Prolonged Wahnstimmung (delusional mood) without development of a psychotic illness in a 50-year-old male.

Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. In this case, the patient reports experiencing this sensation persistently since early childhood. This case suggests that Wahnstimmung may persist for years without developing into full psychosis. This is the first reported case of prolonged and persistent delusional mood in literature. It should be of interest to psychiatry professionals looking to investigate the prodromal phase of psychosis. This case is regarding a 50-year-old, Caucasian male. He presented to clinic with a feeling of excitement. Despite being referred for suicidal ideation, he described himself as "the happiest guy that I know. I wake up every morning feeling excited." This original case should highlight the possibility of this phenomenon in other patients. Ultimately, an understanding of why patients may not progress to full psychotic illness may improve our understanding of protective factors in psychotic illnesses.

INTRODUCTION

Delusional mood, or Wahnstimmung, was first reported by Mishara and Klaus Conrad in 1958.[123] It commonly involves a period, lasting days to months, of the patient experiencing a “feeling that something is in the air.”[24] Conrad referred to this expectational phase as “Trema.”[24] The patient externalizes it to a yet-to-be-understood process in the world.[2] The patient's delusions or delusional system appears in a sudden significant revelation.[24] While delusional mood may last a number of years, there are no cases of lifelong symptoms.[2] The prevalence of Wahnstimmung in schizophrenia spectrum disorder is described between 1% and 8%.[5]

CASE REPORT

This case report regards a 50-year-old, Caucasian male. He presented to the secondary mental health-care team feeling “excited.” He felt that the appointment would provide some explanation of his experiences. When questioned about his mood, he responded, “I am the happiest guy that I know. I wake up every morning feeling excited.” The feeling, he said, is “overwhelming.” He is convinced to be chosen for something special that will transpire in due course.

The patient vividly remembered feeling the same way when he was 4 years old, but until the age of 12, he believed that everybody felt this way. While he experienced some illusions in childhood, he denied any history of hallucinations, lability of mood, or depressive symptoms. He searched for an explanation. Until he reached his 30s, he considered that he may be Jesus and would perform miracles. He never held this idea with delusional intensity. When he discovered that he was unable to perform these miracles, he looked for alternative meanings. The patient first presented with these symptoms to mental health services in 1996. While he indicated a feeling that others may know what he was thinking, he denied any passivity phenomena, thought broadcasting, or hallucinations. There was no evidence of mania in his history. The working diagnosis at the first presentation was a schizotypal personality disorder. There was no evidence of a narcissistic personality disorder. Follow-up was arranged, but the patient was discharged after failing to attend.

His personal history was unremarkable. He was born into a family of four children; one brother and two sisters. The family was bad tempered, but there was no physical violence. His parents divorced when he was 19. He did not enjoy school, but achieved four General Certificate of Secondary Education (GCSE) and began to work as a laborer for the National Health Service (NHS) after graduation. The patient describes himself as always having been very sociable, with a good social network. There is a history of usage of illicit drugs, beginning as a teenager and lasting until his early 20s. This includes extensive use of amphetamines (“speed”), cannabis, and 3,4-methylenedioxymethamphetamine (“ecstasy”). He has been married four times and has been married to his current wife for 11 years. He has four children from the three previous wives.

There was no history of previous mental illness, although the patient is now retired following diagnosis with spinal stenosis. He takes gabapentin and ibuprofen. He smokes 30 cigarettes a day, drinks 23 units/week, and committed an offence for police obstruction many years ago.

On mental state examination, the patient appeared appropriately dressed, calm, maintained good eye contact, and rapport was easy to establish. His communication was expressive. His speech was spontaneous and coherent and appropriate, but mildly pressured. It was normal in volume and rhythm. He described his mood as “excited.” Objectively, his mood was euthymic with no evidence of manic or hypomanic symptoms. His affect was excitable, albeit not labile, and congruous to his mood. There was no abnormality in the form of thought. The content of thought was abnormal, with a prevailing delusional mood/Wahnstimmung and the overvalued idea that he is destined for something special. This manifested itself as a desire for public recognition of his case during the consultation. He admitted that he is now enthusiastic about death, as he feels this will reveal the meaning of his symptoms. There were no overt abnormalities in perception. Cognition was normal: he was well orientated, and attention, concentration, and memory were not impaired. There was no evidence of suicidal or homicidal ideation, intent, or plans. There was partial insight into the possibility of mental illness, albeit driven by a need for an explanation to his feelings.

To help manage these symptoms, the patient was offered amisulpride 200 mg daily. While he reveled in the sensation of excitement, he agreed to trial anything at this stage. Two days later, the mental health team were informed that he had ceased taking his medication.

DISCUSSION

The strengths of this report are the detailed subjective experiences of the patient because this may help to identify comparable cases for future case series. However, limitations also exist due to a lack of diagnostic certainty, the lack of patient follow-up after treatment. While the phenomenon of delusional mood/Wahnstimmung is common in the prodromal stages of psychosis, it rarely persists for as long as Patient has experienced. This raises two clinical concerns; first, “what is the patient's risk of developing psychosis”? and second “what is the best way to relieve Patient A's symptoms and prevent progression”?

We were unable to identify any studies that specifically looked at the treatment of Wahnstimmung. In general, authors interpret it as a prodromal symptom of schizophrenia and therefore suggest antipsychotic treatment. Attenuated (subclinical) psychosis and transient psychotic episodes are shown to increase an individual's risk of future clinical psychosis.[6] Research has suggested that prodromal symptoms may be present in up to 25% of nonpsychotic psychiatric outpatients.[7] High-risk individuals may be protected from psychosis by clinical interventions. A randomized controlled trial of 58 high-risk patients demonstrated a narrowly significant reduction in mean Positive and Negative Syndrome Scale at 12 months following cognitive therapy (P = 0.49), albeit there was no significant effect on function and distress scores.[6] At 3-year follow-up, cognitive therapy significantly decreased antipsychotic prescribing and transition to psychosis after controlling for baseline factors.[8] A double-blind, randomized controlled trial assessing the protective effect of olanzapine in patients with psychotic prodromal symptoms demonstrated a nonsignificant decrease in conversion to psychosis. Despite a relatively large effect size (hazard ratio = 0.4), the sample size (n = 60) may have underpowered the result.[9] Nevertheless, these studies propose two possible treatment avenues to prevent prodromal psychosis from developing into clinical illness.

CONCLUSION

This case report demonstrates a rare, chronic presentation of prodromal psychosis. It should be of interest to psychiatrists and psychologists who may encounter similar presentations and researchers who wish to investigate this phenomenon further. While there is no clear understanding of why certain individuals progress to psychosis, clinical interventions may be effective at reducing the risk of progression. Indeed, the efficacy of cognitive therapy and antipsychotic medication suggests that particular psychological coping mechanisms may prove to be protective in high-risk individuals and warrant further investigation.

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.