The Diagnostic Status of First-Rank Symptoms

OBJECTIVE: In the International Statistical Classification of Diseases, Tenth Revision(ICD-10) and Diagnostic and Statistical Manual of Mental Disorder, Third and Fourth Edition(DSM-III-IV), the presence of one of Schneider "first-rank symptoms" (FRS) is symptomatically sufficient for the schizophrenia diagnosis. Yet, it has been claimed that FRS may also be found in the nonschizophrenic conditions, and therefore, they are not specific or diagnostic for schizophrenia. This review was made to clarify the issue of diagnostic specificity. METHODS: (1) A critical review of FRS studies published in English between 1970 and 2005. (2) A highlight of the 5 most frequently cited studies identified in the Web of Science. (3) Theoretical implications of the epistemological issues of FRS. RESULTS: The reviewed studies do not allow for either a reconfirmation or a rejection of Schneider's claims about FRS. The sources of disagreement between the studies are (1) including or excluding acute patients with potential degradation of consciousness; (2) assessing or not the phenomenological context; (3) assessing patients in different stages of their illness evolution; and (4) differential emphasis on mood symptoms and history of psychiatric symptoms. CONCLUSION: Both DSM-IV and ICD-10 emphasize FRS to a degree that is not supported by the empirical evidence. Until the status of FRS is clarified in depth, we suggest that the FRS, as these are currently defined, should be de-emphasized in the next revisions of our diagnostic systems. Future studies aiming at validation of FRS as diagnostic features need to apply a phenomenological perspective and include a homogenous group of patients across a wide spectrum of diagnoses.