Paraphrenia: illness or living in a modified reality

When we tell a friend that he is “talking” nonsense, we don’t even realize how far we are from the truth, confusing the concepts of delirium and nonsense. In fact, delirium is a mentally abnormal morbid condition that can have various manifestations. Mania of grandeur, characteristic of an extremely severe stage of a delirious state known as paraphrenia, is also one of the varieties of delirium. But, unfortunately, this is not all there is to it.

What is paraphrenia?

Paraphrenia, also known as paraphrenic syndrome, is not just delusion in the sense that we understand it. It is a severe mental disorder that occurs in an obvious form over a long period of time, and not a single case of inappropriate utterance or behavior.

Paraphrenic syndrome itself is not considered a specific disease, as are other medical conditions characterized by a specific group of symptoms but not indicating a specific pathology. Paraphrenia, for example, can be observed in paranoid schizophrenia (one of the types of mental disorder with a predominance of hallucinations and fantastic delusions) or delusional disorder (a mental illness manifested in the form of systematized delusional ideas without elements of bizarreness).

Less frequently, paraphrenic syndrome is observed against the background of exogenous-organic psychoses caused by traumatic factors (stress, mechanical injuries, alcoholism, syphilis, etc.). In some cases, paraphrenia accompanies such pathologies as senile psychosis and dementia.

Praraphrenia is close to the well-known paranoia (persecution mania) and the lesser-known paranoid (persecution mania combined with ideas of external influence, accompanied by sharp mood swings), which are also varieties of delusional states. These states are difficult to differentiate even for people with medical education, which is why there are many disputes around the above-mentioned concepts.

Paraphrenic syndrome is considered the most severe degree of delusional disorder, which reflects both paranoid ideas and an exaggeration of one's own importance against the background of persecution mania.

The phenomenon of paraphrenia was first discovered by the German psychiatrist Emil Kraepelin at the end of the 19th century. At that time, paraphrenia was considered one of the mental illnesses of a person. Nowadays, paraphrenia is not considered a separate illness. It is a syndrome inherent in several pathologies of mental development.

A distinctive feature of paraphrenia is considered to be the systematization of delusional ideas and concepts, significantly divorced from reality and usually of a fantastic nature. At the same time, the connection of delusions with personality traits that contribute to the development of the pathological process, as well as with disorders of perception and mental state, is weakly traced or absent altogether, which cannot be said about paranoid or paranoid syndrome.

Epidemiology

It is simply impossible to clearly determine the prevalence of paraphrenia, since not all patients seek help from psychiatrists. Many go to general practitioners, who cannot always discern the symptoms of mental disorders in the patient's words. Other patients generally consider their condition to be normal, which is typical, for example, for schizophrenia, which means that their illness can only be discovered by chance in connection with other pathologies.

It can only be said that paraphrenia tends to develop at a young age. For men, this age is around 17-28 years, for women – 22-32 years. At the same time, the risk of developing pathology has a seasonal tint. Thus, people born in the spring-winter period have a slightly higher probability of developing delusional pathologies than those born in the summer or autumn.

In childhood, such a diagnosis is not encountered, and in adolescence it is weakly expressed, manifesting itself in the form of affective-delusional ideas or psychoses.

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Causes paraphrenias

Despite the fact that paraphrenic syndrome has been known in medical circles for over a hundred years, its pathogenesis has not yet been thoroughly studied. The widespread prevalence of paraphrenia in the clinical picture of such mental pathologies as schizophrenia and delusional disorder suggests that the origins of the syndrome can be found in the pathogenesis of these diseases. But even here, not everything is so simple.

The fact is that the pathogenesis of schizophrenia also remains a mystery for scientists, who assume that the development of the disease can be contributed to by: hereditary factors, genetic mutations and disorders of neuronal development in the prenatal period and after the birth of the baby, structural changes in various parts of the brain, as well as social factors. At the same time, the trigger that starts the pathological process is the interaction of various risk factors for the development of pathology, one of which is always the social environment and upbringing of the child.

The pathogenesis of delusional disorder is also not particularly clear and unambiguous. As in the case of schizophrenia, there are several theories that try to explain why a person at some point loses touch with reality, giving himself over to the power of delirium and hallucinations.

Many scientists agree that the causes of delusional disorder are the placement of a person with a special genetically determined structure of consciousness in certain conditions of the social environment or upbringing. The special structure of consciousness can include hidden complexes in the sexual sphere:

• Homosexuality (same-sex sexual intercourse),
• incest (sexual intercourse with blood relatives),
• exhibitionism (achieving sexual satisfaction by showing others one's genitals),
• castration complex (a child’s anxiety about the absence of some sexual characteristics and fear of castration), etc.

On this basis, various delusional ideas can develop, such as persecution mania, delusions of a double or reformism, ideas about outside influence on consciousness, etc. This state of affairs can be facilitated by excessive suspiciousness of parents, prolonged stay within a religious sect or community with total control over its inhabitants, the need to emigrate (especially in conditions of ignorance of the language), imprisonment, life conflicts and even some diseases (for example, poor hearing or vision, communication disorders).

Delusional ideas can be associated with constitutional personality traits (systematized delirium usually in one direction), as well as some pathologically modified character traits: lack of self-criticism, excessively high self-esteem, distrust of others, fixation on one's own experiences, etc. Risk factors for such mental disorders can be alcohol and drug abuse, as well as uncontrolled use of psychotropic drugs, as a result of which the activity of the brain is disrupted.

If the reasons for the appearance of delusional states are more or less clear, then the probability of the development of paraphrenia, paranoia or paranoid on this basis remains questionable. Everything depends on which of the factors prevails over consciousness more than others, determining the nature of delusional ideas and their connection with reality.

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Symptoms paraphrenias

Paraphrenia, as a disorder of mental perception, has a fairly broad symptomatology. At the same time, each specific case is unique in its manifestations.

The first signs by which it can be determined that a patient has paraphrenic syndrome are the presence of three components:

• various delusional ideas, which are often systematized and include: delusions of grandeur and persecution, as well as delusions of influence, when a person feels imaginary participation from the outside,
• hallucinations and pseudo-hallucinations (visions detached from reality, non-existent characters and places),
• mental automatism, when the patient perceives his own thoughts and actions as suggested or inspired from outside, which goes hand in hand with delusional influence.

Patients with paraphrenic syndrome stand out from others, since the rich symptomatology of the pathological process is observed against the background of a good mood, a kind of euphoria. The prevailing idea of their delirium is the feeling of being a great and omnipotent person, a real ruler of the Universe. Someone becomes a new Newton or Einstein, while others attribute non-existent features to themselves, considering themselves a person who does not exist in the real world.

Patients consider themselves truly unique and attribute to themselves some superpowers, which gives them confidence in their omnipotence and infallibility. Such ideas are often reinforced by hallucinations based on real events and characters. If this does not help to convince themselves of their superiority over others, the consciousness calls for help pseudo-hallucinations, divorced from reality, in which there are fictitious characters and places of action.

Particular attention should be paid to the patient's speech. It is always confident and emotional. Confidence in their infallibility makes patients convince others of their rightness, thus increasing their already unrealistically high self-esteem. Paraphrenics try to confirm their delusional ideas with statements by great people, comparisons, often in numerical terms, significant facts of universal significance, etc.

Patients with paraphrenia are obsessed with the idea of an approaching grand event, which they predict at every opportunity, while they themselves, in their opinion, also take an active part in preventing the impending catastrophe or are a mediator in concluding peace with aliens. Such fantastic stories usually have one theme, but each time they are supplemented with new colors, characters and plots. Patients are not inclined to change the meaning of their statements, so this happens extremely rarely.

Persecution mania is not always present in paraphrenia, but it often makes itself known in appropriate social conditions. The patient, considering himself an extraordinary person with multiple important ideas for saving our world, may fear that these ideas can be stolen from him by both the inhabitants of our planet and characters from the other world or aliens. At the same time, the paraphrenic can constantly be convinced of the thought that he is not only being watched, but also that someone is trying to control him, instilling other people's thoughts and actions, which he steadfastly resists.

Paraphrenic delirium is characterized by the presence of not only negative characters with whom the patient enters into a struggle. Non-existent positive heroes also fight for his life, helping the paraphrenic to fulfill his mission and once again convincing him of his own importance.

Symptoms of mental automatism in paraphrenia are often in the realm of fantasy. The patient allegedly communicates with fantastic creatures from other worlds or real people who have great influence in society (scientists, politicians, etc.). At the same time, they either feel influenced by others, or are convinced that they themselves, with the help of their genius abilities, can control people and events, read minds, force a person to do something he does not want, etc.

A fairly common symptom of paraphrenic syndrome is the delusion of a negative double, described in 1923 by the French psychiatrist Joseph Capgres. The patient is convinced that he or one of his relatives has been replaced by an invisible double. In this case, all the bad deeds of a person are attributed to his double. The patient is confused in relationships, considering strangers to be close and dear, and rejecting any connections with relatives.

A little less frequently, patients with paraphrenia experience manifestations of Fregoli syndrome (positive double). The patient may consider the people around him to be one and the same character, who for some reason changes his appearance. However, there are also situations of non-recognition, when one person is perceived by the paraphrenic as two different characters.

Along with hallucinations and pseudo-hallucinations, paraphrenics experience such phenomena as confabulation (transferring long-ago events into the present, supplemented with fictitious details) and obsession (obsessive ideas and concepts that have no relation to various fears and obsessive actions that haunt a person).

Stages

Paraphrenia can also act as one of the stages of other mental disorders:

• Fantastic paraphrenia is a delusional disorder saturated with ideas of greatness, wealth, power, which have no constancy and no definite system. This type of paraphrenic syndrome characterizes the fourth stage of oneiroid syndrome with complete or partial disorientation of a person in his personality, surrounding reality and current events with the replacement of reality with fictional pictures of pseudo-hallucinatory delirium.

• Acute paraphrenia. This condition characterizes not the pathology itself as a whole, but rather recurring attacks of sensory emotionally colored delirium, which are characterized by variability. The trigger for such attacks is changes in the environment, certain events in the patient's life. The nature of the delirium depends on these changes. Most often it is a manifestation of schizophrenia or late psychosis.
• Chronic paraphrenia. Here, a certain stable system can already be traced in the form of monotony of statements against the background of the absence of emotional manifestations. It is characterized by a poor vocabulary, incoherent sentences and phrases.

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Forms

In psychiatric practice, it is customary to distinguish the following types of paraphrenic syndrome:

• Systematized paraphrenia, which is characterized by the stability and constancy of delusional ideas. It is characterized to a greater extent by a pronounced manifestation of megalomania, as well as positive or negative double syndromes. Ideas of superiority and a negative (sometimes even aggressive) attitude towards others are clearly outlined. Auditory hallucinations are also clearly expressed.
• Hallucinatory paraphrenia, when the patient is completely under the power of hallucinations and pseudo-hallucinations, rarely resorting to verbal manifestations of delirium in the form of dialogues with opponents, evidence of his delusional ideas. Pseudo-hallucinations are presented in the form of living creatures that do not exist in reality.
• Confabulatory paraphrenia most often develops on the basis of the two above-mentioned varieties of paraphrenic syndrome, and is very rare as an independent type. Here, megalomania comes to the fore in combination with false memories of heroic events and the patient's participation in them, distortion of information about events that once occurred, or memories of events that never happened.

Non-specific types of paraphrenic syndrome:

• Manic paraphrenia is a manic prevalence of the idea of one's own superiority over others, which is characterized by verbal delirium. The fantastic component is weakly expressed.
• Expansive paraphrenia, when various unsystematic delusional ideas are presented against the background of heightened affect (in a constantly elevated mood).

The following types of pathology are also typical for older patients:

• Melancholic or depressive paraphrenia is closely related to the depressive state. It is considered a subtype of confabulation paraphrenic syndrome, but with the absence of delusions of grandeur. Patients, on the contrary, consider themselves unworthy of respect and guilty of all mortal sins, for which they must suffer inevitable punishment. In their sick consciousness, they personify the world's evil, appearing in their untrue memories as negative characters.
• Involutional paraphrenia is based on megalomania and persecution delusions. Such patients are more likely than others to have memory impairments, when events and dates are replaced by others. They are prone to frequent changes in mood and speech patterns.
• Presenile paraphrenia, in which delusions of grandeur acquire a special form. The idea of grandeur is realized through an imaginary sexual connection with a super-great mind (for example, with alien inhabitants). This type of paraphrenia is characterized by the appearance of vivid auditory hallucinations confirming the delusions of grandeur. This type of pathology is typical for the female population of the planet aged 45 to 55 years.
• Erotic paraphrenia arises from an unfavorable experience of family life. It manifests itself in the form of hallucinations in which the patient acts as an immoral character, aware of his inferiority. On the other hand, these hallucinations also contain a “positive” character, a “defender” of morality, who accuses the patient of betrayal and threatens to punish the patient by the method of “fighting fire with fire”, i.e. with the help of sexual violence. This type of pathology is not characterized by constancy of symptoms, its course is paroxysmal. It manifests itself most often in women.
• Late paraphrenia with a conviction of one's uselessness, with ideas that the patient is being offended, deprived, and not loved. This syndrome is characteristic of senile schizophrenia (at the age of 70-90 years), which is practically not treated.

In old age, it is much more difficult to cope with the disease, therefore the consequences of systematic paraphrenic delirium are severe late psychosis, and most often senile dementia, which can be both the cause and the consequence of paraphrenia.

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Complications and consequences

Typically, chronic paraphrenia develops over a long period of time as a complication of a hallucinatory-paranoid state, and not as a separate mental pathology.

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Diagnostics paraphrenias

The main task of diagnostic studies in paraphrenia is to identify differences between similar pathologies, which indicates the severity of mental disorder, because paraphrenic syndrome is considered the most severe stage of delusional state. A special role in this case is given to differential diagnostics.

The similarity of some symptoms in paraphrenic, paranoid and paranoid syndromes makes the diagnosis of paraphrenia very difficult. Differentiating these pathologies is possible only by carefully studying all the symptoms present in the patient.

It is very important to identify the dependence of the appearance of certain symptoms on certain personality traits. In paranoid syndrome, this dependence is clearly visible, i.e. mistrust and suspicion can subsequently lead to persecution mania.

The connection between the appearance of delirium and pathological disorders of perception, mental imbalance plays an important role. In paranoid syndrome, this connection is very clearly visible, while in paraphrenia it may be absent altogether.

Paraphrenia also needs to be differentiated from episodes of delusional states, characteristic of psychosis in adolescence or organic types of psychosis against the background of taking narcotic or psychotropic drugs. Therefore, it is so important to determine the duration of episodes of delirium and their periodicity, as well as for how long the patient has been experiencing such a condition.

In some cases, additional neurological studies of brain function may be required. Paraphrenia is actually a substitution of reality with delusional and fantastic ideas, not associated with disorders of brain function. If delirium is caused by this reason, the diagnosis will be completely different. For example, early dementia, vascular dementia, senile dementia, in which there are disorders in the emotional and volitional spheres.

Paraphrenia as a separate condition occurs extremely rarely, so it is important to find out what disease is accompanied by the symptoms of paraphrenic syndrome, and to treat the disease itself, and not its individual manifestations.

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Treatment paraphrenias

Only after a detailed study of the symptoms and a final diagnosis can effective treatment for paraphrenia be prescribed. A thorough study of the symptoms is important in the sense that different types of paraphrenic syndrome may have different manifestations against the background of a certain mental state. One patient may be in a state of euphoria almost constantly, while another may have a tendency toward depression and self-abasement. Accordingly, the approach to treating such patients will be different.

The main thing is that treatment of this mental disorder is possible except for cases of development of pathology in old age, when changes in the psyche become irreversible. Therapy of paraphrenia can be carried out both in hospital and outpatient settings, but in the latter case, patients are required to visit the hospital at the time established for taking medications.

The main drugs in the treatment of paraphrenic syndrome are considered to be neuroleptics intended for the treatment of psychotic disorders. It is neuroleptics that are called upon to effectively combat increased anxiety, delusions and hallucinations, mood swings, psychomotor agitation, which are more or less characteristic of various types of paraphrenic syndrome.

Preference, of course, should be given to atypical neuroleptics (Clozapine, Quetiapine, Rispolept, etc.), which have significantly fewer side effects than their typical "brothers". But on the other hand, patients with paraphrenia often simply forget to come to the medical institution at the allotted time for taking the medication, in which case it is preferable to prescribe prolonged-release tablets, which, unfortunately, are present only among typical neuroleptics.

The prescription of doses and duration of neuroleptics depends on the form in which the pathology occurs. In the acute form, which is characterized by individual recurring episodes of delirium, drugs are prescribed in large doses precisely at those moments when clinical symptoms are particularly pronounced. For the chronic course of the disease, therapy has a different focus. Neuroleptics are prescribed here in the minimum effective dose, which is gradually increased. The drugs are taken on a permanent basis.

If paraphrenia occurs with frequent depressive dramatizations, which is especially typical for the melancholic and late forms of the pathology, antidepressants and psychotherapy sessions aimed at combating the depressed state are prescribed as additional methods of therapy. The choice of drugs in this case is always up to the doctor. These can be both good old tricyclic antidepressants (Doxepin, Coaxil, etc.), and SSRIs (Fluoxetine, Paroxetine, Sertraline, etc.) or a new development in pharmacology, melatoninergic antidepressants (Agomelatine, also known as Melitor).

Inpatient treatment is provided to patients with severe forms of paraphrenia that pose some danger to others. In such cases, medications are prescribed in high doses until the intensity of symptoms decreases. After that, the patient continues to be treated on an outpatient basis using less severe medications and with dose adjustments.

Prevention

Prevention of paraphrenia makes sense if there are certain prerequisites for the development of the disease. These may be either genetic prerequisites, including cases of mental disorders in the family, or the manifestation of certain personality traits that are a deviation from the norm.

It is clear that it is simply unrealistic to exclude all possible triggers. But if a person is provided with a suitable environment, the disease may never manifest itself. Care and love from parents, good relationships in the family, nurturing positive character traits in the child, and, if necessary, working with a psychologist - all this will help stop the development of the pathological process in its infancy.

In adult life, everything is much more complicated, because it is sometimes not so easy to avoid stressful situations and conflicts. And no one is immune from prison and emigration, as recent events show. But you can help a person not to succumb to the negative influence of others with offers to "have a drink" or "have a joint" by explaining in all colors what such hobbies can turn into.

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Forecast

The prognosis of paraphrenic syndrome is difficult, because when it comes to the human psyche, it is simply impossible to predict anything in advance. According to some reports, only 10% of patients diagnosed with paraphrenia, after undergoing a course of treatment, forget about their illness forever. For the rest, the symptoms return after a while. But this is no reason to despair. Many patients who periodically undergo a course of treatment with neuroleptics in combination with psychotherapy sessions during relapses of the disease, subsequently return to normal life and work, because the pathology does not cause irreversible disorders of thinking and memory, and even more so organic brain damage. So there is still a chance for recovery.

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