Are There Pathognomonic
in Schizophrenia?
An Empiric Investigation of Schneider's First-Rank
William T. Carpenter, Jr., MD, Bethesda, Md; John S. Strauss, MD, Rochester, NY;
The need for operationalized criteria for the identification of schiz-
ophrenia is great. Schneider's diagnostic concept attempts the opti-
mum in diagnostic clarity, using frequently occurring symptoms
which can be reliably identified by various observers, and which he
believes always indicate schizophrenia in the absence of an organic
psychosyndrome. Schneider's approach, although never established
by other investigators, is used for diagnosis throughout most of the
world.
We found that the first-rank symptoms (FRSs) occurred frequently
enough in acute schizophrenia to have diagnostic applicability. Indi¬
vidually, each FRS was found with greater frequency in schizophre¬
nia. However, taken together, these symptoms which he considers
pathognomonic of schizophrenia occur in one fourth of the cohort of
manic-depressive patients. Therefore, Schneider's system for identi¬
fying schizophrenia, while highly discriminating, leads to significant
diagnostic errors if FRSs are regarded as pathognomonic. Further¬
more, FRSs did not have a postdictive or predictive function, as no
relationship could be established between FRSs and duration or out¬
come of illness.
is
much dissatisfaction with current diag¬
Therenostic methods in psychiatry. An inability to identify
homogeneous patient groups reliably has limited our clini¬
cal understanding and impeded research. There is dis¬
agreement among behavioral scientists regarding the na¬
ture of this diagnostic dilemma. Many believe that to date
there is no acceptable diagnostic concept sufficiently oper¬
ationaiized to be reliably applied by various clinicians to
psychotic patients. Others believe that a clear concept of
schizophrenia has been articulated and sufficiently oper¬
ationaiized so that it can be broadly and systematically
applied, but that clinicians and investigators are unwill-
Accepted for publication Nov 15, 1972.
From the Psychiatric Assessment Section, Adult Psychiatry Branch, In-
tramural Research, National Institute of Mental Health, Bethesda, Md (Dr.
Carpenter), Clinical Research Programs, University of Rochester Medical
School, Rochester, NY (Dr. Strauss), and George Washington University
School of Medicine, Washington, DC (Mr. Muleh).
The opinions expressed in this paper do not necessarily represent the
viewpoints of the sponsoring agencies or other investigators of the Inter-
national Pilot Study of Schizophrenia.
Reprint requests to 9000 Rockville Pike, Bldg 10, Room 4N214, Bethesda,
Md 20014 (Dr. Carpenter).
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Symptoms
Symptoms
Salvatore Muleh, Washington, DC
ing to apply the particular diagnostic system. The former
view is representative of the majority of clinical investi¬
gators the United States who believe that schizophrenia
in
may be present in such complex and varied patterns that
no established diagnostic approach lends sufficient clarity
to the problem of categorization. In Europe, this frustra¬
tion is not so keenly experienced and many psychiatrists
believe that it is now possible to conceptualize schizophre¬
nia in a manner that will enable the majority of patients
suffering from this disorder to be identified by highly dis¬
criminating signs and symptoms. Schneider's concept of
schizophrenia1 is regarded by many as meeting these cri¬
teria and has, in fact, received widespread attention in
German-speaking countries, Scandinavia, England, and
other parts of the world. For example, in Britain the reg¬
istrar-general's glossary of mental disorders (1968)2 sug¬
gests certain symptoms that should be used to identify
schizophrenia. The majority of these symptoms are the
first-rank symptoms (FRSs) of Schneider.
Schneider's system of classifying mental disorders at¬
tempts to accomplish what is optimal for the diagnosis of
schizophrenia: the identification of symptoms which are
readily perceived by an observing clinician, easily agreed
upon by several observers, and occur only in schizophrenia.
Enthusiasm for describing such pathognomonic symptoms
has not been characteristic of American psychiatry, in
part because many such symptoms have often turned out
to be as related to institutionalization or chronicity as
they are to schizophrenia, or because they do not occur fre¬
quently enough to be useful. For example, characteristic
schizophrenic symptoms, such as neologisms and word
salad, are so infrequently found in an acute psychotic pop¬
ulation as to have little diagnostic applicability.
Schneider approached the diagnosis of schizophrenia by
identifying symptom groups of diminishing dis¬
criminating value. The FRSs are regarded as pathog¬
nomonic of schizophrenia in the absence of an organic
brain syndrome. The choice of these symptoms has no
theoretical basis. They are chosen pragmatically according
 to the ease with which they can be identified when mani¬
fest by a patient, and the extent to which their presence
reveals schizophrenia. Schneider also described second-
rank symptoms which may be used as evidence for the
presence of schizophrenia, but do not have the diagnostic
power of the FRSs. Schneider emphasizes that the diag¬
nosis of schizophrenia can be made without FRSs. How¬
ever, when a FRS is present, it "must have undisputed
precedence when it comes to the allocation of the individ¬
ual case."ltpl35> He also describes symptoms which have no
diagnostic importance, although they may be very impor¬
tant to the individual suffering with them (eg, ambiva¬
lence). For this report, only the FRSs that Schneider con¬
siders pathognomonic of schizophrenia are investigated.
Schneider's FRSs
There 11 FRSs. A patient with one or more of these
are
symptoms in the presence of a clear sensorium is consid¬
ered schizophrenic. The first three are special forms of
auditory hallucinations: (1) The patient hears voices
speaking his thoughts aloud; (2) the patient experiences
himself as the subject about whom hallucinatory voices
are arguing or discussing; (3) the patient hears halluci¬
nated voices describing his activity as it takes place.
The fourth symptom (4), delusional percept, is a two-
stage phenomena consisting of a normal perception fol¬
lowed by a delusional interpretation of special and highly
personalized significance.
Symptoms, 5 through 11, can be conceptualized as a
deficit in the barrier separating self from environment.
They are as follows: (5) somatic passivity-the patient is a
passive and reluctant recipient of bodily sensation im¬
posed from the outside; (6) thought insertion—the experi¬
ence of one's own thoughts as though they were put in his
mind by an external force; (7) thought withdrawal—the
patient believes that his thoughts are being removed from
his mind by an outside agent; (8) thought broadcast—the
passive experience of one's thoughts being magically
transmitted to others. The remaining symptoms (9, 10,
and 11) consist of affect, impulses, or motor activity expe¬
rienced as imposed and controlled from outside one's body.
These are to be distinguished from somatic passivity,
which are hallucinated somesthetic experiences.
The degree to which Schneider's diagnostic criteria are
operationally defined and the certainty with which they
can apparently be applied in a clinical setting are remark¬
able. (Schneider attempted to determine to what extent
his diagnostic approach to mental illness could be applied
with confidence. In the early 1930s he reviewed records of
diagnosis made by him and his colleagues of almost 3,000
patients admitted to the Psychiatric Department in Mu¬
nich. He found that diagnostic certainty was achieved in
more than 98% of the cases.1) Although the widespread ac¬
ceptance of his concept supports their utility, Schneider,
unfortunately, did not test his system empirically. Nor did
he undertake the development of validating criteria for
his diagnostic groups. Many psychiatrists still believe that
a schizophrenic diagnosis implies a uniformly downhill
course'"; therefore, it is important to avoid unwarranted
certainty about diagnosis, since a complex matrix of psy¬
chosocial pressures may be unleashed which themselves
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can preclude a return to health.712
The purposes of this study are to perform such investi¬
gations to determine the following: (1) whether or not
FRSs in the absence of an organic brain syndrome are
pathognomonic of schizophrenia; (2) the frequency distri¬
bution of FRSs in acute schizophrenia; (3) whether FRSs
are related to prior duration of illness; and (4) whether
FRSs are of prognostic significance.
Methods
This investigation was carried out in the context of the Inter¬
national Pilot Study of Schizophrenia (IPSS). The IPSS is a trans-
cultural psychiatric investigation of 1,202 patients in nine coun¬
tries—Colombia, Czechoslovakia, Denmark, India, Nigeria, China
(Province of Taiwan), Union of Soviet Socialist Republics, United
Kingdom, and the United States of America. It was designed as a
pilot study to lay scientific groundwork for future international
epidemiological studies of schizophrenia and other psychiatric dis¬
orders. Details of the methodology employed in this nine-nation
investigation are provided elsewhere.11 Data for this report were
collected from the cohort of patients evaluated in the United
States comprised of 131 recent psychiatric admissions to three
hospitals serving Prince Georges County, Md. Patients were in¬
cluded if they had no evidence of organic disease, were between
the ages of 15 and 45, had not been hospitalized for more than two,
nor psychotic for more than three, of the last five years, and had
one of the following inclusion criteria: delusions, hallucinations,
inappropriate or bizarre behavior, gross psychomotor disorder, so¬
cial withdrawal, thinking disorder, overwhelming fear, disorder of
affect, depersonalization, self-neglect, or a diagnosis of psychosis
on admission. Patients were evaluated within eight days of admis¬
sion. As a related effort, to insure that there would be a large co¬
hort diagnosed as having primary affective psychosis, 34 patients
hospitalized on two research wards for the study of manic-depres¬
sive psychosis in the Clinical Center of the National Institutes of
Health were evaluated. These patients are not part of the IPSS
series. However, the same interview schedules were used by the
same psychiatrists at a comparable interval following admission.
Admission criteria for these wards are the diagnosis of affective
psychosis, the absence of organic disease, and minimal age of 18
years. Table 1 shows sex, age, and socioeconomic composition in
the various diagnostic groups.
The basic research instrument employed is a standardized in¬
terview schedule modified for use in the IPSS and described in de¬
tail elsewhere." The interviews were administered by two psychi¬
atrists (W.T.C, and J.S.S.) and consist of an open-ended
introduction, followed by systematic inquiry into the various
areas of psychiatric symptomatology. A final section of the sched¬
ule provides ratings of the patient's observed behavior and is com¬
pleted immediately following the interview. Each item is rated
based on the psychiatrist's overall judgment of the presence or ab¬
sence during the past month of a particular symptom. For pur¬
poses of this study, only ratings indicating that a symptom was
definitely present were considered positive and all other ratings,
including questionably present, were considered negative. Accept¬
able interrater reliability has been demonstrated.13
The clinical diagnosis was made by the interviewing psychia¬
trist from the data obtained in the research interview as well as
from data obtained on Psychiatric History Schedules and Social
Description Schedules.13 The psychiatrist rated his diagnosis as
certain or uncertain. Diagnoses were made according to the cate¬
gory definitions in the Diagnostic and Statistical Manual (DSM
II)." (Psychiatric classification is always a difficult problem since
objective criteria for differential diagnosis are not available. Fur¬
thermore, even when rules for classification are stated [eg, DSM
II], one cannot specify how any individual actually integrates clin-
 Table 1.—Description of Patient Sample
Sex Age Social Class* Marital Status
Schizophrenics 103 34 M Median = 27 Class 1 = 3t Never
69 F Range = 15-44 Class 2= 7 married = 42
Class 3 = 29 Ever
Class 4 = 36 married = 61
Class 5 = 26
Affective psychoses 39 9M Median = 42 Class 1 = 9Í Never
30 F Range = 20-72 Class 2 = 9 married = 2
Class 3 = 6 Ever
Class 4 = 7 married = 37
Class 5 =3
Neuroses and 23 7M Median = 32 Class 1 = 2 Never
character disorders 16 F Range = 15-44 Class 2 = 2 married = 3
Class 3 = 9 Ever
Class 4 = 8 married = 20
Class 5=2
*
Hollingshead-Redllch Index.
t Missing data on two patients.
Missing data on five patients.

Table 2.—Interview Questions for First-Rank Symptoms

1. Audible thoughts Do you ever seem to hear your thoughts spoken aloud? (Almost as if someone nearby could hear
them.)
Do they repeat something you have just thought?
Do they sometimes repeat the same sentence many times?
2. Somatic passivity Do you ever feel that someone or something is touching you but when you look there is nobody
there? Oras if there was something creeping under your skin? Oras if your skin was wet?
Did you have any unusual or strange sexual sensations lately? What did you feel? When was that?
How do you explain it?
3. Thought insertion Are thoughts put into your mind which you know are not your own? Thoughts from elsewhere? How
can you tell they are not yours? Who put them there?
Is there a difference between your own thoughts and the other thoughts which have been put into
your mind?_^^^
4. Thought withdrawal Do you ever feel as if your thoughts were being taken away, so that your mind is a complete blank?
Can you describe it?
5. Thought broadcast Do you feel your thoughts being broadcast, transmitted, so that everyone knows what you are
thinking? Can you describe this?
6. Made feelings Or that you are made to want things that you would not want yourself?
& and/or
7. Made impulses
8. Made volition Does some other force than you yourself make you do, or say things that you do not intend? As
though you were an automation, robot without a will of your own?
Issomeone else (or something) making your movements and actions for you without your inten¬
tion?
What about your handwriting, is that controlled?_

ical data and reaches a diagnostic judgment. Although comput¬
erized diagnostic systems such as Catego13 and Diagno18,16 offer an
opportunity for reliable diagnosis with specified rules, empiric in¬
vestigation of the diagnostic assumptions of these systems is
needed just as with Schneider's system.)
Items relevant to all 11 FRSs were represented in the interview
schedule. However, data regarding voices arguing about a patient
or commenting on a patient's behavior were not always scored in
this patient cohort and are thus dropped from this data analysis
(see reference 13). Items which might reveal the presence of a de¬
lusional percept were not scored for the immediacy or person¬
alization of the percept formation and thus could not be safely
judged as delusional percepts rather than delusional notions.1 The
remaining eight FRSs are defined by the interview questions
shown in Table 2. The question of interpretation of somatic pas¬
sivity is discussed below.
The cohort of patients from Prince Georges County was eval¬
uated in follow-up interviews 23 to 25 months after the initial
evaluation. The assessment instruments utilized in the follow-up
evaluations are described elsewhere.17 Outcome criteria were de¬
were time in hospital, work adjustment, social relationships, and
severity of symptoms. Scores from these four dimensions are com¬
bined into a composite outcome rating scaled from 0 to 16. The ap¬
plicability and reliability of this instrument has been demon¬
strated.1"
Results
Four questions were investigated: (1) Are FRSs found
with significant frequency to have diagnostic utility in a
cohort of American diagnosed schizophrenic patients? (2)
Are these symptoms pathognomonic of schizophrenia in
the presence of a clear sensorium? (3) Are FRSs correlated
with previous duration of illness? (4) Are FRSs of prog¬
nostic significance?
One or more FRSs were present in 53 of 103 patients
diagnosed schizophrenic (Table 3). The subgroup diag¬
nosed as paranoid schizophrenic had a significantly higher
frequency of FRSs than the nonparanoid schizophrenics
(2 =
9.272; df 1; P<.005). Presence of FRSs in the
=

rived from the data and were scored for the 12-month period pre¬ schizophrenic group is not related to age, sex, or socioeco-
ceding the two-year follow-up evaluation. Outcome dimensions nomic status. There was a tendency for the diagnostician

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 torn was not significantly different for the two groups.
Table 3.—Prevalence of
To determine whether or not the presence of the FRSs
First-Rank Symptoms in Schizophrenia
is of prognostic significance in schizophrenia, the clinically
Patient % FRS
Positive
diagnosed schizophrenic patients were again divided into
Group those with and those without FRSs at initial evaluation.
All schizophrenics 103 51 The outcome scores for the second year of follow-up were
Paranoid only 54 67
Nonparanoid only_49_35
comparable for the two groups for time spent in the hospi¬
tal, work function, socialization, and symptomatology.
(Reasons for selecting these outcome criteria and defini¬
Table 4.—Frequency Distribution of First-Rank tion of terms is given elsewhere.6) Composite outcome
Symptoms in Schneider Positive Schizophrenia (N = 103) scores calculated by adding the four individual outcome
function ratings for each patient were slightly higher
First-Rank Symptom % Positive
(better outcome) for the patients with FRSs, but this was
Audible thoughts 20
not significant.
Somatic passivity 17
Thought insertion 20 Comment
Thought withdrawal 15
Thought broadcast 33 Phénoménologie investigations of schizophrenia have
Made feelings been plagued by a basic méthodologie problem: the lack of
and/or 11 a systematic approach to collection of behavioral data.
Made impulses This impediment has been significantly reduced by recent
Made volition 28
development of structured clinical interview techniques.
The investigator need no longer rely on happenstance
Table 5.—Incidence of First-Rank Symptoms recording of data in hospital records, nor need he use an
by Diagnosis open-interview technique where what is sought so greatly
influences what is found.
Diagnostic Group % Positive The data in this study were systematically collected on
Schizophrenia 103 51 all patients using a structured interview of established re¬
Affective psychoses 39 23
Neuroses and
liability and applicability.13 The patients were evaluated
as part of another project, prior to conceptualizing this
character disorders 23
particular study, thereby guarding against interviewer
bias in rating the critical behavioral items. However, a
to feel more certain about his schizophrenic diagnosis if number of items evaluated did relate directly to the FRSs
the FRSs were present, but this trend was not statisti¬ of Schneider and permitted testing and clarification of
cally significant. four critical issues.
Table 4 indicates the frequency with which each of the Frequency of FRSs in Schizophrenia.—Schneider believed
eight FRSs was identified in schizophrenic patients. Prev¬ that symptoms he designated as first rank not only were
alence of each FRS ranged between thought broadcast highly discriminating, but occurred with significant fre¬
(33%) and made feelings and/or impulses (11%). quency to have great diagnostic utility. This claim had not
The second question was whether FRSs were found only been investigated by others until Mellor18 interviewed 166
in schizophrenics. Of the cohort of 131 IPSS patients from diagnosed schizophrenics in an effort to determine the fre¬
Prince Georges County, 101 were diagnosed as schizo¬ quency distribution of FRSs. He found FRSs in 119 (72%)
phrenic, 12 were diagnosed as having affective psychosis, of these patients. Using an additional 54 patients, Mellor
and 18 as having neurotic or character disorders. Of the determined the frequency distribution of the various
cohort of 34 NIMH patients admitted to the clinical cen¬ FRSs in 173 Schneider-positive schizophrenic patients. He
ter, 27 were diagnosed as having affective psychosis, five used the same 11 FRSs described at the beginning of this
as having neurotic or character disorder, and two as schiz¬ paper. Eight of the 11 FRSs each appeared in 9% to 21% of
ophrenic. Table 5 shows that 23% of the affective psychosis the patients, while the other three occurred less fre¬
group and 9% of the neurotic and character disorder group quently (delusional percept, 6%; made affect, 6%; and made
had one or more FRSs. Although FRSs are significantly impulse, 3%). The other two symptoms on which we lack
more prevalent in diagnosed schizophrenics than affective direct data—voices arguing and voices commenting—each
psychosis ( 2 8.144; df
=
1; P<.005), they were not
= occurred in 13% of his Schneider-positive patients.
found exclusively in the diagnosed schizophrenics. Valid¬ In another study Taylor19 examined case records of 78
ity of the diagnoses is discussed below. patients diagnosed as schizophrenic and found that 22
To determine whether presence of the FRSs in schizo¬ (28%) had FRSs.
phrenia reflects established chronicity, the schizophrenic The prevalence of FRSs in schizophrenia in our sample
patients were divided into two groups: those with one or of 103 patients is 51%, somewhat lower than Mellor found.
more FRSs, and those with no FRSs. To evaluate possible Our figure might be raised by including the three FRSs
differences in duration of illness, two measures were used. we omitted. Delusional percept is thought to occur in¬
The mean duration of past psychiatric hospitalization was frequently and was present in only 6% of Mellor's pa¬
determined in each group and difference was found. The tients. Our data did not include voices arguing or
length of time from the onset of the first psychotic symp- commenting. However, only three of 103 schizophrenic pa-

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 tients had auditory hallucinations without any FRSs.
Therefore, inclusion of these two FRSs could not increase
the overall prevalence by more than 3%.
The number of patients in the nonschizophrenic diag¬
nostic groups with FRSs was not large enough to justify
presenting detailed results of frequency distribution anal¬
ysis. However, all FRSs were less prevalent in nonschizo-
phrenics and, roughly, proportionately so. There was some
disproportion in that somatic passivity was relatively
more prevalent and thought broadcast relatively less
prevalent in the nonschizophrenic group. Judging somatic
passivity from the somatic hallucination items (Table 2)
poses a problem since the patient must attribute the sen¬
sations to an external source, and this was not specified in
the ratings. This was almost always the case in these pa¬
tient cohorts. However, it is important to note that only
four patients had somatic passivity as their only FRS (two
diagnosed paranoid schizophrenic and two diagnosed ma¬
nic-depressive, depressed type). Therefore, overall results
are not significantly affected by somatic passivity (see
Schneider,1 page 97 for description and example).
Our data together with Mellor's support the first hy¬
pothesis by demonstrating that FRSs can be identified
with structured or open-interview techniques with suffi¬
cient frequency in schizophrenia to have diagnostic utility.
Pathognomonicity of FRSs in Schizophrenia.—Schneider's
FRSs may be approached from two directions. First, are
FRSs highly discriminating in the diagnosis of schizo¬
phrenia? Second, are FRSs pathognomonic of schizophre¬
nia? The first approach has been taken in the Volume I re¬
port of The International Pilot Study of Schizophrenia.13
Here, using data from nine participating countries, the
collaborating investigators found that most FRSs are
highly discriminating of either schizophrenia or paranoid
psychosis. Patients with special auditory hallucinations, or
thought broadcast, insertion or withdrawal, or delusions
of control had a probability between .93 and .97 of being
diagnosed schizophrenic or paranoid psychosis. Therefore,
most of the FRSs are strong diagnostic indicators, al¬
though they do not occur exclusively in schizophrenia. Pos¬
sibility that diagnostic or rating error accounts for the ap¬
pearance of FRSs in diagnoses other than schizophrenia is
considered.
In this paper we take the second approach in order to
evaluate Schneider's claim that FRSs occur only in schizo¬
phrenia (and occasionally in organic psychosyndromes)
and to determine whether a significant error occurs if one
applies his rule that the presence of any one FRS indicates
schizophrenia. The only report testing this hypothesis is
Taylor's finding no FRSs in 44 patients with nonschizo¬
phrenic diagnosis based on a case record review.1" Taylor's
study was not designed to test the pathognomonicity of
FRSs, however, nor is case record review a satisfactory
method for this purpose. Our results reject this hypothesis
by finding that nine (23%) of the 39 patients with diag¬
nosed affective psychosis had one or more FRSs. Two (9%)
of the 23 patients with neurotic or personality disorder
diagnosis also had FRSs, but this group is too small for
consideration.
It is often asserted that US psychiatrists tend to
overuse schizophrenic diagnosis, especially by including
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patients who should be diagnosed as having affective psy¬
chosis. Here the issue is reversed—did we give the diag¬
nosis of affective psychosis in patients who should have
been diagnosed as schizophrenic? Since rejecting the hy¬
pothesis of pathognomonicity is of such importance, we
reviewed the basis for diagnosis in each of the nine affec¬
tive psychosis patients with FRSs. In addition to our diag¬
nosis of affective psychosis, each of the nine patients had
been diagnosed as having affective psychosis by the refer¬
ring and the hospital psychiatrists. One of the patients
was manic at the time of evaluation and had a history of
both manic and depressive episodes. Of the remaining
eight patients, all of whom were depressed at evaluation,
four were bipolar depressives as defined by a history of
hospitalization for mania in the past, three had unipolar
depressive episodes with no history of manic symptoms,
and the remaining patient had recurrent depressive epi¬
sodes with a history of intervening hypomanic behavior
not severe enough to require hospitalization. No reason
was found to question the diagnoses in this review. Diag¬
noses of past illness episodes were always affective dis¬
orders.
This review of the clinical data supports the diagnoses
originally given. It is possible, of course, that errors were
made in rating the FRS items. However, when the rating
was considered questionable by the interviewing psychia¬
trist, it was considered absence for this study. Interrater
reliability for these items is high. Therefore, we conclude
that the postulated pathognomonicity of FRSs is refuted.
It appears that using the rule that the presence of any one
FRS is sufficient to diagnose schizophrenia would lead to
substantial misclassification.
FRSs and Duration of Illness.—The third hypothesis ex¬
amined is that when FRSs appear with increasing fre¬
quency, the greater the duration of illness and, therefore,
the indication is of chronicity. This hypothesis is based on
the assumption that the more fully developed the illness,
the more likely FRSs are to appear. Furthermore, these
symptoms might in part be a result of chronicity or insti-
tutionalization. Some support for this hypothesis is found
in Taylor's work,111 in that poor prognostic features (which
in part are based on measures of duration of illness and
premorbid adjustment) and FRSs are generally found in
the same patients, while good prognostic features are as¬
sociated with absence of FRSs. Mellor1" found, on the con¬
trary, that patients without FRSs had been ill longer and
hospitalized more than those with FRSs. The length of
time in hospitals for psychiatric disorder prior to current
admission, and the length of time since psychotic symp¬
toms first appeared in the patient's life were determined
in our patients. Neither of these variables distinguished
between diagnosed schizophrenic patients with and with¬
out FRSs. We conclude that FRSs do not reflect chronic¬
ity.
FRSs and Prognosis.—The fourth hypothesis states that
FRSs predict a poor outcome. Schneider believed that
FRSs were assocated with poor outcome and cites Bau-
mer's findings20 as support. Taylor found the presence of
FRSs associated with poor prognostic features and the ab¬
sence of FRSs associated with good prognostic features
based on a case record review of 78 young, male patients
 diagnosed as schizophrenic.19 He found the poor prognosis,
Schneider positive group less responsive to short-term
treatment, but did not report long-term follow-up. Taylor
uses the prognostic features of Robins and Guze,21 which
include measures of chronicity and other indices. Since
Taylor does not report relationships between individual
indices and poor outcome, we cannot determine to what
extent the association between FRSs and outcome is a
function of established chronicity at the time of study (see
hypothesis 3).
Results of our two-year follow-up study showed no rela¬
tionship between presence or absence of FRSs and indi¬
vidual outcome indices (duration of hospitalization, work
function, social function, and symptomatology). Overall
outcome was actually slightly, although insignificantly,
better for patients with FRSs. Therefore, we conclude
that our fourth hypothesis is not supported by two-year
follow-up data.
John Bartko, PhD, Biometry Branch, National Institutes of Mental
Health, provided statistical assistance.
This paper is partially based on the data and experience obtained during
participation of the authors in the International Pilot Study of Schizophre¬
nia, a project sponsored by the World Health Organization, and funded by
the World Health Organization, the National Institute of Mental Health,
and the participating field research centers. The collaborating investigators
on this study have been:
At Headquarters in WHO, Geneva, Switzerland, Dr. N. Sartorius (princi¬
pal investigator), Dr. T. Y. Lin (former principal investigator), E. M.
Brooke, Dr. F. Engelsmann, Dr. G. Ginsburg, M. Kimura, Dr. A. Richman,
and Dr. R. Shapiro. In the field research centers in: Aarhus, Denmark, Dr.
E. Stromgren (chief collaborating investigator [cci]), Dr. A Bertelsen, Dr.
M. Fischer, Dr. C. Flach and Dr. N. Juel-Nielsen; Agra, India, Dr. K. C.
Dube [cci] and Dr. B. S. Yadav; Cali, Colombia, Dr. C. Leon [cci], Dr. G. Cal¬
derón and Dr. E. Zambrano; Ibadan, Nigeria, Dr. T. A. Lambo [cci] and Dr.
T. Asuni; London, Dr. J. K. Wing [cci], Dr. J. Birley and Dr. J. P. Leff; Mos¬
cow, USSR, Dr. R. A. Nadzarov [cci] and Dr. N. M. Zharikov; Prague, Czech¬
oslovakia, Dr. L. Hanzlicek [cci] and Dr. C. Skoda; Taipei, Taiwan, Dr. C. C.
Chen [cci] and Dr. T. Tsuang; Washington, D. C, Dr. J. S. Strauss [cci], Dr.
L. C. Wynne, Dr. W. T. Carpenter, Jr., and Dr. John J. Bartko.
References
1. Schneider K: Clinical Psychopathology. Hamilton (trans),
New York, Grune & Stratton Inc, 1959.
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2. Great Britain General Registar's Office Sub-Committee on
Classification of Mental Diseases: A Glossary of Mental Disorders
Based on the International Statistical Classification of Diseases:
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