Francesco Bernardini

History and conceptual problems of the relationship between obsessions and hallucinations.

AbstractContemporary psychiatric nomenclature defines schizophrenia (SCZ) and obsessive-compulsive disorder (OCD) as distinct disease entities characterized by non-overlapping diagnostic criteria. Nevertheless, a complex association between SCZ and OCD exists on the psychopathological level. And although the relationship between obsessions and delusions has been widely studied and discussed, the relationship between obsessions and hallucinations has not received the same attention. This article presents an historical overview of the studies on the co-occurrence of obsessions and hallucinations. We also analyze the clinical significance of this overlap, as discussed in the early descriptions of these phenomena in the nineteenth century and continuing through the most recent, contemporary conceptualizations. In clinical practice today, we may encounter both SCZ patients with typical ego-dystonic obsessive-compulsive symptoms and SCZ patients affected by obsessions that intertwine with psychotic symptoms, generating complex psychopathological syndromes (e.g. “obsessive hallucinations”). A further complication is that some OCD patients show perceptual disturbances. Taking into consideration the possible coexistence of obsessive-compulsive symptoms and psychotic symptoms is crucial for proper diagnosis, prognosis, and treatment. Further investigations are required to fully evaluate the psychopathological interrelationships between obsessions and hallucinations.

Adult-Onset Case of Undiagnosed Neurodegeneration with Brain Iron Accumulation with Psychotic Symptoms

Neurodegeneration with brain iron accumulation (NBIA) is a collective term to indicate a group of neurodegenerative diseases presenting accumulation of iron in the basal ganglia. These disorders can result in progressive dystonia, spasticity, parkinsonism, neuropsychiatric abnormalities, and optic atrophy or retinal degeneration. Onset age ranges from infancy to late adulthood and the rate of progression is very variable. So far, the genetic bases of nine types of NBIA have been identified, pantothenate-kinase-associated neurodegeneration (PKAN) being the most frequent type. The brain MRI “eye-of-the-tiger” sign, T2-weighted hypointense signal in the globus pallidus with a central region of hyperintensity, has been considered virtually pathognomonic for PKAN but recently several reports have denied this. A significant percentage of individuals with clinical and radiographic evidence of NBIA do not have an alternate diagnosis or mutation of one of the nine known NBIA-associated genes (idiopathic NBIA). Here we present an adult-onset case of “undiagnosed” NBIA with the brain MRI “eye-of-the-tiger” sign, and with psychotic symptoms which were successfully treated with antipsychotic and mood stabilizer medications. Here, the term “undiagnosed” is used because the patient has not been screened for all known NBIA genes, but only for two of them.

Correlates of Involuntary Admission: Findings from an Italian Inpatient Psychiatric Unit

BACKGROUND Involuntary admission is challenging in terms of providing the most effective but least restrictive care in accordance with the countrys regulations. A better understanding of correlates of voluntary versus involuntary admission legal status is crucial to improve clinical decision-making and effectiveness of the overall mental health care system. SUBJECTS AND METHODS We collected chart-review data pertaining to 848 patients, discharged between June 2011 and June 2014, from an Italian inpatient psychiatric unit. Diverse sociodemographic and clinical variables were collected. Bivariate analyses and binary logistic regression were performed to examine correlates of involuntary admission. RESULTS Bivariate analyses showed that involuntary status was related to: the reason for hospitalization, not being on psychiatric medications at admission, and being admitted from another inpatient ward (in particular, from the emergency department). The final regression model identified four main variables independently associated with legal status: being admitted for psychotic features, suicidal behavior, or impulsive behavior, and not being on medication at admission (Nagelkerke pseudo R2=0.15, p<0.001). A strong association with length of stay was also documented. CONCLUSIONS Understanding the causes and consequences of involuntary admission will enhance the fields understanding of how to provide the most effective, but least restrictive, psychiatric care.

Prenatal exposure to maternal smoking and symptom severity among offspring with first-episode nonaffective psychosis

Dear Editors, Prenatal exposure to maternal smoking (PEMS) has been linked to diverse negative perinatal outcomes (Cnattingius, 2004) and far-reaching neurobehavioral consequences, including impaired cognition, attention-deficit/hyperactivity disorder, and conduct disorder (Cornelius and Day, 2009; Gaysina et al., 2013). Although one study did not demonstrate a link between PEMS and risk for schizophrenia (Baguelin-Pinaud et al., 2010), Stathopoulou et al. (2013) found that prenatal tobacco exposure was independently associated with a later schizophrenia diagnosis. Ekblad et al. (2010) reported that the exposure is associated with increased risk of psychiatric morbidity including broadly defined psychosis. Other studies suggested that PEMS might increase risk for psychotic symptoms in offspring (Spauwen et al., 2004; Zammit et al., 2009). PEMS could conceivably impact illness manifestation among individuals with psychotic disorders. Smith et al. (2010) showed no association with symptom type or severity, or with symptom change across one year, among first-episode psychosis (FEP) patients, but Stathopoulou et al. (2013) found that PEMS was related to greater severity of negative symptoms. Given limited/inconsistent findings to date, we examined associations between PEMS and symptom severity among FEP patients, while controlling for effects of gender and the patient’s own smoking status. Participants (N = 93; age = 22.7 ± 3.7 years; 75.3% male; 91.4% African American) were recruited during an initial hospitalization as part of a larger study. Their biological mothers completed a questionnaire including items on smoking during the pregnancy. Data on current/past-month symptom severity were collected with the Positive and Negative Syndrome Scale (Kay et al., 1987). Comparisons between those with and without PEMS were made using Student’s t-tests, and factorial analyses of variance (ANOVAs) to examine effects of gender and current smoking status. Among the 93 mothers, 19 (20.4%) had smoked during pregnancy. The average number of cigarettes smoked per month during pregnancy was 113.7. As shown in Table 1, the two groups of FEP patients did not significantly differ on mean PANSS positive symptom severity. However, those with PEMS had greater severity of reality distortion: 13.6 ± 2.8 vs. 11.6 ± 3.0; t = 2.64, df = 91, p = .01; the difference being driven by greater hallucination severity (5.2 ± 1.3 vs. 4.0 ± 1.6; t = 3.06, df = 91, p = .003). Controlling for potential effects of gender and smoking status did not eliminate the effect of PEMS on reality distortion. Gender and smoking status were not significant predictors, but there was a main effect of PEMS (F(1, 79) = 4.94, p = .029). No interactions were observed. Table 1 Differences in mean PANSS subscale scores in first-episode psychosis patients exposed and not exposed to prenatal maternal smoking (n = 93). The two groups did not differ significantly on mean PANSS negative symptom severity (Table 1). However, those with PEMS had lower severity of deficit symptoms (PANSS proxy for the deficit syndrome score): −7.1 ± 3.1 vs. −4.0 ± 3.3; t = 3.69, df = 91, p < .001. Controlling for potential effects of gender and smoking status did not eliminate the effect of PEMS on deficit symptom severity. Gender was not a significant predictor, but there were independent main effects of PEMS (F(1, 79) = 4.66, p = .034), and current smoking status (F(1, 79) = 4.57, p = .036). There were no interactions. Although these initial results require replication, there appears to be an association between PEMS and greater hallucination severity at initial hospitalization for FEP. This is consistent with limited prior studies indicating that PEMS may elevate risk for psychotic symptoms/disorders (Spauwen et al., 2004; Zammit et al., 2009; Ekblad et al., 2010). We found a lower severity of deficit symptoms, which is inconsistent with the prior report indicating that PEMS was associated with greater negative symptom severity (Stathopoulou et al., 2013). Several methodological limitations must be acknowledged: the cross-sectional/retrospective nature of the study, potential for social desirability bias among the mothers, and limited sample size. Nonetheless, our findings suggest that—in addition to potentially increasing risk for psychotic symptoms/disorders—this fetal environmental exposure might worsen severity of hallucinations among those with early-course psychosis.