The Japanese Journal of Psychiatry and Neurology, Vol. 46, No. 4, 1992

Pseudodementia and Delirium in Depression: A Contribution to Psychosomatic Medicine Hiroyuki Koide, M.D. Department of Psychiatry, Gifu University School of Medicine, Gifu

Abstract: Presenting cases of depressional pseudodementia and delirium, we wish to point out the following points in this report. The patient in depression displays a state of pseudodementia when he is regarded as having senile dementia by the people around him. The depressed patient falls into delirium when he is embarrassed by an unexpected situation. In other words, the patient shows pseudodementia when he is continuously out of the world of daily meaning; he would fall into a disturbance of consciousness when he is suddenly put out of the world of meanings. This principle is applicable not only to depression but also to all mental diseases. In mental diseases, the symptoms themselves have some meaning for the patient. However, when the patient is put out of the world of ordinary meaning, mental disease presents the aspect of a somatic disease such as dementia or disturbance of consciousness. Key Words: psychopathology, disturbance of consciousness, meaning, exogenous disease, endogenous disease, mental disease, somatic disease Jpn J Psychiatr Neurol46: 86F876, 1992

INTRODUCTION

Although depression is called an affective disorder, it is known as one of the causes of the disorders which impair intelligence and consciousness, such as (pseudo-)dementia or delirium. A disorder of intelligence and consciousness, as we know, is often seen in exogenous diseases, mainly organic brain disorders, symptomatic psychosis and druginduced psychoses. What should we make of the fact that those disorders also appear in depression, which is an endogenous affective disorder? From the viewpoint of somatic medicine, McHugh P.R. and Robinson R.G.’ have reported that there is some relation be~~

Received for publication on April 10, 1992. Mailing address: Hiroyuki Koide, M.D., Department of Psychiatry, Gifu University School of Medicine, 40 Tsukasa-machi, Gifu 500, Japan.

tween the subcortex which controls emotion and the cortex which controls intelligence/ consciousness. To date there have been papers on this subject, but nobody has reported on pseudodementia and delirium in depression from the psychological and psychopathological point of view. The reason for this may follow the notion that, in depression, the aged often show symptoms like dementia because of a decreased capacity for thinking and judgment, and the notion that the delirium seen in depression is the final symptom of depression. We consider it possible to have a somewhat more detailed psychopathological discussion about these phenomena. Such a discussion is necessary because a psychopathological finding of the factors which bring about pseudodementia and delirium would make it possible to prevent these conditions. The

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cases presented below show the symptoms of pseudodementia and delirium. They will be examined for the psychopathological factors which caused these conditions. PSEUDODEMENTIA OF DEPRESSION

A Case: Seventy-Five- Year-Old Man The patient came by himself for the consultation. His response was ambiguous and slow. His motivation for coming to the consultation was also not at all clear. Although he could not answer our questions precisely, we could summarize what the patient said as follows: “For the last week or so, I cannot get any sleep. I usually do not sleep so well, but I have never experienced such insomnia. In the morning, I don’t want to get up. My brain has become dull. Working in the daytime, I always feel weary from my job. I cannot work even for half an hour at a stretch. I get irritated easily. In the evening, I feel somewhat relieved. As I am rather listless in my home, my family considers me a lazy old man. I have fallen into such a state because I have many family troubles.” When we asked him about committing suicide, he answered, “I sometimes feel like doing it.” His wife, who was told to accompany him to the next session, told the following story: He had never been ill previously, and he had been managing a restaurant. For a couple of years, he had had an ataxic gait, dysarthria, memory disturbance, incontinence, and paralysis in his legs and arms. These symptoms had gradually become worse. About three months before, he had been able to ride on bicycle despite his symptoms. Recently, he had suffered from incontinence almost every day. His family thought that his symptoms could not improve because he was so old. The degree of dementia was not to the extent of forgetting his grandson’s name or needing his family to show him the way to the house when he went out. However, he could not count change or remember what he had eaten the previous day.

Because of these symptoms, it was decided that he should be hospitalized. At that time the diagnosis was depression, in addition to senile-dementia. Soon after hospitalization, his incontinence disappeared. The state of dementia and ataxic gait also rapidly disappeared with the improvement of his depression. After two months, he was discharged from hospital. Later he said that he did not remember what had happened during the period of his hospitalization. A CT scan showed no abnormal findings. Although the patient was at first diagnosed as suffering from depression and seniledementia, afterwards we came to the conclusion that he had pseudodementia of depression. It is a matter of common knowledge that pseudodementia can appear in depression of the elderly, but we have seldom had a patient who also shows the symptom of incontinence. From the fact that the incontinence disappeared soon after hospitalization, it was determined to be related to psychological and environmental factors. When we again listened to the patient’s past history as related by his wife and son after his hospitalization, we found that not only his wife but all of his family had believed that the patient was not ill but merely lazy, and that the patient had fallen into insomnia because he was too worried about his domestic troubles. The depression was never considered an illness by his family, even after he was cured of it. The patient continued to be treated as a sluggish old man, just as he was before his hospitalization. And his family did not let him do anything for fear that he should fall back into his previous state if he continued to worry about trivial matters. We will briefly present another case that shows a remarkable pseudodementia of depression. The patient was 52 years old at the first consultation. He consulted us because of a memory disturbance. According to his wife, “He has come to speak only a few words in recent months. Although he is a quiet person by nature, recently he does not greet anyone even at work. These days, he doesn’t want to

Pseudodementia and Delirium in Depression go to work, but I force him to go. Because I often scold him when he leaves the office early and comes back home, he goes somewhere after leaving work early and comes back home late in the evening as usual. I don’t know where he goes. When I ask him about it, he responds ambiguously, saying that he gets a headache when he reads books or newspapers. He recently went to bed right after returning home. Moreover, these days he stands without doing anything, or absentmindedly stands around outside. Such things have become more frequent.” The patient’s wife, who is almost 10 years younger than him, mentioned that she firmly believes that her husband was at the beginning of seniledementia. The patient himself would not speak spontaneously, but confessed that he has come to greet coworkers in his office in a softer voice. Also, he said that he had a poor appetite, and that he had lost 4-5 kilograms in a few months. Moreover, he said that, he thought to himself recently, “I won’t live long because I have hypertension,” and he had tried to commit suicide by taking sleeping pills, and by inhaling exhaust from the muffler of his car. All the pseudodementia patients of depression we examined were considered by their families to be sluggish or demented old men. And in many cases, not only their families but also the patients themselves thought that they could not get rid of their symptoms because of their age and sluggishness. Among depressed patients, there are younger patients who show a state which we cannot diagnose as either pseudodementia or “fear of dementia.” For instance, a 47-yearold woman came to consult us complaining that she might be suffering from seniledementia. Her children, one a junior high school and the other a high school student, made fun of her by saying that she was “a lazy old woman.” She also recognized her condition as senile-dementia from the knowledge she obtained from books and newspapers, and she had convinced herself that she was at the beginning of senile-dementia.

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Moreover, not only did she show “fear of dementia,” she actually had symptoms of considerable memory disturbance and forgetfulness. As a result, for the reasons behind the symptoms of pseudodementia of depression, there are many factors which should be taken into consideration. For example, it is the patient’s age, the people around the patient such as his family, and what they think about the patient’s condition and also what the patient himself thinks. Among all depressed patients, it is difficult to tell the proportion of patients who show symptoms of pseudodementia. Kaplan J.D.’ supposes that the proportion of pseudodementia patients to all dementia patients is 6.7%, and 60% of these, namely 4% of the total, are depressional pseudodementia. This rate is rather high. And it is surely difficult to know if the proportion of depressional pseudodementia patients is increasing or not, but we assume that it is increasing. We know that the problem of seniledementia is becoming more and more important these days, and it is feared that in coming years the problem of senile-dementia will become even more serious. Books and publications about senile-dementia can be seen everywhere in the world. This helps us to acquire useful information about seniledementia, but such information also leads many to conclude readily that the depression of elderly people is senile-dementia, and even patients themselves believe they suffer from senile-dementia. According to Wells C.E.9, since it is not difficult to differentiate between senile-dementia and depressional pseudodementia, it is important to introduce the right information about depressional pseudodementia to the general public and patients’ families. DELIRIUM IN DEPRESSION

A Case: Forty-Nine-Year-Old Woman Before she came to our hospital, she con-

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sulted a medical practitioner because of insomnia. Once she became better, she stopped consulting him, and her condition became unstable. Later, her symptoms improved very much. But one morning before she consulted us for the first time the patient’s family noticed that the patient had disappeared. They looked for her in vain. Then early the next morning they found her groaning in the garret. She was bleeding from her wrist which she had cut many times. For this, she was taken to a surgeon close to her house, and then she was carried to a university hospital because she was bleeding badly and three tendons had been cut. As she waited for a room there, members of her family alternated taking care of her. Delirium set in before her first consultation. She began to say abnormal things like “The heaven and earth will turn over,” or “My dead father is calling me,” or “We have to leave here because there will be a fire,” so her family admitted her to our hospital. This delirium ceased a few days after admission. However, during this period, as she improved, there appeared a delusion of poverty, with the patient saying, “I can’t pay for this hospitalization.“ She also said with reference to her suicide attempt, “I have done something I can’t make up for. Can I do housework again? Because I did such a foolish thing, I am bothering so many people with my hospitalization.” About the suicide attempt itself, the patient only said, “I was tempted by a devil.” The patient had orthopedic surgery on her wrist and left the hospital after two months. The process by which this patient fell into delirium can be understood if we follow the process in reverse, that is, from delirium to the normal condition. Her words-“I bothered my family by doing such a foolish thing; I might not be able to do housework again; I have done something I can’t make up for”-show that her desperation became firmer and firmer over time. For example, in her delusional state, she went from saying “I can’t pay for this hospitalization,” to “The heaven and earth will turn over.” Of course,

we cannot ignore physiological factors such as the bleeding that resulted from her attempted suicide (red blood cells count 2,460,000 at the first session) for the appearance of delirium. But she was told that she did not need a blood transfusion when she entered the hospital right after her suicide attempt. We believe that psychological factors play a more important role than the somatic factors in inducing delirium. This hypothesis is supported by another case involving a depressed patient who showed obvious delirium. We present the case below. The patient is a 59-year-old man who is engaged in work relating to psychiatry. He had been in a state of depression for some time before the first consultation, and he often thought about committing suicide. One day he was found by his family as he was just about to kill himself by cutting his abdomen. Since there was a young psychiatrist among his relatives, his family consulted him and took the patient to the hospital where he worked. In this hospital, we began to take charge of the patient. In the first period of his hospitalization, the patient commented that it was unthinkable for him to enter a psychiatric hospital while he himself worked at a department of psychiatry. He demanded to be discharged from the hospital. Then a few days after his hospitalization, he became delirious, saying, “The board of directors has a meeting now to dismiss me.” “I can hear their voices.” He tried to run away from the hospital by pushing against the door day and night without the permission of the psychiatrists or nurses. Because of this, until he recovered from his delirium, his freedom of action was restricted. Commonly in depression the patient says, “I can’t make up for what I’ve done.” However, when delirium appears, the situation is not merely irreparable. As we can see from this case, the patient was embarrassed because his suicide attempt had led to his admission to a psychiatric hospital, which was an unexpected result. The previous patient also was embarrassed by unexpected consequences as a

Pseudodementia and Delirium in Depression result of a suicide attempt: she had to go to a surgeon, and her family had to take care of her. Accordingly, we may say the period when delirium appeared in depression was the time when the patient was brought to a situation he had never expected (because of his intention of suicide) and was embarrassed as a result. DISCUSSION

How can we explain why the mental disorder of depression should present the symptoms which are proper to exogenous and somatic diseases, such as dementia or consciousness disorder (delirium)? This concerns the important problem of the relation between the mind and body (psychosomatic relation). Even in hysteria, which is one of the typical psychogenic diseases, pseudodementia and consciousness disorder can be seen-in this case it is not delirium but a twilight state. Hysteria had been thought to be a somatic disease before the period of Charcot. However, the fact that the symptoms of hysteria would appear or disappear under “hypnosis” was made clear by Charcot. Moreover, the meaning of the symptoms of hysteria was made clear by Freud.’ From that point hysteria came to be considered a mental disease (psychogenic disease) rather than a somatic disease. As we can see from this example, the reason why mental disease is called as such is that its symptoms have some meaning. Of course, the symptoms of a somatic disease also have a meaning for the patient, but the meaning is derived from the consequences of somatic disease. For instance, if the patient would have to be absent from his office for several months because of some somatic disease, it would have a significant meaning for his life. But the meaning is merely derived from the consequences of his “somatic” disease, so the “somatic” disease itself does not have any meaning and it does not represent anything in his life. The “somatic” disease

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itself is nothing but an extraneous matter for the patient.’ Therefore, what somatic medicine searches for is not the meaning of the disease but the mechanism by which the disease occurs. By contrast, in mental disease the symptoms have an obvious meaning in themselves, and express some meaning in life. Of course, at first not only the patient but also the psychiatrist cannot guess what the symptoms mean and what they express. The symptoms are a language which cannot be expressed in words; they are the voice of the spirit which cannot find verbal expression. The symptoms express something of which the patient himself is unaware. Therefore, the patient consults a psychiatrist, and the psychiatrist, sensing some meaning in the symptoms which he cannot guess exactly, diagnoses the disease not as physical but as mental. Making clear the meaning of the symptoms is the responsibility of psychiatric medicine, and the reason why the patient has to express himself through his symptoms should be detected. In this sense, hysteria can be called the typical mental disease because it is the first disease whose meaning was clarified in the history of psychiatric medicine, and because, especially in the form of conversion hysteria, the meaning of its symptoms is symbolically expressed in “physical language.” However, when hysteria, which is typical because of its meaning, presents the symptoms of pseudodementia or consciousness disorder, the symptoms no longer express anything by themselves, and they are out of the dimension of meaning. Of course, this does not mean that the words and actions seen in pseudodementia or consciousness disorder do not have a meaning in their own way. But the forms of dementia or consciousness disorder (or of delirium or of the twilight state), themselves do not express anything and are out of the dimension of meaning. It is more proper to say that being out of the dimension of meaning is the definition of dementia or of consciousness disorder. Now, let us think about the subject of this

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paper, depression. Psychiatry shows us that the symptoms of depression also have some meaning in the patient’s life, and they express this meaning in the form of symptoms. According to the current phenomenological psychiatry6 *,the meaning of the symptoms of depression can be expressed as follows: The depressed patient has already identified himself too much with his role in society. So long as he can play this role, everything goes well. However, when he cannot maintain it, the situation is experienced by the patient as something “irreparable.” In short, the symptoms of depression represent the patient’s desperation when he feels that he has fallen behind in his role. But even though the situation is desperate, the meaning lies in this symptom. The patient keeps the link with the world of meaning in the form of despair. He lives in the world of meaning. Therefore, the patient tries to tell others about his despair, but the very reason why he is desperate is that he is living in the world of meaning. But what happens when the patient is separated from the context of meaning? To be separated from the context of meaning is, in the case of pseudodernentia, to be out of the daily world of meaning and to be treated as having senile dementia. In the case of delirium, it is not to be able to situate oneself in the world of meaning because of the unexpected consequences caused by one’s own conduct. In such cases, mental disease no longer presents itself as having a meaning. Rather it shows an aspect of pure physical disease which does not have a meaning. In this way, some cases of depression show symptoms of dementia and delirium. What has been said above seems to hold true not only for depression, or neuroses, such as hysteria, etc., but also for schizophrenia, another endogenous psychosis in addition to depression. In schizophrenia, the patient at first experiences the emergence of an abnormal meaning. This abnormal meaning cannot be fitted into the meaning of daily life, nor expressed in everyday words. In other words, the patient is situated outside of the dimen-

sion of meaning. Therefore, when this abnormal meaning emerges suddenly, namely in a sudden onset, a state like disturbance of consciousness can be seen. In such a case, it is not a delirium or a twilight state but catatonic stupor. In short, when the patient is suddenly situated outside of the world of meaning, disturbance of consciousness can occur. The patient so situated restores the world of meaning again by the creation of a delusional world, as in schizophrenia. The patient who has reconstructed such a world (schizophrenia of delusional type) can return to the world of meaning, delusional as it may be, and can express this delusional world in language which others can ~ n d e r s t a n d By . ~ contrast, the patient who cannot reconstruct such a world of delusional meaning (schizophrenia of hebephrenia type) cannot but remain outside of the world of meaning. He cannot express the delusional world in language which others can understand and will necessarily be separated from others and from the world of meaning. And he will gradually fall into a kind of state of dementia ( p r a e ~ o x ) . ~ This state of dementia could also be called “pseudodementia” in schizophrenia. We can say that all mental disease, as well as depression or schizophrenia which are endogenous diseases, presents symptoms of disturbance of consciousness like delirium when the patient is suddenly situated outside of the world of meaning or dementia when he is situated out of it continuously. This principle is applicable not only to mental disease but also to physical diseases such as seniledementia. Although it seems to be paradoxical, it is not because the patient has fallen into a state of dementia that he is situated outside of the world of meaning; rather it is because he has been situated outside of the world of meaning that he falls into dementia. Moreover, he becomes embarrassed not because of his consciousness disorder; he shows consciousness disorder because of his embarrassment for whatever reason. Lastly, the topic of the so-called “psychosomatic disease” must be touched upon. Al-

Pseudodementia and Delirium in Depression though what are now called “psychosomatic diseases,” such as digestive ulcer, irritable colon, bronchial asthma, hyperthyroidism, and essential hypertension, etc., may actually be psychogenic somatic diseases, the somatic symptoms of these diseases do not have any meaning, unlike the symptoms of mental diseases such as conversion hysteria. We cannot say that a psychosomatic disease is really proved to be a psychogenic physical disease until the meaning that the disease has is detected. In this sense, we may say that psychosomatic medicine has just arrived at the starting point. Besides, if psychosomatic disease is really psychogenic physical disease, the treatment of the disease will be achieved by making the patient understand the meaning of the symptoms, and by making him accept this meaning. But, if the patient accepts the meaning of the symptoms, or at least, if he can recognize it as a psychogenic matter, psychosomatic disease is no longer “psychosomatic disease” but must now be called mental disease. The characteristic difficulties and uniqueness of psychosomatic medicine might fall around these problems. As the name implies, neurosis, like hysteria, was thought at first to be a disease of the nerves, namely a physical disease. And regarding endogenous diseases like depression or schizophrenia, even now there is a tendency to think of them as physical diseases. To make clear that these “mental diseases” are really mental problems, we have to make clear the meaning of the symptoms. In the same way, to prove that “psychosomatic disease” is really psychogenic or mental disease, we also have to make clear the meaning of the symptoms. If this is made clear, psychosomatic medicine might include many more diseases under the heading “psychosomatic disease” than are considered now. CONCLUSION

Dementia and disturbance of consciousness are characteristics of somatogenic diseases. Presenting cases of depressional pseudode-

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mentia and delirium (disturbance of consciousness), the following points were discussed: 1) The patient of depression falls into a state of pseudodementia when people around the patient regard him as having senile dementia or as being at the onset of dementia, and in this situation the patient sometimes regards himself that way as well. 2) The patient of depression falls into delirium when he is embarrassed by an unexpected situation, such as the consequences of his attempt to commit suicide. 3) In other words, the patient of depression would fall into pseudodementia when he is constantly out of the world of daily meaning. He would fall into disturbance of consciousness when he is put out of the world of meaning suddenly. 4) The principle that the patient falls into dementia, being continuously put out of the world of daily meaning, and that he falls into disturbance of consciousness, being put out of it suddenly, is applicable not only to depression but also to mental diseases in general, including neurosis and psychosis. 5 ) It is because the symptoms themselves have a meaning for the patient and have something to express that mental disease is called “mental disease.” 6) However, when the patient is put out of the world of meaning, mental disease shows an aspect of somatic disease, such as dementia or disturbance of consciousness. 7) Regarding the so-called psychosomatic diseases, if they are truly psychogeneous, the symptoms themselves must have some meaning. In psychosomatic disease, not only is this meaning incomprehensible, but also the patient himself does not understand that it has a meaning. But if the patient can understand this, a psychosomatic disease is no longer a psychosomatic disease but becomes a mental disease. Therein lies the characteristic difficulties and uniqueness of psychosomatic medicine.

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suspected hypochondriasis. Shinshin-Igaku (Japanese Journal of Psychosomatic Medicine) 31: 154-156, 1991 (in Japanese). 3. Koide, H.: What is the recovery from schizophrenia? Rinsyo-seishinbyori (Japanese Journal of Psychopathology), 13: 67-75, 1992 (in Japanese). 4. Koide, H.: Psychopathological essay on the negative schizophrenic symptoms. SeishinkaShindangaku (Archives of Psychiatric Diagno-

Depressiver Psychose, Eine existenz-und rollenanalytische Untersuchung, Ferdinand Enke Verlag, Stuttgart, 1977. 7. McHugh, P.R. and Robinson, R.G.: The twoway trade-Psychiatry and Neuroscience. Br J Psychiatry 143: 303-305, 1983. 8. Tellenbach, H.: Melancholie. Springer, Berlin, 1961. 9. Wells, C.E.: Diagnosis and dementia. Psychosomatics. 20: 517-521, 1980.

Pseudodementia and delirium in depression: a contribution to psychosomatic medicine.

Presenting cases of depressional pseudodementia and delirium, we wish to point out the following points in this report. The patient in depression disp...
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