The Nose Knows or Does it? Olfactory Reference Syndrome in Patients Presenting for Assessment of Unusual Body Odor.

Olfactory reference syndrome (ORS) is a rarely diagnosed psychiatric disorder in which individuals falsely believe that they emit an offensive body odor. This retrospective cohort study characterizes the clinical and demographic features of 54 individuals who presented to a Canadian genetics clinic for query trimethylaminuria (TMAU), an inherited disorder in which a pungent fishy odor is produced. The majority (83%) were found to have a likely diagnosis of ORS and a high rate (73.3%) of concomitant psychiatric disorders; only two patients were diagnosed with TMAU. This study highlights the genetics clinic as an unexpected and major ascertainment point for ORS, and shows that ORS can be differentiated from TMAU by age of onset (~28 years), odor characterization (refuse-related), and the presence of associated comorbid psychiatric diagnoses. There is a low diagnostic rate of ORS, attesting to the need for improved education and awareness.

Sociodemographic and clinical correlates of psychotic symptoms in the general population: Findings from the MHGP survey.

BACKGROUND: We aimed to explore the sociodemographic and psychiatric correlates of psychotic symptoms in a large general population sample. METHODS: The French Mental Health in the General Population cross-sectional survey interviewed 38,694 individuals using the Mini International Neuropsychiatric Interview. We looked for associations between the presence of lifetime psychotic symptoms, sociodemographic characteristics (including migrant status over three generations) and clinical characteristics. We then looked for associations regarding only hallucinations, delusional symptoms, and the co-occurrence of both hallucinations and delusional symptoms. To test the psychosis continuum hypothesis, associations with sociodemographic characteristics were compared with the characterized psychotic disorders' associations. RESULTS: We found that 22.3% of the population declared psychotic symptoms without psychotic disorders, including 5.7% who declared hallucinations, 20.5% delusional symptoms, 4.0% both hallucinations and delusional symptoms, and 2.8% characterized psychotic disorders. The presence of psychotic symptoms was associated with young age, migrant status (over three generations), secondary education level, low-income level and never-married and separated marital status. Hallucinations, delusional symptoms and the co-occurrence of both hallucinations and delusional symptoms showed the same correlates, and hallucinations were also associated with elementary education level. Characterized psychotic disorders showed the same correlates. Concerning clinical outcomes, the presence of psychotic symptoms, hallucinations and delusional symptoms was associated with all non-psychotic disorders, i.e., bipolar, depressive, alcohol use, generalized anxiety, social phobia, panic and post-traumatic stress disorders and dysthymia (except dysthymia, which was not associated with hallucinations). CONCLUSIONS: Our results indicate that psychotic symptoms are associated with broad psychopathologies and support the continuum model of psychosis.

Substance use and sociodemographic background as risk factors for lifetime psychotic experiences in a non-clinical sample.

INTRODUCTION: Psychotic experiences (PE) are relatively common in the general population. PE is associated with mental health impairment and may be predictive of clinical psychosis. Substance use predicts PE, but the association is insufficiently understood, particularly the role of illicit substances. The purpose of this study was to describe PE (visual and auditory hallucinations and delusions of reference and persecution) in a population characterized by high levels of substance use and to investigate substance use and sociodemographic background characteristics as risk factors for PE. METHODS: We used data from the Norwegian Offender Mental Health and Addiction Study (NorMA), a cross-sectional survey of 1499 individuals from Norwegian prisons. The outcome was one, two, three or four types of PE during the lifetime. The association between different variables and PE was investigated using multinomial logistic regression with three outcome categories: 0 PE, 1-2 PE and 3-4 PE. RESULTS: The prevalence of lifetime PE was 53.7%. Several substances were strongly associated with PE: For cannabis, the adjusted relative risk ratio (RRR) of 1-2 PE was 2.78 (95% CI 1.89-4.10) and of 3-4 PE it was 4.36 (2.58-7.36). For amphetamine, the RRR of 1-2 PE was 3.26 (2.11-5.05) and of 3-4 PE it was 5.93 (3.72-9.46). For all variables, the association to PE was stronger with more types of PE. CONCLUSIONS: High levels of alcohol use, and lifetime use of cannabis, amphetamine and heroin were associated with PE. These effects were robust even when the substance use variables were adjusted against each other. This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Delusions, anger, and serious violence: new findings from the MacArthur Violence Risk Assessment Study.

INTRODUCTION: Recent research on the association between delusions and violence has suggested complex and differing pathways. Furthermore, it has been emphasized that temporal proximity is fundamental when investigating these relationships. We reanalyzed data from the MacArthur Violence Risk Assessment Study utilizing a different methodological approach to investigate associations between specific delusions and violence. METHODS: Longitudinal study of 1136 male and female civil psychiatric inpatients after discharge. Delusions, affect due to delusions, and violence were measured at baseline and in 5 follow-up assessments. Serious violence was established using the MacArthur Community Violence Interview. Logistic mixed-effect models for repeated measures were performed. RESULTS: A "prospective" model confirmed previous findings that delusions do not predict later violence. However, reanalysis, considering temporal proximity, indicated a relationship between specific delusions and outcome including: being spied upon (adjusted OR [AOR] = 1.62, 95% CI = 1.06-2.47, P = .027), being followed (AOR = 1.90, 95% CI = 1.29-2.80, P = .001), being plotted against (AOR = 1.70, 95% CI = 1.14-2.52, P = .009), being under control of person/force (AOR = 1.92, 95% CI = 1.24-2.97, P = .003), thought insertion (AOR = 1.63, 95% CI = 1.00-2.66, P = .048), and having special gifts/powers (AOR = 1.95, 95% CI = 1.31-2.92, P = .001). All these delusions were associated with angry affect (P < .05). Inclusion of anger in the model significantly attenuated the main effects (except grandiose delusions), indicating an indirect pathway. CONCLUSIONS: Temporal proximity is crucial when investigating relationships between delusions and violence. Anger due to delusions is the key factor in this pathway. Our findings have important implications for identification of psychotic patients at risk for violent behavior and, most importantly, management of their risk.

Socio-economic disadvantage and delusional-like experiences: a nationwide population-based study.

PURPOSE: Delusional-like experiences (DLE) have been associated with low income, suggesting that more broadly defined socio-economic disadvantage may be associated with these experiences. We had the opportunity to explore the association between DLE and both individual- and area-level measures of socio-economic disadvantage. METHOD: Subjects were drawn from the Australian National Survey of Mental Health and Wellbeing 2007. The Composite International Diagnostic Interview was used to identify DLE, common psychiatric disorders, and physical disorders. Individual-level and area-level socio-economic disadvantage measures were available based on variables including income, educational attainment, employment status, and housing. We examined the relationship between the variables of interest using logistic regression, adjusting for potential confounding factors. RESULTS: Of the 8773 subjects, 8.4% (n=776) positively endorsed one or more DLE. DLE screen items were more likely to be endorsed by those who were (a) younger, (b) never married, or widowed, separated or divorced status, (c) migrants, or (d) living in rented houses. There were significant associations between socio-economic disadvantage and increased DLE endorsement, and this was found for both individual-level and area-level measures of socio-economic disadvantage. In general, the associations remained significant after adjusting for a range of potential confounding factors and in planned sensitivity analyses. CONCLUSIONS: DLE are associated with socio-economic disadvantage in the general population. We speculate that the link between socio-economic disadvantage and DLE may be mediated by psychosocial stress and general psychological distress.

An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders.

BACKGROUND: The psychosis-proneness-persistence-impairment model of psychotic disorder incorporates notions of both phenomenological and temporal continuity (persistence) of psychotic experiences (PE), but not structural continuity. Specific testable propositions of phenomenological continuity and persistence are identified. Method Propositions are tested by systematic reviews of the epidemiology of PE, persistence of PE and disorder outcomes, and meta-analyses (including Monte Carlo permutation sampling, MCPS) of reported rates and odds ratios (ORs). RESULTS: Estimates of the incidence and prevalence of PE obtained from 61 cohorts revealed a median annual incidence of 2.5% and a prevalence of 7.2%. Meta-analysis of risk factors identified age, minority or migrant status, income, education, employment, marital status, alcohol use, cannabis use, stress, urbanicity and family history of mental illness as important predictors of PE. The mode of assessment accounted for significant variance in the observed rates. Across cohorts, the probability of persistence was very strongly related to the rate of PE at baseline. Of those who report PE, ∼20% go on to experience persistent PE whereas for ∼80%, PE remit over time. Of those with baseline PE, 7.4% develop a psychotic disorder outcome. CONCLUSIONS: Compelling support is found for the phenomenological and temporal continuity between PE and psychotic disorder and for the fundamental proposition that this relationship is probabilistic. However, imprecision in epidemiological research design, measurement limitations and the epiphenomenological nature of PE invite further robust scrutiny of the continuity theory.

Irrational beliefs and test anxiety in Turkish school adolescents.

The purpose of this descriptive and correlational study was to determine the extent to which irrational beliefs of students in early adolescents predict test anxiety. The study sample consisted of 557 students recruited from primary schools in Turkey. The Irrational Beliefs Scale for Adolescents (IBS-A) and the Test Anxiety scale were used as data-collection instruments. As a result of this study, there was a positive, significant correlation between mean scores on the Text Anxiety scale and total score, and the three subscale (demand for success, demand for comfort, and demand for respect) scores on the IBS-A. It was also found that demand for comfort and success are more statistically significant predictors of test anxiety levels of the students compared to demand for respect.

[Identification errors and delusions of false identification in Alzheimer's disease: a regional survey]. / Troubles de l'identification et délires d'identité dans la maladie d'Alzheimer: une enquête régionale.

INTRODUCTION: Misidentification syndromes are the main symptoms in Alzheimer's disease. Underlain by complex cognitive, agnosic, and amnesic disturbances of degenerative etiology, they can be expressed by misidentification delusions, as in psychoses. To date, research has focused on identification disturbances of persons selected according to various definitions. OBJECTIVE: Our main objective was to evaluate the frequency of identification disturbances among patients suffering from Alzheimer's disease within the current conditions of diagnosis and treatment. The secondary objective aimed to establish a detailed analysis of symptoms and clinical correlations, and evaluate the effects of the troubles on the caregiver. METHODS: We conducted a regional survey using a questionnaire designed for the caregiver, proposed to the 60 geriatric doctors and neurologists in the Poitou-Charentes region of France, for all patients suffering from Alzheimer's disease (defined according to DSM IV criteria) seen between June 1st and August 31st of 2003. Statview software was used for statistical analysis. RESULTS: The survey was completed for 104 patients: 69.5 percent women and 30.5 percent men, with a mean age of 79 years. The majority of the patients were seen by a neurologist and presented an average cognitive deficiency (MMS ranging from 11 to 20). An identification disturbance, whether or not it was delusional, all domains included, was found in 81.6 percent of the patients and was related to a more severe cognitive deficiency and greater hardship on the part of the caregiver. DISCUSSION: We observed a high prevalence of identification disturbance, which can be explained by the systematic and exhaustive search for identification disturbance. The most frequent disturbance concerned the identification of places, whereas self-identification was less often affected; the authentic Capgras delusion was found less often. CONCLUSION: The study of identification disturbances in Alzheimer's disease can contribute to a better understanding of the cognitive, psychopathological, and physiopathological aspects of the disease as well as to a better knowledge and better care for the patient.

Persistence of and changes in neuropsychiatric symptoms in Alzheimer disease over 6 months: the LASER-AD study.

OBJECTIVES: Neuropsychiatric symptoms (NPS) are common in Alzheimer disease (AD). It is important in terms of management to know their natural history and their effects on service use. The authors aimed to determine the persistence and change in severity of NPS over 6 months in participants with AD, and the relationship to initial severity, drug management, use of services, and cost of care. METHODS: NPS scores and data on cognition, psychotropic medication, service use, and costs of care were collected on 224 participants at baseline and on 198 at 6-month follow-up. RESULTS: Of 224 patients, 210 (93.8%) had NPS at baseline; 168 (75.0%) had at least one clinically significant symptom, 118 (80.4%) of whom had persistent significant symptoms at 6-month follow-up. There was no significant change in mean NPS score for any symptom over 6 months, but many individuals became better or worse; 61.2% of those with at least one significant baseline symptom in any domain improved. Those with persistent symptoms had more severe baseline symptoms. Deterioration in NPS was predicted by deterioration in MMSE. Those with at least one clinically significant symptom had higher care costs than those without. CONCLUSIONS: NPS were highly persistent overall, but many individuals became better or worse. Persistence was predicted by having more severe symptoms at baseline. Clinically significant levels of NPS were associated with greater costs of care. The relatively few associations found between specific psychiatric treatments and changes in NPS reflect both undertreatment and the complexity of symptoms.

Psychosis or faith? Clinicians' assessment of religious beliefs.

This study investigated mental health professionals' assessment of the pathognomonic significance of religious beliefs. A total of 110 participants reviewed 3 vignettes depicting individuals possessing the religious beliefs associated with Catholicism, Mormonism, and Nation of Islam. The religious beliefs of the individuals in the vignettes were identified as either being integral to a religious tradition or not and also as either resulting in a threat to harm another or not. Identifying beliefs as religious resulted in lower ratings of pathology for 2 of the religions, and beliefs that did not involve a threat to harm also were rated lower for the same 2 religions. The results reveal a disjuncture between recommendations of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) and clinicians' judgments.

Erotomania : epidemiology and management.

Erotomania is generally classified as a delusional disorder in contemporary classification systems (DSM-IV and ICD-10). The incidence of erotomania is not known, but that of delusional disorder in general has been reported as approximately 15 cases per 100,000 of the population per year, with a female : male ratio of 3 : 1. Both primary and secondary types of erotomania have been identified, the latter being associated with evidence of an aetiologically significant organic or psychiatric condition. The aetiology of primary erotomania is not yet fully understood, but neuroimaging, genetic studies and findings from evolutionary psychopathology hold considerable promise for a deeper and broader understanding of this condition. The initial management of secondary erotomania focuses on treating the underlying organic or psychiatric illness. The management of primary and secondary erotomania involves a combination of pharmacological treatments, psychosocial interventions and risk management strategies. In the past, the antipsychotic medication pimozide was commonly used, at least in certain countries (such as the US and Canada), despite a paucity of systematic studies of its use in this disorder. In recent years, there have been reports of positive therapeutic outcomes with atypical antipsychotics (risperidone, clozapine), which, as a result of their improved tolerability over older agents such as pimozide, will hopefully enhance patient acceptability and, thereby, improve clinical outcome. Despite this advance, there is still a strong need for controlled clinical trials of therapeutic strategies for primary erotomania and related syndromes.

Rating the severity and character of transient cocaine-induced delusions and hallucinations with a new instrument, the Scale for Assessment of Positive Symptoms for Cocaine-Induced Psychosis (SAPS-CIP).

BACKGROUND: Cocaine can induce transient psychotic symptoms. We examined the phenomenology of such cocaine-induced psychosis (CIP) using a modified version of the Scale for Assessment of Positive Symptoms (SAPS), a well-validated instrument for the assessment of schizophrenic psychosis. METHODS: We developed a new instrument, the Scale for Assessment of Positive Symptoms for Cocaine-Induced Psychosis (SAPS-CIP), based on the well-validated SAPS. We interviewed 243 unrelated cocaine-dependent adults using both the SAPS-CIP and an instrument for the identification of cocaine-induced paranoia, the Cocaine Experience Questionnaire (CEQ). RESULTS: One hundred and eighty-one (75%) of the subjects endorsed CIP using the CEQ. With the SAPS-CIP, hallucination (HAL) and delusion (DEL) scores correlated strongly, and the DEL domain showed excellent concurrent validity with the CEQ. We observed significant positive correlations, respectively, between severity of HAL and DEL, and lifetime number of episodes of cocaine use, and negative correlations with age at onset of cocaine use. CONCLUSIONS: The results suggest that CIP consists of transient delusional and hallucinatory symptoms, which tend to occur together and co-vary in severity. It appears that rating cocaine-induced paranoia alone (e.g., with the CEQ) can identify most subjects experiencing CIP. However, the SAPS-CIP is useful for quantifying the severity of CIP according to operational criteria. Our data provide additional evidence that CIP is a sensitizing response.

Effect of voluntariness of participation in treatment on short-term outcome of inpatients with schizophrenia.

OBJECTIVE: The purpose of this study was to examine associations between the voluntary or coercive nature of patients' participation in inpatient treatment and the short-term outcome of inpatient treatment for patients with schizophrenia. METHODS: Eighty-eight adult patients with schizophrenia and delusional disorders who were consecutively admitted to a 320-bed psychiatric hospital in southern Germany over a three-month period in 2002 were assessed with the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) at admission and discharge, a mean of 36.2 days later. The patients were grouped by whether their participation was voluntary or involuntary in each of five aspects of inpatient treatment: admission, hospital stay, medication, discharge, and intention to continue treatment after discharge. Outcome was defined as the change between admission and discharge in scores on the PANSS and the GAF and change in those scores per inpatient day. RESULTS: The outcome measures were not significantly related to the voluntariness of patients' participation in any aspect of treatment. CONCLUSIONS: The short-term outcome of inpatient treatment is independent of whether treatment is voluntary.

De Clérambault syndrome (erotomania) in the criminal justice system: another look at this recurring problem.

While de Clérambault syndrome (erotomania) has long been a subject of scientific study, it has only recently become a frequent topic of media attention. A series of five individuals who were arrested for crimes related to their erotomanic delusion are presented. The psychiatric findings from this sample have potential social policy implication.

The prevalence and management of dementia and other psychiatric disorders in nursing homes.

The prevalence of psychiatric disorders among new admissions to nursing homes is unknown. Such data are needed to estimate the psychiatric needs of this population. We report the prevalence of specific psychiatric disorders in 454 consecutive new nursing home admissions who were evaluated by psychiatrists and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Eighty percent had a psychiatric disorder. The commonest were dementia syndromes (67.4%) and affective disorders (10%). Also, 40% of demented patients had additional psychiatric syndromes such as delusions or depression, and these patients constituted a distinct subgroup that predicted frequent use of restraints and neuroleptics, and the greatest consumption of nursing time. These data demonstrate that the majority of nursing home residents have psychiatric disorders on admission, and that their management is often quite restrictive. Research is now needed to determine the best methods of treatment for nursing home patients with mental disorders.

Prevalence of mental illness in a community nursing home.

A research psychiatrist using a standardized interview found that 94% of a random sample of residents at a large, intermediate-care nursing home had mental disorders according to DSM-III criteria. Primary degenerative dementia and multi-infarct dementia were the most common diagnoses. In addition, the majority of demented patients also had noncognitive symptoms such as delusions and hallucinations, and these residents were significantly more likely to have an associated behavioral disorder than were residents without delusions or hallucinations. Replications of these results would point out the need for major revisions in the funding and delivery of psychiatric care for nursing home residents.

A behavioral classification of welfare children from survey data.

From survey data on 1000 urban Welfare AFDC children aged six to eighteen, a hierarchical cluster analysis yielded six distinct behavioral types of Welfare children. Characteristics of each type, and its relationship to treatment, ethnicity, and other variables are discussed. Advantages of this system of behavioral classification for research and population assessment are outlined.