Issue Year : 2011, Issue Number : 1, Issue Month : March Written By : Wahid Bakhsh Sajid, Shahid Rashid, Farrukh Akhtar

PHENOMENOLOGY OF DELUSIONS AND HALLUCINATIONS IN SCHIZOPHRENIA IN CENTRAL PUNJAB, PAKISTAN

Abstract Objective: To examine the variations in the frequency and contents of delusions and hallucinations in schizophrenia and correlates the significant findings with other studies across culture.Study Design: Case series studyPlace and Duration of Study: Psychiatry Department CMH Kharian for four year duration.Material and Methods: Eighty consecutive patients of schizophrenia (62 men and 18 women) were registered and evaluated for frequency of different delusions and hallucinations. The patients belonged to central Punjab (Pakistan). DSM-IV diagnostic criteria were used for diagnosis.Results: Most patients i.e. 72.25% belonged to lower social class. Auditory hallucinations were the commonest (81.25%) followed by tactile hallucinations (14.75%) and visual hallucinations (7.5%). Delusions of persecution were found in very high percentage (91.25%) delusions of reference in 42.5% and delusions of control in 31.25%. The patients believed that they were influenced by magic, demons and pirs. First rank symptoms of schizophrenia were present in 76.25% of patients; made affect, made impulse and made volition were present in (40.8%) and somatic passivity were present in (18%) of cases.Conclusion: Sociocultural background of the patients is likely to contribute in shaping the phenomenology of delusions and hallucinations and it is recommended that more elaborate/different diagnostic criteria may be designed for diagnosis of schizophrenia in developing countries.

Article INTRODUCTIONSchizophrenia is a syndrome mostly comprising disorders of emotion, perception, thought and motor behavior. The symptomatology in general and delusions and hallucinations in particular are greatly influenced by socio-cultural factors as well as the ethnicity1. The frequency as well as content of the symptoms is affected by the culture. The prevalence of 1st rank symptoms of schizophrenia is quite variable in different countries, e.g. 26.71% in 221 Malay patients2 as compared to 78.3% in 60 Nigerian patients3. Gender and social class may affect the phenomenology. A study in Pakistan found

that male and wealthy patients had delusions of grandiose identity believing that they had special powers while female and poor group had delusions of persecution and being controlled and of erotomania4. A transcultural study in Pakistan, UK and Saudi Arabia concluded that cultural factors are more important than religious affinity in defining symptomatology5. Immediate environment may have a stronger influence on the pathogenesis of delusions and hallucinations6. Modern technology and a rapid change of cultural patterns may also be influencing the expression of schizophrenia. There are only a few themes of extraordinary anthropological importance for the organization of human relationship which can be found in every epoch and different cultures (persecution, grandiosity, guilt, religion, hypochondria, jealousy and love). With the exception of persecution and grandiosity, these themes showed certain variability over times and between cultures. The new themes referring to the development of modern technology and a rapid change of cultural pattern turned out to be only the shaping of basic delusional themes7. Delusional themes that seem sensitive to socio-cultural and political situations include guilt, love/sex, religion and somatic change8. The present study designed to examine the role of socio-cultural influences in determining the content, the frequency as well as the variations in the phenomenology of delusions and hallucinations in our set up. It further examined the possibility of any peculiar symptom which may be more relevant and of help in refining the diagnostic criteria with regard to our population.MATRERIAL AND METHODThe study included 80 consecutive cases who were diagnosed to be suffering from schizophrenia on the basis of DSM IV diagnostic criteria. These patients were enrolled at the psychiatry department, of combined military hospital Kharian Cantonment (Central Punjab). They were accompanied by their relatives who provided detailed account of the current behavior of these patients. All the patients were not taking any psychotropic medication at the time of examination. The subjects experienced delusions or hallucinations or both. They also had other diagnostic symptoms of schizophrenia. The diagnosis of schizophrenia was independently established by two psychiatrists on different occasions before starting active treatment. Only symptoms considered as definitely present were recorded on the proforma for this study.RESULTSThe sample composed of 62 (77.5%) male and 18 (22.5%) female patients. Their ages ranged from 14-35 years (mean age was 30 years). Seventy seven (96.2%) patients were Sunni Muslims and three (3.8%) belonged to Shia sect. Twenty seven (33.8%) cases were illiterate, 39 (48.8%) had studied from class 5th to 10th and only 14 (17.5%) were graduates. Thirty three (41.2%) patients were first born, 13 (16.2%) were second born, 23 (28.8%) were middle born and 11 (13.8%) were last born. Forty patients (50%) were married and 40 (50%) were single. Fifty eight (72.5%) patients came from poor social class, 19 (23.8%) from middle class and 3 (3.8%) from upper class. Majority of the patients i.e. 65 (81.2%) belonged to rural area whereas only 15 (18.8%) cases were from urban background. There was positive family history of psychiatric illness in 42 (52.5%) patients and in 38 (47.5%) patients the history was suggestive of definite past episode of schizophrenia.Seventy three (91.25%) had delusions of various kinds out of which 33 (45.21%) were primary and 40 (54.79%) were secondary delusions. Sixty four (80%) patients had hallucinations while 61 (76.25%) had both delusions and hallucinations. Twenty one (28.77%) believed they were persecuted by relatives, 42 (57. 35%) by neighbors and 10 (13.70%) by outside agencies. Other associated delusions were that of grandeur (23.75%), marital infidelity (14.75%), which is more common in this study as compared to other studies2. Hypochondriacal delusions occurred in 6.25% and delusions of love and of guilt 3.75% each. Among hallucinations, auditory hallucinations figured prominently and were present in 81.25%. In our sample tactile hallucinations occurred in 14.75%. Visual

hallucinations came across in 7.5% of patients. Sense of presence and hallucinations of pain and deep sensation were found in 2.5% only (Table-1).

These hallucinations were present along with other types of hallucinations. Variations in the prevalence of Schneider’s first rank symptoms has been another prominent finding on comparison with the transcultural studies (Table-2).

DISCUSSIONThe purpose of this study was to analyze the differences across various cultures in the content and frequency of delusions and hallucinations in schizophrenia. Schizophrenia has been described in all cultures and socioeconomic groups. In industrialized nations disproportionate number of schizophrenia patients is in the low socioeconomic groups9, a finding that has been replicated in the present work. The most common hallucinations in schizophrenia are auditory which is consistent with the findings in this study. Tactile hallucinations were the 2nd and visual ones the 3rd most common perceptual disturbance. Most of the patients claimed having seen people, demons, pirs and angels. Visual hallucinations were previously considered very rare in schizophrenia10,11. The subsequent studies however, have shown that these are not that rare12-14. Increased frequency of visual hallucinations can be attributed to brain insults due to various environmental causes (traumatic, toxic and infective pathology), thus giving rise to such symptoms in less developed world15. Care should however, be taken to exclude any underlying organic condition whenever tactile or visual hallucinations constitute a part of phenomenology in any patient.Delusions of persecution have been found to be the commonest delusions in studies carried out in Pakistan and abroad4,16. The frequency (90%) in this study was, however, extremely high. An increased incidence of delusions of persecution was not a chance finding. This probably originated from existing uncertain, insecure and hostile environmental conditions faced by the society. Delusions of control/influence figured very prominently. Such an increased frequency is however not very surprising. In this phenomenon the patients believed that they were either possessed by jins/ demons

or influenced by pirs and magic. Such beliefs are a part of our cultural belief system. These delusions are usually shared by the family and the patients are therefore taken to religious/faith healers before being brought to a psychiatrist17-18. This symptom was taken as delusion only in those cases where other diagnostic symptoms were present. Hypochondriacal delusions were reported to be frequent in patients suffering from schizophrenia but this was not replicated in our study. Delusions of marital infidelity were found to be more frequent and were related to the paranoid delusional system19. A variation in the frequency of symptoms of diagnostic importance was another characteristic observation of our study (Table II). First Rank symptoms of schizophrenia occurred in 61 patients (76.20%) in this study which is consistent with study by Malik (67%)15. This probably was because of better expression of this symptom by our people. Other differences in this frequency of symptoms across cultures can be explained on the basis of use of different diagnostic criteria, method of eliciting the symptoms as well as the design of the study. Research diagnostic criteria were used in Nigerian study whereas diagnostic criteria employed in Saudi study were very vague20,21. Similarly in some studies the findings were based on retrospective case notes only.CONCLUSIONSocio-cultural background is likely to affect the phenomenology of delusions and hallucinations in schizophrenic patients. Multiple factors including brain insults, social class, prevailing cultural beliefs and overvalued ideas and immediate environment may contribute to the variation in themes. First rank symptoms of schizophrenia are useful in establishing the diagnosis but their absence doesn’t exclude it. Further studies with better design and methodology across the subcultures within and outside Pakistan are required to establish the differences in phenomenology and their relation to specific variables like social class gender, religion and language. This may help in refining the diagnostic criteria of schizophrenia in the socio-cultural context.References 1.Okulate G. T; Jones O.B.E.(2002). Auditory Hallucinations in schizophrenia and Affective Disorder in Nigerian Patients: phenomenology Comparison. Transcult Psychiatry 2003; (40): 531-41.2.Sulleh, MR, (1992) specificity of Schnieder’s First Rank Symptoms of schizophrenia in Malay patients Psychopathology, 25 (4) 199-2033.Ona, P (1982). Cultural Relativity of First Rank symptoms in schizophrenia. Int J of social. Psychiatry vol 28, No 2, 91-95.4.Sohail K (2003) Phenomenology of delusions in Pakistani patients; effect of gender and social class Psychopathology, 36 (4) 195-1995.Ahmed SH, Naeem, S. (1984). First Rank Symptoms and diagnosis of schizophrenia in developing countries. Psychopathology; 17 (5-6); 275-279.6.Sohail K, Cochrane, R (2002) Effects of cultures and environment on the phenomenology of delusions and hallucinations. Int J social Psychiatry, 48 (2) 126-138.7.Strompe T, Ritter, K; Schanda, H (2003). Old wine in new bottle? Stability and plasticity of the contents of schizophrenic delusions. Psychopathology; 38 (1) 6-12.8.Kim K, H Wei, H, Zhang, LD ct cl (2001). Schizophrenic delusions in Seoul, Shangai and Taipei a transcultural study. J Korean Med sci; 16 (1) 88-949.Sadock, BJ; Sadock, UA.(2003). SchizophreniaS. Synopsis of Psychiatry, Lippen Cott Williams; New York 9th edition, 476.10.Mayer-Gross, W. Slater, E. and Roth, M. (1969). Clinical Psychiatry, London: Bailliere, Tindall and Cassell. Pp 266-275.11.Fish, F. J. (1967). Schizophrenia, Bristol: John Wright. PP 18-57.12.Zarroug, E. T. (1975). The frequency of visual hallucinations in schizophrenic patients in Saudi

Arabia, Br JP Psychiatry,127, 553-555.13.Manford, M., Anderman, F. (1997). Complex visual hallucinations. Clinical and neurobiological insights. Brain. 1998; 121 (pt 10): 1819-40.14.Andreasen, NC (1987). The diagnosis of schizophrenic. Schizophrenia Bull. In Sadock, BJ;Sadock,UA. Schizophrenia Synopsis of Psychiatry, Lippen Cott Williams, New York 9th edition, 491.15.Malik, S. B. et al (1990). Schneider’s first rank symptoms of schizophrenia: Prevalence and diagnostic use. British Journal of Psychiatry, 109-111, 156.16.Strompe, T; Friedure, A, Ortwen G, Strobel R, Chaudrey HR, Najam N, Chaudary,MR (1999). Comparison of delusions among schizophrenics in Austria and in Pakistan. Psychopatholosgy; 32 (5):225-234.17.Fish, F.J. (1962). Clinical psychopathology. Bristol: Jphn Wright. PP 40-41.18.Lucas, F.J. (1962). Recent advances in clinical psychiatry Number one. J. Churchill. London 1971.PP 52-57.19.Soyka, M; Naber, G; Volker, A. (1991) Prevalence of delusional jealousy in different psychiatric disorders. The Br J Psychiatry 158; 549-553.20.Oye Gureje and Bamgboye, (1987). A study of schneider’s first rank symptoms of schizophrenia in Algerian patients. British journal of psychiatry, 150, 868-870.21.Zarrouk, E.T. (1978). The usefulness of first rank symptoms in the diagnosis of schizophrenia in Saudi Arabian population. Britrish Journal of Psychiatry, 132,571-573.

Issue Year : 2007, Issue Number : 3, Issue Month : September Written By : Wahid Bakhsh Sajid, Farrukh Akhtar

MALINGERING A DIAGNOSTIC DILEMMA

Article INTRODUCTIONThe deliberate and voluntary production of false and or psychological symptoms is referred to as malingering. Factitious disorders on the other hand are characterized by feigned physical or psychological symptoms and signs presented with the aim of receiving medical care [1]. They are therefore different from functional symptoms. A distinction should be made between factitious disorders and malingering. Malingerers deliberately feign symptoms to achieve a goal. Military authorities have always been suspicious that doctors attest disability on psychiatric grounds at the cost of discipline and promote malingering resulting in excessive war pension liabilities [2]. The concept of malingering is as old as history of mankind itself. Central to philosophical moral thought has been debate of the rightfulness or wrongfulness of a person's deliberate employment of the capacity to deceive [3].   In medicine, the dichotomy between truth and lies has found expression in the domain of malingering and its detection. Mental illness, because it is difficult to verify objectively and is dramatic and emotional subjectively, is an all-time favorite of the malingerers [4].In the second century AD Galen wrote a treatise, “On Feigned Diseases and the Detection of Them”, in which he described Roman conscripts who cut off thumbs or fingers to evade dangerous duties. In the sixteenth century Paolo Zacchias, considered to be the father of forensic medicine, wrote of madness, "There is no disease more easily feigned, or more difficult to detect [3].According to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) the essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Under some circumstances, malingering may represent adaptive behavior - for example, feigning illness while a captive of the enemy

during wartime [5].In his 1823 Medical Jurisprudence, Beck described the three contexts that have mostly stimulated malingering behavior throughout history. Diseases are generally feigned from one of three causes - fear, shame, or the hope of gain. Thus the individual ordered on service will pretend being afflicted with various maladies to escape the performance of military duty; the mendicant, to avoid labour, and to impose on public or private beneficence and the criminal, to prevent the infliction of punishment. The spirit of revenge, and the hope of receiving exorbitant damages, have also induced some to magnify slight ailments into serious and alarming illness [6].

CASE REPORTA 23 years old cadet from PMA, was transferred to department of psychiatry MH Rawalpindi from officer’s ward CMH Rawalpindi for the purpose of evaluation and disposal on account of his resistant and unexplained paralysis of left lower limb of 7 months duration.

The history revealed that, the patient fell from stairs while going to the classroom in PMA. He sustained blunt injury to his lower back. He felt numbness in his both lower limbs and was unable to move them but had not lost sensations. There was no history of head injury or unconsciousness. He was taken to CMH Abbottabad, where he was admitted and was seen by medical and surgical specialists who advised him analgesics and diathermy to his thoracic and lumbar region.

A week later while hospitalized he fell from a stretcher as he was being carried to the ward and sustained blunt injury to his lower back. Following this he became paraplegic and lost control of his bowels and bladder. CT scan of his thoracic region was carried out in CMH Abbottabad. The report mentioned injury to T12 while MRI thoracic spine reported cord contusion.  These reports were subsequently viewed as doubtful.Patient was therefore transferred to CMH Rawalpindi for opinion and further management by neurosurgeon. During his stay in CMH Rawalpindi he was seen by neurophysician, neurosurgeon, and specialist in rehabilitation medicine. He was subjected to a battery of investigations including MRI lumbar region. The report mentioned left posterior paramedian herniation of nucleus pulposis of L4-5 intervertebral disc. Nerve conduction studies carried out in AFIRM suggested polyneuropathy which was not held so firmly during discussion with the reporter.Subsequently patient started improving during hospitalization. Gradually he regained full power in his right leg but was still unable to move his left leg. He had started walking with the help of crutches dragging his left foot.During his hospital stay at CMH Rawalpindi, not only thorough investigations were carried out but he also received analgesics, nerve tonics and tranquillizers. He was also treated with various modes of physiotherapies, but of no avail, and he remained disabled and crippled.A medical board was held at CMH Rawalpindi for his invalidement out of service with disability class ‘A’, with attendant allowance. While the board proceedings were in progress, he was reviewed by neurophysician, who referred him to the psychiatrist. The psychiatrist during the interview and examination found that the patient was indifferent towards his disability, was excessively emotional and exhibited attention-seeking behavior.

However no psychiatric intervention was considered appropriate at that stage.During this period the ward nursing staff consistently observed that the patient moved his left lower limb during sleep. On the basis of this finding his medical board documents were requested to be returned from GHQ and a special medical board was convened at MH Rawalpindi. The board recommended his transfer to a psychiatric ward for his assessment. The cadet however declined to be transferred to psychiatric ward and resisted his transfer for 2 weeks. He finally had to be transferred under heavy sedation.     There was no history of diurnal variation of mood, disturbed sleep or mood swings, irritability, loss of appetite, or weight loss. He denied any psychoactive substance use. Taking into account history, clinical examination, investigations and psychiatric assessment he was diagnosed as a case of malingering.He was managed with behavior therapy and two sessions of acupuncture therapy to which he responded dramatically. His psychiatric report was initiated with recommendations that he should be discharged on administrative grounds. He was discharged in a perfectly healthy state in only six days. He was up and about without any disability.DISCUSSIONMalingering is a deliberate behavior for a known external purpose. It is not considered a form of mental illness or psychopathology, though it can occur in context of other mental illnesses. The motive(s) behind malingering may be: to avoid difficult and dangerous situations, responsibilities or punishments, to receive compensation, free hospital room, source of drugs or safety from police, to retaliate when patient feels guilt or suffers a financial loss, legal penalty or joblessness [7].The precise incidence of malingering is not known, however it is quite common. It occurs most commonly in settings with preponderance of men – the military, prisons, factories and other industrial settings.Miller outlined certain conditions under which malingering may be suspected: ·         Patient is involved in litigation or criminal proceedings. ·         There is history of malingering or factitious disorders. ·         Patient derives a secondary gain from having a deficit. ·         There is contradictory and inconsistent history and he is uncooperative and evasive during evaluation. ·         Symptoms of his illness are not consistent with known neuropsychological syndromes. ·         There is also presence of antisocial personality disorder and bizarre response to test items [8].        Potential indicators of malingering may be divided into premorbid indicators, which are: antisocial personality traits, borderline personality disorder, prior incapacitating injuries, poor job satisfaction, intolerable life conflicts and behavioral indicators, which are: uncooperative or inconsistent cooperation, suspiciousness, remaining aloof, being ill at ease and unfriendly and evasive during examination [9,10].Malingering differs from factitious disorder in that the motivation for the symptom production in malingering is an external incentive, whereas in factitious disorder external incentives are absent. Evidence of an intrapsychic need to maintain the sick role suggests factitious disorder. Malingering is differentiated from conversion disorder and other somatoform disorders by the intentional production of symptoms and by the obvious, external incentives associated with it. In malingering (in contrast to conversion disorder),

symptom relief is not often obtained by suggestion or hypnosis [11].Diagnosis of malingering should be considered if any combination of following is noted: medicolegal context of presentation, marked discrepancy between claimed stress or disability and objective findings, lack of cooperation during diagnostic evaluation and in complying with prescribing treatment regimen, and the presence of antisocial, histrionic personality disorders. This young cadet on initial interview was found to be having histrionic personality traits, attention seeking behavior and extremely poor motivation for military service. He frankly expressed disliking for the service and stated that he joined army just to please his mother where as he had no aptitude for the same. His sick role was also being reinforced by the ward staff in the hospital. The reward was also remarkably attractive (he was to be discharged with full pension and attendant allowance only after a few months of cadetship. This expected financial gain further perpetuated the sick role. His disability recovered on suggestion psychotherapy thus providing a face-saving measure both for the patient and the therapist. Treatment includes: Medical Care: Do not accuse the patient directly of faking an illness. Hostility, break down of the doctor-patient relationship, lawsuit against the doctor, and, rarely violence may result.The more advisable approach is to confront the person indirectly by remarking that the objective findings do not meet the physician’s objective criteria for diagnosis. Allow the person who is malingering the opportunity to save face. Alternatively, the physician may inform people who are malingering that they are required to undergo invasive testing and uncomfortable treatments (provided such warning is true). Consultation: People who malinger almost never accept psychiatric referral. The success of such consultations is minimal. Therapists should avoid consultations to other medical specialists, because such referrals only perpetuate malingering [12].The diagnosis of malingering is a challenge and dilemma for a doctor especially in military setting. On the one hand he doesn’t want to overlook a treatable disease or give a label of malingering with serious disciplinary implications and on the other he doesn’t want to encourage this highly undesirable behavior which may spread to other soldiers proving detrimental to overall morale and discipline of troops, resulting in huge financial loss to state due to expenditure on expensive tests and disability pension.References 1.      Bay C, May S. ABC of psychological medicine: chronic multiple functional somatic symptoms, a Clinical review. BMJ 2002; 325(7359): 323-6.2.      Ben S. A War of Nerves: soldiers and psychiatrists 1914-94 [Book review] BMJ 2001; 322(7277).3.      Sadock BJ, Sadock VA, editors. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia: Lippincot Williams and Willkins; 2000. p. 1889-1908.4.      Bash IY, Alpert M. The determination of malingering. Ann N Y Acad Sci 1980; 347: 86-99.5.      American Psychiatric Association. Diagnostic and Statistical Manual of mental disorders. Washington DC: The Association; 1994.6.      Beck TR, Beck JB. Elements of Medical Jurisprudence. Philadelphia: JB Lippincott; 1863.7.      Hall HV, Pritchard DA. Detecting Malingering and Deception. St. Delray Beach, FL: Lucie Press; 1996.

8.      Butcher JN, Miller KB. Personality assessment in personal injury litigation. In: Hess AK, weiner IB, editors. The Handbook of Forensic Psychology, New York: Wiley; 1999.9.      Resnick PJ. The detection of malingered mental illness. Behav Sci Law 1984; 2: 21-38.10. Rogers R, Editor. Clinical Assessment of Malingering and Deception. New York: Guilford; 1988.11. Lipian MS. Somatoform disorders. In: Price DR, Lees-Haley PR, editors. The Insurer's Handbook of Psychological Injury Claims. Seattle: Claim books; 1995. p. 83.12. Rogers R, Harrell EH, Liff CD. Feigning neuropsychological impairment: A critical review of methodological and clinical considerations. Clin Psychol Rev 1993; 13(3): 255-74.