In terms of prevalence, they are the undisputed leaders among other mental disorders. According to various sources, they affect up to 30% of those who go to polyclinics and from 10 to 20% of people in the general population (J.M. Chignon, 1991, W. Rief, W. Hiller, 1998; PSKessler, 1994; BTUstun, N. Sartorius, 1995; HW Wittchen, 2005; A.B.Smulevich, 2003). The economic burden associated with their treatment and disability makes up a significant part of the budget in the health care system of different countries (R. Karson, J. Butcher, S. Mineka, 2000; E.B. Lyubov, G.B. Sargsyan, 2006; HW Wittchen, 2005). Depressive, anxiety and somatoform disorders are important risk factors for the occurrence of various forms of chemical dependence (HW Wittchen, 1988; A.G. Hoffman, 2003) and, to a large extent, complicate the course of concomitant somatic diseases (O.P. Vertogradova, 1988; Yu.A. Vasyuk, T.V. Dovzhenko, E.N. Yushchuk, E.L. Shkolnik, 2004; V.N. Krasnov, 2000; E.T. Sokolova, V.V. Nikolaeva, 1995)

Finally, depressive and anxiety disorders are the main risk factor for suicides, according to the number of which our country occupies one of the first places (V.V. Voitsekh, 2006; Starshenbaum, 2005). Against the background of socio-economic instability in recent decades in Russia, there is a significant increase in the number of affective disorders and suicides among young people, the elderly, and able-bodied males (V.V. Voytsekh, 2006; Yu.I. Polischuk, 2006). There is also an increase in subclinical emotional disorders, which are included in the boundaries of the affective spectrum disorders (H.S. Akiskal et al., 1980, 1983; J. Angst et al, 1988, 1997) and have a pronounced negative impact on the quality of life and social adaptation.

Until now, the criteria for distinguishing various variants of affective spectrum disorders, the boundaries between them, the factors of their occurrence and chronicity, targets and methods of assistance remain controversial (G. Winokur, 1973; W. Rief, W. Hiller, 1998; A.E. Bobrov, 1990; O.P. Vertogradova, 1980, 1985; N.A. Kornetov, 2000; V.N. Krasnov, 2003; S.N. Mosolov, 2002; G.P. Panteleeva, 1998; A.B. Smulevich, 2003). Most researchers point out the importance of an integrated approach and the effectiveness of a combination of drug therapy and psychotherapy in the treatment of these disorders (O.P. Vertogradova, 1985; A.E. Bobrov, 1998; A.Sh. Tkhostov, 1997; M. Perrez, U. Baumann , 2005; W. Senf, M. Broda, 1996 and others). At the same time, in different areas of psychotherapy and clinical psychology, various factors of the mentioned disorders are analyzed and specific targets and tasks of psychotherapeutic work are distinguished (B.D. Karvasarsky, 2000; M. Perre, U.Bauman, 2002; F.E. Vasilyuk, 2003, etc. .).

Within the framework of attachment theory, systemically oriented family and dynamic psychotherapy, the violation of family relationships is indicated as an important factor in the onset and course of affective spectrum disorders (S. Arietti, J. Bemporad, 1983; D. Bowlby, 1980, 1980; M. Bowen, 2005 ; E.G. Eidemiller, Yustitskis, 2000; E.T. Sokolova, 2002, etc.). The cognitive-behavioral approach emphasizes skills deficits, impairments to information processing and dysfunctional personal attitudes (A.T. Beck, 1976; N.G. Garanyan, 1996; A.B. Kholmogorova, 2001). Within the framework of social psychoanalysis and dynamically oriented interpersonal psychotherapy, the importance of interpersonal communication disorders is emphasized (K. Horney, 1993; G. Klerman et al., 1997). Representatives of the existential-humanistic tradition highlight the violation of contact with their inner emotional experience, the difficulties of its comprehension and expression (K. Rogers, 1997).

All the factors mentioned above and the targets of psychotherapy for affective spectrum disorders that follow from them do not exclude, but mutually complement each other, which necessitates the integration of various approaches in solving practical problems of providing psychological assistance. Although the task of integration is increasingly coming to the fore in modern psychotherapy, its solution is hampered by significant differences in theoretical approaches (M. Perrez, U.Baumann, 2005; BAAlford, ATBeck, 1997; K. Crave, 1998; AJRush, M. Thase, 2001; W. Senf, M. Broda, 1996; A. Lazarus, 2001; E. T. Sokolova, 2002), which makes the development of theoretical foundations for the synthesis of accumulated knowledge urgent. It should also point to the lack of comprehensive objective empirical research confirming the importance of various factors and the resulting targets of assistance (S.J. Blatt, 1995; K.S. Kendler, R.S. Kessler, 1995; R. Kellner, 1990; T.S.Brugha, 1995, etc.). The search for ways to overcome these obstacles is an important independent scientific task, the solution of which involves the development of methodological means of integration, the conduct of complex empirical studies of the psychological factors of the affective spectrum disorders and the development of scientifically based integrative methods of psychotherapy for these disorders.

Purpose of the study. Development of theoretical and methodological foundations for the synthesis of knowledge accumulated in different traditions of clinical psychology and psychotherapy, a comprehensive empirical study of the system of psychological factors of disorders of the affective spectrum with the allocation of targets and the development of principles of integrative psychotherapy and psychoprophylaxis of depressive, anxiety and somatoform disorders.

Research objectives.

1. Theoretical and methodological analysis of the models of occurrence and methods of treatment of affective spectrum disorders in the main psychological traditions; justification of the necessity and possibility of their integration.
2. Development of methodological foundations for the synthesis of knowledge and integration of psychotherapy methods for affective spectrum disorders.
3. Analysis and systematization of available empirical studies of psychological factors of depressive, anxiety and somatoform disorders based on a multifactorial psycho-social model of affective spectrum disorders and a four-aspect model of the family system.
4. Development of a methodological complex aimed at the systematic study of macrosocial, family, personal and interpersonal factors of emotional disorders and disorders of the affective spectrum.
5. Conducting an empirical study of patients with depressive, anxiety and somatoform disorders and a control group of healthy subjects on the basis of a multifactorial psycho-social model of affective spectrum disorders.
6. Conducting a population empirical study aimed at studying the macrosocial factors of emotional disorders and identifying high-risk groups among children and youth.
7. Comparative analysis of the results of the study of various population and clinical groups, as well as healthy subjects, analysis of the links between macrosocial, family, personal and interpersonal factors.
8. Isolation and description of the target system of psychotherapy for affective spectrum disorders, substantiated by the data of theoretical and methodological analysis and empirical research.
9. Formulation of the basic principles, objectives and stages of integrative psychotherapy for affective spectrum disorders.
10. Determination of the main tasks of psychoprophylaxis of emotional disorders in children from risk groups.

Theoretical and methodological foundations of the work. The methodological basis of the study is the systemic and activity approaches in psychology (B.F. Lomov, A.N. Leontiev, A.V. Petrovsky, M.G. Yaroshevsky), a bio-psycho-social model of mental disorders, according to which in the occurrence and biological, psychological and social factors are involved in the course of mental disorders (G. Engel, HSAkiskal, G. Gabbard, Z. Lipowsky, M. Perrez, Yu. A. Aleksandrovsky, I. Ya. Gurovich, B. D. Karvasarsky, V. Krasnov), ideas about non-classical science, as focused on solving practical problems and integrating knowledge from the point of view of these problems (L.S.Vygotsky, V.G. Gorokhov, V.S.Stepin, E.G. Yudin, N. G. Alekseev, V. K. Zaretsky), the cultural-historical concept of the development of the psyche of L.S. Vygotsky, the concept of mediation by B.V. Zeigarnik, ideas about the mechanisms of reflexive regulation in health and disease (N.G. Alekseev, V.V. Zaretsky, B.V. Zeigarnik, V.V. Nikolaeva, A.B. Kholmogorova), a two-level model of cognitive processes developed in cognitive psychotherapy A. Beck.

Object of study. Models and factors of mental norm and pathology and methods of psychological assistance in affective spectrum disorders.

Subject of study. Theoretical and empirical foundations for the integration of various models of occurrence and methods of psychotherapy for affective spectrum disorders.

Research hypotheses.

1. Different models of occurrence and methods of psychotherapy for affective spectrum disorders focus on different factors; the importance of their complex consideration in psychotherapeutic practice necessitates the development of integrative models of psychotherapy.
2. The developed multifactorial psycho-social model of affective spectrum disorders and a four-aspect model of the family system allow us to consider and study macrosocial, family, personal and interpersonal factors as a system and can serve as a means of integrating various theoretical models and empirical studies of affective spectrum disorders.
3. Macrosocial factors such as social norms and values ​​(the cult of restraint, success and excellence, gender role stereotypes) affect the emotional well-being of people and can contribute to the occurrence of emotional disorders.
4. There are general and specific psychological factors of depressive, anxiety and somatoform disorders associated with different levels (familial, personal, interpersonal).
5. The developed model of integrative psychotherapy for affective spectrum disorders is an effective means of psychological assistance in these disorders.

Research methods.

1. Theoretical and methodological analysis - reconstruction of conceptual schemes for the study of affective spectrum disorders in various psychological traditions.
2. Clinical and psychological - the study of clinical groups using psychological methods.
3. Population - the study of groups from the general population using psychological methods.
4. Hermeneutic - qualitative analysis of interview data and essays.
5. Statistical - the use of methods of mathematical statistics (when comparing groups, the Mann-Whitney test for independent samples and the Wilcoxon T-test for dependent samples were used; to establish correlations, the Spearman correlation coefficient was used; to validate the methods - factor analysis, test-retest, coefficient α - Cronbach, Guttman Split-half; multiple regression analysis was used to analyze the effect of variables). For statistical analysis, we used the SPSS for Windows software package, Standard Version 11.5, Copyright © SPSS Inc., 2002.
6. Expert assessment method - independent expert assessments of interview data and essays; expert assessments of the characteristics of the family system by psychotherapists.
7. Follow-up method - collection of information about patients after treatment.

The developed methodological complex includes the following blocks of techniques in accordance with the research levels:

1) family level - a questionnaire of family emotional communications (SEC, developed by A.B. Kholmogorova together with S.V. Volikova); structured interviews "Scale of stressful events in family history" (developed by A.B.Kholmogorova together with N.G. Garanyan) and "Parental criticism and expectations" (RCO, developed by A.B.Kholmogorova together with S.V. Volikova), test family system (FAST, developed by TMGehring); an essay for parents "My child";

2) the personal level - the questionnaire of the prohibition on the expression of feelings (ZVC, developed by V.K. Zaretsky together with A.B. Kholmogorova and N.G. Garanyan), the Toronto scale of alexithymia (TAS, developed by GJ Taylor, adaptation by D.B. Eresko , G.L. Isurina et al.), Test for emotional vocabulary for children (developed by JHKrystal), test for recognizing emotions (developed by A.I.To, modified by N.S. Kurek), test for emotional vocabulary for adults ( developed by N.G. Garanyan), a perfectionism questionnaire (developed by N.G. Garanyan together with A.B. Kholmogorova and T.Yu. Yudeeva); scale of physical perfectionism (developed by A.B. Kholmogorova together with A.A. Dadeko); a questionnaire of hostility (developed by N.G. Garanyan together with A.B. Kholmogorova);

interpersonal level - social support questionnaire (F-SOZU-22, developed by G. Sommer, T. Fydrich); structured interview “Moscow integrative social network questionnaire” (developed by AB Kholmogorova together with NG Garanyan and GA Petrova); test for the type of attachment in interpersonal relationships (developed by C. Hazan, P. Shaver).

To study psychopathological symptoms, we used the SCL-90-R questionnaire of the severity of psychopathological symptoms (developed by LRDerogatis, adapted by N.V. Tarabrina), a depression questionnaire (BDI, developed by ATBeck et al., Adapted by N.V. Tarabrina), anxiety questionnaire ( BAI, developed by ATBeck and RASteer), a questionnaire of children's depression (CDI, developed by M. Kovacs), a scale of personal anxiety (developed by A.M. Prikhozhan). To analyze the factors of the macrosocial level in the study of risk groups from the general population, the above methods were selectively used. Some of the methods were developed specifically for this study and were validated in the laboratory of clinical psychology and psychotherapy of the Moscow Research Institute of Psychiatry, Roszdrav.

Characteristics of the surveyed groups.

The clinical sample consisted of three experimental groups of patients: 97 patients with depressive disorders , 90 patients with anxiety disorders, 52 patients with somatoform disorders; two control groups of healthy subjects included 90 people; the groups of parents of patients with affective spectrum disorders and healthy subjects included 85 people; the sample of subjects from the general population included 684 school-age children, 66 school-age parents, and 650 adult subjects; additional groups included in the questionnaire validation study were 115 people. A total of 1929 subjects were examined.

The research involved employees of the Laboratory of Clinical Psychology and Psychotherapy of the Moscow Research Institute of Psychiatry, Roszdrav: Ph.D. leading researcher N.G. Garanyan, researchers S.V. Volikova, G.A. Petrova, T.Yu. Yudeeva, as well as students of the department of the same name at the Faculty of Psychological Consulting of the Moscow City Psychological and Pedagogical University A.M. Galkina, A. A. Dadeko, D. Yu. Kuznetsova. The clinical assessment of the patients' condition in accordance with the ICD-10 criteria was carried out by the leading researcher of the Moscow Research Institute of Psychiatry of the Federal Public Health Service, Ph.D. T.V. Dovzhenko. The course of psychotherapy was prescribed to patients according to indications in combination with drug treatment. Statistical data processing was carried out with the participation of Doctor of Pedagogical Sciences, Ph.D. M.G. Sorokova and Candidate of Chemical Sciences O.G. Kalina.

Reliability of results provided by a large volume of surveyed samples; the use of a set of methods, including questionnaires, interviews and tests, which made it possible to verify the results obtained using individual methods; using methods that have passed the procedures of validation and standardization; processing the data obtained using the methods of mathematical statistics.

The main provisions for the defense

1. In the existing areas of psychotherapy and clinical psychology, different factors are emphasized and different targets of work with affective spectrum disorders are highlighted. The current stage in the development of psychotherapy is characterized by tendencies towards the complication of models of mental pathology and the integration of accumulated knowledge based on a systematic approach. The theoretical foundations for the integration of existing approaches and research and the selection on this basis of the target system and the principles of psychotherapy are the multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of the analysis of the family system.

1.1. The multivariate model for affective spectrum disorders includes macrosocial, familial, personality, and interpersonal levels. At the macrosocial level, factors such as pathogenic cultural values ​​and social stresses are distinguished; at the family level - dysfunctions of the structure, microdynamics, macrodynamics and ideology of the family system; at the personal level - disorders of the affective-cognitive sphere, dysfunctional beliefs and strategies of behavior; at the interpersonal level - the size of the social network, the presence of close trusting relationships, the degree of social integration, emotional and instrumental support.

1.2. The four-aspect model for analyzing the family system includes the structure of the family system (degree of intimacy, hierarchy between members, intergenerational boundaries, boundaries with the outside world); microdynamics of the family system (everyday functioning of the family, primarily communication processes); macrodynamics (family history in three generations); ideology (family norms, rules, values).

2. The complex of psychological factors of these disorders, substantiated by the results of a multilevel study of three clinical, two control and ten population groups, acts as an empirical basis for psychotherapy of affective spectrum disorders.

2.1. In the modern cultural situation, there are a number of macrosocial factors of affective spectrum disorders: 1) an increase in the load on the emotional sphere of a person as a result of a high level of stress in life (pace, competition, difficulties in choosing and planning); 2) the cult of restraint, strength, success and perfection, leading to negative attitudes towards emotions, difficulties in processing emotional stress and receiving social support; 3) a wave of social orphanhood against the background of alcoholism and family breakdown.

2.2. In accordance with the research levels, the following psychological factors of depressive, anxiety and somatoform disorders were identified: 1) at the family level - disturbances in structure (symbiosis, coalitions, disunity, closed boundaries), microdynamics (high level of parental criticism and domestic violence), macrodynamics (accumulation stressful events and reproduction of family dysfunctions in three generations) ideology (perfectionist standards, distrust of others, suppression of initiative) of the family system; 2) on a personal level - dysfunctional beliefs and disorders of the cognitive-affective sphere; 3) at the interpersonal level - a pronounced deficit of trusting interpersonal relationships and emotional support. The most pronounced dysfunctions of the family and interpersonal level are observed in patients with depressive disorders. Patients with somatoform disorders have pronounced impairments in the ability to verbalize and recognize emotions.

3. Conducted theoretical and empirical research is the basis for integrating psychotherapeutic approaches and identifying the target system of psychotherapy for affective spectrum disorders. The model of integrative psychotherapy developed on these grounds synthesizes the tasks and principles of cognitive-behavioral and psychodynamic approaches, as well as a number of developments in Russian psychology (concepts of interiorization, reflection, mediation) and systemic family psychotherapy.

3.1. The tasks of integrative psychotherapy and prevention of affective spectrum disorders are: 1) at the macrosocial level: debunking pathogenic cultural values ​​(the cult of restraint, success and perfection); 2) at the personal level: development of the skills of emotional self-regulation through the gradual formation of reflexive ability in the form of stopping, fixing, objectifying (analyzing) and modifying dysfunctional automatic thoughts; transformation of dysfunctional personal attitudes and beliefs (a hostile worldview, unrealistic perfectionist standards, a ban on the expression of feelings); 3) at the family level: working out (comprehending and responding) traumatic life experience and family history events; work with actual dysfunctions of the structure, microdynamics, macrodynamics and ideology of the family system; 4) at the interpersonal level: the development of deficient social skills, the development of the ability to close trusting relationships, the expansion of the system of interpersonal relationships.

3.2. Somatoform disorders are characterized by a fixation on the physiological manifestations of emotions, a pronounced narrowing of the emotional vocabulary and difficulties in comprehending and verbalizing feelings, which determines a certain specificity of integrative psychotherapy of disorders with pronounced somatization in the form of an additional task of developing psychohygiene skills of emotional life.

The novelty and theoretical significance of the research. For the first time, the theoretical foundations for the synthesis of knowledge about affective spectrum disorders, obtained in different traditions of clinical psychology and psychotherapy, were developed - a multifactorial psycho-social model of affective spectrum disorders and a four-aspect model for analyzing the family system.

For the first time, on the basis of these models, a theoretical and methodological analysis of various traditions has been carried out, the existing theoretical and empirical studies of affective spectrum disorders have been systematized, and the need for their integration has been substantiated.

For the first time, on the basis of the developed models, a complex experimental-psychological study of psychological factors of affective spectrum disorders was carried out, as a result of which macrosocial, family interpersonal factors of affective spectrum disorders were studied and described.

For the first time, on the basis of a comprehensive study of psychological factors of affective spectrum disorders and theoretical and methodological analysis of various traditions, a system of psychotherapy targets has been identified and described and an original model of integrative psychotherapy for affective spectrum disorders has been developed.

Original questionnaires have been developed for the study of family emotional communications (SEC), the prohibition on the expression of feelings (EF), and physical perfectionism. Structured interviews have been developed: the scale of stressful events in family history and the Moscow Integrative Social Network Questionnaire, which tests the main parameters of a social network. For the first time in Russian, a tool for studying social support has been adapted and validated - the Sommer-Füdrik social support questionnaire (SOZU-22).

The practical significance of the study. The main psychological factors of affective spectrum disorders and scientifically grounded targets of psychological assistance, which must be taken into account by specialists working with patients suffering from these disorders, are highlighted. Diagnostic techniques have been developed, standardized and adapted, allowing specialists to identify the factors of emotional disorders and highlight the targets of psychological assistance. A model of psychotherapy for affective spectrum disorders has been developed, integrating knowledge accumulated in various traditions of psychotherapy and empirical research. The tasks of psychoprophylaxis of affective spectrum disorders for children of risk groups, their families and specialists from educational and upbringing institutions are formulated.

The research results are implemented:

In the practice of the clinics of the Moscow Research Institute of Psychiatry of Roszdrav, the Scientific Center for Mental Health of the Russian Academy of Medical Sciences, the State Clinical Hospital No. 4 named after Gannushkin and GKPB No. 13 of Moscow, in the practice of the Regional Psychotherapeutic Center at the OKPB No. 2 in Orenburg and the Consultative and Diagnostic Center for Mental Health of Children and Adolescents in Novgorod.

The research results are used in the educational process of the Faculty of Psychological Consulting and the Faculty of Advanced Studies of the Moscow City Psychological and Pedagogical University, the Faculty of Psychology of the Moscow State University. MV Lomonosov, Faculty of Clinical Psychology, Siberian State Medical University, Department of Pedagogy and Psychology, Chechen State University.

Approbation of the study. The main provisions and results of the work were reported by the author at the international conference "Synthesis of psychopharmacology and psychotherapy" (Jerusalem, 1997); at the Russian national symposia "Man and Medicine" (1998, 1999, 2000); at the First Russian-American Conference on Cognitive-Behavioral Psychotherapy (St. Petersburg, 1998); at international educational seminars "Depression in the primary medical network" (Novosibirsk, 1999; Tomsk, 1999); at the breakout sessions of the XIII and XIV congresses of the Russian Society of Psychiatrists (2000, 2005); at the Russian-American symposium "Identifying and treating depression in the primary health care network" (2000); at the First International Conference in memory of B.V. Zeigarnik (Moscow, 2001); at the plenary meeting of the Board of the Russian Society of Psychiatrists in the framework of the Russian conference "Affective and Schizoaffective Disorders" (Moscow, 2003); at the conference "Psychology: modern directions of interdisciplinary research", dedicated to the memory of Corresponding Member. RAS A.V. Brushlinsky (Moscow, 2002); at the Russian conference "Modern trends in the organization of psychiatric care: clinical and social aspects" (Moscow, 2004); at the conference with international participation "Psychotherapy in the system of medical sciences during the formation of evidence-based medicine" (St. Petersburg, 2006).

The thesis was discussed at the meetings of the Scientific Council of the Moscow Research Institute of Psychiatry (2006), the Problem Commission of the Scientific Council of the Moscow Research Institute of Psychiatry (2006) and the Scientific Council of the Faculty of Psychological Consulting of the Moscow State University of Psychiatry (2006).

The structure of the thesis. The text of the thesis is presented in 465 p., Consists of an introduction, three parts, ten chapters, conclusions, conclusions, a list of references (450 titles, 191 of them in Russian and 259 in foreign languages), annexes, includes 74 tables, 7 figures.

MAIN CONTENT OF WORK

In administered substantiated the relevance of the work, formulated the subject, goal, objectives and hypotheses of the study, revealed the methodological foundations of the study, gave a characteristic of the surveyed group and the methods used, scientific novelty, theoretical and practical significance, presented the main provisions for defense.

First part consists of four chapters and is devoted to the development of theoretical foundations for the integration of models of occurrence and methods of psychotherapy for affective spectrum disorders. V first chapter the concept of affective spectrum disorders is introduced as a field of mental pathology with the dominance of emotional disorders and a pronounced psycho-vegetative component (J. Angst, 1988, 1997; HSAkiskal et al., 1980, 1983; O. P. Vertogradova, 1992; V.N. Krasnov, 2003, etc.). The article presents information on the epidemiology, phenomenology and modern classification of depressive, anxiety and somatoform disorders as the most epidemiologically significant. A high level of comorbidity of these disorders is recorded, discussions regarding their status and common etiology are analyzed.

In second chapter analyzed theoretical models of affective spectrum disorders in the main psychotherapeutic traditions - psychodynamic, cognitive-behavioral, existential-humanistic, and considered integrative approaches centered on the family and interpersonal relationships (system-oriented family psychotherapy, attachment theory by D. Bowlby, G. Clairman psychotherapy, G. V.N. Myasishchev's theory of relations). Particular attention is paid to the theoretical developments of Russian psychology, dedicated to reflection, revealed its role for emotional self-regulation.

It is shown that the traditional opposition of the classical models of psychoanalysis, behaviorism and existential psychology is currently being replaced by integrative tendencies in ideas about the structural and dynamic characteristics of the psyche in health and disease: the formation of vulnerability to disorders of the affective spectrum; 2) mechanistic causal relationships (trauma is a symptom; inadequate learning is a symptom) or a complete denial of the principle of determinism are replaced by complex systemic ideas about internal negative representations of oneself and the world and a system of negative distortions of external and internal reality as factors of personal vulnerability to disorders of the affective spectrum.

As a result of the analysis, the complementarity of existing approaches is proved and the need for the synthesis of knowledge for solving practical problems is substantiated. In cognitive-behavioral therapy, the most effective means of working with cognitive distortions and dysfunctional beliefs have been accumulated (A. Beck et al., 2003; Alford, Beck, 1997); in the psychodynamic approach - with traumatic experience and actual interpersonal relationships (Z. Freud, 1983; S. Heim, M. G. Owens, 1979; G. Klerman et al., 1997, etc.); in systemic family psychotherapy - with actual family dysfunctions and family history (E.G. Eidemiller, V.Yustickis, 2000; M. Bowen, 2005); in the domestic tradition, which developed the principle of the subject's activity, ideas about the mechanisms of mediation and emotional self-regulation have been developed (B.V. Zeigarnik, A.B. Kholmogorova, 1986; B.V. Zeigarnik, A.B. Kholmogorova, E.P. Mazur, 1989; E.T. Sokolova, V.V. Nikolaeva, 1995; F.S. Safuanov, 1985; Tkhostov, 2002). A number of general trends in the development of directions in psychotherapy are distinguished: from mechanistic models to systemic ones within traditions; from opposition to integration in relations between traditions; from exposure to cooperation in relationships with patients.

Table 1. Conceptions about the structural and dynamic characteristics of the psyche in the main directions of modern psychotherapy: tendencies towards rapprochement.

Directions psychotherapy Characteristic listiki psyche	Psychodynamic tradition Object theory Relationship	Cognitive-behavioral tradition Beck's cognitive psychotherapy	Existential-humanist tradition Client-centered Rogers psychotherapy
Structure	System of representations about oneself and about the world (object representations)	System of ideas about oneself and about the world (cognitive schemas: beliefs and beliefs)	System of ideas about oneself and about the world (concept I)
Microdynamics	Reflection of reality (protective mechanisms)	Reflection of reality (cognitive distortion)	Reflection of reality (distortion of inner experience)
Macrodynamics	Early experience, nature of attachment (stages of development of object relations)	Early experience, attachment patterns (cognitive schema formation)	Early experience, the nature of attachment (the formation of the concept of "I")

A two-level cognitive model, developed in cognitive psychotherapy by A. Beck, is proposed as one of the grounds that allow the synthesis of approaches, and its high integrative potential is proved (B.A.Alford, A.T. Beck, 1997; A.B. Kholmogorova, 2001).

Chapter Three is devoted to the development of methodological tools for the synthesis of theoretical and empirical knowledge about affective spectrum disorders and methods of their treatment. It outlines the concept of non-classical science, in which the need for the synthesis of knowledge is due to the focus on solving practical problems and the complexity of the latter.

This concept, which goes back to the works of L.S. Vygotsky in the field of defectology, was actively developed by Russian methodologists based on the material of engineering sciences and ergonomics (E.G. Yudin, 1997; V.G. Gorokhov, 1987; N.G. Alekseev, V.V. K. Zaretsky, 1989). Based on these developments, the methodological status of modern psychotherapy as a non-classical science aimed at developing scientifically grounded methods of psychological assistance is substantiated.

The constant growth in the amount of research and knowledge in the sciences of mental health and pathology requires the development of means for their synthesis. In modern science, a systematic approach acts as a general methodology for the synthesis of knowledge (L. von Bertalanffy, 1973; E.G. Yudin, 1997; V.G. Gorokhov, 1987, 2003; B.F. Lomov, 1996; A.V. Petrovsky, M.G. Yaroshevsky, 1994).

In the sciences of mental health, it is refracted into systemic bio-psycho-social models reflecting the complex multifactorial nature of mental pathology, refined by more and more new studies (I.Ya. Gurovich, Ya.A. Storozhakova, A.B. Shmukler, 2004; V. N. Krasnov, 1990; B. D. Karvasarsky, 2000; A. B. Kholmogorova, N. G. Garanyan, 1998; H. Akiskal, G. McKinney, 1975; G. Engel, 1980; J. Lipowsky, 1981; G. Gabbard, 2001, etc.).

As a means of synthesizing psychological knowledge about disorders of the affective spectrum, a multifactorial psychosocial model of these disorders is proposed, on the basis of which the factors are organized into interconnected blocks belonging to one of the following levels: macrosocial, family, personal and interpersonal. Table 2 shows which factors are emphasized by different schools of psychotherapy and clinical psychology.

Table 2. Multilevel psycho-social model of affective spectrum disorders as a means of knowledge synthesis

Levels	Factors in affective spectrum disorders	Traditions psychotherapy and clinical psychology
Macrosocial	Pathogenic and Conflicting Values ​​of Contemporary Culture	Social psychoanalysis
Family	Traumatic experience Insecure attachment Family system dysfunctions	Psychodynamic (Z. Freud) D.Bowlby's attachment theory System-oriented family (S. Minukhin, M. Bowen)
Personal	Negative thinking, dysfunctional beliefs Negative Self-Conception, Disclaimer Repressed aggression, negative self-esteem, alexithymia Reflexive regulation disorders of thinking and behavior	Cognitive-behavioral (A. Beck, A. Ellis) Existential-humanistic (K. Rogers, R. May) Psychodynamic (K. Abraham, Z. Freud, D. Jacobson, P. Sifneos) Thinking research at the Moscow school (N. G. Alekseev, V. K. Zaretsky, B. V. Zeigarnik, A. B. Kholmogorova)
Interpersonal	Failure to cooperate Destructive interpersonal strategies Communication dysfunctions, deficits in social skills Lack of awareness, activity and selectivity in relationships	Individual psychology of A. Adler Social psychoanalysis (G. Sullivan, K. Horney) Interpersonal psychotherapy G. Klerman Psychology of relations of V.N. Myasishchev, personality-reconstructive psychotherapy of B.D. Karvasarsky, G.L. Isurina, V.A.Tashlykov.

Table 3 presents a four-aspect model of the family system as a means of systematizing the conceptual apparatus developed in different schools of systemic family psychotherapy. Based on this model, the synthesis of knowledge about the family factors of affective spectrum disorders and their complex empirical study are carried out.

Table 3. Four-aspect model of the family system as a means of synthesizing knowledge about family factors

Family structure	Family microdynamics	Family Macrodynamics	Family ideology
1.Communication super-inclusion, disunity. autonomy, differentiation coalitions 2.Hierarchy low, high, moderate. Hierarchy inversion 3. Subsystems. parent, child, grandparent. 4.Borders: internal - between generations, external - with the outside world	1.Family Roles - Mixing roles. Role flexibility. 2. Stereotypes of interaction Conflict frequency. The degree of control. 3. Circulation of information in the system. Family secrets. 4. Style of emotional communication in the family. level of criticism, negative emotions, expression of feelings, paradoxical communications 5. Metacommunication communication about communication 6. Triangulation using the third in resolving conflicts between two others	1 family history or evolution relationships and events in 3 generations 2.Family scenario repeating patterns from generation to generation 3. The cycle of family development. Tipping points 4 resistance to change difficulties of restructuring 5 resources for change positive aspects of relationships 6. Transmission accumulation of negative patterns in three generations 7 traumatic events in family history early deaths, serious illnesses, victims of wars and repressions, etc.	1. Family rules, norms. Constructive-dysfunctional 2. Delegation of requirements and expectations. Consistent, inconsistent. destructive, giving support 4. Family values, beliefs and beliefs constructive-dysfunctional 5.Traditions, rituals stable patterns that unite family members 6. General cultural context of the family system cultural values, stereotypes, norms

V fourth chapter the first part presents the results of systematization of empirical studies of psychological factors of affective spectrum disorders based on the developed means.

Macrosocial level. The role of various social stresses (poverty, socio-economic cataclysms) in the growth of emotional disorders is shown (WHO materials, 2001, 2003, V.M. Voloshin, N.V. Vostroknutov, I.A. Kozlova et al., 2001). At the same time, an unprecedented increase in social orphanhood was noted in Russia, which ranks first in the world in terms of the number of orphans: according to official statistics alone, there are more than 700 thousand of them. According to research, orphans are one of the main risk groups for deviant behavior and various mental disorders, including affective spectrum disorders (D. Bowlby, 1951, 1980; I.A. Korobeinikov, 1997; J. Langmeyer, Z. Mateichik , 1984; V.N. Oslon, 2002; V.N. Oslon, A.B. Kholmogorova, 2001; A.M. Prikhozhan, N.N. Tolstykh, 2005; Yu.A. Pishchulina, V.A. Ruzhenkov , OV Rychkova 2004; Dozortseva, 2006, etc.). It has been proven that the risk of depression in women who have lost their mother before 11 years of age increases threefold (G.W. Brown, T.W. Harris, 1978). However, about 90% of orphans in Russia are orphans with living parents, living in orphanages and boarding schools. The main reason for the breakdown of families is alcoholism. Family forms of life arrangement for orphans in Russia are not sufficiently developed, although the need for substitute family care for the mental health of children has been proven by foreign and domestic studies (V.K. Zaretsky et al., 2002, V.N. Oslon, A.B. Kholmogorova, 2001, V. N. Oslon, 2002, I. I. Osipova, 2005, A. Kadushin, 1978, D. Tobis, 1999, etc.).

Macrosocial factors lead to the stratification of society. This is expressed, on the one hand, in the impoverishment and degradation of part of the population, and on the other, in the growth of the number of wealthy families with a request to organize elite educational institutions with perfectionist educational standards. A pronounced orientation towards success and achievement, intensive training loads in these institutions also pose a threat to the emotional well-being of children (S.V. Volikova, A.B. Kholmogorova, A.M. Galkina, 2006).

Another manifestation of the cult of success and excellence in society is the widespread propaganda in the media of unrealistic perfectionist standards of appearance (weight and body proportions), the massive growth of fitness and bodybuilding clubs. For some of the visitors to these clubs, body shaping activities are becoming overvalued. As Western studies show, the cult of physical perfection leads to emotional disorders and eating disorders, also belonging to the spectrum of affective disorders (T. F. Cash, 1997; F. Skerderud, 2003).

Such a macrosocial factor as gender stereotypes also has a significant impact on mental health and emotional well-being, although it still remains poorly understood (J. Angst, C. Ernst, 1990; A.M. Meller-Leimküller, 2004). Epidemiological data indicate a higher prevalence of depressive and anxiety disorders in women, who are significantly more likely to seek help for these conditions. At the same time, it is known that the male population is clearly ahead of the female in the number of completed suicides, alcoholism, and premature mortality (K. Hawton, 2000; V.V. Voitsekh, 2006; A.V. Nemtsov, 2001). Since mood disorders are important factors in suicide and alcoholism, it becomes necessary to explain these data. Features of gender stereotypes of behavior - the cult of strength and masculinity in men - can shed light on this problem. Difficulties in making complaints, seeking help, receiving treatment and support increase the risk of undetected emotional disorders in men, and are expressed in secondary alcoholism and antivital behavior (A.M. Meller-Leimküller, 2004).

Family level. In recent decades, there has been an increased focus of researchers on familial factors in affective spectrum disorders. Starting with the pioneering work of D. Bowlby and M. Ainsworth (Bowlby, 1972, 1980), the problem of insecure attachment in childhood as a factor in depressive and anxiety disorders in adults has been investigated. The most fundamental research in this area belongs to J. Parker (Parker, 1981, 1993), who proposed the well-known Parental Bonding Instrument (PBI) questionnaire for the study of parental attachment. He characterized the parent-child style of depressed patients as "cold control" and anxious as "emotional grip." J. Engel studied family dysfunctions in disorders with severe somatization (G. Engel, 1959). Further research made it possible to identify a whole series of family dysfunctions characteristic of affective spectrum disorders, which are systematized on the basis of a four-aspect model of the family system: 1) structure - symbiosis and disunity, closed boundaries (A.E. Bobrov, M.A. Belyanchikova, 1999; N.V. Samoukina, 2000, E.G. Eidemiller, V.Yustitskis, 2000); 2) microdynamics - a high level of criticism, pressure and control (G. Parker, 1981, 1993; M. Hudges, 1984, etc.); 3) macrodynamics: serious illness and death of relatives, physical and sexual violence in family history (BMPayne, Norfleet, 1986; Sh. Declan, 1998; J. Hill, A. Pickles et all, 2001; J. Scott, WABarker, D. Eccleston, 1998); 4) ideology - perfectionist standards, the value of obedience and success (L.V. Kim, 1997; N.G. Garanyan, A.B. Kholmogorova, T.Yu. Yudeeva, 2001; SJ Blatt., E. Homann, 1992) ... Recently, there has been a growing number of comprehensive studies proving the important contribution of psychological family factors to childhood depression along with biological ones (A. Pike, R. Plomin, 1996), systemic studies of family factors are being conducted (E. G. Eidemiller, V. Yustitskis, 2000; A.B.Kholmogorova, S.V. Volikova, E.V. Polkunova, 2005; S.V. Volikova, 2006).

Personal level. If the works of psychiatrists are dominated by studies of various personality types (typological approach), as a factor of vulnerability to disorders of the affective spectrum (G.S. Bannikov, 1998; D. Yu. Veltischev, Yu. M. Gurevich, 1984; Akiskal et al., 1980 , 1983; H. Thellenbach, 1975; M. Shimoda, 1941), then in modern research of clinical psychologists the parametric approach prevails - the study of individual personality traits, attitudes and beliefs, as well as the study of the affective-cognitive style of personality (ATBeck, et al., 1979; MWEnns, BJCox, 1997; J. Lipowsky, 1989). In studies of depressive and anxiety disorders, the role of such personality traits as perfectionism is emphasized (R. Frost et al., 1993; P. Hewitt, G. Fleet, 1990; N. G. Garanyan, A.B. Kholmogorova, T. Yu. Yudeeva, 2001, N.G. Garanyan, 2006) and hostility (A.A. Abramova, N.V. Dvoryanchikov, S.N. Enikolopov et al., 2001; N.G. Garanyan, A.B. Kholmogorova , T.Yu. Yudeeva, 2003; M.Fava, 1993). Since the introduction of the concept of alexithymia (GSNemiah, PESifneos, 1970), studies of this affective-cognitive style of personality, as a factor of somatization, and discussions regarding its role have not stopped (J. Lipowsky, 1988, 1989; R. Kellner, 1990; V. Nikolaeva, 1991; A.Sh. Tkhostov, 2002; N.G. Garanyan, A.B. Kholmogorova, 2002).

Interpersonal level. The main block of research at this level concerns the role of social support in the onset and course of affective spectrum disorders (M. Greenblatt, MRBecerra, EASerafetinides, 1982; TSBrugha, 1995; A.B. Kholmogorova, N.G. Garanyan, G.A. Petrova, 2003). As these studies show, the lack of close supportive interpersonal relationships, formal, superficial contacts are closely associated with the risk of depressive, anxiety and somatoform disorders.

PartII consists of four chapters and is devoted to the presentation of the results of a comprehensive empirical study of the psychological factors of affective spectrum disorders based on a multifactorial psycho-social model and a four-aspect model of the family system. V first chapter the general design of the study is revealed, a brief description of the surveyed groups and the methods used is given.

Chapter two is devoted to the study of the macrosocial level - the identification of risk groups for affective spectrum disorders in the general population. To avoid stigmatization, the term “emotional disturbances” has been used to describe the manifestations of affective spectrum disorders in the form of symptoms of depression and anxiety in the general population. The data of a survey of 609 schoolchildren and 270 university students are presented, demonstrating the prevalence of emotional disorders in children and young people (about 20% of adolescents and 15% of students fall into the group with high rates of depression symptoms). Table 5 indicates the studied macrosocial factors of affective spectrum disorders.

Table 5. General organization of the study of factors of the macrosocial level

Macrosocial factors	Examined groups	Methodology
Factor 1. Breakdown and alcoholization of families, a wave of social orphanhood, an increase in the number of children with traumatic family experiences of violence and loss	Group 1 - children-social orphans Group 2 - children from socially disadvantaged families Group 3 - children from ordinary families Total - 141 people	Kovak Child Depression Inventory, Parishioners Anxiety Inventory, Crystal Children's Emotional Vocabulary Test
Factor 2. Growth of educational institutions (EE) with increased teaching load, perfectionist training standards	Group 1 - children from educational establishments with increased workload Gr .. 2 - children from regular classes Group 3 - parents of children from educational institutions with increased workload Group 4 - parents of children from regular classes Total - 197 people	Kovak Child Depression Inventory, Parishioners Anxiety Inventory, Perfectionism Inventory
Factor 3. The cult of physical perfection in the form of perfectionist standards of weight and body proportions, their propaganda in the media	Group 1 - girls. body shapers Group 2 - girls not involved in this activity Group 1 - young men doing body shaping Group 4 - boys not involved in this activity Total - 170 people	Beck's Anxiety and Depression Inventories, Physical Perfectionism Scale, Perfectionism Inventory
Factor 4. Sex-role stereotypes of emotional behavior	Group 1 - husband. Floor Gr. 2 - wives floor Total - 210 people	Inhibiting Expression of Feelings Questionnaire (FEI)

Impact research factor 1(disintegration and alcoholization of families, a wave of social orphanhood) for the emotional well-being of children showed that social orphans are the most disadvantaged group of the three studied.

They show the highest scores on the depression and anxiety scales, as well as a narrowed emotional vocabulary. Children living in socially disadvantaged families occupy an intermediate position between children-social orphans who have lost their families and schoolchildren from ordinary families.

Study factor 2(an increase in the number of educational institutions with an increased academic load) showed that among students in classes with an increased load, the percentage of adolescents with emotional disorders is higher compared to schoolchildren from ordinary classes.

Parents of children with symptoms of depression and anxiety exceeding the norm demonstrated significantly higher rates of perfectionism compared with parents of emotionally well-off children; revealed significant correlations between indicators of parental perfectionism and symptoms of childhood depression and anxiety.

Study factor 3(the cult of physical perfection) showed that among young people involved in body shaping activities in fitness and bodybuilding clubs, the indicators of depressive and anxiety symptoms are significantly higher than in groups not involved in this activity.

Table 6. Indicators of depression, anxiety, general and physical perfectionism in the fitness, bodybuilding and control groups.

Groups Questionnaires	Women		Men
	FitnessN=60 M (SD)	Counter. N=60 M (SD)	Bodybuilding. N=25 M (SD)	Counter. N=25 M (SD)
Beck's depression	15** (9)	8 (7)	21* (12)	13 (12)
Beck's anxiety	14* (8)	10 (6)	19** (11)	10 (8)
Overall score on the Perfectionism Questionnaire	43* (10)	41 (12)	50** (9)	44 (14)
Physical Perfectionism Scale	26,5 **(6)	17 (8)	23** (7)	19 (5)

* at p<0,05 (Критерий Манна-Уитни) M – среднее значение

** at p<0,01 (Критерий Манна-Уитни) SD – стандартное отклонение

As can be seen from the table, the groups of boys and girls involved in body shaping activities differ from the control groups by significantly higher indices of general and physical perfectionism. Indicators of the level of physical perfectionism are associated with indicators of emotional distress by direct significant correlations.

Study factor 4(sex-role stereotypes of emotional behavior) showed that men have a higher rate of inhibition of the expression of asthenic emotions of sadness and fear than women. This result clarifies some of the important inconsistencies in the epidemiological data discussed above. The results obtained indicate the expressed difficulties in making complaints and seeking help in males, which prevents the identification of affective spectrum disorders and increases the level of suicidal risk in the male population. These difficulties are associated with such gender-role stereotypes of male behavior as the cult of masculinity, strength and restraint.

Third and fourth chapters the second part is devoted to the study of clinical groups, carried out on the basis of a multifactorial psycho-social model of affective spectrum disorders. Three clinical groups were examined: patients with depressive, anxiety and somatoform disorders. Among the patients of all three groups, women predominated (87.6%; 76.7%; 87.2%, respectively). The main age range in the groups of patients with depressive and anxiety disorders is 21-40 years old (67% and 68.8%, respectively), more than half with higher education (54.6 and 52.2%, respectively). Among patients with somatoform disorders, patients in the age range 31-40 (42.3%) and with secondary education (57%) prevailed. In the presence of comorbid disorders of the affective spectrum, the main diagnosis was made by a psychiatrist based on the dominant symptomatology at the time of examination. In some patients with depressive, anxiety and somatoform disorders, comorbid disorders of the mature personality were revealed (14.4%; 27.8%; 13.5%, respectively). The course of psychotherapy was prescribed according to indications in combination with drug treatment conducted by a psychiatrist.

Table 7. Diagnostic characteristics of patients with depressive disorders

ICD-10 code		Diagnosis	Patients with depressive disorders N=97
			N	%
	F32	Depressive episode	29	29,9
	F32 + F34.1	Combination of a depressive episode and dysthymia	16	16,5
	F32 + F45	Combination of a depressive episode and somatoform solution	4	4,1
F33	F33	Recurrent depressive solution	34	35,1
F34.0	F34.0	Cyclothymia	3	3,1
F34.1	F34.1	Dysthymia	11	11,3
Total:			97	100

The table shows that the predominant diagnoses in the group of depressive disorders are recurrent depressive disorder and a depressive episode.

Table 8. Diagnostic characteristics of patients with anxiety disorders

ICD-10 code		Diagnosis	Patients with anxiety disorders N=90
			N	%
	F40.01	Agoraphobia with Panic Disorder	7	7,8
	F40.01 + F32	Combination of agoraphobia with panic p-vom and depressive episode	5	5,6
	F40.1	Social phobias	9	10
	F40.1 + F32	Combination of social phobia and depressive episode	4	4,4
	F41.0	Panic disorder	6	6,7
	F41.0 + F32	Combination of panic disorder and depressive episode	8	8,8
	F41.1	Generalized alarming district	4	4,4
	F41.1 + F32	Combination of generalized anxious region and a depressive episode	7	7,8
	F41.2	Mixed anxious and depressive	24	26,7
	F41.2 + F41.0	A combination of mixed anxious and depressive r-va and panic r-va	7	7,8
F42	F42	Obsessive-compulsive solution	9	10
Total:			90	100

The table shows that the predominant diagnoses in the group of anxiety disorders are panic disorder with various combinations and mixed anxiety and depressive disorder.

Table 9.Diagnostic characteristics of patients with somatoform disorders

ICD-10 code		Diagnosis	Patients with somatoform disorders N=52
			n	%
	F 45.0	Somatisation disorder	24	46,2
	F 45.3	Somatoform autonomic dysfunction	28	53,8
Total			52	100

As can be seen from the table, the group of somatoform disorders included two main ICD-10 diagnoses. Patients diagnosed with somatisation disorder complained of multiple, repetitive and often localized somatic symptoms. Complaints of patients diagnosed with "somatoform autonomic dysfunction" related to a separate organ or system of the body, most often - to the cardiovascular, gastrointestinal or respiratory.

As can be seen from the graph, in the group of depressive people there is a distinct peak according to the school of depression, in the group of anxious - according to the anxiety scale, and in the group of somatoforms - the highest values ​​on the somatization scale, which is consistent with their diagnoses according to ICD-10 criteria. Depressive patients are distinguished by significantly higher rates on most scales of the symptomatic questionnaire.

In accordance with a multifactorial psycho-social model, psychological factors of somatoform, depressive and anxiety disorders were studied at the family, personal and interpersonal levels. Based on the data of theoretical and empirical studies, as well as our own work experience, a number of hypotheses are put forward. At the family level, on the basis of a four-aspect model, hypotheses about dysfunctions of the family system were put forward: 1) structures (violation of connections in the form of symbiosis, disunity and coalitions, closed external borders); 2) microdynamics (high level of criticism, inducing mistrust in people); 3) macrodynamics (high level of stress in family history); 4) ideologies (perfectionist standards, hostility and mistrust towards people). At the personal level, hypotheses were put forward: 1) about a high level of alexithymia and poorly formed skills of expression and recognition of emotions in patients with somatoform disorders; 2) about the high level of perfectionism and hostility in patients with depressive and anxiety disorders. At the interpersonal level, hypotheses have been put forward about the narrowing of the social network and the low level of emotional support and social integration.

In accordance with the hypotheses put forward, the blocks of techniques were somewhat different for patients with somatoform disorders from the other two clinical groups; different control groups were also selected for them, taking into account the differences in sociodemographic characteristics.

Depressive and anxious patients were examined by a common set of methods, in addition, in order to verify the data of the family level study, two additional groups were examined: parents of patients with depressive and anxiety disorders, as well as parents of healthy subjects.

Table 10 shows the surveyed groups and blocks of methods in accordance with the research levels.

Table 10. The surveyed groups and blocks of methods in accordance with the research levels

Groups Levels	Somatoform patients r-you, healthy subjects Total 82 people	Depressive patients alarming. r-you, healthy subjects Total 247 people	Parents of the sick depressed alarming. r-you, healthy isp. Total 85 people
Family	Family Emotional Communications Questionnaire (SEC), family history stressful life events scale, FAST family system test	SEC questionnaire, scale of stressful life events of family history, method of expert assessments, interview "Parental criticism and expectations"	Questionnaires for SEC, ZVCh, hostility, perfectionism, interviews “Rod. criticism and expectations "essay" My child "
Personal	ESP questionnaire, alexithymia scale, emotion recognition test, emotional vocabulary test	Inhibiting Expression of Feelings (FEF), Perfectionism and Hostility Questionnaires
Interpersonal	Social support questionnaire, Moscow integrative social network questionnaire.	Social support questionnaire, Moscow integrative social network questionnaire, attachment type test

The results of the study of patients with anxiety and depressive disorders revealed a number of dysfunctions of the family, personality and interpersonal levels.

Table 11. General indicators of dysfunctions of the family, personality and interpersonal levels in patients with depressive and anxiety disorders (questionnaires)

Groups Questionnaires	Depressive M (SD)	Disturbing M (SD)	Healthy M (SD)
Family level Family emotional communications (SEC)	49,9** (9,5)	47,7** (10,7)	40,3 (7,3)
Personal level Ban on Expression of Feelings Perfectionism questionnaire Hostility Questionnaire
Interpersonal level Social support questionnaire

* at p<0,05 (Критерий Манна-Уитни) M – среднее значение

** at p<0,01 (Критерий Манна-Уитни) SD – стандартное отклонение

*** at p<0,001 (Критерий Манна-Уитни)

As can be seen from the table, patients are distinguished from healthy subjects by more pronounced family communication dysfunctions, higher rates of inhibition of the expression of feelings, perfectionism and hostility, as well as a lower level of social support.

Analysis of individual indicators on the subscales of the SEC questionnaire shows that the greatest number of dysfunctions occurs in the parental families of patients with depressive disorders; they are significantly distinguished from healthy subjects by high indicators of the level of parental criticism, inducing anxiety, eliminating emotions, the importance of external well-being, inducing distrust in people, and family perfectionism. Anxious patients differ significantly from healthy subjects on three subscales: parental criticism, anxiety induction, and distrust of people.

Both groups significantly differ from the group of healthy subjects in terms of all subscales of the perfectionism and hostility questionnaires. They are distinguished by a tendency to see other people as malevolent, indifferent and despising weakness, high standards of performance, exaggerated demands on themselves and others, fear of not meeting the expectations of others, fixation on failures, polarized thinking on the principle of "all or nothing."

All indicators of the scales of the social support questionnaire differ in patients with depressive and anxiety disorders from the indicators of healthy subjects at a high level of significance. They experience deep dissatisfaction with their social contacts, lack of instrumental and emotional support, trusting connections with other people, they lack a sense of belonging to any reference group.

Correlation analysis shows that familial, personality and interpersonal dysfunctions are associated with each other and with indicators of psychopathological symptoms.

Table 12. Significant correlations of general indicators of questionnaires testing dysfunctions of the family, personality, interpersonal levels and the severity of psychopathological symptoms

** - at p<0,01 (коэффициент корреляции Спирмена)

As can be seen from the table, the general indicators of family dysfunctions, perfectionism and the index of the general severity of psychopathological symptoms are linked by direct correlations at a high level of significance. The general indicator of social support has inverse correlations with all other questionnaires, i.e. disturbed parental relationships and high levels of perfectionism are associated with reduced ability to establish constructive and trusting relationships with others.

Regression analysis was carried out, which showed (p<0,01) влияние выраженности дисфункций родительской семьи на уровень перфекционизма, социальной поддержки и выраженность психопатологической симптоматики у взрослых. Полученная модель позволила объяснить 21% дисперсии зависимой переменной «общий показатель социальной поддержки» и 15% зависимой переменной «общий показатель перфекционизма», а также 7% дисперсии зависимой переменной «общий индекс тяжести психопатологической симптоматики». Из семейных дисфункций наиболее влиятельной оказалась независимая переменная «элиминирование эмоций».

A study of family-level factors using a structured interview "Scale of stressful events in family history" revealed a significant accumulation of stressful life events in three generations of relatives of patients with depressive and anxiety disorders. Their relatives and significantly more often than relatives of healthy ones suffered serious illnesses, life hardships, violence in the form of fights and cruel treatment, cases of alcoholization up to family scenarios, when, for example, father, brother and other relatives drank more often in their families. The patients themselves were more likely to witness serious illness or death of relatives, alcohol abuse of close family members, abuse and fights.

According to the structured interviews "Parental Criticism and Expectations" (conducted with both patients and their parents), patients with depressive disorders more often note the predominance of criticism over praise from the mother (54%), while the majority of patients with anxious - the predominance praise over criticism from her (52%). The majority of patients in both groups assessed the father as critical (24 and 26%) or not at all involved in upbringing (44% in both groups). Patients with depressive disorders faced conflicting demands and communicative paradoxes on the part of the mother (she scolded for stubbornness, but demanded initiative, toughness, assertiveness; she claimed to praise a lot, and listed mainly negative characteristics); they could have earned praise from her for obedience, and patients with anxiousness for achievement. In general, patients with anxiety disorders received more support from their mothers. Parents of patients in both groups are distinguished from healthy subjects by a higher level of perfectionism and hostility. According to expert assessments of the structure of the family system by psychotherapists, disunity is equally represented in the families of patients of both groups (33%); symbiotic relationships prevailed in anxious (40%), but quite often also in depressive ones (30%). A third of families in both groups had chronic conflicts.

The study of interpersonal level factors using a structured interview Moscow integrative social network questionnaire in both groups revealed a narrowing of social connections - a significantly smaller number of people in the social network and its core (the main source of emotional support) compared to healthy people. The test for the type of attachment of Hezen and Shaver in interpersonal relationships revealed the predominance of anxious-ambivalent attachment in depressed (47%), avoidant attachment in anxious (55%), reliable attachment in healthy people (85%). The test data are in good agreement with the data of the study of the parental family - disunity and communication paradoxes in parental families of depressed ones are consistent with constant doubts about the sincerity of a partner (ambivalent attachment), symbiotic relationships in patients with anxiety disorders are consistent with a pronounced desire to distance themselves from people (avoidant attachment).

A study of a group of patients with somatoform disorders also revealed a number of dysfunctions of the family, personality and interpersonal levels.

Table 13. General indicators of dysfunctions of the family, personality and interpersonal levels in patients with somatoform disorders (questionnaire techniques)

* at p<0,05 (Критерий Манна-Уитни) M – среднее значение

** at p<0,01 (Критерий Манна-Уитни) SD – стандартное отклонение

*** at P<0,001 (Критерий Манна-Уитни)

As can be seen from the table, patients with somatoform disorders, in comparison with healthy subjects, have more pronounced communicative dysfunctions in the parental family, higher rates of inhibition of the expression of feelings, their emotional vocabulary is narrowed, the ability to recognize emotions by facial expressions is reduced, the level of alexithymia is higher and the level is lower. social support.

A more detailed analysis of individual subscales of the questionnaires shows that patients with somatoform disorders, compared with healthy subjects, have an increased level of parental criticism, induction of negative experiences and distrust of people, and lower indicators of emotional support and social integration. At the same time, they have a smaller number of dysfunctions of the parental family compared to depressed patients, and the indices of instrumental support do not significantly differ from those in healthy subjects, which indicates their ability to receive sufficient technical assistance from others, in contrast to patients with depressive and anxiety disorders. It can be assumed that the various somatic symptoms characteristic of these patients are an important reason for obtaining it.

Significant correlations were revealed between a number of general indicators of the questionnaires and the scales of somatization and alexithymia, the high values ​​of which distinguish these patients.

Table 14. Correlations of general indicators of questionnaires and tests with the scale of somatization of the SCL-90-R questionnaire and the Toronto alexithymia scale

* - at p<0,05 (коэффициент корреляции Спирмена)

** - at p<0,01 (коэффициент корреляции Спирмена)

As can be seen from the table, the indicator of the somatization scale at a high level of significance correlates with the indicator of alexithymia; both of these indicators, in turn, have direct significant connections with the general index of the severity of psychopathological symptoms and the prohibition on expressing feelings, as well as an inverse relationship with the richness of the emotional vocabulary. This means that somatization, high values ​​of which distinguish the group of somatoforms from depressed and anxious patients, is associated with a reduced ability to focus on the inner world, open expression of feelings and a narrow vocabulary for expressing emotions.

A study using a structured interview "Scale of stressful events in family history" revealed the accumulation of stressful life events in three generations of relatives of patients with somatoform disorders. In parental families of patients, early deaths, as well as violence in the form of abuse and fights, were more likely than in healthy subjects, in addition, they were more likely to be present when a family member was seriously ill or died. In the study of somatoform patients at the family level, Hering's FAST family test was also used. Structural dysfunctions in the form of coalitions and inversion of hierarchy, as well as chronic conflicts, were significantly more frequent in the families of patients than in healthy subjects.

A study using a structured interview "Moscow Integrative Social Network Test" revealed a narrowing of the social network in comparison with healthy subjects and a lack of close trusting ties, the source of which is the core of the social network.

PartIII is devoted to the description of the model of integrative psychotherapy, as well as to the discussion of some of the organizational issues of psychotherapy and psychoprophylaxis of affective spectrum disorders.

In the first chapter Based on the generalization of the results of empirical studies of population and clinical groups, as well as their correlation with the available theoretical models and empirical data, empirically and theoretically substantiated target systems for integrative psychotherapy of affective spectrum disorders are formulated.

Table 15. Multifactorial psycho-social model of affective spectrum disorders as a means of synthesizing data and identifying the target system of psychotherapy

Target factors Traditions Levels Research	Factors of depressive, anxiety and somatoform disorders and targets of psychotherapy	Traditions Psychotherapy and Clinical Psychology
Macrosocial	Social stress, social orphanhood, pathogenic cultural values ​​(cult of strength, restraint, success, perfection)	Social psychoanalysis Research by D. Bowlby et al.
Family	1.structure (symbiosis, disunity, coalitions, violations of the hierarchy, closed borders, weak parental subsystem, peripheral father) 2.microdynamics (high criticism, low warmth and support, conflicting demands and communications, double bond, high control) 3.macrodynamics (accumulation of acute and chronic stress, family dysfunctional scenarios) 4.ideology (the cult of success and external well-being, perfectionism, distrust of people, a ban on open expression of feelings, suppression of initiative)	D.Bowlby's attachment theory System-oriented family Psychodynamic
Personal	Perfectionist standards, hostile worldview prohibition on expressing feelings, lack of emotional self-regulation skills	Cognitive-behavioral Existential-humanistic Psychodynamic Ideas about reflection as the basis of self-regulation (Moscow school)
Interpersonal	Narrow social ties, low level of social integration, emotional support, insecure attachment in a relationship with a partner	Social psychoanalysis, V. N. Myasishchev's theory of relations Interpersonal psychotherapy G. Klerman, Psychodynamic group

In second chapter presents the stages and tasks of psychotherapy for affective spectrum disorders . Integrative psychotherapy for depressive and anxiety disorders begins with the stage of psychodiagnostics, at which, based on a multifactorial model, specific targets for work and resources for change are identified using specially designed interviews and diagnostic tools. There are groups of patients that require different management tactics. In patients with high levels of perfectionism and hostility, these counter-therapeutic factors should be addressed first, as they inhibit the establishment of a working alliance and can lead to premature withdrawal from psychotherapy. The work with the rest of the patients is divided into two large stages: 1) the development of skills of emotional self-regulation and the formation of reflexive ability based on the techniques of cognitive psychotherapy by A. Beck and ideas about reflexive regulation in Russian psychology; 2) work with the family context and interpersonal relationships based on the techniques of psychodynamic and system-oriented family psychotherapy, as well as ideas about reflection as the basis of self-regulation and an active life position. A model of psychotherapy for patients with pronounced somatization is described separately, in connection with specific tasks, for the solution of which an original training for the development of emotional psychohygiene skills has been developed.

Table 16... Conceptual diagram of the stages of integrative psychotherapy of affective spectrum disorders with pronounced somatization.

Tasks Stages	COGNITIVE	PSYCHODYNAMIC
I STEP	DEVELOPMENT OF EMOTIONAL SELF-REGULATION SKILLS
Stage 1 Information and motivating Neoplasms Finding the meaning of psychological work, self-determination - a conscious choice of position in relation to illness and treatment	1. Informing about the connection between emotions and physiological states; general "laws" of emotional life; the consequences of a violation of emotional psychohygiene for mental and physical health. 2. Problematization and presentation of the method of group psychotherapy.	1. Creation of an atmosphere of trust and openness.
Stage 2 Awareness and expressions of feelings Neoplasms Ability to focus on the inner world Means of Symbolizing Emotional Experience	1. Change of negative attitude towards emotions. 2. Awareness of the difficulties of understanding one's own and someone else's emotional life: 3. Development of self-observation and emotional self-expression skills: 4. Development of skills of differentiation of individual emotions in the range of feelings.	1. Creating an atmosphere trust and openness. 2. Establishing a working alliance. 3. Feedback training. 4. Diagnostics of methods of resistance, transference reactions and group themes.
Stage 3 Emotion Management Training Neoplasms Reflexive ability to stop, fix and objectify automatic thoughts	1. Presentation of cognitive and psychodynamic coping methods: 2. Practicing cognitive coping skills 3. Preparing to work with beliefs	1. Labeling of resistance, transference reactions and group themes. 2. Encouraging the expression and response of negative emotions.
II STEP	WORKING WITH A FAMILY CONTEXT AND INTERPERSONAL RELATIONS
Stage 4 Reflexive-positional analysis Neoplasms The ability to analyze one's own position, correlate it with the position of others, self-determination - a conscious choice of a position in a group, gaining experience of trusting relationships	1. Formulating beliefs associated with group position 2. Dealing with mental distortions	1.Determining the position of each of the participants 2.Comparing your own position with the positions of other members of the group 3. Work with resistance, discussion of the "conditional benefit" of the disease. 4. Analysis of the consequences of the position and associated beliefs for life and the process of psychotherapy 5. Drawing up "piggy banks" of individual and group problems and topics 6. Changing the position of the leaders to a more passive one
Stage 5 Working out the family context Neoplasms liberation from accumulated negative feelings, self-determination - a conscious choice of a position in life	Exploring the Sources of Beliefs and Formulating them More Completely	1. Analysis of the family context (roles, rules, norms) in three generations. 2. Revealing parental programming (requirements and expectations, family myths and values). 3. Identifying, responding and working through childhood traumatic experiences and transference reactions
Stage 6 Analysis and elaboration of personal problems and resource identification. Neoplasms New means of solving problems, an active position in relation to them, liberation from the power of the past	Developing new beliefs and practicing new behavioral strategies and skills	Establishing a relationship between current issues and the family context

In accordance with the norms of non-classical science, one of the bases for the integration of approaches is the idea of ​​the sequence of tasks solved in the course of therapy for affective spectrum disorders and those neoplasms that are the necessary basis for the transition from one task to another (Table 16).

The article provides information on the effectiveness of psychotherapy according to the follow-up data. In 76% of patients who underwent a course of integrative psychotherapy in combination with drug treatment, stable remissions take place. Patients report an increase in stress resistance, improved family relations and social functioning, and most associate this effect with the passage of a course of psychotherapy.

Particular attention is paid to the organizational issues of psychotherapy and psychoprophylaxis of affective spectrum disorders. The place of psychotherapy in the complex treatment of disorders of the affective spectrum by specialists of the polyprofessional team was discussed, and the significant possibilities of psychotherapy in improving compliance in drug treatment were considered and substantiated.

In the last paragraph, the tasks of psychoprophylaxis of affective spectrum disorders are formulated when working with risk groups - orphans and children from schools with increased educational loads. As important tasks of psychoprophylaxis of affective spectrum disorders in children-social orphans, the necessity of their family life arrangement with subsequent psychological support of the child and family is substantiated. For the successful integration of an orphan child into a new family system, professional work is required to select an effective professional family, work with the child's traumatic experience in a blood family, as well as help the new family in the complex structural and dynamic restructuring associated with the arrival of a new member. It should be remembered that rejecting a child and returning him to the orphanage is a severe re-trauma, increases the risk of developing affective spectrum disorders, and can negatively affect his ability to develop attachment relationships later.

For children studying in educational institutions with an increased load, psychological work in the following areas acts as the tasks of psychoprophylaxis: 1) with parents - educational work, an explanation of the psychological factors of disorders of the affective spectrum, a decrease in perfectionist standards, a change in requirements for the child, a calmer attitude to assessments freeing up time for rest and socializing with other children, using praise instead of criticism as an incentive; 2) with teachers - educational work, clarification of the psychological factors of affective spectrum disorders, a decrease in the competitive environment in the classroom, refusal of ratings and humiliating comparisons of children with each other, help in experiencing failure, positive mistakes as an inevitable component of activities when learning new things, praise for any success with a child with symptoms of emotional distress, encouraging mutual help and support between children; 3) with children - educational work, the development of psychohygiene skills of emotional life, a culture of experiencing failure, a calmer attitude to assessments and mistakes, the ability to cooperate, friendship and help others.

V conclusion the problem of the contribution of psychological and social factors to the complex multifactorial bio-psycho-social determination of affective spectrum disorders is discussed; the prospects for further research are considered, in particular, the task is to study the influence of the identified psychological factors on the nature of the course and the process of treatment of disorders of the affective spectrum and their contribution to the problem of resistance.

CONCLUSIONS

1. In various traditions of clinical psychology and psychotherapy, theoretical concepts have been developed and empirical data have been accumulated on the factors of mental pathology, including affective spectrum disorders, which mutually complement each other, which necessitates the synthesis of knowledge and the trend towards their integration at the present stage.

2. The methodological foundations of the synthesis of knowledge in modern psychotherapy are a systematic approach and ideas about non-classical scientific disciplines, which involve the organization of various factors into blocks and levels, as well as the integration of knowledge based on the practical tasks of providing psychological assistance. Effective means of synthesizing knowledge about the psychological factors of affective spectrum disorders are a multifactorial psycho-social model of affective spectrum disorders, including macrosocial, family, personality and interpersonal levels and a four-aspect model of the family system, including structure, microdynamics, macrodynamics and ideology.

3. At the macrosocial level in the life of a modern person, there are two opposite tendencies: the growth of stress in life and stress on the emotional sphere of a person, on the one hand, maladaptive values ​​in the form of a cult of success, strength, well-being and perfection, which make it difficult to process negative emotions, on the other. These trends find expression in a number of macrosocial processes leading to a significant prevalence of affective spectrum disorders and the emergence of risk groups in the general population.

3.1. The wave of social orphanhood against the background of alcoholization and family breakdown leads to pronounced emotional disorders in children from disadvantaged families and children-social orphans, and the level of violations is higher in the latter;

3.2. The increase in the number of educational institutions with increased teaching loads and perfectionist educational standards leads to an increase in the number of emotional disorders in students (in these institutions their frequency is higher than in regular schools)

3.3. Perfectionist standards of appearance promoted in the media (reduced weight and specific standards of proportions and body shapes) lead to physical perfectionism and emotional disturbances in young people.

3.4. Sex-role stereotypes of emotional behavior in the form of a ban on the expression of asthenic emotions (anxiety and sadness) in men lead to difficulties in seeking help and receiving social support, which may be one of the reasons for secondary alcoholism and high rates of completed suicides in males.

4. General and specific psychological factors of depressive, anxiety and somatoform disorders can be systematized on the basis of a multifactorial model of affective spectrum disorders and a four-aspect model of the family system.

4.1. Family level. 1) structure: all groups are characterized by dysfunctions of the parental subsystem and the peripheral position of the father; for the depressed - disunity, for the anxious - the symbiotic relationship with the mother, for the somatoform - symbiotic relationships and coalitions; 2) microdynamics: all groups are characterized by a high level of conflicts, parental criticism and other forms of inducing negative emotions; for the depressed - the prevalence of criticism over praise from both parents and communicative paradoxes from the mother, for the anxious - less criticism and more support from the mother; for families of patients with somatoform disorders - elimination of emotions; 3) macrodynamics: all groups are characterized by the accumulation of stressful events in family history in the form of severe hardships in the life of parents, alcoholism and serious illnesses of close relatives, the presence of their illness or death, abuse and fights; in patients with somatoform disorders, early deaths of relatives are added to the increased frequency of these events. 4) ideology: all groups are characterized by the family value of external well-being and a hostile picture of the world, for the depressed and anxious - the cult of achievements and perfectionist standards. The most pronounced familial dysfunctions are observed in patients with depressive disorders.

4.2. Personal level. Patients with affective spectrum disorders have high rates of inhibition of expressing feelings. Patients with somatoform disorders are characterized by a high level of alexithymia, a narrowed emotional vocabulary, and difficulty recognizing emotions. For patients with anxiety and depressive disorders, there is a high level of perfectionism and hostility.

4.3. Interpersonal level. Interpersonal relationships of patients with affective spectrum disorders are characterized by a narrowing of the social network, a lack of close trusting ties, a low level of emotional support and social integration in the form of referring to a certain reference group. In patients with somatoform disorders, in contrast to anxious and depressive ones, there is no significant decrease in the level of instrumental support, the lowest indicators of social support in patients with depressive disorders.

4.4. The data of correlation and regression analysis indicate the mutual influence and systemic relationships of dysfunctions of the family, personal and interpersonal levels, as well as the severity of psychopathological symptoms, which indicates the need for their comprehensive consideration in the process of psychotherapy. The pattern of elimination of emotions in the parental family, combined with the induction of anxiety and distrust in people, has the most destructive effect on the interpersonal relationships of adults.

5. Proven foreign methods social support questionnaire (F-SOZU-22 G. Sommer, T. Fydrich), family system test (FAST, T. Gering) and developed original questionnaires "Family emotional communications" (SEC), "Prohibition of expression Feelings ”(HSP), structured interviews“ Scale of stressful events in family history ”,“ Parental criticism and expectation ”(PSC) and“ Moscow integrative social network questionnaire ”are effective means of diagnosing dysfunctions of the family, personal and interpersonal levels, as well as identifying the targets of psychotherapy ...

6. The tasks of providing psychological assistance to patients with affective spectrum disorders, substantiated by the conducted theoretical analysis and empirical research, involve work at different levels - macrosocial, family, personal, interpersonal. In accordance with the means accumulated for solving these problems in different approaches, integration is carried out based on the cognitive-behavioral and psychodynamic approaches, as well as a number of developments in domestic psychology (concepts of interiorization, reflection, mediation) and systemic family psychotherapy. The basis for the integration of cognitive-behavioral and psychodynamic approaches is a two-level cognitive model developed in cognitive therapy by A. Beck.

6.1. In accordance with different tasks, there are two stages of integrative psychotherapy: 1) the development of skills of emotional self-regulation; 2) work with family context and interpersonal relationships. At the first stage, cognitive tasks dominate, at the second, dynamic ones. The transition from one stage to another presupposes the development of reflexive regulation in the form of the ability to stop, fix and objectify one's automatic thoughts. Thus, a new organization of thinking is formed, which greatly facilitates and accelerates the work at the second stage.

6.2. The tasks of integrative psychotherapy and prevention of affective spectrum disorders are: 1) at the macrosocial level: debunking pathogenic cultural values ​​(the cult of restraint, success and perfection); 2) at the personal level: the development of skills of emotional self-regulation through the gradual formation of reflexive ability; transformation of dysfunctional personal attitudes and beliefs - a hostile picture of the world, unrealistic perfectionist standards, a ban on the expression of feelings; 3) at the family level: working out (comprehending and responding) traumatic life experience and family history events; work with actual dysfunctions of the structure, microdynamics, macrodynamics and ideology of the family system; 4) at the interpersonal level: training deficient social skills, developing the ability to close trusting relationships, expanding interpersonal relationships.

6.3. Somatoform disorders are characterized by a fixation on the physiological manifestations of emotions, a pronounced narrowing of the emotional vocabulary and difficulties in comprehending and verbalizing feelings, which determines the specifics of integrative psychotherapy of disorders with pronounced somatization in the form of an additional task of developing psychohygiene skills of emotional life.

6.4. The analysis of follow-up data of patients with affective spectrum disorders proves the effectiveness of the developed model of integrative psychotherapy (a significant improvement in social functioning and the absence of repeated visits to the doctor is noted in 76% of patients who underwent a course of integrative psychotherapy in combination with drug treatment).

7. The risk groups for the occurrence of affective spectrum disorders in the child population include children from socially disadvantaged families, orphans and children studying in educational institutions with an increased academic load. Psychoprophylaxis in these groups involves solving a number of problems.

7.1. For children from disadvantaged families - social and psychological work to rehabilitate the family and develop emotional psychohygiene skills.

7.2. For orphans - social and psychological work on the organization of family life with the obligatory psychological support of the family and the child in order to process his traumatic experience in the blood family and successful integration into a new family system;

7.3. For children from educational institutions with an increased academic load - educational and advisory work with parents, teachers and children, aimed at correcting perfectionist beliefs, high demands and competitive attitudes, freeing up time for communication and establishing friendly relations of support and cooperation with peers.

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Abstract on the topic "Theoretical and empirical foundations of integrative psychotherapy of affective spectrum disorders" updated: March 13, 2018 by: Scientific Articles.Ru

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Etiology of affective disorders

There are many different approaches to the etiology of mood disorders. This section primarily discusses the role of genetic factors and childhood experiences in the development of a predisposition to the development of affective disorder in adulthood. It then examines the stressors that can trigger mood disorders. What follows is an overview of the psychological and biochemical factors through which predisposing factors and stressors can lead to the development of mood disorders. In all of these aspects, researchers focus on depressive disorders, with much less focus on mania. Compared to most of the other chapters in this book, the etiology is particularly prominent here; the goal is to show how several different types of research can be used to solve the same clinical problem.

GENETIC FACTORS

Heredity factors are studied mainly in moderate to severe cases of affective disorder - to a greater extent than in milder cases (those to which some researchers use the term "neurotic depression"). Most family studies show that parents, siblings, and children of persons with severe depression have a 10-15% risk of developing an affective disorder, compared with 1-2% in the general population. It is also generally accepted that there is no increased incidence of schizophrenia among relatives of probands with depression.

The results of the study of twins clearly indicate that such high rates in families are due mainly to genetic factors. Thus, based on a review of seven studies of twins (Price 1968), it was concluded that in manic-depressive psychosis in monozygotic twins who were brought up together (97 pairs) and separately (12 pairs), concordance was 68% and 67%, respectively, and in dizygotic twins (119 pairs) - 23%. Similar percentages were found in studies conducted in Denmark (Bertelsen et al. 1977).

Studies in foster children also point to a genetic etiology. Thus, Cadoret (1978a) studied eight children adopted (shortly after birth) by healthy married couples, each of whom had one of the biological parents suffering from an affective disorder. Three out of eight developed an affective disorder, versus just eight of 118 foster children whose birth parents either suffered from other mental disorders or were healthy. In a study of 29 adoptive children with bipolar disorder, Mendelwicz and Rainer (1977) found psychiatric disorders (mainly, though not exclusively, affective disorders) in 31% of their biological parents versus just 12% of adoptive parents. In Denmark, Wender et al. (1986) conducted a study of foster children previously treated for major affective disorder. On the material of 71 cases, a significantly increased frequency of such disorders among biological relatives was revealed, while in relation to the adoptive family, a similar picture was not observed (each group of relatives was compared with the corresponding group of relatives of healthy adopted children).

So far, no distinction has been made between cases with only depression (monopolar disorder) and a history of mania (bipolar disorder). Leonhard et al. (1962) were the first to present data proving that bipolar disorders are more common in families of probands with bipolar than with monopolar forms of the disease. Later, these conclusions were confirmed by the results of several studies (see: Nurnberger, Gershon 1982 - review). However, these studies have also demonstrated that monopolar cases are common in families of both "monopolar" and "bipolar" probands; it appears that monopolar disorders, unlike bipolar ones, are not “passed on in such pure form” to offspring (see, for example, Angst 1966). Bertelsen et al. (1977) reported higher rates of concordance in pairs of monozygous twins with bipolar disorder compared with monopolar (74% versus 43%), which also indicates a stronger genetic effect in cases of bipolar disorder.

A few genetic studies of "neurotic depression" (they constitute a minority in the total volume of such works) have revealed increased rates of depressive disorders, both neurotic and other types, in families of probands. However, in the study of twins, similar concordance rates were obtained in monozygotic and dizygotic couples, which should be considered a discovery regardless of whether concordance was determined by the presence of the second twin also "neurotic depression" or, in a broader interpretation, depressive disorder of any kind. Such data suggest that genetic factors are not the main cause of the increased incidence of depressive conditions in families of patients with "neurotic depression" (see: McGuffin, Katz 1986).

There are conflicting theories regarding type of hereditary transmission, since the distribution of the frequency of cases observed in family members who are associated with the proband of various degrees of kinship does not sufficiently correspond to any of the main genetic models. Most family studies of depressive disorders show that women predominate among those affected by these diseases, which suggests a sex-linked inheritance, probably of the dominant gene, but with incomplete penetrance. At the same time, against such a model is evidenced by the presence of a significant number of reports of hereditary transmission from father to son (see, for example, Gershon et al. 1975): after all, sons should receive the X chromosome from the mother, since only the father transmits the Y chromosome ...

Attempts to identify genetic markers for affective disorder were unsuccessful. There are reports of an association between mood disorder and color blindness, blood group Xg and certain HLA antigens, but there is no evidence for this (see: Gershon, Bunney 1976; also Nurnberger, Gershon 1982). Recently, molecular genetic techniques have been used to find the link between identifiable genes and manic-depressive disorder in large families. A North American kinship study of Old Order Amish suggested a link to two markers on the short arm of chromosome 11, namely the insulin gene and the cellular oncogene Ha-ras-1(Egeland et al. 1987). This position is interesting in that it is close to the localization of the gene that controls the enzyme tyrosine hydroxylase, which is involved in the synthesis of catecholamines - substances involved in the etiology of affective disorder (see). However, the association with the above two markers is not supported by findings from a family study in Iceland (Hodgkinson et al. 1987) or from a study of three families in North America (Detera-Wadleigh et al. 1987). Research of this type offers great promise, but a lot of work will be required before the overall significance of the findings can be objectively assessed. Already today, however, modern studies strongly indicate that the clinical picture of severe depressive disorder can be formed as a result of the action of more than one genetic mechanism, and this seems to be extremely important.

Some studies in families of probands with affective disorder have revealed an increased incidence of other mental disorders. This suggested that these mental disorders may be etiologically related to affective disorder - an idea expressed in the title Depressive spectrum disease... Until now, this hypothesis has not been confirmed. Helzer and Winokur (1974) reported an increase in the prevalence of alcoholism among relatives of manic male probands, but Morrison (1975) found this association only when alcoholism was also observed in the probands along with the depressive disorder. Similarly, Winokur et al. (1971) reported an increased prevalence of antisocial personality disorder ("sociopathy") among male relatives of probands with depressive disorder beginning before the age of 40, but this observation was not confirmed by Gershon et al. (1975).

BODY AND PERSONALITY

Kretschmer put forward the idea that people with picnic physique(stocky, dense, with a rounded figure) are especially prone to affective diseases (Kretschmer 1936). But later, in studies using objective measurement methods, it was not possible to identify any stable relationship of this kind (von Zerssen 1976).

Kraepelin suggested that people with cyclothymic personality type(i.e., with constantly recurring mood swings for a long time) are more likely to develop manic-depressive disorder (Kraepelin 1921). Subsequently, it was reported that this association appears to be more pronounced in bipolar disorders than in monopolar disorders (Leonhard et al. 1962). However, if the personality assessment was carried out in the absence of information about the type of disease, then in bipolar patients, the prevalence of cyclothymic personality traits was not found (Tellenbach 1975).

No personality type appears to predispose to unipolar depressive disorder; in particular, in depressive personality disorder, such an association is not apparent. Clinical experience shows that in this regard, personality traits such as obsessional traits and readiness to display anxiety are of the greatest importance. These traits are supposed to be important because they largely determine the nature and intensity of a person's response to stress. Unfortunately, the data obtained in the study of the personality of patients with depression are often not of great value, since the studies were carried out during the period when the patient was in a state of depression, and in this case the results of the assessment cannot give an adequate idea of ​​the premorbid personality.

EARLY ENVIRONMENT

Deprivation of the mother

Psychoanalysts argue that deprivation of maternal love in childhood due to separation or loss of the mother predisposes to depressive disorders in adulthood. Epidemiologists have tried to find out what proportion of the total number of adults with depressive disorder are those who have experienced the loss of parents or separation from them in childhood. In almost all such studies, significant methodological errors were allowed. The results are contradictory; Thus, when studying the materials of 14 studies (Paykel 1981), it turned out that seven of them confirm the hypothesis under consideration, and seven do not. Other studies have shown that the death of one of the parents is associated not with depressive disorders, but with other disorders that subsequently develop in the child, for example, psychoneurosis, alcoholism, and antisocial personality disorder (see: Paykel 1981). Therefore, the link between the loss of parents during childhood and later onset depressive disorder appears uncertain. If it exists at all, it is weak and apparently nonspecific.

Relationship with parents

When examining a patient with depression, it is difficult to retrospectively establish what kind of relationship he had with his parents in childhood; after all, his memories can be distorted by many factors, including the depressive disorder itself. In connection with such problems, it is difficult to come to definite conclusions regarding the etiological significance of some of the features of relationships with parents noted in a number of publications on this issue. This concerns, in particular, reports that patients with mild depressive disorders (neurotic depression) - as opposed to healthy people (control group) or patients with severe depressive disorders - usually recall that their parents were not so caring how much overprotective (Parker 1979).

PRESIPTATIVE ("MANIFESTING") FACTORS

Recent life (stressful) events

According to everyday clinical observation, depressive disorder often follows stressful events. However, before concluding that stressful events are the cause of later onset depressive disorders, several other possibilities must be ruled out. First, the indicated sequence in time may not be a manifestation of a causal connection, but the result of a coincidence. Second, the relationship may be nonspecific: approximately the same number of stressful events may occur in the weeks preceding the onset of some diseases of other types. Third, the connection may turn out to be imaginary; sometimes the patient is inclined to regard events as stressful only in retrospect, trying to find an explanation for his illness, or he could perceive them as stressful, since he was already in a state of depression at that time.

Attempts were made to find ways to overcome the listed difficulties by developing appropriate research methods. To find the answer to the first two questions - is the temporal sequence of events explained by chance coincidence, and if there is any real relationship, is such a relationship non-specific - it is necessary to use control groups appropriately selected from the population as a whole and from among individuals suffering from other diseases. The third problem - whether the relationship is imaginary - requires two other approaches. The first approach (Brown et al. 1973b) is to separate events that were certainly not influenced in any way by the illness (such as the loss of a job due to the liquidation of an entire business) from those that might be secondary to to him (for example, the patient was left without work, while none of his colleagues were fired anymore). In the implementation of the second approach (Holmes, Rahe 1967), each event from the point of view of its "stressfulness" is assigned a certain assessment reflecting the general opinion of healthy people.

With these methods, an increased frequency of stressful events was noted in the months leading up to the onset of depressive disorder (Paykel et al. 1969; Brown and Harris 1978). However, along with this, it was shown that an excess of such events also precedes suicidal attempts, the onset of neurosis and schizophrenia. In order to assess the relative importance of life events for each of these conditions, Paykel (1978) applied a modified form of epidemiological measurements of relative risk. He found that the risk of developing depression within six months after the person has experienced life events of a clearly threatening nature increased sixfold. The risk of schizophrenia under these conditions increases two to four times, and the risk of attempting suicide - seven times. Researchers who have applied another method of assessment - “follow-up observation” (Brown et al. 1973a) - have come to similar conclusions.

Are there specific events that are more likely to trigger a depressive disorder? Since depressive symptoms occur as part of the normal response to bereavement, it has been suggested that loss due to separation or death may be of particular importance. However, research suggests that not all individuals with depressive symptoms report suffering loss. For example, a review of eleven studies (Paykel 1982) that highlighted recent separations found the following. In six of these studies, depressed people reported more separation than controls, suggesting some specificity; however, in five other studies, depressed patients did not mention the importance of separation. On the other hand, among those who experienced loss events, only 10% developed a depressive disorder (Paykel 1974). Thus, the available data do not yet indicate any pronounced specificity of events that can cause depressive disorder.

There is even less certainty about whether mania is triggered by life events. Previously, it was believed that it is entirely due to endogenous causes. However, clinical experience suggests that in some cases the disease is provoked, and sometimes - by events that can cause depression in others (for example, bereavement).

Predisposing life events

Clinicians very often have the impression that events immediately preceding a depressive disorder act as a “last straw” for a person who has been exposed to adverse circumstances for a long time, such as an unhappy marriage, problems at work, unsatisfactory housing. conditions. Brown and Harris (1978) classified predisposing factors into two types. The first type includes prolonged stressful situations, which can in themselves cause depression, as well as exacerbate the consequences of short-term life events. The above authors named such factors long-term difficulties. Predisposing factors of the second type by themselves are not capable of leading to the development of depression, their role is reduced to the fact that they enhance the effect of short-term life events. In relation to such circumstances, they usually use a term such as vulnerability factor. In fact, there is no sharp, well-defined boundary between these two types of factors. Thus, many years of turmoil in married life (long-term difficulties) are probably associated with a lack of trust, and Brown defines the latter as a factor of vulnerability.

Brown and Harris, in their study of a group of working-class women living in Camberwell, London, found three factors acting as vulnerability factors: the need to take care of young children, the lack of work outside the home, and the lack of a trusted person to rely on. In addition, vulnerability was found to be increased by certain events in the past, such as the loss of a mother to death or separation before the age of 11 years.

With further research, the conclusions about the four listed factors did not receive convincing support. By studying the rural population in the Hebrides, Brown was able to reliably confirm only one of his four factors, namely, the factor of having three children under the age of 14 in a family (Brown and Prudo 1981). As for other studies, the results of one of them (Campbell et al. 1983) support the latter observation, but three studies (Solomon, Bromet 1982; Costello 1982; Bebbington et al. 1984) found no evidence in favor of it. Another factor of vulnerability gained more recognition - the lack of a person to trust (lack of "intimacy"); Brown and Harris (1986) cite eight studies that support it and mention two that do not. Thus, the evidence to date does not fully support Brown's interesting idea that certain life circumstances increase vulnerability. While it has been repeatedly reported that a lack of intimate relationships appears to increase vulnerability to depressive disorder, this information can be interpreted in three ways. First, such data may indicate that if a person is deprived of any opportunity to trust someone, this makes him more vulnerable. Secondly, this may indicate that during the period of depression the patient's perception of the degree of intimacy achieved before the development of this state is distorted. Thirdly, it is possible that some hidden underlying cause is due to the fact that it is difficult for a person to trust others, and his vulnerability to depression.

Recently, the focus has shifted from these external factors to the intrapsychic - low self-esteem. Brown suggested that vulnerabilities are partly realized through decreased self-esteem, and intuitively, this point is likely to really matter. However, self-esteem is difficult to measure, and its role as a predisposing factor has not yet been proven by research.

An overview of the evidence supporting and opposing the vulnerability model can be found in Brown and Harris (1986) and Tennant (1985).

Influence of somatic diseases

The links between somatic diseases and depressive disorders are described in chap. 11. It should be noted here that some states are much more often accompanied by depression than others; these include, for example, influenza, infectious mononucleosis, parkinsonism, certain endocrine disorders. It is believed that depressive disorder also occurs more frequently after certain surgeries, especially hysterectomy and sterilization, than could be explained by coincidence. However, these clinical impressions are not supported by prospective studies (Gath et al. 1982a; Cooper et al. 1982). Probably, many somatic diseases can act when provoking depressive disorders as nonspecific stressors, and only a few of them - as specific. From time to time, there are reports of the development of mania in connection with somatic diseases (for example, with a brain tumor, viral infections), drug therapy (especially when taking steroids) and surgery (see: Krauthammer, Klerman 1978 - data review). However, on the basis of these contradictory information, no definite conclusion can be drawn regarding the etiological role of the listed factors.

It should also be mentioned here that the postpartum period (although childbirth is not a disease) is associated with an increased risk of developing affective disorder (see the corresponding subsection of Chapter 12).

PSYCHOLOGICAL THEORIES OF ETIOLOGY

These theories look at the psychological mechanisms by which recent and distant life experiences can lead to depressive disorders. The literature on the subject generally does not properly distinguish between a single symptom of depression and a syndrome of depressive disorder.

Psychoanalysis

The psychoanalytic theory of depression began with an article by Abraham in 1911; it was further developed in the work of Freud "Sadness and Melancholy" (Freud 1917). Noting the similarities between the manifestations of sadness and the symptoms of depressive disorders, Freud suggested that their causes may be similar. It is important to note this: Freud did not believe that the cause of all severe depressive disorders is necessarily the same. Thus, he explained that some disorders "suggest the presence of somatic rather than psychogenic lesions," and pointed out that his ideas should be applied only in relation to those cases in which "the psychogenic nature is not in doubt" (1917, p. 243). Freud suggested that just as sadness arises from loss associated with death, melancholy develops as a result of loss due to other causes. Since it is obvious that not every depressed person suffered a real loss, it was necessary to postulate the loss of "some abstraction", or internal representation, or, in Freud's terminology, the loss of an "object."

Noting that depressed patients often seem to be critical of themselves, Freud suggested that such self-blame is in fact a disguised accusation against someone else - a person to whom the patient "has attachment." In other words, it was believed that depression occurs when a person simultaneously experiences both a feeling of love and hostility (i.e., ambivalence). If the beloved "object" is lost, the patient falls into despair; at the same time, any hostile feelings related to this "object" are redirected to the patient himself in the form of self-accusation.

Along with these reaction mechanisms, Freud also identified predisposing factors. In his opinion, the depressed patient regresses, returning to an early stage of development - the oral stage, at which sadistic feelings are strong. Klein (1934) developed this idea by suggesting that the infant should have the confidence that when the mother leaves him, she will return, even if he is angry. This hypothetical stage of cognition was called the "depressive position." Klein hypothesized that children who do not successfully get through this stage are more likely to develop depression in adulthood.

Subsequently, important modifications of Freud's theory were presented by Bibring (1953) and Jacobson (1953). They hypothesized that loss of self-esteem plays a leading role in depressive disorders, and further suggested that self-esteem is influenced not only by experience in the oral phase, but also by failure in later stages of development. Nevertheless, it should be borne in mind that although low self-esteem is certainly included as one of the components in the syndrome of depressive disorder, there is still no clear data on the frequency of its occurrence before the onset of the disease. It has also not been shown that low self-esteem is more common among those who subsequently develop depressive disorders than those who do not.

According to psychodynamic theory, mania arises as a defense against depression; for most cases, this explanation cannot be considered convincing.

For a review of the psychoanalytic literature on depression, see Mendelson (1982).

Taught helplessness

This explanation for depressive disorders is based on experimental work with animals. Seligman (1975) originally suggested that depression develops when the reward or punishment is no longer clearly dependent on the individual's actions. Studies have shown that animals in special experimental situations in which they cannot control the stimuli that lead to punishment develop a behavioral syndrome known as "learned helplessness." The characteristic features of this syndrome have some similarities with the symptoms of depressive disorders in humans; a decrease in voluntary activity and food intake is especially typical. The original hypothesis was subsequently extended by the assertion that depression occurs when “achieving the most desired results seems almost unrealistic or highly undesirable outcome seems very likely, and the individual believes that no response (on his part) will change this probability” (Abrahamson et al. . 1978, p. 68). This work by Abrahamson, Seligman, and Teasdale (1978) has attracted considerable attention, perhaps more due to its title ("learned helplessness") than to its scientific merit.

Animal Separation Experiments

The suggestion that the loss of a loved one may be the cause of depressive disorders has prompted numerous experiments on primates to investigate the consequences of separation. In most cases, in such experiments, the separation of pups from their mothers was considered, much less often the separation of adult primates. The data obtained in this case do not essentially have an unconditional relationship to a person, since depressive disorders may never arise in young children (see Chapter 20). Nevertheless, such studies are of some interest, deepening the understanding of the consequences of the separation of human babies from their mothers. In a particularly rigorous series of experiments, Hinde and his colleagues studied the effects of separating a rhesus monkey from its mother (see: Hinde 1977). These experiments confirmed earlier observations that separation causes distress in both the calf and the mother. After the initial period of calling and searching, the cub becomes less active, eats and drinks less, moves away from contact with other monkeys, and resembles a sad human being in appearance. Hinde and his team have found that this separation response is dependent on many other variables, including the couple's “relationship” prior to separation.

Compared to the consequences of the separation of young babies from their mothers described above, puberty monkeys separated from their peer group did not show a pronounced stage of “despair”, but instead showed more active exploratory behavior (McKinney et al. 1972). Moreover, when five-year-old monkeys were removed from their family groups, the reaction was observed only when they were housed alone, and did not appear if they were housed with other monkeys, among which were already familiar individuals (Suomi et al. 1975).

Thus, while there is much to learn from the study of the effects of separation in primates, it would be imprudent to use the findings to support one or another etiological theory of depressive disorders in humans.

Cognitive theories

Most psychiatrists believe that the dark thoughts of depressed patients are secondary to the primary mood disorder. However, Beck (1967) suggested that this "depressive thinking" may be the primary disorder, or at least a powerful exacerbating and sustaining factor. Beck categorizes depressive thinking into three components. The first component is a stream of "negative thoughts" (for example, "I am incapable as a mother"); the second is a certain shift in ideas, for example, the patient is convinced that a person can only be happy when he is literally loved by everyone. The third component is a series of "cognitive biases", which can be illustrated by four examples: "arbitrary inference" is expressed in the fact that conclusions are made without any reason or even despite the presence of evidence to the contrary; in "selective abstraction" attention is focused on some detail, while the more essential characteristics of the situation are ignored; "Overgeneralization" is characterized by the fact that far-reaching conclusions are made on the basis of a single case; “Personalization” is manifested in the fact that a person is inclined to perceive external events as directly related to him, establishing an imaginary connection between them and his person in some way that has no real basis.

Beck believes that those who tend to think in this way are more likely to develop depression when faced with minor problems. For example, a sharp refusal will most likely cause depression in a person who considers it necessary for himself to be loved by everyone, comes to an arbitrary conclusion that the refusal indicates hostility towards him, focuses attention on this event, despite the presence of many facts testifying, on the contrary, about its popularity, and draws general conclusions based on this single case. (In this example, you can see that the varieties of thought distortion are not quite clearly demarcated from each other.)

Until now, it has not been proven that the described mechanisms are present in a person before the onset of a depressive disorder, or that they are more common among those who subsequently develop a depressive disorder than among those who do not.

BIOCHEMICAL THEORIES

Monoamine hypothesis

According to this hypothesis, depressive disorder is the result of abnormalities in the monoamine neurotransmitter system in one or more areas of the brain. At an early stage of its development, the hypothesis assumed a violation of the synthesis of monoamines; according to later developments, changes in both monoamine receptors and the concentration or turnover of amines are postulated (see, for example, Garver, Davis 1979). Three monoamine mediators are involved in the pathogenesis of depression: 5-hydroxytryptamine (5-HT) (serotonin), norepinephrine, and dopamine. This hypothesis was tested by studying three types of phenomena: the metabolism of neurotransmitters in patients with mood disorders; the effect of monoamine precursors and antagonists on measurable indicators of the function of monoaminergic systems (usually neuroendocrine indicators); pharmacological properties inherent in antidepressants. Research material from these three species is now being considered in relation to these three transmitters: 5-HT, norepinephrine and dopamine.

Attempts have been made to obtain indirect data on 5-HT functions in the activity of the brain of patients with depression through the study of cerebrospinal fluid (CSF). Ultimately, a decrease in the concentration of 5-hydroxyindoleacetic acid (5-HIAA), the main product of 5-HT metabolism in the brain, has been proven (see, for example, Van Praag, Korf 1971). Direct interpretation of these data would lead to the conclusion that the function of 5-HT in the brain also decreases. However, this interpretation is fraught with some difficulties. First, when receiving CSF by lumbar puncture, it is not clear which part of the 5-HT metabolites was formed in the brain and which in the spinal cord. Second, changes in concentration may simply reflect changes in CSF clearance of metabolites. This possibility can be partially eliminated by prescribing large doses of probenecid, which interferes with the transport of metabolites from the CSF; the results obtained using this method are against the simple transport disruption version. It would seem that interpretation should also be difficult due to the detection of a low or normal concentration of 5-HT in mania, whereas it would be logical to expect an increase in this indicator in this case, given that mania is the opposite of depression. However, the existence of mixed affective disorder (see) suggests that this initial assumption is too simplistic. A more serious argument preventing acceptance of the initial hypothesis is that low concentrations of 5-HIAA persist after clinical recovery (see: Coppen 1972). Such data may indicate that decreased 5-HT activity should be seen as a "hallmark" of people prone to developing depressive disorders, and not simply as a "condition" found only during bouts of illness.

Measurements were made of the concentration of 5-HT in the brains of patients with depression, most of whom died as a result of suicide. While this is a more direct test of the monoamine hypothesis, the results are difficult to interpret for two reasons. First, the observed changes could have occurred after death; secondly, they could be caused even during life, but not by a depressive disorder, but by other factors, for example hypoxia or drugs used in treatment or taken to commit suicide. These limitations may explain the fact that some researchers (eg, Lloyd et al. 1974) report a decrease in the concentration of 5-HT in the brainstem of patients with depression, while others (eg, Cochran et al. 1976) do not mention this. More than one type of 5-HT receptor has recently been found, and there are reports (see: Mann et al. 1986) that in the frontal lobe cortex of suicide victims there is a concentration of one type of serotonin receptor, 5-HT. 2 - increased (an increase in the number of receptors may be a reaction to a decrease in the number of transmitters).

The functional activity of 5-HT systems in the brain is assessed by administering a substance that stimulates 5-HT function and measuring the neuroendocrine response controlled by the 5-HT pathways, usually prolactin release. 5-HT function is enhanced by intravenous infusion of L-tryptophan, the precursor of 5-HT, or oral doses of fenfluramine, which releases 5-HT and blocks its reuptake. The prolactin response to both of these agents is reduced in depressed patients (see: Cowen, Anderson 1986; Heninger et al. 1984). This suggests a decrease in 5-HT function if other mechanisms involved in prolactin secretion are working normally (which has not yet been fully established).

If in depressive disorders the function of 5-HT decreases, then L-tryptophan should have a therapeutic effect, and antidepressants - the property of increasing the function of 5-HT. As reported by some scientists (for example, Coppen, Wood 1978), L-tryptophan has an antidepressant effect, but this effect is not particularly pronounced. Antidepressants affect 5-HT function; in fact, it was this discovery that formed the basis for the hypothesis that 5-HT plays an important role in the etiology of depressive disorder. At the same time, it should be noted that this effect is complex: most of these drugs reduce the number of binding sites for 5-HT 2, and this fact does not fully agree with the hypothesis that in depressive disorders the function of 5-HT is reduced and therefore antidepressants should increase it, and do not reduce. However, when the animals were subjected to repeated electric shocks in such a way that it mimicked the use of ECT in the treatment of patients, the result was an increase in the number of 5-HT 2 binding sites (see: Green, Goodwin 1986).

It should be concluded that the evidence supporting the serotonin hypothesis of the pathogenesis of depression is fragmentary and contradictory.

What is the evidence of violation noradrenergic function? The results of studies of the norepinephrine metabolite 3-methoxy-4-hydroxyphenylethylene glycol (MHPG) in CSF of depressed patients are inconsistent, but there is some evidence to indicate a decrease in the level of the metabolite (see: Van Praag 1982). In postmortem examinations of the brain, measurements did not reveal persistent deviations in the concentration of norepinephrine (see: Cooper et al. 1986). Growth hormone response to clonidine was used as a neuroendocrine test for noradrenergic function. Several studies have demonstrated a reduced response in depressed patients, suggesting a defect in postsynaltic noradrenergic receptors (see: Checkley et al. 1986). Antidepressants have a complex effect on noradrenergic receptors, and tricyclic drugs also have the ability to inhibit the reuptake of norepinephrine by presynaptic neurons. One of the effects caused by these antidepressants is a decrease in the number of beta-noradrenergic binding sites in the cerebral cortex (the same is observed with ECT) - a result that can be primary or secondary, associated with compensation for increased norepinephrine turnover (see: Green , Goodwin 1986). In general, it is difficult to assess the effect of these drugs on noradrenergic synapses. In healthy volunteers, some evidence was found that first transmission is enhanced (presumably through inhibition of reuptake) and then returns to normal, probably due to effects on postsynaptic receptors (Cowen and Anderson 1986). If this fact is confirmed, it will be difficult to reconcile it with the idea that antidepressants act by increasing the noradrenergic function, which is reduced in depressive diseases.

Evidence of violation dopaminergic function with depressive disorders, a little. The corresponding decrease in the concentration of the main dopamine metabolite, homovanilic acid (HVA), has not been proven either; there are no reports on the detection of any significant changes in the concentration of dopamine in the brain of patients with depression during postmortem examination. Neuroendocrine tests do not reveal any changes that would give grounds to assume a violation of dopaminergic function, and the fact that the precursor of dopamine - L-DOPA (levodopa) - does not have a specific antidepressant effect is generally accepted.

It should be concluded that we still have not been able to come to an understanding of biochemical disturbances in patients with depression; it is also unclear how they are corrected by effective drugs. In any case, it would be imprudent to draw far-reaching conclusions regarding the biochemical basis of the disease based on the action of drugs. Anticholinergic drugs alleviate the symptoms of parkinsonism, but the underlying disorder is not increased cholinergic activity, but dopaminergic deficiency. This example recalls that mediator systems interact in the central nervous system and that monoamine hypotheses of the etiology of depressive disorder are based on a significant simplification of the processes occurring at synapses in the central nervous system.

Endocrine Disorders

In the etiology of affective disorders, endocrine disorders play an important role for three reasons. First, some disorders of endocrine function are accompanied by depressive disorders more often than could be explained by coincidence, and, therefore, the idea of ​​a causal relationship arises. Second, the endocrine changes found in depressive disorders suggest a violation of the hypothalamic centers that control the endocrine system. Thirdly, endocrine changes are regulated by hypothalamic mechanisms, which, in turn, are partially controlled by monoaminergic systems, and, therefore, endocrine changes may reflect disturbances in monoaminergic systems. These three areas of research will be considered in turn.

Cushing's syndrome is sometimes accompanied by depression or euphoria, and Addison's disease and hyperparathyroidism are accompanied by depression. Endocrine changes may explain the occurrence of depressive disorders in the premenstrual period, during menopause and after childbirth. These clinical relationships are discussed further in Ch. 12. Here it is only necessary to note that none of them has so far led to a better understanding of the causes of affective disorder.

A lot of research work has been done to study the regulation of cortisol secretion in depressive disorders. In almost half of patients with severe or moderate depressive disorder, the amount of cortisol in the blood plasma is increased. Despite this, they did not show clinical signs of excess cortisol production, possibly due to a decrease in the number of glucocorticoid receptors (Whalley et al. 1986). In any case, excess cortisol production is not specific for depressed patients, as similar changes are observed in patients with mania who are not receiving medical treatment and in patients with schizophrenia (Christie et al. 1986). More important is the fact that patients with depression change the nature of the daily secretion of this hormone. The increased secretion of cortisol could be due to the fact that a person feels sick and this acts on him as a stressor; however, in this case, such an explanation seems unlikely, since stressors do not alter the characteristic circadian rhythm of secretion.

Violation of the secretion of cortisol in patients with depression is manifested in the fact that its level remains high in the afternoon and evening, while normally during this period there is a significant decrease. Research data also show that 20–40% of depressed patients do not experience normal suppression of cortisol secretion after taking a strong synthetic corticosteroid, dexamethasone, around midnight. However, not all patients with increased cortisol secretion are immune to the action of dexamethasone. These deviations are found mainly in depressive disorders with "biological" symptoms, but not in all such cases; they do not appear to be associated with any one specific clinical sign. In addition, abnormalities in the dexamethasone suppression test are detected not only in mood disorders, but also in mania, chronic schizophrenia and dementia, as there are corresponding reports (see: Braddock 1986).

Other neuroendocrine functions have also been studied in patients with depression. Luteinizing hormone and follicle-stimulating hormone responses to gonadotropic hormone are usually normal. However, the response of prolactin and the response of thyroid-stimulating hormone (thyrotropin) to thyrotropin-stimulating hormone is abnormal in almost half of patients with depression - this ratio fluctuates depending on the group being examined and the assessment methods used (see: Amsterdam et al. 1983).

Water-salt exchange

From the book Great Soviet Encyclopedia (ET) of the author TSB
From the book The Family Doctor's Handbook author From the book Philosophical Dictionary the author Comte Sponville André

Clinical Signs of Personality Disorders This section contains information on personality disorders presented in the International Classification of Diseases. This is followed by a brief overview of additional or alternative categories used in DSM-IIIR. Though

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Etiology Since little is known about the factors that determine the formation of normal personality types, it is not surprising that knowledge about the causes of personality disorders is incomplete. Research is hampered by a significant time interval dividing

From the author's book

COMMON CAUSES OF PERSONALITY DISORDERS GENETIC CAUSES Although there is some evidence that normal personality is partially inherited, there is still little data on the role of genetic contributions in the development of personality disorders. Shields (1962) provides

From the author's book

Prognosis of Personality Disorders Just as small changes in the characteristics of a normal personality appear with age, so in the case of a pathological personality, the deviations from the norm may diminish as the person grows older.

From the author's book

Etiology of neuroses This section is devoted to the analysis of the general causes of neuroses. Factors specific to the etiology of certain neurotic syndromes are discussed in the next chapter.

From the author's book

Classification of depressive disorders There is no consensus on the best method for classifying depressive disorders. These attempts can be broadly summarized in three directions. In accordance with the first of them, the classification should

From the author's book

Epidemiology of Mood Disorders Determining the prevalence of depressive disorders is difficult, in part because different researchers use different diagnostic definitions. Thus, in the process of many studies carried out in the United

From the author's book

Etiology Before considering the evidence for the causes of schizophrenia, it is helpful to outline the main areas of research. Among the predisposing causes, genetic factors are the most strongly supported by evidence, but it is clear that an important role is also played by

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Etiology of sexual dysfunction FACTORS TYPICAL FOR MANY FORMS OF SEXUAL DYSFUNCTION Sexual dysfunction usually occurs when poor general relationships between partners are combined (in various combinations) with low sex drive, ignorance of sexual

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Etiology In discussing the causes of childhood mental disorders, much of the same principles apply as described in the chapter on the etiology of disorders in adults. In child psychiatry, fewer delineated mental illnesses and more

From the author's book

Etiology of mental retardation INTRODUCTION Lewis (1929) distinguished two types of mental retardation: subcultural (the lower limit of the curve of the normal distribution of mental abilities among the population) and pathological (caused by specific disease processes). V

• Topic 1.1 Concepts of norm and pathology in the psychodynamic tradition.
• Topic 1.2 Concepts of norm and pathology in the cognitive-behavioral tradition.
• Topic 1.3 Concepts of norm and pathology in the existential-humanistic tradition.
• * Zhdan A.N. History of Psychology. M., 1999. Ch. Descriptive psychology. S.355-361.
• Topic 1.4 Concepts of norm and pathology in Russian psychology.
• Topic 1.5. Family-centered systemic concepts of norm and pathology.
• Section 2. Theoretical models and empirical studies of major mental disorders
• Topic 2.1. Multivariate models and modern classification of mental disorders.
• Topic 2.2. Schizophrenia: a history of research, basic theoretical models and empirical research.
• Topic 2.3. Personality Disorders: A History of Research, Basic Theoretical Models, and Empirical Research.
• Topic 2.4. Depressive and Anxiety Disorders: A History of Research, Basic Theoretical Models, and Empirical Research.
• 4. A list of sample control questions and tasks for independent work.
• Section 1. Basic psychological concepts of norm and pathology.
• Topic 1.1 Concepts of norm and pathology in the psychodynamic tradition.
• Topic 1.2 Concepts of norm and pathology in the cognitive-behavioral tradition.
• Topic 1.3 Concepts of norm and pathology in the existential-humanistic tradition.
• Topic 1.4 Concepts of norm and pathology in Russian psychology.
• Topic 1.5. Family-centered systemic concepts of norm and pathology.
• Section 2. Theoretical models and empirical studies of major mental disorders
• Topic 2.1. Multivariate models and modern classification of mental disorders
• Topic 2.1. Schizophrenia: A History of Research, Theoretical Models, and Empirical Research.
• Topic 2.3. Personality Disorders: Research History, Theoretical Models, and Empirical Research.
• Topic 2.3. Affective Spectrum Disorders: Research History, Theoretical Models, and Empirical Research.
• 5. Approximate topics of abstracts and reports
• Section 1. Basic psychological concepts of norm and pathology.
• Topic 1.1 Concepts of norm and pathology in the psychodynamic tradition.
• Topic 1.2 Concepts of norm and pathology in the cognitive-behavioral tradition.
• Topic 1.3 Concepts of norm and pathology in the existential-humanistic tradition.
• Topic 2.3. Personality Disorders: Research History, Theoretical Models, and Empirical Research.
• Topic 2.4. Affective Spectrum Disorders: Research History, Theoretical Models, and Empirical Research.
• 6. An indicative list of questions for assessing the quality of mastering the discipline
• III. Forms of control
• Application Guidelines for Students
• Section 1. Basic psychological concepts of norm and pathology.
• Topic 1.1 Concepts of norm and pathology in the psychodynamic tradition.
• Topic 1.2 Concepts of norm and pathology in the cognitive-behavioral tradition.
• Topic 1.3 The concept of norm and pathology in the existential-humanistic tradition -6 hours.
• Topic 1.4 Concepts of norm and pathology in Russian psychology.
• Topic 1.5. Family-centered systemic concepts of norm and pathology.
• Section 2. Theoretical models and empirical studies of major mental disorders
• Topic 2.1. Multivariate models and modern classification of mental disorders.
• Topic 2.2. Schizophrenia: A History of Research, Theoretical Models, and Empirical Research.
• Topic 2.3. Personality disorders: history of study, theoretical models, empirical research.
• Topic 2.4. Affective Spectrum Disorders: Research History, Theoretical Models, and Empirical Research.

Topic 2.3. Personality Disorders: Research History, Theoretical Models, and Empirical Research.

Characteristics of primitive personal defenses.

Characteristics of the borderline personality structure according to N. McWilliams.

Stages of development of object relations according to H. Hartmann and M. Mahler.

Structural characteristics of a healthy personality according to O. Kernberg.

The main diagnostic headings contained in the cluster "Personality disorders" according to ICD-10 and DSM-4.

Healthy and pathological narcissism.

Teaching about the characters of E. Kretschmer.

Parametric model of personal pathology by K. Jung.

Cognitive-behavioral model of personality disorders.

Topic 2.4. Affective Spectrum Disorders: Research History, Theoretical Models, and Empirical Research.

Cognitive model of panic disorder.

Stages in the development of Z. Freud's views on anxiety disorder. The case of the country girl and the case of little Hans.

Mechanisms of anxiety formation in psychodynamic (Z. Freud) and behavioral (J. Watson, D. Volpe) approaches.

Bio-psycho-social model of anxiety disorders.

The existential meaning of anxiety (L. Binswanger, R. May)

6. An indicative list of questions for assessing the quality of mastering the discipline

Diathesis-stress-buffer model of mental disorders. Types of stressors. Vulnerability factors and buffer factors.

Modeling ideas about the determinants of normal development in the psychodynamic tradition.

Modeling ideas about the structural and dynamic characteristics of the psyche in the psychodynamic tradition.

Modeling concepts of mental pathology in classical psychoanalysis: model of trauma, model of conflict, model of fixation at different stages of psycho-sexual development.

Modeling ideas about mental norm and pathology in neo-Freudianism (individual psychology of A. Adler, analytical psychology of K. Jung, social psychoanalysis of G. Sulliven, K. Horney and E. Fromm).

Modeling ideas about mental norm and pathology in postclassical psychoanalysis (psychology of "I", theory of object relations, psychology of the self of H. Kohut).

A brief history of the formation and the main theoretical and methodological principles of the psychodynamic tradition.

Basic research rules and procedures and their transformation in the psychodynamic tradition.

Modeling ideas about normal mental development and the mechanisms of deviation from it in radical behaviorism. Characterization of the main models of learning in radical behaviorism.

Research on mental pathology in radical behaviorism.

Characterization of the main research rules and procedures in the cognitive-behavioral tradition.

Research rules and procedures in psychoanalysis and behaviorism. Hermeneutics and Operationalism.

Research rules and procedures in behaviorism and existential-humanistic traditions. Operationalism and the phenomenological method.

Modeling ideas about normal mental development and mechanisms of deviation from it in methodological behaviorism and informational approach (concepts of A. Bandura, D. Rotter, A. Lazarus, the concept of attributive style).

Characterization of the main models of mental pathology in the framework of an integratively oriented cognitive approach (A. Ellis; A. Beck).

Modeling ideas about normal mental development and mechanisms of mental pathology in the concept of K. Rogers.

Modeling ideas about normal mental development and mechanisms of mental pathology in the concepts of W. Frankl and L. Binswanger.

Phenomenological method and two approaches to its understanding in the existential-humanistic tradition.

A brief history of the formation and the main theoretical and methodological principles of the existential-humanistic tradition.

Basic principles of modern classification of diseases

A Brief History of the Study of Schizophrenia. Views of E.Krepelin. The main disorders in schizophrenia according to E. Bleuler.

Analytical models of schizophrenia. The classical psychoanalytic approach is M. Sesche's model. A model of schizophrenia within the interpersonal approach and within the framework of object relations theory.

Existential approach to schizophrenia (R. Lang, G. Benedetti).

Models of thought disorders in schizophrenia K. Goldstein and N. Cameron. The concept of central psychological deficit in schizophrenia in the framework of the cognitive approach.

Domestic studies of thinking disorders in schizophrenia. Violation of the motivational and dynamic side of thinking.

S. Rado's concept of anhedonia and domestic studies of anhedonia.

Research into the familial context of schizophrenia. The concept of "double bond" by G. Bateson.

Research on emotional expressiveness. Features of social networks of patients with schizophrenia.

General criteria and main types of personality disorders in modern classifications.

The history of the study of personality disorders in the framework of psychiatry and psychoanalysis.

Understanding the term "borderline" in Russian psychiatry and modern psychoanalysis.

Three levels of personality organization in modern psychoanalysis.

Characteristics of primitive defense mechanisms in modern psychoanalysis.

Characteristics of parametric and typological models of personality disorders.

The main parametric models of personality disorders in clinical psychology (E. Kretschmer, K. Jung, G. Eysenck, T. Leary, "The Big Five").

The study of personality disorders within the framework of object relations theory.

Object representations: definition and basic characteristics.

H. Kogut's theory of normal and pathological narcissism.

Bio-psycho-social model of personality disorders.

Mood disorders in the form of depression according to ICD-10. Main criteria for a mild depressive episode.

Personal factors of depression and their research (perfectionism, hostility, neuroticism, addiction).

Analytical models of depression.

Cognitive model of depression.

Behavioral model of depression (Saligman's "learned helplessness" theory).

Bio-psycho-social model of depression.

Anxiety, anxiety and anxiety disorders. Types of anxiety disorders according to ICD-10.

Analytical models of anxiety.

The cognitive model of anxiety. Cognitive mechanisms of panic attack.

Bio-psycho-social model of anxiety.

Ministry of Health of the Russian Federation Far Eastern State Medical University

Department of Psychiatry, Narcology and Neurology FPKiPPS

Test work on the course: "Nursing in psychiatry"

Topic: "Affective syndromes"

Khabarovsk, 2008

Plan

INTRODUCTION

1. History

2. Epidemiology

3. Etiology

4. Clinical signs and symptoms

5. Nursing process and peculiarities of caring for patients with affective syndromes

Conclusion

Bibliography

BBeating

Mood characterizes the internal emotional state of the subject; affect is its external expression. There are a number of pathological disorders of mood and affect, the most serious of which are mood disorders, depression and mania. In the DSM-111 classification, depression and mania have been designated as mood disorders. In DSM-111-R, they are collectively referred to as mood disorders.

The mood can be normal, uplifted, or depressed. The range of mood swings is normally very large. A healthy person has a wide range of ways to express the effect and feels in control of his mood and affects. Mood disorders are a group of clinical conditions characterized by mood disturbances, loss of ability to control one's affects, and a subjective feeling of severe distress.

1. History

Information about depression has been preserved since ancient times, and descriptions of cases that are now called affective disorders can be found in many ancient documents. The story of King Saul in the Old Testament contains a description of the depressive syndrome, as well as the story of Ajax's suicide in Homer's Iliad. Around 450 BC, Hippocrates used the terms mania and melancholy to describe mental disorders. Cornelius Celsus, in his work Medicine, circa 100 AD. wrote that melancholy is a depression caused by black bile. The term continued to be used by other authors, including Arateus (120-18 AD), Galen (129-199 AD). In the Middle Ages, medicine existed in Muslim countries, Avicenna and the Jewish physician Maimonides believed that melancholy was a morbid entity. In 1686, Bonet described a mental illness that he called mania-melancholicus.

In 1854 Jules Falre described a condition called Folie circulaire in which the patient suffered from alternating depression and mania. At about the same time, another French psychiatrist, Jules Bayarget, described the state of Folie a double, in which the patient fell into deep depression and then into a stupor state, from which, in the end, he had difficulty getting out. In 1882, German psychiatrist Karl Kalbaum, using the term cyclothymia, described mania and depression as stages of the same disease.

Emil Kraepelin in 1896, based on the knowledge of French and German psychiatrists of the past, created the concept of manic-depressive psychosis, which includes criteria, most of which are used by psychiatrists today to determine the diagnosis. The absence of dementia and malignancy in the course of manic-depressive psychoses made it possible to differentiate them from schizophrenia. Kraepelin also described the type of depression that occurs in women after menopause and in men in adulthood, which is called involutional melancholy.

2. Epidemiology

Mood disorders, especially depression, are the most common mental disorders in adults. The lifetime chance of developing depression is 20% in women and 10% in men. Despite the fact that the majority of patients with mood disorders sooner or later go to the doctor, it has been established that only 20-25% of patients with depression in its main form, which meets the criteria for this disease, receive treatment.

Depression occurs in women twice as often as in men. Although the reasons for this difference are unknown, it is not the result of specific factors that influence the doctor's performance. Causes can include stress, childbirth, helplessness, and hormonal influences.

Depression can begin at any age, but in 50% of patients it begins between the ages of 20 and 50; the average age of onset is about 40 years.

The prevalence of mood disorders is not related to race.

More often, depression occurs in people who do not have close interpersonal ties, in divorced or living separately spouses.

3. Etiology

Etiological theories of mood disorders include biological (including genetic) and psychosocial hypotheses.

Biological aspects.

Biogenic amines. Norepinephrine and serotonin are the two neurotransmitters that are most responsible for the pathophysiological manifestations of mood disorders. In animal models, it has been shown that effective biological treatment with antidepressants is always associated with inhibition of the sensitivity of postsynaptic β-adrenergic and 5 HT-2 receptors after a long course of therapy. These delayed receptor changes in animals correlate with 1-3 weeks of clinical improvement typically seen in patients. This may correspond to a decrease in the function of serotonin receptors after chronic exposure to antidepressants, which reduces the number of serotonin reuptake zones, and an increase in serotonin concentration found in the brains of suicidal patients. It has also been described that in some people with depression, the binding of 3H-imipramine to blood platelets is reduced. There is evidence that dopaminergic activity may be reduced in depression and increased in mania. There is also evidence supporting the dysregulation of acetylcholine in mood disorders. One study described an increase in the number of muscarinic receptors on tissue culture of fibrinogens (eg, 5-HIAA, HVA, MHPG) of blood, urine, and cerebrospinal fluid in patients with mood disorders. The data described are most consistent with the hypothesis that mood disorders are associated with heterogeneous dysregulation of the biogenic amine system.

Other neurochemical features. There is some evidence of the involvement of neurotransmitters (especially GABA0 and neuroactive peptides (especially vasopressin and endogenous opioids) in the pathophysiological mechanisms of some depressive disorders, although this question cannot be considered completely resolved today. Some researchers suggest that secondary regulation systems such as adenylate cyclase, phosphatidyl inositol, or the calcium regulation system may also be an etiological factor.

Neuroendocrine regulation. A number of disorders of neuroendocrine regulation have been described in patients with mood disorders. Although these disorders may be one of the primary etiological factors of brain disorders, today neuroendocrine research is best viewed as a "window" to the brain. Most likely, deviations in the neuroendocrine sphere reflect a dysregulation of the entry of biogenic amines into the hypothalamus.

Sleep disturbance. Sleep disorder is one of the most potent markers of depression. The main disorders are a decrease in the latent period of REM sleep (REM) (the time between falling asleep and the first period of REM sleep), which is observed in 2/3 of depressed patients, an increase in the duration of the first period of REM sleep, and an increase in the volume of REM sleep in the first phase of sleep. Early morning awakening and sleep interruptions with multiple awakenings in the middle of the night are also more frequent.

Other biological data. Disturbances in immunological function are noted in both depression and mania. It was also suggested that depression is a violation of chronobiological regulation.

Studies of living brain imaging have yielded modest results today. Computed tomography scans have shown that some patients with mania or depression have enlarged cerebral ventricles; Positron emission tomography scans indicate a decrease in cerebral metabolism, and other studies find a decrease in cerebral blood flow in depression, especially to the basal ganglia.

Psychosocial hypotheses.

Life events and stress. Most American clinicians assume a link between life stress and clinical depression. Often, when examining medical records, it is possible to identify stresses, especially those associated with events preceding the onset of depressive episodes. It is assumed that events taking place in life play an important role in the onset of depression, which was reflected in such formulations as "Depression started in connection with ...." and "The depression intensified due to ...." Some clinicians believe that life events play a primary or fundamental role in depression, while others are more conservative, believing that the relationship between depression and life events is expressed only in the fact that they determine the time of onset and determine the duration of an already existing episode. At the same time, the data of researchers cited in support of this connection are inconclusive. The strongest evidence for the correlation of this relationship is between the loss of a parent at age 11 and the loss of a spouse at the onset of the disease and the development of severe depression.

Premorbid personality factors. It is not possible to establish any of the character traits or any particular type of personality, which would be signs indicating a predisposition to depression. All people, regardless of personality, can and do become depressed under certain circumstances; however, different personalities have different characteristics of the disease: the individuals suggested become impulsive-compulsive, hysterical personalities are more at risk of becoming depressed than antisocial, paranoid and others of those who use projection and other externalizing defense mechanisms.

Psychoanalytic factors. Karl Abraham believed that the periods of manifestation of the disease are accelerated with the loss of the libido object, which leads to a regressive process in which it passes from its natural functional state to a state in which the infantile trauma of the oral-sadistic stage of libido development dominates due to the fixation of the process in early childhood.

According to Freud's structural theory, the ambivalent introjection of a lost object into the ego leads to the development of typical depressive symptoms, assessed as a loss of energy at the disposal of the ego. The superego, unable to respond to the loss of energy in external expression, hits the psychic representation of the lost subject, which is now internalized into the ego as an introject. When this conquers or merges into the superego, there is a release of energy previously associated with depressive symptoms, resulting in mania with its typical symptoms of redundancy.

A developed feeling of helplessness. In experiments in which the animals were repeatedly exposed to electric shocks and could not be eliminated, they eventually "gave up" and made no attempt at all to avoid further shocks. A similar state of helplessness can be found in people who are depressed. Learning theory suggests that depression can be reduced if the doctor can instill in the patient a sense of control and coping with the situation. Behavioral techniques involving reward and positive reinforcement are used in these endeavors.

Cognitive theories. According to this theory, negatively colored life events, negative self-esteem, pessimism and helplessness contribute to misunderstanding of the situation.

4. Clinical signs and symptoms

The most common affective syndrome is mild depression, which resembles neurotic reactions in its vague emotional discomfort. With this type of depression, patients complain of a certain feeling of discomfort, lack of energy, boredom, and a desire to change places. Favorite words of patients: laziness, powerlessness, lethargy, colorlessness, restlessness, a feeling of slow passage of time, lack of interests, etc.

If these manifestations are joined by some somatic ailments, for example, headaches, loss of appetite, insomnia, then the syndrome becomes similar to neurotic states of a psychogenic nature. This similarity is enhanced when patients have a tendency to obsessions of the catathymic type. The idea that health is threateningly shaken, that work begun is unlikely to be completed, that there is not enough time to raise a child, reinforces the similarity of this mild depression with neurotic depression. The feeling of longing and anxiety here does not yet occupy a leading place in the structure; they arise only as insignificant darkening episodes. “Suddenly it became melancholy,” “it became dreary in my soul,” “a cloud of anxiety ran through” - this is how patients usually characterize these transient affective states.

Usually, this kind of depression is of an undulating nature. They, suddenly appearing, just as suddenly disappear. It is noteworthy that patients can to a certain extent cope with them, continue to work and live in a family.

Some people successfully hide their depression by seeking help from general practitioners for headaches and insomnia.

Distinguishing mild endogenous depression from neurotic depression or neurotic asthenic response is not easy. The main thing to pay attention to is the presence of structural elements of axial endoform syndrome - a decrease in the level of personality, which make up the background of this depression. Without identifying these structural elements, this kind of depression should be interpreted as either cyclothymic or psychogenic.

It should also be noted that psychogenic depression often occurs in connection with any unfavorable situations, breaking the usual stereotype. Although this kind of situation with the considered endoform depression cannot be ruled out, it is precisely the absence of psychogenesis, not quite clarity, the impossibility of withdrawing from the life situation that serves as the main diagnostic factor in clinical assessment. The symptom of boredom, which is the most common type of subpsychic conditions of our contemporaries, complicates the diagnosis. In everyday life, the sources of boredom are satiety, unemployment, the inability to use leisure time rationally, and the inadequacy of the cultural level, which generates a painful feeling of boredom with its inherent experience of the slow passage of time.

Anxiety depression is one of the more severe registers of affective disorders. In this type of depressive syndromes, the general emotional background is an anxious or melancholy mood. Patients complain of a painful, painful state of health. The melancholy experienced by them is of a vital nature, localized in the region of the heart, intensifies in the morning, decreases in the evening. With this type of depression, patients find themselves at the mercy of katatimny thoughts. It seems to them that they are guilty of something, that their physical health is threatened by illness, that mental strength and psyche are on the verge of disaster. Concerns about one's health and moral discomfort create themes for hypochondriacal fixations on bodily sensations and ideas of self-blame. As a rule, with this type of depression, there is a feeling of slowing down the passage of time, a feeling of general heaviness and such a deep focus on one's own inner world that everything around begins to play the role of a kind of neutral amorphous background. Patients become restless.

In some cases, anxiety becomes the dominant affect in these depressions. At first this is a vague feeling, but gradually it acquires the features of objectivity. At the same time, patients show fear for the fate of loved ones, express thoughts that the family is in danger. At the same time, they complain about the loss of love and affection for loved ones. Often, anxiety acquires a hypochondriacal orientation, and then patients claim that they are developing a serious physical illness (cancer, hypertension, sclerosis, heart attack), that the danger of death is imminent.

Weakening of vital impulses, melancholy and anxiety, apathy and hypochondria, a feeling of general numbness or dullness for some time do not obscure a critical attitude towards their condition. At the same time, the ability to compare with what was before the illness is still preserved. At the same time, in the end, this ability is lost, and then experiences of fear and horror appear. Delusional ideas of persecution are also formed, spreading to even relatives and friends.

In the picture of anxiety depressions, depersonalization phenomena are also possible. Patients claim, for example, that their body acquires a death tint, senile flabbiness, that their mental faculties have become dull and will never recover. Some show depersonalization of a different kind: they suffer from the fact that the colors of the world around them have faded, people's faces have acquired mysterious frightening expressions, moving people and cars seem to make very strange alarming movements.

There are two types of anxiety depression. One type is accompanied by motor activity. At the same time, the patients are in continuous movement, sighing loudly and deeply, wringing their hands, pulling out their hair, fiddlingly sorting through the folds of their clothes, and now and then turn to the staff with alarming requests. Another type is retarded depression. At the same time, there is a poverty of motor skills, a frozen expression of suffering on the face, slow and quiet speech, significant pauses in answering questions. In some cases, lethargy can reach stupor.

With a lesser frequency, but no less severity, there are affective disorders of the opposite type - manic syndromes.

Hypomanic syndrome is more common. In some cases, this is an acutely arisen state of licentiousness, increased agility, playfulness, intemperance, disinhibition of drives. A variant of pathological playfulness, or petulence, is more often observed in cases of nuclear schizophrenia, both slowly proceeding and characterized by a violent course (psychopathic form. Hebephrenia). Another variant of the hypomanic syndrome is the state of letitia, which manifests itself in episodes of pathological gaiety, unreasonable glee, an indomitable desire to bring joy to others, to boast, to boast. Letizia is accompanied, as a rule, by ideas of self-revaluation. For example, a woman begins to boast about the slimness of her legs, claims that she has the most fashionable bust in the world, that so many noble men are crazy about her, that she is invited to filming, to model houses, etc. Men often begin to assert that they are capable of great deeds, can set world records in sports, organize big business; they also boast about their physical characteristics, sexual performance, and the like. Patients make it clear that they have decent and powerful connections, that they are included in the "spheres", enjoy enviable success with colleagues, with women, that they could, if they wanted, make a business, writing, scientific career, etc. NS.

A more serious disorder is simple manic syndrome. Elevated mood with expansiveness and irritability is the criterion for this condition. Elevated mood is characterized by euphoria and is often contagious in nature; this sometimes makes it difficult for an inexperienced doctor to correctly diagnose the transition of the disease to the opposite phase. Although people who are in contact with the sick person may not recognize the unusual nature of his mood, people who know the person well can easily distinguish changes in his mood that are unusual for him. The patient's mood can sometimes be irritable, especially if they interfere with the implementation of his extremely ambitious plans. A change in the dominant mood is often observed - from euphoria at the onset of the disease to irritability, which is observed in the further period of its development.

The maintenance of manic patients on an inpatient basis is made difficult by the fact that they violate hospital rules, seek to shift responsibility for their misconduct to others, take advantage of the weakness of others and seek to quarrel staff. Manic sufferers often consume excessive amounts of alcohol, perhaps in an attempt to help themselves. The lack of inhibition, characteristic of these patients, manifests itself in numerous telephone conversations, especially in calls to people living far away in the early morning. Abnormal gambling tendencies, the need to strip naked in public places, wear clothes and jewelry in bright colors and unexpected combinations, and inattention to small details (for example, they forget to put the telephone back in place) are also typical manifestations of this disorder. The impulsive nature of many of the patients' actions is combined with a sense of inner conviction and determination. The sufferer is often gripped by religious, political, financial, sexual or persecutory ideas that can become part of a delusional complex.

In some cases, simple manic syndrome contains in its composition such disorders that belong to the category of obsessive, violent and overvalued ideas. An example of obsession is the deliberate sophistication characteristic of a number of patients. It manifests itself both in the desire to give his speech a profound, aphoristic character, and in the senseless, resonant nature of reflection. So, for example, some patients constantly turned to others with questions of a naive and far-fetched nature: what will happen if the sun rises not from the east, but from the west, what will happen if the phenomenon of magnetism disappears at the North Pole, how can you teach a chicken to swim, etc. ... despite the fact that such patients understand the meaninglessness of these questions, their irrelevance, they nevertheless turn to doctors and patients with them at the most inopportune moment.

As a rule, there are overvalued ideas that are in the nature of unbridled bragging, bragging, and beyond reason.

5. Nursing processand featurescare of patients with affectiveandsyndromesand

Negative bias has developed in society about psychiatry. There are big differences between mental and somatic diseases. Therefore, patients and their relatives are often ashamed of the disease, they hide the fact of going to a psychiatrist. Often, people around, even health workers, treat people with mental disorders unnaturally: with excessive apprehension (even fear), with emphasized pity or condescension. This attitude can make the nursing process difficult at all stages.

The best help for mental patients is provided when their condition is perceived by others only as a disease. This helps sufferers maintain the self-awareness necessary for their healing.

The caregiver should not perceive the patient's personality, with its needs, desires and fears, only in terms of the diagnosis of the disease. Holistic care covers the individual, illness, profession, family, relationships, etc. A mentally ill person is not only an object of care. Actively involving the patient in solving his health problems is the main task of the caring staff. In this sense, caring for the patient does not only mean performing the necessary medical procedures, it means much more: accompaniment, explanation, motivation for action and attention to the patient's problems.

The care process is carried out in stages as follows: collecting information, making a nursing diagnosis, identifying the patient's problems (in case of affective states, the problems will be as follows: in case of depression: depressed mood - hypothymia, decreased volitional activity - hypobulia, motor inhibition, slowing down of the thought process, mania: increased mood - euphoria, increased volitional and physical activity, acceleration of the thought process, cheerfulness, carelessness, etc.), setting care goals, planning care, taking care of and evaluating the results. Evaluation of the effectiveness of care is based on the results of repeated collection of information about the patient's condition and makes it possible to monitor and make the necessary adjustments during the care process.

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. Therefore, a nurse must have communication skills, knowledge of medical psychology and certain personal qualities: respect for the individual, the ability to empathy, endurance, etc.

In dealing with mental patients, one should not raise his voice, order anything, disregard their requests, ignore their appeals and complaints. Any harsh, disrespectful treatment of patients can provoke agitation, aggressive actions, attempts to escape, and suicide. You should refrain from discussing with patients the condition and behavior of other patients, express your point of view on the correctness of treatment, regimen. It is necessary to regulate the behavior of patients, if such a need arises, very correctly. Conversation with patients should concern only the issues of treatment, be aimed at reducing their anxiety, anxiety.

Nurses, junior medical personnel on duty must wear a strict medical gown and a medical cap. Inappropriate are flashy jewelry, demonstrative hairstyles, bright makeup, and anything that can attract increased attention of patients. The pockets of the gown should not contain sharp objects, keys to the compartment, cabinets with medicines. The loss of the keys requires urgent measures to be taken to find them, as this may lead to the escape of patients from the department.

Medical manipulations (distribution of medicines, injections and other procedures) are performed according to the doctor's prescriptions within the specified time frame. It is necessary to monitor whether patients are taking pills. Distribution of medicines without monitoring their intake is not allowed, therefore, medicines are taken by patients only in the presence of a nurse.

There are three types of supervision necessary for the mentally ill. Strict supervision assigned to depressed patients with a tendency to suicide. In the ward where such patients are located, there is a medical post around the clock, the ward is constantly illuminated, there should be nothing but beds in it. Patients can leave the ward only with accompanying persons. Any change in the behavior of patients is immediately reported to the doctor. Enhanced surveillance it is prescribed in cases where it is required to clarify the features of painful manifestations (the nature of sleep, mood). General observation assigned to those patients who do not pose a danger to themselves and others. They can move freely in the department, go for a walk, are actively involved in labor processes (which is typical for manic patients).

Depressive patients can commit suicidal attempts, so a nurse should monitor their attempts to get ropes, laces, cutting objects, medicines. Such patients should not be left unattended. If the attempt is nevertheless realized, it is necessary to take measures to provide emergency medical care and notify the doctor. Also, depressed patients may refuse to eat. The nurse needs to understand the reasons for refusing to eat. In some cases, psychotherapeutic methods, persuasion, and explanation are effective. To stimulate appetite, it is possible to prescribe small doses of insulin (4-8 U) subcutaneously. If attempts to feed the patient are unsuccessful for 3-4 days, one can resort to artificial feeding through a tube or to parenteral feeding by intravenous administration of nutrient solutions.

Patients with manic syndrome often do not want to volunteer for treatment in the clinic, so they have to be coerced. They do not have such a deep understanding of their illness, and treatment in a hospital seems to them sheer absurdity. The nurse must be able to convince the patient of the need to stay in the hospital and take medications. Manic patients are often aggressive, conflicting, medical personnel should remember this and try not to come into conflict with such patients.

Conclusion

Affective syndromes include the polar emotional disorders of depression and mania. Depressive syndrome is characterized by a painfully low mood, melancholy, which are sometimes accompanied by a physically painful feeling of pressure or heaviness in the chest area, intellectual and motor inhibition (difficulty in the flow of thoughts, loss of interest in professional activity, slowing down of movements up to complete immobility-depressive stupor). A pessimistic outlook in depression is accompanied by anxiety, guilt, ideas of little value, which in severe cases acquire the character of delirium of self-accusation or sinfulness, suicidal ideas and tendencies.

Manic syndrome is characterized by a painfully elevated mood, combined with unfounded optimism, accelerated thinking and excessive activity. Patients are characterized by experiences of joy, happiness, overestimation of their own capabilities, sometimes reaching the level of ideas of greatness. There is a lot of talk, a desire to constantly expand the scope of activities and contacts. At the same time, increased irritability, conflict (angry mania) are often found.

Caring for such patients, it is necessary to monitor changes in the state and immediately report these changes to the doctor. A nurse should be aware of all depressed patients with suicidal intentions, be attentive to the statements of patients, monitor their attempts to get objects that may harm the patient. With manic patients, you should not enter into a conflict situation, you should not raise your voice to them, order something, disdain their requests, ignore their appeals, complaints.

Listused literature

1. Zharikov NM, Ursova LG, Khritinin DB, Psychiatry (textbook for students of medical institutes). M., 1998.

2. Kaplan G.I., Sadok B.D. Clinical Psychiatry in 2 volumes. T. 1. 1998, - M .: Medicine.

3. Portnov A.A. General psychopathology: textbook. allowance. - M .: Medicine, 2004

4. Ritter S. Guidelines for nursing work in a psychiatric clinic. Principles and Techniques. - Publishing house "Sphere", Kiev, 1997.