Psychiatry: A Course of Lectures - V. S. Bitensky 2004

Pathology of Thinking

Thinking is a mental process of mediated and generalized cognition of reality. It represents the highest form of worldview comprehension. Thinking cannot be conceived without foundational material derived from sensations and perception. While sensation serves as the initial, primary link in understanding the world, thinking continues and deepens this cognition. The transition to thinking occurs precisely when sensations are no longer able to clarify a given phenomenon. In this case, preconditions emerge for The Development of thinking as a pathway to apprehending reality, where the world is viewed as a unified whole in which all phenomena are interdependent and interconnected. This mutual connection and generalization are defining features of thinking, acting as an instrument for the mediated cognition of reality. According to S. L. Rubinstein (1940), action is the primary form of the existence of thinking. All mental operations (comparison, analysis, synthesis) initially arise as practical operations. Connection with practice serves as the criterion for the correctness of thinking. Thinking reflects existing connections and relationships among objects of reality. It enables humans to comprehend not only the present but also the past, and on The basis of this knowledge, to anticipate the future. Thinking is a social phenomenon, serving as a product of labor activity.

Thinking is interconnected with all mental processes, but a special relationship exists specifically between thinking and speech. Thinking and language are inseparable, with thinking playing the leading role; a dialectical unity exists between them. This idea was formulated with utmost clarity by L. S. Vygotsky (1936): "A thought is not merely expressed in a word, but rather perfected in it; the path from thought to articulate speech unfolds as follows: the motive for The Emergence of thought — inner speech — outer speech."

In human cognitive development, distinct periods are distinguished corresponding to age. The MAIN TYPES OF thinking include: object-action (sensorimotor), concrete-imaginal, and Abstract, or logical (verbal-logical).

Object-action thinking is the primary, earliest form of human intellectual activity, unrelated to language. At this stage, the thinking of apes and children under 2 years of age coincides, remaining chaotic in its early phase. This type of thinking is also characteristic of members of uncivilized tribes. In a child from a civilized society, chaotic object-action thinking quickly transitions into goal-directed thinking because parents provide information by naming specific words, while the child relies on the experience of adults. Consequently, even before mastering language, a child can accurately select their toy from among ten identical ones. The mute period may last up to 3 years in a child, but this does not imply a lack of comprehension of surrounding speech. Around the age of three, the developmental trajectories of thinking and language intersect, and during this period, with parental assistance, the child makes a major discovery in life: realizing that every object has a name. Thinking becomes verbal, and speech becomes meaningful. At this juncture, thinking is inner speech, while language represents thoughts expressed aloud. Unlike language, thinking is far from always accompanied by full verbal formulation. Therefore, Two Types of speech are distinguished: active and passive (which develops earlier). According to J. Piaget, speech may take the form of echolalia (repeating the words of others), monologue, or collective monologue. The latter serves as a verbal accompaniment to the child's own actions. During a collective monologue, the child speaks in the presence of an interlocutor without addressing anyone in particular, speaking essentially for themselves. Thus, the child's speech is egocentric.

Concrete-imaginal thinking relies predominantly on concrete concepts because in children aged two to seven, at the early stage, The ability to assimilate and utilize concepts characterized by a high degree of generalization is not yet sufficiently developed.

Verbal-logical (abstract) thinking gradually forms by the age of 10–12 and becomes the dominant type of thinking. Its main features include a strict adherence to THE PRINCIPLE OF orientation toward the cognition of objective reality, as well as the capacity to encompass problems and issues across various spheres of human activity, accounting for all essential details and demonstrating the ability to penetrate their core essence.

In the Ukrainian psychiatric school (Ye. O. Shevaliov, 1930, 1935; P. P. Frumkin, H. L. Voronkov, I. D. Shevchuk, 1977), Thought Disorders are classified into disturbances of pace and Structure.

Thought Disturbances by Pace

The most convenient scheme for understanding this disturbance is as follows:

1. Accelerated thinking: rapid thinking ("flight of ideas"); mentism (intrusive rushes of thoughts).

2. Retarded thinking: depressive retardation; thought blocking (sperrung); verbigeration; perseveration; stereotypies; pathological circumstantiality (detail-oriented thinking).

Excitement and acceleration of thinking are characterized by an influx of mental associations, facilitated generation, and rapid shifting of thoughts, memories, and images. The patient finds it difficult to concentrate, attention is easily distracted, judgments are superficial, and external connections, contiguous associations, and assonance predominate. The speech of such patients is accelerated, loud, and characterized by excessive talkativeness. In moderately accelerated thinking, an impression of heightened creative activity and high intellectual productivity is created. However, as the pace of thinking increases, a whirlwind of associations and a "flight of ideas" emerges, leading to a loss of goal-directedness in thinking, and the patient's speech becomes disorganized and incoherent. An example of accelerated thought tempo can be found in the speech of Tryndychykha in the popular operetta *Wedding in Malinovka*. In psychiatric practice, however, accelerated thinking is observed in hypomanic and manic states within affective mood disorders, manioform states of exogenous origin, and schizoaffective disorders.

Mentism is a forced, involuntary influx of thoughts, memories, and images. It may manifest either as short-lived episodes of thought surges or as relatively prolonged states. Patients clearly perceive the irrelevance and often the "made" quality of these thoughts, alongside the inability to overcome or control them through any volitional effort. "I constantly feel as if I'm under tension; thoughts just keep running continuously, day and night." The content of these intrusive thoughts can vary widely: ranging from joyfully elevated themes to ideas of self-blame. Mentism is considered a variant of associative automatism; it is a component of Kandinsky-Clérambault syndrome and may occur in Schizophrenia, exogenous-organic diseases, psychotic disorders of alcoholic origin, etc.

Depressive thought retardation is most frequently encountered in depressive syndrome within the framework of Affective Disorders. Affected patients experience difficulties in forming associations and transitioning from one thought to another. Although the patient comprehends the meaning of questions asked, their judgments are sluggish; they struggle with grasping the meaning of inquiries and consequently respond after a significant delay.

It is essential to distinguish depressive thought retardation from the slowing and retardation of thinking associated with organic Brain diseases (such as epidemic encephalitis or Brain Tumors). In such cases, a slowing of the tempo of all mental processes is observed due to pathology in the frontal lobes and Brainstem.

Depressive thought retardation is illustrated by the following clinical case.

Patient Ya., aged 37. Hospitalized in a psychiatric hospital following suicide attempts. In the ward, she is retarded, lying motionlessly in bed with closed eyes. Her facial expression is sorrowful. During the examination, she fails to follow the physician's instructions, yet displays no active resistance; she does not answer questions or provides brief, formal responses after a prolonged pause, frequently stating "I don't know," "I don't remember," and shows virtually no reaction to events occurring in the ward or to the presence of agitated patients.

Thought blocking (Sperrung) is a sudden cessation (blocking) of mental activity, vividly described by patients as a blank space in the mind, a breakdown, or a jam of thoughts. The patient abruptly falls silent, experiencing a temporary sensation of an absence of thoughts; sometimes subsequent utterances bear no connection to the preceding ones. According to E. Bleuler (1920), blocks do not affect the tempo or speed of mental processes and are viewed As a result of impaired goal-directedness in psychological activity.

Verbigeration is the repetition by patients of identical words or expressions. For instance, during catatonic excitement, a patient may shout identical, nonsensical, and often rhythmized words for hours; in anxiety-depression syndrome, verbigeration manifests as the repeated recitation of phrases such as "I am a sinner" or "Kill me."

Perseveration occurs when a patient gets stuck on a single response despite questions of varying content. For example, after stating their name, they respond to subsequent, completely different questions with: "Volodya," "Volodya," "Volodya."

Stereotypy involves the repetitive use of identical words or turns of phrase in the patient's speech. Similar to filler words, this phenomenon can be observed in mentally healthy individuals with a limited vocabulary, such as the speech of Elochka the Cannibal from Ilf and Petrov's novel *The Twelve Chairs*.

Echolalia is the involuntary repetition of words or individual phrases spoken by those around the patient. It is observed in catatonic syndrome.

Pathological circumstantiality of thought manifests as excessive detailing when describing a phenomenon, an inability to separate the main points from secondary ones, mental rigidity (inertia of associations), and getting bogged down in trivialities. During conversation, the patient presents information in a strictly spatiotemporal sequence, starting from afar and repeatedly retelling what has already been stated. For instance, when asked about their well-being during morning rounds, one might hear: "When they woke me up at 7 AM today, I washed, dressed, and asked the nurse on duty to give me my medication, but she was busy with another patient," and so forth. Dwelling on minor, insignificant details, the patient never deviates from the core theme of their narrative. While recounting anything, they mark time, become engrossed in general matters, but ultimately return to the original goal of their story.

Such pathological circumstantiality is characteristic of patients with Epilepsy, in whom thought viscosity is combined with the retardation of all mental processes. Analyzing the autobiography of Napoleon Bonaparte, who suffered from epilepsy, researchers note his mental rigidity and circumstantial thinking, which manifested during the Battle of Waterloo. Scientists believe that this circumstance played an exceptionally critical role in delaying Napoleon's adoption of necessary tactical decisions.

Thought Disturbances by Structure

It is the result of a breakdown in the complex Hierarchy of levels and types of mental activity. Our clinical and pedagogical experience shows that the most convenient framework for understanding this disorder is as follows:

1. Autistic thinking.

2. Paralogical thinking.

3. Symbolic thinking.

4. Conceptual wordiness (reasoning).

5. Fragmentation of thinking:

a) thought slipping;

b) word salad (speech jumble);

c) schizophasia;

d) incoherence.

Autistic thinking represents thoughts and experiences detached from the outside world, locked within a subjective realm, and devoid of adequate connection to reality. Ideas frequently degenerate and transform, acquiring an irrational, symbolic, and hallucinatory-delusional content.

An example is the case of patient K., who, after being discharged, came to the apartment of a ward nurse and announced to the husband who opened the door that he was the nurse's true husband and that they had married during his stay in the hospital. He gave a vivid Description of the wedding and their family life. The patient was deeply convinced of the truth of his statements.

This peculiar restructuring of personality, along with profound changes in thinking and the emotional-volitional sphere, was first designated by E. Bleuler (1911) as “autism.” At the same time, such life-detached autistic daydreams can be observed in people with rich imaginations, particularly in individuals with conversion disorders. However, in the latter cases, the ability to critically evaluate one's fantasy and return to reality is not lost. In the autistic thinking of schizophrenia patients, such critical evaluation of their statements is absent.

Paralogical thinking is an incorrect, erroneous Conclusion made unintentionally based on secondary features due to a violation of the laws and rules of logic. An example is the following excerpt from a medical history.

Yuri N., a 5th-year student at the University's Faculty of Biology, was admitted for Treatment following a conflict with a professor who returned his diploma thesis. The topic of the thesis focused on The impact of the composition and quality of the human diet on the state of the maxillofacial apparatus and the gastrointestinal tract. Using extensive empirical data, Yuri traced the evolutionary connection between the diet of primitive humans, people of the Middle Ages, and modern humans, noting Changes in the maxillofacial apparatus (reduction in the number of Teeth, shape of the lower jaw) and the gastrointestinal tract (reduction in the length of the Small Intestine, etc.). Based on the data studied, he proposed transitioning all people to astronaut food (tubes, tablets) and believed that within 5 years, the human lower jaw would completely atrophy, and the gastrointestinal tract would turn into a “absorption” tube due to disuse.

In 1930, E. O. Shevalyov, in his article “On Paralogical Thinking,” identified a variant of paralogical thinking that he called formal. In this case, patients strive in their judgments to convey a wealth of information using stencil expressions, employing verbal clichés to describe any phenomenon of everyday life. Paralogical thinking is based on faulty premises and is the result of disruptions in the associative process.

Paralogical thinking is encountered in schizophrenia and paranoid personality disorders.

Symbolic thinking in mental illness is the result of the mental patient's creativity, when they attach special significance to some sign, drawing, or word. Determining the meaning of the created symbol is possible only through conversation with the patient.

For example, patient N. demanded that the doctor immediately send his demand to the city mayor. The demand took the form of a red line drawn on white paper, bent at a right angle and ending with the letter “D.” When asked to explain what this meant, he replied: “I demand that the 'Red' hotel be turned into an orphanage.”

Another patient, S., upon entering the lecture hall, greeted the students with the words: “Glory to Queen Tamara” — which meant that he wished happiness to everyone present.

Neologisms and word agglutination (fusion) may be used in symbolic statements.

Of course, symbolism is characteristic of normal thinking; we use it for the vivid expression of our feelings and our attitude toward a certain object. However, these symbols are widely known and popular; they can be either permanent, such as the symbol of female beauty “Venus,” or transient, created by the imagination of various authors or actors.

Symbolic thinking is most frequently encountered in schizophrenia.

Reasoning/sterile philosophizing (rezonerstvo). Its main feature is a propensity for idle, sterile, superficial judgments. Statements are often verbose, pretentious, and ambiguous. A classic example of such verbosity was portrayed by N. V. Gogol in the character of Khlestakov, whose judgments had a general, ambiguous character and were perceived by those around him as manifestations of great intellect. This reasoning may not go beyond the bounds of banal, albeit pretentious, rhetoric that revolves around simple and obvious truths.

In this case, such verbosity is defined as an excessive need for self-expression and self-affirmation.

Resonance (metachromasia) is also observed in schizophrenia, epilepsy, and organic brain damage, especially in old age.

Thought derailment is characterized by The breakdown of associative links between concepts and ideas, causing the patient's spoken language to lose its ability to form grammatically correct phrases and sentences. Derailment can manifest as a "slipping effect," where, following long, logically structured sentences, the patient unconsciously drifts to an entirely different topic: "We listened with great pleasure to the professor's lecture today, in which he presented his understanding of the Etiology AND Pathogenesis of rheumatic diseases, but his speech lacked any reference to the biochemical nature of impulse transmission from one neuron to another, and so on." Derailment can progress to a total loss of logical connection between words within a single sentence (incoherence). Here is an example of a patient's speech: "Take away the aminazine, you can't smoke on an empty Stomach in bed, I told you to drive the lunatics out of here, stop mocking me, I'll show you myself, even though you're crooked and I'm straight, SHOOT a haloperidol injection right on the table (having overheard the doctor tell the nurse that the patient needed a haloperidol injection), I'll smear myself all over like a pig, and so on."

More pronounced derailment can disrupt grammatical structure, making the patient's speech sound like a senseless string of words—a "word salad": "trauma, motion, motor..."

When defect states develop in patients, the symptom of "schizophasia" may be observed, where speech consists of a series of isolated syllables.

The described variants of thought derailment are most commonly encountered in schizophrenia.

Pathological Thought Production

The result of disorders in the pace, structure, and content of thinking is the pathological production of thoughts: obsessive, overvalued, and delusional ideas.

Obsessive Ideas

Obsessive states, or obsessions, are thoughts, memories, fears, or impulses that arise against the patient's will and are distinguished by notable persistence. Patients maintain a critical attitude toward them, recognizing their absurdity, yet are unable to rid themselves of them. Obsessive states are intimately connected to the patient's emotional sphere; they do not form associative links with other elements of thinking, but rather obstruct and inhibit the normal flow of thought. The intrusive Nature of the phenomenon and its morbid character are generally recognized by the patient, who typically maintains a critical perspective on it.

The following clinical case illustrates the emergence of obsessive ideas.

Patient K., 34 years old, a design artist by profession. Due to The Nature of his work, he constantly traveled on business trips. Once, his ship was caught in an extremely severe storm near Novorossiysk. Here is how the patient described his condition: "I was alone in my cabin when an oncoming storm wave gave me the feeling that it would crush and flatten the ship and my cabin. I experienced intense fear accompanied by a rapid heartbeat, and this terror was heightened by the fact that I couldn't leave the cabin or call for help. Deep down in my mind, I understood that my fears were exaggerated, but I couldn't do anything about it. After the storm subsided, I decided to return home by train. Along the route, the train passes through numerous tunnels. Whenever darkness fell, I was gripped by the fear that the tunnel would collapse, rocks would smash my carriage, and I would certainly die; these thoughts were accompanied by pronounced tachycardia. At home, I immediately opened the window in my room and kept it open at all times, regardless of the weather."

For two years, the patient suffered from agoraphobia. He turned down numerous foreign business trips and was afraid to board a ship unless it was securely moored at the pier. In extreme situations when a voyage was absolutely necessary, he was incapable of creative work: "I was paralyzed by the fear that I would die, and the growing tachycardia served as proof of this." The patient maintained a critical attitude toward his obsession, recognized its absurdity, and tried to overcome it on his own, but ultimately was forced to seek help.

Obsessive phenomena are divided into abstract (indifferent, emotionally neutral in content) and figurative or sensory obsessions.

Abstract obsessions include the following.

Arithmomania or mental rumination, manifested as an obsessive compulsion to solve futile, senseless questions over and over again—for example, an obsessive preoccupation with why "Moscow" is called "Moscow," and so on.

Obsessive counting, manifested by a nagging urge to count things, such as the number of steps from home to work; if he makes a mistake, the patient must return home and walk the route again; obsessive counting of windows in buildings, and so on.

Obsessive recollections—the compulsive recalling of forgotten or useless terms, Definitions, or episodes from life.

Figurative obsessions notably include the following.

Obsessive memories—the involuntary intrusion of unpleasant memories into consciousness.

Contrastive or blasphemous thoughts—the intrusive emergence of thoughts and mental images whose content starkly contradicts the individual's moral and ethical values.

Obsessive impulses—the urge to perform absurd and often dangerous acts, such as an obsessive desire to run across the tracks in front of a moving locomotive.

Obsessions involving actions encompass a group of compulsive phenomena of various origins. These include various types of tics, filler words, nail-biting (onychotillomania), Hair-pulling (trichotillomania), and ritualistic behaviors—such as repetitive handwashing, verbal incantations, and so on.

The pathophysiological mechanisms of obsessive states are explained by the emergence of a focus of inert, stagnant excitation in the Cerebral Cortex, the phase states of which—such as the paradoxical or ultra-paradoxical phases—can account for the appearance of contrastive impulses, thoughts, etc. (I. P. Pavlov, 1933).

Obsessive states occur in neurotic disorders, obsessive-compulsive disorders, psychasthenic personality traits, schizophrenia, epilepsy, and organic brain diseases. In these cases, the Clinical Features of obsessions depend on the nature of the underlying condition.

For example, patient K., 28 years old, describes himself as follows: "Ever since childhood, I’ve been somewhat strange. The other boys didn't respect me, and I was afraid of them. In fact, I was afraid of everything. When I was in primary school, I was terrified that my mother would die. But if I managed to count to 10 before she finished pouring tea into her cup, she would live. Walking to school, I was afraid strangers would attack me. I held my schoolbag with the buckle facing inward, which supposedly meant I was coming in peace and didn't want to fight. I finished school and served in the army, where I learned to be a driver. Everything would have been fine, but lately, some stupid thoughts have been getting in my way: all I can think about is making sure all objects around me are arranged symmetrically. My wife yells at me because of this. At work, I need to repair a car, but instead of doing my job, I lay out the wrenches symmetrically. Recently, something happened that I'm ashamed to talk about. I took a local train to my country house. Along the way, I got off at a station and ran to the restroom. I noticed two matches lying in the toilet bowl. As I was leaving, it suddenly hit me like a blow: I had to go back and arrange the matches symmetrically. I went back. It was disgusting to reach into the toilet bowl, but I couldn't just leave. My Heart started pounding, and I broke out in a cold sweat. Still, I couldn't resist—I reached my hand into the toilet and arranged the matches symmetrically, and meanwhile, my train pulled away."

Overvalued ideas

Overvalued ideas were first described by C. Wernicke (1892).

They comprise specific judgments that are affectively charged, exhibit a persistent and fixed character, and resist critical evaluation during that period. A critical attitude toward these ideas emerges only as their affective value diminishes.

A classic example is Othello's overvalued idea of jealousy in W. Shakespeare's drama. The emotional environment surrounding the Moorish commander, Othello, was fraught with suspicion and intrigue; it fostered the development of his overvalued ideas of self-deprecation related to his Skin color, against which Background the conviction of Desdemona's infidelity eventually formed, leading to a tragic finale. However, as soon as the emotional tension dissipated, Othello critically appraised the fatal mistake he had made.

Overvalued ideas should be distinguished from dominant ideas. The prevailing role of the latter is determined by the interests and passions of individuals who actively strive to overcome all obstacles and achieve their goals. Overvalued ideas, by contrast, are pathological in nature and represent a manifestation of a disharmonious personality. They merge with the patient's personality and are perceived as an exclusively correct representation.

The content of overvalued ideas accurately reflects real facts. Frequently, they are associated with ideas of invention and the notion of creating something novel and useful, such as a perpetuum mobile. Overvalued ideas are persistent and characterized by emotional intensity and affective engagement. Correction of an overvalued idea occurs when the patient recognizes its fallacy through their own logical reasoning or under METABOLISM/18.html">The Influence of another person whom they regard as an unquestionable authority in that field.

Overvalued ideas most commonly arise in patients with personality disorders (specifically, paranoid ones). According to P. B. Gannushkin (1933), such ideas frequently occur in religious fanatics, though they are predominantly driven by a certain selflessness. Their struggle is guided by public interests, which they strive to place at the forefront. They serve people devotedly, sacrificing their personal happiness for the sake of an overvalued idea.

The following clinical case serves as an example of an overvalued idea.

Patient Sh., 46 years old, a forestry technician. While measuring tree trunks, he noticed a correlation between their diameter and their distance from the forest edge. He reasoned that if he could derive a formula characterizing this relationship, it would be of great significance for calculating timber volume. He continued his observations and, after some time, derived the formula. Sh. submitted his calculations and articles to various scientific journals, but failed to gain recognition. Reviewers of his work noted that while the topic was relevant, the calculations were unconvincing and required verification. However, being an insistent and overly proud individual, Sh. remained dissatisfied with the explanations provided in the reviews. Personal contacts with specialists also failed to convince him of the flaws in his calculations. Considering the feedback to be biased, he began appealing to judicial authorities to restore justice and engaged in extensive correspondence. In his replies to opponents, Sh. searched for the minutest errors in the Conclusions of disagreeing scientists, viewing them as proof of bias, conservatism, and an avoidance of responsibility. Sh. devoted all his free time from work to correspondence and the pursuit of further evidence for his correctness. Consequently, he neglected his duties, constantly reverted to the topic of his invention in conversations with family members and friends, expressed indignation, grew anxious, and took offense at any objections. He became irritable and suffered from insomnia.

Delusional ideas

Delusional ideas are incorrect, erroneous conclusions that arise on a pathological basis and are impervious to correction and persuasion.

Four characteristics are most essential in defining delusional ideas: incorrect content, a morbid basis for their emergence, firm conviction in their correctness, and inaccessibility to psychological correction.

Incongruity with reality and false content distinguish delusional ideas from overvalued ones. The patients' assertions are frequently absurd and flagrantly contradict facts, indicating a profound impairment of intellectual activity and a significant decline in critical Functions. A leading role in the genesis of delusional ideas belongs to the impairment of all cognitive spheres, with Disorders of the sensory component being of particular importance. Analyzing patients with acute paranoid ideas, A. V. Kebrykov notes that they are rooted in affective disturbances. Hence, he concludes that the primary sources of delusional ideas may lie at a lower stage of cognitive activity, within the sphere of perception and sensation. Thus, a delusional idea arises on a morbid basis, meaning the primary disturbance is linked to brain damage and manifests as pathologically altered thinking.

Patients' certainty in the correctness of delusional ideas is pathological in nature; they do not abandon their convictions, firmly believing that truth is on their side. Consequently, neither logical nor suggestive Methods can persuade the patient otherwise.

Delusional ideas are divided into two main forms: primary and figurative (sensory).

A primary delusional idea is interpretive, rooted in a structural thought disorder (autistic, paralogical, symbolic, and other variants), with facts, external events, or internal experiences serving as the starting point. Primary delusional ideas impair rational cognition of the environment while sensory evaluation remains intact. This form of delusional idea is characterized by persistence and progression leading to The formation of a delusional system (systematized delusion).

Within the framework of primary delusional ideas, several subtypes are distinguished. Delusional insights represent the sudden emergence of a delusional idea. Delusional awareness resembles a flash of clarity—the sudden intuitive grasp of the "true" meaning of a real event. Delusional presentation arises as a sudden intrusion of memories or thoughts endowed with special personal significance (e.g., having once been asked about a family history of Cancer leads to the conviction of having cancer). Delusional perception involves a sharp, radical alteration in the meaning of everything perceived at that moment. Primary delusional ideas also encompass delusions of invention, reform, erotomania, etc.

Sensory (figurative) delusional ideas are secondary delusional ideas grounded in hallucinatory experiences; they possess a sensory-figurative character and are accompanied by active imagination. When patients attempt to explain various perceptual disturbances, delusional ideas are formed. Therefore, sensory delusions are frequently accompanied by bewilderment and anxiety.

Affective delusional ideas (holothymic) are essentially a variant of sensory delusional ideas, arising against the background of a depressive or manic state.

Various clinical variants of secondary delusional ideas are distinguished: hallucinatory delusional ideas, based on hallucinations; cenestopathic delusional ideas, associated with interoceptive disturbances (cenestopathies); confabulatory delusional ideas, formed on the basis of confabulations; and psychogenically induced delusional ideas, arising from a psychotraumatic situation and heightened suggestibility (such as delusions of the deaf, or railway paranoid described by Zhylin (1965), associated with long journeys and unusual external circumstances).

Structurally, delusional ideas are classified as incoherent, coherent (unsystematized), systematized, and residual.

Incoherent delusional ideas lack a unifying plot; they are fragmentary and often driven by isolated facts snatched from the general context, such as in states of altered consciousness (delirium, amencephalia).

Coherent (unsystematized) delusional ideas are observed in thought disorders where a sequence of delusional notions follows logically from one another, such as delusions of physical influence coupled with delusions of hypnotic control.

Systematized delusional ideas frequently occur in paranoid syndrome, where all aspects of a patient's public and personal life are interpreted from the standpoint of persecutory, grandiose, or self-deprecating delusions.

Residual delusional ideas are figurative ideas that persist for some time as a monosymptom following the resolution of other psychotic manifestations and the restoration of a critical attitude toward them.

According to their dynamics, delusions are classified into stable, unstable, transforming, oscillating, and induced.

Stable delusions are characterized by persistence and significant prominence of the pathological ideas, as observed, for example, in paranoid schizophrenia.

Unstable delusions may occur during brief Disorders of Consciousness, such as twilight states or delirium.

Transforming delusions are characterized by the evolution of one delusional content into another: a delusion of persecution gradually shifts into a delusion of grandeur, or vice versa.

Oscillating delusions are characterized by the periodic recurrence of the exact same delusional ideas throughout the course of the pathological process.

Induced delusions may develop in relatives or individuals closely cohabiting with a psychiatric patient, provided There is a certain degree of psychological dependency on the patient (children, intellectually disabled persons, psychologically immature individuals, etc.).

Thus, both Primary and secondary delusions are accompanied by significant affective coloring. This principle underlies the most common Classification of delusions based on their content:

— group of delusions of grandeur;

— group of delusions of self-deprecation;

— group of delusions of persecution.

The group of delusions of grandeur is frequently characterized by an elevated mood. They occur in affective mood disorders, general paresis, schizoaffective disorders, and manic syndromes of exogenous origin. This group includes the following ideas:

1. Delusions of grandeur — the patient's firm belief in possessing immense power or being a messenger of God in the guise of Jesus Christ, etc.

2. Delusions of omnipotence — the patient's belief that all natural and social events depend entirely on their will and desire.

For example, patient B., 53 years old. In the psychiatric ward, he holds himself with confidence, speaks with pomposity and indignation, and is occasionally aggressive. He calls himself a "field marshal" and "ruler of the world," and hears "voices" coming from other PARTS OF THE world that converse with him. He claims he can freely teleport to the Moon, Jupiter, and other planets. From there, he rules the Universe and the motion of celestial bodies. He demands immediate discharge and wishes to travel to Moscow, where he will be "given as much money as he desires."

3. Delusions of wealth — frequently observed in patients with general paresis who assure those around them that they possess untold riches.

4. Delusions of immortality — the patient claims to have lived for millions of years and will continue living, suffering for all of humanity (observed in depressive syndrome).

5. Delusions of inventiveness — patients consider themselves to be ingenious inventors.

For example, patient L., 53 years old, an agronomist. His wife applied to the psychoneurological clinic, reporting that over the past year her husband had abandoned his work, spending entire days and even nights writing something and carefully hiding his notes. Summoned by the physician, the patient stated that he had created the L-2 apparatus, which can intercept thoughts at a distance. In the patient's opinion, this invention could serve as the foundation for a new technological revolution and is of great importance for the country's defense. He brought along A large number of drawings, diagrams, and a thick manuscript in which, using elementary algebra equations and simple laws of physics, he attempts to substantiate his "hypothesis." He told the doctor that he had taken the first copy of the manuscript to Moscow, but his suitcase was stolen along the way. He is absolutely certain that the theft was carried out by foreign intelligence agents. The patient relates all of this with a wealth of detail and meticulous thoroughness. Deeply convinced of his correctness, he rejects any notion that he could be mistaken.

6. Delusions of reform — manifested in a drive to implement social and political restructuring; for instance, proposing a novel method to prolong human life by freezing the body at temperatures of -273 °С, etc.

7. Delusions of being loved (erotomanic delusions) — patients are convinced that a prominent person is in love with them because of their rare beauty and extraordinary attractiveness.

The group of delusions of self-deprecation is accompanied by a depressed, low mood and occurs in depressive and melancholic states, as well as endogenous Delusional syndromes. This group includes:

1. Delusions of guilt — very common in depressive syndromes, where patients accuse themselves of having committed disgraceful acts and are ready to face any punishment, up to and including suicide.

2. Delusions of inferiority — the patient considers themselves worthless, stupid, and unworthy of respect from others.

3. Hypochondriacal delusions — patients are convinced that they suffer from an incurable disease, such as cancer, Syphilis, etc.

A characteristic clinical case is as follows. Patient X., 32 years old, a factory worker. In terms of personality, she is hot-tempered, stubborn, despotic, and highly suspicious: "If a pimple appears on my hand, I run to the doctor to check if it's eczema!" Her medical history includes a gynecological condition for which she received specialist treatment. Once, following accidental contamination of her external genitalia, the thought arose that she had contracted syphilis. She began to experience pain throughout her body and aching sensations. It seemed to her that her Tongue was disintegrating, her Nose was rotting, and red patches were appearing on her skin that could only be discerned with "a very sharp eye." She read a manual on venereal diseases and discovered all the symptoms of syphilis in herself. A dermato-venereologist thoroughly examined the patient and ruled out this Diagnosis. The patient then concluded that she had "latent syphilis." She informed all her friends so as not to infect them, isolated herself from her husband, and boiled her laundry and dishes for hours. All attempts to reassure the patient were futile. She was utterly convinced of her illness and intended to commit suicide. The patient dismissed all objections from the doctor and relatives regarding the baselessness of her suspicions, refusing even to listen to their arguments.

4. Nihilistic delusions (Cotard's syndrome) — patients are convinced that their Internal Organs are missing and that they are dead. They feel food dropping into a void, etc.

The following clinical case is typical. Patient B., 22 years old, a soldier. The mental illness developed acutely following an Influenza infection. He began to complain of constant sore throat, expressed the belief that he was suffering from laryngeal tuberculosis, that his throat had rotted away, that he could not breathe freely, that all his teeth had fallen out, that his chest was hollow, and that everything had rotted. He refuses food because he has no connection to his stomach, «The Stomach is dead,» and «all internal organs have glued together.» He stated that he was a corpse and moved only because an electric current was being passed through him. In the hospital, he does nothing, is isolated, anxious, and has a depressed mood.

5. Delusions of guilt — patients are convinced that they are sinful, have gravely wronged people and humanity as a whole, and therefore demand punishment for themselves.

6. Delusions of impoverishment — the conviction that one lacks the material means for living despite having sufficient household provisions.

7. Delusions of physical deformity — the conviction of having a physical deformity that everyone around them notices.

8. Delusional parasitosis (dermatozoic delusions) — patients claim that there are specific living creatures under their skin.

In the first years of their formation, persecutory delusions are tinged with fear and anxiety, which may later transform into anger and rage toward imaginary persecutors and even lead to violent acts. The group of persecutory delusions includes the following ideas:

1. Delusions of persecution — patients believe they are under the constant surveillance of a person or a group of people: hostile intelligence agents or strangers who are ill-disposed toward them.

An example is the following clinical case. Patient R., 19 years old, a student. He applied to the police with a letter of the following content: «Please take measures and protect me from the persecution of a gang of bandits and hooligans. They locked me in an asylum and are conducting experiments on me. They secretly implanted a radio communication device in my HEAD, 'some kind of central brain,' and constantly negotiate with me using ultra-high frequencies, giving me not a single moment of peace. They stuff dirty thoughts into my head and force me to answer them, and they have put my feelings under an iron cap. For hooligan purposes, they move my tongue, force me to utter obscene words, and cram my head with their provocative conversations. At night they take out my heart and Lungs and put others in their place, 'cybernetic' ones. They say that I am allegedly hypnosis, forcing me to act on people. I have become completely beside myself, even eating and walking automatically. And the whole time they mentally tell me that they have made a robot out of me. Once again, I ask you to immediately take measures against these hooligans.»

2. Delusions of physical influence — patients are convinced that persecutors use technical means of influence, impair their thinking and willpower, and cause unpleasant sensations.

3. Delusions of psychic influence — in content, these are akin to delusions of physical influence, except that here the patient's mental activity is affected through telepathy or hypnosis.

4. Delusions of poisoning — patients are convinced that attempts are being made to poison them or that they are being poisoned with special venoms. This type of delusion is frequently encountered in schizophrenia and organic mental disorders.

5. Delusions of theft (deprivation) — patients are convinced that those around them, most often relatives, are stealing from them and wish to seize their apartment and property. Delusions of theft are frequently encountered in organic mental disorders.

6. Delusions of jealousy — patients are firmly convinced that their spouse is betraying them and is unfaithful in marital relations.

For example, patient K., 42 years old, an engineer. He had been abusing alcohol for 10 years. He was deeply convinced that his wife was cheating on him with the head of the department where she worked as a laboratory assistant. He began to follow her, recorded the time she came home from work, and systematically inspected her underwear. Later, under the threat of a knife, he forced her to place small balls into her Vagina, which he counted upon her return from work. The loss of 1-2 balls served as confirmation of marital infidelity. A final threat to kill her and an axe purchased for this purpose forced the wife to seek help.

7. Delusions of ordinary relations (micromania) — themes of minor losses, intentional spoilage of items, harassment, and attempts at poisoning predominate.

8. Litigious delusions (querulent paranoia) — in this case, patients are convinced that others are violating their rights and treating them unfairly. Patients write numerous Complaints to various authorities and the press, and sue all supposed ill-wishers.

9. Ideas of reference — patients believe they are constantly in the spotlight and that everything around them relates to them. On the radio and television, they constantly hear and see various hints directed at them. A variant of this is sensitive ideas of reference, when patients believe that others think poorly of them, are negatively disposed, discuss them, or ridicule them.

10. Delusions of special significance arise when the patient finds special symbolic «signs» in their surroundings that indicate certain actions directed at the patient, warn of danger, or threaten them, etc.

11. Delusions of doubles may include the symptoms of positive and negative double. In these cases, patients believe that unfamiliar people with hostile intentions bear the likeness of acquaintances or relatives, or conversely, that acquaintances for some reason are hiding their true faces from them.

12. Delusions of dramatization — the surroundings are perceived as artificial, staged, resembling stage sets. Close to this variant are delusions of intermetamorphosis, in which, According to the patient, everything around them is constantly changing and people are transmuting.