1 2 / 7 2 1 7 / 2 0 1 2 3 : 3 0 : 3 1 P M CHAPTER 6 Schizophrenia and related psychoses 218 Disorders related to schizophrenia Both ICD-10 and DSM-IV describe a number of disorders wh ich show signi \201 cant symptomatic overlap with schizophrenia. It is currently unclear w hether these disorders represent distinct disorders, or (as seems more likely) they share s ome degree of common etiology with schizophrenia. Schizoaffective disorder This disorder has features of both affective disorder and schizoph renia which are present in approximately equal proportion. Its nosological status is uncert ain since some believe it to be a variant of schizophre- nia; others, bipolar disorder; and some believe it represents a point on a continuum of \200\230unitary psychosis \200\231 l ying between schizophrenia and mood disorders.1 Lifetime prevalence is 0.5 \200\2230.8% wit h limited data available on gender and age differences. ICD-10 criteria \200 Schizophrenic and affective symptoms simultaneously present and both are equally prominent. Excludes patients with separate episodes of schizophrenia and affective disorders and when episodes are in the context of substance use or other medical disorder. DSM-IV criteria \200 Major depressive, manic, or mixed episode concurrent with symptoms that meet criterion A fo r schizophrenia. \211 \200 2wks of delusions and/or hallucinations without prominent mood symptoms. Symptoms meeting criteria for a mood episode are present for a substantial portio n of the active and residual periods. The disturbance is not due to the direct physiologica l effects of a drug of abuse or medication or a general medical condition. Treatment As for schizophrenia but treat manic or depressive symptoms as outlined in bipola r disorder (see b pp. 326 \200\22331). Prognosis Depressive symptoms are more likely to sig nal a chronic course com- pared to manic presentations. Good/poor prognostic factors are th e same as for schizophrenia. Overall, prognosis is better than schizophrenia (as there is u sually a non-deteriorating course) and worse than primary mood disorder. Schizotypal disorder Schizotypal disorder is classi \201 ed along with schizophrenia and r elated dis- orders in ICD-10, but along with cluster A/ \200\230odd-eccentric \200\231 pers onality dis- orders in DSM-IV. It shares some of the clinical features of schizophrenia, bu t not the delusions or hallucinations. It is seen in approximately 3% of the general popula tion and approximately 4.1% of psychiatric inpatients. The disorder tends to run a stable c ourse. It is currently viewed as representing \200\230partial expression \200\231 of the schiz- o phrenia phenotype \200\224although the underlying mechanism for this is 06_Semple_Chap06.indd 218 12/7/2012 3:30:31 PM DISORDERS RELATED TO SCHIZOPHRENIA 219 unclear. Evidence for this view includes the fact that monozygotic (MZ) twin studies have s hown an increased risk of schizotypy in the unaffected relative, that schizotypy is more co mmon in the other \201 rst-degree rela- tives of schizophrenic subjects than in the gener al population, and that relatives of schizotypal subjects have an increased risk of schizop hrenia. Symptoms (DSM-IV criteria) Ideas of reference. Excessive social anxiety. Odd beliefs or mag ical think- ing. Unusual perceptions (e.g. illusions). Odd/eccentric behavior or appearance . No close friends/con \201 dants. Odd speech. Inappropriate or constricted affect. Suspic iousness or paranoid ideas. Differential diagnosis Autism, Asperger syndrome, expressive/mixed receptive \200\223expres sive lan- guage disorder, chronic substance misuse, other personality disorders (especially borderline, schizoid, and paranoid). Treatment Risperidone ( \211 2mg/day)2 has some support from an RCT. Other antip- sychotics may also be helpful. There is little evidence in support of other interventions but highly structured supportive CBT may be best. Schizophreniform disorder (Included under \200\230other schizophrenia \200\231 in ICD-10) The original term referred to patients with schizophrenic symptoms with a good prognosis3 a nd now refers to a schizophrenia-like psychosis that fails to ful \201 l duration criterio n for schizophrenia in DSM-IV. The treatment is the same as for an acute episode of schizop hrenia. It is most common in adolescence and young adults and is much less common than schi zophre- nia with a lifetime prevalence of 0.2%. DSM-IV \200 \200 Criteria A, D, and E of schizophrenia are met. An episode of the disorder (including prodro mal, active, and residual phases) lasts at least 1mth but less than 6mths. Speci \201 ed a s with good prognostic features (as evidenced by 2+ of: onset of prominent psychotic sympto ms within 4wks of the \201 rst noticeable change in usual behavior or functioning; confus ion or perplexity at the height of the psychotic episode; good premorbid social and occupat ional functioning; no evidence of premorbid personality disorder; absence of blunted or \202 at affect). Course and prognosis Psychosis lasting for more than 1mth but less than 6mths. Patients ret urn to baseline functioning once the disorder has resolved. Progression to schizophrenia is estimated to be between 60 \200\22380%. Some patients have 2 or 3 recurrent episodes. Treatment Antipsychotics a mood stabilizer and psychotherapy. 1 Mellor C (2007) Schizoaffective, paranoid and other psychoses. In: Stein G and Wilkinson G, eds, Seminars in general adult psychiatry, 2nd rev edn, pp. 187 \200\223201. London: Rcp ssych Publications. 2 Koenigsberg HW, Reynolds D, Goodman M, et al. (2003) Risperidone in t he treatment of schizo- typal personality disorder. J Clin Psychiat 64: 628 \200\22334. 3 L angfeldt G (1982) De \201 nition of \200\230schizophreniform psychoses \200\231. Am J Psy chol 139: 703. 06_Semple_Chap06.indd 219 12/7/2012 3:30:31 PM CHAPTER 6 Schizophrenia and related psychoses 220 Delusional disorder 1: clinical features Essence Delusional disorder is an uncommon conditi on in which patients present with circumscribed symptoms of non-bizarre delusions, but with absence of prominent hallucinations and no thought disorder, mood disor- der, or signi \201 cant \202 attening of affect. Symptoms should have been present for at least 1mth (D SM-IV). ICD-10 speci \201 es at least 3mths for delusional disorder but, if it is less tha n this, allows diagnosis under other persistent delusional disorder. DSM-IV speci \201 es particular subtypes (see Box 6.8). Points to note \200 Patients rarely present directly to psychiatrists. More often they may be seen by other phy sicians due to somatic complaints, lawyers due to paranoid ideas, or the police when they a ct on or complain about their delusions. Careful assessment and diagnosis is vital, because delusions are the \201 nal common pathway of many illnesses (see b p. 222). When delusio nal disorder is discovered, treatment can be fraught with dif \201 culty because of the re ticent nature of such patients. With persistence, a combination of biopsychosocial treatmen ts can be effective. Diagnosing pathological delusions \200\224key points1 Clinical judgment is necessary to dis tinguish delusions from over-valued ideas, particularly when the ideas expressed are not ne cessarily bizarre or culturally abnormal (and may actually have some basis in reality). Suc h judgements may be informed by: \200 The degree of plausibility. \200 Evidence of syst emization, complexity, and persistence. \200 The impact of the beliefs on behavior. \200 Allowing for the possibility that they might be culturally sanctioned beliefs different f rom one \200\231s own. Observation of associated characteristics, including hallucinations. History of \200\230morbid change \200\231. Evidence of other risk factors (see \200 \200 Risk factors, b p. 221). Clinical features Level of consciousness is unimpaired; observed behav- iour, speech, and m ood may be affected by the emotional tone of delusional content (e.g. hyperalertness with p ersecutory delusions); thought process is generally unimpaired, but thought content re \202 ects preoccupation with circumscribed (usually single theme), non-bizarre delusions; h allucinations may occur, but generally are not prominent and re \202 ect delusional ideas (more commonly olfactory/tactile than visual/auditory); cognition and memory are generally intact; insight and judgment are impaired to the degree that the delusions in \202 uence t hought and behavior; risk should be formally assessed (e.g. potential for violence to self and others and past history of previous behavior in \202 uence by delusions) \200\224persi stent anger and fear are risk factors for aggressive \200\230acting-out \200\231 behaviors . Epidemiology Relatively uncommon, but not rare \200\224prevalence esti- mated at 0.025 \200\2230.03% (may account for 1 \200\2232% of hospital admissions); age 06_Semple_Chap06.indd 220 12/7/2012 3:30:31 PM DELUSIONAL DISORDER 1: CLINICAL FEATURES 221 range 18 \200\22390yrs (mean 40 \200\22349yrs); 4 = 5 but delusional jealousy more common i n men and erotomania more common in women; 50% of patients are in employment; 80% are marri ed. Risk factors Advanced age, social isolation, group delusions, low socio- economic statu s, premorbid personality disorder, sensory impairment (particularly deafness), recent immig ration, family history, and history of head injury or substance abuse disorders. Course and prognosis Onset may be acute or insidious. Course is very variable \200\224with treatment: remission (33 \200\22350%), improvement (10%), persisting symptoms (33 \200\22350%). Bette r prognosis in acute subtypes, where stress is a factor, and for jealous or persecutory sub types. If symptoms have persisted for >6mths outcome is worse. Box 6.8 DSM-IV subtypes1 \200 Erotomanic (De Cl rambault syndrome) the belief that some important person is secretly in love with them. Clinical samples are often female and forensic samples contain a prepondera nce of males. Patients may make efforts to contact this person, and some cases are associat ed with dangerous or assaultive behavior. Grandiose special relationship, or possess some s pecial ability(ies).They may be involved with social or religious organizations. Jealous th eir spouse or partner has been unfaithful. Often patients try to collect evidence and/or at tempt to restrict their partner \200\231s activities. This type of delusional disorder has been associated with forensic cases involving murder. Persecutory This is the most common p resentation of delusional disorder. Patients are convinced that others are attempting to do them harm. Often they attempt to obtain legal recourse (litigious or \200\230querulous pa ranoia \200\231), and they sometimes may resort to violence. Somatic with physicians reques ting various forms of medical or surgical treatment to patients who are delusionally concer ned with bodily infestation, deformity (see dysmorphophobia b p. 810), or odor. Mixed theme predominating. Unspeci \201 ed listed categories. Patients present with Patients believe they \201 ll some special role, have some 2 (Othello syndrome) Patients possess the \201 xed belief that Varying presentation, from those who have repeat contact Presence of one or more of the above themes; no single The theme cannot be determined or does not \201 t the 1 ICD-10 subtypes are similar: Erotomanic, Grandiose, Jealous, Persecutory, Litigious, Hypo chondriacal, and Self-referential. 2 Shepherd M (1961) Morbid jealousy: some clinical and s ocial aspects of a psychiatric symptom. Journal of Mental Science 107: 607 \200\223753. (Th e \200\230classic \200\231 paper.) 1 Manschreck T (1996) Delusional disorder: the recognition and management of paranoia. J Cl in Psychiat 57(Suppl. 3): 8. 06_Semple_Chap06.indd 221 12/7/2012 3:30:31 PM CHAPTER 6 Schizophrenia and related psychoses 222 Delusional disorder 2: differential diagnosis and etiology Differential diagnoses \200 Substance-induced delusional disorders hallucinogens, steroids, antihistamines, sympathomim etics). Careful history-taking may reveal onset, persistence, and cessation of symptoms to be related to drug use. Other physical disorders investigations should help exclude other d isorders (e.g. head injury, CNS infection, epilepsy). Mood disorders with delusions (manic and depressive types) Mood and related biological symptoms are usually more severe and prec ede delusions. Schizophrenia circumscribed delusions, greater functional impairment. Dement ia and delirium \202 uctuating level of consciousness. Elderly patients (late paraphrenia ) delusional disorder (see b p. 522) and schizophrenia, associated with social isolation, a geing, medical problems/treatments, and sensory loss. Dysmorphophobia/body dysmorphic disor der (see b p. 810) Signi \201 cant overlap with delusional disorder, few signi \201 cant differentiating factors exist. (see b p. 376) Signi \201 cant overlap Obsessive \200\223co mpulsive disorder with delusional disorder and, if reality testing regarding obsessions or compulsions is lost, delusional disorder often is diagnosed. Hypochondriasis more amenable to reality testing and are less \201 xed than in delusional disorder. (see b p. 495) Abse nce of clearly Paranoid personality disorder circumscribed delusions, presence of a pervasi ve, stable pattern of suspiciousness or distrust. Misidenti \201 cation syndromes delusion al disorder, may be associated with other CNS abnormalities. Induced/shared psychotic disor der relatives/close friends share similar delusional beliefs. (e.g. alcohol, stimulants, Focused history, examination, and Presence of psychotic symptoms other than relatively Evidence of cognitive impairment or altered/ Thought to be distinct from (see b p. 808) Health concerns generally are (see b p. 230) Easily confused with (see b p. 228) Evidence that Etiology Delusional disorders represent a heterogeneous group of conditions that appear dis tinct from mood disorders and schizophrenia, although there is signi \201 cant diagnostic (and genetic) overlap with paranoid personality traits/disorder. Data suggest that among pa tients diagnosed with delu- sional disorder, 3 \200\22322% are later reclassi \201 ed as s chizophrenic and fewer than 10% are later diagnosed with a mood disorder. 06_Semple_Chap06.indd 222 12/7/2012 3:30:31 PM DELUSIONAL DISORDER 2: DIFFERENTIAL DIAGNOSIS AND etiology 223 Biological \200 Delusions can be a feature of a number of biological conditions, suggesting possible biolog ic underpinnings for the disorder. Most commonly, neurological lesions associated with the temporal lobe, limbic system, and basal ganglia are implicated in delusional syndromes. Neu rological observations indicate that delusional content is in \202 uenced by the extent an d location of brain injury. Prominent cortical damage often leads to simple, poorly formed, persecutory delusions. Lesions of the basal ganglia elicit less cognitive disturbance and more complex delusional content. Excessive dopaminergic and reduced acetylcholinergic activ ity have been linked to the formation of delusional symptoms. Psychological/psychodynamic \200 Freud proposed that delusions served a defensive function, protecting the patient from intr apsychically unacceptable impulses through reaction formation, projection, and denial. Cogn itive psychology regards delusions as the result of cognitive defects where patients accept ideas with too little evidence for their conclusions; delusions as the result of attemptin g to \201 nd a rational basis for abnormal perceptual experiences. Social/other Certain social situations may increase the chances of developing delusional di sorder, e.g.: \200 \200 \200 \200 \200 \200 distrust and suspicion social isolation jealousy lowered self-esteem people seeing their ow n defects in others rumination over meaning and motivation 06_Semple_Chap06.indd 223 12/7/2012 3:30:31 PM CHAPTER 6 Schizophrenia and related psychoses 224 Delusional disorder 3: assessment and management Assessment Patients with delusional disorder are exceptionally dif \201 cult to assess. At interview they may be evasive, guarded, and suspicious. Often they become irritated, angry , or hostile. They may be overly sensitive to some lines of questioning, even to the point of threatening legal action. Assessment should include: \200 \200 \200 A thorough history and MSE. Information-gathering (third party and other sources). Exclusio n of underlying causation (including physical investigations) to rule out other conditions that commonly present with delusions (see differential diagnosis, b p. 222). Clearly docume nted risk assessment (especially aggression/self-harm). Where there is signi \201 cant risk to another person/partner, duty of care may override p atient con \201 dentiality and allow warning of that individual and/or informing the polic e (see b p. 900). Management Typical obstacles to the treatment of delusional disorder: \200 The patient \200\231s denial of the illness which causes dif \201 culties in establishing a therapeutic alliance. The patient \200\231s experiences of signi \201 cant social and in terpersonal problems (which may con \201 rm their \201 rmly held beliefs). The fact that antipsychotic medication is often of limited ef \201 cacy. Admission to hospital ought to be considered if there is a clear risk of harm to self or vi olence towards others. Otherwise, outpatient treatment is preferred. Approaches to manageme nt include: \200 \200 Separation Pharmacological \200 From source or focus of delusional ideas (if possible). 1 Data for the pharmacotherapy are limited to case reports or small open-label interventions. Given the symptomatic overlap with psychotic disorders, antipsychotics have some utility. There was a widely held anecdotal view supporting the preferential use of pimozide. However , although there are no full-scale clinical trials, what evidence there is suggests that no antispyschotic is preferentially effective; that response rates are around 50%, with 90% o f patients seeing some improvement; and that somatic delusions are the most likely to respo nd. The evidence also favors the use of SSRIs given the overlap with OCD, body dysmorphic d isorder, and mood disorder. Benzodiazepines may be useful when there are marked anxiety sym ptoms. Data for the use of anticonvulsant agents and mood stabilizers are even more limited . 06_Semple_Chap06.indd 224 12/7/2012 3:30:31 PM DELUSIONAL DISORDER 3: ASSESSMENT AND MANAGEMENT 225 Psychological/psychotherapeutic \200 Individual therapy alliance without validating or overtly confronting the patient \200\231s delusional system. Supportive therapy may help with isolation and distress stemming from t he delusional beliefs (reframing problems due to delusional beliefs as symptoms). Cognitive techniques therapy to develop a sense of \200\230creative doubt \200\231 in the internal perception of the world through empathy with the patient \200\231s defensive position. Educ ational and social interventions discussing delusional beliefs in social settings) and mini mizing risk factors (e.g. sensory impairment, isolation, stress, and precipitants of violen ce). requires persistence in establishing a therapeutic : reality testing and reframing. Insight-orientated Social skills training (e.g. not Post-psychotic depression \200 10% or more of delusional disorder patients who respond to antipsychotics may develop sever e depression with risk of suicide. Withdrawal of antipsychotic may improve mood but worsen delusions; hence, the addition of an antidepressant may be indicated whilst maintaining the lowest effective dose of antipsychotic. Later the antidepressant may be gradually withdraw n. 1 Manschreck TC (2006) Recent advances in the treatment of delusional disorder. Can J Psych iatry 51: 114 \200\22319. 06_Semple_Chap06.indd 225 12/7/2012 3:30:31 PM CHAPTER 6 Schizophrenia and related psychoses 226 Acute and transient psychotic disorders (referred to as \200\230Brief psychotic disorder \200\231 in DSM-IV) Clinical features Sudden onset, variable presentation (including per- p lexity, inattention, formal thought disorder, delusions or hallucinations, disorganized or catatonic behavior), usually resolving within less than 1mth (DSM-IV) or 3mths (ICD-10). Et iology Sometimes these disorders occur in the context of an acute stressor (both ICD-10 and DSM-IV allow for specifying \200\230with or without \200\231 marked stressor(s)/acute str ess), e.g. life events such as bereavement, marriage, unemployment, imprisonment, accident, childbirth, or migration and social isolation (with language and cultural factors). Epidem iology Associated with certain personality types (e.g. paranoid, borderline, histrionic); m ore prevalent in developing nations where there is a strong emphasis on traditional values (may demonstrate culture- speci \201 c features, b p. 910). Age of onset is later in indus trialized nations. More common in women. Differential diagnosis \200 \200 Organic disorders \200\224dementia/delirium Bipolar affective disorder (BAD)/depression \200\224delusions of guilt and persecution Drug and alcohol disorders Personality disorder \200\224paranoid/borderline/histrionic Culture-speci \201 c disorders (see Factitious diso rder/malingering Schizophrenia (if it persists for more than 1mth) \200 \200 \200 \200 b p. 910) Management (cf. b p. 224) \200 \200 Assessment is vital to make the appropriate diagnosis. Short-term admission may be necessar y to prevent any suicidal or aggressive tendencies, to provide support, nursing care, and s peci \201 c assistance with psychosocial stressors. Where medication is considered, short- term use of antipsychotics/ BDZs may be helpful (as for acute behavioral disturbance, b p. 988). Antidepressants/mood stabilizers may be useful to prevent relapse/ further episodes. Address speci \201 c social issues and consider reality-orientated, adaptive, supportive p sychotherapy. Course and prognosis \200 By de \201 nition these disorders are brief and resolve within days, weeks, or months. Pro gnosis is better if there is a short interval between onset and full-blown symptoms (DSM-IV : within 4wks). Also better if there is confusion and perplexity, good premorbid social and occupational functioning, and absence of blunted or \202 at affect. Outcome is better th an schizophrenia (both socially and symptomatically). 06_Semple_Chap06.indd 226 12/7/2012 3:30:32 PM ACUTE AND TRANSIENT PSYCHOTIC DISORDERS 227 Relapse is common, with increased mortality and suicide rates compared with the general pop ulation. The chances of recurrence are high and follow-up/low-dose pharmacotherapy is recom mended to continue for at least 1 \200\2232yrs (and withdrawn cautiously with close clinica l review). Box 6.9 ICD-10 subtypes ICD-10 allows for these disorders to occur with or without the pres- ence of an acute stres sor, and outlines the following subtypes: \200 Acute polymorphic psychotic disorder with or without symptoms of schizophrenia \200 Variable and changeable psychotic symptoms (from day to day, or hour to hour) with frequent intense emotional turmoil. Includes Perris \200\231s (1974) \200\230cycloid psychosis \200\231 after Karl Leonard \200\231s description for which the treatment of choice is lith ium (Perris 1978). Also \200\230bouff e d lirante \200\231 (Magnan 1895), the concept of which was reviewed by Allodi (1982) who stressed the avoidance of long-term medication, hi ghlighting sociocultural factors, especially migration and language. Acute schizophrenia-like psychotic disorder \200\230brief schizophreniform psychosis \200 \231 or \200\230schizophrenic reaction \200\231 where the psychotic symptoms are relativel y stable but have not lasted more than a month (ICD-10, DSM-IV brief psychotic disorder), o r have lasted between 1mth and 6mths (DSM-IV schizophreniform disorder). Other acute predom inantly delusional psychotic disorder . \200 Also referred to as Onset is acute (2wks or less), delusions or hallucinations present most of the time. If del usions persist for longer than 3 mths, then the diagnosis is that of persistent delusional disorder (see b p. 220). Includes the Scandinavian concept of \200\230psychogenic/reactive psychosis \200\231 for which the prognosis is good and the treatment of choice is supporti ve psychotherapy and the short-term use of medication (Stromgren 1989). \200\230Hysterical psychosis \200\231 (Hirsch and Hollander 1969), which includes 3 subtypes: culturally sanc tioned behavior (like culture-speci \201 c disorders); appropriation of psychotic behavior (conversion process); true psychosis ( \200\230failure of repression when faced with acute stress in a vulnerable ego \200\231, in e.g. histrionic personality) \200\223 \200\223in U SA this is used as a diagnostic label for \200\230reactive psychosis \200\231. \200\230Ga nser syndrome \200\231 \200\224characterized by approximate answers, disorientation, cloudi ng of consciousness, hallucinations, motor disturbance, anxiety or apathy, normal activitie s of daily living (ADLs), sudden resolution with amnesia for the period of illness. Propose d mechanisms read much like the differential diagnosis for acute and transient psychotic di sorders (see b p. 226): hysterical conversion, organic confusion, psychosis, or malingering . 06_Semple_Chap06.indd 227 12/7/2012 3:30:32 PM CHAPTER 6 Schizophrenia and related psychoses 228 Induced delusional disorder (referred to as \200\230Shared delusional disorder \200\231 in DSM-IV) Also known as \200\230folie deux \200\231 (or even \200\230folie trois \200\231 or \200\230folie familie \200\231!), this disorder was recognized and describe d by Harvey as early as 1651, and recently reviewed as a concept by Howard in 1994. Silveir a and Seeman (1995) also reviewed the literature and found equal sex ratio; broad range of ages; 90% couples, siblings, or parent/child; comorbidity with depression, dementia, and me ntal retardation; 2/3 socially isolated; and a common association with hallucinations. With out intervention the course is usually chronic. The content of the shared belief depends up on the delusions of the individual with the primary illness. Examples may include: persecut ory beliefs ( \200\230them \200\231: the paranoid pseudocommunity1 \200\224 Cameron, 1949), delusional parasitosis, delusional belief in a place being haunted, belief in having a chi ld who does not exist, other misiden \201 ciation delusions, or apocalyptical beliefs in c ults and quasi-religions (with the serious risk of altruistic mass suicide). Subtypes \200 Folie impos e illness are adopted by another healthy individual (separation alone usually cures the normally healthy individual). Folie simultan e develop the same delusions at the same time. Folie communiqu adopts the delusions of a person with primary psychotic illne ss (separation is less successful without other interventions). Folie induite patient has a dopted their fellow patient \200\231s delusions. \200\224the delusions of an individual with a primary psychotic \200\224when two persons with primary psychotic illness \200\224after a period of resistance, a healthy individual \200\224pre-existing primary psychosis in both patients, but one Etiology Psychodynamic theories These include the fear of losing an important relationship in an oth er- wise isolated individual with little scope for reality testing; or the passive acceptor has repressed oedipal fantasies that are released by the psychotic partner causing identi \201 cation of dominant partner with a parent. Learning theory Psychotic thinking is learned through \200\230observational learning \200 \231. Social isolation Isolation due to language, geographical barriers, and personality may also play a part in the development of the illness. Management \200 \200 Separation \200\224may lead to complete remission in up to 40% of cases. Psychological \200 \224aimed at giving up delusional beliefs (equivalent to rejecting a close relationship). P harmacological \200\224for the active case of folie simultan e when both patients require treatment). not the passive partner (except in the 06_Semple_Chap06.indd 228 12/7/2012 3:30:32 PM INDUCED DELUSIONAL DISORDER 229 1 Cameron N (1949) The paranoid pseudo-community. American Journal of Socialogy 49: 32 \200 \2238. 06_Semple_Chap06.indd 229 12/7/2012 3:30:32 PM CHAPTER 6 Schizophrenia and related psychoses 230 Delusional misidenti \201 cation syndromes Usually manifest as symptoms of an underlying d isorder (e.g. schizophre- nia, mood disorder, delusional disorder, organic disorder), these syn- dromes rarely occur in isolation and hence are not included separately in ICD-10 or D SM-IV. Recently, interest has been focused on these rare (and bizarre) symptoms because of the insight they may give into the normal functioning of the brain (a \200\230lesion \200 \231 paradigm). Examples include: Capgras delusion (l \200\231illusion de sosies) \200\224the patient believes others have be en replaced by identical or near identical imposters. Can apply to ani- mals and other obje cts, and often associated with aggressive behavior. Fr goli delusion (l \200\231illusion de Fr goli) \200\224an individual, most often unknow n to the patient, is actually someone they know \200\230in disguise \200\231. The individu al is often thought to be pursuing or persecuting the patient. Intermetamorphosis delusion \200\224the patient believes they can see others change (usuall y temporarily) into someone else (both external appearance and internal personality). Subjective doubles delusion \200\224the patient believes there is a double ( \200\230dop- p elg nger \200\231) who exists and functions independently. Autoscopic syndrome \200\224the patient sees a double of themselves projected onto other pe ople or objects nearby. Reverse subjective double syndrome \200\224the patient believes that they are an imposter i n the process of being physically and psychologically replaced. Reverse Fr goli syndrome \200\224the patient believes others have completely misidenti \201 ed them. Etiology Psychodynamic Views include seeing these syndromes as the extremes of normal misidenti \201 cation due to intense focusing on particular details; the effects of beliefs/emotions on perception; the effects of vivid imagination in a person experiencing a disorder of mood , judgment, and coenesthe- sia; manifestations of the defense mechanisms of projection, spl itting, or regression with loss of identity and \202 awed reconstruction. Biological There may be evidence of underlying right hemisphere dys- function, anterior cor tical atrophy, temporal lobe pathology, bifrontal disconnectivity \200\224with resultant im paired facial recognition, dissociation of sensory information from normal affect, and fail ure to suppress inappro- priate, repetitive behavior. Management \200 \200 \200 Full physical and psychiatric assessment. Interventions should be directed towards any unde rlying problem. Antipsychotics/anticonvulsants may also treat clearly organic cases. 06_Semple_Chap06.indd 230 12/7/2012 3:30:32 PM 231 Chapter 7 Depressive illness Introduction 232 Historical perspective 234 Diagnosis 1: symptoms 236 Diagnosis 2: caseness and subtypes 238 Diagnosis 3: other clinical presentations 240 Epidemiology 242 Etiology 1 244 Etiology 2 246 Differential diagnosis 248 Diagnosis and investigations 249 Course and prognosis 250 Management principles and outpatient treatment 252 Hospital admission 254 Tre ating depressive illness (without psychotic features) 256 Treating depressive illness (with psychotic features) 258 An approach to treatment-resistant depression 260 Atypical depress ive episode 262 Seasonal affective disorder (SAD) 263 Dysthymia (ICD-10)/dysthymic disorder (DSM-IV) 264 Antidepressants 266 Tricyclic antidepressants (TCAs) 270 Monoamine oxidase in hibitors (MAOIs) and reversible monoamine oxidase inhibitors (RIMAs) 272 Selective serotonin reuptake inhibitors (SSRIs) 27 6 Other antidepressants 1 278 Other antidepressants 2 280 ECT 1: background 282 ECT 2: indi cations, contraindications, and considerations 284 ECT 3: work-up and administration 286 EC T 4: notes on treatment 290 ECT 5: further notes on treatment 292 ECT 6: side-effects and o ther speci \201 c problems 294 Neurosurgery for mental disorder (NMD) 296 Other physical t reatments 298 07_Semple_Chap07.indd 231 12/10/2012 6:36:06 PM CHAPTER 7 Depressive illness 232 Introduction Depressive disorders are common, with a prevalence of 5 \200\22310% in primary care settings. They rank fourth as causes of disability worldwide, and it has been project ed that they may rank second by the year 2020. The preva- lence of depressive symptoms may be as high as 30% in the general popula- tion with women being twice as likely to be affect ed as men. Although effective treatments are available, depression often goes undi- agnosed and undert reated. Symptoms often are regarded by both patients and physicians as understandable given current social circumstances and/ or background. Although in many cases this may be true, people should not be denied interventions that may help relieve some of the disabling sympt oms of the disorder, allowing them to cope better with any current social problems. It should be borne in mind that depressive disorder has signi \201 cant potential morbidit y and mortality. Suicide is the second leading cause of death in persons aged 20 \200\22335 yrs and depressive disorder is a major factor in around 50% of these deaths. Depressive dis order also contributes to higher morbidity and mortality when associated with other physica l disor- ders (e.g. myocardial infarction [MI]) and its successful diagnosis and treat- men t has been shown to improve both medical and surgical outcomes. It is also associated with high rates of comorbid alcohol and substance misuse, and has a considerable social impact o n relationships, families, and productivity (through time off work). The majority of patients will present to primary care, often with prob- lems other than low mood (see b p. 240). Physicians ought to remain alert to this possibility as early interve ntions may be critical in the preven- tion of major morbidity and comorbidity. There remains an innate reluctance to consider pharmacological inter- ventions for emotiona l problems, despite overwhelming evidence of ef \201 - cacy. There is also a widespread co ncern that drugs which improve mood must be addictive, despite evidence to the contrary. Wh ile medication is not the only possible treatment for mild to moderate depression, when ant idepressants are prescribed the onus is on the physician to give a thera- peutic dose for a n adequate length of time. Treatment failure is often due to patient non-compliance, partic ularly when the patient feels that their problems have not been taken seriously and they ha ve been \200\230fobbed off \200\231. In a group of patients who generally have feelings of low self-worth or guilt, it is critical that they understand the rationale behind any trea tment, and that their progress is regularly reviewed, at least in the early stages. Depression amongst the famous As depression is common it is not surprising that many famous people have had a depressive illness (see Box 7.1). However, there still remains a stigma attached to psychiatric illness and it is only recently that peo- ple have become more will ing to discuss their illnesses publicly. A recent study examined the lives of almost 300 wo rld-famous men and found that over 40% had experienced some type of depression during their lives.1 Highest rates (72%) were found in writers, but the incidence was also high in arti sts (42%), politicians (41%), intellectuals (36%), composers (35%), and scientists (33%). 07_Semple_Chap07.indd 232 12/10/2012 6:36:06 PM INTRODUCTION 233 Box 7.1 Famous people who have publicly stated they have had a depressive illness include: Alanis Morissette, musician, composer Anthony Hopkins, actor Barbara Bush, former First Lad y (US) Billy Joel, musician, composer Courtney Love, musician, actor Donny Osmond, musician Ellen DeGeneres, comedienne, actor Elton John, musician, composer Germaine Greer, writer H alle Berry, actress Harrison Ford, actor Janet Jackson, musician Jessica Lange, actress Jim Carrey, actor, comedian Joan Rivers, comedienne, TV host John Cleese, comedian, actor, wri ter Leonard Cohen, musician, writer Lou Reed, musician Marie Osmond, musician Marlon Brando, ac tor Monica Seles, athlete (tennis) Ozzy Osbourne, musician Paul Gascoigne, professional foo tballer Paul Merton, comedian Paul Simon, composer, musician Roseanne Barr, actress, writer , comedienne Sheryl Crow, musician Sinead O \200\231Connor, musician S.P. Morrissey, musici an Stephen Hawking, scientist, writer Winona Ryder, actress Other famous people (deceased) known to have had a depressive illness: Samuel Beckett, Mena chem Begin, Kurt Cobain, Michel Foucault, Judy Garland, Ernest Hemingway, Audrey Hepburn, W illiam James, Franz Kafka, Claude Monet, Richard M. Nixon, Laurence Olivier, Wilfred Owen, George S. Patton, Sylvia Plath, Jackson Pollock, Cole Porter, Mark Rothko, Dmitri Shostakov ich, Tennessee Williams, Yves Saint Laurent. 1 Post F (1994) Creativity and psychopathology. A study of 291 world-famous men. Br J Psych iat 165: 22 \200\22334. 07_Semple_Chap07.indd 233 12/10/2012 6:36:06 PM CHAPTER 7 Depressive illness 234 Historical perspective The changing face of depression1 Current ideas of what constitutes d epression date from the mid-18th cen- tury. Earlier, the illness was understood in terms of \200\230melancholia \200\231, from classical humoural theories (melancholia derived from the Greek melaina kole \200\224black bile), re \202 ecting \200\230intensity of idea \200 \231 (Haslam 1809), i.e. the pres- ence of few, rather than many, delusions. Sadness or low mood were not primary symptoms. The \200\230melancholic \200\231 symptoms we now regard a s part of depressive disorder would have been called \200\230vapors \200\231, \200\230hyp ochondria \200\231, or \200\230neuroses \200\231. \200\230Depression \200\231, a term use d to mean \200\230reduced functioning \200\231 in other medical disciplines, came to be as sociated with \200\230mental depression \200\231, adopted because it implied a physiologic al change, de \201 ned as \200\230a condition characterized by a sinking of the spirits, lack of courage or initiative, and a tendency to gloomy thoughts \200\231 (Jastrow 1901). The concept was enlarged and legitimized by Kraepelin (1921) who used the term \200\230dep ressive states \200\231 in his description of the unitary concept of \200\230manic-depress ive illness \200\231, encompassing melancholia simplex and gravis, stupor, fantastical mela ncholia, delirious melancholia, and involutional melancholia. A number of assumptions surro unded the affective disor- ders; they involved the primary pathology of affect, and had sta ble psycho- pathology and brain pathology, were periodic in nature, had a genetic basis, oc curred in persons with certain personality traits, and were \200\230endogenous \200\231 (u nrelated to precipitants).