Psychology of delirium. Delirium: definition and typology

Rave - A thinking disorder, which is characterized by the occurrence of judgments that do not correspond to reality (usually painful), which seem completely logical to the patient and which cannot be corrected or convinced.

This definition is based on the so-called Jaspers triad. In 1913, K. T. Jaspers identified three key characteristics any nonsense:

– delusional judgments do not correspond to reality,

– the patient is completely convinced of their logic,

– delusional judgments cannot be challenged or corrected.

V. M. Bleicher gave a slightly different definition of delirium: “... a set of painful ideas, reasoning and conclusions that take possession of the patient’s consciousness, distortedly reflect reality and cannot be corrected from the outside.” This definition emphasizes the fact that delirium takes possession of the patient’s consciousness. As a consequence, the patient’s behavior is largely subordinate to this delusion.

It is very important to understand that delirium is certainly a disorder of thinking, but it is a consequence of damage and dysfunction of the brain. This is only a consequence, and, according to ideas modern medicine, it is pointless to treat delirium with psychological methods or, for example, increasing the “culture of thinking”. The biological underlying cause must be identified and the underlying cause addressed appropriately (eg, with antipsychotic medications).

The famous specialist on schizophrenia E. Bleuler noted that delusion is always egocentric, that is, it is essential for the patient’s personality, and has a strong affective connotation. There seems to be an unhealthy fusion emotional sphere and thinking. Affectivity disturbs thinking, and disturbed thinking excites affectivity with the help of absurd ideas.

The clinical picture of delirium does not have pronounced cultural, national and historical characteristics. However, the content of delirium varies - both depending on the era and depending on personal experience person. So in the Middle Ages, delusional ideas associated with obsession were “popular” evil spirits, magic, love spell, etc. Nowadays, delusions of influence are often encountered with such topics as aliens, biocurrents, radars, antennas, radiation, etc.

It is necessary to distinguish the scientific concept of “nonsense” from the everyday one. IN spoken language delirium is often called:

– unconsciousness of the patient (for example, at high temperature),

– hallucinations,

– all sorts of meaningless ideas.

Whether delirium can be observed in a completely mentally healthy person is a big question. On the one hand, in psychiatry it is clearly believed that delirium is only a consequence of pathological processes. On the other hand, any affectively colored act of thinking, to a minor or significant extent, can correspond to Jaspers’ triad. Enough typical example here is the state of youthful love. Another example is fanaticism (sports, political, religious).

It should be noted, however, that Jaspers' triad, like Bleicher's definition, is only a definition as a first approximation. IN psychiatric practice To establish delirium, the following criteria are used:

– occurrence on a pathological basis, that is, delirium is a manifestation of the disease;

– paralogicality, that is, construction on the basis of one’s own internal logic of delirium, proceeding from the internal (always affective) needs of the patient’s psyche;

– in most cases, except for some variants of secondary delirium, consciousness remains clear (no disturbances of consciousness);

– redundancy and inconsistency in relation to objective reality, but with a strong conviction in the reality of delusional ideas - this shows the “affective basis of delirium”;

– resistance to any correction, including suggestion and the invariance of a delusional point of view;

– intelligence, as a rule, is preserved or slightly weakened; with a strong weakening of intelligence, the delusional system disintegrates;

– present during delirium deep violations personalities caused by centering around a delusional plot;

– delusional fantasies differ from delusions in the absence of a strong conviction in their authenticity and in the fact that they do not in any way affect the being and behavior of the subject.

The professional experience of a psychiatrist is of great importance for diagnosis.

Delusion is characterized by the exploitation of a single need or instinctive pattern of behavior. For example, a patient may be “fixated” on his maternal duty. Exploitation of resentment is very common. If for a healthy person resentment is associated with an innate ability for hidden aggression, which turns on from time to time, then for a patient the theme of resentment is a cross-cutting one that captures consciousness. Delusions of grandeur are characterized by the exploitation of an innate need for social status. And so on.

Some types of delirium

If delirium completely takes over consciousness and completely subordinates the patient’s behavior, this condition is called acute delirium.

Sometimes the patient is able to adequately analyze the surrounding reality, if this does not relate to the topic of delirium, and control his behavior. In such cases, delirium is called encapsulated.

At primary delirium Only thinking, rational cognition is affected. Distorted judgments are consistently supported by a number of subjective evidence that has its own system. The patient's perception remains normal. It remains functional. You can freely discuss things with him that are not related to the delusional plot. When the delusional plot is touched upon, affective tension and a “logical failure” occur. This variant of delusion includes, for example, paranoid and systematized paraphrenic delusions.

At secondary delirium(sensual, figurative) illusions and hallucinations are observed. Secondary delirium is called that because it is a consequence of them. Delusional ideas no longer have integrity, as in the case of primary delusions; they are fragmentary and inconsistent. The nature and content of delusions depend on the nature and content of hallucinations.

Secondary delusions are divided into sensual and figurative. At sensual delirium the plot is sudden, visual, specific, rich, polymorphic and emotionally vivid. This is nonsense of perception. At figurative delirium scattered, fragmentary ideas arise, similar to fantasies and memories, that is, delusions of imagination.

Nonsense with a plot persecution. Includes a wide variety of forms:

– actual delusion of persecution;

– delusion of damage (the belief that the patient’s property is being damaged or stolen);

– delusion of poisoning (the belief that someone wants to poison the patient);

– delusions of relation (the actions of other people supposedly have something to do with the patient);

– delusion of meaning (everything in the patient’s environment is given special meaning that affects his interests);

- nonsense physical impact(the patient is “impacted” using different rays and devices);

– delusions of mental influence (“influenced” by hypnosis and other means);

– delusions of jealousy (belief that a sexual partner is cheating);

– delusions of litigiousness (the patient fights to restore justice through complaints and courts);

– delusion of staging (the patient’s belief that everything around him is specially arranged, scenes of some kind of performance are being played out, or some kind of psychological experiment is being conducted);

- delirium of obsession;

– presenile dermatozoal delirium.

Nonsense with a plot of its own greatness(expansive nonsense):

- delirium of wealth;

- delirium of invention;

– nonsense of reformism (ridiculous social reforms for the benefit of humanity);

– delusion of origin (belonging to “ blue bloods»);

- nonsense eternal life;

– erotic delirium(the patient is a “sex giant”);

– delirium of love (the patient, usually a woman, thinks that someone very famous is in love with him);

– antagonistic delirium (the patient is a witness or participant in the struggle between the forces of Good and Evil);

– religious delusion - the patient considers himself a prophet, claims that he can perform miracles.

Nonsense with its own plot insignificance (depressive delirium):

– delirium of self-blame, self-abasement and sinfulness;

– hypochondriacal delusion (belief in the presence serious illness);

– nihilistic delusion (the belief that the world does not really exist or that it will soon collapse);

- delirium of sexual inferiority.

Stages of development of delirium

1. Delusional mood. There is a certainty that some changes have taken place around, that trouble is coming from somewhere.

2. Delusional perception. The feeling of anxiety increases. A delusional explanation of the meaning of individual phenomena appears.

3. Delusional interpretation. Expansion of the delusional picture of the world. A delusional explanation of all perceived phenomena.

4. Crystallization of delirium. Formation of harmonious, complete delusional ideas and concepts.

5. Attenuation of delirium. Criticism of delusional ideas—“immunity” to them—appears and develops.

6. Residual delirium. Residual delusions.

We need a blockbuster (about the use of delusional plots in cinema).

Problems of definition:

On the one hand, the word delirium is the name of a disease, for example, prolonged alcoholic delirium, infectious delirium, on the other hand, it is a designation of a certain psychopathological phenomenon, a characteristic phenomenon, but still only a separate symptom, found in a wide variety of diseases.

To avoid misunderstandings, instead of a broad and insufficiently defined term, one should speak in appropriate cases about delusions and delusional ideas as separate signs of psychosis or about delirium, delirious states of alcoholic, infectious or some other origin.

Delusional ideas in a brief definition, these are delusions that have arisen on a painful basis and cannot be corrected either through persuasion or in any other way. In their essence, these are incorrect, false thoughts, errors of judgment, but they stand out from a number of other errors, for example, prejudices, superstitions, current but incorrect opinions, precisely because they develop on painful soil; they are individual, they constitute something inherent in a given mental personality.

Rave can almost exhaust clinical picture psychosis, being, as it were, a monosymptom, for example, in paranoid states, at the same time, all authors agree that delusion is heterogeneous, that it is not a single disorder in structure, and that there are several forms of delusion.

Some definitions:

Ø Delirium is an incorrect conclusion that arises on a pathological basis, completely changes the patient’s worldview, cannot be corrected from the outside and from the inside, and undergoes certain dynamics over time (A.V. Snezhnevsky).

Ø Delusion is a set of painful ideas, reasoning and conclusions that take possession of the patient’s consciousness, distortedly reflect reality and cannot be corrected from the outside (Bleicher, Kruk 1996).

Ø Delusion is a false belief based on a distorted view of reality, which is persistently maintained contrary to the opinions of the absolute majority and despite irrefutable and obvious evidence in favor of the contrary (DSM-IV 1994)

Criteria for delirium (according to K. Jaspers):

• a person's subjective belief that he is right
• impossibility of correction
• delirium may either not correspond to reality, or be somehow consistent with it - the specificity of delirium is that it does not need to be confirmed or refuted

The concept of crystallization of delirium:

• Delusional mood :

ü Tense foreboding of an impending catastrophe;

ü Inexplicable painful anxiety;

ü Acquiring a different meaning for others;

ü Perception of yourself and the world around you as changed

• Delusional perception : a person notices some strange things in the world that confirm his delusional mood

Delusional perception may be preceded by a delusional mood based on the same process, the experience of anxiety, and, less often, elation. In this vague mood, delusional perceptions often mean “something”, but so far nothing definite. The specific content of delusional perception cannot be understood on the basis of an indefinite delusional mood: the second, at best, is part of the first, but cannot be deduced from it.

In terms of emotional coloring, a delusional mood does not even have to coincide with the subsequent delusional perception: a delusional mood can be anxious, and a delusional perception can be blissful.

We should talk about delusional perception in cases when an actual perception without a rationally or emotionally explainable reason is given anomalous meaning, mostly in terms of connection with one's own personality. This meaning is of a special kind: almost always important, urgent, to a certain extent attributable to one’s own account, like some kind of sign, a message from another world. It is as if perception expresses a “higher reality,” as one of the patients put it.

§ Since we are not talking about a noticeable change in what is perceived, but about an anomalous interpretation, poor perception does not refer to disturbances of perception, but to disturbances of “thinking”.

Example of a patient with schizophrenia “On the stairs of the Catholic convent, a dog was lying in wait for me. She sat up straight, looked at me seriously and raised her front paw as I approached. By chance, a few meters ahead of me, another man was walking along the same path, and I hastened to catch up with him to ask if the dog behaved in the same way with him. His surprised “no” convinced me that I was dealing with some kind of revelation here.”

• Delusional performance : rethinking past life events
• Delusional awareness : everything suddenly becomes clear to a person, he even experiences some relief - “delirium falls out like a crystal”

Types of delirium:

There are many classifications of delirium, but among them all two main criteria can be distinguished: form and content. The typology given below is based on the criterion of form; it also presents the substantive aspects of a particular type of delirium.

Paranoid delusion(synonyms: systematic, delirium of interpretation, interpretive):

• A paranoid patient correctly reflects things; they are reflected pervertedly into internal connections.. Mostly abstract cognition is disrupted, the reflection not in general, not of external connections, but of internal connections between things and phenomena is disrupted - the reflection of causal connections is disrupted.
• Such nonsense is always logically justified. The patient can prove, develop a chain of logical evidence, that he is right, that his statement is correct. He endlessly discusses and provides more and more evidence. Paranoid delirium is always systematized; it is a system, although built on crooked logic, but still on logic.
• The onset of delirium is preceded by a state of so-called delusional mood with vague anxiety, a tense feeling of impending threat, a wary perception of what is happening around. The appearance of delirium is accompanied subjective feeling relief, a feeling that the situation has become clear, and vague expectations, a vague assumption have taken shape into a clear system.
• Characterized by gradual development and complication of the delusional system. This delusion develops long enough and chronically. No matter what happens around the patient, he will always interpret the events taking place so that they fit into his delusional system. However, sometimes paranoid delusions develop suddenly, acutely, like an “insight,” a “sudden thought.”
• Paranoid content delirium can reflect everything human feelings, passions, desires (examples):
• delirium of jealousy
• reformist nonsense: the patient develops a system for transforming the world, a system for “making happy” people all over the globe
• delusions of persecution: the patient initially hides his faith, the conviction that he is treated unkindly, he is being persecuted, then suddenly begins to fight against his imaginary persecutors, becomes persecuted! pursuer., or, on the contrary, begins to escape from his pursuers.”migrating paranoids., moving from place to place
• hypochondriacal delirium: a delusional conviction arises, justified by “crooked logic”, that the solo sufferer is suffering from one or another incurable disease. This kind of big people will challenge all medical opinions, all lab tests. Using all modern medical literature, they prove that they have a disease and demand treatment.
• But it must be said that Patients with paranoid delusions are also distinguished by a tendency to fantasize, daydreaming, and immaturity of thinking. Some psychiatrists pointed out that they are generally immature, they also have sexual immaturity, that there is some kind of, if not infantilism, then at least juvenileism in the personality of such patients.

Paranoid delusions(synonyms: figurative, sensual, non-systematic):

§ Such nonsense is also called secondary, bearing in mind that this is not the primary expression of the process, but a delusion that is born sequentially as a result of hallucinations, affect disorder, clouding of consciousness (a person hears hostile voices, therefore, in a “psychologically understandable way” he may have ideas of persecution). With this approach, normal relationships take the place of pathological ones - the patient’s attempt to somehow explain the pathology, a qualitatively different condition, is expressed in the home delirium.

§ If we approach this delusion clinically, descriptively, it should be called delirium sensual, because it lacks logical premises, the “crooked logic” of proof. Consequently, with sensory delirium, ideas are inconsistent, conclusions are random. At the same time, extremely intense affect, impulsive, unmotivated actions and actions, confusion, fragmentation and inconsistency of thinking are noted.

§ Sensual delirium in its syndromological picture is another syndrome, sharply different from paranoid. During its development, a radical change in the patient’s personality is not detected, there is no thoroughness of thinking; on the contrary, thinking is inconsistent, fragmentary, an element of anxiety, fear dominates, and confusion is revealed.

§ In your own way content sensual, figurative delirium is not the same.

Specific content of delirium :

railway paranoid : the patient is traveling in a carriage and suddenly all the passengers begin to be perceived as bandits who sat down with the aim of attacking him in the same compartment of the carriage as him - this is psychogenic (reactive delirium) - a pathological reaction to a changed situation, although a person in all other situations may be quite adequate

nonsense of the deaf : a person who has difficulty hearing may come to the conclusion that others are talking about him

nonsense in a foreign language environment : when a person does not understand the meaning of something foreign language, he may also come to the conclusion that they are talking about him

Cap-GRA syndrome:

• Double symptom:

Positive Double Symptom: the patient recognizes the familiar in the unfamiliar

Negative Twin Symptom: the patient sees strangers in people he knows

• Symptom of false recognitions

Fantastic content of nonsense:

Manichaean nonsense: a person worries that he is in the center of the struggle between Good and Evil

Brad Qatar: a person perceives the death and destruction of his own body.

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 will not seek medical help on his own.

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.

You should not take any false judgment of a person for nonsense, since confidence and persistence in the expressed thoughts can be a manifestation of a 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 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 staging 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, thanks to enormous wealth, divine origin, achievements in the field of science, politics, art, the value of the reforms he proposed
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 person 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 - disguised employees 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 versions of these ideas are associated with the predominance of fear and anxiety in patients, which often determines their aggressive behavior and in this case it 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, words of others in a distorted way, but his painful conclusions in unified system doesn't connect.
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 the existence of 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:

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Delirium (delirium) is a false conclusion that does not correspond to reality, arising in connection with an illness. For delusions, as opposed to errors of judgment, healthy people characterized by illogicality, persistence, often absurdity and fantasticality.

In mental illnesses (for example, schizophrenia), delirium is the main disorder; in somatic illnesses, it can develop due to infections, intoxications, organic and traumatic brain lesions, and also occur after severe psychogenia or other adverse long-term environmental influences. Often delirium is combined with hallucinations, then they speak of hallucinatory-delusional states.

Symptoms

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Acute delusional (hallucinatory-delusional) states

Acute delusional (hallucinatory-delusional) states are characterized by delusional ideas of relationship, persecution, influence, which are often combined with auditory hallucinations, symptoms of mental automatism, and rapidly increasing motor excitation. Affective disorders are clearly identified.

The behavior of patients is determined by the content of hallucinatory-delusional experiences and their extreme relevance, often accompanied by agitation with aggressive, destructive actions, sudden unexpected actions, self-harm, suicidal attempts or attacks on others. The patient believes that everything around him is saturated with a special, threatening meaning for him, he interprets all actually occurring events in a delusional way, seeing in everything a dangerous meaning for him, offensive hints, threats, warnings, etc. The patient often does not understand the meaning of what is happening to him and usually does not seek an explanation for this.

Acute delusional states are characterized by variability, lack of formality in the plot of delirium, and an abundance of auditory hallucinations and mental automatisms. All these phenomena can occur separately (for example, the state is determined only by delusions of persecution, relationship; hallucinations and automatisms may be absent at this stage, etc.), but more often they coexist, intertwined with each other. This structure of the hallucinatory-delusional part of the status usually corresponds to affective disorders in the form of fear, anxiety, confusion, depression.

Depressive-delusional states

Depressive-delusional states are one of the most common variants of acute delusional syndrome and are characterized by a pronounced affective intensity of psychopathological disorders with a predominance of depression with an anxious and melancholy overtones, excitement, fear, and confusion.

Hallucinatory-delusional symptoms

Hallucinatory-delusional symptoms are closely related to affective disorders: it is not so much ideas of persecution that predominate as delusions of condemnation, accusation, guilt, sinfulness, and imminent death. At the height of the attack, nihilistic delirium may occur. Illusory-delusional derealization and depersonalization are noted. In general, it is not so much the delusion of persecution that is characteristic, but the delusion of staging, when the patient seems that everything around him has a special meaning, in the actions and conversations of people he catches hints addressed to him, scenes are played out especially for him.

Instead of auditory hallucinosis, depressive-paranoid states are characterized by illusory hallucinosis, when the patient attributes real-life conversations of those around him to his own account, interpreting the most insignificant phrases in a delusional sense. He often sees hints addressed to himself in broadcasts on radio, television, and newspapers. False recognitions are also common.

Manic-delusional states

Manic-delusional states are to some extent the opposite of depressive-delusional states and are characterized by a predominance high mood with gaiety or anger, irritability, combined with delusional ideas of overestimating one’s own personality, up to delusions of grandeur (patients consider themselves great scientists, reformers, inventors, etc.). They are lively, talkative, interfere in everything, do not tolerate objections, and experience a surge of strength and energy. Patients, due to uncriticality and overestimation of their capabilities for delusional reasons, often experience outbursts of excitement; they commit dangerous actions, can be aggressive and spiteful. Sometimes delirium of grandeur takes on an absurdly fantastic character with ideas of enormity and cosmic influences; in other cases, the behavior of patients acquires a litigious-querulyant character with numerous persistent complaints to various authorities about the alleged injustice.

Subacute delusional states - symptoms

In subacute delusional (hallucinatory-delusional) states, psychomotor agitation may be mildly expressed or absent altogether. The patient’s behavior is not so changeable and impulsive: on the contrary, it may outwardly appear orderly and purposeful, which presents the greatest difficulties in correctly assessing the condition and often leads to serious consequences, since the patient’s behavior is determined by delusional ideas of persecution and hallucinations that are quite relevant to him. Unlike acute conditions, he can, to a certain extent, externally control his condition, knows how to hide it from others, and dissimulate his experiences. Instead of bright affects acute condition in subacute states, anger, tension, and inaccessibility predominate. The delusion of persecution, having lost its boundlessness, variability, imagery, begins to be systematized. The perception of the surrounding world is divided into delusional and non-delusional: specific enemies and well-wishers appear.

Main distinctive feature chronic delusional, hallucinatory or hallucinatory-delusional states lies primarily in the persistence and low variability of the main psychopathological symptoms, i.e. delusions and hallucinations, mental automatisms. Particularly characteristic is the systematization of delirium. Typical for these conditions and relatively low severity affective disorders, in patients an indifferent attitude predominates, “getting used to” the constantly persisting delusions and hallucinations, while orderly behavior often remains without exacerbations of the condition.

Delirium - Diagnosis

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The presence of delusions is an undoubted sign of mental illness with all the ensuing consequences. Therefore, the diagnosis of delusions is very responsible and requires distinguishing it from obsessions, which also represent errors of judgment and are persistent. However, unlike delusions, with obsessions, not only does a critical attitude constantly remain, but the patient struggles with these pathological experiences. The patient strives to overcome intrusive thoughts, fears (phobias), although he does not always succeed.

For correct diagnosis of delusional states and their severity, taking into account the implementation of emergency therapy, the current clinical situation is important, which is associated with the unusually widespread use of psychopharmacotherapy, as a result of which almost all diabetic patients long time(sometimes for years) receive antipsychotic drugs. As a result, the number of mentally ill patients with reduced as a result among the population is increasing. long-term treatment psychopathological (most often delusional) disorders, who spend a long time outside the walls of psychiatric hospitals, live at home, often work in production or in specially created conditions (special workshops, occupational therapy workshops, etc.).
It is due to long-term neuroleptic effects in such patients that the type of progression of the disease decreases, and possibly stops it. However, a deeper remission with a complete reduction of delusions, hallucinations, and mental automatisms often does not occur; they persist, although they lose their “affective charge,” become less relevant and do not determine the patient’s behavior.

Delusional structure in such patients systematized, little changeable, new plot lines usually do not arise for a long time, the patient operates with the same facts, a certain circle of people involved in delirium, etc. Also stable auditory hallucinations, mental automatisms.
Over time, the patient stops responding to persistent disorders and hides them from others. Often in favorable cases, as a result of long-term treatment, elements of a critical attitude arise when patients understand the painful nature of their experiences and willingly undergo treatment. Usually all these patients are not inclined to talk about their mental illness, about systematic treatment with psychotropic drugs, and this is often actively hidden, so doctors and others medical workers You should be aware of this possibility and, in difficult cases, obtain the appropriate information from the regional psychoneurological clinic. The above is very relevant from the standpoint of emergency therapy, when possible exacerbations of the condition should be taken into account both under the influence of exogenous factors and without apparent reason. In these cases, against the background of a chronic, fairly well-compensated state, hallucinations and automatisms intensify, delusional ideas become actualized, affective disorders and agitation increase, i.e. The already described subacute and sometimes acute hallucinatory-delusional states develop.

Urgent Care

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First aid is to ensure safety measures for the patient and surrounding people in case of auto-aggression or aggression. For this purpose, continuous supervision of the patient is organized with persons constantly on duty around him who can keep him from doing the wrong thing. Sharp objects or other things that could be used for attack should be removed from the patient’s field of vision; it is necessary to block the patient’s access to the windows, to avoid the possibility of his escape.

In especially severe cases, the principles of fixation and transportation of patients with impaired mental activity. It is very important to create a calm environment around the patient, not to allow manifestations of fear or panic, but to try to calm the patient down and explain that he is not in danger.

Medical assistance

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It is advisable to administer 2-4 ml of a 2.5% solution of aminazine per 2-4 ml of a 2.5% solution of tizercin intramuscularly (given the ability of these drugs to reduce blood pressure, especially after the first doses, it is advisable to give the patient after the injection horizontal position). After 2-3, the administration of these drugs can be repeated. In the absence of conditions for parenteral administration, aminazine or tizercin should be administered orally at a dose of 120-200 mg on the first day, then the dose can be increased to 300-400 mg.

While continuing to use sedative neuroleptics (aminazine, tizercin) to relieve agitation (if necessary, further increases in doses), anti-delusional and antihallucinatory antipsychotics are prescribed: triftazin (stelazine) 20-40 mg per day (or intramuscularly 1 ml 0.2 % solution) or haloperidol 10-15 mg per day (or intramuscularly 1 ml of 0.5% solution). In case of severe depressive-delusional symptoms, it is advisable to add amitriptyline to the therapy - 150-200 mg per day.

Relief of hallucinatory-delusional arousal and general calming of the patient cannot serve as a basis for reducing doses, much less stopping treatment, since a transition to a subacute state with dissimulation is possible, which requires the continuation of all measures of supervision and treatment.

Hospitalization

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Hospitalization in mental asylum necessary in all cases of acute, subacute conditions or exacerbation of chronic delusional (hallucinatory-delusional) conditions. Before transportation, the patient is administered chlorpromazine or tizercin, sedated, and the precautions described above are observed.

If the treatment route is long, it should be repeated en route. In the case of delusional states occurring with somatic weakness, high temperature(see Infectious delirium), etc., treatment should be organized on site.

Delusional ideas are false, erroneous judgments that arise on a pathological basis, take over the entire consciousness of the patient, and are not amenable to logical correction, despite the obvious contradiction with reality.

Classification of delusional ideas: A. by content (plot of delirium) 1. Delusional ideas persecution(persecution, influence, staging, litigiousness, poisoning, damage, jealousy) 2. Delusional ideas greatness(reformism, wealth, love charm, high birth, invention) 3. Delusional ideas self-deprecation(guilt, impoverishment, sinfulness, dysmorphomania, hypochondriacal delirium)

According to the plot, those. according to the main content of the delusional concept ( system of pathological inferences) in accordance with the classification of the German psychiatrist W. Griesinger, three types of delusions are distinguished: persecution (persecutory), depressive and grandiosity. Each of these types of delusions includes many different clinical variants.

1) Pursuant delirium: actual persecution, poisoning, material damage, jealousy, influence, relationship, witchcraft (damage), possession. The last three concepts (naturally, and some other variants of them, which is associated with the specific ethnocultural characteristics of the patient) constitute the so-called archaic forms of delirium, the content of which directly follows from the ideas existing in society.

Delusional ideas of persecution, especially at the stage of their occurrence, are often accompanied by anxiety, fear, and often act as a determining factor in the patient’s behavior, which can make him dangerous to others and may require emergency involuntary hospitalization. The danger intensifies when the “evil” caused, in the patient’s opinion, finds a specific carrier from the immediate environment.

2) Depressive delirium can occur in the following clinical variants: self-accusation, self-abasement, sinfulness, evil power, hypochondriacal, dysmorphomanic, nihilistic. Each of these options may have its own characteristics and plot. However, they all exist against a background of low mood. Of diagnostic significance here is the establishment of the sequence of appearance of psychopathological phenomena: what is primary – delusional ideas of the corresponding content or a depressive mood.

Depressive ideas can determine the behavior of patients and, accordingly, lead to social danger for the patient (primarily for himself, since attempts at suicide are possible).

The most intense and complex in content depressive delirium occurs during prolonged anxious depression. In these cases, Cotard's delirium often develops. Cotard's delusions are characterized by fantastic ideas of denial or enormity. If there are ideas of denial, the patient reports his lack of moral, intellectual, and physical qualities (no feelings, conscience, compassion, knowledge, ability to feel). In the presence of somatopsychic depersonalization, patients often complain of the absence of the stomach, intestines, lungs, heart, etc. etc. They can talk not about absence, but about destruction internal organs(the brain has dried out, the intestines have atrophied). The idea of ​​denying the physical “I” is called nihilistic delusion. Denial can extend to various concepts of the external world (the world is dead, the planet has cooled down, there are no stars, no centuries).

Often, with Cotard's delusions, patients blame themselves for all sorts of past or future world cataclysms (delusions of negative power) or express ideas about eternal torment and the impossibility of dying (delusions of painful immortality).

3) Delusions of grandeur are always noted against the background of increased self-esteem of the patient and include the following clinical variants: delirium of invention, reformism, high origin, wealth. This also includes the so-called delirium of love (love's charm) and the absurd, usually occurring against the background of severe dementia, megalomanic delirium of grandeur. At the same time, the patient’s statements about his extraordinary abilities, position or activities acquire a grandiose scope, and their inadequacy is striking to any person (“I rule the globe and all the Gods of the universe”). Ideas of grandeur are most often characteristic of more late stages mental illness or for severe, rapidly progressing organic brain lesions leading to dementia.

According to the degree of completeness of the system of delusional conclusions (pathological system of evidence), delirium is usually divided into systematized and unsystematized (fragmentary).

Systematized delirium is characterized by an extensive system of evidence that “confirms” the plot underlying the pathological ideas. All the facts given by the patient are interconnected and have an unambiguous interpretation. As the disease progresses, an increasing number of reality phenomena are included in the delusional system, and the thinking process itself becomes more and more detailed, while the main painful idea is unconditionally preserved. If there is a pronounced systematization of delusions, one should assume a longer, chronic nature of the mental disorder. Acute conditions are often characterized by unsystematized delirium. The same delusion can also be observed with rapidly progressing organic lesions of the brain, when, along with the disintegration of the psyche (the formation of dementia), the previously harmonious system of delusional constructs also disintegrates.

Delirium is also usually divided into the so-called primary and secondary ( although, according to various researchers, this division is conditional).

In primary delusions, the patient's delusional constructions are primarily determined by a disorder in the sphere of thinking, leading to an inadequate interpretation of actually existing phenomena (hence another name for this delusion - interpretive).

Secondary delusions arise on the basis of existing disorders in other areas of mental activity in the presence of other psychopathological phenomena (hallucinations, affective disorders, memory disorders, etc.).

According to the mechanisms of occurrence, the following types of delirium can be distinguished: catathymic, holothymic, induced, residual, confabulatory.

Catathymic delirium is built on the basis of an emotionally charged complex of dominant (in some cases, overvalued) ideas and concepts.

The basis of holothymic delusions (according to E. Bleuler) are changes in the emotional sphere, the content of delusional ideas here corresponds to an altered mood (delirium of love charm when the mood rises in manic state and as a contrast to delusions of self-blame in depression).

With induced delirium, a kind of infection occurs, the transfer of delusional experiences existing in the primarily ill person (inducer) to a person who has not previously shown signs of a mental disorder.

In some cases, the content of delusional ideas among people who communicate closely (and more often live together) may have far-reaching similarities, despite the fact that each of them suffers from an independent mental disorder of various origins. Such delirium (of very different content) is usually called conformal, meaning in this concept only the coincidence of the main plot of delusional constructions with the possibility of a certain discrepancy in the specific statements of each of the sick people.

Residual delirium (according to Neisser) occurs after a state of disturbed consciousness has been suffered and is built on the basis of associated memory disorders (such as “insular memories”) in the absence of any connection with the real phenomena of reality that actually occur after the disappearance of the acute state.

With confabulatory delusions, the content of delusional constructions is determined by false memories, which, as a rule, are of a fantastic nature.

Delirium can also be characterized in terms of stages its development:

delusional mood - experiencing the surrounding world with a feeling of its change and a peculiar expectation of upcoming grandiose events such as impending disaster;

delusional perception - the beginning of a delusional interpretation of individual phenomena of the surrounding world, along with increased anxiety;

delusional interpretation - delusional explanation of perceived phenomena of reality;

crystallization of delusion - completion of the construction of varying degrees of complexity and “logical” sequence of a system of delusional conclusions;

reverse development of delusion - the emergence of criticism of individual delusional constructs or the delusional system as a whole.

Delusional syndromes: A. Paranoid syndrome: represented by a systematized interpretative (primary) delusion, not accompanied by hallucinations or mood disorders, usually monothematic (for example, reformism, invention, jealousy, queralism, etc.) B. Paranoid syndrome: Represented by secondary sensory delusions. Delirium occurs against the background of anxiety, fear, depression, hallucinations, mental automatisms, and catatonic disorders. Therefore, depending on the disorders prevailing in the clinical picture, they speak of: Paranoid syndrome Hallucinatory-paranoid syndrome Depressive-paranoid syndrome Kandinsky-Clerambault syndrome of mental automatisms, etc. V. Paraphrenic syndrome: represented by all manifestations of Kandinsky-Clerambault syndrome (delusions of persecution and influence, pseudohallucinations, mental automatisms) + Megalomaniac delusions (fantastic delusions of grandeur) With schizophrenia, a change is often observed over the years delusional syndromes(dynamics): paranoid -> paranoid -> paraphrenic.