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Anomalous subjective experiences in schizophrenia, bipolar disorder, and unipolar depression
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Comprehensive Psychiatry xx (2013) xxx – xxx www.elsevier.com/locate/comppsych
Anomalous subjective experiences in schizophrenia, bipolar disorder, and unipolar depression Jong-Hoon Kim a,⁎, Ju-Hee Lee b, c , Jinyoung Lee a a
Department of Psychiatry, Gil Medical Center, Gachon University, 1198 Guwol-Dong, Namdong-Gu, Incheon, 405–760, South Korea b School of Medicine, Gachon University, 1198 Guwol-Dong, Namdong-Gu, Incheon, 405–760, South Korea c Graduate School of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-Gu, Seoul, 110–744, South Korea
Abstract Background: The purpose of the present study was to compare anomalous subjective experiences in patients with schizophrenia, bipolar disorder, and unipolar depression, in order to elucidate differences in subjective experiences and examine their potential clinical correlates in schizophrenia and mood disorders. Methods: The subjective experiences of 78 outpatients with schizophrenia (n = 32), bipolar disorder (n = 24) and unipolar depression (n = 22), and 32 healthy controls were comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). Results: The FCQ total score was significantly higher in the schizophrenia and depression groups than in the healthy control group. There were no significant differences in the FCQ total or subscale scores among the schizophrenia, unipolar depression, and bipolar disorder groups. In the schizophrenia group, the Positive and Negative Syndrome Scale negative factor score was a significant negative predictor of the severity of subjective experiences assessed by the FCQ total score. Disruption of subjective experiences in patients with unipolar depression was associated with greater severity of depressive symptoms and younger age. In the bipolar disorder group, women reported more disruptions in subjective experience. Conclusions: Anomalous subjective experiences measured by the FCQ are not specific to schizophrenia, and the severity of these experiences in unipolar depression is substantially high. The finding of a dissimilar pattern of predictors of subjective experiences across different diagnostic groups suggests the complexity and variety of factors contributing to anomalous subjective experiences in schizophrenia and mood disorders. © 2013 Elsevier Inc. All rights reserved.
1. Introduction In recent years, there has been renewed interest in the subtle, self-experienced cognitive, perceptual, and emotional changes that have been noted since the earliest description of dementia praecox [1–3]. Subjective experiences are subtle subjective disturbances in drive, affect, thinking, language, perception, motor action, vegetative functions, and stress tolerance [1,2,4], which constitute a set of symptoms termed “basic symptoms” [1,2,5–7]. Studies have shown that subjective experiences have important clinical implications for schizophrenia and related disorders, in that qualitative or structural alterations of subjective experiences are selfperceived subjective consequences of vulnerability to
⁎ Corresponding author. Tel.: +82 32 460 8505; fax: +82 32 472 8813. E-mail address: [email protected] (J.-H. Kim). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2012.12.017
schizophrenia [1,3,8–12]. In addition, the exploration of subjective experiences may also provide clinicians with the basis for helping patients to use appropriate coping strategies and to avoid ill-conditioned coping mechanisms [13]. Although subjective experiences comprising characteristic and qualitatively peculiar basic symptoms are considered to be a fundamental feature of schizophrenia-spectrum disorders [14,15] and are phenomenologically close to psychotic experiences, the diagnostic specificity of anomalous subjective experiences in general has not been well delineated. In fact, most studies of subjective experiences have been performed in schizophrenia and to a lesser extent in mood disorders. There have been reports that subjective experiences significantly discriminate schizophrenia in remission from psychotic bipolar disorder in remission [16], and a prospective longitudinal follow-up of firstadmission cases suggested that subjective experiences selectively aggregate in schizophrenia-spectrum disorder
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[15,17]. Arduini et al. [18] compared patients with schizophrenia and those with bipolar disorder who were hospitalized for an index episode and found that the schizophrenia patients showed higher scores on a self-rating scale measuring subjective experiences of cognitive and perceptual dysfunction. These results suggest that subjective experiences in schizophrenia may be quantitatively and/or qualitatively different from those in bipolar disorder. However, only a few studies have compared patients with schizophrenia and those with unipolar depressive disorder. Mass et al. [12] reported that other diagnostic groups, such as depressives or neurotics, showed similar high scores on a self-rating scale of subjective experiences. Ebel et al. [19] compared patients with schizophrenia and those in an endogenous-depressive phase of cyclothymia in terms of basic symptoms and found that cognitive symptoms were observed more frequently in the schizophrenia than in the comparison group. Cutting and Dunne [20] compared the subjective experiences of patients with schizophrenia and depression through several stages of assessment and found that the items concerning perceptual dysfunction distinguished the experiences of schizophrenia from those of depression. The data in the literature on the comparison of subjective experiences among patients with schizophrenia, bipolar disorder, and unipolar depression are scarce. A direct comparison among these groups has not yet been reported. Hence, the purpose of the present study was to compare anomalous subjective experiences in patients with schizophrenia, bipolar disorder, and unipolar depression in order to elucidate differences in subjective experiences and examine their potential clinical correlates in schizophrenia and mood disorders. 2. Methods 2.1. Subjects The study protocol was approved by the local ethics committee, and all procedures used in the study were conducted in accordance with international ethical standards, Declaration of Helsinki. A total of 78 patients (39 men, 39 women) with schizophrenia (n = 32), bipolar disorder (n = 24), and unipolar depressive disorder (n = 22), and 32 healthy control subjects (16 men, 16 women) were enrolled in the study. Patients were recruited at an outpatient psychiatric clinic between May 2008 and December 2010. Healthy control subjects were recruited through local advertisements. The psychiatric diagnoses were established using the Structured Clinical Interview for DSM-IV (SCID) [21]. Healthy subjects underwent a complete medical, neurological, and psychiatric examination in order to ensure the absence of disease and were screened for lifetime and current DSM-IV axis I diagnoses by using the SCID [21]. Exclusion criteria for study enrollment included a past or present neurological disorder, alcohol or substance abuse, medical conditions such as immunologic, metabolic, and cardiovas-
cular disorders, and a history of head trauma with loss of consciousness. None of the healthy control subjects were taking any medication at the time of the study enrollment. All patients were receiving psychotropic medications at the time of the study enrollment. In the schizophrenia group, the antipsychotics used were risperidone (n = 20, mean dose: 5.8 ± 2.1 mg/day), olanzapine (n = 6, mean dose: 13.8 ± 3.8 mg/day), quetiapine (n = 2, mean dose: 500.0 ± 141.4 mg/day), long-acting injectable risperidone (n = 2, mean dose: 31.3 ± 8.8 mg), and aripiprazole (n = 1, mean dose: 15 mg/day). One patient was receiving a daily combination of aripiprazole (30 mg) and risperidone (2 mg). Among patients with bipolar disorder, 13 patients were treated with valproic acid (mean dose: 992.3 ± 144.1 mg/day), five with lithium (mean dose: 930.0 ± 222.5 mg/day), four with both valproic acid and lithium (mean dose: valproic acid: 1125.0 ± 287.2 mg/day; lithium: 862.5 ± 75.0 mg/day), and two with quetiapine monotherapy (mean dose: 525.0 ± 106.1 mg/day). In the depression group, the antidepressants used were mirtazapine (n = 7, mean dose: 25.7 ± 4.0 mg/day), sertraline (n = 6, mean dose: 66.7 ± 25.8 mg/day), venlafaxine (n = 4, mean dose: 112.5 ± 0.0 mg/day), escitalopram (n = 3, mean dose: 20.0 ± 0.0 mg/ day), and trazodone (n = 2, mean dose: 62.5 ± 17.7 mg/day). 2.2. Assessments Subjective experiences were comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ) [22], which was standardized for the Korean population [23]. The FCQ is one of the most widely used rating scales for subjective experiences [22], and its psychometric properties have been well established [23–26]. It rates the current level of subjective experiences [22,23]. The FCQ is a wellconstructed instrument for self-assessment and is easy to administer [3,23]. FCQ scores have been found to be strongly correlated with objective neuropsychological test results [27]. The Korean version of the FCQ consists of 103 items, which cover a wide range of subjective cognitive, emotional, and perceptual experiences [23]. The items are subdivided into 10 phenomenological subscales, i.e., anxiety (e.g., “I frequently feel anxious without any reason.”, etc.), disorder of selective attention (e.g., “Noise, which was nothing before, now irritates me and hinders me from concentration.”, “If several persons talk together, all are mixed up and I am unable to concentrate on one person.”, “Sometimes it is hard to keep concentrating on one thing.”, etc.), deterioration of discrimination (e.g., “Sometimes when I see something, it is confusing whether it is what I actually see or just an imagination.”, etc.), psychomotor disorder (e.g., “My body occasionally moves quite differently from my intention.”, etc.), perceptual disorder (e.g., “Sometimes people look distorted.”, etc.), cognitive floating (e.g., “Sometimes I am confused because too many thoughts come into my mind.”, etc.), blocking symptoms (e.g., “Sometimes my thoughts stop and I have to wait in silence.”,
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etc.), language disorder (e.g., “Recently it is hard for me to speak or write logically.”, etc.), automatic behavior disorder (e.g., “When doing a daily routine work, I have to think for a long time about how to do it.”, etc.), and disorder of coping responses (e.g., “I avoid stressful things.”, “I try to escape from the situation that may confuse my mind.”, “I have to be very careful because I may make a mistake in everyday life”, etc.) [23]. Symptoms of schizophrenia were assessed using the Positive and Negative Syndrome Scale (PANSS) [28]. A five-factor model of the PANSS was used, based on previously reported factor analyses [29,30]. The factors were positive, negative, cognitive/disorganized, depression, and excitement. The severity of manic symptoms was assessed using the Young Mania Rating Scale (YMRS) [31], and the 17-item Hamilton Depression Rating Scale (HAMD17) [32] was used to assess severity of depressive symptoms. 2.3. Data analysis and statistical methods Demographic and clinical variables were compared among the groups using one-way analysis of variance (ANOVA) for parametric data and Kruskal-Wallis test for non-parametric data. To test differences in subjective experiences among the groups, the FCQ total and subscale scores were compared using one-way ANOVA with post hoc Scheffé tests. Demographic and clinical predictors of subjective experiences in individual diagnostic groups were analyzed using multiple regression analysis with a stepwise procedure. The FCQ total score was the dependent outcome variable. The level of statistical significance was defined as P b .05 (two-tailed). In the comparison of the 10 phenomenological subscale scores among groups, the strict level of significance was adjusted as P b .005 (two-tailed) using the Bonferroni correction. All statistical analyses were performed using SPSS version 18.0 for Windows (SPSS, Chicago, IL, USA). 3. Results Table 1 presents the demographic characteristics of the four groups. There were no significant differences in age,
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gender distribution, or years of education among the groups (P N .05). The mean duration of illness was significantly longer in the schizophrenia and bipolar disorder groups than in the unipolar depression group (F = 6.92, P b .01). Significant differences were found in marital status; while the control group was divided evenly in terms of married and single status, there were fewer married participants in the patient groups (Chi-square value = 10.24, P b .05). The employment rate was significantly higher in the control group than in the patient groups (Chi-square value = 28.35, P b .001), whereas there were no significant differences among the patient groups (Chi-square value = 3.49, P = .18). The severity of symptoms assessed by the mean score on the PANSS, YMRS, and HAMD-17 was 78.1 ± 21.0, 7.5 ± 6.5, and 17.4 ± 7.2 for the schizophrenia, bipolar disorder, and unipolar depression groups, respectively. Regarding subjective experiences, the FCQ total score was significantly higher in the schizophrenia and depression groups than in the control group (F = 5.63, P = .001) (Table 2). The results of the analysis of covariance with the duration of illness as a covariate revealed no significant differences in the FCQ total score among the three patient groups (F = 2.19, P = .10). As shown in Table 2, there were significant group differences in the scores on the phenomenological subscales of “anxiety”, “deterioration of discrimination”, “psychomotor disorder”, “cognitive floating”, “blocking symptoms”, and “automatic behavior disorder” at the level of P b .005. The scores on the subscales of “disorder of selective attention”, “perceptual disorder”, and “disorder of coping responses” tended to be different among groups at the level of P b .05. Further post hoc analysis revealed that the schizophrenia and depression groups showed significantly higher scores than the control group on the subscales of “psychomotor disorder”, “cognitive floating”, and “blocking symptoms” (Table 2). On the subscales of “anxiety” and “automatic behavior disorder”, only the depression group showed significantly higher scores than the control group (Table 2). On the subscale of “deterioration of discrimination”, all three patient groups showed significantly higher scores than the control group (Table 2). When the control group was excluded from the comparisons, there were no
Table 1 Comparison of demographic variables among groups. Variables a
Age Gender (male, %) Education (yr) a Duration of illness (yr) a Married (%) Employed (%)
Schizophrenia
Bipolar disorder
Unipolar depression
Normal controls
F
P value
41.9 ± 9.1 56.3 12.0 ± 1.5 11.3 ± 8.0 12.9 15.6
43.5 ± 8.3 37.5 12.4 ± 2.4 12.6 ± 7.0 29.2 37.5
44.7 ± 6.9 54.5 12.0 ± 2.7 5.3 ± 5.6 38.1 27.3
38.8 ± 9.9 50.0 13.1 ± 1.4 NA 50.0 78.1
2.33 2.16 b 2.23 6.93 10.24 b 28.35 b
.078 .539 .088 .002 c .017 b.001
NA, not applicable. a Values are presented as mean ± standard deviation. b Chi-square value. c Differences between schizophrenia and unipolar depression as well as between bipolar disorder and unipolar depression on post hoc Scheffé tests (P b .05).
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Table 2 Comparison of FCQ scores among groups. FCQ variables
Schizophrenia
Bipolar disorder
Unipolar depression
Normal controls
F
P value
Total score Anxiety Disorder of selective attention Deterioration of discrimination Psychomotor disorder Perceptual disorder Cognitive floating Blocking symptoms Language disorder Automatic behavior disorder Disorder of coping responses
40.0 ± 14.6 4.1 ± 2.1 3.4 ± 1.9 5.0 ± 2.0 4.5 ± 1.6 4.0 ± 1.4 4.0 ± 1.8 4.1 ± 1.8 3.3 ± 1.5 3.6 ± 1.7 3.3 ± 1.4
35.5 ± 17.6 3.6 ± 2.1 3.0 ± 2.1 4.9 ± 2.1 3.9 ± 1.6 3.4 ± 1.9 3.7 ± 1.9 3.6 ± 2.2 3.0 ± 1.9 3.1 ± 2.1 3.1 ± 1.7
43.5 ± 21.0 5.0 ± 2.5 4.1 ± 2.3 5.5 ± 2.2 4.6 ± 2.1 3.7 ± 1.8 4.6 ± 2.3 4.7 ± 2.4 3.3 ± 2.3 4.4 ± 2.2 3.8 ± 1.9
26.9 ± 20.0 2.8 ± 1.0 2.4 ± 1.4 3.0 ± 1.4 3.2 ± 1.2 2.8 ± 1.5 2.7 ± 1.2 2.5 ± 1.3 2.8 ± 1.8 2.5 ± 1.3 2.4 ± 1.3
5.63 5.62 3.81 9.86 5.14 3.21 5.45 6.32 0.62 4.96 3.92
.001 a .001 b .012 b.001 c .002 a .026 .002 a .001 a .603 .003 b .011
Values are presented as mean ± standard deviation. FCQ, Frankfurt Complaint Questionnaire. a Differences between schizophrenia and normal controls as well as between unipolar depression and normal controls on post hoc Scheffé tests (P b .05). b Difference between unipolar depression and normal controls on post hoc Scheffé tests (P b .05). c Differences between schizophrenia and normal controls, between bipolar disorder and normal controls, and between unipolar depression and normal controls on post hoc Scheffé tests (P b .05).
significant differences among the patient groups on any of the phenomenological subscales (P N .05). Table 3 shows the results of multiple regression analyses performed in each diagnostic group. In the schizophrenia group, the PANSS negative factor score was a significant negative predictor of the severity of subjective experiences as assessed by the FCQ total score (Beta = −0.42, P b .05). Disruption of subjective experiences in patients with unipolar depression was associated with greater severity of depressive symptoms (Beta = 1.04, P b .01) and younger age (Beta = −0.33, P b .01). In the bipolar disorder group, women reported more disruptions in subjective experience (Beta = − 0.52, P b .05).
4. Discussion In the present study, the FCQ total score was significantly higher in the schizophrenia and depression groups than in the healthy control group. No significant differences were observed in the FCQ total or subscale scores among the
Table 3 Multiple regression analysis for predicting the severity of subjective experiences assessed by the FCQ in each diagnostic group. Predictor variables
Unstandardized coefficients B
Standardized P value coefficients
Std. error Beta
t
2
Schizophrenia (R = 0.18, F = 5.65, P = .025) PANSS negative factor score −1.03 0.43 Unipolar depression (R 2 = 0.91, F = 85.09, P b .001) HAMD-17 score 2.91 0.22 Age −1.01 0.24 Bipolar disorder (R 2 = 0.27, F = 6.81, P = .018) Gender −20.26 7.77
−0.42 −2.38
.025
1.04 12.98 b.001 −0.33 −4.15 .001 −0.52 −2.61
.018
FCQ, Frankfurt Complaint Questionnaire; PANSS, Positive and Negative Syndrome Scale; HAMD-17, 17-item Hamilton Depression Rating Scale.
groups of patients with schizophrenia, bipolar disorder, and unipolar depression. These results suggest that the severity of abnormal subjective experiences, as measured by the FCQ, was high and similar across schizophrenia and mood disorders, particularly depressive disorder. Therefore, it does not seem possible to clearly differentiate these disorders on the basis of subjective experiences assessed by the FCQ. Our results are in line with previous reports indicating that subjective experiences as a whole measured by the FCQ are not specific to schizophrenia [12,33]. Our results also extend earlier findings by revealing that the severity of anomalous subjective experiences in unipolar depression is substantially high and similar to that in schizophrenia. The bipolar disorder group also did not show significant differences from the other patient groups on the FCQ scores, suggesting that subtle subjective cognitive and perceptual disturbances may persist in stable outpatients with bipolar disorder, who score low on the YMRS (total mean score: 7.2). Further research should explore the extent to which these subjective experiences influence social and occupational functioning and quality of life in fully remitted patients with bipolar disorder. It should be noted that the severity of abnormal subjective experiences was particularly high in depressive disorder. As Cutting and Dunne [20] suggested, abnormal subjective experiences may be qualitative in schizophrenia and quantitative in depression. In other words, in schizophrenia, subjective experiences may be the correlate of an objective deficit, whereas in patients with depression, subjective experiences may seem to express a quantitative alteration at the level of self-perception, but not necessarily accompanied by a severe concomitant deficit in the psychosocial context [13]. Alternatively, subjective complaints as assessed by the FCQ in depression may reflect patients' subjective well-being, but may not be a substitute for qualitative alterations of subjective experiences.
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In the present study, we used the FCQ to measure subjective experiences. In contrast to the FCQ, the Bonn Scale for the Assessment of Basic Symptoms (BSABS) [34] covers a wide range of basic symptoms [3] and targets the qualitative or structural alterations of subjective experiences [15,35]. If the BSABS had been used, the findings may have led to different conclusions. In a recent study by Szily and Kéri [36], perplexity, self-disorder, and diminished affectivity, as measured by the BSABS, significantly predicted psychosis risk in patients with depression. Moreover, although the FCQ consists of 10 phenomenological subscales, previous studies on the factor structure of the FCQ strongly suggest the unidimensionality of the scale [13,24– 26]. Consequently, subjective experiences as assessed by the FCQ may constitute a single psychopathologic dimension regardless of the phenomenological subscales, and this may be a limitation of the scale. Mass et al. [37] developed a new subscale of the FCQ (FCQ-S), which was reported to be specific to schizophrenia compared with alcoholism. Future studies should include the FCQ-S to clarify its specificity among groups with schizophrenia, bipolar disorder, and unipolar depression. One of the approaches to further test the diagnostic specificity of the FCQ may be to investigate the relationship between FCQ scores and objective cognitive measures in each group [33]. The simultaneous use of subjective and objective measures of cognitive dysfunction may present a more complete picture in patients with schizophrenia and mood disorders, especially in terms of providing relevant targets for rehabilitation in the chronic stage of the illnesses [38]. Although a similar degree of subjective experiences was observed between schizophrenia and mood disorders, it is unclear whether this finding is due to a common underlying neural mechanism or simply reflects the phenomenological overlap between these disorders. Studies of various neurobiological correlates of anomalous subjective experiences are clearly required to understand the underlying nature of subjective experiences in schizophrenia and mood disorders. Notably, the results of the multiple regression analyses suggest that the predictors of subjective experiences may vary across different diagnostic groups. In the schizophrenia group, the PANSS negative factor score was a significant negative predictor, indicating that subjective experiences in schizophrenia were predicted by less severe negative symptoms. Negative symptoms may be associated with fewer subjective experiences, or alternatively, patients suffering from negative symptoms may be less capable of identifying subjective experiences as a consequence of the general blunting of mental process [39–41]. The finding of a dissimilar pattern of predictors of subjective experiences across different diagnostic groups supports the model of cognitive failure in psychiatric disorders, which proposes that intrinsic cognitive and extrinsic non-cognitive processes may be impaired in different ways in each type of psychiatric disorder [33,42].
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Our findings also support the notion of a complexity and variety of factors contributing to subjective experiences, as proposed by Peralta and Cuesta [33]. Further studies with a large sample of subjects at different stages of their illnesses are required to obtain a better understanding of the complex contributing factors associated with subjective experiences in schizophrenia and mood disorders. In the present study, anomalous subjective experiences were assessed based on the concept of basic symptoms. However, patients with severe mental illness such as schizophrenia not only have anomalous subjective experiences but also show a range of difficulties related to how they think about themselves and others, which are referred to as dysfunction in metacognition or mentalizing [43]. Therefore, patients with schizophrenia experience deficits in the ability to make judgments about the thoughts and feelings of others as well as to form larger integrated representations of themselves and others [44]. They also have difficulties recognizing mental states, correctly naming them, and using them in a flexible and reliable way. These difficulties also include problems forming and retrieving the specific autobiographical memories that ground a sense of personal identity [45,46]. Impoverished or diminished autobiographical memory may leave patients more vulnerable to metacognitive dysfunction [45]. Future studies are clearly needed to investigate whether difficulties in autobiographical memory and metacognition are more pronounced in schizophrenia compared to unipolar depression and bipolar disorder. Moreover, literature pertaining to self-experience in severe mental illness diverges as to when alterations of subjective experience emerge [47]. Phenomenological and existential perspectives generally suggest that these alterations may be present long before the illness onset [48]. However, according to the rehabilitative and dialogical points of view, these alterations may develop after the onset of the illness or may appear quite suddenly [49,50]. In our study, the severity of depressive symptoms was significantly associated with the disruption of subjective experiences in patients with unipolar depression, which is consistent with the notion that subjective experiences may develop over time after the onset of illness. Longitudinal studies are clearly required to address the issue of whether abnormal subjective experiences predate the onset of illness and are resolved with symptom remission. Longitudinal assessments of subjective experiences should include qualitative and quantitative measures to assess the richness and depth of personal narratives [47]. The present results should be interpreted in light of some limitations. The findings need to be replicated using other validated rating scales for subjective experiences, such as the BSABS. The study was a cross-sectional one, and the sample size was small. Further prospective research with a larger sample is warranted to confirm the stability of the relationships. The patients were all outpatients receiving medications, and therefore the findings may not be generalized to a
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more diverse group of patients. The severity of clinical symptoms of the bipolar disorder group was relatively low compared to that of the other patient groups, and this may have influenced the results. In addition, there is a clear need for more work, not just with questionnaires but with narrative-based assessments that measure alterations in self-experience. In particular, a profound diminishment in people's ability to coherently narrate their lives is commonly observed in patients with schizophrenia [43]. Assessing the qualities of self-experience within personal narratives may provide valuable insight into the level of symptoms, cognition, and functioning [51,52]. In conclusion, subjective experiences measured by the FCQ are not specific to schizophrenia, and the severity of anomalous subjective experiences in unipolar depression is substantially high and similar to that in schizophrenia. The finding of dissimilar predictors of subjective experiences across diagnostic groups may suggest the complexity and variety of factors contributing to subjective experiences in schizophrenia and mood disorders.
Acknowledgment For J.H. Kim, this work was supported by a grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A070001) and by the Gachon University Gil Medical Center Research Fund.
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Comprehensive Psychiatry xx (2013) xxx – xxx www.elsevier.com/locate/comppsych
Anomalous subjective experiences in schizophrenia, bipolar disorder, and unipolar depression Jong-Hoon Kim a,⁎, Ju-Hee Lee b, c , Jinyoung Lee a a
Department of Psychiatry, Gil Medical Center, Gachon University, 1198 Guwol-Dong, Namdong-Gu, Incheon, 405–760, South Korea b School of Medicine, Gachon University, 1198 Guwol-Dong, Namdong-Gu, Incheon, 405–760, South Korea c Graduate School of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-Gu, Seoul, 110–744, South Korea
Abstract Background: The purpose of the present study was to compare anomalous subjective experiences in patients with schizophrenia, bipolar disorder, and unipolar depression, in order to elucidate differences in subjective experiences and examine their potential clinical correlates in schizophrenia and mood disorders. Methods: The subjective experiences of 78 outpatients with schizophrenia (n = 32), bipolar disorder (n = 24) and unipolar depression (n = 22), and 32 healthy controls were comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). Results: The FCQ total score was significantly higher in the schizophrenia and depression groups than in the healthy control group. There were no significant differences in the FCQ total or subscale scores among the schizophrenia, unipolar depression, and bipolar disorder groups. In the schizophrenia group, the Positive and Negative Syndrome Scale negative factor score was a significant negative predictor of the severity of subjective experiences assessed by the FCQ total score. Disruption of subjective experiences in patients with unipolar depression was associated with greater severity of depressive symptoms and younger age. In the bipolar disorder group, women reported more disruptions in subjective experience. Conclusions: Anomalous subjective experiences measured by the FCQ are not specific to schizophrenia, and the severity of these experiences in unipolar depression is substantially high. The finding of a dissimilar pattern of predictors of subjective experiences across different diagnostic groups suggests the complexity and variety of factors contributing to anomalous subjective experiences in schizophrenia and mood disorders. © 2013 Elsevier Inc. All rights reserved.
1. Introduction In recent years, there has been renewed interest in the subtle, self-experienced cognitive, perceptual, and emotional changes that have been noted since the earliest description of dementia praecox [1–3]. Subjective experiences are subtle subjective disturbances in drive, affect, thinking, language, perception, motor action, vegetative functions, and stress tolerance [1,2,4], which constitute a set of symptoms termed “basic symptoms” [1,2,5–7]. Studies have shown that subjective experiences have important clinical implications for schizophrenia and related disorders, in that qualitative or structural alterations of subjective experiences are selfperceived subjective consequences of vulnerability to
⁎ Corresponding author. Tel.: +82 32 460 8505; fax: +82 32 472 8813. E-mail address: [email protected] (J.-H. Kim). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2012.12.017
schizophrenia [1,3,8–12]. In addition, the exploration of subjective experiences may also provide clinicians with the basis for helping patients to use appropriate coping strategies and to avoid ill-conditioned coping mechanisms [13]. Although subjective experiences comprising characteristic and qualitatively peculiar basic symptoms are considered to be a fundamental feature of schizophrenia-spectrum disorders [14,15] and are phenomenologically close to psychotic experiences, the diagnostic specificity of anomalous subjective experiences in general has not been well delineated. In fact, most studies of subjective experiences have been performed in schizophrenia and to a lesser extent in mood disorders. There have been reports that subjective experiences significantly discriminate schizophrenia in remission from psychotic bipolar disorder in remission [16], and a prospective longitudinal follow-up of firstadmission cases suggested that subjective experiences selectively aggregate in schizophrenia-spectrum disorder
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[15,17]. Arduini et al. [18] compared patients with schizophrenia and those with bipolar disorder who were hospitalized for an index episode and found that the schizophrenia patients showed higher scores on a self-rating scale measuring subjective experiences of cognitive and perceptual dysfunction. These results suggest that subjective experiences in schizophrenia may be quantitatively and/or qualitatively different from those in bipolar disorder. However, only a few studies have compared patients with schizophrenia and those with unipolar depressive disorder. Mass et al. [12] reported that other diagnostic groups, such as depressives or neurotics, showed similar high scores on a self-rating scale of subjective experiences. Ebel et al. [19] compared patients with schizophrenia and those in an endogenous-depressive phase of cyclothymia in terms of basic symptoms and found that cognitive symptoms were observed more frequently in the schizophrenia than in the comparison group. Cutting and Dunne [20] compared the subjective experiences of patients with schizophrenia and depression through several stages of assessment and found that the items concerning perceptual dysfunction distinguished the experiences of schizophrenia from those of depression. The data in the literature on the comparison of subjective experiences among patients with schizophrenia, bipolar disorder, and unipolar depression are scarce. A direct comparison among these groups has not yet been reported. Hence, the purpose of the present study was to compare anomalous subjective experiences in patients with schizophrenia, bipolar disorder, and unipolar depression in order to elucidate differences in subjective experiences and examine their potential clinical correlates in schizophrenia and mood disorders. 2. Methods 2.1. Subjects The study protocol was approved by the local ethics committee, and all procedures used in the study were conducted in accordance with international ethical standards, Declaration of Helsinki. A total of 78 patients (39 men, 39 women) with schizophrenia (n = 32), bipolar disorder (n = 24), and unipolar depressive disorder (n = 22), and 32 healthy control subjects (16 men, 16 women) were enrolled in the study. Patients were recruited at an outpatient psychiatric clinic between May 2008 and December 2010. Healthy control subjects were recruited through local advertisements. The psychiatric diagnoses were established using the Structured Clinical Interview for DSM-IV (SCID) [21]. Healthy subjects underwent a complete medical, neurological, and psychiatric examination in order to ensure the absence of disease and were screened for lifetime and current DSM-IV axis I diagnoses by using the SCID [21]. Exclusion criteria for study enrollment included a past or present neurological disorder, alcohol or substance abuse, medical conditions such as immunologic, metabolic, and cardiovas-
cular disorders, and a history of head trauma with loss of consciousness. None of the healthy control subjects were taking any medication at the time of the study enrollment. All patients were receiving psychotropic medications at the time of the study enrollment. In the schizophrenia group, the antipsychotics used were risperidone (n = 20, mean dose: 5.8 ± 2.1 mg/day), olanzapine (n = 6, mean dose: 13.8 ± 3.8 mg/day), quetiapine (n = 2, mean dose: 500.0 ± 141.4 mg/day), long-acting injectable risperidone (n = 2, mean dose: 31.3 ± 8.8 mg), and aripiprazole (n = 1, mean dose: 15 mg/day). One patient was receiving a daily combination of aripiprazole (30 mg) and risperidone (2 mg). Among patients with bipolar disorder, 13 patients were treated with valproic acid (mean dose: 992.3 ± 144.1 mg/day), five with lithium (mean dose: 930.0 ± 222.5 mg/day), four with both valproic acid and lithium (mean dose: valproic acid: 1125.0 ± 287.2 mg/day; lithium: 862.5 ± 75.0 mg/day), and two with quetiapine monotherapy (mean dose: 525.0 ± 106.1 mg/day). In the depression group, the antidepressants used were mirtazapine (n = 7, mean dose: 25.7 ± 4.0 mg/day), sertraline (n = 6, mean dose: 66.7 ± 25.8 mg/day), venlafaxine (n = 4, mean dose: 112.5 ± 0.0 mg/day), escitalopram (n = 3, mean dose: 20.0 ± 0.0 mg/ day), and trazodone (n = 2, mean dose: 62.5 ± 17.7 mg/day). 2.2. Assessments Subjective experiences were comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ) [22], which was standardized for the Korean population [23]. The FCQ is one of the most widely used rating scales for subjective experiences [22], and its psychometric properties have been well established [23–26]. It rates the current level of subjective experiences [22,23]. The FCQ is a wellconstructed instrument for self-assessment and is easy to administer [3,23]. FCQ scores have been found to be strongly correlated with objective neuropsychological test results [27]. The Korean version of the FCQ consists of 103 items, which cover a wide range of subjective cognitive, emotional, and perceptual experiences [23]. The items are subdivided into 10 phenomenological subscales, i.e., anxiety (e.g., “I frequently feel anxious without any reason.”, etc.), disorder of selective attention (e.g., “Noise, which was nothing before, now irritates me and hinders me from concentration.”, “If several persons talk together, all are mixed up and I am unable to concentrate on one person.”, “Sometimes it is hard to keep concentrating on one thing.”, etc.), deterioration of discrimination (e.g., “Sometimes when I see something, it is confusing whether it is what I actually see or just an imagination.”, etc.), psychomotor disorder (e.g., “My body occasionally moves quite differently from my intention.”, etc.), perceptual disorder (e.g., “Sometimes people look distorted.”, etc.), cognitive floating (e.g., “Sometimes I am confused because too many thoughts come into my mind.”, etc.), blocking symptoms (e.g., “Sometimes my thoughts stop and I have to wait in silence.”,
J.-H. Kim et al. / Comprehensive Psychiatry xx (2013) xxx–xxx
etc.), language disorder (e.g., “Recently it is hard for me to speak or write logically.”, etc.), automatic behavior disorder (e.g., “When doing a daily routine work, I have to think for a long time about how to do it.”, etc.), and disorder of coping responses (e.g., “I avoid stressful things.”, “I try to escape from the situation that may confuse my mind.”, “I have to be very careful because I may make a mistake in everyday life”, etc.) [23]. Symptoms of schizophrenia were assessed using the Positive and Negative Syndrome Scale (PANSS) [28]. A five-factor model of the PANSS was used, based on previously reported factor analyses [29,30]. The factors were positive, negative, cognitive/disorganized, depression, and excitement. The severity of manic symptoms was assessed using the Young Mania Rating Scale (YMRS) [31], and the 17-item Hamilton Depression Rating Scale (HAMD17) [32] was used to assess severity of depressive symptoms. 2.3. Data analysis and statistical methods Demographic and clinical variables were compared among the groups using one-way analysis of variance (ANOVA) for parametric data and Kruskal-Wallis test for non-parametric data. To test differences in subjective experiences among the groups, the FCQ total and subscale scores were compared using one-way ANOVA with post hoc Scheffé tests. Demographic and clinical predictors of subjective experiences in individual diagnostic groups were analyzed using multiple regression analysis with a stepwise procedure. The FCQ total score was the dependent outcome variable. The level of statistical significance was defined as P b .05 (two-tailed). In the comparison of the 10 phenomenological subscale scores among groups, the strict level of significance was adjusted as P b .005 (two-tailed) using the Bonferroni correction. All statistical analyses were performed using SPSS version 18.0 for Windows (SPSS, Chicago, IL, USA). 3. Results Table 1 presents the demographic characteristics of the four groups. There were no significant differences in age,
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gender distribution, or years of education among the groups (P N .05). The mean duration of illness was significantly longer in the schizophrenia and bipolar disorder groups than in the unipolar depression group (F = 6.92, P b .01). Significant differences were found in marital status; while the control group was divided evenly in terms of married and single status, there were fewer married participants in the patient groups (Chi-square value = 10.24, P b .05). The employment rate was significantly higher in the control group than in the patient groups (Chi-square value = 28.35, P b .001), whereas there were no significant differences among the patient groups (Chi-square value = 3.49, P = .18). The severity of symptoms assessed by the mean score on the PANSS, YMRS, and HAMD-17 was 78.1 ± 21.0, 7.5 ± 6.5, and 17.4 ± 7.2 for the schizophrenia, bipolar disorder, and unipolar depression groups, respectively. Regarding subjective experiences, the FCQ total score was significantly higher in the schizophrenia and depression groups than in the control group (F = 5.63, P = .001) (Table 2). The results of the analysis of covariance with the duration of illness as a covariate revealed no significant differences in the FCQ total score among the three patient groups (F = 2.19, P = .10). As shown in Table 2, there were significant group differences in the scores on the phenomenological subscales of “anxiety”, “deterioration of discrimination”, “psychomotor disorder”, “cognitive floating”, “blocking symptoms”, and “automatic behavior disorder” at the level of P b .005. The scores on the subscales of “disorder of selective attention”, “perceptual disorder”, and “disorder of coping responses” tended to be different among groups at the level of P b .05. Further post hoc analysis revealed that the schizophrenia and depression groups showed significantly higher scores than the control group on the subscales of “psychomotor disorder”, “cognitive floating”, and “blocking symptoms” (Table 2). On the subscales of “anxiety” and “automatic behavior disorder”, only the depression group showed significantly higher scores than the control group (Table 2). On the subscale of “deterioration of discrimination”, all three patient groups showed significantly higher scores than the control group (Table 2). When the control group was excluded from the comparisons, there were no
Table 1 Comparison of demographic variables among groups. Variables a
Age Gender (male, %) Education (yr) a Duration of illness (yr) a Married (%) Employed (%)
Schizophrenia
Bipolar disorder
Unipolar depression
Normal controls
F
P value
41.9 ± 9.1 56.3 12.0 ± 1.5 11.3 ± 8.0 12.9 15.6
43.5 ± 8.3 37.5 12.4 ± 2.4 12.6 ± 7.0 29.2 37.5
44.7 ± 6.9 54.5 12.0 ± 2.7 5.3 ± 5.6 38.1 27.3
38.8 ± 9.9 50.0 13.1 ± 1.4 NA 50.0 78.1
2.33 2.16 b 2.23 6.93 10.24 b 28.35 b
.078 .539 .088 .002 c .017 b.001
NA, not applicable. a Values are presented as mean ± standard deviation. b Chi-square value. c Differences between schizophrenia and unipolar depression as well as between bipolar disorder and unipolar depression on post hoc Scheffé tests (P b .05).
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Table 2 Comparison of FCQ scores among groups. FCQ variables
Schizophrenia
Bipolar disorder
Unipolar depression
Normal controls
F
P value
Total score Anxiety Disorder of selective attention Deterioration of discrimination Psychomotor disorder Perceptual disorder Cognitive floating Blocking symptoms Language disorder Automatic behavior disorder Disorder of coping responses
40.0 ± 14.6 4.1 ± 2.1 3.4 ± 1.9 5.0 ± 2.0 4.5 ± 1.6 4.0 ± 1.4 4.0 ± 1.8 4.1 ± 1.8 3.3 ± 1.5 3.6 ± 1.7 3.3 ± 1.4
35.5 ± 17.6 3.6 ± 2.1 3.0 ± 2.1 4.9 ± 2.1 3.9 ± 1.6 3.4 ± 1.9 3.7 ± 1.9 3.6 ± 2.2 3.0 ± 1.9 3.1 ± 2.1 3.1 ± 1.7
43.5 ± 21.0 5.0 ± 2.5 4.1 ± 2.3 5.5 ± 2.2 4.6 ± 2.1 3.7 ± 1.8 4.6 ± 2.3 4.7 ± 2.4 3.3 ± 2.3 4.4 ± 2.2 3.8 ± 1.9
26.9 ± 20.0 2.8 ± 1.0 2.4 ± 1.4 3.0 ± 1.4 3.2 ± 1.2 2.8 ± 1.5 2.7 ± 1.2 2.5 ± 1.3 2.8 ± 1.8 2.5 ± 1.3 2.4 ± 1.3
5.63 5.62 3.81 9.86 5.14 3.21 5.45 6.32 0.62 4.96 3.92
.001 a .001 b .012 b.001 c .002 a .026 .002 a .001 a .603 .003 b .011
Values are presented as mean ± standard deviation. FCQ, Frankfurt Complaint Questionnaire. a Differences between schizophrenia and normal controls as well as between unipolar depression and normal controls on post hoc Scheffé tests (P b .05). b Difference between unipolar depression and normal controls on post hoc Scheffé tests (P b .05). c Differences between schizophrenia and normal controls, between bipolar disorder and normal controls, and between unipolar depression and normal controls on post hoc Scheffé tests (P b .05).
significant differences among the patient groups on any of the phenomenological subscales (P N .05). Table 3 shows the results of multiple regression analyses performed in each diagnostic group. In the schizophrenia group, the PANSS negative factor score was a significant negative predictor of the severity of subjective experiences as assessed by the FCQ total score (Beta = −0.42, P b .05). Disruption of subjective experiences in patients with unipolar depression was associated with greater severity of depressive symptoms (Beta = 1.04, P b .01) and younger age (Beta = −0.33, P b .01). In the bipolar disorder group, women reported more disruptions in subjective experience (Beta = − 0.52, P b .05).
4. Discussion In the present study, the FCQ total score was significantly higher in the schizophrenia and depression groups than in the healthy control group. No significant differences were observed in the FCQ total or subscale scores among the
Table 3 Multiple regression analysis for predicting the severity of subjective experiences assessed by the FCQ in each diagnostic group. Predictor variables
Unstandardized coefficients B
Standardized P value coefficients
Std. error Beta
t
2
Schizophrenia (R = 0.18, F = 5.65, P = .025) PANSS negative factor score −1.03 0.43 Unipolar depression (R 2 = 0.91, F = 85.09, P b .001) HAMD-17 score 2.91 0.22 Age −1.01 0.24 Bipolar disorder (R 2 = 0.27, F = 6.81, P = .018) Gender −20.26 7.77
−0.42 −2.38
.025
1.04 12.98 b.001 −0.33 −4.15 .001 −0.52 −2.61
.018
FCQ, Frankfurt Complaint Questionnaire; PANSS, Positive and Negative Syndrome Scale; HAMD-17, 17-item Hamilton Depression Rating Scale.
groups of patients with schizophrenia, bipolar disorder, and unipolar depression. These results suggest that the severity of abnormal subjective experiences, as measured by the FCQ, was high and similar across schizophrenia and mood disorders, particularly depressive disorder. Therefore, it does not seem possible to clearly differentiate these disorders on the basis of subjective experiences assessed by the FCQ. Our results are in line with previous reports indicating that subjective experiences as a whole measured by the FCQ are not specific to schizophrenia [12,33]. Our results also extend earlier findings by revealing that the severity of anomalous subjective experiences in unipolar depression is substantially high and similar to that in schizophrenia. The bipolar disorder group also did not show significant differences from the other patient groups on the FCQ scores, suggesting that subtle subjective cognitive and perceptual disturbances may persist in stable outpatients with bipolar disorder, who score low on the YMRS (total mean score: 7.2). Further research should explore the extent to which these subjective experiences influence social and occupational functioning and quality of life in fully remitted patients with bipolar disorder. It should be noted that the severity of abnormal subjective experiences was particularly high in depressive disorder. As Cutting and Dunne [20] suggested, abnormal subjective experiences may be qualitative in schizophrenia and quantitative in depression. In other words, in schizophrenia, subjective experiences may be the correlate of an objective deficit, whereas in patients with depression, subjective experiences may seem to express a quantitative alteration at the level of self-perception, but not necessarily accompanied by a severe concomitant deficit in the psychosocial context [13]. Alternatively, subjective complaints as assessed by the FCQ in depression may reflect patients' subjective well-being, but may not be a substitute for qualitative alterations of subjective experiences.
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In the present study, we used the FCQ to measure subjective experiences. In contrast to the FCQ, the Bonn Scale for the Assessment of Basic Symptoms (BSABS) [34] covers a wide range of basic symptoms [3] and targets the qualitative or structural alterations of subjective experiences [15,35]. If the BSABS had been used, the findings may have led to different conclusions. In a recent study by Szily and Kéri [36], perplexity, self-disorder, and diminished affectivity, as measured by the BSABS, significantly predicted psychosis risk in patients with depression. Moreover, although the FCQ consists of 10 phenomenological subscales, previous studies on the factor structure of the FCQ strongly suggest the unidimensionality of the scale [13,24– 26]. Consequently, subjective experiences as assessed by the FCQ may constitute a single psychopathologic dimension regardless of the phenomenological subscales, and this may be a limitation of the scale. Mass et al. [37] developed a new subscale of the FCQ (FCQ-S), which was reported to be specific to schizophrenia compared with alcoholism. Future studies should include the FCQ-S to clarify its specificity among groups with schizophrenia, bipolar disorder, and unipolar depression. One of the approaches to further test the diagnostic specificity of the FCQ may be to investigate the relationship between FCQ scores and objective cognitive measures in each group [33]. The simultaneous use of subjective and objective measures of cognitive dysfunction may present a more complete picture in patients with schizophrenia and mood disorders, especially in terms of providing relevant targets for rehabilitation in the chronic stage of the illnesses [38]. Although a similar degree of subjective experiences was observed between schizophrenia and mood disorders, it is unclear whether this finding is due to a common underlying neural mechanism or simply reflects the phenomenological overlap between these disorders. Studies of various neurobiological correlates of anomalous subjective experiences are clearly required to understand the underlying nature of subjective experiences in schizophrenia and mood disorders. Notably, the results of the multiple regression analyses suggest that the predictors of subjective experiences may vary across different diagnostic groups. In the schizophrenia group, the PANSS negative factor score was a significant negative predictor, indicating that subjective experiences in schizophrenia were predicted by less severe negative symptoms. Negative symptoms may be associated with fewer subjective experiences, or alternatively, patients suffering from negative symptoms may be less capable of identifying subjective experiences as a consequence of the general blunting of mental process [39–41]. The finding of a dissimilar pattern of predictors of subjective experiences across different diagnostic groups supports the model of cognitive failure in psychiatric disorders, which proposes that intrinsic cognitive and extrinsic non-cognitive processes may be impaired in different ways in each type of psychiatric disorder [33,42].
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Our findings also support the notion of a complexity and variety of factors contributing to subjective experiences, as proposed by Peralta and Cuesta [33]. Further studies with a large sample of subjects at different stages of their illnesses are required to obtain a better understanding of the complex contributing factors associated with subjective experiences in schizophrenia and mood disorders. In the present study, anomalous subjective experiences were assessed based on the concept of basic symptoms. However, patients with severe mental illness such as schizophrenia not only have anomalous subjective experiences but also show a range of difficulties related to how they think about themselves and others, which are referred to as dysfunction in metacognition or mentalizing [43]. Therefore, patients with schizophrenia experience deficits in the ability to make judgments about the thoughts and feelings of others as well as to form larger integrated representations of themselves and others [44]. They also have difficulties recognizing mental states, correctly naming them, and using them in a flexible and reliable way. These difficulties also include problems forming and retrieving the specific autobiographical memories that ground a sense of personal identity [45,46]. Impoverished or diminished autobiographical memory may leave patients more vulnerable to metacognitive dysfunction [45]. Future studies are clearly needed to investigate whether difficulties in autobiographical memory and metacognition are more pronounced in schizophrenia compared to unipolar depression and bipolar disorder. Moreover, literature pertaining to self-experience in severe mental illness diverges as to when alterations of subjective experience emerge [47]. Phenomenological and existential perspectives generally suggest that these alterations may be present long before the illness onset [48]. However, according to the rehabilitative and dialogical points of view, these alterations may develop after the onset of the illness or may appear quite suddenly [49,50]. In our study, the severity of depressive symptoms was significantly associated with the disruption of subjective experiences in patients with unipolar depression, which is consistent with the notion that subjective experiences may develop over time after the onset of illness. Longitudinal studies are clearly required to address the issue of whether abnormal subjective experiences predate the onset of illness and are resolved with symptom remission. Longitudinal assessments of subjective experiences should include qualitative and quantitative measures to assess the richness and depth of personal narratives [47]. The present results should be interpreted in light of some limitations. The findings need to be replicated using other validated rating scales for subjective experiences, such as the BSABS. The study was a cross-sectional one, and the sample size was small. Further prospective research with a larger sample is warranted to confirm the stability of the relationships. The patients were all outpatients receiving medications, and therefore the findings may not be generalized to a
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more diverse group of patients. The severity of clinical symptoms of the bipolar disorder group was relatively low compared to that of the other patient groups, and this may have influenced the results. In addition, there is a clear need for more work, not just with questionnaires but with narrative-based assessments that measure alterations in self-experience. In particular, a profound diminishment in people's ability to coherently narrate their lives is commonly observed in patients with schizophrenia [43]. Assessing the qualities of self-experience within personal narratives may provide valuable insight into the level of symptoms, cognition, and functioning [51,52]. In conclusion, subjective experiences measured by the FCQ are not specific to schizophrenia, and the severity of anomalous subjective experiences in unipolar depression is substantially high and similar to that in schizophrenia. The finding of dissimilar predictors of subjective experiences across diagnostic groups may suggest the complexity and variety of factors contributing to subjective experiences in schizophrenia and mood disorders.
Acknowledgment For J.H. Kim, this work was supported by a grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A070001) and by the Gachon University Gil Medical Center Research Fund.
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