Schizophrenia and amphetamine dependence. A case report

Whereas observations of psychotic disorders induced by amphetamines are common, few observations described the impact of chronic amphetamine abuse on schizophrenic patients. We report the case of a schizophrenic patient who presented with amphetamine dependence for several years, without other accompanying addiction. CASE REPORT: During his adolescence, Mr. X. gradually developed delusional beliefs of persecution and telepathy. He believed that the other pupils and teachers spoke about him in malicious terms. At the age of 23, Mr. X began to consume 60-100 mg/week of amphetamines orally. He consumed amphetamines during 7 years. The delusions, in particular the auditory hallucinations worsened after the use of amphetamines. Subsequently, he married and was declared unfit for national service due to the psychotic disorders. Mr. X received neuroleptic treatment with moderate effects on the psychotic symptoms. Between the age of 24 and 30, the patient presented persecutory, megalomanic and physical transformation beliefs, delusions of being controlled as well as auditory, somatic-tactile and visual hallucinations. At the age of 30, while he had stopped his consumption of amphetamines for 9 months, the patient, overwhelmed with the delusions, murdered his wife. He was sent in jail for 13 months, and subsequently hospitalized for one year in a high security psychiatric department and 7 years in our psychiatric department. The neuroleptic treatment was effective, particularly against the hallucinations. Following stabilisation, the symptomatology of the patient was marked by a disorganization syndrome, including prominent thought disorder, disorganized speech, associative loosening, frequent derailments and negative signs of schizophrenia, in particular affective flattening and blunting of emotional expression. When the patient was 43, a trial discharge was authorized owing to improvement of his condition. The neuroleptic treatment was switched with single-drug olanzapine therapy, 10 mg/day which improved the negative symptoms. Mr. X. resumed part-time professional activities and remarried. DISCUSSION: The patient fulfilled the DSM IV criteria for schizophrenia and for amphetamine dependence assessed using the Composite International Diagnostic Interview (CIDI). He presented, in particular, withdrawal syndrome when amphetamines were discontinued. The amphetamine consumption was followed by a marked deterioration in the delusions, particularly the hallucinations. Worsening of the positive symptoms in schizophrenic patients by amphetamines has been established in single dose studies, in particular characterized by persecutory delusions and hallucinations. On the other hand, amphetamines tend to transiently and moderately reduce the negative symptoms. Some stu-dies have shown that amphetamine consumption promoted violent acting out in non-schizophrenic subjects. In our observation, the acting out may be not related to the acute effects of these substances, since it occurred 9 months after stated discontinuation of amphetamine consumption. However, the cerebral toxicity and psycho-behavioural disturbances related to amphetamines might be prolonged after withdrawal. In non-schizophrenic patients, the existence of prolonged neurotoxicity of amphetamines and related psycho-behavioral disturbances has been suggested. The prolonged administration of amphetamines to animals produces neuro-axonal degeneration in the striatum, the frontal cortex, the nucleus accumbens and the amygdala. In human, there are some evidence of persistant deteriorations of the serotoninergic and dopaminergic systems in the caudate nucleus, the putamen and the nucleus accumbens following amphetamine consumption. CONCLUSION: The neurobiological and psycho-behavioural effects of amphetamines may be prolonged following withdrawal in both schizophrenic and non-schizophrenic patients.     

Dreams and hallucinations: A common neurochemical mechanism mediating their phenomenological similarities

Dreams and drug-induced hallucinations have several phenomenological similarities, especially with respect to their visual and emotive components. This similarity is hypothesized to be due to a neurochemical mechanism which is common to both states: the inactivation of the brain serotonin system. This is supported by electrophysiological data indicating that the activity of serotonin-containing neurons is depressed during both dreaming (in REM and non-REM sleep) and in response to hallucinogenic drugs. Further support for the hypothesis derives from neuropharmacological data demonstrating that decreases in synaptic serotonin are associated with increased hallucinatory-like behavior or hallucinatory experience during waking, and increased duration of REM periods during sleep. Reciprocally, increases in synaptic serotonin are associated with decreased hallucinatory-like behavior or hallucinatory experience, and with decreased REM sleep time and dream reports. Neuroanatomical evidence that serotonin is heavily concentrated in brain areas which mediate visual perception and emotive experience is consonant with the strong visual and emotive components of dreams and hallucinations. When these data are considered in conjunction with the exclusively inhibitory synaptic action of serotonin in the forebrain, an explicit hypothesis can be formulated: A cessation, or decrease, in the discharge rate of serotonin-containing neurons, either spontaneously during REM and non-REM sleep, or in response to drugs such as LSD, precipitates, through disinhibition, a dramatic increase in activity of their target neurons in brain areas mediating visual sensation and emotional experience. These latter neural events are a primary physiological substrate for the emergence of strong sensory and emotive processes during dreams and drug-induced hallucinations.     

Levodopa-induced psychosis: a kindling phenomenon

Of 88 patients with idiopathic Parkinson's disease, without prior psychotic symptoms, and without significant dementia, nearly half had experienced vivid dreams, hallucinations, illusions, and nonconfusional as well as confusional psychoses as side effects of chronic levodopa therapy within the previous year of treatment. It was found that 61.3% of all hallucinations were associated with preexistent or concurrent vivid dream phenomena, that all psychotic states were associated with preexistent or concurrent vivid dreams and/or hallucinations, and that nonconfusional psychotic states tended to become confusional. These findings raise the possibility that chronic levodopa therapy may result in dopaminergic kindling and support the hypothesis that chronic dopaminergic agonism may, via such a kindling mechanism, play a role in the development of some types of psychoses.     

Prospective study of hallucinations and delusions in Parkinson's disease

OBJECTIVE: This study was undertaken to determine the prevalence of hallucinations and delusions in Parkinson's disease, to describe such symptoms phenomenologically, and possibly to determine factors associated with their development. In addition, the role of the visual system in relation to visual hallucinations was examined. METHOD: 102 consecutive patients diagnosed with strictly defined Parkinson's disease were examined for the presence of hallucinations and delusions and assessed for visual acuity, cognition, depression using the geriatric depression scale, disease severity as measured by the UPDRS, and other clinical variables. RESULTS: Of 102 consecutive patients, 29.4% (n=30) had hallucinations or delusions, four (3.9%) were determined to be psychotic due solely to delirium and were excluded from further analysis. Of the 98 remaining patients, 26.5% (n=26) had visual hallucinations. Among these, one patient also had delusions, two had auditory hallucinations, and one had gustatory hallucinations. Visual hallucinations were significantly associated with worse visual acuity, lower cognitive score, higher depression score, and worse disease severity. Hallucinations were not associated with history of psychiatric disease, dose or duration of levodopa or other antiparkinsonian medication treatment, or duration of illness. CONCLUSIONS: Visual hallucinations are common symptoms in Parkinson's disease and are most likely of multifactorial origin. Although higher doses of levodopa are known to be related clinically to hallucinations in individual patients, the results suggest that several underlying characteristics of patients with Parkinson's disease (disease severity, dementia, depression, worse visual acuity) may be more important determinants of which patients experience hallucinations. The data also provide preliminary evidence that abnormality of the visual system may be related to visual hallucinations in Parkinson's disease, as has been found in other disorders with visual hallucinations.     

Hallucinations, REM sleep, and Parkinson's disease: a medical hypothesis

BACKGROUND: Patients with PD can have disabling visual hallucinations associated with dopaminergic therapy. Sleep disorders, including vivid dreams and REM sleep with motor behaviors (RBD), are frequent in these patients. METHODS: The association of hallucinations and REM sleep both at night and during the day was examined in 10 consecutive nondemented patients with long-standing levodopa-responsive PD and hallucinations. Seven patients presented with paranoia and paranoid delusions. Overnight sleep recordings and standard multiple daytime sleep latency test were performed. The results were compared to those of 10 similar patients with PD not experiencing hallucinations. RESULTS: RBD was detected in all 10 patients with hallucinations and in six without. Although nighttime sleep conditions were similar in both groups, hallucinators tended to be sleepier during the day. Delusions following nighttime REM period and daytime REM onsets were observed in three and eight of the hallucinators, and zero and two of the others. Daytime hallucinations, coincident with REM sleep intrusions during periods of wakefulness, were reported only by hallucinators. Postmortem examination of the brain of one patient showed numerous Lewy bodies in neurons of the subcoeruleus nucleus, a region that is involved in REM sleep control. CONCLUSION: The visual hallucinations that coincide with daytime episodes of REM sleep in patients who also experience post-REM delusions at night may be dream imagery. Psychosis in patients with PD may therefore reflect a narcolepsy-like REM sleep disorder.     

Factors associated with compliance and resistance to command hallucinations

Command hallucinations (CHs) are hallucinations that direct the patient to perform an action. Beyond issues related to the danger that some CHs may pose, comparatively little is known about the broader clinical context of CHs. To investigate this, 199 patients were interviewed using the Mental Health Research Institute Unusual Perceptions Scale. More than two thirds of the sample reported hearing CHs. A quarter of these patients felt unable to resist them. Patients with CHs reported their voices more negatively than those who did not hear commands. More of those unable to resist CHs rated their hallucinations as intrusive, they had fewer coping strategies than those able to resist, and they were prescribed higher dosages of medication. CHs are associated with a greater degree of adverse hallucinatory and illness experience. Patients who experience CHs may have a more malignant form of the underlying disorder. Thus, CHs warrant special therapeutic attention for reasons beyond any harm that their commands pose to themselves or others.     

Anxiety and hostility in the manifest dreams of schizophrenic patients

Aside from delusions, hallucinations, and thought disorders, affective disturbances belong to the most prominent symptoms of the schizophrenic process. However, nearly no empirical work has been done on the systematic investigation of the dream affects of patients with schizophrenia. We compared 96 dreams of 19 patients with schizophrenia and an equal number of dreams of 19 healthy controls collected over an 8-week period by means of the Gottschalk-Gleser Analysis Scales. Additionally, central psychopathological syndromes were measured by means of the AMDP-scales each day a patient reported a dream. Although cluster analyses showed general similarities in the organization of dream affects in the two groups, we found differences between patient and control groups in the frequency and intensity of anxious and hostile affects. As in delusions of persecution, patients experience themselves in their dreams more frequently as victims of hostility from outside, which corresponds well with a significantly higher intensity of threat anxieties (death, mutilation). On the other hand, value anxieties (guilt and separation) are found less frequently in the dreams of patients with schizophrenia pointing, together with a less differentiated organization of the dream affects, to the typical affective flattening of residual syndromes.     

Analysis of caregiver perceptions of "hallucinations" in people with dementia in institutional settings

This study investigated the meanings and etiologies of hallucinations in persons with dementia. Participants were 74 nursing home residents aged ≥ 65 diagnosed with dementia. Most of the reported visual and auditory hallucinations involved talking to persons who are not present, a phenomenon described as either a visual or auditory hallucination, or both. All participants who were reported to experience a hallucination had poor vision. Current results suggest that hallucination was a term staff caregivers used for the phenomena they could not easily explain, demonstrating their lack of understanding of the resident and/or the phenomena they termed hallucination. The classification of hallucinations into subtypes may not be meaningful, and most visual and auditory hallucinations were not associated with negative affect. Some hallucinations occurred out of boredom, which exacerbated the sensory deprivation experienced by these persons, thereby increasing the likelihood of hallucinations.     

Strange Encounter: The Use of Study Groups with Graduate Students in History

General sleep-related experiences (Watson, 2001), including special dream states such as elevated dream recall, nightmares, hypnagogic hallucinations, flying dreams, and waking dreams, have been shown to be associated with life stress and psychopathological distress (Soffer-Dudek &; Shahar, 2009). In this study, we attempted to examine these associations within the context of terror-related stress. In the week following operation Oferet Yetzuka in Israel, ninety-one participants filled out questionnaires concerning sleep experiences, psychopathological distress, and degree of exposure to terror. These participants were part of a larger study conducted three years earlier (Soffer-Dudek &; Shahar, 2009). General sleep experiences (GSEs) were positively correlated to exposure to terror through media, a link that was mediated through psychopathological symptoms. Surprisingly, GSEs were negatively correlated with physical exposure variables. We suggest that GSEs may be related to a ruminative coping style (i.e., not “letting go,” both by day and by night).     

Posttraumatic stress disorder caused by the misattribution of seizure-related experiential responses

Patients with temporal lobe seizures sometimes experience what John Hughlings Jackson described as “dreamy states” during seizure onset. These phenomena may be characterized by a re-experiencing of past events, feelings of familiarity (déjà vu), and hallucinations. In previous reports, patients have been aware of the illusory nature of their experiences. Here, however, the case of a patient with a documented 37-year history of temporal lobe epilepsy who is not aware is described. Fifteen years ago, the patient saw visions of traumatic autobiographical events that he had never previously recalled. He believed them to be veridical memories from his childhood, although evidence from his family suggests that they were not. The patient's psychological reaction to the “recovery” of these traumatic “memories” was severe enough to qualify as posttraumatic stress disorder (PTSD). To our knowledge, this is the first report of PTSD caused by the misattribution of mental states that accompany a seizure.     

Sleep complaints in periodic paralyses: a web survey.

Neuronal potassium conductance has been shown to influence the sleep-wake cycle and REM sleep homeostasis. The periodic paralyses (PP) are characterized by episodes of muscular weakness associated with changes in serum potassium levels and, therefore, with possible alterations in extracellular neuronal potassium conductance. We submitted a sleep questionnaire to the members of Periodic Paralysis International Listserv, an on-line support and information group for subjects with PP. Three control groups were made up of patients with untreated depression, patients with depression under treatment and healthy subjects. Both subjects with PP and those with untreated depression had a higher frequency of self-reported insufficient sleep quality and a higher number of nocturnal awakenings than patients with depression under treatment and healthy controls. PP subjects had more self-reported daytime sleepiness, sleep-related hallucinations and nightmares/abnormal dreams than the other three groups. Patients affected by PP may have disrupted sleep architecture and homeostasis. In particular, we suggest that the stereotypical abnormal dreams reported by several patients may reflect oneiric elaboration of nocturnal episodes of flaccid paralysis, while the increased frequency of sleep-related hallucinations may be due to enhanced REM sleep expression associated with alterations of neuronal potassium conductance.     

Peduncular hallucinosis caused by a tumour in the right thalamus. A case study

Peduncular hallucinations are vivid, complex visual hallucinations. They generally arise as a result of lesions in the midbrain. A 46-year-old man had peduncular hallucinations arising from a tumour in the right thalamus. The patient was not operated on for this tumour. The visual hallucinations were treated with psychiatric medications. This treatment reduced the patient's anxiety and visual hallucinations and he became better able to cope with his symptoms. Psychiatrists need to increase their knowledge with regard to the diagnosis and treatment of these symptoms.     

Dream features in the early stages of Parkinson’s Disease

Few studies have investigated the relation between dream features and cognition in Parkinson’s disease (PD), although vivid dreams, hallucinations and cognitive decline have been proposed as successive steps of a pathological continuum. Our objectives were therefore to characterize the dreams of early stage PD and to study the relation between dream characteristics, cognitive function, motor status, depression, dopaminergic treatment, and the presence of REM sleep behaviour disorder (RBD) and hallucinations. Dreams of 19 male PD patients and 21 matched control subjects were classified according to Hall and van de Castle system. h statistics was used to compare the dream content between patients and controls. We tested the relation between patients’ dreams characteristics and cognitive function (Frontal assessment battery (FAB) and Mini-Mental State Examination tests) depression (Beck depression inventory), motor function (UPDRS), dopaminergic treatment, the presence of RBD (according to clinical criteria) and hallucinations, using general linear model statistics. Patients and controls differed only on FAB scores. Relevant differences in the Hall and van de Castle scale were found between patient’s dreams and those of the control group, regarding animals, aggression/friendliness, physical aggression, befriender (higher in the patient group) and aggressor and bodily misfortunes (lower in the patient group) features. Cognitive and particularly frontal dysfunction had a significant influence on the frequency of physical aggression and animal related features, while dopaminergic doses, depressive symptoms, hallucinations and RBD did not. We found a pattern of dream alteration characterized by heightened aggressiveness and the presence of animals. These were related to more severe frontal dysfunction, which could be the origin of such changes.     

Posttraumatic stress disorder caused by the misattribution of seizure-related experiential responses

Patients with temporal lobe seizures sometimes experience what John Hughlings Jackson described as "dreamy states" during seizure onset. These phenomena may be characterized by a re-experiencing of past events, feelings of familiarity (déjà vu), and hallucinations. In previous reports, patients have been aware of the illusory nature of their experiences. Here, however, the case of a patient with a documented 37-year history of temporal lobe epilepsy who is not aware is described. Fifteen years ago, the patient saw visions of traumatic autobiographical events that he had never previously recalled. He believed them to be veridical memories from his childhood, although evidence from his family suggests that they were not. The patient's psychological reaction to the "recovery" of these traumatic "memories" was severe enough to qualify as posttraumatic stress disorder (PTSD). To our knowledge, this is the first report of PTSD caused by the misattribution of mental states that accompany a seizure.     

Waking dreams and other metachoric experiences

This paper summarizes the development of the concept of metachoric experiences from 1961 onwards. The name of metachoric experience was given to one in which the whole of the environment was replaced by a hallucinatory one, although this may provide a precise replica of the physical world and appear to be completely continuous with normal experience. Prior to 1968 three types of metachoric experiences had been recognized; lucid dreams, out-of-the-body experiences (OBEs) and false awakenings, all of which showed interrelationships. The Institute's 1968 appeal for apparitional experiences led to a recognition that many of these were probably metachoric. This was suggested among other things by certain cases in which the lighting of the whole field of view changes, thus indicating that the experience was completely hallucinatory. The study of apparitions led also to the concept of waking dreams, i.e. completely hallucinatory experiences which may be initiated and terminated without any awareness of discontinuity on the part of the subject. These experiences seem to be capable of considerable apparent extension in time, thus providing a possible explanation of some reports of UFO sightings and of some of the more anomalous experiences of psychical research. In this connection the paper discusses the well-known Versailles experience of Miss Moberly and Miss Jourdain, and a published case of C.G. Jung. In conclusion some of the most obvious similarities and differences between the different types of metachoric experiences are discussed.     

Cocaine-induced psychosis.

BACKGROUND: Chronic stimulant use can produce a paranoid psychosis that is similar to acute paranoid schizophrenia. While this phenomenon has been systematically explored in amphetamine abusers, it has been relatively unexplored in a systematic fashion in cocaine abusers. METHOD: The experience of cocaine-induced psychosis was evaluated in 55 individuals consecutively admitted for treatment of DSM-III-R cocaine dependence. Each subject was interviewed about their experiences of psychosis while intoxicated by means of a standardized, semistructured interview. RESULTS: Fifty-three percent (29/55) of those interviewed reported experiencing transient cocaine-induced psychosis. There was no significant difference in lifetime amount of cocaine use or amount of cocaine use in the month before admission between those who experienced psychosis and those who did not. The psychosis-positive group used significantly more cocaine in the year prior to admission (p less than or equal to .02) and had a longer duration of use (p less than or equal to .01). Males were significantly (p less than or equal to .05) more likely than females to develop psychosis. Ninety percent (26/29) developed paranoid delusions directly related to drug use. Ninety-six percent (28/29) of the subjects experienced hallucinations: 83% (24/29), auditory hallucinations; 38% (11/29), visual hallucinations; and 21% (6/29), tactile hallucinations. Twenty-seven percent (15/55) of subjects developed transient behavioral stereotypies. CONCLUSION: Cocaine-induced paranoia is a common experience among chronic users. Amount and duration of use are related to its development. Implications for a kindling model of cocaine-induced psychosis will be discussed.     

Fear in dreams of 9- to 11-year-old children

The present study investigated anxiety dreams in 9- to 11-year-old children. 103 children completed a dream questionnaire, in which they were asked about their anxiety dreams and their coping with these dreams. Furthermore, they completed an anxiety inventory to measure their trait anxiety. Girls reported a higher frequency of anxiety dreams than boys, although they could not remember their dreams more often. Girls dreamt more often than boys of the loss of another person, of falling, of socially disturbing situations and small animals, of animals as aggressors, of family members (mainly siblings) and other female persons of known identity. Thus, the dreams clearly reflect the importance of social relationships in girls' lives. Stress from anxiety dreams could only partly be explained by their frequency. Girls and more anxious children of both sexes turned out to be stressed the most. Further studies may concentrate on children's inner experience, if they want to find out the meaning of anxiety dreams in children's emotional development. This could be important for the prevention of affective disorders.     

Hallucinations in the acute schizophrenic-type psychosis: effects of gender and age of illness onset

Our objective was to test the hypothesis that gender, the age of illness onset, or the interaction between these two variables, would distinguish acutely ill schizophrenic and schizoaffective patients who hallucinated from those who did not. Hallucinatory experiences were measured by the hallucination item of the Brief Psychiatric Rating Scale in a sample of 160 drug-free inpatients admitted for the treatment of an acute episode. Patients were categorized as either non-hallucinators or hallucinators. An additional analysis included only those who had 'severe' hallucinations (i.e., score > or = 5). Female gender, but not age of onset, predicted a higher frequency of hallucinations (irrespective of degree of severity) in the total sample, but specifically in the schizophrenic patients. These results indicate that there may be gender differences in the propensity to experience hallucinations during the acute schizophrenic episode.