Confabulation in psychology: what is typical, these are in simple words, examples, reasons

Are you sure you can trust your memories? Did you know that our brain can think through events? And also sometimes he connects real facts with fictional ones, especially when it comes to old memories. In psychology, this is called confabulation, but it is more often talked about in the context of mental disorders. Let's take a closer look at what it is, how it manifests itself, and how it is treated.

What is confabulation

Wikipedia describes it as false memories, in which real or altered facts are combined with fiction, or transferred in time. The name is derived from the Latin word confabulari, which means “to chat,” “to tell.” The phenomenon was discovered by the German psychiatrist K. L. Kahlbaum (1866).

Confabulation is a memory disorder in which a person becomes confused about memories. He connects events from different times, transfers them from one time to another, combines real facts and fiction, transforms real memories. To think through events and feelings of the past, the brain uses events of the present. He comes up with similar, probable, logical scenarios.

Confabulation and pseudo-reminiscence

As a rule, confabulation refers to both inventing events and transferring memories in time. However, in Kahlbaum's original theory, each of these phenomena has its own characteristics.

He called confabulation a condition in which a person makes up memories. And he called the condition in which a person transfers memories from one period to another “pseudo-reminiscence.” In another way, the first is called a hallucination of memory, and the second is called the illusion of memory. Both conditions belong to the same memory disorder - paramnesia.

Modern psychiatrists combine both conditions into one memory disorder - confabulation.

Confabulation in normal and pathological conditions

Most often, confabulation is viewed as a memory disorder. However, this also occurs in healthy people. Moreover, the process can be conscious (a person consciously complements memories) and unconscious (thinking through it is activated as a defense mechanism of the psyche).

Thus, confabulation in psychology is false memories of something fictitious or a real event. In the latter case, the person is confused in time (the facts are real, but the chronology of events has been changed).

Confabulation can be a pathology, a defense mechanism, or the result of suggestion (a person forgot something, and another person told him a made-up fact).

How to detect the cause of a pathological process

Confabulations refer to disorders of thinking and memory. Therefore, an interdisciplinary approach is necessary. Diagnostics is based on several measures.

Anamnesis collection. The specialist collects the patient’s health complaints. These include headaches, confusion and other disorders.
Oral conversation. Necessary to identify memory impairment. It is good if the patient’s relatives are present during the study. It is mandatory to interview the relatives themselves or people who could tell more about the sufferer. For example, friends, close acquaintances.
Specialized memory tests. False memories with a belief in their truth do not arise alone. They are accompanied by massive memory impairment. Therefore, changes will be noticeable immediately. For example, the patient is offered 10 words. Then he names them in free order. A good result is from 6-7. Confabulation may result in complete failure of the test. They also use figures and cards with drawings.
MRI of the brain. To identify possible organic pathologies of cerebral structures.
Electroencephalography. Also rheoencephalography to examine functional disorders of the brain.

The diagnosis doesn't end there. If psychosis is suspected, the patient undergoes a full psychopathological examination, preferably in a hospital setting. The question remains with the doctors.

Types of confabulations

Confabulations are discrete memory disorders. They act as symptoms of various mental illnesses. Psychologists classify confabulations by content and origin.

By content:

ecmnestic – transfer of events to the past, loss of adequate ideas about reality and one’s age;
mnemonic - inventing events in the present;
fantastic - inventing implausible scenarios for the development of events.

By origin:

delusional – not associated with memory disorders, combined with delusional states and ideas;
suggested - emerge in response to an external stimulus (question, hint);
substitutive - thoughts that compensate for forgotten events from the past or present;
oneiric – arise in response to a disturbance of consciousness, reflect the theme of experienced psychosis;
expansive - associated with obsessions that arose as part of megalomania.

Sometimes fantasizing occurs out of confusion. A person comes up with facts that he is not sure of or does not know.

Categories of memory impairment

There are several classifications of confabulation:

- Delusional thinking - characterized by completely fictitious events and phenomena that did not happen in the past and could not possibly have happened;

- Inspired thoughts - a person voices not his own opinion, but inspired thoughts under the influence of someone else;

- Mnestic disorder - characterized by the replacement of some historical events by others. Often occurs with amnesia and other memory disorders;

- Oneiric disorder - false memories arising under the influence of psychosis.

Confabulation: examples

In most cases, the individual himself is not aware of the specifics of his condition. However, if he talks about something that other people remember well, then they may suspect a violation.

Tell me, have you ever had a situation where you or someone said to you: “You told me that yourself then, remember?”, and in response: “I remember our meeting, but I definitely didn’t say that.” The most common example of confabulation in healthy people: we confuse or invent places, words, actions.

Among pathological manifestations, a striking example is the story of a patient from the Highland Psychiatric Hospital. He claimed that the government had sent him to secretly obtain drawings of the catacombs. He talked about it in great detail and excitingly. So brightly that the orderlies even began to believe at some point. But it soon became clear that the patient had schizophrenia, and confabulation was its symptom.

Experiment promotes creative justifications

A groundbreaking experiment has proven that everyone is prone to false memories from time to time. Two American psychologists, Richard E. Nisbett and Timothy Wilson from the University of Michigan, laid out various items of clothing such as nightgowns and nylon stockings. Participants in the experiment were asked to choose an object.

Image by janrye from Pixabay

Participants were asked to say which item was of better quality and explain the rationale for their choice. It could be seen that the vast majority of subjects took the object from the right side. The surprising thing is that when the subjects were asked the reason for their choice, no one gave the obvious reason, namely that the position of the object played a role in the choice. And even more interesting: when they were asked directly whether this position could have had an impact, the answer was no.

Instead, it was possible to identify a series of confabulations: color, nature of material - even with identical things: participants came up with all sorts of reasons that had nothing to do with the obvious, but were nevertheless plausible. That is, they did not admit the obvious, but they sincerely believed in their selection criteria.

Symptoms

Inventing occurs due to amnesia - the loss of part of the memories. However, this is not a mandatory criterion. Sometimes fantasizing occurs along with real memories. And also sometimes there is an overlap of fantasies with each other. In this case, the person suffers from disorientation.

Most often, false memories are of a fantastic nature. They are replete with details and from the outside seem completely ridiculous. Patients talk about discoveries, heroism, etc. Despite the fantastic coloring, the logic of the presentation can be traced. All events are interconnected.

The specificity of the disorder is that confabulation has a paroxysmal nature. That is, a person immerses himself in fantasy for a while, stories about it, and then returns to reality. It’s as if he’s “covered” for some time. At the same time, the person remains in a clear consciousness.

Symptoms

There are several main symptoms. All of them are related to the facts presented. In order to identify manifestations, you need to talk with the patient.

The discrepancy between what happened in reality and what the sufferer says

It is quite simple to identify this - just interview a person. It is important that the data be verifiable. That is, so that the essence of what is being stated can be verified. As a rule, relatives or other people, those who are aware of the situation, are involved in checking. Otherwise, it is impossible to establish the truth or falsity of memories. There are false memories from childhood.

No intention to lie

A lie is a purposeful distortion of reality to please oneself or something else. In the case of confabulation, this component is missing. Confabulations are typical for patients with mental disorders and organic brain lesions. If a person is “not himself,” he is not capable of lying. Simulation is possible, but experienced psychiatrists immediately detect attempts, so the likelihood of error is extremely low. Especially if relatives are present during the survey, especially when they participate.

Fantastic nature of statements

It is observed in schizophrenia. The patient tells something that simply cannot happen in reality. About aliens, intelligence agencies, divine revelations. The plot of delirium, as well as the essence of confabulations, depends on the patient’s initial worldview, since it is usually religious, mystical, and memories are of a typical nature.

Delusionality

Also in schizophrenia. For example, persecution by intelligence agents. With the development of such confabulations, there is no longer any doubt about the diagnosis. But it is necessary to examine the patient with additional methods.

Mood disorders

Especially if you try to convince the patient. Therefore, psychotherapists act gently, striving to ensure that the sufferer himself remembers what happened to him. When they try to convince a patient, he reacts in two ways. The first and most common is anxiety, increased motor activity, and agitation. Attempts to convince everyone who doubts.

The second and rarer option is open aggression.

Reaching physical impact. Although some element of aggression is possible in the first case. The sufferer is upset that they do not believe him. Therefore, relatives need to show maximum tact towards the patient so as not to aggravate the situation.

Dream-speaking

False memories are sometimes reproduced in dreams. The sufferer speaks while he sleeps. This happens especially often with depression, OCD, and psychotic disorders.

The symptoms are typical. Especially for an experienced psychiatrist.

Causes

Reasons for the development of confabulation:

psychological trauma;
physical, organic brain damage;
mental pathologies;
somatic diseases, for example, cancer, ischemia;
intoxication of various etiologies.

A separate risk group consists of older people and people with senile dementia.

Alcohol confabulation deserves special attention. Under the influence of alcohol, a person develops hidden accentuations, suppressed character traits and mental illness (propensity to them). Very often, when intoxicated, people tell their fantasies.

Most often, psychologists have to deal with provoked confabulations (secondary). They appear briefly in response to amnesia, stress, and dementia. Their opposite, spontaneous confabulations (primary), arise on their own, are fantastic, and are not associated with the remarks of other people.

Provoked confabulations can be explored directly in a session with a psychotherapist.

Involutional delusional psychosis, occurring in the form of acute paraphrenia

Introduction

Involutional delusional psychosis, traditionally designated as involutional paranoid, despite more than a hundred years of history of study, is still a rather vague nosological unit. The long-term “classical” discussion about its nosological independence, development mechanisms, features of the clinical picture and prognosis is well known [6, 12, 14]. The lack of a common point of view on these issues was probably one of the reasons for the exclusion of involutional paranoid (as a separate nosological unit) from modern international classifications of diseases. Nevertheless, the need to continue studying this mental disorder is dictated by the realities of clinical practice. Without occupying the reader's attention with a repeated discussion of controversial issues related to the doctrine of involutional paranoid, this article presents the observation of a disease with a rare (but not casuistic) clinical picture and its analysis.

Patient T., born in 1951 (61 years at the start of follow-up)

Anamnesis from the words of the patient (after recovery) and his wife: none of the relatives contacted psychiatrists. My father was domineering, demanding, a military man, and died of stomach cancer at 71. My mother is tough, strong-willed, and worked as a nurse. Alive. Since the age of 70, she has had memory impairment; she says that “the neighbors’ motors are running, which interferes with sleep,” although she lives alone in a private house. The older sister was soft, kind, sympathetic, and died at the age of 55 from stomach cancer.

Born second child. Natural childbirth. There is no information about early childhood. I went to school at the age of 7. I changed it several times because my parents moved. He easily made friends among his peers. He actively participated in the social life of the school. I studied mediocrely. In high school, I became interested in music, played the guitar, and wrote poetry.

After finishing school he served in the army. He quickly settled into the team. There were several encouragements from the unit commander. After demobilization, he entered the Polytechnic Institute, Faculty of Engineering. I studied by correspondence. He was meticulous in completing tasks. I checked the results of my calculations several times. At the same time as studying, he worked as a mechanic at a garment factory, where he met his future wife. After graduating from the institute, he continued to work at the plant as an engineer. He proved himself to be a responsible worker. Received several thanks from management. Got married. A son was born. He devoted a lot of time to his upbringing.

At the age of 46, he lost his job due to layoffs due to the closure of the plant. I had a hard time experiencing what happened. He told his wife: “It’s all my fault, I should have thought about a new job earlier,” “What should I do now?”, “Who needs me now?” A few months later he found a job again. The condition returned to normal spontaneously. However, he did not stay at work for long. Within 3 years I changed several companies. I quit myself. He explained the reasons for his dismissal by conflicts with his superiors: “We didn’t get along in character.”

At the age of 49, soon after another job as an engineer, I began to sleep poorly, was anxious, and my mood decreased. For the first time I turned to psychiatrists. He was stationed in PB No. 8 in Moscow. Upon admission (according to the discharge summary): “lethargic, asthenized, speaks quietly, slowly, monotonously. Inhibited, answers questions with a delay. Fixed on his painful sensations. The mood is low. Looking for help, sympathy. Ready for treatment." He was hospitalized for a month with a diagnosis of “Mixed anxiety and depressive disorder (F41.2).” He received tianeptine, phenazepam, glycine, bellataminal, and physical therapy. The condition has returned to normal. After discharge I felt well. He took maintenance therapy for a year.

He left the factory and got a job as a driver and forwarder for the publishing house where his wife worked. Since then he has worked successfully in this position. He was engaged in the delivery of newspapers from the printing house to distribution points. In his free time from work, he was engaged in household chores, apartment renovation, and arrangement of a country house. He took care of his elderly mother: he cooked food, cleaned the house, and did laundry. According to his wife, “everything was on him.” Relatives did not note any peculiarities in behavior.

At the age of 59 (a year before re-visiting psychiatrists) he changed. Became “soft”, “sentimental”. I could easily cry, for example, when watching Soviet films about the war. I lost interest in work and spent almost all my time “working in the garden.” He became “absent-minded”, could look for his things for a long time, “forgot” why he went to the store.

At the age of 60 (February 2012) the condition suddenly changed. Became withdrawn. Did not sleep. I cried often. Barefoot, he went outside and got frostbite on his feet. He explained it this way: “I wanted to prove that I can walk in the snow.” He told his wife that he “has a second family for which he is responsible.” He claimed that the “second family” had existed for more than 7 years, but “I just remembered it.” He called a work colleague (a friend of his wife) “second wife” whom he did not know closely. “I remembered” that I have a 14-year-old daughter from my “second marriage.” One evening he became excited, was eager to leave the house, and wanted to go to his “second family.” I asked my wife for a phone number so I could call my “second wife and daughter.” He said that they were “in danger” and “I must visit them and warn them.” Fell asleep after taking diazepam. At the insistence of his wife, he was consulted by a local psychiatrist. Sent to the Psychiatry Clinic named after. S.S. Korsakov. Was hospitalized. He was in the hospital from March 27, 2012 to June 20, 2012.

Mental condition . Neatly dressed. Sits hunched over. Looks older than his age. Doesn't look at doctors. He speaks quietly. He says that “there is a second family, a daughter,” which he “remembered recently.” Starts to cry. He asks: “What should I do now?”, “What should I do?” It takes a long time to calm down. He continues to explain that the “second wife” appeared a long time ago: “I just forgot her, but now I remember.” Calls her name. It is impossible to find out anything more about the experiences on the first day. Over the next few days I began to talk more about them. At the beginning of conversations he speaks only about his “second family,” but over time he talks and describes more and more new and unexpected “biographical facts.” He says that “there is a third wife,” but does not know “if there are children, perhaps a son.” He describes how he worked in Afghanistan during the war: “delivering mail on a tarantass.” “I remembered” that I had been in the department where I was being treated before. Some patients and staff are “familiar” to him. During a consultation with a neurologist, he said that he knew her well. He says that he is a “deeply secret intelligence agent.” He explains his “memories” by saying that “a block was put on his memory a long time ago,” “it is now subsiding, and that’s why I remember everything.” Later he began to say that he was a “famous engineer” and “made discoveries.” For example, he “invented a device for measuring pressure.” He adds: “There is still much to be discovered, perhaps even in psychiatry.” Confident in conversation with the attending physician. However, if an unfamiliar doctor enters the office, he becomes silent. The story continues after explaining that this is also a department doctor. He performs intelligence tests only after repeated explanations of the task, very slowly, and retests himself. When performing counting operations, he asks for a sheet of paper. Performs the calculation “100 minus 28 minus 15” only after recording the task. Correctly draws clock hands indicating the named time. Can display a triangle in a square. When writing, the outlines of letters are uneven. Writes with errors: repeats letters in words, misses letters. For example, the word “to say goodbye” is written “say goodbye” or “say goodbye.” In the department he serves himself. Immediately after hospitalization, he is quiet, secluded, and inconspicuous. He doesn’t communicate with anyone, he doesn’t seek conversations with doctors. A few weeks later he asked doctors to allow him to exercise. I ordered a gym mat and a manual for gymnastics from my wife. I started doing physical exercises every day for one to two hours. For example, lying on his back in a room on the floor, he raised his legs to the ceiling. He took full care of himself, kept his bed and bedside table in perfect order.

Somatic condition . During clinical examination, attention is drawn to a slight increase in blood pressure (130/90 mm Hg) and tachycardia (90/min). Clinical blood test, general urine test, biochemical blood test - indicators are within normal limits. The complex of serological reactions to syphilis is negative. Electrocardiogram - deviation of the electrical axis of the heart to the left, mild changes in the myocardium. Echocardiogram - thickening of the aortic walls, slight insufficiency of the mitral and tricuspid valves, decreased diastolic function of the left ventricle. Color duplex scanning of the brachiocephalic arteries - atherosclerotic changes in the extracranial sections of the main arteries of the head with stenosis of the mouth of the left internal carotid artery by 40%, the mouth of the subclavian artery by 40%, deformation of the course of both vertebral arteries in the canal of the transverse processes of the cervical vertebrae. Consultation with an ophthalmologist - vasospasm, arteriolosclerosis, phlebopathy, initial picture of intracranial hypertension.

Neurological condition . Oral automatism reflex, anisoreflexia (D > S), unclearness when performing coordination tests on the left. Electroencephalogram - no pathological changes were detected. Computed tomography - hypodense areas in the subcortical regions (more on the left), probably of vascular origin; the lateral ventricles are not dilated, the width of the cortical grooves corresponds to age. Magnetic resonance imaging of the brain - vascular lesions in the subcortical regions measuring from 0.2 to 0.4 cm. The subarachnoid spaces of the cerebral hemispheres are expanded in the temporoparietal regions (“signs of atrophy”). Consultation with a neurologist - existing changes in neuroimaging of the brain indicate the presence of vascular damage involving the subcortical regions. There are no signs of the atrophic process. Existing organic changes cannot be decisive for the severity of the patient’s mental state.

Therapy and dynamics of the condition . Considering the patient’s vivid delusional experiences, after his admission to the hospital, therapy with risperidone (up to 6 mg/day) and olanzapine (5 mg/day) was started. Given the lack of positive dynamics and increased intensity of delusional symptoms during 3 weeks of observation, risperidone and olanzapine were discontinued. Therapy with haloperidol (15 mg/day) was prescribed. After 2 weeks, the mental state began to improve, which was manifested by the gradual deactualization of delusional ideas. Before discharge: calm. He doesn’t talk about his experiences: “It’s better not to remember.” When questioned, he answers: “I probably made it up, fantasized it.” He asks his wife for forgiveness “for what happened” and “caused such trouble.” He communicates with her warmly. He wonders if she copes with housekeeping and caring for his mother. After discharge he wants to return to work. In a clinical conversation, no signs of memory and intelligence impairment are revealed. Performs tests correctly. There are no violations when writing. Noteworthy are the signs of neuroleptic syndrome (mild akathisia, hypokinesia), which developed shortly after the administration of haloperidol and required the addition of trihexyphenidyl (10 mg/day) to therapy. 3 months after hospitalization, the patient was discharged with recommendations for dynamic observation by a psychiatrist and maintenance therapy with haloperidol (12 mg/day), trihexyphenidyl (10 mg/day).

Catamnesis . The patient was under outpatient observation at the clinic for a year and a half. During this period, there were no signs of deterioration in the condition. Returned to his previous job. He continued to run the household and finished renovating the house. As before, he looked after his mother. When visiting a doctor: friendly, friendly, polite. He himself does not talk about experiences in the past. When questioned, he calls them “fantasies,” “fiction.” Remembering them, he blushes. He adds that he caused “a lot of trouble for his wife and son.” He willingly talks about his life at home. There are no signs of memory impairment or decreased intelligence. Carefully took the prescribed haloperidol therapy (with a gradual dose reduction to 5 mg/day). Despite the correction of the neuroleptic syndrome with trihexyphenidyl, signs of akathisia and hypokinesia persisted. In conversations, he focused the doctor’s attention on the unpleasant sensations in the hips and restlessness. I was interested in the possibility of stopping treatment. Due to persistent extrapyramidal symptoms, after six months of outpatient follow-up, haloperidol was discontinued. Given the uncertainty of the prognosis in the absence of maintenance therapy, risperidone 1 2 mg/day was prescribed. After changing the treatment regimen, the symptoms of neuroleptic syndrome were avoided without additional administration of trihexyphenidyl. A year after the initial visit, he was re-examined instrumentally and consulted by interns at the Psychiatry Clinic named after. S.S. Korsakov. No significant changes (compared to data from a year ago) were detected in routine tests, ECG, EchoCG, neurological status, or MRI of the brain. Over the next six months after the examination, the mental state remained the same. During this period, neuroleptic therapy was discontinued.

1 The drug “risperidone” was used, produced by a domestic company that has proven itself with a number of antipsychotic drugs (clozapine, sulpiride, tiapride).

Discussion

The described clinical observation is of interest from the point of view of the syndromic and nosological qualification of the psychotic state suffered by the patient. Its structure was dominated by confabulatory delusions and delusions of grandeur (“remembered” the “second” and “third” family, “work” in Afghanistan, his “discoveries”, some of which he still “had” to make). This combination of symptoms (in the absence of clear symptoms of another circle) allows us to qualify the condition within the framework of the confabulatory variant 2 of paraphrenic syndrome. However, its atypicality is of interest. The combination of confabulatory delusions and delusions of grandeur is usually observed within the framework of chronic paraphrenia (with a long course of mental pathology) [9]. In acute paraphrenia, which developed in the presented patient, it is rare. The extreme absurdity of confabulations, devoid of any “intellectual assessment” (“delivered mail on a tarantass”, “invented a device for measuring blood pressure”) is noteworthy. The emotional state of the patient is devoid of vivid manifestations characteristic of paraphrenic syndrome (confusion, complacency, malice). On the contrary, there are obvious signs of hypothymia, which is rarely found in paraphrenic states (he cried, talking about his experiences, “what should I do now?”, “What should I do?”). Its development is explained by the patient’s awareness of a “complex moral and ethical situation” (“the presence” of three families), which indicates the preservation of the personality traits of the same name. In addition to confabulatory delusions and delusions of grandeur, the clinical picture included other symptoms of the delusional register - illusory recognitions (recognized acquaintances among doctors and patients of the clinic), elements of persecutory circle delusions (“the second family is in danger”). However, these symptoms were not decisive for the syndromic qualification of the patient's condition.

Another issue, the discussion of which is important for establishing a diagnosis, is the mechanism of delusion formation. True psychosis developed suddenly with the appearance of delusional ideas without immediate anticipation of other striking mental symptoms. The structure of the delusion did not contain false interpretations and incorrect conclusions (the basis of the primary interpretative delusion), significant disturbances of affect or deceptions of perception (the basis of the secondary acute sensory delusion). Therefore, it is obvious that the traditional understanding of the variants of primary and secondary delusions in Russian psychiatry is unacceptable in this case. In this regard, it is worth turning to the works of French psychiatrists [13, 15], who identified delusion of imagination as one of the variants of primary delusion - a concept rarely used in Russian psychiatry 3 . The mechanism of its development lies not in errors of judgment, but in disturbances in the sphere of imagination. This version of delusion occurs in the form of “fantasies” that are not associated with real events, with clear consciousness, the absence of vivid affect or pronounced deceptions of perception. Delusional ideas are megalomaniac in nature. Patients “state” them without providing “logical” evidence (as opposed to interpretive nonsense). The authors who described delusions of imagination pointed to the phenomenon of expanding the content of delusional ideas with active questioning of the patient. This symptom was observed in the presented clinical observation (“at the beginning of conversations, he talks only about the “second family,” but over time, as he talks, he describes more and more new and unexpected “biographical facts”).

Moving on to a discussion of the nosological affiliation of the described psychosis, it is necessary to note the initial difficulties that arose in the diagnostic process. The atypicality of the disease determined the impossibility of its rapid nosological classification “by recognition” and gave rise to a discussion among the staff of the university clinic. The disagreements, however, were successfully resolved after a thorough analysis of the individual clinical characteristics of the disease (including its outcome), i.e. in the process of making a complete (methodological) diagnosis 4 . The reasons for the initial discussion were: atypical current psychopathological symptoms, periods of development of painful conditions in the past, and the presence of organic changes in the brain identified by neuroimaging. Differential diagnosis was carried out between psychosis within the atrophic process, vascular psychosis, the phase of manic-depressive psychosis and involutional delusional psychosis (involutional paranoid).

The assumption about the atrophic nature of the current psychosis was born from the identification of difficulties when the patient performed logical operations (“performs intelligence tests only after repeated explanations, very slowly, double-checks himself”, “performing counting operations, asks for a sheet of paper”, “performs calculations only after writing down the task "), errors in specific tests ("when writing, the outlines of letters are uneven", "writes with repeated errors: repeats letters in words, makes omissions of letters"), the extreme absurdity of paraphrenic ideas, devoid of any "intellectual assessment" ("delivered mail to tarantass", "invented an apparatus for measuring blood pressure") and data on the expansion of the subarachnoid spaces in the temporo-parietal regions (initially interpreted by radiologists as cortical atrophy). However, the diagnosis of atrophic brain disease was rejected. The reasons for this were: the acute onset of the disease, the absence of obvious signs of intellectual-mnestic disorders before the onset of current psychosis, the refutation by neurologists of neuroimaging data on the presence of an atrophic process and, finally, a favorable outcome (restoration of criticism, the absence of signs of memory and intellectual impairment after the psychosis subsided, complete social readaptation).

The acute onset of the disease, periods of psychopathological symptoms in the past (“asthenization”, sentimentality) and data from instrumental examinations (multiple vascular foci in the brain, changes in the myocardium and great vessels) led to the emergence of an opinion about the possibility of the vascular nature of real psychosis (“catastrophe” in neurologically silent areas of the brain). However, a dynamic assessment of the current mental state did not reveal signs characteristic of vascular pathology - exhaustion of mental processes and wave-like flow. Magnetic resonance imaging data 5 indicated vascular damage only to subcortical structures (with the cortex intact) and the absence of signs of acutely developed cerebrovascular accident. The complete “recovery” of the patient is another piece of evidence that there is no direct connection between the psychosis suffered and the vascular factor.

The point of view about the phase origin of psychosis (manic phase within bipolar affective disorder) was born on the basis of the observation of the presence in its structure of ideas of grandeur in combination with increased physical activity (daily long-term physical exercise). This opinion was confirmed by anamnestic information. A period of psychopathological symptoms in the past, regarded as “mixed anxiety and depressive disorder” (“speaks slowly, quietly,” “inhibited, answers questions with a delay,” “low mood”), could be a manifestation of the depressive phase of bipolar disorder. However, the phasic nature of psychosis was quickly rejected, since its structure was determined by delusional rather than affective symptoms. There were no signs of hyperthymia 6.

The sudden onset of the disease in old age with a predominance of delusional symptoms in the clinical picture became the basis for the assumption that the patient developed involutional paranoid 7 . Doubts in this case were associated with the atypical structure of delusional psychosis, since usually involutional paranoids occur with a predominance of delusions of the persecutory group (harm, persecution, jealousy). However, this contradiction was successfully resolved by referring to literature data. Among involutional delusional psychoses, along with involutional paranoid, there are forms that manifest paraphrenic symptoms (“involutional paraphrenia”) [3, 4, 8, 16]. Delusion formation in these psychoses occurs according to the type of delusion of imagination [9]. An interesting opinion is that moderate vascular pathology, often found in old age, can only be regarded as a disease accompanying “involutional paraphrenia” [3]. Therefore, clinical signs of vascular pathology of the brain that were observed in the patient in the past (“asthenia,” sentimentality) can only be regarded as a background or concomitant disease.

The observation of a favorable outcome of the disease in the presented patient deserves separate discussion. Despite the widespread point of view about the protracted chronic course of involutional psychoses [6, 10, 12], in the described case a drug remission was formed, and then intermission 8 (absence of symptoms of the disease for a year while taking antipsychotics and for six months after their discontinuation). Such a favorable outcome is probably associated with the characteristics of psychopathological symptoms that have a favorable course (acute onset, the mechanism of formation of delusions of the “delusions of imagination” type, the predominance of delusional confabulations and delusions of grandeur, the absence of delusional ideas of the persecutory circle). Indications of a favorable prognosis for involutional paraphrenia are found in the literature.

Thus, the above considerations make it possible to formulate a psychiatric diagnosis for the presented patient as: “Involutional delusional psychosis (“involutional paraphrenia”). Acute paraphrenic syndrome with a predominance of confabulatory delusions and delusions of grandeur. The mechanism of delusion formation according to the type of delusion of imagination. Favorable outcome with the formation of intermission.”

2 A novice specialist will be interested in the fact that various forms of paraphrenia [systematized (systematic), expansive, confabulatory (confabulating) and fantastic] were identified by E. Kraepelin [5]. In 1912, in his new classification of mental disorders, he proposed to consider them separate diseases, separating this pathology from schizophrenia. Subsequently, E. Kraepelin’s classification was used to designate types of paraphrenic syndrome [1,2]. 3 It is necessary to note the identification by some domestic authors of delusions of imagination and paraphrenic or confabulatory delusions [7]. It does not always seem to be legal. For example, the development of chronic paraphrenic syndrome during a long course of schizophrenia cannot be explained only by the mechanism of delusion formation like delusion of the imagination. Simultaneously with the emergence of a new “primary” confabulatory delusion (a development mechanism similar to delusions of imagination), the collapse of the “old” delusional system of the persecutory circle is completed (a development mechanism similar to delusions of interpretation). This is probably why some authors note the conventional correspondence between the terms “delusion of imagination” and “paraphrenic” or “confabulatory” delusion [9]. Others talk about the possible interweaving of various forms of delusional formation during the development of one or another delusional syndrome [11]. 4 Nevertheless, the authors are ready to continue the discussion if new points of view appear after the publication of the article. 5 The study was carried out only a month after the patient’s hospitalization due to temporary limitations of technical capabilities. 6 Obviously, complete restoration of mental health (in fact, intermission) after the psychotic state has passed in this case cannot be a reliable criterion for diagnosing bipolar affective disorder. 7 The authors leave outside the scope of this article the discussion about the possible association of involutional paranoids with late schizophrenia. However, it is still worth noting the absence in the presented observation of signs necessary for diagnosing the schizophrenic process (impaired thinking, schizis phenomena, symptoms of mental automatism, emotional-volitional personality changes, signs of progression of the disease). 8 In this case, we do not use the term “recovery”, since it is impossible to assert that the state of mental health will persist throughout the patient’s life. This issue can only be resolved with long-term follow-up observation.

Bibliography

1. Gilyarovsky V.A. Psychiatry: a guide for doctors and students. - M.-Leningrad: State Medical Publishing House, 1931. - 660 p. 2. Gilyarovsky VL. Psychiatry: a guide for doctors and students (fourth edition]. - M.: Medgiz, 1954. - 520 pp. 3. Zhislin S.G. Essays on clinical psychiatry. - M.: Medicine, 1965. - 320 pp. 4. Zhislin S.G. The role of age-related and somatogenic factors in the occurrence and course of some forms of psychosis. - M.: GNIIP, 1956. - 226 pp. 5. Kannabikh Y. History of psychiatry (reprint edition). - M.: TsTR MGP VOS, 1994 - 528 pp. 6. Kontsevoy V.A. Functional psychoses of late age // Guide to psychiatry (ed. A.S. Tiganov]. - T.1. - M.: Medicine, 1999. - P. 667-685 7. Morozov V.M. On the issue of delusions of imagination (abstract of the report] // Selected works. - M.: Media Medica, 2007. - P. 105-106. 8. Morozov V.M. Presenile psychoses (involutional paranoid ] // Selected works. - M.: Media Medica, 2007. - P. 259-271. 9. Morozov G.V., Shumsky N.G. Introduction to clinical psychiatry. - N. Novgorod: Publishing House of NGMA, 1998. - 426 pp. 10. Polishchuk Yu.I. Functional psychoses of late age // Psychiatry: a reference book for a practical doctor (ed. A.G. Hoffman]. — 2nd ed. - M.: MEDpress-inform, 2010. - 608 p. 11. Tiganov A.S. General psychopathology: a course of lectures. - M.: Medical Information Agency LLC, 2008. - 128 p. 12. Shumsky N.G., Shakhmatov N.F., Predescu V. Mental illnesses of presenile and senile age // Guide to psychiatry (ed. G.V. Morozov]. - T. 1. - M.: Medicine, 1988 . - pp. 558-609. 13. Dupre E., Logre M. Les delires d'imagination // L'Encephale. - 1911. - No. 6. - P. 209. 14. Ruffin H. Aging and psychoses of late age // Clinical psychiatry (ed. G. Grule, R. Jung, V. Mayer-Gross, etc.]. - M.: Medicine. 1967. - pp. 780-805. 15. Serieux P., Capgras J. Les Foliesraisonnantes, le delire ^interpretation. - Paris: J.-F. Alcan, 1909. - P. 161. 16. Serko A. Die involutionsparaphrenie // Monatsschrift fur Psychiatrie und Neurologie. - 1919. - No. 5. - S. 245 -286; 334-364.

An involution delirium effect in a form of acute paraphrenia

Danilov DS, Tulpin YG, Lukianova TV, Morosova VD

SUMMARY : A clinical observation of a rare variant of involution delirium psychosis in a form of acute paraphrenia with a delirium-forming mechanism by a fantasy delirium type and a favorable outcome is represented. An analysis of the case described and its comparison with literature data is listed. Syndromal qualification of a patient's state is conducted. A delirium-forming mechanism is analyzed. Nosological affiliation of the observation represented is discussed in a differential-diagnostic aspect.

KEY-WORDS : involution paraphrenia, acute paraphrenia, imagination delirium, confabulation delirium, haloperidol, risperidone.

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Diagnostics

Spontaneous confabulations cannot be studied in laboratory conditions. Provoked confabulations can be explored directly in a session with a psychotherapist. Three methods are used for this:

The Deese-Rodiger-McDermott experience. The client is asked to listen to several lists of words. Each of them is internally connected thematically. The specialist then asks the client to repeat the lists. If he names words that were not there, then confabulation is diagnosed.
Recognition method. The client is asked to view a series of pictures on the computer. Some of them are shown once, some – several. If the client has already seen the picture, then he presses the corresponding button. After a few minutes, the experiment is repeated. If in the second case a person made more mistakes than the first time, then this indicates confusion of memories.
Memory method. The specialist asks the client to remember a well-known story. If a person falsifies events or includes events from another story in a story, then confabulation is diagnosed.

Research methods are selected individually. First, the psychotherapist talks with the patient, puts forward a hypothesis about the disease and its causes. Depending on this, a list of diagnostic measures is selected. Along with psychological techniques, a medical examination is prescribed.

An example from everyday work life

Confabulation can also be observed outside of experimental situations. For example, various studies conclude that candidates with foreign names are at a disadvantage. Suppose the company has applications from a person with a familiar name and a person with a foreign one.

It is much more likely that the second's resume will be rejected. If you ask the hiring manager who is responsible for the refusal, plausible reasons will arise, such as the first candidate's better qualifications and a more convincing performance in the interview.

Image by Stefan Keller from Pixabay

The scary thing is that in most cases this will be confabulated because the decision is largely in favor of the former, even if the candidates are equally qualified. Of course, no recruiter here will admit to being biased. This would undermine his self-image as an unbiased and rational HR manager. All people have a tendency to confabulate, regardless of any previous illness or addiction problems.

Treatment and exercises for memory

Cognitive psychotherapy is used for treatment. Its goal is to help the client realize the falsity of ideas and memories, the specifics of his condition. But first of all, it is necessary to identify and eliminate the cause of the pathology. Medications include nootropics (restoring normal functioning of the central nervous system and blood circulation), vitamins and antioxidants.

Psychotherapy sessions are complemented by the following activities:

support from loved ones;
treatment of secondary or previous diseases, disorders;
drawing up an active lifestyle plan;
normalization of sleep and diet;
avoiding mental and psycho-emotional overload;
refusal of products, habits, activities that depress the functioning of the central nervous system;
daily memory training.

For the last point, we have selected several practical exercises for memory training. Even after recovery, it is recommended to carry out memory training to avoid relapse. The exercises described below will help with this.

Exercise No. 1

Look carefully at the picture for a minute and try to remember everyone who is drawn here. Cover the picture and write down what you remember on a piece of paper. Compare with the original. If you forgot something or wrote it in the wrong order, repeat the exercise. If you wrote everything down correctly, now try to remember it in reverse order.

Exercise No. 2

This exercise can be done every time you have a free minute. Look around carefully, select one object from what surrounds you. Study it for 20–30 seconds, memorize it and name as many details as possible. Now turn away and try to describe this item in as much detail as possible. Size, shape, color, distinctive features, what it is made of, what elements it consists of, etc. Next time, choose a more difficult subject.

Exercise #3

Go into a room and remember as many objects as possible at once (our brain is able to remember and recognize many objects at once). Leave the room and try to describe as much and in detail as possible what you remember. Repeat the exercise, change rooms or rearrange and test your brain again.

Exercise #4

Below are numbers and words. Try to memorize the picture for a minute, and then reproduce it on paper. If this is too difficult, then try to remember only one line or only numbers, then complicate the task.

Prevention

Memory training is a great way to brighten up your leisure time. As a preventative measure, you can strengthen and expand your memory capacity. A few more rules will help avoid the early formation of confabulations:

refusal to drink any alcoholic beverages;
maintaining a healthy sleep and nutrition regime;
avoiding taking medications without a doctor's prescription.

It is not difficult to follow these recommendations, but practice shows that many simply do not want to take care of their health.