Nursing care for schizophrenia. Rehabilitation for schizophrenia Observing and caring for patients with schizophrenia

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Features of caring for patients diagnosed with schizophrenia

Caring for patients diagnosed with schizophrenia has a number of characteristics and challenges. The peculiarities of the disease complicate daily hygiene procedures such as washing, changing clothes and eating. In some cases, patients refuse to eat, in which case it is necessary to use feeding with a probe.

When caring for patients, the nurse and nursing staff should consider the following aspects:

Constant monitoring of the patient's behavior, as well as the manifestation of psychopathological symptoms of the disease. Psychopathological manifestations can be in the form of hallucinations, unexplained fears, the patient can run away and hide, suddenly scream. In such situations, patients usually do not notice the people around them and what is happening around. The patient may also be delirious and run away from medical personnel, be afraid of any objects, refuse food, and so on;

If necessary, medical personnel take care of patients at home. Usually in such cases a nurse is attached to the patient;

Medical personnel must monitor the patient around the clock, because his behavior is not predictable, he can cause physical harm to himself or other people at any time;

During the process of eating, the medical staff must monitor the patient, as well as promote the observance of hygiene standards;

The patient should spend the allotted time in the fresh air;

During the meeting of the patient with his relatives, medical personnel must observe the patient's behavior, and enter data on his behavior in the journal. Does the patient recognize his loved ones, what emotions they cause, joy, anger, aggression;

Monitoring the patient while taking medications and conducting therapy. The medical staff needs to make sure that the patient has taken the medicine, for this you need to check his oral cavity.

Schizophrenia, features of the nursing process in the adult department

abstract on psychiatry schizophrenia.doc

State Autonomous Educational Institution of Secondary Professional Education of the Arkhangelsk Region "Arkhangelsk Medical College"

TOPIC: "Schizophrenia, peculiarities of the nursing process in the adult department."

Pushkina Lidia Vyacheslavovna

nurse GBUZ JSC "Oktyabrsky

Schizophrenia is a mental illness of unknown etiology, prone to a chronic course, manifested by typical changes in the patient's personality and other mental disorders of different severity, often leading to persistent disorders of social adaptation and working capacity.

Schizophrenia is a disease characterized by gradually increasing personality changes (autism, emotional impoverishment, the appearance of oddities and eccentricities), other negative changes (dissociation of mental activity, thought disorders) and productive psychopathological manifestations of various severity and severity (affective, neuro- and psychopathic, delusional , hallucinatory, hebephrenic, catatonic).

The risk of developing the disease ranges from 0.5 to 1%, and this indicator does not depend on nationality or race and does not accumulate in the population over time. A person's social status and cultural level do not affect the incidence of schizophrenia. People with schizophrenia have a higher mortality rate from somatic diseases, and about 10% of patients commit suicide. About 25% of people with schizophrenia abuse alcohol or drugs. The etiology and pathogenesis of schizophrenia are poorly understood. An important role is played by constitutional genetic factors, as well as the sex and age of patients. The genetic factor is involved in the formation of a predisposition to schizophrenia, and the risk of getting sick is directly proportional to the degree of relationship and the number of cases in the family. The most severe forms of the disease are found mainly in men, less progressive - in women.

General clinical characteristics of schizophrenia

Schizophrenia as a separate disease was first identified by the German psychiatrist E. Kraepelin. He took groups of patients who had previously been described with diagnoses of hebephrenia (E. Gekker), catatonia (K. Kalbaum) and paranoids (V. Manyan), and, following them follow-up, found that in a distant period they had a kind of dementia. In this regard, E. Kraepelin combined these three groups of painful conditions and called them early dementia (demencia prhaesokh). Having singled out a separate disease on the basis of the outcome in dementia, E. Kraepelin at the same time admitted the possibility of recovery. Such a well-known contradiction and the principle of classification attracted attention and was critically evaluated. Subsequently, the Swiss psychiatrist E. Bleuler (1911) proposed a new term for the name of this disease - "schizophrenia". They were allocated primary and secondary signs of the disease. To the primary he attributed the loss of social contacts by patients with autism), impoverishment of emotionality, splitting of the psyche (special disorders of thinking, dissociation between various mental manifestations, etc.). All these mental disorders were qualified as a personality change of the schizophrenic type. These changes were considered critical in the diagnosis of schizophrenia.

Other mental disorders, identified by E. Bleuler as secondary, additional, are manifested by senestopathy, illusions and hallucinations, delusional ideas, catatonic disorders, etc. of these, schizophrenia may be more common.

Separate forms of schizophrenia have been identified and described. To the three classical forms: hebephrenic, catatonic and paranoid, a fourth form was added - a simple one. Subsequently, other forms were described: hypochondriacal, periodic, etc. The forms were distinguished on the basis of the leading syndrome. However, as shown by clinical observations, the psychopathological symptoms typical for one form or another of schizophrenia were not stable. The disease, which manifested itself in the early stages as a simple form, could later reveal psychopathological signs characteristic of the paranoid and other forms.

The psychopathological manifestations of schizophrenia are very diverse. According to their characteristics, they are divided into negative and productive. Negative ones reflect the loss or perversion of functions, productive ones - the identification of special psychopathological symptoms: hallucinations, delirium, affective tension, etc. Their ratio and representation in the mental state of the patient depend on the progression and form of the disease.

For schizophrenia, as noted, the most significant are the peculiar disorders that characterize changes in the patient's personality. The severity of these changes reflects the malignancy of the disease process. These changes concern all mental properties of the personality. However, the most typical are the intellectual and the emotional.

Intellectual disorders are manifested in various variants of thinking disorders: patients complain of an uncontrollable flow of thoughts, their blockage, parallelism, etc. It is difficult for them to comprehend the meaning of the text of books, textbooks, etc. words (neologisms). Thinking is often vague, in statements there is, as it were, sliding from one topic to another without a visible logical connection. Logical inconsistency in statements in a number of patients with advanced painful changes takes on the character of speech disruption (schizophasia).

Emotional disturbances begin with a loss of: moral and ethical properties, feelings of affection and compassion for loved ones, and sometimes this is accompanied by hostility and malice. Decreases, and over time, and completely disappears interest in your favorite business. Patients become sloppy, do not observe basic hygienic self-care. An essential symptom of the disease is also the behavior of patients. An early sign of it may be the emergence of isolation, alienation from loved ones, strangeness in behavior: unusual actions, behavior that were previously not characteristic of the person and whose motives cannot be associated with any circumstances. Various peculiar senestopathic manifestations are also typical for schizophrenia: discomfort in the head and other parts of the body. Senestopathies are fanciful in nature: patients complain of a feeling of fullness of one hemisphere in the head, dry stomach, etc. Localization of senestopathic manifestations does not correspond to painful sensations that can occur with somatic diseases.

Perceptual disorders are manifested mainly by auditory hallucinations and often by various pseudo-hallucinations of various sensory organs: visual, auditory, olfactory, etc. From delusional experiences, it is also possible to observe various forms of delusion: paranoid, paranoid and paraphrenic, in the early stages - more often paranoid. Delusion of physical influence is very characteristic of schizophrenia, which is usually combined with pseudohallucinations and is called the Kandinsky-Clerambo syndrome - the authors who described it.

Motor-volitional disorders are diverse in their manifestations. They are found in the form of a disorder of voluntary activity and in the form of a pathology of more complex volitional acts. One of the most striking types of impaired voluntary activity is the catatonic syndrome. Catatonic syndrome includes states of catatonic stupor and agitation. By itself, a catatonic stupor can be of two types: lucid and oneiroid. With lucid stupor, the patient retained an elementary orientation in the environment and his assessment, while with oneiric, the patient's consciousness was changed. Patients with lucid stupor after coming out of this state remember and talk about the events that took place around them during that period. Patients with oneiric states report fantastic visions and experiences, in the power of which they were in the period of a stupor state. Stupor states, as well as catatonic excitement, are complex psychopathological formations, including various symptoms.

More complex volitional acts, volitional processes also undergo various disturbances under the influence of the disease. The most typical is an increase in the decrease in volitional activity, ending in apathy and lethargy, and the severity of volitional disorders, as a rule, correlates with the progression of the disease. However, in some patients, there may be an increase in activity associated with certain painfully conditioned ideas and attitudes. So, for example, in connection with delusional ideas and attitudes, patients are able to overcome exceptional difficulties, show initiative and perseverance, and do a lot of work. The content of painful experiences of delusional ideas in patients may be different. At the same time, it reflects the spirit of the times, certain socially significant phenomena. Over time, the content of psychopathological manifestations of the disease changes. If in the past, evil spirits, religious motives, witchcraft often appeared in the statements of patients, now there are new advances in science and technology.

The question of the prevalence of schizophrenia in the population is an important question, both scientifically and practically. The difficulty in answering it lies in the fact that it is not yet possible to fully identify these patients among the population. This is primarily due to the lack of reliable data for understanding the essence of schizophrenia and diagnostic criteria for its definition. The available statistical data and the results of epidemiological studies allow us to conclude that the indicators of its distribution are almost identical in all countries and account for 1 - 2% of the total population. The initial assumption that schizophrenia is less common in developing countries has not been confirmed. The results of studies specially carried out in developing countries have revealed a similar number of people with schizophrenia per 1000 population with the number of people with schizophrenia in European countries. There is only a difference in the representativeness of certain types of clinical manifestations of the disease. So, among patients living in developing countries, acute states with confusion, catatonic, etc. are more common.

Schizophrenia can start at any age. However, the most typical age for the onset of schizophrenia is 20 to 25 years. At the same time, there are optimal periods for individual initial clinical manifestations of schizophrenia. So, schizophrenia with paranoid manifestation begins more often at the age of over 30 years, with neurosis-like symptoms, thinking disorders - in adolescence and adolescence. In males, the disease begins earlier than in women. In addition, there are differences in the clinical picture of the disease depending on the sex of the patients. In women, the disease is more acute, various affective pathologies are more often and more pronounced.

The nursing process (SP) is currently the backbone of nursing care. SP is a method of evidence-based and practiced by a nurse of their responsibilities to help patients. The joint venture brings a new understanding of the role of a nurse in practical health care, requiring from her not only good technical training, but also the ability to creatively relate to patient care, the ability to work with the patient as a person, and not as a nosological unit, an object of "manipulation technique ".

The constant presence and contact with the patient makes the nurse the main link between the patient and the outside world, the outcome of the disease often depends on the relationship between the nurse and the patient. What does the nursing process give for practice, what goals does it set?

The nursing process first determines the patient's specific care needs. Secondly, it helps to distinguish care priorities and expected results of care from a number of existing needs, in addition, predicts its consequences. Third, it defines the nurse's action plan, a strategy to meet the patient's needs. Fourthly, it evaluates the effectiveness of the work carried out by the nurse, the professionalism of nursing intervention. And most importantly, it guarantees the quality of care that can be monitored.

The organizational structure of the nursing process consists of five main stages:

nursing examination of the patient;

diagnosing its condition (identifying needs and identifying problems);

planning assistance to meet identified needs (problems);

implementation of the plan of necessary nursing interventions;

evaluation of the results obtained with their correction, if necessary.

Negative bias has developed in society about psychiatry. There are large differences between mental and physical illnesses, which is why patients and their relatives are often ashamed of the illness. This attitude can make the nursing process difficult at all stages.

Caregivers should not perceive the patient's personality with its needs, desires and fears only in terms of the diagnosis of the disease.

Holistic care encompasses the individual, family and relationships. The care process is carried out in stages. Quality care is possible through a partnership between patient and caregiver. This interaction can only be achieved by establishing a relationship of trust between the patient and the caregiver. General care of the elderly and senile mentally ill is more complex and requires more attention and time from the medical staff. The main principle of care is respect for his personality, acceptance of him as he is, with all his shortcomings, physical and mental: irritability, talkativeness, in many cases dementia. For medical personnel, in their work with such patients, traits such as patience, tact, and a sense of compassion are important. According to the five stages of the nursing process, the nurse has a framework for making decisions and solving problems in the nurse's care.

2.1. Collection of information

Patients suffering from schizophrenia are often immersed in their experiences, fenced off from the outside world and attempts to collect information, and even more so penetration into their inner world can cause them resistance and even aggression. This is especially possible in patients with paranoid schizophrenia.

Therefore, the duration of the conversation with the patients should be short. Several short conversations are recommended throughout the day, separated by intervals.

In conversations with patients, general expressions, abstract constructions should be avoided in every possible way: the facts and judgments communicated to the patient should be extremely specific. Otherwise, due to disorders of thinking and delusional constructions, the meaning of the conversation in the patient's mind may be distorted.

The autism of patients with schizophrenia, inaccessibility and resistance to communication imply the collection of information not only from patients, but also from their relatives and friends. It should be borne in mind that among the relatives of schizophrenic patients, there are many strange people, with personality deviations, with whom full contact may also not be realized.

Therefore, if possible, it is advisable to ask several people about the patient's problems.

Nursing in schizophrenia

People with dementia are radically different from other patients. Therefore, a special nursing process is required for schizophrenia. A difficult task falls on the shoulders of the medical staff, since often patients in psychiatric clinics do not understand the seriousness of their illness, and some refuse to consider themselves sick.

Dementia is a very dangerous disease. In most cases, the first symptoms of the disease are difficult to spot. A sick person flatly refuses to believe in their oddities and in most cases, tries to hide them. There are different types of mental disorders, among which are possible completely innocent acts or life-threatening actions of both the patient and those around him. But when a diagnosis has already been made, everyone would like to alleviate the condition of a loved one, for which innovative, effective techniques are being undertaken, as well as careful supervision. Nursing care for schizophrenia plays an important role, in which all aspects of the patient's custody are clearly described. Special cadres are being trained for this work, and each nurse, nurse, must clearly understand their responsibilities.

Nursing in Psychiatry: Schizophrenia

The behavior of the medical staff is an integral part of the treatment. The life of a patient is in the hands of a sister, who at any moment can harm himself or those around him.

The medical staff within the walls of a psychiatric clinic have to deal with people with completely different thinking, complex mental disorders. Employees should familiarize themselves with the patient's data in detail - know the last name, first name, patronymic of the patient and the number of the ward in which he is located. Treatment should be correct, affectionate and individual to each individual patient. The nurse is obliged to remember "by heart" what appointments the attending physician made to this or that patient and strictly follow them.

Many people mistakenly believe that the polite attitude of the mentally ill is not noticed. On the contrary, they have a very delicate sensitivity and they will not miss the slightest change in intonation and highly value good nature. But at the same time it is worth remembering that a "golden mean" is needed, the staff should not be too rude, nor too soft, ingratiating. It is categorically not allowed to single out among patients those who would like to give preference to help, care, and immediately neglect others.

It is important to maintain a normal environment within the walls of the clinic, everyone should know their responsibilities. Loud talk, shouting, knocking are not allowed, since the main condition in psychiatric clinics for the calmness of patients is peace and quiet.

Female staff should not wear shiny objects: jewelry, earrings, beads, rings, as patients can rip them off. This is especially true of departments where patients with serious forms of the disease are treated.

In case of a sharp change in the patient's condition, changes in his speech, the nurse is obliged to immediately notify the attending or the doctor on duty about this.

It is impossible to conduct conversations with colleagues in the presence of patients, especially to discuss the condition of other patients. It is unacceptable to laugh or treat even with a small amount of irony, jokes to the wards.
In most psychiatric clinics, visits are prohibited during the acute phase of the illness. Therefore, relatives give their loved ones notes, letters, which should be read before handing them over. If they contain information that can aggravate the patient's condition, the transfer is prohibited, and you will also need to conduct a conversation with relatives. When transferring things, products, it is necessary to carefully examine each package: there should be no sharp, cutting, stabbing objects, matches, alcohol, pens, medicines.

A nurse is responsible for supervising the orderlies. She must clearly set tasks for implementation and monitor their implementation. Constant supervision in such establishments is an important condition. Thus, patients will not be able to injure themselves or their associates, commit suicide, arrange an escape, etc. Wards of psychiatric clinics should not be left alone with themselves for a minute and should not be out of sight of the staff. If the patient is covered with a blanket, you need to come up and open his face.
Temperature measurement and drug administration must also be strictly supervised. In order to commit suicide, the patient may injure himself with a thermometer or swallow a thermometer. Do not turn away and leave the room until the patient drinks them in front of the nurse.

Maintenance of wards in clinics

Often, with complex forms of the disease, patients cannot eat on their own, make the bed, go to the toilet, and wash. Requires light, liquid food that does not cause injury, painful sensations when swallowing. When tube feeding, you should rinse your mouth after each meal.

The bed should always be clean, the patient needs to regularly set the boat, if necessary, use an enema, water procedures are required after each act of defecation and urination. With a catatonic state, urinary retention is possible, therefore, special catheters are used.

Important: the nurse is obliged to examine the patient's body, his skin, twice a day, to make sure that there are no bedsores, diaper rash, redness, edema, and rash.

How to deal with schizophrenia

The answer to this question has been sought for more than one century. The drug that would permanently get rid of mental illness has not yet been invented. But still, there are achievements, thanks to which a stable remission is maintained and two-thirds of the total number of sufferers lead a normal life. The fight against schizophrenia includes a set of measures that must be strictly followed.

Taking medications that stop, stabilize and maintain remission in the patient.
Regular visits to the attending physician, undergoing various kinds of procedures.
Harmonious relationships should be maintained in the house, the patient should not be exposed to seizures due to quarrels, scandals, loud parties, conversations, etc.

An important point in the treatment of mental disorders is to apply only to official specialized institutions. The specialist must have a certificate of compliance with the standards of the Ministry of Health, accreditation, qualification documents. It is best if relatives collect information through forums, where reviews of leading doctors in psychiatric clinics are always reflected.

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Schizophrenia treatment

Schizophrenia treatment challenges

Unpredictable flow
Low effectiveness of therapy
Difficulty in identifying the target syndrome
Combination of schizophrenia and substance use
Severe side effects of psychopharmacological agents

When determining the indications of psychopharmacotherapy in each specific case, it is necessary to take into account the entire set of indicators that affect the success of treatment.

Indicators defining therapy

The severity of the mental state (dangerous actions, including in the past)
The severity of the physical condition, the possibility of its aggravation
Clinical picture (symptoms, syndromes)
Experience of previous therapy (data on tolerance, effect in relatives)
The form of the course and stage of the disease

Therapies for schizophrenia

Active, stopping
Supportive
Preventive, anti-relapse
Anti-Resistant

Febrile schizophrenia

Help is carried out in intensive care
Differentiate with ZNS
Antipsychotic therapy
Benzodiazepines
Fight against hyperthermia, cerebral edema
Vital function support, restorative therapy

Continuously flowing malignant

Catatonic-hebephrenic, catatonic-hallucinatory, catatonic-paranoid
The goal is to achieve out-of-hospital remission at home
Method - maximum reduction of psychopathological disorders

Treatment for a continuous malignant form consists of:

The use of inactive antipsychotics, often in very high doses: clopixol up to 150 mg per day, risplept, haloperidol
Immunomodulators Ikaris
Plasmapheresis
Hemodialysis
Upon reaching out-of-hospital remission - prolongation, rehabilitation measures in PND (LTM)

Progressive paranoid schizophrenia

treatment involves the use of high doses of antipsychotics
To combat agitation, aggression, the use of sedative antipsychotics
To overcome resistance - ECT
Greater efficiency of prolongs

Paroxysmal schizophrenia

It is necessary to strive for the terminating effect of clopixol, haloperidol, triftazine in medium doses
With chronic delirium, combination therapy of triftazine with azaleptin
Rehabilitation measures

Recurrent and schizoaffective

Treatment with drugs with a significant sedative effect clopixol, a combination of triftazine with tisercin or haloperidol with chlorpromazine
Combination with antidepressants if necessary
Normotimics

Sluggish

It is a gradual decrease in emotional and volitional potential.

Treatment is carried out with disinhibiting antipsychotics: sulpiride, amisulpiride, atypical

Represents a condition similar to OCD, but with an increasingly complex storyline

Therapy is carried out with atypical antipsychotics in combination with serotonergic antidepressants (anafranil, remeron), if necessary, benzodiazepines are added

sestrinskij-process24.ru

Nursing process in schizophrenia. Part 1

The role of a nurse in organizing the treatment process and caring for patients with various mental disorders

Mental health care

The role of a nurse in organizing the treatment process and caring for mental patients can hardly be overestimated, since her activity includes a wide range of issues, without which the self-realization of a therapeutic approach to patients and, ultimately, a state of remission or recovery would be impossible.

This is not a mechanical implementation of medical prescriptions and recommendations, but the solution of everyday issues, which include the direct implementation of treatment processes (distribution of drugs, parenteral administration of drugs, the implementation of a number of procedures), carried out taking into account and knowledge of possible side effects and complications.

The Greek word "psychiatry" literally means "the science of healing, healing the soul." Over time, the meaning of this term has expanded and deepened, and now psychiatry is the science of mental illness in the broadest sense of the word, including a description of the causes and mechanisms of development, as well as the clinical picture, methods of treatment, prevention, maintenance and rehabilitation of mentally ill patients. ...

In Kazakhstan, the provision of psychiatric care to the population is carried out by a number of medical institutions. Patients can receive outpatient care in neuropsychiatric dispensaries. Depending on the nature of the disease and its severity, the patient is treated on an outpatient basis, in a day hospital or in a hospital. All procedures and rules of the neuropsychiatric hospital are aimed at improving the health of patients.

Caring for psychiatric patients is very difficult and peculiar due to lack of communication, lack of contact, isolation in some cases and extreme excitement, anxiety - in others. In addition, mental patients may have fear, depression, obsession and delirium. The staff requires endurance and patience, an affectionate and at the same time vigilant attitude towards patients.

The Nurse's Responsibility for Caring for Patients with Mental Disorders

Ultimately, it also means taking responsibility for a range of activities:

1. Prepare the patient for a particular procedure or event, which sometimes requires a lot of effort from the nurse, skills, knowledge of the patient's psychology and the nature of existing psychotic disorders.

2. Convincing the patient of the need to take the medicine and go to one or another procedure - it is often difficult because of his painful products, when he, for ideological and delusional motives of hallucinatory experiences or emotional disorders, resists the conduct of therapeutic measures. In this case, knowledge of the clinic of diseases helps to correctly solve the therapeutic problem, making possible a positive solution to the cure.

3. Until now, the care and supervision of mentally ill people, which are carried out by a nurse, remain relevant. This includes feeding the sick, changing linen, carrying out sanitary and hygienic measures, etc. It is especially difficult to monitor the whole contingent of patients. This applies to depressed patients, patients with catatonic symptoms, patients with acute psychotic disorders and behavioral disorders.

Care and supervision are undoubtedly important links in the general plan of patient care, since the implementation of therapeutic interventions without these important hospital factors is impossible. Information about patients, the dynamics of their diseases, changes in the treatment process, etc. is invaluable in the course of a complex treatment process, which is carried out by a mental patient in psychiatric hospitals.

Only a nurse can state the appearance of a number of delirious symptoms in the evening, prevent the realization of suicidal tendencies, establish daily mood swings in patients by indirect, objective characteristics, and predict their socially dangerous motives.

Ministry of Health of the Republic of Belarus

UO "Grodno State Medical College"

Methodical development of a practical lesson

"Monitoring and caring for patients with schizophrenia and affective mood disorders"

in the specialty 2-79 01 31 "Nursing"

Prepared by the teacher of the discipline

"Nursing in psychiatry and narcology"

Reviewed and discussed at

meeting of the cyclic commission of the medical

massage and narrow clinical disciplines

Minutes No. ____ dated ______

Cycle Commission Chairman

Vnukevich A.A.

Topic: "Monitoring and caring for patients with schizophrenia and affective mood disorders"

Occupation type: combined.

To acquaint with modern concepts and knowledge about endogenous diseases

· To acquaint with the main clinical symptoms, syndromes of schizophrenia;

· To acquaint with the forms of schizophrenia;

· To acquaint with defects, currents, prognosis in schizophrenia;

· To acquaint with delusional and other psychotic disorders;

To familiarize with mood disorders: major depressive and manic episodes.

· To systematize and generalize the knowledge about endogenous diseases, obtained in the theoretical lesson "nursing in psychiatry."

· Contribute to the education of mercy, sensitivity and compassion for patients;

· Contribute to fostering a sense of responsibility for the work performed;

· Contribute to the development of skills in deontology and medical ethics.

· Train students to independently supervise patients;

· Train students to carry out activities for the care of patients with schizophrenia and mood disorders, practical skills;

· Develop the ability to adjust care programs for difficult patients. Solve atypical situational tasks.

· Develop students' clinical thinking;

develop students' ability to work independently with additional literature.

· To ensure the implementation of the educational standard through the creation of a problem situation, the organization of independent work, through the imitation of elements of professional activity, a personality-oriented approach to students.

· To develop skills and abilities for recognition, treatment and patient care;

· To consolidate the knowledge and skills acquired in previous lessons;

· To teach to act in difficult non-standard situations, to improve methods in connection with an individual approach to patients and relatives.

· Assessment of knowledge using text control, creative assignments.

Duration of the lesson: 180 minutes.

Location of the lesson: GOKTs "Psychiatry-Narcology"

"Case histories" , instructions, guidelines for the technique of performing manipulations; equipping manipulations; didactic material; multilevel tasks, visual aid, textbook.

Intersubject and intrasubject communications:

Extract from the curriculum

in the specialty 2-79 01 01 "General Medicine",

approved by the director of the educational institution "Grodno State Medical College" V.T. Pashuk

A mental health professional with drug addiction should

know at the presentation level:

- history of the development of psychiatric care;

- the system of organization of psychiatric care in the Republic of Belarus;

- medical, ethical and legal aspects in psychiatry;

Know at the level of understanding:

- clinical characteristics of the main psychopathological symptoms and syndromes;

- clinic of major mental and drug addiction diseases in accordance with ICD-10, the principles of their diagnosis, treatment and prevention;

- principles of dynamic monitoring of mental patients;

Know at the application level - be able to:

- to diagnose acute and dangerous mental conditions;

- provide emergency first aid for mental disorders;

- to organize the observation and hospitalization of mental patients.

The level of creativity implies the differential diagnosis of atypical cases of diseases, combined pathology, knowledge of modern approaches, the latest views on the issues of psychiatry and narcology: solving atypical situational problems.

Nursing process in the care of patients with mental disorders

The role of a nurse in organizing the treatment process and caring for mental patients can hardly be overestimated, since it includes a wide range of issues, without which the very implementation of a therapeutic approach to patients and, ultimately, the registration of remission conditions or recovery would be impossible. This is not a mechanical implementation of medical prescriptions and recommendations, but the solution of everyday issues, which include the direct implementation of therapeutic processes (distribution of drugs, parenteral administration of drugs, the implementation of a number of procedures), which should be carried out taking into account and knowledge of possible side effects and complications. Ultimately, it also means taking responsibility for a whole range of activities. To prepare a patient for a particular procedure or event sometimes requires a lot of strength, skill, knowledge of the patient's psychology and the nature of existing psychotic disorders from the nurse. It is often difficult to convince the patient of the need to take the medicine and go to a particular procedure because of its painful products, when, for ideological and delusional motives of hallucinatory experiences or emotional disorders, sometimes resists all therapeutic measures. In this case, knowledge of the clinic of diseases helps to correctly solve the therapeutic problem, making possible a positive solution to the cure. Until now, the care and supervision of mentally ill people, which are carried out by a nurse, remains relevant. It includes feeding the sick, changing linen, carrying out sanitary and hygienic measures, and so on. It is especially important to monitor the whole contingent of patients. This applies to depressed patients, patients with catatonic symptoms, patients with acute psychotic disorders and behavioral disorders. Care and supervision are undoubtedly important links in the overall treatment of patients, since it would not be possible to carry out therapeutic interventions without these important hospital factors. Information about patients, the dynamics of their diseases, changes in the treatment process, and so on is invaluable in the course of a complex treatment process that is carried out by a mental patient in psychiatric hospitals. Only a nurse can state the appearance of a number of delirious symptoms in the evening, prevent the realization of suicidal tendencies, establish daily mood swings in patients by indirect, objective characteristics, and predict their socially dangerous motives. Sometimes, in order to calm the patient down, the nurse promises him another meeting with his family, talking on the phone, but then does not fulfill the promise, i.e. deceives the patient. This is completely unacceptable, as the patient loses confidence in the medical staff. If it is impossible to directly and specifically give an answer to a particular question, the conversation should be shifted to another topic, and the patient should be distracted. It is also not recommended to deceive the patient into a hospital. This complicates further contact with him, he becomes distrustful for a long time, does not tell anything about himself, about his experiences, and sometimes becomes embittered. One should not be afraid of the sick, but one should not flaunt excessive courage, as this can lead to serious consequences.

Nursing process in schizophrenia and affective disorders.

Schizophrenia (F20-29) is a chronic progressive (malignant) mental illness with an unexplained etiology, leading to a change in the patient's personality, sometimes subtle, but gradually worsening in the future.

Defect(from Lat. defectus - flaw, defect) means mental, primarily personal loss, which happened due to the transferred psychosis.

The main characteristic of the defect and its main difference from dementia is that, firstly, it is associated with remission and, secondly, it is dynamic.

The dynamics of the defect consists either in its growth (progression), or in its weakening (the formation of remission itself), up to compensation and reversibility.

Affective disorders (F30-F39) are disorders in which the main disorder is a change in emotions and mood towards depression (with or without anxiety) or towards elation. Mood changes are usually accompanied by changes in overall activity level.

The nursing process in schizophrenia and affective mood disorders now includes four components:

1. collection of information (survey),

4) assessment of the effectiveness of interventions.

Before considering each of these stages, let us dwell on the problems of communication with patients suffering from schizophrenia.

Features of communication with patients and their loved ones.

First, it should be borne in mind that patients suffering from schizophrenia and affective mood disorders are often immersed in their experiences, fenced off from the outside world, and attempts to collect information, and even more so to penetrate into their inner world, can cause them resistance and even aggression. This is especially possible in patients with paranoid schizophrenia.

Therefore, the duration of conversations with patients, even in a state of incomplete remission, not to mention the periods of acute manifestations of the disease, should be short. Several short conversations are recommended during the day, separated by intervals.

Since when dealing with patients with schizophrenia and mood disorders. aggression on their part, although infrequently, does occur, we give in an abbreviated form a diagram from a textbook for care professionals (USA):

"MAKE IT PRACTICE - FAST MANAGEMENT OF AGGRESSION AND ANGER"

1. To persuade the client, to transfer his actions to another plane.

2. Enlist the support of colleagues to remove other patients, but keep one near you.

3. Asking specific, non-disturbing questions in a calm, modulated voice.

4. Do not elicit the cause of the aggression, but point out its consequences (hindrance to work, inattention to other patients, etc.).

The autism of patients suffering from schizophrenia and affective mood disorders, inaccessibility and resistance to communication imply the collection of information not only from patients, but also from their relatives and friends. At the same time, one should take into account the fact that among the relatives of schizophrenic patients there are many strange people, with personality deviations, with whom full valuable contact may also not be realized. Therefore, if possible, it is advisable to ask several people about the patient's problems.

Manifestations and consequences of the disease that need to be identified when collecting information, note their presence or absence:

1. The presence of changes in sensory perception (hallucinations, illusions, senestopathy and other manifestations, here it is indicated the presence of depersonalization and derealization).

2. The presence of changes in cognitive processes (delirium, autistic constructions of thinking and other manifestations).

3. The presence of changes in communication - the formality of communication, unwillingness to communicate, complete lack of communication, etc.

4. Changes in the motor sphere - necessary tests and postures, mannerisms, agitation, stupor.

5. Changes in affect - unusually low or high mood, anger, apathy.

6. Increased risk of suicide.

7. Increased risk of violent acts.

8. Changes in family relationships: disunity with the family, family breakdown, family misunderstanding of the patient's condition, rejection of the patient.

9. Presence of problems with employment, drop and loss of working capacity, misunderstanding by colleagues, threat of loss of employment.

10. The presence of a deficit of self-care (carelessness, untidiness, unwillingness to serve oneself, etc.).

11. The presence of unwanted (side) reactions to prescribed psychotropic drugs - tremors, slowing down of movements, reactions to external stimuli, etc.

12. State of sleep (partial, complete insomnia).

Based on the data collection of information, the problems of the patients are determined, and hence the necessary interventions.

Typical patient problems arise from the clinical manifestations of various forms of schizophrenia and mood disorders described above. Here and hallucinatory-delusional manifestations, and a lack of communication, and not uncommon, especially at the onset of the disease or its relapse, psychomotor agitation, manifested in different forms. It should be noted that in modern conditions, with the widespread use of psychotropic drugs, the risk of violent actions on the part of the mentally ill is more of a philistine delusion; it is less at risk of violence in the general population (“healthy”). But the risk of suicide among patients with schizophrenia and affective mood disorders is very high, and antipsychotic therapy does not prevent this. It should also be remembered about the possibility of developing post-schizophrenic depression.

The family problems of patients with schizophrenia and mood disorders are significant. The family and relatives may not understand the patient, consider the symptoms of his illness as manifestations of a bad character. On the other hand, in some cases, the family stubbornly insists that the patient is healthy, and looks for all kinds of excuses for his painful behavioral manifestations.

It is especially undesirable and dangerous when the family does not understand the patient's condition when he is discharged from the hospital, and he seems to her, for example, completely recovered or hopeless and unhappy. Then family members show constant and inappropriate compassion towards the patient, or family and loved ones continue to maintain a tense, hostile relationship; often the family experiences fear and confusion in front of the patient.

It is not uncommon for patients with schizophrenia to lose their jobs.

Patient neglect can be a particularly serious problem - this is fixable when it comes to such manifestations as slovenliness and untidiness, but much more serious when it comes to the loneliness of patients (especially men) as a result of a serious illness or their homelessness (for example, homelessness as a result of fraud or family departure).

Nursing intervention planning and evaluation.

In part, they stem from the provisions that are set out in the sections relating to rehabilitation: patients and psychotherapy. It is necessary to remind once again that in foreign countries where the nursing process is developed, the nurse is the organizing center of the so-called "treatment team", where doctors - psychiatrist and psychologist perform mainly an advisory role.

Interventions should be planned and priority should be determined first.

Typical nursing interventions undertaken for patients with schizophrenia and mood disorders with acute disorders and transition to remission.

1. Perform and monitor the implementation of medicinal and other medical prescriptions, note the effectiveness, side effects of drugs and draw the attention of a doctor to this.

2. Try to identify stressors that enhance the patient's hallucinatory and other experiences. Provide him with a calm, peaceful environment to reduce impulsivity, anxiety, and other manifestations.

3. As hallucinatory-delusional and other experiences subside, first distract the patient from them, making them less relevant; indicate to the patient the consequences, rather than discuss delusional and other experiences. Only in the future bring the patient to a critical assessment of his judgments and behavior.

Help the patient with personal hygiene: dressing, washing, etc., until he (she) learns to do it on his own. Set and designate the exact time of self-service for the patient.

5. To attract and encourage patients to group activity (communication with other patients; participation in psychotherapy groups, occupational therapy, etc.).

6. In every possible way to approve of the patient who is returning to normal judgments, normal behavior and increased activity. Evaluate and increase the patient's self-esteem; thus prevent post-schizophrenic depression.

7. Conduct conversations with the patient about his correct behavior at home and how to prevent recurrence of the disease. Train to recognize the first signs of relapse and the need for urgent medical attention.

8. Thoroughly document and retain everything obtained in interaction with the patient.

9. Actively work with the patient's family. To lead them to an understanding of his painful symptoms and problems, especially after he is discharged from the hospital.

As can be seen from the above, the interventions numbered 1 and 2 refer to the acute period of the disease, and the rest to the period of decay of the process and stabilization of remission. In addition, caregivers often have to deal with the patient's employers to provide the patient with the conditions necessary for rehabilitation, as well as to do things that may seem small on the outside, but are stressful factors for the patient (abandoned animals, unkempt plants, unshipped or unreceived letters, etc.).

Evaluation of the effectiveness of interventions is carried out at different times and depends entirely on their content: for example, when determining the effectiveness of treatment or side effects of drugs - every day; with help in self-care or encouraging the patient to be active - weekly. In general, the recovery of normal behavior in schizophrenia and mood disorders is relatively slow, and US care professionals figuratively compare it to "earning income in extremely small increments."

All interventions in patients with schizophrenia and affective mood disorders are performed while maintaining the basic rules of communication with them: a conversation of short duration, especially at the beginning of communication, concreteness and certainty of statements.

Pediatric Patient Care

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Themes of essays, conversations, sanitary bulletins and sanitary posters for practical lesson No. 5 Group 201

Indications and contraindications for the appointment of galvanization and electrophoresis.

Rules for taking inhalation.

Causes of hemophilia, phenylketonuria and Marfan syndrome.

Emergencies in the clinic of infectious diseases.

Damage to mobile phones.

Why do people love extreme sports?

Yersiniosis. Rotavirus, enterovirus infections. Sanitary and hygienic measures in the outbreaks.

Viral hepatitis A and E. Prevention.

Viral hepatitis B, C, D. Social prevention of acute and chronic viral hepatitis in Belarus.

HIV infection, AIDS, prevention.

Hospital-acquired infections and their prevention.

Types and methods of disinfection, disinsection, deratization.

The principles of organizing a complex of anti-epidemic measures for typhoid fever, paratyphoid fever.

Monitoring and caring for patients with schizophrenia.

Monitoring and caring for patients with mood disorders.

Examination and peculiarities of communication with elderly patients.

Syphilis and its prevention.

Depression, anxiety disorders, dementia of the elderly.

Monitoring and caring for patients with epilepsy.

Phobic disorders (isolated and social phobias)

Reaction to severe stress and adjustment disorders.

What is the danger of a solarium?

Prevention of acute intestinal infections.

Non-pathological changes in mental life and behavior in old age.

Major and minor epileptic seizures. First aid.

Flu. Parainfluenza. Prevention.

Rhinovirus infection. Prevention.

Meningococcal infection. Meningitis. Prevention.

Herpetic infection. Prevention.

Occupational health at radar stations.

Epidemic typhus. Prevention.

Tick-borne systemic borreliosis (Lyme borreliosis). Prevention.

Anthrax. Prevention.

The advantages of using physical factors in treatment, their distinctive features, principles of dosing.

Physical characteristics of ultrasound. Mechanism of action. Therapeutic use of ultrasound.

Types of body hardening.

Sensations: types, impaired sensations (hyperesthesia, hypesthesia, anesthesia, parasthesia, senestopathy, pruritus, pain). Medical professional tactics.

Prevention of neuroses in children.

Nearsightedness and hyperopia. Prevention of visual impairment.

In the world of dreams, sleep and medicine.

Means that affect appetite. Drugs used for violations of the secretory function of the stomach. Emetics, antiemetics.

Acute gastritis. Chronic gastritis. Prevention.

Anaphylactic shock. Quincy's edema. Acute Urticaria. Prevention.

Autoimmune thyroiditis. Prevention.

Coma. Types of coma, their origin and manifestations.

Pustular skin diseases.

Diseases of the lens, choroid. Glaucoma.

Non-drug methods of labor pain relief.

Human genetic diseases.

Bronchial asthma. Causes. Bronchial asthma attack, emergency first aid in case of asthma attack and asthmatic status. Prevention.

Psychological compatibility of people in a team.

Downshifting: Fashion or Necessity?

Infectious monoculosis. Prevention.

Viral encephalitis. Prevention.

Rabies. Prevention. Emergency care for convulsive syndrome and psychomotor agitation.

Mechanisms of the physiological action of electric currents. Electric sleep.

Diadynamic therapy. The main types of diadynamic currents, indications and contraindications for their use.

Physical characteristic of light. The biological effect of light and its dependence on the wavelength of light radiation.

Perception: disturbances in perception (illusions, hallucinations, pareidomies, agnosias, disorders of optical-spatial perception). Medical professional tactics.

Methods of psychotherapy: individual, group, behavioral, fairy tale therapy, bibliotherapy, family psychotherapy, music therapy, art therapy, psychodrama, discussion psychotherapy. The role of nurses in psychotherapy.

Factors influencing the state of health, their role.

Influence of natural radioactive background on human health.

Means acting on the motor function of the gastrointestinal tract. Laxatives. Antidiarrheal drugs.

Stomach and duodenal ulcer. Prevention.

Rheumatoid arthritis. Prevention.

Diabetes. Complications. Prevention.

Stress. Stages, manifestations and significance of stressful conditions.

Emergencies in dermatovenerology: anaphylactic shock, Quincke's edema, Lyell's syndrome, Stevenson-Johnson's, exfoliative dermatitis.

Skin hygiene. Cosmetology.

Mental and behavioral disorders due to the use of psychoactive substances.

Childbirth pathology. The concept of abnormal labor.

Lung abscess, lung gangrene. Prevention.

Radiation in our life.

Allergy at home.

Self-medication - pros and cons.

Ways of formation of psycho-emotional stability of the personality.

Nature as a means of maintaining and strengthening health.

Features of the formation of hygienic skills in school-age children.

What are vaccinations for?

Pets are the best prevention of allergies and asthma

Bril's disease. Prevention.

Skin care for surgical patients. Prevention and treatment of pressure ulcers.

Erysipelas. Tetanus. Prevention.

Amplipulse therapy. The main types of sinusoidally modulated currents. The mechanism of the therapeutic action.

Visible rays. Physiological action. Caloric erythema.

Hygiene of personal belongings of a surgical patient. Hygiene of transfers and visits.

Memory impairments: hypomnesia, amnesia (retrograde, anterograde), paramnesia (confabulation, pseudo-reminiscence), hypermnesia. Medical professional tactics.

Reasons for poor communication. Technique and methods of communication. Levels and channels of communication.

The impact of computer networks on humans.

Preparations of hormones of the sex glands. Anabolic drugs.

Liver cirrhosis. Prevention. Nurse tactics for hepatic coma, "bleeding from varicose veins of the esophagus and stomach."

Tuberculosis as a social disease. Sources of Mycobacterium tuberculosis in nature. Ways of transmission of tuberculosis infection. Prevention.

Malignant and benign tumors. Pretumor and precancerous conditions.

Multifactorial dermatoses. Psoriasis, lichen planus, lupus erythematosus, scleroderma.

Alcoholism. Alcoholic psychics.

Complications of pregnancy: ectopic pregnancy, spontaneous abortion, placenta previa, premature detachment of the normally located placenta. Prevention.

Emphysema of the lungs. Pneumosclerosis. Pneumoconiosis. Prevention.

Hormones and health.

Obesity is a problem of the century.

Gonorrhea and its prevention.

Rare diseases: Stendhal syndrome, Kapgras delusion, living corpse syndrome (Cotard), Munchausen syndrome.

What is curative fasting.

Prevention of cardiovascular diseases.

Why should you never stop learning?

Children of drinking parents.

Physical activity and our health.

How emotions affect health.

Nutrigenomics and Nutraceuticals.

Vaccinations - protection or threat?

About the dangers of smoking.

Meningococcal infection. First aid for infectious-toxic shock, edema-swelling of the brain.

Darsonvalization. Physical characteristics of the applied types of currents. Mechanism of action. Indications and contraindications.

Ultra-violet rays. Their biological effect on the human body. Sensitivity of various persons and parts of the body to ultraviolet radiation.

The role of emotions in human life.

Valve apparatus of the heart. Valve defects.

Vegetarianism is for and against.

Acute and chronic glomerulonephritis. Clinical forms and main symptoms of the disease. Prevention.

Anemia. Classification. Prevention.

Necrosis. Causes and mechanisms of development of necrosis. Types of necrosis. Outcomes of necrosis.

Postpartum purulent-septic diseases. Prevention.

Chronic obstructive pulmonary disease. Prevention.

Treatment at resorts.

Use of nutraceuticals and parapharmaceuticals in medicine.

Mental deprivation and health.

Avitaminosis and hypovitaminosis, signs. Prevention.

The right tan. Tan by skin type. The consequences of improper tanning.

Nails are a mirror of health.

Common diseases of bloggers. Prevention.

Mountains: from physical and mental stress - to health.

Neuro-linguistic programming in therapy.

Decompression sickness. Prevention.

Diseases associated with vibration in the workplace.

Malaria. Prevention. First aid for the development of malarial coma.

Tick-borne encephalitis. How to remove a tick correctly.

Ultratokotherapy. Mechanism of action.

Laser therapy. Indications and contraindications for laser therapy.

Disorders of emotions and feelings: emotional ambivalence, emotional lability, depression, subdepression, mania, dysphoria, apathy).

Phases of cardiac activity. Heart sounds. Electrocardiography and its meaning.

Addiction. Medical and social implications.

Acute pyelonephritis. Causes and predisposing factors. Prevention.

Hemorrhagic diathesis. Prevention.

Dystrophy. The concept of the types of dystrophies.

Fungal skin diseases. Prevention.

Human chromosomal diseases.

Color and character, health.

Addiction: how to get rid of it?

Yoga as one of the oldest systems for healing the mind and body.

Nutritional diseases and their prevention.

How drugs work - placebo effect.

Poisonous plants and mushrooms. Prevention of poisoning of non-microbial etiology.

The relationship between the atmosphere in the family and the level of mental development of the child.

Cerebral palsy.

Alcohol and its negative effects on the body.

Contraception and health.

Coffee is another drug of the 20th century.

Intestinal infections are a summer misfortune. Prevention.

Hemorrhagic fevers. Prevention.

Products that promote the elimination of radionuclides from the body.

Inductothermy. Physical characteristics of an alternating magnetic field. Mechanism of action.

The harmful effects of nitrates and nitrites on the human body. How to reduce their content in food.

The concept of will. Stages of the volitional process. Will disorders: hypobulia, hyperbulia, abulia, catotonic stupor, parabulia).

The concept of parabiosis.

Coffee and coffee drinks. Indications and contraindications.

The mechanism of development of the inflammatory process. Classification. Medicines affecting inflammation processes.

Chronic renal failure. Prevention.

Acute leukemia. Prevention.

Regeneration. Physiological and reparative. Complete and incomplete.

Allergic skin diseases.

Principles, contributing factors, features of the manifestation of the most common precancerous diseases of the female genitalia (cervical erosion, polyps, hyperplasia, leukoplakia). Prevention.

Human diseases: what is their cause?

Cosmetics and everything about its benefits.

Cravings for extreme sports are a sign of depression and suicidal behavior.

Preservatives, dyes, flavors - unhealthy!

How to deal with seasonal depression. Good mood recipes.

How love and health are connected.

Vitamins and minerals during pregnancy.

Gender Identity Disorders.

Ozone for health. Ozone for beauty.

Organization of nursing control over the development of the child.

Food allergies in children.

The main syndromes and symptoms of respiratory diseases (bronchial obstruction, infiltrative compaction, increased airiness of the lung tissue, fluid accumulation in the pleural cavities, cough, sputum, shortness of breath, cyanosis, fever, pain).

Life expectancy from a medical point of view.

Ultrahigh-frequency therapy (UHF-therapy) .Physical characteristics. Mechanism of action.

Water and health.

The basic concepts of gestalt therapy: the relationship between the figure and the background, awareness of needs and focus on the present, opposites, functions of protection, maturity.

The word and its meaning. The impact of words on a person.

Bad habits as health destroyers.

Anaphylactic shock. Emergency care for anaphylactic shock.

Urolithiasis disease. Causes, symptoms. Types of stones. Prevention.

Endemic goiter. Prevention of endemic goiter in the Republic of Belarus.

Inflammation. Causes, signs, classification, outcomes.

Psoriasis. Hair diseases.

Stress and distress.

How to improve immunity.

Sleep and its disturbances.

Poisoning of a person with potent toxic substances: mercury, ammonia, chlorine. Prevention.

How to get up early and not suffer from it.

Diet by blood type.

Childhood autism. Signs and diagnosis of autism.

Animal therapy - treatment with animals.

Human genome in medicine, cloning.

Helminthiasis and their prevention.

The impact of a large city on human health.

Phobias and fears of a person.

Magnesium in the human body.

First aid for thermal injuries.

Shingles. Prevention.

Protection of a person from the biological effects of electromagnetic fields.

Magnetotherapy. Physical characteristics. Mechanism of action.

Types of psychopathy. The difference between accentuations and psychopathies: an important issue in distinguishing between norm and pathology.

Research methods of the central nervous system. Electroencephalography and computed tomography.

The value of biorhythms for humans.

Antioxidants Characteristics of individual drugs.

Allergies. Allergens and their types. Prevention of acute allergies.

Diffuse toxic goiter. Prevention. Emergency care and nursing tactics for thyrotoxic crisis.

Hypoxia and asphyxia. Types, reasons, mechanisms.

Diseases of the sebaceous and sweat glands. Viral dermatoses.

Pneumothorax. Protective breathing reflexes. Bradypnea, apnea, tachypnea, dyspnea.

Appearance, character, health.

Prevention of gastrointestinal diseases.

Physical training of the tourist.

Extreme and adrenaline - real benefits for the human body?

Is 3D video harmful to health? Safety rules for watching 3D.

Honey is good for your health.

What is thrush. Causes, symptoms, treatment. Prevention.

Why laughter is good for your health.

Giardiasis, amebiasis. Prevention.

Potassium in the human body.

Essential oils and health.

Energy drinks - harm and benefit.

Halotherapy - health from nature.

Anorexia. Cachexia. Prevention.

Fast food. Why fast food is dangerous.

Methodical instructions for a practical lesson on the discipline "Fundamentals of automation and the theory of technical systems" for cadets.

The didactic base of the lesson: guidelines for the teacher and students for practical and seminar classes, textbooks.

The current state of science on the organization of production and the prospects for its development

"The revolt of the masses" by J. Ortega y Gasset and the Christian evolutionism of P. Teilhard de Chardin

The entire book is written on the basis of materials taken from the exclusive conversations of its author with Edison Vasilyevich Denisov, held on.

Morality and ethics as universal ways of spiritual and practical mastering of reality

Theoretical approaches to understanding the essence of the concept of "security" and "financial instrument"

Patient care with a subclavian catheter;

The introduction of drugs into the central vein

Complication: air embolism.

Trays - 2 pcs (sterile and clean).

Syringes 10.0 ml.

Wash the hands.
Lay down the patient.
Tell the patient about the upcoming procedure. Explain that he will need to take a deep breath and hold his breath while attaching the drip system or syringe. Ask the patient to inform the nurse about any discomfort they will experience during the procedure. Reassure the patient.
Prepare drug solutions in the treatment room.
Wear sterile gloves before working with the catheter;
Remove the aseptic dressing;
Treat the plug on the catheter with a sterile ball moistened with 70% alcohol;
The plug is punctured with a needle when medicinal substances are injected into the catheter with a syringe, pull the plunger towards you until blood appears in the syringe and the medicinal substance is injected, the needle and syringe are removed without removing the plug;
The catheter is washed with 1-2 ml of isotonic sodium chloride solution and 0.2 ml of heparin is injected (1000 IU per 5 ml of isotonic sodium chloride solution);
The catheterization site is treated with alcohol or 1% alcohol solution of brilliant green, sterile napkins are applied, which are fixed with adhesive plaster. This manipulation is repeated after each infusion;
Disinfect the used equipment.
Remove gloves. Wash the hands.

Indications: long-term infusion of drugs, serious condition of the patient.

Complication: air embolism, phlebitis, thrombophlebitis, sepsis, catheter prolapse.

Sterile gloves.
Sterile gauze balls.
70% ethyl alcohol solution.
Medicinal product for infusion.
Infusion system.
Heparin bottle.
0.9% isotonic sodium chloride solution.

Venous catheter care rules:

Differentiated approaches to psychosocial therapy and rehabilitation of patients with schizophrenia, recognized by the court as legally incompetent The text of the scientific article in the specialty " Medicine and healthcare»

Abstract of a scientific article on medicine and health care, the author of the scientific work is V.A. Ruzhenkov, Yu.S. Minakova.

Clinical-psychopathological and psychometric methods were used to examine 180 schizophrenic patients aged from 16 to 87 (48.7 ± 1.1) years (77 women and 103 men), recognized by the court as legally incompetent. It was found that the main maladjusting factors in the microsocial environment are clinical (early onset of the endogenous process, comorbid alcoholism and drug addiction, heteroaggressive behavior) and social conflicts with relatives and caregivers, absence, inability and unwillingness of guardians to provide proper care for patients. Approaches to psychosocial therapy and rehabilitation are discussed.

Text of the scientific work on the topic "Differentiated approaches to psychosocial therapy and rehabilitation of patients with schizophrenia, recognized by the court as legally incompetent"

DIFFERENTIATED APPROACHES TO PSYCHOSOCIAL THERAPY AND REHABILITATION OF PATIENTS WITH SCHIZOPHRENIA, RECOGNIZED BY THE COURT.

V.A. Yu.S. Ruzhenkov MINAKOVA

Clinical-psychopathological and psychometric methods were used to examine 180 schizophrenic patients aged 16 to 87 (48.7 ± 1.1) years (77 women and 103 men), recognized by the court as legally incompetent. It has been established that the main maladaptive factors in the microsocial environment are clinical (early onset of the endogenous process, comorbid alcoholism and drug addiction, heteroaggressive behavior) and social conflicts with relatives and guardians, absence, inability and unwillingness of guardians to provide proper care for patients. Approaches to psychosocial therapy and rehabilitation are discussed.

Key words: patients with schizophrenia, disability, social maladjustment, psychosocial therapy, rehabilitation.

Schizophrenia is one of the most common mental disorders, with morbidity in the world of 0.8-1% and an incidence of 15 per 100,000 population. Despite the large economic costs of treatment, research and rehabilitation, schizophrenia shortens the patient's life expectancy by an average of 10 years and is one of the ten leading causes of disability. It is believed that the increase in the defect in schizophrenia can be associated not only with the disease, but also with the indifferent attitude of the environment to the patient, and close intrafamily interaction, active involvement of patients in social activities maintains a satisfactory level of social adaptation. Due to the social maladjustment of patients with schizophrenia, the need to rationally spend their money, protect property rights, take care, control treatment, the impossibility of living together due to "psychological incompatibility", the relatives of patients go to court with a claim to declare patients incapacitated and establish guardianship over them.

The aim of the study was to develop differentiated approaches to psychosocial therapy and rehabilitation of schizophrenic patients who were declared incapacitated by the court, depending on the prevailing maladjusting clinical and social factors.

Material and research methods. During 2010-2012. we examined 180 schizophrenic patients aged from 16 to 87 (48.7 ± 1.1) years (77 women and 103 men), recognized by the court as legally incompetent. The main research methods were clinical-psychopathological, clinical-dynamic, psychometric: the scale of positive and negative symptoms PANSS, "Questionnaire for assessing the social functioning and quality of life of mentally ill patients", "Social support scale" (MSPSS) Zimet in the adaptation of N.A. Sirota and V.M. Yaltonsky. Diagnosis of schizophrenia was carried out on the basis of the criteria adopted in Russian psychiatry and compared with the F20 rubrics of ICD-10.

In the course of the study, statistical methods were used (Student's t test, X2 criterion for 2x2 contingency tables) of database processing using the Statistica 6 applied statistical software package.

Comparative analysis was carried out in two groups - the first consisted of 88 (46 men and 42 women) patients living at home, and the second group included 92 (57 men and 35 women) patients, who were mainly in a psychiatric clinic at the stage of preparation for placement. to a neuropsychiatric institution for social security.

Research results and discussion. For the period of examination, patients of the first and second groups did not differ in age - respectively: from 21 to 77 (48.7 ± 1.4) years and from 19 to 87 (48.8 ± 1.6) years. In aggregate, in terms of the level of education, patients of the first and second groups did not differ among themselves: 17% and 23% higher and incomplete higher education, respectively.

Comparative analysis of gender differences in the level of education of patients of the first group showed that higher and incomplete higher education in females was statistically significant in a larger number of surveyed - 13 (31%) cases than in males -

2 (4.3%) patients (% 2 = 8, b53 p = 0.003). In the second group, 19.3% of males and 28.6% of females had higher and incomplete higher education (the differences are not statistically significant).

In aggregate, the patients of both groups did not differ in terms of the level of their social status prior to their disability. Nevertheless, attention is drawn to a certain dissonance between a significant number of patients with a high level of education and an insignificant number of employed in the positions of engineers and employees. This circumstance is associated with the fact that the beginning of the endogenous process fell on the age of the period of study, and by the time of graduation from the educational institution, due to personal changes as a result of an endogenous disease, social adaptation was difficult.

In the first group, females occupied positions of engineers and employees in 13 (31%) cases, and males - only in 3 (6.5%) cases (% 2 = 7.243, p = 0.007). This circumstance is associated with their higher educational level and a later onset of the endogenous process. In the second group, males occupied positions of engineers and employees in 8.8% of cases, and females, although more often 2.6 times (22.8 % of cases), but these differences are not statistically significant.

In the first group, in more than half of the cases - 52 (59.1%), the onset of the endogenous process fell on the age range of 21-30 years, and in the second - in 33 (35.9%) people (% 2 = 8.822, p = o , oos). Noteworthy is the fact that a significant number of schizophrenia debuts in the first and second groups fell on the age of up to 20 years: 27.2% and 45.6%, respectively (% 2 = 5.775, p = 0.01b). In the second group, in some patients, due to the earlier onset of the endogenous process, there was a family maladjustment, which was the reason for the refusal of their relatives and the solution of the issue

about placement in a neuropsychiatric institution for social security.

The duration of schizophrenia in patients of the first and second groups in 68.8% of cases was more than 21 years, which, due to personal changes, led to a pronounced social maladjustment. Patients were recognized by the court as incompetent starting mainly from the sixth year of the disease, almost evenly distributed over its duration. The duration of the period of incapacity until the moment of the present study in most patients of the first and second groups was up to 5 years (72.7% and 79.3%, respectively) ... In the second group, patients were hospitalized more than 15 times statistically significantly more often (x2 = 4.037, p = 0.045) than in the first (50% and 34.1% of cases, respectively).

The reasons for hospitalization of patients in a psychiatric hospital during this examination in the first group were: deterioration of the patient's mental state, correction of supportive antipsychotic therapy, side effects of drugs and much less often - the departure of the guardian and other relatives caring for the patient, and in the second - the collection of the necessary documents for registration in a boarding school.

The typology of the endogenous process in form in patients of the first and second groups is presented in table. 1.

Typology of the endogenous process in form, in patients of the first and second groups

P / p Form First group Second group Total

1 Paranoid 83 94.3 80 87 163 90.6

2 Undifferentiated 2 2.3 3 3.3 5 2.8

3 Residual 0 0 4 4.3 4 2.2

4 Simple 3 3.4 5 5.4 8 4.4

As you can see from the table. 1, in the overwhelming majority of cases - more than 90% in both groups, paranoid schizophrenia dominated.

The typology of the endogenous process by the type of course in patients of the first and second groups is presented in table. 2.

Typology of the endogenous process by the type of course of patients of the first and second groups

No. Type First group Second group Total

n / n flow n% n% n%

1 Continuous-progressive 64 72.7 76 82.6 140 77.8

2 Episodic with increasing defect 18 20.6 13 14.1 31 17.2

3 Episodic with a stable defect 6 6.8 3 3.3 9 5

TOTAL 88 100 92 100 180 100

As you can see from the table. 2, in most cases, the patients of both groups had the most unfavorable course of the disease - continuously progressive.

The characteristics of the leading psychopathological syndrome for the period of examination of patients are presented in table. 3.

Leading psychopathological syndrome for the period of hospitalization of incapacitated patients with schizophrenia

No. Leader First group Second group

n / n syndrome n% n%

1 Psychopathic 17 19.3 24 26

2 Affective-delusional 19 21.6 17 18.5

3 Paranoid 45 51.1 36 39.1

Delusional option 26 29.5 20 21.7

Hallucinatory variant 19 21.6 16 17.4

4 Paraphrenic 7 8.0 15 16.3

TOTAL 88 100 92 100

As can be seen from Table 3, in most cases in patients of both groups, paranoid syndrome prevailed, and in the first group it was somewhat more frequent than in the second, although the differences were not statistically significant.

In the first and second groups, more than half of the patients had comorbid alcoholism - 51.1% and 58.7% of cases, respectively; moreover, males more often than females: in the first group - 62.5% and 35.7% (% 2 = 6.513, p = 0.011) and in the second - 75.4% and 31.4% (% 2 = 15.557, p = 0.001). Alcohol abuse was facilitated by the asocial environment observed in 76.1% of male patients in the first group and in 93% in the second (% 2 = 4.5b1 p = 0.033).

Psychometric examination (scale of positive and negative symptoms RLNB) showed the following (table 4).

Results of the RLMBB scale in patients of the first and second groups

N p / n SYMPTOMS First group Second group 1> p<

1 Delirium 5.1 0.1 5.0 0.1 Differences are not reliable

2 G allucination 4.6 0.2 4.5 0.2

3 Thought disorder 5.9 0.1 5.8 0.1

4 Excitation 4.4 0.2 4.4 0.1

5 Ideas of greatness 3.9 0.2 3.7 0.2

6 Suspiciousness, ideas of persecution 4.2 0.1 4.3 0.1

7 Hostility 3.8 0.1 3.8 0.1

8 Overall assessment in the amount 31.9 1.0 31.5 0.9

1 Blunted affect 4.9 0.1 5.0 0.1 Differences are not significant

2 Emotional isolation 5.1 0.1 5.1 0.1

3 Communication difficulties 4.6 0.1 4.5 0.1

4 Pas.-apat. social exclusion 5.0 0.1 4.9 0.1

5 Violation of abstract. thinking 5.7 0.1 5.8 0.1

6 Violation spontaneity and fluency of speech 4.9 0.1 4.7 0.1

7 Stereotypical thinking 4.8 0.1 4.8 0.1

8 Overall assessment in the amount 35.0 0.7 34.8 0.7

The end of the table. 4

GENERAL PSYCHOPATOLOGICAL SYNDROMES

1 2 3 4 5 6 7 1 8

1 Somatic concern 3.6 0.2 3.5 0.1 Differences are not significant

2 Alarm 3.1 0.2 3.3 0.2

3 Feelings of guilt 2.3 0.2 2.3 0.1

4 Manners and posing 2.7 0.2 2.8 0.2

6 Depression 3.0 0.2 3.0 0.2

7 Motor retardation 4.0 0.1 4.2 0.1

8 Low contact 4.2 0.1 4.1 0.1

9 Unusual content of thoughts 4.8 0.1 4.9 0.1

10 Disorientation 3.7 0.1 3.6 0.1

11 Disorder of attention 4.4 0.1 4.5 0.1

12 Decrease in criticality 5.7 0.1 5.7 0.1

13 Disorder of will 5.7 0.1 5.6 0.1

14 Weakening of impulsivity control 4.0 0.1 3.7 0.1 2.1 I 0.05

15 Loads of psycho. feelings 4.7 0.1 4.8 0.1 Not reliable

16 Active social elimination 5.6 0.1 6.1 0.1 2.9 1 0.01

17 Overall assessment in the amount of 65.2 2.1 66.1 1.9 Not reliable

As can be seen from Table 4, the positive symptomatology of the endogenous process in both groups was moderately and strongly pronounced (the presence of numerous delusional ideas reflected in the behavior and social relations of patients, frequent hallucinatory experiences with delusional interpretation, inconsistency, vague thinking, in some cases disruption, periods psychomotor agitation, in some cases overestimation of one's own personality, ideas of greatness, moderately expressed delusional ideas of persecution, irritability with a tendency to hostility), and negative - expressed to a strong degree (affect is dulled, emotional isolation from people, sick alienated, keep a distance from the interlocutor, passive in communication, do not show interest in the environment, disorders of the associative process, rigidity and stereotyped thinking are expressed). General psychopathological symptoms ranged from mild to severe. In the first group, there was a weakening of the control of impulsivity slightly higher than in the second, which is associated with irregular medication by patients at home. The patients of the second group had a more pronounced, than in the first, active social withdrawal, due to the predominant stay in a psychiatric hospital.

The multidimensional scale of social support of Zimet showed that in patients of the first group, the average score on the scale of "social support of the family" in aggregate is 2.0 ± 0.1 points. Only 10.2% of patients living at home believe that they can count on family support. In the second group, the average score was 0.68 ± 0.07 points ^> 10.8 p<0,001). Лишь 7,6% пациентов считали, что родные придут на помощь в трудной ситуации, у остальных какая-либо поддержка отсутствовала, и они не верили, что родственники действительно хотят им помочь.

The average score on the scale of "social support of friends" of patients of the first group was 0.7 ± 0.08 points. More than half of patients - 56.8%, say that they can talk about their problems with friends, but are not sure that they will really come to their aid in a difficult situation. In the second group, the patients had no social support friends.

The average score on the scale "social support for significant others" of the first group was 0.98 ± 0.1 points. Only a little more than a third of patients - 38.6% - believe that they can talk about their problems with social workers, mental hospital staff and other patients, although they do not count on their help. Patients of the second group note that they have no one to turn to in a difficult situation, and they do not trust the hospital staff and other patients.

The pronounced social maladjustment of the patients of the second group led to the decision to place them in a neuropsychiatric institution for social security. The reason for this was: on the part of the guardian (70.6%) - unwillingness to look after, cramped housing and material conditions, poor health, on the part of the patient (18.5%) - aggressive behavior and the absence of relatives - 10.9%, who could take over the guardianship function (see fig.).

Reasons for placing incapacitated patients with schizophrenia in neuropsychiatric institutions for social security

Patient behavior - Caregiver unwillingness

conditions of guardians - guardians -15.2%

To increase the level of social adaptation of patients and ensure the maximum possible period of their stay at home, we have developed a differentiated program of psychosocial therapy and rehabilitation. The program consists of three sections:

1. Psychoeducational work:

- for relatives and guardians;

2. Training for lost social skills (for patients).

3. Individual psychotherapy - harmonization of the patient's relationship with caregivers and psychotherapeutic correction of heteroaggressive behavior.

Psychoeducational work for relatives and guardians was carried out by psychiatrists of the hospital (if the patient was in the hospital) and the dispensary department - if the patient lived at home. The main goal of this work was to raise awareness in the field of mental disorders, stimulate more active assistance to relatives and guardians of patients in the social adaptation of patients, and intensify cooperation with a local psychiatrist. There were only 5 lessons of 45 minutes on the following topics:

1. Mental disorders are not a sentence. Types and prevalence of mental disorders. Genius and insanity.

2. Features of the social functioning of patients with mental disorders. The role of relatives in increasing the level of social adaptation of patients with schizophrenia.

3. Legislation in the field of psychiatry: the Law of the Russian Federation "On psychiatric care and guarantees of the rights of citizens in its provision" and Federal Law No. 323 "On the basics of protecting the health of citizens in the Russian Federation."

4. Legal capacity and incapacity. The role of relatives in providing assistance to patients who have been declared incapacitated.

5. Interaction of relatives and psychiatric services in the social and psychological rehabilitation of patients recognized as incapacitated.

6. Social and household help at home. Training of lost social skills at home.

7. Socio-psychological assistance when transferring a patient to a neuropsychiatric institution for social security.

Psychoeducational work for patients was carried out 2 times a week, a total of 7 sessions of 45 minutes each. The main goal of this work was to increase the patient's responsibility for his social adaptation, behavior and mobilization of adaptive resources. The topics of the classes were as follows:

1. Mental disorders: their nature, prevalence, impact on social adaptation. The role of the patient in overcoming the maladaptive influence of a mental disorder.

2. Criticality and non-criticality of the patient to mental disorder. The influence of drug treatment on the social functioning of the patient.

3. Legal capacity and incapacity for mental disorders. The role of the symptoms of the disease and disorders in the patient's behavior in the recognition of the patient by the court as legally incompetent.

4. The rights of the incapacitated. The role of treatment in the patient's social adaptation.

5. Conflicts of patients in the microsocial environment and methods of their resolution. The role of disease symptoms in the emergence of conflicts.

6. Methods of job search and adaptation in a microsocial environment in case of disability. Taking care of yourself and your home.

7. Disability and quality of life. Ways to improve the quality of life.

Psychological correction of aggressive behavior was carried out with patients individually and was implemented in three stages.

Stage 1 - installation:

1. Establishing therapeutic contact with the patient, clarifying goals and objectives

therapy, obtaining consent.

2. The choice of the method of psychosocial therapy and psychological correction.

3. Determination of the regimen and schedule of therapy.

Stage 2 - therapeutic:

1. Awareness of the causes of aggression.

2. Awareness of the emotional, cognitive and behavioral components of aggression.

3. Dissociation-association with aggression.

4. Reduction of aggressiveness, including by aversive methods.

Stage 3 - final:

1. Family psychosocial therapy and psychocorrection (correction of destructive

2. Conclusion of an agreement with a guardian.

3. Testing the effectiveness of psychosocial therapy and correction.

To correct heteroaggressive behavior, based on gestalt therapy and neurolinguistic programming (NLP), we have developed the technology of awareness and reduction of heteroaggression (TORG), the technique of aversive reduction of heteroaggression (TARG) and the technique of disactualization of conflict relations in the microsocial environment (TDCO).

The technique of awareness and reduction of heteroaggressive behavior (TORG) was as follows.

1. At the first step, the patient was found out in what specific situations and in relation to whom he personally developed heteroaggressive tendencies. It was proposed to literally recall one of these situations, “to see a person in relation to whom hetero-aggression was manifested,” to recall the pose, clothes, facial expressions of this person, how his voice sounded. At the moment when the patient was completely immersed in the experience of the past experience of heteroaggression, this state was anchored by a kinesthetic and auditory anchor (the visual and spatial anchor was the place of visualization of the object of heteroaggression - often an empty chair).

3. At the third step, the patient was asked to visualize the object of heteroaggression on an empty chair and, in the literal sense of the word, “express to an imaginary opponent all his complaints and discontent”. After that, the patient was asked to sit on a chair and on behalf of his opponent - literally getting used to his image, to answer verbally to the accusations. At this moment, the anchor of the heteroaggressive impulse was actualized (to reduce the aversive reaction to heteroaggression). Then the patient was again asked to sit in his previous place, visualize the opponent and respond to him. Then, once again, sit on the armchair and answer the accusations from the position of the opponent. And so the actions of step 3 are repeated until the conflict is resolved.

4. At the 4th step, constructive methods of conflict resolution were developed using NLP technologies (actualization of existing resources, a generator of new behavior, the use of the resources of other people, etc.).

4. At the 5th step, the patient was asked to visualize his opponent in any other situation in the future and found out, observing the non-verbal signs of heteroaggression, how he would behave towards the opponent and actualized the anchor of the constructive way of resolving the conflict.

When performing this technique in another version after step 5, you can apply from psychotechnology NLP "Swing Technique".

The technique of aversive reduction of heteroaggression (TARG) was based on behavioral methods of reducing behavior and consisted in the fact that when a negative stimulus is attached to a trigger that triggers heteroaggression, a kind of suppression of heteroaggression occurs, it is associated in something unpleasant for the patient, unacceptable. The essence of the method was as follows.

1. At the first step, a powerful aversive stimulus is developed. For this, the patient's personal experience from the past is used, when there were unpleasant situations, substances, spoiled foods, waste products (sight, smell) that cause a gag reflex and disgust. A modified "multiple resource" technique is used to create a consistently powerful aversive reaction. The developed aversive reaction is fixed using a kinesthetic anchor. After that, the patient is distracted. At this step, you can use the patient's left arm outstretched in front of you as an anchor, palms up and visualize the required objects in the palm of your hand.

2. At the second step, it was found out “how the patient learned that he had a heteroaggressive impulse”, what sensations in the body (and where exactly) the patient had during the period of manifestation of heteroaggression. Further, using the method of gestalt therapy "amplification", this feeling is strengthened and further structured: the place of localization, shape, size, consistency is clearly defined, and at the moment the patient is completely immersed in the experience of a heteroaggressive impulse, it is fixed using a kinesthetic anchor. After that, the patient is distracted. At this step, you can use the patient's right arm outstretched in front of you as an anchor, palm up.

3. At the third step, the second anchor is updated and the heteroaggressive impulse is visualized. After it is clear from non-verbal signs that the patient is completely immersed in the experience of heteroaggression, the first anchor is actualized. As a result, a leveling of the heteroaggressive impulse will occur to a certain extent (depending on the power of the generated aversive reaction).

4. After step 3, you can apply from psychotechnology NLP "Swing Technique".

Technique for disactualizing conflict relationships in a microsocial environment

(TDKO) was based on behavioral techniques in their implementation using gestalt therapy methods and consisted in the following.

Step 1. Identification and study of conflicting relationships. Allocation of the object and subjects of the conflict.

Step 2. Sequential playing by the patient of the roles of the subjects of the conflict and studying their point of view on the object of the conflict.

Step 3. Taking a balanced decision on the object of the conflict.

Step 4. Reconciliation of the patient with the subjects of the conflict. In fact, at this stage, family psychotherapy was carried out, since the subjects of the conflict were most often the relatives and friends of the patient with whom he lived in the same house.

The developed program was tested on 24 patients. As a result of the implementation of the program, there was an improvement in the patient's interpersonal relationships in the family, an expansion of the sphere of communication, the emergence of friendly relations with other patients. Family social support has also improved significantly.

Thus, as a result of the study, it was found that the positive symptoms of the endogenous process in both groups were moderately and strongly pronounced, negative - expressed to a strong degree, and general psychopathological symptoms in the range from weak to strong.

Target symptoms for psychosocial therapy and patient rehabilitation are aggressive behavior of the patient (requiring adequate psychopharmacotherapy and psychotherapy), unwillingness or refusal of the caregiver to care for the patient (which is the subject of family psychotherapy), as well as activation of the patient's resources aimed at some recovery of lost social skills.

In addition, in order to increase the level of social adaptation of patients and increase their chances of living at home under the supervision of a guardian in the first group, it is advisable to carry out psychoeducational work with guardians, increase the physical and social activity of patients. To preserve the ability of patients of the second group to live at home, the target symptoms may be “unwillingness of the caregiver to look after the patient” and “aggressive behavior of the patient”, as well as training of lost social skills. Treatment of comorbid alcoholism and drug addiction plays an important role in both groups.

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2. Gurovich, I. Ya. Questionnaire for assessing the social functioning and quality of life of the mentally ill [Text] / I.Ya. Gurovich, A.B. Schmukler // Social and Clinical Psychiatry. -

1998. - T. 8, No. 2. - S. 35-40.

3. Psychiatry [Text]: handbook of practice. a doctor; ed. A.G. Hoffmann. - M.: MEDpress-inform, 2010 .-- 608 p.

4. Mental health: new understanding, new hope [Text]: Dokl. on the state of health in the world / World Health Organization. - Geneva: WHO, 2001 .-- 216 p.

5. Guide to Psychiatry [Text]: in 2 volumes / ed. A.S. Tiganova. - M .: Medicine,

1999. - T. 1. - 712 p.

6. Orphan, N.A. Coping behavior in adolescence: dis. ... Dr. med. sciences / N.A. Sirota-Bishkek, 1994 .-- 283 p.

7. Schizophrenia [Text]: multidisciplinary research. / Acad. medical sciences; ed. A.V. Snezhnevsky. - M .: Medicine, 1972 .-- 398 p.

8. Yaltonsky, V.M. Coping behavior of healthy and drug addicts: dis. ... Dr. med. sciences. -SPb., 1995 .-- 396 p.

9. Tandon, R. Schizophrenia, "Just the Facts" What we know in 2008. 2. Epidemiology and etiology / R. Tandon, M.S. Keshavan, H. A. Nasrallah // Schizoph. Res. - 2008. - Vol. 102, No. 1. - P. 1-18.

10. Woods, B.T. Meta-analysis of the time-course of brain volume reduction in schizophrenia: implications for pathogenesis and early treatment / B.T. Woods, K.E. Ward, E.H. Johnson // Schizoph. Res. -2005. - Vol. 73, no. 2-3. - P. 221-228.

DIFFERENTIAL APPROACHES TO PSYCHOSOCIAL TREATMENT AND REHABILITATION OF SCHIZOPHRENIC FOUND LEGALLY INCOMPETENT BY COURT

V.A. RUZHENKOV Yu. S. MINAKOVA

180 schizophrenics at the age from 16 to 87 (48 ± 1.1) including 77 women and 103 men found legally incompetent by court were surveyed by the clinical-psychopathological and psychometrical methods. It was found the main deconditioning factors in milieu were clinical (early start of the endogenetic processes, comorbide alcoholism and reliance on drugs, hetero-aggressive behavior) and social factors: conflicts with relatives and guardians, the lack attendance or guardians "unwillingness or inability to provide such attendance. Some approaches to psychosocial therapy and rehabilitation were discussed.

Key words: schizophrenics, incapability, social maladjustment, psychosocial therapy, rehabilitation.

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Lecture # 4: Monitoring and caring for patients with schizophrenia. Monitoring and caring for patients with mood disorders.

Mental disorders in schizophrenia. Study history; symptomatology; syndromology; forms;

Flow types; symptoms of schizophrenia from the standpoint of ICD-10.

General principles of treatment. Features of observation and care. Medical rehabilitation.

Mental disorders in affective mood disorders.

Manic episode.

Bipolar Affective Disorder (BAD).

Depressive episode.

Recurrent depressive disorder (RDR).

Chronic mood disorders.

Clinic. Treatment principles. Features of observation and care. Medical rehabilitation.

SCHIZOPHRENIA,

Schizophrenia (from gr. Schizo - splitting, splitting, phren - soul, mind, reason) is a mental illness that proceeds chronically in the form of attacks or continuous and leads to characteristic personality changes. It occurs in people predominantly of young age, at the age of 18-35. It is of great social importance, since it mainly affects the able-bodied part of the population.

SYMPTOMATICS

The clinical manifestations of schizophrenia are very diverse. With this disease, almost all existing psychopathological symptoms and syndromes can be observed.

The main symptoms of schizophrenia are: the splitting of mental activity, emotional and volitional impoverishment, in some cases - the progression of the course.

With the splitting of mental activity, patients gradually lose contact with reality; there is a separation from the outside world, withdrawal into oneself, into the world of one's own painful experiences. This condition is called autism. Autism manifests itself in the form of a tendency to solitude, isolation, inaccessibility to contact. At the same time, the patient's thinking is based on perverted reflections in the consciousness of the surrounding reality.

As the process progresses, the patient loses the unity of mental activity. Her inner disorder sets in. A striking example is the deep fragmentation of thinking in the form of a "verbal crumb", schizophasia.

Characteristic is also symbolic thinking (symbolism), when the patient explains individual objects, phenomena in his own meaning, only for him. For example, the letter "in" in quotation marks means the whole world to him; he perceives a drawing in the form of a ring with a human head as a symbol of his safety; he regards a pit from a cherry as loneliness; an unextinguished cigarette butt is like a dying life.

In connection with the violation of internal (differentiated) inhibition, the patient develops agglutination (gluing) of concepts. He loses the ability to differentiate one concept, representation from another. As a result, new concepts and words - neologisms - appear in his speech; for example, the concept of "pridestoliy" unites the words wardrobe and table, "raklinka" - cancer and a bundle, "trampar" - a tram and a steam locomotive, etc.

Reasoning, or empty philosophizing, is quite common in the clinic of schizophrenia. (For example, the patient's fruitless reasoning about the design of the cabinet table, the advisability of four legs at the chairs, etc.).

Emotional-volitional impoverishment develops after a certain time after the start of the process and is clearly expressed with the manifestation of painful symptoms. This sign is characterized by emotional dullness, affective indifference to everything around, and especially emotional coldness to close ones, relatives! The patient can laugh at sad events and cry at joyful events, or indifferently tell how, during the funeral, he wanted to pour kerosene on his mother and burn it. Emotional and volitional impoverishment is accompanied by lack of will - abulia. Patients do not care about anything, do not care, they have no real plans for the future, or they speak about them extremely reluctantly, in monosyllables, without striving to implement them.

Ambivalence is the duality of ideas, feelings, existing simultaneously and oppositely directed.

Ambitiousness is a similar disorder, manifested in the duality of aspirations, motives, actions, and tendencies of the patient. For example, a patient declares that he loves and hates at the same time, considers himself sick and healthy, that he is God and the devil, a tsar and a revolutionary, etc.

Negativism is the desire to do the opposite of what is proposed. For example, when a hand is extended to the patient for a handshake, he hides his own, and vice versa, if the hand is removed, the patient stretches out his. The negativism is based on the mechanism of the ultra-paradoxical phase that occurs in various spheres of the patient's mental activity.

The progression of the course of schizophrenia is characterized by a gradual complication of the symptoms of the disease, which develops continuously or paroxysmal. Negative signs of the disease and positive symptoms gradually increase. The latter manifests itself in the form of various syndromes, the clinical characteristics of which depend on the form and stage of development of the process.

SYNDROMOLOGY

Schizophrenia is characterized by a number of syndromes reflecting the degree of progression and stages of development of the process. Most of its variants begin with the onset of an asthenic symptom complex. manifested in the form of hypo- or hyperesthesia. Patients complain of increased fatigue, irritability, headaches, sleep disorder, absent-mindedness.

Following asthenic disorders, affective syndromes develop. They include hypomanic and subdepressive manifestations, in some cases accompanied by delusional ideas. Patients become sad, inhibited, express ideas of self-accusation, or, conversely, reveal an unmotivated elevated mood.

As the process progresses, the following delusional syndromes are found.

Paranoid syndrome includes systematized delusional ideas of persecution, poisoning, jealousy, etc.

Hallucinosis is an influx of auditory (verbal) hallucinations. Hallucinosis indicates a more severe course of the process. It can be true or false. In the first case, the patient perceives voices from the environment. With pseudohallucinosis, voices are heard inside the head or in one's own body.

Paranoid syndrome consists of unsystematic delusional ideas, auditory, gustatory and olfactory hallucinations, depersonalization disorders, often includes Kandinsky-Clerambo syndrome.

Paraphrenic syndrome is a combination of the symptoms of previous syndromes, but in this case, the absurd delusions of grandeur, confabulatory delusions come to the fore.

Catatonic syndrome is one of the most severe symptom complexes encountered in schizophrenia. It manifests itself in the form of catatonic stupor or excitement with negativism, movement stereotypes, “echo” symptoms, etc. The so-called secondary catatonia, which usually develops at the end of the disease process, is especially resistant to therapy. The exception is oneiric catatonia, which proceeds more favorably.

In the case of an unfavorable course of schizophrenia, a terminal (final) state of the disease is detected. At the same time, all the symptoms of the above syndromes are leveled, loses its relevance and deep intellectual degradation, emotional and volitional impoverishment of the personality come to the fore.

There are five main "classic" forms of schizophrenia: simple, hebephrenic, paranoid, catatonic and circular.

Simple schizophrenia usually occurs in adolescence and develops slowly. With her, negative disorders come to the fore. Emotional impoverishment, apathy, and difficulty in assimilating newly received information appear. Patients lose interest in studies, work, strive for solitude, do not get out of bed for a long time, are emotionally cold to relatives and friends, complain of loss of thoughts, of "emptiness in the head." Patients do not have a critical attitude to their condition.

Delusional ideas and hallucinations are not common in simple schizophrenia; if they do appear, it is only occasionally and in a rudimentary form (unstable ideas of attitude, persecution, auditory hallucinations in the form of calls by name, etc.).

The simple form of schizophrenia is usually malignant; in some cases, there is a course with a slow development of personality changes according to the schizophrenic type.

Hebephrenic schizophrenia is similar in development to simple schizophrenia. It is also characteristic of adolescence and begins with the emotional-volitional flattening of the personality, with the appearance of intellectual disorders. However, with this form of the disease, along with negative disorders, foolishness, pretentious behavior, fussiness, stereotyped movements against the background of an unreasonably elevated mood appear. Patients tumble, jump, clap their hands, grimace. Their speech is usually torn. In addition, sharply fragmentary delusional ideas and hallucinations with phenomena of mental automatism are observed.

This form of schizophrenia has an extremely poor prognosis, is characterized by a malignant course and the rapid development of deep dementia.

Paranoid schizophrenia usually develops in adulthood, more often in 30-40 years. The leading one here is the paranoid syndrome with the presence of delusional ideas of attitude, persecution, poisoning, physical influence. Delusional statements are accompanied by hallucinatory disorders. The behavior of patients reflects delusional and hallucinatory experiences.

In the paranoid form of schizophrenia, the Kandinsky-Clerambo syndrome, as well as depersonalization disorders, are common. All types of delirium and hallucinations gradually fade with the course of the disease, lose their relevance; the symptoms of apathetic dementia come to the fore.

In catatonic schizophrenia, the symptoms of catatonic syndrome prevail with symptoms of "hood", "wax flexibility", "air cushion" Dupre, with muscle hypertension. In addition, delusional ideas, hallucinatory disorders, as well as an emotional-volitional personality change according to the schizophrenic type are observed. It occurs at 22 - 30 years old, less often at puberty. Patients lie on the bed for days, sometimes months, not communicating with anyone, not talking. Extremely negative, mannered; facial expression is frozen. It should be noted that catatonic schizophrenia can occur with a clear consciousness of patients (lucid catatonia) and with a sleep-like disorder of consciousness (oneiric catatonia).

Circular schizophrenia develops more often in middle-aged people. Its clinical picture consists of periodically arising manic and depressive phases with the inclusion of hallucinatory and hallucinatory-delusional disorders, as well as the Kandinsky-Clerambo syndrome. Insufficient emotional saturation of manic and depressive attacks is noted. The disease is relatively favorable.

TYPES OF CURRENT

A. V. Snezhnevsky and R. A. Nadzharov (1968 - 1970) identified three types of schizophrenia: continuous, paroxysmal-progressive (fur-like; from German schub - shift, attack) and periodic.

1. Continuous schizophrenia is characterized by the absence of autochthonous, spontaneous remissions. The disease exhibits a large polymorphism of symptoms.

2. Sluggish schizophrenia occurs at the age of 16 - 18, sometimes even in childhood. The later the process begins, the softer it proceeds. Symptoms in sluggish schizophrenia are usually limited to a range of minor syndromes: yeurosis-like, hysterical, psychopathic, paranoid with overvalued formations and delusional ideas of attitude. The course of this option is different, but most often it is uneven. At first, symptoms develop rapidly, then the process proceeds slowly and is accompanied by ups and downs of mental disorders.

3. Schizophrenia with an average (paranoid) type of progression of the course usually begins sluggishly, with neurosis-like disorders, at the age of 20 - 40 years. Sometimes there is an earlier development, in adolescence. In this case, paranoid schizophrenia is more malignant.

Already at the very beginning of the disease, personality traits appear that are striking to those around them: isolation, emotional inadequacy, limitation of the range of interests. Anxiety, anxiety, and a feeling of dissatisfaction are occasionally noted.

In the future, a paranoiac syndrome develops, and from that moment on, delusional ideas (persecution, physical pressure, jealousy, etc.) prevail in the manifestation of the disease.

Malignant (juvenile) schizophrenia occurs in adolescence, less often in childhood, much more often in boys than in girls.

The disease begins with negative disorders: the vividness of interests is lost, the emotional sphere becomes scarce, and isolation appears. Patients reveal unmotivated pretentious hobbies for philosophy, religion.

With the development of the disease, polymorphic productive symptoms appear: sharply fragmentary delusional ideas of various contents, catatonic and hebephrenic disorders, the phenomenon of Kandinsky-Clerambo syndrome, violation of the body scheme, etc.

After 2-5 years, a deep personality defect, emotional dullness, and abulia develop.

Symptoms in malignant schizophrenia are highly resistant to therapy.

4. Paroxysmal-progreduated (fur-like) schizophrenia proceeds in the form of seizures with subsequent remissions. But the reverse development of an attack does not end with a complete recovery of mental health: obsessive, hypochondriacal and paranoid disorders remain. From an attack to an attack, the patient more and more reveals a flattening of the emotional-volitional sphere. With fur-coat schizophrenia, the attacks are emotionally colored, delusional ideas are not systematized.

5. With periodic (recurrent) schizophrenia, the autochthonous tendency to phase flow is especially clearly revealed. Remissions are always deep, accompanied by a complete reverse development of productive psychotic symptoms.

ICD-10 diagnostic criteria

According to ICD 10, at least one of the following signs should be detected:

Echo of thoughts (sounding of one's own thoughts), insertion or withdrawal of thoughts, transmission of thoughts over a distance.

Delusions of mastery, influence, inaction related to the whole body (or limbs), thoughts, actions or sensations; delusional perception.

Persistent delusional ideas that are culturally inadequate, ridiculous and grandiose in content. Or at least two of the following:

Chronic (more than a month) hallucinations with delirium, but without pronounced affect.

Neologisms, discontinuity of speech.

Catatonic behaviors such as agitation, freezing or waxy flexibility, negativism, mutism, and stupor.

Negative symptoms (not caused by depression or antipsychotic treatment) are expressed:

Poverty or inadequate emotional responses.

Social isolation.

Social unproductiveness.

Reliable and pronounced changes in the general quality of behavior, manifested by:

Loss of interests

Aimlessness.

Immersion in their own experiences, autism.

With the development of symptoms of schizophrenia, together with severe symptoms of other disorders (affective, epileptic, with other brain diseases, with intoxication with drugs and psychoactive substances), the diagnosis of schizophrenia is not set, and the corresponding diagnostic categories and codes are applied.

Schizophrenia in childhood.

All the various manifestations of schizophrenia in children and adolescents can be grouped into four most typical psychopathological conditions, characteristic to a certain extent for all forms of schizophrenia.

Pathological (delusional) fantasizing is observed mainly in preschool children.

Pathological fantasizing at the beginning of its appearance almost does not differ from the usual fantasies of a child, but in the future it acquires a character completely divorced from reality and is often associated with deceptions of the senses. The child begins to get along with the characters of his fantasy world, in which he is allowed everything that is inaccessible to him in ordinary life. He lives the stereotypical life of the game, which is diametrically opposed to the surrounding reality. In his fantasies, the child tries to realize his aspirations unrealizable in real life, dreams of power, the discovery of unknown countries, is fond of inventions, questions of a philosophical nature - what is life, time, who are people, etc. Claiming (fantasizing) that he is a hare or a horse, the child refuses ordinary food and may demand grass, hay, grain, etc.

Abulia in schoolchildren is observed in a pronounced form.

In this case, the child becomes lethargic and apathetic, ceases to show the activity characteristic of him before, closes in himself, becomes inaccessible and incomprehensible to others. A tendency to a prolonged inactive existence, increasing lethargy, a decrease in mental activity, a sharp drop in working capacity - like chronic fatigue

are early hallmarks of schizophrenia.

As a rule, parents and educators regard abulia as a manifestation of laziness. In reality, this is not laziness, but the beginning of the schizophrenic process. Over time, the decrease in activity manifests itself more and more sharply. The child ceases to fulfill his duties, is not interested in anything, aimlessly

wanders around the house from corner to corner, is in bed for hours or days, he has no drives and desires, he refuses to attend kindergarten or school, does not communicate with family and friends, becomes sloppy. A decrease in volitional activity leads to the fact that the child ceases to perform even the simplest actions (for example, if he is not offered food, then he may not take it, lying in bed all day.) Along with violations of volitional activity, unmotivated, ridiculous actions of the impulsive type. Suddenly, against the background of a calm state, a sick child can scream loudly, unexpectedly hit an adult or kiss a stranger, swear cynically, persistently seek the realization of an absurd desire. These phenomena are often joined by hypochondriacal, delusional ideas of influence and hallucinations. In most cases, they are fragile and fragmentary.

Emotional dullness is one of the persistent and most characteristic manifestations of schizophrenia. Due to the growing extinction of emotions, the sick child loses contact with others, becomes indifferent to what in the past was the basis of his interests, shows indifference to family and friends, to his life. The patient loses his sense of tact, rudeness, shamelessness appear, for the slightest insignificant reason, an explosion of rage occurs, and, on the contrary, no response is manifested to the effect of a strong stimulus, the patient has no relationship between affect and intellect. In far-reaching protracted cases, a sharp disorder of emotions is observed, affective ambivalence is transformed into emotional dullness. The patient loses the brightness and immediacy of feelings, nothing interests him, does not make him happy, does not sadden him, that is, as the disease progresses, emotional reactions acquire the character of complete indifference, the impoverishment of feelings, emotional dullness increases.

Splitting (disrupted) thinking is a symptom typical of any form of schizophrenia. It is characterized by a separation of thinking from reality, a tendency to fruitless philosophizing and symbolism. Some patients talk a lot, others completely stop talking or carefully repeat individual words or phrases, stringing them in disorder one on top of the other. Their speech is replete with new words that are not used in everyday life. In written speech, pretentious letters, curls, underlining, an abundance of punctuation and symbolic designations, etc. prevail.

The main forms of schizophrenia in children and adolescents.

There are several forms of schizophrenia in children and adolescents. A.I. Seletsky highlights the following:

Catatonic form

In some cases, it is characterized by increasing isolation, detachment from the surrounding reality and depression, but more often it is accompanied by catatonic excitement, turning into a stupor, strong muscle tension, freezing in bizarre poses, immobility, negativism and refusal of food and speech contact.

In cases of acute course, the disease is limited

several bouts of stupor and excitement and recovery comes. In the chronic course of schizophrenia in the patient, symptoms of lethargy and lethargy with rare prolonged remissions increase, changes in the psyche occur in the form of affective devastation and increasing dementia.Thus, with this form of schizophrenia, both long-term remissions and complete recovery are characteristic.

Hebephrenic or juvenile schizophrenia

It is characterized by a slow course of schizophrenia, observed in senior school and adolescence. The disease begins gradually, with the appearance of complaints of absent-mindedness, acute headache and insomnia. After the onset of such complaints, months or even years can pass, so the people around the patient often cannot establish the time of the onset of the disease. The leading symptom of the disease is foolishness with unmotivated gaiety and motor excitement. The constant symptoms of this form of the disease are ridiculous gaiety with mannerism, features of foolishness, the same ridiculous antics, a tendency to eccentricity, grimacing and antics.

Simple form of schizophrenia

It begins at any age, but is more common in childhood and less often in adolescence. The leading signs of the disease are progressive loss of interests, increasing lethargy, emotional indifference, isolation and a decrease in indicators associated with intelligence. Occasionally, hallucinations and paranoid states occur, accompanied by vicious aggressiveness towards family and friends, who usually insistently demand that the child attend school. The sick leave home, spend time aimlessly wandering the streets, and engage in antisocial acts.

The vaccinated form of schizophrenia

It is observed in children and adolescents who in the past have suffered any organic brain damage, which caused a delay in mental development, mainly oligophrenia. Before the onset of the disease, the child's personality was characterized by the following features: capricious stubbornness, isolation, outbursts of irritability, past illnesses of unexplained etiology, diathesis, intoxication, craniocerebral trauma, etc. Thus, schizophrenia is already grafted onto biologically altered soil, which significantly complicates the course of the pathological process and leads, especially when the disease occurs in early childhood, to a halt in mental development.

The course and outcome of these forms of schizophrenia can end with recovery, prolonged remission, and apathetic dementia.

In the last decade, significant advances have been made in the treatment of schizophrenia. There are many different therapeutic techniques, sometimes allowing patients, even with a severe psychopathological picture, to achieve significant improvement.

All types of drug treatment for schizophrenia must be combined with psychotherapeutic influences. Patients should be involved in work, properly organizing their regimen during treatment, both in the hospital and at home.

Currently, psychotropic drugs are widely used, as well as comatose methods of treatment (insulin, atropinomatous, electroconvulsive therapy).

The choice of these or those methods of treatment depends on the form, type of course and duration of the disease, as well as on the structure of the leading syndrome.

If there is an acute hallucinatory-delusional syndrome in the clinical picture, antipsychotics are prescribed with a predominantly inhibitory effect in rapidly increasing dosages (chlorpromazine -1 - 400 mg, tizercin - 250 - 400 mg, trisedil - 2 - 5 mg, triftazine - 40 - 60 mg per day and etc).

With the catatonic form of schizophrenia, mazheptil is shown (up to 150 mg per day), with simple schizophrenia - frenolone (up to 80 - 120 mg per day).

The presence of depressive symptoms in the clinical picture requires additional antidepressants (melipramine - up to 75 - 150 mg, amitriptyline - up to 100 - 150 mg, or pyrazidol - up to 150 mg per day in gradually increasing dosages).

Shown and other psychotropic drugs, including drugs with prolonged action, you should also forget about the correctors - Cyclodol, Artan, Parkopan, Romparkin, Dinesin, Noraquin, etc.

Upon reaching a therapeutic effect, patients with schizophrenia are prescribed anti-relapse treatment with psychotropic drugs (preferably with prolonged-release drugs - moditen-depot fluspirylene). At the same time, they carry out rehabilitation measures for their social and labor structure, providing psychotherapeutic assistance, as well as for improving the microsocial environment.

The number of preventive measures should include the need for patients to comply with the correct hygienic regime of work and life, maintaining a healthy lifestyle. Physical and mental fatigue, all kinds of psychogenic trauma and, especially, a state of prolonged forced stress can provoke a relapse. The exacerbation of the process can be facilitated by various intoxications as well as infections.

In many forms of schizophrenia, behavioral disturbances and increased pathological activity are often found. However, serious physical violence against others, much less murder, is rare. In the presence of delusional ideas of persecution in the patient's symptoms, along with auditory hallucinations (especially imperative ones), self-harm and suicidal attempts are possible. About one in ten people with schizophrenia die by suicide.

In a forensic psychiatric assessment of patients with schizophrenia, subjects are usually recognized as insane. In cases where a schizophrenic disorder or a sluggish process is diagnosed, the issue is resolved individually.

Affective mood disorders.

Mood disorders include a wide range of mental disorders, most often manifested either in a pathologically depressed mood - a depressive episode, or in its painful increase - a manic episode. When a patient suffers repeated episodes of depression (but not mania) - recurrent depressive disorders, if during the course of the disease there was at least one episode of mania or hypomania - this is bipolar affective disorder.

Bipolar disorder (formerly manic-depressive psychosis) is a mental disorder that manifests itself in affective states - manic (hypomanic) and depressive, as well as mixed states in which the patient has symptoms of depression and mania at the same time (for example, melancholy with agitation, anxiety , or euphoria with lethargy, d - so-called unproductive mania), or a rapid change in symptoms of (hypo) mania and (sub) depression.

These states periodically, in the form of phases, directly or through "bright" intervals of mental health (the so-called interphases, or intermissions), replace each other, without or almost without a decrease in mental functions, even with a large number of transferred phases and any duration of the disease. Clinical picture, course

The onset of bipolar disorder occurs more often at a young age - 20-30 years. The number of phases possible for each patient, an unpredictable disorder can be limited to only one phase (mania, hypomania or depression) in a lifetime, can manifest itself only as manic, only hypomanic or only depressive phases, or change them with correct or incorrect alternation.

The duration of the phases ranges from several weeks to 1.5-2 years (on average 3-7 months), the duration of the "light" intervals (intermissions or interphases) between the phases can be from 3 to 7 years; The "light" gap may be completely absent; Atypical phases can be manifested by a disproportionate severity of core (affective, motor and ideatorial) disorders, incomplete development of stages within one phase, inclusion of obsessive, senestopathic, hypochondriac, heterogeneous delusional (in particular, paranoid), hallucinatory and catatonic phases in the psychopathological structure.

The course of the manic phase

The manic phase is represented by a triad of main symptoms:

Elevated mood (hyperthymia)

Motor excitement

Ideatorial psychic (tachypsychia) excitement.

During the manic phase, there are five stages.

The hypomanic stage (F31.0no ICD-10) is characterized by an increased mood, the appearance of a feeling of spiritual uplift, physical and mental vigor. Speech is verbose, accelerated, the number of semantic associations decreases with the growth of mechanical associations (in terms of similarity and consonance in space and time). Moderately expressed motor excitement is characteristic. Attention is characterized by increased distraction. Hypermnesia is characteristic. Sleep duration is moderately reduced.

The stage of severe mania is characterized by a further increase in the severity of the main symptoms of the phase. Patients constantly joke, laugh, against which short-term outbursts of anger are possible. Speech arousal is pronounced, reaches the degree of a jump of ideas (lat.fuga idearum). At work, patients build bright prospects, invest in hopeless projects, and design insane structures. The duration of sleep is reduced to 3-4 hours a day.

The stage of manic frenzy is characterized by the maximum severity of the main symptoms. Sharply motor excitement is disordered, speech is outwardly incoherent (during analysis, it is possible to establish mechanically associative connections between the components of speech), consists of fragments of phrases, individual words or even syllables.

The stage of motor sedation is characterized by a reduction in motor excitement against the background of persisting increased mood and speech arousal. The intensity of the last two symptoms also gradually decreases.

The reactive stage is characterized by the return of all components of the symptoms of mania to normal and even a slight decrease compared to the normal mood, mild motor and ideational retardation, asthenia. Some episodes of the stage of severe mania and the stage of manic fury in patients may be amnesiac.

The course of the depressive phase

The depressive phase is represented by the opposite triad of symptoms to the manic stage: depressed mood (hypothymia), slow thinking (bradypsychia) and motor retardation. In general, bipolar disorder is more likely to be depressive than manic. During the depressive phase, four stages are distinguished.

The initial stage of depression is manifested by a mild weakening of the general mental tone, decreased mood, mental and physical performance. Characterized by the appearance of moderate sleep disorders in the form of difficulty falling asleep and its superficiality. For all stages of the course of the depressive phase, an improvement in mood and general well-being in the evening hours is characteristic.

The stage of increasing depression is already characterized by a clear decrease in mood with the appearance of an anxious component, a sharp decrease in physical and mental performance, and motor retardation. Speech is slow, laconic, quiet. Sleep disturbances result in insomnia. A marked decrease in appetite is characteristic.

Stage of severe depression - all symptoms reach their maximum development. Characterized by severe psychotic affects of longing and anxiety, painfully experienced by patients. Speech is sharply slowed down, quiet or whispering, answers to questions are monosyllabic, with a long delay. Patients can sit or lie in one position for a long time (the so-called "depressive stupor"). Anorexia is characteristic. Suicidal attempts are most frequent and dangerous at the beginning of the stage and at the exit from it, when there is no pronounced motor retardation against the background of severe hypothymia. Illusions and hallucinations are rare.

The reactive stage is characterized by a gradual reduction of all symptoms, asthenia persists for some time, but sometimes, on the contrary, there is some hyperthymia, talkativeness, increased motor activity.

Options for the course of bipolar disorder:

Periodic mania - only manic phases alternate;

Periodic depression - only depressive phases alternate;

Correctly intermittent type of flow - through the "light" intervals, the manic phase replaces the depressive, depressive - manic;

Incorrectly intermittent type of flow - through "light" intervals, manic and depressive phases alternate without a strict sequence (after the manic phase, the manic phase may begin again and vice versa);

Double form - a direct change of two opposite phases, followed by a "light" gap;

Circular type of flow - there are no “light” gaps.

The most frequent types of the course are the irregular-intermittent type and intermittent depression.

Depressive phase

Understanding the structure of depression, the type of bipolar disorder in general, and the patient's health is critical to treating the depressive phase of bipolar disorder.

Treatment with antidepressants must be combined with mood stabilizers - normotimics, and even better with atypical antipsychotics. The most progressive is the combination of antidepressants with atypical antipsychotics such as olanzapine, quetiapine or aripiprazole - these drugs not only prevent phase inversion, but also have an antidepressant effect themselves. In addition, it has been shown that olanzapine allows one to overcome resistance to serotonergic antidepressants: now a combined drug - olanzapine + fluoxetine - Symbyax is being produced.

Manic phase

The main role in the treatment of the manic phase is played by normotimics (lithium preparations, carbamazepine, valproic acid, lamotrigine), but antipsychotics are needed to quickly eliminate symptoms, and priority is given to atypical antipsychotics - classical antipsychotics can not only provoke depression, but also cause extrapyramidal disorders, to which patients with bipolar disorder are especially predisposed and, especially, to tardive dyskinesia - an irreversible disorder leading to disability.

Prevention of exacerbations of bipolar disorder. $

For the purpose of prevention, normotimics are used - mood stabilizers. These include: lithium carbonate, carbamazepine (Finlepsin, Tegretol), valproates (Depakin, Konvulex). It is worth noting lamotrigine (Lamictal), which is especially indicated for a fast-cyclic course with a predominance of depressive phases. Atypical antipsychotics are very promising in this regard, and olanzapine and aripiprazole have already been approved in a number of developed countries as mood stabilizers in bipolar disorder.

Depression. Involuntary psychoses.

/ F32 / Depressive episode ”- this is the first time in a person's life endured state of depression. A mild depressive episode, a mild depressive episode, and a severe depressive episode are distinguished. The main symptoms of depression are:

the patient suffers from low mood, loss of interest and pleasure,

decreased energy, which can lead to increased fatigue and decreased activity. There is marked fatigue even with little effort. Other symptoms include:

a) reduced ability to concentrate and attention;

b) decreased self-esteem and self-confidence;

c) ideas of guilt and humiliation (even with a mild type of episode);

d) a gloomy and pessimistic vision of the future;

e) ideas or actions aimed at self-harm or suicide;

f) disturbed sleep;

g) decreased appetite.

Low libido, menstrual irregularities

i) heart pain, tachycardia, fluctuations in blood pressure, constipation, dry skin

Diagnostic instructions:

A mild depressive episode is characterized by:

For a reliable diagnosis, at least 2 of these 3 main symptoms are needed, plus at least 2 more of the other symptoms described above (for F32). None of these symptoms should be profound, and the minimum duration for an entire episode is about 2 weeks.

A moderate depressive episode is characterized by: the presence of at least 2 of the main symptoms, plus 3-4 of other symptoms, while the symptoms are expressed to such an extent that the patient has difficulties in performing professional and domestic duties, and the minimum duration of the entire episode is about 2 weeks ...

A severe depressive episode is characterized by:

The presence of 3 main criteria, plus 4 or more other signs, and at least some of them are severely expressed. The patient is unable to perform even simple household chores. Duration 2 weeks or more.

/ EZZ / Recurrent Depressive Disorder

A disorder characterized by recurrent episodes of depression without a history of individual episodes of elevated mood, hyperactivity that may meet the criteria for mania (F30.1 and F30.2x). The age of onset, severity, duration, and frequency of episodes of depression vary widely. In general, the first episode occurs later than in bipolar depression: on average, in the fifth decade of life. Episodes last 3-12 months (average about 6 months), but they tend to recur more rarely. Although recovery is usually complete in the interictal period, a small proportion of patients show chronic depression, especially in old age (this section is also used for this category of patients). Individual episodes of any severity are often triggered by a stressful situation and, in many cultural conditions, are observed 2 times more often in women than in men.

The risk that a patient with a recurrent depressive episode will not have an episode of mania cannot be completely ruled out, no matter how many depressive episodes there are in the past. If an episode of mania occurs, the diagnosis should be changed to bipolar disorder.

Chronic mood disorders - when the patient's mood disorders persist almost constantly, without light gaps, but their severity is small. These disorders include cyclothymia and dysthymia.

Dysthymia

The clinical picture of dysthymia

Dysthymia is characterized by chronic non-psychotic signs and symptoms of depression that meet specific diagnostic criteria but do not meet the criteria for mild depressive disorder. Dysthymia is characterized by a chronic course without intervals during which pathological symptoms are absent.

The appearance and behavior of the patient. These patients show introversion, gloominess, and low self-esteem. Patients are characterized by many somatic complaints. The main symptom is a feeling of sadness, a vision of the world in a black light, a decrease in interests. Patients with dysthymia are sarcastic, nihilistic, reflective, demanding and complaining. Such patients often have difficulties in interpersonal relationships: with colleagues at work, in family life. Alcohol abuse is possible.

Diagnostic criteria (the diagnosis is made in the presence of 1 symptom and at least three listed under paragraph 2)

Depressed mood for at least 2 years (1 year for children and adolescents), symptom-free period should not exceed 2 months.

The presence of at least two factors:

poor appetite

insomnia / drowsiness

low energy, fatigue

decreased attention

feeling of hopelessness

Absence of an obvious attack of severe depressive disorder within 2 years (for children and adolescents - within 1 year).

No episode of mania or hypomania

Cyclothymia is, as it were, a mitigated form of bipolar disorder, in which the patient, without connection with external events, has a constant alternation of periods of slightly reduced and slightly elevated mood. Manic episode

A manic episode is a combination of increased mood, acceleration of the pace of thinking and increased physical activity.

Patients' physical appearance often reflects Elevated Mood. Patients, especially women, tend to dress brightly and defiantly, and use makeup excessively. The eyes shine, the face is hyperemic, when talking from the mouth, saliva splashes often fly out. Facial expressions are notable for liveliness, movements are quick and impetuous, gestures and postures are emphatically expressive.

Heightened mood is combined with unshakable optimism. All the experiences of patients are colored only in rainbow tones. Patients are carefree, they have no problems. Past troubles and misfortunes are forgotten, the future is drawn only in bright colors.

Increased physical activity - patients are in motion all the time, cannot sit still, walk, interfere with everything, try to command the sick, etc. Patients, during conversations with the doctor, they often change their posture, turn around, jump up from their seats, begin to walk and often even run around the office.

Acceleration of the pace of thinking - patients talk a lot, loudly, quickly, often without stopping. With prolonged speech arousal, the voice becomes hoarse. The content of the statements is inconsistent. Easily move from one topic to another. With the intensification of speech excitement, the thought that does not have time to end is already replaced by another, as a result of which the statements become fragmentary ("a jump of ideas"). The speech alternates with jokes, witticisms, puns, foreign words, quotes.

Sleep disorders are manifested in the fact that patients sleep a little (3-5 hours a day), but at the same time they always feel vigorous, full of energy.

With manic syndrome, an increase in appetite and an increase in libido are almost always noted.

Expansive ideas. Opportunities to realize numerous plans and desires seem limitless to patients, patients do not see obstacles to their implementation. Expansive ideas easily turn into expansive delusions, which are manifested most often by delusional ideas of greatness, invention and reform.

With severe manic syndrome, hallucinations are noted (rarely). Auditory hallucinations are usually praising content (for example, voices tell the patient that he is a great inventor). With visual hallucinations, the patient sees religious scenes.

A hypomanic state (hypomania) is characterized by the same features as pronounced mania, but all symptoms are smoothed out, there are no gross behavioral disturbances leading to complete social maladjustment. Patients are mobile, energetic, prone to jokes, overly talkative. The increase in their mood does not reach the degree of conspicuous indomitable gaiety, but manifests itself in cheerfulness and optimistic faith in the success of any business started. Many plans and ideas arise, sometimes useful and reasonable, sometimes overly risky and frivolous. They make dubious acquaintances, lead an indiscriminate sex life, begin to abuse alcohol, easily take the path of breaking the law.

Also distinguish:

mania without psychotic symptoms: the episode lasts more than 1 week, and the symptoms are so severe that they interfere with the professional and social activities of the patient.

Manias with psychotic symptoms: In patients with characteristic manifestations, delusions, hallucinations and catotonic outbursts are noted.

TREATMENT Basic principles:

Combining drug therapy with psychotherapy

Individual selection of drugs depending on the prevailing symptoms, efficacy and tolerability of drugs. Prescribing small doses of drugs with a gradual increase

Prescription for exacerbation of previously effective drugs

Reconsideration of the treatment regimen in the absence of effect within 4-6 weeks Treatment of depressive episodes

TAD - amitriptyline and imipramine.

Selective serotonin reuptake inhibitors. The drugs are prescribed once in the morning: fluoxetine 20-40 mg / day, sertraline 50-100 mg / day, paroxetine 10-30 mg / day.

MAO inhibitors (for example, nialamide 200-350 mg / day, better in 2 doses in the morning and afternoon

Electroconvulsive therapy (ECT). Clinical studies have shown that the antidepressant effect of ECT develops faster and is more effective in patients with severe depressive disorder with delusional ideas than when using TAD. Thus, ECT is the method of choice in the treatment of patients with depressive disorder with psychomotor retardation and delirium with ineffective drug therapy.