First rank symptoms of schizophrenia

1. FIRST RANK SYMPTOMS
OF
SCHIZOPHRENIA

2. Kurt Schneider (7 January 1887 – 27 October 1967)

3. • Kurt Schneider was a German psychiatrist known largely for his writing on
the diagnosis and understanding of schizophrenia, as well as personality
disorders then known as psychopathic personalities.
• Schneider was born in Crailsheim, Kingdom of Württemberg, and trained in
medicine in Berlin and Tübingen. He was drafted for and completed military
service in World War I and later obtained a postgraduate qualification in
psychiatry. In 1931 he became director of the German Psychiatric Research
Institute in Munich, which was previously founded by Emil Kraepelin.
• Disgusted by the developing tide of psychiatric eugenics championed by the
Nazi Party, Schneider left the institute, but did serve as a doctor for the
german armed forces during World War II.
• After the war, academics who hadn't taken part in the Nazi eugenics policies
were appointed to serve in, and rebuild Germany's medical institutions and
Schneider was given the post of Dean of the Medical School at Heidelberg
University. Schneider kept this post until his retirement in 1955

4. INTRODUCTION
• Schneider accepted Kraepelin’s system of classification and
distinguished between “abnormal personalities”, “abnormal reactions”,
“organic psychosis”, “schizophrenia and cyclothymia”.
• He had taken a group of psychotic patients, excluded those with clear
organic psychosis, reactive psychosis, obvious cyclothymia, and then
performed a statistical analysis of the symptom of the remaining
psychotic patients, who were presumed to have schizophrenia.
• In those patients he termed the most frequently found symptoms as
‘First Rank Symptoms [FRS]’(Schneider 1959).
• As per Schneider, FRS is mostly found in schizophrenia (Crichton,
1996).

5. EVOLUTION OF CONCEPT
• Morel, in 1852 reported a series of cases of severe intellectual
deterioration starting in adolescence and he called this illness demence
precoce.
• In 1874, Kahlbaum drew attention to a mental illness in which stupor
occurred in the absence of disease of nervous system, he called this
illness tension insanity or catatonia.
• In 1893, Kraepelin brought together the syndromes of demence
precoce, hebephrenia, catatonia, and dementia paranoides in the 4th
edition of his textbook and called this group of illness ‘psychological
degeneration process’. In 1899, he used the term dementia praecox to
designate this group of illnesses because intellectual deterioration was
a common feature and the illness usually occurred in young people
(Hamilton,1984).

6. • Bleuler coined the term schizophrenia in 1911.
• According to him, the disease is characterized by a specific type of alteration of
thinking, feeling, and relation to external world, which appears nowhere else in this
particular fashion. He said that certain symptoms of schizophrenia are present at all
times and in every case. Here he is referring to the so-called basic symptoms.
Accessory symptoms on the other had may also occur in other illnesses (Bleuler,
1950). The basic symptoms were characterized by the four A’s
• Ambivalence
• Autism
• Affect disturbances
• Association disturbances
• Schneider wrote that the presence of delusional perception excludes a reactive
experience and always indicates a true psychosis, which in practical terms is a
schizophrenic illness. If the symptom is present in a non-organic psychosis, then we
call that psychosis as schizophrenia as opposed to cyclothymic psychosis or reactive
psychosis in abnormal personality (Hamilton, 1984).

7. EVOLUTION OF THE CONCEPT OF FRS
• Schneider reported that the presence of FRS always signifies schizophrenia but first
rank symptoms need not always be present in schizophrenia. The search for
pathognomic symptoms among positive phenomena is the hallmark of Schneider’s
clinical psychopathology (Monti, 1996).
• However Schneider had given few statistics to demonstrate, not how he arrived at his
choice of FRS but how the use of FRS led to clear cut diagnosis in most cases
(Schneider, 1980).
• In FRS, the use of the term ‘symptoms’ is somewhat idiosyncratic (Boyle, 1990).
Patients do not complain it as a symptom of illness (Crichton, 1996). FRS is referred
to a more or less characteristic but invariably detectable feature of a purely
psychopathological ‘state course complex’ (Schneider, 1980).
• According to some authors (Huber, 1994), Schneider’s personal prestige also
contributed to the success of his concept of FRS. In 1931, Schneider became Director
of German Research Institute for Psychiatry in Munich founded by Kraepelin and led
the honorary professorship at the University of Munich 1934 onward (Huber 1994).

8. CONCEPTS AND DEFINITION
• FRS deals with mainly delusions and hallucinations. First rank symptoms
were regarded as primary symptoms. Schneider said, “From the standpoint
of psychopathology, primary symptoms are final and irreducible” (Sims,
1991).
• According to Jasper (1968) “If we try to get some closer understanding of
these primary experiences of delusion, we soon find we cannot really
appreciate these quite alien modes of experience. They remain largely
incomprehensible, unreal and beyond our understanding.

9. Schneider formulated what he considered to be
pathognomic of first rank symptoms of schizophrenia
(Schneider, 1959).
• 1. Audible thoughts (voices speaking out his thoughts aloud).
• 2. Voices arguing (Referring to the patient in 3rd person)
• 3. Voices commenting on one’s actions.
• 4. Somatic passivity (experiencing externally controlled body changes)
• 5. Thought withdrawal
• 6. Thought insertion
• 7. Thought broadcasting
• 8. Made volition.
• 9. Made affect
• 10. Made impulse
• 11. Delusional perception (a real percept elaborated in a delusional way)

10. • As per Schneider, there were less important criteria for the diagnosis of
schizophrenia other than FRS and he termed them as second rank
symptoms. Those are:
• Other hallucinations
• Delusional notions
• Perplexity
• Depressed or elated mood,
• Experiences of flattened feelings.
• Other abnormal modes of expression eg., disorder of speech and other
motor manifestations were known as third rank symptoms.

11. DIFFERENT CONCEPTS
• FRS does not have a common foundation. But some of them can be grouped
together under the concept of ‘permeability’ of barrier between the individual
and his environment, the so-called ‘loss of ego boundaries’ (Koehler, 1979).
The FRS which come under the heading of ego disturbances are thought
withdrawal, thought control, thought diffusion, and everything that the patient
experiences as imposed on him in the spheres of feeling, drive and volition
(Sims, 1991).
• FRS are disorders of experience and lack the objective qualities of disorders
of behaviour such as negative symptoms (Mellor, 1991).
• Tremble gave the concept that abnormality of temporal lobe produces FRS
(Trimble, 1990).

12. • Mellor (1970) defined FRS individually as follows:
• Audible thoughts: The patient experiences auditory hallucinations, with voices speaking his
thoughts aloud.
• Voices arguing: There are two or more hallucinatory voices in disagreement, or in
discussion. The subject is usually the patient, who is referred to in the third person.
• Voices commenting on one's action: The content of the auditory hallucination is a
description of the patient's activities as they occur.
• Influence playing on the body (somatic passivity): The patient is a passive and invariably a
reluctant recipient of bodily sensations imposed upon him by some external agency.
• Thought withdrawal: The patient describes his thoughts as being taken from his mind. As
his thoughts cease, he simultaneously experiences them being withdrawn by some external
force.
• Thought insertion: The patient experiences thoughts, which have the quality of not being his
own. Patients invariably complain of some external agency imposing the thoughts by varied
means, upon their passive minds.
• Diffusion or broadcasting of thoughts: The patient, during the process of thinking, has the
experience that his thoughts are not contained within his own mind. The thoughts escape
from the confines of the self into the external world, where all around him experiences them.
There is usually a secondary delusional explanation of this phenomenon, which may invoke
the use of telepathy, television etc.

13. • 'Made' feelings: The patient experiences feelings, which do not seem to be his own.
The feelings are attributed to some external source and are imposed upon him.
• Made impulses (drives): A powerful impulse overcomes the patient to which he
almost invariably gives way. The impulse to carry out this action is not felt to be his
own, but the actual performance of act is. Superficially this phenomena resembles
compulsive phenomena of OCD although the drive seeming alien is always
recognized..
• 'Made' volitional acts: The patient experiences his actions as being completely under
the control of an external influence. The movements are initiated and directed
throughout by the controlling influence, and the patient feels like he is an automaton
and the passive observer of his own actions. It should be differentiated from
hysterical automatism. The experience in hysterical automatism is dissociated from
ego and subject is not consciously aware of both action and ego at the same time.
• Delusional perception: Mellor has followed Schneider's description of the delusional
perception as a two-stage phenomenon. The delusion arises from a perception, which
to the patient possesses all the properties of a normal perception, and which he
acknowledges would be regarded as such by anyone else. This perception however
has a private meaning for him, and the second stage, which is development of
delusion, follows immediately.

14. FISH’S DEFINITION OF FRS- (HAMILTON, 1984)
 Audible thought or Gedankenlautwerden- In this, the patient hears their thoughts
being spoken as they think, and the voices which speak their thoughts, may come from
inside or outside the head. So according to the Jasperian concept, it can be a true
hallucination or pseudohallucination.
 Voices heard arguing and voices commenting- Fish explained voices arguing as a
hallucinatory voice in the form of statement and reply, so that patient hears voices
speaking about him in the third person. In voices commenting, person hears voices in
the form of running commentary.
 Somatic passivity -Fish explained it in the way that patient actually experiences bodily
sensation as being produced by external agency.
 Thought Alienation -
o In thought alienation, the patient has the experience that his thoughts are under the control of an
outside agency or others are participating in his thinking.
o Thought insertion –here patient knows that thoughts are being inserted into his mind and he
recognizes them as being foreign and coming from without.
o In thought withdrawal/deprivation – The patient finds that as he is thinking, his thoughts suddenly
disappear and are withdrawn from his mind by foreign influence. In has been suggested that this is
the subjective experience of thought blocking and omission.
o In thought broadcasting the patient knows that as he is thinking, the world is thinking in unison with
him.
• In all this experience of thought alienation, the general interpretation is that the boundary
between the ego and surroundings has broken down.

15.  Delusional Perception - The delusional or apophanous perception is the
attribution of a new meaning, usually in the sense of self-reference to a
normally perceived object. The new meaning cannot be understood as
arising from the patient’s affective state or previous attitudes. This last
provision is important because the delusional perception must not be
confused with the delusional misinterpretation.
 Made Impulse/Made feeling/Made acts - According to Fish, alienation
phenomenon may affect motor actions and feelings. The patient knows that
his actions are not his own and may attribute this control to hypnosis, radio
waves and so on.

16. The below definitions present a possible scheme for use in clinical practice
Delusional Continuum (Koehler, 1979):-
 Delusional mood (Wahnstimmung):
The subject perceives something in the outside world and feels that something is 'going
on' in the sense that he is more or less aware that something is happening to him or in his
familiar surroundings, that these may have specially or significantly changed in an odd,
strange or puzzling way, but he is as yet not certain if or what or how this may be occurring.
 Delusional notion linked to or provoked by a perception (Wahrnehmungsgobundener
Wahneinfall):
The subject perceives something in the outside world and this triggers a special,
significant relatively non-understandable meaning of which he is certain and which is more or
less loosely linked to the triggering perception; that is, the meaning is not contained within
this particular perception itself.
• Delusional perception (Wahnwahrnehmung):
The experience is like above except for the fact that the special, significant but relatively
non-understandable meaning is contained within, not merely linked to the perception itself.

17. Passivity continuum
 Passivity mood (Beeinflussungsstimmung):
The subject experiences that something is ‘going on’ in his inner world in the sense
that he is more or less aware that something may be impinging upon the integrity of his self or
aspects of the self, but he is not as yet certain if or what or how this may be occurring.
 General experience of influence (Allgemeincs Beeinflussungserlebnis):
The experience is like above but now the subject is quite certain that there is
some general control or influence being exerted on him from without.
 Specific experience of influence (Spezifisches Beeinflussungserlebnis):
The experience is like above but now the subject is quite certain about
which specific ego areas, for example HIS OWN thoughts, feelings and so on, are being
controlled or influenced by an outside force.
 Experience of influenced depersonalization (Beeinflussungs- Depeisonalization):
This represents a combination of the more usual experience of depersonalization of
the self or aspects of the self, such as thoughts, feelings and so on, with the above-mentioned
specific experience of influence .

18.  Positive experience of alienation (Beeinflussungerserlebnis mit Ersatz-
Qualitat):
The experience is like specific experience of influence, but now the subject is
quite certain of ‘positively’ experiencing completely alien or foreign thoughts,
feelings and so on; that is, those that are definitely NOT HIS OWN have been
imposed upon him from outside (e.g. thought insertion).
 Negative-active experience of alienation (Beeinflussungserlebnis mit aktiver
Verlust-Qualitat):
The experience is like specific experience of influence ,but now the
subject is quite certain of ‘negatively’ being aware that he has lost HIS OWN
thoughts, feelings and so on because they have been actively taken away from
without (e.g. thought withdrawal).
 Negative-passive experience of alienation (Beeinflussungserlebnis mit passiver
Verlust-Qualitat):
The experience is like specific experience of influence ,but now the
subject is quite certain of 'negatively' being aware that he has lost HIS OWN
thoughts, feelings and so on because in some way they passively diffuse into or are
lost to the outside world against his will (e.g. thought broadcasting).

19. Sense Deception Continuum
 Pseudo-hallucinatory voices (Pseudohalluzinatorische Stimmen):
a) The integrity of the ego areas is no longer experienced by the subject as being
influenced or alienated from without, but rather he hears a voice or voices commenting
on his actions, or voices arguing or discussing among themselves, and this experience
takes place in his head, that is, in his inner world and not in external space.
b)Like above but now the voice or voices speak his own thoughts (Pseudo-hallucinatory
audible thoughts or Gedankenlautwerden).
 Hallucinatory voices (Halluzinatorische Stimmen):
a) Like above but now the experience takes place not in his head but rather in external
space, although there is no actual source for these voices in the outside world.
b)Like above but now the voice or voices speak his own thoughts. (Hallucinatory audible
thoughts of Gedankenlautwerden).

20. FRS in conditions other than schizophrenia
• FRS is not pathognomic for schizophrenia.
• It may occur in other psychiatric disorders, organic mental disorder, and
even in normal population. Prevalence of FRS in a non-schizophrenia
patient is significantly less.
• Schniederien FRS are common in multiple personality disorder (MPD).
MPD had been differentiated from eating disorder, panic disorders and
complex partial seizure disorders by the help of FRS (Ross et al, 1988).
On an average 3.6 to 4.5 FRS had been found in different studies (Kluft,
1987). The frequency of FRS is compared with that of schizophrenia.
Findings suggested that voices commenting and arguing are the two most
common symptoms in MPDs, but most stated that voices came from
inside the head. This is marked as the differentiating feature between the
two.