Delirium: Identifying and Addressing Acute Confusion

In people the course of thought is usually logical, reasonable, consistent with reality and with a presumably correct interpretation of the perceptions and experiences that are lived. When, for whatever reason, a person has a greater or lesser degree of break with the reality that surrounds you, loses the capacity for self-criticism and the content of his thought loses coherence and logic, it can be said that he suffers from a delirium.

How is it produced?

Delirium or the presence of delusional ideas is typical of psychotic psychiatric pathologies, mainly and paranoia, among others. These pathologies occur as a result of a delusional interpretation of events after a normal perception of reality.

These delusional beliefs are false, irrefutable to logic, based on the wrong inference from reality. They tend to be more elaborate in paranoia than in schizophrenia, although in the latter the content of the delusional idea can be more variegated.

Delirium should not be confused with delirium, a generalized and acute cognitive disorder in which there is a global deterioration of higher functions with a decrease in the level of consciousness. It starts abruptly, its course is fluctuating and self-limited and is usually due to medical or toxic causes, such as neurological diseases, drugs, certain drugs or systemic diseases (endocrine diseases, liver diseases,,, acute anemia ...). Disorientation and deterioration of the level of consciousness occurs, which does not happen in psychiatric delirium. In delirium there is a destructuring of thought and perception, as well as the state of mind.

Symptoms

Patients with delirium present alterations in the content of thought due to false or distorted interpretations of external situations that have occurred in reality (for example, believing that they are talking about one because in a library people speak in low voices). In schizophrenia, the interpretation of external realities is more disjointed and variegated (for example, believing that there is going to be an alien invasion because a cat has been seen crossing the street).

Types of delirium

• Of persecution or damage ("everyone is after me and wants to hurt me").
• Jealousy or jealousy ("my partner cheats on me with everyone").
• Of attraction or erotomania ("I am irresistible to everyone").
• Of greatness or megalomania ("I am a very important person").
• Depression ("everything that happens is my fault").
• Control or influence ("they want to control my thoughts").

Likewise, patients with delirium due to schizophrenia or paranoia, for example, may present hallucinations, which are perceptions with no real object that causes them, independent of the will of the patient and without being judged by the patient, that is, they are fully convinced that they are. that you perceive is real. Hallucinations are usually auditory (voices, comments) and sometimes tactile or olfactory; visual hallucinations are more typical of organic disorders.

Diagnosis

The diagnosis will be based on the initial medical history, talking with the patient, allowing him to express himself without judging or questioning his delusional perception. The existence of a family psychiatric history, the patient's clinical data, the consumption of substances and drugs, organic diseases with delusional potential, as well as the precipitating factors and the chronology of the current situation should be assessed.

Likewise, a general physical examination will be carried out, with emphasis on the neurological examination, together with a blood and urine analysis to rule out toxins and alterations in organic functions that may justify the patient's condition. Nor would it be a bad idea to perform a brain imaging test to rule out organic brain pathology (vascular, tumor, degenerative), using a computerized axial tomography (CT) or magnetic resonance imaging (MRI).

Having ruled out other causes of delirium, it is necessary to see in which specific psychiatric pathology the picture is framed, that is, if it is:

• Schizophrenia, with a picture of more than six months with delusions, hallucinations, disorganized language and behavior, affective flattening, etc.
• Schizophreniform disorder, similar to the previous one but lasting between one and six months.
• Brief psychotic disorder, similar to the previous one but lasting less than a month.
• Chronic delusional disorder or paranoia, where delirium is almost the only symptom and is monothematic and highly structured.

It is important to assess various aspects such as the possible risk of suicide, agitation or the possible risk.

Treatment

The initial treatment of delusions will be based on the use of neuroleptic drugs, the most common being haloperidol, risperidone, olanzapine, ziprasidone, quetiapine, and clozapine. These drugs must always be closely monitored and controlled by the psychiatrist, both to assess that the patient is taking them properly and at the appropriate therapeutic dose, and to control the adverse effects that these drugs usually present. In states of great anxiety they can be combined with benzodiazepines

If patients are poor adherents, especially in the case of paranoia, antipsychotics in slow-release (depot) form, such as fluphenazine or zuclopenthixol, may be chosen.

Along with drug treatment, a prolonged psychological approach is important, through individual or group psychotherapy, as well as family therapy and psychological and occupational rehabilitation measures.

Precautionary measures

There are no preventive measures against delirium, that is why it is very important that when these symptoms are suspected, those close to the patient contact a psychiatrist as soon as possible.

WHAT YOU SHOULD KNOW:

• Schizophrenia and paranoia are the two main pathologies in which delirium appears when interpreting reality in a distorted way.
• To think that they talk about you because in a library people speak in low voices is an example of delusion and alteration of reality that can be accompanied by hallucinations.
• Persecution (“everyone chases me to harm me), jealousy (“ my partner cheats on me with everyone ”) or greatness (“ I am very important ”) are some of the themes of delusions.