Perception = process of making sense of physical information we receive with our 5 senses
Illusion = misconception of a real external stimuli e.g. dressing gown on door in dark room looks like a stranger
Pseudohallucination = perception in subjective inner space where patient knows the perception is false
Hallucination = perceptions occurring in the absence of an external stimuli in the objective outer space
Visual hallucinations – causes: commonly in organic conditions e.g. delirium, dementia, epilepsy; as well as LSD, alcoholic hallucinosis.
Charles Bonnet = pts experience complex visual hallucinations assoc with no other psychiatric symtoms, usually in elderly
Hypnagogic hallucination = false perceptions that occur going to sleep (normal)
Hypnopompic hallucination = false perceptions occur as a person wakes (normal)
Auditory hallucinations –
Audible thoughts (first person) – patients hear their own thoughts spoken out loud
Second person – patients hear a voice talking directly to them; assoc with mood disorders
Third person – patients hear voices talking about them
Olfactory
– false perceptions of smell and taste – rule out epilepsy
Somatic – hallucinations of bodily sensations – superficial (tactile, thermal, hygric), visceral and kinaesthetic
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 deceased.
[7]
Delusional jealousy (or delusion of infidelity): A person with this delusion falsely believes a spouse or lover is having an affair.
Delusion of reference: The person falsely believes that insignificant remarks, events, or objects in one's environment have personal meaning or significance.


Erotomania A delusion where someone believes another person is in love with them.
Grandiose delusion : An individual is convinced he has special powers, talents, or abilities. Sometimes, the individual may actually believe he or she is a famous
 person or character (for example, Napoleon).
Persecutory delusion : These are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or obstructed in the pursuit of goals.
 Religious delusion : Any delusion with a religious or spiritual content. These may be combined with other delusions, such as grandiose delusions (the belief that the affected person is a god, or chosen to act as a god, for example).

Somatic delusion : A delusion whose content pertains to bodily functioning, bodily sensations, or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal, or changed
—for example, belief that ones bowels are rotting.

Delusions of parasitosis (DOP) or delusional parasitosis: a delusion in which one feels infested with an insect, bacteria, mite, spiders, lice, fleas, worms, or other organisms. Affected individuals may also report being repeatedly bitten. In some cases, entomologists are asked to investigate cases of mysterious bites.
Sometimes physical manifestations may occur including skin lesions.
 Delusions of Control (1 st rank schizophrenia symptoms) – false belief that ones thoughts, feelings, actions or impulses and controlled or “made” by an external agency – thought insertion, thought withdrawal and thought broadcasting

Disorganised thinking
 Thought Blocking – Interruption of train of speech before completion. e.g. "Am I
 early?" "No, you're just about on..." (silence)
Circumstantiality – Speech that is highly detailed and very delayed at reaching its goal. Can be normal
 Clanging – Sounds, rather than meaningful relationships, appear to govern words or topics. Excessive rhyming, and/or alliteration. e.g. "Many moldy mushrooms
 merge out of the mildewy mud on Mondays." "I heard the bell. Well, hell, then I fell."
Derailment (also Loose Association and Knight's Move thinking ) – Ideas slip off


 the topic's track on to another which is obliquely related or unrelated. e.g. "The next day when I'd be going out you know, I took control, like uh, I put bleach on my hair in California."
Echolalia – Echoing of one's or other people's speech that may only be committed once, or may be continuous in repetition. This may involve repeating only the last few words or last word of the examiner's sentences. This can be a symptom of Tourette's Syndrome. e.g. "What would you like for dinner?", "That's a good question. That's a good question . That's a good question . That's a good question ."
Flight of Ideas – A sequence of loose associations or extreme tangentiality where the speaker goes quickly from one idea to another seemingly unrelated idea. To the listener, the ideas seem unrelated and do not seem to repeat. Often pressured speech is also present. e.g. "I own five cigars. I've been to Havana.
She rose out of the water, in a bikini."
Word salad – Speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent

 gibberish
Neologisms – New word formations. These may also involve elisions of two words that are similar in meaning or in sound. e.g. "I got so angry I picked up a dish and threw it at the geshinker."
Perseveration – Persistent repetition of words or ideas. e.g. "It's great to be here in Nevada, Nevada, Nevada, Nevada, Nevada." This may also involve repeatedly giving the same answer to different questions. e.g. "Is your name Mary?" "Yes."
"Are you in the hospital?" "Yes." "Are you a table?" "Yes." Perseveration can include palilalia and logoclonia and is often an indication of organic brain disease
 such as Parkinson's.
Pressure of speech – An increase in the amount of spontaneous speech compared to what is considered customary. This may also include an increase in the rate of speech. Alternatively it may be difficult to interrupt the speaker; the
 speaker may continue speaking even when a direct question is asked.
Tangentiality – Replying to questions in an oblique, tangential or irrelevant manner. e.g.: Q: "What city are you from?" A: "Well, that's a hard question. I'm from Iowa. I really don't know where my relatives came from, so I don't know if
I'm Irish or French."
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 3 rd
person or
Chronic phase schizophrenia (negative symptoms) a running commentary

Somatic hallucinations

Thought beliefs: thought withdrawal , broadcast , spoken aloud

Delusional perception . insertion
Not first rank but diagnostically useful:


Delusions of persecution / grandeur
Ideas of reference

2 nd person auditory hallucinations
, hears thoughts

Passivity phenomena (feeling of actions being controlled)

Apathy, poor motivation

Social withdrawal

Blunted affect (decreased emotional expression)

Decline in skills associated with activities of daily living (ADLs) e.g.
 hygiene, budgeting, cooking etc.
Cognitive impairments: concentration and memory deficits

Frontal lobe deficits: inability to formulate and execute complex plans

Thought disorder: derailment
Differential diagnosis:
1. Brain pathology (organic disease) especially that associated with temporal lobe epilepsy can result in a delusional disorder resembling schizophrenia.
2. Dementia
3. Delusional disorder – there are five types listed in DSM-IV. Auditory and visual hallucinations (if present) must not be prominent and symptoms must have been present for at least 1 month (3 in ICD-10). The five types are:
Persecutory
Jealous (‘Othello’ syndrome): an abnormal belief that the partner is being unfaithful
– held on irrational grounds (unsound evidence and reasoning) and unaffected by rational argument . Often there is no idea who the supposed lover might be. M>F
Erotomanic (rare): the belief that a (usually inaccessible) person is in love with the patient. The person is often famous. F>>M

Somatic: The belief that the patient suffers from a physical disease or deformity.
Grandiose
Mixed and unspecified other categories that may be used.
4. Bipolar disorder: can present with psychotic symptoms including 40% who present with a first rank symptom e.g.: ideas of reference, 3 rd person hallucinations, and/or delusions of persecutio n (e.g. doctor is jealous of patient’s
‘greatness’).
Useful Questions to ask in history taking :
Delusions
Have you experienced anything strange or unusual?
Thought insertion

Are thoughts put into your head that you know are not your own?

Where do they come from?
Thought withdrawal

Do your thoughts disappear or seem to be taken from your head?

Where do they go?
Thought block

Do your thoughts sometimes stop suddenly so your mind is blank even though your thoughts were flowing freely before?

Why does this happen?
Thought broadcast

Do others hear your thoughts or read your mind?

Can you send messages to other people with your mind?

How do you explain this?
Passivity

Are you always in control of your thoughts and actions?

Who else controls these?

How do they do this?

What do they get you to do/think/say?
Delusional perception:
 When you saw … how did you know what it meant?
Somatic hallucinations:

Have you had any strange or unusal feelings in your body?

Does your body function normally?
Auditory hallucinations

Have you ever heard anything you believe other people cannot?

Do you hear voices?

Whose voices are they?

Are they clear?


How many are there?

Do they come from inside or outside your head?

Do they talk to you or about you?

What sorts of things do they say?

Do they give commands?

Do you have to obey them?
Other hallucinations:

Do you ever see, feel or smell something that you cannot explain?
Typical - Block dopamine D2 receptors (leading to EPSEs) e.g. haloperidol, chlorpromazine
Atypical - Block dopamine D2 receptors and serotonin 2A receptors e.g. risperidone, clozapine (SE: agranulocytosis therefore check FBC regularly)
SEs:
Location of dopamine D2 receptors
Function Clinical effect of dopamine D2receptor antagonism
Mesolimbic pathway Treatment of psychotic symptoms
Mesocorital pathway
Nigrostriatal pathway
(basal ganglia/striatum)
Involved in delusions/ hallucinations/ thought disorder, euphoria and drug depedance
Mediates cognitive and negative symptoms
Controls motor control
Tuberoinfindibular pathway Controls prolactin secretion
(dopamine inhibits release)
Chemoreceptor trigger zone
Controls nausea and vomiting
Worsening of cognitive and negative symptoms
Extra-pyramdial SEs (EPSEs):

Parkinsonian symptoms

Acute dystonia

Akathisia

Tardive dyskinesia

Neuroleptic malignant syndrome
Hyperprolactinaemia
(galactorrhoea, amenorrhea, infertility, sexual dysfunction)
Anti emetic effect: some phenothiazines e.g. prochlorperazine are effective at treating n+v
Other SEs:
Anti-cholinergic: muscurinic receptor blockade
Dry mouth, constipation, urinary retention, blurred vision

Alpha-adrenergic receptor blockade
Histaminergic receptor blockade
Cardiac effects
Dermatological effect
Other
Postural hypotension
Sedation, weight gain
Prolonged QT-interval, arrhythmias, myocarditis, sudden death
Photosensitivity, skin rashes (esp chlorpromazine: blue-grey discolouration in sun)
Lowering seizure threshold, hepatotoxicity, cholestatic jaundice, pancytopenia, agranulocytosis

For dementia to be present there must be memory loss
In addition to this there must be one of the following four:
Apraxia: problems with movements as evidenced by the drawing part of the MMSE
Agnosia: problems in recognition e.g. faces, names etc of friends or relatives
Aphasia: problems in speech or communication, either fluent or non-fluent
Associated symptoms: e.g. problems planning
Amnesia, apraxia, agnosia, aphasia and associated symptoms are the ‘5 As’ of dementia.
In addition, there should be a decline in function over time and should cause problems in social or occupational operation.
Differentials: (the ‘4Ds’): Depression, delirium, drugs, and dementia.
The most common drugs are alcohol, antiepileptics and antipsychotics
Common types
Alzheimers (~60%)

Gradual onset with progressive cognitive decline

Diagnosis of exclusion of other causes of dementia
Vascular (~20%)

Stepwise onset with successive infarcts

Focal neuro signs
Lewy body (~5%)

Vivid visual hallucinations

Increased falls

Fluctuating

Parkinsonian symptoms

Very sensitive to neuroleptic drugs
Frontotemporal

Eatrly decline of social and personal conduct

Early emotional blunting

Early loss of insight

Sparing of other cognitive functions
Invesigations:

Thyroid

Anaemia

Jaundice

MMSE



Pulse (e.g. for AF)
Blood pressure
Focal neuro signs
CT/MRI
5% of dementias are caused by reversible factors – it is important to screen for these

FBC

U&E

Creatinine

Serum [Ca 2+ ]

Serum B
12

Serum Folate

Blood glucose

Thyroid function

Liver function (LFT)

Syphilis serology

Impairment of consciousness with reduced ability to focus or maintain information
Feature Delirium Dementia
Onset
Duration
Course
Consciousness
Perceptual disturbance
Sleep-wake cycles
Acute
Hours to weeks
Fluctuating
Impaired
Common
Disrupted
Gradual
Months to years
Progressive deteriation
Normal
Occurs in late stages
Usually normal

Patient in community,
2
3 with a suspected but undiagnosed mental disorder*
Patient in the community, with a diagnosed mental disorder*
Social worker +
2 doctors. One must be section
12.2 approved and the other should ideally be a psychiatrist.
Next of kin must be informed in section 3.
Assessment and treatment
Treatment for 3 months with further treatment allowed with patient consent or after consultation with an independent psychiatrist
Up to 28 days
Up to 6 months
4
A non-admitted patient, with suspected or known mental disorder* e.g. in A&E or
Outpatients dept.
Social worker + doctor
72 hours
5.2
5.4
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
Doctor
Nurse with mental health training
Detaining a patient who wishes to leave until formal assessment under section 2 or 3. No treatment can be given without consent.
72 hours
6 hours
135
136
Person in a private dwelling
Person in a private dwelling
Police with a magistrates order
Police
Removal of person to a ‘safe place’ to await formal assessment under section 2 or 3. No treatment can be given without
72 hours
72 hours consent.
*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.