The Corpus Callosum

The warming preachers truly are driving people mad with fear...With internet reports like this and this, or Age reports like this and this, how could he tell he was unreasonable? Indeed, some global warming preachers now sound that they need treatment, too.

The comment that "global warming preachers now sound that they need treatment" is merely an expression of prejudice.  With a garnish of hate.  More of the same, here.  Milder version, here.

The physicians who wrote the case report were doing what academic physicians always do: they describe manifestations of illness, then publish their findings.  

This is not meant to be a groundbreaking paper.  The authors are not trying to name a new illness.  In fact, this kind of thing has been described before, just not with the exact delusional content.

Such delusions can occur in mood disorders (depression with psychotic features) and thought disorders (schizophrenia, schizoaffective disorder).

The content of the delusions may vary with the times.  This is well known.  In the early 1950s, it was Communists.  In the late 1950s, satellites.  In the 1960s, lasers.  And so on, for various persons with paranoia.  

What little we can see of the case report suggests that this particular patient had depression with psychotic features.  The themes of apocalypse, death, self-deprivation, unworthiness, and guilt, all are consistent with psychotic depression.  This could occur in unipolar or bipolar depression.

In such a young patient, I would be particularly worried about the possibility of bipolar depression.  However, for this particular person, it will be necessary to see how this evolves over time, in order to have much confidence in the diagnosis.

Update: the full text of the paper has been posted on a "self-serve science" forum here.

The authors report:

Water, water, everywhere, nor any drop to drink: climate
change delusion
Australian and New Zealand Journal of Psychiatry, Volume 42, Issue 4 April 2008 , page 350
DOI: 10.1080/00048670701881603

Joshua Wolf, Department of Paediatrics, University of Melbourne and Integrated Mental Health Service, Royal Children's Hospital and Robert Salo, Integrated Mental Health Service, Royal Children's Hospital, Melbourne, Victoria, Australia:

Clinicians caring for psychotic patients have long noted that delusional systems are determined by ideas and beliefs to which the individual has been exposed. We describe a patient with 'climate change delusion', a previously unreported phenomenon.

A 17-year-old man was referred to the inpatient psychiatric unit at Royal Children's Hospital Melbourne with an 8 month history of depressed mood, social withdrawal, school avoidance, social anxiety, amotivation, poor concentration, anhedonia, feelings of guilt and worthlessness, insomnia, suicidal ideation and self-harm. He also described hearing his own voice making derogatory and command statements, and had visions of apocalyptic events.

Admission was precipitated by acute deterioration in his condition consisting of increased emotional distress and suicidal behaviour. Prior to admission he was treated with fluoxetine (40 mg day) and olanzapine (5 mg day).

The patient had also developed the belief that, due to climate change, his own water consumption could lead within days to the deaths of 'millions of people' through exhaustion of water supplies. He quoted 'internet research' to substantiate this. The patient described that 'I feel guilty about it', had attempted to stop drinking and had been checking for leaking taps in his home to prevent the catastrophe. He was unable to acknowledge that the belief was unreasonable when challenged.

There was no history of substance abuse. Physical examination was normal except for psychomotor retardation and superficial forearm lacerations. The final diagnosis was major depressive disorder with psychotic features. He was treated with oral fluoxetine (60 mg day), clonazepam (1.5 mg day) and olanzapine (10 mg day). After several days his mood improved considerably and he denied persisting delusional beliefs. The experience of hearing his own voice persisted, but he no longer found it as distressing.

There have been numerous reports of incorporation of contemporary phenomena, such as the internet [1-3], into delusional systems, but a search of Medline and Psychlit did not identify reports of delusions related to global warming. Climate change has rapidly become a dominant issue in Australian society. A 2007 poll found that 85% of Australians were 'very' or 'fairly' concerned about climate change, significantly more than the proportion concerned about terrorism [4].

This case provides another fascinating illustration of the cultural and environmental specificity of manifestations of psychosis.

References

1. Tan S, Shea C, Kopala L. Paranoid schizophrenia with delusions regarding the Internet. J Psychiatry Neurosci 1997; 22:143.

2. Schmid-Siegel B, Stompe T, Ortwein-Swoboda G. Being a webcam. Psychopathology 2004; 37:84 5.

3. Lerner V, Libov I, Witztum E. 'Internet delusions': the impact of technological developments on the content of psychiatric symptoms. Isr J Psychiatry Relat Sci 2006; 43:47 51.

4. Gyngell A. Australia and the world: public opinion and foreign policy. Sydney: Lowy Institute for International Policy, 2007. [Cited 22 October 2007.]

After reading the full paper, I still think this describes depressive psychosis.  The "visions of apocalyptic events" and the checking behavior are suggesting of OCD.  OCD, however, rarely attains a psychotic extent, and would not have the full set of vegetative signs.

Note also tha there is a tinge of grandiosity:

[H]is own water consumption could lead within days to the deaths of 'millions of people' through exhaustion of water supplies. He quoted 'internet research' to substantiate this.

That does not change the diagnostic impression, but it does add to the worry that this could be the index episode in what later evolves into bipolar disorder.  

Another notable point:

The experience of hearing his own voice persisted, but he no longer found it as distressing.

Unfortunately, that is fairly common: the hallucinations become less bothersome, quickly, but do not completely resolve for a while.

Persons with conditions such as this generally require treatment with either 1) a combination of antidepressant and an antipsychotic) or 2) ECT, to have a realistic chance of improvement.