Persecutory Delusions Research Articles

Introduction: Queerer than Fiction

In last paragraphs of Freud's essay on paranoid Dr. Schreber, there is discussion of what Freud considers a striking between Schreber's persecutory delusion and Freud's own theory. Freud was indeed later to generalize, famously, that the delusions of paranoiacs have an unpalatable external similarity and internal kinship to systems of our philosophers--among whom he included himself.(1) For all his characteristic slyness, it may be true that putative congruence between paranoia and theory was unpalatable to Freud. In hands of subsequent thinkers, however, it has by now become less an embarrassment than a prescriptive article of faith: for literary and cultural critics, prevailing theoretical challenge has been to find ever more subtle and searching ways of implementing a hermeneutic of suspicion. In a world where no one need be delusional to find evidence of systemic oppression, to theorize out of anything but a paranoid critical stance has come to seem naive or complaisant. Even aside from prestige that now attaches to a hermeneutic of suspicion in critical theory as a whole, queer studies in particular has had a distinctive history of intimacy with paranoid imperative. Freud, of course, traced every instance of paranoia to repression of same-sex desire, whether in women or in men. A chain of powerful, against-the-grain responses to Freud's argument, beginning with Guy Hocquenghem's Homosexual Desire, has established paranoid stance as a uniquely privileged one for understanding not--as in Freudian tradition--homosexuality itself, but rather precisely mechanisms of homophobic and heterosexist enforcement against it.(2) Subversive and demystifying parody, suspicious archaeologies of present, detection of hidden patterns of violence and their exposure: these infinitely doable and teachable protocols of unveiling have become common currency of cultural and historicist studies, and signs in turn of special status that queer and antihomophobic inquiry seems to hold within that movement. If there is any obvious danger in triumphalism of a hermeneutic of suspicion. it is that broad consensual sweep of such methodological assumptions, current near-profession-wide agreement about what constitutes narrative or explanation or adequate historicization, may, if it persists unquestioned, unintentionally impoverish gene-pool of literary-critical perspectives and skills. The trouble with a narrow gene-pool, of course, is its diminished ability to respond to environmental (for instance, political) change. Another danger of present paranoid consensus, however, is that it may require disarticulation, disavowal, and misrecognition of other ways of reading--ways less oriented around suspicion--that are actually being practiced. One premise of present collection is that a closer, more respectful attention to past and present queer reading practices--the kind of attention these essays, in their different ways, all embody--will show how reservoir of practices already in use crucially exceeds theorizations of a consensual hermeneutic of suspicion. Many of these essays are, rightly, incisive and unerring in their methodical suspicion; but what more unites them is a very different impulse and history, which would be badly misrecognized under currently available rubrics. Perhaps instead of battening on Freudian understanding of paranoia, for all its useful definitional linkage to homoerotic issues, it would be more descriptive here to use Melanie Klein's less differentiated, arguably less elegant concept of paranoid position. The interest of Klein's concept lies, it seems to me, in her seeing paranoid position always in oscillatory context of a very different possible one, depressive/reparative position.(3) For Klein's infant or adult, paranoid position--understandably marked by hatred, envy, and anxiety--is a position of terrible alertness to dangers posed by hateful and envious part-objects that one cannot help but ingest from world around one. …

SA88 - PARANOID THINKING IN HEALTHY INDIVIDUALS – ASSOCIATION WITH SCHIZOPHRENIA GENETICS?

Background Paranoid thinking is a psychological phenomenon affecting a considerable part of the general population. According to Freeman and colleagues (2005) there is a “hierarchy of paranoia”, which ranks from social worries and beliefs of persecution to paranoid delusions which are common in schizophrenic disorders. Therefore, the assumption of this continual approach leads to the hypothesis that subclinical paranoid thinking and persecutory delusions in context of schizophrenia share a common genetic basis. Our primary aim was to verify this hypothesis. Methods Associations of 128 genome--wide significant schizophrenia risk variants (Schizophrenia Working Group of the Psychiatric Genomics Consortium, 2014) were investigated on paranoid thinking. Individual paranoid thinking was measured with a newly composed subscale based on the Minnesota Multiphasic Personality Inventory (MMPI), in a German sample including 2635 healthy subjects. From this sample n=1174 individuals with either none (n=558) or high (n=616) scores of paranoid thinking were selected. Results Using a logistic regression model controlling for age, sex and education, six markers showed significant associations to paranoid thinking. Interestingly, these associations could indeed be shown in a comparison of extreme groups, but only very restricted in the following variance analysis of continual associations. Discussion Despite discrepant findings, this study suggests a genetic contribution to the complex development of paranoid thoughts.

Symptom Profile of Patients with Psychotic Disorders

Introduction: According to WHO, schizophrenia is a severe mental disorder affecting about 23 million people worldwide. Psychoses, including schizophrenia, are characterized by distortions in thinking, perception, emotions, language, sense of self and behavior. The impacts of these disorders are severe, with approximately 1 million people committing suicide annually. There is also an increase in co morbidity of these different conditions. So, this study was carried out to assess the symptom profile of patients with schizophrenia and other psychotic disorders (excluding mood disorders, substance induced psychotic disorders, organic psychotic disorders).
 Material and Method: Discharge record sheets of all cases admitted (Total 86) to the psychiatric ward over the study period were reviewed. Cases diagnosed as schizophrenia and other psychotic disorders were enrolled. Major symptoms were listed from the discharge papers.
 Results: Out of the total number of patients enrolled in the research, 68.6% were male while 31.4% were female. The mean age of the patients was found to be 31.03 years with a minimum age of 16 years and maximum 63 years. Most were from lower middle class family, Hindu by religion and unmarried. Among 86 cases, 26(30.2%) were diagnosed as Unspecified nonorganic psychosis, 24(27.9%) as Schizophrenia, 19(22.1%) as Schizoaffective disorder, 14(16.3%) as Acute & Transient Psychotic Disorder, 3(3.5%) as Persistent delusional disorder. Delusion of persecution was present in 46 cases (53.5%), Delusion of reference in 33 cases (38.4%) and Hallucinations in 32 cases (37.2%). Out of the 86 patients enrolled in the study, 15 (17.4%) had at least one suicidal attempt.
 Conclusion: Significant number of patients were diagnosed as Schizophrenia which is itself a chronic, debilitating illness. Hallucinations and delusions were present in most of the cases.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Review of Psychiatric Phenotypes and Management Considerations: A Report of the American Neuropsychiatric Association Committee on Research.

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder characterized by prominent neuropsychiatric symptoms. Given the nature of its pathophysiology, psychiatrists tend to be one of the first clinicians encountering patients with the disease. In the present review of patients described in the literature with psychiatric symptoms, the authors aimed to characterize the psychiatric symptoms of the disease and its management in adults and adolescents as well as children (≤12 years old). A total of 544 patients fulfilled the inclusion criteria. The authors found that 77% of patients with NMDAR encephalitis presented initially with psychiatric symptoms. These were mostly agitation (59%) and psychotic symptoms (in 54%, especially disorganized behavior and visual-auditory hallucinations), with agitation even more commonly being the presenting symptom in children (66%). Where psychotic symptoms were detailed, visual (64%) and auditory (59%) hallucinations were the most common, as well as persecutory delusions (73%). However, delusions were not clearly characterized in most cases. Catatonia was described in 42% of adult patients and 35% of children. Of the patients with documented exposure to antipsychotics, 33% were suspected to have an adverse drug reaction (notably, neuroleptic malignant syndrome in 22% of the cases). On the basis of these findings, it is important to consider anti-NMDAR encephalitis in the differential diagnosis of patients with an acute onset psychosis, especially in association with agitation, catatonia, or adverse response to antipsychotics. Furthermore, it is important to use antipsychotics with caution in patients with suspected or confirmed anti-NMDAR encephalitis.

Delusions in Dementia

Delusion is a common neuropsychiatric symptom in dementia, especially in Alzheimer disease and dementia with Lewy bodies. Persecutory delusions are the most common, and include delusions of theft, jealousy, and abundant. Patients with persecutory delusions have impairment of the psychological processes mediating the formation and maintenance of normal social beliefs. Several disordered psychological processes such as attentional bias, attributional bias, jumping-to-conclusions reasoning bias, and theory of mild deficit may contribute to the delusion formation. Cognitive processes involving information about self, others, and social interaction are required in social cognition. Damage of the neural circuitry involved in social cognition ("social brain"), such as the medial prefrontal cortex, may be a neuroanatomical basis for persecutory delusions in dementia.

Neurosyphilis and classical music: the great composers and "The Great Imitator".

Throughout history, neurosyphilis has victimized many people, including classical composers, with a wide range of clinical presentations. Six articles with descriptions of composers with possible neurosyphilis were reviewed. Neurosyphilis is a possible diagnosis for composers like Beethoven, whose progressive hearing loss influenced his career, culminating in complete deafness. In his autopsy, cochlear nerve atrophy and cochlear inflammation were described. Donizetti developed behavioral changes, as well as headaches, general paresis and seizures. Both Schumann and Wolf suffered from personality changes, persecutory delusions and general paresis. Joplin and Delius also had symptoms attributed to syphilis. Autopsy findings confirmed the diagnosis of Smetana, who developed dementia, deafness and auditory hallucinations with rapid progression. His tinnitus was musically represented in his first String Quartet. Neurosyphilis victimized several notorious composers. It can be argued that neurosyphilis was a major source of inspiration as well, being responsible for the genesis of musical masterpieces.

Réflexions sur un cas d’érotomanie associée dans la perspective freudienne du délire comme « tentative de guérison » dans la psychose

AimThe aim of the paper is to confront the non-deficient conception of delusion supported by psychoanalysis with the reality of the clinical setting, from the study of the delusional construction of an erotomaniac female patient. This means putting a Freudian theoretical hypothesis to the test of a clinical case: the Freudian perspective of delusion as a attempt to heal in psychosis. In this paper, we will also try to show how Lacanian developments on the formulae of sexuation and the concept of “push-towards-the-woman”, conceived in the Freudian logic of delusion as a healing attempt, can also cast light on certain aspects of the erotomaniac position. We will therefore try to highlight how erotomaniac delusion was able to have stabilizing and soothing effects for this patient, unlike the components of persecution delusion. MethodOur method will initially involve a historical review of the conception of erotomania in classic psychiatry, in order to trace the progressive definition of this clinical entity in the nosography. Thus, we will study the first definitions proposed by Esquirol, who like Ball, emphasized the chaste character of erotomaniacs and the absence of desire for realization, to show the contrast that appears between this conception and the medico-legal descriptions by Garnier and Portemer, who both underlined the dangerousness and the risk of violent acting-out. This will also lead us to study specificities of the theses defended by Clérambault, who identified erotomania as an autonomous entity independent from paranoia, whereas most of his contemporaries considered erotomaniac delusion only as one of the possible themes of paranoid or systematized delirium. Then, we will present the specificities of the psychoanalytic approach to erotomaniac delusion, starting from the study of Freud's “grammar” of delusion, and then Lacanian developments on foreclosure and the formulae of sexuation. Finally, we will adopt the methodology of the single case study in order to show the singular process of delusional construction in a psychotic patient. ResultsOur results cast light on the diachronic and progressive character of this patient's delusional construction by way of anamnesis, and they show the singular, soothing constructions that can sometimes conceal the erotomaniac position for a psychotic subject, in line with the Freudian perspective of delusion as an attempt at healing. We have also been able to show how the use of the Lacanian theory of the formulae of sexuation and the “push-towards-the-woman” concept makes it possible to cast light on the mechanisms of this pacifying effect of the erotomaniac delusional component. DiscussionOur discussion will focus on the possibility of establishing an analogy between the delusional construction of this patient and the construction operated by President Schreber, described by Lacan as “push-towards-the-woman”. The question is how the pacifying aspects of the erotomaniac position can be conceived as relating to the economic treatment of the “jouissance” facilitated by a position where the subject comes to embody the figure of “the woman” as an exception. The erotomaniac position could thus have had stabilizing effects in this patient, insofar as it brings about a pacification in the relationship with the Other, a form of consent to be the object of the Other's enjoyment–and this position is dialectically opposed to the delusion of persecution. ConclusionIn conclusion, the clinical relevance of the Freudian hypothesis of delusion as an attempt at healing in psychosis can be underlined, making it possible to envisage the delusional construction of a singular subject in a non-deficient perspective. The Lacanian approach to the formulae of sexuation and “push-towards-the-woman” can also be seen as the prolongation of this non-deficient conception. Nevertheless, caution is required for any generalisation of the results of this study, since it is probable that not all delirious erotomaniac constructions result from a “push-towards-the-woman” effect, and do not in every case have a stabilizing effect. Our article is merely intended to cast light on the mechanisms of the diachronic construction of this erotomaniac position in a singular case. This study should not suggest that every delirious erotomaniac construction inevitably presents these stabilizing effects. Nevertheless, since erotomania is a major component of psychotic transference, returning to the study of erotomaniac delirium via a review of the psychiatric and psychoanalytic literature alongside the case of this patient seems to us of fundamental interest, for its ability to cast light on the question of how to handle transference in the cure of psychotic patients.

Abolition du discernement : état des lieux des pratiques des experts psychiatres dans l’ouest de la France

ObjectivesThe goal of this study was to determine the characteristics of subjects considered to be criminally irresponsible due to abolition of judgment pursuant to article 122-1, §1 of the French Penal Code. Materials and methodsThis retrospective study gathered every forensic assessment in 2016 that concluded in criminal irresponsibility from eight forensic psychiatrists practicing in the west of France. We proceeded to study the frequency of abolitions, the socio-demographic characteristics of the subjects, the psychiatric pathologies as defined by the DSM-5, the crimes committed, the clinical justifications and the conclusions of the forensic psychiatrist concerning the potential forced hospitalisation of the subject, the psychiatric dangerousness, curability and the ability to readapt of the subject. ResultsThirty-eight assessments out of the 763 collected concluded in abolition of judgment, a frequency of 4.98%. The subjects suffered from a schizophrenia spectrum disorder or a paranoid delusional disorder (85.2%). The most present clinical elements were paranoid delusions of persecution (23.1%), from intuitive, interpretative, hallucinatory or mental automatism mechanisms (39.7%) and dissociative syndrome (10.7%). Subjects with abolished judgment weren’t always considered dangerous (for 34.3% of individuals) even if a schizophrenia diagnosis was correlated (f=0.03). Forced hospitalisation was proposed in 50% of assessments and associated with the conclusion of dangerousness (f=0.01). ConclusionsSchizophrenia spectrum disorders or paranoid delusional disorders are the most common pathologies in forensic psychiatric assessments concluding in abolition of judgment.

The paranoia as defence model of persecutory delusions: a systematic review and meta-analysis

An influential psychological model of persecutory delusions proposed that they are caused by a bias towards holding others responsible for negative events (an externalising attributional bias), preventing the individual from becoming aware of underlying low self-esteem. An early version of the model predicted self-esteem would, therefore, be preserved in people with these delusions, but a later version suggested it would be unstable, and that there would be a discrepancy between explicit and implicit self-esteem, with the latter being lower. We did a comprehensive meta-analytical test of the key predictions of this model and assessed the quality of evidence. We searched PubMed from Jan 1, 1994, to July 31, 2018, and collated systematic reviews of the defensive model's predictions in relation to persecutory delusions. We also searched PsycINFO, MEDLINE, Embase, and Web of Science for articles published from Jan 1, 2012, to Sept 10, 2016. Cross-sectional data from case-control, longitudinal, or experimental studies that examined self-esteem or the externalising attributional bias in individuals diagnosed as having schizophrenia-spectrum disorder were eligible for meta-analyses of group differences if at least 50% of participants with psychosis also had current persecutory delusions. Uncontrolled and longitudinal studies were included in meta-analyses of correlations and self-esteem instability, respectively. Study and outcome quality were assessed with the Agency for Healthcare Research and Quality assessment tool, and a modified version of Grading of Recommendations Assessment, Development and Evaluation, respectively. The study protocol is registered with PROSPERO, number CRD42016032782. We screened 3053 records, examined 104 full-text reports, and included 64 eligible studies. Consistent with the predictions of both versions of the model, paranoia severity in psychosis was positively correlated with the degree of externalising attributional bias (21 studies involving 1128 individuals; r=0·18, 95% CI 0·08 to 0·27, with moderate quality evidence). People with persecutory delusions also had a greater externalising attributional bias than non-clinical individuals (27 studies involving 1442 individuals; g=0·48, 95% CI 0·23 to 0·73) and depressed individuals (ten studies involving 421 individuals; g=1·06, 0·48 to 1·63), and people with psychosis without persecutory delusions (11 studies involving 480 individuals; g=0·40, 0·12 to 0·68), all based on moderate quality evidence. Contrary to the predictions in the early version of the model, paranoia severity in psychosis was negatively correlated with explicit self-esteem (23 studies involving 1866 individuals; r=-0·26, 95% CI -0·34 to -0·17, with high quality evidence). People with persecutory delusions also had lower explicit self-esteem than non-clinical individuals (22 studies involving 1256 individuals; g=-0·88, 95% CI -1·10 to -0·66, with high quality evidence) and explicit self-esteem similarly low to that in people with psychosis without persecutory delusions (11 studies involving 644 individuals; g=-0·26, -0·54 to 0·02, with moderate quality evidence). Consistent with the predictions in the later version of the model, self-esteem instability was positively correlated with paranoia severity in psychosis (four studies involving 508 individuals; r=0·23, 95% CI 0·11-0·34, with high quality evidence), and people with persecutory delusions had a greater discrepancy between their implicit and explicit self-esteem than depressed individuals (seven studies involving 398 individuals; g=0·61, 95% CI 0·37 to 0·85, with moderate quality evidence). They had higher explicit self-esteem than depressed individuals (13 studies involving 647 individuals; g=0·89, 95% CI 0·51 to 1·28, with moderate quality evidence), but similarly low implicit self-esteem (seven studies involving 398 individuals; g=-0·19, -0·45 to 0·07, with low quality evidence). In contrast to the later predictions, people with persecutory delusions did not have a greater self-esteem discrepancy than non-clinical individuals (ten studies involving 592 individuals; g=-0·17, 95% CI -0·45 to 0·12), although the evidence was very low quality. People with psychosis with or without persecutory delusions did not differ for implicit self-esteem (four studies involving 167 individuals; g=-0·24, 95% CI -0·77 to 0·30, with low quality evidence) or self-esteem discrepancies (four studies involving 165 individuals; g=0·17, -0·19 to 0·53, with moderate quality evidence). The predictions that self-esteem would be preserved in people with persecutory delusions in the early version of the paranoia as defence model and that implicit-explicit self-esteem discrepancy would be greater in people with persecutory delusions than in non-clinical individuals and people with psychosis without persecutory delusions in the later version of the model were not supported. By contrast, the later version correctly predicted that people with persecutory delusions have a greater self-esteem discrepancy than people with depression and a greater externalising attributional bias than all control groups, and that both this bias and self-esteem instability are associated with increased paranoia severity. Nevertheless, the reviewed data had limitations. Experimental studies, which might include interventionist-causal trials, are needed. None.

Is the paranoia as defence model of persecutory delusions defensible?

Is the paranoia as defence model of persecutory delusions defensible?

No Link Between City Living, Psychosis Found in Poorer Countries

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessNo Link Between City Living, Psychosis Found in Poorer CountriesMark MoranMark MoranSearch for more papers by this authorPublished Online:21 Sep 2018https://doi.org/10.1176/appi.pn.2018.8b22AbstractA study in poorer, developing countries explodes a long-held hypothesis and suggests that the association between “urbanicity” and psychosis in wealthier countries is an artifact of variables specific to city living there.City dwellers in poorer, developing countries are not at greater risk of psychosis, a finding that counters multiple studies in wealthy, developed countries showing an association between “urbanicity” and psychosis. A report appearing in the July JAMA Psychiatry, however, suggests that the association between urbanicity and psychosis, rather than being a universal phenomenon, may be a feature of industrialized countries only.Jordan E. DeVylder, Ph.D., an associate professor in the graduate school of social service at Fordham University, and a team of international researchers analyzed data from the World Health Organization (WHO) World Health Survey, which was conducted in 70 countries from May 2, 2002, through December 31, 2004. Data from a total of 42 countries were analyzed in the final sample, including 17 classified by WHO as “low-income countries” and 25 classified as “middle-income countries.”A total of 215,682 respondents whose place of residence at the time of the survey was either “urban” or “rural” were included in the analysis. Respondents were asked the following questions with answer options of “yes” or “no.”During the last 12 months, have you experienceda feeling that something strange and unexplainable was going on that other people would find hard to believe? (delusional mood)a feeling that people were too interested in you or there was a plot to harm you? (delusions of reference and persecution) a feeling that your thoughts were being directly interfered with or controlled by another person or your mind was being taken over by strange forces? (delusions of control)an experience of seeing visions or hearing voices that others could not see or hear when you were not half asleep, dreaming, or under the influence of alcohol or drugs? (hallucinations)Individuals who endorsed at least one of these four symptoms were considered to have had psychotic experiences.Overall, no significant association of urban residence with psychotic experiences was found in either low-income or middle-income countries. The pooled odds ratio for the association between urbanicity and psychotic experiences for all countries was 0.99 (nonsignificant). Associations between urbanicity and psychotic experiences remained nonsignificant when examined separately in younger adults (aged 18 to 29 years) and those 30 years or older.The researchers suggested that the results call for a re-interpretation of studies—mainly from wealthy, developed countries—showing an association between psychosis and city living. Specifically, it indicates that urbanicity has been a proxy for other variables unique to wealthy, developed countries.“Speculatively, urban-rural disparities in economic deprivation and social isolation in high-income countries may not be present or may be less evident in low- and middle-income countries,” they wrote. “Affluent members of society tend to populate suburban areas in high-income countries, which differs from developing countries. Furthermore, familial and social cohesion may remain stronger in urban areas of developing countries.”In an editorial accompanying the study, John McGrath, M.D., Ph.D., a professor in the school of clinical medicine at Queensland Brain Institute in New Zealand, and two other authors noted that the new study upsets a long unquestioned hypothesis. “Psychiatric epidemiology has a longstanding interest in understanding how the social environment influences mental health,” they wrote. “It felt good to implicate the social environment as a risk factor for schizophrenia; it helped ward off accusations of biological reductionism. If we could address social inequality and reduce discrimination against minority groups, reduce overcrowding, and improve neighborhood social capital, could we reduce the incidence of schizophrenia? It was a very appealing and comforting hypothesis.”McGrath and colleagues concluded: “We now know that these differences appear consistently in high-income Nordic and northern European countries but vanish in low- and middle-income countries. If these findings are mediated by social adversity and neighborhood-level stressors, then the research community will need to revise and particularize hypotheses for some countries but not others. New hypotheses and targeted research investments are strongly needed in this field. This will be the challenge for the next generation of researchers.” ■“Associations of Psychosis With Urbanicity in Low- and Middle-Income Countries” can be accessed here. The editorial is posted here. ISSUES NewArchived

Examining reasoning biases in schizophrenia using a modified “Jumping to Conclusions” probabilistic reasoning task.

Although the Jumping To Conclusion (JTC) bias has been extensively studied in relation to schizophrenia and persecutory delusions, the relationship between JTC and other reasoning biases implicated in delusional ideation is not fully understood. We modified the traditional JTC task to assess co-occurrence of reasoning biases in decision making. Forty-six patients with schizophrenia and 46 healthy controls completed two versions [neutral colored beads and salient comments] of the modified task. We replicated previous findings indicating that patients showed a greater JTC bias, and in both groups, the JTC bias was more pronounced for the salient task. However, we observed a significant effect for non-Bayesian judgments, indicating that patients showed greater difficulty in probabilistic reasoning. When controlling for probabilistic reasoning ability, the observed JTC bias effects were diminished. Our findings that faulty probability assessment accounts for the JTC bias indicates that the traditional JTC bias task may not represent an inherent hasty decision-making bias, but rather an inability to fully understand and execute the stated goals of the task. These results call into question the current understanding of the JTC bias and the independence of this bias apart from the cognitive demands of the task.

Esquizofrenia: papel-chave do Médico de Família e recurso ao internamento em regime compulsivo

Introduction: Schizophrenia is a syndrome characterized by changes in thinking, mood and behaviour. Patients with this disorder lack insight into the disease, which often leads to non-adherence to treatment and worsening of symptoms. Compulsory admission is a last resort in these situations. Because of the difficulty in assessing these patients, close monitoring by the family doctor is required. Thus it is possible to assess the effects of the disease and permit timely initiation of psychiatric treatment. Case description: A 48 year-old woman, divorced, unemployed, and living alone, who was diagnosed with schizophrenia at age 30, consulted her family doctor with persecutory delusions and delusional interpretations. Over a period of four months, she consulted with her family doctor for the same reasons, with a progressive deterioration in her condition. The situation evolved to a state of aggression with immediate danger to herself and others. Because she refused the necessary treatment, the health authority was contacted to arrange for compulsory admission. Comment: Schizophrenia is a highly debilitating disease. When not under control, exacerbations in clinical status are difficult to manage. Portuguese law permits compulsory admission. The family doctor has health resources available and a privileged knowledge of the patient and the family, which can be used effectively to manage psychiatric deterioration.

Football hooliganism, the death drive and Millwall fandom as symbolic masochism

Despite their reputation for violence and hooligan behaviour, south-east London’s Millwall football club has sustained a strong fan base thanks significantly to the siege mentality that has developed around its supporters. This siege mentality is fuelled largely by the antipathy of wider society; by undertaking a Freudian analysis of Millwall fandom as it was during the zenith of the club’s notoriety in the 1970s and 1980s, it is possible to view this collective persecution complex as a manifestation internalized masochism described in the philosopher’s ‘death drive’ theory. Combined with a Lacanian interpretation of the death drive, it is possible to perceive Millwall fandom as a form of symbolic masochism, explaining to some degree the continued support for a team treated in a consistently pejorative manner.

La paranoïa : des aliénistes au DSM-5

From ancient Greek, paranoia, made up of para “besides” and noos “thought, mind”, signifies behaviour “against understanding”. The term paranoia has taken on diverse meanings throughout years and places. In France, paranoia has corresponded to the delusion of persecution as described by Lasègue in 1852, himself a descendant of Esquirol's monomaniacal delusional descriptions. Later, the delusional interpretations of Serieux and Capgras in 1909 or of “folie raisonnante” comes closer to the paranoia described by Kraepelin in 1898 as “a lasting delusional system impossible to undermine and which is established with a complete conservation of clarity and thought order”. Classically, paranoia is thus described as a chronic psychosis of progressive installation and of relatively late emergence (after 35 years of age). In traditional French nosography, we distinguish 3 subtypes: interpretation delusions, passionate delusions (erotomanic, of jealousy and of vengeance) and sensitive delusions. Today, paranoia delusions do not appear as such in the DSM-5 but we find it in “delusional disorders” characterised by the presence of delusional ideas lasting more than one month and which do not fill the criteria of a schizophrenic diagnosis, with the absence of marked alterations in functioning or strangeness. The subtypes are erotomanic, megalomaniac, of jealousy, of persecution and somatic. Furthermore, we find paranoia personality disorders, characterized by an overwhelming suspicion and mistrust towards others, whose intentions are interpreted as malicious. The continuum between personality and delusion remains controversial and recent neurocognitive research shines light on cognitive bias associated to strong anxious components.

La théorie de la dissociation structurelle de la personnalité pour conceptualiser et traiter la psychose dissociative : deux études de cas

ObjectivesWe present the theory of the structural dissociation of the personality as a way to conceptualize dissociative psychosis and illustrate this with two case studies. This theory was developed to help understand trauma related disorders, i.e. dissociative disorders. In line with Janet's work, this theory states that a traumatic event can lead to a division (dissociation) of the personality in two or more parts: an apparently normal part of the personality deals with daily life activities and avoids the traumatic memories, and one or more emotional parts of the personality stay fixated on the traumatic experience and can reach a certain autonomy as in dissociative identity disorder. Dissociative psychosis is understood as the intrusion of emotional parts into the apparently normal part, which gets overwhelmed, with psychotic-like intrusions. In the most severe cases, an emotional part takes over the executive role over a long period of time. Patients/methodsThe first case study is a male patient suffering from repetitive (at least once a year) psychotic episodes with a normal nonpsychotic functioning between episodes. Main psychotic symptoms are mystic delusions, verbal auditory hallucinations and disorganized thinking. Hypnotherapeutic interventions allowed an evaluation of a possible structural dissociation, which then led to the diagnostic of dissociative psychosis. A psychotherapy based on the theory of structural dissociation was then engaged. The second case study is a female patient with depersonalization disorder and a dissociative psychosis several weeks after the traumatic birth of her twin children. Psychotic symptoms were mystic, referential and persecutory delusions. ResultsIn the first case, after three years of adapted psychotherapy, the patient showed no relapse of dissociative psychosis and did not need any hospitalization. A single risk of relapse was avoided with one session of adapted hypno-imaginative interventions. In the second case, after three sessions of hypnotherapeutic treatment based on the theory of the structural dissociation of the personality, the patient was symptom free, also at two and half years follow up. ConclusionsThe theory of the structural dissociation of the personality is useful in conceptualizing dissociative psychosis. Hypnotherapeutic and hypno-imaginative interventions with a light trance and adapted to this theory can be useful in the treatment of such a disorder. Such interventions can help clinicians enter the patient's inner world to better understand the meaning of the symptoms and then suggest a resolution for the trauma related emotional parts involved in the expression of the psychotic-like symptoms. We discuss the necessity of an official diagnostic for this disorder that could be better named reactive dissociative psychosis or reactive dissociative disorder with psychotic features. Clinicians need to be aware of this specific diagnostic that may benefit from specific psychotherapeutic interventions, probably better adapted than those needed for real psychotic disorders.

Persecutory delusions: effects of Cognitive Bias Modification for Interpretation and the Maudsley Review Training Programme on social anxiety, jumping to conclusions, belief inflexibility and paranoia

Background and objectivesThe Threat Anticipation Model (Freeman, 2007) implicates social anxiety, jumping to conclusions (JTC) and belief inflexibility in persecutory delusions. We investigated whether Cognitive Bias Modification for Interpretation (CBM-I; Turner et al., 2011) improves social anxiety by targeting negative interpretation bias of ambiguous social information. We determined whether the Maudsley Review Training Programme (MRTP; Waller et al., 2011) improves JTC, belief inflexibility and paranoia. We also explored effects of CBM-I on JTC/belief inflexibility and paranoia, as well as the MRTP on social anxiety. MethodsTwelve participants from Early Intervention and Recovery Services in East Anglia completed measures of social anxiety, paranoia, JTC and belief inflexibility. A concurrent multiple baseline case series design was used. ResultsThree of twelve participants improved in social anxiety following CBM-I, paranoia improved in 6/12 cases. CBM-I had no effect on JTC/belief inflexibility. The MRTP improved JTC and/or belief inflexibility in 9/12 cases, while improving paranoia for 6/12 individuals. The MRTP improved social anxiety in one case. LimitationsThe small sample size and large effects necessary for single case series designs limit the generality of findings. These are discussed in more detail. ConclusionsThis study suggests that whilst both CBM-I and the MRTP may have a positive impact on paranoia and social anxiety, the effects on JTC/belief inflexibility are largely specific to the MRTP. Relationships between social anxiety, JTC, belief inflexibility and paranoia existed in 10/12 individuals, supporting the Threat Anticipation Model.

The relationship between illicit amphetamine use and psychiatric symptom profiles in schizophrenia and affective psychoses

This study examines whether illicit amphetamine use is associated with differences in the prevalence of specific psychiatric symptoms in a community sample of individuals diagnosed with schizophrenia or affective psychotic disorders. Data was drawn from the Australian Survey of High Impact Psychosis. The Diagnostic Interview for Psychosis was used to measure substance use and psychiatric symptoms. Participants had used amphetamine within their lifetime and had an ICD-10 diagnosis of schizophrenia (n = 347) or an affective psychotic disorder (n = 289). The past year prevalence of psychiatric symptoms was compared among those who had used amphetamine in the past year (past-year use, 32%) with those who had not (former use, 68%). Univariate logistic regression analysis indicated that past-year users with schizophrenia had a significantly higher past year prevalence of hallucinations, persecutory delusions, racing thoughts, dysphoria, and anhedonia relative to former amphetamine users with schizophrenia. There were no significant differences in symptoms between past-year and former users with affective psychotic disorders. The relationship between amphetamine use and specific psychiatric symptoms varies across different psychotic disorders. Amphetamine use may hinder prognosis by exacerbating symptoms of schizophrenia through dopaminergic dysfunctions or depressive vulnerabilities, however, this needs to be confirmed by prospective longitudinal research.

Delusional Themes Across Affective and Non-Affective Psychoses.

The current debate about the diagnostic significance of delusion revolves around two positions. The neurocognitive position conceives delusion as a non-specific, though polymorphic, symptom. The psychopathological position views features of delusion such as content and structure as having meaningful connections with diagnostic entities. This study aims at contributing to this debate by examining the association between delusional themes and diagnosis in a sample of 830 adult psychotic patients. All diagnoses were made by experienced psychiatrists according to DSM-IV or ICD-10 criteria, and in 348 patients were established with the SCID-I. All patients were administered the Brief Psychiatric Rating Scale (BPRS). In each patient, the presence of somatic delusions and delusions of guilt, grandiosity, and persecution was determined by examining the scores on relevant BPRS items. Delusions of guilt were almost pathognomonic for a psychotic depressive condition (psychotic major depression 40%; psychotic bipolar depression 30%; depressed schizoaffective disorder 8%; bipolar and schizoaffective mixed states 6 and 7%, respectively). Only 1% of patients with schizophrenia and no patient with delusional disorder or bipolar or schizoaffective manic state showed such delusions. The difference between unipolar and bipolar depression and the other diagnostic groups was highly significant. Delusions of grandiosity characterized mostly patients with manic symptoms (bipolar mania 20%; bipolar mixed states 19%; manic schizoaffective disorder 10%). They were observed significantly more often in bipolar mania than in schizophrenia (7%). Persecutory delusions were broadly distributed across diagnostic categories. However, they were significantly more frequent among patients with schizophrenia and delusional disorder compared with depressed and manic patients. Somatic delusions were also observed in all diagnostic groups, with no group standing out as distinct from the others in terms of an increased prevalence of somatic delusions. Our findings suggest a middle position in the debate between the neurocognitive and the psychopathological approaches. On the one hand, the widespread observation of persecutory delusions suggests the usefulness of searching for non-specific pathogenic mechanisms. On the other hand, the association between some delusional contents and psychiatric diagnosis suggests that a phenomenological analysis of the delusional experience may be a helpful tool for the clinician in the diagnostic process.

F79. ATTRIBUTION OF INTENTIONS IN PATIENTS WITH SCHIZOPHRENIA SPECTRUM DISORDERS WITH PERSECUTORY DELUSIONS

BackgroundSocial cognitive deficits are considered hallmark features of schizophrenia spectrum disorders. Consistent patterns of relationships have been established between theory of mind impairment and severity of negative symptoms. Some studies have suggested that patients, specifically those with persecutory delusion, can over attribute intentions. Difficulties in theory of mind in patients with schizophrenia can vary between hypo and hyper – mentalization depending on the level of symptoms. The aim of the study was to test model which proposed hypo -mentalization vs. hyper - mentalization deficit in patients with schizophrenia spectrum disorders with persecutory delusions.Methods40 patients diagnosed with schizophrenia spectrum disorder, 19 patients with anxiety, affective and personality disorders without persecutory delusions, and 28 healthy controls were enrolled in the study. Diagnoses were established according to ICD-10 criteria. Animation Task was used for theory of mind assessment. Task consists of 12 videos (moving triangles) with three types of stimuli (random, goal-directed and theory of mind – condition). Stimuli were presented in fixed, random order before symptom assessment. Participants were asked to describe content of videos, and the degree of intentionality and appropriateness was evaluated by two raters according to task`s manual. Mutual rating of raters was used in the present analysis. Brief Psychiatric Rating Scale was used for assessment of symptoms severity.ResultsA repeated measures ANOVA with stimuli type as within-factor and group as between-factor revealed significant effect of Stimuli type (F= 171.585, p < .001), and interaction of factors (F = 5.401, p = .001) on rating of intentionality. Group effect was not significant (F= .836, p = .437). Patients with schizophrenia had significantly lower ratings of intentionality in theory of mind condition, specifically. A second repeated measures ANOVA analyzed differences in levels of appropriateness. Results revealed significant effect of stimuli type (F= 12.698, p < .001), group (F= 6.966, p = .002) and interaction of factors (F = 3.211, p = .020). Responses of patients with schizophrenia were less appropriate than controls in goal-directed and theory of mind condition compared to the random condition. Severity of negative symptoms was associate with lower level of intentionality in random condition. Hostility and suspiciousness were associated with higher level of intentionality in goal directed (rs=.330, p=.037) and theory of mind conditions (rs=.348, p=.028). Severity of suspiciousness was moderately to strongly associated with appropriateness of descriptions in all conditions (rs from -.423 to -.517).DiscussionResults of study highlighted importance of distinguishing between hyper- and hypo-mentalization in patients with schizophrenia as specific impairments were associated with positive and negative symptoms, respectively. Over attribution of intentions to random movement was moderately associated with paranoid symptoms. Patients provided less appropriate descriptions which was associated with higher level of suspiciousness. Implications for development, maintenance treatment of persecutory delusions will be discussed.Research was supported by Psychiatric Society of Slovak Medical Agency – grant no: 02/2015