Introduction to Psychotic Illnesses

1. Introduction to Psychotic Illnesses Dr Greg Chick Senior House Officer in liaison psychiatry, North Manchester General Hospital 8.1.07

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

3. ‘Psychosis’ - definition Mental disorder • in which the thoughts, feelings, affective response, ability to recognise reality • and ability to communicate and relate to others are • sufficiently impaired to interfere grossly with the capacity to deal with reality; • the characteristics of psychosis are impairedreality testing, hallucinations, delusions and illusions. • Kaplan & Saddock “Comprehensive textbook of psychiatry” – 7th ed, glossary p686

4. WHY do I need to know about Psychotic Illnesses? • GP • Is the Front line service • Early detection improves prognosis! • worried relatives asking you to section people • Increased burden on health services; worse physical health • Surgeons / Obs & Gynae – delusional pts insisting on unnecessary operations • A&E – pts present with bizarre complaints & behaviour; overdose • Paediatrics – child protection issues; early onset psychosis • Psychiatry – our area of expertise! • Mental health act, forensic, suicide

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

6. What do I Really Have to Know? • Think ORGANIC! • Oxygenation, Glucose, Electrolyte disturbance, endocrine • Toxicity – iatrogenic, self-inflicted, accidental • Drugs & alcohol • Cerebral pathology • Define: • Delusion • Hallucination (vs illusion)

7. ICD-10 A diagnostic heirarchy • F0- - Organic • F1- - Substance-related • F20s - Schizophrenia… & delusional disorders • F3- - Mood [affective] disorders • F4- - neurotic, stress-related & somatoform dis. • F5- - …physiological.. (inc eating disorders) • F6- - …personality disorders… • F7- - mental retardation etc

8. mental state abnormalities in psychotic illness Thought Behaviour Perception Catatonia Form Content Delusions Hallucinations Illusions Pseudohallucinations Overvalued Ideas Circumstantiality Fusion Knight´s Move Thinking Auditory Derailment Tactile Word Salad Visual Olfactory & Gustatory Thought Block

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

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

11. Delusions of… • Grandeur / ability • Paranoia • Reference • Persecution • Control • Infestation • Love / jealousy • Misidentification • Nihilism

12. Delusions - examples “I am the son of George W Bush • …and a Somali woman. They were on holiday there and left me behind.” grandeur “I have a microchip in my brain which transmits my thoughts to MI5.” control “My family are poisoning my food – it tastes funny” persecution “They’re making a TV programme about me – I keep seeing my name in the newspaper.” reference

13. Persistent Delusional Disorders (F22) • Delusional disorder (F22.0) – including: • Persecutory delusions • delusional jealousy; • De Clérambault’s syndrome – “erotomania” • Induced delusional disorder (folie a deux) (F24) • Delusion shared by people with close emotional links • Only one person suffers from a genuine psychotic disorder • The other person’s delusion disappears when they are separated • Delusional dysmorphophobia (F22.8) • Paranoia querulans (F22.8)

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

15. ‘Delusional mood’ –a feeling that something’s not right: • Imagine… • You’ve bumped someone’s car in a car park. There’s no damage, so you drive off quickly! • Your phone rings in the middle of the night but you miss the call and the number is unknown… • What emotions do you feel? • What goes through your mind? • Who was phoning you? • The next day, you’re still thinking about it and you receive an envelope with a government crest on it… • What emotions now? • What goes through your mind before you open it? • Supposing, in your nervous state, you read it wrong…?

16. How to approach:a delusional patient • Empathise (but don’t patronise) • Test the intensity of the belief • but don’t be confrontational • Ask them ‘could there be an alternative explanation?’ • What have they done about their belief? • (do they believe you’re a real medical student?) • Look up examples of how to phrase your questions • Present State Examination

17. Other delusional syndromes • Fregoli’s delusion • My persecutor takes on the form of different people… • But I KNOW it’s still him! • Schizophrenia / stroke = delusional misidentification • Cotard syndrome • Nihilistic delusions, esp. in psychotic depression • “I’ve got no blood / bowels / breath / money” • “I’m dead / rotting from inside”

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

19. De Clérambault’s syndrome – • “erotomania” • usually in women • convinced that a man • usually older, of higher status • eg the consultant • is in love with her

20. mental state abnormalities in psychotic illness Thought Behaviour Perception Catatonia Form Content Delusions Hallucinations Illusions Pseudohallucinations Overvalued Ideas Circumstantiality Fusion Knight´s Move Thinking Auditory Derailment Tactile Word Salad Visual Olfactory & Gustatory Thought Block

21. Thought Content Overvalued Ideas Delusions of Reference Body image Hypochondriasis Litigation Religious political Control, Passivity of Paranoia: Reference Persecution Grandeur

22. Schizophrenia?

23. Myths & Misconceptions • ‘Schizophrenia’ does literally mean ‘separated mind’ • Greek – applied by Bleuler in 1911 • BUT is nothing to do with ‘split personality’ • …let alone ‘multiple personality’ (very rare) • HAS to do with the brain’s functions separating • eg. You hear a voice but don’t recognise it’s come from your own mind

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

25. Heritable Risk

26. Age of Onset – Bimodal Distribution

27. 1st Rank symptoms • 1950’s - Schneider’s 1st Rank Symptoms: • Primary Delusion = ‘delusional percept’ • Own thoughts spoken aloud = ‘thought echo’ • Voices arguing or discussing • running commentary voices • thought withdrawal and/or thought block • Thought insertion • thought broadcasting (others are thinking it at the same time as you) • Made to feel… ‘passivity of affect’ • Made to want… ‘passivity of impulse’ • Made to do… ‘passivity of volition’ • Done to my body ‘somatic passivity’ eg probed by aliens • Some may occur in illnesses other than schizophrenia eg mania

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

29. Paintings by artist with worsening psychosis – perceptual disturbances

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

31. Hallucinations 2 • Non-pathological: • Hypnagogic (going off to sleep) • Hypnopompic (waking up)

32. When it’s NOT a hallucination • Illusion = misperception of a REAL stimulus • Daydream = imagery • Pseudohallucination • Occurs in inner subjective space • eg voices INSIDE your head • May have quality of your own thoughts • Distressed patients not interested in this distinction!

33. Ideas of reference • On a spectrum • I think people on the bus are looking at me => => • The news is about my life! It means I’m a paedophile. Don’t you believe me?

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

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

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

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

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

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

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

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

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

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

44. Artist with Sz – delusion of being electronically controlled?

45. mental state abnormalities in psychotic illness Thought Behaviour Perception Catatonia Form Content Delusions Hallucinations Illusions Pseudohallucinations Overvalued Ideas Circumstantiality Fusion Knight´s Move Thinking Auditory Derailment Tactile Word Salad Visual Olfactory & Gustatory Thought Block

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

47. Differential Diagnosis: Conditions that look like schizophrenia(similar symptoms) • Organic psychoses – • Temporal Lobe Epilepsy, delirium, delusional disorder, catatonia • substance-induced psychoses – • Cannabis/hallucinogens, stimulants, alcohol (DTs, hallucinosis), etc • “Acute and transient” psychotic disorders • Schizo-affective disorder • Manic episode • Schizotypal disorder • Emotionally unstable personality disorder (can have brief psychotic symptoms) • Trance & possession disorders!

48. Important Reading • ICD-10 (World Health Organisation, 1992) • F20 chapter = • a brief description of what these conditions are and aren’t • DSM-IV is the American equivalent – bigger but gives thumbnail sketches of the conditions • My lecture on schizophrenia from last year  • “Symptoms in the Mind” by Andrew Simms • (the ‘bible’ for descriptive psychopathology)

49. Case Vignette - 2 • Brian began to be a worry to his parents at the age of 17. After doing quite well in his GCSEs, he seemed to lose interest and his ability to concentrate on his studies. He began to spend more time alone in his room listening to music and when he went out with his friends, he appeared dazed and distant on returning home. • His parents suspected he was taking drugs but he denied this. When his mother went into his bedroom to tidy up one day, she found that he had draped a cloth over the mirror. He explained this by saying that he avoided looking at his face because he had a strange look in his eyes, as though he had become hypnotised. His parents tried to persuade him to visit their GP, but he refused to go. He became very quarrelsome and one day he punched one of his friends without warning. That evening, he removed all the light bulbs from their sockets after complaining that they were emitting dangerous radiation. His parents took him to hospital and he was admitted. • www.abpi.org.uk/publications/publication_details/targetSchizophrenia-2003/section2.asp