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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 167-169

An old man who spit pearls-A case discussion


1 Department of Psychiatry, Subharti Medical College, Meerut, Uttar Pradesh, India
2 Department of Psychiatry, S. N. Medical College, Jodhpur, Rajasthan, India

Date of Web Publication27-Dec-2018

Correspondence Address:
Dr. Apoorv Yadav
C/o Dr. Anurag Yadav, 1/124-D, Delhi Gate, Agra - 282 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_19_18

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  Abstract 


In the history of psychiatry, the contents of delusions have always interested the community of mental health professionals. We came across a 65-year-old patient with a peculiar delusion of spitting pearls. This study purports to discuss, first, the late age of onset of the delusions in the absence of any cognitive deficits along with unique delusional content and, second, the possible role of environment in the formulation of delusional content.

Keywords: Delusion, delusional disorders, late-onset psychosis


How to cite this article:
Agarwal S, Yadav A, Tyagi A, Koolwal A, Choudhary S. An old man who spit pearls-A case discussion. J Geriatr Ment Health 2018;5:167-9

How to cite this URL:
Agarwal S, Yadav A, Tyagi A, Koolwal A, Choudhary S. An old man who spit pearls-A case discussion. J Geriatr Ment Health [serial online] 2018 [cited 2019 Apr 22];5:167-9. Available from: http://www.jgmh.org/text.asp?2018/5/2/167/248620




  Introduction Top


A delusion is an idiosyncratic belief or impression maintained despite being contradicted by reality or rational argument. Delusional disorders as per the International Classification of Diseases 10 are defined as a variety of disorders, in which longstanding delusions constitute only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic, or affective. A number of fascinating delusions have been named as “syndromes” consisting either of single delusion (e.g., Othello syndrome) or of clusters of delusions (e.g., delusional misidentification syndrome).[1] Affected individuals with delusional disorder typically complain of infestation, deformity, personal ugliness, exaggerated sizes of body parts, foul body odor, or halitosis. Here, we present the case of an elderly male who had this feeling of spitting pearls out of his mouth and experiencing them under his skin. The uniqueness of his delusional content prompted us to report the case and to explore the possible influence of the environment as a predisposing factor guiding the delusional content, as the patient's family business was selling pearls.


  Case Report Top


A 65-year-old male presented with a history of delusions of spitting pearls out of his mouth and rolling over of pearls in his tongue and under his skin, his bed sheet, and blanket, rubbing them against his body over the past 3 months with gradual onset and progressive course of illness. He would rub himself often and would scratch his skin saying that there were pearls coming out of his skin and mouth. His experience was similar to that usually seen in delusional parasitosis, which is a mistaken belief that parasites have infested the body. He would often clean his bed and clean his clothes saying that there were pearls sticking on them. The patient also developed suspicions of infidelity and referential ideas toward his wife and family. He would not allow his wife to move out of his sight, doubting her and abusing her of cheating on him and collaborating with other family members and talking behind his back. These symptoms were also accompanied by sleep disturbances, irritable behavior, and frequent swallowing movements which the patient explained as attempts to dislodge pearls coming out of his mouth. On detailed history, the patient has a history of epilepsy-generalized tonic–clonic seizures on the treatment for the past 17 years on 300 mg of phenytoin. However, the patient reported that the last seizure episode occurred 2 years ago, which was due to stopping of phenytoin (drug withdrawal seizure). A neurology opinion was sought, and the patient was advised to continue phenytoin 300 mg.

The patient was started on risperidone 2 mg/day, which was increased to 4 mg/day over 2 weeks. The patient responded slowly after 3 months of treatment when a decrease in the intensity of his delusional beliefs about pearls and the infidelity was noted. The patient's insight continued to improve over the subsequent follow-ups over a period of 1 year. The patient is also a known smoker for the last 40 years, with a history of smoking 5–6 beedis/day on an average. Plan regarding nicotine replacement therapy (NRT) was discussed with the patient; however, the patient refused NRT and continued to smoke. There was no history of forgetfulness, confusion, loss of consciousness, head injury, trauma, fever, substance use, and other medical and surgical history. There was no history of any cranial nerve involvement nor any history suggestive of increased intracranial tension or toxicity. On detailed mental status examination, the patient was oriented, and his memory was intact. His thought content showed paranoid ideas and somatic delusions. No visual, auditory, gustatory, and olfactory hallucinations were found. His serial mini–mental status examination scores measured every week throughout the entire duration of his hospital stay of close to a month were found to be in the range of 22–24. There were no significant, motor, sensory, or cognitive deficits. His investigations including complete blood count, random blood sugar, blood urea, serum creatinine, serum electrolytes, liver function tests, and urine routine/microscopy were within normal limits. Noncontrast MRI showed nonspecific white matter ischemic changes seen in bilateral parietal, periventricular and basal ganglia regions, prominence of cerebral sulci, basal cistern, and ventricular system, suggestive of age-related cerebral atrophy.


  Discussion Top


We report the case of a 65-year-old male presenting with unique content of delusion, without any cognitive deficits. There are multiple aspects to be discussed through this case of a delusional disorder in a 65-year-old patient. First, the mean age of onset for delusions is reportedly 40 years and it ranges from 18 to 90 years.[1],[2] A Spanish study conducted by de Portugal et al. looked at medical records of 370 people diagnosed with delusional disorder and found that the mean age in this population was 55 years.[3] It is not rare for psychotic disorders such as delusions, hallucinations, and other psychotic symptoms to occur late in life, but they may be more commonly occurring later in life than previously thought. Ostling in 2007 found that the prevalence of psychotic symptom in a population-based sample of 95-year-old individuals who did not have dementia was 10.4%.[4] Second, the role of the environment needs to be highlighted in the formation of delusional content specific to the patient. Like in our case, our patient's family business was selling pearls and had been working in a pearl industry for a long time before developing these unique somatic delusions. It could be suspected that the influence of constantly being exposed to the working atmosphere of a pearl factory might have reflected in the delusional content of our patient. Previously, Bentall and Fernyhough had postulated that, in psychotic disorders, the role of environmental factors in determining the trajectories of psychosis is grossly neglected. According to him, psychotic symptoms such as delusions were the products of specific cognitive biases and deficits and that the development of these particular patterns of cognitive functioning was influenced by specific kinds of environmental adversity.[5] Delusional disorders are common products of brain dysfunction and occur with similar frequencies in different world populations. However, the content of delusional disorders varies among cultures and reflects the social and cultural setting of delusional individuals.[6] Moreover, a number of risk factors in addition to familial or genetic have been described for delusional disorders. Second, our case did not have any cognitive deficits. Fujii et al (2007) reported in his series that individuals with delusional disorders frequently have a history of “cerebral insult,” for example, traumatic brain injury, stroke and diabetic neuropathy, and a history of psychoactive substance abuse. He argued that subtle brain abnormality may be a predisposing factor for delusional disorder. Others have suggested that aging contributes to the risk, also perhaps related to a matrix of changes captured by the term “subtle brain impairment.”[7] Minimal brain insult in the form of seizures possibly predisposed the patient to develop delusions late in life as seen in the case of our patient. Trimble reported that a long history of uncontrolled seizures can also lead to chronic psychotic state in more than 5% of patients, often with an insidious onset of paranoid delusions and hallucinations; this form of psychosis due to seizure disorder is closer in the form to schizophrenia with less intense affective component, similar to the findings as in our patient.[8] Furthermore, other important domains to discuss about our case is that delusions in dementia are common, with a prevalence of between 10% and 70% and an annual incidence rate of between 1% and 5% that was not the case in our patient.[9],[10] Many authors have described the factor of increasing age and studies have shown that delusions are more common in patients with moderate cognitive impairment, but in our patient, we ruled out the possibility of dementia.[11] It is indeed difficult to pinpoint the precipitating factor responsible for the development of delusions in our patient. It could be suggested that factors such as age, long history of seizures, and the environmental milieu of the patient even without any gross cognitive impairment might have played a role in the formation and the content of delusions in our patient.


  Conclusion Top


Delusional disorders are an ever-interesting psychotic disorder with variable thought content and variable age of onset. Delusional disorders with late age of onset should prompt a thorough examination for cognitive impairment, any causes for underlying minimal brain damage, and any specific environmental triggers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Manjunatha N, Sarma PK, Math SB, Chaturvedi SK. Delusional procreation syndrome: A psychopathology in procreation of human beings. Asian J Psychiatr 2010;3:84-6.  Back to cited text no. 1
    
2.
Köhler S, van Os J, de Graaf R, Vollebergh W, Verhey F, Krabbendam L. Psychosis risk as a function of age at onset: A comparison between early- and late-onset psychosis in a general population sample. Soc Psychiatry Psychiatr Epidemiol 2007;42:288-94.  Back to cited text no. 2
    
3.
de Portugal E, González N, Haro JM, Autonell J, Cervilla JA. A descriptive case-register study of delusional disorder. Eur Psychiatry 2008;23:125-33.  Back to cited text no. 3
    
4.
Ostling S, Gustafson D, Blennow K, Börjesson-Hanson A, Waern M. Psychotic symptoms in a population-based sample of 85-year-old individuals with dementia. J Geriatr Psychiatry Neurol 2011;24:3-8.  Back to cited text no. 4
    
5.
Bentall RP, Fernyhough C. Social predictors of psychotic experiences: Specificity and psychological mechanisms. Schizophr Bull 2008;34:1012-20.  Back to cited text no. 5
    
6.
Kiran C, Chaudhury S. Understanding delusions. Ind Psychiatry J 2009;18:3-18.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Fujii D, Ahmed I. The Spectrum of Psychotic Disorders: Neurobiology, Etiology & Pathogenesis. Cambridge, UK: Cambridge University Press; 2007. p. 128.  Back to cited text no. 7
    
8.
Trimble M. The Psychoses of Epilepsy. NY: Raven Press; 1991. p. 109-35.  Back to cited text no. 8
    
9.
Allen NH, Burns A. The non-cognitive features of dementia. Rev Clin Germtol 1995;5:57-75.  Back to cited text no. 9
    
10.
Ballard C, Oyebode F. Psychotic symptoms in patients with dementia. Int J Geriatric Psychiatry 1995;10:743-52.  Back to cited text no. 10
    
11.
Flynn FG, Cummings JL, Gornbein J. Delusions in dementia syndromes: Investigation of behavioral and neuropsychological correlates. J Neuropsychiatry Clin Neurosci 1991;3:364-70.  Back to cited text no. 11
    




 

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