Schneider's first rank symptoms \(1\)

Schizophrenia 

Dr. Edwin CS Yu 

Consultant Psychogeriatrician 

Kwai Chung Hospital 

18 th July, 2004 

Hong Kong Doctors Union

Epidemiology 

• Incidence : 15-30 new cases per 100,000 

population per year 

• Lifetime risk : 1% 

• Age of onset : usually 15-45 y.o., earlier in 

men than in women 

• Higher incidence in those not married 

• More common in social classes IV and V 

• Urban higher than rural

Aetiology (1) 

Genetics: 

Relationship 

Lifetime expectancy rate 

Parents 6 % 

All siblings 10 % 

Siblings (when 1 parent has schiz) 17 % 

Children 13 % 

Children (when both parents have schiz) 46 % 

Grandchildren 4 % 

Uncles, aunts, nephews and nieces 3 %

Aetiology (2) 

Prenatal factors: 

• Winter births 

• Prenatal infection 

• Minor physical abnormalities e.g. low-set ears, 

greater distance between eyes, single transverse 

palmar crease 

• Obstetric complications

Aetiology (3) 

Personality: 

• Schizotypal personality disorder 

• Eccentricity 

• Affect constriction 

• Excessive social anxiety

Aetiology (4) 

Social factors: 

• Life events in the 3 weeks before relapse 

• Families with high expressed emotions (critical 

comments, over-involvement) 

• Poverty of the social milieu

Clinical picture

Schneider’s first rank symptoms 

(1) 

• Voices commenting 

• Voices arguing or discussing 

• Audible thoughts 

• Thought broadcast 

• Thought withdrawal 

• Thought insertion


(2) 

• Made will 

• Made acts 

• Made affect 

• Somatic passivity 

• Delusional perception


(3) 

• Not unique to schizophrenia 

• 10-15% of manic-depressive psychosis 

• Also in organic brain conditions

Hallucinations 

Auditory hallucinations: 

• Voices usually harsh, critical or frightening 

• Mood incongruent 

• Behavior: Whispering or looking around 

Olfactory hallucinations 

Somatic hallucinations 

Visual hallucinations

Delusions (1) 

• Primary delusions: defy logic, arise 

suddenly and without any foundation 

• Delusions of alien control of thought, 

action, will, affect and somatic function 

• Delusional mood 

• Delusional memories

Delusions (2) 

• Delusion of persecution 

• Delusion of reference 

• Grandiose delusions 

• Nihilistic delusions 

• Delusional system

Disorders of thought 

Unstable goal 

• Tangentiality 

• Distractability 

• Perseveration 

Idiosyncratic thought and language 

Weakening of goal 

• Empty speech 

• Generalisation 

Disorders of flow 

• Poverty of speech 

• Pressure of speech 

• Blocking

Disorders of affect 

• Blunted affect 

• Incongruous affect 

• Depression 

• Prodromal phase 

• Acute phase 

• Chronic phase: 15-25% 

• Anhedonia

Positive symptoms 

•Acute 

•Delusions 

• Hallucinations 

• Formal thought disorder

Negative symptoms 

• Chronic 

• Poverty of speech 

• Blunted affect 

• Poor volition 

• Decreased spontaneous movements

Course and prognosis

Onset 

• Variable modes of onset 

• Insidious: 

• Abrupt: 

• subtle abnormalities in childhood or adolescence 

• often follows a stressful experience 

• Prodromal phase: 

• subtle alteration of behavior, preoccupation, social 

withdrawal

Age of onset 

• Male: 

• Female: 

• Rises rapidly through adolescence to a peak at 22, 

followed by a steady decrease so that onset after 40 

is rare 

• Rises through adolescence, but the peak is later, 

distribution is broader, and an appreciable risk 

persists into middle age

Good prognostic factors 

• Evidence of schizoaffective features 

• Marked mood disturbance at onset 

• Family history of affective illness 

• Outcome is better in females than in males 

• Outcome is better in less developed 

countries

Poor prognostic factors 

• Poor premorbid adjustment 

• Insidious onset 

• Onset in adolescence 

• Marked cognitive impairment 

• Enlargement of cerebral ventricles

Long-term outcome 

• Tendency to resolve eventually in many 

cases, though the time-scale of 

improvement can be several decades 

• In patients who have not yet recovered after 

several decades, acute exacerbations are 

less common than in earlier years. A large 

number exhibit a defect state

10% commit suicide 

• More likely if: 

• Early in illness 

• Males 

• Younger 

• Chronic illness, relapse and remissions 

• Unemployed 

• High educational attainment prior to onset 

• Akathisia 

• Abrupt stoppage of drugs 

• Recent discharge from in-patient care 

• Paranoid 3x more likely than non-paranoid

Post-schizophrenic depression (1) 

• Majority of schizophrenia patients are likely 

to experience depressive features at some 

point 

• Directly related to the illness rather than 

pharmacogenic 

• 25% suffers post-schizophrenic depression, 

may be the major reason for readmission

Post-schizophrenic depression (2) 

• Studies demonstrated the benefits of 

tricyclic antidepressants 

• Value of new antidepressants await 

clarification 

• May be a result of demoralisation and 

hopelessness from appreciation of the 

nature of the illness and its consequences

Drug treatment of schizophrenia 

Neuroleptics = Antipsychotics 

Typical vs Atypical 

Oral vs Depot

Drug treatment 

• Positive symptoms respond better than 

negative symptoms 

• 5-25% of schizophrenics unresponsive to 

conventional neuroleptics 

• 5-10% intolerant because of neurological 

side effects 

• 40-60% non-compliant

Drug treatment 

• Continuous therapy is superior to 

intermittent treatment 

• Of the patients who stop medication, 60- 

70% relapse within 1 year, and 85% within 

2 years, compared to 10-30% of those who 

continue on active medication

Typical antipsychotics 

• Haldol (haloperidol) 

• Largactil (chlorpromazine) 

• Melleril (thioridazine) 

• Stelazine (trifluoperazine) 

• Orap (pimozide) 

• Fluanxol (flupentixol) 

• Neulactil (pericyazine) 

• Moban (molindone)

Typical antipsychotics 

• Choose the antipsychotic according to the 

side effect profile 

•Examples: 

• For more sedative effects, choose Largactil, 

Melleril, or Neulactil 

• If patient has cardiovascular diseases, avoid 

Largactil, Melleril and Orap 

• For high potency drugs, choose Haldol, Stelazine, or 

Orap; but beware of extrapyrimidal S/E

Atypical antipsychotics 

• Clozaril (clozapine) 

• Dogmatil (sulpiride) 

• Risperdal (risperidone) 

• Zyprexa (olanzapine) 

• Seroquel (quetiapine) 

• Zeldox (ziprasodone) 

• Solian (amisulpiride)


• Most of them are the new generation 

antipsychotics, with more favorable side 

effect profile compared with the typical 

antipsychotics 

• Exceptions are clozapine and sulpiride, 

which are from the old generation but with 

a different side effect profile


• More favourable side effect profile: 

• Less extrapyramidal side effects (EPS) 

• Less tardive dyskinesia (TD) 

• Less anticholinergic side effects 

• Less sedation 

• Less postural hypotension and less cardiotoxicity

Clozapine 

• Clozapine is a unique drug as it is the drug of 

choice for resistant schizophrenia 

• Side effect of agranulocytosis (incidence of 0.8% 

at 12 months, with a peak risk in the 3 rd month) 

• WCC monitoring mandatory: weekly for the first 

18 weeks then Q4weeks 

• Sedation and antimuscarinic side effects 

• Less EPS

Oral vs Depot 

• Oral: 

•Depot: 

• First-pass metabolism 

• Variable bioavailability 

• Solves the problem of drug compliance 

• No first-pass effect 

• Decrease relapse rate 

• Once every 4 weeks (2 weeks for Risperdal Consta)

Depot antipsychotics 

• Modecate depot (fluphenazine decanoate) 

• Clopixol depot (zuclopenthixol decanoate) 

• Fluanxol depot (flupentixol decanoate) 

• Haldol depot (haloperidol decanoas) 

• Risperdal Consta

Oral liquid preparations 

• Haldol drops 

• Risperdal drops 

• Useful for elderly patients with swallowing 

difficulties

As general practitioners, it is 

important to recognize the side 

effects of antipsychotics and refer 

back to psychiatrist accordingly.

Non-neurological S/E (1) 

Adverse 

Reaction 

Frequency 

Comment 

General 

Sedation 

“Torpor” (Ataraxy) 

Dry mouth 

++ 

+++ 

+ 

Esp. with low potency drugs 

Blurred vision 

Constipation 

Urinary difficulties 

Impaired sexual 

function 

Weight gain 

+ 

+ 

+ 

+ 

+++ 

Conventionally viewed as 

peripheral anticholinergic effects. 

Some probably include adrenergic 

actions 

May have endocrine component 

Cardiovascular 

Incr. Heart rate 

Hypotension 

+++ 

++ 

Not clinically significant 

Can be fatal – caution with early 

exposure to low potency drugs 

ECG changes 

++ 

Quinidine-like effect : rarely 

causes ventricular 

tachyarrhythmias particularly with 

thioridazine


Adverse 

Reaction 

Frequency 

Comment 

Endocrine 

Hyperprolactinaemia 

+++ 

Universal effect 

(except clozapine) 

- Galactorrhoea 

- Hyper/hypoglycaemia 

Gynaecomastia 

Hyper/hypoglycaemia 

Inappropriate ADH 

Rare 

+ 

Rare 

Rare 

Rare 

Rarely clinically significant 

Hepatic 

Function 

Impaired liver 

++ 

Transient changes common. Jaundice 

esp. with chlorpromazine 

Dermatologic 

al 

Skin rashes 

-Erythematous 

-Urticarial 

-Contact 

Photosensitivity 

Pigmentation 

++ 

++ 

Rare 

Rare 

++ 

? Rare 

Especially with chlorpromazine 

Can result in serious burning. Temp. 

less important than brightness 

Infrequently reported nowadays


Adverse 

Reaction 

Frequency 

Comment 

Haemato 

logical 

Neutropenia 

Agranulocytosis 

Rare 

Rare 

But note – with clozapine :reversible 

Neutropenia (~2%) Can progress to 

agranulocytosis if drug maintained 

Thrombocytopenia 

Haemolytic 

anaemia 

V. Rare 

V. Rare 

Ophthalmic 

Lenticular deposits 

Pigmentary 

retinopathy 

Rare 

Reversible with early detection 

High dose, long-term thioridazine 

only

Acute dystonia (1) 

Presentation 

Affect 

Neck 

Tongue 

Jaw 

Retrocollis 

Torticollis 

Laterocollis 

Anterocollis 

Rotation 

Protrusion 

Retraction 

Forced opening 

Lateral deviation 

Trismus

Acute dystonia (2) 

Presentation 

Extraocular 

Trunk 

Limbs 

Upward (+- lateral) deviation 

Scoliosis 

Opisthotonos 

Affect 

Full range of dystonic postures 

-Hyperpronation of arms 

-Wrist flexion 

-Metacarpal-phalangeal flexion/extension 

-Extension of lower limbs 

-Adductor spasm 

-Plantarflexion-inversion 

-Dorsiflexion-eversion

Parkinsonism (1) 

Feature 

Posture : Flexion 

Hypomimia 

Sialorrhoea 

Seborrhoea 

Loss of background 

body movement 

Loss of pendular arm 

swing 

Tremor : resting 

: action / postural 

In drug related disorder slight hyper-extension of 

spine more common 

“Masked” expression / loss of facial contours 

May be failure to swallow rather than excessive 

production – drooling 

Decreased gesture and interactive postural 

movements 

Early, sensitive sign 

Comment 

~ 6 Hz relatively uncommon, late sign 

~ 15-20 Hz common, early sign

Parkinsonism (2) 

Rigidity 

Instability 

Feature 

Loss of dexterity 

Micrographia 

Impairment of speech 

Impaired initiation of 

voluntary activity 

Disturbance of gait 

Rarely marked 

Comment 

May impair independent living/self-care. 

Caution with driving/operating machinery 

Reduction in vertical and horizontal size 

Loss of pitch and power 

-soft monotonous speech 

-inarticulate 

Reduced length and height of step 

- shuffling/festination

Akathisia 

Feature 

Anxious, tense expression 

Restlessness on sitting 

Inability to sit 

Inability to stand still 

Comment 

Hands fidgety 

“Sitting up” repeatedly 

Side to side movement 

Rocking – backwards/forwards 

Swinging legs 

Crossing / uncrossing legs 

Standing (e.g. in mid-sentence) 

Shifting weight from foot to foot 

Pacing (with “driven” quality)

Tardive Dyskinesia (1) 

Presentation 

Tongue 

Lips 

Effect 

No displacement 

“Vermicular” movements 

Twisting : horizontal/longitudinal axis 

Displacement 

Sweeping buccal surface : “bon bon” sign 

Irregular jerky protrusion : “Fly catcher” sign 

“Tromboning” on voluntary protrusion 

Puckering 

Pouting 

Puffing 

Smacking 

Lateral retraction : “bridling”


Presentation 

Jaw 

Facial expression 

Neck 

Truck 

Effect 

Mouth opening 

Clenching (“Trismus”) 

Grinding (“Bruxism”) 

Forward/lateral protrusion 

Tics 

Grimacing 

Blepharoclonus 

Blepharospasm 

Irregular eyebrow elevation 

Frowning 

Torti-/Retro-/Latero-/Antero-Collis 

(Kinetic (spasmodic) or static) 

Unilateral dystonia : “Pisa syndrome” 

Hyperextension of spine (bilateral dystonia) 

Axial hyperkinesis : “copulatory” movements


Presentation 

Upper limbs 

Oropharynx 

Diaphragm/ 

intercostals 

“Restless” legs 

Squirming : “outsplaying” of toes 

Ankle rotation 

Eversion/inversion 

Stamping 

Dysphagia 

Effect 

Irregular respiration/grunting

Schneider's first rank symptoms \(1\)

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?