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When exploring first rank symptoms, first ask open questions to elicit the patient’s experience in their own words. Then, ask about any remaining symptoms.
Key Knowledge
What Are First Rank Symptoms?
First rank symptoms are a set of experiences originally described by Kurt Schneider as highly characteristic of schizophrenia, but they can also occur in other psychotic states. They are not a diagnosis, nor are they pathognomonic. One review found that they are present in about 60% of people with schizophrenia (1).
They were listed in the ICD-10 diagnostic criteria for schizophrenia (2), but have been dropped in ICD-11 (3). However, you are still expected to know them for exams and they are useful as a starting point for exploring psychotic states.
First rank symptom groups
Thought Interference
● Thought Insertion: Feeling that thoughts are put into your mind by others.
● Thought Withdrawal: Feeling that thoughts are being removed or stolen.
● Thought Broadcasting: Experiencing your thoughts as being broadcasted, so others can hear them.
Auditory Hallucinations
● Third‑person commentary: Voices describing your actions (“She’s going to the kitchen now”).
● Voices arguing: Two or more voices discussing you, often critically.
● Thought Echo: Hearing one’s own thoughts repeated aloud, as if echoed back.
Passivity Phenomena (Delusions of Control)
● Made actions/feelings/impulses: Sensation that your feelings, impulses, or bodily movements are being controlled by an external agent.
● Made bodily sensations: Perceptions as if physical sensations are being created by someone/thing else.
Delusional Perception
● A normal event/perception instantly assigned a false meaning that is often bizarre and irrational (“The light turned red which means the CIA is watching me”)
Differential Diagnosis for First Rank Symptoms
● Primary psychotic disorders e.g. schizophrenia, delusional disorder
● Mood disorders with psychotic features e.g. bipolar disorder, major depressive disorder
● Drug-induced psychosis
● Organic psychosis e.g. brain tumours, Huntington’s disease, autoimmune encephalitis
Essentially, first rank symptoms can be present in any condition with psychotic features.
Communication Tips
● Ask open questions, for example “Has anything new been happening to you?”, “Do you have any new ideas or beliefs that are really important to you?’’
● Avoid check-list style questioning (but in exams, make sure you have covered all the symptom groups)
● Use gentle, clarifying questions which normalize their experiences (“Sometimes people feel their thoughts don’t belong to them. Has this ever happened to you?”)
● Be curious and non-judgmental
● Do not dismiss their experiences, but gently challenge their beliefs to determine how ‘fixed’ they are, for example, “Have you considered any other explanations?”, “Could it have happened just by chance?”
CASC Practice Scenarios
Scenario 1: Eliciting First Rank Symptoms
Candidate Instructions
You are a psychiatry registrar assessing Ms. Leila Ahmed, a 22-year-old woman, who has been brought to the clinic by her parents. They are worried about her increasing social withdrawal and odd behaviour since she dropped out of university six months ago.
Your task is to take a focused psychiatric history with a view to eliciting any first rank symptoms of schizophrenia.
Actor Instructions
You are Leila Ahmed, a 22-year-old. You were a bright, high-achieving computer science student. A year ago, during your second year, you started to feel overwhelmed by the social and academic pressures. You decided to leave university and move back into your parents’ home, but things have only gotten worse. You present as withdrawn and tense, with a look of constant fear and suspicion in your eyes. You are deeply confused and terrified by what is happening to you.
Your psychosis began subtly with feelings of disconnection and paranoia a year ago. However, over the past three months, the symptoms have become much more pronounced and have taken over your life. It all started when you became convinced that you had stumbled upon a secret global surveillance network through your university’s computer lab. You are certain this network is called “Project Thunder.”
You have no privacy in your own mind. It feels like thoughts that are not yours are “popping in” and being placed there by agents of Project Thunder. You believe they are using a form of quantum computing to infiltrate your mind.
At the same time, your own thoughts are suddenly “snatched away” from you, leaving your mind empty and blank. This is your most terrifying symptom, as it confirms to you that they are truly in your mind. You have started wearing a winter hat that you have lined with tin foil to try and stop them interfering with your thoughts.
You hear two distinct female voices coming from just behind you, even when no one is there. They are always talking about you as if they are part of a surveillance team. They are critical and condescending. For example, one might say, “She thinks she can hide from us, but we know what she’s doing,” and the other might reply, “Target is attempting to make a cup of tea, observation confirmed.”
You often feel that your body is not your own. Last week, you suddenly felt an overwhelming urge to cry for no reason, and you were convinced that an agent of Project Thunder was “making you do it” to show you they are in control. You feel like a puppet on strings.
You see the number 44 everywhere—on bus routes, in the corners of TV screens, on license plates. A month ago, you saw the number 44 on a car as it drove past you, and you were instantly filled with an overwhelming, terrifying certainty that it was a sign. It confirmed that you are being monitored by Project Thunder and that your thoughts are no longer safe. You now interpret every appearance of the number as a direct message and a confirmation of your delusion.
You have completely stopped seeing friends. You avoid crowded places and are wary of everyone because you are convinced anyone could be an agent of Project Thunder. You even wonder if your parents are in on it.
You believe your experiences are real and that you have clear evidence to back this up. You are frightened and suspicious of the doctor, but are willing to talk if they are non-judgemental and empathetic.
If asked, you have no plans to harm yourself or others. However, the stress caused by the constant surveillance has affected your sleep and appetite. You rarely leave your room and only eat food in closed packets from the shop, as you are becoming suspicious of your parents. As a result, you have lost some weight. You have not showered for a month.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
Elicit all of the first rank symptoms and assess how fixed the beliefs are
Always assess risk in a history station, even if not directly instructed to do so, and identify risks of self-neglect in this scenario
Communication
A good candidate will:
Be empathetic, for example acknowledging and validating the stressful experiences
Start with open questions and then use a mental check-list to make sure all of the symptoms are covered within the time available
Gently assess the strength of Leila’s beliefs in a non-judgmental way.
Example phrases:
“Thank you for coming in today, Leila. I know this must be difficult. Your parents are very worried about you, and I’d like to understand what’s been going on.”
“You mentioned that when you saw the number 44 on a car, you knew Project Thunder was monitoring you. I wondered if you thought there could be other possible explanations?”
“Thank you for sharing. This all sounds very difficult and stressful for you.”
Scenario 2: Eliciting First Rank Symptoms
Candidate Instructions:
You are in A&E working for psychiatry liaison team and have been asked to assess a 28 year old male, Peter Jones, who has been brought into A&E by the police after being found wandering in traffic.
Please take a focused psychiatric history with a view to eliciting any first rank symptoms of schizophrenia.
Actor Instructions:
You are a 28 year old man called Pete who is very annoyed to have been brought to A&E. You were in the road trying to find the blue car you had seen earlier that evening as you know that it belongs to the leader of the spy ring that has been following you.
You have been struggling for the last 6 months since you went to the GP for some ear wax removal and whilst you were there they inserted a chip into your eardrum. You now hear the spy ring talking about you constantly. The spy ring is made up of 5 men who work for a foreign intelligence agency and you hear all of their voices all the time. They are particularly loud in the evenings and so you have been smoking cannabis as it makes their voices quieter for a short amount of time.
The men talk about how they are harvesting your thoughts through the microchip and that the GP is working for them and inserting microchips into other peoples’ ears as well.
You think other people can now hear your thoughts and you also think the microchip controls some of your bodily movements.
You are very paranoid about the staff in the A&E department and worry that they are working for the intelligence agency also. If the doctor is dismissive and doesn’t take your delusions seriously then you think that they are also part of the spy ring and so do not want to answer their questions.
If asked gently and empathetically about your experiences, you will be more willing to talk. However you do not believe your symptoms are due to a mental illness.
If you had found the blue car tonight you would have known it belonged to the spy ring leader and were planning on ‘messing him up’ so that he would stop interfering with your life. You didn’t have a weapon or anything with you, but had thoughts about punching him.
You don’t have a job because you accused a customers in the bar you used to work at of being part of the spy ring, and were fired. You have a home, but you have been sleeping in different places each night, such as local parks, so that the spy ring doesn’t find you.
If asked, you say you have had no previous contact with the police or any criminal record.
Feedback for Scenario 2
Knowledge & Clinical Skills
A good candidate will:
Follow the patients’ lead but maintain their own checklist in their head to ensure they ask about all of the first rank symptoms
Assess risk to self and others, including harming those perceived to be involved with the delusional world. In this case they determine the patient had some intention to physically assault a spy ring leader, but was not carrying a weapon and had no forensic history.
Communication
The candidate will:
Not rush into asking questions on the checklist and instead start with open questions
Inquire sensitively about thoughts of harm to others, followed up by more direct questions if needed.
Example phrases:
“You seem to be very distressed by something, please can you tell me some more about what is happening to you so I can try and help?”
“Have you had any thoughts about how you might stop these experiences happening to you?’’
Scenario 3: Example Video – Explaining Schizophrenia
Candidate Instructions:
You are working on an acute psychiatric ward. Mr. Jamie Lewis, an 18-year-old recently admitted with a first episode of psychosis, is currently being treated with antipsychotics. He is currently exhibiting symptoms including auditory hallucinations and paranoia. His mother is very upset and wants a clear explanation of his condition and treatment.
Please address her concerns and answer her questions.
Authors/Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
Dr Molly Beazley is a psychiatry speciality registrar in forensics, currently working in London.
References and Resources
1 Mitchell AJ. First-rank symptoms: a first-rank diagnostic test? BJPsych Advances. 2015;21(3):147-149. doi:10.1192/apt.21.3.147
2 World Health Organization (1993). ICD-10: International classification of diseases (10th revision).
3 World Health Organization (2022). ICD-11: International classification of diseases (11th revision).
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
Related Articles:
PTSD Diagnosis & History Taking: https://psychpanda.com/ptsd/
Depression History Taking: https://psychpanda.com/depression/
Understanding & Assessing Delusions: https://psychpanda.com/delusions/