Schneider's First-rank Symptoms Research Articles

Differentiating autoimmune encephalitis from schizophrenia spectrum disorders among patients with first-episode psychosis

BackgroundAlthough differential diagnosis between autoimmune encephalitis and schizophrenia spectrum disorders is crucial for a good outcome, the psychiatric symptoms that distinguish these two conditions have not been identified even though psychiatric symptoms are often the main manifestation of autoimmune encephalitis. Also, there are many situations in clinical psychiatry in which laboratory testing and imaging studies are not available. Because no comparative study of the psychiatric symptoms between these two conditions has been carried out, we explored diagnostically useful psychiatric symptoms in a retrospective case-control study. MethodsWe recruited 187 inpatients with first-episode psychosis who were admitted to our psychiatric unit and categorized them into two groups: the autoimmune encephalitis group (n = 10) and the schizophrenia spectrum disorders group (n = 177). Differences in the symptoms and signs between the two groups were investigated. ResultsSchneider's first-rank symptoms (e.g., verbal commenting hallucinations and delusional self-experience) were observed only in the schizophrenia spectrum disorders group, whereas altered perception was found more frequently in the autoimmune encephalitis group. Functional status was worse in the autoimmune encephalitis group, and neurological and neuropsychological signs were revealed almost exclusively in this group. A history of mental illness was more frequently reported in the schizophrenia spectrum disorders group than in the autoimmune encephalitis group. ConclusionsThe psychiatric symptoms, i.e., Schneider's first-rank symptoms and altered perception, together with neurological and neuropsychological signs, functional status, and past history, may help clinicians accurately differentiate these two conditions among patients with first-episode psychosis.

Schneider's first-rank symptoms have neither diagnostic value for schizophrenia nor higher clinical validity than other delusions and hallucinations in psychotic disorders.

The validity of studies on the diagnostic significance of first-rank symptoms (FRS) for schizophrenia has been put in doubt because of a poor compliance with Schneider's criterion for their definition and the lack of use of the phenomenological method for their assessment. In this study, using a rigorously phenomenological approach to elicit FRS, we examined (a) the degree to which unequivocally present FRS differentiated schizophrenia (n=513) from other psychotic disorders (n=633), and (b) the comparative validity between FRS and other reality-distortion symptoms against 16 external validators in the whole sample of psychotic disorders (n=1146). Diagnostic performance indices (with 95% CIs) of FRS for diagnosing schizophrenia were as follows: sensitivity=0.58 (0.54-0.61), specificity=0.65 (0.62-0.67), positive predictive value=0.57 (0.54-0.60) and negative predictive value=0.65 (0.63-0.68). While the overall association pattern of FRS and non-FRS scores with the validators was rather similar, three validators (premorbid social adjustment, number of hospitalizations and global assessment of functioning) were significantly related to non-FRS scores (p < 0.006) but not to FRS scores (p > 0.05). Furthermore, no validator was significantly related to FRS scores and unrelated to non-FRS scores, all of which indicates an overall better predictive validity for non-FRS delusions and hallucinations. These findings suggest that FRS do not have diagnostic value for diagnosing schizophrenia and that they do not meaningfully add to the external validity showed by other delusions and hallucinations. We believe that much of the misunderstanding about the diagnostic and clinical validity of FRS for schizophrenia is rooted in Schneider's confusing concept of the disorder.

A major flaw in the diagnosis of schizophrenia: what happened to the Schneider's first rank symptoms.

Kurt Schneider introduced in the definition of the first-rank symptoms (FRS) the criterion that, where unequivocally present, the FRS are always psychological primaries and irreducible. This criterion, grounded on 'phenomenology' (description of subjective experiences), cannot be applied, according to Schneider, to delusions, either two-stage FRS delusional perception, or second-rank delusional notions. The Schneider's key criterion was neglected since the initial adoption of the 'Schneider's FRS' in the subsequent international literature (e.g. PSE, RDC, DSM, and ICD). The 'Schneider's FRS' (e.g. thought insertion, thought withdrawal, passivity, and influence) were persistently equivocated as 'delusions', in spite of the Schneider's FRS exclusion criterion. The internationally equivocated 'Schneider's FRS' (only homonymous of the original 'Schneider's FRS'), were eliminated in the DSM-5 and de-emphasized in ICD-11. However, the diagnostic value of the original 'Schneider's FRS', assessed on the basis of the strict compliance with the Schneider's criterion for their definition, was never determined. The 'damnatio memoriae' of the original Schneider's FRS may be premature. The definition and assessment of the 'experienced' symptoms of schizophrenia, only directly observed and reported by the patients, represent a specific, crucial, irreplaceable domain of psychopathology, to be carefully distinguished from the domain of the 'behavioral' symptoms observed by the clinician. Contemporary psychopathology research is aware of the absolute need for psychiatry to enhance precision and exactness in the definition of the experienced symptoms of schizophrenia, through the formulation of unequivocal inclusion and exclusion criteria (descriptive micro-psychopathology), in order to determine their value in research and care.

Schneider's first-rank symptoms as predictors of remission in antipsychotic-naive first-episode psychosis.

Objective:German psychiatrist Kurt Schneider proposed the concept of first-rank symptoms (FRS) of schizophrenia in 1959. However, their relevance for diagnosis and prediction of treatment response are still unclear. Most studies have investigated FRS in chronic or medicated patients. The present study sought to evaluate whether FRS predict remission, response, or improvement in functionality in antipsychotic-naive first-episode psychosis.Methods:Follow-up study of 100 patients at first episode of psychosis (FEP), with no previous treatment, assessed at baseline and after 2 months of treatment. The participants were evaluated with the standardized Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) and for presence of FRS.Results:Logistic regression analysis showed that, in this sample, up to three individual FRS predicted remission: voices arguing, voices commenting on one’s actions, and thought broadcasting.Conclusion:Specific FRS may predict remission after treatment in FEP patients. This finding could give new importance to Kurt Schneider’s classic work by contributing to future updates of diagnostic protocols and improving estimation of prognosis.

The Prehistory of Schneider's First-Rank Symptoms: Texts From 1810 to 1932.

First-rank symptoms (FRS), proposed by Kurt Schneider in 1939, subsequently became influential in schizophrenia diagnosis. We know little of their prehistory. How often were FRS described before 1939 and in which countries and time periods? Which FRS was most frequently noted? Forty psychiatric texts from 37 authors, published 1810-1932, were identified that described FRS. In a systematic subsample, half of the textbooks examined contained such descriptions with little differences between countries or over time. Somatic passivity was most commonly noted, followed by thought insertion, thought withdrawal, and made actions. This pattern resembled that reported in recent studies of schizophrenia. A novel term-delusions of unseen agency-was seen in psychiatric texts and then found, from 1842 to 1905, in a range of official reports, and psychiatric, medical, and general audience publications. The Early Heidelberg School (Gruhle, Mayer-Gross, Beringer) first systematically described "self-disturbances" (Ichstörungen), many of which Schneider incorporated into FRS. From the beginning of Western descriptive psychopathology in the early 19th century, symptoms have been observed later described as first-rank by Schneider. A term "delusion of unseen agency"-closely related to Schneider's first-rank concept-was popular in the second half of the 19th century and described in publications as prominent as the Encyclopedia Britannica and New England Journal of Medicine. The descriptions of these specific symptoms, with substantial continuity, over more than 2 centuries and many countries, suggest that an understanding of their etiology would teach us something foundational about the psychotic illness.

Schizophrenia and other primary psychotic disorders in ICD-11

In the development of the International Classsification of Disorders (ICD-11), the World Health Organisation (WHO) has used a systematic approach with a focus on the utility of the revised classification criteria. For all major groups of mental and behavioural disorders working groups were set up, and these reviewed the scientific evidence and developed suggestions for revised classification criteria. These initial proposals, then submitted to public consultation and review, resulted in updated proposals. The chapter title for the primary psychotic disorders will be "Schizophrenia and other primary psychotic disorders". The clinical subtypes of schizophrenia will be substituted by symptom specifiers, which are applicable to all primary psychotic disorders. The role of Schneider's first-rank symptoms will be deemphasized. Course specifiers will be introduced and will be compatible with the U.S.-American classification system for mental disorders (Diagnostic and Statistical Manual, 5th revision, DSM-5). The group of Acute and Transient Psychotic Disorders will be more clearly differentiated from schizophrenia. Currently, field trials are under way both in clinical and internet-based settings to test the utility of the revised classification criteria. In early 2018, the final classification criteria of ICD-11 should be available.

Schneider's First-rank Symptoms and the Longitudinal Evolution in Psychosis

Schneider's first-rank symptoms have been connected to the diagnosis of Schizophrenia for decades. More recently, these types of symptoms have also been described in other types of psychosis, including affective psychosis. In general, current research focuses on the relationship between Schneider's first-rank symptoms and the subsequent clinical course, i.e. their role in the prognosis of the disorder. Objectives To determine how the presence of Schneider's first-rank symptoms in psychosis can influence the evolution of the disorder. Method We analyzed a group of subjects (N = 106) who had a first-episode psychosis between 1995-1998. This group was divided into two subgroups: one that presented Schneider's first-rank symptoms (N = 70) and another group (N = 36) without these symptoms. The groups were compared in terms of subsequent evolution. It is worth noting that this study only included subjects who were currently in active psychiatric follow-up in the outpatient service. Results There are differences between the two groups in terms of clinical parameters (age, onset, educational level, employment and family status, clinical diagnosis) and disorder progression (number of admissions), but without any statistically significant differences in the first 10 years of evolution. The existence of transparency-influence symptoms in a first-episode psychosis correlates with an increase in the number of hospital admissions after 10 years of evolution. Conclusions The transparency-influence phenomena are correlated with an increase in the number of hospital admissions across the longitudinal evolution.

Proposals for ICD-11: a report for WPA membership.

Proposals for ICD-11: a report for WPA membership.

The reliability of the Standard for Clinicians' Interview in Psychiatry (SCIP): A clinician-administered tool with categorical, dimensional and numeric output

BackgroundExisting standardized diagnostic interviews are not used by psychiatrists in clinical settings. There is an urgent need for a clinician-administered tool for assessment of adult psychopathology that produces dimensional measures, in addition to categorical diagnoses. MethodsThe Standard for Clinicians' Interview in Psychiatry (SCIP) was designed to be used in clinical settings and generates dimensional measures. The reliability of the SCIP was tested at six sites: one hospital and two clinics in USA, two hospitals in Egypt and one clinic in Canada. Participants were adult patients who were admitted for inpatient psychiatric treatment or came for regular office visits in the outpatient clinic. Refusal rate was <1%. Missing data were <1.1%. Patients with dementia, mental retardation or serious medical conditions were excluded. A total of 1,004 subjects were interviewed between 2000 and 2012. ResultsInter-rater reliability (Kappa) was measured for 150 SCIP items: 116 items (77.3%) had good reliability (Kappa>0.7), 28 items (18.7%) had fair reliability (Kappa ranges from 0.5 to 0.7) and six items (4%) had poor reliability (Kappa<0.5). Cronbach's alpha for internal consistency was measured for the SCIP dimensions: anxiety, posttraumatic stress, depression, mania, hallucinations, Schneider first-rank symptoms, delusions, disorganized thoughts, disorganized behavior, negative symptoms, alcohol addiction, drug addiction, attention and hyperactivity. All of the SCIP dimensions had substantial Cronbach's alpha values (>0.7) with the exception of disorganized thoughts (Cronbach's alpha=0.375). ConclusionsThe SCIP is a reliable tool for assessing psychological symptoms, signs and dimensions of the main psychiatric diagnoses.

Poster #T267 PREFRONTAL CORTEX THICKNESS IN PTSD AND SCHIZOPHRENIA AND THE ROLE OF CHILDHOOD TRAUMA

Existing standardized diagnostic interviews are not used by psychiatrists in clinical settings. There is an urgent need for a clinician-administered tool for assessment of adult psychopathology that produces dimensional measures, in addition to categorical diagnoses.The Standard for Clinicians' Interview in Psychiatry (SCIP) was designed to be used in clinical settings and generates dimensional measures. The reliability of the SCIP was tested at six sites: one hospital and two clinics in USA, two hospitals in Egypt and one clinic in Canada. Participants were adult patients who were admitted for inpatient psychiatric treatment or came for regular office visits in the outpatient clinic. Refusal rate was < 1%. Missing data were < 1.1%. Patients with dementia, mental retardation or serious medical conditions were excluded. A total of 1,004 subjects were interviewed between 2000 and 2012.Inter-rater reliability (Kappa) was measured for 150 SCIP items: 116 items (77.3%) had good reliability (Kappa > 0.7), 28 items (18.7%) had fair reliability (Kappa ranges from 0.5 to 0.7) and six items (4%) had poor reliability (Kappa < 0.5). Cronbach's alpha for internal consistency was measured for the SCIP dimensions: anxiety, posttraumatic stress, depression, mania, hallucinations, Schneider first-rank symptoms, delusions, disorganized thoughts, disorganized behavior, negative symptoms, alcohol addiction, drug addiction, attention and hyperactivity. All of the SCIP dimensions had substantial Cronbach's alpha values (> 0.7) with the exception of disorganized thoughts (Cronbach's alpha = 0.375).The SCIP is a reliable tool for assessing psychological symptoms, signs and dimensions of the main psychiatric diagnoses.

Following the development of ICD-11 through World Psychiatry (and other sources).

Following the development of ICD-11 through World Psychiatry (and other sources).

WPA contribution to the development of the chapter on mental disorders of the ICD-11: An update.

The WPA is partnering with the World Health Organization (WHO) in the development of the chapter on mental disorders of the 11th edition of the International Classification of Diseases (ICD), whose publication is expected in the year 2015. WPA Member Societies participated in the WPA-WHO Global Survey on Psychiatrists' Attitudes Towards Mental Disorders Classification 1, which will guide the WHO in improving the clinical utility of the ICD classification of mental disorders. Almost 5,000 psychiatrists worldwide provided their feedback about their use of diagnostic systems in clinical practice, and the desirable characteristics of a classification of mental disorders. Participants expressed preference for a simpler system with 100 or fewer categories. Over two-thirds preferred flexible guidance to a strict criteria-based approach. Significant minorities of psychiatrists in Latin America and Asia reported problems with the cross-cultural applicability of existing classifications. Overall, ratings of ease of use and goodness of fit for specific ICD-10 categories were fairly high, but several categories were described as having poor utility in clinical practice. This is being an important focus for the ICD revision. Several WPA Member Societies and experts are being or will be involved in ICD-11 field trials and in the various translations/adaptations of the diagnostic system. The WPA is actively contributing to the process of harmonization between the ICD-11 and the DSM-5. The WPA Past-President, M. Maj, who chairs the ICD-11 Working Group on Mood and Anxiety Disorders, recently reported 2 about the expected convergences and divergences in the ICD-11 and DSM-5 approaches to the classification of mood disorders. Among the convergences, both systems are likely to include increased activation/energy as a defining symptom for mania, and to acknowledge that a manic/hypomanic syndrome emerging during antidepressant treatment, and persisting beyond the physiological effect of that treatment, qualifies for the diagnosis of manic/hypomanic episode. Furthermore, both systems are going to provide the clinician with the opportunity to acknowledge the occurrence of subsyndromal anxiety symptoms in a patient with a major depressive episode, by using a specifier (“with prominent anxiety symptoms” in ICD-11, “with anxious distress” in DSM-5). In ICD-11, bipolar II disorder is expected to be recognized as a distinct diagnostic entity, while in ICD-10 it is just mentioned among “other bipolar affective disorders”. Expected divergences between the ICD-11 and the DSM-5 will include a different characterization of mixed states and schizoaffective disorders. The ICD-10 bereavement exclusion in the diagnosis of depressive episode will be eliminated in the DSM-5, but two notes introduced in the text should attenuate the divergence from ICD-11, which is going to exclude from the diagnosis of depressive episode, in line with ICD-10, “normal bereavement reactions appropriate to the culture of the individual concerned”. The Chairman of the WPA Section on Schizophrenia, W. Gaebel, who chairs the ICD-11 Working Group on Psychotic Disorders, recently reported 3 about the expected convergences and divergences in the ICD-11 and DSM-5 approaches to the classification of psychotic disorders. Among the convergences, both systems are going to de-emphasize Schneider's first-rank symptoms in the diagnostic criteria for schizophrenia and to omit subtypes of the disorder. These subtypes are going to be replaced by six symptom specifiers (positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, cognitive impairment) in the ICD-11 and by corresponding dimensional assessments in the DSM-5. Among the divergences, the ICD-11 is expected to keep the one month duration criterion for the diagnosis of schizophrenia, and not to include functional impairment as a mandatory criterion. World Psychiatry is one of the main channels through which the international psychiatric community is being updated about the ICD-11 development. A Special Article authored by the ICD-11 International Advisory Group, summarizing the philosophy of the entire process, has been published in the journal 4, as well as the first report of the Working Group on Intellectual Disabilities 5 and a review of evidence and proposals for the ICD-11 classification of feeding and eating disorders 6. Several papers produced by the Working Group on Mood and Anxiety Disorders have been collected in a special supplement to the journal 7. Many relevant contributions have appeared in recent issues of the journal 8–27. All these articles are available on the WPA website (http://www.wpanet.org).

Autism as the clinical core marker in schizophrenia

In his paper published in the June 2012 issue of World Psychiatry, J. Parnas focuses on the fundamental disturbance in patients before the onset of schizophrenic illness 1. He refers to the ICD-8, in which a personality disturbance was considered to be the clinical core marker of schizophrenia. In the ICD-9, this concept was retained including a disturbance of the will (inertia and negativism). In his editorial in the same issue 2, M. Maj calls for follow-up studies on Parnas' Gestalt approach in order to capture the basis of schizophrenia. This dialog immediately brought to my mind the work of another Danish psychiatrist, E. Dein (1922–1975). In the 1950s, Dein performed follow-up studies in patients within the spectrum of schizophrenia 3. He defined autism as “a permanent and socially perceptible deviation as to the interpersonal relations of the individual, characterized by a pervasive tendency to keep an abnormal distance to other people, to adopt a passive attitude and to be emotionally indifferent” 4. He found that 109 of 142 patients with chronic schizophrenia had autism before the onset of their illness, compared to only one of 52 patients with episodic schizophreniform (probably schizoaffective) states 3. The results obtained by Dein confirmed Kraepelin's observation that autism is a clinical core marker of schizophrenia. The Gestalt approach proposed by J. Parnas is a major contribution in this respect. During our validation study on depression and mania scales 5, Dein told me that the most severe case of contact disturbance he had ever observed was in a patient with manic-depressive illness. In that illness, however, the disturbance does not appear outside acute episodes, in contrast to schizophrenia, where it represents a personality trait 4. In his editorial, M. Maj also makes some remarks on the practical problems of Parnas' model. Among these is that the core Gestalt is possibly very reliable in the hands of super experts, but dangerously volatile in ordinary clinical practice 2. In this respect, Dein's words 4 echo Maj's concerns: “It is true that the ability of psychiatrists to perceive subtle shades in contact varies considerably, and perhaps a natural wish to establish contact may lure many psychiatrists into overestimating their rapport with the patient. It is at any rate inexpedient if a criterion so decisive for the diagnosis as autism must depend too much on the individuality of the psychiatrist, and it really may become a problem if the amount of his experience and competence comes to play a dominant role in clinical discussion”. Dein also states that “when evaluating possible autism… one should… try to close one's eyes to other symptoms, as for instance disturbances of thinking, transitivistic phenomena, delusions or hallucinations; these symptoms are sometimes so suggestive of the diagnosis of schizophrenia that one may be prejudiced in favour of the presence of autism” 4. When making an attempt to close the eyes of psychiatrists of the DSM-IV era to Schneider's first-rank symptoms in order to focus on the key feature of schizophrenia, Maj 6 has previously concluded that the concept of autism, as revisited by Parnas 7, deserves attention. We believe that this element should be explicitly introduced in the current debate in the journal.

Did Ezekiel have first-rank symptoms?

Certain verses in the book of Ezekiel provide descriptions which might pass for Schneider's first-rank symptoms, now commonly held to be diagnostic of schizophrenia. Still, trying to link ancient biblical verses to modern concepts of the first-rank symptoms in a religious text which is replete with

Relevance of Schneider's first-rank symptoms in Zulu patients with paranoid schizophrenia

AbstractBackground: The aim of this study was to examine the prevalence of Schneider's first-rank symptoms (FRS) in Zulu patients diagnosed with paranoid schizophrenia and to ascertain the diagnostic and prognostic significance of Schneider's FRS in this group.Methods: This descriptive study was done on 75 psychiatric Zulu in- and outpatients diagnosed with paranoid schizophrenia. A questionnaire was completed and included sociodemographic data, Schneider's FRS and a functional assessment.Results: Fifty-three percent of the patients heard voices at some or other time. Most patients (90.7%) confirmed having experienced at least one of the five related symptoms of thought disturbances and 80% of the patients confirmed the presence of passivity phenomena. Most patients (87%) indicated that they had presented at least one type of primary delusion, at the time of the interview. Regarding functional assessment, some (12%) patients were still entirely productive (“no problems”), 28% rated “mild problems”, 45% “m...

Morphological brain changes associated with Schneider's first-rank symptoms in schizophrenia: an MRI study

Schneider's first-rank symptoms involve an alienated feature of the sense of one's own mental or physical activity. To clarify the brain morphological basis for the production of these symptoms, volumes of the frontal and medial temporal regions and their clinical correlates were examined in patients with schizophrenia. Twenty-two patients with schizophrenia and 44 age- and gender-matched healthy control subjects were included. All patients were in their psychotic episodes with definite Schneiderian symptoms, rated by using the Scale for Assessment of Positive Symptoms. Volumetric measurements of high-resolution magnetic resonance imaging were performed in the prefrontal area, cingulate gyrus, and precentral gyrus, and the medial temporal structures such as the amygdala, hippocampus, and parahippocampal gyrus. Patients had significantly decreased volumes in the cingulate gray matter and the amygdala compared to controls. In the patient group, Schneiderian symptom severity showed significant inverse correlations with volumes of the right posterior cingulate gray matter and of the left anterior parahippocampal gyrus. Schneiderian symptoms may be associated with morphological abnormalities in the limbic-paralimbic regions such as the cingulate gyrus and parahippocampal gyrus, which possibly serve the self-monitoring function and the coherent storage and reactivation of information.

Heritability of Schneider's first-rank symptoms.

Schneider's first-rank symptoms are given particular weight when making a diagnosis of schizophrenia, but the nuclear syndrome, characterised by one or more first-rank symptoms, has been found previously to have no heritability. To estimate the heritability of the nuclear syndrome. A total of 224 twin pairs (106 monozygotic, 118 same-gender dizygotic) were ascertained from the Maudsley Twin Register in London via probands with any psychosis. Lifetime-ever first-rank symptoms were rated using the OPCRIT checklist. Probandwise concordance rates were calculated for the nuclear syndrome and a heritability estimate was derived from biometric model fitting. Probandwise concordance rates were 13/49 (26.5%) for monozygotic and 0/45 to 2/46 (0.0-4.3%) for dizygotic pairs. The heritability estimate for the best-fitting model was 71% (95% CI 57-82). These results indicate that the nuclear syndrome shows substantial heritability, although this is slightly lower than that for schizophrenia as defined by the DSM and ICD systems.

Diagnostic significance of Schneider's first-rank symptoms in schizophrenia. Comparative study between schizophrenic and non-schizophrenic psychotic disorders.

Despite the lack of consistent empirical support, modern diagnostic criteria of schizophrenia give particular emphasis to Schneider's first-rank symptoms (FRSs). To examine the diagnostic significance of FRSs for schizophrenia by trying to overcome the limitations of previous studies. This study examined the diagnostic accuracy of FRSs for schizophrenia in 660 in-patients with the full spectrum of functional psychotic disorders. Schizophrenia was diagnosed according to three criteria: DSM-III-R broad, DSM-III-R narrow and Feighner, the latter being considered as the gold standard because it does not give particular emphasis of FRSs. FRSs were highly prevalent in both schizophrenia and non-schizophrenic psychoses. The likelihood ratios (and 95% CI) of one or more FRSs for Feighner, DSM-III-R narrow and DSM-III-R broad schizophrenia were 1.06 (0.94-1.20), 1.23 (1.09-1.39) and 1.73 (1.44-2.08), respectively. These data indicate that FRSs do not significantly increase the likelihood of having schizophrenia. FRSs are not useful in differentiating schizophrenia from other psychotic disorders. Diagnostic systems for schizophrenia that are heavily based on these symptoms may arise from a tautological definition of the disorder.

Conceptualization of schizophrenia: the symptom-oriented approach.

E. Bleuler proposed to establish the diagnosis of schizophrenia on the basis of fundamental symptoms which he presumed to be particularly linked with the primary deficiency. K. Schneider, on the other hand, based his diagnosis on the presence of symptoms recognizable without difficulty. Modern classifications include both Bleuler's fundamental and Schneider's first-rank symptoms in their diagnostic criteria. This may lead to erroneous attributions in view of the possibility that most first-rank and some of the symptoms Bleuler suspected to be fundamental may be unspecific reactions to different basic disturbances. It can therefore be expected that research on symptoms is better suited for aetiopathogenetic investigations than research based on diagnoses. Strategies to select those symptoms on which research should focus are described and recent findings of symptom-oriented studies are discussed.

Bizarre delusions and first-rank symptoms in a first-admission sample: A preliminary analysis of prevalence and correlates

This report examines the prevalence and correlates of bizarre delusions and Schneider's first-rank symptoms (FRS) in a first-admission sample with psychosis. A total of 196 patients were assessed with the Structured Clinical Interview for DSM-III-R (SCID) and given a consensus diagnosis. Project psychiatrists blind to the consensus diagnoses coded each delusion and hallucination in the sample for both FRS and DSM-III-R bizarreness. Interrater reliability of bizarreness was lower than that of FRS (κ = .681 v 861). The majority of symptoms (72%) were neither bizarre nor FRS, and of the remainder, bizarre delusions that were not also FRS were extremely uncommon. The prevalence of FRS was 70% in schizophrenia, 29% in psychotic bipolar disorder, and 18% in psychotic depression. For seven schizophrenic patients (7.45%), diagnosis of that disorder depended on the presence of a DSM-III-R bizarre delusion to meet criteria. There was a trend for FRS to be associated with poorer prognostic features in the schizophrenic sample. We concluded that although the constructs of bizarre delusions and FRS overlap, FRS were a more important feature in schizophrenia than bizarreness. The rarity of bizarre delusions that were not FRS, combined with the lower reliability of their assessment as compared with that of FRS, raises questions about the continued emphasis on this phenomenon in the definition of schizophrenia.