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Characterizing organic hallucinosis
Characterizing
Organic Hallucinosis
Jack R. Cornelius, Juan Mezzich, Horatio Fahrega, Jr., Marie D. Cornelius, Joyce Myers, and Richard F. Ulrich A first comprehensive description of the clinical features of patients with the rare diagnosis of organic hallucinosis (OH) is presented, based on information from 11 OH patients among 14,889 patients who presented for evaluation over a 5-year period at our institution. This characterization is of particular current relevance to diagnosticians and clinicians because of the proposed major changes in the diagnostic system for OH in the upcoming DSM-IV and because of the virtual total lack of published information concerning this syndrome. This description includes a listing of the prevalence and mean severity of each symptom. The severity of the symptoms of OH are then compared with those of its crude “functional” equivalent of schizophrenia to determine which symptoms distinguish between these categories. Associated factors are also presented concerning demographics, modes of treatment, level of functioning, and current physical problems associated with OH. Copyright 0 1991 by W.B. Saunders Company
A
RESEARCH Task Force of the National Institute of Mental Health found that of all psychiatric illnesses, organic psychosis had been the most severely neglected by researchers.’ Lipowsk? concluded that no area of psychiatry was so riddled with conceptual and semantic confusion as the area of organic brain syndromes. He further concluded that the fundamental issues of terminology and classification of organic brain syndromes must be resolved if progress is to be made in this field. A better understanding of the descriptive psychopathology and clinical correlates of “organic” disorders, such as organic hallucinosis, is also important in developing a clearer perspective on their “functional” equivalents, such as schizophrenia. In an attempt to address these problems, the subsequently issued DSM-III3 and DSM-III-R4 included the new diagnostic category of “organic hallucinosis” (OH), among other changes. However, the DSM-III and DSM-III-R clinical descriptions of this disorder and other published reports provide little information concerning such basic clinical information as the prevalence of various symptoms in patients with this rare syndrome or such clinical correlates as the average age at presentation, gender distribution, duration, frequency of associated features, average level of impairment, prevalence in a large sample who present for evaluation, or associated medical diagnoses.5 Furthermore, the clinical symptoms that distinguish this disorder from the so-called functional psychotic disorders such as schizophrenia have never been enumerated. Consequently, calls continue to be made for research to develop adequate diagnostic criteria and associated clinical correlates for the organic psychoses.’ The initial steps in the evaluation of the diagnostic validity of a newly described disorder necessitates this comprehen-
From the Department of Psychiatry Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA. Supported in part by a National Institute of Mental Health CRCgrant (No. MH-30915). Address reprint requests to Jack R. Cornelius, M.D., M.P.H., Western Psychiatric Institute and Clinic, 3811 O’Hara St, Room E-1011, Pittsburgh, PA 15213. Copyright 0 1991 by WB. Saunders Company 0010-440X/91/3204-0009$03.00/0
338
Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 338-344
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sive description of its clinical features and a delimitation of this syndrome from other disorders.’ Spitzer et al. recently proposed that the distinction between organic and nonorganic psychiatric disorders be discarded in DSM-IV, to be replaced by new diagnostic categories.x For example, this proposed nosology would replace the diagnostic category of OH with a new diagnostic category called “symptomatic hallucinosis.” They also suggested that OH and three other organic mental syndromes (OMS) be broken off from the “traditional” group of OMS (dementia, delirium, and amnestic syndrome) to be reclassified with their respective “functional” disorders. Thus, OH would be reclassified with the psychotic disorders. These changes presumably would be accompanied by other currently unspecified changes in the diagnostic criteria and clinical description of this syndrome. It will be difficult to judge the validity and appropriateness of these proposals because of the lack of data concerning this diagnostic category. The purpose of this report is to provide a basic description of the clinical features of patients who presented at an intake psychiatric setting with OH. This will include an enumeration of the most common clinical symptoms of this syndrome and the respective prevalence and mean severity of each symptom. Following this, the severity of the symptoms in OH are compared with those of its “functional” equivalent of schizophrenia. In addition, associated factors will be presented concerning the demographics, duration, modes of treatment, level of functioning, and current physical problems associated with OH. METHOD
Clinical Setting This study was conducted at the Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh, a large comprehensive, urban university psychiatric facility that also serves as a community mental health center. It admits approximately 1,600 inpatients and has over 100,000 outpatient visits per year. This psychiatric population consists of all age groups, and it experiences a wide variety of forms and levels of psychopathologic symptoms. The immediate setting of this study was the Diagnostic and Evaluation Center (DEC), a 24-hour-a-day, 7-day-a-week, walk-in clinic that serves as the main entry point for inpatient and outpatient care at WPIC. Its major functions arc to provide psychiatric evaluations, emergency care, and clinical dispositions. Patient evaluations were typically conducted by an initial interviewer (a psychiatric resident or a nurse clinician specially trained in psychiatric assessment) and a supervising faculty psychiatrist. The initial interviewer reviews any pertinent records and interviews the patient and accompanying persons according to the Initial Evaluation Form (IEF). This instrument is a semistructured assessment questionnaire having mutually complementary narrative and standardized components. with welldemonstrated interrater reliability and validity.’ The IEF uses the DSM-III diagnostic criteria. including that for OH. A brief physical exam is conducted on all patients as part of their initial assessment before admission or referral for outpatient care. However, more elaborate medical tests, such as computed tomography (CT) scans, are not conducted during this initial diagnostic interview. although any available prior records of such tests are noted. The initial interviewer then presents the case, including a full multiaxial diagnostic formulation, to the faculty psychiatrist, who conducts a brief complementary interview of the patient to clarify any pending issues and the diagnosis. Finally, a disposition decision is made. Completed IEFs are regularly reviewed by a senior unit clinician and their standardized components computerized by a systems specialist as part of our facility’s clinical information system. The IEF form itself contains a standardized symptom inventory, consistingof 64 signs and symptoms rated on a severity scale from “0” (not present) to “3” (severe). It is designed to provide a concise mapping of the patient’s psychopathology. It covers vegetative, substance abuse, and antisocial behaviors; general appearance and behavior; speech and thought rate and patterns; mood and affect;
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thought content and perception; and sensorium, orientation, intellectual functions, and insight. This instrument covers all axes and disorders of the DSM-III. Furthermore, it contains an axis on current functioning, which separately rates, on 5-point scales, occupational functioning, functioning with family, and functioning with other individuals and groups.
RESULTS
From January 1, 1983 until December 31, 1987, a total of 14,889 new patients presented for evaluation and care at the DEC. Of these patients, a total of 11 cases of OH were found on retrospective review of computerized records, which represents 0.07% of all cases and 1.4% of cases with organic brain syndromes. A retrospective analysis was used, rather than a prospective approach, because this syndrome is rare so prospective studies would be prohibitively expensive and time-consuming. Of the 11 patients with OH, five (45.5%) were male and six (54.5%) were female, while six (54.5%) were white and five (45.5%) were nonwhite. The mean age of these patients was 43.2 years. Six of the patients (54.5%) were between the ages of 20 and 39, four (36.4%) were over the age of 60, and one was 9 years old. There were no patients between the age of 40 and 60. The mean duration of symptoms was 7.7 months, and two thirds of the cases had a duration of 2 months or less. Each of the alcohol- and drug-related cases had a duration of 1 month or less, while non-alcohol and drug-related cases had a mean duration of 9.9 months. Neither age, race, nor gender significantly discriminated between OH and a group of 1,010 schizophrenics who presented for initial evaluation during the same 5-year period. Six of the patients had a comorbid axis I diagnosis. The comorbid axis I diagnoses included alcohol dependence in two cases and mixed substance abuse, major depression, adjustment disorder with depressed mood, and mild mental retardation, each in one case. The only axis II diagnosis was antisocial personality disorder in one case. Table 1 exhibits the frequency and severity of the 18 most common (present in ~20% of OH patients) signs and symptoms of OH in decreasing order of frequency. The frequency of these signs and symptoms generally paralleled their severity. The five most common signs and symptoms were hyposomnia (81.8%), visual hallucinations (63.6%), lack of insight (54.5%), general anxiety (54.5%), and other (nonschneiderian) auditory hallucinations (45.5%). Schneiderian symptoms were present in 27.3% of OH patients, while hallucinations of smell, taste, or touch were found in 9.1% of these patients. Table 2 results from a comparison of the severities of the 64 signs and symptoms listed on the IEF in patients with OH versus schizophrenia. The only symptom that was significantly more severe in OH than schizophrenia was “visual hallucinations.” The five symptoms that were significantly more severe in schizophrenia than OH included “flat affect, ” “thought process disorganization,” “speech pressure or flight of ideas,” “self-neglect,” and “bizarre behavior.” The most common treatments received on initial evaluation consisted of neuroleptic medications (27.3%) and minor tranquilizers (27.3%). Antidepressant medications were used in 18.2% of cases, while anticonvulsants, lithium, individual psychotherapy, and group psychotherapy were each used in 9.1% of OH cases. Stimulants, electroconvulsive therapy (ECT), family therapy, and behavioral therapy were not utilized in any cases.
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Table 1. Prevalence and Severity of Symptoms
Symptom 1. Hyposomnia
2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
12. 13. 14. 15. 16. 17. 18. *Code:
Visual hallucinations Lack of insight General anxiety Other auditory hallucinations Poor concentration Suspiciousness Depressed mood Weight decreased Acquired intellectual impairment Delusions of reference persecution, jealousy, or grandiosity Appetite decreased Dissociative symptoms Schneiderian symptoms Alcohol use Increased motor activity Thought process disorganization Self-neglect 0, not present;
1, mild; 2, moderate;
in OH
% of Cases Exhibiting the 5X
Mean Severity Scores*
81.8% 63.6% 54.5% 54.5%
1.3636 1.4545 1.0909 0.6364
45.5% 45.5% 45.5% 36.4% 36.4%
1.0909 0.8182 0.7273 0.8182 0.7273
36.4%
0.5455
27.3% 27.3% 27.3% 27.3% 27.3% 27.3%
0.6364 0.6364 0.5455 0.5455 0.5455 0.3636
27.3% 27.3%
0.2727 0.2727
3, severe.
The current level of functioning in various areas during the 2 weeks before evaluation was evaluated on a scale that varied from 1 (superior functioning) to 5 (markedly impaired functioning). On this scale, current occupational functioning and current group functioning were both moderately impaired (mean, 4.00 for each), while current family functioning was mildly to moderately impaired (mean, 3.45). Patients with OH displayed significantly less current work dysfunction than schizophrenics (mean, 4.00 v 4.88; t = 3.27, P = .OOl), and also displayed significantly less current family dysfunction than schizophrenics (mean, 3.45 v 4.43; t = 2.92, P = .004). Patients with OH also displayed somewhat less current group dysfunction than schizophrenics (mean, 4.00 v 4.53) although the difference was not statistically significant. Table 2. Symptoms
Symptom Visual hallucinations Flat or incongruous affect Thought disorganization process Self-neglect Speech pressure or flight of ideas Bizarre behavior
Distinguishing
Mean Severity in OH*
OH From Schizophrenia
Mean Severity in Schizophrenia
t
df
P
1.4545 0.1818
0.3191 0.8940
2.91 5.64
10.07 11.47
.016 ,000
0.2727 0.2727
1.0238 0.8018
5.17 3.66
11.32 11.15
,000 ,004
0.0909 0.1818
0.4267 0.6085
3.55 3.39
11.68 11.29
,004 ,006
*Code for mean scores: 0, not present;
1, mild; 2, moderate;
3, severe.
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The highest level of adaptive functioning during the past year was evaluated on axis V of the DSM-III diagnostic system, which uses a scale from 1 (superior) to 7 (grossly impaired). On this scale, the highest level of functioning was 4.09 (fair). Patients with OH displayed somewhat less impairment of their adaptive functioning than schizophrenics (mean, 4.69), although the difference was not statistically significant. The level of psychosocial stressors was assessed on axis IV of the DSM-III diagnostic system, which uses a scale from 1 (none) to 7 (catastrophic). On this scale, the mean level of stressors was 3.83 (moderate). The most commonly diagnosed class of medical diagnoses involved neurological disorders. These included three patients with seizures and one patient with severe headaches. In addition, two patients exhibited alcoholic hallucinosis, while concomitant blindness from cataracts and deafness, pneumoconiosis, bone cancer, hypertension, and chronic mixed substance abuse were each noted in one case. DISCUSSION
OH was a relatively uncommon diagnosis in evaluations of new patients at our institute, accounting for 0.07% of all cases and 1.4% of cases with organic brain syndromes. The authors can find no previous studies that have evaluated the prevalence of this diagnostic category in the initial evaluation population of any other psychiatric hospital, so empirical comparisons in prevalence between various psychiatric hospitals cannot be made. However, our findings are consistent with the clinical impressions of Lipowski,” who asserted that organic brain syndromes are rare, other than delirium and dementia. The only previous study assessing the prevalence of OH was performed on psychiatric consult-liaison populations of general hospitals. In this study of consult-liaison patients, Trzepacz et al. Teague, and Lipowski” reported that 3.1% of their organic brain syndrome cases consisted of OH. A majority of the OH patients in this study were young (< 40 years), and a slightly smaller group were elderly ( > 60 years). No middle-aged patients (aged 40 to 60) were diagnosed with OH. The authors are not aware of previous published reports evaluating the age distribution of patients with OH. The majority of cases demonstrated an acute presentation, with symptom duration of 2 months or less for two thirds of cases. However, a substantial minority (22.2%) of cases had a duration of greater than 1 year. Our OH patients demonstrated significant psychopathology in a number of symptom domains other than hallucinations, including delusions, cognitive deficits, affective symptoms, vegetative symptoms, and lack of insight. This finding is consistent with previously published assertions that almost any symptom may occur as an associated feature of OH.” For example, delusions were often diagnosed in our patient sample, as is shown by the observation that “delusions of reference, persecution, jealousy, or grandiosity” were present in 27.3% of patients. Cognitive deficits were often an accompanying clinical feature in OH, as is shown by the prevalence of symptoms such as “poor concentration” (45.5%), “acquired intellectual impairment” (36.4%), and “thought process disorganization” (27.3%). Affective symptoms played a significant role in the overall clinical
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presentation of our OH patients, as is shown by the prevalence of symptoms such as “general anxiety” (54.5%) and “depressed mood” (36.4%). Vegetative symptoms played a prominent role in the phenomenology of this syndrome, as is shown by the prevalence of “hyposomnia” (81.8%) “weight decreased” (36.4%) and “appetite decreased (27.3%). “Lack of insight” was also a prominent feature of this diagnostic category, being present in 54.5% of cases. Our study showed that OH can be distinguished from schizophrenia, its “functional” equivalent, on the basis of the increased prevalence of prominent visual hallucinations and on the relative lack of symptoms associated with thought disorder, bizarre behavior, negative symptoms, and rapid speech. Our findings concerning the higher prevalence of visual hallucinations in OH are consistent with the findings of Cuttig,13 who reported that visual hallucination (but not auditory hallucinations) occurred more commonly in “acute organic psychosis” than in schizophrenia. The most common treatments received on initial evaluation consisted of neuroleptics and minor tranquilizers. The use of neuroleptics in OH is consistent with the recommendation of Hovarth et a1.,14who recommended empirical treatment with haloperidol in persistent hallucinosis. The level of functioning was, in general, found to be moderately impaired in OH, although less so than in schizophrenia. A moderate level of psychosocial stressors was noted, which to a large extent reflects the psychological stress of the patients’ medical illnesses. The most common medical disorder diagnosed in our OH patients was seizures. The link between epilepsy and psychosis has been well documented in the literature.15.” The second most common medical diagnosis was alcoholic hallucinosis. The number of cases related to alcohol would have been much higher if cases involving delirium were not excluded, as the DSM-III stipulates. One case was noted involving sensory deprivation, which was associated with concomitant blindness and deafness. A variety of other medical disorders were also diagnosed in our patients with OH. Etiology, pathophysiology, predictive validity, natural history, anatomical correlates, response to treatment, and community prevalence and incidence rates of patients with OH remain largely unknown.‘7.‘8 Prospective studies with follow-up evaluations are warranted to address these crucial clinical issues. Additional studies are also warranted to evaluate whether a valid diagnostic distinction exists between OH and organic delusional syndrome, since both hallucinations and delusions may occur to some extent in either diagnostic group. These various additional studies are necessary before definitive conclusions can be made concerning the validity of OH as a diagnostic category. Such studies are also important before considering major revisions in the clinical description of this disorder. REFERENCES 1. Research Task Force of the NIMH: Research in the Service of Mental Health. Rockville, MD? National Institute of Mental Health, 1975 2. Lipowski ZJ: Organic brain syndromes: A reformulation. Compr Psychiatry 19:309-322, 1978 3. American Psychiatric Association Committee on Nomenclature and Statistics: Diagnostic and Statistical Manual of Mental Disorders (ed 3). Washington, DC, APA. 1980
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4. American Psychiatric Association Committee on Nomenclature and Statistics: Diagnostic and Statistical Manual of Mental Disorders, (ed 3, revised). Washington, DC, APA, 1987 5. Cornelius JR: Selected organic brain syndromes, in Thase ME, Edelstein BA, Hersen M (eds): Handbook of Outpatient Treatment of Adults. New York, NY, Plenum, 1990, p 389 6. Leuchter AF, Spar JE: The late-onset psychoses clinical and diagnostic features. J Nerv Ment Dis 173:488-494, 1985 7. Feigner JP, Robins E, Guze SB, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63,1972 8. Spitzer RL, Williams JB, First M, et al: A proposal for DSM-IV: Solving the organic/nonorganic problem. J Neuropsychiatry 1:126-127, 1989 9. Mezzich JE, Dow JT, Rich CL, et al: Developing an efficient clinical information system for a comprehensive psychiatric institute. II. Initial evaluation form. Behav Res Methods Instrument 13:464-478, 1981 10. Lipowski ZJ: Organic brain syndromes: New classification, concepts, and prospects. Can J Psychiatry 29:198-204, 1984 11. Trzepacz PT, Teague GB, Lipowski ZJ: Delirium and other organic mental disorders in a general hospital. Gen Hosp Psychiatry 7:101-106,1985 12. Wells CE: Other organic brain syndromes, in Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry IV. Baltimore, MD, Williams & Wilkins, 1985, p 873 13. Cuttig J: The phenomenology of acute organic psychosis. Br J Psychiatry 151:324-332, 1987 14. Hovarth TB, Siever I..J, Mohs RC, et al: Organic mental syndromes and disorders, in Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry V. Baltimore, MD, Williams & Wilkins, 1989, p 599 15. Slater ET, Beard AW: The schizophrenia-like psychoses of epilepsy. Br J Psychiatry 109:95-112, 1963 16. Toone B: Psychoses of epilepsy, in Reynolds EH, Trimble MR (eds): Epilepsy and Psychiatry. New York, NY, Churchill Livingstone, 1981, p 113 17. Asaad G, Shapiro B: Hallucinations: Theoretical and clinical overview. Am J Psychiatry 143:1088-1097,1986 18. Lipowski ZJ: A new look at organic brain syndromes. Am J Psychiatry 137:674-678, 1980
Organic Hallucinosis
Jack R. Cornelius, Juan Mezzich, Horatio Fahrega, Jr., Marie D. Cornelius, Joyce Myers, and Richard F. Ulrich A first comprehensive description of the clinical features of patients with the rare diagnosis of organic hallucinosis (OH) is presented, based on information from 11 OH patients among 14,889 patients who presented for evaluation over a 5-year period at our institution. This characterization is of particular current relevance to diagnosticians and clinicians because of the proposed major changes in the diagnostic system for OH in the upcoming DSM-IV and because of the virtual total lack of published information concerning this syndrome. This description includes a listing of the prevalence and mean severity of each symptom. The severity of the symptoms of OH are then compared with those of its crude “functional” equivalent of schizophrenia to determine which symptoms distinguish between these categories. Associated factors are also presented concerning demographics, modes of treatment, level of functioning, and current physical problems associated with OH. Copyright 0 1991 by W.B. Saunders Company
A
RESEARCH Task Force of the National Institute of Mental Health found that of all psychiatric illnesses, organic psychosis had been the most severely neglected by researchers.’ Lipowsk? concluded that no area of psychiatry was so riddled with conceptual and semantic confusion as the area of organic brain syndromes. He further concluded that the fundamental issues of terminology and classification of organic brain syndromes must be resolved if progress is to be made in this field. A better understanding of the descriptive psychopathology and clinical correlates of “organic” disorders, such as organic hallucinosis, is also important in developing a clearer perspective on their “functional” equivalents, such as schizophrenia. In an attempt to address these problems, the subsequently issued DSM-III3 and DSM-III-R4 included the new diagnostic category of “organic hallucinosis” (OH), among other changes. However, the DSM-III and DSM-III-R clinical descriptions of this disorder and other published reports provide little information concerning such basic clinical information as the prevalence of various symptoms in patients with this rare syndrome or such clinical correlates as the average age at presentation, gender distribution, duration, frequency of associated features, average level of impairment, prevalence in a large sample who present for evaluation, or associated medical diagnoses.5 Furthermore, the clinical symptoms that distinguish this disorder from the so-called functional psychotic disorders such as schizophrenia have never been enumerated. Consequently, calls continue to be made for research to develop adequate diagnostic criteria and associated clinical correlates for the organic psychoses.’ The initial steps in the evaluation of the diagnostic validity of a newly described disorder necessitates this comprehen-
From the Department of Psychiatry Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA. Supported in part by a National Institute of Mental Health CRCgrant (No. MH-30915). Address reprint requests to Jack R. Cornelius, M.D., M.P.H., Western Psychiatric Institute and Clinic, 3811 O’Hara St, Room E-1011, Pittsburgh, PA 15213. Copyright 0 1991 by WB. Saunders Company 0010-440X/91/3204-0009$03.00/0
338
Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 338-344
CHARACTERIZING
ORGANIC
HALLUCINOSIS
339
sive description of its clinical features and a delimitation of this syndrome from other disorders.’ Spitzer et al. recently proposed that the distinction between organic and nonorganic psychiatric disorders be discarded in DSM-IV, to be replaced by new diagnostic categories.x For example, this proposed nosology would replace the diagnostic category of OH with a new diagnostic category called “symptomatic hallucinosis.” They also suggested that OH and three other organic mental syndromes (OMS) be broken off from the “traditional” group of OMS (dementia, delirium, and amnestic syndrome) to be reclassified with their respective “functional” disorders. Thus, OH would be reclassified with the psychotic disorders. These changes presumably would be accompanied by other currently unspecified changes in the diagnostic criteria and clinical description of this syndrome. It will be difficult to judge the validity and appropriateness of these proposals because of the lack of data concerning this diagnostic category. The purpose of this report is to provide a basic description of the clinical features of patients who presented at an intake psychiatric setting with OH. This will include an enumeration of the most common clinical symptoms of this syndrome and the respective prevalence and mean severity of each symptom. Following this, the severity of the symptoms in OH are compared with those of its “functional” equivalent of schizophrenia. In addition, associated factors will be presented concerning the demographics, duration, modes of treatment, level of functioning, and current physical problems associated with OH. METHOD
Clinical Setting This study was conducted at the Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh, a large comprehensive, urban university psychiatric facility that also serves as a community mental health center. It admits approximately 1,600 inpatients and has over 100,000 outpatient visits per year. This psychiatric population consists of all age groups, and it experiences a wide variety of forms and levels of psychopathologic symptoms. The immediate setting of this study was the Diagnostic and Evaluation Center (DEC), a 24-hour-a-day, 7-day-a-week, walk-in clinic that serves as the main entry point for inpatient and outpatient care at WPIC. Its major functions arc to provide psychiatric evaluations, emergency care, and clinical dispositions. Patient evaluations were typically conducted by an initial interviewer (a psychiatric resident or a nurse clinician specially trained in psychiatric assessment) and a supervising faculty psychiatrist. The initial interviewer reviews any pertinent records and interviews the patient and accompanying persons according to the Initial Evaluation Form (IEF). This instrument is a semistructured assessment questionnaire having mutually complementary narrative and standardized components. with welldemonstrated interrater reliability and validity.’ The IEF uses the DSM-III diagnostic criteria. including that for OH. A brief physical exam is conducted on all patients as part of their initial assessment before admission or referral for outpatient care. However, more elaborate medical tests, such as computed tomography (CT) scans, are not conducted during this initial diagnostic interview. although any available prior records of such tests are noted. The initial interviewer then presents the case, including a full multiaxial diagnostic formulation, to the faculty psychiatrist, who conducts a brief complementary interview of the patient to clarify any pending issues and the diagnosis. Finally, a disposition decision is made. Completed IEFs are regularly reviewed by a senior unit clinician and their standardized components computerized by a systems specialist as part of our facility’s clinical information system. The IEF form itself contains a standardized symptom inventory, consistingof 64 signs and symptoms rated on a severity scale from “0” (not present) to “3” (severe). It is designed to provide a concise mapping of the patient’s psychopathology. It covers vegetative, substance abuse, and antisocial behaviors; general appearance and behavior; speech and thought rate and patterns; mood and affect;
340
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thought content and perception; and sensorium, orientation, intellectual functions, and insight. This instrument covers all axes and disorders of the DSM-III. Furthermore, it contains an axis on current functioning, which separately rates, on 5-point scales, occupational functioning, functioning with family, and functioning with other individuals and groups.
RESULTS
From January 1, 1983 until December 31, 1987, a total of 14,889 new patients presented for evaluation and care at the DEC. Of these patients, a total of 11 cases of OH were found on retrospective review of computerized records, which represents 0.07% of all cases and 1.4% of cases with organic brain syndromes. A retrospective analysis was used, rather than a prospective approach, because this syndrome is rare so prospective studies would be prohibitively expensive and time-consuming. Of the 11 patients with OH, five (45.5%) were male and six (54.5%) were female, while six (54.5%) were white and five (45.5%) were nonwhite. The mean age of these patients was 43.2 years. Six of the patients (54.5%) were between the ages of 20 and 39, four (36.4%) were over the age of 60, and one was 9 years old. There were no patients between the age of 40 and 60. The mean duration of symptoms was 7.7 months, and two thirds of the cases had a duration of 2 months or less. Each of the alcohol- and drug-related cases had a duration of 1 month or less, while non-alcohol and drug-related cases had a mean duration of 9.9 months. Neither age, race, nor gender significantly discriminated between OH and a group of 1,010 schizophrenics who presented for initial evaluation during the same 5-year period. Six of the patients had a comorbid axis I diagnosis. The comorbid axis I diagnoses included alcohol dependence in two cases and mixed substance abuse, major depression, adjustment disorder with depressed mood, and mild mental retardation, each in one case. The only axis II diagnosis was antisocial personality disorder in one case. Table 1 exhibits the frequency and severity of the 18 most common (present in ~20% of OH patients) signs and symptoms of OH in decreasing order of frequency. The frequency of these signs and symptoms generally paralleled their severity. The five most common signs and symptoms were hyposomnia (81.8%), visual hallucinations (63.6%), lack of insight (54.5%), general anxiety (54.5%), and other (nonschneiderian) auditory hallucinations (45.5%). Schneiderian symptoms were present in 27.3% of OH patients, while hallucinations of smell, taste, or touch were found in 9.1% of these patients. Table 2 results from a comparison of the severities of the 64 signs and symptoms listed on the IEF in patients with OH versus schizophrenia. The only symptom that was significantly more severe in OH than schizophrenia was “visual hallucinations.” The five symptoms that were significantly more severe in schizophrenia than OH included “flat affect, ” “thought process disorganization,” “speech pressure or flight of ideas,” “self-neglect,” and “bizarre behavior.” The most common treatments received on initial evaluation consisted of neuroleptic medications (27.3%) and minor tranquilizers (27.3%). Antidepressant medications were used in 18.2% of cases, while anticonvulsants, lithium, individual psychotherapy, and group psychotherapy were each used in 9.1% of OH cases. Stimulants, electroconvulsive therapy (ECT), family therapy, and behavioral therapy were not utilized in any cases.
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Table 1. Prevalence and Severity of Symptoms
Symptom 1. Hyposomnia
2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
12. 13. 14. 15. 16. 17. 18. *Code:
Visual hallucinations Lack of insight General anxiety Other auditory hallucinations Poor concentration Suspiciousness Depressed mood Weight decreased Acquired intellectual impairment Delusions of reference persecution, jealousy, or grandiosity Appetite decreased Dissociative symptoms Schneiderian symptoms Alcohol use Increased motor activity Thought process disorganization Self-neglect 0, not present;
1, mild; 2, moderate;
in OH
% of Cases Exhibiting the 5X
Mean Severity Scores*
81.8% 63.6% 54.5% 54.5%
1.3636 1.4545 1.0909 0.6364
45.5% 45.5% 45.5% 36.4% 36.4%
1.0909 0.8182 0.7273 0.8182 0.7273
36.4%
0.5455
27.3% 27.3% 27.3% 27.3% 27.3% 27.3%
0.6364 0.6364 0.5455 0.5455 0.5455 0.3636
27.3% 27.3%
0.2727 0.2727
3, severe.
The current level of functioning in various areas during the 2 weeks before evaluation was evaluated on a scale that varied from 1 (superior functioning) to 5 (markedly impaired functioning). On this scale, current occupational functioning and current group functioning were both moderately impaired (mean, 4.00 for each), while current family functioning was mildly to moderately impaired (mean, 3.45). Patients with OH displayed significantly less current work dysfunction than schizophrenics (mean, 4.00 v 4.88; t = 3.27, P = .OOl), and also displayed significantly less current family dysfunction than schizophrenics (mean, 3.45 v 4.43; t = 2.92, P = .004). Patients with OH also displayed somewhat less current group dysfunction than schizophrenics (mean, 4.00 v 4.53) although the difference was not statistically significant. Table 2. Symptoms
Symptom Visual hallucinations Flat or incongruous affect Thought disorganization process Self-neglect Speech pressure or flight of ideas Bizarre behavior
Distinguishing
Mean Severity in OH*
OH From Schizophrenia
Mean Severity in Schizophrenia
t
df
P
1.4545 0.1818
0.3191 0.8940
2.91 5.64
10.07 11.47
.016 ,000
0.2727 0.2727
1.0238 0.8018
5.17 3.66
11.32 11.15
,000 ,004
0.0909 0.1818
0.4267 0.6085
3.55 3.39
11.68 11.29
,004 ,006
*Code for mean scores: 0, not present;
1, mild; 2, moderate;
3, severe.
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The highest level of adaptive functioning during the past year was evaluated on axis V of the DSM-III diagnostic system, which uses a scale from 1 (superior) to 7 (grossly impaired). On this scale, the highest level of functioning was 4.09 (fair). Patients with OH displayed somewhat less impairment of their adaptive functioning than schizophrenics (mean, 4.69), although the difference was not statistically significant. The level of psychosocial stressors was assessed on axis IV of the DSM-III diagnostic system, which uses a scale from 1 (none) to 7 (catastrophic). On this scale, the mean level of stressors was 3.83 (moderate). The most commonly diagnosed class of medical diagnoses involved neurological disorders. These included three patients with seizures and one patient with severe headaches. In addition, two patients exhibited alcoholic hallucinosis, while concomitant blindness from cataracts and deafness, pneumoconiosis, bone cancer, hypertension, and chronic mixed substance abuse were each noted in one case. DISCUSSION
OH was a relatively uncommon diagnosis in evaluations of new patients at our institute, accounting for 0.07% of all cases and 1.4% of cases with organic brain syndromes. The authors can find no previous studies that have evaluated the prevalence of this diagnostic category in the initial evaluation population of any other psychiatric hospital, so empirical comparisons in prevalence between various psychiatric hospitals cannot be made. However, our findings are consistent with the clinical impressions of Lipowski,” who asserted that organic brain syndromes are rare, other than delirium and dementia. The only previous study assessing the prevalence of OH was performed on psychiatric consult-liaison populations of general hospitals. In this study of consult-liaison patients, Trzepacz et al. Teague, and Lipowski” reported that 3.1% of their organic brain syndrome cases consisted of OH. A majority of the OH patients in this study were young (< 40 years), and a slightly smaller group were elderly ( > 60 years). No middle-aged patients (aged 40 to 60) were diagnosed with OH. The authors are not aware of previous published reports evaluating the age distribution of patients with OH. The majority of cases demonstrated an acute presentation, with symptom duration of 2 months or less for two thirds of cases. However, a substantial minority (22.2%) of cases had a duration of greater than 1 year. Our OH patients demonstrated significant psychopathology in a number of symptom domains other than hallucinations, including delusions, cognitive deficits, affective symptoms, vegetative symptoms, and lack of insight. This finding is consistent with previously published assertions that almost any symptom may occur as an associated feature of OH.” For example, delusions were often diagnosed in our patient sample, as is shown by the observation that “delusions of reference, persecution, jealousy, or grandiosity” were present in 27.3% of patients. Cognitive deficits were often an accompanying clinical feature in OH, as is shown by the prevalence of symptoms such as “poor concentration” (45.5%), “acquired intellectual impairment” (36.4%), and “thought process disorganization” (27.3%). Affective symptoms played a significant role in the overall clinical
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presentation of our OH patients, as is shown by the prevalence of symptoms such as “general anxiety” (54.5%) and “depressed mood” (36.4%). Vegetative symptoms played a prominent role in the phenomenology of this syndrome, as is shown by the prevalence of “hyposomnia” (81.8%) “weight decreased” (36.4%) and “appetite decreased (27.3%). “Lack of insight” was also a prominent feature of this diagnostic category, being present in 54.5% of cases. Our study showed that OH can be distinguished from schizophrenia, its “functional” equivalent, on the basis of the increased prevalence of prominent visual hallucinations and on the relative lack of symptoms associated with thought disorder, bizarre behavior, negative symptoms, and rapid speech. Our findings concerning the higher prevalence of visual hallucinations in OH are consistent with the findings of Cuttig,13 who reported that visual hallucination (but not auditory hallucinations) occurred more commonly in “acute organic psychosis” than in schizophrenia. The most common treatments received on initial evaluation consisted of neuroleptics and minor tranquilizers. The use of neuroleptics in OH is consistent with the recommendation of Hovarth et a1.,14who recommended empirical treatment with haloperidol in persistent hallucinosis. The level of functioning was, in general, found to be moderately impaired in OH, although less so than in schizophrenia. A moderate level of psychosocial stressors was noted, which to a large extent reflects the psychological stress of the patients’ medical illnesses. The most common medical disorder diagnosed in our OH patients was seizures. The link between epilepsy and psychosis has been well documented in the literature.15.” The second most common medical diagnosis was alcoholic hallucinosis. The number of cases related to alcohol would have been much higher if cases involving delirium were not excluded, as the DSM-III stipulates. One case was noted involving sensory deprivation, which was associated with concomitant blindness and deafness. A variety of other medical disorders were also diagnosed in our patients with OH. Etiology, pathophysiology, predictive validity, natural history, anatomical correlates, response to treatment, and community prevalence and incidence rates of patients with OH remain largely unknown.‘7.‘8 Prospective studies with follow-up evaluations are warranted to address these crucial clinical issues. Additional studies are also warranted to evaluate whether a valid diagnostic distinction exists between OH and organic delusional syndrome, since both hallucinations and delusions may occur to some extent in either diagnostic group. These various additional studies are necessary before definitive conclusions can be made concerning the validity of OH as a diagnostic category. Such studies are also important before considering major revisions in the clinical description of this disorder. REFERENCES 1. Research Task Force of the NIMH: Research in the Service of Mental Health. Rockville, MD? National Institute of Mental Health, 1975 2. Lipowski ZJ: Organic brain syndromes: A reformulation. Compr Psychiatry 19:309-322, 1978 3. American Psychiatric Association Committee on Nomenclature and Statistics: Diagnostic and Statistical Manual of Mental Disorders (ed 3). Washington, DC, APA. 1980
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4. American Psychiatric Association Committee on Nomenclature and Statistics: Diagnostic and Statistical Manual of Mental Disorders, (ed 3, revised). Washington, DC, APA, 1987 5. Cornelius JR: Selected organic brain syndromes, in Thase ME, Edelstein BA, Hersen M (eds): Handbook of Outpatient Treatment of Adults. New York, NY, Plenum, 1990, p 389 6. Leuchter AF, Spar JE: The late-onset psychoses clinical and diagnostic features. J Nerv Ment Dis 173:488-494, 1985 7. Feigner JP, Robins E, Guze SB, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63,1972 8. Spitzer RL, Williams JB, First M, et al: A proposal for DSM-IV: Solving the organic/nonorganic problem. J Neuropsychiatry 1:126-127, 1989 9. Mezzich JE, Dow JT, Rich CL, et al: Developing an efficient clinical information system for a comprehensive psychiatric institute. II. Initial evaluation form. Behav Res Methods Instrument 13:464-478, 1981 10. Lipowski ZJ: Organic brain syndromes: New classification, concepts, and prospects. Can J Psychiatry 29:198-204, 1984 11. Trzepacz PT, Teague GB, Lipowski ZJ: Delirium and other organic mental disorders in a general hospital. Gen Hosp Psychiatry 7:101-106,1985 12. Wells CE: Other organic brain syndromes, in Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry IV. Baltimore, MD, Williams & Wilkins, 1985, p 873 13. Cuttig J: The phenomenology of acute organic psychosis. Br J Psychiatry 151:324-332, 1987 14. Hovarth TB, Siever I..J, Mohs RC, et al: Organic mental syndromes and disorders, in Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry V. Baltimore, MD, Williams & Wilkins, 1989, p 599 15. Slater ET, Beard AW: The schizophrenia-like psychoses of epilepsy. Br J Psychiatry 109:95-112, 1963 16. Toone B: Psychoses of epilepsy, in Reynolds EH, Trimble MR (eds): Epilepsy and Psychiatry. New York, NY, Churchill Livingstone, 1981, p 113 17. Asaad G, Shapiro B: Hallucinations: Theoretical and clinical overview. Am J Psychiatry 143:1088-1097,1986 18. Lipowski ZJ: A new look at organic brain syndromes. Am J Psychiatry 137:674-678, 1980