First-rank symptoms: Past, present and future

Abstract

Introduction Conceptualising Schneider’s first-rank symptoms (FRS) as a diagnostic test whose performance can be measured in terms of sensitivity and specificity involves some issues that require reflection. The first formal proposal was contained in a 1939 monograph Schneider wrote, but little is known of their prehistory. In recent years there has been renewed interest in their clinical value. Objectives This work aims to review the the diagnostic the evolution and diagnostic accuracy of FRS. Methods A non-systematic review was performed, searching Pubmed/MEDLINE for articles using the keywords “schizophrenia” and “first rank symptoms”. Results From the beginning of Western descriptive psychopathology in the early 19th century, symptoms have been observed later described as first-rank by Schneider. When FRS are conceived as simple clinical indicators at a low level of inference, the results of the meta-analytic estimate of their diagnostic accuracy can be considered as a valid appraisal of their performance and usefulness. However, when FRS are conceptualised from a psychopathological perspective as strange and incomprehensible experiences that cannot be reduced merely to their propositional content and require substantial expertise and skill to be properly evaluated, the meta-analytic estimates can hardly be seen as a valid evaluation of their diagnostic significance, considering that some FRS are extremely difficult to assess properly. Conclusions The descriptions of these symptoms present substantial temporal and geographical continuity, over two centuries and in many countries. There is contradictory information concerning the validity of FRS as a clinical indicator. Phenomenologically informed studies are needed to address this research gap.