[Characteristics of elderly patients diagnosed with delusional disorders during the COVID-19 pandemic: A study in a memory clinic].

AIM: Since the declaration of an emergency following the spread of COVID-19, the number of elderly patients complaining of delusions has increased. Therefore, we investigated the characteristics of patients diagnosed with delusional disorders in our clinic. METHODS: A total of 1,884 patients ≥ 65 years old who visited the Center for Comprehensive Care on Memory Disorders at Kyorin University Hospital from January 2017 to December 2021 were included in the study. The 17 patients diagnosed with delusional disorders were divided into 2 groups based on the timing of the first declaration of emergency, and the characteristics of each group were investigated. RESULTS: Seven patients were diagnosed with delusional disorder before the first declaration of emergency and 10 after the declaration. The proportion of patients increased by approximately three-fold after the declaration. Post-emergency patients were less motivated to be active than those encountered before the declaration, and many had no history of mental illness. Seven of the 10 post-emergency patients visited the Memory Clinic within 1 year of the onset of delusions. CONCLUSIONS: After the first declaration of an emergency, elderly patients with no history of psychiatric disorders acutely developed delusional disorders.The physical and psychological effects of COVID-19 on the elderly should be considered.

Hallucinations, somatic-functional disorders of PD-DLB as expressions of thalamic dysfunction.

Hallucinations, delusions, and functional neurological manifestations (conversion and somatic symptom disorders) of Parkinson's disease (PD) and dementia with Lewy bodies increase in frequency with disease progression, predict the onset of cognitive decline, and eventually blend with and are concealed by dementia. These symptoms share the absence of reality constraints and can be considered comparable elements of the PD-dementia with Lewy bodies psychosis. We propose that PD-dementia with Lewy bodies psychotic disorders depend on thalamic dysfunction promoting a theta burst mode and subsequent thalamocortical dysrhythmia with focal cortical coherence to theta electroencephalogram rhythms. This theta electroencephalogram activity, also called fast-theta or pre-alpha, has been shown to predict cognitive decline and fluctuations in Parkinson's disease with dementia and dementia with Lewy bodies. These electroencephalogram alterations are now considered a predictive marker for progression to dementia. The resulting thalamocortical dysrhythmia inhibits the frontal attentional network and favors the decoupling of the default mode network. As the default mode network is involved in integration of self-referential information into conscious perception, unconstrained default mode network activity, as revealed by recent imaging studies, leads to random formation of connections that link strong autobiographical correlates to trivial stimuli, thereby producing hallucinations, delusions, and functional neurological disorders. The thalamocortical dysrhythmia default mode network decoupling hypothesis provides the rationale for the design and testing of novel therapeutic pharmacological and nonpharmacological interventions in the context of PD, PD with dementia, and dementia with Lewy bodies. © 2019 International Parkinson and Movement Disorder Society.

Belief, delusion, hypnosis, and the right dorsolateral prefrontal cortex: A transcranial magnetic stimulation study.

According to the Two-Factor theory of delusional belief (see e.g. Coltheart at al., 2011), there exists a cognitive system dedicated to the generation, evaluation, and acceptance or rejection of beliefs. Studies of the neuropsychology of delusion provide evidence that this system is neurally realized in right dorsolateral prefrontal cortex (rDLPFC). Furthermore, we have shown that convincing analogues of many specific delusional beliefs can be created in nonclinical subjects by hypnotic suggestion and we think of hypnosis as having the effect of temporarily interfering with the operation of the belief system, which allows acceptance of the delusional suggestions. If the belief system does depend on rDLPFC, then disrupting the activity of that region of the brain by the application of repetitive transcranial magnetic stimulation (rTMS) will increase hypnotizability. Dienes and Hutton (2013) have reported such an experiment except that it was left DLPFC to which rTMS was applied. An effect on a subjective measure of hypnotizability was observed, but whether there was an effect on an objective measure could not be determined. We report two experiments. The first was an exact replication of the Dienes and Hutton experiment; here we found no effect of rTMS to lDLPFC on any hypnotic measure. Our second experiment used rTMS applied to right rather then left DLPFC. This right-sided stimulation enhanced hypnotizability (when hypnotic response was measured objectively), as predicted by our hypothesis. These results imply a role for rDLPFC in the cognitive process of belief evaluation, as is proposed in our two-factor theory of delusion. They are also consistent with a conception of the acceptance of a hypnotic suggestion as involving suspension of disbelief.

[Possible Signs of Sensory Overload]. / Mögliche Kennzeichen der Reizüberflutung.

Objective To identify, synthesize and structure the defining characteristics of overstimulation. Methods The literature search was conducted in relevant international databases (Pubmed, Medline, CINAHL, Psyndex, PsycArticles, PsychINFO). The literature analysis was conducted according to Mayring's method of qualitative content analysis. Results Despite the scanty data available on symptoms or effects of sensory overload, twelve literature-sources were identified, describing signs and symptoms of sensory overload. A cluster of psychopathological and behavioral characteristics of sensory overload was developed. Conclusions Further research is needed to obtain an evidence-based description of the defining characteristics of sensory overload.

Pimavanserin: First Global Approval.

Pimavanserin (Nuplazid™) is a selective and potent serotonin 2A (5-HT2A) receptor inverse agonist and antagonist developed by ACADIA Pharmaceuticals that has been approved in the US as a treatment for patients with hallucinations and delusions associated with Parkinson's disease psychosis. Up to 60 % of patients with Parkinson's disease may develop Parkinson's disease psychosis, which is associated with increased morbidity and mortality and has few treatment options. This article summarizes the milestones in the development of pimavanserin leading to this first approval for the treatment of hallucinations and delusions in patients with Parkinson's disease psychosis.

[The assessment of spirituality and religiousness in patients with psychosis]. / Pourquoi et comment aborder la spiritualité et la religiosité des patients souffrant de troubles mentaux sévères : une étude de terrain.

OBJECTIVES: There is evidence that psychiatrists are rarely aware of how religion may intervene in their patient's life. That is particularly obvious concerning patients with psychosis. Yet, even for patients featuring delusions with religious content, religious activities and spiritual coping may have a favourable influence. Indeed, patients with psychosis can use religion to cope with life difficulties related to their psychotic condition, in a social perspective but also in order to gain meaning in their lives. Also, religion may be part of explanatory models about their disorder with, in some cases, a significant influence on treatment adhesion. PATIENTS AND METHODS: This paper describes a prospective randomized study about a spiritual assessment performed by the psychiatrists of patients with schizophrenia. The outpatient clinics in which the sample was collected are affiliated with the department of psychiatry at the university hospitals of Geneva. Eighty-four outpatients with psychosis were randomized into two groups: an experimental group receiving both traditional treatment and spiritual assessment with their psychiatrist and a control group of patients receiving only their usual treatment. Psychiatrists were supervised by a clinician (PH) and a psychologist of religions (PYB) for each patient in the spiritual assessment group. Data were collected from both groups before and after 3 months of clinical follow-up. RESULTS: Spiritual assessment was well-tolerated by all patients. Moreover, their wish to discuss religious matters with their psychiatrist persisted following the spiritual assessment. Even though clinicians acknowledged the usefulness of the supervision for some patients, especially when religion was of importance for clinical care, they reported being moderately interested in applying spiritual assessments in clinical settings. Compared to the control group, there were no differences observed in the 3 months' outcome in terms of primary outcome measures for satisfaction with care, yet the attendance at the appointments was significantly increased in the group with spiritual assessment. The same result was found when restricting analyses to patients for whom an intervention was suggested or patients who invested more in religion. Areas of potential intervention were frequent both in a psychiatric and psychotherapeutical perspective. CONCLUSIONS: Spiritual assessment appears to be useful for patients with psychosis. This is in accordance with the recommendations of the World Psychiatric Association which promotes considering the whole person in clinical care. Spiritual assessment is quite simple to perform, providing that clinicians do not prescribe or promote religion, and that no critical comments are made concerning religious issues. Clinicians do not need to know in depth the religious domains of each of their patients, as it appears that each patient accommodates his/her religious background his/her own way.

Hypnosis and belief: A review of hypnotic delusions.

Hypnosis can create temporary, but highly compelling alterations in belief. As such, it can be used to model many aspects of clinical delusions in the laboratory. This approach allows researchers to recreate features of delusions on demand and examine underlying processes with a high level of experimental control. This paper reviews studies that have used hypnosis to model delusions in this way. First, the paper reviews studies that have focused on reproducing the surface features of delusions, such as their high levels of subjective conviction and strong resistance to counter-evidence. Second, the paper reviews studies that have focused on modelling underlying processes of delusions, including anomalous experiences or cognitive deficits that underpin specific delusional beliefs. Finally, the paper evaluates this body of research as a whole. The paper discusses advantages and limitations of using hypnotic models to study delusions and suggests some directions for future research.

Delusions as harmful malfunctioning beliefs.

Delusional beliefs are typically pathological. Being pathological is clearly distinguished from being false or being irrational. Anna might falsely believe that his husband is having an affair but it might just be a simple mistake. Again, Sam might irrationally believe, without good evidence, that he is smarter than his colleagues, but it might just be a healthy self-deceptive belief. On the other hand, when a patient with brain damage caused by a car accident believes that his father was replaced by an imposter or another patient with schizophrenia believes that "The Organization" painted the shops on a street in red and green to convey a message, these beliefs are not merely false or irrational. They are pathological. What makes delusions pathological? This paper explores the negative features because of which delusional beliefs are pathological. First, I critically examine the proposals according to which delusional beliefs are pathological because of (1) their strangeness, (2) their extreme irrationality, (3) their resistance to folk psychological explanations or (4) impaired responsibility-grounding capacities of people with them. I present some counterexamples as well as theoretical problems for these proposals. Then, I argue, following Wakefield's harmful dysfunction analysis of disorder, that delusional beliefs are pathological because they involve some sorts of harmful malfunctions. In other words, they have a significant negative impact on wellbeing (=harmful) and, in addition, some psychological mechanisms, directly or indirectly related to them, fail to perform the jobs for which they were selected in the past (=malfunctioning). An objection to the proposal is that delusional beliefs might not involve any malfunctions. For example, they might be playing psychological defence functions properly. Another objection is that a harmful malfunction is not sufficient for something to be pathological. For example, false beliefs might involve some malfunctions according to teleosemantics, a popular naturalist account of mental content, but harmful false beliefs do not have to be pathological. I examine those objections in detail and show that they should be rejected after all.

[Involuntary treatment in psychiatry]. / Zwangsunterbringung und Zwangsbehandlung in der Psychiatrie.

Involuntary treatment in psychiatry should be reflected under the German constitutional right of self-determination und the ethical principles of autonomy and beneficience. Forced treatment in psychiatry should be applied only as a last resort. A narrative perspective reconstructs the case of Gustl Mollath who was hospitalized in forensic-psychiatric institutions because of an alleged delusion. Psychiatric experts should be aware of the potential of misuse when defining what is real and what seems to be a delusion.

Exaltation in temporal lobe epilepsy: neuropsychiatric symptom or portal to the divine?

Religiosity is a prominent feature of the Geschwind syndrome, a behavioural pattern found in some cases of temporal lobe epilepsy. Since the 1950s, when Wilder Penfield induced spiritual feelings by experimental manipulation of the temporal lobes, development of brain imaging technology has revealed neural correlates of intense emotional states, spurring the growth of neurotheology. In their secular empiricism, psychiatry, neurology and psychology are inclined to pathologise deviant religious expression, thereby reinforcing the dualism of objective and phenomenal worlds. Considering theological perspectives and the idea of cosmic consciousness, the authors urge a holistic approach to the spiritual events of epileptic aura, potentially leading to a deeper understanding of the mind and its transcendent potential.

Modelling psychiatric and cultural possession phenomena with suggestion and fMRI.

Involuntary movements occur in a variety of neuropsychiatric disorders and culturally influenced dissociative states (e.g., delusions of alien control and attributions of spirit possession). However, the underlying brain processes are poorly understood. We combined suggestion and fMRI in 15 highly hypnotically susceptible volunteers to investigate changes in brain activity accompanying different experiences of loss of self-control of movement. Suggestions of external personal control and internal personal control over involuntary movements modelled delusions of control and spirit possession respectively. A suggestion of impersonal control by a malfunctioning machine modelled technical delusions of control, where involuntary movements are attributed to the influence of machines. We found that (i) brain activity and/or connectivity significantly varied with different experiences and attributions of loss of agency; (ii) compared to the impersonal control condition, both external and internal personal alien control were associated with increased connectivity between primary motor cortex (M1) and brain regions involved in attribution of mental states and representing the self in relation to others; (iii) compared to both personal alien control conditions, impersonal control of movement was associated with increased activity in brain regions involved in error detection and object imagery; (iv) there were no significant differences in brain activity, and minor differences in M1 connectivity, between the external and internal personal alien control conditions. Brain networks supporting error detection and object imagery, together with representation of self and others, are differentially recruited to support experiences of impersonal and personal control of involuntary movements. However, similar brain systems underpin attributions and experiences of external and internal alien control of movement. Loss of self-agency for movement can therefore accompany different kinds of experience of alien control supported by distinct brain mechanisms. These findings caution against generalization about single cognitive processes or brain systems underpinning different experiences of loss of self-control of movement.

Schizophrenia or possession?

Schizophrenia is typically a life-long condition characterized by acute symptom exacerbations and widely varying degrees of functional disability. Some of its symptoms, such as delusions and hallucinations, produce great subjective psychological pain. The most common delusion types are as follows: "My feelings and movements are controlled by others in a certain way" and "They put thoughts in my head that are not mine." Hallucinatory experiences are generally voices talking to the patient or among themselves. Hallucinations are a cardinal positive symptom of schizophrenia which deserves careful study in the hope it will give information about the pathophysiology of the disorder. We thought that many so-called hallucinations in schizophrenia are really illusions related to a real environmental stimulus. One approach to this hallucination problem is to consider the possibility of a demonic world. Demons are unseen creatures that are believed to exist in all major religions and have the power to possess humans and control their body. Demonic possession can manifest with a range of bizarre behaviors which could be interpreted as a number of different psychotic disorders with delusions and hallucinations. The hallucination in schizophrenia may therefore be an illusion-a false interpretation of a real sensory image formed by demons. A local faith healer in our region helps the patients with schizophrenia. His method of treatment seems to be successful because his patients become symptom free after 3 months. Therefore, it would be useful for medical professions to work together with faith healers to define better treatment pathways for schizophrenia.

The active therapeutic processes of acceptance and commitment therapy for persistent symptoms of psychosis: clients' perspectives.

BACKGROUND: There is limited research on the applicability and effectiveness of Acceptance and Commitment Therapy (ACT) for people experiencing psychotic disorders. Clinical trials suggest ACT may be efficacious in reducing distress and rehospitalization rates in psychosis. Mindfulness and reduced literal believability of thought content have been associated with reduced distress for this population. AIMS: To better understand ACT for psychosis, this study investigated clients' perspectives of the hypothesized active therapeutic processes of ACT. METHOD: Semi­structured interviews, conducted with nine adults diagnosed with schizophrenia or schizoaffective disorder and persistent positive symptoms, were analysed thematically. RESULTS: Four themes emerged: Usefulness of therapy; Changes attributed to ACT; Understanding of therapy; and Non-specific therapy factors. All participants found therapy useful and recommended ACT. Mindfulness, defusion, acceptance and values work were described as the most useful therapy components and contributing to positive changes. Self-rated frequency of symptoms did not change; however a reduction in the intensity and distress associated with symptoms was reported. Non-specific therapy factors were deemed useful by participants but not directly related to outcome. CONCLUSIONS: These findings are consistent with the theoretically defined underlying active processes of ACT and are relevant for this population. The findings also indicate important clinical implications for ACT for this client group: greater attention to the client connecting metaphors and concepts to the intended meaning may be valuable; caution should be used with some mindfulness and defusion techniques for intense experiences; and values work may be particularly useful for this population.

[Auditory event-related evoked potentials in dynamics of treatment of affective-delusional conditions].

With the aim to study neurophysiologic correlates and to search for some possible predictors of therapeutic response correlation analysis has been carried out of links between temporal parameters of components of auditory event-related potentials (AERPs) and dynamics of quantitative clinical assessments of mental state conditions in two groups of patients--with depressive-delusional conditions (group 1) and with manic-delusional conditions (group 2) in the frames of attack-like schizophrenia. Statistically significant correlations have been revealed between values of peak latencies of main AERPs components and severity of psychopathologic symptoms before beginning of treatment course, as well as between initial (before treatment course) AERPs temporal parameters and quantitative clinical assessments at the stage of remission establishment. Larger severity of residual positive, negative and common psychopathologic symptoms of schizophrenia (and also of depression and anxiety in group 1) after course of treatment was associated with smaller initial (before treatment course) values of peak latencies of "early" (P1 and N1) and with larger initial values of "late" (P2, N2 and P3) AERPs components in both groups of patients. The data obtained allow to justify basic views on brain mechanisms of affective-delusional disorders, and to reveal possible neurophysiologic predictors of treatment efficacy in such disorders.

Cognitive and affective perspectives on formation and maintenance of grandiose delusions of a patient with schizophrenia.

We report on a woman with first-episode schizophrenia with grandiose delusions. She developed a bizarre delusion that she was 'Jesus', who had special powers to talk to animals and predict the future. The grandiose delusions were maintained by her positive emotions, positive imagery of becoming an extraordinary person, and cognitive biases. With the application of cognitive and affective model for formulation of an intervention plan, it was found that the patient had improvement in lowered shamefulness about herself and skills of setting appropriate expectations. The assessment and treatment process of this patient shows the value of applying theory to case formulation and making a care plan for the case management service for patients with first-episode psychosis. This report has clear limitations in that it is a discussion of a single patient, and the case formulation is speculative at this time. The formation and maintenance of grandiose delusions are discussed from the cognitive and affective perspectives.

A laboratory analogue of mirrored-self misidentification delusion: the role of hypnosis, suggestion, and demand characteristics.

Mirrored-self misidentification is the delusional belief that one's own reflection in the mirror is a stranger. In two experiments, we tested the ability of hypnotic suggestion to model this condition. In Experiment 1, we compared two suggestions based on either the delusion's surface features (seeing a stranger in the mirror) or underlying processes (impaired face processing). Fifty-two high hypnotisable participants received one of these suggestions either with hypnosis or without in a wake control. In Experiment 2, we examined the extent to which social cues and role-playing could account for participants' behaviour by comparing the responses of 14 hypnotised participants to the suggestion for impaired face processing (reals) with those of 14 nonhypnotised participants instructed to fake their responses (simulators). Overall, results from both experiments confirm that we can use hypnotic suggestion to produce a compelling analogue of mirrored-self misidentification that cannot simply be attributed to social cues or role-playing.

Treating PTSD in patients with psychosis: a within-group controlled feasibility study examining the efficacy and safety of evidence-based PE and EMDR protocols.

The present study uses a within-group controlled design to examine the efficacy and safety of two psychological approaches to posttraumatic stress disorder (PTSD) in 10 patients with a concurrent psychotic disorder. Patients were randomly assigned either to prolonged exposure (PE; N=5) or eye movement desensitization and reprocessing (EMDR; N=5). Before, during, and after treatment, a total of 20 weekly assessments of PTSD symptoms, hallucinations, and delusions were carried out. Twelve weekly assessments of adverse events took place during the treatment phase. PTSD diagnosis, level of social functioning, psychosis-prone thinking, and general psychopathology were assessed pretreatment, posttreatment, and at three-month follow-up. Throughout the treatment, adverse events were monitored at each session. An intention-to-treat analysis of the 10 patients starting treatment showed that the PTSD treatment protocols of PE and EMDR significantly reduced PTSD symptom severity; PE and EMDR were equally effective and safe. Eight of the 10 patients completed the full intervention period. Seven of the 10 patients (70%) no longer met the diagnostic criteria for PTSD at follow-up. No serious adverse events occurred, nor did patients show any worsening of hallucinations, delusions, psychosis proneness, general psychopathology, or social functioning. The results of this feasibility trial suggest that PTSD patients with comorbid psychotic disorders benefit from trauma-focused treatment approaches such as PE and EMDR.

Transmitting delusional beliefs in a hypnotic model of folie à deux.

Folie à deux is the transference of delusional ideas from one 'primary' individual to one or more 'secondary' individuals (Lasègue & Falret, 1877). However, it is difficult to investigate experimentally because often only one patient is identified as delusional. We investigated whether hypnosis could model the experiences of the secondary in this delusion. Our primary was a confederate, who displayed two delusional beliefs and attempted to transmit them to hypnotised subjects. We manipulated the status of the confederate so that they were portrayed as either "credible" or merely "interesting".Many high hypnotisable individuals adopted the confederate's beliefs and confabulated evidence in support of them.Also, subjects who interacted with a credible confederate extended their delusions beyond those displayed by the confederate. We discuss the strengths and limitations of this approach and suggest ways to improve the validity of this model.

[Between faith and delusion]. / Zwischen Glauben und Wahn.

Religious beliefs can lead to difficulties in psychiatric diagnosis, when it comes to distinguishing between faith and delusion. Delusion is defined as a false assessment of reality combined with subjective certainty, which is in contrast with the reality of the social environment. The problem with this definition is that reality cannot be examined with scientific methods/criteria and that the assessment of reality itself underlies historical and cultural fluctuations. The current diagnostic manuals for psychiatric disorders DSM 5 and ICD-10 require, that the content of the belief has to be inadequate even in the subculture of the patient (ICD-10) and that the cultural and socioeconomic background of the patient has to be taken into account (DSM 5). On the basis of this case-report and of selected publications on this topic we want to discuss this diagnostic problem. After that we present a diagnostic model for delusion, which is easy to handle in the daily routine of psychiatrists.