SIGNS, SYMPTOMS, AND SYNDROMES
4.31 SCHNEIDERIAN FIRST RANK SYMPTOMS
Kurt Schneider (1887–1967) was a very influential German psychiatrist whose classic text Clinical Psychopathology
went through multiple revisions from its first edition in 1939 up to the fifth, and last, edition, published in 1959. In this text, Schneider described a number of hallucinations and delusions that he believed were of ‘first rank’ impor- tance in the diagnosis of schizophrenia. Although these Schneiderian first rank symptoms are, indeed, most com- monly seen in schizophrenia, they may also, as pointed out by Schneider himself, occur in ‘diverse’ other conditions, as described below.
Clinical features
The various Schneiderian first rank symptoms, as noted in Table 4.8, may be divided into those which are auditory hallucinations and those which represent delusions.
Audible thoughts are said to occur when patients hear their own thoughts as if they were spoken out loud and indeed as if others might be able to hear them also. One of Schneider’s (1959) patients said, ‘I hear my own thoughts.
I can hear them when everything is quiet.’
Voices commenting on what the patient does, keep up, as it were, a running commentary on the patient’s behav- ior. One of Schneider’s (1959) patients ‘heard a voice say, whenever she wanted to eat, “Now she is eating, here she is munching again,” ’ and one of Kraepelin’s (1921) patients heard a voice telling her, ‘Mary, you’re talking nonsense, the policeman has seen you already.’
Voices arguing with each other, or, as Schneider (1959) elaborated, merely ‘conversing with one another’, may engage patients’ attention, as if the voices were carrying on a debate about them.
Delusions of passivity or influence are said to be present when ‘feelings, impulses (drives) and volitional acts . . . are experienced by the patient as the work or influence of others’ (Schneider 1959). Such patients believe that their thoughts, feelings or behavior are under the direct and unmediated control of some outside force or agency. Thus passively played upon by these forces, patients feel as if they were robots or automatons. Patients will typically elaborate on this delusion of influence and express a belief as to the source of the influence, for example an ‘electrical device’, ‘distant computers’, or ‘powerful magnets’.
Thought withdrawal represents a delusion wherein patients experience their thoughts being directly removed and withdrawn from their minds. One of Kraepelin’s (1921) patients spoke of his thoughts being ‘drawn off’.
This is quite different from simply losing track of what one was thinking: those who lose track have a sense of having forgotten or lost something, whereas those with thought withdrawal have, as emphasized by Schneider (1959), a definite sense that some other agency or person has directly removed the thought.
Thought insertion represents the delusional belief of patients that the thoughts occurring in their minds are not their own but rather originate from, as Schneider (1959) put it, ‘other people, who intrude their thoughts upon the patient’. Such inserted thoughts are quite different from obsessions: obsessions are recognized by patients as their own thoughts and as originating within them, whereas inserted thoughts are experienced as a kind of cognitive
‘foreign body’.
Thought broadcasting represents the delusion that oth- ers can know what a patient is thinking without the patient in any way relating those thoughts. This ‘thought diffusion’
led one of Schneider’s (1959) patients to complain that, ‘if I think of anything, at once those opposite me know it and it is embarrassing.’ As she believed that ‘the doctor too knew exactly what she was thinking, . . . she suggested that she would stop talking and (the physician) could just lis- ten’. In some cases, patients will elaborate on this delusion, developing further beliefs about how such thought transfer is possible: Kraepelin (1921) noted that some patients believe that ‘their thoughts are conveyed by a machine, there is a “mechanical arrangement”, “a sort of little con- veyance”, telepathy’.
Etiology
It has, at times, been felt that Schneiderian first rank symp- toms were virtually pathognomonic of schizophrenia, occurring in virtually no other condition. The source of this belief is not clear: it certainly does not come from Schneider, who clearly stated that these first rank symp- toms could occur secondary to a ‘number of diverse mor- bid cerebral processes’ (Schneider 1959).
The various causes of the first rank symptoms are listed in Table 4.9. Of all of these, schizophrenia is, by far, the most common cause, with first rank symptoms being found in anywhere from one-third (Radhakrishnan et al.
1983) to over one-half (Tandon and Greden 1987) of such patients. Among patients with schizophrenia, it appears that thought broadcasting and thought insertion are prob- ably most common out of all the first rank symptoms (Mellor 1970). Schizoaffective disorder is probably the next most common cause, with symptoms noted in about one-quarter of these patients (Tandon and Greden 1987).
Mania, as seen in bipolar disorder, during stage II or III, may also cause first rank symptoms, and the diagnosis here Table 4.8 Schneiderian first rank symptoms
Auditory hallucinations Audible thoughts
Voices commenting on what the patient does Voices arguing with each other
Delusions
Delusions of passivity or influence Thought withdrawal
Thought insertion Thought broadcasting
is suggested by typical manic symptoms seen in stage I, such as pressured speech, hyperactivity, increased energy, decreased need for sleep, etc. Depression, as seen in major depressive disorder, is only rarely associated with first rank symptoms, and hence the appearance of such a symptom in a depressed patient should make one pause before giving a diagnosis of major depression; in such cases a diagnosis of schizoaffective disorder may be more likely.
The other causes noted in Table 4.9, although rare, must be kept in mind. Of these, intoxications with ampheta- mines, cocaine, or phencyclidine are perhaps most com- mon. Chronic, severe, alcoholism may be associated with alcohol hallucinosis, which may be characterized by first rank symptoms, and there are case reports of these symp- toms occurring during benzodiazepine withdrawal and as a side-effect to fluvoxamine.
Epileptic conditions associated with first-rank symp- toms include simple partial seizures and the chronic inter- ictal psychosis. In one case of a simple partial seizure, the patient, during the ictus, had ‘blurry vision, abdominal discomfort, sensation of imminent death, intense fear, and the conviction that his body (was) controlled by external forces’ (Mesulam 1981). The chronic interictal psychosis, discussed further in Section 7.1, is seen only in patients with chronic, severe, uncontrolled epilepsy: one of Slater and Beard’s (1963) patients believed that there was a ‘pick- up’ device in his body ‘which transmitted thoughts from the brain, and also made the brain receive’.
The remaining miscellaneous causes listed in Table 4.9 only very rarely cause first rank symptoms.
Treatment
Treatment is directed at the underlying condition.
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Table 4.9 Causes of Schneiderian first rank symptoms Schizophrenia (Tandon and Greden 1987)
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