Tag Archives: delusions

Comparing and Contrasting Dissociative Identity Disorder (DID, Multiple Personality Disorder) with Conversion Disorder (CD)

Dissociative Identity Disorder and Conversion Disorder are similar in that they both stem from stressful events.  In Dissociative Identity Disorder a personality is formed when extreme child abuse or sexual abuse is experienced.  With Conversion Disorder it is a more recent event like a rape or physical or emotional abuse. Other than this similarity the two disorders are quite different.

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Dissociative Identity Disorder is a disorder in which the person affected suffers from as little as 2 distinct personalities and can suffer from as many as 100 or more.  Each personality has a very distinct identity, and will often take control of the person and how they act.  Because of the different identities taking over the people lose time.  They don’t remember the period of time that they were not in control and then have a hard time understanding why everything is different, especially in extreme cases when the other identity takes over for years at a time.  Usually an alternate identity takes over when the primary identity experiences something overly stressful.  It is common for people with this disorder to have other disorders or to have problems with substance abuse.  While DID has been known to last a lifetime, treatment can help.  Treatment usually involves psychotherapy and helps the person to integrate the identities into one.  It can be a painful process as well as time consuming, but according to people who have been able to achieve integration, it is definitely worth it.

Alternatively Conversion Disorder affects people in their sensory areas or physically where voluntary movement is concerned.  It is known to be a somatoform disorder and is said to be a large part of why people visit their primary care physicians.  Basically when people shove their emotions and stress too far inward they turn into physical symptoms.  This is called converting.  The conversion of these symptoms can cause a patient to contact their caregiver nine times as often.  The patient does not control the symptoms and can have a surprisingly painful beginning, and diagnosis can become complicated by a true physical illness.

Conversion Disorder has specific risk factors which include the fact that someone is female, men are less likely to receive this diagnosis.  This diagnosis is more common in the teen years, if there is someone in the family who is already receiving treatment for Conversion Disorder, it is likely to continue in the family line.

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Paranoid Schizophrenia vs Delusional Disorder

Analysis of the common psychopathological features in the various psychotic disorders suggest that symptoms can be clustered into five main categories: (Os & Kapur, 2009, p. 635)

1)      Psychosis, encompassing positive symptoms of delusions and hallucinations.

2)      Alterations in drive and volition, encompassing negative symptoms including lack of motivation, reduction in spontaneous speech, and social withdrawal.

3)      Alterations in neurocognition, encompassing cognitive symptoms including difficulties in memory, attention, and executive functioning.

4)      Affective dysregulation giving rise to depressive symptoms or 5) manic (bipolar) symptoms.

The term schizophrenia is typically applied to a syndrome that is characterized by a long duration, bizarre delusions, negative symptoms, and few affective symptoms (non-affective psychosis).  (Os & Kapur, 2009)  Formerly called dementia praecox, some of its associated features include inappropriate affect, anhedonia, dysphoric mood, lack of insight, depersonalization, and delrealization.  (Colman, 2009, p. 674)  Schizophrenia affects approximately 0.7% of the world’s population, with prevalence greater in men throughout adulthood, but equal by the end of the risk period.  Schizophrenia is highly heritable, with onset being rare before adolescence or after middle age (although men become ill earlier in life than women).  (MacDonald & Schulz, 2009, p. 495)  Schizophrenia subtypes include paranoid, disorganized, catatonic, undifferentiated, and residual types.  This article will focus on paranoid schizophrenia, which tends to be the least severe subtype of schizophrenia.

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“The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusions or auditory hallucinations” where no disorganized speech, disorganized or catatonic behaviors, or flat or inappropriate affect is present.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 313)  Differential diagnosis is an exclusionary process since of all the other subtypes must be eliminated before diagnosing the paranoid subtype.  Paranoid schizophrenia sufferers typically have delusions that are persecutory and/or grandiose; they also typically have a recurrent theme.  Hallucinations are usually related to the same content theme as the delusions, and may include the associate features of anxiety, anger, aloofness, and/or argumentativeness.  Onset tends to be later in life when compared with other subtypes of schizophrenia, and the distinguishing characteristics are often more stable over time.  The prognosis is considerably better when compared with other schizophrenia subtypes, especially regarding occupational functioning and independent living.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 314)

“The essential feature of Delusional Disorder is the presence of one or more non-bizarre delusions that persist for at least 1 month.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 323)  Bizarreness is mostly subjective since it is contingent on socio-cultural norms and expectations.  Bizarre delusions (as in schizophrenia) are “clearly implausible, not understandable, and not derived from ordinary life experiences.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 324)  In contrast, non-bizarre delusions (as in delusional disorder) involve situations that could conceivably happen in real life… like being followed, poisoned, etc.  Subtypes of delusional disorder are categorized based on the content of the delusions or the theme thereof.  They include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified types.  This essay will focus on persecutory delusions, although persecutory delusions often coexist with and are comorbid with other delusion types (particularly grandiose, in mixed presentation).

A determination of persecutory delusions is complicated by the fact that the incidence of persecutory thoughts is relatively common among the general population.  (Brown, 2008, p. 165)  “The criteria used to distinguish between these different categories of psychotic disorder are based on duration, dysfunction, associated substance use, bizarreness of delusions, and presence of depression or mania.”  (Os & Kapur, 2009, p. 635)  In delusional disorders, distortions of reality coexist with realms of rational, realistic thinking.  (Blaney & Millon, 2009, p. 361)  Delusional disorders are distinguished from schizophrenia by the absence of active phase symptoms of schizophrenia (e.g. prominent auditory or visual hallucinations, bizarre delusions, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms).  “Compared with schizophrenia, delusional disorder usually produces less impairment in occupational and social functioning.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 327)

“The assessment of bizarreness is generally absent among lists of delusion dimensions, notwithstanding its key role in the distinction between DD and PS.”  (Blaney & Millon, 2009, p. 365)  To improve decision-making and reduce the chance of misdiagnosis, Brown (2008) suggests we ascertain, to the extent available, base rates of the specific persecutory beliefs (e.g. discrimination and harassment, mental illness stigma, criminal victimization, relationship infidelities, conspiracies, stalking, surveillance, poisoning, etc) in our area.  Secondly, he suggests we consider alternative hypotheses, especially in decisions that have a very low base rate.  While actively searching for disconfirming information, we should postpone decisions until further information is collected.  I agree with his suggestion that we should rely more on information, and less on intuition, when it comes to confirming or disconfirming persecutory beliefs.  (Brown, 2008, p. 172)

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Brown, S. A. (2008). The reality of persecutory beliefs: Base rate information for clinicians. Ethical Human Psychology and Psychiatry, 10(3), 163-179. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1646112241&sid=7&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

MacDonald, A. W., & Schulz, S. C. (2009, May ). What we know: Findings that every theory of schizophrenia should explain. Schizophrenia Bulletin, 35(3), 493-508. doi: 10.1093/schbul/sbp017

Os, J. V., & Kapur, S. (2009, Aug 22-Aug 28). Schizophrenia. The Lancet, 374(9690), 635-645. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1843730411&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Paranoid & Delusional Disorders

The boundary between normal and abnormal appears to be largely subjective.  “One person’s excessive suspiciousness is another’s due caution, and one person’s trust is another’s gullibility.”  (Blaney & Millon, 2009, p. 362)  The “trade-off between vigilance and vulnerability” is something I had not considered… that balance is perceived to be the issue when it comes to paranoid personality disorder (PDD), paranoid schizophrenia (PS), and or delusional disorder (DD).  “Any stubborn genius will have ideas that happen to be wrong as well as those that happen to be right.”  This observation seems to suggest that the people who often suffer from these disorders are extremely intelligent, and thus, may have some beliefs that are in fact sane, relevant, and true.  It would suffice to say that I am going to use caution when pursuing this diagnosis… Einstein was considered to be delusional!

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Most studies that have been done to date have focused on persecutory delusions… either by design or because they are more common and subsequently easier to find suitable samples.  Persecutory delusions involve a degree of suspiciousness, or are generally mistrustful and/or wary.  It is suitably difficult to measure the tangible levels of suspiciousness via self report, however, since some sufferers may be too guarded to admit that they are suspicious.  The very process of self report is likely to “trip the defenses of” and subsequently increase guardedness.  Further compounding the efficacy of self-report inventories is the issue that sufferers may be reporting reality, betraying hypersensitivity, or some combination of both.  This highlights the necessity of multiple-peer reports that can confirm the interpersonal difficulties of the sufferer.  We, as clinicians, will have to be diligent about securing 3rd party sources (schools, work environment, relatives, other individuals whom are close to the client) in order to get as many perspectives on the conditions as possible.

There are several dimensions of delusions… most notably belief certainty (emotional commitment, conviction), self-monitoring (insight), distress, and frequency.  I was particularly interested in the “double awareness phase” in which a patient wavers between embracing a delusion and recognizing that its delusionality.  Of note, is the observation that psychotropic medications reduce engagement in delusions, thereby improving overall functionality, but ultimately leave actual beliefs untouched?  This seems to parallel the overall trend of medications “treating the symptoms and not the cause.”

Some patients may possess some distinctly protective attributes that account for the fact that they do not become delusional.  As a result, quasi-delusional or aberrant beliefs may not always be associated with clinical conditions indicative of a general mental disturbance or distress.  For example, low levels of anhedonia and high levels of openness are commonly thought to be a psychological asset… despite the fact that they may be quasi-delusional.  Such individuals may demonstrate greater levels of control over their unusual perceptions.  (Blaney & Millon, 2009, p. 366)  Perhaps this natural protection can be leveraged to direct treatment of people whom do not have that natural protection.  It seems to me that if we know what can prevent delusions, we should make every attempt to instill those protections in our clients whom suffer without them?

Paranoia and delusions are thought to arise from several different situations or events.  One possible event is migration, in which an individual finds themselves in a new environment that does not provide a sense of security.  Growing frustration with the new locale may leave migrants vulnerable to paranoid disorders.  As is the case with many other disorders, abuse and trauma during childhood often precede delusional experiences in adulthood.  In some cases the delusions are related to that specific event, like trauma flashbacks, or they may be more generalized due to negative schematic models of the self and the world.  This manifests in high levels of self-reported suspiciousness and/or resentment.  Paranoid individuals tend to be characterized by experiences involving victimization or stigmatization by others, whereas depressed individuals were characterized by interpersonal losses.  (Blaney & Millon, 2009, p. 369)  Personally, I am not at all surprised by the childhood abuse antecedent.  The toll of child abuse rises again this week… I am hard pressed to find a disorder that can NOT be predicated by child abuse.

Biologically speaking, some researchers have attempted to attribute these behaviors to processing defects or bias.  Theory of Mind (ToM), for example, suggests that the human mind is characterized by a system that facilitates inferences about the mental processes of other persons.  (Blaney & Millon, 2009, p. 377)  In essence, patients have difficulty discerning others’ intentions correctly.  Some have suggested that delusion-prone individuals are overconfident and quick to reach certainty in the face of incomplete information.  Other research suggests that delusional individuals may have a proposed tendency to attribute specific persons as a source of danger (personalization), thereby revealing an inability to distinguish between external negative events that are situational as opposed to interpersonal.  It has been posited that they may have an exaggerated version of self-consciousness in which they continually preoccupy themselves with how they are seen by others… and subsequently generalize that everyone feels like that.  (Blaney & Millon, 2009, p. 379)  On the whole, there are several theories… all of which seem “plausible.”  I can’t wait to get into the field to test the theory.

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Schizophrenia Information Grab-bag

“Schizophrenia is the most crippling of the psychiatric disorders.”  (Blaney & Millon, 2009, p. 298)  That’s a bold first statement.  I was curious as to the reason why typical onset times are younger (sooner) for males as compared to females.  The developmental perception I am accustomed to generally indicate that females “grow up” sooner than males… I am the slightest bit curious what could cause this phenomenon to flip-flop.  Any insight there readers?

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Although I was alive during the 1980’s, I was so young that I was wholly unaware of the de-institutionalization that took place during that era.  The statement that prisons have become the de factor health care provider reaffirms my belief that working with that population is absolutely critical to our success as a society.

Typical schizophrenia characteristics include hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, and/or negative affective symptoms.  The text states that the most common types of hallucination consist of hearing voices, one or several, typically making commentaries about the individual or conversing with each other.  One word… WOW.  Persecutory, grandiose, or somatic delusions are most common.  The first person accounts depict individuals who are very disturbed to say the least.  In particular, an individual who believed that they were controlled by someone (the “controller”) and the persistent belief that other people have external controllers was beyond comprehension.

Regarding the etiology of the disorder, it is increasingly evident that there is some kind of genetic link involved in schizophrenia.  The diathesis-stress theory of illness is the predominant theory, suggesting that a predisposition may not be sufficient in itself to cause schizophrenia, but probably requires some kind of “trigger” such as exposure to prenatal insults.  (Blaney & Millon, 2009, p. 302)

This is my first exposure to “genotype” and “phenotype.”  Genotype represents the underlying genetic constitution of the individual (genetic predisposition?).  Phenotype refers to the observable traits, characteristics, or behaviors of an individual.  It is entirely possible to have a genotype that suggests a predisposition to a disorder like schizophrenia, but the disorder will not be expressed behaviorally by the phenotype.  “In other words, what the individual inherits is a liability or predisposition for developing the disease, not the disease itself.”  (Blaney & Millon, 2009, p. 305)

With regard to prenatal and perinatal insult, the critical period of exposure appears to be the 2nd trimester (4th-6th month of pregnancy).  Examples might include toxemia, preeclampsia, or labor delivery complications.  Fetal hypoxia (oxygen deprivation) was strongly linked with later schizophrenia.  Prenatal stress, inclining losing a spouse or being exposed to a military invasion, has been implicated in the predisposition of schizophrenia.  Maternal viral infection, including influenza, was also implicated.  Unlike influenza studies, increased risk for offspring exposed to prenatal nutritional deficiencies was primarily attributed to growth and development during the 1st trimester, not the second.

Cognitive impairments are considered to be central, or primary, in schizophrenia.  Typically, they predate the more typical outward signs of the illness (hallucinations, delusions, etc.).  The cognitive impairments can occur in the absence of the other clinical symptoms.  “It is estimated that 90% of patients have clinically meaningful deficits in at least one cognitive domain and that 75% have deficits in at least two.”  (Blaney & Millon, 2009, p. 309)

Neurocognitive assessment is used in contemporary practices to quantify the severity of impairment in clinically relevant domains of cognitive functioning.  Relevant domains are speed of processing, attention/vigilance, working memory, verbal learning, visual learning, reasoning and problem solving, and social cognition.  Typically, a patient with schizophrenia will struggle with verbal learning and vigilance, and have lesser impairments in visual organization and vocabulary.

A neuro-developmental view of schizophrenia is the foundation of high-risk research.  “The majority of individuals who succumb to schizophrenia and other psychotic disorders manifest prodromal signs of behavioral disturbance” in adolescence, and they get progressively worse as they approach young adulthood.  (Blaney & Millon, 2009, p. 321)  The prodromal period represents a clinically significant opportunity for intervention, with high potential to shed light on the etiological origins of schizophrenia.

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.