Followup of psychotic outpatients: dimensions of delusions and work functioning in schizophrenia

We studied three characteristics or dimensions of delusions in schizophrenia patients living in the community, including their influence on work and community functioning. The 149-patient sample included 57 delusional schizophrenia and nonschizophrenia outpatients, 50 nondelusional outpatient controls, and 42 delusional inpatient controls. The data indicated the strength and prominence of acute-phase psychopathology on characteristics of delusions, with large significant differences in intensity of delusions between the acute inpatient phase and the postacute inpatient and outpatient phases. Contrary to some views, the data indicate that the overall presence of any delusions in general, and the various dimensions of delusions, both influence work performance and community functioning, with the greater part of the variance due to the presence of delusions in general. Despite their outpatient status, delusional outpatients showed surprisingly poor self-monitoring about whether others would regard their delusional ideation as unrealistic. Schizophrenia and affectively disordered patients with high emotional commitment to their delusions showed significantly poorer work functioning and were significantly more likely to be rehospitalized (p < 0.05), indicating the important impact on functioning of patients' feelings of immediacy and urgency about their unrealistic beliefs.     

The misattribution of salience in delusional patients with schizophrenia

INTRODUCTION: Delusions may arise from abnormalities in emotional perception. In this study, we tested the hypothesis that delusional schizophrenia patients are more likely than non-delusional schizophrenia patients and healthy participants to assign affective meanings to neutral stimuli. METHODS: Unpleasant, pleasant, and neutral words were randomly presented to three subject groups--patients with schizophrenia with prominent delusions, patients with schizophrenia without delusions, and healthy participants. Participants performed three tasks: one in which they decided whether a letter string was a word or a non-word (lexical decision) and two affective classification tasks in which they judged whether words were 1) neutral or unpleasant, or 2) neutral or pleasant. RESULTS: While there were no significant between-group differences in lexical decision performance, patients with delusions showed selective performance deficits in both affective classification tasks. First, delusional patients were significantly more likely than non-delusional patients and healthy participants to classify words as unpleasant. Second, delusional patients took significantly longer than both other groups to correctly classify neutral words in both affective classification tasks. CONCLUSIONS: Taken together, these findings suggest that delusions are associated with the explicit misattribution of salience to neutral stimuli.     

How frequent is chronic multiyear delusional activity and recovery in schizophrenia: a 20-year multi-follow-up

To determine how frequent chronic multiyear delusional activity is in modern-day schizophrenia, we studied 200 patients over a 20-year period. We also studied the relation of delusions to hallucinations and thought disorder-disorganization, to work disability, and to later periods of global recovery and assessed several protective factors against delusional activity. The sample was assessed 6 times over 20 years and includes 43 patients with schizophrenia. Participants were evaluated at each follow-up for delusions, hallucinations, thought disorder-disorganization, work disability, and global recovery. Possible protective factors were assessed prospectively at index hospitalization. Twenty-six percent of the patients with schizophrenia were delusional at all follow-ups over the 20 years. Overall, 57% had frequently recurring or persistent delusions. A subgroup of over 25% of the schizophrenia patients had no delusional activity at any of the 6 follow-ups over 20 years. Schizophrenia patients with posthospital delusional activity had increased work disability (P < .05). Delusions that persisted after the acute phase in schizophrenia patients predicted a lower likelihood of future global recovery (P < .01). In conclusion, slightly over half of modern-day schizophrenia patients are vulnerable to frequent or "chronic" delusional activity after the acute phase. Schizophreniform patients and other types of psychotic disorders are vulnerable to posthospital delusional activity, but less frequently, less severely, and more episodically. Delusional activity is associated with work disability. Internal factors such as good premorbid developmental achievements and favorable prognostic factors are protective factors that reduce the probability of chronic multiyear, delusional activity in schizophrenia (P < .01).     

Relevant dimensions of delusions: continuing the continuum versus category debate

Delusions and hallucinations are common among healthy individuals but may differ from the symptoms experienced by persons with schizophrenia. It is hypothesized that specific dimensions of delusions, such as the distress associated with them, preoccupation, conviction or their content might be more relevant in distinguishing persons with from persons without schizophrenia than the mere presence of delusional beliefs. Second, it is investigated whether delusional beliefs are as closely linked to hallucinations in a non-clinical population as in persons with schizophrenia. The Peters et al. Delusions Inventory and the Launay Slade Hallucination Scale - Revised were used to assess delusional ideation and hallucinatory experiences in a population sample that reflects the general population in age, education and gender (n=359) and in persons diagnosed with life-time schizophrenia in varying stages of remission (n=53). There was a strong association of delusional ideation and hallucinatory experiences in both groups. Stepwise discriminant function revealed the distress associated with delusions as well as beliefs involving persecution and loss of control to be the most relevant aspects in distinguishing persons with from persons without schizophrenia. It is concluded that delusions should be assessed multi-dimensionally, laying particular emphasis on distress and content of beliefs.     

Delusions in the nonclinical population

Delusions have long been considered a hallmark of psychotic disorders such as schizophrenia. However, delusions may only be most visibly present in psychotic conditions and could also occur in nonclinical groups. The aim of this review is to establish whether delusions, as traditionally considered and assessed in psychiatric conditions, are also present in individuals without a psychiatric or neurologic condition. Clear evidence is found that the rate of delusional beliefs in the general population is higher than the rate of psychotic disorders and that delusions occur in individuals without psychosis. The frequency of delusional beliefs in nonclinical populations varies according to the content of the delusion studied and the characteristics of the sample population. Approximately 1% to 3% of the nonclinical population have delusions of a level of severity comparable to clinical cases of psychosis. A further 5% to 6% of the nonclinical population have a delusion but not of such severity. Although less severe, these beliefs are associated with a range of social and emotional difficulties. A further 10% to 15% of the nonclinical population have fairly regular delusional ideation. There is convincing evidence that delusional ideation, delusions, and clinically severe delusions are related experiences. Information about clinical delusions can therefore be obtained by studying delusional ideation in nonclinical populations.     

Emotional awareness and delusions in schizophrenia and schizoaffective disorder

Background and objectivesEmotion plays a significant role in schizophrenia. Emotional awareness (i.e., attention to and clarity of emotions) is associated with a wide range of outcomes. Given that individuals with schizophrenia and schizoaffective disorder differ in the significance of their mood symptoms, the present research examined whether the association between emotional awareness and delusions differs for these two groups of patients.MethodsEmotional awareness (i.e., attention to and clarity of emotions) was measured with self-report in a sample of 44 individuals diagnosed with either schizophrenia or schizoaffective disorder. Clinical ratings of delusions were made using the Scale for the Assessment of Positive Symptoms.ResultsFor the sample as a whole, individuals with higher levels of attention to emotion tended to have more severe delusions. In addition, diagnostic group significantly moderated the relation between emotional clarity and delusions.LimitationsConclusions regarding causality cannot be drawn due to the cross-sectional design. Replication is particularly important given the small sample sizes.ConclusionsThe present research indicates that emotional awareness is associated with delusions. The results raise the possibility that the emotional factors that contribute to delusional beliefs among individuals with schizophrenia differ in at least some ways from the emotional factors that contribute to delusional beliefs among individuals with schizoaffective disorder.     

The contribution of a cognitive bias against disconfirmatory evidence (BADE) to delusions in schizophrenia

A neuropsychological paradigm is introduced that provides a measure of a bias against disconfirmatory evidence (BADE), and its correspondence with delusions in people with schizophrenia and schizoaffective disorder was investigated. Fifty-two patients diagnosed with schizophrenia or schizoaffective disorder (36 were acutely delusional) and 24 healthy control participants were presented with delusion-neutral pictures in each trial, and were asked to rate the plausibility of four written interpretations of the scenario depicted by that picture. Subsequently, new pictures that provided background information about the depicted scenario were successively presented, and participants were requested to adjust their ratings, taking into account this new information. Two of the interpretations appeared tenable initially but ultimately proved to be implausible, one appeared untenable initially but eventually proved to be plausible, and one appeared untenable at all stages. A BADE was observed for delusional compared to non-delusional patients, as well as for all patients compared to controls. In addition, regardless of symptom profile, patients were more accepting of implausible interpretations than controls. The present work suggests that deficits in reasoning may contribute to the maintenance of delusions via an impairment in the processing of disconfirmatory evidence.     

Delusions in first-admitted patients: gender, themes and diagnoses

Whether there is a specific link between certain delusional symptoms and particular etiologies has not yet been completely clarified. In this study, 639 first ever admitted deluded patients were investigated in order to find out whether age and gender are associated with certain delusional contents, whether age at first admission may be linked to certain etiologies and whether it is possible to detect indicators particularly related to basic dysfunctions. At first admission, delusional female patients were older than men with a significant predomination of delusions of persecution, while men presented significantly more frequently delusions of jealousy and grandiosity. Within delusions of persecution, of religious or metaphysical content and of grandiosity, women were even significantly older than men. Religious or metaphysical and grandiosity contents occurred significantly more frequently in ICD-8 schizophrenia, indicating that these themes seem to be particularly linked to ICD-8 schizophrenia. Additionally, some target symptoms not included in the delusional symptomatology were investigated to test the relationship between delusions and schizophrenia. Overall, the results of the present investigation indicate that delusions are not specific for schizophrenia, and therefore, other symptomatological criteria should be applied for the nosographic attribution.     

Psychopathological and neuropsychological correlates of source monitoring impairment in schizophrenia

Schizophrenic patients are known to show a deficit in the source monitoring function, which refers to the set of processes involved in the attribution of an origin to memories and beliefs. A failure in source monitoring was found to be associated with Schneiderian delusions in the recent literature. This study aimed to explore in a sample of schizophrenic patients and controls two aspects of the source monitoring process-recognition and source attribution- and their possible correlation with psychopathology and basic neuropsychological performances. A group of 45 stabilized schizophrenic patients and 54 normal volunteers were studied with a Source Monitoring Task and a battery of neurocognitive functions known to be disturbed in schizophrenia. Recognition of self-generated items was significantly worse than control values in Schneiderian delusional patients only, while source attribution of recognized self-generated items was significantly biased towards the external sources in all delusional patients in comparison to controls. Among schizophrenic patients, source misattribution of self-generated items was significantly correlated to an executive, planning performance. Both performances were correlated to verbal memory in controls. Results confirm an impairment of different subcomponents of source monitoring performance in schizophrenia, heterogeneously related to psychopathological features and neuropsychological performances known to be impaired in schizophrenia.     

Origins of delusions in Alzheimer's disease

Research over the past two decades supports a shared aetiology for delusions in Alzheimer's disease (AD) and schizophrenia. Functional networks involved in salience attribution and belief evaluation have been implicated in the two conditions, and striatal D2/3 receptors are increased to a comparable extent. Executive/frontal deficits are common to both disorders and predict emergent symptoms. Putative risk genes for schizophrenia, which may modify the AD process, have been more strongly implicated in delusions than those directly linked with late-onset AD. Phenotypic correlates of delusions in AD may be dependent upon delusional subtype. Persecutory delusions occur early in the disease and are associated with neurochemical and neuropathological changes in frontostriatal circuits. In contrast, misidentification delusions are associated with greater global cognitive deficits and advanced limbic pathology. It is unclear whether the two subtypes are phenomenologically and biologically distinct or are part of a continuum, in which misidentification delusions manifest increasingly as the pathological process extends. This has treatment implications, particularly if they are found to have discrete chemical and/or pathological markers.     

Religious delusions in patients admitted to hospital with schizophrenia

Background Religious delusions are clinically important because they may be associated with selfharm and poorer outcomes from treatment. They have not been extensively researched. This study sought to investigate the prevalence of religious delusions in a sample of patients admitted to hospital with schizophrenia, to describe these delusions and to compare the characteristics of the patients with religious delusions with schizophrenia patients with all other types of delusion. Method A cross-sectional investigation was carried out. The prevalence of religious delusions was assessed and comparisons were made between religiously deluded patients and a control group on demographic, symptom, functioning and religious variables. One hundred and ninety-three subjects were examined of whom 24% had religious delusions. Results Patients with religious delusions had higher symptom scores (as measured by the PANSS), they were functioning less well (as measured by the GAF) and they were prescribed more medication than those patients with schizophrenia who had other types of delusion. Conclusion It is concluded that religious delusions are commonly found in schizophrenia and that by comparison with other patients who have schizophrenia, those patients with religious delusions appear to be more severely ill. This warrants further investigation. Accepted: 15 November 2001     

Relationship between the courses of clinical Features of patients with schizophrenia in adolescents and admission to psychiatric clinic]

In order to improve diagnosis of schizophrenia with onset in adolescents at an early stage, we investigated in detail the clinical features of 74 patients with schizophrenia, (23 males) at adolescents psychiatric clinic. Many of the subjects had been suffering from the illness about 14 years old but had not undergone their first psychiatric examination until a few years later. A high percentage (more than 80%) of our subjects presented psychiatric symptoms such as delusional remembrance, delusional moods, delusions of persecution and hypobulia. Additionally, more than 60% of our subjects presented auditory hallucinations. In general, teenage patients with schizophrenia onset show vague symptoms such as anxiety, embarrassment and strange moods rather than obvious hallucinations. Nevertheless, it was possible to identify certain clinical features of this disorder in adolescents: many patients suffer delusional remembrance, delusional moods and delusions of persecution immediately after the onset of the illness. Gradually, problematic behaviors such as anorexia, self injury, offences against their families, voluntary vomiting, etc., develop, but patients do not always receive psychiatric examination at this stage. After socially obvious problems such as school refusal, withdrawal from social activities and lowering of school record develop over a period of time, patients may be urged to undergo psychiatric examination. Our research again underlines the difficulty of achieving diagnosis of schizophrenia at an early stage. The key to early diagnosis appears to be the accurate identification of psychiatric symptoms in the early stages of the illness at school, or at home if possible, before socially problematic behaviors arise.     

Consistency of delusions in schizophrenia and affective disorder

The content of delusions were studied in a group of schizophrenics and affective disorder patients who had an episodic course to ascertain if the content of delusions remained similar or became dissimilar during different episodes. There were 18 schizophrenics and 30 affective disorder cases in this study. Consistency of delusional content was noted in one third of the cases in each group. Delusional content was consistent over episodes more often in Hindus (P less than 0.04), those married (P less than 0.03), and those from a rural background in the schizophrenic group. These differences were not observed in the affective disorder cases. Possible reasons for the consistence or non-consistence of delusional content are discussed.     

Persistence of delusional content among psychotics over consecutive episodes

The present paper examines the persistence of content of delusions in 48 patients diagnosed as either affective disorder or schizophrenia. These patients were attending psychiatric clinic at National Institute of Mental Health and Neurosciences, Bangalore, India, between 1986 and 1988. The type and content of delusion was assessed in each patient at each psychotic episode. Persistence in delusional content was found in one-third of the patients. It is likely that cultural and psychological factors may be contributing to this complex phenomenon of delusional persistence.     

Classification of chronic psychoses including delusional disorders and schizophrenias

A classification of chronic psychoses including nonparanoid schizophrenia, paranoid schizophrenia, paranoid state and paranoia (delusional disorder) is presented. This classification is dependent on a systematic increase in number of symptoms with each group. In particular, delusional disorder is examined with regard to family history. It is clear from the data which are presented that delusional disorder is more likely to be associated with a family history of such traits as suspiciousness, jealousy, secretiveness, and the presence of paranoid behavior or delusions. There is evidence that such familial traits are not seen in schizophrenia, only in delusional disorder.     

Symptomatic determinants of insight in schizophrenia spectrum disorders

Impaired insight in schizophrenia spectrum disorders has been linked to several psychopathologic features including positive symptoms, although not all dimensions of psychopathology have been studied and confounds from other symptoms have not been ruled out. In addition, the nature of the association between insight and specific positive symptoms, in particular delusions, remains unclear. The present investigation examined whether, in patients with schizophrenia spectrum disorders insight is associated with specific symptom dimensions including delusional severity. The factor structure was determined from scores of 151 patients rated on the Signs and Symptoms of Psychotic Illness scale. Associations of the Signs and Symptoms of Psychotic Illness insight item with the resulting components and delusions were assessed using regression-based methodology. Principal component analysis revealed 4 orthogonal symptom clusters. Correlational analyses demonstrated that only depression/anxiety and psychomotor excitation were significantly related to insight. Hierarchical regression indicated that delusions explained unique variance in insight over and above depression/anxiety and psychomotor excitation. These results suggest that depression/anxiety is associated with better insight and that psychomotor excitation and delusions are associated with poorer insight.     

Bizarre delusions and DSM-III-R schizophrenia.

OBJECTIVE: Bizarre delusions are assigned greater weight relative to other delusions in the DSM-III-R diagnosis of schizophrenia. The decision to emphasize bizarre delusions was based largely on historical tradition rather than empirical evidence. This study examined 1) the extent to which a history of bizarre delusions contributes to the diagnosis of schizophrenia and 2) whether schizophrenic patients with bizarre delusions constitute a clinically distinguishable subgroup. METHOD: Two hundred fourteen consecutively admitted psychotic inpatients were assessed for bizarre delusions according to the DSM-III-R criteria. Clinical and demographic correlates of bizarre delusions were examined in subsets of patients diagnosed as schizophrenic according to DSM-III-R who also received CT scans and neuropsychological testing. RESULTS: With the base prevalence rate for schizophrenia of 0.71, bizarre delusions had a sensitivity of 0.79, a specificity of 0.56, and a positive predictive power of 0.82 for the diagnosis of schizophrenia (N = 152) relative to other psychotic disorders (N = 62). Clinical, neurobehavioral, CT scan, and premorbid adjustment data on the schizophrenic patients indicated that beyond manifesting more severe positive symptoms, patients with bizarre delusions did not otherwise constitute a clinically distinguishable subgroup. CONCLUSIONS: The data suggest that criterion A for the diagnosis of schizophrenia in DSM-IV could be improved by removing the special emphasis that was placed on bizarre delusions in DSM-III-R.     

Perpetrators of homicide with schizophrenia: a national clinical survey in England and Wales

OBJECTIVE: Few studies have described rates of schizophrenia in a national sample of homicide perpetrators. This study aimed to describe this group's social and clinical characteristics, mental state features, offense details, and outcome in court. METHOD: Analyses used a national clinical survey that collected data on people convicted of homicide in England and Wales (1996-1999). Data were collected for those with schizophrenia or other delusional disorders from psychiatric reports and questionnaires. RESULTS: Of the 1,594 people convicted of homicide, 85 (5 percent) had schizophrenia. Of the 57 people with schizophrenia for whom data were available, 32 (56 percent) had been ill for less than 12 months, and in the month before the offense, 32 (56 percent) had shown a change in the quality, intensity, or conviction of or emotional response to their delusional beliefs. Twenty-four (28 percent) had no previous contact with psychiatric services. CONCLUSIONS: Regular assessment of delusions may help to detect an increased risk of violence, including homicide. More intensive care should be available for patients with a history of schizophrenia and previous violence.