. 2007 Jun 11;34(1):137–154. doi: 10.1093/schbul/sbm044

Table 1.

Studies of FRS Specificity for Schizophrenia

Reference	Aim	SCH Def.	Sample	FRS Def.	Rating	Results	Comments
1. Mellor¹⁰	Frequency of FRS in SCH Distribution of FRS	No/no	166 SCH inpatients 54 unspecified psychiatric patients	Yes	Consultant Interview	119 + FRS FRS → admissions ↓ and length of illness ↓ 28% SCH without FRS No dominating FRS type	Lack def. of SCH Lack description of 54 patients Method problem 4 and 6
2. Taylor¹¹	Frequency of FRS and “poor or good prognostic features” of Robin and Guze in “finally diagnosed” SCH	No/no	78 male SCH inpatients	Yes	Unclear who is rating Case records	22 of 34 had “poor prognostic features” and FRS Conclude that FRS and “poor prognostic signs” identify the same patients	Methodological error in collapsing FRS and “poor prognostic signs” High prevalence of FRS Only men No def. of SCH Method problem 2, 3, 4, 6, and 7
3. Taylor¹²	To establish diagnostic validity for RDC criteria for manic-depressive illness	No/no	52 manic inpatients patients Patients who received a RDC diagnosis of mania, according to the criteria: hyperactivity, rapid /pressured speech, and a euphoric, expansive or irritable mood	No	Authors Semi structured interview	8 + FRS The presence of FRS did not predict poor outcome FRS are not diagnostically decisive when manic symptoms are present	The criteria of mania are symptoms not different from symptoms of exacerbation of psychosis No concept of mania No def. of SCH Method problem 1, 3, 4, and 5
4. Carpenter¹³	Are FRS pathognomonic for schizophrenia The frequency and distribution of FRS in SCH Relation between FRS and prior duration of illness Prognostic significance of FRS	DSM-II/−	131 psychotic/SCH/anxiety patients 34 patients with manic-depressive disorder	Yes	Psychiatrists Interview journal material	51% FRS+ of SCH patients 23% FRS+ of the affective patients 9% FRS + of the neurotic patients For SCH: no correlation between FRS and prior duration of illness or between FRS and outcome FRS are not pathognomonic for schizophrenia	3 FRS missing Neurotic patients with FRS? The diagnoses seem untrustworthy Patients were not rated with focus on FRS Method problem 1, 4, and 5
5. Abrams¹⁴	Correlating FRS and severity of illness in SCH	No/no	71 SCH patients	No	Case records Severity of illness evaluated by CGI-S	24 FRS+ No dominating FRS No relation between FRS and severity of illness Sex and age was unrelated to the presence of FRS	No def. of SCH Method problem 2, 3, 4, and 6
6. Carpenter¹⁵	Prevalence of FRS in SCH Distribution of FRS Are FRS pathognomonic for SCH?	ICD-8/−	1202 patients from 9 different countries	PSE def.	Psychiatrist PSE interview	Prevalence of FRS was between 31% and 76%—taken together 57% FRS seen in patients with other psychoses 4% of the patients diagnosed with neurosis and personality disorders had FRS FRS are not pathognomonic for SCH	Only 7 FRS are included FRS in nonpsychotic patients? Big difference in the prevalence of FRS between the different countries Method problem: 1
7. Wing¹⁶	Finding “discriminating” symptoms for SCH, manic psychoses, or affective disorders	CATEGO/−	1202 mixed mostly SCH/psychotic patients (from IPSS)	No	Psychiatrists PSE	23 FRS+ patients were not SCH 13 of these 23 FRS+ were manic psychoses	Authors introduce lack of confidence in the diagnostic procedure and FRS rating Method problem 1, 3, and 4
8. Hawk¹⁷	To compare the diagnostic value of Langfeldt and Schneider diagnostic systems with DSM-II, as to predict outcome	DSM-II	131 psychotic patients initially 80 patients at 5 y follow-up	No	Authors PSE	33 FRS+ SCH patients No difference in outcome between FRS-positive and FRS-negative SCHs	No specification of drop-out characteristics No def. of SCH Method problem 1, 3, 4, and 5
9. Koehler¹⁸	To compare the distribution of FRS in Germany and US?	No/no	210 SCH patients randomly sampled among first admissions	Yes	Case records and interviews by senior psychiatrist	Single FRS frequency: 0% (made impulse) to 55% (delusional perception) FRS more frequently described in German sample	The German patients were interviewed with focus on FRS No def. of SCH Method problem 2, 3, 4, and 6
10. Brockington¹⁹	To compare 10 def. of SCH	Yes	Sample 1: 161 psychotic, first-admission patients Sample 2: 134 psychotic patients, mixed first and readmissions	Yes	Psychiatrists PSE Case records	17 FRS+ SCH 19 FRS- SCH FRS without predictive value.	Unclear by what def. “outcome” diagnosis is made Method problem 1, 4, and 5
11. Koehler²⁰	To use the St Louis criteria and Taylor Group criteria for diagnosis in a FRS-positive SCH sample	St Louis criteria and Taylor Group criteria	83 SCH patients with FRS	No	Rater is not described Case records	66.3% received a research diagnosis of either SCH or affective disorder FRS does not clearly enough identify an homogeneous, “uncontaminated” schizophrenic patient sample	No description of rater Method problem 2, 3, 4, 5, and 6
12. Silverstein²¹	Prevalence of FRS in SCH Are FRS more characteristic than a other psychotic symptoms?	Unclear DSM-II ?/−	126 younger inpatients	Yes	Unclear who is rating Structured interview, PSE, PSI	FRS occurred significantly more frequently among SCH than non-SCH FRS do not offer the best differentiation between patient group No evidence that Schneider's diagnostic system is superior to other diagnostic approaches	Unclear how initial diagnosis is made Unclear who is rating the patients Method problem: 1 and 4
13. Bland²²	To compare diagnostic criteria in order to predict outcome	St Louis criteria and the NHSI	43 first-admission SCH patients with FRS	No	Rater is not described Case records and interviews	FRS or number of FRS not correlated to outcome	No description of rater Method problem 3, 4, 5, and 6
14. Kendell²³	To compare diagnostic criteria in order to predict outcome	6 operational def. of SCH/−	134 psychotic patients	Yes, PSE	Psychiatrist PSE Historical data	FRS do not discriminate between SCHs and other psychotic patients	Method problem 1, 4, and 5
15. Chandrasena²⁴	Prevalence of FRS and their prognostic implication in patients in Sri Lanka	ICD-8/−	All admissions over a 2-y period with a diagnose of psychosis	Mellor's	British trained psychiatrists Interview PSE like	169 had FRS Only SCH had FRS Prevalence of FRS was 25.4% No difference in age, sex, and duration of episodes in those with or without FRS	Tautology: only SCH had FRS, and the diagnosis of SCH was made according to ICD-8 Method problem: 1, 4, and 5
16. Preiser²⁵	Do schizophrenics with FRS have more observable pathologic behavior than non-FRS SCH? Do schizophrenics with FRS have a poorer response to treatment?	Bleurian and/or ego function criteria/−	88 inpatients	Mellor's def.	Nurses, recreation therapist, group therapist, and individual therapist did different kinds of rating scales Assessment was reviewed by senior psychiatrist	52 SCH, 25 had FRS, 5 patients had FRS but not SCH At admission SCH with FRS showed a higher degree of worry, sadness, fright, and tiredness The presence of FRS did not indicate poorer response to treatment	Many different people are rating Senior psychiatrist do not interview the patients themselves Method problem: 1, 2, 4, 5, and 8
17. Bland²⁶	FRS's value in predicting outcome in SCH after 14 y	RDC, Feighner, New Haven SCH index/−	43 first-admission SCH	Mellor's def.	Case records	88% had FRS FRS are related to long-term outcome, some FRS are related to good outcome some to poor outcome Delusional perception being the most common FRS, voices arguing and thought withdrawal being the least common FRS	Somatic passivity is left out Method problem: 1, 2, 4, and 6
18. Abrams²⁷	Comparing groups of manic patients with increasing levels of schizophrenic symptoms	−/−	111 inpatients who satisfied the Feighner criteria for mania	?	Authors and a psychiatric resident Interview with a phenomenological approach	42 had no schizophrenic symptoms, the rest had one or more Schizophrenic symptoms do not play an important role in patients who satisfy modern criteria for mania	Most of the symptoms described as manic psychopathology are also symptoms in exacerbation of schizophrenia Method problem: 1, 3, 4, and 5
19. Mellor²⁸	Diagnostic specificity of each FRS type measured at 8 y follow-up.	Yes	57 readmitted SCH patients	Yes	Authors Case records	88% originally FRS + SCH still SCH When “voices discussing” is the only FRS, then a diagnosis of affective disorder will probably be made if the patient receives psychiatric treatment at a later date	“Clinical conservatism”—the diagnosis is hardly re-evaluated every time a patient is readmitted Unclear how the 57 patients were selected Method problem 4 and 6
20. Silverstein²⁹	Examine the relationship between FRS and other non-Schneiderian psychotic symptoms	DSM-II/−	107 SCH patients and 76 non-SCH	Schneider's def. + Wing's def. + Koehler's def	Senior clinicians Structured interview (PSI) and a semi-structured interview	FRS do not appear to have the unique importance or diagnostic importance or diagnostic specificity they have been attributed	Method problem: 1, 3, 4, 5, and 6
21. Lewine³⁰	The relationship between FRS and other commonly occurring psychiatric symptoms and within FRS themselves	CATEGO/−	100 SCH inpatients	PSE	Authors Modified PSE interview	Thought broadcast being the most common FRS and thought withdrawal, thought commentary, and primary delusion being uncommon FRS do not form an empirically homogeneous symptom group No evidence that FRS covaried higher with one another than with other symptoms	Unclear how the initial SCH diagnosis is made Method problem: 1 and 6
22. Stephens³¹	To compare diagnostic criteria in order to predict long-time outcome	9 diagnostic systems incl. FRS	283 first-admission SCH patients Follow-up 5–16 y	No	Authors Case records	FRS or number of FRS not correlated to outcome	Retrospectively collected sample Method problem 2, 3 and 6
23. Ndetei³²	Prevalence and frequency of FRS in Kenyan SCH patients	New Haven Index/−	82 first-admission patients, admitted no longer than 4 weeks	PSE def.	First author is rating, unclear if he rates all the patients Structured interview incl. PSE	73% SCH had FRS 24% non-SCH had FRS (all psychotic) The most common FRS is thought ecco	NHSI is not more true than any other diagnostic system Unclear who is rating, besides the first author Patients admitted more than 4 wk are excluded Method problem: 1 and 4
24. Radhakrishnan³³	Prevalence of FRS in a psychiatric hospital in Vellore	Feighner/ICD-9	All admissions over 18 mo 266 patients, both psychotic and nonpsychotic Follow up after 12 mo	IPPS def.	Unclear who is rating Interviewed according to IPPS	88 SCH, 35.2% had FRS FRS were found in all psychotic groups and in patients with temporal lobe epilepsy FRS has no relation to outcome FRS are not pathognomonic for FRS	Unclear who is rating 12 mo is a very short time for follow-up in SCH Method problem: 1 and 4
25. Maneros³⁴	Do FRS correlate to the following factors: age, sex, length of hospitalization, intellectual capacity, somatic disease	Schneider diagnostic criteria/−	1208 first-admission SCH	Schneider's def. modified	Case records, which are very extensively documented 190 item applied on each patient	47% had FRS Occurrence of FRS increases with increasing age on first hospitalization No difference in frequency of FRS between patients of low and normal intellectual capacity	Method problem: 2, 4, and 6
26. Ndetei³⁵	Frequencies of FRS in SCH from various cultural backgrounds	CATEGO/CATEGO	Inpatients in London 593 SCH patients	?	Case records SCL (Wing¹⁶)	Differences in FRS prevalence are found between different cultural groups, highest prevalence in White English-speaking patients, lowest in African patients	It is well-known that both ethnicity and migration are important for the development of SCH Method problem: 1, 2, 3, 4, and 7
27. Chandrasena³⁶	Prevalence of FRS cross culture	ICD-9/−	All inpatients with functional psychosis 419 Sri Lanka patients 150 UK patients 172 Canadian patients	PSE + Mellor's def.	Author Modified PSE interview	FRS have a higher prevalence in SCH patients than in non-SCH patients = good discriminating value Prevalence of FRS much higher in native UK and Canadian patients than in patients from Sri Lanka Voices arguing is the most common FRS in all 3 countries	The author distinguishes between what he believes to be subcultural belief and FRS Samples are dissimilar in the different countries Only one person is rating 1, 3, 4, and 7
28. Tandon³⁷	Frequency and diagnostic specificity of FRS	RDC 2 or more FRS	294 mixed, primarily affective, patients	No	Case records SADS interview	35 FRS+ in 58 RDC-verified SCH 9 FRS+ in 190 RDC-verified major depressive disorder 22 had 2 or more FRS Predictive value of FRS for SCH was 90% Specificity of FRS for SCH was 97% Sensitivity of FRS for SCH was 60%	If the sensitivity of FRS is 60%, then 40% did not have FRS—how did these patients receive SCH diagnosis? (The diagnosis of SCH was made depending on the presence of FRS) Retrospectively collected sample Delusional perception is left out Method problem 1, 3, and 4
29. Gureje³⁸	Prevalence of FRS among Nigerian SCH, the relation of each FRS to each other	RDC/−	56 SCH inpatients	Combination of def. and PSE def. of Carpenter et al.¹³	Author Interview GAS Part of PSE	Prevalence of FRS 73% Made volition being the most common FRS, delusional perception being the least common FRS	Two different sets of FRS def. is used: Mellor's for some of the FRS and other FRS Method problem: 1, 4, and 6
30. Malik³⁹	Prevalence of FRS among Pakistani SCH	RDC/−	75 SCH inpatients	Mellor's def.	Trained psychiatrists High interrater reliability PSE interview	2/3 of the patients had at least one FRS Somatic passivity, thought broadcast, and thought insertion were the most common FRS, audible thoughts and made affect/impulses were least common	Patients were interviewed using PSE, but FRS were elicited on the basis of Mellor's def.? Method problem: 1 and 6
31. O'Grady⁴⁰	Diagnostic specificity of FRS for SCH (narrow and wide def.)	RDC, Carpenter's flexible system, New Haven index/−	99 inpatients	Yes	Researcher SADS and FRS questionnaire interview	FRS+ had an RDC diagnosis of SCH 5 had other psychosis No subject with nonpsychotic disorder had FRS	Unclear distinction between schizoaffective disorder and affective disorders Method problem: 1, 4, and 5
32. Salleh⁴¹	Prevalence of FRS in Malay patents	ICD-9/−	221 first-contact patients—unclear if they are in- or outpatients Functional psychosis	Mellor's def.	Author or senior psychiatric house staff Modified PSE Interviewed within 48 h of admission	Prevalence of FRS in SCH 26.7% Specificity of FRS for SCH 87.8% Positive predictive value for SCH 90.6% FRS strong indicator for SCH FRS do not occur often enough to have diagnostic potential in SCH	Interviews carried out in the initial acute phase may be questioned—were the patients in a state of clear, unclouded consciousness Author regards possession state as a cause of the illness rather than a symptom of the illness Method problem: 1
33. Tanenberg-Karant⁴²	Frequency of FRS and bizarre delusions in SCH and affective disorder	DSM-III-R/DSM-III-R	196 psychotic inpatients	Yes	Health professional, trained for 3–6 mo SCID interview	FRS+ in 70% of SCH FRS+ in 29% of bipolar patients FRS+ in 18% of patients with major depressive disorder Specificity of FRS for SCH was 72.5% Sensitivity of FRS for SCH was 73.3%	SCID does not include all 11 FRS Risk of false-positive FRS Method problem 1, 4, 5, 7, and 8
34. Peralta⁴³	Diagnostic specificity of FRS for SCH	DSM-III broad and narrow. Feighner (gold standard)/−	660 acute psychotic inpatients	Yes, Mellor (1979) and MAS	Authors All available information	FRS are not useful in differentiating SCH from other psychotic disorders	Feighner criteria are not more valid than other diagnostic systems Method problem 1 and 3
35. Gonzales-Pinto⁴⁴	Frequency of FRS in bipolar patients	−/DSM-IV	103 DSM-IV bipolar, manic or mixed patients	Unclear	Psychiatrists SCID-I and SAPS Case records Relatives	FRS+ in 22.3% of the patients; these were diagnosed manic FRS should be considered symptoms of psychosis	Risk of false positive No def. of SCH No bipolar depression is included Method problem 1, 3, 4, and 5
36. Cecche rini-Nelli⁴⁵	The relationship between FRS and language abnormalities Compare the predictive diagnostic validity of language disturbances and FRS	ICD-10/ICD-10	30 psychotic patients with FRS	Yes, Mellor and Sims	Authors PSE + more detailed questions focusing on FRS and CLANG	FRS could separate nonaffective psychosis from affective disorders CLANG is superior to FRS as to differentiating ICD-10 SCH from other categories including non-SCH psychosis with nuclear symptoms.	Lack of comparison group with mania Study not blinded The whole sample has FRS so how can the FRS dimension differentiate between nonaffective and affective psychosis? “Non-SCH psychosis with nuclear symptoms”? Method problem 1, 4, 5, and 7
37. Gonzales-Pinto⁴⁶	The relationship between age and FRS 3 diagnostic groups were considered for the interaction between FRS and diagnosis: “SCH,” “bipolar disorder,” and “other psychotic disorders”	DSM-IV/DSM-IV	112 first-episode psychotic inpatients	Yes	Authors Interview	FRS+ in 65.2% FRS+ younger than those without	3 diagnostic groups are considered for the interaction between FRS and diagnosis: This is nonsense as Schneider dictated that the diagnosis should be SCH if FRS were present. Method problem 4 and 5
38. Arnold⁴⁷	Frequency of FRS rating in African American patients compared with Euro-American patients	DSM-IV/DSM-IV	1193 psychotic patients	No	Psychologists or social workers with extensive training Interview SAPS	FRS more frequent in African American men No increased rate of SCH in African American men	When the transcripts are “cleansed for ethnic information,” psychopathological information can get lost or changed Method problem 1, 3, 4, 5, and 8
39. Conus⁴⁸	FRS in mania as predictor of poor outcome	−/DSM-III-R	79 bipolar patients, first psychotic episode	No	Highly trained psychologist Interview RPMIP, QLS, SANS, BDI, and BPRS	FRS+ in 63% FRS+ subjects had more negative symptoms than FRS− FRS in the first manic episode identifies subjects with poor short-term outcome	First manic episode with FRS is nonsense in the ICD-10 hierarchy and the FRS+ subgroup of patients could be SCH! No def. of SCH Method problem: 1, 3, and 4
40. Verdoux⁴⁹	The relationship between FRS, handedness, and speech disorder in psychosis	DSM-IV/ DSM-IV	33 psychotic inpatients	SAPS	Unclear who is rating Interview SAPS, SANS, TLC, and CDS	22 FRS+ FRS↑ → dexterity ↓ FRS↑ → speech disorder ↓	Diagnoses unclear Small sample Unclear who is rating Method problem 1, 4, and 7

Note: BDI, Beck Depression Inventory; BPRS, Brief Psychiatric Rating Scale; CDS, Calgory Depression Scale; CGI-S, Clinical Global Impressions Scale-severity; CLANG, Clinical Langauge Disorder Rating Scale; def., definition; DSM, Diagnostic and Statistical Manual of Mental Disorder; FRS, first-rank symptoms; GAS, Global Assessment Scale; ICD, International Statistical Classification of Diseases; incl., included; MAS, Manual for the Assessment of Schizophrenia; NHSI, New Haven Schizophrenia Index; PSE, Present State Examination; PSI, Psychotic Symptoms Inventory; QLS, Quality of Life Scale; RDC, Research Diagnostic Criteria; RPMIP, Royal Park Multidiagnostic Instrument for Psychosis; SADS, Schedule for Affective Disorders and Schizophrenia; SANS, Scale for the Assessment of Negative Symptoms; SCH, Schizophrenia; SCL, Syndrome Check List; SCID, Structured Clinical Interview for DSM-III-R; TLC, scale for assessment of thought, language and communication disorders. Method problems: 1, lack of phenomenological approach in rating interview; 2, symptom rating made from case records; 3, missing or unclear definition of FRS; 4, absence of FRS corating and measures of reliability; 5, few differentiations between individual FRS; 6, major patient samples limited to clinically diagnosed schizophrenic patients; 7, intermixing assessment of other illness variables also hypothetically described to accompany schizophrenia add to the confusion; 8, not rated by psychiatrist/psychologist.