Delusions Of Guilt Research Articles

Case presentation: Very early combined first-line immunotherapy and surgery in tumor-associated anti N-methyl-d-aspartate (NMDA) receptor encephalitis associated with improved outcome

IntroductionAnti N-methyl-d-aspartate receptor (anti-NMDA-R) encephalitis is a potentially reversible cause of psychosis. Nearly all patients (>95.5%) quickly develop additional neurological symptoms, and only about 50 percent fully recover, often with latency. At symptom onset, patients commonly present with isolated psychosis, making it challenging to distinguish the disease from a primary psychiatric disorder: The median time from symptom onset to immunotherapy in adults is 28 days (IQR 14–49), and from symptom onset to surgery in tumor-associated cases 1.4 months (IQR 0.7–2.6). Steroids, intravenous immunoglobulins (IVIG), or plasmapheresis are recommended as first-line immunotherapies.ObjectivesTo highlight a case with improved outcome after very early combined first-line immunotherapy (steroids plus IVIG) and surgery in tumor-associated anti-NMDA-R encephalitis.MethodsWorkup of the clinical case followed by a review of the literature.ResultsWe present the case of a 33-year-old woman with sudden onset of anxiety and jealousy ideas, which within a few days, developed a manifest psychosis with formal thought disorders, paranoid and guilt delusions, distrust, and orientation disorders in the absence of additional neurological deficits. A lower abdominal tumor suspicious of an ovarian tumor was detected sonographically five days before the onset of the first symptoms. Lumbar puncture and abdominal computer tomography were performed within 30 hours after hospital admission, confirming the diagnosis of tumor-associated anti-NMDA-R encephalitis with autoantibodies in CSF and serum at a very early clinical stage. First-line immunotherapy with steroids (methylprednisolone 1000mg, day 6 to 10 after symptom onset) was started immediately and combined with IVIG therapy (0.35g/kg, day 9 to 13 after symptom onset). Surgery of the ovarian tumor was performed on day 14 after admission, with histology revealing an immature teratoma. The neuropsychatric examination on day 1 after surgery showed complete remission of clinical symptoms, which persisted during clinical follow-up after 1 and 4 months.ConclusionsThe present case highlights the role of early CSF diagnostic and tumor assessment if autoimmune encephalitis is suspected. Very early first-line immunotherapy with steroids and IVIG, complemented by tumor surgery, was associated with improved outcome in this case with anti-NMDA-R encephalitis. Further studies are warranted to evaluate the generalizability of the finding.Disclosure of InterestNone Declared

Comparison of the Phenomenology of Hallucination and Delusion Characteristics in People Diagnosed With Borderline Personality Disorder and Schizophrenia.

Hallucinations and delusions in borderline personality disorder (BPD) are understudied. The authors explore the phenomenology of multisensory hallucinations and delusions in individuals with BPD and compare them to those in individuals with schizophrenia spectrum disorders (SSD). Clinical psychopathology was also explored. Eighty-nine adults participated and were categorized into four groups: BPD with voices, BPD without voices, SSD with high BPD traits, and SSD with low BPD traits. Among individuals with BPD, 81% reported visual and tactile hallucinations, 75% reported olfactory hallucinations, and 94% experienced delusions. When comparing BPD with and without voices, there were no significant differences in nonpsychotic psychopathology. Slight differences were found when hallucinations in BPD were compared with hallucinations in SSD, but overall the experiences were similar across diagnoses. The BPD group also reported significantly higher rates of paranoia/suspiciousness and delusions of guilt than the SSD group. Multisensory hallucinations and delusions occur in BPD and should be explored when treating people with BPD.

Patients With Refractory Bipolar Depression May Benefit From ECT

Patients With Refractory Bipolar Depression May Benefit From ECT

Association of treatment facets, severity of manic symptoms, psychomotor disturbances and psychotic features with response to electroconvulsive therapy in bipolar depression

Objectives Clinically useful predictors of response to electroconvulsive therapy (ECT) are warranted, especially in the case of bipolar depression. The aim of this study was to explore the associations between response and its known and putative correlates. Methods Six hundred seventy bipolar depressive patients treated with ECT were included in the study. The association between response (CGI-I ≤ 2) and mean seizure duration, number of treatments, age, sex, bipolar subtype, episode duration, HAM-D and YMRS scores, psychomotor disturbances and psychotic symptoms assessed through BPRS-EV were evaluated by means of univariate and multivariate logistic regression models, including quadratic and/or linear effects of continuous variables. Results Four hundred eighty three patients (72%) were responders. Among known correlates of response, significant quadratic effects were found for seizure duration and number of treatments, while a linear association was confirmed for episode duration. Among putative correlates, severe motor retardation, tension or agitation, hyperactivity and delusions of guilt were significantly associated with response (p<.01) and a significant quadratic effect was found for YMRS score (p<.01). Conclusion Bipolar depressive patients with severe psychomotor disturbances, mood-congruent delusions and severe mixed features are highly responsive to ECT. A significant improvement in response prediction is expected when considering those clinical characteristics.

Psychosis in a Young Patient with a Left Temporal Arachnoid Cyst: A Case Report

Background: Psychiatric disorders can be caused by organic conditions. Arachnoid cysts are suggested to be related to psychiatric disorders since many case reports have be published presenting coexistence of arachnoid cyst and psychosis. Case report: An 18-year-old single male was admitted to the psychiatry hospital with severe fearfulness, disorganized behavior, decreased sleep, and refusal of oral intake. He had delusions of guilt, persecution and misidentification. He also showed periods of incoherent and very poor speech, perplexity, disorientation, and some catatonic features. There was no history of substance use or significant medical problem. Physical, including neurological, examination and laboratory investigations were normal. A brain CT revealed the presence of an arachnoid cyst in the left temporal lobe. He was treated pharmacologically with partial and slow response. Conclusion: Causal relationship between arachnoid cyst and psychosis is difficult to be concluded in this case, but the possibility should not be ignored. This case is reported from Arab region where there is lack of such publications. More in-depth research is needed.

Guilt Delusional Beliefs Increase the Risk of Suicidal Attempt in Elderly Unipolar Psychotic Depressives.

The aim of this study was to investigate the differential effect of various delusion categories, namely, guilt, paranoid, impending disaster, and somatic on suicidal attempts in elderly patients experiencing unipolar psychotic major depression (PMD), because the evidence on this is scarce. The sample consisted of 65 consecutively admitted patients 60 years or older, experiencing PMD, and assessed by means of Structured Clinical Interview for DSM-4 (Patient Edition), Hamilton Depression Rating Scale, Mini-Mental Status Examination (MMSE), and by a physical impairment rating scale. Patients with guilt delusional beliefs had 5.31 times higher odds (95% confidence interval, 1.37-25.40) of a suicidal attempt than the patients without guilt delusional beliefs, controlling for sex, age, prior history of suicide attempt, MMSE, and hallucinations. In addition, 17 PMD patients with lifetime suicidal attempt compared with 48 PMD patients without lifetime suicidal attempt presented only higher age of disorder onset (p = 0.008). Of the four categories of delusions assessed, only guilt delusions were associated with an increased risk for suicidal attempt.

Religious delusions in older adults: Diagnoses, combinations, and delusional characteristics.

Religious delusions (RDs) tend to occur relatively often in patients with affective or non-affective psychosis. Few studies exist about RDs in later life. The current study explores (1) the distribution of RDs across diagnosis, (2) how RDs relate to other types of delusions, and (3) how RDs relate to several dimensions or characteristics of delusions. Inpatients and outpatients in a Geriatric Psychiatry Department in the Netherlands (N=155; mean age 76.5years), and who were diagnosed with an affective or non-affective psychotic disorder, participated in semi structured diagnostic interviews, using the Schedules for Clinical Assessement in Neuropsychiatry 2.1. Religious delusions were most common among patients with psychotic depression (47%) and schizophrenia (32%). The RDs frequently co-occurred with other types of delusions. When combined with delusions of grandeur, RDs were more often classified as bizarre and were accompanied by higher levels of positive psychotic symptoms. When combined with delusions of guilt, RDs were associated with higher levels of distress and a shorter disease duration. The delusional characteristics bizarreness, frequency of psychotic symptoms, and degree of distress were more prevalent for RDs than for any other type of delusion. The current study suggests that the prevalence of RDs in older adults is particularly high in late life psychotic depression. Also, in later life, RDs can be perceived of as independent marker of complex psychotic states, and as a denominator of severe arousal with respect to existential concerns.

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.

Assessment of psychotic symptoms in bipolar disorder

IntroductionBipolar disorder is a disabling condition characterized by the presence of manic, depressive, hypomanic or mixed episodes, affective symptoms that may coexist with several types of psychotic features.ObjectivesThe purpose is to evaluate the frequency of psychotic symptoms among bipolar disorder.MethodThe study included 55 bipolar patients admitted in the Psychiatry Clinical Hospital from January 2012 until May 2013. Inclusion criteria were represented by diagnosis of bipolar disorder, manic or depressive episode, according to DSM-IV-TR and ICD 10 criteria. Clinical instruments used to assess the severity of the current affective episode were Young Mania Rating Scale (YMRS) for manic patients and Hamilton Depression Rating Scale-17 items – (HDRS) for the depressive ones. Psychotic symptoms were evaluated with the Brief Psychiatric Rating Scale-18 items – (BPRS).ResultsOut of the 55 patients, 32 had psychotic symptoms upon admission to the hospital. BPRS results showed delusions of guilt, inutility, hypochondriac and nihilistic delusions for the depressed patients. Delusions of grandiosity and megalomania accounted for most of psychotic symptoms in manic patients. A smaller number of patients showed delusions of invention and reform. Perception disturbances such as auditory hallucinations were present in both diagnosis categories but in a higher percentage in depressive bipolar patients.ConclusionsEven if less frequently than in schizophrenia or schizoaffective disorder, psychotic symptoms are present in bipolar disorder. They influence the general functioning and the outcome of patients diagnosed with this illness.Disclosure of interestThe authors have not supplied their declaration of competing interest.

A COMPARISON OF DYSFUNCTIONAL THOUGHTS BETWEEN ACTIVE AND PASSIVE STUDENTS OF RAZAVI UNIVERSITY OF ISLAMIC SCIENCES

Inefficient mental representation and negative cognitive structures are occurring when a negative event would active inefficient schema. Negative schemas are continuing when people apply a false logic. For example, generalize too much negative items or have more attention to negative issues. One of the measures of inefficient thoughts is depression. Depression is one of the most common psychiatric disorders. The World Health Organization classified depression in the fourth row of the most acute problems of public health across the world. This disorder can disrupt people's normal life such that causes to severe reduction in enjoy daily activities such as socializing, recreation, sports, food, and sex. This inability is reliable and effective. For patient the food is tasteless, job is boring and former meaningful associations would become inane and meaningless. Depressed people are desperate and isolated in terms of emotional, in terms of cognitive features they are suffer from slowdown in thinking process, anxiety, obsessive, inability to make decisions, negative self-concept, self-blame and guilt delusions, in terms of energetic qualities they suffer from Fatigue, loss of appetite and sleep loss and delusions of sin and disease. Article visualizations:

Cotard’s Syndrome: Clinical Case Presentation and Literature Review

In 1880 French neurologist Jules Cotard described a condition characterized by delusion of negation (nihilistic delusion) in a melancholia context. Recently, there has been a resurgence of interest in Cotard’s syndrome. The most prominent symptoms of Cotard’s Syndrome are depressive mood, nihilistic delusions concerning one’s own body and one’s own existence, delusions of guilt, immortality and hypochondria. The aim of the present

Presentación atípica de síntomas psiquiátricos: enfermedad de Fahr

Fahr disease is a syndrome of unknown etiology, consisting of bilateral idiopathic calcifications of basal ganglia and neuropsychiatric symptoms. We describe the case of a 70 year old man with no psychiatric background, admitted to the hospital due to the presence of depressive symptoms with economic and guilt delusions and suicidal idea. He suffered a depression 3 years ago that completely resolved with mirtazapine, and calcifications of basal ganglia were a casual finding in the CT. In the current hospital admission, the lack of efficacy of antidepressant, antipsychotic and anxiolytic treatment lead to a severe melancholy stupor that indicated electroconvulsive therapy, which controlled both the psychotic and affective symptoms, but a cognitive impairment state was observed once the psychiatric symptoms resolved.

Genome-wide significant association between a 'negative mood delusions' dimension in bipolar disorder and genetic variation on chromosome 3q26.1.

Research suggests that clinical symptom dimensions may be more useful in delineating the genetics of bipolar disorder (BD) than standard diagnostic models. To date, no study has applied this concept to data from genome-wide association studies (GWAS). We performed a GWAS of factor dimensions in 927 clinically well-characterized BD patients of German ancestry. Rs9875793, which is located in an intergenic region of 3q26.1 and in the vicinity of the solute carrier family 2 (facilitated glucose transporter), member 2 gene (SLC2A2), was significantly associated with the factor analysis-derived dimension ‘negative mood delusions' (n=927; P=4.65 × 10−8, odds ratio (OR)=2.66). This dimension was comprised of the symptoms delusions of poverty, delusions of guilt and nihilistic delusions. In case–control analyses, significant association with the G allele of rs9875793 was only observed in the subgroup of BD patients who displayed symptoms of ‘negative mood delusions' (allelic χ2 model: PG=0.0001, OR=1.92; item present, n=89). Further support for the hypothesis that rs9875793 is associated with BD in patients displaying ‘negative mood delusions' symptom, such as delusions of guilt, was obtained from an European American sample (GAIN/TGEN), which included 1247 BD patients and 1434 controls (PEA=0.028, OR=1.27).

Misdiagnoses Common in Cases of Depression With Psychosis

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessMisdiagnoses Common in Cases of Depression With PsychosisJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:3 Oct 2008https://doi.org/10.1176/pn.43.19.0020The diagnosis of major depression with psychotic features is often missed in patients, especially in the emergency room, a study reported in the August Journal of Clinical Psychiatry pointed out.The study, which was headed by Anthony Rothschild, M.D., chair of psychiatry at the University of Massachusetts, included 65 inpatients at four academic medical centers. Subjects were recruited from a larger study called the National Institute of Mental Health Study of Pharmacotherapy of Psychotic Depression (STOP-PD), and STOP-PD researchers had determined that all of them had psychotic depression.Moreover, to be in their study, Rothschild explained to Psychiatric News, “all subjects were required to have at least one delusion, and some also had hallucinations. The delusions were most typically somatic delusions, paranoid delusions, delusions of guilt, delusions of poverty, and nihilistic delusions that bad things are about to happen.”Rothschild and his colleagues then gathered each patient's hospital records from the time preceding their enrollment in the STOP-PD study to see what types of diagnoses he or she had received in the hospital emergency room or hospital psychiatric unit. The 65 inpatients had received, altogether, 130 diagnoses, meaning that some had received several diagnoses. Finally Rothschild and his team looked to see whether these 130 diagnoses had been made correctly.Over one-fourth had not, the researchers found. The three most common misdiagnoses were major depressive disorder without psychotic features, depression not otherwise specified, and mood disorder not otherwise specified. Misdiagnoses made less often included delirium, anxiety disorder not otherwise specified, and alcohol dependence.The erroneous diagnoses were more common in emergency rooms than on inpatient psychiatric units, and as Rothschild and his colleagues pointed out,“ It is quite striking that none of the patients with missed diagnoses were considered to have a psychotic disorder. This finding suggests that the physicians are missing the psychosis rather than the mood disorder. In many cases, it may be that the physician does not miss the symptom (for example, guilt, poverty, persecution), but does not recognize that the symptom is a delusion. In particular, the distinction between delusional and nondelusional guilt is frequently difficult.”These findings have important clinical implications, the researchers believe, since major depression with psychotic features often entails considerable morbidity and mortality, and its treatment differs from that for major depression alone. According to the APA 2000 practice guideline on the disorder, either an antipsychotic with an antidepressant or electroconvulsive therapy should be used, they noted.“As the process for DSM-V is beginning,” they continued, “it will be important to revisit the issue of whether 'major depression with psychotic features' should be a separate illness in DSM-V, as was recommended (but rejected) for DSM-IV, rather than a specifier of 'major depressive disorder,' a position where it can more easily be overlooked. The hope would be that if 'major depression with psychotic features' were a separate illness in DSM-V, it would result in greater awareness and more accurate diagnosis among practitioners.”Meanwhile, Rothschild offered the following tips on how psychiatrists can better detect psychotic depression:Develop a therapeutic relationship with patients so that they feel comfortable confiding their thoughts to you.Since patients are often guarded, use nonthreatening terms such as“ irrational worries” instead of “paranoia” or“ psychosis.”Listen carefully for clues of psychosis—for example, a patient saying something such as “My thoughts are not quite right.”Involve family members in the assessment process of the patient. They may have observed strange behavior or speech that might indicate psychosis.Also, Rothschild has written a book, Clinical Manual for the Diagnosis and Treatment of Psychotic Depression, to help physicians better diagnose the disorder. It will be available through American Psychiatric Publishing Inc. in November.The study was funded by the National Institute of Mental Health.An abstract of “Missed Diagnosis of Psychotic Depression at Four Academic Medical Centers” is posted at<www.psychiatrist.com/abstracts/200808/080813.htm>.▪ ISSUES NewArchived

Depression is the core of suicidality – its treatment is the cure

Depression is the core of suicidality – its treatment is the cure

Guilt and Depression: A Cross-Cultural Comparative Study

Although nearly a century has passed since Kraepelin’s investigations in Java [Cbl Nervenheilk Psychiatr 1904; 27:468–469], one crucial question regarding guilt in the course of depression has still not been decided: Is there a more or less stable connection independent of culture, or is guilt confined to certain civilisations? This study investigated this issue in 100 Pakistani and 100 Austrian out-patients diagnosed with ‘major depression’ according to DSM-IV by means of standardised instruments (Schedule for Affective Disorders and Schizophrenia-Life Time Version, Hamilton Rating Scale for Depression, 21-item version). The experiences of guilt were subdivided into ethical feelings (ethical anxiety and feelings of guilt) and delusions of guilt. It turned out that ethical feelings could be found in both cultures regardless of age and sex. They seem to be primarily related to the extent of depressive retardation. However, the distribution of the two subsets of ethical feelings was culture dependent. Delusions of guilt were confined to patients of the Austrian sample. So, our data qualify the exclusivity of the aforementioned two points of view and support the need for a psychopathologically differentiated approach.

Delusion in depression

The present article endeavours an outline of depressive delusions, their symptomatology and their various topics. Their relations to depressive feelings of guilt and anxiety are discussed and differentiated. Delusions of guilt, poverty or disease including their preliminary states are by no means rare but regularly occurring symptoms which substantiate the diagnosis of major depressive disorder/endogenous depression/melancholia. Preliminary states like hypochondriatic fears of guilt and poverty are likewise characteristic clinical signs which may be differentiated with high validity from the kind of anxiety associated to neurotic depression/dysthmia. Delusional depression did not prove to be a nosological entity but as a concept may bear considerable heuristic value concerning therapeutic considerations. This particularly serious form of depression requires specific therapeutic procedures.

Depressive Delusion

In this study of 160 consecutively admitted inpatients who met ICD-9 criteria of endogenous depression, mood-congruent depressive delusions were ascertained in 14.4% (n = 23). The total HRSD score was significantly higher in the delusional than in the nondelusional group. Delusions of guilt were recorded by far the most frequently. There was a correlation between delusions of guilt in the current depressive episode and suicide attempts in the past. In the delusional patients the individual courses of the illness were characterized by marked symptomatological differences from one depressive episode to another. In all but one of the patients, depressive delusions coincided with a thematically identical experience of anxiety. How often anxiety occurs in delusional form depends substantially on the respective theme of anxiety. In accordance with earlier psychopathological literature the findings confirm that depressive delusion is closely linked to the experience of anxiety.

A multivariate predictor analysis of course and outcome in delusional psychosis.

The purpose of the study was to examine whether certain social variables of first-admitted patients with delusional psychosis were of predictive value of course and outcome as illuminated through the dimensions: psychiatric symptoms, impairment, remission, and relapse at 2-year follow-up. Furthermore, the aim was to perform a multivariate analysis of the most informative clinical and social predictors of course and outcome. Several predictors were significantly associated with at least one of the dimensions of poor outcome. In the multivariate logistic analysis an independent significant effect was assigned to male sex, no work, no evasiveness of delusions, perceptual disorder, preoccupation with delusions, dread, and few social contacts. The most informative clinical and social predictors yielded a maximal information of 27% to 47% for the different dimensions of course and outcome. One fifth of the patients had good outcome. This was significantly predicted by the following variables: married, living with others, frequent social contacts, high social group, full time work, clouding, delusions of guilt, and attempt at concealment of delusions and hallucinations, yielding a maximal information of 41%. Frequent social contacts and delusions of guilt had an independent statistical effect on good outcome. It is concluded that good prognosis is exceptional in patients with delusional psychosis and not combined to a single nosological unit. The findings stress the need for a specific investigation of the prognostic importance of social intervention and community care in patients with delusional psychosis.

Suicide attempts correlate with delusional content in major depression.

A retrospective analysis of all medically serious suicide attempts made by 45 patients hospitalized consecutively at the Payne Whitney Clinic with the Diagnostic and Statistical Manual III discharge diagnosis of unipolar major depression recurrent with psychotic features was undertaken. Patients with delusions of persecution in combination with delusions of guilt were significantly more likely to make medically serious suicide attempts than patients with single categories of delusions or combinations other than guilt and persecution.