Exploring Psychosis in Neurodegenerative Dementia: Connecting Symptoms to Neurobiology.

The following commentary discusses a review by Cressot et al. entitled: 'Psychosis in Neurodegenerative Dementias: A Systematic Comparative Review'. The authors describe the epidemiology and phenomenology of psychosis across neurodegenerative dementias. Dementia with Lewy bodies had the highest reported prevalence of psychosis at 74% followed by Alzheimer's disease, 54% and frontotemporal degeneration, 42%. Detailed characterization of psychosis shows differences in the types of hallucinations and delusions by dementia type. These findings suggest that different types of dementia related pathology are associated with high rates of psychosis with more specific symptom profiles than previously appreciated. Understanding the differences and variety of psychotic experiences across dementia types may have diagnostic and therapeutic implications for treating hallucinations and delusions in populations suffering from neurodegenerative diseases.

A Unique Delusion with Depression in Early Stage of Neurocognitive Disorder Due to Vascular Disease: Considerations for Clinicians.

As global aging becomes more prominent, neurocognitive disorders (NCD) incidence has increased. Patients with NCD usually have an impairment in one or more cognitive domains, such as attention, planning, inhibition, learning, memory, language, visual perception, and spatial or social skills. Studies indicate that 50-80% of these adults will develop neuropsychiatric symptoms (NPS), such as apathy, depression, anxiety, disinhibition, delusions, hallucinations, and aberrant motor behavior. The progression of NCD and subsequent NPS requires tremendous care from trained medical professionals and family members. The behavioral symptoms are often more distressing than cognitive changes, causing caregiver distress/depression, more emergency room visits and hospitalizations, and even earlier institutionalization. This signifies the need for early identification of individuals at higher risk of NPS, understanding the trajectory of their NCD, and exploring treatment modalities. In this case report and review, we present an 82-year-old male admitted to our facility for new-onset symptoms of depression, anxiety, and persecutory delusions. He has no significant past psychiatric history, and his medical history is significant for extensive ischemic vascular disease requiring multiple surgeries and two episodes of cerebrovascular accident (CVA). On further evaluation, the patient was diagnosed with major NCD, vascular subtype. We discuss differential diagnoses and development of NPS from NCD in order to explain the significance of more thorough evaluation by clinicians for early detection and understanding of NCD prognosis.

Psychosis in Neurodegenerative Dementias: A Systematic Comparative Review.

Background: Psychosis, characterized by delusions and/or hallucinations, is frequently observed during the progression of Alzheimer's disease (AD) and other neurodegenerative dementias (ND) (i.e., dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD)) and cause diagnostic and management difficulties. Objective: This review aims at presenting a concise and up-to-date overview of psychotic symptoms that occur in patients with ND with a comparative approach. Methods: A systematic review was conducted following the PRISMA guidelines. 98 original studies investigating psychosis phenotypes in neurodegenerative dementias were identified (40 cohort studies, 57 case reports). Results: Psychosis is a frequently observed phenomenon during the course of ND, with reported prevalence ranging from 22.5% to 54.1% in AD, 55.9% to 73.9% in DLB, and 18% to 42% in FTD. Throughout all stages of these diseases, noticeable patterns emerge depending on their underlying causes. Misidentification delusions (16.6-78.3%) and visual hallucinations (50-69.6%) are frequently observed in DLB, while paranoid ideas and somatic preoccupations seem to be particularly common in AD and FTD, (respectively 9.1-60.3% and 3.10-41.5%). Limited data were found regarding psychosis in the early stages of these disorders. Conclusions: Literature data suggest that different ND are associated with noticeable variations in psychotic phenotypes, reflecting disease-specific tendencies. Further studies focusing on the early stages of these disorders are necessary to enhance our understanding of early psychotic manifestations associated with ND and help in differential diagnosis issues.

[The nurse and psychotic disorders in neurocognitive diseases]. / L'infirmière face aux troubles psychotiques au cours de maladies neurocognitives.

Psychotic disorders, such as delusions and hallucinations, cause stress for individuals, their caregivers and healthcare professionals. Attitudes, perceived as behavioral tendencies, in the presence of these symptoms, can either alleviate or exacerbate them. How should we position ourselves in the presence of these disorders? What are the most effective attitudes for calming day-to-day situations?

Revisiting delusion subtypes in schizophrenia based on their underlying structures.

A clear understanding of the pathophysiology of schizophrenia and related spectrum disorders has been limited by clinical heterogeneity. We investigated whether relative severity and predominance of one or more delusion subtypes might yield clinically differentiable patient profiles. Patients (N = 286) with schizophrenia spectrum disorders (SSD) completed the 21-item Peters et al. Delusions Inventory (PDI-21). We performed factor analysis followed by k-means clustering to identify delusion factors and patient subtypes. Patients were further assessed via the Brief Psychiatric Rating Scale, Brief Negative Symptom Scale, Digit Symbol and Digit Substitution tasks, use of cannabis and tobacco, and stressful life events. The overall patient sample clustered into subtypes corresponding to Low-Delusion, Grandiose-Predominant, Paranoid-Predominant, and Pan-Delusion patients. Paranoid-Predominant and Pan-Delusion patients showed significantly higher burden of positive symptoms, while Low-Delusion patients showed the highest burden of negative symptoms. The Paranoia delusion factor score showed a positive association with Digit Symbol and Digit Substitution tasks in the overall sample, and the Paranoid-Predominant subtype exhibited the best performance on both tasks. Grandiose-Predominant patients showed significantly higher tobacco smoking severity than other subtypes, while Paranoid-Predominant patients were significantly more likely to have a lifetime diagnosis of Cannabis Use Disorder. We suggest that delusion self-report inventories such as the PDI-21 may be of utility in identifying sub-syndromes in SSD. From the current study, a Paranoid-Predominant form may be most distinctive, with features including less cognitive impairment and a stronger association with cannabis use.

[Recent developments in the modeling and psychological management of persecutory ideation]. / Actualités récentes dans la modélisation et la prise en charge psychologique des idées de persécution.

Persecutory ideas are a major clinical problem and are associated with impaired functioning, reduced compliance with medication and increased risk of hospitalization. Persecutory ideation is defined as the false conviction that others are threatening or conspiring against one. Although persecutory delusions are mainly described and experienced in schizophrenia spectrum disorders, they also occur in other neurological and psychiatric diagnoses including Alzheimer disease, epilepsy, depression, mania, dementia and post-traumatic stress disorder. Moreover, epidemiological data from general and clinical populations indicated that paranoid beliefs occur on a hierarchy of severity and are present to a lesser degree in the general population, with paranoid delusions representing the severe end of a continuum. In this review we focus on the important advances following a decade of research from psychological sciences, and more particularly the work of Daniel Freeman and Philippa Garety in England. Their work has demonstrated that a range of causal factors are involved in the development and maintenance of delusions beyond the traditional cognitive and behavioural models. Indeed, there is now well-validated evidence that sleep disturbances, worry proneness, reasoning biases, such as failure to consider alternative explanations or belief confirmation bias, abnormal experiences such as hallucinations, negative self-beliefs, and safety behaviours, are central factors that contribute to the paranoid phenomenon. In this review, we describe each of these causal factors in detail as well as the clinical interventions developed by Freeman and his collaborators, including the integrative and modular "Feeling Safe" intervention. Broadly speaking, the aim of this psychological intervention is for patients to relearn safety by exposing them to situations they consider as potentially dangerous after reduction of the influence of the maintenance factors described above. A recent publication showed that the Feeling Safe program led to recovery in persecutory delusions for 50% of patients having poor response to antipsychotic medication, making the intervention as the most effective psychological treatment for persecutory delusions. Finally, we will critically discuss the efficacy data from the numerous clinical studies validating its effectiveness. Prospects for the implementation of the Feeling Safe program in France also is discussed.

Refractory Depression With Persistent Sore Throat and Hypochondriacal Delusion of SARS-CoV-2 Infection: A Case Study.

ABSTRACT: Herein, we present a case of a female patient with a persistent sore throat, which preceded a hypochondriacal delusion of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Both the sore throat and hypochondriacal delusion persisted together, despite the repeatedly negative results of reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 and a moderate improvement in her depression. Four possibilities for the patient's sore throat were discussed: pain symptoms of somatic symptom disorder, pain symptoms of depression, delusion of pain in her throat, and somatic hallucination as a sore throat. Consequently, somatic hallucinations were considered the most likely. In any case, the present findings suggest that sore throat can precede hypochondriacal delusion of SARS-CoV-2 infection in some noninfected patients. When patients continue to complain of a sore throat despite the negative results of SARS-CoV-2 by the RT-PCR test, we should consider that it might be a somatic hallucination and soon hypochondriacal delusions may occur, leading to the manifestation of other symptoms of psychiatric disorders, such as depression, which may be refractory and/or suicidal.

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

OBJECTIVE: The objective of this study is to analyse the coexistence of several delusional misidentification syndromes in a clinical sample. METHODS: Over one year, a sample of six patients presenting two or more types of delusional misidentification syndromes was selected. All these patients were admitted to the psychiatric inpatient unit of a Spanish hospital. RESULTS: Despite the different diagnoses, the patients included presented different types of delusional misidentification syndromes, both hyperidentification and hypoidentification. Antipsychotic treatment was not very effective against these delusional misidentification syndromes. CONCLUSIONS: The coexistence of several delusional misidentification syndromes indicates that the aetiopathogenesis of the different types is similar. It is a field with important clinical implications, due to the poor response to treatment, as well as the possible medico-legal implications.

[Cognitive-behavioural approaches to delusions]. / Kognitiv-verhaltenstherapeutische Ansätze bei Wahnüberzeugungen.

Delusional beliefs can have serious impact on peoples' everyday life. They are often associated with strong negative emotions and can complicate relationships with other people- In severe cases, patients may even organize their everyday lives entirely around their delusional beliefs. In recent years, psychological approaches have come to be seen as an essential parts of an integrative treatment concept. This article gives an overview of the cognitive-behavioural approach to delusions.

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

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

Cholinesterase Inhibitors for Delusions and Hallucinations in Alzheimer Disease and Parkinson Disease: Questionably Significant Benefits.

Delusions and hallucinations are common in Alzheimer disease (AD) and Parkinson disease (PD), especially in the later stages of illness. Antipsychotic drugs are effective in treating these psychotic symptoms but are associated with an increased risk of serious adverse events, including mortality. There is therefore a need to explore other treatment approaches. In this context, a recent individual patient data meta-analysis of 17 randomized controlled trials (RCTs) conducted in AD (12 RCTs) and PD (5 RCTs) found that the cholinesterase inhibitor (ChEI) drugs donepezil, rivastigmine, and galantamine attenuated the severity of both delusions and hallucinations in both AD and PD. Most of these trials were 24 weeks in duration. The effect sizes, expressed as standardized mean differences (SMDs), were, however, small, lying in the -0.08 to -0.14 range. These values are so small as to be perhaps clinically insignificant. When analyses were restricted to data from patients who actually had delusions and hallucinations at baseline, all effect sizes became larger, lying in the -0.13 to -0.39 range; however, after correcting for multiple hypothesis testing, only the finding for delusions in PD remained statistically significant. The meta-analysis did not provide information on what the best doses were, how long it took for improvement to become evident, and what proportion of patients showed remission from psychotic symptoms. Whereas the signal identified in this meta-analysis merits examination in appropriately designed RCTs, the findings of the meta-analysis may not much change current treatment strategies because patients with dementia would probably anyway receive a ChEI. Therefore, if psychotic symptoms persist for 24 weeks despite optimally dosed ChEI treatment, and if behavioral and psychosocial interventions do not help, clinicians may need to consider the potential benefits vs risks of other drugs, such as atypical antipsychotics and pimavanserin, in a shared decision-making process.

Hasty decision making and belief inflexibility in the more delusion prone? A modified disambiguating-scenarios paradigm assessing cognitive biases implicated in delusions.

INTRODUCTION: Contemporary models of psychosis imply that cognitive biases such as the jumping to conclusions (JTC), the bias against disconfirmatory evidence (BADE), and the liberal acceptance (LA) bias play a role in the pathogenesis of delusions. Most of the studies investigating the role of cognitive biases, however, have been conducted with socially neutral or abstract stimuli and have assessed patients with established psychoses. For the present study, we aimed to concurrently investigate multiple biases (i.e., the JTC, BADE, and LA biases) in a community sample with a new paradigm using more socially engaging stimuli. METHODS: A large sample of participants (N = 874) recruited via Amazon Mechanical Turk was subdivided into two groups based on the frequency of their psychotic-like experiences (PLEs) according to the positive subscale score of the Community Assessment of Psychic Experiences (CAPE) and matched based on major demographics variables, resulting in two equally sized groups called High-PLE (at least 2 SD above the mean) and Low-PLE (maximum 0.5 above the mean; n = 46 for each group). Using a modified version of the written-scenarios BADE task, which emphasized social interactions between agents embedded in the scenario, participants rated the plausibility of response options in the face of new information. RESULTS: In line with previous findings, the High-PLE group demonstrated the JTC, BADE, and LA biases. That is, the members of this group made more decisions after the initial piece of information, were less likely to revise their beliefs in light of new information, and provided higher plausibility ratings for implausible response options compared to the Low-PLE group. CONCLUSIONS: Results corroborate prior findings suggesting that the JTC, BADE, and LA biases may be contributing factors in delusional ideation and that metacognitive biases extend to social situations.

"A ghost doesn't need insulin," Cotard's delusion leading to diabetic ketoacidosis and a body-mass index of 15: a case presentation.

BACKGROUND: Cotard's Syndrome (CS) is a rare clinical entity where patients can report nihilistic, delusional beliefs that they are already dead. Curiously, while weight loss, dehydration, and metabolic derangements have been described as discussed above, a review of the literature revealed neither a single case of a severely underweight patient nor a serious metabolic complication such as Diabetic Ketoacidosis. Further, a search on PubMed revealed no articles discussing the co-occurrence of Cotard's Delusion and eating disorders or comorbid metabolic illnesses such as diabetes mellitus. In order to better examine the association between Cotard's Delusion and comorbid eating disorders and metabolic illness, we will present and discuss a case where Cotard's delusion led to a severe metabolic outcome of DKA and a BMI of 15. CASE PRESENTATION: Mr. B is a 19 year old transgender man admitted to the hospital due to diabetic ketoacidosis secondary to Type 1 Diabetes Mellitus. Mr. B had a history of Obsessive-Compulsive Disorder, Major Depressive Disorder, and Post-Traumatic Stress Disorder. The primary pediatric team discovered that Mr. B had not been using his insulin appropriately and was severely underweight, and they believed this could be due to his underlying mental illness. The psychiatric consultation/liaison service found that Mr. B was suffering from Cotard's delusion leading him to be noncompliant with his insulin due to a belief that he was already dead. Cotard's delusion had in this case led to a severe metabolic outcome of DKA and a BMI of 15. CONCLUSIONS: This case provides clinical insight into the interactions of eating disorders and Cotard's delusion as well as the potential medical complications when Cotard's delusion is co-morbid with medical conditions such as Diabetes Mellitus. We recommend that clinicians routinely screen patients for Cotard's delusion and assess whether the presence of which could exacerbate any underlying medical illness. This includes clinicians taking special care in assessing patient's caloric and fluid intake as well as their adherence to medications both psychiatric and medical. Further research could be conducted to explore the potential overlap of Cotard's delusion and eating disorder phenomenology.

ECT for Cotard syndrome in a 13-year-old.

This is a case report about a 13-year-old girl who presented with depression, severely reduced daily functioning, and eventually nihilistic delusions about being dead. The condition was interpreted as a presentation of Cotard syndrome as part of early-onset schizophrenia. Treatment with an antidepressant and multiple antipsychotic medications was not effective. The patient was then treated with ECT, resulting in subjective and measurable positive effects.

Can Cotard Syndrome Be Induced?: Illustration With a Rare Case of Potential Organ Transplant.

ABSTRACT: Cotard syndrome is a rare condition characterized by delusions ranging from a belief that one has lost organs to insisting that one has lost one's soul or is dead. This is the report a case of a 45-year-old man who was comatose after an attempted suicide. This was initially diagnosed as brain death and use of his organs for transplantation was actively considered. However, he awakened days later with new-onset Cotard syndrome. It remains difficult to know the link, unconscious or conscious, between this patient's delusions and the fleeting intention of doctors who intended to transplant his organs. This is the first description of a coincidence between delusional denial of an organ and the potential medico-surgical act of having an organ removed. This case is an opportunity to revisit the philosophical concepts of negation and nihilism. A multidisciplinary reflection is needed to give meaning to other clinical presentations.

Associations between acceptance of the implausible bias, theory of mind and delusions in first-episode psychosis patients; A longitudinal study.

Multiple different cognitive biases, among them the liberal acceptance (LA) bias, have been suggested to contribute to reality distortion in psychotic disorders. Earlier studies have been cross-sectional and considered a limited set of cognitive correlates of psychosis, thus the relationship between LA bias and psychosis remains poorly known. We studied a similar bias (acceptance of the implausible (AOI)) in 62 first-episode psychosis (FEP) patients and 62 control subjects, who watched movie scenes with varying degrees of realism and were asked to evaluate the probability of these events occurring in real life. We assessed theory of mind (ToM) performance using the Hinting task and delusion severity using Brief Psychiatric Rating Scale item 11. We correlated the magnitude of AOI with the severity of delusions and performance in the ToM task. Furthermore, we used 1-year follow-up data from 40 FEP patients and 40 control subjects to disentangle state vs trait-like characteristics of AOI. At baseline FEP patients expressed more AOI than control subjects, and the magnitude of AOI correlated positively with the severity of delusions and negatively with ToM performance. At the one-year follow-up, when most patients were in remission, patients still displayed increased AOI, which no longer correlated with delusions. These findings support the notion that the AOI bias could represent a trait rather than a state feature and support further studies to test the hypothesis that it could be one of the causal factors of psychotic disorders, possibly associated with ToM.