Are paranoid ideation and hallucination spectrum experiences differently associated with affect dynamics? A continuous-time modeling approach

Psychotic experiences have been associated with distortions in affective functioning, including aberrancies in affect dynamics. However, it remains unclear whether the two principal symptom dimensions of psychosis, namely paranoid ideation and hallucination spectrum experiences, are differently associated with affect dynamics, and whether associations hold after statistically controlling for depressive symptoms. We investigate this by using a novel statistical approach, the hierarchical Ornstein-Uhlenbeck (OU) process model. This is a continuous-time stochastic differential equations model in a Bayesian framework that describes dynamics in affective valence and arousal via three core parameters: attractor point, variability, and attractor strength. In a community sample with varying levels of psychotic experiences (n = 116), we measured affective valence and arousal 10 times per day for 7 days, using the experience-sampling method. We found-while statistically controlling for depressive symptoms-credible between-subjects associations between paranoid ideation and attractor points of negative valence and high arousal. We also found a credible positive association between hallucination spectrum experiences and arousal variability. Limited evidence emerged for small associations between paranoid ideation and high valence variability as well as between paranoid ideation and high attractor strengths of valence and arousal. Hallucination spectrum experiences showed some evidence for a small association with high arousal attractor points. The detailed picture of affect dynamics provided by the OU model reveals different cross-sectional affective profiles associated with paranoid ideation versus hallucination spectrum experiences that suggest different affective mechanisms of their formation and maintenance. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An n=1 Clinical Network Analysis of Symptoms and Treatment in Psychosis

INTRODUCTION

Dynamic relationships between the symptoms of psychosis can be shown in individual networks of psychopathology. In a single patient, data collected with the Experience Sampling Method (ESM-a method to construct intensive time series of experience and context) can be used to study lagged associations between symptoms in relation to illness severity and pharmacological treatment.

METHOD

The patient completed, over the course of 1 year, for 4 days per week, 10 daily assessments scheduled randomly between 10 minutes and 3 hours apart. Five a priori selected symptoms were analysed: 'hearing voices', 'down', 'relaxed', 'paranoia' and 'loss of control'. Regression analysis was performed including current level of one symptom as the dependent variable and all symptoms at the previous assessment (lag) as the independent variables. Resulting regression coefficients were printed in graphs representing a network of symptoms. Network graphs were generated for different levels of severity: stable, impending relapse and full relapse.

RESULTS

ESM data showed that symptoms varied intensely from moment to moment. Network representations showed meaningful relations between symptoms, e.g. 'down' and 'paranoia' fuelling each other, and 'paranoia' negatively impacting 'relaxed'. During relapse, symptom levels as well as the level of clustering between symptoms markedly increased, indicating qualitative changes in the network. While 'hearing voices' was the most prominent symptom subjectively, the data suggested that a strategic focus on 'paranoia', as the most central symptom, had the potential to bring about changes affecting the whole network.

CONCLUSION

Construction of intensive ESM time series in a single patient is feasible and informative, particularly if represented as a network, showing both quantitative and qualitative changes as a function of relapse.

Insomnia, Nightmares, and Chronotype as Markers of Risk for Severe Mental Illness: Results from a Student Population

STUDY OBJECTIVES

To group participants according to markers of risk for severe mental illness based on subsyndromal symptoms reported in early adulthood and evaluate attributes of sleep across these risk categories.

METHODS

An online survey of sleep and psychiatric symptomatology (The Oxford Sleep Survey) was administered to students at one United Kingdom university. 1403 students (undergraduate and postgraduate) completed the survey. The median age was 21 (interquartile range = 20-23) and 55.60% were female. The cross-sectional data were used to cluster participants based on dimensional measures of psychiatric symptoms (hallucinations, paranoia, depression, anxiety, and (hypo)mania). High, medium, and low symptom groups were compared across sleep parameters: insomnia symptoms, nightmares, chronotype, and social jet lag.

RESULTS

Insomnia symptoms, nightmares frequency, and nightmare-related distress increased in a dose-response manner with higher reported subsyndromal psychiatric symptoms (low, medium, and high). The high-risk group exhibited a later chronotype (mid sleep point for free days) than the medium- or low-risk group. The majority of participants (71.7%) in the high-risk group screened positive for insomnia and the median nightmare frequency was two per 14 days (moderately severe pathology).

CONCLUSIONS

Insomnia, nightmares, and circadian phase delay are associated with increased subsyndromal psychiatric symptoms in young people. Each is a treatable sleep disorder and might be a target for early intervention to modify the subsequent progression of psychiatric disorder.

Schizophrenia: an integrated sociodevelopmental-cognitive model

Schizophrenia remains a major burden on patients and society. The dopamine hypothesis attempts to explain the pathogenic mechanisms of the disorder, and the neurodevelopmental hypothesis the origins. In the past 10 years an alternative, the cognitive model, has gained popularity. However, the first two theories have not been satisfactorily integrated, and the most influential iteration of the cognitive model makes no mention of dopamine, neurodevelopment, or indeed the brain. In this Review we show that developmental alterations secondary to variant genes, early hazards to the brain, and childhood adversity sensitise the dopamine system, and result in excessive presynaptic dopamine synthesis and release. Social adversity biases the cognitive schema that the individual uses to interpret experiences towards paranoid interpretations. Subsequent stress results in dysregulated dopamine release, causing the misattribution of salience to stimuli, which are then misinterpreted by the biased cognitive processes. The resulting paranoia and hallucinations in turn cause further stress, and eventually repeated dopamine dysregulation hardwires the psychotic beliefs. Finally, we consider the implications of this model for understanding and treatment of schizophrenia.

Social networks and support in first-episode psychosis: exploring the role of loneliness and anxiety

PURPOSE

To investigate social support and network features in people with first-episode psychosis, and to examine anxiety as a possible mediator between loneliness and a rating of paranoia.

METHOD

Thirty-eight people with first-episode psychosis were recruited for a cross-sectional study. Self-report questionnaires and structured interviews assessed symptoms, functioning, and qualitative social network and support features. A mood-induction task involved watching anxiety-inducing pictures on a computer screen. Visual analogue scales assessed changes in paranoia, anxiety and loneliness and a mediation analysis was conducted.

RESULTS

One-third of the sample (34%) had no confidant [95% CI (18.4, 50.0%)]. The average number of weekly contacts was 3.9, with 2.6 lonely days. Poor perceived social support, loneliness and the absence of a confidant were strongly associated with psychosis and depressive symptoms (0.35 < rs < 0.60). The association between loneliness and paranoia was mediated through anxiety (ab = 0.43, z = 3.5; p < 0.001).

CONCLUSIONS

Even at first episode, a large proportion of people with psychosis have poor perceived support, no confidant and report several lonely days a week. Patients without a confidant appear to be more susceptible to feeling lonely and anxious. Anxiety may be one pathway through which loneliness affects psychosis. Interventions which focus on this are indicated.

Putting a Hold on the Downward Spiral of Paranoia in the Social World: A Randomized Controlled Trial of Mindfulness-Based Cognitive Therapy in Individuals with a History of Depression

Context

Paranoia embodies altered representation of the social environment, fuelling altered feelings of social acceptance leading to further mistrust. Mindfulness-based cognitive therapy (MBCT) may relieve paranoia and reduce its impact on social acceptance.

Objective

To determine whether MBCT alters momentary feeling of paranoia and social acceptance in daily life.

Design

Randomized controlled trial of daily-life repeated measures (up to 120 per participant) before and after allocation to MBCT or waiting list control.

Participants

Volunteer sample of 130 eligible men and women with residual affective dysregulation after at least one episode of major depressive disorder.

Interventions

Eight weeks of MBCT in groups of 10–15 participants in addition to participants' usual treatment.

Outcome Measures

Daily-life ratings of paranoia and social acceptance. This manuscript concerns additional analyses of the original trial; hypotheses were developed after data collection (focus initially on depressive symptoms) but before data analysis.

Results

Sixty-six participants were assigned to the waiting list control group and 64 to the MBCT intervention group, of whom 66 and 61 respectively were included in the per-protocol analyses. Intention-to-treat analyses revealed a significant group by time interaction in the model of momentary paranoia (b = −.18, p<0.001, d = −0.35) and social acceptance (b = .26, p<0.001, d = 0.41). Paranoia levels in the intervention group were significantly reduced (b = −.11, p<0.001) and feelings of social acceptance significantly increased (b = .18, p<0.001), whereas in the Control condition a significant increase in paranoia (b = .07, p = 0.008) and a decrease in social acceptance was apparent (b = −.09, p = 0.013). The detrimental effect of paranoia on social acceptance was significantly reduced in the MBCT, but not the control group (group by time interaction: b = .12, p = 0.022).

Conclusions

MBCT confers a substantial benefit on subclinical paranoia and may interrupt the social processes that maintain and foster paranoia in individuals with residual affective dysregulation.

Trial Registration

Netherlands Trial Register NTR1084

Neurocognitive deficits in borderline personality disorder: implications for treatment

The cognitive dimension of Borderline Personality Disorder has received relatively little attention in the clinical literature and is poorly understood. This article illustrates how a range of cognitive problems including attention deficit disorder and learning disabilities may contribute to the cognitive disturbances identified in the disorder including dissociation, paranoia, all or nothing thinking, overvalued ideas, and denial and splitting. A review of relevant research supporting the presence of cognitive deficits is summarized along with a developmental pathway for the expression of the cognitive dimension. Clinical examples are provided. Recommendations for inclusion of assessment and treatment strategies that address cognitive deficits within a psychodynamically based psychotherapy are discussed.

Cognitive behavioural treatment of insomnia in individuals with persistent persecutory delusions: a pilot trial

BACKGROUND AND OBJECTIVES

Insomnia is a putative causal factor for persecutory thinking. Recent epidemiological studies show a strong association of insomnia and paranoia. The clinical implication is that reducing insomnia will reduce paranoid delusions. This study, evaluating for the first time the treatment of insomnia in individuals with persecutory delusions, provides a test of this hypothesis. It was predicted that a brief cognitive behavioural intervention for insomnia (CBT-I) for individuals with persistent persecutory delusions and sleep difficulties would not only reduce the insomnia but that it would also reduce the paranoia.

METHODS

Fifteen patients with persistent persecutory delusions and insomnia in the context of a psychotic disorder were each individually given a standard-format, four-session CBT-I intervention. Outcome assessments were conducted at pre-treatment, post-treatment and one-month follow-up.

RESULTS

There were no missing data. Following the intervention, significant reductions were found in levels of insomnia and the persecutory delusions. The effect sizes were large, and the changes were maintained at the follow-up. At least two-thirds of participants made substantial improvements in insomnia and approximately half showed substantial reductions in the persecutory delusions. There were also reductions in levels of anomalies of experience, anxiety and depression.

LIMITATIONS

The main limitations are the absence of a control group and unblinded assessments. A more methodologically rigorous evaluation of this intervention is now warranted.

CONCLUSIONS

These preliminary findings suggest that CBT-I can be used to treat insomnia in individuals with persecutory delusions and that, consistent with the hypothesised causal role, it also lessens the delusions.

A randomised controlled trial of a worry intervention for individuals with persistent persecutory delusions

Recent research has shown that worry is associated with distressing paranoia. Therefore, the aim was to target worry in a therapeutic intervention for individuals with delusions. It was predicted that a worry intervention would reduce levels of worry and paranoia distress. Twenty-four individuals with persistent persecutory delusions and high levels of worry were randomly assigned to receive a four session cognitive-behavioural worry intervention (W-CBT) or treatment as usual (TAU). The worry intervention was specifically designed not to target the content of delusions. In this open-label evaluation, assessments of worry and paranoia were conducted at baseline, at one month (end of treatment) and at two months. The worry intervention achieved a statistically significant reduction in worry which was maintained at two month follow up. A significant reduction in delusional distress was also reported. There was an indication that the worry intervention may also reduce the frequency of paranoid thoughts but this was not statistically significant. In the first trial specifically for persecutory delusions, a brief worry intervention was shown to have benefits. The results support a causal role for worry in paranoid experience.

Compassionate mind training with people who hear malevolent voices: a case series report

This paper presents a series of case studies to explore the understanding, acceptance and value of compassionate mind training (CMT) with psychotic voice hearers. We were interested in the degree to which such people are able to access and feel the positive emotions of 'warmth' and 'contentment' to become more self-compassionate. We also explored how CMT affected participants' hostile voices, their levels of anxiety, depression, paranoia and self-criticism. Participants were invited to offer suggestions for tailoring this approach for voice hearers. Results showed decreases for all participants in depression, psychoticism, anxiety, paranoia, Obsessive-Compulsive Disorder and interpersonal sensitivity. All participants' auditory hallucinations became less malevolent, less persecuting and more reassuring.

[Seclusion: a medical and political problem]

Seclusion, i.e. locking up psychiatric patients in safety rooms as a coercive measure, is common practice in the Netherlands. The Dutch mental health act permits seclusion of involuntarily admitted patients in acute emergency situations, or when it is absolutely necessary to avert danger caused by the patient's mental illness. Since 2006, a nationwide project aimed at the reduction of the number and duration of seclusion episodes by 10% a year has yielded positive results in one-third of mental hospitals. The Dutch Minister of Health recently advocated a further reduction of seclusion rates by 50% over the next year. We argue that short-term abolition of seclusion is an illusion and that the safety of patients and employees on closed psychiatric wards must be guaranteed. A further reduction in the practice of seclusion requires a major cultural change in psychiatry, adjustment of the law, and the financing of high-care psychiatric wards which are better staffed with appropriately qualified personnel.

Development of psychosis in patients with epilepsy treated with lamotrigine: report of six cases and review of the literature

Lamotrigine (LTG) is a generally well-tolerated antiepileptic drug (AED) with broad-spectrum efficacy in several forms of partial and generalized epilepsy and is also licensed for use in bipolar disorder in several countries. We describe six patients who developed a psychotic disorder--in most, but not all, cases schizophrenia-like in character--under treatment with LTG, within a group of about 1400 patients treated with this drug in our center. This indicates that psychosis is a rare adverse event under LTG treatment. On the background of available drug serum levels, we suggest, in particular, an intrinsic or toxic psychotogenic effect of LTG. Possible risk factors seem to be psychiatric comorbidity and temporal lobe pathology. The described phenomenon is discussed within the context of possible psychotogenic effects of other AEDs.

Persecutory delusions and catastrophic worry in psychosis: Developing the understanding of delusion distress and persistence

In a recent theoretical account of persecutory delusions, it is suggested that anxiety and worry are important factors in paranoid experience [Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. British Journal of Clinical Psychology, 41(4), 331-347]. In emotional disorders worry has been understood in terms of catastrophising. In the current study, the concept of catastrophising is applied for the first time with persecutory delusions. Thirty individuals with current persecutory delusions and 30 non-clinical controls participated in a cross-sectional study. The group with persecutory delusions was also followed up at 3 months to assess predictors of delusion persistence. At its most severe, 21% of individuals with persecutory delusions had clinical worry, 68% had levels of worry comparable with treatment seeking GAD patients. Further, high levels of anxiety, worry and catastrophising were associated with high levels of persecutory delusion distress and with the persistence of delusions over 3 months. If future research replicates these findings, worry reduction interventions for individuals with persecutory delusions may be warranted.

Human clock, PER1 and PER2 polymorphisms: lack of association with cocaine dependence susceptibility and cocaine-induced paranoia

Considerable research points to the importance of genetic mechanisms in psychostimulant addiction. Behavioral sensitization, a well-documented response to repeated stimulant exposure, may be mechanistically important in clinical features of the disorder, including escalating patterns of drug use, craving and drug-induced paranoia. Basic studies in both Drosophila melanogaster and mice have suggested the importance of circadian rhythm genes in locomotor sensitization and reward. The primary objective of the current study was to assess the potential involvement of three human orthologs (CLOCK, PER1 and PER2) in clinical phenotypes of the disorder. Allelic associations of three single nucleotide polymorphisms (SNPs) were assessed for both cocaine dependence and cocaine-induced paranoia in 186 cases and 273 controls. Potential population stratification biases were controlled for by means of within-population comparisons, and by structured association methods (using all populations). No differences in allele frequencies were found for any of the three single nucleotide polymorphisms studied between cocaine dependent and control subjects or between paranoid and nonparanoid cocaine users. These results do not support the involvement of genetic variation in these three circadian gene SNPs for influencing risks for either of these cocaine phenotypes.

[Clinical aspects of witchcraft delusions]

To distinguish clinical variants and to specify nosologic entity of witchcraft delusions, 69 patients (10 males, aged 15-72 years) have been examined. It was found that witchcraft delusions exist in passive and active forms. In a passive form, the patient is sure that unknown (mystic) power damaged him/her; in an active form the patient, possessing a gift for unusual abilities, can influence the others (bewitches, heals, etc). Five clinical syndromes, in the structure of which the above delusions were found, namely, paranoiac-hypochondriac, hallucination-paranoid, depressive-paranoid, paraphrenic and delirious, were identified. Psychoses of schizophrenia spectrum were diagnosed in 52 patients, organic--in 8, alcoholic--in 7 and recurrent depressive disorder--in 2. Clinical significance of witchcraft delusions is closely related to its social aspect. Being combined with ideas of persecution, poisoning and damage, it results in the brutal forms of delusions defense and may be considered as an unfavorable prognostic trait.

Ethnicity/race, paranoia, and hospitalization for mental health problems among men

OBJECTIVES

I tested the hypothesis that Black men with high levels of distrust (i.e., mild paranoia) are at greater risk of hospitalization for mental health problems than their White counterparts.

METHODS

Secondary analysis was conducted of data from a subsample of 180 men in an epidemiological study. Mental health hospitalization was the outcome and ethnicity/race, mild paranoia, and their interaction were main predictors in a logistic regression analysis. The ethnicity/race by mild paranoia interaction tested the study hypothesis.

RESULTS

The ethnicity/race by mild paranoia interaction was statistically significant. Contrary to the hypothesis, Black men with mild paranoia were less likely to be hospitalized.

CONCLUSIONS

Black men's lack of trust regarding the mental health system may cause them not to seek services. Factors critical to increasing their trust are acknowledgment of racial biases in the mental health system and sincere efforts to eliminate racial disparities in mental health treatment.

Fragmented attachments: the paranoid-schizoid experience of loss and persecution

The author discusses paranoid-schizoid patients who have yet to deal with whole-object depressive fears of harming one's object. Their paranoid-schizoid anxiety is more a combination of dread, paranoia, and fear of destroying one's object with neediness, envy, and other oral desires. In this part-self and part-object world, destruction is absolute. Ego functions and object relational capacities such as guilt and grief are not yet fully consolidated. The part-object is not only destroyed but is also equally capable of magically resurrecting itself to seek revenge. Fear of annihilation of the self and object, as well as desperate attempts at keeping each other alive, are the primary focus of this early anxiety state. These infantile fears are at the root of certain difficult treatment situations. Within the transition from paranoid-schizoid to depressive, the ego struggles with highly exaggerated and distorted fantasies of persecution, loss, and primitive guilt by resorting to crude and often self-destructive mechanisms. These include splitting, projective identification, and idealization. During the course of analytic treatment, three overlapping phases are distinguishable. Acting out is the main theme of early treatment. As this externalization of internal conflict is analyzed and contained, a second phase of intrapsychic struggle emerges. The patient exhibits a paralyzing battle between certain ego-object ties and the striving of a defensive death instinct. If the analytic relationship is able to withstand passage through these difficult phases, the patient begins to work through more core issues of persecutory loss and annihilation. Case material is used for illustration.

Arylsulfatase A levels in patients with chronic alcoholism

BACKGROUND

The goal of this study was to find the association between low arylsulfatase A (ASA) activity and psychiatric disorders in chronic alcoholic patients.

METHODS

The study was carried out in 30 chronic alcoholic patients (27 male, 3 female); age range was 25-65 years. There were 20 normal controls (18 males, 2 females), and age range was 24-67 years. ASA and routine aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activity laboratory tests were measured in blood serum from all patients and control subjects.

RESULTS

Alcoholic patients with psychiatric disorders have ASA average values of 68.25 nmol/mL/4 h. This is less than averages found in the alcoholics without psychiatric disorders group (82.48 nmol/mL/4 h) and the control group (90.8 nmol/mL/4 h). There were no statistically significant differences among the three groups studied. Alcoholic subjects with elevated activity of AST and ALT (n = 10) have ASA activity average values of 134.82 nmol/mL/4 h), which is 48.8% higher than the control group (90.6 nmol/mL/4 h). These means show statistically significant differences (p <0.05).

CONCLUSIONS

Results indicate an association between low serum ASA activity and alcoholism. The appearance of psychiatric manifestations could be related to the low activity of this enzyme in chronic alcoholic patients. Alcoholic patients with elevated enzyme activity of AST and ALT in sera also have elevated sera arylsulfatase A (ASA) activity. We consider that these findings may be useful for evaluating the psychiatric state as a prognosis in chronic alcoholic patients, and should be a routine laboratory test in alcoholic patients.

Self-discrepancies and causal attributions: studies of hypothesized relationships

The self-concept and causal attributions are both centrally implicated in psychological disorders including depression and paranoia. In two investigations of the dynamic relationships between causal attributions and self-representations, non-patient participants completed questionnaires derived from Higgins' (1987) Self-Discrepancy Theory before and after completing a measure of causal attribution. In Study 1, consistent with cognitive models of depression, external attributions for negative events were associated with reductions in self-actual:self-ideal discrepancies. Study 2 revealed significantly different effects on self-discrepancies of three types of causal attributions. Internal attributions led to increased self-actual:self-ideal discrepancies as well as increased discrepancies between self-perceptions and the believed views of others about the self (self-actual:other-actual discrepancies). External situational attributions led to no changes in either self-actual:self-ideal or self-actual:other-actual discrepancies. External personal attributions led to no changes in self-actual:self-ideal discrepancies but increased self-actual:other-actual discrepancies. These findings point to the value of distinguishing between different kinds of external attributions. They show that self-representations and causal attributions are closely coupled cognitive domains. The results also suggest that paranoid ideation might be specifically associated with external-personal attributions for negative events.

Deterioration of parkinsonian symptoms following treatment of dopaminergic hallucinosis with olanzapine

The atypical antipsychotic drug olanzapine has been proposed for treatment of dopaminergic psychosis in Parkinson's disease (PD). We report on a 68-year-old patient who developed a severe akinetic-rigid extrapyramidal syndrome, accompanied by additional paranoid symptoms, following olanzapine treatment of optic hallucinosis in PD. Olanzapine may also induce clinically relevant extrapyramidal side effects in PD patients.

[Paranoid nosogenic reactions in patients with somatoform disorders]

The authors examined 16 patients with ischemic heart disease who had psychogenic disorders with ideas of rationalization of therapy. Paranoial personality disorders (paranoial psychopathy) was diagnosed in 11 patients, pseudopsychopathy in residual schizophrenia in 5 patients. The patients had either a fanatic idea of creating new methods of self-therapy and an autoaggressive behavior (performing some dangerous manipulations, usage of non-medicamentous substances, etc.). The premorbid state of such patients was characterized by inclination to paranoial reactions and a special predisposition to them combined with an egodystonic attitude to corporal manifestations. Paranoial reactions of such type were reversible and disappeared in the course of somatic state improvement.

[Paranoid psychosis in acute intermittent porphyria treated with perphenazine]

Several drugs may induce or exacerbate symptoms in acute porphyria. This includes most psychotropic drugs, which makes the treatment of psychiatric symptoms in the porphyric patient difficult. A patient with a paranoid psychotic condition related to acute intermittent porphyria was treated with perphenazine. The use of this drug has not previously been reported in acute intermittent porphyria. Therefore, the treatment was closely monitored clinically and biochemically. No deterioration in the porphyric state was observed. However, further experience is needed before perphenazine may be considered as a drug that can be used safely in acute intermittent porphyria.

Two predictions about paranoid ideation: deluded, depressed and normal participants' subjective frequency and consensus judgments for positive, neutral and negative events

Two groups of patients suffering from persecutory delusions, one consisting of patients also suffering from depression and a non-depressed group, together with clinically depressed and normal controls matched with the deluded patients for age and intelligence, were asked to rate the frequency with which selected positive, negative and neutral events had happened to themselves and to an average other person in the past, and the frequency with which these events were likely to happen to themselves and to an average other person in the future. Results were similar for both past and expected future events. Non-depressed-deluded, depressed-deluded and depressed patients rated negative events as occurring relatively more frequently in comparison to the normal controls. Depressed participants rated positive events as occurring more frequently to others, whereas the normal participants rated negative events as occurring more often to others. Correlational analyses indicated that depression scores were associated with low estimates of the frequency with which positive events happen to self and high estimates of the frequency with which negative events happen to self. Magical ideation scores, an index of psychosis, were associated with high estimates of the frequency of negative events for both self and others. These findings are interpreted in the context of previous evidence on cognitive biases in deluded patients.

Consultations for 'maladaptive denial of illness' in patients with cancer: psychiatric disorders that result in noncompliance

Patients who present with late stages of cancer often have complicated medical and psychiatric problems which are labeled as 'maladaptive delay or denial.' In some of these patients, psychiatric problems have either contributed to the delay in medical presentation for care or have interfered with treatment of the late stage cancer. The authors review some of the factors that contributed to delay and noncompliance in a series of patients with cancer who were evaluated by the psychiatric consultation service of a university hospital. Specifically, psychoses and cognitive impairment played a major role in delay and noncompliance. The authors discuss recommendations for management of such patients, and suggest that clinicians often benefit from the assistance of the psychiatric consultant as part of the treatment team. Multiple resources and multiple types of intervention are needed in order to help such patients negotiate the clinical environment.

Abnormalities of self-representation and persecutory delusions: a test of a cognitive model of paranoia

Patients suffering from persecutory delusions exhibit information processing and social reasoning biases that have been hypothesized to have a self-protective function. In a test of this hypothesis, patients suffering from persecutory delusions who were also depressed and non-depressed deluded subjects were compared with depressed and normal controls on two indirect assessments of self-schemata: the Dysfunctional Attitudes Scale (DAS) and incidental recall of negative and positive trait words that had previously been judged to be self-descriptive or not self-descriptive. Both the depressed subjects and the deluded subjects, whether or not they were depressed, scored highly on the DAS. Like normals, both depressed and non-depressed deluded subjects endorsed more positive than negative trait words as true of themselves whereas the depressed subjects endorsed as many negative as positive trait works. Like the depressed subjects, both groups of deluded subjects recalled as many of the negative words they had endorsed as positive words, whereas the normals remembered more positive words. No such bias was observed in subjects' recall of unendorsed words. The DAS results are interpreted as clearly consistent with a defensive model of persecutory delusions whereas the incidental recall data were equivocally so.

[Successful therapy of the psychiatric patient with catatonic paranoidal syndrome and monitoring of induced cytokine production]

The paper reports the case of a 42-year-old woman with a diagnosed catatonic-paranoidal syndrome and a noted dysfunction as regards lymphocyte subpopulation and the production of some cytokins: Tumor Necrosis Factor (TNF) and interferons (IFN). As the first phase of the treatment had proved unsuccessful and there appeared symptoms hinting at the possibility of a subclinical inflammatory process in the brain, parallel to psychiatric therapy, treatment was instituted in the system of successive three-week cycles with Tołpa's Peat Extract (PTT), Selenium and Zinc on a natural yeast basis (Selenium and Zinc preparations) as well as with encortone. After a month of treatment a complete clinical remission was achieved as well as normalization as regards all the tested immunological markers.

Acute lymphocytic leukemia and psychosis: treatment with electroconvulsive therapy

This paper reports the coocurrence of paranoid psychosis and acute lymphocytic leukemia in a 16-year-old African-American male. Subsequently, he developed a neuroleptic malignant-like syndrome and several other ill-defined complications of antipsychotic therapy, which presented difficult management problems for the medical and psychiatric staff caring for him. Definitive treatment for his psychiatric disorder (ECT) involved possible interactions with his cancer chemotherapy regimen that were not clearly defined.

The role of psychological coronary risk factors in insulin and glucose metabolism

The association between psychological coronary risk factors and serum insulin, and C-peptide and blood glucose concentrations, [the latter measured while fasting and during the oral glucose tolerance test (OGTT)], was examined in healthy middle-aged men (n = 64). The results indicate that among the evaluated psychological risk factors, high levels of hostile paranoia and vital exhaustion were most consistently associated with an enhanced insulin/glucose ratio, and enhanced insulin, C-peptide and glucose responses during OGTT. The associations persisted after controlling for age, smoking, alcohol consumption and visceral fat distribution. Thus, in addition to age, life-style factors and obesity, psychological factors may have an effect on insulin and glucose metabolism.

Criminal activity and crack addiction

The association of crack and criminal activity is commonly believed but not well documented or characterized in any systematic studies of crack addicts. In this survey of 200 crack addicts, daily use of crack correlated more with illicit, criminal activities to obtain a supply of crack than to demographic features. Correspondingly, felony and cocaine dealing was associated with total dollars spent on cocaine but not to other demographic features such as level of property or affluence. Moreover, the majority of crack addicts in this sample used cocaine intranasally before starting crack use. The mean age from onset of crack use to seeking help for cocaine addiction is less than 3 years. Severity of crack use and addiction as measured by daily use was associated with psychosocial consequences more than other demographic features.

A case of paranoid disorder associated with hyperthyroidism

This paper describes a patient presenting with paranoid symptoms who eventually was diagnosed as having Graves' disease. In this patient, paranoid disorder appeared to occur concurrently with hyperthyroidism in a clear state of consciousness. This case underscores the need to maintain a high index of suspicion of possible medical conditions in psychiatric patients. This is especially the case in the presence of unexplained symptoms and when there is a difficulty communicating with the patient. The importance of carrying out a careful physical examination on admission to a psychiatric unit is emphasized. Another indication for further medical investigation in a patient with psychiatric symptoms is the absence of a psychological explanation for a worsening of the psychiatric symptoms.

Global diagnostic ratings compared to DSM-III-R diagnoses in early dyskinesia

1. Two types of psychiatric diagnoses were obtained in a study of the course of early dyskinesia: DSM-III-R and Dimensional Global Ratings of Schizophrenia, Paranoia, Mania and Depression. 2. The strength of association between measures of vulnerability to developing tardive dyskinesia (TD), and clinical components from each of the two methods of obtaining psychiatric diagnoses was established by canonical correlations. 3. Overall, little difference was obtained between DSM-III-R categories and Global Ratings in terms of correlations with TD vulnerability measures. Using components from global diagnostic ratings, the Depression and Schizophrenia Scales made stronger contributions to the canonical functions than Mania and Paranoia. 4. Unipolar depressed patients appear more sensitive to NL: they developed TD after less NL exposure. 5. Dimensional classification appears to be a promising approach to capturing important characteristics of psychoses.

Dilemmas in management of the elderly

Keeping an open mind is often the cornerstone of good management in general practice, especially when treating the elderly as the following cases illustrate.

Idiopathic unconjugated hyperbilirubinemia (Gilbert's syndrome) and concurrent psychotropic drug administration

Gilbert's Syndrome is a benign familial condition in which unconjugated hyperbilirubinemia occurs in the absence of structural liver disease or hemolysis. Phenothiazines and tricyclic medications are often withheld in patients with preexisting liver disease. The authors present four patients with Gilbert's Syndrome and concurrent psychiatric illness. Administration of phenothiazine antipsychotics or tricyclic antidepressants proved beneficial and produced no adverse effects on hepatic function. The authors discuss clinical aspects of Gilbert's Syndrome in psychiatric patients and conclude that phenothiazine antipsychotic medication should not necessarily be withheld from these patients.

Paranoia and the defensive attributional style: deluded and depressed patients' attributions about their own attributions

A data set of Attributional Style Questionnaire responses collected by Kaney & Bentall (1989) from persecutory deluded, normal and depressed subjects was added to a similar data set collected by the first author. The attributions made for hypothetical positive and negative events by the combined pool of subjects were then blind rated for internality by five independent judges. Whereas the internality ratings made by the subjects for their own attributions showed evidence of an exaggerated self-serving bias in the case of the deluded subjects, and an absence of such a bias in the case of the depressed subjects, the independent ratings showed no such group differences. These findings suggest that the differences in internality for positive and negative events observed on the ASQ between deluded, normal and depressed subjects may not reflect differences in the types of causal statements made by these subjects but differences in their attributions about their attributions. The relevance of this observation for attribution theory in general and attributional accounts of psychopathology in particular are discussed.

[Paranoia disorder as the first manifestation of AIDS]

Psychotic features resembling those seen in a functional psychosis--Delusional Disorder--were found in a forty two-year-old male eighteen months before a diagnosis of A.I.D.S. was made. The causal relation between the two entities is discussed making reference to five other similar cases described in the literature.

[Pathogeny of paranoid delirium]

Revisiting the old discussion on the intellectual, or emotional genesis of non-hallucinatory delusions, the author collects the opinion of classical authors on this essential subject of Psychiatry. Based on Kraepelin's description of the constitutive elements of paranoiac delusion, and relating such descriptions to the current advances in Neurobiology--especially Goldar's, on the participation of the limbic brain to the dynamics of personality--the author discusses his position regarding delirious verbal performances, and intends a subdivision of such disorders according to their own pathogenesis.

Monosymptomatic hypochondriacal psychosis

In brief, therefore, we are dealing with an illness characterised by a single delusional system - in this instance with hypochondriacal content - which can occur at any age from late adolescence onwards, appears to affect the sexes equally, and has a very poor prognosis without treatment. Its presentation appears to be relatively independent of cultural factors. A previous history, or a family history, of psychotic illness seems very uncommon. However, substance abuse and/or head injury seem to be background factors in a high proportion of younger patients and I would speculate about the role of the ageing brain in the more elderly patients. Within the delusional system, the patient shows marked illogicality insisting, against all evidence, on a physical aetiology, going to many physicians, and initiating strange 'cures' of his own. Although paranoid anger is not uncommonly a feature, secondary depression, shame and avoidant behaviour are more frequent. The illness causes great anguish, and sometimes suicide. Folie à deux is relatively common. At present, pimozide appears to be the most specific treatment and can be dramatically effective. There are scattered reports of improvement or even cure with other neuroleptics or tricyclic antidepressants but, in general, these seem less effective than pimozide (Cashman & Pollock, 1983; Brotman & Jenike, 1984; Pylko & Sicignan, 1985). However, a single case report recently from the USA is intriguing: an apparently excellent result with amoxapine, currently perhaps the most antidopaminergic of the antidepressant drugs (Tollefson, 1985). However, although the case description is suggestive of MHP, the author regards it as one of major depressive illness.(ABSTRACT TRUNCATED AT 250 WORDS)