- Email: [email protected]
Delusion versus delirium
G Model
ARTICLE IN PRESS Med Clin (Barc). 2016;xxx(xx):xxx–xxx
www.elsevier.es/medicinaclinica
Letter to the Editor
Delusion versus delirium夽 Delirio frente a delirium Dear Editor, In the article Complications of hospitalization in older adults1 an interesting review of 8 major problems affecting the progression and prognosis of hospitalized elderly patients is presented. However, it seems relevant to clarify the term “delusion”, used to name one of the complications explained in the manuscript. In modern psychopathology the term delirium is used to denote the disorders which are mentioned in the review. It refers to mental status changes that occur between normal alertness at one end and stupor and coma on the other. This term is also used for cases with a specific aetiology, such as delirium tremens, and it is listed in the International Classification of Diseases, tenth revision. Recent semiotic research has identified three nuclear domains for this disorder: cognitive domain (attention, memory, orientation, visuospatial ability), the higher-order thinking domain, (course of thought, language, executive function) and the circadian domain (motor activity and sleep-wake cycle). Affective (irritability, instability or affection incongruence) and psychotic (illusions, hallucinations, depersonalization, derealisation, suspiciousness, delusions) symptoms are accessory and may indicate severity or some specific aetiology. Soon new research criteria for delirium (English and Spanish) will be published, based on these clinical features.2 Moreover, the word “delusion” indicates an alteration in the content of thought: false belief, irreducible by logic, which is not shared by the subjects’ social or cultural group. It is a psychotic symptom that can occur in many diseases. Although there are no pathognomonic delusions for any medical entity, the characteristics of these help guide the differential diagnosis. They can be plausible and structured (as in delusional disorder) or unstructured (as in delirium). There are specific presentations, such as delusional perception (common in schizophrenia). The content of delusion also involves a relative symptomatology interest; there are delusional ideas of injury (e.g. in dementia), grandiosity (e.g. in bipolar disorder), enormity (e.g. in syphilis) or nihilists (e.g. in depression), among others.3
夽 Please cite this article as: Martínez-Velilla N, Franco JG, Molina Amaya CM. Delirio frente a delirium. Med Clin (Barc). 2016. http://dx.doi.org/10.1016/ j.medcli.2016.04.005
The confusion between the words delirium and delusion has a historical explanation. Over time many expressions have captured more or less the concept of delirium, e.g.: lethargy or frenzy. Celsus (c. 25 a. C–c. 50 d. C.) first used the expression delirium (Latin for: coming out of the groove) to refer to behavioural disturbances observed both in febrile patients and other forms of “madness”. On the other hand, a systematic observation of patients, conducted by the French Alienists in the XIX century, allowed a dramatic reclassification of “madness” of which many clinical descriptions and terms that still remain in force emerged. Panel (1745–1826) and Esquire (1772–1840) used the French word délire with the same broad sense as Celsus. As the xix century progressed the French expression became more and more reserved to describe the alterations in thought content (delusions), and Chaslin (1857–1923) chose the term “primitive mental confusion” to name what we now call delirium (the term “confusion” is inaccurate since it is also used for certain formal thought disorders)3 . As part of the DSMIII research team, Lipowski (1924–1997) rescued the classic term delirium for use in its current connotation and maintain historical continuity.4 The lack of consensus on the name of a disorder such as delirium, which should involve various specialists and nurses, caregivers and administrative staff, hinders communication and can lead to situations in which different doctors may think they are facing different problems. We often see PubMed and other databases articles originally written in Spanish in which “delusion” was used instead of delirium, misclassified and poorly translated into English, as the Spanish “delirio” means “delusion” in english, not “delirium”. We join Tohen (2014) in their request that language, as the backbone of communication for all who treat patients with mental disorders, should facilitate communication between professionals,5 and we advocate the use of the correct term delirium by all specialists.
References 1. Rojano i Luque X, Sánchez Ferrin P, Salvà A. Complicaciones de la hospitalización en personas mayores. Med Clin (Barc). 2016, http://dx.doi.org/10.1016/ j.medcli.2015.12.015. S0025-7753(16)00014-2 [Epub ahead of print]. 2. Trzepacz PT, Meagher DJ, Franco JG. Comparison of diagnostic classification systems for delirium with new research criteria that incorporate the three core domains. J Psychosom Res. 2016;84:60–8, http://dx.doi.org/10.1016/ j.jpsychores.2016.03.011. 3. Berrios GE. Historia de los síntomas de los trastornos mentales. La psicopatología descriptiva desde el siglo xix. México D. F.: Fondo de Cultura Económica; 2008. 4. Lipowski ZJ. Delirium: how its concept has developed. Int Psychogeriatr. 1991;3:115–20. 5. Tohen M. Psychiatric collaborations in the Hispanic world. Rev Psiquiatr Salud Ment (Barc). 2014;7:155–6.
˜ S.L.U. All rights reserved. 2387-0206/© 2016 Elsevier Espana,
MEDCLE-3617; No. of Pages 2
G Model 2
ARTICLE IN PRESS Letter to the Editor / Med Clin (Barc). 2016;xxx(xx):xxx–xxx
Nicolas Martínez-Velilla a,b,c,∗ , José G. Franco d , Clara Marina Molina Amaya a
d
Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
a
Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain b Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Navarra, Spain c Instituto de Investigación Sanitaria Navarra (IdiSNA), Pamplona, Navarra, Spain
∗ Corresponding author. E-mail address: [email protected] (N. Martínez-Velilla).
ARTICLE IN PRESS Med Clin (Barc). 2016;xxx(xx):xxx–xxx
www.elsevier.es/medicinaclinica
Letter to the Editor
Delusion versus delirium夽 Delirio frente a delirium Dear Editor, In the article Complications of hospitalization in older adults1 an interesting review of 8 major problems affecting the progression and prognosis of hospitalized elderly patients is presented. However, it seems relevant to clarify the term “delusion”, used to name one of the complications explained in the manuscript. In modern psychopathology the term delirium is used to denote the disorders which are mentioned in the review. It refers to mental status changes that occur between normal alertness at one end and stupor and coma on the other. This term is also used for cases with a specific aetiology, such as delirium tremens, and it is listed in the International Classification of Diseases, tenth revision. Recent semiotic research has identified three nuclear domains for this disorder: cognitive domain (attention, memory, orientation, visuospatial ability), the higher-order thinking domain, (course of thought, language, executive function) and the circadian domain (motor activity and sleep-wake cycle). Affective (irritability, instability or affection incongruence) and psychotic (illusions, hallucinations, depersonalization, derealisation, suspiciousness, delusions) symptoms are accessory and may indicate severity or some specific aetiology. Soon new research criteria for delirium (English and Spanish) will be published, based on these clinical features.2 Moreover, the word “delusion” indicates an alteration in the content of thought: false belief, irreducible by logic, which is not shared by the subjects’ social or cultural group. It is a psychotic symptom that can occur in many diseases. Although there are no pathognomonic delusions for any medical entity, the characteristics of these help guide the differential diagnosis. They can be plausible and structured (as in delusional disorder) or unstructured (as in delirium). There are specific presentations, such as delusional perception (common in schizophrenia). The content of delusion also involves a relative symptomatology interest; there are delusional ideas of injury (e.g. in dementia), grandiosity (e.g. in bipolar disorder), enormity (e.g. in syphilis) or nihilists (e.g. in depression), among others.3
夽 Please cite this article as: Martínez-Velilla N, Franco JG, Molina Amaya CM. Delirio frente a delirium. Med Clin (Barc). 2016. http://dx.doi.org/10.1016/ j.medcli.2016.04.005
The confusion between the words delirium and delusion has a historical explanation. Over time many expressions have captured more or less the concept of delirium, e.g.: lethargy or frenzy. Celsus (c. 25 a. C–c. 50 d. C.) first used the expression delirium (Latin for: coming out of the groove) to refer to behavioural disturbances observed both in febrile patients and other forms of “madness”. On the other hand, a systematic observation of patients, conducted by the French Alienists in the XIX century, allowed a dramatic reclassification of “madness” of which many clinical descriptions and terms that still remain in force emerged. Panel (1745–1826) and Esquire (1772–1840) used the French word délire with the same broad sense as Celsus. As the xix century progressed the French expression became more and more reserved to describe the alterations in thought content (delusions), and Chaslin (1857–1923) chose the term “primitive mental confusion” to name what we now call delirium (the term “confusion” is inaccurate since it is also used for certain formal thought disorders)3 . As part of the DSMIII research team, Lipowski (1924–1997) rescued the classic term delirium for use in its current connotation and maintain historical continuity.4 The lack of consensus on the name of a disorder such as delirium, which should involve various specialists and nurses, caregivers and administrative staff, hinders communication and can lead to situations in which different doctors may think they are facing different problems. We often see PubMed and other databases articles originally written in Spanish in which “delusion” was used instead of delirium, misclassified and poorly translated into English, as the Spanish “delirio” means “delusion” in english, not “delirium”. We join Tohen (2014) in their request that language, as the backbone of communication for all who treat patients with mental disorders, should facilitate communication between professionals,5 and we advocate the use of the correct term delirium by all specialists.
References 1. Rojano i Luque X, Sánchez Ferrin P, Salvà A. Complicaciones de la hospitalización en personas mayores. Med Clin (Barc). 2016, http://dx.doi.org/10.1016/ j.medcli.2015.12.015. S0025-7753(16)00014-2 [Epub ahead of print]. 2. Trzepacz PT, Meagher DJ, Franco JG. Comparison of diagnostic classification systems for delirium with new research criteria that incorporate the three core domains. J Psychosom Res. 2016;84:60–8, http://dx.doi.org/10.1016/ j.jpsychores.2016.03.011. 3. Berrios GE. Historia de los síntomas de los trastornos mentales. La psicopatología descriptiva desde el siglo xix. México D. F.: Fondo de Cultura Económica; 2008. 4. Lipowski ZJ. Delirium: how its concept has developed. Int Psychogeriatr. 1991;3:115–20. 5. Tohen M. Psychiatric collaborations in the Hispanic world. Rev Psiquiatr Salud Ment (Barc). 2014;7:155–6.
˜ S.L.U. All rights reserved. 2387-0206/© 2016 Elsevier Espana,
MEDCLE-3617; No. of Pages 2
G Model 2
ARTICLE IN PRESS Letter to the Editor / Med Clin (Barc). 2016;xxx(xx):xxx–xxx
Nicolas Martínez-Velilla a,b,c,∗ , José G. Franco d , Clara Marina Molina Amaya a
d
Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
a
Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain b Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Navarra, Spain c Instituto de Investigación Sanitaria Navarra (IdiSNA), Pamplona, Navarra, Spain
∗ Corresponding author. E-mail address: [email protected] (N. Martínez-Velilla).