Subjective Symptoms of Schizophrenia in Research and the Clinic: The Basic Symptom Concept
2 Department of Psychiatry and Psychotherapy, Early Recognition and Intervention Centre for mental crises (FETZ), University of Cologne, 50924 Cologne, Germany
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Abstract |
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 Top Abstract IntroductionBasic SymptomsBS in the Course...BS Rather Specific to...DiscussionReferences |
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Recent focus on early detection and intervention in psychosis has renewed interest in subtle psychopathology beyond positive and negative symptoms. These are self-experienced subclinical disturbances termed basic symptoms (BS). The phenomenologies of BS and their development in the course of psychotic disorders will be described.
Keywords: psychosis / prodrome / postpsychotic basic stage / anomalous self-experience / self-disturbance
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Introduction |
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TopAbstractIntroductionBasic SymptomsBS in the Course...BS Rather Specific to...DiscussionReferences |
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Diagnosis, treatment, and research studies of psychosis have focused mainly on its cardinal positive and negative symptoms. However, the current attention on prodromal phases of the illness has generated renewed interest in the early subtle, self-experienced changes in mentation that have been observed and described since Kraepelin's articulation of dementia praecox.1–3 The most thorough description of these symptoms is provided within the framework of the basic symptoms (BS) concept developed by the German psychiatrist Gerd Huber.3–5
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Basic Symptoms |
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TopAbstractIntroductionBasic SymptomsBS in the Course...BS Rather Specific to...DiscussionReferences |
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BS are subtle, subjectively experienced subclinical disturbances in drive, affect, thinking, speech, (body) perception, motor action, central vegetative functions, and stress tolerance.4,5 They can occur and have been reported in every stage of the illness, ie, in the prodrome to the first psychotic episode, in prodromes to relapse, in residual states, and even during psychotic episodes per se.4–6
By definition, BS are different from what is considered to be one's "normal" mental self. Being subjective, they remain predominately private and apparent only to the affected person. They are rarely observable to others, although a patient's self-initiated coping strategies (including avoidance strategies and social withdrawal) in response to his/her BS may be recognizable to others. Being self-experiences, BS differ from negative symptoms as they are currently understood, ie, as functional deficits observable to others.1 BS are also distinct from frank psychotic symptoms that are experienced by the patient as real, normal thinking, and feeling. In contrast, BS are spontaneously and immediately recognized by the affected person as disturbances of his/her own (mental) processes. Insight that something is wrong with one's thinking is present, yet some experiences might be so new and strange that they remain nearly inexplicable. The rare, highly introspective person may be able to articulate what is happening, but any detailed description of these experiences usually requires help in the form of guided questioning.6 The ability to experience BS with insight and to cope with them often attenuates with progressive illness and emerging psychotic symptoms but is restored upon remission.4 Thus, an evaluation of BS is often hindered by acute and/or prominent psychotic symptoms.
In Anglo-American psychiatry, 2 researchers, James Chapman7 and John Varsamis,8 described self-experienced symptoms like BS in the 1960s and 1970s without exploring them in as much detail as Huber and colleagues. Recently, BS emphasizing anomalies of self-awareness have been described by Josef Parnas.1,9
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BS in the Course of Schizophrenia |
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TopAbstractIntroductionBasic SymptomsBS in the Course...BS Rather Specific to...DiscussionReferences |
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BS were regarded as the earliest subjectively experienced symptoms of psychosis and the most immediate symptomatic expression of the neurobiological correlates of the illness (figure 1)—thus the term "basic."4,5 According to the original concept, (early) symptoms of psychosis occur in 3 developmental forms: "uncharacteristic" BS affecting mainly drive, volition, and affect, as well as concentration and memory (level 1); "characteristic", qualitatively peculiar BS, especially of thinking, speech, (body) perception, and motor action (level 2); and psychotic symptoms per se (level 3; figure 1).4,5
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Upon debut at level 1, BS will gradually increase in number and severity and, in most cases, will ultimately develop into psychotic symptoms. Temporary improvements, however, are possible (figure 1; thick line). In some cases, level 1 and/or level 2 BS will remit completely and spontaneously before reaching the threshold for psychotic symptoms (figure 1; thin dotted lines on left of the figure). These symptomatic phases without conversion to a frank psychotic episode can mimic true prodromal stages and are called "outpost syndromes" because they herald the subsequent prodrome.5
The emergence of level 2 or characteristic BS and their conversion to level 3 psychotic symptoms can be triggered by everyday situations and demands that overstrain an already pathologically vulnerable information processing capacity.4,5 Given favorable environmental and personal conditions (eg, a supportive social network, good social, and problem solving skills or coping successfully with pressure such as passing difficult exams), BS can be compensated for at any state almost completely as long as their number and/or severity do not overextend personal resources and coping strategies (figure 1; first thick dotted line). Thus, in earlier phases, the developing illness will only become obvious to others when negative coping strategies are employed (eg, social withdrawal or avoidance of certain situations/activities) or when coping abilities are exhausted, and BS start to interfere with behavior as functional deficits and/or disorganizations of communication.
Following the first frank episode, BS evolve into 3 categories of outcome or "postsymptomatic basic stages" (figure 1 on right of the figure): (1) a reversible stage characterized by complete remission of BS within 3 years following treatment (figure 1; thick dotted lines); such an outcome is the hope of early intervention before the outbreak of psychotic symptoms, (2) a prodromal stage of relapse developing from a low-symptom or even an asymptomatic state into a second episode (thick dashed line), and (3) an irreversible symptomatic stage or "pure defect syndrome" with level 1 and level 2 BS, especially disturbances in drive, stress tolerance, and affect and deficits in cognition, persisting on a level interfering with functioning for more than 3 years (thin solid line).
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BS Rather Specific to Psychoses |
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TopAbstractIntroductionBasic SymptomsBS in the Course...BS Rather Specific to...DiscussionReferences |
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Table 1 details some cognitive and perceptual BS that are common to persons with active psychosis, residual psychosis, or risk for psychosis. Statements have been taken from the "Schizophrenia Proneness Instrument, Adult Version (SPI-A)" 6 that gives more extended descriptions of BS and instructions for their assessment.
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Other BS such as disturbances in drive, stress tolerance, affect, body perception, and level 1 cognitive BS may occur in other disorders, especially nonpsychotic affective disorders.10–12 The subset detailed in table 1, however, appear to be rather specific to psychosis10–12 and is currently employed in 2 prodromal criteria sets.6,12
These BS, if present, can be assessed in most persons, including those with mild mental impairment (IQ 
50).13 Even in patients with fully intact cognitive capacity, however, what usually gets described spontaneously are broad, nonspecific complaints such as having trouble concentrating or thinking. Yet, starting from these, specific cognitive BS can be queried about and teased forth. Furthermore, because these phenomena, especially perceptual disturbances, are recognized by the person as not normal, they are often appraised as something extraordinary or "crazy" and beyond understanding. As such, the presence of BS can be kept hidden and might not be volunteered at all unless they are asked for explicitly. When this happens, however, patients often feel empathically understood for the first time and relax.
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Discussion |
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BS are an integral part of the psychoses and can appear throughout various stages of the disorder. Currently, BS are mainly employed in the early detection and preventive intervention of psychosis.3,6,11,12 In clinical practice, the most important feature of BS is that they are experienced and reported as abnormal and burdensome by the patients themselves. As such, they are appropriate to describe in awareness and information campaigns of psychosis to promote early detection and indicated prevention. They should also be described to patients in remission from psychosis as representing early signals of a risk for relapse. BS are also important signals of the need for rehabilitation in residual, postpsychotic states.5 They support a more complete description of the degree of remission beyond positive and negative symptoms. In this, BS can be used for titrating adequate combinations of pharmacological, psychological, and rehabilitative interventions.5
Finally, a patient's encounters with and motivations for treatment may be improved by relating therapeutic strategies to phenomena that are clearly recognized as subjectively burdensome symptoms. The BS concept can also educate patients and their families about the expressions of psychosis and support them in acquiring a deeper understanding of the expected vicissitudes of their illness, an important step in the process of stripping "madness" of some of its intractability and terror.5,14 Finally, consideration of BS may help the therapist in achieving insight into a patient's failure to master some problems that might be a reaction to BS.14
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Footnotes |
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1 To whom correspondence should be addressed; tel: +49-221-478-6098, fax: +49-221-478-3738, e-mail: frauke.schultze-lutter{at}uk-koeln.de.
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Acknowledgments |
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I want to express my deep gratitude to Thomas McGlashan who patiently supported me throughout the preparation of the manuscript. The English manual of the SPI-A is available at www.fioriti.it.
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References |
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- Parnas J, Handest P, Jansson L, Sæbye D. Anomalous subjective experience among first-admitted schizophrenia spectrum patients: empirical investigation. Psychopathology (2005) 38::259–267.[CrossRef][Web of Science][Medline]
- Mayer-Gross W. Die Schizophrenie. Die Klinik. In: Handbuch der Geisteskrankheiten —Bumke O, ed. (1932) Berlin, Germany: Springer. 293–578.
- Klosterkötter J, Schultze-Lutter F, Ruhrmann S. Kraepelin and psychotic prodromal conditions. Eur Arch Psychiatry Clin Neurosci (2008) 258:(suppl 2):74–84.
- Gross G. The ‘basic’ symptoms of schizophrenia. Br J Psychiatry (1989) 7:(suppl):21–25.[Medline]
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- Schultze-Lutter F, Addington J, Ruhrmann S, Klosterkötter J. Schizophrenia Proneness Instrument, Adult Version (SPI-A) (2007) Rom: Giovanni Fioriti Editore s.r.l.
- Chapman J. The early symptoms of schizophrenia. Br J Psychiatry (1966) 112::225–251.
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- Parnas J, Møller P, Kircher T, et al. EASE: examination of anomalous self-experience. Psychopathology (2005) 38::236–258.[CrossRef][Web of Science][Medline]
- Klosterkötter J, Gross G, Huber G, Wieneke A, Steinmeyer EM, Schultze-Lutter F. Evaluation of the ‘Bonn scale for the assessment of basic symptoms—BSABS’ as an instrument for the assessment of schizophrenia proneness: a review of recent findings. Neurol Psychiatry Brain Res (1997) 5::137–150.
- Klosterkötter J, Hellmich M, Steinmeyer EM, Schultze-Lutter F. Diagnosing schizophrenia in the initial prodromal phase. Arch Gen Psychiatry (2001) 58::158–164.
[Abstract/Free Full Text] - Schultze-Lutter F, Klosterkötter J, Picker H, Steinmeyer EM, Ruhrmann S. Predicting first-episode psychosis by basic symptom criteria. Clin Neuropsychiatry (2007) 4:(1):11–22.
- Schultze-Lutter F, Klosterkötter J. Do basic symptoms provide a possible explanation for the elevated risk for schizophrenia among mentally retarded? Neurol Psychiatry Brain Res (1995) 3::29–34.
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