First-rank symptoms: Past, present and future

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.