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1.  Delusional parasitosis with hyperthyroidism in an elderly woman: a case report 
Introduction
Delusional parasitosis is a rare, monosymptomatic psychosis involving a delusion of being infested with parasites. It is commonly observed among female patients over the age of 50. It is classified as a ‘delusional disorder’ according to the 10th revision of the International Classification of Diseases and as a ‘delusional disorder - somatic type’ according to the Diagnostic and Statistical Manual, Fourth Edition. Delusional parasitosis was reported to be associated with physical disorders such as hypoparathyroidism, Huntington’s chorea and Alzheimer’s disease, among others. Other than vitamin deficiencies however, a causal relationship has not to date been identified. We present this case due to the rarity of Turkish patients with this condition, its duration of follow-up, and its temporal pattern of symptoms paralleling thyroid function tests.
Case presentation
Our patient was a 70-year-old white Anatolian Turkish woman with primary school education who had been living alone for the past five years. She presented to our psychiatry department complaining of ‘feeling large worms moving in her body’. The complaints started after she was diagnosed with hyperthyroidism, increased when she did not use her thyroid medications and remitted when she was compliant with treatment. She was treated with pimozide 2mg/day for 20 months and followed-up without any antipsychotic treatment for an additional nine months. At her last examination, she was euthyroid, not receiving antipsychotics and was not having any delusions.
Conclusion
Although endocrine disorders, including hyperthyroidism, are listed among the etiological factors contributing to secondary delusional parasitosis, as far as we are aware this is the first case demonstrating a temporal pattern of thyroid hyperfunction and delusions through a protracted period of follow-up. It may be that the treatment of delusional parasitosis depends on clarifying the etiology and that atypical antipsychotics may help in the management of primary delusional parasitosis. Further studies on the relationship between thyroid hormones and dopaminergic neurotransmission may be warranted.
doi:10.1186/1752-1947-7-17
PMCID: PMC3554433  PMID: 23305525
2.  Differential diagnosis of obsessive-compulsive symptoms from delusions in schizophrenia: A phenomenological approach 
World Journal of Psychiatry  2013;3(3):50-56.
Several studies suggest increased prevalence-rates of obsessive-compulsive symptoms (OCS) and even of obsessive-compulsive disorder (OCD) in patients with schizophrenic disorders. Moreover, it has been recently proposed the existence of a distinct diagnostic sub-group of schizo-obsessive disorder. However, the further investigation of the OCS or OCD-schizophrenia diagnostic comorbidity presupposes the accurate clinical differential diagnosis of obsessions and compulsions from delusions and repetitive delusional behaviours, respectively. In turn, this could be facilitated by a careful comparative examination of the phenomenological features of typical obsessions/compulsions and delusions/repetitive delusional behaviours, respectively. This was precisely the primary aim of the present investigation. Our examination included seven features of obsessions/delusions (source of origin and sense of ownership of the thought, conviction, consistency with one’s belief-system, awareness of its inaccuracy, awareness of its symptomatic nature, resistance, and emotional impact) and five features of repetitive behaviours (aim of repetitive behaviours, awareness of their inappropriateness, awareness of their symptomatic nature, and their immediate effect on underlying thought, and their emotional impact). Several of these clinical features, if properly and empathically investigated, can help discriminate obsessions and compulsive rituals from delusions and delusional repetitive behaviours, respectively, in patients with schizophrenic disorders. We comment on the results of our examination as well as on those of another recent similar investigation. Moreover, we also address several still controversial issues, such as the nature of insight, the diagnostic status of poor insight in OCD, the conceptualization and differential diagnosis of compulsions from other categories of repetitive behaviours, as well as the diagnostic weight assigned to compulsions in contemporary psychiatric diagnostic systems. We stress the importance of the feature of mental reflexivity for understanding the nature of insight and the ambiguous diagnostic status of poor insight in OCD which may be either a marker of the chronicity of obsessions, or a marker of their delusionality. Furthermore, we criticize two major shortcomings of contemporary psychiatric diagnostic systems (DSM-IV, DSM-V, ICD-10) in their criteria or guidelines for the diagnosis of OCD or OCS: first, the diagnostic parity between obsessions and compulsions and, second, the inadequate conceptualization of compulsions. We argue that these shortcomings might artificially inflate the clinical prevalence of OC symptoms in the course of schizophrenic disorders. Still, contrary to a recent proposal, we do not exclude on purely a priori grounds the possibility of a concurrence of genuine obsessions along with delusions in patients with schizophrenia.
doi:10.5498/wjp.v3.i3.50
PMCID: PMC3832861  PMID: 24255875
Schizophrenia; Obsessive-compulsive symptoms; Obsessions; Compulsions; Delusions; Clinical features; Phenomenological approach; Differential diagnosis
3.  Disease Biomarkers in Cerebrospinal Fluid of Patients with First-Onset Psychosis 
PLoS Medicine  2006;3(11):e428.
Background
Psychosis is a severe mental condition that is characterized by a loss of contact with reality and is typically associated with hallucinations and delusional beliefs. There are numerous psychiatric conditions that present with psychotic symptoms, most importantly schizophrenia, bipolar affective disorder, and some forms of severe depression referred to as psychotic depression. The pathological mechanisms resulting in psychotic symptoms are not understood, nor is it understood whether the various psychotic illnesses are the result of similar biochemical disturbances. The identification of biological markers (so-called biomarkers) of psychosis is a fundamental step towards a better understanding of the pathogenesis of psychosis and holds the potential for more objective testing methods.
Methods and Findings
Surface-enhanced laser desorption ionization mass spectrometry was employed to profile proteins and peptides in a total of 179 cerebrospinal fluid samples (58 schizophrenia patients, 16 patients with depression, five patients with obsessive-compulsive disorder, ten patients with Alzheimer disease, and 90 controls). Our results show a highly significant differential distribution of samples from healthy volunteers away from drug-naïve patients with first-onset paranoid schizophrenia. The key alterations were the up-regulation of a 40-amino acid VGF-derived peptide, the down-regulation of transthyretin at ~4 kDa, and a peptide cluster at ~6,800–7,300 Da (which is likely to be influenced by the doubly charged ions of the transthyretin protein cluster). These schizophrenia-specific protein/peptide changes were replicated in an independent sample set. Both experiments achieved a specificity of 95% and a sensitivity of 80% or 88% in the initial study and in a subsequent validation study, respectively.
Conclusions
Our results suggest that the application of modern proteomics techniques, particularly mass spectrometric approaches, holds the potential to advance the understanding of the biochemical basis of psychiatric disorders and may in turn allow for the development of diagnostics and improved therapeutics. Further studies are required to validate the clinical effectiveness and disease specificity of the identified biomarkers.
Protein profiles from 179 cerebrospinal fluid samples yield differences between patients with psychotic disorders and healthy volunteers, suggesting that such biomarkers could assist in the early diagnosis of mental illness.
Editors' Summary
Background.
Psychosis is an abnormal mental state characterized by loss of contact with reality, often associated with hallucinations, delusions, personality changes, and disorganized thinking. Psychotic symptoms occur in several psychiatric disorders, including schizophrenia, bipolar disorder, and psychotic depression. It is not clear what the underlying biological abnormalities in the brain are, and whether they are the same for the different psychotic illnesses. The hope is that recent advances in brain imaging and systematic characterization of genetic activity and protein composition in the brain might help to shed light on mental diseases, eventually leading to better diagnosis, treatment, and possibly even prevention.
Why Was This Study Done?
This study was carried out in order to search for biomarkers for psychosis and schizophrenia by comparing the protein composition in the cerebrospinal fluid (the clear body fluid that surrounds the brain and the spinal cord) of patients with different psychotic disorders and normal individuals who served as controls.
What Did the Researchers Do and Find?
The researchers used a technique called surface-enhanced laser desorption ionization mass spectrometry, which allows a comprehensive analysis of the protein composition of a particular sample, on a total of 179 cerebrospinal fluid samples. The samples came from 90 individuals without mental illness who served as controls, 58 people with schizophrenia who were very recently diagnosed and had not yet taken any medication, 16 patients with depression, five patients with obsessive-compulsive disorder, and ten patients with Alzheimer disease. All of the patients gave their informed consent to participate in the study. The researchers found that samples from treatment-naïve schizophrenic patients had a number of characteristic changes compared with samples from control individuals, and that those changes were not found in the patients with other mental illnesses. The researchers then wanted to test whether they would see the same pattern in a separate set of patients with schizophrenia versus controls, which turned out to be the case. Two of the changes in the cerebrospinal fluid that were associated with schizophrenia, namely higher levels of parts of a protein called VGF and lower levels of a protein called transthyretin, were also found in post-mortem brain samples of patients with schizophrenia compared with samples from controls. Lower levels of transthyretin were also found in serum (blood) of first-onset drug naïve schizophrenia patients.
What Do These Findings Mean?
These results suggest that this approach has the potential to find biomarkers for psychosis and, possibly, schizophrenia that might help in the understanding of the molecular basis for these conditions. If shown, in future studies, to be directly involved in causing the disease symptoms, they would be important targets for treatment and prevention efforts, and might also be useful for diagnostic purposes. Overall, there are promising examples, such as this study, suggesting that new molecular techniques can yield fresh insights into psychiatric illnesses such as schizophrenia and other psychotic disorders. Additional studies are needed to confirm the findings presented here and to address many open questions, and would seem well justified given these results.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030428.
MedlinePlus entries on psychosis and schizophrenia
The National Alliance for Research on Schizophrenia and Depression
The National Alliance for the Mentally Ill
The Schizophrenia Society of Canada
Wikipedia entries on psychosis and schizophrenia (note that Wikipedia is an online encyclopedia that anyone can edit)
doi:10.1371/journal.pmed.0030428
PMCID: PMC1630717  PMID: 17090210
4.  Clinical features and imaging findings in a case of Capgras syndrome 
Capgras syndrome consists of the delusional belief that a person or persons have been replaced by doubles or impostors. It can occur in the context of both psychiatric and organic illness, and seems to be related to lesions of the bifrontal and right limbic and temporal regions. Indeed, magnetic resonance imaging has revealed brain lesions in patients suffering from Capgras syndrome. This case study reports the findings of a thorough diagnostic evaluation in a woman suffering from Capgras syndrome and presenting with the following clinical peculiarities: obsessive modality of presentation of the delusional ideation, intrusiveness of such ideation (that even disturbed her sleep), as well as a sense of alienation and utter disgust towards the double. These characteristics bring to mind the typical aspects of obsessive-compulsive disorder. Neuroanatomic investigation, through magnetic resonance imaging, performed on this patient showed alteration of the bilateral semioval centers, which are brain regions associated with the emotion of disgust and often show alterations in subjects suffering from obsessive-compulsive disorder. Hence, neuroimaging allows researchers to put forward the hypothesis of a common neuroanatomic basis for Capgras syndrome and obsessive-compulsive disorder, at least for cases in which the delusional ideation is associated with deep feelings of disgust and presents with a certain pervasiveness.
doi:10.2147/NDT.S47293
PMCID: PMC3742348  PMID: 23950650
Capgras syndrome; magnetic resonance imaging; electroencephalography; obsessive-compulsive disorder; semioval centers
5.  Psychiatric disorder associated with vacuum-assisted breast biopsy clip placement: a case report 
Introduction
Vacuum-assisted breast biopsy is a minimally invasive technique that has been used increasingly in the treatment of mammographically detected, non-palpable breast lesions. Clip placement at the biopsy site is standard practice after vacuum-assisted breast biopsy.
Case presentation
We present the case of a 62-year-old woman with suspicious microcalcifications in her left breast. The patient was informed about vacuum-assisted breast biopsy, including clip placement. During the course of taking the patient's history, she communicated excellently, her demeanor was normal, she disclosed no intake of psychiatric medication and had not been diagnosed with any psychiatric disorders. Subsequently, the patient underwent vacuum-assisted breast biopsy (11 G) under local anesthesia. A clip was placed at the biopsy site. The pathological diagnosis was of sclerosing adenosis. At the 6-month mammographic follow-up, the radiologist mentioned the existence of the metallic clip in her breast. Subsequently, the woman presented complaining about "being spied [upon] by an implanted clip in [her] breast" and repeatedly requested the removal of the clip. The patient was referred to the specialized psychiatrist of our breast unit for evaluation. The Mental State Examination found that systematized paranoid ideas of persecutory type dominated her daily routines. At the time, she believed that the implanted clip was one of several pieces of equipment being used to keep her under surveillance, the other equipment being her telephone, cameras and television. Quite surprisingly, she had never had a consultation with a mental health professional. The patient appeared depressed and her insight into her condition was impaired. The prevalent diagnosis was schizotypal disorder, whereas the differential diagnosis comprised delusional disorder of persecutory type, affective disorder with psychotic features or comorbid delusional disorder with major depression.
Conclusion
This is the first report of a psychiatric disorder being brought to the fore using a vacuum-assisted breast biopsy clip. Vacuum-assisted breast biopsy, and breast biopsy in general, represent a significant experience, encompassing anxiety and pain; it may thus aggravate psychiatric conditions. Apart from these well-established factors, other aspects, such as the clip, may occasionally become significant. In a modern breast unit, the evaluation of patients should be multidisciplinary. A psychiatrist may be needed for optimal management of anxiety-related issues, as well as for the detection of psychiatric disorders.
doi:10.1186/1752-1947-2-332
PMCID: PMC2579921  PMID: 18928549
6.  Hypochondriacal delusion in an elderly woman recovers quickly with electroconvulsive therapy 
Clinics and Practice  2012;2(1):e11.
A 72-year-old woman without any medical and psychiatric history, suffered from nausea, pain in the epigastria and constipation for over a year. She eventually lost 20 kilograms despite nightly drip-feeding. Extensive additional tests did not reveal any clues for her complaints. She remained convinced that her symptoms were a side-effect of anti-fungal medication she used. She was diagnosed with hypochondria. In the course of time her ideas about her somatic symptoms became delusional and she was diagnosed with a hypochondriacal delusion as part of melancholia, without depressed mood or loss of interest or pleasure as prominent features. It is important to recognize melancholia as soon as possible by continually evaluating other symptoms of depression. This may enable to avoid repetitive and exhaustive somatic examinations, which are not indicated, and to start effective treatment. In our patient electroconvulsive therapy resulted in a fast and complete recovery.
doi:10.4081/cp.2012.e11
PMCID: PMC3981340  PMID: 24765410
hypochondria; melancholia; weight loss; ECT.
7.  Suicidal Ideation and Suicidal Behaviour in Delusional Disorder: A Clinical Overview 
Psychiatry Journal  2014;2014:834901.
Background. Most of the existing studies suggest that suicide is one of the leading causes of premature death in patients with chronic psychotic disorders. However, very few studies have specifically investigated suicidal behaviour in patients with delusional disorder. Thus, our objective was to review the literature regarding the percentage of lifetime ideation and suicidal behaviour in delusional disorder in order to provide suggestions for clinical practice. Methods. MEDLINE and PsycINFO were searched from January 1980 to September 2012 using the following keywords: delusional disorder, paranoia, suicidal ideation, and suicidal behaviour. Results. A total of 10 studies were identified and included in the review. The percentage of suicidal behaviour in delusional disorder was established between 8 and 21%, which is similar to schizophrenia. Suicidal ideation and suicide attempts were more frequent in patients showing persecutory and somatic delusions in the reviewed studies. Conclusions. To the best of our knowledge this is the first attempt to specifically review the suicide phenomenon in patients with delusional disorder. Interestingly, our results support the notion that percentages of both suicidal ideation and behaviour in delusional disorder are similar to patients with schizophrenia.
doi:10.1155/2014/834901
PMCID: PMC3994904  PMID: 24829903
8.  Symptoms of delusion: the effects of discontinuation of low-dose venlafaxine 
Acta Psychiatrica Scandinavica  2009;120(4):329-331.
Objective:
We report a patient who experienced delusional symptoms during gradual discontinuation of low-dose venlafaxine and required antipsychotic treatment.
Method:
Case report.
Results:
A 31-year-old woman with major depression had been treated abroad with venlafaxine before returning to Japan. Since venlafaxine is unavailable here, we supplemented her regular venlafaxine dosage of 37.5 mg/day with clomipramine 20 mg/day. After 5 weeks we reduced venlafaxine to 18.75 mg/day and uptitrated clomipramine to 40 mg/day. Four days later she developed delusions of reference, palpitations and nausea. Clomipramine was increased to 60 mg/day, and her symptoms subsided. Eight weeks later her supply of venlafaxine ran out, and within 4 days her condition deteriorated into more severe symptoms that required 4 months’ antipsychotic treatment.
Conclusion:
We speculate that her symptoms were discontinuation syndrome, including psychotic symptoms and physical symptoms, caused by (i) venlafaxine-clomipramine interaction and/or (ii) the serotonin reuptake inhibitor-like effects of low-dose venlafaxine.
doi:10.1111/j.1600-0447.2009.01433.x
PMCID: PMC2773524  PMID: 19573048
antidepressives; antipsychotics; depression; psychopharmacology; side effects
9.  Breathlessness With Pulmonary Metastases: A Multimodal Approach 
Case Study 
Sarah is a 58-year-old breast cancer survivor, social worker, and health-care administrator at a long-term care facility. She lives with her husband and enjoys gardening and reading. She has two grown children and three grandchildren who live approximately 180 miles away.
SECOND CANCER DIAGNOSIS 
One morning while showering, Sarah detected a painless quarter-sized lump on her inner thigh. While she thought it was unusual, she felt it would probably go away. One month later, she felt the lump again; she thought that it had grown, so she scheduled a visit with her primary care physician. A CT scan revealed a 6.2-cm soft-tissue mass in the left groin. She was referred to an oncologic surgeon and underwent an excision of the groin mass. Pathology revealed a grade 3 malignant melanoma. She was later tested and found to have BRAF-negative status. Following her recovery from surgery, Sarah was further evaluated with an MRI scan of the brain, which was negative, and a PET scan, which revealed two nodules in the left lung.
As Sarah had attended a cancer support group during her breast cancer treatment in the past, she decided to go back to the group when she learned of her melanoma diagnosis. While the treatment options for her lung lesions included interleukin-2, ipilimumab (Yervoy), temozolomide, dacarbazine, a clinical trial, or radiosurgery, Sarah's oncologist felt that ipilimumab or radiosurgery would be the best course of action. She shared with her support group that she was ambivalent about this decision, as she had experienced profound fatigue and nausea with chemotherapy during her past treatment for breast cancer. She eventually opted to undergo stereotactic radiosurgery.
DISEASE RECURRENCE 
After the radiosurgery, Sarah was followed every 2 months. She complained of shortness of breath about 2 weeks prior to each follow-up visit. Each time her chest x-ray was normal, and she eventually believed that her breathlessness was anxiety-related. Unfortunately, Sarah’s 1-year follow-up exam revealed a 2 cm × 3 cm mass in her left lung, for which she had a surgical wedge resection. Her complaints of shortness of breath increased following the surgery and occurred most often with anxiety, heat, and gardening activities, especially when she needed to bend over. Sarah also complained of a burning "pins and needles" sensation at the surgical chest wall site that was bothersome and would wake her up at night.
Sarah met with the nurse practitioner in the symptom management clinic to discuss her concerns. Upon physical examination, observable signs of breathlessness were lacking, and oxygen saturation remained stable at 94%, but Sarah rated her breathlessness as 7 on the 0 to 10 Borg scale. The nurse practitioner prescribed duloxetine to help manage the surgical site neuropathic pain and to assist with anxiety, which in turn could possibly improve Sarah’s breathlessness. Several nonpharmacologic modalities for breathlessness were also recommended: using a fan directed toward her face, working in the garden in the early morning when the weather is cooler, gardening in containers that are at eye level to avoid the need to bend down, and performing relaxation exercises with pursed lip breathing to relieve anxiety-provoked breathlessness. One month later, Sarah reported relief of her anxiety; she stated that the fan directed toward her face helped most when she started to feel "air hungry." She rated her breathlessness at 4/10 on the Borg scale.
SECOND RECURRENCE: MULTIPLE PULMONARY NODULES 
Sarah’s chest x-rays remained clear for 6 months, but she developed a chronic cough shortly before the 9-month exam. An x-ray revealed several bilateral lung lesions and growth in the area of the previously resected lung nodule. Systemic therapy was recommended, and she underwent two cycles of ipilimumab. Sarah’s cough and breathlessness worsened, she developed colitis, and she decided to stop therapy after the third cycle. In addition, her coughing spells triggered bronchospasms that resulted in severe anxiety, panic attacks, and air hunger. She rated her breathlessness at 10/10 on the Borg scale during these episodes. She found communication difficult due to the cough and began to isolate herself. She continued to attend the support group weekly but had difficulty participating in conversation due to her cough.
Sarah was seen in the symptom management clinic every 2 weeks or more often as needed. No acute distress was present at the beginning of each visit, but when Sarah began to talk about her symptoms and fear of dying, her shortness of breath and anxiety increased. The symptom management nurse practitioner treated the suspected underlying cause of the breathlessness and prescribed oral lorazepam (0.5 to 1 mg every 6 hours) for anxiety and codeine cough syrup for the cough. Opioids were initiated for chest wall pain and to control the breathlessness. Controlled-release oxycodone was started at 10 mg every 12 hours with a breakthrough pain (BTP) dose of 5 mg every 2 hours as needed for breathlessness or pain. Sarah noted improvement in her symptoms and reported a Borg scale rating of 5/10. Oxygen therapy was attempted, but subjective improvement in Sarah’s breathlessness was lacking.
END OF LIFE 
Sarah’s disease progressed to the liver, and she began experiencing more notable signs of breathlessness: nasal flaring, tachycardia, and restlessness. Opioid doses were titrated over the course of 3 months to oxycodone (40 mg every 12 hours) with a BTP dose of 10 to 15 mg every 2 hours as needed, but her breathlessness caused significant distress, which she rated 8/10. The oxycodone was rotated to IV morphine continuous infusion with patient-controlled analgesia (PCA) that was delivered through her implantable port. This combination allowed Sarah to depress the PCA as needed and achieve immediate control of her dyspneic episodes. Oral lorazepam was also continued as needed.
Sarah’s daughter moved home to take care of her mother, and hospice became involved for end-of-life care. As Sarah became less responsive, nurses maintained doses of morphine for control of pain and breathlessness and used a respiratory distress observation scale to assess for breathlessness since Sarah could no longer self-report. A bolus PCA dose of morphine was administered by Sarah’s daughter if her mother appeared to be in distress. Sarah died peacefully in her home without signs of distress.
PMCID: PMC4093448  PMID: 25032021
10.  COTARD SYNDROME IN SEMANTIC DEMENTIA 
Psychosomatics  2011;52(6):571-574.
Background
Semantic dementia is a neurodegenerative disorder characterized by the loss of meaning of words or concepts. semantic dementia can offer potential insights into the mechanisms of content-specific delusions.
Objective
The authors present a rare case of semantic dementia with Cotard syndrome, a delusion characterized by nihilism or self-negation.
Method
The semantic deficits and other features of semantic dementia were evaluated in relation to the patient's Cotard syndrome.
Results
Mrs. A developed the delusional belief that she was wasting and dying. This occurred after she lost knowledge for her somatic discomforts and sensations and for the organs that were the source of these sensations. Her nihilistic beliefs appeared to emerge from her misunderstanding of her somatic sensations.
Conclusion
This unique patient suggests that a mechanism for Cotard syndrome is difficulty interpreting the nature and source of internal pains and sensations. We propose that loss of semantic knowledge about one's own body may lead to the delusion of nihilism or death.
doi:10.1016/j.psym.2011.06.004
PMCID: PMC3210438  PMID: 22054629
11.  Erotomania revisited: thirty-four years later. 
Erotomania (also known as De Clerambault's syndrome) is usually described as a rare delusional syndrome that characteristically involves a woman who believes that a man, typically of higher social, economic or political status, is in love with her. Two cases are reviewed here that have been followed for over 30 years, making these some of the longest, single-case longitudinal studies yet reported. De Clerambault's syndrome remains a ubiquitous nosological psychiatric entity with uncertain prognosis. In 1980, we reported in this journal one woman diagnosed as having erotomania. At that time, she had been followed for approximately eight years. She has now been studied for over 30 years. In De Clerambault's original work, as reported by Enoch and Trethowan, a woman whose chronic, erotic delusion remained unchanged was followed for 37 years. Despite some psychological advances, our original patient, like De Clerambault's, has remained essentially entrapped by her psychotic thought disorder and erotomania. A thorough review of the literature to date was contained in our 1980 article and so, to avoid repetition, we refer the interested reader to that reference. At this time, the original patient's history will be presented along with the course of her disorder and treatment implications. Secondly, another patient will be presented and her case reviewed. Finally, we will argue that this disorder is not as rare as has been claimed and call for the continued recognition of this syndrome as its own entity despite recent opinions that such use be discontinued.
PMCID: PMC2569288  PMID: 16749657
12.  Capgras Syndrome in First-Episode Psychotic Disorders 
Psychopathology  2014;47(4):261-269.
Background
Misidentification phenomena, including the delusion of “imposters” named after Joseph Capgras, occur in various major psychiatric and neurological disorders but have rarely been studied systematically in broad samples of modern patients. This study investigated the prevalence and correlated clinical factors of Capgras phenomenon in a broad sample of patient-subjects with first-lifetime episodes of psychotic affective and non affective disorders.
Methods
We evaluated 517 initially hospitalized, first-episode psychotic-disorder patients for prevalence of Capgras phenomenon and its association with DSM-IV-TR diagnoses including schizophreniform, brief psychotic, unspecified psychotic, delusional, and schizoaffective disorders, schizophrenia, bipolar-I disorder and major depression with psychotic features, and with characteristics of interest including antecedent psychiatric and neurological morbidity, onset-type and presenting psychopathological phenomena, using standard bivariate and multivariate statistical methods.
Results
Capgras syndrome was identified in 73/517 (14.1%) patients (8.2%–50% across diagnoses). Risk was greatest with acute or brief psychotic disorders (schizophreniform [50%], brief [34.8%], or unspecified [23.9%] psychoses), intermediate in major depression (15%), schizophrenia (11.4%) and delusional disorder (11.1%), and lowest in bipolar-I (10.3%) and schizoaffective disorders (8.2%). Associated were somatosensory, olfactory and tactile hallucinations, Schneiderian (especially delusional perception), and cycloid features as described by Perris and Brockington including polymorphous psychotic phenomena, rapidly shifting psychomotor and affective symptoms, pan-anxiety, ecstasy, over-concern with death, and perplexity or confusion, as well as rapid-onset, but not sex, age, abuse-history, dissociative features, or indications of neurological disorders.
Conclusions
Capgras syndrome was prevalent across a broad spectrum of first-episode psychotic disorders, most often in acute psychoses of rapid onset.
doi:10.1159/000357813
PMCID: PMC4065173  PMID: 24516070
Capgras syndrome; diagnosis; first-episode; imposters; misidentification; psychotic disorders
13.  Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion 
Both pseudocyesis and delusional pregnancy are said to be rare syndromes, but are reported frequently in developing countries. A distinction has been made between the two syndromes, but the line of demarcation is blurred. The aim of this paper is to review recent cases of pseudocyesis/delusional pregnancy in order to learn more about biopsychosocial antecedents. The recent world literature (2000-2014) on this subject (women only) was reviewed, making no distinction between pseudocyesis and delusional pregnancy. Eighty case histories were found, most of them originating in developing countries. Fifty patients had been given a diagnosis of psychosis, although criteria for making the diagnosis were not always clear. The psychological antecedents included ambivalence about pregnancy, relationship issues, and loss. Very frequently, pseudocyesis/delusional pregnancy occurred when a married couple was infertile and living in a pronatalist society. The infertility was attributed to the woman, which resulted in her experiencing substantial distress and discrimination. When antipsychotic medication was used to treat psychotic symptoms in these women, it led to high prolactin levels and apparent manifestations of pregnancy, such as amenorrhea and galactorrhea, thus reinforcing a false conviction of pregnancy. Developing the erroneous belief that one is pregnant is an understandable process, making the delusion of pregnancy a useful template against which to study the evolution of other, less explicable delusions.
doi:10.12998/wjcc.v2.i8.328
PMCID: PMC4133423  PMID: 25133144
Pseudocyesis; Delusional pregnancy; Infertility; Prolactin; Delusion
14.  Chronic gamma-hydroxybutyric-acid use followed by gamma-hydroxybutyric-acid withdrawal mimic schizophrenia: a case report 
Cases Journal  2009;2:7520.
Introduction
Gamma-hydroxybutyric-acid is a potentially addictive drug known for its use in “rave” parties. Users have described heightened sexual drive, sensuality and emotional warmth. Its euphoric, sedative and anxiolytic-like properties are also sought by frequent users. Abrupt gamma-hydroxybutyric-acid withdrawal can rapidly cause tremor, autonomic dysfunction and anxiety, and may later culminate in severe confusion, delirium, auditory, visual or tactile hallucinations, or even death.
Case presentation
A 23-year-old woman presented to the emergency room with paranoid delusions and auditory hallucinations. Her psychiatric history included two brief psychotic episodes induced by amphetamines and marijuana. In the last six months, she had demonstrated bizarre behaviour, had been more isolated and apathetic, and unable to take care of daily chores. The patient reported occasional use of gamma-hydroxybutyric-acid, but her initial accounts of drug use were contradictory. Since the toxicology urine screen was negative, a schizophrenic disorder was initially suspected and an antipsychotic medication was prescribed. A few hours after her admission, signs of autonomic dysfunction (tachycardia and hypertension) appeared, lasting 24 hours. Severe agitation and confusion were also present. Restraints and a cumulative dose of 7 mg lorazepam were used to stabilize her. The confusion resolved in less than 72 hours. The patient then revealed that she had been using gamma-hydroxybutyric-acid daily for the last six months as self-medication to treat insomnia and anxiety, before stopping it abruptly 24 hours prior to her visit.
Conclusions
In our opinion, this original case illustrates the importance of considering gamma-hydroxybutyric-acid withdrawal delirium in the differential diagnosis of a first-break psychosis. In this case, the effects of chronic GHB use were incorrectly identified as the negative symptoms of schizophrenia prodrome. Likewise, severe gamma-hydroxybutyric-acid withdrawal syndrome was initially mistaken for acute positive symptoms of schizophrenia, until autonomic dysfunction manifested itself more clearly.
doi:10.4076/1757-1626-2-7520
PMCID: PMC2740085  PMID: 19829990
15.  A diagnostic dilemma between psychosis and post-traumatic stress disorder: a case report and review of the literature 
Introduction
Post-traumatic stress disorder is defined as a mental disorder that arises from the experience of traumatic life events. Research has shown a high incidence of co-morbidity between post-traumatic stress disorder and psychosis.
Case presentation
We report the case of a 32-year-old black African woman with a history of both post-traumatic stress disorder and psychosis. Two years ago she presented to mental health services with auditory and visual hallucinations, persecutory delusions, suicidal ideation, recurring nightmares, hyper-arousal, and initial and middle insomnia. She was prescribed trifluoperazine (5 mg/day) and began cognitive-behavioral therapy for psychosis. Her psychotic symptoms gradually resolved over a period of three weeks; however, she continues to experience ongoing symptoms of post-traumatic stress disorder. In our case report, we review both the diagnostic and treatment issues regarding post-traumatic stress disorder with psychotic symptoms.
Conclusions
There are many factors responsible for the symptoms that occur in response to a traumatic event, including cognitive, affective and environmental factors. These factors may predispose both to the development of post-traumatic stress disorder and/or psychotic disorders. The independent diagnosis of post-traumatic stress disorder with psychotic features remains an open issue. A psychological formulation is essential regarding the appropriate treatment in a clinical setting.
doi:10.1186/1752-1947-5-97
PMCID: PMC3061930  PMID: 21392392
16.  Evidence That Onset of Psychosis in the Population Reflects Early Hallucinatory Experiences That Through Environmental Risks and Affective Dysregulation Become Complicated by Delusions 
Schizophrenia Bulletin  2010;38(3):531-542.
Objective:
To examine the hypothesis that the “natural” combination of delusions and hallucinations in psychotic disorders in fact represents a selection of early subclinical hallucinatory experiences associated with delusional ideation, resulting in need for care and mental health service use.
Methods:
In the Early Developmental Stages of Psychopathology study, a prospective, 10-year follow-up of a representative cohort of adolescents and young adults in Munich, Germany (n = 2524), clinical psychologists assessed hallucinations and delusions at 2 time points (T2 and T3). Analyses compared differences in psychopathology, familial liability for nonpsychotic disorder, nongenetic risk factors, persistence, and clinical outcome between groups characterized by: (1) absence of positive psychotic symptoms, (2) presence of isolated hallucinations, (3) isolated delusions, and (4) both hallucinations and delusions.
Results:
Delusions and hallucinations occurred together much more often (T2: 3.1%; T3: 2.0%) than predicted by chance (T2: 1.0%; T3: 0.4%; OR = 11.0; 95% CI: 8.1, 15.1). Content of delusions was contingent on presence of hallucinations but modality of hallucinations was not contingent on presence of delusions. The group with both hallucinations and delusions, compared to groups with either delusions or hallucinations in isolation, displayed the strongest associations with familial affective liability and nongenetic risk factors, as well as with persistence of psychotic symptoms, comorbidity with negative symptoms, affective psychopathology, and clinical need.
Conclusions:
The early stages of psychosis may involve hallucinatory experiences that, if complicated by delusional ideation under the influence of environmental risks and (liability for) affective dysregulation, give rise to a poor prognosis hallucinatory–delusional syndrome.
doi:10.1093/schbul/sbq117
PMCID: PMC3329993  PMID: 21030456
psychosis; delusions; hallucinations; schizophrenia; prevention; risk
17.  A case of cola dependency in a woman with recurrent depression 
BMC Research Notes  2012;5:692.
Background
Cola is an extremely popular caffeinated soft drink. The media have recently cited a poll in which 16% of the respondents considered themselves to be addicted to cola soft drinks. We find the contrast between the apparent prevalence of cola addiction and the lack of scientific literature on the subject remarkable. To our knowledge, this is the first case of cola dependency described in the scientific literature.
Case presentation
The patient is a 40-year-old woman, who when feeling down used cola to give her an energy boost and feel better about herself. During the past seven years her symptoms increased, and she was prescribed antidepressant medication by her family doctor. Due to worsening of symptoms she was hospitalised and later referred to a specialised outpatient clinic for affective disorders. At entry to the clinic she suffered from constant tiredness, lack of energy, failing concentration, problems falling asleep as well as interrupted sleep. She drank about three litres of cola daily, and she had developed a metabolic syndrome.
The patient fulfilled the ICD-10 criteria for dependency, and on the Yale Food Addiction Scale (YFAS) she scored 40 points. Her clinical mental status was at baseline assessed by the Major Depression Inventory (MDI) = 41, Hamilton Depression - 17 item Scale (HAMD-17) = 14, Young Mania Rating Scale (YMRS) = 2 and the Global Assessment of Functioning (GAF) Scale = 45.
During cognitive therapy sessions she was guided to stop drinking cola and was able to moderate her use to an average daily consumption of 200 ml of cola. Her concentration improved and she felt mentally and physically better. At discharge one year after entry her YFAS was zero. She was mentally stable (MDI =1, HAMD-17 = 0, YMRS = 0 and GAF = 85) and without antidepressant medication. She had lost 7.2 kg, her waistline was reduced by 13 cm and the metabolic syndrome disappeared.
Conclusion
This case serves as an example of how the overconsumption of a caffeinated soft drink likely was causing or accentuating the patient’s symptoms of mental disorder. When diagnosing and treating depression, health professionals should pay attention to potential overuse of cola or other caffeinated beverages.
doi:10.1186/1756-0500-5-692
PMCID: PMC3598894  PMID: 23259911
Cola caffeinated soft drink; Depression; Addiction; Metabolic syndrome
18.  Two years of psychogeriatric consultations in a nursing home: reasons for referral compared to psychiatrists' assessment 
Background
In spite of the high prevalence of psychiatric disorders among elderly residents in nursing homes, only a small number of patients in need of specialist care are referred to a psychiatric consultant. The aim of this research was to evaluate the consultation activity and the appropriateness of referral to psychiatric assessment.
Methods
Data were collected and analysed on consultation carried out over a two-year period in a RSA (Residenza Socio-Assistenziale) in Northern-Italy. Data were catalogued with reference to: patients, consultation, diagnosis and recommended medications. Statistical correlation analysis by means of Spearman test and signification test was carried out.
Results
Residents referred to psychiatric consultation at least once were 112 (14.5% of all residents). Reason for referral were: depression (17.2%), delusions and hallucinations (14%), agitation (34.8%), aggressive behaviour (23.5%) and disturbances of sleep (6.8%). Most frequent diagnoses were organic, including symptomatic, mental disorders (33.9%), mood disorders (22.3%) and schizophrenia, schizotypal and delusional syndromes (18.8%). No psychiatric diagnosis was found only in 1.8% of cases, thus confirming high sensibility of referring physicians.
A statistically significant correlation was found when comparing referrals for depression or delusions and allucinations or sleep disturbances and diagnostic confirmation of such symptoms by specialistic assessment (respectively 49.8%, 52.7% and 19.6%).
Correlation between psychotic symptoms and the consequent prescription of antipsychotic drugs had a significant if somewhat modest value (24%) while correlation between depression symptoms and prescription of antidepressant drugs was more noticeable (66.5%).
Conclusion
Main reason for referral to psychiatric consultation resulted to be the presence of agitation, a non-specific symptom often difficult to attribute. Data concerning depression confirm tendency to underestimating this diagnosis in the elderly. Furthermore, symptomatic reasons for referral did not always correspond to subsequent diagnostic definitions by psychiatric consultants, therefore demonstrating modest predictive power.
doi:10.1186/1472-6963-6-73
PMCID: PMC1526431  PMID: 16772021
19.  Hypoadrenalism presenting as a range of mental disorders 
BMJ Case Reports  2011;2011:bcr0920103305.
This case report describes interaction of trauma, endocrine disorder and infection resulting in a complex psychopathology in an 82-year-old, previously healthy lady.
One month after a hip replacement, she developed fluctuating cognitive impairment and delusions, associated with hyponatraemia.
Shortly afterwards, development of severe depression resulted in a prolonged psychiatric admission. During this time, she suffered recurring urinary tract infections (UTIs). Delusions and fluctuating cognition persisted. Persistent hyponatraemia prompted regular cortisol monitoring. Gradual decline was detected and primary adrenal insufficiency was confirmed with Synachten test.
Starting life-long substitution treatment resulted in a normalisation of serum sodium levels, mood and cognition and disappearance of psychotic features.
According to our hypothesis, psychopathology was induced by hypoadrenalism triggered by the hip replacement and perpetuated by recurrent UTIs.
Although delirium-type symptoms are well known to be associated with hyponatraemia, affective disorders have been only described in one previous case report.
doi:10.1136/bcr.09.2010.3305
PMCID: PMC3063253  PMID: 22707626
20.  Depressive Symptom Profiles and Severity Patterns in Outpatients with Psychotic versus Nonpsychotic Major Depression 
Comprehensive psychiatry  2008;49(5):421-429.
Background
Previous research suggests that patients with psychotic major depression (PMD) may differ from those with nonpsychotic major depression (NMD) not only in terms psychotic features, but also in their depressive symptom presentation. The present study contrasted the rates and severity of depressive symptoms in outpatients diagnosed with PMD versus NMD.
Method
The sample consisted of 1,112 patients diagnosed with major depression, of which 60 (5.3%) exhibited psychotic features. Depressive symptoms were assessed by trained diagnosticians at intake using the Structured Clinical Interview for DSM-IV and supplemented by severity items from the Schedule for Affective Disorders and Schizophrenia.
Results
PMD patients were more likely to endorse the presence of weight loss, insomnia, psychomotor agitation, indecisiveness, and suicidality compared to NMD patients. Furthermore, PMD patient showed higher levels of severity on several depressive symptoms, including depressed mood, appetite loss, insomnia, psychomotor disturbances (agitation and retardation), fatigue, worthlessness, guilt, cognitive disturbances (concentration and indecisiveness), hopelessness, and suicidal ideation. The presence of psychomotor disturbance, insomnia, indecisiveness, and suicidal ideation were predictive of diagnostic status even after controlling for the effects of demographic characteristics and other symptoms.
Conclusions
These findings are consistent with past research suggesting that PMD is characterized by a unique depressive symptom profile in addition to psychotic features and higher levels of overall depression severity. The identification of specific depressive symptoms in addition to delusions/hallucinations that can differentiate PMD versus NMD patients can aid in the early detection of the disorder. These investigations also provide insights into potential treatment targets for this high-risk population.
doi:10.1016/j.comppsych.2008.02.007
PMCID: PMC2601715  PMID: 18702928
21.  De Clerambault Syndrome (Erotomania): A Review and Case Presentation 
A syndrome which was first described by G.G. De Clerambault in 1885 is reviewed and a case is presented. Popularly called erotomania, the syndrome is characterized by the delusional idea, usually in a young woman, that a man whom she considers to be of higher social and/or professional standing is in love with her. She develops an elaborate delusional process about this man, his love for her, his pursuit of her, and her inability to escape his “affectionate clutches.” This syndrome may persist for a period of a few weeks to a few months in the recurrent form and be replaced by a similar delusion about another man. In the fixed form, which is the example of the case being presented here, it may persist for several years. The patient presented here has experienced this syndrome for eight years; there are reports in the literature of persons maintaining the syndrome for longer than 25 years.
Patients with this syndrome may be diagnosed as having paranoid vera or other forms of paranoid disorder, or as paranoid schizophrenic. In light of the overwhelming nature of the delusional process affecting this patient's total life experience with marked delusions of persecution, grandeur, jealously, and self-depreciation as well as ideas of reference (illusions), and agitated and sometimes bizarre behavior, it seems quite appropriate that her diagnosis may be termed schizophrenic reaction, paranoid type.
The literature is surveyed in depth and the case is presented in sequential detail.
PMCID: PMC2552541  PMID: 6999163
22.  Williams syndrome and psychosis: a case report 
Introduction
Mental comorbidities, such as phobia, obsessive compulsive symptoms and anxiety disorders, are common in Williams syndrome. However, psychotic symptoms are rare in these patients. We report a case of psychosis in a patient with Williams syndrome.
Case presentation
A 23-year-old Caucasian woman with Williams syndrome arrived at the emergency room with persecutory delusions, auditory and verbal hallucinations, soliloquies and psychomotor agitation. These symptoms were consistently present for 2 months. No evidence of other medical illnesses or psychoactive substances was found. There was no evidence of prior psychiatric symptoms or family history of psychiatric or neurological disorders. She was treated with antipsychotics and her symptoms were resolved.
Conclusion
We describe a rare case of a patient with Williams syndrome who experienced a nonorganic psychotic episode. Literature on this topic is scarce and, therefore, this case report intends to add further data about this comorbidity.
doi:10.1186/1752-1947-8-49
PMCID: PMC3930303  PMID: 24520861
Developmental disability; Intellectual disability; Psychosis; Williams syndrome
23.  The neurobiology of schizotypy: Fronto-striatal prediction error signal correlates with delusion-like beliefs in healthy people 
Neuropsychologia  2012;50(14):3612-3620.
Healthy people sometimes report experiences and beliefs that are strikingly similar to the symptoms of psychosis in their bizarreness and the apparent lack of evidence supporting them. An important question is whether this represents merely a superficial resemblance or whether there is a genuine and deep similarity indicating, as some have suggested, a continuum between odd but healthy beliefs and the symptoms of psychotic illness. We sought to shed light on this question by determining whether the neural marker for prediction error - previously shown to be altered in early psychosis – is comparably altered in healthy individuals reporting schizotypal experiences and beliefs. We showed that non-clinical schizotypal experiences were significantly correlated with aberrant frontal and striatal prediction error signal. This correlation related to the distress associated with the beliefs. Given our previous observations that patients with first episode psychosis show altered neural responses to prediction error and that this alteration, in turn, relates to the severity of their delusional ideation, our results provide novel evidence in support of the view that schizotypy relates to psychosis at more than just a superficial descriptive level. However, the picture is a complex one in which the experiences, though associated with altered striatal responding, may provoke distress but may nonetheless be explained away, while an additional alteration in frontal cortical responding may allow the beliefs to become more delusion-like: intrusive and distressing.
Highlights
► People without psychosis nevertheless hold unusual, psychotic-like beliefs. ► Magical beliefs are associated with inappropriate striatal prediction errors. ► Distressing beliefs are associated with aberrant prefrontal prediction error. ► These findings partially support a continuum from healthy odd beliefs to delusions.
doi:10.1016/j.neuropsychologia.2012.09.045
PMCID: PMC3694307  PMID: 23079501
Schizotypy; Prediction error; fMRI; Delusions; Psychosis
24.  Delusional Infestation 
Clinical Microbiology Reviews  2009;22(4):690-732.
Summary: This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional infestation (DI), also known as delusional parasitosis. It is characterized by the fixed belief of being infested with pathogens against all medical evidence. DI is no single disorder but can occur as a delusional disorder of the somatic type (primary DI) or secondary to numerous other conditions. A set of minimal diagnostic criteria and a classification are provided. Patients with DI pose a truly interdisciplinary problem to the medical system. They avoid psychiatrists and consult dermatologists, microbiologists, or general practitioners but often lose faith in professional medicine. Epidemiology and history suggest that the imaginary pathogens change constantly, while the delusional theme “infestation” is stable and ubiquitous. Patients with self-diagnosed “Morgellons disease” can be seen as a variation of this delusional theme. For clinicians, clinical pathways for efficient diagnostics and etiology-specific treatment are provided. Specialized outpatient clinics in dermatology with a liaison psychiatrist are theoretically best placed to provide care. The most intricate problem is to engage patients in psychiatric therapy. In primary DI, antipsychotics are the treatment of choice, according to limited but sufficient evidence. Pimozide is no longer the treatment of choice for reasons of drug safety. Future research should focus on pathophysiology and the neural basis of DI, as well as on conclusive clinical trials, which are widely lacking. Innovative approaches will be needed, since otherwise patients are unlikely to adhere to any study protocol.
doi:10.1128/CMR.00018-09
PMCID: PMC2772366  PMID: 19822895
25.  Testing the Continuum of Delusional Beliefs 
Journal of Abnormal Psychology  2010;119(1):83-92.
A key problem in studying a hypothesized spectrum of severity of delusional ideation is determining that ideas are unfounded. The first objective was to use virtual reality to validate groups of individuals with low, moderate, and high levels of unfounded persecutory ideation. The second objective was to investigate, drawing upon a cognitive model of persecutory delusions, whether clinical and nonclinical paranoia are associated with similar causal factors. Three groups (low paranoia, high nonclinical paranoia, persecutory delusions) of 30 participants were recruited. Levels of paranoia were tested using virtual reality. The groups were compared on assessments of anxiety, worry, interpersonal sensitivity, depression, anomalous perceptual experiences, reasoning, and history of traumatic events. Virtual reality was found to cause no side effects. Persecutory ideation in virtual reality significantly differed across the groups. For the clear majority of the theoretical factors there were dose–response relationships with levels of paranoia. This is consistent with the idea of a spectrum of paranoia in the general population. Persecutory ideation is clearly present outside of clinical groups and there is consistency across the paranoia spectrum in associations with important theoretical variables.
doi:10.1037/a0017514
PMCID: PMC2834573  PMID: 20141245
delusions; paranoia; cognitive; schizophrenia; continuum

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