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7 The Problems of Early Detection of Schizophrenia

7 The Problems of Early Detection of Schizophrenia

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The Problems of Early Detection of Schizophrenia


The ICD and DSM definitions of schizophrenia are arbitrary, resulting from

expert consensus, and the time of onset varies depending on when the criteria

threshold is exceeded: first-onset episodes by one diagnostic system may be considered pre-onset by a different system (Parnas 2005). The operational definitions

(DSM-IV and ICD-10) rely heavily on manifest, less specific psychotic symptoms,

including first-rank symptoms, whereas the preoperational definitions reflect to a

greater extent the schizophrenic Gestalt.

In DSM-IIIR (p. 194–195) prodromal symptoms (identical with residual symptoms) comprise a list of nine mostly behavioral signs, at least two of which must be

present for a prodromal phase of schizophrenia:







Marked social isolation or withdrawal

Marked impairment in role functioning as wage earner, student, or homemaker

Markedly peculiar behavior

Marked impairment in personal hygiene and grooming

Blunted or inappropriate affect

Digressive, vague, overelaborate, or circumstantial speech, or poverty of speech,

or poverty of content of speech

7. Odd beliefs or magical thinking, influencing behavior and inconsistent with cultural norms, e.g., superstitiousness, belief in clairvoyance, telepathy, “sixth

sense,” “others can feel my feelings,” overvalued ideas, ideas of reference

8. Unusual perceptual experiences, e.g., recurrent illusions, sensing the presence of

a force or person not actually present

9. Marked lack of initiative, interests, or energy

Empirical studies have found a high prevalence of these items in high-school students rendering them nonspecific and of little value for prodromal research (McGorry

et al. 1995; see also Sect. 13.1). The prodrome is identified retrospectively. An observed

change in psychopathology and functioning in a patient displaying schizophrenia spectrum features might also be expressive of an accidental crisis, drug use, and an outpost

syndrome (see above) or be the onset of a symptom-poor schizophrenia (e.g., simple

subtype), and it may be difficult to tell them apart. In prodromal research, the term “at

risk mental state” (ARMS) is, therefore, preferred to “prodrome” (Yung et al. 1996).

Early detection instruments attempt to define prodrome/ARMS operationally.

The CAARMS (Yung et al. 2006) define ARMS in three ways: states (1) family history of psychosis or SPD plus 30 % drop in SOFAS (Social and Occupational

Functioning Assessment Scale, Goldman et al. 1992), (2) attenuated psychosis

defined from subthreshold intensity and frequency ratings of psychosis items, and

(3) BLIPS (brief limited intermittent psychotic symptoms), defined as a psychopathological scale score, resolving spontaneously within a week occurring during

the last year. The first group is not clinically but probabilistically defined, the two

next groups defined as subscale ratings. Psychosis, too, is defined as a cutoff score

in certain subscales.

Early detection using near-psychotic or brief psychotic features centers on the

late-prodromal, prepsychotic phase and is liable of becoming tautological (mild


8 Indicators of Psychosis

psychosis predicting severe psychosis). The attenuated psychosis syndrome of

DSM-5 (p. 783), a “condition for further study,” constructed along this line as an

attempt to capture the schizophrenic prodrome, seems to have a prevalence in general population of no more than 0.3 % (Schultze-Lutter et al. 2014a). The suggested

diagnostic criteria comprise delusions, hallucinations, or disorganized speech “in

attenuated form, with relatively intact reality testing, but of sufficient severity or

frequency to warrant clinical attention.” Furthermore, the symptoms must have

begun or worsened in the past year. Without this onset criterion the prevalence

would rise to 2.6 %.

A more promising approach is related to the occurrence of self-disorders, reflecting

the fundamental generative disorder of schizophrenia spectrum disorders, which aggregate selectively in schizophrenia and schizotypy (Parnas et al. 2005a, b). Self-disorders

predict transition to psychosis in an ultra high risk for psychosis sample (Nelson et al.

2012), and they predict transition to the schizophrenia spectrum in first-admitted nonschizophrenia spectrum patients (Parnas et al. 2011). Some of the cognate basic symptoms have been included in the CAARMS instrument.

For “psychotic-like experiences” (PLEs), see Sect. 8.10.


Other Non-affective Psychoses

This section deals chiefly with chronic non-affective psychoses; acute nonorganic

psychoses apparently without relation to either the schizophrenic or the affective

spectra are relegated to Sect. 11.2.

The delusional (paranoid) psychoses, having structured delusional systems as the

salient feature, constitute a major subgroup of these psychoses. They are characterized by the absence of the fundamental disorders of schizophrenia, and their delusions

are of “empirical” (rather than autistic-solipsistic) nature (Parnas 2004; see above). A

number of monothematic paranoid syndromes have been described, Capgras, Fregoli,

and de Clérambault’s syndromes, hypochondriac paranoia, etc. In de Clérambault’s

syndrome, or erotomania, the core delusion is the belief that a certain person with

higher status is in love with the patient. Delusional hypochondriasis will be treated in

Sect. 10.5. Capgras and Fregoli syndromes are misidentification syndromes, the former “hypo-identification” (disclaiming the identity of relatives) and the latter “hyperidentification” (identifying strangers as the same person in disguise). Conrad describes

further variations of misidentification in initial schizophrenia (2012); the delusional

theme itself is of little use for the differential diagnosis.

Pauleikhoff (1969) lists a series of atypical psychoses (some of which probably

not belonging to the schizophrenia spectrum) such as episodic stupor, episodic catatonia, and amorous paranoia. The DSM-5 now allows the diagnosis of catatonia as

a comorbid diagnosis to other mental disorders or medical conditions.

Late paraphrenia as an independent nosological entity is controversial. Most

cases seem to be schizophrenic. Schizophrenia may have its first appearance at any

age but it is generally accepted that the onset after age 60 is very rare (“very late

onset”). What distinguishes very-late-onset schizophrenia from earlier-onset cases


The Differential Diagnosis of the Autism Spectrum


is a lower score of formal thought disorder, affective blunting, and social withdrawal; a higher score of visual hallucinations, persecutory symptomatology, and

hearing loss and ocular pathology; and a high female-male ratio (Howard et al.

2000; Harris and Jeste 1988; Sato et al. 2004).


The Differential Diagnosis of the Autism Spectrum

The differential diagnosis of the so-called autism spectrum is particularly difficult,

and the relation between the two spectra is still not as yet settled (Hommer and

Swedo 2015). The actual name, autism, was borrowed by Kanner and Asperger

from Bleuler’s fundamental symptom, representing a loss of contact with the world,

to designate certain childhood conditions, characterized by impairment in social

interaction. Kanner (1943) and Rutter (1968) pointed out some further characteristics of his autistic children: a delay in the acquisition of speech together with language abnormalities, an excellent rote memory, and an obsessive desire for the

maintenance of sameness.

The spectrum is made up of high-functioning autists (such as Asperger cases) as

well as low-functioning autists, often having mental retardation. DSM-IV includes

three autism diagnoses: autistic disorder, Asperger’s disorder, and atypical autism

(under pervasive developmental disorder not otherwise specified). In DSM-5, they

have been combined into one diagnosis, the autism spectrum disorder. In ICD-10,

the autistic diagnoses, childhood autism, atypical autism, and Asperger’s syndrome

are located under pervasive developmental disorders.

The psychology of the group of low-functioning autists is, for obvious reasons,

much more difficult to penetrate, and it is therefore doubtful whether they represent

psychopathologically the same fundamental disorder. The spectrum is in all probability a ragbag of cases having serious contact disturbances in common. The autistic

patients have severe difficulty in relating themselves to other people, which may be

of a quality similar to that seen in the schizophrenia spectrum, and some patients

given the autism diagnosis certainly appear to belong to the schizophrenia spectrum. In a sample of 26 adult patients manifesting symptoms of autism spectrum

disorders, 22 had psychotic symptoms, and 16 fulfilled the criteria for schizophrenia

(Raja and Azzoni 2010), which demonstrates the clinical misuse of autism diagnoses even in cases of overt psychosis. Autism spectrum symptoms are more frequent

in genetic disorders (such as Rett’s and Cohen’s syndromes) than in the general

population (Richards et al. 2015) and are found in metabolic syndromes, too.

What has been pinpointed as characteristic for the special quality of autism in the

autistic spectrum is the impairment or loss of theory of mind (a term originated in

primatology in the late 1970s). Baron-Cohen et al. (1985) define it as a metarepresentational capacity necessary for imputing beliefs to others and predicting

their behavior. The loss of theory of mind was evaluated in children by asking

“belief questions” to a puppet play. The autistic child would typically answer

according to his own rather than to the misinformed puppet’s belief. One aspect of

this is the failure to attribute intentionality to other people (“intentionality” here in


8 Indicators of Psychosis

the sense of having intentions and powers to act purposefully; be aware of a different sense of the word used elsewhere in this book). So, autists are supposed to be

“hypo-intentional” as opposed to patients with schizophrenia who are “hyperintentional” (Ciaramidaro et al. 2015), i.e., who tend to over-attribute intentions to

agents and physical events, as evident in, e.g., self-reference. It seems, however, that

there is also a certain impairment of theory of mind in at least some schizophrenia

cases as well as in other psychiatric disorders such as frontal lobe damage (Brüne


In an attempt to separate the autism spectrum (AS) from schizophrenia (SZ),

Nylander (2014) has listed a number of similarities and differences between the

two. She claims that AS, unlike SZ, is present from birth or early childhood, whereas

childhood SZ with onset at age 5–13 is very rare (Table 1, p. 265). This is true for

(psychotic) schizophrenia but not for schizophrenia spectrum disorders. The great

majority of patients within this spectrum have had some kind of nonpsychotic, premorbid or permanent, trait-like condition since early childhood resembling schizotypy, and many of these have always had common sense problems and social

withdrawal. Therefore, Nylander’s criterion is of little use. Some further features of

both spectra overlap: e.g., the language abnormality pointed out by Kanner may

resemble formal thought disorder of the schizophrenia spectrum, and the desire for

sameness may look like the neophobia frequently present in schizophrenia.

Some clinical aspects may be helpful in making the diagnosis. The presence of

other Bleulerian fundamental disorders apart from autism (like formal thought disorder), self-disorder, near-psychotic phenomena, and, among these, severe social

anxiety is indicative of the schizophrenia spectrum. Within this spectrum, patients

indeed display social withdrawal due to social anxiety, but they do not lose interest

in other people: they want sincerely to have friends but have difficulty in interacting

with others. A “squeeze machine” was invented by Grandin (1992), having autistic

disorder herself, with the aim of delivering deep touch pressure to reduce anxiety,

apparently as a substitution of human hugging, a solution probably unlikely in

schizophrenia spectrum patients. Stereotyped speech and gestures have been pointed

out as characteristic of autism (Lord et al. 2000).


Psychotic Phenomena in the General Population

Psychotic experiences (delusions and hallucinations) are reported to be prevalent in

the general population at an average rate of 5 % (van Os et al. 2009) apparently supportive of the idea that psychosis is on a continuum with normality. The relatively

high incidence rate (3 %) is interpreted as an indication that in most cases the psychotic experiences are transitory and disappear over time.

However, the research in this field is flawed by some theoretical and methodological problems. Psychotic-like experiences (PLEs) denote symptoms resembling

those in psychosis apparently found in non-patient populations. There is a great

variation in the definitions and use of assessment tools across the studies (Lee et al.

2016). One of the most widely used instruments for measuring PLEs is the

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7 The Problems of Early Detection of Schizophrenia

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