Organic psychosis: Insight into the biology of psychosis

The association between visual hallucinations and secondary psychosis: a systematic review and meta-analysis

INTRODUCTION

Visual hallucinations are often considered to be suggestive of a secondary cause of psychosis, however, this association has never been assessed meta-analytically. We aimed to compare the presence of visual hallucinations in patients with psychosis due to a primary or secondary cause.

METHOD

We conducted a meta-analysis of case-control studies directly comparing primary and secondary psychosis. A random-effects model, following the DerSimonian and Laird method, was used to pool studies and generate overall odds ratios (OR), 95% confidence intervals (CI) and prediction intervals (PI).

RESULTS

Fourteen studies (904 primary and 804 secondary psychosis patients) were included. Visual hallucinations were significantly associated with secondary psychosis (OR = 3.0, 95% CI = 1.7-5.1, p < 0.001) with moderate between-study heterogeneity (I2 = 70%). Subgroup analysis by type of secondary psychosis (organic, drug-induced, mixed) was non-significant. Analysis of the content of visual hallucinations (51 primary and 142 secondary psychosis patients) found hallucinations of inanimate objects were significantly more likely to be associated with secondary psychosis (OR = 0.1, 95% CI = 0.01-0.8, p = 0.03).

CONCLUSIONS

Visual hallucinations were strongly associated with a secondary cause of psychosis. The presence of visual hallucinations in a patient presenting with psychosis may serve as a potential "red flag" for a secondary cause and warrant further investigation.

Psychiatric manifestations of inborn errors of metabolism: A systematic review

Inborn errors of metabolism (IEMs) are characterized by deficits in metabolic enzymes as a result of an inherited disease, leading to the accumulation or decreased excretion of proteins, carbohydrates and lipids. Although IEMs are often diagnosed during childhood, adolescent and adult onset variants may be accompanied by less somatic and more psychiatric manifestations, which often hampers recognition by psychiatrists of the distinction between a primary and secondary psychiatric disorder. To help clinicians in the diagnostic process, we aimed to provide an overview of psychiatric manifestations in IEMs. Our literature search yielded 4380 records in total, of which 88 studies were included in the qualitative synthesis. Reported psychiatric disorders in adolescent and adult IEMs included depression, anxiety disorder, psychosis, attention deficit hyperactivity disorder, autism spectrum disorder, bipolar disorder and obsessive-compulsive disorder as assessed by semi-structured diagnostic interviews and validated questionnaires. A diagnostic screener and multidisciplinary IEM clinics are proposed to help clinicians during the diagnostic process, to prevent diagnostic delay and to raise awareness of the psychiatric manifestations among IEMs.

Psychotic symptoms in youth with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) may reflect syndrome severity and heterogeneity

OBJECTIVE

In the clinical syndrome Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), obsessive compulsive disorder (OCD) and/or food refusal symptoms have an abrupt-onset (over 48 h) coupled with at least two other specified neuropsychiatric symptoms. We aimed to characterize in detail for the first time, psychotic symptoms experienced by children with PANS as well as the impact of psychotic symptoms on disease severity and course of illness. We inform about the diagnosis of the clinical description: PANS and hope to improve evaluation, treatment, diagnostic validity and future investigation.

METHODS

Retrospective review of 143 consecutive PANS clinic patient charts meeting inclusion criteria. The Caregiver Burden Inventory, Global Impairment Score, and Children's Global Assessment Scale were used to assess impairment.

RESULTS

Visual and auditory hallucinations were each experienced by 36%, of which most (83%) were transient and complex (non-threatening voices or figures). 6.3% and 5.5% of patients experienced delusions and thought disorganization respectively. Those with psychotic symptoms showed statistically significant differences in disease impairment and caregiver burden. There were no differences in time to treatment access or length of illness.

CONCLUSIONS

Over 1/3 of children with PANS experienced transient hallucinations. They were more impaired than those without psychotic symptoms, but showed no differences in disease progression. This difference may point toward heterogeneity in PANS. When evaluating children with acute psychotic symptoms, clinicians should screen for abrupt-onset of a symptom cluster including OCD and/or food refusal, with neuropsychiatric symptoms (enuresis, handwriting changes, tics, hyperactivity, sleep disorder) before initiating treatment.

Decreased cortical complexity in methamphetamine abusers

This study aimed to investigate if methamphetamine (MA) abusers exhibit alterations in complexity of the electroencephalogram (EEG) and to determine if these possible alterations are associated with their abuse patterns. EEGs were recorded from 48 former MA-dependent males and 20 age- and sex-matched healthy subjects. Approximate Entropy (ApEn), an information-theoretical measure of irregularity, of the EEGs was estimated to quantify the degree of cortical complexity. The ApEn values in MA abusers were significantly lower than those of healthy subjects in most of the cortical regions, indicating decreased cortical complexity of MA abusers, which may be associated with impairment in specialization and integration of cortical activities owing to MA abuse. Moreover, ApEn values exhibited significant correlations with the clinical factors including abuse patterns, symptoms of psychoses, and their concurrent drinking and smoking habits. These findings provide insights into abnormal information processing in MA abusers and suggest that ApEn of EEG recordings may be used as a potential supplementary tool for quantitative diagnosis of MA abuse. This is the first investigation to assess the "severity-dependent dynamical complexity" of EEG patterns in former MA abusers and their associations with the subjects' abuse patterns and other clinical measures.

Psychotic features associated with multiple sclerosis

Although once considered rare, several more recent investigations have been published describing psychotic features in multiple sclerosis (MS). The association between the two conditions, however, remains unclear. Large-scale hospital-based, epidemiological and case studies have suggested a relationship between psychosis and MS through demonstrating their higher than chance co-occurrence, their temporal relationship, and their association with particular structural abnormalities in the brain (i.e., periventricular white matter and temporal demyelination). The etiology of psychosis in MS has also not been explained adequately. Regional demyelination and the use of corticosteroids have been implicated, yet their mechanisms of action have not been elucidated. The present review addresses what is known at this point in time regarding the occurrence of psychosis in the context of MS, the data regarding possible etiological factors, and the implications of these data and suggestions regarding diagnosis and treatment. Future research should explore the underlying pathophysiology of psychosis and multiple sclerosis to further our understanding of the central nervous system disease process. This research could help determine the features which would guide clinicians in identifying patients at risk of developing psychosis in the context of MS, as well as propose the optimal pharmacological intervention.

Outcome of psychiatric symptoms presenting at onset of multiple sclerosis: a retrospective study

Psychiatric disturbances may occur at the onset of multiple sclerosis. However, information on their outcome is lacking. Our objective was to document the characteristics of psychiatric symptoms at presentation of multiple sclerosis and to define the long-term evolution of psychiatric disturbances in these patients. Based on a clinical record analysis of patients with defined multiple sclerosis diagnosis and coming under the care of a university multiple sclerosis centre within the period 1997-2007, patients with both psychiatric and neurological symptoms at presentation were identified. Clinical data at onset and at last follow-up were considered. Among 682 evaluated patients, psychiatric disturbances were associated with multiple sclerosis onset in 16 cases (2.3%). Most patients (56%) presented with a mood disorder with clinical characteristics of a major depressive-like episode, five (32%) had psychotic symptoms. Initial psychiatric disturbances improved later than neurological symptoms, or never fully recovered, regardless of the concomitant use of psychotropic medications. In most of the subjects psychiatric disturbances tended to remain over the follow-up period and at last visit, after a mean follow-up of 7.6 years (+/-2.3), 14 subjects (87%) had a supplementary diagnosis of psychiatric illness. Psychiatric symptoms at onset of multiple sclerosis may be indicators of possible maintenance of psychiatric morbidity in a sizeable proportion of patients.

Psychopathology of first-episode psychosis in HIV-positive persons in comparison to first-episode schizophrenia: a neglected issue

This study aims to detect different psychopathological dimensions in first-episode psychoses with different underlying causes. We evaluated 22 subjects with first-episode psychosis, who differed in biological variables (HIV-positive versus HIV-negative) and who were compared by using the Structured Clinical Interview for DSM-III-Reviewer, the 18-item Brief Psychiatric Rating Scale (BPRS), the 17-item Hamilton Depression Rating Scale, the 14-item Hamilton Anxiety Rating Scale and the Mini-Mental State Examination. HIV-positive subjects had higher mean scores on the global BPRS and on the paranoid Positive and Negative Syndrome Scale subscale compared with HIV-negative subjects. Conversely, higher prevalence of affective and anxious symptoms was found in the HIV-negative patients in comparison to HIV-positives. HIV-positives had significantly greater attention/concentration impairment than HIV-negative persons. In conclusion, taking into account psychopathological dimensions may help psychiatrists in clinical decision-making regarding the differential diagnosis of psychotic symptoms. The psychopathological pattern of first-episode psychosis in HIV-positive patients may represent an 'elementary model' of acute psychosis characterized by paranoid delusions in the absence of the usual affective symptoms.

Psychosis in multiple sclerosis associated with left temporal lobe lesions on serial MRI scans

There is retrospective evidence of a correlation between psychosis in multiple sclerosis (MS) patients and temporal lobe pathology. A 35-year-old woman with MS presented with psychosis. There was no concurrent history of medication/substance use or family history. Comparison with previous MRI scans showed significant progression of lesions within the periventricular white matter of the left temporal lobe. This case highlights the association of psychosis and MS progression with worsening of left temporal lobe lesions. Prospective studies are required to ascertain the extent to which left temporal lobe lesions are predictive of future psychosis.

The theory of bowl and bugs: a model for the explanation of the coexistence of psychological and biological etiologies in the psychosis

The origin of the psychiatric features of psychotic patients and whether the features are basically psychological or biological has always been an issue of controversy. Some scientists have tried to prove the absolute relevance of these symptoms to psychological etiologies whereas others have insisted on biological causation. However, others have tried to find a link between the two etiologies in the formation of psychiatric symptoms and signs. In this article, a model is proposed for the coexistence and cocausative role of biology and psychology in the formation of symptoms of psychotic patients and as an explanation for the high rate of coexistence of obsessive thoughts in obsessive-compulsive disorder and schizophrenia and their highly reported relevance. These two disorders are put on two sides of a similar spectrum. Through the article, evidence supporting this model from psychological (especially Jungian and modified Freudian views) and neurobiological theories (neuroanatomical, neurotransmitter, and neural network) models is discussed.