Delusions and delusional disorders--Part II.
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Cognitive Behavioral Therapy↗
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Stalking as paranoid attachment: a typological and dynamic model.
Stalking encompasses a wide range of behavioral patterns, risk factors, interpersonal dynamics, and dangerousness. To account for these diverse phenomena, we propose that stalking behavior is best conceptualized by a dynamic interaction of attachment styles and psychodynamic phenomena. This paper articulates a model that explains stalking behavior within the framework of attachment theory. Four prototypical configurations of stalkers and their victims are developed. Each configuration is discussed in terms of a pattern of internal representations, affective constellations, combinations of aggression and narcissism, and potential for future violence. The four configurations proposed here are maintained through stalkers' over ideational linkage fantasies and projective identifications, which range from shame-prone and needy idealization to malevolent torment of the victim. Our model arrays erotomanic, jealous, and persecutory attachments along a continuum of increasingly paranoid and pathological identifications. We argue that these prototypical attachment configurations provide a theoretically driven means of differentiating phases of stalking, and as such provide useful leads in the empirical study and clinical assessment, treatment, and management of stalkers.
Adult↗
Re-establishing conversational skills in overtly psychotic, chronic schizophrenic patients. Discrete trials training on the psychiatric ward.
A discrete trials procedure incorporating graduated prompts, social and consumable reinforcement, corrective feedback, delay of reinforcement, and a chaining procedure was used to teach four actively psychotic, chronic schizophrenic patients rudimentary conversational skills. In a multiple-baseline design, training was sequentially applied to the target conversational skills of giving a salutation, addressing the trainer by his or her name, making a personal inquiry, and asking a conversational question. Results showed systematic training effects in three of the four subjects. Training gains were reliable but slow, requiring over 70 trials to reach acquisition criterion on certain skills. The fourth subject exhibited only unstable gains on the first target response and minor improvements on the second target response, the latter of which disappeared when training procedures were withdrawn. All subjects displayed spontaneous recovery on the generalization measure of answering a personal inquiry.
Adult↗
Improvement in mood and ideation associated with increase in right caudate volume.
BACKGROUND: The basal ganglia, particularly caudate, are hypothesized to play a role in affective and obsessive-compulsive disorders. The depressive syndrome is a feature of untreated Cushing's disease. The objective of this study was to test the hypothesis that after treatment of Cushing's disease reduces elevated cortisol, improvement in mood and related ideations are associated with increase in caudate volume. METHODS: In this longitudinal, interventional study of 23 patients with Cushing's disease, 24-hour urinary free cortisol, structural magnetic resonance imaging and behavioral measures were obtained prior to treatment and approximately one year after pituitary microadenomectomy. Five SCL-90-R subscales measuring change in mood, related ideations and physical symptoms were utilized. RESULTS: Partial correlations (adjusted for age and time since surgery) showed change in caudate, but not hippocampal, volume was significantly associated with change in behavioral SCL-90-R subscales, indicating selectivity for structure. Right but not left caudate showed associations, suggesting selectivity for lateralization. Right caudate volume increase was significantly associated with decreases in Depression, Anxiety, Obsessive-Compulsive, and Paranoid scores, but not with Somatization (physical symptoms), indicating specificity for behavioral but not physical variables. LIMITATIONS: A limitation is that relatively low-resolution scans were utilized. Although most likely not diminishing the significant findings, less sensitive methodology could lead to an increased probability of a type 2 error. CONCLUSIONS: These findings support the concept that caudate, and likely right caudate, participates in human brain circuitry regulating mood.
Adenoma↗
Social behaviors in persons with and without persecutory delusions.
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Brief Psychiatric Rating Scale↗
Risperidone for AIDS-associated dementia: a case series.
OBJECTIVE: To determine the effect of low-dose risperidone on behavioral disturbances associated with AIDS dementia in young-to-middle-age nursing home patients. Neuroleptics are commonly used for behavioral control in this population, but these drugs often fail to control symptoms, and carry a high risk of movement disorders. Because the AIDS virus attacks the basal ganglia, these patients are highly susceptible to neuroleptic-induced movement disorders that increase the risk of falling. However, low-dose risperidone reportedly carries little risk of movement disorders. METHOD: Nine nursing home patients with AIDS dementia received risperidone for behavioral disturbances (psychomotor agitation, aggressiveness, social withdrawal, uncooperativeness) or psychotic symptoms. Seven were switched to risperidone because their symptoms were unresponsive to conventional neuroleptics and adjunct benzodiazepines, antidepressants, or methylphenidate. One patient was switched because of a neuroleptic-induced movement disorder, and one had no history of antipsychotic medication. Patients were followed up only for periods ranging from 2 weeks to 4 months, because AIDS dementia is a terminal-stage condition for AIDS patients. RESULTS: Patients varied in age from 28 to 57 years. Risperidone dosages ranged from 0.5 mg daily to 1 mg twice daily. Most patients received an adjunct benzodiazepine, antidepressant, or mood stabilizer. Within a week or so after starting risperidone, six of the nine patients exhibited brighter mood, were less agitated or aggressive and more cooperative, and participated more frequently in social activities. Two patients became increasingly agitated or psychotic, and came under control only after risperidone was stopped and replaced with haloperidol. One patient was transferred to a psychiatric unit, because of increased paranoid delusions and auditory hallucinations. CONCLUSIONS: Risperidone effectively controlled behavioral disturbances associated with AIDS dementia in 6 of 9 patients. Risperidone may be an alternative to conventional neuroleptics in patients susceptible to neuroleptic-induced movement disorders or unresponsive to neuroleptics and adjunct psychotropic agents.
AIDS Dementia Complex↗
The effects of guided participation and systematic desensitization in the treatment of a paranoid alcoholic: a case report.
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Adult↗
Paranoia--prognosis and treatment: a review.
Contemporary research indicates that paranoia is directly related to good premorbid adjustment. Also, paranoids tend to have shorter hospitalizations and better recovery of social functioning than nonparanoids, although prognosis for full remission of symptoms is poor. A substantial minority of patients with an early diagnosis of paranoia deteriorate into a more withdrawn nonparanoid psychosis. When remission of paranoid symptoms occurs without chronic deterioration, there is a greater likelihood of relapse than there is for nonparanoid psychoses. In regard to treatment, good premorbid paranoid schizophrenics respond rather well to phenothiazines, whereas good premorbid nonparanoid schizophrenics tend to deteriorate under the influence of standard medication. Systematic desensitization is effective in reducing delusional behavior, but generalization is limited. Many discussions and case studies support the use of psychotherapy with paranoids, but no conclusive outcome studies have been reported. Group therapy, cognitive therapy, and milieu therapy hold promise but need systematic evaluation.
Behavior Therapy↗
Delusion of maternity.
A few case reports on the delusion of pregnancy can be found in the published literature. However, the delusion of maternity, a delusional conviction of the patient that she is a mother of one or more children, has not yet been studied closely. The author describes the case of a 62-year-old childless patient with a diagnosis of chronic paranoid schizophrenia. She developed a delusion of maternity, persistent for many years. This markedly influenced her behaviour.
Delusions↗
Behavioral and medical treatment of chronic polydipsia in a patient with schizophrenia and diabetes insipidus.
OBJECTIVE: This case report describes a novel outpatient behavioral treatment intervention for chronic polydipsia. The program was used in an effort to reduce excessive fluid intake in a woman with chronic paranoid-type schizophrenia who also had a diagnosis of diabetes insipidus. METHODS: The 12-session individual behavioral intervention incorporated self-monitoring, stimulus control, coping skills training, and reinforcement components. RESULTS: The patient engaged fully in the treatment program, and she successfully restricted her fluid intake. Her diabetes insipidus could therefore be treated with desmopressin, a medication that requires fluid restriction, and she experienced a concomitant reduction in polyuria and urinary incontinence. CONCLUSIONS: The outpatient behavioral intervention demonstrated promising outcomes in a chronically mentally ill patient whose polydipsia had underlying psychogenic and physiological components. This case highlights the efficacy of combining behavioral and medical interventions.
Ambulatory Care↗
Familial presenile dementia with psychosis associated with cortical neurofibrillary tangles and degeneration of the amygdala.
We report a family in which 13 members in three generations had the presenile (age 42 to 66 years) onset of dementia with an autosomal dominant pattern of inheritance. An early symptom in eight individuals was prominent antisocial psychotic or belligerent behavior, often leading to the initial clinical diagnosis of paranoid schizophrenia. Duration of illness was longer than is usual in Alzheimer's disease (AD), ranging from 14 to 26 years in six members. Three affected siblings and a cousin have come to autopsy, and all had neurofibrillary tangles without senile plaques in several regions of the neocortex, amygdala, and parahippocampal gyrus. The hippocampus was free of both neurofibrillary tangles and senile plaques in all four, but in three there was neuronal loss with gliosis in the CA1 region of Ammon's horn bilaterally. There also was neuronal loss and neurofibrillary tangles in the nucleus basalis. The neurofibrillary tangles were tau-2 and Alz-50 positive and were composed of paired helical filaments ultrastructurally. The disease in this kindred appears to be a unique hereditary disorder that is distinct from familial AD.
Alzheimer Disease↗
Acute behavioral symptomatology at disappearance of epileptiform EEG abnormality. Paradoxical or "forced" normalization.
Paradoxical or "forced" normalization of the EEG of patients with epilepsy was first described by Landolt in 1953. It refers to conditions where disappearance of epileptiform discharge from the routine scalp EEG is accompanied by some kind of behavioral disorder. The best known of these is a paranoid psychotic state in clear consciousness, which is also known as "alternative" psychosis. Thus, the issue is related to much older observations which indicated a "biological antagonism" between productive psychotic symptomatology and epileptic seizures, which led to the therapy of psychoses with artificially induced convulsions. Apart from psychotic episodes, the clinical manifestations of PN comprise dysphoric states, hysterical and hypochondriacal syndromes, affective disorders, and miscellanea. PN can be observed in both generalized and localization-related epilepsies as a rare complication. A subset where it is more frequently seen are in adults with persistent absence seizures when the latter become finally controlled by succinimide therapy. These seem to be the drugs with the highest hazard of precipitation of PN, but all other AEDs have also been suspected. Sleep disturbance by succinimide treatment may play a crucial role, but a variety of other factors are also involved, including psychosocial factors. The pathogenesis of this condition has given rise to some debate but remains still unresolved. Eleven of the most important hypotheses have been discussed and seem to converge into a more comprehensive hypothesis which basically assumes that, during PN, the epilepsy is still active subcortically, perhaps with spread of discharge along unusual pathways. This activity is supposed to provide energy and, possibly, some of the symptoms included in the psychotic syndrome. A critical clinical condition results, usually with a dysphoric symptomatology, where a development towards psychosis is impending but still depends on the presence or absence of a variety of risk factors. Along with neurophysiological factors such as powerful inhibition of the spread of epileptic discharge, these may also include biographic factors such as the repeated experience of ictal sudden, unexpected loss of consciousness. Because during PN there presumably is ongoing epileptic activity, the differences with respect to other psychotic conditions in epilepsy are probably subtle rather than fundamental. Thus, it could be that ictal psychosis is characterized by a direct expression of epileptic activity, whereas in postictal psychosis a momentum of exhaustion may be added; moreover, in PN the prevailing pathogenic factor could be an abnormally high level of balance between excitatory and inhibitory processes.
Acute Disease↗
Neuroleptic treatment in the borderline patient: advantages and techniques.
A low-dose neuroleptic strategy is indicated in borderline personality disorder as an acute treatment for symptoms of anger, hostility and suspiciousness, referential thinking and paranoid ideation, anxiety and dissociation, depressed mood, and related behavioral dyscontrol. Medication effects are clinically significant although modest in magnitude. Recommended duration of treatment is generally brief (3-12 weeks), although continued pharmacotherapy may be warranted in selected cases. The risks of treatment include the well-recognized side effects of neuroleptics (minimized by low doses) and the possibility of abuse, overdose, or interaction with alcohol or street drugs. Pharmacotherapy is seen as an adjunct to supportive psychosocial intervention.
Antipsychotic Agents↗
[Psychological and behavioral disorders with good outcome in neurosarcoidosis].
INTRODUCTION: Neurological involvement is observed in 5% of cases of sarcoidosis and includes impairment of the central nervous system, the meninges, and the cranial and peripheral nerves. Besides neurological defects, cognitive impairment may be encountered ranging from isolated memory defect to dementia. EXEGESIS: We report a case of neurosarcoidosis occurring in a 40-year-old woman, a native of Reunion Island, with initial meningeal and hypophyseal involvement. Three years later, while treated with low dose prednisolone and methotrexate, she presented a paranoid state associated with cognitive impairment of frontal type and severe behavioral disturbances. After 2 years of high dose steroid treatment associated with hydroxychloroquine, her behavioral status improved, allowing social and familial reinsertion. CONCLUSION: In our observation, sarcoidosis was revealed through a central neurological impairment, with chronic meningitis, facial nerve palsy, and, finally, through psychiatric symptoms and severe behavioral disturbances. A slow favorable outcome was obtained using high dose methylprednisolone and hydroxychloroquine with total regression of behavioral disturbances but with persisting cognitive alteration.
Adult↗
Propranolol-induced psychosis.
A 53-year-old black male with no history of neuropsychiatric behavioral problems was treated successfully with propranolol, furosemide, and minoxidil for previously uncontrolled hypertension. However, paranoid ideations, illusions, severe combativeness, and visual hallucinations developed shortly after initiation of the listed therapy. When atenolol was substituted for propranolol, all psychotic behavior resolved.
Haloperidol↗
Day treatment of patients with personality disorders: experiences from a Norwegian treatment research network.
This study sought to investigate the following research questions: Are time-limited day treatment programs for patients with personality disorder (PD) effective outside resourceful university settings, and what are the overall treatment results when the program is implemented on a larger scale? Do all categories and subtypes of PDs respond favorably to such treatment? How intensive should such day treatment programs be? All patients (n = 1,244) were consecutively admitted to eight different treatment programs in the Norwegian Network of Psychotherapeutic Day Hospitals from 1993 to 2000. Altogether, 1,010 patients were diagnosed with PD. Avoidant, borderline, not otherwise specified (NOS), and paranoid PD were the most common conditions. SCID-II and MINI were used as diagnostic instruments. Outcome measures included GAF Global Assessment of Functioning, (GAF; American Psychiatric Association, 1994), SCL-90R, CIP, Quality of Life, work functioning and parasuicidal behavior, measured at admittance, discharge and 1-year follow up. The attrition rate was 24%. The number of dropouts did not improve over time. As a group, completers with PD improved significantly on all outcome variables from admittance to discharge and improvement was maintained or increased at follow up. Treatment results were best for borderline PD, cluster C patients, PD NOS and No PD, and poorer for cluster A patients. Units with a high treatment dosage did not experience better outcomes than those with a low treatment dosage (10 hours per week). Results from the University unit were not better than those from units at local hospitals or mental health centers.
Adult↗
Desirable versus undesirable life events: their relationship to stress and mental distress.
The research of Holmes, Rahe, and their associates disclosing that life events and stress are related to the onset of physical illness is extended to the psychological domain in the present study. Using a modified version of their life events checklist, it is shown that an accumulation of life events is correlated with self-reported tension and distress, with emotional disturbances manifested by depression, paranoid thinking, suicidal proclivity, and anxiety, as well as with behavioral indications of stress such as drinking and traffic accidents. Most importantly, it is shown that these relationships do not hold for desirable life events but primarily for undesirable events. Thus, the authors suggest that the quality of the events in terms of their desirability is the crucial determinant of stress and the above-mentioned relationships rather than simply the life change produced by the events, as suggested in earlier studies. Methodological and theoretical implications for future research are discussed, emphasizing the importance of studying additional stress-relevant dimensions such as anticipation of the events and control over their outcome.
Affective Symptoms↗
Psychopathology, mother-child interaction, and infant development: substance-abusing mothers and their offspring.
The course of severe depressive symptoms from pregnancy to 6 months postpartum, as well as the occurrence of severe paranoid symptoms prenatally, were examined by the Millon Clinical Multiaxial Inventory I and the Beck Depression Inventory, in 78 women who were heavy, chronic cocaine users and who retained custody of their children after birth. Six months postpartum, the quality of caregiving was observed and assessed in the home, and the children were assessed on the Bayley MDI Index in the laboratory. Mothers who were depressed and paranoid prenatally, regardless of whether the depression continued to 6 months postpartum, were less sensitive in caregiving than women without severe symptoms of paranoia or depression during pregnancy or those who reported only depression that lifted by 6 months postpartum. Mothers who were depressed prenatally and continued to be depressed by 6 months postpartum, regardless of the presence or absence of paranoia, had infants who earned lower Bayley MDI scores than the offspring of women without severe psychological symptoms or women whose depression had lifted. Severe depressive symptoms during pregnancy, if they did not continue to 6 months postpartum, did not appear to adversely influence either caregiving or infant functioning.
Adult↗