All mental disorders are usually divided into two levels: neurotic and psychotic.
The border between these levels is conditional, however, it is assumed that gross, pronounced symptoms are a sign of psychosis ...
Neurotic (and neurosis-like) disorders, on the other hand, are characterized by mild and smooth symptoms.
Mental disorders are called neurosis-like if they are clinically similar to neurotic disorders, but, unlike the latter, are not caused by psychogenic factors and have a different origin. Thus, the concept of the neurotic level of mental disorders is not identical with the concept of neuroses as a group of psychogenic diseases with a non-psychotic clinical picture. In this regard, a number of psychiatrists avoid using the traditional concept of "neurotic level", preferring more precise concepts of "non-psychotic level", "non-psychotic disorders" to it.
Neurotic and psychotic concepts are not associated with any particular disease.
Disorders of the neurotic level often debut progressive mental illnesses, which subsequently, as the symptoms worsen, give a picture of psychosis. In some mental illnesses, such as neuroses, mental disorders never exceed the neurotic (non-psychotic) level.
PB Gannushkin suggested calling the entire group of non-psychotic mental disorders "small", and VA Gilyarovsky - "borderline" psychiatry.
The concept of borderline mental disorders is used to denote mild disorders bordering on the state of health and separating it from the pathological mental manifestations themselves, accompanied by significant deviations from the norm. Disorders of this group violate only certain areas of mental activity. In their emergence and course, social factors play a significant role, which, with a certain degree of conventionality, makes it possible to characterize them as breakdown of mental adaptation... The group of borderline mental disorders does not include neurotic and neurosis-like symptom complexes accompanying psychotic (schizophrenia, etc.), somatic and neurological diseases.
Borderline mental disorders according to Yu.A. Alexandrovsky (1993)
1) the predominance of the neurotic level of psychopathology;
2) the relationship of mental disorder with autonomic dysfunctions, sleep disturbances and somatic disorders;
3) the leading role of psychogenic factors in the onset and decompensation of painful disorders;
4) the presence of "organic" pre-location (MMD), facilitating the development and decompensation of the disease;
5) the relationship of painful disorders with the personality and typological characteristics of the patient;
6) maintaining criticism of one's condition and major painful disorders;
7) the absence of psychosis, progressive dementia or personality endogenous (schizoform, epileptic) changes.
The most characteristic signs borderline psychopathologists:
neurotic level = functional character and reversibility existing violations;
vegetative "accompaniment", the presence of comorbid asthenic, dyssomnic and somatoform disorders;
connection of the occurrence of diseases with psycho-traumatic circumstances and
personality-typological characteristics;
ego dystonicity(unacceptability for the patient's "I") painful manifestations and maintaining a critical attitude towards the disease.
Neurotic disorders(neuroses) - a group of psychogenically conditioned disease states characterized by the partial and ego-dystonic nature of various clinical manifestations that do not change the identity of the individual and the awareness of the disease.
Neurotic disorders disturb only certain areas of mental activity, not accompanied by psychotic phenomena and gross behavioral disturbances, but at the same time they can significantly affect the quality of life.
Definition of neuroses
Neuroses are understood as a group of functional neuropsychic disorders, including emotional-affective and somatovegetative disorders caused by psychogenic factors leading to a breakdown in mental adaptation and self-regulation.
Neurosis is a psychogenic disease without organic pathology of the brain.
Reversible mental disorder caused by exposure to traumatic factors and ongoing with the patient's awareness of the fact of his illness and without disturbing the reflection of the real world.
The doctrine of neuroses: two tendencies:
1 ... Researchers proceed from the recognition of the determinism of neurotic phenomena as certain pathologicalbiological mechanisms , although they do not deny the role of mental trauma as a triggering mechanism and a possible condition for the onset of the disease. However, the psychotrauma itself at the same time acts as one of the possible and equivalent exogenies that violate homeostasis.
Within the framework of negative diagnosis indicates the absence of violations of a different level, neurosis-like and pseudoneurotic disorders of organic, somatic or schizophrenic genesis.
2. The second trend in the study of the nature of neuroses lies in the assumption that the entire clinical picture of neurosis can be deduced from some only psychological mechanisms ... Supporters of this direction believe that information of a somatic nature is fundamentally insignificant for understanding the clinic, genesis and therapy of neurotic conditions.
Concept positive diagnosis neuroses are presented in the works of V.N. Myasishchev.
Positive diagnosis follows from the recognition of the content nature of the category of “psychogenic”.
V.N. Myasishcheva In 1934 g.
V.N.Myasishchev noted that neurosis is personality disease, primarily personality development disease.
By personality disease, he understood the category of neuropsychiatric disorders, which is caused by how a person processes or experiences his reality, his place and his destiny in this reality.
Neuroses are based on the unsuccessfully, irrationally and unproductively resolved contradictions between the personality and the sides of reality that are significant for her, causing painful and painful experiences:
failures in life's struggle, failure to meet needs, an unattained goal, an irreparable loss.
The inability to find a rational and productive way out entails mental and physiological disorganization of the personality.
Neurosis is a psychogenic (usually conflictogenic) neuropsychic disorder that occurs as a result violations of especially significant life relationships personality and manifests itself in specific clinical phenomena in the absence of psychotic phenomena.
E Pilepsy is one of the common neuropsychiatric diseases: its prevalence in the population is in the range of 0.8-1.2%.
It is known that mental disorders are an essential component of the clinical picture of epilepsy, complicating its course. According to A. Trimble (1983), A. Moller, W. Mombouer (1992), there is a close relationship between the severity of the disease and mental disorders, which are much more common in the unfavorable course of epilepsy.
In the past few years, as statistical studies show, in the structure of mental illness there is an increase in forms of epilepsy with non-psychotic disorders ... At the same time, the proportion of epileptic psychoses is decreasing, which reflects the obvious pathomorphosis of the clinical manifestations of the disease, caused by the influence of a number of biological and social factors.
One of the leading places in the clinic for non-psychotic forms of epilepsy is occupied by affective disorders , which often show a tendency towards chronicity. This confirms the position that, despite the achieved remission of seizures, impairments to the emotional sphere are an obstacle to the full recovery of the patient's health (Maksutova E.L., Frecher V., 1998).
In the clinical qualification of certain syndromes of the affective register, it is fundamental to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes proper. In this regard, we can conditionally single out two mechanisms of syndromic formation of a group of affective disorders - primary, where the indicated symptoms act as components of paroxysmal disorders proper, and secondary - without a causal relationship with an attack, but based on various manifestations of reactions to the disease, as well as to additional psycho-traumatic influences.
So, according to the research of patients in a specialized hospital of the Moscow Research Institute of Psychiatry, it was found that phenomenologically non-psychotic mental disorders are represented by three types of conditions:
1) depressive disorder in the form of depression and subdepression;
2) obsessive - phobic disorders;
3) other affective disorders.
Depression spectrum disorders include the following:
1. Dreary depression and subdepression were observed in 47.8% of patients. The prevailing in the clinic here was an anxious-melancholy affect with a persistent decrease in mood, often accompanied by irritability. Patients noted mental discomfort, heaviness in the chest. In some patients, there was a connection between these sensations and physical malaise (headache, discomfort behind the breastbone) and were accompanied by motor restlessness, less often combined with adynamia.
2. Adynamic depression and subdepression were observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. They spent most of the time in bed, with difficulty performing simple self-care functions, complaints of rapid fatigue and irritability were typical.
3. Hypochondriacal depression and subdepression were observed in 13% of patients and were accompanied by a constant feeling of physical damage, heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that sudden death may occur during an attack or they will not be helped in time. Rarely did the interpretation of phobias go beyond the specified storyline. Senestopathies were distinguished by hypochondriac fixation, a feature of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less often, the basis of senestopathies was autonomic disorders.
The variant of hypochondriac depression was more typical for the interictal period, especially in the conditions of chronicity of these disorders. However, their transient forms were often noted in the early postictal period.
4. Anxiety depression and subdepression occurred in 8.7% of patients. Anxiety, as a component of an attack (less often of an interictal state), was distinguished by an amorphous plot. Patients were more likely to be unable to determine the motives for anxiety or the presence of any specific fears and reported that they experience vague fear or anxiety, the cause of which they do not understand. A short-term anxious affect (several minutes, less often within 1-2 hours), as a rule, is characteristic of a variant of phobias, as a component of a seizure (within the aura, the seizure itself, or a post-seizure state).
5. Depression with depersonalization disorders were observed in 0.5% of patients. In this variant, the dominant were the sensations of a change in the perception of one's own body, often with a feeling of alienation. The perception of the environment and time also changed. So, along with a feeling of adynamia, hypothymia, patients noted periods when the environment "changed", time "accelerated", it seemed that the head, arms, etc. were increasing. These experiences, in contrast to the true paroxysms of depersonalization, were characterized by the preservation of consciousness with full orientation and had a fragmentary character.
Psychopathological syndromes with a predominance of anxious affect made up mainly the second group of patients with "obsessive-phobic disorders". An analysis of the structure of these disorders showed that they are closely related to almost all components of the seizure, starting with the precursors, the aura, the seizure itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of paroxysm, preceding or accompanying an attack, manifested itself as a sudden fear, often of an indefinite content, which the patients described as an “impending threat” that increased anxiety, giving rise to a desire to urgently do something or seek help from others. Individual patients often indicated fear of death from an attack, fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, less often there were sociophobic experiences (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. A close connection of obsessive-phobic disorders with the vegetative component was noted, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, thoughts were observed.
In contrast to paroxysmal anxiety, anxious affect in remission approaches in form the classical variants in the form of unmotivated fears for one's health, the health of loved ones, etc. A number of patients have a tendency to form obsessive-phobic disorders with obsessive fears, fears, actions, actions, etc. In some cases, there are protective mechanisms of behavior with peculiar measures to counteract the disease, such as rituals, etc. In terms of therapy, the most unfavorable option is a complex symptom complex, including obsessive-phobic disorders, as well as depressive formations.
The third type of borderline forms of mental disorders in the epilepsy clinic was affective disorders , designated by us as "other affective disorders".
Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphorias, etc.
Among this group of borderline disorders, acting both in the form of paroxysms and prolonged states, were more often observed epileptic dysphoria ... Dysphoria, proceeding in the form of short episodes, more often took place in the structure of the aura, preceding an epileptic seizure or a series of seizures, but they were most widely presented in the interictal period. In terms of clinical features and severity, asthenic-hypochondriac manifestations, irritability, and the affect of anger prevailed in their structure. Protest reactions were often formed. In a number of patients, aggressive actions were observed.
The syndrome of emotional lability was distinguished by a significant amplitude of affective fluctuations (from euphoria to anger), but without noticeable behavioral disturbances characteristic of dysphoria.
Among other forms of affective disorders, mainly in the form of short episodes, there were reactions of weakness, manifested in the form of affect incontinence. Usually, they appeared outside the framework of a formalized depressive or anxiety disorder, representing an independent phenomenon.
In relation to individual phases of an attack, the frequency of associated borderline mental disorders is presented as follows: in the structure of the aura - 3.5%, in the structure of the attack - 22.8%, in the post-attack period - 29.8%, in the interictal period - 43.9% %.
Within the framework of the so-called harbingers of seizures, various functional disorders are well known, mainly of a vegetative nature (nausea, yawning, chills, salivation, fatigue, impaired appetite), against which there is anxiety, decreased mood or mood swings with a predominance of irritable-gloomy affect. A number of observations in this period noted emotional lability with explosiveness, a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can self-stop.
Aura with affective experiences - a frequent component of the subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension, a feeling of "faintness". Less often, there are pleasant sensations (an increase in vitality, a feeling of special lightness and high spirits), followed by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either the affect of fear and anxiety can occur, or a neutral (less often excited-elated) mood is noted.
In the structure of the paroxysm itself, the most frequent syndromes of the affective series are found in the framework of the so-called temporal lobe epilepsy.
As you know, motivational and emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly mediobasal formations included in the limbic system. At the same time, affective disorders are most widely represented in the presence of a temporal focus in one or both temporal lobes.
With the localization of the focus in the right temporal lobe, depressive disorders are more common and have a more outlined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with a different plot of phobias and episodes of arousal. The specified clinic fits completely into the allocated "right hemispheric affective disorder" in the systematics of organic syndromes ICD-10.
TO paroxysmal affective disorders (within an attack) include sudden and lasting for several seconds (less often minutes) attacks of fear, unaccountable anxiety, sometimes with a feeling of melancholy. There may be impulsive short-term states of increased sexual (food) desire, a feeling of increased strength, joyful anticipation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. The predominantly violent nature of these experiences should be emphasized, although individual cases of their arbitrary correction by conditioned reflex techniques indicate their more complex pathogenesis.
"Affective" seizures occur either in isolation or are part of the structure of other seizures, including convulsive seizures. Most often they are included in the structure of the aura of a psychomotor seizure, less often in vegetative-visceral paroxysms.
The group of paroxysmal affective disorders within the framework of temporal lobe epilepsy includes dysphoric conditions, the duration of which can range from several hours to several days. In some cases, dysphoria in the form of short episodes precede the development of another epileptic seizure or a series of seizures.
The second most frequent affective disorders are clinical forms with dominant autonomic paroxysms in the framework of diencephalic epilepsy ... Analogs of the widespread designation of paroxysmal (crisis) disorders as "vegetative attacks" are widely used in neurological and psychiatric practice concepts such as "diencephalic" attack, "panic attacks" and other conditions with a large vegetative accompaniment.
Classic manifestations of crisis disorders include suddenly developed: shortness of breath, feeling short of breath, discomfort from the organs of the chest cavity and abdomen with "sinking of the heart", "interruptions", "pulsation", etc. These phenomena are accompanied, as a rule, by dizziness, chills, tremors , various paresthesias. Possible increased stool frequency, urination. The most powerful manifestations are anxiety, fear of death, fear of going crazy.
Affective symptomatology in the form of individual unstable fears can be transformed both into affective paroxysm itself and into permanent variants with fluctuations in the severity of these disorders. In more severe cases, a transition to a persistent dysphoric state with aggression (less often auto-aggressive actions) is possible.
In epileptological practice, vegetative crises are found mainly in combination with other types (convulsive or non-convulsive) paroxysms, causing polymorphism in the clinical picture of the disease.
Regarding the clinical characteristics of the so-called secondary-reactive disorders, it should be pointed out that we include a variety of psychologically understandable reactions to the disease that arise in epilepsy. At the same time, side effects as a response to therapy, as well as a number of occupational restrictions and other social consequences of the disease include both transient and prolonged conditions. They often manifest themselves in the form of phobic, obsessive-phobic and other symptoms, in the formation of which the individual and personal characteristics of the patient and additional psychogenias play a large role. At the same time, the clinic of protracted forms in a broad sense of situational (reactive) symptoms is largely determined by the nature of cerebral (deficit) changes, which gives them a number of features associated with organic soil. The clinic of emerging secondary reactive disorders also reflects the degree of personal (epithemic) changes.
Within the framework of reactive inclusions patients with epilepsy often have concerns:
- developing a seizure on the street, at work
- get injured or die during a seizure
- go crazy
- inherited disease
- side effects of anticonvulsants
- forced withdrawal of drugs or untimely completion of treatment without guarantees for recurrence of seizures.
The reaction to a seizure at work is usually much more severe than a seizure at home. For fear that a seizure will occur, some patients stop studying, work, and do not go outside.
It should be pointed out that, according to the induction mechanisms, the fear of a seizure may appear in relatives of patients, which requires a lot of family psychotherapeutic assistance.
Fear of the onset of a seizure is more often observed in patients with rare paroxysms. Patients with frequent attacks during a long illness become so used to them that, as a rule, they hardly experience such fear. So, in patients with frequent seizures and a longer duration of the disease, signs of anosognosis and uncritical behavior are usually noted.
Fear of bodily harm or fear of death during a seizure is more easily developed in patients with psychosthenic personality traits. It also matters that they have previously had accidents, bruises due to seizures. Some patients fear not so much the attack itself as the likelihood of injury.
Sometimes the fear of having a seizure is largely due to the unpleasant subjective sensations that occur during the seizure. These experiences include terrifying illusory, hallucinatory, and body schema disturbances.
This distinction between affective disorders is of fundamental importance in determining further therapy.
Principles of therapy
The main direction of therapeutic tactics in relation to individual affective components of the attack itself and the post-attack emotional disorders closely related to it, is the adequate use of anticonvulsants with thymoleptic effect (cardimizepine, valproate, lamotrigine).
While not anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic scheme has a positive effect both on the paroxysms themselves and on secondary affective disorders. However, it is advisable to limit the time of their use to three years due to the risk of addiction.
Recently, anti-anxiety and sedation have been widely used. clonazepam which is highly effective for absences.
For various forms of affective disorders with a depressive radical, the most effective antidepressants ... At the same time, on an outpatient basis, agents with minimal side effects, such as tianeptyl, miaxerin, fluoxetine, are preferred.
In the case of a predominance of the obsessive-compulsive component in the structure of depression, the appointment of paroxetine is justified.
It should be noted that a number of mental disorders in patients with epilepsy may be caused not so much by the disease itself as by long-term therapy with drugs of the phenobarbital series. In particular, this can explain the slowness, rigidity, elements of mental and motor inhibition, which are manifested in some patients. With the emergence of highly effective anticonvulsants in recent years, it became possible to avoid side effects of therapy and attribute epilepsy to a curable disease.
Non-psychotic functional and functional-organic disorders in the long-term period of traumatic brain injury are represented by asthenic, neurosis and psychopathic syndromes.
Asthenic syndrome, being "through" in traumatic illness, in the remote period occurs in 30% of patients (VM Shumakov et al., 1981) and is characterized by a predominance of irritability, increased excitability of patients, affect exhaustion.
Asthenic syndrome in the long-term period is often combined with subdepressive, anxious and hypochondriac reactions, accompanied by severe vegetative-vascular disorders: skin redness, pulse lability, sweating. Affective outbursts usually end in tears, remorse, a feeling of overwhelm, a melancholy mood with ideas of self-blame. Increased exhaustion, impatience are noted when performing precise work that requires tension of attention and concentration. In the process of work, the number of errors in patients increases, the work seems impossible, and they irritably refuse to continue it. Often there are phenomena of hyperesthesia to sound and light stimuli.
Due to the increased distraction of attention, the assimilation of new material is difficult. Sleep disturbances are noted - difficulty falling asleep, nightmarish frightening dreams, reflecting events associated with trauma. Constant complaints of headache, palpitations, especially with sharp fluctuations in atmospheric pressure. Vestibular disorders are often observed: dizziness, nausea when watching movies, reading, driving in transport. Patients do not tolerate the hot season, stay in stuffy rooms. Asthenic symptoms fluctuate in their intensity and qualitative diversity, depending on external influences. Personal processing of a painful state is of great importance.
With electroencephalographic studies, changes are found that indicate weakness of the cortical structures and increased excitability of subcortical formations, primarily of the brain stem.
A psychopathic syndrome in the long-term period of traumatic brain injury is manifested by explosiveness, vicious, brutal affect with a tendency to aggressive actions. The mood is unstable, dysthymia is often noted, which occurs for minor reasons or without direct connection with them. The behavior of patients can acquire features of theatricality, demonstrativeness, in some cases functional seizures appear at the height of affect (a hysterical version of a psychopathic syndrome). Patients conflict, do not get along in a team, often change their place of work. Intellectual and mental disorders are insignificant. Under the influence of additional exogenous hazards, most often alcoholic beverages, repeated craniocerebral trauma and psycho-traumatic situations, which are often created by the patients themselves, traits of explosiveness increase, thinking acquires concreteness, inertia. Overvalued ideas of jealousy, overvalued attitude to one's health, litigious and querulant tendencies arise. Some patients develop epileptoid traits - pedantry, sweetness, a tendency to talk about "outrages". Decreased criticism and memory, the amount of attention is limited.
In some cases, a psychopathic syndrome is characterized by an increased background of mood with a touch of carelessness, complacency (hyperthymic version of the syndrome): patients are talkative, fussy, frivolous, suggestible, uncritical to their condition (A.A. Kornilov, 1981). drives - drunkenness, vagrancy, sexual excesses. In turn, the systematic use of alcoholic beverages increases affective excitability, a tendency to delinquency, hinders social and labor adaptation, as a result of which a kind of vicious circle is formed.
Psychopathic disorders in the absence of additional exogenous hazards proceed regrediently (N. G. Shumsky, 1983). In the long-term period of traumatic brain injury, it is necessary to differentiate between psychopathic disorders and psychopathies. Psychopathic disorders, in contrast to psychopathy, are manifested by affective reactions that do not add up to a complete clinical picture of a pathological nature. The formation of a psychopathic syndrome is due to the severity and localization of traumatic brain injury. The age of the victim, the duration of the disease, the addition of additional harmful factors matter. Neurological data, autonomic and vestibular disorders, symptoms of cerebrospinal fluid hypertension , found on radiographs of the skull and on the fundus indicate a psychopathic syndrome of an organic nature.
The disorders observed in the long-term period of traumatic brain injury include dysphoria arising against the background of cerebro-asthenic phenomena. They are accompanied by bouts of dreary-spiteful or dreary-anxious moods lasting from one to several days. They flow in waves, often accompanied by senesto and
hyperpathies, vegetative-vascular crises, psychosensory disorders and delusional interpretation of the environment, affective narrowing of consciousness. Disorders of drives are sometimes noted - sexual perversion, pyro- and dromomania. Suddenly, the committed action (arson, leaving the house) leads to a decrease in affective tension, the appearance of a feeling of relief. Like other paroxysmal conditions, dysphorias are provoked by traumatic situations or become more frequent if present, which makes them similar to psychopathic reactions
PSYCHOSIS OF A LONG PERIOD
Long-term psychoses include acute transient, protracted, recurrent and chronic traumatic psychotic states. Among acute psychoses, twilight states of consciousness are often observed, which are often provoked by somatic harm, alcoholic excesses and mental trauma. Their development is preceded by headache, dizziness, impaired strength, asthenic symptoms. The peculiarities of twilight states of consciousness of traumatic genesis is the inclusion of delirious, oneiroid components in their structure, followed by partial amnesia. It seems to the patients that the ward is flooded with blood, they can hear "vague voices", "shackle ringing", "singing" coming from the windows and corners of the room. The content of the "voices" reflects unpleasant memories of conflict situations. Quite often the twilight state of consciousness develops at the height of dysphoria.
Psychogenically provoked twilight states of consciousness are heterogeneous in their manifestations. In some cases, consciousness is concentrated on a narrow circle of emotionally saturated experiences, in others, fantastic, close to oneiroid, stage-like hallucinations prevail. The so-called oriented twilight states of consciousness may arise, in which the behavior outwardly looks purposeful, disorientation in the environment is insignificant. The delimitation of psychogenically provoked traumatic and hysterical twilight states of consciousness causes difficulties. It should be borne in mind that in post-traumatic conditions there are fewer psychogenic inclusions, and the disturbances of consciousness are deeper. The organic nature of the syndrome is evidenced by the presence of prodromal phenomena: an increase in asthenic symptoms, the severity of vascular-vegetative disorders, a disturbance in the rhythm of sleep - wakefulness.
There are delirious amentive, delirious-oneiroid syndromes with short-term stuporous states (V.E.Smirnov, 1979), the occurrence of which is often preceded by additional
external harm.
Affective psychoses, as a rule, are observed after 10-15 years
after the trauma and proceed in the form of depressive and manic phases with both monopolar and bipolar course. More common in women.
Manic syndrome in traumatic psychosis is often accompanied by explosiveness, which is quickly replaced by complacency. It is characterized by ideational unproductiveness, exhaustion of affect. Patients lack gaiety, richness of invention, humor. Expansive delirium is accompanied by complaints of poor physical health, weakness, body pain, which is not observed in the manic phase of manic-depressive psychosis. At the height of psychosis, episodes of impaired consciousness are observed. Fragmentary hallucinatory delusional experiences appear. The duration of the attack is from several months to 0.5 years, the course of the disease is progressive, with an increase in organic defect, up to pronounced dysmnestic dementia.
Depressions of traumatic etiology are distinguished by the absence of the vital affect of longing, the predominance of anxiety, often associated with senestopathies, psychosensory and vaso-vegetative disorders. There are depressive-hypochondriacal, depressive-paranoid, asthenodepressive syndromes. With depressive-hypochondriacal syndrome, patients are gloomy, gloomy, sometimes spiteful, prone to dysphoria. In some cases, patients are tearful. Hypochondriacal ideas are accomplished or delusional. In a number of patients, against the background of depression, there are paroxysms of fear, horror, which are accompanied by increased senestopathy, shortness of breath, a feeling of heat in the body, palpitations.
Traumatic hallucinosis is often a local temporal lobe syndrome. Hallucinatory images are distinguished by perceptual-acoustic completeness, are identified with real-life persons, and are localized in objective space. Patients answer "voices" aloud, conduct "conversations", "disputes" with them. The theme is polymorphic, it consists of "threats", "abuse", "dialogues", "chorus of voices", as well as musical phonemes. At times, visual hallucinations join. Patients are absorbed in hallucinations, but when they recover, they critically evaluate painful experiences. Intellectual-mnestic insufficiency and affective instability are noted. Endoform psychosis occurs 8-10 years after the trauma and accounts for 4.8% of all forms of mental disorders in the long-term period.
Polymorphic hallucinatory and hallucinatory-paranoid post-traumatic psychoses were described by V. A. Gilyarovsky (1954), E. N. Markova (1963), V. I. Skryabin (1966), T. N. Gordova (1973). In the picture of late post-traumatic psychosis, hebephrenic, pseudomanic, depressive, hypochondriacal syndromes, Kandinsky-Clerambo syndrome can be observed (L.K. Khokhlov, 1966; L.P. Lobova, 1907; O. G. Vplenskip, 1971; T.N. Gordoya , 1973; V. E. Smirnov, 1979; A. A. Kornilov, 1981).
Late post-traumatic psychoses with schizoform symptoms are expressed in paranoid, hallucinatory-paranoid, catatonic and hebephrenic syndromes, Kandinsky-Clerambo syndrome. Symptoms that distinguish them from schizophrenia include weakening of memory and attention, emotional lability, the presence of an asthenic background, episodes of disturbed consciousness, the concreteness of delusional ideas, their connection with everyday life troubles and conflicts (E.N. Markova, 1963; L.P. Lobova, 1967; G. A. Balan, 1970; T. N. Gordova, 1973; Yu. D. Kulikov, 1977; V. E. Smirnov, 1979; A. A. Kornilov, 1981; N. E. Bacherikov and et al., 1981). In persons with late traumatic psychoses, in contrast to patients with schizophrenia, hereditary burden of mental illness is less often noted and, as a rule, there is a clear connection with the previous head injury. The onset or relapse of psychosis is usually preceded by exogenous or psychogenic harm.
The onset of traumatic psychosis is usually acute, proceeding as a twilight change in consciousness or a depressive-paranoid syndrome, developing against a background of asthenia and symptoms of intracranial hypertension. In the future, the psychopathological picture becomes more complicated, auditory and visual hallucinations, depressive disorders, hypochondriacal delusional ideas, catatonic, senestopathic, diencephalic symptoms, episodes of disturbed consciousness such as stunnedness, twilight state, delirious syndrome are added, Patients are characterized by slowing down or acceleration of thought. , viscosity, fragmentary delusional ideas of attitude and persecution, emanating from the content of hallucinations and emotionally colored. In the emotional-volitional sphere, euphoria or depressive states, not always motivated affective outbursts, and grumbling are noted.
Experimental psychological research helps to reveal the inertia of nervous processes, their increased exhaustion, the difficulty of forming new connections, the concreteness of thinking.
In an electroencephalographic study, along with pathological changes of a diffuse nature (slow potentials, irregular low-amplitude alpha rhythm, increased convulsive readiness, epileptoid discharges, delta rhythm), there is a tendency to localize them in certain parts of the brain. In most cases, a reaction occurs to an emotionally significant stimulus, manifested in an increase in the alpha rhythm and an increase in amplitude. Rheoencephalographic examination reveals the instability of the tone of arterial vessels and venous stasis with a tendency to localize in the system of the vertebral and basilar arteries. Galvanic skin response changes in response to a semantic emotionally significant stimulus. In patients with traumatic psychosis, the neurohumoral response to the subcutaneous injection of 3 ml of 1% solution of nicotinic acid usually has a harmonious character,
in contrast to patients with schizophrenia, in whom it, as a rule, is perverse or null. Thus, in the differential diagnosis of late traumatic psychoses and schizophrenia, the clinical picture of the disease should be assessed taking into account the dynamics, the action of exogenous factors, and additional research data.
Paranoid delusional and overvalued ideas in patients with a long-term traumatic brain injury are most often manifested by ideas of jealousy or litigation. Delirium of jealousy is more often formed in alcohol abusers. Patients inclined to litigation, distrustful, suspect employees of an unfriendly attitude towards them, malicious intent, accuse them of an unfair attitude to duties. They write letters to various authorities, spend a lot of effort to "bring to clean water" those who "abuse their official position."
Defective organic states. Defective-organic states observed in the remote period of traumatic illness include psychoorganic and Korsakov's syndromes, paroxysmal convulsive disorders, traumatic dementia.
There are explosive, euphoric and apathetic variants of the psychoorganic syndrome. This syndrome is manifested by changes in finely differentiated personality traits: a decrease in moral and ethical qualities, the adequacy of emotions and behavior, a sense of distance in communicating with others, criticism of one's behavior, control of emotional reactions, the stability of purposeful activity. In some cases, in the foreground is the pathologically enhanced affective explosiveness, in others - euphoricity, in the third - aspect and adynamism. Previously, such cases were observed after lobotomy.
Korsakov's syndrome with craniocerebral trauma can develop both in the acute and in the long-term period. Subsequently, it can regress, progress, be complicated by other symptoms, or remain unchanged for a long time.
Epileptiform syndrome in the long-term period of traumatic brain injury is characterized by polymorphism and is accompanied by large seizures, local Jackson-type seizures, short-term blackouts, atypical seizures with a pronounced vegetative-vascular and psychosensory component, twilight states of consciousness and dysphoria. The term "traumatic epilepsy" is not entirely adequate, since epileptic personality changes are not observed in patients. It is more correct to talk about the long-term consequences of traumatic brain injury (traumatic encephalopathy) with epileptiform convulsive or other syndrome. Traumatic epileptiform syndrome is usually observed against the background of asthenic, vegetative-vascular and vestibular disorders (Yu. G. Gaponova, 1968). Paroxysmal phenomena in the distant
the period of closed craniocerebral trauma is found in 30.2% of persons (V.M.Shumakov et al., 1981; A. L. Kaplan, 1982).
Among the paroxysmal conditions, convulsive seizures predominate. Often they arise in connection with excitement, have a hysterical character. The absence of a certain sequence of convulsive phases - tonic and clonic, incomplete switching off of consciousness, the safety of the reaction of the pupils to light, its considerable duration make it difficult to distinguish convulsive seizures from hysterical ones.
Diencephalic seizures are characterized by autonomic disorders (tachycardia, chills, polyuria, polydipsia, hyperhidrosis, salivation, adynamia, a feeling of heat), appearing against the background of altered consciousness. Often, these disorders are accompanied by tonic convulsions, which allows us to regard them as mesodiencephalic. In the interictal period, patients have pronounced and persistent vegetative-vascular disorders. To distinguish di-encephalic and mesodiencephalic seizures from hysterical seizures, the following criteria are used: 1) psychogenic-traumatic factors, which, influencing the frequency of seizures, are not the direct cause of their occurrence; 2) in contrast to hysterical seizures, in which motor manifestations are expressive and correspond to the content of certain experiences, in mesodiencephalic seizures, the movements are disordered, purposeful, violent, occur against the background of general muscle tension, it is impossible to establish a reflection of provoking external events in them; 3) in contrast to hysterical seizures, characterized by great variability, mesodiencephalic seizures are stereotyped, vasovegetative disorders, with which the seizure usually begins and which are sharply expressed during it, are noted in patients and in the interictal period, while in hysterical seizures they occur again and are a reaction on affect (T.N. Gordova, 1973). The organic basis of the seizure is confirmed by a decrease in tendon and abdominal reflexes, the appearance of pathological reflexes. For differential diagnosis, it is necessary to carry out laboratory, electro- and pneumoencephalographic studies.
Most patients with convulsive syndrome develop personality changes. In some cases, they are close to epileptic, in others, psychopathic traits or organic intellectual decline predominate. Severe personality changes are formed in individuals with frequent seizures and increasing polymorphism of epileptiform manifestations.
Traumatic dementia is a consequence of wounds or contusions with widespread cortical lesions, especially of the frontal and parietal parts of the cerebral cortex ("convexitic" variant of dementia; MO Gurevich, 1947). It is noted mainly after prolonged coma, in which one of the forms of reverse
The most common development of symptoms was apallic syndrome or akinetic mutism. Deficient disorders in the form of a decrease in the level of personality, mild and severe dementia are found in 11.1% of patients registered in neuropsychiatric dispensaries for mental disorders resulting from craniocerebral lesions (V.M.Shumakov et al., 1981) ...
Traumatic dementia is characterized by a decrease in higher intellectual functions, primarily thinking, which manifests itself in the concreteness of judgment, difficulty in identifying essential features of objects or phenomena, the impossibility of comprehending the figurative meaning of proverbs. Understanding the details of the situation, patients are not able to cover the whole situation as a whole. Characterized by memory impairment in the form of fixative amnesia and some loss of the previous store of knowledge. Patients remember well the circumstances associated with the trauma and emotionally charged events. Increased exhaustion and slowness of mental processes are found. Insufficiency of motives, lack of collection when performing tasks are noted.
In some cases, dementia is combined with euphoria and disinhibition of drives, carelessness; against the background of euphoria, reactions of anger arise. The euphoric variant of dementia indicates damage to the basal-frontal regions of the brain.
The adynamic-apathetic variant of traumatic dementia is characteristic of the defeat of the convexity parts of the frontal lobes. In patients, there is a lack of volitional activity, lack of initiative. They are indifferent to their fate and the fate of their loved ones, sloppy in clothes, silent, they do not complete the action they have begun. Patients do not have an understanding of their failure and emotional reaction.
With a predominant defeat of the basal parts of the temporal lobes of the brain, disinhibition of instincts, aggressiveness, slowness of thinking and motor skills, distrustfulness, and a tendency to litigation develop. From time to time, the occurrence of depressive, ecstatic and dysphoric states with viscosity of thinking, detailing and oligophasia is possible. Traumatic dementia is characterized by lacunarity and lack of progression, but in some cases degradation increases. Repeated injuries are important, especially after a short period of time after the previous one, additional hazards in the post-traumatic period.
The described variety of psychopathological and neurological symptoms is based not only on the pathogenetic mechanisms of traumatic illness, but also on their relationship with external influences (infections, intoxications, traumatic experiences), personal reactions to a painful state, and a changed social situation. The regularity or progression of traumatic mental pathology depends on the effectiveness of treatment,
prevention of additional harmful effects, personality reactions, hereditary and acquired predisposition to the psychopathological type of response.
TREATMENT, SOCIAL AND LABOR READAPTATION OF PATIENTS AND LABOR EXPERTISE
Treatment of patients with traumatic brain disease should be comprehensive, pathogenetic, aimed at normalizing hemo- and cerebrospinal fluid dynamics, eliminating edema and swelling of the brain.
In the initial period of injury, therapy is urgent, aimed at preserving the patient's life. In the initial and acute periods, bed rest must be observed. With a concussion, bed rest is usually prescribed for 8-10 days and then the patient is released from work for 2-4 weeks. With a brain injury, bed rest should be observed for at least 3 weeks, with severe bruises - up to 2 months or more.
Dehydration therapy is used to eliminate cerebral edema. A 30% urea solution prepared in a 10% glucose solution is injected intravenously at the rate of 0.5-1.5 g / kg of body weight per day. You can use a 50% or 30% solution of urea in sugar syrup inside at the same dose. Mannitol (mannitol) is injected intravenously at the rate of 0.5-1.5 g / kg of body weight in the form of a 15% solution prepared in a 5% glucose solution (250-500 ml). Mannitol, having a dehydrating effect, improves microcirculation and does not increase hemorrhages. A good osmotic effect is achieved when a 50% solution of medical glycerin, diluted in fruit juices, is administered orally, at the rate of 0.5-1.5 g / kg of body weight 3-4 times a day. Intravenously or intramuscularly, 10 ml of a 25% solution of magnesium sulfate is injected, intravenously, 20 ml of a 40% glucose solution, 5 ml of a 40% solution of hexamethylenetetramine (urotropin), 10 ml of a 10% solution of calcium gluconate. Diuretics are widely used. The fastest effect is observed from intramuscular or intravenous administration of 2 ml of 1% lasix solution. Furosemide is used orally, 40 mg 2 times a day. In addition, veroshpiron is prescribed 25 mg 2-3 times a day, ethacrynic acid (uregit) 50 or 100 mg 2 times a day, diacarb, fonurite 250 mg 2 times a day (fonurite has the ability to inhibit the formation of cerebrospinal fluid ). When using diuretics, it is necessary to correct the loss of potassium salts, for which potassium orotate should be prescribed,
panangin.
To eliminate the deficiency of potassium salts, Labori's mixture is effective: 1000 ml of 10% glucose solution, 4 g of potassium chloride, 25 IU of insulin (1 IU of insulin per 4 g of glucose), which is injected intravenously in two doses during the day. The daily dose of potassium should not exceed 3 g. To reduce intracranial pressure, take orally 1 -
2 g / kg body weight 50% sorbitol solution (isosorbitol). The dehydration effect occurs when 10 ml of 2.4% solution of aminophylline is administered intravenously, 2 ml of a 24% solution of the drug intramuscularly, or 150 mg orally 2-3 times a day. The complex therapy of cerebral edema includes calcium preparations (10 ml of a 10% solution of calcium chloride is injected intravenously), nicotinic acid (1-2 ml of a 1% solution or 50 mg orally in powder); antihistamines: 3 ml of a 1% solution of diphenhydramine intramuscularly, suprastin 25 mg 3-4 times a day, 1-2 ml of a 2.5% solution of pipolphene intramuscularly or intravenously. Steroid hormones have a decongestant effect: cortisone (100-300 mg per day), prednisolone (30-90 mg), dexazone (20-30 mg). Hormonal drugs not only prevent the growth of cerebral edema, but also participate in carbohydrate and protein metabolism, reduce capillary permeability, and improve hemodynamics. To overcome hypoxia of the brain, antispasmodics are used: 2 ml of a 2% solution of papaverine intramuscularly, but-spu (in the same dose), 20% sodium oxybutyrate solution at the rate of 50-100 mg / kg of body weight, 50-100 mg of cocarboxylase intramuscularly, 2 ml of 1% solution of adenosine triphosphoric acid, 15-100 mg of tocopherol acetate per day, 50-100 mg of calcium pangamate 3-4 times a day, glutamic acid.
Positive results are observed when piracetam (nootropil), aminalon (gammalon), encephabol are used in the acute period of trauma. These drugs in large doses (6-8 g of nootropil, up to 30 g of piracetam per day, 4-6 g of gammalone, up to 900 mg of pyriditol per day) contribute to a faster exit from a coma, regression of mnestic disorders and other mental disorders (G. Ya.Avrutsky, 1981; O. I. Speranskaya, 1982).
A good effect in the fight against hypoxia is given by hyperbaric oxygenation. The method of craniocerebral hypothermia is also used. To reduce intracranial pressure, a puncture is made in the lumbar region with a slow extraction of cerebrospinal fluid.
In case of violation of cardiac and respiratory activity, 2 ml of a 20% solution of camphor or 2 ml of a 10% solution of caffeine, 1-2 ml of cordiamine are prescribed intramuscularly; intravenously - 1-2 ml of 0.06% solution of corglikon with glucose or with isotonic sodium chloride solution, 0.5 ml of 0.05% solution of strophanthin K with glucose; 0.5 ml of 0.1% adrenaline solution, 1 ml of 1% mezaton solution under the skin.
In order to normalize autonomic functions, belloid, bellaspon, bellataminal are used, benzodiazepine tranquilizers - sibazone intramuscularly or orally from 5 to 30 mg, chlosepide (Elenium) from 10 to 50 mg, phenazepam 2-5 mg per day, bromides (Pavlov's mixture).
For the relief of acute traumatic psychosis, which, as a rule, is accompanied by psychomotor agitation, along with the above measures, 2 ml of a 0.5% solution is injected intravenously
sibazone, sodium oxybutyrate and diphenhydramine, as well as intravenously 5-8 ml (5-20 mg) of 0.25% droperidol solution. Other antipsychotics are recommended to take clozapine (leponex), thiorpdazine (co-napax). Care should be taken when prescribing chlorpromazine and tizercin. Taking into account their hypotensive effect and disturbances in the regulation of vascular tone caused by trauma, these drugs are administered with agents that maintain vascular tone - cordiamine, caffeine. At the initial stages of traumatic illness, small doses of antipsychotic drugs are recommended. In case of convulsive syndrome and epileptiform excitement, the introduction of 1-1.5 g of chloral hydrate in enemas has a good effect. Sleep begins in 15-20 minutes and lasts about 6 hours.
In case of epileptiform seizures, 2 ml of a 0.5% solution of sibazone with a 40% glucose solution, up to 10 ml of a 25% solution of magnesium sulfate, intramuscularly 2 ml of a 2.5% solution of diprazip are injected intravenously. Seduxene solution is administered 2-3 times a day until the seizures stop and once a day after they disappear for 5-6 days. The continuation of anticonvulsant treatment is the appointment of these patients with phenobarbital or benzonal at night. For dysphoric disorders, periciazine is indicated (3-5 mg per day), for a depressive state - amitriptyline (12.5-25 mg at night and during the day), in the presence of asthenoabulic symptoms - small tranquilizers at night, in the daytime - acefen ( 0.1-0.3 g), glutamic acid, aminalon, pyriditol (100-150 mg morning and afternoon). In the acute period, patients take 0.001-0.005 g of Nerobol 1-2 times a day for 30-60 days, 1 ml of 5% retabolil solution is administered intramuscularly to them 1 time in 2-3 weeks for 30-60 days. For apathic-abulic syndrome, sydnophen or sydnocarb (0.005-0.01 g), meridil (0.01-0.02 g), nialamide (0.025-1 g) are used.
Patients in the initial and acute periods of injury require constant monitoring and care. It is necessary to prevent aspiration pneumonia, bedsores, urinary tract infection.
With open brain injuries, complicated by purulent meningitis, large doses of antibiotics (benzylpenicillin up to 30,000,000 units per day), endolumbar antibiotics, sulfa drugs are prescribed.
On the 8-10th day of the disease, resorption therapy is prescribed (64 UE lidases and bioquinol intramuscularly up to 15 injections), massage, exercise therapy. Correction of dysfunction of the catecholamine system is carried out with maintenance doses of levodopa (0.5 g 3 times a day after meals). In the future, intravenous infusions of sodium iodide (10 ml of a 10% solution; 10-15 injections per course) are added to the resorption therapy, sayodin is prescribed internally or 3% solution of potassium iodide in milk, ATP, phosphrene, thiamine, cyanocobalamin. Cerebrolysin, anabolic steroids, biogenic stimulants (liquid aloe extract for injection, vitreous body, FiBS) are recommended.
With asthenic syndrome, it is necessary to combine stimulating therapy and sedatives, hypnotics (eunoktin, radedorm). Preventive anticonvulsant therapy should be prescribed if there is a history of seizures and their appearance after trauma, the presence of paroxysmal epileptic discharges and focal epileptiform changes on the EEG during wakefulness and sleep (A.I. Nyagu, 1982; V.S. Mertsalov, 1932) ... Depending on the type of seizure activity, phenobarbital is used at 0.05 g during the day and at night or benzonal at 0.1 g 2-3 times a day, gluferal 1 tablet 2 times a day, as well as a mixture of phenobarbital (0.1 g) , dilantin (0.05 g), nicotinic acid (0.03 g), glucose (0.3 g) - 1 powder at night and 10-20 mg seduxene at night
In the long-term period of traumatic brain injury, the choice of psychotropic drugs is determined by the psychopathological syndrome (see Appendix 1). In an asthenic state with emotional instability and anxiety, trioxazine is prescribed at 0.3-0.9 g, nitrazepam (radedorm, eunoktin) but 0.01 g at night; for asthenia with general weakness and an abulic component - saparal 0.05 g 2-3 times, sydnophen or sydnocarb 0.005-0.01 g per day, tincture of ginseng, lemongrass, aralia, azafen 0.1-0.3 g per day. Patients with long-term consequences of trauma, in whose clinical picture vegetative-vascular and cerebrospinal fluid disorders prevail against the background of severe asthenia, are recommended laser puncture (Ya.V. Pishel, MP Shapiro, 1982).
In psychopathic states, periciazine (neuleptil) is prescribed at 0.015 g per day, small doses of sulfosin, antipsychotics in medium doses; with manic syndrome - alimemazine (teralen), periciazip (neuleptil), chlorprothixene. Haloperidol, triftazine (stelazine) cause severe extrapyramidal disturbances, so their use is not recommended. Anxiety-depressive and hypochondriacal syndromes are stopped with frenolone (0.005-0.03 g), eglonil (0.2-0.6 g), amitriptyline (0.025-0.2 g), carbidine (0.025-0.15 g). With dysphoria and twilight states of consciousness, chlorpromazine up to 300 mg per day, seduxen (4 ml of 0.5% solution) intramuscularly, etaperazine up to 100 mg are effective; with paranoid and hallucinatory-paranoid states - chlorpromazine, sonapax, haloperidol; for "traumatic epilepsy" - anticonvulsants.
The formation of the residual period depends on the timeliness and adequacy of social rehabilitation measures. At the initial stages, it is necessary to carry out activities aimed at creating a benevolent moral and psychological climate in the patient's environment, instill in him confidence in recovery and the ability to continue working. The recommended work should correspond to the functional capabilities, special and general education, personal inclinations of the patient. Work is contraindicated in conditions of noise, at height, transport, in hot and
stuffy room. A clear daily routine is required - regular rest, exclusion of overloads.
One of the important factors in the complex system of restoring the ability to work and reducing the severity of disability is clinical examination with, if necessary, courses of pathogenetic and symptomatic treatment, including psychotherapy, in outpatient, inpatient, sanatorium conditions. The most favorable labor prognosis in patients with asthenic syndrome, relatively favorable - with a psychopathic syndrome in the absence of pronounced progression. In patients with paroxysmal disorders, the labor prognosis depends on the severity and nature of personality changes. Occupational capacity for work in persons with dementia syndrome is steadily reduced or lost. Labor adaptation is possible only in specially created conditions. Professional retraining should be carried out taking into account the characteristics of the disease, work skills, interests and functional capabilities of patients. During the medical examination, all possibilities of restorative treatment and rehabilitation measures should be used. The conclusion about insanity and disability is usually made in case of traumatic psychosis, dementia, or a pronounced degree of psychoorganic syndrome.
SOMATOGENIC MENTAL
DISORDERS
GENERAL AND CLINICAL CHARACTERISTICS
Somatogenic mental illnesses - a combined group of mental disorders resulting from somatic non-infectious diseases. These include mental disorders in cardiovascular, gastrointestinal, renal, endocrine, metabolic and other diseases. Mental disorders of vascular origin (with hypertension, arterial hypotension and atherosclerosis) are traditionally distinguished into an independent group,
Classification of somatogenic mental disorders
1. Borderline non-psychotic disorders: a) asthenic, non-vrose-like conditions caused by somatic non-infectious diseases (code 300.94), metabolic disorders, growth and nutrition (300.95); b) non-psychotic depressive disorders caused by somatic non-communicable diseases (311.4), metabolic, growth and nutritional disorders (311.5), other and unspecified organic brain diseases (311.89 and З11.9): c) neurosis and psychopathic disorders due to somatogenic organic lesions of the brain (310.88 and 310.89).
2. Psychotic conditions developed as a result of functional or organic brain damage: a) acute psychoses (298.9 and
293.08) - asthenic confusion, delirious, amentive and others
confusion syndromes; b) subacute protracted psychoses (298.9
and 293.18) -paranoid, depressive-paranoid, anxious-paranoid, hallucinatory-paranoid. catatonic and other syndromes;
c) chronic psychoses (294) -korsakovskin syndrome (294.08), hallu-
cynic-paranoid, senestopatho-hypochondriacal, verbal hallucinosis, etc. (294.8).
3. Defective-organic states: a) simple psycho-organic
syndrome (310.08 and 310.18); b) Korsakov syndrome (294.08); c) de-
mention (294.18).
Somatic diseases acquire an independent significance in the development of mental disorders, in relation to which they are an exogenous factor. The mechanisms of brain hypoxia, intoxication, metabolic disorders, neuroreflex, immune, and autoimmune reactions are of great importance. On the other hand, as noted by BA Tselibeev (1972), somatogenic psychoses cannot be understood only as a result of a somatic illness. In their development, a predisposition to a psychopathological type of response, psychological personality traits, and psychogenic influences play a role.
The problem of somatogenic mental pathology is becoming increasingly important in connection with the growth of cardiovascular pathology. The pathomorphosis of mental illness is manifested by the so-called somatization, the predominance of non-psychotic disorders over psychotic, "bodily" symptoms over psychopathological ones. Patients with sluggish, "erased" forms of psychosis sometimes end up in general somatic hospitals, and severe forms of somatic diseases are often unrecognized due to the fact that the subjective manifestations of the disease "overlap" the objective somatic symptoms.
Mental disorders are observed in acute short-term, protracted and chronic somatic diseases. They manifest themselves in the form of non-psychotic (asthenic, asthenodepressive, asthenodysthymic, asthenohypochondriac, anxiety-phobic, hysterical), psychotic (delirious, delirious-amentive, onyric, crepuscular, catatonic, parano-hallucinatory) psychoorganic syndrome and dementia) conditions.
According to V. A. Romassnko and K. A. Skvortsov (1961), B. A. Tseli-beev (1972), A. K. Dobrzhanskaya (1973), the exogenous nature of mental disorders of a nonspecific type is usually observed in the acute course of a somatic illness ... In cases of its chronic course with diffuse brain damage of a toxic-anoxic nature, more often than with infections, there is a tendency towards endoformality of psychopathological symptoms.
MENTAL DISORDERS IN SEVERAL SOMATIC DISEASES
Mental disorders in heart disease. Ischemic heart disease (CHD) is one of the most commonly diagnosed forms of heart disease. In accordance with the WHO classification, IHD includes angina pectoris of exertion and rest, acute focal myocardial dystrophy, small- and large-focal myocardial infarction. Coronary-cerebral disorders are always combined. With heart disease, cerebral hypoxia is noted, with lesions of the cerebral vessels, hypoxic changes in the heart are detected.
Panic disorders resulting from acute heart failure can be expressed by syndromes of impaired consciousness, most often in the form of stunnedness and delirium, characterized by
instability of hallucinatory experiences.
Mental disorders in myocardial infarction have been systematically studied in recent decades (I. G. Ravkin, 1957, 1959; L. G. Ursova, 1967, 1968). Depressive states, syndromes of impaired consciousness with psychomotor agitation, euphoria are described. Overvalued formations are often formed. With small focal myocardial infarction, a pronounced asthenic syndrome develops with tearfulness, general weakness, sometimes nausea, chills, tachycardia, low-grade body temperature. With a large-focal infarction with damage to the anterior wall of the left ventricle, anxiety, fear of death occur; with an infarction of the posterior wall of the left ventricle, euphoria, long-windedness, lack of criticism of one's condition with attempts to get out of bed, requests to give any work are observed. In the post-infarction state, lethargy, severe fatigue, and hypochondriasis are noted. Phobic syndrome often develops - anticipation of pain, fear of a second heart attack, getting out of bed at a time when doctors recommend an active regimen.
Mental disorders also occur with heart defects, as pointed out by V.M.Banshchikov, I.S. Romanova (1961), G.V. Morozov, M.S. Lebedinsky (1972). In rheumatic heart diseases, V.V. Kovalev (1974) identified the following variants of mental disorders: 1) borderline (asthenic), neurosis-like (neurasthene-like) with vegetative disorders, cerebrasthenic with mild manifestations of organic cerebral insufficiency, euphoric or depressive-dysthymic mood, hysteroform asthenohypochondriacal conditions; neurotic reactions of depressive, depressive-hypochondriac and pseudo-euphoric types; pathological personality development (psychopathic); 2) psychotic cardiogenic psychoses) - acute with delirious or amentive symptoms and subacute, protracted (anxious-depressive, depressive-paranoid, hallucinatory-paraioid); 3) encephalopathic (psychoorganic) - psychoorganic, epileptoform and corsa
kowski syndromes. Congenital heart defects are often accompanied by signs of psychophysical infantilism, asthenic, neurosis and psychopathic states, neurotic reactions, and delayed intellectual development.
Currently, heart surgeries are widely performed. Surgeons and cardiologists-therapists note a disproportion between the objective physical capabilities of the operated patients and the relatively low actual indicators of rehabilitation of persons who underwent heart surgery (E.I. Chazov, 1975; N.M. Amosov et al., 1980; S. Bernard, 1968 ). One of the most significant reasons for this imbalance is the psychological maladjustment of persons who have undergone heart surgery. Examination of patients with pathology of the cardiovascular system established the presence of pronounced forms of personal reactions (G.V. Morozov, M.S. Lebedinsky, 1972; A.M. Wayne et al., 1974). N. K. Bogolepov (1938), L. O. Badalyan (1963), V. V. Mikheev (1979) indicate a high frequency of these disorders (70-100%). Changes in the nervous system in heart defects were described by L. O. Badalyan (1973, 1976). Insufficiency of blood circulation, which occurs with heart defects, leads to chronic hypoxia of the brain, the emergence of cerebral and focal neurological symptoms, including in the form of seizures.
In patients operated on for rheumatic heart defects, complaints of headache, dizziness, insomnia, numbness and coldness of the extremities, pain in the region of the heart and behind the breastbone, dyspnea, rapid fatigue, shortness of breath, aggravated by physical exertion, weakness of convergence, decreased corneal reflexes, muscle hypotonia, decreased periosteal and tendon reflexes, disturbances of consciousness, often in the form of fainting, indicating impaired circulation in the vertebral and basilar arteries and in the basin of the internal carotid artery.
Mental disorders that arise after cardiac surgery are the result of not only cerebral-vascular disorders, but also a personal reaction. VA Skumin (1978, 1980) identified "cardioprosthetic psychopathological syndrome" that often occurs during mitral valve implantation or multivalve prosthetics. Due to the noise phenomena associated with the activity of the artificial valve, disturbance of the receptive fields at the site of its implantation and disturbances in the rhythm of cardiac activity, the attention of patients is focused on the work of the heart. They have apprehensions and fears about a possible "detachment of the valve", its breakage. The depressed mood intensifies towards night, when the noise from the operation of artificial valves is heard especially clearly. Only in the daytime, when the patient sees medical personnel nearby, he can fall asleep. A negative attitude towards vigorous activity is developed, an anxious-depressive background of mood arises with the possibility of suicidal actions.
V.V. Kovalev (1974) in the uncomplicated postoperative period noted astheno-dynamic states, sensitivity, transient or persistent intellectual-mnestic insufficiency in patients. After operations with somatic complications, acute psychoses often occur with confusion (delirious, delirious-amentive and delirious-oneiroid syndromes), subacute abortive and protracted psychoses (anxiety-depressive, depressive-hypochondriac, depressive-paranoid syndrome) paroxysms.
Mental disorders in patients with renal pathology... Mental disorders in renal pathology are observed in 20-25% of sick persons (V.G. Vogralik, 1948), but not all of them fall into the field of vision of psychiatrists (A.G. Naku, G.N. German, 1981). There are marked mental disorders that develop after kidney transplantation and hemodialysis. A. G. Naku and G. N. German (1981) identified typical nephrogenic and atypical nephrogenic psychoses with the obligatory presence of an asthenic background. The authors include asthenia, psychotic and non-psychotic forms of disturbed consciousness in group 1, and endoform and organic psychotic syndromes (the inclusion of asthenia and non-psychotic disturbance of consciousness syndromes in psychotic states is considered erroneous).
Asthenia in renal pathology, as a rule, precedes the diagnosis of kidney damage. There are unpleasant sensations in the body, "stale head", especially in the morning, nightmares, difficulty concentrating, feeling fatigued, depressed mood, somatoneurological manifestations (coated tongue, grayish-pale complexion, instability of blood pressure, chills and profuse sweating on at night, an unpleasant sensation in the lower back).
Asthenic nephrogenic symptom complex is characterized by a constant complication and increase in symptoms, up to a state of asthenic confusion, in which patients do not perceive changes in the situation, do not notice the objects they need nearby. With an increase in renal failure, the asthenic state can be replaced by amentia. A characteristic feature of nephrogenic asthenia is weakness with the inability or difficulty to mobilize oneself to perform an action when understanding the need for such mobilization. Patients spend most of their time in bed, which is not always justified by the severity of renal pathology. According to A.G. Naku and G.N. German (1981), the often observed change of asthenoadynamic states by asthenosubdepressive ones is an indicator of an improvement in the patient's somatic state, a sign of "affective activation", although it passes through a pronounced stage of a depressive state with ideas of self-abasement ( uselessness, worthlessness, a burden for the family).
Syndromes of darkened consciousness in the form of delirium and amentia with pephropathies are difficult, patients often die. Highlight
There are two variants of amentive syndrome (A. G. Naku, G. N. German, 1981). reflecting the severity of renal pathology and having prognostic significance: hyperkinetic, in which uremic intoxication is mild, and hypokinetic with increasing decompensation of kidney activity, a sharp increase in blood pressure. Severe forms of uremia are sometimes accompanied by psychoses of the type of acute delusions and end in death after a period of deafness with severe motor restlessness, fragmentary delusional ideas. With the deterioration of the condition, productive forms of upset consciousness are replaced by unproductive ones, weakness and doubtfulness increase.
Psychotic disorders in the case of protracted and chronic kidney diseases are manifested by complex syndromes observed against the background of asthenia: anxiety-depressive, depressive and hallucinatory-paranoid and catatonic. The increase in uremic toxicosis is accompanied by episodes of psychotic clouding of consciousness, signs of organic damage to the central nervous system, epileptiform paroxysms and intellectual-mnestic disorders.
According to BA Lebedev (1979), in 33% of the examined patients against the background of severe asthenia, mental reactions of the depressive and hysterical types are noted, in the rest - an adequate assessment of their condition with a decrease in mood, an understanding of the possible outcome. Asthenia can often hinder the development of neurotic reactions. Sometimes, in cases of insignificant severity of asthenic symptoms, hysterical reactions occur, which disappear with an increase in the severity of the disease,
Rheoencephalographic examination of patients with chronic kidney diseases makes it possible to reveal a decrease in vascular tone with a slight decrease in their elasticity and signs of impaired venous flow, which are manifested by an increase in the venous wave (presystolic) at the end of the catacrotic phase and are observed in persons suffering from arterial hypertension for a long time. Instability of vascular tone is characteristic, mainly in the system of vertebral and basilar arteries. In mild forms of kidney disease in the pulse blood filling, pronounced deviations from the norm are not observed (L. V. Pletneva. 1979).
In the later stages of chronic renal failure and with severe intoxication, organ-replacing operations and hemodialysis are performed. After kidney transplantation and during dialysis stable suburemia, chronic nephrogenic toxicodyshomeostatic encephalopathy is observed (MA Tsivilko et al., 1979). Patients have weakness, sleep disorders, depression of mood, sometimes a rapid increase in adynamia, deafness, convulsive seizures appear. It is believed that the syndromes of confused consciousness (delirium, amentia) arise as a result of vascular disorders and postoperative
asthenia, and syndromes of switching off consciousness - as a result of uremic intoxication. In the process of hemodialysis treatment, there are cases of intellectual-mnestic disorders, organic brain damage with a gradual increase in lethargy, loss of interest in the environment. With prolonged use of dialysis, a psychoorganic syndrome develops - "dialysis-uremic dementia", which is characterized by deep asthenia.
Large doses of hormones are used in kidney transplantation, which can lead to disorders of autonomic regulation. During the period of acute graft failure, when azotemia reaches 32.1 - 33.6 mmol, and hyperkalemia - up to 7.0 meq / l, hemorrhagic phenomena (profuse nosebleeds and hemorrhagic rash), paresis, paralysis may occur. In electroencephalographic study, persistent desynchronization is found with an almost complete disappearance of alpha activity and a predominance of slow-wave activity. Rheoencephalographic examination reveals pronounced changes in vascular tone: uneven waves in shape and size, additional venous waves. Asthenia sharply increases, subcomatous and comatose states develop.
Mental disorders in diseases of the digestive tract... Diseases of the digestive system rank second in the overall incidence of the population, second only to cardiovascular pathology.
Disorders of mental functions in pathology of the digestive tract are often limited to the sharpening of characterological features, asthenic syndrome and neurosis-like conditions. Gastritis, peptic ulcer disease and nonspecific colitis are accompanied by depletion of mental functions, sensitivity, lability or torpidity of emotional reactions, anger, a tendency to a hypochondriacal interpretation of the disease, carcinophobia. With gastrointestinal reflux, neurotic disorders (neurasthenic syndrome and obsessional symptoms) are observed that precede the symptoms of the digestive tract. Statements of patients about the possibility of a malignant neoplasm in them are noted within the framework of overvalued hypochondriacal and paranoid formations. Complaints about memory impairment are associated with attention disorder due to both fixation on sensations caused by the underlying disease and depressed mood.
A complication of gastric resection operations in peptic ulcer disease is dumping syndrome, which should be distinguished from hysterical disorders. Dumping syndrome is understood as vegetative crises, which occur in paroxysmal or hypo-glycemic form immediately after a meal or after 20-30 minutes,
sometimes 1-2 hours
Hyperglycemic crises appear after taking hot food containing easily digestible carbohydrates. Suddenly there is a headache with dizziness, tinnitus, less often vomiting, drowsiness,
tremor. "Black dots", "flies" before the eyes, disorders of the body scheme, instability, unsteadiness of objects may appear. They end with profuse urination, drowsiness. At the height of the attack, blood sugar and blood pressure rise.
Hypoglycemic crises occur outside of food intake: weakness, sweating, headache, dizziness appear. After eating, they quickly stop. During a crisis, blood sugar levels decrease, and a drop in blood pressure is observed. Disorders of consciousness are possible at the height of the crisis. Sometimes crises develop in the morning after sleep (R. E. Galperina, 1969). In the absence of timely therapeutic correction, hysterical fixation of this condition is not excluded.
Mental health problems in cancer... The clinical picture of brain neoplasms is determined by their localization. With the growth of tumors, general cerebral symptoms appear more. Almost all types of psychopathological syndromes are observed, including asthenic, psychoorganic, paranoid, hallucinatory-paranoid (A.S. Shmaryan, 1949; I. Ya. Razdolsky, 1954; A. L. Abashev-Konstantinovsky, 1973). Sometimes a brain tumor is detected in a section of deceased persons who have been treated for schizophrenia, epilepsy.
In malignant neoplasms of extracranial localization, V. A. Romasenko and K. A. Skvortsov (1961) noted the dependence of mental disorders on the stage of cancer. In the initial period, there is a sharpening of the characterological traits of patients, neurotic reactions, asthenic phenomena. In the expanded phase, asthenodepressive states and anosognosias are most often noted. In cancer of internal organs in the manifest and predominantly terminal stages, states of "quiet delirium" with adynamia, episodes of delirious and oniric experiences are observed, followed by stunnedness or bouts of excitement with fragmentary delusional statements; delirious-amentive conditions; paranoid states with delusions of relationship, poisoning, damage; depressive states with depersonalization phenomena, senestopathies; reactive hysterical psychoses. Characterized by instability, dynamism, frequent change of psychotic syndromes. In the terminal stage, depression of consciousness gradually increases (stunnedness, stupor, coma).
Mental disorders of the postpartum period... There are four groups of psychoses arising in connection with childbirth: 1) generic; 2) actually postpartum; 3) psychosis of the lactation period; 4) endogenous psychoses provoked by childbirth. The mental pathology of the postpartum period does not represent an independent nosological form. Common to the entire group of psychoses is the situation in which they arise. Birth psychoses are psychogenic reactions that usually develop in primiparous women. They are caused by the fear of anticipating pain, an unknown, frightening event. At the first sign, start
In the coming birth, some women in labor may develop neurotic
or a psychotic reaction, in which, against the background of a narrowed consciousness, hysterical crying, laughter, screaming, sometimes fugiform reactions, less often hysterical mutism appear. Women in labor refuse to follow the instructions given by the medical staff. The duration of the reactions is from several minutes to 0.5 hours, sometimes longer.
Postpartum psychoses are conventionally divided into postpartum and lactation psychosis.
Postpartum psychosis itself develops during the first 1-6 weeks after childbirth, often in a maternity hospital. The reasons for their occurrence: toxicosis in the second half of pregnancy, severe labor with massive tissue trauma, delayed separation of the placenta, bleeding, endometritis, mastitis, etc. The decisive role in their appearance belongs to generic infection, a predisposing moment is toxicosis in the second half of pregnancy. At the same time, psychoses are observed, the occurrence of which cannot be explained by postpartum infection. The main reasons for their development are traumatization of the birth canal, intoxication, neuroreflex and psycho-traumatic factors in their totality. Actually postpartum psychoses are more often observed in primiparous women. The number of sick women who gave birth to boys is almost 2 times higher than that of women who gave birth to girls.
Psychopathological symptoms are characterized by an acute onset, occur after 2-3 weeks, and sometimes 2-3 days after childbirth against the background of increased body temperature. Postpartum women are restless, gradually their actions become erratic, speech contact is lost. Amentia develops, which in severe cases turns into a soporous state.
Amentia in postpartum psychosis is characterized by low dynamics throughout the entire period of the disease. The exit from the amentive state is critical, followed by lacunar amnesia. There are no protracted asthenic states, as is the case with lactation psychosis.
The catatonic (catatonic-oneiroid) form is less common. A feature of postpartum catatonia is the mild severity and instability of symptoms, its combination with oniric disorders of consciousness. With postpartum catatonia, there is no pattern of increasing stiffness, as with endogenous catatonia, there is no active negativism. Characterized by the instability of catatonic symptoms, the episodic nature of oneiric experiences, their alternation with states of stunnedness. With the weakening of catatonic phenomena, patients begin to eat, answer questions. After recovery, they are critical of what they have experienced.
Depressive-paranoid syndrome develops against a background of mildly pronounced stunnedness. It is characterized by a "matte" depression. If the stunnedness increases, the depression is smoothed out, the patients are indifferent, do not answer questions. Self-blame ideas are associated with non-
the consistency of patients during this period. The phenomena of mental anesthesia are often found.
Differential diagnosis of postpartum and endogenous depression is based on the presence of a change in its depth in postpartum depression, depending on the state of consciousness, and the aggravation of depression by the night. In such patients, in a delusional interpretation of their inconsistency, the somatic component sounds more, while in endogenous depression, low self-esteem concerns personal qualities
Psychosis of the lactation period occurs 6-8 weeks after childbirth. They occur about twice as often as the actual postpartum psychoses. This can be explained by the tendency towards rejuvenation of marriages and the psychological immaturity of the mother, the lack of experience in caring for children - younger brothers and sisters. Factors preceding the onset of lactational psychosis include shortening hours of rest in connection with caring for a child and deprivation of night sleep (K.V. Mikhailova, 1978), emotional stress, lactation with irregular nutrition and rest, leading to rapid emaciation.
The disease begins with impaired attention, fixation amnesia. Young mothers do not have time to complete everything necessary due to lack of composure. At first, they try to "catch up" by reducing the hours of rest, "put things in order" at night, do not go to bed, start washing the baby's clothes. Patients forget where they put this or that thing, they look for it for a long time, disrupting the rhythm of work and the difficultly put things in order. The difficulty of comprehending the situation is rapidly growing, confusion appears. The purposefulness of behavior is gradually lost, fear, the affect of bewilderment, and fragmentary interpretive delirium develop.
In addition, there are changes in the state throughout the day: during the day, patients are more collected, in connection with which the impression is created that the state is returning to a painful one. However, with each passing day, the periods of improvement are shortened, anxiety and lack of concentration increase, fear for the life and well-being of the child increases. Amentive syndrome or stunning develops, the depth of which is also variable. The exit from the amentive state is protracted, accompanied by frequent relapses. Amentive syndrome is sometimes replaced by a short-term period of the catatonic-oneiroid state. There is a tendency to an increase in the depth of disturbances of consciousness when trying to maintain lactation, which is often requested by the patient's relatives.
An asthenodepressive form of psychosis is often observed: general weakness, emaciation, deterioration of skin turgor; patients become depressed, express fears for the child's life, ideas of little value. The way out of depression is prolonged: patients have a feeling of instability of their state for a long time, weakness, anxiety that the disease may return is noted.
Endocrine diseases. Violation of the hormonal function of one of the glands; usually causes a change in the state of other endocrine organs. The functional relationship of the nervous and endocrine systems underlies mental disorders. Currently, a special section of clinical psychiatry is distinguished - psychoendo-crinology.
Endocrine disorders in adults, as a rule, are accompanied by the development of non-psychotic syndromes (asthenic, neuroso- and psychopathic) with paroxysmal autonomic disorders, and with an increase in the pathological process, psychotic states: syndromes of clouded consciousness, affective and paranoid psychoses. With congenital forms of endocrinopathy or their occurrence in early childhood, the formation of a psychoorganic neuroendocrine syndrome is clearly manifested. If an endocrine disease appears in adult women or in adolescence, then they often have personal reactions associated with a change in the somatic state and appearance.
In the early stages of all endocrine diseases and with their relatively benign course, there is a gradual development of the psychoendocrine syndrome (endocrine psychosyndrome, according to M. Bleuler, 1948), its transition with the progression of the disease into a psychoorganic (amnestic-organic) syndrome and the emergence of acute or prolonged psychoses against the background of these syndromes (D. D. Orlovskaya, 1983).
Most often, asthenic syndrome appears, which is observed in all forms of endocrine pathology and is part of the structure of the psychoendocrine syndrome. It belongs to the earliest and most persistent manifestations of endocrine dysfunction. In cases of acquired endocrine pathology, asthenic phenomena may long precede the detection of gland dysfunction.
"Endocrine" asthenia is characterized by a feeling of pronounced physical weakness and weakness, accompanied by a myasthenic component. At the same time, the impulses for activity that persist with other forms of asthenic conditions are leveled. Asthenic syndrome very soon acquires the features of an apatoabulic state with impaired motivation. Such a transformation of the syndrome usually serves as the first signs of the formation of a psychoorganic neuroendocrine syndrome, an indicator of the progression of the pathological process.
Neurosis-like changes are usually accompanied by manifestations of asthenia. There are neurasthenic, hysteroform, anxiety-phobic, asthenic
The main symptom of non-psychotic depressive disorder is sleep disturbance - patients experience prolonged insomnia. They also lack a range of positive emotions, they can react sharply to random words, and there is increased anxiety. Treatment is carried out in several ways. The most effective in this case is drug therapy.
At the current stage of the development of psychological sciences, there is a huge number of classified mental disorders. But, in no case can it be said that each disorder could be distinguished by just one criterion. It is worth mentioning that from the side of neurology. This statement is by no means generally accepted, but it is used by at least 80% of professionals. This concept can be used to combine mild disorders and psychotic states. Non-psychotic depressive disorders are not beginning or intermediate stages of psychosis. These disorders are manifestations of pathologies that have their beginning and end.
Diagnostic techniques for non-psychotic depressive disorder
by themselves in depth, as well as the severity of depressive manifestations. The disorder may worsen or manifest due to the loss of a loved one, moral or material damage. In the clinical picture of such disorders, persistent depressed mood is increasingly highlighted.How can non-psychotic depressive disorder be diagnosed?
With this disease, it is not possible to make a diagnosis on your own. Only a qualified doctor can help diagnose the disorder, as well as prescribe effective and correct treatment that can return you or your loved ones to a full life. However, there are symptoms that may indicate the development of non-psychotic depressive disorder:
- the first sign of the disease is disturbances in high-grade sleep, as well as autonomic dysfunctions;
- excessive emotional reaction to events or words;
- psychopathic manifestations on an ongoing basis during any somatic illness;
- a decreased background of mood, tearfulness, but at the same time maintaining a critical attitude to one's condition, as well as to the manifestations of the disease;
Treatment for non-psychotic depressive disorder
- the appointment of potent drugs that will need to be taken for the entire period of treatment. This is the easiest way to get rid of a depressive disorder;
- the appointment of prolonged-release drugs in the form of injections to exit the acute stage of the disease and prevent its occurrence;
- prescribing a course of psychotherapeutic treatment.
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