Delusional Symptoms Research Articles

First Experiences in Combination Therapy Using Olanzapine with SSRIs (Citalopram, Paroxetine) in Delusional Depression

In an open prospective study, 26 patients with delusional depression (mood-congruent psychotic features: DSM-IV 296.4) were treated over 5 weeks with a combination of SSRI (citalopram, n = 22, or paroxetine, n = 4) and the neuroleptic olanzapine. The course of therapy was evaluated with the Hamilton depression scale (HAMD). Not only the total HAMD score, but also the subscores for affectivity and delusional symptoms decreased significantly. After the end of the 5-week combination therapy, 18 out of 26 patients (69%) could be discharged as responders to outpatient treatment. The course of treatment was characterized by excellent tolerance.

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.

Learning to Conduct Psychotherapy with Psychotically Disturbed Patients

A first experience working therapeutically with a psy-chotically-impaired individual challenges a psychologist-in-training with a number of issues. These include how best to establish a therapeutic stance toward symptoms of cognitive disorganization and delusions, and countertransferential difficulties arising from the power differential between patient and therapist. These issues are explored in the context of a twice-weekly psychodynamic treatment with an involuntary patient on a locked inpatient facility. Challenges faced in this type of treatment are important training experiences, and can inform work with higher-functioning patients as well.

Medication adherence in psychosis: predictors and impact on outcome. A 2-year follow-up of first-admitted subjects.

To assess the baseline characteristics predicting poor medication adherence following a first admission for psychosis, and the impact of poor medication adherence on outcome. First-admitted subjects with psychosis (n = 65) were assessed at 6-month intervals over a 2-year follow-up. Medication adherence was assessed using multiple sources of information. Baseline lower occupational status, alcohol misuse and the intensity of delusional symptoms and suspiciousness predicted poor medication adherence during the 2-year follow-up. Over this period, subjects with poor medication adherence presented more frequently with an episodic course of illness and were more frequently readmitted, especially with regard to involuntary readmission. In naturalistic conditions one out of two subjects with psychosis interrupts his/her treatment in the months following his/her first discharge from hospital. Therapeutic programmes aimed at improving medication adherence should be implemented early in the course of psychosis to reduce the deleterious consequences of poor medication adherence on clinical outcome.

Diagnostic, forensic and therapeutic-ethical aspects of false memory of sexual abuse induced by psychotherapy

This article examines the risk of false memories induced by psychotherapy with special regard to sexual abuse. Current psychological constructs based on depth psychology are reviewed critically. The multitude of psychological disorders connected with sexual abuse in recent time and a subjectivistic misunderstanding of empathy frequently lead sometimes to uncritical acceptance of anamnestic reports about sexual abuse. Thus, the question of what really happened often is risen not before forensic appraisals. It can be shown that the descriptive psychiatric view and depth psychological oriented constructs tend to compete with each other with the consequence of different results in therapeutic practise and forensic appraisal if inappropriately applied. The author shows how to distinct between induced delusional symptoms and dissociative phenomena. Furthermore he draws attention on the ethically doubtful long-term results of a not correctly indicated use of psychological constructs based on depth psychology about extreme traumatization in the psychotherapy of strongly suggestible patients.

No interaction between serotonin transporter gene and dopamine receptorD4 gene in symptomatology of major psychoses

Previously, we reported an association of the dopamine receptor D4 (DRD4) gene with delusional symptomatology of major psychoses. However, DRD4 variants accounted for only 2% of the phenotypic variance, indicating that contributions from other genes were probable. The serotonin transporter gene is a primary candidate in major psychoses, and a functional polymorphism in the upstream regulatory region of the serotonin transporter gene (5-HTTLPR) has recently been reported to be associated with a number of psychopathological conditions. In the present study we investigated the original cohort of subjects to evaluate the 5-HTTLPR possible influence on the psychopathology of major psychoses in interaction with DRD4. Four hundred and sixty-one inpatients affected by major psychoses were assessed by the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and were also typed for the 5-HTTLPR and DRD4 variants using polymerase chain reaction techniques. Mania, depression, delusion, and disorganization were the four symptomatologic factors used as phenotype definition. 5-HTTLPR variants did not significantly influence the previously reported association of DRD4 with delusional symptoms. No interaction was observed on the other symptom factors. The serotonin transporter gene does not, therefore, interact with DRD4 in determining the symptomatology of major psychoses.

Compliance in psychoses.

To review the literature on compliance in psychoses and to evaluate the significance of the different compliance components presented. Different definitions of the term compliance were first gathered. A search covering the years 1974-1997 was conducted in Medline and PsycLit databases using the keywords 'schizophrenia' or 'psychosis' and 'compliance'. The studies that took compliance into account as a separate variable were collected for further analysis. Unpleasant side-effects of medication, attitudes towards medication, delusional symptoms, substance abuse, insight, and supportive family environment were found to have the strongest correlation with compliance. The influence of cognitive impairment is not clearly proven. Integrated, cognitive-behavioural and psychoeducational treatment models include several methods to improve therapeutic alliance and compliance. As the majority of the studies have concentrated on neuroleptic treatment, the medication-related factors are best documented. In clinical practice, treatment compliance is based on patient-related, medication-related and interactional factors, such as treatment model and therapeutic alliance. Difficulties with insight and cognitive functioning are specific patient-related factors in the treatment of psychoses.

Persecutory Delusions in Dementia

Persecutory delusions are common in dementia. This study was undertaken to investigate the prevalence, associated factors, and characteristics of persecutory delusions in demented patients. The sample population included 167 demented patients (DSM-III-R criteria) admitted to a geropsychiatric ward. Patients were assessed for the occurrence of any persecutory delusions since the onset of dementia. The content of persecutory delusions, the patients' response to the delusions, and any concomitant psychiatric symptoms were also explored. Of the 167 demented patients, 45 (26.9%) showed symptoms of persecutory delusions. Patients with persecutory delusions had a higher prevalence of other delusions, hallucinations, and physically aggressive behaviors. The deluded patients often thought that their caregivers were their persecutors and had a wide range of responses to their delusions. After they were hospitalized, many of these patients attacked medical staff and were uncooperative with treatment. Persecutory delusions are common in dementia of various types. Deluded patients often have vigorous responses to their delusions including physically aggressive behaviors and suicide attempts. Careful evaluation is needed to assess the potential for violent and suicidal behaviors in these patients. Medical staff should be alert to clinical strategies for handling the treatment of such patients when they become violent or uncooperative.

Symptomatologic analysis of psychotic and non-psychotic depression

Background: The aim of the present study is to evaluate the symptomatologic presentation of delusional compared to non-delusional major depressive episodes. Methods: Two hundred and eighty-eight subjects suffering from mood disorder (144 bipolar, 133 unipolar) were assessed at admission by the Hamilton Depression Rating Scale (HAMD-21). Results: Depressive symptomatology was more severe in the delusional sample, even after the exclusion of the items directly involved with delusional symptoms ( P=0.00002). Conclusions: Our data support the hypothesis of delusional depression as a more severe form of mood disorder.

Posttraumatic stress disorder symptoms related to psychosis and acute involuntary hospitalization in schizophrenic and delusional patients.

The aims of this study were: a) to assess the prevalence of posttraumatic stress disorder (PTSD) after an acute psychotic episode in schizophrenic and delusional patients, b) to explore which psychotic symptoms and aspects of treatment were associated with traumatization, and c) to compare the extent of the traumatic impact of psychosis and involuntary hospitalization. Forty-six schizophrenic and delusional patients were assessed with the Positive and Negative Syndrome Scale (PANSS), the Impact of Event Scale-Revised (IES-R), and the Clinician-Administered PTSD Scale (CAPS) at weeks 1 and 8 after acute psychiatric admission. Traumatic symptoms related to psychosis and coercive measures were scored separately. The prevalence of PTSD was found to be 11%. Sixty-nine percent of traumatic symptoms were related to psychosis and 24% to hospitalization. High PANSS score at week 8 was the strongest risk factor for the development of PTSD. Particularly positive and depressive/anxious symptomatology were associated with psychosis-related traumatic symptoms at both weeks 1 and 8. These data suggest that, in general, schizophrenic and delusional symptoms are more traumatic than the coercive measures used to control them.

Mesolimbic activity associated with psychosis in schizophrenia. Symptom-specific PET studies.

Hallucinations and paranoid delusions are prominent among the positive symptoms of schizophrenia. Such psychotic symptoms are notable for their aberrant representations of, and relation to, the external world and for the emotional/motivational valence associated with the representations. As mesolimbic structures, including the amygdala and ventral striatum, are thought to play a significant role in imparting emotional valence to external stimuli, we here examine the mesolimbic findings of H215O PET studies designed to probe the functional neuroanatomy of psychosis. Patients with schizophrenia (including those with active hallucinations, those with active paranoid delusions, and those without active positive symptoms at the time of scanning) and healthy control subjects were studied. An event-related PET paradigm was used to identify the neural correlates of hallucinations, and a modified emotional stroop paradigm (with threat versus neutral words) was used to test the hypothesis that paranoid patients would have increased mesolimbic activity in response to threat, and even in response to neutral stimuli. The findings suggest that the positive psychotic symptoms of hallucinations and delusions share similar functional neuroanatomical features of increased mesotemporal and ventral striatal activity in the setting of decreased prefrontal activity. The pattern is evident even in a neutral context, unlike the case for normal subjects, who show such features only in response to threat. The implications of these findings for a pathophysiology of psychosis will be discussed in the context of the behavioral neuroanatomical literature in animals and humans.

Factor analysis of delusional disorder symptomatology

Delusional disorder symptomatology has been poorly investigated with factor analytic studies. Most attempts to identify its symptomatologic structure were made with schizophrenic or mixed psychotic populations and included only delusional symptoms. The purpose of this study was to analyze the whole symptomatologic structure of delusional disorder. One hundred eight inpatients with delusional disorder (DSM-III-R) were evaluated for lifetime symptoms using the Operational Criteria (OPCRIT) checklist for psychotic illness and included in a factorial analysis. Four factors were evaluated: (1) core depressive symptoms, (2) hallucinations, (3) delusions, and (4) irritability symptoms. Thus, when scored by the OPCRIT checklist, delusional symptomatology consisted of four independent factors, indicating a substantial heterogeneity of this diagnostic category.

No interaction of GABAA alpha-1 subunit and dopamine receptor D4 exon 3 genes in symptomatology of major psychoses

Previously, we reported on an association of the dopamine receptor D4 (DRD4) gene with delusional symptomatology of major psychoses. However, despite the strength of the association, it only accounted for 2% of the variance, indicating that contributions from other genes were probable. In the present study, we investigated the original cohort of subjects to evaluate the gene for the gamma-aminobutyric acid type A (GABA(A)) receptor alpha-1 subunit (GABRA1). The possible association of GABRA1 with the psychopathology of major psychoses was tested both alone and in interaction with DRD4. Four hundred and sixty-one inpatients affected by major psychoses were assessed by the operational criteria checklist for psychotic illness (OPCRIT) and were also typed for the DRD4 and GABRA1 variants using PCR techniques. Mania, depression, delusion, and disorganization were the four symptomatologic factors used as phenotype definitions. GABRA1 variants were not associated with these symptomatologic factors, and consideration of possible stratification effects such as sex and psychiatric diagnosis also did not reveal any association. GABRA1 variants did not significantly influence the association of DRD4 with delusional symptoms. No interaction was observed on the other symptom factors. The GABA(A) alpha-1 subunit gene does not, therefore, interact with DRD4 in the symptomatology of major psychoses.

Mirtazapine effectiveness in a patient with refractory psychotic depression

The author describes a patient with recurrent depression, according to DSM-IV diagnostic criteria. The features were of a delusional depressive episode lasting 5 years, associated with severe impairment of psychosocial functioning. The patient also had chronic hepatitis, of unknown aetiology, and portal hypertension with some high gastrointestinal bleeding episodes. The depressive episode had been treated unsuccessfully with therapeutic doses of imipramine and lithium augmentation associated with haloperidol and, afterwards, with risperidone. Mirtazapine was introduced, coadministered with haloperidol and after 8 weeks there was an improvement in delusional depressive and other negative symptoms. The patient remained well for 9 months. This case indicates that mirtazapine is an option for patients with psychotic depression who are refractive to tricyclic antidepressants. Mirtazapine is also a safe drug, well tolerated in this severe clinical condition.

Dopamine receptor D 4 gene is associated with delusional symptomatology in mood disorders

Disturbances of the dopaminergic neurotransmitter system have been implicated in the pathogenesis of depressive symptoms. Many studies have, however, failed to detect any association between genetic markers for the dopamine system and mood disorders. A possible reason for this may lie in the definition of phenotype, which is traditionally based on psychiatric diagnosis. In this study, we investigated the possibility that functional variants of the dopamine D 4 receptor (DRD4) gene might be associated with depressive symptomatology in a sample of mood disorder subjects. Seventy-nine inpatients affected by bipolar ( n=37) and major depressive ( n=42) disorder (DSM-IV) were assessed at admission by the Hamilton Depression Rating Scale and were typed for DRD4 variants at the third exon using polymerase chain reaction (PCR) techniques. DRD4 was associated with delusional symptoms ( F=5.56; d.f.=2,145; P=0.005), with DRD4*7 exhibiting higher scores when compared to DRD4*4 ( P=0.006) variants. Polarity of mood disorder did not influence results significantly. The findings are in accordance with our previous report of an association of the DRD4 gene with delusional symptomatology of major psychoses. DRD4*7 should, therefore, be considered a liability factor for delusional symptoms in mood disorders.

Neuropsychological Analysis of a Case of Abrupt Onset Mirror Sign Following a Hypotensive Crisis in a Patient with Vascular Dementia

Abstract The mirror sign is a delusional misidentification symptom (DMS) characterized by an inability to recognize one's own image in the mirror, often in the presence of an intact ability to recognize others in the mirror. The symptom has been only sparsely reported previously, and primarily within the Alzheimer's disease literature. A case is reported of an 82-year-old female with abrupt onset of mirror sign following a hypotensive crisis. Neuroradiographic studies revealed periventricular white matter change in the bifrontal and bilateral parietal occipital regions, right greater than left, as well as scattered lacunar infarcts. The patient was unable to recognize herself in the mirror and became progressively paranoid in response to the stranger in the mirror'. However, there was no evidence of prosopagnosia and she was able to recognize others in the mirror. Results from the neurobehavioral examinations replicated a previous report of mirror sign, and were consistent with those reported for other DMS. The acute onset, vascular changes on MRI, and lateralized neuropsychological findings suggested a right hemisphere-based visual associative etiology to the mirror sign.

Neuropsychological analysis of a case of abrupt onset mirror sign following a hypotensive crisis in a patient with vascular dementia

The mirror sign is a delusional misidentification symptom (DMS) characterized by an inability to recognize one's own image in the mirror, often in the presence of an intact ability to recognize others in the mirror. The symptom has been only sparsely reported previously, and primarily within the Alzheimer's disease literature. A case is reported of an 82-year-old female with abrupt onset of mirror sign following a hypotensive crisis. Neuroradiographic studies revealed periventricular white matter change in the bifrontal and bilateral parietal occipital regions, right greater than left, as well as scattered lacunar infarcts. The patient was unable to recognize herself in the mirror and became progressively paranoid in response to the stranger in the mirror'. However, there was no evidence of prosopagnosia and she was able to recognize others in the mirror. Results from the neurobehavioral examinations replicated a previous report of mirror sign, and were consistent with those reported for other DMS. The acute onset, vascular changes on MRI, and lateralized neuropsychological findings suggested a right hemisphere-based visual associative etiology to the mirror sign.

Cotard syndrome: An important manifestation of melancholia

In 1880 Cotard described a syndrome, the hallmark of which is the delusion of being dead. Since then the debate has centred on whether it is a distinct psychiatric entity or an extreme form of depression. The syndrome has been observed in schizophrenia, confusional states, epilepsy, and senile and presenile conditions. We report five cases of Cotard delusion in patients in whom the differential diagnosis was difficult, immediately pointing to organic or paranoid psychosis being the primary cause of illness. On the basis of the clinical decision that the nihilistic ideation was the prominent feature of a psychotic depression, the patients underwent a series of electroconvulsive therapy (ECT) with striking effect, both on the delusional and on concomitant symptoms. The psychopathology and therapy of delusional depression are discussed. The case histories show the importance of considering depressive illness in patients with nihilistic delusional symptoms with or without depressed mood, and the therapeutic efficacy of ECT in depression with severe psychotic manifestations.

Neuropsychological evidence supporting a neurodevelopmental model of schizophrenia: a longitudinal study

The stability of neuropsychological performance in schizophrenia and its relationship to clinical change was contrasted between 60 patients with schizophrenia (30 first-episode, 30 previously treated) and 38 healthy controls using a comprehensive neuropsychological battery and clinical scales administered at intake and at a 19-month follow-up. Consistent with the neurodevelopmental model of schizophrenia, patients demonstrated deficits in cognitive performance at initial testing and did not show decline at follow-up. There were no differences in neuropsychological performance over time between first-episode and previously treated patients, nor between male and female patients or controls. As expected, patients improved clinically with treatment with respect to both positive and negative symptoms. First-episode patients improved more on the positive symptoms of hallucination and delusion; male and female patients showed equivalent clinical improvement. Clinical improvement correlated positively with neuropsychological change, with improved negative symptomatology accounting for most of the significant correlations.

Delusional misidentification symptom (mirror sign) following watershed infarction: A neurobehavioral case study

Delusional misidentification symptom (mirror sign) following watershed infarction: A neurobehavioral case study