Exacerbation of psychosis by misinterpretation of physical symptoms. (Case Report).

Abstract: Impaired processing of perceptual information is often a prominent aspect of psychotic disorders. Physical symptoms such as pain or discomfort may be either incorrectly perceived or misinterpreted by psychotic patients. Presented here is a series of cases in which somatic symptoms occurred in psychotic patients and worsened their psychotic states but only later were recognized as physical problems. Psychotic patients may be unable to comprehend or describe their physical symptoms adequately. Physical disorders of psychotic patients may be overlooked if clinicians are not vigilant and thorough in assessing the patients' complaints, especially if such complaints sound delusional or bizarre.

Key Words: psychosis, schizophrenia, somatic symptoms

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Abnormalities of information processing have played a central role in the understanding of psychosis since the early descriptions of schizophrenia. Psychotic patients often have profound problems focusing their attention on salient cues and overcoming the disruptive effects of distracting stimuli. Such patients may be rendered vulnerable to stimulus inundation, cognitive fragmentation, and thought disorder induced by the inability to process cognitive cues and stimuli in their environment. (1) Like other stimuli, physical symptoms such as pain or other forms of discomfort may be either perceived inadequately or misinterpreted by psychotic patients, causing them to become confused about the meaning of these stimuli. Because psychotic patients often express delusions or misconceptions, clinicians may ignore their statements regarding physical symptoms, especially if their statements sound bizarre. This report describes a series of cases in which patients attempted to express significant physical symptoms but we re assessed by their clinicians as having nothing more than delusions secondary to psychosis.

Discussion

In addition to these cases, a previous report (2) described a 52-year-old man with bipolar disorder who experienced valproic acid-induced tinnitus, which the patient misinterpreted as coming from some type of device implanted inside his cranium, which his psychiatrist incorrectly diagnosed as a delusion. Another report (3) described a 69-year-old man who developed psychogenic parasitosis that apparently was closely related to pruritus and paresthesias caused by renal failure. These cases suggest that if individuals with mental impairments do not process the stimuli of physical symptoms appropriately, misinterpretation of their significance may lead to psychotic symptoms or delusions. Such patients may unintentionally create bizarre stories or theories to rationalize the confusing stimuli that they cannot comprehend adequately. Elements of the somatic problems are often incorporated into the resulting delusion. For example, Patient 1 clearly perceived that he was having dysesthesias of his lower extremities, b ut because he could not process or comprehend the stimuli adequately, these pains became part of an elaborate delusion about acid being poured on his legs. Gating studies of schizophrenia (4,5) show that information-processing deficits in general, and the failure of sensorimotor gating in particular, may render patients with schizophrenia vulnerable to cognitive fragmentation, which may in turn lead to psychotic symptoms and thought disorder. Other studies (6,7) have found that patients with schizophrenia exhibit abnormal information processing compared with volunteers with regard to visual, auditory, and tactile stimuli. Some investigations of information-processing tests in people with schizophrenia (8,9) suggest a correlative relationship between information-processing deficits and thought disorder.

It is important to recognize that some patients with information-processing deficits may be unable to interpret stimuli associated with physical symptoms reliably. They also may have difficulty in describing their symptoms or relating them appropriately to their care providers. This complicates the management of such patients. Recognition of the physical symptoms of psychotic patients may be difficult if clinicians are not vigilant in assessing these patients' complaints, which in some instances may sound more like delusional ideas than the viable complaints of patients without mental impairments. It is worth noting that, at least in this series, treatment of the underlying physical problem resulted in improvement of the corresponding psychotic symptoms.

Conclusion

Psychotic patients may perceive or misinterpret stimuli related to physical symptoms incorrectly. They may fail to communicate these symptoms properly to others, and their complaints may sound bizarre or delusional. Clinicians who care for such patients should be cautious in assessing their complaints to avoid overlooking a physical problem.

Accepted January 15, 2003.

References

(1.) Braff DL. Information processing and attention dysfunctions in schizophrenia. Schizophr Bull 1993; 19:233-259.

(2.) Reeves RR, Mustain DW, Pendarvis JE. Vaiproate-induced tinnitus misinterpreted as psychotic symptoms. South Med J 2000;93:1030-1031.

(3.) Slaughter JR, Zanol K, Rezvani H, Flax J. Psychogenic parasitosis: A case series and literature review. Psychosoinatics 1998;39:491-500.

(4.) Braff DL, Geyer MA. Sensorimotor gating and schizophrenia: Human and animal model studies. Arch Gen Psychiatry 1990;47:181-188.

(5.) Light GA, Braff DL. Human and animal studies of schizophrenia-related gating deficits. Curr Psychiatry Rep 1999;l:31-40.

(6.) Ford JM, Roth WT, Menon V, Pfefferbaum A. Failures of automatic and strategic processing in schizophrenia: Comparisons of event-related brain potential and startle blink modification. Schizophr Res 1999;37: 149-163.

(7.) Parwani A, Duncan EJ, Bartlett E, Madonick SH, Efferen TR, Rajan R, et al. Impaired prepulse inhibition of acoustic startle in schizophrenia. Biol Psychiatry 2000;47:662-669.

(8.) Perry W, Geyer MA, Braff DL. Sensorimotor gating and thought disturbance measured in close temporal proximity in schizophrenic patients. Arch Gen Psychiatry 1999;56:277-281.

(9.) Braff DL, Swerdlow NR, Geyer MA. Symptom correlates of prepulse inhibition deficits in male schizophrenic patients. Am J Psychiatry 1999;156:596-602.

RELATED ARTICLE: Key Points

* Impaired processing of perceptual information is common in patients with psychotic disorders.

* Psychotic patients may be unable to adequately interpret or cognitively process the stimuli of physical symptoms such as pain or discomfort.

* Descriptions of somatic symptoms by psychotic patients may sound bizarre or be expressed as a delusion.

* Physical disorders of psychotic patients may be missed if clinicians are not vigilant and thorough in assessing the patients' complaints, especially if the complaints sound like the expression of psychotic symptoms.

Case Reports

Patient 1

A 78-year-old man with dementia with psychotic features began complaining that a man was coming into his room and injuring his legs because he had offended him. The patient would wake up at night and complain of his feet stinging and burning and say that the man had poured acid on them. These complaints gradually became more frequent during a period of a few months. The patient's response to quetiapine at dosages titrated up to 200 mg bid was poor. Higher doses could not be tolerated because of excessive sedation. Medical assessment revealed elevated blood urea nitrogen and creatinine, which was suggestive of chronic renal failure. The patient's deep tendon reflexes and distal sensation were decreased in the lower limbs. The electromyograms and nerve conduction velocities were consistent with peripheral neuropathy, likely secondary to renal insufficiency. Treatment of the patient's impaired kidney function and small doses of gabapentin largely alleviated his apparently delusional complaints.

Patient 2

A 72-year-old man with schizophrenia was hospitalized with complaints that an alien device had been implanted into his right ear and was transmitting messages about the future and instructions to leave his personal care home. During his admitting history and physical examination, the right auditory canal was found to be occluded with cerumen, and he could barely hear out of the right ear. li-rigation to remove the cerumen uncovered a cotton ball packed tightly against the tympanic membrane (apparently for several weeks or longer) with adjacent irritation and infection. Removal of the foreign body resulted in spontaneous resolution of the patient's complaints.

Patient 3

A 42-year-old man with schizophrenia treated with risperidone 2 mg bid complained for several months that devils were stabbing him with knives in his left hip, causing pain down his leg. He thought that the devils were trying to enter his body through the wounds. Risperidone was titrated up to 4 mg bid, but the patient's complaints of being stabbed continued to increase. Eventually, he was evaluated by an orthopedist and was found to have hemiation of the L5-S1 intervertebral disc, requiring discectomy and laminectomy, which alleviated his pain. Afterward, he was treated successfully with his original dose of risperidone.

Patient 4

A 68-year-old man with chronic undifferentiated schizophrenia who had resided in a nursing home for approximately 1 year suddenly began expressing delusions that he had been a Secret Service agent. He talked about how he "took five slugs in the back while trying to protect the president. One of the slugs came out of my buttocks and now it hurts me there." For the next week, he continued to complain of gluteal pain at "the exit site of the bullet" until he was examined and found to have developed a decubitus ulcer. When the ulcer was completely healed, the patient's delusions related to the source of pain resolved.

Patient 5

A 32-year-old woman with schizoaffective disorder required treatment with valproic acid and risperidone for several years. She then began talking about seeing haloes and lights around objects and people. She interpreted these visions as spirits and developed elaborate explanations about why they were there and what they were doing. In spite of increasing her dose of valproic acid to 1,000 mg bid and her risperidone dose to 3 mg bid, her preoccupation with "the spirits" became more intense. After she developed more visual symptoms, an ophthalmology consultation was obtained, and she was found to have narrow angle glaucoma. After treatment with timolol ophthalmic drops to decrease her intraocular pressure, her complaints of seeing spirits lessened, and her medication dosages were decreased to their previous levels (valproic acid 500 mg bid, risperidone 2 mg bid).

Patient 6

A 43-year-old man with schizophrenia complained of gradually increasing mid- and lower-back pain. He thought that surgical devices had been implanted into his back and that these were causing the pain. He continued to express this complaint after his olanzapine dosage was increased from 10 to 20 mg qd. Eventually, an examination of his back was performed, which revealed marked paravertebral muscle spasm with tenderness to palpation. His delusion gradually resolved after he was treated with muscle relaxants and physical therapy, and it was then possible to decrease his olanzapine dosage to 10 mg qd.

Patient 7

A 47-year-old man with paranoid schizophrenia began refusing to attend his outpatient appointments and refill his prescriptions. When clinic staff called him, he stated that he was growing vampire teeth and could not go outside during the daytime, or he would be destroyed. His family managed with some difficulty to bring him to the hospital, where he stated that he knew that he was becoming a vampire because he had vampire teeth. An examination revealed that he had lost all of his central upper teeth, leaving the incisors somewhat noticeable on either side. The delusion resolved with the resumption of his antipsychotic medications and the placement of a partial upper dental plate.

From the G.V. (Sonny) Montgomery VA Medical Center and the University of Mississippi School of Medicine, Jackson, MS.

This work was supported in part by the South Central VA Health Care Network Mental Illness Research, Education, and Clinical Center (MIRECC).

Reprint requests to Roy R. Reeves, DO, PhD, Department of Psychiatry, G.V. (Sonny) Montgomery VA Medical Center (116A), 1500 E. Woodrow Wilson Drive, Jackson, MS 39216. Email: [e-mail]

Copyright [C] 2003 by The Southern Medical Association

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