European Psychiatry 37 (2016) 8–13

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European Psychiatry
journal homepage: http://www.europsy-journal.com

Review

Shall we really say goodbye to first rank symptoms?

A. Heinz a, M. Voss a,*, S.M. Lawrie b, A. Mishara c, M. Bauer d, J. Gallinat e, G. Juckel f,
U. Lang g, M. Rapp h, P. Falkai i, W. Strik j, J. Krystal k, A. Abi-Dargham l, S. Galderisi m
a
Department of Psychiatry and Psychotherapy, Charité University Medicine, Saint-Hedwig Hospital, Humboldt University, Berlin, Germany
b
Division of Psychiatry, University of Edinburgh, Kennedy Tower, Royal Edinburgh Hospital, Edinburgh EH10 5HF, UK
c
Department of Clinical Psychology, Chicago School of Professional Psychology, Los Angeles, USA
d
University Hospital Carl Gustav Carus, Department of Psychiatry and Psychotherapy, Technische Universität Dresden, Dresden, Germany
e
University Clinic Hamburg-Eppendorf, Clinic and Policlinic for Psychiatry and Psychotherapy, Hamburg, Germany
f
Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Ruhr-University, Bochum, Germany
g
Psychiatric University Clinics (UPK), Basel, Switzerland
h
Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
i
Department of Psychiatry and Psychotherapy, Ludwig-Maximilians University, Munich, Germany
j
University Hospital of Psychiatry, University of Bern, Bern, Switzerland
k
Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
l
Department of Psychiatry, Columbia University, New York, NY, USA
m
Department of Psychiatry, University of Naples SUN, Naples, Italy

A R T I C L E I N F O A B S T R A C T

Article history: Background: First rank symptoms (FRS) of schizophrenia have been used for decades for diagnostic
Received 13 January 2016 purposes. In the new version of the DSM-5, the American Psychiatric Association (APA) has abolished any
Received in revised form 18 April 2016 further reference to FRS of schizophrenia and treats them like any other ‘‘criterion A’’ symptom (e.g. any
Accepted 19 April 2016
kind of hallucination or delusion) with regard to their diagnostic implication. The ICD-10 is currently
Available online 16 July 2016
under revision and may follow suit. In this review, we discuss central points of criticism that are directed
against the continuous use of first rank symptoms (FRS) to diagnose schizophrenia.
Keywords:
Methods: We describe the specific circumstances in which Schneider articulated his approach to
First rank symptoms
Schizophrenia
schizophrenia diagnosis and discuss the relevance of his approach today. Further, we discuss anthropological
ICD and phenomenological aspects of FRS and highlight the importance of self-disorder (as part of FRS) for the
DSM diagnosis of schizophrenia. Finally, we will conclude by suggesting that the theory and rationale behind the
Self-disorder definition of FRS is still important for psychopathological as well as neurobiological approaches today.
Results: Results of a pivotal meta-analysis and other studies show relatively poor sensitivity, yet
relatively high specificity for FRS as diagnostic marker for schizophrenia. Several methodological issues
impede a systematic assessment of the usefulness of FRS in the diagnosis of schizophrenia. However,
there is good evidence that FRS may still be useful to differentiate schizophrenia from somatic causes of
psychotic states. This may be particularly important in countries or situations with little access to other
diagnostic tests. FRS may thus still represent a useful aid for clinicians in the diagnostic process.
Conclusion: In conclusion, we suggest to continue a tradition of careful clinical observation and fine-
grained psychopathological assessment, including a focus on symptoms regarding self-disorders, which
reflects a key aspect of psychosis. We suggest that the importance of FRS may indeed be scaled down to a
degree that the occurrence of a single FRS alone should not suffice to diagnose schizophrenia, but, on the
other hand, absence of FRS should be regarded as a warning sign that the diagnosis of schizophrenia or
schizoaffective disorder is not warranted and requires specific care to rule out other causes, particularly
neurological and other somatic disorders. With respect to the current stage of the development of ICD-
11, we appreciate the fact that self-disorders are explicitly mentioned (and distinguished from
delusions) in the list of mandatory symptoms but still feel that delusional perceptions and complex
hallucinations as defined by Schneider should be distinguished from delusions or hallucinations of ‘‘any
kind’’. Finally, we encourage future research to explore the psychopathological context and the
neurobiological correlates of self-disorders as a potential phenotypic trait marker of schizophrenia.
ß 2016 Elsevier Masson SAS. All rights reserved.

* Corresponding author. Department of Psychiatry and Psychotherapy, Charité University Medicine, Saint-Hedwig Hospital, Große Hamburger Str. 5-11, 10115 Berlin, Germany.
E-mail address: martin.voss@charite.de (M. Voss).

http://dx.doi.org/10.1016/j.eurpsy.2016.04.010
0924-9338/ß 2016 Elsevier Masson SAS. All rights reserved.
 A. Heinz et al. / European Psychiatry 37 (2016) 8–13
1. Introduction
In the new version of the DSM-5, the American Psychiatric
Association (APA) has abolished any further reference to first rank
symptoms (FRS) of schizophrenia and treats them like any other
‘‘criterion A’’ symptom (e.g. any kind of hallucination or delusion)
with regard to their diagnostic implication [1,2]. As a consequence,
any two criteria A symptoms are required for a diagnosis of
schizophrenia. The ICD-10 [3] is currently under revision and may
follow suit, based on the suggestion that FRSs are unhelpful for
differentiating schizophrenia from other psychoses, as they occur
frequently in other mental disorders [4,5].
FRS have been conceptualized by Schneider [6,7] and have since
been used in several variations to inform diagnosis of schizophre-
nia and schizoaffective disorder [8–10]. In this article, we will refer
to FRS as they are summarized in Schneider’s Clinical Psychopa-
thology [7] and listed in the AMDP system (‘‘Arbeitsgemeinschaft
für Dokumentation und Methodik in der Psychiatrie’’, [10]), which
offers clinical examples of each FRS for regular training of
psychiatrists and psychologists.
In ICD-10, the following FRS are listed [3]:
 audible thoughts;
 voices arguing;
 voices commenting on one’s action;
 influence playing on the body-somatic passivity;
 thought withdrawal;
 thought insertion;
 thought broadcasting;
 made feelings;
 made impulses;
 made volitional acts;
 delusional perception.
Importantly, seven out of these eleven FRS refer to the concept
of so-called ‘‘ego disorders’’ or ‘‘self-disorders’’ (SD), commonly
also termed ‘‘passivity symptoms’’ (and referred to as ‘‘bizarre
delusions’’ in DSM) in the Anglo-American tradition, that include
thought insertion, but also thought broadcasting, thought blockade
and all feelings of alien control of body parts, etc. In the German,
but not the Anglo-American psychopathological tradition, such
‘‘self-disorders’’ have been distinguished from delusions, because
they concern experiences to which the psychotic subject has
privileged access (i.e. the experience that thoughts have been
inserted in the person’s mind by an alien power), while delusions
are concerned with external events to which the psychotic person
and the therapist have equal access [11].
With respect to delusions, Schneider had suggested that only
attributing a delusional meaning to a perception of altered events or
constellations constitutes a first rank symptom of schizophrenia,
because it can be directly checked by the doctor and the patient. The
concept of delusional perception dates back to a term coined by
Schneider’s mentor, Karl Jaspers, ‘‘abnormes Bedeutungsbewusst-
sein’’ [abnormal consciousness of meaning] [12]. Schneider warned
that the diagnosis of other delusional experiences, such as
delusional ideation or systematic delusions could be distorted by
insufficient knowledge or prejudices on the side of the therapist
[6]. This important notion later received some empirical support:
studies investigating inter-rater variability showed limited reliabil-
ity for detecting ‘bizarre delusions’ [13], which were not confined to
classical self-disorders, such as thought insertion but included
culturally highly unusual explanations of external events [8], while
FRS – and SD in particular – were listed among those symptoms
with a high inter-rater reliability [14].
In this review, we will discuss central points of criticism that are
directed against the continuous use of FRS as described by
9
Schneider and listed in ICD-10 to diagnose schizophrenia, then we
will focus on the specific circumstances in which Schneider
articulated his approach to schizophrenia diagnosis and discuss
the relevance of his approach today. Finally, we will conclude by
suggesting that the theory and rationale behind the definition of
FRS is still important for psychopathological as well as neurobio-
logical approaches today. We suggest that the importance of FRS
may indeed be scaled down to a degree that the occurrence of a
single first rank symptom should not suffice to diagnose
schizophrenia, but, on the other hand, we point out that absence
of FRS can be regarded as a warning sign that the diagnosis of
schizophrenia or schizoaffective disorder is not warranted and
requires an in-depth search for other causes, particularly
neurological and other somatic disorders. In conclusion, we
suggest to:
 continue a tradition of careful clinical observation and fine-
grained psychopathological assessment;
 to further explore the neurobiological correlates of self-
disorders on;
 to continue to teach and use ‘‘FRS’’ to inform diagnosis in
schizophrenia.
2. Criticism of FRS – why the occurrence of specific psychotic
experiences is not enough to diagnose schizophrenia but
absence of FRS should be a warning sign
Arguments against FRS can be divided in three sections: first, it
has been argued that FRS are not specific for schizophrenia and
occur in other mental disorders [15,16]. Second, it has been
suggested that the occurrence of psychotic symptoms per se,
including first rank symptoms, is rather frequent even in subjects
who do not suffer from any classifiable mental disorder [17–
19]. Thirdly, the use of FRS has been questioned within a
worldwide context and it has been suggested that the functions
impaired in such FRS refer to specific European traditions of self-
reflection rather than to a general anthropological trait [20,21].
With respect to the first argument, a series of studies has shown
that when applying DSM criteria to diagnose schizophrenia, FRS
may occur in subjects who, according to DSM, are diagnosed with
affective disorders and do not show other symptoms suggesting
presence of schizophrenia [4,15,22]. This argument aims at the
core of the current distinction between affective and schizophrenic
disorders; it can be traced back to Kraepelin’s dichotomous
classification of the then so-called ‘‘endogenous psychosis’’ with
dementia praecox (later schizophrenia) as an increasingly debili-
tating disorder on the one hand and affective disorders that alter
between severe impairment and recovery on the other [23]. How-
ever, a series of current genetic studies suggest that genetic
disposition overlaps considerably between schizophrenia and
bipolar disorder as well as between bipolar disorder and unipolar
depression [24–26]. In this respect, one has to keep in mind that
Schneider [6] did not suggest that his symptoms constitute a
disease entity; instead, he claimed that in case FRS are present, ‘‘in
all modesty we call it schizophrenia’’ [6]. Accordingly, in ICD-10,
the presence of FRS (with the exception of delusional perception)
in conjunction with a severe affective disorder is sufficient to
diagnose a so-called schizoaffective disorder. The implicit assump-
tion behind this approach is that FRS such as complex auditory
hallucinations and thought insertion point to a dysfunction of
central aspects of the self, which suffices to clinically diagnose a
schizophrenia [3]. Some proponents of the DSM may argue that
presence of such single symptoms is not enough to alter the
fundamental nature of an affective disorder. In contrast, we
suggest that self-disorders reflect key aspects of psychotic
10 A. Heinz et al. / European Psychiatry 37 (2016) 8–13
experience and that FRS describe clinically relevant alterations of
personhood that require careful assessment and a search for their
neurobiological correlates [27] [28]. We refer to the dimensional
approach in psychiatry and suggest to further explore the
neurobiological correlates of self-disorders in schizophrenia
[29–31]. Regarding the second argument, we suggest that
particularly those FRS that refer to self-disorders are clinically
highly relevant, because their presence indicates that a person can
act on intentions which are experienced to be under alien control,
thus severely interfering with personal accountability for such
actions [21,32]. Therefore, we suggest to continue to carefully
assess FRS, particularly self-disorders, and to recognize their
importance in current classifications of mental disorders based on
clinical relevance. We are also concerned that eliminating FRS from
diagnostic manuals will promote the loss of important phenome-
nological, anthropological and neurobiological research traditions,
which we will address in more detail below.
A potentially even more important blow to FRS is given by the
observation that such psychotic symptoms occur in isolation in
otherwise apparently healthy individuals [17,19]. Such findings
support a view of mental maladies that suggests to only diagnose a
clinically relevant disorder in case there are not only symptoms of
a disease, i.e. an impairment of a function generally relevant for
human survival, such as a hallucination (which is apparently a
disruption of normal perception), but also an indication of
individual harm caused by this dysfunction [33], either in the
form of individual suffering (the illness experience) or of a severe
impairment in social participation (the sickness aspect of any
clinically relevant disorder) [34,35]. Independent of such consid-
erations, observing self-disorders in apparently healthy subjects
questions the relevance of such alterations for personal account-
ability and hence their status as a core symptom of mental
dysfunction. However, a recent epidemiological study in over
31,000 participants revealed that psychotic experiences (PE) in the
general population are less frequent than previously assumed
(5,8%, SE 0,2) and FRS amongst these are extremely rare (e.g. 0,4%
for thought insertion/or withdrawal, 0,3% for mind control/
passivity); 72% of those with PE reported only one particular type
of psychotic experience and one third (32,2%) just one a single
occurrence of a lifetime PE [17]. These observations suggest that
single brief occurrences of thought insertion and other self-
disorders do not constitute a clinically relevant disorder, while
persistent presence of such alterations causing individual suffering
or impaired social participation may well do.
A review of all FRS-related studies published between 1970 and
2005 addresses several methodological problems that impede the
systematic investigation of the clinical usefulness of FRS, in
particular heterogenic inclusion of patients with respect to
diagnoses as well as severity, stages of illness evolution and
the lack of phenomenological assessment and description of the
symptoms [36]. The authors conclude that ‘‘the reviewed studies do
not allow for either a reconfirmation or a rejection of Schneider’s
claims about FRS’’, and demand that future research should ‘‘apply a
phenomenological perspective and include a homogenous group of
patients across a wide spectrum of diagnoses’’.
Regarding the sensitivity and specificity of FRS to differentiate
schizophrenia from other mental disorders, a recent Cochrane
review [37] sums up the research since 1974. Twenty-one studies
with a total of 6253 participants were included in the review. FRS
differentiated schizophrenia from all other diagnoses with a
sensitivity ranging between 57–61,8% and a specificity between
74,7–94,1%, with a wide range of sensitivities and specificities
altogether. Thus, as the authors put it: ‘‘FRS performs better at
‘ruling out’ rather than ‘ruling in’ schizophrenia’’ [37]. The authors
point out that most of the studies included in the analysis were
more than 20 years old and were not conducted for the purpose of
assessing the diagnostic value of FRS and therefore several
methodological problems have to be taken into account when
interpreting the data. In accordance with that, the Soares-Weiser
et al. [37] conclude: ‘‘Empathetic, considerate use of FRS as a
diagnostic aid – with known limitations – should avoid a good
proportion of these errors’’.
In the light of these limitations, one aspect remains particularly
important for practical reasons: as psychiatrists also trained in
neurology, we are specifically concerned that failing to assess FRS
may increase false classification of somatic disorders as schizo-
phrenia. While it seems less clear that FRS are useful to demarcate
psychotic symptoms in schizophrenia from those occurring in
severe personality disorders, there is good evidence that lack of FRS
can be regarded as a warning sign that points to somatic disorders
other than schizophrenia: FRS (particularly self-disorders) are
virtually absent in a wide variety of somatic disorders with
psychotic features including infections and unwanted medication
effects [38,39].
Finally, it has been questioned whether FRS can be diagnosed
and are clinically relevant on a worldwide level. Some authors have
argued that FRS result from specific practices of self-exploration
and control, e.g. developed within European context [40]. Indeed,
Lambo [20] observed that FRS occur in Yoruba from Nigeria mainly
when they experienced and education oriented at Western
European traditions, while more traditionally raised Yoruba
experienced stronger degrees of confusion and affective involve-
ment when becoming psychotic. On the other hand, FRS have
successfully been used in the international WHO study [35] and
have since been observed in a multitude of interethnic compa-
risons (e.g. [41–44]). With respect to the use of FRS on a worldwide
level, we feel that a renewed attempt is warranted to initiate an in-
depth assessment of the phenomenology of schizophrenia in
different cultures [45].
3. The case for first rank symptoms: anthropological traditions
and specific mechanisms
Schneider developed his FRS in a time when diagnosis of
schizophrenia in Germany would mean that the person was
sterilized against his or her will and may even have been murdered;
indeed, more than one hundred forty thousand psychiatric patients
were murdered in this time [46] (and survivors were at a modest yet
significant risk of developing schizophrenia [47]).
Retrospectively, thus, Schneider’s approach seems cautious:
instead of relying on the expression of psychotic patients, including
criteria such as ‘‘flat affect’’ or ‘‘incoherence’’ (the key symptom of
Bleuler’s understanding of schizophrenia; see [48]), Schneider
relied on symptoms directly reported by the patients [9]. Indeed, all
FRS are based on statements of patients: bizarre delusions such as
passivity phenomena have to be reported, as is the case for complex
hallucinations or delusional perceptions. Diagnosis of schizophre-
nia, in this tradition, is not based on expressive behavior (e.g.
affective flattening or coherence of speech), as Schneider warned
that every expression is an impression on the side of the examiner
and hence can be distorted by prejudices including the inhuman
attitude towards schizophrenia of his time. Given that WHO
classifications have to be used worldwide, this concern in our view
is still valid today. With respect to the specificity of first rank
symptoms, two points have to be distinguished: the occurrence of
FRS in affective disorders, which, as we feel, is sufficient to diagnose
a schizoaffective disorder as currently suggested in ICD-10, and the
occurrence of FRS in isolation or in psychological stress situations of
otherwise healthy individuals.
In DSM-IV, FRS were addressed as follows: ‘‘Only one Criterion A
is required if delusions are bizarre or hallucinations consist of a voice
 A. Heinz et al. / European Psychiatry 37 (2016) 8–13
keeping up a running commentary on the person’s behavior or
thoughts, or two voices conversing with each other’’ [1]. While
Schneider strictly distinguished between delusions that concern
outside events and phenomena such as inserted thoughts, to which
the patient has privileged access (‘‘Ichstörungen’’ or self-disorders),
the term ‘‘bizarre delusions’’ [1] includes both kinds of phenomena.
We agree that it can be difficult to distinguish between common and
highly unusual delusions, which therefore is not a well-defined
term. However, we argue that it is clinically feasible to reliably
assess patients reports on phenomena such as thought insertion or
broadcasting, passivity phenomena and other ‘‘made’’ experiences,
which constitute a rather profound alteration of personal experience
as they interfere with self-agency and authorship of one’s own
thoughts [32,49] and actions [50,51]. We are worried that
eliminating the assessment of FRS may promote the neglect of this
clinically highly relevant aspect of psychotic behavior, i.e. impaired
‘‘mineness’’ of one’s own intentions and actions, which is an
important topic in juridical contexts, in philosophical anthropology
[52] as well as in research traditions aiming to explain psychotic
experiences [28,53]. These research traditions suggest that a
disturbance in the ‘‘mineness of experience’’ is at the heart of the
schizophrenia experience and indicates an alteration of the so-called
‘‘core self’’, ‘‘basic sense of self’’, ‘‘minimum self’’ or ‘‘ipseity’’ (e.g.
[28,53,54]). While specific accounts vary, we agree with a
philosophical and psychopathological tradition, which suggests
that impaired access to one’s own beliefs and thoughts impairs key
aspects of personhood and constitute an important aspect of
psychosis [11].
Indeed, there is increasing evidence that a disturbance of the
‘‘basic self’’ is a phenotypic trait marker of schizophrenia and that
its assessment could be used for the detection of early stages of the
disease (e.g. [28], without suggesting that the prodromal stage
should be included in the diagnostic category of schizophrenia).
Some studies suggest that the vast majority with patients with
dissociative personality disorder (DPD) have first rank symptoms,
even thought DPD and schizophrenia may have different etiologies
[55]. We agree with this latter consideration, and suggest that
findings in schizophrenia and schizoaffective disorder can be
distinguished from the disordered self in personality disorders, such
as borderline or narcissistic disorder when the complex phenome-
nological ‘‘Gestalt’’ or characteristic pattern of all symptoms is taken
into account [36]. Some theoretical accounts, which place FRS at the
core of their explanation of schizophrenia, may argue that absence
of FRS indicates a psychotic state of a different kind or cause
[54,56]. Parnas et al. indeed suggested that in personality disorders,
the self is disturbed on the higher level of the so-called narrative
self, while the more basic sense of self remains intact [57]. The idea
of a disturbed minimal self as a marker for schizophrenia is
corroborated by an increasing number of studies in schizophrenia
patients, which point to specific neurobiological correlates of such
phenomena (e.g. [58]; for an overview see [59,60]). Interestingly,
several studies suggest a common neurocognitive mechanism
underlying disturbances of self-agency in schizophrenia by linking
them to an impairment of internal monitoring and a deficit in
predicting the consequences of one’s own actions in schizophrenia
[50,51,61] (for a review see [62]), as well as in its prodromal stages
[63]. We feel that a more systematic assessment of SD in
schizophrenia and other causes and syndromes (e.g. NDMA-
receptor encephalitis, severe personality disorders, etc.) is still
warranted and remains a promising research field.
4. Practical aspects of retaining a focus on first rank symptoms
Having argued for the continued importance of the assessment
of self-disorders due to their clinical and theoretical importance,
11
we would also like to emphasize the practical utility of assessing
FRS in differential diagnosis. As stated above, we warn that while
FRS do not occur in every patient with schizophrenia, they hardly
ever occur in hallucinatory or delusional states due to a variety of
somatic disorders, where the occurrence of any kind of hallucina-
tion or delusion is frequent, while complex, ‘‘Schneiderian’’
hallucinations, delusional perceptions and self-disturbances are
almost absent [38,39]. Given that ICD is used worldwide, an
exclusion of organic disorders, which is feasibly in the more
wealthy industrialized countries, will not be performed in a
majority of countries worldwide. In accordance with [36], we
would like to point out the usefulness of FRS in the differential
diagnosis of schizophrenia in low-income countries with little
access to other diagnostic tests. Using DSM-5 in such circums-
tances and not demanding to base schizophrenia diagnosis on the
occurrence of more specific forms of hallucinations or self-
disorders can, as we caution, increase misdiagnosis of somatic
disorders as schizophrenia.
We appreciate that some aspects of the schizophrenia
description reported in ICD-10, such as ‘‘[. . .] the disturbance
involves the most basic functions that give the normal person a
feeling of individuality, uniqueness, and self-direction [. . .]’’ are
likely to be kept in ICD-11, because they may represent a useful aid
for clinicians in the diagnostic process.
With respect to the occurrence of FRS in otherwise seemingly
healthy individuals, we suggest to adopt the view that a clinically
relevant mental malady should only be diagnosed if disease
symptoms occur in conjunction with individual suffering or
impaired social participation [34], but we also caution that even
outside of the field of psychiatry, any key symptom can occur in
seemingly healthy individuals. For example, the presence of
functional seizures in the absence of EEG alterations on a
syndromic level does not exclude the use of specific descriptions
of seizures for the clinical classification of epilepsy. Likewise,
occurrence of stroke-like symptoms under stress or other forms of
paresis in dissociative disorders does not preclude a classification
of paralysis in neurology based on clinical symptoms. Instead,
these findings remind us of Bonhoeffer’s warning that comparable
clinical syndromes can have diverse causes [64].
5. Conclusion
Current criticisms of FRS appear valid in that they caution not to
base schizophrenia diagnosis on the occurrence of any single
symptom. Furthermore, the occurrence of such symptoms per se
does not even constitute presence of a clinically relevant malady
[33,34]: subjects hearing voices who neither suffer from them nor
are impaired in their daily functioning should, in our view, not be
diagnosed with a mental disorder at all. On the other hand, FRS
represent a valid approach by focusing on the articulations rather
than on the impression that doctors and other therapists have with
respect to the behavior including the degree of organization and
coherence of speech or adequateness of affect. In anthropological,
psychopathological and neurobiological research contexts, FRS and
particularly self-disorders provide access to basic mechanisms
required for functioning as an active person [27,51]. In transcul-
tural contexts, Schneider’s warning to rely on delusional per-
ceptions for diagnosis of schizophrenia, i.e. on outside events and
circumstances that can be checked by both the patient and
examiner on eye level, is particularly important in intercultural
contact situations, when unusual descriptions of patients may
cause examiners to wrongly diagnose a delusion when in fact the
patient is merely articulating a traditional or religious world view.
In Schneider’s times, Schneider innumerate several incidences of
such misdiagnosis, and current discussions about the reliability of
12 A. Heinz et al. / European Psychiatry 37 (2016) 8–13
schizophrenia diagnoses can profit from hearing Schneider’s
warning to always check what patients say before a delusion is
diagnosed.
In the current stage of the development of ICD-11 [65], at least
two out of seven symptoms are considered mandatory to diagnose
schizophrenia:
1. persistent delusions of any kind;
2. disorders of self-experience (e.g. thoughts are no more felt to be
generated by the subject, up to the point of passivity
phenomena, such as thought insertion or thought withdrawal);
3. persistent hallucinations in any modality;
4. disorders in the form of thought (e.g. tangentiality, loose
associations), resulting in severe cases in incoherence or
irrelevant speech, or neologisms;
5. negative symptoms such as marked apathy and anhedonia,
paucity of speech, and blunting of emotional expressions; it
must be clear that these are not due to depression or to
medication;
6. disorganized behaviour, including odd, eccentric, aimless and
agitated behaviour that would attract attention if seen in
public;
7. psychomotor disorders such as excitement, posturing, or waxy
flexibility, negativism, mutism, and stupor.
Of the two symptoms required for the diagnosis at least one
should be among those listed from 1 to 4, i.e. a positive symptom.
Gaebel et al. [65] state: ‘‘Still, delusions, hallucinations, ego
disturbances or thought disorder need to be present, thus the
classical core symptoms of schizophrenia are retained in the list of
mandatory symptoms’’. We appreciate the fact that self-disorders
are explicitly mentioned (and distinguished from delusions) in the
list of mandatory symptoms. Nevertheless, we are concerned that
ceasing to list and specifically assess other FRS such as delusional
perceptions or complex hallucinations and instead referring to
‘‘delusions of any kind’’ and ‘‘hallucinations of any modality’’ may
increase misdiagnosis of somatic disorders with psychotic features
as schizophrenia. We propose that FRS should continue to be listed
among the criteria to diagnose schizophrenia, while agreeing that
one FRS should never be enough to diagnose schizophrenia
[66]. However, FRS should be used as a discriminative tool:
absence of FRS should caution clinicians from diagnosing
schizophrenia, since any kind of hallucination or delusion is
frequently found in a multitude of somatic and mental disorders,
while evidence – albeit incomplete – indicates that FRS occur
rarely in somatic disorders [38,39]. Indeed, the meta-analysis of
Soares-Weiser et al. [37] suggests that FRS are not useful to detect
schizophrenia due to their low sensitivity (although one may argue
that our current schizophrenia concept is too broad), however, the
acceptable specificity suggests that FRS can be helpful in the
differential diagnosis of schizophrenia [37].
We conclude that scaling down the importance of FRS is
justified; ceasing to list FRS in the diagnostic manual and to
demand their specific assessment is not. Practically, we suggest
that absence of FRS should always be regarded as a warning sign
that diagnosis of schizophrenia is not warranted and further
diagnostic test are necessary.
Disclosure of interest
The authors declare that they have no competing interest.
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