Induced erotomania by online romance fraud - a novel form of de Clérambault's syndrome

BACKGROUND

Although the impact of internet usage on mental health is extensively documented, there is a notable scarcity of reports in the literature concerning internet-induced erotomania. Erotomania is a rare and likely underdiagnosed delusional disorder. It is characterized by an irrational belief held by the affected persons that someone of higher socioeconomic status harbor romantic feelings toward them. Here, we describe the psychopathology of erotomanic delusion induced by online romantic fraud in a female patient. Employing this case as a focal point, we illuminate novel aspects of erotomania that warrant attention and examination.

CASE PRESENTATION

We present a compelling case involving a 70-year-old married Caucasian woman diagnosed with medically controlled persistent depressive disorder for several years. The intricacies of her condition became evident as she became deeply engrossed in online profiles featuring the image of a renowned musician, inadvertently falling victim to an online romantic fraud. Subsequently, this distressing experience triggered the emergence of erotomanic delusions and a suicide attempt. The patient's history reveals an array of medical conditions and stressful life events, contributing to her vulnerability. The diagnosis of erotomanic delusional disorder, dysthymia, and mild cognitive impairment with cerebral vascular background was established. Treatment involved her previous antidepressant with low-dose risperidone, alongside supportive individual and group therapy. Her delusion showed remission four weeks later, prompting her discharge for outpatient follow-up. Although she retained some false beliefs, the intensity of the symptoms had notably diminished and her functionality improved.

CONCLUSION

This case underscores the complex interplay between mental health, online activities, and the consequences of delusions, including suicidal thoughts, shedding light on the need for a comprehensive approach in addressing such challenging psychiatric scenarios.

'Are these my thoughts?': A 20-year prospective study of thought insertion, thought withdrawal, thought broadcasting, and their relationship to auditory verbal hallucinations

The co-occurrence of delusions and other symptoms at the onset of psychosis is a challenge for theories about the aetiology of psychosis. This paper explores the relatedness of delusions about the experience of thinking (thought insertion, thought withdrawal, and thought broadcasting) and auditory verbal hallucinations by describing their trajectories over a 20-year period in individuals diagnosed with schizophrenia, affective and other psychosis, and unipolar depression nonpsychosis. The sample consisted of 407 participants who were recruited at index hospitalization and evaluated over six follow-ups over 20 years. The symptom structure associated with thought insertion included auditory verbal hallucinations, somatic hallucinations, other hallucinations, delusions of thought-dissemination, delusions of control, delusion of self-depreciation, depersonalization and anxiety. The symptom constellation of thought withdrawal included somatic hallucinations, other hallucinations, delusions of thought dissemination, delusions of control, sexual delusions, depersonalization, negative symptoms, depression, and anxiety. The symptom constellation of thought broadcasting included auditory verbal hallucinations, somatic hallucinations, delusions of thought-dissemination, delusion of self-depreciation, fantastic delusions, sexual delusions, and depersonalization. Auditory verbal hallucinations and delusions of self-depreciation were significantly associated with both thought insertion and thought broadcasting. Thought insertion and thought withdrawal were significantly associated with other hallucinations, delusions of control, and anxiety; thought withdrawal and thought broadcasting were significantly related to sexual delusions. We hypothesize that specific symptom constellations over time might be explained as the product of pseudo-coherent realities created to give meaning to the experience of the world and the self of individuals in psychosis based on both prior top-down and ongoing bottom-up elements.

Clinical Characterization, Course, and Treatment of Othello Syndrome: A Case Series and Systematic Review of the Literature

BACKGROUND

Othello syndrome (OS) is a condition characterized by a delusion of jealousy that one's spouse is having extramarital affairs. As in the eponymous Shakespearean tragedy, there is an unfortunate risk of violence. For patients with these symptoms, consultation-liaison psychiatrists may be asked to assist with evaluating the differential diagnosis, assessing safety, and developing treatment options.

OBJECTIVE

This study's objective was to solidify current knowledge of the clinical presentations and management of OS through a systematic review of the literature and description of 2 new cases.

METHODS

We conducted a literature search from the start of relevant databases through August 2023 to identify English language case reports of adults (≥18 years) with OS that described clinical evaluations, biological treatments, and outcomes. We extracted demographics, proposed etiologies, treatment choices and responses, duration of delusions, comorbid psychiatric symptoms, neuro-radiographic findings, and presence of physical violence. We reported clinical findings for 2 new cases.

RESULTS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we screened 705 abstracts and conducted full-text reviews of 118 articles to identify 73 cases published from 1983 to 2023 meeting inclusion criteria. The mean age was 58.2 years with male predominance (M:F = 1.88). Etiologies included primary psychiatric disorders (16, 22%), other medical conditions (38, 52%), and medications or other substances (19, 26%). Delusional disorder, cerebrovascular accident, and dopaminergic agonists were the most common etiologies, respectively, in these groups. Antipsychotics were the most common treatment (57, 78%). Symptom remission was reported in 51 (70%) cases. The average duration of OS was 39.5 months. Of 32 cases reporting brain imaging insults, 12 of 20 (60%) showed right-sided lesions, and 8 of 20 (40%) showed left-sided lesions, with 9 of 32 (28%) located in the frontal lobes. The most commonly co-existing psychiatric symptom was depression (14, 19%). Violence was reported in 25 cases (34%). Our 2 new cases were consistent with these findings.

CONCLUSIONS

OS may be a manifestation of several neuropsychiatric conditions, primarily delusional disorder, cerebrovascular accident, Alzheimer's dementia, and the use of dopaminergic agonists. One-third of cases include violent behaviors. It appears to respond to antipsychotic medications, but treatment is delayed more than 3 years on average. Available data have not localized OS to a specific brain region.

Religious delusions in Dutch older adults in treatment for psychosis: a follow-up study

OBJECTIVE

The course over time of religious delusions (RDs) in late-life schizophrenia and psychotic depression may be relevant to know how long certain aspects of RDs may affect treatment. The present study examines (1) the 1-year follow-up of RDs and other prevalent delusions, (2) the association between RDs and the clinical course of psychotic depression and schizophrenia compared to those without RDs, and (3) associations of RDs and other prevalent delusions with "indicators of complexity" (e.g., suicidality, refusing medication).

DESIGN

Prospective study (half year and 1-year follow-up combined).

SETTING

Outpatients and inpatients in Geriatric Psychiatry Institution of Yulius, South-Holland, the Netherlands.

PARTICIPANTS

One hundred and thirty seven older adult patients, mean age 76.3 (s.d. 8.1).

INTERVENTION

Natural follow-up study.

MEASUREMENTS

Diagnostic interview measures included Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1), positive psychosis items of the Community Assessment of Psychic Experiences-42 (CAPE), and the 20-item measures from the Centre for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Although RDs in older adults decline in the clinical course of psychotic depression, the course is unfavorable compared to psychotic depression without RDs with regard to depressive symptom severity as measured by CES-D. No significant differences were noted in relation to clinical course of positive psychotic symptoms for both psychotic depression and schizophrenia. In schizophrenia, RDs persist more frequently compared to the most prevalent delusions. No significant difference was observed between patients with RDs compared to patients without RDs regarding indicators of clinical complexity.

CONCLUSIONS

RDs predicting a less favorable course over time in psychotic depression. In schizophrenia, RDs appears to be relatively pervasive.

Outcome in patients with religious delusions

We read with interest the recent report on the definition, diagnosis, and clinical implications of religious delusions (RD).1 In our sample of 929 delusional schizophrenia patients who had been admitted to two psychiatric hospitals in Germany between 2010 and 2014, 138 patients (15%) reported RD. In 569 cases, information on religious affiliation was available. Patients with religious affiliation did not differ from patients without religious affiliation in the frequency of RD [χ2(1,569)= 0.02, p= 0.885]. Furthermore, patients with RD did not differ from patients with other types of delusion (OD) in the duration of hospitalisation [t(924)= -0.39, p= 0.695], or the number of hospitalisations [t(927)= -0.92, p= 0.358]. Additionally, in 185 cases, information on Clinical Global Impressions (CGI) and Global Assessment of Functioning (GAF) was available at the beginning and end of the hospital stay. By CGI-scores, no difference was seen in morbidity of subjects with RD relative to subjects with OD on admission [t(183)= -0.78, p= 0.437] and discharge t(183)= -1.10, p= .273 . Likewise, GAF-scores on admission did not differ in these groups [t(183)= 1.50, p= 0.135]. However, a trend was noted for lower GAF-scores on discharge in subjects with RD [t(183)= 1.91, p= .057, d= 0.39, CI 95% (-0.12-0.78)]. While RD have often been associated with a poorer prognosis in schizophrenia,2,3 we argue that this need not apply to all domains. Mohr et al4 reported that patients with RD were less likely to maintain psychiatric treatment, but did not have a more severe clinical status than patients with OD. Iyassu et al5 found higher levels of positive, but also lower levels of negative symptoms in patients with RD compared to patients with OD. Groups did not differ in terms of length of illness or level of medication. Siddle et al6 reported higher symptom scores in patients with RD at their first presentation, but a similar response to treatment when compared to patients with OD after 4 weeks of treatment. Furthermore, Ellersgaard et al7 iindicated that first-episode psychosis patients with RD at baseline were more likely to be non-delusional at follow-ups conducted after years 1, 2 and 5 when compared to patients with OD at baseline. We conclude that RD may thus interfere with short-term clinical outcome. With regard to long-term effects more favourable observations exist8 and the interplay of psychotic delusions with non-psychotic beliefs still warrants further research.

Resolving the Delusion Paradox

BACKGROUND AND HYPOTHESIS

The neurocomputational framework of predictive processing (PP) provides a promising approach to explaining delusions, a key symptom of psychotic disorders. According to PP, the brain makes inferences about the world by weighing prior beliefs against the available sensory data. Mismatches between prior beliefs and sensory data result in prediction errors that may update the brain's model of the world. Psychosis has been associated with reduced weighting of priors relative to the sensory data. However, delusional beliefs are highly resistant to change, suggesting increased rather than decreased weighting of priors. We propose that this "delusion paradox" can be resolved within a hierarchical PP model: Reduced weighting of prior beliefs at low hierarchical levels may be compensated by an increased influence of higher-order beliefs represented at high hierarchical levels, including delusional beliefs. This may sculpt perceptual processing into conformity with delusions and foster their resistance to contradictory evidence.

STUDY DESIGN

We review several lines of experimental evidence on low- and high-level processes, and their neurocognitive underpinnings in delusion-related phenotypes and link them to predicted processing.

STUDY RESULTS

The reviewed evidence supports the notion of decreased weighting of low-level priors and increased weighting of high-level priors, in both delusional and delusion-prone individuals. Moreover, we highlight the role of prefrontal cortex as a neural basis for the increased weighting of high-level prior beliefs and discuss possible clinical implications of the proposed hierarchical predictive-processing model.

CONCLUSIONS

Our review suggests the delusion paradox can be resolved within a hierarchical PP model.

Persistent delusional disorder with delusions of poverty - a case study

We present a case study of a patient who was hospitalized with the initial diagnosis of psychotic depression with predominant delusions of poverty. During his hospital stay despite antidepressant and antipsychotic treatment with 150 mg of sertraline and 20 mg of olanzapine per day, no symptomatic improvement was achieved. Besides, the psychotic features have risen to the fore along with inadequately vaguely expressed affective component. What drew attention was the coherence and permanence of delusional judgements, which, albeit variable in expression, always concerned one theme - the belief of an inevitable bankruptcy. The whole clinical picture, both with the objectifying interview defining the order of emerging symptoms, was suggestive and the verification of diagnosis was made. Persistent delusional disorder with delusions of poverty with subsequent mood disorder was diagnosed. The treatment with 275 mg of clozapine per day was started and we observed a slow gradual withdrawal of psychosis as well as a total normalization of the affective range. The case illustrates the importance of differential diagnosis of mental states in which psychotic features coexist with affective symptoms. It is helpful to determine the sequence of the symptoms development. It should be noted that although the ICD-10 classification distinguishes exclusively 7 subtypes of persistent delusional disorder, in the clinical practice we can encounter other thematic areas of psychosis. It brings substantial therapeutic and prognostic implications.

Delusional beliefs in adolescents with anorexia nervosa, obsessive-compulsive disorder, or first-episode psychosis: A comparative study

Delusional thinking is a key symptom of first-episode psychosis (FEP), but it has also been studied in obsessive-compulsive disorder (OCD) and anorexia nervosa (AN). This study aimed to analyze the psychometric properties of the Brown Assessment of Beliefs Scale (BABS) in a sample of adolescents diagnosed with a FEP, AN, or OCD, and to compare delusional thinking among the three samples. The sample comprised 60 patients in three groups of 20 diagnosed with OCD, AN, or FEP. Participants underwent assessment by diagnostic interview, the BABS scale, and a measure of depressive symptomatology. Specific instruments were also used to assess the main symptomatology of each disorder. The BABS had good internal consistency, and high validity and reliability. The OCD group scored significantly lower than the other two groups in all scale items except for items 4 (fixation of ideas), 6 (insight), and 7 (delusions of reference). A significant difference only existed between the AN and FEP groups for item 7 (delusions of reference). The BABS scale is a valid and reliable tool for assessing delusionality in adolescents diagnosed with OCD, AN, or FEP, with evidence of marked differences between the disorders. Assessing these symptoms could influence management, helping to improve treatment adherence and prognosis.

Evaluation of reliability and validity of the Persian version of Peters et al. delusions inventory (PDI-40) in iranian non-clinical and clinical samples

BACKGROUND

Some individuals may manifest psychotic symptoms that do not fulfill the requisite clinical criteria for a formal diagnosis of psychosis. The assessment of susceptibility to delusions, encompassing both clinical and non-clinical cohorts, frequently makes use of the Peters et al. Delusions Inventory (PDI-40). This study aimed to evaluate the reliability and validity of the Persian version of Peters et al. Delusions Inventory (PDI-40) in Iranian non-clinical and clinical samples.

METHODS

The present study employed a cross-sectional, correlational design in 2020. A total of 1402 Iranian participants were recruited for the study, which consisted of three distinct stages. The first stage involved an Exploratory Factor Analysis (EFA) conducted on a non-clinical sample of 512 participants. The second stage comprising different non-clinical sample 764 participants to perform a Confirmatory Factor Analysis (CFA). In the third stage, a clinical sample of 126 psychotic patients was compared to a non-clinical sample. All participants completed the PDI-40, the Community Assessment of Psychotic Experiences (CAPE-42), and the Depression, Anxiety, and Stress Scale (DASS-21). The internal structure of PDI-40 was examined through the analysis of its factor structure using LISREL 8.8.

RESULTS

The EFA analysis unveiled nine components within Persian version of PDI-40. The CFA analysis demonstrated an excellent fit of the nine-factor structure of Persian PDI-40 to the data. The total score exhibited high internal reliability, as indicated by Cronbach's alpha coefficient of 0.92. Moreover, Persian PDI-40 exhibited satisfactory evidence of convergent validity, as significant correlations were observed between dimensions of PDI-40 and subscales of CAPE-42 and DASS-21. Lastly, findings indicated that psychotic participants scored higher than non-clinical participants in all components of the PDI-40(p < 0.05).

CONCLUSION

Persian version of the PDI-40 demonstrates strong reliability and validity for assessing delusion proneness in both non-clinical and clinical samples in Iran. The observed distinctions between psychotic and non-clinical participants underscore its potential as a valuable tool for discerning delusion proneness in diverse contexts.

The effects of the COVID-19 pandemic on hallucinations and delusions in youth at clinical high-risk for psychosis and outpatients with schizophrenia

Although the COVID-19 pandemic has had detrimental effects on mental health in the general population, the impact on those with schizophrenia-spectrum disorders has received relatively little attention. Assessing pandemic-related changes in positive symptoms is particularly critical to inform treatment protocols and determine whether fluctuations in hallucinations and delusions are related to telehealth utilization and treatment adherence. In the current longitudinal study, we evaluated changes in the frequency of hallucinations and delusions and distress resulting from them across three-time points. Participants included: (1) outpatients with chronic schizophrenia (SZ: n = 32) and healthy controls (CN: n = 31); (2) individuals at clinically high risk for psychosis (CHR: n = 25) and CN (n = 30). A series of questionnaires were administered to assess hallucination and delusion severity, medication adherence, telehealth utilization, and protective factors during the pandemic. While there were no significant increases in the frequency of hallucinations and delusions in SZ and CHR, distress increased from pre-pandemic to early pandemic in both groups and then decreased at the third time point. Additionally, changes in positive symptom severity in SZ were related to psychiatric medication adherence. Findings suggest that positive symptoms are a critical treatment target during the pandemic and that ongoing medication services will be beneficial.

Differential Trajectories of Delusional Content and Severity Over 2 Years of Early Intervention for Psychosis: Comparison Between Chennai, India, and Montréal, Canada

BACKGROUND

There exist few direct studies of delusional content in psychosis across geo-cultural contexts, especially those in which treatment protocols and measures are comparable. To directly examine an illness outcome that is potentially culturally mediated, this study investigated the baseline presentation and longitudinal trajectory of delusions in first-episode psychosis (FEP) across 2 similar treatment settings in Montréal (Canada) and Chennai (India).

STUDY DESIGN

Patients entering an early intervention program for FEP in Chennai (N = 168) and Montréal (N = 165) were compared on site-level differences in the presentation of delusions across specific time points over 2 years of treatment. Delusions were measured using the Scale for Assessment of Positive Symptoms. Chi-square and regression analyses were conducted.

STUDY RESULTS

At baseline, delusions were more frequent in Montréal than in Chennai (93% vs 80%, respectively; X2(1) = 12.36, P < .001). Thematically, delusions of grandiosity, religiosity, and mind reading were more common in Montréal than in Chennai (all P < .001); however, these baseline differences did not persist over time. Regression revealed a significant time-by-site interaction in the longitudinal course of delusions, which differs from the trajectory of other FEP-positive symptom domains.

CONCLUSIONS

To the best of our knowledge, this is the first direct comparison of delusions in similar programs for FEP across 2 different geo-cultural contexts. Our findings support the notion that delusion themes follow consistent ordinal patterns across continents. Future work is needed to unpack the differences in severity that present at baseline and minor differences in content.

Schizophrenia and Increased Distrust-Based Competitiveness in Interpersonal Interactions: A Serial Process Model

BACKGROUND AND HYPOTHESIS

Game theory paradigms, such as the Prisoner's Dilemma Game (PDG), have been used to study nonclinical paranoia, though research using clinical populations has been scarce. We test our novel theoretical model that schizophrenia leads to competitiveness in interpersonal interactions, and that this link is serially mediated by trait paranoia, state paranoia, and distrust.

STUDY DESIGN

In this quasi-experimental study, individuals with schizophrenia spectrum diagnoses with current persecutory delusions (n = 46) and a nonclinical control group (n = 43) played the PDG, and completed measures of trait paranoia, state paranoia, and distrust.

STUDY RESULTS

Individuals with schizophrenia competed more in the PDG than the control group. Supporting our theoretical model, all direct effects were significant: schizophrenia was associated with higher trait paranoia (H1); trait paranoia predicted state paranoia in the PDG (H2); state paranoia in the PDG predicted distrust of the opponent in the PDG (H3); and distrust predicted competition in the PDG (H4). The hypothesized indirect effect of schizophrenia on competition in the PDG via trait paranoia, state paranoia, and distrust was supported in a serial mediation model (H5).

CONCLUSIONS

The findings make clear theoretical and methodological contributions. We provide the first evidence for a theoretical process model by which schizophrenia leads to competitiveness in interpersonal interactions via trait paranoia, state paranoia, and distrust. Game theory paradigms, and the PDG in particular, are important for advancing theory and research on paranoia as it occurs in both clinical and nonclinical populations.

Neural correlates of referential/persecutory delusions in schizophrenia: examination using fMRI and a virtual reality underground travel paradigm

BACKGROUND

The brain functional correlates of delusions have been relatively little studied. However, a virtual reality paradigm simulating travel on the London Underground has been found to evoke referential ideation in both healthy subjects and patients with schizophrenia, making brain activations in response to such experiences potentially identifiable.

METHOD

Ninety patients with schizophrenia/schizoaffective disorder and 28 healthy controls underwent functional magnetic resonance imaging while they viewed virtual reality versions of full and empty Barcelona Metro carriages.

RESULTS

Compared to the empty condition, viewing the full carriage was associated with activations in the visual cortex, the cuneus and precuneus/posterior cingulate cortex, the inferior parietal cortex, the angular gyrus and parts of the middle and superior temporal cortex including the temporoparietal junction bilaterally. There were no significant differences in activation between groups. Nor were there activations associated with referentiality or presence of delusions generally in the patient group. However, patients with persecutory delusions showed a cluster of reduced activation compared to those without delusions in a region in the right temporal/occipital cortex.

CONCLUSIONS

Performance of the metro task is associated with a widespread pattern of activations, which does not distinguish schizophrenic patients and controls, or show an association with referentiality or delusions in general. However, the finding of a cluster of reduced activation close to the right temporoparietal junction in patients with persecutory delusions specifically is of potential interest, as this region is believed to play a role in social cognition.

Body image concerns in patients with persecutory delusions

BACKGROUND

Persecutory fears build on feelings of vulnerability that arise from negative views of the self. Body image concerns have the potential to be a powerful driver of feelings of vulnerability. Body image concerns are likely raised in patients with psychosis given the frequent weight gain. We examined for the first-time body esteem - the self-evaluation of appearance - in relation to symptom and psychological correlates in patients with current persecutory delusions.

METHODS

One-hundred and fifteen patients with persecutory delusions in the context of non-affective psychosis completed assessments of body image, self-esteem, body mass index (BMI), psychiatric symptoms and well-being. Body esteem was also assessed in 200 individuals from the general population.

RESULTS

Levels of body esteem were much lower in patients with psychosis than non-clinical controls (d = 1.2, p < 0.001). In patients, body esteem was lower in women than men, and in the overweight or obese BMI categories than the normal weight range. Body image concerns were associated with higher levels of depression (r = -0.55, p < 0.001), negative self-beliefs (r = -0.52, p < 0.001), paranoia (r = -0.25, p = 0.006) and hallucinations (r = -0.21, p = 0.025). Body image concerns were associated with lower levels of psychological wellbeing (r = 0.41, p < 0.001), positive self-beliefs (r = 0.40, p < 0.001), quality of life (r = 0.23, p = 0.015) and overall health (r = 0.31, p = 0.001).

CONCLUSIONS

Patients with current persecutory delusions have low body esteem. Body image concerns are associated with poorer physical and mental health, including more severe psychotic experiences. Improving body image for patients with psychosis is a plausible target of intervention, with the potential to result in a wide range of benefits.

Coexistence of different delusional misidentification syndromes in clinical practice: A case series

OBJECTIVE

The objective of this study is to analyse the coexistence of several delusional misidentification syndromes in a clinical sample.

METHODS

Over one year, a sample of six patients presenting two or more types of delusional misidentification syndromes was selected. All these patients were admitted to the psychiatric inpatient unit of a Spanish hospital.

RESULTS

Despite the different diagnoses, the patients included presented different types of delusional misidentification syndromes, both hyperidentification and hypoidentification. Antipsychotic treatment was not very effective against these delusional misidentification syndromes.

CONCLUSIONS

The coexistence of several delusional misidentification syndromes indicates that the aetiopathogenesis of the different types is similar. It is a field with important clinical implications, due to the poor response to treatment, as well as the possible medico-legal implications.

Schneider's first-rank symptoms have neither diagnostic value for schizophrenia nor higher clinical validity than other delusions and hallucinations in psychotic disorders

The validity of studies on the diagnostic significance of first-rank symptoms (FRS) for schizophrenia has been put in doubt because of a poor compliance with Schneider's criterion for their definition and the lack of use of the phenomenological method for their assessment. In this study, using a rigorously phenomenological approach to elicit FRS, we examined (a) the degree to which unequivocally present FRS differentiated schizophrenia (n=513) from other psychotic disorders (n=633), and (b) the comparative validity between FRS and other reality-distortion symptoms against 16 external validators in the whole sample of psychotic disorders (n=1146). Diagnostic performance indices (with 95% CIs) of FRS for diagnosing schizophrenia were as follows: sensitivity=0.58 (0.54-0.61), specificity=0.65 (0.62-0.67), positive predictive value=0.57 (0.54-0.60) and negative predictive value=0.65 (0.63-0.68). While the overall association pattern of FRS and non-FRS scores with the validators was rather similar, three validators (premorbid social adjustment, number of hospitalizations and global assessment of functioning) were significantly related to non-FRS scores (p < 0.006) but not to FRS scores (p > 0.05). Furthermore, no validator was significantly related to FRS scores and unrelated to non-FRS scores, all of which indicates an overall better predictive validity for non-FRS delusions and hallucinations. These findings suggest that FRS do not have diagnostic value for diagnosing schizophrenia and that they do not meaningfully add to the external validity showed by other delusions and hallucinations. We believe that much of the misunderstanding about the diagnostic and clinical validity of FRS for schizophrenia is rooted in Schneider's confusing concept of the disorder.

Longitudinal symptomatic interactions in long-standing schizophrenia: a novel five-point analysis based on directed acyclic graphs

BACKGROUND

Recent network models propose that mutual interaction between symptoms has an important bearing on the onset of schizophrenic disorder. In particular, cross-sectional studies suggest that affective symptoms may influence the emergence of psychotic symptoms. However, longitudinal analysis offers a more compelling test for causation: the European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose. We predicted that the persistence of psychotic symptoms would be driven by the continuing presence of affective disturbance.

METHODS

EuroSC included 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures of psychotic and affective symptoms were repeated four times at 6-month intervals, thereby furnishing five time-points. To examine interactions between symptoms both within and between time-slices, we adopted a novel technique for modelling longitudinal data in psychiatry. This was a form of Bayesian network analysis that involved learning dynamic directed acyclic graphs (DAGs).

RESULTS

Our DAG analysis suggests that the main drivers of symptoms in this long-term sample were delusions and paranoid thinking. These led to affective disturbance, not vice versa as we initially predicted. The enduring relationship between symptoms was unaffected by whether patients were receiving first- or second-generation antipsychotic medication.

CONCLUSIONS

In this cohort of people with chronic schizophrenia treated with medication, symptoms were essentially stable over long periods. However, affective symptoms appeared driven by the persistence of delusions and persecutory thinking, a finding not previously reported. Although our findings as ever remain hostage to unmeasured confounders, these enduring psychotic symptoms might nevertheless be appropriate candidates for directly targeted psychological interventions.

Self-Structure in Persecutory Delusions

There is currently limited research examining self-structure in clinical groups and no current data on the extent to which self-structure is amendable to change following psychological therapy. We address this important gap by examining self-structure in individuals with persecutory delusions using the card sort task, an established paradigm measuring key self-structure indices, including the degree to which self-structure is compartmentalized (characterized by primarily positive or negative attributes, as opposed to a mix of both), and the proportion and importance of negative attributes. In Study 1, individuals with a schizophrenia spectrum diagnosis with current persecutory delusions (clinical group, n = 27) and a healthy control group (n = 47) were compared on self-structure indices. In Study 2 (n = 27), the clinical group also completed the card sort task before and after randomization to either a 12-week mindfulness-based psychological therapy or treatment-as-usual control. In Study 1, self-structure differed significantly between the clinical and control groups. The clinical group had a greater proportion of negative attributes, assigned more importance to negative self-aspects, and had more compartmentalized self-structures compared with controls. In Study 2 there were no associations between delusion severity and self-structure. Large effect sizes for reductions in compartmentalization and proportion of negative attributes across self-aspects were found following mindfulness therapy. The findings highlight key differences in self-structure between individuals with persecutory delusions and healthy controls, and suggest that it might be possible to change self-structure following psychological therapy. These data support the central role of the self in theoretical models of paranoid thinking.

[Characteristics of elderly patients diagnosed with delusional disorders during the COVID-19 pandemic: A study in a memory clinic]

AIM

Since the declaration of an emergency following the spread of COVID-19, the number of elderly patients complaining of delusions has increased. Therefore, we investigated the characteristics of patients diagnosed with delusional disorders in our clinic.

METHODS

A total of 1,884 patients ≥ 65 years old who visited the Center for Comprehensive Care on Memory Disorders at Kyorin University Hospital from January 2017 to December 2021 were included in the study. The 17 patients diagnosed with delusional disorders were divided into 2 groups based on the timing of the first declaration of emergency, and the characteristics of each group were investigated.

RESULTS

Seven patients were diagnosed with delusional disorder before the first declaration of emergency and 10 after the declaration. The proportion of patients increased by approximately three-fold after the declaration. Post-emergency patients were less motivated to be active than those encountered before the declaration, and many had no history of mental illness. Seven of the 10 post-emergency patients visited the Memory Clinic within 1 year of the onset of delusions.

CONCLUSIONS

After the first declaration of an emergency, elderly patients with no history of psychiatric disorders acutely developed delusional disorders.The physical and psychological effects of COVID-19 on the elderly should be considered.

[Psychopathology of depressive-delusional states with religious content]

OBJECTIVE

Identification of psychopathological characteristics of depressive-delusional states with religious content, development of a typology, determination of formation features, nosological assessment.

MATERIAL AND METHODS

A total of 79 patients (47 female, 32 male, mean age 27±6.5 years) with depressive-delusional states with religious content within the affective and schizophrenia spectrum disorders were studied. Clinical-psychopathological, psychometric (PANSS, HDRS, S. Huber CRS) and statistical methods were used.

RESULTS

Based on the psychopathological structure, specific mechanisms of development of delusions and themes of the religious experiences, three types of depressive-delusional states were identified: type 1 - with a predominance of depressive delusions congruent with affect and delusional ideas of guilt, sinfulness, abandonment of God (14 patients, 17.7%; 6 women, 8 men; mean age 28±4.5 years; HDRS score 33±5.6, the total PANSS score 71±5.3, the PANSS positive subscale score 15.8±3.7); type 2 - with the addition of incongruent delusional constructs, persecutory disorders and acute sensory delusions to the existing depressive religious delusion, with the phenomenon of confessional ambivalence (27 patients, 34.2%; 16 women, 11 men; mean age at attack manifestation 25±9 years; HDRS score 29.6±4.4, the total PANSS score 87±6.2, the PANSS positive subscale score 23.5±4.2); type 3 - depressive-paranoid states with a predominance of Kandinsky-Clerambault syndrome of religious content (38 cases, 48.1%; 20 women, 18 men; mean age at attack manifestation 23.4±2.5 years; HDRS score 32.7±3.7, the total PANSS score 102±7.3, the PANSS positive subscale score 32.5±4.5).

CONCLUSION

The study of depressive-delusional states with religious content has shown their clinical-psychopathological heterogeneity. The religious experiences served as a pathoplastic factor, which essentially modified the clinical-psychopathological picture of the disease due to presence of the specific religious phenomena. The identified types of depressive-delusional disorders with religious content had different diagnostic value.

Schizophrenia plus – comorbidity of schizophrenia and personality disorders. Clinician’s reflections

Jednoczasowe rozpoznanie schizofrenii oraz zaburzeń osobowości u tego samego pacjenta, budzi kontrowersje. Kryteria diagnostyczne schizofrenii oraz kryteria diagnostyczne zaburzeń osobowości dotyczą tych samych obszarów funkcjonowania psychicznego, za wyjątkiem obecności typowych objawów psychotycznych w schizofrenii (omamów, urojeń, zachowań katatonicznych). Natomiast kontrowersyjne wydaje się rozpoznanie jednocześnie schizofrenii i zaburzeń osobowości, bowiem obie te kategorie diagnostyczne dotyczą osobowości. Skoro schizofrenia to psychoza o przeważająco przewlekłym przebiegu, z zaostrzeniami i okresami o przebiegu stałym, to jednoczesne rozpoznanie u tego samego chorego zaburzeń osobowości które to zaburzenia też mają charakter „stały”, a których znaczna część dotyczy tych samych obszarów funkcjonowania psychicznego, jest co najmniej kontrowersyjne. Oddziaływanie terapeutyczne u chorych na schizofrenię opiera się głównie na farmakoterapii, ale oddziaływania psychoterapeutyczne i praca z rodziną chorego, mają również znaczenie. Farmakoterapia zaburzeń osobowości praktycznie nie jest efektywna, a głównym kierunkiem postępowania jest psychoterapia. Nie stanowi to jednak uzasadnienia dla stosowania tych rozpoznań jednoczasowo u tego samego chorego.

Shared psychotic disorder - a case study of folie à famille

BACKGROUND

Folie à famille is a rare form of shared psychotic disorder. It is defined as the transfer of delusions from one person to another.

CASE REPORT

This paper presents a case of shared psychotic disorder in two brothers, aged 16 and 17 and their mother who were admitted on the same day at the Clinic for psychiatry. The inducer was a mother, suffering from schizophrenia. She transferred her delusions to her sons. Both boys produced mostly the same paranoid delusions, that the others have been recording and monitoring them since their father died. After few days, the older boy, who had more severe psychotic symptoms, was treated with aripiprazole, while both received anxiolytics in low dosage.

RESULTS

We observed a withdrawal of psychotic psychopathology in both kids. Genetic burden, social isolation and strong emotional connection of family members are factors that have contributed to the development of shared psychotic disorder in this case.

CONCLUSIONS

The new approach of treatment for induced psychosis includes not only separation from the primary case, but also specific pharmacotherapy. It is necessary to think about this clinical entity, because this delusional disorder needs specific treatment, with better prognostic outcomes.

Evidence, and replication thereof, that molecular-genetic and environmental risks for psychosis impact through an affective pathway

BACKGROUND

There is evidence that environmental and genetic risk factors for schizophrenia spectrum disorders are transdiagnostic and mediated in part through a generic pathway of affective dysregulation.

METHODS

We analysed to what degree the impact of schizophrenia polygenic risk (PRS-SZ) and childhood adversity (CA) on psychosis outcomes was contingent on co-presence of affective dysregulation, defined as significant depressive symptoms, in (i) NEMESIS-2 (n = 6646), a representative general population sample, interviewed four times over nine years and (ii) EUGEI (n = 4068) a sample of patients with schizophrenia spectrum disorder, the siblings of these patients and controls.

RESULTS

The impact of PRS-SZ on psychosis showed significant dependence on co-presence of affective dysregulation in NEMESIS-2 [relative excess risk due to interaction (RERI): 1.01, p = 0.037] and in EUGEI (RERI = 3.39, p = 0.048). This was particularly evident for delusional ideation (NEMESIS-2: RERI = 1.74, p = 0.003; EUGEI: RERI = 4.16, p = 0.019) and not for hallucinatory experiences (NEMESIS-2: RERI = 0.65, p = 0.284; EUGEI: -0.37, p = 0.547). A similar and stronger pattern of results was evident for CA (RERI delusions and hallucinations: NEMESIS-2: 3.02, p < 0.001; EUGEI: 6.44, p < 0.001; RERI delusional ideation: NEMESIS-2: 3.79, p < 0.001; EUGEI: 5.43, p = 0.001; RERI hallucinatory experiences: NEMESIS-2: 2.46, p < 0.001; EUGEI: 0.54, p = 0.465).

CONCLUSIONS

The results, and internal replication, suggest that the effects of known genetic and non-genetic risk factors for psychosis are mediated in part through an affective pathway, from which early states of delusional meaning may arise.

[Recognizing delusional misidentification syndromes]

Delusional misidentification syndrome is a less common neuropsychiatric symptom and can occur in different diseases as dementia and psychiatric diseases or as part of a somatic disease. It can be difficult to recognise and can give a high burden for the formal caregiver. In this article we describe three cases, the pathophysiology and the possible treatment of a delusional misidentification syndrome.

["ZOOM effect". The TV sign in patients with dementia: Is there an increased incidence during pandemia due to a rise in isolation and virtuality?]

Delusional misidentification syndromes are misperceptions of external stimuli with an associated belief or elaboration that is held with delusional intensity. In the TV sign patient believes that the observed television events are occurring in a real three-dimensional space. It is one of the very rare forms of delusional misidentification syndrome in patients withdementia.Wereport7patientswithcognitiveimpairmentcaseswhohavepresentedTVsignduringtheCOVID-19 pandemic. Two patients had Alzheimer's dementia type diagnosis, 1 atypical Alzheimer dementia, 1 vascular dementia and 3 of them had mixed etiology (2 Alzheimer dementia + vascular and 1 dementia with Lewy bodies + vascular). Three presented other psychotic symptoms and 1 patient also had Capgras syndrome. These 7 cases series raise the possibility of an increase incidence of TV sign in patients with dementia during pandemia triggered by the rise in expo- sure to screen devices and a social isolation during this period.

Revisiting Jerusalem Syndrome: A Case Displaying Similar Symptoms to Jerusalem Syndrome During Mecca Visit

Jerusalem syndrome is a mental illness rarely seen in people who visit Jerusalem, manifests itself with obsessive religious thoughts, delusions, psychotic symptoms, and some characteristic features. In clinical practice, it's uncommon to encounter patients displaying symptoms of the Jerusalem syndrome. In this paper, we report a case of a middle-aged woman who manifested psychiatric symptoms similar to the Jerusalem syndrome after a Mecca visit without any previous psychiatric history. After careful examination, religious delusions, auditory and visual hallucinations, racing thoughts, disorganized speech, and confusion were denoted, therefore the patient was hospitalized. Brain imaging and laboratory examination was unremarkable. After nine days of antipsychotic treatment, the patient's symptoms completely dissolved, and she was discharged. Antipsychotic treatment was ceased entirely after two months. The patient and her family members reported that the patient was symptom-free for the following two years. Keywords: Brief reactive psychosis, religion, travel, differential diagnosis.

Cognitive-affective drivers of fixation in threat assessment

Pathological fixation - preoccupation with a person or a cause that is accompanied by deterioration in social and occupational functioning - has been found to precede most cases of targeted violence. It is clinically observed and theorized to have three different cognitive-affective drivers: delusion, obsession, or extreme overvalued belief. Each driver is explained, and case examples are provided in the context of threat assessment. Extreme overvalued belief as a new concept is discussed in detail, both its historical provenance and its demarcation from delusions and obsessions. Threat management for each separate cognitive-affective driver is briefly summarized, based upon current clinical findings and research. Emphasis is placed upon understanding both the categorical and dimensional nature (intensity) of these cognitive-affective drivers, and suggested guidelines are offered for the assessment of such in a clinical examination by a forensic psychiatrist or psychologist.

Course and symptom and functional correlates of passivity symptoms in schizophrenia: an 18-year multi-follow-up longitudinal study

BACKGROUND

Change in the experience of oneself may lay the groundwork for the development of additional hallucinations and delusions in individuals with schizophrenia. However, to date, the course and symptom and functioning correlates of passivity symptoms (cf. thought insertion, thought withdrawal) have not been measured consistently over long periods of time. Information on the course and correlates of passivity symptoms is essential for developing models of their contribution to schizophrenic illness.

METHOD

Eighty-two individuals diagnosed with schizophrenia or schizoaffective disorder were recruited at an index hospitalization and reassessed at three or more follow-ups over the following 18 years.

RESULTS

The results indicate that a small group of participants report passivity symptoms at all follow-ups, many reported passivity symptoms at some follow-ups, and the majority of individuals never reported passivity symptoms. The prevalence of passivity symptoms was similar to that for delusions of reference and persecutory delusions. Notably, when individuals did experience passivity symptoms, they also had a greater number of additional psychotic symptoms than individuals without passivity symptoms. Further, the presence of passivity symptoms was associated with work impairment at some assessments.

CONCLUSIONS

Passivity symptoms present episodically, at a similar rate as delusions of reference and persecutory delusions, and when present, they are associated with having a higher number of additional psychotic symptoms, as well as having some impact on work functioning. These results suggest that passivity symptoms may increase vulnerability to additional psychotic symptoms and greater work impairment.

The revised Green et al., Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs

BACKGROUND

The Green et al., Paranoid Thoughts Scale (GPTS) - comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) - was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation.

METHODS

In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted.

RESULTS

The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09-3.67) and Persecution (a = 2.37-4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0-9; Persecution: 0-4); elevated (Reference: 10-15; Persecution: 5-10); moderately severe (Reference: 16-20; Persecution:11-17); severe (Reference: 21-24; Persecution: 18-27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion.

CONCLUSIONS

The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.

Extreme Overvalued Beliefs

An extreme overvalued belief is shared by others in a person's cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. Over time, the belief grows more dominant, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service. Study participants (n = 109 forensic psychiatrists) were asked to select among three definitions (i.e., obsession, delusion, and extreme overvalued belief) as the motive for the criminal behavior seen in 12 randomized fictional vignettes. Strong interrater agreement (kappa = 0.91 [95% CI 0.83-0.98]) was seen for vignettes representing extreme overvalued belief. Vignettes representing delusion and obsession also had strong reliability (kappa = 0.99 for delusion and 0.98 for obsession). This preliminary report suggests that forensic psychiatrists, given proper definitions, possess a substantial ability to identify delusion, obsession, and extreme overvalued belief. The rich historical foundation of extreme overvalued belief and this small survey study highlight the benefit of inclusion of "extreme overvalued belief" in future glossaries of the Diagnostic and Statistical Manual.

A major flaw in the diagnosis of schizophrenia: what happened to the Schneider's first rank symptoms

Kurt Schneider introduced in the definition of the first-rank symptoms (FRS) the criterion that, where unequivocally present, the FRS are always psychological primaries and irreducible. This criterion, grounded on 'phenomenology' (description of subjective experiences), cannot be applied, according to Schneider, to delusions, either two-stage FRS delusional perception, or second-rank delusional notions. The Schneider's key criterion was neglected since the initial adoption of the 'Schneider's FRS' in the subsequent international literature (e.g. PSE, RDC, DSM, and ICD). The 'Schneider's FRS' (e.g. thought insertion, thought withdrawal, passivity, and influence) were persistently equivocated as 'delusions', in spite of the Schneider's FRS exclusion criterion. The internationally equivocated 'Schneider's FRS' (only homonymous of the original 'Schneider's FRS'), were eliminated in the DSM-5 and de-emphasized in ICD-11. However, the diagnostic value of the original 'Schneider's FRS', assessed on the basis of the strict compliance with the Schneider's criterion for their definition, was never determined. The 'damnatio memoriae' of the original Schneider's FRS may be premature. The definition and assessment of the 'experienced' symptoms of schizophrenia, only directly observed and reported by the patients, represent a specific, crucial, irreplaceable domain of psychopathology, to be carefully distinguished from the domain of the 'behavioral' symptoms observed by the clinician. Contemporary psychopathology research is aware of the absolute need for psychiatry to enhance precision and exactness in the definition of the experienced symptoms of schizophrenia, through the formulation of unequivocal inclusion and exclusion criteria (descriptive micro-psychopathology), in order to determine their value in research and care.

Is the psychopathology of acute and transient psychotic disorder different from schizophrenic and schizoaffective disorders?

Objective

This study explores psychopathological aspects of acute and transient psychotic disorders (ATPD), a diagnostic category introduced with ICD-10, to elucidate its relationship with schizophrenia and schizoaffective psychoses.

Methods

We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD (F23) during a 5-year period as well as control groups with “positive” schizophrenia (PS) and bipolar schizoaffective disorder (BSAD) matched for gender and age at index episode. For the evaluation of psychopathological parameters during index episode a standardized symptom list was used. Prepsychotic (prodromal) symptoms were also assessed.

Results

During the prepsychotic period few differences between the groups were detected. The most important difference between ATPD and the other two other psychotic disorders regarding phenomenology of the full-blown episodes was a higher frequency of “rapidly changing delusional topics”, “rapidly changing mood” and anxiety in ATPD.

Conclusion

ATPD show a characteristic psychopathological picture consistent with earlier concepts such as cycloid psychoses and bouffée délirante. Nevertheless, psychopathology alone is not enough to establish ATPD as an independent nosological entity.

Validity of the EQ-5D in assessing and valuing health status in patients with schizophrenic, schizotypal or delusional disorders

Purpose

The EQ-5D is a generic questionnaire generating a health profile and a single index score for health-related quality of life. This study aimed to analyse the discriminative ability and validity of the EQ-5D in patients with schizophrenic, schizotypal or delusional disorders.

Subjects and methods

One hundred sixty-six patients with schizophrenic, schizotypal or delusional disorders (ICD-10 F2) completed the EQ-5D. Measures of quality of life (WHOQOL-BREF), utility (TTO), subjective (SCL-90R) and objective (PANSS, CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of EQ-5D scores. Validity of the EQ-5D self-classifier was analysed by assessing differences in related other scores grouped by response levels of EQ-5D items. Validity of the visual analogue scale (EQ VAS) and the EQ-5D index (UK social tariff) was analysed by assessing their correlation with all other scores.

Results

Seventy-nine percent of respondents reported problems in at least one of the EQ-5D dimensions (anxiety/depression 57%, usual activities 45%, pain/discomfort 44%, self-care 29%, mobility 22%). The mean EQ VAS score/EQ-5D index was 65.7/0.71. The four most frequently reported EQ-5D health states covered 45% of all respondents. For almost all EQ-5D dimensions, different response levels were associated with significantly different scores of measures used for comparison. Correlation of EQ VAS score and EQ-5D index were largest with scores of subjective measures (SCL-90R: −0.50 and −0.73; WHOQOL mental subscore 0.62 and 0.58; always P < 0.001).

Discussion and conclusion

The EQ-5D showed a moderate ceiling effect and seems to be reasonably valid in this patient group.

Analogical reasoning in schizophrenic delusions

Purpose

Reasoning ability has often been argued to be impaired in people with schizophrenic delusions, although evidence for this is far from convincing. This experiment examined the analogical reasoning abilities of several groups of patients, including non-deluded and deluded schizophrenics, to test the hypothesis that performance by the deluded schizophrenic group would be impaired.

Subjects/materials

Eleven deluded schizophrenics, 10 depressed subjects, seven non-deluded schizophrenics and 16 matched non-psychiatric controls, who were matched on a number of key variables, were asked to solve an analogical reasoning task.

Results

Performance by the deluded schizophrenic group was certainly impaired when compared with the depressed and non-psychiatric control groups though less convincingly so when compared with the non-deluded schizophrenic group. The impairment shown by the deluded schizophrenic group seemed to occur at the initial stage of the reasoning task.

Discussion

The particular type of impairment shown by the deluded subjects was assessed in relation to other cognitive problems already researched and the implications of these problems on reasoning tasks and theories of delusions was discussed.

Paranoid delusions • ideas of reference • sleep problems • Dx?

► Paranoid delusions ► Ideas of reference ► Sleep problems ► Multiple, vague somatic symptoms.

[Clinical zoanthropy: a woman with the rare delusion of being an animal]

Clinical zoanthropy, or the conviction of having turned into an animal, is a rare delusion. There are different views about its pathogenesis. This delusion can occur with an underlying psychiatric disorder, but it can also be secondary to structural or functional disorders of the brain. Additional investigations with brain imaging and electroencephalogram are therefore advised. Treatment for the underlying disorder is recommended. In this case report we describe a 54-year-old woman who was briefly convinced she was a chicken, followed by a generalized seizure. We discuss the epidemiology, theories about pathogenesis and treatment advice for clinical zoanthropy. We also discuss the possible relevance of epilepsy to this matter. With this case report, we hope to contribute to documenting this rare, but possibly underreported phenomenon.

Characterizing core beliefs in psychosis: a qualitative study

BACKGROUND

Cognitive behavioural treatments are recommended for people with psychosis. Core beliefs regarding the self and others are a key part of the models underpinning cognitive behavioural therapy but detailed understanding of these putative beliefs in people with psychosis are limited. A greater understanding of these mechanisms is necessary to improve and refine treatments.

AIMS

This study utilized a qualitative approach to explore core schematic beliefs in psychosis (strongly held positive and negative beliefs about the self and others) and their relation to hallucinations and delusions.

METHOD

Twenty individuals with psychosis participated in individual semi-structured interviews. Inductive thematic analysis was used to analyse the interviews.

RESULTS

Four emergent themes were identified: (i) the solidity and permanency of core beliefs, (ii) the causes and development of core beliefs, (iii) a synergistic relationship between core beliefs and symptoms, and (iv) core beliefs associated with images and their influence on psychotic symptoms.

CONCLUSIONS

This study provides new insights into the range and character of core beliefs in psychosis and provides important data to guide ongoing and future development of treatment approaches for psychosis.

Increased amygdala-visual cortex connectivity in youth with persecutory ideation

BACKGROUND

Subclinical delusional ideas, including persecutory beliefs, in otherwise healthy individuals are heritable symptoms associated with increased risk for psychotic illness, possibly representing an expression of one end of a continuum of psychosis severity. The identification of variation in brain function associated with these symptoms may provide insights about the neurobiology of delusions in clinical psychosis.

METHODS

A resting-state functional magnetic resonance imaging scan was collected from 131 young adults with a wide range of severity of subclinical delusional beliefs, including persecutory ideas. Because of evidence for a key role of the amygdala in fear and paranoia, resting-state functional connectivity of the amygdala was measured.

RESULTS

Connectivity between the amygdala and early visual cortical areas, including striate cortex (V1), was found to be significantly greater in participants with high (n = 43) v. low (n = 44) numbers of delusional beliefs, particularly in those who showed persistence of those beliefs. Similarly, across the full sample, the number of and distress associated with delusional beliefs were positively correlated with the strength of amygdala-visual cortex connectivity. Moreover, further analyses revealed that these effects were driven by those who endorsed persecutory beliefs.

CONCLUSIONS

These findings are consistent with the hypothesis that aberrant assignments of threat to sensory stimuli may lead to the downstream development of delusional ideas. Taken together with prior findings of disrupted sensory-limbic coupling in psychosis, these results suggest that altered amygdala-visual cortex connectivity could represent a marker of psychosis-related pathophysiology across a continuum of symptom severity.

A new somatic-type delusional disorder subtype: delusion inversus

The interplay between psychiatric and dermatologic conditions has been recognized for decades as evidenced by the widely accepted classification system of psychocutaneous disorders: (1) primary dermatologic disorder with psychiatric sequelae, (2) primary dermatologic disorder exacerbated by stress, (3) primary psychiatric disorder with dermatologic sequelae, and (4) miscellaneous. However, there is minimal literature regarding dermatologic patients who demonstrate a preoccupation with a more severe cutaneous disorder despite evidence confirming a diagnosis of a minor, treatable skin condition. These patients are a hybrid of the first and fourth categories and should be classified under a new entity known as delusion inversus. These patients have a primary dermatologic condition; however, they believe their condition to be more severe and malignant than it is, despite evidence to the contrary. Their beliefs are pathological and analogous to delusion disorder somatic type. Given the scarcity of data concerning delusion inversus, the epidemiology, diagnosis, and management of the disorder as described in this review is extrapolated from reported cases of delusion disorder and delusion disorder somatic-type. Often these patients will present to a non-psychiatric, outpatient clinic for medical care. Thus, it is imperative that dermatologists are able to identify the condition and manage the patient appropriately.

Visual hallucinations in psychosis

The Dutch version of the Visual Hallucination Questionnaire was used to assess lifetime visual hallucinations (VH) characteristics in 27 patients with psychosis. Our results confirmed substantial variance in many VH characteristics. Most patients reported multiple VH types. Complex VH were most prevalent, mainly consisting of people and animals, followed by simple, then geometric VH. Few patients experienced only simple VH. The VH generally had features resembling real perceptions. Insight was usually reduced. VH ranged from 'appropriate' and neutral to peculiar and delusion-associated. VH accompanied by fright and sound seem to be related to experiencing complex or multiple types of VH.

Using the K-SADS psychosis screen to identify people with early psychosis or psychosis risk syndromes

BACKGROUND

Current methods to identify people with psychosis risk involve administration of specialized tools such as the Structured Interview for Psychosis-Risk Syndromes (SIPS), but these methods have not been widely adopted. Validation of a more multipurpose assessment tool-such as the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS)-may increase the scope of identification efforts.

METHODS

We assessed the correspondence between SIPS-determined clinical high risk/early psychosis (CHR/early psychosis) status and K-SADS psychosis screen (child and parent reports and their combination) in a sample of 147 help-seeking individuals aged 12-25. Detailed classification results are reported.

RESULTS

Both the child and parent interviews on the K-SADS psychosis screen were strongly predictive of CHR/early psychosis status, although parent reports contributed no significant additional information beyond child reports. Across informants, the presence of either subthreshold hallucinations or subthreshold delusions was highly suggestive of CHR/early psychosis status as determined by SIPS interview (78% (child) and 74% (parent) accuracy).

CONCLUSIONS

Subthreshold scores on the two-item K-SADS psychosis screen may be good indicators of the presence or absence of early signs of psychosis. The option of using a non-specialized assessment such as the K-SADS as a staged approach to assess for CHR/early psychosis status could increase rates of early psychosis screening and treatment.

Erotomania in Depressive Psychosis: Mood Incongruent Delusion in a Depressive Young Woman

Erotomania is a delusional phenomenon in which patient believes that some celebrity is in love with her. It is associated with various psychiatric illnesses. We herein present a report of a young woman with erotomanic delusion diagnosed with recurrent depression, current episode being severe with psychotic features. A 22-year woman, previously treated for a depressive episode three years ago, was brought by the mother for evaluation. The woman presented with symptoms of depression for the past six months along with the delusion that famous singer SY is in love with her for the past two months. This has resulted in a gross decline in social and academic functioning. Psychometrics revealed Beck's depression inventory (BDI) score of 36 and brief psychiatric rating scale (BPRS) score of 41. A diagnosis of recurrent depression with current severe episode with psychotic features, was made at our psychiatric facility. This case report highlights that psychotic depression can present with a rare mood incongruent delusion of erotomanic content and accurate diagnosis and management require adequate knowledge about this phenomenon.

Psychotic symptoms and suicidal ideation in child and adolescent bipolar I disorder

OBJECTIVES

The purpose of this study was to explore associations between specific types of hallucinations and delusions and suicidal ideation in a sample of children and adolescents with bipolar I disorder.

METHODS

Participants (N = 379) were children and adolescents aged 6-15 years (M = 10.2, SD = 2.7) with DSM-IV diagnoses of bipolar I disorder, mixed or manic phase. The study sample was 53.8% female and primarily White (73.6% White, 17.9% Black, and 8.5% Other). Presence and nature of psychotic symptoms, suicidal ideation, and functioning level were assessed through clinician-administered measures. A series of logistic regressions was performed to assess the contribution of each subtype of psychotic symptom to the presence of suicidal ideation above and beyond age, sex, socio-economic status, age at bipolar disorder onset, and global level of functioning.

RESULTS

Hallucinations overall, delusions of guilt, and number of different psychotic symptom types were uniquely associated with increased odds of suicidal ideation after accounting for covariates. Other forms of delusions (eg, grandiose) and specific types of hallucinations (eg, auditory) were not significantly uniquely associated with the presence of suicidal ideation.

CONCLUSIONS

Findings of this study suggest the presence of hallucinations as a whole, delusions of guilt specifically, and having multiple concurrent types of psychotic symptoms are associated with the presence of suicidal ideation in children and adolescents with bipolar I disorder. Psychotic symptom subtypes, as opposed to psychosis as a whole, are an under-examined, potentially important, area for consideration regarding suicidal ideation in pediatric bipolar I disorder.