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

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

Tracing the Roots of Dementia Praecox: The Emergence of Verrücktheit as a Primary Delusional-Hallucinatory Psychosis in German Psychiatry From 1860 to 1880.

While the roots of mania and melancholia can be traced to the 18th century and earlier, we have no such long historical narrative for dementia praecox (DP). I, here, provide part of that history, beginning with Kraepelin's chapter on Verrücktheit for his 1883 first edition textbook, which, over the ensuing 5 editions, evolved into Kraepelin's mature concepts of paranoia and paranoid DP. That chapter had 5 references published from 1865 to 1879 when delusional-hallucinatory syndromes in Germany were largely understood as secondary syndromes arising from prior episodes of melancholia and mania in the course of a unitary psychosis. Each paper challenged that view supporting a primary Verrücktheit as a disorder that should exist alongside mania and melancholia. The later authors utilized faculty psychology, noting that primary Verrücktheit resulted from a fundamental disorder of thought or cognition. In particular, they argued that, while delusions in mania and melancholia were secondary, arising from primary mood changes, in Verrücktheit, delusions were primary with observed changes in mood resulting from, and not causing, the delusions. In addition to faculty psychology, these nosologic changes were based on the common-sense concept of understandability that permitted clinicians to distinguish individuals in which delusions emerged from mood changes and mood changes from delusions. The rise of primary Verrücktheit in German psychiatry in the 1860-1870s created a nosologic space for primary psychotic illness. From 1883 to 1899, Kraepelin moved into this space filling it with his mature diagnoses of paranoia and paranoid DP, our modern-day paranoid schizophrenia.

Capgras and Fregoli syndromes: delusion and misidentification.

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

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

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

Uncommon and/or bizarre features of dementia. Part II.

In the past decades, clinicians have recognized that dementia may appear as atypical or variant syndromes, as well as the typical form. This study aimed at describing uncommon or bizarre symptoms/syndromes observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published before 2017. Search terms used included delusional jealousy, delusion of pregnancy, dementia, erotomania, folie à deux, and lycanthropy. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms/syndromes were described as case reports and there were no systematic investigations.

Pharmacotherapy for primary delusional jealousy, a retrospective observational study of 32 cases with Othello syndrome.

To determine whether primary delusional jealousy can be treated effectively with antipsychotics or antidepressants, and whether any clinical variables are associated with response to pharmacotherapy, we carried out a retrospective case series observational study by reviewing clinical records of patients with an International Classification of Disease, 9th ed., diagnostic code of 297 (delusional disorders) who were treated at the Department of Psychiatry of a university affiliated hospital from January 2010 to December 2015. Only those records showing obvious delusional jealousy not secondary to other medical conditions, dementia, or schizophrenia were scrutinized thoroughly with respect to types of pharmacotherapy, treatment response, and other demographic and clinical variables likely to be associated with clinical outcomes. All except one of 32 patients, 16 men and 16 women, between 37 and 79 (60.9±10.6) years of age, were treated with low-dose antipsychotics. The general response was favorable as 19 (59.4%) were rated as good and 13 as inadequate responders (seven partial and six limited). Compared with antipsychotic monotherapy, concomitant therapy with antidepressants had a higher rate of good response, although statistically insignificant (75 vs. 53%, P=0.21). Younger age (P=0.01) and presentation at the index visit with their suspected unfaithful spouse were associated with a good response (P=0.036); comorbidity with delusions other than the jealous type was associated with a poor response (P=0.006). The overall outcome for delusional jealousy looks promising if the patients can accept pharmacotherapy in an outpatient setting.

De Clérambault Syndrome, Othello Syndrome, Folie à Deux and Variants.

Non-bizarre delusion, defined as a false belief possible although highly unlikely, is the main manifestation of delusional disorders, previously known as paranoia. Based on the predominant delusional themes, 5 main subtypes may be described - erotomanic, grandiose, jealous, persecutory, and somatic. We present here 2 main delusional disorders, the De Clérambault syndrome and the Othello syndrome, and another closely related to the previous ones - Folie à deux. In the De Clérambault syndrome, the main delusional theme is erotomanic type, related to passional delirium where the patient has strong sexual feelings towards another person and has the belief that this other person is deeply in love with him or her. Patients with the Othello syndrome present a delusional disorder of jealous type, a pathological delusion that the partner is unfaithful. In Folie à deux, 2 individuals shared the same psychiatric symptom. However it may be variable, describing variants such as folie imposée or folie simultenée. The risk of aggressive behavior exists in these patients. Knowledge of these syndromes is essential to allow an accurate diagnosis and prompt treatment.

Transdiagnostic Extension of Delusions: Schizophrenia and Beyond.

Delusion is central to the conceptualization, definition, and identification of schizophrenia. However, in current classifications, the presence of delusions is neither necessary nor sufficient for the diagnosis of schizophrenia, nor is it sufficient to exclude the diagnosis of some other psychiatric conditions. Partly as a consequence of these classification rules, it is possible for delusions to exist transdiagnostically. In this article, we evaluate the extent to which this happens, and in what ways the characteristics of delusions vary according to diagnostic context. We were able to examine their presence and form in delusional disorder, affective disorder, obsessive-compulsive disorder, borderline personality disorder, and dementia, in all of which they have an appreciable presence. There is some evidence that the mechanisms of delusion formation are, at least to an extent, shared across these disorders. This transdiagnostic extension of delusions is an argument for targeting them therapeutically in their own right. However there is a dearth of research to enable the rational transdiagnostic deployment of either pharmacological or psychological treatments.

Do paranoid delusions exist on a continuum with subclinical paranoia? A multi-method taxometric study.

BACKGROUND: There is widespread interest in whether psychosis exists on a continuum with healthy functioning. Previous research has implied that paranoia, a common symptom of psychosis, exists on a continuum but this has not been investigated using samples including both patients and non-patients and up-to-date taxometric methods. AIM: To assess the latent structure of paranoia in a diverse sample using taxometric methods. METHOD: We obtained data from 2836 participants, including the general population as well as at-risk mental state and psychotic patients using the P-scale of the Paranoia and Deservedness Scale. Data were analysed using three taxometric procedures, MAMBAC, MAXEIG and L-MODE (Ruscio, 2016), and two sets of paranoia indicators (subscales and selected items from the P scale), including and excluding the patient groups. RESULTS: Eleven of the twelve analyses supported a dimensional model. Using the full sample and subscales as indicators, the MAMBAC analysis was ambiguous. Overall, the findings converged on a dimensional latent structure. CONCLUSIONS: A dimensional latent structure of paranoia implies that the processes involved in sub-clinical paranoia may be similar to those in clinical paranoia.

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

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

The Perseverative Thinking Questionnaire in Patients with Persecutory Delusions.

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

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

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

Delusion-like experiences in older people with anxiety disorders.

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

The epistemic innocence of motivated delusions.

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

The Fregoli delusion: a disorder of person identification and tracking.

Fregoli delusion is the mistaken belief that some person currently present in the deluded person's environment (typically a stranger) is a familiar person in disguise. The stranger is believed to be psychologically identical to this known person (who is not present) even though the deluded person perceives the physical appearance of the stranger as being different from the known person's typical appearance. To gain a deeper understanding of this contradictory error in the normal system for tracking and identifying known persons, we conducted a detailed survey of all the Fregoli cases reported in the literature since the seminal Courbon and Fail (1927) paper. Our preliminary reading of these cases revealed a notable lack of definitional clarity. So, we first formulated a classification scheme of different person misidentification delusions so as to identify those cases that qualified as instances of Fregoli according to the above characterization: the mistaken belief that a known person is present in the environment in a different guise to his or her typical appearance. We identified 38 clear cases of this type and set out to answer a series of questions motivated by current hypotheses about the origin of the Fregoli delusion. We asked whether the patients misidentified particular strangers, made reference to the misidentified known persons using wigs or plastic surgery (or other techniques to disguise their appearance), misidentified many different strangers or only one, showed other symptoms (in particular, other misidentification delusions), and made inferences about the motives of the known persons in disguise. We conclude by discussing the implications of our findings for current hypotheses concerning the origin of the Fregoli delusion.

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

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

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

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