Delusions, Hallucinations, and Psychotic Symptoms

• Study notes on delusions, hallucinations, disorganized thinking, abnormal motor behavior, and negative symptoms.

Delusions

• Fixed beliefs that don't change despite conflicting evidence.
• Content can include persecutory, referential, somatic, religious, or grandiose themes.
• Persecutory delusions involve the belief that one will be harmed or harassed by an individual, group, or organization, and are the most common.
• Referential delusions involve the belief that gestures, comments, or environmental cues are directed at oneself.
• Grandiose delusions involve the belief that one has exceptional abilities, wealth, or fame.
• Erotomanic delusions involve the false belief that another person is in love with them.
• Nihilistic delusions involve the conviction that a major catastrophe will occur.
• Somatic delusions focus on preoccupations regarding health and organ function.
• Bizarre delusions are implausible, not understandable to same-culture peers, and don't derive from ordinary life experiences, such as the belief that an outside force replaced internal organs without leaving scars.
• Non-bizarre delusions could include the belief of being under police surveillance without convincing evidence.
• Delusions expressing a loss of control over mind or body are generally considered bizarre, including thought withdrawal, thought insertion, or delusions of control.
• Differentiating between a delusion and a strongly held idea can be difficult and depends on the degree of conviction despite contradictory evidence.
• Assessing delusions in individuals from different cultural backgrounds can be challenging because some religious and supernatural beliefs may be considered delusional in some cultures but accepted in others.
• Elevated religiosity can be a feature of psychosis.
• Fears reported by those who have experienced torture, political violence, or discrimination can be misjudged as persecutory delusions and may represent posttraumatic symptoms or intense fears of recurrence.
• A careful evaluation of whether the person’s fears are justified helps to differentiate appropriate fears from persecutory delusions.

Hallucinations

• Perception-like experiences that occur without an external stimulus.
• They are vivid, clear, and have the full impact of normal perceptions, not under voluntary control.
• Can occur in any sensory modality.
• Auditory hallucinations are the most common in schizophrenia and related disorders and are usually experienced as voices distinct from one's own thoughts.
• Hallucinations must occur in the context of a clear sensorium.
• Hallucinations while falling asleep (hypnagogic) or waking up (hypnopompic) are within the range of normal experience.
• Hallucinations may be normal in certain cultural contexts during religious experiences.

Disorganized Thinking (Speech)

• Typically inferred from an individual’s speech.
• Includes switching from one topic to another (derailment or loose associations).
• Answers to questions may be obliquely related or completely unrelated (tangentiality).
• Rarely, speech may be incomprehensible and resemble receptive aphasia (incoherence or "word salad").
• Symptom must be severe enough to substantially impair effective communication because mildly disorganized speech is common and nonspecific.
• Severity may be difficult to evaluate if the diagnostician has a different linguistic background.
• Some religious groups engage in glossolalia (“speaking in tongues”) or describe experiences of possession trance, which are characterized by disorganized speech.
• These instances do not represent signs of psychosis unless accompanied by other clearly psychotic symptoms.
• Less severe disorganized thinking or speech may occur during the prodromal and residual periods of schizophrenia.

Grossly Disorganized or Abnormal Motor Behavior (Including Catatonia)

• May manifest in a variety of ways, from childlike “silliness” to unpredictable agitation.
• Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living.
• Catatonic behavior is a marked decrease in reactivity to the environment.
• Catatonia ranges from resistance to instructions (negativism), maintaining a rigid, inappropriate or bizarre posture, to a complete lack of verbal and motor responses (mutism and stupor).
• Can also include purposeless and excessive motor activity without obvious cause (catatonic excitement).
• Other features are repeated stereotyped movements, staring, grimacing, and the echoing of speech.
• Catatonic symptoms are nonspecific and may occur in other mental disorders and in medical conditions.

Negative Symptoms

• Account for a substantial portion of the morbidity associated with schizophrenia but are less prominent in other psychotic disorders.
• Two prominent negative symptoms in schizophrenia are diminished emotional expression and avolition.
• Diminished emotional expression includes reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to speech.
• Avolition is a decrease in motivated self-initiated purposeful activities.
• Other negative symptoms include alogia, anhedonia, and asociality.
• Alogia is manifested by diminished speech output.
• Anhedonia is the decreased ability to experience pleasure and a reduction in the frequency of engaging in pleasurable activity.
• Asociality refers to the apparent lack of interest in social interactions and may be associated with avolition or be a manifestation of limited opportunities for social interactions.