Introduction to Psychotic Illnesses
Prof elham aljammas Sept 2015 Practical points‘Psychosis’ - definition Mental disorder in which the thoughts, feelings, affective response, ability to recognise reality and ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality; the characteristics of psychosis are impaired reality testing, hallucinations, delusions and illusions.Kaplan & Saddock “Comprehensive textbook of psychiatry” – 7th ed, glossary p686
Contents
Psychotic symptomsDelusional moodHallucinationsDelusionsFirst-rank symptoms“Psychotic illnesses”SchizophreniaDelusional disordersConditions involving psychotic symptomsMania / psychotic depressionDrug-induced psychosesOrganic psychosesDelirium / delirium tremens (DTs)What do I Really Have to Know?
Think ORGANIC!Oxygenation, Glucose, Electrolyte disturbance, endocrineToxicity – iatrogenic, self-inflicted, accidentalDrugs & alcoholCerebral pathologyDefine: DelusionHallucination (vs illusion)ICD-10
A diagnostic heirarchyF0- - OrganicF1- - Substance-relatedF20s - Schizophrenia… & delusional disordersF3- - Mood [affective] disorders F4- - neurotic, stress-related & somatoform dis.F5- - …physiological.. (inc eating disorders)F6- - …personality disorders…F7- - mental retardationetcmental state abnormalities in psychotic illness
PerceptionThought
Behaviour
Hallucinations
Illusions
Auditory
Tactile
Olfactory & Gustatory
Visual
Form
Content
Delusions
Overvalued Ideas
Circumstantiality
Fusion
Derailment
Word Salad
Thought Block
Pseudohallucinations
Catatonia
Delusions - definition
“a false, unshakeable idea or belief which is out of keeping with the patient’s educational, cultural and social background” – Simms* we can never understand how they arrived at the belief – defies normal logic *BUTNeed not be totally unshakeable – cognitive therapy for delusions; many patients have some insightNeed not be false (eg delusional jealousy, then discover partner actually IS unfaithful)Wrongly ARRIVED at beliefPrimary Delusion – ‘out of the blue’Secondary Delusion – arises out of… eg. hallucinationOvervalued idea
A preoccupation which can come to dominate (& ruin) a person’s lifebut you can understand where it came from and it’s sort of believable eg body image distortion in anorexia nervosa eg hypochondriacal disordereg patient fears he has a brain tumour but is briefly reassured by the latest testDelusions of… Grandeur / ability Paranoia Reference Persecution Control Infestation Love / jealousy Misidentification Nihilism
“I have a microchip in my brain which transmits my thoughts to MI5.” “I am the son of George W Bush…and a Somali woman. They were on holiday there and left me behind.” Delusions - examples
grandeur
control
persecution
reference
“They’re making a TV programme about me – I keep seeing my name in the newspaper.” “My family are poisoning my food – it tastes funny”
Persistent Delusional Disorders (F22)
Delusional disorder (F22.0) – including:Persecutory delusionsdelusional jealousy; De Clйrambault’s syndrome – “erotomania”Induced delusional disorder (folie a deux) (F24)Delusion shared by people with close emotional linksOnly one person suffers from a genuine psychotic disorderThe other person’s delusion disappears when they are separatedDelusional dysmorphophobia (F22.8)Paranoia querulans (F22.8)
Delusional percept / “primary delusion”(out of the blue) “A young Irishman was at breakfast with two fellow-lodgers. He felt a sense of unease, that something frightening was going to happen. One of the lodgers pushed the salt cellar towards him (he appreciated at the same time that this was an ordinary salt cellar and his friend's intention was innocent).Almost before the salt cellar reached him he knew he must return home, to greet the Pope, who is visiting Ireland to see his family.”From: Simms “symptoms in the mind”
‘Delusional mood’ – a feeling that something’s not right: Imagine…You’ve bumped someone’s car in a car park. There’s no damage, so you drive off quickly!Your phone rings in the middle of the night but you miss the call and the number is unknown…What emotions do you feel?What goes through your mind?Who was phoning you?The next day, you’re still thinking about it and you receive an envelope with a government crest on it…What emotions now?What goes through your mind before you open it?Supposing, in your nervous state, you read it wrong…?
How to approach: a delusional patient
Empathise (but don’t patronise)Test the intensity of the beliefbut don’t be confrontationalAsk them ‘could there be an alternative explanation?’What have they done about their belief?(do they believe you’re a real medical student?)Look up examples of how to phrase your questionsPresent State ExaminationOther delusional syndromes
Fregoli’s delusionMy persecutor takes on the form of different people…But I KNOW it’s still him!Schizophrenia / stroke = delusional misidentificationCotard syndromeNihilistic delusions, esp. in psychotic depression“I’ve got no blood / bowels / breath / money”“I’m dead / rotting from inside”Other delusional syndromes
Capgras’ delusionA 74-year old married housewife believed that her husband had been replaced by another unrelated man. She refused to sleep with the imposter, locked her bedroom at night, asked her son for a gun, and finally fought with the police when attempts were made to hospitalize her. She easily recognized other family members and would misidentify her husband only.Dementia / stroke = delusional misidentificationThis case is taken from a report by Passer and WarnockDe Clйrambault’s syndrome – “erotomania”usually in womenconvinced that a manusually older, of higher statuseg the consultantis in love with her
mental state abnormalities in psychotic illness
PerceptionThought
Behaviour
Hallucinations
Illusions
Auditory
Tactile
Olfactory & Gustatory
Visual
Form
Content
Delusions
Overvalued Ideas
Circumstantiality
Fusion
Derailment
Word Salad
Thought Block
Pseudohallucinations
Catatonia
Thought
ContentDelusions
Overvalued Ideas
of Reference
Control, Passivity
of Paranoia: Reference Persecution Grandeur
Body image Hypochondriasis Litigation Religious political
Schizophrenia?
Myths & Misconceptions‘Schizophrenia’ does literally mean ‘separated mind’Greek – applied by Bleuler in 1911BUT is nothing to do with ‘split personality’…let alone ‘multiple personality’ (very rare)HAS to do with the brain’s functions separatingeg. You hear a voice but don’t recognise it’s come from your own mind
Definition of Schizophrenia
a “severe and enduring mental illness”A clinical syndrome “a collection of features which tend to occur together”Refined over last 200 years or soRecognised pattern of outcomeSame methods of treatment Biological basis; severe psychosocial consequencesNo definitive cause or mechanism yet identified (multifactorial – see PBL lecture)Neurochemical imbalance‘reality testing’ and ‘theory of mind’ defective+ loss of ‘ego boundaries’ – (what is Me and what is Outside)BUT there is still no single concise definition!
Heritable Risk
Age of Onset – Bimodal Distribution1st Rank symptoms
1950’s - Schneider’s 1st Rank Symptoms:Primary Delusion = ‘delusional percept’Own thoughts spoken aloud = ‘thought echo’Voices arguing or discussingrunning commentary voicesthought withdrawal and/or thought blockThought insertionthought broadcasting (others are thinking it at the same time as you)Made to feel… ‘passivity of affect’Made to want… ‘passivity of impulse’Made to do… ‘passivity of volition’Done to my body ‘somatic passivity’ eg probed by aliensSome may occur in illnesses other than schizophrenia eg maniaIllusion
Incorrect perception of a real stimulus (in any modality)Usually non-pathologicalBush looks like a killer in the dark“cocktail party” illusion: hearing your name across a noisy roomA stray hair may feel like a spider on the neckBUT illusions occur in psychosiseg girl complains her face is melting when she looks in mirrorPaintings by artist with worsening psychosis – perceptual disturbances
HallucinationA perception, which feels real, but has no real stimulus usually abnormal, especially when persistent But occasional hallucinations are more common than we thought! - 10% of British population, at some time Modalities: Auditory heard as if coming from outwith your head (including from another part of the body) cf pseudohallucinations Visual (more indicative of organic pathology!) Somatic / Hygric (visceral) / Sexual Gustatory Olfactory
Hallucinations 2
Non-pathological: Hypnagogic (going off to sleep) Hypnopompic (waking up)When it’s NOT a hallucination Illusion = misperception of a REAL stimulus Daydream = imagery Pseudohallucination Occurs in inner subjective space eg voices INSIDE your head May have quality of your own thoughts Distressed patients not interested in this distinction!
Ideas of reference
On a spectrumI think people on the bus are looking at me=> =>The news is about my life! It means I’m a paedophile. Don’t you believe me?Audible Thoughts
= Gedankenlautwerden, echo de pensees The patient may hear people repeating his thoughts out loud just after he has thought them, answering his thoughts, saying aloud what he is about to think so that his thoughts repeat the voices. He often becomes very upset ill the gross intrusion into his privacy and concerned that he cannot maintain con control of any part of himself, not even his thoughts.Audible Thoughts
A 35 year old painter heard a quiet voice with `an Oxford accent', which he attributed to the BBC. The volume was slightly lower than that of normal conversation and could be heard equally well with either ear. He could locate its source at the right mastoid process. The voice would say, `I can't stand that man, the way he holds his hand he looks like a poof' . . . He immediately experienced whatever the voice was saying as his own thoughts, to the exclusion of all other thoughts. When he read the newspaper the voice would speak aloud whatever his eyes fell on. He had not time to think of what he was reading before it was uttered aloud. Simmsvoices arguing
A 24 year old male patient reported hearing voices coming from the nurse's ofice. The voice, deep in pitch and roughly spoken, repeatedly said, ‘He is a bloody paradox', and another, higher in pitch, said, 'He is that, he should be locked up'. A female voice occasionally interrupted, saying `He is not - he is a lovely man'.voices giving a Running Commentary
…just before, during or after the patient's activities. A housewife heard a voice coming from the house across the road.... The voice went on incessantly in a flat monotone describing everything she was doing, with an admixture of critical comments. `She is peeling potatoes, got hold of the peeler, she does not want that potato, she is putting it back, because she thinks it has a knobble like a penis, she has a dirty mind, she is peeling potatoes, now she is washing them'Passivity experiences
'I am thinking about my mother, and suddenly my thoughts are sucked out of my mind by a phrenological vacuum extractor, and there is nothing in my mind, it is empty.Thought Insertion
‘I look out of the window and I think the garden looks nice and the grass looks cool, but the thoughts of Chris Evans come into my mind. There are no other thoughts there, only his.... He treats my mind like a screen and flashes his thoughts onto it like you flash a picture.’
Thought Broadcasting
Def: whenever your thoughts are accessible to others, eg telepathy, your thoughts on TVA 21 year old student said, “As I think, my thoughts leave my head on a type of mental ticker-tape. Everyone around has only to pass the tape through their mind and they know my thoughts.”Passivity of emotion
A 23 year old female patient reported, `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 onto my brain. They project upon me laughter, for no reason, and you have no idea how terrible it is to laugh and look happy and know it is not your, but their reaction.'Passivity of Impulse
A Jewish woman suffering from schizophrenia said `I feel my hand going up to salute, and my lips saying "Heil Hitler" ... I don't actually say it ... I have to try very hard to stop my arm from going up ... they put drugs in my food; that is what makes it happen.' A 26 year old engineer emptied the contents of a urine bottle over the ward dinner trolley. He said, `The sudden impulse came over me and I must do it. It was not my feeling, it came into me from the X-ray department, that was why I was sent there for implants yesterday. It was nothing to do with me, they wanted it done. So I picked up the bottle and poured it in. It seemed all I could do.'Somatic Passivity
the belief that outside influences are playing on the body A 38 year old man had jumped from a bedroom window, injuring his right knee which was very painful. 'The sun-rays are directed by U.S. army satellites in an intense beam which I can feel entering the centre of my knee and then radiating outwards causing the pain.'Artist with Sz – delusion of being electronically controlled?
mental state abnormalities in psychotic illnessPerception
Thought
Behaviour
Hallucinations
Illusions
Auditory
Tactile
Olfactory & Gustatory
Visual
Form
Content
Delusions
Overvalued Ideas
Circumstantiality
Fusion
Derailment
Word Salad
Thought Block
Pseudohallucinations
Catatonia