Ask the psychiatrist...

I would like to ask the psychiatrist if he knows anything about Capgras syndrome? A friend was diagnosed and was taking tablets, which seemed to help but when she got a bit better she didn't like the side effects of the tablets (bad skin/shaking) and stopped taking them (I think she was also told she could stop taking the medication). She has since gone back to exactly how she was. Should someone with Capgras syndrome be on medication permanently? Is there an organisation for this illness that I can talk to in confidence?

Capgras syndrome is one of a number of syndromes involving delusional misidentification. In Capgras, the individual perceives that someone they know (usually a relative or close friend) has been replaced by an exact double.

Other related syndromes include where the patient believes that one or more individuals have changed their appearance to resemble familiar people in order to persecute or defraud them (Fregoli syndrome); or that there are exact doubles of themselves (doppelganger phenomenon); or even a sort of metamorphosis where people around him/her have swapped identities.

Although these syndromes can occur without other symptoms of a psychosis, they are also found in people who suffer from schizophrenia, major mood disorders, dementia and from neurological disease with a proportion of sufferers showing abnormalities in the temporoparietal area of the right side of the brain.

A comprehensive neurological assessment is essential as the prognosis and treatment will depend to an extent on the cause. Typically, treatment involves the use of antipsychotic medication, sometimes supplemented by an anticonvulsant. Many sufferers will need to take medication permanently. I am not aware of a support organisation specifically for this syndrome that I can recommend.

My son has just been admitted to a low secure unit. Please can you tell me what I should expect on a unit like this?

A low secure unit is just a psychiatric ward where the coming and going of patients is restricted, usually by having an ‘air-lock’ system of doors so that it is difficult for patients to leave the building without staff being aware.

Staffing levels are usually a bit higher than on an ordinary inpatient ward.

All patients will be detained under the Mental Health Act.

The extent to which the building is secure (eg whether there are more internal locks between different parts of the building) varies between units.

You should expect the same good standards of care as in any psychiatric inpatient setting with perhaps more attention to developing treatments for managing the behaviours that led to your son being admitted to the unit. Most of these units will have good access to psychology and occupational therapy in addition to nurses and psychiatrists.

If a patient is under section 2 of the Mental Health Act, is this patient detained in a mental health ward or can they be put on a general ward?

They can be on either, but in practice it is far more usual to be on a mental health ward – this is because the staff in a mental health ward will be more expert at managing the behavioural and risk problems that led to the patient being detained in the first place.

Can disturbed sleep lead to psychosis?

Yes. Disturbed sleep is associated with many psychiatric disorders including the various psychoses. It is hard, of course, to disentangle cause and effect but psychotic symptoms (eg hallucinations) can occur in otherwise healthy people after periods of sleep deprivation and conditions that disturb the usual sleep-wake cycle (eg jet lag) are associated with relapse.

My wife has suffered from paranoid delusions for over two years now. This led to her being sectioned for two months and she is now on medication (15mg of olanzapine), which keeps her calm. For beliefs that are deep seated for so long, what are the chances that she will make a full recovery? Will she realise that she was misinterpreting events or should we expect that she will maintain her beliefs and, hopefully deal with them better?

It is very difficult to give a confident answer without more information about the wider nature of the condition but in general, the longer a delusion persists the less likely it is to be abandoned. In my experience, when improvement occurs it is often that the person just becomes less preoccupied and distressed by the belief and comes to talk of it as something real but in the past.

What are the main differences between bipolar disorder 1 (with emphasis on mania) and a mixed schizophrenia type disorder?

Psychiatric diagnoses are largely descriptive. That is, the diagnosis is made on the basis of the balance of symptoms and the course of the disorder. So in bipolar 1 (mania) the patient has a markedly elevated mood and increased activity together with psychotic symptoms, that are said to reflect the underlying mood (grandiose delusions, hallucinations of voices speaking directly to the patient emphasising his/her beliefs in the possession of extraordinary abilities etc) and there is typically a history of a previous episode of a mood disorder. In schizophrenia, any associated mood change is less prominent and a number of core symptoms of schizophrenia are present such as experiencing one’s thoughts being inserted or withdrawn, or experiencing delusions of being controlled by an outside agency (limbs moved, thoughts inserted) or hearing multiple voices commenting on the patient’s behavior. The course of the two disorders is also different with bipolar disorders tending to have longer periods of more complete recovery between episodes while schizophrenia tends to have a more chronic course. However there is tremendous overlap in all of this and the distinction between these two descriptive diagnoses is among the more controversial in psychiatry.

How is it decided if a nearest relative is 'incapable' of performing their duties under the Mental Health Act? Is 'incapable' the same as lacking capacity as defined in the Mental Capacity Act?

It is somewhat broader though similar principles apply. The person may be ‘incapable’ because of mental or physical illness.

Is it true they are going to change the name of schizophrenia and rechristen the illness?

Not in the immediate future but it is likely that the name will change as more is understood about the cause of the condition. Some experts have proposed terms based on the dysregulation of dopamine neurotransmission. The Japanese Society of Psychiatry and Neurology have already made a change because the original translation of schizophrenia (Seishin Bunrestu Byo = mind-split-disease) was seen by patients and their families as implying a hopeless and stigmatising condition. Their new term ‘Togo Shitcho Sho' means ‘integration disorder’.