33. Hallucinations/disordered thinking Perceptual disturbance Perception = process of making sense of physical information we receive with our 5 senses Illusion = misconception of a real external stimuli e.g. dressing gown on door in dark room looks like a stranger Pseudohallucination = perception in subjective inner space where patient knows the perception is false Hallucination = perceptions occurring in the absence of an external stimuli in the objective outer space Visual hallucinations – causes: commonly in organic conditions e.g. delirium, dementia, epilepsy; as well as LSD, alcoholic hallucinosis. Charles Bonnet = pts experience complex visual hallucinations assoc with no other psychiatric symtoms, usually in elderly Hypnagogic hallucination = false perceptions that occur going to sleep (normal) Hypnopompic hallucination = false perceptions occur as a person wakes (normal) Auditory hallucinations – Audible thoughts (first person) – patients hear their own thoughts spoken out loud Second person – patients hear a voice talking directly to them; assoc with mood disorders Third person – patients hear voices talking about them Olfactory – false perceptions of smell and taste – rule out epilepsy Somatic – hallucinations of bodily sensations – superficial (tactile, thermal, hygric), visceral and kinaesthetic Thought disturbance Overvalued idea = plausible belief that a patient becomes preoccupied with to an unreasonable extent; which causes considerable distress to pt. e.g. anorexia nervosa Delusion = an unshakable false belief that is not accepted by other members of the patients culture Delusions are categorized into four different groups: Bizarre delusion: A delusion that is very strange and completely implausible; an example of a bizarre delusion would be that aliens have removed the affected person's brain. Non-bizarre delusion: A delusion that, though false, is at least possible, e.g., the affected person mistakenly believes that he is under constant police surveillance. Mood-congruent delusion: Any delusion with content consistent with either a depressive or manic state, e.g., a depressed person believes that news anchors on television highly disapprove of him, or a person in a manic state might believe he is a powerful deity. Mood-neutral delusion: A delusion that does not relate to the sufferer's emotional state; for example, a belief that an extra limb is growing out of the back of one's head is neutral to either depression or mania. In addition to these categories, delusions often manifest according to a consistent theme. Although delusions can have any theme, certain themes are more common. Some of the more common delusion themes are: Delusion of control: This is a false belief that another person, group of people, or external force controls one's thoughts, feelings, impulses, or behavior. Nihilistic delusion: This is a false belief that one does not exist or has become deceased. Delusional jealousy (or delusion of infidelity): A person with this delusion falsely believes a spouse or lover is having an affair. Delusion of reference: The person falsely believes that insignificant remarks, events, or objects in one's environment have personal meaning or significance. Erotomania A delusion where someone believes another person is in love with them. Grandiose delusion: An individual is convinced he has special powers, talents, or abilities. Sometimes, the individual may actually believe he or she is a famous person or character (for example, Napoleon). Persecutory delusion: These are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or obstructed in the pursuit of goals. Religious delusion: Any delusion with a religious or spiritual content. These may be combined with other delusions, such as grandiose delusions (the belief that the affected person is a god, or chosen to act as a god, for example). Somatic delusion: A delusion whose content pertains to bodily functioning, bodily sensations, or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal, or changed—for example, belief that ones bowels are rotting. Delusions of parasitosis (DOP) or delusional parasitosis: a delusion in which one feels infested with an insect, bacteria, mite, spiders, lice, fleas, worms, or other organisms. Affected individuals may also report being repeatedly bitten. In some cases, entomologists are asked to investigate cases of mysterious bites. Sometimes physical manifestations may occur including skin lesions. Delusions of Control (1st rank schizophrenia symptoms) – false belief that ones thoughts, feelings, actions or impulses and controlled or “made” by an external agency – thought insertion, thought withdrawal and thought broadcasting Disorganised thinking Thought Blocking – Interruption of train of speech before completion. e.g. "Am I early?" "No, you're just about on..."(silence) Circumstantiality – Speech that is highly detailed and very delayed at reaching its goal. Can be normal Clanging – Sounds, rather than meaningful relationships, appear to govern words or topics. Excessive rhyming, and/or alliteration. e.g. "Many moldy mushrooms merge out of the mildewy mud on Mondays." "I heard the bell. Well, hell, then I fell." Derailment (also Loose Association and Knight's Move thinking) – Ideas slip off the topic's track on to another which is obliquely related or unrelated. e.g. "The next day when I'd be going out you know, I took control, like uh, I put bleach on my hair in California." Echolalia – Echoing of one's or other people's speech that may only be committed once, or may be continuous in repetition. This may involve repeating only the last few words or last word of the examiner's sentences. This can be a symptom of Tourette's Syndrome. e.g. "What would you like for dinner?", "That's a good question. That's a good question. That's a good question. That's a good question." Flight of Ideas – A sequence of loose associations or extreme tangentiality where the speaker goes quickly from one idea to another seemingly unrelated idea. To the listener, the ideas seem unrelated and do not seem to repeat. Often pressured speech is also present. e.g. "I own five cigars. I've been to Havana. She rose out of the water, in a bikini." Word salad – Speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish Neologisms – New word formations. These may also involve elisions of two words that are similar in meaning or in sound. e.g. "I got so angry I picked up a dish and threw it at the geshinker." Perseveration – Persistent repetition of words or ideas. e.g. "It's great to be here in Nevada, Nevada, Nevada, Nevada, Nevada." This may also involve repeatedly giving the same answer to different questions. e.g. "Is your name Mary?" "Yes." "Are you in the hospital?" "Yes." "Are you a table?" "Yes." Perseveration can include palilalia and logoclonia and is often an indication of organic brain disease such as Parkinson's. Pressure of speech – An increase in the amount of spontaneous speech compared to what is considered customary. This may also include an increase in the rate of speech. Alternatively it may be difficult to interrupt the speaker; the speaker may continue speaking even when a direct question is asked. Tangentiality – Replying to questions in an oblique, tangential or irrelevant manner. e.g.: Q: "What city are you from?" A: "Well, that's a hard question. I'm from Iowa. I really don't know where my relatives came from, so I don't know if I'm Irish or French." Differential diagnosis of the psychotic patient 1. schizophrenia 2. schizoaffective disorder 3. delusional disorder 4. affective disorders 5. delirium and dementia 6. personality disorder Schizophrenia 4 types: 1. paranoid – dominated by delusions and hallucinations 2. hebephrenic – disorganised thoughts, disturbed behaviour, inappropriate flat affect – early onset (15-25years) and poor prognosis 3. Catatonic – rare in developed countries 4. Residual – 1 year of predominately negative symptoms but preceded by 1 psychotic episode Incidence: 15-20 / 100k; M=F; peak incidence teensearly adulthood. First rank symptoms Auditory hallucinations in 3rd person or a running commentary Somatic hallucinations Thought beliefs: thought insertion, withdrawal, broadcast, hears thoughts spoken aloud Delusional perception. Passivity phenomena (feeling of actions being controlled) Not first rank but diagnostically useful: Delusions of persecution / grandeur Ideas of reference 2nd person auditory hallucinations Chronic phase schizophrenia (negative symptoms) Apathy, poor motivation Social withdrawal Blunted affect (decreased emotional expression) Decline in skills associated with activities of daily living (ADLs) e.g. hygiene, budgeting, cooking etc. Cognitive impairments: concentration and memory deficits Frontal lobe deficits: inability to formulate and execute complex plans Thought disorder: derailment Differential diagnosis: 1. Brain pathology (organic disease) especially that associated with temporal lobe epilepsy can result in a delusional disorder resembling schizophrenia. 2. Dementia 3. Delusional disorder – there are five types listed in DSM-IV. Auditory and visual hallucinations (if present) must not be prominent and symptoms must have been present for at least 1 month (3 in ICD-10). The five types are: - Persecutory - Jealous (‘Othello’ syndrome): an abnormal belief that the partner is being unfaithful – held on irrational grounds (unsound evidence and reasoning) and unaffected by rational argument. Often there is no idea who the supposed lover might be. M>F - Erotomanic (rare): the belief that a (usually inaccessible) person is in love with the patient. The person is often famous. F>>M - Somatic: The belief that the patient suffers from a physical disease or deformity. Grandiose Mixed and unspecified other categories that may be used. 4. Bipolar disorder: can present with psychotic symptoms including 40% who present with a first rank symptom e.g.: ideas of reference, 3rd person hallucinations, and/or delusions of persecution (e.g. doctor is jealous of patient’s ‘greatness’). Useful Questions to ask in history taking: Delusions Have you experienced anything strange or unusual? Thought insertion Are thoughts put into your head that you know are not your own? Where do they come from? Thought withdrawal Do your thoughts disappear or seem to be taken from your head? Where do they go? Thought block Do your thoughts sometimes stop suddenly so your mind is blank even though your thoughts were flowing freely before? Why does this happen? Thought broadcast Do others hear your thoughts or read your mind? Can you send messages to other people with your mind? How do you explain this? Passivity Are you always in control of your thoughts and actions? Who else controls these? How do they do this? What do they get you to do/think/say? Delusional perception: When you saw … how did you know what it meant? Somatic hallucinations: Have you had any strange or unusal feelings in your body? Does your body function normally? Auditory hallucinations Have you ever heard anything you believe other people cannot? Do you hear voices? Whose voices are they? Are they clear? How many are there? Do they come from inside or outside your head? Do they talk to you or about you? What sorts of things do they say? Do they give commands? Do you have to obey them? Other hallucinations: Do you ever see, feel or smell something that you cannot explain? Antipsychotic drugs Typical - Block dopamine D2 receptors (leading to EPSEs) e.g. haloperidol, chlorpromazine Atypical - Block dopamine D2 receptors and serotonin 2A receptors e.g. risperidone, clozapine (SE: agranulocytosis therefore check FBC regularly) SEs: Location of dopamine D2 receptors Mesolimbic pathway Mesocorital pathway Nigrostriatal pathway (basal ganglia/striatum) Function Involved in delusions/ hallucinations/ thought disorder, euphoria and drug depedance Mediates cognitive and negative symptoms Controls motor control Tuberoinfindibular pathway Controls prolactin secretion (dopamine inhibits release) Chemoreceptor trigger zone Controls nausea and vomiting Clinical effect of dopamine D2receptor antagonism Treatment of psychotic symptoms Worsening of cognitive and negative symptoms Extra-pyramdial SEs (EPSEs): Parkinsonian symptoms Acute dystonia Akathisia Tardive dyskinesia Neuroleptic malignant syndrome Hyperprolactinaemia (galactorrhoea, amenorrhea, infertility, sexual dysfunction) Anti emetic effect: some phenothiazines e.g. prochlorperazine are effective at treating n+v Other SEs: Anti-cholinergic: muscurinic receptor blockade Dry mouth, constipation, urinary retention, blurred vision Alpha-adrenergic receptor blockade Histaminergic receptor blockade Cardiac effects Dermatological effect Other Postural hypotension Sedation, weight gain Prolonged QT-interval, arrhythmias, myocarditis, sudden death Photosensitivity, skin rashes (esp chlorpromazine: blue-grey discolouration in sun) Lowering seizure threshold, hepatotoxicity, cholestatic jaundice, pancytopenia, agranulocytosis Dementia For dementia to be present there must be memory loss In addition to this there must be one of the following four: Apraxia: problems with movements as evidenced by the drawing part of the MMSE Agnosia: problems in recognition e.g. faces, names etc of friends or relatives Aphasia: problems in speech or communication, either fluent or non-fluent Associated symptoms: e.g. problems planning Amnesia, apraxia, agnosia, aphasia and associated symptoms are the ‘5 As’ of dementia. In addition, there should be a decline in function over time and should cause problems in social or occupational operation. Differentials: (the ‘4Ds’): Depression, delirium, drugs, and dementia. The most common drugs are alcohol, antiepileptics and antipsychotics Common types Alzheimers (~60%) Gradual onset with progressive cognitive decline Diagnosis of exclusion of other causes of dementia Invesigations: Thyroid Anaemia Jaundice MMSE Vascular (~20%) Lewy body (~5%) Stepwise onset with Vivid visual successive infarcts hallucinations Focal neuro signs Increased falls Fluctuating Parkinsonian symptoms Very sensitive to neuroleptic drugs Frontotemporal Eatrly decline of social and personal conduct Early emotional blunting Early loss of insight Sparing of other cognitive functions Pulse (e.g. for AF) Blood pressure Focal neuro signs CT/MRI 5% of dementias are caused by reversible factors – it is important to screen for these FBC Serum Folate U&E Blood glucose Creatinine Thyroid function Serum [Ca2+] Liver function (LFT) Serum B12 Syphilis serology Delirium Impairment of consciousness with reduced ability to focus or maintain information Feature Delirium Dementia Onset Acute Gradual Duration Hours to weeks Months to years Course Fluctuating Progressive deteriation Consciousness Impaired Normal Perceptual disturbance Common Occurs in late stages Sleep-wake cycles Disrupted Usually normal Mental Health Act 1983 Section 2 3 4 5.2 5.4 Applies to Used by Patient in community, with a suspected but Social worker + undiagnosed mental 2 doctors. One disorder* must be section 12.2 approved and the other should ideally Patient in the be a psychiatrist. community, with a diagnosed mental Next of kin must disorder* be informed in section 3. A non-admitted patient, with suspected or known mental disorder* e.g. in A&E or Outpatients dept. An admitted patient with suspected or known mental disorder* e.g. a voluntary patient An admitted patient with suspected or known mental disorder* e.g. a voluntary patient Social worker + doctor Doctor Nurse with mental health training 135 Person in a private dwelling Police with a magistrates order 136 Person in a private dwelling Police Used For Duration Assessment and treatment Up to 28 days Treatment for 3 months with further treatment allowed with patient consent Up to 6 or after months consultation with an independent psychiatrist Detaining a patient who wishes to leave until formal assessment under section 2 or 3. No treatment can be given without consent. 72 hours 72 hours 6 hours Removal of person to a ‘safe place’ to await formal assessment under section 2 or 3. No treatment can be given without consent. 72 hours 72 hours *causing such severe problems that they are a risk to their own health or the health and safety of others, refusing to be hospitalised. There is a right to appeal against sections 2 and 3, usually taking 1-2 weeks or 4-5 weeks respectively to resolve.