Differential diagnosis of obsessive-compulsive symptoms from delusions in schizophrenia: A phenomenological approach

Several studies suggest increased prevalence-rates of obsessive-compulsive symptoms(OCS) and even of obsessive-compulsive disorder(OCD) in patients with schizophrenic disorders. Moreover, it has been recently proposed the existence of a distinct diagnostic subgroup of schizo-obsessive disorder. However, the further investigation of the OCS or OCD-schizophrenia diagnostic comorbidity presupposes the accurate clinical differential diagnosis of obsessions and compulsions from delusions and repetitive delusional behaviours, respectively. In turn, this could be facilitated by a careful comparative examination of the phenomenological features of typical obsessions/compulsions and delusions/repetitive delusional behaviours, respectively. Thiswas precisely the primary aim of the present investigation. Our examination included seven features of obsessions/delusions(source of origin and sense of ownership of the thought, conviction, consistency with one's belief-system, awareness of its inaccuracy, awareness of its symptomatic nature, resistance, and emotional impact) and five features of repetitive behaviours(aim of repetitive behaviours, awareness of their inappropriateness, awareness of their symptomatic nature, and their immediate effect on underlying thought, and their emotional impact). Several of these clinical features, if properly and empathically investigated, can help discriminate obsessions and compulsive rituals from delusions and delusional repetitive behaviours, respectively, in patients with schizophrenic disorders. We comment on the results of our examination as well as on those of another recent similar investigation. Moreover, we also address several still controversial issues, such as the nature of insight, the diagnostic status of poor insight in OCD, the conceptualization and differential diagnosis of compulsions from other categories of repetitive behaviours, as well as the diagnostic weight assigned to compulsions in contemporary psychiatric diagnostic systems. We stress the importance of the feature of mental reflexivity for understanding the nature of insight and the ambiguous diagnostic status of poor insight in OCD which may be either a marker of the chronicity of obsessions, or a marker of their delusionality. Furthermore, we criticize two major shortcomings of contemporary psychiatric diagnostic systems(DSM-IV, DSM-V, ICD-10) in their criteria or guidelines for the diagnosis of OCD or OCS: first, the diagnostic parity between obsessions and compulsions and, second, the inadequate conceptualization of compulsions. We argue that these shortcomings might artificially inflate the clinical prevalence of OC symptoms in the course of schizophrenic disorders. Still, contrary to a recent proposal, we do not exclude on purely a priori grounds the possibility of a concurrence of genuine obsessions along with delusions in patients with schizophrenia.

Acute Normalization of Thyroxine Induced Hallucinations and Delusions

The association between disorders of thyroid function and psychiatric symptoms is well established. Generally, hypo-thyroidism is recognized as being able to induce psychotic symptoms. However, psychotic symptoms without affective and cognitive disturbances are rare in hyperthyroidism. We presented a patient with Graves’ disease who suffered from delusions and hallucinations without affective and cognitive disturbances following abrupt normalization of thyroid function. Furthermore, the patient was clinically and biochemically euthyroid when the psychotic symptoms developed. There was resolution of psychotic symptoms in this case. It is suggested that the abrupt change of thyroxine may cause susceptible individuals to become transient psychotic state.

Hydroxytryptamine transporter gene-linked polymorphic region(5HTTLPR)is associated with delusions in Alzheimer’s disease

Background:Serotoninergic pathways underlying delusion symptoms in Alzheimer’s disease(AD)have not been fully clarified.5-Hydroxytryptamine transporter gene-linked polymorphic region(5-HTTLPR)is a variable number tandem repeats in the promoter region of serotonin transporter encoding-gene affecting transcription.Methods:We investigated the association of 5-HTTLPR with delusions in a total of 257 consecutive patients clinically diagnosed as AD according to the National Institute on Aging-Alzheimer’s Association criteria.All participants underwent a comprehensive evaluation with a standardized comprehensive geriatric assessment and Neuropsychiatric Inventory.Results:Delusion symptoms were observed in 171 patients(66.54%).In respect to AD patients without delusions,AD patients with delusions showed a low prevalence of S-plus carriers(5-HTTLPR-L/S+5-HTTLPR-S/S genotypes)[p<0.001;odds ratio(OR)=0.240,95% confidence interval(CI)=0.121–0.471].Logistic regression analysis adjusted for the apolipoprotein E polymorphism showed that in AD patients with delusions the presence of an 5-HTTLPR-S allele may reduce disease duration(p=0.005;OR=0.680,95% CI=0.522–0.886)and increase aberrant motor activity(p=0.013;OR=2.257,95% CI=1.195–4.260).The present findings suggested that 5-HTTLPR might be associated with delusions in AD.S-plus carriers might be associated with protective effect against delusions in AD.Conclusions:More studies on wider samples of high selected demented patients are needed to confirm our results.However,the present findings suggested that a genetic factor related to serotonin metabolism might exert a protective role on the clinical expression of neuropsychiatric clusters in AD with important implications regarding mechanisms underlying delusions and their possible treatment across the AD and dementia spectrum.

What Are the Current and Developing Treatments for Cotard’s Syndrome, Alice in Wonderland Syndrome, and Catatonic Schizophrenia?

Purpose: Cotard’s syndrome, Alice in Wonderland Syndrome, and Catatonia are all rare psychiatric disorders that have relatively little research regarding their treatments. The aim of this article is to highlight any gaps in knowledge regarding represented demographics in these treatment studies, and to discuss the current and upcoming treatment options. Background: This literature review explores under-researched psychiatric conditions: Cotard’s syndrome, Alice in Wonderland syndrome, and Catatonic Schizophrenia. Understanding psychiatric disorders requires basic knowledge of brain anatomy. These conditions are often result of or associated with neurological issues, such as migraines or tumors. The brain has eight lobes, two of four kinds: frontal, parietal, occipital, and temporal lobes, which all govern different functions and abilities. Frontal lobes control judgment, decision-making, personality traits, and fine motor movements. Parietal lobes interpret pain and temperature, occipital lobes handle visual stimuli, and temporal lobes enable hearing. The pre-frontal cortex is associated with high intelligence, psychotic traits, and psychosis. The Broca’s Area in the frontal lobes controls expressive language. These areas and divisions of the brain contribute to the complexity of the psychiatric disorders discussed in this review. Introduction: Cotard’s syndrome is a psychiatric disorder characterized by delusions of being dead or not having certain limbs or organs. It is believed that there is a disconnect between their fusiform face area and the amygdala, causing a lack of familiarity between one’s mind and body. Alice in Wonderland Syndrome (AIWS) is another psychiatric disorder which is characterized by visual hallucinations, such as distorted perceptions of color, size, distance, and speed. The most common symptoms include micropsia and macropsia. Catatonia/Catatonic Schizophrenia is an uncommon type of schizophrenia. This type of schizophrenia is characterized by motor rigidity, verbal rigidity, the flat effect, psychomotor retardation, waxy flexibility, and overall negative symptoms. Thus, these people may come off as emotionally detached, and able to stay frozen in odd positions for periods on end. Treatments and Results: Cotard’s syndrome seemed to be most effectively treated by ECT (electroconvulsive therapy). Alice in Wonderland Syndrome (AIWS) had the highest positive responses to treatment by Valproate (an anti-epileptic drug), as well as intervention to treat the associated neurological conditions they had. Catatonia/Catatonic Schizophrenia seemed to be most effectively treated with a combination of benzodiazepines and ECT. Discussion and Demographics: In all 3 disorders, the Latino and African communities were underrepresented. There also seemed to be an underrepresentation of men in Cotard’s syndrome, and of women in Alice in Wonderland Syndrome. Japan and India seemed to have the highest density of treatment studies in all 3 disorders.

Emerging role of psychosis in Parkinson's disease:From clinical relevance to molecular mechanisms

Parkinson's disease(PD)is the second most common neurodegenerative disease.Psychosis is one of the common psychiatric presentations in the natural course of PD.PD psychosis is an important non-motor symptom,which is strongly correlated with a poor prognosis.Increasing attention is being given to PD psychosis.In this opinion review,we summarized and analyzed the identification,screening,epidemiology,mechanisms,risk factors,and therapeutic approaches of PD psychosis based on the current clinical evidence.PD psychosis tends to have a negative effect on patients'quality of life and increases the burden of family caregiving.Screening and identification in the early stage of disease is crucial for establishing tailored therapeutic strategies and predicting the long-term outcome.Development of PD psychosis is believed to involve a combination of exogenous and endogenous mechanisms including imbalance of neurotransmitters,structural and network changes,genetic profiles,cognitive impairment,and antiparkinsonian medications.The therapeutic strategy for PD psychosis includes reducing or ceasing the use of dopaminergic drug,antipsychotics,cholinesterase inhibitors,and non-pharmacological interventions.Ongoing clinical trials are expected to provide new insights for tailoring therapy for PD psychosis.Future research based on novel biomarkers and genetic factors may help inform individualized therapeutic strategies.

An extremely rare case of delusional parasitosis in a chronic hepatitis C patient during pegylated interferon alpha-2b and ribavirin treatment

During treatment of chronic hepatitis C patients with interferon and ribavirin, a lot of side effects are described. Twenty-three percent to 44% of patients develop depression. A minority of patients evolve to psychosis. To the best of our knowledge, no cases of psychogenic parasitosis occurring during interferon therapy have been described in the literature. We present a 49-year-old woman who developed a delusional parasitosis during treatment with pegylated interferon alpha-2b weekly and ribavirin. She complained of seeing parasites and the larvae of fleas in her stools. This could not be confirmed by any technical examination. All the complaints disappeared after stopping pegylated interferon alpha-2b and reappeared after restarting it. She had a complete sustained viral response.

Understanding the paranoid psychosis of James:Use of the repertory grid technique for case conceptualization

In this paper we illustrate the potential of the repertory grid technique as an instrument for case formulation and understanding of the personal perception and meanings of people with a diagnosis of psychotic disorders.For this purpose,the case of James is presented:A young man diagnosed with schizophrenia and personality disorder,with severe persecutory delusions and other positive symptoms that have not responded to antipsychotic medication,as well with depressive symptomatology.His case was selected because of the way his symptoms are reflected in his personal perception of self and others,including his main persecutory figure,in the different measures that result from the analysis of his repertory grid.Some key clinical hypotheses and possible targets for therapy are discussed.

Schizophreniform Disorder after Onset of Menopause

Schizophrenia is one of the psychotic disorders that is a huge concern with prevalence increasing every year. In this case report, we are discussing the case of a 49-year-old female with no prior history of psychiatric illness and a recent diagnosis of menopause, presenting with signs and symptoms of schizophreniform disorder and menopause. After undergoing treatment with estrogen and risperidone, she experienced complete resolution of her delusions and hallucinations.

Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion

Both pseudocyesis and delusional pregnancy are said to be rare syndromes, but are reported frequently in developing countries. A distinction has been made between the two syndromes, but the line of demarcation is blurred. The aim of this paper is to review recent cases of pseudocyesis/delusional pregnancy in order to learn more about biopsychosocial antecedents. The recent world literature(2000-2014) on this subject(women only) was reviewed, making no distinction between pseudocyesis and delusional pregnancy. Eighty case histories were found, most of them originating in developing countries. Fifty patients had been given a diagnosis of psychosis, although criteria for making the diagnosis were not always clear. The psychological antecedents included ambivalence about pregnancy, relationship issues, and loss. Very frequently, pseudocyesis/delusional pregnancy occurred when a married couple was infertile and living in a pronatalist society. The infertility was attributed to the woman, which resulted in her experiencing substantial distress and discrimination. When antipsychotic medication was used to treat psychotic symptoms in these women, it led to high prolactin levels and apparent manifestations of pregnancy, such as amenorrhea and galactorrhea, thus reinforcing a false conviction of pregnancy. Developing the erroneous belief that one is pregnant is an understandable process, making the delusion of pregnancy a useful template against which to study the evolution of other, less explicable delusions.

Models and Neural Bases of the Believing Process

Departing from the long debates on the role of faith/belief, recent interdisciplinary research has turned to characterize the features of the psychophysical processes underlying believing. Here we review recent cognitive neuroscience models of the believing process and propose a conceptual framework that integrates current theoretical and empiric knowledge about the processes of believing. There are theories that elegantly explain believing as a self-organization process of cognitive and emotional elements. Adding to the component of self-organized belief representation, dual-component models assume a belief evaluation component, which is probably supported by the right dorsolateral prefrontal cortex (DLPFC) and explains the stability of the belief despite the changing environment. Borrowing an idea from the neural models for the mental representation of action or situation, inclusion of both perceptive and action informations as the construct of belief representation allows the intimate relationship between a specific belief and a specific range of behaviour. Furthermore, inclusion of the personal value or affective information in the representation explains the deep impact of one’s emotional and physical state on the believing process. For associating perception, action, and value in a representation, the medial frontal cortex (MFC) may play a key role. Recent neuro-cognitive models of self-cognition explain the developmental origin of such a representation and the hierarchically nested structure of three levels of complexity in the representations: basic physical level, interpersonal level, and higher social level. The integrated model provides a comprehensive perspective of the believing process which suggests the importance and future directions of this interdisciplinary approach.

An Integrative Account of Neural Network Interaction: Neuro-Messenger Theory

Neural interaction is realized by information exchange. It seemed that the information amount does not keep constant and may be reduced during the travel between neural nodes. In addition, recent research of neural coding has suggested that neural information could be represented by parsimonious spiking pattern, named sparse coding. Based on the above observation, neuro-messenger theory (NMT) is proposed to explicate the communicative process between the source and the target neural nodes. Neuro-messenger is a sparse code which does not have to carry every detail of the dynamics in source node. Other formats of neural coding (e.g., temporal and rate coding) could be the precursors of neuro-messengers, and the repeated spatiotemporal patterns buried in the ongoing brain activities may be the circulated neuro-messengers from diverse origins. Referred to chaos/complexity theory, information can be recovered at target node where neuro-messenger serves as a facilitator to locate the trajectory at proper attractor, and hence the associated psychological entity. In contrast to conventional concepts of encoding and decoding, the processes of encoding in source node, issuing neuro-messengers, and recovering information at target node are summarized as “three-facet coding scheme”. The design of neuro-messenger enables the brain to utilize energy in an efficient and economical way. NMT may have substantial implication in several major psychiatric disorders. Some psychiatric conditions could be mediated by abnormal neuro-messengers that coerce the regional neuro-dynamics to delve into maladaptive attractors and hence the characteristic symptoms.

Stealth Adapted Viruses: A Bridge between Molecular Virology and Clinical Psychiatry

Cytopathic “stealth-adapted” viruses bypass the cellular immune defense mechanisms because of molecular deletion or mutation of critical antigen coding genes. They, therefore, do not provoke the inflammatory reaction typical of infections with the conventional viruses from which stealth adapted viruses are derived. Stealth adapted viruses establish persistent, systemic virus infections, which commonly involve the brain. The brain damage can cause major mood and cognitive disorders, fatigue, seizures and various manifestations of an impaired autonomic nervous system. Symptoms can also result from: 1) induced autoimmunity, 2) antibody formation against virus antigens, 3) virus-induced cellular damage to non-brain tissues and 4) induced heightened overall immune reactivity, such that normally unrecognized components of the virus begin to become targeted by the cellular immune system. This last mechanism is relevant to the reported neurological and psychiatric adverse effects of vaccination in certain individuals. It is also appropriate to consider the infectious component of stealth adapted virus infections since family members and others may be at risk for becoming infected.

Chunibyo:A Postmodern Lacanian Symptom Happening in Abjected Adolescence

Chunibyo, a new Japanese slang term, which roughly translates to "fourteen sick", usually occurs among middle school students. Most of the"patients"are teenagers, who see themselves as grown adults and believe they have special power. According to Lacan's theory, this symptom would disappear when people enter the symbolic order. However, some remain"sick"even after they have grown up. In this essay, conceptual explanation will be given to this symptom based on the theory of"abjection",while linking Chunibyo to the epistemological process of paranoiac knowledge rooted in Lacan's psychic synthesis. Afterward,Chunibyo will be analyzed in terms of contemporaneity and spatiality. Some effective ways to treat Chunibyo will also be discussed in the last section.

Woman diagnosed with obsessive-compulsive disorder became delusional after childbirth:A case report

BACKGROUND Obsessive-compulsive disorder(OCD)is a common mental disorder that varies greatly in manifestation and causes much distress to individuals.We describe a case in which a Chinese woman with OCD became delusional after childbirth,and discuss the possible phenomenological and psychological alterations.CASE SUMMARY A 27-year-old woman presented to the Psychiatry Department of our hospital with obsessions and compulsions.After taking medication,her symptoms were alleviated.Three years later,during her pregnancy,the obsessions returned and even progressed into paranoid delusions after childbirth.After multiple adjustments of treatment along with several fluctuations,she finally achieved remission and gained reasonable insight.CONCLUSION This case suggests that the patient with OCD appeared to move along a continuum of beliefs,and highlights the importance of effective intervention during pregnancy,which would exert a significant impact on postpartum exacerbation outcomes.

The Relationship between Exercise and Psychotic Symptoms in College Students: A Cross-Sectional Analysis

An increasing number of studies have suggested that increased physical activity is associated with less mental illness.However,the relationship between exercise and psychotic experiences(PEs)is still unknown.The purpose of this study was to explore the relationship between exercise and PEs in college students in the United States.Data from the Health Mind Survey(2020–2021 round)were analyzed.Respondents included 137,916 college students who were asked about exercise and PEs(lifetime psychotic experiences,delusions,and hallucinations).A multivariate logistic regression analysis was used to investigate the relationship between exercise and PEs while controlling for demographic characteristics.There was a significant correlation between exercise and PEs among college students.Compared to students who exercised less than one hour per week,students who exercisedfive or more hours per week had fewer lifetime psychotic experiences.This samefinding obtained for both male and female college students.Thefindings from the present study indicate that exercising forfive or more hours each week is most correlated with decreased PEs among college students.However,experimental studies are required to extend and confirm ourfindings and determine the causality of this relationship.

Adult Onset Cerebral X-Linked Adrenoleuokodystrophy in 18 Cases

Adrenoleukodystrophy (ALD) is an X-linked inherited metabolic disease associated with the accumulation of very long chain fatty acids (VLCFA) in the nervous system, adrenal cortex, and testes. At least seven phenotypes can be distinguished, which are Addison only, childhood, adolescent and adult cerebral ALD, adrenomyeloneuropathy (AMN), and symptomatic or asymptomatic carriers. Children most often develop rapidly a progressive cerebral disease, whereas adults rarely develop a cerebral disease. The majority of adult-onset ALD patients are AMN. The prognosis of ALD remains unpredictable in individual patients. Family history can be very informative. The plasma VLCFA assay permits precise diagnosis. Specific changes on brain Magnetic Resonance Imaging (MRI) can have diagnostic utility. However, there is considerable overlap among adult-onset leukodystrophies. Adult onset form of cerebral X-linked ALD (AOCALD) is a rare disease. The disease progresses rapidly with widespread demyelination of the cerebral hemispheres. AOCALD is an important differential diagnosis for adults with psychiatric symptoms and progressive cognitive changes. In this article, we review on case reports of AOCALD.

Prevalence of Ringing Delusion among Mobile Phone Users

The exponential application of mobile technology has led to a concern about implications of electromagnetic radiation on human health. As we are aware that mobile phone radiates EMR when users communicate to others and that time subscribers of the device are regularly exposed nearby 40% - 50% of total mobile irradiation. We analyzed the risk of "Ringing Delusion" among normal users, moderate users and heavy users when compared to low users. Although the "Ringing Delusion" has not been added in medical terminology but we found frequently such kind of symptoms among mobile phone users. "Ringing Delusion" may be considered as an imagination of ringing voice from cellular phone. The risk was also compared between urban and rural, male and female and adult and children population. The information was gathered through well designed questionnaires for cellular user’s demographic and social characteristics, adopted safety measures and calling duration. Prevalence of “Ringing Delusion” among rural users was higher than the urban users. A trend for the risk was also observed in male users in comparison to female. Study may support innovators to re-examine health effects of mobile phones.

The Major Psychocutaneous Disorders in Iraqi Patients

Background: Many skin diseases can be evoked by psychological problems. Dermatological conditions could also lead to psychological disorders;hence psychodermatology is an emerging subspecialty that focuses on the interface of psychiatry and dermatology. Objective: To assess the frequency of the major disorders of so-called psychocutaneous disorders which are commonly seen among Iraqi population. Patients and Methods: This case descriptive study had been done in Department of Dermatology-Baghdad Teaching Hospital, Medical City, Baghdad, Iraq during the period from March 2011 to October 2013. All cases were collected and categorized according to the disease problem. Patients were interviewed to search for the main triggering and precipitating factors involved in pathogenesis of these disorders. The clinical picture was well described in order to reach a final diagnosis. Psychological interview and analysis were performed for all patients to reach the specific emotional and psychiatric disease by consultant psychiatrist. Results: A total of 100 patients with major psychocutaneous disorders were seen and evaluated. Nineteen were males and 81 were females with female to male ratio: 4.26:1. Their ages ranged from 7 - 73 (26.5 ± 5.217) years. The frequency of these diseases was as follows: trichotillomania 53%, dermatitis artifacta 37%, delusion of parasitosis 6% and neurotic excoriation 4%. Conclusions: The major psychocutaneous diseases in Iraqi population were: trichotillomania, dermatitis artifacta and these are problems of mainly young females while delusion of parasitosis and neurotic excoriations were diseases of middle age females.

Antithetical Perpetuation in Society： A Study in the Selected Modem Indian Plays

The selected Indian playwrights have questioned the modernity and its implications especially in context of the sanskritization, westernization and transformation of Indians due to the impeccable industrialized, material, secular, mechanized culture. In India, modernity has changed the concept of existence and it has driven Indians to the life of glamour and glitz of technology, gadgets, metropolis and enslavement to mechanics of machinery. Their day to day life is beset with a paradigm shift in their notions of being equipped at the best with techno-world. The playwrights＇ concern is not just to expose the reality of developing people, but they are also a part of that same change. The plays sensitize the readers and spectators with the individual unhappiness, despite the breaking of their weak boundaries and the building of their self-capacity. On one hand there is self-reliance, while at the same time there is heart of ruin. The authors question the value-added Indian legacy of humanity, which is fallen to hypocrisy and usury. These authors poignantly examine human life within the man-made dimensional laws that has wrought human sense eco-critically to understand nature＇s laws and human rights. Therefore these playwrights suggestively are self-critical to raise human intellect in order to do away with their cynical and skeptical concepts for the advancement of their lifestyle and life patterns. Metaphysically, they make aware Indians-how does their inner thought process relate their primary needs with the social milieu, external impressions, environmental issues and existential choices？ How do Indians in contemporary reality of human existence correspond with free-will that is mostly in contradictory conflict due to greed, selfishness, and human need？ How does their alliance with power, sex and religion trap them into the labyrinth of delusive aspirations？

Delusional disorder with depression and history of early trauma: A case report

BACKGROUND The case report supports the recent findings regarding the correlation of posttraumatic stress disorder(PTSD)and schizophrenia.The report accomplished the following objectives:(1)To present a case of an adult female manifesting with somatic type of delusion(foul body odor)and history of PTSD;(2)To discuss the biopsychosocial factors,psychodynamics and management of the patient;and(3)To differentiate delusional disorder from schizophrenia according to recent studies.Schizophrenia and delusional disorder have certain defining features that separate the two.However,at times it may be difficult to actually classify one from the other.A psychiatrist must be able to carefully examine and assess the history of the patient,helping them share early life experiences of past traumatic events.The early past traumatic experiences and life events greatly influence the predisposition of a patient to develop schizophrenia.However,people with schizophrenia were known to underreport their trauma experience.CASE SUMMARY This is a case of a young adult female diagnosed with delusional disorder with a history of PTSD and associated depression.The patient manifested with somatic type of delusion with a fixed false belief that a foul body odor was coming from her underarms.CONCLUSION Developing a therapeutic alliance is vital in achieving therapy goals through empathy,support and warmth between the patient and physician.History of PTSD predisposes patients with schizophrenia to develop depressive disorders as a comorbidity.