Klingsor Syndrome: Genital Self-Mutilation in a Psychotic Patient. / Klingsor Sendromu: Psikotik Hastada Genital Self Mutilasyon.

Self-mutilation attempts are common in psychiatric practice. One form of self-harm, genital self-mutilation (GSM), is less common but may have severe consequences. GSM acts can occur in different diagnoses such as personality disorders, substance abuse disorders, obsessive-compulsive disorders, and psychotic disorders. When GSM is performed due to psychotic symptoms, the clinical picture is called Klingsor Syndrome. GSM is often associated with severe psychosis and often accompanied by religious delusions. In our article, we discussed a case of schizophrenia with penile autoamputation due to religious delusions. A 28-year-old male patient was admitted to our hospital after penile autoamputation. After surgical interventions, the patient's follow-up continued in our clinic. The patient had auditory hallucinations, delusions of persecution, and sinfulness. His symptoms improved after antipsychotic treatment. It is important to identify the risk factors of Klingsor Syndrome, which is a rare but serious condition, and to intervene early in these patients. Keywords: Self-mutilation, Psychosis, Self-injurious Behavior.

The Cotard Delusion in a Patient With Neuropsychiatric Systemic Lupus Erythematosus: The Challenges of Autoimmune Psychosis.

The clinical features of neuropsychiatric systemic lupus erythematosus (NPSLE) are heterogeneous. Furthermore, therapeutic decision-making for NPSLE depends on the recognition of clinical syndromes that have not been sufficiently studied. This report describes the case of a 36-year-old woman with NPSLE who exhibited severe cognitive dysfunction and affective psychosis with persistent nihilistic delusions such as those described in the Cotard delusion. The patient insisted for several months that she was already dead. CSF analysis showed elevated levels of anti-ribosomal P antibodies and a positive determination of oligoclonal bands. Additionally, 18F -FDG PET/CT imaging revealed severe bilateral frontal hypermetabolism suggestive of brain inflammation and occipital hypometabolism. Results from the Systematic Lupus Erythematosus Disease Activity Index 2000 and the Systemic Lupus Erythematosus Disease Activity Score were consistent with an active state of the immunological disease. We then determined by an algorithm that this neuropsychiatric event could be attributed to the activity of the underlying immunological disease. Despite immunosuppressive and symptomatic treatment, only a partial improvement in cognition was achieved. The psychopathological features of the Cotard delusion remained unchanged 4 months after onset. However, we observed rapid remission of affective psychosis and significant improvement in cognition following electroconvulsive therapy. Subsequent follow-up examinations showed a sustained remission. This case describes a protracted form of the Cotard delusion, the diagnostic challenges that arise in the context of SLE, and treatment dilemmas that necessitate collaboration between neurology, psychiatry, and rheumatology.

[Clinical systematics of chronic delusional psychoses in schizophrenia and schizophrenia-spectrum pathology]. / Klinicheskaya sistematika khronicheskikh bredovykh psikhozov pri shizofrenii i patologii shizofrenicheskogo spektra.

OBJECTIVE: To develop a systematics of chronic delusional psychoses in schizophrenia and pathology of the schizophrenic spectrum that takes into account psychopathological structure (the mechanism of delusional formation) and the trajectories of the disease course (the ratio of negative/positive dimensions). MATERIAL AND METHODS: The study sample was recruited from the large Moscow psychiatric hospital in 2019-2024 and included 126 patients (94 male, 32 female, mean age 36.5±12.1 years) hospitalized with ICD-10 diagnosis of paranoid schizophrenia (F20.00) or delusional disorder (F22). A clinical-psychopathological method was used. RESULTS: The study identifies three variants of paranoid domains, the typology of which takes into account both the psychopathological structure and the trajectories of their development, which determine the dominance of predominantly negative or positive symptoms throughout the disease: 1) psychosis with delusional interpretations and predominant orientation of symptoms towards the negative pole of the schizophrenia psychopathology (n=37, 29.4%); 2) psychosis with hallucinatory delusions and predominant direction of symptoms towards the positive pole of the schizophrenia psychopathology (n=50, 39.7%); and 3) «combined¼ hallucinatory-delusional psychosis with a simultaneous orientation of symptoms to the negative/positive poles of the schizophrenia psychopathology (n=39, 30.9%). Detailed phenomenological characteristics of each of the three presented variants are given. CONCLUSION: The developed three-component taxonomy confirms, on the model of chronic delusional psychoses appearing in schizophrenia and the pathology of the schizophrenia spectrum, the concept of simultaneous representation of two relatively independent domains determined by neurobiological processes in the schizophrenia psychopathology positive and negative disorders.

Predictors of clinical insight in first-episode psychosis: Different patterns in men and women.

BACKGROUND: We aimed to explore gender-related differences in the associations of insight impairment with clinical symptoms, metacognition, and social cognition in psychosis. METHODS: Regression analysis of several clinical insight dimensions was conducted on the data from 116 men and 56 women with first-episode psychosis. Various clinical symptoms and measures of metacognition and social cognition were entered as predictors. RESULTS: In both men and women, delusions emerged as a strong predictor of all insight dimensions, and verbal hallucinations as a strong predictor of symptom relabelling. In men, certain negative symptoms as well as self-certainty, lack of self-reflectiveness, impaired theory of mind, attributional biases, and a jumping-to-conclusions bias were additional predictors of poor insight, while good insight was associated with depression, anxiety, avolition, blunted affect, and impaired emotional recognition. In women, poor insight was associated with a self-serving/externalising bias, impaired emotional recognition, and attention disorders. CONCLUSIONS: Poor insight in first-episode psychosis is strongly linked to deficits in metacognition and social cognition, with marked differences between men and women with respect to the specific skills involved in the impairment. Meanwhile, good insight is linked to a variety of affective manifestations in men. These findings suggest new avenues for more targeted cognitive interventions to improve clinical insight in psychosis.

The association of the persecutory ideation questionnaire with clinically-relevant and other outcomes: the moderating role of confidence.

One of the most used self-administered instruments to assess persecutory delusions is the Persecutory Ideation Questionnaire (PIQ). Individual differences in PIQ scores are important because they predict the severity of symptoms associated with psychosis-related disorders. The current research demonstrates that PIQ is associated with two new outcomes: Satisfaction with life (Studies 1 and 2) and therapy length needed for hospital discharge (Study 2). Most relevant, we introduce meta-cognitive confidence in one's scale responses as a construct capable of improving the predictive validity of the PIQ. Across two studies, participants from the general population (Study 1) and from a clinical sample (Study 2) completed the PIQ and then reported the confidence in their responses. As expected, the PIQ was associated with satisfaction with life in both cases and duration of therapy required to receive hospital discharge for the clinical sample. Most importantly, confidence further moderated the extent to which the PIQ scores were linked with both outcomes, with greater consistency between the PIQ and the dependent measures obtained for those with higher confidence. Therefore, asking a single item about the confidence associated with responses to the PIQ enhances the association of PIQ scores and relevant consequences across domains.

Modelling the longitudinal dynamics of paranoia in psychosis: A temporal network analysis over 20 years.

BACKGROUND: Paranoia is a key feature of psychosis that can be highly debilitating. Theories of paranoia mostly interface with short-scale or cross-sectional data models, leaving the longitudinal course of paranoia underspecified. METHODS: We develop an empirical characterisation of two aspects of paranoia - persecutory and referential delusions - in individuals with psychosis over 20 years. We examine delusional dynamics by applying a Graphical Vector Autoregression Model to data collected from the Chicago Follow-up Study (n = 135 with a range of psychosis-spectrum diagnoses). We adjusted for age, sex, IQ, and antipsychotic use. RESULTS: We found that referential and persecutory delusions are central themes, supported by other primary delusions, and are strongly autoregressive - the presence of referential and persecutory delusions is predictive of their future occurrence. In a second analysis we demonstrate that social factors influence the severity of referential, but not persecutory, delusions. IMPLICATIONS: We suggest that persecutory delusions represent central, resistant states in the cognitive landscape, whereas referential beliefs are more flexible, offering an important window of opportunity for intervention. Our data models can be collated with prior biological, computational, and social work to contribute toward a more complete theory of paranoia and provide more time-dependent evidence for optimal treatment targets.

A connectome-based model of delusion in schizophrenia using functional connectivity under working memory task.

Delusion is an important feature of schizophrenia, which may stem from cognitive biases. Working memory (WM) is the core foundation of cognition, closely related to delusion. However, the knowledge of neural mechanisms underlying the relationship between WM and delusion in schizophrenia is poorly investigated. Two hundred and thirty patients with schizophrenia (dataset 1: n = 130; dataset 2: n = 100) were enrolled and scanned for an N-back WM task. We constructed the WM-related whole-brain functional connectome and conducted Connectome-based Predictive Modelling (CPM) to detect the delusion-related networks and built the correlation model in dataset 1. The correlation between identified networks and delusion severity was tested in a separate, heterogeneous sample of dataset 2 that mainly includes early-onset schizophrenia. The identified delusion-related network has a strong correlation with delusion severity measured by the NO.20 item of SAPS in dataset 1 (r = 0.433, p = 2.7 × 10-7, permutation-p = 0.035), and can be validated in the same dataset by using another delusion measurement, that is, the P1 item of PANSS (r = 0.362, p = 0.0005). It can be validated in another independent dataset 2 (NO.20 item of SAPS for r = 0.31, p = 0.0024, P1 item of PANSS for r = 0.27, p = 0.0074). The delusion-related network comprises the connections between the default mode network (DMN), cingulo-opercular network (CON), salience network (SN), subcortical, sensory-somatomotor network (SMN), and visual networks. We successfully established correlation models of individualized delusion based on the WM-related functional connectome and showed a strong correlation between delusion severity and connections within the DMN, CON, SMN, and subcortical network.

Association between cumulative trauma and severity of psychotic symptoms among patients experiencing psychosis.

Psychosis-related trauma is a prevalent condition that significantly impacts patients and often leads to an increased reliance on psychiatric nursing services. This study aimed to provide a deeper understanding of the complex relationship between cumulative trauma and the severity of psychosis symptoms among patients experiencing psychosis. Utilizing a cross-sectional research design, data were collected from 76 community-dwelling patients recruited. Patients' sociodemographic and clinical data, Cumulative Trauma Measure scores, and psychosis symptom severity scale scores were collected. A significant difference was observed between collective identity trauma and the presence of hallucinations and abnormal psychomotor behavior (Z = 4.1 and 2.69, respectively). Significant differences were also observed between role identity trauma and the presence of delusions and abnormal psychomotor behavior (Z = 3.86 and 2.06, respectively); attachment trauma and the presence of hallucinations, abnormal psychomotor behavior, and mania (Z = 2.16, 2.12, and 2.11, respectively); and survival trauma and the presence of disorganized speech (Z = 2.61). Moreover, there was a significant difference regarding secondary trauma and the presence of hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, depression, and mania (Z = 4.29, 2.15, 2.11, 2.12, 4.42, and 3.39, respectively). In conclusion, total cumulative trauma explained 44.2 %, 25.8 %, 24.7 %, 16.2 %, 13.6 %, and 13.2 % of the severity of delusion, hallucination, depression, mania, abnormal psychomotor behavior, and disorganized speech, respectively, among patients experiencing psychosis. Implication for nursing practice, by recognizing the nuanced interplay between cumulative trauma and diverse manifestations of psychosis symptoms, nursing professionals can tailor their approaches to provide more holistic and patient-centered care that may significantly contribute to improved patient outcomes and the overall well-being of individuals navigating the complex landscape of psychosis-related trauma.

Delusions in postpartum psychosis: Implications for cognitive theories.

Postpartum psychosis is a rare but serious condition that can affect women after childbirth. We present a case study of an individual with no comorbidities or psychiatric history who developed postpartum psychosis characterised by prominent misidentification delusions whilst admitted to hospital. The woman recovered quickly with medication and showed no evidence of relapse over the following three years. Whilst still symptomatic and after recovery, the patient was able to provide a detailed description of her experiences. Contemporaneous interviews and observations during her hospital admission and a subsequent detailed retrospective account provide a unique, comprehensive window into her experience of these time-limited delusions. Her case reveals important insights including the triggers for her misidentification delusions, the role of social and contextual influences on delusional beliefs, and her recall of active involvement in evaluating and discarding delusional hypotheses. These insights highlight the complexity of delusional beliefs, challenge existing theories of delusions, and help inform broader theories of belief formation.

Measuring the concurrent validity of the norwegian versions of the psychotic symptom rating scales (PSYRATS) and the positive scale from the positive and negative syndrome scale (PANSS).

PURPOSE: The Positive and Negative Syndrome Scale (PANSS) is one of the most commonly used assessment tools for measuring psychotic symptoms. The Psychotic Symptom Rating Scales (PSYRATS) is another instrument created specifically to assess delusions and auditory hallucinations. However, research on the concurrent validity of PSYRATS with PANSS is limited. There are also inconsistent findings regarding the association between the PSYRATS scales and the PANSS positive scale. The present study aims to add to the understanding of the concurrent validity of these measures, while also incorporating a broader measure of psychiatric symptoms (the symptom scale from the Global Assessment of Functioning Scale - split version, GAF-S). MATERIALS AND METHODS: Spearman's Rank Order Correlations (rho) were calculated for scores from the PANSS positive scale, PSYRATS and GAF-S in a sample of 148 participants with psychotic disorders at three time points. RESULTS: The findings indicate concurrent validity between PSYRATS and PANSS, while the PSYRATS scales were not consistently correlated with GAF-S. CONCLUSIONS: PSYRATS may be a valid assessment tool for evaluating psychotic symptoms. The utility of PSYRATS in research and clinical practice should be investigated further.

Childhood trauma associated with psychotic-like experiences among people living with HIV: The chain mediation effect of stigma and resilience.

BACKGROUND: Previous research established the associations between childhood trauma and psychosis, but the effects of childhood trauma on psychotic-like experiences (PLEs) among people living with HIV (PLWH) and the potential mediation mechanisms in these associations remain unclear. OBJECTIVE: This study aimed to investigate the effects of childhood trauma on PLEs, as well as the chain mediation roles of stigma and resilience in this relationship. Furthermore, we explored whether the aforementioned associations differed when hallucinatory experiences (HEs) and delusional experiences (DEs) were separately modeled. PARTICIPANTS AND SETTING: The sample included 333 outpatients participants (95.2 % males, Mage = 28.24 ± 7.12) living with HIV recruited from Hunan Province, China; and data were collected with a cross-sectional survey. METHOD: The hypothesized chain mediation models were examined using SPSS PROCESS macro 3.3 software. RESULTS: Various influencing mechanisms of childhood trauma on HEs and DEs were examined in this study. Our results showed that, (a) childhood trauma directly exerted negative effect on HEs, while the chain mediation effect of stigma and resilience were not statistically significant. Conversely, (b) childhood trauma exerted no direct influence on DEs but rather through the chain mediation effect of stigma and resilience. CONCLUSIONS: The identification of two different routes between that childhood trauma can have on HEs and DEs highlighted the importance of tailored prevention and intervention among PLWH with a history of childhood trauma.

Psychosis in Alzheimer Disease and Elevations in Disease-Relevant Biomarkers.

Importance: The emergence of psychotic symptoms in Alzheimer disease (AD) is associated with accelerated cognitive and functional decline that may be related to disease pathology. Objective: To investigate the longitudinal dynamics of plasma tau phosphorylated at threonine 181 (p-tau181) and neurofilament light chain protein (NfL) levels in association with the emergence of psychotic symptoms (delusions and hallucinations) in the context of AD. Design, Setting, and Participants: This cohort study used longitudinal data from the Alzheimer Disease Neuroimaging Initiative (ADNI). Baseline analyses compared patients with mild cognitive impairment (MCI) and AD (both with psychosis [AD+P] and without psychosis [AD-P]) and participants who were cognitively unimpaired (CU). For the longitudinal analysis, participants with MCI and AD were subdivided into patients with evidence of psychosis at baseline (AD+P baseline) and patients free of psychosis at baseline who showed incidence of psychosis over the course of the study (AD+P incident). Study data were analyzed between June and November 2023. Exposures: Plasma p-tau181 and NfL measures in individuals with MCI and AD, both with and without psychosis. Main Outcomes and Measures: Plasma p-tau181 and NfL quantifications up to 48 months and concurrent assessments of presence or absence of delusions and hallucinations via the Neuropsychiatric Inventory (NPI) questionnaire. Results: The cohort included 752 participants with AD (mean [SD] age, 74.2 [7.7] years; 434 male [57.7%]). A total of 424 CU participants had a mean (SD) age of 75.4 (6.6) years of whom 222 were female (52.4%). In the longitudinal analysis of p-tau181 trajectories of the AD+P group, the group of patients who showed incidence of psychosis over the course of follow-up (AD+P incident) demonstrated an associated increase in plasma p-tau181 levels compared with the group of patients who had psychosis at baseline (AD+P baseline) and showed an associated decrease in plasma p-tau181 levels (F4, 117 = 3.24; P = .01). The mean slope of p-tau181 change was significantly different in AD+P incident and AD+P baseline groups (F5,746 = 86.76, P < .0001) and when only individuals with amyloid-ß positivity (Aß+), which was determined using positron emission tomography, were compared (F5,455 = 84.60, P < .001). Patients who experienced psychosis at any time had increased levels of NfL relative to those who never experienced psychosis. Conclusions and Relevance: Results of this cohort study suggest that the emergence of psychosis in AD was associated with elevations in plasma levels of p-tau181, highlighting the potential utility of plasma p-tau181 as a biomarker of neuropsychiatric illness in AD, which could have implications for predictive and treatment response strategies.

Neurocognitive function and delusion severity in schizophrenia spectrum disorders.

The role of basic neurocognitive function in delusions is unclear despite the association to difficulties in reasoning and decision-making. We investigated 812 individuals with schizophrenia spectrum disorders (SSD) using a broad neuropsychological test battery encompassing motor and mental processing speed, working memory, learning and memory, and executive function. Premorbid and current intellectual function was assessed with NART and WASI. Delusion level and other clinical symptoms were measured with the PANSS and GAF. Hierarchical and k-means cluster analysis using standardized scores showed the presence of two separate clusters where the group with the higher delusion level (n = 291) was characterized by more severe neurocognitive deficits (>1.5 standard deviations below the healthy control mean), higher PANSS scores, lower GAF scores, and lower intelligence levels compared to the cluster with mild impairments (n = 521). We conclude that a higher delusion level is related to neurocognitive deficits across domains. Further, the validity of the two separate clusters was indicated by significant differences in clinical symptoms, everyday function, and intellectual ability. Compared to those with mild delusion levels, SSD patients with higher delusion levels seem particularly disadvantaged, with co-occurring general symptoms and lower daily function, underscoring the need for clinical and psychosocial support programs. A limitation of this study is the cross sectional design. Longitudinal studies are needed to determine the causal relationship between delusions and neurocognitive function.

The phenomenological nature of schizophrenia and disorder of selfhood.

Schizophrenia continues its resistance to the pathogenetic understanding. We believe that one of the reasons is an oblivion of schizophrenia's characteristic Gestalt expressive of its psychopathological structure. In this article we argue for a crucial role of disorders of selfhood in the constitution of this Gestalt. First, we present a phenomenological account of the self. This is followed by an exposition of basic complaints in schizophrenia which are reflective of a disordered selfhood and which often date back to childhood. We then present characteristic features of the schizophrenic psychosis with its phenomenon of "double bookkeeping". Hallucinations, delusions and double bookkeeping are all associated with the instability of the self. Finally, we briefly address characteristic aspects of the encounter with a schizophrenia patient and argue that self-disorders play an important diagnostic role. We conclude by emphasizing the role of phenomenology in psychiatric research.

Reduction in presynaptic dopamine transporter may be associated with future problematic delusion.

OBJECTIVES: Psychosis, especially in delusions, greatly impairs the quality of life of patients with Parkinson's disease (PD) and their caregivers. Few objective risk indicators of the association between psychosis and clinical features has been reported. It is unclear whether the reduction in DAT binding represents the underlying mechanism of delusion or its association. There are no long-term data on the objective prognostic value of DAT binding for delusions. We investigated whether DAT binding at baseline can be a prognostic risk factor for future development of PD delusions. MATERIALS AND METHODS: We reviewed the detailed clinical chart of patients with PD without a history of psychosis who underwent [123I]FP-CIT SPECT during the disease. The endpoint was defined as when the delusions occurred during the 5 years after the examination of [123I]FP-CIT SPECT. Specific binding ratio (SBR) values were calculated. RESULTS: Sixty-one patients with PD were included in the analysis, and 11 patients had delusions within 5 years of [123I] FP-CIT SPECT. The average (p = 0.004), minimum (p = 0.004), maximum (p = 0.001), right-sided (p = 0.002), and left-sided (p = 0.003) SBRs in the striatum were significantly smaller in patients with delusions than in patients without delusions. Each difference of each SBR was significantly smaller than those without delusions after adjusting after controlling for age, gender, disease severity, timing of [123I]FP-CIT SPECT, anti-parkinsonian medications, hospitalization, administering more or newly anti-parkinsonian drugs, and receiving DBS or LCIG. CONCLUSIONS: PD delusions is still problematic, and lowering DAT binding may be helpful for predicting future delusions, regardless of the timing of [123I]FP-CIT SPECT.

Sociodemographic and clinical correlates of hallucinations in patients entering an early intervention program for first episode psychosis.

Hallucinations are a core feature of psychosis, and their severity during the acute phase of illness is associated with a range of poor outcomes. Various clinical and sociodemographic factors may predict hallucinations and other positive psychotic symptoms in first episode psychosis (FEP). Despite this, the precise factors associated with hallucinations at first presentation to an early intervention service have not been extensively researched. Through detailed interviews and chart reviews, we investigated sociodemographic and clinical predictors in 636 minimally-medicated patients who entered PEPP-Montréal, an early intervention service for FEP, between 2003 and 2018. Hallucinations were measured using the Scale for the Assessment of Positive Symptoms (SAPS), while negative symptoms were assessed using the Scale for the Assessment of Negative symptoms (SANS). Depressive symptoms were evaluated through the Calgary Depression Scale for Schizophrenia (CDSS), and anxiety symptoms via the Hamilton Rating Scale for Anxiety (HAS). A majority (n = 381, 59.9 %) of the sample presented with clinically significant hallucinations (SAPS global hallucinations score ≥ 3) at program entry. These patients had an earlier age at onset, fewer years of education, and a higher severity of delusions, depression and negative symptoms than those without clinical-level hallucinations. These results suggest that individuals with clinically significant hallucinations at admission tend to be younger and have a greater overall symptom burden. This makes it especially important to monitor hallucinations alongside delusions, depression and negative symptoms in order to identify who might benefit from targeted interventions. The implications of these findings for early intervention and person-centered care are discussed.

The contributions of risk-taking and impulsivity to jumping to conclusions in the psychosis spectrum.

The jumping to conclusions (JTC) bias has been linked to the formation and maintenance of delusions across the psychosis spectrum. However, it remains unclear whether this bias reflects a primary cognitive deviation or is secondary to other cognitive processes. To this end, we investigated the relationship between JTC, risk-taking, impulsivity, and sensation seeking in individuals with psychotic-like experiences (PLEs) and controls. A large online community sample (N = 1151) completed the Fish Task as a measure for the JTC bias, as well as the Balloon Analogue Risk Task (BART) and the Brief Risk-Taking Propensity Scale (R-1) as measures of the propensity to take risks. Measures assessing impulsivity (Impulsive Behavior Scale-8, I-8), sensation seeking (Brief Sensation Seeking Scale, BSSS-4), and verbal intelligence (12-item Wordsum test) were also administered. We dichotomized the sample into extreme groups based on the positive subscale of the Community Assessment of Psychotic Experiences (CAPE). The present study confirms the existence of a JTC bias in psychosis-prone individuals. Of note, PLE-high individuals self-reported higher risk-taking propensity in the R-1 while at the same time displaying higher objective risk aversion in the BART relative to controls, speaking for a dissociation of subjective versus objective risk-taking behavior. PLE-high individuals showed deviances in other psychological traits (impulsivity, sensation seeking), but these were not associated with hasty decision-making as measured by JTC or risk-taking propensity. The results speak against impulsivity, sensation seeking, or verbal intelligence as driving mechanisms of JTC and risky decision-making.