Delirium is a disorder of thinking with painful reasoning, ideas, and conclusions inherent in this condition that do not correspond to reality and are not subject to correction, but in which the patient is unshakably and completely convinced. In 1913, this triad was formulated by K. T. Jaspers, he noted that these signs are superficial and do not reflect the very essence delusional disorder, but only assume its presence. This disorder can only appear on a pathological basis. Delirium deeply affects all spheres of the individual’s psyche, especially affecting the affective and emotional-volitional spheres.

Traditional definition of this disorder for the Russian school of psychiatry is the following. Delirium is a set of ideas, painful reasoning and conclusions that have taken possession of the patient’s consciousness, falsely reflect reality and are not subject to correction from the outside.

Within medicine, delusional disorder is considered in general psychopathology and psychiatry. Delusions, along with hallucinations, are included in the group of psychoproductive symptoms. A delusional state, being a disorder of thinking, affects one of the areas of the psyche, with the affected area being the human brain.

Schizophrenia researcher E. Bleuler noted that the delusional state is characterized by:
- egocentricity, with a bright affective coloring, which is formed on the basis of internal needs, and internal needs can only be affective.

The concept of "delirium" in spoken language has a different meaning from the psychiatric one, which leads to its incorrect use with scientific point vision.

For example, in everyday life they call delusional behavior unconsciousness person, accompanied by meaningless, incoherent speech, often occurring in patients with infectious diseases.

From a clinical point of view, this phenomenon should be called amentia, since it is a qualitative disorder of consciousness, not thinking. Likewise, others mistakenly call nonsense in everyday life mental disorders, For example, .

In a figurative sense, a delusional state includes any incoherent and meaningless ideas, which is also incorrect, since they may not correspond to the delusional triad and act as delusions of a mentally healthy person.

Examples of nonsense. The delusional state of paralytics is filled with content about bags of gold, untold riches, thousands of wives. The content of delusional ideas is often concrete, figurative and sensual. For example, a patient can recharge from an electrical outlet, imagining himself as an electric locomotive, or can go without drinking for weeks. fresh water because he considers her dangerous to himself.
Patients with paraphrenia claim that they live for a million years and are convinced of their immortality or that they were senators of Rome and took part in life ancient egypt, other patients claim that they are aliens from Venus or Mars. At the same time, such people operate with figurative, vivid ideas and are in a state of heightened mood.

Symptoms of delirium

Delirium deeply affects all spheres of the individual’s psyche, especially affecting the affective and emotional-volitional spheres. Thinking changes in complete submission to the delusional plot.

Delusional disorder is characterized by paralogicality (false inference). The symptoms are characterized by redundancy and belief in delusional ideas, and in relation to objective reality there is a discrepancy. At the same time, the person’s consciousness remains clear, slightly weakened.

The delusional state should be distinguished from the delusions of mentally healthy individuals, since it is a manifestation of the disease. When differentiating this disorder, it is important to consider several aspects.

1. For delusions to occur, there must be a pathological basis, just as personality delusions are not caused by a mental disorder.

2. Delusions relate to objective circumstances, and delusional disorder relates to the patient himself.

3. Correction is possible for delusions, but for a delirious patient this is impossible, and his delusional belief contradicts the previous worldview before the onset of this disorder. In real practice, sometimes differentiation can be very difficult.

Acute delirium. If consciousness is completely subordinated to a delusional disorder and this is reflected in behavior, then this is acute delirium. Occasionally, the patient can adequately analyze the surrounding reality and control his behavior, if this does not relate to the topic of delirium. In such cases, delusional disorder is called encapsulated.

Primary delirium. Primary delusional disorder is called primordial, interpretive, or verbal. The primary cause of it is a defeat of thinking. The logical, rational consciousness is affected. In this case, the patient’s perception is not impaired and he is able to long time be efficient.

Secondary (figurative and sensory) delusions occurs due to impaired perception. This condition is characterized by a predominance of hallucinations and illusions. Delusional ideas are inconsistent and fragmentary.

Thinking disturbance appears a second time, a delusional interpretation of hallucinations sets in, and there is a lack of conclusions that occur in the form of insights—emotionally rich and vivid insights.

Elimination of the secondary delusional state is achieved mainly by treating the symptom complex and the underlying disease.

There are figurative and sensory secondary delusional disorder. With figurative thinking, fragmentary, scattered ideas arise, similar to memories and fantasies, that is, delusions of representation.

In sensual delirium, the plot is visual, sudden, rich, concrete, emotionally vivid, and polymorphic. This condition is called delusion of perception.

Delusional imagination differs significantly from sensory and interpretative delusional states. With this variant of delusional disorder, ideas are not based on perceptual disorders or on a logical error, but arise on the basis of intuition and fantasy.

There are also delusions of grandeur, delusions of invention, and delusions of love. These disorders are poorly systematized, polymorphic and very variable.

Delusional syndromes

IN domestic psychiatry Currently, it is customary to distinguish three main delusional syndromes.

Paranoid syndrome is unsystematic and is often observed in combination with hallucinations and other disorders.

Paranoid syndrome is an interpretative, systematized delusion. Most often monothematic. With this syndrome, there is no intellectual-mnestic weakening.

Paraphrenic syndrome is fantastic, systematized in combination with mental automatisms and hallucinations.

Mental automatism syndrome and hallucinatory syndrome are close to delusional syndromes.

Some researchers identify a delusional “paranoid” syndrome. It is based on an overvalued idea that arises in paranoid psychopaths.

The plot of delirium. The plot of delirium is understood as its content. The plot, as in cases of interpretative delirium, is not a sign of illness and directly depends on the socio-psychological, political and cultural factors within which the patient lives. There can be a lot of such plots. Often ideas arise that are common to the thoughts and interests of all mankind, as well as characteristic of a given time, beliefs, culture, education and other factors.

Based on this principle, three groups of delusional states are distinguished, united by a common plot. These include:

1. Delusion of persecution or mania of persecution, persecutory delusion, which in turn includes:

• delusion of damage - the belief that the patient’s property is being damaged or stolen by some people;
• delusion of poisoning - the patient is convinced that one of the people wants to poison him;
• delusion of relation - it seems to a person that the entire environment is directly related to him and the behavior of other individuals (actions, conversations) is determined by their special attitude towards him;
• delusion of meaning - a variant of the previous plot of delirium (these two types of delusional state are difficult to differentiate);
• delusion of influence - a person is haunted by the idea of ​​extraneous influence on his feelings, thoughts with an accurate assumption about the nature of this influence (radio, hypnosis, “cosmic radiation”); - erotic delusion - the patient is sure that he is being pursued by his partner;
• delirium of litigiousness - the sick person fights to restore “justice”: courts, complaints, letters to management;
• delusions of jealousy - the patient is convinced that his sexual partner is cheating;
• delusion of staging - the patient’s conviction that everything around is specially arranged and scenes of some kind of performance are being played out, and an experiment is being conducted, and everything is constantly changing its meaning; (for example, this is not a hospital, but a prosecutor’s office; a doctor is an investigator; medical staff and patients are security officers disguised in order to expose the patient);
• delusion of possession - a person’s pathological belief that he has been possessed by devilry or some hostile creature;
• Presenile delirium is the development of a picture of depressive delirium with ideas of condemnation, guilt, and death.

1. Delusions of grandeur (expansive delusions, delusions of grandeur) in all its varieties include the following delusional states:

• delusions of wealth, in which the patient is pathologically convinced that he possesses untold treasures or wealth;
• delirium of invention, when the patient is susceptible to the idea of ​​making a brilliant discovery or invention, as well as unrealistic various projects;
• delirium of reformism - the patient creates social, absurd reforms for the benefit of humanity;
• delusion of origin - the patient believes that his real parents are high-ranking people, or attributes his origin to an ancient noble family, another nation, etc.;
• rave eternal life- the patient is convinced that he will live forever;
• erotic delusion - the patient’s conviction that a certain person is in love with him;
• delusional love conviction, which is noted in female patients by the fact that famous people love them, or everyone who meets them at least once falls in love;
• antagonistic delusion - the patient’s pathological belief that he is a passive witness and contemplator of the struggle of opposing world forces;
• religious delusional belief - when a sick person considers himself a prophet, claiming that he can perform miracles.

1. Depressive delusions include:

• delusions of self-abasement, self-blame, sinfulness;
• hypochondriacal delusional disorder - the patient’s belief that he has a serious illness;
• nihilistic delirium - a false feeling that the patient or the surrounding world does not exist, and the end of the world is coming.

Separately, induced (induced) delusions are distinguished - these are delusional experiences that are borrowed from the patient through close contact with him. This looks like being “infected” with delusional disorder. The person to whom the disorder is induced (transmitted) is not necessarily submissive or dependent on the partner. Usually those people from the patient’s environment who communicate very closely with him and are connected by family relationships are infected (induced) with delusional disorder.

Stages of delirium

The stages of delirium include the following stages.

1. Delusional mood - the belief that changes have occurred around and trouble is approaching from somewhere.

2. Delusional perception arises in connection with an increase in anxiety and a delusional explanation of individual phenomena appears.

3. Delusional interpretation - a delusional explanation of all perceived phenomena.

4. Crystallization of delirium - the formation of complete, coherent, delusional ideas.

5. The fading of delirium - the emergence of criticism of delusional ideas.

6. Residual delirium - residual delusional phenomena.

Treatment of delirium

Treatment of delusional disorder is possible with methods that affect the brain, that is, psychopharmacotherapy (antipsychotics), as well as biological methods(atropine, insulin comas, electrical and drug shock).

The main method of treatment for diseases that are accompanied by delusional disorder is treatment with psychotropic drugs. The choice of antipsychotics depends on the structure of the delusional disorder. In case of primary interpretative with pronounced systematization, drugs with selective nature actions (Haloperidol, Triftazin). For affective and sensory delusional states, antipsychotics are effective wide range actions (Frenolone, Aminazine, Melleril).

Treatment of diseases accompanied by delusional disorder, in many cases, occurs in a hospital setting followed by supportive outpatient therapy. Outpatient treatment is prescribed in cases where the disease is observed without aggressive tendencies and is reduced.

• Delirium (lat. Delirio) is often defined as a disorder of thinking with the emergence of painful ideas, reasoning and conclusions that do not correspond to reality, in which the patient is completely, unshakably convinced and which cannot be corrected. This triad was formulated in 1913 by K. T. Jaspers, and he emphasized that these signs are superficial, do not reflect the essence of delusional disorder and do not define, but only suggest the presence of delusion. Delirium occurs only on a pathological basis. Traditional for the Russian school of psychiatry is the following definition:

  Another definition of delusion is given by G.V. Grule: “the establishment of a relational connection without a basis,” that is, the establishment of relations between events that cannot be corrected without a proper basis.

  Within medicine, delusions are considered in psychiatry and general psychopathology. Along with hallucinations, delusions are included in the group of so-called “psychoproductive symptoms.”

  It is fundamentally important that delirium, being a disorder of thinking, that is, one of the spheres of the psyche, is also a symptom of damage to the human brain. Treatment of delirium, according to ideas modern medicine, is possible only by methods that directly affect the brain, that is, psychopharmacotherapy (for example, antipsychotics) and biological methods - electrical and drug shock, insulin, atropine comas. The latter methods are especially effective when affecting residual and encapsulated delirium.

  The famous schizophrenia researcher E. Bleuler noted that delirium is always:

  Egocentric, that is, it is essential for the patient’s personality; And

  It has a bright affective coloring, since it is created on the basis of internal needs (“delusional needs” according to E. Kraepelin), and internal needs can only be affective.

  According to research carried out by W. Griesinger in the 19th century, in general outline nonsense regarding the development mechanism does not have pronounced cultural, national and historical characteristics. At the same time, a cultural pathomorphosis of delirium is possible: if in the Middle Ages delusional ideas associated with obsession, magic, and love spells prevailed, then in our time delusions of influence by “telepathy,” “biocurrents,” or “radar” are often found.

  In colloquial language, the concept of “delirium” has a different meaning from the psychiatric one, which leads to its scientifically incorrect use. For example, delirium in everyday life is the unconscious state of a patient, accompanied by incoherent, meaningless speech, which occurs in somatic patients with elevated body temperature (for example, in infectious diseases). From a clinical point of view, this[specify] phenomenon should be called “amentia”. Unlike delirium, this is a qualitative disorder of consciousness, not thinking. Also in everyday life, other mental disorders, such as hallucinations, are mistakenly called delusions. In a figurative sense, delirium is considered to be any meaningless and incoherent ideas, which is also not always correct, since they may not correspond to the delusional triad and are mental delusions healthy person.

Inferences that did not arise from information received from the outside world and are not corrected by incoming new information (it does not matter whether the delusional conclusion corresponds to reality or not), a component of productive symptoms in and others.

According to the structure, delirium is classified:

1. Paranoid delusion(syn.: primary - systemic - interpretative - intellectual) - very difficult to detect in the early stages. It is built according to the laws of “crooked logic”. The chain of statements can be very plausible and it takes a lot of experience to find a defect in the patient’s thinking. Paranoid delusions occur in mature age. Usually - 40-45 years. With this type of delirium, “the patient thinks correctly within the limits of falsely established truths.”
2. Paranoid delusions(syn.: secondary - sensitive - figurative) - occurs after other symptoms. Often has an acute peachy character. It catches your eye. Often occurs in the form of the Kandinsky-Clerambault symptom (delusions of persecution or influence, pseudohallucinations, mental automatisms).
3. Paraphrenic delirium- nonsense of fantastic content. Can be combined with other types, for example delusions of persecution + delusions of grandeur. Often paraphrenic delusions disintegrate.

Based on their content, the following types of delirium are distinguished:

• Delirium of noble origin- patients believe that their real parents are high-ranking people.
• Delirium of litigiousness (querulianism)- patients fight for a certain idea - complaints, courts, letters to management (detailed like those of epileptoids). They are hyperactive in achieving goals. It is often formed when a person finds himself in a judicial situation.
• Hypochondriacal delusion - the patient is “in love with his illness.” He is convinced of the presence of some disease. This type of delusion often occurs in schizophrenia. May begin to form from: non-delusional hypochondria → delusional hypochondria. Neurosis → neurotic depression (4-8 years) → symptom pathological development personality (psychopathy) → hypochondriacal personality development.
• Delirium of jealousy- the patient is jealous without the fact of betrayal. “Sadomasochistic complex” of patients with delusions of jealousy - elements of a thorough interrogation of the object of jealousy can be traced.
• Delirium of love's charm- the patient is convinced that he loves him a famous person and he reciprocates.
• "Haunted Stalker"- this type of delirium has 2 stages in its development. The first stage - the patient feels persecuted (he is treated “badly”) - there is an internal deep processing. At a certain point, he openly expresses everything. The second stage - the patient understands that it is useless to fight and runs away (quits) - such patients are often called “migrating paranoids” because they constantly change places of work, move! from city to city, etc.
• Delirium of invention- the patient constantly invents something. Sometimes these are truly talented people.
• Delirium of reformism- the patient is convinced that the world and society need restructuring.

Delusional ideas

Delusional ideas- incorrect conclusions that cannot be corrected. These are false ideas that arise on a painful basis; there is no criticism of them.

Classification of delusional ideas:

1. Persuasive delirium- ideas in which there is a threat to prestige, material, physical well-being. Accompanied by fear and anxiety. For example, delusions of persecution, relationship, influence, poisoning, robbery, jealousy, litigiousness, damage, etc. Delusions of persecution belongs to the persecutory group. Patients are convinced that they are the object of surveillance associated with hostile goals. The circle of persecutors includes not only work employees, but also relatives, strangers, strangers, and sometimes even pets or birds (Dolittle syndrome). Delusions of persecution develop in 2 stages:
   • The patient runs away from the “pursuers.”
   • The patient attacks.
2. Expansive delirium- delusional ideas of self-aggrandizement. For example, delusions of greatness, immortality, wealth, invention, reformism.
3. Depressive delirium- ideas of self-deprecation, self-accusation, hypochondria, physical deformity.

Depressive delusions

With further deepening of depression, depressive, delusional ideas arise. Patients accuse themselves of various offenses (selfishness, cowardice, callousness, etc.) or of committing crimes (debauchery, betrayal, deceit). Many demand a “fair trial” and “deserved punishment” (nonsense of self-blame). Other patients say that they are unworthy of attention, that they are wasting space in the hospital, that they look dirty, that they are disgusting (delusions of self-deprecation). A type of depressive delusion is delirium of ruin and impoverishment; It is especially often observed in elderly and old age.

Hypochondriacal delusions are very common in depression. In some cases, this is a delusion of illness (the patient believes that he has cancer, tuberculosis, AIDS, etc.) - hypochondriacal delusional depression, in others - an unshakable conviction of destruction internal organs(the intestines have atrophied, the lungs have rotted) - depression with nihilistic delirium. Often, especially in old age, depression occurs, accompanied by delusions of persecution, poisoning, harm (paranoid depression).

Delusional syndrome (disorder) is a psychopathological complex of symptoms that is characterized by the presence of delusional ideas that come to the fore. It is classified as a pathology of the content of thinking. Delirium is not specific symptom any disease. It can occur under a variety of mental disorders Therefore, it is necessary to clarify its nature (schizophrenia, organic or schizophrenia-like disorder, etc.).

Definition

Delusional ideas (delusions) are false judgments or conclusions that arise as a result of a painful process and take possession of the patient’s consciousness, which cannot be dissuaded (corrected).

They are not true. The patient is firmly convinced of the correctness of his judgment, despite the evidence contradicting this (there is no criticism on the part of the patient). This is a potential problem for the person himself, since he medical care he won't convert.

The criteria for delirium are the following characteristics:

• it is always a symptom of a disease;
• delusional ideas are not true, this can be proven;
• are not amenable to persuasion (correction) and critical self-reflection (self-criticism);
• they determine the patient’s behavior (his actions), completely dominate the entire psyche (logic, instincts, reflexes), occupying all consciousness.

One should not take any false judgment of a person for nonsense, since confidence and persistence in the expressed thought can be a manifestation of one’s worldview.

Beliefs, unlike delusions, are formed throughout life and are closely related to experience and upbringing. By presenting patients with clear arguments, evidence, evidence aimed at denying the correctness of their thoughts, the doctor sees that they are considered sick.

Delusions and overvalued ideas should not be confused, which is of particular importance in situations where they are the only symptom of a mental disorder. When real life problem in the consciousness of a mentally healthy person acquires an excessively large (priority) importance, in this case they speak of an overvalued idea.

Classification

There are many classifications of delusional ideas.

According to the mechanism of formation, they are divided into:

1. 1. Primary - associated with the interpretation and construction of step-by-step logic, understandable only to the patient himself. It is an independent disorder of the sphere of thinking, which does not relate to other symptoms of mental pathologies.
2. 2. Secondary - associated with the formation of holistic images, for example, under the influence of hallucinations or altered mood. It arises as a result of disturbances in other areas of the psyche.
3. 3. Induced. It manifests itself in the fact that the recipient (healthy person) reproduces the delusional system of the inductor (patient). This situation arises as a result of communication with a close relative who suffers from mental illness.

Delirium, according to the degree of systematization, is divided into fragmentary (fragmentary) and systematized. The second indicates the chronic nature of the course of mental illness. As the disease progresses, the phase of disintegration of the delusional system begins. Thoughts that arise acutely are always devoid of harmony. It differs from chronic unsystematized ideas vivid emotional experiences, the presence dramatization relationship, adjustments, excitement, feelings of change.

Acute delirium responds well to treatment. It is usually possible to achieve high-quality remission or recovery. Treatment is carried out by prescribing antipsychotics (Paliperidone, Ziprasidone, etc.)

The following variants of delusional ideas are distinguished by content:

Variety	Characteristics with examples
Delusions of relationship and meaning	The patient feels that others look at him differently, hinting at his special purpose through their behavior. A person is in the center of attention and interprets environmental phenomena that were previously not significant to him as important.
Pursuit Ideas	The patient assures that he is being watched. He finds a lot of evidence (hidden equipment), gradually noticing that the circle of suspects is expanding. Transitive delusions of persecution are also possible, when a person himself begins to follow imaginary individuals, using aggression against them
Ideas of greatness	The patient is convinced that he has power in the form of exceptional energy or strength, due to his enormous wealth, divine origin, achievements in the field of science, politics, art, the value of the reforms he proposes
Ideas of jealousy	A person is convinced of adultery, although the arguments are absurd. For example, a patient claims that his partner is having sexual intercourse with another through a wall.
Love delirium	Consists of the subjective belief that he/she is the object of love of a movie star, politician or doctor, often a gynecologist. The person in question is often persecuted and forced to reciprocate
Ideas of self-blame and guilt	The patient is convinced that he is guilty before society and loved ones because of his actions; he is awaiting trial and execution. Usually formed against a background of low mood
Hypochondriacal delirium	A person interprets his somatic sensations, senestopathy, paresthesia as a manifestation of an incurable disease (HIV, cancer). Requires examinations, awaits his death
Nihilistic delirium (Cotard's delirium)	The patient assures that his insides have “rotted”, and similar processes are also taking place in the surrounding reality - the whole world is at different stages of decomposition or is dead
Delirium of staging	It lies in the idea that all events in the surrounding world are specially adjusted, as in the theater. Patients and staff in the department actually - employees in disguise intelligence services, the patient’s behavior is staged and shown on television
Delirium of a double	Expressed in the conviction of the presence of a negative or positive double (as opposed to personality traits), which is located at a considerable distance and can be associated with the patient by symbolic or hallucinatory constructions
Manichaean nonsense	A person is convinced that the whole world and himself are an arena for the struggle between good and evil - God and the devil. This system is capable of being confirmed by mutually exclusive pseudohallucinations, that is, voices that argue with each other for possession of the patient's soul
Dysmorphoptic delirium	The patient, often a teenager, is convinced that his face shape has changed, there is an anomaly of the body (most often the genitals), and actively insists on surgical treatment
Delirium of obsession	A person feels himself transformed into some kind of animal. For example, into a vampire, a bear (Lokis symptom), a wolf (lycanthropy) or an inanimate object

The plot of delirium

In psychiatry, there is such a concept as the plot of delirium. It denotes the content or plot of thought. The plot of each person’s delirium is unique and inimitable; in many ways the content corresponds to the ideas that are popular in given time in society. The thought is emotionally experienced by the patient, he is able to experience fear, anger, melancholy, joy, etc.

According to one or another dominant emotion, 3 groups of plots are distinguished:

• Delusion of persecution (persecutory). Various options These ideas are associated with the predominance of fear and anxiety in patients, which often determines their aggressive behavior and in this case is an indication for involuntary hospitalization.
• Depressive delirium. It is an expression of deep emotional experiences - depression, melancholy, disappointment, shame, hopelessness.
• Delirium of grandeur. Various options are usually accompanied by a joyful, upbeat or complacent, calm mood. In this case, patients are tolerant of the circumstances that constrain them, are not prone to aggression, and are friendly.

Often one patient experiences a combination of several plots:

Analogues of delusional ideas in children

The equivalents of delusional ideas in children are overvalued fears and delusional fantasies.

The child talks about an imaginary world and is sure that it really exists, replacing reality. It contains good and evil characters, love and aggression. Fantasy, like delusional ideas, is not subject to criticism, but is very changeable.

Overvalued fears are expressed in fears towards objects that do not themselves have such a phobic component. An example is a situation where a child is afraid of the corners of the room, the window, the radiator, or parts of the parents’ body.

Stages of formation of delusional syndrome

In the process of formation, delusional syndrome goes through several stages of development. They are the following:

1. 1. Affective stage. Manifested by the presence of delusional mood (vague anxiety). It is expressed in a feeling of vague internal restlessness, suspicion, wariness, confidence that dangerous changes are happening around. Then a delusional perception (special meaning) appears. It represents an assessment of the environment, when, along with the usual idea of ​​​​a really existing object, an unreal idea appears, logically unrelated to reality, with the nature of a special attitude towards the patient.
2. 2. Stage of receptor shift. Delusional perception is replaced by a delusional idea (insight, interpretation). It is characterized by the fact that the patient begins to perceive facts, events, and the words of others in a distorted way, but does not connect his painful conclusions into a single system.
3. 3. Interpretation stage. At this stage, considerations are formalized into a system of ideas (“crystallization of delirium”). This process is called delusional awareness.
4. 4. Stage of system disintegration. The final stage of existence delusional syndrome. As the disease progresses, the indifference and calm of the patient, who gradually loses interest in his “persecutors,” become increasingly noticeable.

There are also other stages of development of delusional syndrome proposed by K. Conrad. These include the following:

Delusion is a persistent belief that arose on pathological grounds, is not susceptible to the influence of reasonable arguments or evidence to the contrary and is not an instilled opinion that could be acquired by a person as a result of appropriate upbringing, education received, the influence of traditions and cultural environment.

The above definition is aimed at separating delusions that indicate mental disorder, from other types of persistent beliefs that can occur in healthy people. Usually (but not always) a delusion is a false belief. The criterion for delusion is that it is firmly based on an inadequate basis, that is, this belief is not the result of normal processes logical thinking. The strength of conviction is such that it cannot be shaken even by seemingly irrefutable evidence to the contrary. For example, a patient with a delusional idea that his pursuers are hiding in the neighboring house will not give up this opinion even when he sees with his own eyes that the house is empty; against all odds he will retain his belief, assuming, for example, that the pursuers left the building before it was examined. It should be noted, however, that normal people with ideas of a non-delusional nature, sometimes they remain just as deaf to the arguments of reason; an example of this is the common beliefs of people with common religious or ethnic roots. Thus, a person brought up in the traditions of belief in spiritualism is unlikely to change his beliefs under the influence of strong evidence to the contrary, convincing to anyone whose worldview is not associated with such beliefs.

Although usually, as already noted, Crazy idea- this is a false belief, under exceptional circumstances it may turn out to be true or become so later. A classic example is pathological jealousy (see p. 243). A man may develop delusions of jealousy towards his wife in the absence of any substantiated evidence of her infidelity. Even if the wife is truly unfaithful at the time, the belief is still delusional unless there is a reasonable basis for it. The point to be emphasized is that it is not the falsity of a belief that determines its delusional character, but the nature mental processes that led to this belief. Meanwhile, it is known that in clinical practice the stumbling block is the tendency to consider a belief false just because it seems strange, rather than checking the facts or finding out how the patient came to such a belief. For example, seemingly incredible stories of being stalked by neighbors or of a spouse trying to poison a patient sometimes have a basis in reality, and in the end it can be established that the corresponding conclusions are the result of normal processes of logical thinking and that they are in fact fair.

The definition of delusion emphasizes that a characteristic feature of a delusional idea is its stability. However, the belief may not be so strong before (or after) the delusion is fully formed. Sometimes delusional ideas appear in a person’s mind already fully formed, and the patient is absolutely convinced of their truth from the very beginning, but in other cases they develop more gradually. Similarly, while recovering, the patient may go through a stage of increasing doubt about his delusional ideas before finally rejecting them as false. The term is sometimes used to refer to this phenomenon Partial delirium As, for example, in the Status Survey (see p. 13). It is advisable to use this term only if it is known that either partial delirium was preceded by complete delirium, or it subsequently developed into complete delirium (retrospective approach). Partial delirium can be detected on early stages. However, when identifying this symptom, you should not draw certain conclusions regarding the diagnosis only on this basis. A thorough examination should be performed to look for other signs of mental illness. Despite the fact that the patient may be completely confident in the truth of the delusional idea, this belief does not necessarily affect all his feelings and actions. This separation of belief from feelings and actions, known as Dual orientation, Most often found in chronic schizophrenics. Such a patient, for example, believes that he is a member royal family, but at the same time lives calmly in a house for mentally ill people discharged from hospital. It is necessary to distinguish delirium from Super valuable ideas Which were first described by Wernicke (1900). Super valuable idea- this is an isolated, all-consuming belief of a different nature than delusions and obsessions; it sometimes dominates the patient’s life for many years and can influence his actions. The roots of the belief that occupies the patient’s thoughts can be understood by analyzing the details of his life. For example, a person whose mother and sister died of cancer one after the other may succumb to the belief that cancer is contagious. Although it is not always easy to distinguish between delusion and a super-valuable idea, in practice this rarely leads to serious problems, since the diagnosis of mental illness depends on more than the presence or absence of any one symptom. (For more information on high value ideas, see McKenna 1984.)

There are many types of delusions, which will be described below. The table will help the reader in the next section. 1.3.

Primary, secondary and induced delirium

Primary, or autochthonous, delusion- this is delusion that arises suddenly with complete conviction of the truth of its content, but without any mental events leading to it. For example, a patient with schizophrenia may suddenly have a complete conviction that his gender is changing, although he had never thought about anything like that before and was not preceded by any ideas or events that could push him to such a conclusion in any way. in a logically explicable way. A belief suddenly arises in the mind, fully formed and in an absolutely convincing form. Presumably it is a direct expression pathological process, which is the cause of mental illness, is the primary symptom. Not all primary delusions begin with an idea; delusional mood (see p. 21) or delusional perception (see p. 21) can also arise suddenly and without any antecedent events to explain them. Of course, it is difficult for the patient to remember the exact sequence of such unusual, often painful psychic phenomena, and therefore it is not always possible to establish with complete certainty which of them is primary. Inexperienced doctors usually make the diagnosis of primary delirium too easily, without paying due attention to the study of previous events. Primary delirium is given great value when diagnosing schizophrenia, and it is very important not to register it until you are completely sure of its presence. Secondary delusion Can be regarded as a derivative of any previous pathological experience. A similar effect can be caused by several types of experiences, in particular (for example, a patient who hears voices, on this basis comes to the belief that he is being persecuted), mood (a person in deep depression may believe that people consider him insignificant); In some cases, the delusion develops as a consequence of a previous delusional idea: for example, a person with delusions of impoverishment may fear that losing money will send him to prison because he will not be able to pay his debts. It seems that in some cases secondary delusions perform an integrating function, making the initial sensations more understandable to the patient, as in the first example given. Sometimes, however, it seems to have the opposite effect, increasing the feeling of persecution or failure, as in the third example. The accumulation of secondary delusional ideas can result in the formation of an intricate delusional system in which each idea can be regarded as arising from the previous one. When a complex set of interrelated ideas of this kind is formed, it is sometimes defined as systematic delusion.

Under certain circumstances, induced delirium occurs. As a rule, others consider the patient’s delusional ideas to be false and argue with him, trying to correct them. But it happens that a person who lives with a patient begins to share his delusional beliefs. This condition known as induced delirium, or Insanity for two (Folic A Deux) . While the couple remains together, the other person's delusional beliefs are as strong as those of the partner, but they tend to be quickly reduced when the couple separates.

Table 1.3. Description of delirium

1. By persistence (degree of conviction): complete partial 2. By the nature of occurrence: primary secondary 3. Other delusional states: delusional mood delusional perception retrospective delusion (delusional memory) 4. By content: persecutory (paranoid) relations of grandeur (expansive) guilt and low value nihilistic hypochondriacal religious jealousy sexual or love delusions of control

delusion regarding the possession of one's own thoughts delusion of transmission (broadcasting) of thoughts

(In the domestic tradition, these three symptoms are considered as an ideational component of the syndrome of mental automatism) 5. According to other signs: induced delirium

Delusional moods, perceptions and memories (retrospective delusions)

Typically, when a patient first develops delusions, he also has a certain emotional reaction and perceives his surroundings in a new way. For example, a person who believes that a group of people are going to kill him is likely to feel fear. Naturally, in such a state, he can interpret the reflection of the car seen in the rear-view mirror as evidence that he is being followed.

In most cases, delirium occurs first, and then the remaining components are added. Sometimes observed reverse order: first the mood changes - often this is expressed in the appearance of a feeling of anxiety, accompanied by a bad feeling (it seems as if something terrible is about to happen), and then delirium follows. In German this change in mood is called WaJinstimmung, Which is usually translated as Delusional mood. The latter term cannot be considered satisfactory, because in fact we are talking about the mood from which delirium arises. In some cases, the change that has occurred is manifested in the fact that familiar objects of perception suddenly, without any reason, appear to the patient as if bearing a new meaning. For example, an unusual arrangement of objects on a colleague's desk may be interpreted as a sign that the patient has been chosen by God for some special mission. The described phenomenon is called Delusional perception; This term is also unfortunate because it is not the perception that is abnormal, but the false meaning given to the normal object of perception.

Despite the fact that both terms are far from meeting the requirements, there is no generally accepted alternative to them, so they have to be resorted to if it is necessary to somehow designate a certain state. However, it is usually better to simply describe what the patient is experiencing and record the order in which changes in ideas, affect, and interpretation of sensations occurred. With the corresponding disorder, the patient sees a familiar person, but believes that he has been replaced by an impostor who is an exact copy of the real one. This symptom is sometimes referred to by the French term Vision De Societies(double), but this, of course, is nonsense, not an illusion. The symptom can persist so long and persistently that even a syndrome (Capgras) has been described in which this symptom is the main one. characteristic feature(see p. 247). There is also an erroneous interpretation of the experience that is opposite in nature, when the patient recognizes the presence of different appearances in several people, but believes that behind all these faces is the same disguised pursuer. This pathology is called (Fregoli). A more detailed description of it is given further on p. 247.

Some delusions relate to past rather than present events; in this case we talk about Delusional memories(retrospective delirium). For example, a patient who is convinced of a conspiracy to poison him may attribute new meaning to the memory of an episode in which he vomited after eating long before the delusional system emerged. This experience must be distinguished from the exact memory of a delusional idea formed at that time. The term "delusional memory" is unsatisfactory because it is not the memory that is delusional, but its interpretation.

In clinical practice, delusions are grouped according to their main themes. This grouping is useful because there is some correspondence between certain themes and basic forms mental illness. However, it is important to remember that there are many exceptions that do not fit into the generalized associations mentioned below.

Often call Paranoid Although this definition has, strictly speaking, a broader meaning. The term “paranoid” appears in ancient Greek texts to mean “insanity,” and Hippocrates used it to describe feverish delirium. Much later, this term began to be applied to delusional ideas of grandeur, jealousy, persecution, as well as erotic and religious ones. The definition of “paranoid” in its broad sense is still used today in application to symptoms, syndromes and personality types, while remaining useful (see Chapter 10). Persecutory delusions are usually directed at an individual or at entire organizations that the patient believes are trying to harm him, tarnish his reputation, drive him crazy, or poison him. Such ideas, although typical, do not play a significant role in making a diagnosis, since they are observed in organic conditions, schizophrenia and severe affective disorders. However, the patient's attitude towards delirium may have diagnostic value: it is typical that with severe depressive disorder the patient is inclined to accept the alleged activities of the persecutors as justified, due to his own guilt and worthlessness, while the schizophrenic, as a rule, actively resists, protests, and expresses his anger. In evaluating such ideas, it is important to remember that even seemingly improbable accounts of persecution are sometimes supported by facts, and that in certain cultural environments it is considered normal to believe in witchcraft and attribute failures to the wiles of others.

Delusional relationship is expressed in the fact that objects, events, people acquire special meaning for the patient: for example, a newspaper article read or a remark heard from a television screen is perceived as addressed to him personally; a radio play about homosexuals is “specially broadcast” in order to inform the patient that everyone knows about his homosexuality. Delusions of attitude can also be focused on the actions or gestures of others, which, according to the patient, carry some information about him: for example, if a person touches his hair, this is a hint that the patient is turning into a woman. Although most often ideas of attitude are associated with persecution, in some cases the patient may give a different meaning to his observations, believing that they are intended to testify to his greatness or reassure him.

Delirium of grandeur, or expansive delirium,- This is an exaggerated belief in one’s own importance. The patient may consider himself rich, endowed with extraordinary abilities, or generally an exceptional person. Such ideas occur in mania and schizophrenia.

Delusions of guilt and worthlessness most often found in depression, which is why the term " depressive delirium" Typical of this form of delusion are ideas that some minor violation of the law that the patient has committed in the past will soon be discovered and he will be disgraced, or that his sinfulness will bring divine punishment on his family.

Nihilistic delusion is, strictly speaking, a belief in the non-existence of some person or thing, but its meaning expands to include the patient’s pessimistic thoughts that his career is over, that he has no money, that he will die soon, or that the world is doomed. Nihilistic delusions are associated with extreme depression. It is often accompanied by corresponding thoughts about disturbances in the functioning of the body (for example, that the intestines are allegedly clogged with rotting masses). Classical clinical picture is called Cotard's syndrome after the French psychiatrist who described it (Cotard 1882). This condition is discussed further in Chap. 8.

Hypochondriacal delusion consists of the belief that there is a disease. The patient, despite medical evidence to the contrary, stubbornly continues to consider himself sick. Such delusions more often develop in older people, reflecting increasing anxiety about health, which is typical at this age and in people with a normal psyche. Other delusions may be related to cancer or a sexually transmitted disease, or appearance parts of the body, especially the shape of the nose. Patients with delusions of the latter type often insist on plastic surgery(See the subsection on body dysmorphic disorder, Chapter 12).

Religious nonsense i.e., delusions of religious content, were much more common in the 19th century than at the present time (Klaf, Hamilton 1961), which apparently reflects the more significant role that religion played in life ordinary people in past. If unusual and strong religious beliefs are found among members of religious minorities, it is advisable to first talk to another member of the group before deciding whether these ideas (for example, apparently extreme beliefs about God's punishment for minor sins) are pathological.

Delirium of jealousy more common in men. Not all thoughts caused by jealousy are delusions: less intense manifestations of jealousy are quite typical; in addition, some intrusive thoughts may also be associated with doubts about the fidelity of the spouse. However, if these beliefs are delusional, then they are especially important because they can lead to dangerous aggressive behavior in relation to someone suspected of infidelity. Necessary Special attention, if the patient “spys” on his wife, examines her clothes, trying to detect “traces of sperm,” or rummages through her purse in search of letters. A person suffering from delusions of jealousy will not be satisfied with the lack of evidence to confirm his belief; he will persist in his quest. These important issues are discussed further in Chap. 10.

Sexual or love delirium It is rare and mainly affects women. Delusions associated with sexual intercourse are often secondary to somatic hallucinations felt in the genitals. A woman with delusions of love believes that she is passionate about a man who is inaccessible under normal circumstances and occupies a higher social position, with whom she has never even spoken. Erotic delirium is the most characteristic feature Clerambault syndrome, Which is discussed in Chap. 10.

Delirium of control is expressed in the fact that the patient is convinced that his actions, motives or thoughts are controlled by someone or something outside. Because this symptom strongly suggests schizophrenia, it is important not to record it until its presence is definitely established. A common mistake is diagnosing delusions of control when there is no delusion of control. Sometimes this symptom is confused with the experiences of a patient who hears hallucinatory voices giving commands and voluntarily obeys them. In other cases, misunderstanding arises because the patient misunderstands the question, believing that he is being asked about religious attitudes regarding God's providence guiding human actions. A patient with delusions of control firmly believes that the behavior, actions and every movement of an individual are directed by some outside influence - for example, his fingers take the appropriate position for making the sign of the cross not because he himself wanted to cross himself, but because they were forced by an external force .

Delusions regarding thought ownership characterized by the fact that the patient loses the confidence that is natural for every healthy person that his thoughts belong to himself, that these are purely personal experiences that can become known to other people only if they are spoken out loud or revealed by facial expression, gesture or action. Lack of control over your thoughts can manifest itself in different ways. Patients with Delirium of investing other people's thoughts They are convinced that some of their thoughts do not belong to them, but are inserted into their consciousness by an external force. This experience is different from that of the obsessive, who may be tormented by unpleasant thoughts but never doubts that they originate in his own brain. As Lewis (1957) said, obsessions “are produced at home, but the person ceases to be their master.” A patient with delusions of insertion of thoughts does not recognize that the thoughts arose in his own mind. Patient with Delirium of thoughts being taken away I'm sure the thoughts are being extracted from his mind. Such delirium usually accompanies memory lapses: the patient, feeling a gap in the flow of thoughts, explains this by the fact that the “missing” thoughts were taken away by some outside force, the role of which is often assigned to the alleged persecutors. At Brede transfer(openness) of thoughts, the patient imagines that his unexpressed thoughts become known to other people by transmission using radio waves, telepathy, or in some other way. Some patients also believe that others can hear their thoughts. This belief is often associated with hallucinatory voices that seem to speak out loud the patient’s thoughts. (Gedankenlautwerderi). Three last symptom(In Russian psychiatry they refer to the syndrome of mental automatism) are found in schizophrenia much more often than in any other disorder.

Causes of delirium

Given the obvious paucity of knowledge about the criteria for normal beliefs and the processes underlying their formation, it does not seem surprising that we are almost completely unaware of the causes of delusions. The lack of such information did not prevent, however, the construction of several theories, mainly devoted to delusions of persecution.

One of the most famous theories was developed by Freud. His main ideas were outlined in a work originally published in 1911: “The study of many cases has led me, like other researchers, to the opinion that the relationship between the patient and his persecutor can be reduced to a simple formula. It turns out that the person to whom the delusion ascribes such power and influence is identical with someone who played an equally important role in the emotional life of the patient before his illness, or with an easily recognizable substitute. The intensity of the emotion is projected onto the image external force, while its quality is reversed. The face that is now hated and feared because it is a stalker was once loved and respected. The main purpose of the persecution asserted by the patient’s delusions is to justify a change in his emotional attitude.” Freud further summarized his point by stating that this is the result of the following sequence: “I am not I love Him - me I hate it Him because he’s stalking me”; erotomania follows the series of “I don’t love His-I love Her Because She loves Me", And the delirium of jealousy is the sequence “this is not I Loved this man - this She Loves him” (Freud 1958, pp. 63-64, emphasis in original).

So, according to this hypothesis, it is assumed that patients experiencing persecutory delusions have suppressed homosexual impulses. So far, attempts to verify this version have not provided convincing evidence in its favor (see: Arthur 1964). However, some authors have accepted the basic idea that persecutory delusions involve a projection mechanism.

An existential analysis of delirium has been carried out repeatedly. Each case describes in detail the experience of patients suffering from delusions, and emphasizes the importance of the fact that delusions affect the whole being, that is, it is not just a single symptom.

Conrad (1958), using a Gestalt psychology approach, described delusional experiences into four stages. In accordance with his concept, a delusional mood, which he calls trema (fear and trembling), through a delusional idea, for which the author uses the term “alophenia” (the appearance of a delusional idea, experience), leads to the patient’s efforts to discover the meaning of this experience by revising his vision peace. These efforts are frustrated at the final stage (“apocalypse”), when signs of thought disorder and behavioral symptoms appear. However, although this type of sequence can be observed in some patients, it is certainly not invariable. Learning theory attempts to explain delusions as a form of avoidance of extremely unpleasant emotions. Thus, Dollard and Miller (1950) proposed that delusions are a learned interpretation of events to avoid feelings of guilt or shame. This idea is just as unsupported by evidence as all other theories about the formation of delusions. For readers wishing to receive more detailed information on this issue, reference should be made to Arthur (1964).