©1986 S. Karger AG.

Basel
Psychopathology 19: 244-252 (1986) 0254-4962/86/OI95-0244S2.75/0

First-Rank Symptoms and Bleuler’s Basic Symptoms

New Results in Applying the Polydiagnostic Approach

P. Bernera, H. Katschnig'0, G. Lenza

“Psychiatric Clinic, University of Vienna and
bDepartment of Social Psychiatry, Psychiatric Clinic, University of Vienna, Austria

Abstract. By comparing six different operational diagnostic systems (International Classi­

fication of Diseases, Diagnostic and Statistical Manual; 3rd ed., Research Diagnostic Crite­
ria, St. Louis criteria, Taylor criteria and Vienna Research Criteria), the data presented in
this paper illustrate how attribution to various categories of functional psychoses varies
according to the applied algorithms. Bleuler’s basic symptoms are obviously considered by
all of the compared systems to be more significant for attribution to schizophrenia than
first-rank symptoms.

Introduction lates with regard to the differentiation be­

With the exception of French psychiatry,
the main efforts to divide functional psy­
choses into subgroups were centered until
recently on the diagnosis of schizophrenia.
Two major reasons may be held responsible
for this fact: The first is the incorporation of
Kraepelin's paraphrenias into his concept of
paranoid schizophrenia, which was done be­
cause catamnestic studies demonstrated that
paraphrenic patients may eventually de­
velop residual deficiency states [19]. Thus
for the functional psychoses, the concept of a
simple dichotomy distinguishing only be­
tween schizophrenia and manic-depressive
illness became prevalent. The second reason
tween schizophrenia and affective disorders
that the presence of ‘schizophrenic’ symp­
toms deprives manic-depressive features of
their diagnostic value. Subsequently, the def­
inition of the phenomena to be considered as
schizophrenic became a preoccupation in
which, after Kraepelin, two trends pre­
vailed.
The most eminent representative of the
first of these diagnostic approaches to
schizophrenia is E. Bleuler [6], who aban­
doned the illness course as diagnostic crite­
rion and established two symptom hierar­
chies. The theoretical, etiopathogenetic dis­
tinction between primary symptoms, which
are directly related to the illness process and
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was the explicit or implicit acceptance of are thus autochthonous, and secondary
Univ. of California Santa Barbara

Jaspers’ hierarchical principle, which stipu­ symptoms, which represent reactions to the
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First-Rank Symptoms and Blculcr’s Basic Symptoms
illness process and thus are psychologically
understandable, must not be confused with
the clinical distinction between basic and
accessory symptoms appearing in schizo­
phrenic illness. Basic symptoms are consid­
ered as signs of special value for the diagno­
sis. Some of them belong the the primary,
some to the secondary symptoms. Thus,
Bleuler’s diagnostic rules are not really based
solely on his theory of the illness process, but
they are strongly ‘theory-oriented’. The other
attempt to define schizophrenia phenome­
nologically is a pragmatical one, introduced
by K. Schneider [26] when establishing his
list of ‘first-’ and ‘second-rank’ symptoms.
These symptoms were arbitrarily chosen in
order to draw a clear line between schizo­
phrenic and manic-depressive disorders;
only those symptoms were included which
presented no undue difficulty for conceptual
comprehension and clinical recognition.
Both Bleuler’s and Schneider’s diagnostic
procedures have their specific deficiencies:
Bleulcr’s criteria for schizophrenia have
never been adequately operationalized [7,
13], and Schneider’s neglect of any underly­
ing theoretical concept led many searchers to
question their heuristic value. Furthermore,
the adherence to Jasper’s hierarchical princi­
ple was increasingly considered as a defi­
ciency of both systems: as early as 1933,
Kasanin suggested that patients exhibiting
schizophrenic as well as affective features
may belong to an independent group called
‘schizoaffective psychoses’. Thus, he ques­
tioned at the same time both Jaspers’ hierar­
chical principle and the dichotomy of func­
tional psychoses. Later, especially during the
last decade, numerous psychiatrists [re­
ported in ref. 3, 18, 23, 24] voiced, on the
grounds of empirical data or theoretical con­
siderations, the opinion that ‘schizophrenic
245
symptoms’ may occur in affective disorders
as well; this led some of them to plead for a
reversal of Jaspers’ hierarchical principle.
The doubts expressed in view of the specific­
ity of ‘schizophrenic symptoms’ concerned
most frequently Schneider’s first-rank symp­
toms (FRS), but it might be argued, espe­
cially in consideration of Janzarik’s [ 15] con­
cept of the ’structural dynamic coherency’,
that at least a part of Bleuler’s basic symp­
toms may arise not only in schizophrenic but
also in rapidly alternating manic-depressive
mixed states [4, 9, 21, 22],
More recently formulated diagnostic
tools attempt to counterbalance the fore-
mentioned shortcomings of the classical
bleulerian and Schneiderian diagnostics
mainly through two precedures, namely re­
stricting some well-definable schizophrenic
symptoms and introducing criteria for exclu­
sion. Among the latter figure essentially
manic-depressive symptoms, criteria of ill­
ness course and symptomatological or other
empirical indicators of good prognosis de­
rived mainly from Scandinavian studies on
‘schizophreniform’, ‘psychogenic,’ or ‘reac­
tive psychoses’. Only a few of these modern
diagnostic algorithms base their symptoma­
tological elements solely on some of
Schneider’s (e.g. the CATEGO system) or
some of Bleuler’s schizophrenic symptoms
(e.g. the Vienna Research Criteria, VRC);
most of them are ‘mixed’, i.e. they contain a
combination of selected bleulerian or Schnei­
derian criteria. When choosing one of these
‘mixed’ diagnostic systems, the user is rarely
aware of the real importance it attributes -
through its operational rules - to FRS or to
Bleuler’s basic symptoms for the establish­
ment of the diagnosis of schizophrenia. The
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application of the polydiagnostic approach
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[16], which consists in applying a whole set
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246 Berner/Katschnig/Lenz

of different diagnostic criteria to the same Table I. Frequency of FRS in 97 first-admitted

sample of patients, enables us to elucidate schizophrenic patients (ICD 295)
this problem. n %
The following data are taken from a re­
search project on functional psychoses, At least one FRS 84 86.6
based on 200 first-admission patients to the
Psychiatric Clinic and to the Psychiatric Delusional perceptions 48 49.5
Hospital of Vienna with an ICD diagnosis of Made volition, made affect and 38 39.2
295, 296, 297 or 298. The patients were made impulses
rated with an expanded version of the
Present State Examination [27], and a series Thought withdrawal and thought 29 29.9
of diagnostic criteria for schizophrenia, schi­ insertion
zoaffective disorder and affective disorder Voices commenting 27 27.8
were applied to them. In order to demon­
strate the differences of various diagnostic Voices arguing 26 26.8
systems with regard to the weight they assign
to FRS and basic symptoms, we herewith Thought broadcasting 20 20.6
present the findings obtained with five Somatic passivity experiences 17 17.5
'mixed’) algorithms (Taylor, RDC, ICD-9,
St. Louis, DSM-III). These results are com­ Audible thoughts 12 12.4
pared with those gathered when applying the
VRC, which do not contain FRS and are
exclusively based on certain selected basic
symptoms. This comparison permits some Table II. Frequency of Bleuler’s basic symp-
toms in 97 first-admitted schizophrenic patients
considerations regarding the concordance
(ICD 295)
between FRS and the basic symptoms of
Bleuler. n %

At least one of Blculer’s basic 87 89.7

symptoms
Prevalence of FRS and Basic Symptoms
in ICD Schizophrenic Psychoses Disturbances of affect 66 68

The prevalence of FRS in patients diag­ Disturbances of volition and 45 46.4

nosed as schizophrenic according to various behavior
different diagnostic systems differs consider­
Disturbances of the subjective 45 46.4
ably from one study to another. Mellor [20] experience of self
found that 72% of his schizophrenic patients
had one or more FRS. Prevalence was some­ Formal thought disorder 39 40.2
what lower in the international pilot study of
Autism 27 27.8
schizophrenia with 57% [11]; Huber et al.
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[14] found a prevalence of 77.5% in his Ambivalence 18 18.6

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patients, Bland and Orn [5] one of 88%. The

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First-Rank Symptoms and Bleulcr’s Basic Symptoms
distribution of FRS in our sample corre­
sponds roughly to the frequency given by
Bland and Orn. Table I demonstrates, in ac­
cordance with findings of Koehler et al. [ 17]
and Bland and Orn [5], that the most fre­
quently encountered FRS are ‘delusional
perceptions’. They are closely followed by
‘made volition, affect, or impulses’ whilst all
other FRS occur less often.
Although Bleuler’s basic symptoms are
contained in several diagnostic systems and
research criteria, much less is written about
them compared with the many papers dis­
cussing various aspects of Schneider’s FRS.
This might be due to the above-mentioned
fact that for many of them a satisfactory
operational definition has not yet been for­
mulated, so that they cannot be diagnosed
with sufficient reliability [4, 7], In our sam­
ple the distribution of Bleuler’s basic symp­
toms clearly shows the relative importance
of the ‘disturbances of affect’ (table II). Now­
adays, these symptoms can certainly be elic­
ited much more reliabley with recently de­
veloped instruments, e.g. the ‘scale for the
assessment of negative symptoms’ of An-
dreasen [1], But when discussing the signifi­
cance o f ‘disturbances of affect’ for the diag­
noses of schizophrenia, it should be kept in
mind that this symptomatological category
Table III. Probability of receiving different diag­
noses of schizophrenia for patients who have experi­
enced at last one FRS (n = 121)
Taylor criteria for schizophrenia (n = 96)
RCD schizophrenia (n = 67)
1CD schizophrenia (n = 64)
St. Louis schizophrenia (n = 44)
DSM-III schizophrenia disorder (n = 49)
VRC schizophrenia (n = 40)
247
contains not only ‘affective blunting’ but
also other disturbances especially ‘parathy­
mia’ (inappropriate affect), which quite fre­
quently occur in rapidly changing manic-
depressive mixed states as well.
Discriminative Ability Attributed by
Various Diagnostic Systems to FRS and
Basic Symptoms
The collaborating investigators of the In­
ternational Pilot Study of Schizophrenia
[28], using data from nine participating
countries and putting patients diagnosed as
schizophrenic together with those suffering
from paranoid psychoses, found that most
FRS were highly disciminating: For exam­
ple, a patient who hallucinated voices dis­
cussing him had a 0.95 probability of receiv­
ing a diagnosis of schizophrenic or paranoid
psychosis. A patient who experienced his
thoughts as being broadcast had a 0.97 prob­
ability of receiving these two diagnoses. Sim­
ilarly, thought insertion, thought withdraw­
al, and delusions of control each had a prob­
ability of 0.93-0.97 of being associated with
a diagnosis of schizophrenia or paranoid
psychosis. Therefore, most of the FRS taken
individually were found by the participants
of the study to be strong diagnostic indica­
tors, although they did not occur exclusively
in schizophenia. Table III shows that the dis­
criminative ability attributed to FRS by the
diagnostic systems included in our study in
in general much lower and that it differs also
0.74 - sometimes considerably - from one algo­
0.54 rithm to the other.
0.46 The first findings can be explained by the
0.39
fact that all of the ‘mixed’ diagnostic systems
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0.36
presented in table III contain affective fea­
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0.30
tures as exclusion criteria (the ICD-9 implic­
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248
itly, because the schizoaffective subgroup
has been withdrawn, the others explicitly).
The differences between the various systems
must be located in their specific algorithmic
rules. Thus it is not surprising that Taylor’s
criteria, which consider the presence of at
least one FRS as sufficient for inclusion and
use (apart from clouded consciousness and
somatic disturbance) only affective disorders
as excluding features, attribute the highest
discriminative ability of all compared sys­
tems to FRS. The very low probability rate
of the St. Louis criteria and DSM-III must be
mainly attributed to the requirement of an
illness duration of at least 6 months. As
expected, the RDC, which have reduced this
time limit to 2 weeks, offer a higher proba­
bility for patients who have experienced at
least one FRS to be classified as schizo­
phrenics; this probability remains, however,
much lower than that encountered when us­
ing Taylor’s criteria. This may be attributed
to the fact that the RDC require at least two
of their symptomatological inclusion criteria
for making the diagnosis whilst Taylor is sat­
isfied with one single FRS. The relatively
low probability rate of ICD-9 reflects its de­
pendence on Bleuler’s concept. The lowest
probability is found when applying the VRC
(which also exclude cases fulfilling the crite­
ria for schizophrenia and affective disorders
by diagnosing them as a ‘schizoaffective syn­
drome’). This is certainly due to the fact that
they are not based upon FRS.
Table IV demonstrates the discriminative
ability attributed to Bleuler’s basic symp­
toms: Explanations similar to those exposed
with reference to FRS may also apply to the
differences shown in table IV. The inclusion
of formal thought disorders and affective
blunting in Taylor’s criteria explains the in­
creased probability of patients with Bleuler’s
Berner/Katschnig/Lenz
Tabic IV. Probability of receiving different diag­
noses of schizophrenia for patients who have at least
one of Bleuler’s basic symptoms (n = 91)
Taylor criteria for schizophrenia (n = 96) 0.85
ICD schizophrenia 0.69
(295 without 295.7, n = 64)
RCD schizophrenia (n = 67) 0.59
DSM-III schizophrenic disorder (n = 49) 0.45
VRC schizophrenia (n = 40) 0.44
St. Louis criteria for schizophrenia (n = 44) 0.42
basic symptoms to be included in Taylor’s
schizophrenia. The somewhat lower but still
relatively high probability rate of ICD-9 and
RDC reflects their linkage to Bleuler’s con­
cept of schizophrenia, whilst the low proba­
bility found when applying DSM-III and the
St. Louis criteria has again to be attributed
to the required illness duration. Since the
VRC consider only well-defined formal
thought disorders as features permitting the
diagnoses of schizophrenia, the probability
of receiving this diagnosis when exhibiting at
least one basic symptom is, as expected,
low.
In general, it may be deduced from tables
III, IV that there is a high probability for
patients exhibiting at least one FRS or one
basic symptom to receive the diagnosis of
schizophrenia if the diagnostic algorithm
builds symptomatologically on these symp­
toms only (which applies to Taylor’s crite­
ria). The probability is low, if (as is the case
for all the other ‘mixed’ systems presented)
second-rank and accessory symptoms are
also included in the algorithm and if more
than one FRS or basic symptom is required.
The introduction of a time limit further low­
ers the discriminative ability attributed to
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FRS and basic symptoms. This discrimina­
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tive ability is, of course, also considered to
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First-Rank Symptoms and Bleuler’s Basic Symptoms 249

Table V. Probability of receiving different diagnoses of schizophrenia for patients who experienced differ­
ent FRS [26]

Taylor St. Louis RDC VRC DSM-III ICD

Made volition, made affect and 0.73 0.35 0.48 0.39 0.33 0.50
made impulses
Delusional perceptions 0.71 0.33 0.49 0.23 0.35 0.40
Voices commenting 0.90 0.73 0.87 0.53 0.63 0.87
Voices arguing 0.86 0.46 0.86 0.41 0.51 0.57
Thought withdrawal and 0.82 0.45 0.67 0.61 0.52 0.61
thought insertion
Somatic passivity experiences 0.90 0.52 0.76 0.43 0.52 0.71
Thought broadcasting 0.95 0.45 0.64 0.50 0.50 0.64
Audible thoughts 0.85 0.54 0.69 0.54 0.54 0.69

be low if the algorithm is exclusively built on
a narrow seletion of certain symptoms (as is
the case for the VRC).
Discriminative Ability Attributed to
Single FRS or Basic Symptoms
Table V compares the probabilities of re­
ceiving the diagnosis of schizophrenia for
each FRS. With the exception of Taylor’s
criteria (which impute an equal weight to
each FRS) the compared systems do not
attribute a high discriminative value to most
of the FRS. The symptom ‘voices comment­
ing’ is, however, loaded with a relatively high
probability in all classifications - a finding
which is in line with Bland and Orn’s [5] out­
come study, where the authors found ‘voices
commenting’ negatively correlated on all
outcome measures, which means that this
the exception of the criteria requesting a 6-
month duration of the illness (St. Louis,
DSM-11I), the item ‘thought withdrawal and
thought insertions’ also shows a relatively
high probability rate. In particular the fact
that this applies also to patients diagnosed as
schizophrenic by VRC suggest that there
might be a linkage between observed formal
thought disorders and the subjective experi­
ence of thought withdrawal or thought inser­
tion.
Table VI shows that some of Bleuler’s
basic symptoms have an important discrimi­
native ability in all of the compared systems:
the high probability of receiving a diagnosis
of schizophrenia when formal thought disor­
ders arc present is indeed very impressive.
The somewhat lower probability for the St.
Louis criteria and DSM-III is again due to
the necessity of a 6-month illness duration.
With the exception of the Viennese criteria,
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symptom is a strong predictor for bad out­ ‘autism’ is also loaded with a high probabil­
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come. Furthermore, it is striking that, with ity in all systems.

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250 Berner/Katschnig/Lenz

Table VI. Probability of receiving different diagnoses of schizophrenia for patients with different ‘basic
symptoms’ according to Bleuler

Taylor St. Louis RDC VRC DSM-III 1CD

Disturbances of affect 0.94 0.48 0.62 0.51 0.54 0.75

Formal thought disorder 0.95 0.69 0.90 1.00 0.69 0.90
Disturbances of volition and behavior 0.87 0.45 0.57 0.36 0.49 0.77
Autism 0.97 0.76 0.83 0.55 0.72 0.90
Disturbances of the subjective 0.87 0.44 0.69 0.51 0.44 0.69
experience of self
Ambivalence 0.77 0.39 0.56 0.39 0.39 0.61

Table VII. Frequency (%) of at least one FRS in Table VIII. Frequency (%) of at least one of Bleu-
various diagnostic criteria ler’s basic symptoms in various diagnostic criteria

RDC schizophrenia 97.0 VRC schizophrenic axial syndrome 100.0

St. Louis schizophrenia 93.2 ICD 295 89.7
Taylor schizophrenia 92.7 St. Louis schizophrenia 86.4
RDC schizoaffective, manic type 92.0 DSM-III schizophrenic disorder 83.7
VRC schizophrenic axial syndrome 90.0 RDC schizophrenia 80.6
DSM-III schizophrenic disorders 87.8 Taylor schizophrenia 80.2
RDC schizoaffective, depressive type 87.5 RDC schizoaffective, manic type 76.0
ICD 295 86.6 RDC schizoaffective, depressive type 68.8
Taylor mania 50.0 VRC cyclothymic axial syndrome 25.6
VRC cyclothymic axial syndrome 43.0 Taylor mania 18.2
St. Louis mania 33.3 RDC mania 6.5
RDC mania 32.3 Taylor depression 5.4
Taylor depression 16.1 St. Louis mania 3.7
ICD 296 13.0 St. Louis depression 2.0
St. Louis depression 6.1 RDC major depressive disorder 0
RDC major depressive disorder 4.3 ICD 296 0

Occurrence of FRS and Basic Symptoms
in Disorders Not Diagnosed as
Schizophrenic
As already mentioned in the introduction
several studies have indicated that FRS not
disorders [10]. In their comprehensive re­
view, Pope and Lipinski [23] conclude that a
considerable amount of patients diagnosed
as good prognosis schizophrenia really be­
long to the affective disorders. In order to
further elucidate this assumption, we com­
128.111.121.42 - 3/3/2018 7:41:16 PM

only occur in schizophrenia but also in man­ pared the frequency of FRS and basic symp­
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ic-depressive illness and even in neurotic toms in patients attributed by the compared
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First-Rank Symptoms and Bleuler’s Basic Symptoms
systems to schizophrenic, schizoaffective
and affective disorders. These findings are
presented in tables VII, VIII. Table VII
shows the percentage of patients exhibiting
at least one FRS for each category. It is
noteworthy that there are still many pa­
tients whose symptomatology includes FRS,
even when they fulfill the conditions for
attribution to purely affective disorders.
The same applies, although to a lower de­
gree, to the occurrence of basic symptoms
(table VIII). The fact that the percentage of
patients exhibiting at least one basic symp­
tom is lower than the percentage of patients
with at least one FRS in each category of
affective disorders may indicate that the
compared algorithms consider basic symp­
toms to be superior to FRS as indicators for
a ‘real’ schizophrenia. Which FRS or basic
symptoms were actually present in the pa­
tients assigned to affective disorders could
not be investigated for this paper. The dif­
ferences in frequency of FRS and basic
symptoms between the compared assign­
ments to affective disorders can be ex­
plained by the particularities of each algo­
rithm. Thus, for instance, the St. Louis cri­
teria and the RDC show lower percentages
of FRS and basic symptoms than Taylor’s
system because both contain certain schizo­
phrenic symptoms as criteria for exclusion,
whilst Taylor’s ‘broad affect’ is the only ele­
ment leading to the exclusion of schizo­
phrenic patients.
As is shown in tables VII, VIII, the
percentage of FRS and basic symptoms is
generally much lower in patients assigned to
depression than in those attributed to ma­
nia. This may be explained by the assump­
tion that the diagnosis of mania includes
more patients presenting ‘mixed states’ than
the depressives, the latter suffering, accord­
251
ing to Janzarik [15], from a ‘dynamic re­
striction’.
By comparing six different operational
diagnostic systems, the data presented in this
paper illustrate how attribution to various
categories of functional psychoses varies ac­
cording to the applied algorithms. Bleuler’s
basic symptoms are obviously considered by
all of the compared systems to be more sig­
nificant for attribution to schizophrenia
than FRS.
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Univ. of California Santa Barbara
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