title: Shall we really say goodbye to first rank symptoms?
abstract: First rank symptoms (FRS) of schizophrenia have been used for decades for diagnostic purposes. In the new version of the DSM-5, the American Psychiatric Association (APA) has abolished any further reference to 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. The ICD-10 is currently 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.
  
  
  
  We describe the specific circumstances in which Schneider articulated his approach to schizophrenia diagnosis and discuss the relevance of his approach today. Further, we discuss anthropological and phenomenological aspects of FRS and highlight the importance of self-disorder (as part of FRS) for the diagnosis of schizophrenia. Finally, we will conclude by suggesting that the theory and rationale behind the definition of FRS is still important for psychopathological as well as neurobiological approaches today.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité University Medicine, Saint-Hedwig Hospital, Humboldt University, Berlin, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Heinz
authors.affiliation: Department of Psychiatry and Psychotherapy, Charité University Medicine, Saint-Hedwig Hospital, Humboldt University, Berlin, Germany. Electronic address: martin.voss@charite.de.
authors.forename: M
authors.initials: M
authors.lastname: Voss
authors.affiliation: Division of Psychiatry, University of Edinburgh, Kennedy Tower, Royal Edinburgh Hospital, Edinburgh EH10 5HF, UK.
authors.forename: S M
authors.initials: SM
authors.lastname: Lawrie
authors.affiliation: Department of Clinical Psychology, Chicago School of Professional Psychology, Los Angeles, USA.
authors.forename: A
authors.initials: A
authors.lastname: Mishara
authors.affiliation: University Hospital Carl Gustav Carus, Department of Psychiatry and Psychotherapy, Technische Universität Dresden, Dresden, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Bauer
authors.affiliation: University Clinic Hamburg-Eppendorf, Clinic and Policlinic for Psychiatry and Psychotherapy, Hamburg, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Gallinat
authors.affiliation: Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Ruhr-University, Bochum, Germany.
authors.forename: G
authors.initials: G
authors.lastname: Juckel
authors.affiliation: Psychiatric University Clinics (UPK), Basel, Switzerland.
authors.forename: U
authors.initials: U
authors.lastname: Lang
authors.affiliation: Social and Preventive Medicine, University of Potsdam, Potsdam, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Rapp
authors.affiliation: Department of Psychiatry and Psychotherapy, Ludwig-Maximilians University, Munich, Germany.
authors.forename: P
authors.initials: P
authors.lastname: Falkai
authors.affiliation: University Hospital of Psychiatry, University of Bern, Bern, Switzerland.
authors.forename: W
authors.initials: W
authors.lastname: Strik
authors.affiliation: Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: J
authors.initials: J
authors.lastname: Krystal
authors.affiliation: Department of Psychiatry, Columbia University, New York, NY, USA.
authors.forename: A
authors.initials: A
authors.lastname: Abi-Dargham
authors.affiliation: Department of Psychiatry, University of Naples SUN, Naples, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Galderisi
mesh_terms: D003702:Delusions / Q000175:diagnosis; D039721:Diagnostic and Statistical Manual of Mental Disorders; D006801:Humans; D038801:International Classification of Diseases; D001523:Mental Disorders / Q000145:classification*; D011569:Psychiatric Status Rating Scales; D011599:Psychopathology; D011618:Psychotic Disorders / Q000175:diagnosis*; D012559:Schizophrenia / Q000175:diagnosis*; D012565:Schizophrenic Psychology
keywords: DSM; First rank symptoms; ICD; Schizophrenia; Self-disorder