Delusion

DELUSION, a term having two different meanings in psychiatry: 1. Delirium (delirium), a psychopathological symptom complex characterized by a dream-like state of consciousness, greater or lesser incoherence of thought, and vivid, primarily visual, hallucinations experienced as undoubted reality. Due to the impairment of consciousness, the richness and theatricality of the hallucinations, the patient loses the ability to perceive reality correctly and interprets its phenomena exclusively in the sense of his pathological experiences. The latter are for the most part distinguished by inconsistency, even absurdity, and are not recognized by the patient for the same reason that a sleeping person cannot critically relate to his dreams. Delirium differs from dreaming by a lesser (in most cases) depth of impairment of consciousness, a bright and vivid affective coloring, and an increased striving for activity in the spirit of the affects experienced by the patient. Delirium finds its clinical expression most often in the picture of febrile (or infectious) delirium (delirium febrile) or delirium tremens (delirium tremens) and other intoxication psychoses, but it can also occur episodically in many other psychiatric diseases. According to Bonhoeffer, delirium represents one of the most characteristic forms of the so-called exogenous type of reaction. The duration of delusional states of the described type is short. 2. Delusion—a collection of delusional ideas, thoughts clearly contradicting reality, which, having arisen in a pathological manner, predominantly from the emotional needs of the patient, concern, primarily, his personality and, having turned into an irrefutable conviction, do not yield to correction by logical arguments and other types of psychiatric influence. Delusional ideas are encountered in almost all forms of psychiatric diseases. According to content, one can distinguish the following types: a) Delusion of grandeur—the patient considers himself rich, occupying a high post, a great scientist, poet, or inventor, etc.; b) Delusion of self-abasement, sinfulness, impoverishment—own thoughts seem dirty to the patient, he himself is a criminal, all the evil of the world is embodied in him, his presence brings misfortune and ruin to everything around him; he is a beggar, his family is ruined, etc.; c) Hypochondriacal delusion—the patient is infected with disgusting diseases, his internal organs are rotting, his whole body is filled with pus, his heart is ceasing to work, the intestine is not working at all and feces fill all the cavities, the esophagus and stomach have grown over and do not let food pass, etc.; d) Nihilistic delusion—the patient lacks internal organs, he has died, he does not exist at all; people and objects are only an appearance; e) Delusion of persecution—the patient is being followed, they are preparing to arrest him, they are conspiring to kill him; he is the object of persecution by mysterious gangs, sects, or parties; varieties of the delusion of persecution are: f) Delusion of damage (violation of interests)—the patient is intentionally ignored, his achievements are appropriated, his legal rights are violated (litigious delusion), his love intentions are interfered with, his wife is cheating on him (delusion of jealousy), etc.; g) Delusion of external influence—the patient is being influenced by hypnosis, he is forced to carry out someone else's will, an electric current is passed through him, his brain and internal organs are emptied, his semen is pumped out, women are being raped, etc.; close to this group are: h) Delusion of possession—by divine power or an evil spirit; i) Delusion of bodily transformation—into animals or inanimate objects. Also distinguished are: j) Erotic delusion—the patient believes that a person of the opposite sex, most often occupying a higher social position than himself or distinguished by special beauty, is not indifferent to him; the question of marriage with her has already been decided (or she strives to enter into a relationship with him, apart from marriage); sometimes the fact of allegedly past sexual relations with her is asserted; k) Religious delusion—for the most part differs only by a certain coloring of statements, which are easy to attribute to other categories; thus, for example, thoughts that the patient is the son of God (if a woman, then the Mother of God), a prophet, or a saint can be attributed to ideas of grandeur; opposite ones, for example, identifying oneself with Satan, the Antichrist—to the delusion of abasement and sinfulness; l) Sometimes delusion takes the form of cosmic constructions—the end of the world is coming, the Last Judgment, an astronomical catastrophe, a war of unprecedented grandeur is underway, or the course of world history immediately acquires a prosperous direction, class contradictions are resolved, paradise is established on earth. Of course, there is much that is artificial in dividing delusion by its content into types: the same delusional statements can be attributed simultaneously to different categories. As a general rule, the source of delusional ideas is the desires and fears of patients, which, by coloring certain series of representations (complexes) with one affect or another, concentrate the psychiatric activity of the patient on the latter, in particular, the work of his intellect, which in such cases easily ceases to reckon with the data of experience. This kind of thinking was called catathymic by H. W. Maier; in a number of features, it approaches primitive (as well as autistic, see Autism) thinking. According to Kraepelin, the state of dependence of primitive man on the strength and power of the surrounding nature creates a superstitious attitude toward reality. Uncertainty and fear of something unclear, as if hidden, whether it threatens danger or promises happiness—is the soil for superstition. Here, the decisive influence of feeling clearly emerges everywhere. An auxiliary means, facilitating the explanation of the external world for primitive man (and a child), is reasoning by analogy. Knowledge acquired in this way possesses for him equal and even greater certainty than knowledge based on experience. Some accidental hint, a distant or purely external similarity are accepted without reasoning as a manifestation of reality and are fixed, despite gross internal contradictions; thus, the certainty arises that together with a lock of hair of a smart person, his intelligence is also acquired, that one can kill an enemy by destroying his portrait, that disease and death are sent with the help of witchcraft. Such thinking, guided only by fear and hope, desire and expectation, is alien to doubt—this engine of all higher psychiatric development. The mechanisms of primitive thinking are repeated especially closely in the so-called delusional relations, to which a striving for symbolic interpretation of the most insignificant events is often characteristic. Delusional relation is called the tendency of patients to perceive what is happening around them as standing in some special connection with their personality. Everything appears to them in some special mysterious light, the behavior of people seems suspicious, inspiring fear, and having special significance. The patient thinks that he is the center of universal attention, sees a mysterious meaning in everyday things. It seems to him that passersby on the street are whispering about him, the flight of birds signifies his great future, a casually noticed gesture points to a threatening danger, etc. In all these cases, the conviction of a real correlation of things arises with irresistible force where only the patient's representations of them coincide; in other words, a loose psychiatric connection of representations leads to the thought of a real dependence of phenomena. Catathymic thinking, however, not only uses the path of symbolic interpretations, but often sets in motion those means to which a person blinded by persistent and prolonged passion so willingly resorts, defending his prejudices and preconceptions, namely, crooked logic and one-sided selection of arguments. Sometimes the direction in which the development of delusion goes is determined not by an affect connected only with certain representations, but by a general pathological mood prevailing in the patient; thus, in depressions, the latter is colored for a long time by the affect of melancholy in gloomy tones; in connection with this, sometimes an indefinite feeling of guilt develops first, and then—a delusion of self-accusation, self-abasement, and sinfulness. This type of development of delusion is distinguished by Bleuler from the catathymic, assigning to it the name holothymic. Here, besides the depressive, one must first of all include the so-called expansive delusion formation, i.e., based on an elevated, joyful mood (primarily delusion of grandeur in some of its forms). No matter how strong and deep the affect determining the development of delusion may be, it alone cannot explain the emergence of this mysterious phenomenon. Kraepelin therefore emphasizes that at the heart of the development of a delusional idea, a general disorder of the psychiatric state usually lies. Fluctuations in the emotional sphere, in his opinion, only turn dormant hopes and fears into representations that become a delusion and acquire a force against which even evidence cannot withstand, only due to the patient's loss of the ability for criticism. Here, Kraepelin for some cases brings to the fore the role of impairment of consciousness, for others—the significance of what he calls: psychiatric weakness. The first factor must be assigned a particularly large role in explaining the emergence of delusional ideas in delirious patients (see above—Delirium), who submit to the brightness of sensory deceptions and the affect of fear only because their consciousness is at a level that deprives them of the ability to discover contradictions in the images appearing to them.

As for the second moment, it can be discovered at the basis of the development of the most diverse forms of Delusion: in some cases, as so-called psychic infantilism; in others, in the form of more or less pronounced formal disorders of the intellect (fragmentation of thought in schizophrenia, more or less deep quantitative disturbances of the associative process in phases of manic-depressive psychosis, primarily developing sharp weakening of criticism in progressive paralysis, etc.). It must be added that the main cause of the emergence of Delusion in cases of this kind is, after all, not psychic weakness in itself, but the various states of cerebral excitation accompanying it, which, apparently, cause in patients a tendency toward fantasizing. Of clinically important significance is the division of Delusion according to the character of its construction into systematized and incoherent. The first represents a more or less consistent system of thoughts flowing from some one erroneous idea, closely connected with the personality of the patient and dominant in his consciousness (overvalued); it develops gradually as a result of a peculiar, but psychologically understandable development of the personality, by way of emotional processing and interpretation by it of the data of life experience (see Paranoia). Incoherent delusion in its extreme forms consists of fragmentary and often mutually contradictory absurd thoughts arising in the consciousness in an incomprehensible manner (autochthonously) (such, for example, is the fragmented delusion of schizophrenics). These two extreme types of Delusion, although fundamentally and deeply different from each other, are, in reality, connected by a multitude of transitional forms. Distinguishing them is often helped by establishing the presence or absence at the basis of the Delusion of any non-logical pathological phenomena (e.g., hallucinations). In true forms of systematized Delusion, such phenomena are almost never encountered. Formal analysis of delusional ideas and psychic states in which they are produced has so far yielded very little. G. Specht distinguishes in delusion the material (memories, perceptions, hallucinations, on the basis of which it is built), the fable, the form (systematized or incoherent, fantastic or close to reality), and the direction (this concept allows one to distinguish delusion of grandeur or abasement, depressive and expansive delusion-formation, etc.). Jaspers separates true delusional ideas, arising in consciousness in a primary and psychologically inexplicable manner, from thoughts that, although having a delusional character (wahnhafte Ideen), develop in an understandable manner from affects and other experiences (even from hallucinations). It must be said that this division, essentially coinciding with Wernicke's division into primary and secondary, or explanatory, delusional ideas, only introduces confusion. Any Delusion can to a certain degree be subjected to psychological explanation; not a single case of it can be understood to the end. Furthermore, a Delusion that, upon formal analysis, appears to flow from hallucinations (e.g., from the content of voices heard by the patient), for the most part does not represent their actual consequence at all, but merely another manifestation of one and the same pathological process, which, on the one hand, causes delusion in the consciousness, and on the other, clothes the latter in the plastic form of hallucinatory experiences. Jaspers proposes to distinguish from one another delusional perceptions, delusional representations, and delusional awareness (Wahnbewusstheiten). Of these three groups, only the last is of some interest. The fact is that during acute psychoses rich in experiences, there are moments when, for the patient, suddenly, as if by an epiphany, there arises a consciousness colored by a feeling of unshakeable conviction that colossal world events are occurring, a consciousness that, however, contains no sensory images of what is happening (neither illusions, nor hallucinations, nor any vivid representations whatsoever). Delusion represents a symptom observed in the most diverse psychic diseases and is an expression of the totality of abnormal brain activity, and not the result of damage to any isolated function of it; therefore, the material bases of its emergence are completely different in different cases. It can be said that its development is always due to one or another disorder of the processes determining the direction of associative activity. To explain the property that is most striking in delusional ideas—their logical contradictoriness and incorrigibility—Wernicke proposed the theory of "sejunction," which he, however, extended also to the emergence of psychopathological symptoms in general. According to this theory, the disease primarily produces a loosening in the system of associations, a rupture in it of a series of connections, to which, naturally, a series of deficits must correspond. The circumstance that a person is not aware of contradictions in his statements indicates a disturbance of the connections linking all higher neuro-psychic processes into a single whole. Adjoining the theory of sejunction is Bleuler's theory of the weakening of the tension of associations, which seeks to explain incorrect logical conclusions by the slippage of associative processes from the paths laid out for them due to a weakening of the energy driving these processes: becoming looser and gaining greater freedom, associations easily deviate to the side from the correct path under the influence of affective impacts. The stated theory, even in the more modern form proposed by Bleuler, has evoked a number of objections and is far from supported by everyone. Furthermore, its significance is also weakened by the fact that it was proposed for the explanation exclusively of schizophrenic disorders. As for attempts at a reflexological interpretation of Delusion (Lenz), they are as yet completely undeveloped and, in the form in which they are proposed, do not yet provide guiding threads for penetrating into the essence of the changes in brain mechanics in patients with delusional ideas. Thus, on the question of the physiological pathology of Delusion, modern psychiatry is forced to limit itself only to the general indication that this phenomenon, apparently, is not connected with any limited cerebral localization, but represents an external expression of the most diverse pathological processes in the brain, sometimes grossly anatomical, sometimes only functional, the common feature of which is a disturbance in the activity of the mechanisms determining the direction and content of our thinking. The forensic psychiatric significance of Delusion is determined by the circumstance that the latter almost always exerts a more or less significant influence on the behavior of the personality. Delusional ideas with a negative affective coloring, e.g., Delusion of persecution, can particularly easily lead to the commission of violent acts. French psychiatrists have even distinguished a separate group of patients who themselves became persecutors of the persons with whom they associated their Delusion of persecution (persecutes persecuteurs). But other forms of Delusion, e.g., erotic, also often lead the patient to a collision with the norms of behavior established by society. As a general rule, it must be noted that a Delusion is the more effective, the more stable and systematized it is. Therefore, patients with a relatively well-preserved intellect are often more dangerous than those in whom there are phenomena of psychic decay. Of course, crimes committed under the influence of delusional ideas cannot be imputed to the patients who committed them; however, in the event that the Delusion retains its strength, the court has to take measures to prevent the repetition by the patient of anti-social acts, e.g., by placing him for compulsory treatment in a psychiatric hospital.

P. Zinovyev. Acute delirium (delirium acutum), a term uniting cases of acute mental disorder that are heterogeneous in pathogenesis, with an extremely violent course, usually ending in death. Acute delirium develops most often in connection with infections, but can also be an episodic manifestation of another mental disease (e.g., progressive paralysis). In both cases, it depends on the extremely sharp action of toxins (predominantly infectious) on the brain tissue; since such a disease often unfolds on the basis of infections that are not distinguished by particular malignancy (angina, influenza, etc.), one must admit that there are additional factors, not yet fully clarified, that determine the severity of the disease; apparently, congenital or acquired disability of the brain or its vessels is of significance. Acute delirium is clinically characterized by sharply expressed psychomotor agitation. Patients are restless, jump up, strive to go somewhere, perform aimless movements, speak a lot and incoherently, shouting out individual words or fragments of phrases. Consciousness is clouded, patients are disoriented, hallucinate, express fragmentary delusional ideas, refuse food, suffer from insomnia; t° rises, pulse and respiration quicken. Sometimes convulsive phenomena of an epileptiform nature are observed, especially before death. Usually, patients die within 1-2 weeks, and sometimes a few days after the onset of the disease. Acute delirium differs from ordinary delirious states observed in connection with infections by its particularly violent course, the sharpness of manifestations, the rise in t° (independent of the direct action of the infection), and its malignancy. Pathoanatomically, a number of phenomena are observed indicating an inflammatory lesion of the brain. The meninges and brain substance are hyperemic; microscopically, small hemorrhages are noted in the cortex and other areas of the brain, lymphocytic infiltration in the pia mater and in the adventitia of the vessels, sharp changes in nerve elements with melting of the protoplasm around the nucleus and subsequent death of cells, proliferation of glia and, especially, its amoeboid transformation, which is always a reaction of brain tissue to catastrophically sharp impacts of pathogenic agents.

M. Gurevich.