Imperative pseudohallucinations. Imperative hallucinations in the clinic of modern forms of schizophrenia Imperative hallucinations

A hallucination is the perception of something in the absence of an external stimulus, which has the properties of real perception. Hallucinations have properties such as brightness, materiality, and are perceived as objects (smells, sensations, etc.) located in external objective space. They are distinguished from related phenomena: sleep, which does not involve wakefulness; illusion, which involves distorted or misinterpreted real perception; imagination, which does not imitate real perception and is under human control; and pseudohallucination, which does not imitate real perception but is not under the person's control. Hallucinations are also distinguished from "delusional perception", in which correctly perceived and interpreted stimuli (that is, real perceptions) are given some additional (and usually absurd) meaning. Hallucinations can occur in any sensory modality - visual, auditory, olfactory, gustatory, tactile, proprioceptive, equilibryoceptive, nociceptive, thermoceptive and chronoceptive. The mild form of hallucinations is known as mental imbalance, and can be observed in most sensory modalities. For example, the person may hallucinate the movement of objects in peripheral vision, or the person may hear faint noises and/or voices. Auditory hallucinations are very common in schizophrenia. They can be benevolent (the patient hears good things) or malicious, cursing the person, etc. Auditory hallucinations of the malicious type are often heard, for example, as the voices of people talking about a person behind his/her back. As with auditory hallucinations, the source of visual hallucinations may also be behind the patient's back. Their visual analogue is the feeling that someone is looking at the patient, usually with malicious intent. Often, auditory hallucinations and their visual counterpart are experienced together. Hypnagogic hallucinations and hypnopompic hallucinations are considered normal. Hypnagogic hallucinations can occur when a person falls asleep, while hypnopompic hallucinations occur when a person wakes up. Hallucinations may be associated with drug use (particularly anticholinergic hallucinogens), sleep deprivation, psychosis, neurological disorders, and delirium tremens. The word "hallucination" was introduced into English in the 17th century by the physician Sir Thomas Browne in 1646, as a derivative of the Latin word alucinari, meaning "to wander in the mind."

Classification

Hallucinations can appear in various forms. Different forms of hallucinations affect different senses and sometimes occur simultaneously, creating multiple sensory hallucinations in patients who experience them.

Visual hallucinations

A visual hallucination is “the perception of an external visual stimulus that does not actually exist.” On the other hand, a visual illusion is a distortion of a real external stimulus. Visual hallucinations are divided into simple and complex. Simple visual hallucinations (SVH) are also referred to as unformed visual hallucinations and elementary visual hallucinations. These terms refer to light, color, geometric shapes and homogeneous objects. They can be divided into phosphenes, which are PVGs without structure, and photopsia, PVGs with geometric structures. Complex visual hallucinations (CVH) are also called formed visual hallucinations. SZGs are clear, realistic images or scenes such as people, animals, objects, etc. For example, the patient may hallucinate a giraffe. A simple visual hallucination is an amorphous figure that may have a shape or color similar to that of a giraffe (looking like a giraffe), while a complex visual hallucination is a discrete, realistic image of a giraffe.

Auditory hallucinations

Auditory hallucinations (also known as paracusis) are the perception of sound without an external stimulus. Auditory hallucinations are the most common type of hallucination. Auditory hallucinations can be divided into two categories: elementary and complex. Elementary hallucinations are the perception of sounds, such as hissing, whistling, drawn-out tone, and much more. In many cases, tinnitus is a simple auditory hallucination. However, some people who experience certain types of tinnitus, especially pulsatile tinnitus, actually hear blood rushing through the vessels near the ear. Since there is an auditory stimulus in this situation, this case does not qualify as a hallucination. Complex hallucinations – hallucinations of voices, music or other sounds that may or may not be perceived clearly, may be familiar or completely unfamiliar, friendly or aggressive. Hallucinations of one individual person, one or more speaking voices, are particularly associated with psychotic disorders such as schizophrenia, and are of particular importance in the diagnosis of these conditions. If a group of people experience a complex auditory hallucination, no one person can be labeled psychotic or schizophrenic. Another typical disorder in which auditory hallucinations are common is dissociative identity disorder. In schizophrenia, voices are usually perceived as coming from outside the person, but in dissociative disorders they are perceived as occurring within the person, commenting on events in their head rather than behind their back. Differential diagnosis between schizophrenia and dissociative disorders is complicated by the multitude of overlapping symptoms. However, many people who do not suffer from a diagnosable mental illness may also sometimes hear voices. One important example to consider when forming a differential diagnosis for a patient with paracusis is lateral temporal lobe epilepsy. Despite the tendency to associate the perception of voices or other hallucinations with psychosis and schizophrenia or other mental illnesses, it is extremely important to take into account that even if a person exhibits psychotic traits, he/she does not necessarily suffer from a mental disorder. Disorders such as Wilson's disease, various endocrine diseases, numerous metabolic disorders, multiple sclerosis, systemic lupus erythematosus, porphyria, sarcoidosis, and many others may occur along with psychosis. Musical hallucinations are also relatively common in terms of complex auditory hallucinations, and can result from a wide range of causes ranging from hearing loss (eg, music hearing syndrome, an auditory version of Charles Bonnet syndrome), lateral temporal lobe epilepsy, arteriovenous malformation, stroke, focal lesion , abscess or tumor. Hearing Voices Movement is a support and advocacy group for people who hear hallucinations of voices but do not otherwise show signs of mental illness or impairment. High caffeine consumption was associated with an increased likelihood of auditory hallucinations. A study carried out at La Trobe University's School of Psychological Sciences found that as little as five cups of coffee a day (approximately 500mg of caffeine) can cause this phenomenon.

Imperative hallucinations

Imperative hallucinations are hallucinations in the form of commands; they may be auditory or occur within the person's mind and/or consciousness. The content of hallucinations can range from harmless commands to orders to harm yourself or others. Urgent hallucinations are often associated with schizophrenia. People experiencing such hallucinations may or may not comply with the hallucination's demands, depending on the circumstances. Compliance is often observed in the case of nonviolent commands. Imperative hallucinations are sometimes used as a defense in cases of crime, often murder. Essentially, it is a voice that can be heard and it tells the listener what to do. Sometimes the commands are quite “benign” instructions, such as “get up” or “close the door.” It doesn't matter whether this command is an indication of something simple or a threat, it is still considered a "imperative hallucination". Some useful questions that can help determine whether a person is experiencing this type of hallucination include: “What are the voices telling you to do?” “When did the voices first start giving you instructions?” “Do you recognize the person who is telling you to do things?” harming yourself (others)?”, “In your opinion, can you resist doing what the voices tell you to do?” Patients sometimes refer to imperative hallucinations as instructions. Typically, initiating these commands in patients results in lifestyle changes, such as quitting work if a voice tells them to do so. Many patients consider these commands to be supernatural phenomena because these commands seem meaningful to them. When imperative hallucinations are associated with schizophrenia, the person may hear many unpleasant things. Instructions or commands may, for example, involve yelling at someone or telling someone something specific. A patient suffering from imperative hallucinations has no choice but to comply. Some claim that when they are given instructions, they feel their shoulders tighten and they have no choice but to act on command. The voice may order, for example, to hit one of the patient's family members. Urgent hallucinations are a recurring phenomenon. In addition, the voice may tell the patient to keep in touch with specific people, for example by sending them emails or calling them on the phone, without any specific purpose.

Olfactory hallucinations

Phantosmia (olfactory hallucinations) is the perception of an odor that does not actually exist. Parosmia is the inhalation of a real odor but the perception of it as a different odor, a distortion of the odor (olfactory system), which, in most cases, is not caused by anything serious, and usually goes away on its own over time. This can be the result of a number of conditions, such as nasal infections, nasal polyps, dental problems, migraines, traumatic brain injuries, seizures, strokes or brain tumors. Sometimes these hallucinations are caused by environmental influences, such as smoking, exposure to certain types of chemicals (such as insecticides or solvents), or radiation treatment for head or neck cancer. Olfactory hallucinations can also be a symptom of certain mental disorders, such as depression, bipolar disorder, intoxication or withdrawal symptoms after drug and alcohol withdrawal, or psychotic disorders (such as schizophrenia). The odors experienced are generally unpleasant and are often described as smelling like burning, garbage or rot.

Tactile hallucinations

Tactile hallucinations are the illusion of tactile sensory input, simulating various types of effects on the skin or other organs. A subtype of tactile hallucinations, goosebumps are the sensation of insects crawling under the skin and are often associated with long-term cocaine use. However, goosebumps can also be the result of normal hormonal changes such as menopause, or disorders such as peripheral neuropathy, fever, Lyme disease, skin cancer, and more.

Taste hallucinations

This type of hallucination is the perception of taste in the absence of a stimulus. These hallucinations, which are usually strange or unpleasant, are quite common among individuals who have certain types of focal epilepsy, especially temporal lobe epilepsy. The areas of the brain responsible for taste hallucinations in this case are the insula of Reille and the Sylvian fissure.

General somatic sensations

General somatic sensations of a hallucinogenic nature are experienced when a person feels that his body is disfigured, i.e. twisted, torn or gutted. Other reports involve cases of animals invading human internal organs, such as a snake in the stomach or a frog in the rectum. The general feeling of decay of the flesh is also classified under this type of hallucination.

Cause

Hallucinations can be caused by a number of factors.

Hypnotic hallucinations

These hallucinations occur just before falling asleep and affect a high percentage of the population. In one survey, 37% of respondents said they experience hallucinations twice a week. Hallucinations can last from a few seconds to several minutes; all this time the person, as a rule, remains aware of the true nature of the images. They may be associated with narcolepsy. Hypnagogic hallucinations are sometimes associated with brainstem abnormalities, but this is rare.

Peduncular hallucinosis

Peduncular means “pertaining to the cerebral peduncle,” which is the neural tract extending from and into the pons of the brainstem. These hallucinations tend to occur in the evening, but not during sleep, as is the case with hypnotic hallucinations. The patient is usually fully conscious. As with hypnagogic hallucinations, the understanding of the nature of the images remains intact. False images can occur in any part of the visual field and are rarely multimodal.

Alcohol delirium

One of the most puzzling forms of visual hallucinations is multimodal delirium. Individuals suffering from delirium tremens may appear agitated and confused, especially in the later stages of the disease. The ability to gain insight gradually decreases as the disease progresses. Sleep is disrupted and occurs over a shorter period of time, with rapid eye movement sleep.

Parkinson's disease and dementia with Lewy bodies

Parkinson's disease is related to Lewy body dementia due to similar hallucinatory symptoms. Symptoms begin to appear in the evening in any part of the visual field, and are rarely multimodal. The transition to hallucination may begin with illusions, when sensory perception is greatly distorted, but no new sensory information is received. They usually last for several minutes, during which the subject may be either conscious and normal or drowsy/unavailable. The person's awareness of these hallucinations is usually preserved, and REM sleep is usually reduced. Parkinson's disease is usually associated with a degraded substantia nigra pars compacta, but recent evidence suggests that Parkinson's disease affects the number of areas in the brain. Some areas with marked degradation include the median raphe nuclei, noradrenergic portions of the locus coeruleus, and cholinergic neurons in the parabrachial region and pedunculopontine nucleus of the tegmentum.

Migraine coma

This type of hallucination is usually observed during recovery from a coma. Migraine coma can last up to two days, and is sometimes accompanied by a state of depression. Hallucinations occur during a state of full consciousness, and awareness of the hallucinatory nature of the images is maintained. It has been noted that migraine coma is accompanied by ataxic lesions.

Charles Bonnet syndrome

Charles Bonnet syndrome is the name given to visual hallucinations experienced by a person with partially or severely impaired vision. Hallucinations can happen at any time and can affect people of any age as they may not initially be aware that they are hallucinating. Patients may have concerns about the state of their own mental health, which is why they may not tell loved ones about their hallucinations for a long time. Hallucinations can be frightening and confusing for patients because they become confused about what is real and what is not, and caregivers need to learn how to support patients. Hallucinations can sometimes be "dispelled" by eye movements, or perhaps simply by logic, such as "I see fire, but there is no smoke and no heat from it" or perhaps "we were attacked by rats, but these rats pink ribbons with a bell tied around the neck.” Over months and years, the appearance of hallucinations may change and they may become more or less frequent, along with changes in the ability to see. The length of time a person may suffer from these hallucinations with deteriorating vision varies depending on the underlying wear rate of the eyes. Differential diagnosis: ophthalmopathic hallucinations.

Focal epilepsy

Visual hallucinations due to a focal epileptic seizure vary depending on the area of ​​the brain in which the seizure occurs. For example, visual hallucinations during occipital lobe epilepsy typically involve brightly colored visions, geometric shapes that may move across the visual field, multiply, or form concentric rings, and typically last from a few seconds to several minutes. They, as a rule, are unilateral in nature and localized in one part of the visual field on the opposite side of the convulsive focus. However, unilateral visions moving horizontally across the visual field begin on the contralateral side and move toward the ipsilateral side. Epileptic seizures, on the other hand, can produce complex visual hallucinations of people, scenes, animals, and more, as well as distortions in visual perception. Complex hallucinations may appear real or unreal, may or may not be distorted in size, and may appear disturbing or welcoming, among other things. One rare but notable type of hallucination is heautoscopy, a hallucination of a mirror image of oneself. These “other self-images” may be completely stationary or performing complex tasks, may represent a younger self-image or a real-life image of the patient, and are usually only present for a short time. Complex hallucinations are relatively rare in patients with temporal lobe epilepsy. Rarely, they may be observed during focal seizures or seizures in the parietal lobe. Visual distortions during temporal lobe seizures may include size distortion (micropsia or macropsia), distorted perception of motion (where moving objects may move very slowly or be completely still), the feeling that surfaces such as ceilings and even entire horizons are moving on, similar to Hitchcock's zoom effect, and other illusions. Even when consciousness is damaged, the understanding that the hallucination or illusion is unreal usually remains.

Hallucinations caused by hallucinogens

Sometimes hallucinations are caused by the use of psychoactive substances, such as anticholinergic hallucinogens, psychedelics, and certain stimulants, which are known to cause visual and auditory hallucinations. Some psychedelics, such as lysergic acid diethylamide and psilocybin, can cause hallucinations. Some of these drugs can be used in psychotherapy to treat mental disorders, drug addiction, anxiety, and are used secondarily in advanced stages of cancer.

Hallucinations caused by sensory deprivation

Hallucinations can be caused by sensory deprivation when it occurs over long periods of time, and almost always occur when some modality disappears (visual hallucinations when blindfolded/in the dark, auditory hallucinations when deafened, etc.).

Experimentally induced hallucinations

Abnormal experiences, such as so-called benign hallucinations, can occur in a person in good mental and physical health, even in the apparent absence of a trigger such as fatigue, intoxication, or sensory deprivation. It is now widely accepted that hallucinatory experiences are not only the preserve of persons suffering from mental illness or normal persons in abnormal states, but that they occur spontaneously in a large proportion of the normal population who are in good health and not under special stress or stress. in other atypical circumstances. Evidence for this claim has accumulated over more than a hundred years. Research into benign hallucinatory experiences began in 1886, with early work by the Society for Psychical Research, which reported that approximately 10% of the population had experienced at least one hallucinatory episode during their lifetime. Later studies confirmed these findings; the exact frequency varies depending on the nature of the episode as well as the criteria for "hallucinations", but the main conclusion is now well supported.

Pathophysiology

Visual hallucinations

Sometimes internal imagery can suppress sensory input from external stimuli when neural pathways are shared, or if ambiguous stimuli are perceived in accordance with expectations or beliefs, especially about the environment. This can lead to hallucinations, and this effect is sometimes used to create optical illusions. There are three pathophysiological mechanisms thought to be associated with complex visual hallucinations. These mechanisms include:

Irritation of cortical centers responsible for processing visual information (for example, convulsive activity). Irritation of the primary visual cortex causes simple elementary visual hallucinations.

Lesions that cause deafferentation of the visual system can lead to a cortical release phenomenon that causes visual hallucination.

The activating reticular system has been linked to the genesis of visual hallucinations.

Some specific classifications include: elementary hallucinations, which may include clicks, spots, and beams of light (called phosphenes). Hallucinations with eyes closed in the dark are common when taking psychedelic drugs (ie, LSD, mescaline). Scenic or “panoramic” hallucinations that do not overlap, but vividly replace the entire field of vision with hallucinatory content, similar to dreams; Such picturesque hallucinations may occur in epilepsy (in which they tend to be stereotypical and experiential in nature), hallucinogen use, and, more rarely, in catatonic schizophrenia, mania, and brainstem lesions, among others. Visual hallucinations can be caused by prolonged visual deprivation. In a study in which 13 healthy subjects were blindfolded for 5 days, 10 of the 13 subjects reported visual hallucinations. This finding lends strong support to the idea that simple loss of normal visual information is sufficient to cause visual hallucinations.

Psychodynamic point of view

Various theories have been put forward to explain the occurrence of hallucinations. When psychodynamic (Freudian) theories were popular in psychology, hallucinations were considered projections of unconscious desires and thoughts. As biological theories have become generally accepted, hallucinations have become more commonly thought (at least by psychologists) to be caused by a functional deficit in the brain. With regard to mental illness, the function (or dysfunction) of the neurotransmitters glutamate and dopamine are thought to be particularly important. The Freudian interpretation may have an aspect of truth, since the biological hypothesis explains the physical interactions in the brain, while the Freudian interpretation posits psychological complexes associated with the content of hallucinations, such as the hallucination of voices haunting a person due to feelings of guilt. According to psychological research, hallucinations may result from systematic errors in so-called metacognitive abilities.

Information Processing Perspective

These are abilities that allow us to monitor or infer our own internal psychological states (such as intentions, memories, beliefs and thoughts). The ability to distinguish between internal (self-generated) and external (stimuli) sources of information is considered an important metacognitive skill, but it can be impaired and cause hallucinatory experiences. Projecting an internal state (or a person's own reaction to another person's state) can manifest itself in the form of hallucinations, especially auditory hallucinations. A recent hypothesis that is now gaining acceptance concerns the role of hyperactive top-down processing, or highly perceived expectations, that may generate spontaneously perceived output (i.e., hallucination).

Stages of hallucinations

Biological Perspective

Auditory hallucinations

Auditory hallucinations are the most common type of hallucination. These include the perception of voices and music. In many cases, an individual suffering from auditory hallucinations will hear a voice or voices speaking their own thoughts out loud, commenting on the individual's actions, or ordering the person to do something. These voices tend to be negative and critical of the individual. People who suffer from schizophrenia and have auditory hallucinations often speak with this voice as if they are talking to another person.

Visual hallucinations

The most common modality when people talk about hallucinations involves seeing things that are not present in reality, or visual perceptions that are not related to physical reality. There are many different causes, which are classified as psychophysiological (disturbance of brain structure), psychobiochemical (disturbance of neurotransmitters), psychodynamic (penetration of the unconscious into consciousness), and psychological (for example, significant experiences of consciousness); this also occurs in Alzheimer's disease. Numerous disorders can include visual hallucinations, ranging from psychotic disorders to dementia and migraines, but visual hallucinations alone do not necessarily indicate the presence of a disorder. Visual hallucinations are associated with organic brain disorders and drug and alcohol use disorders and are generally not considered to be the result of a mental disorder.

Schizoid hallucinations

Hallucinations may be caused by schizophrenia. Schizophrenia is a mental disorder associated with the inability to distinguish between real and unreal experiences, think logically, have contextually appropriate emotions, and function in social situations.

Neuroanatomical correlates

Common everyday procedures, such as MRI (magnetic resonance imaging), have been used to learn more about auditory and verbal hallucinations. “Functional magnetic resonance imaging (fMRI) and repetitive transcranial magnetic stimulation (rTMS) have been used to study the pathophysiology of auditory/verbal hallucinations (AVH).” Looking at MRIs of patients, "lower levels of hallucination-related activation in Broca's area predicted greater response to left temporal rTMS." We can achieve a better understanding of why hallucinations occur in the brain by understanding emotions and cognitions and how they can prompt physical responses that can lead to hallucinations. It has been found that hallucinations in schizophrenia are associated with differences in the morphology of the parasingulate sulcus.

It most often develops subacutely—over a number of days and weeks. It can replace an acute polymorphic syndrome (see p. 127) or follow neurosis-like, less often psychopath-like disorders, and even less often a paranoid debut. Acute paranoid syndrome lasts for weeks, 2-3 months; chronic persists for many months and even years. Paranoid syndrome consists of polythematic delusions, which may be accompanied by hallucinations and mental automatisms. Depending on the clinical picture, the following variants of paranoid syndrome can be distinguished. Hallucinatory-paranoid syndrome is characterized by pronounced auditory hallucinations, to which sometimes olfactory hallucinations are also added. Among auditory hallucinations, the most typical are calls by name, imperative voices that give the patient various orders, for example, to refuse food, commit suicide, show aggression towards someone, as well as voices that comment on the patient’s behavior. Sometimes hallucinatory experiences reflect ambivalence. For example, someone’s voice either forces you to engage in masturbation, or scolds you for it. Olfactory hallucinations are usually extremely unpleasant for the patient - the smell of a corpse, gas, blood, sperm, etc. is felt. Often the patient finds it difficult to say what he smells, or gives the smells unusual names (“blue-green smells”). In addition to obvious hallucinations, adolescents are also especially prone to “delusional perception.” The patient “feels” that someone is hiding in the apartment nearby, although he has not seen or heard anyone, “feels” the gaze of others on his back. Due to some incomprehensible or indescribable signs, it seems that the food is poisoned or contaminated, although there seems to be no change in taste or smell. After seeing a famous actress on the television screen, a teenager “discovers” that he resembles her and, therefore, she is his real mother. Delusions in hallucinatory-paranoid syndrome can be either closely related to hallucinations or not stem from hallucinatory experiences. In the first case, for example, when voices are heard threatening to kill, the thought is born about a mysterious organization, a gang that is pursuing the patient. In the second case, delusional ideas seem to be born on their own: the teenager is convinced that they are laughing at him, although he has not noticed any obvious ridicule, and simply any smile on the faces of others is perceived as a hint of some kind of his own shortcoming. Among the different types of delusions, delusions of influence are especially characteristic. Mental automatisms in this syndrome occur as fleeting phenomena. Auditory pseudohallucinations may be more persistent: voices are heard not from somewhere outside, but from inside one’s head. Kandinsky-Clerambault syndrome [Kandinsky V. X., 1880; Clerambault G., 1920], as well as in adults, is characterized by pseudohallucinations, a feeling of mastery or openness of thoughts and delusions of influence [Snezhnevsky A.V., 1983]. In younger and middle-aged adolescents, visual pseudohallucinations are also encountered: various geometric figures, a grid, etc. are seen inside the head. For older adolescence, auditory pseudohallucinations are more typical. Among mental automatisms, the most common are “gaps” in thoughts, feelings of moments of emptiness in the head, and less often, involuntary influxes of thoughts (mentism). There is a feeling of thoughts sounding in your head. It seems that one’s own thoughts are heard or somehow recognized by others (a symptom of openness of thoughts). Sometimes, on the contrary, a teenager feels that he himself has become able to read the thoughts of others, predict their actions and actions. There may be a feeling that someone is controlling the behavior of a teenager from the outside, for example, using radio waves, forcing him to perform certain actions, moving the patient’s hands, encouraging him to pronounce certain words - speech motor hallucinations J. Seglas (1888). Among the various forms of delirium in Kandinsky-Clerambault syndrome, delusions of influence and delusions of metamorphosis are most closely associated with it. The delusional version of the paranoid syndrome is distinguished by a variety of polythematic delusions, but hallucinations and mental automatisms are either completely absent or occur sporadically. Delusional ideas in adolescence have the following features. Delusional relationship occurs more often than others. The teenager believes that everyone looks at him in a special way, grins, and whispers to each other. The reason for this attitude is most often seen in defects in one’s appearance - an ugly figure, small stature in comparison with peers. The teenager is sure that from his eyes they guess that he was engaged in masturbation, or are suspected of some unseemly acts. Relationship ideas intensify when surrounded by unfamiliar peers, among the public staring around, in transport cars. Delusions of persecution often associated with information gleaned from detective films. The teenager is pursued by special organizations, foreign intelligence services, gangs of terrorists and currency traders, robber gangs, and the mafia. Agents sent everywhere are seen watching him and preparing reprisals. Delirium of influence also sensitively reflects the trends of the times. If earlier we were more often talking about hypnosis, now - about the telepathic transmission of thoughts and orders at a distance, about the action of invisible laser beams, radioactivity, etc. Psychic automatisms (“thoughts are stolen from the head” can also be associated with ideas of influence). “they put orders into your head”) and ridiculous hypochondriacal nonsense (“they spoiled the blood”, “affected the genitals”, etc.). Nonsense of other people's parents was described as characteristic of adolescence [Sukhareva G. E., 1937]. The patient “discovers” that his parents are not his own, that he accidentally ended up with them in early childhood (“they got mixed up in the maternity hospital”), that they feel this and therefore treat him badly, want to get rid of him, and imprison him in a psychiatric hospital. Real parents often occupy a high position. Dysmorphomanic delirium differs from dysmorphomania with sluggish neurosis-like schizophrenia in that imaginary deformities are attributed to someone’s evil influence or receive another delusional interpretation (bad heredity, improper upbringing, parents did not care about proper physical development, etc.). Delirium of infection Teenagers often have a hostile attitude towards their mother, who is accused of being unclean and spreading infection. Thoughts about contracting sexually transmitted diseases are especially common, especially in adolescents who have not had sexual intercourse. Hypochondriacal delirium in adolescence, it often affects two areas of the body - the heart and genitals. Differential diagnosis must be made with reactive paranoids if the paranoid syndrome arose after mental trauma. Currently, reactive paranoids in adolescents are quite rare. They can be encountered in the situation of a forensic psychiatric examination [Natalevich E. S. et al., 1976], as well as as a consequence of a real danger to the life and well-being of a teenager and his loved ones (attacks by bandits, disasters, etc.) . The picture of reactive paranoid is usually limited to delusions of persecution and relation. Hallucinatory (usually illusory) experiences arise episodically and in content are always closely related to delusion. The development of reactive paranoids in adolescents can be facilitated by an environment of constant danger and extreme mental stress, especially if they are combined with lack of sleep, as was the case in areas temporarily occupied by the Nazis during the Great Patriotic War [Skanavi E. E., 1962]. But mental trauma can also be a provocateur for the onset of schizophrenia. The provoking role of mental trauma becomes obvious when the paranoid syndrome drags on long after the traumatic situation has passed, and also if delusions of persecution and relationships are joined by other types of delusions that do not in any way arise from the experiences caused by mental trauma, and, finally, if hallucinations begin to occupy an increasing place in the clinical picture and at least fleeting symptoms of mental automatisms appear. Prolonged reactive paranoids are not characteristic of adolescence.

Disorders of perception in the form of hallucinations (imaginary perception, perception without an object), while continuing to remain a key psychopathological sign of the schizophrenic process, have, however, undergone a certain phenomenological evolution over the past decades. The classification of hallucinatory experiences in accordance with the sense organs (visual, auditory, tactile, olfactory, kinesthetic, visceral, muscular, gustatory, complex) has become more specific and expanded. The division of hallucinations by level of complexity has become more complicated: 1) elementary (visual analyzer: photopsia - sparks, lightning, shiny lines; auditory analyzer: acoasmas - elementary sounds (knocking, whistling, noise); phonemes - verbal hallucinations (calls); 2) simple - visual hallucinations arising against the background of a darkened consciousness, and auditory hallucinations - against the background of an altered consciousness (visual analyzer: panoramic hallucinations (scene-like phenomena); auditory analyzer: commentary or imperative voices); 3) complex (combined) hallucinations (for example, the patient simultaneously experiences visual, auditory, tactile and olfactory hallucinations).

It is known (M.V. Korkina, N.D. Lakosina, A.E. Lichko, 1995) that all hallucinations, regardless of whether they relate to visual, auditory or other deceptions of the senses, are divided into true and pseudohallucinations. True hallucinations are always projected outward, associated with a real, concretely existing situation, most often do not raise any doubts in patients about their actual existence, and are just as vivid and natural for the hallucinating person as real things. True hallucinations are sometimes perceived by patients even more vividly and clearly than actually existing objects and phenomena. Pseudohallucinations, more often than true ones, are characterized by the following distinctive features. Most often they are projected inside the patient’s body, mainly in his head (“the voice” sounds inside the head, inside the patient’s head he sees a business card with obscene words written on it, etc.). Pseudohallucinations, first described by V. Kandinsky, resemble ideas, but differ from them, as V. Kandinsky himself emphasized, in the following features: 1) independence from human will; 2) obsession, violence; 3) completeness, formality of pseudohallucinatory images; 4) even if pseudohallucinatory disorders are projected outside one’s own body (which happens much less frequently), then they lack the character of objective reality characteristic of true hallucinations and are completely unrelated to the real situation. Moreover, at the moment of hallucination, this environment seems to disappear somewhere, the patient at this time perceives only his hallucinatory image. The appearance of pseudohallucinations, without causing the patient any doubts about their reality, is always accompanied by a feeling of being done, arranged, induced by these voices or visions. Pseudo-hallucinations are, in particular, an integral part of the Kandinsky-Clerambault syndrome, which also includes delusions of influence, which is why patients are convinced that the “vision” was “made to them using special devices,” “voices are directed directly into the head with transistors.”

Auditory hallucinations are most often expressed in the patient’s pathological perception of certain words, speeches, conversations (phonemes), as well as individual sounds or noises (acoasms). Verbal hallucinations can be very diverse in content: from so-called calls (the patient “hears” a voice calling his name or surname) to entire phrases or even long speeches pronounced by one or more voices.

The object of our research was the most dangerous imperative hallucinations for the condition of patients (from the Latin imperatum - to order), the content of which is imperative in nature. According to our long-term observations, these are imperative orders to do something or prohibitions on actions. Patients often take the orders of their voices personally. They are less often “redirected” to others. Voices may demand to do things that directly contradict the patient’s intentions - to hit or kill someone, insult, commit theft, attempt suicide or self-harm, refuse to take food, medicine, or talk with a doctor, turn away from the interlocutor, close your eyes, squeeze teeth, stand motionless, walk without any purpose, rearrange objects, move from one place to another. Patients with this type of painful experience can be very dangerous both for themselves and for others, and therefore require special supervision and care.

Sometimes the orders of the “voices” are “reasonable”. Under the influence of hallucinations, some patients seek help from psychiatrists without realizing the fact of a mental disorder. Some patients indicate a clear intellectual superiority of the “voices” over them.

The content of imperative deceptions and the degree of their influence on behavior are different, so the clinical significance of this type of deception may vary. Thus, “orders” of a destructive, absurd, negativistic nature indicate a level of personality disorganization close to catatonic. Such orders, like catatonic impulses, are implemented automatically, unconsciously. Orders with a feeling of coercion are also carried out, but the patient tries to resist or at least realizes their unnaturalness. The content of such orders is no longer always destructive or absurd. Orders of persecutory content are observed. There are contradictory, ambiguous orders of voices, when, along with the absurd ones, quite reasonable orders are also heard. Sometimes orders are heard that are in tune with the patient’s conscious attitudes.

Hallucinatory orders, as is known, are not always implemented. Sometimes patients do not attach importance to them, or consider them ridiculous or meaningless. Others find the strength to restrain themselves or “to spite the voices” do the opposite. More often than not, imperative hallucinations have an irresistible influence. Patients do not even try to oppose themselves to them, carrying out the most ridiculous orders. According to patients, at this time they feel “paralysis” of their will and act like “automata, zombies, puppets.” The irresistible imperativeness of hallucinations indicates their closeness to catatonia and phenomena of mental automatism. According to V. Milev (1979), imperative orders can be classified as schizophrenic symptoms of the first rank.

Hallucinations that contain not orders, but persuasion, exhortation, and reporting of false information, which acquire greater persuasive power for patients, are similar to imperative hallucinations. Often imperative hallucinations are observed during suicidal or homicidal behavior.

In one of our patients (at the time of the examination, an 11th grade student), the debut of imperative hallucinations began at the age of 10, which was visually manifested in “freezing”: while walking, he stopped “like a stone” for 2–3 minutes. At first, the frequency of such episodes of “freezing” was 1–2 times a week, then “freezing” was observed daily. It turned out that the “freezing” was caused by orders from the voice to stop (“after a step or several steps, I stop at the order of the voice that follows me from behind”). Sometimes the patient would disobey these orders, but this would not last long. Subsequently, by the age of 15, “my voice became rough... scary... I asked my mother to help me get rid of it”). Imperative hallucinations were accompanied by low mood, anxiety, suspicion, and panic, as a male voice threatened: “If you don’t stop coughing, the boys will strangle me. Check out quickly." Occasionally the “voice” would order me to go somewhere, check something, hit someone.

A study of the mental sphere in this patient revealed a violation of focus and criticality, disorganization of thinking, and distortion of the generalization process. The judgments are varied. Notes a variety of specific, formal and casual connections. For example, he adds “broom” to the “furniture” group, since it is also wooden, and “bed” is combined with “thermometer” due to a situational connection. And a whole series of associations do not have any logical justification at all. For example, “butterfly” + “plane” + “ship”; "bird" + "fish" + "shoe". Due to his intellectual capabilities, the patient cannot cope with many tasks, and, as a rule, cannot explain his decisions.

As a result of treatment (senorm, triphen, cytagexal), the patient's condition improved, imperative auditory hallucinations lost their significance. I became calmer and more adequate. He willingly participated in therapeutic and restorative labor processes. I used the free exit mode. Discharged from the hospital in a state of remission.

Consequently, in the studied patient, imperative hallucinations were observed against the background of disintegration of thinking, distortion of the generalization process, impairment of focus and criticality, and a general decrease in intellectual productivity, which is characteristic of the paranoid form of schizophrenia.

Verbal deceptions that have the nature of instructions or commands are called imperative hallucinations. Basically, they have absurd content that has a dangerous, sadistic meaning that is addressed directly to the patient. Orders coming from voices in the head are always perceived by the patient in such a way that they are not addressed to any stranger, but only to the patient himself. For example, imperative ones are expressed in the fact that a person is ordered to hit himself or someone around him with an ax, pretend to be an animal, set fire to an apartment, and so on.

Many patients, talking about their condition, say that they are very worried, and even panicky, that the voices may order them to attack their loved ones and cause them harm. Some people understand that being in such a state, they lose control over their own actions. Also, imperative hallucinations are characterized by the absence of the patient’s name; usually the voices address the patient in the second person. More often than not, the motivational power of the hallucinatory orders given is quite strong, and patients do not have the strength to oppose anything to them. Moreover, the thought does not even occur to them that it is possible to resist this phenomenon.

A similar state is observed in a person during a hypnotic deep trance, when suggestion from the “voices” is not accompanied by opposition from the patient. As practice shows, there are also delayed effects of imperative-type hallucinations, but this happens rarely. In some cases, vote orders are reasonable. Being influenced by this, many patients independently decide that it is necessary to seek help from a psychiatrist. In addition, patients often note that the voices they hear have a significant intellectual superiority over them.

Causes of imperative hallucinations

It is known that imperative hallucinations are not a separate disease; most often they are signs of serious illnesses and are characteristic. There are statistics according to which the average prevalence of imperative hallucinations in diagnosed patients is fifty-three percent. Thirty percent of patients demonstrate complete submission to the imperative command. In this case, there are very few treatment methods, and moreover, they are not systematically tested. Based on these data, patients claim that the occurrence of imperative hallucinations is typical for patients who are considered resistant to therapy. Moreover, even during hospitalization it is not always possible to prevent the patient from obeying imperative hallucinations.

The content of imperative hallucinations, as well as the degree of their influence on the patient, varies. The clinical significance of this hallucinosis varies. For example, if a patient hears voices issuing ridiculous and destructive orders that are negativistic in nature, then they indicate a catatonic level of disorganization of the patient’s personality. Catatonic impulses can be realized completely unnoticeably, automatically. In particular, orders that have a tinge of coercion are carried out, but at the same time the patient realizes that they are unnatural. Sometimes orders are received that completely correspond to the patient’s own attitudes.

It is known that among people suffering from imperative hallucinations there are individuals who behave “in spite of the voices” and act opposite to the demands of unknown dictators. But this is a rare occurrence. As the patients themselves say, during hallucinations they feel something like paralysis, and all actions are performed in a state of automatism or so-called zombification. Urgent hallucinations begin at different ages. For example, one subject at the age of sixteen, when imperative hallucinations occurred, froze in place and could not take a single step, remaining in this position for at least three minutes. As psychiatrists found out, the voices in his head gave orders to stop.

Treatment of imperative hallucinations

The treatment process for hallucinosis of any type begins with a general thorough examination and identification of the underlying disease that is the cause of the disorder, in this case causing imperative hallucinations. In many cases, specialists prescribe cognitive therapy, among other means. With this technique, the process is aimed at reducing imperative hallucinosis, as well as weakening the power of hallucinations. When examining the sphere of thinking of patients, doctors identify impaired criticality, disorganization of thinking, and a distorted generalization process. Including, a number of formal, casual connections are noted.

Almost always, the patient’s intellectual capabilities are not high enough, and he cannot explain his decisions regarding submission to imperative hallucinations. As a result of the treatment, the patients' condition improves, imperative hallucinations lose their significance, patients return to peace, and the person begins to behave more adequately. Also, thanks to timely treatment, patients are willing to participate in restorative labor processes, a state of remission is achieved, and if they are in a hospital, the patient can be discharged home.