The Association Between Distinct Delusional Ideations and Depressive Symptoms in Alzheimer's Disease: A Re-Analysis of CATIE-AD.

Background: Delusional ideations, one of neuropsychiatric symptoms (NPSs), are frequently shown in the long-term progression of Alzheimer's disease (AD), and comorbid with other NPSs including depression or agitation. Despite various types of delusional ideations, the comorbidity between each delusional ideation and depressive symptoms has not been discussed. Objective: The present cross-sectional study is aimed at testing the hypothetical mechanism of comorbid pattern in AD. Methods: Among 421 patients with AD, we analyzed the dataset of the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease to compare age, sex, racial type, Mini-Mental State Examination (MMSE) scores, and Neuropsychiatric Inventory (NPI) depression score of between the presence and absence of each delusional ideation (delusion of persecution, theft, jealousy, abandonment, phantom boarder, Capgras syndrome, misidentification of place, or television sign). Next, with the stratification based on MMSE score of < or > = 15 points, we further explored association between delusional ideation and depressive symptom that was found significances in the primary analysis. Results: Among eight subtypes of delusional ideations, depression score was higher in those with persecution delusion or Capgras syndrome. Moreover, the Capgras syndrome was associated with presence of depression in severer global cognitive impairment status. Conclusions: As comorbid NPSs of delusional ideation in AD, depressive severity is associated with specific delusional subtype: persecution delusion and Capgras syndrome. Capgras syndrome may be attributable to severe cognitive impairment in addition to depressive symptom. The consideration of pathogenetic differences in the distinct delusional ideations may be helpful for clinicians to select the treatment strategy.

Delusion of pregnancy: Case series.

Delusion of pregnancy is a relatively uncommon manifestation in psychotic patients. Differentiating it from closely related clinical entities like pseudocyesis/pseudopregnancy can be a challenge in clinical setting. Diagnosis of a psychotic illness with delusional pregnancy as the presenting feature in the absence of other florid symptoms of psychosis is a different challenge altogether. Currently, there is no consensus on the pharmacotherapy and psychotherapy of delusional pregnancy. We present a case series on delusional pregnancy with the intent to answer some of these gaps in the literature.

Making Sense of Spiritual, Metaphysical, and Eschatological Elements in Delusions: A Qualitative Study Using Interpretative Phenomenological Analysis.

BACKGROUND: Spiritual, metaphysical, or eschatological elements in delusions (SMEDs) are frequent and often subjectively regarded as profound transformational experiences, similar to mystical experiences. This study aimed (1) to explore how SMEDs are experienced and in which aspects they are similar to mystical experiences and (2) to investigate how individuals make sense of SMED. METHODS: Seven participants were interviewed, and their expressions were analyzed using interpretative phenomenological analysis. RESULTS: We found that SMEDs were similar to mystical experiences with regard to alterations in perception of space, time, and unity. Furthermore, SMEDs were accompanied by a sense of enlightenment that however remained ineffable. SMEDs were interpreted from different viewpoints, i.e., as a source of ontological insight, as a mental health issue, as an inspiration for a new orientation in the world, and, for some participants, as an example of the limits of knowledge. Making sense of SMED appeared to follow a lively internal dialogue in which various, sometimes contradictory positions were reflected upon. Participants usually struggled to align the ostensible ontological significance of SMED to the dominating illness explanation. CONCLUSION: SMEDs have similarities to mystical experiences, but integrating SMED into one's own life is challenging. We propose a philosophical, non-pathological interpretation of SMED derived from a novel perspective on mystical experience which may also have some therapeutic utility.

Consciousness in non-REM-parasomnia episodes.

Sleepwalking and related parasomnias are thought to result from incomplete awakenings out of non-rapid eye movement (non-REM) sleep. Non-REM parasomnia behaviours have been described as unconscious and automatic, or related to vivid, dream-like conscious experiences. Similarly, some observations have suggested that patients are unresponsive during episodes, while others that they can interact with their surroundings. To better grasp and characterise the full spectrum of consciousness and environmental (dis)connection associated with behavioural episodes, 35 adult patients with non-REM sleep parasomnias were interviewed in-depth about their experiences. The level of consciousness during parasomnia episodes was reported to be variable both within and between individuals, ranging from minimal or absent consciousness and largely automatic behaviours (frequently/always present in 36% of patients) to preserved conscious experiences characterised by delusional thinking to varying degrees of specificity (65%), often about impending danger, variably formed, uni- or multisensory hallucinations (53%), impaired insight (77%), negative emotions (75%), and variable, but often pronounced, amnesia (30%). Patients described their experiences as a dream scene during which they felt awake ("awake dreaming"). The surroundings were either realistically perceived, misinterpreted (in the form of perceptual illusions or misidentifications of people), or entirely hallucinated as a function of the prevailing delusion. These observations suggest that the level of consciousness, amnesia and sensory disconnection during non-REM parasomnia episodes is variable and graded. In their full-fledged expression, non-REM parasomnia experiences feature several core features of dreams. They therefore represent a valuable model for the study of consciousness, sleep-related sensory disconnection and dreaming.

Skin Deep: An Overlap of Delusions.

Delusional infestation (DI) describes a fixed, false belief where a person believes that they are infested with living or inanimate pathogens despite the absence of medical evidence for such infestation. Descriptions of alleged pathogens have evolved over time, incorporating inanimate objects such as fibrous strands. With the emergence of Morgellons disease and its controversy, we report a case of a 40-year-old female presenting with a strong belief of scabies infestation along with fibers emerging from her skin. Further, although insects are still the most alleged source of infestation, the overlap of Morgellons disease and the delusion of infestation supports it as a DI variant and questions the notion of its existence as a separate diagnostic entity.

The architecture of paranoia in the general population: A self-report and ecological momentary assessment study.

Paranoia is a common delusion type found in clinical and non-clinical populations. A hierarchical, dimensional model of paranoia in the general population has been proposed, with four categories representing increasing levels of paranoia: interpersonal sensitivity (IP), mistrust (M), ideas of reference (IR), persecutory ideas (PI). What is currently lacking and could provide insights into etiology is a comprehensive clinical characterization of the lower end of the paranoia spectrum, psychological domains that are associated with symptom severity, and how paranoia and its structure fluctuate over time. This study conducted both cross-sectional and longitudinal surveys with 802 participants from the German population assessing paranoia and general psychopathology. Data was collected through Ecological Momentary Assessment (EMA). Several statistical approaches were used including confirmatory factor analysis (CFA), latent class analysis (LCA) and mixed modelling analyses (ME). Paranoid experiences appear to be a common phenomenon that occur in people with and without mental illness. Subjects clustered into four paranoia severity subgroups (IP, M, IR, PI) and showed significant associations in various psychological domains like increased psychiatric symptoms and maladaptive coping. Paranoia fluctuates over time in all four severity subgroups, but the hierarchical subgrouping was stable. Both persecutory ideations and interpersonal sensitivity were significant predictors of paranoia. Findings provide important insights into the architecture of paranoia in the German population by characterizing their hierarchical, dimensional, and dynamic structure and its link to psychopathology.

Prevalence of psychotic symptoms in mild cognitive impairment: A systematic review and meta-analysis.

INTRODUCTION: Neuropsychiatric symptoms may impact prognosis in individuals with mild cognitive impairment (MCI); however, data on frequency of psychotic symptoms are sparse. METHODS: We searched MEDLINE, EMBASE, PsychoINFO from inception to June 2023. We included studies reporting patients with MCI prevalence of (delusions and/or hallucinations. Random effects model were performed to estimate the prevalence, and subgroup and meta-regression analyses were performed to explore heterogeneity. RESULTS: Of 3145 records identified, 36 studies were included, enrolling 20,426 patients. Overall prevalence of hallucinations was 1.78 % (95 % CI, 1.17 - 2.71) and delusions 3.84 % (95 % CI, 2.71 - 5.42), both with significant heterogeneity (/2 = 90 %). Prevalence of hallucinations and delusions were lower when measured by NPI scales and in population-based samples. DISCUSSION: Delusions and hallucinations occur in MCI patients at low rates. Prevalence can be partially explained by the assessment method, sample source and study heterogeneity.

A Rare Presentation of Delusional Parasitosis With Koro-Like Syndrome.

Delusional parasitosis (DP) with Koro-like syndrome poses a complex clinical challenge, demanding a comprehensive and empathetic approach from healthcare professionals. This exceptional combination of fixed beliefs about infestation and experiences of genital retraction can profoundly impact patients' well-being and daily functioning. The associated stigma and misconceptions further compound the difficulties faced by individuals struggling with these co-occurring conditions. Given the rarity of encountering both conditions simultaneously, navigating the diagnosis and treatment of delusional parasitosis with Koro-like syndrome requires a thorough understanding of its multifaceted nature. Embracing a holistic strategy encompassing psychoeducation, psychotherapy, and pharmacological interventions is essential for effectively addressing these dual conditions.

A Case Series of Delusional Infestation in Huntington's Disease.

 Huntington's disease (HD) is an autosomal dominant disorder that affects the basal ganglia, caused by CAG repeats in the huntingtin gene. Delusional infestation (DI) is a rare psychotic manifestation of the disease. This report presents two cases of HD patients with DI, both middle-aged females. The first patient achieved remission of DI with olanzapine, later cross-tapered to risperidone, but had spontaneous relapses. The second experienced gradual resolution of DI with risperidone in the setting of iron repletion and amantadine discontinuation, although her other psychotic symptoms remained. These cases shed light on an uncommon condition and may help guide understanding of the most effective treatment for it.

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.

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.

A Somatic-Type Delusional Disorder Resulted in Severe Weight Loss With a Body Mass Index of 10.2: A Case Report.

Weight loss is not uncommon in the field of psychiatry; however, when severe cases arise, it necessitates attention and thorough evaluation for accurate diagnosis and appropriate treatment. This report highlights the case of a 32-year-old man referred to psychiatry due to significant weight loss. The patient mentioned consuming small food portions, attributing it to an undetected stomach illness despite repeated investigations by previous treating doctors. His current weight stood at 31 kg, with a body mass index (BMI) of 10.2 kg/m². Physical examinations and laboratory investigations were otherwise within normal parameters. A somatic delusion was confirmed, and the patient has been diagnosed with a delusional disorder after excluding other possibilities. This report highlights the importance of considering delusional disorder (somatic type) as a potential diagnosis for substantial weight loss, and it records an unexpected degree of physical well-being despite a notably low BMI.

Psychosis in Neurodegenerative Dementias: A Systematic Comparative Review.

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

Methadone Withdrawal-Induced Psychosis: A Case Report.

Methadone is a synthetic full µ-opioid receptor agonist and N-methyl-D-aspartate antagonist given to patients who have recently stopped using illicit opioids or are tapering off chronic opioid pain medication. Maintenance treatment with methadone is today the most widespread and effective way to treat opiate addiction, which achieves abstinence, decreases morbidity and mortality, improves quality of life, and reduces crime genesis, among other benefits. It is also approved by the Food and Drug Administration for treating moderate-to-severe pain that remains unresponsive to nonopioid medications. Patients sometimes abruptly discontinue the medication for several reasons and sometimes suffer distressing but non-life-threatening withdrawal symptoms. More common withdrawal symptoms include anxiety, agitation, rhinorrhea, nausea, and vomiting, like other opioid agonist medications. Psychosis has been reported in some rare cases of methadone withdrawal. However, more research is required because, although psychotic symptoms have been described in different case reports after the reduction or withdrawal of methadone, they have not been sufficient. This case report contributes to the literature on rare manifestations of psychosis in patients who abruptly discontinue the use of methadone.

Neuroanatomical and neurocognitive correlates of delusion in Alzheimer's disease and mild cognitive impairment.

BACKGROUND: Neuropsychiatric symptoms and delusions are highly prevalent among people with dementia. However, multiple roots of neurobiological bases and shared neural basis of delusion and cognitive function remain to be characterized. By utilizing a fine-grained multivariable approach, we investigated distinct neuroanatomical correlates of delusion symptoms across a large population of dementing illnesses. METHODS: In this study, 750 older adults with mild cognitive impairment and Alzheimer's disease completed brain structural imaging and neuropsychological assessment. We utilized principal component analysis followed by varimax rotation to identify the distinct multivariate correlates of cortical thinning patterns. Five of the cognitive domains were assessed whether the general cognitive abilities mediate the association between cortical thickness and delusion. RESULTS: The result showed that distributed thickness patterns of temporal and ventral insular cortex (component 2), inferior and lateral prefrontal cortex (component 1), and somatosensory-visual cortex (component 5) showed negative correlations with delusions. Subsequent mediation analysis showed that component 1 and 2, which comprises inferior frontal, anterior insula, and superior temporal regional thickness accounted for delusion largely through lower cognitive functions. Specifically, executive control function assessed with the Trail Making Test mediated the relationship between two cortical thickness patterns and delusions. DISCUSSION: Our findings suggest that multiple distinct subsets of brain regions underlie the delusions among older adults with cognitive impairment. Moreover, a neural loss may affect the occurrence of delusion in dementia largely due to impaired general cognitive abilities.

Psychotic illness in people with Prader-Willi syndrome: a systematic review of clinical presentation, course and phenomenology.

BACKGROUND: Prader-Willi syndrome (PWS) is a rare and complex neurodevelopmental disorder resulting from absent paternal expression of maternally imprinted genes at chromosomal locus 15q11-13. This absence of expression occurs as a consequence of a deletion on the chromosome 15 of paternal origin (ca. 70%), a chromosome 15 maternal uniparental disomy (mUPD; ca. 25%), or an imprinting centre defect (IC; ca. 1-3%). At birth, individuals with PWS are severely hypotonic and fail to thrive. Hyperphagia and characteristic physical and neuropsychiatric phenotypes become apparent during childhood. The risk for the development of a co-morbid psychotic illness increases during the teenage years, specifically in those with PWS due to the presence of an mUPD. The primary aim of this literature review is to inform clinical practice. To achieve this, we have undertaken a systematic analysis of the clinical research literature on prevalence, presentation, course, characteristics, diagnosis and treatment of psychotic illness in people with PWS. The secondary aim is to identify clinical aspects of psychotic illness in PWS in need of further investigation. METHODS AND FINDINGS: A systematic literature review on psychosis in PWS was conducted on the databases Web of Knowledge, PubMed and Scopus, using the terms "((Prader-Willi syndrome) OR (Prader Willi Syndrome)) AND ((psychosis) OR (psychotic illness))". All articles written in English and reporting original human research were reviewed. In all but three of the 16 cohort studies in which the genetic types were known, the authors reported higher rates of psychosis in people with PWS resulting from an mUPD, compared to those with the deletion subtype of PWS. When psychosis was present the presentation was psychosis similar regardless of genetic type and was usually characterised by an acute onset of hallucinations and delusions accompanied by confusion, anxiety and motor symptoms. CONCLUSIONS: The onset of confusion, an affective cyclical pattern with the presence of abnormal mental beliefs and experiences, usually of rapid onset is suggestive of the development of psychotic illness. Phenomenologically, this psychosis in people with PWS is atypical in comparison to schizophrenia and bipolar disorder in the general population. The relationship to psychosis in the general population and the optimum treatments remain uncertain.

Koro: a socially-transmitted delusional belief.

INTRODUCTION: Koro is a delusion whereby a man believes his penis is shrinking into his abdomen and this may result in his death. This socially-transmitted non-neuropsychological delusional belief occurs (in epidemic form) in South-East and South Asia. We investigated whether the two-factor theory of delusion could be applied to epidemic Koro. METHODS: We scrutinised the literature on epidemic Koro to isolate features relevant to the two questions that must be answered to provide a two-factor account: What could initially prompt the Koro delusional hypothesis? Why is this hypothesis adopted as a belief? RESULTS: We concluded that the Koro hypothesis is usually prompted by the surprising observation of actual penis shrinkage-but only if the man has access to background beliefs about Koro. Whether the hypothesis is then adopted as a belief will depend on individual factors such as prior belief in the Koro concept or limited formal education and sociocultural factors such as deference to culture, to media, or to rumours spread by word of mouth. Social transmission can influence how the first factor works and how the second factor works. CONCLUSION: The two-factor theory of delusion can be applied to a socially-transmitted delusion that occurs in epidemic form.

Associations of conservatism and jumping to conclusions biases with aberrant salience and default mode network.

AIM: While conservatism bias refers to the human need for more evidence for decision-making than rational thinking expects, the jumping to conclusions (JTC) bias refers to the need for less evidence among individuals with schizophrenia/delusion compared to healthy people. Although the hippocampus-midbrain-striatal aberrant salience system and the salience, default mode (DMN), and frontoparietal networks ("triple networks") are implicated in delusion/schizophrenia pathophysiology, the associations between conservatism/JTC and these systems/networks are unclear. METHODS: Thirty-seven patients with schizophrenia and 33 healthy controls performed the beads task, with large and small numbers of bead draws to decision (DTD) indicating conservatism and JTC, respectively. We performed independent component analysis (ICA) of resting functional magnetic resonance imaging (fMRI) data. For systems/networks above, we investigated interactions between diagnosis and DTD, and main effects of DTD. We similarly applied ICA to structural and diffusion MRI to explore the associations between DTD and gray/white matter. RESULTS: We identified a significant main effect of DTD with functional connectivity between the striatum and DMN, which was negatively correlated with delusion severity in patients, indicating that the greater the anti-correlation between these networks, the stronger the JTC and delusion. We further observed the main effects of DTD on a gray matter network resembling the DMN, and a white matter network connecting the functional and gray matter networks (all P < 0.05, family-wise error [FWE] correction). Function and gray/white matter showed no significant interactions. CONCLUSION: Our results support the novel association of conservatism and JTC biases with aberrant salience and default brain mode.

Spontaneous Pneumomediastinum in a Middle-Aged Female Patient With Schizophrenia: A Case Report.

A middle-aged female patient with schizophrenia and osteoporosis presented to the emergency department with complaints of sore throat, neck pain, and dysphagia, which was identified as spontaneous pneumomediastinum (SPM) on chest CT. SPM has been reported in anorexia nervosa, but this is the first report of SPM in schizophrenia. In anorexia nervosa, an increase in intrathoracic pressure because of vomiting can cause positive pressure SPM, but this patient was considered to have negative pressure SPM because of decreased mediastinal pressure. In schizophrenia patients with unexplained chest pain, neck pain, and dysphagia, SPM should be considered a differential disease, and a chest CT scan is useful for diagnosis.

Case report: A case of anti-recoverin antibody-positive encephalitis exhibiting Cotard and Capgras delusions that was successfully treated with electroconvulsive therapy.

Recoverin is a neuron-specific calcium-binding protein that is mainly located in the retina and pineal gland. Few reports have described patients with anti-recoverin antibody-positive encephalitis, and no cases of psychosis associated with this encephalitis have been reported. We report a patient with anti-recoverin antibody-positive encephalitis with Cotard and Capgras delusions who was successfully treated with electroconvulsive therapy (ECT). The patient was a 25-year-old woman. She exhibited disorientation, executive function deficits, tremors in the upper limbs, generalized athetoid-like involuntary movements, hallucinations, incontinence, and fever, which led to her admission to our hospital. Upon admission, she complained of Cotard delusions. Various diagnostic tests, including cerebrospinal fluid analysis, antibody screening, and brain imaging, were unremarkable, except for positivity for serum anti-recoverin antibodies, non-specific general slowing on electroencephalography and decreased regional cerebral blood flow (rCBF) in the frontal and occipital lobes, and increased rCBF in the basal ganglia and pons on single-photon emission computed tomography. She was eventually diagnosed with encephalitis positive for anti-recoverin antibodies and treated with immunoglobulins and steroids. Her neurological symptoms improved temporarily, but three months later, psychiatric symptoms, i.e., suicidal thoughts and Cotard and Capgras delusions, were exaggerated. After ECT, her condition significantly improved. In conclusion, the present report suggests that pineal gland dysfunction due to anti-recoverin antibody or its cross-reactivity with neuron-specific calcium-binding proteins may contribute to the neuropsychiatric symptoms observed in anti-recoverin antibody-positive encephalitis and that ECT can be a viable treatment option if immunotherapy proves ineffective. Additionally, decreased rCBF in the prefrontal cortex may be associated with the clinical features of Capgras and Cotard delusions.