seminar on psychopathology of delusion..

1. By: Dr. Azfer Ibrahim Jr1
Moderator : Dr. Amir Usmani
Asst.Professor

2.  Formerly called paranoia or paranoid disorder.
 Esquirol (1838) - monomania - characterize delusions
with no associated defect in logical reasoning or
general behavior.
 Kahlbaum (1863) – paranoia - partial insanity that
affects the intellect but not other areas of functioning.

3.  Kraepelin – paranoia - persistent delusional system in
the absence of hallucinations and personality
deterioration.
 Bleuler – paranoia: distinct from schizophrenia; rare
condition.
 Freud – hypothesis that paranoid delusions develop
from repressed homosexual impulses.

4.  Although non-specific concepts of madness have been
around for several thousand years,
 The psychiatrist and philosopher Karl Jaspers was the
first to define the 3 main criteria for a belief to be
considered delusional in his book General
Psychopathology,1913.

5. These criteria are:
 certainty (held with absolute conviction)
 incorrigibility (not changeable by compelling
counterargument or proof to the contrary)
 impossibility or falsity of content (implausible, bizarre
or patently untrue).

6.  Fish defines delusion under heading Disorders of the
content of thinking
“as a false, unshakeable belief that is out of
keeping with the patient’s social and cultural
background and is due to internal morbid process”

7.  Is it all true or is just a working definition

8.  False
“is delusion always be false”

9. Case 1.
A man with delusion of infidelity suspected that
his wife was having affair with his neighbour , due to
repeated stress wife actually developed affair..
 delusion will not cease to exist

10.  Case 2
The same man(case 1) with delusion of infidelity
suspected his wife , and in reality his wife was
cheating…but the reason he gave for his delusion
(delusional evidence) was that the hair of his wife was
turning brown(she recently colored her hair) because
she is having affair with Mr.Brown(his nieghbour)

11.  Being false is not an essential criteria for delusion , it
just makes it easy to identify…

13.  The definition does not characterize the delusional
process,only the end result.
 Like delusions, obsessions and over-valued ideas are
also false notions held with great conviction despite
evidence to the contrary.
 They also result from faulty conclusions, but the
connection between the evidence and the conclusion
makes better sense.

14.  What descriptively defines a delusion is the greater
leap from the evidence to the idea (e.g. “my poor cell
phone service means my neighbors are aiming
electronic beams at my house”),
 or the lack of any reasonable understanding of how
the conclusion was reached (e.g. “they are aiming the
electronic beam because the neighbor’s new dog has
brown spots”).

15.  Karl Jaspers considered the lack of understandability
of how the patient reached the false conclusion to be
the defining factor of a delusional idea.
 The content of the delusional idea can be mundane
(e.g. my spouse is unfaithful)
 or fantastic (e.g. “my spouse is an alien here to conquer
the earth”).

16.  Compared to obsessions and over-valued ideas,
delusional ideas are more often culturally or class
deviant (e.g. the stockbroker believes a witch inhabits
his computer)
or overtly strange (e.g. the patient is convinced he is
dead).
 Delusional ideas also reflect a psychopathological
process that distinguishes them from obsessions and
over-valued ideas.

17.  uncertain and may differ from one disorder to
another.
 Dysfunction of prefrontal and temporal lobes
(Leposavic et al, 2009) and the basal ganglia (Morrison
and Murray, 2009) has been suggested.
 Dysregulation of dopamine (hardly surprising as
dopamine blockade is the most successful T/t).
 endocannabinoid and adenosine systems may be
involved (Morrison and Murray, 2009).

18.  Like perceptual dysfunctions that may arise from ds.
anywhere along the sensory pathways.
 Pathophysiology of delusions may begin at any level of
the nervous system leading to an articulated
conclusion of thought.
 Neuropathology of the process is unclear.

19. Stages in the development of a delusion (Fish, Conrad)
1. Trema – delusional mood
2. Apophany – search for a new meaning
3. Anastrophy – heightening of the psychosis
4. Consolidation – formation of a new world
5. Residuum – eventual autistic state

20.  Delusions that arise from other psychopathology are
defined as secondary delusions.
 delusional process begins with the sufferer perceiving
the immediate environment in such a way that the
delusional conclusion is inescapable.
 Hollywood offers examples of this in films about the
supernatural and extraterrestrials.

21. images on the screen are compelling, and the
audience is frightened.
false images trigger a physiological
flight/fight response
over-riding cortical modulation of the sham
emotional experience, not initially cognitive as
audience members are fully aware of the subterfuge.

22.  Persons in other settings experiencing equally
powerful but false perceptions of their immediate
environment
 i.e. hallucinations or perceptual distortions will also be
frightened.
 Intense and prolonged false perceptions over-ride
cortical modulation.

23.  And despite the protestations of others, the experience
elicits false conclusions based on “I saw it with my
own eyes”.
 The delusional process unfolds, the false perception
eliciting a strong emotional response compromising
judgment and self-assessment,which in turn results in
a false but inescapable delusional conclusion.

24.  The initiating perceptual disturbance trigger an
emotional response strong enough to overcome
judgment, accepting the false interpretation of the
experience:
“it’s real and dangerous” rather than “I’m
hallucinating”.
 This mechanism has been proposed to explain the
delusions in persons with schizophrenia,Capgras,
Fregoli, and delusions of misidentification.

25.  If perceptual processing is intact, a secondary delusion
may still develop if the person’s self-monitoring ability
is overwhelmed by intense and prolonged emotion.
 Delusions associated with depressive illness and manic
states are examples.
 The abnormal emotional state evokes abnormal
memories and compromises judgment.

26.  The compromised judgment confirms the validity of
the abnormal memory and emotional experience,
leading to the delusional idea.

27.  If perceptual processes and emotional expression are
intact, a delusion may still emerge if thinking is faulty
and self-monitoring is compromised.
 These delusions are characterized as primary.
 e.g. delusions associated with cognitive disorders.

28.  when perceptual processing is normal but the memory
of what is being perceived is faulty or not fully
accessible.
 The continuous mismatch is first disturbing, then
frightening and, compromising judgment, leads to the
delusional conclusion.

29.  DM or delusional atmosphere, is a state of unease
during which the immediate environment feels
strange, threatening or ominously changed.
 The sufferer is apprehensive, puzzled, but “senses”
that “something odd is going on”.
 DM emerge in the early phase of a psychotic episode
and may persist for weeks before fully formed
delusions evolve.

30.  often emerge from a delusional mood.
 typically based on biased perceptions that encourage a
morbid self-reference.
 A passer-by’s cough, an ad in the newspaper, a cloud in
the sky are perceived as being odd and then thought to
have specific meaning for the pt.

31.  DP is one of Schneider’s first rank symptoms.
 It is a delusion derived from a presumed accurate
perception that is then given personal significance,
without an understandable connection b/w the
delusional idea and the perception.

32.  Experience of control and alienation.
 sufferer feels helpless during the experience, either
being controlled by an outside force or inhabited by
another person’s thoughts.

33.  Delusions can be categorized in various ways.
 may be both bizarre and systematized.
 Bizarre delusions are absurd and factually not possible.
 They often involve gods or supernatural/space
creatures.

34.  are united by a single theme.
 They are often highly detailed and may remain
unchanged for years.
 Non-systematized delusions may change in content
and level of concern, from day to day or even from
minute to minute.

35.  Beliefs that the individual has exceptional beauty,
intelligence or influence.
 they are an important person who is able to help
others, or may report hearing the voice of God and the
saints, confirming their elevated status.
 Found in schizophrenia , drug dependence , organic
brain ds.

36.  Can take many forms.
 People are talking about him, slandering him, spying
on him.
 Delusions of being poisoned or infected.
 They often involve spies, God, Satan or neighbours.

37.  involve the belief that others are controlling the pt.’s
thoughts,
feelings or
actions.

38.  are the belief that the everyday actions of others are
premeditated and make special reference to the pt.
 Commonly pts. complain about being talked about on TV
or the radio.
 Pts. may believe that music played or words spoken on TV
have been specifically chosen to identify or annoy them.
 People crossing the street or coughing may be interpreted
as purposeful actions, performed to indicate something to
or about the pt.

39.  Also called as “delusions of negation”.
 are the belief that part of the individual or the
external world does not exist or individual is dead.
 Financially comfortable individuals may believe
they are destitute, in spite bank statements to the
contrary.
 Pts. who believe they have no head or are dead, are
unable to explain how that could be possible, but
still hold the belief.
 e.g involutional melanocholia

40.  are false beliefs about the body.
 These may be bizarre or non-bizarre.
 bizarre individual believes his nose is made of gold.
 non-bizarre individual believes he has CA rectum,
in spite of -ve reports from a competent doctor who
has examined the rectum.

41.  belief that individuals are guilty of purposefully or
non-purposefully damaging themselves, other
individuals or important property.
 may believe they are guilty of causing the cancer of the
lady who lives next door, or a drought in Central
Africa.
 Delusion of guilt can give rise to delusion of
persecution.

42.  Misnomer.
 Delusion of marital infedility.
 belief that the partner is being unfaithful, and may
involve checking the partner’s underclothes for stains
or foreign pubic hairs.
 Common in schizophrenia,alcohalics.

43.  Delusion of love or the fantasy lover.
 De Clérembault's syndrome.
 belief of the pt. that another person is in love with him
or her.
 Alleged lover may never have spoken to them.
 Found in personality disorders,schizophrenia.

44.  After a traumatic brain injury to the right parietal area,
a 30-year-old man claimed that his parents were
imposters.
 when he was looking at them, but not when speaking
to them on the telephone.
 Unlike normal persons, the patient’s skin conductance
responses to photographs of familiar people, including
his parents, were not greater than his responses to
photographs of unfamiliar people.
 The patient also had difficulty judging gaze direction.

45. Capgras syndrome
First described in 1923.
> 50% of patients with this delusion have identifiable
neurologic ds.
 the pt. recognizes the face, but the emotional
information identifying the face is unavailable and the
pt. is unable to connect the face to the identity,
eliciting the belief that the person is unfamiliar.

46.  A man claimed that his aunt was his mother (who had
died when the patient was 11 years old).
 A man claimed that an aunt whom he strongly disliked
had been transformed into his mother in order to
harm him.
 A woman believed her lover acquired the physical
characteristics of various persons she knew, including
her father.

47.  First described in 1927 by Courbon and Fail and named
after a famous Italian impersonator and mimic
Leopoldo Fregoli.
 Chzd. by the notion that familiar persons are disguised
as famous people,
 that an ordinary stranger is in fact a famous person.
 Each Fregoli syndrome was associated with a
contributing neurologic ds.
 particularly rt.-sided.

48.  it is reported among manic-depressive patients and in
patients after brain injury.
 Nihilistic delusions are beliefs of “being dead” or
having “no brain, nerves, chest or entrails, and” being
“just skin and bone”.
 The most common nihilistic delusion concerned the
body (86%), existence (69%), and immortality (55%)

49.  A man in his twenties became convinced that he was
someone special.
 He concluded that his parents must have adopted him
and that he was related to a famous family whose
name sounded similar to his.
 He claimed that he owned their large corporation.
 At first elated, he became irritable when the corporate
managers refused to acknowledge him.
 He stalked the family and was arrested, and then
hospitalized.

50.  Other than his delusional conviction he showed no
psychopathology.
 Cognitive assessment suggested an executive function
decline.
 Brain imaging identified NPH , which was relieved by
surgical shunting.
 The delusional syndrome resolved.
 The pt. was a periodic marijuana user and periods of
heavy use were followed by a return of his symptoms.

51.  Unlike the typical manic episode that blossoms within
a few days or weeks,
 DD develops gradually with circumscribed ideas of
self-importance, superior accomplishments, bodily
perfections, and the attention of others becoming
more pronounced and then coalescing into a single
delusional conclusion.

52.  Paramnesia false memories derived from illusions in
association with intense emotion.
 Past events become distorted by the present emotional
state or associated delusions.
 When the patient is convinced of the validity of the
clearly false memories, the term is retrospective
falsification or delusional memory.

53.  The schizophrenic “remembers” the implanting of the
transmitter in his brain.
 The melancholic “remembers” past sins.
 The manic “remembers” being an infant in a palace or
great estate.

54.  An error in matching what is being experienced with
recollections.
 Each is a false memory.
 De´ja` vu is the experience of false familiarity:
“I have been here before” or “I have seen this before”
 Jamais vu is the experience of false unfamiliarity:
“I have never done this” or “I have never been here
before”.

55.  French neurologists Ernest-Charles Lasegue and Jean
Pierre Falret in 1877
 described a phenomenon of “psychological contagion”
 as mutually induced false ideas formed by two or more
closely related people.

56.  Some famous examples….

57. Chain Letter PUBLIC NOTICE Time For True Colours
By Order of the King
Please note: If I was crazy I would have been locked up by now
WARNING: YOU ARE GOING TO LIVE FOREVER (Z provides absolute proof)
There is a hell of a lot to the saga but some of the more interesting points of the
WAR so far include my entire body verging on combustion, my brain being
physically altered to the point where it is in tune with the entire universe (but
it’s still me) including God, Satan and all living things, and flying fully
conscious in the flesh (100% link).
Be Aware: You are all in the hands of the gods. Magic is compulsory. Have a
magic day.
‘Tis a fantastic tale vouched for by the fact that Bad Bill and is army of darkness
are too scared to touch or even talk to me when I’ve told the whole world that
they’ve done and where they’re going is no fun but my hands are clean. The
entire planet is coated with agents of Satan, they hate me just because
I’ve told them the truth. Hotapur himself still tried it on occasionally but
he knows he’s lost. (God and Tom incorporated)…

58.  The above “public notice” was part of a one page document
widely distributed throughout a city by its writer.
 The full document is not presented because the second
half made accusations against named people.
 The writer believed the owners of a coffee lounge were
persecuting him. One night he burned the business down.
He was jailed and died in prison, by suicide, days later.
 A prominent pathological feature is the bizarre and
persecutory delusional material.
 It is also difficult to follow the train of thought.

60.  Above passage is from a biography written by a man
who subsequently drowned himself in a river.
 The injections referred to are injections of long-lasting
antipsychotic medication.
 After this man had ceased his injections for 6 months
he began to misinterpret the environment in a
persecutory manner.
 He believed his friends had been “backbiting” and that
a church leader (whose name has been replaced with
“Anonymous”) said that he should be in prison.

63.  The top letter, along with a CD of documents, was
mailed to many police officials neurosurgeons and
psychiatrists at leading hospitals around Australia.
 The writer provided full contact details and welcomed
any response.
 He believes that an implant was placed in his head by
the CIA in 1999 which caused him to attempt suicide.
 He attributes various events over the years (Deaths of
Princess Diana, Dr David Kelly, and others) to the
same process.

64.  These beliefs have the hallmarks of a detailed
delusional system which may have been present for
some years
 The second letter is a response to this individual from
the Australian Federal Police.
 He had written to them regarding his beliefs, and they
responded stating they were unable to help with his
complaint.

65.  Delusions can occur in a range of mental disorders.
 Diagnosis is only possible after consideration of the
complete clinical picture.
 Delusions may occur in schizophrenia, BMD, MDD,
SAD and organic mental disorders.
 In these disorders, delusions are accompanied by
other signs and symptoms.

66.  PSE provides sets of questions to be asked.
1. Iske baare me chahe apko poora yakeen ho phir bhi
kabhi aisa lagta hai ki shayad ye sach nhi hai ya man
ka wahem hai?
2. Kya aisa mahsoos hota hai ki apko kisi bahar ki
taaqat ya shakti ne apne vash me kar rakha hai?
3. Kya aisa lagta hai ki log apki or ishara karke baate
karte hain ya logo ki baato ke dohre matlab hain ya
log aisa kaam karte hain jinka apke liye khaas matlab
ho?

67. 4. Kya aisa lagta hai ki sabhi log apke baare me baat
karte hain?
5. Kya apko koi jaanboojh kar nuksaan pahuchaane ki
koshish kar raha hai? Jaise apko zaher dene ya maar
dene ki koshish kar raha ho?
6. Kya aisa lagta hai ki log apki madad karne ke liye
khaas taur se intejam kar rahe hain?

68. 7. Kya aap me koi khaas baat hai? Ap me koi khaas
taqat ya shakti aa gyi hai?
8. Kya aap bahut dharmik vicharo ke hain?
9. Kya aisa lagta hai ki koi jadoo tona ho raha hai,upari
kasar ya bhoot preto ka asar hai? Ye sab kaise hota
hai?

69. 10. Kya aisa lagta hai ki bijli,xray,machines ka ap par
asar ho raha hai?
11. Apko kaise pata laga ki yahi wajah hai?
12. Kya in dino apko koi khaas anubhav hua hai ya koi
ajeeb baat hui hai?
13. Apko aisa mehsoos hota hai ki apne koi bada paap ya
apraadh kiya hai jiske liye apko saza milni chahiye?

70. Mental Disorder Comment
Delusional Disorder Delusions only. No other prominent additional
symptoms. Usually involve some form of persecution.
Schizophrenia Delusions may take many forms – persecutory or
bizarre - are accompanied by at least some other
symptoms such as hallucinations, problems with
logical thought or self-neglect.
Bipolar Disorder (mania) Delusions associated with undue confidence, elation
and overactivity, rapid speech. Often grandiose plans
to make a fortune or establish world peace.
Major Depressive Disorder Uncommon. Delusions consistent with low mood.
Contents may include terminal illness, loss of assets
or unfounded guilt.
Substance Abuse Disorder Particularly amphetamines. Persecutory
Organic Mental Disorder Rare. Variable presentations.
Anorexia nervosa AN patients may have fears of weight gain which
reach delusional proportions (Steinglass et al, 2007)
Controversial

71.  A new study provides a novel theory for how delusions
arise and why they persist.
 NYU Medical Center researcher Orrin Devinsky, M.D.,
performed an in-depth analysis of patients with
certain delusions and brain disorders revealing a
consistent pattern of injury to the frontal lobe and
right hemisphere of the human brain.
 Delusional misidentifications and duplications:
“Right brain lesions, left brain delusions”

72.  The cognitive deficits caused by these injuries to the
right hemisphere, leads to the over compensation by
the left hemisphere, resulting in delusions.
 Problems caused by these brain injuries include
impairment in monitoring of self, awareness of errors,
and incorrectly identifying what is familiar and what is
a work of fiction.

73.  Delusions result from the loss of these functions as
well as the over activation of the left hemisphere and
its language structures, that ‘create a story', a story
which cannot be edited and modified to account for
reality.
 Delusions result from right hemisphere lesions, but it
is the left hemisphere that is deluded."

74.  In the study, the author finds that most neurologic patients
with delusions usually have lesions in the right hemisphere
and/or bifrontal areas.
 For example, the neurological disorders of Confabulation
(incorrect or distorted statements made without conscious
effort to deceive),
 Capgras (the ability to consciously recognize familiar faces
but not emotionally connect with them)
 Prosopagnosia (patients who may fail to recognize spouses
or their own face but generate an unconscious response to
familiar faces) result from right sided lesions.

75.  In one study, 9 pts. with right hemisphere infarctions
at a stroke rehabilitation unit had frequent delusion.
 While size of the stroke did not correlate when
compared to the control group, the presence of brain
atrophy was a significant predictor of delusions.
 When delusions occurred, it was usually caused by a
right hemisphere lesion.
 Also, one study pointed out that delusional patients
with Alzheimer's disease usually have significantly
more right frontal lobe damage.

77.  Our knowledge of delusions is limited by our inability
to comprehend the patient's irrational thought
process.
 The pathogenesis of delusions likely includes many
mechanisms that span overlapping psychological,
cognitive and neurological disorders.
 Future research should explore the psychological,
cognitive, and psychologic-anatomic systems that
change during the emergence and resolution of
delusions as well as strategies to treat delusions.

78.  Christian Nevell bovee
 “No man is happy without a delusion of some kind.
Delusions are as necessary to our happiness as
realities.”
Thank you