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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 can prove useful in exploring first rank symptoms when taking a history

Opening the consultation

Introduce yourself

Confirm patient details – name / DOB

“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?”

Auditory hallucinations

Do you ever hear noises or voices when there is nobody else there?

Are the voices like you hear mine right now?

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? (Do you obey?)

Do they tend to comment on what you are doing/thinking?

Are they present all the time?

Does anything make them better/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?

Thought withdrawal, insertion and interruption

Thought interruption

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

Is there anything like hypnosis or telepathy going on?

Is there anyone or anything taking thoughts out of your head?

 

Thought insertion

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

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?

Somatic hallucinations

Do you ever feel that someone or something is touching you when there is nobody there?

Do you ever think there are insects crawling about inside your body?

Delusional perception

Do you ever feel that somebody or something is paying particular attention to you and what you are doing?

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

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

Thank the patient

Summarise your history to the examiner (using the mental state examination as the underlying structure).

State to the examiner that if you had more time you would take a thorough psychiatric history.

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.

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