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196

Section 3

Organic syndromes of schizophrenia: other neurological disorders

Osvaldo P. Almeida and Sergio E. Starkstein

Facts box

ease in association with schizophrenia and delusional
r

disorder.

Poststroke psychosis is uncommon, and the

vast majority of stroke patients will never

develop psychotic symptoms.

r

Psychotic symptoms arising

Psychosis can occur in association with

cerebrovascular disease, but poststroke

after stroke

schizophrenia is rare.

r
Temporoparietal-occipital lesions are more
A case report

likely to be found in association with

JB was a 63-year-old engineer who presented with left-psychosis, although strokes in almost all
sided weakness, left homonymous hemianopia, spatio-other brain areas have been reported in
temporal disorientation and visual hallucinations.

association with psychotic symptoms.

There was no past history of psychiatric disorders. He
r
The prevalence of psychosis in vascular

was alert and cooperative and showed no agitation.

dementia and Alzheimer’s Disease is similar,

JB had impaired memory for recent events, confabu-which suggests that it is not so much vascular
lated spontaneously and often mistook one physician
pathology but the disruption of neuronal

for another. His visual hallucinations were orientated
networks associated with dementia that

to the right visual space only. He reported seeing three
contributes to the development of delusions

young girls dressed in colorful clothes who were mocking
and hallucinations.

him because of his poor performance on the neuro-r
Currently available evidence suggests that, in
logical examination. During the following days, he
isolation, cerebrovascular disease plays a

reported seeing a soldier through the ceiling and a
limited role in the development of

clergyman beside his bed. These complex hallucinations
schizophrenia-like symptoms in later life.

rarely occurred in the evening, and only once did he
report tactile (a dog’s cold nose touching him) and auditory hallucinations (e.g., hearing a Spanish song). Additional findings on neuropsychological evaluation were

a severe hemispatial neglect, motor impersistence, con-The neurobiological mechanisms that ultimately lead
structional apraxia, and spatial dysgraphia. Two weeks
to the development of psychotic symptoms are poorly
after the stroke, the patient became euphoric and jocu-understood, but tentative evidence suggests that cere-lar. He reduplicated body parts (e.g., he reported having
brovascular disease might contribute to the onset of
three arms) and also showed anosognosia, personifica-delusions and hallucinations, particularly in later life.

tion of his weak left arm and misoplegia (morbid dislike
This chapter aims to critically review the available lit-or hatred of paralyzed limb). He obtained a score of 97

erature on this topic. It is divided into two major
on the verbal scale of the WAIS-R, a score of 77 on WAIS-subsections: the first examines studies investigating
R performance scale and a score of 91 on the Wechsler
the emergence of psychotic symptoms in association
Memory Scale. A CT scan showed an extensive right
with established cerebrovascular accidents; the sec-fronto-temporoparietal infarction. JB was re-examined
ond evaluates the presence of cerebrovascular dis-6 months after his acute admission. There were no visual
197

Organic Syndromes of Schizophrenia – Section 3

hallucinations, and he attributed his past hallucinations
logically related to the disturbance, and iii) not occur-to “mistaken impressions”
[1].

ring exclusively during the course of delirium. However, this category has been deleted from the DSM-IV

revision.

Phenomenology of poststroke psychosis

Starkstein and colleagues
[3]
described two types of
Different terms have been used to refer to poststroke
hallucinatory phenomena in stroke patients. Halluci-psychosis, namely, atypical psychosis, peduncular hal-nation refers to a perception in the absence of a stimu-lucinosis, release hallucinations, organic psychosis,
lus, with the qualification that the patient believes that
and agitated delirium. The term “peduncular halluci-the perception is real. When these hallucinations occur
nosis” was coined by L’Hermitte
[2]
to describe the
after a stroke, they should be considered secondary
clinical presentation of a patient with visual halluci-hallucinations. Hallucinosis also involves a perception
nations after a brainstem lesion and preserved insight
without a stimulus, but the patient does not believe the
into the lack of reality of the perception.

perception is real. They listed the following as char-Post-stroke psychosis should be diagnosed using
acteristic of hallucinosis: i) vivid imagery, ii) anoma-the DSM-IV criteria for “Psychotic Disorder Due to a
lous presentation of the images, iii) ego-dystonia (the
General Medical Condition.” The essential features of
false perceptions are not integrated to the patient’s per-this diagnosis are “prominent hallucinations or delu-ception of reality), and iv) preserved awareness on the
sions that are judged to be due to the direct physio-nonreality of the perception. Based on this diagnostic
logical effects of a general medical condition.” How-scheme, hallucinosis occurring after a stroke should be
ever, this is difficult to ascertain in the case of strokes,
labeled secondary hallucinosis.

given the relatively low incidence of psychotic symptoms after stroke. The DSM-IV acknowledges that
“there are no infallible guidelines for determining
whether the relationship between the psychotic distur-Prevalence of poststroke psychosis
bance and the general medical condition is etiological”

Few studies have systematically looked into the associ-and suggests that the temporal association between
ation between stroke and psychosis (i.e. delusions and
psychosis and the medical condition, as well as the
hallucinations)
[4, 5].
Not surprisingly, the prevalence
presence of features that are atypical for a primary
of psychotic symptoms after stroke remains largely
psychotic disorder, are helpful diagnostic considera-unknown. The results from the Study of Assets and
tions. The DSM-III revision (DSM-111-R) had spe-Health Dynamics in the USA showed that stroke is
cific criteria for atypical psychosis, which was consid-associated with increased odds of delusions (odds ratio
ered “a residual category for cases in which there are
(OR): 16.1, 95% confidence interval (CI): 8.87, 29.5)
psychotic symptoms (delusions, hallucinations, inco-and hallucinations (OR: 7.4, 95% CI: 4.1,
13.2)[35].

herence, loosening of associations, markedly illogical
More recently, Kumral and ¨

Oztürk
[6]
reported that
thinking or behavior that is grossly disorganized or
15 out of 360 consecutive patients admitted to hospi-catatonic) that do not meet criteria for any mental
tals after a stroke developed delusions within 3 months
disorder.” This category is now subsumed under the
(4.2%). In most cases, symptoms became apparent
DSM-IV category of “Psychotic Disorder Not Other-during the first week after the stroke. In a record-wise Specified.” The ICD-10 includes specific crite-linkage study of 1,008 incident cases of stroke admit-ria for “Organic Hallucinosis” and for “Organic Delu-ted to hospitals in Western Australia, Almeida and
sional [schizophrenia-like] Disorder.” For both diag-Xiao
[7]
found that 35 people developed a delu-noses there has to be objective evidence of cerebral
sional or schizophreniform disorder during the sub-damage and clear consciousness, as well as persistent
sequent 2 years (3.5%), with an estimated cumula-or recurrent hallucinations for the former and delu-tive incidence of psychosis of 1.1 per 1,000 persons
sions with a varying degree of systematization for the
over 12 years. As these estimates are based on stroke
latter. Finally, the DSM-III-R listed the following as
patients who are in contact with hospital services, it
specific criteria for “organic hallucinosis”: i) promi-seems likely that the true incidence of poststroke psy-nent persistent or recurrent hallucinations, ii) evi-chosis in the community will be lower than 1 per
dence of a specific organic factor judged to be etio-1000 person-years.