Delusional Content Research Articles

Somatic Delusion or Recurrent Pulmonary Embolism? A Case Report

To the Editor: Somatic delusions are common, often subtle, mood-congruent manifestations of major depressive disorder with psychotic features.1 This is a presentation and discussion of a patient with somatic delusions of chest pain that presented a challenge in differentiating thromboembolus from delusion. Case report. Mr A, a 32-year-old recently unemployed and homeless man with a history of cocaine dependence and major depressive disorder, was transferred from the internal medicine ward (where he was treated for pulmonary embolism [PE] for 1 week) to a dual diagnosis inpatient unit in December 2008 for evaluation and management of depressed mood, suicidal ideation, neurovegetative symptoms, and cocaine dependence. On our initial evaluation, the patient reported a 6-week history of progressively depressed mood, suicidal ideation, sleep disturbances, weight loss, and guilt. He also reported 10 years of daily cocaine use, but denied use during the month prior to admission. He displayed paranoia and obsessive thoughts, but showed neither perceptual disturbances nor delusions. We continued anticoagulant dosing: subcutaneous enoxaparin 90 mg every 12 h was administered until the international normalized ratio (INR) was at goal 2.0–3.0; warfarin 5 mg po qhs was administered and continued to maintain therapeutic INR. On hospital day 2, the patient reported chest pain. The vital signs and physical exam were unremarkable. Electrocardiography and laboratory evaluation revealed no abnormalities. The suspicion of pulmonary embolism was low. Further evaluation revealed paranoia, impaired reality testing, and affective blunting consistent with the psychotic features of a major depressive episode (DSM-IV-TR criteria). We initiated aripiprazole (45 mg daily) and citalopram (20 mg daily) therapy. He continued reporting chest pain and displayed the other psychotic signs and symptoms for the next 6–7 days. By hospital day 10, he reported no chest pain, showed no paranoia, displayed more appropriate affect, and reported improved mood. The patient agreed that recurrent PE was unlikely in a well-appearing, therapeutically anticoagulated individual. We discharged the patient on hospital day 14 to an inpatient rehabilitation program. Medical illness is common in patients with psychiatric disease, particularly in patients with co-occurring substance use disorders.2 Psychiatrists often evaluate symptoms and complaints in the setting of acute psychosis, which may complicate the diagnostic assessment. Bunce et al3 showed that most psychiatric inpatients are unable to communicate their physical symptoms adequately with physicians. The recent diagnosis of PE in this patient increased his likelihood of redeveloping thromboembolus; however, evaluation showed a low likelihood of PE. We reconsidered the new onset chest pain complaint in the setting of worsening paranoia, blunted affect, and impaired reality testing. The clinical data and scenario were consistent with a somatic delusion of chest pain. It is important to consider the extent to which his recent PE influenced the chest pain delusion. Somatic delusions may be related to gross misperceptions of bodily functioning4; this patient's recent experience with chest pain possibly influenced the delusional content. Finally, whether the dysfunctional hypothalamic pituitary axis in psychotic depression1 was further influenced (and worsened) by the acute stress of pulmonary embolism and sudden risk of death in a young man remains unknown.

What is Bizarre in Bizarre Delusions? A Critical Review

Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) treats the presence of bizarre delusions (BD) as the heaviest-weighted clinical criterion of schizophrenia. Although BD play a major role in contemporary diagnostic systems, only a few empirical studies explore this issue. These studies provide highly heterogenous results because they are based on different experimental paradigms, in terms of definition, clinical sample, and number of raters. Here, we first discuss the psychopathological sources of the concept of BD, which were initially described as either nonsensical or incomprehensible. Then, we provide a critical review of contemporary studies on the reliability of BD and their methodological and conceptual limitations. Current approaches have focused intensely on BD's reliability and have defined BD strictly in terms of delusional content--mainly in terms of the physical impossibility or the cultural or historical incomprehensibility of the delusional claims. These approaches have neglected formal features of experience that underlie BD and the crucial issue of the nature and validity of BD. In the discussion, we argue that clinical diagnosis of BD cannot be limited to delusional contents alone and requires taking into account the subjective side of BD (how altered experience manifests itself) as well as the conditions of intersubjective encounter (how BD are expressed to and experienced by the clinician). The notion of "bizarreness" in schizophrenia is not purely theoretical; it has practical relevance for the therapeutic encounter and implications on further empirical research and on diagnostic approaches.

P03-119 Shared-induced paranoid disorder (folie á deux) between two sisters. A case report

Introduction:Induced delusional disorder (also known as shared paranoid disorder or folie à deux) is an uncommon disturbance characterized by the presence of similar psychotic symptoms in two or more individuals. Most commonly a primary case can be distinguished from other one or more cases, in whom the symptoms are induced. the patients implied in the shared delusional symptoms are frequently linked by close relationship bonds, mostly family ties. Its epidemiology remains unclear, because very few data is available. There are some requirements concerning the persons involved for the development of this disorder:1.Close coexistence and intimate emotional links between the two people are observed;2.The delusional content is plausible and can be based on past events or expectations;3.Typically, the induced individual has an easily influenciable personality.Case report:We describe and comment one case of shared paranoid disorder between a 29 year old schizophrenic patient and her 43 years old sister. both share a persecution and prejudice delusion involving the Chinese community of their hometown. after a few days of inward treatment at separated psychiatric wards, the delusional symptoms in the older sister started to improve.Conclusion:Our intention is making a review on a diagnosis that remains controversial nowadays. Treatment should begin with the separation of the induced and the inducer. Anyhow, a psychopharmacological treatment is required in both individuals. It seems clear, however, that the prognosis of the induced and the inducer is different, according to a variety of factors.

Psychopathology of Schizophrenia in Ljubljana (Slovenia) From 1881 To 2000: Changes in the Content of Delusions in Schizophrenia Patients Related To Various Sociopolitical, Technical and Scientific Changes

Clinical observations and research have found the content of delusions in schizophrenia to be sensitive to sociopolitical and cultural factors. The aim of this retrospective case-note study was to determine changes in the frequencies of various contents of delusions in schizophrenia patients over time. A total of 120 records of first-time admission schizophrenia patient at Ljubljana's psychiatric hospital in the period from 1881 to 2000 were randomly selected. Information was taken from each record to fill out a form specially created for this study. The frequencies of delusions with regard to their content in various time spans were compared. A marked increase in two delusional themes--persecution and self-reference--was found after the change of political regime (1941-2000) in Slovenia. After the spread of radio in the 1920s and television in the 1950s in Slovenia, there was an obvious increase in delusions of outside influence and control as well as delusions with technical themes. A striking increase in the percentage of Schneiderian first-rank symptoms was found after the spread of Schneider's ideas in the 1950s. Sociopolitical changes and scientific and technical developments have a marked influence on the delusional content in schizophrenia.

Content and affect in persecutory delusions

The study aimed to explore the content of persecutory delusions and its potential links with levels of affective disturbance. Detailed examinations of the phenomenology of delusional beliefs have been rare, but are important for furthering theoretical and clinical understanding. A cross-sectional investigation of 70 individuals with current persecutory delusions was conducted. Taped semi-structured clinical interviews were transcribed for each participant. Using a coding frame devised for the current study, a detailed description of persecutory content was made. Scores on the Beck Depression and Anxiety Inventories, the Rosenberg Self-esteem Scale and the Psychotic Symptom Rating Scales were used as indicators of emotional distress. Data were gathered on the identity and type of persecutor, pervasiveness of threat and the power of the persecutor. Reliability was good. Beliefs involving multiple persecutors, human in nature and identifiable to the individual were common. For the majority threat was severe, ongoing and enduring and coupled with frequent feelings of vulnerability. Specific aspects of delusional content were found to be associated with emotional distress. For example, if participants felt more power in the face of persecution this was coupled with lower depression and higher self-esteem. Persecutory delusions are beliefs concerning severe threat, particularly of physical harm including death, which is personally significant, frequently involving multiple persecutors known to the individual. Depression is higher in those who felt less powerful than their persecutors. Associations, such as this, with emotional distress support a direct role for emotion in delusion formation and maintenance. It is consistent with cognitive models of delusions which emphasize the importance of considering emotional distress in the context of belief appraisal, although interpretation of the results is limited by the cross-sectional study design. Recognizing these links may in turn aid therapists in identifying aspects of beliefs that might be targeted to facilitate emotional change.

Deconstructing delusions: A qualitative study examining the relationship between religious beliefs and religious delusions

Delusions have been conceptualized as forming in response to experience, yet the relationship between religious belief, and beliefs regarded as delusional, has received little research attention. This is despite the high prevalence of delusions featuring religious content. Semi-structured interviews were conducted with seven participants who had been diagnosed as experiencing delusions. Participants from a range of religious backgrounds were asked about their religious experiences and beliefs, family background and experiences of psychosis. These interviews were analysed qualitatively. Whilst religious background affected the content of delusions, the nature of delusions appeared to be influenced by other factors, such as early family experiences, particularly an absent parent and conflict within the family. Individuals often used a religious framework to understand unusual experiences, and there seemed to be a role for the process of identification and wish fulfilment in influencing delusional content. Whilst this research is clearly limited by its exploratory nature, it offers a possible framework of understanding which helps make sense of religious delusions, and suggests approaches which may be helpful in recovery.

“Stereotypic” delusional offending

Some patients with serious mental illness appear to respond violently to the same delusional content throughout the course of their illness. Anecdotal, empirical, and theoretical evidence is presented establishing the premise of "stereotypic" delusional offending. A method for measuring the similarity of two delusions separated in time also is presented. An empirical focus on stereotypic delusional offending may help identify more accurately persons at risk for violence and those at risk for becoming targets of violence. It also may provide a better understanding of successful treatment of outpatient violence and conceivably could inform the ongoing debate on involuntary outpatient commitment laws. Among the major issues of this debate in the United States are the potential benefits of a forced medication provision. One rationale for such a provision may be found in the treatment response of seriously mentally ill outpatients whose violent behavior appears inescapably tied to their persistent or recurrent delusions.

Atribuciones causales explícitas e implícitas en el delirio: estudio de su especificidad en delirios paranoides y no paranoides

In this paper the presence of atributional cognitive biases in delusional patients is studied. Explicit (IPSAQ) and implicit (PIT) attributional measures have been used to analyze the attributional style in a sample of 40 delusional patients (19 paranoid patients and 21 non paranoid patients). The results showed the presence of attributional biases (i.e. externalizing and personalizing) independently of the delusional content when an explicit task was used. Compared to non paranoid patients, the paranoid group showed a different attributional style when it was assessed through an implicit task. Theoretical and clinical implications of the results are discussed.

A qualitative analysis of delusional content

Background: A number of different systems of classification of delusional content exist. The basis for these systems is unclear.Aims: The objective of this study was to investigate the manifest themes of delusions.Methods: Semi-structured interviews were carried out with twenty-five participants. Interpretive phenomenological analysis was used to generate a typology of themes. A second type of analysis used a data-display matrix of participants and themes. The latter matrix displayed the pattern of themes for each individual. A range of verification methods was used.Results: A typology was constructed of 34 themes that fell into 6 general topic “domains” namely, negative self, negative interaction, special self, identity and relationships, specific mental experience, and entities. The majority of themes related to aspects of the self and social relationships. Each individual had a unique selection of themes that tended to cohere as a whole. We also found, as Freeman and Garety (2000) suggested, that some conventional definitions of content are not adequate.Conclusions: The conventional systems for classifying delusions are distorting since they imply that individuals fit into distinct groups, for example, “the grandiose”. Our analysis suggests individuals tend to have a complex set of interconnected themes drawing uniquely from several possible domains.Declaration of interest: No financial support was given for this study. All authors are employed by the relevant government health service listed above.

On the Inadequacies of Theory of Mind Explanations of Schizophrenia

An influential theory of schizophrenia proposes that it can be explained by an inability to understand and reason about the mental states of others. In particular, an inability to correctly infer the mental states of others is believed to give rise to delusions and other psychotic symptoms. Our recent research has shown that patients adequately represent their own and others’ mental states and use this competence to communicate successfully in naturalistic social interaction. In talk with delusional content, patients recognize that others do not agree with their delusional claims and are not persuaded by the justification they provide for these claims. Importantly, they recognize their own and others’ discomfort at the disagreement this causes. However, they do not revise their claims. It is the tenacity with which delusional claims are held that is striking. This is all the more interesting given their ability to appreciate and respond appropriately to others’ mental states and their evident discomfort in the face of others’ disagreement. Questions for further research are whether this incorrigibility is specific to delusions, psychotic symptoms or the condition generally, and why patients are so tenacious in disregarding others’ accounts of their problems.

Neuropsychological equivalences and therapeutic consequences of the dynamic structural model

Firstly the core concepts of the dynamic structural model and the methods from which the model was developed will be discussed. These core concepts include concepts of personality structure and affect dynamic, of dynamic affective derailment with dissociation of individual element structures, the capacity of disactualisation of unwanted mental content, and autopraxis as the basis of memory renewals, which are formed and channelled through selection. Furthermore we will consider the dependence of memory function on texturing, development of coherence, affective freighting and repetition of usage in Janzarik's system. Neuropsychological counterparts are to be found in experimental studies on filter, gating and control functions, in studies on automatic vs. controlled processes, the central executive and executive control function. Autopraxis and priming operations will be related to each other. Furthermore, the connection of neuronal plasticity to a raised signal-to-noise ratio and the relationship to extinction of delusional content through broadening of new fields of experience will be discussed. In a summary of the frappant parallels of experimental and clinical viewpoints of Janzarik's model we will show the therapeutic perspective and the psychotherapeutically important integration of the lifeworld of the patient with experimentally investigated neuropsychological functions through Janzarik's conceptualisation.

Folie a deux versus genetically driven delusional disorder: case reports and nosological considerations

Folie a deux is thought to occur in persons who live close together, so that delusions of the primarily ill patient are adopted by the partner. Alternatively, if both patients are related, they may share the same genetically driven psychiatric illness. We present the cases of two psychotic couples (monozygotic twins and a mother and daughter pair, respectively), in which both subjects featured an almost identical psychopathological syndrome with the same delusional content and thus fulfilled the diagnostic criteria of folie a deux. When Leonhard’s diagnostic system was applied, all four patients were found to suffer from affect-laden paraphrenia, arguing against the presence of folie a deux in those dyads. Thus, thorough psychopathological examination in suspected folie a deux settings can help to obtain valid diagnoses.

Delusional Content and the Public Nature of Meaning: Reply to the Other Contributors

The contribution by professors Bayne and Pacherie (2004) is an earnest attempt to defend a popular model of monothematic delusions against criticisms launched by John Campbell (2001). This model of monothematic delusions holds that such delusions are rational attempts by the sufferer to explain to herself specific kinds of anomalous sensory/affective experiences. Bayne, Pacherie, Campbell, and for that matter Sass, Harper, and Georgaca, write as if semantic meaning accrued to words in a language term by term, as if meaning is "private" to the deluded person, and that she might therefore mean almost anything by her own idiosyncratic use of the public language she otherwise speaks. This is a notorious mistake. As Hilary Putnam famously put it in his classic 1975 paper "The meaning of 'meaning,'" "Cut the pie any way you like, 'meanings' just ain't in the head" (1975, 227). That is, meanings are not ethereal interior mental objects, private to the speaker—they are not private inner episodes that take place in some mental center stage of consciousness. The deluded person does not and cannot succeed in changing the meaning of a term in a public language like English merely by an individual act of imaginative will involving the making of a bizarre assertion—not even if she repeats it a thousand times. The public nature of meaning, if I can coin a phrase for it, is the central theme in the work of the later Wittgenstein. Even before Putnam, Wittgenstein had made the same point in his Philosophical Investigations via a famous footnote in which he writes,

Environmental factors as delusional contents in patients with schizophrenia

In a series of 50 consecutive cases in the outpatients' unit of Environmental Medicine (UEM) at the University Hospital of Aachen, Germany, five patients with the diagnosis of schizophrenia presented delusions of being poisoned by environmental factors. This case report illustrates the clinical features of the paranoid type of schizophrenic psychoses. Schizophrenia represents an important differential diagnosis in the interdisciplinary diagnosis and management of health problems attributed to environmental factors.

Reply to Dr. Cutting and Dr. Fabrega

Reply to Dr. Cutting and Dr. Fabrega

Delusions in First-Admitted Patients: Gender, Themes and Diagnoses

Whether there is a specific link between certain delusional symptoms and particular etiologies has not yet been completely clarified. In this study, 639 first ever admitted deluded patients were investigated in order to find out whether age and gender are associated with certain delusional contents, whether age at first admission may be linked to certain etiologies and whether it is possible to detect indicators particularly related to basic dysfunctions. At first admission, delusional female patients were older than men with a significant predomination of delusions of persecution, while men presented significantly more frequently delusions of jealousy and grandiosity. Within delusions of persecution, of religious or metaphysical content and of grandiosity, women were even significantly older than men. Religious or metaphysical and grandiosity contents occurred significantly more frequently in ICD-8 schizophrenia, indicating that these themes seem to be particularly linked to ICD-8 schizophrenia. Additionally, some target symptoms not included in the delusional symptomatology were investigated to test the relationship between delusions and schizophrenia. Overall, the results of the present investigation indicate that delusions are not specific for schizophrenia, and therefore, other symptomatological criteria should be applied for the nosographic attribution.

A Rating Scale for Psychotic Symptoms (RSPS):: Part II: Subscale 2: distraction symptoms (catatonia and passivity experiences); Subscale 3: delusions and semi-structured interview (SSCI-RSPS)

In the second paper on the Rating Scale for Psychotic Symptoms (RSPS), distraction symptoms (Subscale 2) and delusions (Subscale 3) are described. Subscale 2 includes distraction symptoms, which arise from one of two mechanisms: the symptom may arise either by loss of attentional focus (LAF) due to a competing channel of information, or by the intrusion of the competing channel into the focus of attention [attentional intrusions (AI)]. The symptom classes resulting from loss of attentional focus (LAF) include motor catatonia, negativism, and thought blocking; the attentional intrusions (AI) symptoms rated include three types of passivity experiences (Schneiderian symptoms): (1) thought insertion, (2) movements or action controlled, and (3) speech controlled by an external force. Subscale 3, consisting of delusions, is organized on the basis of content identification. Nineteen types of delusions are rated. Each item of delusional content is rated along three axes (active elaboration, persistence and active extinction) and complexity, and optionally if primary or mixed (i.e. primary with secondary elaborations). The last section of the paper includes the semi-structured interview (SCI-RSPS) for each of the items, as well as guidelines for practical application of the interview.

Delusional symptomatology as seen by a community mental health outreach team

Delusional symptomatology arising in late life may be common but not well understood, particularly among elderly individuals who remain living in the community. In this study, approximately 15% of all cases seen by a geriatric mental health outreach team in a six-month interval involved clients with delusional beliefs.The nature of the delusional presentation, interventions employed, and barriers to intervention were compared between a group of individuals with delusions, but no evidence of dementia (n = 16) and a group with delusions and dementia (n = 29). Overall, a feeling of being plotted against by others was the most common delusion and approximately half of the individuals in each group reported hallucinations. In addition to differences in psychiatric history, preoccupation with delusions, and delusional content, the groups were clearly distinguished in terms of compliance with treatment; moreover, non-compliance was viewed as the main barrier to effective intervention. Implications and suggestions for future research are discussed.

Delusions and self-esteem.

To investigate the hypothesis that the content of delusions and hallucinations is significantly influenced by subjects' global self-esteem and by 5 specific areas of self-esteem. The delusions and hallucinations of 40 psychotic patients were assessed by 2 independent raters for content indicative of positive or negative self-esteem and for the extent to which the delusional content would be self-enhancing (or diminishing) and comforting (or discomforting) to the subject. These ratings were correlated with the results of self-esteem inventories completed by the subjects. The content of delusions reflects both global self-esteem and self-regard. This study demonstrates that 2 specific personality factors, global self-esteem and self-regard, are reflected in the content of delusions and influence whether those delusions are experienced as comfortable (or uncomfortable) and enhancing (or diminishing). Delusional content is therefore consistent with patients' views of themselves, and this may partially account for the persistence of delusions.

Attributional style and delusions: an investigation based on delusional content

Individuals with persecutory delusions have been reported to make external and stable attributions for negative events and to have a tendency towards internal attributions for positive events. It remains unclear whether this abnormality is present in individuals with non-persecutory delusions. Using the Attributional Style Questionnaire, we assessed the attributional style of 19 individuals with persecutory or grandiose delusions (PG), 12 individuals whose delusional beliefs were non-persecutory and non-grandiose (NPG) and 24 controls. The PG group displayed externality in their causal attributions for bad events but those in the NPG group did not differ from controls. Both deluded groups were significantly more stable in their attributions for bad events in comparison to controls. Such findings argue against a primary role for attributional biases in the genesis of delusions, although a role in shaping delusional content and maintaining the disorder and a role for external attributions in defending against reductions in self-esteem cannot be excluded.