400 patients recruited in New York and surroundings characterized by: 1) at least one psychotic...

Martinotti G, Santacroce R, Cinosi E.Dipartimento di Neuroscienze ed Imaging

Università “G.d’Annunzio”- Chieti

The lysergic psychoma: a psychopathological syndrome

• Differences between substance-induced psychosis and primary psychotic onset

• Hallucinatory experience

• Lysergic psychoma

Is there any difference between substance-induced psychosis and

primary psychotic onset?

400 patients recruited in New York and surroundings characterized by:

1) at least one psychotic symptom 2) no psychiatric history (since the 6 months before recruitment)3) alcohol and/or substance abuses in the last 30 days

44% received a diagnosis of substance-induced psychosis

56% received a diagnosis of primary

psychotic disorder

NB: Based on PRISM (Psychiatric Research Interview for Substances and

Mental disorders)

Caton et al. Arch. Gen Psy, 2005

Caton et al. Arch. Gen Psy, 2005

Caton et al. Arch. Gen Psy, 2005

Statistically significant clinical characteristics

1) Primary psychosis group: younger age, higher score in positive symptoms scales;

mostly auditory hallucinations, less insight in negative symptoms and higher scores at

PANSS general psychopatologic scale.

Caton et al. Arch. Gen Psy, 2005

Statistically significant clinical characteristics :

2) Substance-induced psychosis group: more common visual hallucinations and higher

prevalence of suicidal thought during previous year. More violence. Family history of substance

abuse.More insight.

Caton et al. Arch. Gen Psy, 2005

Type of hallucination

Insight

Main differences

• The hallucinatory phenomena were firstly defined in 1574 by JF. Fernel, who used the term “hallucination” in regard to eyes disease.

• Esquirol, in 1817, described the phenomenon as “a perception without an object”, while Jaspers proposed the definition of “false perception”, which is not a sensory distortion or a misinterpretation, but “occurs at the same time as real perceptions”.

The hallucinatory phenomena

• Hallucination• Pseudo-hallucination• Hallucinosis

The hallucinatory phenomena

• According to Jaspers, what clearly distinguishes hallucinations from real perceptions is that they are images coming from the inner space, although the subject reacts as if they were true perceptions coming from outside.

• This characteristic trait allows to set them apart from vivid mental images (pseudohallucinations), which also derive from the inner world but are recognized as such.

The hallucinatory phenomena

• hallucinations determined by drug of abuse, mainly hallucinogens, stimulants and designer drugs.

• These phenomena typically consist of diffuse distortions of the existing world, which can often be seen even when eyes are closed.

Hallucinosis

• In schizophrenia has been evidenced that very high levels of dopamine in limbic system play a major role in determining hallucinations and delusions.

• Antipsychotic medications, which block central dopaminergic activity, determine a reduction of hallucinatory symptoms in psychosis.

• On the other hand, drugs with strong dopaminergic effect, such as L-dopa, methylphenidate, bromocriptine, pramipexole and piribedil, and direct dopamine agonists, like D-amphetamine, may induce hallucinations.

Hallucinations and Dopamine

• A possible role of glutamate in hallucinations has instead been suggested by the finding that glutamate antagonists like phencyclidine and ketamine can induce hallucinations.

• This has led to the hypothesis that psychotic symptoms may in part be attributed to an hypofunction of NMDA receptors.

Hallucinations and Glutamate

• Marsh et al. (1979), proposed the distinction of three types of visual hallucinations in schizophrenics:

• 1) superimposed hallucinations;• 2) spatial and depth distortion;• 3) animations.

Hallucinatory visions

Superimposed hallucinations

• spatially separated from

objective reality

• relatively abstract geometric shapes, and there is some agreement among subjects about their common characteristics

Animations

• spatially integrated with reality

• highly individualized, with interference in visual perception and probably greatly influenced by specific psychodynamic factors

Hallucinatory visions

• As regard to hallucinatory topics, animals and figures may be prominent; a delusional or hyper-religious character is often present, with a “personal significance” and an emotional impression (Small et al., 1966). This is probably the main characteristic of visual hallucinatory phenomenon in schizophrenia, in which the “personal significance” is usually terrific, persecutory, with a feeling of catastrophe (Katastrophale Stimmungstönung des Erlebens of Müller-Suur) and “end of the world” (Weltuntergangserlebnis of Wetzel, 1922).

Hallucinatory visions in Schizophrenia

• Hallucinatory visions in schizophrenia may be characterized by the presence of tiny people, imaginary objects, persons or animals of diminutive size, sometimes considered pleasant and amusing, in the so-called Lilliputian hallucination.

• Other specific alterations of the perception of relative size of the body or external world without other visual disturbances is usually associated with ‘Alice in Wonderland’ syndrome, micro- or macrosomatognosia, which is relatively more common in children, usually linked to migraine or epilepsy, and quite rare in schizophrenia (Todd, 1955; Evans & Rolak, 2004).

Hallucinatory visions in Schizophrenia

• Autoscopy, also called phantom mirror-image, is the experience of seeing one’s own body and knowing it as self. It is not just a visual hallucination because cenestethic and somatic sensations must be present to give the subject the impression that the hallucination is himself.

• Negative Autoscopy is instead the phenomenon of looking in the mirror and seeing no image. Internal Autoscopy is the possibility for the subject to see his internal organs.

Hallucinatory visions in Schizophrenia

• Small animals and insects are most often hallucinated in delirium tremens induce by alcohol. Sometimes, hallucinatory phenomena induced by drug of abuse are really bizarre, and “impossible” in their representation. The “personal significance” could be absent.

Hallucinosis (induced states)

• These phenomena typically consist of diffuse distortions of the existing world, which can often be seen even when eyes are closed. Geometric patterns, grids and lines, often described as ‘form constants’ (Kluver, 1966) are forms of hallucinatory experience in which the subject typically retains good insight, and are quite uncommon in schizophrenia.

Hallucinosis (induced states)

Visual Effects (superimposed hallucinations and illusions)

Color Enhancement

Higher pattern perception

Visual drifting

Tracers

Texture repetition

Scenery slicing

Geometria visiva (Visuals)

• More insight, with less paranoia and thought disorders, and hallucinations carry less “personal significance” than in schizophrenia (Frieske and Wilson, 1966).

• After substance abuse, visual hallucinations often occur without auditory voices, whereas schizophrenics rarely suffer visual hallucination alone, though they may accompany more common auditory hallucinations, especially in acute diseases and in certain culture.

Hallucinosis (induced states)

HALLUCINATORY DELUSION (HENRY EY)

• Psychoactive substances induce hallucinations;• Hallucinations alert the subject;• In a first phase hallucinations are referred to be caused by the

substance;• Twilight, transitional states and delirium complicate the

relationship with reality;• Flash-back phenomenon convinces the patient that something

has changed;• The subjects start to interprete and make connections among

hallucinations and relationships between them and the world;• Paranoid development, pseudoschizophrenia.

Type of hallucination

Insight

The hallucinatory phenomena

LYSERGIC PSYCHOMA: A FOREIGN BODY IN YOUR MIND

PSYCHE

CRITICALEGO

Something new from a psychopathological point of

view.(Hellpach, Cargnello)

PSYCHOME

PSYCHOPATHOLOGICAL SYNDROME CHARACTERIZED BY PERCEPTION OF EXTRANEOUS BODY IN ONE’S OWN MIND :

THE RESIDUAL CRITICAL EGO TAKES POSITION AGANIST THE INTOXICATED PART OF ONE’S OWN SELF (CALLIERI, 1968)

LSD AFFECTS PERCEPTIONS AND UNDERLINES HOW IMPORTANT PERCEPTION IS IN OUR CONSTRUCTION OF REALITY

• FLOATING• FLIP OUT• FLATTENED

• HORROR TRIP/BAD TRIP• FLASHBACK

DANILO CARGNELLO(1911-1998)

“PSICOMA LISERGICO”

LYSERGIC PSYCHOMA:

Consciousness modifications

Affective swings(excitation, depression, rapid cycling of mood;

laughing explosion)

Chromatic perception statess (dyschromatopsies)

Visual perception disorders(macropsia, megalopsia, micropsia,

metamorphopsia, dysmegalopsia, dysopsia, pareidolia, hallucinosis);

LYSERGIC PSYCHOMA:

Depersonalization;

Temporal experience modifications;

(duation, temporal insularity)

Thought disorders;

Traumatic flashbacks of childhood experiences.

HALLUCINOGENS: BODY BOUNDARIES PERCEPTIONS

• To confuse himself with nature or enviroment; (floating)

• Loss of Body boundaries

(floating);

• Unawareness of own body, limbs and propioception (floating)

Psychedelic Experiences

G. ENRICO MORSELLI (1900-1973) PEYOTE/ MESCALINA

Contributo allo studio delle turbe da mescalina, II International Congress Of Neurology

London, 29-07/02-08 1935

“The impression of losing one’s own personality is not related so much to coenesthesics or neurotics as to a real dissociative alteration of the Ego. At a certain point saying my own name meant almost nothing to me: “Morselli!” I shouted, - “Who is he?” I had to have a tremendous willpower in order to remember that Enrico Morselli was me and not somebody else”

Two different ways of being psychotic

To have a psychosis(induced psychosis)

• Body as the place of the

battle between the subject and the “psychoma”;

• The “Body I Have””

• Korper

To be psychotic(psychotic onset)

• Ego experience as the place of the battle between the subject and his tranformation;

• The ”Body I am”

• Leib