Bilateral cerebral pathology and the genesis of delusional misidentification

Effectiveness of pharmacotherapies for delusional disorder in a Swedish national cohort of 9076 patients

BACKGROUND

Little is known on the effective pharmacological treatment of delusional disorder.

AIMS

Study the comparative effectiveness of pharmacotherapies in the prevention of hospitalization due to psychosis and work disability in delusional disorder.

METHODS

Observational registry based cohort study including everyone in Sweden diagnosed with delusional disorder (N = 9076;mean follow-up time 4.9 years). The primary analysis was Cox Proportional Hazards within-individual analysis. Results are reported as adjusted hazard ratios (HRs).

RESULTS

Among the cohort (4835 males/4241 females;mean [SD] age 44.1 [12.5] years), 2074 persons had at least one hospitalization due to psychosis. Risk for hospitalization due to psychosis was 46% lower when any antipsychotic was used (HR 0.54, 95%CI 0.38-0.77, p < 0.001). Use of clozapine (HR 0.24, 95%CI 0.07-0.77, p = 0.016), any long-acting injectable (LAI; HR 0.28, 95%CI 0.16-0.49, p < 0.0001) and oral olanzapine (HR 0.36, 95%CI 0.20-0.67, p = 0.001) were associated with lowest risk. Among those not on disability pension at start of follow-up (n = 5025), in comparison to no use of antipsychotics, use of clozapine (HR 0.08, 95%CI 0.01-0.52, p = 0.008), any LAI (HR 0.44, 95%CI 0.25-0.79, p = 0.006) and oral aripiprazole (HR 0.52, 95%CI 0.31-0.85, p = 0.009) were associated with lowest risk of work disability.

CONCLUSIONS

Use of antipsychotics was associated with a reduced risk of hospitalization due to psychosis and work disability in delusional disorder, with use of clozapine and long-acting injectables being associated with the lowest risk for these very relevant end-points for both individual suffering and costs to society. Clinical trials with these treatments are urgently needed to make informed clinical treatment recommendations.

Brain Metabolic Dysfunction in Capgras Delusion During Alzheimer's Disease: A Positron Emission Tomography Study

Capgras delusion is characterized by the misidentification of people and by the delusional belief that the misidentified persons have been replaced by impostors, generally perceived as persecutors. Since little is known regarding the neural correlates of Capgras syndrome, the cerebral metabolic pattern of a patient with probable Alzheimer's disease (AD) and Capgras syndrome was compared with those of 24-healthy elderly participants and 26 patients with AD without delusional syndrome. Comparing the healthy group with the AD group, the patient with AD had significant hypometabolism in frontal and posterior midline structures. In the light of current neural models of face perception, our patients with Capgras syndrome may be related to impaired recognition of a familiar face, subserved by the posterior cingulate/precuneus cortex, and impaired reflection about personally relevant knowledge related to a face, subserved by the dorsomedial prefrontal cortex.

Capgras Syndrome associated with the use of psychoactive substances

INTRODUCTION

Capgras syndrome has originally been described as psychiatric syndrome. However, in the last few years reports of patients with this syndrome has significantly increased in patients with neurological, metabolic, and infectious diseases and those who consume alcohol. Different hypotheses have been proposed to explain the neurobiology of this very unusual symptom, such as changes in the dopamine circuit and specific dysfunctions in facial processing.

CASE

In this work we present a new case of Capgras syndrome, associated with an acute cocaine overdose, which was transient and reversible.

DISCUSSION

The neurobiological bases of this syndrome are analysed, along with their relationship with the changes induced by cocaine use. Thus, Capgras syndrome could be the expression of functional changes at frontal-temporal level, and the paralimbic region secondary to the consumption of psychoactive substances such as cocaine.

Recent advances in the treatment of delusional disorder

OBJECTIVE

Often considered difficult to treat in the past, even treatment-resistant, delusional disorder is now regarded as a treatable condition that responds to medication in many instances. Munro and Mok previously reviewed the published record of its treatment to 1994. This review aims to update and extend their observations and to examine the impact of new second-generation antipsychotic agents on the treatment of this condition.

METHOD

We attempted to gather all published reports of delusional disorder from 1994 to 2004, using various database strategies. We then assessed the reports for clarity and completeness, treatment, and outcome descriptions, thereby selecting a patient sample for analysis.

RESULTS

Of 224 cases identified as delusional disorder, only 134 case descriptions provided sufficient treatment and outcome data to inform this review. The demographics of this sample were similar to those of the earlier review. Depression as a comorbid condition was more frequent than before. Adherence to medication regimens was seldom explicitly addressed. Most cases showed improvement regardless of which antipsychotic medication the patients received. Pimozide and other conventional antipsychotics, as well as second-generation antipsychotics, and even clozapine, were used in many of the case reports. Family history of delusional disorder was seldom recorded.

CONCLUSIONS

A positive response to medication treatment occurred in nearly 50% of the cases in our review, which is consistent with the earlier review.

Capgras syndrome: a review of the neurophysiological correlates and presenting clinical features in cases involving physical violence

OBJECTIVE

Acts of violence have been frequently reported in cases of Capgras syndrome (CS), a misidentification syndrome characterized by the delusional belief that imposters have replaced people familiar to the individual. CS has been observed in many neuropsychiatric and organic disorders, and neuroimaging studies indicate an association between CS and right hemisphere abnormalities. However, CS has received limited attention from a forensic psychiatric perspective. We propose that elucidating demographic and clinical features noted in cases of violence secondary to CS may highlight important factors in the progression of CS to violence.

METHOD

We review the neurophysiological correlates and clinical factors observed in CS and present characteristics of a series of cases that demonstrate the potential of CS patients for severe physical violence toward the misidentified person.

RESULTS

For patients with CS involving assault, we present and discuss commonly reported demographic and clinical features that may contribute to an increased risk for violence.

CONCLUSIONS

An understanding of the presenting clinical features of CS resulting in aggressive acts may assist clinicians to assess the potential for violence in these patients.