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German Journal of Psychiatry

ISSN 1433-1055

Long-Term Atypical Psychoses

Michele Raja and Antonella Azzoni


Servizio Psichiatrico di Diagnosi e Cura, Ospedale Santo Spirito, Dipartimento di Salute Mentale ASL RM E, Rome, Italy


Corresponding Author: Dr. Michele Raja, M.D., Servizio Psichiatrico di Diagnosi e Cura, Ospedale Santo Spirito, Dipartimento di Salute Mentale ASL RM E, Rome, Italy, Telephone/Fax: +39 065898721, e-mail: raja.russo@iol.it


Abstract

Although psychotic symptoms and signs can be seen in various psychiatric disorders, some patients with delusions or hallucinations cannot be fitted into existing classification systems. The current study, based on 7 case reports, describes a subgroup of these undiagnosed psychotic patients with clinical features typical of dissociative disorders. At present, the nosology status of dissociative disorders, especially Dissociative identity disorder, is controversial. Furthermore, the diagnostic boundaries between dissociative disorders and Borderline personality disorder, Post-traumatic stress disorder, Conversion disorder, and Factitious disorder with psychological signs are ambiguous. The concept of dissociation is erratic. Depending on the way it is defined, dissociation can be seen as a state of mind, as a symptom, as a syndrome or as a clinical diagnosis. We suggest that a conservative Atypical psychosis diagnosis is more reliable and probably less inappropriate than a dissociative spectrum diagnosis for these patients (German J Psychiatry 1999;2:34-48)

Key words: Atypical psychosis - Dissociative disorders – Diagnosis – Hallucinations – Delusions - Psychiatric Comorbidity.

Abbreviations: BPD: Borderline Personality Disorder; DID: Dissociative Identity Disorder; DDNOS: Dissociative Disorder Not Otherwise Specified; FDPSS: Factitious Disorder With Psychological Signs And Symptoms; PDNOS: Psychotic Disorder Not Otherwise Specified; PICU: Psychiatric Intensive Care Unit.


INTRODUCTION

Despite a major advance in the diagnosis of mental disorders in recent years, a significant number of psychiatric patients do not meet criteria for a specific diagnosis. In a sample of adult psychiatric patients, Hudgens (1971) found that about 25% of them were undiagnosed. Using the St. Louis Diagnostic Criteria, Welner et al. (1974) found that 25 of 256 (9.8%) psychiatric patients had an indefinite diagnosis even after 3-year follow-up. Fennig et al. (1994) found that 4.7% of their psychotic patients received a diagnosis of Psychotic Disorder Not Otherwise Specified (PDNOS) and 4.3% had no consensus diagnosis. Our experience is similar. Using DSM-IV definitions of delusions and hallucinations and following the decision tree for the differential diagnosis of psychotic disorders, we had trouble in diagnosing several patients admitted to our psychiatric intensive care unit (PICU).

In our opinion, a residual group of psychotic patients remains who cannot be assigned to any specific DSM-IV category, despite the use of rigorously utilized diagnostic criteria and a wide range of information sources obtained over a long-term period. In this paper, we wish to focus on a specific subgroup of these undiagnosed psychotic patients. Their psychotic experience seemed atypical to our colleagues and to us. They shared some specific psychopathological features suggestive of dissociative disorders. Probably, some authors could make a diagnosis of Dissociative identity disorder (DID) in these cases. We report on 7 patients who should prove useful to highlight the diagnostic dilemma and attempt to focus on several questions that remain unanswered: 1) Are hallucinations and delusions compatible with a DID diagnosis? 2) Are the diagnostic boundaries of dissociative disorders reliable? 3) Does DID represent a distinct psychiatric disorder? 4) Should atypical psychosis diagnostic criteria be broader?

 

CASE REPORTS

Case 1. A 43-year-old, single woman presented in the emergency room, requesting admission. She claimed to "hear voices", to have "strange physical experiences" localized within her body, and to be persecuted by unknown people. She was alert and fully oriented. Although she complained of mild anxiety and depression, she looked relatively untroubled. Her attitude was kind, her form of expression histrionic. Sleep, appetite, psychomotor activity, self-esteem, and involvement in pleasurable activities were normal. During the interview, she reported seeing "strange objects" ("a key on the ground, fallen from the sky"), perceiving "abnormal physical sensations in her genitalia" and perceptions of being touched on her arms, shoulders and legs. Furthermore, she perceived the physical presence of a living being ("perhaps an animal") in her feet and in her legs. Before admission, she had interpreted other persons’ behavior as having a particular meaning for her. She claimed to perceive strong, peculiar unpleasant smells in our ward. We sometimes noted derailment, tangentiality, illogicality, circumstantiality in her speech, and a tendency to giving approximate answers. She did not present alogia, avolition, apathy or affective flatness. Her appearance was sunny, despite dramatic presentation of active-phase symptoms. Her cultural background was poor. However, cognition was normal. She claimed to be engaged to a priest, but we never found factual confirmation of this relationship. She reported to have been sexually abused by her father for 3 years when she was a teenager, and raped several times by different men in more recent years. While narrating these themes, she looked at ease and mimed sexual gestures without being embarrassed. The patient had not had a job nor home for many years and lived in a religious charitable institution. Patient’s behavior in the ward was adequate. The severity of her psychiatric illness had been stable for a number of years. Her medical history was irrelevant. Psychiatric family history was not available because she had lived in an orphanage since her mother's premature death and had met her father just a few times in dramatic circumstances.

On examination, her general medical condition was good. Routine laboratory tests were normal. Screening toxicological test was negative. We gave her haloperidol 6 mg p.o., biperiden 4 mg p.o., and diazepam 6 mg p.o., daily. After 5 days, we discharged the patient less worried, but with her major symptoms unchanged. There was no hostility or confrontation between the patient and the staff.

Case 2. A 57-year-old woman was admitted to the PICU for severe behavioral disorder, with hallucinations and delusions. In the past, she had never been visited by mental health professionals. Seven years before, in 1988, two of the patient’s sons had had a road accident: one of them had died, the other had been seriously injured and undergone repeated surgery. Several months later, the patient had undergone uterus resection for cancer. In 1991, her husband had died of a liver carcinoma. In 1994 two of the patient’s brothers had been diagnosed with lung carcinoma and one of them had died shortly afterwards. Psychiatric symptoms appeared for the first time after her sons’ accident. After reading a book on heavenly life, the patient began to hear her dead son’s voice, and to see his face. The patient’s relatives considered these experiences beneficial since they helped the patient to overcome depressive moods associated with bereavement. After her husband’s death, somatic and tactile hallucinations also appeared. The patient sensed that souls of the dead were present in her body. She claimed that her husband and her son were in contact with the world through her body. She was satisfied with these experiences. Her global functioning was excellent. For the first time in her life, she got a full time job and worked without difficulties for over a year. A few weeks before admission, hallucinations were no longer pleasant, as in the preceding years, but became dreadful. The patient sensed not only "good" but also "bad ghosts" in her body ("3 in her left leg and 2 in her right leg"). To throw them out of her body, she hurt her legs with a knife. On examination, she was alert and oriented. She had the above-mentioned magical and esoteric delusions, and auditory, tactile, and somatic hallucinations. She claimed to hear her son’s voice and to have a dialogue with him, to have strange feelings and painful perceptions of being touched by the ghosts present in her legs. It was impossible to correct the patient’s false beliefs. No disturbance in mood was evident. She conversed in a detached tone of voice and showed adequate behavior on the ward. Negative symptoms were absent. Sleep, appetite, psychomotor activity, and self-esteem were normal. Her compliance to treatment was excellent. None of her relatives had suffered from psychiatric disorder. We gave her haloperidol 15 mg p.o. and diazepam 22 mg p.o. daily, with moderate improvement.

Case 3. A 41-year-old-woman was hospitalized because she had cut her wrists in a penitentiary. She had been arrested at the airport because her bag was full of cocaine. The patient claimed to have got fraudulently involved with an exchange of bags. Police suspected her boyfriend, a drug-abuser with whom she had traveled in South America. She had never abused drugs. The patient had spent her childhood with different relatives because her mother had died young and her father had married again. When she was seven, she was raped by her brother. A few days later, she attempted suicide by fall. In her youth, she was often met on the street "completely forgetful" and confused. In the same period, she saw "the devil in a mirror looking at her", and had sweats that "left the impression of her body on the sheets". She got a secondary school certificate, began to work in a hospital as a nurse, and married a man with whom she had two sons. When she was about twenty, episodes of loss of consciousness first appeared. They were sudden, without motor signs, sometimes associated with headache and vomiting, and often recurred. Although a psychopathological etiology was suspected, no definitive diagnosis was made. Several electroencephalograms (including a recent one) revealed minor, diffuse non-epileptiform anomalies. She was treated with barbiturates, carbamazepine and benzodiazepines. Furthermore, the patient had unusual perceptual experiences, odd beliefs, and magical thinking. She sensed that a good "entity" was present in a wardrobe of her bedroom. She perceived voices commenting on, suggesting or criticizing her behavior. She often talked agreeably with them. Other times, the voices were hostile and cruel. There was also a sensation of estrangement from her body, vague and aspecific pain sensations, intrusive and unwanted memories, and confusion. She gave great importance to astrology, to a lot of paranormal phenomena, and claimed to be in contact with the hereafter. She also reported changing her handwriting frequently, and attributed this to the presence in her body of two persons, E. ("the victim") & M. ("the punisher"). No antisocial personality trait was present. In the past, the patient had received the following diagnoses: Petit mal, Complex partial seizures, Bipolar disorder, Generalized anxiety disorder, Post-traumatic stress disorder (PTSD), Conversion disorder, DID. Her global functioning was quite good: in spite of her symptoms, she had always been able to work as a nurse, had a lot of friends, and was a good mother and a good wife. On examination, she was alert and oriented. She was severely anxious and moderately depressed, with a sense of guilt. She reported auditory and somatic hallucinations, and had a bizarre delusion of being possessed. Sleep, appetite, psychomotor activity, and involvement in pleasurable activities were normal. We found neither evidence of intentional production or feigning of physical or psychological signs or symptoms, nor traits of antisocial personality disorder. Patient’s co-operation with our medical service and with the Court was excellent. We treated her with paroxetine p.o. 20 mg b.i.d.

Case 4. A 51-year-old woman walked into the emergency room asking to be admitted to our ward. In the last 4 days, she had sensed that she was "possessed by an internal voice belonging to a Thinking Energy which had a dialogue with her". This entity had taken absolute possession of her, ordering every action, word, or thought and foreseeing catastrophic events to her and her relatives. The patient had experienced similar symptoms 14 years before when one of her children had died in extremely dramatic circumstances. On that occasion, she had been admitted to a psychiatric clinic and diagnosed as affected by dissociative disorder and a histrionic personality. The duration of that episode had been 45 days, with full return to the premorbid level of functioning. Afterwards, she had always been in good health, devoting herself to her family and to an association that she had founded for the prevention of children's accidents. Patient’s medical history was unremarkable. None of her relatives had suffered from psychiatric disorder. Recently, she had experienced severe stress because her baby’s death had been staged on television. On admission, she claimed to have to pass through such great suffering because she had been destined by the almighty internal entity to a salvation mission. The patient claimed to receive confirmation of her ideas by radio and television. Although she was confident in the charitable omnipotence of her internal entity, she reported strong fear and suicidal rumination. She was aware of being ill and had good compliance to treatment. She was given 7 mg of haloperidol p.o. daily and 14 mg of diazepam p.o. with rapid improvement, and was discharged after 7 days.

Case 5. A 32-year-old woman was brought to the emergency room and admitted to our ward because of behavioral disorder. Patient’s medical history was unremarkable. Her mother had been admitted with a diagnosis of depression several times. Four years before, the patient had been admitted to a general hospital for weight loss and depressed mood and treated with antidepressants. She had been worried with fears of having diseases, and had undergone unwarranted admissions. Her psychiatrist reported that the patient had an atypical personality disorder, affective instability, hypersensitivity to separations, inability to make decisions, and uncontrollable fantasy proneness.

On admission, she was mute, immobile, and apparently confused. Her face looked sad, distressed, and perplexed. The day after, she revealed that shed had lied to her boyfriend, feigning that she was affected by a cerebral neoplasm, with the aim of receiving more attention from him. Her boyfriend confirmed that the patient had made up a cock and bull story, inventing headache, diagnostic procedures (brain CT, MRI), admissions to hospitals, and even brain surgery (making a scar on her scalp with a burning iron). He had become suspicious because these events "happened" just when he traveled on business. Thereafter, he realized that the patient had lied when her relatives reported that the patient often feigned medical illness. Furthermore, when he confronted the patient with evidence that her symptoms were factitious, she admitted having lied. Since then, their love-affair had been in trouble, and the patient had often threatened suicide and other extreme reactions. A few days before admission, she had taken the blanket off the bed where her boyfriend was sleeping to wash it (claiming that "a cat had sat on it"), had woken up her neighbors in the night without any reason, had thrown food, pots, and dishes because "they had been used by her ex-husband", and had uttered senseless sentences. These episodes of disorganized thinking and bizarre behavior were intermingled with periods during which the patient appeared normal. However, she never accounted for her conduct. We prescribed no drug and discharged her after 4 days. Three days later, the patient was again admitted to our ward after an act of aggression towards her boyfriend. She presented psychomotor retardation, anguish, perplexity and derealization ("What is happening?"). Sleep and appetite were normal. We gave her oral daily doses of haloperidol 6 mg, orphenadrine 100 mg, diazepam 12 mg, and amitriptyline 60 mg. Two days after admission, the patient suddenly became agitated and violent and was treated with droperidol (5 mg i.v.) and chlorpromazine (100 mg i.m.). Agitation vanished as abruptly as it had appeared. Then, the patient seemed surprised that so many nurses were near her, but when we "reminded" her what had happened, she became hostile and combative again. After a further i.m. dose of 75 mg chlorpromazine, she became quiet. When nurses moved away, she shouted and became upset, obstinately demanding not to be alone. Afterwards, the patient’s behavior became gradually more adequate and her affect less unstable. Post-hospital care was arranged in a mental health community center. One year after discharge, the patient committed suicide.

Case 6. A 27-year-old man living in a foster home was admitted to a PICU because he had threatened a nurse with a knife. In hospital, he made friends with an inpatient young girl, having a long discussion with her about death. Finally, they resolved on committing suicide, and the patient cut the girl’s and his own wrists. To keep them apart, the staff transferred the patient to our PICU. The patient’s parents were alcoholics. In his childhood, the patient suffered a lot of physical and psychological violence, especially from his father. He spent many years in a college. When the patient was thirteen, he was adopted. The first four years in his new family were untroubled. Afterwards, the adoptive parents divorced and the patient followed his adoptive father, interrupted his studies and began to work with him. In the same period, the patient abused hashish, opioids, cocaine and alcohol. Shortly afterwards, his adoptive father decided to break off relations with him and to "return" him to his biological father. In the following years, the patient presented behavioral disorder, troublesome interpersonal relationships, affective instability, impulsiveness, and shifting goals, values, and vocational aspirations. He attempted suicide at least six times, cutting his wrists and taking drugs. He was admitted 3 times to centers specialized in treating drug abusers and at least 20 times to psychiatric centers. He spent the months preceding admission in a foster home. His medical history was unremarkable. On examination, the patient was quiet and oriented. We detected neither psychotic symptoms nor abnormal speech or thinking. Mood was mildly depressed. Sleep, appetite, psychomotor activity, and involvement in pleasurable activities were normal. Several screening toxicological tests were negative. In the following days, we noted affective instability with episodes of dysphoria, irritability and anxiety, sometimes associated with dangerous acting-out. He was treated with levomepromazine (100 mg t.i.d.), biperiden (4 mg, daily), diazepam (10 mg t.i.d.), carbamazepine (200 mg t.i.d.), and propranolol (20 mg b.i.d.). Several weeks later, the patient disclosed a personal long-standing experience, the clear perception of "the internal voice of an alien person living within his own body". Sometimes, the voice was protective, other times commanding. The patient was convinced of the reality of his experience. A few days after, the patient became suddenly aggressive and agitated, and shouted that the internal voice was ordering him to kill himself or to hit somebody. When he became less hostile several minutes later, he claimed to have been persecuted all the afternoon by the internal voice ordering him to kill an inpatient woman with whom he had often engaged in conversation. He looked upset and revealed his fear that he was going to kill himself that night. Similar episodes occurred in the following days. Two years after discharge, the patient’s clinical state is unchanged.

Case 7. "Jane", a 41-year-old woman was admitted because she presented delusional thinking. After an esoteric seance, she claimed to be in contact with a recently dead friend. Since then, the deceased had always been with her; she saw him and heard his voice. The patient also reported episodes of derealization and depersonalization. On examination, the patient looked frightened and suspicious. Her mood was slightly depressed. She was started with haloperidol 5 mg p.o. and amitriptyline 75 mg a day, discharged after 3 weeks moderately improved, and entrusted to a community mental health center. Three years later, she was again admitted to our ward, one year after her husband’s death. At the beginning of the visit, her eye contact was poor and her attitude was mistrustful and perplexed. Shortly after, she became confidential and reported that she thought she was the reincarnation of Jesus and of Padre Pio, since "they acted through her body". Suddenly, she turned to her self with Padre Pio’s voice ("My dear, it’s not yet come your time, it’s still early to perform miracles!") and soon replied "to him" ("I know, but I am looking forward to revealing myself! Please, do not talk to me so severely"). In the following days, we observed other similar "dialogues". Furthermore, the patient reported visual hallucinations (Padre Pio’s image) and delusions ("nurses will transfer patients’ blood samples to ill children"). She reported that four persons were within herself, the Father, the Son, the Holy Ghost, and "Jane". Her affective concern and insight were minimal. Sleep, appetite, psychomotor activity, self-esteem, and involvement in pleasurable activities were normal. She was given diazepam p.o., 10 mg t.i.d. and discharged after 11 days, with minimal improvement. One month later, she was again brought to our hospital with a committal order because she was agitated, hallucinated ("I saw an old woman coming out of a mirror"), and threatening suicide. She reported a lot of magic-esoteric, religious, and bizarre hallucinations and delusions ("I have been wounded by a shooting star"). She was given haloperidol 6 mg p.o. a day and diazepam p.o., 4 mg t.i.d. and discharged after 8 days with minimal improvement. In the meantime, the patient continued working as a blue-collar worker and looking after her 17-year-old daughter, despite her Schneiderian first-rank symptoms.

 

Table 1. Features that might be important for excluding other diagnoses

Diagnostic features

Patients

 

1

2

3

4

5

6

7

Prominent psychotic symptoms

+

+

+

+

+

+

+

Clinical or laboratory finding supporting a current active medical illness

-

-

-

-

-

-

-

Patient’s history or toxicological laboratory results supporting a current substance-related disorder

-

-

-

-

-

-

-

Good premorbid adjustment

?

+

?

+

+

?

+

Age of onset (years)

?

50

7

37

28

~ 20

41

Current or previous history of mania or major depression

-

-

-

-

-

-

-

Negative symptoms

-

-

-

-

-

-

-

Asymptomatic intervals

-

-

-

+

-

-

-

Borderline symptoms

-

-

+

-

+

+

-

Histrionic symptoms

+

-

-

+

+

-

+

Presence of distinct identities or personality states

-

-

+

-

-

+ (?)

+ (?)

Dissociative fugue or dissociative amnesia

-

-

+ (?)

-

+

-

-

Marked stressor preceding the onset of symptoms

+

+

+

+

-

+

-

Duration of illness > 30 days

+

+

+

+

+

+

+

Possible malingering (medico-legal context, poor cooperation, antisocial personality disorder)

-

-

-

-

-

-

-

Factitious symptoms

+

-

-

-

+

-

-

Derealization or depersonalization

-

-

+

-

+

-

+

Good social functioning

-

+

+

+

-

-

+

Good response to neuroleptics

-

-/+

 

+

-

-

-

+ = present; - = absent; -/+ = partially present; + (?) = possibly present

 

 

DISCUSSION

In these patients, it was easy to rule out some alternative diagnoses. None of them had abused any substance (except patient 6), or suffered from an active general medical condition. The exclusion of a delusional disorder diagnosis was obvious in all patients. Except for patient 4, the duration of the disorder firmly excluded the diagnosis of brief psychotic disorder. Bipolar Disorder with psychotic signs and Schizoaffective Disorder were excluded because these patients had neither a significant and stable mood alteration, nor any typical somatic sign of severe mood disorder. On the contrary, we met greater difficulty in considering the following diagnoses.

Schizophrenia. Several clinical features highlight the differences between schizophrenia and these disorders: absence of typical premorbid and postmorbid personality characteristics, good adjustment and functioning concomitant with active-phase symptoms, atypical age of onset, absence of negative symptoms, patients’ warm attitude during episodes, no schizophrenia spectrum diagnosis in relatives, poor response to neuroleptics. None of the 9 psychiatrists of our team suspected schizophrenia in these patients. However, we found it difficult to identify unequivocal DSM-IV criteria for definitively excluding a schizophrenia diagnosis in some of these patients, because they had unambiguous hallucinations and delusions.

Dissociative disorders. Dissociation can be defined as the failure to integrate into consciousness normal thoughts, memories, identity or perception of environment. It is the essential feature of the dissociative disorders and has been considered a specific defense mechanism to face emotional conflict and internal or external stresses. Some authors (Liotti, 1993) postulate that dissociative experiences are ways of defending from severe stresses or trauma that cannot be escaped. While dissociative amnesia and dissociative fugue are characterized by unmistakable symptoms and signs that ensure a reliable clinical diagnosis, there is less consensus among clinicians about the clinical features of DID, or Dissociative disorder not otherwise specified (DDNOS). As a consequence, different prevalence rates of DID among general adult psychiatric inpatients have been reported: 1.3% (Putnam et al, 1984), 4.4% (Ross, 1987), 3.3% (Saxe et al, 1990), 16% (Bliss & Jeppsen, 1985), 3.3% (Ross et al, 1991). In the USA, a marked increase of DID diagnoses has been reported in recent years and has been subject to different interpretations (APA, 1994).

Is it relevant to consider dissociative disorders in the differential diagnosis of patients with hallucinations and delusions? Several authors consider dissociative experiences (in particular DID) related to psychotic symptoms (Spiegel & Fink, 1979; Rosenbaum, 1980; Ross et al, 1989-a; Ellason & Ross, 1995). Steingard and Frankel (1985) proposed that transient or recurrent psychotic episodes could be due to dissociation and noted that DSM-III had failed to describe the important coexistence of high hypnotizability with dissociative symptoms and psychotic symptoms. These authors suggested that painful experiences suffered in childhood or adolescence can strain ego strength beyond endurance and induce a tendency to dissociate. In a sample of 502 subjects in the general population, Ross and Joshi (1992) found a strong association between childhood abuse and positive psychotic symptoms.

According to Allen and Coyne (1995), patients affected by severe dissociative disorders commonly have true hallucinations (not just flashbacks) in several sensory modalities, confusion, disorganized thinking, and delusions. Furthermore, some patients with dissociative disorders benefit from antipsychotic drugs (Putnam & Loewenstein, 1993). Ellason and Ross (1995) report that as many as 24% to 49% of patients affected by DID have been previously diagnosed and treated for schizophrenia because they presented Schneiderian first-rank symptoms including hallucinations and delusions. According to these authors, the wide Bleulerian criteria of schizophrenia (including "all cases of functional mental disturbances" characterized by a splitting of the personality and manifesting hallucinations and delusions or abnormalities of temperament) have promoted the misdiagnosis of schizophrenia in patients with DID, since the same symptoms are often seen in cases of DID. Ross et al. (1994) suggest the presence of two pathways to positive psychotic symptoms: a trauma pathway and an endogenous biological pathway. They hypothesize a high degree of false-positive diagnoses of schizophrenia and of false-negative diagnoses of DID within the schizophrenia literature until now and recommend systematic screening of schizophrenic patients for dissociative symptoms. Allen and Coyne (1995) caution against the theoretical concept "dissociative therefore non-psychotic". Our patients had some symptoms and signs consistent with a dissociative spectrum diagnosis: severe and prolonged stresses reported in their history, atypical presentation suggesting disparate alternative diagnoses, patterns of symptoms suddenly changing, affective instability due to a marked reactivity of mood, dramatic or histrionic fashion, suggestibility. Furthermore, most of them showed clinical features typical of disorders often coexisting with DID, such as BPD, PTSD, Conversion Disorder, and Factitious Disorder. However, they also had hallucinations and delusions. Really, a noteworthy atypical feature of our patients is an excess of hallucinatory and delusional experiences. Most of them presented their symptoms emphatically and verbosely. When they were asked about the intensity of their psychotic experience, they tended to report that their psychotic symptoms were frequent and vehement, although often not disturbing. Some of them experienced complex multimodal hallucinations (e.g. they saw persons talking to them or touching them). These patients tended to receive scores in the psychotic items of the Brief Psychiatric Rating Scale and in the Scale for the Assessment of Positive Symptoms higher than patients with schizophrenia or affective psychoses. This finding is consistent with the opinion of authors specialized in dissociative disorders. Ross et al. (1989-a) report that Schneiderian first-rank symptoms are more numerous and outstanding in DID than in schizophrenia. Comparing 108 inpatients with DID with a sample of schizophrenic patients studied by Kay et al. (1987), Ellason and Ross (1995) found that DID patients presented more frequent and severe positive symptoms than schizophrenic patients, while schizophrenic patients presented severer negative symptoms than DID patients. Allen and Coyne (1995) found that dissociation was associated with strongly elevated MMPI-2 scores and related most strongly to scales F and 8. The F MMPI scale consists of rarely endorsed items; high scores reflect extreme deviance and raise the question of exaggeration of pathology, or careless responding, while scale 8 is the schizophrenia scale.

Six of the seven patients described were unequivocally delusional and hallucinated. The crucial question that these findings raise is: "Are delusions and hallucinations compatible with a DID diagnosis?" Although Ellason and Ross (1995) consider their findings "congruent with DSM-IV criteria for schizophrenia that emphasize negative symptoms as diagnostic criteria for schizophrenia", DSM-IV criteria for DID do not include positive psychotic symptoms. Concerning hallucinations and delusions in DID, DSM-IV is equivocal. On the one hand, DSM-IV acknowledges the possibility of hallucinations in DID ("An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations"), on the other hand DSM-IV warns against mistaking for a delusion the presence of more than one dissociated personality state, or mistaking for an auditory hallucination the communication from one identity to another. Thus, true hallucinations and delusions seem not to be compatible with a DSM-IV diagnosis of DID. In conclusion, there are no reliable criteria to establish whether "true" delusions or hallucinations occur in DID, or whether other personality’ influences can induce strongly similar experiences in patients with dissociative disorders.

DSM-III states that transient psychotic episodes may complicate Multiple Personality Disorder (MPD), the former name of DID. On the contrary, DSM-III-R does not mention psychotic episodes among the possible complications of MPD and warns against the possibility of misinterpreting symptoms of MPD as hallucinations or delusions. DSM-III-R suggests that patient’s reports of being controlled or influenced by others, or hearing or talking to voices may be actually the experience of the alternate personality’s influence. Criteria to distinguish the "true" delusion of being possessed and the dissociative experience of alternate personality’s influence are not provided. Anyway, DSM-III-R describes experiences similar to delusions and hallucinations in MPD. DSM-IV highlights the existing controversy existing about the differential diagnosis of DID from other mental disorders, including psychotic disorders. According to DSM-IV, the presence of clear-cut dissociative symptomatology with sudden shifts in identity states, reversible amnesia and high scores on measures of dissociation and hypnotizability in individuals who do not have the characteristic presentations of another mental disorder, may support a DID diagnosis.

Remarkably, except for patient 3, none of the patients acknowledged the presence of two or more distinct identities or personality states which is the cardinal criterion for making a DID diagnosis. The behavior of patients 6 and 7 strongly suggests such a presence. However, they never recognized it.

Hysterical psychosis. This is not a DSM diagnosis. Several authors reported atypical disorders reactive to severe stresses, characterized by a sudden onset of hallucinations, delusions, and depersonalization with a favorable outcome. They considered this disorder an extreme presentation of hysterical personality disorder and used the term "hysterical psychosis" to denote it (Hollender & Hirsch, 1964; Hirsch & Hollender, 1969; Richman & White, 1970; Martin, 1971; Cavenar et al, 1979). In the past, it had been emphasized that the differential diagnosis between schizophrenia and hysteria might be particularly difficult in some cases (Ey et al, 1972; Abse, 1959). Some of these cases are likely due to dissociative episodes (Steingard & Frankel, 1985). These cases met the DSM-III and DSM-III-R criteria for Brief Reactive Psychosis and the DSM-IV criteria for Brief Psychotic Disorder. With the possible exception of patient 4, our patients did not meet such criteria because their psychotic symptoms had been present for a significant period of time lasting several years, and their psychotic exacerbations had not occurred shortly after and apparently in response to severe stresses, at least in the more recent phase of the disorder. However, severe stresses are present in the past history of our patients and dramatic psychogenic factors in their familial background. Once again, we face a typical associated feature of DID (or BPD). Severe chronic childhood trauma has been considered a major etiological factor in DID as can be in PTSD (Ross et al, 1989-a; Steingard & Frankel, 1985, Spiegel, 1984; Goodwin, 1985; Putnam, 1985; Wilbur, 1985; Goodwin & Reynolds, 1987; Ross et al, 1989-b). Conversion symptoms and dissociation are closely linked and may share a similar pathogenesis (Miti, 1992). DSM-IV states that dissociative disorders and conversion disorder share symptoms and antecedents and that both disorders often coexist in the same individual. Four of our patients presented histrionic symptoms.

Borderline personality disorder. DSM-IV states that borderline patients may develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, and hypnagogic phenomena) during times of stress. Interestingly, according to DSM-IV, BPD and DID may share some psychopathological features, including severe dissociative symptoms. In particular, borderline patients may engage in self-destructive acts during dissociative experiences. The presence of two or more distinct identities or personality states - specific of DID patients - virtually implies typical clinical features of borderline patients such as unstable interpersonal relationships, markedly and persistently unstable self-image or sense of self, affective instability characterized by changes of mood lasting a few hours, feeling of emptiness. DSM-IV states that "self-mutilative behavior, impulsivity, and sudden and intense changes in relationships may warrant a concurrent diagnosis of BPD" in patients with a DID diagnosis. Furthermore, severe chronic childhood trauma such as physical and sexual abuse, neglect, early parental loss or separation are common in the histories of BPD as well as of DID patients. Finally, both DID and BPD tend to be more manifest before the end of the fourth decade of age. In a sample of 33 cases, Horevitz and Braun (1984) found that 70% of patients met criteria for both BPD and DID. According to some authors (Benner & Joscelyne, 1984; Buck, 1983; Clary et al, 1984), BPD should not be considered an axis II diagnosis, i.e. a personality disorder, but an axis I disorder belonging to the dissociative spectrum.

Patients 5 and 6 (and possibly patient 3) met the diagnostic criteria for BPD. However, these patients reported a long-term history of hallucinations and delusions inconsistent with a BPD diagnosis.

Factitious disorder with psychological symptoms. While we are confident in excluding malingering in these patients, the differential diagnosis from FDPS is more problematic, especially in patients 1 and 5. The only reliable diagnostic criterion of intentionality is difficult to verify in the case of reported psychological symptoms. Even if one suspects pathological lying when patients report behaviors or stresses not confirmed by other informants, it remains puzzling to exclude the possibility of dissociative experiences, since patients who receive a factitious disorder diagnosis have several personality traits similar to patients with dissociative disorders. The criteria for the differential diagnosis between dissociative disorders and FDPS are unreliable. In our opinion, the diagnosis of FDPS remains highly speculative in almost all cases.

Self-manipulated psychic symptoms have been rarely reported. It is difficult to detect them, i.e. to get incontestable proof that patients report psychopathological symptoms or display behavioral disorder on purpose. Most of the reported cases of FDPS are patients who also show factitious somatic disorder (Eckhardt, 1994). Nevertheless, Pope (1982) found 14 patients (6.4%) simulating delusions, hallucinations and thought disorders among 219 patients in a psychiatric hospital. These self-manipulated psychotic symptoms seemed atypical to the clinicians. The prognosis of these patients affected by FDPS was severe. Some of them received long-term neuroleptic treatment and two of them developed tardive dyskinesia. In a 4-7 year follow-up study, most of them had been repeatedly hospitalized for their psychopathological symptoms or had never been discharged from hospital. One patient had committed suicide. Typically, these patients suspended therapies when they were confronted with the factitious nature of their symptoms and turned to physicians unaware of their diagnosis and likely to treat them as psychotics.

One of our patients (no. 5) met the criteria for factitious disorder with physical signs and symptoms. However, she also had concurrent true mental disorders, namely BPD, and possibly DID. The patient experienced intense abandonment fears and had engaged in pathological lying in order to receive more attention from her boyfriend. We remain uncertain whether the patient’s sudden and dramatic changes of behavior are a sign of dissociation or intentional production of spurious psychological signs. We did not find behavior or symptoms supporting the suspicion of a factitious disorder diagnosis in the other patients. They showed no arguing with nurses or physicians, no evidence of excessive resorting to medical services, no disappointment at discharge.

 

CONCLUSIONS

In this uncontrolled series of psychiatric patients with persistent delusions and hallucinations who do not meet standard criteria for any psychotic disorder, we remain uncertain about their diagnosis.

Making a DSM-IV diagnosis of PDNOS for these patients seems unwarranted for the following reasons: 1) information about their clinical course is neither inadequate nor contradictory; 2) several signs and symptoms of these patients strongly suggest specific psychopathological features; 3) compared to DSM-III and DSM-III-R, DSM IV has rather restricted the residual category of PDNOS removing the term Atypical Psychosis and the examples of psychoses with unusual features; 4) no DSM-IV example of PDNOS is similar to our patients’ clinical picture.

We recognized some clinical features suggesting a dissociative spectrum diagnosis in these patients. Some of their psychopathological features seem consistent with the opinion of some authors specialized in dissociative disorders who consider positive psychotic symptoms characteristic of DID and propose changing current diagnostic criteria. Interestingly, all our patients but one were females. Unlike classical psychotic disorders, women outnumber men in DID or BPD.

However, also a DID diagnosis is probably inadequate. First, the nosology status of DID is highly controversial at present. Second, the patients did not meet specific criteria for any specific dissociative diagnosis. Third, some of them also had signs and symptoms specific of other mental disorders whose diagnostic boundaries with dissociative disorders are uncertain, such as BPD, PTSD, FDPS. Therefore, we decided to conservatively formulate the diagnosis of atypical psychosis in these patients.

In conclusion, current DSM criteria for psychotic disorders possibly ignore a group of patients with chronic hallucinations and delusions and some psychopathological features of dissociative disorders. Unless mood symptoms are prominent, most of these patients can receive a diagnosis of schizophrenia although their symptoms and signs are clearly atypical. Because of their good reliability, DSM-III stressed the importance of so-called positive symptoms (delusions, hallucinations, disorganized speech, catatonic features) to validate a schizophrenia diagnosis, making clear-cut boundaries with some personality disorders and other abnormal, bizarre, or flattened behaviors. On the contrary, there are no available DSM criteria to reliably distinguish schizophrenia from other long-term mental disorders characterized by atypical delusions and hallucinations.

In our experience, frequent hallucinations and delusions should be considered inadequate for the A criteria of schizophrenia at least in patients with the following concurrent features: 1) mild difficulty in social functioning; 2) no negative symptoms; 3) no stable conceptual disorganization; 4) highly fluctuating intensity of symptoms (changing from no symptom to extremely severe and vice versa in the course of a few hours); 5) high level of hypnotizability; 6) history of severe stresses, physical and sexual abuse; 7) no schizophrenia spectrum diagnosis in relatives; 8) no response to antipsychotic drugs; 9) dramatic or histrionic fashion; 10) difficult differential diagnosis with BPD, PTSD, FDPS, conversion disorder.

As long as we lack more reliable and valid criteria for this group of patients, we suggest that the diagnosis of atypical psychosis be maintained, broadening its criteria to include similar cases. However, one has to be careful with conclusions as this is a case report study. The issue awaits further empirical data from controlled studies.

 

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