Psychotic disorders: symptoms and treatment. Non-psychotic mental disorders in epilepsy How can non-psychotic depressive disorder be diagnosed?

Pathogenesis of reactive states

This group includes mental disorders that are a pathological reaction of a neurotic and psychotic level to mental trauma or unfavorable situations. Under the influence of mental trauma that causes fear, anxiety, apprehension, resentment, melancholy or other negative emotions, various mental disorders can develop.

In forensic psychiatric clinics, the term “reactive state” is more often used as a broader concept of psychogenic mental disorders, covering both reactive psychoses (mental disorders of the psychotic level) and mental disorders of the neurotic (non-psychotic) level, the so-called reactive neuroses. The distinction between reactive mental disorders of the psychotic and neurotic levels in a forensic psychiatric clinic is of fundamental importance, since further tactics in relation to this accused largely depend on the solution of this issue.

The nature and strength of mental trauma, on the one hand, and constitutional characteristics and premorbid state, on the other, are decisive for the occurrence of a reactive state or psychosis. Mental traumas are divided into spicy And chronic, sharp, in turn, - on shocking, depressing And disturbing. Reactive states occur more easily in psychopathic individuals, as well as in persons weakened by infections, severe somatic diseases, intoxications, traumatic brain injuries, vascular diseases, prolonged insomnia, severe vitamin deficiencies, etc. The age factor can also play a predisposing role. Puberty and menopause are the most vulnerable to external influences. Age also matters in the clinical picture of psychosis. Thus, paranoid reactions and psychoses with delusional syndromes are more characteristic of adulthood. In addition, the individual characteristics of the patient and the type of nervous system play a role in the occurrence and clinical implementation of the reactive state. The mechanism of occurrence of reactive states in the aspect of the doctrine of higher nervous activity can be explained as a disruption of the normal activity of the cerebral cortex as a result of overstrain of irritable and inhibitory processes or their mobility. A “mistake” of irritable and inhibitory processes (hidden grief, suppressed anger, etc.) has a strong psychotraumatic effect.

Clinical picture of stress-related mental disorders

Mental disorders of this group are diagnosed by identifying the so-called Jaspers triad, which includes the following conditions:

mental disorders arise after mental trauma, i.e. there is a direct connection between the development of a mental disorder and psychogenicity;
the course of mental disorders has a regressive nature, when, as time moves away from mental trauma, mental disorders gradually weaken and eventually disappear completely;
there is a psychologically understandable connection between the content of traumatic experiences and the plot of painful disorders.

Stress-related mental disorders are divided into:

1) to affective-shock psychogenic reactions;
2) depressive psychogenic reactions (reactive depression);
3) reactive (psychogenic) delusional psychoses;
4) hysterical psychotic reactions or hysterical psychoses;
5) neuroses.

Affective-shock psychogenic reactions are caused by a sudden strong affect, usually fear due to a threat to life, more often found in mass disasters (fire, earthquake, flood, mountain collapse, etc.). Clinically, these reactions manifest themselves in two forms: hyperkinetic and hypokinetic.

Hyperkinetic form(reactive, psychogenic agitation) - sudden onset of chaotic, meaningless motor restlessness. The patient rushes about, screams, begs for help, sometimes rushes to run without any purpose, often in the direction of a new danger. This behavior occurs against the background of psychogenic twilight disorder consciousness with impaired orientation in the environment and subsequent amnesia. With twilight stupefaction, pronounced fear is observed, facial expressions and gestures express horror, despair, fear, and confusion.

The hyperkinetic form of shock reactions also includes acute psychoses of fear. In these cases, in the clinical picture of psychomotor agitation, the leading symptom is panic, uncontrollable fear. Sometimes psychomotor agitation is replaced by psychomotor retardation, patients seem to freeze in a pose expressing horror and despair. This state of fear usually disappears after a few days, but in the future, any reminder of the traumatic experience can lead to an exacerbation of attacks of fear.

Hypokinetic form (reactive, psychogenic stupor) - sudden immobility. Despite the mortal danger, the person freezes, cannot make a single movement, and is unable to utter a word (mutism). Jet stupor usually lasts from several minutes to several hours. In severe cases, this condition is prolonged. Severe atony or muscle tension occurs. Patients lie in a fetal position or stretched out on their backs, do not eat, their eyes are wide open, their facial expressions reflect either fear or hopeless despair. When mentioning a psychotraumatic situation, patients turn pale or red, become covered in sweat, and experience rapid heartbeat (vegetative symptoms of reactive stupor). Darkened consciousness during reactive stupor causes subsequent amnesia.

Psychomotor retardation may not reach the level of stupor. In these cases, patients are accessible to contact, although they respond briefly, with a delay, and drawl out their words. Motor skills are constrained, movements are slow. Consciousness is narrowed or the patient is stunned. In rare cases, in response to sudden and strong psycho-traumatic influences, so-called emotional paralysis occurs: prolonged apathy with an indifferent attitude to a threatening situation and indifferent registration of what is happening around. In some cases, due to an acute fear reaction, a protracted fear neurosis may subsequently develop.

Affective-shock reactions are always accompanied by autonomic disorders in the form of tachycardia, sudden pallor or hyperemia of the skin, profuse sweat, and diarrhea. Acute shock reactions last from 15-20 minutes to several hours or days.

Depressive psychogenic reactions (reactive depression)

Death loved one, severe life failures can also cause a natural psychological reaction of sadness in healthy people. The pathological reaction differs from the normal one in its excessive strength and duration. In this state, patients are depressed, sad, tearful, walk hunched over, sit in a bent position with their head bowed to their chest, or lie with their legs crossed. Ideas of self-blame do not always occur, but usually experiences are concentrated around circumstances associated with mental trauma. Thoughts about an unpleasant incident are persistent, detailed, often become overvalued, and sometimes reach the level of delirium. Psychomotor retardation sometimes reaches depressive stupor; patients lie or sit all the time, hunched over, with a frozen face, with an expression of deep melancholy or hopeless despair, they are lacking initiative, cannot serve themselves, the environment does not attract their attention, difficult questions are not comprehended.

Reactive depression is sometimes combined with individual hysterical disorders. In these cases, depression manifests itself as shallow psychomotor retardation, an affect of melancholy with expressive external symptoms that do not correspond to the depth of depression: patients gesticulate theatrically, complain of an oppressive feeling of melancholy, take tragic poses, cry loudly, and demonstrate suicidal attempts. During the conversation, they become animated, scold their offenders, and at the mention of a traumatic situation, they become excited to the point of bouts of hysterical despair. Individual puerile, pseudodementia manifestations are often observed.

Sometimes, against the background of a depressed mood, phenomena of derealization, depersonalization, and senestopathic-popochondriacal disorders occur. Against the background of increasing depression with anxiety and fear, individual ideas of relationship, persecution, accusation, etc. may appear. The content of delusion is limited to an incorrect interpretation of the behavior of others and individual random external impressions. The affect of melancholy, when accompanied by anxiety, fear or anger, often develops against the background of psychomotor agitation: patients rush about, cry loudly, wring their hands, bang their heads against the wall, try to throw themselves out of the window, etc. Sometimes this condition takes the form of depressive raptus.

Reactive depressions differ from endogenous ones in that their occurrence coincides with mental trauma; traumatic experiences are reflected in the clinical picture of depression; after the traumatic situation is resolved or after some time, reactive depression disappears. The course of reactive depression depends both on the content of the mental trauma and on the personality characteristics of the patient and his condition at the time of the onset of the mental disorder. Reactive depression in persons who have suffered a traumatic brain injury or are weakened by severe somatic and infectious diseases, as well as in older people with cerebral atherosclerosis, may be delayed. Reactive depressions associated with a severe, unresolved traumatic situation can also be long-lasting.

Reactive (psychogenic) delusional psychoses- a combined group of very different psychogenic reactions.

Reactive paranoid delusional formation - the emergence of paranoid, overvalued delusions that do not go beyond the traumatic situation, are “psychologically understandable” and are accompanied by a lively emotional reaction. These ideas dominate the consciousness, but in the early stages, patients are still amenable to some dissuading. In all other behavior of the patient, not related to the overvalued idea, no noticeable deviations are found. Reactive paranoid delusion, like all reactive states, lasts until the psychotraumatic situation disappears, and completely reflects it, it is not characterized by progression, does not arise negative symptoms. All these features distinguish reactive paranoid states from schizophrenic ones. Paranoid reactive disorders have many individual variants, due to the characteristics of psychogenic influence.

Acute paranoid reaction - paranoid delusional formation, characteristic of psychopathic (paranoid) individuals. Relatively minor everyday difficulties can arouse in them suspicion, anxiety, ideas of relationship and persecution. Such reactions are usually short-lived. Their development is facilitated by a temporary weakening of the nervous system (overwork, lack of sleep, etc.).

Hypochondriacal reaction close in structure to acute paranoid. It usually develops in people with increased attention to their health. A careless phrase from a doctor (iatrogeny), a misunderstood medical text, or news of the death of a friend can lead to the emergence of a hypochondriacal overvalued idea. Patients begin to visit different doctors and specialist consultants, and negative research results do not bring reassurance. Depending on the personality of the patient and the behavior of the doctor, hypochondriacal reactions can be short-term or drag on for years.

Delirium of persecution of the hearing impaired occurs in people with poor hearing due to difficult speech contact with others. Similar conditions are observed when communication is difficult due to lack of knowledge of the language (delusions of persecution in a foreign language environment).

Reactive paranoids are characterized by great syndromic diversity. In some cases, the main symptoms in the clinical picture of psychogenic paranoid are ideas of persecution, relationships, and sometimes physical impact against a background of pronounced fear and confusion. The content of delusional ideas usually reflects a traumatic situation; everything that happens is subject to delusional interpretation and acquires special meaning. In other cases, against the background of a psychogenically caused change in consciousness, usually narrowed, in addition to delusional ideas of persecution, relationship and physical impact, the patient experiences abundant both auditory and visual hallucinations and pseudohallucinations; the status is dominated by the affect of fear.

Diagnosing reactive paranoids usually does not cause much difficulty. The main supporting criteria: situational conditionality, specific, figurative, sensory delirium, the connection of its content with a psychotraumatic situation and the reversibility of this state when the external situation changes.

Paranoid in isolation occurs often (for example, among people under investigation). It is longer than reactive and, as a rule, is accompanied by auditory hallucinations and pseudohallucinations, sometimes in the form of acute hallucinosis: the patient constantly hears the voices of relatives and friends, the crying of children. Numerous voices often seem to be divided into two camps: hostile voices that scold and condemn the patient, and friendly voices that defend and justify him.

Paranoid of the external environment (situational) - acute delusional psychosis; occurs suddenly, sometimes without any warning signs, in an extremely unusual (new) situation for the patient. This is an acute figurative delusion of persecution and an unusually sharp affect of fear. The patient, trying to save his life, throws himself out of the train while moving, sometimes defending himself with a weapon in his hands from imaginary pursuers. There are frequent attempts at suicide in order to get rid of the expected torment. Patients may seek protection from persecutors from government officials, police officers, and military personnel. At the height of the affect of fear, a disturbance of consciousness is noted, followed by partial amnesia for a specified period of time. At the height of psychosis, false recognitions, a symptom of a double, can be observed. The occurrence of such acute paranoids is facilitated by prolonged fatigue, insomnia, somatic weakening, and alcoholism. Such paranoids are usually short-term, and when the patient is removed from this environment, delusional ideas disappear, he calms down, and criticism of psychosis appears.

In forensic psychiatric clinics, psychogenic paranoids and hallucinosis are currently rare.

Hysterical reactions or psychoses manifest themselves in a relatively small number of clinical forms (variants):

1) hysterical twilight stupefaction (Ganser syndrome);
2) pseudodementia;
3) puerilism;
4) psychogenic stupor.

Hysterical twilight stupefaction, or Ganser's syndrome, manifests itself as an acute twilight disorder of consciousness, phenomena of “mimorya” (incorrect answers to simple questions), hysterical sensitivity disorders and sometimes hysterical hallucinations. The painful condition is acute and lasts several days. After recovery, there is a forgetting of the entire period of psychosis and the psychopathological experiences observed in its structure. Currently, this syndrome practically does not occur in forensic psychiatric clinics.

Pseudodementia syndrome (imaginary dementia) observed more often. This is a hysterical reaction, manifested in incorrect answers ("mimoral speech") and incorrect actions ("mimoral actions"), demonstrating the sudden onset of deep "dementia", which subsequently disappears without a trace. With past exposure, patients cannot perform the simplest usual actions, they cannot dress themselves, and they have difficulty eating. With the phenomena of “fleeting speech,” the patient gives incorrect answers to simple questions, cannot name the current year, month, is unable to say how many fingers he has on his hand, etc. Often the answers to questions asked are in the nature of denial (“I don’t know,” “ I don’t remember”) or are directly opposite to the correct answer (the window is called a door, the floor is a ceiling, etc.), or are similar in meaning, or are the answer to the previous question. Incorrect answers are always related to the correct ones, lie in the plane of the question posed and affect the range of correct ideas. In the content of the answer, one can discern a connection with a real traumatic situation, for example, instead of the current date, the patient names the date of arrest or trial, says that everyone is in white coats, which means he is in the store where he was arrested, etc.

Pseudodementia syndrome develops gradually against the background of a depressive-anxious mood, more often in persons with an organic mental disorder of a traumatic, vascular or infectious nature, as well as in psychopathic individuals of emotionally unstable and hysterical types. Unlike Ganser's syndrome, pseudodementia occurs against the background of a hysterically constricted rather than twilight disorder of consciousness. With timely initiation of therapy, and sometimes without it, pseudodementia undergoes reverse development after 2-3 weeks and restoration of all mental functions occurs.

Currently, pseudodementia syndrome as an independent form of reactive psychosis almost never occurs; its individual clinical manifestations are more often noted in the clinical picture of hysterical depression or delusional fantasies.

Puerilism syndrome manifests itself in childish behavior (from lat. puer - child) in combination with a hysterically narrowed consciousness. Puerilism syndrome, like pseudodementia syndrome, usually occurs in individuals with histrionic personality disorder. The most common and persistent symptoms of puerilism are children's speech, children's movements and children's emotional reactions. Patients with all their behavior reproduce the characteristics of a child’s psyche; they speak in a thin voice with childish capricious intonations, construct phrases like a child, address everyone as “you,” call everyone “uncles” and “aunts.” Motor skills acquire a childlike character, patients are mobile, run in small steps, and reach for shiny objects. Emotional reactions are also childish: patients are capricious, offended, pout, cry when they are not given what they ask for. However, in children's forms of behavior of puerile patients, one can note the participation of the entire life experience of an adult, which creates the impression of some uneven disintegration of functions, for example, a child's lisping speech and automated motor skills while eating and smoking, which reflects the experience of an adult. Therefore, the behavior of patients with puerile syndrome differs significantly from true child behavior. Manifestations of childishness in speech and facial expressions, external liveliness of children sharply contrast with the dominant depressive emotional background, affective tension and anxiety observed in all patients. In forensic psychiatric practice, individual features of puerilism are more common than the entire pueril syndrome.

Psychogenic stupor - a state of complete motor immobility with mutism. If there is psychomotor retardation that does not reach the level of stupor, then they speak of a criminal state. Currently, psychogenic stupor does not occur as an independent form of reactive psychoses. In certain forms of reactive psychoses, more often depression, short-term states of psychomotor retardation may occur that do not reach the degree of stupor or substupor.

Hysterical psychoses in recent decades, they have changed significantly in their clinical picture and are not found in forensic psychiatric practice in such diverse, clinically holistic and vibrant forms as they were in the past.

At present, from the group of hysterical psychoses, only delusional fantasies. The term arose for the first time in forensic psychiatric practice to designate clinical forms that occur primarily in prison conditions and are characterized primarily by the presence of fantastic ideas. These psychogenically arising fantastic ideas occupy, as it were, an intermediate position between delusions and fantasies: approaching delusional ideas in content, delusional fantasies differ from them in their liveliness, mobility, lack of cohesion with the personality, lack of the patient’s strong conviction in their reliability, as well as direct dependence on external circumstances . Pathological fantastic creativity is characterized by the rapid development of delusional constructions, characterized by variability, mobility, and volatility. Unstable ideas of greatness and wealth predominate, which in a fantastically hyperbolic form reflect the replacement of a difficult, unbearable situation with content-specific fictions and a desire for rehabilitation. Patients talk about their flights into space, the countless riches they possess, and great discoveries of national importance. Individual fantastic delusional constructions do not add up to a system; they are varied and often contradictory. The content of delusional fantasies bears a pronounced imprint of the influence of a traumatic situation, the worldview of patients, the degree of their intellectual development and life experience and contradicts the main anxious background of the mood. It changes depending on external factors, questions from the doctor.

In other cases, delusional fantastic ideas are more complex and persistent in nature, showing a tendency towards systematization. Just as with unstable, changeable fantastic constructions, all the anxieties, concerns and fears of patients are associated not with the content of ideas, but with a real unfavorable situation. Patients can talk for hours about their "projects" and "works", emphasizing that in comparison with " of greatest importance of the discoveries they made,” their fault is negligible. During the period of reverse development of reactive psychosis, situationally determined depression comes to the fore, fantastic statements fade, reviving only for a short time when the patients are excited.

Reactive psychosis with delusional fantasy syndrome it is necessary to distinguish it from the peculiar non-pathological creativity that occurs in conditions of imprisonment, which reflects the severity of the situation and the need for self-affirmation. In these cases, patients also write “scientific” treatises with absurd, naive content, offering various methods of fighting crime, curing serious illnesses, prolonging life, etc. However, unlike reactive psychosis with delusional fantasy syndrome, in these cases there is no pronounced emotional stress with elements of anxiety, as well as other psychotic hysterical symptoms.

In forensic psychiatric practice, it is often observed hysterical depression. They often develop subacutely after a period of situationally determined emotional stress and emotional depression. The clinical picture of hysterical depression is distinguished by its particular brightness and mobility of psychopathological symptoms. The affect of melancholy in hysterical depression is characterized by particular expressiveness and is often combined with equally expressive anxiety, directly related to the real situation. The patients' voluntary movements and gestures are also distinguished by their expressiveness, plasticity, theatricality, and subtle differentiation, which creates a special pathetic design in the presentation of their suffering. Sometimes a feeling of melancholy is combined with anger, but even in these cases, motor skills and facial expressions remain just as expressive. Often patients harm themselves or make demonstrative suicide attempts. They are not prone to delusional ideas of self-accusation; externally blaming tendencies and a tendency to self-justification are more often noted. Patients blame others for everything, express exaggerated and unjustified fears about their health, and present a wide variety of variable complaints.

The clinical picture of depression may become more complicated, combined with other hysterical manifestations (pseudo-dementia, puerilism).

The listed forms of hysterical states can change from one to another, which is explained in the general pathophysiological mechanisms of their occurrence.

Neuroses are reactive states, the occurrence of which is associated with a long-term psychogenically traumatic situation that causes constant mental stress. In the development of neuroses, personality traits are of great importance, which reflect the low limit of physiological endurance in relation to psychogenies of different subjective significance. Therefore, the occurrence of neurosis depends on the structure of the personality and the nature of the situation, which, due to individual personal properties, turns out to be selectively traumatic and insoluble.

In ICD-10, neuroses are grouped under the rubric of neurotic stress-related disorders. At the same time, many independent forms are distinguished. The most common and traditional in the Russian literature is the classification of neuroses according to clinical manifestations. In accordance with this, three independent types of neuroses are considered: neurasthenia, hysterical neurosis, obsessive-compulsive neurosis.

Neurasthenia is the most common form of neuroses, develops more often in persons with an asthenic constitution in conditions of long-term insoluble conflict situation causing constant mental stress. In the clinical picture, the leading place is occupied by asthenic syndrome, which is characterized by a combination of asthenia itself with autonomic disorders and sleep disorders. Asthenia is characterized by symptoms of mental and physical exhaustion. Increased fatigue is accompanied by a constant feeling of tiredness. Increased excitability and incontinence that appear at first are subsequently combined with irritable weakness, intolerance to ordinary irritants - loud sounds, noise, bright light. Subsequently, the components of mental and physical asthenia itself become more and more pronounced. As a result of a constant feeling of fatigue and physical lethargy, a decrease in working capacity appears; due to exhaustion of active attention and absent-mindedness, the assimilation of new material and the ability to memorize deteriorate, and there is a decrease in creative activity and productivity. Low mood may acquire a depressive coloring with the formation in some cases neurotic depression. Various autonomic disorders are also constant manifestations of neurasthenia: headaches, sleep disturbances, fixation of attention on subjective unpleasant physical sensations. The course of neurasthenia is usually long-term and depends, on the one hand, on the cessation or ongoing action of a traumatic situation (especially if this situation causes constant anxiety, expectation of trouble), on the other, on the characteristics of the individual and the general condition of the body. Under changed conditions, the symptoms of neurasthenia may completely disappear.

Hysterical neurosis usually develops in individuals with histrionic personality disorder. The clinical picture of hysterical neurosis is extremely diverse. The following four groups of mental disorders are characteristic:

1) movement disorders;
2) sensory and sensitivity disorders;
3) autonomic disorders;
4) mental disorders.

Hysterical movement disorders accompanied by tears, moans, screams. Hysterical paralysis and contractures are observed in the muscles of the limbs, sometimes in the muscles of the neck and torso. They do not correspond to anatomical muscle innervation, but reflect the patient’s ideas about the anatomical innervation of the limbs. With long-term paralysis, secondary atrophy of the affected muscle groups may develop. In the past, the phenomenon of astasia-abasia was often encountered, when, with complete preservation of the musculoskeletal system, patients refused to stand and walk. Lying in bed, the patients were able to make certain voluntary movements with their limbs, they could change the position of their body, but when they tried to put them on their feet, they fell and could not lean on their legs. In recent decades, these disorders have given way to less severe movement disorders in the form of weakness of individual limbs. Hysterical paralysis is more common vocal cords, hysterical aphonia (loss of voice sonority), hysterical spasm of one or both eyelids. With hysterical mutism (muteness), the ability to writing and voluntary movements of the tongue are not impaired. Hysterical hyperkinesis is often observed, which manifests itself in trembling of the limbs of varying amplitude. Trembling increases with excitement and disappears in a calm environment, as well as during sleep. Sometimes tics are observed in the form of convulsive contractions of individual muscle groups. Convulsive phenomena in speech manifest themselves in hysterical stuttering.

Sensory hysterical disturbances most often manifested in a decrease or loss skin sensitivity, which also does not correspond to innervation zones, but reflects ideas about anatomical structure limbs and parts of the body (like gloves, stockings). Pain sensations may be observed in different parts of the body and different organs. Disturbances in the activity of individual sense organs are quite common: hysterical blindness (amaurosis), deafness. Often hysterical deafness is combined with hysterical mutism, and a picture of hysterical deaf-muteness (surdomutism) arises.

Autonomic disorders diverse. A spasm of smooth muscles is often observed, which is associated with such typical hysterical disorders as a feeling of a lump in the throat, a feeling of obstruction of the esophagus, and a feeling of lack of air. Hysterical vomiting is common and is not associated with any disease. gastrointestinal tract and is caused solely by spasm of the pylorus. Functional disorders of internal organs may be observed (for example, palpitations, vomiting, shortness of breath, diarrhea, etc.), which usually arise in a subjectively traumatic situation.

Mental disorders also expressive and diverse. Emotional disturbances predominate: fears, mood swings, states of depression, depression. At the same time, very superficial emotions are often hidden behind external expressiveness. Hysterical disorders, when they occur, usually have the character of “conditioned desirability.” In the future, they can be fixed and repeatedly reproduced in subjectively difficult situations through hysterical mechanisms of “flight into illness.” In some cases, the reaction to a traumatic situation manifests itself in increased fantasizing. The content of fantasies reflects the replacement of reality with fictions that are contrasting in content, reflecting the desire to escape from an unbearable situation.

Obsessive-compulsive disorder occurs in forensic psychiatric practice less frequently than hysterical neurosis and neurasthenia. Obsessive phenomena are divided into two main types:

1) obsessions, the content of which is abstract, affectively neutral;
2) sensory-imaginative obsessions with affective, usually extremely painful content.

Abstract obsessions include obsessive counting, obsessive memories of forgotten names, formulations, terms, obsessive philosophizing (mental chewing gum).

Obsessions, predominantly sensory-figurative, with painful affective content are more diverse:

obsessive doubts, constantly arising uncertainty about the correctness and completeness of the actions taken;
obsessive ideas that, despite their obvious implausibility and absurd nature, cannot be eliminated (for example, a mother who has buried a child suddenly has a sensory-figurative idea that the child is buried alive);
intrusive memories - an irresistible, intrusive memory of some unpleasant, negatively emotionally charged event in the past, despite constant efforts not to think about it; obsessive fears about the possibility of performing habitual, automated behaviors and actions;
obsessive fears (phobias) are especially diverse in content, characterized by insurmountability and, despite their senselessness, the inability to cope with them, for example, an obsessive senseless fear of heights, open spaces, squares or enclosed spaces, an obsessive fear for the state of one’s heart (cardiophobia) or the fear of getting sick cancer (cancerophobia);
obsessive actions are movements performed against the wishes of patients, despite all efforts made to restrain them.

Phobias may be accompanied obsessive movements and by actions that arise simultaneously with phobias, they are given a protective character and they quickly take the form of rituals. Ritual actions are aimed at preventing imaginary misfortune and have a protective, protective nature. Despite the critical attitude towards them, they are produced by patients against reason to overcome obsessive fear. In mild cases, due to the complete preservation of criticism and awareness of the painful nature of these phenomena, those suffering from neuroses hide their obsessions and do not switch off from life.

In cases of severe neurosis, the critical attitude towards obsessions disappears for some time and is revealed as a concomitant severe asthenic syndrome and depressed mood. During a forensic psychiatric examination, it should be borne in mind that only in some, very rare cases of severe neurotic conditions obsessive behavior can lead to antisocial behavior. In the overwhelming majority of cases, patients with obsessive-compulsive neuroses, due to a critical attitude towards them and the fight against them, do not commit criminal acts related to the phenomena of obsession.

In some cases, reactive states take a protracted course, in such cases they speak of the development of protracted reactive psychoses. The concept of protracted reactive psychosis is determined not only by the duration of the course (six months, a year and up to five years), but also by the clinical features of individual forms and the characteristic patterns of the dynamics of the disease.

In recent decades, against the background of successful psychopharmacotherapy, only in isolated cases has a prognostically unfavorable course of protracted reactive psychoses been encountered, which is characterized by the irreversibility of profound personal changes and general disability. Such an unfavorable development of reactive psychoses is possible only in the presence of the so-called pathological soil - an organic mental disorder after a head injury, with cerebral atherosclerosis and arterial hypertension, as well as at the age of reverse development (after 50 years).

Among protracted reactive psychoses, “erased forms” currently predominate, and the frequency and severity of hysterical manifestations has sharply decreased. Hysterical symptoms such as hysterical paralysis, paresis, the phenomenon of astasia-abasia, hysterical mutism, which in the past were leading in the clinical picture of protracted reactive psychoses, are practically not observed. The main place is occupied by clinically diverse forms of depression, as well as erased depressive states that do not reach a psychotic level and nevertheless have a protracted course. Patients note a depressed mood, elements of anxiety, they are gloomy, sad, complain of emotional stress, a premonition of misfortune. Usually these complaints are combined with unjustified fears about one’s health. Patients are fixated on their unpleasant somatic sensations, constantly think about the troubles awaiting them, and seek sympathy from others. This condition is accompanied by more or less pronounced disorganization mental activity. Patients usually associate their experiences with a real psychotraumatic situation; they are concerned about the outcome of the case.

With a prolonged course, depression fluctuates in its intensity and its clinical manifestations and their severity depend significantly on external circumstances. A gradual deepening of depression is possible with an increase in psychomotor retardation, the appearance of elements of melancholy, and the inclusion of delusional ideas. Despite the deepening of depression, the condition of patients is characterized by external inexpressiveness, weariness, and suppression of all mental functions. Patients usually do not show initiative in conversation and do not complain about anything. They spend most of their time in bed, remaining indifferent to their surroundings. The depth of melancholy depression is evidenced by the prevailing feeling of hopelessness in the clinical picture, a pessimistic assessment of the future, and thoughts of not wanting to live. Somatovegetative disorders in the form of insomnia, decreased appetite, constipation, physical asthenia and weight loss complement the clinical picture of prolonged depression. This condition can last up to a year or more. In the process of active therapy, a gradual recovery is observed, in which melancholy depression is replaced by situational depression. After the reverse development of painful symptoms long time asthenia remains.

Hysterical depression, when it is prolonged, does not show a tendency to deepen. The leading syndrome, formed in the subacute period of reactive psychosis, remains fixed at a protracted stage. At the same time, the expressiveness inherent in hysterical depression is preserved emotional manifestations, direct dependence of the basic mood on the characteristics of the situation, constant readiness to strengthen affective manifestations when the circumstances related to this situation worsen or only during conversations on this topic. Therefore, the depth of depression has a wave-like character. Often, in the clinical picture of depression, individual unstable pseudodementia-puerile inclusions or delusional fantasies are noted, reflecting the hysterical tendency to “flight into illness,” avoidance of an unbearable real situation, and hysterical repression. Hysterical depression can be long-lasting - up to two years or more. However, in the process of treatment or with a favorable resolution of the situation, sometimes an unexpectedly acute, but more often a gradual exit from the painful state occurs without any subsequent changes in the psyche.

In persons who have suffered prolonged hysterical depression, when the traumatic situation is resumed, relapses and repeated reactive psychoses are possible, the clinical picture of which reproduces the symptoms of the initial reactive psychosis according to the type of well-worn clichés.

The described variants of the course of protracted reactive psychoses, especially with psychogenic delusions, are now relatively rare, however, a clear understanding of the dynamics of individual, even rare forms is of great importance for assessing the prognosis of these conditions, which is necessary when solving expert issues.

E Pilepsy is one of the most common neuropsychiatric diseases: its prevalence in the population is in the range of 0.8-1.2%.

It is known that mental disorders are an essential component of the clinical picture of epilepsy, complicating its course. According to A. Trimble (1983), A. Moller, W. Mombouer (1992), there is a close relationship between the severity of the disease and mental disorders, which occur much more often with an unfavorable course of epilepsy.

In the last few years, as statistical studies show, in the structure of mental morbidity there is an increase in forms of epilepsy with non-psychotic disorders . At the same time, the proportion of epileptic psychoses is decreasing, which reflects the obvious pathomorphism of the clinical manifestations of the disease, caused by the influence of a number of biological and social factors.

One of the leading places in the clinic of non-psychotic forms of epilepsy is occupied by affective disorders , which often show a tendency towards chronicity. This confirms the position that despite the achieved remission of seizures, disturbances in the emotional sphere are an obstacle to the full restoration of patients’ health (Maksutova E.L., Fresher V., 1998).

When clinically qualifying certain syndromes of the affective register, it is fundamental to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes themselves. In this regard, it can be conditionally distinguished two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders themselves, and secondary - without a cause-and-effect relationship with the attack, but based on various manifestations reactions to the disease, as well as to additional psychotraumatic influences.

Thus, according to studies of patients in a specialized hospital at the Moscow Research Institute of Psychiatry, it has been established that phenomenologically non-psychotic mental disorders are represented by three types of conditions:

1) depressive disorder in the form of depressions and subdepressions;
2) obsessive-phobic disorders;
3) others affective disorders.

Depressive spectrum disorders include the following:

1. Melancholy depression and subdepression were observed in 47.8% of patients. The predominant feeling in the clinic here was an anxious-melancholy affect with a persistent decrease in mood, often accompanied by irritability. Patients noted mental discomfort and heaviness in the chest. In some patients, there was a connection between these sensations and physical illness (headache, unpleasant sensations in the chest) and were accompanied by motor restlessness, less often they were combined with adynamia.

2. Adynamic depression and subdepression were observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. They spent most of the time in bed, had difficulty performing simple self-care functions, and were characterized by complaints of fatigue and irritability.

3. Hypochondriacal depression and subdepression were observed in 13% of patients and were accompanied constant feeling physical damage, heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that during an attack a sudden death or they will not receive help on time. Rarely did the interpretation of phobias go beyond the specified plot. Senestopathies were characterized by hypochondriacal fixation, the peculiarity of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less commonly, the basis of senestopathies was vegetative disorders.

The variant of hypochondriacal depression was more typical for the interictal period, especially in conditions of chronicity of these disorders. However, their transient forms were often noted in the early postictal period.

4. Anxiety depression and subdepression occurred in 8.7% of patients. Anxiety, as a component of an attack (less commonly, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experienced vague fear or anxiety, the cause of which was unclear to them. A short-term anxious affect (several minutes, less often within 1-2 hours), as a rule, is characteristic of a variant of phobias as a component of a seizure (within the aura, the attack itself or the post-seizure state).

5. Depression with depersonalization disorders were observed in 0.5% of patients. In this variant, the dominant sensations were changes in the perception of one’s own body, often with a feeling of alienation. The perception of the environment and time also changed. Thus, patients, along with a feeling of adynamia and hypothymia, noted periods when the environment “changed”, time “accelerated”, it seemed that the head, arms, etc. were enlarged. These experiences, in contrast to true paroxysms of depersonalization, were characterized by the preservation of consciousness with full orientation and were fragmentary in nature.

Psychopathological syndromes with a predominance of anxious affect comprised predominantly the second group of patients with “obsessive-phobic disorders.” Analysis of the structure of these disorders showed that their close connections can be traced with almost all components of a seizure, starting with precursors, aura, the attack itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of a paroxysm, preceding or accompanying an attack, was manifested by a sudden fear, often of uncertain content, which patients described as an “impending threat”, increasing anxiety, giving rise to a desire to urgently do something or seek help from others. Individual patients often indicated fear of death from an attack, fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, and less frequently, social phobic experiences were noted (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. There was a close connection between obsessive-phobic disorders and the autonomic component, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, and thoughts were observed.

Unlike paroxysmal anxiety, anxious affect in remissions approaches in form the classical variants in the form of unmotivated fears for one’s health, the health of loved ones, etc. A number of patients have a tendency to develop obsessive-phobic disorders with obsessive concerns, fears, behaviors, actions, etc. In some cases, there are protective mechanisms of behavior with unique measures to counteract the disease, such as rituals, etc. In terms of therapy, the most unfavorable option is a complex symptom complex, including obsessive-phobic disorders, as well as depressive disorders.

The third type of borderline forms of mental disorders in the epilepsy clinic was affective disorders , designated by us as “other affective disorders.”

Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphoria, etc.

Among this group borderline disorders, appearing both in the form of paroxysms and prolonged states, were more often observed epileptic dysphoria . Dysphoria, occurring in the form of short episodes, more often took place in the structure of the aura, preceding an epileptic attack or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, astheno-hypochondriacal manifestations, irritability, and anger affect prevailed in their structure. Protest reactions often formed. Aggressive actions were observed in a number of patients.

The emotional lability syndrome was characterized by a significant amplitude of affective fluctuations (from euphoria to anger), but without noticeable behavioral disturbances characteristic of dysphoria.

Among other forms of affective disorders, mainly in the form of short episodes, there were reactions of weakness, manifested in the form of incontinence of affect. Usually they acted outside the framework of a formalized depressive or anxiety disorder, representing an independent phenomenon.

In relation to the individual phases of an attack, the frequency of borderline mental disorders associated with it is presented as follows: in the aura structure - 3.5%, in the attack structure - 22.8%, in the post-ictal period - 29.8%, in the interictal period - 43.9 %.

Within the framework of the so-called precursors of attacks, various functional disorders, predominantly of a vegetative nature (nausea, yawning, chills, drooling, fatigue, loss of appetite), against the background of which anxiety, decreased mood or fluctuations in mood occur with a predominance of irritable-sullen affect. A number of observations during this period noted emotional lability with explosiveness and a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can be self-limiting.

Aura with affective experiences - a frequent component of subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension and a feeling of “lightheadedness.” Less common are pleasant sensations (increased vitality, a feeling of particular lightness and elation), which are then replaced by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either an affect of fear and anxiety may occur, or a neutral (less often excited-elated) mood may be noted.

In the structure of the paroxysm itself, affective syndromes most often occur within the framework of the so-called temporal lobe epilepsy.

As is known, motivational and emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly the mediobasal formations, which are part of the limbic system. At the same time, affective disorders are most widely represented in the presence of a temporal focus in one or both temporal lobes.

When the lesion is localized in the right temporal lobe depressive disorders are more common and have a more defined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with various plots of phobias and episodes of agitation. This clinic fits completely into the distinguished “right hemisphere affective disorder” in the taxonomy of organic syndromes ICD-10.

TO paroxysmal affective disorders (within an attack) include attacks of fear, unaccountable anxiety, and sometimes with a feeling of melancholy that suddenly occur and last for several seconds (less often than minutes). There may be impulsive short-term states of increased sexual (food) desire, a feeling of increased strength, and joyful anticipation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. It is necessary to emphasize the predominantly violent nature of these experiences, although individual cases of their arbitrary correction using conditioned reflex techniques indicate a more complex pathogenesis.

“Affective” seizures occur either in isolation or are part of the structure of other seizures, including convulsive ones. Most often they are included in the structure of the aura of a psychomotor seizure, less often - vegetative-visceral paroxysms.

The group of paroxysmal affective disorders within temporal lobe epilepsy includes dysphoric states, the duration of which can range from several hours to several days. In some cases, dysphoria in the form of short episodes precedes the development of the next epileptic seizure or series of attacks.

The second place in the frequency of affective disorders is occupied by clinical forms with dominant vegetative paroxysms within diencephalic epilepsy . Analogues of the common designation of paroxysmal (crisis) disorders as “vegetative attacks” are concepts widely used in neurological and psychiatric practice such as “diencephalic” attack, “panic attacks” and other conditions with large vegetative accompaniment.

Classic manifestations of crisis disorders include sudden development: shortness of breath, a feeling of lack of air, discomfort from the organs of the chest cavity and abdomen with “heart sinking,” “interruptions,” “pulsation,” etc. These phenomena are usually accompanied by dizziness, chills, and tremor , various paresthesias. Possible increased frequency of bowel movements and urination. The most powerful manifestations are anxiety, fear of death, fear of going crazy.

Affective symptoms in the form of individual unstable fears can be transformed into both affective paroxysm itself and permanent variants with fluctuations in the severity of these disorders. In more severe cases, a transition to a persistent dysphoric state with aggression (less often, auto-aggressive actions) is possible.

In epileptological practice, vegetative crises occur mainly in combination with other types (convulsive or non-convulsive) paroxysms, causing polymorphism in the clinical picture of the disease.

Regarding the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we include diverse psychologically understandable reactions to the disease that occur in epilepsy. At the same time, side effects as a response to therapy, as well as a number of professional restrictions and other social consequences of the disease, include both transient and prolonged conditions. They more often manifest themselves in the form of phobic, obsessive-phobic and other symptoms, in the formation of which a large role belongs to the individual personality characteristics of the patient and additional psychogenies. At the same time, the clinic of protracted forms in a broad sense of situational (reactive) symptoms is largely determined by the nature of cerebral (deficient) changes, which gives them a number of features associated with organic soil. The clinical picture of emerging secondary reactive disorders is also reflected in the degree of personal (epithymic) changes.

Within reactive inclusions Patients with epilepsy often have concerns about:

development of a seizure on the street, at work
be injured or die during a seizure
go crazy
transmission of disease by inheritance
side effects anticonvulsants
forced withdrawal of drugs or untimely completion of treatment without guarantees for relapse of attacks.

The reaction to a seizure at work is usually much more severe than when it occurs at home. Because of the fear that a seizure will occur, some patients stop studying, working, and do not go out.

It should be pointed out that, according to induction mechanisms, fear of a seizure may also appear in relatives of patients, which requires a large participation of family psychotherapeutic assistance.

Fear of a seizure is more often observed in patients with rare paroxysms. Patients with frequent attacks during a long illness become so accustomed to them that, as a rule, they hardly experience such fear. Thus, in patients with frequent seizures and a longer duration of the disease, signs of anosognosia and uncritical behavior are usually observed.

Fear of bodily harm or fear of death during a seizure is more easily formed in patients with psychasthenic personality traits. It also matters that they have previously had accidents and bruises due to seizures. Some patients fear not so much the attack itself as the possibility of bodily harm.

Sometimes the fear of a seizure is largely due to the unpleasant subjective sensations that appear during an attack. These experiences include frightening illusory, hallucinatory inclusions, as well as body schema disorders.

This distinction between affective disorders is of fundamental importance in determining further therapy.

Principles of therapy

The main direction of therapeutic tactics in relation to individual affective components of the attack itself and closely related post-ictal emotional disturbances, is adequate use anticonvulsants that have a thymoleptic effect (cardimizepine, valproate, lamotrigine).

While not anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic regimen has a positive effect on both the paroxysms themselves and secondary affective disorders. However, it is advisable to limit the time of their use to three years due to the risk of addiction.

IN Lately widely used for anti-anxiety and sedative effects clonazepam , which is highly effective for absence seizures.

For various forms of affective disorders with depressive radicals, they are most effective antidepressants . At the same time, in outpatient setting Preferred drugs with minimal side effects, such as tianeptil, miaxerin, fluoxetine.

If the obsessive-compulsive component predominates in the structure of depression, the prescription of paroxetine is justified.

It should be noted that a number mental disorders in patients with epilepsy may be due not so much to the disease itself as to long-term therapy with phenobarbital drugs. In particular, this can explain the slowness, rigidity, and elements of mental and motor retardation that appear in some patients. With the appearance in last years With the use of highly effective anticonvulsants, it became possible to avoid side effects of therapy and classify epilepsy as a curable disease.

Borderline intelligence indicators (IQ in the zone of 70-80 units) require the identification of the leading pathopsychological symptom complex.

Unlike total defeat with U.O. The organic symptom complex is characterized by such a basic feature as the mosaic nature of damage to mental activity.

Arrested development (of organic origin) manifests itself in developmental lag the youngest brain structures(functions of regulation, control), mild organic damage to the brain with loss of structural and functional elements necessary for analysis, synthesis, abstraction and other intellectual processes. At the same time, potential intellectual capabilities (the ability to learn, accept help, transfer) remain relatively intact.

Phenomena intellectual disability in the structure of the organic symptom complex are formed against the background of a deficit of memory and attention in the form of distractibility, exhaustion, and the “flickering” nature of productive activity. Characterized by disturbances in emotional-volitional (uncontrollability, irritability, “nakedness,” imbalance) and other components of the developing personality.

2. U.O. should be differentiated with dementia, representing a decrease in intellectual functions. Dementia is usually understood as a persistent, irreversible impoverishment of mental activity, its simplification, decline due to destructive changes in brain tissue. Dementia is characterized by the loss of cognitive abilities due to a disease process affecting the brain, and this loss is so pronounced that it leads to impairment of the patient's social and professional activities.

The full clinical picture of dementia in children includes weakening of cognitive activity in creative thinking, the ability to abstract up to the inability to perform simple logical tasks, memory impairment and criticism of one’s condition with certain personality changes, as well as impoverishment of feelings. In advanced cases, the psyche represents “the ruins of mental organization.”

In contrast to mental retardation in dementia, the loss of previously acquired intellectual abilities is correlated not with the average value, but with the premorbid, i.e. before the onset of the disease (for example, encephalitis, epilepsy), the sick child had a higher level of intellectual development.

3. Mental retardation often has to be differentiated from autistic disorder, the distinctive feature of which is severe violations of interpersonal contacts and a gross deficit of communication skills, which is not observed with intellectual underdevelopment.

In addition, for autistic symptom complex is characteristic disorders social adaptation and communication in combination with stereotypical movements and actions, severe disorders of social-emotional interaction, specific disorders of speech, creativity and fantasy. Often the autistic symptom complex is combined with intellectual underdevelopment.

4. Cerebral seizures, in which transient impairment of cognitive functions is noted. The criterion is EEG data in combination with observation of behavior and corresponding experimental psychological techniques.

Landau-Kleffner syndrome (hereditary aphasia with epilepsy): children after a period of normal speech development lose speech, but intelligence may remain intact. Initially, this disorder is accompanied by paroxysmal disturbances on the EEG and, in most cases, epileptic seizures. The disease begins between the ages of 3 and 7 years, and loss of speech can occur over several days or weeks. Presumable etiology is an inflammatory process (encephalitis).

5. Hereditary degenerative diseases, neuroinfections: careful collection of anamnesis, severity of the organic background, neurological microsymptoms, as well as serological blood testing for certain markers of infectious diseases.

6. Mental retardation must be distinguished from intellectual disability that develops as a result of severe neglect and insufficient requirements to a child, depriving him of stimulating environmental factors - for example, sensory or cultural deprivation.

Treatment

Since in most cases the treatment is not etiotropic, but symptomatic, the therapeutic plan must include those areas that are most accessible to therapy and in which the patient experiences more difficulties in everyday life.

The goals of drug treatment are transient severe behavioral disorders, affective excitability, and neurosis-like disorders. Among other types of therapeutic interventions, behavioral therapy is used, aimed at developing independence, the ability to take care of oneself, shopping, and keeping oneself occupied.

As a psychological and pedagogical correction, the earliest possible assistance to sick children and their parents is offered. This assistance includes sensory and emotional stimulation, exercises to develop speech and motor skills, and master reading and writing skills. Reading classes contribute to the development of oral speech. Special techniques are proposed to facilitate the acquisition of these skills by sick children: reading whole in short words(without sound-letter analysis), mastering counting mechanically and using visual material, etc.

Family counseling is carried out for loved ones and the social environment, which indirectly stimulates the development of children, contributes to the achievement of realistic attitudes towards children suffering from mental retardation, and learning adequate ways to interact with them. Not all parents can cope with such grief on their own. In addition, intellectually intact children often grow up in these families. They also need psychological support.

Children are educated according to special programs, often differentiated in special schools.

At forensic psychiatric examination adolescents suffering from a mild degree of U.O., experts are faced with the need to apply special knowledge not only in general, medical and social psychology, but also in such theoretical and practical disciplines as psychology and pathopsychology of children and adolescents, developmental psychology. This predetermines the preference for conducting a comprehensive forensic psychological and psychiatric examination in such cases, taking into account not only the depth of the existing defect, but also the ability of a teenager to predict the consequences of his actions and the presence of other clinical features identified in him. With a mild degree of U.O. Only a few teenagers are considered insane. Teenagers declared sane are taken into account by the court in accordance with Article 22 of the Criminal Code of the Russian Federation, need increased attention during the preliminary investigation, deserve leniency and are often prescribed treatment during the execution of their sentence.

Rehabilitation

Rehabilitation is understood as the use of all measures that, in case of mental retardation, help to adapt to the requirements of learning, professional and public life. Individual components of rehabilitation for mental retardation, as a rule, are distinguished taking into account the international WHO classification. It distinguishes between damage (impairment), restrictions on individual functions disability and social failure (handicap). Since the damage, as a rule, cannot be eliminated, rehabilitation measures are aimed at the last two components - improving the individual’s functional capabilities and reducing negative social impacts. For this purpose, step-by-step programs have been developed with the help of which patients are integrated into professional activities and into society. It is worth mentioning different types of special schools, integrative schools, specialized boarding schools for training a profession and receiving vocational education, medical and occupational workshops that have workplaces equipped in accordance with the abilities and capabilities of patients.

Dynamics and forecast depend on the type and severity of intellectual underdevelopment, on the possible progression of the disorder and on the conditions of development. In recent years, there has been a change in attitude towards serving mentally retarded children in terms of their greater integration into society. To children's groups.

Disability: mild mental retardation is not an indication for referral to a medical and social examination. Mild mental retardation with behavioral disorders can be presented on MSE after examination and treatment in day and round-the-clock hospitals if the therapy performed in an outpatient setting is insufficiently effective. Disabled children are children with moderate, severe and deep shapes mental retardation.

Prevention of mental retardation

Primary prevention mental retardation:

1. a serious threat of UO - the pregnant woman’s use of drugs, alcohol, tobacco products and many medicines, as well as the action of a strong magnetic field, high frequency currents.

2. Many pose a risk to the fetus chemical substances(detergents, insecticides, herbicides) accidentally entering the body of the expectant mother, salts of heavy metals, iodine deficiency of the mother.

3. Severe damage to the fetus is caused by chronic infectious diseases of a pregnant woman (toxoplasmosis, syphilis, tuberculosis, etc.). Acute viral infections are also dangerous: rubella, influenza, hepatitis.

4. Timely diagnosis and treatment of enzymopathies (diet and replacement therapy).

5. Prevention of prematurity and proper management of childbirth.

6. Genetic counseling.

Prevention of complications mental retardation:

1. Prevention of exposure to additional exogenous damaging factors: trauma, infection, intoxication, etc.

2. Creating psychologically favorable conditions for the harmonious development of a child suffering from mental retardation, conducting his vocational guidance and social adaptation.

LIST LITERATURES

1. Vilensky O.G. "Psychiatry. Social aspects", M: University Book, 2007

2. Gillberg K., Hellgren D. “Psychiatry of children and adolescence", GEOTAR-Media, 2004

3. Goffman A.G. "Psychiatry. Directory for doctors", Medpress-inform, 2010

4. Goodman R., Scott S. “Child psychiatry”, Triad-X, 2008.

5. Doletsky S.Ya. Morphofunctional immaturity of the child’s body and its significance in pathology // Impaired maturation of structures and functions child's body and their significance for the clinic and social adaptation. - M.: Medicine, 1996.

6. Zharikov N.N., Tyulpin Yu.G. "Psychiatry", MIA, 2009

7. Isaev D.N. "Psychopathology childhood", Medpress-inform, 2006

8. Kaplan G.I., Sadok B.J. Clinical psychiatry. In 2 vols. T. 2. Per. from English - M: Medicine, 2004.

9. Kovalev V.V. Childhood psychiatry: A guide for doctors: ed. 2nd, revised and expanded. - M.: Medicine, 1995.

10. Remshid X. Child and adolescent psychiatry\ trans. with him. T.N. Dmitrieva. - M.: EKSMO-Press, 2001.

11. Snezhnevsky A.V. “General psychopathology”, Medpres-inform, 2008

12. Sukhareva G.D. " Clinical lectures on childhood psychiatry", Medpress-inform, 2007

13. Ushakov G.K. “Child Psychiatry”, Medicine, 2007

Maksutova E.L., Zheleznova E.V.

Research Institute of Psychiatry, Ministry of Health of the Russian Federation, Moscow

Epilepsy is one of the most common neuropsychiatric diseases: its prevalence in the population is in the range of 0.8–1.2%.

In the last few years, as statistical studies show, in the structure of mental morbidity there has been an increase in forms of epilepsy with non-psychotic disorders. At the same time, the proportion of epileptic psychoses is decreasing, which reflects the obvious pathomorphism of the clinical manifestations of the disease, caused by the influence of a number of biological and social factors.

One of the leading places in the clinic of non-psychotic forms of epilepsy is occupied by affective disorders, which often tend to become chronic. This confirms the position that despite the achieved remission of seizures, disturbances in the emotional sphere are an obstacle to the full restoration of patients’ health (Maksutova E.L., Fresher V., 1998).

When clinically qualifying certain syndromes of the affective register, it is fundamental to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes themselves. In this regard, we can conditionally distinguish two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders themselves, and secondary - without a cause-and-effect relationship with the attack, but based on various manifestations of reactions to the disease, as well as to additional psychotraumatic influences.

1) depressive disorder in the form of depression and subdepression;

2) obsessive-phobic disorders;

3) other affective disorders.

Depressive spectrum disorders include the following:

1. Melancholy depression and subdepression were observed in 47.8% of patients. The predominant feeling in the clinic here was an anxious and melancholy affect with a persistent decrease in mood, often accompanied by irritability. Patients noted mental discomfort and heaviness in the chest. In some patients, there was a connection between these sensations and physical illness (headache, unpleasant sensations in the chest) and were accompanied by motor restlessness, less often they were combined with adynamia.

2. Adynamic depression and subdepression were observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. They spent most of the time in bed, had difficulty performing simple self-care functions, and were characterized by complaints of fatigue and irritability.

3. Hypochondriacal depression and subdepression were observed in 13% of patients and were accompanied by a constant feeling of physical damage and heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that sudden death might occur during an attack or that they would not receive help in time. Rarely did the interpretation of phobias go beyond the specified plot. Senestopathies were characterized by hypochondriacal fixation, the peculiarity of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less commonly, the basis of senestopathies was vegetative disorders.

4. Anxiety depression and subdepression occurred in 8.7% of patients. Anxiety, as a component of an attack (less commonly, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experienced vague fear or anxiety, the cause of which was unclear to them. A short-term anxious affect (several minutes, less often within 1–2 hours), as a rule, is characteristic of a variant of phobias as a component of a seizure (within the aura, the attack itself or the post-seizure state).

5. Depression with depersonalization disorders was observed in 0.5% of patients. In this variant, the dominant sensations were changes in the perception of one’s own body, often with a feeling of alienation. The perception of the environment and time also changed. Thus, patients, along with a feeling of adynamia and hypothymia, noted periods when the environment “changed”, time “accelerated”, it seemed that the head, arms, etc. were enlarged. These experiences, in contrast to true paroxysms of depersonalization, were characterized by the preservation of consciousness with full orientation and were fragmentary in nature.

Psychopathological syndromes with a predominance of anxious affect comprised predominantly the second group of patients with “obsessive-phobic disorders.” Analysis of the structure of these disorders showed that their close connections can be traced with almost all components of a seizure, starting with precursors, aura, the attack itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of a paroxysm, preceding or accompanying an attack, was manifested by a sudden fear, often of uncertain content, which patients described as an “impending threat”, increasing anxiety, giving rise to a desire to urgently do something or seek help from others. Individual patients often indicated fear of death from an attack, fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, and less frequently, social phobic experiences were noted (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. There was a close connection between obsessive-phobic disorders and the vegetative component, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, and thoughts were observed.

The third type of borderline forms of mental disorders in the epilepsy clinic were affective disorders, which we designated as “other affective disorders.”

Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphoria, etc.

Among this group of borderline disorders, occurring both in the form of paroxysms and prolonged states, epileptic dysphoria was more often observed. Dysphoria, occurring in the form of short episodes, more often took place in the structure of the aura, preceding an epileptic attack or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, astheno-hypochondriacal manifestations, irritability, and anger affect prevailed in their structure. Protest reactions often formed. Aggressive actions were observed in a number of patients.

Within the framework of the so-called precursors of attacks, various functional disorders are well known, mainly of a vegetative nature (nausea, yawning, chills, drooling, fatigue, loss of appetite), against the background of which anxiety, decreased mood or its fluctuations with a predominance of irritable-sullen affect occur. A number of observations during this period noted emotional lability with explosiveness and a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can be self-limiting.

An aura with affective feelings is a common component of subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension and a feeling of “lightheadedness.” Less common are pleasant sensations (increased vitality, a feeling of particular lightness and elation), which are then replaced by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either an affect of fear and anxiety may occur, or a neutral (less often excited-elated) mood may be noted.

In the structure of the paroxysm itself, affective syndromes most often occur within the framework of the so-called temporal lobe epilepsy.

When the focus is localized in the right temporal lobe, depressive disorders are more common and have a more defined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with various plots of phobias and episodes of agitation. This clinic fits completely into the distinguished “right hemisphere affective disorder” in the taxonomy of organic syndromes ICD-10.

Paroxysmal affective disorders (within an attack) include attacks of fear, unaccountable anxiety, and sometimes with a feeling of melancholy that suddenly appear and last for several seconds (less often than minutes). There may be impulsive short-term states of increased sexual (food) desire, a feeling of increased strength, and joyful anticipation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. It is necessary to emphasize the predominantly violent nature of these experiences, although individual cases of their arbitrary correction using conditioned reflex techniques indicate a more complex pathogenesis.

The second place in the frequency of affective disorders is occupied by clinical forms with dominant vegetative paroxysms within the framework of diencephalic epilepsy. Analogues of the common designation of paroxysmal (crisis) disorders as “vegetative attacks” are concepts widely used in neurological and psychiatric practice such as “diencephalic” attack, “panic attacks” and other conditions with large vegetative accompaniment.

In epileptological practice, vegetative crises occur mainly in combination with other types (convulsive or non-convulsive) paroxysms, causing polymorphism in the clinical picture of the disease.

Regarding the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we include a variety of psychologically understandable reactions to the disease that occur with epilepsy. At the same time, side effects as a response to therapy, as well as a number of professional restrictions and other social consequences of the disease, include both transient and prolonged conditions. They more often manifest themselves in the form of phobic, obsessive-phobic and other symptoms, in the formation of which a large role belongs to the individual personality characteristics of the patient and additional psychogenies. At the same time, the clinic of protracted forms in a broad sense of situational (reactive) symptoms is largely determined by the nature of cerebral (deficient) changes, which gives them a number of features associated with organic soil. The clinical picture of emerging secondary reactive disorders is also reflected in the degree of personal (epithymic) changes.

As part of reactive inclusions, patients with epilepsy often have concerns:

development of a seizure on the street, at work

be injured or die during a seizure

go crazy

transmission of disease by inheritance

side effects of anticonvulsants

forced withdrawal of drugs or untimely completion of treatment without guarantees for relapse of attacks.

The reaction to a seizure at work is usually much more severe than when it occurs at home. Due to the fear that a seizure will occur, some patients stop studying, working, and do not go out.

This distinction between affective disorders is of fundamental importance in determining further therapy.

Principles of therapy

The main direction of therapeutic tactics in relation to individual affective components of the attack itself and post-ictal emotional disorders closely associated with it is the adequate use of anticonvulsants with a thymoleptic effect (cardimizepine, valproate, lamotrigine).

While not anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic regimen has a positive effect on both the paroxysms themselves and secondary affective disorders. However, it is advisable to limit the time of their use to three years due to the risk of addiction.

Recently, the anti-anxiety and sedative effect of clonazepam, which is highly effective in absence seizures, has been widely used.

For various forms of affective disorders with depressive radicals, antidepressants are most effective. At the same time, in outpatient settings, drugs with minimal side effects are preferred, such as tianeptil, miaxerin, fluoxetine.

If the obsessive-compulsive component predominates in the structure of depression, the prescription of paroxetine is justified.

It should be noted that a number of mental disorders in patients with epilepsy may be caused not so much by the disease itself as by long-term therapy with phenobarbital drugs. In particular, this can explain the slowness, rigidity, and elements of mental and motor retardation that appear in some patients. With the advent of highly effective anticonvulsants in recent years, it has become possible to avoid side effects of therapy and classify epilepsy as a curable disease.

Psychotic disorders are a group of serious mental illnesses. They lead to impaired clarity of thinking, the ability to make correct judgments, react emotionally, communicate with people and adequately perceive reality. People with severe symptoms of the disease are often unable to cope with everyday tasks. Interestingly, such deviations are most often observed among residents of developed countries.

However, even severe types of diseases are amenable to drug treatment to one degree or another.

Definition

Psychotic-level disorders cover a range of illnesses and associated symptoms. Essentially, such disorders are some form of altered or distorted consciousness that persists for a significant period of time and interferes with the normal functioning of a person as a full member of society.

Psychotic episodes may occur as isolated events, but most often they are a sign of significant mental health problems.

Risk factors for the occurrence of psychotic disorders include heredity (especially for schizophrenia), frequent drug use (mainly hallucinogenic drugs). The onset of a psychotic episode can also be triggered by stressful situations.

Kinds

Psychotic disorders have not yet been fully considered; some points differ depending on the approach to their study, so certain disagreements may arise in classifications. This is especially true due to conflicting data on the nature of their occurrence. In addition, it is not always possible to clearly determine the cause of a particular symptom.

Nevertheless, the following main, most common types of psychotic disorders can be distinguished: schizophrenia, psychosis, bipolar disorder, polymorphic psychotic disorder.

Schizophrenia

The disorder is diagnosed when symptoms such as delusions or hallucinations persist for at least 6 months (with at least 2 symptoms occurring continuously for a month or more), with corresponding changes in behavior. Most often, the result is difficulty performing everyday tasks (for example, at work or while studying).

Diagnosis of schizophrenia is often complicated by the fact that similar symptoms can also occur with other disorders, and patients can often lie about the degree of their manifestation. For example, a person may not want to admit that they hear voices due to paranoid delusions or fear of stigmatization, and so on.

Also distinguished:

Schizophreniform disorder. It includes but lasts a shorter period of time: from 1 to 6 months.
Schizoaffective disorder. It is characterized by symptoms of both schizophrenia and diseases such as bipolar disorder.

Psychosis

Characterized by some distorted sense of reality.

A psychotic episode may include so-called positive symptoms: visual and auditory hallucinations, delusions, paranoid reasoning, and disoriented thinking. Negative symptoms include difficulties in constructing indirect speech, commenting and maintaining a coherent dialogue.

Bipolar disorder

Characterized by sudden mood swings. The condition of people with this disease usually changes sharply from maximum excitement (mania and hypomania) to minimum (depression).

Any episode of bipolar disorder may be characterized as an “acute psychotic disorder,” but not vice versa.

Some psychotic symptoms may only subside during the onset of mania or depression. For example, during a manic episode, a person may experience grandiose feelings and believe that they have incredible abilities (for example, the ability to always win any lottery).

Polymorphic psychotic disorder

It can often be mistaken for a manifestation of psychosis. Since it develops like psychosis, with all the accompanying symptoms, but it is also not schizophrenia in its original definition. Refers to the type of acute and transient psychotic disorders. Symptoms appear unexpectedly and constantly change (for example, a person sees new, completely different hallucinations each time), the general clinical picture of the disease usually develops quite quickly. This episode usually lasts from 3 to 4 months.

There are polymorphic psychotic disorder with and without symptoms of schizophrenia. In the first case, the disease is characterized by the presence of signs of schizophrenia, such as prolonged persistent hallucinations and a corresponding change in behavior. In the second case, they are unstable, the visions often have an unclear direction, and the person’s mood constantly and unpredictably changes.

Symptoms

And with schizophrenia, and with psychosis and all others similar types diseases, a person always has the following symptoms characterizing a psychotic disorder. They are often called “positive”, but not in the sense that they are good and useful to others. In medicine, a similar name is used in the context of the expected manifestations of a disease or a normal type of behavior in its extreme form. Positive symptoms include hallucinations, delusions, strange body movements or lack of movement (catatonic stupor), peculiar speech, and strange or primitive behavior.

Hallucinations

They include sensations that do not have a corresponding objective reality. Hallucinations can appear in various forms that parallel the human senses.

Visual hallucinations include deception and seeing objects that don't exist.
The most common type of hearing is voices in the head. Sometimes these two types of hallucinations can be mixed, that is, a person not only hears voices, but also sees their owners.
Olfactory. A person perceives non-existent odors.
Somatic. The name comes from the Greek “soma” - body. Accordingly, these hallucinations are physical, for example, the feeling of the presence of something on or under the skin.

Mania

This symptom most often characterizes an acute psychotic disorder with symptoms of schizophrenia.

Manias are strong irrational and unrealistic beliefs of a person that are difficult to change, even in the presence of indisputable evidence. Most people not associated with medicine believe that mania is only paranoia, persecution mania, excessive suspicion, when a person believes that everything around him is a conspiracy. However, this category also includes unfounded beliefs, manic love fantasies and jealousy bordering on aggression.

Megalomania is a common irrational belief that results in the importance of a person being exaggerated in various ways. For example, the patient may consider himself a president or a king. Often delusions of grandeur take on religious overtones. A person may consider himself a messiah or, for example, sincerely assure others that he is the reincarnation of the Virgin Mary.

Misconceptions related to the characteristics and functioning of the body can also often arise. There have been cases where people refused to eat due to the belief that all the muscles in the throat were completely paralyzed and all they could swallow was water. However, there were no real reasons for this.

Other symptoms

Other signs tend to characterize short-term psychotic disorders. These include strange body movements, constant grimaces and facial expressions uncharacteristic for the person and situation or, as the opposite, catatonic stupor - lack of movement.

There are distortions of speech: incorrect sequence of words in a sentence, answers that make no sense or do not relate to the context of the conversation, mimicking the opponent.

Aspects of childishness are also often present: singing and jumping in inappropriate circumstances, moodiness, unconventional uses of ordinary objects, for example, creating a tin foil hat.

Of course, a person with psychotic disorders will not experience all symptoms at the same time. The basis for diagnosis is the presence of one or more symptoms over a long period of time.

Causes

The following are the main causes of psychotic disorders:

Reaction to stress. From time to time, under severe prolonged stress, temporary psychotic reactions may occur. At the same time, the cause of stress can be both situations that many people face throughout life, for example, the death of a spouse or divorce, as well as more severe ones - a natural disaster, being in a place of war or in captivity. Usually psychotic episode ends as stress decreases, but sometimes this condition can drag on or become chronic.
Postpartum psychosis. Some women have significant hormonal change as a result of childbirth can cause Unfortunately, such conditions are often misdiagnosed and mistreated, resulting in cases where the new mother kills her child or commits suicide.
Protective reaction of the body. It is believed that people with personality disorders are more susceptible to stress, they are less able to cope adult life. In the end, when life circumstances become more severe, a psychotic episode may occur.
Psychotic disorders based on cultural characteristics. Culture is an important factor in determining mental health. In many cultures, what is usually considered a deviation from the generally accepted norm of mental health is part of traditions, beliefs, references to historical events. For example, in some regions of Japan there is a very strong, even manic, belief that the genitals can shrink and be pulled into the body, causing death.

If a behavior is acceptable in a given society or religion and occurs under appropriate conditions, then it cannot be diagnosed as an acute psychotic disorder. Treatment, accordingly, is not required under such conditions.

Diagnostics

In order to diagnose a psychotic disorder, a general practitioner needs to talk with the patient and also check the general state of health to rule out other causes of such symptoms. Most often, blood and brain tests are performed (for example, using MRI) to rule out mechanical damage to the brain and drug addiction.

If no physiological reasons for such behavior are found, the patient is referred to a psychiatrist for further diagnosis and determination of whether the person truly has a psychotic disorder.

Treatment

Most often, a combination of medication and psychotherapy is used to treat psychotic disorders.

As medicine specialists most often prescribe neuroleptics or atypical antipsychotics, which are effective in relieving such alarming symptoms as delusions, hallucinations and distorted perception of reality. These include: "Aripiprazole", "Azenapine", "Brexpiprazole", "Clozapine" and so on.

Some drugs come in the form of tablets that need to be taken daily, others come in the form of injections that only need to be given once or twice a month.

Psychotherapy includes different kinds counseling. Depending on the personal characteristics individual, group or family psychotherapy may be prescribed depending on the patient and the course of the psychotic disorder.

For the most part, people with psychotic disorders receive outpatient treatment, meaning they are not in constant care. medical institution. But sometimes, if there are severe symptoms, there is a threat of harm to oneself and loved ones, or if the patient is unable to take care of himself, hospitalization is performed.

Each patient being treated for a psychotic disorder may respond differently to therapy. For some, progress is noticeable from the first day, for others it will take months of treatment. Sometimes, if you have several severe episodes, you may need to take medication on an ongoing basis. Usually in such cases a minimum dose is prescribed to avoid side effects as much as possible.

Psychotic disorders cannot be prevented. But the sooner you seek help, the easier it will be to undergo treatment.

People with high risk occurrence of such disorders, for example, those who have schizophrenics among close relatives should avoid drinking alcohol and any drugs.