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

1. The lysergicpsychoma: a psychopathologicalsyndrome Martinotti G, Santacroce R, Cinosi E. Dipartimento di Neuroscienze ed Imaging Università “G.d’Annunzio”- Chieti

2. Differencesbetweensubstance-inducedpsychosis and primarypsychoticonset • Hallucinatoryexperience • Lysergicpsychoma

3. Isthereanydifferencebetweensubstance-inducedpsychosis and primarypsychoticonset?

4. 400 patientsrecruited in New York and surroundingscharacterized by: 1) atleastonepsychoticsymptom2) no psychiatrichistory (since the 6 monthsbeforerecruitment)3) alcohol and/or substanceabuses in the last 30 days

5. 44% received a diagnosis of substance-inducedpsychosis56% received a diagnosis of primarypsychoticdisorderNB: Based on PRISM (PsychiatricResearchInterview for Substances and Mentaldisorders) Caton et al. Arch. GenPsy, 2005

6. Caton et al. Arch. GenPsy, 2005

7. Caton et al. Arch. GenPsy, 2005

8. Statisticallysignificantclinicalcharacteristics1) Primarypsychosisgroup: youngerage, higher score in positive symptomsscales; mostlyauditoryhallucinations, lessinsight in negative symptoms and higherscoresatPANSS general psychopatologic scale. Caton et al. Arch. GenPsy, 2005

9. Statisticallysignificantclinicalcharacteristics :2) Substance-inducedpsychosisgroup: more common visualhallucinations and higherprevalence of suicidalthoughtduringpreviousyear. More violence. Family history of substanceabuse.More insight. Caton et al. Arch. GenPsy, 2005

10. Main differences Type of hallucination Insight

11. The hallucinatory phenomena • 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”.

12. The hallucinatory phenomena • Hallucination • Pseudo-hallucination • Hallucinosis

13. 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.

14. Hallucinosis • 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.

15. Hallucinations and Dopamine • 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.

16. Hallucinations and Glutamate • 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.

17. Hallucinatory visions • 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.

18. Hallucinatory visions Superimposed hallucinations Animations spatially integrated with reality highly individualized, with interference in visual perception and probably greatly influenced by specific psychodynamic factors • spatially separated from objective reality • relatively abstract geometric shapes, and there is some agreement among subjects about their common characteristics

19. Hallucinatory visions in Schizophrenia • 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 (KatastrophaleStimmungstönung des Erlebens of Müller-Suur) and “end of the world” (Weltuntergangserlebnis of Wetzel, 1922).

20. 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).

21. 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 Autoscopyis 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.

22. Hallucinosis (induced states) • 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.

23. 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.

24. Visual Effects (superimposedhallucinations and illusions) Color Enhancement Higher pattern perception

25. Visual drifting Tracers

26. Texture repetition Scenery slicing

27. Geometria visiva (Visuals)

28. Hallucinosis (induced states) • 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.

29. Hallucinatorydelusion (HENRY EY) • Psychoactivesubstances induce hallucinations; • Hallucinationsalert the subject; • In a first phasehallucinations are referred to be caused by the substance; • Twilight, transitionalstates and delirium complicate the relationship with reality; • Flash-back phenomenonconvinces the patientthatsomethinghaschanged; • The subjects start to interprete and makeconnectionsamonghallucinations and relationshipsbetweenthem and the world; • Paranoiddevelopment, pseudoschizophrenia.

30. The hallucinatory phenomena Type of hallucination Insight

31. LYSERGIC PSYCHOMA: A FOREIGN BODY IN YOUR MIND Somethingnewfrom a psychopathologicalpointofview. (Hellpach, Cargnello) CRITICAL EGO PSYCHE 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)

32. LSD AFFECTS PERCEPTIONS AND UNDERLINES HOW IMPORTANT PERCEPTION IS IN OUR CONSTRUCTION OF REALITY DANILO CARGNELLO (1911-1998) “PSICOMA LISERGICO” • FLOATING • FLIP OUT • FLATTENED • HORROR TRIP/BAD TRIP • FLASHBACK

33. LYSERGIC PSYCHOMA: Consciousnessmodifications Affectiveswings (excitation, depression, rapid cycling of mood; laughingexplosion) Chromaticperceptionstatess (dyschromatopsies) Visualperceptiondisorders (macropsia, megalopsia, micropsia, metamorphopsia, dysmegalopsia, dysopsia, pareidolia, hallucinosis);

34. LYSERGIC PSYCHOMA: Depersonalization; Temporalexperiencemodifications; (duation,temporalinsularity) Thoughtdisorders; Traumatic flashbacksofchildhoodexperiences.

35. 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)

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

37. Contributo allo studio delle turbe da mescalina, II International Congress Of NeurologyLondon, 29-07/02-08 1935 “The impression of losingone’sownpersonalityisnotrelated so muchto coenesthesics or neuroticsas to a real dissociative alteration of the Ego. At a certainpointsayingmyownnamemeantalmostnothingto me: “Morselli!” I shouted, - “Whoishe?” Ihadtohave a tremendouswillpower in ordertorememberthatEnrico Morselliwas me and notsomebody else”

38. Twodifferent ways of beingpsychotic To have a psychosis (inducedpsychosis) To be psychotic (psychoticonset) Ego experienceas the place of the battlebetween the subject and histranformation; The ”Body I am” Leib • Body as the place of the battlebetween the subject and the “psychoma”; • The “Body I Have”” • Korper