Second edition

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148 Other signs and symptoms
Table 4.9 Causes of Schneiderian first rank symptoms
Schizophrenia (Tandon and Greden 1987)
Schizoaffective disorder (Koehler and Seminario 1979)
Mania (Gonzales-Pinto et al. 2003; Jampala et al. 1989)
Depression (Tandon and Greden 1987)
Substance or medication-related
Intoxications
Amphetamines (Angrist and Gershon 1970; Bell 1973;
Janowsky and Risch 197)
Cocaine (Harris and Batki 2000; Rosse et al. 1994)
Phencyclidine (Rosse et al. 1994)
Alcohol hallucinosis (Marneros 1988)
Benzodiazepine withdrawal (Roberts and Vass 1986)
Fluvoxamine (Ueda et al. 2003)
Epileptic conditions
Simple partial seizures (Mesulam 1981)
Chronic interictal psychosis (Kido and Yamaguchi 1989;
Slater and Beard 1963)
Miscellaneous causes
Cushing’s syndrome (Trethowan and Cobb 1952)
New-variant Creutzfeldt–Jakob disease (Zeidler et al. 1997)
Subacute sclerosing panencephalitis (Duncalf et al. 1989)
Fahr’s syndrome (Cummings et al. 1983)
Metrizamide myelography (Davis et al. 1986)
is suggested by typical manic symptoms seen in stage I,
such as pressured speech, hyperactivity, increased energy,
decreased need for sleep, etc. Depression, as seen in major
depressive disorder, is only rarely associated with first rank
symptoms, and hence the appearance of such a symptom
in a depressed patient should make one pause before giving
a diagnosis of major depression; in such cases a diagnosis
of schizoaffective disorder may be more likely.
The other causes noted in Table 4.9, although rare, must
be kept in mind. Of these, intoxications with amphetamines,
cocaine, or phencyclidine are perhaps most common.
Chronic, severe, alcoholism may be associated with
alcohol hallucinosis, which may be characterized by first
rank symptoms, and there are case reports of these symptoms
occurring during benzodiazepine withdrawal and as
a side-effect to fluvoxamine.
Epileptic conditions associated with first-rank symptoms
include simple partial seizures and the chronic interictal
psychosis. In one case of a simple partial seizure, the
patient, during the ictus, had ‘blurry vision, abdominal
discomfort, sensation of imminent death, intense fear, and
the conviction that his body (was) controlled by external
forces’ (Mesulam 1981). The chronic interictal psychosis,
discussed further in Section 7.1, is seen only in patients
with chronic, severe, uncontrolled epilepsy: one of Slater
and Beard’s (1963) patients believed that there was a ‘pickup’
device in his body ‘which transmitted thoughts from
the brain, and also made the brain receive’.
The remaining miscellaneous causes listed in Table 4.9
only very rarely cause first rank symptoms.
Treatment
Treatment is directed at the underlying condition.
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