Delusional ideas: to whom do they come to mind and why?

If ideas are a form of mental representation of objective reality, then delusional ideas are defined as subjective concepts and beliefs that do not correspond to the really existing interconnections of phenomena. This is a distorted reflection in the mind of certain aspects of reality and situations, which, as a rule, do not go beyond what is possible.

The formation of false representations indicates certain violations of thinking processes that have special diagnostic significance: in almost all cases delusions arise in schizophrenia and manic episodes of bipolar disorder or affective psychosis.

[1], [2], [3]

Epidemiology

Reduction of the epidemiology of delusional disorders is limited and not systematized. According to the American Journal of Neuropathology, the prevalence of delusional disorder is estimated at about 0.2%, which is significantly lower than the incidence of schizophrenia (1%) and mood disorders (5%).

According to British psychiatrists, at the first episode of psychosis, psychotic depression is diagnosed in 19% of cases, schizophrenia - in 12%, a constant delusional disorder - in about 7% of patients treated.

In men, paranoid nonsense is more likely to develop, and for women, crazy ideas of erotic subjects. The average age of onset of the disease is 45-55 years, although this condition can be observed in young people. But, nevertheless, it is more common among the elderly, including at least 57% women.

[4], [5], [6], [7], [8]

Causes of the crazy ideas

In modern psychiatry, the causes of delusional ideas - as well as obsessive and overvalued ideas - are associated with a violation of the cognitive structure of thinking, its orientation (content), associativity and logic. That is, the ability to identify and perceive a logical connection between elements of incoming information is partially lost, giving way to building its own "chain" of subjectively isolated and falsely meaningful facts, additionally distorted by inadequate associations.

Experts argue that the key violation of thinking in delusions is the deformation of his personality-motivational component, and this leads to false interpretations of the inner state of the individual and self-esteem, as well as interpersonal and social connections - with inadequate conclusions about their causes, motives and consequences.

As a possible mechanism for the appearance of delusional conclusions one of the neuropsychological models of the development of schizophrenia and paranoia is considered. It is a model of cognitive bias (or motivated defensive delusion), the meaning of which is that in people with a hypochondriac psychotype, anomalies in the form of delusional ideas serve as a defense against thoughts that threaten their idealized self to preserve self-esteem. Positive events are attributed to oneself (which indicates a decrease in the criticality of thinking), whereas all negative in life correlates only with external influences, and the person always considers the circumstances and surrounding people to be the cause of his personal difficulties.

By the way, according to most psychiatrists,  delusional disorder  and delusional ideas in schizophrenia are not identical states, since cognitive deficits and emotional-behavioral inadequacies are more pronounced in schizophrenia, and the thematically bizarre delusions have a volatile (fragmentary) character.

Risk factors

The main risk factors for the appearance of crazy ideas are:

• background influences of temperament and personality;
• stress and traumatic situations (divorce, loss of employment, recent immigration, low socioeconomic status, celibacy among men and widowhood among women);
• alcoholism and drug addiction;
• use of psycho-stimulating substances;
• damage to the brain due to craniocerebral injuries;
• syphilis of the brain and other infections affecting the brain structures;
• some types of epilepsy;
• neurodegenerative diseases -  Parkinson's disease  and Alzheimer's disease;
• cerebrovascular pathologies (cerebral blood flow disorders), in particular, cerebral amyloid angiopathy (leading to weakening and rupture of the brain vessels), subcortical microcirculation of the brain, ischemic stroke and cerebral infarction.

[9], [10], [11], [12]

Pathogenesis

To clarify the pathogenesis of this mental disorder, research is under way. In particular, a certain role of the genetic predisposition to the emergence of persistent delusions has already been recognized, especially if there are patients with a personality disorder or schizophrenia in the genus.

According to recent studies by geneticists and scientists in the field of cognitive and experimental psychology, in many patients with delusional disorders, polymorphism of dopamine receptor genes (D2) on the membranes of dopaminergic and postsynaptic neurons has been revealed. These receptors ensure the inhibition of signals reaching the neurons, and their genetic anomaly may be affected by the dopamine neuromodulation system of the brain.

In addition, the possibility of accelerated oxidation of this important endogenous neurotransmitter with the formation of quinones and free radicals that have a toxic effect on the cells of the cortex of the cerebral hemispheres and other brain structures is not ruled out.

Although crazy ideas are most often associated with mental disorders, they can occur with neurodegenerative processes associated with a reduction in the number of neurons in the brain. Thus, in elderly and senile patients with  dementia, presenile and senile psychosis, there is a combination of depression with delusions, the appearance of which is due to damage to the right hemisphere of the brain, calcification of the basal ganglia, hypoperfusion of the parietal and temporal lobes, and disorders of the limbic system of the brain.

[13], [14]

Symptoms of the crazy ideas

Psychiatrists view the symptoms of delusional ideas as part of the diagnostic criteria for schizophrenia, delusional or  bipolar affective disorder  (during the mania stages). Obsessive delusional ideas can be one of the symptoms of a paranoid personality disorder.

In the formation of a delusional idea, stages such as:

• emotional tension with mood changes, reflecting total changes in perception of the surrounding reality;
• search for new links and the meaning of non-interconnected events;
• increased feelings associated with a sense of involvement in everything that happens around;
• the formation of a new "psychological set" (retrospective falsification or delusional memory) after the final strengthening of an unshakable belief in the truth of their false notions;
• the appearance of a psychologically uncomfortable state close to the autistic, that is, there are difficulties in communication, social communication and social interaction.

Although at first people who develop delusions tend not to show noticeable violations in their daily lives, and their behavior does not provide an objective reason to consider it bizarre.

The first signs are manifested by an unreasonable change of mood. Affect is consistent with delusional content (increased anxiety, feelings of hopelessness or helplessness, suspiciousness and distrustfulness, suspiciousness or resentment). Regardless of the type of delusional ideas, there may be dysphoria - a gloomy mood and angry irritability.

Because of the characteristics of the emotional state, speech, eye contact and psychomotorics can be affected. But the memory and the level of consciousness are not violated.

Somatic type of delusional ideas can be accompanied by tactile or olfactory hallucinations; auditory or visual hallucinations are characteristic of more severe psychotic disorders, for example, schizophrenia.

In chronic alcoholism with delusions of persecution, verbal alcoholic hallucinosis is observed  .

One should keep in mind the peculiarity of such violations: people who suffer from delusions show absolute certainty about their correctness and do not even perceive the obvious evidence of the opposite.

The content of delusions

Types of false conclusions in psychiatric patients are usually classified according to their subject (content). For example, the content of delusional ideas in schizotypic disorder and paranoid syndrome concerns outside control (the person is convinced that the external force controls his thoughts or actions), his own greatness or persecution.

In domestic clinical psychiatry, as well as in the diagnostic manual of the American Psychiatric Association for Mental Disorders (DSM-5), the following are the main types (types) of delusional ideas.

Delusional ideas of persecution are considered the most common. In these patients, patients are extremely suspicious and believe that someone is following them, wanting to cause harm (deceive, attack, poison, etc.). Moreover, such delusional ideas in schizophrenia lead to a reduction or complete cessation of the social functioning of the personality, and in cases of delusional disorder, delirium of persecution differs in systematization and consistency, and such people often write complaints to various instances, trying to protect themselves from "intruders".

Delusional ideas of jealousy (morbid or psychotic jealousy,  delirium of jealousy ) are pursued by a spouse or sexual partner who is convinced of treason. Obsessed with delirious jealousy controls the partner in all ways and everywhere looking for "proof" of infidelity. This disorder can be diagnosed in connection with schizophrenia or bipolar disorder; it is often associated with alcoholism and sexual dysfunction; can provoke violence (including suicide and murder).

Erotic or love crazy ideas boil down to the patient's false confidence that another person, usually of a higher status, experiences a feeling of love for him. Patients can try to communicate with the object of their lust, and the denial of this feeling on his part is often misinterpreted as a confirmation of love.

Delusional ideas of greatness are expressed in the conviction that an individual possesses exceptional abilities, wealth or fame. Experts attribute this type to the symptoms  of megalomania, narcissism, as well as schizophrenia or manic episodes of bipolar disorder.

Reference delusions or crazy ideas of the relationship consist in projecting personally everything that happens around a person: the patients believe that everything that happens is somehow connected with them and has a special meaning (usually negative).

This type of irrational beliefs makes a person shut up in themselves and refuse to leave the house.

Somatic delusions are associated with the concern of their body and usually consist of erroneous beliefs about physical disabilities, incurable diseases or infection by insects or parasites. Sensory experiences, for example, the sensation of parasites creeping inside, are considered as components of a systematized delusional disorder. Such patients are usually seen for the first time by dermatologists, plastic surgeons, urologists and other doctors, to whom they refer.

In addition, there are:

• Delusional ideas of harm relate to the belief in the constant theft of a person's personal belongings, money, documents, products, kitchen utensils, etc. In theft, everyone can suspect, but, first of all, relatives and neighbors.
• delusional ideas of control or influence - the belief that feelings, thoughts or actions are imposed on a person by some external force that controls them;
• delusional ideas of self-abasement - a false belief that a person does not have any abilities and is not worthy of even the most ordinary household amenities; manifested in the form of a targeted abandonment of all kinds of comfort, normal food and clothing. Characteristic combination of depression with delusions of self-deprecation;
• the delusional idea of guilt and self-flagellation makes one think that he is bad (unworthy), claiming that he has committed an unpardonable sin. It is also common in depression and can be pushed to suicide.

With a mixed type of false beliefs, the patient manifests more than one delirious idea simultaneously without an obvious dominance of any of them.

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Complications and consequences

These disorders of thinking have serious consequences and complications, which manifest themselves as:

• - deep emotional depression;
• aggression and attempts at violent actions against others (especially in cases of delusions of jealousy);
• exclusion;
• spreading crazy ideas to more people or situations;
• persistent violation of logical thinking (alogy);
• partial disorganization or catatonic behavior.

Diagnostics of the crazy ideas

How is the diagnosis of delusional ideas diagnosed and delusional disorder manifested? First of all, on the basis of communication with the patient (with the help of special techniques) and his complete anamnesis, the doctor should be convinced of the presence of the corresponding symptomatology, because the patients themselves are unable to recognize the presence of the problem.

When the diagnosis is made, certain criteria for the identification of pathology are followed (including the diagnostic criteria of DSM-5). The duration of the disorder, the periodicity and the forms of its manifestation; the degree of plausibility of delusions is estimated; reveals the presence or absence of confusion, marked disturbances in mood, excitement, distortion of perception (hallucinations), physical symptoms; the adequacy / inadequacy of behavior is determined.

Specific laboratory tests for the diagnosis of this condition does not exist, but - in order to exclude physical disease as a cause of symptoms - blood tests, as well as instrumental diagnostics, may be required. Basically, this is a computer or magnetic resonance imaging of the brain, which allows you to visualize the damage to its structures that cause CNS diseases.

Differential diagnosis

Especially important is differential diagnosis. According to psychiatrists, it is easiest to identify delusional ideas in schizophrenia (they are always bizarre and absolutely not believable), but it is difficult to distinguish delusional disorder from obsessive-compulsive or paranoid personality disorder. And it is necessary to differentiate the delusional idea from obsessive and overvalued (overvalued or dominant).

Distinctive characteristics of obsessive states from delusional ideas consist in the ability of patients to think rationally about their condition: obsessive ideas cause them anxiety and confidence in their painful origin. Therefore, patients with obsessions, in order not to discredit themselves, are not inclined to talk about their experiences to random people, but are quite frank with the doctor to whom they turn for help. However, clinical observations show that in some cases  obsessive-compulsive disorder  or obsessional neurosis and a delusional idea, that is, their simultaneous presence in patients, it is possible - when patients try to find a justification for them.

Supervalued ideas are extremely rarely strange and concern the usual and plausible aspects of the reality and life circumstances of a person. Such ideas are egosyntonic (perceived positively) and are considered a boundary condition. A pathology is to hyperbolize their importance and significance, as well as human concentration only on them. Some experts distinguish overvalued delusional ideas because of their dominance in consciousness, although overvalued ideas, unlike delusions, are supported by patients with less intensity.

Treatment of the crazy ideas

Treat delusional ideas is difficult for various reasons, including because of the denial of patients that they have psychological problems.

To date, the correction of delusional ideas consists of symptomatic treatment with the use of drugs and cognitive-behavioral and psychotherapy.

Pharmacological group of antipsychotics (antipsychotics) - Pimozide, Olanzapine (other trade names - Olanex, Normiton, Parnasan), Risperidone (Respiron, Leptinorm, Neupilept), Clozapine (Clozasten, Azaleptin, Azaleprol), antidepressants, for example, Clomipramine (Clominal, Clofranil, Anafranil). Dosages of these drugs and duration of reception are determined by the doctor individually - based on the patient's condition, the presence of somatic diseases and the intensity of symptoms.

Contraindications of these medicines and their side effects should be taken into account. So, Pimozide is contraindicated in Parkinson's disease, breast diseases, angina pectoris, liver and kidney deficiency, pregnancy. Olanzapine and Risperidone are not prescribed for epilepsy, psychotic depression, prostate problems, liver problems. You can not take clozapine if you have epilepsy, glaucoma, heart and kidney failure, alcohol dependence.

Pimozide can cause side effects in the form of cardiac arrhythmias, tremors and seizures, muscle spasms, gynecomastia (in men) and breast engorgement (in women). Possible side effects of olanzapine include drowsiness, a century's increase, a decrease in blood pressure and depression of the central nervous system. And when using Risperidone, in addition to pain in the stomach, increased heart rate, lower blood pressure, dizziness and mental disturbance may occur, worsening the well-being of patients with impaired thinking.

Prevention

Is it possible to prevent the appearance of crazy ideas? There is no known method of prevention of this condition. However, early diagnosis and treatment can help reduce problems.

[18], [19]

Forecast

This disorder refers to chronic conditions and usually does not lead to a pronounced disorder or change in personality: most patients do not lose their ability to work.

However, the symptoms may become more pronounced, and the  prognosis  for anyone who suffers from this painful condition varies depending on the type of delusions and life circumstances, including the availability of support and willingness to adhere to treatment. Most often delusional ideas visit a lifetime - with periods of remission.

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