[Article in French]

[Acute schizophrenia concept and definition: investigation of a French psychiatrist population]

F.-J. Baylé, D. Misdrahi, P.-M. Llorca, C. Lançon, V. Olivier, P. Quintin, J.-M. Azorin
L'Encéphale. 2005-02-01; 31(1): 10-17
DOI: 10.1016/S0013-7006(05)82367-X

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Baylé FJ(1), Misdrahi D, Llorca PM, Lançon C, Olivier V, Quintin P, Azorin JM.

Author information:
(1)Université Paris V et Service Hospitalo-Universitaire de Santé Mentale et de
Thérapeutique, Centre Hospitalier Sainte-Anne, 75674 Paris.

For schizophrenic disorders, the clinical conception of « acute state » is widely
used in clinical settings to assess the effectiveness of therapeutic programs as
well as epidemiological studies. Schizophrenic-specific symptomatology
modification, need for hospitalization, significant change in care, disturbances
in social behavior or suicide attempts were all used to define acute
schizophrenic state. The decision to hospitalize is frequently used to define
acute state but refers to multiple factors such as mood disorder, suicide
attempts, drug abuse or social and environmental problems. Indeed, several and
distinct definitions in a criteria basis form are available but no one has
reached consensus. Because recognition of acute schizophrenic state remains
based on the subjective clinician’s advice, epidemiological and therapeutic
studies fail in validity and reliability. The aim of the study was to evaluate
how a population of French psychiatrists define criteria and therapeutic targets
of acute schizophrenic state in their clinical practice. Psychiatrists filled
out a self administered interview. At the time the interview was given,
clinicians were notified that they were participating in a clinical consensus
survey about schizophrenia. Six major indicators for acute state definition
based on the literature data were proposed: general schizophrenic symptomatology
modification (depression, anxiety, agitation, impulsivity/aggressiveness),
specific schizophrenic symptomatology modification (positive symptoms, negative
symptoms, disorganization), need for hospitalization, significant change in
care, disturbance in social behavior and lastly, suicidal behavior. Minimal
duration (1.2 or 4 weeks) of general and specific schizophrenic symptomatology
modification required to define acute state were evaluated. The booklet included
the 30 PANSS symptoms listed with their definitions. Among this symptom list,
clinicians were instructed to select the ten criteria which they estimated best
defined the acute state, followed by the ten most important target symptoms to
be treated. Out of 2,369 questionnaires, 1,584 were collected on time (66.9%).
Among the six majors indicators proposed to define acute state 75% of
psychiatrists considered 1 to 3 criteria. Three were more frequently rated,
including core schizophrenic symptomatology disturbance (68.4%), general
schizophrenic symptomatology disturbance (68.0%) and suicidal behavior (64.9%).
The other criteria were rated as follows: need for hospitalization (26.8%),
significant change in care (18.3%), and disturbance in social behavior (29.1%).
For 53.2% of psychiatrists the definition of acute state requires the presence
of specific schizophrenic symptomatology for a minimal duration of one week. Two
weeks with general symptomatology was required for 45.5% of psychiatrists to
define acute state. Symptoms more often rated within the four first choices for
acute state definition included delusions, conceptual disorganization,
hallucinatory behavior and excitement. Except for grandiosity, all the PANSS
positive subscale items were chosen to be included in the definition (delusions,
conceptual disorganization, hallucinatory behavior, excitement,
suspiciousness/persecution and hostility). Four items, including anxiety,
depression, uncontrolled hostility, inner tension from the general
psychopathology subscale were chosen as part of the ten most important criteria
to define acute state. On the PANSS negative subscale (blunted affect, emotional
withdrawal, poor relationships, passive apathetic withdrawal, difficulty in
abstract thinking, lack of spontaneity/flow of conversation and stereotyped
thinking), no item was rated to be included in the acute state definition. The
highest rated symptoms among the four first choices for treatment included
delusions, hallucinatory behavior, excitement and anxiety. The ten most
important criteria for treatment were the same as for acute state definition
with differences in frequency. Excited state, depression and
suspiciousness/persecution were more rated for treatment than definition whereas
delusion, hostility and conceptual disorganization were less rated as treatment
target than definition criteria. In clinical practice, recognition of acute
schizophrenic state is underscored by the association of specific schizophrenic
symptomatology (positive symptoms, negative symptoms, disorganization) and
general symptomatology (impulsivity/aggressiveness, anxiety, depression,
agitation) of schizophrenia. For most clinicians, acute state definition
requires specific symptom for a minimum of one week and other non-specific
indicators such as suicidal behaviour have to be taken into account. With regard
to PANSS criteria, most positive schizophrenic symptoms and some general
schizophrenic symptoms are necessary for definition and designated as treatment
priorities. Negative symptoms were not taken into account. Hallucinatory
behavior is the first symptom rated in definition and is considered by
psychiatrists as the absolute therapeutic priority. This survey could be a first
step in the construction of an operational and consensual definition. This
definition is strongly needed as a valid measurement in therapeutic and
epidemiological outcome studies, which remain at least partly based on clinician
subjective judgment.