Exploring First Rank Symptoms in a Psychiatric History – OSCE guide

Kurt Schneider, a German psychiatrist, pointed out certain symptoms as being characteristic of schizophrenia and therefore exhibiting a “first-rank” status in the hierarchy of potentially diagnostic symptoms.¹ However first rank symptoms can occur in other disorders such as mania or delirium which is why their isolated presence is not sufficient for a diagnosis of schizophrenia.

This guide provides examples of questions that may be useful in exploring first rank symptoms when taking a psychiatric history.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient: “I have to ask you some questions that may seem a little bizarre and may not make sense. These are questions we ask of everyone. Would that be ok?”

Gain consent to proceed with history taking.

Hallucinations

A hallucination is a perception in the absence of an external stimulus that has qualities of real perception.

Auditory hallucination

An auditory hallucination might involve a patient hearing voices despite the absence of any actual sound.

Questions which may be useful to explore auditory hallucinations include:

• “Do you ever hear noises or voices when there is nobody else there?”
• “Can you hear them in your ears, or are they in your mind?”
• “How many voices are there?”
• “Do you recognise the voices?”
• “What do they say?”
• “Do they tell you to do things and do you obey?”
• “Do they tend to comment on what you are doing or thinking?”
• “Are the voices present all the time?”
• “Does anything make them better or worse?”
• “Do you ever find yourself having a conversation with them?”
• “Do you smell or see anything at the same time that you hear these voices?”

Somatic hallucinations

A perception of being touched in the absence of a sensory stimulus is termed a somatic hallucination. This may result in hallucinations of being touched, assaulted or that insects are beneath the skin.

Questions which may be useful to explore somatic hallucinations include:

• “Do you ever feel that someone or something is touching you when there is nobody there?”
• “Have you ever felt like you’ve been assaulted despite nobody being present?”
• “Have you ever felt like insects are crawling beneath your skin?”

Thought abnormalities

Thought blocking

Thought blocking involves sudden cessation of thought, typically mid-sentence, with the patient being unable to recover what was previously said.

Questions which may be useful to explore thought blocking include:

• “Do you feel able to think clearly?”
• “Do you ever experience your thoughts suddenly stopping as though there were no thoughts left?”
• “What is it like? How do you explain it?”

Thought withdrawal

Thought withdrawal refers to a patient’s belief that thoughts can be removed from their mind by others.

Questions which may be useful to explore thought withdrawal include:

• “Is there anything like hypnosis or telepathy going on?”
• “Is there anyone or anything taking thoughts out of your head?”

Thought insertion

Thought insertion refers to a patient’s belief that thoughts can be inserted into their mind by others.

Questions which may be useful to explore thought insertion include:

• “Are your thoughts your own?”
• “Is there anyone/anything putting thoughts into your head that you know are not your own?”
• “How do you know they aren’t yours? Where do they come from?”

Thought broadcasting

Thought broadcasting refers to a patient’s belief that others can hear their thoughts.

Questions which may be useful to explore thought broadcasting include:

• “Can anyone hear your thoughts? For example, can I hear what you are thinking right now?”
• “Do you ever hear your own thoughts echoed or repeated?”

Delusional perception

Delusions are firm, fixed beliefs based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms. These may include persecutory delusions, in which the patient erroneously believes another individual or group is trying to harm them or ideas of reference, in which the individual incorrectly believes specific events relate to them.

Questions which may be useful to explore delusional perception include:

• “Do you sometimes have thoughts that others tell you are false?”
• “Do you have any beliefs that aren’t shared by others you know?”
• “Do you ever feel that people are out to do you harm?”
• “Do you ever feel that specific events in the world are related to you in some way?”
• “When you watch the television/listen to the radio/hear something, do you feel that the stories are referring to you or something that you have done?”

Passivity

People who experience passivity do not feel in control of their actions, thoughts and perceptions, believing them to influenced by an external agent.

Questions which may be useful to explore passivity include:

• “Do you ever feel as though you are being controlled by someone or something?”
• “Do you ever think that someone or somebody is controlling you?”
• “Are your thoughts/mood/actions under your control or is someone forcing you to behave in this way?”

Closing the consultation

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Summarise your findings to the examiner (using the mental state examination structure).

References

1. Nordgaard J, Arnfred SM, Handest P, Parnas J. The Diagnostic Status of First-Rank Symptoms. Schizophrenia Bulletin. 2008;34(1):137-154. doi:10.1093/schbul/sbm044.