The document discusses the history and conceptualization of first-rank symptoms (FRS) in schizophrenia. It describes how Kraepelin, Bleuler, and Schneider contributed to defining and categorizing FRS. Key points: - Schneider identified 11 FRS including auditory hallucinations and thought disorders that he believed distinguished schizophrenia from other psychoses. - Studies have found FRS occur in other disorders like bipolar disorder and dissociative disorders, though they are more frequent and severe in schizophrenia. - While FRS were once considered pathognomonic of schizophrenia, most research now finds they are not exclusive to or predictive of outcomes in schizophrenia. Their diagnostic specificity has been questioned.

1. PRESENTER : PRAVEEN DAS
CHAIRPERSON : DR ASHOK MV

2. Emil Kraepelin

First delineated separate psychotic
conditions

Two major patterns of primary insanity

Based on long term prognosis and
course of illness
- Manic Depressive Psychosis
- Dementia praecox
1856-1926

3. Eugen Bleuler
Introduced the term Schizophrenia in
1911
 Primary symptoms 4As- abnormal
associations, autistic behavior and
thinking, abnormal affect and
ambivalence
 Secondary- hallucinations, delusions,
social withdrawal and diminished
drive

1857-1959

4. Kurt Schneider

First Rank Symptoms

Clinical Psychopathology

Based on his study of the
Schwabing cohort
Identified a group of
symptoms characteristic to
schizophrenia
 Based on clinical experience

1887-1967

5. Definition
“When we say, for example, that thought
withdrawal is a first rank symptom, we mean
the following. If this symptom is present in a
non-organic psychosis, then we call that
psychosis schizophrenia, as opposed to
cyclothymic psychosis, or reactive psychosis
in an abnormal personality”
Kurt Schneider, “Clinical Psychopathology”
(1958)

6. In other words…
First-rank symptoms (FRS) are a group of
delusional and hallucinatory experiences that, in
Schneider’s experience with the Schwabing cohort,
reliably distinguished “schizophrenic” from
“affective” psychosis.

7. They are…

Auditory Hallucinations
1. Audible thoughts
2. Voices heard arguing
3. Voices heard commenting on one’s action

Thought disorder: Passivity of thought
4. Thought withdrawal
5. Thought Insertion
6. Thought Broadcasting

8. 
Passivity experiences: delusion of control
7. “Made” affect
8. “Made” impulse
9. “ Made” volition
10. Somatic passivity

Delusion:
11. Delusional perception

11. FRS- A separate cluster within positive
symptoms

Principal axis factor analysis (PAF) at baseline (n =
857) and a confirmative factor analysis (CFA) at threeyear follow-up (n = 414) on (FRS) symptom score

A two-factor structure of first rank symptoms, i.e.
FRS-delusional self experience and FRS-auditory
hallucinations, with a moderate to large internal
coherence within each factor and relative stability over
time
(Heering HD et al.,2013)

12. Basis for FRS

Schneider considered these symptoms based on a
diagnostic sense

Empirical rather than thoeretical

Influenced by the phenomenological school of
psychopathology (Husserl, Jaspers)

Some represent a disruption of ego boundaries

13. Reasons for wide acceptance







Easy to elicit
High inter-rater reliability and replicability
Schneider’s reputation
Heuristically useful in clinical work & research
Incorporated into diagnostic criteria ICD-9, 10 &
DSM III, IV
Incorporated in diagnostic tools like PSE
Use in IPSS

14. FRS in ICD 10
Criteria for diagnosis of Schizophrenia
 a to d
 First rank symptoms
 Persistent delusions that are culturally
inappropriate and completely impossible


Should be present for most of the time during a
period of one month

15. FRS in DSM IV
Criterion A
 Voices conversing with each other, running
commentary
 Bizarre delusions – clearly implausible and not
understandable
 Includes thought insertion, withdrawal, broadcast,
delusion of control
 Continuous signs of disturbance for at least six
months with symptoms for most of one month period


16. Explaining FRS…


Phenomenological: defect in the integration of the
self, leading to a “loss of ego boundaries”
Local dysfunction: Trimble (1990) suggested FRS
indicate temporal lobe dysfunction
Right inferior parietal lobule implicated in FRS
(Frith’s Model)
Morphological abnormalities in the limbic-paralimbic
regions such as the cingulate gyrus and
parahippocampal gyrus
(Suzuki M.,2005)

17. Explaining FRS…

Genetics: initial studies (low n) suggested heritability
of zero, later authors (Mc Guffin et al., 2002) found
26.5% concordance in MZ twins, 0.3% in DZ twins

The nuclear symptoms of schizophrenia can be
understood as a failure to establish dominance for a
key component – the phonological sequence – of
language in one hemisphere
(TJ Crow)

18. Current theories for FRS


Neuropsychological: currently has the most evidence
Mainly based on the work of Christopher Frith (1992)

Symptoms of schizophrenia arising from a defect
in self monitoring
Deficits in self monitoring leads to a loss of sense
of

 Agency
 Ownership

Deficits of self monitoring due to a dysfunction in
the internal forward model system

19. Current theories for FRS
According to this theory, deficits in self-monitoring
lead to a loss of the sense of


agency (leading to made phenomena)
ownership (leading to thought alienation
phenomena)

21. The forward model system
Comparator / Self Monitoring System
Agency
Efference Copy/
corollarydischarge
Re-afference Copy
Motor command
Ownership
Motor Act
Proprioceptive Input

22. 
The subjective experience of schizophrenia
patients with body-affecting FRS (made impulses
and made acts) is rooted in the disturbance of
intentionality and diminished sense of agency
(Thomas Fuchs et al., 2010)

23. Evidence for FRS - Imaging
Auditory Hallucinations
 Increased blood oxygen level dependent (BOLD) signal in
Heschl Gyrus in the dominant hemisphere
(Thomas Dierks et al., 1999)
Smaller superior temporal lobe volume is associated with
auditory hallucinations in schizophrenia
(Barta et al 1990)
 Persistence of auditory hallucinations over 5 years of care was
associated with smaller temporal lobe volumes bilaterally

(Milev et al., 2003)

Frontotemporal functional dysconnectivity in schizophrenia
and may be associated with auditory hallucinations
(C Frith et al.,)

24. Evidence for FRS - Imaging
Passivity phenomenon
Involvement of right parietal cortex using PET scan.
Schizophrenic patients with passivity showed
hyperactivation of parietal and cingulate cortices. This
hyperactivation remitted in those subjects in whom
passivity decreased over time
(Spence et al.,1997)
 A significant positive correlation between
Schneiderian scores and rCBF was observed in two
regions of right parietal cortex

(Nancy C Andreason et al.,2002)

25. 
Schizophrenia patients with FRS (antipsychotic naïve)
had significantly larger deficit in right IPL volume in
comparison with healthy controls
(G Venkatsubramanian et al.,2009)

Reduced cortical volume was observed in parietal and
frontal association cortices in the passivity group
(C Pantelis et al)

26. 
Those with FRS had larger splenium than those
without FRS and were closer to controls and
probably have adequate connectivity through
splenium regions; this would support the
hyperconnectivity hypothesis
(Venkatsubramanian G et al.,2011)

27. 
Auditory hallucinations and passivity
experiences are associated with an abnormality
in the self-monitoring mechanism that
normally allows us to distinguish self-produced
from externally produced sensations
(Frith C, Blakemore)

28. 
Facial emotion recognition deficits (FERD) have been
consistently demonstrated in schizophrenia. However
the relation between psychopathology and FERD
remains inconclusive. First Rank Symptoms (FRS) of
schizophrenia is associated with heightened sense of
paranoia and rapid processing of threatful emotional
stimuli. FRS+ group made significantly greater errors
in Over-identification as compared to the FRS- group.
This study supports that FERD is one of the
important deficits in schizophrenia
(Venkatsubramanian G et al.,2011)

29. Brain derived Neurotrophic factor (BDNF)
and FRS
Schizophrenia patients had low BDNF than controls
 FRS(+) patients to have significant deficit in plasma
BDNF level in comparison with healthy controls (p =
0.002); however, FRS(−) patients did not differ from
healthy controls (p = 0.38)

(Sunil Vasu Kalmadi et al .,2013)

30. Prevalence of FRS
investigator
method
No of
patients
FRS %
Huber et al 1967
Chart review
195
72
Mellor 1970
interview
166
72
Carpenter et al 1974
interview
811
57
Wing et al 1975
interview
810
51
Koehler et al 1977
Chart review
210
33
Bland et al
Chart review
50
88
Chandrasena & Rodrigo 1979
interview
169
25.4
Raguram 1980
interview
30
53.3
Ndetei DM & Singh
interview
80
73
Radhakrishnan et al 1983
interview
88
35
Tannenberg-karant et al 1995
interview
94
72
Botros MM et al
interview
42
67
Idrees et al 2010
interview
100
34

31. Prevalence of Individual FRS
Investigator
Highest (%)
Lowest (%)
Mellor (1970)
UK
Thought broadcast
(31%)
Made impulse
(4.2%)
Koehler (1977)
Germany
Ona (1982)
Nigeria
Idrees (2010)
Pakistan
Raguram (1980)
India
Delusional perception
(55%)
Somatic passivity
(80.9%)
Voices commenting
(41.2%)
Thought broadcast
(62.5%)
Insertion (56%)
Withdrawal (56%)
Made impulse
(0%)
Audible thoughts
(6.4%)
Delusional perception
(0%)
Delusional perception
(12.5%)
Made phenomena
(each 12.5%)

32. Are they seen in other disorders also ?
How specific are they ..???

33. 
Several findings indicated that FRS were not more
effective than non- Schneiderian psychotic
symptoms in delineating central characteristics of
the schizophrenic syndrome; they may identify a
subgroup of schizophrenics with a more chronic
course, but they do not appear to have the unique
importance or diagnostic specificity that has been
accorded to them
(Silverstein ML. Harrow M.,1981)

34. Investigators
Diagnosis (N)
FRS %
Taylor, 1972
Mania (7)
Depression (8)
Neuroses & PD(18)
0
0
0
Carpenter et al, 1973
Affective. Psychoses (39)
Neuroses(23)
23
9
Abrams et al, 1974
Mania (43)
9
Taylor et al, 1973
Mania (52)
11.5
Carpenter et al, 1974
Mania (66)
Depression(119)
Neuroses & PD(123)
23
16
12.7
Wing et al, 1975
Mania (79)
Depression (176)
PD/Neuroses (53)
16
5
7.2
Marsha et al (1995)
BPAD (62)
32
Radhakrishnan et al (1983)
Affective Disorders (46)
Hysterical Psychosis (39)
Paranoid State (6)
1
7
2
O'Grady (1990)
Affective disorders (34)
14

35. Prevalence in other mental illness

Affective disorders
 Prevalence 33.3%
 Most common: voices commenting and made acts (31%
each)**

Reactive psychosis
 Prevalence: 23.3%
 Most common: voices commenting, thought insertion &
withdrawal (57%)**
( Raguram, 1980)
**% of those who had FRS

36. 
In an analysis the case records of 83 first admissions
of FRS+ schizophrenics, hospitalized in a
strongly Schneider-oriented German University Clinic
during the period 1962-1971. Research diagnosable
"schizo-affective" disorder was thus found in 27.7% (23
cases) of these patients; 12 of the 23 satisfied "full"
affective research criteria for depression or mania,
whereas 11 fulfilled "adjusted" affective criteria geared
to cover more "labile" mixed mood states. Moreover,
48.2% (40 cases) and 25.3% (21 cases) of the sample
were research-positive for "schizophreniform" illness
and "atypical schizophrenia" respectively (Koehler K.,1979)

37. 
A high rate of FRSs in manic and mixed patients was
found with a higher frequency in men (31%) than in
women (14%; P=0.038)

A monotonic increase in the association between
FRSs and younger age was apparent

These results confirm previous findings that FRSs are
not specific to schizophrenia
(Gonzalez Pinto A et al.,2003)

38. 
FRS has also been described in dissociative
disorders
(Laddis A, Dell PF., 2012; Kluft RP.,1987; Shibayama M.,2011)

Also described in BZD withdrawal (Roberts K 1986)

39. 
One study shows high specificity to schizophrenia
(Tandon et al., 1987)

Most of the other studies: occur frequently but not
exclusively in schizophrenia

FRS are not pathognomonic but very strong indicators
of schizophrenia

40. 
FRS which are considered pathognomonic of
schizophrenia occur in one fourth of the cohort of
manic-depressive patients. Therefore, Schneider's
system for identifying schizophrenia, while highly
discriminating, leads to significant diagnostic
errors if FRSs are regarded as pathognomonic
(Carpenter et al.,1973)

41. FRS and outcome

42. 
Most of the studies
 No correlation between FRS and outcome
 FRSs did not have a postdictive or predictive function, as no
relationship could be established between FRSs and
duration or outcome of illness
(Carpenter et al.,1973)
 Number of FRS in an individual patient does not
predict outcome

(Julie Norgaard 2007)
A few studies
 FRS & poor prognostic signs identify the same patients
(Taylor 1972 )
 FRS in the acute stage and at 2 years predicted lack of
recovery during 20 year follow
(Rosen et al., 2011)

43. 
First-rank symptoms are not exclusive to
schizophrenia; they also occur in some bipolar
patients. However, they are more frequent and more
severe in patients with schizophrenia than bipolar
disorder

Schizophrenia patients with FRS during the acute
phase are more likely to have poorer long-term
outcome than schizophrenia patients who do not have
FRS during the acute phase
(Rosen C, Grossman LS.,2011)

44. FRS Criticism

45. Mellor, 1970
Pointed out three criticisms of FRS
They make no contribution to our
understanding of Schizophrenia
 They are not first rank even in Schneider’s
sense
 The method by which they are elicited is
unreliable


46. Few other criticisms






Various definitions
Unreliability of assessment
Not specific
Does not predict the outcome
Other symptoms may be more specific (negative
symptoms, thought disorder)
Represent only one dimension (core psychotic
symptoms?)

47. DSM 5- Schizophrenia
Two or more of the following present for a
significant duration during a 1 month period.
Atleast one must be 1, 2 or 3
1. Delusions
2. Hallucinations
3. Disorganized speech ( frequent derailment or
incoherence)
4. Grossly disorganized or catatonic behaviour
5. Negative symptoms ( diminished emotional
expression or avolition)


48. 
This change should have little impact on
prevalence because fewer than 5% individuals
receive a diagnosis of schizophrenia based on a
single bizzare delusion or hallucination
(PCNA sept 2012 Vol 35 No 3)

49. FRAH was common in two DSM IV schizophrenia
datasets (42.2% and 55.2%) and BD was present in
the majority of patients (62.5% and 69.7%). However,
FRAH and BD rarely determined the diagnosis. In
database 1, we found only seven cases among 325
patients (2.1%) and in the second database we found
only one case among 201 patients (0.5%) who were
diagnosed based on FRAH or BD alone.
 Among patients with FRAH, 96% had delusions, 1442% had negative symptoms, 15-21% had
disorganized or catatonic behavior, and 20-23% had
disorganized speech.


50. 
Among patients with BD, 88-99% had hallucinations,
17-49% had negative symptoms, 20-27% had
disorganized or catatonic behavior, and 21-25% had
disorganized speech.

FRAH and BD are common features of schizophrenia
spectrum disorders, typically occur in the context of
other psychotic symptoms, and very rarely constitute
the sole symptom criterion for a DSM-IVTR diagnosis of schizophrenia
(Shinn AK, Heckers S.,2013)

51. 

Although bizarre delusions and/or
Schneiderian hallucinations were present in 124
(n=221) patients (56.1%), they were singly
determinative of diagnosis in only one patient
(0.46%). Additionally, only three of the 221
patients (1.4%) with DSM-IV schizophrenia did
not have a delusion, hallucination, or disorganized
speech
DSM-5 changes in criteria A should have a
negligible effect on the prevalence of
schizophrenia, with over 98% of individuals with
DSM-IV schizophrenia continuing to receive a
DSM-5 diagnosis of schizophrenia in this dataset
(Tandon R, Bruijnzeel D, Rankupalli B.,2013)

52. Issues in FRS research

Diagnosis of psychiatric illness, schizophrenia
 Lack of a solid lab test
 Diagnosis is based on conventions
Unclear definitions of FRS
 Difficulty in differentiating schizophrenia and
mood disorders
 To be understood in the context of patient’s total
illness picture


53. As long as the diagnosis of Schizophrenia
depends on FRS, it is logically impossible to
assess the diagnostic specificity of FRS
Nordgaard et al., 2008

54. Conclusions
Schneider’s work on delineating these symptoms
in his cohort and being able to consistently
describe them is unparalleled
 Has served to initiate and propel research on
Schizophrenia, both phenomenological and
neurobiological
 Has influenced current diagnostic systems
 Has shown to be indicative of severity of illness in
a few studies
 As long as hallucinations and delusions remain as
symptoms of psychosis, FRS of Schneider will
influence its diagnosis


55. THANK YOU