Introduction to
Psychotic Illnesses
Dr Greg Chick
Senior House Officer in liaison psychiatry,
North Manchester General Hospital
8.1.07
Aims
Descriptive, not aetiology-based
Definition of psychosis
Definitions of psychotic symptoms


hallucinations vs delusions
useful terminology for your psychiatry placement
Awareness of range of psychotic illnesses
Awareness of ICD-10
How to approach a patient suffering from psychosis
‘Psychosis’ - definition
Mental disorder




in which the thoughts, feelings, affective response,
ability to recognise reality
and ability to communicate and relate to others are
sufficiently impaired to interfere grossly with the
capacity to deal with reality;
the characteristics of psychosis are impaired reality
testing, hallucinations, delusions and illusions.
Kaplan & Saddock “Comprehensive textbook of psychiatry” – 7th ed, glossary p686
WHY do I need to know about
Psychotic Illnesses?
GP




Is the Front line service
Early detection improves prognosis!
worried relatives asking you to section people
Increased burden on health services; worse physical health
Surgeons / Obs & Gynae – delusional pts insisting on
unnecessary operations
A&E – pts present with bizarre complaints &
behaviour; overdose
Paediatrics – child protection issues; early onset
psychosis
Psychiatry – our area of expertise!

Mental health act, forensic, suicide
Contents
Psychotic symptoms




Delusional mood
Hallucinations
Delusions
First-rank symptoms
“Psychotic illnesses”


Schizophrenia
Delusional disorders
Conditions involving psychotic symptoms




Mania / psychotic depression
Drug-induced psychoses
Organic psychoses
Delirium / delirium tremens (DTs)
What do I Really Have to Know?
Think ORGANIC!




Oxygenation, Glucose, Electrolyte disturbance, endocrine
Toxicity – iatrogenic, self-inflicted, accidental
Drugs & alcohol
Cerebral pathology
Define:


Delusion
Hallucination (vs illusion)
ICD-10
A diagnostic heirarchy
F0- - Organic
F1- - Substance-related
F20s - Schizophrenia… & delusional disorders
F3F4F5F6F7-
- Mood [affective] disorders
- neurotic, stress-related & somatoform dis.
- …physiological.. (inc eating disorders)
- …personality disorders…
- mental retardation
etc
mental state abnormalities in psychotic illness
Thought
Perception
Behaviour
Catatonia
Form
Content
Illusions
Hallucinations
Pseudohallucinations
Delusions
Circumstantiality
Fusion
Auditory
Knight´s Move Thinking
Tactile
Derailment
Visual
Word Salad
Olfactory & Gustatory
Thought Block
Overvalued Ideas
Delusions - definition
“a false, unshakeable idea or belief which is out of
keeping with the patient’s educational, cultural and
social background” – Simms
* we can never understand how they arrived at the belief – defies
normal logic *
BUT
 Need not be totally unshakeable – cognitive therapy for
delusions; many patients have some insight
 Need not be false (eg delusional jealousy, then discover
partner actually IS unfaithful)
Wrongly ARRIVED at belief
Primary Delusion – ‘out of the blue’
Secondary Delusion – arises out of… eg. hallucination
Overvalued idea
A preoccupation which can come to dominate
(& ruin) a person’s life


but you can understand where it came from
and it’s sort of believable
eg body image distortion in anorexia nervosa
eg hypochondriacal disorder

eg patient fears he has a brain tumour
but is briefly reassured by the latest test
Delusions of…
Grandeur / ability
Paranoia
Reference
Persecution
Control
Infestation
Love / jealousy
Misidentification
Nihilism
Delusions - examples
“I am the son of George W Bush
…and a Somali woman. They were on holiday there
and left me behind.” grandeur

“I have a microchip in my brain which
transmits my thoughts to MI5.”
“My family are poisoning my food – it tastes funny”
control
persecution
“They’re making a TV programme about me
– I keep seeing my name in the newspaper.” reference
Persistent Delusional Disorders (F22)
Delusional disorder (F22.0) – including:
Persecutory delusions
 delusional jealousy;
 De Clérambault’s syndrome – “erotomania”
Induced delusional disorder (folie a deux) (F24)
 Delusion shared by people with close emotional links
 Only one person suffers from a genuine psychotic disorder
 The other person’s delusion disappears when they are
separated
Delusional dysmorphophobia (F22.8)
Paranoia querulans (F22.8)

Delusional percept / “primary delusion”
(out of the blue)
“A young Irishman was at breakfast with two fellowlodgers. He felt a sense of unease, that something
frightening was going to happen.
One of the lodgers pushed the salt cellar towards him (he
appreciated at the same time that this was an ordinary
salt cellar and his friend's intention was innocent).
Almost before the salt cellar reached him he knew he
must return home, to greet the Pope, who is visiting
Ireland to see his family.”
From: Simms “symptoms in the mind”
‘Delusional mood’ – a feeling that
something’s not right:
Imagine…
You’ve bumped someone’s car in a car park. There’s no damage,
so you drive off quickly!
Your phone rings in the middle of the night but you miss the call
and the number is unknown…
 What emotions do you feel?
 What goes through your mind?
 Who was phoning you?
The next day, you’re still thinking about it and you receive an
envelope with a government crest on it…
 What emotions now?
 What goes through your mind before you open it?
 Supposing, in your nervous state, you read it wrong…?
How to approach:
a delusional patient
Empathise (but don’t patronise)
Test the intensity of the belief


but don’t be confrontational
Ask them ‘could there be an alternative explanation?’
What have they done about their belief ?
(do they believe you’re a real medical student?)
Look up examples of how to phrase your questions

Present State Examination
Other delusional syndromes
Fregoli’s delusion



My persecutor takes on the form of different people…
But I KNOW it’s still him!
Schizophrenia / stroke = delusional misidentification
Cotard syndrome



Nihilistic delusions, esp. in psychotic depression
“I’ve got no blood / bowels / breath / money”
“I’m dead / rotting from inside”
Other delusional syndromes
Capgras’ delusion

A 74-year old married housewife believed that her
husband had been replaced by another unrelated
man. She refused to sleep with the imposter, locked
her bedroom at night, asked her son for a gun, and
finally fought with the police when attempts were
made to hospitalize her. She easily recognized other
family members and would misidentify her husband
only.
Dementia / stroke = delusional misidentification

This case is taken from a report by Passer and Warnock

De Clérambault’s syndrome –
“erotomania”
usually in women
convinced that a man


usually older, of higher status
eg the consultant
is in love with her
mental state abnormalities in psychotic illness
Thought
Perception
Behaviour
Catatonia
Form
Content
Illusions
Hallucinations
Pseudohallucinations
Delusions
Circumstantiality
Fusion
Auditory
Knight´s Move Thinking
Tactile
Derailment
Visual
Word Salad
Olfactory & Gustatory
Thought Block
Overvalued Ideas
Thought
Content
Delusions
Overvalued Ideas
of Reference
Body image
Hypochondriasis
Litigation
Religious
political
of Paranoia:
Reference
Persecution
Grandeur
Control,
Passivity
Schizophrenia?
Myths & Misconceptions
‘Schizophrenia’ does literally mean ‘separated mind’

Greek – applied by Bleuler in 1911
BUT is nothing to do with ‘split personality’
…let alone ‘multiple personality’ (very rare)
HAS to do with the brain’s functions separating
 eg. You hear a voice but don’t recognise it’s come
from your own mind

Definition of Schizophrenia
a “severe and enduring mental illness”
A clinical syndrome




“a collection of features which tend to occur together”
Refined over last 200 years or so
Recognised pattern of outcome
Same methods of treatment
Biological basis; severe psychosocial consequences


No definitive cause or mechanism yet identified (multifactorial – see PBL lecture)
Neurochemical imbalance
‘reality testing’ and ‘theory of mind’ defective

+ loss of ‘ego boundaries’ – (what is Me and what is Outside)
BUT there is still no single concise definition!
Heritable Risk
Age of Onset – Bimodal Distribution
st
1
Rank symptoms
1950’s - Schneider’s 1st Rank Symptoms:
1. Primary Delusion = ‘delusional percept’
2. Own thoughts spoken aloud = ‘thought echo’
3. Voices arguing or discussing
4. running commentary voices
5. thought withdrawal and/or thought block
6. Thought insertion
7. thought broadcasting (others are thinking it at the same time as you)
8. Made to feel… ‘passivity of affect’
9. Made to want… ‘passivity of impulse’
10.Made to do… ‘passivity of volition’
11.Done to my body ‘somatic passivity’ eg probed by aliens

Some may occur in illnesses other than schizophrenia eg mania
Illusion
Incorrect perception of a real stimulus (in any
modality)
Usually non-pathological



Bush looks like a killer in the dark
“cocktail party” illusion: hearing your name across a
noisy room
A stray hair may feel like a spider on the neck
BUT illusions occur in psychosis

eg girl complains her face is melting when she looks in mirror
Paintings by artist with worsening psychosis
– perceptual disturbances
Hallucination
A perception, which feels real, but has no real stimulus
usually abnormal, especially when persistent

But occasional hallucinations are more common than we
thought! - 10% of British population, at some time
Modalities:

Auditory
heard as if coming from outwith your head (including from another
part of the body) cf pseudohallucinations




Visual (more indicative of organic pathology!)
Somatic / Hygric (visceral) / Sexual
Gustatory
Olfactory
Hallucinations 2
Non-pathological:


Hypnagogic (going off to sleep)
Hypnopompic (waking up)
When it’s NOT a hallucination
Illusion = misperception of a REAL stimulus
Daydream = imagery
Pseudohallucination




Occurs in inner subjective space
eg voices INSIDE your head
May have quality of your own thoughts
Distressed patients not interested in this distinction!
Ideas of reference
On a spectrum
I think people on the bus are looking at me
=> =>
 The news is about my life! It means I’m a
paedophile. Don’t you believe me?

Audible Thoughts
= Gedankenlautwerden, echo de pensees
The patient may hear people




repeating his thoughts out loud just after he has thought them,
answering his thoughts,
saying aloud what he is about to think so that his thoughts repeat the
voices.
He often becomes very upset ill the gross intrusion into his privacy and
concerned that he cannot maintain con control of any part of himself,
not even his thoughts.
Audible Thoughts
A 35 year old painter heard a quiet voice with `an Oxford accent',
which he attributed to the BBC. The volume was slightly lower
than that of normal conversation and could be heard equally
well with either ear. He could locate its source at the right
mastoid process. The voice would say, `I can't stand that man,
the way he holds his hand he looks like a poof' . . . He
immediately experienced whatever the voice was saying as his
own thoughts, to the exclusion of all other thoughts. When he
read the newspaper the voice would speak aloud whatever his
eyes fell on. He had not time to think of what he was reading
before it was uttered aloud.
Simms
voices arguing
A 24 year old male patient reported hearing
voices coming from the nurse's ofice. The voice,
deep in pitch and roughly spoken, repeatedly
said,



‘He is a bloody paradox', and another, higher in pitch,
said,
'He is that, he should be locked up'.
A female voice occasionally interrupted, saying `He
is not - he is a lovely man'.
voices giving a
Running Commentary
…just before, during or after the patient's activities.
A housewife heard a voice coming from the house
across the road....
The voice went on incessantly in a flat monotone describing
everything she was doing, with an admixture of critical
comments.
`She is peeling potatoes, got hold of the peeler, she
does not want that potato,
she is putting it back, because she thinks it has a
knobble like a penis, she has a dirty mind, she is peeling
potatoes, now she is washing them'
Passivity experiences
'I am thinking about my mother, and suddenly my
thoughts are sucked out of my mind by a
phrenological vacuum extractor, and there is
nothing in my mind, it is empty.
Thought Insertion
‘I look out of the window and I think the
garden looks nice and the grass looks cool,
but the thoughts of Chris Evans come into my
mind.
There are no other thoughts there, only his....
He treats my mind like a screen and flashes his
thoughts onto it like you flash a picture.’
Thought Broadcasting
Def: whenever your thoughts are accessible to
others, eg telepathy, your thoughts on TV
A 21 year old student said,
“As I think, my thoughts leave my head on a
type of mental ticker-tape.
Everyone around has only to pass the tape
through their mind and they know my thoughts.”
Passivity of emotion
A 23 year old female patient reported,
`I cry, tears roll down my cheeks and I look unhappy,
but inside I have a cold anger because they are using me in
this way, and it is not me who is unhappy,
but they are projecting unhappiness onto my brain. They
project upon me laughter, for no reason, and
you have no idea how terrible it is to laugh and look
happy and know it is not your, but their reaction.'
Passivity of Impulse
A Jewish woman suffering from schizophrenia said `I
feel my hand going up to salute, and my lips saying
"Heil Hitler" ... I don't actually say it ... I have to try very hard
to stop my arm from going up ... they put drugs in my food;
that is what makes it happen.'
A 26 year old engineer emptied the contents of a urine
bottle over the ward dinner trolley. He said, `The
sudden impulse came over me and I must do it. It was
not my feeling, it came into me from the X-ray
department, that was why I was sent there for
implants yesterday. It was nothing to do with me, they wanted
it done. So I picked up the bottle and poured it in. It seemed
all I could do.'
Somatic Passivity
the belief that outside influences are playing on
the body
A 38 year old man had jumped from a bedroom
window, injuring his right knee which was very painful.
'The sun-rays are directed by U.S. army satellites
in an intense beam which I can feel entering the
centre of my knee and then radiating outwards
causing the pain.'
Artist with Sz – delusion of being
electronically controlled?
mental state abnormalities in psychotic illness
Thought
Perception
Behaviour
Catatonia
Form
Content
Illusions
Hallucinations
Pseudohallucinations
Delusions
Circumstantiality
Fusion
Auditory
Knight´s Move Thinking
Tactile
Derailment
Visual
Word Salad
Olfactory & Gustatory
Thought Block
Overvalued Ideas
Thought Disorder
Circumstantiality – “beating about the bush”

(goal eventually reached but tortuously indirect and over-inclusive)
Knight’s Move Thinking
 Illogical jumping between ideas. Listener can’t follow train of
thought.
 “I can’t go to the zoo, no money. Oh... I have a hat - these
members make no sense, man… What’s the problem?”
 NOT the same as Flight Of Ideas, which you CAN follow
Derailment (just losing the plot – goal of speech not reached)
Fusion (themes recur but in odd order, hard to follow)
Thought Block (‘snapping off ’ train of thought. No thoughts
left)
Differential Diagnosis:
Conditions that look like schizophrenia
(similar symptoms)
Organic psychoses –

Temporal Lobe Epilepsy, delirium, delusional disorder,
catatonia
substance-induced psychoses –
Cannabis/hallucinogens, stimulants, alcohol (DTs,
hallucinosis), etc
“Acute and transient” psychotic disorders

Schizo-affective disorder
Manic episode
Schizotypal disorder
Emotionally unstable personality disorder (can have brief
psychotic symptoms)
Trance & possession disorders!
Important Reading
ICD-10 (World Health Organisation, 1992)
F20 chapter =
 a brief description of what these conditions are and
aren’t
 DSM-IV is the American equivalent – bigger but
gives thumbnail sketches of the conditions
My lecture on schizophrenia from last year 

“Symptoms in the Mind” by Andrew Simms
 (the ‘bible’ for descriptive psychopathology)
Case Vignette - 2
Brian began to be a worry to his parents at the age of 17. After doing quite
well in his GCSEs, he seemed to lose interest and his ability to concentrate on
his studies. He began to spend more time alone in his room listening to music
and when he went out with his friends, he appeared dazed and distant on
returning home.
His parents suspected he was taking drugs but he denied this. When his
mother went into his bedroom to tidy up one day, she found that he had
draped a cloth over the mirror. He explained this by saying that he avoided
looking at his face because he had a strange look in his eyes, as though he had
become hypnotised. His parents tried to persuade him to visit their GP, but
he refused to go. He became very quarrelsome and one day he punched one
of his friends without warning. That evening, he removed all the light bulbs
from their sockets after complaining that they were emitting dangerous
radiation. His parents took him to hospital and he was admitted.
www.abpi.org.uk/publications/publication_details/targetSchizophrenia2003/section2.asp