Patients having their first episode of psychosis receive treatment more rapidly if they present with both hallucinations and delusions than if either type of positive symptom occurs on its own, according to a report in Psychiatry Research.

This is one of several findings of an exploratory study examining patterns of symptom onset in first-episode psychosis. To date there has been "remarkably little literature" investigating the initial development of these two key symptoms, said Dr. Michael T. Compton of George Washington University, Washington, and his associates.

Dr. Compton and his colleagues used data from a relatively large sample of 159 patients hospitalized with their first episode of psychosis "to begin to address whether meaningful clinical differences exist ... based on patterns of emergence of delusions and hallucinations in the early, pretreatment course."

The study subjects were participants in two cross-sectional studies of nonaffective psychosis who were recruited from a university-affiliated public hospital, a psychiatric emergency department, and a suburban psychiatric crisis center. They were aged 18-40 years (mean age, 24 years).

Most of these study subjects were male (75%), African American (90%), single (91%), living with family members before hospitalization (65%), and unemployed (65%).

Their diagnoses included schizophrenia, paranoid type (48%); schizophreniform disorder (17%); psychotic disorder not otherwise specified (11%); schizoaffective disorder, depressive type (6%); schizophrenia, disorganized type (4%); schizophrenia, undifferentiated type (4%); brief psychotic disorder (4%); schizoaffective disorder, bipolar type (3%); delusional disorder (2%); and schizophrenia, residual type (1%).

Both the study subjects and their family members or close friends were interviewed separately to gather information on symptom onset, demographic characteristics, and family history. Both groups completed the Symptom Onset in Schizophrenia inventory. Patient’s’ insight was self-assessed using the Birchwood Insight Scale and objectively assessed by researchers using the PANSS.

Symptom severity also was assessed using the PANSS, which included evaluations of excitement, hostility, uncooperativeness, impulse control, conceptual disorganization, mannerisms, posturing, difficulty in abstract thinking, and inattention. Global functioning was assessed using the GAF scale and the Social and Occupational Functioning Assessment (SOFA) scale.

The cohort was categorized according to whether patients had delusions only (18% of subjects), delusions preceding hallucinations by at least 1 month (20%), hallucinations preceding delusions by at least 1 month (16%), or delusions emerging concomitantly with hallucinations (46%). The four patients who had hallucinations only were excluded from the analysis because that sample size was judged too small to yield reliable statistical estimates.

So the first finding of interest was that the prevalence of first-episode psychosis patients who develop hallucinations only is quite low. "The early course of psychosis is seldom characterized by hallucinations in isolation of delusions," Dr. Compton and his associates said (Psychiatry Res. 2012;200:702-7).

This finding appears to support the theory that delusions may arise as an attempt to explain hallucinatory experiences. "Thus, once an individual at imminent risk of developing a psychotic disorder experiences hallucinations, delusional interpretations of those perceptual abnormalities are likely to follow," they noted.

Second, the pattern of symptom onset predicted the length of the delay before patients sought treatment. This interval was significantly shorter for patients with concurrent hallucinations and delusions than for any other group.

This finding makes sense, because the simultaneous emergence of two such symptoms "is likely more readily noticeable and alarming to the individual and others around him or her, being perceived as requiring more immediate treatment," the researchers said.

Efforts at early detection would benefit from the knowledge that treatment is delayed significantly longer for patients who develop only delusions or only hallucinations.

Third, scores on the PANSS and on measures of social/occupational functioning varied widely across the study groups; patients who had delusions only consistently showed less severe symptoms, less impairment, and greater function than did the other groups. It thus appears that patients who develop only delusions in their first psychotic episode may have a better overall prognosis than those who develop both delusions and hallucinations.

And fourth, despite distinct differences in symptom profiles and in function, level of insight was remarkably similar across the study groups. Measures of insight also were quite similar whether gauged by the patients themselves or by trained researchers.

This "suggests the possibility that insight is inherently related to delusional thought content," the investigators said.

Overall, this study demonstrates that the onset of positive symptoms "is a complex and varied process about which remarkably little is definitively known. Further elucidation of specific patterns of symptom emergence would deepen the field’s understanding of early-course phenomenology, and may inform efforts to improve upon nosology, prognostication, and treatment selection," Dr. Compton and his colleagues said.

This study was supported by the National Institute of Mental Health. No financial conflicts of interest were reported.

Hallucinations, delusions, or both in first-episode psychosis?