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1. Psychotic Signs and Symptoms
Keywords
PsychosisDescriptive psychopathologyDelusionsOvervalued ideasHallucinationsPseudohallucinationsEponymsSchneiderian first-rank symptomsSelf-disturbancesFormal thought disorderDisorganizationDisorganized behaviorCatatoniaEssential 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 certain symptoms: delusions or hallucinations, sometimes also including disorganized thinking. Use it only in this technical sense.
Disorders of thought are based on content (delusions) or form (formal thought disorders).
Delusions are beliefs characterized by falsity, certainty, and incorrigibility. However, none of those features while characteristic is essential.
Delusions, hallucinations, formal thought disorder, grossly disorganized behavior, and catatonia are considered positive symptoms.
Overvalued ideas straddle the world of normal beliefs and psychosis. They are often shared by groups of people who fanatically pursue their ideas, regardless of personal cost.
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.
Catatonic symptoms comprise a variety of quite varied motor symptoms that occur in patients with schizophrenia (among other conditions) and may therefore be seen in patients who are psychotic.
Man sieht nur, was man weiß. [1]
(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 label their reported experiences as “symptoms in the mind.” The attempt to accurately describe inner pathological experiences is a branch of descriptive psychopathology known as phenomenology. Karl Jaspers, who wrote the classic text on psychopathology over a century ago [2], 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” [3]. Today we might say that you have to put yourself in the patient’s shoes. Phenomenology in contrast to disease-focused symptomatology is person-centered in that it keeps the person’s subjective experience at the forefront of our clinical thinking [4]. Psychopathology may be a tool to rehumanize psychiatry in cases where the patient was lost in the quest for diagnostic reliability using symptom checklists [5].
“Psychosis” as a term has evolved rather significantly. Originally introduced to separate all disorders that fall into the realm of psychiatry from those of neurology, it has since seen a significant narrowing in meaning [6]. First, it was restricted to serious disorders like schizophrenia spectrum disorders but also including manic-depressive illness (patients typically seen in state hospitals who were “insane” and cared for by the alienists as these hospital-based psychiatrists were known as), in contrast to the neurotic disorders (patients seen in outpatient practices, building on the insights of Freud). In older textbooks, you still see this fundamental distinction. Today, psychosis is operationally defined (delusions, hallucinations, disorganized thinking) at the level of symptoms.
In this chapter, I describe the signs and symptoms to look for when you are trying to decide if somebody is experiencing psychosis or not. Reflecting the importance of French and German psychiatry at the time when psychiatry established itself as a specialty over a century ago [7] and the fight over patients between neurology and psychiatry, you will encounter many foreign language terms, different terms for similar phenomena and obscure concepts. Unfortunately, we are still waiting for a twenty-first-century descriptive psychopathology that harmonizes terminologies and brings clinical observation in line with neuroscience [8]. In the interim, read the descriptions, and 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 one of my mentors, the late George Murray. In addition, read the next chapter to learn more about how to interview a patient to get at his psychotic experiences.
Psychotic Signs and Symptoms
Key Point
In its most narrow conceptualization, psychosis is operationally defined as the presence of delusions or clear-cut hallucinations, punctum. In broader definitions, formal thought disorder, behavioral disorganization, and catatonia are included in its definition [9]. Psychotic symptoms are neither specific for any disorder nor even necessarily pathologic.
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 this “impaired reality testing,” giving rise to the above operationalized definition of (narrowly defined) psychosis as delusions or hallucinations, sometimes including disorganized thinking. A narrow conceptualization is critical to avoid mislabeling anyone “weird” as psychotic. Also do not label patients generically as “psychotic” merely because they appear seriously ill or worse because you do not know what they have but only use psychosis in today’s narrow technical sense (i.e., psychotic symptoms are present).
Delusions
Key Point
For pragmatic, clinical purposes, delusions are fixed, false beliefs: beliefs that are held with great conviction even in the face of overwhelming evidence to the contrary and are not shared by the members of the patient’s own culture or subculture. Delusions are disorders of thought content: what people believe. However, this definition is also epistemologically incorrect: delusions are not necessarily fixed, they are not necessarily false, and they might not be beliefs at all. Delusions force us to reflect on the nature of truth and how we come to know it, including who decides.
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) [10]. 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 delusional assumptions (the basis for cognitive-behavioral treatment for psychosis). They are able to shift their point of view, like Copernicus. 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.” Even far-fetched delusions frequently contain a kernel of truth. To complicate matters further: normal ideas and delusions feel the same to patients. 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 world view, the idea is not considered delusional. This solution worked reasonably well when our world was not connected. Now, people with fringe views including delusion-like ideas can get together virtually and form potentially quite large groups of believers. 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,” in the famous words of Supreme Court Justice Potter Stewart [11]). That said, the distinction toward overvalued ideas (see below) and confabulation [12] may not always be easy.
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, or religious delusions. Table 1.1 lists eponyms of psychotic presentations.
Is the delusion bizarre? Already Kraepelin noted the delusions in dementia praecox “often show … an extraordinary, sometimes whole nonsensical stamp.” While the distinction between bizarre and nonbizarre delusions used to play a big role in psychiatric nosology (e.g., you could not have delusional disorder if your delusions were bizarre), this has been de-emphasized in current nosology, in part because of the difficulties to operationalize “bizarreness.” Still, the presence of a bizarre belief will make you more confident that the belief is delusional. Not even this is an easy task, however, and psychiatrists disagree when a delusion becomes bizarre [13]. I would consider if a belief is (currently) physically possible or not to settle the question of bizarreness in my mind.
Is the delusion mood-congruent? Typically but not necessarily, delusions of depression are morbid, those of mania grandiose.
How pervasive is the delusions? 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 delusions?
How firmly entrenched is the delusions? Is doubt a possibility? Ask, “Is it possible that you are wrong, that you are overinterpreting events and people’s intentions?” “Could chance explain your observation?”
Are you sure you are not dealing with memories of delusions? Patients are not actively psychotic anymore, but they are unable to challenge the accuracy of their past psychotic experiences (“I know a chip was implanted 20 years ago so I cannot have an MRI.”). This matters since antipsychotics cannot change memories of delusions (as opposed to delusional memories which are the result of active psychosis).
Eponyms of psychotic and related presentationsa
Bell’s mania . Delirious mania: A severe form of excited mania in which the patient appears delirious (disoriented and with fever) [14]. Death from exhaustion can occur [15]. Some consider it a form of excited catatonia [16]. |
Capgras syndrome . Delusions 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’s disease. The patient needs to be sent for neurocognitive testing and magnetic resonance imaging (MRI). Capgras syndrome is only one of several delusional misindentification syndromes [17]. In the illusions 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 [18]. The hallucinations are friendly, for example, little people sitting on the coach in the living room. The patient needs to see an ophthalmologist, not a psychiatrist! |
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 imaging infestations with bugs, worms, and insects. The patient often presents to dermatology (“positive matchbox sign” with “trapped” evidence) but should see you (they never do)! Make sure there is not amphetamine misuse. A modern variant is Morgellons disease. |
Cotard’s syndrome . Characterized by nihilistic delusions that can be quite bizarre: Patients believe they are literally dead; they believe they do not exist or that the world does not exist; that they have no heart for example; “I am being prepared for execution.” It occurs in psychotic, depressive state. |
Ganser syndrome . Characterized by vorbeireden – talking past the point; giving approximate answers to simple questions; all answers are absurdly wrong but barely: 3 plus 3 is 7. A camel has five legs. The color green is called orange. Possibly malingering, maybe a twilight state. |
Jerusalem syndrome . Not an eponym but a collection of psychiatric presentations at the interface of religion and psychosis that afflicts travelers to Jerusalem [19]. |
Korsakoff’s psychosis . A misnomer today, as no psychosis in the modern sense is present. It is the possible residual state following acute Wernicke’s 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. |
Münchhausen syndrome . One of the factitious disorders. Patients seek admission to hospital, often with incredible stories (also known as “pseudologia fantastica”). When patients are found wandering from hospital to hospital in search of admission, they are known as “hospital hobos.” |
Othello syndrome . Characterized by delusions of infidelity. Occurs as morbid (pathological to the point of delusional) jealousy in alcoholics and in neurodegenerative disorders. In Shakespeare’s play, Othello was manipulated into believing that his wife Desdemona was unfaithful (a case of “gas-lighting”), and he murdered her. The play gets is right in that patients can pose a danger to their partner. |
Wernicke’s encephalopathy . An acute confusional state due to severe thiamine (vitamin B1) deficiency. Other symptoms include ataxia and ophthalmoplegia to form the classic triad. Alcoholism is an important risk factor for reduced thiamine intake (but not the only one!). |
Although today often understood to mean persecuted, “paranoia” was the term Kraepelin originally used for conditions in which delusions were the only psychopathological feature. The term is still used in that sense in “paranoid schizophrenia,” an unofficial clinical subtype of schizophrenia in which any type of delusion dominates the clinical presentation.
Overvalued Ideas
The German neuropsychiatrist Carl Wernicke (of Wernicke’s encephalopathy and Wernicke’s aphasia [20]) used the term “overvalued idea” for people with a passionate attitude, also known as “fanatics” in lay terms. One important aspect of overvalued ideas is that they are shared with other people, making them potentially destructive. Remember that delusions, by contrast, are generally uniquely false ideas held by individuals and identified by other as erroneous. While most people would not jeopardize their careers or lives for overvalued ideas, some will (and are secretly regarded as heroes by those less inclined to fight for an idea). This is to say that it is not the idea itself but the reckless (toward oneself or others) pursuit that causes isolation and suffering. In forensic settings, extreme nonpsychotic, overvalued ideas might be a more helpful characterization than psychosis if one wants to understand a person’s motivations for action, including violence against society [21]. However, we need to be careful to not overreach and label all persons with differing opinions as holding overvalued ideas as evidence for a clinical condition in need of treatment.
Tip
The best way of getting patients to talk about delusions and delusion-like ideas is by taking a stance of curiosity and confusion, best exemplified by Peter Falk’s LAPD Detective Columbo: “I am confused. On the one hand, you work for the CIA but then you are not getting a paycheck.” With the Columbo technique of approaching your topic of interest obliquely, you challenge inconsistencies without appearing to doubt the patient’s account of events.
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