Introduction to Psychotic Illnesses

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Introduction to Psychotic Illnesses

• Dr Greg Chick
• Senior House Officer in liaison psychiatry, North
  Manchester General Hospital
• 8.1.07

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Aims

• Descriptive, not aetiology-based
• Definition of psychosis
• Definitions of psychotic symptoms
• hallucinations vs delusions
• useful terminology for your psychiatry placement
• Awareness of range of psychotic illnesses
• Awareness of ICD-10
• How to approach a patient suffering from psychosis

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Psychosis - definition

• Mental disorder
• in which the thoughts, feelings, affective
  response, ability to recognise reality
• and ability to communicate and relate to others
  are
• sufficiently impaired to interfere grossly with
  the capacity to deal with reality
• the characteristics of psychosis are impaired
  reality testing, hallucinations, delusions and
  illusions.
• Kaplan Saddock Comprehensive textbook of
  psychiatry 7th ed, glossary p686

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WHY do I need to know about Psychotic Illnesses?

• GP
• Is the Front line service
• Early detection improves prognosis!
• worried relatives asking you to section people
• Increased burden on health services worse
  physical health
• Surgeons / Obs Gynae delusional pts insisting
  on unnecessary operations
• AE pts present with bizarre complaints
  behaviour overdose
• Paediatrics child protection issues early
  onset psychosis
• Psychiatry our area of expertise!
• Mental health act, forensic, suicide

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Contents

• Psychotic symptoms
• Delusional mood
• Hallucinations
• Delusions
• First-rank symptoms
• Psychotic illnesses
• Schizophrenia
• Delusional disorders
• Conditions involving psychotic symptoms
• Mania / psychotic depression
• Drug-induced psychoses
• Organic psychoses
• Delirium / delirium tremens (DTs)

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What do I Really Have to Know?

• Think ORGANIC!
• Oxygenation, Glucose, Electrolyte disturbance,
  endocrine
• Toxicity iatrogenic, self-inflicted, accidental
• Drugs alcohol
• Cerebral pathology
• Define
• Delusion
• Hallucination (vs illusion)

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ICD-10

• A diagnostic heirarchy
• F0- - Organic
• F1- - Substance-related
• F20s - Schizophrenia delusional disorders
• F3- - Mood affective disorders
• F4- - neurotic, stress-related somatoform dis.
• F5- - physiological.. (inc eating disorders)
• F6- - personality disorders
• F7- - mental retardation etc

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Delusions - definition

• a false, unshakeable idea or belief which is out
  of keeping with the patients educational,
  cultural and social background Simms
• we can never understand how they arrived at the
  belief defies normal logic
• BUT
• Need not be totally unshakeable cognitive
  therapy for delusions many patients have some
  insight
• Need not be false (eg delusional jealousy, then
  discover partner actually IS unfaithful)
• Wrongly ARRIVED at belief
• Primary Delusion out of the blue
• Secondary Delusion arises out of eg.
  hallucination

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Overvalued idea

• A preoccupation which can come to dominate (
  ruin) a persons life
• but you can understand where it came from
• and its sort of believable
• eg body image distortion in anorexia nervosa
• eg hypochondriacal disorder
• eg patient fears he has a brain tumour
• but is briefly reassured by the latest test

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Delusions of

• Grandeur / ability
• Paranoia
• Reference
• Persecution
• Control
• Infestation
• Love / jealousy
• Misidentification
• Nihilism

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Delusions - examples

• I am the son of George W Bush
• and a Somali woman. They were on holiday there
  and left me behind.

grandeur
I have a microchip in my brain which transmits
my thoughts to MI5.
control
My family are poisoning my food it tastes
funny
persecution
Theyre making a TV programme about me I keep
seeing my name in the newspaper.
reference
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Persistent Delusional Disorders (F22)

• Delusional disorder (F22.0) including
• Persecutory delusions
• delusional jealousy
• De Clérambaults syndrome erotomania
• Induced delusional disorder (folie a deux) (F24)
• Delusion shared by people with close emotional
  links
• Only one person suffers from a genuine psychotic
  disorder
• The other persons delusion disappears when they
  are separated
• Delusional dysmorphophobia (F22.8)
• Paranoia querulans (F22.8)

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Delusional percept / primary delusion(out of
the blue)

• A young Irishman was at breakfast with two
  fellow-lodgers. He felt a sense of unease, that
  something frightening was going to happen.
• One of the lodgers pushed the salt cellar towards
  him (he appreciated at the same time that this
  was an ordinary salt cellar and his friend's
  intention was innocent).
• Almost before the salt cellar reached him he knew
  he must return home, to greet the Pope, who is
  visiting Ireland to see his family.
• From Simms symptoms in the mind

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Delusional mood a feeling that somethings
not right

• Imagine
• Youve bumped someones car in a car park.
  Theres no damage, so you drive off quickly!
• Your phone rings in the middle of the night but
  you miss the call and the number is unknown
• What emotions do you feel?
• What goes through your mind?
• Who was phoning you?
• The next day, youre still thinking about it and
  you receive an envelope with a government crest
  on it
• What emotions now?
• What goes through your mind before you open it?
• Supposing, in your nervous state, you read it
  wrong?

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How to approacha delusional patient

• Empathise (but dont patronise)
• Test the intensity of the belief
• but dont be confrontational
• Ask them could there be an alternative
  explanation?
• What have they done about their belief?
• (do they believe youre a real medical student?)
• Look up examples of how to phrase your questions
• Present State Examination

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Other delusional syndromes

• Fregolis delusion
• My persecutor takes on the form of different
  people
• But I KNOW its still him!
• Schizophrenia / stroke delusional
  misidentification
• Cotard syndrome
• Nihilistic delusions, esp. in psychotic
  depression
• Ive got no blood / bowels / breath / money
• Im dead / rotting from inside

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Other delusional syndromes

• Capgras delusion
• A 74-year old married housewife believed that her
  husband had been replaced by another unrelated
  man. She refused to sleep with the imposter,
  locked her bedroom at night, asked her son for a
  gun, and finally fought with the police when
  attempts were made to hospitalize her. She easily
  recognized other family members and would
  misidentify her husband only.
• Dementia / stroke delusional misidentification
• This case is taken from a report by Passer and
  Warnock

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De Clérambaults syndrome

• erotomania
• usually in women
• convinced that a man
• usually older, of higher status
• eg the consultant
• is in love with her

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Thought
Content
Delusions
Overvalued Ideas
of Reference
Body image Hypochondriasis Litigation Religious po
litical
Control, Passivity
of Paranoia Reference Persecution Grandeur
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Schizophrenia?
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Myths Misconceptions

• Schizophrenia does literally mean separated
  mind
• Greek applied by Bleuler in 1911
• BUT is nothing to do with split personality
• let alone multiple personality (very rare)
• HAS to do with the brains functions separating
• eg. You hear a voice but dont recognise its
  come from your own mind

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Definition of Schizophrenia

• a severe and enduring mental illness
• A clinical syndrome
• a collection of features which tend to occur
  together
• Refined over last 200 years or so
• Recognised pattern of outcome
• Same methods of treatment
• Biological basis severe psychosocial
  consequences
• No definitive cause or mechanism yet identified
  (multifactorial see PBL lecture)
• Neurochemical imbalance
• reality testing and theory of mind defective
• loss of ego boundaries (what is Me and what
  is Outside)
• BUT there is still no single concise definition!

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Heritable Risk
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Age of Onset Bimodal Distribution
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1st Rank symptoms

• 1950s - Schneiders 1st Rank Symptoms
• Primary Delusion delusional percept
• Own thoughts spoken aloud thought echo
• Voices arguing or discussing
• running commentary voices
• thought withdrawal and/or thought block
• Thought insertion
• thought broadcasting (others are thinking it at
  the same time as you)
• Made to feel passivity of affect
• Made to want passivity of impulse
• Made to do passivity of volition
• Done to my body somatic passivity eg probed by
  aliens
• Some may occur in illnesses other than
  schizophrenia eg mania

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Illusion

• Incorrect perception of a real stimulus (in any
  modality)
• Usually non-pathological
• Bush looks like a killer in the dark
• cocktail party illusion hearing your name
  across a noisy room
• A stray hair may feel like a spider on the neck
• BUT illusions occur in psychosis
• eg girl complains her face is melting when she
  looks in mirror

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Paintings by artist with worsening psychosis
perceptual disturbances
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Hallucination

• A perception, which feels real, but has no real
  stimulus
• usually abnormal, especially when persistent
• But occasional hallucinations are more common
  than we thought! - 10 of British population, at
  some time
• Modalities
• Auditory
• heard as if coming from outwith your head
  (including from another part of the body) cf
  pseudohallucinations
• Visual (more indicative of organic pathology!)
• Somatic / Hygric (visceral) / Sexual
• Gustatory
• Olfactory

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Hallucinations 2

• Non-pathological
• Hypnagogic (going off to sleep)
• Hypnopompic (waking up)

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When its NOT a hallucination

• Illusion misperception of a REAL stimulus
• Daydream imagery
• Pseudohallucination
• Occurs in inner subjective space
• eg voices INSIDE your head
• May have quality of your own thoughts
• Distressed patients not interested in this
  distinction!

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Ideas of reference

• On a spectrum
• I think people on the bus are looking at me
• gt gt
• The news is about my life! It means Im a
  paedophile. Dont you believe me?

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Audible Thoughts

• Gedankenlautwerden, echo de pensees
• The patient may hear people
• repeating his thoughts out loud just after he has
  thought them,
• answering his thoughts,
• saying aloud what he is about to think so that
  his thoughts repeat the voices.
• He often becomes very upset ill the gross
  intrusion into his privacy and concerned that he
  cannot maintain con control of any part of
  himself, not even his thoughts.

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Audible Thoughts

• A 35 year old painter heard a quiet voice with
  an Oxford accent', which he attributed to the
  BBC. The volume was slightly lower than that of
  normal conversation and could be heard equally
  well with either ear. He could locate its source
  at the right mastoid process. The voice would
  say, I can't stand that man, the way he holds
  his hand he looks like a poof' . . . He
  immediately experienced whatever the voice was
  saying as his own thoughts, to the exclusion of
  all other thoughts. When he read the newspaper
  the voice would speak aloud whatever his eyes
  fell on. He had not time to think of what he was
  reading before it was uttered aloud.
• Simms

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voices arguing

• A 24 year old male patient reported hearing
  voices coming from the nurse's ofice. The voice,
  deep in pitch and roughly spoken, repeatedly
  said,
• He is a bloody paradox', and another, higher in
  pitch, said,
• 'He is that, he should be locked up'.
• A female voice occasionally interrupted, saying
  He is not - he is a lovely man'.

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voices giving a Running Commentary

• just before, during or after the patient's
  activities.
• A housewife heard a voice coming from the house
  across the road....
• The voice went on incessantly in a flat monotone
  describing everything she was doing, with an
  admixture of critical comments.
• She is peeling potatoes, got hold of the peeler,
  she does not want that potato,
• she is putting it back, because she thinks it has
  a knobble like a penis, she has a dirty mind, she
  is peeling potatoes, now she is washing them'

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Passivity experiences

• 'I am thinking about my mother, and suddenly my
  thoughts are sucked out of my mind by a
  phrenological vacuum extractor, and there is
  nothing in my mind, it is empty.

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Thought Insertion

• I look out of the window and I think the garden
  looks nice and the grass looks cool,
• but the thoughts of Chris Evans come into my
  mind.
• There are no other thoughts there, only his....
• He treats my mind like a screen and flashes his
  thoughts onto it like you flash a picture.

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Thought Broadcasting

• Def whenever your thoughts are accessible to
  others, eg telepathy, your thoughts on TV
• A 21 year old student said,
• As I think, my thoughts leave my head on a type
  of mental ticker-tape.
• Everyone around has only to pass the tape through
  their mind and they know my thoughts.

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Passivity of emotion

• A 23 year old female patient reported,
• I cry, tears roll down my cheeks and I look
  unhappy,
• but inside I have a cold anger because they are
  using me in this way, and it is not me who is
  unhappy,
• but they are projecting unhappiness onto my
  brain. They project upon me laughter, for no
  reason, and
• you have no idea how terrible it is to laugh and
  look happy and know it is not your, but their
  reaction.'

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Passivity of Impulse

• A Jewish woman suffering from schizophrenia said
  I feel my hand going up to salute, and my lips
  saying "Heil Hitler" ... I don't actually say it
  ... I have to try very hard to stop my arm from
  going up ... they put drugs in my food that is
  what makes it happen.'
• A 26 year old engineer emptied the contents of a
  urine bottle over the ward dinner trolley. He
  said, The sudden impulse came over me and I must
  do it. It was not my feeling, it came into me
  from the X-ray department, that was why I was
  sent there for implants yesterday. It was nothing
  to do with me, they wanted it done. So I picked
  up the bottle and poured it in. It seemed all I
  could do.'

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Somatic Passivity

• the belief that outside influences are playing on
  the body
• A 38 year old man had jumped from a bedroom
  window, injuring his right knee which was very
  painful.
• 'The sun-rays are directed by U.S. army
  satellites in an intense beam which I can feel
  entering the centre of my knee and then radiating
  outwards causing the pain.'

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Artist with Sz delusion of being electronically
controlled?
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Thought Disorder

• Circumstantiality beating about the bush
• (goal eventually reached but tortuously indirect
  and over-inclusive)
• Knights Move Thinking
• Illogical jumping between ideas. Listener cant
  follow train of thought.
• I cant go to the zoo, no money. Oh... I have a
  hat - these members make no sense, man Whats
  the problem?
• NOT the same as Flight Of Ideas, which you CAN
  follow
• Derailment (just losing the plot goal of speech
  not reached)
• Fusion (themes recur but in odd order, hard to
  follow)
• Thought Block (snapping off train of thought.
  No thoughts left)

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Differential Diagnosis Conditions that look
like schizophrenia (similar symptoms)

• Organic psychoses
• Temporal Lobe Epilepsy, delirium, delusional
  disorder, catatonia
• substance-induced psychoses
• Cannabis/hallucinogens, stimulants, alcohol (DTs,
  hallucinosis), etc
• Acute and transient psychotic disorders
• Schizo-affective disorder
• Manic episode
• Schizotypal disorder
• Emotionally unstable personality disorder (can
  have brief psychotic symptoms)
• Trance possession disorders!

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Important Reading

• ICD-10 (World Health Organisation, 1992)
• F20 chapter
• a brief description of what these conditions are
  and arent
• DSM-IV is the American equivalent bigger but
  gives thumbnail sketches of the conditions
• My lecture on schizophrenia from last year ?
• Symptoms in the Mind by Andrew Simms
• (the bible for descriptive psychopathology)

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Case Vignette - 2

• Brian began to be a worry to his parents at the
  age of 17. After doing quite well in his GCSEs,
  he seemed to lose interest and his ability to
  concentrate on his studies. He began to spend
  more time alone in his room listening to music
  and when he went out with his friends, he
  appeared dazed and distant on returning home.
• His parents suspected he was taking drugs but he
  denied this. When his mother went into his
  bedroom to tidy up one day, she found that he had
  draped a cloth over the mirror. He explained this
  by saying that he avoided looking at his face
  because he had a strange look in his eyes, as
  though he had become hypnotised. His parents
  tried to persuade him to visit their GP, but he
  refused to go. He became very quarrelsome and one
  day he punched one of his friends without
  warning. That evening, he removed all the light
  bulbs from their sockets after complaining that
  they were emitting dangerous radiation. His
  parents took him to hospital and he was admitted.
• www.abpi.org.uk/publications/publication_details/t
  argetSchizophrenia-2003/section2.asp