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

Pathogenesis of reactive states

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

In the forensic psychiatric clinic, the term "reactive state" is 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 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 features and premorbid state, on the other, are of decisive importance for the onset of a reactive state or psychosis. Mental trauma is divided into sharp and chronic, sharp, in turn - on shock, depressing and disturbing. Reactive states more easily arise in psychopathic individuals, as well as in persons weakened by infections, severe somatic diseases, intoxication, craniocerebral trauma, vascular diseases, prolonged insomnia, severe vitamin deficiencies, etc. The age factor can also play a predisposing role. The most vulnerable to external influences are puberty and menopause. Age is also important in the design of the clinical picture of psychosis. So, 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 emergence and clinical realization of a reactive state. The mechanism of the emergence 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 strong psychotraumatic effect is exerted by the "error" of the irritable and inhibitory processes (hidden grief, suppressed anger, etc.).

Clinical presentation of mental disorders associated with stress

Mental disorders of this group are diagnosed when the so-called Jaspers triad is identified, which includes the following conditions:

mental disorders occur after mental trauma, i.e. there is a direct link between the development of a mental disorder and psychogenia;
the course of mental disorders has a regreduated nature, when, as the distance from mental trauma is removed, mental disorders gradually weaken and eventually completely stop;
there is a psychologically understandable connection between the content of traumatic experiences and the plot of painful disorders.

Stress-related mental disorders are categorized as:

1) on 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 in connection with a threat to life, are more common in mass disasters (fire, earthquake, flood, mountain landslide, etc.). Clinically, these reactions are manifested in two forms: hyperkinetic and hypokinetic.

Hyperkinetic form(reactive, psychogenic agitation) - a sudden onset of chaotic, senseless 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 a psychogenic twilight disorder of consciousness with a violation of orientation in the environment and subsequent amnesia. With the twilight clouding of consciousness, pronounced fear is observed, facial expressions and gestures express horror, despair, fear, confusion.

Acute psychoses of fear are also referred to the hyperkinetic form of shock reactions. In these cases, in the clinical picture of psychomotor agitation, the leading symptom is panic, unrestrained fear. Sometimes psychomotor agitation is replaced by psychomotor retardation, the patients seem to freeze in a pose that expresses horror and despair. This state of fear usually disappears after a few days, but in the future, any reminder of a 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, cannot utter a word (mutism). Reactive stupor usually lasts from a few minutes to several hours. In severe cases, this condition is prolonged. Severe atony or muscle tension sets in. Patients lie in an embryonic position or stretched out on their backs, do not eat, their eyes are wide open, facial expressions reflect either fear or hopeless despair. At the mention of a traumatic situation, patients turn pale or redden, covered with sweat, palpitations are noted (vegetative symptoms of reactive stupor). Darkened consciousness with a reactive stupor causes subsequent amnesia.

Psychomotor retardation may not reach the degree of stupor. In these cases, patients are available to contact, although they respond briefly, with a delay, drawing out words. The motor skills are constrained, the movements are slowed down. Consciousness is narrowed or the patient is stunned. In rare cases, in response to sudden and strong psycho-traumatic influences, the so-called emotional paralysis occurs: prolonged apathy with an indifferent attitude to the threatening situation and indifferent registration of what is happening around. In some cases, on the basis of the transferred acute reaction of fear, a lingering neurosis of fear may develop in the future.

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

Depressive psychogenic reactions (reactive depression)

The death of a loved one, severe life failures can also cause a natural psychological reaction of sadness in healthy people. The pathological reaction differs from normal in excessive strength and duration. In this state, patients are depressed, dreary, tearful, walk hunched over, sit in a bent position with their heads lowered to their chest, or lie with their legs tucked in. Ideas of self-blame are not always present, but usually experiences are concentrated around the circumstances associated with mental trauma. Thoughts about an unpleasant incident are persistent, detailed, often become overvalued, sometimes reach the degree of delirium. Psychomotor retardation sometimes reaches a depressive stupor; patients all the time lie or sit 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 isolated hysterical disorders. In these cases, depression is manifested by a 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 liven up, scold their offenders, at the mention of a traumatic situation, they are excited up to attacks of hysterical despair. Separate puerile, pseudodement manifestations are often noted.

Sometimes, against the background of a depressed mood, there are phenomena of derealization, depersonalization, senestopathic-pochondriacal disorders. Against the background of growing depression with anxiety and fear, individual ideas of attitudes, persecution, accusations, etc. may appear. The content of delirium is limited to a misinterpretation of the behavior of others and individual random external impressions. The affect of longing, when it is joined 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 a depressive raptus.

Reactive depression differs from endogenous depression in that their occurrence coincides with mental trauma; traumatic experiences are reflected in the clinical picture of depression, after resolving the traumatic situation or after some time, reactive depression disappears. The course of reactive depression depends both on the content of the mental trauma and on the characteristics of the patient's personality 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 the elderly with cerebral atherosclerosis, can be delayed. Reactive depressions associated with a difficult, unresolved psycho-traumatic situation can also be long-lasting.

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

Reactive paranoid delusions - the emergence of paranoid overvalued delusion that does not go beyond the traumatic situation, "psychologically understandable" and accompanied by a lively emotional reaction. These ideas dominate in consciousness, but at the first stages, the patients still lend themselves to some dissuasion. In all the rest of the patient's behavior, which is not associated with an overvalued idea, no noticeable deviations are found. Reactive paranoid delusion, like all reactive states, lasts until the traumatic situation disappears, and reflects it entirely, it is not characterized by progression, and negative symptoms do not arise. All these features distinguish reactive paranoia from schizophrenic ones. Paranoid reactive disorders have many separate variants, due to the characteristics of psychogenic effects.

Acute paranoid reaction - paranoid delusion, characteristic of psychopathic (paranoid) individuals. Relatively minor difficulties in everyday life can make them suspicious, anxious, ideas of attitude and persecution. These reactions are usually short-lived. Their development is facilitated by a temporary weakening of the nervous system (overwork, lack of sleep, etc.).

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

Delirium persecution of the deaf occurs in people with hearing impairment due to difficult speech contact with others. Similar states are observed when communication is difficult due to ignorance of the language (delirium of persecution in a foreign language environment).

Reactive paranoids are distinguished by a large syndromological variety. In some cases, the main symptoms in the clinical picture of psychogenic paranoid are the ideas of persecution, attitude, and sometimes physical impact against the background of pronounced fear and confusion. The content of delusional ideas usually reflects a traumatic situation; everything that happens is subject to delusional interpretation, acquires special significance. In other cases, against the background of a psychogenically conditioned change in consciousness, usually narrowed, in addition to delusional ideas of persecution, attitude and physical influence, the patient experiences abundant both auditory and visual hallucinations and pseudohallucinations; the affect of fear prevails in the status.

Diagnosis of reactive paranoids is usually straightforward. The main support criteria: situational conditioning, specific, figurative, sensual delirium, the relationship of its content with a traumatic situation and the reversibility of this state when the external environment changes.

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

Paranoid of the external environment (situational) - acute delusional psychosis; arises suddenly, sometimes without any precursors, in an extremely unusual (new) situation for the patient. This is a sharp figurative delusion of persecution and an unusually sharp affect of fear. The patient, trying to save his life, is thrown out of the train on the move, sometimes defending himself with weapons in his hands from imaginary pursuers. Suicide attempts are not uncommon in order to get rid of the expected torment. Patients can 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 double symptom, can be observed. The occurrence of such acute paranoids is facilitated by prolonged overwork, insomnia, somatic weakening, and alcoholism. Such paranoids are usually short-lived, and when the patient is removed from this situation, delusional ideas disappear, he calms down, criticism of psychosis appears.

In a forensic psychiatric clinic, psychogenic paranoids and hallucinosis are now rare.

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

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

Hysterical twilight clouding of consciousness, or Ganser's syndrome, manifests itself as an acute twilight disorder of consciousness, phenomena of "mimorechi" (wrong answers to simple questions), hysterical sensory disorders and sometimes hysterical hallucinations. The painful condition is acute and lasts for several days. After recovery, the memory of the entire period of psychosis and the psychopathological experiences observed in its structure is noted. Currently, this syndrome practically does not occur in the forensic psychiatric clinic.

Pseudodementia syndrome (mock dementia) observed more often. This is a hysterical reaction, manifested in wrong answers ("mimic") and wrong actions ("mimo actions"), demonstrating a sudden onset of deep "dementia", which later disappears without a trace. When patients are acting, they cannot perform the simplest habitual actions, they cannot dress on their own, and have difficulty eating. When the symptoms of "mimicry" occur, the patient gives incorrect answers to simple questions, cannot name the current year, month, cannot say how many fingers he has on his hand, etc. I don't remember ") or are directly opposite to the correct answer (a window is called a door, a floor, a ceiling, etc.), or are similar in meaning, or are an answer to a previous question. Wrong answers are always related to the correct ones, lie in the plane of the question posed and affect the circle of correct ideas. In the content of the answer, one can grasp a connection with a real traumatizing 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 that he is in the store where he was arrested, etc.

The syndrome of pseudodementia 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 personalities of emotionally unstable and hysterical types. Unlike Ganser's syndrome, pseudodementia occurs against the background of a hysterically narrowed, rather than twilight, disorder of consciousness. When therapy is started on time, and sometimes without it, pseudodementia undergoes a reverse development in 2-3 weeks and all mental functions are restored.

Currently, pseudodement syndrome as an independent form of reactive psychosis is almost never found, 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 hysterical 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 peculiarities of the child's psyche, they speak in a thin voice with childish capricious intonations, they construct phrases in a childish way, they turn to everyone as "you", they call everyone "uncles", "aunts". Motor skills acquire a childish character, patients are mobile, run in small steps, reach for shiny objects. Emotional reactions are also shaped like a child: patients are capricious, offended, pout, cry when they are not given what they ask for. However, in children's forms of behavior of pueril patients, the participation of the entire life experience of an adult can be noted, which creates the impression of some unevenness in the decay of functions, for example, children's lisping speech and automated motor skills during eating, smoking, which reflects the experience of an adult. Therefore, the behavior of patients with pueril syndrome differs significantly from the true childhood behavior. Manifestations of childishness in speech and facial expressions, external childishness contrast sharply 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 holistic pueril syndrome.

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

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 striking forms as it was 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 mainly 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 delirium and fantasies: when approaching delusional ideas in content, delusional fantasies differ from them in liveliness, mobility, lack of cohesion with the personality, the absence of the patient's persistent conviction of 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 prevail, which in a fantastically exaggerated form reflect the replacement of a difficult, unbearable situation with concrete in content fictions, a desire for rehabilitation. Patients talk about their space flights, about the innumerable riches they possess, great discoveries of national importance. Some fantastic delusional constructions do not add up to a system, they are variegated and often contradictory. The content of delusional fantasies bears a pronounced imprint of the influence of the traumatic situation, the outlook of patients, the degree of their intellectual development and life experience, and contradicts the main alarming mood background. It changes from external moments, doctor's questions.

In other cases, delusional fantastic ideas are more complex and persistent, showing a tendency to systematization. Just as with unstable changeable fantastic constructions, all the anxieties, worries 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 the "greatest significance of the discoveries they made" their guilt is insignificant. In the period of the reverse development of reactive psychosis, situationally conditioned depression comes to the fore, fantastic statements fade, reviving only for a short time when the patients are agitated.

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

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

Perhaps the complication of the clinical picture of depression, a combination with other hysterical manifestations (pseudodementia, puerilism).

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

Reactive states are called neuroses, the occurrence of which is associated with a long-term psychogenically traumatizing 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 psychogenias of various subjective significance. Therefore, the emergence of neurosis depends on the structure of the personality and the nature of the situation, which, due to individual personality traits, turns out to be selectively traumatizing and insoluble.

In ICD-10, neuroses are grouped under the rubric of neurotic stress-related disorders. At the same time, many independent forms stand out. The most widespread and traditional in 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 disorder.

Neurasthenia is the most common form of neurosis, develops more often in persons with an asthenic constitution in conditions of a prolonged 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 the phenomena of mental and physical exhaustion. Increased fatigue is accompanied by a constant feeling of fatigue. The increased excitability that appears at first, incontinence is subsequently combined with irritable weakness, intolerance to ordinary stimuli - loud sounds, noise, bright light. In the future, the components of mental and physical asthenia proper 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 depletion of active attention and absent-mindedness of attention, the assimilation of new material, the ability to memorize worsens, a decrease in creative activity and productivity is noted. A low mood can acquire a depressive coloration with the formation in some cases of 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 and depends, on the one hand, on the cessation or continued action of the traumatic situation (especially if this situation causes constant anxiety, expectation of trouble), on the other, on the personality traits and general state of the body. Under the changed conditions, the symptoms of neurasthenia can completely disappear.

Hysterical neurosis usually develops in individuals with hysterical 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 disturbances and sensory disturbances;
3) vegetative disorders;
4) mental disorders.

Hysterical movement disorders accompanied by tears, groans, screams. Hysterical paralysis and contractures are noted in the muscles of the limbs, sometimes the muscles of the neck, trunk. They do not correspond to the anatomical muscular innervation, but reflect the patient's ideas about the anatomical innervation of the extremities. With long-term paralysis, secondary atrophy of the affected muscle groups can develop. In the past, the phenomena of astasia-abasia were often encountered, when, with the complete safety of the musculoskeletal system, the patients refused to stand and walk. Lying in bed, the patients were able to perform certain arbitrary movements of their limbs, they could change the position of the body, but when they tried to put them on their feet, they fell and could not lean on their feet. In recent decades, these disorders have given way to less pronounced movement disorders in the form of weakness of individual limbs. More often noted are hysterical paralysis of the vocal cords, hysterical aphonia (loss of sonority of the voice), hysterical spasm of one or both eyelids. With hysterical mutism (dumbness), the ability to write is retained and voluntary language movements are not disturbed. Hysterical hyperkinesis is often observed, which manifests itself in tremors of the limbs of various amplitudes. The trembling increases with excitement and disappears in a calm environment, as well as in sleep. Sometimes tics are observed in the form of convulsive contractions of certain muscle groups. Convulsive phenomena from the side of speech are manifested in hysterical stuttering.

Sensory hysterical disturbances most often they manifest themselves in a decrease or loss of skin sensitivity, which also does not correspond to the zones of innervation, but reflects ideas about the anatomical structure of the limbs and parts of the body (like gloves, stockings). Pain can be observed in different parts of the body and in different organs. Quite often there are violations of the activity of individual sense organs: hysterical blindness (amaurosis), deafness. Quite often, hysterical deafness is combined with hysterical mutism, while a picture of hysterical deaf-dumbness arises (deaf-mutism).

Vegetative disorders diverse. Often there is a spasm of smooth muscles, which is associated with such typical hysterical disorders as a feeling of a lump in the throat, a feeling of obstruction of the esophagus, a feeling of lack of air. Quite often there is hysterical vomiting, which is not associated with any disease of the gastrointestinal tract and is solely due to spasm of the pylorus. There may be functional disorders of internal organs (for example, palpitations, vomiting, shortness of breath, diarrhea, etc.), which usually occur in a subjectively traumatic situation.

Mental disorders are also expressive and varied. Emotional disturbances predominate: fears, mood swings, states of depression, depression. At the same time, very superficial emotions are often hidden behind the external expressiveness. Hysterical disorders, when they occur, usually have the character of "conditional desirability". In the future, they can be fixed and re-reproduced in subjectively difficult situations according to the hysterical mechanisms of "flight into illness". In some cases, the reaction to a traumatic situation is manifested in increased fantasy. 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 often than hysterical neurosis and neurasthenia. Obsessions are divided into two main firms:

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

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

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

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

Phobias can be accompanied by obsessive movements and actions that occur simultaneously with phobias, they are given a protective character and they quickly take the form of rituals. Ritual actions are aimed at preventing an imaginary misfortune, have a protective, protective character. Despite the critical attitude towards them, they are produced by the sick in spite of reason to overcome obsessive fear. In mild cases, due to the complete safety of criticism and the consciousness of the painful nature of these phenomena, those suffering from neuroses hide their obsessions and do not exclude themselves from life.

In cases of a severe form of neurosis, a critical attitude to obsessions disappears for some time, it is revealed as a concomitant pronounced asthenic syndrome, depressed mood. In a forensic psychiatric examination, it should be borne in mind that only in some, very rare cases of severe neurotic conditions, obsessional phenomena can lead to antisocial actions. In the overwhelming majority of cases, patients with obsessive-compulsive disorder, due to a critical attitude towards them and the fight against them, do not commit criminal acts associated with 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 a few cases is there a prognostically unfavorable course of protracted reactive psychoses, which is characterized by the irreversibility of the profound personal changes that have occurred, 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 the protracted reactive psychoses, "erased forms" prevail now, the frequency and brightness of hysterical manifestations has sharply decreased. There are practically no hysterical symptoms such as hysterical paralysis, paresis, astasia-abasia phenomena, hysterical mutism, which in the past were leading in the clinical picture of protracted reactive psychoses. The main place is occupied by clinically diverse forms of depression, as well as erased depressive states that do not reach the psychotic level and nevertheless have a protracted course. Patients note in themselves a depressed mood, elements of anxiety, they are gloomy, sad, complain of emotional stress, a premonition of unhappiness. Usually, these complaints are combined with unwarranted fears about their health. Patients are fixed on their unpleasant somatic sensations, constantly think about the troubles awaiting them, and seek sympathy from others. This state is accompanied by more or less pronounced disorganization of mental activity. Patients usually associate their experiences with a real traumatic situation, they are concerned about the outcome of the case.

With a protracted course, depression fluctuates in its intensity and its clinical manifestations and their severity significantly depend on external circumstances. Perhaps a gradual deepening of depression with an increase in psychomotor inhibition, the appearance of elements of melancholy, the inclusion of delusional ideas. Despite the deepening depression, the condition of patients is characterized by external inexpressiveness, weariness, depression of all mental functions. Patients usually do not show initiative in conversation, do not complain about anything. Most of the time they spend 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 unwillingness 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 exit is noted, in which dreary depression is replaced by situational depression. After the reverse development of painful symptoms, asthenia remains for a long time.

Hysterical depression with its protracted course 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 of emotional manifestations inherent in hysterical depression, the direct dependence of the main mood on the characteristics of the situation, a constant readiness to intensify affective manifestations with the aggravation of the circumstances associated with this situation or only during conversations on this topic. Therefore, the depth of the depression has an undulating character. Often in the clinical picture of depression, there are individual unstable pseudodement-puerilic inclusions or delusional fantasies, reflecting the hysterical tendency to "escape into illness", avoidance of an unbearable real situation, and hysterical repression. Hysterical depression can be prolonged - up to two years or more. However, in the course of treatment or with a favorable resolution of the situation, sometimes an unexpectedly acute, but more often gradual exit from the painful state occurs without any subsequent changes in the psyche.

In persons who have undergone a protracted hysterical depression, with the resumption of a traumatizing situation, relapses and repeated reactive psychoses are possible, the clinical picture of which reproduces the symptoms of the initial reactive psychosis in the manner of worked out clichés.

The described variants of the course of protracted reactive psychoses, especially in 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 questions.

NS Pilepsy is one of the 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 are much more common in the unfavorable course of epilepsy.

In the past few years, as statistical studies show, in the structure of mental illness 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 pathomorphosis 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 for 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, impairments to the emotional sphere are an obstacle to the full recovery of the patient's health (Maksutova E.L., Frecher V., 1998).

In the clinical qualification of 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 proper. In this regard, we can conditionally single out two mechanisms of syndromic formation of a group of affective disorders - primary, where the indicated symptoms act as components of paroxysmal disorders proper, and secondary - without a causal relationship with an attack, but based on various manifestations of reactions to the disease, as well as to additional psycho-traumatic influences.

So, according to the research of patients in a specialized hospital of the Moscow Research Institute of Psychiatry, it was found that phenomenologically non-psychotic mental disorders are represented by three types of conditions:

1) depressive disorder in the form of depression and subdepression;
2) obsessive - phobic disorders;
3) other affective disorders.

Depression spectrum disorders include the following:

1. Dreary depression and subdepression were observed in 47.8% of patients. The prevailing in the clinic here was an anxious-melancholy affect with a persistent decrease in mood, often accompanied by irritability. Patients noted mental discomfort, heaviness in the chest. In some patients, there was a connection between these sensations and physical malaise (headache, discomfort behind the breastbone) and were accompanied by motor restlessness, less often 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, with difficulty performing simple self-care functions, complaints of rapid fatigue and irritability were typical.

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

The variant of hypochondriac depression was more typical for the interictal period, especially in the 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 often of an interictal state), was distinguished by an amorphous plot. Patients were more likely to be unable to determine the motives for anxiety or the presence of any specific fears and reported that they experience vague fear or anxiety, the cause of which they do not understand. 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 seizure itself, or a post-seizure state).

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

Psychopathological syndromes with a predominance of anxious affect made up mainly the second group of patients with "obsessive-phobic disorders". An analysis of the structure of these disorders showed that they are closely related to almost all components of the seizure, starting with the precursors, the aura, the seizure itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of paroxysm, preceding or accompanying an attack, manifested itself as a sudden fear, often of an indefinite content, which the patients described as an “impending threat” that increased 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, less often there were sociophobic experiences (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. A close connection of obsessive-phobic disorders with the vegetative component was noted, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, thoughts were observed.

In contrast to paroxysmal anxiety, anxious affect in remission 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 form obsessive-phobic disorders with obsessive fears, fears, actions, actions, etc. In some cases, there are protective mechanisms of behavior with peculiar 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 formations.

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, dysphorias, etc.

Among this group of borderline disorders, acting both in the form of paroxysms and prolonged states, were more often observed epileptic dysphoria ... Dysphoria, proceeding in the form of short episodes, more often took place in the structure of the aura, preceding an epileptic seizure or a series of seizures, but they were most widely presented in the interictal period. In terms of clinical features and severity, asthenic-hypochondriac manifestations, irritability, and the affect of anger prevailed in their structure. Protest reactions were often formed. In a number of patients, aggressive actions were observed.

The syndrome of emotional lability was distinguished 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 affect incontinence. Usually, they appeared outside the framework of a formalized depressive or anxiety disorder, representing an independent phenomenon.

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

Within the framework of the so-called harbingers of seizures, various functional disorders are well known, mainly of a vegetative nature (nausea, yawning, chills, salivation, fatigue, impaired appetite), against which there is anxiety, decreased mood or mood swings with a predominance of irritable-gloomy affect. A number of observations in this period noted emotional lability with explosiveness, a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can self-stop.

Aura with affective experiences - a frequent component of the subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension, a feeling of "faintness". Less often, there are pleasant sensations (an increase in vitality, a feeling of special lightness and high spirits), followed by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either the affect of fear and anxiety can occur, or a neutral (less often excited-elated) mood is noted.

In the structure of the paroxysm itself, the most frequent syndromes of the affective series are found in the framework of the so-called temporal lobe epilepsy.

As you know, motivational and emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly mediobasal formations included in 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.

With the localization of the focus in the right temporal lobe, depressive disorders are more common and have a more outlined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with a different plot of phobias and episodes of arousal. The specified clinic fits completely into the allocated "right hemispheric affective disorder" in the systematics of organic syndromes ICD-10.

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

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

The group of paroxysmal affective disorders within the framework of temporal lobe epilepsy includes dysphoric conditions, the duration of which can range from several hours to several days. In some cases, dysphoria in the form of short episodes precede the development of another epileptic seizure or a series of seizures.

The second most frequent affective disorders are clinical forms with dominant autonomic paroxysms in the framework of diencephalic epilepsy ... Analogs of the widespread designation of paroxysmal (crisis) disorders as "vegetative attacks" are widely used in neurological and psychiatric practice concepts such as "diencephalic" attack, "panic attacks" and other conditions with a large vegetative accompaniment.

Classic manifestations of crisis disorders include suddenly developed: shortness of breath, feeling short of breath, discomfort from the organs of the chest cavity and abdomen with "sinking of the heart", "interruptions", "pulsation", etc. These phenomena are accompanied, as a rule, by dizziness, chills, tremors , various paresthesias. Possible increased stool frequency, urination. The most powerful manifestations are anxiety, fear of death, fear of going crazy.

Affective symptomatology in the form of individual unstable fears can be transformed both into affective paroxysm itself and into 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 are found 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 pointed out that we include a variety of psychologically understandable reactions to the disease that arise in epilepsy. At the same time, side effects as a response to therapy, as well as a number of occupational restrictions and other social consequences of the disease include both transient and prolonged conditions. They often manifest themselves in the form of phobic, obsessive-phobic and other symptoms, in the formation of which the individual and personal characteristics of the patient and additional psychogenias play a large role. 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 (deficit) changes, which gives them a number of features associated with organic soil. The clinic of emerging secondary reactive disorders also reflects the degree of personal (epithemic) changes.

Within the framework of reactive inclusions patients with epilepsy often have concerns:

developing a seizure on the street, at work
get injured or die during a seizure
go crazy
inherited disease
side effects of anticonvulsants
forced withdrawal of drugs or untimely completion of treatment without guarantees for recurrence of seizures.

The reaction to a seizure at work is usually much more severe than a seizure at home. For fear that a seizure will occur, some patients stop studying, work, and do not go outside.

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

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

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

Sometimes the fear of having a seizure is largely due to the unpleasant subjective sensations that occur during the seizure. These experiences include terrifying illusory, hallucinatory, and body schema disturbances.

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 the post-attack emotional disorders closely related to it, is the adequate use of anticonvulsants with thymoleptic effect (cardimizepine, valproate, lamotrigine).

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

Recently, anti-anxiety and sedation have been widely used. clonazepam which is highly effective for absences.

For various forms of affective disorders with a depressive radical, the most effective antidepressants ... At the same time, on an outpatient basis, agents with minimal side effects, such as tianeptyl, miaxerin, fluoxetine, are preferred.

In the case of a predominance of the obsessive-compulsive component in the structure of depression, the appointment 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 drugs of the phenobarbital series. In particular, this can explain the slowness, rigidity, elements of mental and motor inhibition, which are manifested in some patients. With the emergence of highly effective anticonvulsants in recent years, it became possible to avoid side effects of therapy and attribute epilepsy to a curable disease.

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

Unlike total defeat with W.O. an organic symptom complex is characterized by such a basic feature as mosaic damage to mental activity.

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

The phenomena of intellectual disability in the structure of the organic symptom complex are formed against the background of a memory deficit, attention in the form of distraction, exhaustion, and the “flickering” nature of productive activity. Characterized by violations of emotional-volitional (uncontrollability, irritability, "nudity", imbalance) and other components of the emerging personality.

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

The complete clinical picture of dementia in children includes a weakening of cognitive activity in creative thinking, the ability to abstract up to the impossibility of performing simple logical tasks, memory impairments and criticism of one's condition with certain personal changes, as well as in the impoverishment of feelings. In advanced cases, the psyche is "the ruins of the mental organization."

In contrast to mental retardation in dementia, the loss of previously acquired intellectual abilities does not correlate with the average value, but with premorbid, i.e. before the onset of the development 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 hallmark of which are severe disorders of interpersonal contacts and a gross deficit of communication skills, which is not observed with intellectual underdevelopment.

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

4. Cerebral attacks, in which there are transient impairments of cognitive functions. The criterion is EEG data in combination with observation of behavior and the corresponding experimental psychological techniques.

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

5. Hereditary degenerative diseases, neuroinfections: a thorough history taking, the severity of the organic background, neurological microsymptomatics, as well as a serological blood test for certain markers of infectious diseases.

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

Treatment

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

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

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

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

Children are taught 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 in such cases a complex forensic psychological and psychiatric examination, taking into account not only the depth of the existing defect, but also the possibility of predicting the consequences of his actions by the adolescent and the presence of other clinical features revealed in him. With a mild degree, W.O. few adolescents are recognized as insane. Adolescents recognized as sane are taken into account by the court in accordance with Article 22 of the Criminal Code of the Russian Federation, they need increased attention during the preliminary investigation, deserve leniency, and often during the execution of the sentence they are shown treatment.

Rehabilitation

Rehabilitation is understood as the use of all measures that, in case of mental retardation, help to adapt to the requirements of education, professional and social life. Separate components of rehabilitation for mental retardation, as a rule, are distinguished taking into account the international classification of the WHO. It distinguishes between damage (impairment), limitations of the functions of the individual (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 functional capabilities of the individual 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 necessary to name different types of special schools, integrative schools, specialized boarding schools for training a profession and obtaining vocational education, medical and labor workshops, which 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 attitudes 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 the MSE after examination and treatment in day and round-the-clock hospitals with insufficient effectiveness of the therapy performed on an outpatient basis. Disabled children are children with moderate, severe and profound forms of mental retardation.

Prevention of mental retardation

Primary prevention mental retardation:

1. a serious threat to UO is the use of drugs, alcohol, tobacco products and many drugs by a pregnant woman, as well as the effect of a strong magnetic field, high frequency currents.

2. The risk to the fetus is represented by many chemicals (detergents, insecticides, herbicides) that accidentally enter the body of the expectant mother, salts of heavy metals, iodine deficiency state 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 of the fetus and the correct management of childbirth.

6. Genetic counseling.

Prevention of complications mental retardation:

1. Prevention of the impact of additional exogenous damaging factors: trauma, infection, intoxication, etc.

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

LIST LITERATURE

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

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

3. Gofman A.G. "Psychiatry. A guide 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 // Violation of the maturation of the structures and functions of the child's body and their importance for the clinic and social adaptation. - M .: Medicine, 1996.

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

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

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

9. Kovalev V.V. Pediatric Psychiatry: A Guide for Physicians: ed. 2nd, revised and enlarged. - M .: Medicine, 1995.

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

11. Snezhnevsky A.V. "General psychopathology", Medpress-inform, 2008

12. Sukhareva G.D. "Clinical lectures on child 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 past 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 pathomorphosis 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, impairments to the emotional sphere are an obstacle to the full recovery of the patient's health (Maksutova E.L., Frecher V., 1998).

In the clinical qualification of 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 proper. In this regard, it is conditionally possible to distinguish two mechanisms of syndromic formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders proper, and secondary - without a causal relationship with an attack, but based on various manifestations of reactions to the disease, as well as to additional psycho-traumatic influences.

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

2) obsessive - phobic disorders;

3) other affective disorders.

Depression spectrum disorders include the following:

1. Dreary depression and subdepression were observed in 47.8% of patients. Anxiously melancholy affect with a persistent decrease in mood, often accompanied by irritability, was predominant in the clinic. Patients noted mental discomfort, heaviness in the chest. In some patients, there was a connection between these sensations and physical malaise (headache, discomfort behind the breastbone) and were accompanied by motor restlessness, less often 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, with difficulty performing simple self-care functions, complaints of rapid fatigue and irritability were typical.

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

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

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

Psychopathological syndromes with a predominance of anxious affect made up mainly the second group of patients with "obsessive-phobic disorders". An analysis of the structure of these disorders showed that they are closely related to almost all components of the seizure, starting with the precursors, the aura, the seizure itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of paroxysm, preceding or accompanying an attack, manifested itself as a sudden fear, often of indefinite content, which the patients described as an “impending threat” that increased 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, less often there were sociophobic experiences (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 relationship of obsessive-phobic disorders with the vegetative component, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, thoughts were observed.

The third type of borderline forms of mental disorders in the clinic of epilepsy consisted of 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, dysphorias, etc.

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

Within the framework of the so-called harbingers of seizures, various functional disorders, mainly of a vegetative nature (nausea, yawning, chills, drooling, fatigue, impaired appetite), are well known, against which anxiety, decreased mood or mood swings prevail, with a predominance of irritable and gloomy affect. A number of observations in this period noted emotional lability with explosiveness, a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can self-stop.

An aura with affective experiences is a common component of subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension, a feeling of "faintness". Less often, there are pleasant sensations (an increase in vitality, a feeling of special lightness and high spirits), followed by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either the affect of fear and anxiety can occur, or a neutral (less often excited-elated) mood is noted.

In the structure of the paroxysm itself, the most frequent syndromes of the affective series are found in the framework of the so-called temporal lobe epilepsy.

As you know, motivational and emotional disorders are one of the leading symptoms of damage to temporal structures, mainly mediobasal formations included in 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.

With the localization of the focus in the right temporal lobe, depressive disorders are more common and have a more outlined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with a different plot of phobias and episodes of arousal. The indicated clinic fits completely into the allocated "right hemispheric affective disorder" in the systematics of organic syndromes ICD-10.

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

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

In epileptological practice, vegetative crises are found 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 pointed out that we include a variety of psychologically understandable reactions to the disease arising from epilepsy. At the same time, side effects as a response to therapy, as well as a number of occupational restrictions and other social consequences of the disease include both transient and prolonged conditions. They are more often manifested in the form of phobic, obsessive-phobic and other symptoms, in the formation of which the individual-personal characteristics of the patient and additional psychogenias play an important role. 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 (deficit) changes, which gives them a number of features associated with organic soil. The clinic of emerging secondary-reactive disorders also reflects the degree of personal (epithemic) changes.

Within the framework of reactive inclusions in patients with epilepsy, fears often arise:

developing a seizure on the street, at work

get injured or die during a seizure

go crazy

inherited disease

side effects of anticonvulsants

forced withdrawal of drugs or untimely completion of treatment without guarantees for recurrence of seizures.

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

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

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 the post-seizure emotional disorders closely related to it is the adequate use of anticonvulsants with thymoleptic effect (cardimizepin, valproate, lamotrigine).

Not being anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic scheme has a positive effect both on the paroxysms themselves and on 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 absences, has been widely used.

For various forms of affective disorders with a depressive radical, antidepressants are most effective. At the same time, on an outpatient basis, agents with minimal side effects, such as tianeptyl, miaxerin, fluoxetine, are preferred.

In the case of a predominance of the obsessive-compulsive component in the structure of depression, the appointment of paroxetine is justified.

Psychotic disorders are a group of serious mental illnesses. They lead to a violation of the 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 daily tasks. It is interesting that most often such deviations are observed among residents of developed countries.

However, even severe types of diseases are more or less amenable to drug treatment.

Definition

Psychotic-level disorders encompass a range of diseases and related symptoms. In fact, such disorders represent some forms of altered or distorted consciousness that persist for a significant period of time and interfere with the normal functioning of a person as a full-fledged member of society.

Psychotic episodes may appear as an isolated incident, but most often they are a sign of a significant deviation in mental health.

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

Views

Psychotic disorders have not yet been fully addressed, some points differ depending on the approach to their study, so there may be some disagreement 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 symptomatology.

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

Schizophrenia

The disease is diagnosed in cases of manifestation of symptoms such as delusions or hallucinations, for at least 6 months (with at least 2 symptoms must manifest continuously for a month or more), with corresponding changes in behavior. Most often, this results in difficulties in performing daily tasks (for example, at work or during training).

Diagnosis of schizophrenia is often complicated by the fact that similar symptoms can occur with other disorders, and often patients can be cunning about the degree of their manifestation. For example, a person may be reluctant to admit to hearing voices due to paranoid delusions or fear of stigmatization, and so on.

Also distinguish:

Schizophreniform Disorder. It includes, but lasts for 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 can include so-called positive symptoms: visual and auditory hallucinations, delusional ideas, paranoid reasoning, disorientated 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 a similar disease usually changes dramatically from maximum excitement (mania and hypomania) to minimum (depression).

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

Certain psychotic symptoms may only persist during the onset of mania or depression. For example, during a manic episode, a person may have tremendous 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 as a psychosis, with all the accompanying symptoms, but also at the same time it is not schizophrenia in its original definition. Refers to the type of acute and transient psychotic disorders. Symptoms appear unexpectedly and constantly change (for example, each time a person sees new, completely different hallucinations), the overall clinical picture of the disease usually develops quite quickly. This episode usually lasts from 3 to 4 months.

Allocate polymorphic psychotic disorder with and without schizophrenia symptoms. 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, visions often have a fuzzy orientation, a person's mood constantly and unpredictably changes.

Symptoms

And with schizophrenia, and with psychosis and all other similar types of 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 helpful to others. In medicine, a similar name is used in the context of 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

Includes sensations that have no corresponding objective reality. Hallucinations can manifest in various forms parallel to human feelings.

Visual hallucinations include visual illusion and seeing non-existent objects.
The most common auditory type 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 senses non-existent smells.
Somatic. The name comes from the Greek "catfish" - body. Accordingly, these hallucinations are bodily, for example, the sensation of the presence of something on the skin or under the skin.

Mania

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

Mania is a person's strong, irrational and unrealistic beliefs that are difficult to change, even when there is compelling evidence. Most people who are not related to medicine believe that manias are 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 leads to the exaggeration of a person's importance in various ways. For example, a sick person may consider himself a president or a king. Often delusions of grandeur take on a religious connotation. A person can consider himself a messiah or, for example, sincerely assure others that he is the reincarnation of the Virgin Mary.

Misconceptions about the characteristics and functioning of the body can also often arise. There have been cases when 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. At the same time, there were no real reasons for this.

Other symptoms

Other signs, as a rule, characterize short-term psychotic disorders. These include strange body movements, constant grimaces and facial expressions uncharacteristic for a person and situations, or, as an opposite, catatonic stupor - lack of movement.

Distortions of speech take place: incorrect sequence of words in a sentence, answers that neither make sense or do not relate to the context of the conversation, imitation of the opponent.

Also, there are often aspects of childhood: singing and jumping in the wrong circumstances, capriciousness, non-standard use of ordinary objects, for example, creating a foil hat.

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

Causes

There are the following main causes of psychotic disorders:

Reaction to stress. From time to time, with 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 their lives, for example, the death of a spouse or divorce, and more serious ones - a natural disaster, being in places of hostilities or in captivity. Usually, the psychotic episode ends as the stress decreases, but sometimes the condition can be prolonged or chronic.
Postpartum psychosis. In some women, significant hormonal changes as a result of childbirth can cause. Unfortunately, these conditions are often misdiagnosed and treated, as a result of which there are cases when the new mother kills the baby or commits suicide.
The body's defensive reaction. It is believed that people with personality disorders are more susceptible to stress and less adapted to adulthood. As a result, when life's circumstances become more severe, a psychotic episode can occur.
Cultural psychotic disorders. Culture is an important factor in defining mental health. In many cultures, what is usually considered a deviation from the generally accepted norm of mental health is part of tradition, belief, reference to historical events. For example, in some regions of Japan, it is very strong, up to mania, the belief that the genitals can shrink and be drawn into the body, causing death.

If a particular behavior is acceptable in a given society or religion and occurs in the 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, the general practitioner needs to talk with the patient, as well as check the general state of health in order to exclude other causes of such symptoms. Most often, blood and brain tests are performed (for example, using an MRI) to exclude mechanical damage to the brain and drug addiction.

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

Treatment

The most common treatment for psychotic disorders is a combination of medication and psychotherapy.

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

Some drugs are available in the form of tablets, which must be taken daily, while others are in the form of injections, which are sufficient once or twice a month.

Psychotherapy includes various types of counseling. Depending on the personality of the patient and the course of the psychotic disorder, individual, group or family psychotherapy may be prescribed.

Most people with psychotic disorders receive outpatient treatment, that is, they are not constantly in a medical facility. But sometimes, in the presence of severe symptoms, the threat of harm to oneself and loved ones, or if the patient is not able to take care of himself, hospitalization is made.

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

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

People who are at high risk of developing these disorders, such as those with close family schizophrenics, should avoid alcohol and any drug use.