What do bizarre delusions mean in schizophrenia?

What do bizarre delusions mean in schizophrenia?

Editora Sanar
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What do bizarre delusions mean in  schizophrenia?

Rodrigo Sinotta, Ana Luiza Francoa,b, Fábio Schimidta, Cinthia Hiroko Higuchib, Gerardo Maria de Araújo Filhoc, Rodrigo Affonseca Bressanb, Ary Gadelhab and Bruno Bertolucci Ortiza,b*


aDiscipline of Psychiatry, Mogi das Cruzes School of Medicine (FMUMC) – Hospital das Clínicas Luzia de Pinho Melo (SPDM), Mogi das Cruzes, Brazil; bSchizophrenia Program (Proesq), Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil; cDepartment of Psychiatry and Medical Psychology, São José do Rio Preto School of Medicine (FAMERP), São José do Rio Preto, Brazil

(Received 22 July 2015; accepted 23 September 2015)


Background: Bizarre delusions are a hallmark of schizophrenia. The symptom “Unusual Thought Content” (G9) of the Positive and Negative Syndrome Scale (Kay, S.R., Flszbein, A., & Opfer, L.A. (1987). The positive and negative syn- drome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13, 261–276.)  is de?ned as “thinking characterized by strange, fantastic, or bizarre ideas, rang- ing from those which are remote or atypical to those which are distorted, illogi- cal and patently absurd”. The aim of the present study was to investigate the relationship between symptom severity as assessed by PANSS component G9  and the delusional content communicated by the patient.

Methods: We compared the G9 PANSS scores between  patients with  2, 3, 4,  and 5 types of delusions. After that, clinical and demographic variables were compared between patients with G9 ≤ 4 (absent to moderate severity score) and patients with G9 ≥ 5 (severe to extreme severity score).

Result: Patients with more types of delusions tended to have higher G9 mean scores. Patients at ?rst episode of psychosis (P = 0.033), and with early response to antipsychotic (P = 0.001) tended to present lower G9 scores.

Conclusions: This ?nding suggests that the clinical notion of “bizarreness” is more associated with a chaotic diversity of delusional themes out of context than with a single systematized delusional core.

Keywords: bizarre delusions; schizophrenia diagnosis; delusional content



Bizarre thought content was considered by all classic authors the hallmark of schizophrenia. Authors such as Kraepelin, Bleuler, and Jaspers (Cermolacce, Sass,  & Parnas, 2010) stated that schizophrenia resided in the disorganization and coexis- tence of incompatible elements of experience in the realms of cognition, emotion, and action that place the patient beyond the boundaries of interpersonal understand- ing. Jaspers included the incomprehensibility criterion to contrast primary delusion from secondary delusion (Jaspers, 1963). The primary delusion (hallmark of schizophrenia) was said to be psychologically non-understandable in the sense that we  cannot  track  a  given  pathological  judgment  from  past  experiences  such   as

  affects, fears, or cultural in?uences. Non-understandable delusional contents, thus, require an experience inaccessible to common empathy. Later, Kurt Schneider described the “?rst rank symptoms” (FRS) which included experiences of in?uence and passivity such as delusions of control, thought broadcasting, thought insertion, and thought withdrawal (Schneider, 1959). These kinds of “loss of ego boundaries” were very well suited for illustrating bizarre delusions, and in DSM III bizarre delusions were incorporated as one of six essential criteria for schizophrenia (APA, American Psychiatric Association, 1987).


According to Cermolacce et al. (2010), bizarre delusions can be described as dis- torted metaphors that may represent alterations in the patient’s self-awareness status and changes in their temporal or spatial frameworks, expressing physical and logical impossibility. Bizarre delusions can also be manifest as experiences with no contex- tual relationship to previous experience, typically involving the relation between the self and the world. Those delusions can also manifest themselves as beliefs that are not shared by others in a given social or cultural setting, in contrast to empirical delusions, which are expressed in ways analogous to normal beliefs and tend to have practical implications. However, all these notions are far from perfect, as the de?n- ing terms for bizarre delusions require more re?ned speci?city as well as greater validity and reliability. In a study conducted by Bell, Halligan, and Ellis (2006), the reliability of bizarre delusions was found to be inferior to that of delusions in gen- eral. On account of this, those authors concluded that the concept of “bizarreness” is inadequate for scienti?c usage. Moreover, empirical studies addressing this issue are scant and their results are highly heterogeneous, showing that the reliability of the description of bizarre delusions is insuf?cient (Bell et al., 2006).

The Positive and Negative Syndrome Scale (PANSS, Kay, Flszbein, & Opfer, 1987) was conceived as a psychometric tool to quantify the phenomenology of the symptoms of schizophrenia. It generally produces a ?ve-factor solution regarded as “symptom dimensions”, which are positive, negative, disorganized, mood/depres- sion, and excitement/hostility (Higuchi et al., 2014; Wallwork, Fortgang, Hashimoto, Weinberger, & Dickinson, 2012). The symptom “Unusual Thought Content”  (PANSS item G9) is de?ned as “thinking characterized by strange, fantastic, or bizarre ideas, ranging from those which are remote or atypical to those which are distorted, illogical and patently absurd”. Unusual Thought Content (G9) is usually loaded in the “positive factor” alongside Delusions (P1), Hallucinatory  behavior (P3), Grandiosity (P5), Suspiciousness (P6) (Higuchi et al., 2014; Van  der Gaag      et al., 2006; Wallwork et al., 2012).

The aim of the present study was to investigate the relationship between symptom severity, as assessed by PANSS component G9, and the  delusional  content communicated by the patient according to the criteria of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders– Revised (DSM-IV) Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1996)

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were (a) diagnosis of schizophrenia, according to the DSM-IV criteria; (b) absence of brain disease, veri?ed by computed tomography or presence of intellectual disability reported by family; and (c) age between 14 and 60 years. The study was approved by the local research ethic committee (protocol no. 2013/01); all patients and caregivers provided their written informed consent.

Diagnosis and symptom  assessment

Symptom severity was measured using the PANSS, the Clinical Global Impression scale (CGI; Guy, 1976), and the Global Assessment of Functioning scale (GAF; Endicott, Spitzer, Fleiss, & Cohen, 1976). Diagnosis was based on the SCID-I crite- ria. Module B of SCID-I is aimed at identifying psychotic symptoms and requires a detailed description of the delusions experienced by the patient, divided into ?ve types: B1 = delusions of reference; B2 = persecutory delusions; B3 = grandiose delusions; B4 = somatic delusions; and B5 = other delusions (religious, jealousy, guilt, control, thought broadcasting). The remaining items in module B identify hallucinations (B6–B9), catatonic symptoms (B10), disorganized symptoms (B11–B13), and negative symptoms (B14).


Statistical analysis

The frequency of each delusional type according to the module B of SCID-I was:  B1 = 98.1%,  B2 = 98.2%,  B3 = 57.7%,  B4 = 47.3%,  B5 = 95.8%.  No   individual

type of delusion was related to G9. Due to this, we calculated the frequency of mul- tiple types of delusions: 1 type, 0%; 2 types, 5.6%; 3 types, 20.6%; 4 types, 41.9%; and 5 types, 31.9%. Then, we compared the G9 PANSS  scores between patients  with 2, 3, 4 and 5 types of delusions.

In order to compare clinically relevant information about the bizarre delusions, the sample was divided into two groups: patients with G9 ≤ 4 (absent to moderate severity score) and patients with G9 ≥ 5 (severe to extreme severity score). Clinical and demographic variables were compared between the groups. A P-value of < 0.05 was considered signi?cant. All statistical analyses were made with the Statistical Package for the Social Sciences (SPSS), version 20.0.


Patients with more types of delusions tended to have  higher  G9  mean  scores  (Table 1). With respect to G9 groups (G9 ≤ 4 vs. G9 ≥ 5), except for ?rst episode of psychosis (P = 0.033), early response to antipsychotic (P = 0.001) (de?ned as a reduction ≥ 40% in total PANSS score at the fourth week), no statistical differences were found between the groups on the clinical and demographic variables.



In order to better characterize the phenomenon of bizarre delusions, PANSS item G9 scores were assessed in relation to the types of delusion, clinical and demographic characteristics in a sample of 160 patients with schizophrenia. Having a greater number of delusion types was suggested to be a better marker of bizarre content in the present study. This ?nding indicates that the clinical notion of “bizarreness” is 

more associated with a chaotic diversity of delusional themes out of context than with a single systematized delusional core. Furthermore, the presence of G9 ≥ 5 was signi?cantly associated with later response to antipsychotics and having more than one episode of psychosis, suggesting that bizarre delusions may have some prognos- tic value.

In DSM III-R (American Psychiatric Association, 1987), bizarre delusions have been described as one of three suf?cient diagnostic criteria for schizophrenia. In DSM-IV, the presence of bizarre delusions was considered a suf?cient criterion for the diagnosis of schizophrenia, provided that criteria B and C were met (the former assesses occupational and social dysfunction and the latter addresses disease dura- tion). However, DSM-5 (American Psychiatric Association 2013) has excluded bizarre delusions as a suf?cient diagnostic criterion for schizophrenia. Although bizarre delusions may not be implicated with diagnosis, if our ?ndings are replicated in other studies, it will be possible to explore the concept of “bizarre delusions” regarding its prognostic value in schizophrenia.

Disorganized symptoms in schizophrenia are characterized by bizarre speech and bizarre behavior. Disorganized schizophrenia subtype criteria operationalized in the DSM-IV were based on the hebephrenia described by Hecker in 1881 (Taylor, Shorter, Vaidya, & Fink, 2010). According to Sullivan (1953), hebephrenic symp- toms were a marker of worse outcome, and once the hebephrenic change has begun the patient would suffer vivid visual and auditory hallucinations and “changeable, fantastic, bizarre or silly delusions”. These ?ndings are consistent with recent ?nd- ings, where higher rates of disorganization have been correlated with worse response to treatment, while continuous illness has been associated with worse long-term prognosis (Cuesta, Peralta, & De Leon, 1994; Fenton & McGlashan, 1991, Metsanen, Wahlberg, Hakko, Saarento, & Tienari, 2006; Ortiz, Araujo Filho, de Alencar, Medeiros, & Bressan, 2013; Owens, Johnstone, Miller, Macmillan, & Crow, 2010).

Following Sullivan’s understanding of schizophrenia as an interpersonal phe- nomenon, Arieti (1978) reported a progressive poorer interpersonal relation in patients with hebephrenia. In addition, according to Johansen, Iversen, Melle, and


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Hestad (2013), patient ratings of less agreement on treatment goals with therapist were differentially associated with shorter education and more positive psychotic symptoms with unusual thought content and lack of judgment and insight.

This study was limited by the use of a PANSS item that is only probabilistic; therefore, other raters could regard different delusional contents as “extremely sev- ere”. In addition, we could not separate Schneider’s FRS (Schneider, 1959) from other contents of delusions, and only a few outcome clinical characteristics were compared to bizarre delusions. On the other hand, the PANSS description for unu- sual thought content is emphatic with respect to the more severe manifestations of this symptom, as it requires highly nonsensical delusional contents – such as grade   6 severity, in which the “patient expresses many illogical or absurd ideas or some which have a distinctly bizarre quality (e.g. having three heads, being a visitor from another planet)”. No proposition for a statistical assessment of bizarre delusions can be found in the current literature. Considering that the occurrence of more delusion types was associated with more than one episode of psychosis in the present study, a more thorough investigation of these delusions could show promise in identifying diagnostic or even prognostic predictors in schizophrenia.



Disclosure statement

Rodrigo Affonseca Bressan received research funding from FAPESP, CNPq, CAPES, Funda- ção Safra, Fundação ABADS, Janssen, Eli Lilly, Lundbeck, Novartis and Roche, served as a speaker for Astra Zeneca, Bristol, Janssen, Lundbeck and Revista Brasileira de Psiquiatria, and is a shareolder of Radiopharmacus Ltda and Biomolecular Techology Ltda. Ary Gadelha was on the speakers’ bureau and/or has acted as a consultant for Janssen-Cilag in the last 12 months The other authors report no con?icts of interest to disclose.




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