Kurt Schneider(4) identified a set of phenomena that he considered were strongly indicative of schizophrenia in the absence of overt brain disease. These symptoms, listed in Table..!, have become known as first-rank symptoms. Schneider did not consider that the diagnosis could be made simply on the presence of one such symptom; on the contrary, he warned(4), 'a psychotic phenomenon is not like a defective stone in an otherwise perfect mosaic'. Schneider did not define the phenomena precisely, and clinicians have interpreted his writings differently. Mellor (7) formulated a precise set of definitions and found that, according to these strict criteria, 72 per cent of patients with schizophrenia exhibited at least one first-rank symptom. Applying the same criteria, O'Grady (8) found that in a series of cases assessed at admission to hospital, 73 per cent of schizophrenic patients exhibited at least one first-rank symptom, while no cases of affective psychosis did. However, applying less strict criteria, O'Grady found more broadly defined first-rank symptoms in 14 per cent of patients with affective psychosis.
Table 1 Schneiderian first-rank symptoms
Three of the first-rank symptoms (voices commenting, voices discussing, and audible thoughts) involve auditory hallucinations, while the remainder entail delusional attributions to experiences or perceptions. Although Schneider himself avoided speculating on the theoretical implications of these phenomena, it is notable that most of them involve a disorder of the sense of ownership of one's own mental or physical activity. Thought broadcast, thought withdrawal, and thought insertion reflect the experience of loss of autonomy over thought, while made will, made acts, made affect, and somatic passivity reflect loss of autonomy over action, will, affect, and bodily function.
Mellor(7) emphasizes that there are two aspects to these phenomena: the experience of loss of autonomy and the delusional attribution to alien influence. As an illustration of made acts, Mellor reports a patient who reported that his fingers moved to pick up objects 'but I don't control them ... I sit there watching them move, and they are quite independent, what they do is nothing to do with me. I am just a puppet ... I am just a puppet who is manipulated by cosmic strings'. To illustrate made affect, Mellor quotes a young woman: 'I cry, tears roll down my cheeks and I look unhappy, but inside I have a cold anger because they are using me in this way, and it is not me who is unhappy, but they are projecting unhappiness into my brain.'
Delusional perception, in which an entirely unwarranted conclusion is drawn from a normal perception, illustrates the incongruity between a delusional idea and concurrent mental activity, which is characteristic of schizophrenia. However, the way in which delusional perceptions often crystallize from a delusional mood indicates that it is not merely a matter of illogical inference; the delusional idea is more like a divine revelation. Mellor (7) gives the example of an Irishman who experienced a sense of foreboding while seated at the breakfast table in a lodging house. When another lodger innocently pushed the salt cellar towards him, he suddenly knew this meant that he must return home to greet the Pope who was visiting his family to thank them because Our Lord was to be born again to one of the women.
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