Psychotic Signs and Symptoms

Essential Concepts

Descriptive psychopathology provides the building blocks for psychiatric diagnosis. It provides the language for observed behaviors and inner experiences.
In a narrow sense, psychosis is operationally defined as the presence of delusions or hallucinations.
Delusions are beliefs characterized by falsity, certainty, and incorrigibility.
Delusions, hallucinations, formal thought disorder, and catatonia are considered positive symptoms.
Knowing Schneiderian First-Rank Symptoms (FRS) is useful to screen for psychosis, not to make a specific diagnosis. Somebody who reports FRS is clearly actively psychotic.

“Man sieht nur das, was man weiß.”

(“You only see what you know.”)

—Johann Wolfgang von Goethe, 1749-1832

Descriptive psychopathology is that branch of psychiatry that concerns itself with the precise definition of terms for clinical phenomena you might encounter when examining the mental state of a patient such as psychosis, the topic of this book. Descriptive psychopathology includes (a) observing behavior and (b) inquiring into the subjective experience of patients, with the goal not to explain, but to correctly identify their inner experience. The latter is a branch of descriptive psychopathology known as phenomenology. Karl Jaspers, who wrote the classic text on psychopathology, put it best: “Subjective symptoms cannot be perceived by the sense-organs, but have to be grasped by transferring oneself, so to say, into the other individual’s psyche; that is, by empathy.”

In this chapter, I describe the signs and symptoms to look for when deciding if somebody is experiencing psychosis. Read the descriptions, but then find teachers who will show you what the phenomena look like in real patients, to “feel the Mississippi mud between your toes,” in the words of George Murray.

PSYCHOTIC SIGNS AND SYMPTOMS

Conceptually, psychosis is “impaired reality testing,” the famous “break from reality.” Clinically, this is not terribly useful: How do you know when it is present? Attempts have been made to identify clinical signs and symptoms suggestive of psychosis, giving rise to the above operationalized definition of (narrowly defined) psychosis as delusions or hallucinations.

DELUSIONS

You might think a core concept of psychiatry, the “basic characteristic of madness,” as Karl Jaspers called delusions, is well understood. As it turns out, delusions defy easy understanding. Karl Jaspers identified three key characteristics of delusions: impossible content (falsity), held with conviction (certainty), and not susceptible to correction (incorrigibility). All three characteristics do not withstand closer scrutiny. Certainty in a delusional belief is frequently not absolute, but subject to doubt; and many patients can challenge and correct their assumptions (the basis for cognitive-behavioral treatment for psychosis). In contrast, we all hold certain beliefs dear to our heart with conviction and defend them against modification (e.g., scientific beliefs). Probably most problematic from a philosophical point of view is the assumption that “false” (impossible) ideas are somehow different from “unusual” or normal ideas. Often, delusions seem mere grotesque exacerbations of surrounding beliefs
rather than “false.” The impossible content problem leads to the inclusion of a reference group to determine the veracity of an idea by majority vote: if enough people (e.g., your church community) share your worldview, the idea is not considered delusional. I should say that, despite great theoretical problems, delusions are usually easy to spot in the clinic. The problem is reminiscent of defining pornography (“I know it when I see it,” according to Supreme Court Justice Potter Stewart).

Once you have encountered a delusion, assess the following aspects:

What is the delusion about? Delusions as a disorder of thought content are conveniently classified according to the dominant theme, e.g., delusions of grandeur, love, persecution, reference, control, and religious delusions. Table 1.1 lists eponyms of psychotic presentations.
Is the delusion bizarre? This matters because, in current classification systems, bizarre delusions assume prominence: you can make the diagnosis of schizophrenia based on this one symptom alone (assuming the other criteria are fulfilled). If a delusion is considered bizarre, delusional disorder, in which delusions have to be nonbizarre, cannot be diagnosed. Kraepelin noted the delusions in dementia praecox “often show … an extraordinary, sometimes whole nonsensical stamp.” Not even this is easy, however, and psychiatrists disagree when a delusion becomes bizarre (Spitzer et al., 1993). I would ask if an idea is (currently) physically possible to decide this matter.
Is the delusion mood-congruent? Typically but not necessarily, the delusions of depression are morbid, those of mania grandiose.
How pervasive is the delusion? Is it encapsulated within an otherwise intact personality, or are you dealing with a well-formed, systematized delusional system in which everything and everybody is connected to the delusion?
How firmly entrenched is the delusion? Is doubt a possibility? Ask “Is it possible that you are wrong, that you are overinterpreting events and people’s intentions?”

Although today often understood to mean persecuted, paranoia was the term Kraepelin originally used for conditions in which delusions were the only psychopathologic feature. The term is still used in that sense in “paranoid schizophrenia,” a subtype of schizophrenia in which any type of delusion dominates the clinical presentation.

TABLE 1.1. Eponyms of Psychotic Presentations

Bell’s mania Delirious mania: A severe form of excited mania in which the patient appears delirious (disoriented and with fever). Death from exhaustion can occur.

Capgra’s phenomenon Delusion of doubles: A friend or relative has been replaced by an imposter (an exact double). Suspect organicity; it is often seen at some point in Alzheimer disease. The patient needs to be sent for neuropsychiatric testing and magnetic resonance imaging (MRI). Capgras is only one of several delusional misidentification syndromes. In the “illusion of Fregoli,” a persecutor is seen in many people, as the persecutor is disguised and changes in appearance.

Charles Bonnet syndrome Vivid and complex visual (pseudo-) hallucinations that are the result of eye disease. The hallucinations are friendly, for example, little people sitting in living room. The patient needs to see an ophthalmologist.

De Clérambault syndrome Erotomania: Delusional conviction that somebody (usually a man of higher station) is in love with you (usually a female), despite virtually no contact. Can occur in its “pure,” primary form or embedded in other psychiatric illnesses. Three stages: hope, resentment, overt hostility—the loved person is in danger in the third stage.

Ekbom’s syndrome Dermatozoenwahn. Chronic tactile hallucinosis or delusional parasitosis: Patients imagine infestation with bugs, worms, insects. The patient often presents to dermatologist (“positive matchbox sign” with “trapped” evidence), but should see you. Make sure it is not amphetamine misuse.

Cotard’s syndrome Characterized by nihilistic delusions: Patients believe they are dead; they believe they do not exist or that the world does not exist; that they have no heart; “I am being prepared for execution.” It occurs in psychotic, depressive states.

Ganser syndrome Characterized by “vorbeireden”—talking past the point; giving approximate answers to simple questions; all answers are absurdly wrong, but just barely: 3 plus 3 is 7. A camel has five legs. Possibly malingering, maybe twilight state.

Korsakoff’s psychosis A misnomer today, as no psychosis in the modern sense is present. It is the possible residual state of acute Wernicke encephalopathy. Patients cannot form new memories (anterograde amnesia) and confabulate. Try thiamine for treatment.

Kraepelin-Morel disease Rarely used eponym for schizophrenia.

Lhermitte’s (peduncular) hallucinosis Vivid, colorful visual (pseudo-) hallucinations caused by a midbrain lesion.

Münchhaüsen syndrome One of the factitious disorders. Patients seek admission to hospital, often with incredible stories (pseudologia fantastica). When patients are found wandering from hospital to hospital, they are known as “hospital hobos.”

Othello syndrome Characterized by delusions of infidelity. Also occurs in alcoholics as morbid jealousy.

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