Delusions of persecution in psychotic depression. Is psychosis a harbinger of a serious illness? Development of delusional states

20.10.2019 -

Hello, Doctor! Since July 28, I have been taking amitriptyline at a dose of 1/2 tablet at night, because... the condition did not improve. Now it has become a little easier, but there are still palpitations and anxiety in the first half of the day. Does this mean that treatment has not yet eliminated the problem? In order to start discontinuing medications there must be long time wellness? I'm afraid that I'll have to take pills for the rest of my life...

Hello Maria, what does it mean that you are suffering from psychotic depression? How did psychotic symptoms manifest themselves or are they manifesting themselves?

The problem, from my point of view, is that if you suffer from depression, then you need to treat it with antidepressants; only during the presence of delusional symptoms does it make sense to take an antipsychotic and take it only during a period of psychosis.
Judging by your message, you still focus on respiridone, and the antidepressant itself is outdated and, moreover, has pronounced side effects, take in a tiny dose.

If someone tells you that psychotic or other depression can be cured without medication using psychotherapy alone, do not believe it. Drugs come first and only psychotherapy can be used as a supportive treatment, and not vice versa.

I advise you to ask your psychiatrist directly what you are suffering from. Psychosis? Then, really, you need an antipsychotic, if you still have depression without delusional layers, then only an antidepressant. True, not amitriptyline, but a modern one, preferably from the group of selective serotonin drugs, for example, cipralex, paroxetine, citalopram, sertraline, fluoxetine.

So first correct diagnosis, and only then treatment.

I told you everything I could in short form. Now it’s up to your doctors and yourself. Always take a little more personal responsibility for your condition, rather than blindly relying on demigods in white jackets.

In medicine, diagnosis is always made first, followed by treatment. This is an axiom.

Thanks for the answer. I already asked a question about my diagnosis 3 months ago, but did not receive an answer. I will try again. I assume that this is psychosis, because... in January 2008 I was very nervous about work. Then she imagined herself as an energy vampire, bringing nothing but misfortune to people. It seemed that everything bad was happening through my fault, that I had only been causing harm since birth. My husband called an ambulance, I didn’t want to leave, it seemed that the orderlies had come to kill my husband and me. I did not sign any documents at the hospital voluntarily. Only after a week and a half of treatment did I come to my senses. Then, from May 2008 to November 2008, she was treated by a psychotherapist (head of the department of psychiatry, by the way) with hypno-suggestive sessions. He gradually took me off the medications, but at the end of November, at a dose of 1 mg of rispolept and half a tablet. Taking amitriptyline, I lost sleep and began to feel severe pain in my chest. I completely stopped taking medications. There was no delirium. I couldn't sleep. I fell asleep for about an hour or two a night. Thoughts were only about deceased relatives, illnesses and various negative nonsense. (Or is this nonsense?). This went on for 3 weeks. I couldn’t live, I thought all sorts of dirty things. Before the New Year I turned to a private psychiatrist. She immediately prescribed amitriptyline and haloperidol, IVs and injections. After 2 months I switched to Rispolept. I felt good. But now I feel almost satisfactory. In a week I will see a psychiatrist, I will try to clarify the diagnosis again.

And more about psychotherapy. Nobody told me that she more important than drugs. But they said that if you don’t go through it, the disease turns into chronic form and then drugs for life. But I don’t really want to undergo psychotherapy. More precisely, I don’t know what to talk about with a psychotherapist. Can you be cured if you only take medications? Well, so as not to take pills at all?

Judging by your good description, it is necessary to differentiate between psychotic depression (delusional ideas of self-blame, feelings of guilt for the troubles of the world, delusions of persecution - the case with the orderlies, etc.) and pure psychosis (delusional schizophrenia?). The fact that neuroleptics help you well speaks in favor of psychosis and in favor of psychotic depression, especially since at the same time you were taking small doses of amitriptyline.

Head Department of Psychiatry? Something doesn't look the same. Hypnosuggestive therapy for delusional experiences is excluded and contraindicated.

Be sure to ask your doctor what you have, a depressive disorder with delusional ideas or pure psychosis. This is of practical importance; in the first case, an antidepressant must be added to the antipsychotic, in the second, only according to indications. One antipsychotic is enough, and for a long time, at least 1-2 years, in maintenance doses.

Yes, Maria, ask the doctor if you were diagnosed in the hospital with schizoaffective disorder F20 in the form of schizodepressive disorder F25.1?

Hello, Doctor! The diagnosis has not yet been clarified; the psychiatrist is still on vacation. But I know for sure that this is not schizo affective disorder. My husband was told the diagnosis, he remembers something about psychosis. You say that pure psychosis can only be treated with antipsychotics, but on one rispolept I began to experience insomnia and in general my condition worsened. I assume that this is a depressive disorder with delusional ideas. My psychiatrist sees me not from the very beginning of the disease, but 10 months after an acute 3-week period when I did not take medications. She asked about the diagnosis at the PND, her husband said something about psychosis. She prescribed me haloperidol and amitriptyline. After 3 months I tried to stop haloperidol, but I felt unwell and she prescribed me rispolept. Then I wanted to stop taking amitriptyline in August, at least for a while. So I reduced my amitriptyline dosage in June. Everything was fine, but in the second week of July, slight anxiety and excitement appeared in the first half of the day. All the time the pulse is 115-120. Since July 28, I independently increased the dose of amitriptyline to 1/2 tablet. in a day. It got better. All last week it wasn't bad. On weekends, when my husband is nearby, I always feel great. And since this Monday things have gotten worse again. There was excitement from one to two in the afternoon. In the morning I wake up and feel unimportant. A year ago I took rispolept at a dose of 4 mg and amitriptyline 2 tablets. And I had strong feeling causeless fear from morning until lunch. On weekends everything was fine. I contacted my local psychiatrist. Triftazine was prescribed intramuscularly for 10 days. This therapy lasted for 3 weeks. The psychotherapist with whom I then went for sessions of hypno-suggestive therapy (in fact, he is the head of the department of psychiatry, the most important psychiatrist in the city) said that all this was part of my illness, normal in general. \\\"What did you want?\\\" - he asked me, -\\\"Your alarm cannot be turned off.\\\" He gave a graph of the wave-like course of the disease. My question is: 1) why didn’t amitriptyline and rispolept cope with this feeling of fear? What is happening to me now, why these worries and how to deal with them? Is it possible to regard the fact that the condition is significantly better compared to last year, as a movement forward, away from the disease. Or, on the contrary, does anxiety indicate that the treatment is not very effective? ; 2) could it be that without psychotherapy my condition will become chronic and I will take medications for life?; 3) there was a break in treatment for 3 weeks and the condition worsened. Newly started treatment is a return to the beginning of therapy, i.e. taking pills for 10 months. wasted in vain?

Maria, schizoaffective disorder is also psychosis. Please specify the diagnosis, but the exact one in the form of an F code
Once I know your diagnosis accurately, I will be able to answer all your questions and give you advice.

In general, you should always take any of your illnesses seriously and always ask your doctor what is wrong with me, why I am prescribed this or that treatment, and how it works.
Otherwise, it turns out that the patient, the main sufferer, does not know anything for sure about his illness.
But situations are different: today you live in this city, tomorrow you move to another. And there will be no one to ask.

Hello, dear doctor! I asked my psychiatrist about the diagnosis. She said it was an anxiety-depressive disorder, not psychosis. I don’t know the diagnosis that I was given in the hospital. But I also assume that this is not psychosis. The doctors there didn’t know everything that I described to you about my condition. I just lay in bed, and they treated me without asking anything, except that they asked whether I heard voices (I didn’t) and whether I wanted to commit suicide (yes, to live at the moment when I first got I didn’t want to go to the hospital). On August 14, I was increased to amitriptyline (1/4-0-1/2) due to complaints of missing my husband while he was at work, and some anxiety in the first half of the day. The melancholy has passed, but the heartbeat remains (pulse is almost all the time 105-120) and slight unrest, which happens in the first half of the day on weekdays in waves. On August 28, I was increased rispolept to 2.5 mg per day, but the worries did not go away. And today they increased my rispolept to 3 mg. As I understand from other posts, in our country antipsychotics are prescribed for depression, which in principle are not needed. So I’m wondering whether I need rispolept or not. What's wrong with me, depression or psychotic depression? In the hospital, I repeat, they didn’t know anything about my thoughts, that I thought that I was bringing harm to everyone around me, even if I communicate with them by email (the boss at work, to whom I email finished work done at home, broke her leg , and I took it personally). And when I had a 3-week break from taking the pills, I didn’t have any strange thoughts. I simply could not sleep, I only passed out for an hour or two at night. And there was a feeling of losing myself as an individual, not being able to do work and live with my family (I lived with my father-in-law for all these 3 weeks). I don’t know what’s wrong with Rispolept, the doctor asks you to trust her. And my leg is almost constantly in motion (swaying). At a dose of 4 mg, I pumped my leg very hard and constantly moved my tongue in my mouth. There was also fear that tormented me from morning until lunch. The psychotherapist who conducted sessions of hypno-suggestive therapy said that rispolept can give alarming side effects. It even says so in the instructions. And I also read on the Internet about extrapyramidal side effects, they also mention fear and anxiety. Maybe this anxiety is just a side effect for me? But then why only on weekdays? On weekends my husband is home and I feel great. How would you comment on increasing the dose of rispolept? A year ago, to remove fear, I was injected with triphthazine. This helped for 3 weeks. I don’t know the diagnosis made at the hospital. But if it makes a big difference, I'll try to go to the dispensary and find out. But I haven’t been there for a year, I’m being treated by another psychiatrist. I think they also diagnosed me with anxiety-depressive disorder. My psychiatrist believes that this is exactly what I have and that I do not have psychosis. But he treats with rispolept. Sorry for the annoyingness and inaccuracy of the diagnosis, but I have no one else to consult with.

Still, I think that you suffer from, at a minimum, psychotic depression. The idea that your boss broke her leg because you emailed her work you did at home is a crazy idea.

It is possible that your doctors are diagnosing you psychotic disorder, that’s why they prescribe risperidone, but so as not to upset you, they don’t tell you about it.

In general, talk to your doctor, if you have a treatment-resistant form of depression, it would be better to carry out Add-on therapy: to amitriptyline or a more modern antidepressant of the SSRI or SSNRI class, the anti-depressant aripiprazole is added at an initial dose of 5 mg, if necessary, the dose is increased to 10-15 mg per day.

Such combination therapy You can achieve double benefits:

1) if you have psychosis with depressive symptoms, then in any case you need an antipsychotic. Aripiprazole is an atypical antipsychotic with a beneficial profile for patients - no weight gain, no extrapyramidal complications that you already have on risperidone, no sedation, which means inhibition, positive impact on delusional symptoms, neutral effect on prolactin levels, improvement of cognitive function.
True, with simultaneous use In the case of a psychotic disorder, AD needs to be careful because of the possibility of intensifying positive symptoms, in your case delusional ideas. Therefore, doses of AD should be small.

2) if you suffer from a depressive disorder that is resistant to antidepressant therapy, then Add-on therapy with this AAP with one of the antidepressants can lead to a pronounced therapeutic effect.
You just need to remember that in the case of a combination of this AAP with fluoxetine and paroxetine, the dose of aripiprazole should be halved, and if it is used in combination with carbamazepine or St. John's wort, on the contrary, increased by a maximum of 50%.

Hello, Doctor! Your opinion is really needed. I don’t take Ariptprozole because... it is, firstly, very expensive, and, secondly, it is not sold in pharmacies in our city. I take amitriptyline 1/4-0-1/2 tablet. 25 mg and generic rispolept rileptide 1 mg-0-1 mg. I feel good, but sometimes weekdays when my husband is at work (I work from home) in the first half of the day the pulse reaches 120 and slight tremors. The psychiatrist increased my dose of rileptide to 3 mg. But it didn’t help, so I take 2 mg. Please tell me, if I just endure this minor discomfort, will I be able to recover? Or is it necessary to achieve ideal health in order to recover? A year ago I felt very bad even on a dose of 4 mg. There was strong fear and anxiety from morning until lunch. The psychotherapist to whom I then went for hypno-suggestive therapy said that it was impossible to turn off anxiety. He explained about the waves, saying that the gaps between a good state and a bad one would increase. (True, I don’t notice the undulation of my condition, but such strong anxiety has not appeared since November). Do I need to increase the dose of rileptide (which I absolutely do not want, because I experience extrapyramidal side effects) or add another drug (last year in the summer I was prescribed triftazine injections). Or you can simply not pay attention to these little things. And when the time comes to stop taking the drugs, if I experience these jitters, will this mean that it is too early to stop taking the pills?

As I already advised you, it is better to switch from amitriptyline to modern antidepressant class SSRIs, such as cipralex, sertraline, paroxetine or citalopram.
Your problem is that a dose of amitriptyline of 6.25 or 12.5 mg is very small to completely relieve the symptoms of depression, and with increasing dose A. there is a high risk of side effects.

It seems to me that the combination of one of the SSRI class ADs with risperidone at a dose of 2 mg per day will bring you more benefit than the combination of amitripityline + risperidone at the doses you indicated.

Hello, Doctor! At the end of October I had an exacerbation and stopped sleeping. The children were tormented by problems with their studies and household problems. The psychiatrist first increased the dose of rispolept to almost 4 mg and amitriptyline to 1/2-1/2-1/2 tablets. And fenozypam to sleep. But it didn't help. I was switched to haloperidol 1/4-0-1/4 tablets and the dose of amitriptyline was not changed. It was still bad, I didn’t want to live. Since November 30th I have been taking haloperidol 1/4-1/4-1/4, ametriptyline 1-1/2-1/2 and releum 0-1/2-1. The condition has improved. I took Pantogam and cinnaresine for 2 months, Panangin for 1 month due to increased heart rate. I was injected with celebroresin and took vitamin B6. Now I feel good and have no anxiety at all. The psychiatrist does not believe that there is a need to change amitriptyline to a modern antidepressant, because I tolerate amitriptyline well. She also believes that you should not consult about the disease on the Internet. I asked her that if I had already had an exacerbation twice in the fall, then I would have to take pills for life. She said it wasn't necessary at all. you have to fight for your recovery. And the psychotherapist who treated me with suggestive therapy said that I need to start 40 interesting things for myself and then my recovery will speed up. But I can’t find a single interesting activity for myself. I used to be fond of floriculture and sewed my own clothes. Now it's not exciting. A year ago I tried cross stitch, but two pictures were enough to make this activity uninteresting. I tried yoga, but it only lasted for 2 months. Now nothing interests me. I work from home 2 hours a day on the computer. I would love to work more, but there is no work. I used to really love doing housework, but now I do only the most important household chores with great reluctance. I'm sitting at home, I don't have any friends at all. Only family. I’m afraid in my old age to find myself completely alone in the apartment. My husband's father has lived alone for 11 years and has been retired for several years. But he finds interesting things to do, plays computer games, plays solitaire, solves crosswords, and goes for walks. And I'm not interested in anything. I sleep until half past 12 so that I have less time to get bored. The children are no joy, my husband is at work from morning to evening. Do you think I have a chance of getting rid of my pill addiction? And is it possible to take haloperidol in small doses for a long time? The psychiatrist plans to return me to rispolept after some time. But it seems to me that haloperidol works better. Could this be possible?

I cannot interfere with the treatment prescribed to you by your attending physician. I have already expressed my thoughts on diagnosis, treatment and prognosis to you more than once, but you depend on your attending physician and therefore must follow his advice if you trust him.

Apathy and loss of interest and joy in life remain, but this is not surprising, because you are not taking therapeutic doses of amitriptyline (50 mg per day), and this is not enough to get rid of depression. In addition, to relieve anxiety, you constantly use antipsychotics and benzodiazepine tranquilizers, which reduce anxiety, but do not affect the symptoms of depression.

In the development of classical depressive disorder, several stages (levels) can be distinguished, the change of which indicates its single stereotype. The occurrence of corresponding psychopathological manifestations in patients reflects the deepening of the severity of their depressive symptoms. Classical depression begins at a cyclothymic level and increases to a hypothymic (subpsychotic) level. Then it goes through a stage of melancholic level and ends with the formation of a depressive-paranoid clinical picture of the disease. In this case, the development of depressive symptoms can stop at any of these four stages with the formation of cyclothymic, subsyndromal, melancholic and delusional depression.

The cyclothymic stage manifests itself in a decrease in affective tone. Patients with it lose self-confidence, their self-esteem deteriorates, their ability to enjoy life deteriorates, pessimism arises, their range of interests narrows and their general activity. They usually do not yet have suicidal thoughts, ideas of self-blame, an affect of melancholy or anxiety, or psychomotor retardation as such. The cyclothymic stage is characterized by somatovegetative symptoms (decreased appetite, libido, sleep disturbance) and asthenic phenomena. In accordance with ICD-10, such conditions are regarded as a “mild depressive episode” (F 32.0 or F 33.0).

Hypothymic (subpsychotic) stage of formation depressive disorders characterized by the appearance of a moderately expressed melancholy affect. Such patients complain of sadness, sadness, despondency, and hopelessness. At this stage, depressive depersonalization occurs with a feeling of atrial melancholy - “heaviness, a stone in the soul” and ideas of low value. Life seems to patients to be aimless, “wasted.” The problems that arise are regarded by them as insurmountable difficulties. In addition, suicidal thoughts appear on the topic of desirability of death from some disease or thoughts about a method of suicide. These ideational constructions are usually only of an overvalued nature, and patients are, to a certain extent, susceptible to temporary dissuasion. Hypothymic depression is characterized by daily fluctuations in affect with spontaneous improvement in the evening hours and psychomotor retardation. But patients are still able to go to work and perform routine household duties, although this requires significant volitional efforts from them. Characteristic is the appearance of inertia of thinking; their thoughts “flow slowly.” Patients are also characterized by a deterioration in the ability to actively concentrate and complaints of memory loss. Periods of motor retardation may be followed by fussiness. The appearance of such patients takes on a typical depressive appearance: the face is lifeless, suffering, the gaze is dull, the corners of the mouth are downcast, the gait is shuffling, the posture is hunched, sweat sometimes appears on the forehead, the voice is monotonous and rattling, and their whole appearance is somehow “aged.” The hypothymic stage is characterized by pronounced vegetative symptoms (insomnia, constipation, loss of appetite). At this stage of the development of depression, syndromic differentiation of its leading manifestations occurs. Melancholy, anxious, apathetic or depersonalization variants of depressive disorders are formed. The described hypothymic symptoms usually correspond to a “moderate depressive episode” (F 32.1, F 33.1) according to ICD-10.

The melancholic (psychotic, Kraepelin's melanholia gravis) stage of depression causes the patient a feeling of excruciating suffering with pronounced atrial melancholy and the experience of almost physical pain. Typically there is also pronounced psychomotor retardation. Such patients are unable to carry on a conversation; they answer questions briefly and formally - “yes”, “no”, “bad”, etc. They lie down almost all the time. The previously observed daily fluctuations in affect disappear, and depression becomes monotonous. Their appearance is quite typical: a frozen face, dry skin and mucous membranes, extremely poor movements, a bent posture, a lifeless voice. Suicidal thoughts and actions are typical. It is possible that in such patients the so-called melancholic raptus: they begin to rush around the room, moan, wring their hands, and commit suicidal acts. Overvalued ideas of low value are gradually transformed into delusional ideas of self-deprecation. Patients consider themselves “worthless” people: bad children, parents, spouses and employees, and their past life is perceived by them as a continuous series of “mistakes”. With such a depth of depression, patients are no longer able to be dissuaded. They completely lose criticism, and any of their social activities are impossible. This degree of severity of depressive symptoms practically corresponds to the psychotic level of mental pathology. According to ICD-10, melancholic depression, however, is more often classified as “a severe depressive episode without psychotic symptoms"(F 32.2).

The delusional stage of depression occurs in three stages. At the first stage, the patient usually develops delusions of self-blame. On the second - sinfulness, impoverishment or hypochondriacal delirium, accompanied by hallucinations. On the third - paraphrenic delusions of denial and enormity with the development of catatonic symptoms. With delusional ideas of self-blame, patients consider themselves guilty of almost everything: for the “plight” of the family, for the fact that they “ruined” the lives of their loved ones, raised their children incorrectly, did not earn money, “bullied” their parents, wife, and now “ "ruined" the family and "hangs like a yoke around her neck." And they are “worthless” specialists who received undeserved salaries, and apart from a series of “constant mistakes” they have not made anything in life.

At further development Depressive-paranoid symptoms, the dynamics of delusions usually occur within the framework of one of three existential fears of a person: going broke (delusions of impoverishment), committing a crime and getting retribution for it (delusions of sinfulness), getting sick and dying (Cotard’s hypochondriacal delusions). As delusions of self-blame deepen, the clinical picture of the disease begins to be dominated by anxious-depressive affect with acute sensory delusions of staging, ideas of the special significance of what is happening, and false recognitions. Then comes illusory hallucinosis, verbal hallucinations and isolated catatonic symptoms. It seems to the patient that he is not in a hospital, but in a prison, that the orderlies are actually guards in disguise, that everyone around is whispering only about him and pointing fingers at him. At the same time, in the conversations of the patients around him, he hears hints, threats and promises of future retribution. He develops even more confidence that his life is over and the day of his “execution”, and perhaps that of his relatives, is approaching. Patients put forward the most insignificant mistakes and official misconduct as their “crime”.

At the third, paraphrenic stage (Kraepelin's fantastic melancholy), patients are sure that they are guilty of all the sins of the world. That because of them “everything was lost.” What will start these days World War and the world will perish. That they will be left alone and will suffer forever (delirium of denial and enormity). The formation of delusions of mastery is possible, when patients feel that they have turned into the devil, into the Universal Evil. Cotard's nihilistic delirium may also occur, in which patients feel the stench of a rotting body spreading from them, that their internal organs disintegrated and disappeared, or their entire body disappeared. At the paraphrenic stage, it is possible to add catatonic symptoms up to the development of oneiric catatonia.

The described depressive-paranoid syndromes, as a rule, occur in the structure of the psychotic form of “endogenous” depression (“severe depressive episode with psychotic symptoms” F 32.3 according to ICD-10), involutional depression (F 06.32), “schizoaffective disorder” (F 25.1) and “remitting schizophrenia” (F 20.03). Although the development of paraphrenic structures in “endogenous” depression seems quite controversial.

In conclusion, it should be noted that it is necessary to distinguish the described depressive-paranoid syndromes, which develop within the framework of depression and have a certain stereotype of formation, from various delusional psychoses occurring against a depressive background. For example, delusions of persecution in schizophrenia often occur against the background of depressive affect. There are several possible combinations of paranoid and depressive symptoms in patients with schizophrenia. In the variant characteristic of the initial stages of the disease, depressive symptoms replace the previous affect of anxiety, confusion and fear. The latter usually accompanies the primary delusional phenomena that appear in the patient: delusional mood, delusional perception, delusional ideas of meaning. Both depression and delusional phenomena initial stages schizophrenia cannot be clearly differentiated, since it clinical picture still not sufficiently differentiated. That is, painful symptoms still occur at the “subsyndromal” level. With further dynamics of the schizophrenic process, depressive symptoms develop as a reaction of the individual to sensitive delusional ideas, mainly persecution and influence. When paranoid symptoms are reduced at the stage of remission, depressive symptoms may also appear, which can be regarded either as “depressive tails” arising as a result of the pharmacological splitting of delusional symptoms (Avrutsky G.Ya., 1988), or as a personal reaction formed as a result of the patient’s awareness the fact of one’s mental illness (Roy A., 1983), or as the beginning of the formation of “post-schizophrenic” depression. In addition, at distant stages of the schizophrenic process, special, reduced in their clinical manifestations, seizures are “pseudo-furs”. The latter are known in the literature under the name “attacks of the type of depression with delirium” (Tiganov A.S., 1997). They are characterized (as in the initial stages of the disease) by the absence of a clear syndromic structure. However, the amorphous clinical picture of the disease is no longer determined by the “delusional mood”, but by the emerging “negative” symptoms. “Attacks of the type of depression with delusions” occur in the form of protracted or, conversely, transient states. In their clinical structure usually includes melancholy-apathetic and dysphoric radicals of affect, individual delusional and hallucinatory symptoms, as well as rudimentary senesto-hypochondriacal or obsessive-phobic disorders. The above determines the therapeutic tactics.

Primary, secondary and induced delirium

Primary, or autochthonous, delusion- this is delusion that arises suddenly with complete conviction of the truth of its content, but without any mental events leading to it. For example, a patient with schizophrenia may suddenly have a complete conviction that his gender is changing, although he had never thought about anything like that before and was not preceded by any ideas or events that could push him to such a conclusion in any way. in a logically explicable way. A belief suddenly arises in the mind, fully formed and in an absolutely convincing form. Presumably it is a direct expression pathological process, which is the cause of mental illness, is the primary symptom. Not all primary delusions begin with an idea; delusional mood (see p. 21) or delusional perception (see p. 21) can also arise suddenly and without any antecedent events to explain them. Of course, it is difficult for the patient to remember the exact sequence of such unusual, often painful mental phenomena, and therefore it is not always possible to establish with complete certainty which of them is primary. Inexperienced doctors usually make the diagnosis of primary delirium too easily, without paying due attention to the study of previous events. Primary delusions are of great importance in the diagnosis of schizophrenia, and it is very important not to register it until there is complete confidence in its presence. Secondary delusion Can be regarded as a derivative of any previous pathological experience. A similar effect can be caused by several types of experiences, in particular hallucinations (for example, a patient who hears voices, on this basis comes to the belief that he is being persecuted), mood (a person in deep depression can believe that people consider him a nonentity); In some cases, the delusion develops as a consequence of a previous delusional idea: for example, a person with delusions of impoverishment may fear that losing money will send him to prison because he will not be able to pay his debts. It seems that in some cases secondary delusions perform an integrating function, making the initial sensations more understandable to the patient, as in the first example given. Sometimes, however, it seems to have the opposite effect, increasing the feeling of persecution or failure, as in the third example. Accumulation of secondary crazy ideas may result in the formation of an intricate delusional system in which each idea can be regarded as arising from the previous one. When a complex set of interrelated ideas of this kind is formed, it is sometimes defined as systematic delusion.

Under certain circumstances, induced delirium occurs. As a rule, others consider the patient’s delusional ideas to be false and argue with him, trying to correct them. But it happens that a person who lives with a patient begins to share his delusional beliefs. This condition known as induced delirium, or Insanity for two (Folic A Deux) . While the couple remains together, the other person's delusional beliefs are as strong as those of the partner, but they tend to be quickly reduced when the couple separates.

Table 1.3. Description of delirium

1. By persistence (degree of conviction): complete partial 2. By the nature of occurrence: primary secondary 3. Other delusional states: delusional mood delusional perception retrospective delusion (delusional memory) 4. By content: persecutory (paranoid) relations of grandeur (expansive) guilt and low value nihilistic hypochondriacal religious jealousy sexual or love delusions of control

delusion regarding the possession of one's own thoughts delusion of transmission (broadcasting) of thoughts

(In the domestic tradition, these three symptoms are considered as an ideational component of the syndrome of mental automatism) 5. According to other signs: induced delirium

Delusional moods, perceptions and memories (retrospective delusions)

Typically, when a patient first develops delusions, he also has a certain emotional reaction and perceives his surroundings in a new way. For example, a person who believes that a group of people are going to kill him is likely to feel fear. Naturally, in such a state, he can interpret the reflection of a car seen in the rear-view mirror as evidence that he is being followed.

In most cases, delusion occurs first, and then the remaining components are added. Sometimes the reverse order is observed: first the mood changes - often this is expressed in the appearance of a feeling of anxiety, accompanied by a bad feeling (it seems as if something terrible is about to happen), and then delirium follows. In German this change in mood is called WaJinstimmung, Which is usually translated as Delusional mood. The last term cannot be considered satisfactory, because in fact we're talking about about the mood from which delirium arises. In some cases, the change that has occurred is manifested in the fact that familiar objects of perception suddenly, without any reason, appear to the patient as if bearing new meaning. For example, an unusual arrangement of objects on a colleague's desk may be interpreted as a sign that the patient has been chosen by God for some special mission. The described phenomenon is called Delusional perception; This term is also unfortunate because it is not the perception that is abnormal, but the false meaning given to the normal object of perception.

Despite the fact that both terms are far from meeting the requirements, there is no generally accepted alternative to them, so they have to be resorted to if it is necessary to somehow designate a certain state. However, it is usually better to simply describe what the patient is experiencing and record the order in which changes in ideas, affect, and interpretation of sensations occurred. With the corresponding disorder, the patient sees a familiar person, but believes that he has been replaced by an impostor who is an exact copy of the real one. This symptom is sometimes referred to by the French term Vision De Societies(the illusion of a double), but this, of course, is nonsense, not an illusion. The symptom can last so long and persistently that even a syndrome has been described - Capgras syndrome(Capgras), - in which this symptom is the main one characteristic feature(see p. 247). There is also an erroneous interpretation of the experience that is opposite in nature, when the patient recognizes the presence of different appearances in several people, but believes that behind all these faces is the same disguised pursuer. This pathology is called Breda Fregoli(Fregoli). A more detailed description of it is given further on p. 247.

Some delusions relate to past rather than present events; in this case we talk about Delusional memories(retrospective delirium). For example, a patient who is convinced of a conspiracy to poison him may attribute new meaning to the memory of an episode in which he vomited after eating long before the delusional system emerged. This experience must be distinguished from the exact memory of a delusional idea formed at that time. The term "delusional memory" is unsatisfactory because it is not the memory that is delusional, but its interpretation.

In clinical practice, delusions are grouped according to their main themes. This grouping is useful because there is some correspondence between certain themes and basic forms mental illness. However, it is important to remember that there are many exceptions that do not fit into the generalized associations mentioned below.

Delusions of persecution often call Paranoid Although this definition has, strictly speaking, a broader meaning. The term “paranoid” appears in ancient Greek texts to mean “insanity,” and Hippocrates used it to describe feverish delirium. Much later, this term began to be applied to delusional ideas of grandeur, jealousy, persecution, as well as erotic and religious ones. Definition of "paranoid" in in a broad sense and today is used in application to symptoms, syndromes and personality types, while remaining useful (see Chapter 10). Persecutory delusions are usually directed at an individual or at entire organizations that the patient believes are trying to harm him, tarnish his reputation, drive him crazy, or poison him. Such ideas, although typical, do not play a significant role in making a diagnosis, since they are observed in organic conditions, schizophrenia and severe affective disorders. However, the patient's attitude towards delirium may have diagnostic value: It is characteristic that in severe depressive disorder the patient tends to accept the alleged activities of the persecutors as justified, due to his own guilt and worthlessness, while the schizophrenic, as a rule, actively resists, protests, and expresses his anger. In evaluating such ideas, it is important to remember that even seemingly improbable accounts of persecution are sometimes supported by facts, and that in certain cultural environments it is considered normal to believe in witchcraft and attribute failures to the wiles of others.

Delusional relationship is expressed in the fact that objects, events, people are purchased for the patient special meaning: for example, a newspaper article read or a remark heard from a television screen is perceived as addressed to him personally; a radio play about homosexuals is “specially broadcast” in order to inform the patient that everyone knows about his homosexuality. Delusions of attitude can also be focused on the actions or gestures of others, which, according to the patient, carry some information about him: for example, if a person touches his hair, this is a hint that the patient is turning into a woman. Although most often ideas of attitude are associated with persecution, in some cases the patient may give a different meaning to his observations, believing that they are intended to testify to his greatness or reassure him.

Delirium of grandeur, or expansive delirium,- This is an exaggerated belief in one’s own importance. The patient may consider himself rich, endowed with extraordinary abilities, or generally an exceptional person. Such ideas occur in mania and schizophrenia.

Delusions of guilt and worthlessness most often found in depression, which is why the term "depressive delusion" is sometimes used. Typical of this form of delusion are ideas that some minor violation of the law that the patient has committed in the past will soon be discovered and he will be disgraced, or that his sinfulness will bring divine punishment on his family.

Nihilistic delusion is, strictly speaking, a belief in the non-existence of some person or thing, but its meaning expands to include the patient’s pessimistic thoughts that his career is over, that he has no money, that he will die soon, or that the world is doomed. Nihilistic delusions are associated with extreme depression. It is often accompanied by corresponding thoughts about disturbances in the functioning of the body (for example, that the intestines are allegedly clogged with rotting masses). The classic clinical picture is called Cotard's syndrome, named after the French psychiatrist who described it (Cotard 1882). This condition is discussed further in Chap. 8.

Hypochondriacal delusion consists of the belief that there is a disease. The patient, despite medical evidence to the contrary, stubbornly continues to consider himself sick. Such delusions more often develop in older people, reflecting increasing anxiety about health, which is typical at this age and in people with a normal psyche. Other delusions may be related to cancer or venereal disease either with appearance parts of the body, especially the shape of the nose. Patients with delusions of the latter type often insist on plastic surgery(See the subsection on body dysmorphic disorder, Chapter 12).

Religious nonsense i.e., delusions of religious content, were much more common in the 19th century than at the present time (Klaf, Hamilton 1961), which apparently reflects the more significant role that religion played in life ordinary people in past. If unusual and strong religious beliefs are found among members of religious minorities, it is advisable to first talk to another member of the group before deciding whether these ideas (for example, apparently extreme beliefs about God's punishment for minor sins) are pathological.

Delirium of jealousy more common in men. Not all thoughts caused by jealousy are delusions: less intense manifestations of jealousy are quite typical; in addition, some intrusive thoughts may also be associated with doubts about the fidelity of the spouse. However, if these beliefs are delusional, then they are especially important because they can lead to dangerous aggressive behavior towards someone who is suspected of being unfaithful. Necessary Special attention, if the patient “spys” on his wife, examines her clothes, trying to detect “traces of sperm,” or rummages through her purse in search of letters. A person suffering from delusions of jealousy will not be satisfied with the lack of evidence to confirm his belief; he will persist in his quest. These important issues are discussed further in Chap. 10.

Sexual or love delirium It is rare and mainly affects women. Delusions associated with sexual intercourse are often secondary to somatic hallucinations felt in the genitals. A woman with delusions of love believes that she has a passion for her that is inaccessible under ordinary circumstances, occupying a higher place. social status a man she had never even spoken to. Erotic delirium is the most characteristic feature Clerambault syndrome, Which is discussed in Chap. 10.

Delirium of control is expressed in the fact that the patient is convinced that his actions, motives or thoughts are controlled by someone or something outside. Because this symptom strongly suggests schizophrenia, it is important not to record it until its presence is definitely established. A common mistake is diagnosing delusions of control when there is no delusion of control. Sometimes this symptom is confused with the experiences of a patient who hears hallucinatory voices giving commands and voluntarily obeys them. In other cases, misunderstanding arises because the patient misunderstands the question, believing that he is being asked about religious attitudes regarding divine providence, guiding a person's actions. A patient with delusions of control firmly believes that the behavior, actions and every movement of an individual are directed by some outside influence - for example, his fingers take the appropriate position for making the sign of the cross not because he himself wanted to cross himself, but because they were forced by an external force .

Delusions regarding thought ownership characterized by the fact that the patient loses the natural healthy person the belief that his thoughts are his own, that they are purely personal experiences that can become known to other people only if they are spoken out loud or revealed by facial expression, gesture or action. Lack of control over your thoughts can manifest itself in different ways. Patients with Delirium of investing other people's thoughts They are convinced that some of their thoughts do not belong to them, but are inserted into their consciousness by an external force. This experience differs from the experience of a patient with obsessive ideas, who may be tormented by unpleasant thoughts, but never doubts that they are generated by him. with your own brain. As Lewis (1957) said, obsessions“are produced at home, but man ceases to be their owner.” A patient with delusions of insertion of thoughts does not recognize that the thoughts arose in his own mind. Patient with Delirium of thoughts being taken away I'm sure the thoughts are being extracted from his mind. Such delirium usually accompanies memory lapses: the patient, feeling a gap in the flow of thoughts, explains this by the fact that the “missing” thoughts were taken away by some outside force, the role of which is often assigned to the alleged persecutors. At Brede transfer(openness) of thoughts, the patient imagines that his unexpressed thoughts become known to other people by transmission using radio waves, telepathy, or in some other way. Some patients also believe that others can hear their thoughts. This belief is often associated with hallucinatory voices that seem to speak out loud the patient’s thoughts. (Gedankenlautwerderi). The last three symptoms (In Russian psychiatry they refer to the syndrome of mental automatism) occur in schizophrenia much more often than in any other disorder.

Causes of delirium

Given the obvious paucity of knowledge about the criteria for normal beliefs and the processes underlying their formation, it does not seem surprising that we are almost completely unaware of the causes of delusions. The lack of such information did not prevent, however, the construction of several theories, mainly devoted to delusions of persecution.

One of the most famous theories was developed by Freud. His main ideas were outlined in a work originally published in 1911: “The study of many cases of persecutory delusions has led me, like other researchers, to the opinion that the relationship between the patient and his persecutor can be reduced to a simple formula. It turns out that the person to whom the delusion ascribes such power and influence is identical to someone who played equally important role in the emotional life of the patient before his illness, or in an easily recognizable substitute. The intensity of the emotion is projected onto the image of an external force, while its quality is reversed. The face that is now hated and feared because it is a stalker was once loved and respected. The main purpose of the persecution asserted by the patient’s delusions is to justify a change in his emotional attitude.” Freud further summarized his point by arguing that persecutory delusions are the result of the following sequence: “I do not I love Him - me I hate it Him because he’s stalking me”; erotomania follows the series of “I don’t love His-I love Her Because She loves Me", And the delirium of jealousy is the sequence “this is not I Loved this man - this She Loves him” (Freud 1958, pp. 63-64, emphasis in original).

So, according to this hypothesis, it is assumed that patients experiencing persecutory delusions have suppressed homosexual impulses. So far, attempts to verify this version have not provided convincing evidence in its favor (see: Arthur 1964). However, some authors have accepted the basic idea that persecutory delusions involve a projection mechanism.

An existential analysis of delirium has been carried out repeatedly. Each case describes in detail the experience of patients suffering from delusions, and emphasizes the importance of the fact that delusions affect the whole being, that is, it is not just a single symptom.

Conrad (1958), using a Gestalt psychology approach, described delusional experiences into four stages. In accordance with his concept, a delusional mood, which he calls trema (fear and trembling), through a delusional idea, for which the author uses the term “alophenia” (the appearance of a delusional idea, experience), leads to the patient’s efforts to discover the meaning of this experience by revising his vision peace. These efforts are divided into last stage(“apocalypse”), when signs of thought disorder and behavioral symptoms appear. However, although this type of sequence can be observed in some patients, it is certainly not invariable. Learning theory attempts to explain delusions as a form of avoidance of extremely unpleasant emotions. Thus, Dollard and Miller (1950) proposed that delusions are a learned interpretation of events to avoid feelings of guilt or shame. This idea is just as unsupported by evidence as all other theories about the formation of delusions. Readers wishing to receive more detailed information on this issue, one should refer to the work of Arthur (1964).

Psychotic depression is an affective disorder in which, in addition to the typical depressive symptoms psychotic signs such as hallucinations, delusions, etc. are observed.

Reasons for development

This pathology is one of the manifestations that has a hereditary nature and develops as a result of disturbances in biochemical processes in the body.

As a rule, symptoms of the disease appear without a clear relationship with any traumatic factor. In some cases, a psychotraumatic factor can only contribute to the occurrence of the first episode of the disease. Subsequently, a clear relationship is not observed.

The condition of such patients tends to fluctuate seasonally - it worsens in the spring and autumn (then they talk about).

Manifestations

Symptoms of psychotic depression include both purely depressive signs (decreased mood, fatigue, inability to concentrate for a long time, perform the same work) and psychotic components, due to which this pathology is distinguished.

The latter include:

hallucinations;
delusional ideas - hypochondriacal delusions (the patient is sure of the presence serious illness in himself, which in fact does not exist), delusions of physical defects (he thinks that he is incredibly ugly, has a terrible shape of his nose, teeth, eyes, etc.),
stupor - immobility;
agitation - strong emotional arousal combined with causeless feeling fear, anxiety;
there may also be a dream-like stupefaction (oneiroid), when there is an influx visual hallucinations(usually of fantastic content), and the person himself thinks that he is seeing a dream in reality.

Psychotic depression is characterized by a high intensity of major depressive symptoms. They persist for a long time, their severity does not depend on the influence of external traumatic factors.

Daily mood swings are also common. The peak of severity occurs in the morning, and by the evening the condition may improve.

Between 10 and 15% of patients with depressive disorders commit suicide. The risk of such actions is especially high in patients suffering from psychotic depression.

Psychotic depression and schizophrenia

It is worth distinguishing between psychotic depression and diseases such as schizophrenia. Difficulties in distinguishing between these two mental disorders may appear at the beginning of the disease, when not all signs are clearly expressed and there is no dynamics of the disease.

With psychotic depression, symptoms such as depressed mood, motor retardation come to the fore, no events or actions bring joy or pleasure, and this is a burden to the patient.

Although psychotic components are present, they are additional. As a rule, there are only individual signs - for example, only delusional ideas or only agitation. Criticism towards one's condition remains. Even if hallucinations appear, the person does not regard them as real events, but understands that something is wrong with him. The theme of delusional ideas characteristic of depressive disorders is delusions of serious illness, delusions of self-blame.

In most cases of schizophrenia, the first signs of a mental disorder that attract the attention of others are psychotic. There may be delusional ideas, psychomotor agitation. A person’s criticism of his condition, as well as the symptoms that arise, is lost. The characteristic themes of delusional ideas that arise in schizophrenia are persecution (when a person is sure that someone is following him, chasing him), influence (especially mental, through various rays, thoughts, etc.), attitude (someone treats him badly , looks askance, condemns).

Depressed mood is not typical, the motivation for any activity is lost, the person becomes emotionally cold, but this does not bother him at all.

Treatment

If the patient has suicidal intentions, then in order to avoid fatal consequences, treatment in a hospital setting is preferable.

The most effective drugs for treating psychotic depression are antidepressants and antipsychotics. Antidepressants help cope with the main symptoms of depression and normalize changes occurring at the biochemical level in the body.

The choice of antidepressant is based on the presence of certain signs of the disease. If there are pronounced suicidal tendencies, delusional ideas of self-blame, they resort to tricyclic antidepressants (amitriptyline), atypical antidepressants (sertraline, fluoxetine, cipramil).

To eliminate psychotic symptoms, antipsychotics are used (clopixol, thioridazine, chlorprothixene).

The choice of drug and dose is determined by the attending physician individually for each individual patient, depending on the severity of symptoms.

Unfortunately, due to the fact that this disorder is an endogenous disease, there is a high risk of relapses in the future. To avoid them, it is necessary to take the drugs for a long time; in no case should treatment be suddenly interrupted.

Psychotic depression is a subtype major depression. This type of depression is characterized by a combination of severe symptoms of depression with signs of psychosis, such as: hallucinations, delusions, disorientation, depersonalization, derealization, etc. The patient may be persecuted auditory hallucinations in the form of individual words or dialogues involving one or more “voices”. It is also possible to experience visual hallucinations in the form of images of animals, people or inanimate objects. With psychotic depression, illogical, strange delusions may occur. Very often a person is haunted by the feeling that what is happening is being staged. Unlike true psychosis, a person who suffers from psychotic depression retains a critical attitude towards what is happening, in particular towards his own actions. A person often experiences shame and tries to hide his experiences and sensations from others. Ignoring and masking symptoms greatly complicates the diagnosis of this type of depression and its differentiation from other disorders, which is extremely important for full recovery.

In most cases, women with psychotic depression have some kind of break with reality, women with psychotic depression can get irritated easily and get angry easily for no apparent reason.

The behavior of women with psychotic depression can also be very specific - they have difficulty speaking, may sleep all day and stay awake all night, or refuse daily hygiene rituals, changing clothes, etc.

Psychotic depression - causes and risk factors

The exact cause of psychotic depression is not yet known, but most scientists note a frequent increase in blood pressure, associated with increased levels of cortisol, an adrenal hormone, in people suffering from psychotic depression. It is well known that different kinds stress (psychological, physical or emotional) are always accompanied increased level cortisol. This is why some scientists suggest a direct correlation between severe stress and the development of psychotic depression.
It has been noted that the following risk factors may increase the chances of developing psychotic depression:

family history of depression or psychosis;
Hormonal dysfunctions (often changes in levels of female hormones);
Impaired release of neurotransmitters in the brain;
Episodes of severe stress;
Severe physical injuries;
Certain personal characteristics - narcissism, selfishness, suspiciousness, excessive fears, lack of self-esteem, lack of empathy, increased impulsiveness;
Drug or alcohol abuse.

All of the above factors increase the likelihood of developing psychosis.

Psychotic depression - symptoms

During psychotic depression, women may experience a variety of symptoms, but the most common and typical symptoms are:

Abnormal even strange behavior (passive loneliness, constant pessimism, social isolation, hypochondria, physical immobility);
Hallucinations (auditory or visual);
Delusions (a constant ongoing feeling of worthlessness, hopelessness, inability to soberly assess events);
Phobias (paranoid health concerns, fear of illness);
Break with reality;
Suicidal thoughts and/or suicide attempts.

Additional symptoms of psychotic depression may include the following:

Bad mood and irritability,
Fatigue,
Apathy,
Insomnia,
Anxiety,
Paranoia,
Constipation,
Decreased intellectual abilities

Psychotic depression - treatment

Treatment for psychotic depression is usually quite effective. In most cases, treatment for psychotic depression should be carried out in a treatment facility. The main treatment includes a combination medicines(depending on severity, age, sensitivity). In most cases, a combination of antidepressants and antipsychotic drugs is recommended.
Electroconvulsive therapy (ECT) is a rapid and effective means for the treatment of psychotic depression. Due to the severity of psychotic symptoms, electroconvulsive therapy is often the treatment of choice.

Untreated psychotic depression can lead to very serious mental disorders, which is why in case of psychotic depression, timely and comprehensive treatment is necessary.

Psychotic depression - prognosis

In most cases, treatment for psychotic depression is effective (if treatment is started promptly and carried out adequately). Recovery from psychotic depression can last on average 6-12 months. Recurrence of depressive symptoms is quite common, while relapse of psychotic symptoms is quite rare.

Depersonalization in depression is one of the most common forms of self-perception, which is a deviation from the norm. With depersonalization, a person practically loses control over his actions, as a feeling of being an observer from the outside appears. But depressive depersonalization is severe symptom Very large quantity psychological disorders

. The most common of them are:
schizophrenia;
schizotypal disorder;
bipolar disorder;
depression.

Complications of depersonalization

In very rare cases, if depression with depersonalization has nothing to do with other diseases and does not stop for a long time, they are classified as a separate depersonalization disorder (the so-called depersonalization-derealization syndrome). With prolonged depersonalization, a person can often find himself in a situation that leads to suicide.

Obsessive urges towards perfectionism are very acutely felt, manifesting themselves in impeccable order both in the toilet and in everything around them, requiring serious symmetrical placement of things and even alignment of folds.

Transitions from obsessive to impulsive drives were very often observed. Homicidal and suicidal tendencies are also part of the structure of acute depersonalization (called oscillation in one's existence), which most often lead to aggressive actions towards others or towards oneself in the form of suicide.

Return to contents

Cyclotomy phases

IN initial stages There is a noticeable loss of belonging and ordinary feelings, lack of control of movements, thoughts, the feeling of automatic independence suffers and alienation of personalities appears:

alienation of cognitive processes, a feeling of one’s own change, a sharp deterioration in intellectual abilities, difficulties in communicating with other people, characterized by a feeling of loss of personality;
alienation of any emotions in the form of mental anesthesia.

When new symptoms appear, a feeling of bodily change and a difficult experience of spontaneous volitional activity are increasingly felt, which leads to doing something as if automatically, and subsequently - a poverty of perception of the surrounding world, a loss of connection with the emotions of the external environment. The anesthetic experiences that depression brings with it have every chance of existing only local (with a fixation only on the loss of emotions), but they can also be diffuse-partial and total.

During studies in clinics, it was noticed that depressive attacks of schizophrenia very often lead to the progression of a persistent feeling of inferiority, incompleteness, unfinished actions that have been started, and lead to repeated checking of what has been completed.

When studying patients, the structure of allopsychic depersonalization was compiled and divided into subtypes:

Acute feeling of isolation, slow reaction to impressions, loss in space.
At the same time, a person seems to look at all this from the outside.
The world loses its colors, and everything that surrounds such a person becomes gray and dull.

After all the initial phases of cyclotomy, the disorder progresses to total manifestations of the disease:

loss of emotions towards loved ones;
complete lack of psychological perception of art, nature, the difference in shades of color and contours of an object disappears;
loss of a sense of familiarity, of one’s past;
complete lack of feeling of completeness of thought;
absence of pain, anger, resentment;
loss of sense of time;
lack of appetite;
loss of the feeling of sleep upon awakening;
decreased temperature and pain sensitivity;
lack of desire to urinate and defecate;
the whole world becomes distant and appears very dim.

Even if the patient has a completely adequate reaction to his suffering, his emotional impairment is quite often perceived as a complete limitation in his life. Accompanied by the following feelings:

embodied thymic coloring of mental anesthesia (feeling of lack of emotions);
increasing anesthesia as depression develops with the possibility of vitalization of anesthesia ( It's a dull pain from within, mental pain);
painful mental anesthesia with a clearly presented depressive affect and a complete absence of embodied ideational inhibition, although its prevalence is insignificant.

This is all very serious and should not be taken lightly. The methods that are used today in psychiatry can help such people, which is why if someone you know has any of the symptoms listed above, you need to talk with his loved ones and decide whether to send him to a psychotherapist or not, although this is extremely recommended.