Capgras and Fregoli syndromes: delusion and misidentification.

Capgras and Fregoli syndromes are two psychotic and complex conditions also known as Delusional Misidentification Syndromes (DMSs). Their description dates back to the beginning of XX century, and many explanatory models have been formulated through myths, psychoanalytical and psychological hypotheses, as well as neurobiological proposals. Even if DMSs are not fully considered in the modern diagnostic manuals, they still remain intriguing phenomena to be clinically observed and explained. Also, the employment of psychotropics and physical techniques in the treatment of such conditions is not supported by robust evidences and this may encourage further studies. We conclude that it would be of great interest to brush up the neglected MDSs in order to improve our knowledge on the underlying mechanisms of delusion and brain functioning.

The 'dead man walking' disorder: an update on Cotard's syndrome.

In 1880, Jules Cotard described a peculiar syndrome after observing the case of a 43-year-old woman, which was characterized by melancholic anxiety, delusions of damnation or possession, a higher propensity to suicide ideation and deliberate self-harm, analgesia, hypochondriac thoughts of non-existence or ruin of several organs, of the whole body, of the soul, of divinity, and the idea of immortality or inability to die. Several expansions and reinterpretations have been made of the so-called Cotard's syndrome, which is often encompassed in different neurological and psychiatric disorders, complicating and worsening their symptomatic frameworks and making more difficult their treatments. However, the nosographic characterization of Cotard's syndrome remains elusive and is not now classified as a separate disorder in both ICD and DSM-5. Here, we try to give an update, as well as a putative systematization, of current views and opinions about this nosological entity in the light of the recent progress in the clinic, psychopathology and psycho-neurobiology.

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

OBJECTIVES: The purpose of this study was to explore associations between specific types of hallucinations and delusions and suicidal ideation in a sample of children and adolescents with bipolar I disorder. METHODS: Participants (N = 379) were children and adolescents aged 6-15 years (M = 10.2, SD = 2.7) with DSM-IV diagnoses of bipolar I disorder, mixed or manic phase. The study sample was 53.8% female and primarily White (73.6% White, 17.9% Black, and 8.5% Other). Presence and nature of psychotic symptoms, suicidal ideation, and functioning level were assessed through clinician-administered measures. A series of logistic regressions was performed to assess the contribution of each subtype of psychotic symptom to the presence of suicidal ideation above and beyond age, sex, socio-economic status, age at bipolar disorder onset, and global level of functioning. RESULTS: Hallucinations overall, delusions of guilt, and number of different psychotic symptom types were uniquely associated with increased odds of suicidal ideation after accounting for covariates. Other forms of delusions (eg, grandiose) and specific types of hallucinations (eg, auditory) were not significantly uniquely associated with the presence of suicidal ideation. CONCLUSIONS: Findings of this study suggest the presence of hallucinations as a whole, delusions of guilt specifically, and having multiple concurrent types of psychotic symptoms are associated with the presence of suicidal ideation in children and adolescents with bipolar I disorder. Psychotic symptom subtypes, as opposed to psychosis as a whole, are an under-examined, potentially important, area for consideration regarding suicidal ideation in pediatric bipolar I disorder.

The Perseverative Thinking Questionnaire in Patients with Persecutory Delusions.

BACKGROUND: Ruminative negative thinking has typically been considered as a factor maintaining common emotional disorders and has recently been shown to maintain persecutory delusions in psychosis. The Perseverative Thinking Questionnaire (PTQ) (Ehring et al., 2011) is a transdiagnostic measure of ruminative negative thinking that shows promise as a "content-free" measure of ruminative negative thinking. AIMS: The PTQ has not previously been studied in a psychosis patient group. In this study we report for the first time on the psychometric properties of Ehring et al.'s PTQ in such a group. METHOD: The PTQ was completed by 142 patients with current persecutory delusions and 273 non-clinical participants. Participants also completed measures of worry and paranoia. A confirmatory factor analysis was performed on the clinical group's PTQ responses to assess the factor structure of the measure. Differences between groups were used to assess criterion reliability. RESULTS: A three lower-order factor structure of the PTQ (core characteristics of ruminative negative thinking, perceived unproductiveness, and capturing mental capacity) was replicated in the clinical sample. Patients with persecutory delusions were shown to experience significantly higher levels of ruminative negative thinking on the PTQ than the general population sample. The PTQ demonstrated high internal reliability. CONCLUSIONS: This study did not include test-retest data, and did not compare the PTQ against a measure of depressive rumination but, nevertheless, lends support for the validity of the PTQ as a measure of negative ruminative thinking in patients with psychosis.

[Is delusion a reasonable scientific term? Reflections on psychopathology in the psychiatry of the twenty-first century]. / Ist Wahn ein sinnvoller wissenschaftlicher Begriff? Eine Reflexion über die Psychopathologie in der Psychiatrie des 21. Jahrhunderts.

Delusion is a central but difficult and controversial term in psychiatry. Similar to the term schizophrenia at the nosological level, the basic questions in the specialty are linked in the debate on delusion at the clinical psychopathological level, beginning with epistemological and methodological aspects up to concrete embodiment of the physician-patient relationship. The text of this article reflects this development from the nineteenth century up to the present day and makes reference to the lively discussion on the future directions of psychiatric research triggered by the research domain criteria (RDoC). Under certain prerequisites, including in particular an extensive understanding of psychopathology, delusion is considered to be a reasonable scientific term, also in the future.

[Psychosis - clinical differential diagnosis]. / Differenzialdiagnose psychotischer Symptome.

BACKGROUND: Many patients with psychiatric and organic disorders may present primary or secondary psychotic symptoms. Based on the ICD 10 classification, this article describes the possible underlying diseases and their subdivision. The main focus will be differential-diagnostic evaluations of psychotic syndromes. RESULTS: In the clinical setting, the differential diagnosis of the paranoid schizophrenia and other psychotic disorders into three main disease groups is important: 1. other psychiatric diseases, 2. primary and secondary organic diseases and 3. autoimmune diseases. The first group contains, for example, drug-induced psychoses, affective disorders, personality disorders. The second group includes forms of dementia, forms of deliria or metabolic diseases. Recently, another focus is set on autoimmune diseases, especially encephalitides. SUMMARY: A detailed medical history, a physical examination and organic diagnostic can lead to the correct diagnosis and therapy. The differential-diagnostic classification and the detection of organic causes is an important part of psychiatric care, but often a good cooperation with organic specialties is needed.

The epistemic innocence of motivated delusions.

Delusions are defined as irrational beliefs that compromise good functioning. However, in the empirical literature, delusions have been found to have some psychological benefits. One proposal is that some delusions defuse negative emotions and protect one from low self-esteem by allowing motivational influences on belief formation. In this paper I focus on delusions that have been construed as playing a defensive function (motivated delusions) and argue that some of their psychological benefits can convert into epistemic ones. Notwithstanding their epistemic costs, motivated delusions also have potential epistemic benefits for agents who have faced adversities, undergone physical or psychological trauma, or are subject to negative emotions and low self-esteem. To account for the epistemic status of motivated delusions, costly and beneficial at the same time, I introduce the notion of epistemic innocence. A delusion is epistemically innocent when adopting it delivers a significant epistemic benefit, and the benefit could not be attained if the delusion were not adopted. The analysis leads to a novel account of the status of delusions by inviting a reflection on the relationship between psychological and epistemic benefits.

Delusion-like experiences in older people with anxiety disorders.

BACKGROUND: Little is known about the occurrence of psychotic or quasi-psychotic experiences in older people with anxiety disorders. METHODS: We used a cross-sectional national probability sample of community-residing individuals to investigate the prevalence and correlates of delusion-like experiences in older people with DSM-IV anxiety disorders. The 2007 Australian National Survey of Mental Health and Well-being (NSMHWB) included 1,905 persons between the ages of 65 and 85 years. Anxiety disorder diagnoses were established using the Composite International Diagnostic Interview (CIDI v3). Participants were asked about three types of delusion-like experiences: thought control or interference, special meaning, and special powers. We used multivariate logistic regression to examine the relationship between a 12-month history of any anxiety disorder and the presence of these delusion-like experiences, adjusting for several potential confounders. RESULTS: Eighty-two of 1,905 (4.3%) older people met criteria for an anxiety disorder over the previous 12 months. Of these, six reported delusion-like experiences, whereas the prevalence of these experiences among older people without anxiety disorder was 26/1,822 (7.3% vs. 1.4%; χ(2) = 16.5; p = 0.000). In a logistic regression model, male gender (OR 0.38; p = 0.019), separated marital status (OR 4.86; p = 0.017), and the presence of anxiety disorder (OR 5.33; p = 0.001) were independently associated with delusion-like experiences, whereas MMSE (Mini-Mental State Examination) score, general medical conditions and affective disorder were not. CONCLUSIONS: In this cross-sectional study, self-reported delusion-like experiences occurred at increased prevalence among community-residing older persons with anxiety disorder. More work is needed to clarify the nature and significance of these findings.

Delusional versus nondelusional body dysmorphic disorder: recommendations for DSM-5.

The core feature of body dysmorphic disorder (BDD) is distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance. BDD beliefs are characterized by varying degrees of insight, ranging from good (ie, recognition that one's BDD beliefs are not true) through "absent insight/delusional" beliefs (ie, complete conviction that one's BDD beliefs are true). The Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (DSM-III-R) and The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) classified BDD's nondelusional form in the somatoform section of the manual and its delusional form in the psychosis section, as a type of delusional disorder, somatic type (although DSM-IV allowed double-coding of delusional BDD as both a psychotic disorder and BDD). However, little or no evidence on this issue was available when these editions were published. In this article, we review the classification of BDD's delusional and nondelusional variants in earlier editions of DSM and the limitations of their approaches. We then review empirical evidence on this topic, which has become available since DSM-IV was developed. Available evidence indicates that across a range of validators, BDD's delusional and nondelusional variants have many more similarities than differences, including response to pharmacotherapy. Based on these data, we propose that BDD's delusional and nondelusional forms be classified as the same disorder and that BDD's diagnostic criteria include an insight specifier that spans a range of insight, including absent insight/delusional BDD beliefs. We hope that this recommendation will improve care for patients with this common and often-severe disorder. This increased understanding of BDD may also have implications for other disorders that have an "absent insight/delusional" form.

[The psychopathology of acute and transient psychotic disorder]. / Psychopathologie de la bouffée délirante aiguë.

Acute and transient psychotic disorder remains an important element of the clinical field. It was first observed by Philippe Pinel in the 19th century. Other figures, such as Philippe Chaslin and Valentin Magnan, have contributed to the identification of the disorders and a psychopathological classification. While the central clinical element of acute and transient psychotic disorder is delusion and hallucinations, its resolution can be quick or it may be a sign of the gradual onset of a psychiatric pathology.

Classification of delusions in Alzheimer's disease and their neural correlates.

BACKGROUND: Previous findings on neural correlates of delusion in Alzheimer's disease (AD) have been inconsistent because of methodological issues, such as treating multiple delusions as a single entity. In this retrospective study, we classified AD delusions and investigated their neural correlates by using single-photon emission computed tomography data. METHODS: We selected AD patients with delusions from our consecutive outpatients from 2004 to 2010. In this study, eight types of delusions were evaluated with Neuropsychiatric Inventory and classified by factor analysis. Twenty-five of the patients also had single-photon emission computed tomography data, which we used to assess the relationships between cerebral regions of hypoperfusion and hyperperfusion and each classified delusion. The relations were assessed using Statistical Parametric Mapping with normalization to the white matter cerebral blood flow. RESULTS: The delusions were classified into three factors. Factor 1 consisted of a belief that his/her house is not his/her home, phantom boarder symptom, delusion of abandonment, and belief that one's spouse or others are not who they claim to be. Factor 1 was related to hypoperfusion in the right temporal pole and hyperperfusion in the medial frontal and precentral regions. Factor 2 consisted of delusion relating to the television and delusion of persecution. Factor 2 was related to hypoperfusion in the precuneus and hyperperfusion in the insula and thalamus. Factor 3 consisted of delusion of abandonment and delusional jealousy. Factor 3 was related to hypoperfusion in the right inferior temporal and frontal regions and hyperperfusion in the middle frontal gyrus, insula and posterior cingulate gyrus. Delusion of theft was not included in any factors, and it was related to hypoperfusion in the bilateral thalami and left posterior cingulate gyrus and hyperperfusion in the left inferior frontal regions and anterior cingulate gyrus. CONCLUSIONS: Delusions in AD were classifiable, and each classified delusion was related to different neural networks.

[Paranoia and persecution]. / Paranoia et persécution.

The idea of paranoia has existed since Antiquity, but it was only in the 19th centurythat psychiatrists became interested in it and sought to describe it. Delusion and the feeling of persecution are common in all paranoiacs. The origins of the disease can be found in the patient's psychic structure. Establishing and maintaining contact with a caregiver is one way of helping the patient.

[Delusions and hallucinations, definitions and mechanisms]. / Délires et hallucinations, définitions et mécanismes.

The semiology of delusions and hallucinations corresponds to precise definitions. Systematised or not, their mechanisms and their themes are varied. Psychodynamic and biological approaches give an insight into the therapies to use with patients who are affected.

The Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia.

BACKGROUND: Neuropsychiatric symptoms (NPS) affect almost all patients with dementia and are a major focus of study and treatment. Accurate assessment of NPS through valid, sensitive and reliable measures is crucial. Although current NPS measures have many strengths, they also have some limitations (e.g. acquisition of data is limited to informants or caregivers as respondents, limited depth of items specific to moderate dementia). Therefore, we developed a revised version of the NPI, known as the NPI-C. The NPI-C includes expanded domains and items, and a clinician-rating methodology. This study evaluated the reliability and convergent validity of the NPI-C at ten international sites (seven languages). METHODS: Face validity for 78 new items was obtained through a Delphi panel. A total of 128 dyads (caregivers/patients) from three severity categories of dementia (mild = 58, moderate = 49, severe = 21) were interviewed separately by two trained raters using two rating methods: the original NPI interview and a clinician-rated method. Rater 1 also administered four additional, established measures: the Apathy Evaluation Scale, the Brief Psychiatric Rating Scale, the Cohen-Mansfield Agitation Index, and the Cornell Scale for Depression in Dementia. Intraclass correlations were used to determine inter-rater reliability. Pearson correlations between the four relevant NPI-C domains and their corresponding outside measures were used for convergent validity. RESULTS: Inter-rater reliability was strong for most items. Convergent validity was moderate (apathy and agitation) to strong (hallucinations and delusions; agitation and aberrant vocalization; and depression) for clinician ratings in NPI-C domains. CONCLUSION: Overall, the NPI-C shows promise as a versatile tool which can accurately measure NPS and which uses a uniform scale system to facilitate data comparisons across studies.

Varieties of confabulation and delusion.

INTRODUCTION: Different types of confabulation or false memory can arise from brain disease. There are competing explanatory theories for the mechanisms underlying confabulation. Recent literature has attempted to relate the notion of delusion to that of confabulation. METHOD: A brief review of the literature relating to these ideas. RESULTS: The varieties of confabulation or false memory that can arise from brain disease are considered. The varieties of delusion and the contexts in which they arise are considered. Comparisons are made between the characteristics of spontaneous confabulation and those of delusional memory. CONCLUSION: It is suggested that global theories purporting to account for both confabulation and delusions, in whatever circumstances they arise, can have only limited explanatory power. On the other hand, there are resemblances between confabulation and delusional memory, and the similarities and differences between these phenomena deserve further empirical investigation.

What's happened to paraphrenia? A case-report and review of the literature.

Paraphrenia is a chronic psychotic disorder similar to paranoid schizophrenia, but with a better-preserved affect and relation and a much less personality deterioration. It was firstly systematically described by Kraepelin in 1913 in order to define a group of psychotic patients who exhibited characteristic symptoms of dementia praecox, but with minimal disturbances of emotion and volition, and marked delusions. After the publication of the Mayer-Gross's report in 1921, the view to differentiate paraphrenia from schizophrenia was considered to be unfounded and the term "paraphrenia" was not included in the current DSM-IV-TR diagnostic criteria. Consequently, now this disorder is infrequently diagnosed. However, several authors suggest that the concept of paraphrenia has not lost its usefulness. It seems to be that some psychiatrists recognize the illness, but labelled it as "atypical psychosis", "schizoaffective disorder", "delusional disorder" or "psychotic disorder not otherwise specified" for the lack of a better diagnostic category. Very few systematic studies on paraphrenia have been carried out in the past 70 years. Aim of this article is to describe a case of chronic delusional psychosis who meets the Ravindran's modern diagnostic criteria for "paraphrenia redefined", suggesting that it is possible to define and recognize the illness if the practitioners are induced to use a viable diagnostic entity. Further research would benefit paraphrenic and schizophrenic patients.

[Body dysmorphic disorder]. / Körperdysmorphe Störung.

A survey of the body dysmorphic disorder, once known as "dysmorphophobia", is given concerning classification, symptoms, diagnosis, epidemiology, nosology, pathogenesis and therapy. It can be shown that there is no good reason to differentiate between delusional and non-delusional forms as has been done in the international classification systems. Shame is the common affect that leads into the vicious circle of self-observation and bashfulness. The available data just confirm the clinical impression that we have to deal with a unified syndrome. In addition, actual studies show how important comorbidity is, especially comorbid depressions.

[In Alzheimer's disease, the clinical expression of behavioral and psychological signs and symptoms is early and specific of neuropathological stages]. / Dans la maladie d'Alzheimer, l'expression des troubles psychologiques et comportementaux est précoce et spécifique des stades lésionnels.

INTRODUCTION: The early diagnosis of Alzheimer's disease is a new challenge. This study concerns 50 patients, 34 females (68 %) and 16 males (32 %) with Alzheimer (AD), according to NINCDS-ADRDA diagnostic criteria. OBJECTIVES: To systematically evaluate in all patients behavioral and psychological signs and symptoms of dementia (BPSSD), according to the stage of AD, with the patients of our population separated into two MMS groups. METHODS: The first group was composed of patients with an MMS score from 10 to 20 (eight males and 19 females). Patients of the second group had an MMS score between 21 and 28 (eight males and 19 females). The Neuro-Psychiatric Inventory (NPI) was used to collect information on the presence of BPSSD in AD patients. NPI scores were correlated to the cognitive part of the Alzheimer's Disease Assessment Scale (ADAS-Cog) that permits evaluation of the severity of cognitive impairment in AD patients. Before starting the study, all patients gave their informed consent to participate in the study of BPSSD in AD. Statistical treatment of data was performed using STATVIEW. RESULTS: Our study demonstrates that BPSSD are present not only in early but also in moderate stages of AD. As cognitive impairment, BPSSD are an integrate part of the clinical picture. With a frequency of 74 % for the whole population, "anxiety" represented the more predominant BPSSD for all our patients at all stages of AD. At the very early stages of AD, BPSSD appeared to precede cognitive disorders. CONCLUSION: The symptomatic association of "depression", "agitation", and "irritability of mood" may remain in a steady state for a few months before the appearance of verbal episodic memory impairment, which is characteristic of hippocampus involvement. "Irritability" seems to specifically characterise the initial phase of AD. On the other hand, two BPSSD are characteristic of the late stages of AD: "sleep disorder" and "hallucinations".