Bizarre delusions and “Schneiderian” hallucinations were present in a significant proportion of DSM-IV schizophrenia patients (47.1% and 35.6%, respectively) in our sample, but only one patient met criterion A solely on the basis of a single bizarre delusion (0.46%) and no patient met criterion A solely on the basis of a single Schneiderian hallucination (Table 1). The relative proportions of other criterion A symptoms was similar in patients with bizarre and non-bizarre delusions. Likewise,

Discussion

Our data suggest that changes from DSM-IV to DSM-5 in the definition of criterion A symptoms should have little impact on caseness of schizophrenia, with less than 2% of patients with DSM-IV schizophrenia not meeting DSM-5 criteria because of these changes. Our findings are similar to those of the two other studies that have investigated this issue (Peralta and Cuesta, 1999, Allardyce et al., 2007). These datasets were recently re-analyzed to evaluate these questions (personal communication

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