Schizophrenia and delusional disorder

The content of schizophrenic delusions can be varied, but the idea of hostile influence from outside always runs through the delusional reasoning like a "red thread". Experts call gradually developing persecutory delusions combined with the patient's confidence that everything that happens is not accidental, but is addressed to him: words, gestures, comments, actions of others, typical of schizophrenia. Such perception is called delusion of relationship, and it is detected, according to some sources, in about seven out of ten diagnosed schizophrenics. The patient constantly feels himself in the center of what is happening, and perceives the judgments and actions of others on his own account, and almost always evaluates their meaning negatively. As already mentioned, the most pathognomic for schizophrenia is chronic systematized delusion caused by a specific allegorical interpretation of surrounding events (delusional perception).

According to the severity and development of the disease, the following syndromes are distinguished in accordance with the stages of development of the disease (the main differences are described above): paranoid, paranoid and paraphrenic syndromes. [ 1 ]

The role of deceptions of perception in the formation of delusions is considered proven. Everyone knows about auditory hallucinations in schizophrenics, pseudohallucinations are well described, the issue of illusions is less illuminated, but all these phenomena play a large role in the formation of delusions. Deceptions of perception usually occur later than delusions, sometimes a fairly long period of time passes. Thanks to them, delusions become less systematized and real. The presence of both positive symptoms is characteristic of paranoid schizophrenia and is called hallucinatory-delusional (hallucinatory-paranoid) syndrome. V.A. Gilyarovsky noted that when the hallucinatory phase passes, the delusional plot acquires greater clarity, and when combined with vivid hallucinations, delirium fades and "curdles up". [ 2 ]

The Kandinsky-Clerambault syndrome, which is quite common in schizophrenia in the paranoid and paraphrenic stages, is a type of hallucinatory-delusional syndrome with manifestations of mental automatism. The patient believes that he has no control over his thoughts or his body, he is controlled from the outside, like a puppet (thoughts are stolen, words are replaced, facial expressions, gestures, movements, even internal organs work according to the instructions of evil manipulators). In this case, there is a combination of delusions of persecution and influence.

Patients also have distorted visual perception: they do not recognize friends and relatives or see them as completely different people, and when they recognize them, they claim that they have been made up or replaced. The phenomena of delusional perception include disorientation - the patient does not understand where he is. From delusional perception, a later painful understanding of what was perceived is formed through pathological fantasizing. Logical constructions correspond to the main plot of the delirium. [ 3 ]

Patients experience reality in accordance with their delusional experiences and without deceptions of perception. For example, seeing a crowd on the street, the patient may be sure that it has gathered for him, and not with friendly intentions. It seems to him that all eyes are focused on him, conversations are only about him, he even “hears” his name, threats or condemnation addressed to him. This reinforces his ideas. [ 4 ]

According to its content, delusional syndrome in schizophrenia is divided into the following types:

• delusion of reference - everything that happens, from facial expressions and gestures to words and actions, is related to the patient and is interpreted by him in a negative way (they are condemning me, they are trying to hinder me, they hate me, etc.);
• persecutory delusion - the patient is sure that he is being persecuted by real or fictional characters with the aim of causing harm, and in schizophrenia these are often representatives of formations that are unusual for a given culture and the surrounding reality (extraterrestrial civilizations, Masonic or magical organizations, foreign intelligence agencies);
• delusion of influence - the patient is convinced that he acts and thinks according to someone else's, mostly hostile, will: he claims that he is zombified, that he is affected by magnetic (electric) fields, radio waves, magic; as an option - the penetration of foreign objects into the brain, heart, other parts of the body; this also includes openness and theft of thoughts.

These types of delusions are most common in schizophrenia, are combined with each other and are practically not separated from each other. A fairly common variant of delusions of relationships, sometimes a mixture of the main types of delusions, litigious syndrome (querullantism) - endless complaints to various authorities, filing claims in courts, and the patient usually disputes any decisions made. It is impossible to satisfy him. Dissatisfaction may have a real basis, often complaints concern the shortcomings of the housing and communal sector, noisy neighbors, but it can also be delusional - complaints about persecution, witchcraft, attempted murder (more often this is a delusion of poisoning). [ 5 ]

Delusions of grandeur should be mentioned separately. They represent a pathological, unshakable confidence of the patient in his own exceptionalism and significant superiority over others. Delusions or mania of grandeur are much more common in other disorders - paranoid disorder, in the clinic of manic syndrome, organic lesions of cerebral structures, paralytic dementia. Schizophrenia with delusional ideas of grandeur, according to experts, indicates a deep lesion of the brain, and occurs at least at the paranoid stage of the disease. This type of delirium is most characteristic of the late, paraphrenic stage, its undeveloped episodes occur in severe forms of schizophrenia - catatonic (characteristic is the static, theatrical, proud pose of a patient with schizophrenia with delusional ideas) or hebephrenic, for example, in a state of euphoria. Moreover, against the background of depletion of emotional reactions, the patient's behavior can be mistaken for paralytic dementia. Overvalued ideas can develop into delusions of grandeur syndrome. Also, over time, the pathological conviction of persecution turns into delusional knowledge that enemies are interested in the destruction or capture of the patient who possesses a great secret. Delusions of grandeur go hand in hand with the syndrome of invention, or more precisely, creativity (patients are convinced not only of their great discoveries, but also attribute to themselves famous achievements in the field of science and art made by others). [ 6 ]

According to psychiatrists, the following topics are less pathognomic:

• hypochondriacal delirium - a deep conviction that one has a severe somatic pathology, characterized by very eccentric and absurd complaints of the patient and behavior that does not correspond to the described condition;
• delusional poisoning - typical for older patients, may be based on real symptoms of digestive organ pathology;
• delusional jealousy (Othello syndrome) - according to experts, it is not as common in schizophrenics as in other mental disorders (chronic alcoholism, organic brain damage, schizoid psychopathy); in female patients, it is usually combined with severe depressive disorder; in men, it is characterized by excited-aggressive behavior;
• erotic delusion (Clerambault syndrome) - is based on the delusional idea that someone is in love with the patient (the object is real, almost always inaccessible - an actor, politician, astronaut), the patient interprets the looks, gestures, words of the object in favor of his conviction, spending most of the time fantasizing about a relationship with him; more common in women, a famous, wealthy man with a higher social status is chosen as the object; usually systematized; the plot boils down to the fact that various circumstances prevent the lovers from reuniting, the initiative came from the object, the theme of one's own importance for him is exaggerated;
• archaic delirium - the basis is various religious movements, superstitions, witchcraft, legends about vampires, werewolves, etc.;
• false recognition (Capgras syndrome) - the belief that people can change their appearance, naturally, the purpose of such a transformation is to harm the patient; the schizophrenic does not recognize familiar people, and recognizes strangers as close; combined with delusions of persecution, grandeur, creativity and others;
• affective-delusional syndrome in schizophrenia - delusions with mood disorders, often in the direction of decreased emotional reactions with ideas of self-blame, persecution, relationships, often leading to a suicide attempt, is the most common in schizophrenia; however, in some cases there are manifestations of hyperthymia (in inventors and other "great" figures) and bright emotional outbursts of joy, happiness or rage, anger.

Tendency to aggression in schizophrenia is also distinguished as a syndrome. The presence of delusions of persecution, attitude and/or influence, especially in combination with imperative voices of criminal-sadistic content, indicate a high probability of dangerous actions of the patient, directed at himself or others. Most often, unprovoked aggression is shown by persons with paranoid schizophrenia.

In delusional schizophrenia, depersonalization/derealization syndrome may develop. It manifests itself in attacks or takes a chronic protracted course and is combined with the syndrome of mental automatism. Delusional autopsychic depersonalization results in delusions of obsession, mental transformation, Capgras syndrome; somatopsychic provokes delusions of denial, physical transformation into another creature; delusional derealization manifests itself in delusions of changing elements or the entire surrounding reality (intermetamorphoses); delusions about parallel worlds, the end of the world. [ 7 ]

Total depersonalization and derealization lead to the development of a rather rare syndrome called Cotard's delusion. It manifests itself against the background of a depressed mood and is characterized by fantastic nihilistic delusional ideas of a global scale at the level of one's guilt in the death of humanity, the destruction of civilization, hypochondriacal delusions about one's own destruction ("living dead"). Psychiatrists interpret it as a nihilistic and decadent delusion of grandeur with a minus sign.

Not all psychiatrists admit that schizophrenia can involve oneiroid clouding of consciousness, causing fantastic delusional experiences. However, most believe that oneiroid syndrome does exist, although it is not difficult to "overlook" it due to the patient's behavioral characteristics.

Obsessive-compulsive syndrome often develops in the delusional form of schizophrenia, since obsessions and delusions according to I.P. Pavlov have a single mechanism - inertia of the excitation center. Obsessions in schizophrenics are diverse, quickly become overgrown with protective rituals, distinguished by absurdity and reminiscent of the syndrome of mental automatism. They are not caused by external influences - no connection with a stressful situation is established, but a connection with hypochondriacal delusion is often traced. They have a tendency to generalize. There is a noticeable time interval between obsessions (obsessive ideas) and compulsions (ritual protective actions). Obsessive thoughts are usually supplemented by delusional statements. Of the obsessive states, the most common are mysophobia and oxyphobia - fear of contamination and fear of sharp objects.