Delusional reality: signs and symptoms of paranoid schizophrenia

This type of mental illness may also be called psychosis or paranoid symptom in medical practice. It is characterized by the presence of delusions in the patient, which are characterized by systematization. The patient is convinced that there is something false. At the same time, the perceived false is devoid of imagination and whimsicality. Among the manifestations there are the following variants of delirium:

• jealousy;
• persecution;
• dysmorphophobia;
• sensations of unrequited love and others.

Often the perceived manifestations are noticeably exaggerated or completely untrue. Diagnosis of the pathology is complicated by the variability of manifestations. Experts identify several of the most common manifestations.

Organic delusional disorder

The specificity of this variant of delusional personality disorder is a serious physiological disorder associated with the presence of focal lesions in the temporal and parietal regions of the brain, temporal lobe epilepsy. A common cause is previous encephalitis. This pathology also includes epileptic psychoses that are not accompanied by impaired consciousness. It is distinguished by specialists as a separate type of pathology.

Often accompanied by hallucinatory-delusional attacks. With them, patients lose control over aggressive impulses. Accompanied by unmotivated actions and other manifestations of instinctive behavior.

At the moment, doctors are not able to accurately determine the cause of the onset of manifestations. Observations have shown that the onset of the disease may be equally associated with bilateral genetic predisposition and damage to specific brain structures. Delusional disorders in this pathology can be acute or transient organic.

Regardless of the type, the onset is characterized by an acute onset, accompanied by symptoms such as hallucinations, perception disorders, and delusions. There is a severe disturbance in everyday behavior. Often the trigger is serious stress experienced by the patient up to 1-2 weeks before the incident.

Features of delirium in women

The disorder may remain undiagnosed for a long time. The woman leads a socially active lifestyle, but looks slightly extravagant and strange. There is a tendency to exaggerate everything, to suspect everyone, to be jealous of a partner, to be overly intrusive and even hostile. And for some time this is perceived by others as a character trait. Even loved ones do not immediately pay attention to this behavior.

The content of delusions is based on lived experience. Information from the outside world is absorbed by the patient and interpreted incorrectly, altered beyond recognition.

There are a number of types of delirium in women:

1. Erotomanic delirium. As a rule, a feeling of love for a celebrity is characteristic. There are attempts to meet the person on whom the psyche is fixated.
2. Delirium of grandeur. Characterized by a belief in the presence of enormous talent and self-importance. Sometimes patients claim that they have made an important discovery, that they have reached unprecedented heights in some area.
3. Delusions of jealousy in women. She torments herself with imaginary images of her partner cheating on her. She suffers and makes others suffer. She knows that she will suffer, but she is looking for new ways to be jealous. At first, ideas about adultery appear sporadically, often against the background of alcohol intoxication. Then questions arise about the details of the alleged betrayal with a demand to admit his guilt, which he promises to forgive. Next comes aggressiveness. This form can continue for years. It is important to remember that this is not jealousy, but delusion, it needs to be treated.
4. Delirium of persecution. Manifested by thoughts about spying on a person.
5. Hypochondriacal delusions. The lady is sure that she is seriously ill. This could be cancer, leukemia, HIV infection, etc. Delusional hypochondria should be distinguished from somatic symptoms of various types of neuroses.
6. Nihilistic nonsense. Somewhat reminiscent of hypochondriacal delusions, but they are even more developed. It may even seem to a woman that his body is disappearing and does not even exist. Sometimes these beliefs are carried further and begin to relate to the “non-existence” of other people and, finally, the whole world.
7. The ravings of a drunk woman. Caused by prolonged consumption of alcoholic beverages. Often observed in a hangover state. There is a feeling that now she will be killed and destroyed. She “sees” the murder weapon, hears threats. While fleeing, he commits life-threatening actions and can injure himself. Patients ask for help and contact the police. Acute alcoholic delirium lasts from several days to several weeks.

Chronic delusional disorder

In chronic delusional personality disorder, persistent delusions become a persistent symptom. It accompanies a number of mental disorders. They can be characterized as:

• schizophrenic;
• affective;
• organic.

A single picture of delirium or a series of interconnected pictures develops. They can last about three months or be lifelong. The forms of the disease are varied. At the moment, experts identify several leading ones:

• Paranoid syndrome, in which delusions are not accompanied by hallucinations. Delusional states change personality, but in this situation they do not have signs of dementia, due to which patients often seem completely normal to others.
• Paranoid syndrome, in this case, delusion fits into a certain system, but is less logical and more contradictory. Hallucinations become persistent. Patients constantly hear voices in their heads. Without treatment, it leaves an imprint on your professional and personal life.
• With Paraphen syndrome, delirium becomes obsessive, fantastic, fictitious.

Determination of the type of condition is carried out only by a doctor. As well as developing a course of treatment.

Delusional disorder treatment

Therapy includes psychotherapy and medication. It is psychotherapy that turns out to be more effective, as it allows you to solve behavioral and psychotherapeutic problems. After the courses, the patient begins to control his condition and behavior. Family therapy becomes a mandatory step.

The pathology is chronic. Long-term remissions are possible. In some cases, complete recovery is noted.

Organic delusional schizophrenia-like disorder

The disorder is not of endogenous origin. Manifestations lead to the formation of a schizophrenic effect. With this lesion, the following is formed:

• pretentious nonsense;
• delusional disorders of a religious type;
• interpretive nonsense.

Hallucinations are a common secondary manifestation. An astatic and depressive-dysphoric affect occurs. During treatment, medications are used that are determined by the physician.

Hallucinatory delusional disorders

With this lesion, a characteristic feature is the presence, in the complete absence of signs of confusion, of pronounced delusional and hallucinatory disorders. Among the differences:

• confusion;
• severe anxiety;
• motor excitations.

All these manifestations are caused by the constant presence of hallucinations, which are short-lived and occur without provoking factors. They have acute and chronic forms. As the hallucinations become chronic, they become monotonous. The patient adapts to his condition and the pathology becomes less visible to others. The individual distances himself from violations.

Acute delusional disorder

Delusional disorder does not have an organic form. Delirium is devoid of bizarreness. The paranoid personality structure becomes a provocateur. The number of confirmed diagnoses increases in families where there are people with schizophrenia. Due to sthenicity, patients often convince others of the reality of delusional manifestations. Patients often suffer from persecution syndrome and change their place of residence. They are inclined to join heretical sects due to religious ideas and ideas of greatness. The object of love is often chosen by famous stage personalities who do not know about the object experiencing love. A factor confirming pathology is the presence of delusional ideas, the duration of which exceeds three months. Delusions and hallucinations do not meet the criteria for schizophrenia.

Affectively delusional disorder

Disorders associated with disturbance of affect, involving disturbances in the emotional state. They include several pathologies, the most well-known of which are bipolar or major depressive disorder. Often characterized by the manifestation of inappropriate emotions.

The classification is divided into several types of disorders:

• depressive spectrum;
• bipolar spectrum;
• manic spectrum.

Doctors often associate the presence of affective delusional disorder with creativity.

Induced delusional disorder

The pathology initially occurs in a person who is part of a close circle of relatives or friends. The patient in this situation becomes only a recipient, transmitting delusional ideas and disorders of the dominant. Moreover, a mental disorder in this “pair” is present only in the dominant personality. The recipient only copies the behavior and thoughts of the leader.

The couple is often isolated from the outside world. Only the recipient maintains minimal contact. The danger becomes the indignation experienced by the dominant when there is excessive adoration. Such relationships can occur in the same family. Recipients are often women. The patient is unable to distinguish between reality and his own view of the world, accepted from the dominant one.

Delusions in paranoid schizophrenia

Delirium, as the main symptom of the disorder, develops in several stages and symbolizes the “heyday” of the disease.

The first stage of its formation is called paranoid. It is characterized by systematized, interpretive delusions. The concept of systematization means that nonsense has a fairly logical, plausible structure. This stage of the disorder is not accompanied by disturbances of perception, such as hallucinations and mental automatisms.

The most common plot (theme) of delusion is the ideas of persecution, greatness and jealousy, invention, and violation of rights. Thus, a patient who lived with his father and became dependent on his sister after the death of his parent began to rave about damage caused to him by his sister. The patient stated that she infringed on him “in everything,” mocked him, took possession of his father’s inheritance and spent his, the patient’s, money.

Typically, the paranoid delusional stage is accompanied by increased activity. That is, if a person shows delusional ideas of jealousy, then he tries hard to expose his lovers, find his rival and deal with him. In the case of delusions of reformism, the patient turns to all sorts of authorities and looks for resources to implement his ideas.

Delusional themes in paranoid schizophrenia can develop gradually, subacutely or acutely.

Its acute development is accompanied by suddenness and unexpectedness in the patient’s behavior. Unreasonable aggressiveness and motor agitation appear. Thinking is disorganized, torn, or the patient develops fear of something, suspicion, anxiety, he literally becomes numb with horror.

The gradual development of delusional ideas does not cause sharp dissonance in behavior. Oddities in the patient's actions and judgments, inappropriate gestures and grimaces, and changes in interests are periodically observed. A person may complain of confusion of thoughts, emptiness in the head, and inability to concentrate.

A delusional thought, before “settling down” in the mind of a paranoid person, goes through several stages:

• expectation - the patient feels internal anxiety, tension. It is accompanied by the feeling that something big is about to happen, shedding light and dispelling darkness;
• insight - suddenly to the patient “everything becomes clear” in his unrealistic ideas. He begins to look at the world with different eyes, and he himself transforms into a different personality. The true, crazy truth is born, shedding light on the previously incomprehensible;
• systematization - this process is similar to making a mosaic. When individual pieces come together and create a complete picture. Delusional themes completely cover a person, filling his thoughts, past, future and present.

Paranoid delusions can persist for quite a long time. In this case, a diagnosis of paranoid schizophrenia is made.

Treatment of delusional disorder

An important feature of therapy is contacting a specialist. Only a high-level professional is able to adequately convince a patient of the unreality of his ideas.

It is for this reason that psychotherapy courses play a leading role:

• individual;
• family;
• group.

During the course, the psychiatrist and psychotherapist jointly develop a course of procedures focused on the characteristics of each individual patient.

In cases where delusional disorders are severe, medications may be prescribed. The main place on this list is occupied by antidepressants and antipsychotics. If possible, the doctor tries to give up medications in favor of folk remedies, physiotherapy, and massages. Patients are recommended to take long walks and exercise. An effective way is to choose a new hobby, a hobby that distracts you from hallucinations and delusional thoughts. Such gentle therapy is recommended in the early stages of pathology.

Basic scenarios of distorted consciousness

Medicine identifies three common scenarios for distorted perception. These are paranoid, paranoid and paraphrenic syndromes.

With paranoid syndrome, hallucinations and adherence to one topic are observed.

Paranoid syndrome is characterized by fixation on one topic; outside of it, a person’s thinking remains undistorted.

Paraphrenic syndrome is characterized by a person’s fanatical conviction and systematic distortion of perception.

Symptoms of delusional disorder

The presence of delusions distinguishes these disorders from schizophrenia. Pathology is characterized by delusional ideas. Disorders associated with delusions of grandeur may appear; the patient may be tormented by attacks of increased jealousy. The list also includes erotomania, litigiousness and other deviations that are not characteristic of the behavior of a healthy person. The appearance of disorders is often associated with some limitations in life activity. For example, emigrants who are forced to constantly be in an unusual social environment, people suffering from hearing loss or vision loss often suffer from pathology.

The disorder rarely has an organic form. Although a connection has been identified with some neurological or oncological diseases.

The diagnostic process takes into account maintaining an understanding of what is happening and the socialization of patients.

Causes of the occurrence and development of the disease

The exact causes of the disease have not been established. It is known that the condition can develop under the influence of the following factors:

• Genetic predisposition. The presence of mental disorders in close blood relatives.
• Endogenous factor. Imbalance of special neurotransmitter substances in the human brain.
• External influences. The “trigger” for the development of pathology can be alcoholism, drug addiction, stress, and failures in personal life.

Delusional disorders in the elderly

The appearance of delusional disorders in the elderly is often associated with traumatic situations associated with the decline of the body. The most common symptom is the idea of ​​damage; ideas of persecution of different directions are formed. There may be unmotivated complaints about the poor attitude of relatives.

In old age, the occurrence of pathology is often associated with an imbalance of substances responsible for transmitting signals in brain cells of neurotransmitters. In old age, patients often suffer from symptoms of several delusional disorders at once. They rarely manifest themselves in an acute form and usually have a chronic course. Auditory hallucinations associated with delusional symptoms often occur.

The course of therapy necessarily includes a combination of medications and psychotherapy. The pathology can be treated quite successfully, but in some situations, doctors may recommend going to a nursing home, where the elderly patient can receive constant care.

A woman is talking nonsense: what to do

Self-medication is usually ineffective. Doctor's help is needed. An integrated approach, including:

• medicinal methods,
• restorative psychotherapy,
• cognitive trainings,
• restoration of social activity,
• training for relatives and caregivers.

The psychiatrist’s task is to “switch” the patient to real phenomena. Treatment is predominantly outpatient, inpatient - in case of a serious patient’s condition and significant adaptation disorders.

Ignoring delusional disorder can lead to problems in the family, social maladjustment, and loss of relationships with loved ones. There is a risk of developing depression and paranoia.

The Leto Mental Health Center provides effective treatment for delirium in women. Our staff has extensive experience working with mental illness. We use all modern methods of therapy and help the most complex patients. Do not delay contacting until later, because the sooner help is provided, the more favorable the prognosis. We work around the clock. Call us now. Just dial 8(969)060-93-93!

Cost of treating delirium:

Involutional delusional psychosis, occurring in the form of acute paraphrenia

Introduction

Involutional delusional psychosis, traditionally designated as involutional paranoid, despite more than a hundred years of history of study, is still a rather vague nosological unit. The long-term “classical” discussion about its nosological independence, development mechanisms, features of the clinical picture and prognosis is well known [6, 12, 14]. The lack of a common point of view on these issues was probably one of the reasons for the exclusion of involutional paranoid (as a separate nosological unit) from modern international classifications of diseases. Nevertheless, the need to continue studying this mental disorder is dictated by the realities of clinical practice. Without occupying the reader's attention with a repeated discussion of controversial issues related to the doctrine of involutional paranoid, this article presents the observation of a disease with a rare (but not casuistic) clinical picture and its analysis.

Patient T., born in 1951 (61 years at the start of follow-up)

Anamnesis from the words of the patient (after recovery) and his wife: none of the relatives contacted psychiatrists. My father was domineering, demanding, a military man, and died of stomach cancer at 71. My mother is tough, strong-willed, and worked as a nurse. Alive. Since the age of 70, she has had memory impairment; she says that “the neighbors’ motors are running, which interferes with sleep,” although she lives alone in a private house. The older sister was soft, kind, sympathetic, and died at the age of 55 from stomach cancer.

Born second child. Natural childbirth. There is no information about early childhood. I went to school at the age of 7. I changed it several times because my parents moved. He easily made friends among his peers. He actively participated in the social life of the school. I studied mediocrely. In high school, I became interested in music, played the guitar, and wrote poetry.

After finishing school he served in the army. He quickly settled into the team. There were several encouragements from the unit commander. After demobilization, he entered the Polytechnic Institute, Faculty of Engineering. I studied by correspondence. He was meticulous in completing tasks. I checked the results of my calculations several times. At the same time as studying, he worked as a mechanic at a garment factory, where he met his future wife. After graduating from the institute, he continued to work at the plant as an engineer. He proved himself to be a responsible worker. Received several thanks from management. Got married. A son was born. He devoted a lot of time to his upbringing.

At the age of 46, he lost his job due to layoffs due to the closure of the plant. I had a hard time experiencing what happened. He told his wife: “It’s all my fault, I should have thought about a new job earlier,” “What should I do now?”, “Who needs me now?” A few months later he found a job again. The condition returned to normal spontaneously. However, he did not stay at work for long. Within 3 years I changed several companies. I quit myself. He explained the reasons for his dismissal by conflicts with his superiors: “We didn’t get along in character.”

At the age of 49, soon after another job as an engineer, I began to sleep poorly, was anxious, and my mood decreased. For the first time I turned to psychiatrists. He was stationed in PB No. 8 in Moscow. Upon admission (according to the discharge summary): “lethargic, asthenized, speaks quietly, slowly, monotonously. Inhibited, answers questions with a delay. Fixed on his painful sensations. The mood is low. Looking for help, sympathy. Ready for treatment." He was hospitalized for a month with a diagnosis of “Mixed anxiety and depressive disorder (F41.2).” He received tianeptine, phenazepam, glycine, bellataminal, and physical therapy. The condition has returned to normal. After discharge I felt well. He took maintenance therapy for a year.

He left the factory and got a job as a driver and forwarder for the publishing house where his wife worked. Since then he has worked successfully in this position. He was engaged in the delivery of newspapers from the printing house to distribution points. In his free time from work, he was engaged in household chores, apartment renovation, and arrangement of a country house. He took care of his elderly mother: he cooked food, cleaned the house, and did laundry. According to his wife, “everything was on him.” Relatives did not note any peculiarities in behavior.

At the age of 59 (a year before re-visiting psychiatrists) he changed. Became “soft”, “sentimental”. I could easily cry, for example, when watching Soviet films about the war. I lost interest in work and spent almost all my time “working in the garden.” He became “absent-minded”, could look for his things for a long time, “forgot” why he went to the store.

At the age of 60 (February 2012) the condition suddenly changed. Became withdrawn. Did not sleep. I cried often. Barefoot, he went outside and got frostbite on his feet. He explained it this way: “I wanted to prove that I can walk in the snow.” He told his wife that he “has a second family for which he is responsible.” He claimed that the “second family” had existed for more than 7 years, but “I just remembered it.” He called a work colleague (a friend of his wife) “second wife” whom he did not know closely. “I remembered” that I have a 14-year-old daughter from my “second marriage.” One evening he became excited, was eager to leave the house, and wanted to go to his “second family.” I asked my wife for a phone number so I could call my “second wife and daughter.” He said that they were “in danger” and “I must visit them and warn them.” Fell asleep after taking diazepam. At the insistence of his wife, he was consulted by a local psychiatrist. Sent to the Psychiatry Clinic named after. S.S. Korsakov. Was hospitalized. He was in the hospital from March 27, 2012 to June 20, 2012.

Mental condition . Neatly dressed. Sits hunched over. Looks older than his age. Doesn't look at doctors. He speaks quietly. He says that “there is a second family, a daughter,” which he “remembered recently.” Starts to cry. He asks: “What should I do now?”, “What should I do?” It takes a long time to calm down. He continues to explain that the “second wife” appeared a long time ago: “I just forgot her, but now I remember.” Calls her name. It is impossible to find out anything more about the experiences on the first day. Over the next few days I began to talk more about them. At the beginning of conversations he speaks only about his “second family,” but over time he talks and describes more and more new and unexpected “biographical facts.” He says that “there is a third wife,” but does not know “if there are children, perhaps a son.” He describes how he worked in Afghanistan during the war: “delivering mail on a tarantass.” “I remembered” that I had been in the department where I was being treated before. Some patients and staff are “familiar” to him. During a consultation with a neurologist, he said that he knew her well. He says that he is a “deeply secret intelligence agent.” He explains his “memories” by saying that “a block was put on his memory a long time ago,” “it is now subsiding, and that’s why I remember everything.” Later he began to say that he was a “famous engineer” and “made discoveries.” For example, he “invented a device for measuring pressure.” He adds: “There is still much to be discovered, perhaps even in psychiatry.” Confident in conversation with the attending physician. However, if an unfamiliar doctor enters the office, he becomes silent. The story continues after explaining that this is also a department doctor. He performs intelligence tests only after repeated explanations of the task, very slowly, and retests himself. When performing counting operations, he asks for a sheet of paper. Performs the calculation “100 minus 28 minus 15” only after recording the task. Correctly draws clock hands indicating the named time. Can display a triangle in a square. When writing, the outlines of letters are uneven. Writes with errors: repeats letters in words, misses letters. For example, the word “to say goodbye” is written “say goodbye” or “say goodbye.” In the department he serves himself. Immediately after hospitalization, he is quiet, secluded, and inconspicuous. He doesn’t communicate with anyone, he doesn’t seek conversations with doctors. A few weeks later he asked doctors to allow him to exercise. I ordered a gym mat and a manual for gymnastics from my wife. I started doing physical exercises every day for one to two hours. For example, lying on his back in a room on the floor, he raised his legs to the ceiling. He took full care of himself, kept his bed and bedside table in perfect order.

Somatic condition . During clinical examination, attention is drawn to a slight increase in blood pressure (130/90 mm Hg) and tachycardia (90/min). Clinical blood test, general urine test, biochemical blood test - indicators are within normal limits. The complex of serological reactions to syphilis is negative. Electrocardiogram - deviation of the electrical axis of the heart to the left, mild changes in the myocardium. Echocardiogram - thickening of the aortic walls, slight insufficiency of the mitral and tricuspid valves, decreased diastolic function of the left ventricle. Color duplex scanning of the brachiocephalic arteries - atherosclerotic changes in the extracranial sections of the main arteries of the head with stenosis of the mouth of the left internal carotid artery by 40%, the mouth of the subclavian artery by 40%, deformation of the course of both vertebral arteries in the canal of the transverse processes of the cervical vertebrae. Consultation with an ophthalmologist - vasospasm, arteriolosclerosis, phlebopathy, initial picture of intracranial hypertension.

Neurological condition . Oral automatism reflex, anisoreflexia (D > S), unclearness when performing coordination tests on the left. Electroencephalogram - no pathological changes were detected. Computed tomography - hypodense areas in the subcortical regions (more on the left), probably of vascular origin; the lateral ventricles are not dilated, the width of the cortical grooves corresponds to age. Magnetic resonance imaging of the brain - vascular lesions in the subcortical regions measuring from 0.2 to 0.4 cm. The subarachnoid spaces of the cerebral hemispheres are expanded in the temporoparietal regions (“signs of atrophy”). Consultation with a neurologist - existing changes in neuroimaging of the brain indicate the presence of vascular damage involving the subcortical regions. There are no signs of the atrophic process. Existing organic changes cannot be decisive for the severity of the patient’s mental state.

Therapy and dynamics of the condition . Considering the patient’s vivid delusional experiences, after his admission to the hospital, therapy with risperidone (up to 6 mg/day) and olanzapine (5 mg/day) was started. Given the lack of positive dynamics and increased intensity of delusional symptoms during 3 weeks of observation, risperidone and olanzapine were discontinued. Therapy with haloperidol (15 mg/day) was prescribed. After 2 weeks, the mental state began to improve, which was manifested by the gradual deactualization of delusional ideas. Before discharge: calm. He doesn’t talk about his experiences: “It’s better not to remember.” When questioned, he answers: “I probably made it up, fantasized it.” He asks his wife for forgiveness “for what happened” and “caused such trouble.” He communicates with her warmly. He wonders if she copes with housekeeping and caring for his mother. After discharge he wants to return to work. In a clinical conversation, no signs of memory and intelligence impairment are revealed. Performs tests correctly. There are no violations when writing. Noteworthy are the signs of neuroleptic syndrome (mild akathisia, hypokinesia), which developed shortly after the administration of haloperidol and required the addition of trihexyphenidyl (10 mg/day) to therapy. 3 months after hospitalization, the patient was discharged with recommendations for dynamic observation by a psychiatrist and maintenance therapy with haloperidol (12 mg/day), trihexyphenidyl (10 mg/day).

Catamnesis . The patient was under outpatient observation at the clinic for a year and a half. During this period, there were no signs of deterioration in the condition. Returned to his previous job. He continued to run the household and finished renovating the house. As before, he looked after his mother. When visiting a doctor: friendly, friendly, polite. He himself does not talk about experiences in the past. When questioned, he calls them “fantasies,” “fiction.” Remembering them, he blushes. He adds that he caused “a lot of trouble for his wife and son.” He willingly talks about his life at home. There are no signs of memory impairment or decreased intelligence. Carefully took the prescribed haloperidol therapy (with a gradual dose reduction to 5 mg/day). Despite the correction of the neuroleptic syndrome with trihexyphenidyl, signs of akathisia and hypokinesia persisted. In conversations, he focused the doctor’s attention on the unpleasant sensations in the hips and restlessness. I was interested in the possibility of stopping treatment. Due to persistent extrapyramidal symptoms, after six months of outpatient follow-up, haloperidol was discontinued. Given the uncertainty of the prognosis in the absence of maintenance therapy, risperidone 1 2 mg/day was prescribed. After changing the treatment regimen, the symptoms of neuroleptic syndrome were avoided without additional administration of trihexyphenidyl. A year after the initial visit, he was re-examined instrumentally and consulted by interns at the Psychiatry Clinic named after. S.S. Korsakov. No significant changes (compared to data from a year ago) were detected in routine tests, ECG, EchoCG, neurological status, or MRI of the brain. Over the next six months after the examination, the mental state remained the same. During this period, neuroleptic therapy was discontinued.

1 The drug “risperidone” was used, produced by a domestic company that has proven itself with a number of antipsychotic drugs (clozapine, sulpiride, tiapride).

Discussion

The described clinical observation is of interest from the point of view of the syndromic and nosological qualification of the psychotic state suffered by the patient. Its structure was dominated by confabulatory delusions and delusions of grandeur (“remembered” the “second” and “third” family, “work” in Afghanistan, his “discoveries”, some of which he still “had” to make). This combination of symptoms (in the absence of clear symptoms of another circle) allows us to qualify the condition within the framework of the confabulatory variant 2 of paraphrenic syndrome. However, its atypicality is of interest. The combination of confabulatory delusions and delusions of grandeur is usually observed within the framework of chronic paraphrenia (with a long course of mental pathology) [9]. In acute paraphrenia, which developed in the presented patient, it is rare. The extreme absurdity of confabulations, devoid of any “intellectual assessment” (“delivered mail on a tarantass”, “invented a device for measuring blood pressure”) is noteworthy. The emotional state of the patient is devoid of vivid manifestations characteristic of paraphrenic syndrome (confusion, complacency, malice). On the contrary, there are obvious signs of hypothymia, which is rarely found in paraphrenic states (he cried, talking about his experiences, “what should I do now?”, “What should I do?”). Its development is explained by the patient’s awareness of a “complex moral and ethical situation” (“the presence” of three families), which indicates the preservation of the personality traits of the same name. In addition to confabulatory delusions and delusions of grandeur, the clinical picture included other symptoms of the delusional register - illusory recognitions (recognized acquaintances among doctors and patients of the clinic), elements of persecutory circle delusions (“the second family is in danger”). However, these symptoms were not decisive for the syndromic qualification of the patient's condition.

Another issue, the discussion of which is important for establishing a diagnosis, is the mechanism of delusion formation. True psychosis developed suddenly with the appearance of delusional ideas without immediate anticipation of other striking mental symptoms. The structure of the delusion did not contain false interpretations and incorrect conclusions (the basis of the primary interpretative delusion), significant disturbances of affect or deceptions of perception (the basis of the secondary acute sensory delusion). Therefore, it is obvious that the traditional understanding of the variants of primary and secondary delusions in Russian psychiatry is unacceptable in this case. In this regard, it is worth turning to the works of French psychiatrists [13, 15], who identified delusion of imagination as one of the variants of primary delusion - a concept rarely used in Russian psychiatry 3 . The mechanism of its development lies not in errors of judgment, but in disturbances in the sphere of imagination. This version of delusion occurs in the form of “fantasies” that are not associated with real events, with clear consciousness, the absence of vivid affect or pronounced deceptions of perception. Delusional ideas are megalomaniac in nature. Patients “state” them without providing “logical” evidence (as opposed to interpretive nonsense). The authors who described delusions of imagination pointed to the phenomenon of expanding the content of delusional ideas with active questioning of the patient. This symptom was observed in the presented clinical observation (“at the beginning of conversations, he talks only about the “second family,” but over time, as he talks, he describes more and more new and unexpected “biographical facts”).

Moving on to a discussion of the nosological affiliation of the described psychosis, it is necessary to note the initial difficulties that arose in the diagnostic process. The atypicality of the disease determined the impossibility of its rapid nosological classification “by recognition” and gave rise to a discussion among the staff of the university clinic. The disagreements, however, were successfully resolved after a thorough analysis of the individual clinical characteristics of the disease (including its outcome), i.e. in the process of making a complete (methodological) diagnosis 4 . The reasons for the initial discussion were: atypical current psychopathological symptoms, periods of development of painful conditions in the past, and the presence of organic changes in the brain identified by neuroimaging. Differential diagnosis was carried out between psychosis within the atrophic process, vascular psychosis, the phase of manic-depressive psychosis and involutional delusional psychosis (involutional paranoid).

The assumption about the atrophic nature of the current psychosis was born from the identification of difficulties when the patient performed logical operations (“performs intelligence tests only after repeated explanations, very slowly, double-checks himself”, “performing counting operations, asks for a sheet of paper”, “performs calculations only after writing down the task "), errors in specific tests ("when writing, the outlines of letters are uneven", "writes with repeated errors: repeats letters in words, makes omissions of letters"), the extreme absurdity of paraphrenic ideas, devoid of any "intellectual assessment" ("delivered mail to tarantass", "invented an apparatus for measuring blood pressure") and data on the expansion of the subarachnoid spaces in the temporo-parietal regions (initially interpreted by radiologists as cortical atrophy). However, the diagnosis of atrophic brain disease was rejected. The reasons for this were: the acute onset of the disease, the absence of obvious signs of intellectual-mnestic disorders before the onset of current psychosis, the refutation by neurologists of neuroimaging data on the presence of an atrophic process and, finally, a favorable outcome (restoration of criticism, the absence of signs of memory and intellectual impairment after the psychosis subsided, complete social readaptation).

The acute onset of the disease, periods of psychopathological symptoms in the past (“asthenization”, sentimentality) and data from instrumental examinations (multiple vascular foci in the brain, changes in the myocardium and great vessels) led to the emergence of an opinion about the possibility of the vascular nature of real psychosis (“catastrophe” in neurologically silent areas of the brain). However, a dynamic assessment of the current mental state did not reveal signs characteristic of vascular pathology - exhaustion of mental processes and wave-like flow. Magnetic resonance imaging data 5 indicated vascular damage only to subcortical structures (with the cortex intact) and the absence of signs of acutely developed cerebrovascular accident. The complete “recovery” of the patient is another piece of evidence that there is no direct connection between the psychosis suffered and the vascular factor.

The point of view about the phase origin of psychosis (manic phase within bipolar affective disorder) was born on the basis of the observation of the presence in its structure of ideas of grandeur in combination with increased physical activity (daily long-term physical exercise). This opinion was confirmed by anamnestic information. A period of psychopathological symptoms in the past, regarded as “mixed anxiety and depressive disorder” (“speaks slowly, quietly,” “inhibited, answers questions with a delay,” “low mood”), could be a manifestation of the depressive phase of bipolar disorder. However, the phasic nature of psychosis was quickly rejected, since its structure was determined by delusional rather than affective symptoms. There were no signs of hyperthymia 6.

The sudden onset of the disease in old age with a predominance of delusional symptoms in the clinical picture became the basis for the assumption that the patient developed involutional paranoid 7 . Doubts in this case were associated with the atypical structure of delusional psychosis, since usually involutional paranoids occur with a predominance of delusions of the persecutory group (harm, persecution, jealousy). However, this contradiction was successfully resolved by referring to literature data. Among involutional delusional psychoses, along with involutional paranoid, there are forms that manifest paraphrenic symptoms (“involutional paraphrenia”) [3, 4, 8, 16]. Delusion formation in these psychoses occurs according to the type of delusion of imagination [9]. An interesting opinion is that moderate vascular pathology, often found in old age, can only be regarded as a disease accompanying “involutional paraphrenia” [3]. Therefore, clinical signs of vascular pathology of the brain that were observed in the patient in the past (“asthenia,” sentimentality) can only be regarded as a background or concomitant disease.

The observation of a favorable outcome of the disease in the presented patient deserves separate discussion. Despite the widespread point of view about the protracted chronic course of involutional psychoses [6, 10, 12], in the described case a drug remission was formed, and then intermission 8 (absence of symptoms of the disease for a year while taking antipsychotics and for six months after their discontinuation). Such a favorable outcome is probably associated with the characteristics of psychopathological symptoms that have a favorable course (acute onset, the mechanism of formation of delusions of the “delusions of imagination” type, the predominance of delusional confabulations and delusions of grandeur, the absence of delusional ideas of the persecutory circle). Indications of a favorable prognosis for involutional paraphrenia are found in the literature.

Thus, the above considerations make it possible to formulate a psychiatric diagnosis for the presented patient as: “Involutional delusional psychosis (“involutional paraphrenia”). Acute paraphrenic syndrome with a predominance of confabulatory delusions and delusions of grandeur. The mechanism of delusion formation according to the type of delusion of imagination. Favorable outcome with the formation of intermission.”

2 A novice specialist will be interested in the fact that various forms of paraphrenia [systematized (systematic), expansive, confabulatory (confabulating) and fantastic] were identified by E. Kraepelin [5]. In 1912, in his new classification of mental disorders, he proposed to consider them separate diseases, separating this pathology from schizophrenia. Subsequently, E. Kraepelin’s classification was used to designate types of paraphrenic syndrome [1,2]. 3 It is necessary to note the identification by some domestic authors of delusions of imagination and paraphrenic or confabulatory delusions [7]. It does not always seem to be legal. For example, the development of chronic paraphrenic syndrome during a long course of schizophrenia cannot be explained only by the mechanism of delusion formation like delusion of the imagination. Simultaneously with the emergence of a new “primary” confabulatory delusion (a development mechanism similar to delusions of imagination), the collapse of the “old” delusional system of the persecutory circle is completed (a development mechanism similar to delusions of interpretation). This is probably why some authors note the conventional correspondence between the terms “delusion of imagination” and “paraphrenic” or “confabulatory” delusion [9]. Others talk about the possible interweaving of various forms of delusional formation during the development of one or another delusional syndrome [11]. 4 Nevertheless, the authors are ready to continue the discussion if new points of view appear after the publication of the article. 5 The study was carried out only a month after the patient’s hospitalization due to temporary limitations of technical capabilities. 6 Obviously, complete restoration of mental health (in fact, intermission) after the psychotic state has passed in this case cannot be a reliable criterion for diagnosing bipolar affective disorder. 7 The authors leave outside the scope of this article the discussion about the possible association of involutional paranoids with late schizophrenia. However, it is still worth noting the absence in the presented observation of signs necessary for diagnosing the schizophrenic process (impaired thinking, schizis phenomena, symptoms of mental automatism, emotional-volitional personality changes, signs of progression of the disease). 8 In this case, we do not use the term “recovery”, since it is impossible to assert that the state of mental health will persist throughout the patient’s life. This issue can only be resolved with long-term follow-up observation.

Bibliography

1. Gilyarovsky V.A. Psychiatry: a guide for doctors and students. - M.-Leningrad: State Medical Publishing House, 1931. - 660 p. 2. Gilyarovsky VL. Psychiatry: a guide for doctors and students (fourth edition]. - M.: Medgiz, 1954. - 520 pp. 3. Zhislin S.G. Essays on clinical psychiatry. - M.: Medicine, 1965. - 320 pp. 4. Zhislin S.G. The role of age-related and somatogenic factors in the occurrence and course of some forms of psychosis. - M.: GNIIP, 1956. - 226 pp. 5. Kannabikh Y. History of psychiatry (reprint edition). - M.: TsTR MGP VOS, 1994 - 528 pp. 6. Kontsevoy V.A. Functional psychoses of late age // Guide to psychiatry (ed. A.S. Tiganov]. - T.1. - M.: Medicine, 1999. - P. 667-685 7. Morozov V.M. On the issue of delusions of imagination (abstract of the report] // Selected works. - M.: Media Medica, 2007. - P. 105-106. 8. Morozov V.M. Presenile psychoses (involutional paranoid ] // Selected works. - M.: Media Medica, 2007. - P. 259-271. 9. Morozov G.V., Shumsky N.G. Introduction to clinical psychiatry. - N. Novgorod: Publishing House of NGMA, 1998. - 426 pp. 10. Polishchuk Yu.I. Functional psychoses of late age // Psychiatry: a reference book for a practical doctor (ed. A.G. Hoffman]. — 2nd ed. - M.: MEDpress-inform, 2010. - 608 p. 11. Tiganov A.S. General psychopathology: a course of lectures. - M.: Medical Information Agency LLC, 2008. - 128 p. 12. Shumsky N.G., Shakhmatov N.F., Predescu V. Mental illnesses of presenile and senile age // Guide to psychiatry (ed. G.V. Morozov]. - T. 1. - M.: Medicine, 1988 . - pp. 558-609. 13. Dupre E., Logre M. Les delires d'imagination // L'Encephale. - 1911. - No. 6. - P. 209. 14. Ruffin H. Aging and psychoses of late age // Clinical psychiatry (ed. G. Grule, R. Jung, V. Mayer-Gross, etc.]. - M.: Medicine. 1967. - pp. 780-805. 15. Serieux P., Capgras J. Les Foliesraisonnantes, le delire ^interpretation. - Paris: J.-F. Alcan, 1909. - P. 161. 16. Serko A. Die involutionsparaphrenie // Monatsschrift fur Psychiatrie und Neurologie. - 1919. - No. 5. - S. 245 -286; 334-364.

An involution delirium effect in a form of acute paraphrenia

Danilov DS, Tulpin YG, Lukianova TV, Morosova VD

SUMMARY : A clinical observation of a rare variant of involution delirium psychosis in a form of acute paraphrenia with a delirium-forming mechanism by a fantasy delirium type and a favorable outcome is represented. An analysis of the case described and its comparison with literature data is listed. Syndromal qualification of a patient's state is conducted. A delirium-forming mechanism is analyzed. Nosological affiliation of the observation represented is discussed in a differential-diagnostic aspect.

KEY-WORDS : involution paraphrenia, acute paraphrenia, imagination delirium, confabulation delirium, haloperidol, risperidone.

CONTACT