[A patient with Alice in Wonderland syndrome]. / Een patiënt met het Alice in Wonderland-syndroom.

We present the case of a 65-year-old man who was referred to the old-age department of our psychiatric hospital because of a depressed mood and inactivity. During his stay he exhibited a variety of peculiar visual perceptions and bodily experiences. We concluded that he suffered from a severe depressive disorder, as well as from symptoms that fitted largely into the clinical pattern of the Alice in Wonderland syndrome. In this case report we discuss the symptoms, etiology, and treatment options.

[Somatoparaphrenia in a patient with schizophrenia and addiction problems: 'That arm is not mine, doctor']. / Somatoparafrenie bij een patiënt met schizofrenie en verslavingsproblematiek: 'Die arm is niet van mij, dokter'.

Somatoparaphrenia is a disorder of body perception, usually on the left side. One or both limbs are seen as foreign or as belonging to somebody else. In the literature this rare phenomenon has been described in patients with brain damage, usually due to an infarction or other lesion to the right parietal lobe. We describe a patient with schizophrenia and addiction problems who believed that his left forearm was not his, but rather belonged to a Spanish girl. An EEG and an MRI of the brain showed no abnormalities. Despite years of antipsychotic treatment, the delusion persisted. To rule out neurological causes we recommend auxiliary investigations in all patients with somatoparaphrenia. No evidence-based treatments are known for this monothematic delusion in the context of schizophrenia.

[Optical illusions and the work of M.C. Escher]. / Optische illusies en het werk van M.C. Escher.

BACKGROUND: The name Maurits Escher is inextricably linked with the notion of 'optical illusion', a type of illusion evoked by his 'impossible figures'. Despite the sober style in which he realised these figures, they go on to mesmerise generations of art lovers. It is unclear what causes this, and whether other factors than aesthetic ones are involved.
AIM: To gain insight into the genesis of optical illusions in Escher's work, and in the role of the perceptual system in that process.
METHOD: An explorative literature search in PubMed, Science.gov, Google Scholar, and the historical literature.
RESULTS: Since 'impossible figures' cannot be found in our natural environment, and therefore have a high novelty factor to the brain, they inevitably draw our attention. The reason that we remain captivated, is at least partly associated with the fact that the hippocampus and parahippocampal place area come into conflict with each other, and (in vain) accept the challenge to find a 'best fit'.
CONCLUSION: Fundamental research may benefit from Escher's 'impossible figures' to fathom the rules of our visual grammar. The optical illusions they evoke moreover constitute an ongoing source of inspiration for other artists, architects, and film makers.

Musical hallucinations and their relation with epilepsy.

Musical hallucinations are poorly understood phenomena. Their relation with epilepsy was first described over a century ago, but never systematically explored. We, therefore, reviewed the literature, and assessed all descriptions of musical hallucinations attributed to epileptic activity. Our search yielded 191 articles, which together describe 983 unique patients, with 24 detailed descriptions of musical hallucinations related to epilepsy. We also describe six of our own patients. Based on the phenomenological descriptions and neurophysiological data, we distinguish four subgroups of epilepsy-related musical hallucination, comprising auras/ictal, inter-ictal and post-ictal phenomena, and phenomena related to brain stimulation. The case descriptions suggest that musical hallucinations in epilepsy can be conceptualised as lying on a continuum with other auditory hallucinations, including verbal auditory hallucinations, and-notably-tinnitus. To account for the underlying mechanism we propose a Bayesian model involving top-down and bottom-up prediction errors within the auditory network that incorporates findings from EEG and MEG studies. An analysis of phenomenological characteristics, pharmacological triggers, and treatment effects suggests wider ramifications for understanding musical hallucinations. We, therefore, conclude that musical hallucinations in epilepsy open a window to understanding these phenomena in a variety of conditions.

[Brua and psychiatry: A pilot study among Dutch-Antillean patients in the Netherlands]. / Brua en psychiatrie: een pilotstudie onder patiënten in Nederland afkomstig van de voormalige Nederlandse Antillen.

BACKGROUND: Individuals native to Aruba, Bonaire, and Curaçao, the abc islands of the former Netherlands Antilles, often attribute their complaints to brua, although they seldom discuss this with health professionals. This may have a negative influence on the therapeutic relationship and diagnostic processes.
AIM: To explore the role of brua in the illness perception of psychiatric patients in the Netherlands who were originally from the abc islands.
METHOD: A random sample of patients under treatment at Parnassia Psychiatric Institute in The Hague were interviewed with the aid of a semi-structured questionnaire.
RESULTS: Of the 18 psychiatric patients interviewed, 10 (56%) believed in brua, and 3 (17%) considered it the cause of their disease. Although none of the interviewees admitted to an active involvement in brua, 8 (44%) had been in touch with a traditional healer and 9 (50%) possessed artifacts meant to provide protection against evil. Regarding the usefulness of discussing brua with health professionals, opinions were divided.
CONCLUSION: Psychiatric patients in the Netherlands native to the abc islands are all knowledgeable of brua, with more than half of them believing in it. Despite the fear and shame that people often experience, making brua fit for discussion in clinical practice would improve the relationship between health professional and patient, yielding further opportunities for diagnosis and treatment.

[Hallucinations and art]. / Hallucinaties en kunst1.

BACKGROUND Hallucinations and art appear to be inextricably connected, and yet the question remains in how far artists make use of hallucinations for their work in daily practice.
AIM: To chart the ways in which the fine arts are influenced by hallucinations, an explorative literature search was carried out. METHOD The search was carried out in PubMed, Google, and the historical literature.
RESULTS: Some famous examples of artists who drew on hallucinations for their work, are Hildegard of Bingen, William Blake, and Yayoi Kusama. Especially among the surrealists, we also find indications of the use of pareidolias, metamorphopsias, and other positive disorders of visual perception.
CONCLUSION: In the art literature, the term hallucination is often used in a broader sense than in medicine. As a consequence, the suggestion that hallucinations would be lying at the basis of many works of art cannot be confirmed, even though some spectacular examples can certainly be pointed out.

Auditory hallucinations, not necessarily a hallmark of psychotic disorder.

Auditory hallucinations (AH) are often considered a sign of a psychotic disorder. This is promoted by the DSM-5 category of Other Specified Schizophrenia Spectrum And Other Psychotic Disorder (OSSSOPD), the diagnostic criteria for which are fulfilled with the sole presence of persistent AH, in the absence of any other psychotic symptoms. And yet, persistent AH are not synonymous with having a psychotic disorder, and should therefore not be uncritically treated as such. Many people who seek treatment for persistent AH have no other psychotic symptoms, have preserved reality-testing capacities, and will never develop a schizophrenia spectrum disorder. Instead, hallucinations may be the result of many different causes, including borderline personality disorder, post-traumatic stress disorder (PTSD), hearing loss, sleep disorders or brain lesions, and they may even occur outside the context of any demonstrable pathology. In such cases, the usage of the DSM-5 diagnosis of OSSSOPD would be incorrect, and it may prompt unwarranted treatment with antipsychotic medication. We therefore argue that a DSM-5 diagnosis of Schizophrenia Spectrum Disorder (or any other type of psychotic disorder) characterized by AH should require at least one more symptom listed under the A-criterion (i.e. delusions, disorganized speech, disorganized or catatonic behavior or negative symptoms). Adhering to these more stringent criteria may help to distinguish between individuals with persistent AH which are part of a psychotic disorder, for whom antipsychotic medication may be helpful, and individuals with AH in the absence of such a disorder who may benefit from other approaches (e.g. different pharmacological interventions, improving coping style, trauma-related therapy).

Suicidality and hospitalisation in patients with borderline personality disorder who experience auditory verbal hallucinations.

BACKGROUND: In patients with borderline personality disorder (BPD), about 22-50% experience auditory verbal hallucinations (AVH). However, the impact of these hallucinations on suicidal ideation, suicide attempts, crisis-service interventions, and hospital admissions is unknown. METHODS: In a cross-sectional design, data were collected with the Psychotic Symptom Rating Scales (PSYRATS) and the MINI International Neuropsychiatric Interview Plus, as well as from the medical records of a convenience sample of outpatients fulfilling the DSM-IV criteria for BPD. RESULTS: Of the 89 included patients, 27 experienced AVH. In the latter group, the presence of AVH was associated with a significantly higher incidence of suicidal plans and attempts in the month prior to study participation, more hospitalisations, and a shorter interval until hospitalisation. All subscales of the PSYRATS correlated positively with suicide plans, while the phenomenological and emotional subscales also correlated positively with suicide attempts. Moreover, higher scores on the emotional subscale were associated with more hospital admissions. CONCLUSIONS: AVH experienced by patients with BPD might constitute a risk factor for suicide plans and attempts, and hospitalisation. This finding emphasises that this population requires adequate clinical attention, as well as effective treatment for AVH.

[Red tape in psychiatry: on bureaucracy, bureaucratism, and our secret fondness for procedures]. / De paarse krokodil in de psychiatrie: over bureaucratie, bureaucratisme en onze heimelijke liefde voor procedures.

BACKGROUND: A frequent complaint in psychiatry is that the psychiatrist-patient relationship and the quality of care are hampered by bureaucratic processes. AIM: To provide an analysis of various types of bureaucracy in psychiatry that can serve as a starting-point for the improvement of care and the performance of qualitative studies. METHOD: We conducted an exploratory study using PubMed, Google, and various Dutch medical journals. RESULTS: Contemporary psychiatry is characterised by a bureaucratic organization structure. Mental, somatic, and social problems are translated in a standardised manner into medical jargon which gives rise to a DSM diagnosis, a cost-price, and outcome measures. This medical-bureaucratic system has important virtues, provided it is applied efficiently and the patient-psychiatrist relationship remains intact. In the Netherlands, however, this balance has been disturbed. Future research can be facilitated if distinctions are made between various types of bureaucracy (referred to here as Hippocratic, Weberian, and Kafkaesque bureaucracy). In addition, we discuss various national initiatives which aim to counter bureaucracy, including initiatives of the Dutch government. CONCLUSION: If the patient-psychiatrist relationship is to regain its central role, bureaucracy needs to be countered constantly. The government can facilitate this process, but healthcare providers can also play a key role and meanwhile help to bring about a substantial reduction in the costs of care.

[The Alice in Wonderland syndrome. What do we know after 60 years?]. / Het Alice in Wonderland-syndroom; wat weten wij na 60 jaar?

BACKGROUND: The Alice in Wonderland syndrome (AIWS) was conceptualised in 1955 as a group of distortions of visual perception, the body schema and the experience of time. Although 60 years have passed since then, very little is known yet about the syndrome. This is surprising since the AIWS has important diagnostic and therapeutic implications. AIM: To provide an overview of the literature on the AIWS. METHOD: For this review, a literature search was carried out in PubMed and the historical literature. RESULTS: The search yielded 70 papers with a total of 169 case descriptions. As these papers indicate, the AIWS has many causes, the main ones being neurological, infectious and substance-related; sometimes the causes are psychiatric. Among adults and elderly patients the disorders described are mainly neurological; among young people encephalitis is fairly common. Treatment needs to be directed at the (assumed) underlying condition, although in almost half of the cases the patient's main requirement is reassurance rather than treatment. Prevalence rates are unknown, but studies in the general population indicate that the symptoms of the AIWS occur more frequently than previously assumed. CONCLUSION: Clinical suspicion of an AIWS warrants careful auxiliary investigations and - whenever necessary - treatment. The AIWS should not be confused with schizophrenia spectrum disorders and other perceptual disorders, and it deserves to be included in the research agenda of international classifications such as the DSM and ICD.

[Auditory verbal hallucinations in patients with borderline personality disorder]. / Auditieve verbale hallucinaties bij patiënten met een borderline-persoonlijkheidsstoornis.

BACKGROUND: Traditionally, auditory verbal hallucinations (AVH) experienced by patients with a borderline personality disorder (BPD) are considered to be rare, to have a 'pseudo'-quality, and to cause little distress. AIM: To provide an overview of studies of the prevalence and phenomenological characteristics of AVHs in patients with a BPD, and of the ensuing degree of suffering. METHOD: We performed a systematic literature search using PubMed and the Ovid database. RESULTS: 27% of patients with a BPD experience AVH. Phenomenologically, these percepts are indistinguishable from those experienced by patients with a schizophrenia spectrum disorder. Hallucinations in several modalities were present in 50% of the patients with BPD. The mean time-span in which AVH were experienced was 17 years, the mean frequency was several minutes per day. The degree of suffering was high and the patient's life was interrupted to a moderate degree. CONCLUSION: AVH and other hallucinations are common in BPD. We advise clinicians to inquire directly whether patients experience them and to provide treatment whenever possible. However, one of the problems is, that evidence-based treatment methods such as antipsychotics, cognitive-behavioural therapy and transcranial magnetic stimulation have not yet been studied systematically for this specific patient group.

[The delusion of world catastrophe. Is this classic symptom still relevant today?]. / De wereldondergangswaan; een klassiek symptoom met actuele relevantie?

BACKGROUND: The delusion of world catastrophe was conceptualised by classic authors such as Jaspers and Conrad as a specific expression of acute psychosis that deserved special attention in psychiatric diagnosis. We need to find out whether this approach is still relevant today. AIM: To provide an overview of the literature about the delusion of world catastrophe. METHOD: The literature was searched and historical literature was also consulted. RESULTS: A patient's delusion of world catastrophe often begins with a phase known as the 'Wahnstimmung' which may be accompanied by subtle positive disorders of perception. This is followed by frank psychosis, with hallucinations, formal thought disorders, and, in exceptional cases, can lead to suicidality and/or homicidality. Prevalence rates derived from populations of patients diagnosed with a schizophrenia spectrum disorder vary from 1% to 8%, with a single outlier of 63.5%. Wetzel was the first to conceptualise the delusion of world catastrophe as an attempt of the brain to make sense of a world on which it had lost its grip due to the psychotic process. The link Wetzel established between subtle disorders of perception and possible organic causes is still relevant today. CONCLUSION: Patients who are beginning to have delusions of world catastrophe deserve not only to get an early diagnosis of the neurobiological correlates of their perceptual disorders, but also to receive adequate treatment for their psychosis.

Musical hallucinations: review of treatment effects.

BACKGROUND: Despite an increased scientific interest in musical hallucinations over the past 25 years, treatment protocols are still lacking. This may well be due to the fact that musical hallucinations have multiple causes, and that published cases are relatively rare. OBJECTIVE: To review the effects of published treatment methods for musical hallucinations. METHODS: A literature search yielded 175 articles discussing a total number of 516 cases, of which 147 articles discussed treatment in 276 individuals. We analyzed the treatment results in relation to the etiological factor considered responsible for the mediation of the musical hallucinations, i.e., idiopathic/hypoacusis, psychiatric disorder, brain lesion, and other pathology, epilepsy or intoxication/pharmacology. RESULTS: Musical hallucinations can disappear without intervention. When hallucinations are bearable, patients can be reassured without any other treatment. However, in other patients musical hallucinations are so disturbing that treatment is indicated. Distinct etiological groups appear to respond differently to treatment. In the hypoacusis group, treating the hearing impairment can yield significant improvement and coping strategies (e.g., more acoustic stimulation) are frequently helpful. Pharmacological treatment methods can also be successful, with antidepressants being possibly more helpful than antiepileptics (which are still better than antipsychotics). The limited use of acetylcholinesterase inhibitors has looked promising. Musical hallucinations occurring as part of a psychiatric disorder tend to respond well to psychopharmacological treatments targeting the underlying disorder. Musical hallucinations experienced in the context of brain injuries and epilepsy tend to respond well to antiepileptics, but their natural course is often benign, irrespective of any pharmacological treatment. When intoxication/pharmacology is the main etiological factor, it is important to stop or switch the causative substance or medication. CONCLUSION: Treatments for musical hallucinations tend to yield favorable results when they target the main etiological factor of these phenomena. There is a need to establish the natural course of musical hallucinations, their response to non-pharmacological treatments, and their effects on the patient's quality of life. There is also a need to standardize the assessment of treatment responses, and document long-term follow up.

[Brua as an explanatory model for diseases]. / Brua als verklaringsmodel voor ziekten.

A 26-year-old woman from the island of Aruba who had been living in the Netherlands for ten years felt she was misunderstood by the various health professionals she had consulted because of her fear that she was being poisoned and would soon die. Due to her background en her belief in brua, she attributed her symptoms and her illness to 'voodoo', allegedly practiced by members of her husband's family in connection with relationship problems. A culture-sensitive approach to the patient, along with thorough psychiatric and neurological tests, yielded a surprising result. Our findings emphasise how important it is for us as health professionals to acquaint ourselves with explanatory models of the diseases of our patients, and how vital it is for us to be aware of a patient's background, particularly if the patient is of foreign descent.

[The incubus phenomenon: A sleep-related condition, not to be confused with psychosis]. / Het incubusfenomeen: een slaapgerelateerde stoornis, niet te verwarren met psychose.

BACKGROUND: The incubus phenomenon is a paroxysmal condition characterised by sleep paralysis coinciding with a sensed presence and the frightening sensation that something or somebody is exerting pressure on the thorax. AIM: To present an overview of the literature on the incubus phenomenon and to provide practical advice regarding diagnosis and treatment. METHOD: To obtain information for our paper we carried out a search in PubMed and the historical literature. RESULTS: The incubus phenomenon is a relatively unknown condition, even though, world-wide, it has a lifetime prevalence rate of 30% in the general population. The prevalence is even higher among students, psychiatric patients and patients with narcolepsy. It is attributed to a dissociation of the rem sleep phase and the subsequent intrusion of endogenously mediated percepts. The condition rarely requires treatment because it is self-limiting, and generally occurs only once in a lifetime. Repeated attacks, however, may warrant additional diagnostic testing with the aid of polysomnography and may require treatment with anxiolytics, antidepressants, anticholinergics or anti-epileptics. CONCLUSION: The incubus phenomenon is an intrusive condition, but, as far as we currently know, it is benign. Nevertheless, it is important that the condition is recognised and not confused with a psychotic disorder or any other type of severe mental illness. When necessary, it should be treated lege artis.

[Synesthesias in the context of hallucinogen-induced persistent perception disorder following the use of lsd]. / Synesthesieën in het kader van de persisterende waarnemingsstoornis door hallucinogenen na gebruik van lsd.

The hallucinogen-induced persistent perception disorder (hppd) is a disturbing complication resulting from the use of hallucinogens. We report on a case-study in which an artist suffering from visual, auditory and olfactory hallucinations also experienced chromatic-phonemic synesthesias that had persisted for two years after he had stopped using lysergic acid diethylamide (lsd). The case described demonstrates that individuals suffering from hppd can also experience synesthesias that may in fact differ phenomenologically from 'coloured hearing', which is a symptom known to occur in the context of substance abuse.

[Treatment strategies for auditory verbal hallucinations]. / Behandelmogelijkheden voor auditieve verbale hallucinaties.

BACKGROUND: Auditory verbal hallucinations (AVH) are experienced not only by patients diagnosed with schizophrenia, but also by patients with other disorders (some of which may be psychiatric) and in the general population. The ensuing affliction may be severe and can sometimes result in dangerous behaviour. Although various treatment options are available for AVH, only a few have been investigated in randomised placebo-controlled trials. AIM: To provide an overview of the literature relating to the effectiveness of antipsychotics, cognitive-behavioural therapy (CBT), electroconvulsive therapy (ect), and transcranial magnetic stimulation (TMS) in the treatment of avh. METHOD: This review paper is based on the Ph.D. study of the first author; in addition, a literature search was carried out using PubMed. RESULTS: Antipsychotics have never been studied specifically with regard to their effect on AVH, but they are known to lead to a significant decrease in the severity and frequency of hallucinations in general. cbt can reduce the torment caused by AVH, but not the severity or frequency. ect can be helpful in the treatment of drug-resistant psychosis, but it has never been studied specifically with regard to its effect on avh or on other types of hallucinations. tms is effective for the treatment of drug-resistant AVH, but in the cases where it has been used so far, the beneficial effects seem to have been of limited duration. CONCLUSION: Very few of the available treatment strategies have been used specifically to relieve the distress caused by avh. tms and cbt have proved reasonably effective, but there is a need for further research into additional treatment strategies, particularly into those involving TMS.

[Copy number variations and 'schizophrenia']. / Copynumbervariaties en 'schizofrenie'

BACKGROUND: Copy number variations (CNVs) are subtle variations in our genetic material. In view of the scientific claim that schizophrenia depends for 40 to 80% on hereditary factors, we need to find out what role the cnvs play in this process. AIM: To provide an overview of what is currently known about CNVs and to summarise the implications of this information for the conceptualisation of 'schizophrenia' and for the diagnosis and treatment of psychoses. METHOD: We performed a literature search using PubMed. RESULTS: The literature consulted contains discussions of 23 CNVs that are associated with an increased risk of psychosis. However, the relationship between the two variables is heterogeneous and pluriform in the sense that CNVs are often associated with several disorders or their penetrance varies considerably under the influence of gene modifiers and environmental factors. CONCLUSION: Research into CNVs demonstrates that the relationship between psychosis and heredity is of a even more subtle nature than the two pioneers Kraepelin and Rüdin had been able to foresee. It is to be expected that in the near future research will contribute to a deconstruction of the schizophrenia concept, to a blurring of the hitherto sharply defined boundaries between different (particularly severe) mental disorders and to the introduction of genetic counselling into regular psychiatric diagnostic procedures.

[Mitigated presentation of the neuroleptic malignant syndrome]. / Gemitigeerd beeld van het maligne antipsychoticasyndroom.

In clinical practice it can be difficult to distinguish between catatonia and the neuroleptic malignant syndrome (NMS). A female patient with an intellectual disability was treated in hospital with the help of risperidon because of conduct disorders. A few months later readmission followed with an NMS, which was initially interpreted as catatonia because of its mitigated nature, and its appearance several days after the cessation of the antipsychotic medication. On the basis of this case description, we discuss the clinical picture of the nms and its overlap with catatonia.

[Psychiatry and brua]. / Psychiatrie en brua.

BACKGROUND: Patients from Aruba, Bonaire and Curacao are often inclined to attribute mental problems to brua, the Dutch-Antillean counterpart of voodoo. Because little is known about brua and patients are usually reluctant to talk about it, problems can arise in the communication with biomedically trained health practitioners. AIM: To provide an overview of the literature on brua, and of the ways in which brua may interfere with the diagnosis and treatment of Dutch-Antillean patients with mental health problems. METHOD: We searched the literature via PubMed and Embase (up to October 2012) and the historical literature (from 1880 onwards) written in Dutch, English, French, Spanish, and Papiamento. RESULTS: Brua has its origins in folk medicine and magico-religious rituals, which are regarded both as the cause of and a cure for mental illness. Although Antillean patients generally turn to medically trained professionals when they are confronted with medical problems, they often rely on brua medicine when they face either simpler problems, or problems for which Western medicine cannot provide a solution. CONCLUSION: On the basis of the literature, the area of tension between the Western approach to medicine and the brua approach seems to be insignificant, except perhaps in cases where hallucinogens or other psycho-active substances complicate the clinical picture and in cases where the patient's fear for sorcery dominates clinical symptomatology.