What are the First Rank Symptoms of Schizophrenia?
Jul 17, 2023, 8 min read
Schizophrenia is a mental health condition that is often misunderstood, and — without the right support — difficult to live with.
Here, we are taking an in-depth look at schizophrenia to break down what it is, how the different symptoms are graded, first rank symptoms of schizophrenia you may need to know about, how it is diagnosed and treated, and what to do if you have concerns for yourself or a loved one.
At Augmentive, we aim to provide holistic, tailored mental health support to everyone so they can live their life to the fullest, so if you have any questions about schizophrenia, we’re here to help.
What is schizophrenia?
Schizophrenia looks different for everyone, but generally it can cause psychosis (some level of becoming disconnected with reality) and affect all areas of a person’s life, from their personal family life, to their education, to their job.
According to the World Health Organization, schizophrenia affects around 24 million people around the world, which is about 1 in 300 people (0.32%). Stigma against people with schizophrenia is still prevalent, which can cause them to experience social exclusion and discrimination. As a result, more than 2 in 3 people with psychosis don’t receive any specialist mental health care, despite there being many effective care options available.
Although it is not an easy condition to manage whether you have the support of family and friends or not, the right treatment and advice from professionals can make living with schizophrenia much more manageable.
What are the common symptoms of schizophrenia?
Schizophrenia, like most mental health conditions, tends to have a unique set of symptoms for each person, so it can be difficult to diagnose. Symptoms commonly fall into one of three main categories; psychotic symptoms, negative symptoms, and cognitive symptoms.
These are typically changes to the person’s thoughts, actions and how they experience the world around them. Schizophrenia can cause people to lose touch with reality, so they are not experiencing the same world as the people around them, either occasionally or constantly, and they may experience:
- Hallucinations where they see, hear, smell, taste or feel things that aren’t there (hearing voices can be a common symptom in schizophrenia).
- Delusions where they start to develop an unshakeable belief in something others know to be irrational or untrue, for example, that someone is trying to hurt them.
- Thought disorders that make their communication unusual or illogical, for example, stopping mid-sentence to discuss a new topic, or making up nonsense words.
- Movement disorders where they exhibit unusual body movements, like repetitive actions.
“I have bizarre delusions which include psychic battles in which people around me can be perceived as either 'good' or 'evil'. Sometimes I am in a different time zone or move between periods of history in different lives.” - anonymous, via Mind.org.uk
Negative symptoms for people with schizophrenia are often mistaken for symptoms of depression, and might include:
- A loss of interest in activities they once found enjoyable
- Withdrawal from their social life, or interacting in socially awkward ways
- A flat affect when exhibiting emotions, possibly with limited facial expressions
- Difficulty making plans and sticking to them, such as weekly appointments
- Difficulty feeling pleasure in everyday life
- A dull, monotone voice
- Low energy (and in rare cases, ‘catatonia’, where they stop moving or speaking altogether)
People with schizophrenia can develop cognitive issues that make remembering things, communication, interaction and learning difficult. Some cognitive symptoms might include:
- Difficulty processing information
- Difficulty making decisions
- Difficulty retaining and using information
- Difficulty focusing or paying attention
What is ‘emotional overload’?
Emotional overload is a symptom of schizophrenia that leads to a lack of outwardly expressive positive or negative emotions. People with schizophrenia do report feeling emotions in the same way as others do, however studies have found that they tend to display less positive and negative facial expressions than people without schizophrenia when shown emotionally evocative film clips, eating food, or engaging in social interactions.
This is referred to as a ‘flat affect’, and it is indicated through reduced or absent facial expressions, a monotone voice, and a lack of understanding when it comes to others’ emotions.
How are schizophrenia symptoms graded?
The symptoms of schizophrenia are often graded in order to determine the severity of an individual’s condition. Although this severity rating is not required for a diagnosis to be made, it can be helpful when understanding what the person is going through, and assessing the necessary treatment.
Severity of symptoms are based on some of the aforementioned psychosis symptoms; delusions, hallucinations, disorganised speech, abnormal psychomotor behaviour, and negative symptoms. These are rated according to their severity in the last 7 days, on a 5-point scale which ranges between 0 (not present) to 4 (present and severe), and from this, a specialist can determine the intensity of a person’s schizophrenia diagnosis.
What are first rank symptoms of schizophrenia?
First rank symptoms refer to the schizophrenia symptoms other than the ‘negative symptoms’ (i.e. loss of interest in activities, withdrawal from social life, and so on) as these can also be attributed to other mental health conditions such as depression.
The DSM criteria for schizophrenia specifies two or more symptoms present for a significant amount of time in a one month period, and first rank symptoms include:
- Auditory hallucinations: hearing thoughts spoken aloud, hearing voices referring to themselves in the third person, or commentary.
- Thought withdrawal, insertion and interruption: thoughts appear out of their control, and can be ‘taken’ from their mind, inserted, or interrupted by an outside force.
- Thought broadcasting: the person believes everyone can hear their thoughts in the same way they can.
- Somatic hallucinations: the person has a physical experience with their body that is not reality, for example, a lump in their throat that isn’t really there.
- Delusional perception: A real-life perception that the person gives false meaning to, for example, traffic lights turning red symbolising something bad is about to happen.
- Feelings or actions experienced as made or influenced by external agents: Certainty that an action/feeling is being caused by an outside force rather than themselves.
According to German psychiatrist Kurt Schneider, who developed Schneider's First Rank Symptoms (FRS) in 1959, the incidence of even just one first rank symptom can be a key indicator of schizophrenia and could be sufficient enough for a diagnosis.
How is schizophrenia diagnosed and addressed?
Diagnosis for schizophrenia typically happens between the ages of 16 and 30, and this tends to happen after an initial episode of psychosis.
Although epidemiology, genetics and neuroimaging have all advanced in recent years and are sometimes involved in the diagnostic process, psychiatrists still rely on medical history and physical examination to diagnose schizophrenia, and often after other possible conditions have been ruled out.
Diagnosis is based on the stability of first rank psychosis symptoms and their deterioration. Professionals may determine if a patient has one of the 5 schizophrenia subtypes — paranoid, disorganised, catatonic, undifferentiated and residual — but often this does not predict the best treatment.
Treatment for schizophrenia does not cure the condition, but can help individuals manage their symptoms long-term and improve daily functioning so they can pursue goals and develop fulfilling relationships. Treatment options may include a combination of:
- Antipsychotic medications: These can help to lessen the intensity and frequency of psychotic symptoms. There are a number of options for this, including daily pills, regular injections, or other medications requiring regular blood tests to manage potentially harmful side effects.
- Psychosocial treatments: These might include cognitive behavioural therapy (CBT), behavioural skills training, supported employment and more, and these can help people manage day-to-day symptoms and work through everyday challenges so they can continue education, pursue a career, and form relationships. Research has found people who engage in regular psychosocial treatments are less likely to be hospitalised or have symptoms reoccur.
- Coordinated specialty care: Coordinated specialty care (CSC) programs focus on recovery and are designed for people with first episode psychosis, an early stage of schizophrenia. Often multiple specialists will work together, involving the family, to provide CSC including psychotherapy, medication, case management, employment and education support. CSC has been found to be more effective at reducing symptoms, improving quality of life, and helping people stay in school or work.
- Assertive community treatment (ACT): This treatment is specifically created for people likely to be hospitalised or become homeless, and involves a team of medical professionals working together to provide the necessary care.
- Treatment for drug and alcohol misuse: Drug/alcohol issues are unfortunately a common problem for people with schizophrenia, so the right programs that combine treatment for both substance abuse and schizophrenia can help with recovery.
If you have a loved one with schizophrenia, there may also be support available to learn about symptoms, the treatment process, and the best ways to help someone with the condition. This support can help family and friends to manage their emotions around a diagnosis, and cope with the everyday reality of having a loved one with schizophrenia.
Why many people with schizophrenia engage in self-harm
Unfortunately, many people with schizophrenia may have a desire to engage in self-harm practices as a way of "helping" them manage their feelings and symptoms. According to studies, the risk of reported self-harm for people with schizophrenia is 22.59%, and of this, 10% had attempted suicide at least once. Another meta-analysis of studies found a pooled lifetime prevalence of self-harm in people with schizophrenia was 31%, so it’s difficult to know the exact number who engage in this.
One theory for the commonality of this is due to the flat affect mentioned above. By engaging in self-harm, people with schizophrenia may mistakenly feel this helps with affect-regulation, suggesting self-injury can alleviate acute negative affect. One research paper mentioned a patient who described becoming suicidal after long periods of time without self harming, and as a result, believing self-harm prevented her suicidal ideation — of course, this is not the case, and self-harm does not offer a long-term management strategy.
To read more about self-harm and what to do if you engage in this yourself, you can read our article; Let's Talk About Self-Harm Scars
What to do if you have concerns about yourself or a loved one
When someone starts acting unlike themselves, it can be difficult to convince them seeking help is the best way for them to start feeling better. If you have a loved one who is displaying symptoms of schizophrenia, encourage them to seek advice from their GP who can either rule out the condition and get to the bottom of their symptoms, or start the diagnosis process by connecting them with the best services for people with schizophrenia.
If you already have a diagnosis of schizophrenia and are struggling to cope, you can also reach out to private services who may be able to provide medication and therapy options to help. At Augmentive, our free 15 minute consultation can pair you with the professional who is best placed to help you work through the issues you are facing, so whether you believe you need additional advice on schizophrenia symptoms, or managing the stress of supporting a loved one with the condition, we may be able to help.
Whether you’re feeling off-kilter or want to shake up your routine, our the state-of-the-art mental wellbeing platform gives you quick and seamless access to world-class support on your terms, from psychiatric assessments and reviews to broader mental health care: join us today.