Psychopathological analysis of the phenomenon of abstruseness (case of Sasha Shch.)

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Abstruseness is defined as incomprehensibility, excessive complexity, unintelligibility or absurdity of the thoughts, and speculations expressed by a person [1]. According to psychologists and philosophers [2], abstruseness is an “unattainable flight of thought,” a type of stupidity or strange aspects of thinking. Sometimes abstruseness is characterized by excessive, unnecessary complexity, pomposity, and the use of words and speech patterns inappropriate for age and status. Often, abstruseness appears as an “attempt to be smart,” to speak a complex gorgrous language or language filled with scientific terms to attract the attention of the interlocutor, and to create an image of somebody special and exclusive.

According to Kovalev [3], abstruseness as a personality quality presents as a tendency toward overly sophisticated incomprehensible speech, language overloaded with special terminology, and a conscious desire to regurgitate pseudoscientific nonsense and absurdity. Abstruseness manifests in cases when a person perceives himself as insignificant, tries to seem more significant, and talks about something he is unaware of; “abstruseness is the friend of demonstrativeness” [3].

A close but not identical phenomenon is a way of thinking denoted by the term “intellectualization,” i.e., a tendency toward “abstract reasoning, away from reality of life.” In Russian psychiatry, this phenomenon traditionally appears as “metaphysical (philosophical) intoxication” which is a psychopathological syndrome classified as schizophrenic spectrum disorder and characterized by the patient’s fruitless thoughts on abstract topics with distinctive features of disassociation from reality [4, 5]. However, the existence of this psychopathological syndrome within schizophrenia is questioned [6] because of the frequent absence of other pathognomonic symptoms of this disorder.

All researchers agree that the main characteristic of abstruseness is its incomprehensibility for others to perceive. In this regard, the question of whether a client/patient with “abstruseness” can think differently in different situations, not only incomprehensibly but also without being “abstruse,” is of scientific interest. Additionally, whether he understands himself when others say that they do not understand him should be clarified. Moreover, whether “abstruseness” should be attributed to personal qualities or to characteristics/disorders of thinking should be recognized.

The case of 10-year-old Sasha was characterized by difficulties in communicating with peers because he used many words/terms in his speech that were not typical for his age. As a result, he was treated as “strange and abstruse” and was not understood. Some experts considered this a manifestation of demonstrativeness, whereas others revealed that the symptoms were characteristic of schizophrenia.

Clinical case

Ten-year-old Sasha turned to psychiatrists at the insistence of his parents who complained about the peculiarities of his speech, namely, a tendency to make abstruse statements, dividing words into syllables, repetition of the same words (e.g., “and this is what it is, well and so”), poor school performance, behavioral characteristics such as a lack of a sense of distance from adults (allows himself to say everything that comes to mind, which is often inappropriate and provocative), foul language addressed to others, restlessness, inability to concentrate and maintain attention on any activity for a long time, excessive passion for computer and mobile games, aggressive behavior, sleep disturbance (difficulty falling asleep, nightmares), selectivity in food, expressed fears (darkness, animals), and associated enuresis. The visit to psychiatrists was also because of strong recommendations from the teachers and doctors who examined Sasha. The patient made no complaints.

Anamnesis

The patient was born from the first desired pregnancy that was uneventful. Childbirth was characterized by a long period between membrane rupture and delivery and additional stimulation at 37 weeks. Birth weight was 3170 g, and birth length was 51 cm. The Apgar score was 8.9 points. He was discharged from the maternity hospital on day 5. He began to hold his head at the age of 2–2.5 months, his first words were on month 7 (began to pronounce the words “mom,” “dad,” and other simple everyday words, but then fell silent until 3.5 years old), and he began to sit at 8 months old, made his first steps at 1.1 year old, and had phrasal speech at 3.5 years old (spoke sharply and in 6 months, his speech was fully formed).

In early childhood and preschool age, he maintained eye contact with his parents, reacted positively to affection and hugs, had frequent regurgitation, did not demonstrate feelings of hunger, sometimes had to be forced to eat, and showed selectivity in food.

He started attending a preschool institution at 2 years old. It was difficult for him to adapt; he resisted going to kindergarten, cried, and panicked before meeting the nursery-school teacher. Six months later, the parents discovered that the teacher locked the children in the toilet as punishment for crying and violating the daily routine. The teacher was replaced; however, the patient’s attitude toward the kindergarten remained negative. Sasha did not show much interest in the classes, according to his mother, “on the stands next to the drawings of other children, Sasha’s blank sheets were demonstrably hung.” At age 5, he became more interested, but drew mostly black and white drawings. At home, he was keen on Lego construction kits.

Among Sasha’s traits, his mother noted a propensity for fantasizing, inventing various stories, and unbridled imagination. At the age of 5 years, an “imaginary friend” appeared, to whom Sasha trusted his deepest secrets. In grade 1, he was angry that he was not given marks at school. Then, his friend transferred to another country and lost contact with him. Subsequently, imaginary friends no longer appeared. When questioned about this, he reported that this was due to a “lack of face-to-face communication.” In real life, Sasha had only one close friend whom he was jealous of. Sasha did not and does not strive for close communication with peers.

Since then, he began to show disobedience and react negatively to his parents’ requests. He showed provocative behavior; for example, while walking in the yard, out of spite to parents, he would suddenly run toward a busy road, neglecting safety rules. Additionally, his mother notes his irritability and tendency to act aggressively at times when something did not suit him. He was very selective in food; his parents had difficulty forcing him to eat. At times of severe hunger, he became embittered. Moreover, Sasha had difficulty falling asleep. According to his mother, he resisted going to sleep, got angry, and tossed around in bed, and his parents had to hold his arms and legs tightly. He developed a fear of the dark and began to sleep only with his parents and with the light on. One day, he tried to go to bed alone; however, having experienced the fear of “monsters,” he returned to his parents’ bed.

He started attending school at 7 years old; studying was hard due to difficulties in concentrating and restlessness. The relationship with the class teacher did not work out; Sasha claimed, “she was demanding, strict.” Sasha often refused to complete school assignments, criticized the teacher and the educational process, and often argued. According to those around him, he strove to be the center of attention and did not like it when people listened to someone other than him, which is why he often interrupted his classmates in conversations. His circle of friends was small; he was excessively categorical and critical in assessing his peers, dividing everyone into friends and enemies, saying unpleasant things.

Character reference from the school for grades 1–3

Characteristics of psychophysical development: This includes the inability to concentrate. difficulty switching from one type of activity to another. unfocused voluntary attention, exhaustible, and requires great effort.

Features of learning ability: Organizing assistance from the teacher is required in the form of guiding questions and tips. Sasha does not follow the progress of the lesson and is usually abstracted. The school curriculum is difficult for him to master. Regarding maturity of universal educational actions, his motivation for learning is extremely low. The ability to perceive and maintain an educational goal and task is low; and planning its implementation, monitoring, and evaluating his actions depend on his mood. Performance was poor. He does not fully master several logical actions and operations, such as generalization, classification, and exclusion; he solves problems with the help of an adult.

Communicative universal educational activities. The boundaries of moral standards are blurred; he looks only at the dark side of people and events. He does not always consider the interlocutor’s position; expresses his point of view, but not always objectively; does not always organize cooperation with the teacher and peers; and rarely agrees with classmates and come to a common decision. His contact and communication are complicated, and understanding the situation and responding to it is not always or not entirely adequate.

Results of mastering curricula in individual subjects

– Mathematics: the patient cannot complete standard grade 3 tasks independently, does not follow the algorithm for solving the task, and does not use rules to solve it. Sasha completes tests and independent work with bad marks: he cannot concentrate on tasks, does not know how to develop a solution, makes many mistakes in the solution, and manages to complete 1/5 of the work.

– Reading: at the end of grade 3, he spelled out, did not make logical stops, and made several mistakes when placing emphasis. When retelling a text, he concentrates on only one moment from the text and makes stops in the middle of words.

– Russian language: the patient cannot independently characterize sounds, distorts the spelling of letters, cannot apply spelling rules, and does not have self-testing skills. Regarding errors in writing: when copying, he makes omissions, substitutions, and rearrangements of letters and does not comply with spelling and punctuation when writing. His graphomotor skills are not developed. For features of oral speech, his sound pronunciation is not impaired, and he makes illogical stops in words when speaking.

Social and everyday orientation: The patient is outwardly calm; he does many things secretly, and when analyzing situations, he does not admit that he is to blame. He does not always react to adults’ criticism, most often by protesting that his rights are being violated. At lessons, he is often silent; in open lessons, he begins to speak actively, reducing the conversation to the negative. When visiting public places with a group of children, he does not follow the rules of behavior (talks or shouts, without paying attention to the event), and tries to go home on his own or without warning. When the circumstances are clarified, he speaks negatively about the teacher who does not let him go.

General labor skills: Self-service skills are poorly developed; his textbooks are constantly scattered, and he does not clean his workplace after Handicrafts and Fine Arts lessons. He does not know what is in his backpack and often does not prepare for lessons.

Peculiarities of behavior and emotional manifestations: Inhibition and isolation, but at the same time, he is sociable with some children. Most of the children in the class do not understand his thoughts and actions. He is very dependent on his phone. He watches age-inappropriate content on the Internet without hiding and involves some classmates. Owing to this range of problems, his parents transferred him to another school.

Character reference from the new school (grade 4)

During his studies, Sasha shows himself to be a student with a low level of abilities. The boy has difficulties in his studies. He does not master program material in mathematics and the Russian language. He is inactive in lessons and reacts inappropriately to the teacher’s criticism (becomes outraged, does not comply with the teacher’s demands). He is currently finding it difficult to keep pace with the rest of the class. During lessons, he copies information from the board with mistakes and cannot complete tasks independently and gets involved in work slowly, has difficulty concentrating, and learns little from the teacher’s explanations due to constant distractions. He makes mistakes due to carelessness and does not notice them when checking. He is one of the last to understand the essence of the teacher’s explanations, which is characterized by a slow pace of thinking and making solutions.

During lessons, Sasha constantly exhibits subjective and objective signs of fatigue (decreased performance, increased distractibility, reduced quality of work, increased number of errors, complete refusal to work, repeated visits to the toilet, etc.). He rarely shows a lively emotional reaction to events. He is always calm and does not have strong emotional outbursts.

In mathematics, he did not learn the multiplication and division tables; he did not master all the learned addition, subtraction, multiplication, and division techniques. He reads without errors and understands what he reads. In Russian language lessons, he can copy without errors; he writes in dictation with a large number of mistakes, because his sound–letter analysis and synthesis have not been developed, and he does not know orthograms. His handwriting is inaccurate, and he cannot be oriented in his notebooks. In Fine Arts and Handicrafts classes, he shows interest in tasks but often fails to complete the work. He needs additional explanation from the teacher. Conflicts rarely arise with children; Alexander is not aggressive, sociable, nor friendly.

Case history

According to his mother, Sasha’s behavior has changed since early childhood, but over the past 4 years, negative dynamics have been noted. The mother highlighted the “panic fear” of darkness and being alone at home. If he has to be left alone, he turns on the lights in the entire apartment, locks himself in his room, and constantly calls his mother and demands her speedy return. He had enuresis and encopresis from early childhood, especially with severe fear. One day, his mother was late at work, and Sasha constantly called, insisting that she return urgently, complaining that he wanted to go to the toilet. Returning home, the mother discovered that Sasha had not left the room and had urinated on himself in the chair where he was sitting. He could not justify his behavior and promised that this would never happen again.

Furthermore, Sasha still sleeps only with her parents with the lights turned on dimly. Few weeks ago, he decided to go to his room to sleep; he was anxious and was on his phone in the morning. He fell asleep, wrapping his body and face in two layers of blanket, explaining this by the fear of “monsters.”

While at home, he spends most of his time on the computer and phone. Parents note symptoms of hyperactivity, manifested in walking in circles, spontaneous whistling, and restlessness. This is especially pronounced in situations that require concentration or expectation wherein he fidgets, jumps up, and may start running or jumping. However, in some cases, he reacts to criticism (e.g., he was relatively calm during a consultation with a psychologist).

According to the mother, the appeal to psychiatrists was associated with the recommendation of the neurologist who examined Sasha. The neurologist in his referral noted the originality of judgments, demonstrative behavior, distractibility by extraneous topics when answering questions, and singling out from several objects based on strange characteristics. “The hare is superfluous because he doesn’t hit hard, but the rest hit hard.” When asked to undress for a medical examination, Sasha asked the doctor about his sexual orientation and called him a pedophile.

Family history

Sasha’s father is 45 years old, has a higher education, and works as an electrician. According to the mother, the father relatively lacks initiative and rarely shows attention or affection toward his children. He is only interested in Sasha’s performance at school. She notes that from time to time, the father shows aggression toward his son, especially when he is intoxicated and when Sasha is “bothering.” He does not share the mother’s worries about their son’s condition and behavior; he believes that “all children are like this now.” Sasha speaks negatively and hostilely about him. He reported, “He takes vodka like a duck to water; my mother and I often had to carry him in arms out from other people’s houses.” When asked about an ideal day with his family, he replied, “It’s a day without my dad, when I can relax and chat with mom.”

Sasha’s mother is 39 years old; she has a higher education and works as a chief accountant of a construction company. Sasha characterizes their relationship as warm and trusting. His younger sister is 3 years old. According to the mother, heredity is aggravated, as his great-grandmother had a mental disorder and was repeatedly treated in a hospital.

A history of chronic diseases included removal of adenoids under anesthesia at 5 years old and catarrhal diseases.

Mental status

The patient appeared neat. He was oriented in all aspects correctly. His facial expressions were vivid and changeable; periodically, he frowned, smiled, and grimaced. His movements were calm, and he was sedulous, but he periodically changed his body position, crossed his legs, kept his hands in his sweatshirt pockets, or folded his arms crossed across his chest. During the conversation, he actively gestured, sometimes “theatrically” put his palm to his forehead, and sighed loudly. He did not feel embarrassed in front of a large audience of doctors, resident physicians, and medical students. He spoke loudly, assessing how the audience reacts to his answers.

He used terminology that was not typical for his age and was often philosophical. For example, he used the terms “a priori” and “feminism” in a conversation and could explain their meaning competently and correctly. He was inclined to discuss political issues and current events on his own initiative, but his statements on this subject were harsh and intransigeant, with the use of obscene language. In conversations, he strived for provocative statements and assessed the reactions of others to them. At the beginning of the conversation, he asked the audience, “Is it true that medical students study at the university for 6 years?” Having received an affirmative answer, he turned to the audience and theatrically and breathily said, “I’m sorry to hear that.”

He often did not keep his distance, switched to a presumptuous style of communication, interrupted and criticized the doctor, raised his voice, and said whatever came to his mind, often deviating from the essence of the conversation. Sometimes he got irritated in a conversation and showed impatience. He maintained eye contact; at the beginning of the conversation, he enthusiastically examined the atmosphere of the audience, commenting, “The room looks like a courtroom, not bad for the 19th century. Wait, if your building is an alternative, improved version of a 19th century building, why is your symbol very similar to the symbol of Ukraine? And the flower-shaped ceiling lamp was popular not in the 19th century, but from the 1980s to the 2000s.”

His attention was attracted and held in a sufficient extent. He often spontaneously changed the course of the conversation and began to tell details about his favorite computer games. He was capable of suddenly switching to a topic that was discussed about 15 minutes ago. During a conversation, he may abruptly say stop and start asking abstract questions. When asked why he goes to the doctor, he replied, “Well, if you look at the names on your signs, I’m probably crazy.” To the question “Do you have any complaints?,” he paused and said, “What a pity for the builders who built this building, it is huge hemorrhoids.”

When trying to return to the topic, he said, “It’s fun to talk with you, but I don’t trust adults. You write everything down and pass it on to my parents. I know tricks against teenagers.” He began to depict emotionally the dialogue between parents and doctors in the form of a sketch, parodies, changing his voice, and actively gesticulating. “The fact that you are adults, and psychologists at that, forces me not to tell you anything. All adults see a duty to convey information to the parents.”

He asked to see the notes, criticized the doctor’s handwriting, referred to the doctors’ poor education, got up, stepped aside, and posed as a teacher who criticizes the students’ handwriting. Subsequently, he wrote the word “hello” on a piece of notebook paper, declaring, “Even I, a fourth-grader, write better than medical school students.” The two subsequent “sketches” concerned the reason for his distrust of adults and his secret, smoking, which he veiled under the action he called “making baked goods.”

When asked how his condition has changed since the previous conversation, he answered, “Well, Andrei is a crum.” Then, he described in detail conflicts with a classmate who betrays him to teachers. He reported that he studies worse than others at school because he behaves honestly. He repeatedly reported that everyone around him is sucking up and complaining and that he earns grades through honest work. “When I concentrate on one thing for a long time, I get overwhelmed and can’t do it anymore. At home, in this case, I can space out, but at school I have to sit, otherwise they will bitch-slap me. Mathematics is the hardest, but physical education is very interesting. Handicraft is taught incorrectly; girls do really important things, and we make just birdhouses and stools. I don’t understand why this is shared. I want there to be no division by roles in families.”

Sometimes he was indignant that he is treated worse than his peers and is underestimated. He emphasized competition with girls to a greater extent and explained their success with “feminism,” since they believe that “women are morally and physically better.” When asked about friendship with girls, he answered, “I liked one, but I made a big mistake, because girls grow faster, she just used me, buggered about me, manipulated me, and I stopped communicating with her. I used to be a sissy, so I didn’t dare to hit her. I fight mostly with boys, but if girls bother me, I’ll beat them too. I actually don’t care. Now you are not even allowed to bitch-slap girls, but previously women had to stand up before men entered.”

He reported that in his free time from classes, he likes to play with friends, jump around garages, and play war games. When asked about visiting sports sections, he said that soccer was not interesting. He then once again began to demonstrate the specifics of classes in the form of a skit, screaming, and actively moving. “I want to add my own rules to all games,” criticizing the game of tic-tac-toe in detail for 2 minutes.

When asked about his relationship with his parents, he answered: “Dad is a different person when he is intoxicated. If we went to the zoo, he would jump into the pen with the penguins and sabotage their escape. Mom is a good person, but I don’t trust her because she is an adult. I can show aggression in my family; if my sister starts to bother me, I can yell at her or at my parents if they say complete garbage. I’m already having signs of adolescence, puberty started earlier, I use deodorant.”

He repeatedly expressed his suspicion of all adults without exception. “If you put away the notebook and close your ears, I will tell the truth. Otherwise you can retell everything... Yes, sometimes I can talk to myself or invent imaginary friends. But now they are not there; I had them at the age of 4–6 years .” He can repeat the same sentence 3–4 times and observe the reactions of others. When asked what he wants to become, he replied, “I want to join the army for 25 years and fight against the rotten f… bastards. I get these political views from my dad. I used to be a zoomer, subject to many stereotypes, and thought that Russia was not a very good country. Now I’m a Patriot. I’ll enter a technical school so that I don’t have a deferment and will quickly go help my homeland. One day, everyone refused to play a war game with me at school, so I wanted to be in more realistic conditions. People still haven’t gotten smarter, not even Einstein, they’re all stupid rotten monkeys; the countries could have become friends a long time ago. I want to become a president. It is unfair and unjust that women are allowed not to serve. I also want to open the restaurant “Sasha’s Taste” and feed everyone on the planet; then I will become a businessman and a teacher.”

When asked to describe his character, he paused and said, “If you hate yourself, it’s bad, if you love yourself, it’s even worse. I’m in-between. I’m a normal, good guy who thinks differently, but this turns out to be narcissism. I don’t fawn on teachers, I didn’t go to “Vkusno i tochka,” because there were queues the same as 20 years ago in the USSR.” When asking clarifying questions, it becomes difficult for him to continue reasoning.

The mood background was unstable, and the emotional response changed sharply depending on the consideration of subjectively significant topics. His speech had a predominance of “parasitic filler words” (“so, as it were”, “well”) with periodic stuttering, pauses, and sighs. His thinking included repetitive phrases and complex grammatical structures, with a tendency to reason. Delusional ideas and perception disorders were not detected. At the end of the case conference, he asked not to leave, but to stay and “ask more questions.” “I really like talking with doctors and psychologists. This makes me kinder.” He ended the conversation reluctantly and only after repeatedly explaining the reasons for the need to end it.

Psychologist’s report

During the examination, accompanied by his parents, he was generally calm motorly and remained within the workspace throughout the entire examination. At the beginning of the conversation, he showed some loss of distance; he often interrupted the conversation of adults, tried to make his own “corrections” in the description of situations that his mother talked about, sometimes argued with her, and was talkative. He reacted to the psychologist’s criticism, for a short time, but adequately and calmly. In general, he showed interest in communication and strived for interaction and organization. Based on his interests and hobbies, he focused on computer games and talked about them with delight while saying with some sadness that his parents practically do not praise him and that his father rarely spends time with him and does not particularly strive to communicate with him.

He understands and realizes instructions for tasks sufficiently; when performing, in situations of difficulty, he needs external stimulation and corrective assistance. He tried to answer questions in terms of what was asked; however, the answers were often of a concrete and reasoning nature. He tried to “philosophize” and used some cliche phrases, although the statements were generally quite superficial. He often showed verbosity while experiencing difficulties expressing his thoughts in full.

He worked at a moderate pace, strived to find the right solution, and showed some negligence and superficiality. He was interested in the results of his activities and reacts positively to praise from the psychologist. At the end of the examination, satiety and slight exhaustion of mental activity were noticeable.

Experimental psychological examination

When testing attention according to Schulte tables, the results were 1’28”—1’10”—1’33”—1’30”—1’23,” which indicates moderate decrease in concentration and instability phenomena. In testing memory, short-term memorization of 10 words of 7–8–9–8–10 was sufficient. Indirect memorization was not impaired, and he showed only minor indistinctness during reproduction. In performing the “Pictograms” technique, he produced specific and personally significant images for the proposed concepts. For example, for the concept “happiness” he drew a man named Leon and explained, “I got the legendary character Leon in a computer game. This is happiness!” The drawings showed carelessness, chaos, and signs of anxiety and emotional tension.

His thinking was closer to the concrete, with an egocentric orientation, actualization of secondary and insignificant features of objects, and a low level of development of the abstract–logical component. He did not comprehend the figurative meaning of proverbs that were unfamiliar to him. He did not understood the hidden meaning of the story “The Hungry Man,” he could not explain it, and he produced fragmentary, cliched statements: “You have to eat bread...You had to eat two bagels!” and so on. He could not compose a coherent story from a picture and produce fragmentary statements, which was most likely due to his low ability to express his thoughts and insufficient vocabulary.

He demonstrated a low level of development of basic school skills, such as his reading, although fluent, has mistakes, and he cannot fully convey the meaning of the story read, distorts, and finishes thinking about it. His writing was ungrammatical. He could not perform the “Counting 100–7” task. In testing intelligence according to the Raven test, Sasha completed 28 tasks of 36, which corresponds to the “below average” level. Regarding personality, according to the Luscher test, his current state is characterized by activity, the need to possess prizes of life, the desire for dominance, and spontaneity and relaxed behavior. High self-esteem, resistance to circumstances that impede the free self-actualization, ethnicity traits, and a tendency to take risks are combined with such tendencies as skepticism and externally blaming reactions. He feels the need to defend his own attitudes, perseverance, and resistance to circumstances, which is defensive in nature. He is focused on his own opinion and resistant to external environmental influences. He tends to be quick-tempered in conflict situations.

He has a luxuriant imagination, vivid feelings, a need for unusual experiences, and an unsatisfied need for relationships full of mutual understanding, with a tendency to maintain his superiority.

According to the Leonhard–Smishek questionnaire, increased indicators were revealed on the “Hyperthymia” (24 points), “Excitability” (21 points), and “Cyclothymia” (21 points) scales, and decreased indicators on the “Distimacy” scale (6 points). Moreover, high scores on the Hyperthymia and Excitability scales indicate a violent behavioral reaction; behavior is characterized by impulsiveness, increased focus on events in the outside world with a poorly structured internal hierarchy of values, a tendency to use obscene language, lack of distance, and noncriticality to behavior. Distinctive features may include verbosity, emotional mobility, several behavioral programs, and the ability to ignore comments and get out of line, along with a lack of self-criticism. A low “Distimacy” score with high excitability implies an accentuation on the excitability scale, and behavioral reactions can manifest as arrogance and a decrease in internal control.

Thus, at present, there is a tendency toward excitability, manifestations of violent behavioral reactions, insufficient criticality and lack of distance in communication with others, concrete judgments, a low level of development of the abstract–logical component, and difficulties in the development of school skills, in general against relatively intact intellectual–mnestic functions.

Figures 1 and 2 show the drawings by Sasha.

 

Fig. 1. Drawings by Sasha. “The students are fighting against the school, which wants to send them to a place of correctional punishment. All teachers are bad people, not a single one is good, that is why they are for the Third Reich. Everyone is working improperly.”

 

Fig. 2. Drawing by Sasha. “My Family”

 

Conclusion of a neuropsychologist

Functional immaturity of the brain stem, immature interhemispheric interaction, and predisposition to stuttering

Conclusion of a neurologist

Cerebrasthenic and astheno-neurotic syndromes, instability of the cervical spine, microangiopathy along with venous dysfunction

Discussion

The presented clinical case of 10-year-old Sasha is replete with psychopathological mysteries. First, it was the difficulty of qualifying the phenomenon of abstruseness, namely, the tendency to answer questions in a convoluted manner, using words that are not typical for the vocabulary of younger adolescents, which led to misunderstanding on the part of peers, teachers, and elders. Second, there was a discrepancy between the discovered rather high level of intelligence, a copious vocabulary, and a subtle understanding of the interlocutor’s emotions and the formally extremely low indicators of school knowledge, as by the age of 10 years, Sasha had not learned the multiplication table and showed some of the worst academic performance. Third, it was difficult to interpret the boy’s provocative behavior when he consciously or unconsciously put his interlocutors in an awkward position and waited for their reaction. For example, during an examination by a neurologist, when asked to undress, the patient asked the doctor about his sexual orientation and called him a pedophile.

Fear of the darkness, dogs, and “monsters” discovered in Sasha and behavior aimed at protecting from them were the easiest signs for psychopathological assessment. Differentiation was made between fears as a psychological phenomenon and phobia as a psychopathological symptom. Considering that the fears were isolated in nature, were not accompanied by obsessions, and were limited to a certain time of day and place, it must be conceded that they cannot be recognized as a phobic symptom.

Another phenomenon is Sasha’s periodic hyperactivity and impaired concentration. However, this phenomenon could not be attributed to the range of disorders, namely, attention deficit and hyperactivity disorder, since there were no diagnostic criteria typical for it, such as unregulated and excessive activity, disinhibition and loss of control over his own behavior, impulsiveness, and tendency of switching from one task to another without completing them [7].

Sasha’s behavior was changeable; he was periodically overly active (not impulsive) but was often able to engage in any activity for a long time, concentrate, and maintain attention. Thus, during a consultation with a psychiatrist and a 2-hour case conference, the patient was focused, attentive, and did not show signs of hyperactivity. Thus, there were no grounds for diagnosing attention-deficit hyperactivity disorder.

The most difficult aspect was the psychological and psychiatric assessment of the phenomenon of abstruseness, which was indicated by parents and teachers and peers who refused to communicate with Sasha because he spoke to them in an incomprehensible, intricate manner and used many difficult-to-understand terms.

This phenomenon was clearly manifested during the clinical–psychopathological examination. For example, Sasha was inclined to reflect on topics such as feminism and architecture of the 19th century and used words, including “a priori,” that were not typical for a primary school student. Additionally, he provided correct and precise answers to clarifying questions and explaining complex terms and concepts. Each time he made an abstruse speech, he waited for a reaction from the interlocutor (doctor, psychologist, teacher). He liked that attention was paid to him and that his opinion was interesting to others. This was most clearly manifested during the end of the consultation, when he tried in every possible way to extend the meeting time and demanded that he continue communicating with him. It should be noted that not all of Sasha’s speech was replete with abstruse thoughts, as he spoke most of the conversation in simple, understandable language, although he tried to select words carefully that would explain his position and opinion more accurately.

In addition to his penchant for using abstruse speech structures, Sasha liked to put his interlocutor in an awkward position and provoked him. It looked like deliberate actions aimed at causing embarrassment and confusion in that person.

In particular, during the case conference, when the doctor asked him to explain what he meant by the concept of a “patriot,” calling himself that, Sasha said that he was proud of the country “stretching from the southern seas to the polar region.” To the clarifying question “Where did you hear this phrase, an advertising video?,” he said with a cheeky smile, “Well, if the Russian anthem and an advertisement are the same thing for you, then yes.”

Another incident occurred when the patient met a doctor–supervisor. For the examination, additional meetings were required, and the doctor agreed on them with his father, in front of the boy by exchanging phone numbers. After that, the doctor approached Sasha and said, “Let’s get acquainted, who are you?” Sasha replied with a malicious smile, “I am the boy whose father just made a pass at you.” The boy clearly enjoyed his own provocative behavior, and at that moment, a grin appeared on his face.

Abstruseness is the quality of speech production (oral or written)—“the quality of speech” [2]. That is, a person usually does not abstrusely think, but speaks or writes in a similar style. For such abstruseness, there must be a plan and a purpose, as the use of unusual, shocking speech manifests itself in strictly defined situations. In other life circumstances, an “abstruse person” usually does not demonstrate this trait.

In contrast, patients with thinking disorders, who are outwardly similar to those who are “abstruse” (e.g., with the syndrome of “metaphysical (philosophical) intoxication” in adolescent schizophrenia), understand the world and current events distortedly and are therefore prone to pseudo-philosophical speculations. Their pathological thinking style does not depend on the situation and is not subject to self-correction.

Another phenomenon similar to abstruseness should be recognized as a special variant of the development of speech skills in people with autism spectrum disorders, particularly those with Asperger syndrome. In some of these patients, the phenomenon of abstruseness within the behavior of the “little old man” has an incomprehensible and unusual character. According to several authors [8, 9], autistic people may have formal thinking disorders in the form of loosening of associations, illogicality, and others.

Analysis of the mental state of Sasha showed that he did not have any signs of schizophrenia or autism spectrum disorders.

An analysis of the case of Sasha allowed us to conclude that he did not have clinical signs of a mental disorder, and his characteristics of behavior, thinking, and speech were within personal reactions. From our viewpoint, Sasha’s behavioral characteristics and tendency toward abstruseness reflect elements of demonstrativeness, a unique creative way of compensating for his communication difficulties.

Abstruse, or the use of abstruse language, can be a literary or speech technique consisting of the complete or partial rejection of all or some elements of natural language and replacing them with other elements or constructions [10]. It is improper to understand abstruse as a rejection of meaning in general or as an imitation of speech disorders such as schizophrenia.

Further follow-up will provide a reliable evaluation about the presence or absence of any psychopathology in Sasha.

ДОПОЛНИТЕЛЬНО

Финансирование. Исследование не имело спонсорской поддержки.

Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.

Вклад авторов. Менделевич В.Д. — клиническое обследование, аналитический обзор литературы, Нестерина М.К. — клиническое обследование, сбор анамнеза, дифференциальная диагностика, Коновалова В.Н. — клиническое обследование, сбор анамнеза, Хвостанцева Ю.Р. — клиническое обследование.

Funding. This publication was not supported by any external sources of funding.

Conflict of interests. The authors declare no conflicts of interests.

Contribution of the authors. V.D. Mendelevich — clinical examination, analytical review of the literature, M.K. Nesterina — clinical examination, history taking, V.N. Konovalova — clinical examination, history taking, Yu.R. Khvostantseva — clinical examination.

About the authors

Vladimir D. Mendelevich

Kazan State Medical University

Author for correspondence.
Email: mendelevich_vl@mail.ru
ORCID iD: 0000-0002-8476-6083
SPIN-code: 2302-2590

M.D., D. Sci. (Med.), Prof., Head of the Depart., Depart. of Psychiatry and Medical Psychology

Russian Federation, Kazan

Maria K. Nesterina

Kazan State Medical University

Email: mari.nesterina@mail.ru
ORCID iD: 0000-0001-6901-5903
SPIN-code: 5974-4048

Resident, Depart. of Psychiatry and Medical Psychology

Russian Federation, Kazan

Veronika N. Konovalova

Kazan State Medical University

Email: nikakonovalova31@gmail.com
ORCID iD: 0000-0002-4043-0780
SPIN-code: 7579-4441

Postgraduate Student, Depart. of Psychiatry and Medical Psychology

Russian Federation, Kazan

Yulia R. Khvostantseva

Kazan State Medical University

Email: kelleryulya@yandex.ru
ORCID iD: 0009-0002-5476-2476
SPIN-code: 5128-7325

Resident, Depart. of Psychiatry and Medical Psychology

Russian Federation, Kazan

References

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