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Meta-Analysis
. 2015 Jan 25;1(1):CD010653.
doi: 10.1002/14651858.CD010653.pub2.

First rank symptoms for schizophrenia

Karla Soares-Weiser  1 , Nicola Maayan, Hanna Bergman, Clare Davenport, Amanda J Kirkham, Sarah Grabowski, Clive E Adams
Affiliations
Meta-Analysis

First rank symptoms for schizophrenia

Karla Soares-Weiser et al. Cochrane Database Syst Rev. .

Abstract

Background: Early and accurate diagnosis and treatment of schizophrenia may have long-term advantages for the patient; the longer psychosis goes untreated the more severe the repercussions for relapse and recovery. If the correct diagnosis is not schizophrenia, but another psychotic disorder with some symptoms similar to schizophrenia, appropriate treatment might be delayed, with possible severe repercussions for the person involved and their family. There is widespread uncertainty about the diagnostic accuracy of First Rank Symptoms (FRS); we examined whether they are a useful diagnostic tool to differentiate schizophrenia from other psychotic disorders.

Objectives: To determine the diagnostic accuracy of one or multiple FRS for diagnosing schizophrenia, verified by clinical history and examination by a qualified professional (e.g. psychiatrists, nurses, social workers), with or without the use of operational criteria and checklists, in people thought to have non-organic psychotic symptoms.

Search methods: We conducted searches in MEDLINE, EMBASE, and PsycInfo using OvidSP in April, June, July 2011 and December 2012. We also searched MEDION in December 2013.

Selection criteria: We selected studies that consecutively enrolled or randomly selected adults and adolescents with symptoms of psychosis, and assessed the diagnostic accuracy of FRS for schizophrenia compared to history and clinical examination performed by a qualified professional, which may or may not involve the use of symptom checklists or based on operational criteria such as ICD and DSM.

Data collection and analysis: Two review authors independently screened all references for inclusion. Risk of bias in included studies were assessed using the QUADAS-2 instrument. We recorded the number of true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN) for constructing a 2 x 2 table for each study or derived 2 x 2 data from reported summary statistics such as sensitivity, specificity, and/or likelihood ratios.

Main results: We included 21 studies with a total of 6253 participants (5515 were included in the analysis). Studies were conducted from 1974 to 2011, with 80% of the studies conducted in the 1970's, 1980's or 1990's. Most studies did not report study methods sufficiently and many had high applicability concerns. In 20 studies, FRS differentiated schizophrenia from all other diagnoses with a sensitivity of 57% (50.4% to 63.3%), and a specificity of 81.4% (74% to 87.1%) In seven studies, FRS differentiated schizophrenia from non-psychotic mental health disorders with a sensitivity of 61.8% (51.7% to 71%) and a specificity of 94.1% (88% to 97.2%). In sixteen studies, FRS differentiated schizophrenia from other types of psychosis with a sensitivity of 58% (50.3% to 65.3%) and a specificity of 74.7% (65.2% to 82.3%).

Authors' conclusions: The synthesis of old studies of limited quality in this review indicates that FRS correctly identifies people with schizophrenia 75% to 95% of the time. The use of FRS to diagnose schizophrenia in triage will incorrectly diagnose around five to 19 people in every 100 who have FRS as having schizophrenia and specialists will not agree with this diagnosis. These people will still merit specialist assessment and help due to the severity of disturbance in their behaviour and mental state. Again, with a sensitivity of FRS of 60%, reliance on FRS to diagnose schizophrenia in triage will not correctly diagnose around 40% of people that specialists will consider to have schizophrenia. Some of these people may experience a delay in getting appropriate treatment. Others, whom specialists will consider to have schizophrenia, could be prematurely discharged from care, if triage relies on the presence of FRS to diagnose schizophrenia. Empathetic, considerate use of FRS as a diagnostic aid - with known limitations - should avoid a good proportion of these errors.We hope that newer tests - to be included in future Cochrane reviews - will show better results. However, symptoms of first rank can still be helpful where newer tests are not available - a situation which applies to the initial screening of most people with suspected schizophrenia. FRS remain a simple, quick and useful clinical indicator for an illness of enormous clinical variability.

PubMed Disclaimer

Conflict of interest statement

Karla Soares‐Weiser ‐ currently works for Enhance Reviews Ltd, a company that carries out systematic reviews mostly for the public sector, it currently does not provide services for the pharmaceutical industry.

Nicola Maayan ‐ currently works for Enhance Reviews Ltd, a company that carries out systematic reviews mostly for the public sector, it currently do not provide services for the pharmaceutical industry.

Hanna Bergman ‐ currently works for Enhance Reviews Ltd, a company that carries out systematic reviews mostly for the public sector, it currently does not provide services for the pharmaceutical industry.

Clare Davenport ‐ none known.

Sarah Grabowski ‐ none known.

Amanda Kirkham ‐ none known.

Clive E Adams ‐ none known.

Figures

1
1
PRISMA flow diagram.
2
2
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study
3
3
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies
4
4
Summary ROC Plot of 1. FRS to differentiate schizophrenia from all other psychotic and non‐psychotic diagnoses
5
5
Summary ROC Plot of 2. FRS to differentiate schizophrenia from other types of psychosis
6
6
Summary ROC Plot of 3. FRS to differentiate schizophrenia from non‐psychotic disorders
1
1. Test
Schizophrenia vs. All other diagnosis.
2
2. Test
Schizophrenia vs. Other psychosis.
3
3. Test
Schizophrenia vs. Non‐psychotic disorders.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010653

References

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Taylor 1972 {published data only}
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References to studies awaiting assessment

Friedrich 1980 {published data only}
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