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33. Hallucinations/disordered thinking
Perceptual disturbance
Perception = process of making sense of physical information we receive with our 5
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
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.[6]
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:[6]
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
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
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
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
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
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
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 teensearly 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
 Apathy, poor motivation
 Social withdrawal
 Blunted affect (decreased emotional
 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.
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
Useful Questions to ask in history taking:
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?
 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,
Atypical - Block dopamine D2 receptors and serotonin 2A receptors e.g. risperidone,
clozapine (SE: agranulocytosis therefore check FBC regularly)
Location of dopamine D2
Mesolimbic pathway
Mesocorital pathway
Nigrostriatal pathway
(basal ganglia/striatum)
Involved in delusions/
hallucinations/ thought disorder,
euphoria and drug depedance
Mediates cognitive and negative
Controls motor control
Tuberoinfindibular pathway
Controls prolactin secretion
(dopamine inhibits release)
Chemoreceptor trigger
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
(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
Dry mouth, constipation, urinary retention,
blurred vision
Alpha-adrenergic receptor blockade
Histaminergic receptor blockade
Cardiac effects
Dermatological effect
Postural hypotension
Sedation, weight gain
Prolonged QT-interval, arrhythmias,
myocarditis, sudden death
Photosensitivity, skin rashes (esp
chlorpromazine: blue-grey discolouration in
Lowering seizure threshold, hepatotoxicity,
cholestatic jaundice, pancytopenia,
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
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
cognitive decline
 Diagnosis of
exclusion of other
causes of
 Thyroid
 Anaemia
 Jaundice
Vascular (~20%)
Lewy body (~5%)
 Stepwise onset with  Vivid visual
successive infarcts
 Focal neuro signs
 Increased falls
 Fluctuating
 Parkinsonian
 Very sensitive to
neuroleptic drugs
 Eatrly decline of
social and personal
 Early emotional
 Early loss of insight
 Sparing of other
cognitive functions
Pulse (e.g. for AF)
Blood pressure
Focal neuro signs
5% of dementias are caused by reversible factors – it is important to screen for these
 Serum Folate
 U&E
 Blood glucose
 Creatinine
 Thyroid function
 Serum [Ca2+]
 Liver function (LFT)
 Serum B12
 Syphilis serology
Impairment of consciousness with reduced ability to focus or maintain information
Hours to weeks
Months to years
Progressive deteriation
Perceptual disturbance
Occurs in late stages
Sleep-wake cycles
Usually normal
Mental Health Act 1983
Applies to
Used by
Patient in community,
with a suspected but
Social worker +
undiagnosed mental
2 doctors. One
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
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 +
Nurse with
mental health
Person in a private
Police with a
Person in a private
Used For
Assessment and
Up to 28 days
Treatment for 3
months with
further treatment
allowed with
patient consent
Up to 6
or after
with an
Detaining a
patient who
wishes to leave
until formal
under section 2
or 3. No
treatment can be
given without
72 hours
72 hours
6 hours
Removal of
person to a ‘safe
place’ to await
under section 2
or 3. No
treatment can be
given without
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.